Cost-Effectiveness of One-Time Hepatitis C Screening Strategies Among Adolescents and Young Adults in Primary Care Settings.

Background: High hepatitis C virus (HCV) rates have been reported in young people who inject drugs (PWID). We evaluated the clinical benefit and cost-effectiveness of testing among youth seen in communities with a high overall number of reported HCV cases. Methods: We developed a decision analytic model to project quality-adjusted life years (QALYs), costs (2016 US$), and incremental cost-effectiveness ratios (ICERs) of 9 strategies for 1-time testing among 15- to 30-year-olds seen at urban community health centers. Strategies differed in 3 ways: targeted vs routine testing, rapid finger stick vs standard venipuncture, and ordered by physician vs by counselor/tester using standing orders. We performed deterministic and probabilistic sensitivity analyses (PSA) to evaluate uncertainty. Results: Compared to targeted risk-based testing (current standard of care), routine testing increased the lifetime medical cost by $80 and discounted QALYs by 0.0013 per person. Across all strategies, rapid testing provided higher QALYs at a lower cost per QALY gained and was always preferred. Counselor-initiated routine rapid testing was associated with an ICER of $71000/QALY gained. Results were sensitive to offer and result receipt rates. Counselor-initiated routine rapid testing was cost-effective (ICER <$100000/QALY) unless the prevalence of PWID was <0.59%, HCV prevalence among PWID was <16%, reinfection rate was >26 cases per 100 person-years, or reflex confirmatory testing followed all reactive venipuncture diagnostics. In PSA, routine rapid testing was the optimal strategy in 90% of simulations. Conclusions: Routine rapid HCV testing among 15- to 30-year-olds may be cost-effective when the prevalence of PWID is >0.59%.

Multistate US Outbreak of Rapidly Growing Mycobacterial Infections Associated with Medical Tourism to the Dominican Republic, 2013-2014(1).

During 2013, the Maryland Department of Health and Mental Hygiene in Baltimore, MD, USA, received report of 2 Maryland residents whose surgical sites were infected with rapidly growing mycobacteria after cosmetic procedures at a clinic (clinic A) in the Dominican Republic. A multistate investigation was initiated; a probable case was defined as a surgical site infection unresponsive to therapy in a patient who had undergone cosmetic surgery in the Dominican Republic. We identified 21 case-patients in 6 states who had surgery in 1 of 5 Dominican Republic clinics; 13 (62%) had surgery at clinic A. Isolates from 12 (92%) of those patients were culture-positive for Mycobacterium abscessus complex. Of 9 clinic A case-patients with available data, all required therapeutic surgical intervention, 8 (92%) were hospitalized, and 7 (78%) required ≥3 months of antibacterial drug therapy. Healthcare providers should consider infection with rapidly growing mycobacteria in patients who have surgical site infections unresponsive to standard treatment.

Laboratory-acquired vaccinia virus infection in a recently immunized person--Massachusetts, 2013.

On November 26, 2013, the CDC poxvirus laboratory was notified by the Boston Public Health Commission (BPHC) of an inadvertent inoculation of a recently vaccinated (ACAM2000 smallpox vaccine) laboratory worker with wild type vaccinia virus (VACV) Western Reserve. A joint investigation by CDC and BPHC confirmed orthopoxvirus infection in the worker, who had reported a needle stick in his thumb while inoculating a mouse with VACV. He experienced a non-tender, red rash on his arm, diagnosed at a local emergency department as cellulitis. He subsequently developed a necrotic lesion on his thumb, diagnosed as VACV infection. Three weeks after the injury, the thumb lesion was surgically debrided and at 2 months post-injury, the skin lesion had resolved. The investigation confirmed that the infection was the first reported VACV infection in the United States in a laboratory worker vaccinated according to the Advisory Committee on Immunization Practices (ACIP) recommendations. The incident prompted the academic institution to outline biosafety measures for working with biologic agents, such as biosafety training of laboratory personnel, vaccination (if appropriate), and steps in incident reporting. Though vaccination has been shown to be an effective measure in protecting personnel in the laboratory setting, this case report underscores the importance of proper safety measures and incident reporting.

A 29-year-old woman with flu-like symptoms: review of influenza diagnosis and treatment.

Peaks of seasonal influenza activity occur annually in many countries, resulting in significant morbidity and mortality. Using the case of Ms R, a 29-year-old woman who presented with acute onset of respiratory symptoms and was evaluated for influenza, considerations regarding symptoms and signs, evaluation, treatment, and prevention of influenza are discussed. Symptoms of influenza can be similar to those of other respiratory viruses, making diagnosis challenging. Laboratory testing should be reserved for patients who are seriously ill or for whom test results may affect management or have public health implications. For most cases of influenza, treatment is supportive and specific antiviral medication is not needed. Annual vaccination is the most effective way to prevent infection. Educating patients on practical steps to reduce the spread of influenza in the community is critical.

