Food Insecurity During the First Year of COVID-19: Employment and Sociodemographic Factors Among Participants in the CHASING COVID Cohort Study.

OBJECTIVE: While much has been reported about the impact of the COVID-19 pandemic on food insecurity, longitudinal data and the variability experienced by people working in various industries are limited. This study aims to further characterize people experiencing food insecurity during the pandemic in terms of employment, sociodemographic characteristics, and degree of food insecurity. METHODS: The study sample consisted of people enrolled in the Communities, Households and SARS-CoV-2 Epidemiology (CHASING) COVID Cohort Study from visit 1 (April-July 2020) through visit 7 (May-June 2021). We created weights to account for participants with incomplete or missing data. We used descriptive statistics and logistic regression models to determine employment and sociodemographic correlates of food insecurity. We also examined patterns of food insecurity and use of food support programs. RESULTS: Of 6740 participants, 39.6% (n = 2670) were food insecure. Non-Hispanic Black and Hispanic (vs non-Hispanic White) participants, participants in households with children (vs no children), and participants with lower (vs higher) income and education levels had higher odds of food insecurity. By industry, people employed in construction, leisure and hospitality, and trade, transportation, and utilities industries had the highest prevalence of both food insecurity and income loss. Among participants reporting food insecurity, 42.0% (1122 of 2670) were persistently food insecure (≥4 consecutive visits) and 43.9% (1172 of 2670) did not use any food support programs. CONCLUSIONS: The pandemic resulted in widespread food insecurity in our cohort, much of which was persistent. In addition to addressing sociodemographic disparities, future policies should focus on the needs of those working in industries vulnerable to economic disruption and ensure those experiencing food insecurity can access food support programs for which they are eligible.

SARS-CoV-2 incidence and risk factors in a national, community-based prospective cohort of U.S. adults.

BACKGROUND: Prospective cohort studies of SARS-CoV-2 incidence complement case-based surveillance and cross-sectional seroprevalence surveys. METHODS: We estimated the incidence of SARS-CoV-2 infection in a national cohort of 6,738 U.S. adults, enrolled March-August 2020. Using Poisson models, we examined the association of social distancing and a composite epidemiologic risk score with seroconversion. The risk score was created using LASSO regression to identify factors predictive of seroconversion. The selected factors were household crowding, confirmed case in household, indoor dining, gathering with groups ≥ 10, and no masking in gyms/salons. RESULTS: Among 4,510 individuals with ≥1 serologic test, 323 (7.3%, 95% confidence interval [CI] 6.5%-8.1%) seroconverted by January 2021. Among 3,422 participants seronegative in May-September 2020 and retested during November 2020-January 2021, 161 seroconverted over 1,646 person-years of follow-up (9.8 per 100 person-years [95%CI 8.3-11.5]). Seroincidence rate was lower among females compared to males (IRR: 0.69, 95% CI 0.50-0.94) and higher among Hispanic (IRR: 2.09, 95% CI 1.41-3.05) participants compared to White non-Hispanic. In adjusted models, participants who reported social distancing with people they did not know (IRRalways vs. never: 0.42, 95% CI 0.20-1.0) and with people they knew (IRRalways vs. never 0.64, 95%CI 0.39-1.06; IRRsometimes vs. never 0.60, 95% CI 0.38-0.96) had lower seroconversion risk. Seroconversion risk increased with epidemiologic risk score (IRRmedium vs. low 1.68, 95% CI 1.03-2.81; IRRhigh vs. low 3.49, 95% CI 2.26-5.58). Only 29% of those who seroconverted reported isolating and 19% were asked about contacts. CONCLUSION: Modifiable risk factors and poor reach of public health strategies drove SARS-CoV-2 transmission across the U.S.

Psychosocial Stressors and Maternal Mental Health in the U.S. During the First Wave of the COVID-19 Pandemic: A Cross-Sectional Analysis.

