cdc_mmwr_report.json

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  {
    "title": "Expanded Recommendations for Use of Pneumococcal Conjugate Vaccines Among Adults Aged ≥50 Years: Recommendations of the Advisory Committee on Immunization Practices — United States, 2024  | MMWR",
    "content": "Expanded Recommendations for Use of Pneumococcal Conjugate Vaccines Among Adults Aged ≥50 Years: Recommendations of the Advisory Committee on Immunization Practices — United States, 2024  | MMWR Skip directly to site content Skip directly to search Español | Other Languages An official website of the United States government Here's how you know Official websites use .gov A .gov website belongs to an official government organization in the United States. Secure .gov websites use HTTPS A lock ( ) or https:// means you've safely connected to the .gov website. Share sensitive information only on official, secure websites. Centers for Disease Control and Prevention. CDC twenty four seven. Saving Lives, Protecting People Search Submit Morbidity and Mortality Weekly Report ( MMWR ) Expanded Recommendations for Use of Pneumococcal Conjugate Vaccines Among Adults Aged ≥50 Years: Recommendations of the Advisory Committee on Immunization Practices — United States, 2024 Weekly / January 9, 2025 / 74(1);1–8 Print Minus Related Pages Miwako Kobayashi, MD 1 ; Andrew J. Leidner, PhD 2 ; Ryan Gierke, MPH 1 ; Wei Xing, MSTAT 1 ; Emma Accorsi, PhD 1 ; Pedro Moro, MD 3 ; Mini Kamboj, MD 4 ; George A. Kuchel, MD 5 ; Robert Schechter, MD 6 ; Jamie Loehr, MD 7 ; Adam L. Cohen, MD 1 ( View author affiliations ) View suggested citation Summary What is already known about this topic? Before October 2024, a single dose of 15-valent, 20-valent, or 21-valent pneumococcal conjugate vaccine (PCV), was recommended for adults aged 19–64 years with risk conditions for pneumococcal disease and for all adults aged ≥65 years. What is added by this report? On October 23, 2024, the Advisory Committee on Immunization Practices recommended a single dose of PCV for all adults aged ≥50 years who are PCV-naïve or who have unknown vaccination history. The risk-based recommendation for adults aged 19–49 years is unchanged. What are the implications for public health practice? The updated, expanded age-based recommendation is expected to improve pneumococcal disease prevention in adults aged 50–64 years, particularly among demographic groups experiencing higher disease rates. Article Metrics Altmetric: Box Figure Table Related Materials Article PDF Full Issue PDF Abstract Before October 2024, the Advisory Committee on Immunization Practices (ACIP) recommended use of a pneumococcal conjugate vaccine (PCV) for all adults aged ≥65 years, as well as for those aged 19–64 years with risk conditions for pneumococcal disease who have not received a PCV or whose vaccination history is unknown. Options included either 20-valent PCV (PCV20; Prevnar20; Wyeth Pharmaceuticals) or 21-valent PCV (PCV21; CAPVAXIVE; Merck Sharp & Dohme) alone or 15-valent PCV (PCV15; VAXNEUVANCE; Merck Sharp & Dohme) in series with 23-valent pneumococcal polysaccharide vaccine (PPSV23; Pneumovax23; Merck Sharp & Dohme). There are additional recommendations for use of PCV20 or PCV21 for adults who started their pneumococcal vaccination series with 13-valent PCV (PCV13; Prevnar13; Wyeth Pharmaceuticals). The ACIP Pneumococcal Vaccines Work Group employed the Evidence to Recommendations framework to guide its deliberations on expanding the age-based PCV recommendation to include adults aged 50–64 years. On October 23, 2024, ACIP recommended a single dose of PCV for all PCV-naïve adults aged ≥50 years. Recommendations for PCVs among adults aged 19–49 years with risk conditions and PCV13-vaccinated adults have not changed from previous recommendations. This report summarizes evidence considered for these recommendations and provides updated clinical guidance for use of PCV. Top Introduction Streptococcus pneumoniae (pneumococcus) is a common bacterial cause of respiratory tract infections, bacteremia, and meningitis. Widespread use of pneumococcal conjugate vaccine (PCV) in children reduced the incidence of pneumococcal disease, both among children through direct effects and among older children and adults who have not received PCV through indirect effects (i.e., reduction in disease incidence in the population because of decreased transmission of pneumococcus from children) ( 1 , 2 ). However, persons with underlying conditions or factors that increase their risk for pneumococcal disease (risk conditions)* and older adults experience higher pneumococcal disease rates. In addition, racial disparities in pneumococcal disease incidence persist, including higher rates among non-Hispanic Black or African American (Black) and non-Hispanic American Indian or Alaska Native (AI/AN) adults ( 3 ). Before its October meeting, the Advisory Committee on Immunization Practices (ACIP) recommended receipt of a single dose of PCV for all adults aged ≥65 years and those aged 19–64 years with a risk condition who have not received PCV or whose vaccination history is unknown. Options included either 20-valent PCV (PCV20; Prevnar20; Wyeth Pharmaceuticals) ( 4 ) or 21-valent PCV (PCV21; CAPVAXIVE; Merck Sharp & Dohme) ( 5 ) alone, or 15-valent PCV (PCV15; VAXNEUVANCE; Merck Sharp & Dohme) ( 6 ) followed by 23-valent pneumococcal polysaccharide vaccine (PPSV23; Pneumovax23, Merck Sharp & Dohme) ( 7 ). Additional recommendations are applicable for use of PCV20 or PCV21 for adults who commenced their pneumococcal vaccination series with 13-valent PCV (PCV13; Prevnar13, Wyeth Pharmaceuticals) ( 8 , 9 ). In June 2024, ACIP recommended PCV21 as an option for adults who are recommended to receive PCV and proposed a review of available evidence to determine whether data supported lowering the age-based recommendation to ≥50 years for all recommended PCVs ( 8 ). The approval of PCV21, which was specifically developed to target pneumococcal serotypes that commonly cause disease in adults ( Figure ), was seen as a unique opportunity to reduce pneumococcal disease incidence and health disparities among U.S. adults. This report summarizes the evidence considered by ACIP regarding the expansion of the age-based recommendation to include adults aged 50–64 years, highlighting considerations of pneumococcal disease incidence and mortality, health disparities, and resource use. Top Methods During July–October 2024, the ACIP Pneumococcal Vaccines Work Group considered PCV use among PCV-naïve adults aged 50–64 years within the Evidence to Recommendations (EtR) framework. † Published and unpublished data on pneumococcal disease incidence and mortality, pneumococcal vaccination coverage, and economic models of age-based PCV use at age ≥50 years were reviewed; and findings were summarized by race and ethnicity whenever available ( 3 , 10 ). Previous Grading of Recommendations, Assessment, Development and Evaluation (GRADE) reviews for PCV15, PCV20, and PCV21 ( 8 , 11 , 12 ) were supplemented by an updated search of MEDLINE, (using PubMed) and ClinicalTrials.gov to identify additional literature on safety and immunogenicity. Postlicensure safety data on PCV20 from the Vaccine Adverse Event Reporting System (VAERS) and an analysis using Centers for Medicare & Medicaid Services (CMS) data were reviewed. Top Rationale and Evidence Pneumococcal Disease Incidence in Adults Aged ≥19 Years Pneumococcal pneumonia, accounting for 12%–13% of all hospitalized pneumonia cases, has been estimated to result in approximately 225,000 U.S. adult hospitalizations annually ( 13 – 15 ). Among adults aged 50–64 years with invasive pneumococcal disease (IPD) and those hospitalized with pneumococcal pneumonia, approximately 90% had one or more risk condition ( 3 , 14 ). Before the COVID-19 pandemic, approximately 30,000 IPD § cases occurred annually among U.S. adults ( 16 ). In 2022, adults aged 50–64 years experienced IPD incidence and mortality rates of 13.2 and 1.8 per 100,000 population, respectively. These rates were higher than those in all other age groups except adults aged ≥65 years, whose incidence and mortality rates were 17.2 and 2.7 per 100,000 population, respectively ( 1 ). According to CDC’s Active Bacterial Core surveillance (ABCs) data, during 2018–2022 (before PCV20 was widely used and before PCV21 approval among adults), 56% and 83% ¶ of IPD cases were due to pneumococcal serotypes contained in PCV20 and PCV21 in adults aged 50–64 years, respectively ( 17 ). Racial Disparities in Pneumococcal Disease Incidence and Vaccination Coverage An estimated 32%–54% of adults aged 50–64 years had at least one risk condition that qualifies for risk-based pneumococcal vaccination.