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      Indicators of poor mental health and stressors during the COVID-19 pandemic, by disability status: A cross-sectional analysis

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          Abstract

          Background

          Evidence from previous public health emergencies indicates that adults with disabilities have higher risk for morbidity (physical and mental) and mortality than adults without disabilities.

          Objective

          To provide estimates of mental health indicators and stressors for US adults by disability status during April and May 2020, shortly following the emergence of the COVID-19 pandemic.

          Methods

          We analyzed data from Porter Novelli View 360 opt-in Internet panel survey conducted during the weeks of April 20th and May 18th , 2020 among 1004 English-speaking adults aged ≥18 years without and with disabilities (serious difficulty with hearing, vision, cognition, or mobility; any difficulty with self-care or independent living). Weighted logistic regression was used to test for significant differences between calculated prevalence estimates at the P ≤ .05 level.

          Results

          One in four adults reported any disability. Adults with any disability were significantly more likely than adults without disability to report current depressive symptoms, frequent mental distress, suicidal ideation, and COVID-19-related initiated or increased substance use (all p values < .0001). Adults with disabilities also reported significantly higher levels of stressors, such as access to health care services ( p < .0001), difficulty caring for their own (or another’s) chronic condition ( p < .0001), emotional or physical abuse from others ( p < .001), and not having enough food ( p < .01).

          Conclusions

          The disproportionately high levels of poor mental health indicators among adults with disabilities as compared to those without highlight the importance of delivering timely mental health screening and treatment/intervention during and after the COVID-19 pandemic to persons with disabilities.

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          Most cited references40

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          Mental Health, Substance Use, and Suicidal Ideation During the COVID-19 Pandemic — United States, June 24–30, 2020

