Subjective awareness of sleepiness while driving in younger and older adults.

Understanding whether drivers can accurately assess sleepiness is essential for educational campaigns advising drivers to stop driving when feeling sleepy. However, few studies have examined this in real-world driving environments, particularly among older drivers who comprise a large proportion of all road users. To examine the accuracy of subjective sleepiness ratings in predicting subsequent driving impairment and physiological drowsiness, 16 younger (21-33 years) and 17 older (50-65 years) adults drove an instrumented vehicle for 2 h on closed loop under two conditions: well-rested and 29 h sleep deprivation. Sleepiness ratings (Karolinska Sleepiness Scale, Likelihood of Falling Asleep scale, Sleepiness Symptoms Questionnaire) were obtained every 15min, alongside lane deviations, near crash events, and ocular indices of drowsiness. All subjective sleepiness measures increased with sleep deprivation for both age groups (p < 0.013). While most subjective sleepiness ratings significantly predicted driving impairment and drowsiness in younger adults (OR: 1.7-15.6, p < 0.02), this was only apparent for KSS, likelihood of falling asleep, and "difficulty staying in the lane for the older adults" (OR: 2.76-2.86, p = 0.02). This may be due to an altered perception of sleepiness in older adults, or due to lowered objective signs of impairment in the older group. Our data suggest that (i) younger and older drivers are aware of sleepiness; (ii) the best subjective scale may differ across age groups; and (iii) future research should expand on the best subjective measures to inform of crash risk in older adults to inform tailored educational road safety campaigns on signs of sleepiness.

A brief assessment of eye blink drowsiness immediately prior to or following driving detects drowsiness related driving impairment.

Drowsy driving is a major cause of fatal and serious injury motor vehicle accidents. The inability objectively to assess drowsiness has hindered the assessment of fitness to drive and the development of drowsy driving regulations. This study evaluated whether spontaneous eye blink parameters measured briefly pre- and post-drive could be used to detect drowsy driving impairment. Twelve healthy participants (6 female) drove an instrumented vehicle for 2 h on a closed-loop track during a rested (8-10 h awake) and an extended wake condition (32-34 h awake). Pre- and post-drive, the participants completed a 5 min eye blink task, a psychomotor vigilance task (PVT), and the Karolinska sleepiness scale (KSS). Whole drive impairment was defined as >3.5 lane departures per hour. Severe end of drive impairment was defined as ≥2 lane departures in the last 15 min. The pre-drive % of time with eyes closed best predicted the whole drive impairment (area under the curve [AUC] 0.87). KSS had similar prediction ability (AUC 0.85), while PVT reaction time (AUC 0.72) was less accurate. The composite eye blink parameter, the Johns drowsiness scale was the best retrospective detector of severe end of drive impairment (AUC 0.99). The PVT reaction time (AUC 0.92) and the KSS (AUC 0.93) were less accurate. Eye blink parameters detected drowsy driving impairment with an accuracy that was similar to, or marginally better than, PVT and KSS. As eye blink measures are simple to measure, are objective and have high accuracy, they present an ideal option for the assessment of fitness for duty and roadside drowsiness.

Pilot feasibility testing of biomathematical model recommendations for personalising sleep timing in shift workers.

Sleep disturbances and circadian disruption play a central role in adverse health, safety, and performance outcomes in shift workers. While biomathematical models of sleep and alertness can be used to personalise interventions for shift workers, their practical implementation is undertested. This study tested the feasibility of implementing two biomathematical models-the Phillips-Robinson Model and the Model for Arousal Dynamics-in 28 shift-working nurses, 14 in each group. The study examined the overlap and adherence between model recommendations and sleep behaviours, and changes in sleep following the implementation of recommendations. For both groups combined, the mean (SD) percentage overlap between when a model recommended an individual to sleep and when sleep was obtained was 73.62% (10.24%). Adherence between model recommendations and sleep onset and offset times was significantly higher with the Model of Arousal Dynamics compared to the Phillips-Robinson Model. For the Phillips-Robinson model, 27% of sleep onset and 35% of sleep offset times were within ± 30 min of model recommendations. For the Model of Arousal Dynamics, 49% of sleep onset, and 35% of sleep offset times were within ± 30 min of model recommendations. Compared to pre-study, significant improvements were observed post-study for sleep disturbance (Phillips-Robinson Model), and insomnia severity and sleep-related impairments (Model of Arousal Dynamics). Participants reported that using a digital, automated format for the delivery of sleep recommendations would enable greater uptake. These findings provide a positive proof-of-concept for using biomathematical models to recommend sleep in operational contexts.

