A Critical Appraisal of a University's Response to a Campus Mass Shooting: Perspectives from Public Health Students and Researchers at Michigan State University.

Mass shootings are a public health crisis and have become more frequent on U.S. university campuses over the past decade, with the number doubling since 2000. Due to this alarming trend, many institutions have developed response strategies for active shooting events. Yet, the extent to which these response strategies address the needs and minimize harm for students, faculty, and staff has not been evaluated critically after a campus mass shooting. Michigan State University (MSU) experienced a mass shooting on February 13, 2023. Before, during, and 6 months following this tragedy, the university employed an estimated 18 strategies to inform, support, and protect its students, faculty, and staff. While MSU continues to address concerns and roll out programs related to this event, here we aimed to (1) create a timeline of resources and communication provided by MSU from the event to 6 months post-event; (2) critically evaluate the extent to which these resources met the needs of students, faculty, and staff through a survey among persons involved in public health research; and (3) identify potential areas for improvement in the university's responses. We used an online survey where participants (n = 10) rated the university responses and provided additional comments. From our survey, we recommend that, in the event of a campus shooting, other universities are attentive to re-engaging with the community within which the university is situated, holding communal events on campus, offering pauses in classes, and enhancing mental health services. These responses were seen as crucial to re-establish campus life and learning.

High prevalence of diabetes among young First Nations Peoples with metabolic dysfunction-associated steatotic liver disease: a population-based study in Australia.

BACKGROUND: Liver disease is an important contributor to the mortality gap between First Nations Peoples and non-Indigenous Australian adults. Despite a high burden of metabolic comorbidities among First Nations Peoples, data about the epidemiology of metabolic dysfunction-associated steatotic liver disease (MASLD) in this population is scarce. METHODS: A retrospective analysis of all adults hospitalized with MASLD or metabolic dysfunction-associated steatohepatitis (MASH) with/without cirrhosis during 2007-2019 in the state of Queensland was performed. Patients were followed from the first admission with MASLD/MASH (identified based on validated algorithms) to decompensated cirrhosis and overall mortality. We explored differences according to Indigenous status using Multivariable Cox regression. FINDINGS: 439 First Nations Peoples and 7,547 non-Indigenous Australians were followed for a median of 4.6 years (interquartile range 2.7-7.2). Overall, women were overrepresented, but more so in the First Nations cohort (72.7% vs. 57.0%, p < 0.001). First Nations patients were younger, a higher proportion lived in remote and socioeconomic disadvantaged areas, and had higher comorbidity compared to non-Indigenous Australians (all p < 0.001). Diabetes, the most common comorbidity affecting both groups, was overrepresented in First Nations Peoples versus non-Indigenous Australians (43.5% vs. 30.8%, p < 0.001, respectively). Nineteen (4.3%) First Nations Peoples and 332 (4.4%) of non-Indigenous patients progressed to cirrhosis decompensation (9.0% [95%CI 4.5-17.7] vs. 7.7% [95%CI 6.6-8.9; p = 0.956] respectively within 10 years). In multivariable analysis, there was no association between Indigenous status and progression to decompensated cirrhosis (p = 0.759) and survival (p = 0.437). CONCLUSIONS: This study provides the first population-based epidemiological data on MASLD in First Nations Australians. The high prevalence of diabetes (that is associated with advanced fibrosis and liver disease mortality) among young First Nations Peoples with MASLD raises concern about future risk of progressive liver disease in this patient population. These data highlight the importance of early identification of MASLD, and providing culturally appropriate intervention to reduce disease progression in parallel with the management of cardiometabolic comorbidities.

The association between physical availability of cannabis retail outlets and frequent cannabis use and related health harms: a systematic review.

