Leading Cause of Death Long-term effects Vaccine

Deaths and the vaccine…

It’s extremely important that epidemiologists (and for those trying to understand epidemiology) understand the difference between correlation and causation.

When I teach this topic to my graduate students, I start with a classic example…When ice cream sale go up, drownings increase. Does ice cream cause drowning? No. It’s tempting to assume that one pattern causes another. However, correlation might be coincidental or it might be a result of both patterns being caused by a third factor. The third variable here is a hot summer day, which boosts ice cream sales AND swimming, and thus drownings. In other words, correlation (ice cream sales and drownings) does not imply causation (ice cream sales cause drownings).

The same can be applied to a wide variety of public health issues, including the latest hot topic…deaths and vaccines.

As of this morning, Norway reported that 33 people (aged 75+ years) died a few days following their COVID19 immunization. Germany is also investigating 10 deaths. After reading headlines, it’s easy to make the assumption that the vaccine caused the fatal outcome. However, there is a very important third factor… frail, older adults die, and die more often. In Norway, an average of 45 people die each day in nursing homes because of underlying issues. The 33 deaths after vaccination do not represent an excess of deaths. When there’s a mass vaccination campaign, the overlap of vaccination and death is going to happen. It just is.

However, I don’t want to undermine the importance of investigating causation. Norway is investigating 13 of these deaths. And while the Norwegian Medicines Agency and the National Institute of Public Health are still not certain of causality, they did state the possibility that the vaccines’ side effects (like fever) may have exacerbated underlying medical issues that are not dangerous in fitter, younger populations. Dr. Madsen (Director of the Norwegian Medicines Agency) stated: “We are not alarmed or worried about this, because these are very rare occurrences and they occurred in very frail patients with very serious disease”. As of today, 48,000 Norwegian nursing home residents have been vaccinated and did not die.

These deaths will have no impact on Norwegian Medicines Agency’s vaccination strategy. They are still going to first offer vaccinations to those 75+ in nursing homes. But they do urge 80+ patients and their families to discuss the risks and benefits of vaccination with their doctor prior to vaccination.

Love, YLE

Update: Many of you are confusing temporal correlation with direct causation. COVID19 and death is a direct causation evidenced by excess death analyses (search “excess deaths” in my blog). In other words, if COVID19 didn’t infect the patient, they would still be living.

Data Sources:

Long-term effects National changes Predictions

When will this end?

There are basically two ways…


1. The virus could “burn out” (like SARS and MERS) due to effective public health mitigation measures and immunity. BUT, given the ease of transmission (most contagious two days BEFORE symptoms) and given our lack of a national (and international) coordinated response, this is very unlikely now.

2. We could reach “unnatural” herd immunity (ie vaccines). Eradication is 100% dependent on vaccine effectiveness and uptake. We don’t know either yet. If a vaccine prevents clinical disease, strongly reduces transmission and produces long-lasting immunity, eradication is possible. But realistically this is unlikely, especially since it’s clear our next public health hurdle is getting people to trust the vaccine once a safe option is available. “Natural” herd immunity is out of the question.

Option numero two…Pandemic turns into an endemic.

In other words, COVID19 goes on to live among us, like it’s cousins (common cold) or other infectious diseases (HIV or malaria). A pandemic turning into an endemic it’s based on a very loose definition: how risks are perceived by the population. For example, HIV is technically still a pandemic (it’s in every country across the globe). However we’ve found therapies, prevention methods, and the level of awareness has (almost) reached saturation. The “newness” has withered and we have gone on to live with HIV. HIV is now considered an endemic.

If COVID-19 does become an endemic virus, there’s no way of knowing where it will be most prevalent (on the equator like malaria?), when it will be most prevalent (will it be seasonal like the flu?) or what the baseline level of disease will be (eventually this will stabilize at a constant level, R(t)=1).

How we deal with COVID-19 once it becomes endemic will depend on four things. Our interventions (vaccines and treatments) are key aspects. If they can protect people from the most severe outcomes, the infection will become manageable. COVID-19 will then be something we learn to live with and something many people will experience during their lives.

Like everything in this pandemic… TBD.

Love, YLE

Here is a published scientific perspective that complements my perspective if you’re interested (and skeptical):…/10/13/science.abe5960

Children Long-term effects

COVID19 and Child Abuse (an update)

There are, no doubt, pros and cons to opening schools. On one hand, if we open schools quickly, we have the potential to introduce new hotspots and increase community spread.

