Aspirin use for primary prevention among US adults with and without elevated Lipoprotein(a).

Objective: Lipoprotein(a) [Lp(a)] is an atherogenic and prothrombotic lipoprotein associated with atherosclerotic cardiovascular disease (ASCVD). We assessed the association between regular aspirin use and ASCVD mortality among individuals with versus without elevated Lp(a) in a nationally representative US cohort. Methods: Eligible participants were aged 40-70 years without clinical ASCVD, reported on aspirin use, and had Lp(a) measurements from the Third National Health and Nutrition Examination Survey (NHANES III, 1988-1994), the only cycle of this nationally representative US cohort to measure Lp(a). Regular aspirin use was defined as taking aspirin ≥30 times in the previous month. Using NHANES III linked mortality records and weighted Cox proportional hazards regression, the association between regular aspirin use and ASCVD mortality was observed in those with and without elevated Lp(a) (≥50 versus <50 mg/dL) over a median 26-year follow-up. Results: Among 2,990 persons meeting inclusion criteria (∼73 million US adults), the mean age was 50 years, 86% were non-Hispanic White, 9% were non-Hispanic Black, 53% were female, and 7% reported regular aspirin use. The median Lp(a) was 14 mg/dL and the proportion with elevated Lp(a) was similar among those with versus without regular aspirin use (15.1% versus 21.9%, p = 0.16). Among individuals with elevated Lp(a), the incidence of ASCVD mortality per 1,000 person-years was lower for those with versus without regular aspirin use (1.2, 95% CI: 0.1-2.3 versus 3.9, 95% CI: 2.8-4.9). In multivariable modeling, regular aspirin use was associated with a 52% lower risk of ASCVD mortality among individuals with elevated Lp(a) (HR=0.48, 95% CI: 0.28-0.83), but not for those without elevated Lp(a) (HR=1.01, 95% CI: 0.81-1.25; p-interaction=0.001). Conclusion: Regular aspirin use was associated with significantly lower ASCVD mortality in adults without clinical ASCVD who had elevated Lp(a). These findings may have clinical and public health implications for aspirin utilization in primary prevention.

Hypertension in Pregnancy: Current Challenges and Future Opportunities for Surveillance and Research.

Hypertension in pregnancy (HP) includes eclampsia/preeclampsia, chronic hypertension, superimposed preeclampsia, and gestational hypertension. In the United States, HP prevalence doubled over the last three decades, based on birth certificate data. In 2019, the estimated percent of births with a history of HP varied from 10.1% to 15.9% for birth certificate data and hospital discharge records, respectively. The use of electronic medical records may result in identifying an additional third to half of undiagnosed cases of HP. Individuals with gestational hypertension or preeclampsia are at 3.5 times higher risk of progressing to chronic hypertension and from 1.7 to 2.8 times higher risk of developing cardiovascular disease (CVD) after childbirth compared with individuals without these conditions. Interventions to identify and address CVD risk factors among individuals with HP are most effective if started during the first 6 weeks postpartum and implemented during the first year after childbirth. Providing access to affordable health care during the first 12 months after delivery may ensure healthy longevity for individuals with HP. Average attendance rates for postpartum visits in the United States are 72.1%, but the rates vary significantly (from 24.9% to 96.5%). Moreover, even among individuals with CVD risk factors who attend postpartum visits, approximately 40% do not receive counseling on a healthy lifestyle. In the United States, as of the end of September 2023, 38 states and the District of Columbia have extended Medicaid coverage eligibility, eight states plan to implement it, and two states proposed a limited coverage extension from 2 to 12 months after childbirth. Currently, data gaps exist in national health surveillance and health systems to identify and monitor HP. Using multiple data sources, incorporating electronic medical record data algorithms, and standardizing data definitions can improve surveillance, provide opportunities to better track progress, and may help in developing targeted policy recommendations.

Timing of outpatient postpartum care utilization among women with chronic hypertension and hypertensive disorders of pregnancy.

