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Feb. 3, 2021

Morbidity and Mortality Weekly Report Weekly / Vol. 70 / No. 5 February 5, 2021 Sexual minority persons experience health disparities associated with sexual stigma and discrimination and have a high prevalence of several health conditions that have been associated with severe coronavirus disease 2019 (COVID-19) (1,2). Current COVID-19 surveillance systems do not capture information about sexual orientation. To begin bridging the gap in knowledge about COVID-19 risk among sexual minority adults, CDC examined disparities between sexual minority and heterosexual adults in the prevalence of underlying conditions with strong or mixed evidence of associations with severe COVID-19–related illness (3), by using data from the 2017–2019 Behavioral Risk Factor Surveillance System (BRFSS).* When age, sex, and survey year are adjusted, sexual minority persons have higher prevalences than do heterosexual persons of self-reported cancer, kidney disease, chronic obstructive pulmonary disease (COPD), heart disease (including myocardial infarction, angina, or coronary heart disease), obesity, smoking, diabetes, asthma, hypertension, and stroke. Sexual minority adults who are members of racial/ethnic minority groups disproportionately affected by the pandemic also have higher prevalences of several of these health conditions than do racial/ethnic minority adults who are heterosexual. Collecting data on sexual orientation in COVID-19 surveillance and other studies would improve knowledge about disparities in infection and adverse outcomes by sexual orientation, thereby informing more equitable responses to the pandemic. Sexual Orientation Disparities in Risk Factors for Adverse COVID-19–Related Outcomes, by Race/Ethnicity — Behavioral Risk Factor Surveillance System, United States, 2017–2019 Kevin C. Heslin, PhD1; Jeffrey E. Hall, PhD1 *BRFSS collects information on demographics and health, including underlying conditions, use of preventive services, health care access, and health-related behavioral risk factors for the 50 states, District of Columbia, three U.S. territories (American Samoa, Guam, and U.S. Virgin Islands), and two freely associated states (Federated States of Micronesia and Palau). https://www.cdc. gov/brfss/index.html Conducted by the 50 states, the District of Columbia, three U.S. territories, and two freely associated states, BRFSS is a collection of population health surveys that gather demographic and health-related information from noninstitutionalized U.S. residents aged ≥18 years. BRFSS includes standard core INSIDE 155 Decreases in Young Children Who Received Blood Lead Level Testing During COVID-19 — 34 Jurisdictions, January–May 2020 162 Racial and Ethnic Disparities in the Prevalence of Stress and Worry, Mental Health Conditions, and Increased Substance Use Among Adults During the COVID-19 Pandemic — United States, April and May 2020 167 Vital Signs: Prevalence of Multiple Forms of Violence and Increased Health Risk Behaviors and Conditions Among Youths — United States, 2019 174 Demographic Characteristics of Persons Vaccinated During the First Month of the COVID-19 Vaccination Program — United States, December 14, 2020– January 14, 2021 178 Early COVID-19 First-Dose Vaccination Coverage Among Residents and Staff Members of Skilled Nursing Facilities Participating in the Pharmacy Partnership for Long-Term Care Program — United States, December 2020–January 2021 184 QuickStats Continuing Education examination available at https://www.cdc.gov/mmwr/mmwr_continuingEducation.html U.S. Department of Health and Human Services Centers for Disease Control and Prevention Morbidity and Mortality Weekly Report 150 MMWR / February 5, 2021 / Vol. 69 / No. 5 US Department of Health and Human Services/Centers for Disease Control and Prevention The MMWR series of publications is published by the Center for Surveillance, Epidemiology, and Laboratory Services, Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services, Atlanta, GA 30329-4027. Suggested citation: [Author names; first three, then et al., if more than six.] [Report title]. MMWR Morb Mortal Wkly Rep 2021;70:[inclusive page numbers]. Centers for Disease Control and Prevention Rochelle P. Walensky, MD, MPH, Director Anne Schuchat, MD, Principal Deputy Director Daniel B. Jernigan, MD, MPH, Acting Deputy Director for Public Health Science and Surveillance Rebecca Bunnell, PhD, MEd, Director, Office of Science Jennifer Layden, MD, PhD, Deputy Director, Office of Science Michael F. Iademarco, MD, MPH, Director, Center for Surveillance, Epidemiology, and Laboratory Services MMWR Editorial and Production Staff (Weekly) Charlotte K. Kent, PhD, MPH, Editor in Chief Jacqueline Gindler, MD, Editor Brian A. King, PhD, MPH, Guest Science Editor Paul Z. Siegel, MD, MPH, Associate Editor Mary Dott, MD, MPH, Online Editor Terisa F. Rutledge, Managing Editor Teresa M. Hood, MS, Acting Lead Technical Writer-Editor Glenn Damon, Soumya Dunworth, PhD, Catherine B. Lansdowne, MS, Srila Sen, MA, Stacy Simon, MA, Jeffrey D. Sokolow, MA, Technical Writer-Editors Martha F. Boyd, Lead Visual Information Specialist Alexander J. Gottardy, Maureen A. Leahy, Julia C. Martinroe, Stephen R. Spriggs, Tong Yang, Visual Information Specialists Quang M. Doan, MBA, Phyllis H. King, Terraye M. Starr, Moua Yang, Information Technology Specialists MMWR Editorial Board Timothy F. Jones, MD, Chairman Matthew L. Boulton, MD, MPH Carolyn Brooks, ScD, MA Jay C. Butler, MD Virginia A. Caine, MD Jonathan E. Fielding, MD, MPH, MBA David W. Fleming, MD William E. Halperin, MD, DrPH, MPH Christopher M. Jones, PharmD, DrPH, MPH Jewel Mullen, MD, MPH, MPA Jeff Niederdeppe, PhD Celeste Philip, MD, MPH Patricia Quinlisk, MD, MPH Patrick L. Remington, MD, MPH Carlos Roig, MS, MA William Schaffner, MD Nathaniel Smith, MD, MPH Morgan Bobb Swanson, BS Ian Branam, MA, Acting Lead Health Communication Specialist Shelton Bartley, MPH, Lowery Johnson, Amanda Ray, Jacqueline N. Sanchez, MS, Health Communication Specialists Will Yang, MA, Visual Information Specialist questions and optional modules. All participants are asked “Has a doctor, nurse, or other health practitioner ever told you that you have…” followed by a list of health conditions.† The number of jurisdictions opting to include questions on sexual orientation in BRFSS has increased in recent years. Gender identity is addressed in a BRFSS survey question separately from sexual orientation questions. This analysis combined the 3 most recent years of BRFSS data for states that include a sexual orientation question: a total of 28 states in 2017, a total of 29 states in 2018, and a total of 31 states in 2019.§ The percentage of BRFSS respondents who refused to answer the sexual orientation question was 1.8% (both male and female) in 2017, 1.5% (male) and 1.9% (female) in 2018, and 1.6% (male) and 2.0% (female) in 2019. Among states with a sexual † Health conditions were elicited by the question “Has a doctor, nurse, or other health practitioner ever told you that you have…” followed by a set of conditions, including those used in this analysis: a heart attack, also called a myocardial infarction; angina or coronary heart disease; stroke; asthma (with positive responses followed by “Do you still have asthma?”); any other type of cancer (other than skin cancer); chronic obstructive pulmonary disease, emphysema, or chronic bronchitis; kidney disease (not including kidney stones, bladder infection, or incontinence); or diabetes (followed by questions allowing separation of gestational diabetes, prediabetes, and borderline diabetes). Hypertension was assessed separately but with the same question format. Possible responses to these questions were “yes,” “no,” “don’t know/not sure,” or refused. Because coronary heart disease is the most common cause of heart attack/ myocardial infarction, respondents answering affirmatively to questions about a heart attack/myocardial infarction, angina, or coronary heart disease were counted as having heart disease. orientation question, the median overall survey response rate was 42.3% in 2017, 48.5% in 2018, and 46.4% in 2019. For this analysis, respondents were classified as sexual minority persons (versus heterosexual persons) if they selected any of the following responses from the 2017–2019 questions on sexual orientation: “gay,” “lesbian or gay,” or “bisexual¶” (sexual minority: 24,582 [unweighted], 4.7% [weighted]; § Jurisdictions with a sexual orientation question in 2017 were California, Connecticut, Delaware, Florida, Georgia, Hawaii, Illinois, Indiana, Iowa, Louisiana, Massachusetts, Minnesota, Mississippi, Montana, Nevada, New York, North Carolina, Ohio, Oklahoma, Pennsylvania, Rhode Island, South Carolina, Texas, Vermont, Virginia, Washington, Wisconsin, and Guam. Jurisdictions with a sexual orientation question in 2018 were Connecticut, Delaware, Florida, Hawaii, Idaho, Illinois, Kansas, Louisiana, Maryland, Minnesota, Mississippi, Missouri, Montana, Nevada, New York, North Carolina, Ohio, Oklahoma, Pennsylvania, Rhode Island, South Carolina, Tennessee, Texas, Vermont, Virginia, Washington, West Virginia, Wisconsin, and Guam. Jurisdictions with a sexual orientation question in 2019 were Alaska, Arizona, Colorado, Connecticut, Delaware, Florida, Georgia, Hawaii, Idaho, Indiana, Kansas, Louisiana, Maryland, Minnesota, Mississippi, Montana, New York, North Carolina, Ohio, Oklahoma, Rhode Island, South Carolina, Tennessee, Texas, Utah, Vermont, Virginia, Washington, West