Prospective follow-up of New York City residents with e-cigarette, or vaping product use-associated lung injury—2020–2021

Abstract

Background:

A multistate outbreak of e-cigarette, or vaping, product use-associated lung injury (EVALI) occurred in 2019. Because of EVALI’s novelty and severity, the New York City (NYC) Department of Health and Mental Hygiene (DOHMH) prospectively assessed sequelae among NYC residents who received an EVALI diagnosis in 2019.

Methods:

Using existing NYC EVALI surveillance data, DOHMH attempted contact with all living residents who received an EVALI diagnosis in 2019 and conducted 3 waves of telephone interviews during April 2020–March 2021. Interview questions were adapted from the Centers for Disease Control and Prevention’s EVALI case report form and validated surveys. Baseline differences between respondents and nonrespondents were assessed with Chi-square and Fisher’s exact tests; clinical and behavioral characteristics and open-ended responses were summarized.

Results:

In 2019, 53 NYC residents received an EVALI diagnosis; 33 (67%), 14 (29%), and 18 (37%) of 49 living residents participated in the first, second, and third interviews, respectively. Interviews occurred after outpatient diagnosis (6%) or hospital discharge (94%), at a median of 8, 11, and 17 months for each wave. Respondents (N = 33) and nonrespondents (N = 16) did not differ by sex, age, hospitalization status or length. Respondents were mostly male (70%), had a median age of 23 years (range: 16–63 years), and all reported using vaping or e-cigarette products (vaping) with tetrahydrocannabinol (88%), nicotine (49%), or cannabidiol (9%) before diagnosis. Respiratory (first and second interviews) and gastrointestinal (third interviews) symptoms were most commonly reported. Sixteen respondents (49%) reported any new diagnosis during follow-up. Fifteen to 29% of respondents reported vaping at each interview; 58%–93% reported recent non-vaped cannabinoid use.

Conclusion

NYC residents with EVALI reported symptoms throughout the follow-up period, and approximately half reported newly diagnosed health conditions. Further studies are needed to understand EVALI’s relationship with symptoms and health conditions.

Introduction

In summer 2019, the Centers for Disease Control and Prevention (CDC), the Food and Drug Administration, and state and local health departments, including New York City (NYC) Department of Health and Mental Hygiene (DOHMH), began investigating reports of severe lung injuries among persons with a history of e-cigarette or vaping product use (vaping). During August 2019–February 2020, CDC reported 2,807 cases of e-cigarette, or vaping, product use-associated lung injury (EVALI) nationwide. This included 127 (5%) that were reported in New York State (NYS) during August 2019-February 2020.[1] During August–December 2019, NYS reported 113 cases, of which 53 (46%) were NYC residents and are the subject of this report.

CDC described patients from across the United States who received an EVALI diagnosis mostly were young adult males. These persons had vaped tetrahydrocannabinol (THC), nicotine, or other liquids (e-liquids), and experienced respiratory, gastrointestinal, and constitutional symptoms over the course of a few days to several weeks [1]. Because of reports of rehospitalization and death post-discharge from initial EVALI hospitalization, CDC’s guidance on standards of care evolved between the initial recognition of EVALI in August 2019, and January 2020, when management algorithms were updated. This guidance addressed patients’ clinical readiness for hospital discharge, social support and access to mental health and substance use disorder services, best practices for medication adherence, and post-discharge medical follow-up, including with primary care providers and pulmonologists [2].

Despite the clinical severity of certain EVALI cases and concerns about the toxicity of vaping products more broadly,[3,4] the long-term effects of EVALI are not well understood [2,5,6]. Because of the novelty of EVALI and reports of rehospitalization and death, DOHMH prospectively assessed NYC residents who had received an EVALI diagnosis in 2019. We aimed to describe changes in symptoms, diagnosed health conditions, healthcare usage, functional and financial consequences, and substance use over time, among this cohort of NYC residents.

Methods

Data sources

In 2019, potential EVALI cases were identified through passive (reports to poison control centers, NYS Department of Health [DOH], and DOHMH) and active (syndromic) surveillance. At that time, each potential EVALI case was identified and classified using CDC’s 2019 Lung Injury surveillance case definitions [7]. Baseline EVALI surveillance data were collected from provider reports to the NYC Poison Control Center and patient medical records that were obtained directly from NYC hospitals. During April 2020–March 2021, we conducted 3 waves of telephone interviews with surviving NYC residents who had received an EVALI diagnosis in 2019 to follow them over time; the list was confirmed with NYS DOH to ensure that all reported cases were included. Before each wave of interviews, a match with the NYC vital statistics death registry was conducted to assess for any recent deaths.

