Organ transplants fell by a third worldwide during first wave of Covid-19 pandemic, new study shows

The number of solid organ transplants performed during the first wave of Covid-19 in 2020 plunged by 31% compared to the previous year

Peer-Reviewed Publication

EMOTIVE

(Milan, Tuesday 31 August, 2021) The number of solid organ transplants performed during the first wave of Covid-19 in 2020 plunged by 31% compared to the previous year, according to a new global study presented today at the European Society for Organ Transplantation (ESOT) Congress 20211.

According to modelling calculations, the slowdown in transplants resulted in more than 48,000 years of patient life loss.

The research leveraged international data from 22 countries across four continents and revealed major variations in the response of transplant programmes to the Covid-19 pandemic, with transplant activity dropping by more than 90 per cent in some countries.

Kidney transplantation showed the largest reduction across nearly all countries during 2020 compared to 2019, with the study finding a decrease in living donor kidney (-40 per cent) and liver (-33 per cent) transplants. For deceased donor transplants, there was a reduction in kidney (-12 per cent), liver (-9 per cent), lung (-17 per cent) and heart (-5 per cent) transplants.

The research, published today in the Lancet Public Health, highlighted how some countries managed to sustain the rate of transplant procedures whilst others experienced serious reductions in the number of transplants compared to the previous year and, in some areas, living donor kidney and liver transplantation ceased completely. Overall, there was a strong temporal association between increased Covid-19 infection rate and reductions in deceased and living solid organ transplants.

Dr Olivier Aubert, Assistant Professor at the Paris Translational Research Centre for Organ Transplantation and lead author of the study, commented, “The first wave of Covid-19 had a devastating impact on the number of transplants across many countries, affecting patient waiting lists and regrettably leading to a substantial loss of life.” 

Professor Alexandre Loupy, head of the Paris Translational Research Center for Organ Transplantation and last author of the study, furthered, “Living donor transplantation, which reduced more substantially, requires significant resources and planning compared to deceased donor transplantation. This is extremely difficult during a pandemic when resources are stretched and staff redeployed. There are also major ethical concerns for the wellbeing and safety of the donor.”

“It’s clear that there are many indirect deaths associated with Covid-19 and our study confirms that the pandemic has far-reaching consequences on many medical specialties.” added Prof. Loupy.

The estimated numbers of life-years lost were 37,664 years for patients waitlisted for a kidney, 7,370 for a liver, 1,799 years for a lung, and 1,406 for a heart, corresponding to a total 48,239 life-years lost.

Dr Aubert added, “Beyond the near universal reduction in transplant activity, certain countries and regions managed to carry-out procedures despite major challenges presented by the pandemic. These findings warrant further analysis on a regional, national and global level to understand why reductions did or did not occur.”

“Understanding how different countries and healthcare systems responded to Covid-19-related challenges can facilitate improved pandemic preparedness and how to safely maintain transplant programmes to provide life-saving procedures for patients.”

To facilitate understanding of the temporal trends and consequences of the pandemic on worldwide, national, and regional solid organ transplant activities for researchers, clinicians, and public health authorities, the authors created an open-access dashboard that presents data interactively for solid organ transplant activities and COVID-19 cases.

 

