U.S. Department of  Health  and  Human Services  
 
Office of Inspector General  
   
 
 
CDC Found Ways  To Use Data  
To Understand  and Address 
COVID-19 Health  Disparities, 
Despite Challenges With  
Existing  Data  
 
 
 
Christi A. Grimm  
Inspector General  
July 2 022, OEI-05-20-00540   U.S. Department of Health and Human Services  
O  ffice  of  Inspector  General  
 
Report in Brief  
 
Ju ly 2 022, O  EI -05 -20 -00540  
 
CDC Found Ways  To Use Data To Understand  
Why OIG Did This Review  
The COVID-19 pandemic has  
and Address COVID-19 Health Disparities,  
devastated communities  across the  
United States, and  socially   Despite Challenges With Existing  Data  
vulnerable populations  have been  
disproportionately  affected.  From   As the  Nations  lead public  health agency, CDC 
the beginning, reports indicated   Key Takeaway   works to increase  national health security  and  to  
that people of color and people   respond to  public  health threats as they  arise.  In 
CDC worked to  
from economically disadvantaged   doing  this, CDC receives public health data  from  
understand and  
communities were at  increased  risk  State,  Territorial,  and  local entities  (jurisdictions) as 
address COVID -19 
of becoming sick from COVID-19,   well as  from  providers  on a mostly voluntary basis.   
disparities using  
of needing intensive care due to   CDC collects  patient-level  data on several  
racial, ethnic, and  
COVID-19, and of dying from   COVID-19 indicators, including testing, cases,  
socioeconomic data,  
COVID-19 compared to  members   hospitalizations,  and deaths.  Some of  these data  
despite challenges  
of predominantly White  and/or   contain information on patients  race  and  ethnicity,  
with these data.  
affluent communities.  At the same   as well  as indicators of  their  socioeconomic status.   
time, reports revealed that  
What OIG Found  
demographic data on COVID-19 
CDCs racial, ethnic,  and socioeconomic data for COVID-19 testing, cases,  
were incomplete, which  could make  
hospitalizations,  and deaths  have limitations  and  provide an incomplete 
understanding and addressing  
picture of COVID-19 disparities.   Racial and ethnic data associated with  
disparities more difficult.   
COVID-19 reporting  are sometimes  missing, inconsistent,  or inaccurate, while  
How OIG Did This Review   socioeconomic data  in this  reporting  are neither clearly defined nor  
In March and April 2021, we   consistently collected.    
conducted structured interviews  
CDC has  taken steps to  supplement and improve these data.  CDC  analyzed   
with CDC staff responsible for  
disparities  using  additional  data sources,  such as  emergency department data  
collecting and  analyzing COVID-19 
on COVID-like illness  and qualitative data from  ad hoc surveys  on  attitudes  
data;  collaborating  with State, local,  
and beliefs.  CDC  also developed  a methodology  to identify  
and Territorial entities  and with  
disproportionately  impacted communities  of color using Census data.  
Tribal Epidemiology  Centers (TECs); 
Additionally,  CDC has worked  with  the entities  that report  COVID-19 data to  
and developing initiatives to  
improve the quality of these data  at their  source.  
address disparities.  We  also  
conducted structured interviews  
CDC  reported  using  both these supplemental data and  data on  COVID-19 
with staff from  six jurisdictions and   testing, cases, hospitalizations, and deaths  to  address  disparities  via  technical  
two TECs  representing a variety of   assistance to partners, targeted interventions, and  significant  funding  
State, local,  Territorial, and  Tribal 
investments.  For  example, CDC has helped partners  conduct focus group  
entities.  We asked  CDC staff how 
sessions  to learn about challenges faced by disproportionately  impacted  
they used data to identify and  
communities  and  has used  data to  determine equitable locations for  testing  
address disparities and about  
sites.  CDC also reported that it has  elevated  health equity  throughout  its  
support they provided to  
response efforts.   For  instance, it  created  a Chief Health Equity Officer  unit  
jurisdictions  and TECs  throughout  
and  published  a health equity strategy to guide its COVID-19 response.   
the pandemic.  We asked  
jurisdictions  and TECs  about  their   The TECs  and Territory we interviewed  also noted data  limitations  that could  
collaboration with  CDC and about   inhibit  their  ability to  identify and address  COVID-19 disparities.   The TECs  we 
challenges they faced related to the  interviewed reported difficulty accessing public health  data from CDC and  
collection, reporting, and receipt of  
CO  VID-19 data and  analysis.      States,  while  the Territory we interviewed  reported that it  lacked  the technical 
infrastructure to  collect and report  COVID-19 data.   
What OIG Recommends and Agency Response  
We recommend that  CDC:  (1) expand  efforts  both  to improve racial  and  
ethnic data associated with  COVID-19 and  to supplement  them  with 
additional data sources  and  (2)  ensure that  TECs  have timely access to  all 
public health data to which  they  are  entitled.   CDC concurred with both of 
these recommendations. 
     
TABLE OF CONTENTS  
 
 
 
 
BACKGROUND   1 
Methodology   8 
FINDINGS   10 
Racial, ethnic, and socioeconomic data  associated with  COVID-19  testing, cases,   10 
hospitalizations, and deaths  have limitations and  do  not provide a  complete picture  of  
disparities  
Racial and ethnic data associated with  COVID-19 are  sometimes  incomplete,  inconsistent,   10 
or inaccurate  
Socioeconomic data  associated with  COVID-19 are not clearly defined or  consistently   13 
collected  
Data limitations result in an incomplete picture of  disparities in COVID-19 testing, cases,   13 
hospitalizations, and  deaths   
CDC has taken steps to supplement and improve data on COVID-19 testing, cases,   14 
hospitalizations, and deaths   
CDC  used existing data sources  and collected additional data related to COVID-19   14 
disparities to supplement COVID-19 data   
CDC  has worked  to support labs and jurisdictions in addressing data  collection and  15 
reporting challenges unique to COVID-19  
CDC reported using multiple data sources and  analyses to inform efforts to address COVID-19   16 
disparities  
Some  Tribal partners and  at least one Territory  have  experienced challenges  addressing   18 
COVID-19 disparities  due to problems accessing  or managing data  
CONCLUSION AND RECOMMENDATIONS    19 
CDC should  expand its efforts  both to improve racial  and ethnic data  associated with   19 
COVID-19  and to supplement  them  with additional data sources  
CDC should  ensure that Tribal  Epidemiology Centers  have timely access to  all public health  20 
data to which they are entitled   
AGENCY COMMENTS AND OIG RESPONSE   21 
APPENDIX   22 
ACKNOWLEDGMENTS AND CONTACT   27 
ABOUT THE OFFICE  OF INSPECTOR GENERAL   28 
ENDNOTES   29 
   
BACKGROUND  
 
 
Objectives  
1.   To  identify  limitations in  the racial, ethnic, and socioeconomic data  
associated with  COVID-19  testing, cases, hospitalizations,  and deaths  used  
by the Centers for Disease Control and  Prevention (CDC).   
2.   To examine how CDC uses  these racial, ethnic, and socioeconomic  data  in its  
response to COVID-19 disparities.  
3.   To describe CDCs  challenges, successes,  and lessons learned in using these 
data  and supporting jurisdictions  and Tribal Epidemiology Centers  in  
response to the COVID-19 pandemic.  
 
The COVID-19 pandemic has had a historic impact on the Nation, with  Black or 
African American, American Indian  or Alaska Native (AI/AN), Asian, Native Hawaiian  or  
Other Pacific  Islander,  and Hispanic or Latino individuals  and members of  
economically disadvantaged communities  often  hard-hit.   Consistent with wider  
health trends,  available data indicate that members of these communities have been 
more likely to experience poor outcomes from COVID-19 than members of  
predominantly  White and/or affluent communities.   Specifically,  throughout the 
pandemic, reports indicated  that Hispanic  or Latino, Black, AI/AN, and Asian  
individuals  had  higher rates of infection, hospitalizations,  and deaths  compared to  
their White counterparts,1  and residents  of lower-income neighborhoods  are more 
likely not only to contract COVID-19 but also to  die from it.2, 3   Furthermore, data also  
indicate that  members  of other groups,  such as  people who  are experiencing  
homelessness,  people with disabilities,  and people who are incarcerated,  face  
increased  risk  of  poor outcomes from  COVID-19.4, 5, 6  
Early in the pandemic, concerns arose that CDC  was not collecting, or not reporting,  
the racial and ethnic information for COVID-19 testing and cases.7,  8   CDC is the  
Nations  lead public health agency, responsible for  providing health information and 
responding to  health emergencies.   We  conducted this evaluation to  identify  
limitations in  CDCs  racial, ethnic, and socioeconomic  data  for  COVID-19  and  to  
examine how  CDC used these data  to  understand  and address  COVID-19  disparities.    
 
 
 
CDC Found Ways To Use Data To Understand and Address COVID-19 Health Disparities, Despite Challenges With Existing  Data  
OEI-05-20-00540   Background |  1   Public  Health Reporting  
CDC relies on  various State,  Territorial,  and 
role of Tribal 
local entities, hereinafter  referred  to as  
Epidemiology Centers (TECs) 
jurisdictions,  to  collect  and report  data  for  
Twelve TECs function as public 
public health purposes.   Providers such as   health entities for Al/AN Tribal and 
laboratories, hospitals, and outpatient health  urban Indian communities. TECs 
work in partnership with Tribes and 
care facilities  submit most  of these  data,  
perform several functions, including 
including data on COVID-19 testing, cases,  
monitoring data, providing disease 
hospitalizations, and deaths.a   In general, the  surveillance, and promoting public 
authority to mandate public health reporting   health, but they do not report public 
health data to CDC. 
rests with States  and Territories,  not the 
Federal  Government.9   Jurisdictions reporting   TECs are designated public health 
authorities, meaning they have legal 
to CDC  typically  send  anonymized  data  (i.e.,  
access to protected health 
data that cannot be traced to a specific   information. They also have access 
person)  to CDC.   In  most instances,  reporting   to data, monitoring and delivery 
systems, and other protected health 
to CDC is voluntary.  
information held by HHS.  CDC 
provides technical assistance to 
Changes during the COVID-19 pandemic  
TECs in performing their public 
introduced mandatory reporting of  some   health functions. 
public health data to Federal agencies.   
Under  the Coronavirus Aid, Relief, and  
Economic Security  (CARES) Act  in March 2020, Congress required every lab that  
performs or analyzes a  test  intended  to  detect or diagnose a possible case of  
COVID-19  to report test results to  the Secretary  of the Department  of Health and  
Human Services (HHS).   The statute authorized  the Secretary to prescribe the form  
and manner,  and timing and frequency, of such reporting.10   HHSs subsequent  
guidance established August  1, 2020, as the implementation date for  this  reporting, 
provided  instructions to all laboratories  on the specific  required  data elements  to be 
reported  daily  to  CDC, and outlined  avenues for reporting, including  through existing  
public health reporting  mechanisms.11   Beginning in May  2020, the Centers for  
Medicare &  Medicaid  Services  (CMS)  also  began requiring  aggregate weekly  
reporting of COVID-19  data from nursing  homes.b,  12     
CDCs  Data Modernization  Initiative  
CDCs efforts to modernize  public health data and reporting  accelerated  after the 
COVID-19 pandemic exposed gaps in the public health data system.13   CDCs data  
modernization initiative includes several activities, such as  creating interoperable 
      
