Inclusion, Diversity, Access, and Equity in Infectious Diseases Fellowship Training: Tools for Program Directors.

The Infectious Diseases Society of America (IDSA) has set clear priorities in recent years to promote inclusion, diversity, access, and equity (IDA&E) in infectious disease (ID) clinical practice, medical education, and research. The IDSA IDA&E Task Force was launched in 2018 to ensure implementation of these principles. The IDSA Training Program Directors Committee met in 2021 and discussed IDA&E best practices as they pertain to the education of ID fellows. Committee members sought to develop specific goals and strategies related to recruitment, clinical training, didactics, and faculty development. This article represents a presentation of ideas brought forth at the meeting in those spheres and is meant to serve as a reference document for ID training program directors seeking guidance in this area.

Mental health impact of COVID-19 pandemic on therapists at an inpatient rehabilitation facility.

BACKGROUND: Healthcare workers have faced extraordinary work-related stress in the face of the COVID-19 pandemic. Physical therapy, occupational therapy, and speech-language pathology providers at inpatient rehabilitation facilities may represent a distinct at-risk subgroup for work-related stress during the pandemic due to the usual nature of their job duties, including close physical contact and extended treatment times. OBJECTIVE: To evaluate the impact of the COVID-19 pandemic on work-related stress and occurrence of depression and anxiety in physical therapists, occupational therapists, and speech-language pathologists during the first surge of COVID-19 hospitalizations. DESIGN: Cross-sectional survey. SETTING: Academic, freestanding inpatient rehabilitation facility. PARTICIPANTS: Survey responses were collected from 38 therapists. INTERVENTION: A 26-item electronic questionnaire containing a mix of multiple-choice and open-ended questions. MAIN OUTCOME MEASURES: Positive screens for depression or anxiety as measured by the Patient Health Questionnaire-9 (PHQ-9) and the General Anxiety Disorder 7-item (GAD-7) scale, respectively. RESULTS: Seven individuals (19%) scored at or above the clinically significant cutoff of 10 on each the PHQ-9 and GAD-7, corresponding to increased risk for depression and anxiety. Therapists younger than 30 years old had significantly higher GAD-7 scores compared to therapists between 30-39 years old (p < .05). Occupational stress was attributed to a number of causes including concerns for health and safety, unpredictable changes in hospital protocols and work assignments, acquisition of additional work duties, concerns about the ability to provide high-quality patient care in a restricted environment, and the psychological toll of caring for patients with or recovering from COVID-19. CONCLUSION: This cross-sectional survey highlights the impact of the COVID-19 pandemic on occupational stress and mental health of therapists working at an inpatient rehabilitation facility during the first surge of COVID-19 hospitalizations. This research may help institutions identify at-risk individuals who may benefit from support and guide policy changes to resolve potentially modifiable factors at a systems level.

Incidence and Risk Factors for Renal Disease in an Outpatient Cohort of HIV-Infected Patients on Antiretroviral Therapy.

INTRODUCTION: Prior studies found renal disease was common among HIV-infected outpatients. We updated incident renal disease estimates in this population, comparing those with and without tenofovir exposure. METHODS: We conducted a retrospective analysis of the DC Cohort, a longitudinal study of HIV patients in Washington, DC, from 2011 to 2015. We included adults prescribed antiretroviral therapy (ART) with baseline glomerular filtration rate (GFR) ≥15 ml/min per 1.73 m2. We defined renal disease as 50% decrease in GFR or doubled serum creatinine (Cr) within 3 months. We defined cumulative viral load as area under the curve (AUC) of log10 transformed longitudinal HIV RNA viral load (VL). Correlates of time to incident renal disease were identified using Cox proportional hazard regression models, adjusted for demographics and known risk factors for kidney disease. RESULTS: Among 6068 adults, 77% were Black and median age was 48 years. Incident renal disease rate was 0.77 per 100 person-years (95% confidence interval [CI]: 0.65-0.9). Factors associated with renal disease were age (adjusted hazard ratio [aHR]: 1.4; CI 1.1-1.7 per 10 years), public non-Medicaid, non-Medicare insurance (aHR: 3.4; CI: 1.9-6.4), AUC VL (aHR: 1.1; CI: 1.1-1.2), diabetes mellitus (aHR: 1.6; CI: 1.0-2.4), and mildly reduced GFR (60-89 ml/min per 1.73 m2) (aHR: 1.5; CI: 1.0-2.3); recent tenofovir exposure was not associated with renal disease (aHR: 0.7; CI: 0.5-1.1). CONCLUSION: Our study revealed a substantial burden of renal disease among HIV patients. Cumulative VL was associated with renal disease, suggesting that early VL suppression may decrease its incidence.

