Drug overdose deaths in the United States reached record levels during the fentanyl era before recently declining. A plausible hypothesis is that a sudden drop in fentanyl purity ("supply shock") beginning in 2023 caused the downturn in overdose mortality. We evaluated this hypothesis by replicating a published analysis with regional overdose data, using models that account for time trends and autocorrelation, and negative control indicators to test for spurious correlation. Replicating the original paper, we extracted fentanyl purity data from a figure published by the Drug Enforcement Agency; overdose mortality was derived from standard vital statistics sources. We found that when fentanyl purity was rising, the national purity series did not track overdose increases in most regions and showed only a modest association in the West. When both purity and mortality later declined, the observed associations were also seen with unrelated macroeconomic indicators that shared the same time pattern. Canadian studies revealed variation in both strength and direction of association between fentanyl purity and overdose deaths at sub-province levels. Differential selection bias in law enforcement purity assessment may compromise longitudinal and geographic generalizability of DEA data, notably simulated reporting for higher purity wholesale samples in 2023-4. National fentanyl purity alone does not provide sufficient explanation for the recent decline in overdose deaths. A reduction in localized purity may influence overdose decreases, but other causes must also be considered, including drug supply changes, public health interventions, demographic shifts, behavior changes, intercartel dynamics, and fewer new initiates.

BACKGROUND:This study updates the COVID-19 pandemic surveillance in East Asia and the Pacific region that we first conducted in 2020 with 2 additional years of data for the region. OBJECTIVE:First, we aimed to measure whether there was an expansion or contraction of the pandemic in East Asia and the Pacific region when the World Health Organization (WHO) declared the end of the COVID-19 public health emergency of international concern on May 5, 2023. Second, we used dynamic and genomic surveillance methods to describe the dynamic history of the pandemic in the region and situate the window of the WHO declaration within the broader history. Finally, we aimed to provide historical context for the course of the pandemic in East Asia and the Pacific region. METHODS:In addition to updates of traditional surveillance data and dynamic panel estimates from the original study, this study used data on sequenced SARS-CoV-2 variants from the Global Initiative on Sharing All Influenza Data to identify the appearance and duration of variants of concern. We used Nextclade nomenclature to collect clade designations from sequences and Pangolin nomenclature for lineage designations of SARS-CoV-2. Finally, we conducted a 1-sided t test to determine whether the regional weekly speed was greater than an outbreak threshold of 10. We ran the test iteratively with 6 months of data across the sample period. RESULTS:Several countries in East Asia and the Pacific region had COVID-19 transmission rates above an outbreak threshold at the point of the WHO declaration (Brunei, New Zealand, Australia, and South Korea). However, the regional transmission rate had remained below the outbreak threshold for 4 months. In the rolling 6-month window t test for regional outbreak status, the final P value ≤.10 implies a rejection of the null hypothesis (at the α=.10 level) that the region as a whole was not in an outbreak for the period from November 5, 2022, to May 5, 2023. From January 2022 onward, nearly every sequenced SARS-CoV-2 specimen in the region was identified as the Omicron variant. CONCLUSIONS:While COVID-19 continued to circulate in East Asia and the Pacific region, transmission rates had fallen below outbreak status by the time of the WHO declaration. Compared to other global regions, East Asia and the Pacific region had the latest outbreaks driven by the Omicron variant. COVID-19 appears to be endemic in the region, no longer reaching the threshold for a pandemic definition. However, the late outbreaks raise uncertainty about whether the pandemic was truly over in the region at the time of the WHO declaration.

The natural language processing pipeline powered by the BART model is a popular zero-shot text classification system. While the standard approach for using this pipeline can achieve impressive accuracies in many multiclass classification tasks, we believed that there was still room to improve and developed an improved approach for that. Both approaches were used for the classification of narrative reports, and the results showed that the improved approach could increase the accuracies significantly over the standard approach. The improved approach is made general and can be applied to other use cases as well.

This study uses 2021 data on the percentage of unavailable opioid tests in the US to examine how opioid involvement informs injury death investigations.

