Understanding racial/ethnic disparities in COVID-19 mortality using a novel metric: COVID excess mortality percentage.

Prior research on racial/ethnic disparities in COVID-19 mortality has often not considered to what extent they reflect COVID-19-specific factors, versus preexisting health differences. This study examines how racial/ethnic disparities in COVID-19 mortality vary with age, sex, and time period over April-December 2020 in the United States, using mortality from other natural causes as a proxy for underlying health. We study a novel measure, the COVID excess mortality percentage (CEMP), defined as the COVID-19 mortality rate divided by the non-COVID natural mortality rate, converted to a percentage, where the CEMP denominator controls (albeit imperfectly) for differences in population health. Disparities measured using CEMP deviate substantially from those in prior research. In particular, we find very high disparities (up to 12:1) in CEMP rates for Hispanics versus Whites, particularly for nonelderly men. Asians also have elevated CEMP rates versus Whites, which were obscured in prior work by lower overall Asian mortality. Native Americans and Blacks have significant disparities compared with White populations, but CEMP ratios to Whites are lower than ratios reported in other work. This is because the higher COVID-19 mortality for Blacks and Native Americans comes partly from higher general mortality risk and partly from COVID-specific risk.

Child Anxiety and Depression During the COVID-19 Pandemic and Unmet Mental Health Care Needs.

Child anxiety and depression increased in recent years, while access to health care improved in some ways and worsened in others. The purpose of this study was to understand the prevalence of child anxiety and depression during the COVID-19 pandemic, unmet mental health care need among children with these conditions, and whether disparities exist by race/ethnicity and sex. A cross-sectional secondary data analysis was conducted using the 2021 National Survey of Children's Health (ages 3-17 years, unweighted n = 42,175). Parent/caregiver-reported child anxiety and depression prevalence was greater among non-Hispanic White children than those of other racial/ethnic groups and females compared to males, after adjusting for covariates. Unmet mental health care need among children with anxiety and depression was greater among Hispanic children than those of other racial/ethnic groups, after adjusting for covariates. In conclusion, this study identified a disparity in unmet need between Hispanic children and those of other races and ethnicities. Implications for policy and practice are discussed.

Community focus groups about a COVID-19 individual risk assessment tool: access, understanding and usefulness.

To make informed COVID-19 related decisions, individuals need information about their personal risks and how those risks may vary with specific demographic and health characteristics. The Fight COVID Milwaukee web-based risk assessment tool allows for assessment of COVID-19 mortality risk as a function of personal and neighborhood characteristics. The purpose of this study is to explore public understanding of this risk assessment tool and risk perception through community focus groups. Individuals were recruited from the general adult population in Milwaukee County, Wisconsin, USA, to participate in nine online focus groups where the risk assessment tool was presented for feedback. Three main themes were identified in the focus groups regarding the web-based risk assessment tool: some challenges in accessibility, variable ease of understanding, and personal usefulness but uncertain value for others. This paper explores how members of the community interpret individual risk assessments and life expectancy estimations, and how these vary with age, gender, race/ethnicity, socioeconomic status, and pre-existing comorbidities.

Non-parametric recurrent events analysis with BART and an application to the hospital admissions of patients with diabetes.

Much of survival analysis is concerned with absorbing events, i.e., subjects can only experience a single event such as mortality. This article is focused on non-absorbing or recurrent events, i.e., subjects are capable of experiencing multiple events. Recurrent events have been studied by many; however, most rely on the restrictive assumptions of linearity and proportionality. We propose a new method for analyzing recurrent events with Bayesian Additive Regression Trees (BART) avoiding such restrictive assumptions. We explore this new method via a motivating example of hospital admissions for diabetes patients and simulated data sets.

Latino Acculturation and Periodontitis Status Among Mexican-Origin Adults in the United States: NHANES 2009-2012.

This study examined the association between Latino acculturation indicators (language and citizenship/nativity status) and periodontitis using data from the National Health and Nutrition Examination Survey (NHANES) 2009-2012. Descriptive statistics and logistic regression analyses were performed and all analyses were adjusted for the complex survey design. Results showed that 63.2% of participants had periodontitis: 9.4% mild, 37.9% moderate, and 16% severe. Language was significantly associated with periodontitis after adjusting for age, educational level, gender, usual source of care, flossing, smoking, and glycohemoglobin level (P = .02). Dental public and private health efforts should implement culturally tailored oral health promotion education efforts for this population.

