The impact of COVID-19 restrictions on acute hospital presentations due to alcohol-related harm in Waitematā Auckland, New Zealand | OPEN ACCESS
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New Zealand’s public health response to the SARS-CoV-2 virus (COVID-19) pandemic has largely been considered successful, with lower-than-expected mortality.[[1–3]] The initial strategy to switch from infection mitigation to elimination was implemented by a nationwide “lockdown” on 26 March 2020 following evidence of community spread. This strictest level of enforcement, designated as “Level 4” of a four-tiered alert system, was a stay-at-home order and shut down all non-essential businesses. After 5 weeks, the country moved to “Level 3” for a further 2 weeks, which allowed limited contact with close family/whānau, and restricted regional movement.[[4]] This initial lockdown was successful in eliminating COVID-19 for 4 months, with subsequent staged reductions to less stringent restrictions of “Level 2 and 1”. However, cases re-emerged and a further Level 4 lockdown in August 2021 was ordered after the first case of the Delta variant—this lasted 5 weeks in Auckland, the largest city in New Zealand, containing one third of the country’s population. New Zealand then cycled in and out of restrictions thereafter, until 2 December 2021 when a different protection framework was introduced.
By April 2020, nearly half of the world's population was also under some form of lockdown across 90 countries or territories.[[5]] While there has been an apparent overall mortality benefit in countries with stringent lockdowns such as New Zealand and Australia, the United Kingdom (UK) imposed three lockdowns that did not show a clear benefit in terms of excess mortality.[[3]] There has been debate and criticism of the firm lockdown restrictions enforced, in particular that benefits of these interventions may be outweighed by potential harms on the economy, social structure, education and mental health.[[6]] These are amplified in vulnerable populations.[[7,8]]
Clarifying and quantifying excess morbidity related to lockdowns is challenging. The World Health Organization (WHO) estimates that this pandemic has led to a 25% increase in the prevalence of anxiety and depression globally.[[9]] With considerable additional mental health burden, it has been widely reported that alcohol sales and use have increased during this time.[[10–12]] Consumption of alcohol has been shown to be significantly altered after implementation of lockdowns, with a trend towards increased consumption, although there is widespread variability between countries.[[13]] WHO encouraged governments to enforce measures that limited alcohol consumption.[[14]] Social isolation, fear, loss of work in conjunction with disruption to community alcohol and drug services, diversion of hospital resources and medical service avoidance are postulated as contributory.[[15–17]]
Specific research into acute hospital presentations due to alcohol-related harm during the lockdowns and pandemic restrictions in general are limited, both in New Zealand and internationally. They may only report on a narrow spectrum of conditions. While there are suggestions of harm, data may also often be at a population level as opposed to an individual level, and therefore miss important information and nuance.[[18]] Research from New Zealand offers a unique insight as an island nation of 5 million people, where lockdowns were strictly adhered to and initial limited infection numbers reduced the confounding effects of COVID-19 pathology.
We aimed to calculate the proportion of the total number of acute hospital presentations due to alcohol-related harm during each specific alert level period compared to control dates in 2019. In addition, we aimed to clarify the demographics of these patients, specialty involved with their care, final diagnoses and length and cost of their hospital presentation.
Methods
We conducted a retrospective case-controlled analysis of all patients with acute hospital contact due to alcohol-related harm as the primary cause of presentation within the Waitematā District, an area with a catchment of 650,000 people. This lies within Auckland, the largest city in New Zealand, which has a total population of 1.57 million and contains two other tertiary hospitals. We assessed presentations to the North Shore and Waitakere hospitals, which support over 660 and 283 beds respectively. In addition, we reviewed data from the Community Alcohol and Drug Service (CADS), a 10-bed inpatient unit for medically supervised detoxification. People domiciled in the catchment area of each hospital are admitted directly to that hospital.
Patients’ presentations were extracted from clinical coding using ICD10-AM, 11th Edition from 1 January 2019 to 2 December 2021. Codes for disorders due to alcohol including intoxication, harmful use, poisoning, withdrawal, dependence, mental and behavioural disturbance or a medical condition due to alcohol were collected. Each case presentation was then individually reviewed by three doctors. Cases were only included if acute alcohol intake was deemed to be the primary cause of admission. If a case was ambiguous, it was independently reviewed by a fourth doctor.
To adjust for seasonality, admission data from matched calendar dates from the year immediately preceding the commencement of the COVID-19 alert level system were collected to serve as the control groups for each COVID-19 alert level period. Total patient hospital discharge numbers were obtained for 2019 to 2021 for proportional comparison. Local ethical approval was granted (ID: RM15128).
Diagnosis at discharge were categorised into 11 groups, as summarised in Appendix 2, and included acute medical conditions, acute mental and behavioural disorders, alcohol dependence, chronic medical conditions, chronic mental and behavioural disorders, gastrointestinal complaints, hepatitis, non-orthopaedic trauma, orthopaedic trauma, pancreatitis and seizures.
Alert Level Restriction categories can be summarised as:[[4]]
• Level 4 (lockdown): no travel or gatherings, all businesses must close except for necessities.
• Level 3: restricted local travel only, gatherings of up to 10 people allowed for weddings or funerals, contactless businesses may open, reconnection allowed with close family/whānau.
• Level 2: Domestic travel allowed, gatherings of up to 100 people allowed, businesses can open with additional health measures in place, reconnection with friends and socialisation in groups allowed.
• Level 1: No restrictions on personal movement or gatherings, all businesses can open, mask wearing and social distancing continue.
View Tables 1–3 and Figure 1.
The primary outcome was calculation of the proportion of total number of acute hospital presentations due to alcohol-related harm during each alert level period compared to control dates in 2019. An additional review of differences in discharge diagnosis during these dates was also completed. Additional data collected for assessment of secondary outcomes included demographic variables, length of inpatient stay, discharge specialty and estimated cost of admission.
Statistical analysis was performed using IBM SPSS Statistics version 26.0 (New York, USA) and GraphPad Prism version 8.2.0 (California, USA). Inter-group comparisons of continuous variables between groups were performed using one-way analysis of variance (ANOVA), where normal distributions had been confirmed by Kolmogorov–Smirnov testing (p>0.05), with post hoc analysis for pairwise comparisons then being conducted using the multiplicity-adjusted Tukey test. Non-normally distributed continuous data were analysed using the Kruskall–Wallis test and post hoc pairwise comparisons performed using the multiplicity-adjusted Dunn test. Categorical data were compared using the Chi-squared and Fisher’s exact tests. All tests were two-tailed and p<0.05 was considered significant. Data are presented as mean ± SD, median (IQR) or number of presentations (% of presentations), unless otherwise stated.
Results
A total of 3,722 alcohol-related acute hospital presentations occurred during the four COVID-19 alert levels, and 3,479 alcohol-related hospital presentations occurred during the corresponding seasonality-matched control periods from the preceding year (Table 2).
164 patients were excluded from final analysis as their presentations were not assessed to be due to acute alcohol use (120), had incomplete documentation (28) or were an electively arranged review (16).
Overall, alcohol-related presentations accounted for between 1.5–1.8% of all presentations within the district during the four COVID-19 alert levels. Alcohol-related presentations accounted for a greater proportion of all presentations during COVID-19 Alert Levels 3 and 1 when compared to the corresponding seasonality-matched control periods (both p<0.05), but not during Alert Levels 4 and 2 (both p ≥ 0.30). The frequency of alcohol-related presentations by discharge diagnosis per month and alert level is illustrated in Figure 1.