a  Providers submit public health data to public health departments.  Some public health departments  
report these data to CDC directly, while others report to CDC via the public health department of a 
higher jurisdiction.  For example, some local public health departments report directly to CDC while  
others report via the public health departments of their States.   
b  In May 2020, CMS  began requiring  skilled nursing facilities and nursing facilities to report,  on a weekly  
basis, confirmed and suspected COVID-19  infections, total deaths, and COVID-19 deaths among  
residents and staff, per 85 Fed  Reg 27550.  
CDC Found Ways To Use Data To Understand and Address COVID-19 Health Disparities, Despite Challenges With Existing  Data  
OEI-05-20-00540   Background |  2   systems in  public health and health  care to make data sharing easier, upgrading and  
modernizing technology  infrastructure, and strengthening the public health  
workforce.  The data modernization initiative also includes increasing the use of both 
electronic case reporting  and electronic lab reporting.c, 14   One goal of this initiative is  
to make important data,  including racial  and ethnic data, more complete.  
Congress has  provided $1.1 billion in support  of data modernization activities since 
shortly before the pandemic began.   Prior to the pandemic,  CDC  received dedicated 
modernization funding, for the first time,  through its  fiscal year (FY) 2020  
appropriations.15   When the pandemic hit, Congress provided additional funds in the  
CARES Act  to support rapid modernization.16   In addition, CDCs FY 2021  
appropriations and the American Rescue Plan Act  provided additional funding for  
data modernization activities.17    
CDC  expanded  several activities  from  its data modernization initiative during the  
pandemic.18   For example,  CDC rapidly increased the use of electronic lab reporting  
from zero jurisdictions being able to report directly to CDC to  56  jurisdictions  
(representing all of the lab-testing volume  in the country)  by April  2021.19   In addition,  
CDC also greatly increased the use of COVID-19 electronic case reporting  on two  
fronts: (1)  all States,  the District of Columbia, and 12  large, local  jurisdictions  are now  
capable of receiving electronic case reports, up from a handful in 2019, and  (2)  as of  
May  2022, more than 12,400 health  care facilities can send  case reports to  
jurisdictions electronically.20    
COVID-19  Data on Testing, Cases, Hospitalizations, and  Deaths  
Entities  that report  COVID-19 data to CDC  transmit these  data through several new  
and existing reporting systems.  The data transmitted to CDC are individual- or 
patient-level data but are  anonymized, meaning they cannot be traced to  a specific  
person.  CDC maintains several systems that collect  COVID-19 data beyond testing,  
cases, hospitalizations, and deaths, but they  are not the focus of this evaluation.d  
Testing.  CDC  receives information about COVID-19 tests directly from the labs and 
providers that conduct the tests and indirectly through  public health departments  as 
part of the CARES Act reporting requirement.  CDC compiles data on positive and  
      
c  Electronic case reporting is the automated, real-time exchange of case report information between  
electronic health records and public health departments.   This  enables health departments  to obtain  
more complete data from patient health records, including racial and ethnic information.  Electronic lab  
reporting is the transmission of digital laboratory reports from labs to public health departments, health  
care  systems, and CDC.  Please see CDC,  What is eCR?,  at  https://www.cdc.gov/ecr/what-is-ecr.html  and 
CDC,  What is ELR?  at  https://www.cdc.gov/elr/about.html.   
d  This evaluation did not focus on data for vaccinations or CDCs efforts to address disparities in  
vaccination, despite existing concerns, as that campaign was in  the  early stages during our  data 
collection period.  OIG is conducting an evaluation assessing the effectiveness of State vaccination  
systems (OEI-05-22-00010).  See OIG,  Use of States Immunization Information Systems  To Monitor  
COVID-19 Vaccinations  (OEI-05-22-00010), forthcoming  (see OIG Work Plan at  
https://oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-0000571.asp).  
CDC Found Ways To Use Data To Understand and Address COVID-19 Health Disparities, Despite Challenges With Existing  Data  
OEI-05-20-00540   Background |  3   negative tests and disseminates these data along with a 7-day positivity rate on its  
public COVID  Data Tracker.e, 21   HHSs guidance details the required  data  to  be 
reported, including specifics about the test itself, the result, where the test  was  
performed,  and the patients race, ethnicity,  and  ZIP  Code.22   
Cases.  CDC receives information about COVID-19 cases,  along with other  notifiable 
conditions,  through a disease surveillance system.  Local health departments work  
with health  care providers, hospitals, and labs to collect data on COVID-19.  Providers 
and local public health departments report data to their State and Territorial health 
departments,  which then report to CDC.  CDC and the Council of  State and  Territorial  
Epidemiologists coordinate to develop standard surveillance case definitions  for 
reporting each notifiable condition, along with the demographic information (i.e.,  race  
and ethnicity), location, and outcome data that should be reported.f, 23       
Hospitalizations.  CDCs Coronavirus Disease 2019-Associated Hospitalization  
Surveillance Network  (COVID-NET)  collects data  about hospitalizations associated 
with laboratory-confirmed COVID-19 cases.  Hospitals in 99 counties in the  
participating  14 States report detailed data for each case including the age, sex,  
location,  race,  ethnicity, clinical history, and clinical outcomes  for each hospitalized  
COVID-19 patient.24    
CDC  also  has access to  hospital data  from other sources.   The  National Syndromic  
Surveillance Program  contains  data on emergency department visits  that may  be 
related to COVID-19.  The Premier  Healthcare Database contains  hospital discharge  
data  representing about  20 percent of U.S. hospital admissions, including  encounters  
related to  COVID-19.   Additionally,  CDC  has  access  to  some aggregated data on  
COVID-19 hospitalizations  through HHSs Unified  Hospital Dataset  within HHS  
Protect.g  
Deaths.   CDC receives information about deaths via death certificates  filed with State 
and Territorial vital statistics offices.  Death  certificates are  dually  completed by  
funeral directors  and  medical certifiers (e.g.,  physicians, medical examiners, and  
coroners).   In April 2020,  CDC issued guidance indicating that COVID-19 should be 
specified on death certificates if it played a role in the death.25   CDCs recommended  
      
e  Testing data track individual tests and results, not patients.  While testing data are not person-based,  
they do contain personal information about the people being tested, such as race and ethnicity.  
f  The Council of State and Territorial Epidemiologists developed an initial case definition for COVID-19 in 
April 2020 (see  https://www.cste.org/news/520707/CSTE-Interim-Position-Statement-Update-to-COVID-
19-Case-Definition.htm).  In May 2020,  the  CDC developed a COVID-19 case report form.  This form  
standardizes the reporting of information on COVID-19 cases from jurisdictional health departments to  
the  CDC (see https://www.cdc.gov/coronavirus/2019-ncov/downloads/pui-form.pdf).  
g  HHSs Unified Hospital Dataset is maintained on the HHS Protect data platform.  It contains data on  
COVID-19 hospitalizations, such as admissions, inpatient utilization, and ICU utilization.  For more  
information on the Unified Hospital Dataset, please see  https://covid.cdc.gov/covid-data-
tracker/#abouthospitaldata.  For more information on the HHS Protect platform, please see the HHS  
Protect Public Data Hub at  https://protect-public.hhs.gov/.  
CDC Found Ways To Use Data To Understand and Address COVID-19 Health Disparities, Despite Challenges With Existing  Data  
OEI-05-20-00540   Background |  4   standard death  certificate includes the decedents cause and place of death in  
addition to  race, ethnicity,  ZIP  Code,  education, occupation, and industry.26    
Racial, Ethnic, and  Socioeconomic  Data  
CDC  requests that  jurisdictions submit demographic data  (including racial, ethnic, and 
socioeconomic data)  but  has indicated that it does not have the authority to require 
this  information for  COVID-19 cases, hospitalizations, and deaths.27   As authorized by  
the CARES Act and laid out in  HHS  guidance,  labs are required  to report race,  
ethnicity, and  ZIP  Code for COVID-19 test results, which  ultimately  are  reported to  
CDC.28    
Racial and Ethnic Data.   CDCs reporting  instructions generally  use the standard 
minimum  Federal  Office  of Management and Budget (OMB) categories for race and  
ethnicity.h   For race, the categories  are:  American Indian or Alaska Native, Asian, Black  
or African American, Native Hawaiian or Other Pacific Islander, and White; and for  
ethnicity: Hispanic or  Latino and Not Hispanic or Latino.29   However,  jurisdictions may  
choose not to  use these  categories.  Rather, jurisdictions may choose to define race 
and ethnicity differently.  In addition,  jurisdictions  often develop their own reporting  
tools and data systems that  may use different racial  and ethnic categories  when the 
data  are collected.     
Exhibit  1  provides examples of how information on race and ethnicity may  flow to  
select CDC systems tracking COVID-19 testing,  cases, hospitalizations, and  deaths.  
 
 
 
   
 
 
 
 
 
      
h  A  standard death certificate includes more racial and ethnic categories than the minimum OMB  
categories.  Please see the U.S. Standard Certificate of Death  at  
https://www.cdc.gov/nchs/data/dvs/DEATH11-03final-acc.pdf  for more information.    
CDC Found Ways To Use Data To Understand and Address COVID-19 Health Disparities, Despite Challenges With Existing  Data  
OEI-05-20-00540   Background |  5    
Exhibit 1: CDC collects racial  and ethnic  data  for COVID-19 testing, cases, 
hospitalizations, and deaths from providers and public health departments.   
Providers   Labs   Public health   Dataset of positive 
Collect race  Confirm or  departments  and negative test 
and ethnicity  disconfirm  May conduct followup for  results 
data from  COVID-19  missing race and ethnicity data 
patients  I  t 
Cases 
Providers     Public health   National 
Collect race  Labs  departments  Notifiable 
and ethnicity 
data from  Confirm  May conduct followup for  Diseases 
COVID-19  missing race and ethnicity data  Surveillance 
patients 
t 
I  System (N N DSS) 
Hospitalizations 
Hospitals  Surveillance officers 
Collect race  In the 14 States 
and ethnicity  participating in infectious    COVID-NET 
data from  disease surveillance 
patients  programs prior to COV/0-19 
Deaths 
Funeral directors 
National Vital 
Record race and  State vital  It 
ethnicity data with  Statistics System 
records offices 
assistance from friends  (NVSS) 
or relatives of deceased 
 
Note:  This exhibit  represents  racial  and ethnic data on COVID-19 hospitalizations  that CDC  obtains  through 
COVID-NET  reporting.  CDCs additional sources of  COVID-19 hospitalizations  data,  such as  the National Syndromic  
Surveillance Program and the Premier Healthcare Database, may also contain  racial and ethnic data.  
Source:  Office of Inspector General (OIG)  review of CDC and GAO documents, 2021.  
 
