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Figure 1.  Prevalence of Being Unable to Afford Eyeglasses Among Adults at High Risk for Vision Loss in the United States in 2017
Prevalence of Being Unable to Afford Eyeglasses Among Adults at High Risk for Vision Loss in the United States in 2017

A and B, IPR indicates income-to-poverty ratio.

Figure 2.  Prevalence and Population Estimates of Visiting an Eye Care Professional, Receiving a Dilated Eye Examination, and Being Unable to Afford Eyeglasses in the United States in 2002 and 2017
Prevalence and Population Estimates of Visiting an Eye Care Professional, Receiving a Dilated Eye Examination, and Being Unable to Afford Eyeglasses in the United States in 2002 and 2017

A-C, Data are shown for all adults and for adults at high risk for vision loss. Dots indicate population per 100 000. Age, sex, and race/ethnicity were standardized to the 2010 US population using the direct method to allow temporal comparisons between 2002 and 2017 data.

Table 1.  Characteristics of All Adults 18 Years or Older and Adults at High Risk for Vision Loss in the United States in 2002 and 2017a
Characteristics of All Adults 18 Years or Older and Adults at High Risk for Vision Loss in the United States in 2002 and 2017a
Table 2.  Use of Eye Care Among All Adults 18 Years or Older and Adults at High Risk for Vision Loss in the United States in 2017a
Use of Eye Care Among All Adults 18 Years or Older and Adults at High Risk for Vision Loss in the United States in 2017a
Table 3.  Comparing Use of Eye Care Among All US Adults and Adults at High Risk for Vision Loss per the 2002 and 2017 National Health Interview Surveya
Comparing Use of Eye Care Among All US Adults and Adults at High Risk for Vision Loss per the 2002 and 2017 National Health Interview Surveya
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    Original Investigation
    March 12, 2020

    Eye Care Among US Adults at High Risk for Vision Loss in the United States in 2002 and 2017

    Author Affiliations
    • 1Division of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
    • 2Now with the Division of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Hyattsville, Maryland
    • 3National Center for Advancing Translational Sciences, National Institutes of Health, Bethesda, Maryland
    • 4Division of Epidemiology and Clinical Applications, National Eye Institute, Intramural Research Program, National Institutes of Health, Bethesda, Maryland
    JAMA Ophthalmol. Published online March 12, 2020. doi:10.1001/jamaophthalmol.2020.0273
    Key Points

    Question  Are US adults at high risk for vision loss receiving eye care?

    Findings  This survey study used data from the 2002 (n = 30 920) and 2017 (n = 32 886) National Health Interview Survey. In 2017, more than 93 million US adults were at high risk for vision loss (an increase compared with 2002); however, only 56.9% visited an eye care professional annually, and only 59.8% received a dilated eye examination. Among adults who reported needing eyeglasses, approximately 9 in 100 said they could not afford them, up slightly from 2002.

    Meaning  These results suggest improvements in eye care, and affordable options for eyeglasses may prevent vision loss.

    Abstract

    Importance  Timely eye care can prevent unnecessary vision loss.

    Objectives  To estimate the number of US adults 18 years or older at high risk for vision loss in 2017 and to evaluate use of eye care services in 2017 compared with 2002.

    Design, Setting, and Participants  This survey study used data from the 2002 (n = 30 920) and 2017 (n = 32 886) National Health Interview Survey, an annual, cross-sectional, nationally representative sample of US noninstitutionalized civilians. Analysis excluded respondents younger than 18 years and those who were blind or unable to see. Covariates included age, sex, race/ethnicity, marital status, educational level, income-to-poverty ratio, health insurance status, diabetes diagnosis, vision or eye problems, and US region of residence.

    Main Outcomes and Measures  Three self-reported measures were visiting an eye care professional in the past 12 months, receiving a dilated eye examination in the past 12 months, and needing but being unable to afford eyeglasses in the past 12 months. Adults at high risk for vision loss included those who were 65 years or older, self-reported a diabetes diagnosis, or had vision or eye problems. Multivariable logistic regression models incorporating sampling weights were used to investigate associations between measures and covariates. Temporal comparisons between 2002 and 2017 were derived from estimates standardized to the US 2010 census population.

