US Trends in COVID-19-Associated Hospitalization and Mortality Rates Before and After Reopening Economies

Effectiveness of social distancing measures and lockdowns for reducing transmission of COVID-19 in non-healthcare, community-based settings

Social distancing measures (SDMs) are community-level interventions that aim to reduce person-to-person contacts in the community. SDMs were a major part of the responses first to contain, then to mitigate, the spread of SARS-CoV-2 in the community. Common SDMs included limiting the size of gatherings, closing schools and/or workplaces, implementing work-from-home arrangements, or more stringent restrictions such as lockdowns. This systematic review summarized the evidence for the effectiveness of nine SDMs. Almost all of the studies included were observational in nature, which meant that there were intrinsic risks of bias that could have been avoided were conditions randomly assigned to study participants. There were no instances where only one form of SDM had been in place in a particular setting during the study period, making it challenging to estimate the separate effect of each intervention. The more stringent SDMs such as stay-at-home orders, restrictions on mass gatherings and closures were estimated to be most effective at reducing SARS-CoV-2 transmission. Most studies included in this review suggested that combinations of SDMs successfully slowed or even stopped SARS-CoV-2 transmission in the community. However, individual effects and optimal combinations of interventions, as well as the optimal timing for particular measures, require further investigation. This article is part of the theme issue 'The effectiveness of non-pharmaceutical interventions on the COVID-19 pandemic: the evidence'.

COVID-19 Hospitalization Trends in Rural Versus Urban Areas in the United States

Since the summer of 2020, the rate of coronavirus cases in the United States has been higher in rural areas than in urban areas, raising concerns that patients with coronavirus disease 2019 (COVID-19) will overwhelm under-resourced rural hospitals. Using data from the University of Minnesota COVID-19 Hospitalization Tracking Project and the U.S. Department of Health and Human Services, we document disparities in COVID-19 hospitalization rates between rural and urban areas. We show that rural-urban differences in COVID-19 admission rates were minimal in the summer of 2020 but began to diverge in fall 2020. Rural areas had statistically higher hospitalization rates from September 2020 through early 2021, after which rural-urban admission rates re-converged. The insights in this article are relevant to policymakers as they consider the adequacy of hospital resources across rural and urban areas during the COVID-19 pandemic.

Lifting Statewide Mask Mandates and COVID-19 Cases: A Synthetic Control Study

IMPORTANCE

As states reopened their economies state and local officials made decisions on policies and restrictions that had an impact on the evolution of the pandemic and the health of the citizens. Some states made the decision to lift mask mandates starting spring 2021. Data-driven methods help evaluate the appropriateness and consequences of such decisions.

OBJECTIVE

To investigate the association of lifting the mask mandate with changes in the cumulative coronavirus case rate.

DESIGN

Synthetic control study design on lifting mask mandate in the state of Iowa implemented on February 7, 2021.

SETTING

Daily state-level data from the COVID-19 Community Profile Report published by the US Department of Health & Human Services, COVIDcast dataset of the Delphi Research Group, and Google Community Mobility Reports.

EXPOSURES AND OUTCOME

Mask mandate policy lift at the state level. State-day observations of the cumulative case rate measured as the cumulative number of new cases per 100,000 people in the previous 7 days.

RESULTS

The cumulative case rate in Iowa increased by 20%-30% within 3 weeks of lifting the mask mandate as compared with a synthetic control unit. This association appeared to be related to people, in fact, reducing their mask-wearing habits.

CONCLUSIONS

Lifting the mask mandate in Iowa was associated with an increase in new COVID-19 cases. Caution should be applied when making this type of policy decision before having achieved a more stable control of the pandemic.

Impact of mandatory COVID-19 shelter-in-place order on controlled substance use among rural versus urban communities in the United States

PURPOSE

Mandatory COVID-19 shelter-in-place (SIP) orders have been imposed to fight the pandemic. They may also have led to unintended consequences of increased use of controlled substances especially among rural communities due to increased social isolation. Using the data from the American Association of Poison Control Centers, this study tests the hypothesis that the poison control centers received higher rates of calls related to exposures to controlled substances from rural counties than they did from urban counties during the SIP period.

METHODS

Call counts received by the poison control centers between October 19, 2019 and July 6, 2020 due to exposure to controlled substance (methamphetamine, opioids, cocaine, benzodiazepines, and other narcotics) were aggregated to per-county-per-month-per-10,000 population exposure rates. A falsification test was conducted to reduce the possibility of spurious correlations.

FINDINGS

During the study period, 2,649 counties in the United States had mandatory SIP orders. The rate of calls reporting exposure to any of the aforementioned controlled substances among the rural counties was higher (14%; P = .047) relative to the urban counties. This overall increase was due to increases in the rates of calls reporting exposure to opioids (26%; P = .017) and methamphetamine (39%; P = .077). Moreover, the rate of calls reporting exposures at home was also higher among the rural counties (14%; P = .069).

CONCLUSION

The mandatory SIP orders may have had an unintended consequence of exacerbating the use of controlled substances at home in rural communities relative to urban communities.

The SARS-CoV-2 Pandemic in High Income Countries Such as Canada: A Better Way Forward Without Lockdowns

The SARS-CoV-2 pandemic has caused tragic morbidity and mortality. In attempt to reduce this morbidity and mortality, most countries implemented population-wide lockdowns. Here we show that the lockdowns were based on several flawed assumptions, including "no one is protected until everyone is protected," "lockdowns are highly effective to reduce transmission," "lockdowns have a favorable cost-benefit balance," and "lockdowns are the only effective option." Focusing on the latter, we discuss that Emergency Management principles provide a better way forward to manage the public emergency of the pandemic. Specifically, there are three priorities including the following: first, protect those most at risk by separating them from the threat (mitigation); second, ensure critical infrastructure is ready for people who get sick (preparation and response); and third, shift the response from fear to confidence (recovery). We argue that, based on Emergency Management principles, the age-dependent risk from SARS-CoV-2, the minimal (at best) efficacy of lockdowns, and the terrible cost-benefit trade-offs of lockdowns, we need to reset the pandemic response. We can manage risk and save more lives from both COVID-19 and lockdowns, thus achieving far better outcomes in both the short- and long-term.