Discussion on Morbidity and Mortality

Morbidity and Mortality Weekly Report
Weekly / Vol. 69 / No. 49 December 11, 2020
INSIDE
1848 Racial and Ethnic Differences in Parental Attitudes
and Concerns About School Reopening During the
COVID-19 Pandemic — United States, July 2020
1853 COVID-19 Mortality Among American Indian and
Alaska Native Persons — 14 States, January–June 2020
1857 The Advisory Committee on Immunization Practices’
Interim Recommendation for Allocating Initial
Supplies of COVID-19 Vaccine — United States, 2020
1860 Summary of Guidance for Public Health Strategies
to Address High Levels of Community Transmission
of SARS-CoV-2 and Related Deaths, December 2020
1868 Implementing Mitigation Strategies in Early Care
and Education Settings for Prevention of SARSCoV-
2 Transmission — Eight States, September–
October 2020
1873 Notes from the Field: Understanding Smoke
Exposure in Communities and Fire Camps Affected
by Wildfires — California and Oregon, 2020
1876 Notes from the Field: First Case in the United States
of Neisseria gonorrhoeae Harboring Emerging
Mosaic penA60 Allele, Conferring Reduced
Susceptibility to Cefixime and Ceftriaxone
1878 QuickStats
Continuing Education examination available at
https://www.cdc.gov/mmwr/mmwr_continuingEducation.html
U.S. Department of Health and Human Services
Centers for Disease Control and Prevention
Trends in U.S. Emergency Department Visits Related to Suspected or
Confirmed Child Abuse and Neglect Among Children and Adolescents Aged
<18 Years Before and During the COVID-19 Pandemic — United States,
January 2019–September 2020
Elizabeth Swedo, MD1; Nimi Idaikkadar, MPH2; Ruth Leemis, MPH3; Taylor Dias, MPH4,5; Lakshmi Radhakrishnan, MPH4; Zachary Stein, MPH4,6;
May Chen, PhD3; Nickolas Agathis, MD1,7; Kristin Holland, PhD8
Heightened stress, school closures, loss of income, and
social isolation resulting from the coronavirus disease 2019
(COVID-19) pandemic have increased the risk for child
abuse and neglect (1). Using National Syndromic Surveillance
Program (NSSP) data from January 6, 2019–September 6,
2020, CDC tabulated weekly numbers of emergency department
(ED) visits related to child abuse and neglect and
calculated the proportions of such visits per 100,000 ED
visits, as well as the percentage of suspected or confirmed ED
visits related to child abuse and neglect ending in hospitalization,
overall and stratified by age group (0–4, 5–11, and
12–17 years). The total number of ED visits related to child
abuse and neglect began decreasing below the corresponding
2019 period during week 11 (March 15–March 22, 2020)
for all age groups examined, coinciding with the declaration
of a national emergency on March 13 (2); simultaneously,
the proportion of these visits per 100,000 ED visits began
increasing above the 2019 baseline for all age groups. Despite
decreases in the weekly number of ED visits related to child
abuse and neglect, the weekly number of these visits resulting
in hospitalization remained stable in 2020; however, the yearly
percentage of ED visits related to child abuse and neglect
resulting in hospitalization increased significantly among all
age groups. Although the increased proportion of ED visits
related to child abuse and neglect might be associated with a
decrease in the overall number of ED visits, these findings also
suggest that health care–seeking patterns have shifted during
the pandemic. Hospitalizations for child abuse and neglect
did not decrease in 2020, suggesting that injury severity did
not decrease during the pandemic, despite decreased ED
visits. Child abuse is preventable; implementation of strategies
including strengthening household economic supports and
creating family-friendly work policies can reduce stress during
Morbidity and Mortality Weekly Report
1842 MMWR / December 11, 2020 / Vol. 69 / No. 49 US Department of Health and Human Services/Centers for Disease Control and Prevention
The MMWR series of publications is published by the Center for Surveillance, Epidemiology, and Laboratory Services, Centers for Disease Control and Prevention (CDC),
U.S. Department of Health and Human Services, Atlanta, GA 30329-4027.
Suggested citation: [Author names; first three, then et al., if more than six.] [Report title]. MMWR Morb Mortal Wkly Rep 2020;69:[inclusive page numbers].
Centers for Disease Control and Prevention
Robert R. Redfield, MD, Director
Anne Schuchat, MD, Principal Deputy Director
Ileana Arias, PhD, Acting Deputy Director for Public Health Science and Surveillance
Rebecca Bunnell, PhD, MEd, Director, Office of Science
Jennifer Layden, MD, PhD, Deputy Director, Office of Science
Michael F. Iademarco, MD, MPH, Director, Center for Surveillance, Epidemiology, and Laboratory Services
