Management of metastatic melanoma in Texas: disparities in the utilization of immunotherapy following the regulatory approval of immune checkpoint inhibitors.

BACKGROUND: The utilization of modern-immunotherapies, notably immune checkpoint inhibitors (ICIs), has increased markedly in patients with metastatic melanoma over the past decade and are recommended as standard treatment. Given their increasing adoption in routine care for melanoma, understanding patient access to immunotherapy and patterns of its use in Texas is crucial as it remains one of the few states without Medicaid expansion and with high rates of the uninsured population. The objectives of this study were to examine the trend in the utilization of immunotherapy and to determine factors associated with immunotherapy utilization among patients with metastatic melanoma in the era of ICIs in Texas. METHODS: A retrospective cohort study was conducted using the Texas Cancer Registry (TCR) database. The cohort comprised of adult (≥ 18 years) patients with metastatic melanoma diagnosed between June 2011 and December 2018. The trend in immunotherapy utilization was assessed by determining the proportion of patients receiving immunotherapy each year. The Average Annual Percent Change (AAPC) in immunotherapy utilization was assessed using joinpoint regression, while multivariable logistic regression was used to determine the association between patient characteristics and immunotherapy receipt. RESULTS: A total of 1,795 adult patients with metastatic melanoma were identified from the TCR. Immunotherapy utilization was higher among younger patients, those with no comorbidities, and patients with private insurance. Multivariable analysis showed that the likelihood of receipt of immunotherapy decreased with older age [(adjusted Odds Ratio (aOR), 0.92; 95% CI, 0.89- 0.93, p = 0.001], living in high poverty neighborhood (aOR, 0.52; 95% CI, 0.44 - 0.66, p < 0.0001), having Medicaid (aOR, 0.58; 95% CI, 0.44 - 0.73, p = 0.02), being uninsured (aOR, 0.49; 95% CI, 0.31 - 0.64, p = 0.01), and having comorbidities (CCI score 1: aOR, 0.48; 95% CI, 0.34 - 0.71, p = 0.003; CCI score ≥ 2: aOR, 0.32; 95% CI, 0.16 - 0.56, p < 0.0001). CONCLUSIONS AND RELEVANCE: This cohort study identified sociodemographic and socioeconomic disparities in access to immunotherapy in Texas, highlighting the need for policies such as Medicaid expansion that would increase equitable access to this innovative therapy.

Sexual Behaviors and Human Papillomavirus Vaccination in a Heterosexually Active Adult Population at Increased Risk for HIV Infection.

Human papillomavirus (HPV) is the most common sexually acquired infection in the US. Vaccination is effective against infection with high-risk HPV strains, yet HPV vaccine coverage is lower in the US than the national target. This study aimed to determine the relationship between sexual behaviors and HPV vaccination in a heterosexually active population at increased risk for HIV infection. Data from 380 participants aged 18-45 years obtained from the National HIV Behavioral Surveillance system increased risk heterosexuals cycle 5 (2019) in Houston, Texas, was analyzed. RDS-Analyst was used to generate population-based descriptive statistics. Modified Poisson regression models clustered on recruitment chain were conducted in SAS 9.4 to assess the relationship between sexual behaviors and HPV vaccination. Only 11.5% of participants had received at least one dose of the HPV vaccine. Regarding behaviors within the past 12 months, 44.8% reported having condomless casual sex, 51.3% reported having concurrent sexual partnerships while in their most recent relationship, 14.5% reported exchanging sex, and participants had an average of 4-5 sex partners. Further, those who exchanged sex had a significantly lower prevalence of HPV vaccine uptake when compared to those who did not exchange sex (adjusted prevalence ratio 0.23; confidence interval 0.10-0.52), while all other measures of sexual behavior were not significantly associated with HPV vaccination. More research is needed to understand the relationship between exchange sex and low prevalence of vaccination, specifically in women who bear the highest burden of poor HPV-related morbidity and mortality.

Prevalence and risk factors of type II diabetes mellitus among people living with HIV in Texas.

