Implementation and Performance of a Point-of-Care COVID-19 Test Program in 4000 California Schools.

OBJECTIVE: To evaluate the feasibility and accuracy of an unprecedented COVID-19 antigen testing program in schools, which required a healthcare provider order, laboratory director, a Clinical Laboratory Improvement Amendments certificate of waiver, as well as training of school personnel. STUDY DESIGN: Descriptive report of a point-of-care, school-based antigen testing program in California from August 1st, 2021 through May 30, 2022, in which participants grades K-12 self-swabbed and school personnel performed testing. Participants included 944 009 students, personnel, and community members from 4022 California kindergarten through high schools. Outcomes measured include sensitivity and specificity (with polymerase chain reaction [PCR] as comparator) of the Abbott BinaxNOW antigen test, number of tests performed, and active infections identified. RESULTS: Of 102 022 paired PCR/antigen tests, the overall sensitivity and specificity for the antigen test was 81.2% (95% CI: 80.5%-81.8%) and 99.6% (95% CI: 99.5%-99.6%), respectively, using cycle threshold values <30. During January through March 2022, the highest prevalence period, the positive predictive value of antigen testing was 94.7% and the negative predictive value was 94.2%. Overall, 4022 school sites were enrolled and 3 987 840 million antigen tests were performed on 944 009 individuals. A total of 162 927 positive antigen tests were reported in 135 163 individuals (14.3% of persons tested). CONCLUSIONS: Rapidly implementing a school-based testing program in thousands of schools is feasible. Self-swabbing and testing by school personnel can yield accurate results. On-site COVID-19 testing is no longer necessary in schools, but this model provides a framework for future infectious disease threats.

Characterizing the Rise of Disseminated Gonococcal Infections in California, July 2020-July 2021.

BACKGROUND: California has experienced an increase in reported cases of disseminated gonococcal infection (DGI). Given significant morbidity associated with DGI and the ability of Neisseria gonorrhoeae to rapidly develop antibiotic resistance, characterization of these cases can inform diagnosis, management, and prevention of DGI. METHODS: As part of the public health response to increased reports of DGI, we used gonorrhea surveillance data reported to the California Department of Public Health to identify all DGI cases in a geographically-bound region. Standardized case report forms were used to collect epidemiologic risk factors and clinical information obtained from provider/laboratory reports, medical records, and patient interviews. RESULTS: From 1 July 2020 to 31 July 2021, we identified 149 DGI patients among 63 338 total gonorrhea infections, representing 0.24% of gonorrhea cases. Estimated incidence was 0.47 DGI cases per 100 000 person-years. Mean age of DGI patients was 40 years, and 75 (50%) were cisgender men, of whom only 13 were known to have male partners. Where reported, more than one-third (36%) used methamphetamine and nearly one-quarter (23%) experienced homelessness. Clinically, 61% lacked urogenital, pharyngeal, or rectal symptoms; 2 patients died in the hospital. Among 47 isolates from patients with antimicrobial susceptibility testing (AST) results available, all were susceptible to ceftriaxone and cefixime. CONCLUSIONS: Most DGI patients lacked urogenital symptoms and were not among populations for which routine gonorrhea screening is currently recommended. Expanding gonorrhea screening might prevent DGI. Cefixime is likely the best option if transitioning from parenteral to oral therapy when AST results are unavailable.

Reduced Odds of Mpox-Associated Hospitalization Among Persons Who Received JYNNEOS Vaccine - California, May 2022-May 2023.