The impact of break duration, time of break onset, and prior shift duration on the amount of sleep between shifts in heavy vehicle drivers.

This study aimed to examine the impact of break duration between consecutive shifts, time of break onset, and prior shift duration on total sleep time (TST) between shifts in heavy vehicle drivers (HVDs), and to assess the interaction between break duration and time of break onset. The sleep (actigraphy and sleep diaries) and work shifts (work diaries) of 27 HVDs were monitored during their usual work schedule for up to 9 weeks. Differences in TST between consecutive shifts and days off were assessed. Linear mixed models (followed by pairwise comparisons) assessed whether break duration, prior shift duration, time of break onset, and the interaction between break duration and break onset were related to TST between shifts. Investigators found TST between consecutive shifts (mean [SD] 6.38 [1.38] h) was significantly less than on days off (mean [SD] 7.63 [1.93] h; p < 0.001). Breaks starting between 12:01 and 8:00 a.m. led to shorter sleep (p < 0.05) compared to breaks starting between 4:01 and 8:00 p.m. Break durations up to 7, 9, and 11 h (Australian and European minimum break durations) resulted in a mean (SD) of 4.76 (1.06), 5.66 (0.77), and 6.41 (1.06) h of sleep, respectively. The impact of shift duration prior to the break and the interaction between break duration and time of break were not significant. HVDs' sleep between workdays is influenced independently by break duration and time of break onset. This naturalistic study provides evidence that current break regulations prevent sufficient sleep duration in this industry. Work regulations should evaluate appropriate break durations and break onset times to allow longer sleep opportunities for HVDs.

The impact of alcohol consumption on commercial eye blink drowsiness detection technology.

INTRODUCTION: Driver drowsiness detection technology that assesses eye blinks is increasingly being used as a safety intervention in the transport industry. It is unclear how alcohol consumption to common legal driving limits impacts upon this technology. The aim of the study was to assess the impact of a blood alcohol content (BAC) of 0.05% and of 0.08% on drowsiness detection technology during simulated driving. METHODS: Participants completed a 60-min driving simulation and sleepiness questionnaire under three conditions: 1-0.00% BAC, 2-0.05% BAC and 3-0.08% BAC. During the driving simulation task participants wore a commercial eye blink drowsiness detection technology (Optalert) with the drowsiness alarms silenced. RESULTS: Twelve participants (3 female) completed all alcohol conditions. Relative to baseline, all eye blink parameters were affected at 0.08% BAC (all p < 0.05), whereas 0.05% BAC only affected the composite eye blink drowsiness measure (the Johns Drowsiness Scale). CONCLUSIONS: Alcohol consumption to 0.08% BAC impaired eye blink measures to a level that would be considered a moderate drowsiness risk. Therefore, employers should be aware that drowsiness alerts from these technologies may increase after alcohol consumption.

European NCAP Driver State Monitoring Protocols: Prevalence of Distraction in Naturalistic Driving.