Preventing Cushing: Iatrogenic Cushing Syndrome due to Ritonavir-Fluticasone Interaction.

Ritonavir is commonly used in low doses to boost plasma levels of protease inhibitors in patients with human immunodeficiency virus (HIV) infections. It is also a potent inhibitor of cytochrome P450. We present a 50-year-old African American male with past medical history of HIV on highly active antiretroviral therapy (HAART), which also included ritonavir and long standing asthma that has been treated with inhaled fluticasone, who presented with back pain. He had central obesity, prominent abdominal striae and wasted extremities on physical examination. Laboratory tests showed low morning serum cortisol and suboptimal cosyntropin test consistent with adrenal insufficiency. Computed tomography (CT) of the spine showed a fracture of inferior endplate of the lumbar (L3) vertebra. The cause of osteoporosis is believed to be iatrogenic Cushing syndrome caused by enhanced levels of inhaled fluticasone effects secondary to inhibition of cytochrome P450. The patient was managed surgically and fluticasone was discontinued.

Utility of Keywords from Chest Radiograph Reports for Pneumonia Surveillance Among Hospitalized Patients with Influenza: The CDC Influenza Hospitalization Surveillance Network, 2008-2009.

OBJECTIVE: Transcripts from admission chest radiographs could aid in identification of pneumonia cases for public health surveillance. We assessed the reliability of radiographic data abstraction and performance of radiographic key terms to identify pneumonia in patients hospitalized with laboratory-confirmed influenza virus infection. METHODS: We used data on patients hospitalized with laboratory-confirmed influenza virus infection from October 2008 through December 2009 from 10 geographically diverse U.S. study sites participating in the Influenza Hospitalization Surveillance Network (FluSurv-NET). Radiographic key terms (i.e., bronchopneumonia, consolidation, infiltrate, airspace density, and pleural effusion) were abstracted from final impressions of chest radiograph reports. We assessed the reliability of radiographic data abstraction by examining the percent agreement and Cohen's k statistic between clinicians and surveillance staff members. Using a composite reference standard for presence or absence of pneumonia based on International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes and discharge summary data, we calculated sensitivity, specificity, positive predictive value (PPV), and percent agreement for individual and combined radiographic key terms. RESULTS: For each radiographic key term, the percent agreement between clinicians and surveillance staff members ranged from 89.4% to 98.6% and Cohen's k ranged from 0.46 (moderate) to 0.84 (almost perfect). The combination of bronchopneumonia or consolidation or infiltrate or airspace density terms had sensitivity of 66.5%, specificity of 89.2%, PPV of 80.4%, and percent agreement of 80.1%. Adding pleural effusion did not result in significant changes in sensitivity, specificity, PPV, or percent agreement. CONCLUSION: Radiographic key terms abstracted by surveillance staff members from final impressions of chest radiograph reports had moderate to almost perfect reliability and could be used to identify pneumonia among patients hospitalized with laboratory-confirmed influenza virus infection. This method can inform pneumonia surveillance and aid in public health response.

Epidemiology of Methicillin-Resistant Staphylococcus aureus Bloodstream Coinfection Among Adults With Candidemia in Atlanta, GA, 2008-2012.