On the other hand, schools are fundamental to childhood development. Kids also rely on schools for reliable meals, mental health services, social support, physical activity, and safety. In my line of research, kids rely on teachers to detect and report alleged abuse. Of those that “catch” child abuse, the majority are teachers (21% are teachers, 19% are law enforcement, 11% are social services, and 11% are medical personnel).

My colleagues and I are continually working to understand how the COVID19 pandemic (and specifically stay-at-home orders/school closure) impact child abuse. On July 22, I provided preliminary data. Here is an update…

Figure 1 shows doctor visits in which physicians diagnosed child abuse in 2020 compared to 2019. In March/April, there was an alarming drop in the number of kids going to the hospital for child abuse. Unfortunately, though, we hypothesize that this isn’t because child abuse was getting better, but rather because kids were interacting less with mandatory reporters (i.e. teachers). Among kids that WERE going to the hospital for child abuse, physicians reported even MORE severe injuries (traumatic brain injuries, intentional burns) than before the pandemic. Typically, a hospital system has 5-10 child abuse deaths per year. It is not uncommon for a hospital to report 2 child abuse deaths/week in 2020.

Recently, though, we have seen child abuse hospital visits start to increase. In Aug 2020, there were 309 visits (compared to 359 visits in Aug 2019). Our next step is to analyze what is causing this increase. My hypothesis is that it’s because schools are opening.

This pandemic is stressful. Period. And the strains and stresses (like job loss, financial struggles, food insecurity, mental health, and lack of social support) are penetrating homes. Child abuse prevention can start at home. The Prevent Child Abuse America posted some fantastic resources for parents, children, educators and everyone else. This includes tips for staying connected to the community, tips for staying engaged as a family, and tips to manage stress and anxiety. Check it out:

Love, your local (violence) epidemiologist

Data Source: Data comes from my lab in which we are working directly with pediatric hospitals. Data is not published; this is only a high-level preliminary report for my community. We are working on it!

Long-term effects National changes

Research Opportunity

Please consider taking part in this anonymous survey!

My brilliant colleagues, Dr. Meliha Salahuddin and Dr. Divya Patel, at the University of Texas Health Science Center at Tyler are collaborating with the University of Texas Rio Grande Valley School of Medicine to conduct a study on the impact of COVID-19 on your daily life, health and well-being.

If you live in the US and are 18 years or older, please click the link below to get started. It is completely voluntary, anonymous, and takes about 15-20 minutes to complete (I think it took me more like 20-25 minutes).

English version:; Spanish version:

Please feel free to circulate this post or the survey links through your work, community-based and social networks. A direct link to study website can be found at

Love, YLE

Behaviors Long-term effects

Domestic Violence and COVID19

For those of you that don’t know, I am a violence epidemiologist. My research lab focuses on how violence is contagious (just like infectious diseases) and predictable. Because if it’s predictable, then it’s preventable.

We, violence epidemiologists, have been paying very close attention on how stay-at-home policies and isolation have impacted all types of victimization, including domestic violence.

We have consistently hypothesized that pandemic stressors (like job loss, mental health, and lack of social support) have exacerbated the risk of violence at home. Also, domestic violence hotlines have reported 25-50% increase in calls and 150% increase in website traffic.

However, no research has asked victims, themselves, how violence has changed during the pandemic (compared to before the pandemic). Well, the first study was published yesterday…

What was found?

• The majority of victims reported that there was NO CHANGE in victimization during the pandemic compared to prior to the pandemic.

• Among victims that did say victimization changed, more victims said it got BETTER compared to getting WORSE.

• Victimization that got WORSE during the pandemic was due to an increase in hitting, slapping (physical) and rape (sexual).

• Victimization that got BETTER during the pandemic was due to a decrease in physical violence.

These results are surprising and certainly not what the authors hypothesized.

What could explain this discrepancy?

• Pandemic or not, the majority of domestic violence is through controlling behavior. With stay-at-home policies implemented, we can imagine that perpetrators may have more control over victims and more knowledge about whereabouts, thus running into less conflict.

• This study sample was recruited through social media, and then by default, the participants must have had access to a computer or smartphone and internet. It is possible that the most severe of victims do not have these freedoms and so were systematically missed.

Nonetheless, the majority of victimization did NOT change=victims continue to be isolated with their perpetrators. The realities of this crisis are immediate and much more research, engaging victims themselves, is needed.

If you are in need of help, here are a few national resources for you. Emergency domestic violence shelters are STILL open and STILL helping women AND men that are victims of abuse.

National Domestic Abuse Hotline: 1-800-799-7233

National Domestic Abuse Chat (if you can’t talk on your phone):

Dallas Area Rape Crisis Center: 972-641-7273

Love, YLE

Data Source: From the brilliant 🙂 Jetelina KK, Knell G, Molsberry RJ. Changes in intimate partner violence during the early stages of the COVID-19 pandemic in the USA. Injury Prevention.

