Increased prescribing of antibiotics commonly used for respiratory infections, including azithromycin, ceftriaxone, and doxycycline was observed in nursing homes (NH) during the COVID-19 pandemic however antibiotic prescribing was not linked to resident diagnosis. Therefore, our objective was to characterize antibiotic prescribing in residents with SARS-CoV-2 infection in a large cohort of US NHs.We conducted a retrospective cohort study using PointClickCare (PCC) data containing longitudinal NH electronic health records. We included 4,891 NHs that reported ≥1 medication order/month from April 2020-November 2021. We identified the first onset of SARS-CoV-2 infection using ICD-10-CM diagnosis code U07.1. To validate the number of SARS-CoV-2 infections per facility captured in PCC, we compared the total number of SARS-CoV-2 infections documented in PCC to those reported to the National Healthcare Safety Network (NHSN). Antibiotic orders were determined to be associated with a SARS-CoV-2 infection if 3 days before or ≤7 days after diagnosis. We characterized the proportion of residents with a SARS-CoV-2 infection with an associated antibiotic by month.We included 2,086 (43%) NHs that had ≤20% difference in total number of SARS-CoV-2 infections documented in PCC and reported to NHSN. From April 2020-November 2021, a total of 118,180 residents with a SARS-CoV-2 infection were identified and 24% had an associated antibiotic prescription (N=27,972). The highest prescription rate (30%, 95% Confidence Interval [29%-31%]) was observed in April 2020 and varied by less than 8% from May 2020-November 2021 (Fig.1). The most commonly prescribed antibiotics were azithromycin (53%), doxycycline (13%) and ceftriaxone (10%). An antibiotic prescription was linked to up to a quarter of NH residents with SARS-CoV-2 infection, highlighting potential opportunities for avoiding unnecessary antibiotic prescribing for viral infections in NHs. Appropriate antibiotic prescribing in NH populations is important to reduce potential harm when antibiotics offer no treatment benefit to the resident. Identifying facility-level characteristics that lead to variability in antibiotic prescribing is a next step to inform antibiotic stewardship interventions.All Authors: No reported disclosures.

What is already known about this topic? As more persons are exposed to and infected by SARS-CoV-2, reports of patients who experience persistent symptoms or organ dysfunction after acute COVID-19 and develop post-COVID conditions have increased. | What is added by this report? COVID-19 survivors have twice the risk for developing pulmonary embolism or respiratory conditions; one in five COVID-19 survivors aged 18–64 years and one in four survivors aged ≥65 years experienced at least one incident condition that might be attributable to previous COVID-19. | What are the implications for public health practice? Implementation of COVID-19 prevention strategies, as well as routine assessment for post-COVID conditions among persons who survive COVID-19, is critical to reducing the incidence and impact of post-COVID conditions, particularly among adults aged ≥65 years. | A growing number of persons previously infected with SARS-CoV-2, the virus that causes COVID-19, have reported persistent symptoms, or the onset of long-term symptoms, ≥4 weeks after acute COVID-19; these symptoms are commonly referred to as post-COVID conditions, or long COVID (1). Electronic health record (EHR) data during March 2020–November 2021, for persons in the United States aged ≥18 years were used to assess the incidence of 26 conditions often attributable to post-COVID (hereafter also referred to as incident conditions) among patients who had received a previous COVID-19 diagnosis (case-patients) compared with the incidence among matched patients without evidence of COVID-19 in the EHR (control patients). The analysis was stratified by two age groups (persons aged 18–64 and ≥65 years). Patients were followed for 30–365 days after the index encounter until one or more incident conditions were observed or through October 31, 2021 (whichever occurred first). Among all patients aged ≥18 years, 38% of case-patients experienced an incident condition compared with 16% of controls; conditions affected multiple systems, and included cardiovascular, pulmonary, hematologic, renal, endocrine, gastrointestinal, musculoskeletal, neurologic, and psychiatric signs and symptoms. By age group, the highest risk ratios (RRs) were for acute pulmonary embolism (RR = 2.1 and 2.2 among persons aged 18–64 and ≥65 years, respectively) and respiratory signs and symptoms (RR = 2.1 in both age groups). Among those aged 18–64 years, 35.4% of case-patients experienced an incident condition compared with 14.6% of controls. Among those aged ≥65 years, 45.4% of case-patients experienced an incident condition compared with 18.5% of controls. These findings translate to one in five COVID-19 survivors aged 18–64 years, and one in four survivors aged ≥65 years experiencing an incident condition that might be attributable to previous COVID-19. Implementation of COVID-19 prevention strategies, as well as routine assessment for post-COVID conditions among persons who survive COVID-19, is critical to reducing the incidence and impact of post-COVID, particularly among adults aged ≥65 years (2). | Suggested citation for this article: Bull-Otterson L, Baca S, Saydah S, et al. Post–COVID Conditions Among Adult COVID-19 Survivors Aged 18–64 and ≥65 Years — United States, March 2020–November 2021. MMWR Morb Mortal Wkly Rep. ePub: 24 May 2022. | mm7121e1.htm?s_cid=mm7121e1_w | mm7121e1-H.pdf

