Adapting Survey Data Collection to Respond to the COVID-19 Pandemic: Experiences From a Local Health Department

Abstract

The New York City (NYC) Department of Health and Mental Hygiene (“Health Department”) conducts routine surveys to describe the health of NYC residents. During the COVID-19 pandemic, the Health Department adjusted existing surveys and developed new ones to improve our understanding of the impact of the pandemic on physical health, mental health, and social determinants of health and to incorporate more explicit measures of racial inequities.

The longstanding Community Health Survey was adapted in 2020 to ask questions about COVID-19 and recruit respondents for a population-based severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) serosurvey. A new survey panel, Healthy NYC, was launched in June 2020 and is being used to collect data on COVID-19, mental health, and social determinants of health. In addition, 7 Health Opinion Polls were conducted from March 2020 through March 2021 to learn about COVID-19–related knowledge, attitudes, and opinions, including vaccine intentions.

We describe the contributions that survey data have made to the emergency response in NYC in ways that address COVID-19 and the profound inequities of the pandemic. (Am J Public Health. 2021;111(12):2176–2185. https://doi.org/10.2105/AJPH.2021.306515)

On March 16, 2020, Division of Epidemiology staff in the New York City (NYC) Department of Health and Mental Hygiene (“Health Department”) who design and implement surveys left coffee cups on desks and sweaters on chairs and rapidly prepared to begin working from home because of the COVID-19 pandemic. Our immediate goal was to sustain survey operations for routine Health Department public health surveillance and add questions about COVID-19 to our annual survey of adults. As the pandemic exposed the various ways that systemic racism contributed to higher risk of COVID-19 illness and death in Black, Latino, and Indigenous communities,¹ the country also witnessed the killings of Breonna Taylor and George Floyd. Daily protests against racial inequity and police brutality swept the city, and racism was named nationwide as a public health issue.² The Health Department has taken steps during the COVID-19 pandemic to adjust existing surveys and develop new ones to improve our understanding of the impact of the pandemic on physical health, mental health, and social determinants of health and to incorporate more explicit measures of racial inequities.

NEW YORK CITY COMMUNITY HEALTH SURVEY

When the first COVID-19 case was detected in NYC on February 29, 2020,³ the 2020 Community Health Survey (CHS) had been in the field for just over a month. The CHS is an annual multilingual surveillance survey of adults that measures health and risk behaviors.⁴ This survey was telephone based from 2002 to 2020 and has been widely used to guide policy and programming,^5,6 inform the public about the health of NYC residents,^7,8 and answer research questions.⁹ The CHS is used to measure health inequities by demographic characteristics¹⁰ and by neighborhood¹¹ and to measure changes over time.¹² When the first COVID-19 case was detected in NYC, 2 immediate goals developed: (1) how to ensure continuity of survey operations and maintain data to inform trend analyses, and (2) how to adapt the CHS to inform the emergency response.

Adapting Operations

The primary hurdle to operating the CHS during the pandemic was the telephone interview process. Historically, a contracted vendor had conducted CHS interviews on landlines and later cell phones¹³ in physical call centers. The COVID-19 pandemic made it impossible to safely continue call center operations because of the inability to socially distance in centers such as these.¹⁴ The Health Department and its contractor worked together to revise protocols to allow interviewers to work from home by having access to equipment, connectivity, security, and a private space. By the third week of March 2020, virtual call centers were established. Once interviewers began working from home, the vendor and the Health Department continued their standard practice of monitoring telephone interviews to ensure data quality. The survey vendor calculated predictive margins¹⁵ to compare responses to a selection of survey questions among respondents, controlling for the demographic characteristics of the respondent and whether the survey interview was conducted in a physical versus virtual call center.

On several key health indicators, but not all, calls made from the virtual versus physical call centers did not yield statistically different estimates.¹⁶ Another indicator that the shift to virtual call centers was not detrimental was the survey response rates. At the beginning of data collection in early February 2020, CHS response rates were less than 8%. By April 14, they had risen to greater than 10%, where they remained through early August. By contrast, from April through August 2019, CHS response rates approached only 8% in May and never rose higher than 8% (Figure 1). The final 2020 response rate was 7.4%, very similar to the 7.2% response rate in 2019 when all interviews were conducted in physical call centers.