Using group model building to understand factors that influence childhood obesity in an urban environment.

BACKGROUND: Despite increased attention, conventional views of obesity are based upon individual behaviors, and children and parents living with obesity are assumed to be the primary problem solvers. Instead of focusing exclusively on individual reduction behaviors for childhood obesity, greater focus should be placed on better understanding existing community systems and their effects on obesity. The Milwaukee Childhood Obesity Prevention Project is a community-based coalition established to develop policy and environmental change strategies to impact childhood obesity in Milwaukee, Wisconsin. The coalition conducted a Group Model Building exercise to better understand root causes of childhood obesity in its community. METHODS: Group Model Building is a process by which a group systematically engages in model construction to better understand the systems that are in place. It helps participants make their mental models explicit through a careful and consistent process to test assumptions. This process has 3 main components: (1) assembling a team of participants; (2) conducting a behavior-over-time graphs exercise; and (3) drawing the causal loop diagram exercise. RESULTS: The behavior-over-time graph portion produced 61 graphs in 10 categories. The causal loop diagram yielded 5 major themes and 7 subthemes. CONCLUSIONS: Factors that influence childhood obesity are varied, and it is important to recognize that no single solution exists. The perspectives from this exercise provided a means to create a process for dialogue and commitment by stakeholders and partnerships to build capacity for change within the community.

Medical Student Views of the Affordable Care Act.

INTRODUCTION: With new insurance coverage under the Affordable Care Act (ACA) beginning in 2014 and the ever-changing practice of medicine, it is important to understand medical students' recent perspectives on health policy and reform. OBJECTIVE: This study describes the opinions, perceptions, and comprehension of the ACA and health care reform by a cross-section of medical students in Wisconsin. METHODS: A total of 578 students (35%) completed an original survey developed from previous surveys. RESULTS: Of those sampled, one-half identified as liberal or very liberal and 20% as conservative or very conservative. Respondents were split equally in their opinions of whether the United States or other nations had the highest quality care. One-half felt that faculty physicians and the media influenced their opinion of the ACA, while two-thirds felt that coursework and peers had no influence on their views. The vast majority sampled thought everyone is entitled to adequate medical care regardless of ability to pay and that physicians have a major responsibility to help reduce health care costs. A majority of liberal students and a minority of conservative students, supported the ACA. Personal and family experience as a patient influenced most liberals to support and most conservatives to oppose the ACA. One-half felt that medical school spent adequate time on health care policy education.

Incidence of behavior problems in toddlers and preschool children from families living in poverty.

Few studies have examined the incidence of behavior problems in toddlers and preschool children from families living in poverty. The available research suggests behavior problems occur at higher rates in children living in poverty and may have long-term negative outcomes if not identified and properly treated. This study included an ethnically representative sample of 357 children, five years of age and younger, from a diverse, low-income, urban area. All families' incomes met the federal threshold for living in poverty. Behavior problems were assessed by parent report through a questionnaire specifically designed for low-income families. Boys and younger children were reported as demonstrating a higher rate of externalizing behaviors than girls and older children. The overall rate of children scoring at least one standard deviation above the sample's mean for challenging behaviors was 17.4% and was not related to the child's gender, age or ethnicity. This study also sampled children's positive behaviors, which is unique in studies of behavior problems. Gender and age were not related to the frequency of reported positive behaviors. Ethnicity did influence scores on the positive scale. African American children appeared to present their parents more difficulty on items reflecting cooperative behaviors than Caucasian or Latino children. The implications of the study are discussed based on the recognized need for universal screening of behavior problems in young children and the small number professional training programs targeting the identification and treatment of early childhood behavior problems, despite the availability of evidence-based treatment programs tailored to young children in low-income families.

Asthma coalition effects on vulnerable sub groups of children: the most frequent users of health care and the youngest.

