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.

What we know about antibiotics prescribed by dentists in a Brazilian southeastern state

Abstract The objective of this study was to analyze possible associations between antibiotic dental prescriptions in the public health service, health service characteristics, and social characteristics of the municipalities. Using the register of dispensing in the public health service of a state in the Southeast region of Brazil, in 2017 we analyzed patterns of antibiotic prescriptions by dentists. Data were obtained from the Integrated Pharmaceutical Services Management System (SIGAF, in Portuguese). The outcome variable was the number of Daily Defined Doses (DDD) per 1,000 residents/year in each municipality. CART (Classification and Regression Tree) technique was used to determine the influence of the following variables: populational social characteristics (Human Development Index, Gini Index, the proportion of rural population and proportion of families benefiting from the Bolsa Família Program) and oral health services characteristics (access to individual dental care, number of dentists and oral health teams per 1,000 residents, and percentage of preventive and restorative individual dental procedures. Data analysis was performed using IBM SPSS Statistics 21.0. Antibiotics were the medications most prescribed by dentists in the public health service, with penicillin being the most frequently prescribed class. The average DDD/1,000 residents/year for the 421 municipalities surveyed was 96.54 (range 0.008 and 619.660). Select factors were associated with antibiotic prescriptions including access to individual dental care (Adjusted p-value ≤0.001), a number of oral health teams/1,000 inhabitants (Adjusted p-value=0.001), and Gini Index (Adjusted p-value = 0.046). Access to oral health services and inequality were associated with the use of antibiotics.

Risk of COVID-19 in Patients with Cancer Receiving Immune Checkpoint Inhibitors.

OBJECTIVE: The aim of this study was to determine the rate of coronavirus disease-19 (COVID-19) among patients with cancer treated with immune checkpoint inhibitors (ICIs). MATERIALS AND METHODS: This was a retrospective study of 1,545 patients with cancer treated with ICIs between July 1, 2019, and February 29, 2020, and 20,418 age-, sex-, and cancer category-matched controls in a large referral hospital system. Confirmed COVID-19 case and mortality data were obtained with Massachusetts Department of Public Health from March 1 through June 19, 2020. RESULTS: The mean age was 66.6 years, and 41.9% were female. There were 22 (1.4%) and 213 (1.0%) COVID-19 cases in the ICI and control groups, respectively. When adjusting for demographics, medical comorbidities, and local infection rates, ICIs did not increase COVID-19 susceptibility. CONCLUSION: ICIs did not increase the rate of COVID-19. This information may assist patients and their oncologists in decision-making surrounding cancer treatment during this pandemic.

Trends of two HPV-associated cancers in Massachusetts: cervical and oropharyngeal cancer.

PURPOSE: To understand trends in the incidence and mortality of two human papillomavirus (HPV)-associated cancers, cervical and oropharyngeal cancer, in Massachusetts. METHODS: From 2004 to 2014, the Massachusetts Cancer Registry recorded 3,996 incident cases of oropharyngeal cancer and 2,193 incident cases of cervical cancer. Mortality data were obtained from the Massachusetts Registry of Vital Records and Statistics from 2008 to 2014. Rates were age-standardized to the 2000 U.S. population and trends were assessed using joinpoint regression. RESULTS: While the incidence rate of cervical cancer (5.46 per 100,000) decreased by 2.41% annually (p = 0.004), the incidence rate of oropharyngeal cancer among males (7.85 per 100,000) increased by 2.82% annually (p = 0.0002). Mortality rates for both cancers decreased from 2008 to 2014 but were not statistically significant (cervical - 3.73% annually, p = 0.29; oropharyngeal - 1.94% annually, p = 0.44). CONCLUSION: The rising incidence rate of oropharyngeal cancer in men and the decreasing, but relatively high, incidence rate of cervical cancer in women highlight the need for further screening and prevention by HPV vaccination in Massachusetts.

Measuring chronic liver disease mortality using an expanded cause of death definition and medical records in Connecticut, 2004.

