A State Health Department and Health Information Exchange Partnership: An Effective Collaboration for a Data-Driven Response for COVID-19 Contact Tracing in Maryland.

BACKGROUND: Accurate, complete, timely data were essential to effective contact tracing for COVID-19. Maryland Department of Health partnered with Maryland's designated health information exchange, Chesapeake Regional Information System for Our Patients (CRISP), to establish data enhancement processes that provided the foundation for Maryland's successful contact tracing program. METHODS: Hourly, electronic positive COVID-19 test results were routed through CRISP to the contact tracing data platform. The CRISP matched reports against its master patient index to enhance the record with demographic, locating, fatality, vaccination, and hospitalization data. Records were deduplicated and flagged if associated with a congregate setting, select state universities, or recent international travel. χ 2 Tests were used to assess if CRISP-added phone numbers resulted in better contact tracing outcomes. RESULTS: During June 15, 2020, to September 1, 2021, CRISP pushed 531,094 records to the state's contact tracing data platform within an hour of receipt; of those eligible for investigation, 99% had a phone number. The CRISP matched 521,731 (98%) records to their master patient index, allowing for deduplication and enrichment. The CRISP flagged 15,615 cases in congregate settings and 3304 cases as university students; these records were immediately routed for outbreak investigation. Records with an added phone number were significantly more likely to be successfully reached compared with cases with no added phone number ( P = 0.01). CONCLUSIONS: The CRISP enhanced COVID-19 electronic laboratory reports with a near-instant impact on public health actions. The partnership and data processing workflows can serve as a blueprint for data modernization in public health agencies across the United States.

Association of E484K Spike Protein Mutation With Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Infection in Vaccinated Persons: Maryland, January-May 2021.

Among 9048 people infected with SARS-CoV-2 between January and May 2021 in Maryland, in regression-adjusted analysis, SARS-CoV-2 viruses carrying the spike protein mutation E484K were disproportionately prevalent among persons infected after full vaccination against COVID-19 compared with infected persons who were not fully vaccinated (aOR, 1.96; 95% CI: 1.36-2.83).

Economic Burden of Reported Lyme Disease in High-Incidence Areas, United States, 2014-2016.

Approximately 476,000 cases of Lyme disease are diagnosed in the United States annually, yet comprehensive economic evaluations are lacking. In a prospective study among reported cases in Lyme disease-endemic states, we estimated the total patient cost and total societal cost of the disease. In addition, we evaluated disease and demographic factors associated with total societal cost. Participants had a mean patient cost of ≈$1,200 (median $240) and a mean societal cost of ≈$2,000 (median $700). Patients with confirmed disseminated disease or probable disease had approximately double the societal cost of those with confirmed localized disease. The annual, aggregate cost of diagnosed Lyme disease could be $345-968 million (2016 US dollars) to US society. Our findings emphasize the importance of effective prevention and early diagnosis to reduce illness and associated costs. These results can be used in cost-effectiveness analyses of current and future prevention methods, such as a vaccine.

Willingness to Pay for Select Tick-Borne Disease Prevention Measures in Endemic Areas.

Tick-borne diseases (TBDs) are increasing despite prevention recommendations. We explored whether cost is a barrier to prevention use in Connecticut and Maryland, using a cross-sectional survey. Respondents were queried regarding their willingness to pay for chemical, natural, and rodent-targeted yard pesticide treatments and permethrin-treated clothing. We evaluated associations between demographics, TBD knowledge and attitudes, and willingness to pay for prevention methods. Most respondents would pay for yard treatments (85%); 95% preferring natural pesticide, and 82% would pay for permethrin-treated clothing. Most did not want to pay more than $99 for any of the yard treatments. Having a household income of $100 000 was associated with willingness to pay $100 or more for chemical, natural, or rodent-targeted treatments and $25 or more for permethrin self-treated and pretreated clothing. Yard treatments, especially natural pesticides, were acceptable for TBD prevention; however, current pricing may be cost-prohibitive. Permethrin-treated clothing may be an affordable and acceptable prevention method.

Linked Clusters of SARS-CoV-2 Variant B.1.351 - Maryland, January-February 2021.