OBJECTIVE: To examine the impact of Allies Against Asthma, community-based coalitions working to improve asthma outcomes, on vulnerable children: those with the most urgent health care use and those of youngest age. METHODS: Allies zip codes were matched with comparison communities on demographic factors. Five years of Medicaid data (n = 26,836) for significant health care events: hospitalizations, ED and urgent care facility visits, were analyzed. Longitudinal analyses using generalized estimating equations and proportional hazards models compared Allies and comparison group children. RESULTS: In the two start-up years of Allies, odds of having a significant event were greater for Allies children than for comparison children (p < 0.05). During the third and fourth years when Allies activities were fully implemented, for frequent health care users at baseline, odds of an asthma event were the same for both Allies and comparison children, yet in the less frequent users, odds of an event were lower in Allies children (p < 0.0001). In the initial year of Allies efforts, among the youngest, the Allies children had greater odds than comparison children of an event (p < 0.01), but by the fourth year the Allies group had lower odds (p = 0.02) of an event. Hazard ratios over all years of the study for the youngest Allies children and most frequent baseline users of urgent care were lower than for comparison children (p = 0.01 and p = 0.0004). CONCLUSION: Mobilizing a coalition of diverse stakeholders focused on policy and system change generated community-wide reductions over the long-term in health care use for vulnerable children.

Lead Poisoning in Milwaukee: A Medical and Public Health Update.

INTRODUCTION: Every year, children are poisoned with lead with irreversible effects. This exposure most often occurs in older housing built before 1978 with chipping paint from windowsills where children play and ingest the lead particulates. Exposure to lead can cause neurological and psychological dysfunction, among other health issues. OBJECTIVE: This quality improvement study aims to evaluate our knowledge of at-risk children through a public health approach by analyzing the current public health data and possible barriers to lead screening, testing follow-up, and identifying at-risk children. METHODS: We received data on lead-poisoned children and inspected properties from the City of Milwaukee Health Department. We analyzed each child's initial blood lead level, as well as follow-up tests recorded, ZIP code of residence, and family renter versus home ownership. RESULTS: Over 90% of children in the database had recorded follow-up blood lead testing following an initial elevated blood lead level. There was no difference in initial recorded blood lead levels between children with recorded follow-up blood lead levels and children without (21.40, SD = 11.26); t[1.17], P = 0.24). Most affected children were from economically disadvantaged ZIP codes (53206, 53208, 53215), and 94% lived in rented properties. CONCLUSIONS: Over 90% of children in the database had recorded follow-up blood lead testing following an initial elevated blood lead level. There was no difference in initial recorded blood lead levels between children with recorded follow-up blood lead levels and children without (21.40, SD = 11.26); t[1.17], P = 0.24). Most affected children were from economically disadvantaged ZIP codes (53206, 53208, 53215), and 94% lived in rented properties.

Evidence on COVID-19 Mortality and Disparities Using a Novel Measure, COVID excess mortality percentage: Evidence from Indiana, Wisconsin, and Illinois.

COVID-19 mortality rates increase rapidly with age, are higher among men than women, and vary across racial/ethnic groups, but this is also true for other natural causes of death. Prior research on COVID-19 mortality rates and racial/ethnic disparities in those rates has not considered to what extent disparities reflect COVID-19-specific factors, versus preexisting health differences. This study examines both questions. We study the COVID-19-related increase in mortality risk and racial/ethnic disparities in COVID-19 mortality, and how both vary with age, gender, and time period. We use a novel measure validated in prior work, the COVID Excess Mortality Percentage (CEMP), defined as the COVID-19 mortality rate (Covid-MR), divided by the non-COVID natural mortality rate during the same time period (non-Covid NMR), converted to a percentage. The CEMP denominator uses Non-COVID NMR to adjust COVID-19 mortality risk for underlying population health. The CEMP measure generates insights which differ from those using two common measures-the COVID-MR and the all-cause excess mortality rate. By studying both CEMP and COVID-MRMR, we can separate the effects of background health from Covid-specific factors affecting COVID-19 mortality. We study how CEMP and COVID-MR vary by age, gender, race/ethnicity, and time period, using data on all adult decedents from natural causes in Indiana and Wisconsin over April 2020-June 2022 and Illinois over April 2020-December 2021. CEMP levels for racial and ethnic minority groups can be very high relative to White levels, especially for Hispanics in 2020 and the first-half of 2021. For example, during 2020, CEMP for Hispanics aged 18-59 was 68.9% versus 7.2% for non-Hispanic Whites; a ratio of 9.57:1. CEMP disparities are substantial but less extreme for other demographic groups. Disparities were generally lower after age 60 and declined over our sample period. Differences in socio-economic status and education explain only a small part of these disparities.

