Importance:Examining racial and ethnic disparities in pediatric COVID-19 hospitalizations is critical to inform public health efforts to reduce those disparities. Objective:To characterize trends in pediatric COVID-19 hospitalizations by race and ethnicity from March 2020 to September 2023, focusing on recent epidemiologic findings (October 2022 to September 2023). Design, Setting, and Participants:This cross-sectional study used data from the COVID-19 Hospitalization Surveillance Network (COVID-NET) including 13 555 hospitalizations among patients aged 17 years or younger with a laboratory-confirmed SARS-CoV-2 infection who are residents of the COVID-NET catchment area in 12 states, covering approximately 10% of the US population. Exposure:Laboratory-confirmed SARS-CoV-2 infection within 14 days prior to or during hospitalization. Main Outcomes and Measures:Pediatric COVID-19-associated hospitalization rates by race and ethnicity and characteristics associated with COVID-19-associated hospitalizations. Results:Between March 2020 and September 2023, COVID-NET identified 13 555 pediatric hospitalizations (median patient age, 3.3 years [IQR, 0.6-12.5 years]; 7110 boys [52.5%]; 780 non-Hispanic Asian or Pacific Islander children [5.8%], 3837 non-Hispanic Black children [28.3%], 4131 Hispanic children [30.5%], and 4807 non-Hispanic White children [35.5%]). Hospitalization rates were 2.15 (95% CI, 2.01-2.34) times higher for Black children and 2.06 (95% CI, 1.91-2.23) times higher for Hispanic children compared with Asian or Pacific Islander children, who had the lowest rates. Despite overall decreased pediatric hospitalization rates between October 2022 and September 2023, higher rates of intensive care unit admissions among Black and Hispanic children persisted, at 1.88 (95% CI, 1.28-2.74) times higher for Black children and 2.13 (95% CI, 1.47-3.10) times higher for Hispanic children compared with Asian or Pacific Islander children. Among hospitalized children, 61.4% (95% CI, 57.0%-65.8%) of Black patients and 45.5% (95% CI, 41.9%-49.3%) of Hispanic patients had 1 or more underlying medical condition compared with 45.6% (95% CI, 42.1%-49.1%) of White children and 45.0% (95% CI, 41.9%-49.3%) of Asian or Pacific Islander children. Obesity (17.8%; 95% CI, 15.3%-20.5%) and neurologic disorders (15.2%; 95% CI, 13.7%-16.8%) were the most common conditions overall; 11.9% (95% CI, 9.1%-15.1%) of Black children had sickle cell disease, the fourth most common condition in this group. Conclusions and Relevance:This study found that among pediatric patients hospitalized with COVID-19, Black and Hispanic children were disproportionately more likely to be hospitalized for COVID-19 and experience severe disease compared with White and Asian or Pacific Islander children. A higher proportion of hospitalized Black children had underlying medical conditions. This study underlines the need for targeted interventions, particularly for children with underlying medical conditions, and the need for equitable access and use of vaccines and therapeutics for disproportionately affected populations.

Abstract Background SARS-CoV-2 infection can result in serious illness in children. We used COVID-19-Associated Hospitalization Surveillance Network (COVID-NET) data to assess characteristics associated with pediatric COVID-19 hospitalizations, including underlying medical conditions and vaccination status. Percent of COVID-19-Associated Hospitalizations† with Specific Underlying Medical Conditions among U.S. Children Aged ≤17 Years by Age Group — COVID-NET, January–December 2023 Methods U.S. children aged ≤ 17 years with COVID-19 as the likely primary reason for hospitalization during January–December 2023 were identified in the population-based COVID-NET active surveillance system, which includes patients residing in a catchment area of > 300 acute care hospitals in 13 states with a positive SARS-CoV-2 test result during or ≤ 14 days before admission. Medical records of a random sample of children stratified by age-group and site were abstracted; reported percentages were weighted to account for probability of selection. We assessed patient age, underlying medical conditions, and receipt of vaccine dose within 12 months before illness. Results Of 2016 children hospitalized for COVID-19, 1232 (61%) were aged < 2 years (611 aged < 6 months; 621 aged 6–23 months). Overall, 51% had no underlying condition, including 73% of infants aged < 6 months, 58% of children aged 6–23 months, and 24% of children aged 12–17 years (Figure). Among children aged < 2 years, prematurity was the most common underlying condition (17–20%). Neurologic disorders (27–31%) and asthma (21–33%) were most prevalent among children aged ≥ 2 years. Among 1379 children aged ≥ 6 months eligible for vaccination with vaccine data available, only 14% had received ≥ 1 vaccine dose within 12 months before illness, with the lowest frequency (9%) among children aged 6–23 months (Table). Among age-eligible children with neurologic disorders and asthma, only 18% and 16% were vaccinated, respectively. Conclusion Most children aged < 2 years hospitalized for COVID-19 during 2023 had no underlying conditions; underlying conditions were more prevalent among older children. More than 85% of age-eligible children had not received a vaccine dose within 12 months, including among children with underlying conditions. Increasing pediatric COVID-19 vaccination, especially among children with underlying medical conditions, could help reduce COVID-19 hospitalizations. Disclosures Anna Falkowski, Master of Science, Council of State and Territorial Epidemiologists (CSTE): Grant/Research Support

