Electronic Health Record-Based Algorithm for Monitoring Respiratory Virus-Like Illness.

Viral respiratory illness surveillance has traditionally focused on single pathogens (e.g., influenza) and required fever to identify influenza-like illness (ILI). We developed an automated system applying both laboratory test and syndrome criteria to electronic health records from 3 practice groups in Massachusetts, USA, to monitor trends in respiratory viral-like illness (RAVIOLI) across multiple pathogens. We identified RAVIOLI syndrome using diagnosis codes associated with respiratory viral testing or positive respiratory viral assays or fever. After retrospectively applying RAVIOLI criteria to electronic health records, we observed annual winter peaks during 2015-2019, predominantly caused by influenza, followed by cyclic peaks corresponding to SARS-CoV-2 surges during 2020-2024, spikes in RSV in mid-2021 and late 2022, and recrudescent influenza in late 2022 and 2023. RAVIOLI rates were higher and fluctuations more pronounced compared with traditional ILI surveillance. RAVIOLI broadens the scope, granularity, sensitivity, and specificity of respiratory viral illness surveillance compared with traditional ILI surveillance.

How do we use the National Healthcare Safety Network for Hemovigilance in Massachusetts?

BACKGROUND: Use of the National Healthcare Safety Network (NHSN) has been essential to the success of the Massachusetts Hemovigilance Program and has allowed for the timely identification of signals and trends over a defined population that correlate with national and international hemovigilance (HV) data. Here, we outline how the NHSN system is used for monitoring HV data in Massachusetts and encourage adoption of NHSN for nationwide HV surveillance. STUDY DESIGN AND METHODS: A collaboration that grew over time between local HV stakeholders and the Massachusetts Department of Public Health (MDPH) resulted in the change from a paper-based method of reporting adverse reactions and monthly transfusion activity for compliance with state requirements to replacement with statewide adoption of reporting via NHSN. RESULTS: Over 1.5 million blood products were transfused in Massachusetts between 2017 and 2021, with 3000 adverse reactions among 10 defined types reported. Using NHSN, MDPH has been able to produce numerous reports, publications, and presentations that have made previously non-obtainable HV and blood utilization data available. DISCUSSION: Although limitations to these self-reported data exist, such as lack of external validation, successful statewide implementation of NHSN for hospital blood bank reporting is possible and has benefits beyond those for regulatory oversight. It results in standardized, actionable data at both the hospital and state level, enabling inter-facility comparisons, benchmarking, and opportunities for practice improvement.

Is there a relationship between opioid use and transient global amnesia?

BACKGROUND AND PURPOSE: Opioid-associated amnestic syndrome (OAS) and transient global amnesia (TGA) are conditions with clinical overlap. We therefore sought to determine whether opioid use might be associated with TGA. METHODS: Data from the Massachusetts Department of Public Health Syndromic Surveillance program were queried to ascertain the frequency of opioid use among emergency department (ED) encounters for TGA compared to that for all other ED visits between January 2019 and June 2023. RESULTS: A total of 13,188,630 ED visits were identified during the study period. Of 1417 visits for TGA, one visit met the exposure definition for opioid use. There were 13,187,213 visits for other indications, 57,638 of which were considered opioid-exposed. The odds ratio for the relationship between opioid use and TGA was 0.16 (95% confidence interval 0.02, 1.14). CONCLUSION: Despite the clinical overlap between OAS and TGA, surveillance data from ED visits in Massachusetts do not suggest that opioid use is a risk factor for TGA, indicating that OAS and TGA are distinct entities.

Patterns of Infectious Disease Associated With Injection Drug Use in Massachusetts.

BACKGROUND: Since 2014, multiple outbreaks of human immunodeficiency virus (HIV) among people who inject drugs have occurred across the United States along with hepatitis C virus (HCV), skin and soft tissue infections (SSTIs), and infective endocarditis (IE), creating a converging public health crisis. METHODS: We analyzed the temporal patterns of infectious disease and overdose using a hierarchical Bayesian distributed lag logistic regression model examining the probability that a given geographic area experienced at least 1 HIV case in a given month as a function of the counts/rates of overdose, HCV, SSTI, and IE and associated medical procedures at different lagged time periods. RESULTS: Current-month HIV is associated with increasing HCV cases, abscess incision and drainage, and SSTI cases, in distinct temporal patterns. For example, 1 additional HCV case occurring 5 and 7 months previously is associated with a 4% increase in the odds of observing at least 1 current-month HIV case in a given locale (odds ratios, 1.04 [90% credible interval {CrI}: 1.01-1.10] and 1.04 [90% CrI: 1.00-1.09]). No such associations were observed for echocardiograms, IE, or overdose. CONCLUSIONS: Lagged associations in other infections preceding rises in current-month HIV counts cannot be described as predictive of HIV outbreaks but may point toward newly discovered epidemics of injection drug use and associated clinical sequalae, prompting clinicians to screen patients more carefully for substance use disorder and associated infections.