Socioeconomic Data.   While  socioeconomic data  may be defined  in various ways 
depending on the  entity  collecting or  analyzing the data, CDC  collects a range of  
variables for  COVID-19 data  that could be used as socioeconomic indicators.   For  
instance,  CDCs suggested COVID-19 case report form requests information  about  
residence at illness onset,  occupation, and  industry.30   As another example,  the 
recommended standard  death certificate includes information about education,  
occupation,  and industry.31    
CDC Found Ways To Use Data To Understand and Address COVID-19 Health Disparities, Despite Challenges With Existing  Data  
OEI-05-20-00540   Background |  6   Federal Response to  COVID-19 Disparities  
CDC, Congress,  and the Administration  have  taken  numerous  steps to address health 
disparities resulting from the COVID-19 pandemic.  Several key steps are described  
below.i  
CDC.   On January 21,  2020,  CDC  activated its  Emergency Operations Center in  
response to the COVID-19 public health emergency.32   33   The Emergency Operations  
Center,  which is activated for the duration of  a  public health emergency,  uses  an 
incident management system to coordinate CDCs response  to  an  emergency.34   As  
part of its response  to COVID-19, CDC  worked to collect COVID-19 data, facilitate  
more rapid identification of COVID-19 hotspots, and consolidate  available  data.  In  
addition,  it  deployed personnel to address staffing needs in State, Tribal, local, and  
Territorial health departments and monitored  potential outbreaks  and hotspots to  
mitigate the spread of COVID-19.    
To  address the importance of health equity as part of  its COVID-19 response,  CDC  
released the COVID-19 Response Health Equity  Strategy  in  August 2020.  The  strategy  
provides an evidence-based, comprehensive,  and coordinated framework for  
reducing COVID-19 disparities.35  CDCs strategy prioritizes  expanding the evidence 
base, which includes having timely, complete, and representative data  for race and 
ethnicity.j, 36    
Congress.   Since early in the pandemic, Congress has taken  several  steps to  help 
address COVID-19 disparities.  For instance,  given concerns about  the  CDCs lack of  
racial and ethnic data related to COVID-19, Congress passed legislation that requires  
the Secretary, in coordination with other  appropriate departments and  agencies,  to  
disclose racial, ethnic, and other demographic data related to COVID-19.37   In  
addition,  the American Rescue Plan  Act  included  $250 million  in  funding  to  develop 
and support a  community-based workforce to increase COVID-19 vaccinations in  
underserved communities.38   The American Rescue Plan  Act also  included  funding to  
support State and local health departments  COVID-19 response capabilities, which  
may  enable them to  improve access to testing, especially  among  communities of  
color.39  
Administration.   President Biden signed  two  Executive Orders in January 2021  related 
to COVID-19 and health equity.  One establishes  a COVID-19  Health Equity  Task Force 
to develop recommendations for mitigating the health inequities caused  or  
exacerbated by the pandemic and preventing future inequities.40   Another requires  
      
i  This section is not intended to serve as a comprehensive review of all Federal actions to respond to  
COVID-19 disparities.  
j  A September 2020 GAO report found that CDCs strategy lacked critical details to achieve the priority of  
collecting complete data by race and ethnicity.  GAO recommended that CDC determine whether having 
authority to require States and jurisdictions to report racial and  ethnic information is necessary and,  if so,  
to seek such authority from Congress.  It also recommended that CDC involve key stakeholders, such as  
public health departments, to improve the completeness and consistency of demographic data.  Please  
see https://www.gao.gov/products/gao-20-701  for more information.  
CDC Found Ways To Use Data To Understand and Address COVID-19 Health Disparities, Despite Challenges With Existing  Data  
OEI-05-20-00540   Background |  7   increased coordination among  Federal agencies  regarding COVID-19  data collection,  
production, and analysis  of data, including key equity indicators, as  well as  sharing  
such data with State, local, Tribal, and Territorial authorities.41  
Related Office of Inspector General Work  
This report is part of  the Office of Inspector  Generals  (OIGs)  strategic efforts to  
oversee HHSs response to the COVID-19 pandemic, address health equity,  and  
ensure that HHS programs have complete, accurate, and timely data.   Additional OIG  
work in support of these priorities includes, for example, assessments  of the 
completeness  and accuracy of racial and ethnic data for Medicare and Medicaid  
beneficiaries.42   OIGs goals include  both  ensuring that HHS is  protecting the health 
and welfare of  all Americans  and promoting the effectiveness of HHS programs.  
Methodology   
Scope  
This report focuses on the limitations of CDCs  racial, ethnic, and socioeconomic data  
for COVID-19 testing, cases, hospitalizations, and  deaths, and how CDC used these 
data to  understand  and address  COVID-19  disparities.  This report does not focus on 
CDCs use of  racial, ethnic, and socioeconomic data  for COVID-19 vaccinations, as at  
the time of our planning  and data  collection the vaccination campaign was  just  
beginning.   Our primary  data collection occurred  in spring  2021, with updates  
received  from CDC through  January  2022.   
Data Collection  
In March and April  2021, we conducted structured interviews with  CDC  staff 
responsible for collecting  and  analyzing COVID-19 data,  collaborating with  
jurisdictions  and Tribal Epidemiology  Centers (TECs), and  developing initiatives to  
address disparities.  We also conducted structured interviews covering the same 
topics  with staff  from  six  jurisdictions and two  TECs  representing a variety of State,  
Territorial,  local,  and Tribal entities.  The six  jurisdictions  selected  for interviews were 
Mississippi, Nevada, North Dakota,  Puerto Rico, Texas,  and  the  District of Columbia.   
The two  TECs selected  for  interviews were the Navajo Epidemiology Center  and the 
Urban Indian Health Institute.k   We considered several factors  when selecting  
jurisdictions and TECs for interviews, including COVID-19  burden and  the degree to  
which jurisdictions  reported racial  and ethnic data.   The purpose of our  interviews 
with  the  selected jurisdictions  and TECs  was  to provide useful, qualitative insights and 
context regarding experiences  with collecting, reporting,  or  using  racial, ethnic, and  
      
k  The Urban Indian Health Institute  is the TEC  that serves Urban Indian Health programs across the  
country.  Please see https://www.uihi.org/  for more information.  
CDC Found Ways To Use Data To Understand and Address COVID-19 Health Disparities, Despite Challenges With Existing  Data  
OEI-05-20-00540   Background |  8   socioeconomic information  associated with  COVID-19 testing, cases,  hospitalizations,  
and deaths.  
We asked CDC staff how  they  have used racial, ethnic, and socioeconomic data  
related to COVID-19 testing, cases,  hospitalizations, and deaths  to  identify and 
address disparities;  any challenges  they  have faced using the data;  and how they  have 
overcome those challenges.  We also asked about lessons learned during the 
pandemic.   Furthermore, we asked how CDC uses  these data to support jurisdictions  
and TECs,  and how CDC  uses  these data  when working with Federal  agencies.  Lastly,  
we asked CDC about its approach to health equity and how the Chief Health Equity  
Officer  unit  works throughout CDC to address COVID-19 disparities.  In some cases,  
we received written responses to questions in lieu of an interview.  
We asked staff from the jurisdictions  and TECs  about the racial, ethnic, and  
socioeconomic data they share with or receive from CDC,  challenges they  have 
encountered  with the data, and how they  have collaborated  with CDC to use these 
data to address  COVID-19  in their jurisdictions  or among  Tribes.  
In some instances,  we requested supporting documentation or submitted followup 
questions.  This allowed  us to  clarify interview responses and review specific  
documents  or publications discussed during the interviews.    
Data Analysis  
We analyzed our interview data  and supporting documents to  determine  how CDC  
used racial, ethnic, or socioeconomic data to address COVID-19 disparities, and to  
understand barriers and  challenges to using data.  We looked for common themes  
across CDC,  the jurisdictions,  and TECs.    
Limitations  
Our analysis relied on interviews and documents provided by CDC  staff and  staff from  
the jurisdictions and TECs.   We did not directly analyze  CDCs racial, ethnic, and  
socioeconomic data for  COVID-19 testing,  cases,  hospitalizations, or deaths.   We 
reviewed publicly available materials to supplement the information provided in 
interviews and documents.  However,  we did not independently verify the  accuracy of  
the information we received.   In addition, the experiences and perspectives of the six 
jurisdictions and two TECs  that we interviewed do  not necessarily reflect the 
experiences and perspectives of all jurisdictions  and TECs.  
Standards  
We conducted this study in accordance with the Quality Standards for  Inspection and  
Evaluation  issued by the Council of  the Inspectors General on Integrity and Efficiency.   
CDC Found Ways To Use Data To Understand and Address COVID-19 Health Disparities, Despite Challenges With Existing  Data  
OEI-05-20-00540   Background |  9    
FINDINGS  
 
Racial, ethnic, and socioeconomic data associated with 
COVID-19  testing, cases,  hospitalizations,  and deaths  have  
limitations and  do not provide a complete picture of  disparities    
Racial  and  ethnic  data associated with  COVID-19  are  sometimes 
incomplete,  inconsistent,  or  inaccurate  
While  the  quality  of racial and ethnic data  associated with COVID-19 has improved  
since the beginning of the pandemic,  completeness and consistency continue to vary.   
Race and ethnicity are still missing for many COVID-19 tests, cases, and  
hospitalizations.  In addition, jurisdictions and health care providers define racial  and 
ethnic categories differently, which means these  data may not have the same 
meaning across jurisdictions.  Furthermore, racial  and ethnic data  associated with  
COVID-19  testing, cases, hospitalizations,  and  deaths  that are not self-reported  may  
be inaccurate.   
Incomplete.   Although  race and ethnicity  for  
testing and cases have become more complete  
since reporting began, both testing and case  
of COVI D-19 tests were 
data  continue to lack  racial  and ethnic  
missing racial and ethnic data 
information  for a significant portion of data.   
Specifically, as  of January  2022, CDC reported  
34% 
that  67  percent of  COVID-19 testing data  
and  34  percent of COVID-19 case  data  were 
missing race and ethnicity.43   By contrast, race   of COVID-19 cases were 
and ethnicity  for deaths  were nearly  100  percent   missing racial and ethnic data 
complete.  
Challenges  at various stages in the data reporting process  contribute to  CDCs  
incomplete racial and ethnic data on COVID-19  tests and cases.   As shown in Exhibit  2,  
COVID-19 data may  flow to CDC through several  stakeholders, each of  which may  
experience challenges  that impact data completeness.l    
 
 
      
l  Stakeholders include the patient, the provider, health care entities, public health departments, and CDC.    
CDC Found Ways To Use Data To Understand and Address COVID-19 Health Disparities, Despite Challenges With Existing  Data  
OEI-05-20-00540   Findings |  10   Exhibit 2: Data generally  flow through multiple stakeholders before reaching  
CDC.  
Each  stakeholder  faces  obstacles  that  contribute to  the  incompleteness  of racial 
and ethnic data  on COVID-19.     
tt 
Patients 
 
Source: OIG review of CDC documents and interview responses, 2021.  
For example, patients may be uncomfortable sharing racial  or  ethnic information with 
health care providers or  public health entities, and providers may be reluctant to  
request this information.  When these incomplete data reach public health 
departments, the departments may lack the staff  or resources needed to  conduct  
followup.   Also,  health  care providers and other entities that report data to  public  
health departments  sometimes report data  via fax, mail, or email, which  strains public  
health department  resources as staff must  manually enter  these data.   Even if racial 
and ethnic data are successfully collected,  one  State  and CDC  reported  that some  
State laws prohibit them  from sharing these data  with CDC.    
Furthermore,  available data may not  be 
COVID-NET has 
representative of the U.S. population.  For example,  
nearly complete  as of July  2021 jurisdictions varied widely  in the 
completeness of racial and ethnic data  they  
racial and ethnic 
reported  for COVID-19 testing.  As a result,  racial 
data on COVID-19  and ethnic  data for COVID-19 testing may be  
skewed toward the  racial and ethnic composition of  
hospitalizations 
jurisdictions  reporting more complete  data rather  
than representative of  the demographics of the 
but covers only 
United States.   Additionally,  because COVID-NET is  
10% of the  a population-based surveillance system, the racial  
and ethnic data CDC reports through it  cover only  
U.S. population. 
about 10 percent of the U.S. population,  
representing  data from the 14 States participating 
in  it.  While these hospitalizations data have nearly  complete  racial  and ethnic  
information (99  percent),  and the population covered  is  demographically  similar to  
the U.S. population,  COVID-NET data  are  not generalizable to  the country.   
Inconsistent  or  inaccurate.   Racial and ethnic data associated with COVID-19  are, in 
some cases, inconsistent  or inaccurate with respect to the populations they describe.   
Although standard minimum categories are defined for Federal use, officials from  
CDC and two  of the jurisdictions  we interviewed reported that variation exists in the 
categories used at the jurisdictional level to collect racial and ethnic data.44   Generally,  
jurisdictions  have discretion in how they  collect demographic data  for public health 
surveillance.  As a result,  there is variation in the categories used to  collect  racial and  
CDC Found Ways To Use Data To Understand and Address COVID-19 Health Disparities, Despite Challenges With Existing  Data  
OEI-05-20-00540   Findings |  11   ethnic data,  and the same categories  across jurisdictions and reporting entities may  
refer to different groups.   
Some of the inconsistency  of racial and ethnic data for COVID-19  arises from  the way  
various  jurisdictions  aggregate or disaggregate  racial and ethnic categories.   For  
example,  some  State health departments combine categories for race when reporting  
cases to  CDC  such as  placing  AI/AN people in the same category as Native Hawaiians  
or Other  Pacific Islanders.45   Additionally, jurisdictions vary  in  whether they treat  
Hispanic or Latino  as  a racial  category  or  as an ethnic category.   As a result,  
two  people of the same race and ethnicity residing in different  jurisdictions  could  
appear in public health reporting  to belong to  different demographic groups.   This  
impedes  the ability of CDC  or outside researchers to  compare  disparities across 
jurisdictions  or  to  identify national or regional trends.   See Exhibit  3  for  an example.  
Exhibit 3: Inconsistent racial and ethnic categories across jurisdictions could 
obscure the impact of  COVID-19 on certain racial or ethnic groups.  
State A's case reporting form lists American Indian or Alaska 
Native as a stand-alone racial category.  If this person lived 
in State A, they would be reported as American Indian or 
State A  Alaska Native both in the State and to CDC. 
~lmt 
State B's case reporting form lists a combined Other racial 
category that includes both American Indian or Alaska Native 
This person is an 
and Native Hawaiian or Other Pacific Islander. If this person 
American Indian who 
lived in State B, they would be reported as "Other" in the 
contracted COVI 0-19. 
State B  State, obscuring their race as American Indian. 
 
