Characteristics and outcomes of a hospitalized cohort with reduced mortality from COVID-19, White Mountain apache tribal lands, April 1 - July 31, 2020.

BACKGROUND: Widespread transmission of COVID-19 continues to threaten public health, particularly of rural, American Indian communities. Although COVID-19 risk factors for severe disease and clinical characteristics are well described in the general population, there has been little shared on hospitalized American Indian populations. METHODS: In this observational study, we performed chart extractions on all persons hospitalized with COVID-19 from April 1 through July 31, 2020 among an exclusively American Indian population living on or near Tribal lands in eastern Arizona. We provide descriptive statistics for the cohort stratified by presentation, comparing those who self-presented or were referred by an outreach program. Exploratory analyses were performed to identify risk factors for morbidity and mortality. RESULTS: During the observation period, 2262 persons were diagnosed with COVID-19 and 490 (22%) were hospitalized. Hospitalized persons had a median age of 54 years; 92% had at least one comorbidity, 72% had greater than one comorbidity, and 60% had a BMI of > 30. Most persons required supplemental oxygen (83%), but the majority (62%) only required nasal cannula and only 11% were intubated. The case fatality rates were 1.7% for the population, 7.1% among hospitalizations, and 9.3% among hospitalized patients 50 years and older. All rates that are significantly lower than those reported nationally during the same period. CONCLUSIONS: We observed a cohort of American Indian patients hospitalized secondary to COVID-19 with greater number of comorbidities compared to the general population but with lower mortality rates. We posit that the primary driver of mortality reduction for this population and the hospitalized cohort was a community-based referral program that led to disproportionately lower fatality rates among the oldest persons.

Integrated Response to Address a Resurgent Syphilis Epidemic in a Rural American Indian Community, Whiteriver, Arizona, January 2022 to June 2023.

BACKGROUND: The United States has seen a significant rise in syphilis over the past 20 years with a disparate impact on American Indian communities. We conducted a thorough review of the local epidemiology that guided an innovative response to curb the epidemic. METHODS: We analyzed syphilis data from a hospital in rural Arizona that serves an American Indian population of more than 18,000. Testing data were extracted from 2017 to 2023 with detailed chart reviews of all reactive results since January 2022. Descriptive and comparative statistics were computed using parametric and nonparametric methods where appropriate. RESULTS: Among 5888 tested persons, 555 (9.4%) had reactive results and 277 (4.7%) represented new infections. Among new cases, 151 (54.5%) were female and 55 (19.9%) were reinfections. The annualized incidence rate was 10.0 cases per 1000 persons with peak annualized incidence among women aged 30 to 34 years of 22.6 infections per 1000 persons. During the observation period and after the implementation of programmatic changes in June 2022, there were statistically significant reductions in median time to treatment (-80%), test positivity (-70%), infections (-60%), and no congenital syphilis cases during the observation period. CONCLUSIONS: We observed significantly elevated syphilis rates in American Indian/Alaska Native persons compared with the general population. Strategic implementation of new policies and practices led to a measurable and meaningful improvement in several epidemic variables, and our experience may serve as a model to other communities.

Potential Benefits of Expanded Palivizumab in American Indian Children Under the Age of 2 Years.

Severe respiratory syncytial virus (RSV) infections disparately impact American Indian communities. We implemented a program that expanded palivizumab to all children under 2 years of age that led to significant reductions in RSV infections and hospitalizations for both high-risk and non-high-risk recipients in a rural American Indian community in Eastern Arizona.

Integrated COVID-19 Interventions in a Native American Community: Arizona, December 25, 2021-January 31, 2022.

COVID-19 has disproportionately affected Indigenous communities. The Whiteriver Service Unit (WRSU) took an integrated public health-health care system delivery approach in collaboration with the White Mountain Apache Tribe to decrease the case fatality rate (CFR). The WRSU performed daily data analyses identifying risk factors, expeditiously treating and proactively vaccinating people during at-home visits. The WRSU's CFR was 0.3% lower than Arizona's (P = .04). Among communities disproportionally affected, an integrated approach using data to drive real-time decision-making among a culturally competent workforce can contribute to decreased CFR. (Am J Public Health. 2023;113(10):1089-1092. https://doi.org/10.2105/AJPH.2023.307364).

Effectiveness of COVID-19 mRNA Vaccines in Preventing COVID-19-Associated Outpatient Visits and Hospitalizations Among American Indian and Alaska Native Persons, January-November 2021: A Test-Negative Case-Control Analysis Using Surveillance Data.

