Lessons Learned from Cross-Systems Approach to COVID-19 Pandemic Response in Juvenile Justice System, Colorado, USA.

The global COVID-19 pandemic illustrates the importance of a close partnership between public health and juvenile justice systems when responding to communicable diseases. Many setting-specific obstacles must be navigated to respond effectively to limit disease transmission and negative health outcomes while maintaining necessary services for youth in confinement facilities. The response requires multidisciplinary expertise and collaboration to address unique considerations. Public health mitigation strategies must balance the risk for disease against the negative effects of restrictions. Key aspects of the COVID-19 response in the juvenile justice system of Colorado, USA, involved establishing robust communication and data reporting infrastructures, building a multidisciplinary response team, adapting existing infection prevention guidelines, and focusing on a whole-person health approach to infection prevention. We examine lessons learned and offer recommendations on pandemic emergency response planning and managing a statewide public health emergency in youth confinement settings that ensure ongoing readiness.

Provider-Reported Barriers in Sexual Health Care Services for Women With Upstream Barriers: The Case of Syphilis and Congenital Syphilis in Southern Colorado, 2022.

BACKGROUND: Syphilis and congenital syphilis rates have increased sharply in Colorado in the past 5 years. Congenital syphilis is passed during pregnancy in utero and can cause lifelong physical, developmental, and neurologic problems for the child, or can lead to miscarriage, stillbirth, or early infant death. Congenital syphilis is easily prevented if the mother receives timely testing, treatment, and prenatal care. Providers can play a key role in preventing congenital syphilis for women with social vulnerabilities, who have a higher likelihood of syphilis and/or congenital syphilis infection. METHODS: We surveyed 23 and interviewed 4 health care providers in southern Colorado in 2022 to record their experiences in providing sexual health care services. We asked providers with direct care experience about perceived barriers in effectively treating syphilis. RESULTS: The most significant barriers reported in the survey were the cost of treatment (26%) and the loss to follow-up (22%). Interviews revealed further challenges, including discretionary testing procedures, delays in screening results, treatment referral issues, and stigma around substance use and sexual activity. CONCLUSIONS: Elevated syphilis and congenital syphilis rates pose significant public health challenges. Coordinated interventions are necessary to effectively reduce the transmission of syphilis and congenital syphilis among women with upstream barriers. Potential care solutions include expanding rapid, point-of care testing and treatment options, supporting bicillin delivery or web-based inventory systems, offering anti-stigma training for providers, offering mental and behavioral health resources at providers' clinics, and expanding partnerships with syringe access programs.

Evaluating the sensitivity of mortality attributable to pollution to modeling Choices: A case study for Colorado.

We evaluated the sensitivity of estimated PM2.5 and NO2 health impacts to varying key input parameters and assumptions including: 1) the spatial scale at which impacts are estimated, 2) using either a single concentration-response function (CRF) or using racial/ethnic group specific CRFs from the same epidemiologic study, 3) assigning exposure to residents based on home, instead of home and work locations for the state of Colorado. We found that the spatial scale of the analysis influences the magnitude of NO2, but not PM2.5, attributable deaths. Using county-level predictions instead of 1 km2 predictions of NO2 resulted in a lower estimate of mortality attributable to NO2 by âˆ¼ 50 % for all of Colorado for each year between 2000 and 2020. Using an all-population CRF instead of racial/ethnic group specific CRFs results in a 130 % higher estimate of annual mortality attributable for the white population and a 40 % and 80 % lower estimate of mortality attributable to PM2.5 for Black and Hispanic residents, respectively. Using racial/ethnic group specific CRFs did not result in a different estimation of NO2 attributable mortality for white residents, but led to âˆ¼ 50 % lower estimates of mortality for Black residents, and 290 % lower estimate for Hispanic residents. Using NO2 based on home instead of home and workplace locations results in a smaller estimate of annual mortality attributable to NO2 for all of Colorado by 2 % each year and 0.3 % for PM2.5. Our results should be interpreted as an exercise to make methodological recommendations for future health impact assessments of pollution.

For Some Patients, Better Health Starts With Finding A Home.

As the US homeless population grows older and sicker, new programs in Denver, Colorado, and elsewhere link care, services, and housing.

Multimodal Surveillance Model for Enterovirus D68 Respiratory Disease and Acute Flaccid Myelitis among Children in Colorado, USA, 2022.