          The coronavirus disease 2019 (COVID-19) pandemic has been associated with mental health challenges related to the morbidity and mortality caused by the disease and to mitigation activities, including the impact of physical distancing and stay-at-home orders.* Symptoms of anxiety disorder and depressive disorder increased considerably in the United States during April–June of 2020, compared with the same period in 2019 ( 1 , 2 ). To assess mental health, substance use, and suicidal ideation during the pandemic, representative panel surveys were conducted among adults aged ≥18 years across the United States during June 24–30, 2020. Overall, 40.9% of respondents reported at least one adverse mental or behavioral health condition, including symptoms of anxiety disorder or depressive disorder (30.9%), symptoms of a trauma- and stressor-related disorder (TSRD) related to the pandemic † (26.3%), and having started or increased substance use to cope with stress or emotions related to COVID-19 (13.3%). The percentage of respondents who reported having seriously considered suicide in the 30 days before completing the survey (10.7%) was significantly higher among respondents aged 18–24 years (25.5%), minority racial/ethnic groups (Hispanic respondents [18.6%], non-Hispanic black [black] respondents [15.1%]), self-reported unpaid caregivers for adults § (30.7%), and essential workers ¶ (21.7%). Community-level intervention and prevention efforts, including health communication strategies, designed to reach these groups could help address various mental health conditions associated with the COVID-19 pandemic. During June 24–30, 2020, a total of 5,412 (54.7%) of 9,896 eligible invited adults** completed web-based surveys †† administered by Qualtrics. §§ The Monash University Human Research Ethics Committee of Monash University (Melbourne, Australia) reviewed and approved the study protocol on human subjects research. Respondents were informed of the study purposes and provided electronic consent before commencement, and investigators received anonymized responses. Participants included 3,683 (68.1%) first-time respondents and 1,729 (31.9%) respondents who had completed a related survey during April 2–8, May 5–12, 2020, or both intervals; 1,497 (27.7%) respondents participated during all three intervals ( 2 , 3 ). Quota sampling and survey weighting were employed to improve cohort representativeness of the U.S. population by gender, age, and race/ethnicity. ¶¶ Symptoms of anxiety disorder and depressive disorder were assessed using the four-item Patient Health Questionnaire*** ( 4 ), and symptoms of a COVID-19–related TSRD were assessed using the six-item Impact of Event Scale ††† ( 5 ). Respondents also reported whether they had started or increased substance use to cope with stress or emotions related to COVID-19 or seriously considered suicide in the 30 days preceding the survey. §§§ Analyses were stratified by gender, age, race/ethnicity, employment status, essential worker status, unpaid adult caregiver status, rural-urban residence classification, ¶¶¶ whether the respondent knew someone who had positive test results for SARS-CoV-2, the virus that causes COVID-19, or who had died from COVID-19, and whether the respondent was receiving treatment for diagnosed anxiety, depression, or posttraumatic stress disorder (PTSD) at the time of the survey. Comparisons within subgroups were evaluated using Poisson regressions with robust standard errors to calculate prevalence ratios, 95% confidence intervals (CIs), and p-values to evaluate statistical significance (α = 0.005 to account for multiple comparisons). Among the 1,497 respondents who completed all three surveys, longitudinal analyses of the odds of incidence**** of symptoms of adverse mental or behavioral health conditions by essential worker and unpaid adult caregiver status were conducted on unweighted responses using logistic regressions to calculate unadjusted and adjusted †††† odds ratios (ORs), 95% CI, and p-values (α = 0.05). The statsmodels package in Python (version 3.7.8; Python Software Foundation) was used to conduct all analyses. Overall, 40.9% of 5,470 respondents who completed surveys during June reported an adverse mental or behavioral health condition, including those who reported symptoms of anxiety disorder or depressive disorder (30.9%), those with TSRD symptoms related to COVID-19 (26.3%), those who reported having started or increased substance use to cope with stress or emotions related to COVID-19 (13.3%), and those who reported having seriously considered suicide in the preceding 30 days (10.7%) (Table 1). At least one adverse mental or behavioral health symptom was reported by more than one half of respondents who were aged 18–24 years (74.9%) and 25–44 years (51.9%), of Hispanic ethnicity (52.1%), and who held less than a high school diploma (66.2%), as well as those who were essential workers (54.0%), unpaid caregivers for adults (66.6%), and who reported treatment for diagnosed anxiety (72.7%), depression (68.8%), or PTSD (88.0%) at the time of the survey. TABLE 1 Respondent characteristics and prevalence of adverse mental health outcomes, increased substance use to cope with stress or emotions related to COVID-19 pandemic, and suicidal ideation — United States, June 24–30, 2020 Characteristic All respondents who completed surveys during June 24–30, 2020 weighted* no. (%) Weighted %* Conditions Started or increased substance use to cope with pandemic-related stress or emotions¶ Seriously considered suicide in past 30 days ≥1 adverse mental or behavioral health symptom Anxiety disorder† Depressive disorder† Anxiety or depressive disorder† COVID-19–related TSRD§ All respondents 5,470 (100) 25.5 24.3 30.9 26.3 13.3 10.7 40.9 Gender Female 2,784 (50.9) 26.3 23.9 31.5 24.7 12.2 8.9 41.4 Male 2,676 (48.9) 24.7 24.8 30.4 27.9 14.4 12.6 40.5 Other 10 (0.2) 20.0 30.0 30.0 30.0 10.0 0.0 30.0 Age group (yrs) 18–24 731 (13.4) 49.1 52.3 62.9 46.0 24.7 25.5 74.9 25–44 1,911 (34.9) 35.3 32.5 40.4 36.0 19.5 16.0 51.9 45–64 1,895 (34.6) 16.1 14.4 20.3 17.2 7.7 3.8 29.5 ≥65 933 (17.1) 6.2 5.8 8.1 9.2 3.0 2.0 15.1 Race/Ethnicity White, non-Hispanic 3,453 (63.1) 24.0 22.9 29.2 23.3 10.6 7.9 37.8 Black, non-Hispanic 663 (12.1) 23.4 24.6 30.2 30.4 18.4 15.1 44.2 Asian, non-Hispanic 256 (4.7) 14.1 14.2 18.0 22.1 6.7 6.6 31.9 Other race or multiple races, non-Hispanic** 164 (3.0) 27.8 29.3 33.2 28.3 11.0 9.8 43.8 Hispanic, any race(s) 885 (16.2) 35.5 31.3 40.8 35.1 21.9 18.6 52.1 Unknown 50 (0.9) 38.0 34.0 44.0 34.0 18.0 26.0 48.0 2019 Household income (USD) <25,000 741 (13.6) 30.6 30.8 36.6 29.9 12.5 9.9 45.4 25,000–49,999 1,123 (20.5) 26.0 25.6 33.2 27.2 13.5 10.1 43.9 50,999–99,999 1,775 (32.5) 27.1 24.8 31.6 26.4 12.6 11.4 40.3 100,999–199,999 1,301 (23.8) 23.1 20.8 27.7 24.2 15.5 11.7 37.8 ≥200,000 282 (5.2) 17.4 17.0 20.6 23.1 14.8 11.6 35.1 Unknown 247 (4.5) 19.6 23.1 27.2 24.9 6.2 3.9 41.5 Education Less than high school diploma 78 (1.4) 44.5 51.4 57.5 44.5 22.1 30.0 66.2 High school diploma 943 (17.2) 31.5 32.8 38.4 32.1 15.3 13.1 48.0 Some college 1,455 (26.6) 25.2 23.4 31.7 22.8 10.9 8.6 39.9 Bachelor's degree 1,888 (34.5) 24.7 22.5 28.7 26.4 14.2 10.7 40.6 Professional degree 1,074 (19.6) 20.9 19.5 25.4 24.5 12.6 10.0 35.2 Unknown 33 (0.6) 25.2 23.2 28.2 23.2 10.5 5.5 28.2 Employment status†† Employed 3,431 (62.7) 30.1 29.1 36.4 32.1 17.9 15.0 47.8 Essential 1,785 (32.6) 35.5 33.6 42.4 38.5 24.7 21.7 54.0 Nonessential 1,646 (30.1) 24.1 24.1 29.9 25.2 10.5 7.8 41.0 Unemployed 761 (13.9) 32.0 29.4 37.8 25.0 7.7 4.7 45.9 Retired 1,278 (23.4) 9.6 8.7 12.1 11.3 4.2 2.5 19.6 Unpaid adult caregiver status§§ Yes 1,435 (26.2) 47.6 45.2 56.1 48.4 32.9 30.7 66.6 No 4,035 (73.8) 17.7 16.9 22.0 18.4 6.3 3.6 31.8 Region ¶¶ Northeast 1,193 (21.8) 23.9 23.9 29.9 22.8 12.8 10.2 37.1 Midwest 1,015 (18.6) 22.7 21.1 27.5 24.4 9.0 7.5 36.1 South 1,921 (35.1) 27.9 26.5 33.4 29.1 15.4 12.5 44.4 West 1,340 (24.5) 25.8 24.2 30.9 26.7 14.0 10.9 43.0 Rural-urban classification*** Rural 599 (10.9) 26.0 22.5 29.3 25.4 11.5 10.2 38.3 Urban 4,871 (89.1) 25.5 24.6 31.1 26.4 13.5 10.7 41.2 Know someone who had positive test results for SARS-CoV-2 Yes 1,109 (20.3) 23.8 21.9 29.6 21.5 12.9 7.5 39.2 No 4,361 (79.7) 26.0 25.0 31.3 27.5 13.4 11.5 41.3 Knew someone who died from COVID-19 Yes 428 (7.8) 25.8 20.6 30.6 28.1 11.3 7.6 40.1 No 5,042 (92.2) 25.5 24.7 31.0. 