Risk of progression to active tuberculosis among foreign-born persons with latent tuberculosis.

BACKGROUND: Increased risk for tuberculosis (TB) disease has been identified in foreign-born persons in the United States, particularly during the first 5 years after their arrival in the United States. This could be explained by undetected TB disease at entry, increased prevalence of latent TB infection (LTBI), increased progression from LTBI to TB, or a combination of these factors. METHODS: We performed a cluster analysis of TB cases in Boston and a case-control study of risk factors for TB with an unclustered isolate among Boston residents with LTBI to determine whether such persons have an increased risk for reactivation of disease. RESULTS: Of 321 case patients with TB seen between 1996 and 2000, 133 isolates were clustered and 188 were not. In multivariate analysis, foreign birth was associated with an unclustered isolate (odds ratio [OR], 2.2; 95% confidence interval [CI], 1.2 to 3.8; p < 0.01), while being a close contact of a TB case was negatively associated (OR, 0.22; 95% CI, 0.07 to 0.73; p = 0.02). When 188 TB patients with unclustered isolates were compared to 188 age-matched control subjects with LTBI, there was no association between the occurrence of TB and foreign birth (OR, 0.71; 95% CI, 0.42 to 1.3); among foreign-born persons, there was no association between the occurrence of TB and being in the United States

Diagnosing smallpox: would you know it if you saw it?

The intentional release of anthrax in the United States in 2001 and other recent acts of terrorism have highlighted the possibility of intentional release of smallpox by terrorists. Little is known about physicians' ability to diagnose smallpox, especially in the critical first days, when the potential for rapid control of transmission is greatest. During December 2002 and January 2003, primary care and emergency physicians at a large urban academic medical center were surveyed regarding the diagnosis and management of patients who present with vesicular rash illness. In addition to demographic and training-related questions, the questionnaire included items about perceived comfort in diagnosing and evaluating rashes, knowledge of the key differential diagnostic characteristics of chickenpox and smallpox, and the diagnostic interpretation of color photographs of patients with smallpox or chickenpox. Responses were summarized as a perceived comfort score, a differential diagnosis score, and a picture score. Of 266 eligible physicians, 178 (67%) responded. Of these, 95% thought clinicians need more education about bioterrorism; only 17% reported comfort in diagnosing smallpox. Although most physicians recognized pictures of smallpox and chickenpox, only 36% correctly answered 3 of 4 questions regarding differential diagnosis, an important aspect of identifying cases early. Those who were comfortable diagnosing rash illnesses had higher differential diagnosis scores. Strategies for bioterrorism-related training could take advantage of physicians' awareness of their own knowledge deficits.

Immunization registries: costs and savings.

OBJECTIVES: The objectives of this study were to quantify the actual costs of developing, maintaining, and operating the Boston Immunization Information System (BIIS), an electronic registry and tracking system, and to compare the registry's costs with those of performing the same functions manually. METHODS: Cost data were obtained from 23 BIIS health care sites, the city health department, and 13 control sites. Actual costs of developing and operating BIIS in 1998 and projected 1999 costs for a hypothetical expanded registry were measured. Total costs of registry-supported immunization activities were compared with the costs of similar types and volumes of manual activities. RESULTS: The total annual cost of developing, maintaining, and operating BIIS in 1998 was $345,556. Annual total cost per record was $5.45 for all children aged <23 years and $10 when costs were distributed only among active users (children <8 years old). Operating BIIS saved $26,768 in 1998, compared with manual performance. The hypothetical projected total cost of an expanded BIIS in 1999 would have been $577,919, with a projected savings of $689,403 compared with manual costs. CONCLUSIONS: Electronic immunization registries potentially offer an efficient tool for the delivery of immunization services. Registries can save substantial funds if their data are kept up-to-date, and if caregivers are willing and able to use the registries routinely.

Pre-travel health advice-seeking behavior among US international travelers departing from Boston Logan International Airport.