** However, 2022 Behavioral Risk Factor Surveillance System data showed that only 37% of adults aged 50–64 years with a risk-based vaccination recommendation received a pneumococcal vaccine, compared with 70% of adults aged ≥65 years with an age-based recommendation; racial disparities in vaccination rates were apparent †† ( 3 ). ABCs data showed that IPD rates among Black adults peaked at a younger age (55–59 years) compared with rates among non-Black adults whose IPD rates increased with increasing age ( 3 ). Although PCV13 use among U.S. children has reduced disparities in PCV13-type IPD incidence in adults, likely because of indirect effects; remaining racial disparities are driven by non-PCV13 serotypes, with non-PCV13 serotype IPD rates among AI/AN and Black adults (25 and 10 per 100,000 population, respectively) exceeding the population average of six per 100,000 ( 3 ). PCV Immunogenicity and Safety from Clinical Trials An updated literature search identified six PCV15 trials ( 18 – 23 ), three PCV20 trials ( 24 – 26 ), and seven PCV21 trials ( 27 – 32 ) that included immunogenicity and safety data for adults aged ≥50 years. Summary of evidence from the updated literature search remained essentially unchanged from previous summaries ( 3 , 8 , 11 , 12 ). Compared with PCV13, PCV15 met noninferiority criteria for all shared PCV13 serotypes, and immune responses for non-PCV13 serotypes 22F and 33F were statistically significantly higher. PCV20 met noninferiority criteria for all PCV13 serotypes compared with PCV13 and for six of seven non-PCV13 serotypes (not met for serotype 8) compared with PPSV23 ( 24 – 26 ). Compared with PCV20, PCV21 met noninferiority criteria for 10 of 10 shared serotypes, and immune responses for 10 of 11 unique serotypes were statistically significantly higher (not met for serotype 15C). No vaccine-related serious adverse events (SAEs) were reported after PCV15 or PCV20 administration; two vaccine-related SAEs had been previously reported after PCV21 administration ( 8 ). PCV20 Postlicensure Safety Data Analysis of reports to VAERS after PCV20 administration in adults aged ≥19 years during October 2021–August 2024 showed a signal for Guillain-Barré syndrome (GBS); however, the overall reporting rate remained low (0.7 cases per million doses distributed) ( 3 ). Primary analysis of CMS data through May 2024 showed a statistically significant signal for GBS §§ after PCV20 administration in Medicare beneficiaries aged ≥65 years. However, the signal was not statistically significant when applying an alternative GBS definition in sensitivity analysis or adjusted for the positive predictive value of diagnostic codes compared with confirmation by chart review ( 3 ). Economic Analysis Two economic models (Tulane-CDC and Merck) assessed the cost-effectiveness of PCV20 and PCV21 use among PCV-naïve adults aged 50–64 years ( 10 ). A third model (Pfizer) assessed the cost-effectiveness of PCV20 use only ( 10 ). All three models used quality-adjusted life-year (QALY) as the primary health outcome. The Tulane-CDC model estimated costs of $131,023–$214,430 per QALY gained for PCV21 and $251,037–$546,811 for PCV20. The Merck model estimated $251,048–$425,455 per QALY gained for PCV21 and $548,114–$879,117 for PCV20. The Pfizer model estimated $56,376–$133,524 per QALY gained for PCV20. Cost-effectiveness estimates were most sensitive to assumptions about indirect effects from pediatric vaccination and duration of protection from vaccination. Limitations of the models included uncertainties about duration of protection from vaccination, magnitude of indirect effects from pediatric vaccination, and impact of future supplementary pneumococcal vaccine doses for adults. Top Recommendations for Use of PCV ACIP recommended PCV for all PCV-naïve adults aged ≥50 years. Recommendations for PCVs for adults aged 19–49 years with a risk condition and for adults who have previously received PCV13 remain unchanged ( Table ) ( 8 ). The recommendation was supported by several factors, including the potential to improve vaccination coverage and reduce pneumococcal disease incidence and mortality in adults aged 50–64 years, particularly among demographic groups experiencing higher disease rates. Ease of implementing consistent age-based recommendations for all PCVs was also considered. Uncertainties regarding key assumptions guiding the economic models and higher cost per QALY estimates for PCV20 compared with PCV21 were acknowledged. Selection of PCV in Populations with High Proportions of Serotype 4 Pneumococcal Disease In many U.S. settings, PCV21 is expected to cover more circulating pneumococcal strains than do other recommended PCVs. In certain populations in which ≥30% of pneumococcal disease ¶¶ is due to serotype 4, pneumococcal vaccines that include serotype 4 (PCV20 alone or PCV15 and PPSV23 in series) (Figure) are expected to provide broader serotype coverage against locally circulating strains than does PCV21 ( Box ). PPSV23 Use in PCV13-Experienced Adults Who Have Not Completed the Recommended Vaccination Series Among adults aged ≥19 years who have started their pneumococcal vaccination series with PCV13 but have not received all recommended doses, PPSV23 is no longer recommended as an option to complete the series. Either PCV20 or PCV21 is recommended to complete the series as previously recommended. (Table). Coadministration with Other Vaccines In accordance with CDC’s General Best Practice Guidelines for Immunization, routine administration of a pneumococcal vaccine with other age-appropriate doses of vaccines at the same visit is recommended for adults who have no specific contraindications to vaccination at the time of the health care visit ( 33 ). Contraindications and Precautions Vaccination providers should consult the vaccine package insert for precautions, warnings, and contraindications ( 4 – 7 ). Vaccination with PCV or PPSV23 is contraindicated in persons known to have had a severe allergic reaction (e.g., anaphylaxis) to any component of the vaccine. Because PCVs are conjugated to CRM197, a nontoxic genetically altered diphtheria toxin, these vaccines are also contraindicated in persons known to have had a severe allergic reaction to any diphtheria toxoid–containing vaccine ( 4 – 7 ). Reporting of Vaccine Adverse Events Adverse events occurring after administration of any vaccine should be reported to VAERS. Instructions for reporting to VAERS are available at https://vaers.hhs.gov/reportevent.html or by calling 800-822-7967. Future Research and Monitoring Priorities CDC and ACIP will continue to assess safety and public health impact of pneumococcal vaccines among adults. This includes monitoring the duration of vaccine-conferred immunity from PCV to determine the need for a booster to ensure that older adults continue to be protected under the