Alcohol-related presentation characteristics by COVID-19 alert level are summarised in Table 3. Further detail is available in the Appendix 1. Age, gender, ethnicity, admission length and cost of admission did not differ significantly between the four alert levels and the corresponding control periods.
Acute mental and behavioural disorders accounted for a greater proportion of alcohol-related presentations during Alert Levels 4 and 3 (both p≤0.02), chronic medical conditions were present in a higher portion of presentations during Alert Levels 3 and 1 (both p<0.05), while an increased proportion of orthopaedic conditions were observed during Alert Level 2. Alcohol dependence was present in a lower proportion of presentations during Alert Levels 4, 3, and 2 (all p<0.01), while chronic mental and behavioural disorders accounted for a decreased proportion of presentations during Alert Level 3 (p<0.001). Acute medical conditions did not differ from the control periods during all alert levels (all p>0.05).
A higher proportion of cases were discharged from the General Medicine service during all four alert levels than control periods (all p≤0.01), and an increased proportion of patients were also discharged from the General Surgery service during Alert Level 2 (p=0.048). Discharges from the Emergency Medicine service accounted for a lower proportion of alcohol-related admissions during Alert Levels 3 and 1 (both p≤0.01), while a decreased proportion of discharges from the Community Alcohol and Drug Service were observed during Alert Levels 4 and 2 (both p≤0.01).
Discussion
To the best of our knowledge, this is the first study to compare all-cause acute presentations due to alcohol-related harm before, during and after restrictions during the COVID-19 pandemic. During the 67 days Auckland spent in the strictest COVID-19 lockdown (Level 4), there was no change in proportion of alcohol-related presentations as compared to the previous control year (p=0.42). Published data from an online survey of 925 New Zealanders for Te Hiringa Hauora | Health Promotion Agency, Impact of COVID-19, reported a 19% increase in alcohol consumption during the first lockdown, noting stress, boredom and anxiety as key factors for this. However, 47% did not change consumption, and 34% decreased consumption.[[19]] These figures may help to explain this finding, and the reduced proportions of patients diagnosed with alcohol dependence at Levels 4, 3 and 2 respectively: 13 vs 25% (p=0.002), 20 vs 27% (p=0.006), 19 vs 27% p<0.001. Over this time there was little change in the volume of alcohol available for consumption, despite the major disruption to the hospitality industry.[[20]] This must then reflect the availability and prominence of packaged alcohol consumption in New Zealand, which has been shown as problematic.[[21]]
Published national data of drinking practices during the pandemic vary considerably. In Colombia, Mexico [[22]] and South Australia, [[23]] alcohol use reportedly decreased, while in Greece consumption was largely unchanged.[[24]] Surveys from Germany,[[25]] Canada[[26]] and Poland[[27]] suggest substantially increased consumption. In the UK, high risk drinking increased by over 5%, with the prevalence of drinking ≥4 times a week doubling from 12.5% to 26% from before to during the pandemic (p<0.001).[[28]] There is similar data from the United States (US), with a 14% increase of frequency of consumption compared to 2019.[[29]]
However, within New Zealand, there may have been rebound consumption following the complete relaxation of restrictions seen in Level 1, where there were no longer limitations placed on individual movements, gatherings or businesses operations. 1.8% of total presentations were attributable to alcohol, an increase from 1.5% in Level 4, and 0.2% higher than corresponding dates from 2019 (p<0.001) (see Table 2). These findings are supported by the Te Hiringa Hauora | Health Promotion Agency's Impact of COVID-19 survey, indicating 64% returned to their pre-lockdown drinking practices. This suggests that people who may have been drinking less during lockdown may have subsequently increasing their consumption again.[[19]] Along with Level 3, this was also the period where alcohol induced exacerbations of chronic medical conditions were higher than matched controls, 2.3 vs 4.3%; p=0.04 and 4.7 vs 3.5%; p=0.04 in Level 3 and 1 respectively. This rebound effect was also noted with alcohol consumption in Belgium,[[30]] in trauma admissions in South Africa[[31]] and in emergency department presentations in the Netherlands[[32]] and Italy, where the relative frequency of severe alcohol intoxication in adolescents and young adults increased from 0.88% during the last part of the lockdown to 11.3% after lockdown release.[[33]]
There was much concern around resources and preparedness of hospital services for the care of patients.[[34]] General medicine experienced significant increase in numbers of patients with alcohol-related harm at each alert level compared to the 2019 control year. This was most pronounced in Level 4 lockdown (30% vs 19%; p=0.001). This first lockdown was also when the Community Alcohol and Drug Service (CADS) shut, and along with reduced services in the second Level 4 lockdown accounts for the decrease in discharges during this period (22 vs 9% p<0.001). A proportion of these admissions may have been passed onto the general medical service to manage. Certainly in the US, alcohol withdrawal rates in hospitalised patients increased by 34% in 2020 during the pandemic compared to 2019.[[35]]
Concerningly, there was a significant increase in acute mental and behavioural disorders during the strictest lockdown periods, Level 4 and 3. This increased from 20% to 28% (p=0.02) and 20% to 29% (p<0.001) respectively. This is in keeping with data stating that the majority of those who were drinking more said it was to help them “relax or switch off, or because they have been feeling stressed and anxious”.[[19]] In Alberta, Canada, presentations to the ED due to mental and behavioural disorders stemming from alcohol increased significantly from 2.7% in 2019 to 3.5% in 2020.[[36]] In the UK, there was significant association found between increased alcohol consumption and poor overall mental health (odds ratio (OR) 1.64), depressive symptoms and lower mental wellbeing.[[37]] Deaths from mental and behavioural disorders due to alcohol increased by 10.8%, compared to a 1.1% increase between 2018 and 2019.[[38]] In Australia, respondents who reported an increase in alcohol intake were more likely to have higher levels of depression (OR 1.07), anxiety (OR 1.08) and stress (OR 1.10).[[39]]
The influence on presentations due to alcohol-related harm on rates of acute medical conditions, gastrointestinal complaints, hepatitis and pancreatitis was surprisingly limited in our study, with no significant differences seen. In comparison, in the US following the onset of the pandemic, alcoholic liver disease became the most common indication for being listed on the transplant waitlist, and the fastest increasing cause for liver transplant.[[40]] A tertiary liver unit in London reported more than a doubling of referrals for alcohol-related liver disease.[[41]] Japan reported an increase of over 20% of hospital presentations with alcohol-related liver disease or pancreatitis.[[18]]
Presentations with orthopaedic injury or non-orthopaedic related trauma was also stable, aside from an increase in orthopaedic diagnoses at Level 2 (6 vs 2%, p=0.01). A study from Christchurch Hospital in New Zealand noted a 42% reduction in the volume of major trauma admissions during lockdown, yet an increase from 25% to 33% of those associated with alcohol intake pre-lockdown and during lockdown respectively. Post-lockdown, this decreased to 19%, although numbers were small.[[42]]
Patient demographics in our study were also remarkably alike, with no differences seen in presentation patterns based on age, gender or ethnicity during alert levels and control periods.