Abstract Background Risk factors for COVID-19-associated hospitalizations were identified early in the pandemic. Since then, population immunity to SARS-CoV-2 has increased substantially and hospitalizations for COVID-19 have decreased. Identifying populations at greatest risk of COVID-19–associated hospitalization can help guide prevention and treatment efforts. We aimed to update information on chronic conditions as risk factors for COVID-19-associated hospitalization.Figure.Flow diagram of participant selection into analytic population, Coronavirus Disease 2019-Associated Hospitalization Surveillance Network (COVID-NET), 2 October 2022–30 September 2023. Methods We compared hospitalization rates in adults aged ≥ 18 years with vs without 9 chronic conditions during 2 October 2022–30 September 2023. Rate numerators were COVID-19–associated hospitalization counts from the COVID-19–Associated Hospitalization Surveillance Network, a population-based active surveillance system with a 98-county catchment area in 13 states. Rate denominators were counts of adults with and without chronic conditions in the catchment area, estimated with US census county-level population data and state-level estimates of the adult population with and without select chronic conditions from the 2022 Behavioral Risk Factor Surveillance System. Rate ratios and 95% confidence intervals were estimated using Poisson regression with Monte Carlo simulation, adjusting for age group, sex, and race/ethnicity. Results Among 3,500 hospitalized adults, 74% had ≥ 1 chronic condition (Figure, Table 1). Hospitalization rates were higher among those with ≥ 1 chronic condition (vs none); adjusted rate ratios (aRR) ranged from 2.2 in adults aged ≥ 75 years to 4.6 in adults aged 18-49 years (Table 2). Among adults overall, chronic kidney disease was associated with the greatest risk of COVID-19–associated hospitalization (aRR: 4.5), followed by diabetes (2.2), history of stroke (2.0), severe obesity (2.0), coronary artery disease (1.9), COPD (1.9), smoking (1.6), and asthma (1.5); results varied by age and generally attenuated with older age (Table 2). Adjusting for number of chronic conditions, hospitalization rates were higher for adults aged ≥ 75 years relative to 18–49 years (18.5) (Table 3). Conclusion Of 9 chronic conditions, 8 were associated with increased risk of COVID-19–associated hospitalization with risk varying by condition and age group. Older age remains the strongest risk factor. Disclosures Sue Kim, MPH, Council of State and Territorial Epidemiologists: Grant/Research Support

OBJECTIVES:We assessed characteristics associated with pediatric COVID-19 hospitalizations and risk factors for severe disease among hospitalized children aged 6 months and older. METHODS:Using data from COVID-19-Associated Hospitalization Surveillance Network (COVID-NET) during October 1, 2022, to April 30, 2024, we described demographic characteristics, underlying medical conditions, COVID-19 vaccination status, and clinical outcomes, including severe disease (intensive care unit admission, mechanical ventilation, extracorporeal membrane oxygenation, in-hospital death), of hospitalized children aged 6 months to 17 years residing in the COVID-NET catchment area with laboratory-confirmed SARS-CoV-2 infection. Multivariable log-linked Poisson generalized estimating equations were conducted to assess risk factors for severe disease among children aged 6 to 23 months and 2 to 17 years. RESULTS:Of 2490 children hospitalized for COVID-19, 1114 (44.7%) were aged 6 to 23 months; 1358 (54.1%) were male. Overall, 1464 (58.9%) had at least 1 underlying condition: 471 (41.8%) of children aged 6 to 23 months, 290 (61.6%) aged 2 to 4 years, 383 (79.2%) aged 5 to 11 years, and 320 (77.0%) aged 12 to 17 years. One hundred (3.8%) were up to date with recommended COVID-19 vaccination. Among children aged 6 to 23 months, severe disease was associated with underlying chronic lung (adjusted risk ratio [aRR], 1.5; 95% CI, 1.2-1.8) and cardiovascular disease (aRR, 1.4; 95% CI, 1.1-1.7). Among children aged 2 years and older, severity was associated with chronic lung disease (aRR, 1.9; 95% CI, 1.5-2.3), diabetes (aRR, 1.5; 95% CI, 1.2-1.8), and neurologic disorders (aRR, 1.4; 95% CI, 1.2-1.6). CONCLUSION:Most hospitalized children aged 6 months and older had at least 1 underlying condition, and less than 5% were up to date with COVID-19 vaccination. Specific conditions were associated with increased risk of severe illness. Increasing COVID-19 vaccination, particularly among children with high-risk conditions, may reduce pediatric COVID-19 hospitalizations and severe outcomes.