updated vaccine recommendation and to measure any indirect effects on incidence in adults from routine childhood vaccination. Top Acknowledgments Alison Albert, Sofia Bletnitsky, Tarayn Fairlie, Marc Fischer, Julianne Gee, Shelby Miller, Noele Nelson, Laurie Orell, John Su, Liz Velazquez, CDC; Doug Campos-Outcalt, University of Arizona; Rebecca L. Morgan, McMaster University. ACIP Pneumococcal Vaccines Work Group Jamie Loehr, Cayuga Family Medicine; Mini Kamboj, Memorial Sloan Kettering Cancer Center, Joan and Sanford Weill Medical College of Cornell University; George Kuchel, UConn Health; Robert Schechter, California Department of Public Health; Lucia Lee, Tina Mongeau, Food and Drug Administration; Risa Claytor, Health Resources and Services Administration; Uzo Chukwuma, Indian Health Service; Mamodikoe Makhene, Meenu Upadyay, National Institutes of Health; Lynn Fisher, American Academy of Family Physicians; Monica Ardura, American Academy of Pediatrics, Committee on Infectious Diseases; Jason Goldman, Saba Hasan, American College of Physicians; David A. Nace, American Geriatrics Society, Post-Acute and Long-Term Care Medical Association; Cora Hoover, Association of Immunization Managers; Mary Hayney, American Pharmacists Association; Eva Wong, Canadian National Advisory Committee on Immunization; James McAuley, Infectious Diseases Society of America; Robert Hopkins, William Schaffner, National Foundation for Infectious Diseases; Virginia Caine, National Medical Association; Monica M. Farley, Emory University; Keith Klugman, Gates Foundation; Sarah S. Long, Drexel University College of Medicine; Katherine A. Poehling, Wake Forest University School of Medicine; Arthur Reingold, University of California, Berkeley; Lorry Rubin, Cohen Children’s Medical Center of New York; Richard K. Zimmerman, University of Pittsburgh. Top Corresponding author: Miwako Kobayashi, mkobayashi@cdc.gov . Top 1 Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, CDC; 2 Immunization Services Division, National Center for Immunization and Respiratory Diseases, CDC; 3 Immunization Safety Office, CDC; 4 Memorial Sloan Kettering Cancer Center, Joan and Sanford Weill Medical College of Cornell University, New York, New York; 5 UConn Health, Farmington, Connecticut; 6 California Department of Public Health; 7 Cayuga Family Medicine, Ithaca, New York. Top All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. Mini Kamboj reports receipt of payment from the Virginia Department of Health, travel support from Magic Oncology (University of Colorado), and uncompensated service as cochair of the American Society of Clinical Oncology guideline on vaccination of adults with cancer. George A. Kuchel reports grant support from the National Institutes of Health (Patient-Centered Outcomes Research Institute). No other potential conflicts of interest were disclosed. Top * Alcoholism; cerebrospinal fluid leak; chronic heart, liver, or lung disease; chronic renal failure; cigarette smoking; cochlear implant; congenital or acquired asplenia; diabetes mellitus; generalized malignancy; HIV; Hodgkin disease; immunodeficiency; iatrogenic immunosuppression; leukemia, lymphoma, or multiple myeloma; nephrotic syndrome; solid organ transplant; or sickle cell disease or other hemoglobinopathies. † https://www.cdc.gov/acip/evidence-to-recommendations/adults-50-64-without-pneumococcal-vaccine-etr.html § Defined as a pneumococcal infection in a normally sterile site (e.g., blood, cerebrospinal fluid, bone, or joint space). ¶ PCV21 received indication for protection against IPD serotype 15B based on immunogenicity data. The percentage increases to 85% if serotype 15B is included as part of PCV21 serotype. ** At least one of the following conditions, according to the 2020 National Health Interview Survey: chronic heart disease, chronic lung disease, chronic liver disease, diabetes, smoking, alcoholism, weakened immune system due to prescriptions, weakened immune system due to health condition, solid cancer (not including nonmelanoma skin cancer or unknown type of skin cancer), and blood cancer. The percentages were 32% for non-Hispanic Asian (Asian) adults; 43% for Hispanic or Latino (Hispanic) adults; 50% for non-Hispanic White (White) adults; and 54% for Black adults. †† According to 2022 Behavioral Risk Factor Surveillance System data, coverage with any pneumococcal vaccine among adults aged 50–64 years with risk-based recommendation by race and ethnicity was 27.9% (Hispanic), 39.3% (White), 38.2% (Black), 36.5% (Asian), and 35.1% (AI/AN); coverage among adults aged ≥65 years by race and ethnicity was 55.1% (Hispanic), 72.7% (White), 63.1% (Black), 64.1% (Asian), and 62.1% (AI/AN). §§ These cases were based on claims without chart confirmation. Therefore, in addition to the GBS definition used for the primary analysis ( International Classification of Diseases, Tenth Revision, Clinical Modification [ICD-10-CM] code: G61.0), an alternative definition based on literature search (ICD-10-CM codes: G61.0, G61.81, G61.1, G61.8, and G61.9) was used for sensitivity analysis. ¶¶ The 30% threshold was guided by economic models that showed that once the percentage of cases of pneumococcal disease caused by serotype 4 exceeds 30%, PCV21 use might result in higher cost and, in some cases, worse health outcomes compared with PCV20 use. https://www.cdc.gov/acip/downloads/slides-2024-06-26-28/02-Pneumococcal-Stoecker-508.pdf Top References CDC. Active bacterial core surveillance (ABCs): ABCs bact facts interactive data dashboard. Atlanta, GA: US Department of Health and Human Services, CDC; 2024. https://www.cdc.gov/abcs/bact-facts/data-dashboard.html Matanock A, Lee G, Gierke R, Kobayashi M, Leidner A, Pilishvili T. 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Pivotal phase 3 randomized clinical trial of the safety, tolerability, and immunogenicity of 20-valent pneumococcal conjugate vaccine in adults aged ≥18 years. Clin Infect Dis 2022;75:390–8. https://doi.org/10.1093/cid/ciab990 PMID:34940806 Hurley D, Griffin C, Young M Jr, et al. Safety, tolerability, and immunogenicity of a 20-valent pneumococcal conjugate vaccine (PCV20) in adults 60 to 64 years of age. Clin Infect Dis 2021;73:e1489–97. https://doi.org/10.1093/cid/ciaa1045 PMID:32716500 Haranaka M, Young Song J, Huang KC, et al. A phase 3 randomized trial of the safety and immunogenicity of 20-valent pneumococcal conjugate vaccine in adults ≥60 years of age in Japan, South Korea, and Taiwan. Vaccine 2024;42:1071–7. https://doi.org/10.1016/j.vaccine.2024.01.004 PMID:38267330 Platt H, Omole T, Cardona J, et al. Safety, tolerability, and immunogenicity of a 21-valent pneumococcal conjugate vaccine, V116, in healthy adults: phase 1/2, randomised, double-blind, active comparator-controlled, multicentre, US-based trial. Lancet Infect Dis 2023;23:233–46. https://doi.org/10.1016/S1473-3099(22)00526-6 PMID:36116461 Platt HL, Bruno C, Buntinx E, et al.; STRIDE-3 Study Group. Safety, tolerability, and immunogenicity of an adult pneumococcal conjugate vaccine, V116 (STRIDE-3): a randomised, double-blind, active comparator controlled, international phase 3 trial. Lancet Infect Dis 2024;24:1141–50. https://doi.org/10.1016/S1473-3099(24)00344-X PMID:38964361 Scott P, Haranaka M, Choi JH, et al.; STRIDE-6 study group. A phase 3 clinical study to evaluate the safety, tolerability, and immunogenicity of V116 in pneumococcal vaccine-experienced adults 50 years of age or older (stride-6). Clin Infect Dis 2024;79:1366–74. https://doi.org/10.1093/cid/ciae383 PMID:39082735 Merck Sharp & Dohme. A phase 3 randomized, double-blind, placebo-controlled clinical study to evaluate the safety, tolerability, and immunogenicity of V116 when administered concomitantly with influenza vaccine in adults 50 years of age or older. Rahway, NJ: Merck Sharp & Dohme; 2023. https://clinicaltrials.gov/study/NCT05526716 Merck Sharp & Dohme. A phase 3, multicenter, randomized, double-blind, active comparator-controlled study to evaluate the safety, tolerability, and immunogenicity of V116 in adults living with HIV. Rahway, NJ: Merck Sharp & Dohme; 2023. https://clinicaltrials.gov/study/NCT05393037 Merck Sharp & Dohme. Safety and immunogenicity of V116 in pneumococcal vaccine-naïve adults 50 years of age or older (V116–010, STRIDE-10). Rahway, NJ: Merck Sharp & Dohme; 2024. https://www.clinicaltrials.gov/study/NCT05569954?term=V116-010&rank=1 Kroger A, Bahta L, Long S, Sanchez P. General best practice guidelines for immunization. Atlanta, GA: US Department of Health and Human Services, CDC; 2024. www.cdc.gov/vaccines/hcp/acip-recs/general- recs/downloads/general-recs.pdf Top FIGURE . Serotypes* , † included in pneumococcal vaccines currently recommended for adults — United States, 2024 Abbreviations: PCV = pneumococcal conjugate vaccine; PCV15 = 15-valent PCV; PCV20 = 20-valent PCV; PCV21 = 21-valent PCV; PPSV23 = 23-valent pneumococcal polysaccharide vaccine. * PCV21 is approved for the prevention of invasive pneumococcal disease caused by serotype 15B based upon prespecified criteria for the proportion of participants with fourfold or more rise in opsonophagocytic activity responses. https://www.fda.gov/media/179426/download?attachment † PCV21 contains serotype 20A. Top TABLE. Clinical guidance for implementing pneumococcal vaccine recommendations for adults aged ≥19 years — United States, October 2024 Risk or age group Vaccine received previously Options for vaccination Adults aged ≥50 years None or PCV7 only at any age A single dose of PCV21, PCV20, or PCV15. If PCV15 is administered, a single dose of PPSV23* should be administered ≥1 year after the PCV15 dose. A minimum interval of 8 weeks can be considered if PCV15 is used in adults with an immunocompromising condition, † cochlear implant, or CSF leak. PPSV23 only A single dose of PCV21, PCV20, or PCV15 ≥1 year after the last PPSV23 dose. PCV13 only A single dose of PCV21 or PCV20 ≥1 year after the PCV13 dose. PCV13 at any age and PPSV23 at age <65 years A single dose of PCV21 or PCV20 ≥5 years after the last pneumococcal vaccine dose. PCV13 at any age and PPSV23 at age ≥65 years Shared clinical decision-making is recommended regarding administration of either a single dose of PCV21 or PCV20 for any adult aged ≥65 years who has completed the recommended vaccination series with both PCV13 and PPSV23 (i.e., PPSV23 administered at age ≥65 years) but PCV21, PCV20, or PCV15 not yet received. If a decision to administer PCV21 or PCV20 is made, a single dose is recommended ≥5 years after the last pneumococcal vaccine dose. Adults aged 19–49 years with an immunocompromising condition, † a CSF leak, or a cochlear implant None or PCV7 only at any age A single dose of PCV21, PCV20, or PCV15. If PCV15 is used, administer a single dose of PPSV23* ≥8 weeks after the PCV15 dose. PPSV23 only A single dose of PCV21, PCV20, or PCV15 ≥1 year after the last PPSV23 dose. PCV13 only A single dose of PCV21 or PCV20 administered ≥1 year after the PCV13 dose. PCV13 and 1 dose of PPSV23 A single dose of PCV21 or PCV20 ≥5 years after the last pneumococcal vaccine dose. The pneumococcal vaccination series is complete, and it need not be followed by additional pneumococcal vaccine doses. PCV13 and 2 doses of PPSV23 The pneumococcal vaccination recommendations should be reviewed again when the person turns age 50 years. Alternatively, a single dose of either PCV21 or PCV20 should be administered ≥5 years after the last pneumococcal vaccine dose. If PCV21 or PCV20 is used, the series is complete, and it need not be followed by additional pneumococcal vaccine doses. Adults aged 19–49 years with chronic medical conditions § None or PCV7 only at any age A single dose of PCV21, PCV20, or PCV15. If PCV15 is administered, a single dose of PPSV23* should be administered ≥1 year after the PCV15 dose. PPSV23 only A single dose of PCV21, PCV20, or PCV15 ≥1 year after the last PPSV23 dose. PCV13 only A single dose of PCV21 or PCV20 ≥1 year after the PCV13 dose. PCV13 and 1 dose of PPSV23 The pneumococcal vaccination recommendations should be reviewed again when the person reaches age 50 years. Abbreviations : CSF = cerebrospinal fluid; PCV = pneumococcal conjugate vaccine; PCV7 = 7-valent PCV; PCV13 = 13-valent PCV; PCV15 = 15-valent PCV; PCV20 = 20-valent PCV; PCV21 = 21-valent PCV; PPSV23 = 23-valent pneumococcal polysaccharide vaccine. * For adults who have received PCV15 but have not completed their recommended pneumococcal vaccine series with PPSV23, 1 dose of PCV21 or PCV20 may be used if PPSV23 is not available. † Chronic renal failure, nephrotic syndrome, immunodeficiency, iatrogenic immunosuppression, generalized malignancy, HIV infection, Hodgkin disease, leukemia, lymphoma, multiple myeloma, solid organ transplant, congenital or acquired asplenia, or sickle cell disease or other hemoglobinopathies. § Alcoholism; chronic heart disease, including congestive heart failure and cardiomyopathies; chronic liver disease; chronic lung disease, including chronic obstructive pulmonary disease, emphysema, and asthma; cigarette smoking; or diabetes mellitus. Top BOX. Clinical guidance on selection of pneumococcal conjugate vaccine in communities with high percentages of serotype 4 pneumococcal disease — United States, 2024 PCV21 contains eight pneumococcal serotypes that are not included in previously recommended pneumococcal vaccines (i.e., PCV15, PCV20, and PPSV23). However, PCV21 does not contain certain pneumococcal serotypes that are contained in previously recommended pneumococcal vaccines, one of which is pneumococcal serotype 4. In certain adult populations in the western United States, high percentages (i.e., ≥30%) of IPD caused by serotype 4 have occurred. The available IPD serotype data from CDC’s Active Bacterial Core surveillance, as well as similar surveillance from Alaska and Navajo Nation, indicate that this serotype is particularly prevalent in Alaska, Colorado, Navajo Nation, New Mexico, and Oregon. Serotype 4 IPD occurs across age groups; however, cases are frequently observed among adults aged <65 years who have underlying conditions, such as alcoholism, chronic lung disease, cigarette smoking, homelessness, and injection drug use. In such populations in these geographic areas, other recommended pneumococcal vaccines (e.g., PCV20 alone or both PCV15 and PPSV23) are expected to provide broader serotype coverage against locally circulating strains compared with PCV21. The percentages of serotype 4 IPD cases in other areas of the western United States without IPD surveillance are currently unknown. IPD surveillance from other geographic areas in the United States (e.g., midwestern, eastern, and southern regions) has not detected significant percentages of serotype 4. This clinical guidance will be reviewed and updated as pneumococcal disease epidemiology evolves. Abbreviations: IPD = invasive pneumococcal disease; PCV = pneumococcal conjugate vaccine; PCV13 = 13-valent PCV; PCV15 = 15-valent PCV; PCV20 = 20-valent PCV; PCV21 = 21-valent PCV; PPSV23 = 23-valent pneumococcal polysaccharide vaccine. Top Suggested citation for this article: Kobayashi M, Leidner AJ, Gierke R, et al. Expanded Recommendations for Use of Pneumococcal Conjugate Vaccines Among Adults Aged ≥50 Years: Recommendations of the Advisory Committee on Immunization Practices — United States, 2024. MMWR Morb Mortal Wkly Rep 2025;74:1–8. DOI: http://dx.doi.org/10.15585/mmwr.mm7401a1 . MMWR and Morbidity and Mortality Weekly Report are service marks of the U.S. Department of Health and Human Services. Use of trade names and commercial sources is for identification only and does not imply endorsement by the U.S. Department of \r\nHealth and Human Services. References to non-CDC sites on the Internet are \r\nprovided as a service to MMWR readers and do not constitute or imply \r\nendorsement of these organizations or their programs by CDC or the U.S. \r\nDepartment of Health and Human Services. CDC is not responsible for the content \r\nof pages found at these sites. URL addresses listed in MMWR were current as of \r\nthe date of publication. All HTML versions of MMWR articles are generated from final proofs through an automated process. \r\nThis conversion might result in character translation or format errors in the HTML version. \r\nUsers are referred to the electronic PDF version ( https://www.cdc.gov/mmwr ) \r\nand/or the original MMWR paper copy for printable versions of official text, figures, and tables. Questions or messages regarding errors in formatting should be addressed to mmwrq@cdc.gov . 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    "scraped_date": "2025-11-14T16:26:01.044553"