Change in the overall observed solid organ transplant counts between 2020 from the date of the first 100 reported cumulative COVID-19 cases until the end of follow-up (latest date of available data through December 31st 2020) and the same period of time in 2019, by country and organ
Nation	Overall	Kidney	Liver	Lung	Heart
Argentina, N. (%)*	-564 (-60·91%)	-429 (-64·32%)	-107 (-56·61%)	-8 (-47·06%)	-20 (-37·74%)
Austria, N. (%)	-56 (-10·22%)	-53 (-17·91%)	6 (5·08%)	0 (0%)	-9 (-16·36%)
Belgium, N. (%)	-166 (-22·46%)	-78 (-22·67%)	-49 (-20·68%)	-16 (-17·39%)	-23 (-34·85%)
Brazil, N. (%)	-2174 (-28·9%)	-1735 (-32·89%)	-307 (-16·51%)	-50 (-56·82%)	-82 (-27·42%)
Canada, N. (%)	-227 (-9·86%)	-229 (-16·29%)	5 (1·09%)	4 (1·47%)	-7 (-4·24%)
Chile, N. (%)*	-47 (-54·02%)	-23 (-46·94%)	-10 (-45·45%)	-6 (-85·71%)	-8 (-88·89%)
Croatia, N. (%)	-85 (-37·28%)	-35 (-36·84%)	-34 (-33·01%)	0 (NaN%)	-16 (-53·33%)
Finland, N. (%)	-48 (-13·68%)	-38 (-15·38%)	5 (9·26%)	-5 (-20·83%)	-10 (-38·46%)
France, N. (%)	-1410 (-28·96%)	-1041 (-34·28%)	-219 (-19·04%)	-101 (-31·27%)	-49 (-13·65%)
Germany, N. (%)	-328 (-10·53%)	-236 (-13·15%)	-46 (-6·5%)	-36 (-11·32%)	-10 (-3·4%)
Greece, N. (%)*	-11 (-12·22%)	-6 (-8·7%)	-2 (-14·29%)	1 (Inf%)†	-4 (-57·14%)
Hungary, N. (%)	-132 (-37·29%)	-79 (-37·26%)	-27 (-39·71%)	0 (0%)	-26 (-43·33%)
Italy, N. (%)	-525 (-16·18%)	-296 (-16·17%)	-162 (-15·25%)	-40 (-30·08%)	-27 (-12·27%)
Japan, N. (%)	-1413 (-66·71%)	-1112 (-69·63%)	-257 (-67·45%)	-18 (-26·47%)	-26 (-36·11%)
Netherlands, N. (%)	-187 (-17·64%)	-166 (-21·15%)	-7 (-4·46%)	-19 (-21·35%)	5 (17·24%)
Norway, N. (%)	-24 (-7·12%)	-6 (-2·99%)	3 (4·11%)	-6 (-22·22%)	-15 (-41·67%)
Portugal, N. (%)	-156 (-24·19%)	-67 (-19·76%)	-75 (-33·63%)	-10 (-15·62%)	-4 (-21·05%)
Slovenia, N. (%)	7 (8·43%)	7 (21·21%)	-2 (-9·52%)	6 (66·67%)	-4 (-20%)
Spain, N. (%)	-1033 (-24·02%)	-745 (-26·89%)	-176 (-18·6%)	-88 (-26·19%)	-24 (-9·68%)
Switzerland, N. (%)	-6 (-1·34%)	-7 (-2·69%)	-15 (-11·63%)	6 (20%)	10 (34·48%)
United Kingdom, N. (%)	-1298 (-31·31%)	-1076 (-35·54%)	-147 (-17·95%)	-69 (-47·92%)	-6 (-3·87%)
United States, N. (%)	-1370 (-4·13%)	-1110 (-5·44%)	-91 (-1·23%)	-237 (-10·18%)	68 (2·25%)
Overall, N. (%)	-11253 (-15·92%)	-8560 (-19·14%)	-1714 (-10·57%)	-692 (-15·51%)	-287 (-5·44%)

 

*Argentina, Chile, and Greece follow-up ended earlier than other countries due to data availability. Argentina ends on 2020-08-18, Chile end on 2020-05-27, and Greece ends on 2020-07-28. The remaining countries include through December 31st 2020. †There were no lung transplants in Greece in 2019.

 

ENDS

Notes to Editors:

A reference to the ESOT Congress 2021 must be included when communicating the information within this press release.

Please note that the open-access dashboard providing data for solid organ transplant activities and COVID-19 cases will go live during the Congress. To access the dashboard, please visit: www.covidtransplants.org

For further information, to access the full paper or to request an expert interview, please contact Luke Paskins or Sean Deans at press@esot.org or call +44 (0) 208 154 6396.

About the Expert:

Dr Olivier Aubert is an assistant professor and nephrologist at the Necker Hospital, Paris, France. He also has a PhD in biostatistics from the Paris Translational Research Centre for Organ Transplantation.

