The impacts of COVID-19 pandemic on mental health: A scoping review

Background: This scoping review assessed the COVID-19 impacts on mental health and associated risk factors. Methods: A literature search for relevant articles published between March 2020 and July 2022, was conducted in the APA PsychInfo, JBI Evidence Synthesis, Epistemonikos, PubMed, and Cochrane databases. Results: The article inclusion criteria were met by 72 studies. The commonly used mental health assessment tools were the Patient Health Questionnaire (41.7%), Generalized Anxiety Disorder Scale (36%), 21-item Depression, Anxiety, and Stress (13.9%), Impact of Event Scale (12.5%), Pittsburgh Sleep Quality Index (9.7%), Symptom Checklist and the General Health Questionnaire (6.9% each). The prevalence rate of depression ranged from 5-76.5%, 5.6-80.5% for anxiety, 9.1- 65% for Post-Traumatic Stress Disorder, 8.3-61.7% for sleep disorders, 4.9-70.1% for stress, 7-71.5% for psychological distress, and 21.4-69.3% for general mental health conditions. The risks included female gender, healthcare related/frontline jobs, isolation/quarantine, poverty, lower education, COVID-19 risk, age, commodities, mental illness history, negative psychology, and higher social media exposure. The incidence of mental disorders increased along with the increasing cases of COVID-19 and the corresponding government restrictions. Conclusion: Standard mental health assessment tools were used in these studies conducted during COVID-19. Mental health disorders like depression, anxiety, and stress increased during the COVID-19 pandemic and lockdowns. Various factors impacted the prevalence of mental health disorders. Policymakers need to provide social protective measures to improve coping in critical health events. Further studies should investigate the effectiveness of interventions for reducing the prevalence and risk factors for mental health conditions during a public health emergency.

Are there missed opportunities for vaccinating against hepatitis B among people who inject drugs in the UK?

Sustaining the impact of hepatitis B virus (HBV) vaccination on incidence and prevalence of HBV infection requires increasing and maintaining the uptake of vaccine among those at risk. In recent years, the level of vaccine uptake among people who inject drugs (PWID) in the UK has levelled-off. Data (2015-2016) from the national unlinked-anonymous monitoring survey of PWID, an annual survey that collects data from PWID across England, Wales and Northern Ireland, were used to examine HBV vaccine uptake. Data from participants who had injected drugs during the previous year were used to investigate sources of hepatitis B vaccine doses as well as factors associated with vaccine uptake. Among the 3175 anti-HBc-negative participants, 3138 (99%) reported their vaccination status; 23% (714) reported no vaccine uptake. Among those not vaccinated, 447 (63%) reported being sexually active and 116 (16%) reported sharing needles and syringes. Majority of those not vaccinated reported accessing services in the previous year that could have provided hepatitis B vaccine doses. These missed opportunities for vaccinating of PWID indicate a need for additional targeted interventions.

Low levels of hepatitis C diagnosis and testing uptake among people who inject image and performance enhancing drugs in England and Wales, 2012-15.

INTRODUCTION: People injecting image and performance enhancing drugs (IPEDs) have traditionally not been perceived as being at high risk of hepatitis C virus (HCV) infection. However, recent studies indicate the HCV antibody (anti-HCV) prevalence in this group is 10-times that in the general population. HCV testing uptake and undiagnosed infections are examined using data from a voluntary unlinked-anonymous survey. METHOD: People injecting IPEDs across England and Wales completed a short bio-behavioural survey (2012-15). Anti-HCV status and self-reports of HCV testing were used in the analysis. RESULTS: The participants median age was 31 years, 98% were men, 14% had also injected psychoactive drugs and the anti-HCV prevalence was 4.8% (N=564). Among those who had never injected psychoactive drugs the anti-HCV prevalence was 1.4%; among those who had recently injected psychoactive drugs (preceding 12 months) prevalence was 39% and among those who had done this previously 14% (p<0.001). Overall, 37% had been tested for HCV: among those who had recently injected psychoactive drugs 78% had been tested, as had 56% of those who had injected psychoactive drugs previously; 33% of those never injecting psychoactive drugs were tested (p<0.001). Overall, 44% of those with anti-HCV were aware of this; however, only 14% of those who had never injected psychoactive drugs were aware. CONCLUSIONS: One-in-twenty people who inject IPEDs have anti-HCV. HCV infections among those who had never injected psychoactive drugs were mostly undiagnosed, though this group had a lower prevalence. Targeted HCV testing interventions are also needed for those injecting IPEDs.

