Impact of the COVID-19 pandemic on hospital episodes for falls and fractures associated with new-onset disability and frailty in England: a national cohort study.

BACKGROUND: Older people with frailty are at risk of harm from immobility or isolation, yet data about how COVID-19 lockdowns affected them are limited. Falls and fractures are easily measurable adverse outcomes correlated with frailty. We investigated whether English hospital admission rates for falls and fractures varied from the expected trajectory during the COVID-19 pandemic, and how these varied by frailty status. METHODS: NHS England Hospital Episode Statistics Admitted Patient Care data were analysed for observed versus predicted outcome rates for 24 January 2020 to 31 December 2021. An auto-regressive integrated moving average time-series model was trained using falls and fracture incidence data from 2013 to 2018 and validated using data from 2019. Models included national and age-, sex- and region-stratified forecasts. Outcome measures were hospital admissions for falls, fractures, and falls and fractures combined. Frailty was defined using the Hospital Frailty Risk Score. RESULTS: 144,148,915 pre-pandemic hospital admissions were compared with 42,267,318 admissions after pandemic onset. For the whole population, falls and fracture rates were below predicted for the first period of national lockdown, followed by a rapid return to rates close to predicted. Thereafter, rates followed expected trends. For people living with frailty, however, falls and fractures increased above expected rates during periods of national lockdown and remained elevated throughout the study period. Effects of frailty were independent of age. CONCLUSIONS: People living with frailty experienced increased fall and fracture rates above expected during and following periods of national lockdown. These remained persistently elevated throughout the study period.

A comparison of excess deaths by UK country and region during the first year of the COVID-19 pandemic.

We compare the impact of the first two waves of the COVID-19 pandemic on risk of age-standardized mortality by sex, UK country, and English region. Each wave is defined as lasting 26 weeks and are consecutive beginning in 2020 week 11. The expected rate is estimated from 2015 to 2019 mean and the projected mortality trend from the same period are used to estimate excess mortality. By both measures, excess mortality was highest and lowest in regions of England, London and the South-West, respectively. Excess mortality was consistently higher for males than females.

Sociodemographic inequalities of suicide: a population-based cohort study of adults in England and Wales 2011-21.

BACKGROUND: The risk of suicide is complex and often a result of multiple interacting factors. Understanding which groups of the population are most at risk of suicide is important to inform the development of targeted public health interventions. METHODS: We used a novel linked dataset that combined the 2011 Census with the population-level mortality data in England and Wales. We fitted generalized linear models with a Poisson link function to estimate the rates of suicide across different sociodemographic groups and to identify which characteristics are independent predictors of suicide. RESULTS: Overall, the highest rates of suicide were among men aged 40-50 years, individuals who reported having a disability or long-term health problem, those who were unemployed long term or never had worked, and those who were single or separated. After adjusting for other characteristics such as employment status, having a disability or long-term health problem, was still found to increase the incidence of suicide relative to those without impairment [incidence rate ratio minimally adjusted (women) = 3.5, 95% confidence interval (CI) = 3.3-3.6; fully adjusted (women) 3.1, 95% CI = 3.0-3.3]. Additionally, while the absolute rate of suicide was lower in women compared with men, the relative risk in people reporting impairments compared with those who do not was higher in women compared with men. CONCLUSIONS: The findings of this work provide novel population-level insights into the risk of suicide by sociodemographic characteristics in England and Wales. Our results highlight several sociodemographic groups who may benefit from more targeted suicide prevention policies and practices.

Employment outcomes of people with Long Covid symptoms: community-based cohort study.

