Key Points Question What has been the burden of opioid-related deaths in the United States over a recent 15-year period? Findings In this serial cross-sectional study, we found that the percentage of all deaths attributable to opioids increased 292% (from 0.4% to 1.5%) between 2001 and 2016, resulting in approximately 1.68 million person-years of life lost in 2016 alone (5.2 per 1000 population). The burden was particularly high among adults aged 24 to 35 years; in 2016, 20% of deaths in this age group involved opioids. Meaning Premature death from opioids imposes an enormous and growing public health burden across the United States.

V irtual care, commonly defined as medical care delivered at a distance by means of technology, has existed since the 1970s. 1 Despite substantial interest and investment in virtual care by both the federal and provincial governments, 2-4 widespread adoption was modest. 5,6 Research suggested that barriers to virtual care uptake in Ontario before the pandemic included limited physician reimbursement and government mandates that virtual visits use an approved video platform. 7 As the novel coronavirus disease 2019 (COVID-19) pandemic evolved, payers around the globe acted with unprecedented speed by altering fee schedules to encourage virtual visits to reduce the risk of viral transmission, protect patients with chronic diseases who need ongoing medical attention and conserve personal protective equipment. 8 In Ontario, during the first wave of the pandemic, the Ontario Health Insurance Plan quickly approved new temporary billing codes that allowed any type of technology, including telephone calls and commercial videoconferencing software (e.g., Skype, Zoom), to be used for virtual care. These temporary billing codes, as well as the preexisting video visit codes, are reimbursed at the same amount as in-person visits. It has been widely reported that virtual care adoption has accelerated during the COVID-19 pandemic, but published data are limited. Previous studies have largely been limited to nongeneralizable patient subgroups. 9,10 There has also been widespread concern that virtual care may worsen disparities because vulnerable populations (e.g., older adults, lower-income

Objective To estimate the effectiveness of mRNA covid-19 vaccines against symptomatic infection and severe outcomes (hospital admission or death). Design Test negative design study. Setting Ontario, Canada between 14 December 2020 and 19 April 2021. Participants 324 033 community dwelling people aged ≥16 years who had symptoms of covid-19 and were tested for SARS-CoV-2. Interventions BNT162b2 (Pfizer-BioNTech) or mRNA-1273 (Moderna) vaccine. Main outcome measures Laboratory confirmed SARS-CoV-2 by reverse transcription polymerase chain reaction (RT-PCR) and hospital admissions and deaths associated with SARS-CoV-2 infection. Multivariable logistic regression was adjusted for personal and clinical characteristics associated with SARS-CoV-2 and vaccine receipt to estimate vaccine effectiveness against symptomatic infection and severe outcomes. Results Of 324 033 people with symptoms, 53 270 (16.4%) were positive for SARS-CoV-2 and 21 272 (6.6%) received at least one dose of vaccine. Among participants who tested positive, 2479 (4.7%) were admitted to hospital or died. Vaccine effectiveness against symptomatic infection observed ≥14 days after one dose was 60% (95% confidence interval 57% to 64%), increasing from 48% (41% to 54%) at 14-20 days after one dose to 71% (63% to 78%) at 35-41 days. Vaccine effectiveness observed ≥7 days after two doses was 91% (89% to 93%). Vaccine effectiveness against hospital admission or death observed ≥14 days after one dose was 70% (60% to 77%), increasing from 62% (44% to 75%) at 14-20 days to 91% (73% to 97%) at ≥35 days, whereas vaccine effectiveness observed ≥7 days after two doses was 98% (88% to 100%). For adults aged ≥70 years, vaccine effectiveness estimates were observed to be lower for intervals shortly after one dose but were comparable to those for younger people for all intervals after 28 days. After two doses, high vaccine effectiveness was observed against variants with the E484K mutation. Conclusions Two doses of mRNA covid-19 vaccines were observed to be highly effective against symptomatic infection and severe outcomes. Vaccine effectiveness of one dose was observed to be lower, particularly for older adults shortly after the first dose.

volution of the SARS-CoV-2 virus over the course of the COVID-19 pandemic has resulted in the emergence of four variants of concern (VOC)-Alpha (B.1.1.7), Beta (B.1.351), Gamma (P.1) and Delta (B.1.617.2)-to date. Alpha was first detected in the

