mm7303 H

Morbidity and Mortality Weekly Report
Weekly / Vol. 73 / No. 3 January 25, 2024
Prevalence of Cardiometabolic Diseases Among Racial and Ethnic Subgroups in

Adults — Behavioral Risk Factor Surveillance System, United States, 2013–2021
Alain K. Koyama, ScD1; Kai McKeever Bullard, PhD1; Fang Xu, PhD1; Stephen Onufrak, PhD1; Sandra L. Jackson, PhD2; Ryan Saelee, PhD1;
Yoshihisa Miyamoto, MD, PhD1; Meda E. Pavkov, MD, PhD1
Abstract cardiovascular disease (coronary heart disease, heart failure,

Although diabetes and cardiovascular disease account for or stroke) (1). Few recent studies have provided estimates of
substantial disease prevalence among adults in the United the prevalence of cardiometabolic diseases in disaggregated
States, their prevalence among racial and ethnic subgroups is racial and ethnic subgroups in large nationwide samples (2,3).
inadequately characterized. To fill this gap, CDC described Documentation of racial and ethnic disparities in cardiometa-
the prevalence of diagnosed cardiometabolic diseases among bolic diseases is typically aggregated because sample sizes are
U.S. adults, by disaggregated racial and ethnic subgroups, insufficient or because racial and ethnic subgroup data were not
among 3,970,904 respondents to the Behavioral Risk Factor collected. These limitations can obscure differences in disease
Surveillance System during 2013–2021. Prevalence of each dis- prevalence among disaggregated subgroups that might result
ease (diabetes, myocardial infarction, angina or coronary heart from differences in social determinants of health and other
disease, and stroke), stratified by race and ethnicity, was based drivers of health inequities.
on self-reported diagnosis by a health care professional, adjust- Although racial and ethnic disparities in cardiometabolic
ing for age, sex, and survey year. Overall, mean respondent disease prevalence have been documented,†,§,¶ a disaggregated
age was 47.5 years, and 51.4% of respondents were women. analysis of racial and ethnic groups might better characterize
Prevalence of cardiometabolic diseases among disaggregated
†
race and ethnicity subgroups varied considerably. For example, §
https://www.cdc.gov/diabetes/data/statistics-report/appendix.html#tabs-1-1
https://www.cdc.gov/heartdisease/facts.htm
diabetes prevalence within the aggregated non-Hispanic Asian ¶ https://www.cdc.gov/nchs/data/hus/2018/013.pdf
category (11.5%) ranged from 6.3% in the Vietnamese sub-
group to 15.2% in the Filipino subgroup. Prevalence of angina
or coronary heart disease for the aggregated Hispanic or Latino
category (3.8%) ranged from 3.1% in the Cuban subgroup INSIDE
to 6.3% in the Puerto Rican subgroup. Disaggregation of 57 Underuse of Antiviral Drugs to Prevent Progression
cardiometabolic disease prevalence data by race and ethnicity to Severe COVID-19 — Veterans Health
identified health disparities among subgroups that can be used Administration, March–September 2022
to better help guide prevention programs and develop cultur- 62 Deaths of U.S. Citizens Undergoing Cosmetic
Surgery — Dominican Republic, 2009–2022
ally relevant interventions.
66 Notes from the Field: Nontuberculous Mycobacteria
Infections After Cosmetic Surgery Procedures in
Introduction
Florida — Nine States, 2022–2023
Cardiometabolic diseases affect a substantial proportion 68 QuickStats
of adults in the United States, including approximately 11%
who have diagnosed diabetes,* and 10% who have diagnosed
Continuing Education examination available at
* https://www.cdc.gov/diabetes/data/statistics-report/index.html#anchor_40084 https://www.cdc.gov/mmwr/mmwr_continuingEducation.html
U.S. Department of Health and Human Services

Centers for Disease Control and Prevention
unique patterns of disease prevalence that can more effectively by CDC, deemed not research, and was conducted consistent
guide prevention and treatment strategies in disaggregated with applicable federal law and CDC policy.††
racial and ethnic subgroups at higher risk. To address this gap,
CDC evaluated the prevalence of cardiometabolic diseases Measurements
among selected racial and ethnic subgroups among approxi- Demographic information included age and sex. Respondents
mately 4 million adult respondents to the Behavioral Risk who reported Hispanic or Latino (Hispanic) ethnicity were cat-
Factor Surveillance System (BRFSS) during 2013–2021. egorized as Hispanic regardless of race. Non-Hispanic respon-
dents were categorized by race. Race and ethnicity choices and
Methods corresponding disaggregated subgroups on the questionnaire
included Hispanic (Cuban, Mexican, Puerto Rican, or Other
Study Population
Hispanic), non-Hispanic American Indian or Alaska Native
BRFSS is an annual random-digit–dialed landline and
(AI/AN), non-Hispanic Asian (Asian [Chinese, Filipino,
cellular telephone-based survey representative of noninstitu-
Indian, Japanese, Korean, Vietnamese, or Other Asian]), non-
tionalized adults aged ≥18 years from all 50 states, the District
Hispanic Black or African American (Black), non-Hispanic
of Columbia, and three U.S. territories.** BRFSS includes
Pacific Islander (Pacific Islander [Guamanian or Chamorro,
questions on health-related behavioral risk factors, health care
Native Hawaiian, Samoan, or other Pacific Islander]), non-
access, and chronic conditions. The study period included
Hispanic White (White), non-Hispanic Multiracial, and
2013, the first year that BRFSS collected disaggregated data
non-Hispanic Other. Other variables included weight status
on selected race and ethnicity subgroups, through 2021.
(underweight, normal, overweight, or obesity as determined
Among the 4,030,567 total respondents, the analysis excluded
by body mass index [BMI] in kg/m2 using World Health
58,743 (1.5%) who were missing data on age, sex, or race and
Organization criteria for Asian and non-Asian populations) (4),
ethnicity, and 1,525 (0.4%) who did not include data on any
physical activity (defined as leisure-time physical activity at
cardiometabolic diseases. The analysis included the remaining
least one time in the last month), and smoking status (cur-
3,970,904 (98.5%) respondents. This activity was reviewed
rent, former, or never). Prevalence of cardiometabolic diseases
** https://www.cdc.gov/brfss/about/index.htm †† 45 C.F.R. part 46.102(l)(2), 21 C.F.R. part 56; 42 U.S.C. Sect. 241(d); 5
U.S.C. Sect. 552a; 44 U.S.C. Sect. 3501 et seq.
The MMWR series of publications is published by the Office of Science, Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human
Services, Atlanta, GA 30329-4027.
Suggested citation: [Author names; first three, then et al., if more than six.] [Report title]. MMWR Morb Mortal Wkly Rep 2024;73:[inclusive page numbers].
Centers for Disease Control and Prevention
Mandy K. Cohen, MD, MPH, Director
Debra Houry, MD, MPH, Chief Medical Officer and Deputy Director for Program and Science
Paul Muntner, PhD, MHS, Acting Director, Office of Science
MMWR Editorial and Production Staff (Weekly)

Charlotte K. Kent, PhD, MPH, Editor in Chief Phyllis H. King, Symone Hairston, MPH,
Rachel Gorwitz, MD, MPH, Acting Executive Editor Acting Lead Health Communication Specialist Acting Lead Health Communication Specialist
Jacqueline Gindler, MD, Editor Alexander J. Gottardy, Maureen A. Leahy, Kiana Cohen, MPH,
Cynthia Ogden, PhD, MRP, Guest Science Editor Stephen R. Spriggs, Armina Velarde, Tong Yang, Leslie Hamlin, Lowery Johnson,
Paul Z. Siegel, MD, MPH, Associate Editor Visual Information Specialists Health Communication Specialists
Mary Dott, MD, MPH, Online Editor Quang M. Doan, MBA, Dewin Jimenez, Will Yang, MA,
Terisa F. Rutledge, Managing Editor Terraye M. Starr, Moua Yang, Visual Information Specialists
Teresa M. Hood, MS, Lead Technical Writer-Editor Information Technology Specialists
Glenn Damon, Jacqueline Farley, MS,
Tiana Garrett, PhD, MPH, Ashley Morici,
Stacy Simon, MA, Morgan Thompson,
Suzanne Webb, PhD, MA,
Technical Writer-Editors
MMWR Editorial Board
Timothy F. Jones, MD, Chairman
Matthew L. Boulton, MD, MPH David W. Fleming, MD Patrick L. Remington, MD, MPH
Carolyn Brooks, ScD, MA William E. Halperin, MD, DrPH, MPH Carlos Roig, MS, MA
Virginia A. Caine, MD Jewel Mullen, MD, MPH, MPA William Schaffner, MD
Jonathan E. Fielding, MD, MPH, MBA Jeff Niederdeppe, PhD Morgan Bobb Swanson, MD, PhD
Patricia Quinlisk, MD, MPH
52
US Department of Health and Human Services | Centers for Disease Control and Prevention | MMWR | January 25, 2024 | Vol. 73 | No. 3
(diabetes [excluding gestational diabetes], myocardial infarc- Discussion

