Reduced Odds of Severe Acute Respiratory Syndrome Coronavirus 2 Reinfection After Vaccination Among New York City Adults, July 2021-November 2021.

BACKGROUND: Belief that vaccination is not needed for individuals with prior infection contributes to coronavirus disease 2019 (COVID-19) vaccine hesitancy. Among individuals infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) before vaccines became available, we determined whether vaccinated individuals had reduced odds of reinfection. METHODS: We conducted a case-control study among adult New York City residents who tested positive for SARS-CoV-2 infection in 2020 and had not died or tested positive again >90 days after an initial positive test as of 1 July 2021. Case patients with reinfection during July 2021-November 2021 and controls with no reinfection were matched (1:3) on age, sex, timing of initial positive test in 2020, and neighborhood poverty level. Matched odds ratios (mORs) and 95% confidence intervals (CIs) were calculated using conditional logistic regression. RESULTS: Of 349 827 eligible adults, 2583 were reinfected during July 2021-November 2021. Of 2401 with complete matching criteria data, 1102 (45.9%) were known to be symptomatic for COVID-19-like illness, and 96 (4.0%) were hospitalized. Unvaccinated individuals, compared with individuals fully vaccinated within the prior 90 days, had elevated odds of reinfection (mOR, 3.21; 95% CI, 2.70 to 3.82), of symptomatic reinfection (mOR, 2.97; 95% CI, 2.31 to 3.83), and of reinfection with hospitalization (mOR, 2.09; 95% CI, .91 to 4.79). CONCLUSIONS: Vaccination reduced odds of reinfections when the Delta variant predominated. Further studies should assess risk of severe outcomes among reinfected persons as new variants emerge, infection- and vaccine-induced immunity wanes, and booster doses are administered.

Reinfection With Severe Acute Respiratory Syndrome Coronavirus 2 Among Previously Infected Healthcare Personnel and First Responders.

BACKGROUND: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus testing among first responders and healthcare personnel who participated in a May 2020-August 2020 serosurvey that assessed spike protein antibodies provided an opportunity to assess reinfection. METHODS: Serology survey data were merged with virus testing results from Rhode Island (1 March 2020-17 February 2021) and New York City (10 March 2020-14 December 2020). Participants with a positive virus test ≥14 days before their serology test were included. Reinfection was defined as a second positive SARS-CoV-2 test ≥90 days after the first positive test. The association between serostatus and reinfection was assessed with a proportional hazards model. RESULTS: Among 1572 previously infected persons, 40 (2.5%) were reinfected. Reinfection differed by serostatus: 8.4% among seronegative vs 1.9% among seropositive participants (P < .0001). Most reinfections occurred among Rhode Island nursing home and corrections personnel (n = 30) who were most frequently tested (mean 30.3 tests vs 4.6 for other Rhode Island and 2.3 for New York City participants). The adjusted hazard ratio (aHR) for reinfection in seropositive vs seronegative persons was 0.41 (95% confidence interval [CI], .20-.81). Exposure to a household member with coronavirus disease 2019 (COVID-19) before the serosurvey was also protective (aHR, 0.34; 95% CI, .13-.89). CONCLUSIONS: Reinfections were uncommon among previously infected persons over a 9-month period that preceded widespread variant circulation. Seropositivity decreased reinfection risk. Lower reinfection risk associated with exposure to a household member with COVID-19 may reflect subsequently reduced household transmission.

Rapid Emergence and Epidemiologic Characteristics of the SARS-CoV-2 B.1.526 Variant - New York City, New York, January 1-April 5, 2021.