AIM: Chronic liver disease (CLD) is a leading cause of death and is defined based on a specific set of underlying cause-of-death codes on death certificates. This conventional approach to measuring CLD mortality underestimates the true mortality burden because it does not consider certain CLD conditions like viral hepatitis and hepatocellular carcinoma. We measured how much the conventional CLD mortality case definition will underestimate CLD mortality and described the distribution of CLD etiologies in Connecticut. METHODS: We used 2004 Connecticut death certificates to estimate CLD mortality two ways. One way used the conventional definition and the other used an expanded definition that included more conditions suggestive of CLD. We compared the number of deaths identified using this expanded definition with the number identified using the conventional definition. Medical records were reviewed to confirm CLD deaths. RESULTS: Connecticut had 29 314 registered deaths in 2004. Of these, 282 (1.0%) were CLD deaths identified by the conventional CLD definition while 616 (2.1%) were CLD deaths defined by the expanded definition. Medical record review confirmed that most deaths identified by the expanded definition were CLD-related (550/616); this suggested a 15.8 deaths/100 000 population mortality rate. Among deaths for which hepatitis B, hepatitis C and alcoholic liver disease were identified during medical record review, only 8.6%, 45.4% and 36.5%, respectively, had that specific cause-of-death code cited on the death certificate. CONCLUSION: An expanded CLD mortality case definition that incorporates multiple causes of death and additional CLD-related conditions will better estimate CLD mortality.

Causes of death and characteristics of decedents with viral hepatitis, United States, 2010.

BACKGROUND: Previous research indicates that the mortality burden from viral hepatitis is growing, particularly among middle-aged persons. To monitor progress toward prevention goals, it is important to continue to document characteristics and comortalities of these deaths. This study sought to examine demographic characteristics and the most frequent causes of death among decedents with a viral hepatitis-related death. METHODS: A cross-sectional study was performed on approximately 2.4 million death records from 2010. We calculated mortality rates for decedents with and without hepatitis A, B, and C virus (HAV, HBV, and HCV) and relative risks for the most frequently cited conditions in decedents with and without HBV and HCV. RESULTS: In 2010, there were 18 473 (0.7%) deaths with HAV, HBV, and HCV listed among causes of death, disproportionately in those aged 45-64 years. Among the 10 frequent causes of death, decedents listing HBV or HCV died, on average, 22-23 years earlier than decedents not listing these infections. HBV- and HCV-infected decedents aged 45-64 years had an increased risk of having the following conditions reported than decedents without these infections: cancer of liver and intrahepatic bile duct; fibrosis, cirrhosis, and other liver diseases; alcohol-related liver disease; gastrointestinal hemorrhage; human immunodeficiency infection; acute and unspecified renal failure; and septicemia (HCV only). CONCLUSIONS: Decedents with other causes of death that include HBV or HCV died 22-23 years earlier than decedents not listing these infections. These data suggest and support the need for prevention, early identification, and treatment of HBV and HCV.

Hepatitis C virus: an overview for dental health care providers.

BACKGROUND: and Overview. Changes in the science of hepatitis C virus (HCV) infection and transmission in a private dental practice provide an opportunity to update dental health care providers about this pathogen. The authors' aims in this review were to create awareness of health care- associated transmission of hepatitis C and provide an update on the changes in testing and treatment. The authors include data from population-based epidemiologic surveys, clinical practice guidelines, surveillance reports and practice protocols. RESULTS: In the United States, the elevated prevalence of chronic HCV infection among baby boomers-people born during the period from 1945 through 1965-led the Centers for Disease Control and Prevention to release new national screening guidelines. The authors summarize information about the natural history and epidemiology of hepatitis C and describe the new guidelines and novel treatment options. In addition, the authors provide an overview of how outbreaks of health care-associated HCV are detected and prevented. Practical Implications. Because dental health care professionals likely will treat people with current infection, education in the current science of HCV infection is useful.

Indications for testing among reported cases of HCV infection from enhanced hepatitis surveillance sites in the United States, 2004-2010.

OBJECTIVES: Centers for Disease Control and Prevention has recommended a 1-time HCV test for persons born from 1945 through 1965 to supplement current risk-based screening. We examined indications for testing by birth cohort (before 1945, 1945-1965, and after 1965) among persons with past or current HCV. METHODS: Cases had positive HCV laboratory markers reported by 4 surveillance sites (Colorado, Connecticut, Minnesota, and New York) to health departments from 2004 to 2010. Health department staff abstracted demographics and indications for testing from cases' medical records and compiled this information into a surveillance database. RESULTS: Of 110, 223 cases of past or current HCV infection reported during 2004-2010, 74, 578 (68%) were among persons born during 1945-1965. Testing indications were abstracted for 45, 034 (41%) cases; of these, 29 ,544 (66%) identified at least 1 Centers for Disease Control and Prevention-recommended risk factor as a testing indication. Overall, 74% of reported cases were born from 1945 to 1965 or had an injection drug use history. CONCLUSIONS: These data support augmenting the current HCV risk-based screening recommendations by screening adults born from 1945 to 1965.

