Yesterday in JAMA Network Open, a study of adolescents admitted to eight children's hospitals for mental illness before and during the COVID-19 pandemic reveals a steep increase in the monthly proportion of hospitalizations tied to psychological issues after the emergence of SARS-CoV-2 in the United States but not in France.

Harvard Medical School researchers led the study of 9,696 US and French 11- to 17-year-olds hospitalized for at least one mental health condition before the pandemic (Feb 1, 2019, to Mar 31, 2020) and 11,101 admitted after it began (Apr 1, 2020, to Apr 30, 2021). Median hospital stay was 7 days during both periods.

Average age was 14.6 years in the prepandemic group and 14.7 in the pandemic group; 61.5% and 68.5%, respectively, were girls. The 8 hospitals, 5 in the United States and 3 in France, were participants in the Consortium for Clinical Characterization of COVID-19.

Girls hit particularly hard

The monthly proportion of mental illness hospitalizations rose 0.60% after the pandemic began. When aggregated by country, the average differences in proportion weren't significant in France (0.32%) but were in the United States (0.80%). During the pandemic, there was a significant increase (0.77%) in the monthly proportion of hospitalizations for girls.

The most common diagnoses were anxiety (57.4%), depression (48.0%), and suicidality or self-injury (44.2%). The share of monthly hospitalizations during the pandemic rose for anxiety (0.55%), depression (0.50%), and suicidality or self-injury (0.38%).

Adolescents were diagnosed as having anxiety disorders in 5,083 hospitalizations (52.4%) before the pandemic, rising to 6,066 (57.4%) after it began. The proportion of adolescents diagnosed with suicidality or self-injury also climbed significantly between the two periods (4,101 [42.3%] to 4,673 [44.2%]), although no significant change was seen in the percent diagnosed with depression (4,545 [46.9%] vs 5,065 [48.0%]).

The study authors noted that physical distancing measures limited educational and recreational activities and social interactions and increased exposure to stressors at home. "These findings support the need for greater resources within children's hospitals to care for adolescents with mental health conditions during the pandemic and beyond," they wrote.

A new study from Boston University School of Public Health researchers shows 90% of corpses in a Zambian morgue were positive for COVID-19 during peak transmission, but only 10% of the individuals tested positive while alive. The study, published in BMJ Open, found that the overall postmortem positivity rate was 32%.

The study was conducted at a busy inner-city morgue in Lusaka. It involved 1,118 decedents among three waves of the pandemic, involving Alpha, Beta, and Delta variants, which peaked in July 2020, January 2021, and June 2021, respectively.

Overall, COVID-19 was detected among 32.0% (358/1,116) of the bodies. Antemortem (before-death) testing occurred for 52.6% (302/574) of facility deaths, but only 1.8% (10/544) of community deaths and overall, only approximately 10% of COVID-19 positive deaths were identified in life, the authors found. During peak transmission periods, COVID-19 was detected in approximately 90% of all deaths.

The authors of the study said the stark contrast is because antemortem testing was rarely done for those who died in the community. Antemortem testing occurred for 52.6% (302/574) of facility deaths, but only 1.8% (10/544) of community deaths, the authors said.

The study may help explain the relatively low COVID-19 death rates reported in Africa compared to the rest of the world: Africa has reported more than 12 million COVID-19 cases and 260,000 deaths, compared to the United States, which has reported 100 million cases and 1.08 million deaths.

"We tend to think of this just in terms of poor health and a high incidence of infectious diseases, but it also reflects the ability of poorer countries to map the impact of such diseases on its populations," said Christopher Gill, PhD, lead author of the study, in a press release. "Rather than an 'African paradox,' the far simpler explanation is that COVID-19 has affected African countries just as the virus has everywhere else, but has gone undocumented."

In a report released today, the World Health Organization (WHO) said urgent action is needed if countries around the globe want to reach their water and sanitation goals. The WHO and UN-Water's Global Analysis and Assessment of Sanitation and Drinking-Water (GLAAS) report shows significant barriers to the United Nations (UN) Sustainable Development Goal 6—water and sanitation for all by 2030.

