Structure and toxicity of AZA-59, an azaspiracid shellfish poisoning toxin produced by Azadinium poporum (Dinophyceae).

To date, the putative shellfish toxin azaspiracid 59 (AZA-59) produced by Azadinium poporum (Dinophyceae) has been the only AZA found in isolates from the Pacific Northwest coast of the USA (Northeast Pacific Ocean). Anecdotal reports of sporadic diarrhetic shellfish poisoning-like illness, with the absence of DSP toxin or Vibrio contamination, led to efforts to look for other potential toxins, such as AZAs, in water and shellfish from the region. A. poporum was found in Puget Sound and the outer coast of Washington State, USA, and a novel AZA (putative AZA-59) was detected in low quantities in SPATT resins and shellfish. Here, an A. poporum strain from Puget Sound was mass-cultured and AZA-59 was subsequently purified and structurally characterized. In vitro cytotoxicity of AZA-59 towards Jurkat T lymphocytes and acute intraperitoneal toxicity in mice in comparison to AZA-1 allowed the derivation of a provisional toxicity equivalency factor of 0.8 for AZA-59. Quantification of AZA-59 using ELISA and LC-MS/MS yielded reasonable quantitative results when AZA-1 was used as an external reference standard. This study assesses the toxic potency of AZA-59 and will inform guidelines for its potential monitoring in case of increasing toxin levels in edible shellfish.

AIDS Drug Assistance Program disenrollment is associated with loss of viral suppression beyond differences in homelessness, mental health, and substance use disorders: An evaluation in Washington state 2017-2019.

AIDS Drug Assistance Programs (ADAPs) are state-administered programs that pay for medical care for people living with HIV in the US. Maintaining enrollment in the programs is challenging, and a large proportion of clients in Washington state (WA) fail to recertify and are disenrolled. In this study we sought to quantify the impact of disenrollment from ADAPs on viral suppression. We conducted a retrospective cohort study of the 5238 clients in WA ADAP from 2017 to 2019 and estimated the risk difference (RD) of viral suppression before and after disenrollment. We performed a quantitative bias analysis (QBA) to assess the effect of unmeasured confounders, as the factors that contribute to disenrollment and medication discontinuation may overlap. Of the 1336 ADAP clients who disenrolled ≥1 time, 83% were virally suppressed before disenrollment versus 69% after (RD 12%, 95%CI 9-15%). The RD was highest among clients with dual Medicaid-Medicare insurance (RD 22%, 95%CI 9-35%) and lowest among privately insured individuals (RD 8%, 95%CI 5-12%). The results of the QBA suggest that unmeasured confounders do not negate the overall RD. The ADAP recertification procedures negatively impact the care of clients who struggle to stay in the program; alternative procedures may reduce this impact.

Baylisascaris procyonis Roundworm Infection in Child with Autism Spectrum Disorder, Washington, USA, 2022.

We describe a case of Baylisascaris procyonis roundworm infection in a child in Washington, USA, with autism spectrum disorder. Environmental assessment confirmed nearby raccoon habitation and B. procyonis eggs. B. procyonis infections should be considered a potential cause of human eosinophilic meningitis, particularly among young children and persons with developmental delays.

Insights from a workplace SARS-CoV-2 specimen collection program, with genomes placed into global sequence phylogeny.

In 2020, the Department of Energy established the National Virtual Biotechnology Laboratory (NVBL) to address key challenges associated with COVID-19. As part of that effort, Pacific Northwest National Laboratory (PNNL) established a capability to collect and analyze specimens from employees who self-reported symptoms consistent with the disease. During the spring and fall of 2021, 688 specimens were screened for SARS-CoV-2, with 64 (9.3%) testing positive using reverse-transcriptase quantitative PCR (RT-qPCR). Of these, 36 samples were released for research. All 36 positive samples released for research were sequenced and genotyped. Here, the relationship between patient age and viral load as measured by Ct values was measured and determined to be only weakly significant. Consensus sequences for each sample were placed into a global phylogeny and transmission dynamics were investigated, revealing that the closest relative for many samples was from outside of Washington state, indicating mixing of viral pools within geographic regions.

