Assessing COVID-19 pandemic policies and behaviours and their economic and educational trade-offs across US states from Jan 1, 2020, to July 31, 2022: an observational analysis.
Assessing COVID-19 pandemic policies and behaviours and their economic and educational trade-offs across US states from Jan 1, 2020, to July 31, 2022: an observational analysis.
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评估 2020 年 1 月 1 日至 2022 年 7 月 31 日期间美国各州的 COVID-19 大流行政策和行为及其经济和教育权衡：观察分析。
DOI：
10.1016/s0140-6736(23)00461-0
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发表时间：
2023-04-22
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美国在应对新冠肺炎疫情方面举步维艰，但并不是所有国家都同样举步维艰。确定与感染和死亡率跨州差异相关的因素有助于改进对这一大流行和未来大流行的应对。我们试图回答以下五个与政策相关的关键问题：1)社会、经济和种族不平等在新冠肺炎结果的州际差异中扮演了什么角色；2)拥有更大医疗保健和公共卫生能力的州是否具有更好的结果；3)政治如何影响结果；4)实施更多政策授权并保持更长时间的州是否具有更好的结果；5)在一个累积SARS-CoV-2感染和新冠肺炎总死亡人数较少的州及其经济和教育结果之间是否存在权衡。按美国各州分类的数据摘自公共数据库，包括来自健康指标和评估研究所的新冠肺炎数据库的新冠肺炎感染和死亡率估计；经济分析局关于各州国内生产总值的数据；美联储关于就业率的经济数据；国家教育统计中心关于学生标准化考试成绩的数据；以及美国人口普查局关于各州种族和族裔的数据。我们对人口密度的感染率、年龄死亡率和主要合并症的流行率进行了标准化，以便于比较各州在缓解新冠肺炎影响方面的成功。我们根据流行前的国家特征(如教育程度和人均卫生支出)、各州在大流行期间采取的政策(如口罩强制令和企业关闭)以及人口层面的行为反应(如疫苗覆盖率和流动性)对这些健康结果进行了回归。我们使用线性回归探索了将国家层面的因素与个人层面的行为联系起来的潜在机制。我们量化了大流行期间各州国内生产总值、就业和学生测试分数的下降，以确定与这些结果相关的政策和行为反应，并评估这些结果和新冠肺炎结果之间的权衡。显著性被定义为P<；0·05。2020年1月1日至2022年7月31日期间的标准化累积新冠肺炎死亡率在美国各地各不相同(全国死亡率为每百 000人口372例死亡[95%不确定区间364-379])，标准化死亡率最低的是夏威夷(147例每百 000例死亡)和新罕布夏州(215例每100 000例[183-271])，最高的是亚利桑那州(每100 000例581例[509-672])和华盛顿特区(每100 000例526例[425-631])。较低的贫困率、较高的平均受教育年限和较大比例的人表达人际信任在统计上与较低的感染率和死亡率相关，而人口中较大比例认同为黑人(非西班牙裔)或拉美裔的州与较高的累积死亡率相关。在州一级，获得优质医疗服务(由国际卫生与环境研究所的医疗保健可获得性和质量指数衡量)与新冠肺炎总死亡人数和SARS-CoV-2感染人数的减少相关，但更高的公共医疗支出和更多的公共卫生人员并不相关。州长的政治背景与较低的非典型肺炎冠状病毒感染或新冠肺炎死亡率无关，但新冠肺炎结果较差与该州选民投票给2020年共和党总统候选人的比例有关。州政府使用保护性命令与较低的感染率有关，使用口罩、流动性较低和较高的接种率也是如此，而接种率与较低的死亡率有关。州GDP和学生阅读测试成绩与州COVD-19政策反应、感染率或死亡率无关。然而，就业与餐馆关闭以及更多的感染和死亡有着统计上的显著关系：平均而言，在就业率增加一个百分点的州，每10 000人口中有1574人(95%UI884-7107)额外感染。一些政策命令和保护性行为与四年级数学考试成绩较低有关，但我们的研究结果没有发现与州一级学校停课估计的联系。新冠肺炎放大了美国社会已经存在的两极分化和持续存在的社会、经济和种族不平等，但下一次大流行威胁不必做同样的事情。美国各州缓解了这些结构性不平等，部署了以科学为基础的干预措施，如疫苗接种和有针对性的疫苗强制令，并推动全社会采用疫苗，这些州能够在最大限度地降低新冠肺炎死亡率方面赶上表现最好的国家。这些发现可能有助于设计和确定临床和政策干预措施的目标，以促进在未来的危机中取得更好的健康结果。比尔和梅琳达·盖茨基金会、J·斯坦顿、T·吉莱斯皮、J和E·诺德斯特龙以及彭博慈善机构。
The USA struggled in responding to the COVID-19 pandemic, but not all states struggled equally. Identifying the factors associated with cross-state variation in infection and mortality rates could help to improve responses to this and future pandemics. We sought to answer five key policy-relevant questions regarding the following: 1) what roles social, economic, and racial inequities had in interstate variation in COVID-19 outcomes; 2) whether states with greater health-care and public health capacity had better outcomes; 3) how politics influenced the results; 4) whether states that imposed more policy mandates and sustained them longer had better outcomes; and 5) whether there were trade-offs between a state having fewer cumulative SARS-CoV-2 infections and total COVID-19 deaths and its economic and educational outcomes. Data disaggregated by US state were extracted from public databases, including COVID-19 infection and mortality estimates from the Institute for Health Metrics and Evaluation's (IHME) COVID-19 database; Bureau of Economic Analysis data on state gross domestic product (GDP); Federal Reserve economic data on employment rates; National Center for Education Statistics data on student standardised test scores; and US Census Bureau data on race and ethnicity by state. We standardised infection rates for population density and death rates for age and the prevalence of major comorbidities to facilitate