No longer 'written off' - times have changed for the BBV-infected dental professional.

There is a recognised potential risk of transmission of blood-borne viruses (BBVs) from infected healthcare workers to patients during exposure prone procedures (EPPs). The restrictions placed on performance of EPPs by infected clinicians in the UK have had a particularly significant impact on dentists because of the exposure-prone nature of most dental procedures and the difficulties in identifying alternative career pathways in the profession that do not involve EPPs. More recently, the significant positive impact of antiviral drugs on viral load, together with a re-categorisation of EPPs in dentistry have resulted in evolution of the guidance with a consequent significant improvement to the career prospects of dentists infected with BBVs. This paper provides an update for practitioners on the progress that has been made and outlines the current position with respect to practice restrictions.

Not in the vein: 'missed hits', subcutaneous and intramuscular injections and associated harms among people who inject psychoactive drugs in Bristol, United Kingdom.

BACKGROUND: The extent of intentional or accidental subcutaneous and intramuscular injections and the factors associated with these have rarely been studied among people who inject drugs, yet these may play an important role in the acquisition bacterial infections. This study describes the extent of these, and in particular the factors and harms associated with accidental subcutaneous and intramuscular injections (i.e. 'missed hits'). METHODS: People who inject drugs were recruited using respondent driven sampling. Weighted data was examined using bivariate analyses and logistic regression. RESULTS: The participants mean age was 33 years (31% aged under 30-years), 28% were women, and the mean time since first injection was 12 years (N=329). During the preceding three months, 97% had injected heroin, 71% crack-cocaine, and 16% amphetamines; 36% injected daily. Overall, 99% (325) reported that they aimed to inject intravenously; only three aimed to inject subcutaneously and one intramuscularly. Of those that aimed to inject intravenously, 56% (181) reported ever missing a vein (for 51 this occurred more than four times month on average). Factors associated with 'missed hits' suggested that these were the consequence of poor vascular access, injection technique and/or hygiene. 'Missed hits' were twice as common among those reporting sores/open wounds, abscesses, or redness, swelling and tenderness at injection sites. CONCLUSION: Intentional subcutaneous and intramuscular injections are rare in this sample. 'Missed hits' are common and appear to be associated with poor injection practice. Interventions are required to reduce risk through improving injecting practice and hygiene.

Going into the groin: Injection into the femoral vein among people who inject drugs in three urban areas of England.

BACKGROUND: There have been increasing concerns about injection into the femoral vein - groin injecting - among people who inject drugs in a number of countries, though most studies have been small. The extent, reasons and harms associated with groin injecting are examined. METHOD: Participants were recruited using respondent driven sampling (2006-2009). Weighted data was examined using bivariate analyses and logistic regression. RESULTS: The mean age was 32 years; 25% were women (N=855). During the preceding 28 days, 94% had injected heroin and 13% shared needles/syringes. Overall, 53% reported ever groin injecting, with 9.8% first doing so at the same age as starting to inject. Common reasons given for groin injecting included: "Can't get a vein elsewhere" (68%); "It is discreet" (18%); and "It is quicker" (14%). During the preceding 28 days, 41% had groin injected, for 77% this was the only body area used (for these "It is discreet" was more frequently given as a reason). In the multivariable analysis, groin injection was associated with: swabbing injection sites; saving filters for reuse; and receiving opiate substitution therapy. It was less common among those injecting into two body areas, and when other people (rather than services) were the main source of needles. Groin injection was more common among those with hepatitis C and reporting ever having deep vein thrombosis or septicaemia. CONCLUSIONS: Groin injection was common, often due to poor vascular access, but for some it was out of choice. Interventions are required to reduce injecting risk and this practice.

