OBJECTIVE: In April 2020, the US Centers for Disease Control and Prevention (CDC) recommended community masking to prevent the transmission of SARS-CoV-2. Since then, a total of 39 US states and DC issued mask mandates. Despite CDC recommendations and supporting evidence that masking reduces COVID-19 community transmission, from January to June 20, 2021 states lifted their mask mandates for all individuals. This study examined the association between lifting state-issued mask mandates and mask-wearing behavior in 2021. DESIGN: We estimated a difference-in-difference model, comparing changes in the likelihood for individuals to wear a mask in states that lifted their mask mandate relative to states that kept their mandates in place between February and June of 2021. SETTING: Individuals were surveyed from across the United States. PARTICIPANTS: We used masking behavior data collected by the Porter Novelli View 360 + national surveys (N = 3459), and data from state-issued mask mandates obtained by CDC and the University of Nevada, Las Vegas. MAIN OUTCOMES: The outcome variable of interest was self-reported mask use during the 30 days prior to the survey data collection. RESULTS: In the overall population, lifting mask mandates did not significantly influence mask-wearing behavior. Mask wearing did significantly decrease in response to the lifting of mask mandates among individuals living in rural counties and individuals who had not yet decided whether they would receive a COVID-19 vaccine. CONCLUSION: Policies around COVID-19 behavioral mitigation, specifically amongst those unsure about vaccination and in rural areas, may help reduce the transmission of COVID-19 and other respiratory viruses, especially in communities with low vaccination rates.

Drinking water fluoridated at the level recommended by the U.S. Public Health Service (USPHS) reduces dental caries (cavities) by approximately 25% in children and adults (1). USPHS recommends fluoride levels to achieve oral health benefits and minimize risks associated with excess fluoride exposure. To provide the benefits of community water fluoridation, water systems should target a level of 0.7 mg/L and maintain levels ≥0.6 mg/L (2). The Environmental Protection Agency (EPA) sets a safety standard at 2.0 mg/L to prevent mild or moderate dental fluorosis, a condition that causes changes in the appearance of tooth enamel caused by hypermineralization resulting from excess fluoride intake during tooth-forming years (i.e., before age 8 years). During 2016-2021, fluoride measurements for 16.3% of population-weighted monthly fluoride measurements (person-months) reported by community water systems to CDC's Water Fluoridation Reporting System (WFRS) were <0.6 mg/L; only 0.01% of person-months exceeded 2.0 mg/L. More than 80% of population-weighted fluoride measurements from community water systems reporting to WFRS were above 0.6 mg/L. Although 0.7 mg/L is the recommended optimal level, ≥0.6 mg/L is still effective for the prevention of caries. A total of 4,080 community water systems safely fluoridated water 99.99% of the time with levels below the secondary safety standard of 2.0 mg/L. Water systems are encouraged to work with their state programs to report their fluoride data into WFRS and meet USPHS recommendations to provide the full benefit of fluoridation for caries prevention.

OBJECTIVE: State-issued behavioral policy interventions (BPIs) can limit community spread of COVID-19, but their effects on COVID-19 transmission may vary by level of social vulnerability in the community. We examined the association between the duration of BPIs and the incidence of COVID-19 across levels of social vulnerability in US counties. METHODS: We used COVID-19 case counts from USAFacts and policy data on BPIs (face mask mandates, stay-at-home orders, gathering bans) in place from April through December 2020 and the 2018 Social Vulnerability Index (SVI) from the Centers for Disease Control and Prevention. We conducted multilevel linear regression to estimate the associations between duration of each BPI and monthly incidence of COVID-19 (cases per 100000 population) by SVI quartiles (grouped as low, moderate low, moderate high, and high social vulnerability) for 3141 US counties. RESULTS: Having a BPI in place for longer durations (ie, 2 months) was associated with lower incidence of COVID-19 compared with having a BPI in place for <1 month. Compared with having no BPI in place or a BPI in place for <1 month, differences in marginal mean monthly incidence of COVID-19 per 100000 population for a BPI in place for 2 months ranged from -4 cases in counties with low SVI to -401 cases in counties with high SVI for face mask mandates, from -31 cases in counties with low SVI to -208 cases in counties with high SVI for stay-at-home orders, and from -227 cases in counties with low SVI to -628 cases in counties with high SVI for gathering bans. CONCLUSIONS: Establishing COVID-19 prevention measures for longer durations may help reduce COVID-19 transmission, especially in communities with high levels of social vulnerability.