Asthma as a Risk Factor for Hospitalization in Children and Youth With COVID-19: A Retrospective Cohort Study.

BACKGROUND: Studies examining the association between asthma and hospitalization among children and youth with coronavirus disease 2019 (COVID-19) have yielded mixed results. Both asthma and COVID-19 hospitalization are characterized by racial, ethnic and socioeconomic disparities which also pattern geographically, yet no studies to date have adjusted for neighborhood context in the assessment of this association. METHODS: Mixed effects logistic regression was used to estimate the association between asthma and hospitalization due to COVID-19 in a sample of 28,997 children and youth diagnosed with COVID-19 in Milwaukee County, Wisconsin, from March 1, 2020, to May 31, 2022. Models adjusted for individual-level sociodemographic factors (age, gender, race, ethnicity and city/suburb residence) and season of diagnosis were examined as moderators. Random intercepts by census tract accounted for geographic variation in neighborhood factors and census tract-level measures of education, health and environment, and social and economic factors were assessed via childhood opportunity indices. RESULTS: Asthma history was statistically significantly associated with hospitalization due to COVID-19 among children and youth. Hospitalization rates varied statistically significantly by census tract, and results were unchanged after accounting for childhood opportunity indices and census tract. Season of diagnosis was not found to moderate the effect of asthma history on COVID-19 hospitalization. CONCLUSION: Our study suggests that asthma history is a risk factor for hospitalization in the context of COVID-19 infection among children and youth, warranting observation and follow-up of children with asthma as well as continued measures to prevent COVID-19 in this population.

Improvements in health care use associated with community coalitions: long-term results of the allies against asthma initiative.

OBJECTIVES: We assessed changes in asthma-related health care use by low-income children in communities across the country where 6 Allies Against Asthma coalitions (Hampton Roads, VA; Washington, DC; Milwaukee, WI; King County/Seattle, WA; Long Beach, CA; and Philadelphia, PA) mobilized stakeholders to bring about policy changes conducive to asthma control. METHODS: Allies intervention zip codes were matched with comparison communities by median household income, asthma prevalence, total population size, and race/ethnicity. Five years of data provided by the Center for Medicare and Medicaid Services on hospitalizations, emergency department (ED) use, and physician urgent care visits for children were analyzed. Intervention and comparison sites were compared with a stratified recurrent event analysis using a Cox proportional hazard model. RESULTS: In most of the assessment years, children in Allies communities were significantly less likely (P < .04) to have an asthma-related hospitalization, ED visit, or urgent care visit than children in comparison communities. During the entire period, children in Allies communities were significantly less likely (P < .02) to have such health care use. CONCLUSIONS: Mobilizing a diverse group of stakeholders, and focusing on policy and system changes generated significant reductions in health care use for asthma in vulnerable communities.

Team science criteria and processes for promotion and tenure of Health Science University Faculty.

Although team science has expanded with far-reaching benefits, universities generally have not established criteria to recognize its value in faculty promotion and tenure. This paper recommends how institutions might weigh a faculty member's engagement in team science in the promotion and tenure process. Seventeen team science promotion and tenure criteria are recommended based on four sources - an evaluation framework, effectiveness metrics, collaborative influences, and authorship criteria. Suggestions are made for adaptation of the 17 criteria to committee guidelines, faculty team science portfolios, and the roles of individuals and institutions participating in large, cross-disciplinary research projects. Future research recommendations are advanced.

Navigating misinformation and political polarization of COVID-19: interviews with Milwaukee, Wisconsin county public health officials.

