Design and Modification of COVID-19 Case Investigation and Contact Tracing Interview Scripts Used by Health Departments Throughout the COVID-19 Pandemic.

OBJECTIVES: We sought to (1) document how health departments (HDs) developed COVID-19 case investigation and contact tracing (CI/CT) interview scripts and the topics covered, and (2) understand how and why HDs modified those scripts. DESIGN: Qualitative analysis of CI/CT interview scripts and in-depth key informant interviews with public health officials in 14 HDs. Collected scripts represent 3 distinct points (initial, the majority of which were time stamped May 2020; interim, spanning from September 2020 to August 2021; and current, as of April 2022). SETTING: Fourteen state, local, and tribal health jurisdictions and Centers for Disease Control and Prevention (CDC). PARTICIPANTS: Thirty-six public health officials involved in leading CI/CT from 14 state, local, and tribal health jurisdictions (6 states, 3 cities, 4 counties, and 1 tribal area). MAIN OUTCOME MEASURE: Interview script elements included in CI/CT interview scripts over time. RESULTS: Many COVID-19 CI/CT scripts were developed by modifying questions from scripts used for other communicable diseases. Early in the pandemic, scripts included guidance on isolation/quarantine and discussed symptoms of COVID-19. As the pandemic evolved, the length of scripts increased substantially, with significant additions on contact elicitation, vaccinations, isolation/quarantine recommendations, and testing. Drivers of script changes included changes in our understanding of how the virus spreads, risk factors and symptoms, new treatments, new variants, vaccine development, and adjustments to CDC's official isolation and quarantine guidance. CONCLUSIONS: Our findings offer suggestions about components to include in future CI/CT efforts, including educating members of the public about the disease and its symptoms, offering mitigation guidance, and providing sufficient support and resources to help people act on that guidance. Assessing the correlation between script length and number of completed interviews or other quality and performance measures could be an area for future study.

Tuberculosis Testing and Latent Tuberculosis Infection Treatment Practices Among Health Care Providers - United States, 2020-2022.

CDC recommends testing persons at increased risk for tuberculosis (TB) infection as part of routine health care, using TB blood tests, when possible, and, if a diagnosis of latent TB infection (LTBI) is made, prescribing a rifamycin-based, 3- or 4-month treatment regimen (short-course) to prevent the development of TB disease. In 2022, approximately three quarters (73%) of reported TB cases in the United States occurred among non-U.S.-born persons. To assess TB-related practices among health care providers (HCPs) in the United States, CDC analyzed data from the 2020-2022 Porter Novelli DocStyles surveys. Approximately one half (53.3%) of HCPs reported routinely testing non-U.S.-born patients for TB, and of those who did, 35.7% exclusively ordered recommended blood tests, 44.2% exclusively ordered skin tests, and 20.2% ordered TB skin tests and blood tests. One third (33.0%) of HCPs reported prescribing recommended short-course LTBI treatment regimens, and 4.0% reported doing none of the treatment practices available for patients with LTBI (i.e., prescribing short-course regimens, longer course regimens, or referring patients to a health department). Further efforts are needed to identify and overcome barriers for providers to test for and treat persons at risk for TB.

Home-Based Testing and COVID-19 Isolation Recommendations, United States.

Using a nationally representative panel survey, we examined isolation behaviors among persons in the United States who had positive SARS-CoV-2 test results during January 2021-March 2022. Compared with persons who received provider-administered results, persons with home-based results had 29% (95% CI 5%-47%) lower odds of following isolation recommendations.

Experiences with COVID-19 case investigation and contact tracing: A qualitative analysis.