BACKGROUND: The postpartum period represents an opportunity to assess the cardiovascular health of women who experience chronic hypertension or hypertensive disorders of pregnancy. OBJECTIVE: This study aimed to determine whether women with chronic hypertension or hypertensive disorders of pregnancy access outpatient postpartum care more quickly compared to women with no hypertension. STUDY DESIGN: We used data from the Merative MarketScan Commercial Claims and Encounters Database. We included 275,937 commercially insured women aged 12 to 55 years who had a live birth or stillbirth delivery hospitalization between 2017 and 2018 and continuous insurance enrollment from 3 months before the estimated start of pregnancy to 6 months after delivery discharge. Using the International Classification of Diseases Tenth Revision Clinical Modification codes, we identified hypertensive disorders of pregnancy from inpatient or outpatient claims from 20 weeks gestation through delivery hospitalization and identified chronic hypertension from inpatient or outpatient claims from the beginning of the continuous enrollment period through delivery hospitalization. Distributions of time-to-event survival curves (time-to-first outpatient postpartum visit with a women's health provider, primary care provider, or cardiology provider) were compared between the hypertension types using Kaplan-Meier estimators and log rank tests. We used Cox proportional hazards models to estimate adjusted hazard ratios and 95% confidence intervals. Time points of interest (3, 6, and 12 weeks) were evaluated per clinical postpartum care guidelines. RESULTS: Among commercially insured women, the prevalences of hypertensive disorders of pregnancy, chronic hypertension, and no documented hypertension were 11.7%, 3.4%, and 84.8%, respectively. The proportions of women with a visit within 3 weeks of delivery discharge were 28.5%, 26.4%, and 16.0% for hypertensive disorders of pregnancy, chronic, and no documented hypertension, respectively; by 12 weeks, the proportions increased to 62.4%, 64.5%, and 54.2%, respectively. Kaplan-Meier analyses indicated significant differences in utilization by hypertension type and interaction between hypertension type, and time before and after 6 weeks. In adjusted Cox proportional hazards models, the utilization rate before 6 weeks among women with hypertensive disorders of pregnancy was 1.42 times the rate for women with no documented hypertension (adjusted hazard ratio, 1.42; 95% confidence interval, 1.39-1.45). Women with chronic hypertension also had higher utilization rates compared to women with no documented hypertension before 6 weeks (adjusted hazard ratio, 1.28; 95% confidence interval, 1.24-1.33). Only chronic hypertension was significantly associated with utilization compared to the no documented hypertension group after 6 weeks (adjusted hazard ratio, 1.09; 95% confidence interval, 1.03-1.14). CONCLUSION: In the 6 weeks following delivery discharge, women with hypertensive disorders of pregnancy and chronic hypertension attended outpatient postpartum care visits sooner than women with no documented hypertension. However, after 6 weeks this difference extended only to women with chronic hypertension. Overall, postpartum care utilization remained around 50% to 60% by 12 weeks in all groups. Addressing barriers to postpartum care attendance can ensure timely care for women at high risk for cardiovascular disease.

Stroke Mortality Among Black and White Adults Aged ≥35 Years Before and During the COVID-19 Pandemic - United States, 2015-2021.

Stroke is the fifth leading cause of death and a leading cause of long-term disability in the United States (1). Although stroke death rates have declined since the 1950s, age-adjusted rates remained higher among non-Hispanic Black or African American (Black) adults than among non-Hispanic White (White) adults (1,2). Despite intervention efforts to reduce racial disparities in stroke prevention and treatment through reducing stroke risk factors, increasing awareness of stroke symptoms, and improving access to treatment and care for stroke (1,3), Black adults were 45% more likely than were White adults to die from stroke in 2018.* In 2019, age-adjusted stroke death rates (AASDRs) (stroke deaths per 100,000 population) were 101.6 among Black adults and 69.1 among White adults aged ≥35 years. Stroke deaths increased during the early phase of the COVID-19 pandemic (March-August 2020), and minority populations experienced a disproportionate increase (4). The current study examined disparities in stroke mortality between Black and White adults before and during the COVID-19 pandemic. Analysts used National Vital Statistics System (NVSS) mortality data accessed via CDC WONDER† to calculate AASDRs among Black and White adults aged ≥35 years prepandemic (2015-2019) and during the pandemic (2020-2021). Compared with that during the prepandemic period, the absolute difference in AASDR between Black and White adults during the pandemic was 21.7% higher (31.3 per 100,000 versus 38.0). During the pandemic period, an estimated 3,835 excess stroke deaths occurred among Black adults (9.4% more than expected) and 15,125 among White adults (6.9% more than expected). These findings underscore the importance of identifying the major factors contributing to the widened disparities; implementing prevention efforts, including the management and control of hypertension, high blood cholesterol, and diabetes; and developing tailored interventions to reduce disparities and advance health equity in stroke mortality between Black and White adults. Stroke is a serious medical condition that requires emergency care. Warning signs of a stroke include sudden face drooping, arm weakness, and speech difficulty. Immediate notification of Emergency Medical Services by calling 9-1-1 is critical upon recognition of stroke signs and symptoms.

