CDC Found Ways To Use Data To Understand and Address COVID-19 Health Disparities, Despite Challenges With Existing Data
- Issuer
- Office of Inspector General
- Document type
- Brief
Summary
A report of the U.S. Department of Health and Human Services Office of Inspector General, OEI-05-20-00540, dated July 2022, evaluating how CDC used racial, ethnic and socioeconomic data on COVID-19 testing, cases, hospitalizations and deaths. OIG found that racial and ethnic data associated with COVID-19 reporting are sometimes missing, inconsistent or inaccurate, and that socioeconomic data are neither clearly defined nor consistently collected. The report describes CDC's steps to supplement these data and states that the Tribal Epidemiology Centers interviewed reported difficulty accessing public health data. OIG recommends that CDC expand efforts to improve and supplement racial and ethnic data and ensure TECs have timely access to public health data, and CDC concurred with both. The review drew on structured interviews conducted in March and April 2021.
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U.S. Department of Health and Human Services
Office of Inspector General
CDC Found Ways To Use Data
To Understand and Address
COVID-19 Health Disparities,
Despite Challenges With
Existing Data
Christi A. Grimm
Inspector General
July 2022, OEI-05-20-00540
U.S. Department of Health and Human Services
Office of Inspector General
Report in Brief
July 2022, OEI -05 -20 -00540
Why OIG Did This Review CDC Found Ways To Use Data To Understand
The COVID-19 pandemic has
devastated communities across the
and Address COVID-19 Health Disparities,
United States, and socially Despite Challenges With Existing Data
vulnerable populations have been
disproportionately affected. From As the Nation’s lead public health agency, CDC
the beginning, reports indicated Key Takeaway works to increase national health security and to
that people of color and people respond to public health threats as they arise. In
CDC worked to
from economically disadvantaged doing this, CDC receives public health data from
understand and
communities were at increased risk State, Territorial, and local entities (jurisdictions) as
address COVID-19
of becoming sick from COVID-19, well as from providers on a mostly voluntary basis.
disparities using
of needing intensive care due to CDC collects patient-level data on several
racial, ethnic, and
COVID-19, and of dying from COVID-19 indicators, including testing, cases,
socioeconomic data,
COVID-19 compared to members hospitalizations, and deaths. Some of these data
despite challenges
of predominantly White and/or contain information on patients’ race and ethnicity,
with these data.
affluent communities. At the same as well as indicators of their socioeconomic status.
time, reports revealed that
demographic data on COVID-19 What OIG Found
were incomplete, which could make CDC’s racial, ethnic, and socioeconomic data for COVID-19 testing, cases,
understanding and addressing hospitalizations, and deaths have limitations and provide an incomplete
disparities more difficult. picture of COVID-19 disparities. Racial and ethnic data associated with
COVID-19 reporting are sometimes missing, inconsistent, or inaccurate, while
How OIG Did This Review socioeconomic data in this reporting are neither clearly defined nor
In March and April 2021, we consistently collected.
conducted structured interviews
CDC has taken steps to supplement and improve these data. CDC analyzed
with CDC staff responsible for
disparities using additional data sources, such as emergency department data
collecting and analyzing COVID-19
on COVID-like illness and qualitative data from ad hoc surveys on attitudes
data; collaborating with State, local,
and beliefs. CDC also developed a methodology to identify
and Territorial entities and with
disproportionately impacted communities of color using Census data.
Tribal Epidemiology Centers (TECs);
Additionally, CDC has worked with the entities that report COVID-19 data to
and developing initiatives to
improve the quality of these data at their source.
address disparities. We also
conducted structured interviews CDC reported using both these supplemental data and data on COVID-19
with staff from six jurisdictions and testing, cases, hospitalizations, and deaths to address disparities via technical
two TECs representing a variety of assistance to partners, targeted interventions, and significant funding
State, local, Territorial, and Tribal investments. For example, CDC has helped partners conduct focus group
entities. We asked CDC staff how sessions to learn about challenges faced by disproportionately impacted
they used data to identify and communities and has used data to determine equitable locations for testing
address disparities and about sites. CDC also reported that it has elevated health equity throughout its
support they provided to response efforts. For instance, it created a Chief Health Equity Officer unit
jurisdictions and TECs throughout and published a health equity strategy to guide its COVID-19 response.
the pandemic. We asked
jurisdictions and TECs about their The TECs and Territory we interviewed also noted data limitations that could
collaboration with CDC and about inhibit their ability to identify and address COVID-19 disparities. The TECs we
challenges they faced related to the interviewed reported difficulty accessing public health data from CDC and
collection, reporting, and receipt of
COVID-19 data and analysis.
States, while the Territory we interviewed reported that it lacked the technical
infrastructure to collect and report COVID-19 data.
What OIG Recommends and Agency Response
We recommend that CDC: (1) expand efforts both to improve racial and
ethnic data associated with COVID-19 and to supplement them with
additional data sources and (2) ensure that TECs have timely access to all
public health data to which they are entitled. CDC concurred with both of
these recommendations.
TABLE OF CONTENTS
BACKGROUND 1
Methodology 8
FINDINGS 10
Racial, ethnic, and socioeconomic data associated with COVID-19 testing, cases, 10
hospitalizations, and deaths have limitations and do not provide a complete picture of
disparities
Racial and ethnic data associated with COVID-19 are sometimes incomplete, inconsistent, 10
or inaccurate
Socioeconomic data associated with COVID-19 are not clearly defined or consistently 13
collected
Data limitations result in an incomplete picture of disparities in COVID-19 testing, cases, 13
hospitalizations, and deaths
CDC has taken steps to supplement and improve data on COVID-19 testing, cases, 14
hospitalizations, and deaths
CDC used existing data sources and collected additional data related to COVID-19 14
disparities to supplement COVID-19 data
CDC has worked to support labs and jurisdictions in addressing data collection and 15
reporting challenges unique to COVID-19
CDC reported using multiple data sources and analyses to inform efforts to address COVID-19 16
disparities
Some Tribal partners and at least one Territory have experienced challenges addressing 18
COVID-19 disparities due to problems accessing or managing data
CONCLUSION AND RECOMMENDATIONS 19
CDC should expand its efforts both to improve racial and ethnic data associated with 19
COVID-19 and to supplement them with additional data sources
CDC should ensure that Tribal Epidemiology Centers have timely access to all public health 20
data to which they are entitled
AGENCY COMMENTS AND OIG RESPONSE 21
APPENDIX 22
ACKNOWLEDGMENTS AND CONTACT 27
ABOUT THE OFFICE OF INSPECTOR GENERAL 28
ENDNOTES 29
BACKGROUND
Objectives
1. To identify limitations in the racial, ethnic, and socioeconomic data
associated with COVID-19 testing, cases, hospitalizations, and deaths used
by the Centers for Disease Control and Prevention (CDC).
2. To examine how CDC uses these racial, ethnic, and socioeconomic data in its
response to COVID-19 disparities.
3. To describe CDC’s challenges, successes, and lessons learned in using these
data and supporting jurisdictions and Tribal Epidemiology Centers in
response to the COVID-19 pandemic.
The COVID-19 pandemic has had a historic impact on the Nation, with Black or
African American, American Indian or Alaska Native (AI/AN), Asian, Native Hawaiian or
Other Pacific Islander, and Hispanic or Latino individuals and members of
economically disadvantaged communities often hard-hit. Consistent with wider
health trends, available data indicate that members of these communities have been
more likely to experience poor outcomes from COVID-19 than members of
predominantly White and/or affluent communities. Specifically, throughout the
pandemic, reports indicated that Hispanic or Latino, Black, AI/AN, and Asian
individuals had higher rates of infection, hospitalizations, and deaths compared to
their White counterparts, 1 and residents of lower-income neighborhoods are more
likely not only to contract COVID-19 but also to die from it. 2, 3 Furthermore, data also
indicate that members of other groups, such as people who are experiencing
homelessness, people with disabilities, and people who are incarcerated, face
increased risk of poor outcomes from COVID-19. 4, 5, 6
Early in the pandemic, concerns arose that CDC was not collecting, or not reporting,
the racial and ethnic information for COVID-19 testing and cases. 7, 8 CDC is the
Nation’s lead public health agency, responsible for providing health information and
responding to health emergencies. We conducted this evaluation to identify
limitations in CDC’s racial, ethnic, and socioeconomic data for COVID-19 and to
examine how CDC used these data to understand and address COVID-19 disparities.
CDC Found Ways To Use Data To Understand and Address COVID-19 Health Disparities, Despite Challenges With Existing Data
OEI-05-20-00540 Background | 1
Public Health Reporting
CDC relies on various State, Territorial, and
local entities, hereinafter referred to as
role of Tribal
Epidemiology Centers (TECs)
jurisdictions, to collect and report data for
Twelve TECs function as public
public health purposes. Providers such as health entities for Al/AN Tribal and
laboratories, hospitals, and outpatient health urban Indian communities. TECs
care facilities submit most of these data, work in partnership with Tribes and
including data on COVID-19 testing, cases,
perform several functions, including
monitoring data, providing disease
hospitalizations, and deaths. a In general, the surveillance, and promoting public
authority to mandate public health reporting health, but they do not report public
rests with States and Territories, not the health data to CDC.
Federal Government. 9 Jurisdictions reporting TECs are designated public health
to CDC typically send anonymized data (i.e., authorities, meaning they have legal
access to protected health
data that cannot be traced to a specific information. They also have access
person) to CDC. In most instances, reporting to data, monitoring and delivery
to CDC is voluntary. systems, and other protected health
information held by HHS. CDC
Changes during the COVID-19 pandemic provides technical assistance to
TECs in performing their public
introduced mandatory reporting of some health functions.
public health data to Federal agencies.
Under the Coronavirus Aid, Relief, and
Economic Security (CARES) Act in March 2020, Congress required every lab that
performs or analyzes a test intended to detect or diagnose a possible case of
COVID-19 to report test results to the Secretary of the Department of Health and
Human Services (HHS). The statute authorized the Secretary to prescribe the form
and manner, and timing and frequency, of such reporting. 10 HHS’s subsequent
guidance established August 1, 2020, as the implementation date for this reporting,
provided instructions to all laboratories on the specific required data elements to be
reported daily to CDC, and outlined avenues for reporting, including through existing
public health reporting mechanisms. 11 Beginning in May 2020, the Centers for
Medicare & Medicaid Services (CMS) also began requiring aggregate weekly
reporting of COVID-19 data from nursing homes. b, 12
CDC’s Data Modernization Initiative
CDC’s efforts to modernize public health data and reporting accelerated after the
COVID-19 pandemic exposed gaps in the public health data system. 13 CDC’s data
modernization initiative includes several activities, such as creating interoperable
a Providers submit public health data to public health departments. Some public health departments
report these data to CDC directly, while others report to CDC via the public health department of a
higher jurisdiction. For example, some local public health departments report directly to CDC while
others report via the public health departments of their States.
b In May 2020, CMS began requiring skilled nursing facilities and nursing facilities to report, on a weekly
basis, confirmed and suspected COVID-19 infections, total deaths, and COVID-19 deaths among
residents and staff, per 85 Fed Reg 27550.
