key: cord-0820978-am4dcmqv authors: Calderon-Anyosa, Renzo J.C.; Kaufman, Jay S. title: Impact of COVID-19 lockdown policy on homicide, suicide, and motor vehicle deaths in Peru date: 2020-11-21 journal: Prev Med DOI: 10.1016/j.ypmed.2020.106331 sha: a64da977b4b77fc76e57bce3be30f14895e3aece doc_id: 820978 cord_uid: am4dcmqv Although lockdown measures to stop COVID-19 have direct effects on disease transmission, their impact on violent and accidental deaths remains unknown. Our study aims to assess the early impact of COVID-19 lockdown on violent and accidental deaths in Peru. Based on data from the Peruvian National Death Information System, an interrupted time series analysis was performed to assess the immediate impact and change in the trend of COVID-19 lockdown on external causes of death including homicide, suicide, and traffic accidents. The analysis was stratified by sex and the time unit was every 15 days. All forms of deaths examined presented a sudden drop after the lockdown. The biggest drop was in deaths related to traffic accidents, with a reduction of 12.22 deaths per million men per month (95% CI: −14.45, −9.98) and 3.55 deaths per million women per month (95% CI:-4.81, −2.30). Homicide and suicide presented similar level drop in women, while the homicide reduction was 2.5 the size of the suicide reduction in men. The slope in homicide in men during the lock-down period increased by 6.66 deaths per million men per year (95% CI:3.18, 10.15). External deaths presented a sudden drop after the lockdown was implemented and an increase in homicide in men was observed. Falls in mobility have a natural impact on traffic accidents, however, the patterns for suicide and homicide are less intuitive and reveal important characteristics of these events, although we expect all of these changes to be transient. COVID-19 has had a serious impact on population health worldwide 1 , not only as a direct consequence of the infection but also due to the measures taken to reduce its transmission. These unprecedented changes in the lifestyles of millions have also impacted mental health, society and economy in various ways 2, 3 . The main strategies to reduce COVID-19 transmission are social distancing and isolation measures. Policies range from advising individuals to keep 2 meters apart in public spaces all the way to generalized lockdowns 4 , all to reduce the pace of transmission and to prevent health services from being overwhelmed 5 . By the middle of June 2020, Latin-America had become a focus of COVID-19 infection. To slow the spread, most of the region have taken severe lockdown measures 6 . Peru was one of the countries with the earliest and strictest national lockdown in Latin-America and has won international recognition for its pandemic response, starting restrictions right after the first confirmed case in mid-March 2020 and lasting for over 100 days until the end of June in most of losses, and reduced incomes have the potential to influence mortality due to violent crimes, suicides, domestic violence, and other external causes of death [16] [17] [18] [19] . Early reports have indicated a substantial drop in violent crime rates across the world, with a drop in crime close to 50% in some cities following some of the most restrictive measures 20, 21 . Reports of domestic violence have increased since social distancing measures came into effect, as victims are forced to be isolated with their abusers 22, 23 . The UN has estimated that domestic violence increased by over 30% in some countries since lockdown with a surge in the need for shelters 24, 25 . Lockdowns have also been accompanied by travel bans and a reduction in mobility, leading to a decrease in the use of motor vehicles 26 with a consequential drop in traffic accidents and resultant emergency visits and deaths 27, 28 . The mental health effects of COVID-19 and of the accompanying economic crisis have also been profound, with suicide as a concern 16 . Previous pandemic scenarios have also shown a change in suicide trends including the 1918 influenza pandemic and 2003 SARS epidemic 29, 30 . Developing countries appear to be more susceptible to the effects of confinement on mental health, due to economic constraints, unavailability of food and overall socio-economic insecurity, which could aggravate psychological conditions 31 . Increased suicides related to economic hardship as well as a result of the lockdown have been reported in Bangladesh 32-34 , Pakistan 35 and India 36 . Furthermore, there have been reports on special cases of suicides during the COVID-19 pandemic, such as couples making suicide pacts 37 , mother and son suicide pacts due to COVID-19-related online learning issues 33 , suicide due to non-treatment by healthcare staff 34 , and infanticide-suicide 38 . A common denominator in these cases is the financial instability and uncertainty experienced during the pandemic, which makes an in-depth analysis of the issue necessary to take measures that can prevent this loss of life. Although by the end June 2020 most countries have relaxed their lockdown measures, their diverse consequences are still unclear and are just now beginning to be studied empirically. Our study aims to assess the early impact of the COVID-19 national lockdown on homicide, suicide, and traffic accident deaths in the Peruvian setting. We used data from the Peruvian National Death Information System (SINADEF) 39 which collects daily death certificates nationwide with available data since 2017. SINADEF has improved the quality of data registration in the recent years, managing to improve its coverage including close to 80% of all deaths in the national territory 40 . Even though coverage has improved, the updating of the database has a certain degree of delay. To assess this delay, the database published on SINADEF's web page 41 has been downloaded on a daily basis for one month. It was