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Background: COVID-19 related stay-at-home (SAH) orders created many economic and social stressors, possibly increasing the risk of drug/alcohol abuse in the community and trauma population. Objectives: Describe changes in alcohol/drug use in traumatically injured patients after SAH orders in California and evaluate demographic or injury pattern changes in alcohol or drug-positive patients. Methods: A retrospective analysis of 11 trauma centers in Southern California (1/1/2020-6/30/2020) was performed. Blood alcohol concentration, urine toxicology results, demographics, and injury characteristics were collected. Patients were grouped based on injury date – before SAH (PRE-SAH), immediately after SAH (POST-SAH), and a historical comparison (3/19/2019-6/30/2019) (CONTROL) – and compared in separate analyses. Groups were compared using chi-square tests for categorical variables and Mann-Whitney U tests for continuous variables. Results: 20,448 trauma patients (13,634 male, 6,814 female) were identified across three time-periods. The POST-SAH group had higher rates of any drug (26.2% vs. 21.6% and 24.7%, OR = 1.26 and 1.08, p <.001 and p =.035), amphetamine (10.4% vs. 7.5% and 9.3%, OR = 1.43 and 1.14, p <.001 and p =.023), tetrahydrocannabinol (THC) (13.8% vs. 11.0% and 11.4%, OR = 1.30 and 1.25, p <.001 and p <.001), and 3,4-methylenedioxy methamphetamine (MDMA) (0.8% vs. 0.4% and 0.2%, OR = 2.02 and 4.97, p =.003 and p <.001) positivity compared to PRE-SAH and CONTROL groups. Alcohol concentration and positivity were similar between groups (p >.05). Conclusion: This Southern California multicenter study demonstrated increased amphetamine, MDMA, and THC positivity in trauma patients after SAH, but no difference in alcohol positivity or blood concentration. Drug prevention strategies should continue to be adapted within and outside of hospitals during a pandemic. [ABSTRACT FROM AUTHOR]

Background To slow the spread of the COVID-19 virus, governments across the globe instituted stay-at-home orders leading to increased stress and social isolation. Not surprisingly, alcohol sales increased during this period. While most studies primarily focused on alcohol consumption among college students or adults, this study investigates alcohol misuse among marginalized youth in the USA. We examined risk factors associated with hazardous alcohol use and binge drinking including risk behaviors, life stressors and demographic characteristics. Methods In October 2020, youth living with or at high risk for acquiring human immunodeficiency virus (HIV), participating in community-based research to improve HIV prevention and care, were invited to complete an online survey to assess the impact of the stay-at-home orders on multiple aspects of their daily life. Results Respondents (n  = 478) were on average 23 years old; cisgender (84%), not-heterosexual (86.6%), Latino or Black/African American (73%) and assigned male at birth (83%); 52% reported being employed and 14% reported living with HIV. White participants and those who use drugs had higher odds of hazardous alcohol use and binge drinking, compared with other race categories and non-drug users, respectively. Conclusion Contrary to findings from adult studies, we did not observe an increase in hazardous or binge drinking among youth at risk for HIV. Hazardous alcohol use and binge drinking was more likely among White participants, those who use drugs and those who were hazardous/binge drinkers prior to the COVID-19 lockdown, which points to the importance of identifying and treating youth who misuse alcohol early to prevent future alcohol misuse. [ABSTRACT FROM AUTHOR]

Introduction: We investigated whether greater concentrations of on‐ and off‐sale alcohol outlets were associated with crime and whether this association was moderated by COVID‐19 shelter‐in‐place orders (SIP) that restricted on‐premises consumption of alcohol. Methods: Crimes (2019–2020) and addresses of licenced alcohol outlets in a medium‐sized California city were geocoded within census block groups (N = 61). On‐ and off‐sale alcohol outlet density was calculated as licenced outlets/2.59 km2 (1 square mile). Multilevel negative binomial regression analyses were conducted to examine associations between alcohol outlet density and crime, and possible moderating effects of SIP, controlling for block group demographic characteristics and density of other retail businesses. Results: On‐sale outlet density was positively associated with total crimes and Part 2 crimes, while off‐sale outlet density was inversely associated with total crime and Part 2 crimes. Overall, SIP was not significantly associated with crime, but moderated the associations of on‐sale density with total crime and Part 1 crimes such that reductions in crime during SIP were observed in higher density areas. The association of off‐sale outlets with crime was not moderated by SIP policies. Discussion and Conclusion: On‐sale outlet density, but not off‐sale density, appears to be associated with increased crime. The results further indicate that restrictions in hours and service imposed by SIP policies reduced crime in high on‐sale outlet density areas. These findings reinforce the importance of regulating alcohol outlet density and hours of service, especially for on‐sale outlets, as a crime reduction strategy. [ABSTRACT FROM AUTHOR]

The spread of COVID-19 in the Spring of 2020 prompted state and local governments to implement a variety of policies, including stay-at-home (SAH) orders and mandatory mask requirements, aimed at reducing the infection rate and the severity of the pandemic's impact. We implement a discrete choice experiment survey in three major U.S. States-California, Georgia, and Illinois-to empirically quantify individuals' willingness to stay (WTS) home, measured as the number of weeks of a potential new SAH order, to prevent the spread of the COVID-19 disease and explore factors leading to their heterogeneous WTS. Our results demonstrate broad support for statewide mask mandates. In addition, the estimate of WTS to lower new positive cases is quite large, approximately five and half weeks, even though staying home lowers utility. We also find that individuals recognize the trade-offs between case reduction and economic slowdown stemming from SAH orders when they decide to stay home or not. Finally, pandemic related factors such as age, ability to work from home, and unemployment status are the main drivers of the heterogeneity in individuals' WTS., Competing Interests: No authors have competing interests.

There is limited data regarding the rates and severity of child maltreatment in medical settings during the COVID-19 pandemic, and the reports are somewhat contradictory. To examine the rates of emergency department (ED) child maltreatment (CM) diagnosis before and after the California statewide stay-at-home order, as well as potential disparities by age, gender, race/ethnicity, and Medicaid status. A retrospective pre-post interrupted time series was conducted using data from the electronic health records of children (<18 years) with at least one emergency department visit between January 1, 2019 and September 30, 2021. Enactment of the stay-at-home order in California, March 2020 was used to determine a change in trend of rates of diagnosis of CM in the ED. Overall the study included 407,228 pediatric ED visits. There was a significant change in the percentage of CM visits immediately after the stay-at-home order, followed by small month to month decreases returning to near pre-stay-at-home order levels. This significant increase was driven by higher risk for children <4 years old. The increased rate of CM in the first month after the stay-at-home order was also elevated for female, Black, and Hispanic children. Our results indicated the rates of CM diagnoses in the ED doubled after the March 2020 stay-at-home order in California. Additionally, our findings suggest that some children may be at higher risk than others, which supports the importance of social safety nets for children in times of national emergency. [ABSTRACT FROM AUTHOR]

