Interlaboratory agreement of coccidioidomycosis enzyme immunoassay from two different manufacturers.

Coccidioidomycosis, a fungal infection endemic to the Southwestern United States, is challenging to diagnose. The coccidioidomycosis enzyme immunoassay (EIA) test is the least expensive and simplest to perform to detect coccidioidomycosis antibodies in the serum. Concerns regarding falsely positive immunoglobulin (Ig) M EIA test results have led to questions about the agreement of commercially available EIA test kits among laboratories. We sought to evaluate the laboratory agreement of the EIA test at three laboratories using both IMMY and Meridian EIA test kits. Sensitivity and specificity of EIA IgM and IgG were calculated as secondary outcomes. The percent agreement of the EIA IgM and IgG test results among all three laboratories was 90% and 89% for IMMY test kits, respectively, and 67% and 80.5% for Meridian test kits, respectively. Agreement between IgM and IgG combined test results was 85.5% and 70.5%, for IMMY and Meridian, respectively. Combined IgM and IgG assays demonstrated a sensitivity of 68% (62.7%-76%) and a specificity of 99.3% (98%-100%) [IMMY] and a sensitivity of 72.4% (57.3%-87.3%) and a specificity of 91.3% (74%-100%) [Meridian]. In summary, results from the IMMY EIA test kit agreed more often across laboratories than Meridian EIA results, especially for the IgM assay. Isolated positive IgM EIA results using the Meridian test kit should be interpreted with caution and consideration of clinical information and test methodology. Further study of the sensitivity and specificity of coccidioidomycosis EIA test kits is warranted.

Geolocalization of Influenza Outbreak Within an Acute Care Population: A Layered-Surveillance Approach.

STUDY OBJECTIVE: We seek to use a novel layered-surveillance approach to localize influenza clusters within an acute care population. The first layer of this system is a syndromic surveillance screen to guide rapid polymerase chain reaction testing. The second layer is geolocalization and cluster analysis of these patients. We posit that any identified clusters could represent at-risk populations who could serve as high-yield targets for preventive medical interventions. METHODS: This was a prospective observational surveillance study. Patients were screened with a previously derived clinical decision guideline that has a 90% sensitivity and 30% specificity for influenza. Patients received points for the following signs and symptoms within the past 7 days: cough (2 points), headache (1 point), subjective fever (1 point), and documented fever at triage (temperature >38°C [100.4°F]) (1 point). Patients scoring 3 points or higher were indicated for influenza testing. Patients were tested with Xpert Flu (Cepheid, Sunnyvale, CA), a rapid polymerase chain reaction test. Positive results were mapped with ArcGIS (ESRI, Redlands, CA) and analyzed with kernel density estimation to create heat maps. RESULTS: There were 1,360 patients tested with Xpert Flu with retrievable addresses within the greater Phoenix metro area. One hundred sixty-seven (12%) of them tested positive for influenza A and 23 (2%) tested positive for influenza B. The influenza A virus exhibited a clear cluster pattern within this patient population. The densest cluster was located in an approximately 1-square-mile region southeast of our hospital. CONCLUSION: Our layered-surveillance approach was effective in localizing a cluster of influenza A outbreak. This region may house a high-yield target population for public health intervention. Further collaborative efforts will be made between our hospital and the Maricopa County Department of Public Health to perform a series of community vaccination events before the next influenza season. We hope these efforts will ultimately serve to reduce the burden of this disease on our patient population, and that this system will serve as a framework for future investigations locating at-risk populations.

Clinical Data Systems to Support Public Health Practice: A National Survey of Software and Storage Systems Among Local Health Departments.