This study aimed to determine the prevalence and risk factors associated with type II diabetes mellitus (T2DM) among people living with HIV (PLWH). Cross-sectional data of 989 PLWH in Texas obtained from the 2015-2017 Texas and Houston Medical Monitoring Project were examined. T2DM was identified by formal medical chart diagnosis, insulin/oral hypoglycemic prescriptions, or most recent fasting blood glucose ≥126 mg/dL. T2DM adjusted prevalence ratios and 95% confidence intervals (CIs) were estimated using multiple logistic regression. Participants were mostly male (72%), ≥40 years (68%), overweight (31%) or obese (28%) and virally suppressed (62%). T2DM prevalence was 15% with variations by age, body mass index, education and health insurance (p < 0.05 for all). Compared to PLWH ≥60 years, 18-39-year-olds had significantly lower likelihood of T2DM (p < 0.001). Overweight and obese PLWH were 2.11 (95% CI: 1.23-3.63) and 3.89 times (95% CI: 2.30-6.56) more likely to have T2DM compared to normal weight PLWH. Over 1 in 6 PLWH in Texas had T2DM, with age and BMI as significant predictors. Since DM is a risk factor for cardiovascular disease and PLWH are living longer, increased education and lifestyle modification interventions are warranted to prevent T2DM development among PLWH.

Prevalence and risk factors of high cholesterol and triglycerides among people with HIV in Texas.

BACKGROUND: People with HIV (PWH) commonly have elevated cholesterol and triglycerides levels that have been linked to medications. However, healthy behaviors including lifestyle changes can lower high cholesterol (CHOL) or high triglycerides (TG), thereby reducing individual risk for cardiovascular diseases. This study aimed to determine the prevalence and risk factors associated with high CHOL or TG among PWH in Texas. METHODS: Cross-sectional data of 981 PWH from the 2015-2017 Texas and Houston Medical Monitoring Projects were examined. High CHOL or TG was identified by medical chart diagnosis, CHOL or TG medication use, or most recent fasting lab ≥ 200 mg/dl (total CHOL) or ≥ 150 mg/dl (TG). High CHOL or TG associations with sociodemographic and clinical characteristics were assessed using Rao-Scott chi-square tests. Prevalence of high CHOL or TG development was calculated using multivariable logistic regression model. RESULTS: High CHOL or TG prevalence was 41% with participants being mostly male (73%), ≥ 40 years (68%), with overweight (31%) or obesity (28%), and virally suppressed (62%). Compared with PWH < 40 years of age, PWH in their 40s, 50s, and ≥ 60s were 57%, 64%, and 62% more likely to have high CHOL or TG, respectively. Participants with overweight and obesity were 41% and 30% more likely to have high CHOL or TG than those with normal weight (BMI: 18.5- < 25), respectively. CONCLUSION: Since high CHOL and TG are modifiable CVD risk factors, increased education and lifestyle modification interventions are warranted to prevent the development of high CHOL or TG among PWH.

Polypharmacy among COVID-19 patients: A systematic review.

BACKGROUND: Polypharmacy, the concomitant use of 5 or more medications, is highly prevalent among older adults and individuals with multimorbid conditions and has been linked to suboptimal clinical outcomes in various diseases. However, little is known about the impact of polypharmacy on clinical outcomes among coronavirus disease 2019 (COVID-19) patients. OBJECTIVE: This systematic review summarizes the available literature on the association between polypharmacy and specific drug classes, and clinical outcomes among COVID-19 patients. METHODS: We conducted an electronic database search on Embase, Medline, Cochrane, Scopus, Google Scholar, clinicaltrials.gov, LITCOVID, PubMed, PubMed Central (PMC), and China national knowledge infrastructure for studies on Polypharmacy among COVID-19 patients using relevant combinations of the keywords. Only studies published between November 2019 to September 2020 were included. Seven articles out of 1502 unique articles met the inclusion criteria and were used for the current study. We adopted the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline in conducting and reporting this systematic review. RESULTS: The total sample size of all studies was 474,342, out of which 10,519 patients were COVID-19 positive, and 4818 COVID-19 positive patients experienced polypharmacy. Five out of the 7 included studies found associations between polypharmacy and negative clinical outcomes among COVID-19 patients. Polypharmacy was associated with increase in the relative risk of a positive COVID-19 test result (P < 0.01), death among male COVID-19 patients (P < 0.001), increase in the rate of acute kidney injury (P = 0.003), and adverse drug reactions (P < 0.001). Antipsychotic drugs were associated with severe COVID-19 morbidity (OR = 2.79; 95% CI 2.23-3.49) and increased risk of death among COVID-19 infected men (OR = 1.71; 95% CI 1.18-2.48) and women (OR = 1.96; 95% CI 1.41-2.73). CONCLUSION: Polypharmacy and selected drug classes are associated with increased risk of adverse clinical outcomes among COVID-19 patients. Understanding these relationships can enhance risk stratification and evidence-based decision-making that may improve care and clinical outcomes of COVID-19 patients.

