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      COVID-19 Outbreak — New York City, February 29–June 1, 2020

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      , PhD 1 , , , MSPH 1 , 1 , 1 , , MPH 1 , , MPH 1 , , MPH 1 , 1 , , PhD 1 , , MPH 1 , , MPH 1 , , MPH 1 , , MPH 1 , 1 , , MPH 1 , , MPH 1 , , MD 1 , , PhD 1 , , MPH 1 , , PhD 1 , , MPH 1 , , MPH 1 , , MPH 1 , , MPH 1 , , MPH 1 , , MD 1 , , MPH 1 , , PhD 1 , , MPH 1 , , MPH 1 , 1 , , MPH 1 , , MPH 1 , , MPH 1 , , MPH 1 , , MPH 1 , , MD 1 , , MPH 1 , , MPH 1 , , MHA 1 , , MPH 1 , , PhD 1 , , MPH 1 , , PhD 1 , , MPH 1 , , MD 1 , , MD 1 , , DrPH 1 , , MPH 1 , , MD 1
      Morbidity and Mortality Weekly Report
      Centers for Disease Control and Prevention

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          Abstract

          New York City (NYC) was an epicenter of the coronavirus disease 2019 (COVID-19) outbreak in the United States during spring 2020 ( 1 ). During March–May 2020, approximately 203,000 laboratory-confirmed COVID-19 cases were reported to the NYC Department of Health and Mental Hygiene (DOHMH). To obtain more complete data, DOHMH used supplementary information sources and relied on direct data importation and matching of patient identifiers for data on hospitalization status, the occurrence of death, race/ethnicity, and presence of underlying medical conditions. The highest rates of cases, hospitalizations, and deaths were concentrated in communities of color, high-poverty areas, and among persons aged ≥75 years or with underlying conditions. The crude fatality rate was 9.2% overall and 32.1% among hospitalized patients. Using these data to prevent additional infections among NYC residents during subsequent waves of the pandemic, particularly among those at highest risk for hospitalization and death, is critical. Mitigating COVID-19 transmission among vulnerable groups at high risk for hospitalization and death is an urgent priority. Similar to NYC, other jurisdictions might find the use of supplementary information sources valuable in their efforts to prevent COVID-19 infections. This report describes cases of laboratory-confirmed COVID-19 among NYC residents diagnosed during February 29–June 1, 2020, that were reported to DOHMH. DOHMH began COVID-19 surveillance in January 2020 when testing capacity for SARS-CoV-2 (the virus that causes COVID-19) using real-time reverse transcription–polymerase chain reaction (RT-PCR) was limited by strict testing criteria because of limited test availability only through CDC. The NYC and New York State public health laboratories began testing hospitalized patients at the end of February and early March. DOHMH encouraged patients with mild symptoms to remain at home rather than seek health care because of shortages of personal protective equipment and laboratory tests at hospitals and clinics. Commercial laboratories began testing for SARS-CoV-2 in mid- to late March. During February 29–March 15, patients with laboratory-confirmed COVID-19 were interviewed by DOHMH, and close contacts were identified for monitoring. The rapid rise in laboratory-confirmed cases (cases) quickly made interviewing all patients, as well as contact tracing, unsustainable. Subsequent case investigations first included medical chart review for patients who were hospitalized or who had died, but then progressed to chart review only for patients who had died, and then finally only for deaths in patients aged <65 years. On April 14, DOHMH began to report probable COVID-19–associated deaths (i.e., no known positive SARS-CoV-2 test result and death certificate listing cause of death as COVID-19 or an equivalent term [e.g., COVID, SARS-CoV-2, or another term]). DOHMH quickly recognized the need for supplementary information sources and relied on direct data importation and matching of patient identifiers for data on hospitalization status, the occurrence of death, race/ethnicity, and presence of underlying medical conditions, including diabetes, lung disease, cancer, immunodeficiency, heart disease, asthma, kidney disease, gastrointestinal/liver disease, and obesity. These supplementary data systems included emergency department