OBJECTIVES: The COVID pandemic has had widespread impacts on maternal mental health. This research aims to examine the relationship between psychosocial stressors and symptoms of depression and anxiety and the extent to which emotional support or resilient coping moderates the relationship between psychosocial stressors and maternal mental health during the first wave of the COVID pandemic. METHODS: This analysis includes data collected in October and November 2020 from a geographically and sociodemographically diverse sample of 776 mothers in the U.S. with children ≤ 18 years of age. Log binomial models were used to estimate the association between moderate or severe symptoms of anxiety and depression and psychosocial stressors. RESULTS: Symptoms of moderate or severe anxiety and depression were reported by 37.5% and 37.6% of participants, respectively. Moderate (aRR 2.76 [95% CI 1.87, 4.07]) and high (aRR 4.95 [95% CI 3.40, 7.20]) levels of perceived stress were associated with greater risk of moderate or severe anxiety symptoms. Moderate and high levels of parental burnout were also associated with greater prevalence of moderate or severe anxiety symptoms in multivariable models. Results were similar when examining the relationship among stress, parental burnout, and depressive symptoms. Neither resilient coping nor social support modified the relationship between psychosocial stressors and mental health. CONCLUSIONS FOR PRACTICE: Evidence-based strategies to reduce stress and parental burnout and improve the mental health of mothers are urgently needed. Strategies focused on bolstering coping and social support may be insufficient to improve maternal mental health during acute public health emergencies.

The Importance of Incorporating At-Home Testing into SARS-CoV-2 Point Prevalence Estimates: Findings from a U.S. National Cohort, February 2022.

BACKGROUND: Passive case-based surveillance underestimates the true extent of active infections in the population due to undiagnosed and untested cases, the exclusion of probable cases diagnosed point-of-care rapid antigen tests, and/or the exclusive use of at-home rapid tests which are not reported as part of case-based surveillance. The extent in which COVID-19 surveillance may be underestimating the burden of infection is likely due to time-varying factors such as decreased test-seeking behaviors and increased access to and availability of at-home testing. OBJECTIVE: The objective of this study was to estimate the prevalence of SARS-CoV-2 based on different definitions of a case to ascertain the extent to which cases of SARS-CoV-2 may be underestimated by case-based surveillance. METHODS: A survey on COVID-19 exposure, infection, and testing was administered to calculate point prevalence of SARS-CoV-2 among a diverse sample of cohort adults between 8-22 February 2022. Three-point prevalence estimates were calculated among the cohort 1) proportion positives based on PCR and/or rapid antigen tests, 2) proportion positive based on testing exclusively with rapid at-home tests, and 3) proportion of probable undiagnosed cases. Test positivity and prevalence differences across booster status were also examined. RESULTS: Among a cohort of 4328, there were a total of 644 cases. The point prevalence estimate based on PCR and/or rapid antigen tests was 5.5% (95% CI: 4.8% - 6.2%), 3.7% (95% CI: 3.1%- 4.2%) based on at-home rapid tests and 5.7% (95% CI: 5.0% - 6.4%) based on the case definition of a probable case. The total point prevalence across all definitions was 14.9% (95% CI: 13.8% - 16.0%). The percent positivity among PCR and/or rapid tests was 50.2%. No statistically significant differences were observed in prevalence between participants with a COVID-19 booster compared to fully vaccinated and non-boosted participants except among exclusive at-home rapid testers. CONCLUSIONS: Our findings suggest a substantial proportion of cases were missed by case-based surveillance systems during the Omicron BA.1 surge, when at-home testing was common. Point prevalence surveys may be a rapid tool to be used to understand SARS-CoV-2 prevalence and would be especially important during case surges to measure the scope and spread of active infections in the population.

Racial/Ethnic Disparities in Exposure, Disease Susceptibility, and Clinical Outcomes during COVID-19 Pandemic in National Cohort of Adults, United States.

We examined racial/ethnic disparities for COVID-19 seroconversion and hospitalization within a prospective cohort (n = 6,740) in the United States enrolled in March 2020 and followed-up through October 2021. Potential SARS-CoV-2 exposure, susceptibility to COVID-19 complications, and access to healthcare varied by race/ethnicity. Hispanic and Black non-Hispanic participants had more exposure risk and difficulty with healthcare access than white participants. Participants with more exposure had greater odds of seroconversion. Participants with more susceptibility and more barriers to healthcare had greater odds of hospitalization. Race/ethnicity positively modified the association between susceptibility and hospitalization. Findings might help to explain the disproportionate burden of SARS-CoV-2 infections and complications among Hispanic/Latino/a and Black non-Hispanic persons. Primary and secondary prevention efforts should address disparities in exposure, vaccination, and treatment for COVID-19.

Household factors and the risk of severe COVID-like illness early in the U.S. pandemic.

