Port Liberte commuters will get a $1.30 discount per trip when the NY Waterway resumes ferry service at the development Aug. 1, company officials announced Tuesday.
The per-trip price, $11.70 for Port Liberte residents and $13 for everyone else, is the reason Jersey City has proposed purchasing the ferry terminal building there, councilwomen Mira Prinz-Arey and Denise Ridley said.
I think the press release by NY Waterway speaks to exactly the reason we are looking to acquire the ferry terminal, it puts the city and its residents at the head of these transportation discussions, said Ridley, who represents the Greenville neighborhood.
It is the citys intention for this ferry terminal to serve all Jersey City residents. I believe NY Waterway would attract more riders by evening the scale.
NY Waterway announced the reopening less than a week after the Jersey City City Council introduced an ordinance to take over the ferry terminal from the developer Ironstate for $1. The ferry service at Port Liberte, which runs to Wall Street and the Manhattan financial district, has been suspended since the start of the coronavirus pandemic in March 2020.
The NY Waterway announcement is a total slap in the face, Prinz-Arey said, since the city council ordinance calls for the city take an active role in subsidizing rates, increasing ridership, and significantly expanding access to the terminal for residents in the Greenville and West Side neighborhoods by leveraging the highly successful Via Jersey City.
The ordinance was introduced at the June 15 meeting and is expected to be approved at next weeks meeting.
NY Waterway spokesman Wiley Norvell confirmed the pricing schedule is not related to the Jersey City ordinance. The $13 charge is the highest among the companys Hudson County routes, matching Port Imperial in Weehawken.
Were excited to be back at Port Liberte, Norvell said. The prices reflect the costs of operating the ferry route, which is one of the longest in the NY Waterway system. We continue to work with the mayor and local council members on ways to lower commuting costs and increase options across the city.
The cost of the ferry out of Paulus Hook runs between $7 and $9, depending on the destination.
Mira Prinz-Arey, who represents the West Side, distanced the city from the NY Waterway announcement.
This is why we as a city are starting to walk down this path, she said. ... This is a multi-phase project. The first project is going into the lease agreement. and the next phase is looking at other possible service providers. What (NY Waterway) is doing now is fine, its a nice gesture, but it has nothing to do with the citys larger plan.
The ferries will offer direct service from the Port Liberte development to Paulus Hook and Wall Street, with connecting service to World Financial Center and Midtown.
Norvell said the service will be provided on a trial basis between August and October, and will assess future service based on ridership.
Wiley said the Port Liberte residents are being offered the 10% discount because it funded much of the construction of the facility, through the homeowners association. A 10-trip pass is $108 for Port Liberte commuters and $120 for non-Port Liberte residents.
Ferries will depart from Port Liberte between 6:05am and 9:05am, making stops at Paulus Hook and Pier 11. Returning ferries in the afternoon will depart Pier 11 between 4:15pm and 7:15pm, bound for Port Liberte.
For full Port Liberte ferry schedules and fares, nywaterway.com/PortLiberte
Back in February of 2021, mental-health educator and wellness coach Minaa B. wrote about the concept and importance of community care in an op-ed for Well+Good: "The idea of community care, essentially, is to use our power, privilege, and resources to better the people who are both in and out of our scope of reach."
There's no denying that the world looks a bit different a year and a half after she penned the piece: Airlines have lifted mask mandates and COVID-19 testing requirements for international and domestic flights, and almost every state in the country has relaxed its pandemic restrictions. But as the United States continues racing to conditions of pre-pandemic lifeeven as the number of infections continues to growthe definition of community care remains the same, and the way in which folks practice it is perhaps more important than ever. In a time when it feels that the government has more or less wiped its hands of COVID-19 as a public health issue, the honor and burden of community care falls back on individualsmeaning, you, me, each one of us. But, how?
Community-oriented care comes in many forms. While the idea and practice is prevalent across the world, the concept of public healththe American government's answer to community carestarted in the early 1900s. Since the idea found its way to American soil, the average American lifespan has increased 30 years25 of which are attributed to public-health advancements including vaccinations, safer workplaces, family planning, and cleaner drinking water.
Of course, community care has also stemmed from local, grassroots movements: The Hispanic Federation assembled after Hurricane Maria devastated Puerto Rico. Food banks have played a crucial role in feeding millions in the last few years. And, more recently, Well+Good Changemaker and Liberate Abortion leader Sharmin Hossain is leading an abortion caravan through Jackson, Mississippi, to teach people how to self-manage abortions in a time whenRoe v. Wadeis likely to be overturned. Such efforts are less quantifiable than those enacted by the government; nevertheless, they are and will continue to be vitalespecially as we navigate what community care looks like as it pertains to COVID-19.
That is, how do we practice community care in a time when public health is politically divisive; when only 67 percent of the population has been fully vaccinated against COVID-19 (and vaccination acceptance overall is on the decline)? And whendespite the fact that one million Americans have now died of COVID-19 and others live with long COVIDgetting folks to take the virus seriously remains a challenge?
I asked Isaac P. Dapkins, MD, chief medical officer at the Family Health Centers at NYU Langone, who has worked at the intersection of medicine and community care for about six years, for his thoughts. Since the start of the pandemic, he says that he and his team have spoken a lot about how doctors can orient their work toward community careand one strategy in particular has stood out to him.
When New York City became the epicenter of the pandemic in March of 2020, Dr. Dapkins saw the impact COVID-19 had on the community where he practices: Sunset Park, Brooklyn. "When we had the highest rate of infection, I think the worst part was that, if you got COVID, it really meant that you were putting your family at risk. Whether it was your older parents or your children," he says.
Folks who lived in multi-generational householdsspecifically Black people, Hispanic people, and people of Asian descentstood the greatest chance of passing a COVID-19 infection onto one or several loved ones. This risk came to define how Dr. Dapkins spoke to people about community care.
"For example, I had a woman who was in her early fifties, who was adamantly against vaccination, and she had issues that would make her at risk. I was able to connect with her about getting a vaccine by talking to her about how she would protect her motherwhom she was really worried would get sick," says Dr. Dapkins. Ultimately, he was able to convince the woman to get the vaccine for the health and safety of her family.
"The way to communicate with people is to find common ground, things that people share value-wise." Isaac P. Dapkins, MD, chief medical officer at the Family Health Centers, NYU Langone
Although not all of us are doctors, Dr. Dapkins believes that the future of community care will hinge on getting really good at talking to those we love about how their actions inform the health of their closest communities. "Doctors are really focused on communicating with individual people about their risk [for COVID-19], and I don't believe that's a very effective way to change people's minds. The way to communicate with people is to find common ground, things that people share value-wise," he says.
I know what you're thinking: Finding common ground is a difficult ask. Try as we might to use our power, privilege, and resources to connect with those who have decided the pandemic is over, and these conversations can feel like banging your hands against a brick wall. But if we stop trying, what then?
"If you're out on the street, and there's a little kid who looks like they're going to run out into the road, most people are going to stop the kid. I think there's some nugget of opportunity in that community-care conversation," says Dr. Dapkins. "Would you let a little kid run out into the street and get hit by a car? When you start to frame it in an emotional way for people that's real and doesn't have to do with sort of dry numbers and risk, it at least facilitates the conversation."
Besides having these difficult conversations, another way to practice community care right now is leading by example. If you're someone who, for instance, is fully vaccinated but still prefers to wear a mask in public spaces, wear your mask on the plane. Make it clear that you want to social distance at the supermarket. Require people to show proof of vaccination at your wedding.
The reverse is also true: Your respect and adherence to your family and friends' preferred COVID-19 safety measures is a form of community care. "Again, it's really about trying to encourage people to accept what others want to do about reducing their risk rather than focusing on what your perceived risk is," says Dr. Dapkins.
Infection rates and COVID-19-related deaths stats are importantthere's no arguing that. But when it comes to community care, human empathy may be the key to showing up for your peopleespecially when the government has decided to move on.
