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.

Identifying and characterizing hepatitis C virus hotspots in Massachusetts: a spatial epidemiological approach.

BACKGROUND: Hepatitis C virus (HCV) infections have increased during the past decade but little is known about geographic clustering patterns. METHODS: We used a unique analytical approach, combining geographic information systems (GIS), spatial epidemiology, and statistical modeling to identify and characterize HCV hotspots, statistically significant clusters of census tracts with elevated HCV counts and rates. We compiled sociodemographic and HCV surveillance data (n = 99,780 cases) for Massachusetts census tracts (n = 1464) from 2002 to 2013. We used a five-step spatial epidemiological approach, calculating incremental spatial autocorrelations and Getis-Ord Gi* statistics to identify clusters. We conducted logistic regression analyses to determine factors associated with the HCV hotspots. RESULTS: We identified nine HCV clusters, with the largest in Boston, New Bedford/Fall River, Worcester, and Springfield (p < 0.05). In multivariable analyses, we found that HCV hotspots were independently and positively associated with the percent of the population that was Hispanic (adjusted odds ratio [AOR]: 1.07; 95% confidence interval [CI]: 1.04, 1.09) and the percent of households receiving food stamps (AOR: 1.83; 95% CI: 1.22, 2.74). HCV hotspots were independently and negatively associated with the percent of the population that were high school graduates or higher (AOR: 0.91; 95% CI: 0.89, 0.93) and the percent of the population in the "other" race/ethnicity category (AOR: 0.88; 95% CI: 0.85, 0.91). CONCLUSION: We identified locations where HCV clusters were a concern, and where enhanced HCV prevention, treatment, and care can help combat the HCV epidemic in Massachusetts. GIS, spatial epidemiological and statistical analyses provided a rigorous approach to identify hotspot clusters of disease, which can inform public health policy and intervention targeting. Further studies that incorporate spatiotemporal cluster analyses, Bayesian spatial and geostatistical models, spatially weighted regression analyses, and assessment of associations between HCV clustering and the built environment are needed to expand upon our combined spatial epidemiological and statistical methods.

Postpartum Laboratory Follow-up in Women With Hepatitis B in Massachusetts From 2007 to 2012.

GOALS: To determine postpartum hepatitis B virus (HBV) laboratory testing rates and identify factors associated with a lack of follow-up testing in Massachusetts. BACKGROUND: Screening for HBV infection in pregnant women is standard of care. Guidelines recommend that patients with chronic HBV have ongoing care and laboratory testing, but little is known about postpartum maternal HBV care outcomes. STUDY: We conducted a retrospective cohort study using Massachusetts Virtual Epidemiologic Network, an electronic public health surveillance system maintained by the Massachusetts Department of Public Health. We identified women who tested hepatitis B surface antigen positive during their first reported (index) pregnancy in Massachusetts from 2007 to 2012 and measured HBV-related laboratory tests reported to Massachusetts Department of Public Health during and after pregnancy. RESULTS: We identified 983 hepatitis B surface antigen positive pregnant women. Half (492/983) did not have evidence of additional postpartum HBV laboratory testing following their index pregnancy. Women who had postpartum laboratory tests reported were younger [mean age (SD): 29 (5.3) vs. 31 (5.5) y, P=0.0001] and more likely to have >1 pregnancy during the study period (41% vs. 1%, P<0.0001). There were no differences in race, ethnicity, and US born status. On multivariable logistic regression, older age predicted a lower likelihood of having postpartum laboratory testing (odds ratio, 0.77; 95% confidence interval, 0.70-0.90). CONCLUSIONS: Postpartum maternal HBV follow-up laboratory testing occurred in only half of Massachusetts women and did not vary by race, ethnicity, or US born status. Our results were limited to a single state surveillance database, which likely underestimates the number of tests ordered.

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.

Emerging epidemic of hepatitis C virus infections among young nonurban persons who inject drugs in the United States, 2006-2012.

