The ongoing spread coronavirus disease worldwide has caused major disruptions and led to lockdowns. Everyday lifestyle changes and antenatal care inaccessibility during the coronavirus disease 2019 (COVID-19) pandemic have variable results that affect pregnancy outcomes. This study aimed to assess the alterations in stillbirth, neonatal-perinatal mortality, preterm birth, and birth weight during the COVID-19 national lockdown.We used the data from the Jordan stillbirths and neonatal death surveillance system to compare pregnancy outcomes  between two studied periods (11 months before the pandemic (May 2019 to March 2020) vs. 9 months during the pandemic (April 2020 to March 1st 2020). Separate multinomial logistic and binary logistic regression models were used to compare the studied outcomes between the two studied periods after adjusting for the effects of mother’s age, income, education, occupation, nationality, health sector, and multiplicity.P value <0.001)There were 31106 registered babies during the study period; among them, 15311 (49.2%) and 15795 (50.8%) births occurred before and during the COVID-19 lockdown, respectively. We found no significant differences in preterm birth and stillbirth rates, neonatal mortality, or perinatal mortality before and during the COVID-19 lockdown. Our findings report a significantly lower incidence of extreme low birth weight (ELBW) infants (<1kg) during the COVID-19 lockdown period than that before the lockdown  decreased significantly. More research is needed to determine the impact of cumulative socio-environmental and maternal behavioral changes that occurred during the pandemic on the factors that contribute to ELBW infants. Numerous coronavirus outbreaks posing a great public health threat have occurred throughout the years, including the Middle East respiratory syndrome and severe acute respiratory syndrome (SARS-CoV). The current alarming worldwide spread of SARS-CoV-2 has caused worldwide disarray, with the World Health Organization (WHO) declaring it a public emergency in January 2020 .The coronavirus disease (COVID-19) pandemic has caused an international outcry, leading to lockdowns, as well as health care and economic crises, in many countries . GloballIndividual studies and systematic reviews are increasingly giving evidence on the influence of other recent viral epidemics on pregnancy outcomes. According to the current literature, pregnancy may worsen the course of COVID-19 infection when compared to non-pregnant women of the same age. COVID-19 has been linked to an increase in obstetric complications like fetal distress, cesarean delivery, and both iatrogenic and spontaneous preterm birth . The repIn the context of the 2014-2019 Ebola outbreak in West Africa, evidence suggests that nearly all pregnant women who contract Ebola have a negative pregnancy outcome. Perinatal mortality among Ebola-infected women's infants is extremely high, with only a small percentage surviving the neonatal period . A comprWith an increasing number of pregnant women being diagnosed with COVID-19 worldwide, our understanding of the effect of COVID-19 on fetal outcomes at population level remains limited. As healthcare services become overwhelmed by COVID-19 cases and means of addressing them, there is a threat of the already fragile infrastructure collapsing. There are concerns regarding whether these services can provide adequate antenatal care, especially in low- and middle-income countries .During the early months of 2020, COVID-19 caused a worldwide healthcare emergency. Among other countries, it affected Jordan, a Middle Eastern upper-middle-income country with approximately 10 million inhabitants in 2020 . The staGiven the novelty of the virus, only modeling studies have investigated whether the COVID-19 pandemic affects mothers and their babies, with many of them anticipating decreased accessibility to health services. Several studies have attributed maternal mortality during the COVID-19 pandemic to comorbidities; on the other hand, neonatal mortality has been attributed to prematurity rather than infection –18. The Prematurity is the leading cause of death in children aged < 5 years  and is aAlthough this is a sudden and unfortunate occurrence, it is important to identify a silver lining. Specifically, the pandemic provides a unique opportunity to evaluate its effects as a “natural experiment” . Like thth, 2020, the Jordanian government suspended schools, banned public gatherings, and closed borders and airports. During this period, the Ministry of Health advised the public to adhere to social distancing and proper hand hygiene. The government announced a lockdown on March 17th, 2020, which subsequently turned into a strictly enforced curfew with stay-at-home orders. The more cautious relaxation measures, driven by data, were applied on 30th April 2020, where the Jordanian government moved to ease the lockdown . On 5th May 2020, the government issued a defense order, punishing those who do not abide by safety regulations and by wearing of masks in public with a fine. These unique conditions could pose environmental risks or benefits to pregnant women. Using a prospective maternal and newborn health registry study, we analyzed data collected from May 2019 to December 2020. Stillbirth, neonatal-perinatal mortality, gestational age of preterm births, and low birth weight trends were collected from five pilot hospitals in Jordan over the set period during the COVID-19 pandemic. Subsequently, we compared these trends with the data of pre-lockdown trends.On March 14Regarding the current pandemic, data were retrieved from the J-SANDS . The J-SANDS is a secure electronic surveillance system that was established in 2019 to collect and report standardized perinatal and neonatal mortality data from five main hospitals in Jordan. The system uses the WHO application of International Classification of Diseases, ICD-10, to classify deaths during the perinatal period (ICD-PM). These five hospitals include a university teaching hospital, a private hospital, and three public hospitals in three major governorates in Jordan. We included all births, as well as maternal demographic data, obtained from May 2019 to December 2020. We analysed data collected 11 months before the pandemic (May 2019 to March 2020) and 9 months during the pandemic (April 2020 to December 2020). The inclusion criteria were neonates born between 24 and 42 gestation weeks, with no further exclusion criteria being applied.Data on mothers’ socio-demographic characteristics including age, nationality, hospital birth site, income, multiple pregnancies, and parity were extracted from the JSANDS. Multiplicity was divided into singleton, twin, and triplet pregnancies, while parity included primiparous, low multiparity (having 2–4 births), and grand multiparity (having ≥ 5 births).Prematurity was classified into extremely preterm infants (born at < 28 weeks), very preterm (born at 28–32 weeks), and moderate-to-late preterm (born at 32–37 weeks). Birth weight was divided into normal, low (< 2500 g), very low (< 1500 g), and extremely low birth weight (< 1000 g). Stillbirth was defined as delivery at ≥ 24 gestation weeks or with a birth weight of ≥ 500 g without signs of life, irrespective of death. Stillbirths include antepartum stillbirth (death before labor onset) and intrapartum stillbirth . Neonatal death was defined as a live-born baby at ≥ 24 gestation weeks or with a birth weight of ≥ 500 g who died before 28 completed days after birth. In the JSANDS, neonatal deaths are divided into early neonatal death (death before 7 completed days after birth) and late neonatal death (death between 8 and 47 completed days after birth). Perinatal death was defined as fetal death after 24 gestation weeks and before 7 post-birth days.This study was approved by the Institutional Review Board at Jordan University of Science and Technology . To ensure data privacy, the data were exported without identifying information (e.g. name or phone number). Informed consent was obtained from all participated mothers. All methods were carried out in accordance with relevant guidelines and regulations of the Institutional Review Board of Jordan University of Science and Technology.Statistical analyses were performed using SPSS version 24 . Data were described using means (SD) and percentages. Chi-square test was used to compare percentages. Separate binary logistic regression analyses (models) were used to compare the dichotomous outcome variables  between the two studied periods (during the COVID-19 lockdown vs. before COVID-19). For nominal outcome variables , we conducted separate multinomial logistic regression analysis for each outcome to compare the outcome between the two studied periods. The main independent variable in each model was the period (during the COVID-19 lockdown vs. before COVID-19). The differences in the pregnancy outcomes between two study periods were adjusted for mother’s age, income, education, occupation, nationality, health sector, and multiplicity. These variables were selected and included in the models based on the Wald Chi-Square test statistic. A p-value of less than 0.05 was considered statistically significant.p <0.001).From May 2019 to December 2020, 29592 women were admitted to the five pilot hospitals for delivery, with 31106 babies being born . During the study period, 14989 (50.7%) vaginal births occurred, out of which 7228 (48.2%) and 7761 (51.8%) births occurred before and during the lockdown, respectively. Additionally, 14603 (49.3%) births occurred, by C-section out of which 7088 [48.5%] and 7515 [51.5%] were births before and during the lockdown, respectively. Table The proportion of babies born with low or very low birth weight was significantly lower during COVID-19 pandemic than that before the pandemic Table . The perp = 0.016). Unexpectedly, these findings were not observed when both the lockdown and the de-escalation periods were considered. The differences in outcomes according to the period may be attributable to changes that occurred as a result of the COVID-19 pandemic, including infection prevention and control measures, the presence of around-the-clock access to emergency departments, life style and eating pattern changes, and restricted mobility of pregnant women with persistent stay home ordersVery low birth weight (VLBW) and extremely low birth weight (ELBW) infants contribute significantly to under-5 mortality. In this context, it is important to have a better understanding of the impact of the COVID-19 pandemic on outcomes associated with preterm gestation age and low birth weight based on more appropriately standardized perinatal and neonatal mortality data. This would allow provision of more qualified care to pregnant women and the newborn. The current study reports that babies born during the period of COVID-19 were significantly less likely to be born with extremely low birth weight (0.56% vs 1.52%), even after adjusting for sociodemographic confounders. Similarly, Philip et al. reported that a significant reduction in the rate of ELBW and VLBW in Ireland includes multiple gestations , our findings are representative of Jordan’s population and could facilitate further studies on the effect of cumulative socioenvironmental and maternal behavioral alteration on the factors contributing to extremely low birth weight, which has adverse effects on neonatal wellbeing and added long-term morbidity during the coronavirus pandemic [To our knowledge, our study is by far the largest to have assessed the impact of COVID-19 mitigation measures on birth outcomes in a middle-income country. Given the large sample size of our study (pandemic . AdditioOur study has several limitations. First, we could not compare our results to previous Jordanian findings since the J-SANDS was only recently established in August 2019. A longer analysis period could have yielded more reliable rates since Jordan has a limited data system in place documenting stillbirths and other neonatal outcomes.Second, the J-SANDS only includes five hospitals in Jordan, which could limit the generalizability of the results nationwide.After adjustment for sociodemographic factors, the study found that there were significant differences in the populations of the two periods in terms of the rate of extreme low birth weight infants, but no difference in the rates of preterm birth, neonatal-perinatal death, and stillbirth. To see if the changes persist, birth outcomes must be tracked throughout the second year of the COVID-19 pandemic and beyond. Future epidemiological and experimental research is needed to better understand the effects of socioeconomic, maternal behavioral, and nutritional factors on the variable reported birth outcomes that occurred worldwide during the pandemic in order to develop effective preventive strategies.