Background: Policies to restrict population mobility are a commonly used strategy to limit the transmission of contagious diseases. Among measures implemented during the COVID-19 pandemic were dynamic stay-at-home orders informed by real-time, regional-level data. California was the first state in the U.S. to implement this novel approach; however, the effectiveness of California's four-tier system on population mobility has not been quantified. Methods: Utilizing data from mobile devices and county-level demographic data, we evaluated the impact of policy changes on population mobility and explored whether demographic characteristics explained variability in responsiveness to policy changes. For each California county, we calculated the proportion of people staying home and the average number of daily trips taken per 100 persons, across different trip distances and compared this to pre-COVID-19 levels. Results: We found that overall mobility decreased when counties moved to a more restrictive tier and increased when moving to a less restrictive tier, as the policy intended. When placed in a more restrictive tier, the greatest decrease in mobility was observed for shorter and medium-range trips, while there was an unexpected increase in the longer trips. The mobility response varied by geographic region, as well as county-level median income, gross domestic product, economic, social, and educational contexts, the prevalence of farms, and recent election results. Conclusions: This analysis provides evidence of the effectiveness of the tier-based system in decreasing overall population mobility to ultimately reduce COVID-19 transmission. Results demonstrate that socio-political demographic indicators drive important variability in such patterns across counties. [ABSTRACT FROM AUTHOR]

Emergency department (ED) visits for conditions unrelated to the Coronavirus Disease 2019 (COVID-19) pandemic decreased during the early pandemic, raising concerns about critically ill patients forgoing care and increasing their risk of adverse outcomes. It is unclear if Hispanic and Black adults, who have a high prevalence of chronic conditions, sought medical assistance for acute emergencies during this time. This study used 2018–2020 ED visit data from the largest safety net hospital in Los Angeles County to estimate ED visit differences for cardiac emergencies, diabetic complications, and strokes, during the first societal lockdown among Black and Hispanic patients using time series analyses. Emergency department visits were lower than the expected levels during the first societal lockdown. However, after the lockdown ended, Black patients experienced a rebound in ED visits while visits for Hispanics remained depressed. Future research could identify barriers Hispanics experienced that contributed to prolonged ED avoidance. [ABSTRACT FROM AUTHOR]

Background: In 2020, the COVID‐19 pandemic and control measures changed alcohol consumption in the United States (US) and globally. Before the pandemic, alcohol‐impaired crashes contributed to approximately one‐third of all road traffic crash injuries and fatalities nationally. We examined the impact of the COVID‐19 pandemic on crashes and examined differences in alcohol‐involved crashes across various subgroups. Methods: The University of California Berkeley Transportation Injury Mapping Systems provided information on all crashes reported to the California Highway Patrol from January 1, 2016 through December 31, 2021. Using autoregressive integrated moving average (ARIMA) models applied to weekly time series data, we estimated the effect of California's first mandatory statewide shelter‐in‐place order (March 19, 2020) on crashes per 100,000 population. We also examined crash subgroups according to crash severity, sex, race/ethnicity, age, and alcohol involvement. Results: In California, the mean crash rate per week before the pandemic (January 1, 2016–March 18, 2020) was 9.5 crashes per 100,000 population, and 10.3% of those were alcohol‐involved. After the initiation of the COVID‐19 stay‐at‐home order, the percentage of crashes that were alcohol‐involved rose to 12.7%. Overall, the crash rate across California decreased significantly (−4.6 crashes per 100,000; 95% CI: −5.3, −3.9), including across all examined subgroups, with the greatest decrease among the least severe crashes. However, there was a 2.3% absolute increase in the proportion of crashes that were alcohol‐involved (0.02 crashes per 100,000; 95% CI: 0.02, 0.03). Conclusions: The initiation of a COVID‐19 stay‐at‐home ordinance in California was associated with a substantial decrease in overall crash rates. While crashes have returned to pre‐pandemic levels, alcohol‐involved crashes remain elevated. The initiation of the stay‐at‐home order significantly increased alcohol‐impaired driving, which has remained elevated. [ABSTRACT FROM AUTHOR]

INTRODUCTION American Indian (AI) people experience a disproportionate tobacco and marijuana burden which may have been exacerbated by the COVID-19 pandemic. Little is known about the tobacco and marijuana habits of American Indian individuals during the COVID-19 pandemic. The objective of this study is to examine tobacco and marijuana use as well as change in use during the COVID-19 pandemic among the American Indian community. METHODS This cross-sectional study analyzes survey data from a convenience sample of American Indian individuals residing in California and Oklahoma and included adults with and without cancer that resided in both rural and urban areas (n=1068). RESULTS During October 2020 -- January 2021, 36.0% of participants reported current use of tobacco products, 9.9% reported current use of marijuana products, and 23.7% reported increased use of tobacco and/or marijuana in the past 30 days, with no difference between those with cancer and those without cancer. Tobacco use was associated with marital status, age, employment status, COVID-19 exposure, COVID-19 beliefs, and alcohol consumption. Marijuana use was associated with COVID-19 beliefs, alcohol consumption, and income level. Increased tobacco and/or marijuana use was associated with baseline use of those products. Nearly a quarter of participants reported increased use of tobacco and/ or marijuana products during the COVID-19 pandemic. CONCLUSIONS We observed high rates of tobacco use during the COVID-19 pandemic, consistent with other studies. Research is needed to examine whether tobacco and marijuana use will decrease to pre-pandemic levels post-pandemic or if these behaviors will persist post-pandemic. Given these findings, there is a pressing need to increase access to evidence-based tobacco and marijuana treatment services in the AI population post COVID-19 pandemic. [ABSTRACT FROM AUTHOR]

Lower respiratory tract infections disproportionately affect children and are one of the main causes of hospital referral and admission. COVID‐19 stay‐at‐home orders in early 2020 led to substantial reductions in hospital admissions, but the specific contribution of changes in air quality through this natural experiment has not been examined. Capitalizing on the timing of the stay‐at‐home order, we quantified the specific contribution of fine‐scale changes in PM2.5 concentrations to reduced respiratory emergency department (ED) visits in the pediatric population of San Diego County, California. We analyzed data on pediatric ED visits (n = 72,333) at the ZIP‐code level for respiratory complaints obtained from the ED at Rady Children's Hospital in San Diego County (2015–2020) and ZIP‐code level PM2.5 from an ensemble model integrating multiple machine learning algorithms. We examined the decrease in respiratory visits in the pediatric population attributable to the stay‐at‐home order and quantified the contribution of changes in PM2.5 exposure using mediation analysis (inverse of odds ratio weighting). Pediatric respiratory ED visits dropped during the stay‐at‐home order (starting on 19 March 2020). Immediately after this period, PM2.5 concentrations, relative to the counterfactual values based in the 4‐year baseline period, also decreased with important spatial variability across ZIP codes in San Diego County. Overall, we found that decreases in PM2.5 attributed to the stay‐at‐home order contributed to explain 4% of the decrease in pediatric respiratory ED visits. We identified important spatial inequalities in the decreased incidence of pediatric respiratory illness and found that brief decline in air pollution levels contributed to a decrease in respiratory ED visits. Plain Language Summary: Children are commonly affected by respiratory tract infections, which can lead to hospitalization in some cases. During the COVID‐19 lockdown in early 2020, pediatric cases of respiratory illnesses decreased substantially. We examined the contribution in the lower levels of fine particle pollution observed in San Diego County, over the lockdown period, on the decreased number of visits to pediatric Emergency Department facilities. Key Points: We assessed changes in pediatric respiratory emergency department (ED) visits and PM2.5 in 2020 with respect to the preceding 4 yearsWe observed a sustained decline in pediatric respiratory ED visits, while decreases in PM2.5 concentrations were short‐livedWe estimated a 4% contribution of PM2.5 changes on the reduction in pediatric respiratory ED visits during the stay‐at‐home period [ABSTRACT FROM AUTHOR]

