Quantifying the human impact of Melbourne's 111-day hard lockdown experiment on the adult population.

Lockdown was used worldwide to mitigate the spread of severe acute respiratory syndrome coronavirus 2 and was the cornerstone non-pharmaceutical intervention of zero-COVID strategies. Many previous impact evaluations of lockdowns are unreliable because lockdowns co-occurred with severe coronavirus disease related health and financial insecurities. This was not the case in Melbourne's 111-day lockdown, which left other Australian jurisdictions unaffected. Interrogating nationally representative longitudinal survey data and quasi-experimental variation, and controlling for multiple hypothesis testing, we found that lockdown had some statistically significant, albeit small, impacts on several domains of human life. Women had lower mental health (-0.10 s.d., P = 0.043, 95% confidence interval (CI) = -0.21 to -0) and working hours (-0.13 s.d., P = 0.006, 95% CI = -0.22 to -0.04) but exercised more often (0.28 s.d., P < 0.001, 95% CI = 0.18 to 0.39) and received more government transfers (0.12 s.d., P = 0.048, 95% CI = 0.001 to 0.24). Men felt less part of their community (-0.20 s.d., P < 0.001, 95% CI = -0.30 to -0.10) and reduced working hours (-0.12 s.d., P = 0.004, 95% CI = -0.20 to -0.04). Heterogeneity analyses demonstrated that families with children were driving the negative results. Mothers had lower mental health (-0.27 s.d., P = 0.014, 95% CI = -0.48 to -0.06), despite feeling safer (0.26 s.d., P = 0.008, 95% CI = 0.07 to 0.46). Fathers increased their alcohol consumption (0.35 s.d., P = 0.002, 95% CI = 0.13 to 0.57). Some outcomes worsened with lockdown length for mothers. We discuss potential explanations for why parents were adversely affected by lockdown.

Economic preferences and obesity: Evidence from a clinical lab-in-field study.

Many studies which describe the relationship between obesity and economic preference rely on healthy, clinically-irrelevant populations. Instead, we study economic decision-making of a clinically-relevant population of 299 people with obesity who participated in a 6-months Randomized Controlled Trial in two Sydney-based hospitals to prevent diabetes onset. To elicit preferences, we use incentive-compatible experimental tasks that participants completed during their medical screening examination. In this population, we find that participants are risk averse, show no evidence of present bias, and have impatience levels comparable to healthy samples described in the international literature. Variations in present bias and impatience are not significantly associated with variations in markers of obesity. We find however a statistically significant negative association between risk tolerance and markers of obesity for women. Importantly, impatience moderates the link between risk tolerance and obesity, a finding which we are able to replicate in nationally-representative survey data. We discuss explanations for why our findings deviate markedly from the literature for this understudied but highly policy-relevant population. One explanation is that our specific population consists of forward-looking, well-educated individuals, who are willing to participate in an intensive health intervention. Hence, other factors may be at play for why these individuals live with obesity.

What happened to the predicted COVID-19-induced suicide epidemic, and why?

Two years ago, in the early stages of the COVID-19 pandemic, there were widespread and grim predictions of an ensuing suicide epidemic. Not only has this not happened but also by the end of 2021 in the majority of countries and regions with available data, the suicide rates had, if anything, declined. We discuss four reasons why the predictions of suicide models were exaggerated: (1) government intervention reduced the economic and mental costs of lockdowns, (2) the pandemic itself and lockdowns had less of an effect on mental health than assumed, (3) the evidence for a link between economic downturns, distress and suicide is weaker and less consistent than the models assumed and (4) predicting suicide is generally hard. Predictive models have an important place, but their strong modelling assumptions need to acknowledge the inherent high degree of uncertainty which has been further augmented by behavioural responses of pandemic management.

Emulating a target trial of intensive nurse home visiting in the policy-relevant population using linked administrative data.

