We published a new paper on Covid-19 and ER visits for suicide attempts/self harm incidents in Epidemiology and Community Health today
Rachel Bergmans, an epidemiologist from the University of Michigan Institute for Social Research (and soon the University of Michigan Medical School) and I recently wrote a paper on the impact of Covid-19 and Covid-19 policy in the state of Michigan on emergency room visits for suicide and self harm incidents.
I am happy to say that it appeared today in Epidemiology and Community Health and encourage everyone to read it here.
Many worried that Covid-19 and the resulting “lockdown” measures would result in rapid increases in suicide attempts due to increased unemployment and social isolation. We did not find an increase in ER visits for self harm and suicide attempts at the University of Michigan Hospital in Ann Arbor, MI. In fact, we found a decline in visits that continued into the winter.
Though it is impossible to know (from this data) what the actual reasons for this decline were, these results suggest that the Covid-19 crisis might not be comparable to previous economic downturns. It might suggest that efforts to financially support those left out of work by the shutdown might mitigate the worst effects of an rapid unemployment.
I am very proud of this work, here is the abstract:
Objective Determine the early impact of the COVID-19 pandemic on emergency department (ED) encounters for suicide attempt and intentional self-harm at a regional tertiary academic medical centre in Washtenaw County, Michigan, which is one of the wealthier and more diverse counties in the state.
Methods Interrupted time series analysis of daily ED encounters from October 2015 through October 2020 for suicide attempt and intentional self-harm (subject n=3002; 62% female; 78% Caucasian) using an autoregressive integrated moving average modelling approach.
Results There were 39.9% (95% CI 22.9% to 53.1%) fewer ED encounters for suicide attempt and intentional self-harm during the first 12 weeks of the COVID-19 pandemic (ie, on or after 10 March 2020, when the first cases of COVID-19 were identified in Michigan).
Conclusions Fewer individuals sought emergency care for suicide-related behaviour during the earlier phase of the COVID-19 pandemic than expected when compared to prior years. This suggests initial outbreaks of COVID-19 and state of emergency executive orders did not increase suicide-related behaviour in the short term. More work is needed to determine long-term impacts of the COVID-19 pandemic on suicide-related behaviour and whether there are high-risk groups.
There really isn’t much out there. I found 15 papers on PubMed and Web of Science. I am looking for more.
(Davidson, 1970; Erulu, Okumu, Ochola, & Gikunju, 2018)
I found two case reports. The first was from 1970 documenting a case of a white woman being bitten in Voi when a black-necked spitting cobra (Naja nigricollis) entered her bed at night. She received prompt care of polyvalent antivenom, travelled to Mombasa the next day, received treatment again and was relatively mobile within a week. It too three months for a hole in her foot to finally heal and for normal sensation to return to her toes.
The second documented a bite from a black mamba (Dendroaspis polylepis) in Watamu. A 13-year-old boy presented to Watamu Hospital with labored breathing, frothing at the mouth, severe ptosis, pupils non-responsive with unreadable blood pressure and elevated heat rate. He was administered the SAVP polyvalent antivenom and the boy recovered.
Hospital based surveillance and clinician surveys
(Coombs et al., 1997; Ochola, Okumu, Muchemi, Mbaria, & Gikunju, 2018; M. Okumu et al., 2018; M. O. Okumu et al., 2019; Ooms et al., 2020)
Coombs, et al gathered data from four areas of Kenya using Ministry of Health records. It was found that bite cases varied by region. Documented deaths are rare. The incidence rate of snakebites varied by region, with Kakamega being low and areas like Samburu and Baringo being high. Documentation of snake bites was often incomplete. Many bites were recorded as “Other” in hospital records. Though environmental factors and habitats account for some variation in bite incidence rates, a lack of coordination of health facilities and inconsistent record keeping might also be a factor. Authors conclude that surveillance capacity needs to improve and that community should be educated to identify bites and provide appropriate treatment (i.e. only using tourniquets for neurotoxic bites from snakes like mambas.) Transport and proximity are noted as barriers to treatment.