Impact of COVID-19-related care disruptions on blood pressure management and control in community health centers.

BACKGROUND: Uncontrolled hypertension is a leading risk factor for cardiovascular disease. To ensure continuity of care, community health centers (CHCs) nationwide implemented virtual care (telehealth) during the pandemic. CHCs use the Centers for Medicare & Medicaid Services (CMS) 165v8 Controlling High Blood Pressure measure to report blood pressure (BP) control performance. CMS 165v8 specifications state that if no BP is documented during the measurement period, the patient's BP is assumed uncontrolled. METHODS: To examine trends in BP documentation and control rates in CHCs as telehealth use increased during the pandemic compared with pre-pandemic period, we assessed documentation of BP measurement and BP control rates from December 2019 - October 2021 among persons ages 18-85 with a diagnosis of hypertension who had an in-person or telehealth encounter in 11 CHCs. Rates were compared between CHCs that did and did not implement self-measured BP monitoring (SMBP). RESULTS: The percent of patients with hypertension with no documented BP measurement was 0.5% in December 2019 and increased to 15.2% (overall), 25.6% (non-SMBP CHCs), and 11.2% (SMBP CHCs) by October 2021. BP control using CMS 165v8 was 63.5% in December 2019 and decreased to 54.9% (overall), 49.1% (non-SMBP), and 57.2% (SMBP) by October 2021. When assessing BP control only in patients with documented BP measurements, CHCs largely maintained BP control rates (63.8% in December 2019; 64.8% (overall), 66.0% (non-SMBP), and 64.4% (SMBP) by October 2021). CONCLUSIONS: The transition away from in-person to telehealth visits during the pandemic likely increased the number of patients with hypertension lacking a documented BP measurement, subsequently negatively impacting BP control using CMS 165v8. There is an urgent need to enhance the flexibility of virtual care, improve EHR data capture capabilities for patient-generated data, and implement expanded policy and systems-level changes for SMBP, an evidence-based strategy that can build patient trust, increase healthcare engagement, and improve hypertension outcomes.

Commitment to Hypertension Control During the COVID-19 Pandemic: Million Hearts Initiative Exemplars.

Hypertension is a major risk factor for cardiovascular diseases, but 3 of 4 US adults do not have their blood pressure adequately controlled. Million Hearts (US Department of Health and Human Services) is a national initiative that promotes a set of priorities and interventions to optimize delivery of evidence-based strategies to manage cardiovascular disease, including hypertension. The COVID-19 pandemic, however, has disrupted routine care and preventive service delivery. We identified examples of clinical and health organizations that adapted services and care processes to continue a focus on monitoring and controlling hypertension during the pandemic. Eight Hypertension Control Exemplars were identified and interviewed. They reported various adapted care strategies including telemedicine, engaging patients in self-measured blood pressure monitoring, adapting or implementing medication management services, activating partnerships to respond to patient needs or expand services, and implementing unique patient outreach approaches. Documenting these hypertension control strategies can help increase adoption of adaptive approaches during public health emergencies and routine care.

County-Level Trends in Hypertension-Related Cardiovascular Disease Mortality-United States, 2000 to 2019.