BACKGROUND: Populations willing to participate in randomized trials may not correspond well to policy-relevant target populations. Evidence of effectiveness that is complementary to randomized trials may be obtained by combining the 'target trial' causal inference framework with whole-of-population linked administrative data. METHODS: We demonstrate this approach in an evaluation of the South Australian Family Home Visiting Program, a nurse home visiting programme targeting socially disadvantaged families. Using de-identified data from 2004-10 in the ethics-approved Better Evidence Better Outcomes Linked Data (BEBOLD) platform, we characterized the policy-relevant population and emulated a trial evaluating effects on child developmental vulnerability at 5 years (n = 4160) and academic achievement at 9 years (n = 6370). Linkage to seven health, welfare and education data sources allowed adjustment for 29 confounders using Targeted Maximum Likelihood Estimation (TMLE) with SuperLearner. Sensitivity analyses assessed robustness to analytical choices. RESULTS: We demonstrated how the target trial framework may be used with linked administrative data to generate evidence for an intervention as it is delivered in practice in the community in the policy-relevant target population, and considering effects on outcomes years down the track. The target trial lens also aided in understanding and limiting the increased measurement, confounding and selection bias risks arising with such data. Substantively, we did not find robust evidence of a meaningful beneficial intervention effect. CONCLUSIONS: This approach could be a valuable avenue for generating high-quality, policy-relevant evidence that is complementary to trials, particularly when the target populations are multiply disadvantaged and less likely to participate in trials.

Unintended consequences of welfare reform: Evidence from birthweight of Aboriginal children in Australia.

In 2007, Australia introduced its most radical welfare reform in recent history, targeting Aboriginal communities with the aim of protecting children from harm. The 'income management' policy forced Aboriginal welfare recipients to spend at least half of their government transfers on essentials (e.g. food, housing), and less on non-essentials (e.g. alcohol, tobacco). By exploiting its staggered rollout, we estimate the impact of in utero exposure to the policy rollout on birthweight. We find that exposure to the income management policy reduced average birthweight robustly by 85 g and increased the risk of low birth weight by 3 percentage points. This finding is not explained by behavioral change (fertility, maternal risk behavior, access to care), or survival probabilities of at-risk fetuses. More likely, a lack of policy implementation planning and infrastructure led to acute income insecurity and stress during the rollout period, exacerbating the existing health inequalities it sought to address.

Effect of lockdown on mental health in Australia: evidence from a natural experiment analysing a longitudinal probability sample survey.

BACKGROUND: Many studies have examined population mental health during the COVID-19 pandemic but have been unable to isolate the direct effect of lockdowns. The aim of this study was to examine changes in the mental health of Australians aged 15 years and older during the COVID-19 pandemic using a quasi-experimental design to disentangle the lockdown effect. METHODS: We analysed data from ten annual waves (2011-20) of the longitudinal Household, Income and Labour Dynamics in Australia (HILDA) Survey to identify changes in the mental health of respondents from the pre-COVID-19 period (2011-19) to the COVID-19 period (2020). Difference-in-differences models were used to compare these changes between respondents in the state of Victoria who were exposed to lockdown at the time of the 2020 interviews (treatment group) and respondents living elsewhere in Australia (who were living relatively free of restrictions; control group). The models included state, year (survey wave), and person-specific fixed effects. Mental health was assessed using the five-item Mental Health Inventory (MHI-5), which was included in the self-complete questionnaire administered during the survey. FINDINGS: The analysis sample comprised 151 583 observations obtained from 20 839 individuals from 2011 to 2020. The treatment group included 3568 individuals with a total of 37 578 observations (34 010 in the pre-COVID-19 and 3568 in the COVID-19 period), and the control group included 17 271 individuals with 114 005 observations (102 867 in the pre-COVID-19 and 11 138 in the COVID-19 period). Mean MHI-5 scores did not differ between the treatment group (72·9 points [95% CI 72·8-73·2]) and control group (73·2 points [73·1-73·3]) in the pre-COVID-19 period. In the COVID-19 period, decreased mean scores were seen in both the treatment group (69·6 points [69·0-70·2]) and control group (70·8 points [70·5-71·2]). Difference-in-differences estimation showed a small but statistically significant effect of lockdown on MHI-5 scores, with greater decline for residents of Victoria in 2020 than for those in the rest of Australia (difference -1·4 points [95% CI -1·7 to -1·2]). Stratified analyses showed that this lockdown effect was larger for females (-2·2 points [-2·6 to -1·7]) than for males (-0·6 [-0·8 to -0·5]), and even larger for women in couples with children younger than 15 years (-4·4 points [-5·0 to -3·8]), and for females who lived in flats or apartments (-4·1 points [-5·4 to -2·8]) or semi-detached houses, terraced houses, or townhouses (-4·8 points [-6·4 to -3·2]). INTERPRETATION: The imposition of lockdowns was associated with a modest negative change in overall population mental health. The results suggest that the mental health effects of lockdowns differ by population subgroups and for some might have exaggerated existing inequalities in mental health. Although lockdowns have been an important public health tool in suppressing community transmission of COVID-19, more research is needed into the potential psychosocial impacts of such interventions to inform their future use. FUNDING: US National Institutes of Health.