26.1 13.4 10.9 41.0 Receiving treatment for previously diagnosed condition Anxiety Yes 536 (9.8) 59.6 52.0 66.0 51.9 26.6 23.6 72.7 No 4,934 (90.2) 21.8 21.3 27.1 23.5 11.8 9.3 37.5 Depression Yes 540 (9.9) 52.5 50.6 60.8 45.5 25.2 22.1 68.8 No 4,930 (90.1) 22.6 21.5 27.7 24.2 12.0 9.4 37.9 Posttraumatic stress disorder Yes 251 (4.6) 72.3 69.1 78.7 69.4 43.8 44.8 88.0 No 5,219 (95.4) 23.3 22.2 28.6 24.2 11.8 9.0 38.7 Abbreviations: COVID-19 = coronavirus disease 2019; TSRD = trauma- and stressor-related disorder. * Survey weighting was employed to improve the cross-sectional June cohort representativeness of the U.S. population by gender, age, and race/ethnicity according to the 2010 U.S. Census with respondents in which gender, age, and race/ethnicity were reported. Respondents who reported a gender of “Other” or who did not report race/ethnicity were assigned a weight of one. † Symptoms of anxiety disorder and depressive disorder were assessed via the four-item Patient Health Questionnaire (PHQ-4). Those who scored ≥3 out of 6 on the Generalized Anxiety Disorder (GAD-2) and Patient Health Questionnaire (PHQ-2) subscales were considered symptomatic for each disorder, respectively. § Disorders classified as TSRDs in the Diagnostic and Statistical Manual of Mental Disorders (DSM–5) include posttraumatic stress disorder (PTSD), acute stress disorder (ASD), and adjustment disorders (ADs), among others. Symptoms of a TSRD precipitated by the COVID-19 pandemic were assessed via the six-item Impact of Event Scale (IES-6) to screen for overlapping symptoms of PTSD, ASD, and ADs. For this survey, the COVID-19 pandemic was specified as the traumatic exposure to record peri- and posttraumatic symptoms associated with the range of stressors introduced by the COVID-19 pandemic. Those who scored ≥1.75 out of 4 were considered symptomatic. ¶ 104 respondents selected “Prefer not to answer.” ** The Other race or multiple races, non-Hispanic category includes respondents who identified as not being Hispanic and as more than one race or as American Indian or Alaska Native, Native Hawaiian or Pacific Islander, or “Other.” †† Essential worker status was self-reported. The comparison was between employed respondents (n = 3,431) who identified as essential vs. nonessential. For this analysis, students who were not separately employed as essential workers were considered nonessential workers. §§ Unpaid adult caregiver status was self-reported. The definition of an unpaid caregiver for adults was a person who had provided unpaid care to a relative or friend aged ≥18 years to help them take care of themselves at any time in the last 3 months. Examples provided included helping with personal needs, household chores, health care tasks, managing a person’s finances, taking them to a doctor’s appointment, arranging for outside services, and visiting regularly to see how they are doing. ¶¶ Region classification was determined by using the U.S. Census Bureau’s Census Regions and Divisions of the United States. https://www2.census.gov/geo/pdfs/maps-data/maps/reference/us_regdiv.pdf. *** Rural-urban classification was determined by using self-reported ZIP codes according to the Federal Office of Rural Health Policy definition of rurality. https://www.hrsa.gov/rural-health/about-us/definition/datafiles.html. Prevalences of symptoms of adverse mental or behavioral health conditions varied significantly among subgroups (Table 2). Suicidal ideation was more prevalent among males than among females. Symptoms of anxiety disorder or depressive disorder, COVID-19–related TSRD, initiation of or increase in substance use to cope with COVID-19–associated stress, and serious suicidal ideation in the previous 30 days were most commonly reported by persons aged 18–24 years; prevalence decreased progressively with age. Hispanic respondents reported higher prevalences of symptoms of anxiety disorder or depressive disorder, COVID-19–related TSRD, increased substance use, and suicidal ideation than did non-Hispanic whites (whites) or non-Hispanic Asian (Asian) respondents. Black respondents reported increased substance use and past 30-day serious consideration of suicide in the previous 30 days more commonly than did white and Asian respondents. Respondents who reported treatment for diagnosed anxiety, depression, or PTSD at the time of the survey reported higher prevalences of symptoms of adverse mental and behavioral health conditions compared with those who did not. Symptoms of a COVID-19–related TSRD, increased substance use, and suicidal ideation were more prevalent among employed than unemployed respondents, and among essential workers than nonessential workers. Adverse conditions also were more prevalent among unpaid caregivers for adults than among those who were not, with particularly large differences in increased substance use (32.9% versus 6.3%) and suicidal ideation (30.7% versus 3.6%) in this group. TABLE 2 Comparison of symptoms of adverse mental health outcomes among all respondents who completed surveys (N = 5,470), by respondent characteristic* — United States, June 24–30, 2020 Characteristic Prevalence ratio ¶ (95% CI¶) Symptoms of anxiety disorder or depressive disorder † Symptoms of a TSRD related to COVID-19 § Started or increased substance use to cope with stress or emotions related to COVID-19 Serious consideration of suicide in past 30 days Gender Female vs. male 1.04 (0.96–1.12) 0.88 (0.81–0.97) 0.85 (0.75–0.98) 0.70 (0.60–0.82)** Age group (yrs) 18–24 vs. 25–44 1.56 (1.44–1.68)** 1.28 (1.16–1.41)** 1.31 (1.12–1.53)** 1.59 (1.35–1.87)** 18–24 vs. 45–64 3.10 (2.79–3.44)** 2.67 (2.35–3.03)** 3.35 (2.75–4.10)** 6.66 (5.15–8.61)** 18–24 vs. ≥65 7.73 (6.19–9.66)** 5.01 (4.04–6.22)** 8.77 (5.95–12.93)** 12.51 (7.88–19.86)** 25–44 vs. 45–64 1.99 (1.79–2.21)** 2.09 (1.86–2.35)** 2.56 (2.14–3.07)** 4.18 (3.26–5.36)** 25–44 vs. ≥65 4.96 (3.97–6.20)** 3.93 (3.18–4.85)** 6.70 (4.59–9.78)** 7.86 (4.98–12.41)** 45–64 vs. ≥65 2.49 (1.98–3.15)** 1.88 (1.50–2.35)** 2.62 (1.76–3.9)** 1.88 (1.14–3.10) Race/Ethnicity†† Hispanic vs. non-Hispanic black 1.35 (1.18–1.56)** 1.15 (1.00–1.33) 1.19 (0.97–1.46) 1.23 (0.98–1.55) Hispanic vs. non-Hispanic Asian 2.27 (1.73–2.98)** 1.59 (1.24–2.04)** 3.29 (2.05–5.28)** 2.82 (1.74–4.57)** Hispanic vs. non-Hispanic other race or multiple races 1.23 (0.98–1.55) 1.24 (0.96–1.61) 1.99 (1.27–3.13)** 1.89 (1.16–3.06) Hispanic vs. non-Hispanic white 1.40 (1.27–1.54)** 1.50 (1.35–1.68)** 2.09 (1.79–2.45)** 2.35 (1.96–2.80)** Non-Hispanic black vs. non-Hispanic Asian 1.68 (1.26–2.23)** 1.38 (1.07–1.78) 2.75 (1.70–4.47)** 2.29 (1.39–3.76)** Non-Hispanic black vs. non-Hispanic other race or multiple races 0.91 (0.71–1.16) 1.08 (0.82–1.41) 1.67 (1.05–2.65) 1.53 (0.93–2.52) Non-Hispanic black vs. non-Hispanic white 1.03 (0.91–1.17) 1.30 (1.14–1.48)** 1.75 (1.45–2.11)** 1.90 (1.54–2.36)** Non-Hispanic Asian vs. non-Hispanic other race or multiple races 0.54 (0.39–0.76)** 0.78 (0.56–1.09) 0.61 (0.32–1.14) 0.67 (0.35–1.29) Non-Hispanic Asian vs. non-Hispanic white 0.62 (0.47–0.80)** 0.95 (0.74–1.20) 0.64 (0.40–1.02) 0.83 (0.52–1.34) Non-Hispanic other race or multiple races vs. non-Hispanic white 1.14 (0.91–1.42) 1.21 (0.94–1.56) 1.05 (0.67–1.64) 1.24 (0.77–2) Employment status Employed vs. unemployed 0.96 (0.87–1.07) 1.28 (1.12–1.46)** 2.30 (1.78–2.98)** 3.21 (2.31–4.47)** Employed vs. retired 3.01 (2.58–3.51)** 2.84 (2.42–3.34)** 4.30 (3.28–5.63)** 5.97 (4.20–8.47)** Unemployed vs. retired 3.12 (2.63–3.71)** 2.21 (1.82–2.69)** 1.87 (1.30–2.67)** 1.86 (1.16–2.96) Essential vs. nonessential worker§§ 1.42 (1.30–1.56)** 1.52 (1.38–1.69)** 2.36 (2.00–2.77)** 2.76 (2.29–3.33)** Unpaid caregiver for adults vs. not¶¶` 2.55 (2.37–2.75)** 2.63 (2.42–2.86)** 5.28 (4.59–6.07)** 8.64 (7.23–10.33)** Rural vs. urban residence*** 0.94 (0.82–1.07) 0.96 (0.83–1.11) 0.84 (0.67–1.06) 0.95 (0.74–1.22) Knows someone with positive SARS-CoV-2 test