Assault weapon and large capacity magazine bans are potential tools for policymakers to prevent public mass shootings. However, the efficacy of these bans is a continual source of debate. In an earlier study, we estimated the impact of the Federal Assault Weapons Ban (FAWB) on the number of public mass shooting events. This study provides an updated assessment with three additional years of firearm surveillance data to characterize the longer-term effects. To estimate the impact of the FAWB on trends in public mass shootings from 1966 to 2022. We use linear regression to estimate the impact of the FAWB on the five-year simple moving average of annual, public mass shootings, defined by events with four or more deaths in a 24-hour period, not including the perpetrator. The study period spans 1966 to 2022. The model includes indicator variables for both the period of the FAWB (1995-2004) and the period after its removal (2005-2022). These indicators were interacted with a linear time trend. Estimates controlled for the national homicide rate. After estimation, the model provided counterfactual estimates of public mass shootings if (1) the FAWB were never imposed and (2) if the FAWB remained in place. The overall upward trajectory in the number of public mass shootings substantially fell while the FAWB was in place. These trends are specific to events in which the perpetrator used an assault weapon or large capacity magazine. Estimates suggest the FAWB prevented five public mass shootings while the ban was active. A continuation of the FAWB/LCMB would have prevented up to thirty-eight public mass shootings. The FAWB, which included a ban on large capacity magazines, was associated with fewer public mass shooting events, fatalities, and nonfatal gun injuries. Gun control legislation is an important public health tool in the prevention of public mass shootings. n/a

Background: This study updates the initial COVID-19 pandemic surveillance in sub-Saharan Africa (SSA) from 2020 byproviding 2 additional years of data for the region. Objective: First, we aimed to measure whether there was an expansion or contraction in the pandemic in SSA when the WorldHealth Organization (WHO) declared an end to the public health emergency for the COVID-19 pandemic on May 5, 2023. Second,we used dynamic and genomic surveillance methods to describe the history of the pandemic in the region and situate the windowof the WHO declaration within the broader history. Third, we aimed to provide historical context for the course of the pandemicin SSA. Methods: In addition to updates of traditional surveillance data and dynamic panel estimates from the original study by Postet al (2021), this study used data on sequenced SARS-CoV-2 variants from the Global Initiative on Sharing All Influenza Data(GISAID) to identify the appearance and duration of variants of concern. We used Nextclade nomenclature to collect cladedesignations from sequences and used Pangolin nomenclature for lineage designations of SARS-CoV-2. Finally, we conducteda 1-sided t-test to assess whether regional weekly speed was greater than an outbreak threshold of 10. We ran the test iterativelywith a rolling 6-month window of data across the sample period. Results: Speed for the region remained well below the outbreak threshold before and after the WHO declaration. Accelerationand jerk were also low and stable. The 7-day persistence coefficient remained somewhat large (1.11) and statistically significant.However, both shift parameters for the weeks around the WHO declaration were negative, meaning the clustering effect of new COVID-19 cases had become recently smaller. From November 2021 onward, Omicron was the predominant variant of concernin sequenced viral samples. The rolling t-test of speed equal to 10 was insignificant for the entire sample period. Conclusions: While COVID-19 continues to circulate in SSA, the region never reached outbreak status, and the weeklytransmission rate remained below 1 case per 100,000 population for well over 1 year ahead of the WHO declaration. COVID-19is endemic in the region and no longer reaches the threshold for its classification as a pandemic. Both standard and enhancedsurveillance metrics confirm that the pandemic ended in SSA by the time the WHO made its declaration. (JMIR Public Health Surveill 2024;10:e53409) doi: 10.2196/53409

Background:Assault weapon and large-capacity magazine bans are potential tools for policy makers to prevent public mass shootings. However, the efficacy of these bans is a continual source of debate. In an earlier study, we estimated the impact of the Federal Assault Weapons Ban (FAWB) on the number of public mass shooting events in the United States. This study provides an updated assessment with 3 additional years of firearm surveillance data to characterize the longer-term effects. Objective:This study aims to estimate the impact of the FAWB on trends in public mass shootings from 1966 to 2022. Methods:We used linear regression to estimate the impact of the FAWB on the 4-year simple moving average of annual public mass shootings, defined by events with 4 or more deaths in 24 hours, not including the perpetrator. The study period spans 1966 to 2022. The model includes indicator variables for both the FAWB period (1995-2004) and the period after its removal (2005-2022). These indicators were interacted with a linear time trend. Estimates were controlled for the national homicide rate. After estimation, the model provided counterfactual estimates of public mass shootings if the FAWB was never imposed and if the FAWB remained in place. Results:The overall upward trajectory in the number of public mass shootings substantially fell while the FAWB was in place. These trends are specific to events in which the perpetrator used an assault weapon or large-capacity magazine. Point estimates suggest the FAWB prevented up to 5 public mass shootings while the ban was active. A continuation of the FAWB and large-capacity magazine ban would have prevented up to 38 public mass shootings, but the CIs become wider as time moves further away from the period of the FAWB. Conclusions:The FAWB, which included a ban on large-capacity magazines, was associated with fewer public mass shooting events, fatalities, and nonfatal gun injuries. Gun control legislation is an important public health tool in the prevention of public mass shootings.