Recent studies have documented the emergence and rapid growth of B.1.526, a novel variant of interest (VOI) of SARS-CoV-2, the virus that causes COVID-19, in the New York City (NYC) area after its identification in NYC in November 2020 (1-3). Two predominant subclades within the B.1.526 lineage have been identified, one containing the E484K mutation in the receptor-binding domain (1,2), which attenuates in vitro neutralization by multiple SARS-CoV-2 antibodies and is present in variants of concern (VOCs) first identified in South Africa (B.1.351) (4) and Brazil (P.1).* The NYC Department of Health and Mental Hygiene (DOHMH) analyzed laboratory and epidemiologic data to characterize cases of B.1.526 infection, including illness severity, transmission to close contacts, rates of possible reinfection, and laboratory-diagnosed breakthrough infections among vaccinated persons. Preliminary data suggest that the B.1.526 variant does not lead to more severe disease and is not associated with increased risk for infection after vaccination (breakthrough infection) or reinfection. Because relatively few specimens were sequenced over the study period, the statistical power might have been insufficient to detect modest differences in rates of uncommon outcomes such as breakthrough infection or reinfection. Collection of timely viral genomic data for a larger proportion of citywide cases and rapid integration with population-based surveillance data would enable improved understanding of the impact of emerging SARS-CoV-2 variants and specific mutations to help guide public health intervention efforts.

A fatal case report of antibody-dependent enhancement of dengue virus type 1 following remote Zika virus infection.

BACKGROUND: Dengue virus (DENV) is endemic in many parts of the world. Antibody dependent enhancement (ADE) in DENV infections occurs when a person with primary immunity is infected by a second, different DENV strain. Antibodies to Zika virus (ZIKV), which emerged in the Western Hemisphere in 2015, are cross reactive with DENV and theoretically could provoke ADE in a DENV naïve individual. CASE PRESENTATION: DENV infection was suspected in a child who had recently returned from a one-month stay in the Dominican Republic. The child presented with fever, vomiting, abdominal pain, and in hypovolemic shock. Volume and pressor resuscitation were unsuccessful, and the child died less than 24 h after hospitalization. Laboratory results suggested an early acute first DENV infection since serum, plasma, and spinal fluid had DENV1 detected by polymerase chain reaction (PCR), yet the serum lacked IgG antibodies to DENV nonstructural protein 1 (NS1) of all four DENV serotypes. This acute DENV infection occurred in the presence of a remote ZIKV infection as determined by antibodies to ZIKV NS1 envelope by multiplex microsphere immunoassay and an exceptionally high plaque reduction neutralization titer to ZIKV. ZIKV IgG avidity index was high, confirming a past infection. DENV1 RNA was detected in all ten organs and tissues examined by PCR. The severe and fatal complications reported here suggest that a remote ZIKV infection may provoke an exaggerated immune response leading to hypovolemic shock when primarily infected by DENV1. CONCLUSION: We report the first known patient in the United States with a rapidly progressive and fatal case of travel-associated DENV in which prior exposure to ZIKV likely played a role in triggering an ADE phenomenon. This association of prior ZIKV immunity and subsequent new dengue infection is a worrisome phenomenon and an important contribution to the body of knowledge on immunity to flaviviruses.

COVID-19 Outbreak - New York City, February 29-June 1, 2020.

New York City (NYC) was an epicenter of the coronavirus disease 2019 (COVID-19) outbreak in the United States during spring 2020 (1). During March-May 2020, approximately 203,000 laboratory-confirmed COVID-19 cases were reported to the NYC Department of Health and Mental Hygiene (DOHMH). To obtain more complete data, DOHMH used supplementary information sources and relied on direct data importation and matching of patient identifiers for data on hospitalization status, the occurrence of death, race/ethnicity, and presence of underlying medical conditions. The highest rates of cases, hospitalizations, and deaths were concentrated in communities of color, high-poverty areas, and among persons aged ≥75 years or with underlying conditions. The crude fatality rate was 9.2% overall and 32.1% among hospitalized patients. Using these data to prevent additional infections among NYC residents during subsequent waves of the pandemic, particularly among those at highest risk for hospitalization and death, is critical. Mitigating COVID-19 transmission among vulnerable groups at high risk for hospitalization and death is an urgent priority. Similar to NYC, other jurisdictions might find the use of supplementary information sources valuable in their efforts to prevent COVID-19 infections.

SARS-CoV-2-Associated Deaths Among Persons Aged <21 Years - United States, February 12-July 31, 2020.