OBJECTIVE: examine the prevalence of driver distraction in naturalistic driving when implementing European New Car Assessment Program (Euro NCAP)-defined distraction behaviours. BACKGROUND: The 2023 introduction of Occupant Status monitoring (OSM) into Euro NCAP will accelerate uptake of Driver State Monitoring (DSM). Euro NCAP outlines distraction behaviours that DSM must detect to earn maximum safety points. Distraction behaviour prevalence and driver alerting and intervention frequency have yet to be examined in naturalistic driving. METHOD: Twenty healthcare workers were provided with an instrumented vehicle for approximately two weeks. Data were continuously monitored with automotive grade DSM during daily work commutes, resulting in 168.8 hours of driver head, eye and gaze tracking. RESULTS: Single long distraction events were the most prevalent, with .89 events/hour. Implementing different thresholds for driving-related and driving-unrelated glance regions impacts alerting rates. Lizard glances (primarily gaze movement) occurred more frequently than owl glances (primarily head movement). Visual time-sharing events occurred at a rate of .21 events/hour. CONCLUSION: Euro NCAP-described driver distraction occurs naturalistically. Lizard glances, requiring gaze tracking, occurred in high frequency relative to owl glances, which only require head tracking, indicating that less sophisticated DSM will miss a substantial amount of distraction events. APPLICATION: This work informs OEMs, DSM manufacturers and regulators of the expected alerting rate of Euro NCAP defined distraction behaviours. Alerting rates will vary with protocol implementation, technology capability, and HMI strategies adopted by the OEMs, in turn impacting safety outcomes, user experience and acceptance of DSM technology.

Tracheostomy clinical practices and patient outcomes in three tertiary metropolitan hospitals in Australia.

BACKGROUND: There is a paucity of literature in Australia on patient-focused tracheostomy outcomes and process outcomes. Exploration of processes of care enables teams to identify and address existing barriers that may prevent earlier therapeutic interventions that could improve patient outcomes following critical care survival. OBJECTIVES: The objectives of this study were to examine and provide baseline data and associations between tracheostomy clinical practices and patient outcomes across three large metropolitan hospitals. METHODS: We performed a retrospective multisite observational study in three tertiary metropolitan Australian health services who are members of the Global Tracheostomy Collaborative. Deidentified data were entered into the Global Tracheostomy Collaborative database from Jan 2016 to Dec 2019. Descriptive statistics were used for the reported outcomes of length of stay, mortality, tracheostomy-related adverse events and complications, tracheostomy insertion, airway, mechanical ventilation, communication, swallowing, nutrition, length of cannulation, and decannulation. Pearson's correlation coefficient and one-way analyses of variance were performed to examine associations between variables. RESULTS: The total cohort was 380 patients. The in-hospital mortality of the study cohort was 13%. Overall median hospital length of stay was 46 days (interquartile range: 31-74). Length of cannulation was shorter in patients who did not experience any tracheostomy-related adverse events (p= 0.036) and who utilised nonverbal communication methods (p = 0.041). Few patients (8%) utilised verbal communication methods while mechanically ventilated, compared with 80% who utilised a one-way speaking valve while off the ventilator. Oral intake was commenced in 20% of patients prior to decannulation. Patient nutritional intake varied prior to and at the time of decannulation. Decannulation occurred in 83% of patients. CONCLUSIONS: This study provides baseline data for tracheostomy outcomes across three large metropolitan Australian hospitals. Most outcomes were comparable with previous international and local studies. Future research is warranted to explore the impact of earlier nonverbal communication and interventions targeting the reduction in tracheostomy-related adverse events.

Maternal sleep behaviours preceding fetal heart rate events on cardiotocography.

In Australia, a significant proportion of stillbirths remain unexplained. Recent research has highlighted nocturnal maternal behaviours as potentially modifiable contributors. This study determined whether sleep-related behaviours including sleep position and sleep-disordered breathing adversely affect fetuses overnight, in both uncomplicated pregnancies and those at increased risk due to hypertensive disorders or fetal growth restriction (FGR). All participants underwent polysomnography with time-synchronized fetal heart rate (FHR) monitoring (cardiotocography - CTG) in late pregnancy. CTGs were analysed for abnormal FHR events, including decelerations and reduced variability, by two blinded observers and exported into the sleep study to temporally align FHR events with sleep behaviours. For each FHR event, 10 control epochs with normal FHR were randomly selected for the same participant. Conditional logistic regression assessed the relationships between FHR events and sleep behaviours. From 116 participants, 52 had a total of 129 FHR events overnight; namely prolonged decelerations and prolonged periods of reduced variability. Significantly more FHR events were observed in women with FGR and/or a hypertensive disorder compared with uncomplicated pregnancies (P = 0.006). FHR events were twice as likely to be preceded by a change in body position within the previous 5 min, compared with control epochs (P = 0.007), particularly in hypertensive pregnancies both with and without FGR. Overall, FHR events were not temporally related to supine body position, respiratory events or snoring. Our results indicate that most fetuses tolerate sleep-related stressors, but further research is needed to identify the interplay of maternal and fetal conditions putting the fetus at risk overnight. KEY POINTS: Maternal sleep behaviours including supine position and sleep-disordered breathing are potential contributors to stillbirth but much of this work is based on self-reported data. Using time-synchronized polysomnography and cardiotocography, we found that nocturnal fetal heart rate decelerations were more likely to be preceded by a change in body position compared with epochs containing normal fetal heart rate, particularly in hypertensive pregnancies with or without fetal growth restriction. There was no temporal relationship between maternal sleeping position, snoring or apnoeic events and an abnormal fetal heart rate overnight. We conclude that most fetuses can tolerate sleep-related stressors with no evidence of fetal heart rate changes indicating compromised wellbeing. Further work needs to identify how sleep behaviours contribute to stillbirth risk and how these intersect with underlying maternal and fetal conditions.