Only 45% countries are on track with their national safe drinking water targets, and 25% are on track with their sanitation goals. A third of countries don't have the human resources to carry out key drinking-water, sanitation and hygiene (WASH) functions.

"We are facing an urgent crisis: Poor access to safe drinking water, sanitation, and hygiene claim millions of lives each year, while the increasing frequency and intensity of climate-related extreme weather events continue to hamper the delivery of safe WASH services," said Tedros Adhanom Ghebreyesus, PhD, WHO director-general, in a news release.

Poor access to safe drinking water, sanitation, and hygiene claim millions of lives each year.

Key in the report are data concerning WASH and climate change: Just over two thirds of countries have measures in their WASH policies to reach populations disproportionately affected by climate change, the WHO said. But only about one third monitor progress or allocate explicit funding to these populations.

The report is published ahead of next year's historic water and sanitation meeting, the first time in 50 years the global community—through the UN—will review progress and make firm commitments to renew action on water and sanitation with global leaders, the WHO said.

A modeling study involving patients with urinary tract infections (UTIs) in three African countries found that, contrary to previous research, antibiotic misuse was most common among the least deprived, researchers reported this week in the Lancet Global Health.

In the mixed-methods study, researchers with the Holistic Approach to Unraveling Antimicrobial Resistance Consortium collected data from 6,827 outpatients with UTI symptoms in Kenya, Tanzania, and Uganda from Feb 10, 2019, to Sep 10, 2020.

Patients provided urine samples and answered a questionnaire about treatment seeking, antibiotic use, and knowledge of antibiotic resistance, and researchers conducted in-depth interviews and held focus-group discussions with a subset of patients. Using an adapted version of the Multidimensional Poverty Index (global MPI), the researchers then investigated the association between multidimensional poverty and antibiotic misuse, which included self-reported antibiotic self-medication and nonadherence (ie, skipping a dose or not completing a course).

Of the 6,345 patients with complete data (79.2% female, 60.5% younger than 35 years), 42.6% were not deprived, 9.5% were vulnerable to poverty, 16.6% were deprived, and 31.4% lived in severe poverty. Controlling for age and sex, the analysis found that all categories of antibiotic misuse were more common among those least deprived and lowest among those living in severe multidimensional poverty. Regardless of poverty status, difficulties in affording healthcare and more familiarity with antibiotics were related to more antibiotic misuse.

Data from 82 linked, qualitative, in-depth patient interviews and unlinked focus-group discussions with community members (44 groups) suggested that self-medication and treatment nonadherence were driven by perceived inconvenience of the healthcare system, financial barriers, time constraints, seeking healthcare advice from people other than doctors, and ease of unregulated antibiotic access.

The behaviours of less deprived people might contribute more to the development of antimicrobial resistance than previously acknowledged.

The authors note that the findings also call into question the idea that improving knowledge and awareness of antibiotics can improve antibiotic use.

"In conclusion, although poverty has an important role in the antimicrobial resistance crisis, we should not assume that poorer subgroups drive antibiotic misuse," they wrote. "The behaviours of less deprived people might contribute more to the development of antimicrobial resistance than previously acknowledged, yet they are the least likely to suffer the consequences."

Global flu activity continues to rise, mainly driven by ongoing high levels in North America and rising levels in Europe and a few other regions, the World Health Organization (WHO) said in its latest global flu update, which covers roughly the last half of November.

The United States, Canada, and Mexico all reported high levels, with the United States and Canada reporting markers above prepandemic levels. In Europe, nine countries are reporting widespread activity, mainly involving the H3N2 strain, but with the other strains also present. Eastern Europe, including Russia, is reporting rising 2009 H1N1 activity.

In East Asia, southern China and South Korea note increasing activity, mainly from H3N2. Also, a few countries in the Southern Hemisphere's temperate region continue to report elevated activity, including Argentina and Chile.

Globally, of respiratory specimens that tested positive for flu at national flu labs during the latter part of November, 97.9% were influenza A. Of the subtyped influenza A samples, 85.6% were H3N2.