Objectives: This study assessed the associations between parent intent to have their child receive the COVID-19 vaccination, and demographic factors and various child activities, including attendance at in-person education or childcare. Methods: Persons undergoing COVID-19 testing residing in Minnesota and Los Angeles County, California with children aged &lt;12 years completed anonymous internet-based surveys between 10 May and 6 September 2021 to assess factors associated with intention to vaccinate their child. Factors influencing the parents' decision to have their child attend in-person school or childcare were examined. Estimated adjusted odds rations (AORs, 95% CI) were computed between parents' intentions regarding children's COVID-19 vaccination and participation in school and extra-curricular activities using multinomial logistic regression. Results: Compared to parents intending to vaccinate their children (n = 4686 [77.2%]), those undecided (n = 874 [14.4%]) or without intention to vaccinate (n = 508 [8.4%]) tended to be younger, non-White, less educated, and themselves not vaccinated against COVID-19. Their children more commonly participated in sports (aOR:1.51 1.17-1.95) and in-person faith or community activities (aOR:4.71 3.62-6.11). A greater proportion of parents without intention to vaccinate (52.5%) indicated that they required no more information to make their decision in comparison to undecided parents (13.2%). They further indicated that additional information regarding vaccine safety and effectiveness would influence their decision. COVID-19 mitigation measures were the most common factors influencing parents' decision to have their child attend in-person class or childcare. Conclusions: Several demographic and socioeconomic factors are associated with parents' decision whether to vaccinate their &lt;12-year-old children for COVID-19. Child participation in in-person activities was associated with parents' intentions not to vaccinate. Tailored communications may be useful to inform parents' decisions regarding the safety and effectiveness of vaccination.

The National Immunization Survey Adult COVID Module used a random-digit-dialed phone survey during April 22, 2021-January 29, 2022 to quantify COVID-19 vaccination, intent, attitudes, and barriers by detailed race/ethnicity, interview language, and nativity. Foreign-born respondents overall and within racial/ethnic categories had higher vaccination coverage (80.9%), higher intent to be vaccinated (4.2%), and lower hesitancy towards COVID-19 vaccination (6.0%) than US-born respondents (72.6%, 2.9%, and 15.8%, respectively). Vaccination coverage was significantly lower for certain subcategories of national origin or heritage (e.g., Jamaican (68.6%), Haitian (60.7%), Somali (49.0%) in weighted estimates). Respondents interviewed in Spanish had lower vaccination coverage than interviewees in English but higher intent to be vaccinated and lower reluctance. Collection and analysis of nativity, detailed race/ethnicity and language information allow identification of disparities among racial/ethnic subgroups. Vaccination programs could use such information to implement culturally and linguistically appropriate focused interventions among communities with lower vaccination coverage.

The COVID-19 pandemic has magnified longstanding health care and social inequities, resulting in disproportionately high COVID-19-associated illness and death among members of racial and ethnic minority groups (1). Equitable use of effective medications (2) could reduce disparities in these severe outcomes (3). Monoclonal antibody (mAb) therapies against SARS-CoV-2, the virus that causes COVID-19, initially received Emergency Use Authorization (EUA) from the Food and Drug Administration (FDA) in November 2020. mAbs are typically administered in an outpatient setting via intravenous infusion or subcutaneous injection and can prevent progression of COVID-19 if given after a positive SARS-CoV-2 test result or for postexposure prophylaxis in patients at high risk for severe illness.(†) Dexamethasone, a commonly used steroid, and remdesivir, an antiviral drug that received EUA from FDA in May 2020, are used in inpatient settings and help prevent COVID-19 progression(§) (2). No large-scale studies have yet examined the use of mAb by race and ethnicity. Using COVID-19 patient electronic health record data from 41 U.S. health care systems that participated in the PCORnet, the National Patient-Centered Clinical Research Network,(¶) this study assessed receipt of medications for COVID-19 treatment by race (White, Black, Asian, and Other races [including American Indian or Alaska Native, Native Hawaiian or Other Pacific Islander, and multiple or Other races]) and ethnicity (Hispanic or non-Hispanic). Relative disparities in mAb** treatment among all patients(††) (805,276) with a positive SARS-CoV-2 test result and in dexamethasone and remdesivir treatment among inpatients(§§) (120,204) with a positive SARS-CoV-2 test result were calculated. Among all patients with positive SARS-CoV-2 test results, the overall use of mAb was infrequent, with mean monthly use at 4% or less for all racial and ethnic groups. Hispanic patients received mAb 58% less often than did non-Hispanic patients, and Black, Asian, or Other race patients received mAb 22%, 48%, and 47% less often, respectively, than did White patients during November 2020-August 2021. Among inpatients, disparities were different and of lesser magnitude: Hispanic inpatients received dexamethasone 6% less often than did non-Hispanic inpatients, and Black inpatients received remdesivir 9% more often than did White inpatients. Vaccines and preventive measures are the best defense against infection; use of COVID-19 medications postexposure or postinfection can reduce morbidity and mortality and relieve strain on hospitals but are not a substitute for COVID-19 vaccination. Public health policies and programs centered around the specific needs of communities can promote health equity (4). Equitable receipt of outpatient treatments, such as mAb and antiviral medications, and implementation of prevention practices are essential to reducing existing racial and ethnic inequities in severe COVID-19-associated illness and death.