Racial/ethnic differences in treatment quality among youth with primary care provider-initiated versus mental health specialist-initiated care for major depressive disorders.

OBJECTIVES: To compare the racial/ethnic differences in treatment quality among youth with primary care provider-initiated versus mental health specialist-initiated care for major depressive disorders (MDD). METHODS: A retrospective cohort study was conducted using the 2005-2007 Medicaid claims data from Texas. Youth aged 10-20 during the study period were identified if they had two consecutive MDD diagnoses and received either medications for MDD or psychotherapy. Patients who received ≥84 days of medications and/or ≥4 sessions of psychotherapy for MDD treatment during 4 months of follow-up were considered meeting the minimum adequacy of treatment. RESULTS: The generalized linear multilevel model (MLM) analysis revealed that both Hispanics and Blacks were approximately 30% less likely to receive adequate treatment (Hispanics - OR: 0.67; 95% CI: 0.6-0.8) (Blacks - OR: 0.66; 95% CI: 0.6-0.8) and Hispanic children were 50% more likely to undergo MH-related hospitalization (OR: 1.53; 95% CI: 1.1-2.2) compared to their White counterparts. The odds of meeting the minimum MDD treatment adequacy were comparable between pediatric MDD cases first identified by primary care providers (PCP-I) and psychiatrists (PSY-I) (PCP-I vs. PSY-I: OR: 0.97; 95% CI: 0.8-1.2), and slightly lower in those first identified by social workers/psychologists (SWP-I) as compared to PSY-I (SWP-I vs. PSY-I: OR: 0.81; 95% CI: 0.7-0.9). In all models, the interaction between race/ethnicity and type of provider who initiated MDD care was not statistically significant. CONCLUSIONS: Minority youths received less adequate MDD treatment compared to Whites. Hispanic children had the highest risk of having mental health-related hospitalization. The specialty of provider who initiated MDD care had limited impact on treatment quality and was not associated with the racial/ethnic variations in treatment completion and mental health-related hospitalizations.

Metabolic Syndrome Among People Living with HIV Receiving Medical Care in Southern United States: Prevalence and Risk Factors.

Using representative data among 1861 in care people living with HIV (PLWH) in four southern states (Texas, Mississippi, Florida, and Georgia) from the 2013-2014 Medical Monitoring Project (MMP) survey, we estimated the prevalence and odds of metabolic syndrome (MetS) among various demographic and HIV related risk factors. Overall MetS prevalence was 34%, with our participants being mostly black (55%), male (72%), ≥ 50 years old (46%), and overweight or obese (60%) with undetectable viral loads (≤ 200 copies/ml, 69%), and were currently taking antiretroviral medication (98%). Compared to those who were ≥ 60 years, 18-39 year olds had a 79% (95% CI 0.13-0.33) lower odds of having MetS. Women were 2.24 times more likely to have MetS than men (95% CI 1.69-2.97). Age and sex were significant predictors of MetS. Since MetS is a combination of chronic disease risk factors, regular screening for MetS risk factors among aging PLWH is crucial.

Applying infectious disease forecasting to public health: a path forward using influenza forecasting examples.

BACKGROUND: Infectious disease forecasting aims to predict characteristics of both seasonal epidemics and future pandemics. Accurate and timely infectious disease forecasts could aid public health responses by informing key preparation and mitigation efforts. MAIN BODY: For forecasts to be fully integrated into public health decision-making, federal, state, and local officials must understand how forecasts were made, how to interpret forecasts, and how well the forecasts have performed in the past. Since the 2013-14 influenza season, the Influenza Division at the Centers for Disease Control and Prevention (CDC) has hosted collaborative challenges to forecast the timing, intensity, and short-term trajectory of influenza-like illness in the United States. Additional efforts to advance forecasting science have included influenza initiatives focused on state-level and hospitalization forecasts, as well as other infectious diseases. Using CDC influenza forecasting challenges as an example, this paper provides an overview of infectious disease forecasting; applications of forecasting to public health; and current work to develop best practices for forecast methodology, applications, and communication. CONCLUSIONS: These efforts, along with other infectious disease forecasting initiatives, can foster the continued advancement of forecasting science.

The Impact of Pharmacotherapy on Substance Use in Adolescents With Attention-Deficit/Hyperactivity Disorder: Variations Across Subtypes.

