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      Social vulnerability and county stay-at-home behavior during COVID-19 stay-at-home orders, United States, April 7–April 20, 2020

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          Abstract

          Purpose

          Early COVID-19 mitigation relied on people staying home except for essential trips. The ability to stay home may differ by sociodemographic factors. We analyzed how factors related to social vulnerability impact a community's ability to stay home during a stay-at-home order.

          Methods

          Using generalized, linear mixed models stratified by stay-at-home order (mandatory or not mandatory), we analyzed county-level stay-at-home behavior (inferred from mobile devices) during a period when a majority of United States counties had stay-at-home orders (April 7–April 20, 2020) with the Centers for Disease Control and Prevention Social Vulnerability Index (CDC SVI).

          Results

          Counties with higher percentages of single-parent households, mobile homes, and persons with lower educational attainment were associated with lower stay-at-home behavior compared with counties with lower respective percentages. Counties with higher unemployment, higher percentages of limited-English-language speakers, and more multi-unit housing were associated with increases in stay-at-home behavior compared with counties with lower respective percentages. Stronger effects were found in counties with mandatory orders.

          Conclusions

          Sociodemographic factors impact a community's ability to stay home during COVID-19 stay-at-home orders. Communities with higher social vulnerability may have more essential workers without work-from-home options or fewer resources to stay home for extended periods, which may increase risk for COVID-19. Results are useful for tailoring messaging, COVID-19 vaccine delivery, and public health responses to future outbreaks.

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          Most cited references 26

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          Severe Outcomes Among Patients with Coronavirus Disease 2019 (COVID-19) — United States, February 12–March 16, 2020