The effectiveness of 1 dose of JYNNEOS vaccine (modified vaccinia Ankara vaccine, Bavarian Nordic) against hospitalization for mpox (caused by Monkeypox virus), has been demonstrated; however, the impact of 2 doses on hospitalization risk, especially among persons infected with HIV, who are at higher risk for severe disease, is an important factor in evaluating vaccine effectiveness against mpox disease severity and Monkeypox virus infection. Surveillance data collected by the California Department of Public Health were used to evaluate whether receipt of 2 doses of JYNNEOS vaccine reduced the odds of hospitalization among persons with mpox. The odds of hospitalization among persons with mpox who had received 1 or 2 JYNNEOS doses were 0.27 (95% CI = 0.08-0.65) and 0.20 (95% CI = 0.01-0.90), respectively, compared with unvaccinated mpox patients. In mpox patients with HIV infection, the odds of hospitalization among those who had received 1 JYNNEOS vaccine dose was 0.28 (95% CI = 0.05-0.91) times that of those who were unvaccinated. No mpox-associated hospitalizations were identified among persons infected with HIV who had received 2 JYNNEOS vaccine doses. To optimize durable immunity, all eligible persons at risk for mpox, especially those infected with HIV, should complete the 2-dose JYNNEOS series.

Preferences for Shigellosis-Related Health Promotion Materials for Gay, Bisexual, and Other Men Who Have Sex With Men: Results From a Qualitative Assessment, Atlanta, GA.

BACKGROUND: Shigellosis, an acute diarrheal disease, is the third most common bacterial infection in the United States. Shigellosis most commonly affects children younger than 5 years; however, clusters and outbreaks of shigellosis have been reported among gay, bisexual, and other men who have sex with men (MSM). Evidence suggests that knowledge of shigellosis among MSM is low, indicating health promotion outreach is needed for this population. METHODS: To inform the development of shigellosis-related health communication materials and strategies, 6 focus groups were conducted in 2017, in Atlanta, GA among 24 self-identified gay and bisexual men. Participants were asked about their preferences and recommendations for health communication materials. RESULTS: Participants indicated they would prefer a range of physical and virtual materials placed in diverse locations where the community would see them. Respondents recommended health messages be simple, quick to read, and concise with limited word counts. Participants also advised the use of diverse images that were inclusive of couples of varying sexual orientations to reduce stigma. Participants advocated for the use of humor and provocative images to increase user engagement. CONCLUSIONS: The results emphasize the potential benefits of conducting formative research when designing health communication materials. Incorporating messaging preferences of MSM in the development of shigellosis-related health communication materials could enhance their relevance for the target population while also avoiding unintended consequences associated with stigmatizing MSM.

Large-Scale Implementation of a Daily Rapid Antigen Testing Program in California for Detecting SARS-CoV-2.

Objectives. To evaluate a daily antigen testing program for health care personnel. Methods. We examined antigen testing results between December 13, 2020, and April 30, 2021, from 5 forensic psychiatric inpatient hospitals throughout California. Results. Among 471 023 antigen tests administered, 449 positives (0.0036% false positives) were detected. Conclusions. Antigen tests had low false-positive rates, high positive predictive value, and high levels of acceptability, important characteristics when considering their application in the community. Public Health Implications. Daily antigen testing was feasible and should be considered to reduce COVID-19 transmission. (Am J Public Health. 2022;112(3):467-471. https://doi.org/10.2105/AJPH.2021.306588).

Congenital syphilis prevention in the context of methamphetamine use and homelessness.

BACKGROUND AND OBJECTIVES: Congenital syphilis (CS) is increasing in the United States and is associated with intersecting social and structural determinants of health. This study aimed to delineate birthing parent characteristics associated with CS in an adjusted model. METHODS (N = 720): People diagnosed with syphilis during pregnancy from 2017 to 2018 who were interviewed and linked to infants in the California state surveillance system were included (herein, "birthing parents"). Sociodemographic and clinical CS risk factors informed a stepwise multivariable logistic regression model in which the outcome of interest was infants born with CS. CS prevention continuums delineated the proportion of pregnant people with syphilis who completed steps (e.g., prenatal care entry, syphilis testing, treatment) needed to prevent CS; the outcome was delivering an infant without CS. We stratified continuums by homelessness and methamphetamine use to explore differences in CS outcomes. RESULTS: Of 720 birthing parents, 245 (34%) delivered an infant with CS. Although CS was initially associated with homelessness (odds ratio [OR] = 2.5, 95% confidence interval [CI]: 1.6, 4.0) and methamphetamine use (OR = 2.1, 95% CI: 1.4, 3.1), the addition of prenatal care into a final adjusted model attenuated these associations to not significant. In CS prevention continuums, delivering an infant without CS was less likely for people who reported methamphetamine use (p < .001) and/or homelessness (p < .001). However, when examining only those who received prenatal care, statistical differences for these predictors no longer existed. In the final adjusted model the following were associated with CS: no prenatal care (OR = 16.7, 95% CI: 9.2, 30.3) or late prenatal care (OR = 2.9, 95% CI: 1.9, 4.2); early stage of syphilis (OR = 2.6, 95% CI: 1.8, 3.7); living in Central California (OR = 2.1, 95% CI: 1.1, 4.2). CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE: This is the first analysis to explore birthing parent characteristics associated with delivering an infant with CS in an adjusted model. We demonstrate that prenatal care, when accessed, can result in effective CS prevention among people who are unhoused and/or using methamphetamine equally well compared to counterparts without these risk factors.