Surveillance for emerging pathogens is critical for developing early warning systems to guide preparedness efforts for future outbreaks of associated disease. To better define the epidemiology and burden of associated respiratory disease and acute flaccid myelitis (AFM), as well as to provide actionable data for public health interventions, we developed a multimodal surveillance program in Colorado, USA, for enterovirus D68 (EV-D68). Timely local, state, and national public health outreach was possible because prospective syndromic surveillance for AFM and asthma-like respiratory illness, prospective clinical laboratory surveillance for EV-D68 among children hospitalized with respiratory illness, and retrospective wastewater surveillance led to early detection of the 2022 outbreak of EV-D68 among Colorado children. The lessons learned from developing the individual layers of this multimodal surveillance program and how they complemented and informed the other layers of surveillance for EV-D68 and AFM could be applied to other emerging pathogens and their associated diseases.

Colorado drugged driving prevalence and impaired driving conviction rates: Effects of impaired driving definitions and a 5-nanogram limit for delta-9 tetrahydrocannabinol.

Objectives: How prevalent is drugged driving among Colorado drivers convicted of Driving Under the Influence (DUI)? What are the conviction rates of Colorado drivers charged with DUI, including impairment by marijuana's delta-9 tetrahydrocannabinol (THC)? Is Colorado's THC permissible inference law effective? To answer these questions, this report analyzes data published primarily in appendices of Colorado drugged driving reports.Methods: In 2017 Colorado began requiring annual analyses of Driving Under the Influence (DUI) offenses, including causes and judicial consequences of DUI offenses. These analyses are performed by the Division of Criminal Justice's Office of Research and Statistics (ORS) within the Department of Public Safety. Each analysis requires ORS to link toxicology and court data bases. Data linking enables reporting of charges and convictions by categories including alcohol only, THC only, and polydrug use (two or more drugs simultaneously). Reports have been published annually for 5 years, the latest published in 2023 which covers case filings for 2020.Results: A rough estimate of one-half of the state's DUI filings were attributed to drug use and half were attributed to alcohol only. The largest component of drugged driving was polydrug impairment, rather than impairment by a single drug like THC. Conviction rates in 2020 were 91% for alcohol only, 90% for polydrug cases, and 72% for THC only. Blood drug levels and law structure (per se, permissible inference, DUI definition) affected conviction rates significantly by defendant subsets. THC conviction rates in 2020 ranged from 11% to 100%, depending on blood drug levels and the legal charges.Conclusions: Efforts to educate the public about the dangers of drugged driving should emphasize polydrug impairment, not simply THC impairment. States should analyze data on causes and consequences of DUI arrests to understand what their drugged driving problems are and what they are not. Non-zero drug per se levels and defining DUI as "incapable of safe driving" can severely reduce the effectiveness of DUI laws.

Short Interpregnancy Intervals Among Women Experiencing Homelessness in Colorado.

Importance: Short interpregnancy intervals (SIPIs) are associated with increased risk of adverse maternal and neonatal outcomes. Disparities exist across socioeconomic status, but there is little information on SIPIs among women experiencing homelessness. Objective: To investigate (1) differences in rates and characteristics of SIPIs between women experiencing homelessness and domiciled women, (2) whether the association of homelessness with SIPIs differs across races and ethnicities, and (3) whether the association between SIPIs of less than 6 months (very short interpregnancy interval [VSIPIs]) and maternal and neonatal outcomes differs between participant groups. Design, Setting, and Participants: This cohort study used a Colorado statewide database linking the Colorado All Payer Claims Database, Homeless Management Information System, death records, and infant birth records. Participants included all women who gave birth between January 1, 2016, and December 31, 2021. Data were analyzed from September 1, 2022, to May 10, 2023. Exposures: Homelessness and race and ethnicity. Main Outcomes and Measures: The primary outcome consisted of SIPI, a binary variable indicating whether the interval between delivery and conception of the subsequent pregnancy was shorter than 18 months. The association of VSIPI with maternal and neonatal outcomes was also tested. Results: A total of 77 494 women (mean [SD] age, 30.7 [5.3] years) were included in the analyses, of whom 636 (0.8%) were women experiencing homelessness. The mean (SD) age was 29.5 (5.4) years for women experiencing homelessness and 30.7 (5.3) years for domiciled women. In terms of race and ethnicity, 39.3% were Hispanic, 7.3% were non-Hispanic Black, and 48.4% were non-Hispanic White. Associations between homelessness and higher odds of SIPI (adjusted odds ratio [AOR], 1.23 [95% CI, 1.04-1.46]) were found. Smaller associations between homelessness and SIPI were found among non-Hispanic Black (AOR, 0.59 [95% CI, 0.37-0.96]) and non-Hispanic White (AOR, 0.57 [95% CI, 0.39-0.84]) women compared with Hispanic women. A greater association of VSIPI with emergency department visits and low birth weight was found among women experiencing homelessness compared with domiciled women, although no significant differences were detected. Conclusions and Relevance: In this cohort study of women who gave birth from 2016 to 2021, an association between homelessness and higher odds of SIPIs was found. These findings highlight the importance of conception management among women experiencing homelessness. Racial and ethnic disparities should be considered when designing interventions.