Since February 12, 2020, approximately 6.5 million cases of SARS-CoV-2 infection, the cause of coronavirus disease 2019 (COVID-19), and 190,000 SARS-CoV-2-associated deaths have been reported in the United States (1,2). Symptoms associated with SARS-CoV-2 infection are milder in children compared with adults (3). Persons aged <21 years constitute 26% of the U.S. population (4), and this report describes characteristics of U.S. persons in that population who died in association with SARS-CoV-2 infection, as reported by public health jurisdictions. Among 121 SARS-CoV-2-associated deaths reported to CDC among persons aged <21 years in the United States during February 12-July 31, 2020, 63% occurred in males, 10% of decedents were aged <1 year, 20% were aged 1-9 years, 70% were aged 10-20 years, 45% were Hispanic persons, 29% were non-Hispanic Black (Black) persons, and 4% were non-Hispanic American Indian or Alaska Native (AI/AN) persons. Among these 121 decedents, 91 (75%) had an underlying medical condition,* 79 (65%) died after admission to a hospital, and 39 (32%) died at home or in the emergency department (ED).† These data show that nearly three quarters of SARS-CoV-2-associated deaths among infants, children, adolescents, and young adults have occurred in persons aged 10-20 years, with a disproportionate percentage among young adults aged 18-20 years and among Hispanics, Blacks, AI/ANs, and persons with underlying medical conditions. Careful monitoring of SARS-CoV-2 infections, deaths, and other severe outcomes among persons aged <21 years remains particularly important as schools reopen in the United States. Ongoing evaluation of effectiveness of prevention and control strategies will also be important to inform public health guidance for schools and parents and other caregivers.

Characteristics of Persons Who Died with COVID-19 - United States, February 12-May 18, 2020.

During January 1, 2020-May 18, 2020, approximately 1.3 million cases of coronavirus disease 2019 (COVID-19) and 83,000 COVID-19-associated deaths were reported in the United States (1). Understanding the demographic and clinical characteristics of decedents could inform medical and public health interventions focused on preventing COVID-19-associated mortality. This report describes decedents with laboratory-confirmed infection with SARS-CoV-2, the virus that causes COVID-19, using data from 1) the standardized CDC case-report form (case-based surveillance) (https://www.cdc.gov/coronavirus/2019-ncov/php/reporting-pui.html) and 2) supplementary data (supplemental surveillance), such as underlying medical conditions and location of death, obtained through collaboration between CDC and 16 public health jurisdictions (15 states and New York City).

Development and Validation of Surveillance-Based Algorithms to Estimate Hepatitis C Treatment and Cure in New York City.

CONTEXT: Treatment options for chronic hepatitis C virus (HCV) have improved in recent years. The burden of HCV in New York City (NYC) is high. Measuring treatment and cure among NYC residents with HCV infection will allow the NYC Department of Health and Mental Hygiene (DOHMH) to appropriately plan interventions, allocate resources, and identify disparities to combat the hepatitis C epidemic in NYC. OBJECTIVE: To validate algorithms designed to estimate treatment and cure of HCV using RNA test results reported through routine surveillance. DESIGN: Investigation by NYC DOHMH to determine the true treatment and cure status of HCV-infected individuals using chart review and HCV test data. Treatment and cure status as determined by investigation are compared with the status determined by the algorithms. SETTING: New York City health care facilities. PARTICIPANTS: A total of 250 individuals with HCV reported to the New York City Department of Health and Mental Hygiene (NYC DOHMH) prior to March 2016 randomly selected from 15 health care facilities. MAIN OUTCOME MEASURES: The sensitivity and specificity of the algorithms. RESULTS: Of 235 individuals successfully investigated, 161 (69%) initiated treatment and 96 (41%) achieved cure since the beginning of 2014. The treatment algorithm had a sensitivity of 93.2% (95% confidence interval [CI], 89.2%-97.1%) and a specificity of 83.8% (95% CI, 75.3%-92.2%). The cure algorithm had a sensitivity of 93.8% (95% CI, 88.9%-98.6%) and a specificity of 89.4% (95% CI, 83.5%-95.4%). Applying the algorithms to 68 088 individuals with HCV reported to DOHMH between July 1, 2014, and December 31, 2016, 28 392 (41.7%) received treatment and 16 921 (24.9%) were cured. CONCLUSIONS: The algorithms developed by DOHMH are able to accurately identify HCV treatment and cure using only routinely reported surveillance data. Such algorithms can be used to measure treatment and cure jurisdiction-wide and will be vital for monitoring and addressing HCV. NYC DOHMH will apply these algorithms to surveillance data to monitor treatment and cure rates at city-wide and programmatic levels, and use the algorithms to measure progress towards defined treatment and cure targets for the city.

