Population Segmentation for COVID-19 Vaccine Outreach: A Clustering Analysis and Implementation in Missouri.

OBJECTIVES: The purpose of this work was to segment the Missouri population into unique groups related to COVID-19 vaccine acceptance using data science and behavioral science methods to develop tailored vaccine outreach strategies. METHODS: Cluster analysis techniques were applied to a large data set that aggregated vaccination data with behavioral and demographic data from the American Community Survey and Deloitte's HealthPrism™ data set. Outreach recommendations were developed for each cluster, specific to each group's practical and motivational barriers to vaccination. RESULTS: Following selection procedures, 10 clusters-or segments-of census tracts across Missouri were identified on the basis of k -means clustering analysis of 18 different variables. Each cluster exhibited unique geographic, demographic, socioeconomic, and behavioral patterns, and outreach strategies were developed on the basis of each cluster's practical and motivational barriers. DISCUSSION: The segmentation analysis served as the foundation for "working groups" comprising the 115 local public health agencies (LPHAs) across the state. LPHAs with similar community segments in their service area were grouped together to discuss their communities' specific challenges, share lessons learned, and brainstorm new approaches. The working groups provided a novel way for public health to organize and collaborate across the state. Widening the aperture beyond Missouri, population segmentation via cluster analysis is a promising approach for public health practitioners interested in developing a richer understanding of the types of populations they serve. By pairing segmentation with behavioral science, practitioners can develop outreach programs and communications campaigns that are personalized to the specific behavioral barriers and needs of the population in focus. While our work focused on COVID-19, this approach has broad applicability to enhance the way public health practitioners understand the populations they serve to deliver more tailored services.

The Effects of COVID-19 Pandemic Policy on Social Needs Across the State of Kansas and Western Missouri: Paired Survey Response Testing.

BACKGROUND: Studying patients' social needs is critical to the understanding of health conditions and disparities, and to inform strategies for improving health outcomes. Studies have shown that people of color, low-income families, and those with lower educational attainment experience greater hardships related to social needs. The COVID-19 pandemic represents an event that severely impacted people's social needs. This pandemic was declared by the World Health Organization on March 11, 2020, and contributed to food and housing insecurity, while highlighting weaknesses in the health care system surrounding access to care. To combat these issues, legislators implemented unique policies and procedures to help alleviate worsening social needs throughout the pandemic, which had not previously been exerted to this degree. We believe that improvements related to COVID-19 legislature and policy have positively impacted people's social needs in Kansas and Missouri, United States. In particular, Wyandotte County is of interest as it suffers greatly from issues related to social needs that many of these COVID-19-related policies aimed to improve. OBJECTIVE: The research objective of this study was to evaluate the change in social needs before and after the COVID-19 pandemic declaration based on responses to a survey from The University of Kansas Health System (TUKHS). We further aimed to compare the social needs of respondents from Wyandotte County from those of respondents in other counties in the Kansas City metropolitan area. METHODS: Social needs survey data from 2016 to 2022 were collected from a 12-question patient-administered survey distributed by TUKHS during a patient visit. This provided a longitudinal data set with 248,582 observations, which was narrowed down into a paired-response data set for 50,441 individuals who had provided at least one response before and after March 11, 2020. These data were then bucketed by county into Cass (Missouri), Clay (Missouri), Jackson (Missouri), Johnson (Kansas), Leavenworth (Kansas), Platte (Missouri), Wyandotte (Kansas), and Other counties, creating groupings with at least 1000 responses in each category. A pre-post composite score was calculated for each individual by adding their coded responses (yes=1, no=0) across the 12 questions. The Stuart-Maxwell marginal homogeneity test was used to compare the pre and post composite scores across all counties. Additionally, McNemar tests were performed to compare responses before and after March 11, 2020, for each of the 12 questions across all counties. Finally, McNemar tests were performed for questions 1, 7, 8, 9, and 10 for each of the bucketed counties. Significance was assessed at P<.05 for all tests. RESULTS: The Stuart-Maxwell test for marginal homogeneity was significant (P<.001), indicating that respondents were overall less likely to identify an unmet social need after the COVID-19 pandemic. McNemar tests for individual questions indicated that after the COVID-19 pandemic, respondents across all counties were less likely to identify unmet social needs related to food availability (odds ratio [OR]=0.4073, P<.001), home utilities (OR=0.4538, P<.001), housing (OR=0.7143, P<.001), safety among cohabitants (OR=0.6148, P<.001), safety in their residential location (OR=0.6172, P<.001), child care (OR=0.7410, P<0.01), health care access (OR=0.3895, P<.001), medication adherence (OR=0.5449, P<.001), health care adherence (OR=0.6378, P<.001), and health care literacy (0.8729, P=.02), and were also less likely to request help with these unmet needs (OR=0.7368, P<.001) compared with prepandemic responses. Responses from individual counties were consistent with the overall results for the most part. Notably, no individual county demonstrated a significant reduction in social needs relating to a lack of companionship. CONCLUSIONS: Post-COVID-19 responses showed improvement across almost all social needs-related questions, indicating that the federal policy response possibly had a positive impact on social needs across the populations of Kansas and western Missouri. Some counties were impacted more than others and positive outcomes were not limited to urban counties. The availability of resources, safety net services, access to health care, and educational opportunities could play a role in this change. Future research should focus on improving survey response rates from rural counties to increase their sample size, and to evaluate other explanatory variables such as food pantry access, educational status, employment opportunities, and access to community resources. Government policies should be an area of focused research as they may affect the social needs and health of the individuals considered in this analysis.