We conducted interviews in English or in respondent’s primary language (n = 1, in Mandarin) using a telephone interpreter service. NYC residents who received an EVALI diagnosis were called up to three times during each wave of interviews. For those not reached in the first call attempt, we left voicemails and sent text messages or emails to help schedule interviews. We mailed letters to all persons not reached during the first interview wave, informing them of the surveillance project and requesting their participation. Approximately three months after completing the first wave of interviews, we initiated second interviews with the initial respondents. We also attempted to interview all nonrespondents from the first wave of calls who had not opted out of participation, completing abbreviated first interviews with those reached. After another three months, the final wave of interviews began, including only respondents with whom at least one previous interview had been completed (Fig 1).

[Figure omitted. See PDF.]

Interview questions included age, sex assigned at birth, symptoms, health conditions, healthcare use, insurance coverage, substance use, functional, student, and employment status. Effects of EVALI on finances were mostly categorical and adapted from CDC’s EVALI case report form [8] and validated surveys. This included the NYC Community Health Survey, [9] Youth Risk Behavior Survey, [10] and National Survey on Drug Use and Health [11]. Abbreviated interviews included a shorter set of primarily open-ended questions that covered the same content areas.

Information about hospitalization, including duration of stay and intubation status, were abstracted from medical records, along with sex, age, and race and ethnicity. We did not include interview questions about race and ethnicity, because we had intended to use NYS DOH case interview data from the initial outbreak. However, these data were missing for most NYC residents with an EVALI diagnosis, something we did not learn until the follow-up interviews were already completed. Instead, we used electronic medical record data to supplement this information because provider reports, which were used to identify cases did not include race or ethnicity.

This study was reviewed by CDC and was conducted consistent with federal law and CDC policy (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.) Data were stored in restricted access file folders on secure agency share drives. This activity was reviewed by the CDC Institutional Review Board and the Institutional Review Board for the NYC Department of Health and Mental Hygiene and was determined to be non-research public health surveillance. As such, formal consent was not required; however, background on this surveillance activity was provided to each participant, and we did not proceed without their verbal assent. When the participant was a minor, the protocol required interviewers to speak with a parent or guardian to obtain permission for further communication with the minor. Assent for the adults or minors to participate, or their refusal, was documented (see Supporting Information: S1, S2 and S3).

Data analyses

Data from the first wave of interviews using the full interview form and data from those interviewed for the first time during the second wave using the abbreviated interview form, were merged and recoded as first interview. Open-ended responses from the abbreviated interviews were coded to match the categories from the full interview form, when possible. All three waves of interviews were coded as third interview, regardless of the number of prior interviews. Baseline differences between respondents and nonrespondents were assessed with Chi-square and Fisher’s exact tests using SAS^® version 9.4 (SAS Institute, Inc., Cary, North Carolina). Symptoms, health conditions, healthcare use, substance use patterns, functional status, and effects of EVALI on finances were also summarized for each wave of interviews. Symptom trends among the respondents who completed all three interviews were summarized to assess for resolution over time. Because of missing data, race and ethnicity were not used in any analyses.

Results

Baseline characteristics

In 2019, a total of 53 NYC residents received an EVALI diagnosis. Most were male (72%); median age was 23 years (range: 15–63 years). Four (8%) died of EVALI (Table 1). Decedents were mostly male (n = 3; 75%) and had a median age of 28 years (range: 17–34 years). Two decedents had been hospitalized (mean = 13 days) and intubated; one decedent died at home, and one decedent presented to the emergency department in cardiac arrest and did not survive.

[Figure omitted. See PDF.]

Interview participation and respondent demographics

Interviews occurred from 5 to 19 months after initial hospitalization or injury, at a median of 8, 11, and 17 months for each interview wave. Among 49 potential respondents, 33 (67%) completed the first interview (24 in the first wave and 9 during the second wave), 14 (29%) completed the second interview, and 18 (37%) completed the third interview; overall, 33 (67%) respondents completed ≥1 interview and 22 (45%) completed ≥2 interviews. Ten respondents (20%) completed interviews during all three waves (Fig 1).