In late January 2021, a clinical laboratory notified the Maryland Department of Health (MDH) that the SARS-CoV-2 variant of concern B.1.351 had been identified in a specimen collected from a Maryland resident with COVID-19 (1). The SARS-CoV-2 B.1.351 lineage was first identified in South Africa (2) and might be neutralized less effectively by antibodies produced after vaccination or natural infection with other strains (3-6). To limit SARS-CoV-2 chains of transmission associated with this index patient, MDH used contact tracing to identify the source of infection and any linked infections among other persons. The investigation identified two linked clusters of SARS-CoV-2 infection that included 17 patients. Three additional specimens from these clusters were sequenced; all three had the B.1.351 variant and all sequences were closely related to the sequence from the index patient's specimen. Among the 17 patients identified, none reported recent international travel or contact with international travelers. Two patients, including the index patient, had received the first of a 2-dose COVID-19 vaccination series in the 2 weeks before their likely exposure; one additional patient had a confirmed SARS-CoV-2 infection 5 months before exposure. Two patients were hospitalized with COVID-19, and one died. These first identified linked clusters of B.1.351 infections in the United States with no apparent link to international travel highlight the importance of expanding the scope and volume of genetic surveillance programs to identify variants, completing contact investigations for SARS-CoV-2 infections, and using universal prevention strategies, including vaccination, masking, and physical distancing, to control the spread of variants of concern.

Completeness of HIV nucleotide sequence ascertainment and its potential impact on understanding HIV transmission - Maryland, 2011-2013.

HIV nucleotide sequences generated through routine drug resistance testing (DRT) and reported to Maryland's Molecular HIV Surveillance system are most effective for elucidating transmission patterns and identifying outbreaks if DRT is ordered promptly and sequences are reported completely. Among reported cases of HIV infection newly diagnosed during 2011-2013 in Maryland residents aged ≥13 years, we assessed sequence ascertainment completeness. To better understand which populations were most likely to have a sequence, we examined associations between sequence ascertainment and clinical and demographic characteristics. During 2011-2013, 4423 new HIV infection diagnoses were reported; sequences were ascertained for 1282 (29.0%). Among 3267 cases with complete data, odds for having a sequence ascertained were highest for cases in persons living inside Maryland's Central Region with initial CD4 counts ≤500 cells/mm3 (adjusted odds ratio [aOR] 2.4, 95% confidence interval [CI] 1.9-3.1). Sequence ascertainment did not vary significantly by patient age, sex, race/ethnicity or HIV transmission category. Educational interventions, policy changes and improved processes to increase timely DRT and subsequent sequence reporting with a focus on testing at entry to care, particularly for those with higher CD4 counts and those living outside the Central Region, might improve ascertainment completeness.

Influenza A(H3N2) Variant Virus Outbreak at Three Fairs - Maryland, 2017.

On September 17, 2017, the Maryland Department of Agriculture (MDA) was notified by fair and 4-H officials of ill swine at agricultural fair A, held September 14-17. That day, investigation of the 107 swine at fair A revealed five swine with fever and signs of upper respiratory tract illness. All five respiratory specimens collected from these swine tested positive for influenza A virus at the MDA Animal Health Laboratory, and influenza A(H3N2) virus was confirmed in all specimens by the U.S. Department of Agriculture National Veterinary Services Laboratory (NVSL). On September 18, MDA was notified by fair and 4-H officials that swine exhibitors were also ill. MDA alerted the Maryland Department of Health (MDH). A joint investigation with MDH and the local health department was started and later broadened to Maryland agricultural fairs B (September 13-17) and C (September 15-23). In total, 76 persons underwent testing for variant influenza, and influenza A(H3N2) variant (A(H3N2)v) virus infection was identified in 40 patients with exposure to swine at these fairs (Figure), including 30 (75%) who had more than one characteristic putting them at high risk for serious influenza complications; 24 (60%) of these were children aged <5 years. Twenty-six (65%) patients reported direct contact with swine (i.e., touching swine or swine enclosure), but 14 (35%) reported only indirect contact (e.g., walking through a swine barn). Two children required hospitalization; all patients recovered. This outbreak highlights the risk, particularly among children, for contracting variant influenza virus at agricultural fairs after direct or indirect swine contact. Publicizing CDC's recommendation that persons at high risk for serious influenza complications avoid pigs and swine barns might help prevent future variant influenza outbreaks among vulnerable groups (1).