To better understand coronavirus disease 2019 (COVID-19) transmission among healthcare workers (HCWs), we investigated occupational and nonoccupational risk factors associated with cumulative COVID-19 incidence among a Massachusetts HCW cohort.The retrospective cohort study included adult HCWs in a single healthcare system from March 9 to June 3, 2020.The SARS-CoV-2 nasopharyngeal RT-PCR results and demographics of the study participants were deidentified and extracted from an established occupational health, COVID-19 database at the healthcare system. HCWs from each particular job grouping had been categorized into frontline or nonfrontline workers. Incidence rate ratios (IRRs) and odds ratios (ORs) were used to compare subgroups after excluding HCWs involved in early infection clusters before universal masking began. A sensitivity analysis was performed comparing jobs with the greatest potential occupational risks with others.P < .001; multivariate-adjusted IRR, 1.89; 95% CI, 1.03–3.44 comparing fifth to first quintile of community rates). After multivariate adjustment, African-American and Hispanic HCWs had higher incidence of COVID-19 than non-Hispanic white HCWs . After adjusting for race and residential rates, frontline HCWs had a higher IRR  than nonfrontline HCWs overall, but not within specific job categories nor when comparing the highest risk jobs to others.Of 5,177 HCWs, 152 (2.94%) were diagnosed with COVID-19. Affected HCWs resided in areas with higher community attack rates (median, 1,755.2 vs 1,412.4 cases per 100,000; After universal masking was instituted, the strongest risk factors associated with HCW COVID-19 infection were residential community infection rate and race. A study conducted in China showed that none of the HCWs deployed to Wuhan during the outbreak tested positive after 6–8 weeks of serving on the front line.11The occupational risk factors of COVID-19 infection for HCWs include inadequate use of personal protective equipment (PPE), close contact with source patients and infected coworkers, suboptimal hand hygiene, and long working hours.12 little research has investigated nonoccupational risk factors for HCWs. Race-related health disparities have been reported in the COVID-19 pandemic, with minorities being at higher risk of morbidity and mortality.13 In addition, residential community infection rates may contribute to HCW COVID-19 incidence because most HCWs have continued to have personal exposures with their families and communities. A recently published Dutch study investigated the severe acute respiratory coronavirus virus 2 (SARS-CoV-2) virology among HCWs and hospitalized patients and found no evidence of nosocomial infection.14 The study indirectly supports the hypothesis that COVID-19 infection among HCWs may be driven by community attack rates or other nonoccupational factors. Therefore, we conducted this study to examine HCW occupational risks with regards to their working departments and jobs, as well as their nonoccupational risks, to identify the main contributors to COVID-19 incidence among HCWs during the pandemic.Although potential infection transmission routes in HCW work environments have been established and evidence-based infection control strategies have been implemented in healthcare facilities accordingly,The HCWs of a Massachusetts community healthcare system have been under surveillance for COVID-19 infection, including from March 9 to the end of the current study period, June 3, 2020. A COVID-19 “hotline” was set up by the occupational medicine service of the healthcare system to telephonically triage any HCW with regard to their symptoms, travel, and exposure history, followed by further referral for SARS-CoV-2 testing as clinically indicated. To optimally understand HCW infection rates, the occupational health hotline also collected HCW demographic and administrative information, which included age, race, sex, and their residential area from the system’s human resources department.All HCWs >18 years of age and actively serving in the healthcare system by June 3, 2020, were retrospectively included in this study. The contracted, permanently remote work force consisting of HCWs residing outside the New England area was excluded for the analyses involving residential locations.15The details of the HCW cohort, triage, and testing have been published previously.15 and are only summarized here. The outcome of interest was COVID-19 as confirmed by SARS-CoV-2 testing results and the corresponding cumulative incidence of COVID-19 as of June 3, 2020. After an HCW contacted the hotline due to either (1) travel; (2) potential contact with a COVID-19–positive/–suspected person; or (3) possible viral symptoms and was telephonically interviewed, the HCW was referred for a nasopharyngeal swab. Specimens were transferred to a laboratory for a real-time, reverse-transcriptase–polymerase-chain-reaction (RT-PCR) diagnostic panel that qualitatively detected nucleic acid from SARS-CoV-2. The test has limits of detection ranging from 600 to 5,400 nucleic acid-based amplification tests (NAATs) detectable units/mL.16 For those with initial negative assays but progressive symptom(s), a second testing referral was arranged after the hotline follow-up telephonic interviews.The details of the outcome measurement are available in the published study,We considered HCWs as clinically COVID-19 free if they never underwent a hotline triage; were never tested, or consistently tested negative for SARS-CoV-2. We considered HCWs as COVID-19 cases if they had any positive PCR assays during the study period. Each HCW was only entered once into the final database used for the analyses.From human resources, we collected data on HCWs’ working locations, job titles, and whether they worked at the front line or faced patients directly. The research team held meetings with human resources and infection prevention leadership of the healthcare system to best classify the occupational status of each HCW during the pandemic. We defined a total of 15 job groups: registered nurse (RN), other nurse , medical provider , clinical support , mental health provider/social worker/psychologist, milieu counselor/social worker on in-patient psychiatry unit, rehabilitation, ancillary job , radiology technician, pharmacy, laboratory , interpreter, dental hygiene/dental assistant, administrative worker , and others. All 15 job groups were further categorized into either frontline or nonfrontline based on whether the workers had been assigned to shifts at the COVID-19 testing sites, at the COVID-19 units, or in COVID-19 clinics and whether the HCW did patient-facing or non–patient-facing work for the job groups that were ineligible for the frontline work assignments , Notably, dental hygienist and dental assistants were all patient-facing, and administrative workers were all nonfrontline.17 or the county level (other states in the New England area)18 based on the residential zip code in the database.Nonoccupational variables, including demographic information and residential area, were cross validated between the medical personnel of the occupational service hotline and the human resource department of the healthcare system. We obtained the cumulative COVID-19 attack rate in the residential area of each HCW to the city or town level (Massachusetts)15All relevant data were extracted from the hotline database up to June 3, 2020. The database was electronically stored on a secured sever and was accessible only through password-protected computers. The database was deidentified prior to statistical analysis. The research protocol was reviewed by the institutional review board of the healthcare system and was determined to be exempt from human-subject research approval based on the use of existing, HIPAA-deidentified data.19 was implemented in an effort to conserve initially limited mask supplies. Therefore, because universal masking intervention could have fundamentally changed the dynamics around transmission, we excluded such cases from the main analysis.We identified the HCW cases that were involved in workplace clusters that were likely to be HCW-to-HCW transmission and analyzed them separately. The clusters all took place in the earliest stage of the pandemic  and started before universal masking21 the overall testing propensity was higher among the study population than the general population of Massachusetts during the study period. We calculated the testing rate of the healthcare system and had the rate divided by the community testing rate17 to derive a testing propensity weight. This weight was taken into account when comparing the cumulative COVID-19 attack rate among the HCWs and their respective communities of residence.Since SARS-CoV-2 testing was prioritized for HCWs,2 test of independence after the Yates continuity correction or the Fisher exact test, as appropriate. Continuous variables were checked for normality with Q-Q plots, and are reported as mean ± standard deviation or median (Q1–Q3), as appropriate, and the data were compared between groups with the parametric t test or the nonparametric Wilcoxon test, respectively. For HCW residential community cumulative attack rates, we calculated the median and 95% confidence interval (CI) using exact methods or bootstrapping methods if exact methods were not applicable. We further categorized the residential community cumulative attack rates into quintiles, and we demonstrated the case distribution trends across the quintiles. No imputation was made for