Lessons Learned From Implementation of Mpox Surveillance During an Outbreak Response in Tennessee, 2022.

OBJECTIVES: Mpox surveillance was integral during the 2022 outbreak response. We evaluated implementation of mpox surveillance in Tennessee during an outbreak response and made recommendations for surveillance during emerging infectious disease outbreaks. METHODS: To understand surveillance implementation, system processes, and areas for improvement, we conducted 8 semistructured focus groups and 7 interviews with 36 health care, laboratory, and health department representatives during September 9-20, 2022. We categorized and analyzed session transcription and notes. We analyzed completeness and timeliness of surveillance data, including 349 orthopoxvirus-positive laboratory reports from commercial, public health, and health system laboratories during July 1-August 31, 2022. RESULTS: Participants described an evolving system and noted that existing informatics platforms inefficiently supported iterations of reporting requirements. Clear communication, standardization of terminology, and shared, adaptable, and user-friendly informatics platforms were prioritized for future emerging infectious disease surveillance systems. Laboratory-reported epidemiologic information was often incomplete; only 55% (191 of 349) of reports included patient address and telephone number. The median time from symptom onset to specimen collection was 5 days (IQR, 3-6 d), from specimen collection to laboratory reporting was 3 days (IQR, 1-4 d), from laboratory reporting to patient interview was 1 day (IQR, 1-3 d), and from symptom onset to patient interview was 9 days (IQR, 7-12 d). CONCLUSIONS: Future emerging infectious disease responses would benefit from standardized surveillance approaches that facilitate rapid implementation. Closer collaboration among informatics, laboratory, and clinical partners across jurisdictions and agencies in determining system priorities and designing workflow processes could improve flexibility of the surveillance platform and completeness and timeliness of laboratory reporting. Improved timeliness will facilitate public health response and intervention, thereby mitigating morbidity.

Demographic and Clinical Characteristics of Mpox in Persons Who Had Previously Received 1 Dose of JYNNEOS Vaccine and in Unvaccinated Persons - 29 U.S. Jurisdictions, May 22-September 3, 2022.

As of November 14, 2022, monkeypox (mpox) cases had been reported from more than 110 countries, including 29,133 cases in the United States.* Among U.S. cases to date, 95% have occurred among males (1). After the first confirmed U.S. mpox case on May 17, 2022, limited supplies of JYNNEOS vaccine (Modified Vaccinia Ankara vaccine, Bavarian Nordic) were made available to jurisdictions for persons exposed to mpox. JYNNEOS vaccine was approved by the Food and Drug Administration (FDA) in 2019 as a 2-dose series (0.5 mL per dose, administered subcutaneously) to prevent smallpox and mpox disease.† On August 9, 2022, FDA issued an emergency use authorization to allow administration of JYNNEOS vaccine by intradermal injection (0.1 mL per dose) (2). A previous report on U.S. mpox cases during July 31-September 3, 2022, suggested that 1 dose of vaccine offers some protection against mpox (3). This report describes demographic and clinical characteristics of cases occurring ≥14 days after receipt of 1 dose of JYNNEOS vaccine and compares them with characteristics of cases among unvaccinated persons with mpox and with the vaccine-eligible vaccinated population in participating jurisdictions. During May 22-September 3, 2022, among 14,504 mpox cases reported from 29 participating U.S. jurisdictions,§ 6,605 (45.5%) had available vaccination information and were included in the analysis. Among included cases, 276 (4.2%) were among persons who had received 1 dose of vaccine ≥14 days before illness onset. Mpox cases that occurred in these vaccinated persons were associated with lower percentage of hospitalization (2.1% versus 7.5%), fever, headache, malaise, myalgia, and chills, compared with cases in unvaccinated persons. Although 1 dose of JYNNEOS vaccine offers some protection from disease, mpox infection can occur after receipt of 1 dose, and the duration of protection conferred by 1 dose is unknown. Providers and public health officials should therefore encourage persons at risk for acquiring mpox to complete the 2-dose vaccination series and provide guidance and education regarding nonvaccine-related prevention strategies (4).

Improving efficiency of COVID-19 aggregate case and death surveillance data transmission for jurisdictions: current and future role of application programming interfaces (APIs).