CONTEXT: Numerous software and data storage systems are employed by local health departments (LHDs) to manage clinical and nonclinical data needs. Leveraging electronic systems may yield improvements in public health practice. However, information is lacking regarding current usage patterns among LHDs. OBJECTIVE: To analyze clinical and nonclinical data storage and software types by LHDs. DESIGN: Data came from the 2015 Informatics Capacity and Needs Assessment Survey, conducted by Georgia Southern University in collaboration with the National Association of County and City Health Officials. PARTICIPANTS: A total of 324 LHDs from all 50 states completed the survey (response rate: 50%). MAIN OUTCOME MEASURES: Outcome measures included LHD's primary clinical service data system, nonclinical data system(s) used, and plans to adopt electronic clinical data system (if not already in use). Predictors of interest included jurisdiction size and governance type, and other informatics capacities within the LHD. Bivariate analyses were performed using χ and t tests. RESULTS: Up to 38.4% of LHDs reported using an electronic health record (EHR). Usage was common especially among LHDs that provide primary care and/or dental services. LHDs serving smaller populations and those with state-level governance were both less likely to use an EHR. Paper records were a common data storage approach for both clinical data (28.9%) and nonclinical data (59.4%). Among LHDs without an EHR, 84.7% reported implementation plans. CONCLUSIONS: Our findings suggest that LHDs are increasingly using EHRs as a clinical data storage solution and that more LHDs are likely to adopt EHRs in the foreseeable future. Yet use of paper records remains common. Correlates of electronic system usage emerged across a range of factors. Program- or system-specific needs may be barriers or facilitators to EHR adoption. Policy makers can tailor resources to address barriers specific to LHD size, governance, service portfolio, existing informatics capabilities, and other pertinent characteristics.

Association Between Asthma Hospital Visits and Ozone Concentration in Maricopa County, Arizona (2007-2012).

The objective of this study was to evaluate the association of asthma hospital visits with ozone concentrations in Maricopa County, Arizona. We used time plots and distributed lag nonlinear models to achieve these objectives while accounting for some potential confounders including temperature and day of the week. A total of 90,381 asthma hospitalizations were retrieved from the dataset (daily median = 39, range: 8-122). Asthma hospitalizations were highest in 2008 (16,949), during the months of November through December, and lowest in 2011 (13,213), during the months of June through July. By contrast, the average daily ozone concentration ranged from 27.05 parts per billion (ppb) in 2012 to 30.15 ppb in 2008 and from 13.96 ppb in December to 40.58 ppb in May. The association between asthma hospitalizations (relative risk [RR/per 10 ppb increase of ozone]) start at -1.046 (95% confidence interval [1.029, 1.064] at lag 0) and gradually decrease over several days. Our findings suggest exposure to ozone is associated with increased RR of asthma hospital visits in Maricopa County lasting several days. This study used recently developed methods that are freely available and could be used to evaluate other health events that are measured over time.

Viruses associated with acute respiratory infections and influenza-like illness among outpatients from the Influenza Incidence Surveillance Project, 2010-2011.

BACKGROUND: The Influenza Incidence Surveillance Project (IISP) monitored outpatient acute respiratory infection (ARI; defined as the presence of ≥ 2 respiratory symptoms not meeting ILI criteria) and influenza-like illness (ILI) to determine the incidence and contribution of associated viral etiologies. METHODS: From August 2010 through July 2011, 57 outpatient healthcare providers in 12 US sites reported weekly the number of visits for ILI and ARI and collected respiratory specimens on a subset for viral testing. The incidence was estimated using the number of patients in the practice as the denominator, and the virus-specific incidence of clinic visits was extrapolated from the proportion of patients testing positive. RESULTS: The age-adjusted cumulative incidence of outpatient visits for ARI and ILI combined was 95/1000 persons, with a viral etiology identified in 58% of specimens. Most frequently detected were rhinoviruses/enteroviruses (RV/EV) (21%) and influenza viruses (21%); the resulting extrapolated incidence of outpatient visits was 20 and 19/1000 persons respectively. The incidence of influenza virus-associated clinic visits was highest among patients aged 2-17 years, whereas other viruses had varied patterns among age groups. CONCLUSIONS: The IISP provides a unique opportunity to estimate the outpatient respiratory illness burden by etiology. Influenza virus infection and RV/EV infection(s) represent a substantial burden of respiratory disease in the US outpatient setting, particularly among children.

Heat-Associated Mortality in a Hot Climate : Maricopa County, Arizona, 2006-2016.