CDC Found Ways To Use Data To Understand and Address COVID-19 Health Disparities, Despite Challenges With Existing Data
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systems in public health and health care to make data sharing easier, upgrading and
modernizing technology infrastructure, and strengthening the public health
workforce. The data modernization initiative also includes increasing the use of both
electronic case reporting and electronic lab reporting. c, 14 One goal of this initiative is
to make important data, including racial and ethnic data, more complete.
Congress has provided $1.1 billion in support of data modernization activities since
shortly before the pandemic began. Prior to the pandemic, CDC received dedicated
modernization funding, for the first time, through its fiscal year (FY) 2020
appropriations. 15 When the pandemic hit, Congress provided additional funds in the
CARES Act to support rapid modernization. 16 In addition, CDC’s FY 2021
appropriations and the American Rescue Plan Act provided additional funding for
data modernization activities. 17
CDC expanded several activities from its data modernization initiative during the
pandemic. 18 For example, CDC rapidly increased the use of electronic lab reporting
from zero jurisdictions being able to report directly to CDC to 56 jurisdictions
(representing all of the lab-testing volume in the country) by April 2021. 19 In addition,
CDC also greatly increased the use of COVID-19 electronic case reporting on two
fronts: (1) all States, the District of Columbia, and 12 large, local jurisdictions are now
capable of receiving electronic case reports, up from a handful in 2019, and (2) as of
May 2022, more than 12,400 health care facilities can send case reports to
jurisdictions electronically. 20
COVID-19 Data on Testing, Cases, Hospitalizations, and Deaths
Entities that report COVID-19 data to CDC transmit these data through several new
and existing reporting systems. The data transmitted to CDC are individual- or
patient-level data but are anonymized, meaning they cannot be traced to a specific
person. CDC maintains several systems that collect COVID-19 data beyond testing,
cases, hospitalizations, and deaths, but they are not the focus of this evaluation. d
Testing. CDC receives information about COVID-19 tests directly from the labs and
providers that conduct the tests and indirectly through public health departments as
part of the CARES Act reporting requirement. CDC compiles data on positive and
c Electronic case reporting is the automated, real-time exchange of case report information between
electronic health records and public health departments. This enables health departments to obtain
more complete data from patient health records, including racial and ethnic information. Electronic lab
reporting is the transmission of digital laboratory reports from labs to public health departments, health
care systems, and CDC. Please see CDC, What is eCR?, at https://www.cdc.gov/ecr/what-is-ecr.html and
CDC, What is ELR? at https://www.cdc.gov/elr/about.html.
d This evaluation did not focus on data for vaccinations or CDC’s efforts to address disparities in
vaccination, despite existing concerns, as that campaign was in the early stages during our data
collection period. OIG is conducting an evaluation assessing the effectiveness of State vaccination
systems (OEI-05-22-00010). See OIG, Use of States’ Immunization Information Systems To Monitor
COVID-19 Vaccinations (OEI-05-22-00010), forthcoming (see OIG Work Plan at
https://oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-0000571.asp).
CDC Found Ways To Use Data To Understand and Address COVID-19 Health Disparities, Despite Challenges With Existing Data
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negative tests and disseminates these data along with a 7-day positivity rate on its
public COVID Data Tracker. e, 21 HHS’s guidance details the required data to be
reported, including specifics about the test itself, the result, where the test was
performed, and the patient’s race, ethnicity, and ZIP Code. 22
Cases. CDC receives information about COVID-19 cases, along with other notifiable
conditions, through a disease surveillance system. Local health departments work
with health care providers, hospitals, and labs to collect data on COVID-19. Providers
and local public health departments report data to their State and Territorial health
departments, which then report to CDC. CDC and the Council of State and Territorial
Epidemiologists coordinate to develop standard surveillance case definitions for
reporting each notifiable condition, along with the demographic information (i.e., race
and ethnicity), location, and outcome data that should be reported.f, 23
Hospitalizations. CDC’s Coronavirus Disease 2019-Associated Hospitalization
Surveillance Network (COVID-NET) collects data about hospitalizations associated
with laboratory-confirmed COVID-19 cases. Hospitals in 99 counties in the
participating 14 States report detailed data for each case including the age, sex,
location, race, ethnicity, clinical history, and clinical outcomes for each hospitalized
COVID-19 patient. 24
CDC also has access to hospital data from other sources. The National Syndromic
Surveillance Program contains data on emergency department visits that may be
related to COVID-19. The Premier Healthcare Database contains hospital discharge
data representing about 20 percent of U.S. hospital admissions, including encounters
related to COVID-19. Additionally, CDC has access to some aggregated data on
COVID-19 hospitalizations through HHS’s Unified Hospital Dataset within HHS
Protect. g
Deaths. CDC receives information about deaths via death certificates filed with State
and Territorial vital statistics offices. Death certificates are dually completed by
funeral directors and medical certifiers (e.g., physicians, medical examiners, and
coroners). In April 2020, CDC issued guidance indicating that COVID-19 should be
specified on death certificates if it “played a role in the death.” 25 CDC’s recommended
e Testing data track individual tests and results, not patients.
While testing data are not person-based,
they do contain personal information about the people being tested, such as race and ethnicity.
f The Council of State and Territorial Epidemiologists developed an initial case definition for COVID-19 in
April 2020 (see https://www.cste.org/news/520707/CSTE-Interim-Position-Statement-Update-to-COVID-
19-Case-Definition.htm). In May 2020, the CDC developed a COVID-19 case report form. This form
standardizes the reporting of information on COVID-19 cases from jurisdictional health departments to
the CDC (see https://www.cdc.gov/coronavirus/2019-ncov/downloads/pui-form.pdf).
g HHS’s Unified Hospital Dataset is maintained on the HHS Protect data platform. It contains data on
COVID-19 hospitalizations, such as admissions, inpatient utilization, and ICU utilization. For more
information on the Unified Hospital Dataset, please see https://covid.cdc.gov/covid-data-
tracker/#abouthospitaldata. For more information on the HHS Protect platform, please see the HHS
Protect Public Data Hub at https://protect-public.hhs.gov/.
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standard death certificate includes the decedent’s cause and place of death in
addition to race, ethnicity, ZIP Code, education, occupation, and industry. 26
Racial, Ethnic, and Socioeconomic Data
CDC requests that jurisdictions submit demographic data (including racial, ethnic, and
socioeconomic data) but has indicated that it does not have the authority to require
this information for COVID-19 cases, hospitalizations, and deaths. 27 As authorized by
the CARES Act and laid out in HHS guidance, labs are required to report race,
ethnicity, and ZIP Code for COVID-19 test results, which ultimately are reported to
CDC. 28
Racial and Ethnic Data. CDC’s reporting instructions generally use the standard
minimum Federal Office of Management and Budget (OMB) categories for race and
ethnicity. h For race, the categories are: American Indian or Alaska Native, Asian, Black
or African American, Native Hawaiian or Other Pacific Islander, and White; and for
ethnicity: Hispanic or Latino and Not Hispanic or Latino. 29 However, jurisdictions may
choose not to use these categories. Rather, jurisdictions may choose to define race
and ethnicity differently. In addition, jurisdictions often develop their own reporting
tools and data systems that may use different racial and ethnic categories when the
data are collected.
Exhibit 1 provides examples of how information on race and ethnicity may flow to
select CDC systems tracking COVID-19 testing, cases, hospitalizations, and deaths.
h A standard death certificate includes more racial and ethnic categories than the minimum OMB
categories. Please see the U.S. Standard Certificate of Death at
https://www.cdc.gov/nchs/data/dvs/DEATH11-03final-acc.pdf for more information.
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Exhibit 1: CDC collects racial and ethnic data for COVID-19 testing, cases,
hospitalizations, and deaths from providers and public health departments.
Providers Labs Public health Dataset of positive
• • • t
Collect race Confirm or departments and negative test
and ethnicity disconfirm May conduct followup for
COVID-19
results
data from missing race and ethnicity data
patients
I
Cases
Providers Public health National
• • t •
Collect race Notifiable
Labs departments
and ethnicity
data from
Confirm May conduct followup for Diseases
COVID-19 missing race and ethnicity data Surveillance
patients
System (N N DSS)
I
Hospitalizations
Hospitals Surveillance officers
Collect race In the 14 States
and ethnicity participating in infectious • COVID- NET
data from disease surveillance
patients programs prior to COV/0- 19
Deaths
Funeral directors
Record race and National Vital
ethnicity data with
assistance from friends
State vital
records offices
It Statistics System
(NVSS)
or relatives of deceased
Note: This exhibit represents racial and ethnic data on COVID-19 hospitalizations that CDC obtains through
COVID-NET reporting. CDC’s additional sources of COVID-19 hospitalizations data, such as the National Syndromic
Surveillance Program and the Premier Healthcare Database, may also contain racial and ethnic data.
Source: Office of Inspector General (OIG) review of CDC and GAO documents, 2021.
Socioeconomic Data. While socioeconomic data may be defined in various ways
depending on the entity collecting or analyzing the data, CDC collects a range of
variables for COVID-19 data that could be used as socioeconomic indicators. For
instance, CDC’s suggested COVID-19 case report form requests information about
residence at illness onset, occupation, and industry. 30 As another example, the
recommended standard death certificate includes information about education,
occupation, and industry. 31
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Federal Response to COVID-19 Disparities
CDC, Congress, and the Administration have taken numerous steps to address health
disparities resulting from the COVID-19 pandemic. Several key steps are described
below. i
CDC. On January 21, 2020, CDC activated its Emergency Operations Center in
response to the COVID-19 public health emergency. 32 33 The Emergency Operations
Center, which is activated for the duration of a public health emergency, uses an
incident management system to coordinate CDC’s response to an emergency. 34 As
part of its response to COVID-19, CDC worked to collect COVID-19 data, facilitate
more rapid identification of COVID-19 hotspots, and consolidate available data. In
addition, it deployed personnel to address staffing needs in State, Tribal, local, and
Territorial health departments and monitored potential outbreaks and hotspots to
mitigate the spread of COVID-19.