BACKGROUND: Patients with candidemia are at risk for other invasive infections, such as methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infection (BSI). OBJECTIVE: To identify the risk factors for, and outcomes of, BSI in adults with Candida spp. and MRSA at the same time or nearly the same time. DESIGN: Population-based cohort study. SETTING: Metropolitan Atlanta, March 1, 2008, through November 30, 2012. PATIENTS: All residents with Candida spp. or MRSA isolated from blood. METHODS: The Georgia Emerging Infections Program conducts active, population-based surveillance for candidemia and invasive MRSA. Medical records for patients with incident candidemia were reviewed to identify cases of MRSA coinfection, defined as incident MRSA BSI 30 days before or after candidemia. Multivariate logistic regression was performed to identify factors associated with coinfection in patients with candidemia. RESULTS: Among 2,070 adult candidemia cases, 110 (5.3%) had coinfection within 30 days. Among these 110 coinfections, MRSA BSI usually preceded candidemia (60.9%; n=67) or occurred on the same day (20.0%; n=22). The incidence of coinfection per 100,000 population decreased from 1.12 to 0.53 between 2009 and 2012, paralleling the decreased incidence of all MRSA BSIs and candidemia. Thirty-day mortality was similarly high between coinfection cases and candidemia alone (45.2% vs 36.0%, P=.10). Only nursing home residence (odds ratio, 1.72 [95% CI, 1.03-2.86]) predicted coinfection. CONCLUSIONS: A small but important proportion of patients with candidemia have MRSA coinfection, suggesting that heightened awareness is warranted after 1 major BSI pathogen is identified. Nursing home residents should be targeted in BSI prevention efforts.

Household-level risk factors for influenza among young children in Dhaka, Bangladesh: a case-control study.

OBJECTIVES: To identify household-level factors associated with influenza among young children in a crowded community in Dhaka, Bangladesh. METHODS: We conducted a case-control study using existing active surveillance for respiratory illness. Cases were children aged 12-59 months with laboratory-confirmed influenza. Controls were children frequency-matched by age group with no respiratory illness in the prior 6 months. We interviewed caregivers and observed household handwashing behaviour. Soap consumption was estimated by summing weight differences of three bars of soap sequentially left in each household. We measured concentrations of airborne particulate matter <2.5 µg in diameter (PM2.5) in a subset of households. We used logistic regression to estimate adjusted odds ratios (aOR) and 95% confidence intervals (CI). RESULTS: We enrolled 145 cases and 341 controls between March 2009 and April 2010. Case and control household members were observed to wash hands with similar frequency during a 5-h period (mean, 0.64 events vs. 0.63, P = 0.87), and similar daily soap consumption per capita (mean 2.92 grams vs. 2.93, P = 0.92). Case households were more likely than controls to have crowded (≥4 persons) sleeping areas (aOR = 1.67, CI: 1.06-2.63) and cross-ventilated cooking spaces (aOR = 1.75, CI: 1.16-2.63). Case and control households had similar median 24-h geometric mean PM2.5 concentrations in the cooking (69.2 vs. 69.6 µg/m(3), P = 0.45) and sleeping (65.4 vs. 67.4 µg/m(3), P = 0.19) spaces. CONCLUSIONS: Handwashing with soap was practiced infrequently and was not associated with paediatric influenza in this community. Interventions aimed at crowded households may reduce influenza incidence in young children.

Isolated pulmonary valve infective endocarditis in a middle aged man caused by Candida albicans: a case report.