tion [MI], angina or coronary heart disease [CHD], or stroke) Findings from this study illustrate pronounced differences
was based on self-reported diagnosis by a physician or other in cardiometabolic disease prevalence among racial and ethnic
health care professional. subgroups, with the largest variation occurring in diabetes
prevalence. Among Hispanic subgroups, diabetes prevalence
Statistical Analysis
was highest for Mexican and Puerto Rican adults and lowest
Prevalence of each cardiometabolic disease was estimated for Cuban adults. Among Asian subgroups, diabetes preva-
from multivariable logistic models adjusted for age, sex, and lence was highest for Filipino and Indian adults and lowest
survey year. Sample weights and design variables were used to for Chinese, Korean, and Vietnamese adults.
account for the complex survey design. Two-sided p-values
<0.05 were considered statistically significant. Analyses Hispanic Subgroups
were conducted using SAS (version 9.4; SAS Institute) and In the current study, although the prevalence of diabetes
SUDAAN (version 11.0.1; Research Triangle Institute). was the same among both Puerto Rican and Mexican adults,
prevalence of angina or CHD was approximately twice as
Results high among Puerto Rican adults. In a cohort study during
Among a total of 3,970,904 adults, the mean respondent age 2008–2011, elevated prevalence of cardiometabolic diseases
was 47.5 years, and 51.4% were women (Table 1). Among both in the Puerto Rican subgroup was associated with a higher
aggregated groups and disaggregated subgroups, the proportion prevalence of cardiovascular risk factors such as smoking (5).
of adults reporting less than a high school education varied Increased acculturation was also associated with a higher preva-
from 2.7% among Korean adults to 41.5% among Mexican lence of cardiovascular disease risk factors (5). Prevalence of
adults. The proportion of adults with obesity ranged from current smoking was higher in the Puerto Rican group than
12.0% among Chinese adults to 51.2% among Samoan adults. in the Mexican group, both in the current study and during
2008–2011. The prevalence of physical activity during the
Diabetes past month was lower in the Puerto Rican group in the current
The overall prevalence of diabetes was 10.9% (Table 2); the study; Puerto Rican adults had higher educational attainment
range among aggregated race and ethnicity groups was from and a slightly lower prevalence of overweight and obesity. It
9.1% among White adults to 16%–17% among AI/AN, Black, is unclear how this overall combination of risk factors might
and Pacific Islander adults. Prevalence was 11.5% for the aggre- explain the observed pattern of cardiometabolic diseases in
gated Asian category; among disaggregated Asian subgroups, the current study.
prevalence ranged from 6.3% for Vietnamese adults to 15.2%
for Filipino adults. Diabetes prevalence among all subgroups Asian and Pacific Islander Subgroups
was highest among Samoan adults (20.3%). A higher prevalence of most cardiometabolic diseases
among Filipino and Indian adults compared with other Asian
Angina, Coronary Heart Disease, Myocardial Infarction, subgroups might be partly attributed to differences in the
and Stroke
prevalences of hypertension, hyperlipidemia, and overweight
The overall prevalence of angina or CHD was 4.1%; the or obesity (2,6). In the current study, prevalence of overweight
range among aggregated race and ethnicity groups was from or obesity was higher among Filipino and Indian adults than
2.8% among Asian adults to 6.1% among AI/AN adults. among other Asian subgroups, as has been reported previ-
Among subgroups, prevalence ranged from 1.1% among ously (2,6). Because of small sample sizes, high variability
Korean adults to 7.2% among Guamanian or Chamorro adults. in prevalence estimates makes subgroup disparities difficult
The prevalence for the aggregated Hispanic category was 3.8% to infer among Pacific Islander adults. In the current study,
and ranged from 3.1% among Cuban adults to 6.3% among educational attainment and prevalence of physical activity in
Puerto Rican adults. Overall prevalence of MI was 4.3%; the past month were higher among Native Hawaiian adults
the pattern of variation among aggregated race and ethnicity compared with other Pacific Islander subgroups, although
groups was similar to that of angina or CHD. Prevalence of variability of prevalence estimates overall was high. Similarly,
stroke was 3.2% overall, ranging from 1.8% among Asian a previous study of 561 patients hospitalized with ischemic
adults to 6.2% among AI/AN adults. stroke suggested that Native Hawaiian adults might have a
more favorable cardiovascular profile than do other Pacific
Islander adults (7).
53
TABLE 1. Characteristics of adults aged ≥18 years, by race and ethnicity — Behavioral Risk Factor Surveillance System, United States,
2013–2021
% (95% CI)
Less than Weight status† Physical Smoking status§
Group Mean age, yrs high school activity in
(no. of persons; %)* (95% CI) Women education Overweight Obese past month¶ Never Former Current
Total (3,970,904) 47.5 51.4 13.6 35.7 30.8 74.9 59.8 24.2 15.9
(47.5–47.6) (51.3–51.5) (13.5–13.7) (35.6–35.8) (30.7–30.9) (74.8–75.0) (59.7–60.0) (24.1–24.3) (15.9–16.0)
American Indian or 46.3 49.8 20.3 33.6 37.1 71.6 46.3 24.7 28.9
Alaska Native, NH (46.0–46.6) (48.9–50.6) (19.6–21.1) (32.8–34.4) (36.2–37.9) (70.8–72.4) (45.5–47.2) (24.0–25.5) (28.1–29.7)
(66,022; 1.0%)
Asian, NH 40.9 50.1 4.7 41.5 20.5 79.9 80.2 12.2 7.6
(90,298; 5.3%) (40.7–41.2) (49.4–50.8) (4.4–5.1) (40.7–42.2) (19.9–21.0) (79.4–80.5) (79.6–80.8) (11.7–12.6) (7.3–8.0)
Chinese 39.5 52.6 3.1 38.1 12.0 81.6 85.3 8.6 6.1
(14,035; 1.0%) (38.9–40.0) (51.0–54.1) (2.5–3.9) (36.5–39.8) (10.9–13.2) (80.2–82.8) (84.1–86.5) (7.7–9.6) (5.4–6.9)
Filipino 45.7 59.9 6.1 43.0 27.4 77.8 75.2 15.7 9.0
(17,063; 0.7%) (44.9–46.5) (57.9–61.8) (5.1–7.2) (41.0–45.2) (25.6–29.3) (76.1–79.5) (73.4–77.0) (14.3–17.2) (7.9–10.3)
Indian 40.4 43.0 3.7 46.6 22.5 80.4 84.9 9.5 5.6
(17,851; 1.2%) (40.0–40.8) (41.7–44.4) (3.2–4.3) (45.2–48.0) (21.3–23.7) (79.3–81.5) (84.0–85.8) (8.8–10.2) (5.1–6.2)
Japanese 55.4 57.6 3.8 36.8 25.8 80.7 61.9 28.7 9.4
(12,663; 0.3%) (54.4–56.4) (54.8–60.4) (2.7–5.3) (34.0–39.6) (23.1–28.7) (78.3–82.9) (58.9–64.8) (26.0–31.5) (7.7–11.5)
Korean 37.4 50.6 2.7 40.1 16.1 81.6 68.5 18.0 13.5
(4,355; 0.3%) (36.4–38.3) (47.6–53.6) (2.0–3.7) (37.0–43.3) (14.0–18.4) (78.9–84.0) (65.7–71.1) (15.9–20.4) (11.7–15.5)
Vietnamese 36.8 46.9 7.0 37.6 13.5 78.3 81.3 9.7 9.0
(3,142; 0.3%) (35.7–37.8) (43.5–50.2) (4.8–10.2) (34.4–40.9) (11.6–15.6) (75.6–80.7) (78.7–83.6) (8.0–11.8) (7.4–10.9)
Other Asian 39.1 49.0 6.0 40.8 22.5 79.2 80.4 11.5 8.1
(21,189; 1.5%) (38.6–39.6) (47.6–50.4) (5.3–6.8) (39.4–42.2) (21.3–23.7) (78.1–80.3) (79.3–81.5) (10.6–12.4) (7.4–8.7)
Black or African 45.7 54.2 14.4 33.5 39.6 70.1 65.9 16.0 18.1
American, NH (45.6–45.8) (53.8–54.5) (14.1–14.6) (33.2–33.8) (39.2–39.9) (69.8–70.4) (65.5–66.2) (15.8–16.2) (17.9–18.4)
(315,725; 11.8%)
Pacific Islander, NH 40.6 49.1 11.8 32.6 35.5 76.7 62.3 18.8 19.0
(16,421; 0.2%) (40.1–41.2) (47.3–50.8) (10.7–13.0) (30.9–34.4) (33.8–37.3) (75.2–78.2) (60.5–64.0) (17.4–20.2) (17.6–20.4)
Guamanian or 42.0 50.6 18.9 36.8 40.6 72.5 53.6 18.1 28.3
Chamorro (40.7–43.3) (46.6–54.6) (16.3–21.9) (32.4–41.4) (36.8–44.5) (69.1–75.6) (49.7–57.5) (15.6–20.9) (25.0–31.7)
(5,163; 0.02%)
Native Hawaiian 43.6 51.1 8.3 32.7 38.1 79.3 55.2 24.7 20.1
(3,411; 0.04%) (42.4–44.8) (47.6–54.6) (6.6–10.3) (29.5–36.1) (34.9–41.5) (76.3–82.1) (51.7–58.8) (21.8–27.8) (17.3–23.2)
Samoan 37.6 42.8 10.5 29.2 51.2 75.5 56.5 17.7 25.8
(938; 0.02%) (36.2–39.0) (36.9–49.0) (7.5–14.4) (23.4–35.7) (44.5–57.8) (70.0–80.3) (49.9–62.8) (12.6–24.3) (21.0–31.3)
Other Pacific Islander 40.0 49.1 11.6 32.3 31.7 77.0 66.6 17.5 16.0
(6,909; 0.1%) (39.3–40.8) (46.6–51.5) (10.0–13.3) (30.0–34.7) (29.4–34.1) (74.8–79.0) (64.1–68.9) (15.7–19.4) (14.2–17.9)
White, NH 50.3 51.4 8.3 35.3 29.3 77.0 54.6 28.6 16.7
(3,041,848; 62.8%) (50.2–50.3) (51.3–51.5) (8.2–8.4) (35.2–35.5) (29.2–29.4) (76.9–77.1) (54.5–54.7) (28.5–28.7) (16.7–16.8)
Hispanic or Latino 41.3 50.3 35.5 37.3 33.6 68.4 70.7 16.9 12.5
(333,673; 17.0%) (41.2–41.4) (50.0–50.7) (35.2–35.8) (36.9–37.6) (33.3–34.0) (68.1–68.7) (70.3–71.0) (16.6–17.1) (12.2–12.7)
Cuban 47.9 49.2 18.9 37.8 30.7 65.6 62.6 20.0 17.4
(7,566; 0.5%) (47.0–48.8) (46.9–51.5) (17.0–21.0) (35.4–40.2) (28.5–33.1) (63.2–67.9) (60.2–64.9) (18.1–21.9) (15.6–19.5)
Mexican 40.4 49.8 41.5 37.5 36.2 69.6 71.5 16.3 12.2
(149,206; 9.2%) (40.2–40.5) (49.3–50.3) (41.0–42.0) (37.0–38.1) (35.7–36.7) (69.1–70.1) (71.1–72.0) (16.0–16.7) (11.8–12.5)
Puerto Rican 44.8 52.9 22.9 35.5 33.1 61.1 65.4 19.0 15.6
(75,871; 2.4%) (44.6–45.0) (52.3–53.5) (22.4–23.5) (34.9–36.2) (32.5–33.7) (60.5–61.7) (64.8–66.0) (18.5–19.5) (15.1–16.1)
Other Hispanic or 40.7 50.2 32.4 37.6 29.4 70.2 72.7 16.5 10.8
Latino (40.5–40.9) (49.6–50.8) (31.8–33.0) (37.0–38.2) (28.8–30.0) (69.6–70.7) (72.1–73.2) (16.1–17.0) (10.4–11.2)
(101,030; 4.9%)
Multiracial, NH 42.3 51.3 11.2 32.2 31.8 78.2 53.6 23.2 23.3
(80,117; 1.4%) (42.0–42.6) (50.6–52.1) (10.7–11.8) (31.5–32.9) (31.1–32.5) (77.6–78.8) (52.8–54.3) (22.5–23.8) (22.6–23.9)
Other, NH 47.8 46.3 12.7 35.8 27.5 75.0 59.2 23.0 17.8
(26,800; 0.5%) (47.4–48.3) (45.1–47.5) (11.8–13.6) (34.6–37.0) (26.3–28.6) (74.0–76.0) (58.0–60.4) (22.0–24.1) (16.8–18.7)
Abbreviation: NH = non-Hispanic.