BACKGROUND:This study updates the COVID-19 pandemic surveillance in the Middle East and North Africa (MENA) we first conducted in 2020 with 2 additional years of data for the region. OBJECTIVE:The objective of this study is to determine whether the MENA region meets the criteria for moving from a pandemic to endemic. In doing so, this study considers pandemic trends, dynamic and genomic surveillance methods, and region-specific historical context for the pandemic. These considerations continue through the World Health Organization (WHO) declaration of the end of the public health emergency for the COVID-19 pandemic on May 5, 2023. METHODS:In addition to updates to traditional surveillance data and dynamic panel estimates from the original study by Post et al, this study used data on sequenced SARS-CoV-2 variants from the Global Initiative on Sharing All Influenza Data (GISAID) to identify the appearance and duration of variants of concern. We used Nextclade nomenclature to collect clade designations from sequences and Pangolin nomenclature for lineage designations of SARS-CoV-2. Finally, we conducted a 1-sided t test to determine whether regional weekly speed of COVID-19 spread was greater than an outbreak threshold of 10. We ran the test iteratively with 6 months of data from September 4, 2020, to May 12, 2023. RESULTS:The speed of COVID-19 spread for the region had remained below the outbreak threshold for 7 continuous months by the time of the WHO declaration. Acceleration and jerk were also low and stable. Although the 1- and 7-day persistence coefficients remained statistically significant and positive, the weekly shift parameters suggested the coefficients had most recently turned negative, meaning the clustering effect of new COVID-19 cases became even smaller in the 2 weeks around the WHO declaration. From December 2021 onward, Omicron was the predominant variant of concern in sequenced viral samples. The rolling t test of the speed of spread equal to 10 became entirely insignificant from October 2022 onward. CONCLUSIONS:The COVID-19 pandemic had far-reaching effects on MENA, impacting health care systems, economies, and social well-being. Although COVID-19 continues to circulate in the MENA region, the rate of transmission remained well below the threshold of an outbreak for over 1 year ahead of the WHO declaration. COVID-19 is endemic in the region and no longer reaches the threshold of the pandemic definition. Both standard and enhanced surveillance metrics confirm that the pandemic had transitioned to endemic by the time of the WHO declaration.

Background: Prevention strategies for suicide emphasize restrictions on firearm access. These restrictions may lose efficacy if individuals substitute other lethal suicide methods. Aims: The objective of this study is to determine the extent to which individuals who die by suicide in the United States substitute hanging for firearm injury. Methods: This study is a repeated cross-sectional analysis of suicide deaths in the United States from 2003 to 2021. Multiple regression was used to estimate the effect of firearm access proxies on individual suicide methods (hanging vs. firearm injury). Results: The probability of death by hanging was significantly and negatively associated with proxies of firearm access. Limitations: This study does not compare crude rates of suicide by state, which rise on average with rates of firearm ownership. The National Violent Death Reporting System expanded over the sample period, so early years have incomplete ascertainment. Rates of gun ownership and gun safety law scales are measured as proxies. Conclusions: Although means restriction around firearm access is a critical tool for suicide prevention, complementary strategies for prevention around hanging merit further study.

Opioid-related mortality remains a critical public health issue in the United States, particularly in rural areas. This study examines the determinants of age-adjusted opioid death rates in U.S. farming counties, focusing on the roles of economic deprivation and pharmaceutical marketing in rural farm communities. We evaluate two competing hypotheses: (1) that economic vulnerability, as captured by the “deaths of despair” framework, drives opioid-related mortality, and (2) that increased reliance on and promotion of opioids by pharmaceutical companies contributes significantly to the crisis. : We use a double-hurdle model to analyze county-level data on age-adjusted opioid death rates from 2007, 2012, and 2017, focusing on the share of farmland operated by Limited Resource Farmers, and pharmaceutical company payments to physicians. Data sources include the CDC Wonder database, ProPublica’s Dollars for Docs, and the U.S. Census of Agriculture. Regional dummy variables allow for exploring spatial differences, with the Basin and Range region serving as the reference category. Findings reveal that economic vulnerability plays a significant role in opioid-related mortality. The share of farmland operated by Limited Resource Farmers is positively associated with age-adjusted opioid death rates, with elasticities changing from 0.0707 in 2007 to 0.0532 in 2012 and turning slightly negative in 2017. This trend suggests that as the opioid epidemic spread, the relative influence of economic deprivation in farming counties was diluted. Conversely, the elasticity of county-level opioid-related mortality with respect to pharmaceutical payments to physicians is not statistically significant, failing to support the hypothesis that pharmaceutical marketing drives the crisis. Economic vulnerability, particularly among Limited Resource Farmers, is a key driver of opioid-related mortality in U.S. farming counties, supporting the “deaths of despair” framework. The lack of significant effects for pharmaceutical payments suggests a limited role for physician-targeted marketing in this context. These findings emphasize the need for interventions addressing economic instability in farming communities and tailoring regional responses to the opioid epidemic. Future research should explore additional factors, including healthcare access and mental health resources, to deepen understanding and inform more effective policies. Opioid Mortality, Farming Counties, Limited Resource Farmers, Economic Vulnerability, Pharmaceutical Marketing, Deaths of Despair, Rural America