Virginia, Wisconsin, and Guam. ¶ In 2017, the BRFSS question on sexual orientation was “Do you consider yourself to be: straight, lesbian or gay, or bisexual?” The interviewer recorded responses of “other,” “don’t know/not sure,” and refusals. In 2018 and 2019, the BRFSS question on sexual orientation was “Which of the following best represents how you think of yourself?” Response options for men were “gay”; “straight, that is, not gay”; “bisexual”; and “something else.” Response options for women were “lesbian or gay”; “straight, that is, not gay”; “bisexual”; and “something else.” The interviewer recorded “don’t know” responses and refusals. The analysis excludes 3.4% of respondents who responded “something else,” “other,” or “don’t know” to the sexual orientation question or who refused to respond. Morbidity and Mortality Weekly Report US Department of Health and Human Services/Centers for Disease Control and Prevention MMWR / February 5, 2021 / Vol. 70 / No. 5 151 heterosexual: 619,374 [unweighted], 95.3% [weighted]). Race and ethnicity were categorized as Hispanic (any race), non-Hispanic Black, non-Hispanic White, and non-Hispanic other; the non-Hispanic other category includes non-Hispanic Asian, non-Hispanic American Indian/Alaskan Native, and non-Hispanic persons of other races/ethnicities. Adults with the following conditions are at increased risk for severe illness from COVID-19: cancer, chronic kidney disease, COPD, heart conditions, obesity, pregnancy, sickle cell disease, smoking, and type 2 diabetes mellitus (3). In addition, adults with the following conditions might be at increased risk for severe illness from COVID-19: asthma, cerebrovascular disease, cystic fibrosis, hypertension, immunocompromised state, neurologic conditions (e.g., dementia), liver disease, overweight, pulmonary fibrosis, thalassemia, and type 1 diabetes mellitus. Among these conditions with strong or mixed evidence of associations with adverse COVID-19–related outcomes (3,4), the following variables from the BRFSS core module were included: asthma (current and ever), cancer (except nonmelanoma skin cancer), COPD, heart disease (myocardial infarction, angina, or coronary heart disease) (4), diabetes, hypertension, kidney disease, obesity (current), smoking (current), and stroke. Hypertension questions were asked only in 2017 and 2019.** Adjusted percentages and adjusted prevalence ratios (aPRs) comparing sexual minority persons and heterosexual persons with each condition were calculated overall and stratified by race/ethnicity. Using Stata (version 16.0; StataCorp) software to account for the BRFSS survey design, all estimates were adjusted for age, sex (male or female), and survey year, using multivariate logistic regression with the margins and nonlinear combination of estimators (nlcom) postestimation commands. The nlcom procedure takes nonlinear transformations of a parameter estimate from a fitted model and applies the delta method to calculate the variance. All aPRs with 95% confidence intervals that exclude 1 are considered statistically significant. Among all racial/ethnic groups combined, sexual minority persons had higher adjusted prevalences of asthma (current and ever), cancer, heart disease, COPD, hypertension, kidney ** The differences between the CDC list of conditions that place adults at increased risk for severe illness from COVID-19 and the BRFSS variables are the following, respectively: current cancer versus lifetime history of (ever) cancer; current chronic kidney disease versus ever kidney disease; current chronic obstructive pulmonary disease versus ever chronic obstructive pulmonary disease; current heart condition versus ever coronary heart disease, angina, or heart attack/myocardial infarction; obesity and severe obesity versus obesity; and current type 2 diabetes mellitus versus ever diabetes. BRFSS does not include a variable on sickle cell disease, which is one of the conditions on the CDC “at increased risk” list. The differences between the CDC list and BRFSS variables are the following, respectively: moderate to severe asthma versus asthma; current cerebrovascular disease versus ever stroke; current hypertension versus ever hypertension; and current type 1 diabetes mellitus versus ever diabetes. disease, obesity (current), smoking (current), and stroke than did heterosexual persons (Table). Among non-Hispanic Black persons, sexual minority persons had higher adjusted prevalences of asthma (current and ever), COPD, and smoking (current) than did heterosexual persons. Among non-Hispanic White persons, sexual minority persons had higher adjusted prevalences of asthma (current and ever), cancer, COPD, diabetes, hypertension, kidney disease, obesity (current), smoking (current), and stroke than did heterosexual persons. Among Hispanic persons, sexual minority persons had higher adjusted prevalences of asthma (current and ever), cancer, COPD, smoking (current), and stroke than did heterosexual persons. Among non-Hispanic other persons, sexual minority persons had higher adjusted prevalences of asthma (current and ever), cancer, heart disease, COPD, obesity (current), and smoking (current) than did heterosexual persons. Among the 11 conditions studied, the highest significant aPRs were observed among sexual minority persons overall, and for eight of these 11 conditions, the highest significant aPRs were among sexual minority persons within a racial/ethnic minority group. None of the 11 conditions studied was more prevalent among heterosexual persons than among members of sexual minority groups. Discussion This analysis found that several underlying health conditions that increase or might increase the risk for more severe COVID-19–related illness were more prevalent among sexual minority persons than heterosexual persons, both within the overall population and within specific racial/ethnic groups. Non-Hispanic Black and Hispanic populations have been disproportionately affected by the COVID-19 pandemic in the United States, and the increased prevalence of certain risk factors among sexual minority members of these racial/ethnic minority populations is of particular concern. Because of their sexual orientation, sexual minority persons experience stigmatization and discrimination (1) that can increase vulnerabilities to illness and limit the means to achieving optimal health and well-being through meaningful work and economic security, routine and critical health care, and relationships in which sexual orientation and gender identity can be openly expressed (5). Persons who are members of both sexual minority and racial/ethnic minority groups might therefore experience a convergence of distinct social, economic, and environmental disadvantages that increase chronic disease disparities and the risk for adverse COVID-19–related outcomes. In November 2020, CDC conducted a series of group listening sessions with representatives of advocacy and health care organizations serving sexual and gender minority communities across the United States to gather information on the effect of the pandemic on their constituents and patient Morbidity and Mortality Weekly Report 152 MMWR / February 5, 2021 / Vol. 70 / No. 5 US Department of Health and Human Services/Centers for Disease Control and Prevention TABLE. Adjusted prevalence and adjusted prevalence ratios (aPRs)* of underlying health conditions† among sexual minority§ and heterosexual adults, by race and Hispanic origin — Behavioral Risk Factor Surveillance System, United States, 2017–2019 Characteristic % (95% CI) All Black, non-Hispanic White, non-Hispanic Other, non-Hispanic Hispanic Respondents, no. 643,956 54,486 495,278 51,781 42,411 Sexual minority persons,¶ no. (%) 24,582 (4.7) 2,004 (4.7) 17,656 (4.4) 2,616 (5.5) 2,306 (5.3) Underlying condition Asthma, current Sexual minority 13.8 (13.0–14.6) 14.5 (12.2–16.8) 13.3 (12.4–14.3) 13.5 (11.1–16.0) 14.2 (11.5–16.9) Heterosexual 8.9 (8.8–9.1) 10.7 (10.2–11.2) 9.2 (9.0–9.3) 8.1 (7.5–8.7) 6.8 (6.3–7.3) aPR 1.55 (1.45–1.64) 1.35 (1.13–1.58) 1.46 (1.35–1.56) 1.67 (1.35–2.00) 2.09 (1.67–2.51) Asthma, ever Sexual minority 19.8 (18.8–20.8) 21.0 (18.2–23.8) 19.1 (18.0–20.1) 19.7 (16.7–22.8) 20.9 (17.7–24.0) Heterosexual 14.1 (13.9–14.2) 15.9 (15.3–16.5) 14.3 (14.1–14.6) 13.3 (12.5–14.0) 11.8 (11.2–12.4) aPR 1.41 (1.34–1.48) 1.32 (1.14–1.50) 1.33 (1.25–1.41) 1.49 (1.24–1.73) 1.78 (1.49–2.06) Cancer** Sexual minority 9.2 (8.4–10.0) 7.9 (5.6–10.2) 9.2 (8.4–9.9) 9.1 (6.5–11.6) 9.7 (6.2–13.3) Heterosexual 7.3 (7.2–7.4) 6.1 (5.8–6.5) 7.8 (7.6–7.9) 5.8 (5.3–6.4) 5.9 (5.4–6.5) aPR 1.26 (1.15–1.37) 1.29 (0.90–1.67) 1.18 (1.08–1.28) 1.56 (1.10–2.02) 1.64 (1.02–2.26) Heart disease†† Sexual minority 8.0 (7.3–8.9) 8.8 (6.2–11.4) 7.3 (6.6–8.0) 10.9 (7.8–14.1) 9.8 (6.6–13.0) Heterosexual 6.8 (6.6–6.9) 7.0 (6.6–7.4) 6.7 (6.6–6.8) 7.0 (6.5–7.5) 6.7 (6.1–7.3) aPR 1.19 (1.08–1.30) 1.26 (0.88–1.64) 1.09 (0.98–1.19) 1.56 (1.10–2.03) 1.46 (0.97–1.95) COPD Sexual minority 10.3 (9.5–11.1) 10.2 (7.8–12.7) 10.1 (9.4–11.1) 9.2 (7.1–11.3) 10.3 (7.3–13.3) Heterosexual 6.9 (6.8–7.0) 7.1 (6.7–7.6) 7.3 (7.2–7.5) 5.9 (5.4–6.3) 4.8 (4.3–5.3) aPR 1.49 (1.37–1.61) 1.44 (1.09–1.78) 1.40 (1.28–1.52) 1.45 (1.14–1.76) 2.15 (1.49–2.81) Diabetes Sexual minority 12.5 (11.6–13.4) 18.5 (15.3–21.7) 11.0 (10.1–11.9) 17.4 (13.1–21.6) 14.6 (11.4–17.7) Heterosexual 11.6 (11.4–11.7) 17.1 (16.6–17.7) 9.8 (9.6–9.9) 13.7 (12.9–14.4) 16.1 (15.3–16.8) aPR 1.08 (1.00–1.16) 1.08 (0.89–1.27) 1.12 (1.03–1.22) 1.27 (0.95–1.59) 0.91 (0.71–1.11) Hypertension§§ Sexual minority 35.7 (34.2–37.1) 45.4 (41.5–49.4) 34.9 (33.2–36.5) 35.9 (30.1–41.1) 32.3 (27.4–37.2) Heterosexual 33.6 (33.3–33.9) 45.2 (44.3–46.1) 32.1 (31.8–32.4) 31.0 (29.7–32.2) 32.1 (31.1–33.1) aPR 1.06 (1.02–1.11) 1.01 (0.92–1.09) 1.09 (1.05–1.14) 1.16 (0.98–1.33) 1.01 (0.85–1.16) Kidney disease Sexual minority 4.7 (4.0–5.4) 7.2 (4.2–10.2) 4.2 (3.6–4.8) 4.5 (3.0–5.9) 5.8 (2.7–8.8) Heterosexual 3.2 (3.1–3.3) 4.2 (3.8–4.5) 2.9 (2.8–3.0) 3.6 (3.0–4.1) 3.7 (3.3–4.1) aPR 1.47 (1.25–1.69) 1.73 (0.99–2.46) 1.42 (1.22–1.63) 1.25 (0.80–1.70) 1.55 (0.71–2.39) Obesity (BMI≥30 kg/m2) Sexual minority 34.1 (32.9–35.3) 41.4 (37.6–45.1) 33.6 (32.3–35.0) 26.2 (22.8–29.7) 35.4 (31.5–39.3) Heterosexual 31.9 (31.6–32.1) 41.0 (40.2–41.8) 30.5 (30.2–30.7) 22.1 (21.1–23.0) 35.4 (34.4–36.5) aPR 1.07 (1.03–1.11) 1.01 (0.92–1.10) 1.10 (1.06–1.15) 1.19 (1.03–1.35) 1.00 (0.89–1.11) Smoking, current Sexual minority 22.1 (21.1–23.1) 22.4 (19.4–25.4) 22.9 (21.7–24.0) 19.1 (16.2–22.0) 19.1 (16.0–22.2) Heterosexual 15.5 (15.3–15.7) 16.9 (16.3–17.5) 16.5 (16.3–16.7) 12.8 (12.2–13.5) 11.5 (10.8–12.1) aPR 1.43 (1.36–1.50) 1.32 (1.14–1.51) 1.39 (1.31–1.46) 1.49 (1.25–1.73) 1.67 (1.38–1.95) Stroke Sexual minority 4.7 (4.1–5.4) 7.5 (5.1–9.9) 4.0 (3.4–4.5) 5.7 (3.2–8.2) 6.2 (3.5–8.9) Heterosexual 3.4 (3.4–3.5) 5.5 (5.2–5.9) 3.2 (3.1–3.3) 3.6 (3.2–4.0) 3.0 (2.6–3.4) aPR 1.37 (1.19–1.56) 1.36 (0.91–1.81) 1.24 (1.05–1.43) 1.59 (0.88–2.30) 2.08 (1.13–3.00) Abbreviations: BMI = body mass index; CI = confidence interval; COPD = chronic obstructive pulmonary disease. * Adjusted for age, sex (female or male), and Behavioral Risk Factor Surveillance System survey year. Adjusted prevalence ratios with 95% CIs that exclude 1 are statistically significant. † Includes conditions with strong or mixed evidence of associations with COVID-19–associated adverse outcomes. § Includes persons who identified as gay, lesbian or gay, or bisexual. The analysis excludes those who responded to the sexual orientation question with “something else,” “other,” or “don’t know” or who refused (3.4% of respondents). ¶ Unweighted number of respondents. ** Lifetime history of cancer, except nonmelanoma skin cancer. †† Includes heart attack/myocardial infarction, coronary heart disease, or angina. §§ 2017 and 2019 Behavioral Risk Factor Surveillance Systems only. Morbidity and Mortality Weekly Report US Department of Health and Human Services/Centers for Disease Control and Prevention MMWR / February 5, 2021 / Vol. 70 / No. 5 153 populations. A major concern expressed in these sessions was that information about sexual orientation and gender identity is not standard in COVID-19 data collection systems. Privacy issues around sexual orientation and concerns about nonresponse or refusals to answer such questions have often been used as justification for not including these elements in public health surveillance and patient record systems (6); however, regarding public health surveillance systems, CDC surveys such as BRFSS, the National Health Interview Survey, and the National Survey on Family Growth have demonstrated the feasibility of collecting sexual orientation data from the civilian, noninstitutionalized population on an ongoing basis (2). Several months into the COVID-19 pandemic, several states and local jurisdictions responded to demands from advocacy organizations to begin collecting these data. For example, in July 2020, California Health and Human Services announced emergency regulations that required local health departments and service providers to collect and report voluntary data on sexual orientation and gender identity to better understand the effect of COVID-19 in these population subgroups. Illinois has included a COVID-19 module in its 2020 BRFSS that also includes questions on sexual orientation and gender identity (7). Pennsylvania, the District of Columbia, and several other jurisdictions are taking steps toward including sexual orientation and gender identity information in COVID-19–related data collection; however, these data are not yet available (6). The findings in this report are subject to at least six limitations. First, all conditions are self-reported, and all but three (asthma, obesity, and smoking) refer to lifetime instead of current prevalence. Second, although the 3-year data set included as many as 31 states in 2019, the data are not nationally representative. Third, although BRFSS variables used in this analysis are general measures of the list of underlying health conditions identified by CDC as COVID-19 risk factors (3), they do not always reflect the clinical specificity of the condition list; for example, the diabetes question does not distinguish between type 1 and type 2 diabetes, and the heart disease variable includes conditions that might not affect COVID-19 outcomes (4). Fourth, several important underlying health conditions, such as sickle cell disease, have no corresponding variable in BRFSS. Fifth, although BRFSS includes a question on gender identity, the number of respondents identifying as transgender or nonbinary was too small for reliable estimates compared with the majority cisgender population. Finally, the large number of respondents in the aggregated non-Hispanic other race/ethnicity category could potentially obscure disparities between sexual minority and heterosexual populations within these smaller communities. Summary What is already known about this topic? Risks for COVID-19 acquisition and severe associated illness vary by characteristics, including race/ethnicity, age, and urban/rural residence. U.S. COVID-19 surveillance systems lack information on sexual orientation, hampering examination of COVID-19– associated disparities among sexual minority adults. What is added by this report? Sexual minority persons in the United States have higher self-reported prevalences of several underlying health conditions associated with severe outcomes from COVID-19 than do heterosexual persons, both in the overall population and among racial/ethnic minority groups. What are the implications for public health practice? Inclusion of sexual orientation and gender identity data in COVID-19 surveillance and other data collections could improve knowledge about disparities in infections and adverse outcomes among sexual and gender minority populations, overall and by race/ethnicity. Despite the numerous studies among racial/ethnic minority groups and the increasing number of studies among sexual minority groups, examinations of health outcomes by combinations of sexual orientation and race/ethnicity remain relatively rare. Attention to potentially larger disparities at the intersections of sexual orientation and race/ethnicity is critical to ensuring health equity for all, including subpopulations whose circumstances often remain uncaptured despite acknowledgments of their distinct importance and needs. Because of longstanding social inequities and higher prevalences of several underlying health conditions, sexual minority populations might be vulnerable to COVID-19 acquisition and associated severe outcomes, and this vulnerability might be magnified when coupled with other demographic characteristics such as race/ethnicity (8). However, because data on sexual orientation are not collected in existing COVID-19 data systems, the effect of COVID-19 on sexual minority populations is unknown. This data gap underscores the need to extend COVID-19 surveillance and other studies to include measures of sexual orientation and gender identity. This recommendation is consistent with the emphasis on “key equity indicators” in the January 2021 Executive Order on Ensuring a Data-Driven Response to COVID-19 and Future High-Consequence Public Health Threats (9). Expanding sexual orientation and gender identity data collection to surveillance systems with shorter lags in data reporting could support more equitable representation of sexual and gender minority populations in public health data systems to facilitate improved decision-making during and after the pandemic. Morbidity and Mortality Weekly Report 154 MMWR / February 5, 2021 / Vol. 70 / No. 5 US Department of Health and Human Services/Centers for Disease Control and Prevention Corresponding author: Kevin C. Heslin, kheslin@cdc.gov. 1CDC COVID-19 Response Team. All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed. References 1. Logie C. The case for the World Health Organization’s Commission on the Social Determinants of Health to address sexual orientation. Am J Public Health 2012;102:1243–6. PMID:22594723 https://doi. org/10.2105/AJPH.2011.300599 2. US Department of Health and Human Services. Healthy people 2020: lesbian, gay, bisexual, and transgender health. Washington, DC: US Department of Health and Human Services; 2020. https://www.healthypeople.gov/2020/topics-objectives/topic/ lesbian-gay-bisexual-and-transgender-health 3. CDC. COVID-19: people with certain medical conditions. Atlanta, GA: US Department of Health and Human Services, CDC; 2020. https:// www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/peoplewith-medical-conditions.html 4. Silver SR, Li J, Boal WL, Shockey TL, Groenewold MR. Prevalence of underlying medical conditions among selected essential critical infrastructure workers—Behavioral Risk Factor Surveillance System, 31 states, 2017–2018. MMWR Morb Mortal Wkly Rep 2020;69:1244–9. PMID:32914769 https://doi.org/10.15585/mmwr.mm6936a3 5. Flentje A, Heck NC, Brennan JM, Meyer IH. The relationship between minority stress and biological outcomes: a systematic review. J Behav Med 2020;43:673–94. PMID:31863268 https://doi.org/10.1007/ s10865-019-00120-6 6. Krause KD. Implications of the COVID-19 pandemic on LGBTQ communities. J Public Health Manag Pract 2021;27(Suppl 1):S69–71. PMID:33239566 https://doi.org/10.1097/PHH.0000000000001273 7. Cahill S, Grasso C, Keuroghlian A, Sciortino C, Mayer K. Sexual and gender minority health in the COVID-19 pandemic: why data collection and combatting discrimination matter now more than ever. Am J Public Health 2020;110:1360–1. PMID:32783729 https://doi.org/10.2105/ AJPH.2020.305829 8. Gray DM 2nd, Anyane-Yeboa A, Balzora S, Issaka RB, May FP. COVID-19 and the other pandemic: populations made vulnerable by systemic inequity. Nat Rev Gastroenterol Hepatol 2020;17:520–2. PMID:32541960 https://doi.org/10.1038/s41575-020-0330-8 9. Executive Office of the President. Ensuring a data-driven response to COVID-19 and future high-consequence public health threats. Fed Regist 2021 Jan 26;86(15):7189–91. https://www.federalregister.gov/ documents/2021/01/26/2021-01849/ensuring-a-data-driven-responseto-covid-19-and-future-high-consequence-public-health-threats Morbidity and Mortality Weekly Report US Department of Health and Human Services/Centers for Disease Control and Prevention MMWR / February 5, 2021 / Vol. 70 / No. 5 155 Decreases in Young Children Who Received Blood Lead Level Testing During COVID-19 — 34 Jurisdictions, January–May 2020 Joseph G. Courtney, PhD1; Stella O. Chuke, MBBS1; Kelly Dyke1; Kimball Credle1; Carolina Lecours, MPH1; Kathryn B. Egan, PhD1; Monica Leonard, MPH1 Exposure to lead, a toxic metal, can result in severe effects in children, including decreased ability to learn, permanent neurologic damage, organ failure, and death. CDC and other health care organizations recommend routine blood lead level (BLL) testing among children as part of well-child examinations to facilitate prompt identification of elevated BLL, eliminate source exposure, and provide medical and other services (1). To describe BLL testing trends among young children during the coronavirus disease 2019 (COVID-19) pandemic, CDC analyzed data reported from 34 state and local health departments about BLL testing among children aged <6 years conducted during January–May 2019 and January–May 2020. Compared with testing in 2019, testing during January–May 2020 decreased by 34%, with 480,172 fewer children tested. An estimated 9,603 children with elevated BLL were missed because of decreased BLL testing. Despite geographic variability, all health departments reported fewer children tested for BLL after the national COVID-19 emergency declaration (March–May 2020). In addition, health departments reported difficulty conducting medical follow-up and environmental investigations for children with elevated BLLs because of staffing shortages and constraints on home visits associated with the pandemic. Providers and public health agencies need to take action to ensure that children who missed their scheduled blood lead screening test, or who required follow-up on an earlier high BLL, be tested as soon as possible and receive appropriate care. CDC identifies no safe BLL in children and considers a blood lead reference value (BLRV) of 5.0 µg/dL* sufficient to prompt clinical and public health intervention (1,2). Among children aged <6 years, very high BLL (>70 µg/dL) can cause neurologic problems (e.g., seizures or coma), organ failure, and death. Lower, but still elevated, BLL can affect the nervous system, causing permanent neurologic damage, behavioral disorders, and cognitive impairment (1). In the United States, the most common childhood lead exposures are from lead-based paint *CDC uses a BLRV of 5.0 µg/dL to identify children with blood lead levels that are higher than those of most children. The BLRV is based on the 97.5th percentile of the NHANES blood lead distribution in children aged 1–5 years. The current BLRV is based on NHANES data from 2007–2008 and 2009–2010. that was used in pre-1978 housing,† lead-contaminated soil or lead-containing pollutants from industrial sources, and water from old lead pipes and fixtures (3). Very young children might ingest lead dust or paint because of their tendency to put fingers or objects (toys or paint chips) in their mouths, and they more readily absorb lead because their bodies are rapidly developing. Primary prevention focuses on reducing lead exposures in homes, schools, and communities. Secondary prevention consists of BLL screening as part of routine wellchild examinations. Early identification of children with lead exposure can help identify and eliminate lead sources (and future exposures for other children); reduce their BLL over time; and link children with high BLLs to medical, nutritional, and educational services. Medicaid-enrolled children are required to be screened at ages 12 and 24 months; many states have additional screening requirements (4). In 1995, elevated BLLs became a nationally reportable condition (5). CDC funds 53 state and local childhood lead poisoning prevention programs to conduct ongoing surveillance of BLL testing among children.§ During May and June 2020, CDC received anecdotal reports of declines in BLL testing. To understand BLL testing trends during the COVID-19 pandemic, including after a national emergency was declared in March 2020, CDC requested that state and local health departments report the total number of children aged <6 years with BLL tests by month during January–May 2019 and January–May 2020. This activity was reviewed by CDC and was conducted consistent with applicable federal law and CDC policy.¶ Health departments could also submit qualitative information. Based on the 2007–2010 National Health and Nutrition Examination Survey (NHANES) data and subsequent trends** (1), an estimated 2.0% of children who did not have a BLL test were conservatively assumed to have levels exceeding the BLRV. † The U.S. Consumer Products Safety Commission banned lead-based paints for residential use in 1978. § https://www.cdc.gov/nceh/lead/programs/default.htm ¶ 45 C.F.R. part 46.102(l)(2), 21 C.F.R. part 56; 42 U.S.C. Sect. 241(d); 5 U.S.C. Sect. 552a; 44 U.S.C. Sect. 3501 et seq. ** Trends in NHANES blood lead levels are in the National Report on Human Exposure to Environmental Chemicals Updated Tables, January 2019. https:// www.cdc.gov/exposurereport/pdf/FourthReport_UpdatedTables_Volume1_ Jan2019-508.pdf Morbidity and Mortality Weekly Report 156 MMWR / February 5, 2021 / Vol. 70 / No. 5 US Department of Health and Human Services/Centers for Disease Control and Prevention Data for the period of interest for children aged <6 years were received from 34 state and local health departments, including the District of Columbia and New York City.†† Overall, the number of children aged <6 years who had BLL tests during January–May 2020 (948,844) was lower by 33.6% (480,172) than the number who had BLL tests during January–May 2019 (1,429,016) (Figure), resulting in an estimated 9,603 children with elevated BLLs being missed. During the analysis period, the number of children with BLL testing was lower during every month during January–May 2020 compared with the number with testing during the same period in 2019; the largest proportional decrease (66.4%) occurred in April 2020. During the early pandemic period (March–May 2020), the number of children with BLL tests (481,199) decreased by 52.5% compared with the same period in 2019 (880,812). Despite geographic variation, all 34 responding state and local health departments reported decreased BLL testing during March–May 2020 compared with testing during 2019 (Table). Several health departments reported difficulties in conducting home nursing visits and environmental investigations following identification of children with BLL above the reference value because of staffing shortages and difficulties conducting home visits. In addition, some families whose children had elevated BLLs were no longer in the listed residence. Discussion Approximately 500,000 fewer children in the reporting jurisdictions were tested for lead exposure during the first 5 months of 2020 than during the same period in 2019. Estimating from this finding, approximately 10,000 children with elevated BLL were missed because of decreased testing. Reported challenges to conducting follow-up medical visits and environmental investigations indicate delays in exposure elimination and linkage to critical services for these children. Although socioeconomic data were not collected, a disproportionate impact is anticipated among children at risk for increased lead exposure, including children from racial or ethnic minority groups, from families who have been economically or socially marginalized, and those living in older housing with lead-based paint (1,3). These groups have also been disproportionately affected by the COVID-19 pandemic (6,7). Lead testing trends among young children mirror declines in other pediatric medical services during the pandemic, including emergency department visits †† Alabama, Alaska, Arizona, California, Colorado, Delaware, District of Columbia, Florida, Georgia, Hawaii, Illinois, Indiana, Iowa, Kansas, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Missouri, Nevada, New Hampshire, New Mexico, New York State (excludes New York City), New York City, Ohio, Oregon, Rhode Island, Tennessee, Texas, Washington, West Virginia, and Wisconsin. FIGURE. Number of children aged <6 years who received blood lead level (BLL) tests,* by month — 34 U.S. jurisdictions,† 2019–2020 0 50,000 100,000 150,000 200,000 250,000 300,000 350,000 Jan Feb Mar Month Apr May No. of