missing data.Categoric variables were reported as counts with percentages, and the data were compared between groups using the χ14 Point estimates and 95% CIs are reported.We used Poisson and logistic regression models to calculate incidence rate ratios (IRRs) or odds ratios (ORs), regressing PCR-diagnosed COVID-19 positivity on the sociodemographic factors of interest . The variable selection was based on our domain knowledge and existing evidence.P values presented are 2-tailed. A P < .05 was considered statistically significant. R version 3.6.3 statistical software  was used for the analyses.All We analyzed HCWs deemed by infection prevention as having the greatest presumed potential risks of exposure in a sensitivity analysis for occupational risks. Those HCWs included SARS-CoV-2 testing personnel, anesthesia specialists, intensive care unit (ICU) providers, ICU RNs, other ICU nurses, respiratory technicians, emergency room (ER) providers, ER RNs, and other ER nurses. IRRs were calculated to compare the HCWs of the greatest presumed risk group versus other HCWs.P < .001). In addition, COVID-19 cases lived in communities with significantly higher average cumulative attack rates   were clinically diagnosed with COVID-19 after laboratory confirmed SARS-CoV-2 positive PCR assays, and another 5,025 HCWs were either clinically COVID-19 free without SARS-CoV-2 testing referral  or had consistently negative PCR assays (n = 749). Among the 901 occupational hotline-triaged HCWs, 14 (1.6%) had a travel history, 225 (25.0%) had potential contact with a COVID-19–positive/–suspected person, and 812 (90.1%) had possible viral symptoms. Also, 240 HCWs (26.6%) received >1 PCR testing referral. For the entire cohort, the average age was 44.3 ± 13.5 years old, and most were female (75.0%). There was no age or sex difference between positive cases and negative subjects, but COVID-19 cases were more likely to be nonwhite minorities  and that for Hispanic HCWs was 3.17  compared to non-Hispanic white HCWs. After adjusting for age, sex, residential community rates, and frontline or patient-facing working status, the IRRs for African-American and Hispanic HCWs were 2.78  and 2.41 , respectively, compared to the COVID-19 incidence among non-Hispanic white HCWs  (Table 1 online). In a further sensitivity analysis, there were 416 HCWs with the greatest presumed exposure  and 15 (3.6%) of them were diagnosed with COVID-19. When comparing these HCWs of interest with other HCWs , the race and community rate-adjusted IRR remained nonsignificant .After excluding the 29 non–index-cluster cases, overall frontline or patient-facing HCWs had a 1.73 times odds for being diagnosed with COVID-19  compared to nonfrontline HCWs. Subgroup analyses based on frontline working status were performed for each job category. None of the frontline or patient-facing HCWs had significantly higher odds for being a COVID-19 case, compared to nonfrontline HCWs, after adjusting for race and residential area’s cumulative attack rate  of higher infection rates among frontline HCWs compared to nonfrontline HCWs for each stratified job group. We detected no significant difference when comparing HCWs of the greatest presumed exposure risk categories with others.23 Despite accumulating literature arguing that HCW work-related transmission is not negligible,24 a recently published study in which whole viral genome sequencing was conducted among infected HCWs in the southern Netherlands found that infections among HCWs were more likely to be due to community transmission.14 A German study investigated frontline HCW serology on a weekly basis. The low SARS-CoV-2 seroprevalence (1%–2%) was reassuring given concerns that frontline HCWs could have higher incidence during the pandemic.9 Consistent with the other emerging studies, we failed to find strong evidence of patient-to-HCW transmission. Instead, we found robust evidence of community transmission, driven by racial and community health disparities.Even though the health of HCWs has been widely discussed during the pandemic, no strong evidence has demonstrated whether HCWs have a higher risk of being infected.1 Professional guidelines have been published defining strategies to protect HCWs, and PPE use is one of the most important measures.26 Different levels of PPE have been recommended for different patient-facing scenarios. For example, surgical masks, in addition to standard precautions  should be sufficient for HCWs who are not in close contact with diagnosed or suspected COVID-19 patients, although N-95 respirators with standard precautions are recommended for HCWs in close contact with diagnosed and suspected COVID-19 cases.27 We observed no infections among our anesthesia teams despite their frequent involvement in intubations of COVID-19 patients. The healthcare system where we conducted the study has also used extended use and reuse of N-95 respirators for all COVID-19–confirmed or –suspected patients since the inception of the pandemic. Thus, our present study suggests that such protective strategies work well for HCWs, which is in agreement with the evidence that PPE offers adequate protection against COVID-19.19These results, however, do not mean that occupational risk for HCWs is negligible, as evidenced by the early clusters before universal masking and the modest increase observed among all frontline HCWs when pooled together. HCW health and workforce protection have been focal points of the pandemic response since the initial outbreaks.13 In fact, the US CDC has recognized racial minorities as a vulnerable population that needs extra protection during the pandemic. Nationwide statistics as of June 12, 2020, show that African-American and Hispanic populations had a 4–5 times higher COVID-19 hospitalization or death rate than non-Hispanic white populations.28 Similar trends have also been demonstrated in the United Kingdom, with the proportion of COVID-19 confirmed cases among racial minorities being double the expected proportion based on the minority proportion of population in the last census.29 A recently published review paper discussed potential causes of the racial disparity in COVID-19 pandemic.29 Accumulating evidence has shown socioeconomic disadvantages among minorities with regard to their jobs, living conditions, and access to healthcare, among other factors.29Another novel finding of this study is the racial disparity of COVID-19 incidence in healthcare work environment. Our results show that African-American and Hispanic HCWs are disproportionately affected by COVID-19, even after adjusting for residential area attack rates. These findings of health disparities are in accordance with existing evidence.The current study has several strengths. First, the occupational variables, demographics, and residential areas were extracted from an established database, and each HCW’s occupational status was classified according to an agreement between the research team, human resources, and infection prevention leadership of the healthcare system. All relevant exposure data were collected before the HCW’s COVID-19 diagnosis, freeing our study from recall bias. Second, the healthcare system has been utilizing consistent policies regarding workers’ screening criteria and PPE use, following professional guidelines, since the initial outbreak. Therefore, the outcome measurement was consistent throughout the study period. Third, the hotline followed each referred HCW and determined whether that HCW needed a second testing, minimizing the possibility of a false negative due to single testing. Fourth, we performed sensitivity analysis for occupational risk factors, and the results remained in agreement with the main analysis, reinforcing our findings. Finally, all adult employees of the healthcare system were included in the study. Nonhealthcare personnel, such as maintenance workers, contractors, and security staff, were also included in the analysis. Therefore, our results may be generalized to larger working populations with similar settings.This study has some limitations. First, not all workers in the healthcare system were tested, and those who did not undergo hotline triage were assumed to be clinically COVID-19 free. Therefore, we cannot exclude the possibility that these people were asymptomatic or subclinical cases that were not detected. However, the outcome misclassification should not be associated with HCW jobs or demographics, and, therefore, the related information bias is nondifferential. Second, the data on race, sex, and residential area were missing for some contract HCWs. However, we had ∼90% complete information for the analyses, and the missingness was independent of COVID-19 testing; hence, we believe the study results are unbiased. The category assignments of frontline and nonfrontline or patient-facing or non–patient-facing were based on imperfect employment records and may have misclassified some HCWs, but to the extent it occurred, it was likely nondifferential. Finally, we could not evaluate individual compliance with proper handwashing, hygiene, and PPE use.In conclusion, the current study shows that the major risk factors associated with COVID-19 infection among HCWs are residential area attack rate and race. No significant infection difference between frontline and nonfrontline HCWs were found, neither did high-risk jobs have higher incidence rates. Future studies and public health efforts that can reduce racial and socioeconomic health disparities in the pandemic are warranted.