result vs. not 0.95 (0.86–1.05) 0.78 (0.69–0.88)** 0.96 (0.81–1.14) 0.65 (0.52–0.81)** Knew someone who died from COVID-19 vs. not 0.99 (0.85–1.15) 1.08 (0.92–1.26) 0.84 (0.64–1.11) 0.69 (0.49–0.97) Receiving treatment for anxiety vs. not 2.43 (2.26–2.63)** 2.21 (2.01–2.43)** 2.27 (1.94–2.66)** 2.54 (2.13–3.03)** Receiving treatment for depression vs. not 2.20 (2.03–2.39)** 1.88 (1.70–2.09)** 2.13 (1.81–2.51)** 2.35 (1.96–2.82)** Receiving treatment for PTSD vs. not 2.75 (2.55–2.97)** 2.87 (2.61–3.16)** 3.78 (3.23–4.42)** 4.95 (4.21–5.83)** Abbreviations: CI = confidence interval; COVID-19 = coronavirus disease 2019; PTSD = posttraumatic stress disorder; TSRD = trauma- and stressor-related disorder. * Number of respondents for characteristics: gender (female = 2,784, male = 2,676), age group in years (18–24 = 731; 25–44 = 1,911; 45–64 = 1,895; ≥65 = 933), race/ethnicity (non-Hispanic white = 3453, non-Hispanic black = 663, non-Hispanic Asian = 256, non-Hispanic other race or multiple races = 164, Hispanic = 885). † Symptoms of anxiety disorder and depressive disorder were assessed via the four-item Patient Health Questionnaire (PHQ-4). Those who scored ≥3 out of 6 on the Generalized Anxiety Disorder (GAD-2) and Patient Health Questionnaire (PHQ-2) subscales were considered to have symptoms of these disorders. § Disorders classified as TSRDs in the Diagnostic and Statistical Manual of Mental Disorders (DSM–5) include PTSD, acute stress disorder (ASD), and adjustment disorders (ADs), among others. Symptoms of a TSRD precipitated by the COVID-19 pandemic were assessed via the six-item Impact of Event Scale (IES-6) to screen for overlapping symptoms of PTSD, ASD, and ADs. For this survey, the COVID-19 pandemic was specified as the traumatic exposure to record peri- and posttraumatic symptoms associated with the range of stressors introduced by the COVID-19 pandemic. Persons who scored ≥1.75 out of 4 were considered to be symptomatic. ¶ Comparisons within subgroups were evaluated on weighted responses via Poisson regressions used to calculate a prevalence ratio, 95% CI, and p-value (not shown). Statistical significance was evaluated at a threshold of α = 0.005 to account for multiple comparisons. In the calculation of prevalence ratios for started or increased substance use, respondents who selected “Prefer not to answer” (n = 104) were excluded. ** P-value is statistically significant (p<0.005). †† Respondents identified as a single race unless otherwise specified. The non-Hispanic, other race or multiple races category includes respondents who identified as not Hispanic and as more than one race or as American Indian or Alaska Native, Native Hawaiian or Pacific Islander, or ‘Other’. §§ Essential worker status was self-reported. The comparison was between employed respondents (n = 3,431) who identified as essential vs. nonessential. For this analysis, students who were not separately employed as essential workers were considered nonessential workers. ¶¶ Unpaid adult caregiver status was self-reported. The definition of an unpaid caregiver for adults was having provided unpaid care to a relative or friend aged ≥18 years to help them take care of themselves at any time in the last 3 months. Examples provided included helping with personal needs, household chores, health care tasks, managing a person’s finances, taking them to a doctor’s appointment, arranging for outside services, and visiting regularly to see how they are doing. *** Rural-urban classification was determined by using self-reported ZIP codes according to the Federal Office of Rural Health Policy definition of rurality. https://www.hrsa.gov/rural-health/about-us/definition/datafiles.html. Longitudinal analysis of responses of 1,497 persons who completed all three surveys revealed that unpaid caregivers for adults had a significantly higher odds of incidence of adverse mental health conditions compared with others (Table 3). Among those who did not report having started or increased substance use to cope with stress or emotions related to COVID-19 in May, unpaid caregivers for adults had 3.33 times the odds of reporting this behavior in June (adjusted OR 95% CI = 1.75–6.31; p<0.001). Similarly, among those who did not report having seriously considered suicide in the previous 30 days in May, unpaid caregivers for adults had 3.03 times the odds of reporting suicidal ideation in June (adjusted OR 95% CI = 1.20–7.63; p = 0.019). TABLE 3 Odds of incidence* of symptoms of adverse mental health, substance use to cope with stress or emotions related to COVID–19 pandemic, and suicidal ideation in the third survey wave, by essential worker status and unpaid adult caregiver status among respondents who completed monthly surveys from April through June (N = 1,497) — United States, April 2–8, May 5–12, and June 24–30, 2020 Symptom or behavior Essential worker† vs. all other employment statuses (nonessential worker, unemployed, retired) Unpaid caregiver for adults§ vs. not unpaid caregiver Unadjusted Adjusted¶ Unadjusted Adjusted** OR (95% CI)†† p-value†† OR (95% CI)†† p-value†† OR (95% CI)†† p-value†† OR (95% CI)†† p-value†† Symptoms of anxiety disorder§§ 1.92 (1.29–2.87) 0.001 1.63 (0.99–2.69) 0.056 1.97 (1.25–3.11) 0.004 1.81 (1.14–2.87) 0.012 Symptoms of depressive disorder§§ 1.49 (1.00–2.22) 0.052 1.13 (0.70–1.82) 0.606 2.29 (1.50–3.50) <0.001 2.22 (1.45–3.41) <0.001 Symptoms of anxiety disorder or depressive disorder§§ 1.67 (1.14–2.46) 0.008 1.26 (0.79–2.00) 0.326 1.84 (1.19–2.85) 0.006 1.73 (1.11–2.70) 0.015 Symptoms of a TSRD related to COVID–19¶¶ 1.55 (0.86–2.81) 0.146 1.27 (0.63–2.56) 0.512 1.88 (0.99–3.56) 0.054 1.79 (0.94–3.42) 0.076 Started or increased substance use to cope with stress or emotions related to COVID–19 2.36 (1.26–4.42) 0.007 2.04 (0.92–4.48) 0.078 3.51 (1.86–6.61) <0.001 3.33 (1.75–6.31) <0.001 Serious consideration of suicide in previous 30 days 0.93 (0.31–2.78) 0.895 0.53 (0.16–1.70) 0.285 3.00 (1.20–7.52) 0.019 3.03 (1.20–7.63) 0.019 Abbreviations: CI = confidence interval, COVID–19 = coronavirus disease 2019, OR = odds ratio, TSRD = trauma– and stressor–related disorder. * For outcomes assessed via the four-item Patient Health Questionnaire (PHQ–4), odds of incidence were marked by the presence of symptoms during May 5–12 or June 24–30, 2020, after the absence of symptoms during April 2–8, 2020. Respondent pools for prospective analysis of odds of incidence (did not screen positive for symptoms during April 2–8): anxiety disorder (n = 1,236), depressive disorder (n = 1,301) and anxiety disorder or depressive disorder (n = 1,190). For symptoms of a TSRD precipitated by COVID–19, started or increased substance use to cope with stress or emotions related to COVID–19, and serious suicidal ideation in the previous 30 days, odds of incidence were marked by the presence of an outcome during June 24–30, 2020, after the absence of that outcome during May 5–12, 2020. Respondent pools for prospective analysis of odds of incidence (did not report symptoms or behavior during May 5–12): symptoms of a TSRD (n = 1,206), started or increased substance use (n = 1,408), and suicidal ideation (n = 1,456). † Essential worker status was self–reported. For Table 3, essential worker status was determined by identification as an essential worker during the June 24–30 survey. Essential workers were compared with all other respondents, not just employed respondents (i.e., essential workers vs. all other employment statuses (nonessential worker, unemployed, and retired), not essential vs. nonessential workers). § Unpaid adult caregiver status was self–reported. The definition of an unpaid caregiver for adults was having provided unpaid care to a relative or friend 18 years or older to help them take care of themselves at any time in the last 3 months. Examples provided included helping with personal needs, household chores, health care tasks, managing a person’s finances, taking them to a doctor’s appointment, arranging for outside services, and visiting regularly to see how they are doing. ¶ Adjusted for gender, employment status, and unpaid adult caregiver status. ** Adjusted for gender, employment