BackgroundDefinitions and Concepts
Behavior can be described as challenging when it exhibits a recurrent pattern or interferes with or is at risk of interfering with optimal learning or engagement in prosocial interactions with peers and adults.1 Emotional dysregulation and challenging behaviors may adversely impact interpersonal competences and academic performance, leaving the child with enduring effects.2 However, cultural sensitivity led to variations in distinguishing what is deemed inappropriate behavior considering the different norms and beliefs.3,4
Behavioral problems have been grouped into two broad spectrums: internalizing and externalizing.5,6 Internalizing behaviors are expressed inward and often go undetected, such as difficulty concentrating, being anxious, persistent avoidance of activities, social withdrawal, crying or hiding.6,7 Externalizing behaviors are expressed toward the outer environment such as hitting, spitting, property destruction, fleeing and yelling.6,7
However, it is not uncommon for children and adolescents to exhibit co-occurring disorders of both types.8 For instance, food insecurity, homelessness, exposure to violence, abuse or neglect may lead to both internalizing (eg, being secretive, self-conscious, experiencing aches and pain, anxious, fearful) and externalizing challenging behaviors (eg, exaggerated startle responses, aggression, bullying or fighting).69
COVID-19 and the imposed restrictive measures have affected to a large-scale the psychological wellbeing of children and adolescents.10 Disruption of daily routines and shifting into remote learning have resulted in an increased frequency or severity of challenging behaviors, representing a particular source of stress to parents/families.11 A study conducted during the early stages of the pandemic in the Philippines indicated that having a higher number of children in the family was positively associated with a higher level of psychological distress.12 Furthermore, Ren et al13 in their study evaluated the psychological impact of COVID-19 following school reopening and found that 32.4% of students showed symptoms of depression, while 15.5% exhibited anxiety symptoms. The study also revealed that those at higher grades and fears of being infected were at greater risk of adverse psychological outcomes.13
Comparative results were obtained even at later stages of the pandemic. Among 1771 adolescents in China, depression and anxiety were estimated to be 30.8% and 28.3%, respectively. Sleep quality, resilience, social/school status, perceived social support, and adaptive coping strategies were amongst the protective factors, while maladaptive coping strategies were a risk factor.14
Challenging behaviors are relatively prevalent, even prior to the emergence of COVID-19. A study in Boulder County, USA, indicated that yells and screams (73%), hurting oneself/others (69.5%), and getting irritable/frustrated easily (66.1%) were amongst the most common challenging behaviors reported by parents.15 In New Zealand, a parental survey of 10,457 children aged 3 to 14 years revealed that 8% of children had substantial social, emotional, or behavioral issues, while 7% had a borderline score.16
Several interrelated factors have been shown to influence childrens behavior, including developmental, environmental, and socio-cultural aspects.17 The prevalence of challenging behaviors in young children was estimated to be about 10% and may reach as high as 25% for those coming from low-income families.17,18
Preschoolers are three times more likely to be expelled from a childcare program due to active behavioral problems, as compared to grades K12.19 Aggressive and antisocial behaviors may persist beyond the age of three in about 3 to 15% of preschool-age children.20 Approximately, half of these children are embarking on a path that will inevitably lead to delinquency and criminal acts in adolescence and adulthood.21
While some children may outgrow this kind of behavior by the time of school entry, others demonstrate persistent and even intensifying patterns, leading to academic failure and social maladjustment.22 Fifty percent or more of toddlers and preschoolers with disruptive disorders were found to exhibit challenging behaviors at least up to four years later.16
In a qualitative study conducted by Fox et al17 families reported that behavioral problems invariably impacted the family structure, routines, and activities. The conclusion of the study has given support to the system perspective, which considers children and family struggles to be the product of interconnected family situations rather than a single environmental element.23
Disruption of daily routines, home confinement, lack of coping strategies, and changes in sleeping and eating patterns over the period of the COVID-19 pandemic are likely associated with rising rates of mental health challenges, most markedly among children, adolescents, and their families.24 Evidence from several studies2530 indicated the importance of early management of behavioral problems in prevention of future risks and adverse outcomes. For example, mental health difficulties, physical health burden, relationship and parenting problems, substance abuse and sexual risk taking.2530 Hence, structured regulation strategies tackling emotional, behavioral, and psychological perspectives are pivotal to mitigate the adverse effects of the pandemic. Understanding the factors that influence behavior is useful for successfully implementing effective interventions.
Thus, the present review aims to synthesize the available literature on (i) the impact of COVID-19 on children and adolescents behaviors (ii) determinants of challenging behaviors in relation to environment and social-emotional development; and (iii) a family-centered strategic interventional framework for the management of such behaviors.
We reviewed the literature pertaining to determinants and intervention strategies aimed at managing challenging behaviors among children and adolescents. We conducted an electronic search for studies from July 2021 through September 2021, using the following electronic databases: PubMed, ScienceDirect, Medline, and Scopus. A combination of the following keywords was used to search for titles and abstracts: challenging behavior OR maladaptive behavior OR social-emotional OR internalizing OR externalizing OR children OR adolescents OR Pyramid Model OR COVID-19 OR Behavioral intervention OR positive behavioral support OR family-centered OR school. We then conducted hand searches using reference sections from retrieved articles. To maximize the potential of studies included no restriction to publication date or language was applied.
The inclusion criteria established for the selection of the articles were: (1) focusing on children and adolescents behavior up to 18 years old; (2) addressing developmental and socio-emotional determinants of challenging behavior; (3) discussing the impact of COVID-19 on children/adolescents behavior; (4) Provide assessment of challenging behavior using Positive Behavioral Support, and (5) manage in the context of families and/or schools. Articles were excluded from the review if they examined children with developmental or mental disabilities due to the likelihood of interference with the prevalence, severity, assessment, or management of challenging behaviors.
Two independent reviewers were involved in the database search, and any disagreement was resolved by discussion or by a third reviewer. Articles that met the selection criteria were retrieved for this review and the relevant contents of the articles were divided into five theoretical categories, including: (i) developmental milestones; (ii) the Pyramid Model; (iii) Positive Behavioral Support; (iv) management strategies for challenging behavior in the context of families and schools; and (v) the impact of COVID-19 on childrens or adolescents behavior.
It is critical to recognize the age-appropriate childhood developmental milestones (ie, motor, verbal, social, emotional, and cognitive skills) as markers for behavioral acts, particularly throughout the transition into more advanced milestones.31 Some challenging behaviors are developmentally appropriate for youngsters as they gain new abilities and progress through life stages.32 For example, the peak of physical aggression between the ages of 17 and 42 months is considered typical in this developmental period.33
Transitions such as separation from parents, attempting to be more independent, or frustration due to a lack of abilities may stimulate emotional distress.34 Nevertheless, it is important to acknowledge that every behavior serves a function or purpose. For example, communication difficulties such as delayed language or speech or poor social competence may trigger challenging behavior as a way of communicating with their environment, especially during anxious or stressful situations.35
The Pyramid Model is an evidence-based, multi-tiered framework that supports young childrens social, emotional, and behavioral development in early years settings.36 It is conceptualized to provide three levels of intervention practice: universal promotion for all children, secondary preventions for those at risk of social emotional delays, and tertiary interventions for those with persisting behavioral problems37 (Figure 1).
Figure 1 The Pyramid Model.
Targeted social-emotional support: the focus of this level is to support social skills and emotional regulation, especially for at risk children who need more systematic and focused instructions.41 Children are assisted in expressing their emotions, improving problem solving skills, cooperative responding, peer interaction, and dealing with negative emotions such as anger.4143 For example, parents and teachers can lead activities through behavioral modeling and role-play with positive reinforcement strategies when a desired behavior is demonstrated.41
Individualized intensive intervention: children with persistent behavioral problems not responding to previous tiers are offered a rigorous, tailored intervention using PBS. Progress is continuously monitored in relation to specific pre-determined goals.44,45
PBS is a person-centered, evidence-based strategy to assist children with behavioral problems in a variety of settings.46 It deems challenging behavior as a product of multiple interactive variables of interpersonal relationships, physical environment, reactions of others and the way support is provided.47 Individual factors such as trauma, intellectual disability, general health, and mental health should all be considered.48,49
PBS is most effective when planned strategies are implemented in a consistent manner.50 Families and teachers are encouraged to work together to achieve the level of fidelity required to produce desirable outcomes.50,51 PBS consists of four main steps: FBA; developing a hypothesis about why the behavior is happening; undertaking a functional behavior analysis to test the hypothesis; and developing a BIP.51,52
FBA is a method used to identify the associations between physiological or environmental factors and behavioral problems.53 The goal is to detect variables related to the occurrence of a specific behavior and to determine the function or purpose of that behavior in relation to one of four categories:53 social attention, escape, tangible, ie, the desire for certain things, or sensory, ie, internally rewarding or assisting in coping with negative emotions such as boredom or anxiety.
Topography, incidence, and duration of behavioral problems are identified through interviews, observations, and analysis.54 Precedent events that occur prior to the problematic behaviors are outlined, as are the consequences that maintain the behavior.54 Successful implementation of PBS was shown to be effective in minimizing challenging behavior through enhancement of new target skills.5559
Behavior is assessed broadly in three stages: indirect, direct, and hypothesis testing.60 Indirect evaluation includes gathering information from existing databases through interviews with parents, teachers, or peers.60 The key is to establish a valid definition of the target behavior. For example, a defiant tantrum can be expressed by throwing materials off the desk, folding the arm and/or using inappropriate language. In the direct stage, extended analysis is carried out to identify frequency, duration, topography, and the environment in which the behavior occurs. In the final stage, hypothesis testing aims to translate the findings of previous steps into an A-B-C statement that addresses the causes of the problematic behavior, the consequences that reinforce a behavior, and the provision of replacement behaviors. Examples of ABC observation for challenging behavior are illustrated in (Table 1) and real-world scenario examples of ABC behavior are shown in (Table 2).
Table 1 Examples of ABC Observation for Challenging Behavior
Table 2 Real Scenario Examples of ABC Observation
BIP consists of multicomponent interventions that are aligned with patterns observed throughout the assessment.61 Given that behaviors can be context-dependent (eg, a child only hits when sibling takes away his toys) and multi-functional (eg, screaming occurs both to obtain parental attention and delay certain tasks), combined interventions are usually recommended.61
BIP include a clear explanation of the behavior, the relationship between cause and effect, interventions used and their outcomes, behavioral goals, a plan for supporting new behavior, a description of success, evaluation, and monitoring process.62,63
When an intervention strategy is selected, guidance might aim for either changing the antecedents and/or the consequences related to a behavior (ie, using antecedent and consequence strategies) or developing more socially appropriate and adaptive replacement skills.63 Focusing on behavioral triggers, antecedent interventions promote behavioral change through either eliminating or adding antecedents that ultimately reduce the likelihood of challenging behavior.64 Examples of ABC strategies by behavioral function are presented in (Table 3).
