Public Health Dashboards in Overdose Prevention: The Rhode Island Approach to Public Health Data Literacy, Partnerships, and Action.

As the field of public health rises to the demands of real-time surveillance and rapid data-sharing needs in a postpandemic world, it is time to examine our approaches to the dissemination and accessibility of such data. Distinct challenges exist when working to develop a shared public health language and narratives based on data. It requires that we assess our understanding of public health data literacy, revisit our approach to communication and engagement, and continuously evaluate our impact and relevance. Key stakeholders and cocreators are critical to this process and include people with lived experience, community organizations, governmental partners, and research institutions. In this viewpoint paper, we offer an instructive approach to the tools we used, assessed, and adapted across 3 unique overdose data dashboard projects in Rhode Island, United States. We are calling this model the "Rhode Island Approach to Public Health Data Literacy, Partnerships, and Action." This approach reflects the iterative lessons learned about the improvement of data dashboards through collaboration and strong partnerships across community members, state agencies, and an academic research team. We will highlight key tools and approaches that are accessible and engaging and allow developers and stakeholders to self-assess their goals for their data dashboards and evaluate engagement with these tools by their desired audiences and users.

Differences in Substance Use and Harm Reduction Practices by Race and Ethnicity: Rhode Island Harm Reduction Surveillance System, 2021-2022.

CONTEXT: In the United States, minority populations are disproportionately affected by the overdose epidemic, have higher mortality rates, and unequal access to harm reduction and treatment services. OBJECTIVE: This analysis aims to better understand harm reduction utilization and substance use patterns among minority populations to improve overdose outreach and prevention initiatives in Rhode Island. DESIGN: The present analysis used data from the Harm Reduction Surveillance System from January 2021 to December 2022 (N = 393). Chi-square tests and multivariable regression models were used to investigate differences in substance use behaviors by race and ethnicity. SETTING: Rhode Island. PARTICIPANTS: Participants include individuals who self-reported the use of illicit drugs, currently reside in Rhode Island, and were older than 18 years. MAIN OUTCOME MEASURES: Methods of drug use and uptake of harm reduction practices. RESULTS: Among survey participants, 41% were non-Hispanic White, 57% were aged 25 to 44 years, 62% identified as male, and 95% had health insurance coverage. Most participants reported smoking as their method of drug use (90%) and harm reduction practices were underutilized by all race and ethnicity groups. Fewer non-Hispanic Black participants reported carrying naloxone compared to the other race and ethnicity groups. Non-Hispanic Black and Hispanic participants were significantly less likely to inject drugs compared with non-Hispanic White participants (adjusted odds ratio [AOR] = 0.14; 95% confidence interval [CI], 0.04-0.45) (AOR = 0.40; 95% CI, 0.18-0.90). CONCLUSIONS: Smoking was the most common self-reported method of substance administration for all participants, whereas injection was more prevalent among non-Hispanic White participants. There is a continued need for minority-led and culturally informed harm reduction and treatment services for minority populations.

On-farm colorimetric detection of Pasteurella multocida, Mannheimia haemolytica, and Histophilus somni in crude bovine nasal samples.

This work modifies a loop-mediated isothermal amplification (LAMP) assay to detect the bovine respiratory disease (BRD) bacterial pathogens Pasteurella multocida, Mannheimia haemolytica, and Histophilus somni in a colorimetric format on a farm. BRD causes a significant health and economic burden worldwide that partially stems from the challenges involved in determining the pathogens causing the disease. Methods such as polymerase chain reaction (PCR) have the potential to identify the causative pathogens but require lab equipment and extensive sample processing making the process lengthy and expensive. To combat this limitation, LAMP allows accurate pathogen detection in unprocessed samples by the naked eye allowing for potentially faster and more precise diagnostics on the farm. The assay developed here offers 66.7-100% analytical sensitivity, and 100% analytical specificity (using contrived samples) while providing 60-100% concordance with PCR results when tested on five steers in a feedlot. The use of a consumer-grade water bath enabled on-farm execution by collecting a nasal swab from cattle and provided a colorimetric result within 60 min. Such an assay holds the potential to provide rapid pen-side diagnostics to cattle producers and veterinarians.

Rhode Island's Opioid Overdose Hospital Standards and Emergency Department Naloxone Distribution, Behavioral Counseling, and Referral to Treatment.