These data represent a detailed and complete overview of the impact of COVID-19 on a whole healthcare system. We believe that overall, it demonstrates that this population has largely managed to limit some of the harmful effects of alcohol harms seen in other countries. The New Zealand Government has been praised in its response and public health measures, with daily televised briefings re-enforcing key themes of 1) open, honest and straightforward communication, 2) distinctive and motivational language, and 3) expressions of care.[[43]] Frequent references to the New Zealand public as a “team of 5 million”, with a slogan of “be kind”, along with implementation of widespread social support structures including wage subsidy and leave support schemes may have helped to partially mitigate some of the negative effects of lockdown seen elsewhere.
Strengths of this study include the complete, real-world picture of the burden of alcohol harm on hospitalisation within Waitematā, Auckland. Studies reporting on only a specific or narrow spectrum of conditions may miss counter reactionary outcomes in other areas or specialties not measured. Individual case review of each presentation allowed for accurate inclusion and exclusion of cases. It is likely that accurate full population data within our catchment area was obtained, as at the onset of the pandemic people were advised to return to their home address. Patients domiciled in the area of each hospital are only admitted directly to that hospital, with few inter-hospital transfers and no acute private healthcare facilities functioning to see patients to provide acute care for alcohol-related harm. The initial low rates of infection and community transmission, and minimal hospital occupancy with COVID-19 cases, limited confounding of illnesses. A long follow-up period allowed for measurement of any rebound phenomenon; however, further data collection should be continued. Legacy effects of previous mass crises, such as the severe acute respiratory syndrome (SARS) epidemic of 2003, which led to increases in alcohol use including in hospital workers at a rate nearly 1.5 times higher even 3 years after this outbreak.[[44,45]]
This study is limited by its retrospective design. Quantification of excess alcohol that caused presentations was not recorded. Severity of illnesses of the patients was not measured, although we note there were no large differences in length of hospital stay or cost of hospitalisation, which may suggest otherwise. There was a considerable decrease of over 4,800 total acute hospital presentations during 67 days spent during the strict lockdown (Level 4). These data do not capture many patients who may have not presented to hospital that ordinarily would have. Research from New Zealand confirms that concerns regarding the risk of COVID-19 was prevalent and affected the decision to present to hospital.[[46]] Comparisons of alcohol-related presentations as a proportion of all hospital presentations between the COVID-19 alert levels and seasonality-matched control periods might have partially mitigated this bias. In addition, this study does not take into account primary care presentations or ambulance callouts to homes, which have been reported to be considerably higher in some areas.[[47]] Although this data may be generalisable to larger New Zealand cities, it is difficult to extrapolate to other countries given the substantial differences in pre-pandemic alcohol misuse, variations in restrictions enforced, other social responses and national geography including rurality.[[48]]
In conclusion, alcohol-related presentations were unchanged compared to matched control periods during the strictest level of lockdown. There was a significant increase in presentations with acute mental and behavioural disorders due to alcohol misuse in this period, although presentations with alcohol dependence were consistently lower even as restrictions eased. The general medical service saw a significantly increased burden of patients with alcohol-related harm. Although difficult to compare internationally, New Zealand appears to have largely avoided the general trend of increased alcohol-related harms during the COVID-19 pandemic and its lockdown restrictions.
View Appendices.
Summary
Abstract
Aim
New Zealand’s public health response to the COVID-19 pandemic has largely been considered successful, although there have been concerns surrounding the potential harms of the lockdown restrictions enforced, including alteration of alcohol consumption. New Zealand utilised a four-tiered alert level system of lockdowns and restrictions, with Level 4 denoting strict lockdown. This study aimed to compare alcohol-related hospital presentations during these periods with corresponding calendar-matched dates from the preceding year.
Method
We conducted a retrospective case-controlled analysis of all alcohol-related hospital presentations between 1 January 2019 to 2 December 2021 and compared COVID-19 restriction periods to corresponding calendar-matched pre-pandemic periods.
Results
A total of 3,722 and 3,479 alcohol-related acute hospital presentations occurred during the four COVID-19 restriction levels and corresponding control periods respectively. Alcohol-related presentations accounted for a greater proportion of all admissions during COVID-19 Alert Levels 3 and 1 than the respective control periods (both p<0.05), but not during Levels 4 and 2 (both p>0.30). Acute mental and behavioural disorders accounted for a greater proportion of alcohol-related presentations during Alert Levels 4 and 3 (both p≤0.02), although alcohol dependence was present in a lower proportion of presentations during Alert Levels 4, 3, and 2 (all p<0.01). There was no difference in acute medical conditions including hepatitis and pancreatitis during all alert levels (all p>0.05).
Conclusion
Alcohol-related presentations were unchanged compared to matched control periods during the strictest level of lockdown, although acute mental and behavioural disorders accounted for a greater proportion of alcohol-related admissions during this period. New Zealand appears to have avoided the general trend of increased alcohol-related harms seen internationally during the COVID-19 pandemic and its lockdown restrictions.
Author Information
Acknowledgements
Correspondence
Correspondence Email
Competing Interests
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The impact of COVID-19 restrictions on acute hospital presentations due to alcohol-related harm in Waitematā Auckland, New Zealand | OPEN ACCESS
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New Zealand’s public health response to the SARS-CoV-2 virus (COVID-19) pandemic has largely been considered successful, with lower-than-expected mortality.[[1–3]] The initial strategy to switch from infection mitigation to elimination was implemented by a nationwide “lockdown” on 26 March 2020 following evidence of community spread. This strictest level of enforcement, designated as “Level 4” of a four-tiered alert system, was a stay-at-home order and shut down all non-essential businesses. After 5 weeks, the country moved to “Level 3” for a further 2 weeks, which allowed limited contact with close family/whānau, and restricted regional movement.[[4]] This initial lockdown was successful in eliminating COVID-19 for 4 months, with subsequent staged reductions to less stringent restrictions of “Level 2 and 1”. However, cases re-emerged and a further Level 4 lockdown in August 2021 was ordered after the first case of the Delta variant—this lasted 5 weeks in Auckland, the largest city in New Zealand, containing one third of the country’s population. New Zealand then cycled in and out of restrictions thereafter, until 2 December 2021 when a different protection framework was introduced.
By April 2020, nearly half of the world's population was also under some form of lockdown across 90 countries or territories.[[5]] While there has been an apparent overall mortality benefit in countries with stringent lockdowns such as New Zealand and Australia, the United Kingdom (UK) imposed three lockdowns that did not show a clear benefit in terms of excess mortality.[[3]] There has been debate and criticism of the firm lockdown restrictions enforced, in particular that benefits of these interventions may be outweighed by potential harms on the economy, social structure, education and mental health.[[6]] These are amplified in vulnerable populations.[[7,8]]
Clarifying and quantifying excess morbidity related to lockdowns is challenging. The World Health Organization (WHO) estimates that this pandemic has led to a 25% increase in the prevalence of anxiety and depression globally.[[9]] With considerable additional mental health burden, it has been widely reported that alcohol sales and use have increased during this time.[[10–12]] Consumption of alcohol has been shown to be significantly altered after implementation of lockdowns, with a trend towards increased consumption, although there is widespread variability between countries.[[13]] WHO encouraged governments to enforce measures that limited alcohol consumption.[[14]] Social isolation, fear, loss of work in conjunction with disruption to community alcohol and drug services, diversion of hospital resources and medical service avoidance are postulated as contributory.[[15–17]]
Specific research into acute hospital presentations due to alcohol-related harm during the lockdowns and pandemic restrictions in general are limited, both in New Zealand and internationally. They may only report on a narrow spectrum of conditions. While there are suggestions of harm, data may also often be at a population level as opposed to an individual level, and therefore miss important information and nuance.[[18]] Research from New Zealand offers a unique insight as an island nation of 5 million people, where lockdowns were strictly adhered to and initial limited infection numbers reduced the confounding effects of COVID-19 pathology.