Few studies have researched young adults' experiences taking HIV pre-exposure prophylaxis (PrEP) after the start of California's COVID-19 shelter-in-place (SIP) orders. The purpose of this study was to examine the experiences of young adults with sex, dating, and PrEP use during SIP and their perceptions on how to improve PrEP care in this age group. In this mixed-methods study, PrEP users ages 18–29 living in California between April 2020 and June 2021 completed a quantitative survey (N = 37) and one-on-one qualitative interviews (N = 18). Over half of survey participants reported trouble accessing PrEP care during SIP, citing difficulty obtaining medication refills, clinic appointments, and access to completing lab work. In qualitative interviews, participants expressed their preferences for more accessible PrEP service delivery across the PrEP care continuum. Despite pandemic SIP orders and trouble accessing PrEP services, young adults continued to engage in sexual behaviors. [ABSTRACT FROM AUTHOR]

Emergency department (ED) visits for psychiatric care in the US reportedly declined during the COVID-19 pandemic. This work, however, does not control for strong temporal patterning in visits before the pandemic and does not examine a potential "rebound" in demand for psychiatric care following the relaxation of initial societal restrictions. Here, we examine COVID-19-related perturbations in psychiatric care during and after the 1st stage of societal restrictions in the largest safety-net hospital in Los Angeles. We retrieved psychiatric ED visit data (98,888 total over 156 weeks, Jan 2018 to Dec 2020) from Los Angeles County + USC Medical Center. We applied interrupted time series methods to identify and control for autocorrelation in psychiatric ED visits before examining their relation with the 1st stage of societal restrictions (i.e., March 13 to May 8, 2020), as well as the subsequent "rebound" period of relaxed restrictions (i.e., after May 8, 2020). Psychiatric ED visits fell by 78.13 per week (i.e., 12%) during the 1st stage of societal restrictions (SD = 23.99, p < 0.01). Reductions in ED visits for alcohol use, substance use, and (to a lesser extent) anxiety disorders accounted for the overall decline. After the 1st stage of societal restrictions, however, we observe no "rebound" above expected values in psychiatric ED visits overall (coef = − 16.89, SD = 20.58, p = 0.41) or by diagnostic subtype. This pattern of results does not support speculation that, at the population level, foregoing ED care during initial societal restrictions subsequently induced a psychiatric "pandemic" of urgent visits. [ABSTRACT FROM AUTHOR]

Research suggests that people's experiences of COVID-19 lockdowns have been detrimental to their lives and wellbeing. The current research compared the experiences and perceptions on health, wellbeing and social interaction of 300 UK adults and 450 adults in California. Individuals reported whether aspects of their life had changed for the better, worse, or not at all during lockdown in April 2020, and what the "best" and "worst" things about lockdown were. There were more similarities than differences in the regional comparison of perceptions of changes in specific aspects of 'health and wellbeing' and 'social interaction'. Both regions reported the same number and nature of best and worst things about lockdown. Overarching themes of 'health, self and wellbeing', 'being with others', and 'concerns with daily living' were identified. Although reports of life changes and the positives and negatives of lockdown were similar across different demographic groups, some differences were present by age, sex, relationship, and family-status. Incorporating knowledge of unified and positive experiences of lockdown can be useful in informing future lockdown restrictions and supporting the population when restrictions are lifted. [ABSTRACT FROM AUTHOR]

Background: The Stay at Home order in Colorado and The Stay Safe at Home order in California during COVID-19 pandemic have forced a majority of the endocrinologists/diabetologists to adapt to providing diabetes care remotely through telehealth. This may provide increased access to diabetes health care in certain settings. However, health care disparities continue to challenge availability of diabetes technologies for underprivileged communities. We report our experience with two patients providing diabetes care effectively and preventing hospital admissions by using telehealth. Methods: Two adult patients with type 1 diabetes (T1D): one new onset and the other one with established T1D are presented where telehealth facilitated by Clarity Software and the "Share" feature with the use of Dexcom G6 continuous glucose monitoring (CGM) for management of diabetic ketosis and hyperglycemia. Results: Both patients were managed effectively virtually despite higher risk of diabetic ketoacidosis (DKA). Shared glucose data through CGM facilitated frequent insulin dose adjustments, increased fluid and carbohydrate intake, and prevented hospital admissions in both cases. In the case of new onset patient with T1D, most of the education was done remotely by certified diabetes care and education specialists. Conclusion: Acute diabetes complication like DKA increases morbidity and mortality in addition to adding cost to the health care system. The current pandemic of COVID-19 has allowed newer ways (with the help of newer technologies) to manage high-risk patients with T1D and DKA through telehealth and may result in lasting benefits to people with T1D. [ABSTRACT FROM AUTHOR]

Objectives: Limited data are available on how the closure of pediatric dental clinics because of the COVID-19 pandemic affected hospital pediatric emergency department (ED) visits in the United States. We evaluated changes in dental-related visits at a pediatric ED and associated urgent care centers (UCCs) after the shutdown of a large pediatric dental clinic because of the COVID-19 pandemic. Methods: We conducted a single-center retrospective medical record review of 811 patients aged 0 to 17 years who presented to a pediatric ED or associated UCC at Rady Children's Hospital–San Diego for dental-related concerns from March 19, 2019, through January 17, 2021. Patients were classified into 3 periods: before shutdown, during shutdown, and after shutdown. We collected data on demographic characteristics; International Classification of Diseases, Tenth Revision codes; dental diagnosis; treatment; and COVID-19 test results. We compared the frequency and proportion of patients seen for dental-related concerns, dental diagnosis, and treatment during the 3 periods. Results: The proportion of dental-related concerns in the ED doubled during the shutdown (0.7%) and was 1.5 times higher after the shutdown (0.6%) compared with before the shutdown (0.4%; P <.001). Significantly more patients were seen in EDs than in UCCs during and after the shutdown than before the shutdown (P =.005). During and after the shutdown, admission to the hospital for antibiotic treatment increased significantly to 6.5% and 7.9%, respectively, compared with before the shutdown (2.8%; P =.022), and nonaerosolized procedures and ED/UCC discharge increased to 13.4% and 9.3%, respectively, compared with before the shutdown (6.2%; P =.015). Conclusions: Mitigating future closures of dental offices is important given the shifted burden of dental care to the ED. [ABSTRACT FROM AUTHOR]

This study aimed to examine the depression and anxiety among men of color (primarily African American and Latinx) who have sex with men after the lockdown due to the COVID-19 pandemic. Outcomes included 21-item Beck Depression Inventory (BDI), 7-item Generalized Anxiety Disorder (GAD), and a 10-item COVID-related anxiety measure using a modified H1N1-related anxiety question. Independent variables were food insecurity and belief in government efficiency. Data were analyzed by Regression models with random cluster effects. Food insecurity experiences were significantly associated with higher depression (p < 0.001), higher anxiety (p < 0.001), and higher pandemic-related anxiety (p < 0.001). Higher levels of belief in government efficiency were significantly associated with lower depression (p < 0.05), less anxiety (p < 0.05), and less pandemic-related anxiety (p-value < 0.001). These findings emphasize the importance of establishing trust between government and at-risk communities when issuing public health policies, especially during unforeseen circumstances, as well as to ensure basic human rights, such as food security. [ABSTRACT FROM AUTHOR]

During the COVID-19 pandemic, reports to child abuse and neglect hotlines have dropped significantly across the United States. Yet, during this same period, calls to domestic violence hotlines have increased. The purpose of this study was to examine if there have been measurable changes in domestic violence-related reports to child abuse and neglect hotlines. Using administrative child protection records from California, we plotted counts and proportions of child maltreatment reports with and without domestic violence allegations before and through the onset of school closures associated with the COVID-19 pandemic. We used an interrupted time series analysis to evaluate whether or not there was a change in domestic violence allegations in child protection reports corresponding to the COVID-19 pandemic. We document that during the first two quarters of 2020 there was a 14.3% drop in the overall number of child protection reports. Despite a decline in maltreatment reporting overall, there was a 25% increase in the proportion of reports with allegations of domestic violence. Our findings suggest both the count and composition of reports to child protection agencies were affected by the COVID-19 pandemic. The current analyses also showcase the seasonality of CPS reports generally, and reports with DV allegations, specifically. [ABSTRACT FROM AUTHOR]

