Differences in meningococcal disease incidence by health insurance type and among persons experiencing homelessness-United States, 2016-2019.

Meningococcal disease is a serious but rare disease in the United States. Prior publications suggest incidence differs among privately vs publicly-insured persons, and that incidence is higher among persons experiencing homelessness (PEH) than persons not known to be experiencing homelessness (non-PEH). Using insurance claims data for persons aged <1 to 64 years, we calculated meningococcal disease incidence among a population with employer-sponsored commercial insurance and persons enrolled in state Medicaid programs nationwide. We also examined meningococcal disease incidence by PEH status in Medicaid data. From 2016 through 2019, persons who met our study inclusion criteria contributed a total of 84,460,548 person-years (PYs) to our analysis of commercial insurance data and 253,496,622 PYs to our analysis of Medicaid data. Incidence was higher among persons enrolled in Medicaid (0.12 cases per 100,000 PYs) than persons with commercial insurance (0.06 cases per 100,000 PYs). Incidence was 3.17 cases per 100,000 PYs among PEH in Medicaid, 27 times higher than among non-PEH in Medicaid. Understanding the underlying drivers of the higher meningococcal disease incidence among PEH and persons enrolled in Medicaid may inform prevention strategies for populations experiencing a higher burden of disease.

Tetanus, Diphtheria, and Acellular Pertussis Vaccination Coverage Among Publicly Insured Pregnant Women, U.S., 2016-2019.

Introduction: Vaccination with tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine during pregnancy is highly effective against Bordetella pertussis in young infants. We aimed to evaluate the uptake of maternal tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccination during the recommended gestation period of 27 through 36 weeks among women enrolled in a public medical insurance plan in the U.S. Methods: In this analysis using Centers for Medicare and Medicaid Services insurance claims data, we identified women aged 15 through 49 years who delivered a live-born infant from 2016 through 2019. We identified claims for tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccination to calculate the proportion of women who were vaccinated during Weeks 27 through 36 of gestation in each calendar year. We also assessed the average annual maternal tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis coverage by age group, race and ethnicity, U.S. Census region of residence, and plan type. Data were analyzed in 2021. Results: Among 4,318,823 deliveries, the 4-year national average for tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccination was 26%, improving from 22% in 2016 to 31% in 2019 (p<0.001). Within subgroups, the lowest 4-year average coverage was among women aged 15 through 18 years (22%); Black, non-Hispanic (23%) and Hispanic women (24%); those residing in the South (18%); those enrolled in a Children's Health Insurance Program plan (22%); and those covered by a fee-for-service plan (19%). Coverage increased across all subgroups from 2016 through 2019. Conclusions: Although maternal tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis coverage among publicly insured women in the U.S. increased from 2016 through 2019, it remained considerably lower than estimated national coverage, with notable differences by race and ethnicity.

Demographic, clinical, and epidemiologic characteristics of persons under investigation for Coronavirus Disease 2019-United States, January 17-February 29, 2020.

BACKGROUND: The Coronavirus Disease 2019 (COVID-19) pandemic, caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), evolved rapidly in the United States. This report describes the demographic, clinical, and epidemiologic characteristics of 544 U.S. persons under investigation (PUI) for COVID-19 with complete SARS-CoV-2 testing in the beginning stages of the pandemic from January 17 through February 29, 2020. METHODS: In this surveillance cohort, the U.S. Centers for Disease Control and Prevention (CDC) provided consultation to public health and healthcare professionals to identify PUI for SARS-CoV-2 testing by quantitative real-time reverse-transcription PCR. Demographic, clinical, and epidemiologic characteristics of PUI were reported by public health and healthcare professionals during consultation with on-call CDC clinicians and subsequent submission of a CDC PUI Report Form. Characteristics of laboratory-negative and laboratory-positive persons were summarized as proportions for the period of January 17-February 29, and characteristics of all PUI were compared before and after February 12 using prevalence ratios. RESULTS: A total of 36 PUI tested positive for SARS-CoV-2 and were classified as confirmed cases. Confirmed cases and PUI testing negative for SARS-CoV-2 had similar demographic, clinical, and epidemiologic characteristics. Consistent with changes in PUI evaluation criteria, 88% (13/15) of confirmed cases detected before February 12, 2020, reported travel from China. After February 12, 57% (12/21) of confirmed cases reported no known travel- or contact-related exposures. CONCLUSIONS: These findings can inform preparedness for future pandemics, including capacity for rapid expansion of novel diagnostic tests to accommodate broad surveillance strategies to assess community transmission, including potential contributions from asymptomatic and presymptomatic infections.

