Abstract
Purpose
The COVID-19 pandemic impacted testing and incidence of sexually transmitted infections (STIs), with some studies showing uneven effects across sociodemographic groups. We aim to determine whether rates of gonorrhea and chlamydia testing and infections were affected by the pandemic, overall and by subgroups, defined by sociodemographic factors and comorbidities.
Methods
We conducted a retrospective cohort study from January 1, 2016 through December 31, 2022 among adolescents and young adults ages 15–29 years within Kaiser Permanente Northern California (KPNC). We determined the rate of testing for gonorrhea/chlamydia, and the incident rates of infections before and during the COVID-19 pandemic by sociodemographic factors. We compared incidence rates of gonorrhea/chlamydia testing and infection before and during the pandemic using Poisson regression.
Results
Gonorrhea/chlamydia testing during the pandemic was 19% lower than pre-pandemic baseline. Testing among Black patients was 1.8-fold higher than White patients. Black patients had 5.5 and 3.6-fold higher rate of gonorrhea and chlamydia infections, respectively, compared with White patients. Patients living in more deprived neighborhoods also had higher rates of infection compared to those in the least deprived neighborhoods. In multivariable analyses stratified by the period before and during the COVID-19 pandemic, there were no significant differences in the incidence rate ratios of testing or infections for any specific sociodemographic factor.
Discussion
STI testing in adolescents and young adults dropped dramatically after the start of the pandemic and has not recovered to its prior levels. Preexisting disparities in STI testing and infections were not exacerbated by the pandemic.
Keywords: Adolescent Health, STI, COVID-19, Health Disparities, Integrated Health System
Introduction
Sexually transmitted infections (STIs) continue to be a growing public health concern in the United States (U.S.). In 2022, Chlamydia trachomatis (chlamydia) was the most common STI reported to the Centers for Disease Control and Prevention (CDC), with a rate of 495.0 cases per 100,000 in the U.S. population, followed by Neisseria gonorrhea (gonorrhea) infection with a rate of 194.4 cases per 100,000.1 Within California, chlamydia cases have risen by 7.7% and gonorrhea by 16.8% from 2020 to 2021.2
National and state level data, as well as independent studies, have consistently documented healthcare disparities in STI incidence and prevalence.1–5 The CDC 2022 STI Surveillance data showed that both chlamydia and gonorrhea infections occur more frequently in Black, Hispanic, American Indian, and Native Hawaiian/Pacific Islander groups compared to the non-Hispanic White group. In California, Black females had almost 5 times higher rate of chlamydia infection compared with White counterparts.2 Similarly, Black males had 5.2 times the rate of gonorrhea infections as compared with White males.2 Adolescents and young adults ages 15 to 29 also have disproportionately higher rates of chlamydia and gonorrhea infections and represent the majority of gonorrhea and chlamydia infections in California.2
The COVID-19 pandemic disrupted routine medical care with significant reductions in STI testing and infections.1 In California, there was a significant decrease in gonorrhea and chlamydia testing and reported cases of infection.6,7 Furthermore, in the US Veterans Affairs (VA) integrated health system, there was a decrease in STI testing from 2019 to 2022 which has not reached pre-pandemic levels.8
To our knowledge, the impact on COVID-19 pandemic on sociodemographic disparities in STI testing and infections among adolescents and young adults has not been documented in the literature. The objective of this study was to investigate trends in chlamydia and gonorrhea testing and new infections among adolescents and young adults in a large, diverse, integrated health care system and to characterize sociodemographic patterns and changes before and after the onset of the COVID-19 pandemic.
Methods
Study setting, population, and design
This observational, retrospective study was conducted in Kaiser Permanente Northern California (KPNC), an integrated healthcare delivery organization that provides comprehensive medical care to over 4 million people. Patients receive almost all their medical care at KPNC facilities, including clinics, hospitals, pharmacies, and laboratories. All healthcare information is captured in a comprehensive electronic health record system which also includes membership, enrollment, and demographics. Testing for gonorrhea and chlamydia was conducted within a centralized KPNC laboratory.
The study cohort included adolescents and young adults ages 15–29 years who had KPNC membership between January 1, 2016 to December 31, 2022. The study was approved by the KPNC Institutional Review Board with a waiver of informed consent.