During the coronavirus disease-2019 (COVID-19) pandemic, the Centers for Disease Control and Prevention (CDC) supplemented traditional COVID-19 case and death reporting with COVID-19 aggregate case and death surveillance (ACS) to track daily cumulative numbers. Later, as public health jurisdictions (PHJs) revised the historical COVID-19 case and death data due to data reconciliation and updates, CDC devised a manual process to update these records in the ACS dataset for improving the accuracy of COVID-19 case and death data. Automatic data transfer via an application programming interface (API), an intermediary that enables software applications to communicate, reduces the time and effort in transferring data from PHJs to CDC. However, APIs must meet specific content requirements for use by CDC. As of March 2022, CDC has integrated APIs from 3 jurisdictions for COVID-19 ACS. Expanded use of APIs may provide efficiencies for COVID-19 and other emergency response planning efforts as evidenced by this proof-of-concept. In this article, we share the utility of APIs in COVID-19 ACS.

Covid-19 Rates by Time since Vaccination during Delta Variant Predominance.

BACKGROUND: With the emergence of the delta variant, the United States experienced a rapid increase in Covid-19 cases in 2021. We estimated the risk of breakthrough infection and death by month of vaccination as a proxy for waning immunity during a period of delta variant predominance. METHODS: Covid-19 case and death data from 15 U.S. jurisdictions during January 3 to September 4, 2021 were used to estimate weekly hazard rates among fully vaccinated persons, stratified by age group and vaccine product. Case and death rates during August 1 to September 4, 2021 were presented across four cohorts defined by month of vaccination. Poisson models were used to estimate adjusted rate ratios comparing the earlier cohorts to July rates. RESULTS: During August 1 to September 4, 2021, case rates per 100,000 person-weeks among all vaccine recipients for the January to February, March to April, May to June, and July cohorts were 168.8 (95% confidence interval [CI], 167.5 to 170.1), 123.5 (95% CI, 122.8 to 124.1), 83.6 (95% CI, 82.9 to 84.3), and 63.1 (95% CI, 61.6 to 64.6), respectively. Similar trends were observed by age group for BNT162b2 (Pfizer-BioNTech) and mRNA-1273 (Moderna) vaccine recipients. Rates for the Ad26.COV2.S (Janssen-Johnson & Johnson) vaccine were higher; however, trends were inconsistent. BNT162b2 vaccine recipients 65 years of age or older had higher death rates among those vaccinated earlier in the year. Protection against death was sustained for the mRNA-1273 vaccine recipients. Across age groups and vaccine types, people who were vaccinated 6 months ago or longer (January-February) were 3.44 (3.36 to 3.53) times more likely to be infected and 1.70 (1.29 to 2.23) times more likely to die from COVID-19 than people vaccinated recently in July 2021. CONCLUSIONS: Our study suggests that protection from SARS-CoV-2 infection among all ages or death among older adults waned with increasing time since vaccination during a period of delta predominance. These results add to the evidence base that supports U.S. booster recommendations, especially for older adults vaccinated with BNT162b2 and recipients of the Ad26.COV2.S vaccine. (Funded by the Centers for Disease Control and Prevention.).

Surveillance, Epidemiology, and Estimated Burden of Neonatal Abstinence Syndrome, Tennessee, 2013-2016.

OBJECTIVES: Between 2003 and 2013, the rate of neonatal abstinence syndrome (NAS)-a postnatal drug withdrawal syndrome-in Tennessee increased approximately 10-fold. NAS surveillance is relatively new, and underestimation associated with surveillance has not been described. We compared data from the Tennessee NAS public health surveillance system (TNSS) with a second source of NAS data, hospital discharge data system (HDDS), and estimated the true number of infants with NAS using capture-recapture methods. METHODS: We obtained NAS data on cases of NAS among Tennessee infants from TNSS and HDDS from January 1, 2013, through December 31, 2016. We matched cases of NAS identified in TNSS to cases identified in HDDS. We estimated the true number of infants with NAS by using the Lincoln-Peterson estimator capture-recapture methodology. RESULTS: During the study period, 4070 infants with NAS were reported to TNSS, and 5321 infants with NAS were identified in HDDS; 2757 were in both data sets. Using capture-recapture methods, the total estimated number of infants with NAS during the study period was 7855 (annual mean = 1972; estimated range = 1531-2427), which was 93% more than in TNSS and 48% more than in HDDS. Drugs used for the medication-assisted treatment of substance use disorder were the most commonly reported substances associated with NAS (n = 2389, 59%). CONCLUSIONS: TNSS underestimated the total burden of NAS based on the capture-recapture estimate. Case-based public health surveillance is important for monitoring the burden of and risk factors for NAS and helping guide public health interventions.

Cross Disciplinary Consultancy to Bridge Public Health Technical Needs and Analytic Developers: Negation Detection Use Case.