OBJECTIVES: Maricopa County, Arizona (2017 population about 4.3 million), is located in the Sonoran Desert. In 2005, the Maricopa County Department of Public Health (MCDPH) established a heat-associated mortality surveillance system that captures data on circumstances of death for Maricopa County residents and visitors. We analyzed 2006-2016 surveillance system data to understand the characteristics and circumstances of heat-associated deaths. METHODS: We classified heat-associated deaths based on International Classification of Diseases, Tenth Revision codes (X30, T67.X, and P81.0) and phrases (heat exposure, environ, exhaustion, sun, heat stress, heat stroke, or hyperthermia) in part I or part II of the death certificate. We summarized data on decedents' demographic characteristics, years lived in Arizona, location of death (indoors vs outdoors), presence and functionality of air conditioning, and whether the decedent had been homeless. We examined significant associations between variables by using the Pearson χ2 tests and logistic regression. RESULTS: During 2006-2016, MCDPH recorded data on 920 heat-associated deaths, 912 of which included location of injury. Of 565 (62%) heat-associated deaths that occurred outdoors, 458 (81%) were among male decedents and 243 (43%) were among decedents aged 20-49. Of 347 (38%) heat-associated deaths that occurred indoors, 201 (58%) were among decedents aged ≥65. Non-Arizona residents were 5 times as likely as Arizona residents to have a heat-associated death outdoors (P < .001). Of 727 decedents with data on duration of Arizona residency, 438 (60%) had resided in Arizona ≥20 years. CONCLUSIONS: Ongoing evaluation of interventions that target populations at risk for both outdoor and indoor heat-associated deaths can further inform refinement of the surveillance system and identify best practices to prevent heat-associated deaths.

Temporal association of implementation of the Arizona Health Care Cost Containment System (AHCCCS) with changes in dental-related emergency department visits in Maricopa County from 2006 to 2012.

OBJECTIVE: To evaluate changes in emergency department (ED) dental-related visits in Maricopa County before and after the elimination of dental benefits for adult Medicaid-insured patients as of October 2010. METHODS: Hospital visits extracted from a hospital discharge dataset were used to calculate a yearly rate ratio of dental-related versus non-dental-related ED visits (as a comparison group) for adults, children, and payer types. Changes in ED visits over time were evaluated from 2006 to 2012. RESULTS: Overall, 1.3 percent of all ED visits (8,030,767) were for dental-related purposes. Medicaid-insured patients accounted for 41.9 percent and 44.3 percent of all dental-related ED visits in 2006 and 2012, respectively. The rate ratio for the percentage of dental-related versus non-dental-related ED visits in each age category and payer type showed little fluctuation over time indicating no evidence of change in the dental-related ED visits as a proportion of the overall number of visits due to the cuts in the dental benefits for adult Medicaid-insured patients. CONCLUSION: We found no evidence that cuts in dental benefits for adult Medicaid-insured patients resulted in increased dental-related ED visits in Maricopa County during the study period. Rather, we found evidence of a shift in payer type after the 2010 policy change where dental-related ED visits by self-paid patients increased as dental-related ED visits by Medicaid-insured patients decreased. Such payer shifts will result in high uncompensated care burdens for providers and, ultimately, governmental payers.

Public Health Surveillance Strategies for Mass Gatherings: Super Bowl XLIX and Related Events, Maricopa County, Arizona, 2015.

Super Bowl XLIX took place on February 1, 2015, in Glendale, Arizona. In preparation for this event and associated activities, the Maricopa County Department of Public Health (MCDPH) developed methods for enhanced surveillance, situational awareness, and early detection of public health emergencies. Surveillance strategies implemented from January 22 to February 6, 2015, included enhanced surveillance alerts; animal disease surveillance; review of NFL clinic visits; syndromic surveillance for emergency room visits, urgent care facilities, and hotels; real-time onsite syndromic surveillance; all-hazards mortality surveillance; emergency medical services surveillance, review of poison control center reports; media surveillance; and aberration detection algorithms for notifiable diseases. Surveillance results included increased influenzalike illness activity reported from urgent care centers and a few influenza cases reported in the NFL clinic. A cyanide single event exposure was investigated and determined not to be a public health threat. Real-time field syndromic surveillance documented minor injuries at all events and sporadic cases of gastrointestinal and neurological (mostly headaches) disease. Animal surveillance reports included a cat suspected of carrying plague and tularemia and an investigation of highly pathogenic avian influenza in a backyard chicken flock. Laboratory results in both instances were negative. Aberration detection and syndromic surveillance detected an increase in measles reports associated with a Disneyland exposure, and syndromic surveillance was used successfully during this investigation. Coordinated enhanced epidemiologic surveillance during Super Bowl XLIX increased the response capacity and preparedness of MCDPH to make informed decisions and take public health actions in a timely manner during these mass gathering events.

