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Aiden Lee Publications

Publish Date
Preventing Chronic Disease

There is no published national research reporting child care professionals’ physical health, depression, or stress during the COVID-19 pandemic. Given their central role in supporting children’s development, child care professionals’ overall physical and mental health is important. In this large-scale national survey, data were collected through an online survey from May 22, 2020 to June 8, 2020. We analyzed the association of sociodemographic characteristics with four physical health conditions (asthma, heart disease, diabetes, and obesity), depression, and stress weighted to national representativeness. Sociodemographic characteristics included race, ethnicity, age, gender, medical insurance status, and child care type. Our findings highlight that child care professionals’ depression rates during the pandemic were much higher than before the pandemic, and depression, stress and asthma rates were higher than U.S. adult depression rates during the pandemic. Given the essential work child care professionals provide during the pandemic, policy makers and public health officials should consider what can be done to support the physical and mental health of child care professionals.

Discussion Paper

The relationship between the use of nonpharmaceutical interventions and COVID-19 vaccination among U.S. child care providers remains unknown. If unvaccinated child care providers are also less likely to employ nonpharmaceutical interventions, then a vaccine mandate across child care programs may have larger health and safety benefits. To assess and quantify the relationship between the use of nonpharmaceutical interventions and COVID-19 vaccination among U.S. child care providers, we conducted a prospective cohort study of child care providers (N = 20,013) from all 50 states, the District of Columbia, and Puerto Rico. Child care providers were asked to complete a self-administered email survey in May-June 2020 assessing the use of nonpharmaceutical interventions (predictors) and a follow-up survey in May-June 2021 assessing COVID-19 vaccination (outcome). Nonpharmaceutical interventions were dichotomized as personal mitigation measures (e.g., masking, social distancing, handwashing) and classroom mitigation measures (e.g., temperature checks of staff/children, symptom screening for staff/children, cohorting).

For each unendorsed personal mitigation measure during 2020, the likelihood of vaccination in 2021 decreased by 7% (Risk Ratio = 0.93 [95% 0.93 – 0.95]). No significant association was found between classroom mitigation measures and child care provider vaccination (Risk Ratio = 1.01 [95% CI 1.00-1.01]).

Child care providers who used less personal mitigation measures were also less likely to get vaccinated for COVID-19 as an alternative form of protection. The combined nonadherence to multiple types of preventative health behaviors, that is, both nonpharmaceutical interventions and vaccination, among some child care providers may support a role for mandatory vaccination to achieve pandemic control.


To characterize vaccine uptake among US child care providers, we conducted a multistate cross-sectional survey of the child care workforce. Providers were identified through various national databases and state registries. A link to the survey was sent via e-mail between May 26 and June 23, 2021. A 37.8% response yielded 21 663 respondents, with 20 013 satisfying inclusion criteria. Overall COVID-19 vaccine uptake among US child care providers (78.2%, 90% confidence interval: 77.5% to 78.9%) was higher than the US general adult population (65%). Vaccination rates varied between states from 53.5% to 89.4%. Vaccine uptake among respondents differed significantly (P < .01) based on respondent age (70.0% for ages 25–34, 91.6% for ages 75–84), race (70.0% for Black or African Americans, 92.5% for Asian Americans), annual household income (70.8% for <$35 000, 85.1% for >$75 000), and child care setting (73.0% for home-based, 79.7% for center-based).

JAMA Network Open

The COVID-19 pandemic and resulting childcare closures have left many parents and guardians struggling to find care for their children while continuing to work, leading to adverse mental health and financial outcomes for families. Thus, keeping childcare programs open safely is of paramount importance. Although exposure to childcare early in the pandemic demonstrated no increased risk of contracting COVID-19, the highly contagious B.1.617.2 (Delta) variant has increased community prevalence, and COVID-19 outbreaks in childcare and among younger children are now well described. Furthermore, the attack rate for the B.1.1.7 (Alpha) variant, another highly contagious strain, is similar for both children and adults during childcare outbreaks.

Face masks reduce SARS-CoV-2 respiratory droplet transmission in the community and high-risk environments. In kindergarten through 12th grade schools, masks are part of successful risk mitigation bundles that facilitate a safe return to in-person education. Studies suggest that with strict masking policies social distancing can be safely reduced from 6 to 3 feet. However, child masking has not been studied in childcare, where children are typically younger than 5 years, social distancing is challenging, and adherence to masking is less than in older children. This gap in science is particularly problematic given current public debate regarding the benefits and risks of masking younger children not yet eligible for vaccination. We hypothesized that child masking, regardless of social distancing practices, is associated with reduced risk of a childcare program closing because of COVID-19 cases in either staff or children.