found that after 15 days, the database did not show an increase in data greater than 1% from the first day. For the present study, data on deceased adults (18 years old or older) is Only essential activities including food supply, pharmacies, and banking remained accessible. Moreover, international borders were closed, military and police patrolled the streets, and a curfew was instituted from 8 p.m. to 5 a.m. Public transport capacity was also reduced by half and movement between regions within the country was banned. Although some of the components of the lockdown have changed throughout its implementation, the core aspects of the lockdown remained constant until the end of June 2020, after this point, the lockdown measures were relaxed maintaining the state of national emergency and with focalized lockdowns in some regions 7, 8 . Because the lockdown was implemented in the middle of March and there is a relatively low count of daily deaths, we chose to aggregate the data in bins of 15 days each to have a uniform time unit throughout our study period. Information on the cause of death, sex, and age were taken directly from the SINADEF report. The death certificate in the SINADEF system makes the distinction between non-external death, as death from an underlying disease or complication, and external death, as one that occurs as direct or indirect consequence of an injury (accidental, non-accidental or of undetermined intention) or of an injury that is the consequence of violence (homicide, suicide, accident or suspicion of having been caused intentionally) 42 . The specification of each type of external death is reported in an independent item for homicide, suicide, traffic accidents, work accidents and J o u r n a l P r e -p r o o f Journal Pre-proof other types of accidental death. This item was used to identify the type of death, obviating the need to use the ICD 10 coding, which is underreported on the death certificates 40 . The number of events was transformed into the rate per 1,000,000 population for better comparison based on the population report from the latest National Census 43 . Because the COVID-19 pandemic imposes additional stress on health workers and the health system, the reporting, and coding of deaths could be affected by this overload of work 44, 45 . To estimate if external deaths recording was affected by this scenario, we estimated the proportion of external deaths labeled as "unspecified" as a proportion of the total external deaths. This fraction was assessed in the same way as the main outcomes to find any change in the trends after lockdown. We also examined trends in non-external deaths to ensure that registration was consistent before and during the lockdown. To have a measure of the degree of compliance with lockdown and an approximation to the use of motor vehicles we used descriptive data from the mobile-phone mobility data provided by Google Community Mobility Reports for public transit places 46 . This report presents the percent change in visits to transport places for each day compared to a baseline value. To assess the immediate impact and change in the trend of COVID-19 lockdown, we analyzed the external death rates per population using an interrupted time series analysis 47 There was no change in the level or the trend of the unspecified external death proportion ( Figure 3A ) and the registration of non-external deaths was also consistent in the post-lockdown period (Appendix Figure 1 ). The mobility data ( Figure 3B ) shows an early drop in mobility to transit stations right after the first confirmed case with a gradual reduction until the start of the lockdown. After lockdown, the mobility fell below -75% after the second day and held constant at around -80% for 40 days. After that period, mobility gradually recovered, with an increasing tendency through the end of the lockdown. The episodic drops shown close to -100% represent the strict curfew on Sundays and holidays. Expectations about homicide are also not so clear. As lockdown measures began, conventional crimes began to slow down around the world. Studies that evaluated the short-term effects of lockdown on different types of crime reports in Los Angeles and Indianapolis in the USA found a marked decrease in the robbery, burglary, and aggravated assault after the stay-at-home measures took place 18, 52 . Most homicides in men in Latin-America and around the world are associated with crime 53, 54 , and since lockdown, both murder and crime decreased in the region 55 . In Mexico, murder rates, which started at a historic high in 2020, dropped dramatically almost halfway from the national average of 81 per day to 54 after social distancing measures were put in place 56 Similarly, a study conducted in the USA found that the COVID-19 pandemic was associated with a 7.5% increase in domestic violence service calls during the 12 weeks after social distancing began 60 . The reduction in women"s homicides found in this study might reflect the conditions in which partner-perpetrated violence occurs. According to a study carried out in autopsies of women victims of violence, the most frequent place where the body was found was in public places, rivers, or open fields (43.4%), compared to the home (22.9%) 61 . Lockdown restrictions may have imposed an additional barrier in the occurrence of these tragic acts as police and military were constantly watching the streets. Mental health during lockdown has also been a constant concern 13, 15, 16, 62, 63 . Some initial reports show the increase in suicides rate during this pandemic as a consequence of lockdown, financial stress, uncertainty, and isolation 63, 64 . This financial uncertainty has also been reported in developed countries. In Canada two possible projection scenarios based on an increase in unemployment following the COVID-19 pandemic resulted in a projected total of 11.6 to 13.6 