comparison of states' successes in mitigating the effects of COVID-19. We regressed these health outcomes on prepandemic state characteristics (such as educational attainment and health spending per capita), policies adopted by states during the pandemic (such as mask mandates and business closures), and population-level behavioural responses (such as vaccine coverage and mobility). We explored potential mechanisms connecting state-level factors to individual-level behaviours using linear regression. We quantified reductions in state GDP, employment, and student test scores during the pandemic to identify policy and behavioural responses associated with these outcomes and to assess trade-offs between these outcomes and COVID-19 outcomes. Significance was defined as p<0·05. Standardised cumulative COVID-19 death rates for the period from Jan 1, 2020, to July 31, 2022 varied across the USA (national rate 372 deaths per 100 000 population [95% uncertainty interval [UI] 364–379]), with the lowest standardised rates in Hawaii (147 deaths per 100 000 [127–196]) and New Hampshire (215 per 100 000 [183–271]) and the highest in Arizona (581 per 100 000 [509–672]) and Washington, DC (526 per 100 000 [425–631]). A lower poverty rate, higher mean number of years of education, and a greater proportion of people expressing interpersonal trust were statistically associated with lower infection and death rates, and states where larger percentages of the population identify as Black (non-Hispanic) or Hispanic were associated with higher cumulative death rates. Access to quality health care (measured by the IHME's Healthcare Access and Quality Index) was associated with fewer total COVID-19 deaths and SARS-CoV-2 infections, but higher public health spending and more public health personnel per capita were not, at the state level. The political affiliation of the state governor was not associated with lower SARS-CoV-2 infection or COVID-19 death rates, but worse COVID-19 outcomes were associated with the proportion of a state's voters who voted for the 2020 Republican presidential candidate. State governments' uses of protective mandates were associated with lower infection rates, as were mask use, lower mobility, and higher vaccination rate, while vaccination rates were associated with lower death rates. State GDP and student reading test scores were not associated with state COVD-19 policy responses, infection rates, or death rates. Employment, however, had a statistically significant relationship with restaurant closures and greater infections and deaths: on average, 1574 (95% UI 884–7107) additional infections per 10 000 population were associated in states with a one percentage point increase in employment rate. Several policy mandates and protective behaviours were associated with lower fourth-grade mathematics test scores, but our study results did not find a link to state-level estimates of school closures. COVID-19 magnified the polarisation and persistent social, economic, and racial inequities that already existed across US society, but the next pandemic threat need not do the same. US states that mitigated those structural inequalities, deployed science-based interventions such as vaccination and targeted vaccine mandates, and promoted their adoption across society were able to match the best-performing nations in minimising COVID-19 death rates. These findings could contribute to the design and targeting of clinical and policy interventions to facilitate better health outcomes in future crises. Bill & Melinda Gates Foundation, J Stanton, T Gillespie, J and E Nordstrom, and Bloomberg Philanthropies.