The role and limitations of electronic medical records versus patient interviews for determining symptoms, underlying comorbidities, and medication usage for patients with COVID-19.

Electronic medical records (EMR) are important for rapidly compiling information to determine disease characteristics (e.g., symptoms) and risk factors (e.g., underlying comorbidities, medications) for disease-related outcomes. To assess EMR data accuracy, agreement between EMR abstractions and patient interviews was evaluated. Symptoms, medical history, and medication usage among COVID-19 patients collected from EMR and patient interviews were compared using overall agreement (same answer in EMR and interview), reported agreement (yes answer in both EMR and interview among those who reported yes in either), and Kappa statistics. Overall, patients reported more symptoms in interviews than in EMR abstractions. Overall agreement was high (≥50% for 20/23 symptoms), but only subjective fever and dyspnea had reported agreement of ≥50%. Kappa statistics for symptoms were generally low. Reported medical conditions had greater agreement with all condition categories (10/10) having ≥50% overall agreement and half (5/10) having ≥50% reported agreement. More non-prescription medications were reported in interviews than in EMR abstractions leading to low reported agreement (28%). Discordance was observed for symptoms, medical history, and medication usage between EMR abstractions and patient interviews. Investigations utilizing EMR to describe clinical characteristics and identify risk factors should consider the potential for incomplete data, particularly for symptoms and medications.

Incomplete tissue product tracing during an investigation of a tissue-derived tuberculosis outbreak.

In the United States, there is currently no system to track donated human tissue products to individual recipients. This posed a challenge during an investigation of a nationwide tuberculosis outbreak that occurred when bone allograft contaminated with Mycobacterium tuberculosis (Lot A) was implanted into 113 patients in 18 US states, including 2 patients at 1 health care facility in Colorado. A third patient at the same facility developed spinal tuberculosis with an isolate genetically identical to the Lot A outbreak strain. However, health care records indicated this patient had received bone allograft from a different donor (Lot B). We investigated the source of this newly identified infection, including the possibilities of Lot B donor infection, product switch or contamination during manufacturing, product switch at the health care facility, person-to-person transmission, and laboratory error. The findings included gaps in tissue traceability at the health care facility, creating the possibility for a product switch at the point of care despite detailed tissue-tracking policies. Nationally, 6 (3.9%) of 155 Lot B units could not be traced to final disposition. This investigation highlights the critical need to improve tissue-tracking systems to ensure unbroken traceability, facilitating investigations of recipient adverse events and enabling timely public health responses to prevent morbidity and mortality.

Evaluation of Correctional Facility COVID-19 Outbreaks With Layered Mitigation Strategies Including Vaccination: Colorado, 2020-2021.

In 2020-2021, a Colorado corrections facility experienced four COVID-19 outbreaks. Case counts, attack rates (ARs) in people who are detained or incarcerated (PDI), and mitigation measures used in each outbreak were compared to evaluate effects of combined strategies. Serial PCR testing, isolation/quarantine, and masking were implemented in outbreak 1. Daily staff antigen testing began in outbreak 2. Facility-wide COVID-19 vaccination started in outbreak 3 and coverage increased by the end of outbreak 4 (PDI: <1% to 59%, staff: 27% to 40%). Despite detection of variants of concern, outbreaks 3 and 4 had 97% lower PDI ARs (both 1%) than outbreak 2 (29%). Daily staff testing and increasing vaccination coverage, with other outbreak mitigation strategies, are important to reduce COVID-19 transmission in congregate settings.

Health Care Personnel Exposures to Subsequently Laboratory-Confirmed Monkeypox Patients - Colorado, 2022.

The risk for monkeypox transmission to health care personnel (HCP) caring for symptomatic patients is thought to be low but has not been thoroughly assessed in the context of the current global outbreak (1). Monkeypox typically spreads through close physical (often skin-to-skin) contact with lesions or scabs, body fluids, or respiratory secretions of a person with an active monkeypox infection. CDC currently recommends that HCP wear a gown, gloves, eye protection, and an N95 (or higher-level) respirator while caring for patients with suspected or confirmed monkeypox to protect themselves from infection† (1,2). The Colorado Department of Public Health and Environment (CDPHE) evaluated HCP exposures and personal protective equipment (PPE) use in health care settings during care of patients who subsequently received a diagnosis of Orthopoxvirus infection (presumptive monkeypox determined by a polymerase chain reaction [PCR] DNA assay) or monkeypox (real-time PCR assay and genetic sequencing performed by CDC). During May 1-July 31, 2022, a total of 313 HCP interacted with patients with subsequently diagnosed monkeypox infections while wearing various combinations of PPE; 23% wore all recommended PPE during their exposures. Twenty-eight percent of exposed HCP were considered to have had high- or intermediate-risk exposures and were therefore eligible to receive postexposure prophylaxis (PEP) with the JYNNEOS vaccine§; among those, 48% (12% of all exposed HCP) received the vaccine. PPE use varied by facility type: HCP in sexually transmitted infection (STI) clinics and community health centers reported the highest adherence to recommended PPE use, and primary and urgent care settings reported the lowest adherence. No HCP developed a monkeypox infection during the 21 days after exposure. These results suggest that the risk for transmission of monkeypox in health care settings is low. Infection prevention training is important in all health care settings, and these findings can guide future updates to PPE recommendations and risk classification in health care settings.