Turning the head while walking (an action often required during daily living) is particularly challenging to maintain balance. It can therefore potentially reveal subtle impairments in early-stage people with multiple sclerosis who still show normal locomotion (NW-PwMS). This would help in identifying those subjects who can benefit from early preventive exercise aimed at slowing the MS-related functional decline.To analyze if the assessment of walking with horizontal head turns (WHHT) through inertial sensors can discriminate between healthy subjects (HS) and NW-PwMS and between NW-PwMS subgroups. To assess if the discriminant ability of the instrumented WHHT is higher compared to clinical scores. To assess the concurrent validity of the sensor-based metrics.In this multicenter study, 40 HS and 59 NW-PwMS  were tested. Participants executed Item-6 of the Fullerton Advanced Balance scale-short (FAB-s) wearing three inertial sensors on the trunk and ankles. The item required to horizontally turn the head at a beat of the metronome (100 bpm) while walking. Signals of the sensors were processed to compute spatiotemporal, regularity, symmetry, dynamic stability, and trunk sway metrics descriptive of WHHT.p ≤ 0.001), and showed moderate discriminant ability (area under the receiver operator characteristic curve [AUC]: 0.71–0.73). AP symmetry and ML stability were reduced (p ≤ 0.026) in EDSS: 2–2.5 vs. EDSS: 0–1.5 subgroup (AUC: 0.69–0.70). The number of NW-PwMS showing at least one abnormal instrumented metric (68%) was larger (p ≤ 0.002) than the number of participants showing abnormal FAB-s-Item6 (32%) and FAB-s clinical scores (39%). EDSS: 2–2.5 subgroup included more individuals showing abnormal instrumented metrics (86%) compared to EDSS: 0–1.5 subgroup (57%). The instrumented metrics significantly correlated with FAB-s-Item6 and FAB-s scores , thus demonstrating their concurrent validity.Mediolateral regularity, anteroposterior symmetry, and mediolateral stability were reduced in NW-PwMS vs. HS (The instrumented assessment of WHHT provided valid objective metrics that discriminated, with higher sensitivity than clinical scores, between HS and NW-PwMS and between EDSS subgroups. The method is a promising tool to complement clinical evaluation, and reveal subclinical impairments in persons who can benefit from early preventive rehabilitative interventions. The head is a natural reference frame for movement since it contains the visual and vestibular systems indispensable to correctly detect self-motion in space . Since hMoving the head during locomotion naturally challenges the balance control system since it requires the accurate integration of vestibular, visual, and proprioceptive information to modulate the vestibulo-ocular and vestibulospinal reflexes responsible for gaze stabilization/redirection and dynamic balance maintenance , 4. Conshow a task is performed  test , no studThis multicenter cross-sectional study aims at analyzing the discriminant ability and the concurrent validity of an IMU-based assessment of WHHT in early-stage PwMS with normal natural walking (NW-PwMS). We hypothesized that the instrumented assessment of WHHT (i) can discriminate between healthy subjects and NW-PwMS, and between NW-PwMS subgroups, (ii) its discriminant ability is higher compared to clinical scales, and (iii) provides valid indexes to complement clinical assessments of WHHT and dynamic balance in early-stage PwMS.A total of 82 consecutive PwMS  were enrolled from three clinical Italian centers in Milan, Turin, and Genoa. Inclusion criteria were: age ≥ 18 years, MS diagnosis based on McDonald criteria , diseaseA total of 40 healthy subjects (HS) without any musculoskeletal or neurological disorders  were also recruited. All the participants signed a written informed consent to the study that was approved by the local ethical committee of each center .People with multiple sclerosis were assessed with the Timed 25-foot Walk test (T25FWT) and with an IMU-based instrumented gait test.The T25FWT measures the time taken to walk at maximum speed along a 7.62-m linear course . ParticiThe remaining participants were required to walk a 15-m straight corridor at their maximum speed wearing three IMUs  above lateral malleoli and on the lower back. The latter position was chosen as it is the most widely used during gait tests, as described in the review by Vienne-Jumeau et al. . SignalsIn addition to the T25FWT and the 15-m instrumented test, the following clinical assessments were administered to NW-PwMS: the 12-item Multiple Sclerosis Walking Scale (MSWS-12) and the Fullerton Advanced Balance-short Scale (FAB-s). FAB-s was administered also to HS.The MSWS-12 is a patient-reported questionnaire on walking ability. The questions focused on the self-perceived impact of MS on 12 daily-life locomotor activities in the last 2 weeks. The transformed total score is between 0 and 100, with higher scores indicating higher perceived walking difficulties , 33. TheHealthy subjects (HS) and NW-PwMS were equipped with three wireless IMUs  secured on both shanks  and the sternum. The position of the latter IMU was chosen to better describe sway and possible instability of the upper trunk that, based on our clinical experience, seem to occur more frequently during locomotor tasks particularly demanding in terms of dynamic balance  and AP symmetry .The number of participants showing abnormal values of ML regularity was comparable between EDSS subgroups  and FAB-s score .pχ2 = 0.019) in EDSS: 2–2.5 [19/22 (86%)] vs. EDSS: 0–1.5 subgroup [21/37 (57%)] (pχ2 ≥ 0.226).The number of individuals presenting at least one abnormal instrumented metric was larger (7 (57%)] . The sam7 (57%)] , althougrs ≤ 0.17, pBH ≥ 0.222).ML stride regularity, AP iHR, and ML sLyE showed low non-significant correlations between each other   have notInterestingly two of the three selected metrics (regularity and stability) were abnormal in ML direction. Previous studies on PwMS have demonstrated that several ML parameters descriptive of balance , 62 are While the clinical scores were comparable between EDSS subgroups, the instrumented WHHT revealed that the EDSS: 2–2.5 subgroup was characterized by lower AP symmetry and reduced ML dynamic stability compared to the EDSS: 0–1.5 subgroup. This indicated that the instrumented assessment of WHHT could be a sensitive tool to detect differences also between subgroups of PwMS in the lower range of EDSS. These findings suggest that AP symmetry and ML dynamic stability describing WHHT could be responsive indexes to monitor the disease progression. Further longitudinal studies including subjects with a larger spectrum of disability should be performed to corroborate this hypothesis.Compared to the FAB-s clinical scores, the instrumented WHHT demonstrated a higher ability to discriminate between HS and NW-PwMS: the percentage of participants showing at least one abnormal instrumented metric (68%) was statistically larger than that detected by FAB-s-Item6 subscore (32%) and FAB-s score 39%). This result was found also considering separately the two EDSS subgroups, further supporting the larger sensitivity of the instrumented WHHT. Finally, the correlation analysis between the FAB-s scores and the instrumented metrics revealed a moderate concurrent validity of the proposed indexes to measure dynamic balance impairments. Interestingly, ML dynamic stability, as measured by sLyE, was significantly correlated with the MSWS-12. This finding complements previous results showing that balance dysfunctions and instability are major contributors to the perceived MS-related walking disturbances also in the early stage of MS %. This r. This reFirst, the proposed instrumented metrics were computed on five strides that are those required by the FAB-s instructions but are less than those suggested to increase the robustness of the parameters (10–20 strides) , 63. HowThe present results confirmed our hypotheses: the IMU-based assessment of WHHT provides valid objective metrics able to discriminate, with a higher sensitivity than clinical scores, between HS and NW-PwMS and between EDSS subgroups. The method is a promising tool to complement clinical assessments and detect subtle impairments in early-stage non-disabled PwMS who still show normal natural walking. This approach would help in tracking these impairments over time and identifying those individuals who may benefit from preventive motor exercise since the very early stages of MS, when rehabilitation may still have neuroprotective and disease-modifying effects, as recently suggested . Future The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by the local Ethical Committee of each center. These were: Comitato Etico della Sezione “IRCCS Fondazione Don Carlo Gnocchi” del Comitato Etico IRCCS Regione Lombardia , Comitato Etico Interaziendale dell'A.O “SS. Antonio e Biagio e Cesare Arrigo” , and Comitato Etico Regionale della Liguria . The patients/participants provided their written informed consent to participate in this study.Conception and design of the study, software implementation, data processing, data analysis, data interpretation, and drafting the manuscript by IC. Instrumented data collection, clinical assessment, and data organization by EG, DA, and RD. Data collection and organization by AT. Recruitment of patients and clinical assessment by GB, PC, CS, and MR. Conceptualization and design of the study, data analysis and interpretation, and coordination by DC. Conceptualization and design of the study and coordination by MF, CS, and GB. All authors contributed to data interpretation, critically reviewed the manuscript, and approved the final version of the manuscript.This study was supported by the Italian Multiple Sclerosis Foundation—FISM  and by the Italian Ministry of Health (Fondi di Ricerca Corrente).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Despite high rates of gender-based violence (GBV) in India, culturally sensitive measures that examine universal and culturally relevant trauma reactions are lacking. Although the Harvard Trauma Questionnaire (HTQ) has been used in India, no study has adapted the measure in full for use with this population. Similarly, the  PTSD checklist-5 (PCL-5) has not yet been validated in India. This study describes the adaptation, validation, and results from the adapted HTQ, and embedded PCL-5, for Indian women from slums reporting GBV.This study used the adaptation framework proposed by the HTQ measure developers. The adapted HTQ contained a (1) trauma screen relevant for stressors faced by Indian women from slums, (2) description of the index trauma, (3) description of any ongoing stressors, (4) universal trauma reactions , and culturally relevant trauma reactions . This measure was piloted on 111 women from Indian slums in face-to-face interviews. Trauma characteristics, types of ongoing stressors, and psychometric properties of the PCL-5 and idioms of distress scale were explored. These scales were validated against measures of depression (PHQ-9), anxiety (GAD-7), and somatic complaints (PHQ-15).rs between .54 and .80, ps < .05).The majority of participants (77%) reported physical beatings, 18% reported unwanted sexual touch, and 28.8% reported infidelity as the primary emotional abuse. Further, 96.7% of GBV was perpetrated by partner or family member and over half reported ongoing stressors . The PCL-5 embedded in the HTQ yielded good internal consistency  as did the idioms of distress scale with deletion of one item . Both scales were externally valid, yielding large correlations with depression, anxiety, and somatic complaints (This is the first study to develop a comprehensive measure of trauma exposure with universal and culturally relevant trauma reactions in India. This study also enhances HTQ usage in India by delineating all the steps in the adaptation process. Results can inform the development of trauma-focused interventions for Indian women from slums.The online version contains supplementary material available at 10.1186/s12905-022-01595-3. The gang rape of a New Delhi medical student in 2012 garnered global attention and catapulted India into national protests and discourse about gender-based violence (GBV)  that disGender-based violence in India is defined by physical, sexual, emotional, and economic abuses that typically occur within the family setting. National lifetime rates of GBV range from 8% for sexual violence  to 41% fVariation in the prevalence of GBV is partly attributable to how GBV is defined and assessed. Domestic violence (DV) is the most common type of GBV studied in India . The WHOAccording to a systematic review of 137 studies on GBV from India, 89% of studies focused on DV, excluding other forms of GBV . Only 11While studies evaluate depression, anxiety, and suicide risk among Indian women , 20–22, Research demonstrates that PTSD symptoms are cross-culturally universal, although the endorsement rate of symptoms varies considerably by cultural setting . As suchsafed pani’ (white water), which refers to complaints of abnormal vaginal discharge and is associated with psychosocial factors such as marital strife and GBV [Studies from India highlight three idioms of distress that are not incorporated by the diagnostic criteria of trauma and stressors-related disorders. First, Indian women complain of ‘ and GBV –32. Seco and GBV , 34, 35. and GBV .Altogether, scholarship from India documents high rates of GBV and it is associated with depression, anxiety, and somatic complaints. Yet, few