Ochola, et al. Study on snakebites from four hospitals including Kakamega Provincial, Makueni District and two others. Two year retrospective study of hospital records form 2007-2009. 176 total bites, 91 in 2009. Bites peaked at 1-15 years of age, 132/176 bites occurred on the lower extremities. 49/176 were given antivenom. Most bites occurred in the dry season, in the bush and in the evening. Mortality was 2.27%. Authors found that antivenom was often not available, and use was inconsistent. Patients presented to hospitals 2 to 6 hours after the bite, mostly due to travel distance. 75% if clinicians believe that patients saw traditional healers before arriving at the hospital. Manual laborers at highest risk.
Ooms et al. study of health care workers in three countries including Kenya. HCWs reported that there was no gender disparity in snakebite victims, that most victims are between 21 and 30 and that most people are bitten when conducting farm related activities or walking. Only 12% of HCWs received training in snakebite management. Only 20% claimed that medicines were available. Snakebite incidence occurred in both urban and rural areas of all countries. Half of all respondents claimed that people seek traditional treatments before coming to formal facilities.
Okumu et al Paper on general poisonings. Snakebites are only one part of the paper but make up 33% of all cases that appeared at Jaramogi Oginga Odinga Teaching and Referral Hospital. Antivenom used in 58% of all snakebite case. “Black snakes” accounted for 37% of bites. Victims were not able to identify snake species in 38.6% of bites.
Okumu, 2019 Paper on cost of snakebite treatment. 127 snakebite victims attending JOOOTRH between January 2011 and Dec 2016. Most victims were 13024 years of age, 64 were female, 94 were from rural areas, 92 were bitten on the lower limbs. 49 bitten at night, 43 attempted to self-treat, median time to the hospital was 4.5 hours. Outcomes included cellulitis, compartment syndrome, gangrenous foot, psychiatric disorder and death. 1-5 days in the hospital. Median cost $26. Authors call for public health programs to educate the public on how to identify and treat snakebites.
(Snow et al., 1994)
Retrospective study of 4,712 households. Most bites were not from venomous snakes. Most people identified both venomous and non-venomous snakes as being potentially venomous. 68% of people sought treatment from traditional healers. Authors suggest that traditional healers be integrated int primary health care and hospital-based systems. Household heads were approached and administered a questionnaire in Kilifi and ask to retrospectively report bites. Out of 4,712 visits there were 121 case of snake bite reported, 57% were male. Most were Giriama. 55% were bitten at night. A73% on the foot. 94% bitten outdoors. Only 39% could reliably describe the snake. No deaths were recorded. 79% performed some kind of first aid immediately after the bite. 88% sought treatment, with 78% visiting the healer. Only 29% visited a hospital. There was evidence to suggest clustering of bites.
(Anne-Sophie, Neil, & Aida, 2017; Eucabeth & Augustine, 2017; Omara, 2020; B. O. Owuor & Kisangau, 2006; Bethwell O. Owuor, Mulemi, & Kokwaro, 2005)
(Benson, Mohamed, Soliman, Hassan, & Abou Mandour, 2017; Harrison et al., 2017; Omara, 2020)
Anne-Sophie, D., Neil, D. B., & Aida, C.-S. (2017). Medicinal Plant Trade in Northern Kenya: Economic Importance, Uses, and Origin^sup 1. Economic Botany, 71(1), 13.
Benson, R. A., Mohamed, N. M. A., Soliman, M., Hassan, M., & Abou Mandour, M. A. (2017). Application of k 0-INAA for the determination of essential and toxic elements in medicinal plants from West Pokot County, Kenya. Journal of Radioanalytical and Nuclear Chemistry, 314(1), 23. Retrieved from https://link.springer.com/content/pdf/10.1007%2Fs10967-017-5370-3.pdf
Coombs, M. D., Dunachie, S. J., Brooker, S., Haynes, J., Church, J., & Warrell, D. A. (1997). Snake bites in Kenya: a preliminary survey of four areas. Transactions of the Royal Society of Tropical Medicine and Hygiene, 91(3), 319-321. doi:10.1016/s0035-9203(97)90091-2
Davidson, R. A. (1970). Case of African cobra bite. British medical journal, 4(5736), 660-660. doi:10.1136/bmj.4.5736.660
Erulu, V., Okumu, M., Ochola, F., & Gikunju, J. (2018). Revered but Poorly Understood: A Case Report of Dendroaspis polylepis (Black Mamba) Envenomation in Watamu, Malindi Kenya, and a Review of the Literature. Tropical medicine and infectious disease, 3(3), 104. doi:10.3390/tropicalmed3030104
Eucabeth, O. a.-M. a., & Augustine, A. (2017). Identity Construction in Three AbaGusii Bewitchment Narratives. International Journal of Society, Culture & Language, 5(1), 29.
