Trends in Postpartum Depression before and during the COVID-19 Pandemic and Correlates of Treatment Choices: A Population-Based Retrospective Cohort Study

Objectives: COVID-19-related stressors - including social distancing, material hardship, increased intimate partner violence, and loss of childcare, among others - may result in a higher prevalence of depression among postpartum individuals. This study examines trends in postpartum depression in the US from 2018 to 2022, as well as correlates of treatment choices among women with postpartum depression. Method(s): 1,108,874 women aged 14-64 in the Komodo Healthcare Map with 1+ live birth between April 2018 and December 2021 and had continuous enrollment 2+ years before and 4+ months after the delivery date were included. Prevalence of depression during postpartum (within 3 months after delivery) was calculated before (April 2018-March 2020) and during (April 2020-March 2022) COVID-19. Multinomial logistic regression was used to investigate correlates of treatment choices (no treatment, medication-only, psychotherapy-only, or both). Result(s): The prevalence of postpartum depression increased from 9.7% pre-pandemic to 12.0% during the pandemic (p < 0.001). Among 119,788 women with postpartum depression in 2018-2022, 47.0% received no treatment, 35.0% received medication-only, 10.0% received psychotherapy-only, and 7.4% received both within one month following their first depression diagnosis. Factors associated with an increase in the odds of receiving medication-psychotherapy treatment (vs. no treatment) included older ages;commercial insurance coverage;lower social vulnerability index;history of anxiety or mood disorder during and before pregnancy;and being diagnosed by a nurse practitioner, physician assistant, or behavioral care practitioner (vs. physician). Similar patterns were observed for medication-only and psychotherapy-only treatments. Conclusion(s): In this large, nationally representative sample of US insured population, the prevalence of postpartum depression increased significantly by 2.3 percentage-points during the pandemic (or a relative increase of 23.7%). Nonetheless, almost half of women with postpartum depression received no treatment, and only 7.5% received both medication and psychotherapy. The study highlighted potential socioeconomic and provider variation in postpartum depression treatment.Copyright © 2023

Should population density be used to rank social vulnerability in disaster preparedness planning?

The CDC Social Vulnerability Index (SVI) was developed to help public health officials and policymakers to identify geospatial variations in social vulnerability for each community to better respond to hazardous events, including disease outbreaks. However, the SVI does not include information on population density, which is a significant omission when considering the usefulness of the index in allocating scarce resources such as medical supplies and personnel, bedding, food, and water to locations they are most needed. Using county-level data from the initial U.S. COVID-19 outbreak, we provide empirical evidence that the existing SVI underestimates (overestimates) county-level infection rates in densely (sparsely) populated counties if population density is not accounted for. Population density remains significant even after allowing for spatial spillover effects. Going forward, the inclusion of population density to construct SVI can improve its usefulness in aiding policymakers in allocating scarce resources for future disasters, especially those with spatial dependence. © 2022 Elsevier B.V.

Utilization of Telemedicine among Medicare beneficiaries undergoing Hepatopancreatic Surgery during the COVID-19 Pandemic.

INTRODUCTION: Telemedicine may serve as an important avenue to address disparities in access to cancer care. We sought to define factors associated with telemedicine use among Medicare beneficiaries who underwent hepatopancreatic (HP) surgery, as well as characterize trends in telemedicine usage relative to community vulnerability based on the enactment of the Medicare telemedicine coverage waiver. METHODS: Patients who underwent HP surgery between 2013-2020 were identified from the Medicare Standard Analytic Files (SAF). Telemedicine utilization was assessed pre- versus post- implementation of the Medicare telemedicine coverage waiver; the county-level social vulnerability index (SVI) was obtained from the Center for Disease Control. Interrupted time series analysis with negative binomial and multivariable logistic regression methods were used to assess changes in telemedicine utilization after the implementation of the Medicare telemedicine coverage waiver relative to SVI. RESULTS: Pre-waiver telemedicine visits were scarce among 16,690 patients (0.2%, n = 28), while post-waiver telemedicine adoption was substantial among 3,301 patients (45.8%, n = 1,388). Post-waiver, the median patient age was 70 years (IQR, 66-74) with the majority of patients being age 65-69 (n = 994, 32.8%); 1,599 (52.8%) were female. Most patients self-identified as White (n = 2641, 87.1%), while a minority of patients self-identified as Black (n = 190, 6.3%), Asian (n = 18, 0.6%), Hispanic (n = 35, 1.2%), or Other/unknown (n = 147, 4.9%). On multivariable regression analysis, patients who lived in highly vulnerable counties (referent Low SVI; moderate SVI: OR 1.09, 95% CI 0.86-1.39, p = 0.449; high SVI: OR 0.72, 95% CI 0.55-0.94, p = 0.001) and individuals with advancing age (referent 18-64; 65-69, OR 0.68, 95%CI 0.54-0.86; 70-74, OR 0.56, 95%CI 0.44-0.71; 75-79, OR 0.57, 95%CI 0.44-0.75; 80-84, OR 0.43, 95%CI 0.30-0.61; 85 + , OR 0.25, 95%CI 0.13-0.49) had lower odds of utilizing telemedicine. In contrast, Black patients (referent White; OR 2.26, 95% CI 1.65-3.10) and patients with a higher CCI score > 2 (referent ≤ 2; OR 1.49, 95% CI 1.28-1.71) were more likely to use telemedicine (all p < 0.001). CONCLUSIONS: Medicare beneficiaries residing in counties with extreme vulnerability, as well as elderly individuals, were markedly less likely to use telemedicine services related to HP surgical episodes of care. The lower utilization of telemedicine in areas of high social vulnerability was attributable to concomitant lower rates of internet access in these areas.