MMWR Editorial and Production Staff (Weekly)
Charlotte K. Kent, PhD, MPH, Editor in Chief
Jacqueline Gindler, MD, Editor
Paul Z. Siegel, MD, MPH, Guest Associate Editor
Mary Dott, MD, MPH, Online Editor
Emilio Dirlikov, PhD, Guest Associate Online Editor
Terisa F. Rutledge, Managing Editor
Douglas W. Weatherwax, Lead Technical Writer-Editor
Glenn Damon, Soumya Dunworth, PhD,
Teresa M. Hood, MS, Jeffrey D. Sokolow, MA,
Technical Writer-Editors
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Alexander J. Gottardy, Maureen A. Leahy,
Julia C. Martinroe, Stephen R. Spriggs, Tong Yang,
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Information Technology Specialists
MMWR Editorial Board
Timothy F. Jones, MD, Chairman
Matthew L. Boulton, MD, MPH
Carolyn Brooks, ScD, MA
Jay C. Butler, MD
Virginia A. Caine, MD
Jonathan E. Fielding, MD, MPH, MBA
David W. Fleming, MD
Kate Galatas, MPH
William E. Halperin, MD, DrPH, MPH
Jewel Mullen, MD, MPH, MPA
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Health Communication Specialists
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Visual Information Specialist
difficult times and increase children’s opportunities to thrive in
safe, stable, and nurturing relationships and environments (3).
Despite known risk for child abuse and neglect during pandemics
(4) and preliminary reports of increased severity of child abuse
and neglect in some facilities (5), official reports to child protection
agencies have declined across the United States by 20%–70%,
attributed to decreased in-person contact between children and
mandated reporters (e.g., teachers, social workers, and physicians)
(6). Lack of timely data on child abuse and neglect in the context
of COVID-19 highlights the value of near real-time data from
NSSP, which provide the opportunity to examine trends in ED
visits and hospitalizations for suspected or confirmed child abuse
and neglect before and during the COVID-19 pandemic.
Data for U.S. ED visits among children and adolescents
aged <18 years were obtained from NSSP’s BioSense Platform
using a query for suspected and confirmed ED visits related to
child abuse and neglect developed by NSSP, CDC’s Division of
Violence Prevention, and local and state health departments (7).
NSSP is a collaboration among CDC, federal partners, local and
state health departments, and academic and private sector partners
to support the collection and analysis of electronic health
data from EDs, urgent and ambulatory care centers, inpatient
health care facilities, and laboratories. As of March 31, 2020,
a total of 3,310 EDs in 47 states and the District of Columbia
contributed data to the platform daily, providing information
on approximately 73% of all ED visits in the United States.
Visits were included if the ED provider or facility documented
suspected or confirmed physical, sexual, or emotional abuse
or physical or emotional neglect of a child or adolescent aged
<18 years by a parent or other caregiver (8). To limit the impact
of data quality on resulting trends, only visits from facilities that
consistently sent informative* discharge diagnoses for ≥70% of
cases with ≤20% standard deviation were included; the number
of facilities meeting these criteria varied from week to week but
averaged 2,970 facilities during the study period (approximately
90% of NSSP’s participating EDs).
Data were analyzed to examine national trends in ED visits
for suspected or confirmed child abuse and neglect during
January 6, 2019–September 6, 2020, the period before and
during the U.S. COVID-19 pandemic. Weekly numbers and
proportions of visits related to child abuse and neglect per
100,000 ED visits were computed overall and stratified by age
group (0–4, 5–11, and 12–17 years). In addition, weekly and
annual† percentages of ED visits related to child abuse and
neglect resulting in hospitalization were calculated. The change
in mean ED visits related to child abuse and neglect per week
during the early pandemic period (March 31–April 27, 2020)
and the comparison period (March 29–April 25, 2019) was calculated
as the mean difference in total ED visits related to child
abuse and neglect between the two 4-week periods. Statistically
significant differences in annual percentages of ED visits
related to child abuse and neglect ending in hospitalizations
* Discharge diagnoses were not null or did not simply include terms
like “unknown.”
† Complete year for 2019 compared with partial year for 2020.
Morbidity and Mortality Weekly Report
MMWR / December US Department of Health and Human Services/Centers for Disease Control and Prevention 11, 2020 / Vol. 69 / No. 49 1843