Prof. Alexandre Loupy is a professor and nephrologist at the Necker Hospital, Paris, France. He is also the head of the Paris Translational Research Centre for Organ Transplantation.

About ESOT:

The European Society for Organ Transplantation (ESOT) was founded over 30 years ago and is dedicated to the pursuit of excellence in organ transplantation. Facilitating a wealth of international clinical trials and research collaborations over the years, ESOT remains committed to its primary aim of improving patient outcomes in transplantation. With a community of over 8,000 affiliates from around the world, ESOT is an influential international organisation and the facilitator of the biennial congress which hosts approximately 3,500 experts who come to meet to explore and discuss the latest scientific research. For more information visit: https://esot.org/

About the ESOT Congress 2021:

The ESOT Congress 2021, taking place in-person and on-line and in Milan, Italy, features the latest research and innovation from the most prominent scientists and physicians in the field of organ transplantation. For more information visit:          https://www.esotcongress.org/

References:

1. COVID-19 Pandemic Consequences On Worldwide Organ Transplantation: a population-based study. Presented at the ESOT Congress 2021.

 

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JOURNAL

The Lancet

DOI

10.1016/S2468-2667 

METHOD OF RESEARCH

Observational study

ARTICLE TITLE

COVID-19 pandemic and worldwide organ transplantation: a population-based study

ARTICLE PUBLICATION DATE

29-Aug-2021

Disclaimer: AAAS and EurekAlert! ar

Fighting vaccine hesitancy: Family physicians tap into digital communication tools to better inform patients

Grant and Award Announcement

UNIVERSITY OF OTTAWA

 

IMAGE: UNIVERSITY OF OTTAWA COLOR LOGO view more 

CREDIT: UNIVERSITY OF OTTAWA

Family physicians across the country are harnessing the power of digital communication to tackle vaccine hesitancy, relying on text and email to share evidence-based resources regarding COVID-19 vaccines with patients who are hesitating or facing barriers to vaccination.

Physicians from the University of Ottawa’s Department of Family Medicine and the Institut du Savoir at the Montfort Hospital have partnered with the Eastern Ontario Health Unit to support family physician’s bid to bolster COVID-19 vaccine uptake. The Public Health Agency of Canada is funding this $450,000 project, which will involve 300 family physicians and nurse practitioners.

The goal of the pan-Canadian randomized controlled trial is to identify segments of the patient population with common reasons for vaccine hesitancy or lack of access, by age, language, education level, rurality, gender, and ethnicity. Primary care providers can then provide these groups with appropriately tailored digital information by e-mail and text message. 

“We want to help family physicians or primary care practitioners to learn about patients’ perspectives and survey if they are vaccinated or not. And, if not, why?” says Dr. Sharon Johnston, Associate Professor in the Faculty of Medicine and an Investigator at the Institut du Savoir Montfort and Bruyère Research Institute.

“By understanding the concerns and barriers faced by this subgroup, we can amass data that can guide us on communicating more effectively. We will be able to identify groups of patients who share similar reasons for being unvaccinated and common features, and we can create short messages to share reliable and relevant resources on COVID-19 vaccines to help them with their decision-making,” adds Dr. Johnston.

Family practitioners will use the Canadian Primary Care Information Network (CPIN), an automated patient engagement system for primary care practices, to rapidly inform patients about new procedures for clinic visits, availability of vaccines from COVID-19 to flu, or patient education materials for managing conditions like back pain. CPIN also offers a reliable and confidential system to collect anonymous feedback on patients’ experiences by including a link to a short survey at the end of each message.

“This tool will help primary care communicate better with patients in an effective way, reaching their patients more easily,” Johnston says. “By learning what patients prefer – such as a virtual visit or an in-person one, or what factors led to their hesitancy to be vaccinated – we can try to develop a tool that will lessen the workload, share good information and help our patients to make well informed decisions when it comes to their health.”

Primary care practitioners often see patients from within a 100-kilometre radius, making this innovative research project a means of delivering information to patients from a physician who may not be familiar with their home area and the services available to them.