Source:  OIG review of CDC  and State interview responses, 2021.  
Finally, racial  and ethnic information for COVID-19 deaths  may be inaccurate.   Racial 
and ethnic data for COVID-19 deaths  are nearly  100  percent complete,  but  previous  
analyses have indicated  that  death  certificates for  as many as     percent  of AI/AN  
40
people misclassify them  as White or other races.m, 46   As a result, COVID-19 death  data  
may understate the burden of COVID-19 on AI/AN people.   More accurate death data  
would help CDC understand the true impact  of COVID-19 on  vulnerable populations.   
 
 
      
m  CDC reported that the issue of racial and ethnic misclassification likely extends to any data type where  
race and ethnicity are reported by proxy.    
CDC Found Ways To Use Data To Understand and Address COVID-19 Health Disparities, Despite Challenges With Existing  Data  
OEI-05-20-00540   Findings |  12   Socioeconomic  data associated with  COVID-19  are not clearly  
defined  or consistently  collected  
CDC  does  not set a standard for reporting  socioeconomic data  elements  across 
COVID-19  testing, cases, hospitalizations,  and  deaths.  Socioeconomic data  can 
include a wide range of elements such as  ZIP  Codes,  health insurance status,  and 
occupations, and reporting entities  are often the decisionmakers  regarding  which 
measures, if any, to collect.   Two jurisdictions  we interviewed reported that guidance 
and standards would be needed to improve completeness and standardization of  
socioeconomic data at the individual level.   
In lieu of patient-level COVID-19 socioeconomic  data, both  CDC and  jurisdictions  
reported using  community-level data such as data from the Census Bureau or  CDCs 
Social Vulnerability Index  (SVI).n   These community-level  data  enable CDC and  
jurisdictions to  identify  and understand  community vulnerabilities and target  
interventions to address  them.o   However,  while  CDC reported  these data  are useful  
for steering community-level interventions, they do not  allow  for direct analysis of  
individual socioeconomic disparities  in COVID-19  testing, cases, hospitalizations, or 
deaths.   
Data  limitations  result in an incomplete  picture  of disparities  in  
COVID-19  testing, cases, hospitalizations, and  deaths   
Although CDC  used  racial, ethnic, and socioeconomic  data  to report on COVID-19  
disparities, its analyses had  gaps and limitations.   For example,  an August  2020 CDC  
report on COVID-19  among AI/AN people included only 23 States  because the 
remaining  States  case data  lacked  sufficient racial and ethnic  information.47  CDC has 
not published findings  about  disparities in  COVID-19  cases for AI/AN people  in the 
more than half  of  States that lacked  sufficient data.   Furthermore, in a  2020  report  
that CDC  conducted on  COVID-19  racial and ethnic disparities in  hotspot counties,  
CDC had to limit its analysis to  counties where  at least 50  percent  of case data  
included race.   This  meant that  CDC  could  include  in its analysis  only  79 of the 205 
counties it identified as hotspotsjust  38.5 percent.48   Racial and ethnic data may  
have improved since these analyses  were conducted.   
      
n  SVI is a tool that helps emergency response planners and public health officials identify, map, and plan  
support for communities that  will most likely need support before, during, and after a public health  
emergency.  It ranks each census tract on 15 American Community Survey variables to determine each 
tracts relative social vulnerability.  Please see  https://svi.cdc.gov/Documents/FactSheet/SVIFactSheet.pdf  
for more information.  
o  Research supports the use of  social vulnerability measures for anticipating and addressing the  
needs  of  disadvantaged communities in emergencies.  Please see Karaye and  Horney,  
2020  (https://doi.org/10.1016/j.amepre.2020.06.006), Gaynor  and Wilson,  2020  
(https://doi.org/10.1111/puar.13264), and Oates et al.,  2021  
(https://doi.org/10.1007/s10900-021-00998-x) for examples.    
CDC Found Ways To Use Data To Understand and Address COVID-19 Health Disparities, Despite Challenges With Existing  Data  
OEI-05-20-00540   Findings |  13   Additionally,  CDC may lack sufficiently  granular  data to understand certain  disparities, 
even with complete racial and ethnic data.   For example,  some jurisdictions in our  
small sample reported that information  on individuals Tribal affiliation  would be  
useful for understanding  and addressing COVID-19  in Tribes.   However,  jurisdictions  
vary as to whether they  collect this  information.p   If the data are not collected in the 
jurisdictions,  CDC  cannot receive them.   Without data on Tribal affiliation, it may be  
more difficult for  CDC,  States, and Tribal partners  to identify or respond to  
Tribal-specific outbreaks  or inequities.    
CDC has taken  steps  to supplement  and improve  data on  
COVID-19 testing, cases,  hospitalizations,  and deaths  
CDC reported  that it has  attempted to overcome  limitations  in  demographic data for  
COVID-19 testing,  cases,  hospitalizations, and deaths  in several ways.   First,  CDC  
supplements  these  data by  using information  from  multiple  existing data  sources  and 
by  conducting  additional  data collection  via ad hoc surveys and listening sessions.   
CDC reported that  this  combination of  supplemental data and the demographic  data 
on  COVID-19 testing, cases,  hospitalizations,  and deaths  has been  sufficient to  
demonstrate the existence of racial, ethnic,  and socioeconomic disparities  and  to  
begin to  understand  their  nature and magnitude.   Second,  CDC took steps to support  
the entities that report COVID-19 data to  CDC to  improve the quality of COVID-19  
data at their source.    
 
While more robust race and ethnicity data would  provide a  more  
comprehensive view  of the pandemic, the data reported to  CDC 
and shared with  Federal partners has been sufficient to document 
major disparities.  
 CDC  official  
 
CDC used  existing data sources and  collected  additional data 
related  to COVID-19  disparities  to  supplement COVID-19  data  
Recognizing the limitations of  racial, ethnic, and socioeconomic  data  associated with  
COVID-19 testing,  cases,  hospitalizations, and deaths, CDC has leveraged  its broad  
array of  existing  public health data sources to bolster its understanding of  disparities.   
CDC  combines data on COVID-19  testing, cases, hospitalizations,  and deaths with 
      
p  The standard death certificate includes an option to report Tribal affiliation for AI/AN individuals.   
Please see the U.S. Standard Certificate of Death  at  https://www.cdc.gov/nchs/data/dvs/DEATH11-03final-
acc.pdf  for more information.  
CDC Found Ways To Use Data To Understand and Address COVID-19 Health Disparities, Despite Challenges With Existing  Data  
OEI-05-20-00540   Findings |  14   these other data  sources, such as emergency department and Census data, to  better  
understand  COVID-19 disparities.  For example:  
   CDC uses  clinical data from  research and health plan networks and emergency  
department data on COVID-like illness.q   CDC reported that its emergency  
department data,  which come directly from electronic health records, can offer  
more complete racial and ethnic data because multiple records are  
automatically scanned  for information on patients race and ethnicity.    
   CDC also developed a methodology to identify disproportionately impacted  
communities of  color  at the county level using Census data on race and  
ethnicity.49  
   CDC has used a  geospatial toolthe SVIto  identify geographic areas  
that  may be  at  higher risk  for  severe outcomes  due to  social factors.  
CDC also  gathers additional qualitative data  that  provide information it could not get  
even from  complete quantitative COVID-19 data,  such as insights into beliefs and  
attitudes.   CDC uses surveys and listening sessions to gather  these data  on the impact 
of COVID-19  on diverse populations.  For example, CDC  conducted a survey on 
mental health during the pandemic for which racial and ethnic data were more  
than  99  percent complete.50   Furthermore, CDC  conducted 18 listening sessions with 
diverse audiences to learn more about the beliefs  and needs of disproportionately  
impacted populations.  These surveys  and listening sessions captured information on  
topics such as vaccine hesitancy, mask adherence, and beliefs about COVID-19, none 
of which are included  in patient-level COVID-19 data.    
CDC has  worked  to  support  labs  and jurisdictions in  addressing 
data collection  and  reporting  challenges  unique  to COVID-19  
The COVID-19 pandemic presented unique challenges that impacted how  data were 
collected  and reported.   Although these challenges were not specific to racial, ethnic,  
or socioeconomic data, they complicated general  COVID-19 data collection  activities  
and therefore may have contributed to data quality concerns.  CDC has taken  steps to  
support labs and jurisdictions in collecting and  reporting better data for COVID-19,  
including improved racial, ethnic, and socioeconomic data.   
The scale of the COVID-19 pandemic created challenges for labs that were reporting  
testing data.  To increase testing capacity, many labs that had not previously done 
routine testing opened new testing sites.  CDC and jurisdictions reported that many  of  
these new  testing sites were unfamiliar  with the reporting process, and many were not  
set up to report data electronically or to collect information on race, ethnicity, or  
socioeconomic status.   Additionally, in contrast to most public health reporting, labs  
that do COVID-19 testing must report COVID-19 results for both positive and  
negative results.51   This meant  that some labs had to develop new electronic reporting  
      