were assessed using t-tests. All analyses were performed using
R software (version 4.0.2; The R Foundation). This activity
was reviewed by CDC and was conducted consistent with
applicable federal law and CDC policy.§
The total number of 2020 ED visits meeting the syndrome
definition for child abuse and neglect (Table) began decreasing
to below the number of visits that occurred during the corresponding
2019 prepandemic period in week 11 (March 15–
March 22), coinciding with the president’s Proclamation
Declaring a National Emergency Concerning the Novel
Coronavirus Disease (COVID-19) Outbreak on March 13,
2020 (Figure 1). This pattern was observed for all age groups
examined (Supplementary Figure, https://stacks.cdc.gov/view/
cdc/98213). At the same time, the proportion of ED visits
related to child abuse and neglect per 100,000 ED visits began
increasing above the proportion seen during the corresponding
period in 2019 (Figure 1). ED visits related to child abuse
and neglect among children and adolescents aged <18 years
reached their nadir during week 13 (March 29–April 4, 2020).
During the 4-week period following this early pandemic nadir
(March 29–April 25), the number of ED visits related to
child abuse and neglect among children and adolescents aged
<18 years averaged 53% less than the number that occurred
during the corresponding period in 2019 (March 31–April 27)
(Figure 1). The number of ED visits related to child abuse
and neglect was lower during this period in 2020, compared
with visits during the corresponding period in 2019 for every
age group, with the largest proportional declines in number
of visits by children aged 5–11 years (61%) (Supplementary
Figure, https://stacks.cdc.gov/view/cdc/98213).
Despite decreases in the total number of ED visits related
to child abuse and neglect, the number of these ED visits
resulting in hospitalization did not decline in 2020 (Figure 2).
As a result of the consistent number of hospitalizations and
the decrease in the number of overall ED visits, the percentage
of ED visits related to child abuse and neglect ending in
hospitalization increased significantly among children and
adolescents aged <18 years, from 2.1% in 2019 to 3.2% in
2020 (p<0.001) (Figure 2). Significant increases in the percentage
of ED visits related to child abuse and neglect ending in
hospitalization were also observed for children aged 0–4 years
(3.5% in 2019 versus 5.3% in 2020; p<0.001) and 5–11 years
(0.7% in 2019 versus 1.3% in 2020; p<0.001), and adolescents
aged 12–17 years (1.6% in 2019 versus 2.2% in 2020;
p = 0.002) (Supplementary Figure, https://stacks.cdc.gov/
view/cdc/98213).
§ 45 C.F.R. part 46.102(l)(2), 21 C.F.R. part 56; 42 U.S.C. Sect. 241(d); 5 U.S.C.
Sect. 552a; 44 U.S.C. Sect. 3501 et seq.
Discussion
ED visits related to suspected or confirmed child abuse and
neglect decreased beginning the week of March 15, 2020,
coinciding with the declaration of a national emergency related
to COVID-19 and implementation of community mitigation
measures (5). The 53% decrease in ED visits related to
child abuse and neglect among children aged <18 years in
early 2020 compared with the number of visits during early
2019 mirrors trends reported for all ED visits; during weeks
13–16 of 2020, the volume of U.S. ED visits declined by 72%
among children aged ≤10 years and 71% among children and
adolescents aged 11–14 years compared with ED visits during
2019 (9). Although the total number of ED visits related
to child abuse and neglect decreased, the proportion of these
visits per 100,000 ED visits increased, suggesting that health
care–seeking patterns shifted during the pandemic, with ED
visits for other causes declining more than ED visits for child
abuse and neglect declined. Despite the ongoing pandemic,
caregivers were more likely to take children to EDs for evaluation
of complaints related to child abuse and neglect relative
to other chief complaints. This pattern might reflect decreased
health care–seeking for other medical complaints or a need to
seek medical care because of persistence or worsening of child
abuse and neglect. The decreased number of ED visits related
to child abuse and neglect coincides with decreases in reports
of child abuse and neglect to child protective services (4). The
consistent number of visits related to child abuse and neglect
requiring hospitalization from 2019 to 2020, despite decreased
number of ED visits related to child abuse and neglect, suggests
that injury severity did not decrease during the pandemic.
The COVID-19 pandemic and the social and economic effects of
mitigation measures, such as loss of income, increased stress related
to parental child care and schooling responsibilities, and increased