status, and essential worker status. †† Respondents who completed surveys from all three waves (April, May, June) were eligible to be included in an unweighted longitudinal analysis. Comparisons within subgroups were evaluated via logit–linked Binomial regressions used to calculate unadjusted and adjusted odds ratios, 95% confidence intervals, and p–values. Statistical significance was evaluated at a threshold of α = 0.05. In the calculation of odds ratios for started or increased substance use, respondents who selected “Prefer not to answer” (n = 11) were excluded. §§ Symptoms of anxiety disorder and depressive disorder were assessed via the PHQ–4. Those who scored ≥3 out of 6 on the two–item Generalized Anxiety Disorder (GAD–2) and two-item Patient Health Questionnaire (PHQ–2) subscales were considered symptomatic for each disorder, respectively. ¶¶ Disorders classified as TSRDs in the Diagnostic and Statistical Manual of Mental Disorders (DSM–5) include posttraumatic stress disorder (PTSD), acute stress disorder (ASD), and adjustment disorders (ADs), among others. Symptoms of a TSRD precipitated by the COVID–19 pandemic were assessed via the six–item Impact of Event Scale (IES–6) to screen for overlapping symptoms of PTSD, ASD, and ADs. For this survey, the COVID–19 pandemic was specified as the traumatic exposure to record peri– and posttraumatic symptoms associated with the range of potential stressors introduced by the COVID–19 pandemic. Those who scored ≥1.75 out of 4 were considered symptomatic. Discussion Elevated levels of adverse mental health conditions, substance use, and suicidal ideation were reported by adults in the United States in June 2020. The prevalence of symptoms of anxiety disorder was approximately three times those reported in the second quarter of 2019 (25.5% versus 8.1%), and prevalence of depressive disorder was approximately four times that reported in the second quarter of 2019 (24.3% versus 6.5%) ( 2 ). However, given the methodological differences and potential unknown biases in survey designs, this analysis might not be directly comparable with data reported on anxiety and depression disorders in 2019 ( 2 ). Approximately one quarter of respondents reported symptoms of a TSRD related to the pandemic, and approximately one in 10 reported that they started or increased substance use because of COVID-19. Suicidal ideation was also elevated; approximately twice as many respondents reported serious consideration of suicide in the previous 30 days than did adults in the United States in 2018, referring to the previous 12 months (10.7% versus 4.3%) ( 6 ). Mental health conditions are disproportionately affecting specific populations, especially young adults, Hispanic persons, black persons, essential workers, unpaid caregivers for adults, and those receiving treatment for preexisting psychiatric conditions. Unpaid caregivers for adults, many of whom are currently providing critical aid to persons at increased risk for severe illness from COVID-19, had a higher incidence of adverse mental and behavioral health conditions compared with others. Although unpaid caregivers of children were not evaluated in this study, approximately 39% of unpaid caregivers for adults shared a household with children (compared with 27% of other respondents). Caregiver workload, especially in multigenerational caregivers, should be considered for future assessment of mental health, given the findings of this report and hardships potentially faced by caregivers. The findings in this report are subject to at least four limitations. First, a diagnostic evaluation for anxiety disorder or depressive disorder was not conducted; however, clinically validated screening instruments were used to assess symptoms. Second, the trauma- and stressor-related symptoms assessed were common to multiple TSRDs, precluding distinction among them; however, the findings highlight the importance of including COVID-19–specific trauma measures to gain insights into peri- and posttraumatic impacts of the COVID-19 pandemic ( 7 ). Third, substance use behavior was self-reported; therefore, responses might be subject to recall, response, and social desirability biases. Finally, given that the web-based survey might not be fully representative of the United States population, findings might have limited generalizability. However, standardized quality and data inclusion screening procedures, including algorithmic analysis of click-through behavior, removal of duplicate responses and scrubbing methods for web-based panel quality were applied. Further the prevalence of symptoms of anxiety disorder and depressive disorder were largely consistent with findings from the Household Pulse Survey during June ( 1 ). Markedly elevated prevalences of reported adverse mental and behavioral health conditions associated with the COVID-19 pandemic highlight the broad impact of the pandemic and the need to prevent and treat these conditions. Identification of populations at increased risk for psychological distress and unhealthy coping can inform policies to address health inequity, including increasing access to resources for clinical diagnoses and treatment options. Expanded use of telehealth, an effective means of delivering treatment for mental health conditions, including depression, substance use disorder, and suicidal ideation ( 8 ), might reduce COVID-19-related mental health consequences. Future studies should identify drivers of adverse mental and behavioral health during the COVID-19 pandemic and whether factors such as social isolation, absence of school structure, unemployment and other financial worries, and various forms of violence (e.g., physical, emotional, mental, or sexual abuse) serve as additional stressors. Community-level intervention and prevention efforts should include strengthening economic supports to reduce financial strain, addressing stress from experienced racial discrimination, promoting social connectedness, and supporting persons at risk for suicide ( 9 ). Communication strategies should focus on promotion of health services §§§§ , ¶¶¶¶ , ***** and culturally and linguistically tailored prevention messaging regarding practices to improve emotional well-being. Development and implementation of COVID-19–specific screening instruments for early identification of COVID-19–related TSRD symptoms would allow for early clinical interventions that might prevent progression from acute to chronic TSRDs. To reduce potential harms of increased substance use related to COVID-19, resources, including social support, comprehensive treatment options, and harm reduction services, are essential and should remain accessible. Periodic assessment of mental health, substance use, and suicidal ideation should evaluate the prevalence of psychological distress over time. Addressing mental health disparities and preparing support systems to mitigate mental health consequences as the pandemic evolves will continue to be needed urgently. Summary What is already known about this topic? Communities have faced mental health challenges related to COVID-19–associated morbidity, mortality, and mitigation activities. What is added by this report? During June 24–30, 2020, U.S. adults reported considerably elevated adverse mental health conditions associated with COVID-19. Younger adults, racial/ethnic minorities, essential workers, and unpaid adult caregivers reported having experienced disproportionately worse mental health outcomes, increased substance use, and elevated suicidal ideation. What are the implications for public health practice? The public health response to the COVID-19 pandemic should increase intervention and prevention efforts to address associated mental health conditions. Community-level efforts, including health communication strategies, should prioritize young adults, racial/ethnic minorities, essential workers, and unpaid adult caregivers.
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            Preliminary Estimates of the Prevalence of Selected Underlying Health Conditions Among Patients with Coronavirus Disease 2019 — United States, February 12–March 28, 2020