Effectiveness of Residential Acaricides to Prevent Lyme and Other Tick-borne Diseases in Humans.

BACKGROUND: In the northeastern United States, tick-borne diseases are a major public health concern. In controlled studies, a single springtime application of acaricide has been shown to kill 68%-100% of ticks. Although public health authorities recommend use of acaricides to control tick populations in yards, the effectiveness of these pesticides to prevent tick bites or human tick-borne diseases is unknown. METHODS: We conducted a 2-year, randomized, double-blinded, placebo-controlled trial among 2727 households in 3 northeastern states. Households received a single springtime barrier application of bifenthrin or water according to recommended practices. Tick drags were conducted 3-4 weeks after treatment on 10% of properties. Information on human-tick encounters and tick-borne diseases was collected through monthly surveys; reports of illness were validated by medical record review. RESULTS: Although the abundance of questing ticks was significantly lower (63%) on acaricide-treated properties, there was no difference between treatment groups in human-tick encounters, self-reported tick-borne diseases, or medical-record-validated tick-borne diseases. CONCLUSIONS: Used as recommended, acaricide barrier sprays do not significantly reduce the household risk of tick exposure or incidence of tick-borne disease. Measures for preventing tick-borne diseases should be evaluated against human outcomes to confirm effectiveness.

Multistate US Outbreak of Rapidly Growing Mycobacterial Infections Associated with Medical Tourism to the Dominican Republic, 2013-2014(1).

During 2013, the Maryland Department of Health and Mental Hygiene in Baltimore, MD, USA, received report of 2 Maryland residents whose surgical sites were infected with rapidly growing mycobacteria after cosmetic procedures at a clinic (clinic A) in the Dominican Republic. A multistate investigation was initiated; a probable case was defined as a surgical site infection unresponsive to therapy in a patient who had undergone cosmetic surgery in the Dominican Republic. We identified 21 case-patients in 6 states who had surgery in 1 of 5 Dominican Republic clinics; 13 (62%) had surgery at clinic A. Isolates from 12 (92%) of those patients were culture-positive for Mycobacterium abscessus complex. Of 9 clinic A case-patients with available data, all required therapeutic surgical intervention, 8 (92%) were hospitalized, and 7 (78%) required ≥3 months of antibacterial drug therapy. Healthcare providers should consider infection with rapidly growing mycobacteria in patients who have surgical site infections unresponsive to standard treatment.

Likely Sexual Transmission of Zika Virus from a Man with No Symptoms of Infection - Maryland, 2016.

In June 2016, the Maryland Department of Health and Mental Hygiene (DHMH) was notified of a nonpregnant woman who sought treatment for a subjective fever and an itchy rash, which was described as maculopapular by her provider. Laboratory testing at the Maryland DHMH Laboratories Administration confirmed Zika virus infection. Case investigation revealed that the woman had not traveled to a region with ongoing transmission of Zika virus, but did have sexual contact with a male partner who had recently traveled to the Dominican Republic. The male partner reported exposure to mosquitoes while traveling, but no symptoms consistent with Zika virus infection either before or after returning to the United States. The woman reported no other sex partners during the 14 days before onset of her symptoms and no receipt of blood products or organ transplants.

Lyme disease testing by large commercial laboratories in the United States.