An outbreak of HIV infection among people who inject drugs in northeastern Massachusetts: findings and lessons learned from a medical record review.

BACKGROUND: We conducted a medical record review for healthcare utilization, risk factors, and clinical data among people who inject drugs (PWID) in Massachusetts to aid HIV outbreak response decision-making and strengthen public health practice. SETTING: Two large community health centers (CHCs) that provide HIV and related services in northeastern Massachusetts. METHODS: Between May and July 2018, we reviewed medical records for 88 people with HIV (PWH) connected to the outbreak. The review period included care received from May 1, 2016, through the date of review. Surveillance data were used to establish date of HIV diagnosis and assess viral suppression. RESULTS: Sixty-nine (78%) people had HIV infection diagnosed during the review period, including 10 acute infections. Persons had a median of 3 primary care visits after HIV diagnosis and zero before diagnosis. During the review period, 72% reported active drug or alcohol use, 62% were prescribed medication assisted treatment, and 41% were prescribed antidepressants. The majority (68, 77%) had a documented ART prescription. HIV viral suppression at < 200 copies/mL was more frequent (73%) than the overall across the State (65%); it did not correlate with any of the sociodemographic characteristics studied in our population. Over half (57%) had been hospitalized at least once during the review period, and 36% had a bacterial infection at hospitalization. CONCLUSIONS: Medical record review with a field investigation of an outbreak provided data about patterns of health care utilization and comorbidities not available from routine HIV surveillance or case interviews. Integration of HIV screening with treatment for HIV and SUD can strengthen prevention and care services for PWID in northeastern Massachusetts.

Human Immunodeficiency Virus (HIV) Outbreak Investigation Among Persons Who Inject Drugs in Massachusetts Enhanced by HIV Sequence Data.

BACKGROUND: The Massachusetts Department of Public Health and the Centers for Disease Control and Prevention collaborated to characterize a human immunodeficiency virus (HIV) outbreak in northeastern Massachusetts and prevent further transmission. We determined the contributions of HIV sequence data to defining the outbreak. METHODS: Human immunodeficiency virus surveillance and partner services data were analyzed to understand social and molecular links within the outbreak. Cases were defined as HIV infections diagnosed during 2015-2018 among people who inject drugs with connections to northeastern Massachusetts or HIV infections among other persons named as partners of a case or whose HIV polymerase sequence linked to another case, regardless of diagnosis date or geography. RESULTS: Of 184 cases, 65 (35%) were first identified as part of the outbreak through molecular analysis. Twenty-nine cases outside of northeastern Massachusetts were molecularly linked to the outbreak. Large molecular clusters (75, 28, and 11 persons) were identified. Among 161 named partners, 106 had HIV; of those, 40 (38%) diagnoses occurred through partner services. CONCLUSIONS: Human immunodeficiency virus sequence data increased the case count by 55% and expanded the geographic scope of the outbreak. Human immunodeficiency virus sequence and partner services data each identified cases that the other method would not have, maximizing prevention and care opportunities for HIV-infected persons and their partners.

Opioid Use Fueling HIV Transmission in an Urban Setting: An Outbreak of HIV Infection Among People Who Inject Drugs-Massachusetts, 2015-2018.