Factors Associated With Latent Tuberculosis Infection Treatment Failure Among Patients With Commercial Health Insurance-United States, 2005-2016.

CONTEXT: Approximately 80% of US tuberculosis (TB) cases verified during 2015-2016 were attributed to untreated latent TB infection (LTBI). Identifying factors associated with LTBI treatment failure might improve treatment effectiveness. OBJECTIVE: To identify patients with indicators of isoniazid (INH) LTBI treatment initiation, completion, and failure. METHODS: We searched inpatient and outpatient claims for International Classification of Diseases (Ninth and Tenth Revisions), National Drug, and Current Procedural Terminology codes. We defined treatment completion as 180 days or more of INH therapy during a 9-month period. We defined LTBI treatment failure as an active TB disease diagnosis more than 1 year after starting LTBI treatment among completers and used exact logistic regression to model possible differences between groups. Among treatment completers, we matched 1 patient who failed treatment with 2 control subjects and fit regression models with covariates documented on medical claims paid 6 months or less before INH treatment initiation. PARTICIPANTS: Commercially insured US patients in a large commercial database with insurance claims paid during 2005-2016. MAIN OUTCOME MEASURES: (1) Trends in treatment completion; (2) odds ratios (ORs) for factors associated with treatment completion and treatment failure. RESULTS: Of 21 510 persons who began LTBI therapy during 2005-2016, 10 725 (49.9%) completed therapy. Treatment noncompletion is associated with those younger than 45 years, living in the Northeast or South Census regions, and women. Among persons who completed treatment, 30 (0.3%) progressed to TB disease. Diagnoses of rheumatoid arthritis during the 6 months before treatment initiation and being aged 65 years or older (reference: ages 0-24 years) were significantly associated with INH LTBI treatment failure (adjusted exact OR = 5.1; 95% CI, 1.2-28.2; and adjusted exact OR = 5.1; 95% CI, 1.2-25.3, respectively). CONCLUSION: Approximately 50% of persons completed INH LTBI therapy, and of those, treatment failure was associated with rheumatoid arthritis and persons 65 years or older among a cohort of US LTBI patients with commercial health insurance.

Characteristics of and meningococcal disease prevention strategies for commercially insured persons receiving eculizumab in the United States.

INTRODUCTION: Eculizumab is a licensed treatment for several rare, complement-mediated diseases. Eculizumab use is associated with an approximately 2,000-fold increased meningococcal disease risk. In the United States, meningococcal vaccines are recommended for eculizumab recipients but there are no recommendations on use of long-term antibiotic prophylaxis. We describe characteristics of and meningococcal vaccine and antibiotic receipt in U.S. eculizumab recipients to inform meningococcal disease prevention strategies. METHODS: Persons in the IBM® MarketScan® Research Databases with ≥1 claim for eculizumab injection during 2007-2017 were included. Indication for eculizumab use, meningococcal vaccine receipt, and antibiotic receipt were assessed using International Classification of Diseases-9/10 diagnosis codes, vaccine administration procedure codes, and antibiotic codes from pharmacy claims, respectively. RESULTS: Overall 696 persons met the inclusion criteria. Paroxysmal nocturnal hemoglobinuria (PNH) and atypical hemolytic uremic syndrome (aHUS) were the most common indications for eculizumab use (41% and 37%, respectively); 20% had an undetermined indication. From June 2015 through December 2017, 28% (41/148) of continuously-enrolled patients received ≥1 serogroup B vaccine dose. For serogroup ACWY conjugate vaccine, 45% (91/201) of patients received ≥1 dose within five years of their most recent eculizumab dose, as recommended. Of eculizumab recipients with outpatient prescription data, 7% (41/579) received antibiotics for ≥50% of the period of increased risk for meningococcal disease. CONCLUSION: Many eculizumab recipients had an undetermined indication for eculizumab use; few were up-to-date for recommended meningococcal vaccines or were prescribed antibiotics long-term. These findings can inform further investigation of how to best protect this population from meningococcal disease.

