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Infectious disease surveillance frequently lacks complete information on race and ethnicity, making it difficult to identify health inequities. Greater awareness of this issue has occurred due to the COVID-19 pandemic, during which inequities in cases, hospitalizations, and deaths were reported but with evidence of substantial missing demographic details. Although the problem of missing race and ethnicity data in COVID-19 cases has been well documented, neither its spatiotemporal variation nor its particular drivers have been characterized. Using individual-level data on confirmed COVID-19 cases in Massachusetts from March 2020 to February 2021, we show how missing race and ethnicity data: (1) varied over time, appearing to increase sharply during two different periods of rapid case growth; (2) differed substantially between towns, indicating a nonrandom distribution; and (3) was associated significantly with several individual- and town-level characteristics in a mixed-effects regression model, suggesting a combination of personal and infrastructural drivers of missing data that persisted despite state and federal data-collection mandates. We discuss how a variety of factors may contribute to persistent missing data but could potentially be mitigated in future contexts.

States that report CD4+ T cell counts appear to report AIDS cases at an earlier stage of infection. The case definition of AIDS was changed in 1993 to include CD4+ T cell counts less than 200. Many states began reporting CD4+ counts in preparation for the changed definition. A survey of states found that states that reported CD4+ counts also reported more AIDS cases compared to states that did not report CD4+ counts. States with CD4+ reporting also reported AIDS cases at an earlier stage when the disease is amenable to treatment.

AbstractBackground:Antimicrobial resistance is an urgent public health threat. Identifying trends in antimicrobial susceptibility can inform public health policy at the state and local levels.Objective:To determine the ability of statewide antibiogram aggregation for public health surveillance to identify changes in antimicrobial resistance trends.Design:Facility-level trend analysis.Methods:Crude and adjusted trend analyses of the susceptibility of Escherichia coliand Klebsiella pneumoniaeto particular antibiotics, as reported by aggregated antibiograms, were examined from 2008 through 2018. Multivariable regression analyses via generalized linear mixed models were used to examine associations between hospital characteristics and trends of E. coliand K. pneumoniaesusceptibility to ciprofloxacin and ceftriaxone.Results:E. coliand K. pneumoniaeshowed inverse trends in drug susceptibility over time. K. pneumoniaesusceptibility to fluoroquinolones increased by 5% between 2008 and 2018 (P< .05). In contrast, E. colisusceptibility declined during the same period to ceftriaxone (6%), gentamicin (4%), and fluoroquinolones (4%) (P< .05). When compared to Boston hospitals, E. coliisolates from hospitals in other regions had a >4% higher proportion of susceptibility to ciprofloxacin and a >3% higher proportion of susceptibility to ceftriaxone (P< .05). Isolates of K. pneumoniaehad higher susceptibility to ciprofloxacin (>3%) and ceftriaxone (>1.5%) in all regions when compared to Boston hospitals (P< .05).Conclusions:Cumulative antibiograms can be used to monitor antimicrobial resistance, to discern regional and facility differences, and to detect changes in trends. Furthermore, because the number of years that hospitals contributed reports to the state-level aggregate had no significant influence on susceptibility trends, other states should not be discouraged by incomplete hospital compliance.

Changes in the science of hepatitis C virus (HCV) infection and transmission in a private dental practice provide an opportunity to update dental health care providers about this pathogen. The authors' aims in this review were to create awareness of health care– associated transmission of hepatitis C and provide an update on the changes in testing and treatment. The authors include data from population-based epidemiologic surveys, clinical practice guidelines, surveillance reports and practice protocols.

Objective. We compared the quality of data reported to the Centers for Disease Control and Prevention (CDC) from sites that received funding for acute viral hepatitis surveillance through CDC's Emerging Infections Program (EIP) with sites that have electronic infrastructure to collect data but do not receive funding from CDC to support viral hepatitis surveillance.Methods. Descriptive analysis was conducted on acute hepatitis A, B, and C cases reported from EIP sites and National Electronic Disease Surveillance System (NEDSS)-based states (NBS) sites from 2005 to 2007. Data were compared for (1) completeness of demographic and risk behavior/exposure information; (2) adherence to CDC/Council of State and Territorial Epidemiologists (CSTE) case definition for confirmed cases of acute hepatitis A, B, and C; and (3) timeliness of reporting to the health department.Results. Data reported for sex and age were at least 98% complete for both EIP and NBS sites and race/ethnicity was more complete for EIP sites. For acute hepatitis A, B, and C, case reports from EIP sites were more likely than those from NBS sites to include a “yes” response to at least one risk behavior/exposure variable and were more likely to meet the CDC/CSTE case definition. EIP sites received case reports in a more timely fashion than did NBS sites. The case definition for acute hepatitis C proved problematic for both EIP and NBS sites.Conclusions. Data from the EIP sites were more complete and reported in a more timely way to health departments than data from the NBS sites. Funding for follow-up activities is essential to providing surveillance data of higher quality for decision-making and public health response.