Background The incidence of SARS-CoV-2 infection, including among those who have received 2 doses of COVID-19 vaccines, has increased substantially since Omicron was first identified in the province of Ontario, Canada. Methods Applying the test-negative design to linked provincial data, we estimated vaccine effectiveness against infection (irrespective of symptoms or severity) caused by Omicron or Delta between November 22 and December 19, 2021. We included individuals who had received at least 2 COVID-19 vaccine doses (with at least 1 mRNA vaccine dose for the primary series) and used multivariable logistic regression to estimate the effectiveness of two or three doses by time since the latest dose. Results We included 3,442 Omicron-positive cases, 9,201 Delta-positive cases, and 471,545 test-negative controls. After 2 doses of COVID-19 vaccine, vaccine effectiveness against Delta infection declined steadily over time but recovered to 93% (95%CI, 92-94%) ≥7 days after receiving an mRNA vaccine for the third dose. In contrast, receipt of 2 doses of COVID-19 vaccines was not protective against Omicron. Vaccine effectiveness against Omicron was 37% (95%CI, 19-50%) ≥7 days after receiving an mRNA vaccine for the third dose. Conclusions Two doses of COVID-19 vaccines are unlikely to protect against infection by Omicron. A third dose provides some protection in the immediate term, but substantially less than against Delta. Our results may be confounded by behaviours that we were unable to account for in our analyses. Further research is needed to examine protection against severe outcomes.

ImportanceThe incidence of SARS-CoV-2 infection, including among individuals who have received 2 doses of COVID-19 vaccine, increased substantially following the emergence of the Omicron variant in Ontario, Canada. Understanding the estimated effectiveness of 2 or 3 doses of COVID-19 vaccine against outcomes associated with Omicron and Delta infections may aid decision-making at the individual and population levels.ObjectiveTo estimate vaccine effectiveness (VE) against symptomatic infections due to the Omicron and Delta variants and severe outcomes (hospitalization or death) associated with these infections.Design, Setting, and ParticipantsThis test-negative case-control study used linked provincial databases for SARS-CoV-2 laboratory testing, reportable disease, COVID-19 vaccination, and health administration in Ontario, Canada. Participants were individuals aged 18 years or older who had COVID-19 symptoms or severe outcomes (hospitalization or death) and were tested for SARS-CoV-2 between December 6 and 26, 2021.ExposuresReceipt of 2 or 3 doses of the COVID-19 vaccine and time since last dose.Main Outcomes and MeasuresThe main outcomes were symptomatic Omicron or Delta infection and severe outcomes (hospitalization or death) associated with infection. Multivariable logistic regression was used to estimate the effectiveness of 2 or 3 COVID-19 vaccine doses by time since the latest dose compared with no vaccination. Estimated VE was calculated using the formula VE = (1 – [adjusted odds ratio]) × 100%.ResultsOf 134 435 total participants, 16 087 were Omicron-positive cases (mean [SD] age, 36.0 [14.1] years; 8249 [51.3%] female), 4261 were Delta-positive cases (mean [SD] age, 44.2 [16.8] years; 2199 [51.6%] female), and 114 087 were test-negative controls (mean [SD] age, 42.0 [16.5] years; 67 884 [59.5%] female). Estimated VE against symptomatic Delta infection decreased from 89% (95% CI, 86%-92%) 7 to 59 days after a second dose to 80% (95% CI, 74%-84%) after 240 or more days but increased to 97% (95% CI, 96%-98%) 7 or more days after a third dose. Estimated VE against symptomatic Omicron infection was 36% (95% CI, 24%-45%) 7 to 59 days after a second dose and 1% (95% CI, –8% to 10%) after 180 days or longer, but 7 or more days after a third dose, it increased to 61% (95% CI, 56%-65%). Estimated VE against severe outcomes was high 7 or more days after a third dose for both Delta (99%; 95% CI, 98%-99%) and Omicron (95%; 95% CI, 87%-98%).Conclusions and RelevanceIn this study, in contrast to high estimated VE against symptomatic Delta infection and severe outcomes after 2 doses of COVID-19 vaccine, estimated VE was modest and short term against symptomatic Omicron infection but better maintained against severe outcomes. A third dose was associated with improved estimated VE against symptomatic infection and with high estimated VE against severe outcomes for both variants. Preventing infection due to Omicron and potential future variants may require tools beyond the currently available vaccines.