q  CDC reported there is no broad Federal requirement for States to report emergency department data 
to CDC.  However, some funding opportunities may require States to report these data.    
CDC Found Ways To Use Data To Understand and Address COVID-19 Health Disparities, Despite Challenges With Existing  Data  
OEI-05-20-00540   Findings |  15   systems to satisfy the requirement to report negatives.  These factors have strained  
the resources of labs  already stretched thin.  
CDC took steps to support labs in reporting these data.   Following the release of HHS  
guidance on the CARES Actwhich required labs to report race, ethnicity, and  ZIP  
CodeCDC provided labs with additional information and technical assistance for  
establishing electronic reporting.52, 53   For example, CDC  clarified which labs must  
report testing data, how labs could report data using standard terminology, and 
answered frequently asked questions.  However,  CDC also acknowledged  that labs  
cannot control providers data collection practices or patients willingness to provide 
demographic data, stating  that  laboratories should make every reasonable effort to  
provide the required data elements.54   
Given broader  concerns  about inconsistency, CDC  worked to  standardize COVID-19  
case reportsincluding racial and ethnic databy creating a reporting worksheet for  
and providing related technical assistance  to jurisdictions.  The worksheet uses the 
minimum standard Federal racial and ethnic  categories, but may not be sufficient to  
standardize racial and ethnic data for cases if jurisdictions systems are not  set up to  
capture data at the same level of specificity as the  Federal categories.  For  example,  
some  jurisdictions  collect racial data across multiple Federal race  categories (such  as  
Asian and Native Hawaiian or Other Pacific Islander) only in a single,  umbrella  
category.  
CDC reported  using multiple data sources  and  analyses  to 
inform  efforts  to  address COVID-19 disparities  
CDC reported that it uses  the  variety of  data and analyses  described above to  inform  
its efforts to  address  racial, ethnic, and socioeconomic disparities in COVID-19  
through  technical assistance to partners, targeted interventions,  and funding.   
CDC  also  reported that it  elevated  health equity as a priority in its  pandemic  response,  
which  has  influenced  its  use of  data to  address disparities.   CDC included  a health 
equity unit in its  COVID-19 incident response structure.  For  the first  time,  CDC  placed  
a senior leaderthe Chief Health Equity Officeron its incident management  
leadership team.   The health equity  unit has  centered  data in its activities, explicitly  
calling for improved racial, ethnic, and socioeconomic data  on COVID-19 and  
espousing data-driven approaches to  advancing health equity.    
Technical assistance.   Jurisdictions  and Tribal entities may  request  technical assistance  
from  CDC  to analyze challenges and identify  data-driven solutions.   As of  
December  2021, CDC  reported that it had  responded to  more than 300 such requests  
related to  health disparities.  For example, CDC has responded to requests  from Tribes  
and Indian Health Service units for support in epidemiology, data management, and  
health communication.   In one  case,  CDC  deployed staff  to  the  Navajo Nation  to help 
the Tribe  assess  water  access and  construct  water-access points.  This  supported  
COVID-19 prevention efforts by  increasing  Tribal residents access to  water for 
CDC Found Ways To Use Data To Understand and Address COVID-19 Health Disparities, Despite Challenges With Existing  Data  
OEI-05-20-00540   Findings |  16   handwashing.  CDC reported that it also routinely  monitors COVID-19 data and has  
conducted outreach to populations that appear to need additional support.   For  
example, CDC proactively reached out to Tribal communities when surveillance data  
indicated high COVID-19 burden.  
Exhibit 4: See below  for examples of technical assistance CDC  provided to  
partners.  
with the National Center for Farmworker Health to build 
capacity in organizations serving agricultural workers and develop 
COVID-19 mitigation strategies for farmworker communities 
Deployed a tailored tool to help Tribes integrate COVID-19 data 
and visualize the impact of COVID-19 on Tribal communities 
Held focus group discussions with members of Marshallese and 
Hispanic or Latino communities in Arkansas to identify 
COVID-19-related challenges and needs 
 
Source:  OIG review of  CDC web  pages and interview responses, 2021.  
Designing and implementing targeted interventions.   CDC  reported that it has  
partnered  with Federal agencies to use racial, ethnic, and socioeconomic data to  
design and implement targeted interventions to address disparities.  CDC  reported  
that it  has  used  these data to determine which interventions and  what guidance are 
needed, and for  whom.  For instance, CDC  used data to determine locations for  
community-based testing sites,  to ensure that its messaging and ad  campaigns were 
targeted to the communities most at risk, and to inform the distribution of masks  
purchased by the Government. 
COVID-19-related funding opportunities.   CDC  reported that it addresses  disparities  
in COVID-19 by providing funding opportunities  including  cooperative agreements  
paired with technical assistance  with an emphasis  on health equity.   In some cases,  
CDC  has  offered  funding  specifically to address COVID-19 disparities among  
disproportionately affected communities, as in the $2.25  billion grant opportunity  
CDC posted through its  Center for State, Tribal, Local, and Territorial Support in 
March  2021.55  This grant aims to address COVID-19-related health disparities among  
people living in rural areas as well as racial and ethnic minority groups.  CDC  has  also  
offered $300 million  to support  community health workers  in  addressing  COVID-19-
related health disparities  in high-risk populations,  including communities of color.56   
In other  cases,  CDC awarded funds to the CDC Foundation,  which gave jurisdictions  
resources to support health equity.r   CDC also reported that it considers health equity  
      
r  The CDC Foundation is an independent nonprofit created by Congress to marshal philanthropic and 
private resources for CDC.  For more information, see https://www.cdcfoundation.org/.  
CDC Found Ways To Use Data To Understand and Address COVID-19 Health Disparities, Despite Challenges With Existing  Data  
OEI-05-20-00540   Findings |  17   issues,  unintended  impacts on minority populations,  and  alignment with  the  Health  
Equity Strategy  when reviewing proposals  for funding.  
Some of  these  health equity  funding opportunities  also  promote data quality  
improvement.   For example,  the March 2021  opportunity  includes  strategies  for 
jurisdictions to increase and improve data  collection and reporting for populations  
disproportionately impacted by COVID-19.   It encourages recipients to  improve data  
collection by race and ethnicity,  to educate providers on the importance of racial  and 
ethnic  data, and to  disseminate  health equity data and other materials  that are  
culturally and  linguistically tailored, among other  activities.57    
Some  Tribal partners and  at least one  Territory  have  
experienced challenges  addressing  COVID-19 disparities  due to  
problems  accessing or managing  data  
Despite their status as  public health authorities,  the two  TECs  we interviewed  reported  
difficulty accessing  COVID-19 data on  AI/AN  people from both CDC and  States.   
These challenges,  which were also reported in media accounts  and testimony from  a  
nonprofit Tribal organization in the summer of 2020,  stemmed from  staff  confusion 
regarding the public health authority  of the TECs.58, 59, 60   Specifically, the  partners we 
interviewed  reported that CDC staff and State health departments denied  several of  
their  data requests  throughout the pandemic, citing privacy concerns  and questioning  
Tribal partners authority  to access these data.   CDC published guidance  in 2015  
affirming  the TECs  had  access to  HHS  data  under the Indian Health Care Improvement  
Act,61  and CDC  reported that it  took steps to provide these  partners with access to  
datasets on  HHS Protect  and  that  the issue had been  resolved.  However,  the  TECs we 
interviewed  reported that CDC staff and State health departments did not consistently  
know or apply the 2015  guidance,  and that  they continued  to face challenges  due to  
poor-quality  racial data  and logistical hurdles.   For example, both TECs  reported they  
had to negotiate across multiple Federal, State, and Tribal entities to access the 
COVID-19 data they needed.   
Additionally,  the Territory we interviewed  experienced challenges addressing  
COVID-19 because it  lacked  the technical infrastructure  needed  to collect, analyze,  
and report  COVID-19  data.   CDC provided  this Territory,  whose population  is mostly  
people of color,  with  additional support  to limit its COVID-19 burden.   Specifically,  
CDC  deployed staff  to assist  the Territory in  quickly establishing IT systems for 
conducting public health surveillance and managing  COVID-19 data.    
CDC Found Ways To Use Data To Understand and Address COVID-19 Health Disparities, Despite Challenges With Existing  Data  
OEI-05-20-00540   Findings |  18    
CONCLUSION  AND  RECOMMENDATIONS  
 
 
To combat health disparities most effectively both  during the COVID-19 pandemic  
and more broadly, CDC needs adequate data on health outcomes for diverse 
populations.  The pandemic  has  highlighted and exacerbated existing  racial, ethnic,  
and socioeconomic  health disparities.   At the same time, the pandemic  has strained  
the Nations  public health system  and exposed gaps in its infrastructure,  including  
limited demographic information  in  key public health data.   While CDC has  made 
efforts to improve its racial and ethnic data for COVID-19 testing, cases,  
hospitalizations, and deaths,  some  data remain incomplete,  inaccurate,  or  
inconsistent.    
CDC has opportunities to improve the way it works with jurisdictions,  labs, and  
hospitals  to collect and use data to address  COVID-19 disparities.  Despite data  
limitations, CDC has been able to improve its understanding of COVID-19 disparities  
and take steps to  address them.  CDC faces choices about the best balance of  
approaches for ensuring  adequate  resources to support an equitable response.   
Furthermore,  TECs and  certain jurisdictions, such  as Territories, may  need more 
support from  CDC to address COVID-19 due to problems accessing data  or lack of  
resources.    
We recommend  that  CDC:    
Expand its efforts  both to improve  racial  and ethnic data 
associated with COVID-19 and  to supplement  them  with 
additional data sources   
CDC should expand its two-pronged approach of:  (1) improving racial  and ethnic data  
for COVID-19 testing, cases, hospitalizations, and  deaths;  and (2)  using additional  data  
sources to enhance its insights into racial, ethnic,  and socioeconomic disparities.   Both  
efforts  are  valuable,  and  CDC should  determine the  appropriate balance  of  activities  
and resource investments  to  support each.    
As part of its efforts to improve the quality of  racial  and ethnic data  associated with  
COVID-19,  CDC  should  pursue several additional steps.   CDC should assess the 
breadth of  jurisdictions  need for support in developing  adequate data collection and 
management systems  and  use its findings  to inform the type and level of  support  it  
provides  (e.g., technical assistance,  staff deployments, funding).  CDC  could also use 
this information to inform its ongoing data modernization initiative.   Additionally,  
CDC could  work  with jurisdictions and  labs  to encourage  or incentivize  the adoption  
of  the minimum Federal  standards for  racial  and ethnic categories.   Finally,  CDC could  
CDC Found Ways To Use Data To Understand and Address COVID-19 Health Disparities, Despite Challenges With Existing  Data  
OEI-05-20-00540   Conclusion and  Recommendations |  19   consider  taking actions to  encourage  the  collection of Tribal affiliation,  such as 
developing  guidance on how it could be standardized  and  used, and best practices  
from jurisdictions  already collecting it.  CDC could also consider whether and how  
those data  could be submitted to CDC.    
Ensure that Tribal  Epidemiology Centers  have timely access to 
all public health data to which they are entitled  
CDC should  work with  TECs  to  understand which  HHS  data or systems they  lack  
access  to  and  what barriers they have faced, and  work to resolve them.  CDC  should  
also  ensure that all CDC  staff  working  with data  and with Tribal partners  are aware of  
TECs  status as public  health  authorities and CDCs legal obligations toward them  to  
provide access  to HHS data.   GAO has made similar recommendations  for  HHS and  
CDC to take actions to improve TECs access to  HHS data.62   CDC could also  clarify  
TECs  authority  for States,  if needed.  
 
 
 
   
CDC Found Ways To Use Data To Understand and Address COVID-19 Health Disparities, Despite Challenges With Existing  Data  
OEI-05-20-00540   Conclusion and  Recommendations |  20   AGENCY COMMENTS AND OIG RESPONSE 
 
 
 
CDC concurred with  our first  recommendation  to  expand its efforts to improve and  
supplement racial and ethnic data associated with COVID-19.  In its response,  CDC  
described several actions it is taking  to improve and supplement these data, including  
planning a $3 billion funding opportunity for public health agencies to address  
infrastructure and  workforce needs and  collaborating with the Council of State and  
Territorial Epidemiologists to survey jurisdictions about their challenges  with  
collecting and sharing racial and ethnic data.   We hope to see CDC continue its  efforts 
to improve racial and ethnic data  going forward,  beyond the expiration of the 
COVID-19 public health emergency.    
CDC concurred with our  second  recommendation  to ensure that TECs  have timely  
access to all public health data to which they are entitled.   In its  response, CDC  stated 
that it planned to develop written guidance for TECs on requesting  public health data.    
In our draft report,  we also  recommended that CDC  assess  the costs and  benefits of  
standardizing and collecting socioeconomic data  at the individual level, compared  to  
the costs and benefits of  using  socioeconomic data at the community level.   CDC 
disagreed with  our  recommendation but  affirmed  the  value of  socioeconomic data  for 
understanding  and addressing  COVID-19  disparities.  In its response, CDC  provided 
support for its conclusion  that collecting  community-level socioeconomic data  
through surveys  was  more economically efficient  and feasible than attempting to  
collect  individual-level  socioeconomic  data and linking  it to case surveillance data.   
CDC also  described how its Data  Modernization  Initiative  would  help improve  
community-level socioeconomic data.   The considerations and assessments that CDC  
included in its response met the intent of our recommendation and,  as such,  we did 
not include it  as a recommendation in our final report.  We appreciate CDCs  
commitment to improving socioeconomic data  at  the community level and  to using  
these  data to advance health equity in its COVID-19 response.  
For the full text of CDCs  comments, see the Appendix.  
 