An increasing number of regions have or are considering legalising the sale of cannabis for adult use. Experience from tobacco and alcohol regulation has found that greater access to physical retail stores is positively associated with increased substance use and harm. Whether this association exists for cannabis is unclear. We completed a systematic review examining the association between cannabis retail store access and adverse health outcomes. We identified articles up until July 20, 2023 by searching four databases. We included studies examining the association between measures of cannabis store access and adverse outcomes: frequent or problematic cannabis use, healthcare encounters due to cannabis use (e.g., cannabis-induced psychosis), and healthcare encounters potentially related to cannabis (e.g., self-harm episodes). Results were compared by study design type, retail access measure, and by subgroups including: children, adolescents, young adults, adults, and pregnant individuals. This review was registered with PROSPERO (CRD42021281788). The search generated 5750 citations of which we included 32 studies containing 44 unique primary analyses (unique retail measure and outcome pairs). Studies come from 4 countries (United States, Canada, Netherlands and Uruguay). Among the included analyses, there were consistent positive associations between greater cannabis retail access and 1) increased healthcare service use or poison control calls directly due to cannabis (10/12 analyses; 83%) (2) increased cannabis use and cannabis-related hospitalization during pregnancy (4/4; 100%) and 3) frequent cannabis use in adults and young adults (7/11; 64%). There was no consistent positive association between greater cannabis retail and increased frequent cannabis use in adolescents (1/4; 25%), healthcare service use potentially related to cannabis (2/6; 33%) or increased adverse neonatal birth outcomes (2/7; 26.8%). There is a positive association between greater cannabis store access and increases in cannabis harm. In countries with legal cannabis, retail restrictions may reduce use and harm. Funding: Canadian Centre on Substance Use and Addiction (CCSA).

Key influences on university students' physical activity: a systematic review using the Theoretical Domains Framework and the COM-B model of human behaviour.

BACKGROUND: Physical activity is important for all aspects of health, yet most university students are not active enough to reap these benefits. Understanding the factors that influence physical activity in the context of behaviour change theory is valuable to inform the development of effective evidence-based interventions to increase university students' physical activity. The current systematic review a) identified barriers and facilitators to university students' physical activity, b) mapped these factors to the Theoretical Domains Framework (TDF) and COM-B model, and c) ranked the relative importance of TDF domains. METHODS: Data synthesis included qualitative, quantitative, and mixed-methods research published between 01.01.2010-15.03.2023. Four databases (MEDLINE, PsycINFO, SPORTDiscus, and Scopus) were searched to identify publications on the barriers/facilitators to university students' physical activity. Data regarding study design and key findings (i.e., participant quotes, qualitative theme descriptions, and survey results) were extracted. Framework analysis was used to code barriers/facilitators to the TDF and COM-B model. Within each TDF domain, thematic analysis was used to group similar barriers/facilitators into descriptive theme labels. TDF domains were ranked by relative importance based on frequency, elaboration, and evidence of mixed barriers/facilitators. RESULTS: Thirty-nine studies involving 17,771 participants met the inclusion criteria. Fifty-six barriers and facilitators mapping to twelve TDF domains and the COM-B model were identified as relevant to students' physical activity. Three TDF domains, environmental context and resources (e.g., time constraints), social influences (e.g., exercising with others), and goals (e.g., prioritisation of physical activity) were judged to be of greatest relative importance (identified in > 50% of studies). TDF domains of lower relative importance were intentions, reinforcement, emotion, beliefs about consequences, knowledge, physical skills, beliefs about capabilities, cognitive and interpersonal skills, social/professional role and identity, and behavioural regulation. No barriers/facilitators relating to the TDF domains of memory, attention and decision process, or optimism were identified. CONCLUSIONS: The current findings provide a foundation to enhance the development of theory and evidence informed interventions to support university students' engagement in physical activity. Interventions that include a focus on the TDF domains 'environmental context and resources,' 'social influences,' and 'goals,' hold particular promise for promoting active student lifestyles. TRIAL REGISTRATION: Prospero ID-CRD42021242170.

Systematic review of best practices for GPS data usage, processing, and linkage in health, exposure science and environmental context research.