substance use and mental health conditions among adults (10),
increase the risk for child abuse and neglect. These pandemic-related
risk factors might be tied to the observed increased proportions of
ED visits related to child abuse and neglect.
The findings in this report are subject to at least six limitations.
First, the denominator for proportion estimates declined
substantially during the pandemic, making interpretation of
temporal proportion trends more difficult. Second, the number
of facilities participating in NSSP might change over time, as
facilities are added, and, more rarely, as they close. Proportions
and counts might be influenced by characteristics of the populations
served by participating facilities. Third, the syndrome
definition used in this analysis might under- or overestimate
facility visits related to suspected or confirmed child abuse
and neglect because of jurisdictional or temporal differences
in coding, reporting, or availability of chief complaints and
discharge diagnoses. To minimize the impact of fluctuating
Morbidity and Mortality Weekly Report
1844 MMWR / December 11, 2020 / Vol. 69 / No. 49 US Department of Health and Human Services/Centers for Disease Control and Prevention
TABLE. Syndrome definition description and chief complaint search terms, diagnosis codes, and negations included in syndrome definitions
for emergency department visits related to suspected and confirmed child abuse and neglect — United States, January 2019–September 2020
Outcome
Description of
syndrome definition
Chief complaint
search terms* Diagnosis codes Negations†
Suspected and confirmed
child abuse and neglect
The suspected and confirmed
child abuse and neglect (CAN)
syndromic surveillance
definition uses International
Classification of Diseases, Ninth
Revision, Clinical Modification
(ICD-9-CM) codes International
Classification of Diseases, Tenth
Revision, Clinical Modification
(ICD- 10-CM) codes,
Systematized Nomenclature of
Medicine (SNOMED) codes, and
free text terms to detect cases of
suspected child abuse and
neglect in emergency
department and ambulatory
health care settings. For the
purposes of the CAN syndromic
definition, suspected child
abuse or neglect visits are
categorized as visits related to
suspected or confirmed physical,
sexual, or emotional abuse; or
physical or emotional neglect as
perpetrated by parents,
caregivers, or an authorized
custodian of the child. Acts of
violence perpetrated by peers,
siblings, or intimate partners are
excluded from the CAN
definition.
Sexual Abuse Nurse Exam
(SANE),§ non-accidental
trauma (NAT), neglect,
abuse, Child to Adult Abuse
Response Team (CAART),
abandon, forensic,§ molest,
Forensic Nurse Exam (FNE),§
rape,§ assault,§ Sexual
Assault Forensic Examiner
(SAFE),§ Sexual Abuse
Response Team (SART),§
force sex,§ suspected
sexual,§ alleged sexual*
§AND mother, mom,
stepmom, grandmom,
fostermom, grandma,
grandpa, stepdad, fosterdad,
granddad, babysitter, nanny,
parent, fosterparent,
stepparent, grandparent,
custodian, guardian, uncle,
aunt
T74.02, T74.12, T74.22, T74.32,
T74.4, T74.52, T74.62, T74.72,
T74.92, T76.02, T76.12, T76.22,
T76.32, T76.4, T76.52, T76.62,
T76.72, T76.92, Z04.81,
Z04.82, Z04.42,¶ Z04.72,¶
Y07.1, Y07.4, Y07.5, Y07.6,
Y07.9, 995.5, E904.0, E967.1,
E967.2, E967.6, E967.7,
E967.8, E967.9, V71.5, V71.81,
432464008, 713834002,
777996001, 418189009,
386702006, 242037000,
162596006, 397940009,
702954001, 242037000,
95930005, 397660003,
217635005, 217634009,
217633003, 697951004,
12399131000119105,
473453008, 371775004,
700254002, 95922009,
228143000, 697949003,
12242871000119109,
371779005, 397864009,
237461000119103,
700229002, 720824009,
225824003, 720823003,
225826001, 371776003,
397660003, 777996001,
102458000, 213015009,
419261006, 430139008,
225823009, 361217003,
713821003, 41358001,
23776007, 70167006,
51347003, 213017001,
242046006, 361217003
Y07.0
Y07.4
E967.3
E967.4
E967.5
433960002
Athero
Left side or right side
Stroke
Medical neglect
Alcohol
Drug
Substance
Polysubstance
Cannabis
Weed
Hallucinogen
THC
Marijuana
History of abuse
Xanax
Stimulant
Meth
Cocaine
Tobacco
Opioid
Inhalant
Denies any abuse
House
Mill
Building
Motor vehicle
Intoxication
DUI
Crash
Molestacion
Molestia
Molestar
Molesta
Molesto
Molestra
Molestio
Assaulted by friend
Assaulted by boyfriend
Assaulted by girlfriend
Assaulted by sibling
Assaulted by brother
Assaulted by sister
Assaulted by half
brother
Assaulted by half sister
Assaulted by classmate
Denies assault
Enforcement
Urin
No force
Sexton
Air force
Chemo
* To maintain specificity of the query, certain chief complaint terms were included in the search only when paired with parent/caregiver perpetrator terms to exclude