Background: Despite the disproportionate morbidity and mortality experienced by American Indian and Alaska Native (AI/AN) persons during the coronavirus disease 2019 (COVID-19) pandemic, few studies have reported vaccine effectiveness (VE) estimates among these communities. Methods: We conducted a test-negative case-control analysis among AI/AN persons aged ≥12 years presenting for care from January 1, 2021, through November 30, 2021, to evaluate the effectiveness of mRNA COVID-19 vaccines against COVID-19-associated outpatient visits and hospitalizations. Cases and controls were patients with ≥1 symptom consistent with COVID-19-like illness; cases were defined as those test-positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and controls were defined as those test-negative for SARS-CoV-2. We used unconditional multivariable logistic regression to estimate VE, defined as 1 minus the adjusted odds ratio for vaccination among cases vs controls. Results: The analysis included 207 cases and 267 test-negative controls. Forty-four percent of cases and 78% of controls received 2 doses of either BNT162b2 or mRNA-1273 vaccine. VE point estimates for 2 doses of mRNA vaccine were higher for hospitalized participants (94.6%; 95% CI, 88.0-97.6) than outpatient participants (86.5%; 95% CI, 63.0-95.0), but confidence intervals overlapped. Conclusions: Among AI/AN persons, mRNA COVID-19 vaccines were highly effective in preventing COVID-associated outpatient visits and hospitalizations. Maintaining high vaccine coverage, including booster doses, will reduce the burden of disease in this population.

Point-of-care molecular diagnostics for the detection of group A Streptococcus in non-invasive skin and soft tissue infections: a validation study.

BACKGROUND: Skin and soft tissue infections (SSTIs) are commonly caused by group A Streptococcus (GAS). Rapid molecular assays for detecting GAS in wounds would help with clinical management. This study assessed a point-of-care system for the detection of GAS in non-severe SSTIs in a Native American community in the Southwest. METHODS: Patients presenting with a new non-severe SSTI were eligible if a swab was collected. The swab was tested by traditional culture methods and using the cobas® Liat® point-of-care (POC) system and results were compared. RESULTS: 399 samples were included. The final result from the POC assay was positive for 52.0% of samples. Compared to culture, the POC assay had a sensitivity of 100% and specificity of 99.5%. CONCLUSIONS: The cobas® Liat® system accurately and efficiently identified GAS in non-severe SSTIs. Having a POC test available to rapidly identify or rule out GAS could help to minimize overuse of antibiotics.

Innovative and Integrated Contact Tracing: Indian Health Service, Arizona, December 2020-January 2021.

SARS-CoV-2 has exposed limitations of public health mitigation measures such as traditional case investigations and contact tracing. The Whiteriver Service Unit is a rural, acute care hospital on the Fort Apache Indian Reservation in Arizona with integrated health care delivery and public health services. During the first wave of COVID-19 cases in May-June 2020, we developed an innovative case investigation contact tracing approach that relied heavily on cross-trained personnel, in-person encounters, and baseline clinical evaluations. A second COVID-19 surge during December 13, 2020-January 31, 2021, caused incidence to peak at 413 cases per 100 000 community members. During that second surge, we investigated all 769 newly identified COVID-19 cases and notified 1911 (99.4%) of 1922 reported contacts. Median time interval from nasopharyngeal specimen collection to both case investigation and contact notification was 0 days (range, 0-5 days and 0-13 days, respectively). Our primary lesson was the importance of cross-trained personnel who integrated tasks along the testing-tracing continuum (eg, in-person interviews, prompt referral for additional testing and evaluation). These successive steps fed forward to identify new cases and their respective contacts. Our innovative community-based approach was both successful and efficient; our experience suggests that when adapted based on local needs, case investigation and contact tracing remain valuable and feasible public health tools, even in rural, resource-limited settings.

Evaluation of iron intake in preschool children in a setting with high anemia burden.

BACKGROUND: Iron deficiency anemia affects millions of children worldwide. Iron intake assessments can inform targeted interventions. METHODS: This cross-sectional study describes diet and hemoglobin levels of children 1-5 y of age in a resource-limited setting in the Dominican Republic. The study team performed meal observations and measurements, dietary questionnaires, and point-of-care hemoglobin testing. RESULTS: Iron intake and bioavailability were low, with liberal estimates indicating that not more than 40% of subjects consumed the recommended daily allowance for iron. Forty of 80 children had anemia, with 23% demonstrating moderate or severe anemia. CONCLUSIONS: Poor observed iron intake likely contributes to the high prevalence of anemia in this population.

High-Risk Outreach for COVID-19 Mortality Reduction in an Indigenous Community.

Indigenous populations have been disproportionally affected by COVID-19, particularly those in rural and remote locations. Their unique environments and risk factors demand an equally unique public health response. Our rural Native American community experienced one of the highest prevalence outbreaks in the world, and we developed an aggressive management strategy that appears to have had a considerable effect on mortality reduction. The results have implications far beyond pandemic response, and have reframed how our community addresses several complicated health challenges. (Am J Public Health. 2021;111(11):1939-1941. https://doi.org/10.2105/AJPH.2021.306472).