Sharp truth: health care workers remain at risk of bloodborne infection.

BACKGROUND: In 2013, new regulations for the prevention of sharps injuries were introduced in the UK. All health care employers are required to provide the safest possible working environment by preventing or controlling the risk of sharps injuries. AIMS: To analyse data on significant occupational sharps injuries among health care workers in England, Wales and Northern Ireland before the introduction of the 2013 regulations and to assess bloodborne virus seroconversions among health care workers sustaining a blood or body fluid exposure. METHODS: Analysis of 10 years of information on percutaneous and mucocutaneous exposures to blood or other body fluids from source patients infected with a bloodborne virus, collected in England, Wales and Northern Ireland through routine surveillance of health care workers reported for the period 2002-11. RESULTS: A total of 2947 sharps injuries involving a source patient infected with a bloodborne virus were reported by health care workers. Significant sharps injuries were 67% higher in 2011 compared with 2002. Sharps injuries involving an HIV-, hepatitis B virus- or hepatitis C virus (HCV)-infected source patient increased by 107, 69 and 60%, respectively, between 2002 and 2011. During the study period, 14 health care workers acquired HCV following a sharps injury. CONCLUSIONS: Our data show that during a 10-year period prior to the introduction of new regulations in 2013, health care workers were at risk of occupationally acquired bloodborne virus infection. To prevent sharps injuries, health care service employers should adopt safety-engineered devices, institute safe systems of work and promote adherence to standard infection control procedures.

Factors associated with recently acquired hepatitis C virus infection in people who inject drugs in England, Wales and Northern Ireland: new findings from an unlinked anonymous monitoring survey.

Monitoring infections and risk in people who inject drugs (PWID) is important for informing public health responses. In 2011, a novel hepatitis C antibody (anti-HCV) avidity-testing algorithm to identify samples compatible with recent primary infection was introduced into a national surveillance survey. PWID are recruited annually, through >60 needle-and-syringe programmes and prescribing services. Of the 980 individuals that could have been at risk of HCV infection, there were 20 (2%) samples that were compatible with recent primary infection. These were more common among: those imprisoned ⩾5 times [8/213; adjusted odds ratio (aOR) 8·7, 95% confidence interval (CI) 2·04-37·03]; women (8/230; aOR 3·8, 95% CI 1·41-10·38); and those ever-infected with hepatitis B (5/56; aOR 6·25, 95% CI 2·12-18·43). This study is the first to apply this algorithm and to examine the risk factors associated with recently acquired HCV infection in a national sample of PWID in the UK. These findings highlight underlying risks and suggest targeted interventions are needed.

Injection site infections and injuries in men who inject image- and performance-enhancing drugs: prevalence, risks factors, and healthcare seeking.

People who inject drugs are vulnerable to infections and injuries at injection sites, but these have rarely been studied in those injecting image- and performance-enhancing drugs (IPEDs). This study examined the factors associated with reported symptoms of injection site infections and injuries in IPED injectors. Of the 366 male IPED injectors surveyed, 42% reported ever having redness, swelling and tenderness (36% in the preceding year), and 6·8% had ever had an abscess or open wound at an injection site. Having these symptoms was associated with a range of factors related to drug use and healthcare utilization. One sixth (17%) of those reporting redness, tenderness and swelling had ever sought treatment, as had the majority (76%) of those reporting an abscess, sore or open wound. Most common sources of advice were emergency clinics and General Practitioners. Interventions are needed to support access to appropriate injecting equipment and provide targeted harm reduction advice.

Healthcare seeking and hospital admissions by people who inject drugs in response to symptoms of injection site infections or injuries in three urban areas of England.