children with BLL tests 2019 2020 * CDC requested that state and local health departments report the total number of children with BLL tests by month during January–May 2019 and January–May 2020. Data for children aged <6 years were received from 34 state and local health departments, including the District of Columbia and New York City. † Alabama, Alaska, Arizona, California, Colorado, Delaware, District of Columbia, Florida, Georgia, Hawaii, Illinois, Indiana, Iowa, Kansas, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Missouri, Nevada, New Hampshire, New Mexico, New York (excluding New York City), New York City, Ohio, Oregon, Rhode Island, Tennessee, Texas, Washington, West Virginia, and Wisconsin. (8), well-child visits and screenings,§§ and orders for childhood vaccines (9) and vaccination coverage (10). As a result of COVID-19 shelter-in-place orders and school closures, there is also concern that children spending more time in contaminated environments could have ongoing or increased exposure. Although telemedicine and other remote service delivery strategies provide an alternative to office and clinic visits during the pandemic, in-person visits are still necessary for many essential health examinations, including BLL testing among children. During the pandemic, the American Academy of Pediatrics recommends that well-child examinations occur in person whenever possible and within the child’s medical home where continuity of care can be established.¶¶ CDC guidance recommends that health care providers identify children who have missed well-child visits or recommended vaccinations and contact them to schedule in-person appointments, with prioritization of infants, children aged <24 months, and §§ https://www.medicaid.gov/resources-for-states/downloads/medicaid-chipbeneficiaries-18-under-COVID-19-snapshot-data.pdf ¶¶ https://services.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/ clinical-guidance/ Morbidity and Mortality Weekly Report US Department of Health and Human Services/Centers for Disease Control and Prevention MMWR / February 5, 2021 / Vol. 70 / No. 5 157 school-aged children.*** It is important that health care providers ensure that all children receive lead testing, including those who missed routine BLL screening, those with prior elevated BLLs who need follow-up testing, and those with possible lead exposure. Collaborations among health departments; Special Supplementation Nutrition Program for Women, Infants, and Children programs; immunization programs; Medicaid; refugee health organizations; and other health service providers for children at risk, including outreach to parents and providers and reminders to test children at risk for lead exposure, can help ensure that these children receive needed health assessments. States and local childhood lead poisoning prevention programs can examine data from blood lead surveillance and Medicaid to identify children in need of lead testing. The findings in this report are subject to at least two limitations. First, this report is based on preliminary surveillance data. Observed declines could be partially caused by delays in laboratory reporting and data entry backlogs. Second, use of laboratory and health department resources for COVID-19 activities could have also affected these preliminary data. However, given broader national trends for pediatric medical services, it is likely that these BLL testing data reflect actual declines. CDC has developed guidance for conducting environmental inspections and public health home visits during the COVID-19 pandemic,††† and the Health Resources and Services Administration’s Maternal and Child Health Bureau has developed guidance for conducting home health visits for young children.§§§ Childhood lead poisoning prevention programs can collaborate with federal and local housing and environmental health agencies to address priority housing hazards. CDC will continue to work with health *** Developmental surveillance and early childhood screenings, including developmental and autism screening, should continue along with referrals for early intervention services and further evaluation if concerns are identified. https://www.cdc.gov/coronavirus/2019-ncov/hcp/pediatric-hcp.html ††† https://www.cdc.gov/coronavirus/2019-ncov/community/organizations/ ph-inspectors-employees.html §§§ https://mchb.hrsa.gov/Home-Visiting-Information-During-COVID-19 Summary What is already known about this topic? Lead can affect a young child’s ability to learn and cause other adverse health effects; no safe blood lead level (BLL) is known. Routine testing can detect elevated BLLs. What is added by this report? During January–May 2020, 34% fewer U.S. children had BLL testing compared with those during January–May 2019, with an estimated 9,603 children with elevated BLLs missed. All 34 reporting jurisdictions reported that fewer children were tested following the COVID-19 national emergency declaration in March. What are the implications for public health practice? COVID-19 has adversely affected identification of children with elevated BLLs, exposure elimination, and linkage to services. It remains important that providers ensure that young children receive appropriate lead testing and care management. departments and other partners to develop and disseminate strategies for BLL testing during the pandemic. As surveillance data become available, CDC will conduct analyses to guide decision-making and interventions toward ensuring all children receive blood lead screening and appropriate care management during the pandemic. Acknowledgments State and local lead poisoning prevention programs. Corresponding author: Joseph G. Courtney, jcourtney@cdc.gov. 1Division of Environmental Health Science and Practice, National Center for Environmental Health, CDC. All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed. Morbidity and Mortality Weekly Report 158 MMWR / February 5, 2021 / Vol. 70 / No. 5 US Department of Health and Human Services/Centers for Disease Control and Prevention TABLE. Number of children aged <6 years with blood lead level (BLL) tests,* absolute change, and percentage change, by jurisdiction — 34 U.S. jurisdictions, 2019–2020 Jurisdiction Month No. of children tested 2019 2020 Absolute change, no. % Change U.S. totals (for programs reporting data) Jan 287,343 286,261 −1,082 −0.4 Feb 260,861 244,384 −16,477 −6.3 Mar 282,150 171,298 −110,852 −39.3 Apr 301,380 101,388 −199,992 −66.4 May 297,282 145,513 −151,769 −51.1 5-month totals Jan–May 1,429,016 948,844 −480,172 −33.6 Alabama Jan 3,376 3,060 −316 −9.4 Feb 2,914 2,219 −695 −23.9 Mar 2,972 1,928 −1,044 −35.1 Apr 3,563 1,328 −2,235 −62.7 May 2,732 1,097 −1,635 −59.8 Alaska Jan 701 561 −140 −20.0 Feb 544 526 −18 −3.3 Mar 659 325 −334 −50.7 Apr 627 334 −293 −46.7 May 581 417 −164 −28.2 Arizona Jan 5,571 5,278 −293 −5.3 Feb 4,701 4,501 −200 −4.3 Mar 5,278 3,060 −2,218 −42.0 Apr 5,470 1,819 −3,651 −66.7 May 5,233 2,300 −2,933 −56.0 California Jan 41,972 39,719 −2,253 −5.4 Feb 36,939 35,170 −1,769 −4.8 Mar 41,215 24,210 −17,005 −41.3 Apr 43,778 12,746 −31,032 −70.9 May 43,734 21,006 −22,728 −52.0 Colorado Jan 1,994 1,406 −588 −29.5 Feb 1,882 1,113 −769 −40.9 Mar 1,826 803 −1,023 −56.0 Apr 1,963 716 −1,247 −63.5 May 2,060 609 −1,451 −70.4 Delaware Jan 1,177 885 −292 −24.8 Feb 1,068 759 −309 −28.9 Mar 1,166 517 −649 −55.7 Apr 1,358 126 −1,232 −90.7 May 1,319 270 −1,049 −79.5 District of Columbia Jan 1,411 1,109 −302 −21.4 Feb 1,126 1,186 60 5.3 Mar 1,357 828 −529 −39.0 Apr 1,465 264 −1,201 −82.0 May 1,408 567 −841 −59.7 Florida Jan 17,839 16,928 −911 −5.1 Feb 16,001 14,444 −1,557 −9.7 Mar 15,165 11,667 −3,498 −23.1 Apr 17,473 8,061 −9,412 −53.9 May 16,993 11,385 −5,608 −33.0 Georgia Jan 9,079 9,401 322 3.5 Feb 8,104 7,302 −802 −9.9 Mar 8,059 4,905 −3,154 −39.1 Apr 8,154 3,818 −4,336 −53.2 May 8,222 4,490 −3,732 −45.4 Hawaii Jan 1,593 1,456 −137 −8.6 Feb 1,378 1,315 −63 −4.6 Mar 1,437 976 −461 −32.1 Apr 1,627 578 −1,049 −64.5 May 1,688 980 −708 −41.9 See table footnotes on page 161. Morbidity and Mortality Weekly Report US Department of Health and Human Services/Centers for Disease Control and Prevention MMWR / February 5, 2021 / Vol. 70 / No. 5 159 TABLE. (Continued) Number of children aged <6 years with blood lead level (BLL) tests,* absolute change, and percentage change, by jurisdiction — 34 U.S. jurisdictions, 2019–2020 Jurisdiction Month No. of children tested 2019 2020 Absolute change, no. % Change Illinois Jan 17,426 18,219 793 4.6 Feb 18,094 16,693 −1,401 −7.7 Mar 19,265 11,326 −7,939 −41.2 Apr 21,269 5,760 −15,509 −72.9 May 21,014 8,700 −12,314 −58.6 Indiana Jan 6,349 7,801 1,452 22.9 Feb 5,920 6,586 666 11.3 Mar 6,503 4,592 −1,911 −29.4 Apr 6,622 2,285 −4,337 −65.5 May 6,487 3,911 −2,576 −39.7 Iowa Jan 5,396 5,241 −155 −2.9 Feb 5,066 4,361 −705 −13.9 Mar 5,616 3,567 −2,049 −36.5 Apr 5,937 2,472 −3,465 −58.4 May 5,969 3,277 −2,692 −45.1 Kansas Jan 2,462 2,485 23 0.9 Feb 2,104 2,083 −21 −1.0 Mar 2,317 1,603 −714 −30.8 Apr 2,670 1,163 −1,507 −56.4 May 2,580 1,523 −1,057 −41.0 Louisiana Jan 2,837 2,808 −29 −1.0 Feb 2,576 2,307 −269 −10.4 Mar 2,675 1,639 −1,036 −38.7 Apr 2,718 1,145 −1,573 −57.9 May 3,086 1,931 −1,155 −37.4 Maine Jan 1,231 1,862 631 51.3 Feb 1,013 1,420 407 40.2 Mar 1,207 988 −219 −18.1 Apr 1,271 766 −505 −39.7 May 1,361 1,137 −224 −16.5 Maryland Jan 6,300 6,153 −147 −2.3 Feb 5,662 5,004 −658 −11.6 Mar 6,498 3,535 −2,963 −45.6 Apr 6,876 1,626 −5,250 −76.4 May 7,271 2,726 −4,545 −62.5 Massachusetts Jan 18,682 18,470 −212 −1.1 Feb 15,917 14,996 −921 −5.8 Mar 18,170 10,012 −8,158 −44.9 Apr 18,868 5,594 −13,274 −70.4 May 19,852 8,007 −11,845 −59.7 Michigan Jan 12,006 13,224 1,218 10.1 Feb 12,242 11,201 −1,041 −8.5 Mar 13,421 7,181 −6,240 −46.5 Apr 13,093 3,008 −10,085 −77.0 May 13,400 2,266 −11,134 −83.1 Minnesota Jan 7,551 8,040 489 6.5 Feb 6,877 6,717 −160 −2.3 Mar 7,180 4,803 −2,377 −33.1 Apr 8,272 3,323 −4,949 −59.8 May 8,096 4,198 −3,898 −48.1 Missouri Jan 6,860 6,252 −608 −8.9 Feb 5,881 4,851 −1,030 −17.5 Mar 6,415 3,154 −3,261 −50.8 Apr 6,886 1,350 −5,536 −80.4 May 6,666 2,012 −4,654 −69.8 See table footnotes on page 161. Morbidity and Mortality Weekly Report 160 MMWR / February 5, 2021 / Vol. 70 / No. 5 US Department of Health and Human Services/Centers for Disease Control and Prevention See table footnotes on page 161. Jurisdiction Month No. of children tested 2019 2020 Absolute change, no. % Change Nevada Jan 663 691 28 4.2 Feb 617 701 84 13.6 Mar 699 409 −290 −41.5 Apr 761 206 −555 −72.9 May 726 279 −447 −61.6 New Hampshire Jan 1,900 1,974 74 3.9 Feb 1,627 1,551 −76 −4.7 Mar 1,887 1,175 −712 −37.7 Apr 1,932 853 −1,079 −55.8 May 1,979 1,278 −701 −35.4 New Mexico Jan 1,276 1,162 −114 −8.9 Feb 1,117 881 −236 −21.1 Mar 1,152 781 −371 −32.2 Apr 1,365 357 −1,008 −73.8 May 1,255 398 −857 −68.3 New York (excluding New York City) Jan 19,553 20,385 832 4.3 Feb 18,130 17,293 −837 −4.6 Mar 20,463 12,771 −7,692 −37.6 Apr 20,351 8,806 −11,545 −56.7 May 21,633 13,088 −8,545 −39.5 New York City Jan 26,415 27,190 775 2.9 Feb 23,736 23,026 −710 −3.0 Mar 26,556 13,618 −12,938 −48.7 Apr 26,970 3,703 −23,267 −86.3 May 27,779 10,286 −17,493 −63.0 Ohio Jan 14,382 15,154 772 5.4 Feb 13,440 12,865 −575 −4.3 Mar 13,533 9,555 −3,978 −29.4 Apr 14,878 6,377 −8,501 −57.1 May 14,243 6,938 −7,305 −51.3 Oregon Jan 1,817 1,843 26 1.4 Feb 1,644 1,710 66 4.0 Mar 1,566 1,153 −413 −26.4 Apr 1,880 968 −912 −48.5 May 1,707 1,330 −377 −22.1 Rhode Island Jan N/A N/A N/A N/A Feb N/A N/A N/A N/A Mar 1,360 711 −649 −47.7 Apr 1,425 227 −1,198 −84.1 May 1,547 512 −1,035 −66.9 Tennessee Jan 7,350 8,379 1,029 14.0 Feb 6,616 7,338 722 10.9 Mar 7,179 5,968 −1,211 −16.9 Apr 8,256 4,629 −3,627 −43.9 May 7,634 4,451 −3,183 −41.7 Texas Jan 30,459 27,570 −2,889 −9.5 Feb 26,647 24,147 −2,500 −9.4 Mar 27,352 16,441 −10,911 −39.9 Apr 30,569 13,107 −17,462 −57.1 May 26,280 18,833 −7,447 −28.3 Washington Jan 2,521 1,876 −645 −25.6 Feb 1,802 1,701 −101 −5.6 Mar 2,343 1,328 −1,015 −43.3 Apr 2,200 1,010 −1,190 −54.1 May 2,649 943 −1,706 −64.4 TABLE. (Continued) Number of children aged <6 years with blood lead level (BLL) tests,* absolute change, and percentage change, by jurisdiction — 34 U.S. jurisdictions, 2019–2020 Morbidity and Mortality Weekly Report US Department of Health and Human Services/Centers for Disease Control and Prevention MMWR / February 5, 2021 / Vol. 70 / No. 5 161 TABLE. (Continued) Number of children aged <6 years with blood lead level (BLL) tests,* absolute change, and percentage change, by jurisdiction — 34 U.S. jurisdictions, 2019–2020 Jurisdiction Month No. of children tested 2019 2020 Absolute change, no. % Change West Virginia Jan 1,604 1,484 −120 −7.5 Feb 1,569 1,328 −241 −15.4 Mar 1,782 1,049 −733 −41.1 Apr 1,876 624 −1,252 −66.7 May 1,861 930 −931 −50.0 Wisconsin Jan 7,590 8,195 605 8.0 Feb 7,907 7,089 −818 −10.3 Mar 7,877 4,720 −3,157 −40.1 Apr 8,957 2,239 −6,718 −75.0 May 8,237 3,438 −4,799 −58.3 Abbreviation: N/A = not available. * CDC requested that state and local health departments report the total number of children with BLL tests by month during January–May 2019 and January–May 2020. Data for children aged <6 years were received from 34 state and local health departments, including the District of Columbia and New York City. References 1. Council on Environmental Health. Prevention of childhood lead toxicity. Pediatrics 2016;138:e20161493. PMID:27325637 https://doi. org/10.1542/peds.2016-1493 2. CDC. Advisory Committee on Childhood Lead Poisoning Prevention. Low level lead exposure harms children: a renewed call for primary prevention. Atlanta, GA: US Department of Health and Human Services, CDC; 2012. https://www.cdc.gov/nceh/lead/docs/final_ document_030712.pdf 3. Dignam T, Kaufmann RB, LeStourgeon L, Brown MJ. Control of lead sources in the United States, 1970–2017: public health progress and current challenges to eliminating lead exposure. J Public Health Manag Pract 2019;25(Suppl 1):S13–22. PMID:30507765 https://doi. org/10.1097/PHH.0000000000000889 4. Michel JJ, Erinoff E, Tsou AY. More guidelines than states: variations in U.S. lead screening and management guidance and impacts on shareable CDS development. BMC Public Health 2020;20:127. PMID:31996264 https://doi.org/10.1186/s12889-020-8225-8 5. CDC. Changes in notifiable diseases data presentation. MMWR Morb Mortal Wkly Rep 1995;43:955–6. PMID:7799909 6. Ogedegbe G, Ravenell J, Adhikari S, et al. Assessment of racial/ethnic disparities in hospitalization and mortality in patients with COVID-19 in New York City. JAMA Netw Open 2020;3:e2026881. PMID:33275153 https://doi.org/10.1001/jamanetworkopen.2020.26881 7. Podewils LJ, Burket TL, Mettenbrink C, et al. Disproportionate incidence of COVID-19 infection, hospitalizations, and deaths among persons identifying as Hispanic or Latino—Denver, Colorado, March– October 2020. MMWR Morb Mortal Wkly Rep 2020;69:1812–6. PMID:33270613 https://doi.org/10.15585/mmwr.mm6948a3 8. Hartnett KP, Kite-Powell A, DeVies J, et al. Impact of the COVID-19 pandemic on emergency department visits—United States, January 1, 2019–May 30, 2020. MMWR Morb Mortal Wkly Rep 2020;69:699–704. PMID:32525856 https://doi.org/10.15585/mmwr.mm6923e1 9. Santoli JM, Lindley MC, DeSilva MB, et al. Effects of the COVID-19 pandemic on routine pediatric vaccine ordering and administration— United States, 2020. MMWR Morb Mortal Wkly Rep 2020;69:591–3. PMID:32407298 https://doi.org/10.15585/mmwr.mm6919e2 10. Bramer CA, Kimmins LM, Swanson R, et al. Decline in child vaccination coverage during the COVID-19 pandemic—Michigan Care Improvement Registry, May 2016–May 2020. MMWR Morb Mortal Wkly Rep 2020;69:630–1. PMID:32437340 https://doi.org/10.15585/ mmwr.mm6920e1 Morbidity and Mortality Weekly Report 162 MMWR / February 5, 2021 / Vol. 70 / No. 5 US Department of Health and Human Services/Centers for Disease Control and Prevention Racial and Ethnic Disparities in the Prevalence of Stress and Worry, Mental Health Conditions, and Increased Substance Use Among Adults During the COVID-19 Pandemic — United States, April and May 2020 Lela R. McKnight-Eily, PhD1; Catherine A. Okoro, PhD2; Tara W. Strine, PhD1; Jorge Verlenden, PhD1; NaTasha D. Hollis, PhD2; Rashid Njai, PhD1; Elizabeth W. Mitchell, PhD1; Amy Board, DrPH3; Richard Puddy, PhD1; Craig Thomas, PhD1 In 2019, approximately 51 million U.S. adults aged ≥18 years reported any mental illness,* and 7.7% reported a past-year substance use disorder† (1). Although reported prevalence estimates of certain mental disorders, substance use, or substance use disorders are not generally higher among racial and ethnic minority groups, persons in these groups are often less likely to receive treatment services (1). Persistent systemic social inequities and discrimination related to living conditions and work environments, which contribute to disparities in underlying medical conditions, can further compound health problems faced by members of racial and ethnic minority groups during the coronavirus disease 2019 (COVID-19) pandemic and worsen stress and associated mental health concerns (2,3). In April and May 2020, opt-in Internet panel surveys of Englishspeaking U.S. adults aged ≥18 years were conducted to assess the prevalence of self-reported mental health conditions and initiation of or increases in substance use to cope with stress, psychosocial stressors, and social determinants of health. Combined prevalence estimates of current depression, initiating or increasing substance use, and suicidal thoughts/ideation were 28.6%, 18.2%, and 8.4%, respectively. Hispanic/Latino (Hispanic) adults reported a higher prevalence of psychosocial stress related to not having enough food or stable housing than did adults in other racial and ethnic groups. These estimates highlight the importance of population-level and tailored interventions for mental health promotion and mental illness prevention, substance use prevention, screening and treatment services, and increased provision of resources to address social determinants of health. How Right Now (Qué Hacer Ahora) is an evidence-based and culturally appropriate communications campaign designed to promote and strengthen the emotional well-being and resiliency of populations adversely affected by COVID-19–related stress, grief, and loss (4). *Adults with any mental illness were defined as those having any mental, behavioral, or emotional disorder in the past year that met specified criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, (DSM-IV) (excluding developmental disorders and substance use disorders). † Persons who met the criteria for dependence or abuse for alcohol or illicit drugs in the past 12 months based on criteria specified in the DSM-IV were defined as having a substance use disorder. CDC licensed results from Porter Novelli’s PN View 360, a nationwide, weekly opt-in Internet panel survey of U.S. adults. The survey was administered by ENGINE Insights in English to U.S. adults aged ≥18 years using the Lucid platform (5); respondents who had not taken a survey in the previous 20 waves of survey administration were eligible to participate. Quota sampling was conducted by ENGINE Insights to identify respondents, and statistical weighting was used during the analysis to match proportions in the 2019 Current Population Survey; therefore, the sample was representative of the overall U.S. population by sex, age, region, race/ethnicity, and education. CDC licensed the results of the PN View 360 survey after data collection from Porter Novelli. This activity was reviewed by CDC and was conducted consistent with applicable federal law and CDC policy.