OBJECTIVE: To investigate the role of children in the home and household crowding as risk factors for severe COVID-19 disease. METHODS: We used interview data from 6,831 U.S. adults screened for the Communities, Households and SARS/CoV-2 Epidemiology (CHASING) COVID Cohort Study in April 2020. RESULTS: In logistic regression models, the adjusted odds ratio [aOR] of hospitalization due to COVID-19 for having (versus not having) children in the home was 10.5 (95% CI:5.7-19.1) among study participants living in multi-unit dwellings and 2.2 (95% CI:1.2-6.5) among those living in single unit dwellings. Among participants living in multi-unit dwellings, the aOR for COVID-19 hospitalization among participants with more than 4 persons in their household (versus 1 person) was 2.5 (95% CI:1.0-6.1), and 0.8 (95% CI:0.15-4.1) among those living in single unit dwellings. CONCLUSION: Early in the US SARS-CoV-2 pandemic, certain household exposures likely increased the risk of both SARS-CoV-2 acquisition and the risk of severe COVID-19 disease.

Provider preferences for delivery of HIV care coordination services: results from a discrete choice experiment.

INTRODUCTION: The PROMISE study was launched in 2018 to assess and document the implementation of changes to an existing HIV Care Coordination Programme (CCP) designed to address persistent disparities in care and treatment engagement among persons with HIV in New York City. We evaluated provider endorsement of features of the CCP to understand drivers of engagement with the programme. METHODS: We used a discrete choice experiment to measure provider endorsement of four CCP attributes, including: (1) how CCP helps with medication adherence, (2) how CCP helps with primary care appointments, (3) how CCP helps with issues other than primary care and (4) where CCP visits take place (visit location). Each attribute had three to four levels. Our primary outcomes were relative importance and part-worth utilities, measures of preference for the levels of the four CCP program attributes, estimated using a hierarchical-Bayesian multinomial logit model. All non-medical providers in the core CCP positions of patient navigator, care coordinator and programme director or other administrator from each of the 25 revised CCP-implementing agencies were eligible to participate. RESULTS: We received responses from 152 providers, 68% of whom identified as women, 49% identified as Latino/a, 34% identified as Black and 60% were 30-49 years old. Visit location (28.6%, 95% confidence interval [CI] 27.0-30.3%) had the highest relative importance, followed by how staff help with ART adherence (24.3%, 95% CI 22.4-26.1%), how staff help with issues other than primary care (24.2%, 95% CI 22.7-25.7%) and how staff help with primary care appointments (22.9%, 95% CI 21.7-24.1%). Within each of the above attributes, respectively, the levels with the highest part-worth utilities were home visits 60 minutes from the program or agency (utility 19.9, 95% CI 10.7-29.0), directly observed therapy (utility 26.1, 95% CI 19.1-33.1), help with non-HIV specialty medical care (utility 26.5, 95% CI 21.5-31.6) and reminding clients about and accompanying them to primary care appointments (utility 20.8, 95% CI 15.6-26.0). CONCLUSIONS: Ongoing CCP refinements should account for how best to support and evaluate the intensive CCP components endorsed by providers in this study.

Missed routine pediatric care and vaccinations in US children during the first year of the COVID-19 pandemic.

The COVID-19 pandemic has decreased uptake of pediatric preventive care, including immunizations. We estimate the prevalence of missed pediatric routine medical visits and vaccinations over the first year of the COVID-19 pandemic. We conducted a cross-sectional online survey of 2074 US parents of children ≤12 years in March 2021 to measure the proportion of children who missed pediatric care and vaccinations over the first 12 months of the COVID-19 pandemic. Poisson regression models were fitted to estimate adjusted prevalence ratios (aPR). All analyses were weighted to represent the target population. Overall, 41.3% (95%CI 38.3-43.8) of parents reported their youngest child missed a routine medical visit due to the COVID-19 pandemic. Missed care was more common among children ≥2 years compared to <2 years (aPR 1.82; 95%CI 1.47-2.26) and Hispanics compared to non-Hispanic Whites (aPR 1.31; 95%CI 1.14-1.51). A third of parents (33.1%; 95%CI 30.7-35.5) reported their child had missed a vaccination. Compared to the 2019-20 flu season, pediatric influenza vaccination decreased in 2020-21 (51.3% vs. 62.2%; p < 0.0001). A high proportion of US children ≤12 years missed routine pediatric care during the COVID-19 pandemic. Catch-up efforts are needed to ensure continuity of preventive care for all children.

