HUNT COVID-19 - Helseundersøkelsen i Trøndelag
Siden oppdagelsen av COVID-19-viruset har den verdensomspennende pandemien hatt en katastofal innvirkning.
The COVID-19 pandemic is bringing an unprecedented set of challenges that may impact the somatic and mental health of populations around the world (Torales et al. 2020). Whilst 25 million people worldwide have been infected between January-August 2020, many now fear the emergence of a secondary pandemic of mental distress and illness. The direct effects of morbidity and mortality associated with the illness, which presently has no specific treatment or vaccine, have brought suffering and bereavement, often in the absence of usual family and social support, to victims and their families. First-responders and healthcare providers have faced overwhelming stress and trauma associated with caring for victims, compounded by inadequate protective equipment and fears for their own health. The physical distancing imposed on communities has led to drastic disruptions of social connections and community supports that are known to buffer stress. Interruptions of schooling and socialization for young people threaten long-term effects on development (Soest et al 2020). Unemployment, economic downturns, food and housing insecurity resulting from efforts to control the pandemic, such as quarantine, curfew, and lockdown measures, result in further distress in more vulnerable populations, straining resources for mental healthcare. In addition, those at risk by virtue of pre-existing mental disorders are often cut off from usual care (Gonçalves-Pinho et al. 2020). Patients with dementia may show an acceleration of decline due to isolation. Suicide rates are expected to rise in the coming months (Sher et al 2020). The unprecedented scale and scope of the pandemic and its fallout mean that the evidence-base for optimal prevention and treatment strategies is limited. All of this is occurring against a backdrop of already rising rates of psychiatric illness in Norway.
Norway declared a lockdown on March 13, having identified 1118 cases, but with a daily increase of >200 cases, closing all kindergartens, schools and universities. On March 28, prohibition and closure of cultural events, sports events, organized sports activities, most restaurants, bars, pubs and nightlife were initiated. Restrictions were later established for visitors to all countries' health institutions, prohibition of travel abroad to most European countries and everyone who came from travel outside the Nordic region were quarantined, later also Sweden, regardless of symptoms or not. Between March 19 and April 21, it was prohibited to visit your own cabins located outside your municipality. Many countries introduced similar measures, but several of them still experienced a disastrous increase in infected and deaths. In Norway, the epidemic came rapidly under control, but the many restrictions were largely maintained till early August. But for an unforeseen future, social distancing, thorough hand hygiene, and in many cases PPEs, will be the general rules. The schools and kindergartens have reopened, but home office is still recommended if possible. Once more, the number of infected has increased, so this is far from over yet.
In Trøndelag, only 626 cases, and 3 deaths are registered up till now. Still, Frosta municipality (2600 inhabitants) was forced to institute the first total municipality quarantine in Norway already on March 12, due to 22 infected cases after a weeding celebration.
The strict infection control measures in Norway, have undoubtedly been successful in stopping the spread of the virus, and may have had positive effects on several health-related conditions , but there are reasons to believe that the negative effect of lockdown and isolation on the well-being and general health of the total population could be significant. There is a concern that the pandemic is in fact exposing and widening existing inequalities within societies, not uniting societies and countries in shared experience. Wright et al. (2020), found clear inequalities in adverse experiences during the COVID-19 pandemic in the early weeks of lockdown in the UK. However, this and similar studies, are missing valid comparable, prospective data collected prior to the pandemic.
In close collaboration with the municipalities and Trøndelag County Council over years, we have organized one of the largest and most comprehensive population studies internationally (Krokstad et al. 2013, Holmen et al. 2014). Since 1984, the HUNT Study (the Trøndelag Health Study) has been conducted in four surveys, the most recent, HUNT4 (170,000 participants), between 2017-2019. Thus, we have acquired a rich collection of health data, clinical measurement, blood samples and large-scale omics analyses only 12-24 months before the outbreak of the COVID-19 pandemic.
The COVID-19 has also been described as an exogenous shock (Bonaccorsi G; Science 2020). Exogenous shocks may arise from other unforeseen developments, such as natural disasters, new technologies or even demographic changes such as the baby-boom. The knowledge created by the present projects can improve the ability of the healthcare society to respond more adequately to changes caused by such developments, so that the negative consequences to vulnerable individuals may be reduced. The project will create high-quality research and offers rich opportunity to strengthen research networks across disciplines and types of research, as indicated below.