Table 3 Examples of ABC Strategies by Behavioral Function
In school settings, interventions may include environmental modifications such as allowing students to sit in a specific location in the class or providing a quiet, distraction-free environment. Working in small groups, changing tasks, oral tests, curriculum material adaptations and group/individual counselling, are further examples.59,65 Flowchart of FBA and BIP is illustrated in (Figure 2).
Figure 2 Flowchart of Functional Behavioral Assessment (FBA) and Behavioral Intervention Plan (BIP).
Aside from educating a child on the appropriate methods of communication, the way parents/teachers react to a particular behavior remarkably contributes to the duration, frequency, or intensity of such behavior.58 A message should be conveyed to the child that challenging behavior will not be successful.
The verbal or physical redirection method is a simple but highly effective strategy for shifting a childs behavior into a more desirable one.66 For example, once Sarah appears ready to toss a toy when she is not getting attention, her mom can redirect her by saying, As soon as you put away the toys, we can read your favorite bedtime story.
Being primary caregivers, parents are considered the most valuable resources for the management of challenging behaviors.67 Interventions are more likely to have an impact when parental focus is shifted from consequences to reasons of misbehavior.33 Parental coaching aims to support parents in employing new skills when challenging behaviors occur. It is based on problem-solving skills gained through scaffolding, with an emphasis on three areas of support: cognitive, emotional, and autonomy.57
Family-centered methodology works on improving parents capacity to principally understand their childs social and emotional cues and consequently, promote self-regulatory behavior and emotional intelligence.68 Natural environments such as home and school are considered the ideal settings for interventions, allowing observation of multiple interrelated factors that can affect childrens behavior.69,70 Lucyshyn et al71 demonstrated the significance of interventional modeling and parental coaching through problem-solving discussions, behavioral rehearsal, self-monitoring, and evaluation.
The aim of the model is to foster family involvement in supporting their childs early development. Instead of addressing behavioral problems with either parents or children independently, strategies are viewed in terms of parent-child interactions.72 Roggman et al73 proposed that parents need to be actively supported in recognizing their own resources, strengths, and needs, focusing on their own children rather than a standardized curriculum. Helping parents discuss their ideas, actions in place, and feedback with the provision of problem-solving scenarios are crucial for successful outcomes.74
The way in which adults provide children assistance to obtain new skills as they grow through the stages of development is described as scaffolding.75 For instance, caregivers may breakdown a certain task into smaller, simple steps and provide elements of basic understanding that will help in the solution and actual demonstration of the task. To enhance the effectiveness of scaffolding and reduce the level of frustration caused by lack of skill, modelling, provision of hints or cues, and adapting materials may be used.75
Scaffolding has been identified as a high-quality parenting approach leading to favorable behavioral tendencies and self-regulation using childrens own abilities.76 Prior to the occurring of a challenging behavior, it is important for parents to teach their children problem solving skills instead of long speeches that the child may or may not comprehend.77 Three types of scaffolding have been identified, including cognitive, emotional, and autonomous.33
This type of support aims to empower children to understand and apply new strategies, review problem solving steps, and realize rational underlying decisions in the direction of self-guided learning.26 Through effective feedback, cognitive support helps children accept different viewpoints and create a balance between pride in their abilities and recognizing the importance of reliable guidance that promotes self-confidence.78
Scaffolding with emotional support implies the use of positive reinforcement, verbal, and nonverbal communication to enhance emotional regulation.33 Mothers who help their children develop emotional literacy and teach coping strategies through play, storytelling, role modelling, taking turn, and sharing, tend to have children who are engaged in more prosocial behavior, while aggressive behaviors are associated with those who are inattentive of their childs emotional triggers.79
Refers as the ability of parents to provide support for their children, while preserving their independency and decision-making skills.33 Autonomy-promoting questions give opportunities for children to reflect on their own mental processes.78 For example, asking the child How do you think we should handle this? or How do you feel? enables self-expression and improve ones sense of control. Therefore, instead of asking the child to say sorry, he/she can describe their feelings and how they believe it can be-improved. Autonomy support via stimulating parent-child interaction and minimizing judgment/control will improve problem-solving abilities, empathy, compassion, and prosocial behaviors.33
The unexpected disruption of the social fabric and norms has affected the behavioral and mental health of the public, including children.8090 The psychosocial wellbeing of children has been affected in several ways, as this unprecedented situation changed the way they typically grow, learn, play, behave, interact, and regulate emotions.
Schools closures, transition into remote learning, and the absence of face-to-face peer interactions have impacted important perspectives in childrens lives. Children, especially younger ones, were deprived of opportunities such as physical activity, playing and group activities, resulting in substantial disruption to critical developmental milestones.91
In China, Wang et al92 explored the psychosocial and behavioral problems of 11,072 children and adolescents in the early stages of reopening schools. Among psychosocial behaviors, parent-offspring conflict, prolonged homework time, increased sedentary behavior and screen time, sleep problems, and physical inactivity were most frequently identified. Higher internalizing and externalizing behaviors were noted, specifically, children aged 611 who returned to school showed more depression, compulsive behavior, and hyperactivity, while adolescents of age 1216 showed more aggressive behavior, compared to those who were home schooled.92,93
Previous studies have demonstrated that in addition to the increase in clinging, inattentive and irritability documented at the beginning of the epidemic, with its link to disrupted school and daily routine, poor dietary habits leading to obesity, and increased use of electronic devices, can further aggravate adverse effects on children and adolescents.9496
School reopening has brought a ray of hope around the world in terms of restoring the sense of structure and stimulation necessary for childrens psychosocial wellbeing.97,98 However, the readjustment period is expected to deal with several negative sequelae emerging from academic pressure, students relationships with teachers and peers, and difficulty adjusting to school routine.
Previous studies indicated that academic pressure driven by parents or teachers expectations, irrespective of age and sex, was amongst the most identified stressors in students.99,100
Children who were disproportionally affected including those with preexisting mental health concerns, developmental disorders, learning disabilities or any other challenges may experience greater adjustment issues and require individualized learning plan with additional support.101
This review had certain limitations, mainly attributed to the subjective nature of the narrative style literature. First, there is the possibility of misinterpretation of results and drawing conclusions (which is usually due to selection bias, subjective weighing of included studies, and unspecified data synthesis). To mitigate this limitation, we adopted several methods (ie, forming a search strategy, the process of selection and data synthesis) more characteristic of systematic reviews. Use of these methods helped to reduce selection bias by ensuring our source selection decisions were procedurally structured and precise.
The second limitation is the inclusion of a small number of studies that were conducted during the COVID-19 pandemic, creating a perception of theoretical rather than practical relevance. To overcome this limitation, we have enriched the introduction with additional post-pandemic (at early and later stage) study results to show the significance of the increasing trends and potential related mental health illness.
The results of the present review highlighted the considerable impact of the COVID-19 pandemic on children/adolescents behaviors and their mental wellbeing. Identifying behaviors determinants in the context of developmental, environmental, and sociocultural remains the key step to mitigating the adverse effects such as social maladjustment, academic failure, and future risky acts. Scalable and family-based mental health interventions built on the Pyramid Model, FBA, and BIP will promote effective and sustainable outcomes.
The present review supports that enhancing parental capacity through training, coaching, and empowering them to identify their own resources and strengths will help construct positive parent-child interactions. Additional attention should be given to the children/adolescents who are more susceptible to mental health challenges through a collaborative approach involving parents, schools, healthcare providers, and mental health services.
Owing to the COVID-19 containment measures and the impediment to traditional face-to-face services, other innovative psychological supports, such as Internet Cognitive Behavioral Therapy, may be an effective alternative to reduce barriers to access mental health resources.
The empirical literature synthesis focuses on several key stakeholders (parents, schools, practitioners, community, policymakers, and researchers) who work with children or adolescents. The framework of Functional Behavioral Assessment and Behavioral Intervention Plan offers a strategic template that facilitates and supports a comprehensive array of evidence-based services components, from developmental surveillance, promotion, and prevention to intensive intervention, through an individualized plan tailored to the child and familys needs.
Professional development for practitioners, schools, and parents is important to ensure they have the adequate skills and knowledge to conduct behavioral assessments, identify determinants, socio-emotional competences, and implement effective interventions within natural environments accordingly. The current review provides an expanded understanding of the role of mental health support within the school environment, allowing for continuous monitoring and evaluation.
The results from this review have provided sufficient grounds for further longitudinal research to examine the impact of supportive environments, parental coaching, and interventions on childrens behaviors as well as the consequences of persistent challenging behavior in developing future mental health illnesses or risky acts. Another avenue for research would be to examine the adverse effects related to COVID-19 restrictive measures on the mental health of children, adolescents, and families.
Not applicable because of review type of the article. All data and material are available under references.
All authors approved the final version to be published and agree to be accountable for any part of the work.
Open Access funding provided by the Qatar National Library.
The authors declare that the manuscript was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
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In the last two years, COVID-19 has followed a predictable, if painful, pattern: When coronavirus transmission has rebounded, California has been flooded with new cases and hospitals have strained under a deluge of seriously ill patients, a distressing number of whom die.
But in a world awash in vaccines and treatments, and with healthcare providers armed with knowledge gleaned over the course of the pandemic, the latest wave isnt sticking to that script.