Perception of Local COVID-19 Transmission and Use of Preventive Behaviors Among Adults with Recent SARS-CoV-2 Infection - Illinois and Michigan, June 1-July 31, 2022.

During the early stages of the COVID-19 pandemic, use of preventive behaviors was associated with perceived risk for contracting SARS-CoV-2 infection (1,2). Over time, perceived risk has declined along with waning COVID-19-related media coverage (3,4). The extent to which communities continue to be aware of local COVID-19 transmission levels and are implementing recommended preventive behaviors is unknown. During June 1-July 31, 2022, health departments in DuPage County, Illinois and metropolitan Detroit, Michigan surveyed a combined total of 4,934 adults who had received a positive test result for SARS-CoV-2 during the preceding 3 weeks. The association between awareness of local COVID-19 transmission and use of preventive behaviors and practices was assessed, both in response to perceived local COVID-19 transmission levels and specifically during the 2 weeks preceding SARS-CoV-2 testing. Both areas had experienced sustained high COVID-19 transmission during the study interval as categorized by CDC COVID-19 transmission levels.* Overall, 702 (14%) respondents perceived local COVID-19 transmission levels as high, 987 (20%) as substantial, 1,902 (39%) as moderate, and 581 (12%) as low; 789 (16%) reported they did not know. Adjusting for geographic area, age, gender identity, and combined race and ethnicity, respondents who perceived local COVID-19 transmission levels as high were more likely to report having made behavioral changes because of the level of COVID-19 transmission in their area, including wearing a mask in public, limiting travel, and avoiding crowded places or events. Continued monitoring of public perceptions of local COVID-19 levels and developing a better understanding of their influence on the use of preventive behaviors can guide COVID-19 communication strategies and policy making during and beyond the pandemic.

Fetal heart rate events during sleep, and the impact of sleep disordered breathing, in pregnancies complicated by preterm fetal growth restriction: An exploratory observational case-control study.

OBJECTIVES: To evaluate fetal heart rate (FHR) patterns during sleep in pregnancies complicated by preterm fetal growth restriction (FGR). To determine whether co-existing sleep-disordered breathing (SDB) impacts on acute FHR events or perinatal outcome. DESIGN: Observational case control study. SETTING AND POPULATION: Women with preterm FGR and gestation-matched well grown controls (estimated fetal weight above the 10th percentile with normal Doppler studies); tertiary maternity hospital, Australia. METHODS: A polysomnogram, a test used to measure sleep patterns and diagnose sleep disorders, and concurrent cardiotocography (CTG), were analysed for respiratory events and FHR changes. MAIN OUTCOME MEASURES: Frequency of FHR events overnight in FGR cases versus controls and in those with or without SDB. RESULTS: Twenty-nine patients with preterm FGR and 29 controls (median estimated fetal weight 1st versus 60th percentile, P < 0.001) underwent polysomnography with concurrent CTG at a mean gestation of 30.2 weeks. The median number of FHR events per night was higher among FGR cases than among controls (3.0 events, interquartile range [IQR] 1.0-4.0, versus 1.0 [IQR 0-1.0]; P < 0.001). Women with pregnancies complicated by preterm FGR were more likely than controls to be nulliparous, receive antihypertensive medications, be supine at sleep onset, and to sleep supine (32.9% of total sleep time versus 18.3%, P = 0.03). SDB was common in both FGR and control pregnancies (48% versus 38%, respectively, P = 0.55) but was generally mild and not associated with an increase in overnight FHR events or adverse perinatal outcome. CONCLUSIONS: Acute FHR events overnight are more common in pregnancies complicated by preterm FGR than in pregnancies with normal fetal growth. Mild SDB was common in late pregnancy and well tolerated, even by fetuses with preterm FGR. TWEETABLE ABSTRACT: Mild sleep-disordered breathing seems well tolerated even by highly vulnerable fetuses.