FIGURE 1—

Community Health Survey Response Rates: NYC, 2019 and 2020

Note. NYC = New York City. We calculated response rates using the American Association for Public Opinion Research Response Rate #3 calculation for combined landline and cell phones, except in February 12–March 3, 2020, when only cell phones were dialed. In addition, the dates shown represent 2020 dates of reporting; 2019 dates were reported on slightly different days, almost always within 2 days of the 2020 dates. In 2019, data collection did not begin until March, and therefore data are not available for earlier months.

Adapting Questionnaire Content

The Health Department recognized during the early days of the pandemic that the CHS representative sample design could be used to collect COVID-19 burden of disease data. However, the survey needed to be adapted in 2 ways. First, the questionnaire was finalized in November 2019, but we needed to add COVID-19–related questions. We developed questions capturing respondent symptoms in the past 30 days that were consistent with COVID-19–like illness (CLI),¹⁷ as well as questions about underlying conditions and health care–seeking behavior. Among households with children, we asked adult respondents about CLI symptoms of a randomly selected child aged 0 to 17 years in their household. On March 20, 2020, we initiated the CHS COVID-19 module. We adapted the COVID-19 module in subsequent months as knowledge emerged about COVID-19 symptoms, racial inequities in morbidity and mortality, and impacts of the pandemic on social and economic security.^18–20 For example, we added questions about loss of smell and taste, symptoms strongly associated with COVID-19,²¹ broadened a question about experiencing discrimination in connection to COVID-19 from being asked only of respondents who had experienced symptoms to all respondents, and added a question about job loss owing to the pandemic.

Adapting Survey Weights

A second adaptation of the CHS was the creation of special survey weights. In a typical year of CHS data collection, 1 set of weights is created to enhance the representativeness of the data. For the COVID-19 questions, however, more sample weights were needed, including a weight of all respondents who completed the survey in a calendar month, a cumulative weight, and a weight to enable monthly estimates of people with new symptom onset for a given month. This last weight included respondents interviewed in a given month, as well as those interviewed for the subsequent 30 days, because the survey asked about symptoms within the past 30 days. Respondents were given greater weight for the proportion of their 30-day look-back period that occurred in the month of interest, in order to estimate monthly incidence of a new onset of symptoms.¹⁷ Although this weighting approach could have introduced bias if the COVID-19 case rate changed from week to week, respondents who were interviewed later in any given month were unlikely to differ in other dimensions from those interviewed earlier because the CHS was a random-digit dialing telephone survey.

HEALTHY NYC

Data collection for the 2020 CHS concluded on August 31, and we needed to find a different format for collecting COVID-19 data starting in September 2020. Before the COVID-19 pandemic, the Health Department had started to plan the creation of a probability-based panel of survey respondents that could facilitate Health Department survey research. Although panels have limitations, including possible panel attrition,²² by drawing on an engaged group of panel members who have already agreed to participate in surveys, survey panels offer a timely and cost-effective option for public health surveillance, as they decrease recruitment costs and increase response rates.²³ In fall 2019, we started to investigate survey software programs to facilitate survey administration and panel maintenance and developed a sampling methodology. Most participants would be recruited through an address-based sample, which would be supplemented by participants in previous probability-based Health Department surveys who had agreed to be recontacted.

The pandemic posed an urgent need for the Health Department to establish the new Healthy NYC panel so that monthly COVID-19 data collection could continue. Healthy NYC would also enable more in-depth exploration of occupational risk factors, the mental health burden of COVID-19, and racial inequities in COVID-19 prevalence, testing, and morbidity.²⁴ A grant to build epidemiology and laboratory capacity from the Centers for Disease Control and Prevention helped support the launch of Healthy NYC.

We initially planned to conduct Healthy NYC surveys online, with paper surveys sent by mail to nonresponders. However, because staff were working from home, we did not have staff in the office to process questionnaires. Therefore, we created a virtual telephone call center for respondents who were unable or unwilling to use the Internet. We trained 25 Health Department staff to conduct surveys by telephone and enter data into an online data capture system. After recruitment efforts in June and September 2020, Healthy NYC had 9315 panelists by January 2021.

Healthy NYC was particularly suited to supporting the emergency response because the Health Department would fully manage and operate data collection, aside from using contracted survey software and incentive distribution. Moving most work in-house rather than using vendors enabled the Health Department to be nimble in survey administration. City government contracting processes start long before a project begins and do not allow much flexibility once they are in place. By moving away from vendors and contracts, we were able to quickly implement surveys and adapt them when the pandemic evolved.