Measuring the Impact of the COVID-19 Pandemic on Sexually Transmitted Diseases Public Health Surveillance and Program Operations in the State of California.

BACKGROUND: As public health personnel and resources are redirected to COVID-19, sexually transmitted diseases (STD) programs have been unable to sustain pre-COVID-19 activities. METHODS: We used California (CA) surveillance data to describe trends in case reporting for gonorrhea, chlamydia, and syphilis of any stage in the pre- versus post-COVID-19 eras (January-June 2019 and January-June 2020). We also analyzed data from an electronic survey administered by the CA STD Control Branch to local health jurisdictions in April, June, and September of 2020, assessing the impact of COVID-19 on STD programs. RESULTS: There were sharp declines in cases of all reportable bacterial STDs occurring in conjunction with the March 19, 2020 CA stay-at-home order, most of which did not return to baseline by July. Comparing January-June 2020 to January-June of 2019, there were decreases in reported cases of chlamydia (31%), late syphilis (19%), primary/secondary syphilis (15%), early nonprimary nonsecondary syphilis (14%), and gonorrhea (13%). The largest percentage declines in STD case reporting were among Hispanic, Asian/Pacific Islander, and Black persons. Seventy-eight percent of local health jurisdiction respondents indicated that half or more of their workforce had been redeployed to COVID-19 by September 2020. CONCLUSIONS: During the COVID-19 era, STD case reporting and programmatic functions have diminished throughout CA. Because this may contribute to decreases or delays in STD diagnosis and treatment-with resultant increases in STD transmission-providers and public health officials should prepare for potential increases in STD-related morbidity in the months and years to come.

Neurosyphilis Surveillance: Exploring the Use of Multiple Data Sources to Better Understand Morbidity in California.

ABSTRACT: Accurate reporting of neurosyphilis diagnoses is important to quantify and monitor severe outcomes associated with infection of Treponemal pallidum. This analysis compared the demographic distribution of neurosyphilis diagnoses in sexually transmitted disease surveillance data with administrative hospital data in the California Project Area from 2016 to 2018. Although neurosyphilis morbidity was similar, significant differences were noted by sex, age group, race/ethnicity, and region. Both sexually transmitted disease surveillance and administrative hospital data may be imperfect systems to understand the true morbidity of neurosyphilis.

Shigellosis Among Gay and Bisexual Men: A Qualitative Assessment to Examine Knowledge, Attitudes, and Practices.