BACKGROUND: Reports of acute hepatitis C in young persons in the United States have increased. We examined data from national surveillance and supplemental case follow-up at selected jurisdictions to describe the US epidemiology of hepatitis C virus (HCV) infection among young persons (aged ≤30 years). METHODS: We examined trends in incidence of acute hepatitis C among young persons reported to the Centers for Disease Control and Prevention (CDC) during 2006-2012 by state, county, and urbanicity. Sociodemographic and behavioral characteristics of HCV-infected young persons newly reported from 2011 to 2012 were analyzed from case interviews and provider follow-up at 6 jurisdictions. RESULTS: From 2006 to 2012, reported incidence of acute hepatitis C increased significantly in young persons-13% annually in nonurban counties (P = .003) vs 5% annually in urban counties (P = .028). Thirty (88%) of 34 reporting states observed higher incidence in 2012 than 2006, most noticeably in nonurban counties east of the Mississippi River. Of 1202 newly reported HCV-infected young persons, 52% were female and 85% were white. In 635 interviews, 75% of respondents reported injection drug use. Of respondents reporting drug use, 75% had abused prescription opioids, with first use on average 2.0 years before heroin. CONCLUSIONS: These data indicate an emerging US epidemic of HCV infection among young nonurban persons of predominantly white race. Reported incidence was higher in 2012 than 2006 in at least 30 states, with largest increases in nonurban counties east of the Mississippi River. Prescription opioid abuse at an early age was commonly reported and should be a focus for medical and public health intervention.

Perspectives on benefits and risks of creation of an "injection drug use" billing code.

People with substance use disorder (SUD) face barriers to prevention and treatment services, increasing risk for hospitalization and death. Injection drug use (IDU) can lead to an increased risk of overdose and infections. However, identifying people who inject drugs (PWID) within healthcare systems is challenging. International Classification of Disease (ICD-10) codes are used for billing and tracking healthcare utilization. In this commentary, experts in the field weigh the benefits and risks of creating an IDU-specific ICD-10 code. Potential benefits include earlier identification, better access to health services, and improved systems of resource allocation. Potential risks include further stigmatization of PWID and, if not tied to financial reimbursement, low rates of code utilization. As the current systems of identifying PWID are lacking, we feel that a guided operationalization of an ICD code to identify PWID could improve quantitative and epidemiological research accuracy and, therefore, support the health and well-being of PWID.

Patient and Provider Experience with Artificial Intelligence Screening Technology for Diabetic Retinopathy in a Rural Primary Care Setting.

Introduction: The development of autonomous artificial intelligence for interpreting diabetic retinopathy (DR) images has allowed for point-of-care testing in the primary care setting. This study describes patient and provider experiences and perceptions of the artificial intelligence DR screening technology called EyeArt by EyeNuk during implementation of the tool at Western Maine Primary Care in Norway, Maine. Methods: This non-randomized, single-center, prospective observational study surveyed 102 patients and 13 primary care providers on their experience of the new screening intervention. Results: All surveyed providers agreed that the new screening tool would improve access and annual screening rates. Some providers also identified initial challenges in incorporating the tool into the primary care visit (31%). Patients expressed a favorable view of the service, sharing an openness to being screened more regularly (75%) and a desire to have screenings performed at Western Maine Primary Care going forward (81%). Discussion: Patients were generally favorable about their experience with the new DR screening technology. Providers indicated challenges due to the limited availability of trained medical assistant photographers during the initial implementation of DR screening, as well as timing issues in coordinating screening with regular office appointments. Conclusions: This study supports further investigation of this technology in primary care, particularly in areas with challenges to care access. The potential benefits of this innovative tool in caring for people with diabetes includes improving access to retinopathy screenings and supporting wider detection of vision-threatening retinopathy.

Understanding the Role of Misinformation in COVID-19 Vaccine Hesitancy in a Rural State.

Objective: to identify factors associated with COVID19 vaccine hesitancy, including sources of information among residents of Maine. Methods: 148 study participants, recruited through community partners and primary care offices in Maine, completed an anonymous 15 item online survey. Recruitment and data collection occurred from May to September, 2021. Hesitancy was determined through a single question, "Will you get one of the COVID vaccines when it is offered to you?" Results: vaccine hesitant respondents were younger than not hesitant respondents (p = 0.01). Hesitant individuals were significantly more likely to report concerns regarding the speed of COVID-19 vaccine production, vaccine efficacy, and potential vaccine side effects (p < 0.05 for each). Hesitant individuals were also significantly more likely to have discussed vaccination with their primary physician (p = 0.04). Conclusions: overall, hesitant individuals are more likely to be younger and had less trust in information from government sources, but they sought input from primary care. They were also more concerned about efficacy, side effects, and the rapid development of COVID-19 vaccines. Primary care physicians are in key positions to address these concerns due to contact with individuals who need accurate information.

