Progress Toward Equitable Mpox Vaccination Coverage: A Shortfall Analysis - United States, May 2022-April 2023.

More than 30,000 monkeypox (mpox) cases were reported in the United States during the 2022 multinational outbreak; cases disproportionately affected gay, bisexual, and other men who have sex with men (MSM). Substantial racial and ethnic disparities in incidence were also reported (1). The national mpox vaccination strategy* emphasizes that efforts to administer the JYNNEOS mpox vaccine should be focused among the populations at elevated risk for exposure to mpox (2). During May 2022-April 2023, a total of 748,329 first JYNNEOS vaccine doses (of the two recommended) were administered in the United States.† During the initial months of the outbreak, lower vaccination coverage rates among racial and ethnic minority groups were reported (1,3); however, after implementation of initiatives developed to expand access to mpox vaccination,§ coverage among racial and ethnic minority groups increased (1,4). A shortfall analysis was conducted to examine whether the increase in mpox vaccination coverage was equitable across all racial and ethnic groups (5). Shortfall was defined as the percentage of the vaccine-eligible population that did not receive the vaccine (i.e., 100% minus the percentage of the eligible population that did receive a first dose). Monthly mpox vaccination shortfalls were calculated and were stratified by race and ethnicity; monthly percent reductions in shortfall were also calculated compared with the preceding month's shortfall (6). The mpox vaccination shortfall decreased among all racial and ethnic groups during May 2022-April 2023; however, based on analysis of vaccine administration data with race and ethnicity reported, 66.0% of vaccine-eligible persons remained unvaccinated at the end of this period. The shortfall was largest among non-Hispanic Black or African American (Black) (77.9%) and non-Hispanic American Indian or Alaska Native (AI/AN) (74.5%) persons, followed by non-Hispanic White (White) (66.6%) and Hispanic or Latino (Hispanic) (63.0%) persons, and was lowest among non-Hispanic Asian (Asian) (38.5%) and non-Hispanic Native Hawaiian and other Pacific Islander (NH/OPI) (43.7%) persons. The largest percentage decreases in the shortfall were achieved during August (17.7%) and September (8.5%). However, during these months, smaller percentage decreases were achieved among Black persons (12.2% and 4.9%, respectively), highlighting the need for a focus on equity for the entirety of a public health response. Achieving equitable progress in JYNNEOS vaccination coverage will require substantial decreases in shortfalls among Black and AI/AN persons.

Urban and Rural Mpox Incidence Among Persons Aged 15-64 Years - United States, May 10-December 31, 2022.

During May 10-December 31, 2022, a total of 29,980 confirmed and probable† U.S. monkeypox (mpox) cases were reported to CDC, predominantly in cisgender adult men reporting recent same-gender sexual partners (1). Urban-rural differences in health (2) and diagnosis of HIV (3,4) and other sexually transmitted infections (5) are well documented nationally. This report describes urban-rural differences in mpox incidence (cases per 100,000 population) among persons aged 15-64 years, by gender and race and ethnicity. Urbanicity was assessed using the 2013 National Center for Health Statistics (NCHS) Urban-Rural Classification Scheme for Counties (2). Substantial differences in incidence by urbanicity, gender, and race and ethnicity were observed; most (71.0%) cases occurred in persons residing in large central urban areas. Among the cases in large central urban areas, most (95.7%) were in cisgender men. The overall incidence of mpox in the United States was 13.5 per 100,000 persons aged 15-64 years and peaked in August in both urban and rural areas. Among cisgender men, incidence in rural areas was approximately 4% that in large central urban areas (risk ratio [RR] = 0.04). Among cisgender women, incidence in rural areas was approximately 11% that in large central urban areas (RR = 0.11). In both urban and rural areas, incidence among non-Hispanic Black or African American (Black) and Hispanic or Latino (Hispanic) persons was consistently higher than that among non-Hispanic White (White) persons; RRs between Black and White persons were highest in rural areas. Support and maintenance of mpox surveillance and prevention efforts including vaccinations should focus on urban areas with the highest incidence of mpox during the 2022 outbreak; however, surveillance and prevention efforts should include all genders, persons of color, and persons residing in both urban and rural areas who are at increased risk for mpox.

