How Governor Directives Changed Health Workforce Flexibility in Response to the COVID-19 Pandemic.

OBJECTIVES: In times of heightened population health needs, the health workforce must respond quickly and efficiently, especially at the state level. We examined state governors' executive orders related to 2 key health workforce flexibility issues, scope of practice (SOP) and licensing, in response to the COVID-19 pandemic. METHODS: We conducted an in-depth document review of state governors' executive orders introduced in 2020 in all 50 states and the District of Columbia. We conducted a thematic content analysis of the executive order language using an inductive process and then categorized executive orders by profession (advanced practice registered nurses, physician assistants, and pharmacists) and degree of flexibility granted; for licensing, we indicated yes or no for easing or waiving cross-state regulatory barriers. RESULTS: We identified executive orders in 36 states containing explicit directives addressing SOP or out-of-state licensing, with those in 20 states easing regulatory barriers pertaining to both workforce issues. Seventeen states issued executive orders expanding SOP for advanced practice nurses and physician assistants, most commonly by completely waiving physician practice agreements, while those in 9 states expanded pharmacist SOP. Executive orders in 31 states and the District of Columbia eased or waived out-of-state licensing regulatory barriers, usually for all health care professionals. CONCLUSION: Governor directives issued through executive orders played an important role in expanding health workforce flexibility in the first year of the pandemic, especially in states with restrictive practice regulations prior to COVID-19. Future research should examine what effects these temporary flexibilities may have had on patient and practice outcomes or on permanent efforts to relax practice restrictions for health care professionals.

Surveillance for Violent Deaths - National Violent Death Reporting System, 48 States, the District of Columbia, and Puerto Rico, 2020.