studies explicitly examine how GBV is associated with trauma reactions such as PTSD. To our knowledge, no published studies examine how GBV is associated with culturally relevant trauma reactions, such as idioms of distress. Scholars have called for culturally sensitive assessments to characterize trauma reactions more accurately in India , 38. CroThe HTQ is a PTSD assessment originally developed for refugee populations . It has DSM-5, which features 20—rather than 16—symptoms.One study from India sampled adults in Kashmir Valley to validate Part IV of the HTQ against the psychiatrist-administered MINI using one broad screening question for trauma exposure . They foDSM-5 [An alternative to the HTQ-IV is the PTSD checklist-5 (PCL-5). The PCL-5 is a self-report measure assessing 20 symptoms of PTSD according to the DSM-5 . The PCLDSM-5  and is aDSM-5 –56. OnlyDSM-5 , 58 and The current study addresses the specific gaps of prior HTQ studies in India by detailing the adaptation and validation of the full HTQ including the PCL-5 embedded into it. This study has three major aims: (1) Document the prevalence of multiple types of GBV; (2) Establish the reliability of two subscales of the HTQ-IV ; and (3) Establish the external validity of the two subscales of the HTQ-IV  were included in the study. All study procedures were approved for ethical research conduct by an institutional review board at an American university and by CORO for Literacy. Data were collected in two waves: June to August 2015 and August to October 2018.Data were collected through verbal administration due to low literacy rates in Indian slums . ParticiThe HTQ was adapted following the established procedures of the measure developers in a recent study of Iraqi refugees . These mThe HTQ was adapted to assess PTEs and stressors relevant in India by explicitly querying for PTEs that included GBV and non-GBV stressors. The PTEs and stressors were created from an extensive literature review about Indian women . The PTEParticipants were asked to briefly describe their index trauma. All symptom reports in HTQ-IV were linked to this index trauma to keep consistent with the intended administration of the PCL-5. Participants were also asked: “Under your current living situation, what is the worst event that has happened to you, if different from above. Please specify where and when these events occurred.” Responses to this question were recorded as descriptive information and also coded dichotomously as ‘0’ (when participants endorsed no ongoing stress) and ‘1’ (when participants endorsed ongoing stress).DSM-5 derived from the PCL-5 [The HTQ was adapted to assess three types of trauma-related symptoms after participants endorsed a PTE or stressor. These included 20 PTSD symptoms in the he PCL-5  and 12 iDSM-5 [A 20-item checklist, the PCL-5 assesses PTSD symptoms from the DSM-5 . Each syDSM-5 .A 12-item checklist, the idioms of distress scale contains idioms of distress gleaned from literature review and during discussions with two Indian key informants who were bilingual and familiar with trauma-related reactions. Examples of idioms included somatic complaints, such as orthostatic dizziness and pain in the nerves; culturally-laden cognitions, such as believing that the trauma was written in one’s destiny; and affective reactions, such as tension. Each symptom is rated for severity on a 4-point Likert scale ranging from 1 to 4, so total scores could range from 12 to 48. As this study did not validate the idioms of distress scale against a clinician-administered measure, the level at which symptoms were clinically elevated could not be determined.Consistent with other cross-cultural assessment tool adaptation, steps to translate and back-translate the instrument to ensure technical, semantic, and conceptual equivalence were undertaken . The assAs the wording of PTSD symptoms may not have been comprehensible to participants who may not be familiar with PTSD in this cultural context, the Hindi PCL-5 was also subjected to a comprehension check. A subsample (12%) were administered the comprehension check. For items the subsample endorsed , they were asked to provide examples of the symptoms. For the items the subsample did not endorse (rated ‘0’), participants were asked to explain the meaning of the prompt to ensure conceptual clarity. Answers were recoded verbatim and later coded by both authors against the prompts on the CAPS-5, a gold-standard clinician-administered PTSD assessment. Results of the coding process and disagreements were resolved through discussion and consensus.A 9-item screening instrument, the PHQ-9  assessess α = 0.84).A 7-item screening instrument, the GAD-7 , assesses α = 0.79).A 15-item screening instrument, the PHQ-15 , assesseSD = 9.64) years old on average. They completed an average of 6.97 (SD = 3.76) years of education and subsisted on an average monthly per capita income of 57.99 USD (SD = 61.06 USD). The majority of participants were married (78.57%), of Dalit ethnicity (42.86%), and originated from a city (69.39%).Participants were 34.13 (SD = 2.36) GBV events, 1.12 (SD = 0.94) non-GBV events, and 5.09 (SD = 2.80) total traumatic events. Nearly all (96.91%) reported that GBV events were perpetrated by their partners, family members, or in-laws and 62.92% of participants selected a GBV event as their index trauma. The most common GBV events were being kicked or beaten, directly witnessing others being kicked or beaten, and directly witnessing others attacked with a weapon. The prevalence of each Criterion A event surveyed can be found in Table On average, participants endorsed 3.97  reported ongoing stressors. Types of ongoing stressors included poverty-related stress , caregiving stress , and emotional abuse . Notably, 13 participants  reported that their ongoing stressor was a traumatic event that met the definition of Criterion A .SD = 17.06). Table The full-scale reliability of the total PCL-5 scale was good (Cronbach’s α = 0.88). The mean inter-item correlation for the full-scale PCL-5 was 0.27, indicating a satisfactory item agreement. The mean full-scale Hindi PCL-5 score was 29.88 . Participants who misunderstood flashbacks typically reported general difficulty with understanding it or described ruminative symptoms instead. Similarly, globalized negative beliefs about oneself, the world, and others also proved problematic to comprehend (75% comprehension rate). Participants typically misunderstood this item to mean wishing ill of others and were quick to deny this reaction.SD = 7.11). Table safed pani , nas mein dard (pain in the nerves), and attributing the trauma to being a woman were the least frequently endorsed and yielded the lowest mean item scores. Most items appeared to be worth retaining as deletion would result in a decrease in the scale’s reliability. However, deleting the item, “Believing that you deserved what happened because you are a woman,” would increase the scale’s Cronbach’s α from 0.79 to 0.81 , nas mein dard (pain in the nerves), believing that you deserved what happened because you are a woman. These items were endorsed less frequently and with less intensity in this sample. Barring one item—“believing that you deserved what happened because you are a woman,”—the idioms of distress scale retained good reliability by including the remaining skewed items.The full-scale reliability of the idioms of distress scale was acceptable (Cronbach’s α = 0.79). The mean inter-item correlation for this scale was 0.23, indicating a satisfactory item agreement. The mean idioms of distress scale score was 24.59 (p < 0.001) to 0.80   and also demonstrated convergent validity with known correlates of PTSD.Results indicated that the Hindi PCL-5 demonstrated good reliability estimates, adding to a body of literature from HICs –75 and LSimilarly, results support the validity of the Hindi PCL-5. Medium-to-large positive correlations between full-scale PTSD, depression, and anxiety indicate that the Hindi PCL-5 assessed a construct that was related to depression and anxiety in the expected direction and magnitude. These findings align with the validity literature from HICs , 74 and Certain items on the Hindi PCL-5 did not appear to measure PTSD in this cultural context. The hypervigilance item evinced nearly zero correlation with the remaining items on its arousal subscale, suggesting that it was not measuring PTSD-related arousal in this sample. Perhaps hypervigilance in the Indian slum context, where participants had to live more cautiously overall, did not function as an arousal symptom of PTSD in this setting. Slum communities in Bombay are characterized by frequent adversities, including home destruction by the government, lack of sanitation, lack of privacy for bathing and defecating, water and electricity shortages, and rat infestations . It is pstop thinking of their stressful experiences and ruminated on the details. This item also received the lowest endorsement, with only 14% of participants rating it at or above ‘2’ on a 0 to 4 scale. In other words, most participants (86%) reported no difficulty remembering important parts of the index trauma. Notably, trauma-related amnesia is endorsed less frequently in non-HIC cultural groups and it is considered an inconsistent item across cultures [Trauma-related amnesia also evinced nearly zero correlation with the remaining items on the NACM subscale. Participants responded to this item by emphasizing that they could not cultures , 87, 88 cultures . In contcultures , 91. Thesar mein garmi (heat in the head), dil mein udasi (sadness in the heart), and dizziness. Tension emerged as the most strongly endorsed idiom, which is consistent with the existing literature that tension is a common idiom across linguistic groups indicating depression and anxiety [Idioms of distress are particularly relevant to assess given the problematic nature of two PTSD symptoms  measured by the Hindi PCL-5. The idioms of distress scale yielded good reliability following deletion of one item about believing the traumatic event was deserved for being a woman. The highest mean rating assigned to idioms was for tension, believing the traumatic event was predestined,  anxiety , 92, 93. anxiety , 34, 93, anxiety . Tichy e anxiety . The intsar mein garmi (heat in the head), dil mein udasi (sadness in the heart), and dizziness, are also consistent with the literature on somatization in India [DSM-5 criteria. The fact that these three idioms diverged from PTSD symptoms suggests their potential clinical utility as trauma-related idioms to assess, and target for treatment, for Indian women from slums. This finding, however, is tempered by the finding that endorsement patterns were at low levels of severity. The level of severity may be partly explained by sample characteristics, as this study recruited a community sample.The somatic idioms, such as in India –37, 95. in India , 85, 96.The idioms of distress scale also showed large positive correlations with depression, anxiety, and somatic complaints. Considering that these idioms indicate meaningful reactions related to depression, anxiety, and somatic complaints, it is possible that the idioms might also indicate clinically elevated distress. However, as the idioms of distress scale is a novel scale created for this study, future studies should validate it against clinician-administered interviews and measures of functional impairment to verify if the scale measures clinically elevated distress.This study is limited by a small sample size and by use of referral sampling rather than random sampling. Women who were referred by others or self-referred to the study may systematically differ from other women exposed to GBV. Although a fair representation of women living in urban poverty in India , the stuDSM-5 PTSD symptoms in association with GBV for this population. This study is also one of the few to systematically record and report ongoing stressors in trauma-exposed populations from LMICs. Although more nuanced measures of ongoing stress are needed for future studies in India, the descriptive information about ongoing stressors better contextualized study results, such as why the hypervigilance item may have proved problematic. Finally, this study also improves upon psychometric studies set in LMICs by reporting multiple reliability and validity indicators for universal  and culturally relevant reactions . Notably, this study was conducted before the COVID-19 pandemic . Therefore, the effects of GBV and psychological distress during national lockdowns is not reflected in our study.Notwithstanding these limitations, this study also has strengths. This study is the first to investigate PTSD in an under studied population of Indian women from slums exposed to GBV. Published studies from Indian slums mirror the demographic characteristics of the current study sample , indicatThe adapted HTQ is a reliable and culturally valid assessment that includes a comprehensive trauma screen for India, an assessment of ongoing stressors, universal trauma reactions , and culturally relevant trauma reactions . As certain PTSD items may not be relevant for Indian women from slums, assessing idioms of distress is doubly relevant. Findings from this assessment can inform which treatment targets to focus on and sections of this measure may be abbreviated for use depending on the assessment needs in question.Additional file 1. Adapted Harvard Trauma Questionnaire (HTQ) for Indian women from slums containing the PTSD Checklist-5 (PCL-5) - English version.


