Association between Combined Sewer Overflow Events and Gastrointestinal Illness in Massachusetts Municipalities with and without River-Sourced Drinking Water, 2014-2019.

BACKGROUND: Combined sewer overflow (CSO) events release untreated wastewater into surface waterbodies during heavy precipitation and snowmelt. Combined sewer systems serve ∼40 million people in the United States, primarily in urban and suburban municipalities in the Midwest and Northeast. Predicted increases in heavy precipitation events driven by climate change underscore the importance of quantifying potential health risks associated with CSO events. OBJECTIVES: The aims of this study were to a) estimate the association between CSO events (2014-2019) and emergency department (ED) visits for acute gastrointestinal illness (AGI) among Massachusetts municipalities that border a CSO-impacted river, and b) determine whether associations differ by municipal drinking water source. METHODS: A case time-series design was used to estimate the association between daily cumulative upstream CSO discharge and ED visits for AGI over lag periods of 4, 7, and 14 days, adjusting for temporal trends, temperature, and precipitation. Associations between CSO events and AGI were also compared by municipal drinking water source (CSO-impacted river vs. other sources). RESULTS: Extreme upstream CSO discharge events (>95th percentile by cumulative volume) were associated with a cumulative risk ratio (CRR) of AGI of 1.22 [95% confidence interval (CI): 1.05, 1.42] over the next 4 days for all municipalities, and the association was robust after adjusting for precipitation [1.17 (95% CI: 0.98, 1.39)], although the CI includes the null. In municipalities with CSO-impacted drinking water sources, the adjusted association was somewhat less pronounced following 95th percentile CSO events [CRR= 1.05 (95% CI: 0.82, 1.33)]. The adjusted CRR of AGI was 1.62 in all municipalities following 99th percentile CSO events (95% CI: 1.04, 2.51) and not statistically different when stratified by drinking water source. DISCUSSION: In municipalities bordering a CSO-impacted river in Massachusetts, extreme CSO events are associated with higher risk of AGI within 4 days. The largest CSO events are associated with increased risk of AGI regardless of drinking water source. https://doi.org/10.1289/EHP14213.

Deployment of the National Notifiable Diseases Surveillance System during the 2022-23 mpox outbreak in the United States-Opportunities and challenges with case notifications during public health emergencies.

Timely case notifications following the introduction of an uncommon pathogen, such as mpox, are critical for understanding disease transmission and for developing and implementing effective mitigation strategies. When Massachusetts public health officials notified the Centers for Disease Control and Prevention (CDC) about a confirmed orthopoxvirus case on May 17, 2023, which was later confirmed as mpox at CDC, mpox was not a nationally notifiable disease. Because existing processes for new data collections through the National Notifiable Disease Surveillance System were not well suited for implementation during emergency responses at the time of the mpox outbreak, several interim notification approaches were established to capture case data. These interim approaches were successful in generating daily case counts, monitoring disease transmission, and identifying high-risk populations. However, the approaches also required several data collection approvals by the federal government and the Council for State and Territorial Epidemiologists, the use of four different case report forms, and the establishment of complex data management and validation processes involving data element mapping and record-level de-duplication steps. We summarize lessons learned from these interim approaches to inform and improve case notifications during future outbreaks. These lessons reinforce CDC's Data Modernization Initiative to work in close collaboration with state, territorial, and local public health departments to strengthen case-based surveillance prior to the next public health emergency.

LatinX harm reduction capital, medication for opioid use disorder, and nonfatal overdose: A structural equation model analysis among people who use drugs in Massachusetts.

BACKGROUND: We introduce the concept of harm reduction capital (HRCap) as the combination of knowledge, resources, and skills related to substance use risk reduction, which we hypothesize to predict MOUD use and opioid overdose. In this study, we explored the interrelationships between ethnicity, HRCap, nonfatal overdose, and MOUD use among PWUD. METHODS: Between 2017 and 2019, people who currently or in the past used opioids and who lived in Massachusetts completed a one-time survey on substance use history, treatment experiences, and use of harm reduction services. We fit first-order measurement constructs for positive and negative HRCap (facilitators and barriers). We used generalized structural equation models to examine the inter-relationships of the latent constructs with LatinX self-identification, past year overdose, and current use of MOUD. RESULTS: HRCap barriers were positively associated with past-year overdose (b=2.6, p<0.05), and LatinX self-identification was inversely associated with HRCap facilitators (b=-0.49, p<0.05). There was no association between overdose in the past year and the current use of MOUD. LatinX self-identification was positively associated with last year methadone treatment (b=0.89, p<0.05) but negatively associated with last year buprenorphine treatment (b=-0.68, p<0.07). Latinx PWUD reported lower positive HRCap than white non-LatinX PWUD and had differential utilization of MOUD. CONCLUSION: Our findings indicate that a recent overdose was not associated with the current use of MOUD, highlighting a severe gap in treatment utilization among individuals at the highest risk. The concept of HRCap and its use in the model highlight substance use treatment differences, opportunities for intervention, and empowerment.