Racial and Ethnic Disparities in Mpox Cases and Vaccination Among Adult Males - United States, May-December 2022.

As of December 31, 2022, a total of 29,939 monkeypox (mpox) cases* had been reported in the United States, 93.3% of which occurred in adult males. During May 10-December 31, 2022, 723,112 persons in the United States received the first dose in a 2-dose mpox (JYNNEOS)† vaccination series; 89.7% of these doses were administered to males (1). The current mpox outbreak has disproportionately affected gay, bisexual, and other men who have sex with men (MSM) and racial and ethnic minority groups (1,2). To examine racial and ethnic disparities in mpox incidence and vaccination rates, rate ratios (RRs) for incidence and vaccination rates and vaccination-to-case ratios were calculated, and trends in these measures were assessed among males aged ≥18 years (males) (3). Incidence in males in all racial and ethnic minority groups except non-Hispanic Asian (Asian) males was higher than that among non-Hispanic White (White) males. At the peak of the outbreak in August 2022, incidences among non-Hispanic Black or African American (Black) and Hispanic or Latino (Hispanic) males were higher than incidence among White males (RR = 6.9 and 4.1, respectively). Overall, vaccination rates were higher among males in racial and ethnic minority groups than among White males. However, the vaccination-to-case ratio was lower among Black (8.8) and Hispanic (16.2) males than among White males (42.5) during the full analytic period, indicating that vaccination rates among Black and Hispanic males were not proportionate to the elevated incidence rates (i.e., these groups had a higher unmet vaccination need). Efforts to increase vaccination among Black and Hispanic males might have resulted in the observed relative increased rates of vaccination; however, these increases were only partially successful in reducing overall incidence disparities. Continued implementation of equity-based vaccination strategies is needed to further increase vaccination rates and reduce the incidence of mpox among all racial and ethnic groups. Recent modeling data (4) showing that, based on current vaccination coverage levels, many U.S. jurisdictions are vulnerable to resurgent mpox outbreaks, underscore the need for continued vaccination efforts, particularly among racial and ethnic minority groups.

Epidemiologic and Clinical Features of Mpox-Associated Deaths - United States, May 10, 2022-March 7, 2023.

As of March 7, 2023, a total of 30,235 confirmed and probable monkeypox (mpox) cases were reported in the United States,† predominantly among cisgender men§ who reported recent sexual contact with another man (1). Although most mpox cases during the current outbreak have been self-limited, cases of severe illness and death have been reported (2-4). During May 10, 2022-March 7, 2023, 38 deaths among persons with probable or confirmed mpox¶ (1.3 per 1,000 mpox cases) were reported to CDC and classified as mpox-associated (i.e., mpox was listed as a contributing or causal factor). Among the 38 mpox-associated deaths, 94.7% occurred in cisgender men (median age = 34 years); 86.8% occurred in non-Hispanic Black or African American (Black) persons. The median interval from symptom onset to death was 68 days (IQR = 50-86 days). Among 33 decedents with available information, 93.9% were immunocompromised because of HIV. Public health actions to prevent mpox deaths include integrated testing, diagnosis, and early treatment for mpox and HIV, and ensuring equitable access to both mpox and HIV prevention and treatment, such as antiretroviral therapy (ART) (5).

Influenza and Pneumococcal Vaccination Among Male Veterans and Nonveterans, 2016-2018.