    Results  Among 30 920 individuals in 2002, 16.0% were 65 years or older, and 52.0% were female; among 32 886 individuals in 2017, 20.0% were 65 years or older, and 51.8% were female. In 2017, more than 93 million US adults (37.9%; 95% CI, 37.0%-38.7%) were at high risk for vision loss compared with almost 65 million (31.5%; 95% CI, 30.7%-32.3%) in 2002, a difference of 6.4 (95% CI, 5.2-7.6) percentage points. Use of eye care services improved (56.9% [95% CI, 55.7%-58.7%] reported visiting an eye care professional annually, and 59.8% [95% CI, 58.6%-61.0%] reported receiving a dilated eye examination), but 8.7% (95% CI, 8.0%-9.5%) said they could not afford eyeglasses (compared with 51.1% [95% CI, 49.9%-52.3%], 52.4% [95% CI, 51.2%-53.6%], and 8.3% [95% CI, 7.7%-8.9%], respectively, in 2002). In 2017, individuals with lower income compared with high income were more likely to report eyeglasses as unaffordable (13.6% [95% CI, 11.6%-15.9%] compared with 5.7% [95% CI, 4.9%-6.6%]).

    Conclusions and Relevance  Compared with data from 2002, more US adults were at high risk for vision loss in 2017. Although more adults used eye care, a larger proportion reported eyeglasses as unaffordable. Focusing resources on populations at high risk for vision loss, increasing awareness of the importance of eye care, and making eyeglasses more affordable could promote eye health, preserve vision, and reduce disparities.

    Introduction

    Vision loss can lead to adverse health consequences, including increased risk for falls and injury, social isolation, depression, and reduced health-related quality of life and daily functioning.1-7 In 2015, an estimated 12 million adults 40 years or older in the United States had visual impairment: 1 million were blind, 3 million had uncorrectable visual impairment, and 8 million had visual impairment owing to uncorrected refractive errors.8 Vision loss and eye problems cost the United States an estimated $139 billion annually in 2013 US dollars for direct medical costs, indirect costs, and lost productivity.9

    Age-related macular degeneration, diabetic retinopathy, and glaucoma are common eye diseases that in their most severe forms can result in irreversible vision loss. Cataracts and refractive errors are largely treatable, but these highly prevalent conditions can cause unnecessary vision loss if people do not use or have access to eye care services. Preventing vision loss and treating vision disorders begin with understanding gaps in eye care, especially for adults at high risk for vision loss. Risk factors for vision loss include age 65 years or older, self-reported diabetes diagnosis, existing vision or eye problems, and a family history of eye disease.10

    To prevent vision loss, national public health goals (eg, Healthy People 2020) recognize the importance of vision and eye health and the need for proper eye care.11 Regular eye examinations are recommended every 1 to 2 years for most adults at high risk for vision loss by the American Academy of Ophthalmology.12 Using data from the 2002 National Health Interview Survey (NHIS), Zhang and colleagues10 reported that more than 61 million US adults were at high risk for vision loss and documented disparities in US eye care access and use. The objectives of our survey study were to estimate the number and percentage of US adults 18 years or older at high risk for vision loss in 2017 and to evaluate whether use of eye care services changed since 2002.

    Methods
    Study Design

    This survey study used publicly available, deidentified data from the NHIS. Approved by the research ethics review board of the National Center for Health Statistics (a part of the Centers for Disease Control and Prevention and the US Office of Management and Budget), the NHIS is an annual, cross-sectional, in-person, household interview survey of a nationally representative sample of US noninstitutionalized civilians. All NHIS respondents provided oral consent before participation. Using a complex sampling design, the survey collects social, demographic, and health information. It had annual response rates of 74.3% for the 2002 NHIS and 53.0% for the 2017 NHIS.13,14 Briefly, NHIS data are collected continuously through an in-person, household interview in all 50 states and the District of Columbia. Families in interviewed households provided basic demographic and health information for all family members, with 1 adult and 1 child randomly selected for a more detailed health interview. This analysis included sampled adults 18 years or older (30 920 in 2002 and 32 886 in 2017). Adults who were blind or unable to see were excluded from the present analysis (124 adults in 2002 and 123 adults in 2017).