Introduction: The spread of misinformation combined with the political polarization of the COVID-19 vaccine created major challenges for public health officials responding to the COVID pandemic and vaccine roll-out. The challenges public health officials faced when making safety recommendations and promoting the vaccine only exacerbated the already exhausting work conditions they experienced since the start of the pandemic. Combating misinformation while receiving inadequate political support led to burnout for many public health officials. As such, they had to adapt and develop new strategies for increasing vaccine acceptance and decreasing vaccine hesitancies. Method: This study was conducted through qualitative interviews with seven Milwaukee County public health officials. This study aimed to determine how public health officials perceived misinformation and political polarization during the pandemic. Additionally, the study aimed to learn more about strategies county health officials used to combat misinformation while increasing vaccine uptake in their communities. Results: Thematic analysis of the interviews identified three major challenges faced by public health officials in promoting vaccination: dissemination of misinformation in media, political polarization of COVID and its contribution to vaccine acceptance and COVID fatigue, and assessment of the risks associated with disease severity versus vaccine safety considering limited public health resources. Discussion: Learning from public health officials allows us to better understand their perceptions of the extent of local vaccine hesitancies and their advice on how to counteract fears and misinformation and to promote COVID vaccine uptake. Political polarization of COVID and misinformation affected community vaccine acceptance and challenged local public health leadership.

Fight COVID Milwaukee protective behaviors and risk communications associated with the COVID-19 pandemic.

The COVID-19 pandemic has had a major impact on society, causing significant disruptions to everyday life. Risk communication strategies can play an important role in risk management as they allow individuals to prepare for and respond to public health emergencies appropriately. The aim of this study is to investigate public risk behaviors, perceptions of risk and risk communication, and experiences with COVID-19 to better understand the impact of COVID-19 on our community and to better inform public health decisions about communicating and reducing personal risk. Nine virtual focus groups were conducted with 79 residents of Milwaukee County. Audio transcripts of focus group recordings were qualitatively analyzed using MAXQDA. Predominant themes identified include public risk protective behaviors, the emotional toll associated with lockdown measures, and risk communication. Our findings provide a better understanding of how adults, African American and Hispanic groups in particular, viewed the risk communications and protective behaviors associated with COVID-19, how their lives were impacted by the pandemic, and how to effectively communicate public information about personal risk. These findings can help guide risk communication efforts and public health policy interventions for potential infection outbreaks in the future.

Student Leadership Development Initiative for Medical Students: Lessons Learned From Transitioning to Virtual Modalities.

Leadership training is a necessary component of undergraduate medical education. Our group successfully implemented a student-led organization starting from 2016 (Student Leadership Development Initiative; SLDI) that aimed to provide medical students with exposure to physician-leader career paths in an informal, organic, interactive setting. The COVID-19 pandemic necessitated a shift to online programming, and given the high prevalence of ZOOMTM fatigue, we incorporated monthly, freely available, self-directed modules as an additional leadership training opportunity. The goals of this study are to assess the (1) feasibility of and participation in a virtual student organization focused on leadership training, (2) whether students' perceptions of the importance of leadership were associated with participation in SLDI, and (3) lessons learned from transitioning to virtual modalities. An anonymous, retrospective cross-sectional survey with 13-items was distributed through an email listserv and a 6-question survey was sent to attendees following each virtual group-discussion. A Fisher's exact test was conducted to assess whether the number of modules completed was associated with students' perception of leadership importance. Survey results showed that 85% strongly agreed or agreed that SLDI helped them develop professional goals and career paths, and 74% reported benefits in becoming more compassionate physician leaders and valuing wellness. All respondents completed ≥1 self-directed module, and the students' perception of leadership importance did not influence the number of self-directed modules completed (p > .05). Most participants (63%) attended ≥67% of virtual events, and postevent feedback was positive; however, only 46% of respondents reported meeting someone new at events and 32% reported that they intended on connecting with new contacts. Our results suggest that virtual leadership student-organization, involving small-group discussions and self-directed modules, is feasible and beneficial for medical students. However, the inability to promote meaningful networking opportunities is a major limitation of a virtual training model.

COVID-19 Boosters: If The US Had Matched Israel's Speed And Take-Up, An Estimated 29,000 US Lives Would Have Been Saved.