Behaviors Long-term effects

Health Behavior Changes during COVID-19 Pandemic

Back in April, my colleague and I asked YOU to take a survey via YLE (and other social media platforms).

In total, we reached 47,796 social media users (i.e. people who read the post), and, ultimately, 2,440 of you took the survey. This is the first peer-reviewed, published analysis of YOUR data (that is if you participated).

The purpose of this paper: How did healthy and unhealthy behaviors (physical activity, substance use, and sleeping) change in the beginning of the pandemic (compared to before the pandemic):

• For the majority of people behaviors remained the same after immediate shut down policies

• Among those that reported changes…

o Tobacco use: More people increased use compared to decreased use after stay-at-home orders were put in place. This was especially true among females and those with depression

o Marijuana use increased…especially among those with depression

o Alcohol consumption increased…especially among those with kids, were college graduate, and had depression

o Physical activity decreased…especially among females, among those that spent more time at home, and among those with depression.

o Sleep quality worsened…especially among females, college graduates, those with more than 1 comorbid condition, and those with depression

• Why did we see changes?

o Boredom

o More worried

o Stress relief

o Less motivation

o More time available

So…what? These behaviors have a direct impact on our health and our overall quality of life RIGHT NOW. These changes will also have long-term effects. The full picture will take a few years to see, but we are starting to get a peek.

Other papers with YOUR data are in the pipeline. I’m particularly excited about my paper on intimate partner violence, which is in press now. We also have an alcohol consumption paper and a depression paper coming soon. Stay tuned.

Love, YLE

P.S. If you’re ever asked, please take part in research surveys and studies. PLEASE. (Census…cough cough). We really only know what’s going on when you are willing to share your experiences.

Data Source:

Long-term effects

Impact on all body systems

Name one body system and we have scientific evidence that COVID19 has left a mark there.

Why? Organs have doors called ACE2 receptors. The little spikes on the COVID19 virus are keys to these doors. It takes about 10 minutes for COVID19 to open the door and make a cell its home. Once in, the virus starts multiplying eventually killing the cell (and sometimes even killing all the cells in the organ). On top of this, our immune system then “overreacts” to these cells dying causing even more problems.

We have these COVID19 doors on almost all of our organ systems. This leads to short- and long-term health problems (yes, among young and healthy individuals too)…

Lungs (of course): Lose the ability to pass oxygen to the blood and remove carbon dioxide. This leads to distress (and sometimes requires ventilation)

Brain: Loss of smell and taste, headaches, and dizziness. 33% patients experience neurological or psychological “COVID19 fog”. Mental health issues lead to struggling for words, simple math, or just trying to think.

Heart: Chest pain, heart racing, and heart attacks. 20-30% of patients have heart damage. Patients have increased heart failure (yes, even among young people and those with mild symptoms).

Nervous System: Break in communication between the nerves and muscles, causing MS like symptoms (tingling, numbness, weakness)

Kidney: 78% of patients in ICU develop kidney injury

Digestive system (stomach, pancreas, gallbladder): 33% report diarrhea, nausea, abdominal pain. 17% have severe pancreatic damage leading to chronic disease

Blood: Extensive clotting in the veins and other small blood vessels of patients’ hearts, kidneys, liver, brain, and lungs

THIS is why we cannot ignore the COVID19 pandemic. We cannot let this disease “run its course” because it impacts all systems in the human body. And shouldn’t be taken lightly. (Can we finally say this isn’t the flu?)

Love, your local epidemiologist

Data Sources:



Nervous system:


Digestive System:;


Hospitalizations Leading Cause of Death Long-term effects National changes


In February 2020, the WHO reported that we’re not only fighting COVID-19, but also an infodemic. “An overabundance of information—some accurate and some not—that makes it hard for people to find trustworthy sources and reliable guidance when they need it.” Information overload.

Which can (and does) cause anxiety, even if the information is true. The problem is if people get the wrong information from unreliable sources we are going to have a hard time stopping this virus. And we are in the United States.

In fact, scientists just published an article showing how the infodemic (and specifically misinformation) has impacted mortality, public health interventions, and treatment. They examined rumors, stigma and conspiracy theories circulating on social media between December-April 2020.