* Row percentages are weighted and represent the proportion of the total population for each group or disaggregated subgroup.
† Categories are based on World Health Organization thresholds of body mass index (kg/m2) (non-Asian: <18.5 [underweight], 18.5–24.9 [normal], 25.0–29.9 [overweight],
≥30 [obese]; Asian: <18.5 [underweight], 18.5–22.9 [normal], 23.0–27.4 [overweight], or ≥27.5 [obese]).
§ Current smokers are defined as respondents who reported having smoked at least 100 cigarettes in their lifetime and now smoke every day or some days. Former
smokers are those who reported having smoked at least 100 cigarettes in their lifetime and currently do not smoke. Never smokers are those who reported they
had not smoked at least 100 cigarettes in their lifetime.
¶ Defined as self-reported leisure-time physical activity at least once in the past month.
54
TABLE 2. Adjusted prevalence of cardiometabolic diseases among adults aged ≥18 years, by race and ethnicity — Behavioral Risk Factor
Surveillance System, United States, 2013–2021
% (95% CI)*
Angina or coronary
Group (no. of persons) Diabetes heart disease Myocardial infarction Stroke
Total (3,970,904) 10.9 (10.8–11.0) 4.1 (4.1–4.2) 4.3 (4.3–4.3) 3.2 (3.1–3.2)
American Indian or Alaska Native, NH (66,022) 16.8 (16.2–17.4) 6.1 (5.7–6.4) 7.9 (7.5–8.3) 6.2 (5.9–6.6)
Asian, NH (90,298) 11.5 (11.0–12.0) 2.8 (2.5–3.1) 2.6 (2.4–2.9) 1.8 (1.6–2.1)
Chinese (14,035) 7.0 (6.1–8.1) 1.7 (1.3–2.4) 1.7 (1.3–2.3) 1.3 (1.0–1.8)
Filipino (17,063) 15.2 (13.8–16.8) 3.6 (2.9–4.6) 3.1 (2.3–4.1) 2.4 (1.8–3.2)
Indian (17,851) 14.7 (13.7–15.7) 3.5 (2.9–4.1) 3.3 (2.8–4.0) 1.4 (1.1–1.8)
Japanese (12,663) 9.6 (8.1–11.4) 2.2 (1.6–3.1) 1.9 (1.3–2.8) 2.1 (1.5–2.9)
Korean (4,355) 7.2 (5.8–9.0) 1.1 (0.7–1.8) 1.7 (1.1–2.5) 3.0 (1.5–5.8)†
Vietnamese (3,142) 6.3 (4.7–8.4) 1.7 (0.9–3.1) 2.3 (1.3–3.9) 2.0 (1.1–3.5)
Other Asian (21,189) 11.8 (10.8–13.0) 3.0 (2.4–3.6) 2.9 (2.4–3.4) 1.8 (1.4–2.3)
Black or African American, NH (315,725) 16.2 (16.0–16.4) 4.1 (3.9–4.2) 4.6 (4.4–4.7) 5.0 (4.9–5.1)
Pacific Islander, NH (16,421) 16.6 (15.2–18.0) 5.1 (4.1–6.3) 5.4 (4.5–6.4) 4.3 (3.6–5.3)
Guamanian or Chamorro (5,163) 19.9 (17.1–23.1) 7.2 (4.8–10.7) 6.1 (4.7–8.0) 5.8 (3.9–8.6)
Native Hawaiian (3,411) 14.6 (12.1–17.4) 5.6 (3.7–8.4) 7.6 (5.5–10.4) 6.1 (4.2–8.9)
Samoan (938) 20.3 (14.8–27.1) 5.1 (2.8–9.2)† 5.6 (3.5–8.8) 4.3 (2.6–7.1)
Other Pacific Islander (6,909) 16.0 (14.2–18.0) 4.5 (3.2–6.2) 4.5 (3.3–6.0) 3.4 (2.5–4.6)
White, NH (3,041,848) 9.1 (9.0–9.1) 4.2 (4.2–4.3) 4.2 (4.2–4.3) 2.9 (2.9–3.0)
Hispanic or Latino (333,673) 15.3 (15.1–15.6) 3.8 (3.7–4.0) 4.4 (4.3–4.6) 2.9 (2.8–3.0)
Cuban (7,566) 11.0 (9.7–12.4) 3.1 (2.3–4.0) 4.5 (3.6–5.5) 2.4 (1.8–3.1)
Mexican (149,206) 16.7 (16.3–17.1) 3.2 (2.9–3.4) 4.1 (3.9–4.3) 2.8 (2.6–3.0)
Puerto Rican (75,871) 16.7 (16.2–17.1) 6.3 (6.0–6.6) 5.3 (5.0–5.6) 3.2 (2.9–3.5)
Other Hispanic or Latino (101,030) 12.6 (12.2–13.1) 3.5 (3.3–3.8) 4.4 (4.2–4.7) 3.0 (2.8–3.2)
Multiracial, NH (80,117) 12.8 (12.3–13.3) 5.6 (5.3–6.0) 6.5 (6.1–6.9) 5.4 (5.1–5.8)
Other, NH (26,800) 11.3 (10.6–12.0) 4.4 (4.0–4.8) 4.6 (4.2–5.0) 3.9 (3.5–4.4)
Abbreviation: NH = non-Hispanic.
* Prevalence is adjusted for age, sex, and survey year. Each cardiometabolic disease (diabetes, myocardial infarction, angina or coronary heart disease, or stroke) is
based on self-reported diagnosis by a health care professional.
† Estimate has a relative SE ≥0.30 and is therefore considered statistically unreliable.
Cardiometabolic Disease and BMI did not collect disaggregated data for AI/AN (e.g., by tribal
Evidence suggests that a specific distribution of ectopic fat as affiliation or tribal enrollment status), Black, and White adults,
a measure of adiposity might be a stronger marker of cardio- potential subgroup disparities could not be assessed among
metabolic diseases than BMI (8). The generally low BMI but these groups. Finally, information was not available on other
high diabetes risk among Asian populations (9) might provide relevant factors related to disaggregated race and ethnicity, such
unique opportunities to better understand diabetes etiology as country of birth or English language proficiency.
and shed light on the paradoxical continuing increase in obesity
rates§§ concurrent with recent declining diabetes incidence in Implications for Public Health Practice
the United States.¶¶ Continued collection and analysis of disaggregated data
could enable more accurate characterization of racial and
Limitations ethnic disparities in cardiometabolic diseases among U.S.
The findings in this report are subject to at least three adults. Collection of clinical data with comparable definitions
limitations. First, self-reported information might be sub- of race and ethnicity might allow comparison of prevalence
ject to bias, including underreporting of disease prevalence. estimates with self-reported data. Further, as availability of
Underreporting, such as that associated with undiagnosed disaggregated data increases, increased use of such data might
disease, might affect prevalence estimates to different degrees allow implementation of better tailored disease prevention and
in different groups. Second, because the survey questionnaire management programs. A greater body of evidence might allow
an evaluation of how best to implement and financially sustain
§§ https://www.cdc.gov/nchs/data/hus/2019/026-508.pdf these programs, train staff members in cultural competency,
¶¶ https://www.cdc.gov/diabetes/data/statistics-report/index.html#anchor_63700 and maximize the effectiveness in reducing health disparities.
55
References
Summary
1. Tsao CW, Aday AW, Almarzooq ZI, et al.; American Heart Association
What is already known about this topic? Council on Epidemiology and Prevention Statistics Committee and Stroke
Diabetes and cardiovascular disease account for substantial Statistics Subcommittee. Heart disease and stroke statistics—2023 update: a
disease prevalence among U.S. adults. report from the American Heart Association. Circulation 2023;147:e93–621.
PMID:36695182 https://doi.org/10.1161/CIR.0000000000001123
What is added by this report? 2. Satish P, Sadaf MI, Valero-Elizondo J, et al. Heterogeneity in cardio-
In this survey of nearly 4 million U.S. adults, prevalence of metabolic risk factors and atherosclerotic cardiovascular disease among
diagnosed cardiometabolic diseases varied up to twofold Asian groups in the United States. Am J Prev Cardiol 2021;7:100219.
among disaggregated racial and ethnic subgroups. Diabetes PMID:34611645 https://doi.org/10.1016/j.ajpc.2021.100219
prevalence among U.S. Asian subgroups ranged from 6.3% 3. Shah NS, Luncheon C, Kandula NR, Cho P, Loustalot F, Fang J. Self-
reported diabetes prevalence in Asian American subgroups: Behavioral
among Vietnamese adults to 15.2% among Filipino adults.
Risk Factor Surveillance System, 2013–2019. J Gen Intern Med
Among U.S. Hispanic or Latino subgroups, prevalence of angina 2022;37:1902–9. PMID:34109541 https://doi.org/10.1007/
or coronary heart disease ranged from 3.1% among Cuban s11606-021-06909-z
adults to 6.3% among Puerto Rican adults. 4. WHO Expert Consultation. Appropriate body-mass index for Asian
What are the implications for public health practice? populations and its implications for policy and intervention strategies.
Lancet 2004;363:157–63. PMID:14726171 https://doi.org/10.1016/
Disaggregated categories of race and ethnicity are crucial in S0140-6736(03)15268-3
accurately identifying and addressing disparities in cardiometa- 5. Daviglus ML, Talavera GA, Avilés-Santa ML, et al. Prevalence of major
bolic diseases and can be used to help guide prevention cardiovascular risk factors and cardiovascular diseases among Hispanic/
programs and development of culturally relevant interventions Latino individuals of diverse backgrounds in the United States. JAMA
among U.S. adults. 2012;308:1775–84. PMID:23117778 https://doi.org/10.1001/
jama.2012.14517
6. Singh GK, Lin SC. Dramatic increases in obesity and overweight
Corresponding author: Alain K. Koyama, akoyama@cdc.gov. prevalence among Asian subgroups in the United States, 1992–2011.
1Division of Diabetes Translation, National Center for Chronic Disease
ISRN Prev Med 2013;2013:898691. PMID:24967142 https://doi.
org/10.5402/2013/898691
Prevention and Health Promotion, CDC; 2Division for Heart Disease and 7. Nakagawa K, MacDonald PR, Asai SM. Stroke disparities: disaggregating
Stroke Prevention, National Center for Chronic Disease Prevention and Health Native Hawaiians from other Pacific Islanders. Ethn Dis 2015;25:157–61.
Promotion, CDC.
PMID:26118142
All authors have completed and submitted the International 8. Neeland IJ, Ross R, Després JP, et al.; International Atherosclerosis Society;
Committee of Medical Journal Editors form for disclosure of potential International Chair on Cardiometabolic Risk Working Group on Visceral
Obesity. Visceral and ectopic fat, atherosclerosis, and cardiometabolic
conflicts of interest. No potential conflicts of interest were disclosed. disease: a position statement. Lancet Diabetes Endocrinol 2019;7:715–25.
PMID:31301983 https://doi.org/10.1016/S2213-8587(19)30084-1
9. Kanaya AM, Hsing AW, Panapasa SV, et al. Knowledge gaps, challenges,
and opportunities in health and prevention research for Asian Americans,
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Institutes of Health workshop. Ann Intern Med 2022;175:574–89.
PMID:34978851 https://doi.org/10.7326/m21-3729
56
Underuse of Antiviral Drugs to Prevent Progression to Severe COVID-19 —

