Characteristics and Outcomes of Contacts of COVID-19 Patients Monitored Using an Automated Symptom Monitoring Tool - Maine, May-June 2020.

SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19), is spread from person to person (1-3). Quarantine of exposed persons (contacts) for 14 days following their exposure reduces transmission (4-7). Contact tracing provides an opportunity to identify contacts, inform them of quarantine recommendations, and monitor their symptoms to promptly identify secondary COVID-19 cases (7,8). On March 12, 2020, Maine Center for Disease Control and Prevention (Maine CDC) identified the first case of COVID-19 in the state. Because of resource constraints, including staffing, Maine CDC could not consistently monitor contacts, and automated technological solutions for monitoring contacts were explored. On May 14, 2020, Maine CDC began enrolling contacts of patients with reported COVID-19 into Sara Alert (MITRE Corporation, 2020),* an automated, web-based, symptom monitoring tool. After initial communication with Maine CDC staff members, enrolled contacts automatically received daily symptom questionnaires via their choice of e-mailed weblink, text message, texted weblink, or telephone call until completion of their quarantine. Epidemiologic investigations were conducted for enrollees who reported symptoms or received a positive SARS-CoV-2 test result. During May 14-June 26, Maine CDC enrolled 1,622 contacts of 614 COVID-19 patients; 190 (11.7%) eventually developed COVID-19, highlighting the importance of identifying, quarantining, and monitoring contacts of COVID-19 patients to limit spread. In Maine, symptom monitoring was not feasible without the use of an automated symptom monitoring tool. Using a tool that permitted enrollees to specify a method of symptom monitoring was well received, because the majority of persons monitored (96.4%) agreed to report using this system.

Heat-related morbidity and mortality in New England: Evidence for local policy.

BACKGROUND: Heat-related morbidity and mortality is a recognized public health concern. However, public health officials need to base policy decisions on local evidence, which is often lacking for smaller communities. OBJECTIVES: To evaluate the association between maximum daily heat index (HI) and morbidity and mortality in 15 New England communities (combined population: 2.7 million) in order to provide actionable evidence for local officials. METHODS: We applied overdispersed Poisson nonlinear distributed lag models to evaluate the association between HI and daily (May-September) emergency department (ED) admissions and deaths in each of 15 study sites in New Hampshire, Maine, and Rhode Island, controlling for time trends, day of week, and federal holidays. Site-specific estimates were meta-analyzed to provide regional estimates. RESULTS: Associations (sometimes non-linear) were observed between HI and each health outcome. For example, a day with a HI of 95°F vs. 75°F was associated with a cumulative 7.5% (95% confidence interval [CI]: 6.5%, 8.5%) and 5.1% (95% CI: 0.2%, 10.3%) higher rate of all-cause ED visits and deaths, respectively, with some evidence of regional heterogeneity. We estimate that in the study area, days with a HI≥95°F were associated with an annual average of 784 (95% CI: 658, 908) excess ED visits and 22 (95% CI: 3, 39) excess deaths. CONCLUSIONS: Our results suggest the presence of adverse health impacts associated with HI below the current local guideline criteria of HI≥100°F used to issue heat advisories. We hypothesize that lowering this threshold may lead to substantially reduced heat-related morbidity and mortality in the study area.

A Mixed Methods Approach to Understanding the Public Health Impact of a School-Based Citizen Science Program to Reduce Arsenic in Private Well Water.

BACKGROUND: Exposure to arsenic (As) in well water is a well-documented public health issue for Maine and New Hampshire, as well as for other states in the United States and abroad. Arsenic contamination of well water in these locations is primarily attributed to metasedimentary bedrock that leaches As into groundwater. However, As can also enter groundwater reserves from soils contaminated by the historical use of arsenical pesticides. Approximately half of the households in Maine and New Hampshire rely on private wells, many of which have elevated As. Arsenic exposure has been associated with an increased risk of cancer, cardiovascular disease, reduced infection resistance, and lower intelligence quotient in children. Despite these known health impacts, well water testing and treatment are not universal. OBJECTIVES: We have approached the problem of low well water testing rates in Maine and New Hampshire communities by developing the All About Arsenic (AAA) project, which engages secondary school teachers and students as citizen scientists in collecting well water samples for analysis of As and other toxic metals and supports their outreach efforts to their communities. METHODS: We assessed this project's public health impact by analyzing student data relative to existing well water quality datasets in both states. In addition, we surveyed private well owners who contributed well water samples to the project to determine the actions taken to mitigate As in well water. RESULTS: Students collected 3,070 drinking water samples for metals testing, and 752 exceeded New Hampshire's As standard of 5 ppb. The AAA data has more than doubled the amount of information available to public health agencies about well water quality in multiple municipalities across both states. Students also collected information about well types and treatment systems. Their data reveal that some homeowners did not know what type of wells they had or whether they had filtration systems. Those with filtration systems were often unaware of the type of system, what the system was filtering for, or whether the system was designed to remove As. Through interviews with pilot survey participants, we learned that some had begun mitigating their exposure to As and other toxic metals in response to test results from the AAA project. DISCUSSION: A school-based approach to collecting and analyzing private well water samples can successfully reach communities with low testing rates for toxic elements, such as As and other metals. Importantly, information generated through the program can impact household decision-making, and students can influence local and state policymaking by sharing information in their communities. https://doi.org/10.1289/EHP13421.

Assessing arsenic exposure in households using bottled water or point-of-use treatment systems to mitigate well water contamination.