Outcomes
The outcomes of interest were gonorrhea and chlamydia testing and infection (positive test by polymerase chain reaction [PCR]) as per the electronic health record. Since gonorrhea and chlamydia can remain positive for a period of time after treatment, all positive tests occurring within 21 days apart were considered the same infection.9,10 Infections identified more than 21 days apart were considered as multiple infections.
Exposure/time period of interest
We assessed gonorrhea and chlamydia testing and infection rate before and during the COVID-19 pandemic. The pre-COVID-19 period was defined as January 1, 2016 to March 1, 2020, and the COVID-19 pandemic period as after March 1, 2020 until the end of the study period December 31, 2022.
Sociodemographic factors
Sociodemographic factors examined included gender (male, female, transgender, unknown), self-reported race and ethnicity (classified as Hispanic; Black, non-Hispanic; White, non-Hispanic; Asian/Pacific Islander; or other/unknown race and ethnicity), type of insurance (subsidized [i.e., government subsidized] or non-subsidized), and a neighborhood deprivation index (NDI). NDI is standardized measurement of socioeconomic status derived from U.S. Census American Community Survey (ACS) data.11 NDI is calculated using data from the ACS and combines eight socioeconomic measures, including: percent of men in management and professional occupations, percent of crowded housing, percent of households in poverty, percent of woman-headed households with dependents, percent of households on public assistance, percent of households earning less than $30,000 per year, percent earning less than high school education, and percent unemployed.
Statistical Analysis
We determined the frequency and percentage of each categorical variable of interest and means and standard deviation for continuous variables.
For each time period, we calculated the total and monthly number of gonorrhea and chlamydia tests and infections and calculated the overall and monthly incidence rate of testing and infection for the period before the COVID-19 pandemic and the period during the pandemic by dividing the number of tests and infections by the total number of persons or person-time at risk. We compared the incidence rate of testing and infection during the pre-COVID-19 period to the rate of testing and infection during COVID-19, adjusting for age at study entry, gender, race/ethnicity, NDI and insurance status using multivariable Poisson regression. We also conducted supplemental analysis to describe the distribution of tests and infections by sociodemographic groups, overall and by time defined by the COVID-19 pandemic (pre-COVID-19 and during COVID-19).
All analyses were conducted using SAS version 9.4 (SAS Institute, Cary, NC) and statistical significance was assessed at two-sided p≤0.05.
Results
The study population included 1,736,850 adolescents and young adults ages 15–29 years who had KPNC membership any time during 2016–2022. The mean age was 22.5 ± 4.1 years and 51% were male. The cohort was racially and ethnically diverse, with 31.1% White, non-Hispanic; 23.5% Hispanic; 6.5% Black, non-Hispanic; 17.9% Asian, and 20.9% other or unknown race and ethnicity. (Table 1)
Table 1:
Demographic Characteristics of the Adolescent and Young Adult Cohort, 2016–2022
| Study Population | N = 1,736,850 (%) |
|---|---|
| Age categories | |
| 15 – 19 years | 466,612 (26.9) |
| 20 – 24 years | 634,607 (36.4) |
| 25 – 29 years | 635,631 (36.6) |
| Mean age, years (SD) | 22.5 (4.1) |
| Sex | |
| Male | 886,474 (51.0) |
| Female | 848,418 (48.9) |
| Transgender | 1,018 (0.1) |
| Other/Unknown | 940 (0.1) |
| Race and Ethnicity | |
| White, non-Hispanic | 539,973 (31.1) |
| Hispanic | 408,551 (23.5) |
| Black, non-Hispanic | 113,346 (6.5) |
| Asian, non-Hispanic | 311,451 (17.9) |
| Other/Unknown | 363,529 (20.9) |
| Insurance status | |
| Subsidized or government | 62,899 (3.6) |
| Non-subsidized | 1,673,951 (96.4) |
| Neighborhood Deprivation Index | |
| 1st quartile (least deprived) | 428,098 (24.7) |
| 2nd quartile | 427,839 (24.6) |
| 3rd quartile | 428,464 (24.7) |
| 4th quartile (most deprived) | 427,998 (24.6) |
| Missing | 24,451 (1.4) |
| Individuals tested for gonorrhea | 626,459 (0.4) |
| Individuals tested for chlamydia | 626,456 (0.4) |
Testing
A total of 1,526,385 PCR tests for gonorrhea or chlamydia were performed between January 1, 2016 and December 31, 2022. Of these, 979,481 tests were performed prior to March 1, 2020 (pre-COVID-19 pandemic), and 546,904 tests were after March 1, 2020 and up to December 31, 2022 (during COVID-19 pandemic). (Supplemental Table 1)
During the pre-COVID-19 pandemic period, the average rate per 1,000 person-months of gonorrhea and chlamydia testing was 24.9 tests compared to 19.69 tests during the pandemic period. Monthly testing rates varied across the overall study period, with the lowest rate of 7.46 tests per 1,000 person-months occurring during the pandemic in the month of April 2020. Since April 2020, monthly testing rates have increased, reaching 20.14 tests per 1,000 person-months by December 2022. (Figure 1)
Figure 1:
Trends in Gonorrhea and Chlamydia Testing Incidence (calculated monthly per 1,000)
Blue line: average rate of testing per 1,000 prior to March 1, 2020
Red line: average rate of testing per 1,000 after March 1, 2020
There was a 19% decline in the rate of testing during the COVID-19 pandemic (adjusted incidence rate ratio [aIRR] 0.81, 95% confidence interval [CI] 0.77–0.86). (Table 2)
Table 2.