Objectives. To describe and control an outbreak of HIV infection among people who inject drugs (PWID).Methods. The investigation included people diagnosed with HIV infection during 2015 to 2018 linked to 2 cities in northeastern Massachusetts epidemiologically or through molecular analysis. Field activities included qualitative interviews regarding service availability and HIV risk behaviors.Results. We identified 129 people meeting the case definition; 116 (90%) reported injection drug use. Molecular surveillance added 36 cases to the outbreak not otherwise linked. The 2 largest molecular groups contained 56 and 23 cases. Most interviewed PWID were homeless. Control measures, including enhanced field epidemiology, syringe services programming, and community outreach, resulted in a significant decline in new HIV diagnoses.Conclusions. We illustrate difficulties with identification and characterization of an outbreak of HIV infection among a population of PWID and the value of an intensive response.Public Health Implications. Responding to and preventing outbreaks requires ongoing surveillance, with timely detection of increases in HIV diagnoses, community partnerships, and coordinated services, all critical to achieving the goal of the national Ending the HIV Epidemic initiative.

Transmission of Mobile Colistin Resistance (mcr-1) by Duodenoscope.

BACKGROUND: Clinicians increasingly utilize polymyxins for treatment of serious infections caused by multidrug-resistant gram-negative bacteria. Emergence of plasmid-mediated, mobile colistin resistance genes creates potential for rapid spread of polymyxin resistance. We investigated the possible transmission of Klebsiella pneumoniae carrying mcr-1 via duodenoscope and report the first documented healthcare transmission of mcr-1-harboring bacteria in the United States. METHODS: A field investigation, including screening targeted high-risk groups, evaluation of the duodenoscope, and genome sequencing of isolated organisms, was conducted. The study site included a tertiary care academic health center in Boston, Massachusetts, and extended to community locations in New England. RESULTS: Two patients had highly related mcr-1-positive K. pneumoniae isolated from clinical cultures; a duodenoscope was the only identified epidemiological link. Screening tests for mcr-1 in 20 healthcare contacts and 2 household contacts were negative. Klebsiella pneumoniae and Escherichia coli were recovered from the duodenoscope; neither carried mcr-1. Evaluation of the duodenoscope identified intrusion of biomaterial under the sealed distal cap; devices were recalled to repair this defect. CONCLUSIONS: We identified transmission of mcr-1 in a United States acute care hospital that likely occurred via duodenoscope despite no identifiable breaches in reprocessing or infection control practices. Duodenoscope design flaws leading to transmission of multidrug-resistant organsisms persist despite recent initiatives to improve device safety. Reliable detection of colistin resistance is currently challenging for clinical laboratories, particularly given the absence of a US Food and Drug Administration-cleared test; improved clinical laboratory capacity for colistin susceptibility testing is needed to prevent the spread of mcr-carrying bacteria in healthcare settings.

Characteristics of Cases With Repeated Sexually Transmitted Infections, Massachusetts, 2014-2016.

Background: Persons with prior sexually transmitted infections (STIs) are at high risk for reinfection. No recent studies have examined frequency with which persons are diagnosed and reported with multiple bacterial STIs over time. Methods: We conducted a retrospective, of confirmed syphilis, gonorrhea, and chlamydial infections reported to Massachusetts state surveillance system within a 2-year period, 28 July 2014-27 July 2016. Results: Among Massachusetts population aged 13-65 years (4847510), 49142 (1.0%) were reported with ≥1 STIs; 6999 (14.2% of those with ≥1 STI) had ≥2 STIs, accounting for 27.7% of STIs. Of cases with ≥5 or more STIs (high-volume repeaters), 118 (74%) were men and 42 (26%) were women. Men spanned the age spectrum and were predominantly non-Hispanic white; 87% reported same-sex contacts. Women were younger, predominantly nonwhite, and without known same-sex contacts. Women were reinfected with gonorrhea and chlamydia or chlamydia alone; none had syphilis or human immunodeficiency virus (HIV) infection. All men with syphilis also had gonorrhea and/or chlamydia; 35% were diagnosed with HIV before, during, or within 10 months after study period. The majority (56%) of high-volume repeaters were seen at more than 1 care site/system. Conclusions: In Massachusetts, a large proportion of bacterial STIs are reported from a small subpopulation, many of whom have repeated infections and are likely to have higher impact on STI and HIV rates. Public health can play a crucial role in reaching high-volume repeaters whose STI histories may be hidden from clinicians due to fragmented care.

Transfusion-transmitted babesiosis: one state's experience.