We aimed to calculate the proportion of the total number of acute hospital presentations due to alcohol-related harm during each specific alert level period compared to control dates in 2019. In addition, we aimed to clarify the demographics of these patients, specialty involved with their care, final diagnoses and length and cost of their hospital presentation.
Methods
We conducted a retrospective case-controlled analysis of all patients with acute hospital contact due to alcohol-related harm as the primary cause of presentation within the Waitematā District, an area with a catchment of 650,000 people. This lies within Auckland, the largest city in New Zealand, which has a total population of 1.57 million and contains two other tertiary hospitals. We assessed presentations to the North Shore and Waitakere hospitals, which support over 660 and 283 beds respectively. In addition, we reviewed data from the Community Alcohol and Drug Service (CADS), a 10-bed inpatient unit for medically supervised detoxification. People domiciled in the catchment area of each hospital are admitted directly to that hospital.
Patients’ presentations were extracted from clinical coding using ICD10-AM, 11th Edition from 1 January 2019 to 2 December 2021. Codes for disorders due to alcohol including intoxication, harmful use, poisoning, withdrawal, dependence, mental and behavioural disturbance or a medical condition due to alcohol were collected. Each case presentation was then individually reviewed by three doctors. Cases were only included if acute alcohol intake was deemed to be the primary cause of admission. If a case was ambiguous, it was independently reviewed by a fourth doctor.
To adjust for seasonality, admission data from matched calendar dates from the year immediately preceding the commencement of the COVID-19 alert level system were collected to serve as the control groups for each COVID-19 alert level period. Total patient hospital discharge numbers were obtained for 2019 to 2021 for proportional comparison. Local ethical approval was granted (ID: RM15128).
Diagnosis at discharge were categorised into 11 groups, as summarised in Appendix 2, and included acute medical conditions, acute mental and behavioural disorders, alcohol dependence, chronic medical conditions, chronic mental and behavioural disorders, gastrointestinal complaints, hepatitis, non-orthopaedic trauma, orthopaedic trauma, pancreatitis and seizures.
Alert Level Restriction categories can be summarised as:[[4]]
• Level 4 (lockdown): no travel or gatherings, all businesses must close except for necessities.
• Level 3: restricted local travel only, gatherings of up to 10 people allowed for weddings or funerals, contactless businesses may open, reconnection allowed with close family/whānau.
• Level 2: Domestic travel allowed, gatherings of up to 100 people allowed, businesses can open with additional health measures in place, reconnection with friends and socialisation in groups allowed.
• Level 1: No restrictions on personal movement or gatherings, all businesses can open, mask wearing and social distancing continue.
View Tables 1–3 and Figure 1.
The primary outcome was calculation of the proportion of total number of acute hospital presentations due to alcohol-related harm during each alert level period compared to control dates in 2019. An additional review of differences in discharge diagnosis during these dates was also completed. Additional data collected for assessment of secondary outcomes included demographic variables, length of inpatient stay, discharge specialty and estimated cost of admission.
Statistical analysis was performed using IBM SPSS Statistics version 26.0 (New York, USA) and GraphPad Prism version 8.2.0 (California, USA). Inter-group comparisons of continuous variables between groups were performed using one-way analysis of variance (ANOVA), where normal distributions had been confirmed by Kolmogorov–Smirnov testing (p>0.05), with post hoc analysis for pairwise comparisons then being conducted using the multiplicity-adjusted Tukey test. Non-normally distributed continuous data were analysed using the Kruskall–Wallis test and post hoc pairwise comparisons performed using the multiplicity-adjusted Dunn test. Categorical data were compared using the Chi-squared and Fisher’s exact tests. All tests were two-tailed and p<0.05 was considered significant. Data are presented as mean ± SD, median (IQR) or number of presentations (% of presentations), unless otherwise stated.
Results
A total of 3,722 alcohol-related acute hospital presentations occurred during the four COVID-19 alert levels, and 3,479 alcohol-related hospital presentations occurred during the corresponding seasonality-matched control periods from the preceding year (Table 2).
164 patients were excluded from final analysis as their presentations were not assessed to be due to acute alcohol use (120), had incomplete documentation (28) or were an electively arranged review (16).
Overall, alcohol-related presentations accounted for between 1.5–1.8% of all presentations within the district during the four COVID-19 alert levels. Alcohol-related presentations accounted for a greater proportion of all presentations during COVID-19 Alert Levels 3 and 1 when compared to the corresponding seasonality-matched control periods (both p<0.05), but not during Alert Levels 4 and 2 (both p ≥ 0.30). The frequency of alcohol-related presentations by discharge diagnosis per month and alert level is illustrated in Figure 1.
Alcohol-related presentation characteristics by COVID-19 alert level are summarised in Table 3. Further detail is available in the Appendix 1. Age, gender, ethnicity, admission length and cost of admission did not differ significantly between the four alert levels and the corresponding control periods.
Acute mental and behavioural disorders accounted for a greater proportion of alcohol-related presentations during Alert Levels 4 and 3 (both p≤0.02), chronic medical conditions were present in a higher portion of presentations during Alert Levels 3 and 1 (both p<0.05), while an increased proportion of orthopaedic conditions were observed during Alert Level 2. Alcohol dependence was present in a lower proportion of presentations during Alert Levels 4, 3, and 2 (all p<0.01), while chronic mental and behavioural disorders accounted for a decreased proportion of presentations during Alert Level 3 (p<0.001). Acute medical conditions did not differ from the control periods during all alert levels (all p>0.05).
A higher proportion of cases were discharged from the General Medicine service during all four alert levels than control periods (all p≤0.01), and an increased proportion of patients were also discharged from the General Surgery service during Alert Level 2 (p=0.048). Discharges from the Emergency Medicine service accounted for a lower proportion of alcohol-related admissions during Alert Levels 3 and 1 (both p≤0.01), while a decreased proportion of discharges from the Community Alcohol and Drug Service were observed during Alert Levels 4 and 2 (both p≤0.01).