The COVID-19-Associated Hospitalization Surveillance Network (COVID-NET) was established in March 2020 to monitor trends in hospitalizations associated with SARS-CoV-2 infection. COVID-NET is a geographically diverse population-based surveillance system for laboratory-confirmed COVID-19-associated hospitalizations with a combined catchment area covering approximately 10% of the US population. Data collected in COVID-NET includes monthly counts of hospitalizations for persons with confirmed SARS-CoV-2 infection who reside within the defined catchment area. A Bayesian modeling approach is proposed to estimate US national COVID-associated hospital admission rates based on information reported in the COVID-NET system. A key component of the approach is the ability to estimate uncertainty resulting from extrapolation of hospitalization rates observed within COVID-NET to the US population. In addition, the proposed model enables estimation of other contributors to uncertainty including temporal dependence among reported COVID-NET admission counts, the impact of unmeasured site-specific factors, and the frequency and accuracy of testing for SARS-CoV-2 infection. Based on the proposed model, an estimated 6.3 million (95% uncertainty interval (UI) 5.4-7.3 million) COVID-19-associated hospital admissions occurred in the United States from September 2020 through December 2023. Between April 2020 and December 2023, model-based monthly admission rate estimates ranged from a minimum of 1 per 10,000 population (95% UI 0.7-1.2) in June of 2023 to a highest monthly level of 16 per 10,000 (95% UI 13-19) in January 2022.

BACKGROUND:In California, the 2022 mpox outbreak cumulated 5572 cases, 20% of US cases, as of November 28, 2022; 0.3% of cases were among children <16 years old. The secondary attack rate (SAR) for children sharing households with infected adults is unknown. METHODS:A line list of pediatric mpox household contacts aged <16 years reported through August 31, 2022 was created. It included demographic and clinical information on the contacts. Pediatric contact lists were crossmatched with the state vaccination database to identify those who received postexposure prophylaxis (PEP) with the JYNNEOS vaccine. RESULTS:We identified 129 pediatric household contacts with median age of 7 years (range, 0-15 years). Among 18 symptomatic contacts, 12 (66.7%) underwent mpox testing; 5 (41.2%) were confirmed cases, 6 (50%) were negative, and 1 (0.8%) had an indeterminate result. Six symptomatic children were not tested for mpox (33.3%). Overall, 6 infected contacts were identified, resulting in a SAR of 4.7% (6 of 129). The majority of pediatric household contacts and 4 of 6 infected children identified as Hispanic/Latino. Only 18 children (14%) reported receiving PEP. CONCLUSIONS:The SAR was overall low among pediatric household contacts; none had severe disease. This may be underestimated given low testing rates.

Populations at high risk for COVID-19- including Spanish speakers-may face additional barriers to obtaining COVID-19 vaccinations; by understanding their challenges, we can create more equitable vaccine interventions. In this study, we used interviews to identify barriers and enablers to COVID-19 vaccine uptake among participants in the San Francisco Department of Public Health contact tracing program. Data analysis employed Capability, Opportunity, Motivation Behavior model (COM-B) and the Behavior Change Wheel framework as guides to target barriers with interventions and supporting policies. This paper presents data from interviews focused on COVID-19 vaccine uptake that was part of a project to improve COVID-19 preventive behaviors in San Francisco. We completed seventeen interviews between February and May 2021; six (35%) were completed in English and 11 (65%) in Spanish. Barriers to vaccine uptake included an unprepared health system, fear of side effects, limited knowledge, and conflicting information. Behavioral factors influencing vaccine uptake were mainly related to physical opportunity, automatic motivation, and psychological capability. Interventions that could address the most significant number of barriers included education, enablement, and environmental restructuring. Finally, communication and marketing policies that use diverse multi-lingual social media and environmental planning that includes accessible vaccine sites for people with disabilities, literacy barriers, and limited English proficiency could significantly increase vaccination. Public health departments should tailor interventions to high-risk populations by understanding the specific barriers they face. This exploratory study suggests how implementation science can provide frameworks to achieve this.

