Evidence of leaky protection following COVID-19 vaccination and SARS-CoV-2 infection in an incarcerated population.

Whether SARS-CoV-2 infection and COVID-19 vaccines confer exposure-dependent ("leaky") protection against infection remains unknown. We examined the effect of prior infection, vaccination, and hybrid immunity on infection risk among residents of Connecticut correctional facilities during periods of predominant Omicron and Delta transmission. Residents with cell, cellblock, and no documented exposure to SARS-CoV-2 infected residents were matched by facility and date. During the Omicron period, prior infection, vaccination, and hybrid immunity reduced the infection risk of residents without a documented exposure (HR: 0.36 [0.25-0.54]; 0.57 [0.42-0.78]; 0.24 [0.15-0.39]; respectively) and with cellblock exposures (0.61 [0.49-0.75]; 0.69 [0.58-0.83]; 0.41 [0.31-0.55]; respectively) but not with cell exposures (0.89 [0.58-1.35]; 0.96 [0.64-1.46]; 0.80 [0.46-1.39]; respectively). Associations were similar during the Delta period and when analyses were restricted to tested residents. Although associations may not have been thoroughly adjusted due to dataset limitations, the findings suggest that prior infection and vaccination may be leaky, highlighting the potential benefits of pairing vaccination with non-pharmaceutical interventions in crowded settings.

Covid-19 vaccine acceptance among individuals incarcerated in Connecticut state jails.

BACKGROUND: Vaccine hesitancy is common among incarcerated populations and, despite vaccination programs, vaccine acceptance within residents remains low, especially within jails. With the goal of assessing the Connecticut DOC's COVID-19 vaccine program within jails we examined if residents of DOC operated jails were more likely to become vaccinated following incarceration than in the community. Specifically, we conducted a retrospective cohort analysis among people who spent at least one night in a DOC-operated jail between February 2 and November 8, 2021, and were eligible for vaccination at the time of incarceration (intake). We compared the vaccination rates before and after incarceration using an age-adjusted survival analysis with a time-varying exposure of incarceration and an outcome of vaccination. RESULTS: During the study period, 3,716 people spent at least one night in jail and were eligible for vaccination at intake. Of these residents, 136 were vaccinated prior to incarceration, 2,265 had a recorded vaccine offer, and 479 were vaccinated while incarcerated. The age-adjusted hazard of vaccination following incarceration was significantly higher than prior to incarceration (12.5; 95% Confidence Intervals: 10.2-15.3). CONCLUSIONS: We found that residents were more likely to become vaccinated in jail than in the community. Though these findings highlight the utility of vaccination programs within jails, the low level of vaccination in this population speaks to the need for additional program development within jails and the community.

Testing Frequency Matters: An Evaluation of the Diagnostic Performance of a Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Rapid Antigen Test in US Correctional Facilities.

BACKGROUND: The Centers for Disease Control and Prevention recommends serial rapid antigen assay collection within congregate facilities. Although modeling and observational studies from communities and long-term care facilities have shown serial collection provides adequate sensitivity and specificity, the accuracy within correctional facilities remains unknown. METHODS: Using Connecticut Department of Correction data from 21 November 2020 to 15 June 2021, we estimated the accuracy of a rapid assay, BinaxNOW (Abbott), under 3 collection strategies: single test collection and serial collection of 2 and 3 tests separated by 1-4 days. The sensitivity and specificity of the first (including single), second, and third serially collected BinaxNOW tests were estimated relative to RT-PCRs collected ≤1 day of the BinaxNOW test. The accuracy metrics of the testing strategies were then estimated as the sum (sensitivity) and product (specificity) of tests in each strategy. RESULTS: Of the 13 112 residents who contributed ≥1 BinaxNOW test during the study period, 3825 contributed ≥1 RT-PCR paired BinaxNOW test. In relation to RT-PCR, the 3-rapid-antigen-test strategy had a sensitivity of 95.9% (95% CI: 93.6-97.5%) and specificity of 98.3% (95% CI: 96.7-99.1%). The sensitivities of the 2- and 1-rapid-antigen-test strategies were 88.8% and 66.8%, and the specificities were 98.5% and 99.4%, respectively. The sensitivity was higher among symptomatic residents and when RT-PCRs were collected before BinaxNOW tests. CONCLUSIONS: We found serial antigen test collection resulted in high diagnostic accuracy. These findings support serial collection for outbreak investigation, screening, and when rapid detection is required (such as intakes or transfers).