CDC Found Ways To Use Data To Understand and Address COVID-19 Health Disparities, Despite Challenges With Existing  Data  
OEI-05-20-00540   Agency Comments and OIG Response  | 21   APPENDIX - Agency Comments
TO:  Gregory E. Demske  
Acting Principal Deputy Inspector General 
FROM:   Centers for Disease Control and Prevention (CDC) 
DATE:  May 6, 2022 
SUBJECT:  Office of Inspector General (OIG) Draft Report, CDC Found Ways To Use Data To 
Understand and Address COVID-19 Health Disparities, Despite Challenges With 
Existing Data, OEI-05-20-00540 
Attached is the Centers for Disease Control and Prevention (CDC) response to the Office of Inspector 
General (OIG). This response details CDCs planned actions regarding recommendations contained in the 
OIG report, CDC Found Ways To Use Data To Understand and Address COVID-19 Health Disparities, 
Despite Challenges With Existing Data, OEI-05-20-00540. 
CDC appreciates the opportunity to review and comment on this report prior to its final release. 
Sincerely, 
Rochelle P. Walensky, MD, MPH 
Director, CDC, and 
Administrator, ATSDR 
1 
CDC Found Ways To Use Data To Understand and Address COVID-19 Health Disparities, Despite Challenges With Existing Data 
OEI-05-20-00540                                Appendix | 22 OIG Recommendation (1) 
OIG recommends CDC expand efforts to improve racial and ethnic data associated with COVID-19 and 
to supplement them with additional data sources. 
CDC Response:  
CDC concurs with the OIG recommendation. CDC is committed to continuing to expand its efforts to 
improve racial and ethnic data associated with coronavirus disease 2019 (COVID-19) and supplement 
them with additional data sources. CDC has several ongoing activities to improve race and ethnicity data, 
as well as additional data sources. Examples include:   
 A currently forecasted funding opportunity through CDCs Center for Surveillance,
Epidemiology, and Laboratory Services, CDC-RFA-OE22-2203, Strengthening U.S. Public
Health Infrastructure, Workforce, and Data Systems, with an estimated funding amount of $3
billion. This funding is a first of its kind, approached as non-categorical and cross-cutting,
and intended to help meet critical infrastructure and workforce needs in the short term; it
should also make possible strategic investments that will have lasting effects on public health
agencies across the United States. To that end, it will support strategically strengthening
public health capacity and systems related to the workforce, foundational capabilities, data
modernization, physical infrastructure, and support from national public health partners.
 CDCs National Center for Health Statistics (NCHS) is committed to improving data on race
and ethnicity collected from death certificates. In Fiscal Year 2022, NCHS began targeted
outreach and training for funeral directors, who are often responsible for proxy reporting of
race and ethnicity of the decedent on the death certificate. This training reinforces existing
NCHS guidance for funeral directors to consult with the decedents family or close friends
when determining race and ethnicity. NCHS has also focused on the misclassification of race
and ethnicity for the American Indian and Alaska Native (AI/AN) population. To help correct
misclassification of race and ethnicity on U.S. death certificates and to compute more reliable
estimates, NCHS uses linked death certificate and self-reported census data. NCHS issued a
recent report that provided an adjusted mortality profile for the AI/AN population for 2019.
This report used linked census and National Vital Statistics System (NVSS) mortality data to
assess the level of misclassification by select characteristics, generate correction factors, and
apply these corrections to observed NVSS mortality data. This work produced more reliable
mortality statistics for the AI/AN population. NCHS will continue to expand efforts to correct
misclassification on death certificates.
 CDC continues efforts to promote the adoption of Electronic Case Reporting (eCR). For
example, as of January 1, 2022, eCR is required by the Centers for Medicare & Medicaid
Services Promoting Interoperability Program for eligible hospitals and critical access
hospitals and the Merit-Based Incentive Payment System eligible clinicians.
 CDC collaborated with the Council for State and Territorial Epidemiologists (CSTE) on a
survey of jurisdictions to learn their experiences with barriers to collecting and sharing race
and ethnicity data. Released in April 2022, Addressing Gaps in Public Health Reporting of
Race and Ethnicity Data for COVID-19  Findings & Recommendations Among 45 State &
Local Health Departments findings suggest that multiple factors, including incomplete
healthcare provider and laboratory reporting of race and ethnicity data to public health; the
lack of a modern, interoperable public health data infrastructure; and the need for additional
staff at public health agencies hampered the ability to identify and respond to the enormous
disparities in the impact of COVID-19 on racial and ethnic minority groups. CDC will work
with CSTE to assess next steps based on the recommendations from the Assessment.
2 
CDC Found Ways To Use Data To Understand and Address COVID-19 Health Disparities, Despite Challenges With Existing Data 
OEI-05-20-00540                           Appendix | 23 OIG Recommendation (2)  
OIG recommends CDC assess the costs and benefits of standardizing and collecting socioeconomic data 
at the individual level. 
CDC Response:  
CDC non-concurs with the OIG recommendation to assess the costs and benefits of standardizing and 
collecting socioeconomic data at the individual level for COVID-19 testing, cases, hospitalizations, and 
deaths. Throughout the COVID-19 response, CDC has been considering ways to use data to understand 
the impact of socioeconomic status and other important factors on COVID-19 outcomes. At this time, 
working to improve completeness of existing data fields, using existing data sources for analyses, and 
leveraging the data modernization initiative will lead to greater improvements for use of socioeconomic 
and related data than conducting the described assessment. 
At the same time, CDC strongly agrees that there is value in using socioeconomic data to identify, 
understand, and address health disparities. CDC understands the costs and benefits of using these data, 
and the agencys focus is on assessing how to effectively collect and use these data as well as leveraging 
existing data, such as the American Community Survey and other population-level data sources.   
It is far more economically efficient and feasible to collect community-level socioeconomic data through 
surveys than to collect individual-level data and link it to case surveillance data. The latter would require 
state and local public health staff to contact individuals to ask questions about their socioeconomic status 
and access non-public health databases that they likely do not have access to in order to link 
socioeconomic data to case reports. These efforts would require coordination with several other agencies; 
CDC could not collect these data independently.  
Examples of efforts to use socioeconomic data include a wide range of work by NCHS. NCHS has a 
robust data linkage program that links their own population and provider surveys, at the individual person 
level, to other sources of health-related data including Medicare and Medicaid health insurance and 
federal housing assistance programs to better understand the role of socioeconomic status and social 
support programs in individual health outcomes. These linkages create new sources of data that combine 
survey reported information on personal and socioeconomic characteristics, health conditions and health 
care access and utilization with more detailed information on program participation found in 
administrative data files. These linked data resources are used by researchers and other analysts to inform 
evidence-based policymaking.   
NCHSs National Health Interview Survey (NHIS) collects information on a variety of income sources as 
well as estimates of total combined family income. The NHIS asks adult participants about their work 
status in the week before the interview, main reason for not working, hours worked, work benefits for 
those working, and days of sick leave taken. The NHIS also asks about educational attainment, measured 
as the highest level of school or highest degree completed. On a rotating basis, the NHIS asks about the 
sample adults occupation, industry, and work activities through a series of questions allowing for 
verbatim text responses. Those responses are then coded by statistical clerks at the U.S. Census Bureau 
into standardized industry and occupation codes.   
NCHSs National Health and Nutrition Examination Survey (NHANES) collects the following 
information on socioeconomic data from survey participants 
 Income: annual household income, annual family income; ratio of family income to poverty
 Education: highest grade or level of school completed, or highest degree received
 Employment status.
3 
CDC Found Ways To Use Data To Understand and Address COVID-19 Health Disparities, Despite Challenges With Existing Data 
OEI-05-20-00540                             Appendix | 24 NCHS population survey data from NHIS and NHANES can be linked at the person level to death 
certificates, administrative data, and other statistical data to understand the health of the American 
population.   
CDC agrees that socioeconomic data are important in health equity analyses; however, CDC does not 
agree with the specific recommendations provided. CDC does not plan to focus on the costs and the 
authority to collect standardized socioeconomic data at the individual level for COVID-19 testing, cases, 
and hospitalizations. Health equity remains central to CDCs COVID-19 response and we will continue to 
identify existing data sources for community-level analyses as well as linkages, such as those described 
above. 
Too often, the data needed to support public health actions are neither structured nor standardized and are 
not collected in a consistent manner. As part of CDCs Data Modernization Initiative, CDC is working 
with the Office of the National Coordinator for Health Information Technology and state, tribal, local, and 
territorial partners via U.S. Core Data for Interoperability (USCDI) and USCDI+ to address these 
complex and critical issues. This work will benefit socioeconomic status data in addition to demographic 
and other important data. 
 Adopting USCDI will help make public health data more compatible with healthcare providers,
payers, and other partners.
 Development of a nationwide forum will enable practitioners to identify mission-critical data
elements and send a consistent signal about what matters and what is most important to public
health. The data identified through USCDI+ will help provide a common baseline to support
public health data sharing more broadly.
 Strengthening existing standards management and harmonization activities across public health
will aid in identifying and overcoming barriers to efficient data sharing.
 Technical support will ensure USCDI and USCDI+ are adopted in ways that help improve the
timeliness, relevance, and reliability of data shared to support public health purposes.
OIG Recommendation (3) 
OIG recommends CDC ensures that tribal partners have timely access to all public health data to which 
they are entitled. 
CDC Response:  
CDC concurs with OIGs recommendation. However, CDC requests OIG revise the language used in this 
recommendation to focus specifically on Tribal Epidemiology Centers (TECs) and not on all tribal 
partners. As described in Objective 3, OIG focused on TECs, not all tribal partners. CDC requests this 
recommendation coincide with the OIG objective and is revised to read: CDC ensures that Tribal 
Epidemiology Centers (TECs) have timely access to all public health data enabling them to fulfill their 
public health mission. 
This OIG recommendation aligns with the recommendations that the Government Accountability Office 
(GAO) issued to CDC, Indian Health Service, and Health and Human Services (HHS) in its March 2022 
report, Tribal Epidemiology Centers: HHS Actions Needed to Enhance Data Access, GAO-22-104698. 
CDC is committed to ensuring that TECs have access to the epidemiological data they need to ensure they 
can fulfill their public health missions.  
During the COVID-19 pandemic, CDC has worked with TECs to ensure that they have access to timely 
COVID-19 case surveillance and vaccine administration data. Looking beyond the COVID-19 pandemic, 
CDC understands that there is a need to ensure a systematic process to share public health data with 
TECs. CDC agrees that there is a need to make data sharing easier, less burdensome, and clearer for 
4 
CDC Found Ways To Use Data To Understand and Address COVID-19 Health Disparities, Despite Challenges With Existing Data 
OEI-05-20-00540                             Appendix | 25 TECs. To implement this recommendation, CDC will utilize the approach for the GAO report and 
develop written guidance for TECs on how to request data.   
5 
CDC Found Ways To Use Data To Understand and Address COVID-19 Health Disparities, Despite Challenges With Existing Data 
OEI-05-20-00540                             Appendix | 26  
ACKNOWLEDGMENTS AND CONTACT  
 
Acknowledgments  
Nicole Hrycyk served as the team leader for this study, and Abigail Wydra served as  
the lead analyst.  Others in the Office of Evaluation and Inspections  who  conducted  
the study include Camille Harper, Jonathan Jones,  and Rebekah Schwartz.   Office of 
Evaluation and Inspections staff  who provided support include Rob Gibbons and Mike 
Novello.   
This report was prepared under the direction of Laura Kordish, Regional Inspector  
General for  Evaluation and Inspections in the Chicago regional office;  Adam Freeman,  
Deputy Regional  Inspector General;  and Hilary Slover, Assistant Regional Inspector  
General.  
Contact  
To obtain additional information concerning this report, contact the Office of Public  
Affairs at  Public.Affairs@oig.hhs.gov.  OIG reports and other information can be found  
on the OIG website at  oig.hhs.gov.  
Office of  Inspector General  
U.S. Department of Health and Human Services  
330 Independence Avenue, SW  
Washington, DC 20201  
CDC Found Ways To Use Data To Understand and Address COVID-19 Health Disparities, Despite Challenges With Existing  Data  
OEI-05-20-00540   Acknowledgments and Contact |  27    
ABOUT THE OFFICE OF INSPECTOR GENERAL  
 