Israel was the first country to launch COVID-19 boosters, in late July 2021, with strong public health messaging. The booster campaign reversed rising infection rates from the Delta variant and reduced hospitalizations and deaths. The US booster rollout was slower, and public health messaging was mixed. We used the Israeli experience to ask the counterfactual question: How many lives could the US have saved if it had authorized boosters sooner? We estimated that through June 30, 2022, if the US had moved at Israel's speed and booster take-up percentages, it would have saved 29,000 lives. US regulatory caution, in the middle of a pandemic, thus had a large, avoidable cost. Yet the US booster rollout still avoided 42,000 deaths. Moving more slowly to approve boosters, as some advocated, would have cost many additional lives.

Understanding COVID-19 Vaccine Effectiveness against Death Using a Novel Measure: COVID Excess Mortality Percentage.

COVID-19 vaccines have saved millions of lives; however, understanding the long-term effectiveness of these vaccines is imperative to developing recommendations for booster doses and other precautions. Comparisons of mortality rates between more and less vaccinated groups may be misleading due to selection bias, as these groups may differ in underlying health status. We studied all adult deaths during the period of 1 April 2021-30 June 2022 in Milwaukee County, Wisconsin, linked to vaccination records, and we used mortality from other natural causes to proxy for underlying health. We report relative COVID-19 mortality risk (RMR) for those vaccinated with two and three doses versus the unvaccinated, using a novel outcome measure that controls for selection effects. This measure, COVID Excess Mortality Percentage (CEMP), uses the non-COVID natural mortality rate (Non-COVID-NMR) as a measure of population risk of COVID mortality without vaccination. We validate this measure during the pre-vaccine period (Pearson correlation coefficient = 0.97) and demonstrate that selection effects are large, with non-COVID-NMRs for two-dose vaccinees often less than half those for the unvaccinated, and non-COVID NMRs often still lower for three-dose (booster) recipients. Progressive waning of two-dose effectiveness is observed, with an RMR of 10.6% for two-dose vaccinees aged 60+ versus the unvaccinated during April-June 2021, rising steadily to 36.2% during the Omicron period (January-June, 2022). A booster dose reduced RMR to 9.5% and 10.8% for ages 60+ during the two periods when boosters were available (October-December, 2021; January-June, 2022). Boosters thus provide important additional protection against mortality.

Selection Effects and COVID-19 Mortality Risk after Pfizer vs. Moderna Vaccination: Evidence from Linked Mortality and Vaccination Records.

Prior research generally finds that the Pfizer-BioNTech (BNT162b2) and Moderna (mRNA1273) COVID-19 vaccines provide similar protection against mortality, sometimes with a Moderna advantage due to slower waning. However, most comparisons do not address selection effects for those who are vaccinated and with which vaccine. We report evidence on large selection effects, and use a novel method to control for these effects. Instead of directly studying COVID-19 mortality, we study the COVID-19 excess mortality percentage (CEMP), defined as the COVID-19 deaths divided by non-COVID-19 natural deaths for the same population, converted to a percentage. The CEMP measure uses non-COVID-19 natural deaths to proxy for population health and control for selection effects. We report the relative mortality risk (RMR) for each vaccine relative to the unvaccinated population and to the other vaccine, using linked mortality and vaccination records for all adults in Milwaukee County, Wisconsin, from 1 April 2021 through 30 June 2022. For two-dose vaccinees aged 60+, RMRs for Pfizer vaccinees were consistently over twice those for Moderna, and averaged 248% of Moderna (95% CI = 175%,353%). In the Omicron period, Pfizer RMR was 57% versus 23% for Moderna. Both vaccines demonstrated waning of two-dose effectiveness over time, especially for ages 60+. For booster recipients, the Pfizer-Moderna gap is much smaller and statistically insignificant. A possible explanation for the Moderna advantage for older persons is the higher Moderna dose of 100 µg, versus 30 µg for Pfizer. Younger persons (aged 18-59) were well-protected against death by two doses of either vaccine, and highly protected by three doses (no deaths among over 100,000 vaccinees). These results support the importance of a booster dose for ages 60+, especially for Pfizer recipients. They suggest, but do not prove, that a larger vaccine dose may be appropriate for older persons than for younger persons.