BACKGROUND: Evidence on the long-term employment consequences of SARS-CoV-2 infection is lacking. We used data from a large, community-based sample in the UK to estimate associations between Long Covid and employment outcomes. METHODS: This was an observational, longitudinal study using a pre-post design. We included survey participants from 3 February 2021 to 30 September 2022 when they were aged 16-64 years and not in education. Using conditional logit modelling, we explored the time-varying relationship between Long Covid status ≥12 weeks after a first test-confirmed SARS-CoV-2 infection (reference: pre-infection) and labour market inactivity (neither working nor looking for work) or workplace absence lasting ≥4 weeks. RESULTS: Of 206 299 participants (mean age 45 years, 54% female, 92% white), 15% were ever labour market inactive and 10% were ever long-term absent during follow-up. Compared with pre-infection, inactivity was higher in participants reporting Long Covid 30 to <40 weeks [adjusted odds ratio (aOR): 1.45; 95% CI: 1.17-1.81] or 40 to <52 weeks (aOR: 1.34; 95% CI: 1.05-1.72) post-infection. Combining with official statistics on Long Covid prevalence, and assuming a correct statistical model, our estimates translate to 27 000 (95% CI: 6000-47 000) working-age adults in the UK being inactive because of Long Covid in July 2022. CONCLUSIONS: Long Covid is likely to have contributed to reduced participation in the UK labour market, though it is unlikely to be the sole driver. Further research is required to quantify the contribution of other factors, such as indirect health effects of the pandemic.

Point Prevalence Estimates of Activity-Limiting Long-term Symptoms Among United States Adults ≥1 Month After Reported Severe Acute Respiratory Syndrome Coronavirus 2 Infection, 1 November 2021.

BACKGROUND: Although most adults infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) fully recover, a proportion have ongoing symptoms, or post-COVID conditions (PCC), after infection. The objective of this analysis was to estimate the number of United States (US) adults with activity-limiting PCC on 1 November 2021. METHODS: We modeled the prevalence of PCC using reported infections occurring from 1 February 2020 to 30 September 2021, and population-based, household survey data on new activity-limiting symptoms ≥1 month following SARS-CoV-2 infection. From these data sources, we estimated the number and proportion of US adults with activity-limiting PCC on 1 November 2021 as 95% uncertainty intervals, stratified by sex and age. Sensitivity analyses adjusted for underascertainment of infections and uncertainty about symptom duration. RESULTS: On 1 November 2021, at least 3.0-5.0 million US adults, or 1.2%-1.9% of the US adult population, were estimated to have activity-limiting PCC of ≥1 month's duration. Population prevalence was higher in females (1.4%-2.2%) than males. The estimated prevalence after adjusting for underascertainment of infections was 1.7%-3.8%. CONCLUSIONS: Millions of US adults were estimated to have activity-limiting PCC. These estimates can support future efforts to address the impact of PCC on the US population.

Estimating the Effectiveness of First Dose of COVID-19 Vaccine Against Mortality in England: A Quasi-Experimental Study.

Estimating real-world vaccine effectiveness is vital to assessing the coronavirus disease 2019 (COVID-19) vaccination program and informing the ongoing policy response. However, estimating vaccine effectiveness using observational data is inherently challenging because of the nonrandomized design and potential for unmeasured confounding. We used a regression discontinuity design to estimate vaccine effectiveness against COVID-19 mortality in England using the fact that people aged 80 years or older were prioritized for the vaccine rollout. The prioritization led to a large discrepancy in vaccination rates among people aged 80-84 years compared with those aged 75-79 at the beginning of the vaccination campaign. We found a corresponding difference in COVID-19 mortality but not in non-COVID-19 mortality, suggesting that our approach appropriately addressed the issue of unmeasured confounding factors. Our results suggest that the first vaccine dose reduced the risk of COVID-19 death by 52.6% (95% confidence limits: 15.7, 73.4) in those aged 80 years, supporting existing evidence that a first dose of a COVID-19 vaccine had a strong protective effect against COVID-19 mortality in older adults. The regression discontinuity model's estimate of vaccine effectiveness is only slightly lower than those of previously published studies using different methods, suggesting that these estimates are unlikely to be substantially affected by unmeasured confounding factors.

Relationship between asthma and severe COVID-19: a national cohort study.

