Public Health Response to SARS-CoV-2 in Assisted Living Facilities in New York State: March 2020-December 2022.

CONTEXT: Assisted living facility (ALF) residents are especially vulnerable to SARS-CoV-2 infection due to the age and comorbidities of the resident population and the social nature of these facilities. OBJECTIVE: To collate all New York State Department of Health guidance and regulations to control transmission of SARS-CoV-2 infection within ALFs from March 2020 through December 2022 and to include US Food and Drug Administration COVID-19 testing and vaccine authorizations. DESIGN: A narrative chronological review of all New York State Department of Health guidance. RESULTS: Documents and associated guidance and regulations are divided into 4 sections: (1) lockdown until COVID-19 vaccine emergency use authorization; (2) COVID-19 vaccine authorization until phased reopening; (3) phased reopening, vaccination requirements, and booster vaccination; (4) the period of the bivalent booster. CONCLUSION: Controlling the spread of SARS-CoV-2 within ALFs required a multifactorial approach that included stringent infection control measures, testing, and vaccination and careful attention to the social structure and support systems within ALFs. The SARS-CoV-2 pandemic highlighted the complexity of controlling spread of an easily transmissible respiratory pathogen in assisted living communities and the need to structure infection control programs within the diverse ALFs that provide care for our aging population.

Estimating the return on investment of the New York Tobacco Control Programme: a synthetic control study.

OBJECTIVE: To assess the return on investment (ROI) of the New York Tobacco Control Programme (NY TCP). SETTING: New York and other states of the USA. INTERVENTIONS: NY TCP. OUTCOMES: Smoking prevalence, smoking-attributable healthcare expenditures (SAEs), smoking-attributable mortality, years of life lost (YLL), the dollar value of YLL and the ROI for healthcare expenditures and mortality. DESIGN AND METHODS: We used a synthetic control method to estimate the effectiveness of NY TCP funding on smoking prevalence. The synthetic control method created a comparison group that best matched the adult smoking prevalence trend in New York state in the period prior to implementation of the NY TCP and compared smoking prevalence in the state to smoking prevalence in the synthetic control in the period after treatment (2001-2019). The synthetic control group represents what the trend in smoking prevalence in New York would have been had there been no tobacco control expenditures. The ROI was calculated as net savings for each outcome divided by net programme expenditures. RESULTS: Cumulative savings in SAE in New York from 2001 to 2019 amounted to US$13.2 billion. An estimated 41 771 smoking-attributable deaths (SADs) were averted in New York from 2001 to 2019, and an estimated 672 141 YLL averted as a result of NY TCP funding in the same period. From 2001 to 2019, the ROI for SAE in New York was approximately 14, the economic value ROI of the YLL due to SAD was nearly 145 and the combined ROI was almost 160. CONCLUSIONS: In this study, we found relatively large ROIs for the NY TCP, which suggests that the programme-which lowers SAE and saves lives-is an efficient use of public funds.

Unexpected severe malaria in a postoperative patient, New York, USA.

Severe malaria is not routinely considered when evaluating a febrile patient in the postoperative setting. Common bacterial infections, along with adverse drug reactions, are the usual differential concerns. We present a case of severe malaria emerging unexpectedly eight days after routine craniotomy.

Disadvantaged groups have greater spatial access to pharmacies in New York state.

BACKGROUND: The accessibility of pharmacies has been associated with overall health and wellbeing. Past studies have suggested that low income and racial minority communities are underserved by pharmacies. However, the literature is inconsistent in finding links between area-level income or racial and ethnic composition and access to pharmacies. Here we aim to assess area-level spatial access to pharmacies across New York State (NYS), hypothesizing that Census Tracts with higher poverty rates and higher percentages of Black and Hispanic residents would have lower spatial access. METHODS: The population weighted mean shortest road network distance (PWMSD) to a pharmacy in 2018 was calculated for each Census Tract in NYS. This statistic was calculated from the shortest road network distance to a pharmacy from the centroid of each Census block within a tract, with the mean across census blocks weighted by the population of the census block. Cross-sectional analyses were conducted to assess links between Tract-level socio demographic characteristics and Tract-level PWMSD to a pharmacy. RESULTS: Overall the mean PWMSD to a pharmacy across Census tracts in NYS was 2.07 Km (SD = 3.35, median 0.85 Km). Shorter PWMSD to a pharmacy were associated with higher Tract-level % poverty, % Black/African American (AA) residents, and % Hispanic/Latino residents and with lower Tract-level % of residents with a college degree. Compared to tracts in the lowest quartile of % Black/AA residents, tracts in the highest quartile had a 70.7% (95% CI 68.3-72.9%) shorter PWMSD to a pharmacy. Similarly, tracts in the highest quartile of % poverty had a 61.3% (95% CI 58.0-64.4%) shorter PWMSD to a pharmacy than tracts in the lowest quartile. CONCLUSION: The analyses show that tracts in NYS with higher racial and ethnic minority populations and higher poverty rates have higher spatial access to pharmacies.