The Social Vulnerability Index: A Literature Review

This chapter provides a non-exhaustive review of the literature on the Social Vulnerability Index in order to share with Disaster Studies scholars and other professionals a general overview of the subject. This work analyzes selected case studies on the construction of a Social Vulnerability Index at national and local scales, and then specifically focuses on cases concerning social vulnerability to climate change, natural hazards, and COVID-19. © 2023, The Author(s), under exclusive license to Springer Nature Switzerland AG.

Can psychological distress account for the associations between COVID-19 vaccination acceptance and socio-economic vulnerability?

Socially disadvantaged individuals and communities consistently showed lower COVID-19 vaccination acceptance. We aimed to examine the psychological mechanisms that could explain such vaccination disparities. This study used data from serial population-based surveys conducted since the COVID-19 vaccination programme being launched in Hong Kong (N = 28,734). We first assessed the correlations of community-level and individual-level social vulnerability with COVID-19 vaccination acceptance. Structural equation modelling (SEM) was then conducted to test whether psychological distress measured by PHQ-4 can account for the associations between participants' socio-economic vulnerability and COVID-19 vaccination acceptance. The third part analysis examined whether perceived negativity of vaccine-related news and affect towards COVID-19 vaccines accounted for the association between psychological distress and COVID-19 vaccination. Communities with higher social vulnerability scores and participants who had more vulnerable socio-economic status showed lower COVID-19 vaccination acceptance. Individuals with more vulnerable socio-economic status reported higher psychological distress, which lowered COVID-19 vaccination acceptance. Furthermore, higher psychological distress was associated with lower vaccination acceptance through its psychological mechanisms of processing vaccine-related information. We proposed a renewed focus on tackling psychological distress rather than merely increasing vaccine accessibility in more socio-economic-disadvantaged groups for promoting COVID-19 vaccination acceptance.

Impact of the COVID-19 pandemic on cardiovascular disease mortality in a major metropolitan area.

Background: The mortality from COVID-19 alone cannot account for the impact of the pandemic. Cardiovascular disease (CVD) mortality has increased disproportionately in specific racial/ethnic populations. Objective: This study aimed to characterize how the COVID-19 pandemic impacted the association between CVD mortality and social and demographic factors as characterized by the Social Vulnerability Index (SVI). Methods: Medical Examiner Case Archive of Cook County, Illinois was utilized to identify CVD deaths in 2019 (pre-pandemic) and 2020 (pandemic). Rate ratios (RRs) were used to compare age-adjusted mortality rates (AAMRs). Addresses of deaths were geocoded to Chicago Community Areas. The Spearman's rank correlation coefficient (ρ) test was used to identify the association between SVI and CVD mortality. Results: AAMRs of CVD deaths significantly increased among non-Hispanic Black individuals (AAMRR, 1.1; 95 % CI, 1.1-1.2) and Hispanic individuals (AAMRR, 1.8; 95 % CI, 1.5-2.1) from 2019 to 2020. Among non-Hispanic White individuals, the AAMR did not significantly increase (AAMRR, 1.0; 95 % CI, 0.9-1.1). A significant positive association was observed between SVI and the percentage of non-Hispanic Black residents (ρ = 0.45; P < 0.05), while the inverse was observed with the percentage of non-Hispanic White residents (ρ = -0.77; P < 0.05). A significant positive association between SVI and CVD mortality rate increased (ρ = 0.24 and 0.28; P < 0.05). Conclusions: Significant association between SVI and CVD mortality was strengthened from 2019 to 2020, and CVD mortality increased among non-Hispanic Black and Hispanic populations. These findings demonstrate that the COVID-19 pandemic has led to an exacerbation of health inequities among different racial/ethnic populations resulting in increased CVD mortality.