BACKGROUND: The risk for tickborne exposure to Babesia microti infection exists statewide in Massachusetts. Broad exposure complicates investigations of transfusion-transmitted babesiosis (TTB). We summarize 8 years of the epidemiology of TTB and highlight the role of public health in prevention and control. STUDY DESIGN AND METHODS: Cases of babesiosis are routinely reported to the Massachusetts Department of Public Health. These are investigated to determine whether they meet the surveillance case definition and to identify whether they were potentially transfusion transmitted. Frequencies from 2009 to 2016 are described and incidence rates calculated using population denominators from the US census. Changes over time were analyzed using simple linear regression. RESULTS: From 2009 to 2016, there were 2578 cases of babesiosis reported; of these, 45 (1.7%) were transfusion transmitted. Of the 45 cases of TTB, 15 (33%) received blood products from two or more suppliers. In 11 TTB cases, the Department of Public Health was notified first, who in turn notified the appropriate blood provider. In 2009, the crude rate of reported babesiosis was 1.2 per 100,000 population and increased significantly through 2016 to 7.8 per 100,000 population (p = 0.006). The number of blood donors reported with laboratory evidence of B. microti infection increased from 19 in 2012 to 78 in 2016; at the same time, the number of TTB cases decreased from six to three. CONCLUSION: TTB remains a major challenge, and blood donor screening strategies are currently in the process of implementation. While population and environmental changes facilitate increases in babesiosis, donor screening has the potential to eliminate TTB.

Factors Associated with Pre-exposure Prophylaxis in a Highly Insured Population of Urban Men Who Have Sex with Men, 2014.

In the United States, an estimated 25% of men who have sex with men (MSM) have indications for receiving pre-exposure prophylaxis to prevent HIV infection (PrEP), but <4% reported PrEP use in the past 12 months. We evaluate factors associated with having heard of, willingness to use, and use of PrEP in a venue-based, time-spaced sample of 316 urban, highly insured Boston MSM in the 2014 NHBS. We found that 53.7% of respondents reported receiving usual medical care from a doctor's office or health maintenance organization, 57.6% had an indication for PrEP, 66.6% had heard of PrEP, 53.6% reported willingness to use PrEP, and 5.8% reported use of PrEP in the past 12 months. In multivariable analyses, an indication for PrEP was statistically associated with having heard of, willingness to use and use of PrEP in the past 12 months. Findings guide statewide efforts to evaluate and promote PrEP.

Hemovigilance in Massachusetts and the adoption of statewide hospital blood bank reporting using the National Healthcare Safety Network.

A collaboration that grew over time between local hemovigilance stakeholders and the Massachusetts Department of Public Health (MDPH) resulted in the change from a paper-based method of reporting adverse reactions and monthly transfusion activity for regulatory compliance purposes to statewide adoption of electronic reporting via the National Healthcare Safety Network (NHSN). The NHSN is a web-based surveillance system that offers the capacity to capture transfusion-related adverse events, incidents, and monthly transfusion statistics from participating facilities. Massachusetts' hospital blood banks share the data they enter into NHSN with the MDPH to satisfy reporting requirements. Users of the NHSN Hemovigilance Module adhere to specified data entry guidelines, resulting in data that are comparable and standardized. Keys to successful statewide adoption of this reporting method include the fostering of strong partnerships with local hemovigilance champions and experts, engagement of regulatory and epidemiology divisions at the state health department, the leveraging of existing relationships with hospital NHSN administrators, and the existence of a regulatory deadline for implementation. Although limitations exist, successful implementation of statewide use of the NHSN Hemovigilance Module for hospital blood bank reporting is possible. The result is standardized, actionable data at both the hospital and state level that can facilitate interfacility comparisons, benchmarking, and opportunities for practice improvement.

Sustained Reduction in HIV Diagnoses in Massachusetts, 2000-2014.

OBJECTIVES: To describe secular trends in reported HIV diagnoses in Massachusetts concurrent with treatment access expansion. METHODS: We characterized cases of HIV infection reported to the Massachusetts HIV/AIDS Surveillance Program between 2000 and 2014 by sex, age, race/ethnicity, and exposure mode. We used Poisson regression to test the statistical significance of trends in diagnoses. RESULTS: Between 2000 and 2014, annual new HIV infections diagnosed in Massachusetts decreased by 47% (P < .001 for trend). We observed significant reductions in diagnoses among women (58% when comparing 2000 with 2014), men (42%), Whites (54%), Blacks (51%), and Hispanics (35%; P < .001 for trend). New diagnoses decreased significantly among men who have sex with men (19%), persons who inject drugs (91%), and heterosexuals (86%; P < .001 for trend). We saw statistically significant downward trends among all men by race/ethnicity, but the trend among Black men who have sex with men was nonsignificant. CONCLUSIONS: Sustained reduction in new HIV diagnoses was concurrent with Massachusetts's Medicaid expansion, state health care reform, and public health strategies to improve care access. A contributory effect of expanded HIV treatment and population-level viral suppression is hypothesized for future research.