To address the importance of health equity as part of its COVID-19 response, CDC
released the COVID-19 Response Health Equity Strategy in August 2020. The strategy
provides “an evidence-based, comprehensive, and coordinated framework for
reducing COVID-19 disparities.” 35 CDC’s strategy prioritizes expanding the evidence
base, which includes having timely, complete, and representative data for race and
ethnicity. j, 36
Congress. Since early in the pandemic, Congress has taken several steps to help
address COVID-19 disparities. For instance, given concerns about the CDC’s lack of
racial and ethnic data related to COVID-19, Congress passed legislation that requires
the Secretary, in coordination with other appropriate departments and agencies, to
disclose racial, ethnic, and other demographic data related to COVID-19. 37 In
addition, the American Rescue Plan Act included $250 million in funding to develop
and support a community-based workforce to increase COVID-19 vaccinations in
underserved communities. 38 The American Rescue Plan Act also included funding to
support State and local health departments’ COVID-19 response capabilities, which
may enable them to improve access to testing, especially among communities of
color. 39
Administration. President Biden signed two Executive Orders in January 2021 related
to COVID-19 and health equity. One establishes a COVID-19 Health Equity Task Force
to develop recommendations for mitigating the health inequities caused or
exacerbated by the pandemic and preventing future inequities. 40 Another requires
i This section is not intended to serve as a comprehensive review of all Federal actions to respond to
COVID-19 disparities.
j A September 2020 GAO report found that CDC’s strategy lacked critical details to achieve the priority of
collecting complete data by race and ethnicity. GAO recommended that CDC determine whether having
authority to require States and jurisdictions to report racial and ethnic information is necessary and, if so,
to seek such authority from Congress. It also recommended that CDC involve key stakeholders, such as
public health departments, to improve the completeness and consistency of demographic data. Please
see https://www.gao.gov/products/gao-20-701 for more information.
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increased coordination among Federal agencies regarding COVID-19 data collection,
production, and analysis of data, including key equity indicators, as well as sharing
such data with State, local, Tribal, and Territorial authorities. 41
Related Office of Inspector General Work
This report is part of the Office of Inspector General’s (OIG’s) strategic efforts to
oversee HHS’s response to the COVID-19 pandemic, address health equity, and
ensure that HHS programs have complete, accurate, and timely data. Additional OIG
work in support of these priorities includes, for example, assessments of the
completeness and accuracy of racial and ethnic data for Medicare and Medicaid
beneficiaries. 42 OIG’s goals include both ensuring that HHS is protecting the health
and welfare of all Americans and promoting the effectiveness of HHS programs.
Methodology
Scope
This report focuses on the limitations of CDC’s racial, ethnic, and socioeconomic data
for COVID-19 testing, cases, hospitalizations, and deaths, and how CDC used these
data to understand and address COVID-19 disparities. This report does not focus on
CDC’s use of racial, ethnic, and socioeconomic data for COVID-19 vaccinations, as at
the time of our planning and data collection the vaccination campaign was just
beginning. Our primary data collection occurred in spring 2021, with updates
received from CDC through January 2022.
Data Collection
In March and April 2021, we conducted structured interviews with CDC staff
responsible for collecting and analyzing COVID-19 data, collaborating with
jurisdictions and Tribal Epidemiology Centers (TECs), and developing initiatives to
address disparities. We also conducted structured interviews covering the same
topics with staff from six jurisdictions and two TECs representing a variety of State,
Territorial, local, and Tribal entities. The six jurisdictions selected for interviews were
Mississippi, Nevada, North Dakota, Puerto Rico, Texas, and the District of Columbia.
The two TECs selected for interviews were the Navajo Epidemiology Center and the
Urban Indian Health Institute. k We considered several factors when selecting
jurisdictions and TECs for interviews, including COVID-19 burden and the degree to
which jurisdictions reported racial and ethnic data. The purpose of our interviews
with the selected jurisdictions and TECs was to provide useful, qualitative insights and
context regarding experiences with collecting, reporting, or using racial, ethnic, and
k The Urban Indian Health Institute is the TEC that serves Urban Indian Health programs across the
country. Please see https://www.uihi.org/ for more information.
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socioeconomic information associated with COVID-19 testing, cases, hospitalizations,
and deaths.
We asked CDC staff how they have used racial, ethnic, and socioeconomic data
related to COVID-19 testing, cases, hospitalizations, and deaths to identify and
address disparities; any challenges they have faced using the data; and how they have
overcome those challenges. We also asked about lessons learned during the
pandemic. Furthermore, we asked how CDC uses these data to support jurisdictions
and TECs, and how CDC uses these data when working with Federal agencies. Lastly,
we asked CDC about its approach to health equity and how the Chief Health Equity
Officer unit works throughout CDC to address COVID-19 disparities. In some cases,
we received written responses to questions in lieu of an interview.
We asked staff from the jurisdictions and TECs about the racial, ethnic, and
socioeconomic data they share with or receive from CDC, challenges they have
encountered with the data, and how they have collaborated with CDC to use these
data to address COVID-19 in their jurisdictions or among Tribes.
In some instances, we requested supporting documentation or submitted followup
questions. This allowed us to clarify interview responses and review specific
documents or publications discussed during the interviews.
Data Analysis
We analyzed our interview data and supporting documents to determine how CDC
used racial, ethnic, or socioeconomic data to address COVID-19 disparities, and to
understand barriers and challenges to using data. We looked for common themes
across CDC, the jurisdictions, and TECs.
Limitations
Our analysis relied on interviews and documents provided by CDC staff and staff from
the jurisdictions and TECs. We did not directly analyze CDC’s racial, ethnic, and
socioeconomic data for COVID-19 testing, cases, hospitalizations, or deaths. We
reviewed publicly available materials to supplement the information provided in
interviews and documents. However, we did not independently verify the accuracy of
the information we received. In addition, the experiences and perspectives of the six
jurisdictions and two TECs that we interviewed do not necessarily reflect the
experiences and perspectives of all jurisdictions and TECs.
Standards
We conducted this study in accordance with the Quality Standards for Inspection and
Evaluation issued by the Council of the Inspectors General on Integrity and Efficiency.
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FINDINGS
Racial, ethnic, and socioeconomic data associated with
COVID-19 testing, cases, hospitalizations, and deaths have
limitations and do not provide a complete picture of disparities
Racial and ethnic data associated with COVID-19 are sometimes
incomplete, inconsistent, or inaccurate
While the quality of racial and ethnic data associated with COVID-19 has improved
since the beginning of the pandemic, completeness and consistency continue to vary.
Race and ethnicity are still missing for many COVID-19 tests, cases, and
hospitalizations. In addition, jurisdictions and health care providers define racial and
ethnic categories differently, which means these data may not have the same
meaning across jurisdictions. Furthermore, racial and ethnic data associated with
COVID-19 testing, cases, hospitalizations, and deaths that are not self-reported may
be inaccurate.
Incomplete. Although race and ethnicity for
testing and cases have become more complete
since reporting began, both testing and case
of COVI D-19 tests were
data continue to lack racial and ethnic missing racial and ethnic data
information for a significant portion of data.
Specifically, as of January 2022, CDC reported
that 67 percent of COVID-19 testing data
and 34 percent of COVID-19 case data were 34%
missing race and ethnicity. 43 By contrast, race of COVID-19 cases were
and ethnicity for deaths were nearly 100 percent missing racial and ethnic data
complete.
Challenges at various stages in the data reporting process contribute to CDC’s
incomplete racial and ethnic data on COVID-19 tests and cases. As shown in Exhibit 2,
COVID-19 data may flow to CDC through several stakeholders, each of which may
experience challenges that impact data completeness. l
l Stakeholders include the patient, the provider, health care entities, public health departments, and CDC.
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Exhibit 2: Data generally flow through multiple stakeholders before reaching
CDC.
Each stakeholder faces obstacles that contribute to the incompleteness of racial
and ethnic data on COVID-19.
tt
Patients
Source: OIG review of CDC documents and interview responses, 2021.
For example, patients may be uncomfortable sharing racial or ethnic information with
health care providers or public health entities, and providers may be reluctant to
request this information. When these incomplete data reach public health
departments, the departments may lack the staff or resources needed to conduct
followup. Also, health care providers and other entities that report data to public
health departments sometimes report data via fax, mail, or email, which strains public
health department resources as staff must manually enter these data. Even if racial
and ethnic data are successfully collected, one State and CDC reported that some
State laws prohibit them from sharing these data with CDC.
Furthermore, available data may not be
COVID-NET has representative of the U.S. population. For example,
nearly complete as of July 2021 jurisdictions varied widely in the
completeness of racial and ethnic data they
racial and ethnic reported for COVID-19 testing. As a result, racial
and ethnic data for COVID-19 testing may be
data on COVID-19 skewed toward the racial and ethnic composition of
hospitalizations jurisdictions reporting more complete data rather
than representative of the demographics of the
but covers only United States. Additionally, because COVID-NET is
a population-based surveillance system, the racial
10% of the and ethnic data CDC reports through it cover only
U.S. population. about 10 percent of the U.S. population,
representing data from the 14 States participating
in it. While these hospitalizations data have nearly complete racial and ethnic
information (99 percent), and the population covered is demographically similar to
the U.S. population, COVID-NET data are not generalizable to the country.
Inconsistent or inaccurate. Racial and ethnic data associated with COVID-19 are, in
some cases, inconsistent or inaccurate with respect to the populations they describe.
Although standard minimum categories are defined for Federal use, officials from
CDC and two of the jurisdictions we interviewed reported that variation exists in the
categories used at the jurisdictional level to collect racial and ethnic data. 44 Generally,
jurisdictions have discretion in how they collect demographic data for public health
surveillance. As a result, there is variation in the categories used to collect racial and
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ethnic data, and the same categories across jurisdictions and reporting entities may
refer to different groups.
Some of the inconsistency of racial and ethnic data for COVID-19 arises from the way
various jurisdictions aggregate or disaggregate racial and ethnic categories. For
example, some State health departments combine categories for race when reporting
cases to CDC such as placing AI/AN people in the same category as Native Hawaiians
or Other Pacific Islanders. 45 Additionally, jurisdictions vary in whether they treat
Hispanic or Latino as a racial category or as an ethnic category. As a result,
two people of the same race and ethnicity residing in different jurisdictions could
appear in public health reporting to belong to different demographic groups. This
impedes the ability of CDC or outside researchers to compare disparities across
jurisdictions or to identify national or regional trends. See Exhibit 3 for an example.