Respondents (N = 33; 67%) and nonrespondents (N = 16; 33%) did not significantly differ by sex, age group at diagnosis, intubation status, hospitalization status, or length of hospitalization (Table 1). Respondents were mostly male (n = 23; 70%), had a median age of 23 years (range: 16–63 years), were hospitalized (n = 31; 94%) for a median of 6 days (range: 0–13 days), and were not intubated (n = 30; 91%). Approximately half of respondents reported that at the time of hospitalization or diagnosis they had employer-based or private health insurance (n = 18; 55%). Race and ethnicity were incomplete for 16 of 49 surviving NYC residents who received an EVALI diagnosis in 2019 (33% of potential respondents) and data were not used.

In terms of substance use patterns, 100% of respondents reported vaping, with either tetrahydrocannabinol (THC) (88%), nicotine (49%), or cannabidiol (CBD) (9%) before diagnosis (Table 2). Some respondents (15%–29%) reported recent vaping at each interview, and most respondents (58%–93%) reported recent non-vaped (e.g., smoked or edible) cannabinoid use. A limited number of respondents reported smoking cigarettes (0%–6%) or other tobacco products (0%–11%).

[Figure omitted. See PDF.]

Preexisting and newly diagnosed health conditions

Respondents reported preexisting mental health conditions (49%), including anxiety (36%), depression (24%) and other conditions (15%); asthma (27%), cardiovascular (12%) conditions, including hypertension, hyperlipidemia, and heart disease; and diabetes (3%). At first interview, respondents reported receiving new diagnoses of anxiety (27%), depression (15%), other mental health conditions (3%), asthma (9%), other respiratory (3%) or cardiovascular (9%) conditions, and diabetes (3%) (Table 3). Overall, 16 respondents (49%) reported receiving a new diagnosis during the follow-up period.

[Figure omitted. See PDF.]

Symptoms

Between EVALI diagnosis and first interview, and during the three months before the second wave of interviews, respiratory symptoms were commonly reported (50%); however, gastrointestinal symptoms were most commonly reported (50%) during the three months before the third wave of interviews.

Among the 10 respondents who completed all three interviews, gastrointestinal symptoms were the most common (60%), and half (30%) remained unresolved by the third interview (Fig 2). Similarly, approximately half of respiratory, constitutional, and chest pain symptoms remained unresolved by the third interview.

[Figure omitted. See PDF.]

*Mental health includes attention deficit disorder (ADD), attention deficit hyperactivity disorder (ADHD), anxiety, depression, or post-traumatic stress disorder (PTSD); respiratory includes sleep apnea, asthma, or chronic obstructive pulmonary disorder; constitutional includes fevers, tiredness, or decreased appetite; and gastrointestinal includes nausea, vomiting, diarrhea, bloating, or abdominal pain.

Effects on personal function and finances

In the months after an EVALI diagnosis, nine of 33 respondents (27%) required help with routine needs such as everyday household chores, four (12%) required help with personal care such as bathing or eating, and 10 (30%) reported financial problems because of EVALI. By the third wave of interviews, only two (11%) respondents reported requiring help with routine needs, no respondents required help with personal care, and one (6%) respondent reported recent financial problems because of EVALI.

Most (70%, n = 23) respondents were employed and 33% (n = 11) were in school when diagnosed. All students returned to school or graduated, and 74% of those employed (n = 17) returned to the same job after their diagnosis. Nine (53%) of those who returned to the same job missed from one week to one month of work; 35% (n = 6) missed one week of work or less; and 6% (n = 1) missed from one to three months of work. Accommodations were made for 18% (n = 3) on return to work and 30% (n = 3) on return to school.

Healthcare use

Between diagnosis or hospital discharge and first interview, 91% of respondents had received treatment by a health care provider, most often a pulmonologist (79%) or an ambulatory primary care provider (55%). Respondents continued to interact with health care providers, with 93% and 83% receiving treatment from healthcare providers during the three months preceding second and third interviews respectively; they most frequently visited mental health providers (43% and 17%) and primary care providers (29% and 50%) during this time frame.

Discussion

Respondents reported symptoms throughout the follow-up period, and approximately half reported new-onset morbidity. Although many symptoms resolved, especially during the latter part of the follow-up period, our findings suggest that changes to vaping behavior and mindset endured. The periodic interviews also allowed us to collect data regarding effects on education and employment, but the nature of the surveillance data we utilized limited our ability to rule out contributions from social and economic stressors of the COVID-19 pandemic to the mental health symptoms and employment challenges reported.