Increase in Functional Tic Presentations in Sexual Orientation and Gender Identity Minority Youth During Coronavirus Disease 2019.

BACKGROUND: Functional tic disorders are among the least common functional movement disorders, but their prevalence rose during the coronavirus disease 2019 (COVID-19) pandemic. Although female adolescents develop functional neurological disorders at higher rates than males, investigations into sexual orientation and gender identity (SOGI) status of these patients are limited. METHODS: We completed a retrospective, cross-sectional time series examining the incidence of new-onset functional tic disorders in youth presenting to the Massachusetts General Hospital Movement Disorder clinics before and during the COVID-19 pandemic. Data were collected by searching for relevant International Classification of Diseases (ICD)-10 diagnostic codes in youth aged nine to 26 years using a hospital-wide data repository. Individual cases were reviewed for inclusion based on clinical criteria and expert consensus. RESULTS: The prevalence of functional tic presentations in youth rose 8.6-fold from pre- to postpandemic levels (Fisher exact test P < 0.001), whereas the prevalence of developmental tic presentations pre- and postpandemic remained stable (114 vs 112). SOGI minority youth comprised 37% of those with functional tics (total n = 19). Ninety five percent of patients with functional tics identified as female, with 10% of these identifying as transgender. CONCLUSIONS: Our data confirm previously demonstrated dramatic rises in functional tic presentations during the COVID-19 pandemic and, more notably, reveal a strong association with SOGI minority status. We highlight the potential link between functional tic disorders and SOGI minority status. Providing a safe and supportive clinical environment and addressing stress linked to SOGI minority status may help to improve patient prognosis.

Medicaid Inmate Exclusion Policy and Infectious Diseases Care for Justice-Involved Populations.

The Medicaid Inmate Exclusion Policy (MIEP) prohibits using federal funds for ambulatory care services and medications (including for infectious diseases) for incarcerated persons. More than one quarter of states, including California and Massachusetts, have asked the federal government for authority to waive the MIEP. To improve health outcomes and continuation of care, those states seek to cover transitional care services provided to persons in the period before release from incarceration. The Massachusetts Sheriffs' Association, Massachusetts Department of Correction, Executive Office of Health and Human Services, and University of Massachusetts Chan Medical School have collaborated to improve infectious disease healthcare service provision before and after release from incarceration. They seek to provide stakeholders working at the intersection of criminal justice and healthcare with tools to advance Medicaid policy and improve treatment and prevention of infectious diseases for persons in jails and prisons by removing MIEP barriers through Section 1115 waivers.

Identifying data-driven subtypes of major depressive disorder with electronic health records.

BACKGROUND: Efforts to reduce the heterogeneity of major depressive disorder (MDD) by identifying subtypes have not yet facilitated treatment personalization or investigation of biology, so novel approaches merit consideration. METHODS: We utilized electronic health records drawn from 2 academic medical centers and affiliated health systems in Massachusetts to identify data-driven subtypes of MDD, characterizing sociodemographic features, comorbid diagnoses, and treatment patterns. We applied Latent Dirichlet Allocation (LDA) to summarize diagnostic codes followed by agglomerative clustering to define patient subgroups. RESULTS: Among 136,371 patients (95,034 women [70 %]; 41,337 men [30 %]; mean [SD] age, 47.0 [14.0] years), the 15 putative MDD subtypes were characterized by comorbidities and distinct patterns in medication use. There was substantial variation in rates of selective serotonin reuptake inhibitor (SSRI) use (from a low of 62 % to a high of 78 %) and selective norepinephrine reuptake inhibitor (SNRI) use (from 4 % to 21 %). LIMITATIONS: Electronic health records lack reliable symptom-level data, so we cannot examine the extent to which subtypes might differ in clinical presentation or symptom dimensions. CONCLUSION: These data-driven subtypes, drawing on representative clinical cohorts, merit further investigation for their utility in identifying more homogeneous patient populations for basic as well as clinical investigation.