San Francisco implemented one of the most intensive, comprehensive, multipronged COVID-19 pandemic responses in the United States using 4 core strategies: (1) aggressive mitigation measures to protect populations at risk for severe disease, (2) prioritization of resources in neighborhoods highly affected by COVID-19, (3) timely and adaptive data-driven policy making, and (4) leveraging of partnerships and public trust. We collected data to describe programmatic and population-level outcomes. The excess all-cause mortality rate in 2020 in San Francisco was half that seen in 2019 in California as a whole (8% vs 16%). In almost all age and race and ethnicity groups, excess mortality from COVID-19 was lower in San Francisco than in California overall, with markedly diminished excess mortality among people aged >65 years. The COVID-19 response in San Francisco highlights crucial lessons, particularly the importance of community responsiveness, joint planning, and collective action, to inform future pandemic response and advance health equity.

Contact tracing is a core public health intervention for a range of communicable diseases, in which the primary goal is to interrupt disease transmission and decrease morbidity. In this article, we present lessons learned from COVID-19, HIV, and syphilis in San Francisco to illustrate factors that shape the effectiveness of contact tracing programs and to highlight the value of investing in a robust disease intervention workforce with capacity to pivot rapidly in response to a range of emerging disease trends and outbreak response needs.

OBJECTIVES:Public health detailing is an intervention in which a public health professional visits health care providers to educate them about evidence-based approaches to improve health. The San Francisco Department of Public Health conducted a public health detailing program from 2016 to 2018 to improve sexual health care and preexposure prophylaxis services in the city.METHODS:We conducted a mixed-methods study to understand the implementation of detailing and explore examples of changes to clinicians' clinical behaviors. We surveyed 203 clinicians, conducted 60-minute qualitative interviews with 7 clinicians and 4 detailers, and analyzed tracking forms. We used descriptive statistics to assess associations in the surveys. We used qualitative thematic analysis to understand facilitators and barriers to detailing and identify ways to improve the process and identify its potential benefits.RESULTS:In interviews, both clinicians and detailers had a favorable view of detailing as a tool to connect health department expertise to clinicians. Detailers cited challenges such as limited clinic time, provider turnover, and policies that limit their access to clinicians. These challenges may attenuate the real-world benefits of detailing. Clinicians offered examples of how detailing altered their behaviors, such as taking sexual health histories, building knowledge and confidence about sexual health, and using health department services. Matched surveys (n = 21) showed preliminary changes to prescribing preexposure prophylaxis.CONCLUSIONS:Public health detailing is a promising approach to increase clinicians' knowledge and confidence to offer sexual health care services, build buy-in, and support connection to health departments. Detailing programs require sufficient investment and staff support to build lasting and collaborative relationships between clinicians and public health departments and to assess the impact of the intervention.

When COVID-19 cases surge, identifying ways to improve the efficiency of contact tracing and prioritize vulnerable communities for isolation and quarantine support services is critical. During a fall 2020 COVID-19 resurgence in San Francisco, California, prioritization of telephone-based case investigation by zip code and using a chatbot to screen for case participants who needed isolation support reduced the number of case participants who would have been assigned for a telephone interview by 31.5% and likely contributed to 87.5% of Latinx case participants being successfully interviewed. (Am J Public Health. 2022;112(1):43-47. https://doi.org/10.2105/AJPH.2021.306563).

Abstract Background The extent to which vaccinated persons diagnosed with coronavirus disease 2019 (COVID-19) can transmit to other vaccinated and unvaccinated persons is unclear. Methods Using data from the San Francisco Department of Public Health, this report describes outcomes of household contact tracing during 29 January–2 July 2021, where fully vaccinated patients with COVID-19 were the index case in the household. Results Among 248 fully vaccinated patients with breakthrough infections, 203 (82%) were symptomatic and 105 were identified as the index patient within their household. Among 179 named household contacts, 71 (40%) contacts tested, over half (56%) were fully vaccinated and the secondary attack rate was 28%. Overall transmission from a symptomatic fully vaccinated patient with breakthrough infection to household contacts was suspected in 14 of 105 (13%) of households. Viral genomic sequencing of samples from 44% of fully vaccinated patients showed that 82% of those sequenced were infected by a variant of concern or interest and 77% by a variant carrying mutation(s) associated with resistance to neutralizing antibodies. Conclusions Transmission from fully vaccinated symptomatic index patients to vaccinated and unvaccinated household contacts can occur. Indoor face masking and timely testing of all household contacts should be considered when a household member receives a positive test result in order to identify and interrupt transmission chains.