BACKGROUND: Pulmonary valve endocarditis without the involvement of other valves represents 1.5-2% of all cases of infective endocarditis. Isolated pulmonary valve endocarditis caused by Candida is extremely rare with only one reported case in the literature and none reported in the United States. Guidelines for management of Candida endocarditis recommend a combination of medical and surgical therapy. CASE PRESENTATION: A 61-year-old homeless male presented with fever, cough and shortness of breath. He was urgently intubated for hypoxia. He was initially diagnosed with pneumonia but did not improve with empiric antibacterial therapy. Candida species were isolated from bronchoalveolar lavage fluid and the patient eventually developed persistent C. albicans bloodstream infection. On further workup he was found to have infective endocarditis with a large vegetation across the pulmonary valve. No other valves were involved. He was treated with intravenous antifungal therapy for eight weeks. Valvular surgery was not performed. Follow up echocardiography after completion of therapy did not show any vegetations and the patient clinically improved. CONCLUSION: This is the second reported case of isolated pulmonary valve endocarditis caused by Candida and the first to be successfully managed with antifungal therapy alone. Pulmonary valve endocarditis should be considered in cases of pneumonia with Candida and persistent fungemia. While surgery should be considered in all cases of Candida endocarditis, cure may be achieved with antifungal therapy alone.

Household air quality risk factors associated with childhood pneumonia in urban Dhaka, Bangladesh.

To inform interventions to reduce the high burden of pneumonia in urban settings such as Kamalapur, Bangladesh, we evaluated household air quality risk factors for radiographically confirmed pneumonia in children. In 2009-2010, we recruited children < 5 years of age with pneumonia and controls from a population-based surveillance for respiratory and febrile illnesses. Piped natural gas was used by 85% of 331 case and 91% of 663 control households. Crowding, a tin roof in the living space, low socioeconomic status, and male sex of the child were risk factors for pneumonia. The living space in case households was 28% less likely than in control households to be cross-ventilated. Particulate matter concentrations were not significantly associated with pneumonia. With increasing urbanization and supply of improved cooking fuels to urban areas, the high burden of respiratory illnesses in urban populations such as Kamalapur may be reduced by decreasing crowding and improving ventilation in living spaces.

The burden and severity of illness due to 2009 pandemic influenza A (H1N1) in a large US city during the late summer and early fall of 2009.

In estimates of illness severity from the spring wave of the 2009 influenza A (H1N1) pandemic, reported case fatality proportions were less than 0.05%. In prior pandemics, subsequent waves of illness were associated with higher mortality. The authors evaluated the burden of the pandemic H1N1 (pH1N1) outbreak in metropolitan Atlanta, Georgia, in the fall of 2009, when increased influenza activity heralded the second wave of the pandemic in the United States. Using data from a community survey, existing surveillance systems, public health laboratories, and local hospitals, they estimated numbers of pH1N1-associated illnesses, emergency department (ED) visits, hospitalizations, intensive care unit (ICU) admissions, and deaths occurring in metropolitan Atlanta during the period August 16, 2009-September 26, 2009. The authors estimated 132,140 pediatric and 132,110 adult symptomatic cases of pH1N1 in metropolitan Atlanta during the investigation time frame. Among children, these cases were associated with 4,560 ED visits, 190 hospitalizations, 51 ICU admissions, and 4 deaths. Among adults, they were associated with 1,130 ED visits, 590 hospitalizations, 140 ICU admissions, and 63 deaths. The combined symptomatic case hospitalization proportion, case ICU admission proportion, and case fatality proportion were 0.281%, 0.069%, and 0.024%, respectively. Influenza burden can be estimated using existing data and local surveys. The increased severity reported for subsequent waves in past pandemics was not evident in this investigation. Nevertheless, the second pH1N1 pandemic wave led to substantial numbers of ED visits, hospitalizations, and deaths in metropolitan Atlanta.

Risk factors for tuberculin skin test conversion among HIV-infected patients in New York City.

BACKGROUND: We assessed the incidence of and risk factors for tuberculin skin test (TST) conversion among HIV-infected adults at a New York City clinic. METHODS: All adult HIV-infected patients were eligible for inclusion if they had a negative baseline TST result and at least one subsequent documented TST test result. RESULTS: A total of 414 HIV-infected patients had a negative baseline TST result; 288 (69.6%) were male. Among 348 patients who had a place of birth documented, 50% were born outside of mainland USA. Twenty-two (5.3%) of 414 patients had documented TST conversions, giving a crude incidence rate of 1.77 per 100 person-years. Being a foreign-born Asian individual (p=0.02), having lived in a shelter (p=0.004), and having an increase in CD4 cell count (p=0.02) while under care were independent risk factors for TST conversion. CONCLUSIONS: We found a high TST conversion rate among HIV-infected patients attending an urban clinic. Annual TST testing is particularly important for patients who are foreign-born from high-endemic countries, those with a history of homelessness, and those with an increase in CD4 cell count since the baseline negative TST test.