STUDY OBJECTIVE: We sought to determine the influence of the Levels of Care for Rhode Island Emergency Departments and Hospitals for Treating Overdose and Opioid Use Disorder (Levels of Care) on emergency department (ED) provision of take-home naloxone, behavioral counseling, and referral to treatment. METHODS: A retrospective analysis of Rhode Island ED visits for opioid overdose from 2017 to 2018 was performed using data from a statewide opioid overdose surveillance system. Changes in provision of take-home naloxone, behavioral counseling, and referral to treatment before and after Levels of Care implementation were assessed using interrupted time series analysis. We compared outcomes by hospital type using multivariable modified Poisson regression models with generalized estimating equation estimation to account for hospital-level variation. RESULTS: We analyzed 245 overdose visits prior to Levels of Care implementation (January to March 2017) and 1340 overdose visits after implementation (hospital certification to December 2018). After implementation, the proportion of patients offered naloxone increased on average by 13% (95% confidence interval [CI] 5.6% to 20.4%). Prior to implementation, the proportion of patients receiving behavioral counseling and treatment referral was declining. After implementation, this decline slowed and stabilized, and on average 18.6% more patients received behavioral counseling (95% CI 1.3% to 35.9%) and 23.1% more patients received referral to treatment (95% CI 2.7% to 43.5%). Multivariable analysis showed that after implementation, there was a significant increase in the likelihood of being offered naloxone at Level 1 (adjusted relative risk [aRR] 1.31 [95% CI 1.06 to 1.61]) and Level 3 (aRR 3.13 [95% CI 1.08 to 9.06]) hospitals and an increase in referrals for medication for opioid use disorder (from 2.5% to 17.8%) at Level 1 hospitals (RR 7.73 [95% CI 3.22 to 18.55]). Despite these increases, less than half of the patients treated for an opioid overdose received behavioral counseling or referral to treatment CONCLUSION: The establishment of ED policies for treatment and services after opioid overdose improved naloxone distribution, behavioral counseling, and referral to treatment at hospitals without previously established opioid overdose services. Future investigations are needed to better characterize implementation barriers and evaluate policy influence on patient outcomes.

Multidisciplinary Team Reviews of Drug Overdose Deaths and the Use of Minigrants to Advance Recommendations: A Statewide Pilot in Rhode Island.

CONTEXT: Rhode Island has been significantly impacted by the opioid epidemic, ranking 11th in unintentional drug overdose rates in the United States in 2017. Illicit fentanyl was involved in the majority of these deaths. PROGRAM: To enhance surveillance of this epidemic, the RI Department of Health piloted in-depth, multidisciplinary, and multiagency team reviews of drug overdose deaths. The goals were to identify gaps in policies and programming and develop recommendations to prevent future deaths. Time-sensitive minigrants were offered to nonprofit organizations as a novel way to further the recommendations put forth from these reviews. IMPLEMENTATION: Legal agreements between select state agencies and institutions enabled broad team representation and the sharing of information during each meeting. Reviews, revolving around a common theme, were conducted for up to 10 deaths each quarter. Recommendations for prevention were generated by the team and summarized in a report to the Governor's Overdose Prevention and Intervention Task Force and the public within 1 month of each meeting. Announcements of minigrant opportunities and funding to advance the community-specific recommendations were paired with each meeting. EVALUATION: From November 2016 through May 2018, the pilot team convened 7 times, generated 78 recommendations, and distributed 31 minigrants. Early process evaluations of these grants have shown positive impact within local environments. Following the pilot phase, state legislation for these reviews was passed in June 2018. DISCUSSION: The RI Department of Health was able to successfully pilot a multidisciplinary review process for overdose deaths and has recently institutionalized this process through legislation. The successful implementation of many of the team's community-oriented recommendations, supported through a minigrant process, highlights the impact that small financial investments can have to address the opioid epidemic and may be a model for other jurisdictions seeking to advance recommendations from these types of reviews.

Emergency Department and Hospital Care for Opioid Use Disorder: Implementation of Statewide Standards in Rhode Island, 2017-2018.