Patterns of SARS-CoV-2 Testing Preferences in a National Cohort in the United States: Latent Class Analysis of a Discrete Choice Experiment.

BACKGROUND: Inadequate screening and diagnostic testing in the United States throughout the first several months of the COVID-19 pandemic led to undetected cases transmitting disease in the community and an underestimation of cases. Though testing supply has increased, maintaining testing uptake remains a public health priority in the efforts to control community transmission considering the availability of vaccinations and threats from variants. OBJECTIVE: This study aimed to identify patterns of preferences for SARS-CoV-2 screening and diagnostic testing prior to widespread vaccine availability and uptake. METHODS: We conducted a discrete choice experiment (DCE) among participants in the national, prospective CHASING COVID (Communities, Households, and SARS-CoV-2 Epidemiology) Cohort Study from July 30 to September 8, 2020. The DCE elicited preferences for SARS-CoV-2 test type, specimen type, testing venue, and result turnaround time. We used latent class multinomial logit to identify distinct patterns of preferences related to testing as measured by attribute-level part-worth utilities and conducted a simulation based on the utility estimates to predict testing uptake if additional testing scenarios were offered. RESULTS: Of the 5098 invited cohort participants, 4793 (94.0%) completed the DCE. Five distinct patterns of SARS-CoV-2 testing emerged. Noninvasive home testers (n=920, 19.2% of participants) were most influenced by specimen type and favored less invasive specimen collection methods, with saliva being most preferred; this group was the least likely to opt out of testing. Fast-track testers (n=1235, 25.8%) were most influenced by result turnaround time and favored immediate and same-day turnaround time. Among dual testers (n=889, 18.5%), test type was the most important attribute, and preference was given to both antibody and viral tests. Noninvasive dual testers (n=1578, 32.9%) were most strongly influenced by specimen type and test type, preferring saliva and cheek swab specimens and both antibody and viral tests. Among hesitant home testers (n=171, 3.6%), the venue was the most important attribute; notably, this group was the most likely to opt out of testing. In addition to variability in preferences for testing features, heterogeneity was observed in the distribution of certain demographic characteristics (age, race/ethnicity, education, and employment), history of SARS-CoV-2 testing, COVID-19 diagnosis, and concern about the pandemic. Simulation models predicted that testing uptake would increase from 81.6% (with a status quo scenario of polymerase chain reaction by nasal swab in a provider's office and a turnaround time of several days) to 98.1% by offering additional scenarios using less invasive specimens, both viral and antibody tests from a single specimen, faster turnaround time, and at-home testing. CONCLUSIONS: We identified substantial differences in preferences for SARS-CoV-2 testing and found that offering additional testing options would likely increase testing uptake in line with public health goals. Additional studies may be warranted to understand if preferences for testing have changed since the availability and widespread uptake of vaccines.

Cohort profile: a national, community-based prospective cohort study of SARS-CoV-2 pandemic outcomes in the USA-the CHASING COVID Cohort study.

PURPOSE: The Communities, Households and SARS-CoV-2 Epidemiology (CHASING) COVID Cohort Study is a community-based prospective cohort study launched during the upswing of the USA COVID-19 epidemic. The objectives of the cohort study are to: (1) estimate and evaluate determinants of the incidence of SARS-CoV-2 infection, disease and deaths; (2) assess the impact of the pandemic on psychosocial and economic outcomes and (3) assess the uptake of pandemic mitigation strategies. PARTICIPANTS: We began enrolling participants from 28 March 2020 using internet-based strategies. Adults≥18 years residing anywhere in the USA or US territories were eligible. 6740 people are enrolled in the cohort, including participants from all 50 US states, the District of Columbia, Puerto Rico and Guam. Participants are contacted regularly to complete study assessments, including interviews and dried blood spot specimen collection for serologic testing. FINDINGS TO DATE: Participants are geographically and sociodemographically diverse and include essential workers (19%). 84.2% remain engaged in cohort follow-up activities after enrolment. Data have been used to assess SARS-CoV-2 cumulative incidence, seroincidence and related risk factors at different phases of the US pandemic; the role of household crowding and the presence of children in the household as potential risk factors for severe COVID-19 early in the US pandemic; to describe the prevalence of anxiety symptoms and its relationship to COVID-19 outcomes and other potential stressors; to identify preferences for SARS-CoV-2 diagnostic testing when community transmission is on the rise via a discrete choice experiment and to assess vaccine hesitancy over time and its relationship to vaccine uptake. FUTURE PLANS: The CHASING COVID Cohort Study has outlined a research agenda that involves ongoing monitoring of the incidence and determinants of SARS-CoV-2 outcomes, mental health outcomes and economic outcomes. Additional priorities include assessing the incidence, prevalence and correlates of long-haul COVID-19.