Adjusted and Unadjusted Incidence Rate Ratios (IRR) for Testing and Infection with Gonorrhea and Chlamydia
| Group | Testing | Chlamydia | Gonorrhea | |||
|---|---|---|---|---|---|---|
| Unadjusted IRR (95% CI) | Adjusted IRR (95% CI) | Unadjusted IRR (95% CI) | Adjusted IRR (95% CI) | Unadjusted IRR (95% CI) | Adjusted IRR (95% CI) | |
| COVID-19 | ||||||
| Pre | Reference | Reference | Reference | Reference | Reference | Reference |
| During | 0.87 (0.72–1.05) | 0.81 (0.77–0.86) | 0.92 (0.75–1.13) | 0.90 (0.83–0.97) | 1.16 (0.95–1.42) | 1.14 (1.04–1.25) |
| Age | ||||||
| 15–19 years | 0.81 (0.63–1.04) | 0.63 (0.58–0.68) | 1.27 (0.97–1.65) | 0.90 (0.81–1.00) | 0.62 (0.46–0.84) | 0.41 (0.35–0.47) |
| 20–24 years | 1.28 (1.04–1.57) | 1.23 (1.16– 1.31) | 1.87 (1.49–2.35) | 1.70 (1.56–1.85) | 1.14 (0.92–1.42) | 1.00 (0.90–1.10) |
| 25–29 years | Reference | Reference | Reference | Reference | Reference | Reference |
| Gender | ||||||
| Male | Reference | Reference | Reference | Reference | Reference | Reference |
| Female | 3.79 (3.12–4.61) | 2.97 (2.78–3.17) | 2.74 (2.25–3.33) | 2.04 (1.88–2.20) | 0.81 (0.66–1.00) | 0.57 (0.52–0.63) |
| Trans/Other | 5.83 (0.70–48.67) | 3.13 (1.53–6.38) | 8.96 (0.53–152.1) | 4.31 (1.38–13.42) | 24.11 (5.58104.2) | 13.42 (6.79–26.53) |
| Race | ||||||
| White, non-Hispanic | Reference | Reference | Reference | Reference | Reference | Reference |
| Hispanic | 1.11 (0.89–1.39) | 1.17 (1.09–1.25) | 1.55 (1.22–1.96) | 1.61 (1.47–1.77) | 1.42 (1.11–1.80) | 1.52 (1.34–1.72) |
| Black, non-Hispanic | 1.59 (1.18–2.13) | 1.76 (1.60–1.93) | 3.25 (2.49–4.25) | 3.60 (3.24–4.01) | 4.79 (3.76–6.11) | 5.46 (4.81–6.20) |
| Asian | 0.89 (0.67–1.18) | 0.79 (0.73–0.87) | 0.81 (0.58–1.11) | 0.79 (0.69–0.90) | 0.80 (0.57–1.11) | 0.75 (0.63–0.89) |
| Other/Unknown | 0.59 (0.38–0.92) | 0.53 (0.47–0.61) | 0.67 (0.42–1.05) | 0.65 (0.54–0.78) | 0.84 (0.54–1.31) | 0.62 (0.49–0.78) |
| NDI | ||||||
| 1st quartile | Reference | Reference | Reference | Reference | Reference | Reference |
| 2nd quartile | 1.01 (0.79–1.29) | 1.00 (0.92–1.08) | 1.30 (0.98–1.73) | 1.24 (1.10–1.39) | 1.05 (0.78–1.42) | 1.05 (0.91–1.21) |
| 3rd quartile | 1.02 (0.80–1.31) | 1.00 (0.92–1.08) | 1.36 (1.03–1.80) | 1.38 (1.24–1.54) | 1.14 (0.85–1.53) | 1.18 (1.02–1.35) |
| 4th quartile | 1.04 (0.81–1.33) | 1.00 (0.92–1.08) | 1.65 (1.26–2.17) | 1.63 (1.46–1.81) | 1.51 (1.15–1.99) | 1.56 (1.37–1.78) |
| Missing | 0.03 (0.01–0.11) | 0.02 (0.01–0.03) | 0.05 (0.01–0.22) | 0.03 (0.02–0.05) | 0.10 (0.02–0.43) | 0.05 (0.02–0.09) |
| Insurance status | ||||||
| Subsidized | 0.19 (0.15–0.24) | 0.15 (0.14–0.17) | 0.24 (0.19–0.31) | 0.19 (0.17–0.21) | 0.27 (0.21–0.34) | 0.21 (0.19–0.24) |
| Non-subsidized | Reference | Reference | Reference | Reference | Reference | Reference |