BACKGROUND:Housing instability in the United States is a critical social determinant of health, influencing health outcomes and health care utilization. This scoping review aimed to analyze literature on US health system screening and response programs addressing housing instability, highlighting methodologies, geographic and demographic variations, and policy implications. METHODS:Adhering to PRISMA-ScR guidelines, the review included studies focusing on US health systems that screen and refer for housing instability. Major scholarly databases, including PubMed and Scopus, were queried. Screening and response program characteristics, methodologies, and outcomes were characterized. RESULTS:Thirty studies published between 2003 and 2023 were included in this study. Included studies were primarily cross-sectional (26.7%) or quality improvement (20.0%), among 9 other designs. Screening programs were predominantly implemented in academic hospital systems (46.7%) and in the Northeast (63.3%). Of the 25 adult population studies, 68.0% were in outpatient settings, and of the 23 studies providing detailed information on their process, 52.2% used electronic health record entry. Of the 22 studies that describe their screening tool, 15 used institution-specific tools, and only 4 of the remaining 7 studies used identical tools. Of the 20 studies that described their response to positive screenings, 13 provided patients with a paper or electronic referral to a collaborating community partner, while only 6 aided the patient in connecting with community resources. CONCLUSION:This study found significant variability in screening and response programs for housing instability among US health care providers. A lack of standardized definitions and methodologies hampers effective comparison and implementation of these programs. Future research should focus on standardizing screening methods and measurement of interventions and outcomes to address housing instability.

Background Opioid overdose death rates are increasing for adults aged 55 and older, with especially high rates in large urban areas. In parallel, admissions to treatment programs for older adults using illicit substances are increasing as well. Despite these trends, there is a lack of information about older adults who use non-medical opioids (NMO) and even less knowledge about their health and service encounters. Conducted in Chicago, Illinois, this qualitative study explores the perspectives of health care and harm reduction service providers who work with older adults using non-medical opioids. Methods The study used snowball sampling to locate participants with expertise in working with older adults who use non-medical opioids. In total, we conducted 26 semi-structured interviews from September 2021-August 2022. We explored questions regarding participants’ perceptions of older adult opioid use patterns, comorbidities, and involvement in harm reduction outreach and opioid use disorder treatment. Results Many of the providers we interviewed consider older adults who use NMO as a distinct population that employ unique use behaviors with the intent to protect them from opioid overdose. However, these same unique behaviors may potentiate their risk for overdose in today’s climate. Providers report initial encounters that are not care seeking for opioid use and primarily oriented around health conditions. Older adults who use non-medical opioids are seen as complex patients due to the need to diagnostically untangle symptoms of substance use from co-morbidities and conditions associated with aging. Treatment for this population is also viewed as complicated due to the interactions between aging, comorbidities, and substance use. Providers also noted that older adults who use NMO have use behaviors that make them less visible to outreach and treatment service providers, potentially putting them at increased risk for overdose and health conditions associated with opioid use. Conclusions Findings from this study are intended to inform future research on care provision for older adults who use non-medical opioids and may be especially applicable to large urban reas with histories of opioid use dating back to earlier drug epidemics of the 1970s, 1980s, and 1990s.