Socially Vulnerable Patients with Inflammatory Bowel Disease Are at Increased Risk for Vaccine Preventable Illness

INTRODUCTION: Inflammatory bowel disease (IBD) affects patients across diverse ethnic, minority, cultural, and socioeconomic backgrounds;however, the relationship between these social determinants of health (SDOH) and IBD outcomes is not well-studied. SDOH have a known impact on disparities in vaccination, but these effects may be more salient in the IBD population where patients are at greater risk for vaccine-preventable illness from immunosuppressive therapies. The social vulnerability index (SVI) is a tool provided by Centers for Disease Control that can identify individuals at risk for health care disparities by estimating neighborhood-level social need on a 0-1 scale (higher scores indicating greater social vulnerability). Utilizing census tract-level SVI data, we aimed to identify the relationship between the SDOH and vaccination rates in patients with IBD. METHOD(S): We used a retrospective cohort design of patients seen at a single IBD center between 01/01/2015 and 08/31/2022. Using the current address listed in the electronic medical record, we geocoded patients to individual census tracts and linked them to corresponding SVI and subscales (Figure 1). Controlling a priori for age, gender, race, ethnicity, marital status, English proficiency, electoral district, and religious affiliation, we used multivariable linear regression to examine the relationship between SVI and vaccination against influenza, Covid-19, pneumococcal pneumonia (conjugate and polysaccharide), and Zoster. RESULT(S): 15,245 patients with IBD were included and the percent of unvaccinated individuals was high across all vaccine types: flu (42.8%), Covid-19 (50.9%), pneumonia (62.4%), and Zoster (89.6%). High total levels of social vulnerability were associated with lower vaccination rates across all vaccine groups: flu (B -1.3, 95% CI -1.5, -1.2, p<0.001), Covid-19 (B -0.99, 95% CI -1.1, -0.88), p<0.001), pneumonia (B -0.21, 95% CI -0.27, -0.14, p<0.001), Zoster (B -0.23, 95% CI -0.27, -0.19, p<0.001). On SVI sub-scales, high scores in Socioeconomic Status, Household Composition, and Housing/Transportation were important predictors of vaccine uptake while Minority Status/Language was non-significant (Table 1). CONCLUSION(S): Living in a socially vulnerable community is associated with lower vaccination rates across all vaccine types. Higher scores on neighborhood level Socioeconomic Status, Household Composition, and Housing/Transportation were also associated with lower vaccine uptake. Many factors may affect why socially vulnerable patients are under-vaccinated, including a lack of patient and provider knowledge of routine vaccines, lack of access to care, and poor trust in vaccines and healthcare system. Further research is needed improve IBD health maintenance in gastroenterology clinics and ensure equitable distribution of vaccines to socially vulnerable patients. [Formula presented] [Formula presented]Copyright © 2023

Racial and Socioeconomic Disparities in Colorectal Cancer Screening During the COVID-19 Pandemic