Depression and self-harm are leading causes of disability in young people, but prospective data on how maternal depression and self-harm thoughts contribute to these outcomes, and how they may interact is lacking.The study sample consisted of 8,425 mothers and offspring from the Avon Longitudinal Study of Parents and Children, an ongoing birth cohort study. Exposures were maternal self-harm ideation and depression measured using the Edinburgh Postnatal Depression Scale, collected at eleven time points over the period 18 weeks’ gestation to 18 years post-partum. Outcomes were offspring past-year major depressive disorder and lifetime self-harm assessed at age 24.Nearly one-fifth (16.7%) of mothers reported thoughts of self-harm on at least one of the eleven assessment points. The frequency of maternal self-harm ideation was related to both outcomes in a dose-response manner. Young adults whose mothers had self-harm ideation on 5–11 occasions were over three times more likely (Odds ratio (OR), 3.32; 95% CI, 1.63–6.76) to be depressed and over 1.5 times as likely  to have self-harmed than their peers whose mothers had never reported self-harm thoughts. Maternal self-harm thoughts remained associated with both offspring outcomes independent of maternal depression, and no evidence was found for an interaction between the two exposures.Clinicians collecting data on maternal depression may consider paying attention to questions about self-harm ideation in assessments. Examining accumulated maternal self-harm ideation over time may provide insights into which children are most at risk for later self-harm and depression. Depression and self-harm represent a significant public health burden. A diagnosis of depression is amongst the most important risk factors for thoughts of self-harm , and botMaternal thoughts of self-harm are associated with greater severity of depression  which, iIn the UK, current NICE  guidelines encourage routine screening for depression in expectant mothers, with the Edinburgh Postnatal Depression Scale (EPDS)  recommenWe extend prior work on maternal self-harm ideation  and deprThe study sample comprised participants from the Avon Longitudinal Study of Parents and Children (ALSPAC). A total of 14,451 pregnant mothers residing in the former Avon Health Authority in the south-west of England with expected dates of delivery between 1 April 1991 and 31 December 1992 were initially enroled in the study. These pregnancies resulted in 14,062 live births, of which 13,998 were alive at 1 year of age. For further details on the cohort profile, representativeness, and phases of recruitment, see never, (1) hardly ever, (2) sometimes, to (3) quite often. Maternal self-harm ideation was measured with item 10 of the EPDS: “The thought of harming myself has occurred to me.” To maintain consistency with prior work   was admiior work , we codeConsistent with prior analyses , we defiTo examine the interaction between maternal depression and self-harm ideation, an ordinal variable reflecting each of the four possible combinations of the two variables was created for each of the 11 time points: (0) neither self-harm ideation nor depression, (1) depression but no self-harm ideation, (2) self-harm ideation but no depression, and (3) both depression and self-harm ideation.“I have felt sad or miserable”. Mothers were categorised into responses of “mostly” or “quite often” versus “hardly ever” or “never” on this item. Analyses for the interaction between maternal self-harm ideation and depression were conducted using this EPDS item instead of the cut-off for major depression.We choose the initial comparisons of the self-harm ideation item with how the EPDS is most commonly used, a score of 13 or higher. In contrast to our binary MDD exposure variable, the self-harm ideation variable was based on a single item, thus potentially increasing the likelihood of measurement error. In order to examine this possibility, we therefore conducted a series of sensitivity analyses comparing our main findings with those obtained with models using another single item from the EPDS, item 8 Offspring major depressive episode and self-harm were assessed at the age 24 using the self-administered computerized version of the Clinical Interview Schedule – Revised (CIS-R). The CISAnalyses controlled for the highest level of maternal education achieved at 32 weeks’ gestation, maternal age, and maternal marital status (married versus not married), which have all been shown to influence both the exposures  and outcBinary logistic regression was used to examine associations between maternal self-harm ideation and depression with offspring age 24 depression and self-harm. Logistic regression was also used to assess associations between the timing of maternal self-harm ideation at each of the 11 time points, from 8 weeks’ gestation to 18 years post-partum, with offspring outcome. Mothers with neither depression nor self-harm ideation served as the reference group. All analyses controlled for maternal education, age, and marital status.These analyses were repeated for each exposure-outcome combination using all available data to examine the potential impact of missingness on results. A priori level of statistical significance was set at 0.05 and all tests were 2-sided. Analyses were conducted using Stata version 16  .SE = 0.02). For a total of 2914 mothers self-harm ideation data was available at all eleven timepoints. There was no indication in the pattern of missingness in individual EPDS items that the self-harm ideation question was more often missing than others.The pattern of missing data in the study sample are presented in eN = 8425). Multiple imputation by chained equations  and 48.72% of the offspring were female . 16.67% Multivariable logistic regressions indicated a dose-response relationship between the frequencies of maternal self-harm ideation and depression with both offspring outcomes . Young adults whose mothers who had reported self-harm ideation on 5–11 occasions were over 1.5 times as likely to have self-harmed by age 24  and overboth maternal self-harm ideation and depression was worse for offspring mental health outcomes was less convincing. Confidence intervals were wide, reflecting the low numbers of mothers with self-harm ideation who were not depressed. When mothers had both self-harm thoughts and met depression criteria, odds ratios were largest at only three timepoints  for offspring self-harm  and depression . The majority of the associations were in the expected direction, such that the presence of self-harm ideation and maternal depression at each of the eleven time points was associated with elevated odds for later offspring depression and self-harm. Evidence for whether the presence of elf-harm , and at elf-harm .Table 4LIn terms of timing, the strongest associations between maternal self-harm ideation with  and without  maternal depression emerged with offspring self-harm at 11 years post-partum . MaternaResults using the unimputed sample of mothers with incomplete self-harm ideation were substantively consistent (eTables 4–7) with those obtained using the imputed sample. Imputed results were more precise as evidenced by the smaller confidence intervals. Results from sensitivity analyses of the interaction between maternal self-harm ideation and depression using the sad/miserable item were largely consistent (eTables 8–9) with those obtained using the cut-off for major depressive disorder.Over the 17 years that the mothers in this study were followed, nearly 17% reported having thought of harming themselves sometimes or often; the vast majority of these mothers also met criteria for major depression. Self-harm thoughts peaked when the index child was 18 years of age, and we identified the existence of a dose-response relationship between maternal self-harm thoughts and maternal depression with both offspring mental health outcomes. These associations did not appear to be specific, in that maternal self-harm ideation was not more strongly associated with offspring self-harm, and the same was true for depression. In fact, the risk for offspring depression from maternal self-harm thoughts was higher than for maternal depression, suggesting that self-harm ideation may have been accompanied by other changes in the environment that may have triggered subsequent dysphoria in the child. There are a number of possible exposures that might fall into this category, including witnessing traumatising acts of maternal self-harm and associated adversities . Further research should examine whether these variables confound or mediate the association between maternal self-harm ideation and subsequent offspring depression. Furthermore, future studies should use more sophisticated longitudinal modelling techniques to examine how the timing of maternal self-harm ideation and depression influence offspring outcomes, as these data points are correlated.One potential mechanism for the relationship between maternal self-harm ideation  and offsAnother possible explanatory mechanism is via the bi-directional relationship between maternal and offspring psychopathology, which may be partially mediated by direct and indirect genetic effects. Firstly, we observed the greatest peak in maternal self-harm ideation at offspring age 18, an age where depression has commonly already had its onset in adolescents. This onset of adolescence depression could be underlying the peak of maternal self-harm ideation and may support the idea of a bi-directional relationship where mothers have ideas of self-harm because their child is depressed and vice versa. This may have roots in direct and indirect genetic effects.Mothers, particularly in the perinatal period, may have been reluctant to report their thoughts of self-harm. Second, participant loss at follow-up may have biased all available data analyses. However, substantive findings were similar using the imputed dataset, suggesting that the impact of this bias was minimal. We also assumed that our data were missing at random, and to address this we used auxiliary data in our multiple imputation. There were differences between participants with missing data on several indices of socio-economic disadvantage, which may further limit generalisability of our results. Due to low numbers at each time point, we did not include measures of maternal self-harm behaviour, which has been found to increase risk for offspring depression and self-harm .Although maternal self-harm ideation conferred risk for both offspring outcomes, from a public health perspective, mothers with depression should still be focused on, as they represent a larger proportion of the population. Self-harm ideation is a component of the EPDS, which is already widely used in clinical practice. Clinicians may consider giving more weight to endorsements of this item as a way of identifying which offspring may be at greatest future risk for mental health problems. Future research should explore mediating pathways and include data on the father as well. Future research could also specifically examine the risk factors for maternal self-harm ideation and explore if self-harm thoughts earlier in life are a risk factor for later maternal self-harm ideation and depression.All authors declare no conflicts of interest.