Adherence to and experiences of K-12 students in modified and standard home quarantine during the SARS-CoV-2 pandemic in Missouri.

BACKGROUND: In November 2020, during the SARS-CoV-2 pandemic, Missouri allowed local public health jurisdictions the option to implement a modified quarantine policy allowing kindergarten through 12 (K-12) students with low-risk exposures to continue in-person learning. We assessed adherence to quarantine among participants in modified quarantine and standard home quarantine and the psychosocial impacts of quarantine on students and families. METHODS: In January-March 2021, as part of an investigation of in-school transmission of SARS-CoV-2, parents of 586 participating K-12 students identified as a close contact with a person with SARS-CoV-2 were sent a survey to assess their activities and psychosocial impacts to the child and family. RESULTS: Among the 227 (39%) survey respondents, 26 (11%) participated in modified quarantine and 201 (89%) participated in standard home quarantine. Forty-six percent of students in modified quarantine and 72% of students in standard home quarantine reported abstaining from non-school activities during quarantine. Parents of 17 (65%) students in modified quarantine and 80 (40%) in standard home quarantine reported low or neutral levels of stress in their children. Parents of students in standard home quarantine described greater stress, negative impacts to family functioning, and interruptions to educational opportunities for students. CONCLUSIONS: Students in modified quarantine reported lower adherence to quarantine recommendations but lower daily impact and stressors than those in standard home quarantine. Because in-school transmission of SARS-CoV-2 has been shown to be low when layered prevention strategies are in place regardless of the use of modified or standard home quarantine, this modified quarantine approach provides a reasonable option for balancing the needs of students and families with SARS-CoV-2 prevention measures.

Emergency Medicine Telehealth: A Pandemic Becomes a Gateway for Virtual Care in Missouri.

Telehealth provides a novel bridge between patient needs and available resources. On-demand telehealth visits provide urgent medical services in a virtual setting. Telehealth can be used to provide care for patients despite geographical distance. Emergency Medicine quickly adapted in response to the COVID-19 pandemic through utilization of telehealth to solve various problems. Tele-triage was used to coordinate COVID-19 testing and treatment. Greater utilization of all current and emerging telehealth modalities could increase access and quality of care for all Missourians.

Quantifying inequities in COVID-19 vaccine distribution over time by social vulnerability, race and ethnicity, and location: A population-level analysis in St. Louis and Kansas City, Missouri.