COVID-19 mortality among Massachusetts workers and the association with telework ability, 2020.

BACKGROUND: Working outside the home put some workers at risk for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) exposure and might partly explain elevated coronavirus disease 2019 (COVID-19) mortality rates in the first months of the pandemic in certain groups of Massachusetts workers. To further investigate this premise, we examined COVID-19 mortality among Massachusetts workers, with a specific focus on telework ability based on occupation. METHODS: COVID-19-associated deaths between January 1 and December 31, 2020 among Massachusetts residents aged 18-64 years were analyzed. Deaths were categorized into occupation-based quadrants (Q) of telework ability. Age-adjusted rates were calculated by key demographics, industry, occupation, and telework quadrant using American Community Survey workforce estimates as denominators. Rate ratios (RRs) and 95% confidence intervals comparing rates for quadrants with workers unlikely able to telework (Q2, Q3, Q4) to that among those likely able to telework (Q1) were calculated. RESULTS: The overall age-adjusted COVID-19-associated mortality rate was 26.4 deaths per 100,000 workers. Workers who were male, Black non-Hispanic, Hispanic, born outside the US, and with lower than a high school education level experienced the highest rates among their respective demographic groups. The rate varied by industry, occupation and telework quadrant. RRs comparing Q2, Q3, and Q4 to Q1 were 0.99 (95% confidence interval [CI]: 0.8-1.2), 3.2 (95% CI: 2.6-3.8) and 2.5 (95% CI: 2.0-3.0), respectively. CONCLUSION: Findings suggest a positive association between working on-site and COVID-19-associated mortality. Work-related factors likely contributed to COVID-19 among Massachusetts workers and should be considered in future studies of COVID-19 and similar diseases.

Offspring cardiometabolic outcomes and postnatal growth trajectories after exposure to maternal SARS-CoV-2 infection.

OBJECTIVE: The objective of this study is to determine whether in utero exposure to SARS-CoV-2 is associated with increased risk for a cardiometabolic diagnosis by 18 months of age. METHODS: This retrospective electronic health record (EHR)-based cohort study included the live-born offspring of all individuals who delivered during the COVID-19 pandemic (April 1, 2020-December 31, 2021) at eight hospitals in Massachusetts. Offspring exposure was defined as a positive maternal SARS-CoV-2 polymerase chain reaction test during pregnancy. The primary outcome was presence of an ICD-10 code for a cardiometabolic disorder in offspring EHR by 18 months. Weight-, length-, and BMI-for-age z scores were calculated and compared at 6-month intervals from birth to 18 months. RESULTS: A total of 29,510 offspring (1599 exposed and 27,911 unexposed) were included. By 18 months, 6.7% of exposed and 4.4% of unexposed offspring had received a cardiometabolic diagnosis (crude odds ratio [OR] 1.47 [95% CI: 1.10 to 1.94], p = 0.007; adjusted OR 1.38 [1.06 to 1.77], p = 0.01). Exposed offspring had a significantly greater mean BMI-for-age z score versus unexposed offspring at 6 months (z score difference 0.19 [95% CI: 0.10 to 0.29], p < 0.001; adjusted difference 0.04 [-0.06 to 0.13], p = 0.4). CONCLUSIONS: Exposure to maternal SARS-CoV-2 infection was associated with an increased risk of receiving a cardiometabolic diagnosis by 18 months preceded by greater BMI-for-age at 6 months.

Acute exposure to pollen and airway inflammation in adolescents.