Case investigation and contact tracing (CI/CT) is a critical part of the public health response to COVID-19. Individuals' experiences with CI/CT for COVID-19 varied based on geographic location, changes in knowledge and guidelines, access to testing and vaccination, as well as demographic characteristics including age, race, ethnicity, income, and political ideology. In this paper, we explore the experiences and behaviors of adults with positive SARS-CoV-2 test results, or who were exposed to a person with COVID-19, to understand their knowledge, motivations, and facilitators and barriers to their actions. We conducted focus groups and one-on-one interviews with 94 cases and 90 contacts from across the United States. We found that participants were concerned about infecting or exposing others, which motivated them to isolate or quarantine, notify contacts, and get tested. Although most cases and contacts were not contacted by CI/CT professionals, those who were reported a positive experience and received helpful information. Many cases and contacts reported seeking information from family, friends, health care providers, as well as television news and Internet sources. Although participants reported similar perspectives and experiences across demographic characteristics, some highlighted inequities in receiving COVID-19 information and resources.

Isolation and Quarantine for Coronavirus Disease 2019 in the United States, 2020-2022.

BACKGROUND: Public health programs varied in ability to reach people with coronavirus disease 2019 (COVID-19) and their contacts to encourage separation from others. For both adult case patients with COVID-19 and their contacts, we estimated the impact of contact tracing activities on separation behaviors from January 2020 until March 2022. METHODS: We used a probability-based panel survey of a nationally representative sample to gather data for estimates and comparisons. RESULTS: An estimated 64 255 351 adults reported a positive severe acute respiratory syndrome coronavirus 2 test result; 79.6% isolated for ≥5 days, 60.2% isolated for ≥10 days, and 79.2% self-notified contacts. A total of, 24 057 139 (37.7%) completed a case investigation, and 46.2% of them reported contacts to health officials. More adults who completed a case investigation isolated than those who did not complete a case investigation (≥5 days, 82.6% vs 78.2%, respectively; ≥10 days, 69.8% vs 54.8%; both P < .05). A total of 84 946 636 adults were contacts of a COVID-19 case patient. Of these, 73.1% learned of their exposure directly from a case patient; 49.4% quarantined for ≥5 days, 18.7% quarantined for ≥14 days, and 13.5% completed a contact tracing call. More quarantined among those who completed a contact tracing call than among those who did not complete a tracing call (≥5 days, 61.2% vs 48.5%, respectively; ≥14 days, 25.2% vs 18.0%; both P < .05). CONCLUSIONS: Engagement in contact tracing was positively correlated with isolation and quarantine. However, most adults with COVID-19 isolated and self-notified contacts regardless of whether the public health workforce was able to reach them. Identifying and reaching contacts was challenging and limited the ability to promote quarantining, and testing.

Seizure- or Epilepsy-Related Emergency Department Visits Before and During the COVID-19 Pandemic - United States, 2019-2021.

Seizures, transient signs or symptoms caused by abnormal surges of electrical activity in the brain, can result from epilepsy, a neurologic disorder characterized by abnormal electrical brain activity causing recurrent, unprovoked seizures, or from other inciting causes, such as high fever or substance abuse (1). Seizures generally account for approximately 1% of all emergency department (ED) visits (2,3). Persons of any age can experience seizures, and outcomes might range from no complications for those with a single seizure to increased risk for injury, comorbidity, impaired quality of life, and early mortality for those with epilepsy (4). To examine trends in weekly seizure- or epilepsy-related (seizure-related) ED visits† in the United States before and during the COVID-19 pandemic, CDC analyzed data from the National Syndromic Surveillance Program (NSSP).§ Seizure-related ED visits decreased abruptly during the early pandemic period. By the end of 2020, seizure-related ED visits returned almost to prepandemic levels for persons of all ages, except children aged 0-9 years. By mid-2021, however, this age group gradually returned to baseline as well. Reasons for the decrease in seizure-related ED visits in 2020 among all age groups and the slow return to baseline among children aged 0-9 years compared with other age groups are unclear. The decrease might have been associated with fear of exposure to COVID-19 infection in EDs deterring parents or guardians of children from seeking care, adherence to mitigation measures including avoiding public settings such as EDs, or increased access to telehealth services decreasing the need for ED visits (5). These findings reinforce the importance of understanding factors associated with ED avoidance among persons with epilepsy or seizure, the importance that all eligible persons be up to date¶ with COVID-19 vaccination, and the need to encourage persons to seek appropriate care for seizure-related emergencies** to prevent adverse outcomes.