Rate of testing was also lower among patients aged 15–19 years compared with those aged 25–29 years (aIRR 0.63, 95% CI 0.58–0.68), although higher among patients ages 20–24 years compared with the same reference group (aIRR 1.23, 95% CI 1.16–1.31). Across racial/ethnic groups, Black patients had the highest incident testing (aIRR 1.76, 95% CI 1.60–1.93) compared with White patients. Patients who lived in neighborhoods with the 4th NDI quartile (most deprived) had a similar rate of testing compared with those who lived in neighborhoods with the 1st NDI quartile (least deprived) (aIRR 1.00, 95% CI 0.92–1.08). However, patients with subsidized insurance had a lower incident testing (aIRR 0.15, 95% CI, 0.14–0.17) compared with patients with non-subsidized insurance.
Chlamydia Infections
The overall average monthly rate of chlamydia prior to the pandemic was 117 per 100,000 person-months. During COVID-19, the monthly rate of chlamydia reached an average of 102 per 100,000 person-months. (Figure 2) After the start of COVID-19, the monthly rate of laboratory diagnosed chlamydia decreased to a nadir of 52 infections per 100,000 person-months during April 2020. There was a 10% decrease in chlamydia infection during the pandemic compared to the period before the pandemic (aIRR 0.90, 95% CI 0.83–0.97). (Table 2)
Figure 2.
Trends in monthly rate of Gonorrhea and Chlamydia Infections (per 100,000)
Among chlamydia diagnoses, 47% were 20–24 years old, 67% were females, 35.6% were Hispanic, 21.9% were Black, 25.8% were White, and 11.9% were Asian. The proportion of Hispanic patients among chlamydia positives was increased during the pandemic (33.8% before versus 38.4% during the pandemic) and the proportion of White patients among chlamydia positives decreased (27.9% before to 22.4% during the pandemic). (Supplemental Table 2)
Female patients had two times the risk of having a positive chlamydia test compared to males (aIRR 2.04, 95% CI 1.88–2.20). (Table 2) Black patients had more than three times the risk of a positive chlamydia test compared to White patients (aIRR = 3.60, 95% CI 3.24–4.01). Those in the 4th NDI quartile (most deprived) had a 63% higher risk of chlamydia infection compared to those in the 1st NDI quartile (least deprived) (aIRR 1.63, 95% CI 1.46–1.81).
Gonorrhea Infections
The average monthly rate of gonorrhea during COVID-19 rose to 25 per 100,000 person-months compared with 22 per 100,000 person-months prior to the pandemic. (Figure 2) There was a 14% increase in gonorrhea infections after the start of the pandemic (aIRR 1.14, 95% CI 1.04–1.25). (Table 2)
Among gonorrhea diagnoses, 42% were 25–29 years old, 64% were males, 30.9% were Hispanic, and 29.4% were Black. The proportion of Hispanic patients among gonorrhea positives was slightly increased during the pandemic (29.1% before versus 33.2% during the pandemic). However, the proportion of Black patients did not change (29.7% before versus 29.1% during the pandemic). (Supplemental Table 3)
In adjusted analysis, Black patients had 5.5 times the risk of gonorrhea infection when compared with White patients (aIRR 5.46, 95% CI 4.81–6.20). (Table 2) Those in the 4th NDI quartile (most deprived) had a 56% higher risk of gonorrhea infection compared with the least deprived group (aIRR 1.56, 95% CI 1.37–1.78).