Despite wide circulation of the coronavirus the latest peak is the third-highest of the pandemic the impact on hospitals has been relatively minor. Even with the uptick in transmission, COVID-19 deaths have remained fairly low and stable.
And this has occurred even with officials largely eschewing new restrictions and mandates.
In some ways, thats what is supposed to happen: As health experts get better at identifying the coronavirus, vaccinating against it and treating the symptoms, new surges in cases shouldnt lead to excessive jumps in serious illnesses.
But todays environment is not necessarily tomorrows baseline. The coronavirus can mutate rapidly, potentially upending the public health landscape and meriting a different response.
The one thing that is predictable about COVID, in my mind, is that its unpredictable, said UCLA epidemiologist Dr. Robert Kim-Farley.
While its too soon to say for certain, there are signs the current wave is starting to recede. Over the weeklong period ending Thursday, California reported an average of just over 13,400 new cases per day down from the latest spikes high point of nearly 16,700 daily cases, according to data compiled by The Times.
By comparison, last summers Delta surge topped out at almost 14,400 new cases per day, on average.
And more than 8,300 coronavirus-positive patients were hospitalized statewide on some days at the height of Delta almost three times as many as during the most recent wave.
The difference in each surges impact on intensive care units has been even starker. During Delta, there were days with more than 2,000 coronavirus-positive patients in ICUs statewide. In the latest wave, however, that daily census has so far topped out at around 300.
That gap in hospitalizations illustrates how the pandemic has changed.
At the very beginning of the pandemic, we noted right away the game-changers were going to be vaccines, easy access to testing and therapeutics and now we have all those things, said Los Angeles County Public Health Director Barbara Ferrer.
It doesnt say the pandemics over. Thats not what weve accomplished, she stressed. What weve accomplished is weve reduced the risk, but we havent eliminated the risk.
And though hospitalizations have been lower, in the aggregate, during the latest wave, Ferrer noted that each infection still carries its own dangers not just severe illness, but the chance of long COVID, as well. Taking individual action to protect yourself, she said, carries the added benefit of helping safeguard those around you, including those at higher risk of serious symptoms or who work jobs that regularly bring them into contact with lots of people.
For me, it makes clear that layering in some protection is still the way to go while enjoying just about everything you want to enjoy, she said.
Californias most restrictive efforts to rein in the coronavirus ended almost exactly a year ago, when the state celebrated its economic reopening by scrapping virtually all restrictions that had long provided the backbone of its pandemic response.
Roughly a month later, with the then-novel Delta variant on the rampage, some parts of the state reinstituted mask mandates in hopes of blunting transmission.
Toward the end of the year, another new foe would arise: the Omicron variant. This highly transmissible strain brought unprecedented viral spread, sending case counts and hospitalizations soaring and prompting officials to reissue a statewide mask mandate for indoor public spaces.
The fury with which those two surges struck left some fearing, and others advocating for, the return of the stringent orders that restricted peoples movements and shut down broad swaths of the economy. However, both waves came and went without California officials resorting to that option.
And during this latest wave fueled by an alphanumeric soup of Omicron subvariants, including BA.2 and BA.2.12.1 such aggressive action seems off the table.
I think, deep in my heart, unless we see a new variant that evades our current vaccine protection, we are not going to need to go back to the more drastic tools we had to use early on the pandemic when we didnt have vaccines, when we didnt have access to testing, when we didnt have therapeutics, Ferrer said in an interview.
During both Delta and the initial Omicron surge, California carefully evaluated the unique characteristics of each variant to determine how to best handle the changes in the behavior of the virus, and used the lessons of the last two years to approach mitigation and adaptation measures through effective and timely strategies, according to the state Department of Public Health.
These lessons and experiences informed our approach to manage each surge and variant. In addition, there were more tools available for disease control during each subsequent surge, including the Delta and Omicron surges, the department wrote in response to an inquiry from The Times. So, rather than using the same mitigation strategies that had been used previously, CDPH focused on vaccines, masks, tests, quarantine, improving ventilation and new therapeutics.
The state has also eschewed its previous practice of setting specific thresholds to tighten or loosen restrictions in favor of what it calls the SMARTER plan which focuses on preparedness and applying lessons learned to better armor California against future surges or new variants.
Each surge and each variant brings with it unique characteristics relative to our neighborhoods and communities specific conditions, the Department of Public Health said in its statement to The Times.
Chief among those, the department added, are getting vaccinated and boosted when eligible and properly wearing high-quality face masks when warranted.
The U.S. Centers for Disease Control and Prevention recommends public indoor masking in counties that have a high COVID-19 community level, the worst on the agencys three-tier scale. That category indicates not only significant community transmission but also that hospital systems may grow strained by coronavirus-positive patients.
We certainly are not at a level at these numbers where you would say, OK, its now, quote, endemic, and we just go about business as usual, Kim-Farley said. I think, though, it is probably indicative of what we might see in the future going forward, that we will see low levels in the community, people can relax and let their guard down a bit. But there will then be other times when we might see surges coming in. ... Thats a time when we mask up again. So I think there may be some on and off a little bit, and hopefully these surges become fewer, more spread out and less intense as we go forward.
As of Thursday, 19 California counties were in the high community level Alameda, Butte, Contra Costa, Del Norte, El Dorado, Fresno, Kings, Lake, Madera, Marin, Monterey, Napa, Placer, Sacramento, San Benito, Santa Clara, Solano, Sonoma and Yolo. However, only Alameda County has reinstituted a public indoor mask mandate.
Ferrer has said Los Angeles County would do the same should it fall in the high COVID-19 community level for two consecutive weeks.
L.A. County, like the state as a whole, continues to strongly recommend residents wear masks indoors in public. But Ferrer acknowledged its a very tough needle to thread and said an unintended consequence of years of health orders might be that people dont grasp the urgency of a recommendation.
People are now assuming if we dont issue orders and require safety measures then its because its not essential, and thats not what we meant, she said. We have always benefited from having folks that are able to listen, ask questions and then, for the most part, align with the safety measures. And I think because its been such a long duration, because theres so much fatigue at this point and desperation in some senses to get back to customary practices, people are waiting for that order before they go ahead and take that sensible precaution.
With recent UK data suggesting that the BA.4 and BA.5 Covid variants are kicking off a new wave of infections, experts answer the key questions about reinfection and prevention.
Though rare at the start of the pandemic, reinfections have become increasingly common as the months and years wear on particularly since the arrival of Omicron, which prompted a 15-fold increase in the rate of reinfections, data from the Office for National Statistics suggests.
In part, this is because of a decline in protective antibodies triggered by infection and/or vaccination over time, but the virus has also evolved to evade some of these immune defences, making reinfection more likely.
The original Omicron BA.1 variant was itself massively immune-evasive, causing a huge breakthrough caseload, even in the vaccinated, said Danny Altmann, a professor of immunology at Imperial College London. It is also poorly immunogenic, which means that catching it offers little extra protection against catching it again. On top of that, theres now further evidence of the very marginal ability of prior Omicron to prime any immune memory for BA.4 or 5, the sub-variants that seem to be driving the latest wave of infections.
The virus has also evolved to become more transmissible, meaning even fleeting exposure to an infected person means you may inhale enough viral particles to become infected yourself.
There are definitely a lot of people who got Covid at the start of the year who are getting it again, including some with BA.4/5 who had BA.1/2 just four months ago, who thought they would be protected, said Prof Tim Spector, who leads the Zoe Health Study (formerly known as the Zoe Covid Study).
We still dont have enough data to work out exactly when the susceptible periods [for reinfection] are, which is one reason why we need people to keep logging their symptoms. We do know its still quite rare within three months, and it used to also be rare within six months, but thats not the case any more.
According to unpublished data from Denmark, which looked at reinfections with the BA.2 Omicron sub-variant within 60 days of catching BA.1, such reinfections were most common among young, unvaccinated people with mild disease. Other studies have similarly suggested that Covid-19 vaccination provides a substantial added layer of protection against reinfection by boosting peoples immune responses.
However, Omicron infection in itself appears to be a poor booster of immunity, meaning that if you were infected during earlier pandemic waves, your immune response is unlikely to have been strengthened by catching it again earlier this year.
In general, infections should be less severe the second, third or fourth time around, because people should have some residual immunity particularly if theyve also been vaccinated, which would further raise their levels of immune protection. However, there are always exceptions to this. Anecdotally, some people are getting it for longer this time around than they did the last time, Spector said.
It is also too early to know about the risk of long Covid associated with BA.4/5, he added.
As the UK heads into a period dominated by BA.4 and 5, the potential for reinfection seems high. Were in quite a serious situation due to a convergence of factors: a country where a moderately successful third booster campaign is now long past, with immunity waned and successive large waves of Omicron through to the emerging dominance of BA.4/5, said Altmann.
The bottom line is that we should all consider ourselves essentially unprotected, except perhaps from intensive care unit admission and death, and then, as before, with the risks increasing with age.
Face masks and ventilation continue to provide important additional layers of protection especially in crowded settings. I still wear a mask, but not a cheap mask I wear a proper FFP2 or 3 mask, said Spector. These new variants are still very much airborne and you need an even smaller amount to get infected, so I think a mask is definitely a good idea when as many as one in 30 people have it again.
Good evening. Im Karen Kaplan, and its Tuesday, June 21. Heres the latest on whats happening with the coronavirus in California and beyond.
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California has been averaging 13,768 new coronavirus cases per day over the last week. If health officials had reported a number like that back in the early months of the pandemic, wed have been seriously freaking out.