Problem/Condition: In 2020, approximately 71,000 persons died of violence-related injuries in the United States. This report summarizes data from CDC's National Violent Death Reporting System (NVDRS) on violent deaths that occurred in 48 states, the District of Columbia, and Puerto Rico in 2020. Results are reported by sex, age group, race and ethnicity, method of injury, type of location where the injury occurred, circumstances of injury, and other selected characteristics. Period Covered: 2020. Description of System: NVDRS collects data regarding violent deaths obtained from death certificates, coroner and medical examiner records, and law enforcement reports. This report includes data collected for violent deaths that occurred in 2020. Data were collected from 48 states (all states with exception of Florida and Hawaii), the District of Columbia, and Puerto Rico. Forty-six states had statewide data, two additional states had data from counties representing a subset of their population (35 California counties, representing 71% of its population, and four Texas counties, representing 39% of its population), and the District of Columbia and Puerto Rico had jurisdiction-wide data. NVDRS collates information for each violent death and links deaths that are related (e.g., multiple homicides, homicide followed by suicide, or multiple suicides) into a single incident. Results: For 2020, NVDRS collected information on 64,388 fatal incidents involving 66,017 deaths that occurred in 48 states (46 states collecting statewide data, 35 California counties, and four Texas counties), and the District of Columbia. In addition, information was collected for 729 fatal incidents involving 790 deaths in Puerto Rico. Data for Puerto Rico were analyzed separately. Of the 66,017 deaths, the majority (58.4%) were suicides, followed by homicides (31.3%), deaths of undetermined intent (8.2%), legal intervention deaths (1.3%) (i.e., deaths caused by law enforcement and other persons with legal authority to use deadly force acting in the line of duty, excluding legal executions), and unintentional firearm deaths (<1.0%). The term "legal intervention" is a classification incorporated into the International Classification of Diseases, Tenth Revision, and does not denote the lawfulness or legality of the circumstances surrounding a death caused by law enforcement.Demographic patterns and circumstances varied by manner of death. The suicide rate was higher for males than for females. Across all age groups, the suicide rate was highest among adults aged ≥85 years. In addition, non-Hispanic American Indian or Alaska Native (AI/AN) persons had the highest suicide rates among all racial and ethnic groups. Among both males and females, the most common method of injury for suicide was a firearm. Among all suicide victims, when circumstances were known, suicide was most often preceded by a mental health, intimate partner, or physical health problem or by a recent or impending crisis during the previous or upcoming 2 weeks. The homicide rate was higher for males than for females. Among all homicide victims, the homicide rate was highest among persons aged 20-24 years compared with other age groups. Non-Hispanic Black (Black) males experienced the highest homicide rate of any racial or ethnic group. Among all homicide victims, the most common method of injury was a firearm. When the relationship between a homicide victim and a suspect was known, the suspect was most frequently an acquaintance or friend for male victims and a current or former intimate partner for female victims. Homicide most often was precipitated by an argument or conflict, occurred in conjunction with another crime, or, for female victims, was related to intimate partner violence. Nearly all victims of legal intervention deaths were male, and the legal intervention death rate was highest among men aged 35-44 years. The legal intervention death rate was highest among AI/AN males, followed by Black males. A firearm was used in the majority of legal intervention deaths. When a specific type of crime was known to have precipitated a legal intervention death, the type of crime was most frequently assault or homicide. When circumstances were known, the three most frequent circumstances reported for legal intervention deaths were as follows: the victim's death was precipitated by another crime, the victim used a weapon in the incident, and the victim had a substance use problem (other than alcohol use).Other causes of death included unintentional firearm deaths and deaths of undetermined intent. Unintentional firearm deaths were most frequently experienced by males, non-Hispanic White (White) persons, and persons aged 15-24 years. These deaths most frequently occurred while the shooter was playing with a firearm and were precipitated by a person unintentionally pulling the trigger. The rate of deaths of undetermined intent was highest among males, particularly among AI/AN and Black males, and among adults aged 30-54 years. Poisoning was the most common method of injury in deaths of undetermined intent, and opioids were detected in nearly 80% of decedents tested for those substances. Interpretation: This report provides a detailed summary of data from NVDRS on violent deaths that occurred in 2020. The suicide rate was highest among AI/AN and White males, whereas the homicide rate was highest among Black male victims. Intimate partner violence precipitated a large proportion of homicides for females. Mental health problems, intimate partner problems, interpersonal conflicts, and acute life stressors were primary circumstances for multiple types of violent death. Public Health Action: Violence is preventable, and states and communities can use data to guide public health action. NVDRS data are used to monitor the occurrence of violence-related fatal injuries and assist public health authorities in developing, implementing, and evaluating programs, policies, and practices to reduce and prevent violent deaths. For example, the Colorado Violent Death Reporting System (VDRS), Kentucky VDRS, and Oregon VDRS have used their VDRS data to guide suicide prevention efforts and generate reports highlighting where additional focus is needed. In Colorado, VDRS data were used to examine the increased risk for suicide among first and last responders in the state. Kentucky VDRS used local data to highlight how psychological and social effects of the COVID-19 pandemic might increase risk for suicide, particularly among vulnerable populations. Oregon VDRS used their data to develop a publicly available data dashboard displaying firearm mortality trends and rates in support of the state's firearm safety campaign. Similarly, states participating in NVDRS have used their VDRS data to examine homicide in their state. Illinois VDRS, for example, found that state budget cuts were associated with notable increases in homicides among youths in Chicago. With an increase of participating states and jurisdictions, this report marks progress toward providing nationally representative data.

Psychosocial impacts of the COVID-19 pandemic from a cross-sectional Survey of people living with HIV in Washington, DC.

BACKGROUND: COVID-19 has not only taken a staggering toll in terms of cases and lives lost, but also in its psychosocial effects. We assessed the psychosocial impacts of the COVID-19 pandemic in a large cohort of people with HIV (PWH) in Washington DC and evaluated the association of various demographic and clinical characteristics with psychosocial impacts. METHODS: From October 2020 to December 2021, DC Cohort participants were invited to complete a survey capturing psychosocial outcomes influenced by the COVID-19 pandemic. Some demographic variables were also collected in the survey, and survey results were matched to additional demographic data and laboratory data from the DC Cohort database. Data analyses included descriptive statistics and multivariable logistic regression models to evaluate the association between demographic and clinical characteristics and psychosocial impacts, assessed individually and in overarching categories (financial/employment, mental health, decreased social connection, and substance use). RESULTS: Of 891 participants, the median age was 46 years old, 65% were male, and 76% were of non-Hispanic Black race/ethnicity. The most commonly reported psychosocial impact categories were mental health (78% of sample) and financial/employment (56% of sample). In our sample, older age was protective against all adverse psychosocial impacts. Additionally, those who were more educated reported fewer financial impacts but more mental health impacts, decreased social connection, and increased substance use. Males reported increased substance use compared with females. CONCLUSIONS: The COVID-19 pandemic has had substantial psychosocial impacts on PWH, and resiliency may have helped shield older adults from some of these effects. As the pandemic continues, measures to aid groups vulnerable to these psychosocial impacts are critical to help ensure continued success towards healthy living with HIV.