In March 2017, Rhode Island released treatment standards for care of adult patients with opioid use disorder. These standards prescribe three levels of hospital and emergency department treatment and prevention of opioid use disorder and opioid overdose and mechanisms for referral to treatment and epidemiological surveillance. By June 2018, all Rhode Island licensed acute care facilities had implemented policies meeting the standards' requirements. This policy has standardized care for opioid use disorder, enhanced opioid overdose surveillance and response, and expanded linkage to peer recovery support, naloxone, and medication for opioid use disorder.

Development of a Statewide, Publicly Accessible Drug Overdose Surveillance and Information System.

In response to Rhode Island's overdose epidemic, we developed a collaborative, statewide online "dashboard" to provide the public with timely overdose surveillance data. The Web site- www.PreventOverdoseRI.org (PORI)-offers user-friendly data visualizations, plain language education, and interactive resource maps. Development of the site has improved overdose data sharing and transparency in Rhode Island. Preliminary results suggest a successful site launch. Future research will evaluate the effectiveness of PORI in terms of informing strategic initiatives to reduce overdoses in affected communities.

Can Emergency Department, Hospital Discharge, and Death Data Be Used to Monitor Burden of Drug Overdose in Rhode Island?

CONTEXT: Drug overdoses are a growing public health problem in the United States. Rhode Island is also confronted with a serious epidemic of drug overdose deaths and ranks sixth worst in the United States for age-adjusted drug overdose death rate. OBJECTIVE: To monitor trends of drug overdose-related emergency department (ED) visits, hospitalizations, and deaths and classify the drug overdoses by demographics, discharge status, intent, and specific drug involved to plan for health care resource allocation, mental health services, drug abuse treatment, prevention, and policies. DESIGN: Cross-sectional study. SETTING: The 2005-2014 ED, hospital discharge, and death data were used for this study. MAIN OUTCOME MEASURE: Age-adjusted rates were calculated by using age-specific Rhode Island 2010 standard population. Healthcare Cost and Utilization Project cost-to-charge ratios were used to convert total hospital charges to costs. The descriptive analysis was performed. RESULTS: Hospitalizations generally represent the most severe cases; there are substantially fewer cases than are seen in the ED, and their characteristics are different from ED visits. More than half of the ED cases were an unintentional injury by drug overdose, but more than half of the hospital discharge data cases were a suicide/self-inflicted injury by drug overdose. There were typically much more females than males that result in a hospital admission. In Rhode Island, there were 249 drug overdose deaths in 2014. Drug overdose fatalities were more likely to be young, male, white, and those who reside in suburban regions. IMPLICATIONS: Nonfatal and fatal drug overdose data are important for understanding the scope, incidence, and breadth of this public health epidemic and can guide overdose intervention efforts. In Rhode Island, policy makers can use drug overdose data to target high-risk subpopulations to reduce overdose injuries and fatalities. The Rhode Island study can be shared with other states. CONCLUSIONS: Regardless of the type of drug, overdoses remain a public health crisis in Rhode Island. It is a dynamic epidemic and needs partnership among public health, behavioral health, public safety, clinic, pharmacy, and communities. The ability to track drug overdose in real time will be an essential tool to respond to the constantly evolving drug overdose epidemic in Rhode Island quickly and effectively.

Successful resolution of a preputial prolapse in an alpaca using medical therapy.

A 2-year-old intact male alpaca was presented for a post-breeding preputial prolapse of 5 days duration. The internal lamina of the prepuce was prolapsed approximately 6 cm and the exposed preputial epithelium was edematous and necrotic. Following 7 days of medical treatment, resolution of the preputial prolapse was achieved.

Résolution réussie d'un prolapsus du prépuce chez un alpaga à l'aide d'un traitement médical. Un alpaga mâle intact âgé de 2 ans a été présenté pour un prolapsus du prépuce d'une durée de 5 jours après l'accouplement. La membrane interne du prépuce avait subi un prolapsus d'environ 6 cm et l'épithélium exposé du prépuce était œdémateux et nécrosé. Après 7 jours de traitement médical, la résolution du prolapsus a été obtenue.(Traduit par Isabelle Vallières).

Field Morphology and Interpretation.