OBJECTIVE: The primary purpose of this study was to investigate the impact of attention-deficit/hyperactivity disorder (ADHD) pharmacotherapy on the risk of substance use within each ADHD subtype. METHODS: The study used data from the National Comorbidity Survey-Adolescent supplement, a nationally representative sample of US adolescents (ages 13-18) collected from 6,483 adolescent-parent interviews conducted between 2001 and 2004. ADHD was categorized into three subtypes: ADHD-predominantly hyperactive-impulsive type (ADHD-H); ADHD-predominantly inattentive type (ADHD-I); and ADHD-combined type (ADHD-C) using Diagnostic and Statistical Manual of Mental Disorders-IV criteria. Substance use information was obtained from the adolescents' interview. The impact of ADHD-pharmacotherapy on substance use was examined using multivariable logistic regression analysis. RESULTS: Among the adolescents with ADHD, ADHD pharmacotherapy significantly associated with reduced risk of substance use (OR = 0.53, 95%CI [0.31-0.90]); with regards to ADHD subtypes, ADHD pharmacotherapy is negatively associated with substance use in adolescents with ADHD-C (OR = 0.53, 95%CI [0.24-0.97]) and those with ADHD-H (OR = 0.23, 95% CI [0.07-0.78]), but it did not have statistically significant effect on risk of substance use in those with ADHD-I subtype (OR = 0.49, 95%CI [0.17-1.39]). Among the group who never received ADHD-pharmacotherapy before the interview, individuals with ADHD-H and ADHD-C had a similar risk of substance use compared to adolescents with ADHD-I (ADHD-C: OR = 1.5, 95%CI [0.77-2.95] and ADHD-H: OR = 2.10, 95%CI [0.87-4.95]). CONCLUSIONS: Adolescents with ADHD were equally susceptible to future substance use disregard their ADHD subtypes. Receipt of pharmacotherapy could decrease risk of substance use in adolescents with ADHD-H and ADHD-C, but it may not affect risk of substance use among individuals with ADHD-I.

Disparities in Survival Outcomes Among Patients With Metastatic Melanoma in Texas: Implications for Policy and Interventions in the Era of Immune Checkpoint Inhibitors.

OBJECTIVES: Disparities exist in the length and quality of survival from melanoma. This study evaluated, in a Texas cohort, patient factors associated with melanoma survival and examined if newer immune-oncologic agents extend survival compared with conventional therapies. METHODS: A retrospective analysis of patients diagnosed with metastatic melanoma from 2011 to 2018 in the Texas Cancer Registry database. Multivariable Cox proportional hazard regression was used to evaluate patient characteristics associated with cancer-specific survival (CSS) and overall survival (OS). The patient cohort was then grouped based on receipt of first-line immunotherapy or other therapies. The association between receipt of immunotherapy and survival was assessed with Kaplan-Meier analysis and inverse probability treatment weighted Cox regression. RESULTS: There were 1372 patients with metastatic melanoma. Factors associated with increased melanoma mortality risk (CSS) included being male (HR: 1.13, 95% CI: 1.02-1.26), non-Hispanic black (HR: 1.28, 95% CI: 1.13-1.45), living in poorer counties (HR: 1.40, 95%CI: 1.20-1.64), and having multimorbidity (HR: 1.35, 95% CI: 1.05-1.74). All minority races and Hispanics had poorer OS compared with non-Hispanic Whites. Patients who received first-line immunotherapy had significantly longer median (interquartile range) survival (CSS: 27.00 [21.00 to 42.00] mo vs. 16.00 [14.00 to 19.00] mo; OS: 22.00 [17.00 to 27.00] mo vs. 12.00 [11.00 to 14.00] mo). They also had reduced mortality risk (HR for CSS: 0.80; 95% CI: 0.73-0.88; P <0.0001; HR for OS: 0.76; 95% CI: 0.69-0.83; P <0.0001) compared with the nonimmunotherapy cohort. CONCLUSIONS: This study showed differences in risks from melanoma survival based on patient demographic and clinical characteristics. Low socioeconomic status increased mortality risk, and first-line immunotherapy use favored survival. Health policies and tailored interventions that will promote equity in patient survival and survivorship are essential for managing metastatic melanoma.

Modeling covariates of self-perceived and epidemiologic notions of risk for acquiring STIs/HIV among military personnel: a comparative analysis.