Summary | What is already known about this topic | | As more persons are exposed to and infected by SARS-CoV-2, reports of patients who experience persistent symptoms or organ dysfunction after acute COVID-19 and develop post-COVID conditions have increased. | | What is added by this report | | COVID-19 survivors have twice the risk for developing pulmonary embolism or respiratory conditions; one in five COVID-19 survivors aged 1864 years and one in four survivors aged 65 years experienced at least one incident condition that might be attributable to previous COVID-19. | | What are the implications for public health practice | | Implementation of COVID-19 prevention strategies, as well as routine assessment for post-COVID conditions among persons who survive COVID-19, is critical to reducing the incidence and impact of post-COVID conditions, particularly among adults aged 65 years.

IMPORTANCE: Information on underlying conditions and severe COVID-19 illness among children is limited. OBJECTIVE: To examine the risk of severe COVID-19 illness among children associated with underlying medical conditions and medical complexity. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study included patients aged 18 years and younger with International Statistical Classification of Diseases, Tenth Revision, Clinical Modification code U07.1 (COVID-19) or B97.29 (other coronavirus) during an emergency department or inpatient encounter from March 2020 through January 2021. Data were collected from the Premier Healthcare Database Special COVID-19 Release, which included data from more than 800 US hospitals. Multivariable generalized linear models, controlling for patient and hospital characteristics, were used to estimate adjusted risk of severe COVID-19 illness associated with underlying medical conditions and medical complexity. EXPOSURES: Underlying medical conditions and medical complexity (ie, presence of complex or noncomplex chronic disease). MAIN OUTCOMES AND MEASURES: Hospitalization and severe illness when hospitalized (ie, combined outcome of intensive care unit admission, invasive mechanical ventilation, or death). RESULTS: Among 43 465 patients with COVID-19 aged 18 years or younger, the median (interquartile range) age was 12 (4-16) years, 22 943 (52.8%) were female patients, and 12 491 (28.7%) had underlying medical conditions. The most common diagnosed conditions were asthma (4416 [10.2%]), neurodevelopmental disorders (1690 [3.9%]), anxiety and fear-related disorders (1374 [3.2%]), depressive disorders (1209 [2.8%]), and obesity (1071 [2.5%]). The strongest risk factors for hospitalization were type 1 diabetes (adjusted risk ratio [aRR], 4.60; 95% CI, 3.91-5.42) and obesity (aRR, 3.07; 95% CI, 2.66-3.54), and the strongest risk factors for severe COVID-19 illness were type 1 diabetes (aRR, 2.38; 95% CI, 2.06-2.76) and cardiac and circulatory congenital anomalies (aRR, 1.72; 95% CI, 1.48-1.99). Prematurity was a risk factor for severe COVID-19 illness among children younger than 2 years (aRR, 1.83; 95% CI, 1.47-2.29). Chronic and complex chronic disease were risk factors for hospitalization, with aRRs of 2.91 (95% CI, 2.63-3.23) and 7.86 (95% CI, 6.91-8.95), respectively, as well as for severe COVID-19 illness, with aRRs of 1.95 (95% CI, 1.69-2.26) and 2.86 (95% CI, 2.47-3.32), respectively. CONCLUSIONS AND RELEVANCE: This cross-sectional study found a higher risk of severe COVID-19 illness among children with medical complexity and certain underlying conditions, such as type 1 diabetes, cardiac and circulatory congenital anomalies, and obesity. Health care practitioners could consider the potential need for close observation and cautious clinical management of children with these conditions and COVID-19.

