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Association of Race/Ethnicity With Likeliness of COVID-19 Vaccine Uptake Among Health Workers and the General Population in the San Francisco Bay Area

Association of Race/Ethnicity With Likeliness of COVID-19 Vaccine Uptake Among Health Workers and... Letters 1. Knepper BC, Miller AM, Young HL. Impact of an automated hand hygiene inability to assess the quality of hand hygiene. The timeline monitoring system combined with a performance improvement intervention on illustrated in Figures 1 and 2 and the concomitant changes in hospital-acquired infections. Infect Control Hosp Epidemiol. 2020;41(8):931-937. hand hygiene opportunities suggest the compliance surge was doi:10.1017/ice.2020.182 driven by fear and increased awareness of the importance of 2. Gould DJ, Moralejo D, Drey N, Chudleigh JH, Taljaard M. Interventions to hand hygiene associated with the start of the pandemic, as well improve hand hygiene compliance in patient care. Cochrane Database Syst Rev. 2017;9(9):CD005186. doi:10.1002/14651858.CD005186.pub4 as fewer room entries and exits resulting from fewer patient 3. Masroor N, Doll M, Stevens M, Bearman G. Approaches to hand hygiene visitors, remote rounding by clinicians, and nurse batching of monitoring: from low to high technology approaches. Int J Infect Dis. 2017;65: tasks while in patient rooms. High compliance was not sus- 101-104. doi:10.1016/j.ijid.2017.09.031 tained and returned to baseline. As hospitals set hand hy- 4. Leis JA, Powis JE, McGeer A, et al. Introduction of group electronic giene goals, this study suggests high compliance is possible, monitoring of hand hygiene on inpatient units: a multicenter cluster even with automated monitoring, yet difficult to sustain. The randomized quality improvement study. Clin Infect Dis. 2020;71(10):e680-e685. doi:10.1093/cid/ciaa412 recent decline in compliance should be a clarion call to hos- 5. Limper HM, Garcia-Houchins S, Slawsky L, Hershow RC, Landon E. pitals currently experiencing COVID-19 surges. A validation protocol: assessing the accuracy of hand hygiene monitoring technology. Infect Control Hosp Epidemiol. 2016;37(8):1002-1004. doi:10.1017/ ice.2016.133 Sonya Makhni, MD, MBA 6. Moore LD, Robbins G, Quinn J, Arbogast JW. The impact of COVID-19 Craig A. Umscheid, MD, MS pandemic on hand hygiene performance in hospitals. Am J Infect Control. 2021; Jackie Soo, MPH, ScD 49(1):30-33. doi:10.1016/j.ajic.2020.08.021 Vera Chu, MS, MLS(ASCP)CM Allison Bartlett, MD, MS Emily Landon, MD AssociationofRace/EthnicityWithLikelinessof Rachel Marrs, DNP, RN, CIC COVID-19VaccineUptakeAmongHealthWorkersand theGeneralPopulationintheSanFranciscoBayArea Author Affiliations: Department of Medicine, University of Chicago Medicine Surveys have demonstrated racial differences in the public’s and Biological Sciences Division, Chicago, Illinois (Makhni, Umscheid, Landon); 1,2 willingness to receive a COVID-19 vaccine but have not di- Center for Healthcare Delivery Science and Innovation (HDSI), University of rectly compared vaccine intentions among health workers and Chicago Medicine, Chicago, Illinois (Makhni, Umscheid, Bartlett, Landon); Center for Health and the Social Sciences (CHeSS), University of Chicago the general public. We investigated COVID-19 vaccine inten- Biological Sciences Division, Chicago, Illinois (Umscheid, Soo); Infection tions among racially and ethnically diverse samples of health Prevention and Control Program, University of Chicago Medicine, Chicago, workers and the general population. Illinois (Chu, Bartlett, Landon, Marrs); Department of Pediatrics, University of Chicago Medicine and Biological Sciences Division, Chicago, Illinois (Bartlett). Methods | We conducted a cross-sectional survey from Novem- Accepted for Publication: February 22, 2021. ber 27, 2020, to January 15, 2021, nested within 2 longitudi- Published Online: April 26, 2021. doi:10.1001/jamainternmed.2021.1429 nal cohort studies of prevalence and incidence of SARS- Corresponding Author: Rachel Marrs, DNP, RN, CIC, Infection Prevention and Control Program, University of Chicago Medicine, 5841 S Maryland Ave, Room CoV-2 infection in 6 San Francisco Bay Area counties. The L-313, Chicago, IL 60637 (rachel.marrs@uchospitals.edu). general population cohort comprised 3935 community- Conflict of Interest Disclosures: Dr Landon has received travel support from residing adults sampled from randomly selected households, GOJO Industries to speak about hand hygiene but has not received honoria or and the medical center em- any other form of financial support. No other disclosures were reported. ployee cohort comprised 2501 Author Contributions: Dr Marrs had full access to all of the data in the study Supplemental content employees of 3 large medical and takes responsibility for the integrity of the data and the accuracy of the data analysis. centers, who volunteered for biweekly to monthly COVID-19 Concept and design: Makhni, Umscheid, Bartlett, Landon, Marrs. testing. The main outcome measure was likeliness of vaccine Acquisition, analysis, or interpretation of data: All authors. uptake, derived from 2 survey items: (1) “How likely are you Drafting of the manuscript: Makhni, Umscheid, Soo, Landon, Marrs. to get an approved COVID-19 vaccine when it becomes avail- Critical revision of the manuscript for important intellectual content: Makhni, Umscheid, Soo, Chu, Bartlett, Landon. able?” (using a 1-7 Likert scale anchored at “not at all likely” Statistical analysis: Makhni, Soo. and “very likely”), and (2) “How early would you ideally like Administrative, technical, or material support: Makhni, Umscheid, Chu, to receive the COVID-19 vaccine?” (asked of respondents Bartlett, Marrs. scoring ≥3 on the first item). The survey also included items Supervision: Umscheid, Bartlett. asking about reasons to get, and to not get, vaccinated. Funding/Support: The evaluation was supported in part by the Center for Healthcare Delivery Science and Innovation (HDSI) at the University of Respondents self-identified race/ethnicity (see eMethods in Chicago Medicine. the Supplement for details on sampling and the survey Role of the Funder/Sponsor: The Center for Healthcare Delivery Science and 2 instrument). Crude results were compared using 2-tailed χ Innovation at the University of Chicago Medicine had no role in the design and tests, with P < .05 considered significant. Logistic regres- conduct of the study; collection, management, analysis, and interpretation of sion models stratified by cohort tested association of race/ the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. ethnicity with vaccine willingness, adjusting for age, gen- Additional Contributions: We would like to acknowledge Stephen Weber, MD, der, and level of education. All statistical analyses were MS (Chief Medical Officer, University of Chicago Medical Center) for his review performed using SAS, version 9.4 (SAS Institute). American of our study, and Mark Connolly, MEng (Business Intelligence Lead, Data and Association for Public Opinion Research Response Rate 1 Analytics, University of Chicago Medical Center) for providing COVID data. definition was used. Neither received compensation for their role. 1008 JAMA Internal Medicine July 2021 Volume 181, Number 7 (Reprinted) jamainternalmedicine.com Letters Table. Characteristics of Respondents in the Medical Center Employee and General Population Cohorts No. (%) Medical center employee General population cohort Characteristic cohort (n = 1803) (n = 