Associations of Serum Perfluoroalkyl Substances and Placental Human Chorionic Gonadotropin in Early Pregnancy, Measured in the UPSIDE Study in Rochester, New York.

BACKGROUND: Per- and polyfluoroalkyl substances (PFAS) are widely detected in pregnant women and associated with adverse outcomes related to impaired placental function. Human chorionic gonadotropin (hCG) is a dimeric glycoprotein hormone that can indicate placental toxicity. OBJECTIVES: Our aim was to quantify the association of serum PFAS with placental hCG, measured as an intact molecule (hCG), as free alpha-(hCGα) and beta-subunits (hCGß), and as a hyperglycosylated form (h-hCG), and evaluate effect measure modification by social determinants and by fetal sex. METHODS: Data were collected from 326 pregnant women enrolled from 2015 to 2019 in the UPSIDE study in Rochester, New York. hCG forms were normalized for gestational age at the time of blood draw in the first trimester [multiple of the median (MoM)]. Seven PFAS were measured in second-trimester maternal serum. Multivariate imputation by chained equations and inverse probability weighting were used to evaluate robustness of linear associations. PFAS mixture effects were estimated by Bayesian kernel machine regression. RESULTS: Perfluorohexane sulfonic acid (PFHxS) [hCGß: 0.29 log MoM units per log PFHxS; 95% confidence interval (CI): 0.08, 0.51] and perfluorodecanoic acid (PFDA) (hCG: -0.09; 95% CI: -0.16, -0.02) were associated with hCG in the single chemical and mixture analyses. The PFAS mixture was negatively associated with hCGα and positively with hCGß. Subgroup analyses revealed that PFAS associations with hCG differed by maternal race/ethnicity and education. Perfluoropentanoic acid (PFPeA) was associated with hCGß only in Black participants (-0.23; 95% CI: -0.37, -0.09) and in participants with high school education or less (-0.14; 95% CI: -0.26, -0.02); conversely, perfluorononanoic acid (PFNA) was negatively associated with hCGα only in White participants (-0.15; 95% CI: -0.27, -0.03) and with hCGß only in participants with a college education or greater (-0.19; 95% CI: -0.36, -0.01). These findings were robust to testing for selection bias, confounding bias, and left truncation bias where PFAS detection frequency was <100%. Two associations were negative in male (and null in female) pregnancies: Perfluoroundecanoic acid (PFUnDA) with hCGα, and PFNA with h-hCG. CONCLUSIONS: Evidence was strongest for the association between PFHxS and PFDA with hCG in all participants and for PFPeA and PFNA within subgroups defined by social determinants and fetal sex. PFAS mixture associations with hCGα and hCGß differed, suggesting subunit-specific types of toxicity and/or regulation. Future studies will evaluate the biological, clinical and public health significance of these findings. https://doi.org/10.1289/EHP12950.

Perspectives on Injectable HIV Pre-Exposure Prophylaxis: A Qualitative Study of Health Care Providers in the United States.