BACKGROUND: Laboratory testing is helpful when evaluating patients with suspected Lyme disease (LD). A 2-tiered antibody testing approach is recommended, but single-tier and nonvalidated tests are also used. We conducted a survey of large commercial laboratories in the United States to assess laboratory practices. We used these data to estimate the cost of testing and number of infections among patients from whom specimens were submitted. METHODS: Large commercial laboratories were asked to report the type and volume of testing conducted nationwide in 2008, as well as the percentage of positive tests for 4 LD-endemic states. The total direct cost of testing was calculated for each test type. These data and test-specific performance parameters available in published literature were used to estimate the number of infections among source patients. RESULTS: Seven participating laboratories performed approximately 3.4 million LD tests on approximately 2.4 million specimens nationwide at an estimated cost of $492 million. Two-tiered testing accounted for at least 62% of assays performed; alternative testing accounted for <3% of assays. The estimated frequency of infection among patients from whom specimens were submitted ranged from 10% to 18.5%. Applied to the total numbers of specimens, this yielded an estimated 240 000 to 444 000 infected source patients in 2008. DISCUSSION: LD testing is common and costly, with most testing in accordance with diagnostic recommendations. These results highlight the importance of considering clinical and exposure history when interpreting laboratory results for diagnostic and surveillance purposes.

Notes from the field: rapidly growing nontuberculous Mycobacterium wound infections among medical tourists undergoing cosmetic surgeries in the Dominican Republic--multiple states, March 2013-February 2014.

In August 2013, the Maryland Department of Health and Mental Hygiene (MDHMH) was notified of two persons with rapidly growing nontuberculous mycobacterial (RG-NTM) surgical-site infections. Both patients had undergone surgical procedures as medical tourists at the same private surgical clinic (clinic A) in the Dominican Republic the previous month. Within 7 days of returning to the United States, both sought care for symptoms that included surgical wound abscesses, clear fluid drainage, pain, and fever. Initial antibiotic therapy was ineffective. Material collected from both patients' wounds grew Mycobacterium abscessus exhibiting a high degree of antibiotic resistance characteristic of this organism.

Raccoon rabies virus variant transmission through solid organ transplantation.

IMPORTANCE: The rabies virus causes a fatal encephalitis and can be transmitted through tissue or organ transplantation. In February 2013, a kidney recipient with no reported exposures to potentially rabid animals died from rabies 18 months after transplantation. OBJECTIVES: To investigate whether organ transplantation was the source of rabies virus exposure in the kidney recipient, and to evaluate for and prevent rabies in other transplant recipients from the same donor. DESIGN: Organ donor and all transplant recipient medical records were reviewed. Laboratory tests to detect rabies virus-specific binding antibodies, rabies virus neutralizing antibodies, and rabies virus antigens were conducted on available specimens, including serum, cerebrospinal fluid, and tissues from the donor and the recipients. Viral ribonucleic acid was extracted from tissues and amplified for nucleoprotein gene sequencing for phylogenetic comparisons. MAIN OUTCOMES AND MEASURES: Determination of whether the donor died from undiagnosed rabies and whether other organ recipients developed rabies. RESULTS: In retrospect, the donor's clinical presentation (which began with vomiting and upper extremity paresthesias and progressed to fever, seizures, dysphagia, autonomic dysfunction, and brain death) was consistent with rabies. Rabies virus antigen was detected in archived autopsy brain tissue collected from the donor. The rabies viruses infecting the donor and the deceased kidney recipient were consistent with the raccoon rabies virus variant and were more than 99.9% identical across the entire N gene (1349/1350 nucleotides), thus confirming organ transplantation as the route of transmission. The 3 other organ recipients remained asymptomatic, with rabies virus neutralizing antibodies detected in their serum after completion of postexposure prophylaxis (range, 0.3-40.8 IU/mL). CONCLUSIONS AND RELEVANCE: Unlike the 2 previous clusters of rabies virus transmission through solid organ transplantation, there was a long incubation period in the recipient who developed rabies, and survival of 3 other recipients without pretransplant rabies vaccination. Rabies should be considered in patients with acute progressive encephalitis of unexplained etiology, especially for potential organ donors. A standard evaluation of potential donors who meet screening criteria for infectious encephalitis should be considered, and risks and benefits for recipients of organs from these donors should be evaluated.

Human-tick encounters as a measure of tickborne disease risk in lyme disease endemic areas.