OBJECTIVES: The Advisory Committee on Immunization Practices recommends persons aged ≥6 months receive an influenza vaccination annually, and certain adults aged ≥19 years receive the 23-valent pneumococcal polysaccharide vaccine alone or in series with the 13-valent pneumococcal conjugate vaccine, depending on age, chronic conditions, and smoking status. This study examines the prevalence of influenza and pneumococcal vaccination relative to Healthy People 2020 goals to understand how vaccination receipt differs by veteran status and sociodemographic subgroups. METHODS: We analyzed pooled data from the 2016-2018 National Health Interview Survey (N = 35 094) in 2021 to estimate the prevalence of influenza and pneumococcal vaccination for men aged 25-64 years and for men aged ≥65 years by veteran status and selected sociodemographic subgroups. We used 2-tailed t tests with an α = .05 to identify significant differences. RESULTS: Among men, 44.7% of veterans and 33.5% of nonveterans aged 25-64 years and 71.0% of veterans and 64.9% of nonveterans aged ≥65 years received an influenza vaccine in the past year. Among men aged 25-64 years at high risk for pneumococcal disease, 35.9% of veterans and 20.8% of nonveterans had ever received ≥1 dose of any pneumococcal vaccination. Disparities in the prevalence of vaccination within examined sociodemographic characteristics were often smaller in magnitude among veterans than among nonveterans for both vaccinations. CONCLUSIONS: Vaccination rates were below Healthy People 2020 targets for both groups, except influenza vaccination among veterans aged ≥65 years. Understanding differences in vaccine uptake may inform efforts to improve vaccination rates by identifying subgroups who are at high risk of disease and have low vaccination rates.

Prescription Opioid Use Among Adults With Chronic Pain: United States, 2019.

Objective-This report presents prevalence estimates of prescription opioid use among U.S. adults with chronic pain.

Multiple Chronic Conditions Among Veterans and Nonveterans: United States, 2015-2018.

Objectives-This report describes the prevalence of multiple (two or more) chronic conditions (MCC) among veterans and nonveterans and examines whether differences by veteran status may be explained by differences in sociodemographic composition, smoking behavior, and weight status based on body mass index. Methods-Data from the 2015-2018 National Health Interview Survey were used to estimate the prevalence of MCC among adults aged 25 and over by veteran status and sex. Estimates (age-stratified and age-adjusted) were also presented by race and Hispanic origin, educational attainment, poverty status, smoking status, and weight status. Multivariate logistic regression models examined the odds of MCC by veteran status after age stratification (65 and over or under 65) and further adjustment for age and other covariates. Results-Among adults aged 25 and over, age-adjusted prevalence of MCC was higher among veterans compared with nonveterans for both men and women (22.2% compared with 17.0% for men aged 25-64, 66.9% compared with 61.9% for men aged 65 and over, 25.4% compared with 19.6% among women aged 25-64, and 74.1% compared with 61.8% among women aged 65 and over). Following stratification by age and adjustment for selected sociodemographic characteristics, the prevalence of MCC remained higher among veterans compared with nonveterans for both men and women. After further adjustment for smoking status and weight status, differences in the prevalence of MCC by veteran status were reduced but remained statistically significant, with the exception of men aged 65 and over.

Assessing Linkage Eligibility Bias in the National Health Interview Survey.

Background Linking health survey data to administrative records expands the analytic utility of survey participant responses, but also creates the potential for new sources of bias when not all participants are eligible for linkage. Residual differences-bias-can occur between estimates made using the full survey sample and the subset eligible for linkage. Objective To assess linkage eligibility bias and provide examples of how bias may be reduced by changes in questionnaire design and adjustment of survey weights for linkage eligibility. Methods Linkage eligibility bias was estimated for various sociodemographic groups and health-related variables for the 2000-2013 National Health Interview Surveys. Conclusions Analysts using the linked data should consider the potential for linkage eligibility bias when planning their analyses and use approaches to reduce bias, such as survey weight adjustments, when appropriate.

Chronic Pain and High-impact Chronic Pain Among U.S. Adults, 2019.