Veterans Health Administration, March–September 2022
Paul A. Monach, MD, PhD1,2,3; Sonia T. Anand, PhD1; Nathanael R. Fillmore, PhD1,3,4; Jennifer La, PhD1; Westyn Branch-Elliman, MD1,2,3,5
Abstract by late 2022, monoclonal antibodies had lost activity against

Antiviral drugs reduce the rate of progression to severe prevalent variants (2).
COVID-19 when given to patients with mild-to-moderate Despite demonstrated effectiveness and guideline endorse-
disease within 5 days of symptom onset. Despite being rec- ment (3,4), use of antiviral medications appears to be con-
ommended for patients at high risk for progression to severe siderably lower than expected, based on the prevalence of
COVID-19 because of age or chronic conditions, reported risk factors for severe COVID-19. A recent study of patients
antiviral use among the general adult population has been in the Veterans Health Administration (VA) reported use of
≤35%. To ascertain reasons for underuse of antiviral medica- outpatient antiviral medications among 24% of all docu-
tions to prevent severe COVID-19 and propose interventions mented SARS-CoV-2 infections in 2022, remaining at that
accordingly, a detailed review was conducted of 110 Veterans level through early 2023 (5). Description of the untreated
Health Administration patients with mild-to-moderate infec- comparison group clearly showed that many patients would
tion at high risk for progression because of underlying condi- have met treatment criteria. Similar overall rates of use (maxi-
tions (organ transplantation or hematologic malignancies) who mum = 34%) were observed in a large cohort from health care
did not receive an antiviral drug. Among these 110 patients, systems participating in the National Patient-Centered Clinical
all of whom had received COVID-19 vaccine, 22 (20.0%) Research Network (PCORnet) (6).
were offered treatment but declined, and 88 (80.0%) were To identify barriers to antiviral use that might be addressed
not offered treatment. Among the 88 patients not offered through novel implementation strategies, a sample of VA
treatment, provider reasons included symptom duration of patients with COVID-19 was reviewed to ascertain the rea-
>5 days (22.7%), concern about possible drug interactions sons for the nontreatment of patients with mild-to-moderate
(5.7%), or absence of symptoms (22.7%); however, among disease at the time of initial evaluation and testing. These
nearly one half (43 of 88; 48.9%) of these patients, no reason patients had all received COVID-19 vaccination and had one
other than mild symptoms was given. Among 24 (55.8%) of of three relatively common conditions associated with severe
those 43 patients, follow-up was limited to telephone calls to immunocompromise, placing them at risk for progression
report test results and inquire about symptom evolution, with to severe COVID-19 despite vaccination (solid organ trans-
no documentation of treatment being offered. These findings plantation, chronic lymphocytic leukemia [CLL], or plasma
suggest that education of patients, providers, and medical cell malignancies).
personnel tasked with follow-up calls, combined with advance
planning in the event of a positive test result, might improve Methods
the rate of recommended antiviral medication use to prevent Study Cohort and Patient Characteristics
severe COVID-19–associated illness, including death. Data on vaccination and SARS-CoV-2 infection and
demographic and clinical data were obtained from the VA
Introduction COVID-19 Shared Data Resource (7) and from electronic
Use of the antiviral drugs nirmatrelvir/ritonavir (Paxlovid) medical records (EMRs) and vital status in the Corporate Data
and remdesivir (Veklury) is approved by the Food and Drug Warehouse, respectively. The VA Joint Legacy Viewer interface,
Administration (FDA); molnupiravir (Lagevrio) is authorized a web application that provides an integrated read-only view
for emergency use.* These antiviral medications reduce the risk of EMR data from the VA, Department of Defense, and com-
of hospitalization and death and are recommended for patients munity partners†,§ was used for chart review.
with mild-to-moderate COVID-19 who are at high risk for
progression to severe COVID-19 because of age or medical † https://www.va.gov/vdl/documents/Clinical/Joint_Longitudinal_Viewer_
conditions (1). All three of these drugs have retained activity (JLV)/jlv_2_9_ug.pdf
§ Care at a non-VA facility is not always documented in patients’ records.
against different circulating SARS-CoV-2 variants. In contrast, Although some patients might have received care at a non-VA facility, all
110 patients included in the analysis had sufficient VA data to be classified.
* https://www.fda.gov/media/155055/download Patients whose records suggested that they might have received an antiviral
elsewhere were excluded from the analysis.
57
The first date of a documented positive SARS-CoV-2 test assigned number until the target number of cases meeting
result was used to define infection after vaccination. Data criteria for inclusion was obtained.
were limited to infections documented from March 1, 2022 After chart review, patients were included in the analysis of
(when effective oral antivirals became widely available to treat reasons for nonreceipt of antiviral medication if the patients
outpatients with mild-to-moderate COVID-19) (5), through met the following criteria: 1) confirmation of a diagnosis of
September 30, 2022. Patients with a diagnosis of solid organ solid organ transplantation, CLL, or plasma cell malignancy;
transplantation, CLL, or plasma cell malignancies were ini- 2) confirmation of no evidence of antiviral use at either a VA
tially identified by single use of International Classification or non-VA facility; and 3) initial medical evaluation of mild-
of Diseases, Tenth Revision (ICD-10) codes during January 1, to-moderate COVID-19. Review proceeded until 110 cases
2021–September 30, 2022. Use of immunosuppressive or meeting inclusion criteria were classified. A target of 100 cases
antineoplastic drugs was ascertained 3–12 months before the was chosen to allow reasonable precision in estimating the fre-
date of infection (depending on the drug). Nonuse of oral quency of a common event (for example, an outcome of 28%
(by outpatient pharmacy dispensing records) or intravenous would have a 95% CI of 20%–36%) for a time-intensive pro-
antiviral drugs (by orders placed) was preliminarily ascertained cess. The aim was to include similar numbers of cases of solid
from 5 days before (to identify treatment based on a non-VA organ transplantation and hematologic malignancies (includ-
test) to 28 days after the VA test. The electronic search for pre- ing numbers of patient with CLL or plasma cell malignancies).
scription of an antiviral was limited to nirmatrelvir/ritonavir,
molnupiravir, and monoclonal antibodies, because pharmacy Data Analysis
records preclude distinguishing between remdesivir use to treat A member of the study team conducted chart review and
versus prevent severe COVID-19 (5). Severe COVID-19 was classified each case using the following criteria: 1) antiviral
defined as 1) death within 28 days after the positive test result, was offered, and the patient declined treatment; or antiviral
or 2) hospitalization with either use of dexamethasone or evi- was not offered because of 2) symptom duration >5 days;
dence of at least mild hypoxemia (minimum oxygen saturation 3) concern about drug interactions expressed by the provider;
<94% or any use of supplemental oxygen) (8). 4) administrative barriers or delays; or 5) not determined to
Comorbidities were defined using ICD-10 codes per the be indicated because of mild or asymptomatic disease, with
Chronic Conditions Warehouse¶ during the 12 months preced- the option for antiviral treatment either rejected by the pro-
ing initial vaccination.** Presence of comorbidities was sum- vider or not mentioned. Reference to a patient’s or provider’s
marized as a count (0–6) of six chronic conditions that have concern for Paxlovid rebound (a phenomenon of temporary
been associated with severe COVID-19 after vaccination (8,9). recurrence of symptoms shortly after completing a standard
To improve representativeness of the high-risk VA population 5-day Paxlovid treatment) was also recorded.
and to reduce the prevalence of missing data, the study was Among cases that were reviewed but did not meet inclusion
limited to patients who had documentation of either 2 doses criteria for analysis, the proportion for which an antiviral was
of an mRNA COVID-19 vaccine or 1 dose of an adenoviral received for mild-to-moderate COVID-19 but was not discern-
COVID-19 vaccine. ible from the initial electronic screen of EMR (e.g., remdesivir
given for 3 days, or an oral antiviral given in the emergency
Sampling and Inclusion Criteria department or through a non-VA pharmacy) was determined,
The full cohort comprised 1,196 VA patients who received to better estimate under usage of antivirals. This activity was
a vaccination for COVID-19; had an ICD-10 code indicating determined to be exempt from Institutional Review Board
solid organ transplantation, CLL, or plasma cell malignancy; (IRB) oversight or a requirement for informed consent by the
and had received a positive SARS-CoV-2 test result during IRB of the VA Boston Healthcare System.††
March 1–September 30, 2022. A random sample of patients
without EMR evidence of prescription of antiviral medication Results
was then selected for detailed chart review. To obtain a random Patient Characteristics
sample, a random number was assigned to each case, and cases
Among all 1,196 patients, 96% were male, nearly two
were reviewed in sequential order beginning with the lowest
thirds (64%) were non-Hispanic White, and 84% had
¶ https://www2.ccwdata.org/web/guest/home/
received a COVID-19 vaccine booster dose (Table 1).
** Comorbidities included Alzheimer disease and other forms of dementia, Those with solid organ transplantation (317) were younger
chronic kidney disease, chronic obstructive pulmonary disease or (mean age = 64.6 years) than were the 472 patients with CLL
bronchiectasis, diabetes, heart failure, and peripheral vascular disease.
†† 38 C.F.R 16.104d(4)iii.
58
TABLE 1. Demographic and clinical characteristics of COVID-19–vaccinated veterans with selected immunosuppressive conditions and mild-
to-moderate or asymptomatic COVID-19* — Veterans Health Administration, United States, March–September 2022
No. (%)
Total Solid organ transplantation Chronic lymphocytic leukemia Plasma cell malignancy
All cases Reviewed† All cases Reviewed† All cases Reviewed† All cases Reviewed†
Characteristic N = 1,196 n = 110 N = 317 n = 50 N = 472 n = 30 N = 407 n = 30
Age, yrs, mean (SD) 71.6 (10.9) 70.5 (11.0) 64.6 (10.5) 65.1 (10.9) 75.3 (9.7) 78.3 (9.2) 72.7 (9.9) 71.8 (7.2)
Male sex 1,146 (95.8) 101 (91.8) 294 (92.7) 45 (90.0) 457 (96.8) 26 (86.7) 395 (97.1) 30 (100)
Race and ethnicity§
Asian 7 (0.6) 1 (0.9) 5 (1.6) 1 (2.0) 1 (0.2) 0 (—) 1 (0.2) 0 (—)
Black or African American 333 (27.8) 43 (39.1) 109 (34.4) 19 (38.0) 69 (14.6) 9 (30.0) 155 (38.1) 15 (50.0)
Native American or 15 (1.3) 1 (0.9) 3 (0.9) 0 (—) 3 (0.6) 1 (3.3) 9 (2.2) 0 (—)
Hawaiian
White 766 (64.0) 61 (55.5) 170 (53.6) 28 (56.0) 373 (79.0) 19 (63.3) 223 (54.8) 14 (46.7)
Hispanic or Latino 91 (7.6) 11 (10.0) 29 (9.1) 8 (16.0) 27 (5.7) 3 (10.0) 35 (8.6) 0 (—)
Unknown 75 (6.3) 4 (3.6) 30 (2.5) 2 (4.0) 26 (5.5) 1 (3.3) 19 (4.7) 1 (3.3)
U.S. region where primary vaccination series was completed¶
Continental 179 (15.0) 12 (10.9) 44 (13.9) 5 (20.0) 69 (14.6) 2 (6.7) 66 (16.2) 5 (16.7)
Midwest 202 (16.9) 16 (14.5) 47 (14.8) 3 (6.0) 97 (20.6) 6 (20.0) 58 (14.3) 7 (23.3)
North Atlantic 294 (24.6) 28 (25.5) 86 (27.1) 13 (26.0) 110 (23.3) 10 (33.3) 98 (24.1) 5 (16.7)
Pacific 228 (19.0) 21 (19.1) 69 (21.8) 8 (16.0) 92 (19.5) 7 (23.3) 67 (16.5) 6 (20.0)
Southeast 287 (24.0) 33 (30.0) 70 (22.1) 21 (42.0) 103 (21.8) 5 (16.7) 114 (28.0) 7 (23.3)
Unknown 6 (0.5) 0 (—) 1 (0.3) 0 (—) 1 (0.2) 0 (—) 4 (1.0) 0 (—)
Vaccine booster** 1,003 (83.9) 90 (81.8) 272 (85.8) 40 (80.0) 384 (81.4) 22 (73.3) 347 (85.3) 28 (93.3)
Comorbidity score (0–6),†† 1.3 (1.2) 1.2 (1.0) 1.7 (1.0) 1.7 (0.7) 1.1 (1.2) 0.8 (1.0) 1.2 (1.2) 0.9 (1.0)
mean (SD)
Antiviral drug received§§ 335 (28.0) 0 (—) 94 (29.7) 0 (—) 148 (31.4) 0 (—) 93 (22.9) 0 (—)
Severe COVID-19¶¶ 207 (17.3) 12 (10.9) 42 (13.2) 4 (8.0) 94 (19.9) 5 (16.7) 71 (17.4) 3 (10.0)
Death*** 30 (2.5) 2 (1.8) 8 (2.5) 0 (—) 11 (2.3) 2 (6.7) 11 (2.7) 0 (—)
Abbreviation: VA = Veterans Health Administration.
* First documented SARS-CoV-2 infection after vaccination.
† All patients in the reviewed subcohorts had mild-to-moderate COVID-19 or asymptomatic infection at the time of initial evaluation and were not given antiviral drugs.
§ VA patients self-report Hispanic or Latino (Hispanic) ethnicity separately from race; therefore, Hispanic patients are also included in the race categories. Persons
of Hispanic origin might be of any race but are categorized as Hispanic; all racial groups are non-Hispanic.
¶ Continental: Arkansas, Colorado, Louisiana, Mississippi, Montana, Oklahoma, Texas, Utah, and Wyoming; Midwest: Illinois, Indiana, Michigan, Minnesota, Missouri,
Nebraska, North Dakota, Ohio, South Dakota, and Wisconsin; North Atlantic: Connecticut, Delaware, District of Columbia, Maine, Maryland, Massachusetts, New
Hampshire, New Jersey, New York, North Carolina, Pennsylvania, Rhode Island, Vermont, Virginia, and West Virginia; Pacific: Alaska, Arizona, California, Hawaii,
Idaho, Nevada, New Mexico, Oregon, and Washington; and Southeast: Alabama, Florida, Georgia, Kentucky, Puerto Rico, South Carolina, and Tennessee.
** Receipt of ≥1 additional vaccine dose after completion of the initial vaccination series; no attempt was made to determine the number of additional doses.
†† Based on number of persons with the following six comorbidities: Alzheimer disease or other dementias, chronic kidney disease, chronic obstructive pulmonary
disease, diabetes, heart failure, and peripheral vascular disease.
§§ Using VA pharmacy records, which do not detect prescriptions sent to non-VA pharmacies nor some medications given in the emergency department.
¶¶ Within 28 days of the positive results of SARS-CoV-2 test performed at the VA.
*** Defined as either death within 28 days of the positive results of SARS-CoV-2 test performed at the VA, or hospitalization with either administration of dexamethasone
or evidence of hypoxemia (minimum pulse oximetry <94% or any use of supplemental oxygen).
(75.3 years) or the 407 patients with plasma cell malignancies to determine whether disease was severe at initial evaluation
(72.7 years). All patients with solid organ transplantation and or whether mild-to-moderate disease later progressed to severe
most patients with CLL (67.4%) or plasma cell malignancies disease. Thirty (2.5%) patients died within 28 days of the
(81.8%) were currently receiving immunosuppressive or anti- positive SARS-CoV-2 test result.
neoplastic medications (Supplementary Table; https://stacks.
cdc.gov/view/cdc/141955). Overall, 861 (72.0%) patients Reasons for Not Administering Antiviral Medications
were initially classified in EMR as not having received antiviral Among 110 patients with mild-to-moderate COVID-19
drugs, including 223 (70.3%) with solid organ transplanta- at initial evaluation who did not receive antiviral drugs, 22
tion, 324 (68.6%) with CLL, and 314 (77.1%) with plasma (20.0%) were offered treatment but declined (Table 2). Among
cell malignancies. Among the 207 (17.3%) patients who met the 88 who were not offered antiviral treatment, 20 (22.7%
criteria for severe COVID-19 (including 42 [13.2%] with [18.2% of all 110 who did not receive antiviral drugs]) were
solid organ transplantation, 94 [19.9%] with CLL, and 71 not offered treatment because symptoms had been present for
[17.4%] with plasma cell malignancies), it was not possible >5 days, and five (5.7% [4.5%]) were not offered treatment
59
TABLE 2. Reasons for nonreceipt of antiviral medication among COVID-19–vaccinated veterans with mild-to-moderate or asymptomatic
COVID-19 and immunosuppressive conditions — Veterans Health Administration, United States, March–September 2022
Diagnosis, no. (%)
All Solid organ transplantation Plasma cell malignancy CLL
Reason for nonreceipt of antiviral drug N = 110 n = 50 n = 30 n = 30
Antiviral offered (22)
Patient declined 22 (20.0) 13 (26.0) 7 (23.3) 2 (6.7)
Antiviral not offered (88)
Symptom duration of >5 days 20 (18.2) 7 (14.0) 3 (10.0) 10 (33.3)
Concern about drug interaction* 5 (4.5) 3 (6.0) 0 (—) 2 (6.7)
Concern about Paxlovid rebound† 0 (—) 0 (—) 0 (—) 0 (—)
Patient asymptomatic§ 20 (18.2) 10 (20.0) 6 (20.0) 4 (13.3)
Mild-to-moderate disease or reason not mentioned 43 (39.1) 17 (34.0) 14 (46.7) 12 (40.0)
Telephone follow-up only§ 24 (21.8) 11 (22.0) 5 (16.7) 8 (26.7)
Abbreviation: CLL = chronic lymphocytic leukemia.
* The drug interactions noted were of ritonavir with tacrolimus for all three patients with solid organ transplantation. Among the patients with CLL, the interaction
was ritonavir with a statin in one patient and not specified in the other patient.
† A phenomenon in which symptoms recur after having resolved during a standard 5-day treatment with Paxlovid.
§ Description as asymptomatic or with the only follow-up of a positive SARS-CoV-2 test result by telephone are not mutually exclusive; among other cases, test results
were obtained while the patient was present, either in the hospital, emergency department, or urgent care.
because of concern about possible drug interactions (in three (5.7%), or asymptomatic infection (22.7%), with no reason
cases, tacrolimus and ritonavir). In 63 cases (71.6% [57.3%]), other than mild symptoms given for 43 of 88 (48.9%) cases.
no treatment was offered because the patient was considered Limited information is available on reasons for failure to
asymptomatic (20 cases) or had mild disease (43 cases). In prescribe antivirals to eligible patients with COVID-19.
no cases was concern about Paxlovid rebound mentioned as Algorithms to determine these reasons using EMR review
a reason for patient or provider deciding against treatment. would have to be based entirely on text data; therefore, mea-
Sixteen of the asymptomatic infections were detected by hos- sures to develop them would likely be prone to bias. VA EMR
pital, emergency department, or transplant clinic screening data also underestimate antiviral use, because chart review iden-
procedures, or before elective procedures; 24 patients with tified evidence of antiviral therapy in 16.3% of reviewed cases
mild illness received follow-up from clinical staff members in which antiviral therapy was not detected through the initial
only by telephone, with no documented reference to possible EMR-based algorithm. Thus, reported use among 23.9% of
antiviral treatment. the general VA population (5) and 28.0% seen in this study
The study required review of 233 cases to obtain 110 that are both underestimates, but the proportion of eligible patients
met inclusion criteria for analysis. The 123 excluded cases who are not offered an antiviral is still substantial.
included 38 (16.3% of all 233 cases reviewed) in which chart
review determined that an antiviral drug was given during Limitations
mild-to-moderate COVID-19, although this had not been The findings in this report are subject to at least six limita-
detected in the initial EMR screen. The undetected treatments tions. First, the study was conducted among a population of
included an outpatient regimen of remdesivir (23 patients), patients who were at particularly high risk for severe disease;
delivery of a monoclonal antibody at a VA (4 patients) or drivers of limited antiviral use might be different among popu-
non-VA facility (1 patient), or delivery of an oral antiviral at lations at lower, but still substantial, risk. Second, these results
a VA facility (4 patients) or non-VA pharmacy (6 patients). might not be applicable to non-VA health care systems. For
example, results could differ in systems that do not routinely
Discussion test all patients at hospital admission, that rely on offsite
During March–September 2022, among 110 patients in the private pharmacies for prescriptions, that do not adhere to
VA system with solid organ transplantation, CLL, or plasma recommended timelines for antiviral treatment, or that have
cell malignancies who had previously received a COVID-19 no standardized mechanisms for communicating with patients
vaccine but who did not receive antiviral treatment after after positive test results. Rates of prescription of antiviral
receiving positive SARS-CoV-2 test results during a mild-to- medications could be higher in other health care systems,
moderate or asymptomatic infection, 20% were offered treat- but available data suggest prescription rates were similar in
ment and declined. The remainder were not offered treatment the VA and U.S. systems participating in PCORnet through
because symptoms were present for >5 days (22.7% of those not mid-2022 (5,6). Third, results might not be generalizable to
offered treatment), concern about possible drug interactions women or to persons of Hispanic, Asian, or Native American
60
Corresponding author: Paul A. Monach, Paul.Monach@va.gov.