 
The mission of the Office of  Inspector General (OIG), as mandated by  Public Law 95-
452, as amended, is to protect the integrity of the Department of Health and Human 
Services (HHS) programs, as well as the health and welfare of beneficiaries served by  
those programs.  This statutory mission is  carried  out through a nationwide network  
of audits, investigations,  and inspections  conducted by the following operating  
components:  
The  Office  of  Audit  Services  (OAS)  provides auditing services for HHS,  
either by conducting  audits with its own audit resources  or by overseeing  audit work  
done by others.  Audits examine the performance of HHS programs and/or its  
grantees and  contractors in carrying out their respective responsibilities and are 
intended to provide independent assessments  of  HHS programs and operations.   
These audits help reduce waste, abuse, and mismanagement and promote economy  
and efficiency throughout HHS.  
The  Office  of  Evaluation  and Inspections  (OEI)  conducts national  
evaluations to provide HHS, Congress,  and the public with timely, useful, and reliable 
information on significant issues.  These evaluations focus on preventing fraud, waste,  
or abuse and promoting  economy, efficiency, and  effectiveness of departmental  
programs.  To promote impact, OEI reports also present practical  recommendations  
for improving program operations.  
The Office of  Investigations  (OI)  conducts criminal, civil, and  administrative  
investigations of fraud and misconduct related to HHS programs, operations, and 
beneficiaries.   With investigators working in all 50 States and the  District of Columbia,  
OI utilizes its resources by actively coordinating  with the Department of Justice and  
other Federal, State, and  local law enforcement  authorities.  The investigative efforts  
of OI often lead to criminal convictions,  administrative sanctions, and/or civil  
monetary penalties.  
The Office of  Counsel to  the Inspector  General  (OCIG)  provides  
general legal services to  OIG, rendering advice and opinions on HHS programs and  
operations and providing all legal support for OIGs internal operations.  OCIG 
represents OIG in all civil  and administrative fraud  and abuse cases involving HHS  
programs, including False Claims Act, program exclusion, and  civil monetary penalty  
cases.   In connection with these cases, OCIG also  negotiates and monitors  corporate 
integrity agreements.  OCIG renders  advisory opinions, issues compliance program  
guidance, publishes  fraud alerts, and provides other guidance to the health care 
industry concerning the anti-kickback statute and other OIG enforcement authorities. 
CDC Found Ways To Use Data To Understand and Address COVID-19 Health Disparities, Despite Challenges With Existing  Data  
OEI-05-20-00540   About  OIG  | 28   ENDNOTES  
 
 
1  CDC,  Risk for COVID-19 Infection, Hospitalization, and Death  by Race/Ethnicity, updated on July 16, 2021.  Accessed at 
https://www.cdc.gov/coronavirus/2019-ncov/covid-data/investigations-discovery/hospitalization-death-by-race-ethnicity.html  
on August 9, 2021.  
2  Jenny Gathright, Study Finds  Significant Racial, Socioeconomic Disparities  In COVID-19 Among Children, NPR,  
August  7,  2020.  Accessed  at  https://www.npr.org/local/305/2020/08/07/900166845/study-finds-significant-racial-
socioeconomic-disparities-in-c-o-v-i-d-19-among-children  on August 3, 2021.   
3  Michael Schwirtz and Lindsey  Rogers Cook, These N.Y.C. Neighborhoods Have the Highest Rates of  Virus Deaths,  New York  
Times, May 18, 2020.  Accessed at  https://www.nytimes.com/2020/05/18/nyregion/coronavirus-deaths-nyc.html  on August  3,  
2021.  
4  CDC, Race/Ethnicity, Underlying Medical Conditions, Homelessness, and Hospitalization Status of Adult Patients With  
COVID-19 at an Urban Safety-Net Medical CenterBoston,  Massachusetts, 2020,  MMWR,  Vol. 69, No. 27, July 10, 2020, p. 864.   
Accessed at  https://www.cdc.gov/mmwr/volumes/69/wr/pdfs/mm6927a3-H.pdf  on August 26, 2021.   
5  CDC,  Underlying Medical Conditions Associated With Higher  Risk for Severe COVID-19: Information for Healthcare  
Professionals, updated on May 13, 2021.  Accessed at  https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-
care/underlyingconditions.html  on August 31, 2021.  
6  Brendan Saloner, Kalind Parish, and Julie Ward, COVID-19 Cases and Deaths in Federal and State Prisons,  JAMA,  July 8, 2020.   
Accessed at  https://jamanetwork.com/journals/jama/fullarticle/2768249  on October 20, 2021.  
7  Nidhi Prakhash, Doctors Are Concerned That Black Communities Might Not Be Getting Access  To Coronavirus Tests,  
Buzzfeed News, March 22, 2020.  Accessed at https://www.buzzfeednews.com/article/nidhiprakash/coronavirus-tests-covid-19-
black  on August 5, 2021.   
8  Senator Elizabeth Warren; Representative Ayanna Pressley; two other Senators, and one other Representative, letter to HHS  
Secretary Alex M. Azar II, March 27, 2020.  Accessed at  
https://www.booker.senate.gov/imo/media/doc/2020.03.27%20Letter%20to%20HHS%20re%20racial%20disparities%20in%20C 
OVID%20response.pdf  on August 5, 2021.  
9  Congressional Research Service,  Tracking COVID-19: U.S.  Public Health Surveillance and Data, R46588, November 2, 2020.   
Accessed at  https://crsreports.congress.gov/product/pdf/R/R46588  on July 13, 2021.  
10  Coronavirus Aid, Relief, and Economic Security (CARES) Act, P.L. No. 116-136 (enacted on March 27, 2020),  18115(a).  
11  HHS,  COVID-19 Pandemic Response, Laboratory Data Reporting: CARES Act Section 18115,  March  8, 2022.  This guidance  was  
originally  issued on June 4, 2020, and updated on March 8, 2022.  Accessed at  https://www.cdc.gov/coronavirus/2019-
ncov/downloads/lab/HHS-Laboratory-Reporting-Guidance-508.pdf  on March 15, 2022.  
12  85 Fed. Reg. 27550 (May 8, 2020); See also CMS, State Survey Agency Director  memo, May 6, 2020, (QSO-20-29-NH).   
Accessed at  https://www.cms.gov/files/document/qso-20-29-nh.pdf  on August 9, 2021.  
13  CDC,  Data Modernization Initiative, DMI Basics,  The Why, What, and How of Data Modernization, March 2021, p. 6.  Accessed  
at  https://www.cdc.gov/surveillance/pdfs/dmi_basics_external_audiences-March_2021.pdf  on August 6, 2021.  
14  Ibid, pp. 67.  
15  Ibid., p. 9; CDC,  FY 2020 Operating Plan, p. 3.  Accessed at  https://www.cdc.gov/budget/documents/fy2020/fy-2020-cdc-
operating-plan.pdf  on August 6, 2021.  
 
CDC Found Ways To Use Data To Understand and Address COVID-19 Health Disparities, Despite Challenges With Existing  Data  
OEI-05-20-00540   Endnotes | 29    
16  CDC,  Data Modernization Initiative, DMI Basics: The Why, What, and How of Data Modernization, March 2021, p. 9.  (See 
Endnote 13 for URL information.); Coronavirus Aid, Relief, and Economic  Security Act (CARES Act), P.L. No. 116-136, (enacted  
March  27, 2020).  134 STAT 281, Division B, Title VIII.  
17  CDC,  Data Modernization Initiative, DMI Basics: The Why, What, and How of Data Modernization, March 2021, p. 9.  (See 
Endnote 13 for URL information.); CDC,  FY 2021 Operating Plan, p. 3.  Accessed at  
https://www.cdc.gov/budget/documents/fy2021/FY-2021-CDC-Operating-Plan.pdf  on August 6, 2021; American Rescue Plan 
Act of 2021, P.L. No. 117-2 (enacted March  11, 2021),  2404.  
18  Please see https://www.cdc.gov/coronavirus/2019-ncov/science/data-improvements.html  for more information on CDCs  
data improvement efforts.  
19  CDC,  COVID-19 Electronic Laboratory Reporting Implementation by State, Footnote.  Accessed at  
https://www.cdc.gov/coronavirus/2019-ncov/lab/electronic-reporting-map.html  on August 6, 2021.  See also CDC,  Data 
Modernization Initiative,  DMI Basics: The Why, What, and How of Data Modernization, p. 7.  (See Endnote 13 for URL  
information.)  
20  CDC,  CDCs COVID-19 Data Improvement, updated October 29, 2021.   Accessed at  https://www.cdc.gov/coronavirus/2019-
ncov/science/data-improvements.html  on May 20, 2022.   See also  CDC,  Healthcare Facilities in Production for COVID-19 
Electronic Case Reporting, updated on  May 13, 2022.  Accessed at  https://www.cdc.gov/coronavirus/2019-ncov/hcp/electronic-
case-reporting/hcfacilities-map.html  on May 20, 2022.  
21  CDC, COVID Data Tracker.   Accessed at  https://covid.cdc.gov/covid-data-tracker/#cases_testsper100k7day  on July 19, 2021.  
22  HHS,  COVID-19 Pandemic Response, Laboratory Data Reporting: CARES Act Section 18115,  March  8, 2022.  This guidance  was  
originally issued on June 4, 2020, and updated on  March  8, 2022.  (See Endnote 11 for URL information.)  
23  Congressional Research Service,  Tracking COVID-19: U.S Public Health Surveillance and Data, R46588, November 2, 2020.   
(See Endnote 9 for URL information.)   
24  CDC,  Coronavirus Disease 2019 (COVID-19)-Associated Hospitalization Surveillance Network (COVID-NET), August 28, 2020.   
Accessed at  https://www.cdc.gov/coronavirus/2019-ncov/covid-data/covid-net/purpose-methods.html  on September 1, 2021.   
25  CDC, Guidance for Certifying  Deaths Due to Coronavirus Disease 2019 (COVID19),  Vital Statistics Reporting Guidance,  
No.  3, April 2020.  Accessed at  https://www.cdc.gov/nchs/data/nvss/vsrg/vsrg03-508.pdf  on July 16, 2021.  
26  CDC,  Death Edit Specification for the 2003 Revision of the U.S. Standard Certificate of Death,  updated on February 18, 2005.   
Accessed at  https://www.cdc.gov/nchs/data/dvs/death_edit_specifications.pdf  on August 31, 2021.  
27  GAO,  COVID-19: Federal Efforts Could Be Strengthened by Timely and Concerted Actions, GAO-20-701, September  21, 2020.   
Accessed at  https://www.gao.gov/products/gao-20-701  on November 2, 2021.    
28  CARES Act  18115(a); HHS,  COVID-19 Pandemic Response,  Laboratory Data Reporting: CARES Act Section 18115,  March  8,  
2022.  This guidance was originally issued on June 4, 2020, and updated on  March  8, 2022.  (See Endnote 11 for URL  
information.)  
29  CARES Act   18115(a); 62 Fed. Reg. 58782 (October  30, 1997); HHS,  Implementation Guidance on Data Collection Standards  
for Race, Ethnicity, Sex, Primary Language, and Disability Status, p. 3.  Accessed at  
https://aspe.hhs.gov/sites/default/files/private/pdf/76331/index.pdf  on August 6, 2021.  
30  CDC, Human Infection With Coronavirus Disease 2019 (COVID-19) Surveillance Worksheet, updated  May  2022.  Accessed  
at  https://www.cdc.gov/coronavirus/2019-ncov/downloads/php/COVID19-Worksheet-CSV-annotated.pdf  on June 9, 2022.  
31  CDC, U.S. Standard Certificate of  Death, revised November 2003.  Accessed at  
https://www.cdc.gov/nchs/data/dvs/DEATH11-03final-ACC.pdf  on September 1, 2021.  
 