Associations between Adolescent Marijuana Use, Driving after Marijuana Use and Recreational Retail Sale in Colorado, USA.

OBJECTIVE: We investigated associations between the retail distribution of recreational marijuana in Colorado and (i) past 30-day marijuana use and (ii) driving after marijuana use (DAMU) among a representative sample of public high school students using four waves of data from a state surveillance system. METHODS: Past 30-day marijuana use was assessed among all sampled students (n = 85,336). DAMU was assessed among students 15 years or older who indicated driving (n = 47,518). Modified Poisson regression with robust variance estimates was used to estimate prevalence ratios (PR) comparing the pre-distribution (2013) and post-distribution (2015, 2017, 2019) periods for marijuana-related behaviors. Frequency of behavioral engagement was assessed using a multinomial approach. RESULTS: An estimated 20.3% of students engaged in past 30-day marijuana use and 10.5% of student drivers engaged in DAMU. Retail distribution of recreational marijuana was not significantly associated with the prevalence of any marijuana use or DAMU. However, it was associated with 1.16 (95% CI: 1.04-1.29) times the prevalence of using marijuana one or two times in the last 30 days, 1.27 (1.03, 1.55) times the prevalence of DAMU one time, and 0.82 (0.69, 0.98) times the prevalence of DAMU six or more times. No significant associations were observed for the remaining frequency categories. CONCLUSIONS: Approximately 1 in 10 students who drive reported DAMU. Varying prevalence in the frequency of past 30-day marijuana use and DAMU was observed following the retail distribution of recreational marijuana in Colorado. Care should be taken to properly educate adolescent drivers regarding the dangers of DAMU.

Surveillance for Avian Bornavirus in Colorado and Wyoming, USA, Raptor Populations.

Avian bornavirus (ABV) is known to infect at least 80 avian species and is associated with avian bornaviral ganglioneuritis (ABG). Avian bornaviral ganglioneuritis is characterized by a lymphoplasmacytic infiltration of the nervous tissue, mainly affecting the nerves that supply the gastrointestinal tract of birds. This disease is diagnosed commonly in psittacines under human care and has been demonstrated in wild bird species; however, its occurrence in raptors is largely unknown. Because of the commonality of ABV in the pet bird population, there is concern about the spread of this virus to other companion avian species, such as falconry birds, as well as wildlife. This prospective study used reverse-transcription quantitative PCR (RT-qPCR) to survey free-ranging Colorado and Wyoming, US, raptor populations for ABV. Quantitative PCR was performed on mixed conjunctival-choanal-cloacal swabs collected from live birds (n=139). In dead birds, a combination of mixed swabs (n=265) and tissue samples of the brain (n=258), heart (n=162), adrenal glands (n=162), liver (n=162), kidney (n=139), spinal cord (n=139), and brachial plexus (n=139) were evaluated. All 1,565 swab and tissue samples RT-qPCR results from the 404 birds evaluated were negative. Based on these results and a lack of clinical signs suggestive of ABG, ABV is likely not a prevalent pathogen in Colorado and Wyoming raptor populations at this time.

SARS-CoV-2 surveillance in a veterinary health system provides insight into transmission risks.

OBJECTIVE: To investigate the prevalence and seropositivity of SARS-CoV-2 in companion and exotic animals in a veterinary healthcare system. SAMPLE: A total of 341 animals were sampled by a combination of oral and nasal swabs. Serum from whole blood was collected from a subset of animals (86 canines, 25 felines, and 6 exotic animals). METHODS: After informed owner consent, convenience samples from client-owned animals and the pets of students and staff members associated with Colorado State University's Veterinary Health System were collected between May 2021 and September 2022. Study samples were collected by trained veterinarians, Veterinary Health System staff, and veterinary students. RESULTS: SARS-CoV-2 RNA was detected by reverse transcription PCR in 1.6% (95% CI, 0.5% to 4.6%) of domestic canines and 1.1% (95% CI, 0.2% to 6.1%) of domestic felines. No RNA was detected in any of the exotic animal species tested (n = 66). Plaque reduction neutralization tests indicated that 12.8% (95% CI, 7.3% to 21.5%) of canines and 12.0% (95% CI, 4.2% to 30.0%) of felines had neutralizing antibodies against SARS-CoV-2. CLINICAL RELEVANCE: This study provides insight regarding SARS-CoV-2 spillover in domestic companion and exotic animals and contributes to our understanding of transmission risk in the veterinary setting.