Entomological measures have long served as proxies for human risk of Lyme disease (LD) and other tickborne diseases (TBDs) in endemic areas of the United States, despite conflicting results regarding the correlation between these measures and human disease outcomes. Using data from a previous TBD intervention study in Connecticut, Maryland and New York, we evaluated whether human-tick encounters can serve as an accurate proxy for risk of TBDs in areas where LD and other Ixodes scapularis-transmitted infections are common. Among 2,590 households consisting of 4,210 individuals, experiencing a tick encounter was associated with an increased risk of both self-reported (RR = 3.17, 95% CI: 2.05, 4.91) and verified TBD (RR = 2.60, 95% CI: 1.39, 4.84) at the household level. Household characteristics associated with experiencing any tick encounter were residence in Connecticut (aOR = 1.86, 95% CI: 1.38, 2.51) or New York (aOR = 1.66, 95% CI: 1.25, 2.22), head of household having a graduate level education (aOR = 1.46, 95% CI: 1.04, 2.08), owning a pet (aOR = 1.80, 95% CI: 1.46, 2.23) and a property size of 2 acres or larger (aOR = 2.30, 95% CI: 1.42, 3.70). Results for individual characteristics were similar to those for households. Future prevention studies in LD endemic areas should consider using human-tick encounters as a robust proxy for TBD risk.

Love the ones you're with: Characteristics and behaviour of Maryland pets and their owners in relation to tick encounters.

We conducted a cross-sectional study to evaluate associations between pet characteristics and behaviours and risk of tick encounters among pets and pet owners. We defined a tick encounter as ticks found crawling on or attached to a pet or pet owner. Information about pet characteristics, interactions between owners and pets, and tick encounters were captured through an online survey. Associations were evaluated using univariate and multivariable analyses. In univariate analysis, walking dogs only on pavement reduced risk of tick encounter among owners (prevalence ratio (PR) = 0.51, 95% confidence interval (CI): 0.30, 0.84). Having a dog or cat that hunted small animals increased risk of tick encounter among owners (PR = 1.66, 95% CI: 1.30, 2.13; PR = 1.57, 95% CI: 1.05, 2.34, respectively). No direct interactions between owners and pets (e.g., pets sleeping on owners' beds) were associated with increased risk of tick encounters among owners. In multivariable analysis among dog owners, having a pet with a tick encounter within the last six months was associated with increased risk of owner tick encounter (adjusted odds ratio (aOR) = 4.17, 95% CI: 2.94, 5.92); in addition, having a dog that hunts small animals was associated with increased risk of owner tick encounter (aOR = 1.97, 95% CI: 1.25, 3.11). These results suggest that the location of pet-owner interactions may be more important than the type of interactions. Pet owners should avoid tick habitat with pets; when that is not possible, proper use of tick preventive products for pets, wearing repellents by owners and conducting tick checks for both pets and owners is critical for prevention of tick encounters and tick-borne disease.

Domestically acquired seoul virus causing hemorrhagic fever with renal syndrome-Maryland, 2008.

Hantaviruses are rodent-borne viruses capable of causing human disease. The Seoul virus is a hantavirus that causes hemorrhagic fever with renal syndrome in East Asia. To our knowledge, we report the first domestically acquired case of hemorrhagic fever with renal syndrome caused by the Seoul virus, confirmed by serology testing, reverse-transcriptase polymerase chain reaction, and nucleotide sequence analysis. The patient presented with myalgias and fever, and developed acute renal failure.

Impacts of misclassification on Lyme disease surveillance.

In Maryland, Lyme disease (LD) is the most widely reported tickborne disease. All laboratories and healthcare providers are required to report LD cases to the local health department. Given the large volume of LD reports, the nuances of diagnosing and reporting LD, and the effort required for investigations by local health department staff, surveillance for LD is burdensome and subject to underreporting. To determine the degree to which misclassification occurs in Maryland, we reviewed medical records for a sample of LD reports from 2009. We characterized what proportion of suspected and "not a case" reports could be reclassified as confirmed or probable once additional information was obtained from medical record review, explored the reasons for misclassification, and determined multipliers for a more accurate number of LD cases. We reviewed medical records for reports originally classified as suspected (n = 44) and "not a case" (n = 92). Of these 136 records, 31 (23%) suspected cases and "not a case" reports were reclassified. We calculated multipliers and applied them to the case counts from 2009, and estimate an additional 269 confirmed and probable cases, a 13.3% increase. Reasons for misclassification fell into three general categories: lack of clinical or diagnostic information from the provider; surveillance process errors; and incomplete information provided on laboratory reports. These multipliers can be used to calculate a better approximation of the true number of LD cases in Maryland, but these multipliers only account for underreporting due to misclassification, and do not account for cases that are not reported at all (e.g., LD diagnoses based on erythema migrans alone that are not reported) or for cases that are not investigated. Knowing that misclassification of cases occurs during the existing LD surveillance process underscores the complexities of LD surveillance, which further reinforces the need to find alternative approaches to LD surveillance.