Zika Virus Surveillance and Preparedness - New York City, 2015-2016.

Zika virus has rapidly spread through the World Health Organization's Region of the Americas since being identified in Brazil in early 2015. Transmitted primarily through the bite of infected Aedes species mosquitoes, Zika virus infection during pregnancy can cause spontaneous abortion and birth defects, including microcephaly (1,2). New York City (NYC) is home to a large number of persons who travel frequently to areas with active Zika virus transmission, including immigrants from these areas. In November 2015, the NYC Department of Health and Mental Hygiene (DOHMH) began developing and implementing plans for managing Zika virus and on February 1, 2016, activated its Incident Command System. During January 1-June 17, 2016, DOHMH coordinated diagnostic laboratory testing for 3,605 persons with travel-associated exposure, 182 (5.0%) of whom had confirmed Zika virus infection. Twenty (11.0%) confirmed patients were pregnant at the time of diagnosis. In addition, two cases of Zika virus-associated Guillain-Barré syndrome were diagnosed. DOHMH's response has focused on 1) identifying and diagnosing suspected cases; 2) educating the public and medical providers about Zika virus risks, transmission, and prevention strategies, particularly in areas with large populations of immigrants from areas with ongoing Zika virus transmission; 3) monitoring pregnant women with Zika virus infection and their fetuses and infants; 4) detecting local mosquito-borne transmission through both human and mosquito surveillance; and 5) modifying existing Culex mosquito control measures by targeting Aedes species of mosquitoes through the use of larvicides and adulticides.

Comparative hospitalization risk for SARS-CoV-2 Omicron and Delta variant infections, by variant predominance periods and patient-level sequencing results, New York City, August 2021-January 2022.

BACKGROUND: Comparing disease severity between SARS-CoV-2 variants among populations with varied vaccination and infection histories can help characterize emerging variants and support healthcare system preparedness. METHODS: We compared COVID-19 hospitalization risk among New York City residents with positive laboratory-based SARS-CoV-2 tests when ≥98% of sequencing results were Delta (August-November 2021) or Omicron (BA.1 and sublineages, January 2022). A secondary analysis defined variant exposure using patient-level sequencing results during July 2021-January 2022, comprising 1-18% of weekly confirmed cases. RESULTS: Hospitalization risk was lower among patients testing positive when Omicron (16,025/488,053, 3.3%) than when Delta predominated (8268/158,799, 5.2%). In multivariable analysis adjusting for demographic characteristics and prior diagnosis and vaccination status, patients testing positive when Omicron predominated, compared with Delta, had 0.72 (95% CI: 0.63, 0.82) times the hospitalization risk. In a secondary analysis of patients with sequencing results, hospitalization risk was similar among patients infected with Omicron (2042/29,866, 6.8%), compared with Delta (1780/25,272, 7.0%), and higher among the subset who received two mRNA vaccine doses (adjusted relative risk 1.64; 95% CI: 1.44, 1.87). CONCLUSIONS: Hospitalization risk was lower among patients testing positive when Omicron predominated, compared with Delta. This finding persisted after adjusting for prior diagnosis and vaccination status, suggesting intrinsic virologic properties, not population-based immunity, explained the lower severity. Secondary analyses demonstrated collider bias from the sequencing sampling frame changing over time in ways associated with disease severity. Representative data collection is necessary to avoid bias when comparing disease severity between previously dominant and newly emerging variants.

