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Abstract Background Track PCC includes five geographic surveillance sites to conduct standardized population-based surveillance to estimate and track Post-COVID Conditions (PCC) by age, sex, race/ethnicity, geographic area, severity of initial infection, and risk factors among persons with evidence of SARS-CoV-2 infection (based on the Council of State and Territorial Epidemiologist [CSTE] case definitions for confirmed cases or laboratory-confirmed evidence of infection). Methods The study will estimate the incidence, prevalence, including temporal trends, and duration and severity of PCC symptoms, among children, adolescents, and adults. PCCs include a broad range of symptoms and conditions that continue or develop after acute SARS-CoV-2 infection or COVID-19 illness. Surveillance includes both passive and active components for diverse populations in Arizona, Indiana, and Utah as well as the Bronx Borough, NY, and part of Philadelphia County, PA. Passive surveillance will utilize electronic health records and health information exchanges within each site catchment area to longitudinally follow persons with COVID-19 to estimate PCC occurring at least 30 days after acute COVID-19 illness. Active surveillance will utilize self-report of PCCs from detailed surveys of persons ages 7 years and older with evidence of SARS-CoV-2 infection in the past 3 months. Respondents will complete follow-up surveys at 6-, 12- and 18-months post-infection. Discussion These data can help identify which groups are most affected by PCC, and what health differences among demographic groups exist, as well as indicate potential barriers to care. These additional levels of granularity can inform public health action and help direct needed clinical care for patients.

Indiana faces significant challenges in maternal and infant health, ranking 45th worst in infant mortality with a rate of 6.5 deaths per 1,000 live-births, and 21st in stillbirths. Indiana further has the 3rd highest rate of maternal mortality with 44 deaths per 100,000 live-births. Despite these alarming statistics, comprehensive surveillance of maternal and infant health is absent, and data often remains fragmented across disparate information systems. In response, the Indiana University Fairbanks School of Public Health and Regenstrief Institute secured a cooperative agreement through the CDC's Pregnant People-Infant Linked Longitudinal Surveillance (PILLARS) program, collaborating with the Indiana Health Information Exchange, Indiana Department of Health, and Marion County Public Health Department. The initiative aims to enhance Indiana's infrastructure for surveillance of maternal and child health (MCH) using electronic health records (EHRs), public health, and administrative data. Key efforts have included development, validation, and application of linkage algorithms across records for mothers and children; integration of case data across data sources; design of routine surveillance reports; and design of longitudinal studies to examine determinants and outcomes in MCH populations. Using deterministic linkage algorithms, we have created over 800,000 mother-infant dyads; this number will expand with the implementation of probabilistic approaches. We also have developed a computational phenotype for identifying cases of pregnancy in the EHR even when not explicitly flagged in the EHR. Future efforts will build on this infrastructure to draw from additional public health data sources and/or expand surveillance efforts to include prioritized MCH outcomes.

Abstract Background Data are lacking regarding the risk of viral SARS-CoV-2 transmission during a large indoor sporting event involving fans utilizing a controlled environment. We sought to describe case characteristics, mitigation protocols used, variants detected, and secondary infections detected during the 2021 National Collegiate Athletic Association (NCAA) Men’s Basketball Tournament involving collegiate athletes from across the U.S. Methods This retrospective cohort study used data collected from March 16 to April 3, 2021, as part of a closed environment which required daily reverse transcription-polymerase chain reaction (RT-PCR) testing, social distancing, universal masking, and limited contact between tiers of participants. Nearly 3000 players, staff, and vendors participated in indoor, unmasked activities that involved direct exposure between cases and noninfected individuals. The main outcome of interest was transmission of SARS-CoV-2 virus, as measured by the number of new infections and variant(s) detected among positive cases. Secondary infections were identified through contact tracing by public health officials. Results Out of 2660 participants, 15 individuals (0.56%) screened positive for SARS-CoV-2. Four cases involved players or officials, and all cases were detected before any individual played in or officiated a game. Secondary transmissions all occurred outside the controlled environment. Among those disqualified from the tournament (4 cases; 26.7%), all individuals tested positive for the Iota variant (B.1.526). All other cases involved the Alpha variant (B.1.1.7). Nearly all teams (N = 58; 85.3%) reported that some individuals had received at least one dose of a vaccine. Overall, 17.9% of participants either had at least one dose of the vaccine or possessed documented infection within 90 days of the tournament. Conclusion In this retrospective cohort study of the 2021 NCAA Men’s Basketball Tournament closed environment, only a few cases were detected, and they were discovered in advance of potential exposure. These findings support the U.S. Centers for Disease Control and Prevention (CDC) guidelines for large indoor sporting events during the COVID-19 pandemic.

Summary: Background: Understanding the usefulness of additional COVID-19 vaccine doses—particularly given varying disease incidence—is needed to support public health policy. We characterize the benefits of COVID-19 booster doses using number needed to vaccinate (NNV) to prevent one COVID-19-associated hospitalization or emergency department encounter. Methods: We conducted a retrospective cohort study of immunocompetent adults at five health systems in four U.S. states during SARS-CoV-2 Omicron BA.1 predominance (December 2021–February 2022). Included patients completed a primary mRNA COVID-19 vaccine series and were either eligible to or received a booster dose. NNV were estimated using hazard ratios for each outcome (hospitalization and emergency department encounters), with results stratified by three 25-day periods and site. Findings: 1,285,032 patients contributed 938 hospitalizations and 2076 emergency department encounters. 555,729 (43.2%) patients were aged 18–49 years, 363,299 (28.3%) 50–64 years, and 366,004 (28.5%) ≥65 years. Most patients were female (n = 765,728, 59.6%), White (n = 990,224, 77.1%), and non-Hispanic (n = 1,063,964, 82.8%). 37.2% of patients received a booster and 62.8% received only two doses. Median estimated NNV to prevent one hospitalization was 205 (range 44–615) and NNV was lower across study periods for adults aged ≥65 years (110, 46, and 88, respectively) and those with underlying medical conditions (163, 69, and 131, respectively). Median estimated NNV to prevent one emergency department encounter was 156 (range 75–592). Interpretation: The number of patients needed to receive a booster dose was highly dependent on local disease incidence, outcome severity, and patient risk factors for moderate-to-severe disease. Funding: Funding was provided by the Centers for Disease Control and Prevention though contract 75D30120C07986 to Westat, Inc. and contract 75D30120C07765 to Kaiser Foundation Hospitals.