BACKGROUND: Shigellosis is a highly contagious enteric bacterial disease transmitted through the fecal-oral route. It is primarily transmitted through person-to-person contact and via contaminated food and water. Outbreaks of shigellosis among men who have sex with men (MSM) attributed to sexual person-to-person contact have been reported. These outbreaks are of concern because they are often caused by multidrug-resistant strains of Shigella. Little is known about shigellosis-related knowledge, attitudes, and practices among gay, bisexual, and other MSM. METHODS: Six focus groups were conducted among self-identified gay or bisexual men in Atlanta, GA, in Fall 2017. Participants were asked about shigellosis-related knowledge, attitudes, and practices. Focus groups were audio recorded, and the transcribed audio was analyzed using inductive and deductive thematic coding. RESULTS: Among the 24 focus group participants, most perceived that diarrheal illness was caused by contaminated food. Knowledge of shigellosis and Shigella was low, with most never having heard of the disease or bacteria. Participants did not perceive shigellosis to be a serious health concern, especially when compared with HIV; however, they did perceive gay and bisexual men to be at risk of Shigella infection. Participants reported mixed intentions to change sexual behaviors to prevent shigellosis or talk with sexual partners about diarrhea. CONCLUSIONS: Health communication and education efforts could be used to increase knowledge about shigellosis and shift perceptions about the severity of shigellosis among gay, bisexual, and other MSM. Additional work is needed to identify effective ways to promote shigellosis-related prevention behaviors among gay, bisexual, and other MSM.

Public Health Responses to COVID-19 Outbreaks on Cruise Ships - Worldwide, February-March 2020.

An estimated 30 million passengers are transported on 272 cruise ships worldwide each year* (1). Cruise ships bring diverse populations into proximity for many days, facilitating transmission of respiratory illness (2). SARS-CoV-2, the virus that causes coronavirus disease (COVID-19) was first identified in Wuhan, China, in December 2019 and has since spread worldwide to at least 187 countries and territories. Widespread COVID-19 transmission on cruise ships has been reported as well (3). Passengers on certain cruise ship voyages might be aged ≥65 years, which places them at greater risk for severe consequences of SARS-CoV-2 infection (4). During February-March 2020, COVID-19 outbreaks associated with three cruise ship voyages have caused more than 800 laboratory-confirmed cases among passengers and crew, including 10 deaths. Transmission occurred across multiple voyages of several ships. This report describes public health responses to COVID-19 outbreaks on these ships. COVID-19 on cruise ships poses a risk for rapid spread of disease, causing outbreaks in a vulnerable population, and aggressive efforts are required to contain spread. All persons should defer all cruise travel worldwide during the COVID-19 pandemic.

Acute HIV Discovered During Routine HIV Screening With HIV Antigen-Antibody Combination Tests in 9 US Emergency Departments.

STUDY OBJECTIVE: Newer combination HIV antigen-antibody tests allow detection of HIV sooner after infection than previous antibody-only immunoassays because, in addition to HIV-1 and -2 antibodies, they detect the HIV-1 p24 antigen, which appears before antibodies develop. We determine the yield of screening with HIV antigen-antibody tests and clinical presentations for new diagnoses of acute and established HIV infection across US emergency departments (EDs). METHODS: This was a retrospective study of 9 EDs in 6 cities with HIV screening programs that integrated laboratory-based antigen-antibody tests between November 1, 2012, and December 31, 2015. Unique patients with newly diagnosed HIV infection were identified and classified as having either acute HIV infection or established HIV infection. Acute HIV infection was defined as a repeatedly reactive antigen-antibody test result, a negative HIV-1/HIV-2 antibody differentiation assay, or Western blot result, but detectable HIV ribonucleic acid (RNA); established HIV infection was defined as a repeatedly reactive antigen-antibody test result and a positive HIV-1/HIV-2 antibody differentiation assay or Western blot result. The primary outcomes were the number of new HIV diagnoses and proportion of patients with laboratory-defined acute HIV infection. Secondary outcomes compared reason for visit and the clinical presentation of acute HIV infection. RESULTS: In total, 214,524 patients were screened for HIV and 839 (0.4%) received a new diagnosis, of which 122 (14.5%) were acute HIV infection and 717 (85.5%) were established HIV infection. Compared with patients with established HIV infection, those with acute HIV infection were younger, had higher RNA and CD4 counts, and were more likely to have viral syndrome (41.8% versus 6.5%) or fever (14.3% versus 3.4%) as their reason for visit. Most patients with acute HIV infection displayed symptoms attributable to acute infection (median symptom count 5 [interquartile range 3 to 6]), with fever often accompanied by greater than or equal to 3 other symptoms (60.7%). CONCLUSION: ED screening using antigen-antibody tests identifies previously undiagnosed HIV infection at proportions that exceed the Centers for Disease Control and Prevention's screening threshold, with the added yield of identifying acute HIV infection in approximately 15% of patients with a new diagnosis. Patients with acute HIV infection often seek ED care for symptoms related to seroconversion.