Compliance with a New York State 2010 HIV Testing Law: Is There Racial/Ethnic Bias in HIV Testing? Experience of Monroe County, New York, 2012.

BACKGROUND: While routine HIV testing in the general population is a national recommendation, actual practice may vary. PURPOSE: To determine risk factors associated with HIV testing after the adoption of a New York State law in 2010 mandating that health care providers offer HIV testing in all clinical settings. METHODS: Survey data from Monroe County, New York, were collected in 2012 for adults aged 18-64 years and analyzed in 2014. Logistic regression was used to identify risk factors independently associated with HIV testing and high-risk behavior. RESULTS: Among adults aged 18-34, fewer Whites were offered HIV testing in the past year by their doctors compared with Blacks (34% vs 64%) despite having similar rates of any HIV high-risk behavior (20% overall). For adults aged 35-64 years, fewer Whites than Blacks were ever tested for HIV (42% vs 71%), offered HIV testing in past year (17% vs 40%), and reported any HIV high-risk behavior (3% vs 13%). Latinos showed intermediate levels. With logistic regression analysis, ever tested for HIV was independently associated with only race/ethnicity; offered HIV testing in the past year was associated with females, Blacks and Latinos, aged 18-34 years, and having a routine health checkup in past year; any HIV high-risk behavior was associated with only younger age. CONCLUSIONS: To improve HIV testing rates as well as compliance with state laws and national guidelines, targeted efforts should be considered that improve perceptions of risk and emphasize the value of routine HIV screening, including those directed at White adults and their health care providers.

Using smartphone apps in STD interviews to find sexual partners.

OBJECTIVES: Smartphone applications (apps) are increasingly used to facilitate casual sexual relationships, increasing the risk of sexually transmitted diseases (STDs). In STD investigations, traditional contact elicitation methods can be enhanced with smartphone technology during field interviews. METHODS: In 2013, the Monroe County Department of Public Health conducted a large, multi-infection STD investigation among men who have sex with men (MSM) using both index case and cluster interviews. When patients indicated meeting sexual partners online, disease intervention specialists (DISs) had access to smartphone apps and were able to elicit partners through access to inboxes and profiles where traditional contact information was lacking. Social network mapping was used to display the extent of the investigation and the impact of access to smartphones on the investigation. RESULTS: A total of 14 index patient interviews and two cluster interviews were conducted; 97 individuals were identified among 117 sexual dyads. On average, eight partners were elicited per interview (range: 1-31). The seven individuals who used apps to find partners had an average of three Internet partners (range: 1-5). Thirty-six individuals either had a new STD (n=7) or were previously known to be HIV-positive (n=29). Of the 117 sexual dyads, 21 (18%) originated either online (n=8) or with a smartphone app (n=13). Of those originating online or with a smartphone app, six (29%) partners were located using the smartphone and two (10%) were notified of their exposure via a website. Three of the new STD/HIV cases were among partners who met online. CONCLUSION: Smartphone technology used by DISs in the field improved contact elicitation and resulted in successful partner notification and case finding.

Declines in elevated blood lead levels among children, 1997-2011.

BACKGROUND: Early childhood lead exposure is associated with numerous adverse health effects. Eliminating blood lead poisoning is a national health objective for 2020. OBJECTIVE: To assess temporal trends in childhood elevated blood lead level (EBLL) rates. METHODS: Laboratory surveillance data were collected from 1997 to 2011 and analyzed in 2013 using linear regression to assess trends in confirmed EBLL rates among children aged <6 years in the U.S., New York State ([NYS], excluding New York City), and Monroe County NY. Monroe County was also examined as a case study of local public health efforts to reduce childhood lead exposures. Blood lead screening and home lead hazard inspection data were collected from 1990 to 2012 and analyzed in 2013. RESULTS: The prevalence of EBLL≥10 µg/dL per 100 tested children decreased from 13.4 to 1.1 in Monroe County, 6.3 to 1.0 in NYS, and 7.6 to 0.6 in the U.S. between 1997 and 2011. The absolute yearly rate of decline in Monroe County (slope=-0.0083, p<0.001) occurred 2.4-fold faster than that in NYS (slope=-0.0034, p<0.001) and 1.8-fold faster than that in the U.S. (slope=-0.0046, p<0.001). The childhood blood lead testing rate was consistently higher in Monroe County than in NYS and the U.S.; however, testing increased for all three areas (all slopes>0, p<0.05), with greater improvements observed for U.S. children overall (slope=0.0075, p<0.001). CONCLUSIONS: In addition to national and statewide policies, local efforts may be important drivers of population-based declines in childhood EBLL rates.