The first cases of 2009 pandemic influenza A (H1N1) virus infection in the United States: a serologic investigation demonstrating early transmission.

BACKGROUND: The first two laboratory-confirmed cases of 2009 pandemic influenza A (H1N1) virus (H1N1pdm09) infection were detected in San Diego (SD) and Imperial County (IC) in southern California, April 2009. OBJECTIVES: To describe H1N1pdm09 infections and transmission early in the 2009 H1N1 pandemic. PATIENTS/METHODS: We identified index case-patients from SD and IC with polymerase chain reaction (PCR)-confirmed H1N1pdm09 infections and investigated close contacts for a subset of case-patients from April 17-May 6, 2009. Acute and convalescent serum was collected. Serologic evidence for H1N1pdm09 infection was determined by microneutralization and hemagglutination inhibition assays. RESULTS: Among 75 close contacts of seven index case-patients, three reported illness onset prior to patient A or B, including two patient B contacts and a third with no links to patient A or B. Among the 69 close contacts with serum collected >14 days after the onset of index case symptoms, 23 (33%) were seropositive for H1N1pdm09, and 8 (35%) had no fever, cough, or sore throat. Among 15 household contacts, 8 (53%) were seropositive for H1N1pdm09. The proportion of contacts seropositive for H1N1pdm09 was highest in persons aged 5-24 years (50%) and lowest in persons aged ≥ 50 years (13%) (P = 0·07). CONCLUSIONS: By the end of April 2009, before H1N1pdm09 was circulating widely in the community, a third of persons with close contact to confirmed H1N1pdm09 cases had H1N1pdm09 infection in SD and IC. Three unrelated clusters during March 21-30 suggest that transmission of H1N1pdm09 had begun earlier in southern California.

Transmission of 2009 pandemic influenza A (H1N1) virus among healthcare personnel-Southern California, 2009.

OBJECTIVE: In April 2009, 2009 pandemic influenza A (H1N1) (hereafter, pH1N1) virus was identified in California, which caused widespread illness throughout the United States. We evaluated pH1N1 transmission among exposed healthcare personnel (HCP) and assessed the use and effectiveness of personal protective equipment (PPE) early in the outbreak. DESIGN: Cohort study. SETTING: Two hospitals and 1 outpatient clinic in Southern California during March 28-April 24, 2009. PARTICIPANTS: Sixty-three HCP exposed to 6 of the first 8 cases of laboratory-confirmed pH1N1 in the United States. METHODS: Baseline and follow-up questionnaires were used to collect demographic, epidemiologic, and clinical data. Paired serum samples were obtained to test for pH1N1-specific antibodies by microneutralization and hemagglutination-inhibition assays. Serology results were compared with HCP work setting, role, and self-reported PPE use. RESULTS: Possible healthcare-associated pH1N1 transmission was identified in 9 (14%) of 63 exposed HCP; 6 (67%) of 9 seropositive HCP had asymptomatic infection. The highest attack rates occurred among outpatient HCP (6/19 [32%]) and among allied health staff (eg, technicians; 8/33 [24%]). Use of mask or N95 respirator was associated with remaining seronegative (P = .047). Adherence to PPE recommendations for preventing transmission of influenza virus and other respiratory pathogens was inadequate, particularly in outpatient settings. CONCLUSIONS: pH1N1 transmission likely occurred in healthcare settings early in the pandemic associated with inadequate PPE use. Organizational support for a comprehensive approach to infectious hazards, including infection prevention training for inpatient- and outpatient-based HCP, is essential to improve HCP and patient safety.

Description of antiviral treatment among adults hospitalized with influenza before and during the 2009 pandemic: United States, 2005-2009.