Global Positioning System (GPS) technology is increasingly used in health research to capture individual mobility and contextual and environmental exposures. However, the tools, techniques and decisions for using GPS data vary from study to study, making comparisons and reproducibility challenging. OBJECTIVES: The objectives of this systematic review were to (1) identify best practices for GPS data collection and processing; (2) quantify reporting of best practices in published studies; and (3) discuss examples found in reviewed manuscripts that future researchers may employ for reporting GPS data usage, processing and linkage of GPS data in health studies. DESIGN: A systematic review. DATA SOURCES: Electronic databases searched (24 October 2023) were PubMed, Scopus and Web of Science (PROSPERO ID: CRD42022322166). ELIGIBILITY CRITERIA: Included peer-reviewed studies published in English met at least one of the criteria: (1) protocols involving GPS for exposure/context and human health research purposes and containing empirical data; (2) linkage of GPS data to other data intended for research on contextual influences on health; (3) associations between GPS-measured mobility or exposures and health; (4) derived variable methods using GPS data in health research; or (5) comparison of GPS tracking with other methods (eg, travel diary). DATA EXTRACTION AND SYNTHESIS: We examined 157 manuscripts for reporting of best practices including wear time, sampling frequency, data validity, noise/signal loss and data linkage to assess risk of bias. RESULTS: We found that 6% of the studies did not disclose the GPS device model used, only 12.1% reported the per cent of GPS data lost by signal loss, only 15.7% reported the per cent of GPS data considered to be noise and only 68.2% reported the inclusion criteria for their data. CONCLUSIONS: Our recommendations for reporting on GPS usage, processing and linkage may be transferrable to other geospatial devices, with the hope of promoting transparency and reproducibility in this research. PROSPERO REGISTRATION NUMBER: CRD42022322166.

A systematic review of audit tools for evaluating the quality of green spaces in mental health research.

Research showing the relationship between exposure to green space and health has yielded conflicting results, possibly due to the oversight of green space quality in quantitative studies. This systematic review, guided by the PRISMA framework (registered under Prospero ID CRD42023279720), focused on audit tools for green space quality in mental health research. From 4028 studies, 13 were reviewed, with 77 % linking better mental health outcomes to higher green space quality. Eight tools, especially Public Open Space and Dillen et al. tools demonstrated strong correlations with mental health. Certain green space qualities like grass, pathways, and water elements showed positive health associations. Future research should aim for standardized quality metrics and robust methodologies to support causal inferences and efficient assessments.

Saliva identification in forensic samples by automated microextraction and intact mass analysis of statherin.

The enzyme α-amylase has long been a commonly targeted protein in serological tests for saliva. While being especially abundant in saliva, α-amylase is detectable in vaginal secretions, sweat, fecal matter, breast milk and other matrices. As a result, assays for α-amylase only provide a presumptive indication of saliva. The availability of mass spectrometry-based tools for the detection of less abundant, but more specific, protein targets (e.g., human statherin) has enabled the development of high confidence assays for human saliva. Sample throughput, however, has traditionally been low due to multi-step workflows for protein extraction, quantitation, enzymatic digestion, solid phase cleanup, and nano-/capillary-based chromatography. Here, we present two novel "direct" single-stage extraction strategies for sample preparation. These feature immunoaffinity purification and reversed-phase solid-phase microextraction in conjunction with intact mass analysis of human statherin for saliva identification. Mass analysis was performed on the Thermo Scientific Q-Exactive™ Orbitrap mass spectrometer with a 10-min analytical run time. Data analysis was performed using Byos® from Protein Metrics. Two sample sets were analyzed with a population of 20 individuals to evaluate detection reliability. A series of casework-type samples were then assayed to evaluate performance in an authentic forensic context. Statherin was confidently identified in 92% and 71% of samples extracted using the immunoaffinity purification and solid phase microextraction approaches, respectively. Overall, immunoaffinity purification outperformed the solid phase microextraction, especially with complex mixtures. In toto, robotic extraction and intact mass spectrometry enable the reliable identification of trace human saliva in a variety of sample types.

Standards for the care of people with cystic fibrosis; establishing and maintaining health.

This is the second in a series of four papers updating the European Cystic Fibrosis Society (ECFS) standards for the care of people with CF. This paper focuses on establishing and maintaining health. The guidance is produced using an evidence-based framework and with wide stakeholder engagement, including people from the CF community. Authors provided a narrative description of their topic and statements, which were more directive. These statements were reviewed by a Delphi exercise, achieving good levels of agreement from a wide group for all statements. This guidance reinforces the importance of a multi-disciplinary CF team, but also describes developing models of care including virtual consultations. The framework for health is reinforced, including the need for a physically active lifestyle and the strict avoidance of all recreational inhalations, including e-cigarettes. Progress with cystic fibrosis transmembrane conductance regulator (CFTR) modulator therapy is reviewed, including emerging adverse events and advice for dose reduction and interruption. This paper contains guidance that is pertinent to all people with CF regardless of age and eligibility for and access to modulator therapy.

