Drug use and COVID-19 testing, vaccination, and infection among underserved, minority communities in Miami, Florida.

The Coronavirus Disease 2019 (COVID-19) pandemic has disproportionately impacted people who use drugs (PWUD). This study explored relationships between drug use, COVID-19 testing, vaccination, and infection. This cross-sectional study was conducted in Miami, Florida between March 2021 and October 2022 as part of the National Institutes of Health (NIH) Rapid Acceleration of Diagnostics-Underserved Populations (RADx-UP) initiative and the Miami Adult Studies on HIV (MASH) cohort. Users of cannabis, cocaine/crack, heroin/fentanyl, methamphetamines, hallucinogens, and/or prescription drug misuse in the previous 12 months were considered PWUD. Sociodemographic data, COVID-19 testing history, and vaccination-related beliefs were self-reported. Vaccinations were confirmed with medical records and positivity was determined with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) testing. Statistical analyses included chi-square tests and logistic regression. Of 1,780 participants, median age was 57 years, 50.7% were male, 50.2% Non-Hispanic Black, and 66.0% reported an annual income less than $15,000. Nearly 28.0% used drugs. PWUD were less likely than non-users to self-report ever testing positive for SARS-CoV-2 (14.7% vs. 21.0%, p = 0.006). However, 2.6% of participants tested positive for SARS-CoV-2, with no significant differences between PWUD and non-users (3.7% vs. 2.2%, p = 0.076). PWUD were more likely than non-users to experience difficulties accessing testing (10.2% vs. 7.1%, p = 0.033), vaccine hesitancy (58.9% vs. 43.4%, p = 0.002) and had lower odds of receiving any dose of a COVID-19 vaccine compared to non-users (aOR, 0.63; 95% CI, 0.49-0.81; p<0.001). PWUD presented with greater difficulties accessing COVID-19 testing, greater vaccine hesitancy, and lower odds of vaccination. Testing and immunization plans that are tailored to the needs of PWUD and consider access, trust-building campaigns, and education may be needed.

Community-Engaged Research: COVID-19 Testing, Infection, and Vaccination among Underserved Minority Communities in Miami, Florida.

Community collaboration is a cornerstone of modern public health efforts. This work aimed to use community-engaged research to explore COVID-19 vaccination, testing, and infection in a minoritized community. This study was conducted in Miami, Florida, from March 2021 to February 2022 in community partner sites and the Miami Adult Studies on HIV (MASH) cohort. Sociodemographic characteristics, vaccination and testing beliefs, and COVID-19 challenges were self-reported. COVID-19 vaccinations were verified with medical records, testing history was self-reported, and severe acute respiratory syndrome coronavirus 2 positivity was determined via real-time reverse transcription-polymerase chain reaction (rt-PCR). Of 1689 participants, the median age was 57, 51% were male, 49% were non-Hispanic Black, 66% reported an income < USD 15,000/year, and 75.9% received at least one dose of a COVID-19 vaccine. Belief that COVID-19 vaccination is effective was associated with lower odds of COVID-19 positivity and was the strongest predictor of vaccination. Challenges accessing health care, housing, food, and transportation were associated with lower odds of vaccination. Employment, health insurance, higher education, and greater perceived test accuracy were associated with greater odds of COVID-19 testing. Social determinants of health and the belief that vaccines are effective and tests are accurate predicted behaviors and thus should be considered during public health crises in vulnerable communities.

Disability and COVID-19: Challenges, testing, vaccination, and postponement and avoidance of medical care among minoritized communities.

