U.S. Department of Health and Human Services

Purpose To (1) assess whether residential rurality/urbanicity was associated with the prevalence of 30‐ or 90‐day long COVID, and (2) evaluate whether differences in long COVID risk factors might explain this potential disparity. Methods We used data from the Michigan COVID‐19 Recovery Surveillance Study, a population‐based probability sample of adults with COVID‐19 (n = 4,937). We measured residential rurality/urbanicity using dichotomized Rural‐Urban Commuting Area codes (metropolitan, nonmetropolitan). We considered outcomes of 30‐day long COVID (illness duration ≥30 days) and 90‐day long COVID (illness duration ≥90 days). Using Poisson regression, we estimated unadjusted prevalence ratios (PRs) to compare 30‐ and 90‐day long COVID between metropolitan and nonmetropolitan respondents. Then, we adjusted our model to account for differences between groups in long COVID risk factors (age, sex, acute COVID‐19 severity, vaccination status, race and ethnicity, socioeconomic status, health care access, SARS‐CoV‐2 variant, and pre‐existing conditions). We estimated associations for the full study period (Jan 1, 2020‐May 31, 2022), the pre‐vaccine era (before April 5, 2021), and the vaccine era (after April 5, 2021). Findings Compared to metropolitan adults, the prevalence of 30‐day long COVID was 15% higher (PR = 1.15 [95% CI: 1.03, 1.29]), and the prevalence of 90‐day long COVID was 27% higher (PR = 1.27 [95% CI: 1.09, 1.49]) among nonmetropolitan adults. Adjusting for long COVID risk factors did not reduce disparity estimates in the pre‐vaccine era but halved estimates in the vaccine era. Conclusions Our findings provide evidence of a rural‐urban disparity in long COVID and suggest that the factors contributing to this disparity changed over time as the sociopolitical context of the pandemic evolved and COVID‐19 vaccines were introduced.

BACKGROUND AND OBJECTIVES Understanding the real-world impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) mitigation measures, particularly vaccination, in children and adolescents in congregate settings remains important. We evaluated protection against SARS-CoV-2 infection using school-based testing data. METHODS Using data from Utah middle- and high-school students participating in school-wide antigen testing in January 2022 during omicron (BA.1) variant predominance, log binomial models were fit to estimate the protection of previous SARS-CoV-2 infection and coronavirus disease 2019 vaccination against SARS-CoV-2 infection. RESULTS Among 17 910 students, median age was 16 years (range: 12–19), 16.7% had documented previous SARS-CoV-2 infection; 55.6% received 2 vaccine doses with 211 median days since the second dose; and 8.6% of students aged 16 to 19 years received 3 vaccine doses with 21 median days since the third dose. Protection from previous infection alone was 35.9% (95% confidence interval [CI]: 12.9%–52.8%) and 23.8% (95% CI: 2.1%–40.7%) for students aged 12 to 15 and 16 to 19 years, respectively. Protection from 2-dose hybrid immunity (previous SARS-CoV-2 infection and vaccination) with <180 days since the second dose was 58.7% (95% CI: 33.2%–74.4%) for students aged 12 to 15 and 54.7% (95% CI: 31.0%–70.3%) for students aged 16 to 19 years. Protection was highest (70.0%, 95% CI: 42.3%–84.5%) among students with 3-dose hybrid immunity, although confidence intervals overlap with 2-dose vaccination. CONCLUSIONS The estimated protection against infection was strongest for those with hybrid immunity from previous infection and recent vaccination with a third dose.

The risk of reinfection has been difficult to quantify throughout the pandemic, making the case for COVID-19 vaccination and receipt of booster doses to the public difficult for the public health community. To address this question, Michigan statewide COVID-19 infection and vaccination data was utilized in this cross-sectional study to determine the risk of reinfection by vaccination status. Cases were divided into subgroups by vaccination status, and the risk of reinfection in the various vaccination categories was then calculated by dividing the cumulative incidence of reinfection in a vaccine category by the cumulative incidence of reinfection of those not in that category Within this population, the risk of becoming reinfected was 1.6 times higher for those who were unvaccinated than those who were vaccinated; those with a primary series saw a 27% reduced risk of reinfections compared to those without a primary series. Those with an additional booster dose had a modest improvement, with 35% reduced risk of reinfection when compared to the other groups combined. These results provide population level data to support current public health vaccination recommendations.