Chronic pain (1) and chronic pain that frequently limits life or work activities, referred to in this report as high-impact chronic pain (2), are among the most common reasons adults seek medical care (3) and are associated with decreased quality of life, opioid dependence, and poor mental health (1,4,5). This report examines chronic pain and high-impact chronic pain in the past 3 months among U.S. adults aged 18 and over by selected demographic characteristics and urbanization level.

Hearing Difficulty, Vision Trouble, and Balance Problems Among Male Veterans and Nonveterans.

Objective-This report describes hearing difficulty, vision trouble, dual sensory impairment (hearing and vision loss), and balance problems among male veterans and nonveterans. Methods-Sample adult data from the 2016 National Health Interview Survey (NHIS) were used to assess degree of hearing difficulty, vision trouble, and dual sensory impairment in men aged 18 and over by veteran status. Data from the 2016 NHIS Sample Adult Balance Supplement were also used to create estimates of balance or dizziness problems for men by veteran status. Results-Male veterans were significantly less likely to have excellent or good hearing than nonveterans (72.9% compared with 84.1%), and significantly more likely to have a little or moderate trouble hearing (23.2% compared with 13.6%), as well as more likely to have a lot of hearing difficulty or to be deaf (3.9% compared with 2.4%). Male veterans were also more likely to have dual sensory impairment and balance problems than nonveterans (5.0% compared with 2.5% and 24.3% compared with 18.7%, respectively). When data were stratified by age, male veterans aged 18-44 were over three times more likely to have a little or moderate trouble hearing compared with nonveteran men in the same age group (18.0% compared with 5.3%). Male veterans in age groups 45-64 and 65-74 were also more likely to have a little or moderate trouble hearing compared with nonveteran men in the same age groups. When the data were stratified by age, male veterans and nonveterans had similar percentages of dual sensory impairment. Lastly, male veterans in age groups 45-64 and 65-74 were more likely to have balance problems than nonveteran men in the same age groups.

Reported Importance and Access to Health Care Providers Who Understand or Share Cultural Characteristics With Their Patients Among Adults, by Race and Ethnicity.

Objective-This report examines racial and ethnic differences in the reported importance and frequency of seeing culturally competent health care providers among U.S. adults. Methods-Using the 2017 National Health Interview Survey, estimates of the importance and frequency of seeing health care providers who shared or understood respondents' culture were examined by race and Hispanic ethnicity, and stratified by other demographic characteristics. Results-Among adults who had seen a health care professional in the past 12 months, the percentage of non-Hispanic white adults who thought it was very important to have a health care provider who shared or understood their culture was significantly lower than that among all other race and Hispanic-ethnicity groups. Among those who thought it was at least slightly important to have a health care provider who shared or understood their culture, minority groups were generally more likely to report never being able to see a culturally similar health care provider compared with non-Hispanic white adults, and this pattern persisted regardless of sex, age group, or urbanicity.

Surveying Strategies for Hard-to-Survey Populations: Lessons From the Native Hawaiian and Pacific Islander National Health Interview Survey.

Calls for remedies for the persistent scarcity of accurate, reliable, national, disaggregated health statistics on hard-to-survey populations are common, but solutions are rare. Survey strategies used in community and clinical studies of hard-to-survey populations often cannot be, and generally are not, implemented at the national level.This essay presents a set of approaches, for use in combination with traditional survey methods in large-scale surveys of these populations, to overcome challenges in 2 domains: sampling and motivating respondents to participate. The first approach consists of using the American Community Survey as a frame, and the second consists of implementing a multifaceted community engagement effort.We offer lessons learned from implementing these strategies in a national survey, some of which are relevant to all survey planners. We then present evidence of the quality of the resulting data set. If these approaches were used more widely, hard-to-survey populations could become more visible and accurately represented to those responsible for setting national priorities for health research and services.

Prevalence of Chronic Pain and High-Impact Chronic Pain Among Adults - United States, 2016.