What makes me so sure? Its at least four times higher than any statewide case count reported during the pandemics first spring, according to data from the Centers for Disease Control and Prevention. In fact, California didnt see cases reach that level until late November 2020, when the devastating fall-and-winter surge was taking off. (We were definitely freaking out at that point.)
Now that were two-plus years into the outbreak, that case count barely registers with the public as a cause for concern.
Pretty much every public health leader from CDC Director Dr. Rochelle Walensky on down has lobbied hard for people to get their COVID-19 boosters, but only 47% of eligible Americans have done so. State and local health officials strongly recommend that people wear masks in indoor public settings, but most dont.
To some degree, this nonchalance is a sign of COVID-19 burnout. Were tired of letting the coronavirus dictate what we can and cannot do. We just want our lives to go back to normal.
At the same time, theres a reason that masks are strongly recommended but not required (at least, not yet): Although the Omicron variant is circulating widely and the current wave includes the third-highest peak of the pandemic, the number of people hospitalized with COVID-19 is still quite manageable, and deaths arent rising out of control.
Friends from Palisades Charter High School ride the MTA Expo Line in Los Angeles.
(Genaro Molina / Los Angeles Times)
Thats not to say the deaths are negligible California reported 74 deaths on Monday and was averaging 30 deaths each day over the prior week. (Plenty of those deaths were preventable; the risk of death for unvaccinated people is more than 10 times higher than for those who are vaccinated and boosted, state health officials report.)
But compared with earlier periods of the pandemic, we have a lot more tools at our disposal to stave off COVID-19s worst effects. And these tools are a lot more targeted than the stay-at-home orders, capacity restrictions and mandates weve had in the past.
The most important tools are vaccines: 72% of Californians are fully vaccinated, and 58% of those eligible have received at least one booster shot.
Adding to that is the natural immunity people have gained by surviving an infection. In December, the CDC estimated that nearly 95% of Americans had coronavirus antibodies due to vaccination, past infection or a combination of both.
There are also plentiful coronavirus test kits, antiviral pills such as Paxlovid and Lagevrio (also known as molnupiravir) and the IV medicine Veklury (remdesivir). (Monoclonal antibodies used to be on this list, but they arent very effective against Omicron and its subvariants.)
And lets not discount all the experience doctors, nurses, respiratory therapists and other healthcare professionals have acquired by caring for millions of COVID-19 patients.
This helps explain why the current wave, fueled by the Omicron subvariant known as BA.2.12.1, has seen far fewer hospitalizations than last years Delta surge despite causing more infections.
The current wave peaked with about 16,700 new daily cases in California, compared with almost 14,400 during the Delta days. But Delta sent 8,342 coronavirus-positive patients to the states hospitals on its worst day, while BA.2.12.1 hasnt surpassed 2,808.
ICU admissions diverged even more. With Delta, there were as many as 2,008 infected patients in intensive care units throughout the state at the same time. That number hasnt risen above 300 in the current wave.
At the very beginning of the pandemic, we noted right away the game-changers were going to be vaccines, easy access to testing and therapeutics and now we have all those things, Los Angeles County Public Health Director Barbara Ferrer told my colleague Luke Money.
That progress is something to appreciate, but it doesnt guarantee were out of the woods. If another variant comes along thats able to circumvent our vaccines and treatments, we could go back to seeing hospitalizations and deaths rising higher for a given increase in infections.
We certainly are not at a level at these numbers where you would say, OK, its now, quote, endemic, and we just go about business as usual, UCLA epidemiologist Dr. Robert Kim-Farley told Money.
I think, though, it is probably indicative of what we might see in the future, he added. Hopefully these surges become fewer, more spread out and less intense as we go forward.
California cases and deaths as of 4:40 p.m. on Tuesday:
Track Californias coronavirus spread and vaccination efforts including the latest numbers and how they break down with our graphics.
If youre having trouble swallowing the glass-half-full outlook outlined above, youre not alone. What looks like hard-won progress to some seems like complacency or even capitulation to others.
Dr. Elisabeth Rosenthal is most definitely in the latter camp. In an Op-Ed, the editor in chief of Kaiser Health News lays out the litany of ways in which America has simply surrendered the fight against the coronavirus.
The countrys vaccination rate has stalled out at around 67% (though itll probably rise a bit now that the shots have been made available to the nations 18.7 million children under 5). Boosters are even less popular than the initial doses.
President Biden requested $22.5 billion to continue funding the countrys COVID-19 response, including money to pay doctors who care for uninsured patients and cash to buy vaccines, tests and treatments. The Senate responded with a $10-billion package that doesnt include any funds to help squelch outbreaks overseas. Now even that compromise bill is being held up by the politics of immigration.
Dr. Ashish Jha, the White House COVID coordinator, has warned that we would see a lot of unnecessary loss of life if the money doesnt materialize. So far, that hasnt been enough of an incentive to break the impasse.
The lack of urgency is shared by state and local governments, in Rosenthals view. Theyve rescinded mask mandates even for high-risk settings, including places like bars and music venues where people crowd together indoors. Health officials arent acting with urgency to get more people boosted even though its become increasingly clear that a booster dose is essential to ward off Omicron.
When the government wont take preventive measures seriously, its hard to blame private employers for following suit. Few stores still require workers and customers to mask up; even if mask rules are still posted, theyre rarely enforced. (The latest example: Broadway theaters in New York City announced Tuesday that mask use during performances would become optional next week.)
In March, the Biden administration unveiled a plan to help Americans coexist with the coronavirus as safely as possible. The plans stated goal is to get back to our more normal routines. Who wouldnt get behind that?
Unfortunately, in response, our elected representatives and much of the country essentially sighed, preferring to move on and give up the fight, Rosenthal writes.
The problem isnt just that people are sick of caring about public health. The problem is that its inherently difficult to make people care about it.
Thats because if public health officials are respected, well-funded and allowed to do their job heres the result: Literally nothing happens, Rosenthal writes. Outbreaks dont lead to pandemics.
Maria Fernanda works on contact tracing in a half-empty office at the Florida Department of Health in Miami-Dade County in 2020.
(Lynne Sladky / Associated Press)
Health officials cant go around crowing about the bad stuff that didnt happen. But when people dont take their warnings seriously, theyre the ones who are blamed.
Theyre also the ones who get short shrift from politicians and the public. In the year before the pandemic, the CDCs budget was cut by 9%, according to the Trust for Americas Health. Money for programs like suicide prevention and HIV care was only slightly higher in 2020 than it was in 2008, after accounting for inflation.
At the state level, spending on public health didnt see significant growth between 2008 and 2018, except for programs aimed at preventing injuries, according to a 2021 study in the journal Health Affairs. State health departments weathered big cuts to cope with the Great Recession, and that funding hadnt been restored by the time COVID-19 came along, leaving them ill equipped to respond, the study authors wrote.
The cuts have resulted in the elimination of at least 38,000 state and local public health jobs, Rosenthal notes. Thats partly why states and cities have yet to spend much of the $2.25 billion allocated in March 2021 by the Biden administration to help reduce COVID disparities, she writes. There are now too few on-the-ground public health officials who know how to spend it.
Public health was front and center for awhile in the pre-vaccine era, when people were more afraid of the coronavirus and of having to use an iPad to say goodbye to a loved one hooked up to a ventilator in an ICU. Now our attention has shifted to mass shootings, inflation, the war in Ukraine and the abortion case before the U.S. Supreme Court.
A trio of anthropologists from George Washington University agree its important to keep COVID-19s victims at the top of our minds, especially when so much of the culture is determined to behave as if things are already back to normal. And they have some ideas for doing so.
Sarah E. Wagner, Roy R. Grinker and Joel C. Kuipers start by suggesting a national commission to take a hard look at how the country allowed the pandemics death toll to exceed 1 million. By documenting how we got here, the country would be holding itself accountable ultimately an act of healing for survivors, they write.
They also recommend a national day of remembrance for COVID-19 victims. Resolutions in both the House of Representatives and the Senate would turn the first Monday in March into COVID19 Victims and Survivors Memorial Day.
A designated national memorial day would make the pandemic visible for decades to come, they write.
See the latest on Californias vaccination progress with our tracker.
Its been a year and a half since the first COVID-19 vaccines received emergency use authorization from the U.S. Food and Drug Administration. During that time, the conversation around the vaccines has shifted from how to stop unscrupulous people from jumping the line to how to entice holdouts to roll up their sleeves.
So if you found yourself feeling ho-hum about the latest vaccine news that COVID-19 shots are now available for kids as young as 6 months try looking at it from McKenzie Packs perspective.
Pack has a 3-year-old son named Fletcher. Hes not old enough to remember a time before the pandemic. But once the vaccine builds up his coronavirus immunity, he can start doing things he would have otherwise taken for granted.
Hes never really played with another kid inside before, McKenzie Pack said. This will be a really big change for our family.
That change was made possible by the FDAs decision to grant emergency use authorization to two COVID-19 vaccines for infants, toddlers and preschoolers. Both are reformulated versions of the mRNA vaccines available to U.S. adults.
The one from Moderna is a two-shot series for kids ages 6 months to 5 years. Each injection contains one-quarter the dose used for adults. The two shots should be given four to eight weeks apart; young children with compromised immune systems should get a third dose as well.