Discussion
To the best of our knowledge, this is the first study to compare all-cause acute presentations due to alcohol-related harm before, during and after restrictions during the COVID-19 pandemic. During the 67 days Auckland spent in the strictest COVID-19 lockdown (Level 4), there was no change in proportion of alcohol-related presentations as compared to the previous control year (p=0.42). Published data from an online survey of 925 New Zealanders for Te Hiringa Hauora | Health Promotion Agency, Impact of COVID-19, reported a 19% increase in alcohol consumption during the first lockdown, noting stress, boredom and anxiety as key factors for this. However, 47% did not change consumption, and 34% decreased consumption.[[19]] These figures may help to explain this finding, and the reduced proportions of patients diagnosed with alcohol dependence at Levels 4, 3 and 2 respectively: 13 vs 25% (p=0.002), 20 vs 27% (p=0.006), 19 vs 27% p<0.001. Over this time there was little change in the volume of alcohol available for consumption, despite the major disruption to the hospitality industry.[[20]] This must then reflect the availability and prominence of packaged alcohol consumption in New Zealand, which has been shown as problematic.[[21]]
Published national data of drinking practices during the pandemic vary considerably. In Colombia, Mexico [[22]] and South Australia, [[23]] alcohol use reportedly decreased, while in Greece consumption was largely unchanged.[[24]] Surveys from Germany,[[25]] Canada[[26]] and Poland[[27]] suggest substantially increased consumption. In the UK, high risk drinking increased by over 5%, with the prevalence of drinking ≥4 times a week doubling from 12.5% to 26% from before to during the pandemic (p<0.001).[[28]] There is similar data from the United States (US), with a 14% increase of frequency of consumption compared to 2019.[[29]]
However, within New Zealand, there may have been rebound consumption following the complete relaxation of restrictions seen in Level 1, where there were no longer limitations placed on individual movements, gatherings or businesses operations. 1.8% of total presentations were attributable to alcohol, an increase from 1.5% in Level 4, and 0.2% higher than corresponding dates from 2019 (p<0.001) (see Table 2). These findings are supported by the Te Hiringa Hauora | Health Promotion Agency's Impact of COVID-19 survey, indicating 64% returned to their pre-lockdown drinking practices. This suggests that people who may have been drinking less during lockdown may have subsequently increasing their consumption again.[[19]] Along with Level 3, this was also the period where alcohol induced exacerbations of chronic medical conditions were higher than matched controls, 2.3 vs 4.3%; p=0.04 and 4.7 vs 3.5%; p=0.04 in Level 3 and 1 respectively. This rebound effect was also noted with alcohol consumption in Belgium,[[30]] in trauma admissions in South Africa[[31]] and in emergency department presentations in the Netherlands[[32]] and Italy, where the relative frequency of severe alcohol intoxication in adolescents and young adults increased from 0.88% during the last part of the lockdown to 11.3% after lockdown release.[[33]]
There was much concern around resources and preparedness of hospital services for the care of patients.[[34]] General medicine experienced significant increase in numbers of patients with alcohol-related harm at each alert level compared to the 2019 control year. This was most pronounced in Level 4 lockdown (30% vs 19%; p=0.001). This first lockdown was also when the Community Alcohol and Drug Service (CADS) shut, and along with reduced services in the second Level 4 lockdown accounts for the decrease in discharges during this period (22 vs 9% p<0.001). A proportion of these admissions may have been passed onto the general medical service to manage. Certainly in the US, alcohol withdrawal rates in hospitalised patients increased by 34% in 2020 during the pandemic compared to 2019.[[35]]
Concerningly, there was a significant increase in acute mental and behavioural disorders during the strictest lockdown periods, Level 4 and 3. This increased from 20% to 28% (p=0.02) and 20% to 29% (p<0.001) respectively. This is in keeping with data stating that the majority of those who were drinking more said it was to help them “relax or switch off, or because they have been feeling stressed and anxious”.[[19]] In Alberta, Canada, presentations to the ED due to mental and behavioural disorders stemming from alcohol increased significantly from 2.7% in 2019 to 3.5% in 2020.[[36]] In the UK, there was significant association found between increased alcohol consumption and poor overall mental health (odds ratio (OR) 1.64), depressive symptoms and lower mental wellbeing.[[37]] Deaths from mental and behavioural disorders due to alcohol increased by 10.8%, compared to a 1.1% increase between 2018 and 2019.[[38]] In Australia, respondents who reported an increase in alcohol intake were more likely to have higher levels of depression (OR 1.07), anxiety (OR 1.08) and stress (OR 1.10).[[39]]
The influence on presentations due to alcohol-related harm on rates of acute medical conditions, gastrointestinal complaints, hepatitis and pancreatitis was surprisingly limited in our study, with no significant differences seen. In comparison, in the US following the onset of the pandemic, alcoholic liver disease became the most common indication for being listed on the transplant waitlist, and the fastest increasing cause for liver transplant.[[40]] A tertiary liver unit in London reported more than a doubling of referrals for alcohol-related liver disease.[[41]] Japan reported an increase of over 20% of hospital presentations with alcohol-related liver disease or pancreatitis.[[18]]
Presentations with orthopaedic injury or non-orthopaedic related trauma was also stable, aside from an increase in orthopaedic diagnoses at Level 2 (6 vs 2%, p=0.01). A study from Christchurch Hospital in New Zealand noted a 42% reduction in the volume of major trauma admissions during lockdown, yet an increase from 25% to 33% of those associated with alcohol intake pre-lockdown and during lockdown respectively. Post-lockdown, this decreased to 19%, although numbers were small.[[42]]
Patient demographics in our study were also remarkably alike, with no differences seen in presentation patterns based on age, gender or ethnicity during alert levels and control periods.
These data represent a detailed and complete overview of the impact of COVID-19 on a whole healthcare system. We believe that overall, it demonstrates that this population has largely managed to limit some of the harmful effects of alcohol harms seen in other countries. The New Zealand Government has been praised in its response and public health measures, with daily televised briefings re-enforcing key themes of 1) open, honest and straightforward communication, 2) distinctive and motivational language, and 3) expressions of care.[[43]] Frequent references to the New Zealand public as a “team of 5 million”, with a slogan of “be kind”, along with implementation of widespread social support structures including wage subsidy and leave support schemes may have helped to partially mitigate some of the negative effects of lockdown seen elsewhere.
Strengths of this study include the complete, real-world picture of the burden of alcohol harm on hospitalisation within Waitematā, Auckland. Studies reporting on only a specific or narrow spectrum of conditions may miss counter reactionary outcomes in other areas or specialties not measured. Individual case review of each presentation allowed for accurate inclusion and exclusion of cases. It is likely that accurate full population data within our catchment area was obtained, as at the onset of the pandemic people were advised to return to their home address. Patients domiciled in the area of each hospital are only admitted directly to that hospital, with few inter-hospital transfers and no acute private healthcare facilities functioning to see patients to provide acute care for alcohol-related harm. The initial low rates of infection and community transmission, and minimal hospital occupancy with COVID-19 cases, limited confounding of illnesses. A long follow-up period allowed for measurement of any rebound phenomenon; however, further data collection should be continued. Legacy effects of previous mass crises, such as the severe acute respiratory syndrome (SARS) epidemic of 2003, which led to increases in alcohol use including in hospital workers at a rate nearly 1.5 times higher even 3 years after this outbreak.[[44,45]]
This study is limited by its retrospective design. Quantification of excess alcohol that caused presentations was not recorded. Severity of illnesses of the patients was not measured, although we note there were no large differences in length of hospital stay or cost of hospitalisation, which may suggest otherwise. There was a considerable decrease of over 4,800 total acute hospital presentations during 67 days spent during the strict lockdown (Level 4). These data do not capture many patients who may have not presented to hospital that ordinarily would have. Research from New Zealand confirms that concerns regarding the risk of COVID-19 was prevalent and affected the decision to present to hospital.[[46]] Comparisons of alcohol-related presentations as a proportion of all hospital presentations between the COVID-19 alert levels and seasonality-matched control periods might have partially mitigated this bias. In addition, this study does not take into account primary care presentations or ambulance callouts to homes, which have been reported to be considerably higher in some areas.[[47]] Although this data may be generalisable to larger New Zealand cities, it is difficult to extrapolate to other countries given the substantial differences in pre-pandemic alcohol misuse, variations in restrictions enforced, other social responses and national geography including rurality.[[48]]
In conclusion, alcohol-related presentations were unchanged compared to matched control periods during the strictest level of lockdown. There was a significant increase in presentations with acute mental and behavioural disorders due to alcohol misuse in this period, although presentations with alcohol dependence were consistently lower even as restrictions eased. The general medical service saw a significantly increased burden of patients with alcohol-related harm. Although difficult to compare internationally, New Zealand appears to have largely avoided the general trend of increased alcohol-related harms during the COVID-19 pandemic and its lockdown restrictions.