The introduction of injectable HIV pre-exposure prophylaxis (PrEP) has the potential to significantly change the biomedical HIV prevention landscape. However, effective implementation will require health care providers to adopt, prescribe, and administer injectable PrEP within clinical settings. This study qualitatively examined challenges and benefit of injectable PrEP implementation from the perspective of health care providers. From April to August 2022, we conducted 19 in-depth interviews with current PrEP-prescribing health care providers in New York State, including 3 physician assistants, 5 physicians, and 11 nurse practitioners. Interviews were audio-recorded, transcribed verbatim, and thematically analyzed to report semantic-level themes regarding injectable PrEP implementation. More than half of participants (61%) were aware of injectable PrEP; only 21% had experience prescribing it. Qualitative findings highlighted five themes. Three themes represented implementation challenges, including speculative concerns about side effects, appointment compliance, and practical and logistical considerations. The remaining two themes described benefits of injectable PrEP relative to oral PrEP, which included greater convenience and enhanced privacy. Findings from this qualitative study make significant applied contributions to the sparse knowledge on health care provider perspectives of injectable PrEP post-US Food and Drug Administration approval and their concerns and considerations regarding implementation in real-world clinical settings.

Integrated Hepatitis C-Opioid Use Disorder Care Through Facilitated Telemedicine: A Randomized Trial.

Importance: Facilitated telemedicine may promote hepatitis C virus elimination by mitigating geographic and temporal barriers. Objective: To compare sustained virologic responses for hepatitis C virus among persons with opioid use disorder treated through facilitated telemedicine integrated into opioid treatment programs compared with off-site hepatitis specialist referral. Design, Setting, and Participants: Prospective, cluster randomized clinical trial using a stepped wedge design. Twelve programs throughout New York State included hepatitis C-infected participants (n = 602) enrolled between March 1, 2017, and February 29, 2020. Data were analyzed from December 1, 2022, through September 1, 2023. Intervention: Hepatitis C treatment with direct-acting antivirals through comanagement with a hepatitis specialist either through facilitated telemedicine integrated into opioid treatment programs (n = 290) or standard-of-care off-site referral (n = 312). Main Outcomes and Measures: The primary outcome was hepatitis C virus cure. Twelve programs began with off-site referral, and every 9 months, 4 randomly selected sites transitioned to facilitated telemedicine during 3 steps without participant crossover. Participants completed 2-year follow-up for reinfection assessment. Inclusion criteria required 6-month enrollment in opioid treatment and insurance coverage of hepatitis C medications. Generalized linear mixed-effects models were used to test for the intervention effect, adjusted for time, clustering, and effect modification in individual-based intention-to-treat analysis. Results: Among 602 participants, 369 were male (61.3%); 296 (49.2%) were American Indian or Alaska Native, Asian, Black or African American, multiracial, or other (ie, no race category was selected, with race data collected according to the 5 standard National Institutes of Health categories); and 306 (50.8%) were White. The mean (SD) age of the enrolled participants in the telemedicine group was 47.1 (13.1) years; that of the referral group was 48.9 (12.8) years. In telemedicine, 268 of 290 participants (92.4%) initiated treatment compared with 126 of 312 participants (40.4%) in referral. Intention-to-treat cure percentages were 90.3% (262 of 290) in telemedicine and 39.4% (123 of 312) in referral, with an estimated logarithmic odds ratio of the study group effect of 2.9 (95% CI, 2.0-3.5; P < .001) with no effect modification. Observed cure percentages were 246 of 290 participants (84.8%) in telemedicine vs 106 of 312 participants (34.0%) in referral. Subgroup effects were not significant, including fibrosis stage, urban or rural participant residence location, or mental health (anxiety or depression) comorbid conditions. Illicit drug use decreased significantly (referral: 95% CI, 1.2-4.8; P = .001; telemedicine: 95% CI, 0.3-1.0; P < .001) among cured participants. Minimal reinfections (n = 13) occurred, with hepatitis C virus reinfection incidence of 2.5 per 100 person-years. Participants in both groups rated health care delivery satisfaction as high or very high. Conclusions and Relevance: Opioid treatment program-integrated facilitated telemedicine resulted in significantly higher hepatitis C virus cure rates compared with off-site referral, with high participant satisfaction. Illicit drug use declined significantly among cured participants with minimal reinfections. Trial Registration: ClinicalTrials.gov Identifier: NCT02933970.

Barriers and facilitators to collaborative care implementation within the New York State Collaborative Care Medicaid Program.