Tuberculosis - United States, 2022.

Incidence of reported tuberculosis (TB) decreased gradually in the United States during 1993-2019, reaching 2.7 cases per 100,000 persons in 2019. Incidence substantially declined in 2020 to 2.2, coinciding with the COVID-19 pandemic (1). Proposed explanations for the decline include delayed or missed TB diagnoses, changes in migration and travel, and mortality among persons susceptible to TB reactivation (1). Disparities (e.g., by race and ethnicity) in TB incidence have been described (2). During 2021, TB incidence partially rebounded (to 2.4) but remained substantially below that during prepandemic years, raising concerns about ongoing delayed diagnoses (1). During 2022, the 50 U.S. states and the District of Columbia (DC) provisionally reported 8,300 TB cases to the National Tuberculosis Surveillance System. TB incidence was calculated using midyear population estimates and stratified by birth origin and by race and ethnicity. During 2022, TB incidence increased slightly to 2.5 although it remained lower than during prepandemic years.* Compared with that in 2021, TB epidemiology in 2022 was characterized by more cases among non-U.S.-born persons newly arrived in the United States; higher TB incidence among non-Hispanic American Indian or Alaska Native (AI/AN) and non-Hispanic Native Hawaiian or other Pacific Islander (NH/OPI) persons and persons aged ≤4 and 15-24 years; and slightly lower incidence among persons aged ≥65 years. TB incidence appears to be returning to prepandemic levels. TB disparities persist; addressing these disparities requires timely TB diagnosis and treatment to interrupt transmission and prevention of TB through treatment of latent TB infection (LTBI).

Maintaining Adherence to COVID-19 Preventive Practices and Policies Pertaining to Masking and Distancing in the District of Columbia and Other US States: Systematic Observational Study.

BACKGROUND: Prior to the development of effective vaccines against SARS-CoV-2, masking and social distancing emerged as important strategies for infection control. Locations across the United States required or recommended face coverings where distancing was not possible, but it is unclear to what extent people complied with these policies. OBJECTIVE: This study provides descriptive information about adherence to public health policies pertaining to mask wearing and social distancing and examines differences in adherence to these policies among different population groups in the District of Columbia and 8 US states. METHODS: This study was part of a national systematic observational study using a validated research protocol for recording adherence to correct mask wearing and maintaining social distance (6 feet/1.83 meters) from other individuals. Data were collected from December 2020 to August 2021 by research team members who stationed themselves in outdoor areas with high pedestrian traffic, observed individuals crossing their paths, and collected data on whether individuals' masks were present (visible or not visible) or worn (correctly, incorrectly, not at all) and whether social distance was maintained if other individuals were present. Observational data were entered electronically into Google Forms and were exported in Excel format for analysis. All data analyses were conducted using SPSS. Information on local COVID-19 protection policies (eg, mask wearing requirements) was obtained by examining city and state health department websites for the locations where data were being collected. RESULTS: At the time these data were collected, most locations in our study required (5937/10,308, 57.6%) or recommended (4207/10,308, 40.8%) masking. Despite this, more than 30% of our sample were unmasked (2889/10136, 28.5%) or masked incorrectly (636/10136, 6.3%). Masking policy was significantly related to correct masking with locations that required or recommended masking (66% correct masking vs 28/164, 17.1% in locations that did not require masking, P<.001). Participants who maintained social distance from others were more likely to be correctly masked than those who were not (P<.001). Adherence to masking policy by location was significant (P<.001); however, this was driven by 100% compliance in Georgia, which did not require masks at any point during the data collection period. When the same analysis was conducted for compliance with mask requirements and recommendations, there was no significant difference by location. Overall adherence to masking policies was 66.9. CONCLUSIONS: Despite a clear relationship between mask policies and masking behavior, one-third of our sample was nonadherent to those policies, and approximately 23% of our sample did not have any mask, either on or visible. This may speak to the confusion surrounding "risk" and protective behaviors, as well as pandemic fatigue. These results underscore the importance of clear public health communication, particularly given variations in public health policies across states and localities.