BACKGROUND: We aimed to determine whether children and adults with poorly controlled or more severe asthma have greater risk of hospitalisation and/or death from COVID-19. METHODS: We used individual-level data from the Office for National Statistics Public Health Data Asset, based on the 2011 census in England, and the General Practice Extraction Service data for pandemic planning and research linked to death registration records and Hospital Episode Statistics admission data. Adults were followed from 1 January 2020 to 30 September 2021 for hospitalisation or death from COVID-19. For children, only hospitalisation was included. RESULTS: Our cohort comprised 35 202 533 adults and 2 996 503 children aged 12-17 years. After controlling for sociodemographic factors, pre-existing health conditions and vaccine status, the risk of death involving COVID-19 for adults with asthma prescribed low dose inhaled corticosteroids (ICS) was not significantly different from those without asthma. Adults with asthma prescribed medium and high dosage ICS had an elevated risk of COVID-19 death; HRs 1.18 (95% CI 1.14 to 1.23) and 1.36 (95% CI 1.28 to 1.44), respectively. A similar pattern was observed for COVID-19 hospitalisation; fully adjusted HRs 1.53 (95% CI 1.50 to 1.56) and 1.52 (95% CI 1.46 to 1.56) for adults with asthma prescribed medium and high-dosage ICS, respectively. Risk of hospitalisation was greater for children with asthma prescribed one (2.58 (95% CI 1.82 to 3.66)) or two or more (3.80 (95% CI 2.41 to 5.95)) courses of oral corticosteroids in the year prior to the pandemic. DISCUSSION: People with mild and/or well-controlled asthma are neither at significantly increased risk of hospitalisation with nor more likely to die from COVID-19 than adults without asthma.

Ethnic differences in COVID-19 mortality in the second and third waves of the pandemic in England during the vaccine rollout: a retrospective, population-based cohort study.

BACKGROUND: Ethnic minority groups in England have been disproportionately affected by the COVID-19 pandemic and have lower vaccination rates than the White British population. We examined whether ethnic differences in COVID-19 mortality in England have continued since the vaccine rollout and to what extent differences in vaccination rates contributed to excess COVID-19 mortality after accounting for other risk factors. METHODS: We conducted a retrospective, population-based cohort study of 28.8 million adults aged 30-100 years in England. Self-reported ethnicity was obtained from the 2011 Census. The outcome was death involving COVID-19 during the second (8 December 2020 to 12 June 2021) and third wave (13 June 2021 to 1 December 2021). We calculated hazard ratios (HRs) for death involving COVID-19, sequentially adjusting for age, residence type, geographical factors, sociodemographic characteristics, pre-pandemic health, and vaccination status. RESULTS: Age-adjusted HRs of death involving COVID-19 were elevated for most ethnic minority groups during both waves, particularly for groups with lowest vaccination rates (Bangladeshi, Pakistani, Black African, and Black Caribbean). HRs were attenuated after adjusting for geographical factors, sociodemographic characteristics, and pre-pandemic health. Further adjusting for vaccination status substantially reduced residual HRs for Black African, Black Caribbean, and Pakistani groups in the third wave. Fully adjusted HRs only remained elevated for the Bangladeshi group (men: 2.19 [95% CI 1.72-2.78]; women: 2.12 [1.58-2.86]) and Pakistani men (1.24 [1.06-1.46]). CONCLUSIONS: Lower COVID-19 vaccination uptake in several ethnic minority groups may drive some of the differences in COVID-19 mortality compared to White British. Public health strategies to increase vaccination uptake in ethnic minority groups would help reduce inequalities in COVID-19 mortality, which have remained substantial since the start of the vaccination campaign.

Socio-demographic differences in access to psychological treatment services: evidence from a national cohort study.

BACKGROUND: Since 2008, the Improving Access to Psychological Therapies (IAPT) programme has offered adults in England evidence-based psychological treatments for common mental disorders (CMDs) such as depression and anxiety disorders. However, inequalities in access have not been explored at the national level. METHODS: Using a unique individual patient dataset that linked 2011 Census information of English residents to national IAPT data collected between April 2017 and March 2018, we estimated the rate of access by a wide range of socio-demographic characteristics that are not routinely available. A large household survey was used to estimate the prevalence of probable CMDs by these socio-demographic characteristics. We estimated the probability of access to IAPT amongst people with CMDs by comparing the rates of access from IAPT data and the estimates of prevalence of CMDs from the household survey. Both unadjusted and adjusted (for important patient characteristics) access rates were estimated in logistic regression models. RESULTS: As a proportion of those with a probable CMD, access to IAPT varied markedly by socio-demographic characteristics. Older adults, males, people born outside of the UK, people with religious beliefs, people from Asian ethnic backgrounds, people reporting a disability and those without any academic or professional qualifications were underrepresented in IAPT services nationally, in adjusted models. CONCLUSIONS: The identification of patients who may be underrepresented in IAPT provides an opportunity for services to target outreach and engagement with these groups. Further understanding of barriers to access should help increase equity in access.