INTRODUCTION: Colorectal cancer (CRC) screening has reduced CRC mortality. The COVID-19 pandemic led to a reduction in screening volume. We sought to evaluate whether specific populations or socioeconomic groups were disproportionately impacted by the reduced access to care. METHOD(S): Patients eligible for CRC screening in a large integrated healthcare system, who had a primary care visit between January 2016 and April 2022, were evaluated. Trends in CRC screening were assessed by age, race, gender, insurance type, and geographic delineation by state and classification of urban or rural areas. Multilevel logistic regression models evaluated region-level cluster effects of CRC screening by patient demographics, insurance, and social vulnerability index (SVI), including socioeconomic status, household composition and disability, minority status and language, and housing and transportation domains. The interaction between trend in CRC screening and race was also investigated. RESULT(S): A total of 654,386 patients were screeneligible between January 2016 and April 2022. The cohort screening rate peaked at 70% in 2019 with a subsequent downtrend to a nadir of 63.6% through the first part of 2022. Whereas the Native American population is consistently the least screened population, the Asian population demonstrated the most significant decrease in screening during and after the COVID-19 pandemic, falling from a peak at 69.1% in 2019 to 59.3% in 2021;this remains low in 2022 at 58.9%. Further, older patients, males, location in an urban area, White ethnicity and use of commercial insurance were significantly associated with higher odds of CRC screening (p< 0.001). Conversely, patients living in more vulnerable census tracts based on the SVI socioeconomic status and housing/transportation domain had lower odds of having CRC screening (p< 0.001). Finally, there was a significant interaction between trend in CRC screening and race. The CRC screening rate increased between 2016 and 2019 and then decreased for all races, but Asian patients had the most significant decrease in CRC screening between 2020 and 2021 (68.3% versus 60.2%, p< 0.001;Figure 1). CONCLUSION(S): This is the first study to demonstrate that the COVID-19 pandemic led to a population-wide decrease in CRC screening volume that disproportionately affected the Asian population and those of lower socioeconomic status. We are currently evaluating whether this impacted stage migration and mortality. (Figure Presented).

Potential Epidemic Vulnerability and Socioepidemiological Profile of SARS-CoV2 in the Brazilian Northeast Region.

BACKGROUND: COVID-19 is a significant public health problem that can have a negative impact, especially in vulnerable regions. OBJECTIVE: This study aimed to provide evidence that could positively influence coping with COVID-19 based on the relationship between the potential epidemic vulnerability index (PEVI) and socioepidemiological variables. This could be used as a decision-making tool for the planning of preventive initiatives in regions with relevant vulnerability indices for the spread of SARS-CoV-2. METHODOLOGY: We performed a cross-sectional study, with the analysis of the population characteristics of COVID-19 cases associated with neighborhoods' PEVIs in the conurbation region of Crajubar, northeastern Brazil, through the mapping of socioeconomic-demographic factors and spatial autocorrelation. RESULTS: The PEVI distribution indicated low vulnerability in areas with high real estate and commercial value; as communities moved away from these areas, the vulnerability levels increased. As for the number of cases, three of the five neighborhoods with a high-high autocorrelation, and some other neighborhoods showed a bivariate spatial correlation with a low-low PEVI but also high-low with indicators that make up the PEVI, representing areas that could be protected by public health measures to prevent increases in COVID-19 cases. CONCLUSIONS: The impact of the PEVI revealed areas that could be targeted by public policies to decrease the occurrence of COVID-19.

Socially Vulnerable Patients with Inflammatory Bowel Disease Are at Increased Risk for Vaccine Preventable Illness

INTRODUCTION: Inflammatory bowel disease (IBD) affects patients across diverse ethnic, minority, cultural, and socioeconomic backgrounds;however, the relationship between these social determinants of health (SDOH) and IBD outcomes is not well-studied. SDOH have a known impact on disparities in vaccination, but these effects may be more salient in the IBD population where patients are at greater risk for vaccine-preventable illness from immunosuppressive therapies. The social vulnerability index (SVI) is a tool provided by Centers for Disease Control that can identify individuals at risk for health care disparities by estimating neighborhood-level social need on a 0-1 scale (higher scores indicating greater social vulnerability). Utilizing census tract-level SVI data, we aimed to identify the relationship between the SDOH and vaccination rates in patients with IBD. METHOD(S): We used a retrospective cohort design of patients seen at a single IBD center between 01/01/2015 and 08/31/2022. Using the current address listed in the electronic medical record, we geocoded patients to individual census tracts and linked them to corresponding SVI and subscales (Figure 1). Controlling a priori for age, gender, race, ethnicity, marital status, English proficiency, electoral district, and religious affiliation, we used multivariable linear regression to examine the relationship between SVI and vaccination against influenza, Covid-19, pneumococcal pneumonia (conjugate and polysaccharide), and Zoster. RESULT(S): 15,245 patients with IBD were included and the percent of unvaccinated individuals was high across all vaccine types: flu (42.8%), Covid-19 (50.9%), pneumonia (62.4%), and Zoster (89.6%). High total levels of social vulnerability were associated with lower vaccination rates across all vaccine groups: flu (B -1.3, 95% CI -1.5, -1.2, p<0.001), Covid-19 (B -0.99, 95% CI -1.1, -0.88), p<0.001), pneumonia (B -0.21, 95% CI -0.27, -0.14, p<0.001), Zoster (B -0.23, 95% CI -0.27, -0.19, p<0.001). On SVI subscales, high scores in Socioeconomic Status, Household Composition, and Housing/ Transportation were important predictors of vaccine uptake while Minority Status/ Language was non-significant (Table 1). CONCLUSION(S): Living in a socially vulnerable community is associated with lower vaccination rates across all vaccine types. Higher scores on neighborhood level Socioeconomic Status, Household Composition, and Housing/Transportation were also associated with lower vaccine uptake. Many factors may affect why socially vulnerable patients are under-vaccinated, including a lack of patient and provider knowledge of routine vaccines, lack of access to care, and poor trust in vaccines and healthcare system. Further research is needed improve IBD health maintenance in gastroenterology clinics and ensure equitable distribution of vaccines to socially vulnerable patients. (Figure Presented).