Harrison, R. A., Oluoch, G. O., Ainsworth, S., Alsolaiss, J., Bolton, F., Arias, A. S., . . . Casewell, N. R. (2017). Preclinical antivenom-efficacy testing reveals potentially disturbing deficiencies of snakebite treatment capability in East Africa. PLoS Negl Trop Dis, 11(10), e0005969. doi:10.1371/journal.pntd.0005969
Ochola, F. O., Okumu, M. O., Muchemi, G. M., Mbaria, J. M., & Gikunju, J. K. (2018). Epidemiology of snake bites in selected areas of Kenya. Pan Afr Med J, 29, 217. doi:10.11604/pamj.2018.29.217.15366
Okumu, M., Patel, M., Bhogayata, F., Olweny, I., Ochola, F., & Onono, J. (2018). Acute Poisonings at a Regional Referral Hospital in Western Kenya. Tropical medicine and infectious disease, 3(3), 96. doi:10.3390/tropicalmed3030096
Okumu, M. O., Patel, M. N., Bhogayata, F. R., Ochola, F. O., Olweny, I. A., Onono, J. O., & Gikunju, J. K. (2019). Management and cost of snakebite injuries at a teaching and referral hospital in Western Kenya. F1000Res, 8, 1588. doi:10.12688/f1000research.20268.1
Omara, T. (2020). Plants Used in Antivenom Therapy in Rural Kenya: Ethnobotany and Future Perspectives. J Toxicol, 2020, 1828521. doi:10.1155/2020/1828521
Ooms, G. I., Van Oirschot, J., Waldmann, B., Von Bernus, S., Van Den Ham, H. A., Mantel-Teeuwisse, A. K., & Reed, T. (2020). The Current State of Snakebite Care in Kenya, Uganda, and Zambia: Healthcare Workers’ Perspectives and Knowledge, and Health Facilities’ Treatment Capacity. The American Journal of Tropical Medicine and Hygiene. doi:10.4269/ajtmh.20-1078
Owuor, B. O., & Kisangau, D. P. (2006). Kenyan medicinal plants used as antivenin: a comparison of plant usage. J Ethnobiol Ethnomed, 2(1), 7. doi:10.1186/1746-4269-2-7
Owuor, B. O., Mulemi, B. A., & Kokwaro, J. O. (2005). Indigenous Snake Bite Remedies of the Luo of Western Kenya. Journal of Ethnobiology, 25(1), 129-141. doi:10.2993/0278-0771(2005)25[129:Isbrot]2.0.Co;2
Snow, R. W., Bronzan, R., Roques, T., Nyamawi, C., Murphy, S., & Marsh, K. (1994). The prevalence and morbidity of snake bite and treatment-seeking behavior among a rural Kenyan population. Annals of Tropical Medicine and Parasitology, 88.
Among other things. Check out the full interview here:
To date, there has been no data on incidence of Covid 19 cases in the workplace in Michigan.
The State of Michigan, as part of Executive Order 2020-114 requires that businesses immediately notify the local public health department and any co-workers, contractors, or suppliers who may have come into contact with the person with a confirmed case of COVID-19 within 24 hours. Businesses must also shut down operations when any person is found to show symptoms of Covid 19 in the establishment and has a positive test.
But anecdotal reports are suggesting that compliance with the directive is spotty. No doubt, businesses will be hesitant to shut down operations with little notice or to draw undue attention to themselves. However, after one local business (so far the only one to do so) issued a public statement that one of their employees tested positive for the disease, the public is becoming skeptical of the private sector’s commitment to responding to potential exposures.
Rumors are flying through service workers that businesses are slow to respond or are actively covering up information on cases that have appeared in their workplaces. Of course, these are rumors and anecdotes, but even if the incidents are wholly unsubstantiated, public skepticism on social media is not. The public does not trust businesses, and particularly service businesses to adhere to the guidelines spelled out in the executive order.
Clearly, we are in real trouble. Cases have spiked in the past week, hospitalizations are up, and many states have lost or are about to lose the gains they have made. Hospitals in Texas are overflowing. Even the US military has extended bans on movement or personnel into specific states, most notably, my own while lifting them for other states.