The Association Between Receiving the Flu and COVID-19 Vaccines and Related Factors, Data from the StopFlu Campaign in Eight States and the District of Columbia, 2022.

Given the evolving nature of the COVID-19 pandemic and the importance of vaccines, it is imperative to understand the relationships between receiving the COVID-19 vaccine and other vaccines, such as the flu vaccine. Data were obtained from a survey as part of an evaluation of the StopFlu Kaiser Permanente media campaign, promoting the flu and COVID-19 vaccines in communities of color across eight states and the District of Columbia. The outcome considered was receiving the COVID-19 vaccine. The exposure considered was receiving the flu vaccine. Covariates included demographic factors, and sources of trusted health information. Overall, 4,185 participants had complete data and were included the analysis. Logistic regression was used to assess the relationship between receiving the flu vaccine and COVID-19 vaccine. Among participants, 77.8% reported receiving the COVID-19 vaccine and 55.4% received the flu vaccine. After adjusting for demographics and sources of trusted health information, participants reporting receiving the flu vaccine had 5.18 times the odds of also receiving the COVID-19 vaccine [Adjusted Odds Ratio (AOR): 5.18 95% Confidence Interval (CI): 4.24-6.32]. Trusting advice from a doctor and healthcare organization also had increased odds of receiving the COVID-19 vaccine. (AOR: 1.84 95%CI: 1.45-2.33, AOR: 2.08 95%CI: 1.64-2.63). This study demonstrates that promotion of one vaccine may influence uptake of other vaccines, which is important given the highly politicized nature of the COVID-19 vaccine. Further research could provide more insight into how promotion of a vaccine could impact behavior with regards to another.

Gun violence in United States during the second year of the COVID-19 pandemic.

Objective: In the first year of the COVID-19 pandemic, gun violence (GV) rates in the United States (US) rose by 30%. We estimate the relative risk of GV in the US in the second year compared to the first year of the pandemic, in time and space. Methods: Daily police reports of gun-related injuries and deaths in the 50 states and the District of Columbia from March 1, 2020, to February 28, 2022, were obtained from the GV Archive. Generalized linear mixed-effects models in the form of Poisson regression analyses were utilized to estimate state-specific rates of GV. Results: Nationally, GV rates during the second year of the pandemic (March 1, 2021, through February 28, 2022) remained the same as that of the first year (March 1, 2020, through February 28, 2021) (Intensity Ratio = 0.996; 95% CI 0.98, 1.01; p = 0.53). Nevertheless, hotspots of GV were identified. Nine (18%) states registered a significantly higher risk of GV during the second year of the pandemic compared to the same period in the first year. In 10 (20%) states, the risk of GV during the second year of the pandemic was significantly lower compared to the same period in the first year. Conclusion: GV risk in the US is heterogeneous. It continues to be a public health crisis, with 18% of the states demonstrating significantly higher GV rates during the second year of the COVID-19 pandemic compared to the same timeframe 1 year prior.

COVID-19 Vaccination Coverage and Demographic Characteristics of Infants and Children Aged 6 Months-4 Years - United States, June 20-December 31, 2022.