The vaccine from Pfizer and BioNTech requires three doses for everyone. The first two shots are given three to eight weeks apart, and the third one follows at least eight weeks after the second dose. Its made for children ages 6 months to 4 years, and contains one-tenth the dose used in the adult vaccine.
The CDCs vaccine advisory panel spent two days debating the pros and cons of the vaccines before endorsing them on Saturday. Walensky accepted their advice and urged parents and caregivers to make a date with a needle, even for children whove already had COVID-19.
In clinical trials, the pediatric vaccines were less effective than the adult versions were when they began rolling out 18 months ago. Thats because new coronavirus variants especially versions of Omicron have become more adept at evading antibodies induced by the shots. The trial data suggested the new vaccines would probably reduce the risk of COVID-19 symptoms in young children by 30% to 60%.
We cannot let the perfect be the enemy of the good, said Dr. Oliver Brooks, chief healthcare officer of Watts Medical Corp. in Los Angeles and a member of the CDCs Advisory Committee on Immunization Practices. Thats the bottom line.
The advisors said they were persuaded by evidence that young childrens antibody response to the new vaccines was on par with the antibody response seen in older children and adults, two groups for which the vaccine has been shown to be protective. Clinical trials also established that the vaccine was safe among nearly 8,000 young children, there were no deaths and very few serious adverse events, such as high fever.
The Western States Scientific Safety Review Workgroup a coalition of public health experts from California, Nevada, Oregon and Washington conducted its own review over the weekend and announced its support for the new vaccines on Sunday.
California has ordered almost 400,000 doses, and it began allowing parents and caregivers to book appointments on the My Turn site on Tuesday. But many providers that showed up in search results didnt appear ready to accommodate the youngest children.
The website for the L.A. County Department of Public Health notified users that vaccines for children younger than 5 were on the way. It provided a list of sites that were expected to offer the vaccine as soon as it arrives. A spokesman for the department said most of those sites should have doses available by Wednesday.
Both the county health department and the state offered a heads-up that pharmacies couldnt vaccinate children under age 3. That means a visit to a pediatrician or health clinic is in order.
In other COVID-19 vaccine news, a study published last week in the New England Journal of Medicine found that two initial doses without a follow-up booster offered essentially no lasting protection against an infection with Omicron. Researchers also reported that an infection was about as good as a booster at preventing a new Omicron-fueled illness.
On the plus side, the study found that either type of immunity offered lasting protection against serious illness, hospitalization and death.
I think this is really the important part: The immunity against severe COVID-19 was really very much preserved, said study co-author Laith Jamal Abu-Raddad, an infectious disease epidemiologist at Weill Cornell Medicine-Qatar.
Moving on to treatments, Pfizer said Paxlovid didnt seem to help COVID-19 patients who were not at high risk of becoming severely ill. That became clear in a study testing its antiviral drug in a broader population of people who were relatively healthy and unvaccinated, or who were fully vaccinated but had a medical condition that made them more vulnerable to a serious case of COVID-19.
California is having trouble getting Paxlovid to patients who need it. In the month since the state began its test-to-treat system, fewer than 800 people received a prescription, even though thousands of Californians became infected each day.
The programs goal is to make antivirals available right away to high-risk patients who test positive for a coronavirus infection, since the drugs work best when taken shortly after symptoms begin. A total of 1,219 people had been screened for the drugs as of mid-June, and 768 got Paxlovid pills.
I think its a new concept that people are still getting used to, said Katharine Sullivan, who oversees a test-to-treat site in west Berkeley.
And finally, the World Health Organizations latest weekly report on COVID-19 said there were more than 8,700 deaths in the week that ended June 12. That number is notable because it represents a 4% increase over the prior week and the first increase since early May.
The Americas saw the largest increase in the COVID-19 death toll (21%), followed by the Western Pacific region (17%). Europe, Southeast Asia, the eastern Mediterranean and Africa all saw declines.
Todays question comes from readers who want to know: Whats the criteria for having a high COVID-19 community level?
This is important because if and when L.A. County crosses this threshold and stays there for two weeks, its indoor mask mandate will return.
To back up for a moment, COVID-19 community levels are a measure the CDC uses to gauge how the coronavirus and the disease it causes are affecting peoples health in a particular place, either directly (through illness) or indirectly (by placing undo strain on local healthcare resources, making them unavailable to others). They come in three flavors: low, medium and high.
Three factors determine a countys COVID-19 community level: the number of new infections diagnosed over the last week; the number of new COVID-19 patients admitted to local hospitals over the last week; and the percentage of hospital beds occupied by patients with COVID-19.
There are multiple combinations of these variables that would qualify a county (or state or territory) as having a high COVID-19 community level.
Start with the coronavirus case count. See whether your county has recorded at least 200 new cases per 100,000 people over the last week. L.A. County did: It saw 337 cases per 100,000 residents in the last week.
Since were over the 200 mark, were ineligible for the low level. But we can stay in the medium level if we have fewer than 10 new COVID-19 hospitalizations per 100,000 residents over the last week and fewer than 10% of hospital beds are filled by COVID-19 patients.
The latest CDC figures show that L.A. County hospitals are admitting 7.3 new COVID-19 patients per 100,000 residents per week, and that 3.5% of hospital beds are devoted to patients with COVID-19. That means our COVID-19 community level is still medium. But if either metric climbs too high, well be reclassified into the high category.
If our new case count were below 200 per 100,000 residents per week, we could still have a high COVID-19 community level if we had at least 20 new hospitalizations per 100,000 per week, or if at least 15% of hospital beds were filled with COVID-19 patients. However, those combinations are a lot less likely.
You can look up the COVID-19 community level for any U.S. state, territory or county on the CDC website.
We want to hear from you. Email us your coronavirus questions, and well do our best to answer them. Wondering if your questions already been answered? Check out our archive here.
(Shawn Thew / Associated Press)
He was the last person I expected to catch the coronavirus, but this pandemic is full of surprises.
The National Institutes of Health announced Wednesday that none other than Dr. Anthony Fauci had come down with a mild case of COVID-19. Fauci, 81, is fully vaccinated and double-boosted and still well enough to work from home, where he is isolating according to CDC guidelines.
Less than two months ago, the nations top infectious disease expert heralded the arrival of more of a controlled phase of the pandemic. But he was quick to add: By no means does that mean the pandemic is over.
In this case, Im sure he wishes hed been wrong about that.
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Introduction
In his State of the Union address earlier this year, President Joe Biden spoke of a new moment where the coronavirus will be more manageable and the need for masks less frequent. States have moved toward this transition as positive cases, hospitalization, and deaths began to drop. In the first week of March, governors inMississippi, Texas,Alabama, Arizona, West Virginia and Connecticut announced significant loosening of statewide pandemic restrictions like mask mandates and indoor capacity limits. These states joined several others in loosening statewide coronavirus restrictions much earlier in the year.
As we transition toward directly battling COVID-19 to the next phase in the process, we must note that living with the virus means something much different for those struggling with the symptoms of long COVID-19. Long COVID-19 is associated with chronic symptoms like fatigue, cognitive problems, and respiratory challenges that can linger for months after the initial coronavirus infection has passed. Long-haulers, or people who experience prolonged symptoms more than three or four weeks after infection could need several months to recover.
It is important to recognize that experiencing longer-term challenges with COVID is rather pervasive and affects not only those with severe cases, but those with relatively mild symptoms as well as Americans who are generally healthy, not just those with underlying conditions. In fact, our colleagues here at Brookings have estimated that 31 million working-age Americansmore than one in sevenmay have experienced, or be experiencing, lingering COVID-19 symptoms.
The persistence of these symptoms and their ability to limit major life activities creates new considerations for immediate and long-term policy solutions. The COVID-19 pandemic increases the need to protect vulnerable communities based on current knowledge and predictions of the extension of disparate health conditions.
Similar to all other health outcomes associated with the pandemic, there are significant racial inequalities associated with long COVID-19 as vast inequalities in underlying conditions make the severity of longer-term cases more pronounced for racial and ethnic minorities. This blog post summarizes a few considerations about the racial differences among COVID-19 patients with longer-term symptoms and identifies policy solutions to help address these challenges.
The glaring racial inequalities in COVID-19 outcomes have been well documented by Brookings and a wide range of other scholars and think tanks. It is clear that Native Americans, African Americans, and Latinos have all experienced higher rates of coronavirus infection, hospitalization and casualties throughout the pandemic.
However, our knowledge of how race impacts long-term challenges with COVID-19 is unfortunately pretty limited. A key report focused on the State of Black America and COVID-19 has identified that Black Americans have not been sufficiently included in long COVID-19 trials, treatment programs and registries. There is unfortunately limited research on other racial and ethnic minorities as well.
It has now become clear that access to a primary care physician and adequate health care coverage as well as appropriate disability coverage will be crucial to the ways in which Americans navigate long COVID-19.
First, primary care doctors will be key to patients with long COVID-19, as many patients require comprehensive assessment to exclude serious complications that might be associated with their symptoms. A primary care clinician who knows the patient and his or her life circumstances is in an optimal position to coordinate and personalize the recovery plan and understand the barriers the patient may face along the way. Ideally patients with difficult cases would have access to holistic clinical intervention and followup.
Unfortunately, there is a significant gap in access to a primary care physicians for Americans from diverse backgrounds. TheAfrican American Research Collaborative/Commonwealth Fund American COVID-19 Vaccine Pollis an extensive, diverse national survey with measures of access to primary care physician. According to the survey, 82% of white Americans reporting having a primary care doctor while only 74% of Black, 69% of Latino, and 72% of Native Americans have access to a doctor they see regularly for care.