Exhibit 3: Inconsistent racial and ethnic categories across jurisdictions could
obscure the impact of COVID-19 on certain racial or ethnic groups.
State A's case reporting form lists American Indian or Alaska
Native as a stand-alone racial category. If this person lived
in State A, they would be reported as American Indian or
Alaska Native both in the State and to CDC.
State A
This person is an
American Indian who
~lmt
contracted COVI 0 -19.
State B
State B's case reporting form lists a combined Other racial
category that includes both American Indian or Alaska Native
and Native Hawaiian or Other Pacific Islander. If this person
lived in State B, they would be reported as " Other" in the
State, obscuring their race as American Indian .
Source: OIG review of CDC and State interview responses, 2021.
Finally, racial and ethnic information for COVID-19 deaths may be inaccurate. Racial
and ethnic data for COVID-19 deaths are nearly 100 percent complete, but previous
analyses have indicated that death certificates for as many as 40 percent of AI/AN
people misclassify them as White or other races. m, 46 As a result, COVID-19 death data
may understate the burden of COVID-19 on AI/AN people. More accurate death data
would help CDC understand the true impact of COVID-19 on vulnerable populations.
m CDC reported that the issue of racial and ethnic misclassification likely extends to any data type where
race and ethnicity are reported by proxy.
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Socioeconomic data associated with COVID-19 are not clearly
defined or consistently collected
CDC does not set a standard for reporting socioeconomic data elements across
COVID-19 testing, cases, hospitalizations, and deaths. Socioeconomic data can
include a wide range of elements such as ZIP Codes, health insurance status, and
occupations, and reporting entities are often the decisionmakers regarding which
measures, if any, to collect. Two jurisdictions we interviewed reported that guidance
and standards would be needed to improve completeness and standardization of
socioeconomic data at the individual level.
In lieu of patient-level COVID-19 socioeconomic data, both CDC and jurisdictions
reported using community-level data such as data from the Census Bureau or CDC’s
Social Vulnerability Index (SVI). n These community-level data enable CDC and
jurisdictions to identify and understand community vulnerabilities and target
interventions to address them. o However, while CDC reported these data are useful
for steering community-level interventions, they do not allow for direct analysis of
individual socioeconomic disparities in COVID-19 testing, cases, hospitalizations, or
deaths.
Data limitations result in an incomplete picture of disparities in
COVID-19 testing, cases, hospitalizations, and deaths
Although CDC used racial, ethnic, and socioeconomic data to report on COVID-19
disparities, its analyses had gaps and limitations. For example, an August 2020 CDC
report on COVID-19 among AI/AN people included only 23 States because the
remaining States’ case data lacked sufficient racial and ethnic information. 47 CDC has
not published findings about disparities in COVID-19 cases for AI/AN people in the
more than half of States that lacked sufficient data. Furthermore, in a 2020 report
that CDC conducted on COVID-19 racial and ethnic disparities in “hotspot” counties,
CDC had to limit its analysis to counties where at least 50 percent of case data
included race. This meant that CDC could include in its analysis only 79 of the 205
counties it identified as hotspots—just 38.5 percent. 48 Racial and ethnic data may
have improved since these analyses were conducted.
n SVI is a tool that helps emergency response planners and public health officials identify, map, and plan
support for communities that will most likely need support before, during, and after a public health
emergency. It ranks each census tract on 15 American Community Survey variables to determine each
tract’s relative social vulnerability. Please see https://svi.cdc.gov/Documents/FactSheet/SVIFactSheet.pdf
for more information.
o Research supports the use of social vulnerability measures for anticipating and addressing the
needs of disadvantaged communities in emergencies. Please see Karaye and Horney,
2020 (https://doi.org/10.1016/j.amepre.2020.06.006), Gaynor and Wilson, 2020
(https://doi.org/10.1111/puar.13264), and Oates et al., 2021
(https://doi.org/10.1007/s10900-021-00998-x) for examples.
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Additionally, CDC may lack sufficiently granular data to understand certain disparities,
even with complete racial and ethnic data. For example, some jurisdictions in our
small sample reported that information on individuals’ Tribal affiliation would be
useful for understanding and addressing COVID-19 in Tribes. However, jurisdictions
vary as to whether they collect this information. p If the data are not collected in the
jurisdictions, CDC cannot receive them. Without data on Tribal affiliation, it may be
more difficult for CDC, States, and Tribal partners to identify or respond to
Tribal-specific outbreaks or inequities.
CDC has taken steps to supplement and improve data on
COVID-19 testing, cases, hospitalizations, and deaths
CDC reported that it has attempted to overcome limitations in demographic data for
COVID-19 testing, cases, hospitalizations, and deaths in several ways. First, CDC
supplements these data by using information from multiple existing data sources and
by conducting additional data collection via ad hoc surveys and listening sessions.
CDC reported that this combination of supplemental data and the demographic data
on COVID-19 testing, cases, hospitalizations, and deaths has been sufficient to
demonstrate the existence of racial, ethnic, and socioeconomic disparities and to
begin to understand their nature and magnitude. Second, CDC took steps to support
the entities that report COVID-19 data to CDC to improve the quality of COVID-19
data at their source.
“While more robust race and ethnicity data would provide a more
comprehensive view of the pandemic, the data reported to CDC
and shared with Federal partners has been sufficient to document
major disparities.”
— CDC official
CDC used existing data sources and collected additional data
related to COVID-19 disparities to supplement COVID-19 data
Recognizing the limitations of racial, ethnic, and socioeconomic data associated with
COVID-19 testing, cases, hospitalizations, and deaths, CDC has leveraged its broad
array of existing public health data sources to bolster its understanding of disparities.
CDC combines data on COVID-19 testing, cases, hospitalizations, and deaths with
p The standard death certificate includes an option to report Tribal affiliation for AI/AN individuals.
Please see the U.S. Standard Certificate of Death at https://www.cdc.gov/nchs/data/dvs/DEATH11-03final-
acc.pdf for more information.
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these other data sources, such as emergency department and Census data, to better
understand COVID-19 disparities. For example:
• CDC uses clinical data from research and health plan networks and emergency
department data on COVID-like illness. q CDC reported that its emergency
department data, which come directly from electronic health records, can offer
more complete racial and ethnic data because multiple records are
automatically scanned for information on patients’ race and ethnicity.
• CDC also developed a methodology to identify disproportionately impacted
communities of color at the county level using Census data on race and
ethnicity. 49
• CDC has used a geospatial tool—the SVI—to identify geographic areas
that may be at higher risk for severe outcomes due to social factors.
CDC also gathers additional qualitative data that provide information it could not get
even from complete quantitative COVID-19 data, such as insights into beliefs and
attitudes. CDC uses surveys and listening sessions to gather these data on the impact
of COVID-19 on diverse populations. For example, CDC conducted a survey on
mental health during the pandemic for which racial and ethnic data were more
than 99 percent complete. 50 Furthermore, CDC conducted 18 listening sessions with
diverse audiences to learn more about the beliefs and needs of disproportionately
impacted populations. These surveys and listening sessions captured information on
topics such as vaccine hesitancy, mask adherence, and beliefs about COVID-19, none
of which are included in patient-level COVID-19 data.
CDC has worked to support labs and jurisdictions in addressing
data collection and reporting challenges unique to COVID-19
The COVID-19 pandemic presented unique challenges that impacted how data were
collected and reported. Although these challenges were not specific to racial, ethnic,
or socioeconomic data, they complicated general COVID-19 data collection activities
and therefore may have contributed to data quality concerns. CDC has taken steps to
support labs and jurisdictions in collecting and reporting better data for COVID-19,
including improved racial, ethnic, and socioeconomic data.
The scale of the COVID-19 pandemic created challenges for labs that were reporting
testing data. To increase testing capacity, many labs that had not previously done
routine testing opened new testing sites. CDC and jurisdictions reported that many of
these new testing sites were unfamiliar with the reporting process, and many were not
set up to report data electronically or to collect information on race, ethnicity, or
socioeconomic status. Additionally, in contrast to most public health reporting, labs
that do COVID-19 testing must report COVID-19 results for both positive and
negative results. 51 This meant that some labs had to develop new electronic reporting
q CDC reported there is no broad Federal requirement for States to report emergency department data
to CDC. However, some funding opportunities may require States to report these data.
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OEI-05-20-00540 Findings | 15
systems to satisfy the requirement to report negatives. These factors have strained
the resources of labs already stretched thin.
CDC took steps to support labs in reporting these data. Following the release of HHS
guidance on the CARES Act—which required labs to report race, ethnicity, and ZIP
Code—CDC provided labs with additional information and technical assistance for
establishing electronic reporting. 52, 53 For example, CDC clarified which labs must
report testing data, how labs could report data using standard terminology, and
answered frequently asked questions. However, CDC also acknowledged that labs
cannot control providers’ data collection practices or patients’ willingness to provide
demographic data, stating that “laboratories should make every reasonable effort to
provide” the required data elements. 54
Given broader concerns about inconsistency, CDC worked to standardize COVID-19
case reports—including racial and ethnic data—by creating a reporting worksheet for
and providing related technical assistance to jurisdictions. The worksheet uses the
minimum standard Federal racial and ethnic categories, but may not be sufficient to
standardize racial and ethnic data for cases if jurisdictions’ systems are not set up to
capture data at the same level of specificity as the Federal categories. For example,
some jurisdictions collect racial data across multiple Federal race categories (such as
Asian and Native Hawaiian or Other Pacific Islander) only in a single, umbrella
category.
CDC reported using multiple data sources and analyses to
inform efforts to address COVID-19 disparities
CDC reported that it uses the variety of data and analyses described above to inform
its efforts to address racial, ethnic, and socioeconomic disparities in COVID-19
through technical assistance to partners, targeted interventions, and funding.
CDC also reported that it elevated health equity as a priority in its pandemic response,
which has influenced its use of data to address disparities. CDC included a health
equity unit in its COVID-19 incident response structure. For the first time, CDC placed
a senior leader—the Chief Health Equity Officer—on its incident management
leadership team. The health equity unit has centered data in its activities, explicitly
calling for improved racial, ethnic, and socioeconomic data on COVID-19 and
espousing “data-driven approaches” to advancing health equity.