BACKGROUND: Equity in vaccination coverage is a cornerstone for a successful public health response to COVID-19. To deepen understanding of the extent to which vaccination coverage compares with initial strategies for equitable vaccination, we explore primary vaccine series and booster rollout over time and by race/ethnicity, social vulnerability, and geography. METHODS AND FINDINGS: We analyzed data from the Missouri Department of Health and Senior Services on all COVID-19 vaccinations administered across 7 counties in the St. Louis region and 4 counties in the Kansas City region. We compared rates of receiving the primary COVID-19 vaccine series and boosters relative to time, race/ethnicity, zip-code-level Social Vulnerability Index (SVI), vaccine location type, and COVID-19 disease burden. We adapted a well-established tool for measuring inequity-the Lorenz curve-to quantify inequities in COVID-19 vaccination relative to these key metrics. Between 15 December 2020 and 15 February 2022, 1,763,036 individuals completed the primary series and 872,324 received a booster. During early phases of the primary series rollout, Black and Hispanic individuals from high SVI zip codes were vaccinated at less than half the rate of White individuals from low SVI zip codes, but rates increased over time until they were higher than rates in White individuals after June 2021; Asian individuals maintained high levels of vaccination throughout. Increasing vaccination rates in Black and Hispanic communities corresponded with periods when more vaccinations were offered at small community-based sites such as pharmacies rather than larger health systems and mass vaccination sites. Using Lorenz curves, zip codes in the quartile with the lowest rates of primary series completion accounted for 19.3%, 18.1%, 10.8%, and 8.8% of vaccinations while representing 25% of the total population, cases, deaths, or population-level SVI, respectively. When tracking Gini coefficients, these disparities were greatest earlier during rollout, but improvements were slow and modest and vaccine disparities remained across all metrics even after 1 year. Patterns of disparities for boosters were similar but often of much greater magnitude during rollout in fall 2021. Study limitations include inherent limitations in the vaccine registry dataset such as missing and misclassified race/ethnicity and zip code variables and potential changes in zip code population sizes since census enumeration. CONCLUSIONS: Inequities in the initial COVID-19 vaccination and booster rollout in 2 large US metropolitan areas were apparent across racial/ethnic communities, across levels of social vulnerability, over time, and across types of vaccination administration sites. Disparities in receipt of the primary vaccine series attenuated over time during a period in which sites of vaccination administration diversified, but were recapitulated during booster rollout. These findings highlight how public health strategies from the outset must directly target these deeply embedded structural and systemic determinants of disparities and track equity metrics over time to avoid perpetuating inequities in healthcare access.

SARS-CoV-2 and influenza co-infection: A cross-sectional study in central Missouri during the 2021-2022 influenza season.

As SARS-CoV-2 and influenza viruses co-circulate, co-infections with these viruses generate an increasing concern to public health. To evaluate the prevalence and clinical impacts of SARS-CoV-2 and influenza A virus co-infections during the 2021-2022 influenza season, SARS-CoV-2-positive samples from 462 individuals were collected from October 2021 to January 2022. Of these individuals, 152 tested positive for influenza, and the monthly co-infection rate ranged from 7.1% to 48%. Compared to the Delta variant, individuals infected with Omicron were less likely to be co-infected and hospitalized, and individuals who received influenza vaccines were less likely to become co-infected. Three individuals had two samples collected on different dates, and all three developed a co-infection after their initial SARS-CoV-2 infection. This study demonstrates high prevalence of co-infections in central Missouri during the 2021-2022 influenza season, differences in co-infection prevalence between the Delta and the Omicron waves, and the importance of influenza vaccinations against co-infections.

Geographic disparities and determinants of COVID-19 incidence risk in the greater St. Louis Area, Missouri (United States).