Disparities in COVID-19 Monoclonal Antibody Delivery: a Retrospective Cohort Study.

BACKGROUND: Disparities in access to anti-SARS-CoV-2 monoclonal antibodies have not been well characterized. OBJECTIVE: We sought to explore the impact of race/ethnicity as a social construct on monoclonal antibody delivery. DESIGN/PATIENTS: Following implementation of a centralized infusion program at a large academic healthcare system, we reviewed a random sample of high-risk ambulatory adult patients with COVID-19 referred for monoclonal antibody therapy. MAIN MEASURES: We examined the relationship between treatment delivery, race/ethnicity, and other demographics using descriptive statistics, binary logistic regression, and spatial analysis. KEY RESULTS: There was no significant difference in racial composition between patients who did (n = 25) and patients who did not (n = 378) decline treatment (p = 0.638). Of patients who did not decline treatment, 64.8% identified as White, 14.8% as Hispanic/Latinx, and 11.1% as Black. Only 44.6% of Hispanic/Latinx and 31.0% of Black patients received treatment compared to 64.1% of White patients (OR 0.45, 95% CI 0.25-0.81, p = 0.008, and OR 0.25, 95% CI 0.12-0.50, p < 0.001, respectively). In multivariable analysis including age, race, insurance status, non-English primary language, county Social Vulnerability Index, illness severity, and total number of comorbidities, associations between receiving treatment and Hispanic/Latinx or Black race were no longer statistically significant (AOR 1.32, 95% CI 0.69-2.53, p = 0.400, and AOR 1.34, 95% CI 0.64-2.80, p = 0.439, respectively). However, patients who were uninsured or whose primary language was not English were less likely to receive treatment (AOR 0.16, 95% CI 0.03-0.88, p = 0.035, and AOR 0.37, 95% CI 0.15-0.90, p = 0.028, respectively). Spatial analysis suggested decreased monoclonal antibody delivery to Cook County patients residing in socially vulnerable communities. CONCLUSIONS: High-risk ambulatory patients with COVID-19 who identified as Hispanic/Latinx or Black were less likely to receive monoclonal antibody therapy in univariate analysis, a finding not explained by patient refusal. Multivariable and spatial analyses suggested insurance status, language, and social vulnerability contributed to racial disparities.

Impact of COVID-19 Pandemic, Social Vulnerability, and Opioid Overdoses in Chicago.

Introduction: This research was undertaken to examine the individual and neighborhood drivers that contributed to increases in opioid overdose deaths during the COVID-19 pandemic. Methods: The incident location and Centers for Disease Control and Prevention Social Vulnerability Index (along with the individual indicators) were then geocoded to 1 of the 77 Chicago Community Areas. Changes in opioid overdose death rates were calculated and compared for each Chicago Community Area using linear regression between 2019 and 2020. Results: Opioid overdose deaths increased by 45% from 2019 to 2020. Chicago Community Areas in the highest 25th percentile of social vulnerability before the pandemic had a 2.8 times higher rate of opioid overdose deaths than Chicago Community Areas in the lowest 25th percentile. The increase in opioid overdose death rate observed from 2019 to 2020 was 10.2 times higher in the most socially vulnerable Chicago Community Areas than in the least vulnerable communities. Chicago Community Areas with the highest degree of social vulnerability had a higher baseline and disproportionate relative increase in opioid overdose death rate compared with the least vulnerable Chicago Community Areas. Conclusions: COVID-19 has revealed the urgent need for policies that better support the social and economic security of disadvantaged communities, particularly for residents who use opioids.