Hepatitis C virus (HCV) contributes to liver-related morbidity and mortality throughout Africa despite effective antivirals. HCV is endemic in the Democratic Republic of the Congo (DRC) but data on HCV/HIV co-infection in pregnancy is limited. We estimated the prevalence of and risk factors for HCV/HIV co-infection among pregnant women in the Kinshasa province of the DRC. This cross-sectional study was conducted as a sub-study of an ongoing randomized trial to assess continuous quality improvement interventions (CQI) for prevention of mother-to-child transmission (PMTCT) of HIV . HIV-infected women in the CQI-PMTCT cohort were tested for HCV, and risk factors were evaluated using logistic regression. The prevalence of HCV/HIV co-infection among Congolese women was 0.83% (95% CI 0.43-1.23). Women who tested positive for HCV were younger, more likely to live in urban areas, and more likely to test positive during pregnancy versus postpartum. HCV-positive women had significantly higher odds of infection with hepatitis B virus (HBV) . An inverse relationship was noted between HCV infection and the overall capacity of the health facility as measured by the service readiness index (SRI) . Women who presented to rural, for-profit and PEPFAR-funded health facilities were more likely to test positive for HCV. In summary, this study identified that the prevalence of HCV/HIV co-infection was < 1% among Congolese women. We also identified HBV infection as a major risk factor for HCV/HIV co-infection. Individuals with triple infection should be linked to care and the facility-related differences in HCV prevalence should be addressed in future studies. A recent national survey in the Democratic Republic of the Congo (DRC) found an HCV prevalence of 0.9%, although prevalence estimates varied by province2. Effective antiviral treatment for HCV exists but is not accessible for most inhabitants of SSA, thus perpetuating the epidemic.Hepatitis C virus (HCV) accounts for a large proportion of morbidity and mortality from liver disease globally, particularly in sub-Saharan Africa (SSA). Recent data suggests that prevalence of HCV in SSA ranges from 0.72% in Southern Africa to 7.82% in Central Africa3. Liver-related complications have been demonstrated to be a frequent cause of mortality in co-infected individuals as well4. Infection with both HCV and HIV has been seen throughout SSA. Several sub-Saharan countries, including Togo, Nigeria, Cameroon, Gabon, Mozambique and the DRC, are considered to be high-prevalence areas (> 3.5% according to published definitions) for HCV/HIV co-infection6.Health outcomes in individuals with HCV are far poorer when in the setting of co-infection with HIV. HCV/HIV co-infection has been associated with accelerated liver fibrosis7. It is important to identify HCV/HIV co-infected pregnant women and to determine risk factors for co-infection in order to mitigate this risk and to prevent future infections. We previously conducted a cross-sectional study investigating hepatitis B virus (HBV) and HIV co-infection in pregnant and postpartum women, demonstrating a high prevalence of co-infection and raising concern for increased risk of vertical transmission of both HIV and HBV8. Considering the limited data on HCV/HIV co-infection, we expanded upon this previous study to determine the prevalence of and risk factors for HCV-HIV co-infection in Congolese women within the Kinshasa province. We also investigated facility-level factors that were associated with HCV status, such as location and type of facility the women attended, as well as the service readiness index, a measure of the quality of care a facility provides.Although HCV/HIV co-infection has a clear impact on individuals living in SSA, data on the prevalence of and risk factors for HCV/HIV co-infection in pregnancy are limited. Mother-to-child transmission (MTCT) of HCV is higher among HCV/HIV co-infected mothers compared to HCV mono-infected mothers 9. This study gathered data from 105 sites, all of which were located within the Kinshasa province  on long-term anti-retroviral therapies (ART) outcomes among pregnant and breastfeeding women receiving care in Kinshasa province through the Continuous Quality Improvement-Prevention of Mother to Child Transmission (CQI-PMTCT) study, NCT03048669The parent CQI-PMTCT study is prospective in nature, enrolling women at any point from early pregnancy to 12 months postpartum. At enrollment, the HCV status of the eligible participants was assessed. The study was approved by the Ohio State University Institutional Review Board and the Kinshasa School of Public Health Ethical Committee. All methods were carried out in accordance with relevant guidelines and regulations. Pregnant women under the age of 18 were considered emancipated minors in the DRC and were consented directly per the 1987 Law of Emancipation (See Supplementary Information). Written informed consent was obtained from all subjects. This method of consent was approved by the Ethics Committee that reviewed the application. The age of emancipation in the DRC changed to ≥ 18 years in 2019, but enrollment and activities for this study had been completed by that time.All HIV-infected pregnant or breastfeeding women receiving care at any of the selected MCH facilities between November 2016 and July 2019 were eligible for the parent study, as described previously. Women were excluded if they refused to participate or if they were beyond 12 months postpartum. For this study, women were also excluded if they refused to be tested for HCV.10.Eligible participants were referred to study staff for informed consent and enrollment in the study upon presentation for routine visits any time during pregnancy and 12 months postpartum. A participant questionnaire for baseline demographic and clinical data was administered to individuals who consented to be involved in the study. The participants completed survey questions via paper questionnaires administered by the study personnel. These questionnaires were comprised of mostly structured questions, with a few open-ended components. An adapted version of the World` Health Organization (WHO)’s Service Availability and Readiness Assessment (SARA) questionnaire was used to assess the capacity of health facilities to provide general health servicesBetween August and November 2016, we surveyed the 105 sites of enrollment using an adapted version of SARA. Our adapted instrument contained 185 items organized into 12 domains: (1) General information and service availability of the health facility, (2) General service readiness, (3) Staffing, management and quality assurance, (4) Diagnostic services, (5) Antenatal care, (6) PMTCT of HIV infection, (7) Delivery and newborn care services, (8) Well baby clinic, (9) Child curative care services, (10) Family planning services (11), and (12) HIV treatment, care and support.The service readiness index (SRI) was modeled after the WHO’s service readiness availability index [25], which contains 50 items that are grouped into five categories: (1) basic amenities, (2) basic equipment, (3) infection prevention, (4) diagnostic capacity, and (5) essential medicines (Supplementary Table 12.The primary outcome of interest for this study was the HCV antibody status of participants (positive or negative). This was measured using the SD Bioline HCV rapid antibody test, verified for use within the region13.Other variables considered in this analysis, as in a previous analysis of HBV/HIV co-infection, included participants’ socio-demographic information, clinical features and health facility characteristics. Participant socio-demographic characteristics included the following: maternal age , marital status (married/cohabitating vs. divorced/separated/widowed/never married), educational level , alcohol consumption (no vs. yes), and socioeconomic status (SES) - measured by a wealth index score. Calculation of the wealth index score is described by Mpody et al.14, duration of ART in months , disclosure of HIV status to anyone (yes vs. no), primigravida (yes vs. no), report of any intimate partner violence  and HIV virological suppression [Viral load (VL) ≤ 1000 copies/mL (suppressed) vs. VL > 1000 copies/mL (unsuppressed)].Clinical characteristics included: HBV infection (yes vs. no – using the Alere HBsAg rapid test)Facility factors included location , type of facility , and whether they receive direct PEPFAR funding support for HIV care (yes vs. no). Of note, maternity clinics in Kinshasa receive funding for the provision of HIV care either from PEPFAR or from the Global Fund. Non-HIV care is provided via fee-for-service care across the various types of facilities.8. We calculated the proportion of participants with a positive HCV antibody test as a measure of HCV prevalence with associated 95% binomial confidence intervals (CIs). Bivariate and multivariable logistic regression modeling was used to estimate prevalence odd ratios (OR) and Wald’s 95% CI comparing the prevalence of HCV antibody across levels of covariates. Covariates were included in the multivariable model if the p-value was < 0.20 in bivariate analysis. Generalized estimating equation was used to account for potential clustering at the level of health facilities. Only participants with complete data on all covariates were included in the final analysis. All analyses were conducted using SAS, version 9.3 , and STATA/IC version 14.0 . All tests, unless otherwise indicated, were conducted using a two-sided 0.05 significance level, without correction for multiple comparisons.Statistical analyses were similar to those of a previous study of HBV/HIV co-infection in the same populationOf 1,942 HIV-positive Congolese women tested for HCV, 16  were HCV/HIV co-infected  in HCV mono-infected mothers, rates of MTCT of HCV are higher (10–20%) among HCV/HIV co-infected women17. As expected, women attending facilities with a higher capacity to provide general maternal and child health services (high SRI score) were less likely to be infected with HCV. We also found that HCV-positive women were more likely to attend facilities with direct PEPFAR funding. PEPFAR supported facilities are typically large urban hospitals and generally provide better HIV care services13, thus it is possible that this association is due to residual confounding.This study highlights facility-level, socio-demographic and clinical factors associated HCV/HIV co-infection in pregnant and breastfeeding women. HCV/HIV co-infected women were more likely to present for care during pregnancy than in the postpartum period, which argues that pregnant women should be targeted for screening during a time when they are more likely to seek care. HCV/HIV co-infected women were also younger and more likely to live in urban areas. We found that women who attended private facilities in general, and for-profit facilities in particular, were more likely to be HCV-positive. The primary route of HCV transmission in African settings is via nosocomial spread, and thus facility characteristics  are important to examine in depth in future studiesThe strength of this study lies in its contribution to a field with a current paucity in data. There is very little research available investigating HIV/HCV co-infection in pregnant Congolese women, making this study one of the first to evaluate this specific population. This study also considers both typical HCV risk factors as well as factors specific to the facilities in which women seek care.A primary limitation of this study was its generalizability, as data was obtained from pregnant women only within Kinshasa Province and therefore may not generalizable outside of this region. Additionally, as with any cross-sectional study, we were not able to imply causation. This study was also limited by a lack of confirmatory HCV RNA testing, with only HCV antibody status testing evaluated. Thus, we were not able to decipher timing of infection (active vs. past). An additional limitation of this study was the testing method used to evaluate HCV status in the patient population. Although the Abbott Determine HCV test has been verified in other settings , no data is available regarding its analytical performance in the DRC.The prevalence of HCV/HIV co-infection among pregnant Congolese women in this study was consistent with previous estimates of HCV prevalence in the region. HCV/HIV co-infected women tended to be younger, live in urban areas, and seek care in private and PEPFAR-funded clinics. Facility-related risk factors should be further researched, as nosocomial transmission is a major risk factor for HCV infection in African settings. HCV/HIV co-infected women had a much higher odds of being triple-infected with HBV as well, a phenomenon that warrants further investigation. Future studies should target women during pregnancy for HCV screening in order to implement curative treatment post-pregnancy and thus prevent transmission in subsequent pregnancies.Supplementary Information.