Chronic pain, one of the most common reasons adults seek medical care (1), has been linked to restrictions in mobility and daily activities (2,3), dependence on opioids (4), anxiety and depression (2), and poor perceived health or reduced quality of life (2,3). Population-based estimates of chronic pain among U.S. adults range from 11% to 40% (5), with considerable population subgroup variation. As a result, the 2016 National Pain Strategy called for more precise prevalence estimates of chronic pain and high-impact chronic pain (i.e., chronic pain that frequently limits life or work activities) to reliably establish the prevalence of chronic pain and aid in the development and implementation of population-wide pain interventions (5). National estimates of high-impact chronic pain can help differentiate persons with limitations in major life domains, including work, social, recreational, and self-care activities from those who maintain normal life activities despite chronic pain, providing a better understanding of the population in need of pain services. To estimate the prevalence of chronic pain and high-impact chronic pain in the United States, CDC analyzed 2016 National Health Interview Survey (NHIS) data. An estimated 20.4% (50.0 million) of U.S. adults had chronic pain and 8.0% of U.S. adults (19.6 million) had high-impact chronic pain, with higher prevalences of both chronic pain and high-impact chronic pain reported among women, older adults, previously but not currently employed adults, adults living in poverty, adults with public health insurance, and rural residents. These findings could be used to target pain management interventions.

Trends in Health Insurance and Type Among Military Veterans: United States, 2000-2016.

OBJECTIVES: To describe long-term national trends in health insurance coverage among US veterans from 2000 to 2016 in the context of recent health care reform. METHODS: We used 2000 to 2016 National Health Interview Survey data on veterans aged 18 to 64 years to examine trends in insurance coverage and uninsurance by year, income, and state Medicaid expansion status. We also explored the current proportions of veterans with each type of insurance by age group. RESULTS: The percentage of veterans with private insurance decreased from 70.8% in 2000 to 56.9% in 2011, whereas between 2000 and 2016 Department of Veterans Affairs (VA) health care coverage (only) almost tripled, Medicaid (without concurrent TRICARE or private coverage) doubled, and TRICARE coverage of any type tripled. After 2011, the percentage of veterans who were uninsured decreased. In 2016, low-income veterans in Medicaid expansion states had double the Medicaid coverage (41.1%) of low-income veterans in nonexpansion states (20.1%). CONCLUSIONS: Our estimates, which are nationally representative of noninstitutionalized veterans, show marked increases in military-related coverage through TRICARE and VA health care. In 2016, only 7.2% of veterans aged 18 to 64 years and 3.7% of all veterans (aged 18 years or older) remained uninsured.

Selected Health Conditions Among Native Hawaiian and Pacific Islander Adults: United States, 2014.

KEY FINDINGS: Although the Asian or Pacific Islander federal race category was split into two in 1997 (1), few reliable health statistics are available for the Native Hawaiian and Pacific Islander (NHPI) population. In 2014, the National Center for Health Statistics (NCHS) fielded a first-of-its-kind federal survey focused exclusively on NHPI population health. This report uses data from that survey, in combination with 2014 data from the annual National Health Interview Survey (NHIS), to highlight differences in the prevalence of selected health conditions between the NHPI population and the Asian population with whom they have historically been combined.

Sexual Identity, Stigma, and Depression: the Role of the "Anti-gay Propaganda Law" in Mental Health among Men Who Have Sex with Men in Moscow, Russia.