This paper describes a continuing initiative of the International Society for Disease Surveillance designed to bring together public health practitioners and analytics solution developers from both academia and industry. Funded by the Defense Threat Reduction Agency, a series of consultancies have been conducted on a range of topics of pressing concern to public health (e.g. developing methods to enhance prediction of asthma exacerbation, developing tools for asyndromic surveillance from chief complaints). The topic of this final consultancy, conducted at the University of Utah in January 2017, is focused on defining a roadmap for the development of algorithms, tools, and datasets for improving the capabilities of text processing algorithms to identify negated terms (i.e. negation detection) in free-text chief complaints and triage reports.

Population survey of attitudes and beliefs regarding organic, genetically modified, and irradiated foods.

BACKGROUND: Sales of organic foods are increasing due to public demand, while genetically modified (GM) and irradiated foods are often viewed with suspicion. AIM: The aim of this research was to examine consumer attitudes toward organic, GM and irradiated foods to direct educational efforts regarding their consumption Methods: A telephone survey of 1838 residents in Tennessee, USA was conducted regarding organic, GM, and irradiated foods. RESULTS: Approximately half of respondents (50.4%) purchased organic food during the previous 6 months ('consumers'). The most common beliefs about organic foods by consumers were higher cost (92%), and fewer pesticides (89%). Consumers were more likely than non-consumers to believe organic food tasted better (prevalence ratio 3.6; 95% confidence interval 3.02-4.23). A minority of respondents were familiar with GM foods (33%) and irradiated foods (22%). CONCLUSION: Organic food consumption is common in Tennessee, but knowledge about GM and irradiated foods is less common. Consumer health education should emphasize the benefits of these food options, and the safety of GM and irradiated foods.

Inadequacy of IgM antibody tests for diagnosis of Rocky Mountain Spotted Fever.

Among 13 suspected Rocky Mountain spotted fever (RMSF) cases identified through an enhanced surveillance program in Tennessee, antibodies to Rickettsia rickettsii were detected in 10 (77%) patients using a standard indirect immunofluorescent antibody (IFA) assay. Immunoglobulin M (IgM) antibodies were observed for 6 of 13 patients (46%) without a corresponding development of IgG, and for 3 of 10 patients (30%) at least 1 year post-onset. However, recent infection with a spotted fever group rickettsiae could not be confirmed for any patient, based on a lack of rising antibody titers in properly timed acute and convalescent serologic specimens, and negative findings by polymerase chain reaction testing. Case definitions used in national surveillance programs lack specificity and may capture cases that do not represent current rickettsial infections. Use of IgM antibodies should be reconsidered as a basis for diagnosis and public health reporting of RMSF and other spotted fever group rickettsiae in the United States.

High-risk use by patients prescribed opioids for pain and its role in overdose deaths.

IMPORTANCE: From January 1, 2003, through December 31, 2010, drug overdose deaths in Tennessee increased from 422 to 1059 per year. More of these deaths involved prescription opioids than heroin and cocaine combined. OBJECTIVE: To assess the contribution of certain opioid-prescribing patterns to the risk of overdose death. DESIGN, SETTING, AND PARTICIPANTS: We performed a matched case-control study that analyzed opioid prescription data from the Tennessee Controlled Substances Monitoring Program (TNCSMP) from January 1, 2007, through December 31, 2011, to identify risk factors associated with opioid-related overdose deaths from January 1, 2009, through December 31, 2010. Case patients were ascertained from death certificate data. Age- and sex-matched controls were randomly selected from among live patients in the TNCSMP. MAIN OUTCOMES AND MEASURES: We defined a high-risk number of prescribers or pharmacies as 4 or more per year and high-risk dosage as a daily mean of more than 100 morphine milligram equivalents (MMEs) per year. The main outcome was opioid-related overdose death. RESULTS: From January 1, 2007, through December 31, 2011, one-third of the population of Tennessee filled an opioid prescription each year, and opioid prescription rates increased from 108.3 to 142.5 per 100 population per year. Among all patients in Tennessee prescribed opioids during 2011, 7.6% used more than 4 prescribers, 2.5% used more than 4 pharmacies, and 2.8% had a mean daily dosage greater than 100 MMEs. Increased risk of opioid-related overdose death was associated with 4 or more prescribers (adjusted odds ratio [aOR], 6.5; 95% CI, 5.1-8.5), 4 or more pharmacies (aOR, 6.0; 95% CI, 4.4-8.3), and more than 100 MMEs (aOR, 11.2; 95% CI, 8.3-15.1). Persons with 1 or more risk factor accounted for 55% of all overdose deaths. CONCLUSIONS AND RELEVANCE: High-risk use of prescription opioids is frequent and increasing in Tennessee and is associated with increased overdose mortality. Use of prescription drug­monitoring program data to direct risk-reduction measures to the types of patients overrepresented among overdose deaths might reduce mortality associated with opioid abuse.