3161) P value Age categories 18-39 y 898 (49.8) 885 (28.0) 40-64 y 851 (47.2) 1534 (48.5) <.001 ≥65 y 45 (2.5) 742 (23.5) Unknown 9 (0.5) 0 Gender Female 1348 (74.8) 1702 (53.8) Male 343 (19.0) 1431 (45.3) NA Other 8 (0.4) 27 (0.9) Unknown 104 (5.8) 1 (0) Race/ethnicity group White 989 (54.9) 1928 (61.0) Black 23 (1.3) 116 (3.7) Hispanic/Latinx 154 (8.5) 312 (9.9) Asian 365 (20.2) 575 (18.2) <.001 Multiple races 105 (5.8) 154 (4.9) Other 50 (2.8) 73 (2.3) Unknown 117 (6.5) 3 (0.1) Education Less than college 18 (1.0) 340 (10.8) College 689 (38.2) 1506 (47.6) <.001 Higher than college 979 (54.3) 1261 (39.9) Unknown 117 (6.5) 54 (1.7) Occupation Physician, advanced practitioner, nurse 1382 (76.7) NA Pharmacist, therapist, technician 217 (12.0) NA Other medical center occupation 204 (11.3) NA NA Employed in health sector NA 258 (8.2) Not employed in health sector NA 2903 (91.8) Abbreviation: NA, not applicable. Likeliness of vaccine uptake 1507 (83.6) 2071 (65.5) <.001 a 2 P values are from χ tests. Figure. Likeliness of Vaccine Uptake by Cohort and Race/Ethnicity The University of California, San Francisco, and Stanford Institutional Review Boards designated the general popula- White Asian tion cohort study a public health surveillance study and ap- Black/African American Other race proved the medical center employee cohort study protocol. Latinx/Hispanic Multiple races Written electronic informed consent was obtained at enrollment. Results | A total of 3161 of 3935 (80.3%) participants in the gen- eral population cohort and 1803 of 2501 (72.1%) participants in the medical center employee cohort responded to the vac- cine survey (Table). Although a higher proportion of medical 40 center employees than members of the general population re- ported likeliness of vaccine uptake, racial/ethnic differences in likeliness were comparable in both cohorts (Figure). In the medical center cohort, the adjusted odds ratio (aOR) (95% CI) Medical center cohort General population cohort of likeliness of vaccine uptake relative to White respondents was 0.24 (0.10-0.60) for Black respondents, 0.50 (0.31-0.79) Data shown are crude results. for Latinx respondents, 0.37 (0.27-0.51) for Asian respon- jamainternalmedicine.com (Reprinted) JAMA Internal Medicine July 2021 Volume 181, Number 7 1009 Respondents reporting likeliness of vaccine uptake, % Letters dents, 0.28 (0.15-0.53) for respondents of other races, and 0.49 Kevin Grumbach, MD (0.29-0.82) for respondents of multiple races. In the general Timothy Judson, MD, MPH population cohort, the aOR (95% CI) relative to White respon- Manisha Desai, PhD dents was 0.29 (0.20-0.43) for Black respondents, 0.55 (0.43- Vivek Jain, MD, MAS 0.71) for Latinx respondents, 0.57 (0.47-0.70) for Asian re- Christina Lindan, MD, MS spondents, 0.62 (0.38-1.02) for respondents of other races, and Sarah B. Doernberg, MD, MAS 0.65 (0.46-0.92) for respondents of multiple races. Ratings of Marisa Holubar, MD, MS reasons to get vaccinated were similar across racial/ethnic groups, but Black, Latinx, and Asian respondents were signifi- Author Affiliations: Department of Family and Community Medicine, University of California, San Francisco (Grumbach); Division of Hospital cantly more likely than White respondents to endorse rea- Medicine, Department of Medicine, University of California, San Francisco sons to not get vaccinated, especially less confidence in the (Judson); Quantitative Sciences Unit, Department of Medicine, Stanford vaccine preventing COVID-19 (aOR [95% CI] for Black, Latinx, University, Stanford, California (Desai); Division of HIV, Infectious Diseases & and Asian respondents having low confidence relative to White Global Medicine, San Francisco General Hospital, San Francisco, California (Jain); Department of Epidemiology and Biostatistics, University of California, San respondents, 2.39 [1.58-3.61], 2.04 [1.58-2.64], and 1.85 [1.51- Francisco (Lindan); Division of Infectious Diseases, Department of Medicine, 2.27], respectively); less trust in companies making the vac- University of California, San Francisco (Doernberg); Division of Infectious cine (aOR [95% CI] for Black, Latinx, and Asian respondents Diseases and Geographic Medicine, Stanford University School of Medicine, having low trust relative to White respondents, 3.08 [2.00- Stanford, California (Holubar). 4.73], 1.85 [1.38-2.48], and 1.34 [1.04-1.72], respectively); and Accepted for Publication: March 6, 2021. more worry that government rushed the approval process (aOR Published Online: March 30, 2021. doi:10.1001/jamainternmed.2021.1445 [95% CI] for Black, Latinx, and Asian respondents relative to Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Grumbach K et al. JAMA Internal Medicine. White respondents, 2.10 [1.44-3.05], 1.68 [1.34-2.10], and 1.81 Corresponding Author: Kevin Grumbach, MD, San Francisco General Hospital, [1.53-2.15], respectively). Department of Family and Community Medicine, University of California, San Francisco, 1001 Potrero Ave, Ward 83, Room 310, San Francisco, CA 94110 Discussion | In this survey study including a diversity of racial/ (kevin.grumbach@ucsf.edu). ethnic groups, occupational immersion in a health care set- Author Contributions: Dr Grumbach had full access to all of the data in the ting did not offset disparities in COVID-19 vaccination inten- study and takes responsibility for the integrity of the data and the accuracy of the data analysis. tions. We found that Asian individuals, multiracial individuals, Concept and design: Grumbach, Judson, Jain, Lindan, Doernberg, Holubar. and those of other races were more similar to Black and Latinx Acquisition, analysis, or interpretation of data: Grumbach, Desai, Jain, Lindan, individuals than White individuals in their likeliness of vac- Doernberg, Holubar. cine uptake. Limitations of this study include that the sample Drafting of the manuscript: Grumbach, Judson, Holubar. Critical revision of the manuscript for important intellectual content: All authors. was drawn from people sufficiently concerned about their risk Statistical analysis: Desai, Holubar. of COVID-19 and trusting of research to volunteer for a study Administrative, technical, or material support: Grumbach, Judson, Jain, Lindan. involving repeated COVID-19 testing and the survey not in- Supervision: Grumbach, Judson, Jain, Lindan, Doernberg. cluding additional domains, such as perceived access, that Conflict of Interest Disclosures: Dr Jain reported receiving grants from the Centers for Disease Control and Prevention/President’s Emergency Plan For might influence reported likeliness of vaccine uptake. How- AIDS Relief not related to this work during the conduct of the study. Dr Lindan ever, it is striking that even among individuals motivated to reported receiving grants from the Chan Zuckerberg Initiative during the participate in a longitudinal COVID-19 testing study, there were conduct of the study. Dr Doernberg reported receiving grants from the Chan racial/ethnic differences in COVID-19 vaccination intentions Zuckerberg Initiative during the conduct of the study and receiving personal fees from Genentech and Basilea Pharmaceutica for consulting outside the and concerns about the vaccine. submitted work. No other disclosures were reported. Black, Latinx, Asian, and Native American communities Funding/Support: This work was supported by the Chan Zuckerberg Initiative. have borne a disproportionate toll of the COVID-19 pandemic Dr Grumbach’s effort was partly supported by a grant from the National