CDC’s clinical guidance recommends outpatient primary care or pulmonary specialist follow up, optimally within 48 hours of discharge, and social support and access to mental health and substance use disorder services [12]. Although many of our respondents received a diagnosis before the October 2019 guidance release, overall treatment was consistent with this guidance. Almost all respondents had been treated by ≥1 health care providers by their first interview. Per CDC, cardiac disease, chronic pulmonary disease, diabetes, and older age were risk factors for higher morbidity and mortality among those who received an EVALI diagnosis. Nationwide, anxiety, depression, attention deficit disorder (ADD), attention deficit hyperactivity disorder (ADHD>), and other mental and behavioral health conditions were common among EVALI patients [2,13]. Our findings were consistent with CDC’s nationwide findings; however, the mortality rate in NYC (7.5%) among those who received a diagnosis in 2019 was higher than the national rate (2.4%), which included cases through February 2020. The higher rate may be attributable to the different time periods used in these analyses, as providers had less guidance on how to triage and treat EVALI earlier in the outbreak; the majority of EVALI diagnoses among NYC residents in 2019 (60%) occurred before the October 2019 guidance release.

Approximately half (49%) of respondents had preexisting behavioral health conditions. The rate of preexisting depression in our cohort (24%) was approximately three times the overall rate in NYC (10%)[9]. National survey data suggest that self-medication (e.g., use of alcohol, cannabis, or nicotine to address anxiety) for mental health conditions is not uncommon [14]. Approximately half of respondents reported new diagnoses for other physical or behavioral health conditions during the follow-up period. Prior to their EVALI diagnoses, respondents also reported higher rates of asthma than the overall adult rate in NYC (13.5% [9]) and then continued to report new asthma diagnoses during the follow-up period. The possibility exists that some of these new diagnoses were preexisting, but undiagnosed conditions. Young adults generally use the health care system less than other age groups overall, but have higher rates of emergency department use [15]. Our findings indicate that closer medical follow-up after EVALI may have facilitated additional diagnoses and improved care. EVALI might have also been a contributing factor to some of the newly diagnosed behavioral health and respiratory conditions. Fewer than half of our respondents were treated by mental health providers. However, supporting recovery from EVALI will require some degree of mental health follow-up and substance use treatment to reduce the risk for reinjury or other secondary pulmonary complications. More consistent use of outpatient services for young adults might also prevent or reduce severity of future EVALI cases.

Two other published studies have looked at long-term outcomes after EVALI. Blagev et al. tracked 73 patients in Utah through medical records abstraction and conducted clinical screening activities at 12-months post-diagnosis [16]. Triantafyllou et al. retrospectively reviewed electronic medical records of 41 patients who received an EVALI diagnosis and admitted to any of the University of Pittsburgh Medical Center hospitals [17]. Both studies reported similar age and sex distributions, rates of behavioral health and cardiovascular disease, and proportions of respondents using e-cigarettes with THC or nicotine, consistent with our interview findings. Blagev et al. and our interviews reported similar median lengths of stay in the hospital (5 and 6 days respectively). Our findings contribute prospective data from a third jurisdiction at multiple timepoints on the physical, mental, and functional health of respondents, and social effects. One main difference between our findings and those from the other two studies is that Triantafyllou et al. included hospital admissions through September 2020 and Blagev et al. included diagnoses through August 2021. However, our respondents all received an EVALI diagnosis in 2019. Thus, our time frame excluded the potential for COVID-19 to be a factor in the initial hospitalization and case identification. In addition, compared with Triantafyllou et al., a higher proportion of our respondents reported a history of asthma (27% vs 8%). Among our respondents, although only some reported continued vaping (15%–29% across waves), most reported using non-vaped cannabinoids, often by smoking or dabbing (i.e., inhaling a smoked or aerosolized concentrated cannabis resin). Participants in the Blagev et al. study were more likely to report nicotine consumption (vaped and smoked) and cannabis vaping after receiving their EVALI diagnosis than our respondents.