Although severe COVID-19 illness and hospitalization are more common among older adults, children can also be affected (1). More than 3 million cases of COVID-19 had been reported among infants and children aged <5 years (children) as of December 2, 2022 (2). One in four children hospitalized with COVID-19 required intensive care; 21.2% of cases of COVID-19-related multisystem inflammatory syndrome in children (MIS-C) occurred among children aged 1-4 years, and 3.2% of MIS-C cases occurred among infants aged <1 year (1,3). On June 17, 2022, the Food and Drug Administration issued an Emergency Use Authorization (EUA) of the Moderna COVID-19 vaccine for children aged 6 months-5 years and the Pfizer-BioNTech COVID-19 vaccine for children aged 6 months-4 years. To assess COVID-19 vaccination coverage among children aged 6 months-4 years in the United States, coverage with ≥1 dose* and completion of the 2-dose or 3-dose primary vaccination series† were assessed using vaccine administration data for the 50 U.S. states and District of Columbia submitted from June 20 (after COVID-19 vaccine was first authorized for this age group) through December 31, 2022. As of December 31, 2022, ≥1-dose COVID-19 vaccination coverage among children aged 6 months-4 years was 10.1% and was 5.1% for series completion. Coverage with ≥1 dose varied by jurisdiction (range = 2.1% [Mississippi] to 36.1% [District of Columbia]) as did coverage with a completed series (range = 0.7% [Mississippi] to 21.4% [District of Columbia]), respectively. By age group, 9.7 % of children aged 6-23 months and 10.2% of children aged 2-4 years received ≥1 dose; 4.5% of children aged 6-23 months and 5.4% of children aged 2-4 years completed the vaccination series. Among children aged 6 months-4 years, ≥1-dose COVID-19 vaccination coverage was lower in rural counties (3.4%) than in urban counties (10.5%). Among children aged 6 months-4 years who received at least the first dose, only 7.0% were non-Hispanic Black or African American (Black), and 19.9% were Hispanic or Latino (Hispanic), although these demographic groups constitute 13.9% and 25.9% of the population, respectively (4). COVID-19 vaccination coverage among children aged 6 months-4 years is substantially lower than that among older children (5). Efforts are needed to improve vaccination coverage among children aged 6 months-4 years to reduce COVID-19-associated morbidity and mortality.

Trends in US State Public Health Emergency Laws, 2021-2022.

Objectives. To identify and categorize US state legislation introduced between January 1, 2021, and May 20, 2022, that addresses emergency health authority. Methods. We adapted standard policy surveillance methods to collect and code state bills and enacted laws limiting or expanding the emergency public health authority of state and local officials and agencies. Results. State legislators introduced 1531 bills addressing public health authority; 191 of those were enacted in 43 states and the District of Columbia, including 17 expanding and 65 contracting emergency authority, 163 regulating use, and 30 preempting local use of specific measures such as mask mandates. Conclusions. State laws setting the scope and limits of emergency authority are crucial to effective public health response. These laws are changing in ways that threaten to reduce response capacity. Tracking changes in health law infrastructure is important for evaluating changes in health authority and ensuring that stakeholders recognize these changes. Public Health Implications. The COVID-19 pandemic called for quick, decisive action to limit infections, and when the next outbreak hits, new laws limiting health authority will make such action even more difficult. (Am J Public Health. 2023;113(3):288-296. https://doi.org/10.2105/10.2105/AJPH.2022.307214).

An exploratory study of COVID-19-related changes in abortion service availability and use in Washington, DC, Maryland, and Virginia.

OBJECTIVES: This exploratory study aimed to assess COVID-19-related changes in abortion service availability and use in Washington, DC, Maryland, and Virginia. DESIGN: Data came from a convenience sample of eight abortion clinics in this region. We implemented a cross-sectional survey and collected retrospective aggregate monthly abortion data overall and by facility type, abortion type, and patient characteristics for March 2019-August 2020. We evaluated changes in the distribution of the total number of patients for March-August in 2019 compared to March-August 2020. We also conducted segmented regression analyses and produced scatter plots of monthly abortion patients overall and by facility type, abortion type, and patient characteristics, with separate fitted regression lines from the segmented regression models for the pre- and during-COVID-19 periods. RESULTS: Five clinics reported a reduced number of appointments early in the pandemic while four reported increased call volume. There were declines in the monthly abortion trend at hospital-based clinics at the outset of the pandemic. Monthly number of medication abortions increased from March 2020 through August 2020 compared to pre-COVID-19 trends while instrumentation abortions 11 up to 19 weeks decreased. The share of abortions to Black individuals increased during the early phase of the pandemic, as did the monthly trend in abortions among this group. We also saw changes in payment type, with declines in patients paying out-of-pocket. CONCLUSIONS: Results revealed differences in abortion services, numbers, and types during the early stages of the COVID-19 pandemic in Washington, DC, Maryland, and Virginia.

Vaccination Coverage with Selected Vaccines and Exemption Rates Among Children in Kindergarten - United States, 2021-22 School Year.