Potential implications of six American Indian patients with myopathy, statin exposure and anti-HMGCR antibodies.

OBJECTIVES: Statin-associated autoimmune myopathy is a rare condition associated with the formation of autoantibodies to 3-hydroxy-3-methylglutaryl-coenzyme A reductase. Underlying environmental and genetic risk factors remain poorly understood. American Indians have high rates of cardiovascular disease and associated co-morbidities that require lipid-lowering therapies. We observed this autoimmune myopathy in a series of American Indian statin users in rural Arizona. METHODS: We reviewed the charts of six American Indian patients with statin-associated autoimmune myopathy. We provide an illustrative case in addition to summaries of clinical presentations and treatment courses. RESULTS: This is the first report of statin-associated autoimmune myopathy in American Indians. These cases were all identified at the same geographically isolated hospital that exclusively serves an American Indian population with only 1800 statin users. There is relatively low migration. Each case was consistent with the previously described classical presentations for the disease. All six of our cases had diabetes and developed myopathy on high-dose atorvastatin, often with a recent change in statin type or dose. CONCLUSION: Providers serving American Indians need to be aware of the possibility of statin-associated autoimmune myopathy and familiar with its presentation. Larger, inclusive, population-based investigations are needed to elucidate risk factors for this condition, in particular the potential interactions between predisposing HLA alleles, diabetes and specific statin exposures. This is necessary to identify effective and safe lipid-lowering medications.

Disparate Effects of Invasive Group A Streptococcus on Native Americans.

Active surveillance of invasive group A Streptococcus (iGAS) disease indicates that its incidence in the US general population is low, but limited studies show rates for American Indians and Alaska Natives (AI/AN) are severalfold higher. Major disparities in rates of iGAS exist between Indigenous and non-Indigenous populations of Australia, New Zealand, and Canada, but much less is understood about iGAS among AI/AN in the United States. Although complex host-pathogen interactions influence the rates of iGAS, including strain variation and virulence, the number and type of concurrent conditions, and socioeconomic status, the relative contribution of each remains unclear. We highlight the poor correlation between the substantial effect of iGAS among Indigenous persons in industrialized countries and the current understanding of factors that influence iGAS disease in these populations. Prospective, large-scale, population-based studies of iGAS are needed that include AI/AN as a necessary first step to understanding the effects of iGAS.

Vaccine-preventable disease and the under-utilization of immunizations in complex humanitarian emergencies.

Complex humanitarian emergencies affect 40-60 million people annually and are a growing public health concern worldwide. Despite efforts to provide medical and public health services to populations affected by complex emergencies, significant morbidity and mortality persist. Measles is a major communicable disease threat, but through vaccination of broader target age groups beyond the traditional immunization schedule, measles-related mortality has been significantly reduced during crises. Yet, a limited number of vaccine-preventable diseases continue to contribute disproportionately to morbidity and mortality in complex emergencies. The literature suggests that Streptococcus pneumoniae, Rotavirus, and Haemophilus influenzae type-b should be key targets for vaccination programs. Because of the significant contribution of these three pathogens to complex humanitarian emergencies in low and middle-income countries regardless of disaster type, geography, or population, their vaccines should be considered essential components of the standard emergency response effort. We discuss the barriers to vaccine distribution and provide evidence for strategies to improve distribution, including expanded target age-range and reduced dose schedules. Our review includes specific recommendations for the expanded use of these three vaccines in complex emergencies in low and middle-income countries as a way to guide future policy discussions.

Persistent penetration of MPTP through the nasal route induces Parkinson's disease in mice.

The aetiology of idiopathic Parkinson's disease (PD) is poorly defined but environmental aggression may be relevant. Here, we report a new model of PD in mice, based on chronic inoculation with neurotoxins in the nasal cavity, which is a natural route of contact with the environment. C57BL/6 mice, submitted to daily intranasal inoculation with MPTP for 30 days, developed motor deficits that correlated with a progressive and severe depletion of striatal dopamine levels, and loss of tyrosine hydroxylase and dopamine transporter staining in substantia nigra and striatum. Moreover, mice intranasally inoculated with MPTP developed strong astrogliosis and microgliosis in substantia nigra and striatum. Consistent with these observations, a role for oxidant aggression was demonstrated by increased levels of Mn-superoxide dismutase. However, alpha-synuclein aggregation was not observed. This new animal model provides a new tool for studying PD symptoms that develop slowly over time, and it may be used to asses risk from environmental neurotoxins.