What did they find?
• Misinformation was present in 87 countries and 25 languages
• Of this misinformation, 89% were rumors, 8% were conspiracy theories, and 4% were stigma
• 24% of claims had to do with transmission and mortality; 21% public health interventions; 19% treatment and cure; 15% origin of the disease
• Countries with the highest rate of misinformation (in order): India; United States; China; Spain; UK

Their conclusions?
• Misinformation can have severe implications on public health if prioritized over science
• “Health agencies must track misinformation associated with COVID19 in real-time, and engage stakeholders to debunk misinformation”

Love, your local epidemiologist

Data Source: Islam et al., (2020) COVID19 related infodemic and its impact on public health: A global social media analysis. Am. J. Top. Med. Hyg. 

Long-term effects National changes Social Distancing

Pitting public health against economic health

Pitting public health against economic health through a simple trade-off (saving lives vs. saving the economy) is unhelpful and simply not accurate.

Something that gets lost in public conversation is how interdependent the two are. Health systems know that financial health is a critical part of people’s well-being. On the flip side, the financial community knows that having healthy workers and families is vital for productivity and viability. It’s just time to get the public (and policy makers) to understand the interdependence.

A study was just published that asked: Do nationwide shut-downs negatively impact the economy? Scientists compared spending patterns (bank records of more than 800,000 people) in Denmark (who had strict shut-down) compared to spending patterns in Sweden (who didn’t have a lock down). And yes, they compared spending patterns AFTER taking into account things like stock market indexes, unemployment claims, cross-country spending, time of year, etc., etc..

What did they find?

  • There was only a 4% difference in spending between the two countries (Denmark saw a 29% drop in spending; and Sweden saw a 25% drop in spending) after the pandemic was declared
  • There was a bigger drop in spending among 18-29 years olds in Denmark compared to Sweden. In other words, a shutdown constrains the young, who in the absence of a shutdown, would contribute the most to spreading the disease
  • There was a bigger drop in spending among 70+ year olds in Sweden compared to Denmark. In other words, a shutdown contained the spread of the disease and reduce the need for extreme isolation among the most at risk (and reduced mortality).  
Sheridan et al. (Aug 2020). Social Distancing Laws Cause Only Small Losses of Economic Activity during the COVID-19 Pandemic in Scandinavia. Proceedings of the National Academy of Sciences of the United States of America.
Sheridan et al. (Aug 2020). Social Distancing Laws Cause Only Small Losses of Economic Activity during the COVID-19 Pandemic in Scandinavia. Proceedings of the National Academy of Sciences of the United States of America.

Translation? Social distancing laws only cause small losses in the economy while having major benefits on morbidity and mortality. Instead, the virus itself causes economic turmoil (people cut back on consumption, cut back on work due to personal health risks, social norms, or a sense of civic duty). By reducing the spread of disease quickly (through shut downs in this case), more people will be comfortable with going outside, spending money, and working.

How does this apply to other countries? The authors comment on this too. Unfortunately, in the US, we have three things going against us:

  1. Our national “strategy” is a long, drawn out, uncoordinated response
  2. Lack of social insurance policies
  3. A diverse range of civic and social responsibility

The authors state, “A combination of these factors may correlate with reductions in economic activity and, hence, results in the impact of government-mandated shutdowns.”

Love, your local epidemiologist

Data Source: Sheridan et al. (Aug 2020). Social Distancing Laws Cause Only Small Losses of Economic Activity during the COVID-19 Pandemic in Scandinavia. Proceedings of the National Academy of Sciences of the United States of America.

Children Long-term effects

Mental health of parents and their children

In March, many working parents were asked to do the impossible: Seamlessly transition to work from home, continue productivity (or in some cases increase productivity [looking at you public health workers]), and act as childcare or in-home schooling. On top of this, many high-risk parents (like doctors, nurses, police officers) separated to reduce COVID19 risk at home. This led to an additional adjective: SINGLE working parent. To me, this immediate transition had to have been one of the toughest couple weeks.

Scientists at Vanderbilt University sent out a US national survey to parents. Parents were asked whether things have changed since the pandemic. If they did change…was it better or worse? I’ve been waiting on this type of data to be published.

So, what did they find?

-27% of parents reported worse mental health and 18% worse physical health

-Parents that were female, unmarried, and with younger kids reported much worse mental and physical health compared to their counterparts

-The worsening mental health for parents occurred alongside loss of regular childcare, change in insurance status, and worsening food security.

-15% of parents reported worsening in their children’s behavioral health

As the upcoming school year comes, some parents are again faced with impossible decisions. As a community, we need to keep the unique needs of families with children in mind as we move forward. It takes a village, right?

Love, your local epidemiologist

Data Source: Patrick et al., (2020). Well-being of parents and children during the COVID19 pandemic: A national survey. Pediatrics.