    The following 3 main outcomes of interest were collected by self-report: whether the adult (1) visited an eye care professional in the past 12 months (yes or no), (2) received a dilated eye examination in the past 12 months (yes or no), and (3) could not afford eyeglasses when needed in the past 12 months (yes or no). Each of these outcomes measures a different aspect of eye care access and use, including possible financial barriers.

    High risk for vision loss is based on the definition by Zhang et al.10 Adults were considered to be at high risk for vision loss if they (1) were 65 years or older, (2) self-reported a systemic condition associated with a high risk for blindness (eg, diagnosed diabetes), and (3) self-reported having an ocular disease or condition (age-related macular degeneration, cataract, diabetic retinopathy, glaucoma, or eye injury) or had visual symptoms of trouble seeing with glasses or contact lenses or activity limitations owing to vision problems.

    Covariates of interest included the following: age (categorized as 18-44, 45-64, or ≥65 years), sex, race/ethnicity (non-Hispanic white, non-Hispanic black, Hispanic, or non-Hispanic other), current marital status (not married or living alone vs married or living with a partner), educational level (less than high school, high school graduate [including general equivalency diploma], or some college or higher), self-reported diabetes diagnosis (yes or no), existing self-reported vision or eye problems (yes or no), and US region of residence (Northeast, Midwest, South, or West). Poverty level was categorized based on the income-to-poverty ratio (IPR) as poor (IPR <1.0), near poor (IPR 1.0 to <2.0), or not poor (IPR ≥2.0). Health insurance status included a public category and a private category. The public category included recipients who reported coverage with Medicare, Medicaid, a State Children’s Health Insurance Program, the Indian Health Service, military care, or other public or government insurance. For our analysis, we considered adults in the following 4 health insurance categories: public only, private only, both public and private, or none.

    Statistical Analysis

    All estimates were weighted to the US civilian noninstitutionalized population using final sampling weights provided by the National Center for Health Statistics that account for probability of selection and adjust for nonresponse.14 To account for the complex survey design, SAS, version 9.3 (SAS Institute Inc), and SAS-callable SUDAAN, version 11.0.1 (Research Triangle Institute), were used. Measures of effect size were average adjusted predictions for the 3 outcomes of interest obtained from multivariable logistic regression models run in SUDAAN. Regression models were adjusted for all demographics, IPR, health insurance status, self-reported diabetes diagnosis, existing self-reported vision or eye problems, and US region of residence. To compare access to care and use between 2002 and 2017, estimates in both years were standardized by age, sex, and race/ethnicity to the US 2010 census population. The IPR was multiply imputed when missing, and all models and prevalence estimates for 2002 and 2017 used the imputed income files (n = 5) provided by the National Center for Health Statistics.15 We applied the same definitions used in 2017 to data previously published in 2002 to compare the 2002 data with the outcomes contained in this study.

    Results

    Among 30 920 individuals in 2002, 16.0% were 65 years or older, and 52.0% were female. Among 32 886 individuals in 2017, 20.0% were 65 years or older, and 51.8% were female.

    Populations at High Risk for Vision Loss

    In 2017, more than 93 million US adults 18 years or older (37.9%; 95% CI, 37.0%-38.7%) were at high risk for vision loss compared with almost 65 million (31.5%; 95% CI, 30.7%-32.3%) in 2002, a difference of 6.4 (95% CI, 5.2-7.6) percentage points (20% relative) increase in prevalence from 2002 (Table 1). Among those at high risk for vision loss, the proportion of individuals 65 years or older increased by 2.3 (95% CI, 0.5-4.1) percentage points (from 50.6% [95% CI, 49.3%-51.9%] to 52.9% [95% CI, 51.6%-54.2%]), and the proportion self-reporting a diabetes diagnosis increased by 4.1 (95% CI, 2.7-5.5) percentage points (from 20.5% [95% CI, 19.6%-21.4%] to 24.6% [95% CI, 23.5%-25.6%]) in 2017 compared with 2002. Proportionally fewer non-Hispanic white individuals and more minorities were at high risk for vision loss in 2017, in part because of the changing demographic distribution of the US population.