The Protective Effects of Social Support on Hypertension Among African American Adolescents Exposed to Violence.

African Americans develop hypertension earlier in life than Whites and the racial/ethnic disparities in blood pressure level can appear as early as adolescence. Violence victimization, a prevalent environmental stressor among inner-city youth, may play a role in such disparities. In a sample of inner-city youth in the United States, the current study examines the relationship between violence victimization and hypertension while investigating the role of social support in moderating that relationship. We analyzed eight waves of data from a longitudinal study of African American youth (n = 353, 56.7% female) from mid-adolescence (9th grade, mean age = 14.9 years old) to emerging adulthood (mean age = 23.1 years old) using probit regression. Higher levels of self-reported violence victimization during ages 14-18 was associated with more reports of hypertension during ages 20-23, after adjusting for sex, socioeconomic status, substance use, and mental distress. The relationship of violence victimization with hypertension was moderated by friends' support, but not parental support. The association between victimization and hypertension was weaker and non-significant among individuals with more peer support compared to those with less support. Researchers have reported many instances of associations of early violence exposure to later risk for hypertension; however, most have focused on childhood maltreatment or intimate partner violence. We extend these findings to violence victimization in an African American sample of youth from adolescence to early adulthood, while examining social support modifiers. The disparity in African American hypertension rates relative to Whites may partly be explained by differential exposure to violence. Our findings also suggest that having supportive friends when faced with violence can be beneficial for young adulthood health outcomes.

Preferences for Shigellosis-Related Health Promotion Materials for Gay, Bisexual, and Other Men Who Have Sex With Men: Results From a Qualitative Assessment, Atlanta, GA.

BACKGROUND: Shigellosis, an acute diarrheal disease, is the third most common bacterial infection in the United States. Shigellosis most commonly affects children younger than 5 years; however, clusters and outbreaks of shigellosis have been reported among gay, bisexual, and other men who have sex with men (MSM). Evidence suggests that knowledge of shigellosis among MSM is low, indicating health promotion outreach is needed for this population. METHODS: To inform the development of shigellosis-related health communication materials and strategies, 6 focus groups were conducted in 2017, in Atlanta, GA among 24 self-identified gay and bisexual men. Participants were asked about their preferences and recommendations for health communication materials. RESULTS: Participants indicated they would prefer a range of physical and virtual materials placed in diverse locations where the community would see them. Respondents recommended health messages be simple, quick to read, and concise with limited word counts. Participants also advised the use of diverse images that were inclusive of couples of varying sexual orientations to reduce stigma. Participants advocated for the use of humor and provocative images to increase user engagement. CONCLUSIONS: The results emphasize the potential benefits of conducting formative research when designing health communication materials. Incorporating messaging preferences of MSM in the development of shigellosis-related health communication materials could enhance their relevance for the target population while also avoiding unintended consequences associated with stigmatizing MSM.

Emergency Department Visits for COVID-19 by Race and Ethnicity - 13 States, October-December 2020.

Hispanic or Latino (Hispanic), non-Hispanic Black or African American (Black), and non-Hispanic American Indian or Alaska Native (AI/AN) persons have experienced disproportionately higher rates of hospitalization and death attributable to COVID-19 than have non-Hispanic White (White) persons (1-4). Emergency care data offer insight into COVID-19 incidence; however, differences in use of emergency department (ED) services for COVID-19 by racial and ethnic groups are not well understood. These data, most of which are recorded within 24 hours of the visit, might be an early indicator of changing patterns in disparities. Using ED visit data from 13 states obtained from the National Syndromic Surveillance Program (NSSP), CDC assessed the number of ED visits with a COVID-19 discharge diagnosis code per 100,000 population during October-December 2020 by age and race/ethnicity. Among 5,794,050 total ED visits during this period, 282,220 (4.9%) were for COVID-19. Racial/ethnic disparities in COVID-19 ED visit rates were observed across age groups. Compared with White persons, Hispanic, AI/AN, and Black persons had significantly more COVID-19-related ED visits overall (rate ratio [RR] range = 1.39-1.77) and in all age groups through age 74 years; compared with White persons aged ≥75 years, Hispanic and AI/AN persons also had more COVID-19-related ED visits (RR = 1.91 and 1.22, respectively). These differences in ED visit rates suggest ongoing racial/ethnic disparities in COVID-19 incidence and can be used to prioritize prevention resources, including COVID-19 vaccination, to reach disproportionately affected communities and reduce the need for emergency care for COVID-19.