Body Lice among People Experiencing Homelessness and Access to Hygiene Services during the COVID-19 Pandemic-Preventing Trench Fever in Denver, Colorado, 2020.

Eight people with human body louse-borne Bartonella quintana infections were detected among people experiencing homelessness (PEH) in Denver during January-September 2020, prompting a public health investigation and community outreach. Public health officials conducted in-person interviews with PEH to more fully quantify body lice prevalence, transmission risk factors, access to PEH resources, and how the COVID-19 pandemic has affected resource access. Recent body lice exposure was reported by 35% of 153 interview participants. In total, 75% of participants reported reduced access to PEH services, including essential hygiene activities to prevent body lice, during Colorado's COVID-19 stay-at-home orders. Future pandemic planning should consider hygiene resource allocation for PEH populations to prevent emerging and reemerging infections such as B. quintana.

Investigation of COVID-19 Outbreak among Wildland Firefighters during Wildfire Response, Colorado, USA, 2020.

A COVID-19 outbreak occurred among Cameron Peak Fire responders in Colorado, USA, during August 2020-January 2021. The Cameron Peak Fire was the largest recorded wildfire in Colorado history, lasting August-December 2020. At least 6,123 responders were involved, including 1,260 firefighters in 63 crews who mobilized to the fire camps. A total of 79 COVID-19 cases were identified among responders, and 273 close contacts were quarantined. State and local public health investigated the outbreak and coordinated with wildfire management teams to prevent disease spread. We performed whole-genome sequencing and applied social network analysis to visualize clusters and transmission dynamics. Phylogenetic analysis identified 8 lineages among sequenced specimens, implying multiple introductions. Social network analysis identified spread between and within crews. Strategies such as implementing symptom screening and testing of arriving responders, educating responders about overlapping symptoms of smoke inhalation and COVID-19, improving physical distancing of crews, and encouraging vaccinations are recommended.

Risk Factors for SARS-CoV-2 Infection Among US Healthcare Personnel, May-December 2020.

To determine risk factors for coronavirus disease (COVID-19) among US healthcare personnel (HCP), we conducted a case-control analysis. We collected data about activities outside the workplace and COVID-19 patient care activities from HCP with positive severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) test results (cases) and from HCP with negative test results (controls) in healthcare facilities in 5 US states. We used conditional logistic regression to calculate adjusted matched odds ratios and 95% CIs for exposures. Among 345 cases and 622 controls, factors associated with risk were having close contact with persons with COVID-19 outside the workplace, having close contact with COVID-19 patients in the workplace, and assisting COVID-19 patients with activities of daily living. Protecting HCP from COVID-19 may require interventions that reduce their exposures outside the workplace and improve their ability to more safely assist COVID-19 patients with activities of daily living.

Symptom Profiles and Progression in Hospitalized and Nonhospitalized Patients with Coronavirus Disease, Colorado, USA, 2020.

To improve recognition of coronavirus disease (COVID-19) and inform clinical and public health guidance, we randomly selected 600 COVID-19 case-patients in Colorado. A telephone questionnaire captured symptoms experienced, when symptoms occurred, and how long each lasted. Among 128 hospitalized patients, commonly reported symptoms included fever (84%), fatigue (83%), cough (73%), and dyspnea (72%). Among 236 nonhospitalized patients, commonly reported symptoms included fatigue (90%), fever (83%), cough (83%), and myalgia (74%). The most commonly reported initial symptoms were cough (21%-25%) and fever (20%-25%). In multivariable analysis, vomiting, dyspnea, altered mental status, dehydration, and wheezing were significantly associated with hospitalization, whereas rhinorrhea, headache, sore throat, and anosmia or ageusia were significantly associated with nonhospitalization. General symptoms and upper respiratory symptoms occurred earlier in disease, and anosmia, ageusia, lower respiratory symptoms, and gastrointestinal symptoms occurred later. Symptoms should be considered alongside other epidemiologic factors in clinical and public health decisions regarding potential COVID-19 cases.