BACKGROUND: The 2009 influenza pandemic led to guidelines emphasizing antiviral treatment for all persons hospitalized with influenza, including pregnant women. We compared antiviral use among adults hospitalized with influenza before and during the pandemic. METHODS: The Emerging Infections Program conducts active population-based surveillance for persons hospitalized with community-acquired, laboratory-confirmed influenza in 10 states. We analyzed data collected via medical record review of patients aged ≥18 years admitted during prepandemic (1 October 2005 through 14 April 2009) and pandemic (15 April 2009 through 31 December 2009) time frames. RESULTS: Of 5943 adults hospitalized with influenza in prepandemic seasons, 3235 (54%) received antiviral treatment, compared with 4055 (82%) of 4966 during the pandemic. Forty-one (22%) of 187 pregnant women received antiviral treatment in prepandemic seasons, compared with 369 (86%) of 430 during the pandemic. Pregnancy was a negative predictor of antiviral treatment before the pandemic (adjusted odds ratio [aOR], 0.24; 95% confidence interval [CI], .16-.35) but was independently associated with treatment during the pandemic (aOR, 1.97; 95% CI, 1.32-2.96). Antiviral treatment among adults hospitalized >2 days after illness onset increased from 43% before the pandemic to 79% during the pandemic (P < .001). CONCLUSIONS: Antiviral treatment of hospitalized adults increased during the pandemic, especially among pregnant women. This suggests that many clinicians followed published guidance to treat hospitalized adults with antiviral agents. However, compliance with antiviral recommendations could be improved.

Characteristics of patients with oseltamivir-resistant pandemic (H1N1) 2009, United States.

During April 2009-June 2010, thirty-seven (0.5%) of 6,740 pandemic (H1N1) 2009 viruses submitted to a US surveillance system were oseltamivir resistant. Most patients with oseltamivir-resistant infections were severely immunocompromised (76%) and had received oseltamivir before specimen collection (89%). No evidence was found for community circulation of resistant viruses; only 4 (unlinked) patients had no oseltamivir exposure.

Serial intervals and the temporal distribution of secondary infections within households of 2009 pandemic influenza A (H1N1): implications for influenza control recommendations.

A critical issue during the 2009 influenza A (H1N1) pandemic was determining the appropriate duration of time individuals with influenza-like illness (ILI) should remain isolated to reduce onward transmission while limiting societal disruption. Ideally this is based on knowledge of the relative infectiousness of ill individuals at each point during the course of the infection. Data on 261 clinically apparent pH1N1 infector-infectee pairs in households, from 7 epidemiological studies conducted in the United States early in 2009, were analyzed to estimate the distribution of times from symptom onset in an infector to symptom onset in the household contacts they infect (mean, 2.9 days, not correcting for tertiary transmission). Only 5% of transmission events were estimated to take place >3 days after the onset of clinical symptoms among those ill with pH1N1 virus. These results will inform future recommendations on duration of isolation of individuals with ILI.

Investigating 2009 pandemic influenza A (H1N1) in US schools: what have we learned?

US investigations of school-based outbreaks of 2009 pandemic influenza A (H1N1) virus infection characterized influenza-like illness (ILI) attack rates, transmission risk factors, and adherence to nonpharmaceutical interventions. We summarize seven school-based investigations conducted during April-June 2009 to determine what questions might be answered by future investigations. Surveys were administered 5-28 days after identification of the outbreaks, and participation rates varied among households (39-86%) and individuals (24-49%). Compared with adults (4%-10%) and children aged <4 years (2%-7%), elementary through university students had higher ILI attack rates (4%-32%). Large gatherings or close contact with sick persons were identified as transmission risk factors. More participants reported adherence to hygiene measures, but fewer reported adherence to isolation measures. Challenges included low participation and delays in survey initiation that potentially introduced bias. Although school-based investigations can increase our understanding of epidemiology and prevention strategy effectiveness, investigators should decide which objectives are most feasible, given timing and design constraints.