Questionnaire Development

In August 2020, we conducted the first survey among Healthy NYC panelists, a COVID-19 survey that mirrored the COVID-19 module in the CHS. This survey was implemented concurrently with the last month of CHS 2020 data collection, which enabled us to compare the CHS-based and Healthy NYC–based estimates. The different survey modes and sampling frames between the 2 surveys produced similar estimates of CLI incidence, defined as CLI symptoms starting on August 1 or later (4.3% CHS; 5.7% Healthy NYC; P > .05). However, Healthy NYC yielded higher estimates of CLI prevalence than did CHS, where prevalence was defined as CLI symptoms during the past 30 days, irrespective of the date of symptom onset (10.8% CHS; 18.1% Healthy NYC; P < .05).²⁵ It is possible that survey respondents felt more comfortable affirming symptoms of COVID-19 in the predominantly Web-based Healthy NYC than in the telephone-based CHS because of Web surveys raising fewer concerns about social desirability²⁶ or contact tracing.

In September, we continued to revise the COVID-19 questions to improve measurement of CLI. For example, we asked respondents about symptom onset in the last calendar month instead of the past 30 days to improve and simplify weighting and incidence calculations. We revised symptom questions to align with the updated interim case definition from the Council of State and Territorial Epidemiologists for CLI.²⁷ We removed questions about children living with survey respondents because of small sample sizes and to shorten the survey. As evidence emerged that some COVID-19 patients were experiencing prolonged symptoms after COVID-19 infection, we added questions to assess prevalence of “long COVID.”²⁸

The transition of COVID-19 data collection from CHS to Healthy NYC also enabled us to include questions to better capture inequities, social determinants of health, and mental health consequences of COVID-19. For example, early in the pandemic it was apparent that hospital workers and frontline essential workers were contracting COVID-19 at higher rates than was the general public.²⁹ We added questions to capture respondents’ occupation and industry, as well as questions about the use of public transportation, ability to maintain distance from others at work, and interactions with patients in health care settings. These data will allow us to measure the association between employment risk factors and CLI or severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) seropositivity.

We also conducted a Healthy NYC survey focused on mental health that asked about respondents’ emotions; symptoms of depression and anxiety; sources of stress, loneliness, and mental health care; and their children’s mental health. This survey expanded on the CHS questions on mental health, which were limited to the Kessler 6 distress scale³⁰; questions about having received medication or counseling; and questions about unmet mental health care need. In addition, building on a 2017 survey about social determinants of health that included questions about experiences of discrimination, social relationships, material hardship, and other topics,³¹ we conducted a similar survey in 2020 with the new panel, adding questions about whether health care appointments were missed because of fear of the virus or lack of provider availability owing to the pandemic and social isolation in the context of the pandemic.

Implementing a Serosurvey

As the pandemic evolved, interest grew in measuring the proportion of the NYC population who may have ever had a SARS-CoV-2 infection. In June 2020, the Health Department began recruitment from the CHS for a population-based serosurvey to measure SARS-CoV-2 antibody prevalence among NYC adults. We contracted with a vendor to schedule appointments and send phlebotomists to participants’ homes to collect blood specimens. Specimens were tested at the Health Department Public Health Laboratory. We aimed to recruit a minimum of 1000 participants for specimen collection from June through October; however, only 497 survey respondents consented to participate and completed the blood draw. By mid-June, recognizing that the response rate was lower than anticipated, we added a $30 gift card incentive. Before the incentive went into effect, 27.1% of CHS participants agreed to be contacted for the serosurvey; by the end of the CHS data collection period, 31.4% had agreed to be contacted. In addition, we developed a hybrid approach for determining whether respondents had SARS-CoV-2 antibodies: we used serosurvey data from those who provided blood and self-reported data from those who did not but provided a self-reported antibody test result.³²

We conducted our second population-based SARS-CoV-2 serosurvey via Healthy NYC from November 2020 through February 2021. Participants were recruited from Healthy NYC respondents who answered the COVID-19 survey questions. Having already learned from the CHS that serosurvey recruitment was lower than expected, we included a question in the COVID-19 module of Healthy NYC surveys administered from August through October asking whether the respondent would be willing to be contacted during the upcoming year to participate in the serosurvey, so our sample would not be limited to respondents beginning in November. Of the 7629 people who were invited to take Healthy NYC surveys that included serosurvey recruitment, 1929 agreed to participate and 763 completed the blood draw. Although the respondents who had their blood drawn may be different from those who did not, we have mitigated possible bias by creating survey weights to adjust for differences between serosurvey participants and the NYC adult population and for differences between respondents and nonrespondents.