Recovery of multireassortant bluetongue virus serotype 6 sequences from a mule deer (Odocoileus hemionus) and Dorset sheep (Ovis aries) in Colorado.

We report the discovery of two bluetongue virus serotype 6 (BTV-6) reassortants recovered from a domestic sheep and a free-ranging mule deer in northern Colorado. At the time of this publication, whole-genome sequencing of BTV-6 isolates in the Western U.S. have not been undertaken. These findings reflect the incursive movement of geographically distinct BTV serotypes into important agricultural areas of the U.S. and demonstrate reassortment with regionally circulating serotypes.

Duration of Enterovirus D68 RNA Shedding in the Upper Respiratory Tract and Transmission among Household Contacts, Colorado, USA.

Enterovirus D68 (EV-D68) causes cyclical outbreaks of respiratory disease and acute flaccid myelitis. EV-D68 is primarily transmitted through the respiratory route, but the duration of shedding in the respiratory tract is unknown. We prospectively enrolled 9 hospitalized children with EV-D68 respiratory infection and 16 household contacts to determine EV-D68 RNA shedding dynamics in the upper respiratory tract through serial midturbinate specimen collections and daily symptom diaries. Five (31.3%) household contacts, including 3 adults, were EV-D68-positive. The median duration of EV-D68 RNA shedding in the upper respiratory tract was 12 (range 7-15) days from symptom onset. The most common symptoms were nasal congestion (100%), cough (92.9%), difficulty breathing (78.6%), and wheezing (57.1%). The median illness duration was 20 (range 11-24) days. Understanding the duration of RNA shedding can inform the expected rate and timing of EV-D68 detection in associated acute flaccid myelitis cases and help guide public health measures.

Outbreak of Invasive Group A Streptococcus in Children-Colorado, October 2022-April 2023.

BACKGROUND: In the fall of 2022, we observed a sharp rise in pediatric Invasive Group A Streptococcus (iGAS) hospitalizations in Colorado. We compared the epidemiology, clinical features, and patient outcomes in this outbreak to prior years. METHODS: Between October 2022 and April 2023, we prospectively identified and reviewed iGAS cases in hospitalized pediatric patients at Children's Hospital Colorado. Using laboratory specimen records, we also retrospectively compared the number of patients with sterile site GAS-positive cultures across three time periods: pre-COVID-19 (January 2015-March 2020), height of COVID-19 pandemic (April 2020-September 2022), and outbreak (October 2022-April 2023). RESULTS: Among 96 prospectively identified iGAS cases, median age was 5.7 years old; 66% were male, 70% previously healthy, 39% required critical care, and four patients died. Almost 60% had associated respiratory viral symptoms, 10% had toxic shock syndrome, and 4% had necrotizing fasciitis. Leukopenia, bandemia, and higher C-reactive protein values were laboratory findings associated with need for critical care. There were significantly more cases during the outbreak (9.9/month outbreak vs 3.9/month pre-pandemic vs 1.3/month pandemic), including more cases with pneumonia (28% outbreak vs 15% pre-pandemic vs 0% pandemic) and multifocal disease (17% outbreak vs 3% pre-pandemic vs 0% pandemic), P < .001 for all. CONCLUSIONS: Outbreak case numbers were almost triple the pre-pandemic baseline. The high percentage of cases with associated viral symptoms suggests a link to coinciding surges in respiratory viruses during this time. Invasive GAS can be severe and evolve rapidly; clinical and laboratory features may help in earlier identification of critically ill children.

Diagnostic yield of workups ordered by pediatric ophthalmologists for bilateral pediatric cataracts at a tertiary pediatric hospital in the United States.