Background Amid stagnating declines in national cardiovascular disease (CVD) mortality, documenting trends in county-level hypertension-related CVD death rates can help activate local efforts prioritizing hypertension prevention, detection, and control. Methods and Results Using death certificate data from the National Vital Statistics System, Bayesian spatiotemporal models were used to estimate county-level hypertension-related CVD death rates and corresponding trends during 2000 to 2010 and 2010 to 2019 for adults aged ≥35 years overall and by age group, race or ethnicity, and sex. Among adults aged 35 to 64 years, county-level hypertension-related CVD death rates increased from a median of 23.2 per 100 000 in 2000 to 43.4 per 100 000 in 2019. Among adults aged ≥65 years, county-level hypertension-related CVD death rates increased from a median of 362.1 per 100 000 in 2000 to 430.1 per 100 000 in 2019. Increases were larger and more prevalent among adults aged 35 to 64 years than those aged ≥65 years. More than 75% of counties experienced increasing hypertension-related CVD death rates among patients aged 35 to 64 years during 2000 to 2010 and 2010 to 2019 (76.2% [95% credible interval, 74.7-78.4] and 86.2% [95% credible interval, 84.6-87.6], respectively), compared with 48.2% (95% credible interval, 47.0-49.7) during 2000 to 2010 and 66.1% (95% credible interval, 64.9-67.1) for patients aged ≥65 years. The highest rates for both age groups were among men and Black populations. All racial and ethnic categories in both age groups experienced widespread county-level increases. Conclusions Large, widespread county-level increases in hypertension-related CVD mortality sound an alarm for intensified clinical and public health actions to improve hypertension prevention, detection, and control and prevent subsequent CVD deaths in counties across the nation.

Modeling the Transmission of COVID-19: Impact of Mitigation Strategies in Prekindergarten-Grade 12 Public Schools, United States, 2021.

BACKGROUND: Schools are an integral part of the community; however, congregate settings facilitate transmission of SARS-CoV-2, presenting a challenge to school administrators to provide a safe, in-school environment for students and staff. METHODS: We adapted the Centers for Disease Control and Prevention's COVIDTracer Advanced tool to model the transmission of SARS-CoV-2 in a school of 596 individuals. We estimate possible reductions in cases and hospitalizations among this population using a scenario-based analysis that accounts for (a) the risk of importation of infection from the community; (b) adherence to key Centers for Disease Control and Prevention-recommended mitigation strategies: mask wearing, cleaning and disinfection, hand hygiene, and social distancing; and (c) the effectiveness of contact tracing interventions at limiting onward transmission. RESULTS: Low impact and effectiveness of mitigation strategies (net effectiveness: 27%) result in approximately 40% of exposed staff and students becoming COVID-19 cases. When the net effectiveness of mitigation strategies was 69% or greater, in-school transmission was mostly prevented, yet importation of cases from the surrounding community could result in nearly 20% of the school's population becoming infected within 180 days. The combined effects of mitigation strategies and contact tracing were able to prevent most onward transmission. Hospitalizations were low among children and adults (<0.5% of the school population) across all scenarios examined. CONCLUSIONS: Based on our model, layering mitigation strategies and contact tracing can limit the number of cases that may occur from transmission in schools. Schools in communities with substantial levels of community spread will need to be more vigilant to ensure adherence of mitigation strategies to minimize transmission. Our results show that for school administrators, teachers, and parents to provide the safest environment, it is important to utilize multiple mitigation strategies and contract tracing that reduce SARS CoV-2 transmission by at least 69%. This will require training, reinforcement, and vigilance to ensure that the highest level of adherence is maintained over the entire school term.

The Impact of Covid-19 State Closure Orders on Consumer Spending, Employment, and Business Revenue.

CONTEXT: In response to the COVID-19 pandemic, states across the United States implemented various strategies to mitigate transmission of SARS-CoV-2 (the virus that causes COVID-19). OBJECTIVE: To examine the effect of COVID-19-related state closures on consumer spending, business revenue, and employment, while controlling for changes in COVID-19 incidence and death. DESIGN: The analysis estimated a difference-in-difference model, utilizing temporal and geographic variation in state closure orders to analyze their impact on the economy, while controlling for COVID-19 incidence and death. PARTICIPANTS: State-level data on economic outcomes from the Opportunity Insights data tracker and COVID-19 cases and death data from usafacts.org. INTERVENTIONS: The mitigation strategy analyzed within this study was COVID-19-related state closure orders. Data on these orders were obtained from state government Web sites containing executive or administrative orders. MAIN OUTCOME MEASURES: Outcomes include state-level estimates of consumer spending, business revenue, and employment levels. RESULTS: Analyses showed that although state closures led to a decrease in consumer spending, business revenue, and employment, they accounted for only a small portion of the observed decreases in these outcomes over the first wave of COVID-19. CONCLUSIONS: The impact of COVID-19 on economic activity likely reflects a combination of factors, in addition to state closures, such as individuals' perceptions of risk related to COVID-19 incidence, which may play significant roles in impacting economic activity.

Addressing Racial and Ethnic Disparities in COVID-19 Among School-Aged Children: Are We Doing Enough?