State and local school vaccination requirements protect students and communities against vaccine-preventable diseases (1). This report summarizes data collected by state and local immunization programs* on vaccination coverage and exemptions to vaccination among children in kindergarten in 49 states† and the District of Columbia and provisional enrollment or grace period status for kindergartners in 27 states§ for the 2021-22 school year. Nationwide, vaccination coverage with 2 doses of measles, mumps and rubella vaccine (MMR) was 93.5%¶; with the state-required number of diphtheria, tetanus, and acellular pertussis vaccine (DTaP) doses was 93.1%**; with poliovirus vaccine (polio) was 93.5%††; and with the state-required number of varicella vaccine doses was 92.8%.§§ Compared with the 2020-21 school year, vaccination coverage decreased 0.4-0.9 percentage points for all vaccines. Although 2.6% of kindergartners had an exemption for at least one vaccine,¶¶ an additional 3.9% who did not have an exemption were not up to date with MMR. Although there has been a nearly complete return to in-person learning after COVID-19 pandemic-associated disruptions, immunization programs continued to report COVID-19-related impacts on vaccination assessment and coverage. Follow-up with undervaccinated students and catch-up campaigns remain important for increasing vaccination coverage to prepandemic levels to protect children and communities from vaccine-preventable diseases.

Reporting and Availability of COVID-19 Demographic Data by US Health Departments (April to October 2020): Observational Study.

BACKGROUND: There is an urgent need for consistent collection of demographic data on COVID-19 morbidity and mortality and sharing it with the public in open and accessible ways. Due to the lack of consistency in data reporting during the initial spread of COVID-19, the Equitable Data Collection and Disclosure on COVID-19 Act was introduced into the Congress that mandates collection and reporting of demographic COVID-19 data on testing, treatments, and deaths by age, sex, race and ethnicity, primary language, socioeconomic status, disability, and county. To our knowledge, no studies have evaluated how COVID-19 demographic data have been collected before and after the introduction of this legislation. OBJECTIVE: This study aimed to evaluate differences in reporting and public availability of COVID-19 demographic data by US state health departments and Washington, District of Columbia (DC) before (pre-Act), immediately after (post-Act), and 6 months after (6-month follow-up) the introduction of the Equitable Data Collection and Disclosure on COVID-19 Act in the Congress on April 21, 2020. METHODS: We reviewed health department websites of all 50 US states and Washington, DC (N=51). We evaluated how each state reported age, sex, and race and ethnicity data for all confirmed COVID-19 cases and deaths and how they made this data available (ie, charts and tables only or combined with dashboards and machine-actionable downloadable formats) at the three timepoints. RESULTS: We found statistically significant increases in the number of health departments reporting age-specific data for COVID-19 cases (P=.045) and resulting deaths (P=.002), sex-specific data for COVID-19 deaths (P=.003), and race- and ethnicity-specific data for confirmed cases (P=.003) and deaths (P=.005) post-Act and at the 6-month follow-up (P<.05 for all). The largest increases were race and ethnicity state data for confirmed cases (pre-Act: 18/51, 35%; post-Act: 31/51, 61%; 6-month follow-up: 46/51, 90%) and deaths due to COVID-19 (pre-Act: 13/51, 25%; post-Act: 25/51, 49%; and 6-month follow-up: 39/51, 76%). Although more health departments reported race and ethnicity data based on federal requirements (P<.001), over half (29/51, 56.9%) still did not report all racial and ethnic groups as per the Office of Management and Budget guidelines (pre-Act: 5/51, 10%; post-Act: 21/51, 41%; and 6-month follow-up: 27/51, 53%). The number of health departments that made COVID-19 data available for download significantly increased from 7 to 23 (P<.001) from our initial data collection (April 2020) to the 6-month follow-up, (October 2020). CONCLUSIONS: Although the increased demand for disaggregation has improved public reporting of demographics across health departments, an urgent need persists for the introduced legislation to be passed by the Congress for the US states to consistently collect and make characteristics of COVID-19 cases, deaths, and vaccinations available in order to allocate resources to mitigate disease spread.

A school of public health responds to the pandemic: A case study from Washington D.C.