    In addition to demographic changes in the population, other key measures of interest changed over the course of 15 years in the US noninstitutionalized civilian population, including educational level, poverty level, and health insurance status (Table 1). The percentage of adults who reported finishing high school or having some college or higher education increased, and the proportion of families living at or below the poverty level decreased. The proportion of adults who reported not having health insurance also decreased between 2002 and 2017, and the proportion covered by public insurance only increased. The proportion of adults at high risk for vision loss due to diabetes or vision problems also increased. The prevalence of self-reported diabetes diagnosis increased from 6.5% (95% CI, 6.2%-6.8%) to 9.3% (95% CI, 8.9%-9.8%). Self-reported prevalence of refractive error, age-related eye diseases, or both conditions also increased nationally from 9.0% (95% CI, 8.6%-9.4%) to 10.6% (95% CI, 10.1%-11.1%). These changes were observed among all adults and among those at high risk for vision loss. Those at high risk for vision loss are included in the estimates for all adults.

    Eye Care in 2017

    In 2017 among all adults, 43.1% (95% CI, 42.2%-43.9%) reported visiting an eye care professional in the past 12 months, 44.4% (95% CI, 43.5%-45.2%) reported receiving a dilated eye examination in the past 12 months, and 5.8% (95% CI, 5.4%-6.2%) reported needing but being unable to afford eyeglasses (Table 2). Among adults at high risk for vision loss, 56.9% (95% CI, 55.7%-58.7%) reported visiting an eye care professional annually, 59.8% (95% CI, 58.6%-61.0%) reported receiving a dilated eye examination, and 8.7% (95% CI, 8.0%-9.5%) reported being unable to afford eyeglasses (compared with 51.1% [95% CI, 49.9%-52.3%], 52.4% [95% CI, 51.2%-53.6%], and 8.3% [95% CI, 7.7%-8.9%], respectively, in 2002). For both groups, use of eye care increased with age. Approximately 60% (58.5%; 95% CI, 56.4%-60.6%) of all adults 65 years or older visited an eye care professional and received a dilated eye examination in the past 12 months, and just over one-third (34.7%; 95% CI, 33.4%-36.0%) of all adults younger than 45 years reported receiving eye care. Eye care use was greater among individuals with the following characteristics: female sex, educational level beyond high school, higher poverty level, both public and private insurance, self-reported diabetes diagnosis, and existing self-reported vision or eye problems. Hispanic individuals were least likely to use eye care, and non-Hispanic white individuals were most likely to use eye care.

    Among all adults who reported being unable to afford eyeglasses, percentages were higher among those aged 45 to 64 years (8.5%; 95% CI, 7.7%-9.4%), women (7.1%; 95% CI, 6.6%-7.8%), individuals not married or living alone (6.1%; 95% CI, 5.5%-6.7%), those without health insurance (11.8%; 95% CI, 10.2%-13.5%), those who had a self-reported diabetes diagnosis (7.1%; 95% CI, 5.9%-8.4%), and those with existing self-reported vision or eye problems (13.2%; 95% CI, 11.8%-14.8%) (Table 2). Findings were similar or sometimes more pronounced for adults at high risk for vision loss. Among adults at high risk for vision loss, 13.6% (95% CI, 11.6%-15.9%) of those who were poor reported being unable to afford eyeglasses compared with 5.7% (95% CI, 4.9%-6.6%) of those who were not poor. Reports of being unable to afford eyeglasses differed by age group, race/ethnicity, and poverty level (Figure 1). Middle-aged adults (age range, 45-64 years) who were poor had the highest prevalence of reporting being unable to afford eyeglasses (30.1%; 95% CI, 25.6%-35.1%), whereas adults 65 years or older who were not poor had the lowest prevalence (2.0%; 95% CI, 1.6%-2.6%). Regardless of age, adults who were not poor were least likely to report being unable to afford eyeglasses.