Lives saved during economic downturns: Evidence from Australia.

Worldwide, countries have been restricting work and social activities to counter the emerging public health crisis due to the coronavirus pandemic. These measures have caused dramatic increases in unemployment. Some commentators argue that the "draconian measures" will do more harm than good due to the economic contraction, despite a large literature that finds mortality rates decline during recessions. We estimate the relationship between unemployment, a proxy for economic climate, and mortality in Australia, a country with universal health care. Using administrative time-series data on mortality by state, age, sex, and cause of death for 1979-2017, we find no relationship between unemployment and mortality on average. However, we observe beneficial health effects in economic downturns for young men, associated with a reduction in transport accidents. Our estimates imply 431 fewer deaths in 2020 if unemployment rates double as forecast. For the early 1980s, we find a procyclical pattern in infant mortality rates. However, this pattern disappears starting from the mid-1980s, coincident with the 1984 implementation of universal health care. Our results suggest that universal health care may insulate individuals from the health effects of macroeconomic fluctuations.

Puumala and Tula Virus Differ in Replication Kinetics and Innate Immune Stimulation in Human Endothelial Cells and Macrophages.

Old world hantaviruses cause hemorrhagic fever with renal syndrome (HFRS) upon zoonotic transmission to humans. In Europe, the Puumala virus (PUUV) is the main causative agent of HFRS. Tula virus (TULV) is also widely distributed in Europe, but there is little knowledge about the pathogenicity of TULV for humans, as reported cases are rare. We studied the replication of TULV in different cell types in comparison to the pathogenic PUUV and analyzed differences in stimulation of innate immunity. While both viruses replicated to a similar extent in interferon (IFN)-deficient Vero E6 cells, TULV replication in human lung epithelial (A549) cells was slower and less efficient when compared to PUUV. In contrast to PUUV, no replication of TULV could be detected in human microvascular endothelial cells and in macrophages. While a strong innate immune response towards PUUV infection was evident at 48 h post infection, TULV infection triggered only a weak IFN response late after infection of A549 cells. Using appropriate in vitro cell culture models for the orthohantavirus infection, we could demonstrate major differences in host cell tropism, replication kinetics, and innate immune induction between pathogenic PUUV and the presumably non- or low-pathogenic TULV that are not observed in Vero E6 cells and may contribute to differences in virulence.

Introducing a GP copayment in Australia: Who would carry the cost burden?

Recent policy changes designed to contain unsustainable health expenditure growth imply that many more Australians may soon be charged a copayment to consult a GP. We explore the distributional consequences associated with a range of hypothetical GP copayment scenarios using nationally-representative Australian survey data. For each scenario, we estimate the cost burden that individuals and households across the income distribution would need to absorb to maintain their current GP service utilisation. Even when concessional patients are charged a third or a quarter of the non-concessional copayment rate, the average estimated cost burden in the lowest income quartile is typically between three and six times that of the highest, and the average cost burden for women is significantly higher than for men within every income quartile. These disparities are intensified for those with a chronic illness. We conclude that the widespread implementation of GP copayments would disproportionately burden lower-income families, who experience higher rates of chronic illness, higher demand for GP services, and lower capacity to absorb price increases. The regressive nature of GP copayments is reduced when concessional and child patients are exempted entirely, highlighting the importance of supporting GPs-particularly in disadvantaged areas-to maintain bulk-billing arrangements for vulnerable patient groups.

Efficacy Testing of H56 cDNA Tattoo Immunization against Tuberculosis in a Mouse Model.