In additional multivariable analyses stratified by the period before and after COVID-19, there were similar rates of testing, chlamydia infections, and gonorrhea infections for all examined sociodemographic groups. (Table 3)
Table 3.
Adjusted Incidence Rate Ratios for Testing and Infections before and during the COVID-19 Pandemic
| Group | Testing | Chlamydia | Gonorrhea | |||
|---|---|---|---|---|---|---|
| Pre-COVID | During COVID | Pre-COVID | During COVID | Pre-COVID | During COVID | |
| IRR (95% CI) | IRR (95% CI) | IRR (95% CI) | IRR (95% CI) | IRR (95% CI) | IRR (95% CI) | |
| Age | ||||||
| 15–19 years | 0.67 (0.60– 0.75) | 0.55 (0.49–0.62) | 0.96 (0.83–1.11) | 0.82 (0.71–0.94) | 0.42 (0.35–0.52) | 0.38 (0.32–0.46) |
| 20–24 years | 1.26 (1.15–1.38) | 1.19 (1.09– 1.30) | 1.71 (1.51–1.94) | 1.69 (1.50–1.89) | 0.99 (0.85–1.15) | 1.01(0.88–1.16) |
| 25–29 years | Reference | Reference | Reference | Reference | Reference | Reference |
| Gender | ||||||
| Male | Reference | Reference | Reference | Reference | Reference | Reference |
| Female | 3.06 (2.79–3.36) | 2.82 (2.57–3.09) | 2.05 (1.83–2.30) | 2.01 (1.81–2.24) | 0.55 (0.48–0.64) | 0.60 (0.52–0.68) |
| Transgender/Other | 2.99 (0.96–9.29) | 3.24 (1.38–7.62) | 4.28 (0.72–25.60) | 4.41 (1.12–17.37) | 19.68 (6.77–57.22) | 10.84 (4.57–25.70) |
| Race and Ethnicity | ||||||
| White, non-Hispanic | Reference | Reference | Reference | Reference | Reference | Reference |
| Hispanic | 1.14 (1.04–1.26) | 1.22 (1.10–1.34) | 1.49 (1.30–1.71) | 1.83 (1.61–2.09) | 1.40 (1.16–1.67) | 1.69 (1.42–2.01) |
| Black, non-Hispanic | 1.70 (1.49–1.93) | 1.89 (1.66–2.15) | 3.38 (2.90–3.93) | 4.05 (3.49–4.70) | 5.14 (4.29–6.16) | 5.96 (4.98–7.14) |
| Asian | 0.79 (0.70–0.90) | 0.80 (0.70–0.90) | 0.78 (0.65–0.94) | 0.81 (0.68–0.98) | 0.73 (0.57–0.93) | 0.78 (0.61–1.0) |
| Other/Unknown | 0.53 (0.43–0.65) | 0.55 (0.46–0.65) | 0.62 (0.46–0.82) | 0.72 (0.57–0.90) | 0.57 (0.40–0.82) | 0.69 (0.51–0.92) |
| NDI | ||||||
| 1st quartile | Reference | Reference | Reference | Reference | Reference | Reference |
| 2nd quartile | 1.04 (0.93–1.16) | 0.94 (0.84–1.05) | 1.27 (1.07–1.49) | 1.19 (1.02–1.39) | 1.05 (0.85–1.29) | 1.04 (0.86–1.27) |
| 3rd quartile | 1.03 (0.92–1.16) | 0.94 (0.84–1.05) | 1.38 (1.18–1.62) | 1.38 (1.19–1.60) | 1.19 (0.97–1.45) | 1.16 (0.96–1.41) |
| 4th quartile | 1.01 (0.91–1.14) | 0.98 (0.87–1.09) | 1.61 (1.38–1.88) | 1.66 (1.44–1.91) | 1.55 (1.28–1.87) | 1.59 (1.33–1.89) |
| Missing | 0.02 (0.01–0.04) | 0.01 (0.01–0.03) | 0.03 (0.02–0.07) | 0.02 (0.01–0.06) | 0.04 (0.02–0.11) | 0.05 (0.02–0.15) |
| Insurance status | ||||||
| Subsidized | 0.15 (0.13–0.17) | 0.17 (0.15–0.19) | 0.18 (0.16–0.21) | 0.21 (0.18–0.24) | 0.20 (0.17–0.24) | 0.23 (0.20–0.27) |
| Non-subsidized | Reference | Reference | Reference | Reference | Reference | Reference |
IRR = incidence rate ratio; CI = confidence interval; NDI = neighborhood deprivation index
Discussion
In a large integrated health care system, we found that the COVID-19 pandemic had a significant, but not uniform, effect on testing and incidence rates of gonorrhea and chlamydia in adolescents and young adults. By the end of 2022, testing rates were at 81% of their pre-pandemic level. Infection data also show that while chlamydia infections remained 10% lower than their pre-pandemic levels, gonorrhea infections steadily rose and surpassed pre-pandemic levels.