Utilization of cumulative antibiograms for public health surveillance: Trends in Escherichia coli and Klebsiella pneumoniae susceptibility, Massachusetts, 2008-2018.

BACKGROUND: Antimicrobial resistance is an urgent public health threat. Identifying trends in antimicrobial susceptibility can inform public health policy at the state and local levels. OBJECTIVE: To determine the ability of statewide antibiogram aggregation for public health surveillance to identify changes in antimicrobial resistance trends. DESIGN: Facility-level trend analysis. METHODS: Crude and adjusted trend analyses of the susceptibility of Escherichia coli and Klebsiella pneumoniae to particular antibiotics, as reported by aggregated antibiograms, were examined from 2008 through 2018. Multivariable regression analyses via generalized linear mixed models were used to examine associations between hospital characteristics and trends of E. coli and K. pneumoniae susceptibility to ciprofloxacin and ceftriaxone. RESULTS: E. coli and K. pneumoniae showed inverse trends in drug susceptibility over time. K. pneumoniae susceptibility to fluoroquinolones increased by 5% between 2008 and 2018 (P < .05). In contrast, E. coli susceptibility declined during the same period to ceftriaxone (6%), gentamicin (4%), and fluoroquinolones (4%) (P < .05). When compared to Boston hospitals, E. coli isolates from hospitals in other regions had a >4% higher proportion of susceptibility to ciprofloxacin and a >3% higher proportion of susceptibility to ceftriaxone (P < .05). Isolates of K. pneumoniae had higher susceptibility to ciprofloxacin (>3%) and ceftriaxone (>1.5%) in all regions when compared to Boston hospitals (P < .05). CONCLUSIONS: Cumulative antibiograms can be used to monitor antimicrobial resistance, to discern regional and facility differences, and to detect changes in trends. Furthermore, because the number of years that hospitals contributed reports to the state-level aggregate had no significant influence on susceptibility trends, other states should not be discouraged by incomplete hospital compliance.

Anomalous Antimicrobial Susceptibility Trend Identification.

Antibiotic resistant bacterial infections are a growing global health crisis. Antibiograms, aggregate antimicrobial resistance reports, are critical for tracking antibiotic susceptibility and prescribing antibiotics. This research leverages fifteen years of the expansive Massachusetts statewide antibiogram dataset curated by the Massachusetts Department of Public Health. Given the lengthy annual antibiogram creation process, data are not timely. Our prior research involved forecasting the current antimicrobial susceptibility given historic antibiograms. The objective for this research is to expand upon this prior work by identifying which antibiotic-bacteria combinations have resistance trends that are not well forecasted. For that, our proposed Previous Year Anomalous Trend Identification (PYATI) strategy employs a cluster driven outlier detection solution to identify the trends to remove before forecasting. Employing PYATI to remove antibiotic-bacteria combinations with anomalous trends statistically significantly reduces the forecasting error for the remaining combinations. As antibiotic resistance is furthered by prescribing ineffective antibiotics, PYATI can be leveraged to improve antibiotic prescribing.

Using public health surveillance data to measure Clostridium difficile infection population burden in Massachusetts.

Clostridium difficile occurs both inside and outside of health care facilities, but surveillance has been traditionally limited to the hospital setting. To measure the population-based burden of C difficile infection (CDI), we used multiple routine sources of data. We found an overall rate of CDI in Massachusetts in 2016 of 132.5 per 100,000 population, with mortality in 2014 of 6.4 per 100,000 population. Population-based measurement of CDI burden appears feasible without conducting a special study.

Follow-up testing for hepatitis C virus infection: an analysis of Massachusetts surveillance data, 2007-2010.

The Massachusetts Department of Public Health (MDPH) identified cases of hepatitis C virus (HCV) infection reported from 2007 through 2010 to assess evidence of appropriate follow-up testing for the diagnosis of active HCV infection. Surveillance data were used to assess the number of people with reported HCV who had an antibody test and nucleic acid test (NAT) for HCV, to determine the time between tests, and to identify demographic characteristics. Out of the 34,005 cases of HCV reported with laboratory results during the study period, 45% (n=15,279) had only an antibody test reported and 55% (n=18,726) had a NAT reported, with differences by age, gender, and region of residence. Nearly half of those with reported cases of HCV infection in Massachusetts did not have a NAT reported to MDPH, indicating that these individuals may not have received appropriate diagnostic testing. Analysis of demographics suggests differences by age, gender, and region.