  },
  {
    "title": "Gaps in Mental Health Care–Seeking Among Health Care Providers During the COVID-19 Pandemic — United States, September 2022–May 2023  | MMWR",
    "content": "Gaps in Mental Health Care–Seeking Among Health Care Providers During the COVID-19 Pandemic — United States, September 2022–May 2023  | MMWR Skip directly to site content Skip directly to search Español | Other Languages An official website of the United States government Here's how you know Official websites use .gov A .gov website belongs to an official government organization in the United States. Secure .gov websites use HTTPS A lock ( ) or https:// means you've safely connected to the .gov website. Share sensitive information only on official, secure websites. Centers for Disease Control and Prevention. CDC twenty four seven. Saving Lives, Protecting People Search Submit Morbidity and Mortality Weekly Report ( MMWR ) Gaps in Mental Health Care–Seeking Among Health Care Providers During the COVID-19 Pandemic — United States, September 2022–May 2023 Weekly / January 16, 2025 / 74(2);19–25 Print Minus Related Pages Anthony Papa, PhD 1 ; John P. Barile, PhD 1 ; Haomiao Jia, PhD 2 ; William W. Thompson, PhD 3 ; Rebecca J. Guerin, PhD 4 ( View author affiliations ) View suggested citation Summary What is already known about this topic? Providing patient care during the COVID-19 pandemic has been associated with high levels of mental health symptoms among U.S. health care workers. What is added by this report? Among providers surveyed, 26% reported mental health symptoms at levels meeting diagnostic criteria during September 2022–May 2023; however, only 20% of providers sought mental health care during the preceding year. Support from supervisors reduced the effect of work stressors on mental health symptoms. The primary barriers to care-seeking were difficulty getting time off from work and concerns about confidentiality and cost. What are the implications for public health practice? Gaps in mental health care–seeking might be reduced by organizational and governmental efforts to reduce stigma, addressing concerns about confidentiality and licensing, and increasing supervisor training. Article Metrics Altmetric: Figure Tables Table 1 Table 2 Related Materials Article PDF Full Issue PDF Abstract Health care workers experience substantial chronic stress, burnout, and mental distress, and the COVID-19 pandemic might have exacerbated these conditions. To identify ways to improve mental health care–seeking among this population, mental health symptoms, care-seeking, and self-reported barriers to seeking mental health care among U.S. health care providers during the pandemic were studied. During September 2022–May 2023, 2,603 primary care physicians, pediatricians, nurse practitioners, and physician assistants participated in a national Internet panel survey. Approximately one half (45.4%) of participants reported that they did not need mental health care, and only one in five (20.3%) had sought care. One quarter (25.6%) of providers reported mental distress severe enough to meet diagnostic criteria for psychopathology. Among these providers, only 38% reported seeking care; 20.1% indicated that they did not need care, despite severe symptoms. The average number of years in practice was lower for providers reporting care-seeking. Providers who identified as female were also more likely to report care-seeking. The most frequently reported barriers to care-seeking included difficulty getting time off from work, cost of care, and concerns about confidentiality. Increased pandemic-related work stressors were associated with increased symptom severity, but support from work supervisors mitigated these effects. Organizational human resources practices, supervisor training on managing employee stress, and public health messaging to normalize mental health care–seeking and its effects on licensing might help address gaps in provider care-seeking and improve patient outcomes. Top Introduction Health care workers have long experienced high levels of chronic stress, burnout, and mental distress*; for some health care workers, these conditions were exacerbated by providing care during the COVID-19 pandemic ( 1 ). Two known and potentially interrelated factors affecting provider mental health are mental health care–seeking and social-emotional support from work supervisors. To help guide activities to increase mental health care–seeking among this population, this study examined the associations among self-reported mental health needs, care-seeking, factors associated with care-seeking, and perceived support from supervisors among a national sample of health care providers. Top Methods Data Source and Data Collection Data were collected by Porter Novelli Public Services as part of its DocStyles survey from two Internet-delivered panel surveys of U.S. health care providers during September 9–November 3, 2022, and during March 17–May 15, 2023. † Primary care physicians, pediatricians, nurse practitioners, and physician assistants (2,063) § practicing for ≥3 years who completed at least one survey were included in this cross-sectional data analysis. ¶ Mental health needs were evaluated using standardized questionnaires. Anxiety and depressive symptoms** experienced during the preceding 2 weeks were determined using the Generalized Anxiety Disorder-2 scale and Patient Health Questionnaire-2 depression scale ( 2 ). Posttraumatic stress because of the COVID-19 pandemic was measured using the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition –indexed Posttraumatic Stress Disorder (PTSD) Primary Care Screen ( 3 ). Overall mental well-being was measured as mentally unhealthy days using one item from the CDC Health-Related Quality of Life-4 survey asking how many of the previous 30 days respondents’ mental health was not good ( 4 ). Participants selected work stressors experienced from a list derived from existing literature on COVID-19–related occupational stressors for nurses. †† Perceived social support from work supervisors was determined using a modified item from the 2017 CDC Behavioral Risk Factor Surveillance System survey. §§ Mental health care–seeking was determined by asking, “In the past year, have you seen a doctor or other health professional about any of your emotions, nerves, or mental health?” Responses included, “Yes, I saw someone,” “No, I haven’t seen anyone,” “No, I didn’t need emotional or mental care,” or “Prefer not to say.” Those who did not seek care could select as many of the seven barriers to care-seeking as applied to them. Data Analysis Statistical differences among care-seeking groups were determined using two-sided z- tests of equality for proportions or t -tests for mean scores. Logistic regression was used to determine how supervisor support, as a moderating variable, influenced the association between work stress, as a dependent variable, and the likelihood of meeting diagnostic criteria for a mental disorder in separate models for anxiety, depression, and posttraumatic stress symptoms, as well as mentally unhealthy days, as dependent variables with no covariates. Analyses were completed using R (version 4.2.2; R Foundation). ¶¶ This activity was reviewed by CDC, deemed not research, and was conducted consistent with applicable federal law and CDC policy.