Objectives. We described seroprevalence of antibody to hepatitis A virus (anti-HAV) in the United States during 1999–2006 and compared it with seroprevalence before the availability of vaccine.Methods. We analyzed data from the 1988–1994 and 1999–2006 National Health and Nutrition Examination Survey (NHANES) to obtain estimates of anti-HAV seroprevalence for the U.S. household population. We grouped region of residence based on the 1999 Advisory Committee on Immunization Practices recommendations into 17 states with any recommendation (vaccinating) and 33 states without any recommendation (non-vaccinating).Results. During 1999–2006, the overall seroprevalence of anti-HAV was 34.9% (95% confidence interval [CI] 33.1, 36.7). During 1999–2006, U.S.-born children living in vaccinating states (33.8%, 95% CI 26.2, 42.2) had a higher seroprevalence than children in non-vaccinating states (11.0%, 95% CI 9.4, 12.8; p<0.001). Seroprevalence among children increased from 8.0% (95% CI 6.3, 10.1) during 1988–1994 to 20.2% (95% CI 16.0, 24.8) during 1999–2006 (p<0.001). For U.S.-born children aged 6–19 years, the strongest factor associated with seroprevalence was residence in vaccinating states. Among U.S.-born adults aged >19 years, the overall age-adjusted seroprevalence of anti-HAV was 29.9% (95% CI 28.3, 31.5) during 1999–2006, which was not significantly different from the seroprevalence during 1988–1994 (32.2%, 95% CI 30.1, 34.4).Conclusions. Increases in seroprevalence among children in vaccinating states suggest a positive effect of the 1999 vaccination recommendations.

Objectives. Both HIV and hepatitis C virus (HCV) can be transmitted through percutaneous exposure to blood in similar high-risk populations. HCV and HIV/AIDS surveillance databases were matched in Colorado, Connecticut, and Oregon to measure the frequency of co-infection and to characterize co-infected people.Methods. We defined a case of HCV infection as a person with a reactive antibody for hepatitis C, medical diagnosis, positive viral-load test result, or positive genotype reported to any of three state health departments from the start of each state's hepatitis C registry through June 30, 2008. We defined a case of HIV/AIDS as a person diagnosed and living with HIV/AIDS at the start of each state's respective hepatitis C registry through June 30, 2008. HIV/AIDS and hepatitis C datasets were matched using Link King, public domain record linkage and consolidation software, and all potential matches were manually reviewed before acceptance as a match.Results. The proportion of reported hepatitis C cases co-infected with HIV/AIDS was 1.8% in Oregon, 1.9% in Colorado, and 4.9% in Connecticut. Conversely, the proportion of HIV/AIDS cases co-infected with hepatitis C was consistently higher in the three states: 4.4% in Oregon, 9.7% in Colorado, and 23.6% in Connecticut.Conclusions. Electronic matching of registries is a potentially useful and efficient way to transfer information from one registry to another. In addition, it can provide a measure of the public health burden of HIV/AIDS and hepatitis C co-infection and provide insight into prevention and medical care needs for respective states.

In 2005 in the United States, an estimated 94,370 new, invasive infections and 18,650 deaths were associated with methicillin-resistant Staphylococcus aureus(MRSA); most of these infections were in people with exposures in health care settings. MRSA also has emerged as a community-based pathogen, causing primarily skin infections that are not life-threatening, but occasionally causing more severe and invasive infections. The authors describe the history of MRSA; identify populations at greatest risk of experiencing MRSA colonization and infection; compare characteristics of MRSA infections occurring in health care and community settings; and summarize strategies, based on U.S. Centers for Disease Control and Prevention recommendations and the literature, to prevent transmission of MRSA in dental offices.

Objective.To describe methods to assess the practical impact of risk adjustment for central line-days on the interpretation of central line–associated bloodstream infection (BSI) rates, because collecting these data is often burdensome.Methods.We analyzed data from 247 hospitals that reported to the adult and pediatric intensive care unit component of the National Nosocomial Infections Surveillance System from 1995 through 2003. For each unit each year, we calculated the percentile error as the absolute value of the difference between the percentile based on a risk-adjusted or more-sophisticated measure (eg, the central line–day rate) and the percentile based on a crude or less-sophisticated measure (eg, the patient-day rate). Using rate per central line–day as the “gold standard,” we calculated performance characteristics (eg, sensitivity and predictive values) of rate per patient-day for finding central line–associated BSI rates higher or lower than the mean. Greater impact of risk adjustment is indicated by higher values for percentile error and lower values for performance characteristics.Results.The median percentile error was ± 7 (ie, the percentile based on central line-days could be 7% higher or lower than the percentile based on patient-days). This error was less than 10 percentile points for 62% of the unit-years, was between 10 and 19 percentile points for 22% of the unit-years, and was 20 percentile points or more for 15% of the unit-years. Use of the rate based on patient-days had a sensitivity of 76% and a positive predictive value of 61% for detecting a significantly high or low central line–associated BSI rate.Conclusions.We found that risk adjustment for central line–days has an important impact on the calculated central line–associated BSI percentile for some units. Similar methods can be used to evaluate the impact of other risk adjustment methods. Our results support current recommendations to use central line–days for surveillance of central line–associated BSI when comparisons are made among facilities.

