Lessons Learned from Public Health and State Prison Collaborations during COVID-19 Pandemic and Multifacility Tuberculosis Outbreak, Washington, USA.

The large COVID-19 outbreaks in prisons in the Washington (USA) State Department of Corrections (WADOC) system during 2020 highlighted the need for a new public health approach to prevent and control COVID-19 transmission in the system's 12 facilities. WADOC and the Washington State Department of Health (WADOH) responded by strengthening partnerships through dedicated corrections-focused public health staff, improving cross-agency outbreak response coordination, implementing and developing corrections-specific public health guidance, and establishing collaborative data systems. The preexisting partnerships and trust between WADOC and WADOH, strengthened during the COVID-19 response, laid the foundation for a collaborative response during late 2021 to the largest tuberculosis outbreak in Washington State in the past 20 years. We describe challenges of a multiagency collaboration during 2 outbreak responses, as well as approaches to address those challenges, and share lessons learned for future communicable disease outbreak responses in correctional settings.

Tuberculosis Outbreak in a State Prison System - Washington, 2021-2022.

During 2014-2020, no tuberculosis (TB) cases were reported within the Washington state prison system. However, during July 2021-June 2022, 25 TB cases were reported among persons incarcerated or formerly incarcerated in two Washington state prisons. Phylogenetic analyses of whole genome sequencing data indicated that Mycobacterium tuberculosis isolates from all 11 patients with culture-confirmed TB were closely related, suggesting that these cases represented a single outbreak. The median infectious period for 12 patients who were considered likely contagious was 170 days. As of November 15, 2022, the Washington State Department of Corrections (WADOC) and Washington State Department of Health (WADOH), with technical assistance from CDC, had identified 3,075 contacts among incarcerated residents and staff members at five state prisons, and 244 contacts without a known TB history received a diagnosis of latent TB infection (LTBI). Persons who were evaluated for TB disease were isolated; those receiving a diagnosis of TB then initiated antituberculosis therapy. Persons with LTBI were offered treatment to prevent progression to TB disease. This ongoing TB outbreak is the largest in Washington in 20 years. Suspension of annual TB screening while limited resources were redirected toward the COVID-19 response resulted in delayed case detection that facilitated TB transmission. In addition, fear of isolation might discourage residents and staff members from reporting symptoms, which likely also leads to delayed TB diagnoses. Continued close collaboration between WADOC and WADOH is needed to end this outbreak and prevent future outbreaks.

Tuberculosis in Older Adults: Seattle and King County, Washington.

BACKGROUND: In the United States, tuberculosis (TB) incidence rates are highest among adults aged ≥65 years. We performed this study to evaluate outcomes of older patients undergoing treatment for TB disease, including the frequency of adverse events related to TB treatment. METHODS: This study evaluated adult patients who were diagnosed with pulmonary TB from 2009 to 2014 in King County, Washington. Patient characteristics, manifestation of TB, and treatment outcomes in different age groups were compared. Frequency and type of adverse events that resulted in treatment interruption were evaluated and patients aged ≥65 years were compared with selected younger patients. RESULTS: There were 403 patients who met the study criteria, 111 of whom were aged ≥65 years. Older patients were significantly less likely to have cavitation on chest radiographs. Patients aged ≥65 years were less likely to complete TB treatment (76.6% vs 94.9%, P < .0001) and were more likely to die during treatment (18.9% vs 2.1%, P < .0001). The difference in these outcomes was heightened for those aged ≥75 years compared with those aged <75 years. Those aged ≥75 years were also more likely to have an adverse event attributable to TB medication and were more likely to have an adverse event later in therapy. Regardless of age, pyrazinamide was responsible for the majority of adverse reactions. CONCLUSIONS: Adults aged ≥65 years with pulmonary TB had less-advanced disease but a higher risk of complications during treatment such as death or adverse events. This effect was most pronounced among those aged ≥75 years.

Impact of an Electronic Medical Record-Based System to Promote Human Immunodeficiency Virus/Hepatitis C Virus Screening in Public Hospital Primary Care Clinics.