COVID-19 vaccination uptake amongst ethnic minority communities in England: a linked study exploring the drivers of differential vaccination rates.

BACKGROUND: Despite generally high coronavirus disease 2019 (COVID-19) vaccination rates in the UK, vaccination hesitancy and lower take-up rates have been reported in certain ethnic minority communities. METHODS: We used vaccination data from the National Immunisation Management System (NIMS) linked to the 2011 Census and individual health records for subjects aged ≥40 years (n = 24 094 186). We estimated age-standardized vaccination rates, stratified by ethnic group and key sociodemographic characteristics, such as religious affiliation, deprivation, educational attainment, geography, living conditions, country of birth, language skills and health status. To understand the association of ethnicity with lower vaccination rates, we conducted a logistic regression model adjusting for differences in geographic, sociodemographic and health characteristics. ResultsAll ethnic groups had lower age-standardized rates of vaccination compared with the white British population, whose vaccination rate of at least one dose was 94% (95% CI: 94%-94%). Black communities had the lowest rates, with 75% (74-75%) of black African and 66% (66-67%) of black Caribbean individuals having received at least one dose. The drivers of these lower rates were partly explained by accounting for sociodemographic differences. However, modelled estimates showed significant differences remained for all minority ethnic groups, compared with white British individuals. CONCLUSIONS: Lower COVID-19 vaccination rates are consistently observed amongst all ethnic minorities.

Occupation and COVID-19 mortality in England: a national linked data study of 14.3 million adults.

OBJECTIVES: To estimate occupational differences in COVID-19 mortality and test whether these are confounded by factors such as regional differences, ethnicity and education or due to non-workplace factors, such as deprivation or prepandemic health. METHODS: Using a cohort study of over 14 million people aged 40-64 years living in England, we analysed occupational differences in death involving COVID-19, assessed between 24 January 2020 and 28 December 2020.We estimated age-standardised mortality rates (ASMRs) per 100 000 person-years at risk stratified by sex and occupation. We estimated the effect of occupation on COVID-19 mortality using Cox proportional hazard models adjusted for confounding factors. We further adjusted for non-workplace factors and interpreted the residual effects of occupation as being due to workplace exposures to SARS-CoV-2. RESULTS: In men, the ASMRs were highest among those working as taxi and cab drivers or chauffeurs at 119.7 deaths per 100 000 (95% CI 98.0 to 141.4), followed by other elementary occupations at 106.5 (84.5 to 132.4) and care workers and home carers at 99.2 (74.5 to 129.4). Adjusting for confounding factors strongly attenuated the HRs for many occupations, but many remained at elevated risk. Adjusting for living conditions reduced further the HRs, and many occupations were no longer at excess risk. For most occupations, confounding factors and mediators other than workplace exposure to SARS-CoV-2 explained 70%-80% of the excess age-adjusted occupational differences. CONCLUSIONS: Working conditions play a role in COVID-19 mortality, particularly in occupations involving contact with patients or the public. However, there is also a substantial contribution from non-workplace factors.

Ethnic differences in COVID-19 mortality during the first two waves of the Coronavirus Pandemic: a nationwide cohort study of 29 million adults in England.