BACKGROUND: People with disabilities face heightened vulnerability to COVID-19. OBJECTIVE: This study investigated (1) the relationships between disability and COVID-19-related challenges, testing, vaccination, and infection and (2) predictors of loss of healthcare coverage and postponement and avoidance of medical care during the pandemic. METHODS: This cross-sectional study was conducted in Miami, Florida, between March 2021 and February 2022 as part of the NIH Rapid Acceleration of Diagnostics-Underserved Populations initiative. Disability was defined using a standard measure that assesses six universal functions. Participants reported sociodemographic data, COVID-19 testing, infection history, challenges, and healthcare history. Vaccinations were confirmed with medical records and COVID-19 positivity was assessed using real-time reverse transcription-polymerase chain reaction. Statistical analyses included multivariable logistic regression. RESULTS: Among 1,689 participants with a median age of 57.0, 50.6% were male, and 48.9% were non-Hispanic Black. Disability was associated with greater odds of all assessed COVID-19 challenges: healthcare (aOR:1.60; 95% CI:1.23-2.07), housing (aOR:2.15; 95% CI:1.62-2.87), insufficient food (aOR:1.97; 95% CI:1.54-2.52), water scarcity (aOR:2.33; 95% CI:1.60-3.37), medications (aOR:2.04; 95% CI:1.51-2.77), and transportation (aOR:2.56; 95% CI:1.95-3.36). Those reporting employment disability were less likely to have received COVID-19 testing (81.1% vs. 85.3%, p = 0.026) or to have history of COVID-19 positivity (aOR:0.63; 95% CI:0.44-0.92). Disability predicted avoidance (aOR:2.76; 95% CI:1.95-3.91) and postponement (aOR: 2.24; 95% CI:1.72-2.91) of medical care. CONCLUSIONS: Disability is associated with higher odds of COVID-19 challenges and postponement and avoidance of medical care. Those reporting employment disability had a lower likelihood of COVID-19 testing. Public health responses to healthcare crises should prioritize the special challenges of people living with disabilities.

Remission of severe forms of long COVID following monoclonal antibody (MCA) infusions: A report of signal index cases and call for targeted research.

OBJECTIVE: Long COVID has afflicted tens of millions globally leaving many previously-healthy persons severely and indefinitely debilitated. The objective here was to report cases of complete, rapid remission of severe forms of long COVID following certain monoclonal antibody (MCA) infusions and review the corresponding pathophysiological implications. DESIGN: Case histories of the first three index events (among others) are presented. Unaware of others with similar remissions, each subject independently completed personal narratives and standardized surveys regarding demographics/occupation, past history, and the presence and respective severity grading of 33 signs/symptoms associated with long COVID, comparing the presence/severity of those symptoms during the pre-COVID, long-COVID, post-vaccination, and post-MCA phases. SETTING: Patient interviews, e-mails and telephone conversations. SUBJECTS: Three previously healthy, middle-aged, highly-functioning persons, two women and one man (ages 60, 43, and 63 years respectively) who, post-acute COVID-19 infection, developed chronic, unrelenting fatigue and cognitive impairment along with other severe, disabling symptoms. Each then independently reported incidental and unanticipated complete remissions within days of MCA treatment. INTERVENTIONS: The casirivimab/imdevimab cocktail. MEASUREMENTS AND MAIN RESULTS: Irrespective of sex, age, medical history, vaccination status, or illness duration (18, 8 and 5 months, respectively), each subject experienced the same complete remission of their persistent disabling disease within a week of MCA infusion. Each rapidly returned to normal health and previous lifestyles/occupations with normalized exercise tolerance, still sustained to date over two years later. CONCLUSIONS: These index cases provide compelling clinical signals that MCA infusions may be capable of treating long COVID in certain cases, including those with severe debilitation. While the complete and sustained remissions observed here may only apply to long COVID resulting from pre-Delta variants and the specific MCA infused, the striking rapid and complete remissions observed in these cases also provide mechanistic implications for treating/managing other post-viral chronic conditions and long COVID from other variants.

Monkeypox 2022 Identify-Isolate-Inform: A 3I Tool for frontline clinicians for a zoonosis with escalating human community transmission.