HIV Prevention and Treatment: The Evolving Role of the Emergency Department.

Historically, the role of the emergency physician in HIV care has been constrained to treating sick patients with opportunistic infections and postexposure prophylaxis for occupational exposures. However, advances in HIV care have led to medications that have substantially fewer issues with toxicity and resistance, opening up an exciting new opportunity for emergency physicians to participate in treating the HIV virus itself. With this new role, it is crucial that emergency physicians be familiar with the advances in testing and medications for HIV prevention and treatment. To our knowledge, to date there has not yet been an article addressing this expansion of practice. We have compiled a summary of what the emergency physician needs to know, including misconceptions associated with antiretroviral therapy, medication complexity, toxicity, resistance, and usability. Additionally, we review potential indications for prescribing these drugs in the emergency department, including the role of the emergency physician in postexposure prophylaxis, preexposure prophylaxis, and treatment of acute HIV, as well as how emergency physicians can engage with chronic HIV infection.

Comparing 7-Day Versus 6-8-Day Penicillin Treatment Intervals Among Pregnant People With Syphilis of Late or Unknown Duration: No Difference Found in Incidence of Congenital Syphilis.

Background: Guidelines recommend that pregnant patients with syphilis of late/unknown duration be treated with benzathine penicillin G, dosed as 3 weekly intramuscular injections (BPGx3) given ideally at strict 7-day intervals. Given limited pharmacokinetic data, it is unknown whether more flexible BPG treatment intervals might be effective in preventing congenital syphilis (CS). Methods: We used California surveillance data to identify birthing parent/infant dyads wherein the pregnant parent had syphilis of late/unknown duration between January 1, 2016 - June 30, 2019. We divided the dyads into 3 groups based on prenatal treatment: (1) BPGx3 at strict 7-day intervals, (2) BPGx3 at 6-8 day intervals, and (3) no/inadequate treatment. We then compared CS incidence among infants in each group. Results: We analyzed 1,092 parent/infant dyads: 607 (55.6%) in the 7-day treatment group, 70 (6.4%) in the 6-8 day treatment group, and 415 (38.0%) in the no/inadequate treatment group. The incidence proportion of infants meeting CS criteria in each group was, respectively, 5.6%, 5.7%, and 36.9%. Compared with BPGx3 at 7-day intervals, the odds of CS were 1.0 [95% CI 0.4-3.0] in the 6-8 day group and 9.8 [95% CI 6.6-14.7] in the no/inadequate treatment group. Conclusions: Prenatal BPGx3 at 6-8 days was no more likely to lead to CS in infants than 7-days. These findings hint that 6-8-day intervals might be adequate to prevent CS among pregnant people with syphilis of late/unknown duration. Consequently, it is possible that CS evaluation beyond an RPR at delivery may be unnecessary in asymptomatic infants whose parents received BPGx3 at 6-8 days.

Pathogen genomics in public health laboratories: successes, challenges, and lessons learned from California's SARS-CoV-2 Whole-Genome Sequencing Initiative, California COVIDNet.

The capacity for pathogen genomics in public health expanded rapidly during the coronavirus disease 2019 (COVID-19) pandemic, but many public health laboratories did not have the infrastructure in place to handle the vast amount of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) sequence data generated. The California Department of Public Health, in partnership with Theiagen Genomics, was an early adopter of cloud-based resources for bioinformatics and genomic epidemiology, resulting in the creation of a SARS-CoV-2 genomic surveillance system that combined the efforts of more than 40 sequencing laboratories across government, academia and industry to form California COVIDNet, California's SARS-CoV-2 Whole-Genome Sequencing Initiative. Open-source bioinformatics workflows, ongoing training sessions for the public health workforce, and automated data transfer to visualization tools all contributed to the success of California COVIDNet. While challenges remain for public health genomic surveillance worldwide, California COVIDNet serves as a framework for a scaled and successful bioinformatics infrastructure that has expanded beyond SARS-CoV-2 to other pathogens of public health importance.