Tuberculosis (TB), caused by Mycobacterium tuberculosis (Mtb), remains a global threat. The only approved vaccine against TB, Mycobacterium bovis bacillus Calmette-Guérin (BCG), provides insufficient protection and, being a live vaccine, can cause disseminated disease in immunocompromised individuals. Previously, we found that intradermal cDNA tattoo immunization with cDNA of tetanus toxoid fragment C domain 1 fused to cDNA of the fusion protein H56, comprising the Mtb antigens Ag85B, ESAT-6, and Rv2660c, induced antigen-specific CD8+ T cell responses in vivo. As cDNA tattoo immunization would be safer than a live vaccine in immunocompromised patients, we tested the protective efficacy of intradermal tattoo immunization against TB with H56 cDNA, as well as with H56_E, a construct optimized for epitope processing in a mouse model. As Mtb antigens can be used in combination with BCG to boost immune responses, we also tested the protective efficacy of heterologous prime-boost, using dermal tattoo immunization with H56_E cDNA to boost BCG immunization in mice. Dermal H56 and H56_E cDNA immunization induced H56-specific CD4+ and CD8+ T cell responses and Ag85B-specific IgG antibodies, but did not reduce bacterial loads, although immunization with H56_E ameliorated lung pathology. Both subcutaneous and intradermal immunization with BCG resulted in broad cellular immune responses, with increased frequencies of CD4+ T effector memory cells, T follicular helper cells, and germinal center B cells, and resulted in reduced bacterial loads and lung pathology. Heterologous vaccination with BCG/H56_E cDNA induced increased H56-specific CD4+ and CD8+ T cell cytokine responses compared to vaccination with BCG alone, and lung pathology was significantly decreased in BCG/H56_E cDNA immunized mice compared to unvaccinated controls. However, bacterial loads were not decreased after heterologous vaccination compared to BCG alone. CD4+ T cells responding to Ag85B- and ESAT-6-derived epitopes were predominantly IFN-γ+TNF-α+ and TNF-α+IL-2+, respectively. In conclusion, despite inducing appreciable immune responses to Ag85B and ESAT-6, intradermal H56 cDNA tattoo immunization did not substantially enhance the protective effect of BCG under the conditions tested.

Origins of adulthood personality: The role of adverse childhood experiences.

We test whether adverse childhood experiences - exposure to parental maltreatment and its indirect effect on health - are associated with age 30 personality traits. We use rich longitudinal data from a large, representative cohort of young US Americans and exploit differences across siblings to control for the confounding influences of shared environmental and genetic factors. We find that maltreatment experiences are significantly and robustly associated with neuroticism, conscientiousness, and openness to experience, but not with agreeableness and extraversion. High levels of neuroticism are linked to sexual abuse and neglect; low levels of conscientiousness and openness to experience are linked to parental neglect. The associations are partially explained by the indirect effects of maltreatment on adolescence physical and mental health. Maltreatment experiences, in combination with their health effects, explain a substantial fraction of the relationship between adulthood conscientiousness and earnings or human capital. Our findings provide a possible explanation for why personality traits are important predictors of adulthood labor market outcomes.

Exploring the intergenerational persistence of mental health: evidence from three generations.

This paper uses data from the 1970 British Cohort Study to quantify the intergenerational persistence of mental health, and the long-run economic costs associated with poor parental mental health. We find a strong and significant intergenerational correlation that is robust to different covariate sets, sample restrictions, model specifications and potential endogeneity. Importantly, the intergenerational persistence is economically relevant, with maternal mental health associated with lasting effects on the child's educational attainment, future household income and the probability of having criminal convictions. These results do not disappear after controlling for children's own childhood and adulthood mental health.

Getting stuck in the blues: persistence of mental health problems in Australia.

Do episodes of mental health (MH) problems cause future MH problems, and if yes, how strong are these dynamics? We quantify the degree of persistence in MH problems using nationally representative, longitudinal data from Australia and system generalized method of moments (GMM), and correlated random effects approaches are applied to separate true from spurious state dependence. Our results suggest only a moderate degree of persistence in MH problems when assuming that persistence is constant across the MH distribution once individual-specific heterogeneity is accounted for. However, individuals who fell once below a threshold that indicates an episode of depression are up to five times more likely to experience such a low score again a year later, indicating a strong element of state dependence in depression. Low income is a strong risk factor in state dependence for both men and women, which has important policy implications.