BACKGROUND: Since 2015, the New York State Office of Mental Health has provided state primary care clinics with outreach, free training and technical assistance, and the opportunity to bill Medicaid for the Collaborative Care Model (CoCM) as part of its Collaborative Care Medicaid Program. This study aims to describe the characteristics of New York State primary care clinics at each step of CoCM implementation, and the barriers and facilitators to CoCM implementation for the New York State Collaborative Care Medicaid Program. METHODS: In this mixed-methods study, clinics were categorized into RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) steps. Clinics were sent a survey, which included questions related to payer mix, funding sources, billing codes used, and patient population demographics. Qualitative interviews were conducted with clinic representatives, focusing on barriers or facilitators clinics experienced affecting their progression to the next RE-AIM step. RESULTS: One thousand ninety-nine surveys were sent to primary care clinics across New York State, with 107 (9.7%) completing a survey. Significant differences were observed among the different RE-AIM steps for multiple demographic variables including primary payer, percentage of patients with a diagnose of depression or anxiety, and percent of behavioral health services that are reimbursed, in addition to others. Three main themes regarding barriers and facilitators to implementing CoCM for New York State Medicaid billing emerged from 31 qualitative interviews: (1) Billing requirements, (2) Reimbursement rates, and (3) Buy-in to CoCM. CONCLUSIONS: Survey data align with what we would expect to see demographically in NYS primary care clinics. Qualitative data indicated that CoCM billing requirements/structure and reimbursement rates were perceived as barriers to providing CoCM, particularly with New York State Medicaid, and that buy-in, which included active involvement from organizational leaders and providers that understand the Collaborative Care model were facilitators. Having dedicated staff to manage billing and data reporting is one way clinics minimize barriers, however, there appeared to be a disconnect between what clinics can bill for and the reimbursed amount several clinics are receiving, illustrating the need for stronger billing workflows and continued refinement of billing options across different payers.

Cancer incidence trends in New York State and associations with common population-level exposures 2010-2018: an ecological study.

The impact of common environmental exposures in combinations with socioeconomic and lifestyle factors on cancer development, particularly for young adults, remains understudied. Here, we leveraged environmental and cancer incidence data collected in New York State at the county level to examine the association between 31 exposures and 10 common cancers (i.e., lung and bronchus, thyroid, colorectal, kidney and renal pelvis, melanoma, non-Hodgkin lymphoma, and leukemia for both sexes; corpus uteri and female breast cancer; prostate cancer), for three age groups (25-49, 50-69, and 70-84 year-olds). For each cancer, we stratified by age group and sex, and applied regression models to examine the associations with multiple exposures simultaneously. The models included 642,013 incident cancer cases during 2010-2018 and found risk factors consistent with previous reports (e.g., smoking and physical inactivity). Models also found positive associations between ambient air pollutants (ozone and PM2.5) and prostate cancer, female breast cancer, and melanoma of the skin across multiple population strata. Additionally, the models were able to better explain the variation in cancer incidence data among 25-49 year-olds than the two older age groups. These findings support the impact of common environmental exposures on cancer development, particularly for younger age groups.

Gender dysphoria and gender-affirming surgery: The New York state experience.

BACKGROUND: Transgender and gender nonconforming (TGNC) individuals experience incongruence between their self-identified gender versus their birth-assigned sex. In some cases, TGNC patients undergo gender-affirming surgical (GAS) procedures. Although GAS is an evolving surgical field, there is currently limited literature documenting patient characteristics and procedures. Addressing this knowledge gap, this retrospective cohort analysis described the characteristics of New York State's TGNC residents with gender dysphoria (GD) diagnosis, including patients undergoing at least one gender-affirming surgical procedure. METHODS: Using the New York Statewide Planning and Research Cooperative System (SPARCS) database from 2002 to 2018, we identified patients' first-time TCNC records and their risk characteristics. Patients who received GAS procedures were sub-classified as top-only, bottom-only, or combined top/bottom procedures and were compared with TGNC patients who did not receive GAS. RESULTS: Of 24,615 records extracted from TGNC SPARCS database, 11,427 (46.4%) were transmasculine (female-to-male) and 13,188 (53.6%) were transfeminine (male-to-female). Overall, 2.73% of transgender patients received at least one GAS procedure. Of these patients, 78.2% had masculinizing and 21.8% had feminizing surgeries. After a diagnosis of GD, the positive predictors for a GAS-based procedure included female birth sex, pediatric age (<18 years) or older age (60+ years), commercial insurance coverage, and Hispanic race. In contrast, negative GAS predictors included male birth sex and government insurance coverage (i.e., Medicare and Medicaid). CONCLUSIONS: Compared with transgender women, transgender men were more likely to receive at least one GAS procedure. Because the race, ethnicity, and payor status of TGNC patients can impact GAS treatment rates, additional research is warranted to examine post-diagnosis GAS treatment disparities among TGNC patients.