BACKGROUND: As a result of the continuing surge of COVID-19, many patients have delayed or missed routine screening and preventive services. Medical conditions, such as coronary heart disease, mental health issues, and substance use disorder, may be identified later, leading to increases in patient morbidity and mortality. METHODS: The National Emergency Medical Services Information System (NEMSIS) data were used to assess 911 Emergency Medical Services (EMS) activations during 2018-2020. For specific activation types, the percentage of total activations was calculated per week and joinpoint analysis was used to identify changes over time. RESULTS: Since March 2020, the number of 911 emergency medical services (EMS) activations has decreased, while the percentages of on-scene death, cardiac arrest, and opioid use/overdose EMS activations were higher than pre-pandemic levels. During the early pandemic period, percentages of total EMS activations increased for on-scene death (from 1.3% to 2.4% during weeks 11-15), cardiac arrest (from 1.3% to 2.2% during weeks 11-15), and opioid use/overdose (from 0.6% to 1.1% during weeks 8-18); the percentages then declined, but remained above pre-pandemic levels through calendar week 52. CONCLUSIONS: The COVID-19 pandemic has indirect consequences, such as relative increases in EMS activations for cardiac events and opioid use/overdose, possibly linked to disruptions is healthcare access and health-seeking behaviors. Increasing telehealth visits or other opportunities for patient-provider touch points for chronic disease and substance use disorders that emphasize counseling, preventive care, and expanded access to medications can disrupt delayed care-seeking during the pandemic and potentially prevent premature death.

Persons from racial and ethnic minority groups are disproportionately affected by COVID-19, including experiencing increased risk for infection (1), hospitalization (2,3), and death (4,5). Using administrative discharge data, CDC assessed monthly trends in the proportion of hospitalized patients with COVID-19 among racial and ethnic groups in the United States during March-December 2020 by U.S. Census region. Cumulative and monthly age-adjusted COVID-19 proportionate hospitalization ratios (aPHRs) were calculated for racial and ethnic minority patients relative to non-Hispanic White patients. Within each of the four U.S. Census regions, the cumulative aPHR was highest for Hispanic or Latino patients (range = 2.7-3.9). Racial and ethnic disparities in COVID-19 hospitalization were largest during May-July 2020; the peak monthly aPHR among Hispanic or Latino patients was >9.0 in the West and Midwest, >6.0 in the South, and >3.0 in the Northeast. The aPHRs declined for most racial and ethnic groups during July-November 2020 but increased for some racial and ethnic groups in some regions during December. Disparities in COVID-19 hospitalization by race/ethnicity varied by region and became less pronounced over the course of the pandemic, as COVID-19 hospitalizations increased among non-Hispanic White persons. Identification of specific social determinants of health that contribute to geographic and temporal differences in racial and ethnic disparities at the local level can help guide tailored public health prevention strategies and equitable allocation of resources, including COVID-19 vaccination, to address COVID-19-related health disparities and can inform approaches to achieve greater health equity during future public health threats.

This cohort study uses data from the Premier Healthcare Database Special COVID-19 Release to assess the association of demographic and clinical characteristics with severe COVID-19 illness among hospitalized US pediatric patients with COVID-19.

Approximately 375,000 deaths during 2020 were attributed to COVID-19 on death certificates reported to CDC (1). Concerns have been raised that some deaths are being improperly attributed to COVID-19 (2). Analysis of International Classification of Diseases, Tenth Revision (ICD-10) diagnoses on official death certificates might provide an expedient and efficient method to demonstrate whether reported COVID-19 deaths are being overestimated. CDC assessed documentation of diagnoses co-occurring with an ICD-10 code for COVID-19 (U07.1) on U.S. death certificates from 2020 that had been reported to CDC as of February 22, 2021. Among 378,048 death certificates listing U07.1, a total of 357,133 (94.5%) had at least one other ICD-10 code; 20,915 (5.5%) had only U07.1. Overall, 97.3% of 357,133 death certificates with at least one other diagnosis (91.9% of all 378,048 death certificates) were noted to have a co-occurring diagnosis that was a plausible chain-of-event condition (e.g., pneumonia or respiratory failure), a significant contributing condition (e.g., hypertension or diabetes), or both. Overall, 70%-80% of death certificates had both a chain-of-event condition and a significant contributing condition or a chain-of-event condition only; this was noted for adults aged 18-84 years, both males and females, persons of all races and ethnicities, those who died in inpatient and outpatient or emergency department settings, and those whose manner of death was listed as natural. These findings support the accuracy of COVID-19 mortality surveillance in the United States using official death certificates. High-quality documentation of co-occurring diagnoses on the death certificate is essential for a comprehensive and authoritative public record. Continued messaging and training (3) for professionals who complete death certificates remains important as the pandemic progresses. Accurate mortality surveillance is critical for understanding the impact of variants of SARS-CoV-2, the virus that causes COVID-19, and of COVID-19 vaccination and for guiding public health action.