Worksites with on-site operations have experienced coronavirus disease (COVID-19) outbreaks. We analyzed data for 698 nonresidential, nonhealthcare worksite COVID-19 outbreaks investigated in Los Angeles County, California, USA, during March 19, 2020‒September 30, 2020, by using North American Industry Classification System sectors and subsectors. Nearly 60% of these outbreaks occurred in 3 sectors: manufacturing , retail trade , and transportation and warehousing . The largest number of outbreaks and largest number and highest incidence rate of outbreak-associated cases occurred in manufacturing. Furthermore, 7 of the 10 industry subsectors with the highest incidence rates were within manufacturing. Approximately 70% of outbreak-associated case-patients reported Hispanic ethnicity. Facilities employing more on-site staff had larger and longer outbreaks. Identification of highly affected industry sectors and subsectors is necessary for targeted public health planning, outreach, and response, including ensuring vaccine access, to reduce burden of COVID-19 in vulnerable workers. Worksites that have had on-site operations during the coronavirus disease (COVID-19) pandemic have been vulnerable to COVID-19 outbreaks. The effect of COVID-19 on essential workers in food manufacturing has been well-described, but limited data exist on the burden of COVID-19 in other industry sectors  on March 19, 2020, and by September 30, 2020, LACDPH had investigated 698 worksite outbreaks. Safer at home orders required all nonessential businesses in Los Angeles County to close operations during March 16‒May 8, 2020, when some businesses opened under modified operations. The number of COVID-19 worksite outbreaks mirrored trends in community transmission. Worksite outbreak numbers increased until mid-July, followed by a gradual decrease until September 30. This analysis identifies the industries that were most affected by COVID-19 outbreaks in Los Angeles County during March 19‒September 30, 2020, and describes worksite outbreak characteristics to understand the risk of exposure at the various worksites and to help guide public health outbreak prevention and response strategies.>5 suspected or laboratory-confirmed COVID-19 cases occurred within 14 days, with >1 case being laboratory-confirmed. On May 29, upon increased testing capacity and development of state definitions, a worksite outbreak was subsequently defined as >3 laboratory-confirmed cases occurring within 14 days. A county health officer order was issued requiring worksites to report any suspected outbreaks that might meet the definition. All reported, suspected outbreaks were investigated by LACDPH to determine if the cluster met outbreak criteria, including presence of epidemiologic links between cases indicating worksite transmission. Persons with COVID-19 were determined to be outbreak-associated cases on the basis of timing of symptoms or positive test result, exposure at the worksite during the investigation period, and absence of verifiable COVID-19 exposure outside the worksite.This analysis included COVID-19 outbreaks at nonresidential worksites in Los Angeles County but excluded healthcare settings, homelessness services, and emergency medical services because outbreaks in these settings are investigated under different public health protocols. We excluded outbreaks in Pasadena and Long Beach because they have their own health departments. Initially, a worksite outbreak was identified when Worksite outbreaks were investigated by an investigation team consisting of a public health investigator or public health nurse, a physician, and an environmental health inspector. Guidance on COVID-19 best practices was issued by the outbreak investigator to the worksite; guidance included recommendations on isolation of cases, contact investigation in the workplace, testing of close contacts, entry screening, physical distancing, masking, and cleaning/disinfection protocols. In addition, we conducted telephone conferences, as well as on-site visits, if needed, to assess worksite compliance with COVID-19 safety protocols. Worksites that failed to comply risked closure. Worksites were required to submit case line lists to LACDPH, and these lists were used for documentation and tracking of outbreak-associated cases at each site. The public health investigator regularly communicated with the site contact during each worksite outbreak (3‒5 times/wk) to monitor for additional cases until at least 2 weeks after the last outbreak-associated case.2 tests were used to assess differences in case characteristics between sectors. All analyses were conducted by using SAS version 9.4 (https://www.sas.com).We classified outbreaks by industry sector and subsector as described by the North American Industry Classification System used for classifying businesses  were still under investigation at the time of analysis. A total of 7,625 cases were associated with these outbreaks. We provide descriptive statistics for worksite outbreaks by North American Industry Classification System sector . Most ouA total of 62 cases in nonemployees were excluded from IR calculations. Most (n = 15) nonemployee cases were in students within the educational services sector and children in daycare (n = 38) within the healthcare and social assistance sector. The remaining 9 nonemployee cases were spread across multiple different sectors and identified as being in vendors/contractors working on-site during the outbreak. The overall outbreak-associated IR was 171.8. The highest IRs were for manufacturing (980.8), transportation and warehousing (425.1), and wholesale trade (304.0). The overall median cases per outbreak was 6 (range 3‒277), median on-site staff per outbreak was 95 , and median outbreak duration was 13 (range 0‒189) days. The number of on-site employees showed a moderately positive correlation with the number of outbreak-associated cases (ρ = 0.49), as well as outbreak duration (ρ = 0.54) (p<0.05).Of 7,625 outbreak-associated case-patients, 79%  were ≥18 years of age and had demographic and outcome information available for analysis. Outbreak-associated case-patients were predominantly ≤50 years of age, male, and Hispanic; there were some differences by sector (p<0.05) . The othWe further analyzed worksite outbreaks by industry subsectors. Among the 69 subsectors represented in our data, most outbreaks were in food and beverage stores , followed by food manufacturing  and food services and drinking places . The highest number of outbreak-associated cases among subsectors were in food manufacturing ; warehousing and storage ; and apparel manufacturing . Subsectors within the manufacturing, transportation and warehousing, and public administration sectors had the highest IRs . The topThe manufacturing, transportation and warehousing, and retail trade sectors had the highest number of COVID-19 outbreaks and outbreak-associated cases among 698 worksite outbreaks in Los Angeles County. Manufacturing had the highest IR, which was >5 times the overall IR and twice that of the next highest sector. Among the top 10 subsectors by IR, 7 were from the manufacturing sector. Many worksites within the most affected subsectors were among those designated as essential critical infrastructure in California, enabling continued on-site operations through the pandemic. In addition, some nonessential manufacturing worksites redirected operations to the production of essential goods. Continued in-person operations probably contributed to increased risk of COVID-19 exposure and transmission at these facilities. Four of 5 outbreak-associated case-patients within manufacturing were Hispanic, the highest number for any sector. Worksite outbreak data can help identify vulnerable workers and enable public health departments to target policies and response, including ensuring vaccine access, to employees most affected by COVID-19.These findings are supported by an analysis in Utah that reported similar results in manufacturing  and grocery stores (subsector: food and beverage stores). Recommendations such as physical distancing might be more challenging to implement in manufacturing sites because of interdependent workflow processes and less modifiable physical environments. In addition, food facilities such as grocery stores and restaurants that routinely interact with public health departments because of permit requirements or regular inspections might have more knowledge and experience responding to DPH recommendations, which could contribute to higher compliance in these settings. Limited data has been published on compliance with COVID-19 prevention measures and potential barriers to compliance by industry. A closer and more systematic analysis of compliance with infection control measures by industry sector/subsector is needed.Hispanic persons comprised 70% of outbreak-associated case-patients, which is almost twice the proportion of Hispanic persons employed in Los Angeles County in the 18 industry sectors represented in this analysis (40%) .This study highlights key sectors that have been affected by COVID-19 outbreaks and would benefit most from public health outreach and education. A better understanding of employer- and employee-level barriers that decrease compliance with public health measures and directives in specific industries is needed. COVID-19 safety protocols tailored to each industry that are culturally and linguistically appropriate to the employees at the worksite must be developed. Local champions can help build trust and support communication efforts.Public health departments should cultivate and maintain relationships with labor representatives, worker advocates, and trade associations so that they can remain engaged with public health priorities and can help implement health directives when needed. Public health departments must continue to target essential workers in the affected industries in vaccination efforts to address gaps in vaccine access and barriers to uptake. The burden of disease, as well as the highest ethnic minority representation within manufacturing, underscores this sector as a priority area in Los Angeles County. The COVID-19 pandemic has highlighted infrastructure disparities and labor challenges faced by the Los Angeles County workforce and is an opportunity to improve worker safety and well-being across all industries.