The disproportionate impact of COVID-19 and associated disparities among Hispanic, non-Hispanic Black, and non-Hispanic American Indian/Alaska Native children and teenagers has been documented. Reducing these disparities along with overcoming unintended negative consequences of the pandemic, such as the disruption of in-person schooling, calls for broad community-based collaborations and nuanced approaches. Based on national survey data, children from some racial and ethnic minority groups have a higher prevalence of obesity, asthma, type 2 diabetes, and hypertension; were diagnosed more frequently with COVID-19; and had more severe outcomes compared with their non-Hispanic White (NHW) counterparts. Furthermore, a higher proportion of children from some racial and ethnic minority groups lived in families with incomes less than 200% of the federal poverty level or in households lacking secure employment compared with NHW children. Children from some racial and ethnic minority groups were also more likely to attend school via online learning compared with NHW counterparts. Because the root causes of these disparities are complex and multifactorial, an organized community-based approach is needed to achieve greater proactive and sustained collaborations between local health departments, local school systems, and other public and private organizations to pursue health equity. This article provides a summary of potential community-based health promotion strategies to address racial and ethnic disparities in COVID-19 outcomes and educational inequities among children and teens, specifically in the implementation of strategic partnerships, including initial collective work, outcomes-based activities, and communication. These collaborations can facilitate policy, systems, and environmental changes in school systems that support emergency preparedness, recovery, and resilience when faced with public health crises.

Decline in COVID-19 Hospitalization Growth Rates Associated with Statewide Mask Mandates - 10 States, March-October 2020.

SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19), is transmitted predominantly by respiratory droplets generated when infected persons cough, sneeze, spit, sing, talk, or breathe. CDC recommends community use of face masks to prevent transmission of SARS-CoV-2 (1). As of October 22, 2020, statewide mask mandates were in effect in 33 states and the District of Columbia (2). This study examined whether implementation of statewide mask mandates was associated with COVID-19-associated hospitalization growth rates among different age groups in 10 sites participating in the COVID-19-Associated Hospitalization Surveillance Network (COVID-NET) in states that issued statewide mask mandates during March 1-October 17, 2020. Regression analysis demonstrated that weekly hospitalization growth rates declined by 2.9 percentage points (95% confidence interval [CI] = 0.3-5.5) among adults aged 40-64 years during the first 2 weeks after implementing statewide mask mandates. After mask mandates had been implemented for ≥3 weeks, hospitalization growth rates declined by 5.5 percentage points among persons aged 18-39 years (95% CI = 0.6-10.4) and those aged 40-64 years (95% CI = 0.8-10.2). Statewide mask mandates might be associated with reductions in SARS-CoV-2 transmission and might contribute to reductions in COVID-19 hospitalization growth rates, compared with growth rates during <4 weeks before implementation of the mandate and the implementation week. Mask-wearing is a component of a multipronged strategy to decrease exposure to and transmission of SARS-CoV-2 and reduce strain on the health care system, with likely direct effects on COVID-19 morbidity and associated mortality.

A Multilevel Workforce Study on Drivers of Turnover and Training Needs in State Health Departments: Do Leadership and Staff Agree?

OBJECTIVES: To characterize agreement between senior governmental public health staff and their subordinates concerning drivers for staff turnover, and skill importance and ability. DESIGN: Data were combined from 2 national surveys conducted in 2017; one was a nationally representative, individual-level survey of public health workers, and one was an individual-level survey of their leadership. SETTING: State health agencies. PARTICIPANTS: Respondents who held scientific, nonsupervisory positions at state health agency central offices (n = 3606) were matched with leadership (n = 193) who provided programmatic area oversight. MAIN OUTCOME MEASURES: Drivers of turnover and training needs are the primary outcomes examined in this article. RESULTS: Leaders and their staff agreed on the main 2 drivers of turnover (low salary and lack of opportunities for advancement), but discordance was observed for other major drivers of turnover. Substantial discordance was observed between leaders and their staff in terms of perceived staff proficiency with selected skills. CONCLUSIONS: This multilevel assessment of workplace perceptions offers evidence around training needs and drivers of turnover in state health agencies. Although staff and leaders agree on some major drivers of turnover, other potential reasons for leaving cited by staff, and the difference in perceptions of skills, can help target job satisfaction, training, and retention efforts in state health agencies.

A Novel Approach for Workforce Surveillance at the US Department of Health and Human Services.