People who inject drugs (PWID) are vulnerable to infections and injuries at injection sites. The factors associated with reporting symptoms of these, seeking related advice, and hospital admission are examined. PWID were recruited in Birmingham, Bristol and Leeds using respondent-driven sampling (N = 855). During the preceding year, 48% reported having redness, swelling and tenderness (RST), 19% an abscess, and 10% an open wound at an injection site. Overall, 54% reported ⩾1 symptoms, with 45% of these seeking medical advice (main sources emergency departments and General Practitioners). Advice was often sought ⩾5 days after the symptom first appeared (44% of those seeking advice about an abscess, 45% about an open wound, and 35% for RST); the majority received antibiotics. Overall, 9·5% reported hospital admission during the preceding year. Ever being diagnosed with septicaemia and endocarditis were reported by 8·8% and 2·9%, respectively. Interventions are needed to reduce morbidity, healthcare burden and delays in accessing treatment.

Universal treatment success among healthcare workers diagnosed with occupationally acquired acute hepatitis C.

Healthcare workers (HCWs) are at risk of occupationally acquired hepatitis C. In the UK, 17 HCWs were diagnosed with occupationally acquired acute hepatitis C between 2002 and 2011. All 17 cases involved percutaneous injuries from hollowbore needles, 16 known to be contaminated with blood. Of these 17 HCWs, 15 received antiviral therapy and 14 are known to have achieved viral clearance. Treatment success was irrespective of genotype. The successful treatment of HCWs emphasizes the need for UK guidelines on the management of occupationally acquired acute hepatitis C.

Two decades of successes and failures in controlling the transmission of HIV through injecting drug use in England and Wales, 1990 to 2011.

Responses to injecting drug use have changed focus over the last 20 years. Prevalence and incidence of human immunodeficiency virus (HIV) among people who inject drugs (PWID) in England and Wales were examined in relation to these changes. A voluntary unlinked-anonymous surveillance study obtained a biological sample and questionnaire data from PWID through annual surveys since 1990. Prevalence and incidence trends were estimated via generalised linear models, and compared with a policy time-line. Overall HIV prevalence among 38,539 participations was 1.15%. Prevalence was highest among those who started injecting before 1985; throughout the 1990s, prevalence fell in this group and was stable among those who started injecting later. Prevalence was higher in 2005 than 2000 (odds ratio: 3.56 (95% confidence interval (CI) 1.40­9.03) in London, 3.40 (95% CI 2.31­5.02) elsewhere). Estimated HIV incidence peaked twice, around 1983 and 2005. HIV was an important focus of policy concerning PWID from 1984 until 1998. This focus shifted at a time when drug use and risk were changing. The increased incidence in 2005 cannot be ascribed to the policy changes, but these appeared to be temporally aligned. Policy related to PWID should be continually reviewed to ensure rapid responses to increased risk.

Factors associated with recent symptoms of an injection site infection or injury among people who inject drugs in three English cities.

BACKGROUND: People who inject drugs (PWID) are at risk of injection site infections and injuries. The factors associated with recent symptoms of these problems are examined. METHOD: PWID recruited using respondent driven sampling, underwent a computer-assisted interview and provided a dried-blood spot sample. Weight data were examined using logistic regression. RESULTS: The mean age of the 855 participants was 32 years, and 25% were women. During the preceding 28 days, 94% had injected heroin and 50% crack-cocaine; with 41% injecting into their arms and 47% their groin. The passing on of used needles/syringes was reported by 9.7% and receiving by 8.0%. During the preceding 28 days, 21% reported having redness, swelling and tenderness, 6.1% an abscess, and 5.2% a sore/open wound at an injection site; with a quarter (24%) reporting one or more of these. A range of factors were associated with these symptoms; all three symptoms were associated with more frequent injection and the use of multiple injection sites; two of the symptoms were also associated with having recently overdosed and the use of particular injection sites. CONCLUSIONS: Injection site infections and injuries are common among PWID and targeted interventions are needed to reduce risk.