INTRODUCTION: Pollen exposure is known to exacerbate allergic asthma and allergic rhinitis symptoms, yet few studies have investigated if exposure to pollen affects lung function or airway inflammation in healthy children. METHODS: We evaluated the extent to which higher pollen exposure was associated with differences in airway inflammation and lung function among 490 early adolescent participants (mean age of 12.9 years) in Project Viva, a prebirth cohort based in Massachusetts. We obtained regional daily total pollen counts, including tree, grass, and weed pollen, from a Rotorod pollen counter. We evaluated associations of 3- and 7-day moving averages of pollen with fractional exhaled nitric oxide (FeNO) and lung function using linear regression models and evaluated the linearity of associations with penalized splines. We tested if associations of pollen with FeNO and lung function were modified by current asthma diagnosis, history of allergic rhinitis, aeroallergen sensitivity, temperature, precipitation, and air pollution. RESULTS: Three- and 7-day median pollen concentrations were 19.0 grains/m3 (IQR: 73.4) and 20.9 grains/m3 (IQR: 89.7). In main models, higher concentrations of total pollen over the preceding 3 and 7 days were associated with a 4.6% (95% CI: 0.1,9.2) and 7.4% (95% CI: 0.9,14.3) higher FeNO per IQR of pollen, respectively. We did not find associations of pollen with lung function in main models. Asthma, allergic rhinitis, precipitation, and air pollution (nitrogen dioxide and ozone) modified associations of pollen with lung function (Pinteraction < 0.1), while temperature, sex, and aeroallergen sensitization did not. CONCLUSION: Short-term exposure to pollen was associated with higher FeNO in early adolescents, even in the absence of allergic sensitization and asthma.

Association between social vulnerability and place of death during the first 2 years of COVID-19 in Massachusetts.

We investigated the relationship between individual-level social vulnerability and place of death during the infectious disease emergency of the COVID-19 pandemic in Massachusetts. Our research represents a unique contribution by matching individual-level death certificates with COVID-19 test data to analyse differences in distributions of place of death.

Drug poisoning deaths by occupation and drug type, Massachusetts 2010-2019.

OBJECTIVE: To investigate variation in drug poisoning mortality rates by drug type and occupation in Massachusetts. METHODS: Death certificates for deaths by drug poisonings occurring between 2010 and 2019 in Massachusetts were coded based on the decedent's occupation. Mortality rates and rate ratios (with all other occupations as the reference group) were calculated based on the occupation of the workers according to drug type. Poisson regression was used to determine significantly elevated mortality rates and trends in drug poisoning deaths by occupation and drug type. RESULTS: The rate of drug poisoning deaths increased from 2010 to 2016 after which they plateaued. With respect to specific substances, fentanyl- and cocaine-related deaths increased throughout the surveillance period. For drug poisoning deaths overall, workers in construction trades (3,017); food preparation and serving (1,116); transportation and material moving (1,062) occupations had the highest number of drug poisoning deaths. When adjusting for age, sex, race/ethnicity, and educational attainment, workers in 7 occupations had significantly elevated mortality rate ratios for drug poisonings overall: farming, fishing, and forestry (3.42, P < 0.001); construction trades (2.58, P < 0.001); health care support (1.61, P < 0.001); community and social service (1.60, P < 0.001); food preparation and serving related (1.54, P < 0.001); personal care and service (1.37, P < 0.001); and arts, design, entertainment, sports, and media (1.21, P = 0.010). In many cases, workers in these same occupations had elevated mortality rate ratios for poisonings from specific substances. Health care practitioners and technical occupation workers only had elevated rates for methadone-related poisonings (1.73, P = 0.010). CONCLUSIONS: These findings highlight that workers in certain occupations have an elevated risk for drug poisonings and that the patterns differ with respect to the drug type. These findings can be useful for providing services to workers in high-risk occupations and in identifying occupational factors that may be related to the risk of drug poisoning death. While previous research has begun to uncover work-related factors that may contribute to opioid use, further work is needed to identify occupational factors that may contribute to psychostimulant and benzodiazepine use.

Massachusetts companion program bolsters COVID-19 vaccine rates among seniors.

In parts of the United States, COVID-19 vaccination rates remained low until late in Fall 2021 owing to both limited vaccine access and hesitancy. With colliding epidemics of RSV, flu, and COVID-19 in the winter, the retrospective evaluation of vaccine incentive policies is needed to inform future routine immunization campaigns. The Massachusetts companion program is one example of a policy that could boost vaccine uptake among older populations. Our regression discontinuity analysis suggests that the program was associated with an increase of up to 22 percentage points in the proportion of individuals aged 75 and older who have been fully vaccinated. Going forward, similar intervention strategies could be invaluable in scenarios where household contacts pose the greatest risk of transmission or where social ties can strongly influence individual decision-making.

Medication Treatment for Youth in Substance Use Disorder Residential Treatment.