We need businesses to adhere to the guidelines for reporting in the executive order, but we also need to use that data to inform the public on risks for infection when visiting businesses. While businesses are required to report to local health authorities, there is no indication that the data will be made public and very little indication that the data will be disseminated in a manner that will facilitate research on specific risks in different types of businesses.
Supposedly, you can call your local health department and they will tell you if you if you might have been exposed when you went to Place X. That requires a lot of work on the part of the consumer, and how are they going to know to ask about a specific business without having an alarm raised anyway? I can’t see how that can work.
Public health authorities and the private sector MUST work together to implement systems and information sharing that protects the public health. While businesses are right to be concerned about their survival, becoming the center of a superspreader event will be a public relations disaster as we saw in Lansing, MI over the weekend.
Bars and restaurants need to develop systems to inform customers when a staff member tests positive for Covid 19
Fauci noted that “Bars are bad news” during a Senate hearing on covid 19 today, and he’s right. No one should be going to a bar right now. No one should be playing music in a bar. No one should be working in a bar right now. Just a terrible idea all around.
But people are doing it anyway, and, though the risks are very high, there have to be systems in place to minimize that risk and help insure the safety of customers and workers.
At least two bars in Ann Arbor, MI have had staff members test positive for Covid 19 within the past week. One did the right thing. They shut down operations and had their entire staff tested immediately. A couple of days later, they issued a statement informing the public of what happened and what they did. The other has yet to do anything at all, unfortunately.
Closures and public statements are good things, but maybe there’s another step that businesses can take to inform customers in a timely manner. I suggest collected phone or email contact information from customers each night.
Businesses would send out a text or an email message informing the customer a staff member tested positive and it is possible that they may have been exposed to covid19 and should get tested and isolate as soon as possible.
As this system would be voluntary, no privacy would be violated. It is likely that most patrons would consent to receiving such notices. Personally, I would like to know. I would also like to receive that information sooner rather than later.
A QR code app based system such as that being implement in South Korea would be preferable, but it is unlikely that such a system would be acceptable in the US, aside from issues of cost. A simple email list might be an easy, low cost method of informing the public when they might have been at risk for infection.
But so far, that’s not happening.
In the past week employees at a handful of business in the tiny college town of Ann Arbor have tested positive for Covid 19. I won’t name names because I think that each businesses needs to be afforded an opportunity to make create a response and write a formal announcement.
Responses, however, should be immediate. Any delay in messaging puts the public at unnecessary risk. Businesses should be required by law to immediately make it public when an employee has tested positive.
When an employee tests positive for Covid 19, operations should be shut down, and every employee of that business should be tested without fail. Once everyone has been cleared, people can return to work and operations might commence.
Every single person who entered those businesses or had contact with employees needs to be immediately informed that they might have been exposed to Covid 19. Businesses must do this so that patrons can be tested if possible and isolate themselves if necessary.
Businesses who fail to do these things should be shut down.
One business is currently still open. I have it on good knowledge that an employee tested positive for Covid 19 there, yet there has been no announcement and business moved forward as usual (at the time of my walking past it yesterday.)
Covid 19 is no joke. People should be staying at home. They should not be eating out. Restaurants, bars and entertainment venues should not be open, but they are. If we are going to reopen these places, we need to do so under strict regulation that keeps the public informed and protected.
We went from 74 new cases of Covid 19 on June 15 to 389 cases on June 26, a five fold increase after several weeks of people partying like it is 2019.
Assuming that nothing changes between now and then, we will exceed the peak of new cases found (1,953) in Michigan back on April 3rd…. by the middle of July.
Certainly, case fatality rates are down, but if disease is not, this leaves us with even larger numbers of people suffering debilitating disease. Some will suffer for years and some of them might die earlier than they would otherwise.
Local bars, restaurants and music venues are opening up and trying to get people to come out like they did before, albeit under new rules. Some places are making a greater effort to protect workers and customers than others.
A local bar discovered that one of their staff tested positive for Covid 19 and, to their credit, shut down operations and tested the entire staff. But the infected staff member could have been infected up to two weeks ago and could have infected other staff, who could have infected customers. Every single person who stepped into that building needs to be informed. Is there a mechanism to do this? Obviously not, but there should be.