    Comparing Access to and Use of Eye Care in 2002 and 2017

    In 2017 compared with 2002, the prevalence of all adults and those at high risk for vision loss who visited an eye care professional in the past 12 months, received a dilated eye examination in the past 12 months, and could not afford eyeglasses when needed in the past 12 months increased (Figure 2). Using 2002 data recoded with 2017 definitions, the eTable in the Supplement lists the equivalent estimates to compare with those reported in Table 2 for 2017. However, the demographic changes in the United States between 2002 and 2017 (Table 1) indicate that a direct comparison of estimates from the 2 periods may be misleading. After standardizing to the US 2010 census population, we found increases in the estimated percentages of individuals visiting an eye care professional and receiving a dilated eye examination between 2002 and 2017 for each covariate category, including among those who were poor (Table 3). The estimated proportion of adults who reported being unable to afford eyeglasses also increased for most categories of people, indicating little progress in efforts to make eyeglasses more affordable. Among adults at high risk for vision loss (Table 3), the estimated percentage who reported visiting an eye care professional or receiving a dilated eye examination also increased between 2002 and 2017 for almost every category. Approximately 1 in 4 poor adults at high risk for vision loss remained unable to afford eyeglasses, and the percentage was even higher among those without insurance.

    Discussion

    More than 93 million US adults were at high risk for vision loss in 2017 compared with almost 65 million in 2002, an increase of 28 million between 2002 and 2017. The aging population contributed to part of this increase. The proportion of adults 65 years or older increased nationally from 16.0% (95% CI, 15.4%-16.5%) to 20.0% (95% CI, 19.4%-20.7%) during this period, and the prevalence of self-reported diabetes diagnosis increased from 6.5% (95% CI, 6.2%-6.8%) to 9.3% (95% CI, 8.9%-9.8%) (Table 1). Self-reported prevalence of refractive error, age-related eye diseases, or both conditions also increased nationally from 9.0% (95% CI, 8.6%-9.4%) to 10.6% (95% CI, 10.1%-11.1%). With the population of adults 65 years or older16 expected to double from 43 million in 2012 to almost 65 million by 2050 and the prevalence of diabetes17 anticipated to remain high in 2060, the size of the US population at high risk for vision loss and in need of eye care is likely to continue to increase in the coming years.

    Among adults at high risk for vision loss, just over one-half reported receiving eye care. Although the percentage has increased over the past 15 years, the increase has been modest, and disparities by race/ethnicity, poverty level, health insurance status, and US region of residence remain. Demographic shifts in the US population alter the prevalence of various conditions associated with vision loss because these conditions vary by race/ethnicity.18 For example, Hispanic individuals reportedly have a higher prevalence of vision loss owing to cataracts,19 whereas non-Hispanic white individuals are at higher risk for age-related macular degeneration.20-22 Reducing gaps in eye care use and access to increase eye care visits for non-Hispanic black individuals and Hispanic individuals might help reduce current racial/ethnic disparities in vision loss. Although ongoing surveillance activities can monitor reported use of eye care services, reasons for the disparities require detailed study.

    Differences in use of eye care services by educational level and poverty level persisted between 2002 and 2017. Adults with more education and who were not poor were more likely to report visiting an eye care professional and receiving a dilated eye examination in both years. Not surprisingly, adults without health insurance were less likely to report receiving eye care and more likely to report being unable to afford eyeglasses. Although not having eye problems and not getting around to receiving eye care were most frequently reported as reasons adults did not receive eye care in the past 2 years (42% and 35%, respectively), more than 25% of adults reported cost as the reason.23 These disparities have persisted for decades,18,24,25 and innovative interventions are needed to increase awareness among public health officials and health care workers, as well as insurers, of the need for eye care and the financial support required to help people obtain it.

    Disparities by US region of residence have also persisted over time, with residents in the Northeast approximately 5 percentage points more likely to receive eye care compared with residents in other regions, even after adjustment for demographic differences across regions (Table 1). Analysis of data from the American Community Survey indicated that Northeast US counties had lower levels of severe vision problems compared with South US counties,26 although no reasons for regional differences were given. Access to eye care does not appear to explain these differences, at least among adults 65 years or older. A 2016 report examining access to eye care in the United States based on driving time found that more than 90% of US Medicare beneficiaries live within 30 minutes of eye care services.27 The availability of local resources may influence differences in use of eye care services and reductions in vision loss, as was highlighted in 2016 by the National Academies of Sciences, Engineering, and Medicine.28 The Centers for Disease Control and Prevention is strengthening partnerships with several states to increase their ability to address vision health and to increase education efforts on its importance.29 Similarly, the National Eye Institute’s National Eye Health Education Program aims to help health and community professionals increase awareness about eye health through social media campaigns designed to reach populations at higher risk for eye disease and vision loss and to promote use of rehabilitation services for those with vision loss.30