Implementation of California COVIDNet - a multi-sector collaboration for statewide SARS-CoV-2 genomic surveillance.

Introduction: The SARS-CoV-2 pandemic represented a formidable scientific and technological challenge to public health due to its rapid spread and evolution. To meet these challenges and to characterize the virus over time, the State of California established the California SARS-CoV-2 Whole Genome Sequencing (WGS) Initiative, or "California COVIDNet". This initiative constituted an unprecedented multi-sector collaborative effort to achieve large-scale genomic surveillance of SARS-CoV-2 across California to monitor the spread of variants within the state, to detect new and emerging variants, and to characterize outbreaks in congregate, workplace, and other settings. Methods: California COVIDNet consists of 50 laboratory partners that include public health laboratories, private clinical diagnostic laboratories, and academic sequencing facilities as well as expert advisors, scientists, consultants, and contractors. Data management, sample sourcing and processing, and computational infrastructure were major challenges that had to be resolved in the midst of the pandemic chaos in order to conduct SARS-CoV-2 genomic surveillance. Data management, storage, and analytics needs were addressed with both conventional database applications and newer cloud-based data solutions, which also fulfilled computational requirements. Results: Representative and randomly selected samples were sourced from state-sponsored community testing sites. Since March of 2021, California COVIDNet partners have contributed more than 450,000 SARS-CoV-2 genomes sequenced from remnant samples from both molecular and antigen tests. Combined with genomes from CDC-contracted WGS labs, there are currently nearly 800,000 genomes from all 61 local health jurisdictions (LHJs) in California in the COVIDNet sequence database. More than 5% of all reported positive tests in the state have been sequenced, with similar rates of sequencing across 5 major geographic regions in the state. Discussion: Implementation of California COVIDNet revealed challenges and limitations in the public health system. These were overcome by engaging in novel partnerships that established a successful genomic surveillance program which provided valuable data to inform the COVID-19 public health response in California. Significantly, California COVIDNet has provided a foundational data framework and computational infrastructure needed to respond to future public health crises.

COVID-19 Testing Strategies for K-12 Schools in California: A Cost-Effectiveness Analysis.

Public health officials must provide guidance on operating schools safely during the COVID-19 pandemic. Using data from April-December 2021, we conducted a cost-effectiveness analysis to assess six screening strategies for schools using SARS-CoV-2 antigen and PCR tests and varying screening frequencies for 1000 individuals. We estimated secondary infections averted, quality-adjusted life years (QALYs), cost per QALY gained, and unnecessary school days missed per infection averted. We conducted sensitivity analyses for the more transmissible Omicron variant. Weekly antigen testing with PCR follow-up for positives was the most cost-effective option given moderate transmission, adding 0.035 QALYs at a cost of USD 320,000 per QALY gained in the base case (Reff = 1.1, prevalence = 0.2%). This strategy had the fewest needlessly missed school days (ten) per secondary infection averted. During widespread community transmission with Omicron (Reff = 1.5, prevalence = 5.8%), twice weekly antigen testing with PCR follow-up led to 2.02 QALYs gained compared to no test and cost the least (USD 187,300), with 0.5 needlessly missed schooldays per infection averted. In periods of moderate community transmission, weekly antigen testing with PCR follow up can help reduce transmission in schools with minimal unnecessary days of school missed. During widespread community transmission, twice weekly antigen screening with PCR confirmation is the most cost-effective and efficient strategy. Schools may benefit from resources to implement routine asymptomatic testing during surges; benefits decline as community transmission declines.

Geospatial Social Determinants of Health Correlate with Disparities in Syphilis and Congenital Syphilis Cases in California.