Representation of Women and Underrepresented Groups in US Academic Medicine by Specialty

Research Letter 

Health Policy

August 30, 2021

Alexander Yoo, MD¹; Benjamin P. George, MD, MPH¹; Peggy Auinger, MS¹; et alEmma Strawderman²; David A. Paul, MD³

Author Affiliations Article Information

JAMA Netw Open. 2021;4(8):e2123512. doi:10.1001/jamanetworkopen.2021.23512

Introduction

Diversity in the physician workforce has always been and remains a critical issue. Prior studies demonstrate the number of women and members of underrepresented groups in medicine (URM), such as American Indian or Alaskan Native, Black, Latino or Hispanic, and Native Hawaiian or other Pacific Islander individuals, are increasing throughout academic medicine.^1,2 However, little is known in the current literature regarding variation and trends in demographics of academic faculty across medical specialties or the retention of residents identifying as women or URM as academic faculty. This study adds to the literature by examining 30-year demographic trends across academic medicine departments and providing novel comparisons of the proportion of individuals identifying as women or URM between academic faculty and specialty-matched residents.

Methods

This cross-sectional study was deemed exempt from review and informed consent by the University of Rochester institutional review board because it was deemed non–human participant research. This study is reported following the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.

We evaluated the distribution of women and URM among US medical school faculty for 16 clinical academic medicine departments using the Association of American Medical Colleges Faculty Roster from 1990 through 2019. Race/ethnicity of faculty was self-identified. Linear mixed-effects models were used to estimate the mean change per year (ie, linear slope) in percentages of women and percentages of URM, which included department, time, and a department-by-time interaction term with an autoregressive correlation structure for repeated measures (eAppendix in the Supplement). Bonferroni correction for multiple comparisons was used; statistical significance defined as 2-sided P < .003.

Demographics, including race and ethnicity, of US resident physicians from 2012 to 2013 were obtained from the Accreditation Council of Graduate Medical Education. Representation ratios³ were calculated by dividing the proportion of women or URM faculty in 2019 by the proportion of women or URM residents in the 2012 to 2013 academic year (allowing for a 6-year time lag). This metric denotes the representativeness of women or URM faculty compared to the corresponding trainee pipeline (eAppendix in the Supplement).

Analyses were performed using SAS version 94 (SAS Institute), and representation ratios were calculated using R version 4.04 (R Project for Statistical Computing). Data were analyzed in December 2019.

Results

From 1990 to 2019, there were a total of 3 146 342 faculty entries, including 1 089 892 women (34.6%) and 2 252 134 faculty entries for White physicians (71.9%). Proportions of women faculty increased, with women comprising more than 50% of faculty members in 5 of 16 clinical academic departments by 2019 (Table). Proportions of URM faculty also increased for 8 of 16 specialties (Table).

In 2019, specialties with high proportions of women faculty did not necessarily have high representativeness compared with residents. Obstetrics and gynecology, which has the highest proportion of women faculty, demonstrated the third lowest representation ratio (0.81). In contrast, despite having the lowest overall proportion of women faculty, orthopedic surgery had the highest representation ratio (1.48) (Figure, A). In respect to URM, most specialties had representation ratios less than 1.0 (overall representation ratio, 0.76) (Figure, B-D).

Discussion

This cross-sectional study found increases in the proportions of women faculty across clinical academic departments over the past 3 decades. Racial and ethnic diversity among faculty also increased, although at a lower rate. Increasing faculty diversity can be partially attributed to comparably modest improvements in diversity among medical students and residents.⁴ However, URM faculty are underrepresented compared with the resident pipelines for most specialties. Nearly all departments captured only a fraction of the available URM resident pipeline, and there were differences in representation ratios across departments for women. Further investigation is needed to understand factors that may dissuade or obstruct women and URM trainees from pursuing academic careers. Previous studies, such as a 2013 study by Peek et al,⁵ have found that medical schools with URM role models and available, experienced mentors (URM and non-URM) were more likely to have high proportions of URM students. Studies are needed to determine modifiable differences and how to implement change to optimize faculty demographics.