potential cases of peer or intimate partner violence.
† Coding very specific negations can be used to negate false positives.
§ These chief complaint terms are only included when paired with a parent/caregiver perpetrator term, such as mother, mom, stepmom, grandmom, fostermom,
grandma, grandpa, stepdad, fosterdad, granddad, babysitter, nanny, parent, fosterparent, stepparent, grandparent, custodian, guardian, uncle, aunt.
¶ ICD-10-CM codes Z04.42 (“Suspected child sexual abuse, ruled out”) and Z04.72 (“Suspected physical abuse, ruled out”) were included in the CAN query because,
during query validation, this code was found to be inconsistently applied to both identify and rule out cases.
Morbidity and Mortality Weekly Report
MMWR / December US Department of Health and Human Services/Centers for Disease Control and Prevention 11, 2020 / Vol. 69 / No. 49 1845
FIGURE 1. Number (A) and proportion (B) of emergency department (ED) visits related to suspected and confirmed child abuse and neglect
among children and adolescents aged <18 years, by week — National Syndromic Surveillance Program, United States, 2019–2020
Declaration of national emergency, 2020
0
400
800
1,200
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51
No. of ED visits
Week
2019
2020
Declaration of national emergency, 2020
0
200
400
600
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51
Proportion of child abuse/neglect visits per 100,000 ED visits
Week
2019
2020
Morbidity and Mortality Weekly Report
1846 MMWR / December 11, 2020 / Vol. 69 / No. 49 US Department of Health and Human Services/Centers for Disease Control and Prevention
FIGURE 2. Number (A) and percentage (B) of emergency department (ED) visits related to suspected and confirmed child abuse and neglect ending in
hospitalization among children and adolescents aged <18 years, by week — National Syndromic Surveillance Program, United States, 2019–2020
0
10
20
30
40
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51
No. of ED visits ending in hospitalization
Week
Percentage of visits related to child abuse and
neglect ending in hospitalization
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51
Week
0
2
4
6
100
Declaration of national emergency, 2020
Declaration of national emergency, 2020
2019
2020
2019
2020
Morbidity and Mortality Weekly Report
MMWR / December US Department of Health and Human Services/Centers for Disease Control and Prevention 11, 2020 / Vol. 69 / No. 49 1847
Summary
What is already known about this topic?
Public health emergencies increase risk for child abuse and
neglect because of increased stressors and loss of financial and
social supports.
What is added by this report?
During the COVID-19 pandemic, the total number of emergency
department visits related to child abuse and neglect decreased,
but the percentage of such visits resulting in hospitalization
increased, compared with 2019.
What are the implications for public health practice?
The pandemic has affected health care–seeking patterns for child
abuse and neglect, raising concerns that victims might not have
received care and that severity of injuries remained stable or
worsened. Implementation of strategies to prevent child abuse and
neglect is important, particularly during public health emergencies.
data quality, only data from the most consistently reporting
facilities were used. Fourth, NSSP data are not nationally or
regionally representative, and results are not generalizable to
nonparticipating facilities. Fifth, the data source does not
distinguish between incident and recurrent health care facility
visits; thus, interpretation of results is limited to ED visits,
not patients. Finally, data were transmitted to NSSP in near
real-time and are not considered final; results might change
over time as additional data are added.
Continued surveillance of child abuse and neglect during the
pandemic is warranted, and syndromic surveillance data enable
the monitoring of these outcomes in near real-time. Importantly,
this report demonstrates that ED visits related to abuse and neglect
declined during the COVID-19 pandemic, despite evidence that
pandemics increase risk for child abuse and neglect (1). Identification
and support of alternative means to detect and report child abuse
and neglect is needed during the COVID-19 pandemic. Because of
the numerous negative consequences of child abuse and neglect on
children’s short-term and long-term physical and mental health (6),
further research into the epidemiology of child abuse and neglect
during the COVID-19 pandemic (e.g., risk factors and protective
factors, types of abuse observed, types of injuries sustained, and