On 19 March 2020, California put in place Stay‐At‐Home orders to reduce the spread of SARS‐CoV‐2. As a result, decreases up to 50% in traffic occurred across the South Coast Air Basin (SoCAB). We report that, compared to the 19 March to 30 June period of the last 5 years, the 2020 concentrations of PM2.5 and NOx showed an overall reduction across the basin. O3 concentrations decreased in the western part of the basin and generally increased in the downwind areas. The NOx decline in 2020 (approximately 27% basin‐wide) is in addition to ongoing declines over the last two decades (on average 4% less than the −6.8% per year afternoon NO2 concentration decrease) and provides insight into how air quality may respond over the next few years of continued vehicular reductions. The modest changes in O3 suggests additional mitigation will be necessary to comply with air quality standards. Plain Language Summary: On 19 March 2020, California put in place Stay‐At‐Home orders to reduce the spread of SARS‐CoV‐2. As a result, there was much less traffic in Southern California. Reduced traffic along with a month‐long stretch of unusually rainy weather at the beginning of the lockdown led to significant reductions in PM2.5 and NOx levels across the basin. Concentrations of O3, on the other hand, showed inconsistent changes across the basin. The response of O3 to these large changes in nitrogen oxide concentrations suggests mitigation efforts beyond those associated with continuing vehicle emission reductions will be important to meet clean air goals. Key Points: SoCAB maximum 1‐hr NOx and 24‐hr PM2.5 concentrations decreased 27% and 29%, respectively, between 19 March and 30 June of 2015–2019 and 2020The 8‐hr daily maximum O3 showed inconsistent changes across the basin during the COVID‐19 associated decrease of atmospheric NOx concentrationsDuring a shift to a NOx‐limited regime, a better understanding of VOC emission sources is needed to improve air quality in the SoCAB [ABSTRACT FROM AUTHOR]

Caregivers of persons with dementia (PWDs) were socially isolated with little support during the COVID-19 pandemic "Stay-At-Home" order in the United States. To enhance social and emotional connection for diverse caregivers, a culturally/linguistically appropriate telephone intervention provided compassionate listening, mindful breathing, and COVID-19 safety education. The study purpose was to understand caregiving challenges and to evaluate the intervention for caregivers during the early pandemic using a qualitative approach. Twenty-three caregivers participated in the intervention provided by bilingual research assistants for 3 months. Call logs were used to describe the caregivers' dialogue. Thematic analysis identified (a) the challenges, including fear of coronavirus disease, providing around-the-clock care, and forced isolation and negative emotions; and (b) caregivers' experience with the intervention, including connecting with the outside, relief from emotional stress, reliable COVID-19 information, and reinformed caregiving skills. Results suggest that the telephone support was of benefit to diverse caregivers of PWDs during the pandemic by promoting social connection and reducing emotional distress. [ABSTRACT FROM AUTHOR]

Background: Little is known regarding utilization of school‐based health centers (SBHCs) during prolonged school closures, such as those that occurred during the COVID‐19 pandemic. We sought to compare SBHC utilization before and after pandemic‐related school closures across a network of SBHCs affiliated with a large Southern Californian urban school district. Methods: We conducted a secondary analysis of encounter data extracted from electronic health records from 12 SBHCs that remained open despite school closures, including patient demographics and diagnostic and billing codes. We used the Clinical Classifications Software Refined to group encounters for common primary care conditions. Utilization before and during pandemic‐related school closures was compared using logistic regression with cluster‐robust standard errors to account for clustering within clinics, after adjusting for month of encounter. Results: During the pandemic, study SBHCs conducted 52,530 encounters and maintained ∼4040 encounters/month. The frequency of encounters for annual preventative health exams increased for school‐aged patients but decreased for other age groups while the frequency of encounters for mental health problems increased for all age groups. Implications for School Health Policy, Practice, and Equity: Despite pandemic‐related school closures, SBHCs appeared play a critical role in providing primary care to vulnerable communities. Conclusions: SBHCs may hold value beyond their co‐location with academic instruction. [ABSTRACT FROM AUTHOR]

An editorial is presented which addresses California Health Interview Survey data collection during the COVID-19 global pandemic, and it mentions adaptations to changes and public health surveillance in California. Telephone interviewing and postal mail outs of surveys are examined, along with web surveys and changes involving a questionnaire.

A shelter‐in‐place order (SIPO) is one of the most restrictive non‐pharmaceutical interventions designed to curb the spread of COVID‐19. On March 19, 2020, California Governor Gavin Newsom issued the first statewide SIPO in the United States. The order closed non‐essential businesses and required residents to shelter in place for all but essential activities such as grocery shopping, retrieving prescriptions from a pharmacy, or caring for relatives. This study is the first in the economics literature to estimate the effect of a statewide SIPO on public health. Using daily state‐level coronavirus data and a synthetic control research design, we find that California's statewide SIPO reduced COVID‐19 cases by 160.9 to 194.7 per 100,000 population by April 20, one month following the order. We further find that California's SIPO led to as many as 1,566 fewer COVID‐19 deaths during this period. Back‐of‐the‐envelope calculations suggest that there were about 649 to 703 job losses per life saved, and about 14 to16 job losses per case averted during this post‐treatment period. [ABSTRACT FROM AUTHOR]

Public institutions are facing natural and manmade hazards of increasing frequency and severity. While the costs of disasters can be greatly reduced when individuals prepare, successfully encouraging preparation is difficult for governments, given the low salience of such risks. We examine whether the increased salience of other types of risks can influence individual willingness to prepare for natural and manmade hazards, and whether message impact varies with recipients' levels of trust in their source. We capitalize upon a rare policy experiment—the staged rollout of COVID-19 lockdowns in California—to assess if increases in the salience of the pandemic were associated with greater willingness to store water for earthquake-induced system outages. We find that experiences of a disaster in a different domain (public health) and higher levels of trust in message source both increase willingness to store water. This suggests that public agencies should encourage preparedness during actual emergencies, or "not let a crisis go to waste." [ABSTRACT FROM AUTHOR]

Background After coronavirus disease 2019 (COVID-19) shelter-in-place (SIP) orders, viral suppression (VS) rates initially decreased within a safety-net human immunodeficiency virus (HIV) clinic in San Francisco, particularly among people living with HIV (PLWH) who are experiencing homelessness. We sought to determine if proactive outreach to provide social services, scaling up of in-person visits, and expansion of housing programs could reverse this decline. Methods We assessed VS 24 months before and 13 months after SIP using mixed-effects logistic regression followed by interrupted time series (ITS) analysis to examine changes in the rate of VS per month. Loss to follow-up (LTFU) was assessed via active clinic tracing. Results Data from 1816 patients were included; the median age was 51 years, 12% were female, and 14% were experiencing unstable housing/homelessness. The adjusted odds of VS increased 1.34 fold following institution of the multicomponent strategies (95% confidence interval [CI], 1.21–1.46). In the ITS analysis, the odds of VS continuously increased 1.05 fold per month over the post-intervention period (95% CI, 1.01–1.08). Among PLWH who previously experienced homelessness and successfully received housing support, the odds of VS were 1.94-fold higher (95% CI, 1.05–3.59). The 1-year LTFU rate was 2.8 per 100 person-years (95% CI, 2.2–3.5). Conclusions The VS rate increased following institution of the multicomponent strategies, with a lower LFTU rate compared with prior years. Maintaining in-person care for underserved patients, with flexible telemedicine options, along with provision of social services and permanent expansion of housing programs, will be needed to support VS among underserved populations during the COVID-19 pandemic. [ABSTRACT FROM AUTHOR]