Healthcare-Associated Pertussis Outbreak in Arizona: Challenges and Economic Impact, 2011.

An outbreak investigation identified 15 pertussis cases among 5 infants and 10 healthcare professionals at 1 hospital's neonatal intensive care unit (NICU). The cost of the outbreak to this hospital was $97 745. Heightened awareness of pertussis in NICUs is key to preventing healthcare-associated spread and minimizing outbreak-control-related costs. Bordetella pertussis is a highly communicable bacterial pathogen that causes a prolonged cough illness and is spread by respiratory droplet transmission. Infants aged ≤6 months are most susceptible to B pertussis infection and pertussis-associated complications, including pneumonia, encephalopathy, and death, and are commonly hospitalized for treatment [ 1]. Despite a universal pertussis vaccination program, 27 550 pertussis cases were reported in the United States during 2010 [ 2]. Pertussis outbreaks in healthcare settings can be challenging and costly to control [3]. On September 13, 2011 and September 15, 2011, 3 pertussis cases, including 2 confirmed by B pertussis isolation, among preterm infants discharged ≤30 days previously from a 71-bed NICU of a general hospital (NICU A) were reported by Hospital B, a large pediatric facility, to Maricopa County Department of Public Health. This report describes the outbreak, examines outbreak-associated costs and risk factors that might have contributed to healthcare-associated transmission, and provides guidance to prevent outbreaks in healthcare settings.

Knowledge, attitudes, and practices regarding Rocky Mountain spotted fever among healthcare providers, Tennessee, 2009.

Tennessee has a high incidence of Rocky Mountain spotted fever (RMSF), the most severe tick-borne rickettsial illness in the United States. Some regions in Tennessee have reported increased illness severity and death. Healthcare providers in all regions of Tennessee were surveyed to assess knowledge, attitudes, and perceptions regarding RMSF. Providers were sent a questionnaire regarding knowledge of treatment, diagnosis, and public health reporting awareness. Responses were compared by region of practice within the state, specialty, and degree. A high proportion of respondents were unaware that doxycycline is the treatment of choice in children ≤ 8 years of age. Physicians practicing in emergency medicine, internal medicine, and family medicine; and nurse practitioners, physician assistants, and providers practicing for < 20 years demonstrated less knowledge regarding RMSF. The gaps in knowledge identified between specialties, designations, and years of experience can help target education regarding RMSF.

Pandemic 2009 influenza A(H1N1) virus illness among pregnant women in the United States.

CONTEXT: Early data on pandemic 2009 influenza A(H1N1) suggest pregnant women are at increased risk of hospitalization and death. OBJECTIVE: To describe the severity of 2009 influenza A(H1N1) illness and the association with early antiviral treatment among pregnant women in the United States. DESIGN, SETTING, AND PATIENTS: Surveillance of 2009 influenza A(H1N1) in pregnant women reported to the Centers for Disease Control and Prevention (CDC) with symptom onset from April through December 2009. MAIN OUTCOME MEASURES: Severity of illness (hospitalizations, intensive care unit [ICU] admissions, and deaths) due to 2009 influenza A(H1N1) among pregnant women, stratified by timing of antiviral treatment and pregnancy trimester at symptom onset. RESULTS: We received reports on 788 pregnant women in the United States with 2009 influenza A(H1N1) with symptom onset from April through August 2009. Among those, 30 died (5% of all reported 2009 influenza A[H1N1] influenza deaths in this period). Among 509 hospitalized women, 115 (22.6%) were admitted to an ICU. Pregnant women with treatment more than 4 days after symptom onset were more likely to be admitted to an ICU (56.9% vs 9.4%; relative risk [RR], 6.0; 95% confidence interval [CI], 3.5-10.6) than those treated within 2 days after symptom onset. Only 1 death occurred in a patient who received treatment within 2 days of symptom onset. Updating these data with the CDC's continued surveillance of ICU admissions and deaths among pregnant women with symptom onset through December 31, 2009, identified an additional 165 women for a total of 280 women who were admitted to ICUs, 56 of whom died. Among the deaths, 4 occurred in the first trimester (7.1%), 15 in the second (26.8%), and 36 in the third (64.3%); CONCLUSIONS: Pregnant women had a disproportionately high risk of mortality due to 2009 influenza A(H1N1). Among pregnant women with 2009 influenza A(H1N1) influenza reported to the CDC, early antiviral treatment appeared to be associated with fewer admissions to an ICU and fewer deaths.