Semen morphology evaluation in the field should always be performed at 1000× with oil immersion. The development of a spermiogram will aid the practitioner to interpret potential fertility of semen at the time of sampling as well as determine potential causes of an abnormal spermiogram. Bulls, which experience stress or impairment of thermoregulation of the testes for any reason, often experience a transitory decrease in the quality of sperm morphology. This can be recognized by a sequence of appearances of morphologic defects coupled with a thorough patient history.

Ancillary Methods for Semen Evaluation.

The cause of subfertility or poor fertility in naturally mated bulls should be differentiated from impotentia coeundi, generandi, or erigendi prior to ancillary semen evaluation. Bulls used for artificial insemination may undergo ancillary semen evaluation following low fertility rates as judged by poor conception or low pregnancy rates. Morphologically abnormal sperm have long been associated with bull subfertility and infertility. Some morphological defects such as improper sperm chromatin condensation are not visible using traditional light microscopy and require specialized staining. Ancillary semen evaluation is useful in cases where the reason for low or absence of fertility needs to be identified. As compared to SEM, TEM can be extremely useful for identifying minuscule acrosome defects, issues with chromatin, and centrosome defects and is considered the gold standard method for the identification of midpiece and tail defects.

Tritrichomonas foetus testing in bulls.

OBJECTIVE: To provide a video tutorial on how to perform preputial scraping for the testing of Tritrichomonas foetus in bulls. ANIMALS: Postpubertal bulls. METHODS: A preputial scraping device is inserted in the prepuce, and back-and-forth scraping movements are made to collect smegma and T foetus organisms. The sample is placed in an appropriate media and prepared for shipment to the diagnostic laboratory. RESULTS: Preputial sampling is an effective method for diagnosing T foetus in infected bulls. CLINICAL RELEVANCE: Bulls are the primary carriers of T foetus, a protozoan parasite responsible for bovine trichomoniasis. By sampling and testing bulls, veterinarians can identify infected animals and implement control measures to prevent the spread of the disease within herds. Trichomoniasis can lead to significant reproductive problems in cattle, including infertility, embryonic death, and abortions. Sampling bulls allows for the detection of infection, enabling prompt intervention to protect the reproductive health of the entire herd. Trichomoniasis outbreaks can result in substantial economic losses for cattle producers due to reduced conception rates, increased calving intervals, and decreased calf crops. Sampling bulls helps to mitigate these losses by identifying and removing infected animals from the breeding pool, thereby minimizing the spread of the disease and its associated reproductive inefficiencies. In many regions, T foetus testing in bulls is a regulatory requirement for cattle movement and trade. Sampling bulls and obtaining negative test results are often necessary for obtaining health certificates and complying with interstate or international movement regulations.

Describing the Reproductive Microbiome of Tritrichomonas foetus Chronically Infected Bulls and Diagnostic Collection Device Performance.

Tritrichomonas foetus (T. foetus), the causative agent of bovine trichomoniasis, is an obligate protozoan parasite of the bovine reproductive tract and can be found on the penis, prepuce, and distal urethra of the bull and from the cranial vagina to the oviduct in the infected cow. To date, the microbiome of bulls infected with T. foetus has not been described. The objectives of this study were to (1) describe the preputial and penile microbiome of bulls chronically infected by T. foetus, (2) describe the seminal microbiome of T. foetus-infected bulls, and (3) evaluate different collection devices that could be used for sampling. Eleven bulls naturally infected with T. foetus were utilized for the collection of samples. Samples were obtained during the process of a routine breeding soundness exam utilizing either a dacron swab, pizzle stick, double-guarded swab, or semen collection. The preputial and seminal microbiome of T. foetus-infected bulls was dominated by bacterial members of the phyla Fusobacteriota, Firmicutes, Bacteroidota, Actinobacteria, and Campylobacterota. Semen collection yielded the most microbial diversity; however, there was no significant difference between the four methods (p ≥ 0.05). This study characterizes both the preputial and seminal microbial communities of bulls chronically infected by T. foetus.

Students value relationship building in a student mentorship program.