in the US ; inequities in vaccination would compound these Institutes of Health Community Engagement Alliance Against COVID-19 disparities. Our survey was fielded at the time of the first emer- Disparities program (21-312-0217571-66106L). gency use authorization of COVID-19 vaccines in the US. Vac- Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of cination rollout since then has revealed barriers to accessing the data; preparation, review, or approval of the manuscript; and decision to vaccination among historically marginalized populations who submit the manuscript for publication. are highly motivated to be vaccinated. Vaccination inten- Disclaimer: The contents of the article are solely the responsibility of the tions must be understood as a deliberative and dynamic pro- authors and do not necessarily represent the official views of the National cess; a focus on intentions must not distract from the impor- Institutes of Health. tanceofensuringequitableaccesstovaccination. Specialeffort Additional Contributions: Yvonne Maldonado, MD (Division of Pediatric Infectious Diseases, Stanford University School of Medicine), and George W. is required to reach historically marginalized populations, in- Rutherford, MD (Department of Epidemiology and Biostatistics, University of cluding those in health occupations, to support informed vac- California, San Francisco), serve as principal investigators of the California cination decision-making and facilitate access. Efforts must ac- Pandemic Consortium and obtained study funding, designed the cohort knowledge a history of racism that has degraded the studies, and provided input into survey study design. Yingjie Weng, MS, Di Lu, MS, and Derek Boothroyd, PhD, of the Quantitative Sciences Unit, Department trustworthiness of health and medical science institutions of Medicine, Stanford University, provided consultation on analytic methods among historically marginalized populations, undermined and performed data analysis. Jenna Bollyky, MD (Division of Infectious Diseases confidence in COVID-19 vaccines, and perpetuated inequi- and Geographic Medicine, Stanford University School of Medicine), and Hannah Sample, BS (Department of Epidemiology and Biostatistics, University of table access to care. 1010 JAMA Internal Medicine July 2021 Volume 181, Number 7 (Reprinted) jamainternalmedicine.com Letters California, San Francisco), managed the study cohorts. Beatrice Huang, BA tions for fibromyalgia treatments into the perspective of (Department of Family and Community Medicine, University of California, treatments for other types of chronic pain. The small effect San Francisco), contributed to survey instrument development and sizes of these classes of drugs in treatment of fibromyalgia administration. The authors thank all additional project staff for their dedicated are similar to those of analgesics for any chronic pain condi- work on this study and community partners who collaborated on recruitment of participants for the general population cohort. These individuals did not receive tion, including paracetamol and nonsteroidal anti- compensation for their contributions beyond their employment salaries. inflammatory drugs for osteoarthritis. 1. Khubchandani J, Sharma S, Price JH, Wiblishauser MJ, Sharma M, Webb FJ. The treatment of all chronic pain conditions is challeng- COVID-19 vaccination hesitancy in the United States: a rapid national ing, because there are no analgesic therapies—pharmacologic assessment. J Community Health. 2021;46(2):270-277. doi:10.1007/s10900- 020-00958-x or nonpharmacologic—that have anything greater than small to moderate effect sizes. Health care professionals have 2 op- 2. Hamel L, Kirzinger A, Muñana C, Brodie M. KFF COVID-19 Vaccine Monitor: December 2020. Accessed March 12, 2021. https://www.kff.org/coronavirus- tions. We can throw up our hands in dismay and say that there covid-19/report/kff-covid-19-vaccine-monitor-december-2020/ is nothing we can do to treat these individuals, or we can do 3. Shaw J, Stewart T, Anderson KB, et al. Assessment of US health care the best we can with combinations of nonpharmacological and personnel (HCP) attitudes towards COVID-19 vaccination in a large university pharmacological therapies that, together, may lead to cumu- health care system. Clin Infect Dis. Published online January 25, 2021. doi:10. lative improvements in patients’ conditions. Choosing which 1093/cid/ciab054 therapies to use requires a joint decision-making approach that 4. Rossen LM, Branum AM, Ahmad FB, Sutton P, Anderson RN. Excess deaths associated with COVID-19, by age and race and ethnicity—United States, accounts for patient preferences and broadens the focus to January 26–October 3, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(42): more than pain. Indeed, many useful therapies for fibromy- 1522-1527. doi:10.15585/mmwr.mm6942e2 algia do not target pain directly, but instead target function, 5. Corbie-Smith G. Vaccine hesitancy is a scapegoat for structural racism. JAMA sleep, or mood. Health Forum. Published online March 25, 2021. doi:10.1001/jamahealthforum. 2021.0434 6. Cooper LA, Crews DC. COVID-19, racism, and the pursuit of health care and Maria J. Silveira, MD, MA, MPH research worthy of trust. J Clin Invest. 2020;130(10):5033-5035. doi:10.1172/ Kevin F. Boehnke, PHD JCI141562 Dan Clauw, MD COMMENT & RESPONSE Author Affiliations: Division of Geriatric and Palliative Medicine, University of Michigan, Ann Arbor (Silveira); Veterans Affairs Ann Arbor Healthcare System, Michigan (Silveira); Chronic Pain and Fatigue Research Center, University of Treatment of Fibromyalgia in the 21st Century Michigan, Ann Arbor (Boehnke, Clauw). To the Editor The thorough, systematic review of therapies for Corresponding Author: Maria J. Silveira, Division of Geriatric and Palliative fibromyalgia written by Mascarenhas et al concludes that Medicine, University of Michigan, 1500 E Medical Center Dr, University Hospital antidepressants and central nervous system depressants are South, F7896, Ann Arbor, MI 48109-5233 (mariajs@med.umich.edu). effective treatments for this condition, but the effect sizes Published Online: March 8, 2021. doi:10.1001/jamainternmed.2020.9276 are small and fail to reach the threshold for clinical impor- Conflict of Interest Disclosures: Dr Boehnke reported sitting on a Data Safety tance. While their findings are congruent with clinical trials, and Monitoring Committee for Vireo Health. Dr Clauw reported personal fees from Aptinyx, Eli Lilly, Lundbeck Pharma, Nix Patterson LLP on behalf of the their discussion assumes that most patients with fibromyal- State of Oklahoma, Pfizer, Samumed, and Tonix. No other disclosures gia are treated with a single modality at a time (pharmaco- were reported. logic or otherwise); however, the current standard of care for 1. Mascarenhas RO, Souza MB, Oliveira MX, et al. Association of therapies with fibromyalgia and other chronic pain conditions is to use a reduced pain and improved quality of life in patients with fibromyalgia. JAMA stepped care model where multiple therapies are layered Intern Med. 2021;181(1):104-112. doi:10.1001/jamainternmed.2020.5651 atop one another sequentially to achieve meaningful 2. Goldenberg DL, Clauw DJ, Palmer RH, Mease P, Chen W, Gendreau RM. Durability of therapeutic response to milnacipran treatment for fibromyalgia: improvements in multiple symptom domains over time. results of a randomized, double-blind, monotherapy 6-month extension study. There is mounting evidence