Limitations

The limited number of potential respondents (n = 48) and the nonresponse rate (32%) suggest that the findings might not have captured the full range of post-discharge health sequelae among the potential respondents. However, respondents and nonrespondents did not differ by sex, age, initial hospitalization status, or length of stay. Economic or other circumstantial differences imposed by the COVID-19 pandemic might have been a barrier to participation or with ongoing follow-up. The conclusions also involved self-reported findings from a local municipal population, which are subject to recall bias and cannot be generalized to the broader population affected by EVALI, especially given the variable state and local regulatory environment for cannabis and e-cigarettes. A robust effort was made to abstract race and ethnicity information from available electronic health records; however, these data were found to be incomplete and inadequate for identifying associated disparities [18]. Although the interviews were confidential and used nonjudgmental survey questions administered by experienced interviewers, they were not anonymous. The possibility exists that some persons responded to the surveys based on perceptions of social desirability, need to share their story for benefit of others, or to affirm a positive outcome with their health. Because of DOHMH staffing constraints during the pandemic, some respondents also did not speak with the same investigator each time. Further, follow-up surveillance with NYC residents who received an EVALI diagnosis was inherently limited by lack of a comparison group, making it challenging to assess the relationship between EVALI and the sequalae described.

Public health implications

Limited regulation and oversight of new consumer products, including ingredients in nicotine and cannabis products, contributed to the EVALI outbreak [19]. These products continue to evolve, which presents a challenge to the development and communication of health risk information. Ongoing surveillance is particularly crucial, because cannabis was legalized for adult use in NYS in 2021, and new products continue to emerge. Although vitamin E acetate has been identified as a contributor to EVALI, certain respondents vaped only nicotine products before receiving a diagnosis, which are not known to contain vitamin E acetate. Consistent with the conclusion reached by other researchers, we lack sufficient information about vaping product constituents and excipients involved in each lung injury to provide specific new warning to the public or establish more protective regulations for manufacturers.

Given the rapid evolution of products, periodic follow-up with a group of consumers might help supplement other traditional modes of surveillance. For example, one respondent inquired about risks for nicotine-free vaping products being marketed as wellness products or personal diffusers, which claimed to deliver essential oils. This led NYC DOHMH to update communications for the public, retailers, and clinicians to include these products.

NYC DOHMH maintains some active and passive surveillance of EVALI, identifying approximately three or four cases of EVALI per month. As the COVID-19 pandemic progressed during spring of 2020, we noted that the clinical assessment of patients began to evolve, often with repeated COVID-19 testing, which highlighted the continued challenge of recognizing and diagnosing EVALI. Detailed substance-use histories often led to the ultimate diagnosis and appropriate treatment. Subsequently, state and local agencies collaborated to develop guidance informing health care providers that EVALI cases continue to occur and should be considered alongside other etiologies [20].

The preponderance of preexisting and new mental health diagnoses among respondents also suggests that clinical follow up by behavioral health providers might be beneficial for addressing substance use and psychological trauma of injury, hospitalization, and any emotional and social adjustments to long-term physical impairments suffered by patients. Although it is unclear how directly EVALI diagnosis is associated with new-onset symptoms and morbidity described by respondents, these findings highlight the importance of close monitoring and follow-up by healthcare providers of these patients and more broadly, of patients who vape.

Conclusion

NYC residents with EVALI reported symptoms throughout the follow-up period, and approximately half reported new-onset morbidity. These findings have guided clinician education and public health messaging and might influence e-cigarette policy and individual health behaviors. Findings and follow-up have also guided surveillance efforts, both for other emerging products and for emerging injuries or illnesses that might result in chronic disease. Other studies are needed to better understand long-term health of EVALI cases and to more fully understand causes of EVALI associated with various vaping products.

Supporting Information

S1 File. NYC DOHMH IRB Determination.

https://doi.org/10.1371/journal.pone.0304918.s001

S2 File. CDC IRB EVALI Project Determination.

https://doi.org/10.1371/journal.pone.0304918.s002

S3 File. Assent Script and Protocol.

https://doi.org/10.1371/journal.pone.0304918.s003

Acknowledgments

We wish to acknowledge Tabassum Z. Insaf, PhD, Monica P. Nordstrom, MSPH, from the New York State Department of Health, and Philip C. DiSalvo, MD, of the Carle Illinois College of Medicine, formerly of the New York City Department of Health and Mental Hygiene’s Poison Control Center and the staff of the Poison Control Center, for their exceptional assistance supporting our lung injury surveillance and identification of New York City EVALI cases in 2019. We also acknowledge Kim Kessler, JD, Assistant Commissioner of the Bureau of Chronic Disease Prevention (BCDP), New York City Department of Health and Mental Hygiene and Jennifer G. Wright, DVM, MPH from the Centers for Disease Control and Prevention’s Division of Partnership Support (PHIC) and Division of Workforce Development (DWD) for their detailed manuscript reviews, edits and comments. We also thank Lourdes M. Cifuentes, MPH, of the Food Bank for New York City, a former BCDP staff member, who conducted interviews and supported the data collection process during the first wave of interviews.