Reduced COVID-19 hospitalizations among New York City residents following age-based SARS-CoV-2 vaccine eligibility: Evidence from a regression discontinuity design.

BACKGROUND: In clinical trials, several SARS-CoV-2 vaccines were shown to reduce risk of severe COVID-19 illness. Local, population-level, real-world evidence of vaccine effectiveness is accumulating. We assessed vaccine effectiveness for community-dwelling New York City (NYC) residents using a quasi-experimental, regression discontinuity design, leveraging a period (January 12-March 9, 2021) when ≥ 65-year-olds were vaccine-eligible but younger persons, excluding essential workers, were not. METHODS: We constructed segmented, negative binomial regression models of age-specific COVID-19 hospitalization rates among 45-84-year-old NYC residents during a post-vaccination program implementation period (February 21-April 17, 2021), with a discontinuity at age 65 years. The relationship between age and hospitalization rates in an unvaccinated population was incorporated using a pre-implementation period (December 20, 2020-February 13, 2021). We calculated the rate ratio (RR) and 95% confidence interval (CI) for the interaction between implementation period (pre or post) and age-based eligibility (45-64 or 65-84 years). Analyses were stratified by race/ethnicity and borough of residence. Similar analyses were conducted for COVID-19 deaths. RESULTS: Hospitalization rates among 65-84-year-olds decreased from pre- to post-implementation periods (RR 0.85, 95% CI: 0.74-0.97), controlling for trends among 45-64-year-olds. Accordingly, an estimated 721 (95% CI: 126-1,241) hospitalizations were averted. Residents just above the eligibility threshold (65-66-year-olds) had lower hospitalization rates than those below (63-64-year-olds). Racial/ethnic groups and boroughs with higher vaccine coverage generally experienced greater reductions in RR point estimates. Uncertainty was greater for the decrease in COVID-19 death rates (RR 0.85, 95% CI: 0.66-1.10). CONCLUSION: The vaccination program in NYC reduced COVID-19 hospitalizations among the initially age-eligible ≥ 65-year-old population by approximately 15% in the first eight weeks. The real-world evidence of vaccine effectiveness makes it more imperative to improve vaccine access and uptake to reduce inequities in COVID-19 outcomes.

Built by epidemiologists for epidemiologists: an internal COVID-19 dashboard for real-time situational awareness in New York City.

Objective: New York City (NYC) experienced a large first wave of coronavirus disease 2019 (COVID-19) in the spring of 2020, but the Health Department lacked tools to easily visualize and analyze incoming surveillance data to inform response activities. To streamline ongoing surveillance, a group of infectious disease epidemiologists built an interactive dashboard using open-source software to monitor demographic, spatial, and temporal trends in COVID-19 epidemiology in NYC in near real-time for internal use by other surveillance and epidemiology experts. Materials and methods: Existing surveillance databases and systems were leveraged to create daily analytic datasets of COVID-19 case and testing information, aggregated by week and key demographics. The dashboard was developed iteratively using R, and includes interactive graphs, tables, and maps summarizing recent COVID-19 epidemiologic trends. Additional data and interactive features were incorporated to provide further information on the spread of COVID-19 in NYC. Results: The dashboard allows key staff to quickly review situational data, identify concerning trends, and easily maintain granular situational awareness of COVID-19 epidemiology in NYC. Discussion: The dashboard is used to inform weekly surveillance summaries and alleviated the burden of manual report production on infectious disease epidemiologists. The system was built by and for epidemiologists, which is critical to its utility and functionality. Interactivity allows users to understand broad and granular data, and flexibility in dashboard development means new metrics and visualizations can be developed as needed. Conclusions: Additional investment and development of public health informatics tools, along with standardized frameworks for local health jurisdictions to analyze and visualize data in emergencies, are warranted.

Estimating the infection-fatality risk of SARS-CoV-2 in New York City during the spring 2020 pandemic wave: a model-based analysis.