This study examined the socio-demographic and selected behavioral characteristics associated with self-perceived and epidemiologic notions of risk for acquiring STIs/HIV infection using data from a cross-sectional survey involving 346 consenting female military personnel from two cantonments in Southwestern Nigeria. Findings revealed significant discordance in participants' risk status based on the two assessment methods, with Kappa coefficients ranging from -0.021 to 0.115. Using epidemiologic assessment as the "gold standard", 45.4% of the study population were able to accurately assess their risk levels through self-perception with significant (P < 0.01) socio-demographic variations. Multivariate logistic regression analyses indicate that STIs/HIV risk models using both self-perceived and epidemiologic notions of risk were significantly determined by different set of covariates. It is recommended that STIs/HIV prevention intervention should integrate the identified covariates and be targeted at changing individual risk behaviors and perceptions, as well as the social contexts in which risky behaviors occur in the military population.

Pediatric diarrhea patients living in urban areas have a higher incidence of Clostridioides difficile infection.

Clostridioides difficile infection (CDI) is a major cause of antibiotic-associated diarrhea and an unappreciated contributor to child mortality in low- and middle-income countries where the diagnosis may be difficult. There is little information about the prevalence of CDI among infants, children, and adolescents in Africa. Using a cross-sectional design, seventy-six samples were collected from pediatric patients presenting with diarrhea, including infants (≤ 2 years old), children (2-12 years), and adolescents (13 ≤17 years) from three hospitals between January and December 2019. Demographic data, medical history, and prior antibiotic use were recorded. Toxigenic culture and PCR were used to detect and validate the presence of C. difficile in the samples. Data obtained were analyzed using descriptive and inferential statistics. A total of 29 (38.7%), 39 (52.0%) and 7 (9.3%) samples were from infants, children, and adolescents, respectively. The average age of the patients was 4.4 years. Of these samples, 31 (41%) were positive for C. difficile by culture and were verified by PCR amplification of C. difficile-specific genes (tcdA and tcdB). The most positive cases were children (53.3%) and infants (40.0%) with the majority of them residing in urban areas. Forty-nine (66.2%) of the patients had no known antibiotics exposure, whereas 29.0% and 29.7% reported the use of over-the-counter antibiotics at 14 and 90 days, prior to the hospital visit, respectively. CDI is relatively common among children with diarrhea in Northern Nigeria. Therefore, for effective management and treatment, more attention should be given to testing for C. difficile as one of the causative agents of diarrhea.

Predictors of opioid prescription among outpatients with osteoarthritis in the United States.

BACKGROUND: Osteoarthritis (OA) management targets pain reduction through multimodal strategies to improve functional status. Among pharmaceutical options, opioids have been selected as a treatment option for pain management, without endorsement by evidence-based guidelines. OBJECTIVE: To examine the predictors of opioid prescriptions for OA during outpatient visits in the United States (US). DESIGN: This study was based on the National Ambulatory Medical Care Survey (NAMCS) database (2012-2016), with a retrospective, cross-sectional study design of US adult outpatient visits with OA. The primary outcome was opioid prescription, and socio-demographic and clinical characteristics were independent variables. Weighted descriptive, bivariate, and multivariable logistic regression analyses were utilized to study patient characteristics and to assess the predictors of opioid prescription. RESULTS: Approximately, 51.68 million (95 percent CI = 44.41-58.95 million) OA-related outpatient visits were made between 2012 and 2016. Most patients were established patients (82.32 percent), and 20.58 percent of the visits resulted in opioid prescriptions. Key prescriptions within the opioid analgesic and combination categories were tramadol-based (5.16 percent) and hydrocodone-based (9.10 percent). Patients who paid through Medicaid were three times more likely (aOR = 3.25, 95 percent CI = 1.60-6.61, p = 0.0012) than those who paid through private insurance to receive an opioid prescrip-tion, new patients were 59 percent less likely (aOR = 0.41, 95 percent CI = 0.24-0.68, p = 0.0007) to receive an opioid prescription as compared to established patients, and obese patients were twice as likely (aOR = 1.88, 95 percent CI = 1.11-3.20, p = 0.0199) than nonobese patients to receive an opioid prescription. CONCLUSIONS: Payment source, obesity, and patient visit status were associated with the receipt of an opioid prescription among OA outpatients. Further research is needed to establish intrinsic factors that drive opioid prescription in this population.

Regional transmission patterns of carbapenemase-producing Enterobacterales: A healthcare network analysis.