Background Primary care providers (PCP) differ in their ability to address the needs and reduce use of costly services among complex Medicaid beneficiaries. Among PCPs, Health Resources and Services Administration (HRSA)-funded health centers (HCs) are shown to provide high-value care. Objective We compared health care utilization of complex Medicaid managed care beneficiaries whose PCPs were HCs versus 3 other groups. Research Design Cross-sectional study using propensity score matching comparing health care use by provider type, controlling for demographics, health status, and other covariates. Subjects California Medicaid administrative data for complex adult managed care beneficiaries with at least 1 primary care visit in 2018. Measures Primary and specialty care evaluation & management visits and services; emergency department (ED) visits; and hospitalizations. PCPs included HCs, clinics not funded by HRSA, solo, and group practice providers. Results HRSA-funded HCs had lower predicted rates of specialty evaluation & management and other services than all others; lower predicted probability of any ED visits than clinics not funded by HRSA [54% (95% CI: 53%–55%) vs. 56% (95% CI: 55%–57%)] and group practice providers [51% (95% CI: 51%–52%) vs. 52% (95% CI: 52%–53%)]; and lower PP of any hospitalizations than solo [20% (95% CI: 19%–20%) vs. 23% (95% CI: 22%–24%)] and group practice providers [21% (95% CI: 20%–21%) vs. 24% (95% CI: 23%–24%)]. Conclusions Differences in HC care delivery and practices were associated with lower use of specialty, ED, and hospitalization visits compared with other PCPs for complex Medicaid managed care beneficiaries. Understanding the underlying reasons for these utilization differences may promote better outcomes among these patients.

In this history and overview of the first major federal effort to apply behavioral science to human services in the United States, the authors share how the unique context of federally funded human services programs made behavioral science a simultaneously promising and uncertain approach. The chapter details the efforts of a federal research office in the Administration for Children and Families, an agency of the U.S. Department of Health and Human Services, to stand up a portfolio of work using behavioral science to diagnose problems that federally funded human services programs were facing, design behaviorally informed interventions to address these challenges, and test the interventions with randomized controlled trials. The chapter explores reasons that some programs that went through this behavioral diagnosis and design process ultimately did not complete evaluations, shares examples of the common types of nudges tested, and describes lessons learned about translating behavioral science to these complex populations and programs.

This cross-sectional study analyzes the use of patient portal apps and third-party apps for managing multiple patient portals between 2019 and 2022.

Background Implementation is an important piece of effective policymaking, but connecting local organizations with federal policy can be challenging. A virtual workshop structure can help engage implementation partners, especially when in-person events are not possible. The workshops described here leveraged virtual outreach and facilitation methods to foster community engagement, forge connections, and build relationships at the regional, state, and local levels. Methods This article focuses on five virtual workshops. The planning phase consisted of selecting the geographic scope of each workshop, developing outreach and facilitation materials, and supporting event logistics. The execution and summary phase included tailoring materials, hosting the events, and producing follow-up materials. Networking, resource sharing, collaboration, and active facilitation were employed to promote engagement. Results Registration for the virtual workshops included 223 individuals representing organizations in 28 states. Participants shared 133 resources. In a post-event evaluation, 93% of respondents indicated they could identify at least one new resource to support their efforts to increase youth sports participation in their community, and 94% indicated they plan to follow up and explore potential partnerships/collaborations with others they met or heard from at the workshop. Networking and resource sharing were identified as the most useful aspects of the workshops. Conclusions With careful planning and collaboration, virtual workshops represent a useful community engagement mechanism to bring policy into practice. Creating events focused on the participant experience supports health promotion professionals, engages communities, and takes a policy off the page and out to the people.