          On March 18, 2020, this report was posted online as an MMWR Early Release. Globally, approximately 170,000 confirmed cases of coronavirus disease 2019 (COVID-19) caused by the 2019 novel coronavirus (SARS-CoV-2) have been reported, including an estimated 7,000 deaths in approximately 150 countries ( 1 ). On March 11, 2020, the World Health Organization declared the COVID-19 outbreak a pandemic ( 2 ). Data from China have indicated that older adults, particularly those with serious underlying health conditions, are at higher risk for severe COVID-19–associated illness and death than are younger persons ( 3 ). Although the majority of reported COVID-19 cases in China were mild (81%), approximately 80% of deaths occurred among adults aged ≥60 years; only one (0.1%) death occurred in a person aged ≤19 years ( 3 ). In this report, COVID-19 cases in the United States that occurred during February 12–March 16, 2020 and severity of disease (hospitalization, admission to intensive care unit [ICU], and death) were analyzed by age group. As of March 16, a total of 4,226 COVID-19 cases in the United States had been reported to CDC, with multiple cases reported among older adults living in long-term care facilities ( 4 ). Overall, 31% of cases, 45% of hospitalizations, 53% of ICU admissions, and 80% of deaths associated with COVID-19 were among adults aged ≥65 years with the highest percentage of severe outcomes among persons aged ≥85 years. In contrast, no ICU admissions or deaths were reported among persons aged ≤19 years. Similar to reports from other countries, this finding suggests that the risk for serious disease and death from COVID-19 is higher in older age groups. Data from cases reported from 49 states, the District of Columbia, and three U.S. territories ( 5 ) to CDC during February 12–March 16 were analyzed. Cases among persons repatriated to the United States from Wuhan, China and from Japan (including patients repatriated from cruise ships) were excluded. States and jurisdictions voluntarily reported data on laboratory-confirmed cases of COVID-19 using previously developed data collection forms ( 6 ). The cases described in this report include both COVID-19 cases confirmed by state or local public health laboratories as well as those with a positive test at the state or local public health laboratories and confirmation at CDC. No data on serious underlying health conditions were available. Data on these cases are preliminary and are missing for some key characteristics of interest, including hospitalization status (1,514), ICU admission (2,253), death (2,001), and age (386). Because of these missing data, the percentages of hospitalizations, ICU admissions, and deaths (case-fatality percentages) were estimated as a range. The lower bound of these percentages was estimated by using all cases within each age group as denominators. The corresponding upper bound of these percentages was estimated by using only cases with known information on each outcome as denominators. As of March 16, a total of 4,226 COVID-19 cases had been reported in the United States, with reports increasing to 500 or more cases per day beginning March 14 (Figure 1). Among 2,449 patients with known age, 6% were aged ≥85, 25% were aged 65–84 years, 18% each were aged 55–64 years and 45–54 years, and 29% were aged 20–44 years (Figure 2). Only 5% of cases occurred in persons aged 0–19 years. FIGURE 1 Number of new coronavirus disease 2019 (COVID-19) cases reported daily*,† (N = 4,226) — United States, February 12–March 16, 2020 * Includes both COVID-19 cases confirmed by state or local public health laboratories, as well as those testing positive at the state or local public health laboratories and confirmed at CDC. † Cases identified before February 28 were aggregated and reported during March 1–3. The figure is a histogram, an epidemiologic curve showing 4,226 coronavirus disease 2019 (COVID-19) cases, by date of case report, in the United States during February 12–March 16, 2020. Figure 2 Coronavirus disease 2019 (COVID-19) hospitalizations,* intensive care unit (ICU) admissions, † and deaths, § by age group — United States, February 12– March 16, 2020 * Hospitalization status missing or unknown for 1,514 cases. † ICU status missing or unknown for 2,253 cases. § Illness outcome or death missing or unknown for 2,001 cases. The figure is a bar chart showing the number of coronavirus disease 2019 (COVID-19) hospitalizations, intensive care unit admissions, and deaths, by age group, in the United States during February 12– March 16, 2020. Among 508 (12%) patients known to have been hospitalized, 9% were aged ≥85 years, 36% were aged 65–84 years, 17% were aged 55–64 years, 18% were 45–54 years, and 20% were aged 20–44 years. Less than 1% of hospitalizations were among persons aged ≤19 years (Figure 2). The percentage of persons hospitalized increased with age, from 2%–3% among persons aged ≤19 years, to ≥31% among adults aged ≥85 years. (Table). TABLE Hospitalization, intensive care unit (ICU) admission, and case–fatality percentages for reported COVID–19 cases, by age group —United States, February 12–March 16, 2020 Age group (yrs) (no. of cases) %* Hospitalization ICU admission Case-fatality 0–19 (123) 1.6–2.5 0 0 20–44 (705) 14.3–20.8 2.0–4.2 0.1–0.2 45–54 (429) 21.2–28.3 5.4–10.4 0.5–0.8 55–64 (429) 20.5–30.1 4.7–11.2 1.4–2.6 65–74 (409) 28.6–43.5 8.1–18.8 2.7–4.9 75–84 (210) 30.5–58.7 10.5–31.0 4.3–10.5 ≥85 (144) 31.3–70.3 6.3–29.0 10.4–27.3 Total (2,449) 20.7–31.4 4.9–11.5 1.8–3.4 * Lower bound of range = number of persons hospitalized, admitted to ICU, or who died among total in age group; upper bound of range = number of persons hospitalized, admitted to ICU, or who died among total in age group with known hospitalization status, ICU admission status, or death. Among 121 patients known to have been admitted to an ICU, 7% of cases were reported among adults ≥85 years, 46% among adults aged 65–84 years, 36% among adults aged 45–64 years, and 12% among adults aged 20–44 years (Figure 2). No ICU admissions were reported among persons aged ≤19 years. Percentages of ICU admissions were lowest among adults aged 20–44 years (2%–4%) and highest among adults aged 75–84 years (11%–31%) (Table). Among 44 cases with known outcome, 15 (34%) deaths were reported among adults aged ≥85 years, 20 (46%) among adults aged 65–84 years, and nine (20%) among adults aged 20–64 years. Case-fatality percentages increased with increasing age, from no deaths reported among persons aged ≤19 years to highest percentages (10%–27%) among adults aged ≥85 years (Table) (Figure 2). Discussion Since February 12, 4,226 COVID-19 cases were reported in the United States; 31% of cases, 45% of hospitalizations, 53% of ICU admissions, and 80% of deaths occurred among adults aged ≥65 years with the highest percentage of severe outcomes among persons aged ≥85 years. These findings are similar to data from China, which indicated >80% of deaths occurred among persons aged ≥60 years ( 3 ). These preliminary data also demonstrate that severe illness leading to hospitalization, including ICU admission and death, can occur in adults of any age with COVID-19. In contrast, persons aged ≤19 years appear to have milder COVID-19 illness, with almost no hospitalizations or deaths reported to date in the United States in this age group. Given the spread of COVID-19 in many U.S. communities, CDC continues to update current recommendations and develop new resources and guidance, including for adults aged ≥65 years as well as those involved in their care ( 7 , 8 ). Approximately 49 million U.S. persons are aged ≥65 years ( 9 ), and many of these adults, who are at risk for severe COVID-19–associated illness, might depend on services and support to maintain their health and independence. To prepare for potential COVID-19 illness among persons at high risk, family members and caregivers of older adults should know what medications they are taking and ensure that food and required medical supplies are available. Long-term care facilities should be particularly vigilant to prevent the introduction and spread of COVID-19 ( 10 ). In addition, clinicians who care for adults should be aware that COVID-19 can result in severe disease among persons of all ages. Persons with suspected or confirmed COVID-19 should monitor their symptoms and call their provider for guidance if symptoms worsen or seek emergency care for persistent severe symptoms. Additional guidance is available for health care providers on CDC’s website (https://www.cdc.gov/coronavirus/2019-nCoV/hcp/index.html). This report describes the current epidemiology of COVID-19 in the United States, using preliminary data. The findings in this report are subject to at least five limitations. First, data were missing for key variables of interest. Data on age and outcomes, including hospitalization, ICU admission, and death, were missing for 9%–53% of cases, which likely resulted in an underestimation of these outcomes. Second, further time for follow-up is needed to ascertain outcomes among active cases. Third, the initial approach to testing was to identify patients among those with travel histories or persons with more severe disease, and these data might overestimate the prevalence of severe disease. Fourth, data on other risk factors, including serious underlying health conditions that could increase risk for complications and severe illness, were unavailable at the time of this analysis. Finally, limited testing to date underscores the importance of ongoing surveillance of COVID-19 cases. Additional investigation will increase the understanding about persons who are at risk for severe illness and death from COVID-19 and inform clinical guidance and community-based mitigation measures.* The risk for serious disease and death in COVID-19 cases among persons in the United States increases with age. Social distancing is recommended for all ages to slow the spread of the virus, protect the health care system, and help protect vulnerable older adults. Further, older adults should maintain adequate supplies of nonperishable foods and at least a 30-day supply of necessary medications, take precautions to keep space between themselves and others, stay away from those who are sick, avoid crowds as much as possible, avoid cruise travel and nonessential air travel, and stay home as much as possible to further reduce the risk of being exposed ( 7 ). Persons of all ages and communities can take actions to help slow the spread of COVID-19 and protect older adults. † Summary What is already known about this topic? Early data from China suggest that a majority of coronavirus disease 2019 (COVID-19) deaths have occurred among adults aged ≥60 years and among persons with serious underlying health conditions. What is added by this report? This first preliminary description of outcomes among patients with COVID-19 in the United States indicates that fatality was highest in persons aged ≥85, ranging from 10% to 27%, followed by 3% to 11% among persons aged 65–84 years, 1% to 3% among persons aged 55-64 years, <1% among persons aged 20–54 years, and no fatalities among persons aged ≤19 years. What are the implications for public health practice? COVID-19 can result in severe disease, including hospitalization, admission to an intensive care unit, and death, especially among older adults. Everyone can take actions, such as social distancing, to help slow the spread of COVID-19 and protect older adults from severe illness.
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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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              Estimating the burden of United States workers exposed to infection or disease: A key factor in containing risk of COVID-19 infection