Cluster of an Unusual Amnestic Syndrome - Massachusetts, 2012-2016.

In November 2015, a neurologist in the Boston, Massachusetts, area reported four cases of an uncommon amnestic syndrome involving acute and complete ischemia of both hippocampi, as identified by magnetic resonance imaging (MRI), to the Massachusetts Department of Public Health (MDPH) (1). A subsequent e-mail alert, generated by the Massachusetts Board of Registration in Medicine and sent to relevant medical specialists (including neurologists, neuroradiologists, and emergency physicians), resulted in the identification of 10 additional cases that had occurred during 2012-2016. All 14 patients (mean and median age = 35 years) had been evaluated at hospitals in eastern Massachusetts. Thirteen of the 14 patients underwent routine clinical toxicology screening at the time of initial evaluation; eight tested positive for opioids, two for cocaine, and two for benzodiazepines. Apart from sporadic cases (2-6), this combination of clinical and imaging findings has been reported rarely. The apparent temporospatial clustering, relatively young age at onset (19-52 years), and associated substance use among these patients should stimulate further case identification to determine whether these observations represent an emerging syndrome related to substance use or other causes (e.g., a toxic exposure).

The Critical Role of the Staff Nurse in Antimicrobial Stewardship--Unrecognized, but Already There.

An essential participant in antimicrobial stewardship who has been unrecognized and underutilized is the "staff nurse." Although the role of staff nurses has not formally been recognized in guidelines for implementing and operating antimicrobial stewardship programs (ASPs) or defined in the medical literature, they have always performed numerous functions that are integral to successful antimicrobial stewardship. Nurses are antibiotic first responders, central communicators, coordinators of care, as well as 24-hour monitors of patient status, safety, and response to antibiotic therapy. An operational analysis of inpatient admissions evaluates these nursing stewardship activities and analyzes the potential benefits of nurses' formal education about, and inclusion into, ASPs.

Underascertainment of acute hepatitis C virus infections in the U.S. surveillance system: a case series and chart review.

BACKGROUND: In 2010, the incidence of hepatitis C virus (HCV) infection in the United States was estimated to be 17 000 cases annually, based on 850 acute HCV cases reported to the Centers for Disease Control and Prevention by local public health authorities. Absence of symptomatic disease and lack of a specific laboratory test for acute infection complicates diagnosis and surveillance. OBJECTIVE: To validate estimates of the incidence of acute HCV infection by determining the reporting rate of clinical diagnoses of acute infection to the Massachusetts Department of Public Health (MDPH) and Centers for Disease Control and Prevention. DESIGN: Case series and chart review. SETTING: Two hospitals and the state correctional health care system in Massachusetts. PATIENTS: 183 patients clinically diagnosed with acute HCV infection from 2001 to 2011 and participating in a research study. MEASUREMENTS: Rate of electronic case reporting of acute HCV infection to the MDPH and rate of subsequent confirmation according to national case definitions. RESULTS: 149 of 183 (81.4%) clinical cases of acute HCV infection were reported to the MDPH for surveillance classification. The MDPH investigated 43 of these reports as potential acute cases of HCV infection based on their surveillance requirements; ultimately, only 1 met the national case definition and was counted in nationwide statistics published by the Centers for Disease Control and Prevention. Discordance in clinical and surveillance classification was often related to missing clinical or laboratory data at the MDPH as well as restrictive definitions, including requirements for negative hepatitis A and B laboratory results. LIMITATION: Findings may not apply to other jurisdictions because of differences in resources for surveillance. CONCLUSION: Clinical diagnoses of acute HCV infection were grossly underascertained by formal surveillance reporting. Incomplete clinician reporting, problematic case definitions, limitations of diagnostic testing, and imperfect data capture remain major limitations to accurate case ascertainment despite automated electronic laboratory reporting. These findings may have implications for national estimates of the incidence of HCV infection. PRIMARY FUNDING SOURCE: National Institutes of Health.