CDC Found Ways To Use Data To Understand and Address COVID-19 Health Disparities, Despite Challenges With Existing  Data  
OEI-05-20-00540   Endnotes | 30    
32  CDC,  CDCs Response,  Updated February 12, 2021.  Accessed at   https://www.cdc.gov/coronavirus/2019-
ncov/cdcresponse/index.html  on August 3, 2021.  
33  The Secretary  of Health and Human Services  declared a nationwide public health emergency in response to the COVID-19 
outbreak on January  31,  2020, retroactive to January 27, 2020.  Alex M. Azar II, Secretary, U.S. Department of Health and  
Human Services, Determination  that a Public Health Emergency Exists, January 31, 2020.  Accessed at 
https://www.phe.gov/emergency/news/healthactions/phe/Pages/2019-nCoV.aspx  on February 25, 2021.  Secretary Azar 
renewed the public health emergency in April 2020, July 2020, October 2020, and January 2021.   Secretary  Xavier  Becerra  
renewed it in April 2021, July 2021, October 2021,  January 2022, and April 2022.  See 
https://aspr.hhs.gov/legal/PHE/Pages/COVID19-12Apr2022.aspx,  
https://www.phe.gov/emergency/news/healthactions/phe/Pages/covid19-21apr2020.aspx,  
https://www.phe.gov/emergency/news/healthactions/phe/Pages/covid19-23June2020.aspx, 
https://www.phe.gov/emergency/news/healthactions/phe/Pages/covid19-2Oct2020.aspx,  
https://www.phe.gov/emergency/news/healthactions/phe/Pages/covid19-07Jan2021.aspx,  
https://www.phe.gov/emergency/news/healthactions/phe/Pages/COVID-15April2021.aspx,  
https://www.phe.gov/emergency/news/healthactions/phe/Pages/COVID-19July2021.aspx,  
https://www.phe.gov/emergency/news/healthactions/phe/Pages/COVDI-15Oct21.aspx,  
https://aspr.hhs.gov/legal/PHE/Pages/COVID19-14Jan2022.aspx, and  
https://aspr.hhs.gov/legal/PHE/Pages/COVID19-12Apr2022.aspx.  
34  CDC,  CDC Emergency  Operations Center: How an EOC Works.   Accessed at  https://www.cdc.gov/cpr/eoc/how-eoc-works.htm  
on November 29, 2021.  
35  CDC,  Report to Congress on Paycheck Protection Program and Health Care Enhancement Act  Disaggregated Data on U.S.  
Coronavirus Disease 2019 (COVID-19) Testing, 3rd 30-Day Update, August 2020.  Accessed  at 
https://www.help.senate.gov/download/fy2020-cdc-rtc-on-covid-19-testing-data_3rd-30-day-update_-final  on August 4, 2021.  
36  CDC,  CDC COVID-19 Response Health Equity Strategy: Accelerating Progress Towards Reducing COVID-19 Disparities and  
Achieving Health Equity, July 2020.  This strategy was originally issued in July 2020 and updated on August  21, 2020.  Accessed  
at  https://www.cdc.gov/coronavirus/2019-ncov/community/health-equity/cdc-strategy.html  on August 9, 2021.  
37  Paycheck Protection Program and Health Care Enhancement  Act, P.L. No. 116-139 (enacted on April  24, 2020), Division B,  
Title I, 134 STAT. 626.  
38  American Rescue Plan Act of  2021, P.L. No. 117-2 (enacted  on March  11, 2021),  2501, 135 STAT. 4; HHS, HHS Announces  
$250 Million from American Rescue Plan To Develop and Support a Community-Based Workforce  to Increase COVID-19 
Vaccinations in Underserved Communities.  Accessed at  https://www.hhs.gov/about/news/2021/05/04/hhs-announces-250-
million-from-american-rescue-plan-to-develop-and-support-underserved-communities.html  on August 27, 2021.  
39  American Rescue Plan Act of  2021, P.L. No. 117-2 (enacted  on March 11, 2021),  2401, 135 STAT. 4; Lisa Cooper, Joshua  
Sharfstein, Rachel L.J. Thornton, What the American Rescue  Plan Means for Health Equity,  JAMA Health Forum, Vol. 2, No.  4,  
April 1, 2021.  Accessed at  https://jamanetwork.com/journals/jama-health-forum/fullarticle/2778283  on August 27, 2021.  
40  Executive Order No. 13995, published at 86 Fed. Reg. 7193 (January 26, 2021).  To view the Health Equity Task Forces final 
report and recommendations, see https://www.minorityhealth.hhs.gov/omh/browse.aspx?lvl=2&lvlid=100.  
41  Executive Order No. 13994, published at 86 Fed. Reg. 7189 (January 26, 2021).   
42  OIG,  Race and Ethnicity Data for Medicare Beneficiaries (OEI-02-21-00100).  Accessed at https://oig.hhs.gov/reports-and-
publications/workplan/summary/wp-summary-0000548.asp  on March 16, 2022; OIG,  Race  and Ethnicity Data for Medicaid  
Beneficiaries  (OEI-02-22-00130).  Accessed at  https://oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-
0000641.asp  on March 16, 2022.   
43  CDC,  Report to Congress on Paycheck Protection Program and Health Care Enhancement Act  Disaggregated Data on U.S . 
Coronavirus Disease  2019 (COVID-19) Testing 20th 30-Day Update,  January 20  2 2. 
 
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OEI-05-20-00540   Endnotes | 31    
44  62 Fed. Reg. 58782 (October  30, 1997).    
45  GAO,  COVID-19: Federal Efforts Could Be Strengthened by Timely and Concerted Actions,  GAO-20-701, p. 39, September  21,  
2020.  (See Endnote 27 for URL information.)  
46  CDC, The Validity of Race and Hispanic-origin Reporting on Death Certificates in the United States: An Update,  Vital and  
Health Statistics 2, No. 172, August 2016.  Accessed at https://www.cdc.gov/nchs/data/series/sr_02/sr02_172.pdf  on July 23,  
2021.   See also CDC, Health Disparities: Provisional Death Counts for Coronavirus Disease 2019 (COVID-19), Notes.  Accessed  
at  https://www.cdc.gov/nchs/nvss/vsrr/covid19/health_disparities.htm#Notes  on February 23, 2022.  
47  CDC, COVID-19 Among American Indian and Alaska Native Persons23 States, January 31July 3, 2020,  MMWR, Vol. 69,  
No. 34, August 28, 2020, p. 1166.  Accessed at https://www.cdc.gov/mmwr/volumes/69/wr/pdfs/mm6934e1-H.pdf  on August 6,  
2021.   
48  CDC, Disparities in Incidence of COVID-19 Among Underrepresented Racial/Ethnic Groups  in Counties Identified as  
Hotspots During June 518, 202022 States, FebruaryJune 2020,  MMWR,  Vol. 69, No. 33, August 21, 2020, p. 1122.  Accessed  
at  https://www.cdc.gov/mmwr/volumes/69/wr/pdfs/mm6933e1-H.pdf  on August 6, 2021.   
49  CDC,  Report to Congress on Paycheck Protection Program and Health Care Enhancement Act  Disaggregated Data on U.S.  
Coronavirus Disease 2019 (COVID-19) Testing, 3rd 30-Day Update, August 2020.  (See Endnote 35 for URL information.)  See  
also CDC, Counties With High COVID-19 Incidence and Relatively Large Racial and Ethnic Minority PopulationsUnited 
States,  April 1December 22, 2020,  MMWR, Vol. 70, No. 13,  April 2, 2021, p. 483.  Accessed at  
https://www.cdc.gov/mmwr/volumes/70/wr/pdfs/mm7013e1-H.pdf  on July 7, 2020.  
50  CDC, Mental Health, Substance Use, and Suicidal Ideation During the COVID-19 PandemicUnited States, June 24-30,  
2020,  MMWR,  Vol.  69, No. 32,  August 14, 2020, p. 1052.  Accessed at 
https://www.cdc.gov/mmwr/volumes/69/wr/pdfs/mm6932a1-H.pdf  on July 8, 2021.  
51  CDC,  How To Report COVID-19 Laboratory Data,  Frequently  Asked  Questions No. 7,  updated  on January  26, 2021.  Accessed  
at  https://www.cdc.gov/coronavirus/2019-ncov/lab/reporting-lab-data.html  on August 10, 2021.  
52  HHS,  COVID-19 Pandemic Response, Laboratory Data Reporting: CARES Act Section 18115,  March  8,  2022.  This guidance  was  
originally issued on June 4, 2020, and updated on  March  8, 2022.  (See Endnote 11 for URL information.)  
53  CDC,  How to Report COVID-19 Laboratory Data, updated  on January 26, 2021.  (See Endnote 50 for URL information.)  
54  Ibid.  
55  CDC,  National Initiative  to Address COVID-19 Health Disparities Among  Populations at High-Risk and Underserved, Including 
Racial and Ethnic Minority Populations and Rural Communities.  Accessed at  
https://www.cdc.gov/publichealthgateway/partnerships/COVID-19-Health-Disparities-OT21-2103.html  on July  7,  2021.  
56  CDC, CDC Plans To Provide $332 Million To Support Community Health Workers for COVID-19 Prevention and Control,  
March 25, 2021.  Accessed at https://www.cdc.gov/media/releases/2021/p0325-community-healthworkers-support.html  on 
December 28, 2021.    
57  CDC-RFA-OT21-2103, National Initiative To Address COVID-19 Health Disparities Among Populations at High-Risk and 
Underserved, Including Racial and Ethnic Minority Populations and Rural Communities, Grant Opportunity, CDC Office for 
State, Tribal, Local, and Territorial Support, May 3, 2021.  Accessed at  https://www.grants.gov/web/grants/view-
opportunity.html?oppId=332034  on July 7, 2021.  
58  Lizzie Wade, COVID-19 data on Native Americans is a national disgrace. This scientist is fighting to be counted,  Science,  
September 24, 2020.  Accessed  at  https://www.sciencemag.org/news/2020/09/covid-19-data-native-americans-national-
disgrace-scientist-fighting-be-counted  on July 9, 2021.  
 
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OEI-05-20-00540   Endnotes | 32    
59  Darius Tahir and Adam Cancryn, American Indian tribes thwarted in efforts to get coronavirus data,  Politico, June 11, 2020.   
Accessed at  https://www.politico.com/news/2020/06/11/native-american-coronavirus-data-314527  on July 9, 2021.   
60  National Indian Health Board,  COVID-19 in Indian Country:  The Impact of Federal Broken Promises on Native Americans,  
written testimony submitted to the United States Commission on Civil Rights, July 17, 2020.   Accessed at  
https://www.nihb.org/covid-19/wp-content/uploads/2020/07/FINAL-NIHB-TESTIMONY-USCCR-COVID19-July-16-2020.pdf  on 
July 9, 2021.  
61  CDC,  Tribal Epidemiology Centers Designated as Public Health Authorities Under the Health Insurance Portability and 
Accountability Act, April 16, 2015.  Accessed at  https://www.cdc.gov/phlp/docs/tec-issuebrief.pdf  on July 9, 2021; 25 U.S.C.S.   
1621m(e).  
62  GAO,  Tribal Epidemiology Centers: HHS Actions Needed to Enhance Data Access,  GAO-22-104698,  March  4, 2022.  Accessed at   
https://www.gao.gov/products/gao-22-104698  on March 9, 2022.    
CDC Found Ways To Use Data To Understand and Address COVID-19 Health Disparities, Despite Challenges With Existing  Data  
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