OBJECTIVE: To identify potential strategies to mitigate COVID-19 transmission in a Utah meat-processing facility and surrounding community. DESIGN/SETTING: During March-June 2020, 502 workers at a Utah meat-processing facility (facility A) tested positive for SARS-CoV-2. Using merged data from the state disease surveillance system and facility A, we analyzed the relationship between SARS-CoV-2 positivity and worker demographics, work section, and geospatial data on worker residence. We analyzed worker survey responses to questions regarding COVID-19 knowledge, beliefs, and behaviors at work and home. PARTICIPANTS: (1) Facility A workers (n = 1373) with specimen collection dates and SARS-CoV-2 RT-PCR test results; (2) residential addresses of all persons (workers and nonworkers) with a SARS-CoV-2 diagnostic test (n = 1036), living within the 3 counties included in the health department catchment area; and (3) facility A workers (n = 64) who agreed to participate in the knowledge, attitudes, and practices survey. MAIN OUTCOME MEASURES: New cases over time, COVID-19 attack rates, worker characteristics by SARS-CoV-2 test results, geospatially clustered cases, space-time proximity of cases among workers and nonworkers; frequency of quantitative responses, crude prevalence ratios, and counts and frequency of coded responses to open-ended questions from the COVID-19 knowledge, attitudes, and practices survey. RESULTS: Statistically significant differences in race (P = .01), linguistic group (P < .001), and work section (P < .001) were found between workers with positive and negative SARS-CoV-2 test results. Geographically, only 6% of cases were within statistically significant spatiotemporal case clusters. Workers reported using handwashing (57%) and social distancing (21%) as mitigation strategies outside work but reported apprehension with taking COVID-19-associated sick leave. CONCLUSIONS: Mitigating COVID-19 outbreaks among workers in congregate settings requires a multifaceted public health response that is tailored to the workforce. IMPLICATIONS FOR POLICY AND PRACTICE: Tailored, multifaceted mitigation strategies are crucial for reducing COVID-19-associated health disparities among disproportionately affected populations.

We compared the characteristics of hospitalized and nonhospitalized patients who had coronavirus disease in Atlanta, Georgia, USA. We found that risk for hospitalization increased with a patient's age and number of concurrent conditions. We also found a potential association between hospitalization and high hemoglobin A1c levels in persons with diabetes.

Mass gatherings have been implicated in higher rates of transmission of SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19), and many sporting events have been restricted or canceled to limit disease spread (1). Based on current CDC COVID-19 mitigation recommendations related to events and gatherings (2), Major League Baseball (MLB) developed new health and safety protocols before the July 24 start of the 2020 season. In addition, MLB made the decision that games would be played without spectators. Before a three-game series between teams A and B, the Philadelphia Department of Public Health was notified of a team A player with laboratory-confirmed COVID-19; the player was isolated as recommended (2). During the series and the week after, laboratory-confirmed COVID-19 was diagnosed among 19 additional team A players and staff members and one team B staff member. Throughout their potentially infectious periods, some asymptomatic team A players and coaches, who subsequently received positive SARS-CoV-2 test results, engaged in on-field play with teams B and C. No on-field team B or team C players or staff members subsequently received a clinical diagnosis of COVID-19. Certain MLB health and safety protocols, which include frequent diagnostic testing for rapid case identification, isolation of persons with positive test results, quarantine for close contacts, mask wearing, and social distancing, might have limited COVID-19 transmission between teams.