BACKGROUND:Homicide is one of the 5 leading causes of death in the United States for persons aged 1 to 44 years. In 2019, 75% of US homicides were by gun. Chicago has a gun-homicide rate 4 times the national average, and 90% of all homicides are by gun. The public health approach to violence prevention calls for a 4-step process, beginning with defining and monitoring the problem. Insight into the characteristics of gun-homicide decedents can help frame next steps, including identifying risk and protective factors, developing prevention and intervention strategies, and scaling effective responses. Although much is known about gun homicide because it is a long-standing, entrenched public health problem, it is useful to monitor trends to update ongoing prevention efforts.OBJECTIVE:This study aimed to use public health surveillance data and methods to describe changes in the race/ethnicity, sex, and age of Chicago gun-homicide decedents from 2015-2021, in the context of year-to-year variation and an overall increase in the city's gun-homicide rate.METHODS:We calculated the distribution of gun-related homicide deaths by 6 race/ethnicity and sex groups (non-Hispanic Black female, non-Hispanic White female, Hispanic female, non-Hispanic Black male, non-Hispanic White male, and Hispanic male), age in years, and age by age group. We used counts, percentages, and rates per 100,000 persons to describe the distribution of deaths among these demographic groups. Comparisons of means and column proportions with tests of significance set at P≤.05 were used to describe changes in the distribution of gun-homicide decedents over time by race-ethnicity-sex and age groups. The comparison of mean age by race-ethnicity-sex group is done using 1-way ANOVA with significance set at P≤.05.RESULTS:The distribution of gun-homicide decedents in Chicago by race/ethnicity and sex groups had been relatively stable from 2015 to 2021 with 2 notable exceptions: a more than doubling of the proportion of gun-homicide decedents who were non-Hispanic Black female (3.6% in 2015 to 8.2% in 2021) and an increase of 3.27 years in the mean age of gun-homicide decedents. The increase in mean age coincided with a decrease in the proportion of non-Hispanic Black male gun-homicide decedents between the ages of 15-19 and 20-24 years and, conversely, an increase in the proportion of non-Hispanic Black male gun-homicide decedents aged 25-34 years.CONCLUSIONS:The annual gun-homicide rate in Chicago had been increasing since 2015 with year-to-year variation. Continued monitoring of trends in the demographic makeup of gun-homicide decedents is necessary to provide the most relevant and timely information to help shape violence prevention efforts. We detected several changes that suggest a need for increased outreach and engagement marketed toward non-Hispanic Black female and non-Hispanic Black male individuals between the ages of 25-34 years.

Gender-based violence (GBV) is a global public health and human rights problem that is exacerbated by social and environmental stressors for a multitude of interpersonal, cultural, and economic reasons. Through sudden disruptions in the microclimate of a region, climate shocks often have a negative impact on food security, which correlates with increases in GBV. Associations between the various combinations of GBV, climate change, and food insecurity have been documented in the growing international literature, but questions remain about these associations that require further clarification. The impact of the COVID-19 pandemic caused by SARS-CoV-2 provides insight through a real time demonstration into these interactions. This review of the global literature examines the interplay between GBV, climate change, and food insecurity—including recent literature regarding the COVID-19 pandemic. This review covers original research studies employing both quantitative and qualitative methodology, those that conducted secondary analyses of existing data sources and perspective pieces derived from observed evidence. An additional analytic layer of system dynamics modeling allowed for the integration of findings from the scoping review and discovery of additional insights into the interplay between disasters, food insecurity, and GBV. Findings from this review suggest that the development and adaptation of evidence-based, focused interventions and policies to reduce the effects of climate shocks and bolster food security may ultimately decrease GBV prevalence and impact.

This study updates the COVID-19 pandemic surveillance in Central Asia we first conducted in 2020 by providing two additional years of data for the region. The historical context provided through additional data can inform regional preparedness and early responses to infectious outbreaks of either the SARS-CoV-2 virus or future pathogens in Central Asia.

This cross-sectional study investigates the prevalence of alcohol in unintentional opioid overdose deaths in Illinois from 2017 through 2020.