OBJECTIVE: To assess the needs and values of students regarding a new mentoring program. METHODS: An online survey was developed and sent to veterinary students through institutional email at the beginning and end of the year of initiating a faculty-student mentorship program. RESULTS: In September and May, the most commonly desired outcome of the program for students was the building of relationships. In the fall, the most anticipated concerns were that the meetings would not occur or there would be incompatibility between mentors and mentees. In the spring, the most common concerns were that some faculty were disinterested or meetings did not happen. CONCLUSIONS: The experiences of veterinary students in the faculty-student mentoring program were often positive but variable. At the outset, students were hoping to build relationships through the program, and in May, some of them reported that this objective had been fulfilled. However, some students expressed frustration with faculty disengagement with the program. A faculty-student mentorship program has the potential to build relationships between students and faculty when faculty are engaged participants in the program. CLINICAL RELEVANCE: Based on our findings, students are eager to build relationships with faculty within the context of a faculty-student mentorship program, and this goal is achievable. However, much depends on the engagement and participation of the faculty, which was incomplete using our approach of assigning all faculty to participate.

Characterizing opioid overdose hotspots for place-based overdose prevention and treatment interventions: A geo-spatial analysis of Rhode Island, USA.

OBJECTIVE: Examine differences in neighborhood characteristics and services between overdose hotspot and non-hotspot neighborhoods and identify neighborhood-level population factors associated with increased overdose incidence. METHODS: We conducted a population-based retrospective analysis of Rhode Island, USA residents who had a fatal or non-fatal overdose from 2016 to 2020 using an environmental scan and data from Rhode Island emergency medical services, State Unintentional Drug Overdose Reporting System, and the American Community Survey. We conducted a spatial scan via SaTScan to identify non-fatal and fatal overdose hotspots and compared the characteristics of hotspot and non-hotspot neighborhoods. We identified associations between census block group-level characteristics using a Besag-York-Mollié model specification with a conditional autoregressive spatial random effect. RESULTS: We identified 7 non-fatal and 3 fatal overdose hotspots in Rhode Island during the study period. Hotspot neighborhoods had higher proportions of Black and Latino/a residents, renter-occupied housing, vacant housing, unemployment, and cost-burdened households. A higher proportion of hotspot neighborhoods had a religious organization, a health center, or a police station. Non-fatal overdose risk increased in a dose responsive manner with increasing proportions of residents living in poverty. There was increased relative risk of non-fatal and fatal overdoses in neighborhoods with crowded housing above the mean (RR 1.19 [95 % CI 1.05, 1.34]; RR 1.21 [95 % CI 1.18, 1.38], respectively). CONCLUSION: Neighborhoods with increased prevalence of housing instability and poverty are at highest risk of overdose. The high availability of social services in overdose hotspots presents an opportunity to work with established organizations to prevent overdose deaths.

Dynamics of the nasopharyngeal microbiome of apparently healthy calves and those with clinical symptoms of bovine respiratory disease from disease diagnosis to recovery.

Introduction: Bovine respiratory disease (BRD) is a multifactorial disease complex in which bacteria in the upper respiratory tract play an important role in disease development. Previous studies have related the presence of four BRD-pathobionts (Mycoplasma bovis, Histophilus somni, Pasteurella multocida, and Mannheimia haemolytica) in the upper respiratory tract to BRD incidence and mortalities in the dairy and beef cattle industry, but these studies typically only use one time point to compare the abundance of BRD-pathobionts between apparently healthy and BRD-affected cattle. The objective of this study was to characterize the longitudinal development of the nasopharyngeal (NP) microbiome from apparently healthy calves, and in calves with clinical signs of BRD, the microbiota dynamics from disease diagnosis to recovery. Methods: Deep nasopharyngeal swabs were taken from all calves immediately after transport (day 0). If a calf was diagnosed with BRD (n = 10), it was sampled, treated with florfenicol or tulathromycin, and sampled again 1, 5, and 10 days after antibiotic administration. Otherwise, healthy calves (n = 20) were sampled again on days 7 and 14. Bacterial community analysis was performed through 16S rRNA gene amplicon sequencing. Results: The NP microbiome of the healthy animals remained consistent throughout the study, regardless of time. The NP microbiota beta diversity and community composition was affected by tulathromycin or florfenicol administration. Even though BRD-pathobionts were identified by 16S rRNA gene sequencing in BRD-affected animals, no difference was observed in their relative abundance between the BRD-affected and apparently healthy animals. The abundance of BRD-pathobionts was not predictive of disease development while the relative abundance of BRD pathobionts was unique to each BRD-affected calf. Interestingly, at the end of the study period, the genera Mycoplasma was the most abundant genus in the healthy group, while Lactobacillus was the most abundant genus in the animals that recovered from BRD. Discussion: This study highlights that injected antibiotics seem to improve the NP microbiome composition (higher abundance of Lactobacillus and lower abundance of Mycoplasma), and that the relative abundance of BRD-pathobionts differs between individual calves but is not strongly predictive of BRD clinical signs, indicating that additional factors are likely important in the clinical progression of BRD.