Objective. The purpose of this study was to provide a national estimate of the number of healthcare-associated infections (HAI) and deaths in United States hospitals.Methods. No single source of nationally representative data on HAIs is currently available. The authors used a multi-step approach and three data sources. The main source of data was the National Nosocomial Infections Surveillance (NNIS) system, data from 1990–2002, conducted by the Centers for Disease Control and Prevention. Data from the National Hospital Discharge Survey (for 2002) and the American Hospital Association Survey (for 2000) were used to supplement NNIS data. The percentage of patients with an HAI whose death was determined to be caused or associated with the HAI from NNIS data was used to estimate the number of deaths.Results. In 2002, the estimated number of HAIs in U.S. hospitals, adjusted to include federal facilities, was approximately 1.7 million: 33,269 HAIs among newborns in high-risk nurseries, 19,059 among newborns in well-baby nurseries, 417,946 among adults and children in ICUs, and 1,266,851 among adults and children outside of ICUs. The estimated deaths associated with HAIs in U.S. hospitals were 98,987: of these, 35,967 were for pneumonia, 30,665 for bloodstream infections, 13,088 for urinary tract infections, 8,205 for surgical site infections, and 11,062 for infections of other sites.Conclusion. HAIs in hospitals are a significant cause of morbidity and mortality in the United States. The method described for estimating the number of HAIs makes the best use of existing data at the national level.

To characterize women reported with AIDS and invasive cervical cancer in the first year of the expanded AIDS surveillance case definition.

We describe a community-oriented primary care (COPC) preventive medicine residency. Through the residency, medical, nursing, dental, and other health professionals work as fellows to combine clinical and public health skills in primary care practices. We describe the steps that fellows used to begin transforming one community health center into a COPC practice, and we highlight the activities of one specific environmental cleanliness project as an example. COPC activities have laid the foundation for further advances in developing a professional partnership between the center and the community it serves.

Although the prevalence of smoking has decreased since 1980 among active duty military personnel, it remains higher than among the adult civilian population; among military veterans, the prevalence of smoking has not been well described. The objectives of this study were to describe patterns of cigarette smoking behaviors among United States veterans and nonveterans and to examine the association between military veteran status and cigarette smoking. We analyzed data from a cross-sectional survey from a national probability sample of the civilian, noninstitutionalized adult population (National Health Interview Survey supplements). We estimated the prevalence of ever, current, and former smoking, as well as crude and adjusted odds ratios (AORs) of each outcome measure among veterans and nonveterans, by gender. The prevalence of ever smoking was 74.2% (±0.7%) among veterans and 48.4% (±0.5%) among nonveterans; current smoking prevalence was 33.9% (±1.0%) among veterans and 27.7% (±0.5%) among nonveterans. Among those who had not initiated smoking before the age of 18 years, veterans were more likely than nonveterans to report ever smoking (AOR = 1.8 for men and 1.9 for women) and current smoking (AOR = 1.9 for both men and women). After statistical adjustment, no difference was seen in cessation behavior. We concluded that the prevalence of ever and current smoking was higher among U.S. military veterans. The association was the strongest among veterans who had not initiated smoking before the age of 18 years. These findings are consistent with the hypothesis that military service is a risk factor for cigarette smoking, and they support the military’s current prevention and cessation efforts.

Objectives Widespread SARS-CoV-2 testing is critical to identify infected people and implement public health action to interrupt transmission. With SARS-CoV-2 testing supplies and laboratory capacity now widely available in the United States, understanding the spatial heterogeneity of associations between social determinants and the use of SARS-CoV-2 testing is essential to improve testing availability in populations disproportionately affected by SARS-CoV-2.Methods We assessed positive and negative results of SARS-CoV-2 molecular tests conducted from February 1 through June 17, 2020, from the Massachusetts Virtual Epidemiologic Network, an integrated web-based surveillance and case management system in Massachusetts. Using geographically weighted regression and Moran’s Ispatial autocorrelation tests, we quantified the associations between SARS-CoV-2 testing rates and 11 metrics of the Social Vulnerability Index in all 351 towns in Massachusetts.Results Median SARS-CoV-2 testing rates decreased with increasing percentages of residents with limited English proficiency (median relative risk [interquartile range] = 0.96 [0.95-0.99]), residents aged ≥65 (0.97 [0.87-0.98]), residents without health insurance (0.96 [0.95-1.04], and people residing in crowded housing conditions (0.89 [0.80-0.94]). These associations differed spatially across Massachusetts, and localized models improved the explainable variation in SARS-CoV-2 testing rates by 8% to 12%.Conclusion Indicators of social vulnerability are associated with variations in SARS-CoV-2 testing rates. Accounting for the spatial heterogeneity in these associations may improve the ability to explain and address the SARS-CoV-2 pandemic at substate levels.

The authors aimed to measure population-based preventable emergency department (ED) visits related to infectious oral conditions (IOCs) in Massachusetts and to examine the associated sociodemographic factors to support prevention efforts.