Access to firearms is associated with increased risk of violence, injury, and death including suicide. U.S. military Veterans are at higher risk for firearmrelated suicide: according to VA sources, over 69% of Veteran suicides involved firearms, compared to 47.9% of nonVeteran adults.1 In the general population, lesbian, gay, bisexual, transgender, queer, intersex, and other sexualand genderdiverse (LGBTQI+) people have higher risk for suicide.2 Despite this, we were unable to identify any studies that have assessed firearms access, and related injury, death, and suicidal behavior in LGBTQI+ Veterans. In a non– Veteranfocused study, lesbian, gay, and bisexual respondents were less likely to report owning a firearm.3 Moreover, there is little information about factors that contribute to the higher risk of suicide, such as access to firearms, substance use, and mental health disorders or whether targeted interventions, prevention strategies, or health policies can reduce risk among LGBTQI+ Veterans.2,3 Our research is a step toward addressing these gaps, by addressing Recommendation 3 of the executive summary of the 2009 Academic Emergency Medicine Consensus Conference: Incorporate the principles of public health, population health, and prevention into the core curriculum of emergency medicine.4 The Veterans Affairs Health Administration (VA) is committed to providing affirming and comprehensive preventive and primary care to LGBTQI+ Veterans, aiming to mitigate health disparities experienced by this patient group. VA has one of the most comprehensive, national electronic health records (EHR) in the United States,5 yet until recently, there was no structured data field to identify LGBTQI+ status. However, such information may be contained in clinical notes. Despite the heavy toll of suicide, and firearms identified as a leading lethal method for suicide in Veterans, we also cannot readily determine if Veterans were screened or counseled for firearm safety during a clinical encounter. We determined LGBTQI+ status using clinical notes in primary care visits and firearm screening/access documentation in emergencyrelated visit (ED) clinical notes. We next determined whether LGBTQI+ status was associated with ED visits and firearm screening and access. Our study was approved by the institutional review boards of the VA Connecticut and Washington DC Healthcare Systems. We constructed a national cohort of Veterans (n = 9.54 million) with at least one outpatient VA visit between 2015 and 2018. Demographic and clinical data (e.g., International Classification of Diseases, 10th Revision [ICD10] diagnosis codes) were obtained from the VA EHR. We identified disorders with two or more outpatient visits (on separate days) or one or more inpatient stays with ICD10 code(s) associated with suicide risk (e.g., major depressive disorders [MDDs], and alcohol use disorders [AUDs])6 in the literature, and that are associated with LGBTQI+ status based upon our data. We then used natural language processing (NLP) to identify documentation of LGBTQI+ status in outpatient primary care notes.7 Search terms (e.g., lesbian, bisexual, transgender) were identified by members of the team and from LGBTQI+supportive websites such as HRC (https://www.hrc.org/resou rces/gloss aryofterms). Next, we extracted clinical notes for any VA ED visits by cohort members using VA stop codes 130 for ED and 131 for urgent care. We then applied NLP and machine learning (ML) algorithms to identify documentation of firearm screening and access in those notes (positive/ negative).8 Finally, we assessed ED utilization, screening, and access (e.g., positive, negative) among those screened, by LGBTQI+ status. The NLP method had 88.2% sensitivity and 91.5% specificity to identify LGBT status.7 Bivariate statistics included frequencies and means for demographic and clinical factors. Group differences were identified using chisquare or Studentt tests, as appropriate. Multivariable logistic regression was used to adjust for potential confounding. Model fit was examined using quasiinformation criterion and residual plots. Hypotheses were tested at a twosided significance level of α = 0.05. All statistical analyses were conducted using SAS version 9.4 (SAS Institute). The analytic sample included 1,159,247 Veterans (from the cohort of 9,541,086 Veterans) with documentation in clinical notes of LGBTQI+ status. Almost 20% of the analytic sample (n = 227,180) were identified as LGBTQI+. LGBTQI+ Veterans were younger (49.8 [IQR = 37– 61] years vs. 52.0 [IQR = 38– 64] years); were more likely to identify as female (24.8% vs. 11.0%); were less likely to report White race (60.2% vs. 64.0%); were more likely to have been diagnosed with MDD (15.4% vs. 9.1%), posttraumatic stress disorder (PTSD; 21.4% vs. 15.7%), or AUD (12.1% vs. 8.0%); were more likely to be a current smoker (41.8% vs. 35.1%); and were more likely to have an ED visit than nonLGBTQI+ veterans (38.5% vs. 29.8%; all p < 0.0001). In models adjusted for these factors, LGBTQI+ Veterans were significantly more likely to have had one or more

This cross-sectional study examines changes in rates of opioid-involved overdose deaths from 1999 to 2020 in US counties categorized from most urban to most rural.