BACKGROUND: As the COVID-19 pandemic continues to unfold, the infection-fatality risk (ie, risk of death among all infected individuals including those with asymptomatic and mild infections) is crucial for gauging the burden of death due to COVID-19 in the coming months or years. Here, we estimate the infection-fatality risk of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in New York City, NY, USA, the first epidemic centre in the USA, where the infection-fatality risk remains unclear. METHODS: In this model-based analysis, we developed a meta-population network model-inference system to estimate the underlying SARS-CoV-2 infection rate in New York City during the 2020 spring pandemic wave using available case, mortality, and mobility data. Based on these estimates, we further estimated the infection-fatality risk for all ages overall and for five age groups (<25, 25-44, 45-64, 65-74, and ≥75 years) separately, during the period March 1 to June 6, 2020 (ie, before the city began a phased reopening). FINDINGS: During the period March 1 to June 6, 2020, 205 639 people had a laboratory-confirmed infection with SARS-CoV-2 and 21 447 confirmed and probable COVID-19-related deaths occurred among residents of New York City. We estimated an overall infection-fatality risk of 1·39% (95% credible interval 1·04-1·77) in New York City. Our estimated infection-fatality risk for the two oldest age groups (65-74 and ≥75 years) was much higher than the younger age groups, with a cumulative estimated infection-fatality risk of 0·116% (0·0729-0·148) for those aged 25-44 years and 0·939% (0·729-1·19) for those aged 45-64 years versus 4·87% (3·37-6·89) for those aged 65-74 years and 14·2% (10·2-18·1) for those aged 75 years and older. In particular, weekly infection-fatality risk was estimated to be as high as 6·72% (5·52-8·01) for those aged 65-74 years and 19·1% (14·7-21·9) for those aged 75 years and older. INTERPRETATION: Our results are based on more complete ascertainment of COVID-19-related deaths in New York City than other places and thus probably reflect the true higher burden of death due to COVID-19 than that previously reported elsewhere. Given the high infection-fatality risk of SARS-CoV-2, governments must account for and closely monitor the infection rate and population health outcomes and enact prompt public health responses accordingly as the COVID-19 pandemic unfolds. FUNDING: National Institute of Allergy and Infectious Diseases, National Science Foundation Rapid Response Research Program, and New York City Department of Health and Mental Hygiene.

First 12 Months of Life for Infants in New York City, New York, With Possible Congenital Zika Virus Exposure.

BACKGROUND: Our goal was to characterize the epidemiology and clinical significance of congenital Zika virus (ZIKV) exposure by prospectively following a cohort of infants with possible congenital exposure through their first year of life. METHODS: We included infants born in New York City between 2016 and 2017 who had or were born to a woman who had laboratory evidence of ZIKV infection during pregnancy. We conducted provider/patient interviews and reviewed medical records to collect information about the pregnant women and, for infants, clinical and neurodevelopmental status at birth and 2, 6, and 12 months of age. RESULTS: Of the 404 infants who met inclusion criteria, most (385 [95.3%]) appeared well, whereas 19 (4.7%) had a possible ZIKV-associated birth defect. Seven had congenital ZIKV syndrome, and 12 were microcephalic without other abnormalities. Although infants with congenital ZIKV syndrome manifested clinical and neurodevelopmental sequelae during their first year of life, all 12 infants with isolated microcephaly were normocephalic and appeared well by 2 months of age. Laboratory evidence of ZIKV was detected for 22 of the infants, including 7 (31.8%) with a birth defect. Among 148 infants without a birth defect and negative/no laboratory results on ZIKV testing, and for whom information was available at 1 year, 4 presented with a developmental delay. CONCLUSIONS: Among infants with possible congenital ZIKV exposure, a small proportion had possible ZIKV-associated findings at birth or at follow-up, or laboratory evidence of ZIKV. Identifying and monitoring infants with possible ZIKV exposure requires extensive efforts by providers and public health departments. Longitudinal studies using standardized clinical and developmental assessments are needed for infants after possible congenital ZIKV exposure.