COVID-19 Trends Among School-Aged Children - United States, March 1-September 19, 2020.

Approximately 56 million school-aged children (aged 5-17 years) resumed education in the United States in fall 2020.* Analysis of demographic characteristics, underlying conditions, clinical outcomes, and trends in weekly coronavirus disease 2019 (COVID-19) incidence during March 1-September 19, 2020 among 277,285 laboratory-confirmed cases in school-aged children in the United States might inform decisions about in-person learning and the timing and scaling of community mitigation measures. During May-September 2020, average weekly incidence (cases per 100,000 children) among adolescents aged 12-17 years (37.4) was approximately twice that of children aged 5-11 years (19.0). In addition, among school-aged children, COVID-19 indicators peaked during July 2020: weekly percentage of positive SARS-CoV-2 test results increased from 10% on May 31 to 14% on July 5; SARS-CoV-2 test volume increased from 100,081 tests on May 31 to 322,227 on July 12, and COVID-19 incidence increased from 13.8 per 100,000 on May 31 to 37.9 on July 19. During July and August, test volume and incidence decreased then plateaued; incidence decreased further during early September and might be increasing. Percentage of positive test results decreased during August and plateaued during September. Underlying conditions were more common among school-aged children with severe outcomes related to COVID-19: among school-aged children who were hospitalized, admitted to an intensive care unit (ICU), or who died, 16%, 27%, and 28%, respectively, had at least one underlying medical condition. Schools and communities can implement multiple, concurrent mitigation strategies and tailor communications to promote mitigation strategies to prevent COVID-19 spread. These results can provide a baseline for monitoring trends and evaluating mitigation strategies.

Changing Age Distribution of the COVID-19 Pandemic - United States, May-August 2020.

As of September 21, 2020, the coronavirus disease 2019 (COVID-19) pandemic had resulted in more than 6,800,000 reported U.S. cases and more than 199,000 associated deaths.* Early in the pandemic, COVID-19 incidence was highest among older adults (1). CDC examined the changing age distribution of the COVID-19 pandemic in the United States during May-August by assessing three indicators: COVID-19-like illness-related emergency department (ED) visits, positive reverse transcription-polymerase chain reaction (RT-PCR) test results for SARS-CoV-2, the virus that causes COVID-19, and confirmed COVID-19 cases. Nationwide, the median age of COVID-19 cases declined from 46 years in May to 37 years in July and 38 in August. Similar patterns were seen for COVID-19-like illness-related ED visits and positive SARS-CoV-2 RT-PCR test results in all U.S. Census regions. During June-August, COVID-19 incidence was highest in persons aged 20-29 years, who accounted for >20% of all confirmed cases. The southern United States experienced regional outbreaks of COVID-19 in June. In these regions, increases in the percentage of positive SARS-CoV-2 test results among adults aged 20-39 years preceded increases among adults aged ≥60 years by an average of 8.7 days (range = 4-15 days), suggesting that younger adults likely contributed to community transmission of COVID-19. Given the role of asymptomatic and presymptomatic transmission (2), strict adherence to community mitigation strategies and personal preventive behaviors by younger adults is needed to help reduce their risk for infection and subsequent transmission of SARS-CoV-2 to persons at higher risk for severe illness.

Recent Increase in COVID-19 Cases Reported Among Adults Aged 18-22 Years - United States, May 31-September 5, 2020.