Cyberthreats: A primer for healthcare professionals.

INTRODUCTION: Cyberattacks are one of the most widespread, damaging, and disruptive forms of action against healthcare entities. Data breaches, ransomware attacks, and other intrusions can lead to significant cost both in monetary and personal harm to those affected and may result in large payouts to cyber criminals, crashes of information technology systems, leaks of protected health and personal information, as well as fines and lawsuits. This study is a descriptive analysis of healthcare-related cyber breaches affecting 500 or more individuals in the past decade in the United States. METHODS: The publicly available U.S. breach report database was downloaded in the Microsoft Excel (Microsoft, Redmond, Washington, USA) format and searched for all reported breaches occurring between January 1, 2011 - December 31, 2021 (10 years). Breaches were subdivided by category and analyzed by states, breach submission dates, types of breach, location of breached information, entity type, and individuals affected. All subcategories were predefined by the breach report. RESULTS: There were a total of 3822 PHI breaches that affected 283,335,803 people in the United States from January 1, 2011 to December 31, 2021. Of the 3822 PHI breaches, 1593 (41.7%) were hacking/ IT related, 1055 (27.6%) were listed as unknown, 819 (21.4%) were theft related, 194 (5.1%) were loss related, 97 (2.5%) were related to improper disposal and 64 (1.7%) were listed as "others". Year 2020 saw the most breaches with 631 and California was the state with the highest number of breaches at 403. CONCLUSION: Cyberattacks and healthcare breaches are one of the most costly and disruptive situations facing healthcare today. A total of 3822 breaches affecting 283,335,803 people in the United States were recorded from January 1, 2011 to December 31, 2021. By understanding the extent of cyberthreats this will better prepare healthcare organizations and providers to mitigate, respond, and recover from these devastating attacks.

Effects of geometric attributes of horizontal and sag vertical curve combinations on freeway crash frequency.

The geometric design of the combinations of horizontal and sag vertical curves (sag combinations or sag combined curves) is vital to road safety. However, there is little research that investigates the safety effects of their geometric attributes based on the analysis of real-world crash data. To this end, the crash, traffic, geometric design, and roadway configuration data are collected from 157 sag combinations on six freeways in Washington State, during 2011-2017. Poisson, negative binomial (NB), hierarchical Poisson, and hierarchical NB models are developed for analyzing the crash frequency of sag combinations. The models are estimated and compared in the context of Bayesian inference. The results indicate that significant over-dispersion and cross-group heterogeneity exist in the crash data and that the hierarchical NB model yields the best overall performance. The parameter estimates show that: five geometric attributes, including horizontal curvature, vertical curvature, departure grade, the ratio of horizontal curvature to vertical curvature, and the layout of front dislocation, have significant effects on the crash frequency of sag combinations. Freeway section length, annual average daily traffic, and speed limits are also important predictors of crash frequency. The analysis results and the proposed model are useful for evaluating the safety performance of freeway sag combinations and optimizing their geometric design based on substantive safety evaluation.

Excess Injury Mortality in Washington State During the 2021 Heat Wave.

PUBLIC HEALTH IMPLICATIONS: Under global warming scenarios, heat waves of this magnitude will become much more common. Adaptation and planning efforts are needed to protect residents of the historically temperate Pacific Northwest for a range of health outcomes. (Am J Public Health. 2023;113(6):657-660. https://doi.org/10.2105/AJPH.2023.307269).

Geographic Variation In Effective Contraceptive Use Among Medicaid Recipients In 2018.