Meningitis in a School-Aged Child due to Haemophilus influenzae Type E during the Post-Conjugate Vaccine Era-Monroe County, NY, 2011.

In late October 2011, the Monroe County Department of Public Health (MCDPH) was notified of a suspected case of meningitis in a 9-year old girl from Monroe County, NY. Laboratory testing at the New York State Department of Health (NYSDOH) Wadsworth Center confirmed the identification of Haemophilus influenzae serotype e (Hie) isolated from the patient's cerebrospinal fluid (CSF) using real-time polymerase chain reaction (RT-PCR). The universal immunization of infants with conjugate H. influenzae type b (Hib) vaccine has significantly reduced the incidence of invasive Hib disease, including meningitis, one of the most serious complications for infected children. Not surprisingly, as the epidemiology of invasive H. influenzae continues to change, non-Hib serotypes will likely become more common. The findings reported here underscore the importance for clinicians, public health officials, and laboratory staff to consider non-Hib pathogens in pediatric cases of meningitis, especially when initial investigations are inconclusive.

Outbreak of Mycobacterium chelonae infection associated with tattoo ink.

BACKGROUND: In January 2012, on the basis of an initial report from a dermatologist, we began to investigate an outbreak of tattoo-associated Mycobacterium chelonae skin and soft-tissue infections in Rochester, New York. The main goals were to identify the extent, cause, and form of transmission of the outbreak and to prevent further cases of infection. METHODS: We analyzed data from structured interviews with the patients, histopathological testing of skin-biopsy specimens, acid-fast bacilli smears, and microbial cultures and antimicrobial susceptibility testing. We also performed DNA sequencing, pulsed-field gel electrophoresis (PFGE), cultures of the ink and ingredients used in the preparation and packaging of the ink, assessment of source water and faucets at tattoo parlors, and investigation of the ink manufacturer. RESULTS: Between October and December 2011, a persistent, raised, erythematous rash in the tattoo area developed in 19 persons (13 men and 6 women) within 3 weeks after they received a tattoo from a single artist who used premixed gray ink; the highest occurrence of tattooing and rash onset was in November (accounting for 15 and 12 patients, respectively). The average age of the patients was 35 years (range, 18 to 48). Skin-biopsy specimens, obtained from 17 patients, showed abnormalities in all 17, with M. chelonae isolated from 14 and confirmed by means of DNA sequencing. PFGE analysis showed indistinguishable patterns in 11 clinical isolates and one of three unopened bottles of premixed ink. Eighteen of the 19 patients were treated with appropriate antibiotics, and their condition improved. CONCLUSIONS: The premixed ink was the common source of infection in this outbreak. These findings led to a recall by the manufacturer.

Treating patients with multiple cardiovascular conditions: an analysis of outpatient data in the United States, 2005.

BACKGROUND: Few studies have examined treatment rates in patients with multiple cardiovascular risk factors. This study assessed outpatient visit and treatment patterns among patients having > or =1 cardiovascular conditions. METHODS: Nationally representative outpatient survey data were used to identify patients > or =25 years with hypertension, hyperlipidemia, diabetes mellitus, ischemic heart disease or congestive heart failure during the year 2005 (n=15,060 records). Prevalence and visit patterns were examined for each cardiovascular condition by race/ethnicity, sex and age. Adherence to recommended treatment was also assessed using logistic regression. RESULTS: Prevalence rates generally increased with age, and several subgroup patterns were observed for some cardiovascular conditions. Visit rates were similar, with most patients seeing their providers about 3-4 times during the year. Hypertension, the most prevalent condition, had the highest treatment rate (88%) versus ischemic heart disease, one of the least prevalent conditions, which had the lowest treatment rate (28%). Treatment rates decreased with increasing numbers of cardiovascular conditions. Appropriate treatment was independently associated with decreasing numbers of cardiovascular conditions, treatment by the primary care provider and treatment with a combination agent-but not race/ethnicity, sex or primary payment source. CONCLUSIONS: While patients with multiple cardiovascular conditions visit their providers several times during the year, they are still largely undertreated, particularly as their cardiovascular disease burden increases. These findings may suggest that patients with multiple cardiovascular conditions are getting lower-quality care because of the greater demands placed on their physicians. Adherence to treatment guidelines may improve with adoption of a polypill and by encouraging patients to have a primary care home.