Ethnic minorities have experienced disproportionate COVID-19 mortality rates in the UK and many other countries. We compared the differences in the risk of COVID-19 related death between ethnic groups in the first and second waves the of COVID-19 pandemic in England. We also investigated whether the factors explaining differences in COVID-19 death between ethnic groups changed between the two waves. Using data from the Office for National Statistics Public Health Data Asset, a linked dataset combining the 2011 Census with primary care and hospital records and death registrations, we conducted an observational cohort study to examine differences in the risk of death involving COVID-19 between ethnic groups in the first wave (from 24th January 2020 until 31st August 2020) and the first part of the second wave (from 1st September to 28th December 2020). We estimated age-standardised mortality rates (ASMR) in the two waves stratified by ethnic groups and sex. We also estimated hazard ratios (HRs) for ethnic-minority groups compared with the White British population, adjusted for geographical factors, socio-demographic characteristics, and pre-pandemic health conditions. The study population included over 28.9 million individuals aged 30-100 years living in private households. In the first wave, all ethnic minority groups had a higher risk of COVID-19 related death compared to the White British population. In the second wave, the risk of COVID-19 death remained elevated for people from Pakistani (ASMR: 339.9 [95% CI: 303.7-376.2] and 166.8 [141.7-191.9] deaths per 100,000 population in men and women) and Bangladeshi (318.7 [247.4-390.1] and 127.1 [91.1-171.3] in men and women) background but not for people from Black ethnic groups. Adjustment for geographical factors explained a large proportion of the differences in COVID-19 mortality in the first wave but not in the second wave. Despite an attenuation of the elevated risk of COVID-19 mortality after adjusting for sociodemographic characteristics and health status, the risk was substantially higher in people from Bangladeshi and Pakistani background in both the first and the second waves. Between the first and second waves of the pandemic, the reduction in the difference in COVID-19 mortality between people from Black ethnic background and people from the White British group shows that ethnic inequalities in COVID-19 mortality can be addressed. The continued higher rate of mortality in people from Bangladeshi and Pakistani background is alarming and requires focused public health campaign and policy changes.

Risk of COVID-19 death in adults who received booster COVID-19 vaccinations in England.

The emergence of the COVID-19 vaccination has been critical in changing the course of the COVID-19 pandemic. To ensure protection remains high in vulnerable groups booster vaccinations in the UK have been targeted based on age and clinical vulnerabilities. We undertook a national retrospective cohort study using data from the 2021 Census linked to electronic health records. We fitted cause-specific Cox models to examine the association between health conditions and the risk of COVID-19 death and all-other-cause death for adults aged 50-100-years in England vaccinated with a booster in autumn 2022. Here we show, having learning disabilities or Down Syndrome (hazard ratio=5.07;95% confidence interval=3.69-6.98), pulmonary hypertension or fibrosis (2.88;2.43-3.40), motor neuron disease, multiple sclerosis, myasthenia or Huntington's disease (2.94, 1.82-4.74), cancer of blood and bone marrow (3.11;2.72-3.56), Parkinson's disease (2.74;2.34-3.20), lung or oral cancer (2.57;2.04 to 3.24), dementia (2.64;2.46 to 2.83) or liver cirrhosis (2.65;1.95 to 3.59) was associated with an increased risk of COVID-19 death. Individuals with cancer of the blood or bone marrow, chronic kidney disease, cystic fibrosis, pulmonary hypotension or fibrosis, or rheumatoid arthritis or systemic lupus erythematosus had a significantly higher risk of COVID-19 death relative to other causes of death compared with individuals who did not have diagnoses. Policy makers should continue to priorities vulnerable groups for subsequent COVID-19 booster doses to minimise the risk of COVID-19 death.

Associations between residential greenspace exposure and mortality in 4 645 581 adults living in London, UK: a longitudinal study.

BACKGROUND: Urban greenspaces could reduce non-communicable disease (NCD) risk. The links between greenspaces and NCD-related mortality remain unclear. We aimed to estimate associations between residential greenspace quantity and access and all-cause mortality, cardiovascular disease mortality, cancer mortality, respiratory mortality, and type 2 diabetes mortality. METHODS: We linked 2011 UK Census data of London-dwelling adults (aged ≥18 years) to data from the UK death registry and the Greenspace Information for Greater London resource. We calculated percentage greenspace area, access point density (access points per km2), and distance in metres to the nearest access point for each respondent's residential neighbourhood (defined as 1000 m street network buffers) for greenspaces overall and by park type using a geographic information system. We estimated associations using Cox proportional hazards models, adjusted for a range of confounders. FINDINGS: Data were available for 4 645 581 individuals between March 27, 2011, and Dec 31, 2019. Respondents were followed up for a mean of 8·4 years (SD 1·4). All-cause mortality did not differ with overall greenspace coverage (hazard ratio [HR] 1·0004, 95% CI 0·9996-1·0012), increased with increasing access point density (1·0076, 1·0031-1·0120), and decreased slightly with increasing distance to the nearest access point (HR 0·9993, 0·9987-0·9998). A 1 percentage point (pp) increase in pocket park (areas for rest and recreation under 0·4 hectares) coverage was associated with a decrease in all-cause mortality risk (0·9441, 0·9213-0·9675), and an increase of ten pocket park access points per km2 was associated with a decreased respiratory mortality risk (0·9164, 0·8457-0·9931). Other associations were observed, but the estimated effects were small (eg, all-cause mortality risk for increases of 1 pp in regional park area were 0·9913, 0·9861-0·9966 and increases of ten small open space access points per km2 were 1·0247, 1·0151-1·0344). INTERPRETATION: Increasing the quantity of, and access to, pocket parks might help mitigate mortality risk. More research is needed to elucidate the mechanisms that could explain these associations. FUNDING: Health Data Research UK (HDRUK).