OBJECTIVE: Residential is a common treatment setting for youth with high-severity substance use disorders (SUD). This study evaluated the prevalence of psychiatric symptoms and medication for youth in residential SUD treatment. METHODS: Youth in Massachusetts state licensed and funded SUD residential programs completed questionnaires assessing demographics, primary substance of use, and psychopathology symptoms (Youth Self Report [YSR]/Adult Self Report [ASR]). De-identified medication lists were provided by the programs. Descriptive statistics were used to describe the sample. RESULTS: Among the 47 youth who participated, 51.1% were male, 72.3% white, 83% non-Hispanic, mean age 20.7 years. Opioids were the most common primary substance identified by youth (51.1%), and 75% had at least one clinically elevated subscale on the YSR/ASR. Most youth were prescribed at least one medication (89.4%) with a mean of 2.9 medications. CONCLUSION: Youth in SUD residential treatment frequently have clinically elevated psychiatric symptoms, and psychotropic medication was commonly prescribed.

Cost-effectiveness of expanded latent TB infection testing and treatment: Lynn City, Massachusetts, USA.

BACKGROUND: Between October 2016 and March 2019, Lynn Community Health Center in Massachusetts implemented a targeted latent TB infection testing and treatment (TTT) program, increasing testing from a baseline of 1,200 patients tested to an average of 3,531 patients tested, or 9% of the population per year.METHODS: We compared pre-implementation TTT, represented by the first two quarters of implementation data, to TTT, represented by 12 quarters of data. Time, diagnostic, and laboratory resources were estimated using micro-costing. Other cost and testing data were obtained from the electronic health record, pharmaceutical claims, and published reimbursement rates. A Markov cohort model estimated future health outcomes and cost-effectiveness from a societal perspective in 2020 US dollars. Monte Carlo simulation generated 95% uncertainty intervals.RESULTS: The TTT program exhibited extended dominance over baseline pre-intervention testing and had an incremental cost-effectiveness ratio (ICER) of US$52,603 (US$22,008â-"US$95,360). When compared to baseline pre-TTT testing, the TTT program averted an estimated additional 7.12 TB cases, 3.49 hospitalizations, and 0.16 deaths per lifetime cohort each year.CONCLUSIONS: TTT was more cost-effective than baseline pre-implementation testing. Lynn Community Health Centerâ-™s experience can help inform other clinics considering expanding latent TB infection testing.

Disparities in SARS-CoV-2 Infection by Race, Ethnicity, Language, and Social Vulnerability: Evidence from a Citywide Seroprevalence Study in Massachusetts, USA.

OBJECTIVES: Uncovering and addressing disparities in infectious disease outbreaks require a rapid, methodical understanding of local epidemiology. We conducted a seroprevalence study of SARS-CoV-2 infection in Holyoke, Massachusetts, a majority Hispanic city with high levels of socio-economic disadvantage to estimate seroprevalence and identify disparities in SARS-CoV-2 infection. METHODS: We invited 2000 randomly sampled households between 11/5/2020 and 12/31/2020 to complete questionnaires and provide dried blood spots for SARS-CoV-2 antibody testing. We calculated seroprevalence based on the presence of IgG antibodies using a weighted Bayesian procedure that incorporated uncertainty in antibody test sensitivity and specificity and accounted for household clustering. RESULTS: Two hundred eighty households including 472 individuals were enrolled. Three hundred twenty-eight individuals underwent antibody testing. Citywide seroprevalence of SARS-CoV-2 IgG was 13.1% (95% CI 6.9-22.3) compared to 9.8% of the population infected based on publicly reported cases. Seroprevalence was 16.1% (95% CI 6.2-31.8) among Hispanic individuals compared to 9.4% (95% CI 4.6-16.4) among non-Hispanic white individuals. Seroprevalence was higher among Spanish-speaking households (21.9%; 95% CI 8.3-43.9) compared to English-speaking households (10.2%; 95% CI 5.2-18.0) and among individuals in high social vulnerability index (SVI) areas based on the CDC SVI (14.4%; 95% CI 7.1-25.5) compared to low SVI areas (8.2%; 95% CI 3.1-16.9). CONCLUSIONS: The SARS-CoV-2 IgG seroprevalence in a city with high levels of social vulnerability was 13.1% during the pre-vaccination period of the COVID-19 pandemic. Hispanic individuals and individuals in communities characterized by high SVI were at the highest risk of infection. Public health interventions should be designed to ensure that individuals in high social vulnerability communities have access to the tools to combat COVID-19.