Sociodemographic and Occupational Characteristics Associated with Early and Continued COVID-19 Vaccine Uptake Among Healthcare Personnel: Monroe County, NY.

OBJECTIVE: Identify characteristics of healthcare personnel (HCP) who did not have timely initiation of the COVID-19 primary series, as well as HCP who did not receive a booster vaccine. METHODS: Characteristics of HCP enrolled in a COVID-19 vaccine effectiveness study between 12/28/2020-12/01/2022 were compared by timing of receipt of 1st mRNA dose, and by receipt of a booster dose. Data for this retrospective cohort analysis came from HCP working at a large healthcare system in Monroe County, New York, and included standardized questionnaires and verified vaccination status. HCP were categorized by whether they received their 1stmRNA COVID-19 vaccine between 12/14/2020-03/30/2021 (earlier) or 04/01/2021-09/28/2021 (later) based on timing of local vaccine eligibility and mandates, and by whether they received a 3rdmRNA booster dose by 12/01/22. Logistic regression models were run to identify characteristics of HCP who had later 1stdose receipt or did not receive a booster. RESULTS: 3,375 HCP were enrolled. Of these, 86.8 % had early initiation of their 1stCOVID-19 vaccine, and 85.0 % received a booster dose. Low education, low household income, younger age (<50), non-White race and public health insurance were all significant predictors of later receipt of 1stdose and lack of uptake of a booster. However, advanced professional role was only found to be a significant predictor of early 1stdose receipt. CONCLUSIONS: Continual monitoring of COVID-19 vaccine uptake among HCP to identify those less likely to receive new booster doses will be crucial to support targeted vaccine campaigns in this important population.

Long term trends in source apportioned particle number concentrations in Rochester NY.

During the past two decades, efforts have been made to further reduce particulate air pollution across New York State through various Federal and State policy implementations. Air quality has also been affected by economic drivers like the 2007-2009 recession and changing costs for different approaches to electricity generation. Prior work has focused on particulate matter with aerodynamic diameter ≤2.5 µm. However, there is also interest in the effects of ultrafine particles on health and the environment and analyses of changes in particle number concentrations (PNCs) are also of interest to assess the impacts of changing emissions. Particle number size distributions have been measured since 2005. Prior apportionments have been limited to seasonal analyses over a limited number of years because of software limitations. Thus, it has not been possible to perform trend analyses on the source-specific PNCs. Recent development have now permitted the analysis of larger data sets using Positive Matrix Factorization (PMF) including its diagnostics. Thus, this study separated and analyzed the hourly averaged size distributions from 2005 to 2019 into two data sets; October to March and April to September. Six factors were resolved for both data sets with sources identified as nucleation, traffic 1, traffic 2, fresh secondary inorganic aerosol (SIA), aged SIA, and O3-rich aerosol. The resulting source-specific PNCs were combined to provide continuous data sets and analyzed for trends. The trends were then examined with respect to the implementation of regulations and the timing of economic drivers. Nucleation was strongly reduced by the requirement of ultralow (<15 ppm) sulfur on-road diesel fuel in 2006. Secondary inorganic particles and O3-rich PNCs show strong summer peaks. Aged SIA was constant and then declined substantially in 2015 but rose in 2019. Traffic 1 and 2 have steadily declined bur rose in 2019.

Implementation of a Pharmacist-Led, Long-Acting, Injectable Cabotegravir/Rilpivirine Program for HIV-1 at Health System-Based Clinics in the New York Metropolitan Area.