syndromic surveillance, the New York State Hospital Emergency Response Data System, regional health information organizations, NYC public hospitals, DOHMH’s electronic death registry system, and remote access to hospitals’ electronic health record systems. Even with these supplementary data sources, many variables (e.g., race/ethnicity) were still incomplete, given variable data quality. Descriptive statistics were calculated using SAS software (version 9.4; SAS Institute). Age-adjusted rates were calculated using direct standardization for age and weighting by the U.S. 2000 standard population ( 2 ). Crude rates of cumulative cases, deaths, and testing per 100,000 population were mapped by modified U.S. Census Bureau ZIP code tabulation area* using ArcGIS software (version 10.6.1; ESRI). Neighborhood-level poverty was defined as the percentage of residents within a ZIP code with household incomes <100% of the federal poverty level, per the American Community Survey 2013–2017 (low: <10%, medium: 10%–19.9%, high: 20%–29.9%, very high: ≥30%). Population estimates (for 2018) for age, sex, borough (county) of residence, racial/ethnic group, and neighborhood poverty were produced by DOHMH using U.S. Census Bureau Population Estimate Program files (unpublished data, NYC DOHMH, 2020). † During February 29–June 1, 2020, a total of 203,792 COVID-19 cases were diagnosed and reported § among residents of NYC, including 54,211 (26.6%) in persons known to have been hospitalized and 18,679 (9.2%) in persons who died. The age-adjusted cumulative citywide incidences were 2,263 cases, 582 hospitalizations, and 198 deaths per 100,000 population. Case counts increased rapidly from a weekly mean of 274 diagnosed cases per day during the week of March 8 to a peak weekly mean of 5,132 cases per day by the week of March 29 (Figure 1). Hospital admissions also peaked the week of March 29 (weekly mean = 1,566 admissions per day). Deaths peaked during the week of April 5 (weekly mean = 566 per day). The median duration of hospitalization was 6 days (interquartile range [IQR] = 3–11 days). Among decedents with laboratory-confirmed COVID-19, the median interval from diagnosis to death was 8 days (IQR = 4–16 days). Among hospitalized patients, 32.1% were known to have died. The weekly proportion of hospitalized patients who died was highest among those admitted during March 22–April 5 (mean = 36.4%; range = 33.5%–38.2%). FIGURE 1 Daily laboratory-confirmed COVID-19 cases, associated hospitalizations, and deaths — New York City, February 29–June 1, 2020 Abbreviation: COVID-19 = coronavirus disease 2019. The figure is a series of epidemiologic curves showing the numbers of daily laboratory-confirmed COVID-19 cases by diagnosis date, associated hospitalizations by admission date, and confirmed deaths by date of death, in New York City, during February 29–June 1, 2020. Age-specific incidence was highest among adults aged 45–64 years (7,007 per 100,000) (Table). Hospitalization and death rates were highest among patients aged ≥75 years (2,146 and 1,311 per 100,000, respectively); among persons aged ≥75 years with confirmed cases, 38.3% were known to have died. Age-adjusted incidence, hospitalization rate, and death rate were higher among males than females, and all increased with increasing levels of neighborhood poverty. By borough, age-adjusted incidence, hospitalization rate, and death rate were consistently highest in the Bronx and lowest in Manhattan. Among the race/ethnicity groups with known identity, incidence was highest among Black/African American (Black) persons (1,590 per 100,000). Age-adjusted rates of hospitalization and death were highest among Black (699 and 248 per 100,000, respectively) and Hispanic/Latino (Hispanic) persons (658 and 260 per 100,000, respectively). TABLE Characteristics of cumulative laboratory-confirmed COVID-19 cases, hospitalizations, and deaths among New York City residents reported to the New York City Department of Health and Mental Hygiene — New York City, February 29–June 1, 2020* Characteristic Cases Hospitalizations Deaths No. Rate† No. (row %) Rate† No. (row %) Rate† Total 203,792 2,263 54,211 (26.6) 582 18,679 (9.2) 