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Citation: Tannert Niang KM, Grasso AB, Debchoudhury I, Bushman D, Jasek JP, Fairclough MA, et al. (2025) Prospective follow-up of New York City residents with e-cigarette, or vaping product use-associated lung injury—2020–2021. PLoS One 20(4): e0304918. https://doi.org/10.1371/journal.pone.0304918

About the Authors:

Kathryn M. Tannert Niang

Roles: Conceptualization, Formal analysis, Investigation, Methodology, Project administration, Writing – original draft, Writing – review & editing

E-mail: [email protected]

¶☯ KTN and ABG are contributed equally to this work. ID, JPJ, and MAF are also contributed equally to this work.

Affiliation: New York City Department of Health and Mental Hygiene, Center for Health Equity and Community Wellness, New York, New York, United States of America,

ORICD: https://orcid.org/0000-0002-9954-7385

Aviva B. Grasso

Roles: Formal analysis, Investigation, Writing – original draft, Writing – review & editing

¶☯ KTN and ABG are contributed equally to this work. ID, JPJ, and MAF are also contributed equally to this work.

Affiliation: New York City Department of Health and Mental Hygiene, Center for Health Equity and Community Wellness, New York, New York, United States of America,

ORICD: https://orcid.org/0000-0002-3105-973X

Indira Debchoudhury

Roles: Formal analysis, Software, Validation, Writing – review & editing

¶☯ KTN and ABG are contributed equally to this work. ID, JPJ, and MAF are also contributed equally to this work.

Affiliation: New York City Department of Health and Mental Hygiene, Center for Health Equity and Community Wellness, New York, New York, United States of America,

Dena Bushman

Roles: Conceptualization, Data curation, Investigation, Methodology, Project administration, Resources, Supervision, Visualization, Writing – review & editing

¶‡ The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Affiliations: Division of Scientific Education and Professional Development, CDC, Epidemic Intelligence Service, Atlanta, Georgia, United States of America,, Corewell Health, Women’s Health & Wellness Center, Grand Rapids, Michigan, United States of America,

John P. Jasek

Roles: Conceptualization, Data curation, Formal analysis, Methodology, Supervision, Writing – review & editing

¶☯ KTN and ABG are contributed equally to this work. ID, JPJ, and MAF are also contributed equally to this work.

Affiliation: New York City Department of Health and Mental Hygiene, Center for Health Equity and Community Wellness, New York, New York, United States of America,

Monique A. Fairclough

Roles: Data curation, Methodology, Writing – review & editing

¶☯ KTN and ABG are contributed equally to this work. ID, JPJ, and MAF are also contributed equally to this work.

Affiliation: New York City Department of Health and Mental Hygiene, Center for Health Equity and Community Wellness, New York, New York, United States of America,

Katherine R. Van Oss

Roles: Conceptualization, Data curation, Methodology, Project administration, Writing – review & editing

Affiliation: Corewell Health, Women’s Health & Wellness Center, Grand Rapids, Michigan, United States of America,

Shadi Chamany

Roles: Conceptualization, Methodology, Writing – review & editing

Affiliation: New York City Department of Health and Mental Hygiene, Center for Health Equity and Community Wellness, New York, New York, United States of America,

Kendall D. LaSane

Roles: Conceptualization, Project administration, Writing – review & editing

Affiliation: Department of Health Policy and Management, University of North Carolina Gillings School of Global Public Health, Chapel Hill, North Carolina, United States of America,

Sharraine M. Franklin

Roles: Investigation, Writing – review & editing

Current address: New York City Department of Health and Mental Hygiene, Center for Health Equity and Community Wellness, New York, NY, USAE

Affiliation: New York City Department of Health and Mental Hygiene, Center for Health Equity and Community Wellness, New York, New York, United States of America (Retired)

Achala K. Talati

Roles: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Resources, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing

¶☯ KTN and ABG are contributed equally to this work. ID, JPJ, and MAF are also contributed equally to this work.

Affiliation: New York City Department of Health and Mental Hygiene, Center for Health Equity and Community Wellness, New York, New York, United States of America,

ORICD: https://orcid.org/0009-0000-5044-0854

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