Long-acting cabotegravir/rilpivirine (LA-CAB/RPV) is the first complete injectable antiretroviral for patients living with HIV. To facilitate patient access to long-acting injectable treatment, a system-wide, pharmacist-led, LA-CAB/RPV transition program was developed at four health system-based New York clinics. Provider referrals were received across four clinics between January 22nd, 2021, and December 31st, 2022. All referrals were evaluated by a pharmacist for clinical eligibility and medication access. The primary outcome was the treatment retention rate defined as the percentage of patients who remained on LA-CAB/RPV at 3 months post-transition. A total of 171 referrals were received, with 73 patients (43%) initiating LA-CAB/RPV. Baseline demographics included a median age of 38 years, 81% patients were male, 41% were African American, and 49% had commercial insurance coverage. The treatment retention rate was 90% at 3 months post-transition. By the end of the study period, 84% of patients who transitioned remained on LA-CAB/RPV. Treatment was discontinued due to reasons such as viral breakthrough (4%), emergence of mutations (4%), and intolerable side effects (4%). Injection site reactions were commonly reported (51%), but only resulting in treatment discontinuation for one patient. A pharmacist-led program can transition a diverse population of patients living with HIV to LA-CAB/RPV. Results from this study further add to clinical experiences with LA-CAB/RPV, demonstrating real-world treatment retention despite more frequent clinic visits for patients.

The 15-minute city quantified using human mobility data.

Amid rising congestion and transport emissions, policymakers are embracing the '15-minute city' model, which envisions neighbourhoods where basic needs can be met within a short walk from home. Prior research has primarily examined amenity access without exploring its relationship to behaviour. We introduce a measure of local trip behaviour using GPS data from 40 million US mobile devices, defining '15-minute usage' as the proportion of consumption-related trips made within a 15-minute walk from home. Our findings show that the median resident makes only 14% of daily consumption trips locally. Differences in access to local amenities can explain 84% and 74% of the variation in 15-minute usage across and within urban areas, respectively. Historical data from New York zoning policies suggest a causal relationship between local access and 15-minute usage. However, we find a trade-off: increased local usage correlates with higher experienced segregation for low-income residents, signalling potential socio-economic challenges in achieving local living.

Simulating the Simultaneous Impact of Medication for Opioid Use Disorder and Naloxone on Opioid Overdose Death in Eight New York Counties.

BACKGROUND: The United States is in the midst of an opioid overdose epidemic; 28.3 per 100,000 people died of opioid overdose in 2020. Simulation models can help understand and address this complex, dynamic, and nonlinear social phenomenon. Using the HEALing Communities Study, aimed at reducing opioid overdoses, and an agent-based model, Simulation of Community-Level Overdose Prevention Strategy, we simulated increases in buprenorphine initiation and retention and naloxone distribution aimed at reducing overdose deaths by 40% in New York Counties. METHODS: Our simulations covered 2020-2022. The eight counties contrasted urban or rural and high and low baseline rates of opioid use disorder treatment. The model calibrated agent characteristics for opioid use and use disorder, treatments and treatment access, and fatal and nonfatal overdose. Modeled interventions included increased buprenorphine initiation and retention, and naloxone distribution. We predicted a decrease in the rate of fatal opioid overdose 1 year after intervention, given various modeled intervention scenarios. RESULTS: Counties required unique combinations of modeled interventions to achieve a 40% reduction in overdose deaths. Assuming a 200% increase in naloxone from current levels, high baseline treatment counties achieved a 40% reduction in overdose deaths with a simultaneous 150% increase in buprenorphine initiation. In comparison, low baseline treatment counties required 250-300% increases in buprenorphine initiation coupled with 200-1000% increases in naloxone, depending on the county. CONCLUSIONS: Results demonstrate the need for tailored county-level interventions to increase service utilization and reduce overdose deaths, as the modeled impact of interventions depended on the county's experience with past and current interventions.

A unified framework for assessing interaction effects among environmental exposures in epidemiologic studies: A case study on temperature, air pollution, and kidney-related conditions in New York state.