OBJECTIVE: Carbapenem-resistant Enterobacterales (CRE) pose a serious public health threat and spread rapidly between healthcare facilities (HCFs) during interfacility patient movement. We examined patterns of transmission of CRE associated with network clustering and positions during patient interfacility transfer. METHODS: A retrospective cohort study was conducted in the Greater Houston region ofTexas, , and social network analysis was performed by constructing facility-to-facility patient transfer network using CRE surveillance data. The network method (community detection algorithm) was used to detect clustering patterns of CRE in the network. In addition, network measures of centrality and local connectivity (clustering coefficient) were computed for each healthcare facility. Zero-inflated negative binomial regression analysis was applied to test the association between network measures and facility-specific incidence rate of CRE. RESULTS: A network of 268 healthcare facilities was identified, in which 10 acute-care hospitals (ACHs) alone accounted for 63% of identified CRE cases. Transmission of New Delhi metallo-ß-lactamase-producing CRE occurred in 3 clusters, yet all cases were traced to patients who had had medical care abroad. The incidence rate of CRE attributed to ACHs was >4-fold (adjusted rate ratio, 4.5; 95% confidence interval [CI], 3.02-6.72) higher than that of long-term care facilities. Each additional patient shared with another HCF conferred a 3% (95% CI, 2%-4%) increase in the incidence rate of CRE at that HCF. CONCLUSIONS: The incidence rates of CRE at a given HCF was predicted by the healthcare network metrics. Increased surveillance and selective targeting of high-risk facilities are warranted.

Development and internal validation of a risk prediction model for HIV disease severity among people living with HIV and mental illness or substance use disorder.

PURPOSE: Mental illness (MI) and substance use disorders (SUD) are highly prevalent among people living with HIV (PLWH), and have been linked to poor HIV clinical outcomes. Innovative tools for early risk identification can facilitate timely interventions for PLWH and MI/SUD to improve their health outcomes, however, this is currently lacking in Texas, a state with the 4th largest population of PLWH in the United States. To address this gap, we developed a predictive model to estimate the risk of suboptimal HIV clinical outcomes among PLWH and MI/SUD in Texas. METHODS: The Texas Medical Monitoring Project data obtained from June 2015-May 2020 were used to develop and internally validate the predictive model. Univariate descriptive and bivariate inferential statistics were performed to describe the characteristics of the study population and unadjusted associations with HIV clinical outcomes. Multivariable logistic regression was used to develop the prediction model. Internal validation was performed using the bootstrap method. RESULTS: A total of 518 respondents aged 18 years and above, representing 27,255 adults living with HIV and mental illness or substance use disorders in Texas were included. Most participants were male (77.0%), less than 50 years of age (60.0%), and had mild diagnosed mental illness and substance use disorder (54.8%). The risk predictive model contained eight predictors, which together yielded an area under the receiver operating characteristic (ROC) curve of 0.727. Non-retention in care appeared to be the strongest risk predictor for having suboptimal HIV clinical outcome (adjusted odds ratio (aOR) = 3.27; 95% confidence interval (CI) = 1.45, 7.42). CONCLUSIONS: The predictive model had good discrimination between persons at risk of poor HIV clinical outcomes and those not at risk.

Intersection of Perceived COVID-19 Risk, Preparedness, and Preventive Health Behaviors: Latent Class Segmentation Analysis.