Low-Cost Animal Rabies Vaccination Clinics in Maryland Facilitate Access to Rabies Vaccination for Pets.

Rabies is a zoonotic disease that poses a serious public health risk. To facilitate pet owner compliance with statewide mandatory animal rabies immunization requirements, Maryland statute requires Maryland's local health departments to conduct low-cost animal rabies vaccination clinics at least twice per year. We describe the outputs of these public low-cost clinics by documenting the number of animals vaccinated, number of clinics held annually, and cost per vaccine to pet owners for the years 2015-2016. These data are compared with clinic data from 2006 to 2008, providing insight into changes that have occurred in the decade interval between the surveys and consequently informing future clinic policies and procedures. The Maryland low-cost rabies clinic model allows for the vaccination of roughly 20,000 pet animals per year, representing ∼1% of the Maryland pet population, and can be adopted by other states to allow for more comprehensive rabies vaccination coverage in other regions of the country.

Knowledge, attitudes, and behaviors regarding tick-borne disease prevention in endemic areas.

As part of a TickNET collaboration we evaluated the knowledge, attitudes, and behaviors related to tick-borne disease (TBD) prevention among persons living in endemic areas of Connecticut (CT) and Maryland (MD). Up-to-date information on the use of various prevention methods, as well as attitudes toward available and potential prevention options, is critical for effective promotion of recommended behaviors. During 2016-2017, printed invitations were mailed via the post office to 27,029 households requesting participation in an online survey regarding knowledge of TBD, risk perceptions, and prevention behaviors. Prevention behaviors included tick checks, showering/bathing, insect repellents, pet tick control, and chemical or natural pesticide use on residential properties. Associations of sociodemographic characteristics and knowledge and attitude variables with prevention behaviors were assessed in unadjusted analyses and multivariable models to calculate adjusted odds ratios (aOR). Participants were also asked if they would be willing to get a Lyme disease (LD) vaccine, if one becomes available. Overall, 1883 (7%) persons completed the survey. Participants reported using preventive behaviors most of the time or always as follows: pet tick control (83%), tick checks (58%), showering/bathing (42%), insect repellent (31%), and chemical (23%) or natural (15%) pesticides on property. Self-rated knowledge of LD, perceived prevalence of LD, perceived severity of LD, and perceived likelihood of contracting LD or another TBD were significantly (p < 0.05) associated with performing a tick check [aOR 2.5, aOR 1.71, aOR 1.36, aOR 1.83, respectively]. Female gender and perceived prevalence of LD were significantly associated with applying insect repellent [aOR 1.56, aOR 1.64, respectively]. Perceived prevalence of LD was significantly associated with showering or bathing, insect repellents, and pet tick control [aOR 1.42, aOR 1.64, aOR 1.92, respectively]. Income > $100,000 was significantly associated with applying a chemical or natural pesticide to one's property [aOR 1.29, aOR 1.40, respectively]. A majority of respondents (84%) reported that they were very likely or somewhat likely to get a LD vaccine if one were available. Few behaviors (tick checks and pet tick control) were reported to be practiced by more than half of the respondents living in LD endemic areas. Perceived prevalence of LD was the only factor associated with performing most of the prevention behaviors (tick checks, showering/bathing, use of insect repellents, and pet tick control). Use of chemical or natural pesticides appears to be driven by income. Greater efforts are needed to encourage use of prevention behaviors in endemic areas, and this may be facilitated by increasing awareness of local prevalence.