BACKGROUND: Globally mobile populations are at higher risk of acquiring geographically restricted infections and may play a role in the international spread of infectious diseases. Despite this, data about sources of health information used by international travelers are limited. METHODS: We surveyed 1,254 travelers embarking from Boston Logan International Airport regarding sources of health information. We focused our analysis on travelers to low or low-middle income (LLMI) countries, as defined by the World Bank 2009 World Development Report. RESULTS: A total of 476 survey respondents were traveling to LLMI countries. Compared with travelers to upper-middle or high income (UMHI) countries, travelers to LLMI countries were younger, more likely to be foreign-born, and more frequently reported visiting family as the purpose of their trip. Prior to their trips, 46% of these travelers did not pursue health information of any type. In a multivariate analysis, being foreign-born, traveling alone, traveling for less than 14 days, and traveling for vacation each predicted a higher odds of not pursuing health information among travelers to LLMI countries. The most commonly cited reason for not pursuing health information was a lack of concern about health problems related to the trip. Among travelers to LLMI countries who did pursue health information, the internet was the most common source, followed by primary care practitioners. Less than a third of travelers to LLMI countries who sought health information visited a travel medicine specialist. CONCLUSIONS: In our study, 46% of travelers to LLMI countries did not seek health advice prior to their trip, largely due to a lack of concern about health issues related to travel. Among travelers who sought medical advice, the internet and primary care providers were the most common sources of information. These results suggest the need for health outreach and education programs targeted at travelers and primary care practitioners.

Direct cost associated with the development and implementation of a local syndromic surveillance system.

OBJECTIVE: Enhancing public health surveillance to include electronic syndromic surveillance systems has received increased attention in recent years. Although cost continually serves as a critical factor in public health decision making, few studies have evaluated direct costs associated with syndromic surveillance systems. In this study, we calculated the direct costs associated with developing and implementing a syndromic surveillance system in Boston, Massachusetts, from the perspective of local, state, and federal governments. METHODS: Between December 2003 and July 2005, the Boston Public Health Commission (BPHC), in collaboration with the Centers for Disease Control and Prevention (CDC), and the Massachusetts Department of Public Health developed a syndromic surveillance system in which limited demographic and chief complaint data are collected from all Boston acute care emergency departments every 24 hours. Costs were divided into three categories: development, operation, and upgrade. Within these categories, all fixed and variable costs incurred by both BPHC and CDC were assessed, including those associated with development of syndromic surveillance-related city regulations and system enhancements. RESULTS: The total estimated direct cost of system development and implementation during the study period was $422,899 ($396,716 invested by BPHC and $26,183 invested by CDC). Syndromic system enhancements to improve situational awareness accounted for $74,389. CONCLUSION: Development, implementation, and operation of a syndromic surveillance system accounted for a relatively small proportion of surveillance costs in a large urban health department. Funding made available for a future cost-benefit analysis, and an assessment of local epidemiologic capacity will help to guide decisions for local health departments. Although not a replacement for traditional surveillance, syndromic surveillance in Boston is an important and relatively inexpensive component of a comprehensive local public health surveillance system.

Predictors of failure to complete treatment for latent tuberculosis infection.

OBJECTIVE: Low rates of completion of treatment for latent tuberculosis infection (LTBI) limit its usefulness as a strategy for elimination of tuberculosis (TB) in the United States. This retrospective cohort study assessed predictors of completion of LTBI treatment among patients seen at an urban United States TB clinic in 1998. METHODS: A retrospective cohort study of acceptance and completion of LTBI treatment among patients first seen in a TB clinic in 1998 was performed. RESULTS: Of 2621 persons with a positive tuberculosis skin test (TST), 1723 were offered treatment and 1572 (91.2%) accepted. Of the 1572 who accepted, treatment was completed by 607 (38.6%). Of those persons who failed to complete treatment, 517/965 (54%) dropped out before the end of the first month of the course. Among 1375 persons under 35 years of age who initiated LTBI treatment, failure to complete was associated with birth in Haiti (OR=2.17, CI(95%) 1.49-3.17) or the Dominican Republic (OR=1.93, CI(95%) 1.08-3.43). CONCLUSION: These results suggest that country-specific cultural and behavioral factors may contribute to failure to complete LTBI treatment, and that interventions to increase completion should focus on the first month after initiation.

Local collaborations: development and implementation of Boston's bioterrorism surveillance system.

The Boston Public Health Commission developed and implemented an active surveillance system for bioterrorism and other infectious disease emergencies. A bioterrorism Surveillance Task Force was formed with representatives from local emergency medicine, infection control, infectious diseases, public health, and emergency medical services. These local agencies worked together to develop a reliable, easy to use electronic surveillance system. Collaboration at the local level and building on existing relationships is a key component of this system. Effective follow-up systems and technology back-up plans are essential. Improved communication networks and increased bioterrorism education for clinicians and the general public have also been achieved.