POLLING ABOUT COVID-19

In 2019, the Health Department launched a new Health Opinion Poll (HOP) to capture NYC residents’ health-related knowledge, opinions, and attitudes. Five surveys had been conducted by the time the COVID-19 emergency began. Adult respondents were quota-sampled from nonprobability online panels through a vendor and weighted per American Community Survey 5-year estimates to match the NYC population on county, race/ethnicity, age, sex, and educational attainment. Recognizing the importance of opinion data as a complement to case-based surveillance and population surveys, we conducted 6 polls in 2020. These surveys assessed knowledge about COVID-19 transmission and prevention, awareness of information sources about COVID-19 and trust in those sources, adherence to social distancing and face-covering guidelines, opinions about NYC’s efforts to contain the outbreak, concerns about contact tracing and quarantine guidelines, attitudes toward vaccination and testing, experiences of discrimination, and the impact of the pandemic on health care access, physical activity, mental health,³³ financial stress, household food security, and children’s behavioral and emotional health.

These data have illustrated the inequities in New Yorkers’ experiences throughout the pandemic. For example, in October 2020, anxiety was more commonly reported among respondents in higher poverty neighborhoods than in lower poverty neighborhoods, and financial stress was more common among Latino and Black respondents than among White respondents.³⁴ HOP data have been particularly essential to guiding the Health Department in its efforts to implement a COVID-19 vaccination campaign (Table 1).

TABLE 1—

Description of COVID-19 Vaccine-Related Data Collected and How Data Have Been and Will Be Used to Inform the Health Department’s COVID-19 Vaccine Rollout: NYC Health Opinion Poll; October and December 2020

Data Collected	How Data Have Been and Will Be Used
COVID-19 vaccine intentions (evaluated at multiple time points)	Evaluation over time of the impact of vaccine availability, vaccination campaigns, and promotional messages on vaccine acceptance Identification of groups that may benefit from tailored promotional messages
Reasons people are or are not getting COVID-19 vaccines	Creation of promotional messages to be used in a citywide vaccination campaign Development of community engagement strategies
Preferences for which populations should receive early limited doses of vaccine	Development of communication to explain prioritization decisions where they are not aligned with NYC residents’ preferences Preparation for vaccine rollout Planning for gathering further public input about prioritization
Preferences for where to receive a COVID-19 vaccine	Informing decisions on vaccine allocation to vaccination sites during the distribution phase in which there is wide public availability
Trusted sources to increase comfort level in receiving a COVID-19 vaccine	Development of promotional messages and community-based partnerships Understanding of potential influence of Health Department messaging Communication to providers emphasizing their role in providing vaccine recommendations to increase uptake Identifying trusted messengers

Note. NYC = New York City.

In March 2021 HOP was conducted for the first time through the Healthy NYC panel. One methodological challenge that emerged as HOP data collection transitioned from a vendor’s nonprobability online panels to the Health Department’s probability-based panel was how to interpret changes in estimates over time. For example, in December 2020, using the nonprobability panels, we found that 55.3% of NYC adults intended to be vaccinated. In March 2021, using the Healthy NYC panel, we found that 81.6% of adults had already been or intended to be vaccinated.³⁵ Because of the difference in sampling frames between the December and March polls, it is difficult to know the extent to which this change over time is attributable to survey methodology versus a true attitudinal shift or vaccine availability. Future HOPs using Healthy NYC will allow us to examine trends over time.