*** Top Results Mental Health and Care-Seeking Among 2603 surveyed healthcare workers, 667 (25.6%) reported levels of mental distress severe enough to meet diagnostic criteria for a mental disorder, but only 526 (20.3%) of respondents reported seeking mental health care (226 [43.0%] of these reported diagnostic levels of symptoms) ( Table 1 ). Of providers who reported diagnostic levels of mental distress, 20.1% reported not needing care. The percentage of providers reporting mental distress meeting diagnostic levels was higher among those who did not seek care for their health needs than it was among those who reported not needing care, when measuring depression (38.3% versus 18.8%), anxiety (39.1% versus 16.4%), posttraumatic stress (34.5% versus 22.2%), and mentally unhealthy days per month (37.9% versus 14.6%). The proportion of providers reporting symptom severity indicating they met criteria for a mental disorder was similar for those who sought mental health care and those who had not sought this care. The percentage of providers reporting diagnostic levels of mental distress was lower for those who preferred not to report mental health care–seeking than for those reporting not needing care. Provider Characteristics Associated with Care-Seeking Providers who reported they did not need care had been in practice the longest (median [IQR] = 13.0 years [15.0]). Fewer male providers sought care (16.0%) than did female providers (26.1%) or those identifying as other than male or female (18.8%). Primary care physicians, 68.7% of whom were male, reported the lowest prevalence of seeking care (16.4%). Nurse practitioners (33.9%; 81.7% female), physician assistants (27.9%; 68.5% female), and pediatricians (24.4%; 50.1% female) reported the highest prevalence of seeking care. Work Stressors and Barriers to Seeking Mental Health Care The main work stressors reported by health care providers were extra stress at work (68.2%), burnout (58.9%), lack of adequate staffing (58.9%), higher workload or job demands (57.2%), fear of becoming ill with COVID-19 (55.6%), and COVID-19 misinformation (51.3%) ( Table 2 ). Among respondents who did not seek care, the most frequently reported barrier was difficulty getting time off work, followed by concerns about confidentiality, cost, and being seen as weak. Association of Outcomes with Supervisor Support Each increase in the number of work stressors increased the odds of meeting diagnostic criteria for psychopathology by 9% for the anxiety scale (OR = 1.09; 95% CI = 1.06–1.12), 3% for the depression scale (OR = 1.03; 95% CI = 1.00–1.07), 35% for the posttraumatic stress scale (OR = 1.35; 95% CI = 1.29–1.41), and 12% for number of mentally unhealthy days (OR = 1.12; 95% CI = 1.08–1.17). However, the strength of association between the level of reported work stressors (low to high) and the likelihood of meeting diagnostic criteria for a mental health problem (anxiety, depression, and mentally unhealthy days) decreased as social support from supervisors increased ( Figure ). Similarly, among providers who did not seek mental health care, increased supervisor support reduced the association between increases in barriers to care-seeking and increased likelihood of meeting diagnostic criteria for a mental health problem. Supervisor support did not affect the probability of meeting a mental health diagnosis for posttraumatic stress. Top Discussion During September 2022–May 2023, approximately one quarter of U.S. health care providers included in the survey sample reported mental distress severe enough to meet diagnostic criteria, of which less than 40% reported seeking mental health care, with approximately one in five providers reporting that they did not need care. Experiencing higher numbers of COVID-19–related work stressors was associated with high symptom severity for anxiety, depression, and general mental health, but support from work supervisors appeared to mitigate the effect of these factors on mental health, with an exception for PTSD. The percentage of providers who reported burnout as an ongoing stressor is consistent with estimates from a 2021 survey of U.S. physicians (62.8%) ( 5 ). Similar to studies that have found significant stigma regarding reporting difficulties in mental health among providers ( 1 , 6 ), 6% of respondents indicated they preferred not to report mental health care–seeking and reported lower levels of symptom severity than did those who indicated they did not need care, possibly demonstrating reticence in reporting care-seeking extended to reporting work stressors. Overall, the high levels of clinically relevant symptoms reported by U.S. health care providers in this study might indicate problems in current health care workforce readiness, especially given that 57.4% of providers self-reporting severe symptoms did not seek mental health care, or indicated that they did not need care, potentially affecting patient outcomes ( 7 ). Limitations The findings in this report are subject to at least four limitations. First, the respondents opted into the survey, which limits the representativeness of the results. Second, retrospective reporting on previous experience might have been subject to recall bias. Third, although the survey was anonymous, self-reported symptom severity and care-seeking might be subject to social desirability bias. Finally, other relevant indicators of adjustment beyond mental health, such as substance abuse, were not included. Implications for Public Health Practice Organizational and governmental interventions will likely reduce stigma among health care providers by normalizing and supporting mental health care–seeking ( 8 ) and addressing perceived negative consequences of seeking health care on medical licensing ( 5 ). Mental health awareness and self-care training could be made a requirement of continuing education for maintenance of board certification and licensure at state levels. A recent review of interventions and resources to address health care workers’ mental health ( 9 ) identified organizational approaches to addressing the needs and barriers identified in this study. These include leadership development on organizational practices and work conditions affecting provider well-being; mentoring and peer support programs; training in mindfulness, stress reduction, self-compassion, and interpersonal communication; and brief psychotherapy programming. However, broad organizational implementation is lacking ( 10 ) and often does not reach those in community practice. Recent activities by Lorna Breen Act grantees ††† funded by the Health Resources and Services Administration include identifying effective organizational strategies, such as training for managers to address health care worker mental health and burnout. The Impact Wellbeing campaign §§§ from the National Institute for Occupational Safety and Health promotes the removal of barriers and reducing stigma for seeking mental health services and might provide a road map for advancing health care worker well-being. Top Corresponding author: Anthony Papa, papaa@hawaii.edu . Top 1 Department of Psychology, University of Hawaii at Manoa, Honolulu, Hawaii; 2 Department