The effect on women's health of extending parental leave: a quasi-experimental registry-based cohort study.

BACKGROUND: Parental leave policies have been hypothesized to benefit mothers' mental health. We assessed the impact of a 6-week extension of parental leave in Denmark on maternal mental health. METHODS: We linked individual-level data from Danish national registries on maternal sociodemographic characteristics and psychiatric diagnoses. A regression discontinuity design was applied to study the increase in parental leave duration after 26 March 1984. We included women who had given birth between 1 January 1981 and 31 December 1987. Our outcome was a first psychiatric diagnosis following the child's birth, ascertained as the first day of inpatient hospital admission for any psychiatric disorder. We presented cumulative incidences for the 30-year follow-up period and reported absolute risk differences between women eligible for the reform vs not, in 5-year intervals. RESULTS: In all, 291 152 women were followed up until 2017, death, emigration or date of first psychiatric diagnosis. The median follow-up time was 29.99 years, corresponding to 10 277 547 person-years at risk. The cumulative incidence of psychiatric diagnoses at 30 years of follow-up was 59.5 (95% CI: 57.4 to 61.6) per 1000 women in the ineligible group and 57.5 (95% CI: 55.6 to 59.4) in the eligible group. Eligible women took on average 32.85 additional days of parental leave (95% CI: 29.20 to 36.49) and had a lower probability of having a psychiatric diagnosis within 5 years [risk difference (RD): 2.4 fewer diagnoses per 1000 women, 95% CI: 1.5 to 3.2] and up to 20 years after the birth (RD: 2.3, 95% CI: 0.4 to 4.2). In subgroup analyses, the risk reduction was concentrated among low-educated, low-income and single women. CONCLUSIONS: Longer parental leave may confer mental health benefits to women, in particular to those from disadvantaged backgrounds.

Excess mortality among essential workers in England and Wales during the COVID-19 pandemic: an updated analysis.

BACKGROUND: Excess mortality from all causes combined during the COVID-19 pandemic in England and Wales in 2020 was predominantly higher for essential workers. In 2021, the vaccination programme had begun, new SARS-CoV-2 variants were identified and different policy approaches were used. We have updated our previous analyses of excess mortality in England and Wales to include trends in excess mortality by occupation for 2021. METHODS: We estimated excess mortality for working age adults living in England and Wales by occupational group for each month in 2021 and for the year as a whole. RESULTS: During 2021, excess mortality remained higher for most groups of essential workers than for non-essential workers. It peaked in January 2021 when all-cause mortality was 44.6% higher than expected for all occupational groups combined. Excess mortality was highest for adults working in social care (86.9% higher than expected). CONCLUSION: Previously, we reported excess mortality in 2020, with this paper providing an update to include 2021 data. Excess mortality was predominantly higher for essential workers during 2021. However, unlike the first year of the pandemic, when healthcare workers experienced the highest mortality, the highest excess mortality during 2021 was experienced by social care workers.

Risk of suicide after diagnosis of severe physical health conditions: A retrospective cohort study of 47 million people.