HEALTH DEPARTMENT SURVEYS IN 2021

During the second year of the COVID-19 pandemic, the Health Department is continuing to collect survey data to support the emergency response. The CHS began data collection in March 2021, and it includes the COVID-19 module as well as recruitment for a third SARS-CoV-2 serosurvey. To account for the effect of vaccination, the third serosurvey asks whether respondents have been vaccinated, the number of doses they should have received, and the number and timing of doses they actually received. Another survey, NYC KIDS, is a biennial survey that was telephone based in 2017 and 2019 and collects data from a parent or guardian about children aged 1 to 13 years. The survey is being conducted in NYC on schedule in 2021 using new sampling frames and survey modes and includes questions on CLI symptoms and health care–seeking behavior, as well as questions about CLI in a randomly selected child aged 14 to 17 years among households that have a child in that age range. The high school and middle school Youth Risk Behavior Surveys, planned for fall 2021 and 2022, respectively, will also include questions capturing how the pandemic has affected youths.

In addition, a central effort of our surveillance surveys is to measure and describe pandemic-related inequities. The health inequities of the COVID-19 pandemic and its economic outcomes, combined with continued police violence toward Black and Latino NYC residents, have further exposed systemic racism in NYC.³⁴ In an effort to measure the public health crisis of racism,² social and economic insecurity, and mental health need, our surveys include questions that assess the mental health and socioeconomic impacts of the pandemic for children, adolescents, and adults. For example, our surveys ask about topics such as food and housing insecurity, financial stress, emergency childcare arrangements for essential workers, and technology access for students during remote learning.

Healthy NYC is fielding regular surveys measuring vaccine attitudes, access, and uptake, and the data are being analyzed by race/ethnicity of respondents. Additionally, the Health Department has added more questions about racial and ethnic heritage or ancestry groups to improve our ability to provide data for specific groups. Healthy NYC, NYC KIDS, and CHS currently include questions about Asian, Black, and Latino heritage or ancestry, and the 2021 NYC KIDS and CHS surveys additionally include questions about Middle Eastern/North African and Native American heritage or ancestry. For the first time, the High School Youth Risk Behavior Survey planned for 2021 will include detailed Asian and Latino heritage or ancestry questions. These changes will provide more complete data to measure potential health and racial inequities associated with the COVID-19 pandemic.

COVID-19 has also reinforced the need to confront decades of distrust toward the government in communities of color, including how we build trust with survey participants. HOP data show that in December 2020, 56.6% of Asian/Pacific Islander, 33.2% of Black, 51.4% of Latino, and 50.5% of other or multiracial respondents planned to get the COVID-19 vaccine, compared with 72.5% of White respondents (Table 2),³⁵ a disparity likely rooted, in part, in medical mistrust.³⁶ By March 2021, the gap between race/ethnicity groups had attenuated, with 87.6% of Asian/Pacific Islander, 77.1% of Black, 77.5% of Latino, 74.1% of other or multiracial, and 86.6% of White respondents having received or planning to receive the vaccine.³⁵ The HOP also recorded racial/ethnic differences in willingness to share information on close contacts with contact tracers, concerns about racial discrimination during contact tracing, and concerns about protection from law enforcement and immigration officials during contact tracing (Table 2). To provide transparency and build trust among survey participants, we have continued to write survey recruitment materials with the goal of making respondents feel protected as research participants, focusing on our commitment to protecting privacy.

TABLE 2—

Indicators of Distrust in Contact Tracing and the COVID-19 Vaccine: NYC, 2020

Question	%	P
If you were diagnosed with COVID-19, would you share with a NYC contact tracer a list of people you have been in close contact with? (% responding “yes, all contacts”)a
Overall	81.0
Race/ethnicity
Asian/Pacific Islander	72.7	< .01
Black	78.7	.01
Latino/a	80.8	.03
Other/multiracial	66.1	.04
White (Ref)	87.3
When it comes to contact tracing and receiving support services for people who are exposed to COVID-19, how concerned are you that you might be treated disrespectfully, receive lower quality services, or be discriminated against in another way based on your race/ethnicity? (% responding “very or somewhat concerned”)b
Overall	55.2
Race/ethnicity
Asian/Pacific Islander	73.6	< .01
Black	62.8	< .01
Latino/a	59.7	< .01
Other/multiracial	61.9	.02
White (Ref)	38.4
If a NYC contact tracer reached out to you, how confident are you that your personal information would be protected from law enforcement and immigration officials? (% responding “Not confident at all”)b
Overall	18.2
Race/ethnicity
Asian/Pacific Islander	23.4	.03
Black	22.6	.02
Latino/a	16.5	.4
Other/multiracial	25.8	.23
White	13.9	Ref
When a coronavirus vaccine becomes available to you, will you get vaccinated? (% responding “yes”)35,a
Overall	55.3
Race/ethnicity
Asian/Pacific Islander	56.6	< .01
Black	33.2	< .01
Latino/a	51.4	< .01
Other/Multiracial	50.5	.03
White	72.5	Ref

Note. NYC = New York City. Race and ethnicity groups are mutually exclusive, so individuals who identify as Latino/a are in the Latino/a group, regardless of race selected. We used 2 sample z tests to test for differences between groups, testing the null hypothesis that the proportions are equal at a 95% confidence level.