Background Growing evidence suggests that individuals with COVID-19 face stigmatization, which is associated with poor health outcomes and behaviors. However, very few population-based studies have examined risk factors for experiencing COVID-19 stigma. This study examined prevalence and predictors of perceived COVID-19 stigma using a population-based probability sample of adults with COVID-19. Methods We included adults with polymerase chain reaction-confirmed SARS-CoV-2 in Michigan between January 1, 2020 and July 31, 2021. Perceived COVID-19 stigma was considered present if a respondent answered affirmatively to any of the following items due to people thinking they might have COVID-19: “you were treated badly,” “people acted as if they were scared of you,” and “you were threatened or harassed.” We conducted modified Poisson regression with robust standard errors to estimate associations between perceived COVID-19 stigma and potential predictors, including sex, age, race and ethnicity, household income, education, employment, smoking status, body mass index, preexisting diagnosed physical or mental comorbidities, and COVID-19 illness severity. Results Perceived COVID-19 stigma was commonly reported among our respondents (38.8%, n = 2,759). Compared to those over 65 years, respondents who were 18 − 34 (adjusted prevalence ratio (aPR): 1.41, 95% confidence intervals (CI): 1.12 − 1.77) and 35 − 44 years old (aPR: 1.66, 95% CI: 1.31 − 2.09) reported higher perceived stigma. Female respondents had 1.23 times higher prevalence of perceived COVID-19 stigma (95% CI: 1.10 − 1.37) than male respondents and non-Hispanic Black respondents had 1.22 times higher prevalence of perceived COVID-19 stigma (95% CI: 1.04 − 1.44) than non-Hispanic White respondents. Moreover, respondents with pre-existing diagnosed psychological or psychiatric comorbidities were more likely to report perceived COVID-19 stigma (aPR: 1.29, 95% CI: 1.13 − 1.48) compared to those without diagnosed comorbidities. Respondents with very severe COVID-19 symptoms were also more likely to report perceived COVID-19 stigma (aPR: 1.47, 95% CI: 1.23 − 1.75) than those with asymptomatic or mild symptoms. Conclusions We found that populations who are marginalized in United States, such as females, non-Hispanic Black adults, or individuals with chronic conditions, are more likely to report perceived COVID-19 stigma. Continuing to monitor COVID-19 stigma, especially in vulnerable populations, may provide useful insights for anti-stigma campaigns and future pandemics.

Background Previous studies have shown an association between living alone and cancer mortality; however, findings by sex and race/ethnicity have generally been inconsistent, and data by socioeconomic status are sparse. The association between living alone and cancer mortality by sex, race/ethnicity, and socioeconomic status in a nationally representative US cohort was examined. Methods Pooled 1998–2019 data for adults aged 18–64 years at enrollment from the National Health Interview Survey linked to the National Death Index (N = 473,648) with up to 22 years of follow-up were used to calculate hazard ratios (HRs) for the association between living alone and cancer mortality. Results Compared to adults living with others, adults living alone were at a higher risk of cancer death in the age-adjusted model (HR, 1.32; 95% CI, 1.25–1.39) and after additional adjustments for multiple sociodemographic characteristics and cancer risk factors (HR, 1.10; 95% CI, 1.04–1.16). Age-adjusted models stratified by sex, poverty level, and educational attainment showed similar associations between living alone and cancer mortality, but the association was stronger among non-Hispanic White adults (HR, 1.33; 95% CI, 1.25–1.42) than non-Hispanic Black adults (HR, 1.18; 95% CI, 1.05–1.32; p value for difference < .05) and did not exist in other racial/ethnic groups. These associations were attenuated but persisted in fully adjusted models among men (HR, 1.13; 95% CI, 1.05–1.23), women (HR, 1.09; 95% CI, 1.01–1.18), non-Hispanic White adults (HR, 1.13; 95% CI, 1.05–1.20), and adults with a college degree (HR, 1.22; 95% CI, 1.07–1.39). Conclusions In this nationally representative study in the United States, adults living alone were at a higher risk of cancer death in several sociodemographic groups.