reasons for hospitalization) is needed to better understand the
pandemic’s effects on child abuse and neglect.
Child abuse and neglect is preventable. CDC’s technical package
for preventing child abuse and neglect outlines prevention strategies
based on the best available evidence, some of which might
be particularly useful during public health emergencies (6). These
prevention opportunities include strengthening families’ economic
supports, ensuring family-friendly work policies so that parents
can continue to work while balancing childcare responsibilities,
and modifying early home visitation practices to be virtual while
social distancing measures are in effect. Broad implementation
of prevention strategies can reduce child abuse and neglect and
help ensure that children and adolescents experience safe, stable,
nurturing relationships and environments (6).
Acknowledgments
Colorado Tri-County Health Department; Texas Public Health
Regions 2 and 3; Nebraska Department of Health and Human Services.
Corresponding author: Elizabeth Swedo, [email protected].
1Community Interventions and Critical Populations Task Force, CDC
COVID-19 Response Team; 2Division of Injury Prevention, National Center
for Injury Prevention and Control, CDC; 3Division of Violence Prevention,
National Center for Injury Prevention and Control, CDC; 4Division of Health
Informatics and Surveillance, Center for Surveillance, Epidemiology, and
Laboratory Services, CDC; 5Deloitte, New York, New York; 6ICF, Atlanta,
Georgia; 7Epidemic Intelligence Service, CDC; 8Division of Overdose
Prevention, National Center for Injury Prevention and Control, CDC.
All authors have completed and submitted the International
Committee of Medical Journal Editors form for disclosure of potential
conflicts of interest. No potential conflicts of interest were disclosed.
References
1. World Health Organization. Global status report on preventing violence
against children 2020. Geneva, Switzerland: World Health Organization;
2020. https://www.who.int/publications/i/item/9789240004191
2. Office of the Federal Register. Declaring a national emergency
concerning the novel coronavirus disease (COVID-19) outbreak:
proclamation 9994 of March 13, 2020. Washington, DC: Office
of the Federal Register; 2020. https://www.federalregister.gov/
documents/2020/03/18/2020-05794/declaring-a-national-emergencyconcerning-
the-novel-coronavirus-disease-covid-19-outbreak
3. Fortson B, Klevens J, Merrick M, Gilbert L, Alexander S. Preventing
child abuse and neglect: a technical package for policy, norm, and
programmatic activities. Atlanta, GA: US Department of Health and
Human Services, CDC; 2016. https://www.cdc.gov/violenceprevention/
pdf/can-prevention-technical-package.pdf
4. Peterman A, Potts A, O’Donnell M, et al. Pandemics and violence
against women and children. Washington, DC: Centre for
Global Development; 2020. https://www.cgdev.org/publication/
pandemics-and-violence-against-women-and-children
5. Sidpra J, Abomeli D, Hameed B, Baker J, Mankad K. Rise in the
incidence of abusive head trauma during the COVID-19 pandemic.
Arch Dis Child 2020. Epub July 2, 2020. PMID:32616522 https://
doi.org/10.1136/archdischild-2020-319872
6. Welch M, Haskins R. What COVID-19 means for America’s child welfare
system. Washington, DC: Brookings Institution; 2020. https://www.brookings.
edu/research/what-covid-19-means-for-americas-child-welfare-system/
7. CDC. National Syndromic Surveillance Program (NSSP). Atlanta, GA:
US Department of Health and Human Services, CDC; 2020. https://
www.cdc.gov/nssp/index.html
8. Leeb R, Paulozzi L, Melanson C, Simon TR, Arias I. Child maltreatment
surveillance: uniform definitions for public health and recommended
data elements, version 1.0. Atlanta, GA: US Department of Health and
Human Services, CDC; 2008. https://www.cdc.gov/violenceprevention/
pdf/cm_surveillance-a.pdf
9. Hartnett KP, Kite-Powell A, DeVies J, et al.; National Syndromic
Surveillance Program Community of Practice. Impact of the COVID-19
pandemic on emergency department visits—United States, January 1,
2019–May 30, 2020. MMWR Morb Mortal Wkly Rep 2020;69:699–704.
PMID:32525856 https://doi.org/10.15585/mmwr.mm6923e1
10. Czeisler MÉ, Lane RI, Petrosky E, et al. Mental health, substance use,
and suicidal ideation during the COVID-19 pandemic—United States,
June 24–30, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1049–57.
PMID:32790653 https://doi.org/10.15585/mmwr.mm6932a1
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Do you struggle with finance? No need to torture yourself if finance is not your cup of tea. You can order your finance paper from our academic writing service and get 100% original work from competent finance experts.