Technical assistance. Jurisdictions and Tribal entities may request technical assistance
from CDC to analyze challenges and identify data-driven solutions. As of
December 2021, CDC reported that it had responded to more than 300 such requests
related to health disparities. For example, CDC has responded to requests from Tribes
and Indian Health Service units for support in epidemiology, data management, and
health communication. In one case, CDC deployed staff to the Navajo Nation to help
the Tribe assess water access and construct water-access points. This supported
COVID-19 prevention efforts by increasing Tribal residents’ access to water for
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OEI-05-20-00540 Findings | 16
handwashing. CDC reported that it also routinely monitors COVID-19 data and has
conducted outreach to populations that appear to need additional support. For
example, CDC proactively reached out to Tribal communities when surveillance data
indicated high COVID-19 burden.
Exhibit 4: See below for examples of technical assistance CDC provided to
partners.
with the National Center for Farmworker Health to build
capacity in organizations serving agricultural workers and develop
COVID-19 mitigation strategies for farmworker communities
Deployed a ta ilored tool to help Tribes integrate COVID-19 data
and visualize the impact of COVID-19 on Tribal communities
Held focus group discussions with members of Marshallese and
Hispanic or Latino communities in Arkansas to identify
COVID-19-related challenges and needs
Source: OIG review of CDC web pages and interview responses, 2021.
Designing and implementing targeted interventions. CDC reported that it has
partnered with Federal agencies to use racial, ethnic, and socioeconomic data to
design and implement targeted interventions to address disparities. CDC reported
that it has used these data to determine which interventions and what guidance are
needed, and for whom. For instance, CDC used data to determine locations for
community-based testing sites, to ensure that its messaging and ad campaigns were
targeted to the communities most at risk, and to inform the distribution of masks
purchased by the Government.
COVID-19-related funding opportunities. CDC reported that it addresses disparities
in COVID-19 by providing funding opportunities including cooperative agreements
paired with technical assistance with an emphasis on health equity. In some cases,
CDC has offered funding specifically to address COVID-19 disparities among
disproportionately affected communities, as in the $2.25 billion grant opportunity
CDC posted through its Center for State, Tribal, Local, and Territorial Support in
March 2021.55 This grant aims to address COVID-19-related health disparities among
people living in rural areas as well as racial and ethnic minority groups. CDC has also
offered $300 million to support community health workers in addressing COVID-19-
related health disparities in high-risk populations, including communities of color. 56
In other cases, CDC awarded funds to the CDC Foundation, which gave jurisdictions
resources to support health equity. r CDC also reported that it considers health equity
r The CDC Foundation is an independent nonprofit created by Congress to marshal philanthropic and
private resources for CDC. For more information, see https://www.cdcfoundation.org/.
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OEI-05-20-00540 Findings | 17
issues, unintended impacts on minority populations, and alignment with the Health
Equity Strategy when reviewing proposals for funding.
Some of these health equity funding opportunities also promote data quality
improvement. For example, the March 2021 opportunity includes strategies for
jurisdictions to increase and improve data collection and reporting for populations
disproportionately impacted by COVID-19. It encourages recipients to improve data
collection by race and ethnicity, to educate providers on the importance of racial and
ethnic data, and to disseminate health equity data and other materials that are
culturally and linguistically tailored, among other activities. 57
Some Tribal partners and at least one Territory have
experienced challenges addressing COVID-19 disparities due to
problems accessing or managing data
Despite their status as public health authorities, the two TECs we interviewed reported
difficulty accessing COVID-19 data on AI/AN people from both CDC and States.
These challenges, which were also reported in media accounts and testimony from a
nonprofit Tribal organization in the summer of 2020, stemmed from staff confusion
regarding the public health authority of the TECs. 58, 59, 60 Specifically, the partners we
interviewed reported that CDC staff and State health departments denied several of
their data requests throughout the pandemic, citing privacy concerns and questioning
Tribal partners’ authority to access these data. CDC published guidance in 2015
affirming the TECs had access to HHS data under the Indian Health Care Improvement
Act, 61 and CDC reported that it took steps to provide these partners with access to
datasets on HHS Protect and that the issue had been resolved. However, the TECs we
interviewed reported that CDC staff and State health departments did not consistently
know or apply the 2015 guidance, and that they continued to face challenges due to
poor-quality racial data and logistical hurdles. For example, both TECs reported they
had to negotiate across multiple Federal, State, and Tribal entities to access the
COVID-19 data they needed.
Additionally, the Territory we interviewed experienced challenges addressing
COVID-19 because it lacked the technical infrastructure needed to collect, analyze,
and report COVID-19 data. CDC provided this Territory, whose population is mostly
people of color, with additional support to limit its COVID-19 burden. Specifically,
CDC deployed staff to assist the Territory in quickly establishing IT systems for
conducting public health surveillance and managing COVID-19 data.
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OEI-05-20-00540 Findings | 18
CONCLUSION AND RECOMMENDATIONS
To combat health disparities most effectively both during the COVID-19 pandemic
and more broadly, CDC needs adequate data on health outcomes for diverse
populations. The pandemic has highlighted and exacerbated existing racial, ethnic,
and socioeconomic health disparities. At the same time, the pandemic has strained
the Nation’s public health system and exposed gaps in its infrastructure, including
limited demographic information in key public health data. While CDC has made
efforts to improve its racial and ethnic data for COVID-19 testing, cases,
hospitalizations, and deaths, some data remain incomplete, inaccurate, or
inconsistent.
CDC has opportunities to improve the way it works with jurisdictions, labs, and
hospitals to collect and use data to address COVID-19 disparities. Despite data
limitations, CDC has been able to improve its understanding of COVID-19 disparities
and take steps to address them. CDC faces choices about the best balance of
approaches for ensuring adequate resources to support an equitable response.
Furthermore, TECs and certain jurisdictions, such as Territories, may need more
support from CDC to address COVID-19 due to problems accessing data or lack of
resources.
We recommend that CDC:
Expand its efforts both to improve racial and ethnic data
associated with COVID-19 and to supplement them with
additional data sources
CDC should expand its two-pronged approach of: (1) improving racial and ethnic data
for COVID-19 testing, cases, hospitalizations, and deaths; and (2) using additional data
sources to enhance its insights into racial, ethnic, and socioeconomic disparities. Both
efforts are valuable, and CDC should determine the appropriate balance of activities
and resource investments to support each.
As part of its efforts to improve the quality of racial and ethnic data associated with
COVID-19, CDC should pursue several additional steps. CDC should assess the
breadth of jurisdictions’ need for support in developing adequate data collection and
management systems and use its findings to inform the type and level of support it
provides (e.g., technical assistance, staff deployments, funding). CDC could also use
this information to inform its ongoing data modernization initiative. Additionally,
CDC could work with jurisdictions and labs to encourage or incentivize the adoption
of the minimum Federal standards for racial and ethnic categories. Finally, CDC could
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OEI-05-20-00540 Conclusion and Recommendations | 19
consider taking actions to encourage the collection of Tribal affiliation, such as
developing guidance on how it could be standardized and used, and best practices
from jurisdictions already collecting it. CDC could also consider whether and how
those data could be submitted to CDC.
Ensure that Tribal Epidemiology Centers have timely access to
all public health data to which they are entitled
CDC should work with TECs to understand which HHS data or systems they lack
access to and what barriers they have faced, and work to resolve them. CDC should
also ensure that all CDC staff working with data and with Tribal partners are aware of
TECs’ status as public health authorities and CDC’s legal obligations toward them to
provide access to HHS data. GAO has made similar recommendations for HHS and
CDC to take actions to improve TECs’ access to HHS data.62 CDC could also clarify
TECs’ authority for States, if needed.
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OEI-05-20-00540 Conclusion and Recommendations | 20
AGENCY COMMENTS AND OIG RESPONSE
CDC concurred with our first recommendation to expand its efforts to improve and
supplement racial and ethnic data associated with COVID-19. In its response, CDC
described several actions it is taking to improve and supplement these data, including
planning a $3 billion funding opportunity for public health agencies to address
infrastructure and workforce needs and collaborating with the Council of State and
Territorial Epidemiologists to survey jurisdictions about their challenges with
collecting and sharing racial and ethnic data. We hope to see CDC continue its efforts
to improve racial and ethnic data going forward, beyond the expiration of the
COVID-19 public health emergency.
CDC concurred with our second recommendation to ensure that TECs have timely
access to all public health data to which they are entitled. In its response, CDC stated
that it planned to develop written guidance for TECs on requesting public health data.
In our draft report, we also recommended that CDC assess the costs and benefits of
standardizing and collecting socioeconomic data at the individual level, compared to
the costs and benefits of using socioeconomic data at the community level. CDC
disagreed with our recommendation but affirmed the value of socioeconomic data for
understanding and addressing COVID-19 disparities. In its response, CDC provided
support for its conclusion that collecting community-level socioeconomic data
through surveys was more economically efficient and feasible than attempting to
collect individual-level socioeconomic data and linking it to case surveillance data.
CDC also described how its Data Modernization Initiative would help improve
community-level socioeconomic data. The considerations and assessments that CDC
included in its response met the intent of our recommendation and, as such, we did
not include it as a recommendation in our final report. We appreciate CDC’s
commitment to improving socioeconomic data at the community level and to using
these data to advance health equity in its COVID-19 response.
For the full text of CDC’s comments, see the Appendix.
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OEI-05-20-00540 Agency Comments and OIG Response | 21
APPENDIX - Agency Comments
TO: Gregory E. Demske
Acting Principal Deputy Inspector General
FROM: Centers for Disease Control and Prevention (CDC)
DATE: May 6, 2022
SUBJECT: Office of Inspector General (OIG) Draft Report, “CDC Found Ways To Use Data To
Understand and Address COVID-19 Health Disparities, Despite Challenges With
Existing Data,” OEI-05-20-00540
Attached is the Centers for Disease Control and Prevention (CDC) response to the Office of Inspector
General (OIG). This response details CDC’s planned actions regarding recommendations contained in the
OIG report, “CDC Found Ways To Use Data To Understand and Address COVID-19 Health Disparities,
Despite Challenges With Existing Data,” OEI-05-20-00540.
CDC appreciates the opportunity to review and comment on this report prior to its final release.
Sincerely,
Rochelle P. Walensky, MD, MPH
Director, CDC, and
Administrator, ATSDR
1
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OEI-05-20-00540 Appendix | 22
OIG Recommendation (1)
OIG recommends CDC expand efforts to improve racial and ethnic data associated with COVID-19 and
to supplement them with additional data sources.