Persons Evaluated for 2019 Novel Coronavirus - United States, January 2020.

In December 2019, a cluster of cases of pneumonia emerged in Wuhan City in central China's Hubei Province. Genetic sequencing of isolates obtained from patients with pneumonia identified a novel coronavirus (2019-nCoV) as the etiology (1). As of February 4, 2020, approximately 20,000 confirmed cases had been identified in China and an additional 159 confirmed cases in 23 other countries, including 11 in the United States (2,3). On January 17, CDC and the U.S. Department of Homeland Security's Customs and Border Protection began health screenings at U.S. airports to identify ill travelers returning from Wuhan City (4). CDC activated its Emergency Operations Center on January 21 and formalized a process for inquiries regarding persons suspected of having 2019-nCoV infection (2). As of January 31, 2020, CDC had responded to clinical inquiries from public health officials and health care providers to assist in evaluating approximately 650 persons thought to be at risk for 2019-nCoV infection. Guided by CDC criteria for the evaluation of persons under investigation (PUIs) (5), 210 symptomatic persons were tested for 2019-nCoV; among these persons, 148 (70%) had travel-related risk only, 42 (20%) had close contact with an ill laboratory-confirmed 2019-nCoV patient or PUI, and 18 (9%) had both travel- and contact-related risks. Eleven of these persons had laboratory-confirmed 2019-nCoV infection. Recognizing persons at risk for 2019-nCoV is critical to identifying cases and preventing further transmission. Health care providers should remain vigilant and adhere to recommended infection prevention and control practices when evaluating patients for possible 2019-nCoV infection (6). Providers should consult with their local and state health departments when assessing not only ill travelers from 2019-nCoV-affected countries but also ill persons who have been in close contact with patients with laboratory-confirmed 2019-nCoV infection in the United States.

Monitoring the hepatitis C care cascade using administrative claims data.

OBJECTIVES: With the availability of curative therapies, it is important to ensure that individuals infected with hepatitis C virus (HCV) receive recommended testing, care, and treatment. We sought to evaluate insurance claims data as a source for monitoring progression along the HCV care cascade. STUDY DESIGN: Longitudinal evaluation of disease progression, from diagnosis to treatment, among commercially insured enrollees with chronic HCV. METHODS: We validated and used algorithms derived from standardized procedure and diagnosis codes to identify enrollees with chronic HCV in large insurance claims databases to describe the HCV care cascade, including the proportion engaged in HCV-specific care (13 possible definitions), the proportion prescribed HCV treatment, and the proportion who received an HCV RNA test 30 or more days after initiating treatment. RESULTS: Approximately 90% of individuals with an HCV RNA test procedure code followed by either 3 or more chronic HCV diagnosis codes on different service dates or 2 or more chronic HCV diagnosis codes separated by more than 60 days truly had chronic HCV. Using these algorithms, we identified 5791 HCV cases from January 1, 2013, to June 30, 2014. Among enrollees with HCV, 95% were engaged in HCV care, but only 49% initiated treatment and 43% received a follow-up HCV RNA test 30 or more days after initiating treatment. CONCLUSIONS: With validated case-finding algorithms, insurance claims data can be used to describe and monitor portions of the HCV care cascade. Although nearly all enrollees with HCV were engaged in HCV care, only half received treatment, indicating that even commercially insured enrollees may find it challenging to access treatment.

Hepatitis B Virus Testing and Care among Pregnant Women Using Commercial Claims Data, United States, 2011-2014.