Although children and young adults are reportedly at lower risk for severe disease and death from infection with SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19), than are persons in other age groups (1), younger persons can experience infection and subsequently transmit infection to those at higher risk for severe illness (2-4). Although at lower risk for severe disease, some young adults experience serious illness, and asymptomatic or mild cases can result in sequelae such as myocardial inflammation (5). In the United States, approximately 45% of persons aged 18-22 years were enrolled in colleges and universities in 2019 (6). As these institutions reopen, opportunities for infection increase; therefore, mitigation efforts and monitoring reports of COVID-19 cases among young adults are important. During August 2-September 5, weekly incidence of COVID-19 among persons aged 18-22 years rose by 55.1% nationally; across U.S. Census regions,* increases were greatest in the Northeast, where incidence increased 144.0%, and Midwest, where incidence increased 123.4%. During the same period, changes in testing volume for SARS-CoV-2 in this age group ranged from a 6.2% decline in the West to a 170.6% increase in the Northeast. In addition, the proportion of cases in this age group among non-Hispanic White (White) persons increased from 33.8% to 77.3% during May 31-September 5. Mitigation and preventive measures targeted to young adults can likely reduce SARS-CoV-2 transmission among their contacts and communities. As colleges and universities resume operations, taking steps to prevent the spread of COVID-19 among young adults is critical (7).

Transmission Dynamics by Age Group in COVID-19 Hotspot Counties - United States, April-September 2020.

CDC works with other federal agencies to identify counties with increasing coronavirus disease 2019 (COVID-19) incidence (hotspots) and offers support to state, tribal, local, and territorial health departments to limit the spread of SARS-CoV-2, the virus that causes COVID-19 (1). Understanding whether increasing incidence in hotspot counties is predominantly occurring in specific age groups is important for identifying opportunities to prevent or reduce transmission. The percentage of positive SARS-CoV-2 reverse transcription-polymerase chain reaction (RT-PCR) test results (percent positivity) is an important indicator of community transmission.* CDC analyzed temporal trends in percent positivity by age group in COVID-19 hotspot counties before and after their identification as hotspots. Among 767 hotspot counties identified during June and July 2020, early increases in the percent positivity among persons aged ≤24 years were followed by several weeks of increasing percent positivity in persons aged ≥25 years. Addressing transmission among young adults is an urgent public health priority.

Shigellosis Among Gay and Bisexual Men: A Qualitative Assessment to Examine Knowledge, Attitudes, and Practices.

BACKGROUND: Shigellosis is a highly contagious enteric bacterial disease transmitted through the fecal-oral route. It is primarily transmitted through person-to-person contact and via contaminated food and water. Outbreaks of shigellosis among men who have sex with men (MSM) attributed to sexual person-to-person contact have been reported. These outbreaks are of concern because they are often caused by multidrug-resistant strains of Shigella. Little is known about shigellosis-related knowledge, attitudes, and practices among gay, bisexual, and other MSM. METHODS: Six focus groups were conducted among self-identified gay or bisexual men in Atlanta, GA, in Fall 2017. Participants were asked about shigellosis-related knowledge, attitudes, and practices. Focus groups were audio recorded, and the transcribed audio was analyzed using inductive and deductive thematic coding. RESULTS: Among the 24 focus group participants, most perceived that diarrheal illness was caused by contaminated food. Knowledge of shigellosis and Shigella was low, with most never having heard of the disease or bacteria. Participants did not perceive shigellosis to be a serious health concern, especially when compared with HIV; however, they did perceive gay and bisexual men to be at risk of Shigella infection. Participants reported mixed intentions to change sexual behaviors to prevent shigellosis or talk with sexual partners about diarrhea. CONCLUSIONS: Health communication and education efforts could be used to increase knowledge about shigellosis and shift perceptions about the severity of shigellosis among gay, bisexual, and other MSM. Additional work is needed to identify effective ways to promote shigellosis-related prevention behaviors among gay, bisexual, and other MSM.