CDC Response:
CDC concurs with the OIG recommendation. CDC is committed to continuing to expand its efforts to
improve racial and ethnic data associated with coronavirus disease 2019 (COVID-19) and supplement
them with additional data sources. CDC has several ongoing activities to improve race and ethnicity data,
as well as additional data sources. Examples include:
• A currently forecasted funding opportunity through CDC’s Center for Surveillance,
Epidemiology, and Laboratory Services, CDC-RFA-OE22-2203, Strengthening U.S. Public
Health Infrastructure, Workforce, and Data Systems, with an estimated funding amount of $3
billion. This funding is a first of its kind, approached as non-categorical and cross-cutting,
and intended to help meet critical infrastructure and workforce needs in the short term; it
should also make possible strategic investments that will have lasting effects on public health
agencies across the United States. To that end, it will support strategically strengthening
public health capacity and systems related to the workforce, foundational capabilities, data
modernization, physical infrastructure, and support from national public health partners.
• CDC’s National Center for Health Statistics (NCHS) is committed to improving data on race
and ethnicity collected from death certificates. In Fiscal Year 2022, NCHS began targeted
outreach and training for funeral directors, who are often responsible for proxy reporting of
race and ethnicity of the decedent on the death certificate. This training reinforces existing
NCHS guidance for funeral directors to consult with the decedent’s family or close friends
when determining race and ethnicity. NCHS has also focused on the misclassification of race
and ethnicity for the American Indian and Alaska Native (AI/AN) population. To help correct
misclassification of race and ethnicity on U.S. death certificates and to compute more reliable
estimates, NCHS uses linked death certificate and self-reported census data. NCHS issued a
recent report that provided an adjusted mortality profile for the AI/AN population for 2019.
This report used linked census and National Vital Statistics System (NVSS) mortality data to
assess the level of misclassification by select characteristics, generate correction factors, and
apply these corrections to observed NVSS mortality data. This work produced more reliable
mortality statistics for the AI/AN population. NCHS will continue to expand efforts to correct
misclassification on death certificates.
• CDC continues efforts to promote the adoption of Electronic Case Reporting (eCR). For
example, as of January 1, 2022, eCR is required by the Centers for Medicare & Medicaid
Services’ Promoting Interoperability Program for eligible hospitals and critical access
hospitals and the Merit-Based Incentive Payment System eligible clinicians.
• CDC collaborated with the Council for State and Territorial Epidemiologists (CSTE) on a
survey of jurisdictions to learn their experiences with barriers to collecting and sharing race
and ethnicity data. Released in April 2022, Addressing Gaps in Public Health Reporting of
Race and Ethnicity Data for COVID-19 – Findings & Recommendations Among 45 State &
Local Health Departments findings suggest that multiple factors, including incomplete
healthcare provider and laboratory reporting of race and ethnicity data to public health; the
lack of a modern, interoperable public health data infrastructure; and the need for additional
staff at public health agencies hampered the ability to identify and respond to the enormous
disparities in the impact of COVID-19 on racial and ethnic minority groups. CDC will work
with CSTE to assess next steps based on the recommendations from the Assessment.
2
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OEI-05-20-00540 Appendix | 23
OIG Recommendation (2)
OIG recommends CDC assess the costs and benefits of standardizing and collecting socioeconomic data
at the individual level.
CDC Response:
CDC non-concurs with the OIG recommendation to assess the costs and benefits of standardizing and
collecting socioeconomic data at the individual level for COVID-19 testing, cases, hospitalizations, and
deaths. Throughout the COVID-19 response, CDC has been considering ways to use data to understand
the impact of socioeconomic status and other important factors on COVID-19 outcomes. At this time,
working to improve completeness of existing data fields, using existing data sources for analyses, and
leveraging the data modernization initiative will lead to greater improvements for use of socioeconomic
and related data than conducting the described assessment.
At the same time, CDC strongly agrees that there is value in using socioeconomic data to identify,
understand, and address health disparities. CDC understands the costs and benefits of using these data,
and the agency’s focus is on assessing how to effectively collect and use these data as well as leveraging
existing data, such as the American Community Survey and other population-level data sources.
It is far more economically efficient and feasible to collect community-level socioeconomic data through
surveys than to collect individual-level data and link it to case surveillance data. The latter would require
state and local public health staff to contact individuals to ask questions about their socioeconomic status
and access non-public health databases that they likely do not have access to in order to link
socioeconomic data to case reports. These efforts would require coordination with several other agencies;
CDC could not collect these data independently.
Examples of efforts to use socioeconomic data include a wide range of work by NCHS. NCHS has a
robust data linkage program that links their own population and provider surveys, at the individual person
level, to other sources of health-related data including Medicare and Medicaid health insurance and
federal housing assistance programs to better understand the role of socioeconomic status and social
support programs in individual health outcomes. These linkages create new sources of data that combine
survey reported information on personal and socioeconomic characteristics, health conditions and health
care access and utilization with more detailed information on program participation found in
administrative data files. These linked data resources are used by researchers and other analysts to inform
evidence-based policymaking.
NCHS’s National Health Interview Survey (NHIS) collects information on a variety of income sources as
well as estimates of total combined family income. The NHIS asks adult participants about their work
status in the week before the interview, main reason for not working, hours worked, work benefits for
those working, and days of sick leave taken. The NHIS also asks about educational attainment, measured
as the highest level of school or highest degree completed. On a rotating basis, the NHIS asks about the
sample adult’s occupation, industry, and work activities through a series of questions allowing for
verbatim text responses. Those responses are then coded by statistical clerks at the U.S. Census Bureau
into standardized industry and occupation codes.
NCHS’s National Health and Nutrition Examination Survey (NHANES) collects the following
information on socioeconomic data from survey participants
• Income: annual household income, annual family income; ratio of family income to poverty
• Education: highest grade or level of school completed, or highest degree received
• Employment status.
3
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OEI-05-20-00540 Appendix | 24
NCHS population survey data from NHIS and NHANES can be linked at the person level to death
certificates, administrative data, and other statistical data to understand the health of the American
population.
CDC agrees that socioeconomic data are important in health equity analyses; however, CDC does not
agree with the specific recommendations provided. CDC does not plan to focus on the costs and the
authority to collect standardized socioeconomic data at the individual level for COVID-19 testing, cases,
and hospitalizations. Health equity remains central to CDC’s COVID-19 response and we will continue to
identify existing data sources for community-level analyses as well as linkages, such as those described
above.
Too often, the data needed to support public health actions are neither structured nor standardized and are
not collected in a consistent manner. As part of CDC’s Data Modernization Initiative, CDC is working
with the Office of the National Coordinator for Health Information Technology and state, tribal, local, and
territorial partners via U.S. Core Data for Interoperability (USCDI) and USCDI+ to address these
complex and critical issues. This work will benefit socioeconomic status data in addition to demographic
and other important data.
• Adopting USCDI will help make public health data more compatible with healthcare providers,
payers, and other partners.
• Development of a nationwide forum will enable practitioners to identify mission-critical data
elements and send a consistent signal about what matters and what is most important to public
health. The data identified through USCDI+ will help provide a common baseline to support
public health data sharing more broadly.
• Strengthening existing standards management and harmonization activities across public health
will aid in identifying and overcoming barriers to efficient data sharing.
• Technical support will ensure USCDI and USCDI+ are adopted in ways that help improve the
timeliness, relevance, and reliability of data shared to support public health purposes.
OIG Recommendation (3)
OIG recommends CDC ensures that tribal partners have timely access to all public health data to which
they are entitled.
CDC Response:
CDC concurs with OIG’s recommendation. However, CDC requests OIG revise the language used in this
recommendation to focus specifically on Tribal Epidemiology Centers (TECs) and not on all tribal
partners. As described in Objective 3, OIG focused on TECs, not all tribal partners. CDC requests this
recommendation coincide with the OIG objective and is revised to read: “CDC ensures that Tribal
Epidemiology Centers (TECs) have timely access to all public health data enabling them to fulfill their
public health mission.”
This OIG recommendation aligns with the recommendations that the Government Accountability Office
(GAO) issued to CDC, Indian Health Service, and Health and Human Services (HHS) in its March 2022
report, “Tribal Epidemiology Centers: HHS Actions Needed to Enhance Data Access, GAO-22-104698.”
CDC is committed to ensuring that TECs have access to the epidemiological data they need to ensure they
can fulfill their public health missions.
During the COVID-19 pandemic, CDC has worked with TECs to ensure that they have access to timely
COVID-19 case surveillance and vaccine administration data. Looking beyond the COVID-19 pandemic,
CDC understands that there is a need to ensure a systematic process to share public health data with
TECs. CDC agrees that there is a need to make data sharing easier, less burdensome, and clearer for
4
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OEI-05-20-00540 Appendix | 25
TECs. To implement this recommendation, CDC will utilize the approach for the GAO report and
develop written guidance for TECs on how to request data.
5
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OEI-05-20-00540 Appendix | 26
ACKNOWLEDGMENTS AND CONTACT
Acknowledgments
Nicole Hrycyk served as the team leader for this study, and Abigail Wydra served as
the lead analyst. Others in the Office of Evaluation and Inspections who conducted
the study include Camille Harper, Jonathan Jones, and Rebekah Schwartz. Office of
Evaluation and Inspections staff who provided support include Rob Gibbons and Mike
Novello.
This report was prepared under the direction of Laura Kordish, Regional Inspector
General for Evaluation and Inspections in the Chicago regional office; Adam Freeman,
Deputy Regional Inspector General; and Hilary Slover, Assistant Regional Inspector
General.
Contact
To obtain additional information concerning this report, contact the Office of Public
Affairs at Public.Affairs@oig.hhs.gov. OIG reports and other information can be found
on the OIG website at oig.hhs.gov.
Office of Inspector General
U.S. Department of Health and Human Services
330 Independence Avenue, SW
Washington, DC 20201
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OEI-05-20-00540 Acknowledgments and Contact | 27
ABOUT THE OFFICE OF INSPECTOR GENERAL
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-
452, as amended, is to protect the integrity of the Department of Health and Human
Services (HHS) programs, as well as the health and welfare of beneficiaries served by
those programs. This statutory mission is carried out through a nationwide network
of audits, investigations, and inspections conducted by the following operating
components:
The Office of Audit Services (OAS) provides auditing services for HHS,
either by conducting audits with its own audit resources or by overseeing audit work
done by others. Audits examine the performance of HHS programs and/or its
grantees and contractors in carrying out their respective responsibilities and are
intended to provide independent assessments of HHS programs and operations.
These audits help reduce waste, abuse, and mismanagement and promote economy
and efficiency throughout HHS.