The emergence of COVID-19 immediately affected higher education, and the closure of campuses at the start of the pandemic in March of 2020 forced educational institutions to quickly adapt to changing circumstances. Schools of public health faced challenges not only of shifting to remote learning and work environments, but also uniquely redirecting public health research and service efforts toward COVID-19. This paper offers a case study of how the Milken Institute School of Public Health at the George Washington University (GWSPH), the only school of public health in the nation's capital, initially adapted to the COVID-19 pandemic. Using a modified version of the Public Health Preparedness and Response Core Competency Model created by the Association of Schools and Programs of Public Health and the Centers for Disease Control and Prevention, we analyze how GWSPH worked in three areas-research, education, service/operations. We reviewed this initial response across four domains: model leadership; communication and management of information; planning and improving practice; and protecting worker (and student) health and safety. The adaptation of the model and the analysis of GWSPH's initial response to the pandemic can be useful to other schools of public health and health sciences in the United States and beyond, in preparing for all hazards. We hope that such analysis also informs the current concerns of schools such as return to in-person education as well as planning for future public health crises.

Association Between State-Issued COVID-19 Vaccine Mandates and Vaccine Administration Rates in 12 US States and the District of Columbia.

Importance: Some US states have issued COVID-19 vaccine mandates; however, the association of these mandates with vaccination rates remains unknown. Objective: To examine the association between announcing state-issued COVID-19 vaccine mandates that did not provide a test-out option for workers and the vaccine administration rates in terms of state-level first-dose vaccine administration and series completion coverage. Design, Setting, and Participants: This cross-sectional study used publicly available, state-level aggregated panel data to fit linear regression models with 2-way fixed effects (state and time) estimating vaccine coverage changes 8 weeks before and 8 weeks after a state-issued COVID-19 vaccine mandate was announced. Mandates were announced on or after July 26, 2021, and were included only if they went into effect before December 31, 2021. Data were included from 13 state-level jurisdictions with a vaccine mandate in effect as of December 31, 2021, that did not allow recurring testing in lieu of vaccination (mandate group), and 14 state-level jurisdictions that allowed a test-out option and/or did not restrict vaccine requirements (comparison group). Interventions/Exposures: The event of interest was the announcement of a state-issued COVID-19 vaccine mandate applicable to specific groups of workers. Main Outcomes and Measures: The outcome measures were state-level daily COVID-19 vaccine first-dose administration and series completion coverage, reported as mean percentage point changes. Results: Of 5 508 539 first-dose administrations in the 8-week postannouncement period, an estimated 634 831 (11.5%) were associated with the mandate announcement. First-dose administration coverage among 13 jurisdictions increased starting at 3 weeks after the mandate announcement, with statistically significant differences of 0.20, 0.33, 0.39, 0.45, 0.49, and 0.59 percentage points higher than the referent category coverage of 62.9%. Increases in vaccine series completion coverage were observed from 5 to 8 weeks after the announcement, but statistically significant differences from the referent category coverage of 56.3% were observed only during weeks 7 and 8 after the announcement (both differed by 0.2 percentage points; P = .05 and P = .02, respectively). Conclusions and Relevance: The findings of this cross-sectional event study suggest that the announcement of state-issued vaccine mandates may be associated with short-term increases in vaccine uptake. This observed association may be a product of both a direct outcome experienced by groups governed by the mandate as well as the spillover outcome due to a government signaling the importance of vaccination to the general population of the state.

Utility of a Test-to-Return Strategy to Identify Individuals With Coronavirus Disease 2019 (COVID-19) in the Prekindergarten Through Grade 12 School Setting-District of Columbia, January 2022.

The highly transmissible severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) Omicron variant led to increased hospitalizations, staffing shortages, and increased school closures. To reduce spread in school-aged children during the Omicron peak, the District of Columbia implemented a test-to-return strategy in public and public charter schools after a 2-week break from in-person learning.

Digital Tools Adopted by Public Health Agencies to Support COVID-19 Case Investigation and Contact Tracing, United States, 2020-2021.