Relationships Between Social Vulnerability and Coronavirus Disease 2019 Vaccination Coverage and Vaccine Effectiveness.

BACKGROUND: Coronavirus disease 2019 (COVID-19) vaccination coverage remains lower in communities with higher social vulnerability. Factors such as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) exposure risk and access to healthcare are often correlated with social vulnerability and may therefore contribute to a relationship between vulnerability and observed vaccine effectiveness (VE). Understanding whether these factors impact VE could contribute to our understanding of real-world VE. METHODS: We used electronic health record data from 7 health systems to assess vaccination coverage among patients with medically attended COVID-19-like illness. We then used a test-negative design to assess VE for 2- and 3-dose messenger RNA (mRNA) adult (≥18 years) vaccine recipients across Social Vulnerability Index (SVI) quartiles. SVI rankings were determined by geocoding patient addresses to census tracts; rankings were grouped into quartiles for analysis. RESULTS: In July 2021, primary series vaccination coverage was higher in the least vulnerable quartile than in the most vulnerable quartile (56% vs 36%, respectively). In February 2022, booster dose coverage among persons who had completed a primary series was higher in the least vulnerable quartile than in the most vulnerable quartile (43% vs 30%). VE among 2-dose and 3-dose recipients during the Delta and Omicron BA.1 periods of predominance was similar across SVI quartiles. CONCLUSIONS: COVID-19 vaccination coverage varied substantially by SVI. Differences in VE estimates by SVI were minimal across groups after adjusting for baseline patient factors. However, lower vaccination coverage among more socially vulnerable groups means that the burden of illness is still disproportionately borne by the most socially vulnerable populations.

Should population density be used to rank social vulnerability in disaster preparedness planning?

The CDC Social Vulnerability Index (SVI) was developed to help public health officials and policymakers to identify geospatial variations in social vulnerability for each community to better respond to hazardous events, including disease outbreaks. However, the SVI does not include information on population density, which is a significant omission when considering the usefulness of the index in allocating scarce resources such as medical supplies and personnel, bedding, food, and water to locations they are most needed. Using county-level data from the initial U.S. COVID-19 outbreak, we provide empirical evidence that the existing SVI underestimates (overestimates) county-level infection rates in densely (sparsely) populated counties if population density is not accounted for. Population density remains significant even after allowing for spatial spillover effects. Going forward, the inclusion of population density to construct SVI can improve its usefulness in aiding policymakers in allocating resources for future disasters, especially those with spatial dependence.

Primary health care disaster preparedness: A review of the literature and the proposal of a new framework

With the publication of the Health Emergency and Disaster Risk Management (H-EDRM) Frame-work in 2019, the World Health Organization (WHO) emphasized the need for disaster prepared-ness in all sectors of the health system, including primary health care (PHC). PHC disaster pre-paredness plays a crucial role in guaranteeing continuity of care and responding to the health needs of vulnerable populations during disasters. While this is universally acknowledged as an important component of disaster management (DM), there is still a severe paucity of scholarship addressing how to practically ensure that a PHC system is prepared for disasters. The objective of this study is to propose a new framework that describes key characteristics for PHC disaster pre-paredness and lays the groundwork to deliver operational recommendations to assess and im-prove PHC disaster preparedness. A systematic literature review was performed and a total of 145 records were analyzed. Twenty-five characteristics that contribute to a well-prepared PHC system were identified and categorized according to the WHO Health System Building Blocks to form a new PHC disaster preparedness framework. The findings will contribute to the elaboration of a set of guidelines for PHC systems to follow in order to assess and then boost their disaster pre-paredness. This manuscript will hopefully help to raise awareness among international policy -makers and health practitioners on the importance to design interventions that integrate the PHC system into overall DM strategies, as well as to assess the preparedness of PHC systems in differ-ent political, developmental, and cultural contexts.

Effectiveness of the COVID-19 Community Vulnerability Index in explaining COVID-19 deaths.