            On March 11, 2020, the World Health Organization declared Coronavirus Disease 2019 (COVID-19) a pandemic ( 1 ). As of March 28, 2020, a total of 571,678 confirmed COVID-19 cases and 26,494 deaths have been reported worldwide ( 2 ). Reports from China and Italy suggest that risk factors for severe disease include older age and the presence of at least one of several underlying health conditions ( 3 , 4 ). U.S. older adults, including those aged ≥65 years and particularly those aged ≥85 years, also appear to be at higher risk for severe COVID-19–associated outcomes; however, data describing underlying health conditions among U.S. COVID-19 patients have not yet been reported ( 5 ). As of March 28, 2020, U.S. states and territories have reported 122,653 U.S. COVID-19 cases to CDC, including 7,162 (5.8%) for whom data on underlying health conditions and other known risk factors for severe outcomes from respiratory infections were reported. Among these 7,162 cases, 2,692 (37.6%) patients had one or more underlying health condition or risk factor, and 4,470 (62.4%) had none of these conditions reported. The percentage of COVID-19 patients with at least one underlying health condition or risk factor was higher among those requiring intensive care unit (ICU) admission (358 of 457, 78%) and those requiring hospitalization without ICU admission (732 of 1,037, 71%) than that among those who were not hospitalized (1,388 of 5,143, 27%). The most commonly reported conditions were diabetes mellitus, chronic lung disease, and cardiovascular disease. These preliminary findings suggest that in the United States, persons with underlying health conditions or other recognized risk factors for severe outcomes from respiratory infections appear to be at a higher risk for severe disease from COVID-19 than are persons without these conditions. Data from laboratory-confirmed COVID-19 cases reported to CDC from 50 states, four U.S. territories and affiliated islands, the District of Columbia, and New York City with February 12–March 28, 2020 onset dates were analyzed. Cases among persons repatriated to the United States from Wuhan, China, and the Diamond Princess cruise ship were excluded. For cases with missing onset dates, date of onset was estimated by subtracting 4 days (median interval from symptom onset to specimen collection date among cases with known dates in these data) from the earliest specimen collection. Public health departments reported cases to CDC using a standardized case report form that captures information (yes, no, or unknown) on the following conditions and potential risk factors: chronic lung disease (inclusive of asthma, chronic obstructive pulmonary disease [COPD], and emphysema); diabetes mellitus; cardiovascular disease; chronic renal disease; chronic liver disease; immunocompromised condition; neurologic disorder, neurodevelopmental, or intellectual disability; pregnancy; current smoking status; former smoking status; or other chronic disease ( 6 ). Data reported to CDC are preliminary and can be updated by health departments over time; critical data elements might be missing at the time of initial report; thus, this analysis is descriptive, and no statistical comparisons could be made. The percentages of patients of all ages with underlying health conditions who were not hospitalized, hospitalized without ICU admission, and hospitalized with ICU admission were calculated. Percentages of hospitalizations with and without ICU admission were estimated for persons aged ≥19 years with and without underlying health conditions. This part of the analysis was limited to persons aged ≥19 years because of the small sample size of cases in children with reported underlying health conditions (N = 32). To account for missing data among these preliminary reports, ranges were estimated with a lower bound including cases with both known and unknown status for hospitalization with and without ICU admission as the denominator and an upper bound using only cases with known outcome status as the denominator. Because of small sample size and missing data on underlying health conditions among COVID-19 patients who died, case-fatality rates for persons with and without underlying conditions were not estimated. As of March 28, 2020, a total of 122,653 laboratory-confirmed COVID-19 cases (Figure) and 2,112 deaths were reported to CDC. Case report forms were submitted to CDC for 74,439 (60.7%) cases. Data on presence or absence of underlying health conditions and other recognized risk factors for severe outcomes from respiratory infections (i.e., smoking and pregnancy) were available for 7,162 (5.8%) patients (Table 1). Approximately one third of these patients (2,692, 37.6%), had at least one underlying condition or risk factor. Diabetes mellitus (784, 10.9%), chronic lung disease (656, 9.2%), and cardiovascular disease (647, 9.0%) were the most frequently reported conditions among all cases. Among 457 ICU admissions and 1,037 non-ICU hospitalizations, 358 (78%) and 732 (71%), respectively occurred among persons with one or more reported underlying health condition. In contrast, 1,388 of 5,143 (27%) COVID-19 patients who were not hospitalized were reported to have at least one underlying health condition. FIGURE Daily number of reported COVID-19 cases* — United States, February 12–March 28, 2020† * Cases among persons repatriated to the United States from Wuhan, China, and the Diamond Princess cruise ship are excluded. † Cumulative number of COVID-19 cases reported daily by jurisdictions to CDC using aggregate case count was 122,653 through March 28, 2020. The figure is a histogram, an epidemiologic curve showing the number of COVID-19 cases, by date of report, in the United States during February 12–March 28, 2020. TABLE 1 Reported outcomes among COVID-19 patients of all ages, by hospitalization status, underlying health condition, and risk factor for severe outcome from respiratory infection — United States, February 12–March 28, 2020 Underlying health condition/Risk factor for severe outcomes from respiratory infection (no., % with condition) No. (%) Not hospitalized Hospitalized, non-ICU ICU admission Hospitalization status unknown Total with case report form (N = 74,439) 12,217 5,285 1,069 55,868 Missing or unknown status for all conditions (67,277) 7,074 4,248 612 55,343 Total with completed information (7,162) 5,143 1,037 457 525 One or more conditions (2,692, 37.6%) 1,388 (27) 732 (71) 358 (78) 214 (41) Diabetes mellitus (784, 10.9%) 331 (6) 251 (24) 148 (32) 54 (10) Chronic lung disease* (656, 9.2%) 363 (7) 152 (15) 94 (21) 47 (9) Cardiovascular disease (647, 9.0%) 239 (5) 242 (23) 132 (29) 34 (6) Immunocompromised condition (264, 3.7%) 141 (3) 63 (6) 41 (9) 19 (4) Chronic renal disease (213, 3.0%) 51 (1) 95 (9) 56 (12) 11 (2) Pregnancy (143, 2.0%) 72 (1) 31 (3) 4 (1) 36 (7) Neurologic disorder, neurodevelopmental, intellectual disability (52, 0.7%)† 17 (0.3) 25 (2) 7 (2) 3 (1) Chronic liver disease (41, 0.6%) 24 (1) 9 (1) 7 (2) 1 (0.2) Other chronic disease (1,182, 16.5%)§ 583 (11) 359 (35) 170 (37) 70 (13) Former smoker (165, 2.3%) 80 (2) 45 (4) 33 (7) 7 (1) Current smoker (96, 1.3%) 61 (1) 22 (2) 5 (1) 8 (2) None of the above conditions¶ (4,470, 62.4%) 3,755 (73) 305 (29) 99 (22) 311 (59) Abbreviation: ICU = intensive care unit. * Includes any of the following: asthma, chronic obstructive pulmonary disease, and emphysema. † For neurologic disorder, neurodevelopmental, and intellectual disability, the following information was specified: dementia, memory loss, or Alzheimer’s disease (17); seizure disorder (5); Parkinson’s disease (4); migraine/headache (4); stroke (3); autism (2); aneurysm (2); multiple sclerosis (2); neuropathy (2); hereditary spastic paraplegia (1); myasthenia gravis (1); intracranial hemorrhage (1); and altered mental status (1). § For other chronic disease, the following information was specified: hypertension (113); thyroid disease (37); gastrointestinal disorder (32); hyperlipidemia (29); cancer or history of cancer (29); rheumatologic disorder (19); hematologic disorder (17); obesity (17); arthritis, nonrheumatoid, including not otherwise specified (16); musculoskeletal disorder other than arthritis (10); mental health condition (9); urologic disorder (7); cerebrovascular disease (7); obstructive sleep apnea (7); fibromyalgia (7); gynecologic disorder (6); embolism, pulmonary or venous (5); ophthalmic disorder (2); hypertriglyceridemia (1); endocrine (1); substance abuse disorder (1); dermatologic disorder (1); genetic disorder (1). ¶ All listed chronic conditions, including other chronic disease, were marked as not present. Among patients aged ≥19 years, the percentage of non-ICU hospitalizations was higher among those with underlying health conditions (27.3%–29.8%) than among those without underlying health conditions (7.2%–7.8%); the percentage of cases that resulted in an ICU admission was also higher for those with underlying health conditions (13.3%–14.5%) than those without these conditions (2.2%–2.4%) (Table 2). Small numbers of COVID-19 patients aged <19 years were reported to be hospitalized (48) or admitted to an ICU (eight). In contrast, 335 patients aged <19 years were not hospitalized and 1,342 had missing data on hospitalization. Among all COVID-19 patients with complete information on underlying conditions or risk factors, 184 deaths occurred (all among patients aged ≥19 years); 173 deaths (94%) were reported among patients with at least one underlying condition. TABLE 2 Hospitalization with and without intensive care unit (ICU) admission, by age group among COVID-19 patients aged ≥19 years with and without reported underlying health conditions — United States, February 12–March 28, 2020* Age group (yrs) Hospitalized without ICU admission, No. (% range†) ICU admission, No. (% range†) Underlying condition present/reported§ Underlying condition present/reported§ Yes No Yes No 19–64 285 (18.1–19.9) 197 (6.2–6.7) 134 (8.5–9.4) 58 (1.8–2.0) ≥65 425 (41.7–44.5) 58 (16.8–18.3) 212 (20.8–22.2) 20 (5.8–6.3) Total ≥19 710 (27.3–29.8) 255 (7.2–7.8) 346 (13.3–14.5) 78 (2.2–2.4) * Includes COVID-19 patients aged ≥19 years with known status on underlying conditions. † Lower bound of range = number of persons hospitalized or admitted to an ICU among total in row stratum; upper bound of range = number of persons hospitalized or admitted to an ICU among total in row stratum with known outcome status: hospitalization or ICU admission status. § Includes any of following underlying health conditions or risk factors: chronic lung disease (including asthma, chronic obstructive pulmonary disease, and emphysema); diabetes mellitus; cardiovascular disease; chronic renal disease; chronic liver disease; immunocompromised condition; neurologic disorder, neurodevelopmental, or intellectual disability; pregnancy; current smoker; former smoker; or other chronic disease. Discussion Among 122,653 U.S. COVID-19 cases reported to CDC as of March 28, 2020, 7,162 (5.8%) patients had data available pertaining to underlying health conditions or potential risk factors; among these patients, higher percentages of patients with underlying conditions were admitted to the hospital and to an ICU than patients without reported underlying conditions. These results are consistent with findings from China and Italy, which suggest that patients with underlying health conditions and risk factors, including, but not limited to, diabetes mellitus, hypertension, COPD, coronary artery disease, cerebrovascular disease, chronic renal disease, and smoking, might be at higher risk for severe disease or death from COVID-19 ( 3 , 4 ). This analysis was limited by small numbers and missing data because of the burden placed on reporting health departments with rapidly rising case counts, and these findings might change as additional data become available. It is not yet known whether the severity or level of control of underlying health conditions affects the risk for severe disease associated with COVID-19. Many of these underlying health conditions are common in the United States: based on self-reported 2018 data, the prevalence of diagnosed diabetes among U.S. adults was 10.1% ( 7 ), and the U.S. age-adjusted prevalence of all types of heart disease (excluding hypertension without other heart disease) was 10.6% in 2017 ( 8 ). The age-adjusted prevalence of COPD among U.S. adults is 5.9% ( 9 ), and in 2018, the U.S. estimated prevalence of current asthma among persons of all ages was 7.9% ( 7 ). CDC continues to develop and update resources for persons with underlying health conditions to reduce the risk of acquiring COVID-19 ( 10 ). The estimated higher prevalence of these conditions among those in this early group of U.S. COVID-19 patients and the potentially higher risk for more severe disease from COVID-19 associated with the presence of underlying conditions highlight the importance of COVID-19 prevention in persons with underlying conditions. The findings in this report are subject to at least six limitations. First, these data are preliminary, and the analysis was limited by missing data related to the health department reporting burden associated with rapidly rising case counts and delays in completion of information requiring medical chart review; these findings might change as additional data become available. Information on underlying conditions was only available for 7,162 (5.8%) of 122,653 cases reported to CDC. It cannot be assumed that those with missing information are similar to those with data on either hospitalizations or underlying health conditions. Second, these data are subject to bias in outcome ascertainment because of short follow-up time. Some outcomes might be underestimated, and long-term outcomes cannot be assessed in this analysis. Third, because of the limited availability of testing in many jurisdictions during this period, this analysis is likely biased toward more severe cases, and findings might change as testing becomes more widespread. Fourth, because of the descriptive nature of these data, attack rates among persons with and without underlying health conditions could not be compared, and thus the risk difference of severe disease with COVID-19 between these groups could not be estimated. Fifth, no conclusions could be drawn about underlying conditions that were not included in the case report form or about different conditions that were reported in a single, umbrella category. For example, asthma and COPD were included in a chronic lung disease category. Finally, for some underlying health conditions and risk factors, including neurologic disorders, chronic liver disease, being a current smoker, and pregnancy, few severe outcomes were reported; therefore, conclusions cannot be drawn about the risk for severe COVID-19 among persons in these groups. Persons in the United States with underlying health conditions appear to be at higher risk for more severe COVID-19, consistent with findings from other countries. Persons with underlying health conditions who have symptoms of COVID-19, including fever, cough, or shortness of breath, should immediately contact their health care provider. These persons should take steps to protect themselves from COVID-19, through washing their hands; cleaning and disinfecting high-touch surfaces; and social distancing, including staying at home, avoiding crowds, gatherings, and travel, and avoiding contact with persons who are ill. Maintaining at least a 30-day supply of medication, a 2-week supply of food and other necessities, and knowledge of COVID-19 symptoms are recommended for those with underlying health conditions ( 10 ). All persons should take steps to protect themselves from COVID-19 and to protect others. All persons who are ill should stay home, except to get medical care; should not go to work; and should stay away from others. This is especially important for those who work with persons with underlying conditions or who otherwise are at high risk for severe outcomes from COVID-19. Community mitigation strategies, which aim to slow the spread of COVID-19, are important to protect all persons from COVID-19, especially persons with underlying health conditions and other persons at risk for severe COVID-19–associated disease (https://www.cdc.gov/coronavirus/2019-ncov/downloads/community-mitigation-strategy.pdf). Summary What is already known about this topic? Published reports from China and Italy suggest that risk factors for severe COVID-19 disease include underlying health conditions, but data describing underlying health conditions among U.S. COVID-19 patients have not yet been reported. What is added by this report? Based on preliminary U.S. data, persons with underlying health conditions such as diabetes mellitus, chronic lung disease, and cardiovascular disease, appear to be at higher risk for severe COVID-19–associated disease than persons without these conditions. What are the implications for public health practice? Strategies to protect all persons and especially those with underlying health conditions, including social distancing and handwashing, should be implemented by all communities and all persons to help slow the spread of COVID-19.
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              Coronavirus Disease 2019 Case Surveillance — United States, January 22–May 30, 2020