Australian doctors' satisfaction with their work: results from the MABEL longitudinal survey of doctors.

OBJECTIVE: To compare the level and determinants of job satisfaction between four groups of Australian doctors: general practitioners, specialists, specialists-in-training, and hospital non-specialists. DESIGN, PARTICIPANTS AND SETTING: National cross-sectional questionnaire survey as part of the baseline cohort of a longitudinal survey of Australian doctors in clinical practice (Medicine in Australia - Balancing Employment and Life [MABEL]), undertaken between June and November 2008, including 5193 Australian doctors (2223 GPs, 2011 specialists, 351 hospital non-specialists, and 608 specialists-in-training). MAIN OUTCOME MEASURES: Job satisfaction scores for each group of doctors; the association between job satisfaction and doctor, job and geographical characteristics. RESULTS: 85.7% of doctors were moderately or very satisfied with their jobs. There were no differences in job satisfaction between GPs, specialists and specialists-in-training. Hospital non-specialists were the least satisfied compared with GPs (odds ratio [OR], 0.56 [95% CI, 0.39-0.81]). For all doctors, factors associated with high job satisfaction were a good support network (OR, 1.72 [95% CI, 1.41-2.10]), patients not having unrealistic expectations (OR, 1.48 [95% CI, 1.25-1.75]), and having no difficulty in taking time off work (OR,1.48 [95% CI, 1.20-1.84]). These associations did not vary across doctor types. Compared with GPs, on-call work was associated with lower job satisfaction for specialists (OR, 0.48 [95% CI, 0.23-0.98]) and hospital non-specialists (OR, 0.25 [95% CI, 0.08-0.83]). CONCLUSION: This is the first national survey of job satisfaction for doctors in Australia. It provides an important baseline to examine the impact of future health care reforms and other policy changes on the job satisfaction of doctors.

The effects of an incentive program on quality of care in diabetes management.

An incentive program for general practitioners to encourage systematic and igh-quality care in chronic disease management was introduced in Australia in 1999. There is little empirical evidence and ambiguous theoretical guidance on which effects to expect. This paper evaluates the impact of the incentive program on quality of care in diabetes, as measured by the probability of ordering an HbA1c test. The empirical analysis is conducted with a unique data set and a bivariate probit model to control for the self-selection process of practices into the program. The study finds that the incentive program increased the probability of an HbA1c test being ordered by 20 percentage points and that participation in the program is facilitated by the support of Divisions of General Practice.

Systemic activation of the immune system induces aberrant BAFF and APRIL expression in B cells in patients with systemic lupus erythematosus.

OBJECTIVE: Elevated levels of BAFF and APRIL are characteristic of patients with systemic lupus erythematosus (SLE). The reasons for enhanced cytokine production are not well understood. This study was undertaken to identify the cells responsible for the overproduction of these cytokines. METHODS: BAFF expression was analyzed on peripheral blood mononuclear cells by multiparameter flow cytometry and in tissue samples by immunofluorescence staining. The levels of BAFF and APRIL mRNA were quantified in sorted B cells. In vitro cultures were used to analyze whether B cell survival and differentiation was supported by autocrine BAFF and/or APRIL. RESULTS: Aberrant activation of B cells in patients with SLE was associated with a significant up-regulation of BAFF expression in naive, memory, and plasma cells. Furthermore, strong expression of BAFF and APRIL was found in plasma cells from the lymph node, bone marrow, and kidney. The levels of BAFF and APRIL mRNA in CD19+ B cells correlated both with the titer of anti-double stranded DNA antibodies and with the SLE Disease Activity Index. In vitro experiments demonstrated that B cells released functional BAFF/APRIL upon activation. CONCLUSION: Our data show that B cells contribute to the enhanced levels of circulating BAFF and APRIL. The aberrant up-regulation of these cytokines may initiate a vicious circle in which enhanced levels of BAFF and APRIL act in an autocrine manner to reinforce the systemic activation of the humoral immune system.