Obesity* is a recognized risk factor for severe COVID-19 (1,2), possibly related to chronic inflammation that disrupts immune and thrombogenic responses to pathogens (3) as well as to impaired lung function from excess weight (4). Obesity is a common metabolic disease, affecting 42.4% of U.S. adults (5), and is a risk factor for other chronic diseases, including type 2 diabetes, heart disease, and some cancers.(†) The Advisory Committee on Immunization Practices considers obesity to be a high-risk medical condition for COVID-19 vaccine prioritization (6). Using data from the Premier Healthcare Database Special COVID-19 Release (PHD-SR),(§) CDC assessed the association between body mass index (BMI) and risk for severe COVID-19 outcomes (i.e., hospitalization, intensive care unit [ICU] or stepdown unit admission, invasive mechanical ventilation, and death). Among 148,494 adults who received a COVID-19 diagnosis during an emergency department (ED) or inpatient visit at 238 U.S. hospitals during March-December 2020, 28.3% had overweight and 50.8% had obesity. Overweight and obesity were risk factors for invasive mechanical ventilation, and obesity was a risk factor for hospitalization and death, particularly among adults aged <65 years. Risks for hospitalization, ICU admission, and death were lowest among patients with BMIs of 24.2 kg/m(2), 25.9 kg/m(2), and 23.7 kg/m(2), respectively, and then increased sharply with higher BMIs. Risk for invasive mechanical ventilation increased over the full range of BMIs, from 15 kg/m(2) to 60 kg/m(2). As clinicians develop care plans for COVID-19 patients, they should consider the risk for severe outcomes in patients with higher BMIs, especially for those with severe obesity. These findings highlight the clinical and public health implications of higher BMIs, including the need for intensive COVID-19 illness management as obesity severity increases, promotion of COVID-19 prevention strategies including continued vaccine prioritization (6) and masking, and policies to ensure community access to nutrition and physical activities that promote and support a healthy BMI.

BACKGROUND: Older adults and people from certain racial and ethnic groups are disproportionately represented in coronavirus disease 2019 (COVID-19) hospitalizations and deaths. METHODS: Using data from the Premier Healthcare Database on 181( )813 hospitalized adults diagnosed with COVID-19 during March-September 2020, we applied multivariable log-binomial regression to assess the associations between age and race/ethnicity and COVID-19 clinical severity (intensive care unit [ICU] admission, invasive mechanical ventilation [IMV], and death) and to determine whether the impact of age on clinical severity differs by race/ethnicity. RESULTS: Overall, 84( )497 (47%) patients were admitted to the ICU, 29( )078 (16%) received IMV, and 27( )864 (15%) died in the hospital. Increased age was strongly associated with clinical severity when controlling for underlying medical conditions and other covariates; the strength of this association differed by race/ethnicity. Compared with non-Hispanic White patients, risk of death was lower among non-Hispanic Black patients (adjusted risk ratio, 0.96; 95% CI, 0.92-0.99) and higher among Hispanic/Latino patients (risk ratio [RR], 1.15; 95% CI, 1.09-1.20), non-Hispanic Asian patients (RR, 1.16; 95% CI, 1.09-1.23), and patients of other racial and ethnic groups (RR, 1.13; 95% CI, 1.06-1.21). Risk of ICU admission and risk of IMV were elevated among some racial and ethnic groups. CONCLUSIONS: These results indicate that age is a driver of poor outcomes among hospitalized persons with COVID-19. Additionally, clinical severity may be elevated among patients of some racial and ethnic minority groups. Public health strategies to reduce severe acute respiratory syndrome coronavirus 2 infection rates among older adults and racial and ethnic minorities are essential to reduce poor outcomes.