Since 2012, eighteen states and the District of Columbia have legalized recreational cannabis. Past research suggests this policy change is associated with increased cannabis exposures however this has not yet been studied in California, despite its status as the world's largest legal cannabis market. This observational, retrospective study analyzed trends in cannabis exposures reported to the California Poison Control System (CPCS) from 2010 to 2020. We assessed shifts in exposures before and after the legalization of recreational cannabis in November 2016, the establishment of recreational retail sales in January 2018, and the institution of a statewide shelter-in-place order due to the COVID-19 pandemic in March 2020 using interrupted time-series analysis and reviewed all records to identify specific products associated with exposures. Between 2010 and 2020 edible exposures increased from near zero to 79% of exposures in 2020. Cannabis exposures significantly increased following recreational legalization in 2016 (by an estimated 2.07 exposures per month [CI: 0.60, 3.55]; p < 0.01) and initiation of retail sales in 2018 (0.85 [CI: 0.12, 1.58]; p < 0.05). There was no significant change in cannabis exposures following the first shelter-in-place order of the COVID-19 pandemic (1.59 [CI: −1.61, 3.68]; p = 0.43). Cannabis exposures for those thirteen and under increased significantly both after recreational legalization (1.04 [CI: 0.38, 1.70]) and after the opening of the retail sales market (0.73 [CI: 0.34, 1.12]), but not following the shelter-in-place order (1.59 [CI: −1.61, 3.68]), nor was there a significant change for those older than thirteen. Our findings suggest that cannabis legalization is linked to increased exposures, particularly for products such as gummies and candy edibles among children under the age of thirteen. Clinicians should be aware of these risks and communicate them to patients, and policymakers should consider stronger regulations on packaging to reduce these exposures. Question: How have cannabis exposures changed following legalization of recreational use, the opening of the recreational retail sales market, and the institution of shelter-in-place orders during the COVID-19 pandemic? Findings: In this retrospective review of 10,757 cases reported to the California Poison Control System (CPCS) between 2010 and 2020, exposures increased significantly after the legalization of recreational cannabis use and the opening of the recreational retail sales market, particularly among children, who primarily consumed candies and gummies. Meaning: Stronger regulation of cannabis edibles that mimic other products is warranted to decrease exposures among children. [ABSTRACT FROM AUTHOR]

COVID-19 led to a massive shutdown of businesses in the second quarter of 2020. Estimates from the Current Population Survey, for example, indicate that the number of active business owners dropped by 22% from February to April 2020. We provide the first analysis of losses in sales among the universe of businesses in California using administrative data from the California Department of Tax and Fee Administration. Losses in taxable sales average 17% in the second quarter of 2020 relative to the second quarter of 2019 even though year-over-year sales typically grow by 3-4%. We find that sales losses were largest in businesses affected by mandatory lockdowns such as accommodations, which lost 91%, whereas online sales grew by 180%. Placing business types into different categories based on whether they were considered essential or nonessential (and thus subject to early lockdowns) and whether they have a moderate or high level of person-to-person contact, we find interesting correlations between sales losses and COVID-19 cases per capita across counties in California. The results suggest that local implementation and enforcement of lockdown restrictions as safety measures for public health and voluntary behavioral responses as reactions to the perceived local COVID-19 spread both played a role. Plain English Summary: Business sales dropped by 17% on average due to the pandemic during the second quarter of 2020 in California. Accommodations lost 91% of sales, whereas online sales grew by 180%. Sales fell more steeply in counties with more COVID-19 cases. We examine how much businesses lost in sales using administrative sales tax data. The average losses of 17% in the second quarter of 2020 relative to the second quarter of 2019 occurred even though year-over-year sales typically grow by 3-4%. We find that sales losses were largest in businesses affected by mandatory lockdowns such as accommodations, drinking places, and arts, entertainment, and recreation. Distinguishing between essential and nonessential businesses, which were subject to early lockdowns, and by the level of person-to-person contact, we find that local implementation and enforcement of lockdown restrictions for public health safety and voluntary responses to the perceived local COVID-19 spread both played a role. The results suggest that small businesses may need more support from governments and consumers to mitigate the strong shift to online vendors, and that the pandemic must be brought under control as a prerequisite to a full recovery. [ABSTRACT FROM AUTHOR]

This study aimed to determine the prevalence of and associations between anxiety, social isolation, and loneliness in a sample of older adults in Northern California during the stay-at-home order enacted during the COVID-19 pandemic. 514 older adults completed a 24-item survey. Perceived isolation and loneliness were reported in 56.4% and 36.0% of participants, respectively. Loneliness was found to be associated with both social isolation and COVID-19-related anxiety; however, social isolation and coronavirus-related anxiety were unrelated. Healthcare providers, social service providers, and families are encouraged to maintain or increase contact with older adults during the COVID-19 pandemic. [ABSTRACT FROM AUTHOR]

Increasing hospitalizations for COVID-19 in the United States and elsewhere have ignited debate over whether to reinstate shelter-in-place policies adopted early in the pandemic to slow the spread of infection. The debate includes claims that sheltering in place influences deaths unrelated to infection or other natural causes. Testing this claim should improve the benefit/cost accounting that informs choice on reimposing sheltering in place. We used time-series methods to compare weekly nonnatural deaths in California with those in Florida. California was the first state to begin, and among the last to end, sheltering in place, while sheltering began later and ended earlier in Florida. During weeks when California had shelter-in-place orders in effect, but Florida did not, the odds that a nonnatural death occurred in California rather than Florida were 14.4% below expected levels. Sheltering-in-place policies likely reduce mortality from mechanisms unrelated to infection or other natural causes of death. [ABSTRACT FROM AUTHOR]