Epidemiological Characteristics and Laboratory Findings of Zika Virus Cases in New York City, January 1, 2016-June 30, 2017.

BACKGROUND: An outbreak of Zika virus (ZIKV) began in May 2015 in Brazil and rapidly spread throughout the Americas; New York City (NYC) has a diverse population with ∼1.8 million residents who were born in ZIKV-affected areas. Before July 24, 2017, the Centers for Disease Control and Prevention (CDC) ZIKV testing recommendations included nucleic acid amplification-based tests for serum and urine specimens collected ≤14 days of illness onset or last potential exposure, and ZIKV immunoglobulin M (IgM) assay when ZIKV RNA is not detected or for specimens collected within 2-12 weeks of illness onset or last potential exposure, followed by a plaque reduction neutralization test (PRNT). However, the New York public health laboratories and commercial laboratories tested specimens collected beyond these time frames. METHODS: We analyzed 1080 noncongenital ZIKV cases in NYC residents who met the Council for State and Territorial Epidemiologist's ZIKV case definitions. RESULTS: Among cases, 98% were travel associated, 1% were sexually transmitted, and 1% had unknown exposures; 412 (38%) cases were pregnant women. Of 672 patients with ZIKV RNA detected in serum or urine specimens, 48 (7%) tested positive >14 days after either symptom onset or last potential exposure date (range 15-99 days). Of 390 patients diagnosed based on serology alone (i.e., not tested or not detectable for ZIKV RNA), 60 (15%) had a positive ZIKV IgM and PRNT >12 weeks after symptom onset or last potential exposure date (range 85-273 days). CONCLUSION: Our findings correspond with CDC's updated guidance to test symptomatic pregnant women up to 12 weeks past onset of symptoms. ZIKV IgM antibody testing may also be warranted for pregnant women regardless of symptoms if their exposure occurred during their pregnancy or periconception period. Providers should understand the scope of diagnostic testing and its limitations to appropriately counsel patients, especially pregnant women.

Zika Virus Infection Among Pregnant Women and Their Neonates in New York City, January 2016-June 2017.

OBJECTIVE: To describe and compare differences in the epidemiologic, clinical, and laboratory characteristics of pregnant women with confirmed or probable Zika virus infection and to compare the risk of having a neonate with laboratory evidence of Zika virus infection with that of having a neonate without evidence of Zika virus infection by maternal characteristics. METHODS: We conducted a retrospective cohort study of women with Zika virus infection who completed pregnancy in New York City from January 1, 2016 to June 30, 2017. Confirmed Zika virus infection was defined as 1) nucleic acid amplification test-detected Zika virus, or 2) a nonnegative enzyme-linked immunosorbent assay test result and a plaque-reduction neutralization test result positive for Zika virus but negative for dengue virus, or 3) delivery of a neonate with laboratory evidence of Zika virus infection. Probable infection was defined as a nonnegative enzyme-linked immunosorbent assay test result and a positive plaque-reduction neutralization test result for Zika virus and dengue virus. RESULTS: We identified 390 women with confirmed (28%) or probable (72%) Zika virus infection. Fever, rash, arthralgia, or conjunctivitis was reported by 31% of women and were more common among women with confirmed than with probable infection (43% vs 26%, P=.001). Of 366 neonates born to these women, 295 (81%) were tested for Zika virus and 22 (7%) had laboratory-diagnosed congenital Zika virus infection. The relative risk (RR) for having a neonate with laboratory evidence of Zika virus infection was greater among women with fever (RR 4.8, 95% CI 2.1-10.7), tingling (RR 4.8, CI 1.7-13.7), or numbness (RR 6.9, CI 2.6-18.2) during pregnancy or the periconception period. However, the RR did not differ whether the mother had confirmed or probable Zika virus infection (RR 1.6, CI 0.7-4.1). CONCLUSION: In New York City, a greater proportion of women had probable Zika virus infection than confirmed infection. Women with some symptoms during pregnancy or periconceptionally were more likely to have a neonate with laboratory evidence of Zika virus infection. Neonates born to women with confirmed or probable Zika virus infection should be tested for Zika virus infection.