With wave after wave of SARS-CoV-2 variants, COVID-19 patients filled the worlds' hospitals and morgues because not everybody had access to vaccines or were willing to be vaccinated.1Tangcharoensathien V Bassett MT Meng Q Mills A Are overwhelmed health systems an inevitable consequence of covid-19? Experiences from China, Thailand, and New York State.BMJ. 2021; 372: n83PubMed Google Scholar, 2Dhawan M Priyanka AS Choudhary OP Vaccine inequity and hesitancy: dual factors in the emergence of novel SARS-CoV-2 variants.Ann Med Surg. 2022; 73103186Crossref PubMed Scopus (6) Google Scholar Omicron (B.1.1.529) is no different. Although most scientists were expecting an increase in cases during late 2021, it was surprising that vaccinated and previously infected people were contracting the novel omicron variant so easily and how fast it was transmitting,3Viana R Moyo S Amoako DG et al.Rapid epidemic expansion of the SARS-CoV-2 omicron variant in southern Africa.Nature. 2022; (published online Jan 7.)https://doi.org/10.1038/s41586-022-04411-yCrossref PubMed Scopus (80) Google Scholar which raised several questions. Would existing vaccines still prevent SARS-CoV-2 infection?4Andrews N Stowe J Kirsebom F et al.Effectiveness of COVID-19 vaccines against the omicron (B. 1.1. 529) variant of concern.medRxiv. 2021; (published online Dec 14.) (preprint).https://doi.org/10.1101/2021.12.14.21267615Google Scholar Was omicron more transmissible than previous variants?5Lundberg AL Lorenzo-Redondo R Ozer EA et al.Has omicron changed the evolution of the pandemic?.JMIR Public Health Surveill. 2022; 8e35763Crossref PubMed Scopus (4) Google Scholar What were the consequences of omicron's wide and rapid spread infecting millions of people, including a high number of breakthrough cases? Would it have worse or better outcomes than the worst SARS-CoV-2 variant on record, the delta variant (B.1.617.2)? In The Lancet, Tommy Nyberg and colleagues report their findings about omicron for individuals who are vaccinated, previously infected, or unvaccinated.6Nyberg T Ferguson NM Nash SG et al.Comparative analysis of the risks of hospitalisation and death associated with SARSCoV-2 omicron (B.1.1.529) and delta (B.1.617.2) variants in England: a cohort study.Lancet. 2022; (published online March 16.)https://doi.org/10.1016/S0140-6736(22)00462-7Summary Full Text Full Text PDF PubMed Scopus (15) Google Scholar This outstanding study included an unparalleled 37% of SARS-CoV-2 cases in England. A longitudinal cohort was analysed when the delta variant was still ongoing and omicron outcompeted delta to become the dominant variant. Initial omicron studies included fewer cases than included by Nyberg and colleagues6Nyberg T Ferguson NM Nash SG et al.Comparative analysis of the risks of hospitalisation and death associated with SARSCoV-2 omicron (B.1.1.529) and delta (B.1.617.2) variants in England: a cohort study.Lancet. 2022; (published online March 16.)https://doi.org/10.1016/S0140-6736(22)00462-7Summary Full Text Full Text PDF PubMed Scopus (15) Google Scholar because analysis occurred earlier in the outbreak, such as in South Africa,7Wolter N Jassat W Walaza S et al.Early assessment of the clinical severity of the SARS-CoV-2 omicron variant in South Africa: a data linkage study.Lancet. 2022; 399: 437-446Summary Full Text Full Text PDF PubMed Scopus (71) Google Scholar Denmark,8Bager P Wohlfahrt J Bhatt S et al.Reduced risk of hospitalisation associated with infection with SARS-CoV-2 omicron relative to delta: a Danish cohort study.SSRN. 2022; (published online Jan 14.) (preprint).https://ssrn.com/abstract=4008930Google Scholar Norway,9Veneti L Bøås H Kristoffersen AB et al.Reduced risk of hospitalisation among reported COVID-19 cases infected with the SARS-CoV-2 omicron BA. 1 variant compared with the delta variant, Norway, December 2021 to January 2022.Eurosurveillance. 2022; 272200077Crossref Scopus (12) Google Scholar or Scotland,10Sheikh A Kerr S Woolhouse M McMenamin J Robertson C Severity of omicron variant of concern and vaccine effectiveness against symptomatic disease: national cohort with nested test negative design study in Scotland.Edinburgh Research Explorer. 2021; (published online Dec 22.) (preprint).https://www.pure.ed.ac.uk/ws/portalfiles/portal/245818096/Severity_of_Omicron_variant_of_concern_and_vaccine_effectiveness_against_symptomatic_disease.pdfGoogle Scholar or were restricted to smaller regions and hospitals. Nyberg and colleagues have conducted the first large scale severity study based on 1 516 702 individuals with COVID-19, of whom 1 067 859 were infected with the omicron variant, using a mix of epidemiological and genetic molecular data.9Veneti L Bøås H Kristoffersen AB et al.Reduced risk of hospitalisation among reported COVID-19 cases infected with the SARS-CoV-2 omicron BA. 1 variant compared with the delta variant, Norway, December 2021 to January 2022.Eurosurveillance. 