Key Points: Question: Are emergency department encounters among youth with suicidal thoughts or behaviors higher during the COVID-19 pandemic? Findings: In this cross-sectional study, the incidence rates of suicide-related emergency department encounters among youth in 2020 were comparable with 2019 incidence rates except for a decrease in March to May 2020 vs the same period in 2019 and an increase among girls in June through December 2020 vs the same period in 2019. Youth with no previously documented mental health treatment had more visits in September to December 2020 compared with this period in 2019. Meaning: The COVID-19 pandemic may worsen mental health for some groups of youth; emergency department–based interventions may support this population. This cross-sectional study characterizes population-level and relative change in suicide-related emergency department encounters among youth during the COVID-19 pandemic compared with 2019. Importance: Population-level reports of suicide-related emergency department (ED) encounters among youth during the COVID-19 pandemic are lacking, along with youth characteristics and preexisting psychiatric service use. Objective: To characterize population-level and relative change in suicide-related ED encounters among youth during the COVID-19 pandemic compared with 2019. Design, Setting, and Participants: This cross-sectional study evaluated ED encounters in 2019 and 2020 at Kaiser Permanente Northern California—a large, integrated, community-based health system. Youth aged 5 to 17 years who presented to the ED with suicidal thoughts or behaviors were included. Exposure: The COVID-19 pandemic. Main Outcomes and Measures: Population-level incidence rate ratios (IRRs) and percent relative effects for suicide-related ED encounters as defined by the US Centers for Disease Control and Prevention–recommended International Statistical Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes in 4 periods in 2020 compared with the same periods in 2019. Results: There were 2123 youth with suicide-related ED encounters in 2020 compared with 2339 in 2019. In the 2020 group, 1483 individuals (69.9%) were female and 1798 (84.7%) were aged 13 to 17 years. In the 2019 group, 1542 (65.9%) were female, and 1998 (85.4%) were aged 13 to 17 years. Suicide-related ED encounter incidence rates were significantly lower in March through May 2020 compared with this period in 2019 (IRR, 0.57; 95% CI, 0.51-0.63; P <.001), then returned to prepandemic levels. However, suicide-related ED visits among female youth from June 1 to August 31, 2020, and September 1 through December 15, 2020, were significantly higher than in the corresponding months in 2019 (IRR, 1.19; 95% CI, 1.04-1.35; P =.04 and IRR, 1.22; 95% CI, 1.11-1.35; P <.001, respectively), while suicide-related ED visits for male youth decreased from September 1 through December 15, 2020 (IRR, 0.81; 95% CI, 0.69 to 0.94). Youth with no history of outpatient mental health or suicide encounters (129.4%; 95% CI, 41.0-217.8) and those with comorbid psychiatric conditions documented at the ED encounter (6.7%; 95% CI, 1.0-12.3) had a higher risk of presenting with suicide-related problems from September to December 2020 vs the same period in 2019. Conclusions and Relevance: In this cross-sectional study of youth experiencing suicidal thoughts and behaviors, suicide-related presentations to the ED initially decreased during the COVID-19 pandemic, likely owing to shelter-in-place orders, then were similar to 2019 levels. However, a greater number of female youth, youth with no psychiatric history, and youth with psychiatric diagnoses at the time of the ED encounter presented for suicide-related concerns during the pandemic, suggesting these may be vulnerable groups in need of further interventions. Adjustments in care may be warranted to accommodate these groups during periods of crisis. [ABSTRACT FROM AUTHOR]

Whether being treated for COVID-19 related complications or otherwise, patients, families, and healthcare providers are all enduring various impacts of the COVID-19 pandemic. The inpatient Palliative Care Service at the University of California, Los Angeles, has observed prevailing themes of isolation, rapid decision making, and multifaceted distress during the COVID-19 pandemic. This paper discusses lessons learned and provides resources to mitigate these additional complexities to care being provided. [ABSTRACT FROM AUTHOR]

To measure disparities in coronavirus disease 2019 (COVID-19) hospitalization and intensive care unit (ICU) transfer among racially/ethnically marginalized groups before and after implementation of the California statewide shelter-in-place (SIP) policy, we conducted a retrospective cohort study within a health-care system in California. COVID-19 patients diagnosed from January 1, 2020, to August 31, 2020, were identified from electronic health records. We examined hospitalizations and ICU transfers by race/ethnicity and pandemic period using logistic regression. Among 16,520 people with COVID-19 (mean age = 46.6 (standard deviation, 18.4) years; 54.2% women), during the post-SIP period, patients were on average younger and a larger proportion were Hispanic. In adjusted models, odds of hospitalization were 20% lower post-SIP as compared with the SIP period, yet all non-White groups had higher odds (odds ratios = 1.6–2.1) than non-Hispanic White individuals, regardless of period. Among hospitalized patients, odds of ICU transfer were 33% lower post-SIP than during SIP. Hispanic and Asian patients had higher odds than non-Hispanics. Disparities in hospitalization persisted and ICU risk became more pronounced for Asian and Hispanic patients post-SIP. Policy-makers should consider ways to proactively address racial/ethnic inequities in risk when considering future population-level policy interventions for public health crises. [ABSTRACT FROM AUTHOR]

Background: Initial reports of significantly worse outcomes for cancer patients with COVID-19 led to guidelines for triaging surgical cancer treatment. We sought to evaluate the effects of the COVID-19 pandemic on oncologic surgical specialty referrals.Methods: We compared referrals to oncologic surgical specialty clinics at an academic tertiary care institution following implementation of stay-at-home orders in California (3/19/20-7/31/20, "COVID") to the same time period the year prior (3/19/19-7/31/19, "Pre-COVID"). The number of appointments, consulted surgical services, insurance types, acuity of diagnoses, and times from referral to first appointment (TRFA) were assessed.Results: The overall number of patients seen in matched time periods decreased by 21.6% from 900 (pre-COVID) to 705 (COVID). Proportions of patients with malignant and suspicious diagnoses, surgical and thoracic oncology visits, and Medicaid insurance differed from comparison groups during the COVID period (P < .05). Overall median (interquartile range) TRFA decreased from 14 (20) to 12 (19) days (P = .001) during COVID.Conclusion: After implementation of stay-at-home orders, higher acuity and vulnerable patients were appropriately seen in oncologic surgical specialty clinics. While the long-term effects of decreased clinic visits during COVID remain uncertain, further examination of scheduling practices that led to shorter referral times may identify methods to improve timeliness of care and surgical oncologic outcomes in non-pandemic settings. [ABSTRACT FROM AUTHOR]

We survey college students during California's stay-at-home order to test whether compliance with social distancing requirements depends on primary preferences and characteristics that affect their marginal benefit from doing so. We find a quarter of students violated the order. Yet, neither risk preference, altruism, nor preexisting health conditions were predictive of compliance. Our findings raise doubt about the efficiency of minimally enforced social distancing policies, as well as commonly assumed motivations for compliance. Our results also imply that those with preexisting health conditions may not voluntarily comply, resulting in higher health care congestion than otherwise expected. [ABSTRACT FROM AUTHOR]

The COVID-19 pandemic has overwhelmed health systems around the globe, and intensified the lethality of social and political inequality. In the United States, where public health departments have been severely defunded, Black, Native, Latinx communities and those experiencing poverty in the country's largest cities are disproportionately infected and disproportionately dying. Based on our collective ethnographic work in three global cities in the U.S. (San Francisco, Los Angeles, and Detroit), we identify how the political geography of racialisation potentiated the COVID-19 crisis, exacerbating the social and economic toll of the pandemic for non-white communities, and undercut the public health response. Our analysis is specific to the current COVID19 crisis in the U.S, however the lessons from these cases are important for understanding and responding to the corrosive political processes that have entrenched inequality in pandemics around the world. [ABSTRACT FROM AUTHOR]

Background There is an urgent need to understand the dynamics and risk factors driving ongoing severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission during shelter-in-place mandates. Methods We offered SARS-CoV-2 reverse-transcription polymerase chain reaction (PCR) and antibody (Abbott ARCHITECT IgG) testing, regardless of symptoms, to all residents (aged ≥4 years) and workers in a San Francisco census tract (population: 5174) at outdoor, community-mobilized events over 4 days. We estimated SARS-CoV-2 point prevalence (PCR positive) and cumulative incidence (antibody or PCR positive) in the census tract and evaluated risk factors for recent (PCR positive/antibody negative) vs prior infection (antibody positive/PCR negative). SARS-CoV-2 genome recovery and phylogenetics were used to measure viral strain diversity, establish viral lineages present, and estimate number of introductions. Results We tested 3953 persons (40% Latinx; 41% White; 9% Asian/Pacific Islander; and 2% Black). Overall, 2.1% (83/3871) tested PCR positive: 95% were Latinx and 52% were asymptomatic when tested; 1.7% of census tract residents and 6.0% of workers (non–census tract residents) were PCR positive. Among 2598 tract residents, estimated point prevalence of PCR positives was 2.3% (95% confidence interval [CI], 1.2%–3.8%): 3.9% (95% CI, 2.0%–6.4%) among Latinx persons vs 0.2% (95% CI,.0–.4%) among non-Latinx persons. Estimated cumulative incidence among residents was 6.1% (95% CI, 4.0%–8.6%). Prior infections were 67% Latinx, 16% White, and 17% other ethnicities. Among recent infections, 96% were Latinx. Risk factors for recent infection were Latinx ethnicity, inability to shelter in place and maintain income, frontline service work, unemployment, and household income <$50 000/year. Five SARS-CoV-2 phylogenetic lineages were detected. Conclusions SARS-CoV-2 infections from diverse lineages continued circulating among low-income, Latinx persons unable to work from home and maintain income during San Francisco's shelter-in-place ordinance. [ABSTRACT FROM AUTHOR]