Patterns and correlates of public health informatics capacity among local health departments: an empirical typology.

OBJECTIVE: Little is known about the nationwide patterns in the use of public health informatics systems by local health departments (LHDs) and whether LHDs tend to possess informatics capacity across a broad range of information functionalities or for a narrower range. This study examined patterns and correlates of the presence of public health informatics functionalities within LHDs through the creation of a typology of LHD informatics capacities. METHODS: Data were available for 459 LHDs from the 2013 National Association of County and City Health Officials Profile survey. An empirical typology was created through cluster analysis of six public health informatics functionalities: immunization registry, electronic disease registry, electronic lab reporting, electronic health records, health information exchange, and electronic syndromic surveillance system. Three-categories of usage emerged (Low, Mid, High). LHD financial, workforce, organization, governance, and leadership characteristics, and types of services provided were explored across categories. RESULTS: Low-informatics capacity LHDs had lower levels of use of each informatics functionality than high-informatics capacity LHDs. Mid-informatics capacity LHDs had usage levels equivalent to high-capacity LHDs for the three most common functionalities and equivalent to low-capacity LHDs for the three least common functionalities. Informatics capacity was positively associated with service provision, especially for population-focused services. CONCLUSION: Informatics capacity is clustered within LHDs. Increasing LHD informatics capacity may require LHDs with low levels of informatics capacity to expand capacity across a range of functionalities, taking into account their narrower service portfolio. LHDs with mid-level informatics capacity may need specialized support in enhancing capacity for less common technologies.

The Ratio of Emergency Department Visits for ILI to Seroprevalence of 2009 Pandemic Influenza A (H1N1) Virus Infection, Florida, 2009.

BACKGROUND: A seroprevalence survey carried out in four counties in the Tampa Bay area of Florida provided an estimate of cumulative incidence of infection due to the 2009 influenza A (H1N1) as of the end of that year's pandemic in the four counties from which seroprevalence data were obtained Methods. Excess emergency department (ED) visits for influenza-like illness (ILI) during the pandemic period (compared to four non-pandemic years) were estimated using the ESSENCE-FL syndromic surveillance system for the four-county area. RESULTS: There were an estimated 44 infections for every ILI ED visit. Age-specific ratios rose from 19.7 to 1 for children aged <5 years to 143.8 to 1 for persons aged >64 years. CONCLUSIONS: These ratios provide a way to estimate cumulative incidence. These estimated ratios can be used in real time for planning and forecasting, when carrying out timely seroprevalence surveys is not practical. Syndromic surveillance data allow age and geographic breakdowns, including for children.

Maternal and neonatal outcomes among pregnant women with 2009 pandemic influenza A(H1N1) illness in Florida, 2009-2010: a population-based cohort study.

INTRODUCTION: Pregnant women have been identified as a high risk group for severe illness with 2009 pandemic influenza A(H1N1) virus infection (pH1N1). Obesity has also been identified as a risk factor for severe illness, though this has not been thoroughly assessed among pregnant women. The objectives of this study were to provide risk estimates for adverse maternal and neonatal outcomes associated with pH1N1 illness during pregnancy and to assess the role of obesity in these outcomes. METHODS: We established a retrospective population-based cohort of all live births occurring in Florida during the first 15 months of the pandemic. Illness with pH1N1 during pregnancy was ascertained through record linkage with the Florida state notifiable disease surveillance database. Data from the birth record, including pre-pregnancy body mass index, were analyzed to assess risk of adverse outcomes associated with pH1N1 illness. RESULTS: A total of 194 women were identified through surveillance with pH1N1 illness during pregnancy. Children born to women with pH1N1 illness during pregnancy were at increased risk for low birth weight [OR (95%CI): 1.78 (1.11-2.860)], premature birth [2.21 (1.47-3.330)], and infant death [4.46 (1.80-11.00)], after adjusting for other factors. Women with pH1N1 illness during pregnancy were at increased risk for severe outcomes including admission to an intensive care unit. Obesity was an observed risk factor, both for the more severe pH1N1 illness detected through surveillance, and for severe maternal outcomes. CONCLUSIONS: Case-patients in this analysis likely represent the most severely ill subset of all women infected with pH1N1 during pregnancy, limiting the generalizability of these findings to more severely ill patients rather than influenza infection in general. Nevertheless, these results suggest that more severe pH1N1 illness during pregnancy is associated with adverse neonatal outcomes and that pregnant women should continue to be targeted for appropriate prophylaxis and early treatment.