              Introduction With the global spread of COVID-19, there is a compelling public health interest in quantifying who is at increased risk of contracting disease. Occupational characteristics, such as interfacing with the public and being in close quarters with other workers, not only put workers at high risk for disease, but also make them a nexus of disease transmission to the community. This can further be exacerbated through presenteeism, the term used to describe the act of coming to work despite being symptomatic for disease. Quantifying the number of workers who are frequently exposed to infection and disease in the workplace, and understanding which occupational groups they represent, can help to prompt public health risk response and management for COVID-19 in the workplace, and subsequent infectious disease outbreaks. Methods To estimate the number of United States workers frequently exposed to infection and disease in the workplace, national employment data (by Standard Occupational Classification) maintained by the Bureau of Labor Statistics (BLS) was merged with a BLS O*NET survey measure reporting how frequently workers in each occupation are exposed to infection or disease at work. This allowed us to estimate the number of United States workers, across all occupations, exposed to disease or infection at work more than once a month. Results Based on our analyses, approximately 10% (14.4 M) of United States workers are employed in occupations where exposure to disease or infection occurs at least once per week. Approximately 18.4% (26.7 M) of all United States workers are employed in occupations where exposure to disease or infection occurs at least once per month. While the majority of exposed workers are employed in healthcare sectors, other occupational sectors also have high proportions of exposed workers. These include protective service occupations (e.g. police officers, correctional officers, firefighters), office and administrative support occupations (e.g. couriers and messengers, patient service representatives), education occupations (e.g. preschool and daycare teachers), community and social services occupations (community health workers, social workers, counselors), and even construction and extraction occupations (e.g. plumbers, septic tank installers, elevator repair). Conclusions The large number of persons employed in occupations with frequent exposure to infection and disease underscore the importance of all workplaces developing risk response plans for COVID-19. Given the proportion of the United States workforce exposed to disease or infection at work, this analysis also serves as an important reminder that the workplace is a key locus for public health interventions, which could protect both workers and the communities they serve.
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                Author and article information

                Journal
                Ann Epidemiol
                Ann Epidemiol
                Annals of Epidemiology
                Elsevier
                1047-2797
                1873-2585
                6 September 2021
                December 2021
                6 September 2021
                : 64
                : 76-82
                Affiliations
                [a ]Agency for Toxic Substances and Disease Registry, Geospatial Research, Analysis, and Services Program, Atlanta, GA
                [b ]Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
                [c ]Centers for Disease Control and Prevention, Atlanta, GA
                [d ]Cuebiq, Inc., New York, NY
                Author notes
                [* ]Corresponding author. K.M. Fletcher, Agency for Toxic Substances and Disease Registry, Geospatial Research, Analysis, and Services Program, 4770 Buford Hwy NE, Atlanta, GA 30341.
                Article
                S1047-2797(21)00280-5
                10.1016/j.annepidem.2021.08.020
                8523174
                34500085
                ffe8db2d-219d-473a-b122-6611d6fcc658

                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.

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