Nebuliser systems for drug delivery in cystic fibrosis.

BACKGROUND: Nebuliser systems are used to deliver medications to the lungs, to control the symptoms and the progression of lung disease in people with cystic fibrosis (CF). There are many different nebulised-medications prescribed for people with CF and there are many different types of nebuliser systems. Some of these nebulised medications are licenced for, and can be taken via only one type of nebuliser system; some are licensed for, and can be taken via more than one type of nebuliser system. This is an update to a previous systematic review. OBJECTIVES: To assess the time efficiency, effectiveness, safety, cost and impact of use (e.g. burden of care, adherence, quality of life (QoL)) of different nebuliser systems, when used with different inhaled medications for people with CF. SEARCH METHODS: We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising references identified from comprehensive electronic database searches, handsearching of relevant journals and abstract books containing conference proceedings. We searched the reference lists of each study for additional publications and approached the manufacturers of both nebuliser systems and nebulised medications for published and unpublished data. We also searched online trial registries. Date of the most recent search: 9 August 2023. SELECTION CRITERIA: Randomised controlled trials (RCTs) or quasi-RCTs comparing nebuliser systems, including conventional nebulisers, vibrating mesh technology (VMT) systems, adaptive aerosol delivery (AAD) systems and ultrasonic nebuliser systems. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed studies for inclusion. They also independently extracted data and assessed the risk of bias. A third review author assessed studies where agreement could not be reached. They assessed the certainty of the evidence using GRADE. MAIN RESULTS: The search identified 216 studies with 33 of these (2270 participants) included in the review. These studies compared the delivery of tobramycin, colistin, dornase alfa, hypertonic saline and other solutions through the different nebuliser systems in children and adults with CF. This review demonstrates variability in the delivery of medication depending on the nebuliser system used. The certainty of the evidence ranged from low to very low. Some conventional nebuliser systems providing higher flows, higher respirable fractions, and smaller particles decrease treatment time, increase deposition (the amount of drug reaching the lung), and may be preferred by people with CF, as compared to other conventional nebuliser systems providing lower flows, lower respirable fractions and larger particles. Newer nebuliser systems using AAD, or VMT (or both) reduce treatment time compared to conventional systems. Deposition (as a percentage of priming dose) with AAD is greater than with conventional systems. VMT systems may give greater deposition than conventional systems when measuring sputum levels. The available data indicate that these newer systems are safe when used with an appropriate priming dose, which may be different to the priming dose used for conventional systems. There is an indication that adherence is maintained or improved and that individuals prefer AAD or VMT systems, but also that some nebuliser systems using VMT may be subject to increased system failures. There is limited, unclear evidence on the impact of different nebuliser systems on lung function and a lack of data on the impact of different nebuliser systems on our outcomes of quality of life (QoL), adverse effects, respiratory exacerbations and related implications, adherence, satisfaction, cost and device reliability. AUTHORS' CONCLUSIONS: Newer technologies e.g. AAD and VMT have advantages over conventional systems in terms of treatment time, deposition as a percentage of priming dose, preference and adherence. Data are lacking for all varieties of medications which are used in CF care, including different inhaled antibiotics or hypertonic saline, with all delivery (nebuliser system) possibilities. Long-term RCTs are needed to evaluate different nebuliser systems to determine patient-focused outcomes (such as QoL and burden of care), safe and effective dosing levels of a wide variety of medications, clinical outcomes (such as hospitalisations and need for antibiotics), and an economic evaluation of their use. There are insufficient data to establish whether one nebuliser system is better than another overall. Clinicians should be aware of the variability in the performance of different nebuliser systems, compatibility with specific nebulised medication, and they must work with their patients to choose the best nebuliser system for each individual. This is likely to be an ongoing process as the needs and circumstances of each individual change over time.

Effects of an 8-Week Mindfulness Course in People With Voice Disorders.