BACKGROUND: Evidence seems to suggest that the risk of Coronavirus Disease 2019 (COVID-19) might vary across communities due to differences in population characteristics and movement patterns. However, little is known about these differences in the greater St Louis Area of Missouri and yet this information is useful for targeting control efforts. Therefore, the objectives of this study were to investigate (a) geographic disparities of COVID-19 risk and (b) associations between COVID-19 risk and socioeconomic, demographic, movement and chronic disease factors in the Greater St. Louis Area of Missouri, USA. METHODS: Data on COVID-19 incidence and chronic disease hospitalizations were obtained from the Department of Health and Missouri Hospital Association, respectively. Socioeconomic and demographic data were obtained from the 2018 American Community Survey while population mobility data were obtained from the SafeGraph website. Choropleth maps were used to identify geographic disparities of COVID-19 risk and several sociodemographic and chronic disease factors at the ZIP Code Tabulation Area (ZCTA) spatial scale. Global negative binomial and local geographically weighted negative binomial models were used to investigate associations between ZCTA-level COVID-19 risk and socioeconomic, demographic and chronic disease factors. RESULTS: There were geographic disparities found in COVID-19 risk. Risks tended to be higher in ZCTAs with high percentages of the population with a bachelor's degree (p<0.0001) and obesity hospitalizations (p<0.0001). Conversely, risks tended to be lower in ZCTAs with high percentages of the population working in agriculture (p<0.0001). However, the association between agricultural occupation and COVID-19 risk was modified by per capita between ZCTA visits. Areas that had both high per capita between ZCTA visits and high percentages of the population employed in agriculture had high COVID-19 risks. The strength of association between agricultural occupation and COVID-19 risk varied by geographic location. CONCLUSIONS: Geographic disparities of COVID-19 risk exist in the St. Louis area and are associated with sociodemographic factors, population movements, and obesity hospitalization risks. The latter is particularly concerning due to the growing prevalence of obesity and the known immunological impairments among obese individuals. Therefore, future studies need to focus on improving our understanding of the relationships between COVID-19 vaccination efficacy, obesity and waning of immunity among obese individuals so as to better guide vaccination regimens and reduce disparities.

An Examination of SARS-CoV-2 Transmission Based on Classroom Distancing in Schools With Other Preventive Measures in Place-Missouri, January-March 2021.

OBJECTIVES: Classroom layout plays a central role in maintaining physical distancing as part of a multicomponent prevention strategy for safe in-person learning during the COVID-19 pandemic. We conducted a school investigation to assess layouts and physical distancing in classroom settings with and without in-school SARS-CoV-2 transmission. METHODS: We assessed, measured, and mapped 90 K-12 (kindergarten through grade 12) classrooms in 3 Missouri public school districts during January-March 2021, prior to widespread prevalence of the Delta variant; distances between students, teachers, and people with COVID-19 and their contacts were analyzed. We used whole-genome sequencing to further evaluate potential transmission events. RESULTS: The investigation evaluated the classrooms of 34 students and staff members who were potentially infectious with COVID-19 in a classroom. Of 42 close contacts (15 tested) who sat within 3 ft of possibly infectious people, 1 (2%) probable transmission event occurred (from a symptomatic student with a longer exposure period [5 days]); of 122 contacts (23 tested) who sat more than 3 ft away from possibly infectious people with shorter exposure periods, no transmission events occurred. CONCLUSIONS: Reduced student physical distancing is one component of mitigation strategies that can allow for increased classroom capacity and support in-person learning. In the pre-Delta variant period, limited physical distancing (<6 ft) among students in K-12 schools was not associated with increased SARS-CoV-2 transmission.

Detection of Bourbon Virus-Specific Serum Neutralizing Antibodies in Human Serum in Missouri, USA.

Bourbon virus (BRBV) was first discovered in 2014 in a fatal human case. Since then it has been detected in the tick Amblyomma americanum in the states of Missouri and Kansas in the United States. Despite the high prevalence of BRBV in ticks in these states, very few human cases have been reported, and the true infection burden of BRBV in the community is unknown. Here, we developed two virus neutralization assays, a vesicular stomatitis virus (VSV)-BRBV pseudotyped rapid assay and a BRBV focus reduction neutralization assay, to assess the seroprevalence of BRBV neutralizing antibodies in human sera collected in 2020 in St. Louis, MO. Of 440 human serum samples tested, three (0.7%) were able to potently neutralize both VSV-BRBV and wild-type BRBV. These findings suggest that human infections with BRBV are more common than previously recognized. IMPORTANCE Since the discovery of the Bourbon virus (BRBV) in 2014, a total of five human cases have been identified, including two fatal cases. BRBV is thought to be transmitted by the lone star tick, which is prevalent in the eastern, southeastern, and midwestern United States. BRBV has been detected in ticks in Missouri and Kansas, and serological evidence suggests that it is also present in North Carolina. However, the true infection burden of BRBV in humans is not known. In the present study, we developed two virus neutralization assays to assess the seroprevalence of BRBV-specific antibodies in human sera collected in 2020 in St. Louis, MO. We found that a small subset of individuals are seropositive for neutralizing antibodies against BRBV. Our data suggest that BRBV infection in humans is more common than previously thought.