Medicaid is the largest payer for publicly funded contraception, serving millions of women across the United States. However, relatively little is known about the extent to which effective contraceptive services vary geographically for Medicaid recipients. This study used national Medicaid claims to assess county-level variation in rates of provision of the most or moderately effective methods of contraception and provision of long-acting reversible contraception (LARC) across forty states and Washington, D.C., in 2018. County-level rates of most or moderately effective contraceptive use varied almost fourfold across states, from a low of 10.8 percent to a high of 44.4 percent. Rates of LARC provision varied almost tenfold, from a low of 1.0 percent to a high of 9.6 percent. Despite the fact that contraception is a core benefit within Medicaid, access and use vary substantially across and within states. Medicaid agencies have a variety of options to ensure that people have access to a choice of the full range of contraceptive methods, including removing or loosening utilization controls, incorporating quality metrics or value-based payments into contraceptive services, and adjusting reimbursement to remove barriers to the clinical provision of LARC.

Comparing public support for nuclear and wind energy in Washington State.

The proliferation of country and state-level net zero-emission commitments, rising energy costs, and the quest for energy security in the wake of the Ukraine crisis have renewed the debate about the future of energy sources. As opposed to elite discourse, the energy policy preferences of the public remain less explored. While many public opinion surveys report preferences for a specific type of clean energy, there is less work on understanding choices among different types. We explore whether support for nuclear over wind energy at the state level depends on how people assess the impact of these energy sources on health, local jobs, landscape disruption, and the stability of the electricity supply. Importantly, we seek to understand where people physically reside (and their experience of existing energy possibilities) might influence their energy policy preferences. We estimate multiple regression models with OLS with our original survey data of a representative sample of Washington residents (n = 844). We find that the physical proximity to existing energy facilities does not influence support for nuclear over wind energy. However, this support is shaped by the importance respondents attach to health (-), jobs (-), landscapes (+), and supply stability (+) dimensions of energy source. Moreover, the physical proximity to existing energy facilities moderates the importance respondents attach to these dimensions.

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.

Genomic Characterization of Respiratory Syncytial Virus during 2022-23 Outbreak, Washington, USA.

We sequenced 54 respiratory syncytial virus (RSV) genomes collected during 2021-22 and 2022-23 outbreaks in Washington, USA, to determine the origin of increased RSV cases. Detected RSV strains have been spreading for >10 years, suggesting a role for diminished population immunity from low RSV exposure during the COVID-19 pandemic.

SoundToxins: A Research and Monitoring Partnership for Harmful Phytoplankton in Washington State.

The more frequent occurrence of marine harmful algal blooms (HABs) and recent problems with newly-described toxins in Puget Sound have increased the risk for illness and have negatively impacted sustainable access to shellfish in Washington State. Marine toxins that affect safe shellfish harvest because of their impact on human health are the saxitoxins that cause paralytic shellfish poisoning (PSP), domoic acid that causes amnesic shellfish poisoning (ASP), diarrhetic shellfish toxins that cause diarrhetic shellfish poisoning (DSP) and the recent measurement of azaspiracids, known to cause azaspiracid poisoning (AZP), at low concentrations in Puget Sound shellfish. The flagellate, Heterosigma akashiwo, impacts the health and harvestability of aquacultured and wild salmon in Puget Sound. The more recently described flagellates that cause the illness or death of cultivated and wild shellfish, include Protoceratium reticulatum, known to produce yessotoxins, Akashiwo sanguinea and Phaeocystis globosa. This increased incidence of HABs, especially dinoflagellate HABs that are expected in increase with enhanced stratification linked to climate change, has necessitated the partnership of state regulatory programs with SoundToxins, the research, monitoring and early warning program for HABs in Puget Sound, that allows shellfish growers, Native tribes, environmental learning centers and citizens, to be the "eyes on the coast". This partnership enables safe harvest of wholesome seafood for consumption in the region and helps to describe unusual events that impact the health of oceans, wildlife and humans.

Was Coccidioides a Pre-Columbian Hitchhiker to Southcentral Washington?