Factors associated with short versus prolonged tracheostomy length of cannulation and the relationship between length of cannulation and adverse events.

BACKGROUND: Tracheostomy management and care is multifaceted and costly, commonly involving complex patients with prolonged hospitalisation. Currently, there are no agreed definitions of short and prolonged length of tracheostomy cannulation (LOC) and no consensus regarding the key factors that may be associated with time to decannulation. OBJECTIVES: The aims of this study were to identify the factors associated with short and prolonged LOC and to examine the number of tracheostomy-related adverse events of patients who had short LOC versus prolonged LOC. METHODS: A retrospective observational study was undertaken at a large metropolitan tertiary hospital. Factors known at the time of tracheostomy insertion, including patient, acuity, medical, airway, and tracheostomy factors, were analysed using Cox proportional hazards model and Kaplan-Meier survival curves, with statistically significant factors then analysed using univariate logistic regression to determine a relationship to short or prolonged LOC as defined by the lowest and highest quartiles of the study cohort. The number of tracheostomy-related adverse events was analysed using the Kaplan-Meier survival curve. RESULTS: One hundred twenty patients met the inclusion criteria. Patients who had their tracheostomy performed for loss of upper airway were associated with short LOC (odds ratio [OR]: 2.30 (95% confidence interval [CI]: 1.01-5.25) p = 0.049). Three factors were associated with prolonged LOC: an abdominal/gastrointestinal tract diagnosis (OR: 5.00 [95% CI: 1.40-17.87] p = 0.013), major surgery (OR: 2.51 [95% CI: 1.05-6.01] p = 0.038), and intubation for >12 days (OR: 0.30 [95% CI: 0.09-0.97] p = 0.044). Patients who had one or ≥2 tracheostomy-related adverse events had a high likelihood of prolonged LOC (OR: 5.21 [95% CI: 1.95-13.94] p = ≤0.001 and OR: 12.17 [95% CI: 2.68-55.32] p ≤ 0.001, respectively). CONCLUSION: Some factors that are known at the time of tracheostomy insertion are associated with duration of tracheostomy cannulation. Tracheostomy-related adverse events are related to a high risk of prolonged LOC.

Mental Health and Substance Use Among Adults with Disabilities During the COVID-19 Pandemic - United States, February-March 2021.

Adults with disabilities, a group including >25% of U.S. adults (1), experience higher levels of mental health and substance use conditions and lower treatment rates than do adults without disabilities* (2,3). Survey data collected during April-September 2020 revealed elevated adverse mental health symptoms among adults with disabilities (4) compared with the general adult population (5). Despite disproportionate risk for infection with SARS-CoV-2, the virus that causes COVID-19, and COVID-19-associated hospitalization and mortality among some adults with disabilities (6), information about mental health and substance use in this population during the pandemic is limited. To identify factors associated with adverse mental health symptoms and substance use among adults with disabilities, the COVID-19 Outbreak Public Evaluation (COPE) Initiative† administered nonprobability-based Internet surveys to 5,256 U.S. adults during February-March 2021 (response rate = 62.1%). Among 5,119 respondents who completed a two-item disability screener, nearly one third (1,648; 32.2%) screened as adults with disabilities. These adults more frequently experienced symptoms of anxiety or depression (56.6% versus 28.7%, respectively), new or increased substance use (38.8% versus 17.5%), and suicidal ideation (30.6% versus 8.3%) than did adults without disabilities. Among all adults who had received a diagnosis of mental health or substance use conditions, adults with disabilities more frequently (42.6% versus 35.3%; p <0.001) reported that the pandemic made it harder for them to access related care or medication. Enhanced mental health and substance use screening among adults with disabilities and improved access to medical services are critical during public health emergencies such as the COVID-19 pandemic.