Background The COVID-19 pandemic has led to a notable increase in telemedicine adoption. However, the impact of the pandemic on telemedicine use at a population level in rural and remote settings remains unclear. Objective This study aimed to evaluate changes in the rate of telemedicine use among rural populations and identify patient characteristics associated with telemedicine use prior to and during the pandemic. Methods We conducted a repeated cross-sectional study on all monthly and quarterly rural telemedicine visits from January 2012 to June 2020, using administrative data from Ontario, Canada. We compared the changes in telemedicine use among residents of rural and urban regions of Ontario prior to and during the pandemic. Results Before the pandemic, telemedicine use was steadily low in 2012-2019 for both rural and urban populations but slightly higher overall for rural patients (11 visits per 1000 patients vs 7 visits per 1000 patients in December 2019, P<.001). The rate of telemedicine visits among rural patients significantly increased to 147 visits per 1000 patients in June 2020. A similar but steeper increase (P=.15) was observed among urban patients (220 visits per 1000 urban patients). Telemedicine use increased across all age groups, with the highest rates reported among older adults aged ≥65 years (77 visits per 100 patients in 2020). The proportions of patients with at least 1 telemedicine visit were similar across the adult age groups (n=82,246/290,401, 28.3% for patients aged 18-49 years, n=79,339/290,401, 27.3% for patients aged 50-64 years, and n=80,833/290,401, 27.8% for patients aged 65-79 years), but lower among younger patients <18 years (n=23,699/290,401, 8.2%) and older patients ≥80 years (n=24,284/290,401, 8.4%) in 2020 (P<.001). There were more female users than male users of telemedicine (n=158,643/290,401, 54.6% vs n=131,758/290,401, 45.4%, respectively, in 2020; P<.001). There was a significantly higher proportion of telemedicine users residing in relatively less rural than in more rural regions (n=261,814/290,401, 90.2% vs n=28,587/290,401, 9.8%, respectively, in 2020; P<.001). Conclusions Telemedicine adoption increased in rural and remote areas during the COVID-19 pandemic, but its use increased in urban and less rural populations. Future studies should investigate the potential barriers to telemedicine use among rural patients and the impact of rural telemedicine on patient health care utilization and outcomes.

ObjectiveTo describe the contributions of prescribed and non-prescribed opioids to opioid related deaths.DesignPopulation based cohort study.SettingOntario, Canada, from 1 January 2013 to 31 December 2016.ParticipantsAll Ontarians who died of an opioid related cause.ExposureActive opioid prescriptions, defined as those with a duration overlapping the date of death, and recent opioid prescriptions, defined as those dispensed in the 30 and 180 days preceding death. Postmortem toxicology results from the Drug and Drug/Alcohol Related Death database were used to characterise deaths on the basis of presence of prescribed and non-prescribed (that is, diverted or illicit) opioids, overall and stratified by year and age.Results2833 opioid related deaths occurred. An active opioid prescription on the date of death was relatively common but declined slightly throughout the study period (38.2% (241/631) in 2013 and 32.5% (278/855) in 2016; P for trend=0.03). Older people and women were relatively more likely to have an active opioid prescription at time of death. In 2016, 46% (169/364) of people aged 45-64 had an active opioid prescription compared with only 12% (8/69) among those aged 24 or younger (P for trend<0.001). Similarly, 46% (124/272) of women had an active opioid prescription at time of death compared with 26.4% (154/583) of men (P<0.001). Among people with active opioid prescriptions at time of death, 37.8% (375/993) also had evidence of a non-prescribed opioid on postmortem toxicology. By 2016, the non-prescribed opioid most commonly identified after death was fentanyl (41%; 47 of 115 cases). Among people without an active opioid prescription at time of death, fentanyl was detected in 20% (78/390) of deaths in 2013, increasing to 47.5% (274/577) by 2016 (P<0.001).ConclusionsPrescribed, diverted, and illicit opioids all play an important role in opioid related deaths. Although more than half of all opioid related deaths still involved prescription drugs (either dispensed or diverted) in 2016, the increased rate of deaths involving fentanyl between 2015 and 2016 is concerning and suggests the need for a multifactorial approach to this problem that considers both the prescribed and illicit opioid environments.