Case-control study of hepatitis B and hepatitis C in older adults: Do healthcare exposures contribute to burden of new infections?

UNLABELLED: Reports of hepatitis B virus (HBV) and hepatitis C virus (HCV) transmission associated with unsafe medical practices have been increasing in the United States. However, the contribution of healthcare exposures to the burden of new infections is poorly understood outside of recognized outbreaks. We conducted a case-control study at three health departments that perform enhanced viral hepatitis surveillance in New York and Oregon. Reported cases of symptomatic acute hepatitis B and hepatitis C occurring in persons≥55 years of age from 2006 to 2008 were enrolled. Controls were identified using telephone directories and matched to individual cases by age group (55-59, 60-69, and ≥70 years) and residential postal code. Data collection covered exposures within 6 months before symptom onset (cases) or date of interview (controls). Forty-eight (37 hepatitis B and 11 hepatitis C) case and 159 control patients were enrolled. Case patients were more likely than controls to report one or more behavioral risk exposures, including sexual or household contact with an HBV or HCV patient, >1 sex partner, illicit drug use, or incarceration (21% of cases versus 4% of controls exposed; matched odds ratio [mOR]=7.1; 95% confidence interval [CI]: 2.1, 24.1). Case patients were more likely than controls to report hemodialysis (8% of cases; mOR=13.0; 95% CI: 1.5, 115), injections in a healthcare setting (58%; mOR=2.7; 95% CI: 1.3, 5.3), and surgery (33%; mOR=2.3; 95% CI: 1.1, 4.7). In a multivariate model, behavioral risks (adjusted OR [aOR]=5.4; 95% CI: 1.5, 19.0; 17% attributable risk), injections (aOR=2.7; 95% CI: 1.3, 5.8; 37% attributable risk), and hemodialysis (aOR=11.5; 95% CI: 1.2, 107; 8% attributable risk) were associated with case status. CONCLUSION: Healthcare exposures may represent an important source of new HBV and HCV infections among older adults.

Evolving epidemiology of hepatitis C virus in the United States.

The impact of hepatitis C virus (HCV) infection on health and medical care in the United States is a major problem for infectious disease physicians. Although the incidence of HCV infection has declined markedly in the past 2 decades, chronic infection in 3 million or more residents now accounts for more disease and death in the United States than does human immunodeficiency virus (HIV)/AIDS. Current trends in the epidemiology of HCV infection include an apparent increase in young, often suburban heroin injection drug users who initiate use with oral prescription opioid drugs; infections in nonhospital healthcare (clinic) settings; and sexual transmission among HIV-infected persons. Infectious disease physicians will increasingly have the responsibility of diagnosing and treating HCV patients. An understanding of how these patients were infected is important for determining whom to screen and treat.

Use of and exposure to HIV prevention programs and services by persons at high risk for HIV.

Although HIV information is widely available in this country, little is known about how commonly used HIV prevention activities reach persons at highest risk for HIV. In this paper, we describe the extent to which HIV prevention strategies reach a sample of high-risk persons and whether such exposure correlates with having been tested for HIV. Data are from the 2000 HIV Testing Survey, an anonymous interview study of men who have sex with men (MSM), injection drug users (IDU), and high-risk heterosexuals (HRH), recruited from appropriate venues in seven states and New York City. We report the proportion of persons exposed to three types of interventions: information (media messages, brochures), counseling or skills-building (group counseling, role play, calling an AIDS hotline), and prevention supplies (provision of condoms, bleach kits), stratified by HIV testing status (ever, never). Exposure to information interventions was high among 2491 respondents (85%-96%) and did not differ by testing status. Use of counseling or skills-building interventions varied by testing status for IDU (8% untested versus 41% tested, p < 0.01) and HRH (14% versus 20%, p = 0.03) but not MSM (15% versus 23%, p = 0.08). Among tested IDU, those receiving bleach kits were more likely to report consistent bleach use when injecting with nonsterile needles (25% versus 9%, p = 0.003). Exposure to HIV prevention information is high but exposure to counseling or skills-building interventions is less common and more prevalent among those previously tested. Prevention initiatives should focus on counseling and testing, skills-building, and prevention supplies.