198 Age group, yrs 0–17 6,016 348 508 (8.4) 29 12 (0.2) 1 18–44 74,654 2,215 8,474 (11.4) 251 686 (0.9) 20 45–64 73,998 7,007 18,219 (24.6) 1,725 4,183 (5.7) 396 65–74 25,182 2,518 12,009 (47.7) 1,201 4,634 (18.4) 463 ≥75 23,942 3,425 15,001 (62.7) 2,146 9,164 (38.3) 1,311 Sex Female 98,992 2,060 23,612 (23.9) 456 7,494 (7.6) 136 Male 104,675 2,511 30,589 (29.2) 744 11,183 (10.7) 283 Race/Ethnicity Hispanic/Latino 36,498 1,514 15,288 (41.9) 658 5,743 (15.7) 260 Black/African American 32,458 1,590 14,676 (45.2) 699 5,215 (16.1) 248 White 31,029 988 11,057 (35.6) 314 4,745 (15.3) 123 Asian/Pacific Islander 8,122 601 3,441 (42.4) 258 1,403 (17.3) 111 American Indian/Alaska Native 196 973 33 (16.8) 168 5 (2.6) 27 Other race/Missing 95,489 —§ 9,716 (10.2) —§ 1,568 (1.6) —§ Neighborhood poverty¶ Low 33,114 1,787 7,498 (22.6) 358 2,756 (8.3) 125 Medium 79,327 2,169 20,907 (26.4) 551 7,404 (9.3) 193 High 48,998 2,315 15,034 (30.7) 700 5,184 (10.6) 241 Very high 36,642 2,706 10,341 (28.2) 796 3,305 (9) 268 Borough of residence Bronx 46,085 3,157 12,076 (26.2) 826 3,870 (8.4) 268 Brooklyn 56,548 2,104 15,125 (26.7) 556 5,563 (9.8) 205 Manhattan 25,315 1,369 7,867 (31.1) 408 2,476 (9.8) 123 Queens 62,260 2,507 16,806 (27) 637 5,882 (9.4) 217 Staten Island 13,577 2,701 2,337 (17.2) 423 888 (6.5) 158 Abbreviation: COVID-19 = coronavirus disease 2019. * Data missing on sex for 138 persons, on borough for nine persons, and on neighborhood poverty for 6,660 persons. † Per 100,000 population; rates for sex, race/ethnicity, neighborhood poverty, and borough of residence were age-adjusted. § Rates not calculated because no population denominator. ¶ Neighborhood-level poverty was defined as the percentage of residents in a ZIP code with household incomes <100% of the federal poverty level, per the American Community Survey 2013–2017. Low poverty: <10%; medium poverty: 10%–19.9%; high poverty: 20%–29.9%; very high poverty: ≥30%. Some neighborhoods with high case rates also had high testing rates (e.g., North Bronx and Northwest Queens) (Figure 2). However, other neighborhoods had low or medium testing rates and high percent positivity with medium to high case rates (Southeast Queens, East Brooklyn, West Bronx, and Northern Manhattan), suggesting possible underascertainment of cases. Citywide, the percentage of tests with positive results increased from 27% the week of March 8 to a peak of 65% during the week of March 22. The growth of testing rates lagged behind the growth of percent positivity but increased steadily from 86 per 100,000 during the week of March 8 to 1,634 per 100,000 by the week of May 24. FIGURE 2 Cumulative crude rates of COVID-19 testing per 100,000 population, percentage of tests positive for SARS-CoV-2, and cumulative crude rates of COVID-19 cases per 100,000 population,* by modified ZIP code tabulation areas — New York City, February 29–June 1, 2020 Abbreviation: COVID-19 = coronavirus disease 2019. * All data are displayed by four levels of natural breaks. The figure is a series of three maps of New York City showing the cumulative crude rates of COVID-19 testing per 100,000 population, the percentage of tests positive for SARS-CoV-2, and the cumulative crude rates of COVID-19 cases per 100,000 population during February 29–June 1, 2020, by modified ZIP code tabulation areas. Among 85% of decedents with known underlying medical conditions, the majority (75%) of decedents with a confirmed laboratory test had two or more underlying conditions; heart disease (73%), diabetes (58%), and chronic kidney disease (23%) were the most commonly reported conditions (NYC DOHMH, unpublished data; 2020). During March 11–June 1, 4,516 probable COVID-19–associated deaths were known to have occurred among NYC residents. These deaths occurred more commonly at home (30%) or in a nursing home (26%), compared with confirmed COVID-19 deaths (4% at home and 8% in a nursing home). Deaths occurring in a hospital were frequently laboratory-confirmed as COVID-19–associated (86%). Among 23,195 probable and confirmed deaths, 22.5% (5,226) were known to have occurred among residents of a nursing home. Discussion Phylogenetic analysis and sentinel surveillance