Healthcare workers' perceptions of occupational exposure to blood-borne viruses and reporting barriers: a questionnaire-based study.

BACKGROUND: Healthcare workers (HCWs) are at significant risk of exposure to blood-borne viruses (BBV). AIM: To investigate HCW perceptions concerning occupational exposures to BBV and possible barriers involved in reporting incidents. METHODS: A total of 120 HCWs based at the Dental Institute, King's College Hospital NHS Foundation Trust, completed an anonymous questionnaire as part of a multicentre study. FINDINGS: Eighty-six percent (99/115) of respondents worried about developing a BBV infection at work. Of those who feared hepatitis C virus (HCV) the most, 69% (31/45) also believed that HCV posed the greatest risk to their health, versus 53% (10/19) and 13% (5/40) with regard to hepatitis B virus (HBV) and HIV infection, respectively (P < 0.001). Of respondents with ≥21 years of health service experience, 75% (18/24) knew the risk of HIV transmission versus 13% (2/16) of respondents with <5 years of health service experience (P = 0.002). All (23/23) respondents with ≥21 years of service were aware of HIV PEP versus 20% (12/60) with <21 years of service. Ninety-two percent of respondents (104/113) agreed that it was important to report all body fluid exposure incidents but only 58% (28/48) had reported all their exposure incidents. Fifty-nine percent (60/102) agreed that an electronic reporting system would improve reporting of such incidents. CONCLUSIONS: This study identified a need to improve HCWs' knowledge of BBV infection risks and their management. Data gathered in this study will be used to inform the development of a web-based system for the surveillance of occupational exposures to BBV in the UK.

Occupational transmission of hepatitis C in healthcare workers and factors associated with seroconversion: UK surveillance data.

The study aims were to describe a case series of occupationally acquired hepatitis C (HCV) infections in UK healthcare workers and examine factors associated with transmission using exposure data reported to the Health Protection Agency between July 1997 and December 2007. Fifteen reported cases of documented HCV seroconversion occurred after percutaneous exposure, the majority from hollow-bore needles used in the source patient's vein or artery and contaminated with blood or blood-stained fluid. The seroconversion rate was 2.2% (14/626). In multivariable analysis of healthcare workers with percutaneous exposure to blood or blood-stained fluid, we demonstrate that blood sampling procedures (odds ratio [OR], 5.75; 95% CI, 1.33-24.91; P = 0.01) and depth of injury (OR for deep vs superficial injury, 21.99; 95% CI, 2.02-239.61; P = 0.02) are independently associated with a greater risk of HCV seroconversion. This is the first UK study of occupationally acquired HCV in healthcare workers. It has reinforced our knowledge of risk factors for HCV transmission. Most of these exposures and transmissions were preventable. Healthcare employers should provide regular education on the risks of occupational exposure and prevention through standard infection control procedures. They should ensure the availability of effective prevention measures and facilitate prompt reporting and adequate follow-up of exposures.

Modelling HIV in the injecting drug user population and the male homosexual population in a developed country context.

In many high income countries men who have sex with men (MSM) and injecting drug users (IDUs) are the two groups with the highest HIV prevalence. Yet these two groups are not mutually exclusive, and those MSM who are also IDUs (MSM-IDUs) may be particularly vulnerable to HIV infection. This may be particularly relevant to the IDU population in countries, like the UK, with a much lower HIV prevalence amongst IDUs than MSM, as the MSM-IDUs could provide a route of HIV infection into the IDU population. In this research two alternative modelling approaches that describe the transmission dynamics of HIV within the IDU, MSM, and heterosexual populations are proposed. These models are constructed with two aims. The first is to investigate the possible impact of interventions that target HIV transmission in the MSM and IDU populations, and the second aim is to investigate the impact of the model structure on the model results. An examination of the assortativity of mixing between risk groups is also undertaken. The models are parameterised for England and Wales. While the MSM-IDU population is small, targeting MSM-IDUs was the most efficient intervention strategy in terms of cases averted per 100 individuals targeted with the intervention. Sensitivity analysis showed that variations in the assumed assortativity of mixing between the population groups in both models have a large impact on model results. This means that to generate quantitatively robust estimates for the impact of different intervention strategies it will be necessary to obtain estimates for assortativity values through empirical work.