BACKGROUND: There are various methods to assess interaction effects. However, current methods have limitations, and quantification of interaction effects is rarely performed. This study aimed to develop a unified quantitative framework for assessing interaction effects. METHODS: We proposed a novel framework using log-linear models with a product term(s) across the exposures that generates parametric bi-variate association and interaction effect surfaces and allows flexible functional forms for exposures in the interaction term(s). In a case study, we assessed the interaction effects between temperature and air pollution (i.e., PM2.5, NO2, and O3) on risk for kidney-related conditions in New York State (2007-2016) using a case-crossover design with conditional logistic models. Our measures of exposure were the moving averages at lag 0-5 days for air pollution (linear) and daytime mean outdoor wet-bulb globe temperature (WBGT; using a natural cubic spline). RESULTS: We derived closed-form expressions for the magnitude of multiplicative interaction effects (the joint relative risk divided by the product of the two conditional relative risks) and their uncertainties. In the case study, we found a Bonferroni-corrected significant multiplicative interaction effect (IE) between outdoor WBGT at the 99th percentile (median as the reference) and (1) PM2.5 (per 5 µg/m3 increase, IE = 1.052; 95 % confidence interval [CI]: 1.019, 1.087) for acute kidney failure and (2) O3 (per 5 ppb increase; IE = 1.022; 95 % CI: 1.008, 1.036) for urolithiasis (the latter being inconclusive based on the sensitivity analysis). CONCLUSIONS: Our framework allows different functional forms of exposure variables in the interaction term, quantifies the magnitudes of entire-exposure-range (in addition to discrete exposure level) multiplicative interaction effects and their uncertainties in a categorical or continuous (linear or non-linear) manner, and harmonizes the two-way evaluation of effect modification. The case study underscores co-consideration of heat and air pollution when estimating health burden and designing heat/pollution alert systems.

Phytoplankton assemblage responses to nitrogen following COVID-19 stay-in-place orders in western Long Island Sound (New York/Connecticut).

This study evaluated water quality, nitrogen (N), and phytoplankton assemblage linkages along the western Long Island Sound (USA) shoreline (Nov. 2020-Dec. 2021) following COVID-19 stay-in-place (SIP) orders through monthly surveys and N-addition bioassays. Ammonia-N (AmN; NH3+NH4+) negatively correlated with total chlorophyll-a (chl-a) at all sites; this was significant at Alley Creek, adjacent to urban wastewater inputs, and at Calf Pasture, by the Norwalk River (Spearman rank correlation, p < 0.01 and 0.02). Diatoms were abundant throughout the study, though dinoflagellates (Heterocapsa, Prorocentrum), euglenoids/cryptophytes, and both nano- and picoplankton biomass increased during summer. In field and experimental assessments, high nitrite + nitrate (N + N) and low AmN increased diatom abundances while AmN was positively linked to cryptophyte concentrations. Likely N + N decreases with presumably minimal changes in AmN and organic N during COVID-19 SIP resulted in phytoplankton assemblage shifts (decreased diatoms, increased euglenoids/cryptophytes), highlighting the ecological impacts of N-form delivered by wastewater to urban estuaries.

2022 Polio outbreak, Rockland County, NY: Cost evaluation of strategies to prevent future outbreaks of vaccine-preventable diseases.

In 1994, the World Health Organization Region of the Americas was declared polio-free. In July 2022, a confirmed case of paralytic polio in an unvaccinated adult resident of Rockland County, New York was reported by the New York State Department of Health (NYSDOH) and Rockland County Department of Health (RCDOH). While only one case was identified, a single case of paralytic polio represents a public health emergency in the United States. The patient's county of residence was identified to have low vaccination coverage indicating that the community was at risk for additional cases. Disease outbreaks are resource-intensive and incur high costs to the patient, local health departments, and to society. These costs are potentially avoidable for vaccine-preventable diseases and thus, highlight the urgency to not only interrupt transmission but to prevent future vaccine-preventable disease outbreaks by improving vaccination coverage. Following case confirmation, an investigation and response was initiated by NYSDOH, along with local health departments and the Centers for Disease Control and Prevention (CDC). After the initial investigation and response, collaborative efforts to mitigate risk and strengthen routine immunization continued, which included provider outreach and immunization record assessments of Head Start and licensed childcare facilities (primarily those with missing or incomplete required vaccination coverage reports from the previous year) in Rockland County. We estimated the costs of (1) provider outreach and (2) childcare and pre-kindergarten immunization record assessments of select licensed childcare and Head Start facilities in Rockland County. The total labor cost incurred for these activities was $138,514 with a total of 2,555 h incurred. Often there are unique opportunities in the midst of an outbreak for public health to implement activities to proactively address low vaccination and strengthen vaccination coverage and possibly prevent future outbreaks. Understanding the cost of these activities might help inform future outbreak planning.