for this approach; for example, Pain Med. 2010;11(2):180-194. doi:10.1111/j.1526-4637.2009.00755.x there are higher overall response rates in patients with fibro- 3. Gilron I, Chaparro LE, Tu D, et al. Combination of pregabalin with duloxetine myalgia who are treated with a serotonin-norepinephrine for fibromyalgia: a randomized controlled trial. Pain. 2016;157(7):1532-1540. reuptake inhibitor and an α2δ-subunit calcium channel doi:10.1097/j.pain.0000000000000558 ligand together, than with either alone. Similarly, there are 4. Schmidt-Wilcke T, Clauw DJ. Pharmacotherapy in fibromyalgia (FM)—implications for the underlying pathophysiology. Pharmacol Ther. 2010; greater reductions in pain for patients receiving duloxetine 3 127(3):283-294. doi:10.1016/j.pharmthera.2010.03.002 plus pregabalin than for those receiving either alone. The 5. Zhang Y, Zhang B, Wise B, Niu J, Zhu Y. Statistical approaches to evaluating increased effectiveness of layering therapies is not surprising the effect of risk factors on the pain of knee osteoarthritis in longitudinal given that pain testing and functional neuroimaging have studies. Curr Opin Rheumatol. 2009;21(5):513-519. doi:10.1097/BOR. demonstrated that that there are various neurotransmitter 0b013e32832ed69d and receptor abnormalities present in centralized or noci- plastic pain conditions like fibromyalgia, and it is unlikely In Reply We are grateful for the opportunity to respond to the that any single therapy will work well in most patients. Letter to the Editor written by Silveira et al regarding our Origi- Thus, clinicians should not necessarily discount a treatment nal Investigation, which questioned how we interpreted our because it alone fails to make an analgesic impact that findings. Silveira et al stated that there is mounting evidence reaches the threshold for what is clinically meaningful. for the use of a stepped care model approach where multiple Moreover, we believe that it is important to place expecta- therapies are used sequentially over time instead of the ap- jamainternalmedicine.com (Reprinted) JAMA Internal Medicine July 2021 Volume 181, Number 7 1011 © 2021 American Medical Association. All rights reserved. Supplemental Online Content Grumbach K, Judson T, Desai M, et al. Association of race/ethnicity with likeliness of COVID-19 vaccine uptake among health workers and the general population in the San Francisco Bay Area. JAMA Intern Med. Published online March 30, 2021. doi:10.1001/jamainternmed.2021.1445 eMethods. eReferences. This supplemental material has been provided by the authors to give readers additional information about their work. © 2021 Grumbach K et al. JAMA Internal Medicine. eMethods Sampling method for cohort enrollment The General Population Cohort Study used an address-based stratified random sampling strategy to select households in the 6 counties of the San Francisco Bay Area eligible for study recruitment, with enrollment occurring between July and December, 2020. Two strata were considered in the sampling scheme: estimated cases per census tract determined by modeling, and county. Household risk was estimated by modeling prevalent cases within census tracts as reported by counties as a function of sociodemographic, occupational, health and poverty characteristics using data from the 2018 American Community Survey and UCSF Health Atlas. One adult from each randomly selected household was eligible for participation. The Medical Center Employee Cohort study recruited adults employed in diverse occupations by the three medical centers in the San Francisco Bay Area (UCSF Health, Stanford Health Care, and San Francisco General Hospital), enrolled from July through November, 2020. Survey administration Participants in both cohorts were sent an electronic survey about COVID-19 vaccination. Surveys were provided in English, Spanish and Chinese languages. Those who did not respond were invited to complete the survey in person at a regular study testing visit. The survey was fielded with the General Population Cohort Study from December 14, 2020 to January 15, 2021, and with the Medical Center Employee Cohort Study from November 27 to December 27, 2020, around the time of the announcements of emergency use authorizations for the Pfizer (December 11, 2020 and Moderna (December 18, 2020) vaccines. Survey instrument Vaccination survey instruments were adapted from the NIH Community Engagement Alliance (CEAL) Against COVID-19 Disparities Draft Common Survey, and informed by well-established conceptual models of vaccine 3, 4 hesitancy. A binary measure of was derived from two survey items. The first item asked, “How likely are you to get an approved COVID-19 vaccine when it becomes available?”, using a 1-7 Likert scale with 1 indicating “not at all likely” and 7 “very likely.” Respondents who scored 3 or greater were asked a second question, “How early would you ideally like to receive the COVID-19 vaccine?”, with response options of “I'd like to be among the earliest,” “I'd like to receive it early, but not in the first round of people,” “ I'd like to receive it later in the distribution process,” “or “I'd like to wait at least two months to see what the experience is.” Respondents who selected 3 or greater on the first item and answered “I’d like to be among the earliest” or “I’d like to receive it early…” to the second item were categorized as having . Participants received a baseline survey at initial cohort enrollment ascertaining demographic characteristics. Participants self-identified their race-ethnicity using Office of Management and Budget categories, with one question on Hispanic/Latino ethnicity and one on racial identity. Participants could select more than one race. The ethnicity and race items were then combined to create a single race-ethnicity variable with mutually exclusive categories, including a multi-racial category. The few respondents who selected Hispanic/Latino ethnicity and Black race were categorized as Black. We use the term people of color to refer to respondents identifying as Black, Latinx/ Hispanic, Asian, multi-racial, and race other than white. Other sociodemographic variables included age, gender, occupation, and highest level of education attained. © 2021 Grumbach K et al. JAMA Internal Medicine. eReferences 1. UCSF School of Medicine Dean’s Office of Population Health and Health Equity. UCSF Health Atlas. Accessed February 16, 2021. https://healthatlas.ucsf.edu/?active=covid_new_cases_percap 2. National Institutes of Health. Community Engagement Alliance.; 2020. Accessed February 16, 2021. https://covid19community.nih.gov/about 3. MacDonald NE. Vaccine hesitancy: Definition, scope and determinants. Vaccine. 2015;33(34):4161-4164. doi:10.1016/j.vaccine.2015.04.036 4. Larson HJ, Jarrett C, Eckersberger E, Smith DMD, Paterson P. Understanding vaccine hesitancy around vaccines and vaccination from a global perspective: A systematic review of published literature, 2007–2012. Vaccine. 2014;32(19):2150-2159. doi:10.1016/j.vaccine.2014.01.081 © 2021 Grumbach K et al. JAMA Internal Medicine. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA Internal Medicine American Medical Association

Association of Race/Ethnicity With Likeliness of COVID-19 Vaccine Uptake Among Health Workers and the General Population in the San Francisco Bay Area

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American Medical Association
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Copyright 2021 Grumbach K et al. JAMA Internal Medicine.