suggest that the introduction of COVID-19 into NYC from travelers started during early to mid-February 2020 ( 3 , 4 ), although the first case of laboratory-confirmed COVID-19 in NYC was diagnosed on February 29. The subsequent 3-month period was characterized by a rapid acceleration in the epidemic, resulting in approximately 203,000 cases and 18,600 deaths among persons with laboratory-confirmed COVID-19. Reported diagnoses of cases peaked 1 week after physical distancing orders were enacted (March 22). The overall crude case fatality rate of 9.2% is an overestimate because of underascertainment of cases, given the restrictive testing guidance and limited availability of tests for the first 2 months of the epidemic. ¶ Similar to findings from the United Kingdom,** approximately 30% of hospitalized patients with laboratory-confirmed COVID-19 were known to have died. The increased case fatality rate among hospitalized patients during the peak period of reported cases suggests that health care system capacity constraints might have influenced patient outcomes. As has been previously reported ( 5 ), COVID-19 incidence and related hospitalization and mortality were elevated among Black and Hispanic persons and among residents of high-poverty neighborhoods. The finding of neighborhoods with low testing rates and a high percentage of positive test results suggests barriers to accessing testing in areas with considerable community transmission. The rapid spread of COVID-19, combined with a lack of testing availability early in 2020, led to considerable surveillance challenges. DOHMH quickly ceased labor-intensive individual case investigations for all patients and sought supplementary sources of information. In addition, publishing NYC DOHMH data online in real-time †† allowed the public to access basic and important information on COVID-19 in NYC. The findings in this report are subject to at least four limitations. First, these data are based primarily on laboratory-confirmed disease, which is more likely to represent severe illness, especially early in the epidemic when COVID-19 testing was mostly limited to hospitalized patients. Second, hospitalizations were underestimated because of incomplete ascertainment from external sources. Third, race and ethnicity information was missing for a large proportion of nonhospitalized, nonfatal cases. Finally, rates are likely underestimated for more affluent neighborhoods because denominators do not reflect the differential exodus of wealthy NYC residents ( 6 ). The initial wave of COVID-19 in NYC demonstrated that persons who were older, had underlying medical conditions, or resided in poorer neighborhoods, and racial and ethnic minority populations suffered disproportionately from SARS-Cov-2 infection and death. These trends represent the downstream effect of long-term policies, practices, attitudes, and cultural messages that promote, reinforce, and fail to eliminate inequities ( 7 ). In addition, Black and Hispanic persons are disproportionately employed in lower-paid, often frontline industries and occupations, work with limited ability to social distance, and are more likely to lack employer-based health insurance ( 8 ). Mitigating future morbidity and mortality from COVID-19 across NYC in the absence of a vaccine, §§ particularly among persons who are at increased risk, is an urgent priority. Summary What is already known about this topic? New York City (NYC) was an early epicenter of the COVID-19 pandemic in the United States. What is added by this report? Approximately 203,000 cases of laboratory-confirmed COVID-19 were reported in NYC during the first 3 months of the pandemic. The crude fatality rate among confirmed cases was 9.2% overall and 32.1% among hospitalized patients. Incidence, hospitalization rates, and mortality were highest among Black/African American and Hispanic/Latino persons, as well as those who were living in neighborhoods with high poverty, aged ≥75 years, and with underlying medical conditions. What are the implications for public health practice? Mitigating COVID-19 transmission among vulnerable groups at high risk for hospitalization and death is an urgent priority.