OBJECTIVES: Nearly every modern textbook on the etiology and treatment of voice disorders (VD) recommends stress reduction for VD patients. The benefits of mindfulness for stress reduction are well documented, but published literature on mindfulness and VD is sparse. Our objective was to determine whether an 8-week mindfulness course could increase mindfulness and lower stress in people with VD, leading to a decrease in vocal handicap. STUDY DESIGN: Mixed methods study. METHODS: Participants: 69 individuals with VD: 39 were mindfulness course participants (MCP), 30 were in a waitlist control group (WCG). Exclusionary criteria: patients in voice therapy. Before and after the 8-week timeframe, participants took the Mindful Attention and Awareness Scale (MAAS), Perceived Stress Scale-10 (PSS-10), Voice Handicap Index (VHI), and-for singers (n = 36)-the Singing Voice Handicap Index (SVHI). Follow-up interviews were conducted with select participants. RESULTS: In the MCP, each of the outcomes significantly changed in the direction hypothesized, resulting in increased MAAS (P = 0.000) and decreased PSS-10 (P = 0.007), VHI (P = 0.000), and SVHI (P = 0.021, n = 22) scores. Using a 2 × 2 Repeated Measures ANOVA, two outcomes were statistically different for the MCP from pre to postcourse-MAAS increased (P = 0.006, ES = 0.107) and VHI decreased (P = 0.034, ES = 0.065)-in comparison to no change in the WCG. Follow-up interviews revealed increased acceptance of the VD; reduced stress, physical tension, and pain/discomfort; increased somatic (or interoceptive) awareness; community with other VD patients; and positive speaking and singing voice changes. CONCLUSIONS: An 8-week mindfulness course shows promise for reducing stress in people with VD, lowering voice handicap, and improving quality of life. Future research should evaluate mindfulness in patients with specific voice disorders; patients with higher and lower VHI scores; singers; and patients who experience throat pain. Mindfulness should also be evaluated within a standard voice therapy protocol.

A rationale and framework for addressing physician cognitive impairment.

Medical error is costly, in terms of the health and wellbeing of the patient, their family, and the financial burden placed on the medical system. Reducing medical error is paramount to minimizing harm and improving outcomes. One potential source of medical error is physician cognitive impairment. Determining how to effectively assess and mange physician cognitive impairment is an important, albeit difficult problem to address. There have been calls and attempts to implement age-based cognitive screening, but this approach is not optimal. Instead, we propose that neuropsychological assessment is the gold standard for fitness-for-duty evaluations and that there is a need for the development of physician-based, normative data to improve these evaluations. Here, we outline the framework of our research protocol in a large, academic medical center, in partnership with hospital leadership and legal counsel, which can be modeled by other medical centers. With high rates of physician burnout and an aging physician population, the United States is facing a looming public health crisis that requires proactive management.

Inequities in COVID-19 Vaccination Coverage Among Pregnant Persons, by Disaggregated Race and Ethnicity - Massachusetts, May 2021-October 2022.

National estimates suggest that COVID-19 vaccination coverage among pregnant persons is lower among those identifying as Hispanic or Latino (Hispanic) and non-Hispanic Black or African American. When examining COVID-19 vaccination coverage during pregnancy by race and ethnicity, however, data are typically limited to large, aggregate categories that might obscure within-group inequities. To address this, Massachusetts examined COVID-19 vaccination coverage among pregnant persons by combinations of 12 racial and 34 ethnic groupings. Among 102,275 persons with a live birth in Massachusetts during May 1, 2021-October 31, 2022, receipt of ≥1 dose of a COVID-19 vaccine before or during pregnancy was 41.6% overall and was highest among persons who identified as Asian (55.0%) and lowest among those who identified as Hispanic (26.7%). However, within all broad racial and ethnic groupings, disparities in COVID-19 vaccination coverage were identified when the data were disaggregated into more granular categories; for example, COVID-19 vaccination coverage ranged from 10.8%-61.1% among pregnant persons who identified as Hispanic. Disaggregated analyses reveal diverse experiences within broad racial and ethnic groupings. This information can be used to guide outreach to pregnant persons in communities with lower rates of COVID-19 vaccination coverage during pregnancy.

American Trauma Care: A System of Systems.