              The coronavirus disease 2019 (COVID-19) pandemic resulted in 5,817,385 reported cases and 362,705 deaths worldwide through May, 30, 2020, † including 1,761,503 aggregated reported cases and 103,700 deaths in the United States. § Previous analyses during February–early April 2020 indicated that age ≥65 years and underlying health conditions were associated with a higher risk for severe outcomes, which were less common among children aged 10% of persons in this age group. TABLE 2 Reported underlying health conditions* and symptoms † among persons with laboratory-confirmed COVID-19, by sex and age group — United States, January 22–May 30, 2020 Characteristic No. (%) Total Sex Age group (yrs) Male Female ≤9 10–19 20–29 30–39 40–49 50–59 60–69 70–79 ≥80 Total population 1,320,488 646,358 674,130 20,458 49,245 182,469 214,849 219,139 235,774 179,007 105,252 114,295 Underlying health condition§ Known underlying medical condition status* 287,320 (21.8) 138,887 (21.5) 148,433 (22.0) 2,896 (14.2) 7,123 (14.5) 27,436 (15.0) 33,483 (15.6) 40,572 (18.5) 54,717 (23.2) 50,125 (28.0) 34,400 (32.7) 36,568 (32.0) Any cardiovascular disease¶ 92,546 (32.2) 47,567 (34.2) 44,979 (30.3) 78 (2.7) 164 (2.3) 1,177 (4.3) 3,588 (10.7) 8,198 (20.2) 16,954 (31.0) 21,466 (42.8) 18,763 (54.5) 22,158 (60.6) Any chronic lung disease 50,148 (17.5) 20,930 (15.1) 29,218 (19.7) 363 (12.5) 1,285 (18) 4,537 (16.5) 5,110 (15.3) 6,127 (15.1) 8,722 (15.9) 9,200 (18.4) 7,436 (21.6) 7,368 (20.1) Renal disease 21,908 (7.6) 12,144 (8.7) 9,764 (6.6) 21 (0.7) 34 (0.5) 204 (0.7) 587 (1.8) 1,273 (3.1) 2,789 (5.1) 4,764 (9.5) 5,401 (15.7) 6,835 (18.7) Diabetes 86,737 (30.2) 45,089 (32.5) 41,648 (28.1) 12 (0.4) 225 (3.2) 1,409 (5.1) 4,106 (12.3) 9,636 (23.8) 19,589 (35.8) 22,314 (44.5) 16,594 (48.2) 12,852 (35.1) Liver disease 3,953 (1.4) 2,439 (1.8) 1,514 (1.0) 5 (0.2) 19 (0.3) 132 (0.5) 390 (1.2) 573 (1.4) 878 (1.6) 1,074 (2.1) 583 (1.7) 299 (0.8) Immunocompromised 15,265 (5.3) 7,345 (5.3) 7,920 (5.3) 61 (2.1) 146 (2.0) 646 (2.4) 1,253 (3.7) 2,005 (4.9) 3,190 (5.8) 3,421 (6.8) 2,486 (7.2) 2,057 (5.6) Neurologic/Neurodevelopmental disability 13,665 (4.8) 6,193 (4.5) 7,472 (5.0) 41 (1.4) 113 (1.6) 395 (1.4) 533 (1.6) 734 (1.8) 1,338 (2.4) 2,006 (4.0) 2,759 (8.0) 5,746 (15.7) Symptom§ Known symptom status† 373,883 (28.3) 178,223 (27.6) 195,660 (29.0) 5,188 (25.4) 12,689 (25.8) 51,464 (28.2) 59,951 (27.9) 62,643 (28.6) 70,040 (29.7) 52,178 (29.1) 28,583 (27.2) 31,147 (27.3) Fever, cough, or shortness of breath 260,706 (69.7) 125,768 (70.6) 134,938 (69.0) 3,278 (63.2) 7,584 (59.8) 35,072 (68.1) 42,016 (70.1) 45,361 (72.4) 51,283 (73.2) 37,701 (72.3) 19,583 (68.5) 18,828 (60.4) Fever †† 161,071 (43.1) 80,578 (45.2) 80,493 (41.1) 2,404 (46.3) 4,443 (35.0) 20,381 (39.6) 25,887 (43.2) 28,407 (45.3) 32,375 (46.2) 23,591 (45.2) 12,190 (42.6) 11,393 (36.6) Cough 187,953 (50.3) 89,178 (50.0) 98,775 (50.5) 1,912 (36.9) 5,257 (41.4) 26,284 (51.1) 31,313 (52.2) 34,031 (54.3) 38,305 (54.7) 27,150 (52.0) 12,837 (44.9) 10,864 (34.9) Shortness of breath 106,387 (28.5) 49,834 (28.0) 56,553 (28.9) 339 (6.5) 2,070 (16.3) 13,649 (26.5) 16,851 (28.1) 18,978 (30.3) 21,327 (30.4) 16,018 (30.7) 8,971 (31.4) 8,184 (26.3) Myalgia 135,026 (36.1) 61,922 (34.7) 73,104 (37.4) 537 (10.4) 3,737 (29.5) 21,153 (41.1) 26,464 (44.1) 28,064 (44.8) 28,594 (40.8) 17,360 (33.3) 6,015 (21.0) 3,102 (10.0) Runny nose 22,710 (6.1) 9,900 (5.6) 12,810 (6.5) 354 (6.8) 1,025 (8.1) 4,591 (8.9) 4,406 (7.3) 4,141 (6.6) 4,100 (5.9) 2,671 (5.1) 923 (3.2) 499 (1.6) Sore throat 74,840 (20.0) 31,244 (17.5) 43,596 (22.3) 664 (12.8) 3,628 (28.6) 14,493 (28.2) 14,855 (24.8) 14,490 (23.1) 13,930 (19.9) 8,192 (15.7) 2,867 (10.0) 1,721 (5.5) Headache 128,560 (34.4) 54,721 (30.7) 73,839 (37.7) 785 (15.1) 5,315 (41.9) 23,723 (46.1) 26,142 (43.6) 26,245 (41.9) 26,057 (37.2) 14,735 (28.2) 4,163 (14.6) 1,395 (4.5) Nausea/Vomiting 42,813 (11.5) 16,549 (9.3) 26,264 (13.4) 506 (9.8) 1,314 (10.4) 6,648 (12.9) 7,661 (12.8) 8,091 (12.9) 8,737 (12.5) 5,953 (11.4) 2,380 (8.3) 1,523 (4.9) Abdominal pain 28,443 (7.6) 11,553 (6.5) 16,890 (8.6) 349 (6.7) 978 (7.7) 4,211 (8.2) 5,150 (8.6) 5,531 (8.8) 6,134 (8.8) 3,809 (7.3) 1,449 (5.1) 832 (2.7) Diarrhea 72,039 (19.3) 32,093 (18.0) 39,946 (20.4) 704 (13.6) 1,712 (13.5) 9,867 (19.2) 12,769 (21.3) 13,958 (22.3) 15,536 (22.2) 10,349 (19.8) 4,402 (15.4) 2,742 (8.8) Loss of smell or taste 31,191 (8.3) 12,717 (7.1) 18,474 (9.4) 67 (1.3) 1,257 (9.9) 6,828 (13.3) 6,907 (11.5) 6,361 (10.2) 5,828 (8.3) 2,930 (5.6) 775 (2.7) 238 (0.8) Abbreviation: COVID-19 = coronavirus disease 2019. * Status of underlying health conditions known for 287,320 persons. Status was classified as “known” if any of the following conditions were reported as present or absent: diabetes mellitus, cardiovascular disease (including hypertension), severe obesity (body mass index ≥40 kg/m2), chronic renal disease, chronic liver disease, chronic lung disease, immunocompromising condition, autoimmune condition, neurologic condition (including neurodevelopmental, intellectual, physical, visual, or hearing impairment), psychologic/psychiatric condition, and other underlying medical condition not otherwise specified. † Symptom status was known for 373,883 persons. Status was classified as “known” if any of the following symptoms were reported as present or absent: fever (measured >100.4°F [38°C] or subjective), cough, shortness of breath, wheezing, difficulty breathing, chills, rigors, myalgia, rhinorrhea, sore throat, chest pain, nausea or vomiting, abdominal pain, headache, fatigue, diarrhea (≥3 loose stools in a 24-hour period), or other symptom not otherwise specified on the form. § Responses include data from standardized fields supplemented with data from free-text fields. Information for persons with loss of smell or taste was exclusively extracted from a free-text field; therefore, persons exhibiting this symptom were likely underreported. ¶ Includes persons with reported hypertension. ** Includes all persons with at least one of these symptoms reported. †† Persons were considered to have a fever if information on either measured or subjective fever variables if “yes” was reported for either variable. Among 287,320 (22%) cases with data on individual underlying health conditions, those most frequently reported were cardiovascular disease (32%), diabetes (30%), and chronic lung disease (18%) (Table 2); the reported proportions were similar among males and females. The frequency of conditions reported varied by age group: cardiovascular disease was uncommon among those aged ≤39 years but was reported in approximately half of the cases among persons aged ≥70 years. Among 63,896 females aged 15–44 years with known pregnancy status, 6,708 (11%) were reported to be pregnant. Among the 1,320,488 cases, outcomes for hospitalization, ICU admission, and death were available for 46%, 14%, and 36%, respectively. Overall, 184,673 (14%) patients were hospitalized, including 29,837 (2%) admitted to the ICU; 71,116 (5%) patients died (Table 3). Severe outcomes were more commonly reported for patients with reported underlying conditions. Hospitalizations were six times higher among patients with a reported underlying condition than those without reported underlying conditions (45.4% versus 7.6%). Deaths were 12 times higher among patients with reported underlying conditions compared with those without reported underlying conditions (19.5% versus 1.6%). The percentages of males who were hospitalized (16%), admitted to the ICU (3%), and who died (6%) were higher than were those for females (12%, 2%, and 5%, respectively). The percentage of ICU admissions was highest among persons with reported underlying conditions aged 60–69 years (11%) and 70–79 years (12%). Death was most commonly reported among persons aged ≥80 years regardless of the presence of underlying conditions (with underlying conditions 50%; without 30%). TABLE 3 Reported hospitalizations,* , † intensive care unit (ICU) admissions, § and deaths ¶ among laboratory-confirmed COVID-19 patients with and without reported underlying health conditions, ** by sex and age — United States, January 22–May 30, 2020 Characteristic (no.) Outcome, no./total no. (%)†† Reported hospitalizations*,† (including ICU) Reported ICU admission§ Reported deaths¶ Among all patients Among patients with reported underlying health conditions Among patients with no reported underlying health conditions Among all patients Among patients with reported underlying health conditions Among patients with no reported underlying health conditions Among all patients Among patients with reported underlying health conditions Among patients with no reported underlying health conditions Sex Male (646,358) 101,133/646,358 (15.6) 49,503/96,839 (51.1) 3,596/42,048 (8.6) 18,394/646,358 (2.8) 10,302/96,839 (10.6) 864/42,048 (2.1) 38,773/646,358 (6.0) 21,667/96,839 (22.4) 724/42,048 (1.7) Female (674,130) 83,540/674,130 (12.4) 40,698/102,040 (39.9) 3,087/46,393 (6.7) 11,443/674,130 (1.7) 6,672/102,040 (6.5) 479/46,393 (1.0) 32,343/674,130 (4.8) 17,145/102,040 (16.8) 707/46,393 (1.5) Age group (yrs) ≤9 (20,458) 848/20,458 (4.1) 138/619 (22.3) 84/2,277 (3.7) 141/20,458 (0.7) 31/619 (5.0) 16/2,277 (0.7) 13/20,458 (0.1) 4/619 (0.6) 2/2,277 (0.1) 10–19 (49,245) 1,234/49,245 (2.5) 309/2,076 (14.9) 115/5,047 (2.3) 216/49,245 (0.4) 72/2,076 (3.5) 17/5,047 (0.3) 33/49,245 (0.1) 16/2,076 (0.8) 4/5,047 (0.1) 20–29 (182,469) 6,704/182,469 (3.7) 1,559/8,906 (17.5) 498/18,530 (2.7) 864/182,469 (0.5) 300/8,906 (3.4) 56/18,530 (0.3) 273/182,469 (0.1) 122/8,906 (1.4) 24/18,530 (0.1) 30–39 (214,849) 12,570/214,849 (5.9) 3,596/14,854 (24.2) 828/18,629 (4.4) 1,879/214,849 (0.9) 787/14,854 (5.3) 135/18,629 (0.7) 852/214,849 (0.4) 411/14,854 (2.8) 21/18,629 (0.1) 40–49 (219,139) 19,318/219,139 (8.8) 7,151/24,161 (29.6) 1,057/16,411 (6.4) 3,316/219,139 (1.5) 1,540/24,161 (6.4) 208/16,411 (1.3) 2,083/219,139 (1.0) 1,077/24,161 (4.5) 58/16,411 (0.4) 50–59 (235,774) 31,588/235,774 (13.4) 14,639/40,297 (36.3) 1,380/14,420 (9.6) 5,986/235,774 (2.5) 3,335/40,297 (8.3) 296/14,420 (2.1) 5,639/235,774 (2.4) 3,158/40,297 (7.8) 131/14,420 (0.9) 60–69 (179,007) 39,422/179,007 (22.0) 21,064/42,206 (49.9) 1,216/7,919 (15.4) 7,403/179,007 (4.1) 4,588/42,206 (10.9) 291/7,919 (3.7) 11,947/179,007 (6.7) 7,050/42,206 (16.7) 187/7,919 (2.4) 70–79 (105,252) 35,844/105,252 (34.1) 20,451/31,601 (64.7) 780/2,799 (27.9) 5,939/105,252 (5.6) 3,771/31,601 (11.9) 199/2,799 (7.1) 17,510/105,252 (16.6) 10,008/31,601 (31.7) 286/2,799 (10.2) ≥80 (114,295) 37,145/114,295 (32.5) 21,294/34,159 (62.3) 725/2,409 (30.1) 4,093/114,295 (3.6) 2,550/34,159 (7.5) 125/2,409 (5.2) 32,766/114,295 (28.7) 16,966/34,159 (49.7) 718/2,409 (29.8) Total (1,320,488) 184,673/1,320,488 (14.0) 90,201/198,879 (45.4) 6,683/88,441 (7.6) 29,837/1,320,488 (2.3) 16,974/198,879 (8.5) 1,343/88,441 (1.5) 71,116/1,320,488 (5.4) 38,812/198,879 (19.5) 1,431/88,441 (1.6) Abbreviation: COVID-19 = coronavirus disease 2019. * Hospitalization status was known for 600,860 (46%). Among 184,673 hospitalized patients, the presence of underlying health conditions was known for 96,884 (53%). † Includes reported ICU admissions. § ICU admission status was known for 186,563 (14%) patients among the total case population, representing 34% of hospitalized patients. Among 29,837 patients admitted to the ICU, the status of underlying health conditions was known for 18,317 (61%). ¶ Death outcomes were known for 480,565 (36%) patients. Among 71,116 reported deaths through case surveillance, the status of underlying health conditions was known for 40,243 (57%) patients. ** Status of underlying health conditions was known for 287,320 (22%) patients. Status was classified as “known” if any of the following conditions were noted as present or absent: diabetes mellitus, cardiovascular disease including hypertension, severe obesity body mass index ≥40 kg/m2, chronic renal disease, chronic liver disease, chronic lung disease, any immunocompromising condition, any autoimmune condition, any neurologic condition including neurodevelopmental, intellectual, physical, visual, or hearing impairment, any psychologic/psychiatric condition, and any other underlying medical condition not otherwise specified. †† Outcomes were calculated as the proportion of persons reported to be hospitalized, admitted to an ICU, or who died among total in the demographic group. Outcome underreporting could result from outcomes that occurred but were not reported through national case surveillance or through clinical progression to severe outcomes that occurred after time of report. Discussion As of May 30, a total of 1,761,503 aggregate U.S. cases of COVID-19 and 103,700 associated deaths were reported to CDC. Although average daily reported cases and deaths are declining, 7-day moving averages of daily incidence of COVID-19 cases indicate ongoing community transmission. ¶¶¶¶ The COVID-19 case data summarized here are essential statistics for the pandemic response and rely on information systems developed at the local, state, and federal level over decades for communicable disease surveillance that were rapidly adapted to meet an enormous, new public health threat. CDC aggregate counts are consistent with those presented through the Johns Hopkins University (JHU) Coronavirus Resource Center, which reported a cumulative total of 1,770,165 U.S. cases and 103,776 U.S. deaths on May 30, 2020.***** Differences in aggregate counts between CDC and JHU might be attributable to differences in reporting practices to CDC and jurisdictional websites accessed by JHU. Reported cumulative incidence in the case surveillance population among persons aged ≥20 years is notably higher than that among younger persons. The lower incidence in persons aged ≤19 years could be attributable to undiagnosed milder or asymptomatic illnesses among this age group that were not reported. Incidence in persons aged ≥80 years was nearly double that in persons aged 70–79 years. Among cases with known race and ethnicity, 33% of persons were Hispanic, 22% were black, and 1.3% were AI/AN. These findings suggest that persons in these groups, who account for 18%, 13%, and 0.7% of the U.S. population, respectively, are disproportionately affected by the COVID-19 pandemic. The proportion of missing race and ethnicity data limits the conclusions that can be drawn from descriptive analyses; however, these findings are consistent with an analysis of COVID-19–Associated Hospitalization Surveillance Network (COVID-NET) ††††† data that found higher proportions of black and Hispanic persons among hospitalized COVID-19 patients than were in the overall population ( 4 ). The completeness of race and ethnicity variables in case surveillance has increased from 20% to >40% from April 2 to June 2. Although reporting of race and ethnicity continues to improve, more complete data might be available in aggregate on jurisdictional websites or through sources like the COVID Tracking Project’s COVID Racial Data Tracker. §§§§§ The data in this report show that the prevalence of reported symptoms varied by age group but was similar among males and females. Fewer than 5% of persons were reported to be asymptomatic when symptom data were submitted. Persons without symptoms might be less likely to be tested for COVID-19 because initial guidance recommended testing of only symptomatic persons and was hospital-based. Guidance on testing has evolved throughout the response. ¶¶¶¶¶ Whereas incidence among males and females was similar overall, severe outcomes were more commonly reported among males. Prevalence of reported severe outcomes increased with age; the percentages of hospitalizations, ICU admissions, and deaths were highest among persons aged ≥70 years, regardless of underlying conditions, and lowest among those aged ≤19 years. Hospitalizations were six times higher and deaths 12 times higher among those with reported underlying conditions compared with those with none reported. These findings are consistent with previous reports that found that severe outcomes increased with age and underlying condition, and males were hospitalized at a higher rate than were females ( 2 , 4 , 5 ). The findings in this report are subject to at least three limitations. First, case surveillance data represent a subset of the total cases of COVID-19 in the United States; not every case in the community is captured through testing and information collected might be limited if persons are unavailable or unwilling to participate in case investigations or if medical records are unavailable for data extraction. Reported cumulative incidence, although comparable across age and sex groups within the case surveillance population, are underestimates of the U.S. cumulative incidence of COVID-19. Second, reported frequencies of individual symptoms and underlying health conditions presented from case surveillance likely underestimate the true prevalence because of missing data. Finally, asymptomatic cases are not captured well in case surveillance. Asymptomatic persons are unlikely to seek testing unless they are identified through active screening (e.g., contact tracing), and, because of limitations in testing capacity and in accordance with guidance, investigation of symptomatic persons is prioritized. Increased identification and reporting of asymptomatic cases could affect patterns described in this report. Similar to earlier reports on COVID-19 case surveillance, severe outcomes were more commonly reported among persons who were older and those with underlying health conditions ( 1 ). Findings in this report align with demographic and severe outcome trends identified through COVID-NET ( 4 ). Findings from case surveillance are evaluated along with enhanced surveillance data and serologic survey results to provide a comprehensive picture of COVID-19 trends, and differences in proportion of cases by racial and ethnic groups should continue to be examined in enhanced surveillance to better understand populations at highest risk. Since the U.S. COVID-19 response began in January, CDC has built on existing surveillance capacity to monitor the impact of illness nationally. Collection of detailed case data is a resource-intensive public health activity, regardless of disease incidence. The high incidence of COVID-19 has highlighted limitations of traditional public health case surveillance approaches to provide real-time intelligence and supports the need for continued innovation and modernization. Despite limitations, national case surveillance of COVID-19 serves a critical role in the U.S. COVID-19 response: these data demonstrate that the COVID-19 pandemic is an ongoing public health crisis in the United States that continues to affect all populations and result in severe outcomes including death. National case surveillance findings provide important information for targeted enhanced surveillance efforts and development of interventions critical to the U.S. COVID-19 response. Summary What is already known about this topic? Surveillance data reported to CDC through April 2020 indicated that COVID-19 leads to severe outcomes in older adults and those with underlying health conditions. What is added by this report? As of May 30, 2020, among COVID-19 cases, the most common underlying health conditions were cardiovascular disease (32%), diabetes (30%), and chronic lung disease (18%). Hospitalizations were six times higher and deaths 12 times higher among those with reported underlying conditions compared with those with none reported. What are the implications for public health practice? Surveillance at all levels of government, and its continued modernization, is critical for monitoring COVID-19 trends and identifying groups at risk for infection and severe outcomes. These findings highlight the continued need for community mitigation strategies, especially for vulnerable populations, to slow COVID-19 transmission.
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                Author and article information

                Journal
                Disabil Health J
                Disabil Health J
                Disability and Health Journal
                Elsevier
                1936-6574
                1876-7583
                21 April 2021
                October 2021
                21 April 2021
                : 14
                : 4
                : 101110
                Affiliations
                [a ]4770 Buford Hwy NE, Division of Human Development and Disability, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, 30341-3717, USA
                [b ]CDC COVID-19 Response, 1600 Clifton Rd., Atlanta, GA, 30333, USA
                [c ]Commissioned Corps, U.S. Public Health Service, USA
                Author notes
                []Corresponding author. Division of Human Development and Disability, Centers for Disease Control and Prevention, 4770 Buford Hwy NE, MS S106-4, Atlanta, GA, 30341-3717, USA.
                Article
                S1936-6574(21)00056-X 101110
                10.1016/j.dhjo.2021.101110
                8436151
                33962896
                920b98b6-53e3-4b42-9620-5e3520801b99

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                disabilities,coronavirus,mental health,stress,health disparities

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