Depression is a major public health problem in the Russian Federation and is particularly of concern for men who have sex with men (MSM). MSM living in Moscow City were recruited via respondent-driven sampling and participated in a cross-sectional survey from October 2010 to April 2013. Multiple logistic regression models compared the relationship between sexual identity, recent stigma, and probable depression, defined as a score of ≥23 on the Center for Epidemiological Studies Depression scale. We investigated the interactive effect of stigma and participation in the study after the passage of multiple "anti-gay propaganda laws" in Russian provinces, municipalities, and in neighboring Ukraine on depression among MSM. Among 1367 MSM, 36.7% (n = 505) qualified as probably depressed. Fifty-five percent identified as homosexual (n = 741) and 42.9% identified as bisexual (n = 578). Bisexual identity had a protective association against probable depression (reference: homosexual identity AOR 0.71; 95%CI 0.52-0.97; p < 0.01). Those who experienced recent stigma (last 12 months) were more likely to report probable depression (reference: no stigma; AOR 1.75; 95%CI 1.20-2.56; p < 0.01). The interaction between stigma and the propaganda laws was significant. Among participants with stigma, probable depression increased 1.67-fold after the passage of the anti-gay laws AOR 1.67; 95%CI 1.04-2.68; p < 0.01). Depressive symptoms are common among MSM in Russia and exacerbated by stigma and laws that deny homosexual identities. Repeal of Russia's federal anti-gay propaganda law is urgent but other social interventions may address depression and stigma in the current context.

The Development of an HIV Risk Environment Scale of Exotic Dance Clubs.

Exotic dancers have received little research attention despite evidence of high-risk behaviours within exotic dance clubs (EDCs). We developed and assessed the reliability and validity of a risk environment score, examining differences between dancers (n = 107) and other staff (n = 172). In the summer of 2013, anonymous surveys were administered via A-CASI in EDCs (N = 26) in Baltimore among exotic dancers and staff. Surveys consisted of a brief demographic section followed by 65 statements. The overall domain had an alpha = 0.77 and subdomains had the following: social (alpha = 0.87), economic (alpha = 0.92), drug (alpha = 0.89), and policy (alpha = 0.66). In a factor analysis, each domain contributed significantly to the overall latent construct. The results indicate a high level of HIV/STI risk for dancers in EDCs and underscore the need for targeted interventions in these environments. As we continue to unpack the function of the broader environment in STI/HIV risk transmission, the scale could be instructive for other settings.

Health Conditions and Behaviors of Native Hawaiian and Pacific Islander Persons in the United States, 2014.

The body of nationally representative health statistics for the Native Hawaiian and Pacific Islander (NHPI) population is limited, because even the largest health surveys generally do not have an adequate NHPI sample to calculate reliable NHPI statistics. Using data from the Native Hawaiian and Pacific Islander National Health Interview Survey (NHPI NHIS) from the National Center for Health Statistics (NCHS), this report fills this gap by presenting statistics on health conditions and behaviors for (a) the total NHPI population and the multiple- and singlerace NHPI populations, in comparison with other federal race groups and the total U.S. population; (b) single-race NHPI persons compared with multiple-race NHPI persons; and (c) detailed NHPI race groups in comparison with each other and the total U.S.

Health Care Access and Utilization Among Native Hawaiian and Pacific Islander Persons in the United States, 2014.

The body of nationally representative health statistics for the Native Hawaiian and Pacific Islander (NHPI) population is limited, because even the largest health surveys generally do not have an adequate NHPI sample to calculate reliable NHPI statistics. Using data from the Native Hawaiian and Pacific Islander National Health Interview Survey (NHPI NHIS) from the National Center for Health Statistics (NCHS), this report fills this gap by presenting statistics on health care access and utilization for (a) the total NHPI population and the multiple- and single-race NHPI populations in comparison with other federal race groups and the total U.S. population; (b) single-race NHPI persons compared with multiple-race NHPI persons; and (c) detailed NHPI race groups in comparison with each other and the total U.S.

Data Quality Assessment of the 2014 Native Hawaiian and Pacific Islander National Health Interview Survey.

The 2014 Native Hawaiian and Pacific Islander National Health Interview Survey (NHPI NHIS) is the first federal survey designed exclusively to measure the health of the noninstitutionalized civilian NHPI population of the United States.