BACKGROUND: Expert groups have recommended ongoing monitoring of the public health workforce to determine its ability to execute designated objectives. Resource- and time-intensive surveys have been a primary data source to monitor the workforce. We evaluated an administrative data source containing US Department of Health and Human Services (HHS) aggregate federal civil service workforce-related data to determine its potential as a workforce surveillance system for this component of the workforce. METHODS: We accessed FedScope, a publicly available online database containing federal administrative civilian HHS personnel data. Using established guidelines for evaluating surveillance systems and identified workforce characteristics, we evaluated FedScope attributes for workforce surveillance purposes. RESULTS: We determined FedScope to be a simple, highly accepted, flexible, stable, and timely system to support analyses of federal civil service workforce-related data. Data can be easily accessed, analyzed, and monitored for changes across years and draw conclusions about the workforce. FedScope data can be used to calculate demographics (eg, sex, race or ethnicity, age group, and education level), employment characteristics (ie, supervisory status, work schedule, and appointment type), retirement projections, and characterize the federal workforce into standard occupational categories. CONCLUSIONS: This study indicates that an administrative data source containing HHS personnel data can function as a workforce surveillance system valuable to researchers, public health leaders, and decision makers interested in the federal civil service public health workforce. Using administrative data for workforce development is a model that can be applicable to federal and nonfederal public health agencies and ultimately support improvements in public health.

Estimated Resource Costs for Implementation of CDC's Recommended COVID-19 Mitigation Strategies in Pre-Kindergarten through Grade 12 Public Schools - United States, 2020-21 School Year.

As school districts across the United States consider how to safely operate during the 2020-21 academic year, CDC recommends mitigation strategies that schools can adopt to reduce the risk for transmission of SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19) (1). To identify the resources and costs needed to implement school-based mitigation strategies and provide schools and jurisdictions with information to aid resource allocation, a microcosting methodology was employed to estimate costs in three categories: materials and consumables, additional custodial staff members, and potential additional transportation. National average estimates, using the national pre-kindergarten through grade 12 (preK-12) public enrollment of 50,685,567 students, range between a mean of $55 (materials and consumables only) to $442 (all three categories) per student. State-by-state estimates of additional funds needed as a percentage of fiscal year 2018 student expenditures (2) range from an additional 0.3% (materials and consumables only) to 7.1% (all three categories); however, only seven states had a maximum estimate above 4.2%. These estimates, although not exhaustive, highlight the level of resources needed to ensure that schools reopen and remain open in the safest possible manner and offer administrators at schools and school districts and other decision-makers the cost information necessary to budget and prioritize school resources during the COVID-19 pandemic.

Implementing Mitigation Strategies in Early Care and Education Settings for Prevention of SARS-CoV-2 Transmission - Eight States, September-October 2020.

The Head Start program, including Head Start for children aged 3-5 years and Early Head Start for infants, toddlers, and pregnant women, promotes early learning and healthy development among children aged 0-5 years whose families meet the annually adjusted Federal Poverty Guidelines* throughout the United States.† These programs are funded by grants administered by the U.S. Department of Health and Human Services' Administration for Children and Families (ACF). In March 2020, Congress passed the Coronavirus Aid, Relief, and Economic Security (CARES) Act,§ which appropriated $750 million for Head Start, equating to approximately $875 in CARES Act funds per enrolled child. In response to the coronavirus disease 2019 (COVID-19) pandemic, most states required all schools (K-12) to close or transition to virtual learning. The Office of Head Start gave its local programs that remained open the flexibility to use CARES Act funds to implement CDC-recommended guidance (1) and other ancillary measures to provide in-person services in the early phases of community transmission of SARS-CoV-2, the virus that causes COVID-19, in April and May 2020, when many similar programs remained closed. Guidance included information on masks, other personal protective equipment, physical setup, supplies necessary for maintaining healthy environments and operations, and the need for additional staff members to ensure small class sizes. Head Start programs successfully implemented CDC-recommended mitigation strategies and supported other practices that helped to prevent SARS-CoV-2 transmission among children and staff members. CDC conducted a mixed-methods analysis to document these approaches and inform implementation of mitigation strategies in other child care settings. Implementing and monitoring adherence to recommended mitigation strategies reduces risk for COVID-19 transmission in child care settings. These approaches could be applied to other early care and education settings that remain open for in-person learning and potentially reduce SARS-CoV-2 transmission.