Computer science

Computer science is a tough subject. Fortunately, our computer science experts are up to the match. No need to stress and have sleepless nights. Our academic writers will tackle all your computer science assignments and deliver them on time. Let us handle all your python, java, ruby, JavaScript, php , C+ assignments!

Psychology

While psychology may be an interesting subject, you may lack sufficient time to handle your assignments. Don’t despair; by using our academic writing service, you can be assured of perfect grades. Moreover, your grades will be consistent.

Engineering

Engineering is quite a demanding subject. Students face a lot of pressure and barely have enough time to do what they love to do. Our academic writing service got you covered! Our engineering specialists follow the paper instructions and ensure timely delivery of the paper.

Nursing

In the nursing course, you may have difficulties with literature reviews, annotated bibliographies, critical essays, and other assignments. Our nursing assignment writers will offer you professional nursing paper help at low prices.

Sociology

Truth be told, sociology papers can be quite exhausting. Our academic writing service relieves you of fatigue, pressure, and stress. You can relax and have peace of mind as our academic writers handle your sociology assignment.

Business

We take pride in having some of the best business writers in the industry. Our business writers have a lot of experience in the field. They are reliable, and you can be assured of a high-grade paper. They are able to handle business papers of any subject, length, deadline, and difficulty!

Statistics

We boast of having some of the most experienced statistics experts in the industry. Our statistics experts have diverse skills, expertise, and knowledge to handle any kind of assignment. They have access to all kinds of software to get your assignment done.