of Biostatistics, Mailman School of Public Health and School of Nursing, Columbia University, New York, New York; 3 Division of Viral Hepatitis, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC; 4 Western States Division, National Institute for Occupational Safety and Health, CDC. Top All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed. Top * https://doi.org/10.17226/25521 † Porter Novelli Public Services collected data as a part of its DocStyles survey using the global market research company SERMO’s Global Medical panel adhering to the Insights Association’s standards and codes of conduct. https://www.insightsassociation.org/Resources/Code-of-Standards § A total of 3,008 surveys were completed during fall 2022 and spring 2023 administrations. The fall 2022 survey (September 9–November 3, 2022) had a 66% response rate (1,505) and the spring 2023 survey (March 17–May 15, 2023) had a 64% response rate (1,503). ¶ Providers were matched by a unique survey identification number (no personally identifying information was included in the datasets) across the two data collection wave; 405 providers were identified as having completed both surveys, in which case, spring 2023 responses were not included in the analyses as these responses were further away from the pandemic’s peak. Thus, a total of 2,603 providers were included in the final analysis. Based on the number of questions completed, providers received a $50–$65 honorarium in the fall and $25–$39 in the spring. The questionnaires reported in this paper were the same for both DocStyles surveys. However, the spring survey had fewer questions overall, hence the difference in honorarium. Despite this, the response rates were comparable (66% versus 64%). ** All adjustment scales for anxiety, depression, posttraumatic stress, and mentally unhealthy days have established cutoff scores, demarcating a high probability of meeting diagnostic criteria for psychopathology. †† https://www.icn.ch/system/files/documents/2020-09/Analysis_COVID-19%20survey%20feedback_14.09.2020%20EMBARGOED%20VERSION_0.pdf §§ The question, “How often do you get the social and emotional support you need,” from the 2017 CDC Behavioral Risk Factor Surveillance System survey ( https://www.cdc.gov/brfss/questionnaires/pdf-ques/2017_BRFSS_Pub_Ques_508_tagged.pdf ) was modified to ask, “How often do you get the social and emotional support from your supervisor you need?” Respondents answered on a scale of 1–5 (never to always). ¶¶ https://www.r-project.org/ *** 45 C.F.R. part 46, 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. ††† Lorna Breen was an emergency department physician who died by suicide after not seeking mental health care for burnout during the COVID-19 pandemic for fear that receiving this care would jeopardize her medical career. https://drlornabreen.org/ §§§ https://www.cdc.gov/niosh/healthcare/impactwellbeing/about.html Top References Umbetkulova S, Kanderzhanova A, Foster F, Stolyarova V, Cobb-Zygadlo D. Mental health changes in healthcare workers during COVID-19 pandemic: a systematic review of longitudinal studies. Eval Health Prof 2024;47:11–20. https://doi.org/10.1177/01632787231165076 PMID:37143216 Staples LG, Dear BF, Gandy M, et al. Psychometric properties and clinical utility of brief measures of depression, anxiety, and general distress: the PHQ-2, GAD-2, and K-6. Gen Hosp Psychiatry 2019;56:13–8. https://doi.org/10.1016/j.genhosppsych.2018.11.003 PMID:30508772 Bovin MJ, Kimerling R, Weathers FW, et al. Diagnostic accuracy and acceptability of the Primary Care Posttraumatic Stress Disorder Screen for the Diagnostic and Statistical Manual of Mental Disorders (fifth edition) among US veterans. JAMA Netw Open 2021;4:e2036733. https://doi.org/10.1001/jamanetworkopen.2020.36733 PMID:33538826 Slabaugh SL, Shah M, Zack M, et al. Leveraging health-related quality of life in population health management: the case for healthy days. Popul Health Manag 2017;20:13–22. https://doi.org/10.1089/pop.2015.0162 PMID:27031869 Shanafelt TD, West CP, Dyrbye LN, et al. Changes in burnout and satisfaction with work-life integration in physicians during the first 2 years of the COVID-19 pandemic. Mayo Clin Proc 2022;97:2248–58. https://doi.org/10.1016/j.mayocp.2022.09.002 PMID:36229269 Mehta SS, Edwards ML. Suffering in silence: mental health stigma and physicians’ licensing fears. Am J Psychiatry Resid J 2018;13:2–4. https://doi.org/10.1176/appi.ajp-rj.2018.131101 Schlak AE, Aiken LH, Chittams J, Poghosyan L, McHugh M. Leveraging the work environment to minimize the negative impact of nurse burnout on patient outcomes. Int J Environ Res Public Health 2021;18:610. https://doi.org/10.3390/ijerph18020610 PMID:33445764 Howard J, Houry D. Protecting the mental health and well-being of the nation’s health workforce. Am J Public Health 2024;114(S2):137–41. https://doi.org/10.2105/AJPH.2023.307475 PMID:38354354 Anger WK, Dimoff JK, Alley L. Addressing healthcare workers’ mental health: a systematic review of evidence-based interventions and current resources. Am J Public Health 2024;114(S2):213–26. https://doi.org/10.2105/AJPH.2023.307556 PMID:38354343 Longo BA, Schmaltz SP, Williams SC, Shanafelt TD, Sinsky CA, Baker DW. Clinician well-being assessment and interventions in Joint Commission–accredited hospitals and federally qualified health centers. Jt Comm J Qual Patient Saf 2023;49:511–20. https://doi.org/10.1016/j.jcjq.2023.04.007 PMID:37248109 Top TABLE 1. Sample characteristics and mental health outcomes among a sample of health care providers, by health care–seeking — Porter Novelli DocStyles survey, United States, fall 2022 and spring 2023 Characteristic No. (%) Total sample N = 2,603 (100.0%) Sought care n = 526 (20.3%) Did not seek care n = 743 (28.7%) Did not need care n = 1,179 (45.4%) Preferred not to say n = 155 (6.0%) Column % (95% CI) Row % (95% CI) p-values* Row % (95% CI) p-value † Row % (95% CI) Row % (95% CI) p-value † Provider type Pediatrician (n = 431) 16.6 (15.2–18.0) 24.4 (20.5–28.6) 0.081, <0.001 28.8 (24.6–33.2) <0.001 41.1 (36.5–45.8) 5.8 (3.9–8.3) <0.001 Physician assistant (n = 219) 8.4 (7.4–9.5) 27.9 (22.2–34.1) 0.858, <0.001 27.4 (21.8–33.6) <0.001 40.6 (34.3–47.2) 4.1 (2.1–7.4) <0.001 Primary care physician (n = 1,723) 66.2 (64.4–68.0) 16.4 (14.7–18.2) <0.001, <0.001 29.6 (27.5–31.8) <0.001 47.4 (45.1–49.8) 6.6 (5.5–7.9) <0.001 Nurse practitioner (n = 230) 8.8 (7.8–10.0) 33.9 (28.0–40.2) <0.001, 0.002 21.3 (16.4–26.9) <0.001 41.7 (35.5–48.2) 3.0 (1.4–5.9) <0.001 Gender identification Female (n = 1,072) 41.2 (39.3–43.1) 26.1 (23.6–28.8) 0.257, <0.001 29.0 (26.4–31.8) <0.001 40.1 (37.2–43.1) 4.8 (3.6–6.2) <0.001 Male (n = 1,499) 57.6 (55.7–59.5) 16.0 (14.2–17.9) <0.001, <0.001 28.5 (26.2–30.8) <0.001 49.2 (46.6–51.7) 6.3 (5.2–7.7) <0.001 Other (n = 32) 1.2 (0.9–1.7) 18.8 (8.2–34.6) 0.144, <0.001 15.6 (6.2–30.9) <0.001 37.5 (22.4–54.8) 28.1 (14.9–45.1) 0.023 Exceeded established cut scores on mental health symptom measures indicating a high probability of meeting diagnostic criteria for psychopathology § Above any cut score 25.6 (23.9 – 27.4) 37.6 (33.8–41.5) 0.904, <0.001 37.3 (33.5–41.2) <0.001 20.1 (17.1–23.5) 5.0 (3.5–7.0) <0.001 Anxiety 17.3 (15.9–18.8) 38.4 (34.0–43.0) 0.812, <0.001 39.1 (34.7–43.7) <0.001 16.4 (13.2–20.1) 6.0 (4.1–8.5) 0.001 Depression 10.2 (9.1–11.4) 35.0 (29.4–40.8) 0.219, <0.001 38.3 (32.7–44.3) <0.001 18.8 (14.5–23.8) 7.9 (5.1–11.6) 0.001 Mentally unhealthy days 11.1 (9.9–12.4) 41.0 (35.2–47.0) 0.271, <0.001 37.9 (32.2–43.9) <0.001 14.6 (10.7–19.2) 6.5 (4.0–10.0) 0.006 Posttraumatic stress 6.6 (5.7–7.6) 37.4 (30.4–44.8) 0.284, <0.001 34.5 (27.7–41.8) <0.001 22.2 (16.5–28.9) 5.8 (3.0–10.1) <0.001 Other measures and characteristics Anxiety score, mean** 1.3 (1.3–1.4) 2.1 (2.0–2.3) <0.001, <0.001 1.7 (1.6–1.8) <0.001 