Health Care Access and Use Among Adults with Diabetes During the COVID-19 Pandemic - United States, February-March 2021.

Diabetes affects approximately one in 10 persons in the United States† and is a risk factor for severe COVID-19 (1), especially when a patient's diabetes is not well managed (2). The extent to which the COVID-19 pandemic has affected diabetes care and management, and whether this varies across age groups, is currently unknown. To evaluate access to and use of health care, as well as experiences, attitudes, and behaviors about COVID-19 prevention and vaccination, a nonprobability, Internet-based survey was administered to 5,261 U.S. adults aged ≥18 years during February-March 2021. Among respondents, 760 (14%) adults who reported having diabetes currently managed with medication were included in the analysis. Younger adults (aged 18-29 years) with diabetes were more likely to report having missed medical care during the past 3 months (87%; 79) than were those aged 30-59 years (63%; 372) or ≥60 years (26%; 309) (p<0.001). Overall, 44% of younger adults reported difficulty accessing diabetes medications. Younger adults with diabetes also reported lower intention to receive COVID-19 vaccination (66%) compared with adults aged ≥60 years§ (85%; p = 0.001). During the COVID-19 pandemic, efforts to enhance access to diabetes care for adults with diabetes and deliver public health messages emphasizing the importance of diabetes management and COVID-19 prevention, including vaccination, are warranted, especially in younger adults.

Mental Health Among Parents of Children Aged <18 Years and Unpaid Caregivers of Adults During the COVID-19 Pandemic - United States, December 2020 and February-⁠March 2021.

Early during the COVID-19 pandemic, nearly two thirds of unpaid caregivers of adults reported adverse mental or behavioral health symptoms, compared with approximately one third of noncaregivers† (1). In addition, 27% of parents of children aged <18 years reported that their mental health had worsened during the pandemic (2). To examine mental health during the COVID-19 pandemic among U.S. adults on the basis of their classification as having a parenting role (i.e., unpaid persons caring for children and adolescents aged <18 years, referred to as children in this report) or being an unpaid caregiver of adults (i.e., persons caring for adults aged ≥18 years),§ CDC analyzed data from cross-sectional surveys that were administered during December 2020 and February-March 2021 for The COVID-19 Outbreak Public Evaluation (COPE) Initiative.¶ Respondents were categorized as parents only, caregivers of adults only, parents-caregivers (persons in both roles), or nonparents/noncaregivers (persons in neither role). Adjusted odds ratios (aORs) for any adverse mental health symptoms, particularly suicidal ideation, were higher among all respondents who were parents, caregivers of adults, or both compared with respondents who were nonparents/noncaregivers and were highest among persons in both roles (parents-caregivers) (any adverse mental health symptoms: aOR = 5.1, 95% confidence interval [CI] = 4.1-6.2; serious suicidal ideation: aOR = 8.2, 95% CI = 6.5-10.4). These findings highlight that parents and caregivers, especially those balancing roles both as parents and caregivers, experienced higher levels of adverse mental health symptoms during the COVID-19 pandemic than adults without these responsibilities. Caregivers who had someone to rely on for support had lower odds of experiencing any adverse mental health symptoms. Additional measures are needed to improve mental health among parents, caregivers, and parents-caregivers.

Pulmonary embolus in patients with COVID-19: an Australian perspective.

Pulmonary embolus (PE) is a known complication of coronavirus disease 2019 (COVID-19). The diagnosis of PE in our hospitalised patients with COVID-19 correlated with more severe disease and occurred despite the use of routine thromboprophylaxis. Higher D-dimers were seen on admission in patients who developed PE and rose at PE diagnosis, suggesting a role for D-dimer in risk stratification.

Early public adherence with and support for stay-at-home COVID-19 mitigation strategies despite adverse life impact: a transnational cross-sectional survey study in the United States and Australia.