Tuberculosis and HIV co-infection in healthcare workers in England and Wales, 1999-2005.

This study used linked national tuberculosis (TB) and HIV surveillance data to investigate recent trends and factors associated with HIV co-infection (TB-HIV) in healthcare workers (HCWs) with TB in England and Wales. Methods applied were the χ2 trend test and logistic regression. Overall 14% (231/1627) of HCWs with TB were co-infected with HIV, increasing from 8% in 1999 to 14% in 2005 (P<0·001). Most (78%) HCWs were non-UK born and 74% of these developed TB ⩾2 years post-entry. Being born in Sub-Saharan Africa was an independent predictor for TB-HIV, especially for female HCWs (odds ratio 66·5, 95% confidence interval 16·3-271·1), who also had a lower median CD4 count than other co-infected women (106/mm3, interquartile range 40-200, P<0·01). Voluntary HIV testing of new HCWs should be encouraged as an opportunity for early diagnosis. Post-entry, a high index of clinical suspicion for TB in those most at risk remains important.

Hepatitis C infection among recent initiates to injecting in England 2000-2008: Is a national hepatitis C action plan making a difference?

Around 80% of hepatitis C virus (HCV) infections in England are among injecting drug users (IDUs). The HCV Action Plan launched in 2004 includes targets to reduce HCV prevalence in recent initiates (those starting injecting in the preceding 3 years), and to increase HCV voluntary confidential testing (VCT). The Action Plan's impact is examined using surveillance data from recent initiates participating in an annual survey of IDUs in contact with specialist services across England, 2000-2008. Participants provided an oral fluid sample (tested for anti-HCV) and completed a short questionnaire (including HCV VCT and result of last test). Overall, anti-HCV prevalence among the recent initiates was 18% (619/3463); in 2004, it was 20% (59/291), other than being lower in 2000 [11%, 73/672, adjusted odds ratio (AOR) = 0.63 95%CI 0.42-0.93] there was no change over time. Prevalence increased with age; was higher among those ever imprisoned, using a needle exchange, and having a HCV VCT; and varied by region. Overall, 42% (1460) had ever had a HCV VCT; in 2004 uptake was 45% (130/291) having increased from 26% (175/672, AOR = 0.57 95%CI 0.42-0.77) in 2000, and it rose to 62% (197/320, AOR = 2.12 95%CI 1.50-2.99) in 2008. The proportion of anti-HCV-positive IDUs aware of their infection was higher in 2006-2008 than in earlier years. The HCV Action Plan has probably helped increase recent initiates' uptake of HCV VCT and the proportion of those diagnosed with HCV infection. However, its impact on HCV transmission is unclear. There is a need to reinvigorate, and improve coverage of, interventions to prevent HCV transmission.

Spatial mapping of hepatitis C prevalence in recent injecting drug users in contact with services.

In developed countries the majority of hepatitis C virus (HCV) infections occur in injecting drug users (IDUs) with prevalence in IDUs often high, but with wide geographical differences within countries. Estimates of local prevalence are needed for planning services for IDUs, but it is not practical to conduct HCV seroprevalence surveys in all areas. In this study survey data from IDUs attending specialist services were collected in 52/149 sites in England between 2006 and 2008. Spatially correlated random-effects models were used to estimate HCV prevalence for all sites, using auxiliary data to aid prediction. Estimates ranged from 14% to 82%, with larger cities, London and the North West having the highest HCV prevalence. The methods used generated robust estimates for each area, with a well-identified spatial pattern that improved predictions. Such models may be of use in other areas of study where surveillance data are sparse.