Summary
1VA Boston Cooperative Studies Program, Boston, Massachusetts; 2Department
What is already known about this topic?
of Medicine, VA Boston Healthcare System, Boston, Massachusetts; 3Harvard
Antiviral drugs reduce progression to severe COVID-19 among Medical School, Boston, Massachusetts; 4Dana-Farber Cancer Institute, Boston,
high-risk patients with nonsevere disease; however, reported Massachusetts; 5 VA Boston Center for Healthcare Organization &
use is low. Implementation Research, Boston, Massachusetts.
What is added by this report? All authors have completed and submitted the International
Review of 110 immunosuppressed patients with nonsevere Committee of Medical Journal Editors form for disclosure of potential
COVID-19 at risk for progression who did not receive an antiviral conflicts of interest. Paul A. Monach reports institutional support from
drug found that 80% were not offered such treatment. For Gilead Sciences, consulting fees from HI-Bio, and honorarium from
nearly one half of these, the only reason given for not offering Brigham and Women’s Hospital for Continuing Medical Education
antiviral treatment was mild symptoms. Other reasons included lecture on Intensive Review of Internal Medicine (2023). Westyn
symptom duration >5 days (22.7%), lack of symptoms (22.7%), Branch-Elliman reports institutional support from Gilead Sciences.
and concern about drug interactions (5.7%). One fifth of the No other potential conflicts of interest were disclosed.
110 patients were offered treatment but declined.
What are the implications for public health practice? References
Education of providers, patients, and staff members tasked with 1. National Institutes of Health. Coronovirus disease 2019 (COVID-19)
follow-up calls might increase use of antiviral medications for treatment guidelines. Washington, DC: US Department of Health and
mild-to-moderate COVID-19, especially if combined with Human Services, National Institutes of Health; 2023. https://www.
covid19treatmentguidelines.nih.gov/
advance planning for possible antiviral treatment at the time of
2. National Institutes of Health. COVID-19 treatment guidelines: anti-
testing or earlier. SARS-CoV-2 monoclonal antibodies. Washington, DC: US Department
of Health and Human Services, National Institutes of Health; 2023.
https://www.covid19treatmentguidelines.nih.gov/therapies/antivirals-
ethnicity and race, and who were underrepresented or not including-antibody-products/anti-sars-cov-2-monoclonal-antibodies/
represented in this study. Fourth, EMRs underestimated anti- 3. CDC. COVID-19. Interim clinical considerations for COVID-19
viral use and have other limitations. However, focus on chart treatment in outpatients. Atlanta, GA: US Department of Health and
review ensured that all patients 1) had solid organ transplants, Human Services, CDC; 2023. Accessed February 10, 2023. https://www.
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CLL, or plasma cell malignancies; 2) had SARS-CoV-2 infec- overview.html
tion; 3) were evaluated during mild-to-moderate COVID-19; 4. Infectious Diseases Society of America. IDSA guidelines on the
and 4) did not receive an antiviral. Fifth, chart review, when treatment and management of patients with COVID-19. Arlington, VA:
Infectious Diseases Society of America; 2021. https://www.idsociety.org/
it focuses on information not available through electronic practice-guideline/covid-19-guideline-treatment-and-management/#null
searches, involves subjective judgment and limits the numbers 5. Yan L, Streja E, Li Y, et al. Anti–SARS-CoV-2 pharmacotherapies among
of cases that can be assessed. Accordingly, a research question nonhospitalized US veterans, January 2022 to January 2023. JAMA Netw
Open 2023;6:e2331249. PMID:37651140 https://doi.org/10.1001/
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8. Vo AD, La J, Wu JT, et al. Factors associated with severe COVID-19
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ous discussions about antivirals and have decided they would 9. Agrawal U, Bedston S, McCowan C, et al. Severe COVID-19
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about the indications for antiviral treatment to reduce risk for
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information and a plan in place regarding antiviral treatment.
61
Deaths of U.S. Citizens Undergoing Cosmetic Surgery —