Syphilis and congenital syphilis (CS) are increasing in California (CA). From 2015 through 2019, for example, CA cases of early syphilis among reproductive-age females (15−44) and CS each increased by >200%. Certain populations­including people experiencing homelessness, using drugs, and/or belonging to certain racial/ethnic groups­have been disproportionately impacted. We hypothesized that geospatial social determinants of health (SDH) contribute to such health inequities. To demonstrate this, we geospatially described syphilis in CA using the Healthy Places Index (HPI). The HPI is a composite index that assigns a score to each CA census tract based on eight socioeconomic characteristics associated with health (education, housing, transportation, neighborhood conditions, clean environment, and healthcare access as well as economic and social resources). We divided CA census tracts into four quartiles based on HPI scores (with the lowest quartile having the least healthy socioeconomic and environmental conditions), then used 2013−2020 CA sexually transmitted diseases surveillance data to compare overall syphilis (among adults and adolescents) and CS case counts, incidence rates (per 100,000 population or live births), and incidence rate ratios (IRRs) among these quartiles. From 2013 to 2020, across all stages of syphilis and CS, disease burden was greatest in the lowest HPI quartile and smallest in the highest quartile (8308 cases (representing 33.2% of all incidents) versus 3768 (15.1%) for primary and secondary (P&S) syphilis; 5724 (31.6%) versus 2936 (16.2%) for early non-primary non-secondary (NPNS) syphilis; 11,736 (41.9%) versus 3026 (10.8%) for late/unknown duration syphilis; and 849 (61.9%) versus 57 (4.2%) for CS; all with p < 0.001). Using the highest HPI quartile as a reference, the IRRs in the lowest quartile were 17 for CS, 4.5 for late/unknown duration syphilis, 2.6 for P&S syphilis, and 2.3 for early NPNS syphilis. We thus observed a direct relationship between less healthy conditions (per HPI) and syphilis/CS in California, supporting our hypothesis that SDH correlate with disparities in syphilis, especially CS. HPI could inform allocation of resources to: (1) support communities most in need of assistance in preventing syphilis/CS cases and (2) reduce health disparities.

Integrated Cases Section: a course designed to promote clinical reasoning in year 2 medical students.

BACKGROUND: Medical students often have difficulty applying basic science knowledge within clinical contexts as they transition into clerkships. DESCRIPTION: To enhance clinical reasoning skills in 2nd-year medical students, we developed a 7-week transition course called the Integrated Cases Section. Curricular instruction incorporated analytic and nonanalytic clinical reasoning models. Practice with variable case scenarios enhanced students' application of basic science knowledge to clinical problem solving. EVALUATION: We evaluated curricular design and objectives by measuring student perceptions during the course and following completion of 2 clerkship rotations. To obtain measurement of students' clinical reasoning ability we administered a script concordance test immediately before and after the course. CONCLUSIONS: Students reported increased confidence in their diagnostic reasoning ability during the course and after completion of 2 clerkships. Students' clinical reasoning showed a significant gain after the Integrated Cases Section on a script concordance test. Student support has solidified Integrated Cases Section in the curriculum.

High Feasibility of Empiric HIV Treatment for Patients With Suspected Acute HIV in an Emergency Department.

Earlier intervention in acute HIV infection limits HIV reservoirs and may decrease HIV transmission. We developed criteria for empiric antiretroviral therapy (ART) in an emergency department (ED) routine HIV screening program. We assessed the feasibility and willingness of patients with suspected acute HIV infection in the ED to begin ART. A suspected acute HIV infection was defined as a positive HIV antigen antibody combination immunoassay with pending HIV-antibody differentiation test results and HIV RNA viral load. During the study period, there were 16 confirmed cases of acute HIV infection: 11 met our criteria for empiric ART and agreed to treatment, 10 were prescribed ART, and 1 left the ED against medical advice without a prescription for ART. Eight patients completed at least one follow-up visit. Empiric HIV treatment in an ED is feasible, well received by patients, and offers a unique entry point into the HIV care continuum.