Second, people with long COVID-19 will need adequate health coverage to manage both the financial and health components of care management. Unfortunately, racial inequalities in access to health insurance are vast, particularly for Latinos. This is a direct consequence of the several jobs held by people of color lacking sufficient healthcare benefits. Additionally, states in which Medicaid has not been expanded complicate the way in which people of color are able to manage long COVID-19.
It is important to note that long COVID-19, particularly in vulnerable groups, may be complicated by other longterm conditions, notably diabetes, hypertension, ischemic heart disease, and chronic mental health conditions.[1] Racial and ethnic minorities are more likely to experience all of these conditions which strongly suggests that we should anticipate more complex and challenging cases for all non-white groups.
One of the other health issues associated with long-haulers is insomnia, a condition that can last months and possibly longer among Americans with long-term challenges due to COVID-19. Like most chronic health conditions, challenges with insomnia are greater among racial and ethnic minorities already, particularly for those who have high levels of perceived discrimination. Given the correlation between lack of quality sleep and a wide range of other health conditions, this may generate even greater racial inequalities in health outcomes down the line. The challenges with sleeping are likely to be exasperated by a host of underlying forces that impact sleep, including sub-par housing conditions.
The long-term effects of COVID-19 have not been realized. Our health systems and structures and the policies that regulate them will need major overhauling to be flexible enough to manage the impending social and health implications of long COVID-19. In closing, while we all enjoy the ability to feel more comfortable with expanded social interaction, and the ability to not have to wear our masks as often when we leave our homes, we must recognize that those struggling with the symptoms of long COVID-19 are far from being able to return to normalcy.
Finally, people suffering from the persistence of symptoms are eligible for disability services according to the Department of Health and Human Services. The physical impairment due to long COVID-19 can affect walking, standing, speaking, breathing, and many other physical functions that may limit ones role in their ability to manage daily activities with their families, and in their current jobs. Because long COVID-19 can be experienced by youth and young adults, there is additional guidance on how primary, secondary, and post-secondary schools should evaluate, assess, and make academic adjustments for those in school and higher education settings.
In this post we identify the gaping racial inequalities not only associated with long COVID-19 cases, but in the resources needed to properly manage a lingering case. In future posts we will summarize the policy solutions needed to help address the challenges raised in this blog, as well as the economic consequences associated with long COVID-19 for communities of color who are already being squeezed by inflation and a slower recovery from the economic downturn.
[1] See for example: https://pubmed.ncbi.nlm.nih.gov/32419765/
A recent study published in Clinical Infectious Diseases assessed deaths due to fungal infections during the coronavirus disease 2019 (COVID-19) pandemic in the United States (US).
Study: Increased deaths from fungal infections during the COVID-19 pandemicNational Vital Statistics System, United States, January 2020December 2021. Image Credit: Kateryna Kon/Shutterstock
Yeasts, molds, dimorphic fungi, and yeast-like fungi are common fungal pathogens. Clinically, fungal infections result in superficial lesions as well as life-threatening conditions. Severe infections typically affect immunosuppressed individuals like cancer patients, recipients of solid organ or stem cell grafts, users of immunosuppressive medication, etc.
More than a million people have succumbed to COVID-19 in the US to date. Moreover, COVID-19 might elevate the risk for severe fungal infection due to COVID-19-associated immune dysfunction, lung damage, and therapies, impairing the host immune system against pathogenic fungi. Evidence suggests that severe fungal infection in COVID-19 patients could result in poor clinical outcomes.
The present study analyzed data from the US National Vital Statistics System (NVSS) to examine demographic information, fungal disease burden, and temporal trends. They used provisional mortality data for 2021 and final mortality data for 2018 2020 from NVSS. Deaths involving fungal infections were identified and coded according to the International Classification of Diseases, tenth revision (ICD-10) codes. Deaths involving COVID-19 were similarly coded.
The number, percentage, and age-adjusted rates of fungal deaths from January 2018 to December 2021 were analyzed by the fungal pathogen, year, and COVID-19 association (whether COVID-19 was a contributory factor). The monthly number of fungal deaths during the COVID-19 pandemic was examined by investigating whether COVID-19 contributed to mortality; concurrent monthly COVID-19 deaths were also analyzed.
Data on fungal deaths between January 2020 and December 2021 were stratified by the COVID-19 association; the age-adjusted death rates were examined by race/ethnicity, sex, fungal pathogens, and the US census division of residence.
Between 2018 and 2021, 22,700 deaths occurred due to fungal infections/pathogens. The number of fungal deaths per 100,000 people for 2018 and 2019 was similar, with 4746 and 4833 deaths, respectively, and the age-adjusted rate was 1.2 during both years. However, it increased to 5922 in 2020, with a mortality rate of 1.5. Likewise, about 7199 (fungal) deaths were observed in 2021, with a rate of 1.8.
COVID-19-associated deaths during 2020 and 2021 accounted for 21.9% of the 13,121 fungal deaths in that period. COVID-19 represented the most common underlying cause of death (90.5%) among the COVID-19-associated fungal deaths, accounting for 0.3% of COVID-19 deaths during 2020-21. Candida and Aspergillus were the common fungal pathogens constituting 24.4% and 16.4% of the total number of fungal deaths for 2020-21.
Nevertheless, the pathogen was unspecified for more than 35% of all fungal deaths in the same period. Notably, COVID-19-associated fungal deaths were predominantly due to Candida and Aspergillus infections relative to non-COVID-19-associated fungal deaths. On average, 399 fungal deaths were recorded per month during 2018-19, and 423 fungal deaths occurred during the peak of the first COVID-19 wave (April 2020). Nonetheless, it peaked in January 2021 and October 2021 with 690 and 718 fungal deaths coinciding with the COVID-19 mortality peak(s).
Most deaths from fungal infections in 2020-21 were recorded in males (59.7%) and people aged 65 or above. The age-adjusted rates for COVID-19-associated fungal deaths were higher for individuals who were non-Hispanic American Indian or Alaska Native (AI/AN) [1.3], Hispanic (0.7), and Black (0.6) than non-Hispanic White (0.2) and non-Hispanic Asian (0.3) populations.
Consistently, for non-COVID-19-associated deaths from fungal infections, the age-adjusted death rates were higher in AI/AN (3), Hispanic (1.9), and non-Hispanic native Hawaiian (NHPI) [2.4] and Black populations than White (1.1) or Asian (1.2) individuals. The crude fungal death rate was higher for people from non-metropolitan areas than metropolitan residents.
The age-adjusted fungal death rates were higher in the Mountain (2.1) and Pacific (2) US census divisions but lower in the New England (1.3) division. Mountain and West South-Central divisions showed higher rates (0.5) of non-COVID-19-associated deaths, while it was lower in New England division (0.2).
The researchers observed that more people died from fungal infections in 2020-21, an upward trend compared to preceding years. COVID-19-associated fungal deaths drove this increase, highlighting the critical significance of fungal infections in COVID-19 patients. Fungal deaths increased in tandem with COVID-19 peaks in January and October 2021 but not in April 2020.
In conclusion, the study demonstrated that fungal infections pose a substantial burden in the US. These results might help inform efforts to identify, treat, or prevent severe fungal infections in COVID-19 patients, particularly in some ethnic and racial groups and geographic regions.
In a recent study published in Nature Biotechnology, researchers assessed the role of smartphone apps during the coronavirus disease 2019 (COVID-19) pandemic.
Smartphone apps were widely used for tracing, tracking, and educating the general public about COVID-19. While there are major concerns related to data privacy and data security, evidence suggests the usefulness of apps in understanding the infection outbreaks, individual screening as well as contact tracing.
In the present study, researchers reviewed and assessed major digital app projects according to outbreak epidemiology, individual screening, and contact tracing.
The team divided the COVID-19 epidemiology into (1) surveillance of active user participants, (2) population-level tracking of passive users, (3) individual risk assessment, and (4) forecasting viral illness. Participatory surveillance was performed using phone and text-based surveys to obtain syndromic surveillance data in places where web-based applications were unavailable.
Various syndromic reporting platforms, including Flu Near You used in the US, InfluenzaNet in Europe, and Reporta in Mexico, allowed citizen scientists to report influenza-like symptoms into a reporting platform based on either the web or an app. Such reporting has shown great promise in correlating the timing and extent of viral illness activity.
Since there was a significant overlap between COVID-19 and influenza symptoms, several of the aforementioned apps also tracked COVID-19. Another app-based platform from Brazil obtained syndromic data from a total of 861 participants and found that the data collected matched the temporal as well as spatial trends observed in the traditional surveillance methods used for COVID-19. This platform also identified communities that should be prioritized for testing and improved the surveillance conducted in regions lacking healthcare facilities.
Passive crowdsourcing of outbreak data from social media, web queries, and lay media-generated large-scale data could provide warning signals earlier than those provided by traditional means of surveillance. Healthmaps Outbreaks Near Me platform monitored, organized, and visualized the location as well as the time when the infectious disease outbreak was reported globally via electronic media. This enabled near-real-time visualization as well as identification of clusters of infection cases reported by the media in a region which helps public health responders recognize new outbreaks faster than traditional measures.