PrEP patient attitudes, beliefs and perceived barriers surrounding HPV vaccination: a qualitative study of semistructured interviews with PrEP patients in primary care clinics in Kansas and Missouri.

OBJECTIVES: Men who have sex with men who use pre-exposure prophylaxis (PrEP) have not traditionally been targets for human papillomavirus (HPV) vaccine programmes, despite their high risk for HPV-related cancers and HPV vaccine being approved by the U.S. Food and Drug Administration (FDA) for people up to age 45. The objective of this study was to assess attitudes and barriers towards HPV vaccine for adult PrEP users in the primary care context. METHODS: Semistructured phone interviews of 16 primary care patients taking PrEP in the Kansas City metropolitan area were conducted, with interviews assessing HPV vaccination status, and attitudes, beliefs and perceived barriers surrounding HPV vaccine. Interview notes were open-coded by student authors, and themes were generated through code review and consensus. Data were then analysed using thematic analysis. RESULTS: The results showed that most patients believed that preventative health was important and felt the HPV vaccine was important. Most patients were open to vaccination if recommended by their primary care physician and covered by insurance. Most participants believed HPV infection to be far worse in women, and there were gaps in knowledge surrounding HPV and its effects in men. CONCLUSIONS: While more research is needed to better understand facilitators of a linkage between PrEP and HPV vaccine in clinical settings for groups at high risk for HPV-related cancers, getting primary care providers involved in educating high-risk patients about the importance of HPV vaccination and actively recommending the vaccine to those patients has the potential to prevent HPV-related cancers.

Impact of the COVID-19 Pandemic on Patients Without COVID-19 With Acute Myocardial Infarction and Heart Failure.

Background Excess mortality from cardiovascular disease during the COVID-19 pandemic has been reported. The mechanism is unclear but may include delay or deferral of care, or differential treatment during hospitalization because of strains on hospital capacity. Methods and Results We used emergency department and inpatient data from a 12-hospital health system to examine changes in volume, patient age and comorbidities, treatment (right- and left-heart catheterization), and outcomes for patients with acute myocardial infarction (AMI) and heart failure (HF) during the COVID-19 pandemic compared with pre-COVID-19 (2018 and 2019), controlling for seasonal variation. We analyzed 27 427 emergency department visits or hospitalizations. Patient volume decreased during COVID-19 for both HF and AMI, but age, race, sex, and medical comorbidities were similar before and during COVID-19 for both groups. Acuity increased for AMI as measured by the proportion of patients with ST-segment elevation. There were no differences in right-heart catheterization for patients with HF or in left heart catheterization for patients with AMI. In-hospital mortality increased for AMI during COVID-19 (odds ratio [OR], 1.46; 95% CI, 1.21-1.76), particularly among the ST-segment-elevation myocardial infarction subgroup (OR, 2.57; 95% CI, 2.24-2.96), but was unchanged for HF (OR, 1.02; 95% CI, 0.89-1.16). Conclusions Cardiovascular volume decreased during COVID-19. Despite similar patient age and comorbidities and in-hospital treatments during COVID-19, mortality increased for patients with AMI but not patients with HF. Given that AMI is a time-sensitive condition, delay or deferral of care rather than changes in hospital care delivery may have led to worse cardiovascular outcomes during COVID-19.

Geographic disparities and predictors of COVID-19 hospitalization risks in the St. Louis Area, Missouri (USA).