Monkeypox 2022, a zoonotic virus similar to smallpox, presented as a rapidly escalating human outbreak with community transmission outside endemic regions of Africa. In just over one month of detection, confirmed cases escalated to over 3300, with reports of patients in at least 43 non-African nations. Mechanisms of transmission in animals and the reservoir host remain uncertain; spread from humans to wild or domestic animals risks the creation of new endemic zones. While initial cases were reported in men who have sex with men (MSM), monkeypox is not considered a sexually transmitted infection. Anyone with close contact with an infected person, aerosolized infectious material (e.g., from shaken bedsheets), or contact with fomites or infected animals is at risk. In humans, monkeypox typically presents with a non-specific prodromal phase followed by a classic rash with an incubation period of 5-21 days (usually 6-13 days). The prodrome may be subclinical, and the monkeypox virus may be transmissible from person-to-person before observed symptom onset. Most clinicians are unfamiliar with monkeypox. Information is rapidly evolving, producing an urgent need for immediate access to clear, concise, fact-based, and actionable information for frontline healthcare workers in prehospital, emergency departments/hospitals, and acute care/sexual transmitted infection clinics. This paper provides a novel Identify-Isolate-Inform (3I) Tool for the early detection and management of patients under investigation for monkeypox 2022. Patients are identified as potentially exposed or infected after an initial assessment of risk factors and signs/symptoms. Management of exposed patients includes consideration of quarantine and post-exposure prophylaxis with a smallpox vaccine. For infectious patients, providers must immediately don personal protective equipment and isolate patients. Healthcare workers must report suspected and confirmed cases in humans or animals to public health authorities. This innovative 3I Tool will assist emergency, primary care, and prehospital clinicians in effectively managing persons with suspected or confirmed monkeypox.

Monkeypox 2022: A Primer and Identify-Isolate-Inform (3I) Tool for Emergency Medical Services Professionals.

Monkeypox 2022 exhibits unprecedented human-to-human transmission and presents with different clinical features than those observed in prior outbreaks. Previously endemic only to West and Central Africa, the monkeypox virus spread rapidly world-wide following confirmation of a case in the United Kingdom on May 7, 2022 of an individual that had traveled to Nigeria. Detection of cases with no travel history confirms on-going community spread. Emergency Medical Services (EMS) professionals will likely encounter patients suspected or confirmed to have monkeypox, previously a rare disease and therefore unfamiliar to most clinicians. Consequently, it is critical for EMS medical directors to immediately implement policies and procedures for EMS teams - including emergency medical dispatchers - to identify potential monkeypox cases. These must include direction on actions EMS professionals should take to protect themselves and others from virus transmission. Monkeypox 2022 may manifest more subtly than it has historically. Presentations include a subclinical prodrome and less dramatic skin lesions - potentially limited to genital or anal body regions - which can be easily confused with dermatologic manifestations of common sexually transmitted infections (STIs). While most readily spread by close contact with infectious skin lesions on a patient, it is also transmissible from fomites, such as bed sheets. Additionally, droplet transmission can occur, and the virus can be spread by aerosolization under certain conditions. The long incubation period could have profound negative consequences on EMS staffing if clinicians are exposed to monkeypox. This report summarizes crucial information needed for EMS professionals to understand and manage the monkeypox 2022 outbreak. It presents an innovative Identify-Isolate-Inform (3I) Tool for use by EMS policymakers, educators, and clinicians on the frontlines who may encounter monkeypox patients. Patients are identified as potentially exposed or infected after an initial assessment of risk factors with associated signs and symptoms. Prehospital workers must immediately don personal protective equipment (PPE) and isolate infectious patients. Also, EMS professionals must report exposures to their agency infection control officer and alert health authorities for non-transported patients. Prehospital professionals play a crucial role in emerging and re-emerging infectious disease mitigation. The monkeypox 2022 3I Tool includes knowledge essential for all clinicians, plus specific information to guide critical actions in the prehospital environment.

Systematic review of registered trials of Hydroxychloroquine prophylaxis for COVID-19 health-care workers at the first third of 2020.

In the absence of a vaccine the medical and scientific community is looking intensely at utilizing a pre or post exposure drug that could decrease viremia. The search for a medication that could reduce risk of serious disease, and ideally of any manifestation of disease from SARS-CoV2, and of asymptomatic shedding of SARS-CoV2 is of urgent interest. Repurposing existing pharmaceuticals is among the approaches to achieve these ends. We performed a systematic review of all interventional studies registered in ClinicalTrials.gov with a focus on one repurposed drug, Hydroxychloroquine (HCQ). The detailed analysis of these studies, some of them already recruiting, provide an overall picture of HCQ use as a COVID-19 prophylaxis around the world. Among the included studies, all but three were randomized and parallel and most of them (74%, 23/31) were double-blinded to quadruple-blinded studies. We found a great diversity in dosing and nearly all the possible scientifically reasonable regimens are under evaluation. This diversity offers benefits as well as challenges. Importantly, the final analysis of these trials should be done through an extensive reading of the results in regard to the clinical design, it will be crucial to carefully read and evaluate the results of each study in regards to the clinical design rather than quickly glancing a 140 characters-based social media message announcing the failure or success of a drug against a disease.