During the COVID-19 pandemic, public health agencies implemented an array of technologies and digital tools to support case investigation and contact tracing. Beginning in May 2020, the Association of State and Territorial Health Officials compiled information on digital tools used by its membership, which comprises 59 chief health officials from each of the 50 states, 5 US territories, 3 freely associated states, and the District of Columbia. This information was presented online through a publicly available technology and digital tools inventory. We describe the national landscape of digital tools implemented by public health agencies to support functions of the COVID-19 response from May 2020 through May 2021. We also discuss how public health officials and their informatics leadership referenced the information about the digital tools implemented by their peers to guide and refine their own implementation plans. We used a consensus-based approach through monthly discussions with partners to group digital tools into 5 categories: surveillance systems, case investigation, proximity technology/exposure notification, contact tracing, and symptom tracking/monitoring. The most commonly used tools included the National Electronic Disease Surveillance System Base System (NBS), Sara Alert, REDCap, and Maven. Some tools such as NBS, Sara Alert, REDCap, Salesforce, and Microsoft Dynamics were repurposed or adapted for >1 category. Having access to the publicly available technology and digital tools inventory provided public health officials and their informatics leadership with information on what tools other public health agencies were using and aided in decision making as they considered repurposing existing tools or adopting new ones.

The Impact of Housing Insecurity on Access to Care and Services among People Who Use Drugs in Washington, DC.

People who use drugs are highly marginalized communities and are disproportionately affected by environmental changes-e.g., neighborhood gentrification-that affect housing availability and stability, particularly in urban locations. These changes could negatively affect individuals' access to and utilization of health care and social services, resulting in poorer health outcomes. This study examined the impact of gentrification and housing instability on drug users' access to harm reduction and other health services. Data were collected from 139 clients of a large harm reduction organization. Results showed that 67% of the participants were either unstably housed or homeless, and about one-third of participants indicated that their current housing situations negatively affected their access to primary care (33.9%), behavioral health services (36.7%) and basic services (38.3%). While homeless individuals were still able to access services generally, a greater percentage-compared to those unstably or stably housed-reported difficulty accessing care. As these data were collected prior to the COVID pandemic, it is likely that many of our participants faced greater struggles with housing insecurity and health care access issues due to shutdowns and increased need for social isolation and quarantine. More work is needed to address housing instability and homelessness among already marginalized populations.

Food Security Challenges and Resilience during the COVID-19 Pandemic: Corner Store Communities in Washington, D.C.

The COVID-19 pandemic exacerbates the complexities of food inequity. As one of the social determinants of health, food insecurity significantly impacts overall health across the life course. Guided by the Getting to Equity Framework, this qualitative community-engaged participatory project examines the impact of the pandemic on food security among adults in Washington, DC. Semi-structured interviews (n = 79) were conducted by trained community health workers between November 2020 and December 2021 at corner stores. Data analysis was performed using thematic network analysis in NVivo. Results are grouped into four key themes: (1) impact of the pandemic on food access, including expanded services and innovative solutions to meet needs; (2) coping and asset-based strategies at the individual and community level; (3) sources of information and support, and (4) impact of the pandemic on health and well-being. The importance of lived experience research in public health is increasingly recognized as an innovative approach that offers benefits through community engagement and empowerment.

COVID-19 impacts on abortion care-seeking experiences in the Washington, DC, Maryland, and Virginia regions of the United States.

CONTEXT: Many people wanted to avoid or delay childbearing during the COVID-19 pandemic. This study sought to examine the extent COVID-19 influenced abortion care-seeking in a region that did not enact policy restricting abortion due to the pandemic, has high service availability, and few abortion-restrictive policies. METHODOLOGY: We conducted telephone surveys with adults (n=72) requesting abortion appointments between September 2020 and March 2021 at five clinics in Washington, DC, Maryland, and Virginia. We used χ2 tests to compare sociodemographic, reproductive history, service delivery characteristics, and pandemic-related life changes by whether COVID-19 influenced abortion care-seeking. RESULTS: Most respondents (93%) had an abortion at the time of the survey, 4% were awaiting their scheduled appointment, and 3% did not have an appointment scheduled. Nearly 40% of people reported COVID-19 influenced their decision to have an abortion. These individuals were significantly more likely to report "not financially prepared" (44% vs. 16%) as a reason for termination compared to people reporting no influence of COVID-19. They were also more likely to have lost or changed their health insurance due to pandemic-related employment changes (15% vs. 2%), report substantial money difficulties due to COVID-19 (59% vs. 33%), and report that paying for their abortion was "very difficult" (25% vs. 2%). CONCLUSION: COVID-19 influenced many people to have an abortion, particularly those financially disadvantaged by the pandemic. Expansion of Medicaid abortion coverage in Washington, DC and Virginia could reduce financial barriers to care and help people to better meet their reproductive needs amid future crises.