0.8 (0.7–0.8) 1.3 (1.1–1.6) <0.001 Depression score, mean †† 0.9 (0.8–0.9) 1.4 (1.3–1.5) 0.010, <0.001 1.2 (1.1–1.3) <0.001 0.5 (0.4–0.5) 1.0 (0.8–1.2) <0.001 No. of mentally unhealthy days, mean ¶ 4.2 (3.9–4.5) 7.8 (7.1–8.6) <0.001, <0.001 5.4 (4.8–6.0) <0.001 1.8 (1.6–2.1) 5.1 (3.5–6.7) <0.001 No. of patients per week, mean 104.6 (101.8–107.4) 103.1 (96.7–109.5) 1.000, 1.000 103.6 (98.8–108.4) 1.00 105.9 (101.6–110.1) 105.0 (93.8–116.2) 1.00 No. of work stressors, mean ¶¶ 8.3 (8.0–8.6) 10.1 (9.6–10.7) <0.001, <0.001 8.8 (8.4–9.3) <0.001 7.0 (5.8–8.1) 7.4 (7.1–7.8) 0.971 Posttraumatic stress score, mean §§ 1.2 (1.1–1.2) 1.7 (1.6–1.9) <0.001, <0.001 1.4 (1.4–1.5) <0.001 0.8 (0.7–0.9) 1.0 (0.8–1.2) 0.262 Supervisor social support score, mean*** 2.6 (2.6–2.7) 2.8 (2.7–2.9) 0.262, 0.014 2.6 (2.5–2.7) 0.693 2.5 (2.4–2.6) 2.6 (2.4–2.8) 0.946 No. of years practicing medicine, mean 15.3 (14.9–15.6) 13.0 (12.3–13.7) 0.004, <0.001 14.9 (14.2–15.5) <0.001 16.9 (16.4–17.5) 12.7 (11.5–13.9) <0.001 * p-values reported are for comparisons with “Did not seek care” and “Did not need care,” respectively. † p-values reported are for comparisons with “Did not need care.” § Cut scores are empirically established scores that, if exceeded, demarcate the threshold when the probability for a person to meet the diagnostic criteria for a related psychiatric diagnosis is very high. ¶ Mean number of mentally unhealthy days in the previous month (range = 0–30). Scores ≥14 indicate a strong likelihood of having a mental health diagnosis. ** Mean Generalized Anxiety Disorder-2 total score; two items rated 0–3 (not at all to nearly every day) (range = 0–6). Scores ≥3 indicate a strong likelihood of having a mental health diagnosis. †† Mean Patient Health Questionnaire-2 total score; two items rated 0–3 (not at all to nearly every day) (range = 0–6). Scores ≥3 indicate a strong likelihood of having a mental health diagnosis. §§ Mean Posttraumatic Stress Disorder-Primary Care Screen total score where respondents indicated how many of the five core symptoms of posttraumatic stress they had experienced because of the pandemic (range = 0–5). Scores ≥4 indicate a strong likelihood of having a mental health diagnosis. ¶¶ Mean number of work stressors experienced during the pandemic (range = 0–14). *** Mean score of social support from supervisors, rated on a scale ranging from 1–5 (never to always). Top TABLE 2. Work stressors and barriers to mental health care* reported by a sample of health care providers, by health care–seeking — Porter Novelli DocStyles survey, United States, fall 2022 and spring 2023 Work stressors/Barriers % (95% CI) Total N = 2,603 (100.0%) Sought care n = 526 (20.3%) Did not seek care n = 743 (28.7%) Did not need care n = 1,179 (45.4%) Preferred not to say n = 155 (6.0%) Work stressors Burnout 58.9 (57.0–60.7) 75.7 (71.9–79.2) 63.4 (59.9–66.8) 48.8 (45.9–51.6) 56.8 (48.9–64.4) COVID-19 misinformation 51.3 (49.4–53.2) 61.6 (57.4–65.7) 51.1 (47.6–54.7) 48.3 (45.5–51.2) 39.4 (31.9–47.2) Extra stress at work 68.2 (66.3–69.9) 81.6 (78.1–84.7) 70.4 (67.0–73.6) 61.7 (58.9–64.5) 60.6 (52.8–68.1) Fear of becoming ill with COVID-19 55.6 (53.6–57.5) 61.4 (57.2–65.5) 58.0 (54.4–61.5) 53.4 (50.6–56.3) 40.0 (32.5–47.8) Fear of spreading COVID-19 to others 49.3 (47.4–51.2) 59.9 (55.7–64.0) 52.2 (48.6–55.8) 43.5 (40.7–46.4) 43.9 (36.2–51.7) Higher workload or job demands 57.2 (55.3–59.1) 68.3 (64.2–72.1) 58.1 (54.6–61.7) 52.8 (50.0–55.7) 48.4 (40.6–56.2) Insufficient capacity to give self-care 34.2 (32.3–36.0) 49.8 (45.5–54.1) 42.5 (39.0–46.1) 22.2 (19.9–24.7) 31.6 (24.7–39.2) Isolation from family or friends 41.5 (39.0–44.0) 57.2 (51.4–62.9) 46.8 (42.2–51.4) 32.9 (29.6–36.4) 35.1 (26.1–44.9) Lack of adequate staffing 58.9 (57.0–60.7) 66.9 (62.8–70.8) 61.0 (57.4–64.4) 55.4 (52.5–58.2) 47.7 (40.0–55.6) Lack of beds for COVID-19 patients 27.2 (25.5–28.9) 31.6 (27.7–35.6) 29.1 (25.9–32.4) 25.2 (22.8–27.7) 18.7 (13.2–25.4) Lack of clear guidance or treatment protocols 45.1 (43.2–47.0) 54.2 (49.9–58.4) 45.9 (42.3–49.5) 42.3 (39.5–45.2) 31.0 (24.1–38.5) Lack of COVID-19 tests and timely results 37.8 (36.0–39.7) 43.7 (39.5–48.0) 36.2 (32.8–39.7) 37.6 (34.8–40.4) 27.1 (20.6–34.5) Lack of manager concern for my well-being 23.9 (22.3–25.6) 31.2 (27.3–35.2) 27.7 (24.6–31.0) 18.3 (16.2–20.6) 23.2 (17.1–30.3) Lack of personal protective equipment 34.1 (32.3–35.9) 39.9 (35.8–44.2) 36.7 (33.3–40.3) 30.8 (28.2–33.5) 26.5 (20.0–33.8) Lack of supplies (e.g., for cleaning) 32.5 (30.7–34.3) 39.4 (35.2–43.6) 34.7 (31.4–38.2) 29.0 (26.5–31.6) 25.2 (18.8–32.4) Longer shifts or work hours 41.2 (39.3–43.1) 47.5 (43.3–51.8) 46.7 (43.1–50.3) 34.9 (32.2–37.6) 41.9 (34.4–49.8) My job was putting me at great risk 45.2 (43.3–47.1) 54.0 (49.7–58.2) 48.5 (44.9–52.0) 40.0 (37.3–42.9) 39.4 (31.9–47.2) Need for constant awareness or vigilance 44.5 (42.6–46.4) 53.4 (49.2–57.7) 46.4 (42.9–50.0) 41.3 (38.5–44.1) 29.7 (22.9–37.2) Shortages of equipment (e.g., ventilators) 25.9 (24.2–27.6) 30.4 (26.6–34.4) 28.5 (25.4–31.9) 23.1 (20.7–25.5) 18.7 (13.2–25.4) Stigma from caring for COVID-19 patients 17.3 (15.9–18.8) 20.3 (17.1–23.9) 19.7 (16.9–22.6) 14.2 (12.3–16.2) 19.4 (13.7–26.1) Barriers to seeking care* Care costs too much money — — 19.5 (16.8–22.5) — — I am afraid of losing my job — — 6.5 (4.9–8.4) — — I am worried about confidentiality — — 21.8 (18.9–24.9) — — I had treatment before, and it didn’t help — — 5.0 (3.6–6.7) — — It’s difficult to get time off work — — 44.4 (40.9–48.0) — — I would be seen as weak — — 12.1 (9.9–14.6) — — Other reason not listed — — 39.7 (36.2–43.3) — — * Only among providers who did not seek care. Top FIGURE . Interaction* of supervisor social support † and number of work stressors § on the probability of meeting diagnostic criteria for a mental health disorder based on responses to measures of anxiety ¶ (A), depression** (B), and mentally unhealthy days †† (C) — Porter Novelli Services DocStyles Survey, United States, September 2022–May 2023 §§ * Four separate logistic regressions were assessed to determine how supervisor support, as a moderating variable, influenced the association between work stress, as a dependent variable, and the likelihood of meeting diagnostic criteria for a mental disorder in separate models for anxiety, depression, and posttraumatic stress symptoms, as well as mentally unhealthy days as dependent variables with no covariates. † Supervisor social support was rated on a scale ranging from 1–5 (never to always). § Mean number of work stressors experienced during the pandemic (range = 0–14). ¶ Anxiety was measured using the Generalized Anxiety Disorder–2 total score; two items rated from 0–3 (not at all to nearly every day) (range = 0–6). Scores ≥3 indicate a strong likelihood of having a mental health diagnosis. ** Depression was measured using the Patient Health Questionnaire–2 total score; two items rated from 0–3 (not at all to nearly every day) (range = 0–6). Scores ≥3 indicate a strong likelihood of having a mental health diagnosis. †† Mentally unhealthy days in the last month (range = 0–30). Scores ≥14 indicate a strong likelihood of having a mental health diagnosis. §§ Supervisor support did not affect the probability of meeting a mental health diagnosis for posttraumatic stress. Top Suggested citation for this article: Papa A, Barile JP, Jia H, Thompson WW, Guerin RJ. Gaps in Mental Health Care–Seeking Among Health Care Providers During the COVID-19 Pandemic — United States, September 2022–May 2023. MMWR Morb Mortal Wkly Rep 2025;74:19–25. DOI: http://dx.doi.org/10.15585/mmwr.mm7402a1 . MMWR and Morbidity and Mortality Weekly Report are service marks of the U.S. Department of Health and Human Services. 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    "scraped_date": "2025-11-14T16:26:01.383862"
  }
]