Coronavirus disease 2019 (COVID-19) is a complex clinical illness with potential complications that might require ongoing clinical care (1-3). Few studies have investigated discharge patterns and hospital readmissions among large groups of patients after an initial COVID-19 hospitalization (4-7). Using electronic health record and administrative data from the Premier Healthcare Database,* CDC assessed patterns of hospital discharge, readmission, and demographic and clinical characteristics associated with hospital readmission after a patient's initial COVID-19 hospitalization (index hospitalization). Among 126,137 unique patients with an index COVID-19 admission during March-July 2020, 15% died during the index hospitalization. Among the 106,543 (85%) surviving patients, 9% (9,504) were readmitted to the same hospital within 2 months of discharge through August 2020. More than a single readmission occurred among 1.6% of patients discharged after the index hospitalization. Readmissions occurred more often among patients discharged to a skilled nursing facility (SNF) (15%) or those needing home health care (12%) than among patients discharged to home or self-care (7%). The odds of hospital readmission increased with age among persons aged ≥65 years, presence of certain chronic conditions, hospitalization within the 3 months preceding the index hospitalization, and if discharge from the index hospitalization was to a SNF or to home with health care assistance. These results support recent analyses that found chronic conditions to be significantly associated with hospital readmission (6,7) and could be explained by the complications of underlying conditions in the presence of COVID-19 (8), COVID-19 sequelae (3), or indirect effects of the COVID-19 pandemic (9). Understanding the frequency of, and risk factors for, readmission can inform clinical practice, discharge disposition decisions, and public health priorities such as health care planning to ensure availability of resources needed for acute and follow-up care of COVID-19 patients. With the recent increases in cases nationwide, hospital planning can account for these increasing numbers along with the potential for at least 9% of patients to be readmitted, requiring additional beds and resources.

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.

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.

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).

On March 13, 2020, the United States declared a national emergency to combat coronavirus disease 2019 (COVID-19). As the number of persons hospitalized with COVID-19 increased, early reports from Austria (1), Hong Kong (2), Italy (3), and California (4) suggested sharp drops in the numbers of persons seeking emergency medical care for other reasons. To quantify the effect of COVID-19 on U.S. emergency department (ED) visits, CDC compared the volume of ED visits during four weeks early in the pandemic March 29-April 25, 2020 (weeks 14 to 17; the early pandemic period) to that during March 31-April 27, 2019 (the comparison period). During the early pandemic period, the total number of U.S. ED visits was 42% lower than during the same period a year earlier, with the largest declines in visits in persons aged </=14 years, females, and the Northeast region. Health messages that reinforce the importance of immediately seeking care for symptoms of serious conditions, such as myocardial infarction, are needed. To minimize SARS-CoV-2, the virus that causes COVID-19, transmission risk and address public concerns about visiting the ED during the pandemic, CDC recommends continued use of virtual visits and triage help lines and adherence to CDC infection control guidance.

On January 19, 2020, the state of Washington reported the first U.S. laboratory-confirmed case of coronavirus disease 2019 (COVID-19) caused by infection with SARS-CoV-2 (1). As of April 19, a total of 720,630 COVID-19 cases and 37,202 associated deaths* had been reported to CDC from all 50 states, the District of Columbia, and four U.S. territories (2). CDC recommends, with precautions, the proper cleaning and disinfection of high-touch surfaces to help mitigate the transmission of SARS-CoV-2 (3). To assess whether there might be a possible association between COVID-19 cleaning recommendations from public health agencies and the media and the number of chemical exposures reported to the National Poison Data System (NPDS), CDC and the American Association of Poison Control Centers surveillance team compared the number of exposures reported for the period January-March 2020 with the number of reports during the same 3-month period in 2018 and 2019. Fifty-five poison centers in the United States provide free, 24-hour professional advice and medical management information regarding exposures to poisons, chemicals, drugs, and medications. Call data from poison centers are uploaded in near real-time to NPDS. During January-March 2020, poison centers received 45,550 exposure calls related to cleaners (28,158) and disinfectants (17,392), representing overall increases of 20.4% and 16.4% from January-March 2019 (37,822) and January-March 2018 (39,122), respectively. Although NPDS data do not provide information showing a definite link between exposures and COVID-19 cleaning efforts, there appears to be a clear temporal association with increased use of these products.