This study has some limitations. The interpretation of the representation ratio in this study is limited by the inability to control for trainee preferences for academics and does not account for personal and structural factors that may influence career choice. Other limitations include the use of nationally aggregated deidentified data, which prohibits control of confounding factors, including regional demographics and status of Historically Black Colleges and Universities. Further study of individualized faculty and institutional-level data are needed.

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Article Information

Accepted for Publication: June 28, 2021.

Published: August 30, 2021. doi:10.1001/jamanetworkopen.2021.23512

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Yoo A et al. JAMA Network Open.

Corresponding Author: Alexander Yoo, MD, Department of Neurology, University of Rochester Medical Center, 601 Elmwood Ave, Box 673, Rochester, NY 14642 (alexander_yoo@urmc.rochester.edu).

Author Contributions: Dr Yoo had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Yoo, George, Paul.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Yoo, George.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Auinger, Paul.

Administrative, technical, or material support: Yoo, George.

Supervision: George.

Conflict of Interest Disclosures: None reported.

References

1.

Yehia  BR, Cronholm  PF, Wilson  N,  et al.  Mentorship and pursuit of academic medicine careers: a mixed methods study of residents from diverse backgrounds.   BMC Med Educ. 2014;14:26. doi:10.1186/1472-6920-14-26PubMedGoogle ScholarCrossref

2.

Ogunwole  SM, Dill  M, Jones  K, Golden  SH.  Trends in internal medicine faculty by sex and race/ethnicity, 1980-2018.   JAMA Netw Open. 2020;3(9):e2015205. doi:10.1001/jamanetworkopen.2020.15205
ArticlePubMedGoogle Scholar

3.

Hofler  LG, Hacker  MR, Dodge  LE, Schutzberg  R, Ricciotti  HA.  Comparison of women in department leadership in obstetrics and gynecology with those in other specialties.   Obstet Gynecol. 2016;127(3):442-447. doi:10.1097/AOG.0000000000001290PubMedGoogle ScholarCrossref

4.

Lett  LA, Murdock  HM, Orji  WU, Aysola  J, Sebro  R.  Trends in racial/ethnic representation among US medical students.   JAMA Netw Open. 2019;2(9):e1910490. doi:10.1001/jamanetworkopen.2019.10490
ArticlePubMedGoogle Scholar

5.

Peek  ME, Kim  KE, Johnson  JK, Vela  MB.  “URM candidates are encouraged to apply”: a national study to identify effective strategies to enhance racial and ethnic faculty diversity in academic departments of medicine.   Acad Med. 2013;88(3):405-412. doi:10.1097/ACM.0b013e318280d9f9PubMedGoogle ScholarCrossref

THIRD WORLD USA

750,000 households face eviction by January with possible 'severe' public health consequences, Goldman says

jzeballos@businessinsider.com (Joseph Zeballos-Roig)

 The Maricopa County constable signs an eviction order on

 October 7, 2020 in Phoenix, Arizona. 

John Moore/Getty Images

Goldman Sachs projects 750,000 households face eviction by January with potentially "severe" COVID-19 consequences.

The Supreme Court struck down the federal eviction moratorium last week.

Democrats and the White House are prioritizing fixes to an emergency rent relief program.

Goldman Sachs projects that landlords could evict 750,000 households by the end of 2021 after the Supreme Court's recent decision to strike down a federal eviction ban. They also warned there could be "severe" public health consequences from the coming wave of evictions."

The Goldman analysts estimated 3.5 million households are struggling to catch up on rent, the group said in a note released Sunday. Collectively, those households owe landlords around $17 billion in unpaid rent, Goldman projected.

Goldman wrote that while the coming evictions may dent household consumption and job growth, the public health consequences are probably more "severe" and it may increase virus infections. COVID-19 cases from the Delta variant have surged nationwide, along with hospitalizations in many parts of the US.

Up until July 31, renters who hadn't made monthly payments were shielded from eviction due to a moratorium imposed by the Centers for Disease Control and Prevention. That went in tandem with an emergency rental assistance program designed to provide renters with federal aid so they can stay in their homes.