Elective and isolated carotid endarterectomy: health disparities in utilization and outcomes, but not readmission.

BACKGROUND: Carotid endarterectomy (CEA) has been shown to decrease future ischemic stroke risk in selected patients. However, clinical trials did not examine the risk-benefit ratio for nonwhites, who have a greater ischemic stroke risk than whites. In general, few studies have examined the effects of race on CEA use and complications, and data on race and CEA readmission are lacking. METHODS: This study used administrative data for patients discharged from California hospitals between January 1 and December 31, 2000. Selection criteria of cases included: ICD-9 principal procedure code 38.12, principal diagnostic code 433 and diagnosis-related group 5. There were 8,080 white and 1196 nonwhite patients (228 blacks, 643 Hispanics, 325 Asians/Pacific Islanders) identified that underwent an elective and isolated CEA. For both groups, CEA rates were compared. Logistic regression was used to examine the independent effects of race on in-hospital death and stroke, as well as CEA readmission. RESULTS: Rates of CEA use were more than three times greater for whites than nonwhites, although nonwhites were more likely to have symptomatic disease. For all patients, the complication rate was 1.9%. However, the odds of in-hospital death and stroke were greater for nonwhites than whites, but after adjustment for patient and hospital factors, these differences were only significant for stroke (OR = 1.7, P = 0.013). For both outcomes, the final models had good predictive accuracy. Overall, CEA readmission risk was 7%, and no significant racial differences were observed (P = 0.110). CONCLUSIONS: The data suggest that CEA is performed safely in California. However, nonwhites had lower rates of initial CEA use but higher rates of in-hospital death and stroke than whites. Racial differences in stroke risk persisted after adjustment for patient and hospital factors. Finally, this study found that despite significant racial disparities in initial CEA use, whites and nonwhites were similar in their CEA readmission rates. These findings may suggest that screening initiatives are lacking for nonwhites, which may increase their risk for poorer outcomes.

Does race predict stroke readmission? An analysis using the truncated negative binomial model.

BACKGROUND: Although it is known that the risk of first-ever stroke is higher for blacks than for whites, it is unclear what their relative risk is for stroke recurrence. METHODS: Using statewide inpatient data from California, 4,784 blacks and 33,684 whites having one or more stroke admissions during the year 2000 were identified. For blacks and whites, age- and sex-adjusted incidence rates were calculated for the index stroke admission using direct standardization (to the U.S. resident population for the year 2000). Various statistical models for count data were applied, with the best one being used in subsequent age-specific multivariate analyses for the number of stroke admissions. RESULTS: For the index stroke admission, the age- and sex-adjusted incidence rate per 100,000 was 366 (95% CI 355-377) for blacks and 204 (95% CI 202-207) for whites. Those having two or more stroke admissions accounted for less than 20% of the total number of patients. The truncated negative binomial (TNB) model gave the best fit not only to the California data but also to the data reanalyzed from several prior studies done in various countries [i.e., the United Kingdom (Oxfordshire and South London), Switzerland (Lausanne). Australia (Western Australia) and the United States (Nueces County, TX)]. In this study, predictors of stroke readmission changed according to age. For those aged 65-74 years old, blacks showed a higher risk of readmission than whites by 40% after adjustment for patient and hospital factors (RR 1.40, 95% CI 1.19-1.64). This excess risk was lower in other age groups. CONCLUSIONS: These findings suggest that blacks remain a high-risk group after an initial stroke and warrant appropriate intervention. Future studies on recurrent stroke should consider age-specific TNB models.

Predicting readmission stroke type among blacks and whites in California.