Introduction: Pregnant women should receive hepatitis B virus (HBV) testing with hepatitis B surface antigen (HBsAg), but it is unclear whether HBV-infected pregnant women are linked to care. Methods: We analyzed MarketScan™ commercial insurance claims. We included pregnant women, aged 10-50 years, with 42 weeks of continuous enrollment before (predelivery) and 6 months after (postdelivery) the first delivery claim for each unique pregnancy between 1/1/2011 and 6/30/2014. We identified claims for HBsAg testing by CPT code and described the care continuum among pregnancies with an associated ICD-9 HBV diagnosis code by demographic and clinical characteristics, including HBV-directed care ([HBV DNA or hepatitis B e antigen] and ALT test codes) and antiviral treatment (claims for tenofovir, entecavir, lamivudine, adefovir, or telbivudine) pre- and postdelivery. Results: There were 870,888 unique pregnancies (819,752 women) included. Before delivery, 714,830 (82%) pregnancies had HBsAg test claims, but this proportion decreased with subsequent pregnancies (p < 0.0001): second (80%), third (71%), and fourth (61%). We identified 1,190 (0.14%) pregnancies with an associated HBV diagnosis code: most were among women aged ≥ 30 years (76%) residing in the Pacific (34%) or Middle Atlantic (18%) regions. Forty-two percent of pregnancies with an HBV diagnosis received HBV-directed care (42% predelivery and 39% postdelivery). Antiviral treatment was initiated before delivery in 128 (13%) of 975 pregnancies and postdelivery in 16 (1.6%) pregnancies. Conclusions: While most of these commercially insured pregnant women received predelivery HBV screening, we identified gaps in HBV testing and the HBV care continuum which highlight potential targets for public health interventions.

Population-level Outcomes and Cost-Effectiveness of Expanding the Recommendation for Age-based Hepatitis C Testing in the United States.

Background: The US Centers for Disease Control and Prevention and the U.S. Preventive Services Task Force recommend one-time hepatitis C virus (HCV) testing for persons born 1945-1965 and targeted testing for high-risk persons. This strategy targets HCV testing to a prevalent population at high risk for HCV morbidity and mortality, but does not include younger populations with high incidence. To address this gap and improve access to HCV testing, age-based strategies should be considered. Methods: We used a simulation of HCV to estimate the effectiveness and cost-effectiveness of HCV testing strategies: 1) standard of care (SOC) - recommendation for one-time testing for all persons born 1945-1965, 2) recommendation for one-time testing for adults ≥40 years (≥40 strategy), 3) ≥30 years (≥30 strategy), and 4) ≥18 years (≥18 strategy). All strategies assumed targeted testing of high-risk persons. Inputs were derived from national databases, observational cohorts and clinical trials. Outcomes included quality-adjusted life expectancy, costs, and cost-effectiveness. Results: Expanded age-based testing strategies increased US population lifetime case identification and cure rates. Greatest increases were observed in the ≥18 strategy. Compared to the SOC, this strategy resulted in an estimated 256,000 additional infected persons identified and 280,000 additional cures at the lowest cost per QALY gained (ICER = $28,000/QALY). Conclusions: In addition to risk-based testing, one-time HCV testing of persons 18 and older appears to be cost-effective, leads to improved clinical outcomes and identifies more persons with HCV than the current birth cohort recommendations. These findings could be considered for future recommendation revisions.

Hepatitis C Antibody Testing in a Commercially Insured Population, 2005-2014.

INTRODUCTION: In the U.S., the burden of hepatitis C virus (HCV) infection and associated sequelae is substantial. HCV prevalence is highest among those born in 1945-1965 (Birth Cohort). Newly diagnosed infections are increasing in younger people concurrent with rising opioid/heroin use. The Centers for Disease Control and Prevention (2012) and U.S. Preventive Services Task Force (2013) recommend HCV testing for at-risk individuals and one-time testing for the Birth Cohort. This study describes national trends in HCV antibody testing from 2005 to 2014. METHODS: Using commercial and Medicare supplemental insurance claims data, people were identified who were continuously enrolled for ≥2 years during the 10-year study period, without prior HCV diagnosis (N=190,926,299). Current Procedural Terminology codes identified 3,382,267 unique antibody tests. Temporal trends in annual testing were evaluated using the Cochran-Armitage test, and primary ICD-9-CM diagnosis codes used at the time of testing were described. Data were analyzed in 2015 and 2016. RESULTS: Testing was highest among those aged 18-29 and 30-39 years, increasing by 123% (1.66% to 3.71%) and 108% (1.99% to 4.13%), respectively (p<0.0001). Among the Birth Cohort, there was a 136% increase in HCV antibody testing from 2005 to 2014, with a 91% increase from 1.71% in 2011 to 3.26% 2014 (p<0.0001). CONCLUSIONS: Although the increased HCV antibody testing observed among the Birth Cohort from 2011 to 2014 likely reflects early adoption of updated national testing recommendations, overall testing remains low in this commercially insured population, indicating a clear need for improvement.