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          Structural racism and health inequities in the USA: evidence and interventions

          The Lancet, 389(10077), 1453-1463
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            COVID-19 and Racial/Ethnic Disparities

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              COVID-19 exacerbating inequalities in the US

              COVID-19 does not affect everyone equally. In the US, it is exposing inequities in the health system. Aaron van Dorn, Rebecca E Cooney, and Miriam L Sabin report from New York. In the US, New York City has so far borne the brunt of the coronavirus disease 2019 (COVID-19) pandemic, with the highest reported number of cases and the highest death toll in the country. The first COVID-19 case in the city was reported on March 1, but community transmission was firmly established on March 7. As of April 14, New York State has tested nearly half a million people, among whom 195 031 have tested positive. In New York City alone, 106 763 people have tested positive and 7349 have died. “New York is the canary in the coal mine. What happens to New York is going to wind up happening to California, and Washington State and Illinois. It's just a matter of time”, said New York Governor Andrew Cuomo, while asking for greater federal assistance. The response within New York City, known for its historically strong public health responses, has been to ramp up for the surge, but also to tailor the approach to address some of the most basic touchpoints that could worsen health outcomes, including providing three meals a day to all New York residents in need. Oxiris Barbot, commissioner of the New York City Department of Health and Mental Hygiene stated, “Our primary focus at this moment has to be on keeping our city's communities safe. This means supporting the public hospitals with supplies; connecting underserved people to free access to care; and delivering health guidance through the trusted voices of community organizations. The COVID-19 pandemic will come to an end eventually, but what is needed afterward is a renewed focus to ensure that health is not a byproduct of privilege. Public health has a fundamental role to play in shaping our future to be more just and equitable.” Confirming existing disparities, within New York City and other urban centres, African American and other communities of colour have been especially affected by the COVID-10 pandemic. Across the country, deaths due to COVID-19 are disproportionately high among African Americans compared with the population overall. In Milwaukee, WI, three quarters of all COVID-19 related deaths are African American, and in St Louis, MO, all but three people who have died as a result of COVID-19 were African American. According to Sharrelle Barber of Drexel University Dornsife School of Public Health (Philadelphia, PA, USA), the pre-existing racial and health inequalities already present in US society are being exacerbated by the pandemic. “Black communities, Latino communities, immigrant communities, Native American communities—we're going to bear the disproportionate brunt of the reckless actions of a government that did not take the proper precautions to mitigate the spread of this disease”, Barber said. “And that's going to be overlaid on top of the existing racial inequalities.” Part of the disproportionate impact of the COVID-19 pandemic on communities of colour has been structural factors that prevent those communities from practicing social distancing. Minority populations in the US disproportionally make up “essential workers” such as retail grocery workers, public transit employees, and health-care workers and custodial staff. “These front-line workers, disproportionately black and brown, then are typically a part of residentially segregated communities”, said Barber. “They don't have that privilege of quote unquote ‘staying at home’, connecting those individuals to the communities they are likely to be a part of because of this legacy of residential segregation, or structural racism in our major cities and most cities in the United States.” The negative consequences of health disparities for people who live in rural areas in the US were already a problem before the pandemic. Underserved African Americans face higher HIV incidence and greater maternal and infant mortality rates. Undocumented Latino communities working in rural industries such as farming, poultry, and meat production often have no health insurance. Poor white communities have been badly hit by the opioid crisis and across rural areas, especially in the southern states, high rates of non-communicable diseases are driven by conditions such as obesity. With higher COVID-19 mortality among those with underlying health conditions, these areas could be hit hard. © 2020 Spencer Platt/Getty Images 2020 Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active. 