The Office of Evaluation and Inspections (OEI) conducts national
evaluations to provide HHS, Congress, and the public with timely, useful, and reliable
information on significant issues. These evaluations focus on preventing fraud, waste,
or abuse and promoting economy, efficiency, and effectiveness of departmental
programs. To promote impact, OEI reports also present practical recommendations
for improving program operations.
The Office of Investigations (OI) conducts criminal, civil, and administrative
investigations of fraud and misconduct related to HHS programs, operations, and
beneficiaries. With investigators working in all 50 States and the District of Columbia,
OI utilizes its resources by actively coordinating with the Department of Justice and
other Federal, State, and local law enforcement authorities. The investigative efforts
of OI often lead to criminal convictions, administrative sanctions, and/or civil
monetary penalties.
The Office of Counsel to the Inspector General (OCIG) provides
general legal services to OIG, rendering advice and opinions on HHS programs and
operations and providing all legal support for OIG’s internal operations. OCIG
represents OIG in all civil and administrative fraud and abuse cases involving HHS
programs, including False Claims Act, program exclusion, and civil monetary penalty
cases. In connection with these cases, OCIG also negotiates and monitors corporate
integrity agreements. OCIG renders advisory opinions, issues compliance program
guidance, publishes fraud alerts, and provides other guidance to the health care
industry concerning the anti-kickback statute and other OIG enforcement authorities.
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OEI-05-20-00540 About OIG | 28
ENDNOTES
1 CDC, Risk for COVID-19 Infection, Hospitalization, and Death by Race/Ethnicity, updated on July 16, 2021.
Accessed at
https://www.cdc.gov/coronavirus/2019-ncov/covid-data/investigations-discovery/hospitalization-death-by-race-ethnicity.html
on August 9, 2021.
2 Jenny Gathright, “Study Finds Significant Racial, Socioeconomic Disparities In COVID-19 Among Children,” NPR,
August 7, 2020. Accessed at https://www.npr.org/local/305/2020/08/07/900166845/study-finds-significant-racial-
socioeconomic-disparities-in-c-o-v-i-d-19-among-children on August 3, 2021.
3 Michael Schwirtz and Lindsey Rogers Cook, “These N.Y.C. Neighborhoods Have the Highest Rates of Virus Deaths,” New York
Times, May 18, 2020. Accessed at https://www.nytimes.com/2020/05/18/nyregion/coronavirus-deaths-nyc.html on August 3,
2021.
4 CDC, “Race/Ethnicity, Underlying Medical Conditions, Homelessness, and Hospitalization Status of Adult Patients With
COVID-19 at an Urban Safety-Net Medical Center—Boston, Massachusetts, 2020,” MMWR, Vol. 69, No. 27, July 10, 2020, p. 864.
Accessed at https://www.cdc.gov/mmwr/volumes/69/wr/pdfs/mm6927a3-H.pdf on August 26, 2021.
5 CDC, Underlying Medical Conditions Associated With Higher Risk for Severe COVID-19: Information for Healthcare
Professionals, updated on May 13, 2021. Accessed at https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-
care/underlyingconditions.html on August 31, 2021.
6 Brendan Saloner, Kalind Parish, and Julie Ward, “COVID-19 Cases and Deaths in Federal and State Prisons,” JAMA, July 8, 2020.
Accessed at https://jamanetwork.com/journals/jama/fullarticle/2768249 on October 20, 2021.
7 Nidhi Prakhash, “Doctors Are Concerned That Black Communities Might Not Be Getting Access To Coronavirus Tests,”
Buzzfeed News, March 22, 2020. Accessed at https://www.buzzfeednews.com/article/nidhiprakash/coronavirus-tests-covid-19-
black on August 5, 2021.
8 Senator Elizabeth Warren; Representative Ayanna Pressley; two other Senators, and one other Representative, letter to HHS
Secretary Alex M. Azar II, March 27, 2020. Accessed at
https://www.booker.senate.gov/imo/media/doc/2020.03.27%20Letter%20to%20HHS%20re%20racial%20disparities%20in%20C
OVID%20response.pdf on August 5, 2021.
9 Congressional Research Service, Tracking COVID-19: U.S. Public Health Surveillance and Data, R46588, November 2, 2020.
Accessed at https://crsreports.congress.gov/product/pdf/R/R46588 on July 13, 2021.
10 Coronavirus Aid, Relief, and Economic Security (CARES) Act, P.L. No. 116-136 (enacted on March 27, 2020), § 18115(a).
11 HHS, COVID-19 Pandemic Response, Laboratory Data Reporting: CARES Act Section 18115, March 8, 2022. This guidance was
originally issued on June 4, 2020, and updated on March 8, 2022. Accessed at https://www.cdc.gov/coronavirus/2019-
ncov/downloads/lab/HHS-Laboratory-Reporting-Guidance-508.pdf on March 15, 2022.
12 85 Fed. Reg. 27550 (May 8, 2020); See also CMS, State Survey Agency Director memo, May 6, 2020, (QSO-20-29-NH).
Accessed at https://www.cms.gov/files/document/qso-20-29-nh.pdf on August 9, 2021.
13 CDC, Data Modernization Initiative, DMI Basics, The Why, What, and How of Data Modernization, March 2021, p. 6. Accessed
at https://www.cdc.gov/surveillance/pdfs/dmi_basics_external_audiences-March_2021.pdf on August 6, 2021.
14 Ibid, pp. 6–7.
15 Ibid., p. 9; CDC, FY 2020 Operating Plan, p. 3. Accessed at https://www.cdc.gov/budget/documents/fy2020/fy-2020-cdc-
operating-plan.pdf on August 6, 2021.
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OEI-05-20-00540 Endnotes | 29
16 CDC, Data Modernization Initiative, DMI Basics: The Why, What, and How of Data Modernization, March 2021, p. 9. (See
Endnote 13 for URL information.); Coronavirus Aid, Relief, and Economic Security Act (CARES Act), P.L. No. 116-136, (enacted
March 27, 2020). 134 STAT 281, Division B, Title VIII.
17 CDC, Data Modernization Initiative, DMI Basics: The Why, What, and How of Data Modernization, March 2021, p. 9.
(See
Endnote 13 for URL information.); CDC, FY 2021 Operating Plan, p. 3. Accessed at
https://www.cdc.gov/budget/documents/fy2021/FY-2021-CDC-Operating-Plan.pdf on August 6, 2021; American Rescue Plan
Act of 2021, P.L. No. 117-2 (enacted March 11, 2021), § 2404.
18 Please see https://www.cdc.gov/coronavirus/2019-ncov/science/data-improvements.html for more information on CDC’s
data improvement efforts.
19 CDC, COVID-19 Electronic Laboratory Reporting Implementation by State, Footnote. Accessed at
https://www.cdc.gov/coronavirus/2019-ncov/lab/electronic-reporting-map.html on August 6, 2021. See also CDC, Data
Modernization Initiative, DMI Basics: The Why, What, and How of Data Modernization, p. 7. (See Endnote 13 for URL
information.)
20 CDC, CDC’s COVID-19 Data Improvement, updated October 29, 2021. Accessed at https://www.cdc.gov/coronavirus/2019-
ncov/science/data-improvements.html on May 20, 2022. See also CDC, Healthcare Facilities in Production for COVID-19
Electronic Case Reporting, updated on May 13, 2022. Accessed at https://www.cdc.gov/coronavirus/2019-ncov/hcp/electronic-
case-reporting/hcfacilities-map.html on May 20, 2022.
21 CDC, COVID Data Tracker. Accessed at https://covid.cdc.gov/covid-data-tracker/#cases_testsper100k7day on July 19, 2021.
22 HHS, COVID-19 Pandemic Response, Laboratory Data Reporting: CARES Act Section 18115, March 8, 2022. This guidance was
originally issued on June 4, 2020, and updated on March 8, 2022. (See Endnote 11 for URL information.)
23 Congressional Research Service, Tracking COVID-19: U.S Public Health Surveillance and Data, R46588, November 2, 2020.
(See Endnote 9 for URL information.)
24 CDC, Coronavirus Disease 2019 (COVID-19)-Associated Hospitalization Surveillance Network (COVID-NET), August 28, 2020.
Accessed at https://www.cdc.gov/coronavirus/2019-ncov/covid-data/covid-net/purpose-methods.html on September 1, 2021.
25 CDC, “Guidance for Certifying Deaths Due to Coronavirus Disease 2019 (COVID–19),” Vital Statistics Reporting Guidance,
No. 3, April 2020. Accessed at https://www.cdc.gov/nchs/data/nvss/vsrg/vsrg03-508.pdf on July 16, 2021.
26 CDC, Death Edit Specification for the 2003 Revision of the U.S. Standard Certificate of Death, updated on February 18, 2005.
Accessed at https://www.cdc.gov/nchs/data/dvs/death_edit_specifications.pdf on August 31, 2021.
27 GAO, COVID-19: Federal Efforts Could Be Strengthened by Timely and Concerted Actions, GAO-20-701, September 21, 2020.
Accessed at https://www.gao.gov/products/gao-20-701 on November 2, 2021.
28 CARES Act § 18115(a); HHS, COVID-19 Pandemic Response, Laboratory Data Reporting: CARES Act Section 18115, March 8,
2022. This guidance was originally issued on June 4, 2020, and updated on March 8, 2022. (See Endnote 11 for URL
information.)
29 CARES Act § 18115(a); 62 Fed. Reg. 58782 (October 30, 1997); HHS, Implementation Guidance on Data Collection Standards
for Race, Ethnicity, Sex, Primary Language, and Disability Status, p. 3. Accessed at
https://aspe.hhs.gov/sites/default/files/private/pdf/76331/index.pdf on August 6, 2021.
30 CDC, “Human Infection With Coronavirus Disease 2019 (COVID-19) Surveillance Worksheet,” updated May 2022. Accessed
at https://www.cdc.gov/coronavirus/2019-ncov/downloads/php/COVID19-Worksheet-CSV-annotated.pdf on June 9, 2022.
31 CDC, “U.S. Standard Certificate of Death,” revised November 2003.
Accessed at
https://www.cdc.gov/nchs/data/dvs/DEATH11-03final-ACC.pdf on September 1, 2021.
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OEI-05-20-00540 Endnotes | 30
32 CDC, CDC’s Response, Updated February 12, 2021. Accessed at https://www.cdc.gov/coronavirus/2019-
ncov/cdcresponse/index.html on August 3, 2021.