OBJECTIVE: The benefits of organized trauma systems have been well-documented during 50 years of trauma system development in the United States. Unfortunately, despite this evidence, trauma system development has occurred only sporadically in the 50 states. METHODS: The relevant literature related to trauma system design and development was reviewed based on relevance to the study. Information from these sources was summarized into a SWOT (strengths, weaknesses, opportunities, and threats) analysis. RESULTS: Strengths discovered were leadership brought forth by the American College of Surgeons Committee on Trauma and meaningful change generated from The National Academy of Sciences, Engineering, and Medicine report addressing the fractionation of the nation's trauma systems, whereas weaknesses included patient outcome disparities due to the lack of a national governing authority, undertriage, underresourced rural trauma, and underfunded trauma research. Opportunities included the creation of level IV trauma centers; telemedicine; the development of rural trauma management courses; air medical transport to bring high-intensity care to the patient, particularly in rural areas; trauma research; and trauma prevention through outreach and educational programs. The following threats were determined: mass casualty incidents, motor vehicle collisions because of the high rate of motor vehicle collision deaths in the United States relative to other developed countries, and underfunded trauma systems. CONCLUSION: Much work remains to be done in the development of an American trauma system. Recommendations include implementation of trauma care governance at the federal level; national oversight and support of emergency medical services systems, particularly in rural areas with strict reporting processes for emergency medical services programs; national organization of our mass casualty response; increased federal and state funding allocated to trauma centers; a consistent model for trauma system development; and trauma research.

Commensal Escherichia coli Strains of Bovine Origin Competitively Mitigated Escherichia coli O157:H7 in a Gnotobiotic Murine Intestinal Colonization Model with or without Physiological Stress.

Cattle are a primary reservoir of enterohemorrhagic Escherichia coli (EHEC) O157:H7. Currently, there are no effective methods of eliminating this important zoonotic pathogen from cattle, and colonization resistance in relation to EHEC O157:H7 in cattle is poorly understood. We developed a gnotobiotic EHEC O157:H7 murine model to examine aspects of the cattle pathogen-microbiota interaction, and to investigate competitive suppression of EHEC O157:H7 by 18 phylogenetically distinct commensal E. coli strains of bovine origin. As stress has been suggested to influence enteric colonization by EHEC O157:H7 in cattle, corticosterone administration (±) to incite a physiological stress response was included as an experimental variable. Colonization of the intestinal tract (IT) of mice by the bovine EHEC O157:H7 strain, FRIK-2001, mimicked characteristics of bovine IT colonization. In this regard, FRIK-2001 successfully colonized the IT and temporally incited minimal impacts on the host relative to other EHEC O157:H7 strains, including on the renal metabolome. The presence of the commensal E. coli strains decreased EHEC O157:H7 densities in the cecum, proximal colon, and distal colon. Moreover, histopathologic changes and inflammation markers were reduced in the distal colon of mice inoculated with commensal E. coli strains (both propagated separately and communally). Although stress induction affected the behavior of mice, it did not influence EHEC O157:H7 densities or disease. These findings support the use of a gnotobiotic murine model of enteric bovine EHEC O157:H7 colonization to better understand pathogen-host-microbiota interactions toward the development of effective on-farm mitigations for EHEC O157:H7 in cattle, including the identification of bacteria capable of competitively colonizing the IT.

Characteristics of Hard Tick Relapsing Fever Caused by Borrelia miyamotoi, United States, 2013-2019.

Borrelia miyamotoi, transmitted by Ixodes spp. ticks, was recognized as an agent of hard tick relapsing fever in the United States in 2013. Nine state health departments in the Northeast and Midwest have conducted public health surveillance for this emerging condition by using a shared, working surveillance case definition. During 2013-2019, a total of 300 cases were identified through surveillance; 166 (55%) were classified as confirmed and 134 (45%) as possible. Median age of case-patients was 52 years (range 1-86 years); 52% were male. Most cases (70%) occurred during June-September, with a peak in August. Fever and headache were common symptoms; 28% of case-patients reported recurring fevers, 55% had arthralgia, and 16% had a rash. Thirteen percent of patients were hospitalized, and no deaths were reported. Ongoing surveillance will improve understanding of the incidence and clinical severity of this emerging disease.

Syndromic Surveillance for COVID-19, Massachusetts, February 2020-November 2022: The Impact of Fever and Severity on Algorithm Performance.