SARS-CoV-2 Testing Service Preferences of Adults in the United States: Discrete Choice Experiment.

BACKGROUND: Ascertaining preferences for SARS-CoV-2 testing and incorporating findings into the design and implementation of strategies for delivering testing services may enhance testing uptake and engagement, a prerequisite to reducing onward transmission. OBJECTIVE: This study aims to determine important drivers of decisions to obtain a SARS-CoV-2 test in the context of increasing community transmission. METHODS: We used a discrete choice experiment to assess preferences for SARS-CoV-2 test type, specimen type, testing venue, and results turnaround time. Participants (n=4793) from the US national longitudinal Communities, Households and SARS-CoV-2 Epidemiology (CHASING) COVID Cohort Study completed our online survey from July 30 to September 8, 2020. We estimated the relative importance of testing method attributes and part-worth utilities of attribute levels, and simulated the uptake of an optimized testing scenario relative to the current typical testing scenario of polymerase chain reaction (PCR) via nasopharyngeal swab in a provider's office or urgent care clinic with results in >5 days. RESULTS: Test result turnaround time had the highest relative importance (30.4%), followed by test type (28.3%), specimen type (26.2%), and venue (15.0%). In simulations, immediate or same-day test results, both PCR and serology, or oral specimens substantially increased testing uptake over the current typical testing option. Simulated uptake of a hypothetical testing scenario of PCR and serology via a saliva sample at a pharmacy with same-day results was 97.7%, compared to 0.6% for the current typical testing scenario, with 1.8% opting for no test. CONCLUSIONS: Testing strategies that offer both PCR and serology with noninvasive methods and rapid turnaround time would likely have the most uptake and engagement among residents in communities with increasing community transmission of SARS-CoV-2.

Testing, Testing: What SARS-CoV-2 testing services do adults in the United States actually want?

Importance: Ascertaining preferences for SARS-CoV-2 testing and incorporating findings into the design and implementation of strategies for delivering testing services may enhance testing uptake and engagement, a prerequisite to reducing onward transmission. Objective: To determine important drivers of decisions to obtain a SARS-CoV-2 test in the context of increasing community transmission. Design : A discrete choice experiment (DCE) was used to assess the relative importance of type of SARS-CoV-2 test, specimen type, testing venue, and results turnaround time. Uptake of an optimized testing scenario was simulated relative to the current typical testing scenario of polymerase chain reaction (PCR) via nasopharyngeal (NP) swab in a provider office or urgent care clinic with results in >5 days. Setting: ​ Online survey, embedded in an existing cohort study, conducted during July 30 - September 8, 2020. Participants: ​Participants (n=4,793) were enrolled in the CHASING COVID Cohort Study, a national longitudinal cohort of adults >18 years residing in the 50 US states, Washington, DC, Puerto Rico, or Guam. Main Outcome(s) and Measure(s): Relative importance of SARS-CoV-2 testing method attributes, utilities of specific attribute levels, and probability of choosing a testing scenario based on preferences estimated from the DCE, the current typical testing option, or choosing not to test. Results: ​Turnaround time for test results had the highest relative importance (30.4%), followed by test type (28.3%), specimen type (26.2%), and venue (15.0%). Participants preferred fast results on both past and current infection and using a noninvasive specimen, preferably collected at home. Simulations suggested that providing immediate or same day test results, providing both PCR and serology, or collecting oral specimens would substantially increase testing uptake over the current typical testing option. Simulated uptake of a hypothetical testing scenario of PCR and serology via a saliva sample at a pharmacy with same day results was 97.7%, compared to 0.6% for the current typical testing scenario, with 1.8% opting for no test. Conclusions and Relevance: ​Testing strategies that offer both PCR and serology with non-invasive methods and rapid turnaround time would likely have the most uptake and engagement among residents in communities with increasing community transmission of SARS-CoV-2.