Emerging natural threats and the deliberate use of biological agents.

Over the past several years there has been an increasing awareness and interest by the medical community, the media, and government at all levels regarding the need to plan for and defend against biological weapons. This article offers an overview of various new and emerging natural biological threats.

Viral hemorrhagic fevers.

A taxonomically diverse set of single-stranded ribonucleic acid(ssRNA) viruses from four diverse viral families Arenaviridae,Bunyaviridae, Filoviridae, and Flaviviridae cause an acute systemic febrile syndrome called viral hemorrhagic fever (VHF). The syndrome produces combinations of prostration, malaise, increased vascular permeability, and coagulation maladies. In severe illness,VHF may include generalized bleeding but the bleeding does not typically constitute a life-threatening loss of blood volume. To a certain extent, it is a sign of damage to the vascular endothelium and is an indicator of disease severity in specific target organs. Although the viruses that cause hemorrhagic fever (HF) can productively replicate in endothelial cells, much of the disease pathology including impairment to the vascular system is thought to result primarily from the release of a variety of mediators from virus-infected cells, such as monocytes and macrophages that subsequently alter vascular function and trigger the coagulation disorders that epitomize these infections. While significant progress has been made over the last several years in dissecting out the molecular biology and pathogenesis of the HF viruses, there are currently no vaccines or drugs licensed available for most of the VHFs.

Anatomic laboratory and forensic aspects of biological threat agents.

Anatomic pathology of surgical and cytologic samples and forensic autopsies is a critical component of our defense against biological terrorism. In many instances, rapid, valuable diagnosis may be obtained by the proper immediate use of the anatomic pathology laboratory. Included in this field is the work of medical examiners and coroners, who are essential public health partners for terrorism preparedness and response. The investigation of sudden, suspicious, violent, unattended, and unexplained deaths may provide the first clue to a deliberate biological attack. Medicolegal autopsies are essential to making organism-specific diagnoses in deaths caused by biological terrorism.

A multidisciplinary approach to teach responses to weapons of mass destruction and terrorism using combined simulation modalities.

STUDY OBJECTIVE: To reinforce concepts presented in the lectures; understand the complexity and speed of casualty and information generation during a Weapons of Mass Destruction and Terrorism (WMD/T) event; experience the novelty of combined weapons' effects; recognize the time course of the various chemical, biological, and radiation agents; and make challenging decisions with incomplete and conflicting information. SETTINGS: Two environments simulated simultaneously: one a major trauma center emergency room (ER) with two patient simulators and several human actors; the other an Emergency Operations Command Center (EOC). TARGET AUDIENCE: Students for this course included: clinicians, scientists, military and intelligence officers, lawyers, administrators, and logistic personnel whose jobs involve planning and executing emergency response plans to WMD/T. SIMULATION SCRIPT: A WMD/T attack in Washington, D.C., has occurred. Clinical students performed in their real life roles in the simulated ER, while nonclinical students did the same in the simulated EOC. Six ER casualties with combined WMD/T injuries were presented and treated over 40 minutes. In the EOC, each person was given his or her role title with identification tag. The EOC scenario took cues from the action in the ER via two television (TV) news feeds and telephone calls from other Emergency Operations Assets. PERFORMANCE EXPECTATIONS: Students were expected to actively engage in their roles. Student performances were self-evaluated during the debriefing. DEBRIEFING: The two groups were reunited and debriefed utilizing disaster crisis resource management tools. ASSESSMENT OF EFFECTIVENESS: Students answered an 18-point questionnaire to help evaluate the usefulness and acceptance of multimodality patient simulation. LESSONS LEARNED: Large-scale multimodality patient simulation can be used to train both clinicians and nonclinicians for future events of WMD/T. Students accepted the simulation experience and thought that scenario was appropriately realistic, complex, and overwhelming. Difficulties include the extensive man-hours involved in designing and presenting the live simulations. EOC-only sessions could be staged with only a few video cassette recorders, TVs, telephones, and callers.

A Multidisciplinary Approach to Teach Responses to Weapons of Mass Destruction and Terrorism Using Combined Simulation Modalities.