Coccidioides immitis, a pathogenic environmental fungus that causes Valley fever (coccidioidomycosis) primarily in the American Southwest and parts of Central and South America, has emerged over the past 12 years in the Columbia River Basin region, near the confluence with the Yakima River, in southcentral Washington state, USA. An initial autochthonous Washington human case was found in 2010, stemming from a wound derived from soil contamination during an all-terrain vehicle crash. Subsequent analysis identified multiple positive soil samples from the park where the crash occurred (near the Columbia River in Kennewick, WA), and from another riverside location several kilometers upstream from the park location. Intensified disease surveillance identified several more cases of coccidioidomycosis in the region that lacked any relevant travel history to known endemic locales. Genomic analysis of both patient and soil isolates from the Washington cases determined that all samples from the region are phylogenetically closely related. Given the genomic and the epidemiological link between case and environment, C. immitis was declared to be a newly endemic fungus in the region, spawning many questions as to the scope of its presence, the causes of its recent emergence, and what it predicts about the changing landscape of this disease. Here, we review this discovery through a paleo-epidemiological lens in the context of what is known about C. immitis biology and pathogenesis and propose a novel hypothesis for the cause of the emergence in southcentral Washington. We also try to place it in the context of our evolving understanding of this regionally specific pathogenic fungus.

Using targeted sequencing and TaqMan approaches to detect acaricide (bifenthrin, bifenazate, and etoxazole) resistance associated SNPs in Tetranychus urticae collected from peppermint fields and hop yards.

Tetranychus urticae (Koch) is an economically important pest of many agricultural commodities world-wide. Multiple acaricides, including bifenazate, bifenthrin, and extoxazole, are currently registered to control T. urticae. However, populations of T. urticae in many different growing regions have developed acaricide resistance through multiple mechanisms. Within T. urticae, single nucleotide polymorphisms (SNPs) have been documented in different genes which are associated with acaricide resistance phenotypes. The detection of these mutations through TaqMan qPCR has been suggested as a practical, quick, and reliable tool to inform agricultural producers of acaricide resistance phenotypes present within their fields and have potential utility for making appropriate acaricide application and integrated pest management decisions. Within this investigation we examined the use of a TaqMan qPCR-based approach to determine genotypes which have been previously associated with acaricide resistance in field-collected populations of T. urticae from peppermint fields and hop yards in the Pacific Northwest of the United States and confirmed the results with a multiplex targeted sequencing. The results suggest that a TaqMan qPCR approach accurately genotypes T. urticae populations for SNPs that have been linked to Bifenazate, Bifenthrin, and Etoxazole resistance. The results also demonstrated that different populations of mites in Washington and Idaho displayed varying frequencies of the examined SNPs. While we were able to detect the SNPs associated with the examined acaricides, the mutation G126S was not an appropriate or accurate indicator for bifenazate resistance.

Benzodiazepine analysis by an improved LC-MS/MS method illustrates usage patterns in Washington State.

BACKGROUND: The standard approach for benzodiazepine detection often includes immunoassay followed by liquid chromatography-tandem mass spectrometry (LC-MS/MS). The illicit use of non-prescribed benzodiazepines has been trending up nationally. METHODS: We developed and validated an improved LC-MS/MS assay for benzodiazepine detection in urine. We expanded the testing panel by adding five drugs to the previous panel of ten. We determined the prevalence of individual benzodiazepines in our patient population. Immunoassay results were compared with LC-MS/MS to evaluate assay performance. RESULTS: Clonazepam and alprazolam were the most common benzodiazepines present. Etizolam and flualprazolam were also prevalent in Washington State. Compared with the LC-MS/MS assay, the immunoassay had variable cross-reactivity, which explained false negative and false positive immunoassay results. The inclusion of new drugs in the LC-MS/MS panel significantly reduced the incidence of immunoassay results interpreted as falsely positive. CONCLUSION: New illicit benzodiazepines have emerged regionally and nationally. The inclusion of novel drugs in LC-MS/MS assay was helpful in properly characterizing the epidemiology of benzodiazepine use in our patient population. This information will lead to better assay result interpretations and patient care, and our experiences provide a roadmap for other clinical laboratories looking to expand their testing menu or transition to new instrumentation.