BACKGROUND: It is generally assumed that initial and recurrent strokes are of the same type, but data from South London, United Kingdom; Lausanne, Switzerland; and other studies suggest this may not be true for certain subtypes. In these studies, however, the number of recurrent strokes observed during the follow-up period was small, thereby limiting the ability of these studies to provide reliable estimates of stroke type concordance. METHODS: Using a large, diverse, inpatient database, this study sought to: (1) estimate the relative agreement (Cohen's kappa) between initial and recurrent stroke types for blacks and whites; and (2) develop a risk-adjusted logistic model for readmission stroke type, with the initial admission stroke type as the main predictor and race, other sociodemographic variables, and clinical and hospital characteristics as potential covariates. RESULTS: Stroke type concordance was similar for blacks (kappa = 0.77, 95% confidence interval [CI] = 0.71-0.83) and whites (kappa = 0.77, 95% CI = 0.74-0.79). In the adjusted logistic regression models, the initial admission stroke type strongly predicted the readmission stroke type (subarachnoid hemorrhage: odds ratio [OR] = 738.31, 95% CI = 422.58-1289.93; intracerebral hemorrhage [ICH]: OR = 80.86, 95% CI = 61.57-106.19; ischemic: OR = 125.81, 95% CI = 96.12-164.67). Other patient factors, but not race, also predicted readmission stroke type (e.g., younger age increased the odds of having an subarachnoid hemorrhage readmission; atrial fibrillation increased the odds of having an ICH readmission; older age, diabetes mellitus, and heart failure increased the odds of having an ischemic stroke readmission). CONCLUSION: This study showed that the initial stroke type and other factors were independently associated with the readmission stroke type and that patterns of stroke type concordance were similar for blacks and whites. These results may help to identify patients in high-risk subgroups who are more likely to have a recurrent hemorrhagic stroke, which could inform patient treatment decisions. For example, patients with atrial fibrillation may be at greater risk for having an ICH readmission because of the adverse effects of anticoagulant therapy, antiplatelet treatment, or both, which should be investigated further.

Trends in hospitalized stroke for blacks and whites in the United States, 1980-1999.

BACKGROUND: Racial differences in stroke mortality are widely recognized, but it is unclear whether or not these differences are due mainly to blacks having a greater stroke incidence or higher case fatality rates compared to those of whites. OBJECTIVES: The aim of this study was to describe the race-specific US trends in hospital discharge rates and in-hospital mortality among stroke patients for the period 1980-1999. It was hypothesized that the hospital discharge rates and in-hospital mortality among stroke patients would be greater for blacks than for whites. METHODS: Data from the National Hospital Discharge Survey for the period 1980-1999 were used to identify stroke subjects according to the codes of the International Classification of Diseases, ninth revision (codes 430-434 and 436). Direct standardization and Poisson regression were used to compare hospitalized stroke morbidity and mortality rates between blacks and whites. The main outcome measures were the number of stroke discharges and in-hospital deaths for black and white stroke patients. RESULTS: Between the years 1980 and 1999, the hospital discharge rates for stroke increased for blacks (n = 8,700) and decreased for whites (n = 46,154); the in-hospital mortality rates decreased for both black and white stroke patients. Generally, the risk of a stroke hospitalization was greater for blacks than for whites by more than 70%, whereas both groups were similar in terms of in-hospital mortality rates among stroke patients. CONCLUSIONS: Differences between blacks and whites in terms of stroke mortality are more likely due to differences in stroke incidence rather than case fatality. These data imply that greater attention should be given to primary/secondary prevention and that additional research is needed to understand the reasons for these patterns.

Does race predict short-term mortality after carotid surgery? The results of a meta-analysis.

Although African Americans are more likely to have an ischemic stroke and suffer a greater burden of stroke-related mortality and disability, they are less likely to have carotid surgery treatment than whites, even after accounting for clinical characteristics and ability to pay. Not surprisingly, little is known about their short- and long-term outcomes, including death, after undergoing carotid endarterectomy (CEA). The purpose of this study was to systematically review the published literature to clarify what role race has with respect to perioperative mortality risk following CEA. A search of MEDLINE (1966-May 2000), Scientific Citations (1945-May 2000), and the Cochrane Collaboration Stroke Group databases was performed to identify studies that related to African American-white differences for CEA mortality. Three studies met the specified eligibility criteria that allowed for the inclusion of 224,554 subjects (5,569 African Americans and 218,985 whites). Each showed some indication of increasing perioperative mortality risk for African Americans, but the findings were only significant for the studies of Hsia and colleagues (odds ratio (OR), 1.365; 95% confidence interval (CI), 1.164-1.600) and Huber and coworkers(28) (OR, 2.247; 95% Cl, 1.367-3.695) but not for the study of Estes and colleagues (OR, 1.429; 95% Cl, 0.827-2.469). After pooling the data, using a fixed-effects model, the OR was 1.429 (95% CI, 1.235-1.654). There was no evidence of significant heterogeneity between the studies and the random-effects model gave comparable results. African Americans, as compared to whites, appear to have a greater likelihood of short-term death following carotid surgery by more than 40%. This excess risk is possibly related to coexisting illness, which needs to be carefully weighed when considering a patient for CEA. Prospective studies are needed to further clarify these observed differences.