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2168-6106
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10.1001/jamainternmed.2021.1445
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Abstract

Letters 1. Knepper BC, Miller AM, Young HL. Impact of an automated hand hygiene inability to assess the quality of hand hygiene. The timeline monitoring system combined with a performance improvement intervention on illustrated in Figures 1 and 2 and the concomitant changes in hospital-acquired infections. Infect Control Hosp Epidemiol. 2020;41(8):931-937. hand hygiene opportunities suggest the compliance surge was doi:10.1017/ice.2020.182 driven by fear and increased awareness of the importance of 2. Gould DJ, Moralejo D, Drey N, Chudleigh JH, Taljaard M. Interventions to hand hygiene associated with the start of the pandemic, as well improve hand hygiene compliance in patient care. Cochrane Database Syst Rev. 2017;9(9):CD005186. doi:10.1002/14651858.CD005186.pub4 as fewer room entries and exits resulting from fewer patient 3. Masroor N, Doll M, Stevens M, Bearman G. Approaches to hand hygiene visitors, remote rounding by clinicians, and nurse batching of monitoring: from low to high technology approaches. Int J Infect Dis. 2017;65: tasks while in patient rooms. High compliance was not sus- 101-104. doi:10.1016/j.ijid.2017.09.031 tained and returned to baseline. As hospitals set hand hy- 4. Leis JA, Powis JE, McGeer A, et al. Introduction of group electronic giene goals, this study suggests high compliance is possible, monitoring of hand hygiene on inpatient units: a multicenter cluster even with automated monitoring, yet difficult to sustain. The randomized quality improvement study. Clin Infect Dis. 2020;71(10):e680-e685. doi:10.1093/cid/ciaa412 recent decline in compliance should be a clarion call to hos- 5. Limper HM, Garcia-Houchins S, Slawsky L, Hershow RC, Landon E. pitals currently experiencing COVID-19 surges. A validation protocol: assessing the accuracy of hand hygiene monitoring technology. Infect Control Hosp Epidemiol. 2016;37(8):1002-1004. doi:10.1017/ ice.2016.133 Sonya Makhni, MD, MBA 6. Moore LD, Robbins G, Quinn J, Arbogast JW. The impact of COVID-19 Craig A. Umscheid, MD, MS pandemic on hand hygiene performance in hospitals. Am J Infect Control. 2021; Jackie Soo, MPH, ScD 49(1):30-33. doi:10.1016/j.ajic.2020.08.021 Vera Chu, MS, MLS(ASCP)CM Allison Bartlett, MD, MS Emily Landon, MD AssociationofRace/EthnicityWithLikelinessof Rachel Marrs, DNP, RN, CIC COVID-19VaccineUptakeAmongHealthWorkersand theGeneralPopulationintheSanFranciscoBayArea Author Affiliations: Department of Medicine, University of Chicago Medicine Surveys have demonstrated racial differences in the public’s and Biological Sciences Division, Chicago, Illinois (Makhni, Umscheid, Landon); 1,2 willingness to receive a COVID-19 vaccine but have not di- Center for Healthcare Delivery Science and Innovation (HDSI), University of rectly compared vaccine intentions among health workers and Chicago Medicine, Chicago, Illinois (Makhni, Umscheid, Bartlett, Landon); Center for Health and the Social Sciences (CHeSS), University of Chicago the general public. We investigated COVID-19 vaccine inten- Biological Sciences Division, Chicago, Illinois (Umscheid, Soo); Infection tions among racially and ethnically diverse samples of health Prevention and Control Program, University of Chicago Medicine, Chicago, workers and the general population. Illinois (Chu, Bartlett, Landon, Marrs); Department of Pediatrics, University of Chicago Medicine and Biological Sciences Division, Chicago, Illinois (Bartlett). Methods | We conducted a cross-sectional survey from Novem- Accepted for Publication: February 22, 2021. ber 27, 2020, to January 15, 2021, nested within 2 longitudi- Published Online: April 26, 2021. doi:10.1001/jamainternmed.2021.1429 nal cohort studies of prevalence and incidence of SARS- Corresponding Author: Rachel Marrs, DNP, RN, CIC, Infection Prevention and Control Program, University of Chicago Medicine, 5841 S Maryland Ave, Room CoV-2 infection in 6 San Francisco Bay Area counties. The L-313, Chicago, IL 60637 (rachel.marrs@uchospitals.edu). general population cohort comprised 3935 community- Conflict of Interest Disclosures: Dr Landon has received travel support from residing adults sampled from randomly selected households, GOJO Industries to speak about hand hygiene but has not received honoria or and the medical center em- any other form of financial support. No other disclosures were reported. ployee cohort comprised 2501 Author Contributions: Dr Marrs had full access to all of the data in the study Supplemental content employees of 3 large medical and takes responsibility for the integrity of the data and the accuracy of the data analysis. centers, who volunteered for biweekly to monthly COVID-19 Concept and design: Makhni, Umscheid, Bartlett, Landon, Marrs. testing. The main outcome measure was likeliness of vaccine Acquisition, analysis, or interpretation of data: All authors. uptake, derived from 2 survey items: (1) “How likely are you Drafting of the manuscript: Makhni, Umscheid, Soo, Landon, Marrs. to get an approved COVID-19 vaccine when it becomes avail- Critical revision of the manuscript for important intellectual content: Makhni, Umscheid, Soo, Chu, Bartlett, Landon. able?” (using a 1-7 Likert scale anchored at “not at all likely” Statistical analysis: Makhni, Soo. and “very likely”), and (2) “How early would you ideally like Administrative, technical, or material support: Makhni, Umscheid, Chu, to receive the COVID-19 vaccine?” (asked of respondents Bartlett, Marrs. scoring ≥3 on the first item). The survey also included items Supervision: Umscheid, Bartlett. asking about reasons to get, and to not get, vaccinated. Funding/Support: The evaluation was supported in part by the Center for Healthcare Delivery Science and Innovation (HDSI) at the University of Respondents self-identified race/ethnicity (see eMethods in Chicago Medicine. the Supplement for details on sampling and the survey Role of the Funder/Sponsor: The Center for Healthcare Delivery Science and 2 instrument). Crude results were compared using 2-tailed χ Innovation at the University of Chicago Medicine had no role in the design and tests, with P < .05 considered significant. Logistic regres- conduct of the study; collection, management, analysis, and interpretation of sion models stratified by cohort tested association of race/ the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. ethnicity with vaccine willingness, adjusting for age, gen- Additional Contributions: We would like to acknowledge Stephen Weber, MD, der, and level of education. All statistical analyses were MS (Chief Medical Officer, University of Chicago Medical Center) for his review performed using SAS, version 9.4 (SAS Institute). American of our study, and Mark Connolly, MEng (Business Intelligence Lead, Data and Association for Public Opinion Research Response Rate 1 Analytics, University of Chicago Medical Center) for providing COVID data. definition was used. Neither received compensation for their role. 1008 JAMA Internal Medicine July 2021 Volume 181, Number 7 (Reprinted) jamainternalmedicine.com Letters Table. Characteristics of Respondents in the Medical Center Employee and General Population Cohorts No. (%) Medical center employee General population cohort Characteristic