§ In both April and May, 502 respondents participated, for a combined total of 1,004 respondents; the survey included questions about increases in or initiation of substance use during the COVID-19 pandemic,¶ symptoms of current depression,** and suicidal thoughts/ideation,†† as well as questions about psychosocial stress (e.g., feeling isolated and alone), stigma or discrimination (from being blamed for spreading COVID-19), and social determinants of health (e.g., food instability). Combined and weighted response percentages and 95% confidence intervals (CIs) were calculated by using PROC SURVEYFREQ in SAS statistical software (version 9.4; SAS Institute). Because respondents were recruited from an § 45 C.F.R. part 4601[b][2]. ¶ Substance use initiation or increase was defined as an affirmative response to the question “Have you started or increased using substances to help you cope with stress or emotions during the COVID-19 pandemic? Substance use includes alcohol, legal or illegal drugs, or prescriptions drugs that are taken in a way not recommended by your doctor.” ** Current depression was defined as a score of ≥10 on the eight-item Patient Health Questionnaire (PHQ-8). The PHQ-8 is adapted from the nine-item PHQ (PHQ-9), which is based on the nine criteria for diagnosis of depressive disorders in the DSM-IV. †† Having suicidal thoughts/ideation was defined as an affirmative response to the question “At any time in the past 30 days, did you seriously think about trying to kill yourself?” Morbidity and Mortality Weekly Report US Department of Health and Human Services/Centers for Disease Control and Prevention MMWR / February 5, 2021 / Vol. 70 / No. 5 163 opt-in panel rather than by probability sampling, other than using CIs, no inferential statistical tests were performed.§§ The overall prevalence estimates of current depression, suicidal thoughts/ideation, and initiation of or increase in substance use were 28.6%, 8.4%, and 18.2%, respectively (Table). Symptoms of current depression were reported 59% more frequently by Hispanic adults (40.3%) than by non-Hispanic White (White) persons (25.3%). Estimates of self-reported suicidal thoughts/ideation among Hispanic persons (22.9%) were four times those among non-Hispanic Black (Black) persons (5.2%) and White persons (5.3%) and approximately twice those of multiracial and non-Hispanic persons of other races/ ethnicities (8.9%).¶¶ Increased or newly initiated substance use was reported among 36.9% of Hispanic respondents, compared with 14.3%–15.6% among all other respondents. Among U.S. adults overall, sources of psychosocial stress included family health (36.3%), feelings of isolation or loneliness (28.6%), worry about getting ill from COVID-19 or infecting others (25.7%), worry about the death of a loved one or persons dying (15.2%), workplace COVID-19 exposure (13.5%), and stigma or discrimination from being blamed for spreading COVID-19 (4.1%) (Figure 1). White adults were more likely to report stress and worry about the health of family members and loved ones (39.3%) than were Black adults (24.5%). A larger percentage of multiracial and nonHispanic adults of other races/ethnicities reported stress and §§ The standard errors assume that the weighted estimates used in the Taylor series linearization are approximately unbiased or at the very least are consistent. This assumption of approximate unbiasedness is based on the assertion that any differences between the survey sample and the target population on key survey outcomes are corrected by the weighting. No analysis was conducted to validate that assertion. https://www.aapor.org/AAPOR_ Main/media/MainSiteFiles/NPS_TF_Report_Final_7_revised_ FNL_6_22_13.pdf ¶¶ Other non-Hispanic minority groups included participants who identified as Native American/Alaska Native, Asian, multiracial, or another race/ethnicity. worry about stigma or discrimination associated with being blamed for spreading COVID-19 (12.9%) than did White (2.4%) or Hispanic (3.7%) adults. Estimates of stress and worry about social determinants of health included possible job loss (27.1%), ability to obtain needed health care (18.4%), not having enough food (14.4%), and housing instability (11.8%) (Figure 2). A higher percentage of Hispanic adults reported stress about not having enough food (22.7%) or stable housing (20.7%) than did White adults (11.9% and 9.2%, respectively). Discussion Selected mental health conditions and initiation of or increase in substance use to cope with stress or emotions during the COVID-19 pandemic were commonly reported by U.S. adults responding to an opt-in survey in April and May 2020. The prevalence of current depression, suicidal thoughts/ ideation, and increased or newly initiated substance use was also higher for some racial and ethnic minority groups, especially Hispanic respondents. Hispanic adults reported higher levels of stress and worry about not having enough food or stable housing than did White adults. A review of baseline mental health data from other national surveys, which used different study designs and methodologies, suggests potential increases in the mental health outcomes included in this report. Current depression among adults aged ≥18 years was estimated to be 7.0% by the 2019 National Health Interview Survey (6) and 23.5% by the 2020 Household Pulse Survey during April 23–May 5, 2020,*** compared with an estimated 28.6% of adults aged ≥18 years in this report. In the 2019 National Survey on Drug Use and Health, 4.8% of U.S. adults aged ≥18 years reported serious suicidal thoughts (1), whereas 8.4% of adults in this report *** https://www.cdc.gov/nchs/covid19/pulse/mental-health.htm TABLE. Weighted prevalence estimates of current depression,* suicidal thoughts/ideation,† and substance use increase or initiation§ among adults aged ≥18 years, by race/ethnicity — Porter Novelli View 360 survey, United States, April and May 2020 Race/Ethnicity Unweighted no. of persons Weighted % (95% CI) Current depression Suicidal thoughts/Ideation Substance use increase or initiation Total 1,004 28.6 (25.6–31.5) 8.4 (6.6–10.2) 18.2 (15.7–20.7) White, NH 657 25.3 (21.9–28.7) 5.3 (3.6–6.9) 14.3 (11.6–17.0) Black, NH 100 27.7 (18.7–36.7) 5.2 (0.7–9.7) 15.6 (8.4–22.7) Hispanic/Latino 118 40.3 (31.3–49.3) 22.9 (15.2–30.6) 36.9 (28.1–45.7) Other, NH¶ 129 31.4 (22.8–40.0) 8.9 (3.6–14.1) 15.1 (8.4–21.7) Abbreviations: CI = confidence interval; DSM-IV = Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition; NH = non-Hispanic/Latino. * Defined as a score of ≥10 on the eight-item Patient Health Questionnaire (PHQ-8). The PHQ-8 is adapted from the nine-item PHQ (PHQ-9), which is based on the nine criteria for diagnosis of depressive disorders in the DSM-IV. † Defined as an affirmative response to the question “At any time in the past 30 days, did you seriously think about trying to kill yourself?” § Defined as an affirmative response to the question “Have you started or increased using substances to help you cope with stress or emotions during the COVID-19 pandemic? Substance use includes alcohol, legal or illegal drugs, or prescriptions drugs that are taken in a way not recommended by your doctor.” ¶ Includes participants who identified as Native American/Alaska Native, Asian, multiracial, or another race/ethnicity. Morbidity and Mortality Weekly Report 164 MMWR / February 5, 2021 / Vol. 70 / No. 5 US Department of Health and Human Services/Centers for Disease Control and Prevention FIGURE 1. Weighted prevalence estimates* of self-reported stress and worry about psychosocial stressors among adults aged ≥18 years (N = 1,004), overall and by race/ethnicity† — Porter Novelli View 360 survey, United States, April and May 2020 0 10 20 30 40 50 60 70 100 Getting ill from COVID-19 Health of family and loved ones Workplace exposure to COVID-19 Feeling isolated and alone Death of loved one/Persons dying Stigma or discrimination for spreading COVID-19 Percentage White, NH Black, NH Hispanic/Latino Other, NH Psychosocial stressors Total Abbreviations: COVID-19 = coronavirus disease 2019; NH = non-Hispanic/Latino. * With 95% confidence intervals shown by error bars. † Other non-Hispanic minority groups include participants who identified as Native American/Alaska Native, Asian, multiracial, or another race/ethnicity. indicated having suicidal thoughts/ideation. Recent data from another U.S. panel survey indicated that 40.9% of respondents aged ≥18 years reported mental or behavioral health concerns during the COVID-19 pandemic, with 13.3% of respondents reporting that they increased or initiated substance use (7), compared with nearly 20% of respondents in this report. In 2019, not having enough food was reported three times more frequently by Black persons and two times more frequently by Hispanic persons than by White persons (8). Stigma, including harassment and discrimination, combined with social or structural determinants of health, such as inadequate access to safe housing, healthy food, transportation, and health care, can increase the risk for chronic stress among persons