    Eyeglasses are an effective way to improve vision and reduce disability from refractive error; however, they are not cost free, and they require periodic investments to replace old frames and update lens prescriptions. An inability to afford needed eyeglasses results in unnecessary vision loss owing to uncorrected or inadequately corrected refractive error. Although the percentage of US adults who could not afford eyeglasses was still less than 10% in 2017, it was higher in 2002 and 2017 among all adults who were poor or near poor and among working-age adults, particularly those at high risk for vision loss (Figure 1). In another nationally representative survey of US adults, one-half were found to need refractive correction, and inadequately corrected refractive error was statistically significantly more common across all age groups and among Mexican American and non-Hispanic black compared with non-Hispanic white individuals.31 Among US Medicare beneficiaries 65 years or older, use of eyeglasses was also decreased for minority populations and those with lower educational levels.32 We found that, in 2017, adults at high risk for vision loss who were poor were 2 to 3 times more likely to report being unable to afford eyeglasses compared with adults who were wealthier (Figure 1). Difficulty affording eyeglasses, even among those with visual impairment who used eye care, is a long-standing issue with wide-reaching implications for health, public safety, individual productivity, and quality of life.33

    Strengths and Limitations

    This study has both strengths and limitations. Because of the nationally representative design, routine data collection, and large sample size of the data used, we were able to calculate and directly compare estimates for diverse demographic population subgroups to discern whether changes in access to and use of eye care services have occurred over 15 years. However, all interview surveys, no matter how well designed, depend on self-reported data. Individuals with vision problems or diabetes may be more likely to report receiving care if they are aware of the importance of eye examinations. Previous studies34,35 have found that people tend to overreport how often they receive eye examinations and dilated eye examinations, which may lead to overestimated prevalence of eye care services use. In addition, our definition of a high-risk population does not include additional risk factors, such as family history, smoking, or concomitant health conditions (eg, high blood pressure and obesity), that may predispose a person to vision problems. The results of the present study may underestimate the prevalence of people at high risk for vision loss. Finally, we did not measure refractive error, so we cannot confirm that the percentage of persons who reported being unable to afford eyeglasses accurately reflects all individuals who need them.

    Conclusions

    Because of shifting demographics, including the aging population and an increased prevalence of diabetes, the percentage of US adults at high risk for vision loss increased 40% (from 65 million to 93 million) between 2002 and 2017 (eFigure in the Supplement). Just under 60% reported receiving eye care in 2017. More than 8 million adults who know they need eyeglasses said they could not afford them. Disparities in access to and use of eye care services that existed in 2002 persisted in 2017, although some progress has been made to improve access to eye care and knowledge of its importance. Increased public health efforts to enhance access, awareness, and affordability could reduce unnecessary vision loss in the United States.

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    Article Information

    Accepted for Publication: January 21, 2020.

    Corresponding Author: Sharon H. Saydah, PhD, Division of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 3311 Toledo Rd, Hyattsville, MD 20782 (ssaydah@cdc.gov).

    Published Online: March 12, 2020. doi:10.1001/jamaophthalmol.2020.0273

    Author Contributions: Dr Saydah and Mr Gerzoff had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: Saydah, Gerzoff, Saaddine, Cotch.

    Acquisition, analysis, or interpretation of data: Saydah, Gerzoff, Zhang, Cotch.

    Drafting of the manuscript: Saydah, Gerzoff.

    Critical revision of the manuscript for important intellectual content: Gerzoff, Zhang, Saaddine, Cotch.

    Statistical analysis: Saydah, Gerzoff.

    Administrative, technical, or material support: Saydah, Zhang, Cotch.

    Supervision: Saydah, Saaddine.

    Conflict of Interest Disclosures: None reported.

    Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention or the National Institutes of Health.

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