cohort (n = 1803) (n = 3161) P value Age categories 18-39 y 898 (49.8) 885 (28.0) 40-64 y 851 (47.2) 1534 (48.5) <.001 ≥65 y 45 (2.5) 742 (23.5) Unknown 9 (0.5) 0 Gender Female 1348 (74.8) 1702 (53.8) Male 343 (19.0) 1431 (45.3) NA Other 8 (0.4) 27 (0.9) Unknown 104 (5.8) 1 (0) Race/ethnicity group White 989 (54.9) 1928 (61.0) Black 23 (1.3) 116 (3.7) Hispanic/Latinx 154 (8.5) 312 (9.9) Asian 365 (20.2) 575 (18.2) <.001 Multiple races 105 (5.8) 154 (4.9) Other 50 (2.8) 73 (2.3) Unknown 117 (6.5) 3 (0.1) Education Less than college 18 (1.0) 340 (10.8) College 689 (38.2) 1506 (47.6) <.001 Higher than college 979 (54.3) 1261 (39.9) Unknown 117 (6.5) 54 (1.7) Occupation Physician, advanced practitioner, nurse 1382 (76.7) NA Pharmacist, therapist, technician 217 (12.0) NA Other medical center occupation 204 (11.3) NA NA Employed in health sector NA 258 (8.2) Not employed in health sector NA 2903 (91.8) Abbreviation: NA, not applicable. Likeliness of vaccine uptake 1507 (83.6) 2071 (65.5) <.001 a 2 P values are from χ tests. Figure. Likeliness of Vaccine Uptake by Cohort and Race/Ethnicity The University of California, San Francisco, and Stanford Institutional Review Boards designated the general popula- White Asian tion cohort study a public health surveillance study and ap- Black/African American Other race proved the medical center employee cohort study protocol. Latinx/Hispanic Multiple races Written electronic informed consent was obtained at enrollment. Results | A total of 3161 of 3935 (80.3%) participants in the gen- eral population cohort and 1803 of 2501 (72.1%) participants in the medical center employee cohort responded to the vac- cine survey (Table). Although a higher proportion of medical 40 center employees than members of the general population re- ported likeliness of vaccine uptake, racial/ethnic differences in likeliness were comparable in both cohorts (Figure). In the medical center cohort, the adjusted odds ratio (aOR) (95% CI) Medical center cohort General population cohort of likeliness of vaccine uptake relative to White respondents was 0.24 (0.10-0.60) for Black respondents, 0.50 (0.31-0.79) Data shown are crude results. for Latinx respondents, 0.37 (0.27-0.51) for Asian respon- jamainternalmedicine.com (Reprinted) JAMA Internal Medicine July 2021 Volume 181, Number 7 1009 Respondents reporting likeliness of vaccine uptake, % Letters dents, 0.28 (0.15-0.53) for respondents of other races, and 0.49 Kevin Grumbach, MD (0.29-0.82) for respondents of multiple races. In the general Timothy Judson, MD, MPH population cohort, the aOR (95% CI) relative to White respon- Manisha Desai, PhD dents was 0.29 (0.20-0.43) for Black respondents, 0.55 (0.43- Vivek Jain, MD, MAS 0.71) for Latinx respondents, 0.57 (0.47-0.70) for Asian re- Christina Lindan, MD, MS spondents, 0.62 (0.38-1.02) for respondents of other races, and Sarah B. Doernberg, MD, MAS 0.65 (0.46-0.92) for respondents of multiple races. Ratings of Marisa Holubar, MD, MS reasons to get vaccinated were similar across racial/ethnic groups, but Black, Latinx, and Asian respondents were signifi- Author Affiliations: Department of Family and Community Medicine, University of California, San Francisco (Grumbach); Division of Hospital cantly more likely than White respondents to endorse rea- Medicine, Department of Medicine, University of California, San Francisco sons to not get vaccinated, especially less confidence in the (Judson); Quantitative Sciences Unit, Department of Medicine, Stanford vaccine preventing COVID-19 (aOR [95% CI] for Black, Latinx, University, Stanford, California (Desai); Division of HIV, Infectious Diseases & and Asian respondents having low confidence relative to White Global Medicine, San Francisco General Hospital, San Francisco, California (Jain); Department of Epidemiology and Biostatistics, University of California, San respondents, 2.39 [1.58-3.61], 2.04 [1.58-2.64], and 1.85 [1.51- Francisco (Lindan); Division of Infectious Diseases, Department of Medicine, 2.27], respectively); less trust in companies making the vac- University of California, San Francisco (Doernberg); Division of Infectious cine (aOR [95% CI] for Black, Latinx, and Asian respondents Diseases and Geographic Medicine, Stanford University School of Medicine, having low trust relative to White respondents, 3.08 [2.00- Stanford, California (Holubar). 4.73], 1.85 [1.38-2.48], and 1.34 [1.04-1.72], respectively); and Accepted for Publication: March 6, 2021. more worry that government rushed the approval process (aOR Published Online: March 30, 2021. doi:10.1001/jamainternmed.2021.1445 [95% CI] for Black, Latinx, and Asian respondents relative to Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Grumbach K et al. JAMA Internal Medicine. White respondents, 2.10 [1.44-3.05], 1.68 [1.34-2.10], and 1.81 Corresponding Author: Kevin Grumbach, MD, San Francisco General Hospital, [1.53-2.15], respectively). Department of Family and Community Medicine, University of California, San Francisco, 1001 Potrero Ave, Ward 83, Room 310, San Francisco, CA 94110 Discussion | In this survey study including a diversity of racial/ (kevin.grumbach@ucsf.edu). ethnic groups, occupational immersion in a health care set- Author Contributions: Dr Grumbach had full access to all of the data in the ting did not offset disparities in COVID-19 vaccination inten- study and takes responsibility for the integrity of the data and the accuracy of the data analysis. tions. We found that Asian individuals, multiracial individuals, Concept and design: Grumbach, Judson, Jain, Lindan, Doernberg, Holubar. and those of other races were more similar to Black and Latinx Acquisition, analysis, or interpretation of data: Grumbach, Desai, Jain, Lindan, individuals than White individuals in their likeliness of vac- Doernberg, Holubar. cine uptake. Limitations of this study include that the sample Drafting of the manuscript: Grumbach, Judson, Holubar. Critical revision of the manuscript for important intellectual content: All authors. was drawn from people sufficiently concerned about their risk Statistical analysis: Desai, Holubar. of COVID-19 and trusting of research to volunteer for a study Administrative, technical, or material support: Grumbach, Judson, Jain, Lindan. involving repeated COVID-19 testing and the survey not in- Supervision: Grumbach, Judson, Jain, Lindan, Doernberg. cluding additional domains, such as perceived access, that Conflict of Interest Disclosures: Dr Jain reported receiving grants from the Centers for Disease Control and Prevention/President’s Emergency Plan For might influence reported likeliness of vaccine uptake. How- AIDS Relief not related to this work during the conduct of the study. Dr Lindan ever, it is striking that even among individuals motivated to reported receiving grants from the Chan Zuckerberg Initiative during the participate in a longitudinal COVID-19 testing study, there were conduct of the study. Dr Doernberg reported receiving grants from the Chan racial/ethnic differences in COVID-19 vaccination intentions Zuckerberg Initiative during the conduct of the study and receiving personal fees from Genentech and Basilea Pharmaceutica for consulting outside the and concerns about the vaccine. submitted work. No other disclosures were reported. Black, Latinx, Asian, and Native American communities Funding/Support: This work was supported by the Chan