View Appendices.
Summary
Abstract
Aim
New Zealand’s public health response to the COVID-19 pandemic has largely been considered successful, although there have been concerns surrounding the potential harms of the lockdown restrictions enforced, including alteration of alcohol consumption. New Zealand utilised a four-tiered alert level system of lockdowns and restrictions, with Level 4 denoting strict lockdown. This study aimed to compare alcohol-related hospital presentations during these periods with corresponding calendar-matched dates from the preceding year.
Method
We conducted a retrospective case-controlled analysis of all alcohol-related hospital presentations between 1 January 2019 to 2 December 2021 and compared COVID-19 restriction periods to corresponding calendar-matched pre-pandemic periods.
Results
A total of 3,722 and 3,479 alcohol-related acute hospital presentations occurred during the four COVID-19 restriction levels and corresponding control periods respectively. Alcohol-related presentations accounted for a greater proportion of all admissions during COVID-19 Alert Levels 3 and 1 than the respective control periods (both p<0.05), but not during Levels 4 and 2 (both p>0.30). Acute mental and behavioural disorders accounted for a greater proportion of alcohol-related presentations during Alert Levels 4 and 3 (both p≤0.02), although alcohol dependence was present in a lower proportion of presentations during Alert Levels 4, 3, and 2 (all p<0.01). There was no difference in acute medical conditions including hepatitis and pancreatitis during all alert levels (all p>0.05).
Conclusion
Alcohol-related presentations were unchanged compared to matched control periods during the strictest level of lockdown, although acute mental and behavioural disorders accounted for a greater proportion of alcohol-related admissions during this period. New Zealand appears to have avoided the general trend of increased alcohol-related harms seen internationally during the COVID-19 pandemic and its lockdown restrictions.
Author Information
Acknowledgements
Correspondence
Correspondence Email
Competing Interests
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The impact of COVID-19 restrictions on acute hospital presentations due to alcohol-related harm in Waitematā Auckland, New Zealand | OPEN ACCESS
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New Zealand’s public health response to the SARS-CoV-2 virus (COVID-19) pandemic has largely been considered successful, with lower-than-expected mortality.[[1–3]] The initial strategy to switch from infection mitigation to elimination was implemented by a nationwide “lockdown” on 26 March 2020 following evidence of community spread. This strictest level of enforcement, designated as “Level 4” of a four-tiered alert system, was a stay-at-home order and shut down all non-essential businesses. After 5 weeks, the country moved to “Level 3” for a further 2 weeks, which allowed limited contact with close family/whānau, and restricted regional movement.[[4]] This initial lockdown was successful in eliminating COVID-19 for 4 months, with subsequent staged reductions to less stringent restrictions of “Level 2 and 1”. However, cases re-emerged and a further Level 4 lockdown in August 2021 was ordered after the first case of the Delta variant—this lasted 5 weeks in Auckland, the largest city in New Zealand, containing one third of the country’s population. New Zealand then cycled in and out of restrictions thereafter, until 2 December 2021 when a different protection framework was introduced.
By April 2020, nearly half of the world's population was also under some form of lockdown across 90 countries or territories.[[5]] While there has been an apparent overall mortality benefit in countries with stringent lockdowns such as New Zealand and Australia, the United Kingdom (UK) imposed three lockdowns that did not show a clear benefit in terms of excess mortality.[[3]] There has been debate and criticism of the firm lockdown restrictions enforced, in particular that benefits of these interventions may be outweighed by potential harms on the economy, social structure, education and mental health.[[6]] These are amplified in vulnerable populations.[[7,8]]
Clarifying and quantifying excess morbidity related to lockdowns is challenging. The World Health Organization (WHO) estimates that this pandemic has led to a 25% increase in the prevalence of anxiety and depression globally.[[9]] With considerable additional mental health burden, it has been widely reported that alcohol sales and use have increased during this time.[[10–12]] Consumption of alcohol has been shown to be significantly altered after implementation of lockdowns, with a trend towards increased consumption, although there is widespread variability between countries.[[13]] WHO encouraged governments to enforce measures that limited alcohol consumption.[[14]] Social isolation, fear, loss of work in conjunction with disruption to community alcohol and drug services, diversion of hospital resources and medical service avoidance are postulated as contributory.[[15–17]]
Specific research into acute hospital presentations due to alcohol-related harm during the lockdowns and pandemic restrictions in general are limited, both in New Zealand and internationally. They may only report on a narrow spectrum of conditions. While there are suggestions of harm, data may also often be at a population level as opposed to an individual level, and therefore miss important information and nuance.[[18]] Research from New Zealand offers a unique insight as an island nation of 5 million people, where lockdowns were strictly adhered to and initial limited infection numbers reduced the confounding effects of COVID-19 pathology.
We aimed to calculate the proportion of the total number of acute hospital presentations due to alcohol-related harm during each specific alert level period compared to control dates in 2019. In addition, we aimed to clarify the demographics of these patients, specialty involved with their care, final diagnoses and length and cost of their hospital presentation.
Methods
We conducted a retrospective case-controlled analysis of all patients with acute hospital contact due to alcohol-related harm as the primary cause of presentation within the Waitematā District, an area with a catchment of 650,000 people. This lies within Auckland, the largest city in New Zealand, which has a total population of 1.57 million and contains two other tertiary hospitals. We assessed presentations to the North Shore and Waitakere hospitals, which support over 660 and 283 beds respectively. In addition, we reviewed data from the Community Alcohol and Drug Service (CADS), a 10-bed inpatient unit for medically supervised detoxification. People domiciled in the catchment area of each hospital are admitted directly to that hospital.
Patients’ presentations were extracted from clinical coding using ICD10-AM, 11th Edition from 1 January 2019 to 2 December 2021. Codes for disorders due to alcohol including intoxication, harmful use, poisoning, withdrawal, dependence, mental and behavioural disturbance or a medical condition due to alcohol were collected. Each case presentation was then individually reviewed by three doctors. Cases were only included if acute alcohol intake was deemed to be the primary cause of admission. If a case was ambiguous, it was independently reviewed by a fourth doctor.
To adjust for seasonality, admission data from matched calendar dates from the year immediately preceding the commencement of the COVID-19 alert level system were collected to serve as the control groups for each COVID-19 alert level period. Total patient hospital discharge numbers were obtained for 2019 to 2021 for proportional comparison. Local ethical approval was granted (ID: RM15128).
Diagnosis at discharge were categorised into 11 groups, as summarised in Appendix 2, and included acute medical conditions, acute mental and behavioural disorders, alcohol dependence, chronic medical conditions, chronic mental and behavioural disorders, gastrointestinal complaints, hepatitis, non-orthopaedic trauma, orthopaedic trauma, pancreatitis and seizures.
Alert Level Restriction categories can be summarised as:[[4]]
• Level 4 (lockdown): no travel or gatherings, all businesses must close except for necessities.
• Level 3: restricted local travel only, gatherings of up to 10 people allowed for weddings or funerals, contactless businesses may open, reconnection allowed with close family/whānau.