Overall, our study demonstrated a fall and rise in testing rates in the adolescent and young adult population which mirrors the patterns seen on a state and national level.1,6,12 Surveillance data from California and data from other integrated health systems have shown decreases in testing after the start of the COVID-19 pandemic.6,7,8 Reasons why testing in 2022 did not reach or surpass pre-pandemic levels is unclear. Within KPNC, collection for STI testing can be performed by a provider or by self-collection at any KPNC laboratory. Patients are able to request testing through an office visit, telephone message, or through secure message through the patient portal. Therefore, access to testing should not be a significant barrier within KPNC. It is possible that behaviors could have changed during the pandemic, but the rise in new gonorrhea infections suggests ongoing sexual activity and community transmission. Further qualitative studies would be helpful to address the reduction in gonorrhea/chlamydia testing.
Our data also illustrate persistent sociodemographic disparities in STI incidence. Those who reside in the most deprived neighborhoods experienced 1.6-fold higher incidence of gonorrhea and chlamydia infections compared to the least deprived quartile. Young Hispanic and Black patients had significantly higher rates of STI infection compared to White patients. Our results suggest disparities in infections existed prior to the pandemic and persisted during the pandemic. In our analysis, the pandemic did not exacerbate pre-existing or create new disparities. Further studies are needed to determine why certain populations, though engaging in appropriate preventative care, experience disproportionate rates of infection.
There are several limitations to our study. First, KPNC patients are insured and therefore our findings may not represent uninsured or socioeconomically vulnerable populations impacted by STIs. Over 96% of the study population had non-subsidized insurance, which likely impacted our analysis of the impact on gonorrhea/chlamydia testing and infections in the subsidized insurance group. Second, we were unable to account for STI testing data performed outside of KPNC, although this would be unlikely to occur due to accessibility and convenience of KPNC laboratories. Third, we had insufficient data on sexual orientation, gender of sexual partners, transgender, and non-binary gender identities to further examine gonorrhea and chlamydia testing and infection rates associated with these factors. Despite these limitations, our study includes a sociodemographically diverse population receiving care within an integrated healthcare delivery system.13
Conclusion
In summary, the COVID-19 pandemic led to a reduction in STI testing rates that have not returned to pre-pandemic levels. Our study also shows a persistent, high burden of chlamydia and gonorrhea infection among adolescents and young adults and persistent disparities in infection rates for Hispanic and Black populations and those residing in areas with less socioeconomic advantage. While the COVID-19 pandemic did not exacerbate these disparities in our healthcare system, further studies and targeted interventions are needed to address the high STI rates in priority populations.
Supplementary Material
Implications and Contributions.
Sexually transmitted infections are a growing public health threat affecting adolescents and young adults. This study determines the rates of gonorrhea and chlamydia testing and infections before and during the pandemic and its impact on sociodemographic groups in a large, integrated health system.
Acknowledgements:
We thank Dr. Joan Lo for her help with manuscript revisions and support of Graduate Medical Education research.
Financial Sources:
This work was supported by grants from the National Institute of Allergy and Infectious Diseases (K01AI139275 to O.Z.) and research analyst support from the Kaiser Permanente Northern California Graduate Medical Education Program. Dr. Klein reported receiving research support from Pfizer, Merck, GlaxoSmithKline, Sanofi, and Seqirus.
Footnotes
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