Background Disease from Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) remains the seventh leading cause of death in the United States. Many patients infected with this virus develop later cardiovascular complications including myocardial infarctions, stroke, arrhythmia, heart failure, and sudden cardiac death (20–28%). The purpose of this study is to understand the primary mechanism of myocardial injury in patients infected with SARS-CoV-2. Methods We investigated a consecutive cohort of 48 medical examiner cases who died with PCR-positive SARS-CoV-2 (COVpos) infection in 2020. We compared them to a consecutive cohort of 46 age- and sex-matched controls who were PCR-negative for SARS-CoV-2 (COVneg). Clinical information available at postmortem examination was reviewed on each patient. Formalin-fixed sections were examined using antibodies directed against CD42 (platelets), CD15 (myeloid cells), CD68 (monocytes), C4d, fibrin, CD34 (stem cell antigen), CD56 (natural killer cells), and myeloperoxidase (MPO) (neutrophils and neutrophil extracellular traps(NETs)). We used a Welch 2-sample T-test to determine significance. A cluster analysis of marker distribution was also done. Results We found a significant difference between COVpos and COVneg samples for CD42, CD15, CD68, C4d, fibrin, and MPO, all of which were significant at p < 0.001. The most prominent features were neutrophils (CD15, MPO) and MPO-positive debris suggestive of NETs. A similar distribution of platelets, monocytes, fibrin and C4d was seen in COVpos cases. Clinical features were similar in COVpos and COVneg cases for age, sex, and body mass index (BMI). Conclusion These findings suggest an autoinflammatory process is likely involved in cardiac damage during SARS-CoV-2 infection. No information about clinical cardiac disease was available.

Despite the growing importance of community health workers (CHWs) in public health, it has been difficult to characterize the roles and scope of services for this workforce in part because of the variability in the employment status of CHWs, ranging from full-time, part-time, to volunteer. Based on analysis of survey data from a statewide assessment of the CHW workforce in Nebraska (n = 142) conducted between 2019 and 2020, the proportions of CHWs who worked full-time, part-time, or volunteer were respectively 64%, 12%, and 21%. Over three quarters (76.7%) of volunteer CHWs were primarily working with Hispanic communities, as compared to less than 30% among full-time and part-time CHWs. About 80% of volunteer CHWs received training before becoming a CHW, substantially higher than the corresponding proportions among full-time (46.2%) and part-time CHWs (52.9%). In terms of tasks performed, the proportion of volunteer CHWs who provided health screenings (70%) were much higher than full or part-time CHWs (41.8% and 11.8% respectively, p < 0.001); whereas the latter two groups were significantly more likely than volunteer CHWs to provide other tasks such as coordinating care, health coaching, social support, transportation, interpretation, data collection, advocacy, and cultural awareness. Volunteer CHWs may hold potential for serving non-Hispanic communities. Future development of the CHW workforce can benefit from understanding and leveraging the significant differences in roles and scope of services among CHWs with various employment statuses.

Introduction People Living with HIV (PLWH) have higher prevalence of adverse COVID-19 outcomes, and many reside in socially vulnerable communities. Our aim is to evaluate how engagement in HIV care may increase vaccination likelihood. Methods Michigan HIV surveillance data were extracted from the Enhanced HIV/AIDS Reporting System (eHARS) and matched at the person-level to COVID-19 vaccination records from the Michigan Care Improvement Registry (MCIR) (through December 31, 2021 (n=15,537)). Based on residential census tract, we classified PLWH into quartiles (<25 th percentile (least vulnerable), 25 th to <50 th , 50 th to <75 th , ≥75 th (most vulnerable)) of the 2018 CDC Social Vulnerability Index 1. Using log binomial regression, we estimated the relative prevalence of COVID-19 vaccine series initiation among PLWH by quartile of social vulnerability and Ryan White participation; models were adjusted for covariates. Results By December 31, 2021, 67% of PLWH in Michigan had initiated a COVID-19 vaccine series; 47% resided in an area deemed most vulnerable and 54% had participated in Ryan White services. Compared to PLWH in the most vulnerable quartile, those who resided in least vulnerable quartiles had higher prevalence of vaccine initiation (Prevalence Ratio (95% Confidence Interval): 1.67 (1.50, 1.86). Participants in Ryan White had greater prevalence of initiation (1.52 (1.42, 1.62) compared to those who were not participants; initiation remained higher when adjusted for covariates including social vulnerability quartile. Conclusion Ryan White participation was associated with increased COVID-19 vaccine initiation regardless of community-level vulnerability. Wraparound services may be key in vaccine promotion interventions in this vulnerable population.