BACKGROUND: Governments worldwide recommended unprecedented measures to contain the coronavirus disease 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). As pressure mounted to scale back measures, understanding public priorities was critical. We assessed initial public adherence with and support for stay-at-home orders in nations and cities with different SARS-CoV-2 infection and COVID-19 death rates. METHODS: Cross-sectional surveys were administered to representative samples of adults aged ≥18 years from regions with different SARS-CoV-2 prevalences from April 2-8, 2020. Regions included two nations [the United States (US-high prevalence) and Australia (AU-low prevalence)] and two US cities [New York City (NY-high prevalence) and Los Angeles (LA-low prevalence)]. Regional SARS-CoV-2 and COVID-19 prevalence (cumulative SARS-CoV-2 infections, COVID-19 deaths) as of April 8, 2020: US (363,321, 10,845), AU (5956, 45), NY (81,803, 4571), LA (7530, 198). Of 8718 eligible potential respondents, 5573 (response rate, 63.9%) completed surveys. Median age was 47 years (range, 18-89); 3039 (54.5%) were female. RESULTS: Of 5573 total respondents, 4560 (81.8%) reported adherence with recommended quarantine or stay-at-home policies (range of samples, 75.5-88.2%). Additionally, 29.1% of respondents screened positive for anxiety or depression symptoms (range of samples, 28.6-32.0%), with higher prevalences among those of younger age, female gender, and those in quarantine or staying at home most of the time versus those who did not report these behaviours. Despite elevated prevalences of adverse mental health symptoms and significant life disruptions, 5022 respondents (90.1%) supported government-imposed stay-at-home orders (range of samples, 88.9-93.1%). Of these, 90.8% believed orders should last at least three more weeks or until public health or government officials recommended, with support spanning the political spectrum. CONCLUSIONS: Public adherence with COVID-19 mitigation policies was highly prevalent, in both highly-affected (US, NY) and minimally-affected regions (AU, LA). Despite disruption of respondents' lives, the vast majority supported continuation of extended stay-at-home orders. Despite common support, these two countries diverged in stringent mitigation implementation, which may have contributed to subsequent outcomes. These results reveal the importance of surveillance of public support for and adherence with such policies during the COVID-19 pandemic and for future infectious disease outbreaks.

Mental Health, Substance Use, and Suicidal Ideation During the COVID-19 Pandemic - United States, June 24-30, 2020.

The coronavirus disease 2019 (COVID-19) pandemic has been associated with mental health challenges related to the morbidity and mortality caused by the disease and to mitigation activities, including the impact of physical distancing and stay-at-home orders.* Symptoms of anxiety disorder and depressive disorder increased considerably in the United States during April-June of 2020, compared with the same period in 2019 (1,2). To assess mental health, substance use, and suicidal ideation during the pandemic, representative panel surveys were conducted among adults aged ≥18 years across the United States during June 24-30, 2020. Overall, 40.9% of respondents reported at least one adverse mental or behavioral health condition, including symptoms of anxiety disorder or depressive disorder (30.9%), symptoms of a trauma- and stressor-related disorder (TSRD) related to the pandemic† (26.3%), and having started or increased substance use to cope with stress or emotions related to COVID-19 (13.3%). The percentage of respondents who reported having seriously considered suicide in the 30 days before completing the survey (10.7%) was significantly higher among respondents aged 18-24 years (25.5%), minority racial/ethnic groups (Hispanic respondents [18.6%], non-Hispanic black [black] respondents [15.1%]), self-reported unpaid caregivers for adults§ (30.7%), and essential workers¶ (21.7%). Community-level intervention and prevention efforts, including health communication strategies, designed to reach these groups could help address various mental health conditions associated with the COVID-19 pandemic.

Delay or Avoidance of Medical Care Because of COVID-19-Related Concerns - United States, June 2020.