But the money has been slow to get to beleaguered renters in most states and cities due to bureaucratic snags and onerous documentation requirements, among other problems. It helped spark a last-minute Democratic push to extend the moratorium so renters could have more time to receive federal relief, but it collapsed because of resistance from moderates.

Faced with withering pressure from progressives, the Biden administration enacted a limited moratorium in counties struggling with high infection rates earlier this month. But the Supreme Court struck that down on Thursday evening in a 6-3 ruling.

Video: Federal ban on evictions expires as renters face rising covid cases (The Washington Post)

Conservative justices banded together and ruled that the public health agency had overstepped its authority, which could pave the way for additional federal overreach.

In the wake of the ruling shutting down the federal eviction ban, only seven states and the District of Columbia have eviction moratoriums. Housing experts warn a looming wave of evictions could hit low-income Black Americans the hardest.

"Evictions will occur where unemployment rates are highest-that is, where poor and mostly black service industry workers live," Paul Williams, a fellow at the Jain Family Institute, wrote Monday on Twitter. He added most homeless shelters are already at capacity.

On Friday, the White House appeared to concede Democrats couldn't muster the votes in Congress to renew a federal eviction ban. Instead, it was prioritizing ironing out the problems in the rental relief program.

"If there were enough votes to pass an eviction moratorium in Congress, it would have happened," White House Press Secretary Jen Psaki said at a daily news briefing. "It hasn't happened."

Reps. Alexandria Ocasio Cortez of New York and Cori Bush of Missouri joined 61 House Democrats in calling for Democratic leaders to assist in extending the moratorium.

"The impending eviction crisis is a matter of public health and safety that demands an urgent legislative solution to prevent further harm and needless loss of human life," the letter said.

Read the original article on Business Insider

Original Investigation 

Public Health

August 30, 2021

Eviction Moratoria Expiration and COVID-19 Infection Risk Across 

Strata of Health and Socioeconomic Status in the United States

Sebastian Sandoval-Olascoaga, MSc^1,2; Atheendar S. Venkataramani, MD, PhD^3,4; Mariana C. Arcaya, ScD, MCP¹

Author Affiliations Article Information

JAMA Netw Open. 2021;4(8):e2129041. doi:10.1001/jamanetworkopen.2021.29041

Key Points

Question  Is lifting a state-level eviction moratorium associated with the risk of individuals in that state being diagnosed with COVID-19?

Findings  In this cohort study of 509 694 individuals living in the United States, a difference-in-differences survival analysis found that residents in states that lifted eviction moratoria had an increased risk of receiving a COVID-19 diagnosis 12 weeks after the moratorium was lifted relative to residents in states where moratoria remained in place. These associations increased over time, particularly among individuals with more comorbidities and lower socioeconomic status.

Meaning  These findings suggest that eviction-led housing insecurity may have exacerbated the COVID-19 pandemic.

Abstract

Importance  Housing insecurity induced by evictions may increase the risk of contracting COVID-19.

Objective  To estimate the association of lifting state-level eviction moratoria, which increased housing insecurity during the COVID-19 pandemic, with the risk of being diagnosed with COVID-19.

Design, Setting, and Participants  This retrospective cohort study included individuals with commercial insurance or Medicare Advantage who lived in a state that issued an eviction moratorium and were diagnosed with COVID-19 as well as a control group comprising an equal number of randomly selected individuals in these states who were not diagnosed with COVID-19. Data were collected from OptumLabs Data Warehouse, a database of deidentified administrative claims. The study used a difference-in-differences analysis among states that implemented an eviction moratorium between March 13, 2020, and September 4, 2020.

Exposures  Time since state-level eviction moratoria were lifted.

Main Outcomes and Measures  The primary outcome measure was a binary variable indicating whether an individual was diagnosed with COVID-19 for the first time in a given week with International Statistical Classification of Diseases and Related Health Problems, Tenth Revision code U07.1. The study analyzed changes in COVID-19 diagnosis before vs after a state lifted its moratorium compared with changes in states that did not lift it. For sensitivity analyses, models were reestimated on a 2% random sample of all individuals in the claims database during this period in these states.