BACKGROUND: Children with unexplained bilateral cataracts routinely undergo testing for genetic, infectious, and metabolic etiologies. We evaluated the diagnostic yield of various tests ordered by pediatric ophthalmologists to evaluate bilateral cataracts in children at a single institution. METHODS: We retrospectively identified all children with bilateral unexplained cataracts who underwent cataract surgery by a pediatric ophthalmologist at Children's Hospital Colorado from 2006 to 2022. We reviewed the results of genetic, infectious, and metabolic testing ordered by pediatric ophthalmologists to evaluate the cataracts in these children. RESULTS: A total of 43 children met inclusion criteria. Of these, 34 (79%) had genetic testing, 34 (79%) had infectious disease testing, 33 (77%) had galactosemia testing, and 17 (40%) had urine-reducing substances testing performed during their cataract evaluation. Of the genetic tests ordered, 17 (50%) revealed a pathogenic mutation associated with cataracts. Twenty-three (68%) patients were IgG-positive for a TORCH infection, but no child was found to be positive on confirmatory testing. Of the galactosemia and URS tests ordered, 3 tests (9%) and 1 (6%) test were initially found to be abnormal, respectively, but confirmatory testing and clinical judgment ruled out metabolic disease in each case. CONCLUSIONS: Genetic testing should be strongly considered in all cases of unexplained bilateral pediatric cataracts. Metabolic and infectious testing is best considered only after consultation with the child's pediatrician, guided by the patient's clinical context and the availability of genetic testing.

Retrospective evaluation of Postnatal Growth and Retinopathy of Prematurity (G-ROP) and Colorado Retinopathy of Prematurity (CO-ROP) screening algorithms in University of Pittsburgh Medical Centers cohort.

Of the 70,000 infants screened for retinopathy of prematurity (ROP) each year in the United States, only 43% develop any ROP, and <10% develop treatment-requiring ROP. Investigators have tried to develop new methods for determining more specific screening criteria, including the Postnatal Growth and Retinopathy of Prematurity (G-ROP) and Colorado Retinopathy of Prematurity (CO-ROP), to reduce the number of infants being screened while maintaining a high degree of sensitivity. We evaluated the records of 138 premature infants who received treatment for ROP between 2010 and 2021 with respect to G-ROP (129 infants) and CO-ROP (102 infants) to test the sensitivity of each. Using the G-ROP criteria, 0.8% (1/129) of treated infants had type 1 ROP that would have been missed and 3.1% (4/129) of total infants treated were missed. These infants would not have been screened or received treatment if G-ROP guidelines were followed. Using the CO-ROP criteria, 2% (2/102) of treated infants had type 1 ROP that would have been missed and 4.9% (5/102) of total infants treated were missed. In our study cohort, both sets of criteria proved less sensitive than our current screening guidelines.

Prevalence of SARS-CoV-2 Antibodies Among Healthy Children From Colorado From 2020 to 2021: A Brief Report.

There are few estimates of the seroprevalence of SARS-CoV-2 antibodies among children in the United States. We measured vaccine and infection induced seroprevalence among nearly 5000 healthy 1 to 17-year-old children in Colorado from 2020 to 2021. By December 2021, 89% of older children, ages 12 to 18, had antibodies detected. The increase was largely driven from vaccination rather than infection.

Retrospective validation of the postnatal growth and retinopathy of prematurity (G-ROP) and Colorado retinopathy of prematurity (CO-ROP) models in a Turkish cohort.

BACKGROUND: The aim of this study was to investigate the effectiveness of the Postnatal Growth and Retinopathy of Prematurity (G-ROP) and Colorado Retinopathy of Prematurity (CO-ROP) models in predicting the risk of Retinopathy of Prematurity (ROP) in preterm infants at a tertiary ROP diagnostic and treatment center. METHODS: The G-ROP and CO-ROP models were applied to the study group using the data obtained. The sensitivity and specificity of both models were then calculated. RESULTS: One hundred and twenty-six infants were included in the study. When the G-ROP model was applied to the study group, the model`s sensitivity at detecting any stage ROP was 88.7%, while it was 93.3% for the treated group. The specificity of the model was 10.9% for any stage ROP, and 11.7% for the treated group. For the CO-ROP model in the same study group, the sensitivity at detecting any stage ROP was 87.3%, while it was 100% for the treated group. The CO-ROP model's specificity was 40% for any stage ROP, and 27.9% for the treated group. When cardiac pathology criteria were introduced to both models, the sensitivity of the G-ROP and CO-ROP models increased to 94.4% and 97.2%, respectively. CONCLUSIONS: It was found that the G-ROP and CO-ROP models are simple and effective models for predicting any degree of ROP development, but that they are unable to be 100% accurate. When the models were modified by introducing cardiac pathology criteria, it was observed that they began to produce more accurate results. Studies with larger groups are needed in order to assess the applicability of the modified criteria.