Background: COVID-19 risk perception is a factor that influences the pandemic spread. Understanding the potential behavioral responses to COVID-19, including preparedness and adoption of preventive measures, can inform interventions to curtail its spread. Objective: We assessed self-perceived and latent class analysis (LCA)-based risks of COVID-19 and their associations with preparedness, misconception, information gap, and preventive practices among residents of a densely populated city in Nigeria. Methods: We used data from a cross-sectional survey conducted among residents (N=140) of Onitsha, Nigeria, in March 2020, before the government-mandated lockdown. Using an iterative expectation-maximization algorithm, we applied LCA to systematically segment participants into the most likely distinct risk clusters. Furthermore, we used bivariate and multivariable logistic regression models to determine the associations among knowledge, attitude, preventive practice, perceived preparedness, misconception, COVID-19 information gap, and self-perceived and LCA-based COVID-19 risks. Results: Most participants (85/140, 60.7%) had good knowledge and did not perceive themselves as at risk of contracting COVID-19. Three-quarters of the participants (102/137, 74.6%; P<.001) experienced COVID-19-related information gaps, while 62.9% (88/140; P=.04) of the participants had some misconceptions about the disease. Conversely, most participants (93/140, 66.4%; P<.001) indicated that they were prepared for the COVID-19 pandemic. The majority of the participants (94/138, 68.1%; P<.001) self-perceived that they were not at risk of contracting COVID-19 compared to 31.9% (44/138) who professed to be at risk of contracting COVID-19. Using the LCA, we identified 3 distinct risk clusters (P<.001), namely, prudent or low-risk takers, skeptics or high-risk takers, and carefree or very high-risk takers with prevalence rates (probabilities of cluster membership that represent the prevalence rate [γc]) of 47.5% (95% CI 40%-55%), 16.2% (95% CI 11.4%-20.9%), and 36.4% (95% CI 28.8%-43.9%), respectively. We recorded a significantly negative agreement between self-perceived risk and LCA-based segmentation of COVID-19 risk (κ=-0.218, SD 0.067; P=.01). Knowledge, attitude, and perceived need for COVID-19 information were significant predictors of COVID-19 preventive practices among the Onitsha city residents. Conclusions: The clustering patterns highlight the impact of modifiable risk behaviors on COVID-19 preventive practices, which can provide strong empirical support for health prevention policies. Consequently, clusters with individuals at high risk of contracting COVID-19 would benefit from multicomponent interventions delivered in diverse settings to improve the population-based response to the pandemic.

Population-based assessment of the burden of COVID-19 infection in African countries: a first-year report card and public health implications.

Background: The COVID-19 pandemic constitutes a global health threat and poses a major burden on the African continent. We assessed the real-world burden of COVID-19 infection in African Union (AU) member states to determine the distributional patterns of epidemiological measures during the first 1 year of the pandemic. Methods: This retrospective cross-sectional study utilized COVID-19 data from publicly available data repositories of the African Center for Disease Control and Prevention and Our World in Data for the period February 2020 to January 2021. AU member states were classified into low, medium, and high burdens based on COVID-19 morbidity. We conducted descriptive and inferential analyses of COVID-19-reported cases, deaths, recoveries, active cases, COVID-19 tests, and epidemiological measures that included morbidity and mortality rates, case fatality rate (CFR), and case ratios. Results: A total of 3.21 million cases were reported during the 1-year period, with 2.6 million recoveries, 536,784 cases remaining active, and 77,486 deaths. Most countries (49.1%, n = 26) in AU experienced a low burden of COVID-19 infection compared to 28.3% (n = 15) with medium burden and 22.6% (n = 12) with high burden. AU nations with a high burden of the disease were mainly in the northern and southern regions. South Africa recorded the highest number of cases (1.31 million), followed by Morocco with 457,625 and Tunisia with 175,065 cases. Correspondently, death tolls for these countries were 36,467, 7888, and 5528 deaths, respectively. Of the total COVID-19 tests performed (83.8 million) during the first 1 year, 62.43% were from high-burden countries. The least testing occurred in the medium-burden (18.42%) countries. The overall CFR of AU was 2.21%. A morbidity rate of 327.52/105 population and mortality rate of 5.96/105 population were recorded during the first 1-year period with significant variations (p < 0.0001) across burden levels. Continental morbidity and mortality rates of 17,359/105 and 315.933/105 populations were recorded with significant correlation (r = 0.863, p < 0.0001) between them and variations across selected epidemiological measures by COVID-19 burden levels. Conclusion: Understanding the true burden of the disease in AU countries is important for establishing the impact of the pandemic in the African continent and for intervention planning, preparedness, and deployment of resources during COVID-19 surges and future pandemics.

Awareness of human papillomavirus and reported human papillomavirus vaccine uptake in a high-risk population.