The first reported U.S. case of coronavirus disease 2019 (COVID-19) was detected in January 2020 (1). As of June 15, 2020, approximately 2 million cases and 115,000 COVID-19-associated deaths have been reported in the United States.* Reports of U.S. patients hospitalized with SARS-CoV-2 infection (the virus that causes COVID-19) describe high proportions of older, male, and black persons (2-4). Similarly, when comparing hospitalized patients with catchment area populations or nonhospitalized COVID-19 patients, high proportions have underlying conditions, including diabetes mellitus, hypertension, obesity, cardiovascular disease, chronic kidney disease, or chronic respiratory disease (3,4). For this report, data were abstracted from the medical records of 220 hospitalized and 311 nonhospitalized patients aged >/=18 years with laboratory-confirmed COVID-19 from six acute care hospitals and associated outpatient clinics in metropolitan Atlanta, Georgia. Multivariable analyses were performed to identify patient characteristics associated with hospitalization. The following characteristics were independently associated with hospitalization: age >/=65 years (adjusted odds ratio [aOR] = 3.4), black race (aOR = 3.2), having diabetes mellitus (aOR = 3.1), lack of insurance (aOR = 2.8), male sex (aOR = 2.4), smoking (aOR = 2.3), and obesity (aOR = 1.9). Infection with SARS-CoV-2 can lead to severe outcomes, including death, and measures to protect persons from infection, such as staying at home, social distancing (5), and awareness and management of underlying conditions should be emphasized for those at highest risk for hospitalization with COVID-19. Measures that prevent the spread of infection to others, such as wearing cloth face coverings (6), should be used whenever possible to protect groups at high risk. Potential barriers to the ability to adhere to these measures need to be addressed.

BACKGROUND: To accurately assess micronutrient status, it is necessary to characterize the effects of inflammation and the acute-phase response on nutrient biomarkers. OBJECTIVE: Within a norovirus human challenge study, we aimed to model the inflammatory response of C-reactive protein (CRP) and alpha-1-acid glycoprotein (AGP) by infection status, model kinetics of micronutrient biomarkers by inflammation status, and evaluate associations between inflammation and micronutrient biomarkers from 0 to 35 d post-norovirus exposure. METHODS: Fifty-two healthy adults were enrolled into challenge studies in a hospital setting and followed longitudinally; all were exposed to norovirus, half were infected. Post hoc analysis of inflammatory and nutritional biomarkers was performed. Subjects were stratified by inflammation resulting from norovirus exposure. Smoothed regression models analyzed the kinetics of CRP and AGP by infection status, and nutritional biomarkers by inflammation. Linear mixed-effects models were used to analyze the independent relations between CRP, AGP, and biomarkers for iron, vitamin A, vitamin D, vitamin B-12, and folate from 0 to 35 d post-norovirus exposure. RESULTS: Norovirus-infected subjects had median (IQR) peak concentrations for CRP [16.0 (7.9-29.5) mg/L] and AGP [0.9 (0.8-1.2) g/L] on day 3 and day 4 postexposure, respectively. Nutritional biomarkers that differed (P < 0.05) from baseline within the inflamed group were ferritin (elevated day 3), hepcidin (elevated days 2, 3), serum iron (depressed days 2-4), transferrin saturation (depressed days 2-4), and retinol (depressed days 3, 4, and 7). Nutritional biomarker concentrations did not differ over time within the uninflamed group. In mixed models, CRP was associated with ferritin (positive) and serum iron and retinol (negative, P < 0.05). CONCLUSION: Using an experimental infectious challenge model in healthy adults, norovirus infection elicited a time-limited inflammatory response associated with altered serum concentrations of certain iron and vitamin A biomarkers, confirming the need to consider adjustments of these biomarkers to account for inflammation when assessing nutritional status. These trials were registered at clinicaltrials.gov as NCT00313404 and NCT00674336.

We sought datasets with granular age distributions of rotavirus-positive presentations among children <5 years of age, before the introduction of rotavirus vaccines. We identified 117 datasets and fit parametric age distributions to each country dataset and mortality stratum and calculated the median age, and cumulative proportion of rotavirus gastroenteritis events expected to occur at ages between birth and 5.0 years. The median age of rotavirus-positive hospital admissions was 38 weeks (inter-quartile range IQR: 25-58) in countries with very high child mortality and 65 weeks (IQR: 40-107) in countries with very low/low child mortality. In countries with very high child mortality 69% of rotavirus-positive admissions <5 years were in the first year of life, with 3% by 10 weeks, 8% by 15 weeks and 27% by 26 weeks. This information is critical for assessing the potential benefits of alternative rotavirus vaccination schedules in different countries, and for monitoring programme impact.