• Level 2: Domestic travel allowed, gatherings of up to 100 people allowed, businesses can open with additional health measures in place, reconnection with friends and socialisation in groups allowed.
• Level 1: No restrictions on personal movement or gatherings, all businesses can open, mask wearing and social distancing continue.
View Tables 1–3 and Figure 1.
The primary outcome was calculation of the proportion of total number of acute hospital presentations due to alcohol-related harm during each alert level period compared to control dates in 2019. An additional review of differences in discharge diagnosis during these dates was also completed. Additional data collected for assessment of secondary outcomes included demographic variables, length of inpatient stay, discharge specialty and estimated cost of admission.
Statistical analysis was performed using IBM SPSS Statistics version 26.0 (New York, USA) and GraphPad Prism version 8.2.0 (California, USA). Inter-group comparisons of continuous variables between groups were performed using one-way analysis of variance (ANOVA), where normal distributions had been confirmed by Kolmogorov–Smirnov testing (p>0.05), with post hoc analysis for pairwise comparisons then being conducted using the multiplicity-adjusted Tukey test. Non-normally distributed continuous data were analysed using the Kruskall–Wallis test and post hoc pairwise comparisons performed using the multiplicity-adjusted Dunn test. Categorical data were compared using the Chi-squared and Fisher’s exact tests. All tests were two-tailed and p<0.05 was considered significant. Data are presented as mean ± SD, median (IQR) or number of presentations (% of presentations), unless otherwise stated.
Results
A total of 3,722 alcohol-related acute hospital presentations occurred during the four COVID-19 alert levels, and 3,479 alcohol-related hospital presentations occurred during the corresponding seasonality-matched control periods from the preceding year (Table 2).
164 patients were excluded from final analysis as their presentations were not assessed to be due to acute alcohol use (120), had incomplete documentation (28) or were an electively arranged review (16).
Overall, alcohol-related presentations accounted for between 1.5–1.8% of all presentations within the district during the four COVID-19 alert levels. Alcohol-related presentations accounted for a greater proportion of all presentations during COVID-19 Alert Levels 3 and 1 when compared to the corresponding seasonality-matched control periods (both p<0.05), but not during Alert Levels 4 and 2 (both p ≥ 0.30). The frequency of alcohol-related presentations by discharge diagnosis per month and alert level is illustrated in Figure 1.
Alcohol-related presentation characteristics by COVID-19 alert level are summarised in Table 3. Further detail is available in the Appendix 1. Age, gender, ethnicity, admission length and cost of admission did not differ significantly between the four alert levels and the corresponding control periods.
Acute mental and behavioural disorders accounted for a greater proportion of alcohol-related presentations during Alert Levels 4 and 3 (both p≤0.02), chronic medical conditions were present in a higher portion of presentations during Alert Levels 3 and 1 (both p<0.05), while an increased proportion of orthopaedic conditions were observed during Alert Level 2. Alcohol dependence was present in a lower proportion of presentations during Alert Levels 4, 3, and 2 (all p<0.01), while chronic mental and behavioural disorders accounted for a decreased proportion of presentations during Alert Level 3 (p<0.001). Acute medical conditions did not differ from the control periods during all alert levels (all p>0.05).
A higher proportion of cases were discharged from the General Medicine service during all four alert levels than control periods (all p≤0.01), and an increased proportion of patients were also discharged from the General Surgery service during Alert Level 2 (p=0.048). Discharges from the Emergency Medicine service accounted for a lower proportion of alcohol-related admissions during Alert Levels 3 and 1 (both p≤0.01), while a decreased proportion of discharges from the Community Alcohol and Drug Service were observed during Alert Levels 4 and 2 (both p≤0.01).
Discussion
To the best of our knowledge, this is the first study to compare all-cause acute presentations due to alcohol-related harm before, during and after restrictions during the COVID-19 pandemic. During the 67 days Auckland spent in the strictest COVID-19 lockdown (Level 4), there was no change in proportion of alcohol-related presentations as compared to the previous control year (p=0.42). Published data from an online survey of 925 New Zealanders for Te Hiringa Hauora | Health Promotion Agency, Impact of COVID-19, reported a 19% increase in alcohol consumption during the first lockdown, noting stress, boredom and anxiety as key factors for this. However, 47% did not change consumption, and 34% decreased consumption.[[19]] These figures may help to explain this finding, and the reduced proportions of patients diagnosed with alcohol dependence at Levels 4, 3 and 2 respectively: 13 vs 25% (p=0.002), 20 vs 27% (p=0.006), 19 vs 27% p<0.001. Over this time there was little change in the volume of alcohol available for consumption, despite the major disruption to the hospitality industry.[[20]] This must then reflect the availability and prominence of packaged alcohol consumption in New Zealand, which has been shown as problematic.[[21]]
Published national data of drinking practices during the pandemic vary considerably. In Colombia, Mexico [[22]] and South Australia, [[23]] alcohol use reportedly decreased, while in Greece consumption was largely unchanged.[[24]] Surveys from Germany,[[25]] Canada[[26]] and Poland[[27]] suggest substantially increased consumption. In the UK, high risk drinking increased by over 5%, with the prevalence of drinking ≥4 times a week doubling from 12.5% to 26% from before to during the pandemic (p<0.001).[[28]] There is similar data from the United States (US), with a 14% increase of frequency of consumption compared to 2019.[[29]]
However, within New Zealand, there may have been rebound consumption following the complete relaxation of restrictions seen in Level 1, where there were no longer limitations placed on individual movements, gatherings or businesses operations. 1.8% of total presentations were attributable to alcohol, an increase from 1.5% in Level 4, and 0.2% higher than corresponding dates from 2019 (p<0.001) (see Table 2). These findings are supported by the Te Hiringa Hauora | Health Promotion Agency's Impact of COVID-19 survey, indicating 64% returned to their pre-lockdown drinking practices. This suggests that people who may have been drinking less during lockdown may have subsequently increasing their consumption again.[[19]] Along with Level 3, this was also the period where alcohol induced exacerbations of chronic medical conditions were higher than matched controls, 2.3 vs 4.3%; p=0.04 and 4.7 vs 3.5%; p=0.04 in Level 3 and 1 respectively. This rebound effect was also noted with alcohol consumption in Belgium,[[30]] in trauma admissions in South Africa[[31]] and in emergency department presentations in the Netherlands[[32]] and Italy, where the relative frequency of severe alcohol intoxication in adolescents and young adults increased from 0.88% during the last part of the lockdown to 11.3% after lockdown release.[[33]]
There was much concern around resources and preparedness of hospital services for the care of patients.[[34]] General medicine experienced significant increase in numbers of patients with alcohol-related harm at each alert level compared to the 2019 control year. This was most pronounced in Level 4 lockdown (30% vs 19%; p=0.001). This first lockdown was also when the Community Alcohol and Drug Service (CADS) shut, and along with reduced services in the second Level 4 lockdown accounts for the decrease in discharges during this period (22 vs 9% p<0.001). A proportion of these admissions may have been passed onto the general medical service to manage. Certainly in the US, alcohol withdrawal rates in hospitalised patients increased by 34% in 2020 during the pandemic compared to 2019.[[35]]
Concerningly, there was a significant increase in acute mental and behavioural disorders during the strictest lockdown periods, Level 4 and 3. This increased from 20% to 28% (p=0.02) and 20% to 29% (p<0.001) respectively. This is in keeping with data stating that the majority of those who were drinking more said it was to help them “relax or switch off, or because they have been feeling stressed and anxious”.[[19]] In Alberta, Canada, presentations to the ED due to mental and behavioural disorders stemming from alcohol increased significantly from 2.7% in 2019 to 3.5% in 2020.[[36]] In the UK, there was significant association found between increased alcohol consumption and poor overall mental health (odds ratio (OR) 1.64), depressive symptoms and lower mental wellbeing.[[37]] Deaths from mental and behavioural disorders due to alcohol increased by 10.8%, compared to a 1.1% increase between 2018 and 2019.[[38]] In Australia, respondents who reported an increase in alcohol intake were more likely to have higher levels of depression (OR 1.07), anxiety (OR 1.08) and stress (OR 1.10).[[39]]
The influence on presentations due to alcohol-related harm on rates of acute medical conditions, gastrointestinal complaints, hepatitis and pancreatitis was surprisingly limited in our study, with no significant differences seen. In comparison, in the US following the onset of the pandemic, alcoholic liver disease became the most common indication for being listed on the transplant waitlist, and the fastest increasing cause for liver transplant.[[40]] A tertiary liver unit in London reported more than a doubling of referrals for alcohol-related liver disease.[[41]] Japan reported an increase of over 20% of hospital presentations with alcohol-related liver disease or pancreatitis.[[18]]
Presentations with orthopaedic injury or non-orthopaedic related trauma was also stable, aside from an increase in orthopaedic diagnoses at Level 2 (6 vs 2%, p=0.01). A study from Christchurch Hospital in New Zealand noted a 42% reduction in the volume of major trauma admissions during lockdown, yet an increase from 25% to 33% of those associated with alcohol intake pre-lockdown and during lockdown respectively. Post-lockdown, this decreased to 19%, although numbers were small.[[42]]
Patient demographics in our study were also remarkably alike, with no differences seen in presentation patterns based on age, gender or ethnicity during alert levels and control periods.