There is little published literature on the efficacy of strategies to reduce exposure to residential well water arsenic. The objectives of our study were to: 1) determine if water arsenic remained a significant exposure source in households using bottled water or point-of-use treatment systems; and 2) evaluate the major sources and routes of any remaining arsenic exposure. We conducted a cross-sectional study of 167 households in Maine using one of these two strategies to prevent exposure to arsenic. Most households included one adult and at least one child. Untreated well water arsenic concentrations ranged from <10 µg/L to 640 µg/L. Urine samples, water samples, daily diet and bathing diaries, and household dietary and water use habit surveys were collected. Generalized estimating equations were used to model the relationship between urinary arsenic and untreated well water arsenic concentration, while accounting for documented consumption of untreated water and dietary sources. If mitigation strategies were fully effective, there should be no relationship between urinary arsenic and well water arsenic. To the contrary, we found that untreated arsenic water concentration remained a significant (p ≤ 0.001) predictor of urinary arsenic levels. When untreated water arsenic concentrations were <40 µg/L, untreated water arsenic was no longer a significant predictor of urinary arsenic. Time spent bathing (alone or in combination with water arsenic concentration) was not associated with urinary arsenic. A predictive analysis of the average study participant suggested that when untreated water arsenic ranged from 100 to 500 µg/L, elimination of any untreated water use would result in an 8%-32% reduction in urinary arsenic for young children, and a 14%-59% reduction for adults. These results demonstrate the importance of complying with a point-of-use or bottled water exposure reduction strategy. However, there remained unexplained, water-related routes of exposure.

Evaluation of a heat vulnerability index on abnormally hot days: an environmental public health tracking study.

BACKGROUND: Extreme hot weather conditions have been associated with increased morbidity and mortality, but risks are not evenly distributed throughout the population. Previously, a heat vulnerability index (HVI) was created to geographically locate populations with increased vulnerability to heat in metropolitan areas throughout the United States. OBJECTIVES: We sought to determine whether areas with higher heat vulnerability, as characterized by the HVI, experienced higher rates of morbidity and mortality on abnormally hot days. METHODS: We used Poisson regression to model the interaction of HVI and deviant days (days whose deviation of maximum temperature from the 30-year normal maximum temperature is at or above the 95th percentile) on hospitalization and mortality counts in five states participating in the Environmental Public Health Tracking Network for the years 2000 through 2007. RESULTS: The HVI was associated with higher hospitalization and mortality rates in all states on both normal days and deviant days. However, associations were significantly stronger (interaction p-value < 0.05) on deviant days for heat-related illness, acute renal failure, electrolyte imbalance, and nephritis in California, heat-related illness in Washington, all-cause mortality in New Mexico, and respiratory hospitalizations in Massachusetts. CONCLUSION: Our results suggest that the HVI may be a marker of health vulnerability in general, although it may indicate greater vulnerability to heat in some cases.

Fish consumption and mercury exposure among Louisiana recreational anglers.

BACKGROUND: Methylmercury (MeHg) exposure assessments among average fish consumers in the United States may underestimate exposures among U.S. subpopulations with high intakes of regionally specific fish. OBJECTIVES: We examined relationships among fish consumption, estimated mercury (Hg) intake, and measured Hg exposure within one such potentially highly exposed group, recreational anglers in the state of Louisiana, USA. METHODS: We surveyed 534 anglers in 2006 using interviews at boat launches and fishing tournaments combined with an Internet-based survey method. Hair samples from 402 of these anglers were collected and analyzed for total Hg. Questionnaires provided information on species-specific fish consumption during the 3 months before the survey. RESULTS: Anglers' median hair Hg concentration was 0.81 µg/g (n = 398; range, 0.02-10.7 µg/g); 40% of participants had levels >1 µg/g, which approximately corresponds to the U.S. Environmental Protection Agency's reference dose. Fish consumption and Hg intake were significantly positively associated with hair Hg. Participants reported consuming nearly 80 different fish types, many of which are specific to the region. Unlike the general U.S. population, which acquires most of its Hg from commercial seafood sources, approximately 64% of participants' fish meals and 74% of their estimated Hg intake came from recreationally caught seafood. CONCLUSIONS: Study participants had relatively elevated hair Hg concentrations and reported consumption of a wide variety of fish, particularly locally caught fish. This group represents a highly exposed subpopulation with an exposure profile that differs from fish consumers in other regions of the United States, suggesting a need for more regionally specific exposure estimates and public health advisories.

Concentration of metals in blood of Maine children 1-6 years old.

Blood lead concentrations are higher in young children than in other age groups, whereas little is known regarding concentrations of other metals in young children. We measured the concentrations of a suite of metals in the blood of children 1-6 years of age, and assessed potential differences by age, season, or region of Maine. We used blood submitted to the Maine State Health and Environmental Testing Laboratory for blood lead analysis to determine the concentrations of arsenic (As), antimony (Sb), cadmium (Cd), manganese (Mn), mercury (Hg), selenium (Se), tin (Sn), and uranium (U) in 1350 children 1-6 years of age. The essential metals Mn and Se were detected in all samples, and As and Sb were detected in >90% of samples. Hg was detected in approximately 60% of samples. U and Cd were less often detected in blood samples, at approximately 30% and 10% of samples, respectively. Sn was not detected in any sample. Concentrations of As, Hg, and Se increased with age, whereas Sb decreased with age. Concentrations also varied by season and region for some though not all metals. Significant pairwise correlations were observed for a number of metals. Blood is a reasonable compartment for measurement of most of these metals in young children. The use of convenience samples provided a cost-effective mechanism for assessing exposure of young children in Maine.