Temporary disruptions in routine and nonemergency medical care access and delivery have been observed during periods of considerable community transmission of SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19) (1). However, medical care delay or avoidance might increase morbidity and mortality risk associated with treatable and preventable health conditions and might contribute to reported excess deaths directly or indirectly related to COVID-19 (2). To assess delay or avoidance of urgent or emergency and routine medical care because of concerns about COVID-19, a web-based survey was administered by Qualtrics, LLC, during June 24-30, 2020, to a nationwide representative sample of U.S. adults aged ≥18 years. Overall, an estimated 40.9% of U.S. adults have avoided medical care during the pandemic because of concerns about COVID-19, including 12.0% who avoided urgent or emergency care and 31.5% who avoided routine care. The estimated prevalence of urgent or emergency care avoidance was significantly higher among the following groups: unpaid caregivers for adults* versus noncaregivers (adjusted prevalence ratio [aPR] = 2.9); persons with two or more selected underlying medical conditions† versus those without those conditions (aPR = 1.9); persons with health insurance versus those without health insurance (aPR = 1.8); non-Hispanic Black (Black) adults (aPR = 1.6) and Hispanic or Latino (Hispanic) adults (aPR = 1.5) versus non-Hispanic White (White) adults; young adults aged 18-24 years versus adults aged 25-44 years (aPR = 1.5); and persons with disabilities§ versus those without disabilities (aPR = 1.3). Given this widespread reporting of medical care avoidance because of COVID-19 concerns, especially among persons at increased risk for severe COVID-19, urgent efforts are warranted to ensure delivery of services that, if deferred, could result in patient harm. Even during the COVID-19 pandemic, persons experiencing a medical emergency should seek and be provided care without delay (3).

Demographic Characteristics, Experiences, and Beliefs Associated with Hand Hygiene Among Adults During the COVID-19 Pandemic - United States, June 24-30, 2020.

Frequent hand hygiene, including handwashing with soap and water or using a hand sanitizer containing ≥60% alcohol when soap and water are not readily available, is one of several critical prevention measures recommended to reduce the spread of SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19).* Previous studies identified demographic factors associated with handwashing among U.S. adults during the COVID-19 pandemic (1,2); however, demographic factors associated with hand sanitizing and experiences and beliefs associated with hand hygiene have not been well characterized. To evaluate these factors, an Internet-based survey was conducted among U.S. adults aged ≥18 years during June 24-30, 2020. Overall, 85.2% of respondents reported always or often engaging in hand hygiene following contact with high-touch public surfaces such as shopping carts, gas pumps, and automatic teller machines (ATMs).† Respondents who were male (versus female) and of younger age reported lower handwashing and hand sanitizing rates, as did respondents who reported lower concern about their own infection with SARS-CoV-2§ and respondents without personal experience with COVID-19. Focused health promotion efforts to increase hand hygiene adherence should include increasing visibility and accessibility of handwashing and hand sanitizing materials in public settings, along with targeted communication to males and younger adults with focused messages that address COVID-19 risk perception.

Public Attitudes, Behaviors, and Beliefs Related to COVID-19, Stay-at-Home Orders, Nonessential Business Closures, and Public Health Guidance - United States, New York City, and Los Angeles, May 5-12, 2020.

SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19), is thought to be transmitted mainly by person-to-person contact (1). Implementation of nationwide public health orders to limit person-to-person interaction and of guidance on personal protective practices can slow transmission (2,3). Such strategies can include stay-at-home orders, business closures, prohibitions against mass gatherings, use of cloth face coverings, and maintenance of a physical distance between persons (2,3). To assess and understand public attitudes, behaviors, and beliefs related to this guidance and COVID-19, representative panel surveys were conducted among adults aged ≥18 years in New York City (NYC) and Los Angeles, and broadly across the United States during May 5-12, 2020. Most respondents in the three cohorts supported stay-at-home orders and nonessential business closures* (United States, 79.5%; New York City, 86.7%; and Los Angeles, 81.5%), reported always or often wearing cloth face coverings in public areas (United States, 74.1%, New York City, 89.6%; and Los Angeles 89.8%), and believed that their state's restrictions were the right balance or not restrictive enough (United States, 84.3%; New York City, 89.7%; and Los Angeles, 79.7%). Periodic assessments of public attitudes, behaviors, and beliefs can guide evidence-based public health decision-making and related prevention messaging about mitigation strategies needed as the COVID-19 pandemic evolves.