Dominican Republic, 2009–2022
Matthew Hudson, MD1,2; Jose A. Matos, MD3; Bianca Alvarez, MD4; Jacqueline Safstrom, MPH1; Francisco Torres, MD3; Sharmeen Premjee, MPA4;
Luis Bonilla, MD, PhD4; Benjamin Park, MD1; Elizabeth Bancroft, MD1,*; Macarena Garcia, DrPH4,*
Abstract from a variety of sources including families, funeral homes,

Although infections resulting from cosmetic surgery per- and the Instituto Nacional de Ciencias Forenses (National
formed outside the United States have been regularly reported, Institute of Forensic Sciences), which conducts autopsies on
deaths have rarely been identified. During 2009–2022, 93 U.S. all foreign citizens who die within the Dominican Republic.
citizens died after receiving cosmetic surgery in the Dominican During 2009–2018, a mean of 4.1 deaths in U.S. citizens who
Republic. The number of deaths increased from a mean of had received cosmetic surgery in the Dominican Republic
4.1 per year during 2009–2018 to a mean of 13.0 during occurred each year (range = 1–8 deaths); however, the number
2019–2022 with a peak in of 17 in 2020. A subset of post- of cosmetic surgery–associated deaths increased to 12 in 2019
cosmetic surgery deaths occurring during peak years was inves- and 17 in 2020. Because of this increase, the U.S. Embassy con-
tigated, and most deaths were found to be the result of embolic tacted CDC. In collaboration with the Dominican Republic
events (fat emboli or venous thromboembolism) for which Ministry of Health (MOH), CDC launched an investigation
a high proportion of the patients who died had risk factors, to identify the etiology and epidemiology of and preventable
including obesity and having multiple procedures performed risk factors for death among U.S. citizens who underwent
during the same operation. These risk factors might have been cosmetic surgery in the Dominican Republic.
mitigated or prevented with improved surgical protocols and
postoperative medical care, including prophylactic measures Methods
against venous thromboembolism. U.S. citizens interested in A case was defined as a death occurring in a U.S. citizen
receiving elective cosmetic surgery outside the United States who had received cosmetic surgery in the Dominican Republic
should consult with their health care professionals regarding within the preceding 3 weeks and who died in the Dominican
their risk for adverse outcomes. Public health authorities can Republic during 2009–2022.† Cosmetic surgical procedures
support provider education on the importance of preopera- were defined as all procedures falling under the American
tive patient evaluation and the potential danger of performing Society of Plastic Surgeons’ designations as cosmetic surgery,
multiple cosmetic procedures in one operation. such as breast procedures, abdominoplasty, liposuction, and
gluteal augmentation (3). CDC analyzed the number of
Introduction deaths collected by the Consular Section at the U.S. Embassy,
Traveling to another country to receive medical care (medical conducted a review of available medical and autopsy reports
tourism), including travel related to cosmetic surgery, is increas- provided by the MOH during 2019–2020, and extracted
ingly common among U.S. residents because the cost is lower information on known risk factors for perioperative death.
and wait times for procedures are shorter than in the United This activity was reviewed by CDC, deemed not research,
States (1). The Dominican Republic is popular for medical and was conducted consistent with applicable federal law and
tourism because it is close to the United States, has an existing CDC policy.§
tourism infrastructure, and some doctors from the Dominican
Republic advertise in the United States. Since 2003, CDC has Results
documented adverse events occurring in U.S. citizens after A total of 93 cosmetic surgery–related deaths of U.S. citizens
cosmetic surgery in the Dominican Republic (2). Most reports in the Dominican Republic occurred during 2009–2022; all
of adverse events after medical tourism for cosmetic surgery but one occurred in women. The mean decedent age was
have cited infections; deaths have rarely been reported (1).
Since 2009, the Consular Section of the U.S. Embassy in the † The Dominican Republic MOH is aware of 70–80 clinics that provide plastic
Dominican Republic has recorded cosmetic surgery–associated surgery; however, how many of these clinics provide plastic surgery to medical
tourists, including to those who are U.S. citizens, is unknown. In addition, the
deaths among U.S. citizens. Notices of deaths are obtained number of private cosmetic surgeons who might operate outside of a clinic
setting is unknown.
§ 45 C.F.R. part 46, 21 C.F.R. part 56; 42 U.S.C. Sect. 241(d); 5 U.S.C. Sect.
* These senior authors contributed equally to this report.
552a; 44 U.S.C. Sect. 3501 et seq.
62
40 years (range = 19–69 years). The number of deaths varied to death was 2.8 days (range = 0–18 days). Nine surgical
from one to 17 per year, with the peak in 2020 (Figure). clinics were linked to the deaths; two clinics were linked
to two or more deaths.
Patient Characteristics
Medical records were available for 24 (83%) of the 29 deaths Cause of Death
that occurred during 2019–2020, including 10 in 2019 and 14 Autopsy reports were available for 20 (83%) cases with medi-
in 2020 (Table). All 24 deaths occurred in women; the mean cal records; all autopsy-confirmed deaths were attributed to
age was 41 years (range = 26–61 years), and the mean body intraoperative and postoperative complications. Fat embolism
mass index (BMI) was 32 kg/m2 (range = 24–44 kg/m2); in was the cause of death in 11 (55%) of 20 cases and pulmonary
22 (92%) cases, comorbid conditions associated with increased venous thromboembolism in seven (35%).
risk for venous thromboembolism were reported. Among
23 decedents with information on BMI available, 22 (96%) Discussion
had overweight or obesity,¶ two of 24 (8%) reported diabetes A total of 93 U.S. citizens were reported to have died in the
mellitus, three (13%) reported current tobacco use, and two Dominican Republic during 2009–2022 soon after receiving
(8%) reported current use of oral contraceptives. No other cosmetic surgery. Medical records were available for 24 of
patient-specific risk factors for venous thromboembolism 29 decedents during 2019–2020, most of whom were young
were identified. A preoperative evaluation by a cardiologist to middle-aged women. Among the 20 fatalities during 2019–
was documented for 18 (75%) of the 24 decedents and by a 2020 with an autopsy report available for review, 18 (90%)
pulmonologist for 11 (46%). deaths were attributed to embolic phenomena. A large propor-
tion of decedents had personal (92%) or procedural (100%)
Procedures risk factors for perioperative embolism. Among deaths due to
Liposuction was performed in all 24 fatal cases (100%), glu- fat emboli, all patients had undergone liposuction and gluteal
teal fat transfer in 22 (92%), abdominoplasty in 14 (58%), and fat transfer. Fat embolism is a recognized risk associated with
breast augmentation in 11 (46%). A mean of three procedures fat injections, particularly as used in gluteal augmentation, a
(range = two to four) were performed for each decedent procedure in which fat is harvested from the patient and then
during surgery. In 14 (58%) cases, death occurred within injected into the buttocks to augment the body silhouette (4).
24 hours of surgery; the mean interval from procedure Recommendations to avoid injecting the fat into the deep
¶ Overweight is defined as a BMI = 25.0–29.9 kg/m2; obesity is defined as a
muscular layers of the buttocks to reduce the possibility of fat
BMI ≥30 kg/m2. https://www.cdc.gov/obesity/basics/adult-defining.html embolism have been previously published (4,5). Risk factors
FIGURE. Perioperative cosmetic surgery–related deaths*,† among U.S. citizens, by year (N = 93) — Dominican Republic, 2009–2022
18
16
14
12
No. of deaths
10
0
2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022
Year
* Data provided by the U.S. Embassy Consular Section, Santo Domingo, Dominican Republic.
† Deaths occurring among U.S. citizens, in the Dominican Republic, within 3 weeks of the cosmetic surgical procedure.
63
TABLE. Characteristics of perioperative deaths associated with cosmetic anticoagulant and antithrombotic agents) to protect against
surgery procedures performed among U.S. citizens* (N = 24) — periprocedural venous thromboembolism†† (9). The findings
Dominican Republic, 2019–2020
in this report highlight the importance of considering patient
No. (%)
and operative risk factors when determining whether to pro-
Characteristic Total 2019 2020
ceed with elective cosmetic surgery.
Total no. of decedents 24 (100) 10 (40) 14 (60)
Female sex 24 (100) 10 (100) 14 (100) Limitations
Mean BMI† (range) 32 (24–44) 31 (25–38) 32 (24–44)
The findings in this report are subject to at least three limitations.
Mean age (range) 41 (26–61) 40 (26–61) 41 (29–55)
Risk factor for venous thromboembolism
First, no reliable statistics on the number of U.S. citizens who receive
BMI ≥25 kg/m2,† no./No. 22/23 (96) 10/10 (100) 12/13 (92) cosmetic surgery in the Dominican Republic each year are available,
Aged ≥40 years 12 (50) 4 (40) 8 (57) precluding calculation of the risk for perioperative death. Second,
Diabetes mellitus 2 (8) 1 (10) 1 (7)
Current tobacco use 3 (13) 1 (10) 2 (14) this report might be an underestimate of the number of deaths
Current oral contraceptive use 2 (8) 0 (—) 2 (14) among U.S. citizens receiving cosmetic surgery in the Dominican
Body (trunk) procedure§ 24 (100) 10 (100) 14 (100) Republic because it only included deaths that were reported to
≥2 procedures 24 (100) 10 (100) 14 (100)
≥3 procedures 18 (75) 5 (50) 13 (93) the U.S. Embassy. Other investigators have documented adverse
Preoperative evaluation documented outcomes from cosmetic surgeries performed in the Dominican
Cardiologist 18 (75) 8 (80) 10 (71) Republic that were only recognized after the patient had returned
Pulmonologist 11 (46) 4 (40) 7 (50)
to the United States (1,2). Finally, perioperative deaths are rare
Procedure
Liposuction 24 (100) 10 (100) 14 (100) complications of cosmetic surgery, and this report does not address
Gluteal fat transfer 22 (92) 9 (90) 13 (93) other well-documented adverse events such as postsurgical infections
Abdominoplasty 14 (58) 4 (40) 10 (71)
Breast augmentation or reduction 11 (46) 3 (30) 8 (57)
that can result in substantial morbidity (1,2).
No. of procedures performed, mean 3.0 (2–4) 2.6 (2–4) 3.2 (2–4)
(range) per decedent Implications for Public Health Practice
Timing of death Public health departments can make recommendations to
Death within 24 hours 14 (58) 4 (40) 10 (71)
Interval from procedure to death, 2.8 (0–18) 3.3 (0–12) 2.4 (0–18) improve medical care within their jurisdictions, and surveil-
days, mean (range) lance can identify new or ongoing health concerns. In 2019,
Cause of death available from 20 (83) 8 (80) 12 (86) the Dominican Republic MOH issued safety and quality rec-
autopsy report
Fat embolism 11 (55) 5 (63) 6 (50) ommendations to cosmetic surgeons, including training and
Pulmonary venous thromboembolism 7 (35) 2 (25) 5 (42) licensure requirements, specific recommendations for patients
Hemorrhagic shock 1 (5) 0 (—) 1 (8)
Sepsis¶ 1 (5) 1 (13) 0 (—)
to have cardiac and pulmonary evaluations before surgery, and
that no more than two major procedures should be scheduled
Abbreviation: BMI = body mass index.
* Information was available for 24 of 29 deaths that occurred in 2019 and 2020. during one operation (5). After CDC shared preliminary results
† BMI missing for one record from 2020.
§ Body (trunk) procedures included abdominoplasty, liposuction, gluteal fat
of the investigation of cosmetic surgery–associated deaths,
transfer, and breast augmentation or reduction. the MOH distributed the safety and quality guidelines (5) to
¶ Due to intestinal perforation.
cosmetic surgeons in the country, made monitoring visits to
77 facilities that offered cosmetic surgery, and certified infec-
for venous thromboembolism in this report included BMI
tion control committees for high volume cosmetic surgery cen-
≥25 kg/m2 (96% of patients), aged ≥40 years (50%), having
ters. The MOH created a multilateral commission, including
undergone procedures on the trunk of the body (100%), or
representatives from the Dominican Society of Plastic Surgery,
having undergone two or more procedures during the same
to review perioperative adverse events, including deaths, and
operation (100%) (6–8). Preoperative ascertainment of patient
recommend disciplinary or administrative sanctions when
risk for venous thromboembolism should be considered an
warranted. Results of ongoing passive surveillance by the
expected standard of care during the preoperative evaluation
Dominican Republic government are provided to the U.S.
and can be accomplished using validated risk-assessment
Embassy regarding deaths of U.S. citizens after medical care.
models (e.g., Caprini score)** to help guide and incorporate
As a result of this investigation, the U.S. State Department
the appropriate use of mechanical methods (e.g., early ambu-
updated the Medical Tourism and Elective Surgery advisory on
lation or compression devices) and chemoprophylaxis (e.g.,
the website of the U.S. Embassy in the Dominican Republic§§
** https://capriniriskscore.org/ †† https://pubmed.ncbi.nlm.nih.gov/37882602/; https://doi.org/10.1002/
aorn.14019
§§ https://do.usembassy.gov/services/medical-assistance
64
1Division of Healthcare Quality Promotion, National Center for Emerging