BACKGROUND: There is evidence of geographic disparities in COVID-19 hospitalization risks that, if identified, could guide control efforts. Therefore, the objective of this study was to investigate Zip Code Tabulation Area (ZCTA)-level geographic disparities and identify predictors of COVID-19 hospitalization risks in the St. Louis area. METHODS: Hospitalization data for COVID-19 and several chronic diseases were obtained from the Missouri Hospital Association. ZCTA-level data on socioeconomic and demographic factors were obtained from the American Community Survey. Geographic disparities in distribution of COVID-19 age-adjusted hospitalization risks, socioeconomic and demographic factors as well as chronic disease risks were investigated using choropleth maps. Predictors of ZCTA-level COVID-19 hospitalization risks were investigated using global negative binomial and local geographically weighted negative binomial models. RESULTS: COVID-19 hospitalization risks were significantly higher in ZCTAs with high diabetes hospitalization risks (p < 0.0001), COVID-19 risks (p < 0.0001), black population (p = 0.0416), and populations with some college education (p = 0.0005). The associations between COVID-19 hospitalization risks and the first three predictors varied by geographic location. CONCLUSIONS: There is evidence of geographic disparities in COVID-19 hospitalization risks that are driven by differences in socioeconomic, demographic and health-related factors. The impacts of these factors vary by geographical location implying that a 'one-size-fits-all' approach may not be appropriate for management and control. Using both global and local models leads to a better understanding of geographic disparities. These findings are useful for informing health planning to identify geographic areas likely to have high numbers of individuals needing hospitalization as well as guiding vaccination efforts.

Suicide Risk in Adolescents During the COVID-19 Pandemic.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic created high levels of psychological distress and may have increased suicide risk. METHODS: We used the 4-item Ask Suicide-Screening Questions (ASQ) to assess suicide risk among all patients 12 to 24 years of age at a children's hospital. We compared demographics, encounter type (telehealth or face-to-face [F2F]), and screening results from April to June 2020 (T2) to those from April to June 2019 (T1). RESULTS: Fewer patients were seen at T2 than T1 (17 986 vs 24 863). A greater proportion of visits at T2 were by telehealth (0% vs 43%). The rate of positive suicide screens was higher in T2 than in T1 (12.2% vs 11.1%, adjusted odds ration [aOR], 1.24; 95% confidence interval [CI], 1.15-1.35). The odds of a positive screen were greater for older patients (aOR of 1.12 for age in years; 95% CI, 1.10-1.14), female patients (aOR, 2.23; 95% CI, 2.00-2.48), patients with public versus private insurance (aOR, 1.88; 95% CI, 1.72-2.07), and lower for Black versus White patients (aOR, 0.85; 95% CI, 0.77-0.95). Rates of positive screens were highest among inpatients (20.0%), intermediate for emergency department patients (14.4%), and lowest in outpatient clinics (9.9%) (P < .05). CONCLUSIONS: Rates of positive suicide risk screens among adolescents rose in the pandemic's early months with differences related to sociodemographics and visit type. Changes in health care delivery highlight the complexities of assessing and responding to mental health needs of adolescents. Additional research might determine the effects of screening methods and patient populations on screening results.

Over-the-Counter Medication Prescribing in a Pediatric Emergency Department: Health Records Review.

OBJECTIVE: The purpose of this project was to describe patterns in over-the-counter medication prescribing for nonacute patients with Medicaid in a pediatric emergency department. Differences were also tested in visit time and charges between patients with and without over-the-counter medication prescriptions. METHODS: Retrospective chart review of children with Missouri Medicaid presenting to a single site between January 1, 2018 and December 31, 2018 was conducted. Low-acuity patients with common diagnoses were included. Over-the-counter medications prescribed, the cost of prescriptions, the time spent in the emergency department, provider care time, patient age, and the month of visit were extracted. Data were analyzed with descriptive statistics and t tests. RESULTS: Approximately 37% of children were prescribed over-the-counter medications, most commonly antipyretics. When comparing visits in which an over-the-counter medication was prescribed to visits without an over-the-counter medication prescription, we found no significant difference in the associated charges, total time in the department, and provider care time. CONCLUSION: Over-the-counter medications were prescribed for more than one-third of children cared for in the pediatric emergency department for low-acuity presentations. These visits may represent a substantial area for Medicaid access barriers, system redesign, and cost savings.