Association between any underlying health condition and COVID-19-associated hospitalization by age group, Washington State, 2020-2021: a retrospective cohort study.

BACKGROUND: Presence of at least one underlying health condition (UHC) is positively associated with severe COVID-19, but there is limited research examining this association by age group, particularly among young adults. METHODS: We examined age-stratified associations between any UHC and COVID-19-associated hospitalization using a retrospective cohort study of electronic health record data from the University of Washington Medicine healthcare system for adult patients with a positive SARS-CoV-2 test from February 29, 2020, to March 13, 2021. Any UHC was defined as documented diagnosis of at least one UHC identified by the CDC as a potential risk factor for severe COVID-19. Adjusting for sex, age, race and ethnicity, and health insurance, we estimated risk ratios (aRRs) and risk differences (aRDs), overall and by age group (18-39, 40-64, and 65 + years). RESULTS: Among patients aged 18-39 (N = 3,249), 40-64 (N = 2,840), 65 + years (N = 1,363), and overall (N = 7,452), 57.5%, 79.4%, 89.4%, and 71.7% had at least one UHC, respectively. Overall, 4.4% of patients experienced COVID-19-associated hospitalization. For all age groups, the risk of COVID-19-associated hospitalization was greater for patients with any UHC vs. those without (18-39: 2.2% vs. 0.4%; 40-64: 5.6% vs. 0.3%; 65 + : 12.2% vs. 2.8%; overall: 5.9% vs. 0.6%). The aRR comparing patients with vs. those without UHCs was notably higher for patients aged 40-64 years (aRR [95% CI] for 18-39: 4.3 [1.8, 10.0]; 40-64: 12.9 [3.2, 52.5]; 65 + : 3.1 [1.2, 8.2]; overall: 5.3 [3.0, 9.6]). The aRDs increased across age groups (aRD [95% CI] per 1,000 SARS-CoV-2-positive persons for 18-39: 10 [2, 18]; 40-64: 43 [33, 54]; 65 + : 84 [51, 116]; overall: 28 [21, 35]). CONCLUSIONS: Individuals with UHCs are at significantly increased risk of COVID-19-associated hospitalization regardless of age. Our findings support the prevention of severe COVID-19 in adults with UHCs in all age groups and in older adults aged 65 + years as ongoing local public health priorities.

Population structure and adaptive differentiation in the sea cucumber Apostichopus californicus and implications for spatial resource management.

A growing body of evidence suggests that spatial population structure can develop in marine species despite large population sizes and high gene flow. Characterizing population structure is important for the effective management of exploited species, as it can be used to identify appropriate scales of management in fishery and aquaculture contexts. The California sea cucumber, Apostichopus californicus, is one such exploited species whose management could benefit from further characterization of population structure. Using restriction site-associated DNA (RAD) sequencing, we developed 2075 single nucleotide polymorphisms (SNPs) to quantify genetic structure over a broad section of the species' range along the North American west coast and within the Salish Sea, a region supporting the Washington State A. californicus fishery and developing aquaculture production of the species. We found evidence for population structure (global fixation index (FST) = 0.0068) with limited dispersal driving two patterns of differentiation: isolation-by-distance and a latitudinal gradient of differentiation. Notably, we found detectable population differences among collection sites within the Salish Sea (pairwise FST = 0.001-0.006). Using FST outlier detection and gene-environment association, we identified 10.2% of total SNPs as putatively adaptive. Environmental variables (e.g., temperature, salinity) from the sea surface were more correlated with genetic variation than those same variables measured near the benthos, suggesting that selection on pelagic larvae may drive adaptive differentiation to a greater degree than selection on adults. Our results were consistent with previous estimates of and patterns in population structure for this species in other extents of the range. Additionally, we found that patterns of neutral and adaptive differentiation co-varied, suggesting that adaptive barriers may limit dispersal. Our study provides guidance to decision-makers regarding the designation of management units for A. californicus and adds to the growing body of literature identifying genetic population differentiation in marine species despite large, nominally connected populations.