2022; 272200077Crossref Scopus (12) Google Scholar This study reports both encouraging and discouraging findings related to decreased severity of disease (vs delta) and partial vaccine escape, respectively. Nyberg and colleagues found that the risk of hospitalisation and death due to omicron is substantially lower than for delta. Except for children younger than 10 years, individuals with a documented previous SARS-CoV-2 infection had lower hospitalisations and deaths than for delta, even unvaccinated individuals. However, individuals who had received an mRNA vaccination faired far better than unvaccinated or previously infected individuals. Patients who had been boosted with an mRNA vaccine had 70% fewer adverse outcomes than unvaccinated individuals. This cohort was 53·2% female, all age groups were well represented, and 83·3% participants were White and 5·3% were Black. Comparing omicron with delta, the hazard ratios (HRs) were 0·56 (95% CI 0·54–0·58) for a hospital visit, 0·41 (0·39–0·43) for hospital admission, and 0·31 (0·26–0·37) for death. Past infection gave protection for omicron and delta variants against death in both vaccinated (HR 0·47 [0·32–0·68]) and unvaccinated (HR 0·18 [0·06–0·57]) individuals. Notably, for vaccinated individuals, past infection offered no additional protection (HR 0·96 [0·88–1·04]). Coronaviruses in general have significant waning immunity requiring boosters, even with previous infections.11Townsend JP Hassler HB Wang Z et al.The durability of immunity against reinfection by SARS-CoV-2: a comparative evolutionary study.Lancet Microbe. 2021; 2: e666-e675Summary Full Text Full Text PDF PubMed Scopus (27) Google Scholar Similarly, immunised individuals or those with previous documented SARS-CoV-2 infections had little protection against contracting the omicron variant, raising the question of whether it is time to develop a novel vaccine more effective against the SARS-CoV-2 infections. Nevertheless, Nyberg and colleagues show that the individual risk of omicron versus delta for severe outcomes (such as hospitalisations and death) is significantly less. This study also highlights that, although vaccines cannot prevent infections or reinfections with the omicron variant, mRNA vaccine boosters still offer a high level of protection against hospitalisations and deaths. Although this study is timely and an important contribution to the SARS-CoV-2 literature, there are also some limitations. Despite decreased individual risks for hospitalisation and death (omicron vs delta), Nyberg and colleagues did not emphasise the considerable threat to public health. Given that omicron is more transmissible than the delta variant, there were record levels of cases globally that led to record numbers of hospitalisations in some countries, such as the USA.12Centers for Disease Control and PreventionCOVID data tracker.https://covid.cdc.gov/covid-data-tracker/#new-hospital-admissionsDate accessed: March 11, 2022Google Scholar For every new infection, there is the risk of SARS-CoV-2 evolving yet again due to novel mutations, either within the omicron lineages (such as further evolution of the BA.1 and BA.2 omicron subvariants) or from new independent lineages (as has happened with every variant of concern thus far). However, as this study shows, omicron has led to a new pandemic scenario where a substantial proportion of the population in countries with high incidence rates has acquired immunity either through vaccination, infection, or both. In this environment, spikes in hospitalisations are rarer due to a combination of pre-existing immunity and selection of less pathogenic SARS-CoV-2 variants, such as omicron. Yet, we cannot dismiss the fact that highly pathogenic or transmissible variants might develop. In low-income and middle-income countries where fewer people are vaccinated, SARS-CoV-2 will diversify more rapidly. The global community must keep pushing for equity in access to COVID-19 vaccines and treatments in countries with low immunisation rates. Preventing the spread of SARS-CoV-2 will obstruct the virus from adapting whilst more directed data-driven prevention measures are implemented in highly immunised countries. With advancing SARS-CoV-2 knowledge—especially from large studies like that of Nyberg and colleagues—together with new and developing vaccines, treatments, and therapeutics, we might be on the precipice of more targeted, preventive measures that allow us to avoid blanket, highly restrictive policies that have harmful costs to the economy, society, and public health. We declare no competing interests. Comparative analysis of the risks of hospitalisation and death associated with SARS-CoV-2 omicron (B.1.1.529) and delta (B.1.617.2) variants in England: a cohort studyThe risk of severe outcomes following SARS-CoV-2 infection is substantially lower for omicron than for delta, with higher reductions for more severe endpoints and significant variation with age. Underlying the observed risks is a larger reduction in intrinsic severity (in unvaccinated individuals) counterbalanced by a reduction in vaccine effectiveness. Documented previous SARS-CoV-2 infection offered some protection against hospitalisation and high protection against death in unvaccinated individuals, but only offered additional protection in vaccinated individuals for the death endpoint. Full-Text PDF Open Access