Estimating influenza incidence and rates of influenza-like illness in the outpatient setting.

BACKGROUND: Estimating influenza incidence in outpatient settings is challenging. We used outpatient healthcare practice populations as a proxy to estimate community incidence of influenza-like illness (ILI) and laboratory-confirmed influenza-associated ILI. METHODS: From October 2009 to July 2010, 38 outpatient practices in seven jurisdictions conducted surveillance for ILI (fever with cough or sore throat for patients ≥ 2 years; fever with ≥ 1 respiratory symptom for patients <2 years). From a sample of patients with ILI, respiratory specimens were tested for influenza. RESULTS: During the week of peak influenza activity (October 24, 2009), 13% of outpatient visits were for ILI and influenza was detected in 72% of specimens. For the 10-month surveillance period, ILI and influenza-associated ILI incidence were 20.0 (95% CI: 19.7, 20.4) and 8.7/1000 (95% CI: 8.2, 9.2) persons, respectively. Influenza-associated ILI incidence was highest among children aged 2-17 years. Observed trends were highly correlated with national ILI and virologic surveillance. CONCLUSIONS: This is the first multistate surveillance system demonstrating the feasibility of using outpatient practices to estimate the incidence of medically attended influenza at the community level. Surveillance demonstrated the substantial burden of pandemic influenza in outpatient settings and especially in children aged 2-17 years. Observed trends were consistent with established syndromic and virologic systems.

rotavirus-coded deaths in children, United States, 1999-2007.

The introduction of specific International Classification of Diseases-10th revision code for rotavirus in 1999 prompted us to examine the US mortality data for 1999-2007 to validate rotavirus-coded deaths. Of 38 rotavirus-coded deaths identified in the national multiple cause-of-death database, results of laboratory testing could be obtained for 21 deaths, all of which had confirmation of rotavirus by either microbiologic or histopathologic testing.

Prevalence of 2009 pandemic influenza A (H1N1) virus antibodies, Tampa Bay Florida--November-December, 2009.

BACKGROUND: In 2009, a novel influenza virus (2009 pandemic influenza A (H1N1) virus (pH1N1)) caused significant disease in the United States. Most states, including Florida, experienced a large fall wave of disease from September through November, after which disease activity decreased substantially. We determined the prevalence of antibodies due to the pH1N1 virus in Florida after influenza activity had peaked and estimated the proportion of the population infected with pH1N1 virus during the pandemic. METHODS: During November-December 2009, we collected leftover serum from a blood bank, a pediatric children's hospital and a pediatric outpatient clinic in Tampa Bay Florida. Serum was tested for pH1N1 virus antibodies using the hemagglutination-inhibition (HI) assay. HI titers ≥40 were considered seropositive. We adjusted seroprevalence results to account for previously established HI assay specificity and sensitivity and employed a simple statistical model to estimate the proportion of seropositivity due to pH1N1 virus infection and vaccination. RESULTS: During the study time period, the overall seroprevalence in Tampa Bay, Florida was 25%, increasing to 30% after adjusting for HI assay sensitivity and specificity. We estimated that 5.9% of the population had vaccine-induced seropositivity while 25% had seropositivity secondary to pH1N1 virus infection. The highest cumulative incidence of pH1N1 virus infection was among children aged 5-17 years (53%) and young adults aged 18-24 years (47%), while adults aged ≥50 years had the lowest cumulative incidence (11-13%) of pH1N1 virus infection. CONCLUSIONS: After the peak of the fall wave of the pandemic, an estimated one quarter of the Tampa Bay population had been infected with the pH1N1 virus. Consistent with epidemiologic trends observed during the pandemic, the highest burdens of disease were among school-aged children and young adults.