Objectives: To explore the effectiveness of a COVID-19 specific social vulnerability index, we examined the relative importance of four COVID-19 specific themes and three general themes of the COVID-19 Community Vulnerability Index (CCVI) in explaining COVID-19 mortality rates in Cook County, Illinois. Methods: We counted COVID-19 death records from the Cook County Medical Examiner's Office, geocoded incident addresses by census tracts, and appended census tracts' CCVI scores. Negative binomial regression and Random Forest were used to examine the relative importance of CCVI themes in explaining COVID-19 mortality rates. Results: COVID-19 specific Themes 6 (High risk environments) and 4 (Epidemiological factors) were the most important in explaining COVID-19 mortality (incidence rate ratio (IRR) = 6.80 and 6.44, respectively), followed by a general Theme 2 (Minority status & language, IRR = 3.26). Conclusion: The addition of disaster-specific indicators may improve the accuracy of social vulnerability indices. However, variance for Theme 6 was entirely from the long-term care resident indicator, as the other two indicators were constant at the census tract level. Thus, CCVI should be further refined to improve its effectiveness in identifying vulnerable communities. Also, building a more robust local data infrastructure is critical to understanding the vulnerabilities of local places.

Socioeconomic status correlations with confirmed COVID-19 cases and SARS-CoV-2 wastewater concentrations in small-medium sized communities.

Over two years into the COVID-19 pandemic, it is apparent that some populations across the world are more susceptible than others to SARS-CoV-2 infection and spread. Understanding how populations with varying demographic patterns are impacted by COVID-19 may highlight which factors are most important in targeting to combat global suffering. The first objective of this study was to investigate the association of various socioeconomic status (SES) parameters and confirmed COVID-19 cases in the state of Ohio, USA. This study examines the largest and capital city of Ohio (Columbus) and various small-medium-sized communities. The second objective was to determine the relationship between SES parameters and community-level SARS-CoV-2 concentrations using municipal wastewater samples from each city's respective wastewater treatment plants from August 2020 to January 2021. SES parameters include population size, median income, poverty, race/ethnicity, education, health care access, types of COVID-19 testing sites, and social vulnerability index. Statistical analysis results show that confirmed (normalized and/or non-normalized) COVID-19 cases were negatively associated with White percentage and registered hospitals, and positively associated with registered physicians and various COVID-19 testing sites. Wastewater viral concentrations were negatively associated with poverty, and positively associated with median income, community health centers, and onsite rapid testing locations. Additional analyses conclude that population is a significant factor in determining COVID-19 cases and SARS-CoV-2 wastewater concentrations. Results indicate that community healthcare parameters relate to a negative health outcome (COVID-19) and that demographic parameters can be associated with community-level SARS-CoV-2 wastewater concentrations. As the first study that examines the association between socioeconomic parameters and SARS-CoV-2 wastewater concentrations as well as confirmed COVID-19 cases, it is apparent that social determinants have an impact in determining the health burden of small-medium sized Ohioan cities. This study design and innovative approach are scalable and applicable for endemic and pandemic surveillance across the world.

COMPARISON OF THE ASSOCIATION OF THE AREA DEPRIVATION INDEX, COVID-19 COMMUNITY VULNERABILITY INDEX, MINORITY HEALTH-SOCIAL VULNERABILITY INDEX, AND SOCIAL VULNERABILITY INDEX WITH US COVID-19 INCIDENCE AND MORTALITY