Background: The diagnosis of a severe physical health condition can cause psychological distress and lead to severe depression. The association between severe physical health conditions and the risk of suicide, and how the risk of suicide changes in the months following diagnosis, are not clear. Methods: We estimated whether a diagnosis of severe physical health conditions is associated with an increase in the risk of death by suicide using a dataset based on the 2011 Census linked to hospital records and death registration records covering 47,354,696 people alive on 1 January 2017 in England. Patients diagnosed with a low-survival cancer, chronic ischaemic heart disease, chronic obstructive pulmonary disease, or degenerative neurological condition were matched to individuals using socio-demographic characteristics from the Census. Using the Aalen-Johansen estimator, we estimated the cumulative incidence of death by suicide occurring between 1 January 2017 and 31 December 2021 (registered by 31 December 2021) in patients and matched controls, adjusted for other potential confounders using inverse probability weighting. Findings: Diagnosis of severe conditions was associated with an increased risk of dying by suicide. One year after diagnosis, the rate of suicide was 21.6 (95% confidence intervals: 14.9-28.4, number of events (N): 39) per 100,000 low-survival cancer patients compared to 9.5 (5.6-14.6, N:16) per 100,000 matched controls. For COPD patients, the one-year suicide rate was 22.4 (19.4-25.5, N:208) per 100,000 COPD patients (matched controls: 10.6, 8.3-13.0, N:85), for ischaemic heart disease 16.1 (14.1-18.2, N:225) per 100,000 patients (matched controls: 8.8, 7.1-10.4, N:128), for degenerative neurological conditions 114.5 (49.6-194.7, N:11) per 100,000 patients. The increase in risk was more pronounced in the first six months after diagnosis or first treatment. Interpretation: A diagnosis of severe physical illness is associated with higher suicide risk. The interaction of physical and mental illness emphasises the importance of collaborative physical and mental health care in these patients. Funding: The Office for National Statistics. KES is the Laing Galazka chair in palliative care at King's College London, funded by an endowment from Cicely Saunders International and the Kirby Laing Foundation.

Inequalities in SARS-CoV-2 case rates by ethnicity, religion, measures of socioeconomic position, English proficiency, and self-reported disability: cohort study of 39 million people in England during the alpha and delta waves.

Objective: To examine sociodemographic inequalities in people with SARS-CoV-2 during the second (alpha) and third (delta) waves of the covid-19 pandemic. Design: Retrospective, population based cohort study. Setting: Resident population of England. Participants: 39 006 194 people aged 10 years and older who were enumerated in the 2011 census, registered with the NHS, and alive on 1 September 2020. Main outcome measures: Age standardised SARS-CoV-2 case rates (ie, the number of people who received a positive test result per 100 000 person weeks at risk) during the second wave (1 September 2020 to 22 May 2021) or third wave (23 May to 10 December 2021) of the pandemic. Age standardised rates were calculated by sociodemographic characteristics and adjusted rate ratios were estimated using generalised linear regression models with a Poisson distribution (models were adjusted for covariates including sex, age, geographical variables, and sociodemographic characteristics). Results: During the study period, 5 767 584 people (14.8% of the study population) tested positive for SARS-CoV-2. In the second wave, the fully adjusted relative risks of having a positive test were highest for the Bangladeshi and Pakistani ethnic groups compared with the white British group, with rate ratios of 1.75 (95% confidence interval 1.73 to 1.77) and 1.69 (1.68 to 1.70), respectively. Muslim and Sikh religious groups had fully adjusted rate ratios of 1.51 (1.50 to 1.51) and 1.64 (1.63 to 1.66), respectively, compared with the Christian group. Greater area deprivation, disadvantaged socioeconomic position, living in a care home, and low English language proficiency were also associated with higher relative risk of having a positive test. However, the inequalities among groups varied over time. Being Christian, white British, without a disability, and from a more advantaged socioeconomic position were associated with increased relative risk of testing positive during the third wave. Conclusion: Research is urgently needed to understand the large sociodemographic inequalities in SARS-CoV-2 case rates in order to inform policy interventions in future waves or pandemics.

Risk of death following COVID-19 vaccination or positive SARS-CoV-2 test in young people in England.

Several studies have reported associations between COVID-19 vaccination and risk of cardiac diseases, especially in young people; the impact on mortality, however, remains unclear. We use national, linked electronic health data in England to assess the impact of COVID-19 vaccination and positive SARS-CoV-2 tests on the risk of cardiac and all-cause mortality in young people (12 to 29 years) using a self-controlled case series design. Here, we show there is no significant increase in cardiac or all-cause mortality in the 12 weeks following COVID-19 vaccination compared to more than 12 weeks after any dose. However, we find an increase in cardiac death in women after a first dose of non mRNA vaccines. A positive SARS-CoV-2 test is associated with increased cardiac and all-cause mortality among people vaccinated or unvaccinated at time of testing.