Need for Improved Timeliness of Reporting on Drug Overdose Fatalities: The HEALing Communities Study.

OBJECTIVE: Timely data on drug overdose deaths can help identify community needs, evaluate the effectiveness of interventions, and allocate resources. We identified variations in death investigation and reporting systems within and between states that affect the timeliness and accuracy of death certificate information. METHODS: The HEALing Communities Study (HCS) is a community-engaged, data-driven approach to combating the opioid crisis in 67 communities in 4 states: Kentucky, Massachusetts, New York, and Ohio. HCS conducted a survey of coroners and medical examiners to understand variability in drug overdose death data. We compared survey results in Massachusetts, New York, and Ohio with national data to investigate the completeness of provisional death counts by type of death investigation system. RESULTS: Communities in each HCS state had different ways of collecting and reporting mortality data. Completion of death certificates for drug overdoses ranged from <2 weeks in 23% (7 of 31) of those surveyed to more than 3 months in 10% (3 of 31) of those surveyed. Variabilities in the timeliness of reporting drug overdose deaths were not associated with type of coroner or medical examiner office in each state, urban versus rural setting, or specificity of drug information on the death certificate. CONCLUSION: Having specific drug information on the death certificate may increase death certificate quality, comparability, and accuracy. We recommend the following: (1) all coroners and medical examiners should be trained on conducting death investigations, interpreting toxicology reports, and completing death certificates; (2) 1 office in each state should oversee all coroners and medical examiners to increase data consistency; and (3) communities should identify and address barriers to timely death certification.

Rising Inpatient Utilization and Costs of Cannabis Hyperemesis Syndrome Hospitalizations in Massachusetts After Cannabis Legalization.

GOALS: We described the demographics, inpatient utilization, and cost of services among patients hospitalized for putative cannabinoid hyperemesis syndrome (CHS) predating and postdating cannabis legalization in Massachusetts. BACKGROUND: As the recreational use of cannabis has been widely legalized nationally, the resulting shifts in clinical presentation, health care utilization, and estimated costs of CHS hospitalizations remain unclear in the postlegalization era. STUDY: We performed a retrospective cohort study among patients admitted to a large urban hospital between 2012 and 2021, before and after the date of cannabis legalization in Massachusetts (Dec 15, 2016). We examined the demographic and clinical characteristics of patients admitted for putative CHS, the utilization of hospital services, and estimated inpatient costs pre and postlegalization. RESULTS: We identified a significant increase in putative CHS hospitalizations pre and post-cannabis legalization in Massachusetts (0.1% vs 0.02% of total admissions per time period, P < 0.05). Across 72 CHS hospitalizations, patient demographics were similar pre and postlegalization. Hospital resource utilization increased postlegalization, with increased length of stay (3 d vs 1 d, P < 0.005), and need for antiemetics ( P < 0.05). Multivariate linear regression confirmed that postlegalization admissions were independently associated with increased length of stay ( Β = 5.35, P < 0.05). The mean cost of hospitalization was significantly higher postlegalization ($18,714 vs $7460, P < 0.0005), even after adjusting for medical inflation ($18,714 vs $8520, P < 0.001) with intravenous fluid administration and endoscopy costs increased ( P < 0.05). On multivariate linear regression, hospitalization for putative CHS during postlegalization predicted increased costs ( Β = 10,131.25, P < 0.05). CONCLUSIONS: In the postlegalization era of cannabis in Massachusetts, we found increased putative CHS hospitalizations, with a concomitant increased length of hospital stay and total cost per hospitalization. As cannabis use increases, the recognition and costs of its deleterious effects are necessary to incorporate into future clinical practice strategies and health policy.

Evaluating COVID-19 Risk to Essential Workers by Occupational Group: A Case Study in Massachusetts.