OBJECTIVES: Syndromic surveillance can help identify the onset, location, affected populations, and trends in infectious diseases quickly and efficiently. We developed an electronic medical record-based surveillance algorithm for COVID-19-like illness (CLI) and assessed its performance in 5 Massachusetts medical practice groups compared with statewide counts of confirmed cases. MATERIALS AND METHODS: Using data from February 2020 through November 2022, the CLI algorithm was implemented in sites that provide ambulatory and inpatient care for about 25% of the state. The initial algorithm for CLI was modeled on influenza-like illness: an International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis code for COVID-19 and an ICD-10-CM diagnosis code suggesting severe lower respiratory tract infection or ≥1 ICD-10-CM diagnosis code for upper or lower respiratory tract infection plus fever. We generated weekly counts of CLI cases and patients with ≥1 clinical encounter and visually compared trends with those of statewide laboratory-confirmed cases. RESULTS: The initial algorithm tracked well with the spring 2020 wave of COVID-19, but the components that required fever did not clearly detect the November 2020-January 2021 surge and identified <1% of weekly encounters as CLI. We revised the algorithm by adding more mild symptoms and removing the fever requirement; this revision improved alignment with statewide confirmed cases through spring 2022 and increased the proportion of encounters identified as CLI to about 2% to 6% weekly. Alignment between CLI trends and confirmed COVID-19 case counts diverged again in fall 2022, likely because of decreased COVID-19 testing and increases in other respiratory viruses. PRACTICE IMPLICATIONS: Our work highlights the importance of using a broad definition for COVID-19 syndromic surveillance and the need for surveillance systems that are flexible and adaptable to changing trends and patterns in disease or care.

Dynamics of eastern equine encephalitis virus during the 2019 outbreak in the Northeast United States.

Eastern equine encephalitis virus (EEEV) causes a rare but severe disease in horses and humans and is maintained in an enzootic transmission cycle between songbirds and Culiseta melanura mosquitoes. In 2019, the largest EEEV outbreak in the United States for more than 50 years occurred, centered in the Northeast. To explore the dynamics of the outbreak, we sequenced 80 isolates of EEEV and combined them with existing genomic data. We found that, similar to previous years, cases were driven by multiple independent but short-lived virus introductions into the Northeast from Florida. Once in the Northeast, we found that Massachusetts was important for regional spread. We found no evidence of any changes in viral, human, or bird factors which would explain the increase in cases in 2019, although the ecology of EEEV is complex and further data is required to explore these in more detail. By using detailed mosquito surveillance data collected by Massachusetts and Connecticut, however, we found that the abundance of Cs. melanura was exceptionally high in 2019, as was the EEEV infection rate. We employed these mosquito data to build a negative binomial regression model and applied it to estimate early season risks of human or horse cases. We found that the month of first detection of EEEV in mosquito surveillance data and vector index (abundance multiplied by infection rate) were predictive of cases later in the season. We therefore highlight the importance of mosquito surveillance programs as an integral part of public health and disease control.

Human-Biting Ixodes scapularis Submissions to a Crowd-Funded Tick Testing Program Correlate with the Incidence of Rare Tick-Borne Disease: A Seven-Year Retrospective Study of Anaplasmosis and Babesiosis in Massachusetts.

Tick-borne zoonoses pose a serious burden to global public health. To understand the distribution and determinants of these diseases, the many entangled environment-vector-host interactions which influence risk must be considered. Previous studies have evaluated how passive tick testing surveillance measures connect with the incidence of human Lyme disease. The present study sought to extend this to babesiosis and anaplasmosis, two rare tick-borne diseases. Human cases reported to the Massachusetts Department of Health and submissions to TickReport tick testing services between 2015 and 2021 were retrospectively analyzed. Moderate-to-strong town-level correlations using Spearman's Rho (ρ) were established between Ixodes scapularis submissions (total, infected, adult, and nymphal) and human disease. Aggregated ρ values ranged from 0.708 to 0.830 for anaplasmosis and 0.552 to 0.684 for babesiosis. Point observations maintained similar patterns but were slightly weaker, with mild year-to-year variation. The seasonality of tick submissions and demographics of bite victims also correlated well with reported disease. Future studies should assess how this information may best complement human disease reporting and entomological surveys as proxies for Lyme disease incidence in intervention studies, and how it may be used to better understand the dynamics of human-tick encounters.