Background: As the coronavirus pandemic public health emergency begins to ebb in the United States, policymakers and providers need to evaluate how the addiction treatment system functioned during the public health emergency and draw lessons for future emergencies. One important question is whether the pandemic curtailed the use of addiction treatment and the extent to which telehealth was able to mitigate access barriers. Methods: To begin to answer this question, we conducted a survey of specialty addiction treatment providers in California from June 2020 through July 2020. The survey focused specifically on provider organizations that served Medicaid beneficiaries. Results: Of the 133 respondents, 50% reported a decrease in patients since the stay-at-home order in March 2020, with the largest decline among new patients, and 58% said more patients were relapsing. Eighty-one percent of providers said that telemedicine use had increased since the stay-at-home order. Most said that telemedicine had moderately (48%) or completely (30%) addressed access barriers. Conclusion: More efforts are needed to ensure that patients, and in particular new patients, receive addiction treatment during public health emergencies. [ABSTRACT FROM AUTHOR]

Although the COVID-19 pandemic has disrupted elective shoulder arthroplasty throughput, traumatic shoulder arthroplasty procedures are less apt to be postponed. We sought to evaluate shoulder arthroplasty utilization for fracture during the COVID-19 pandemic and California's associated shelter-in-place order compared to historical controls. We conducted a cohort study with historical controls, identifying patients who underwent shoulder arthroplasty for proximal humerus fracture in California using our integrated electronic health record. The time period of interest was following the implementation of the statewide shelter-in-place order: March 19, 2020-May 31, 2020. This was compared to three historical periods: January 1, 2020-March 18, 2020, March 18, 2019-May 31, 2019, and January 1, 2019-March 18, 2019. Procedure volume, patient characteristics, in-hospital length of stay, and 30-day events (emergency department visit, readmission, infection, pneumonia, and death) were reported. Changes over time were analyzed using linear regression adjusted for usual seasonal and yearly changes and age, sex, comorbidities, and postadmission factors. Surgical volume dropped from an average of 4.4, 5.2, and 2.6 surgeries per week in the historical time periods, respectively, to 2.4 surgeries per week after shelter-in-place. While no more than 30% of all shoulder arthroplasty procedures performed during any given week were for fracture during the historical time periods, arthroplasties performed for fracture was the overwhelming primary indication immediately after the shelter-in-place order. More patients were discharged the day of surgery (+33.2%, P =.019) after the shelter-in-place order, but we did not observe a change in any of the corresponding 30-day events. The volume of shoulder arthroplasty for fracture dropped during the time of COVID-19. The reduction in volume could be due to less shoulder trauma due to shelter-in-place or a change in the indications for arthroplasty given the perceived higher risks associated with intubation and surgical care. We noted more patients undergoing shoulder arthroplasty for fracture were safely discharged on the day of surgery, suggesting this may be a safe practice that can be adopted moving forward. Level III; Retrospective Case-control Comparative Study [ABSTRACT FROM AUTHOR]

Approximately 1.2 million people are living with HIV in the United States, with 16,000 in San Francisco. Many HIV-positive individuals have difficulty maintaining follow-up clinic visits under normal circumstances, and this is complicated by the coronavirus disease 2019 (COVID-19) pandemic as many institutions transition to a telehealth-focused model of care to maintain patient and provider safety. However, it was unknown how telehealth would impact patient attendance and perceptions about their care, particularly in populations at high risk of appointment nonattendance. To quantify the impact of telehealth on retention in care for a vulnerable HIV-infected population and to identify patient perspectives of telehealth and its effect on appointment attendance, we studied patients at the University of California, San Francisco (UCSF) 360 Wellness Center, an HIV primary care clinic in urban San Francisco, California. Anonymous surveys were conducted to assess patient perceptions of telehealth, and 21% of patients sent surveys responded. Appointment attendance rates for all visits were analyzed before and after the shelter-in-place order in San Francisco on March 16, 2020. With the transition to telehealth, the overall nonattendance rate decreased by ∼3%. Most common perceived strengths of telehealth included convenience and safety, whereas disadvantages included technical barriers and unfamiliarity. Despite barriers and disadvantages listed by patients, a majority are willing to attend telehealth visits, as 80.5% of respondents reported being equally or more likely to attend telehealth visits. This is a critical finding during the COVID-19 pandemic and beyond; we believe that telehealth can improve appointment attendance for vulnerable populations who often face barriers to receiving health care. [ABSTRACT FROM AUTHOR]

Introduction: In March 2020, shelter-in-place orders were enacted to attenuate the spread of coronavirus 2019 (COVID-19). Emergency departments (EDs) experienced unexpected and dramatic decreases in patient volume, raising concerns about exacerbating health disparities. Methods: We queried our electronic health record to describe the overall change in visits to a two-ED healthcare system in Northern California from March--June 2020 compared to 2019. We compared weekly absolute numbers and proportional change in visits focusing on race/ethnicity, insurance, household income, and acuity. We calculated the z-score to identify whether there was a statistically significant difference in proportions between 2020 and 2019. Results: Overall ED volume declined 28% during the study period. The nadir of volume was 52% of 2019 levels and occurred five weeks after a shelter-in-place order was enacted. Patient demographics also shifted. By week 4 (April 5), the proportion of Hispanic patients decreased by 3.3 percentage points (pp) (P = 0.0053) compared to a 6.2 pp increase in White patients (P = 0.000005). The proportion of patients with commercial insurance increased by 11.6 pp, while Medicaid visits decreased by 9.5 pp (P < 0.00001) at the initiation of shelter-in-place orders. For patients from neighborhoods <300% federal poverty levels (FPL), visits were --3.8 pp (P = 0.000046) of baseline compared to +2.9 pp (P = 0.0044) for patients from ZIP codes at >400% FPL the week of the shelterin- place order. Overall, 2020 evidenced a consistently elevated proportion of high-acuity Emergency Severity Index (ESI) level 1 patients compared to 2019. Increased acuity was also demonstrated by an increase in the admission rate, with a 10.8 pp increase from 2019. Although there was an increased proportion of high-acuity patients, the overall census was decreased. Conclusion: Our results demonstrate changing ED utilization patterns circa the shelter-in-place orders. Those from historically vulnerable populations such as Hispanics, those from lower socioeconomic areas, and Medicaid users presented at disproportionately lower rates and numbers than other groups. As the pandemic continues, hospitals should use operations data to monitor utilization patterns by demographic, in addition to clinical indicators. Messaging about availability of emergency care and other services should include vulnerable populations to avoid exacerbating healthcare disparities. [ABSTRACT FROM AUTHOR]