Moreover, the public needs to know which establishments have positive cases and when so that people can judge the relative safety of businesses and can act accordingly when they believe that they might have been at risk. This is also not happening but it should be.
People will inevitably say “it is worse everywhere else.” That doesn’t do anything to help a person on a vent. We are in real trouble, we need to act like it.
What will the State of Michigan do about this? Will we have another shut down? What does this bode for the future? Whatever it is, it isn’t good.
So… wear your damn mask. Stay the fuck home. Get carry out. Ignore all these people trying to get you to go out and act like life is the same as before, because it just isn’t.
The risks of covid19 are well known at this point. While we all need to be sympathetic to the need for people to earn a livelihood, a living should not come at the expense of public health and worker safety. This should be a given.
I have seen some businesses who are doing quite well right now. While my sample size is certainly small and my observations subject to my own biases, it is easy to tell apart the businesses who make an effort and the ones who do not.
We should support businesses who 1) require masks without fail, 2) offer masks and gloves to both workers and customers, 3) limit the number of customers in the store at any given time and 4) build plexiglass shields to separate customers and workers.
We should not support businesses who take a lax approach to masks, do not offer masks to customers who don’t have them, allow large numbers of people in the store proportional to size and do not have plexiglass shields in front of the register.
All of these modifications are easy and cheap to implement. There are few occasions where there is any valid excuse for not doing all of them in normal retail and food service industries.
Which bring me to the the point of this post. How can customers know how seriously businesses are taking covid19? Certainly, online review sites like Yelp or Google are going to be helpful, but these do not provide any indication of progress that businesses might make (“evolution”) or provide standards so that we can easily compare one business with another.
Many municipalities provide public record of compliance with health regulations. The New York City Health Department performs unannounced inspections of all restaurants in the five boroughs at least once an year and makes the data public. The public can search for any food provider in the city for any type of violation and even has a grading system. The Washtenaw County Health Department and the Michigan Department of Agriculture and Rural Development conduct regular inspections of food service establishments within their jurisdictions and publish the results online. The worst offenders often make the papers.
We need such a system for all businesses to make sure that they comply with efforts to contain the spread of covid19. Consumers have a right to know whether a business is compliant or not BEFORE they make the decision to visit that business. While the logistics of such a system are complicated and likely expensive, they are necessary.
Will this be on our legislature’s agenda? Do local health departments already have the authority to implement such a system? Would businesses push back against cheap masks and plexi? Certainly, there are challenges to implementation, but it isn’t impossible.
A friend suggested recently that I revive my blog, though I seem to notice that my last 20 posts all say something to the effect of reviving my blog… which sort of begs the question of whether this endless revival contradicts the idea that it was ever dead.
Regardless, I used to have a feature called “Movie of the Week” where I would write some sentences about some film that I found particularly impressive. I still watch an inordinate amount of movies, so much so, that the streaming services are almost dead to me; there’s not much left to watch that I haven’t seen that at least *looks* interesting. Open to suggestions though!
MUBI, however, is an endless trove of cinematic gems, adding and taking away films from its catalogue almost daily. Michigan Theater members got three months free during the Covid-19 lockdown, which has been a real life saver right now. So far, I have caught up on some recent Japanese productions that I missed (that I won’t even mention since it just isn’t polite to speak ill of the dead), got to see the Ryuichi Sakamoto doc “Coda” from 2017 (which was superb) and a number of oddball Russian productions that I would have missed otherwise (Beanpole from 2019 is highly recommended).
A standout, however, was “Tehran Taboo,” a German-Austrian production by Iranian born German director Ali Soozandeh. Tehran Taboo is the story of three women and one man, navigating the complex dissonance between strict rules on sex and economic, human and social realities.
Shot in Germany and Austria using Persian speaking actors, the film is rotoscoped. That is, the visuals are traced over live actors, in the same vein as Bakshi’s 1978 production of Lord of the Rings. Rotoscoping for Tehran Taboo availed the director of having to film sensitive material in Iran. He could shoot in Germany and then simply draw over the action to create settings that at least “look” like Iran without fear of having the religious police (who are central to the film) arrest everyone involved. Aside from the practical issues the film just looks great and the animated approach brings out the immediacy of the subject matter.
Alrighty, then, there’s my blog post. I win.