Occupational exposure to SARS-CoV-2 varies by profession, but "essential workers" are often considered in aggregate in COVID-19 models. This aggregation complicates efforts to understand risks to specific types of workers or industries and target interventions, specifically towards non-healthcare workers. We used census tract-resolution American Community Survey data to develop novel essential worker categories among the occupations designated as COVID-19 Essential Services in Massachusetts. Census tract-resolution COVID-19 cases and deaths were provided by the Massachusetts Department of Public Health. We evaluated the association between essential worker categories and cases and deaths over two phases of the pandemic from March 2020 to February 2021 using adjusted mixed-effects negative binomial regression, controlling for other sociodemographic risk factors. We observed elevated COVID-19 case incidence in census tracts in the highest tertile of workers in construction/transportation/buildings maintenance (Phase 1: IRR 1.32 [95% CI 1.22, 1.42]; Phase 2: IRR: 1.19 [1.13, 1.25]), production (Phase 1: IRR: 1.23 [1.15, 1.33]; Phase 2: 1.18 [1.12, 1.24]), and public-facing sales and services occupations (Phase 1: IRR: 1.14 [1.07, 1.21]; Phase 2: IRR: 1.10 [1.06, 1.15]). We found reduced case incidence associated with greater percentage of essential workers able to work from home (Phase 1: IRR: 0.85 [0.78, 0.94]; Phase 2: IRR: 0.83 [0.77, 0.88]). Similar trends exist in the associations between essential worker categories and deaths, though attenuated. Estimating industry-specific risk for essential workers is important in targeting interventions for COVID-19 and other diseases and our categories provide a reproducible and straightforward way to support such efforts.

Experiences of Midwives Attending Home Births in Massachusetts During the COVID-19 Pandemic.

INTRODUCTION: Public interest in home birth in the United States increased during the COVID-19 pandemic. Midwives attend the vast majority of home births and are experts in providing home birth care. However, limited data are available about the experiences of midwives attending home births during the pandemic in the United States. METHODS: We developed a cross-sectional survey comprising 34 questions, which included 5 open-ended questions. The survey was distributed online in June 2021 to midwives attending home birth in Massachusetts. We calculated descriptive statistics for the quantitative survey responses and identified qualitative free-text responses illustrating the results. RESULTS: Eighteen midwives and 2 midwife apprentices responded to the survey, approximately 50% of Massachusetts' total number of midwives known to attend homebirths. The majority of the 20 respondents reported an increase in public interest in home birth (n = 17) and higher caseloads (n = 14) since the start of the pandemic. Respondents reported an increase in the number of clients transferring to their practices at a later gestational age (n = 13) and who identified as people of color (n = 8). They described both better and worse transfer of care to hospital experiences. Work-life balance and unpredictable income were the top 2 reported obstacles to home birth practice. DISCUSSION: The results of our study indicate that midwives providing home birth care in Massachusetts witnessed a surge in demand for their services during the pandemic. Implementing policies and practices that provide support for certified professional midwives could strengthen the home birth workforce, enhance access to home birth options, and optimize transfers to hospital settings when necessary.

The Impact of Modest Price Increases and Single Cigar Restrictions on Youth Cigar Use.

INTRODUCTION: In 2011, Boston restricted cigar sales to packages of at least 4 cigars unless sold at a minimum of $2.50 per cigar. Nearly 200 localities in Massachusetts have since adopted policies establishing minimum pack quantities of 2-5 or minimum prices of $2.50-5.00 per cigar. The objective of this study was to examine the impact of these policies on youth cigar use. METHODS: Biennial data from 1999 to 2019 were obtained from the Massachusetts Youth Risk Behavior Survey and analyzed in 2023. Final analytic samples included 15,674 youth for the Boston analyses and 35,674 youth for the statewide analyses. For Boston, change in use was examined from prepolicy (1999-2011) to postpolicy (2012-2019). For statewide analyses, the percentage of the state covered by a policy was estimated. Multivariable logistic regressions examined the impact of cigar policies on cigar and cigarette use. Analyses were adjusted for sociodemographic characteristics and stratified by sex and race. RESULTS: Policy enactment was associated with significant decreases in the odds of cigar use in Boston (AOR: 0.28; 95% CI: 0.17-0.47) and statewide (AOR: 0.98; 95% CI: 0.98-0.99), with similar findings for cigarette use. Results were consistent among males and females statewide but only among males in Boston. By race statewide and in Boston, odds of cigar use decreased significantly among White, Black, and Hispanic youth, but not youth of other races. CONCLUSIONS: These findings indicate small increases in the quantity and price of cigar packs could discourage young people from purchasing and using cigars, providing significant benefits for local tobacco control efforts.