Canine models of Charcot-Marie-Tooth: MTMR2, MPZ, and SH3TC2 variants in golden retrievers with congenital hypomyelinating polyneuropathy.

Congenital hypomyelinating polyneuropathy (HPN) restricted to the peripheral nervous system was reported in 1989 in two Golden Retriever (GR) littermates. Recently, four additional cases of congenital HPN in young, unrelated GRs were diagnosed via neurological examination, electrodiagnostic evaluation, and peripheral nerve pathology. Whole-genome sequencing was performed on all four GRs, and variants from each dog were compared to variants found across >1,000 other dogs, all presumably unaffected with HPN. Likely causative variants were identified for each HPN-affected GR. Two cases shared a homozygous splice donor site variant in MTMR2, with a stop codon introduced within six codons following the inclusion of the intron. One case had a heterozygous MPZ isoleucine to threonine substitution. The last case had a homozygous SH3TC2 nonsense variant predicted to truncate approximately one-half of the protein. Haplotype analysis using 524 GR established the novelty of the identified variants. Each variant occurs within genes that are associated with the human Charcot-Marie-Tooth (CMT) group of heterogeneous diseases, affecting the peripheral nervous system. Testing a large GR population (n = >200) did not identify any dogs with these variants. Although these variants are rare within the general GR population, breeders should be cautious to avoid propagating these alleles.

Composition and diversity of the seminal microbiota in bulls and its association with semen parameters.

The male bovine microbiota is a relatively unexplored area even though it has been shown to impact the fertility of not only the male but also the female. With this study, our aim was to evaluate the bacterial composition of semen from bulls with either satisfactory or unsatisfactory semen quality as represented by poor sperm motility and/or morphology. We hypothesized based on findings in human and other domestic animal studies, that the microbiota diversity and composition may be associated with decreased sperm quality. Semen samples from 45 beef bulls were collected, 32 of those bulls were classified as having satisfactory spermiograms according to Society for Theriogenology bull breeding soundness exam standards with the remaining 13 bulls being classified as unsatisfactory. Microbiota profiling was performed using 16S rRNA gene amplicon sequencing of the V4 region. The most abundant genera in the seminal microbiome include Bacteroides, Corynebacterium 1, Escherichia, Gemella, and S5-A14a (an uncultured bacterium from the Clostridiales order). Bulls with satisfactory spermiograms had a higher abundance of sequence types belonging to many genera including Bacteroides, S5-A14a, Trueperella, and two methanogenic archaea genera Methanosphaera and Methanobrevibacter. Comparatively, samples from bulls with unsatisfactory speriograms had greater abundance of sequence types belonging to Veillonellaceae, Campylobacter, and Methanobacterium. Network analysis was also performed for satisfactory and unsatisfactory samples and indicated that cooccurrence of microbial taxa was less common in the S group than in the U group. In the satisfactory group, Methanobrevibacter cooccurred with twelve amplicon sequence variants (ASVs), indicating that it may be important for maintenance of the microbiota in satisfactory samples, and members of this genus were enriched in the satisfactory group. Opportunistic pathogens such as Campylobacter, and Fusobacterium co-occurred with four and ten ASVs, respectively, in the unsatisfactory group, potentially indicating they are acting in synergy with other member of the microbial community, but only in the unsatisfactory group.

Comparing Projected Fatal Overdose Outcomes and Costs of Strategies to Expand Community-Based Distribution of Naloxone in Rhode Island.