Introduction: Disparities in human papillomavirus (HPV) awareness and HPV vaccine uptake are likely exacerbated among racial/ethnic minority populations living in low-income areas. This study aims to determine the prevalence and correlates of HPV awareness and HPV vaccine uptake in an urban, low-income, racial/ethnic minority population. Methods: Secondary data analyses were performed in 2021 using 380 participants aged 18-45 years from the 2019 National HIV Behavioral Surveillance for high-risk heterosexuals, which monitors HIV risk behaviors among individuals living in high-poverty, high HIV prevalence neighborhoods. Prevalence estimates and modified Poisson regression models were used to assess the relationship between HPV awareness and HPV vaccine uptake, and sociodemographic characteristics. Results: Only 53% of participants had heard of HPV and 11.5% had received at least one dose of the HPV vaccine. Those who were female, non-Hispanic White or other, had public health insurance, lived above the federal poverty level, had experienced homelessness and incarceration, and had usual source of healthcare showed higher awareness of HPV while those who were younger, female, non-Hispanic White or other, recently incarcerated, had a usual source of healthcare, and had a healthcare encounter in the past year showed higher prevalence of HPV vaccine uptake. Conclusions: Prevalence of HPV vaccination in this high-risk population was low and there was a lack of preventive care utilization. Further research is needed on how to effectively target these populations to not only increase vaccine uptake, but to mitigate barriers that contribute to low awareness and suboptimal vaccination uptake in high-risk heterosexual populations.

Clinical epidemiology of carbapenem-resistant Enterobacterales in the Greater Houston region of Texas: a 6-year trend and surveillance analysis.

OBJECTIVES: Carbapenem-resistant Enterobacterales (CRE) remain an urgent public health priority in the United States. CRE poses a major threat to patients in healthcare and a potential risk to the community. This study examined the epidemiological trends, clinical, and microbiological data of CRE in the Greater Houston region of Texas. METHODS: A multi-institutional retrospective observational study was conducted using surveillance data collected from 2015 to 2020. Predictors of incidence rates of CRE were determined by a negative binomial regression fit using a generalized estimation equation. RESULTS: Over a 6-year period, 4236 CRE cases were reported, of which Klebsiella pneumoniae accounted for 84.8%. The results show a steady increase in CRE cases, with a sharp rise since 2018. The majority of carbapenemase-producing Enterobacterales were Klebsiella pneumoniae carbapenemase (KPC)-producing (77.2%), followed by other rare carbapenemases, which includes OXA-48, NDM, IMP, VIM, coproduction of KPC with OXA-48, KPC with NDM, and NDM with OXA-48. Acute care hospitals (ACH) accounted for 68.5% of the source of CRE cases. The incidence rate of CRE cases reported from ACH and long-term acute care (LTAC) facilities was 1.16 times that of long-term care facilities (adjusted rate ratio [ARR] = 1.16, 95% confidence interval [CI]:1.04-1.30). The incidence rate of CRE among patients with indwelling devices was 15% (ARR = 0.85, 95% CI: 0.79-0.92) lower than that of patients without indwelling devices. CONCLUSION: The rise in the rate of CRE cases despite aggressive infection prevention and control strategies in the region is alarming. Evaluating and improving the current infection control strategies may be warranted.

Clinical Outcomes Associated with Co-infection of Carbapenem-Resistant Enterobacterales and other Multidrug-Resistant Organisms.

Background: Infections with carbapenem-resistant Enterobacterales (CRE) are associated with increased risk of death. Polymicrobial infections with antimicrobial-resistance may add to the burden of clinical care and patients' clinical prognosis. Aim: To examine the impact of CRE co-infection with other multi-drug resistant organisms (MDRO) on patient clinical outcomes. Study Design: A retrospective observational study was conducted to compare the clinical outcomes of CRE patients who were co-infected with carbapenem-resistant Pseudomonas aeruginosa (CRPA), multidrug-resistant Acinetobacter baumannii (MDRA) and Methicillin-resistant Staphylococcus aureus (MRSA). Results: A total of 224 CRPA and 209 MDRA co-infections with CRE were identified from 4,236 cases from 2015-2020. The overall 90-day all-cause mortality was 21.6% but increased to 35.0% and 33.5% among patients who were co-infected with CRPA and MDRA, respectively. The odds of all-cause mortality among CRE patients who were co-infected with CRPA was twice that of patients identified with CRE alone [adjusted odds ratio (AOR) = 2.02, 95% confidence interval (CI): 1.18-3.46]. Further, the odds of all-cause mortality among CRE patients who were concomitantly identified with MRSA was more than twice that of patients who were not identified with MRSA [AOR = 2.16, 95%CI:1.31-3.56]. The clinical outcome of patients with CRE did not differ significantly depending on the presence of carbapenemase genes. Conclusion: The results show that CRPA and CRE co-infections have synergistic effects on clinical outcomes. Further investigation is necessary to understand the mechanism. Screening high risk patients for concomitant antimicrobial-resistant infections may have a significant clinical impact, including effective therapies, antibiotic stewardship, and infection control policies.