Introduction: Hospitals and emergency departments (EDs) faced profound uncertainty during the COVID-19 pandemic. Early concerns regarding demand far exceeding capacity were balanced by anecdotal reports of decreased patient visits, including those for specific high-acuity conditions. This study sought to identify changes in ED volume and acuity, within a specific managed care environment, associated with the onset of the pandemic. Methods: Data from patient visits to 2 San Diego, California, EDs--within an integrated health-care system--were extracted from the electronic health record. Daily patient visits, hospital admissions from the ED, Emergency Severity Index scores, and mode of arrival were compared between two 28-day periods, with the 28 days following a "stay at home" order issued by the governor of California and a control period of the same dates in 2019. Results: These EDs observed a significant decrease in daily visits (42% compared to the previous year) associated with the pandemic. An increased rate of hospital admissions (16.6%-21.6%) was suggestive of an overall increase in acuity; however, changes in the distribution of Emergency Severity Index scores were less pronounced. The overall number of admissions declined significantly. Although overall ambulance traffic decreased, the proportion of patients arriving by ambulance was unchanged. Conclusion: Patient volume in 2 EDs dropped significantly in association with a statewide response to the COVID-19 pandemic. There was also a shift in acuity as measured by the proportion of patients admitted to the hospital, but overall admissions declined, suggesting sicker patients also did not seek care. [ABSTRACT FROM AUTHOR]

Introduction: Shelter-in-place orders altered facilitators and barriers to tobacco use (e.g., outlet closures, restricted social gatherings). This study examined whether the duration of time in shelter in place and compliance with different shelter-in-place orders influenced adolescent cigarette and E-cigarette use and how the use may differ by demographic characteristics.Methods: Shelter-in-place policy data obtained from government websites were merged with cross-sectional 2020 survey data on adolescents in California. Treatment variables included the proportion of time in shelter in place and self-reported compliance with shelter-in-place orders (for essential businesses and retail spaces and social and outdoor contexts). Multilevel logit models for dichotomous past 6-month cigarette and E-cigarette use and multilevel negative binomial regression models for past 6-month frequency of use were used. Moderation analyses were conducted on demographic measures. The sample included 1,196 adolescents (mean age=15.8 years, age range=13-19 years, 49.2% female, 50.0% White). Analyses were conducted in 2022.Results: No associations were found between the proportion of time in shelter in place and outcomes. Shelter-in-place compliance with essential business and retail space orders was associated with lower odds of using cigarettes and E-cigarettes in the past 6 months. Compliance with social and outdoor context-related orders were associated with lower odds of using E-cigarettes and fewer days using cigarettes and E-cigarettes. Being aged ≥18 years moderated the associations between essential business/retail space and social/outdoor context-related shelter-in-place compliance orders and past 6-month frequency of cigarette smoking.Conclusions: Findings support tailored interventions for less compliant and older adolescents for future pandemic mitigation measures. [ABSTRACT FROM AUTHOR]

Background Limited systematic surveillance for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in the early months of the US epidemic curtailed accurate appraisal of transmission intensity. Our objective was to perform case detection of an entire rural community to quantify SARS-CoV-2 transmission using polymerase chain reaction (PCR) and antibody testing. Methods We conducted a cross-sectional survey of SARS-CoV-2 infection in the rural town of Bolinas, California (population 1620), 4 weeks after shelter-in-place orders. Participants were tested between April 20 and 24, 2020. Prevalence by PCR and seroprevalence from 2 forms of antibody testing were performed in parallel (Abbott ARCHITECT immunoglobulin [Ig]G and in-house IgG enzyme-linked immunosorbent assay). Results Of 1891 participants, 1312 were confirmed Bolinas residents (>80% community ascertainment). Zero participants were PCR positive. Assuming 80% sensitivity, it would have been unlikely to observe these results (P  < .05) if there were >3 active infections in the community. Based on antibody results, estimated prevalence of prior infection was 0.16% (95% credible interval [CrI], 0.02%–0.46%). The positive predictive value (PPV) of a positive result on both tests was 99.11% (95% CrI, 95.75%–99.94%), compared with PPV 44.19%–63.32% (95% CrI, 3.25%–98.64%) if 1 test was utilized. Conclusions Four weeks after shelter-in-place, SARS-CoV-2 infection in a rural Northern California community was extremely rare. In this low-prevalence setting, use of 2 antibody tests increased seroprevalence estimate precision. This was one of the first community-wide studies to successfully implement synchronous PCR and antibody testing, particularly in a rural setting. Widespread testing remains an underpinning of effective disease control in conjunction with consistent uptake of public health measures. [ABSTRACT FROM AUTHOR]

Background: By the end of March 2020, more than a fifth of the world's population was in various degrees of "lockdown" in order to slow the spread of COVID-19. This enforced confinement led some to liken lockdown to imprisonment. We directly compared individual's experiences of lockdown with prisoners' experiences of imprisonment in order to determine whether psychological parallels can be drawn between these two forms of confinement. Methods: Online surveys of adults in lockdown in the UK (N = 300) and California (N = 450) were conducted 4 and 5 weeks into lockdown in each region, respectively. The UK data was then compared to Souza and Dhami's (2010) sample of 267 medium security prisoners in England, and the Californian data was compared to Dhami et al.'s (2007) sample of 307 medium security Federal prisoners in California. We measured the effects of Group (Lockdown v. Prison) on five categories of dependent variables (i.e., activity, social contact, thoughts, feelings, and rule-breaking), controlling for demographic differences between the groups. Results: In both regions, people in lockdown thought significantly less often about missing their freedom, as well as missing their family and friends living elsewhere than did first-time prisoners. However, people in lockdown in both regions were also significantly less engaged in a range of daily activities than were first-time prisoners. Additionally, in both regions, people in lockdown reported feeling more hopeless than first-time prisoners. Conclusion: Although Governments introducing lockdown policies do not intend to punish their citizens as courts do when sending convicted offenders to prison, such policies can have unintended adverse consequences. Psychological parallels can be drawn between the two forms of confinement. [ABSTRACT FROM AUTHOR]

More than six months after the Shelter-in-Place executive order in the San Francisco Bay Area, this paper analyzes how an essential public works construction project put a COVID-19 safety protocol in place. It describes a four-step protocol, details challenges and successes of implementation, and provides insight for construction as well as other industries, including healthcare. [ABSTRACT FROM AUTHOR]

To contain the spread of the novel coronavirus (COVID-19), local and state governments in the U.S. have imposed restrictions on daily life, resulting in dramatic changes to how and where people interact, travel, socialize, and work. Using a social practice perspective, we explore how California's Shelter-in-Place (SIP) order impacted household energy activities. To do so, we conducted an online survey of California residents (n = 804) during active SIP restrictions (May 5–18, 2020). We asked respondents about changes to home occupancy patterns and household energy activities (e.g., cooking, electronics usage) due to SIP restrictions, as well as perspectives toward smart energy technologies. Households reported increased midday (10am–3pm) occupancy during SIP, and this increase is related to respondent and household characteristics, such as education and the presence of minors in the home. Examining change in the frequency of household activities during SIP, presence of minors and increased midday occupancy proved important. Finally, we considered relationships to intention to purchase smart home technologies, with the presence of minors and increased activity frequency relating to greater intention to purchase. These findings demonstrate how household activities and occupancy changed under COVID restrictions, how these changes may be related to energy use in the home, and how such COVID-related changes could be shaping perspectives toward smart home technology, potentially providing insight into future impacts on household practices and electricity demand. • We surveyed California residents during COVID-19 Shelter-in-Place restrictions. • Home occupancy in the middle of the day increased. • Frequency of home activities using energy increased. • Increases in home energy activities related to presence of minors. • Intention to adopt smart technology related to increases in home energy activities. [ABSTRACT FROM AUTHOR]