STUDY OBJECTIVE: To reinforce concepts presented in the lectures; understand the complexity and speed of casualty and information generation during a Weapons of Mass Destruction and Terrorism (WMD/T) event; experience the novelty of combined weapons' effects; recognize the time course of the various chemical, biological, and radiation agents; and make challenging decisions with incomplete and conflicting information. SETTINGS: Two environments simulated simultaneously: one a major trauma center emergency room (ER) with two patient simulators and several human actors; the other an Emergency Operations Command Center (EOC). TARGET AUDIENCE: Students for this course included: clinicians, scientists, military and intelligence officers, lawyers, administrators, and logistic personnel whose jobs involve planning and executing emergency response plans to WMD/T. SIMULATION SCRIPT: A WMD/T attack in Washington, D.C., has occurred. Clinical students performed in their real life roles in the simulated ER, while nonclinical students did the same in the simulated EOC. Six ER casualties with combined WMD/T injuries were presented and treated over 40 minutes. In the EOC, each person was given his or her role title with identification tag. The EOC scenario took cues from the action in the ER via two television (TV) news feeds and telephone calls from other Emergency Operations Assets. PERFORMANCE EXPECTATIONS: Students were expected to actively engage in their roles. Student performances were self-evaluated during the debriefing. DEBRIEFING: The two groups were reunited and debriefed utilizing disaster crisis resource management tools. ASSESSMENT OF EFFECTIVENESS: Students answered an 18-point questionnaire to help evaluate the usefulness and acceptance of multimodality patient simulation. LESSONS LEARNED: Large-scale multimodality patient simulation can be used to train both clinicians and nonclinicians for future events of WMD/T. Students accepted the simulation experience and thought that scenario was appropriately realistic, complex, and overwhelming. Difficulties include the extensive man-hours involved in designing and presenting the live simulations. EOC-only sessions could be staged with only a few video cassette recorders, TVs, telephones, and callers.

TLR2 and TLR4 serve distinct roles in the host immune response against Mycobacterium bovis BCG.

Toll-like receptor (TLR) proteins mediate cellular activation by microbes and microbial products. To delineate the role of TLR proteins in the development of host immune responses against mycobacteria, wild-type and TLR-deficient mice were infected with nonpathogenic Mycobacterium bovis bacillus Calmette-Guerin (BCG). Two weeks after intraperitoneal challenge with BCG, few bacilli were present in the lungs of wild-type and TLR4(-/-) mice, whereas bacterial loads were tenfold higher in the lungs of infected TLR2(-/-) mice. BCG challenge in vitro strongly induced proinflammatory cytokine secretion by macrophages from wild-type and TLR4(-/-) mice but not by TLR2(-/-) macrophages. In contrast, intracellular uptake, intracellular bacterial growth, and suppression of intracellular bacterial growth in vitro by interferon-gamma (IFN-gamma) were similar in macrophages from all three mouse strains, suggesting that BCG growth in the lungs of TLR2(-/-) mice was a consequence of defective adaptive immunity. Antigenic stimulation of splenocytes from infected wild-type and TLR4(-/-) mice induced T cell proliferation in vitro, whereas T cells from TLR2(-/-) mice failed to proliferate. Unexpectedly, activated CD4(+) T cells from both TLR-deficient mouse strains secreted little IFN-gamma in vitro compared with control T cells. A role for TLR4 in the control of bacterial growth and IFN-gamma production in vivo was observed only when mice were infected with higher numbers of BCG. Thus, TLR2 and TLR4 appear to regulate distinct aspects of the host immune response against BCG.

Lethal invasive cestodiasis in immunosuppressed patients.

Using both traditional methods and broad-range 18S ribosomal DNA (rDNA) polymerase chain reaction, we examined 2 cases of lethal cestodiasis, in which the disease agent had been poorly identified or misidentified. In one case, involving a patient with AIDS, we identified the human dwarf tapeworm, Hymenolepis nana, as a cause of aberrant metastatic larval disease. In the second case with similar pathologic abnormalities, involving a patient with Hodgkin disease, we identified a larval cestode with a previously uncharacterized 18S rDNA sequence. A prior report of this case nearly 30 years ago, based on tissue examination, had suggested that the parasite was a sparganum.