^aData source: NYC Health Opinion Poll, December 2020, NYC Department of Health and Mental Hygiene.

^bData source: NYC Health Opinion Poll, October 2020, NYC Department of Health and Mental Hygiene.

LIMITATIONS AND CONCLUSIONS

The NYC Health Department has updated and transformed our survey-based surveillance efforts to support the COVID-19 emergency efforts through surveys that cover the life-span of New York City residents (Figure 2). This has included adapting existing surveys, developing new ones, and creating a unique panel of NYC residents to take periodic surveys. Combined, these efforts have provided important data on the burden of CLI in NYC and highlighted the racial and ethnic inequities and collateral consequences of the pandemic, ranging from economic stress to mental health. Although the COVID-19 public health emergency presented a large disruption, Health Department staff were able to sustain survey operations while adapting practices to meet rapidly evolving safety standards and the need to flexibly adapt surveys in support of the Health Department’s COVID-19 response.

FIGURE 2—

Adapting and Adding to Health Department Surveys to Address the COVID-19 Pandemic: NYC, 2020–2022

Note. NYC = New York City.

Survey data have been particularly valuable in complementing traditional surveillance mechanisms during this emergency response for several reasons. First, administrative data measuring COVID-19 test results, emergency department and hospital visits, and deaths do not capture the percentage of the population who had symptoms of COVID-19 and did not seek care or testing, which our COVID-19 surveys have been crucial in establishing.¹⁷ Second, administrative data do not capture COVID-19–related experiences of discrimination, social and economic insecurity, and mental health, which our surveys were uniquely equipped to measure. Our survey data were especially helpful complements to administrative data because administrative data tend to have a great deal of missing race/ethnicity data,³⁷ unlike our surveys, which have the benefit of being self-reported and have low amounts of missing data in these fields. Finally, as our local government implemented a range of approaches to addressing the COVID-19 public health emergency, our surveys enabled policymakers to receive input from the public about their knowledge, attitudes, and opinions about the emergency and the public health interventions implemented to address it.

Our survey efforts have been limited by several factors. First, the speed at which the pandemic evolved and the inability to work with people in person have made it challenging to implement our typical approaches to questionnaire design. Under nonpandemic conditions, we conduct extensive cognitive testing of survey questions. During the pandemic, we have been more limited in our ability to conduct cognitive testing for the HOP surveys and have increased our reliance on expert review of questionnaires.

Second, the first 6 HOP surveys used nonprobability panels. These can have respondent bias, which we tried to mitigate through quota sampling and weighting. Beginning in March 2021, we implemented the HOP through our probabilistically sampled Healthy NYC panel.

Third, surveys cannot be limitless in length because of respondent fatigue, and therefore the added focus on COVID-19 in HOP came at the expense of questions about other topics.

Fourth, although we have continued routine surveillance data collection about non–COVID-19 health issues, given the disruptions that COVID-19 has caused in NYC, we will not know if any differences we see are attributable to actual changes over time or survey methodology features.

Finally, in the Healthy NYC panel, New Yorkers who were not accessible through the address-based sample frame because of circumstances such as homelessness, incarceration, or living outside New York City at the time that Healthy NYC recruitment invitations were sent did not have the opportunity to be included.

Surveys have played an important role in the Health Department’s emergency response to COVID-19. By adapting to unexpected circumstances and modifying operations, the Health Department has seized this moment as an opportunity to collect COVID-19 symptom-based data and data on the social context of COVID-19 and its impact on people’s well-being. Additionally, the societal dialogue on racism during the pandemic served as a further impetus to strengthen how we collect data on race/ethnicity and social determinants of health. The lessons we learned about how to be more nimble and flexible in data collection, and the new data collection systems we have established, will help the Health Department better respond to future public health emergencies and continue to address the unequal impacts of the pandemic.