This repository contains the pertinent datasets used in the manuscript, Predominance of antibody-resistant SARS-CoV-2 variants in vaccine breakthrough cases from the San Francisco Bay Area, California.

We evaluated the impact of language concordance-clinician or public health worker fluency in a patient's primary language-on coronavirus disease 2019 (COVID-19) contact tracing outcomes among 2668 Spanish-speaking adults in San Francisco. Language concordance was associated with 20% greater odds of COVID-19 testing and 53% greater odds of support service referrals.

Abstract Background Rapid coronavirus disease 2019 (COVID-19) diagnosis and isolation of infectious persons are critical to stopping forward transmission, and the care cascade framework can identify gaps in the COVID-19 response. Methods We described a COVID-19 symptom to isolation cascade and barriers among symptomatic persons who tested polymerase chain reaction positive for severe acute respiratory disease coronavirus 2 (SARS-CoV-2) at a low-barrier testing site serving a low-income Latinx community in San Francisco. Steps in the cascade are defined as days from symptom onset to test, test to result, and result to counseling on self-isolation. We examined SARS-CoV-2 cycle threshold (Ct) values to assess the likelihood of infectiousness on the day of testing and during missed isolation days. Results Among 145 persons, 97% were Latinx and 81% had an income of <$50 000. The median time from symptom onset to isolation (interquartile range [IQR]) was 7 (5–10) days, leaving a median (IQR) of 3 (0–6) days of isolation. Eighty-three percent had moderate to high levels of virus (Ct <33), but by disclosure 23% were out of their isolation period. The longest intervals were symptom onset to test (median [IQR], 4 [2–9] days) and test to results notification (median [IQR], 3 [2–4] days). Access to a test site was the most common barrier to testing, and food and income loss was the most common barrier to isolation. Conclusions Over half of the 10-day isolation period passed by the time of disclosure, and over a fifth of people were likely outside the window of infectiousness by the time they received results. Improvements in test access and turnaround time, plus support for isolation, are needed for epidemic control of SARS-CoV-2 in highly impacted communities.

Darpun D. Sachdev, MD; Hannah K. Brosnan, MPH; Michael J. A. Reid, MD, MPH; Michelle Kirian, MPH; Stephanie E. Cohen, MD, MPH; Trang Q. Nguyen, PhD, MPH; Susan Scheer, PhD, MPH

BACKGROUND:Early virologic suppression (VS) after human immunodeficiency virus (HIV) infection improves individual health outcomes and decreases onward transmission. In San Francisco, immediate antiretroviral therapy (ART) at HIV diagnosis was piloted in 2013-2014 and expanded citywide in 2015 in a rapid start initiative to link all new diagnoses to care within 5 days and start ART at the first care visit. METHODS:HIV providers and linkage navigators were trained on a rapid start protocol with sites caring for vulnerable populations prioritized. Dates of HIV diagnosis, first care visit, ART initiation, and VS were abstracted from the San Francisco Department of Public Health HIV surveillance registry. RESULTS:During 2013-2017, among 1354 new HIV diagnoses in San Francisco, median days from diagnosis to first VS decreased from 145 to 76 (48%; P < .0001) and from first care visit to ART initiation decreased from 28 to 1 (96%; P < .0001). By 2017, 28% of new diagnoses had a rapid start, which was independently associated with Latinx ethnicity (AOR, 1.73; 95% CI, 1.15-2.60) and recent year of diagnosis (2017; AOR, 16.84; 95% CI, 8.03-35.33). Persons with a rapid ART start were more likely to be virologically suppressed within 12 months of diagnosis than those with a non-rapid start (RR, 1.17; 95% CI, 1.10-1.24). CONCLUSIONS:During a multisector initiative to optimize ART initiation, median time from diagnosis to VS decreased by nearly half. Immediate ART at care initiation was achieved across many, but not all, populations, and was associated with improved suppression rates.

Coronavirus disease 2019 can cause significant mortality in the elderly in long-term care facilities (LTCF). We describe 4 LTCF outbreaks where mass testing identified a high proportion of asymptomatic infections (4%-41% in healthcare workers and 20%-75% in residents), indicating that symptom-based screening alone is insufficient for monitoring for COVID-19 transmission.