in racial and ethnic minority groups and potentially affect their mental and physical health, including contributing to poor outcomes from COVID-19 (3,4,7). Additional evidence-based measures to promote population-level mental health in adults are important,††† including screening for mental illness (e.g., depression) (9) and substance misuse (e.g., alcohol misuse) (10). Persons identified by screening as having a higher risk for mental illness are best served when treated or referred to a health care provider for intervention, including counseling, referral to services, or treatment (9,10). Because a substantial proportion of mental health care occurs in primary care settings,§§§ health care access is important for addressing mental health and substance use conditions, including opioid use. Although racial and ethnic minority group members did not report more psychosocial stress related to health care access than did White persons, disparities in access to health care, ††† https://www.cdc.gov/coronavirus/2019-ncov/daily-life-coping/managingstress-anxiety.html §§§ https://www.cdc.gov/nchs/products/databriefs/db311.htm#ref3 Morbidity and Mortality Weekly Report US Department of Health and Human Services/Centers for Disease Control and Prevention MMWR / February 5, 2021 / Vol. 70 / No. 5 165 0 5 10 15 20 25 30 35 40 100 Loss of job or income Getting needed health care services Not enough food Housing instability/inability to pay rent Total White, NH Black, NH Hispanic/Latino Other, NH Percentage Social determinants of health FIGURE 2. Weighted prevalence estimates* of self-reported stress and worry about social determinants of health among adults aged ≥18 years (N = 1,004), overall and by race/ethnicity† — Porter Novelli View 360 survey, United States, April and May 2020 Abbreviations: COVID-19 = coronavirus disease 2019; NH = non-Hispanic/Latino. * With 95% confidence intervals shown by error bars. † Other non-Hispanic minority groups include participants who identified as Native American/Alaska Native, Asian, multiracial, or another race/ethnicity. including having a usual source of care, are preexisting factors that affect physical and mental health.¶¶¶ Additional public health measures are critical to address the mental and behavioral health consequences of the COVID-19 pandemic. How Right Now (Qué Hacer Ahora) is a communications campaign designed to promote and strengthen the emotional well-being and resiliency of populations adversely affected by COVID-19–related stress, grief, and loss. The campaign offers evidence-based and culturally appropriate information and resources to address the emotional health needs of adults in both English and Spanish (4). CDC is working with national, tribal, state, and community partners; academic institutions; and other federal agencies to define, measure, and improve the emotional well-being and quality of life of the U.S. population across the lifespan. Additional resources are available from CDC.**** Behavioral health and addiction services resources are available through a free ¶¶¶ https://www.ahrq.gov/research/findings/nhqrdr/nhqdr18/index.html **** https://www.cdc.gov/populationhealth/well-being Substance Abuse and Mental Health Services Administration’s Disaster Distress Helpline (1-800-985-5990)†††† and addiction treatment locators.§§§§ The findings in this report are subject to at least five limitations. First, all responses were self-reported and might be subject to recall, response, or social desirability biases. Second, although survey responses were weighted to be representative of U.S. population demographics, whether responses in this optin panel sample are representative of the broader U.S. population and which biases might have affected the findings are not known. Third, the generalizability of estimates for Hispanic populations was limited because the survey was administered in English on the Internet; therefore, Spanish-only speakers might not have been included. This report suggests that additional studies are needed, and consideration of surveys that focus on sampling Hispanic/Latino populations who speak Spanish might be helpful. Fourth, the data are cross-sectional, which †††† https://www.samhsa.gov/find-help/disaster-distress-helpline §§§§ https://www.samhsa.gov/medication-assisted-treatment/practitionerprogram-data/treatment-practitioner-locator Morbidity and Mortality Weekly Report 166 MMWR / February 5, 2021 / Vol. 70 / No. 5 US Department of Health and Human Services/Centers for Disease Control and Prevention precludes the ability to make causal inferences. Finally, the sample size was small (1,004), which limited certain types of analysis and resulted in small cell sizes for some comparisons. Addressing barriers or disruptions to access to and delivery of mental health and substance use services during the COVID-19 pandemic, including considerations for health care systems, practices, and providers using telehealth coverage¶¶¶¶; consideration of parity in insurance coverage for mental health and substance use services; and use of virtual mental health treatment and substance use recovery groups, is important. Policies and structural programs can be adapted or developed to reduce preexisting racial and ethnic group disparities in social determinants of health (e.g., housing,***** food, access to health care, and income security) while also addressing psychosocial stressors unique to communities with large racial and ethnic minority populations. The mental health and psychosocial needs of U.S. adults, including persons in racial and ethnic minority groups, are an important consideration when promoting community resilience and preserving access to and provision of services during the COVID-19 pandemic. Acknowledgments Survey respondents; William Thompson, Fred Fridinger, CDC COVID-19 Response Team; Deanne Weber, Porter-Novelli Public Styles. Corresponding author: Lela R. McKnight-Eily, lmcknighteily@cdc.gov. 1CDC COVID-19 Social and Behavioral Health Team; 2Division of Human Development and Disability, National Center on Birth Defects and Developmental Disabilities, CDC; 3CDC COVID-19 Response Team. All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed. References 1. Center for Behavioral Health Statistics and Quality. Results from the 2019 National Survey on Drug Use and Health: detailed tables. Rockville, MD: US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality; 2020. https://www.samhsa. gov/data/report/2019-nsduh-detailed-tables 2. Millett GA, Jones AT, Benkeser D, et al. Assessing differential impacts of COVID-19 on black communities. Ann Epidemiol 2020;47:37–44. PMID:32419766 https://doi.org/10.1016/j.annepidem.2020.05.003 ¶¶¶¶ https://www.cdc.gov/coronavirus/2019-ncov/hcp/telehealth.html ***** https://www.jchs.harvard.edu/sites/default/files/sonhr14-color-full_0.pdf Summary What is already known about this topic? Racial and ethnic minority groups have experienced disparities in mental health and substance misuse related to access to care, psychosocial stress, and social determinants of health. What is added by this report? Combined prevalence estimates of current depression, initiating or increasing substance use, and suicidal thoughts/ ideation among U.S. adults aged ≥18 years were 28.6%, 18.2%, and 8.4%, respectively. Hispanic adults reported a higher prevalence of psychosocial stress related to not having enough food or stable housing than did adults in other racial and ethnic groups. What are the implications for public health practice? Addressing psychosocial stressors, mental health conditions, and substance misuse among U.S. adults during the COVID-19 pandemic is important, as are interventions tailored for racial and ethnic minority groups. 3. Kim SJ, Bostwick W. Social vulnerability and racial inequality in COVID-19 deaths in Chicago. Health Educ Behav 2020;47:509–13. PMID:32436405 https://doi.org/10.1177/1090198120929677 4. CDC Foundation. How right now. Finding what helps. Atlanta, GA: CDC Foundation; 2020. https://howrightnow.org 5. Coppock A, McClellan OA. Validating the demographic, political, psychological, and experimental results obtained from a new source of online survey respondents. Research & Politics 2019;6:1–14. https:// doi.org/10.1177/2053168018822174 6. Villarroel MA, Terlizzi EP. Symptoms of depression among adults: United States, 2019. NCHS data brief, no. 379. Hyattsville, MD: US Department of Health and Human Services, CDC, National Center for Health Statistics; 2020. https://www.cdc.gov/nchs/products/databriefs/ db379.htm 7. Czeisler MÉ, Lane RI, Petrosky E, et al. Mental health, substance use, and suicidal ideation during the COVID-19 pandemic—United States, June 24–30, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1049–57. PMID:32790653 https://doi.org/10.15585/mmwr.mm6932a1 8. Coleman-Jensen A, Rabbitt MP, Gregory CA, Singh A. Household food security in the United States in 2019. Washington, DC: US Department of Agriculture, Economic Research Service; 2020. https://www.ers.usda. gov/webdocs/publications/99282/err-275.pdf?v=9004.7 9. Siu AL, Bibbins-Domingo K, Grossman DC, et al; US Preventive Services Task Force. Screening for depression in adults: U.S. Preventive Service Task Force recommendation statement. JAMA 2016;315:380–7. PMID:26813211 https://doi.org/10.1001/jama.2015.18392 10. Curry SJ, Krist AH, Owens DK, et al; US Preventive Services Task Force. Screening and behavioral counseling interventions to reduce unhealthy alcohol use in adolescents and adults. JAMA 2018;320:1899–909. PMID:30422199 https://doi.org