Zuckerberg Initiative. have borne a disproportionate toll of the COVID-19 pandemic Dr Grumbach’s effort was partly supported by a grant from the National in the US ; inequities in vaccination would compound these Institutes of Health Community Engagement Alliance Against COVID-19 disparities. Our survey was fielded at the time of the first emer- Disparities program (21-312-0217571-66106L). gency use authorization of COVID-19 vaccines in the US. Vac- Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of cination rollout since then has revealed barriers to accessing the data; preparation, review, or approval of the manuscript; and decision to vaccination among historically marginalized populations who submit the manuscript for publication. are highly motivated to be vaccinated. Vaccination inten- Disclaimer: The contents of the article are solely the responsibility of the tions must be understood as a deliberative and dynamic pro- authors and do not necessarily represent the official views of the National cess; a focus on intentions must not distract from the impor- Institutes of Health. tanceofensuringequitableaccesstovaccination. Specialeffort Additional Contributions: Yvonne Maldonado, MD (Division of Pediatric Infectious Diseases, Stanford University School of Medicine), and George W. is required to reach historically marginalized populations, in- Rutherford, MD (Department of Epidemiology and Biostatistics, University of cluding those in health occupations, to support informed vac- California, San Francisco), serve as principal investigators of the California cination decision-making and facilitate access. Efforts must ac- Pandemic Consortium and obtained study funding, designed the cohort knowledge a history of racism that has degraded the studies, and provided input into survey study design. Yingjie Weng, MS, Di Lu, MS, and Derek Boothroyd, PhD, of the Quantitative Sciences Unit, Department trustworthiness of health and medical science institutions of Medicine, Stanford University, provided consultation on analytic methods among historically marginalized populations, undermined and performed data analysis. Jenna Bollyky, MD (Division of Infectious Diseases confidence in COVID-19 vaccines, and perpetuated inequi- and Geographic Medicine, Stanford University School of Medicine), and Hannah Sample, BS (Department of Epidemiology and Biostatistics, University of table access to care. 1010 JAMA Internal Medicine July 2021 Volume 181, Number 7 (Reprinted) jamainternalmedicine.com Letters California, San Francisco), managed the study cohorts. Beatrice Huang, BA tions for fibromyalgia treatments into the perspective of (Department of Family and Community Medicine, University of California, treatments for other types of chronic pain. The small effect San Francisco), contributed to survey instrument development and sizes of these classes of drugs in treatment of fibromyalgia administration. The authors thank all additional project staff for their dedicated are similar to those of analgesics for any chronic pain condi- work on this study and community partners who collaborated on recruitment of participants for the general population cohort. These individuals did not receive tion, including paracetamol and nonsteroidal anti- compensation for their contributions beyond their employment salaries. inflammatory drugs for osteoarthritis. 1. Khubchandani J, Sharma S, Price JH, Wiblishauser MJ, Sharma M, Webb FJ. The treatment of all chronic pain conditions is challeng- COVID-19 vaccination hesitancy in the United States: a rapid national ing, because there are no analgesic therapies—pharmacologic assessment. J Community Health. 2021;46(2):270-277. doi:10.1007/s10900- 020-00958-x or nonpharmacologic—that have anything greater than small to moderate effect sizes. Health care professionals have 2 op- 2. Hamel L, Kirzinger A, Muñana C, Brodie M. KFF COVID-19 Vaccine Monitor: December 2020. Accessed March 12, 2021. https://www.kff.org/coronavirus- tions. We can throw up our hands in dismay and say that there covid-19/report/kff-covid-19-vaccine-monitor-december-2020/ is nothing we can do to treat these individuals, or we can do 3. Shaw J, Stewart T, Anderson KB, et al. Assessment of US health care the best we can with combinations of nonpharmacological and personnel (HCP) attitudes towards COVID-19 vaccination in a large university pharmacological therapies that, together, may lead to cumu- health care system. Clin Infect Dis. Published online January 25, 2021. doi:10. lative improvements in patients’ conditions. Choosing which 1093/cid/ciab054 therapies to use requires a joint decision-making approach that 4. Rossen LM, Branum AM, Ahmad FB, Sutton P, Anderson RN. Excess deaths associated with COVID-19, by age and race and ethnicity—United States, accounts for patient preferences and broadens the focus to January 26–October 3, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(42): more than pain. Indeed, many useful therapies for fibromy- 1522-1527. doi:10.15585/mmwr.mm6942e2 algia do not target pain directly, but instead target function, 5. Corbie-Smith G. Vaccine hesitancy is a scapegoat for structural racism. JAMA sleep, or mood. Health Forum. Published online March 25, 2021. doi:10.1001/jamahealthforum. 2021.0434 6. Cooper LA, Crews DC. COVID-19, racism, and the pursuit of health care and Maria J. Silveira, MD, MA, MPH research worthy of trust. J Clin Invest. 2020;130(10):5033-5035. doi:10.1172/ Kevin F. Boehnke, PHD JCI141562 Dan Clauw, MD COMMENT & RESPONSE Author Affiliations: Division of Geriatric and Palliative Medicine, University of Michigan, Ann Arbor (Silveira); Veterans Affairs Ann Arbor Healthcare System, Michigan (Silveira); Chronic Pain and Fatigue Research Center, University of Treatment of Fibromyalgia in the 21st Century Michigan, Ann Arbor (Boehnke, Clauw). To the Editor The thorough, systematic review of therapies for Corresponding Author: Maria J. Silveira, Division of Geriatric and Palliative fibromyalgia written by Mascarenhas et al concludes that Medicine, University of Michigan, 1500 E Medical Center Dr, University Hospital antidepressants and central nervous system depressants are South, F7896, Ann Arbor, MI 48109-5233 (mariajs@med.umich.edu). effective treatments for this condition, but the effect sizes Published Online: March 8, 2021. doi:10.1001/jamainternmed.2020.9276 are small and fail to reach the threshold for clinical impor- Conflict of Interest Disclosures: Dr Boehnke reported sitting on a Data Safety tance. While their findings are congruent with clinical trials, and Monitoring Committee for Vireo Health. Dr Clauw reported personal fees from Aptinyx, Eli Lilly, Lundbeck Pharma, Nix Patterson LLP on behalf of the their discussion assumes that most patients with fibromyal- State of Oklahoma, Pfizer, Samumed, and Tonix. No other disclosures gia are treated with a single modality at a time (pharmaco- were reported. logic or otherwise); however, the current standard of care for 1. Mascarenhas RO, Souza MB, Oliveira MX, et al. Association of therapies with fibromyalgia and other chronic pain conditions is to use a reduced pain and improved quality of life in patients with fibromyalgia. JAMA stepped care model where multiple therapies are layered Intern Med. 2021;181(1):104-112. doi:10.1001/jamainternmed.2020.5651 atop one another sequentially to achieve meaningful 2. Goldenberg DL, Clauw DJ, Palmer