Duplicate hepatitis C antibody testing in New York City, 2006-2010.

Repeating a hepatitis C virus antibody test for a person who previously tested positive provides no new information, wastes resources, and may reflect poor coordination of medical care. Using public health surveillance data collected by the New York City Department of Health and Mental Hygiene, we evaluated the magnitude of duplicate antibody testing and assessed patient-level and facility-level risk factors for duplicate testing. From 2006 to 2010, 70,257 duplicate tests were performed for 58,886 individuals in New York City, costing an estimated $1.4 million. Analyses using a polytomous logistic regression model indicated that individuals in correctional and substance abuse treatment facilities were more likely to undergo duplicate testing. Future efforts should focus on coordinating medical information and care for hepatitis C antibody-positive individuals to ensure that the recommended diagnostic follow-up and treatment services are provided.

Half a diagnosis: gap in confirming infection among hepatitis C antibody-positive patients.

BACKGROUND: Recent guidelines recommend testing all individuals born during 1945-1965 for hepatitis C virus (HCV) antibody. For antibody-positive patients, subsequent RNA testing is necessary to determine current infection status. This study aimed to assess whether clinicians order HCV RNA tests as recommended for antibody-positive patients and to identify barriers to such testing. METHODS: We sampled individuals newly reported to the New York City Department of Health and Mental Hygiene's HCV surveillance system and collected information from clinicians. For patients without RNA test results, we asked the reason an RNA test was not ordered and requested that the clinician order the test. RESULTS: Of 245 antibody-positive patients, 67% were tested for HCV RNA (for 21% of these, the test was ordered only after our request); 33% had no RNA testing despite our request. Patients without RNA testing were seen in medical facilities (47%), detox facilities (30%), and jail/prison (15%). Reasons RNA testing was not done were that the patient did not return for follow-up (35%), the facility does not do RNA testing (22%), and the patient was tested in jail (15%). CONCLUSIONS: In our study, one third of patients did not get complete testing for accurate diagnosis of HCV, which is essential for medical management. Additional education for clinicians about the importance of RNA testing may help. However, with improved antiviral treatments now available for HCV, it is time for reflex HCV RNA testing for positive antibody tests to become routine, just as reflex Western blot testing is standard for human immunodeficiency virus.

Enhanced chronic hepatitis C surveillance in New York City, April 2009-January 2011.

OBJECTIVE: We analyzed and evaluated enhanced chronic hepatitis C virus (HCV) surveillance in New York City (NYC), which involved detailed investigations on a sample of newly reported HCV patients. METHODS: Beginning in July 2009, we generated a simple random sample bimonthly from all patients newly reported with a positive HCV test. We administered questionnaires to clinicians and patients to collect clinical and epidemiological information on patients diagnosed from April 2009 to January 2011 and evaluated the staff resources required to conduct enhanced surveillance. RESULTS: Of 205 patients meeting inclusion criteria, 40 (19.5%) tested HCV ribonucleic acid (RNA) negative. For the remaining 165 patients, questionnaires were completed by 164 clinicians (99.4%) and 77 patients (46.7%). Many patients (54.0%) were born between 1945 and 1964, and most patients were Hispanic (32.7%) or non-Hispanic black (32.7%). Common risk factors were injection (43.0%) and intranasal (33.9%) drug use. One-third of patients were diagnosed in nontraditional medical settings including substance abuse/detoxification centers (25.0%), jail/prison (6.7%), and psychiatric facilities (1.8%). Of 98 patients with positive HCV RNA tests, 38.8% were immune to hepatitis A and 39.8% were immune to hepatitis B. Investigators required approximately 3.5 hours to complete each investigation and averaged 50 days from assignment to completion. CONCLUSIONS: Although conducting enhanced HCV surveillance requires significant resources, investigating a representative sample provides detailed information about NYC's HCV population. Surveillance data have been used to plan educational initiatives for clinicians and patients, which may have led to increased awareness of HCV status, improved patient support, and better overall care.