Recent large-scale genome-wide association studies (GWAS) have started to identify potential genetic risk loci associated with risk of suicide; however, a large portion of suicide-associated genetic factors affecting gene expression remain elusive. Dysregulated gene expression, not assessed by GWAS, may play a significant role in increasing the risk of suicide death. We performed the first comprehensive genomic association analysis prioritizing brain expression quantitative trait loci (eQTLs) within regulatory regions in suicide deaths from the Utah Suicide Genetic Risk Study (USGRS). 440,324 brain-regulatory eQTLs were obtained by integrating brain eQTLs, histone modification ChIP-seq, ATAC-seq, DNase-seq, and Hi-C results from publicly available data. Subsequent genomic analyses were conducted in whole-genome sequencing (WGS) data from 986 suicide deaths of non-Finnish European (NFE) ancestry and 415 ancestrally matched controls. Additional independent USGRS suicide deaths with genotyping array data (n = 4657) and controls from the Genome Aggregation Database were explored for WGS result replication. One significant eQTL locus, rs926308 (p = 3.24e−06), was identified. The rs926308-T is associated with lower expression of RFPL3S, a gene important for neocortex development and implicated in arousal. Gene-based analyses performed using Sherlock Bayesian statistical integrative analysis also detected 20 genes with expression changes that may contribute to suicide risk. From analyzing publicly available transcriptomic data, ten of these genes have previous evidence of differential expression in suicide death or in psychiatric disorders that may be associated with suicide, including schizophrenia and autism (ZNF501, ZNF502, CNN3, IGF1R, KLHL36, NBL1, PDCD6IP, SNX19, BCAP29, and ARSA). Electronic health records (EHR) data was further merged to evaluate if there were clinically relevant subsets of suicide deaths associated with genetic variants. In summary, our study identified one risk locus and ten genes associated with suicide risk via gene expression, providing new insight into possible genetic and molecular mechanisms leading to suicide.

Background The peer support workforce has become an established aspect of behavioral health care, with endorsement since 1999 as Medicaid reimbursable and with steady uptake of credentialing by 49 states and the District of Columbia. Yet sustainability issues due to wage and entry-level stagnation lacking advancement paths is a concern for the Certified Peer Support Specialists (CPSSs) workforce. Methods This analysis compared cross-regional survey data of employed CPPSs in Utah (U) to a prior Michigan (M) sample. The core areas of investigation were 1) health and well-being, 2) professional settings, activities, and opportunities, and 3) perceptions regarding professional practice. Results Over 85% of Utah peers expressed satisfaction with work hours, physical safety at work, and supportiveness of supervisors, similar to 75% Michigan sample satisfaction. Job security satisfaction differed at 87% in Utah and 67% in Michigan, with a higher average wage in Utah. Less satisfaction was reported for promotion opportunities (U-57%, M-41%) and coworker awareness of peer roles (U-34%, M-42%). Conclusions Results indicate similar workforce conditions across regions, but with higher pay and slightly higher satisfaction ratings in the Utah sample of mixed recovery and mental health peers. Both areas demonstrate a need for training non-peer staff on CPSS job roles, indicating a lack of clarity regarding the professional contributions of peers. Practical administrative steps to support sustainability include stigma-reducing workplace policies, trainings, career laddering with increased responsibility, sustainable wage and benefit packages consistent with career laddering, and reinforcing consensus around defined roles and competencies of peer support.

This commentary highlights the impact of Michael Johnson’s work, and the concept that intimate partner violence (IPV) is not a “one-size fits all” phenomena, on the mental health field. Johnson’s, 1995 typology led to a paradigm shift in research and the clinical work of many mental health providers who seek to prevent or treat IPV. Johnson’s idea that there is more than one type of violence, i.e., situational couple violence and intimate terrorism, moved many from the idea that it is never appropriate to offer conjoint treatment to couples who have experienced IPV. Instead, it became increasingly clear that clinicians have a responsibility to provide a clear determination of if there has been IPV in the couple we are treating, and if so, to determine the type of IPV to individualize treatment based on the IPV type. In this commentary, we also address the impact of Johnson’s work on our own clinical work and on the mental health field. Finally, as we review Johnson’s work and the work of other scholars in this special issue, we focus on how this can guide clinical work to improve the lives of clients who have experienced IPV (either as victims, offenders, or both).