Results  The cohort consisted of 509 694 individuals (254 847 [50.0%] diagnosed with COVID-19; mean [SD] age, 47.0 [23.6] years; 239 056 [53.3%] men). During the study period, 43 states and the District of Columbia implemented an eviction moratorium and 7 did not. Among the states that implemented a moratorium, 26 (59.1%) lifted their moratorium before the US Centers for Disease Control and Prevention issued their national moratorium, while 18 (40.1%) maintained theirs. In a Cox difference-in-differences regression model, individuals living in a state that lifted its eviction moratorium experienced higher hazards of a COVID-19 diagnosis beginning 5 weeks after the moratorium was lifted (hazard ratio [HR], 1.39; 95% CI, 1.11-1.76; P = .004), reaching an HR of 1.83 (95% CI, 1.36-2.46; P < .001) 12 weeks after. Hazards increased in magnitude among individuals with preexisting comorbidities and those living in nonaffluent and rent-burdened areas. Individuals with a Charlson Comorbidity Index score of 3 or greater had an HR of 2.37 (95% CI, 1.67-3.36; P < .001) at the end of the study period. Those living in nonaffluent areas had an HR of 2.14 (95% CI, 1.51-3.05; P < .001), while those living in areas with a high rent burden had an HR of 2.31 (95% CI, 1.64-3.26; P < .001).

Conclusions and Relevance  The findings of this difference-in-differences analysis suggest that eviction-led housing insecurity may have exacerbated the COVID-19 pandemic.

Introduction

On September 4, 2020, the US Centers for Disease Control and Prevention (CDC) enacted a national eviction moratorium because “the evictions of tenants could be detrimental to public health control measures to slow the spread of the virus that causes COVID-19.”¹ The moratorium came at a time when an estimated 47.0% of individuals in renter-occupied housing behind on their payments were likely to leave their homes due to eviction,² sequalae of the United States’ long-standing housing-affordability crisis and the COVID-19 pandemic’s impact on employment and income.³

A growing body of evidence suggests that eviction activity may be associated with increased COVID-19 infection rates. For example, a study⁴ using ecologic data on COVID-19 infection rates and timing of state-level eviction bans found that COVID-19 rates increased after eviction moratoria expired. Other investigations using simulations have since found that households experienced an increased risk of infection not just due to personal experiences but also due to spillover from the transmission processes amplified by community evictions.⁵

However, limitations in public health surveillance data do not allow for exploration of differential policy effects based on individual-level health and socioeconomic characteristics. Understanding whether expiring eviction moratoria are particularly dangerous for people and local geographies that have already experienced disproportionate effects of the pandemic, including individuals with preexisting health problems and low-income communities, could help to inform how nonpharmaceutical interventions are deployed with an equity focus. For example, shelter-in-place orders, which protect professional class workers but not essential workers from occupational exposures, likely have different distributional impacts than do eviction moratoria, which we expect to disproportionately protect lower-income and rent-burdened populations and places.

We used detailed health care claims data from a large national database in the United States to conduct what we believe to be the first individual-level analysis of how eviction policy affects the hazard of a COVID-19 diagnosis within health and neighborhood-level socioeconomic strata. We used a difference-in-differences research strategy to compare changes in the risk of being diagnosed with COVID-19 before and after the lifting of state-level eviction moratoria vs the same changes in states that maintained these moratoria. We also assessed how associations between eviction moratoria and the risk of COVID-19 diagnosis varied by an individual’s Charlson Comorbidity Index (CCI) score as well as by zip code–level poverty and rent burden prevalence, to test the hypotheses that (1) individuals with poorer baseline health, as measured by the CCI, will experience higher risk of infection after moratoria are allowed to expire because baseline health status and eviction risk are both socially patterned and (2) individuals in low-income and rent-burdened communities will be at heightened risk of infection after expiring moratoria due to higher risk of exposure to eviction-related COVID-19 transmission driven by local evictions and subsequent crowding.

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 Eviction Moratoria Expiration and COVID-19 Infection Risk Across Strata of Health and Socioeconomic Status in the United States | Health Disparities | JAMA Network Open | JAMA Network