Adoption of Strategies to Mitigate Transmission of COVID-19 During a Statewide Primary Election - Delaware, September 2020.

Elections occurring during the coronavirus disease 2019 (COVID-19) pandemic have been affected by notable changes in the methods of voting, the number and type of polling locations, and in-person voting procedures (1). To mitigate transmission of COVID-19 at polling locations, jurisdictions have adopted changes to protocols and procedures, informed by CDC's interim guidance, developed in collaboration with the Election Assistance Commission (2). The driving principle for this guidance is that voting practices with lower infection risk will be those which reduce the number of voters who congregate indoors in polling locations by offering a variety of methods for voting and longer voting periods. The guidance for in-person voting includes considerations for election officials, poll workers, and voters to maintain healthy environments and operations. To assess knowledge and adoption of mitigation strategies, CDC collaborated with the Delaware Department of Health and Social Services and the Delaware State Election Commission on a survey of poll workers who served during the statewide primary election on September 15, 2020. Among 522 eligible poll workers, 93% correctly answered all three survey questions about COVID-19 transmission. Respondents noted that most voters and poll workers wore masks. However, masks were not always worn correctly (i.e., covering both the nose and mouth). Responses suggest that mitigation measures recommended for both poll workers and voters were widely adopted and feasible, but also highlighted gaps in infection prevention control efforts. Strengthening of measures intended to minimize the risk of poll workers acquiring COVID-19 from ill voters, such as additional training and necessary personal protective equipment (PPE), as well as support for alternative voting options for ill voters, are needed. Adherence to mitigation measures is important not only to protect voters but also to protect poll workers, many of whom are older adults, and thus at higher risk for severe COVID-19-associated illness. Enhanced attention to reducing congregation in polling locations, correct mask use, and providing safe voting options for ill voters are critical considerations to minimize risk to voters and poll workers. Evidence from the Delaware election supports the feasibility and acceptability of implementing current CDC guidance for election officials, poll workers, and voters for mitigating COVID-19 transmission at polling locations (2).

The State of the US Governmental Public Health Workforce, 2014-2017.

Public health workforce development efforts during the past 50 years have evolved from a focus on enumerating workers to comprehensive strategies that address workforce size and composition, training, recruitment and retention, effectiveness, and expected competencies in public health practice. We provide new perspectives on the public health workforce, using data from the Public Health Workforce Interests and Needs Survey, the largest nationally representative survey of the governmental public health workforce in the United States. Five major thematic areas are explored: workforce diversity in a changing demographic environment; challenges of an aging workforce, including impending retirements and the need for succession planning; workers' salaries and challenges of recruiting new staff; the growth of undergraduate public health education and what this means for the future public health workforce; and workers' awareness and perceptions of national trends in the field. We discussed implications for policy and practice.

Public Health Workforce Development Needs: A National Assessment of Executives' Perspectives.

INTRODUCTION: Workforce development is one of the ten essential public health services. Recent studies have better characterized individual worker perceptions regarding workforce interests and needs, but gaps remain around workforce needs from program managers' perspectives. This study characterized management perspectives regarding subordinate's abilities and training needs and perceived challenges to recruitment and retention. METHODS: In 2017, the Directors Assessment of Workforce Needs Survey was sent to 574 managers at state health agencies across the U.S. Respondents were invited based on the positions they held (i.e., to be included, respondents had to be employed as managers and oversee specific program areas). In 2018, descriptive statistics were calculated, including Fisher's exact for inferential comparisons and Tukey's test for multiple comparisons, as appropriate. RESULTS: Response rate was 49% after accounting for undeliverable e-mails; 226 respondents met the inclusion criteria. The largest perceived barriers to staff recruitment were wages or salaries (74%) and private sector competition (56%). Similarly, wages or salaries were identified as the main cause of turnover by 70% of respondents, followed by lack of opportunities for advancement (68%), and opportunities outside the agency (67%). CONCLUSIONS: The Directors Assessment of Workforce Needs Survey fills important knowledge gaps and complements previously identified evidence to guide refinement of workforce development efforts. Although competition from the private sector remains challenging, these findings indicate that recruitment and retention must be top priorities in state health agencies nationwide. Prioritizing individual state health agency workforce gaps and committing to provide specific local-level interventions to those priorities is crucial for individual health agencies.