Importance: In 2021, the state of Rhode Island distributed 10 000 additional naloxone kits compared with the prior year through partnerships with community-based organizations. Objective: To compare various strategies to increase naloxone distribution through community-based programs in Rhode Island to identify one most effective and efficient strategy in preventing opioid overdose deaths (OODs). Design, Setting, and Participants: In this decision analytical model study conducted from January 2016 to December 2022, a spatial microsimulation model with an integrated decision tree was developed and calibrated to compare the outcomes of alternative strategies for distributing 10 000 additional naloxone kits annually among all individuals at risk for opioid overdose in Rhode Island. Interventions: Distribution of 10 000 additional naloxone kits annually, focusing on people who inject drugs, people who use illicit opioids and stimulants, individuals at various levels of risk for opioid overdose, or people who misuse prescription opioids vs no additional kits (status quo). Two expanded distribution implementation approaches were considered: one consistent with the current spatial distribution patterns for each distribution program type (supply-based approach) and one consistent with the current spatial distribution of individuals in each of the risk groups, assuming that programs could direct the additional kits to new geographic areas if required (demand-based approach). Main Outcomes and Measures: Witnessed OODs, cost per OOD averted (efficiency), geospatial health inequality measured by the Theil index, and between-group variance for OOD rates. Results: A total of 63 131 simulated individuals were estimated to be at risk for opioid overdose in Rhode Island based on current population data. With the supply-based approach, prioritizing additional naloxone kits to people who use illicit drugs averted more witnessed OODs by an estimated mean of 18.9% (95% simulation interval [SI], 13.1%-30.7%) annually. Expanded naloxone distribution using the demand-based approach and focusing on people who inject drugs had the best outcomes across all scenarios, averting an estimated mean of 25.3% (95% SI, 13.1%-37.6%) of witnessed OODs annually, at the lowest mean incremental cost of $27 312 per OOD averted. Other strategies were associated with fewer OODs averted at higher costs but showed similar patterns of improved outcomes and lower unit costs if kits could be reallocated to areas with greater need. The demand-based approach reduced geospatial inequality in OOD rates in all scenarios compared with the supply-based approach and status quo. Conclusions and Relevance: In this decision analytical model study, variations in the effectiveness, efficiency, and health inequality of the different naloxone distribution expansion strategies and approaches were identified. Future efforts should be prioritized for people at highest risk for overdose (those who inject drugs or use illicit drugs) and redirected toward areas with the greatest need. These findings may inform future naloxone distribution priority settings.

Identification of bovine respiratory disease through the nasal microbiome.

BACKGROUND: Bovine respiratory disease (BRD) is an ongoing health and economic challenge in the dairy and beef cattle industries. Multiple risk factors make an animal susceptible to BRD. The presence of Mannheimia haemolytica, Pasteurella multocida, Histophilus somni, and Mycoplasma bovis in lung tissues have been associated with BRD mortalities, but they are also commonly present in the upper respiratory tract of healthy animals. This study aims to compare the cattle nasal microbiome (diversity, composition and community interaction) and the abundance of BRD pathogens (by qPCR) in the nasal microbiome of Holstein steers that are apparently healthy (Healthy group, n = 75) or with BRD clinical signs (BRD group, n = 58). We then used random forest models based on nasal microbial community and qPCR results to classify healthy and BRD-affected animals and determined the agreement with the visual clinical signs. Additionally, co-occurring species pairs were identified in visually BRD or healthy animal groups. RESULTS: Cattle in the BRD group had lower alpha diversity than pen-mates in the healthy group. Amplicon sequence variants (ASVs) from Trueperella pyogenes, Bibersteinia and Mycoplasma spp. were increased in relative abundance in the BRD group, while ASVs from Mycoplasma bovirhinis and Clostridium sensu stricto were increased in the healthy group. Prevalence of H. somni (98%) and P. multocida (97%) was high regardless of BRD clinical signs whereas M. haemolytica (81 and 61%, respectively) and M. bovis (74 and 51%, respectively) were more prevalent in the BRD group than the healthy group. In the BRD group, the abundance of M. haemolytica and M. bovis was increased, while H. somni abundance was decreased. Visual observation of clinical signs agreed with classification by the nasal microbial community (misclassification rate of 32%) and qPCR results (misclassification rate 34%). Co-occurrence analysis demonstrated that the nasal microbiome of BRD-affected cattle presented fewer bacterial associations than healthy cattle. CONCLUSIONS: This study offers insight into the prevalence and abundance of BRD pathogens and the differences in the nasal microbiome between healthy and BRD animals. This suggests that nasal bacterial communities provide a potential platform for future studies and potential pen-side diagnostic testing.