33 The Secretary of Health and Human Services declared a nationwide public health emergency in response to the COVID-19
outbreak on January 31, 2020, retroactive to January 27, 2020. Alex M. Azar II, Secretary, U.S. Department of Health and
Human Services, “Determination that a Public Health Emergency Exists,” January 31, 2020. Accessed at
https://www.phe.gov/emergency/news/healthactions/phe/Pages/2019-nCoV.aspx on February 25, 2021. Secretary Azar
renewed the public health emergency in April 2020, July 2020, October 2020, and January 2021. Secretary Xavier Becerra
renewed it in April 2021, July 2021, October 2021, January 2022, and April 2022. See
https://aspr.hhs.gov/legal/PHE/Pages/COVID19-12Apr2022.aspx,
https://www.phe.gov/emergency/news/healthactions/phe/Pages/covid19-21apr2020.aspx,
https://www.phe.gov/emergency/news/healthactions/phe/Pages/covid19-23June2020.aspx,
https://www.phe.gov/emergency/news/healthactions/phe/Pages/covid19-2Oct2020.aspx,
https://www.phe.gov/emergency/news/healthactions/phe/Pages/covid19-07Jan2021.aspx,
https://www.phe.gov/emergency/news/healthactions/phe/Pages/COVID-15April2021.aspx,
https://www.phe.gov/emergency/news/healthactions/phe/Pages/COVID-19July2021.aspx,
https://www.phe.gov/emergency/news/healthactions/phe/Pages/COVDI-15Oct21.aspx,
https://aspr.hhs.gov/legal/PHE/Pages/COVID19-14Jan2022.aspx, and
https://aspr.hhs.gov/legal/PHE/Pages/COVID19-12Apr2022.aspx.
34 CDC, CDC Emergency Operations Center: How an EOC Works. Accessed at https://www.cdc.gov/cpr/eoc/how-eoc-works.htm
on November 29, 2021.
35 CDC, Report to Congress on Paycheck Protection Program and Health Care Enhancement Act Disaggregated Data on
U.S.
Coronavirus Disease 2019 (COVID-19) Testing, 3rd 30-Day Update, August 2020. Accessed at
https://www.help.senate.gov/download/fy2020-cdc-rtc-on-covid-19-testing-data_3rd-30-day-update_-final on August 4, 2021.
36 CDC, CDC COVID-19 Response
Health Equity Strategy: Accelerating Progress Towards Reducing COVID-19 Disparities and
Achieving Health Equity, July 2020. This strategy was originally issued in July 2020 and updated on August 21, 2020. Accessed
at https://www.cdc.gov/coronavirus/2019-ncov/community/health-equity/cdc-strategy.html on August 9, 2021.
37
Paycheck Protection Program and Health Care Enhancement Act, P.L. No. 116-139 (enacted on April 24, 2020), Division B,
Title I, 134 STAT. 626.
38 American Rescue Plan Act of 2021, P.L. No. 117-2 (enacted on March 11, 2021), § 2501, 135 STAT. 4; HHS, “HHS Announces
$250 Million from American Rescue Plan To Develop and Support a Community-Based Workforce to Increase COVID-19
Vaccinations in Underserved Communities.” Accessed at https://www.hhs.gov/about/news/2021/05/04/hhs-announces-250-
million-from-american-rescue-plan-to-develop-and-support-underserved-communities.html on August 27, 2021.
39 American Rescue Plan Act of 2021, P.L. No. 117-2 (enacted on March
11, 2021), § 2401, 135 STAT. 4; Lisa Cooper, Joshua
Sharfstein, Rachel L.J. Thornton, “What the American Rescue Plan Means for Health Equity,” JAMA Health Forum, Vol. 2, No. 4,
April 1, 2021. Accessed at https://jamanetwork.com/journals/jama-health-forum/fullarticle/2778283 on August 27, 2021.
40 Executive Order No. 13995, published at 86 Fed. Reg. 7193 (January 26, 2021). To view the Health Equity Task Force’s final
report and recommendations, see https://www.minorityhealth.hhs.gov/omh/browse.aspx?lvl=2&lvlid=100.
41 Executive Order No. 13994, published at 86 Fed. Reg. 7189 (January 26, 2021).
42 OIG, Race and Ethnicity Data for Medicare Beneficiaries (OEI-02-21-00100).
Accessed at https://oig.hhs.gov/reports-and-
publications/workplan/summary/wp-summary-0000548.asp on March 16, 2022; OIG, Race and Ethnicity Data for Medicaid
Beneficiaries (OEI-02-22-00130). Accessed at https://oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-
0000641.asp on March 16, 2022.
43
CDC, Report to Congress on Paycheck Protection Program and Health Care Enhancement Act Disaggregated Data on U.S.
Coronavirus Disease 2019 (COVID-19) Testing 20th 30-Day Update, January 2022.
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OEI-05-20-00540 Endnotes | 31
44 62 Fed. Reg. 58782 (October 30, 1997).
45 GAO, COVID-19: Federal Efforts Could Be Strengthened by Timely and Concerted Actions, GAO-20-701, p. 39, September 21,
2020. (See Endnote 27 for URL information.)
46 CDC, “The Validity of Race and Hispanic-origin Reporting on Death Certificates in the United States: An Update,” Vital and
Health Statistics 2, No. 172, August 2016. Accessed at https://www.cdc.gov/nchs/data/series/sr_02/sr02_172.pdf on July 23,
2021. See also CDC, “Health Disparities: Provisional Death Counts for Coronavirus Disease 2019 (COVID-19),” Notes. Accessed
at https://www.cdc.gov/nchs/nvss/vsrr/covid19/health_disparities.htm#Notes on February 23, 2022.
47 CDC, “COVID-19 Among American Indian and Alaska Native Persons—23 States, January 31–July 3, 2020,” MMWR, Vol. 69,
No. 34, August 28, 2020, p. 1166. Accessed at https://www.cdc.gov/mmwr/volumes/69/wr/pdfs/mm6934e1-H.pdf on August 6,
2021.
48 CDC, “Disparities in Incidence of COVID-19 Among Underrepresented Racial/Ethnic Groups in Counties Identified as
Hotspots During June 5–18, 2020—22 States, February–June 2020,” MMWR, Vol. 69, No. 33, August 21, 2020, p. 1122. Accessed
at https://www.cdc.gov/mmwr/volumes/69/wr/pdfs/mm6933e1-H.pdf on August 6, 2021.
49 CDC, Report to Congress on Paycheck Protection Program and Health Care Enhancement Act Disaggregated Data on U.S.
Coronavirus Disease 2019 (COVID-19) Testing, 3rd 30-Day Update, August 2020. (See Endnote 35 for URL information.) See
also CDC, “Counties With High COVID-19 Incidence and Relatively Large Racial and Ethnic Minority Populations—United
States, April 1–December 22, 2020,” MMWR, Vol. 70, No. 13, April 2, 2021, p. 483. Accessed at
https://www.cdc.gov/mmwr/volumes/70/wr/pdfs/mm7013e1-H.pdf on July 7, 2020.
50 CDC, “Mental Health, Substance Use, and Suicidal Ideation During the COVID-19 Pandemic—United States, June 24-30,
2020,” MMWR, Vol. 69, No. 32, August 14, 2020, p. 1052. Accessed at
https://www.cdc.gov/mmwr/volumes/69/wr/pdfs/mm6932a1-H.pdf on July 8, 2021.
51 CDC, How To Report COVID-19 Laboratory Data, Frequently Asked Questions No. 7, updated on January 26, 2021. Accessed
at https://www.cdc.gov/coronavirus/2019-ncov/lab/reporting-lab-data.html on August 10, 2021.
52 HHS, COVID-19 Pandemic Response, Laboratory Data Reporting: CARES Act Section 18115, March 8, 2022. This guidance was
originally issued on June 4, 2020, and updated on March 8, 2022. (See Endnote 11 for URL information.)
53 CDC, How to Report COVID-19 Laboratory Data, updated on January 26, 2021. (See Endnote 50 for URL information.)
54 Ibid.
55 CDC, National Initiative to Address COVID-19 Health Disparities Among Populations at High-Risk and Underserved, Including
Racial and Ethnic Minority Populations and Rural Communities. Accessed at
https://www.cdc.gov/publichealthgateway/partnerships/COVID-19-Health-Disparities-OT21-2103.html on July 7, 2021.
56 CDC, “CDC Plans To Provide $332 Million To Support Community Health Workers for COVID-19 Prevention and Control,”
March 25, 2021. Accessed at https://www.cdc.gov/media/releases/2021/p0325-community-healthworkers-support.html on
December 28, 2021.
57 CDC-RFA-OT21-2103, “National Initiative To Address COVID-19 Health Disparities Among Populations at High-Risk and
Underserved, Including Racial and Ethnic Minority Populations and Rural Communities,” Grant Opportunity, CDC Office for
State, Tribal, Local, and Territorial Support, May 3, 2021. Accessed at https://www.grants.gov/web/grants/view-
opportunity.html?oppId=332034 on July 7, 2021.
58 Lizzie Wade, “COVID-19 data on Native Americans is ‘a national disgrace.’ This scientist is fighting to be counted,” Science,
September 24, 2020. Accessed at https://www.sciencemag.org/news/2020/09/covid-19-data-native-americans-national-
disgrace-scientist-fighting-be-counted on July 9, 2021.
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OEI-05-20-00540 Endnotes | 32
59 Darius Tahir and Adam Cancryn, “American Indian tribes thwarted in efforts to get coronavirus data,” Politico, June 11, 2020.
Accessed at https://www.politico.com/news/2020/06/11/native-american-coronavirus-data-314527 on July 9, 2021.
60 National Indian Health Board, “COVID-19 in Indian Country: The Impact of Federal Broken Promises on Native Americans,”
written testimony submitted to the United States Commission on Civil Rights, July 17, 2020. Accessed at
https://www.nihb.org/covid-19/wp-content/uploads/2020/07/FINAL-NIHB-TESTIMONY-USCCR-COVID19-July-16-2020.pdf on
July 9, 2021.
61 CDC, Tribal Epidemiology Centers Designated as Public Health Authorities Under the Health Insurance Portability and
Accountability Act, April 16, 2015. Accessed at https://www.cdc.gov/phlp/docs/tec-issuebrief.pdf on July 9, 2021; 25 U.S.C.S. §
1621m(e).
62 GAO, Tribal Epidemiology Centers: HHS Actions Needed to Enhance Data Access, GAO-22-104698, March 4, 2022. Accessed at
https://www.gao.gov/products/gao-22-104698 on March 9, 2022.
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OEI-05-20-00540 Endnotes | 33
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