14 US states (mostly in the south and the Plains) have refused to accept the Affordable Care Act Medicaid expansion, leaving millions of the poorest and sickest Americans without access to health care, with the added effect of leaving many regional and local hospitals across the US closed or in danger of closing because of the high cost of medical care and a high proportion of rural uninsured and underinsured people. People with COVID-19 in those states will have poor access to the kind of emergency and intensive care they will need. Native American populations also have disproportionately higher levels of underlying conditions, such as heart disease and diabetes, that would make them particularly at risk of complications from COVID-19. Health care for Native American communities has a unique place in the US. As part of treaty obligations owed by the US government to tribal groups, the Indian Health Service (IHS) provides direct point of care health care for the 2·6 million Native Americans living on tribal reservations. According to the IHS, there are currently 985 confirmed cases of COVID-19 on tribal reservations, and 536 cases in the Navajo Nation alone (the largest reservation). However, the IHS's ability to respond to the crisis might be limited: according to according to Kevin Allis, Chief Executive Officer of the National Congress of American Indians, the largest Native American advocacy organisation, the IHS has only 1257 hospital beds and 36 intensive care units, and many people covered by the IHS are hours away from the nearest IHS facility. The IHS also does not cover care from external providers. Although there is a provision of the CARES Act stimulus bill that is intended to cover those costs, it is unclear how effective it would be if someone covered by the IHS is transferred to a non-IHS facility. © 2020 Reuters/Kevin Lamarque 2020 Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active. The CARES Act also included US$8 billion to supplement the health and economies of Native Americans and Alaska Natives. Even that number was an increase from what President Donald Trump's administration originally wanted. “We knew the White House wanted to give us nothing”, Allis said. “And senate Republicans were okay with a billion and it fine-tuned its way to $8 billion.” But the deep history of injustice by the US government towards these people means that the US response will be looked on with suspicion. At the national level, the response has varied widely by state, with many states that voted for Trump in 2016—notably Florida, Texas, and Georgia—responding to the emerging pandemic later and with more lax measures. Florida Governor Ron DeSantis, a Republican Trump ally, was slow to implement social-distancing measures and close non-essential businesses, and Georgia Governor Brian Kemp ordered beaches closed by local authorities to be reopened on April 3. However, the trend has not been universal: in Ohio, Republican Governor Mike DeWine was swift in issuing orders to shut non-essential businesses and in responding to the crisis. The federal response has also been overtly political. States with governors that Trump sees as political allies (such as Florida), have received the full measure of requested personal protective equipment from the federal stockpile, while states with governors whom Trump identifies as political enemies (such as New York's Cuomo, Oregon's Jay Inslee, and Michigan's Gretchen Whitmer, all Democrats) have received only a fraction of their requests. Trump has also publicly attacked the responses of those governors on Twitter and during his daily briefings. In distributing funds made available by the CARES Act, Trump also appears to be playing favourites: New York received only a fraction of the $30 billion hospital relief funds from the bill ($12 000 per patient), while other states much more lightly affected received more ($300 000 per patient in Montana and Nebraska, and more than $470 000 per patient in West Virginia, all states that voted for Trump in 2016). Although the numbers of reported cases seem to be levelling off in New York City and other urban areas, perhaps evidence that social-distancing measures are beginning to have an effect, emerging morbidity and mortality data have already clearly demonstrated what many have feared: a pandemic in which the brunt of the effects fall on already vulnerable US populations, and in which the deeply rooted social, racial, and economic health disparities in the country have been laid bare.
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                Journal
                MMWR Morb Mortal Wkly Rep
                MMWR Morb Mortal Wkly Rep
                WR
                Morbidity and Mortality Weekly Report
                Centers for Disease Control and Prevention
                0149-2195
                1545-861X
                20 November 2020
                20 November 2020
                : 69
                : 46
                : 1725-1729
                Affiliations
                [1 ]New York City Department of Health and Mental Hygiene, Long Island City, New York.
                Author notes
                Corresponding author: Corinne N. Thompson, cthompson2@ 123456health.nyc.gov .
                Article
                mm6946a2
                10.15585/mmwr.mm6946a2
                7676643
                33211680
                65d73f62-926c-4c3f-be6a-0a158c29e448

                All material in the MMWR Series is in the public domain and may be used and reprinted without permission; citation as to source, however, is appreciated.

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