Law

Writing a law essay may prove to be an insurmountable obstacle, especially when you need to know the peculiarities of the legislative framework. Take advantage of our top-notch law specialists and get superb grades and 100% satisfaction.

What discipline/subjects do you deal in?

We have highlighted some of the most popular subjects we handle above. Those are just a tip of the iceberg. We deal in all academic disciplines since our writers are as diverse. They have been drawn from across all disciplines, and orders are assigned to those writers believed to be the best in the field. In a nutshell, there is no task we cannot handle; all you need to do is place your order with us. As long as your instructions are clear, just trust we shall deliver irrespective of the discipline.

Are your writers competent enough to handle my paper?

Our essay writers are graduates with bachelor's, masters, Ph.D., and doctorate degrees in various subjects. The minimum requirement to be an essay writer with our essay writing service is to have a college degree. All our academic writers have a minimum of two years of academic writing. We have a stringent recruitment process to ensure that we get only the most competent essay writers in the industry. We also ensure that the writers are handsomely compensated for their value. The majority of our writers are native English speakers. As such, the fluency of language and grammar is impeccable.

What if I don’t like the paper?

There is a very low likelihood that you won’t like the paper.

Reasons being:

• When assigning your order, we match the paper’s discipline with the writer’s field/specialization. Since all our writers are graduates, we match the paper’s subject with the field the writer studied. For instance, if it’s a nursing paper, only a nursing graduate and writer will handle it. Furthermore, all our writers have academic writing experience and top-notch research skills.
• We have a quality assurance that reviews the paper before it gets to you. As such, we ensure that you get a paper that meets the required standard and will most definitely make the grade.

In the event that you don’t like your paper:

• The writer will revise the paper up to your pleasing. You have unlimited revisions. You simply need to highlight what specifically you don’t like about the paper, and the writer will make the amendments. The paper will be revised until you are satisfied. Revisions are free of charge
• We will have a different writer write the paper from scratch.
• Last resort, if the above does not work, we will refund your money.

Will the professor find out I didn’t write the paper myself?

Not at all. All papers are written from scratch. There is no way your tutor or instructor will realize that you did not write the paper yourself. In fact, we recommend using our assignment help services for consistent results.

What if the paper is plagiarized?

We check all papers for plagiarism before we submit them. We use powerful plagiarism checking software such as SafeAssign, LopesWrite, and Turnitin. We also upload the plagiarism report so that you can review it. We understand that plagiarism is academic suicide. We would not take the risk of submitting plagiarized work and jeopardize your academic journey. Furthermore, we do not sell or use prewritten papers, and each paper is written from scratch.

When will I get my paper?

You determine when you get the paper by setting the deadline when placing the order. All papers are delivered within the deadline. We are well aware that we operate in a time-sensitive industry. As such, we have laid out strategies to ensure that the client receives the paper on time and they never miss the deadline. We understand that papers that are submitted late have some points deducted. We do not want you to miss any points due to late submission. We work on beating deadlines by huge margins in order to ensure that you have ample time to review the paper before you submit it.

Will anyone find out that I used your services?

We have a privacy and confidentiality policy that guides our work. We NEVER share any customer information with third parties. Noone will ever know that you used our assignment help services. It’s only between you and us. We are bound by our policies to protect the customer’s identity and information. All your information, such as your names, phone number, email, order information, and so on, are protected. We have robust security systems that ensure that your data is protected. Hacking our systems is close to impossible, and it has never happened.

How our Assignment Help Service Works

1. Place an order

You fill all the paper instructions in the order form. Make sure you include all the helpful materials so that our academic writers can deliver the perfect paper. It will also help to eliminate unnecessary revisions.

2. Pay for the order

Proceed to pay for the paper so that it can be assigned to one of our expert academic writers. The paper subject is matched with the writer’s area of specialization.

3. Track the progress

You communicate with the writer and know about the progress of the paper. The client can ask the writer for drafts of the paper. The client can upload extra material and include additional instructions from the lecturer. Receive a paper.

4. Download the paper

The paper is sent to your email and uploaded to your personal account. You also get a plagiarism report attached to your paper.

GET A PERFECT SCORE!!!

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