Several apps, including the Safer-Covid app, provided users with information related to individual risk taking into account the age, type of activity, and location. The Health Code surveillance app from China categorized individuals into three classifications according to their level of risk based on mining location, contact data, and payment platform. Individuals belonging to the high-risk categories were barred entry into specific public places, transit systems, and buildings. Such individual risk assessments also could enhance the usage of non-pharmaceutical interventions (NPIs), including mask-wearing, increased testing, social distancing, or stay-at-home measures.
The symptom-checker apps were divided into active or passive according to their need for user engagement.
These apps required frequent active interaction with the app as the participant reported symptoms on a regular basis. Continuous reliance on user reporting led to survey fatigue resulting in smaller-than-expected sample sizes, waning user retention as well as participant bias. These factors limited the apps ability to form meaningful inferences about the local trends with respect to COVID-19 infections.
Passive screening obtained data from wearables used by the participants to detect COVID-19 or any other viral illnesses. Such screening required minimal participation on the users behalf. Initial studies evidenced the potential of these apps in understanding ambulatory physiology and identifying subclinical forms of the viral disease. A study app called the digital engagement and tracking for early control and treatment (DETECT) employed a hybrid active and passive approach using data collected from Fitbit or any other wrist sensor connected to either data obtained from Google Fit or Apple HealthKit, along with symptom questionnaires.
The team noted that the analysis of resting heart rate (RHR) among symptomatic COVID-19 patients in the DETECT cohort revealed an average initial increase in RHR followed by transient bradycardia. This was further followed by prolonged relative tachycardia, which was resolved almost three months after the onset of symptoms.
An Oxford University study showed that contact tracing could potentially mitigate the COVID-19 outbreaks. Smartphones enabled contact tracing due to their ability to detect proximity between persons using technologies such as bluetooth low-energy systems. Moreover, global position systems, internet protocol addresses, proximity to cell towers, and international mobile equipment identity numbers could enable the geolocation of certain persons.
According to the authors, further research is essential to investigate the efficacy of COVID-19 apps.
COVID-19 surveillance program in Pune, India
Pune city-located in western India around 150km east of Mumbai (Fig.1a)launched a COVID-19 surveillance program during the early stages of the pandemic (January 2020). Pune Municipal Corporation (PMC) collaborated with multiple public and private health facilities to establish SARS-CoV-2 diagnostics, quarantine facilities for asymptomatic persons, and hospital/critical care beds for moderate to severely ill patients diagnosed with COVID-19. In addition, community-based workers were mobilized to conduct contact tracing activities. A publicly accessible dashboard was established to report the cumulative COVID-19 caseload in the PMCs 41 Prabhags (also known as electoral wards). The number tested and individual-level data, such as age, sex, residential address, COVID-19 test results, and COVID-19 outcomes, were centrally compiled on a regular (almost daily) basis22.
(a) Location of Pune City, India. (b) Geographic boundaries of ward offices located within Pune Municipal Corporation (PMC). Fill color indicates the quartile of population density (persons per square kilometer) and the proportion of slum population in each ward. Numbers inside the olive boxes indicate the official ward office number (see Supplemental Table S1 for the name corresponding to each ward office number). (c) the number of COVID-19 patients in each PMC ward office at beginning of the pandemic (left panel), at the end of the nationwide lockdown (middle panel), and at the end of the study period (right panel). The date is located at the top of each panel. Dark gray indicates<50 patients, white indicates no patients, and the transition between blues and reds seen in the middle panel denotes approximately 600 patients.
Indias initial response to the pandemic comprised travel advisories on international travel and suspension of visas from mid-January through mid-March. During this period, COVID-19 testing was administered to travelers who were returning from China and other foreign countries and had fever, cough or other viral respiratory symptoms20. Those testing positive were hospitalized for quarantine, and their close contacts were traced and underwent COVID-19 testing. The first nationwide lockdown was implemented from March 25th to April 14th, 2020 (Lockdown 1). Nearly all services and factories were suspended with reports of arrests for lockdown violations. During this time, Pune city expanded COVID-19 testing capacity, making testing available to persons with viral symptoms or within 14days of COVID-19 exposure. The nationwide lockdown was extended from April 15th to May 3rd (Lockdown 2). Agricultural activities and essential services were allowed to function from April 20th, and Pune city areas were classified into red, orange, and green zones based on infection clusters. Red zones were defined by the central government based on case counts, doubling rate, and testing/surveillance findings. Initially, the central government defined the red zone as a particular area/district with more than 15 active cases. The area with<15 cases with no recent surge were defined as the orange zone. The area with zero COVID cases were green zones. However later as the cases surged in the country, the central government allowed the states to categorize the zones. Notably, interstate transport was allowed for stranded individuals, and during the month of May alone, approximately one million migrants traveled via roads or trains to their home states, mostly from Maharashtra state. The lockdown was extended again from May 4th to May 17th (Lockdown 3), but with more relaxations in green zones where lower infection rates were reported. The final extension spanned May 18th to May 31st (Lockdown 4). States were given more authority to demarcate infection zones, and red zones were further divided into containment zones, which maintained stricter enforcement of lockdown norms than other zones.
The unlocking (resumption) of economic activities began in June 2020. During the first phase (Unlock 1, June 1st to June 30th), interstate travel was allowed with few state-specific restrictions while containment zones continued to follow lockdown norms. Phased unlocking continued in July (Unlock 2) when the authority to impose lockdowns was further decentralized to local governments. Pune city and the adjoining areas implemented a regional lockdown from July 14th to July 23rd in response to a sharp rise in COVID-19 patients. City and state authorities enforced a strict lockdown during the first weeka complete shutdown of all essential services, except emergency healthcare. This resulted in minimal movement in Punes public spaces. Slight relaxations in the supply of essential goods and services followed during the second week and Unlock 2 resumed in Pune on July 24th. August 1st to August 31st (Unlock 3) witnessed further relaxations in interstate travel and an end to nationwide curfews. Pune shopping malls and market complexes could remain open until evening, and cab services could operate with a restricted passenger load. However, lockdown restrictions continued in containment zones. During September (Unlock 4), gatherings of up to 50 persons were permitted while containment zones continued to follow lockdown norms. Early in September, Pune experienced a sharp rise in COVID-19 patients and became a top national COVID-19 hotspot (The lockdown events are summarized in the supplemental Fig.1).
The area within PMC limits is divided into 15 administrative units, called ward offices (Fig.1b), which are further divided into 41 electoral wards with similar populations, called prabhags. Individual-level data were included for the time period spanning February 1st to September 15th, 2020. According to daily press reports released by PMC, a total of 542,946 samples were collected for COVID-19 testing during the study period, and of these, 313,373 records were available. These data were curated to remove records with missing data. The remaining records were assigned to a prabhag using a machine learning based geocoder that was developed in house. The geocoding methodology is described in the supplementary material 1. Records with a confidence score below 0.5 out of 1.0 (provided by the ML geocoder) and records for persons residing outside PMC limits were removed. The final dataset used for this analysis comprises 241,629 records.
This analysis was done retrospectively on programmatic data without personal identifiers, hence individual patient consent was not obtained as infeasible. The Ethics Committee of Indian Institute of Science Education and Research, Pune, India approved the analysis of COVID-19 programmatic data and has waived the need for obtaining the consent. The analysis and reporting were performed in accordance with the relevant guidelines and regulations.
The primary endpoint was weekly change in incident COVID-19 patients. The secondary endpoint was weekly infection rate; infection rate was calculated as the number of positive SARS-CoV-2 results divided by the total number of tests per 1000 population. Other endpoints included risk of COVID-19, defined as an incident COVID-19 case. Primary and secondary endpoints were assessed pre-lockdown, during lockdown and post-lockdown in the overall dataset and by population characteristics, namely sex, age group, and ward office-specific subcategories (population density and proportion residing in slum areas). Population density was calculated as number of people per 1 square kilometer and has been reported for all 15 PMC ward offices. For this analysis, population density was binarized as high (above the 3rd quartile of PMC ward office density, n=6) or low-average (below the 3rd quartile of PMC ward office density, n=9) (Fig.1b). Since differences in infection rates existed among ward offices, the effect of lockdown on the primary endpoint was assessed using a multilevel Poisson regression model with random effects for ward office and test week. Change in the weekly infection rate over the study period was estimated using quasi-Poisson regression analysis. Logistic regression was used to assess the effect of risk factors on mortality. Epidemic curves for trends of incident patients over time were plotted using nonparametric locally weighted regression for the overall population and by sex, age group, and ward-specific subcategories.
We modelled the trajectory of the natural epidemic to estimate the delay of the peak of the pandemic. For this, we used a 9-compartmental model INDSCI-SIM that enables robust predictions taking into account the effects of various non-pharmaceutical measures (Supplementary appendix)23,24. There are a wide range of estimates for the value of R0; for example, Hilton and Keeling estimated R0 between 2 and 325 while India specific study by Sinha found out the value to be around 1.8. In order to avoid overestimation of total patients, we also considered R0 =1.826. Although there is no unique way to estimate actual number of patients, we assume infection on the first day (taken to be 1st April 2020) of the simulation to be three times reported patients. We note here that the choice of R0 and initial values may affect the final outcome, but our choices are conservative and more accurate estimation may make the results worse than reported here. We assessed the geospatial spread of COVID-19 patients over time and the visualizations were generated using the Python library geopandas (version 0.7.0, https://pypi.org/project/geopandas/0.7.0/). (Supplementary appendix). Data were analyzed in Stata Version 142.