These data represent a detailed and complete overview of the impact of COVID-19 on a whole healthcare system. We believe that overall, it demonstrates that this population has largely managed to limit some of the harmful effects of alcohol harms seen in other countries. The New Zealand Government has been praised in its response and public health measures, with daily televised briefings re-enforcing key themes of 1) open, honest and straightforward communication, 2) distinctive and motivational language, and 3) expressions of care.[[43]] Frequent references to the New Zealand public as a “team of 5 million”, with a slogan of “be kind”, along with implementation of widespread social support structures including wage subsidy and leave support schemes may have helped to partially mitigate some of the negative effects of lockdown seen elsewhere.
Strengths of this study include the complete, real-world picture of the burden of alcohol harm on hospitalisation within Waitematā, Auckland. Studies reporting on only a specific or narrow spectrum of conditions may miss counter reactionary outcomes in other areas or specialties not measured. Individual case review of each presentation allowed for accurate inclusion and exclusion of cases. It is likely that accurate full population data within our catchment area was obtained, as at the onset of the pandemic people were advised to return to their home address. Patients domiciled in the area of each hospital are only admitted directly to that hospital, with few inter-hospital transfers and no acute private healthcare facilities functioning to see patients to provide acute care for alcohol-related harm. The initial low rates of infection and community transmission, and minimal hospital occupancy with COVID-19 cases, limited confounding of illnesses. A long follow-up period allowed for measurement of any rebound phenomenon; however, further data collection should be continued. Legacy effects of previous mass crises, such as the severe acute respiratory syndrome (SARS) epidemic of 2003, which led to increases in alcohol use including in hospital workers at a rate nearly 1.5 times higher even 3 years after this outbreak.[[44,45]]
This study is limited by its retrospective design. Quantification of excess alcohol that caused presentations was not recorded. Severity of illnesses of the patients was not measured, although we note there were no large differences in length of hospital stay or cost of hospitalisation, which may suggest otherwise. There was a considerable decrease of over 4,800 total acute hospital presentations during 67 days spent during the strict lockdown (Level 4). These data do not capture many patients who may have not presented to hospital that ordinarily would have. Research from New Zealand confirms that concerns regarding the risk of COVID-19 was prevalent and affected the decision to present to hospital.[[46]] Comparisons of alcohol-related presentations as a proportion of all hospital presentations between the COVID-19 alert levels and seasonality-matched control periods might have partially mitigated this bias. In addition, this study does not take into account primary care presentations or ambulance callouts to homes, which have been reported to be considerably higher in some areas.[[47]] Although this data may be generalisable to larger New Zealand cities, it is difficult to extrapolate to other countries given the substantial differences in pre-pandemic alcohol misuse, variations in restrictions enforced, other social responses and national geography including rurality.[[48]]
In conclusion, alcohol-related presentations were unchanged compared to matched control periods during the strictest level of lockdown. There was a significant increase in presentations with acute mental and behavioural disorders due to alcohol misuse in this period, although presentations with alcohol dependence were consistently lower even as restrictions eased. The general medical service saw a significantly increased burden of patients with alcohol-related harm. Although difficult to compare internationally, New Zealand appears to have largely avoided the general trend of increased alcohol-related harms during the COVID-19 pandemic and its lockdown restrictions.
View Appendices.
Summary
Abstract
Aim
New Zealand’s public health response to the COVID-19 pandemic has largely been considered successful, although there have been concerns surrounding the potential harms of the lockdown restrictions enforced, including alteration of alcohol consumption. New Zealand utilised a four-tiered alert level system of lockdowns and restrictions, with Level 4 denoting strict lockdown. This study aimed to compare alcohol-related hospital presentations during these periods with corresponding calendar-matched dates from the preceding year.
Method
We conducted a retrospective case-controlled analysis of all alcohol-related hospital presentations between 1 January 2019 to 2 December 2021 and compared COVID-19 restriction periods to corresponding calendar-matched pre-pandemic periods.
Results
A total of 3,722 and 3,479 alcohol-related acute hospital presentations occurred during the four COVID-19 restriction levels and corresponding control periods respectively. Alcohol-related presentations accounted for a greater proportion of all admissions during COVID-19 Alert Levels 3 and 1 than the respective control periods (both p<0.05), but not during Levels 4 and 2 (both p>0.30). Acute mental and behavioural disorders accounted for a greater proportion of alcohol-related presentations during Alert Levels 4 and 3 (both p≤0.02), although alcohol dependence was present in a lower proportion of presentations during Alert Levels 4, 3, and 2 (all p<0.01). There was no difference in acute medical conditions including hepatitis and pancreatitis during all alert levels (all p>0.05).
Conclusion
Alcohol-related presentations were unchanged compared to matched control periods during the strictest level of lockdown, although acute mental and behavioural disorders accounted for a greater proportion of alcohol-related admissions during this period. New Zealand appears to have avoided the general trend of increased alcohol-related harms seen internationally during the COVID-19 pandemic and its lockdown restrictions.
Author Information
Acknowledgements
Correspondence
Correspondence Email
Competing Interests
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The impact of COVID-19 restrictions on acute hospital presentations due to alcohol-related harm in Waitematā Auckland, New Zealand | OPEN ACCESS
The World Health Organization (WHO) estimates that this pandemic has led to a 25% increase in the prevalence of anxiety and depression globally. With considerable additional mental health burden, it has been widely reported that alcohol sales and use have increased during this time.
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