Summary Zoonotic and Infectious Diseases, CDC; 2Epidemic Intelligence Service, CDC;
What is already known about this topic? 3Dominican Republic Ministry of Health, Santo Domingo, Dominican Republic;
4CDC Dominican Republic Country Office, Global Health Center, CDC.
Infections regularly occur after cosmetic surgery performed
outside the United States, but deaths are rarely reported. All authors have completed and submitted the International
What is added by this report? Committee of Medical Journal Editors form for disclosure of potential
The number of deaths after cosmetic surgery among U.S. citizens conflicts of interest. No potential conflicts of interest were disclosed.
in the Dominican Republic increased from a mean of 4.1 per year
References
during 2009–2018 to a mean of 13.0 during 2019–2022 with a
peak in of 17 in 2020. A review of the 29 deaths during 2019– 1. McAuliffe PB, Muss TEL, Desai AA, Talwar AA, Broach RB,
2020 revealed that the deaths were associated with fat or venous Fischer JP. Complications of aesthetic surgical tourism treated in
thromboembolism. A high proportion of patients who died had the USA: a systematic review. Aesthetic Plast Surg 2023;47:455–64.
PMID:36315261 https://doi.org/10.1007/s00266-022-03041-z
risk factors for embolism, including obesity and having multiple
2. CDC. Brief report: nontuberculous mycobacterial infections after
procedures performed during the same operation. cosmetic surgery—Santo Domingo, Dominican Republic, 2003–2004.
What are the implications for public health practice? MMWR Morb Mortal Wkly Rep 2004;53:509. PMID:15201844
3. American Society of Plastic Surgeons. Cosmetic procedures: list of
Persons interested in cosmetic surgery should discuss the risks
procedures. Arlington Heights, IL: American Society of Plastic Surgeons;
with their regular medical professional. Public health authorities 2024. https://www.plasticsurgery.org/cosmetic-procedures
can support provider education on the importance of preopera- 4. O’Neill RC, Abu-Ghname A, Davis MJ, Chamata E, Rammos CK,
tive patient evaluation and the potential danger of performing Winocour SJ. The role of fat grafting in buttock augmentation.
multiple cosmetic procedures in one operation. Semin Plast Surg 2020;34:38–46. PMID:32071578 https://doi.
org/10.1055/s-0039-3401038
5. Pública S. Resolución No. 000006 del 26/06/2019 de carácter transitorio
to provide a list of steps to take to reduce the risk for adverse que pone en vigencia una serie de medidas para garantizar la seguridad
outcomes, including a recommendation to obtain interna- del paciente en cirugías plásticas de tipo estético. Santo Domingo,
tional travel insurance to cover medical evacuation back to Dominican Republic: Gobierno de la República Dominicana, Salud
Pública; 2019. https://repositorio.msp.gob.do/handle/123456789/1472
the United States. 6. Winocour J, Gupta V, Kaoutzanis C, et al. Venous thromboembolism
U.S. citizens considering cosmetic surgery abroad should in the cosmetic patient: analysis of 129,007 patients. Aesthet Surg J
consult with their primary health professionals about their 2017;37:337–49. PMID:28207041 https://doi.org/10.1093/asj/sjw173
7. Valente DS, Carvalho LA, Zanella RK, Valente S. Venous thromboembolism
inherent risk for adverse events after surgery and preventive following elective aesthetic plastic surgery: a longitudinal prospective study
measures they can take to reduce the risk. They should con- in 1254 patients. Plast Surg Int 2014;2014:565793. PMID:25374678
sult with a travel medicine specialist ≥1 month before travel, https://doi.org/10.1155/2014/565793
8. Gupta V, Winocour J, Rodriguez-Feo C, et al. Safety of aesthetic surgery
and, as air travel and surgery independently increase the risk in the overweight patient: analysis of 127,961 patients. Aesthet Surg J
for blood clots, patients should allow adequate time between 2016;36:718–29. PMID:26895958 https://doi.org/10.1093/asj/sjv268
flying to and from a destination for surgery to reduce the risk 9. Bartlett MA, Mauck KF, Stephenson CR, Ganesh R, Daniels PR.
for complications (10). Perioperative venous thromboembolism prophylaxis. Mayo Clin
Proc 2020;95:2775–98. PMID:33276846 https://doi.org/10.1016/j.
mayocp.2020.06.015
Acknowledgment
10. Crist M, Appiah G, Leidel L, Stoney R. Traveler’s health: medical
Consular Section, U.S. Embassy, Santo Domingo, Dominican Republic. tourism. In: CDC Yellow Book 2024. Atlanta, GA: US Department
of Health and Human Services, CDC; 2024. https://wwwnc.cdc.gov/
Corresponding author: Elizabeth Bancroft, ebancroft@cdc.gov.
travel/yellowbook/2020/travel-for-work-other-reasons/medical-tourism
65
Notes from the Field
Nontuberculous Mycobacteria Infections After to symptom onset was 69 days (range = 33–119 days). Patients
Cosmetic Surgery Procedures in Florida — Nine reported swelling, purulent drainage, redness, or pain at surgi-
States, 2022–2023 cal sites. Pharmaceutical treatments for M. abscessus included
Katharine E. Saunders, DNP1,2; Juliana M. Reyes, MS2; Lorrie Cyril, MPH2; oral and intravenous antibiotics with prolonged courses up to
Molly Mitchell, PhD3; Stephanie Colter, DrPH2; Jalysa Erskine, MPH2; 2–6 months. In addition to prescribing medication, health
Kiara X. McNamara, DNP4; Jennifer C. Hunter, DrPH4; care providers performed incision, drainage, and debridement.
Kiran M. Perkins, MD4; Argentina Charles, MPH2
(Table). Seven patients’ wound isolates were available for
Introduction TABLE. Demographic and epidemiologic characteristics of patients