1.1 State of the art, knowledge needs and project objectives
There is an urgent need to study the public health consequences of the COVID-19 pandemic in Norway. Both to cope with the ongoing pandemic that may be long-lasting, but also to be able to cope with new epidemics in the future. The Trøndelag Health Study (HUNT) offers very special benefits for such studies in Norway, having comprehensive baseline data on 170,000 inhabitants aged 13 to 100 years collected just before the epidemic broke out. The HUNT Study and the scientists at HUNT Research Centre possess the resources and the scientific skills necessary for carrying out this study. Re-examining the same population, enable us to prospectively register any changes in population health due to the pandemic, both negative and positive, both for the relatively few infected, but more importantly the effect of the infection control measures for the entire population from 13 yrs and above.
The ongoing fruitful collaboration with the county council and the municipalities also covers a Young-HUNT cohort (13-19 yrs) and a HUNT 70+ cohort, especially tailored to study specific health issues for these groups. Scientific reports addressing health-related challenges on a municipality level have also previously been developed by HUNT researchers and shared with both politicians, administrators and health workers (Sund et al. 2020, Rangul & Kvaløy 2020). Both the county council and the municipalities have had influence on the topics covered, and the data are being used actively in public health and strategic plans in collaboration with HUNT Research Centre.
Primary objective: To study the effects of the COVID-19 pandemic and the national control measures on public health in a Norwegian setting.
Secondary objectives: • As a follow-up of the HUNT4 Survey (2017-2019, 170.000 participants) we will examine the effects of national control measures on health and wellbeing based on demographic factors, lifestyle, socio-economic positions and mental health through all age groups (questionnaire data collection - 2021) • To study the risk factors for COVID-19 infection and severity in a representative selection of HUNT4 participants by collecting data through clinical examinations, bio-sampling and questionnaire (2022-2023) • We will build on an already well-established collaboration with public health services on county and municipality level and focus specifically on physical health (biomarkers, genetic factors, antibody levels), mental health and social inequalities.
1.2 Research questions and hypotheses, theoretical approach and methodology Despite a relatively low infection rate both nationwide and regionally by the corona virus, SARS-CoV2, we have reasons to believe that the national control measures and the fear of being infected and taken seriously ill, have affected the general population significantly with clear impact on public health. There were, however, also serious outbursts of COVID-19 in at least one municipality covered by the HUNT Study in Trøndelag, Frosta Municipality, that lead to the first total lockdown in Norway, setting the entire municipality in quarantine. In this project, we want to study the effect of the pandemic on multiple levels in close collaboration with the county council and the municipalities of Trondheim and Frosta. Based on the HUNT4 Survey (2017-2019), with a 60 % attendance rate for the total adult population in Frosta, and 54% overall for adults 75% for adolescents in Nord-Trøndelag, we have an excellent baseline of recent prospective health data and biological markers to study both health related and social consequences of the pandemic.
2.1 Potential impact of the proposed research
The consequences of the COVID-19 pandemic and the measures taken to protect the population are of greatest scientific interest in many research disciplines, and we expect that the publications from this project will be of high scientific value. The COVID-19 pandemic represents a unique natural public health experiment. Combined with the opportunity to run high quality cohort studies in a population, makes this project, from an epidemiological point of view, an excellent and unique opportunity. We expect the papers to become highly influential in several disciplines like clinical-, psychiatric- and social epidemiology, youth medicine and geriatric. In all national, regional and local contingency plans, the risks of new epidemics are listed. We are now in the middle of a new pandemic and many realize that the plans have been insufficient. In addition, each new epidemic brings something new and unpredictable. New epidemics will always arise, but we must any how learn from the experiences we are now gaining to be better prepared the next time, on all levels, governmental, regional, local, organizational and individual. Knowledge of the effects of the public health measures that have been implemented will enable us to make wise and balanced choices now, and in the future, to take care of both political, social, cultural, and economic aspects in the society.
The project will contribute with scientifically driven knowledge about which groups of patients with chronic diseases have increased and reduced the risk of acquiring COVID 19 - based on detailed background knowledge about their geno- and phenotype in HUNT. This will contribute to clearly improved medical treatment and prevention strategies in the future. Further, the project will describe vulnerable groups in society to mental stress, at risk for self-harm and collateral damage caused by bereavement leaves, disruptions of social connections, unemployment, economic insecurity and cut off from usual care. The project will analyze changes in health care utilization, and positive effects of control measures. This will have impact on public health policy and health care planning and stimulate collective initiatives in the society. The results will also probably show several positive effects of the infection control measures implemented, many relevant for the UN sustainable development goals – extremely valuable information for future public health and general policy.