BACKGROUND: To promote equitable allocation of scarce COVID-19 resources, most US states added place-based social disadvantage indices in allocation plans. Here we compare how 4 common indices of social disadvantage (differing on social variables including race, and geographic levels)-the Social Vulnerability Index (SVI), Area Deprivation Index (ADI), COVID-19 Community Vulnerability Index (CCVI), and Minority Health-Social Vulnerability Index (MH-SVI)-are associated with COVID-19 incidence/mortality. METHODS: This cross-sectional study uses aggregated COVID-19 cases/ deaths in 3,135 US counties/county-equivalents reported by health departments (New York Times repository), merged with social disadvantage indices from CDC (SVI and MH-SVI), Surgo Ventures® (CCVI), and University of Wisconsin Neighborhood Atlas® (ADI). The SVI, MH-SVI, and CCVI are available at the US county level. ADI was transformed from census block group level to county-level using a population-weighted average. All indices/subindices are national percentile rankings. SVI, MH-SVI, and CCVI range from 0-1 and ADI range from 0-100;higher scores indicating greater disadvantage. For analysis, we converted all indices/subindices into deciles. Mixed effects negative binomial regression models adjusted for population density, urbanicity, and including an offset for county population, were used to estimate associations of each index/subindex with COVID-19 incidence/ mortality, as of July 31, 2021. RESULTS: All 4 disadvantage indices had similar positive associations with COVID-19 incidence (incidence rate ratios [IRR] ranging from 1.03-1.04). Each index was also significantly associated with COVID-19 mortality, but ADI had a stronger association (IRR 1.17, 95%CI 1.16-1.18) than CCVI (IRR 1.07, 95%CI 1.06-1.08), SVI (IRR 1.06, 95%CI 1.05-1.07), and MH-SVI (IRR 1.04, 95%CI 1.03-1.04). Each SVI, MH-SVI, and CCVI subindex was significantly associated with COVID-19 incidence, and most were significantly associated with mortality. CONCLUSIONS: With Omicron and other emerging COVID-19 variants, the need may again arise for allocation of scarce resources like testing, vaccines, and treatments. Despite differences in component measures and weighting, all 4 indices demonstrated an association between greater disadvantage and increased COVID-19 incidence/mortality, suggesting that any index can be used to assist public health leaders in targeting COVID-19 resources to regions most vulnerable to negative COVID-19 outcomes. Of note, unlike SVI, MH-SVI, and CCVI, the ADI does not include race, which can matter for legal/political issues associated with prioritization. Targeting underserved populations with indices that include race as a variable has been challenged by some state policymakers with allegations of reverse discrimination. Policymakers may weigh potential tradeoffs in the political/ practical acceptability when considering use of these indices to target equitable allocation of COVID-19 resources.

TELEHEALTH VERSUS IN-PERSON PRIMARY CARE VISITS POST-EMERGENCY DEPARTMENT (ED) DISCHARGE: ASSOCIATIONS WITH RETURN TO ED OR HOSPITALIZATION

BACKGROUND: Ensuring appropriate outpatient follow-up is a mainstay of Emergency Medicine to avoid poor patient outcomes. During the COVID-19 pandemic, many post-ED discharge visits were rapidly transitioned from inperson to telehealth. Our study investigates the associations between ED recidivism or subsequent hospitalization after either telehealth or in-person visits follow-up visits. We hypothesize that telehealth visits are less successful than in-person visits at preventing either outcome. METHODS: This retrospective study used electronic health record data from an urban academic health system. All adult patients were included if they presented to either of two in-system EDs between 1/1/20 - 10/31/21 with a chief complaint of chest pain, syncope, abdominal pain, or altered mental status. If patients had multiple ED visits, only their first was included. The post-ED follow-up window was restricted to two weeks. We used multivariate logistic regressions, which controlled for patient age, sex, race, ethnicity, primary language, insurance type, and social vulnerability index, to estimate the association between the type of post-ED follow-up and two outcomes within 30 days after the follow-up appointment: 1) returning to the ED or 2) hospitalization. RESULTS: Of 23,856 ED visits that met criteria, 10,180 (42%) had follow-up telehealth visits, 3,925 (16%) had in-person follow-up, and 9,760 (40%) had no follow-up. A total of 2,119 (9%) patients returned to the ED after their follow-up: 12% of whom had telehealth visits, 7% had in-person visits, and 6% had no follow-up visit. 684 (3%) of patients were admitted: 6% of those with telehealth visits, 2% with in-person visits, and 0.2% with no follow-up visit. Compared to having no visit, telehealth visits were associated with an adjusted OR (aOR) of returning to the ED of 2.7 (95% CI, 2.4 -3.1), and in-person visits were associated with an aOR of 1.8 (95% CI, 1.5 -2.1). Compared to those with an in-person visit, telehealth follow-up was associated with an aOR of 1.5 (95% CI, 1.3 -1.8) of returning to the ED. Compared to having no visit, telehealth visits were associated with an aOR of 27.8 (95% CI, 17.4 -44.4), and in-person visits were associated with an aOR of 12.1 (95% CI, 7.2 -20.1) of hospitalization. Compared to those with an in-person visit, telehealth was associated with an aOR of 2.3 (95% CI, 1.8 -2.9) of hospitalization. All aORs were significant with p < 0.001. CONCLUSIONS: Telehealth follow-up visits were associated with higher odds of returning to the ED and hospitalization compared to in-person visits;though some of this association is likely due to patients who are sicker choosing telemedicine over in-person, this finding also suggests in-person follow-up may be more effective than telehealth at decreasing repeat ED visits and hospitalizations. Further analysis that adjusts for patient comorbidities and illness severity will help us to better understand the impact of post-ED followup on ED recidivism and hospitalization.