Association Between California's State Insurance Gender Nondiscrimination Act and Utilization of Gender-Affirming Surgery.

Importance: Gender-affirming surgery is often beneficial for gender-diverse or -dysphoric patients. Access to gender-affirming surgery is often limited through restrictive legislation and insurance policies. Objective: To investigate the association between California's 2013 implementation of the Insurance Gender Nondiscrimination Act, which prohibits insurers and health plans from limiting benefits based on a patient's sex, gender, gender identity, or gender expression, and utilization of gender-affirming surgery among California residents. Design, Setting, and Participants: Population epidemiology study of transgender and gender-diverse patients undergoing gender-affirming surgery (facial, chest, and genital surgery) between 2005 and 2019. Utilization of gender-affirming surgery in California before and after implementation of the Insurance Gender Nondiscrimination Act in July 2013 was compared with utilization in Washington and Arizona, control states chosen because of geographic similarity and because they expanded Medicaid on the same date as California-January 1, 2014. The date of last follow-up was December 31, 2019. Exposures: California's Insurance Gender Nondiscrimination Act, implemented on July 9, 2013. Main Outcomes and Measures: Receipt of gender-affirming surgery, defined as undergoing at least 1 facial, chest, or genital procedure. Results: A total of 25 252 patients (California: n = 17 934 [71%]; control: n = 7328 [29%]) had a diagnosis of gender dysphoria. Median ages were 34.0 years in California (with or without gender-affirming surgery), 39 years (IQR, 28-49 years) among those undergoing gender-affirming surgery in control states, and 36 years (IQR, 22-56 years) among those not undergoing gender-affirming surgery in control states. Patients underwent at least 1 gender-affirming surgery within the study period in 2918 (11.6%) admissions-2715 (15.1%) in California vs 203 (2.8%) in control states. There was a statistically significant increase in gender-affirming surgery in the third quarter of July 2013 in California vs control states, coinciding with the timing of the Insurance Gender Nondiscrimination Act (P < .001). Implementation of the policy was associated with an absolute 12.1% (95% CI, 10.3%-13.9%; P < .001) increase in the probability of undergoing gender-affirming surgery in California vs control states observed in the subset of insured patients (13.4% [95% CI, 11.5%-15.4%]; P < .001) but not self-pay patients (-22.6% [95% CI, -32.8% to -12.5%]; P < .001). Conclusions and Relevance: Implementation in California of its Insurance Gender Nondiscrimination Act was associated with a significant increase in utilization of gender-affirming surgery in California compared with the control states Washington and Arizona. These data might inform state legislative efforts to craft policies preventing discrimination in health coverage for state residents, including transgender and gender-diverse patients.

Emergency Department Visits by Incarcerated Adults for Nonfatal Injuries - United States, 2010-2019.

During 2010-2019, U.S. correctional authorities held 1.4-1.6 million persons in state and federal prisons annually, and 10.3-12.9 million persons were admitted to local jails each year (1,2). Incarcerated persons experience a disproportionate burden of negative health outcomes, including unintentional and violence-related injuries (3,4). No national studies on injury-related emergency department (ED) visits by incarcerated persons have been conducted, but a previous study demonstrated a high rate of such visits among a Seattle, Washington jail population (5). To examine nonfatal injury-related ED visits among incarcerated adults, CDC analyzed 2010-2019 National Electronic Injury Surveillance System-All Injury Program (NEISS-AIP) data. During 2010-2019, an estimated 733,547 ED visits by incarcerated adults occurred in the United States. The proportion of ED visits resulting from assault* and self-harm among incarcerated adults was five times as high as those among nonincarcerated adults. Among incarcerated adults, men and adult persons aged <65 years had the highest proportion of assault-related ED visits. Falls accounted for the most ED visits among incarcerated adults aged ≥65 years. A higher proportion of ED visits by incarcerated women than incarcerated men were for overdose or poisoning. These findings suggest that injuries among incarcerated adults differ from those among nonincarcerated adults and might require development and implementation of age- and sex-specific prevention strategies for this population.