excess suicides in 2020-2021 per 100 000 65 . The main factors contributing to suicidal behaviour during the pandemic have been characterized in terms of anxiety, stress, social isolation, fear of getting infected, uncertainty, and economic difficulties 66, 67 . These factors may lead to the exacerbation of phycological distress in vulnerable populations including those with pre-existing psychiatric conditions, persons with low resilience, individuals who live in high disease areas and people who have someone close who has died of or is infected with COVID-19 [66] [67] [68] [69] . Furthermore, those with pre-existing conditions include not only patients who were under retreatment before the pandemic, who might have difficulties finding treatment during the pandemic, but also a very large number of people with psychiatric conditions who did not receive treatment even before the pandemic 70 . People in suicidal crises require special attention, and the assistance services might be interrupted during the pandemic. Our results show that after lockdown the immediate rate of suicides declined, however, men presented an increase in the slope of suicides in the post-lockdown period. One of the factors may be the loss of employment and financial stressors which are well-recognised risk factors for suicide 73 . Nearly 81% of men in Peru have a paid job compare to 64% women 74 , and during the pandemic, the male working population in the country capital decreased by 47.3% and the female working population by 48.1% 75 . These initial changes in suicide trends may give us an idea of what might come next as a result of these social changes. Furthermore, the lockdown might also affect the younger population differently. An exploratory study based on media reports found that reported suicides among adolescents and youths during the lockdown were related to loneliness, overwhelming academic distress and social media related psychological distress 76 . Traffic accidents were the type of external death that decreased the most and this observation is consistent with many of the specific restrictions adopted, including the general limit of transit as well as the imposition of strict curfews at night and on Sundays. Other countries have also seen a decline in emergency room visits for trauma injuries related to traffic accidents after the lockdown 28,77 . An increasing rate towards the end of the lockdown is more apparent for traffic accidents than for other types of death. This mirrors quite closely the changes observed in mobility trends. Both, traffic accident deaths and the mobility change present as U-shaped trends during lockdown, demonstrating that the lockdown measures were not fully adopted at the beginning and that they eased gradually towards the end. Other forms of external death have also shown a decline and even appear to be in decline after the lockdown, however, as economic activities resume, this rate may recover the baseline level as with the other types of death. This report constitutes an initial analysis of the trends in external deaths and as such, we recognize some limitations. Although we found that there was no major change in the occurrence of deaths coded as "unknown" cause, after lockdown, underreporting may be possible for other coding variables. This is a nationwide analysis and some differences by region may not be captured. Peru has tremendous diversity of lifestyle between coastal, mountain and jungle regions, and data come from large cities and small rural communities with radically different rates of events. Competing risk due to COVID-19 is also a possibility although most of the external deaths occur in the younger population, and not necessarily in the population at risk of dying because of COVID-19. For suicide, however, the populations may overlap to a greater extent 78 . Our analysis only considers the beginning and end of the lockdown thus the sudden initial drop that we have described may be accompanied by a sudden increase after the measures are lifted and a later follow-up analysis would be informative. There is an urgency to consider and understand the myriad indirect mortality consequences of the policies adopted to respond to COVID-19. It is expected that some time after the lockdowns are completely lifted around the world, the lives lost from the impacts of these various policies on the J o u r n a l P r e -p r o o f economy, lifestyle, and mental health will outweigh the number of lives lost directly from infection. Indicators of this broad impact, including the types of external deaths studied here, will be crucial for future decision-making 79 . Lockdown due to COVID-19 has impacted the rates of external deaths, showing a sudden drop after its implementation. The biggest change was seen in deaths related to traffic accidents. This initial drop should not be encouraging, since just as there was a marked drop at the beginning, it is likely to be an equally sharp increase after the lockdown is lifted and the economic activities are resumed. The patterns for suicide and homicide are less intuitive, however, and reveal important clues about the causes and characteristics of these events. There is an urgency for implementing a comprehensive response service for mental health during the pandemic, those services could be enhanced by the surveillance of factors contributing to suicidal behaviours as well as suicide trends in vulnerable populations. In the same way, assistance and prevention services against violence against women could benefit from close monitoring of feminicides and other types of violence. Usual intervention efforts need to be intensified during the lockdown and plan for when the lockdown ends, as a rebound effect might be expected. Policies should take into consideration other aspects of health that might be overlooked during this pandemic. 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