RH, Mease P, Chen W, Gendreau RM. Durability of therapeutic response to milnacipran treatment for fibromyalgia: improvements in multiple symptom domains over time. results of a randomized, double-blind, monotherapy 6-month extension study. There is mounting evidence for this approach; for example, Pain Med. 2010;11(2):180-194. doi:10.1111/j.1526-4637.2009.00755.x there are higher overall response rates in patients with fibro- 3. Gilron I, Chaparro LE, Tu D, et al. Combination of pregabalin with duloxetine myalgia who are treated with a serotonin-norepinephrine for fibromyalgia: a randomized controlled trial. Pain. 2016;157(7):1532-1540. reuptake inhibitor and an α2δ-subunit calcium channel doi:10.1097/j.pain.0000000000000558 ligand together, than with either alone. Similarly, there are 4. Schmidt-Wilcke T, Clauw DJ. Pharmacotherapy in fibromyalgia (FM)—implications for the underlying pathophysiology. Pharmacol Ther. 2010; greater reductions in pain for patients receiving duloxetine 3 127(3):283-294. doi:10.1016/j.pharmthera.2010.03.002 plus pregabalin than for those receiving either alone. The 5. Zhang Y, Zhang B, Wise B, Niu J, Zhu Y. Statistical approaches to evaluating increased effectiveness of layering therapies is not surprising the effect of risk factors on the pain of knee osteoarthritis in longitudinal given that pain testing and functional neuroimaging have studies. Curr Opin Rheumatol. 2009;21(5):513-519. doi:10.1097/BOR. demonstrated that that there are various neurotransmitter 0b013e32832ed69d and receptor abnormalities present in centralized or noci- plastic pain conditions like fibromyalgia, and it is unlikely In Reply We are grateful for the opportunity to respond to the that any single therapy will work well in most patients. Letter to the Editor written by Silveira et al regarding our Origi- Thus, clinicians should not necessarily discount a treatment nal Investigation, which questioned how we interpreted our because it alone fails to make an analgesic impact that findings. Silveira et al stated that there is mounting evidence reaches the threshold for what is clinically meaningful. for the use of a stepped care model approach where multiple Moreover, we believe that it is important to place expecta- therapies are used sequentially over time instead of the ap- jamainternalmedicine.com (Reprinted) JAMA Internal Medicine July 2021 Volume 181, Number 7 1011 © 2021 American Medical Association. All rights reserved. Supplemental Online Content Grumbach K, Judson T, Desai M, et al. Association of race/ethnicity with likeliness of COVID-19 vaccine uptake among health workers and the general population in the San Francisco Bay Area. JAMA Intern Med. Published online March 30, 2021. doi:10.1001/jamainternmed.2021.1445 eMethods. eReferences. This supplemental material has been provided by the authors to give readers additional information about their work. © 2021 Grumbach K et al. JAMA Internal Medicine. eMethods Sampling method for cohort enrollment The General Population Cohort Study used an address-based stratified random sampling strategy to select households in the 6 counties of the San Francisco Bay Area eligible for study recruitment, with enrollment occurring between July and December, 2020. Two strata were considered in the sampling scheme: estimated cases per census tract determined by modeling, and county. Household risk was estimated by modeling prevalent cases within census tracts as reported by counties as a function of sociodemographic, occupational, health and poverty characteristics using data from the 2018 American Community Survey and UCSF Health Atlas. One adult from each randomly selected household was eligible for participation. The Medical Center Employee Cohort study recruited adults employed in diverse occupations by the three medical centers in the San Francisco Bay Area (UCSF Health, Stanford Health Care, and San Francisco General Hospital), enrolled from July through November, 2020. Survey administration Participants in both cohorts were sent an electronic survey about COVID-19 vaccination. Surveys were provided in English, Spanish and Chinese languages. Those who did not respond were invited to complete the survey in person at a regular study testing visit. The survey was fielded with the General Population Cohort Study from December 14, 2020 to January 15, 2021, and with the Medical Center Employee Cohort Study from November 27 to December 27, 2020, around the time of the announcements of emergency use authorizations for the Pfizer (December 11, 2020 and Moderna (December 18, 2020) vaccines. Survey instrument Vaccination survey instruments were adapted from the NIH Community Engagement Alliance (CEAL) Against COVID-19 Disparities Draft Common Survey, and informed by well-established conceptual models of vaccine 3, 4 hesitancy. A binary measure of was derived from two survey items. The first item asked, “How likely are you to get an approved COVID-19 vaccine when it becomes available?”, using a 1-7 Likert scale with 1 indicating “not at all likely” and 7 “very likely.” Respondents who scored 3 or greater were asked a second question, “How early would you ideally like to receive the COVID-19 vaccine?”, with response options of “I'd like to be among the earliest,” “I'd like to receive it early, but not in the first round of people,” “ I'd like to receive it later in the distribution process,” “or “I'd like to wait at least two months to see what the experience is.” Respondents who selected 3 or greater on the first item and answered “I’d like to be among the earliest” or “I’d like to receive it early…” to the second item were categorized as having . Participants received a baseline survey at initial cohort enrollment ascertaining demographic characteristics. Participants self-identified their race-ethnicity using Office of Management and Budget categories, with one question on Hispanic/Latino ethnicity and one on racial identity. Participants could select more than one race. The ethnicity and race items were then combined to create a single race-ethnicity variable with mutually exclusive categories, including a multi-racial category. The few respondents who selected Hispanic/Latino ethnicity and Black race were categorized as Black. We use the term people of color to refer to respondents identifying as Black, Latinx/ Hispanic, Asian, multi-racial, and race other than white. Other sociodemographic variables included age, gender, occupation, and highest level of education attained. © 2021 Grumbach K et al. JAMA Internal Medicine. eReferences 1. UCSF School of Medicine Dean’s Office of Population Health and Health Equity. UCSF Health Atlas. Accessed February 16, 2021. https://healthatlas.ucsf.edu/?active=covid_new_cases_percap 2. National Institutes of Health. Community Engagement Alliance.; 2020. Accessed February 16, 2021. https://covid19community.nih.gov/about 3. MacDonald NE. Vaccine hesitancy: Definition, scope and determinants. Vaccine. 2015;33(34):4161-4164. doi:10.1016/j.vaccine.2015.04.036 4. Larson HJ, Jarrett C, Eckersberger E, Smith DMD, Paterson P. Understanding vaccine hesitancy around vaccines and vaccination from a global perspective: A systematic review of published literature, 2007–2012. Vaccine. 2014;32(19):2150-2159. doi:10.1016/j.vaccine.2014.01.081 © 2021 Grumbach K et al. JAMA Internal Medicine.

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