BACKGROUND: United States guidelines recommend that all adolescents and adults be tested for human immunodeficiency virus (HIV) and that persons born between 1945 and 1965 be tested for hepatitis C virus (HCV). METHODS: We used electronic medical record (EMR) data to identify patients in 3 primary care clinics in Seattle, Washington who met national criteria for routine HCV or HIV testing and had no documented history of prior testing. Clinic staff received daily lists of untested patients with scheduled appointments. We used generalized linear models to compare the percentage of patients tested and newly diagnosed with HIV and HCV in the 18 months before and during the intervention. RESULTS: A total of 16784 patients aged 18-64 and 9370 patients born between 1945 and 1965 received care from January 2011 to December 2015. Comparing the preintervention and intervention periods, the percentage of previously untested patients tested for HIV and HCV increased from 14.9% to 30.8% and from 18.0% to 35.5%, respectively (P < .0001 for both). Despite this increase in testing, there was no change in the percentage of patients newly diagnosed with HIV (0.7% in both periods, P = .96) or HCV (3.6% vs 3.7%, P = .81). We estimate that 1.2%-15% of HCV-infected primary care patients in our medical center are undiagnosed. CONCLUSIONS: EMR-based HCV/HIV testing promotion increased testing but not case finding among primary care patients in our medical center. In our institution, most HCV-infected patients are already diagnosed, primarily through risk-based and clinical screening, highlighting the need to concentrate future efforts on increasing HCV treatment.

Risk factors for infections in international travelers: an analysis of travel-related notifiable communicable diseases.

BACKGROUND: We sought to describe travel-related illness among our residents and gain insight into targeting pre-travel health advice to prevent travel-related illness. METHODS: A supplemental travel questionnaire was developed and administered for cases with a legally notifiable communicable disease reported in 2011-2012, who spent at least part of their exposure period outside the United States. RESULTS: Among 451 cases meeting the eligibility criteria, 259 were interviewed. Forty four percent reported receiving pre-travel advice. Two-thirds adhered fully with risk behavior recommendations; 94% followed immunization recommendations partially or fully; and 84% adhered fully with malaria prophylaxis recommendations. The primary reasons for not obtaining pre-travel advice were being unaware of the need (47.5%), or believing they already knew what to do (34.5%). Adults (OR = 2.8, 95% CI = 1.4-5.5), males (OR = 1.8, 95% CI = 1.1-3.0), those born outside the United States (OR = 2.0, 95% CI = 1.1-3.7), and those with planning time under two weeks (OR = 4.8, 95% CI = 1.5-15.9) or travel duration less than 7 days (OR = 7.9, 95% CI = 3.0-20.9) were more likely to travel without seeking pre-travel advice. CONCLUSIONS: The majority of cases reported not receiving pre-travel advice. Understanding the predictors of failure to receive pre-travel advice may help target public health prevention efforts.

Concomitant use of prescription drugs and dietary supplements in ambulatory elderly people.

OBJECTIVES: To analyze baseline data on concomitant use of prescription drugs and dietary supplements in elderly people from the Ginkgo Evaluation of Memory (GEM) Study, in which information was collected on all drugs and supplements used by participant. DESIGN: Cross-sectional correlation analysis. SETTING: GEM Study sites in California, Maryland, North Carolina, and Pennsylvania. PARTICIPANTS: Three thousand seventy ambulatory individuals aged 75 and older enrolled between September 2000 and June 2002. MEASUREMENTS: Use of prescription drugs and dietary supplements identified through bottles brought to the clinic. RESULTS: Almost three-quarters (74.2%) of the cohort combined use of at least one prescription drug and one dietary supplement, with 32.5% using three or more prescription drugs and three or more supplements. The 15 most-prevalent prescription drugs exhibited substantial concomitant use with dietary supplements, ranging from 77.6% for diuretics to 93.6% for estrogen preparations. Although supplements were taken concomitantly with all classes of prescription drugs, the use of supplements was more likely in individuals using nonsteroidal anti-inflammatory drugs, thyroid drugs, and estrogens. The use of drugs for diabetes mellitus was negatively associated with the use of supplements, with most of this attributed to low use in those taking multivitamins, glucosamine and chondroitin, and echinacea. CONCLUSION: There is substantial concomitant use of prescription drugs and dietary supplements in elderly people. Further investigations are needed to define the clinical importance of this concomitant use, especially in elderly patients who consume multiple prescription drugs or have experienced an adverse event secondary to their prescription medications.