Mycobacterium abscessus is a species of intrinsically multi- with nontuberculous mycobacteria infections after receiving
drug–resistant, rapidly growing nontuberculous mycobacteria cosmetic surgery at clinic A (N = 15) — Florida, 2022–2023
(NTM) known to cause health care–associated infections (1) Characteristic No. (%)
and implicated in skin and soft tissue infections after cosmetic Sex
Male 0 (—)
surgical procedures (2,3). On February 7, 2023, CDC notified Female 15 (100)
the Florida Department of Health (FDOH) of a non-Florida Race or ethnicity
resident with NTM infection after a cosmetic procedure at a Black or African American, non-Hispanic 3 (20)
surgery clinic (clinic A) in south Florida. FDOH and CDC White, non-Hispanic 1 (7)
White, Hispanic or Latino 2 (13)
issued national Epidemic Information Exchange (Epi-X) Hispanic or Latino 1 (7)
notices in March 2023 (http://www.cdc.gov/epix) to identify Unknown 8 (53)
additional infections. During the ensuing investigation in Age group, yrs
18–29 4 (27)
March 2023, FDOH identified a total of 15 NTM infections 30–39 8 (53)
in patients who underwent surgical procedures by a plastic 40–49 2 (13)
surgeon in solo practice at clinic A, an alternative practice 50–59 1 (7)
State of residence
location that was used during renovation of the permanent California 4 (27)
facility (clinic B). Florida 4 (27)
Illinois 1 (7)
Kansas 1 (7)
Investigation and Outcomes Massachusetts 1 (7)
Missouri 1 (7)
Case Definition Texas 1 (7)
A case was defined as the isolation of M. abscessus from Washington 1 (7)
Wisconsin 1 (7)
a wound culture obtained from a patient who underwent
Wound site
a cosmetic procedure at clinic A during August–December Buttocks 10 (67)
2022. Among 19 reported infections, a total of 15 patients Abdomen 3 (20)
(including the index patient) from nine U.S. states met the case Hip 1 (7)
Breast 1 (7)
definition (Table). The other four patients experienced signs Procedure performed*
and symptoms of postsurgical infection but lacked confirma- Liposuction 15 (100)
tory laboratory results and were not included in the analysis. Gluteal augmentation with autologous fat transfer 12 (80)
Abdominoplasty 2 (13)
This activity was reviewed by CDC, deemed not research, Breast reduction or lift 1 (7)
and was conducted consistent with applicable federal law and More than one procedure 14 (93)
CDC policy.* Outcome
Required intravenous antibiotics 6 (40)
Required additional interventions† 4 (27)
Characteristics of Cases Inpatient hospitalization§ 1 (7)
All patients were women, and the median age was 33 years Death 0 (—)
(range = 24–51 years). The median interval from the procedure * Patients might have had multiple procedures at the time of surgery; therefore,
the total number of procedures exceeds the total number of patients.
† Including computerized tomography–guided percutaneous abscess drainage,
* 45 C.F.R. part 46.102(l)(2), 21 C.F.R. part 56; 42 U.S.C. Sect. 241(d); 5 U.S.C.
needle aspiration, incision and drainage, wound debridement, and surgical
Sect. 552a; 44 U.S.C. Sect. 3501 et seq.
skin excision with drainage.
§ Data obtained from available records.
66
analysis by the Florida Bureau of Public Health Laboratories.

Summary
Whole genome sequencing determined that four isolates were
What is already known about this topic?
closely related† (4). Clinic A was closed after identification
of the cluster; the closure precluded environmental sampling Nontuberculous mycobacteria (NTM) have been reported as a
cause of health care–associated infections.
during the investigation.
What is added by this report?
On-site Assessment Investigation of a case of NTM infection in a patient who received
On March 3, 2023, FDOH conducted an on-site infection a cosmetic surgical procedure in Florida identified a total of
15 cases in nine states in patients who received cosmetic surgical
control assessment at clinic B, which operated with the same procedures at the same facility in Florida. Multiple lapses in
surgeon, staff members, and protocols as did clinic A. The infection control and prevention were found at an outpatient
assessment detected gaps in environmental cleaning practices, cosmetic surgery clinic operating with the same staff members.
use of proper personal protective equipment, and disinfection What are the implications for public health practice?
during surgical device reprocessing. Health care providers should have a high index of suspicion for
extrapulmonary NTM when evaluating patients for postsurgical
Preliminary Conclusions and Actions infection after cosmetic procedures and should be aware of the
This cluster was challenging to identify because patients threshold for notifying public health officials of these cases.
were located throughout the United States and because NTM
infections are not nationally notifiable. Collaboration among Acknowledgments
health jurisdictions and CDC was crucial in identifying the Florida Department of Health Care-Associated Infection
initial extrapulmonary NTM infection. Subsequent case Prevention Program; Florida Bureau of Public Health Laboratories;
finding required active surveillance to encourage reporting California Department of Public Health; Michigan Department of
by providers as well as outreach to patients using nontradi- Health & Human Services; Ohio Department of Health; Kansas
tional approaches, such as social media and online reviews of Department of Health and Environment; Texas Department of State
businesses (e.g., Facebook or Yelp), because patients reported Health Services; Illinois Department of Public Health; Wisconsin
symptoms on these sites. Department of Health Services; Massachusetts Department of
Public Health; Minnesota Department of Health; Rhode Island
Implications for Public Health Practice Department of Health; Washington State Department of Health;
Missouri Department of Health and Senior Services.
Health care providers should have a high index of suspi-
Corresponding author: Katharine E. Saunders, ksaunders2@cdc.gov.
cion for extrapulmonary NTM when evaluating patients for
postsurgical infection after cosmetic procedures and should 1Epidemic Intelligence Service, CDC; 2Florida Department of Health; 3Florida
be aware of the existing threshold for notifying public health Bureau of Public Health Laboratories; 4Division of Healthcare Quality Promotion,
National Center for Emerging and Zoonotic Infectious Diseases, CDC.
officials, realizing NTM infections could develop months after
surgery. Standard case definitions and thresholds for report- All authors have completed and submitted the International
ing to improve surveillance have been published.§,¶ Although Committee of Medical Journal Editors form for disclosure of potential
conflicts of interest. No potential conflicts of interest were disclosed.
the specific source associated with clinic A’s cluster has not
yet been identified, FDOH found gaps in infection control, References
including cleaning practices, use of personal protective equip- 1. Sood G, Parrish N. Outbreaks of nontuberculous mycobacteria. Curr Opin
ment, and surgical device disinfection, that can contribute to Infect Dis 2017;30:404–9. PMID:28548990 https://doi.org/10.1097/
NTM transmission. FDOH will use these findings to develop QCO.0000000000000386
2. Safe IP, Macedo V, Marcelo W, et al. Nontuberculous mycobacterial infections
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statewide to help prevent future outbreaks in this setting (5). Aesthet Dermatol 2021;14:46–9. PMID:33841617
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ijwd.2014.12.007
67
QuickStats
FROM THE NATIONAL CENTER FOR HEALTH STATISTICS
Percentage* of Children and Adolescents Aged ≤17 Years Who Visited

an Urgent Care Center or a Clinic in a Drug Store or Grocery Store in the Past
12 Months,† by Age Group and Year — National Health Interview Survey,§
United States, 2021–2022
100
2021
40 2022
30
Percentage
20
10
0
All ages 0–5 6–11 12–17
Age group, yrs
* With 95% CIs indicated by error bars.

† Based on responses to the survey question, “During the past 12 months, how many times has (child’s name)
gone to an urgent care center or clinic in a drug store or grocery store about his/her/their health?“
§ Estimates are based on household interviews of a sample of the civilian, noninstitutionalized U.S. population
and are derived from the National Health Interview Survey Sample Child component.
The percentage of children and adolescents aged ≤17 years who had at least one visit to an urgent care center or a clinic in a
drug store or grocery store in the past 12 months increased from 21.6% in 2021 to 28.4% in 2022. This increase was noted for
all age groups during 2021–2022. In 2021, urgent care or retail health clinic visits were lower among children aged 0–5 years
than those aged 6–11 years and 12–17 years. In 2022, visits for those aged 12–17 years (30.3%) were higher than for those aged
6–11 years (26.6%). Other observed differences among age groups were not significant.
Source: National Center for Health Statistics, National Health Interview Survey, 2021–2022 data. https://www.cdc.gov/nchs/nhis/index.htm
Reported by: Elizabeth M. Briones, PhD, ebriones@cdc.gov; Dzifa Adjaye-Gbewonyo, PhD.
68
The Morbidity and Mortality Weekly Report (MMWR) Series is prepared by the Centers for Disease Control and Prevention (CDC) and is available free
of charge in electronic format. To receive an electronic copy each week, visit MMWR at https://www.cdc.gov/mmwr/index.html.
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the MMWR Series to Editor-in-Chief, MMWR Series, Mailstop V25-5, CDC, 1600 Clifton Rd., N.E., Atlanta, GA 30329-4027 or to mmwrq@cdc.gov.
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Morbidity and Mortality Weekly Report

Weekly / Vol. 73 / No. 3 January 25, 2024

Prevalence of Cardiometabolic Diseases Among Racial and Ethnic Subgroups in

Abstract cardiovascular disease (coronary heart disease, heart failure,

U.S. Department of Health and Human Services

MMWR Editorial and Production Staff (Weekly)

(diabetes [excluding gestational diabetes], myocardial infarc- Discussion

Underuse of Antiviral Drugs to Prevent Progression to Severe COVID-19 —

Abstract by late 2022, monoclonal antibodies had lost activity against

Corresponding author: Paul A. Monach, Paul.Monach@va.gov.

Deaths of U.S. Citizens Undergoing Cosmetic Surgery —

Abstract from a variety of sources including families, funeral homes,

1Division of Healthcare Quality Promotion, National Center for Emerging

Notes from the Field

Introduction TABLE. Demographic and epidemiologic characteristics of patients

analysis by the Florida Bureau of Public Health Laboratories.

FROM THE NATIONAL CENTER FOR HEALTH STATISTICS

Percentage* of Children and Adolescents Aged ≤17 Years Who Visited

* With 95% CIs indicated by error bars.

ISSN: 0149-2195 (Print)

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