Abstract To improve cancer care in Indiana, a telementoring program using the Extension for Community Healthcare Outcomes (ECHO) model was introduced in September 2019 to promote best-practice cancer prevention, screening, and survivorship care by primary care providers (PCPs). The aim of this study was to evaluate the program’s educational outcomes in its pilot year, using Moore’s Evaluation Framework for Continuing Medical Education and focusing on the program’s impact on participants’ knowledge, confidence, and professional practice. We collected data in 22 semi-structured interviews (13 PCPs and 9 non-PCPs) and 30 anonymous one-time surveys (14 PCPs and 16 non-PCPs) from the program participants (hub and spoke site members), as well as from members of the target audience who did not participate. In the first year, average attendance at each session was 2.5 PCPs and 12 non-PCP professionals. In spite of a relatively low PCP participation, the program received very positive satisfaction scores, and participants reported improvements in knowledge, confidence, and practice. Both program participants and target audience respondents particularly valued three features of the program: its conversational format, the real-life experiences gained, and the support received from a professional interdisciplinary community. PCPs reported preferring case discussions over didactics. Our results suggest that the Cancer ECHO program has benefits over other PCP-targetted cancer control interventions and could be an effective educational means of improving cancer control capacity among PCPs and others. Further study is warranted to explain the discrepancies among study participants’ perceptions of the program’s strengths and the relatively low PCP participation before undertaking a full-scale effectiveness study.

Abstract Background Much of what is known about COVID-19 risk factors comes from patients with serious symptoms who test positive. While risk factors for hospitalization or death include chronic conditions and smoking; less is known about how health status or nicotine consumption is associated with risk of SARS-CoV-2 infection among individuals who do not present clinically. Methods Two community-based population samples (including individuals randomly and nonrandomly selected for statewide testing, n = 8214) underwent SARS-CoV-2 testing in nonclinical settings. Each participant was tested for current (viral PCR) and past (antibody) infection in either April or June of 2020. Before testing, participants provided demographic information and self-reported health status and nicotine and tobacco behaviors (smoking, chewing, vaping/e-cigarettes). Using descriptive statistics and a bivariate logistic regression model, we examined the association between health status and use of tobacco or nicotine with SARS-CoV-2 positivity on either PCR or antibody tests. Results Compared to people with self-identified “excellent” or very good health status, those reporting “good” or “fair” health status had a higher risk of past or current infections. Positive smoking status was inversely associated with SARS-CoV-2 infection. Chewing tobacco was associated with infection and the use of vaping/e-cigarettes was not associated with infection. Conclusions In a statewide, community-based population drawn for SARS-CoV-2 testing, we find that overall health status was associated with infection rates. Unlike in studies of COVID-19 patients, smoking status was inversely associated with SARS-CoV-2 positivity. More research is needed to further understand the nature of this relationship.

Abstract Background The number of congenital syphilis (CS) cases in the United States are increasing. Effective prevention of CS requires routine serologic testing and treatment of infected pregnant women. The Centers for Disease Control and Prevention (CDC) recommends testing all pregnant women at their first prenatal visit and subsequent testing at 28 weeks gestation and delivery for women at increased risk. Methods We conducted a cross-sectional cohort study of syphilis testing among pregnant women with a livebirth delivery from January 2014 to December 2016 in Marion County, Indiana. We extracted and linked maternal and infant data from the vital records in a local health department to electronic health records available in a regional health information exchange. We examined syphilis testing rates and factors associated with non-testing among women with livebirth delivery. We further examined these rates and factors among women who reside in syphilis prevalent areas. Results Among 21260 pregnancies that resulted in livebirths, syphilis testing in any trimester, including delivery, increased from 71.7% in 2014 to 86.6% in 2016. The number of maternal syphilis tests administered only at delivery decreased from 16.6% in 2014 to 4.04% in 2016. Among women living in areas with high syphilis rates, syphilis screening rates increased from 79.6% in 2014 to 94.2% in 2016. Conclusion Improvement in prenatal syphilis screening is apparent and encouraging, yet roughly 1-in-10 women do not receive syphilis screening during pregnancy. Adherence to recommendations set out by CDC improved over time. Given increasing congenital syphilis cases, the need for timely diagnoses and prevention of transmission from mother to fetus remains a priority for public health.

Abstract Background Coordination of care, especially after a patient experiences an acute care event, is a challenge for many health systems. Event notification is a form of health information exchange (HIE) which has the potential to support care coordination by alerting primary care providers when a patient experiences an acute care event. While promising, there exists little evidence on the impact of event notification in support of reengagement into primary care. The objectives of this study are to 1) examine the effectiveness of event notification on health outcomes for older adults who experience acute care events, and 2) compare approaches to how providers respond to event notifications. Methods In a cluster randomized trial conducted across two medical centers within the U.S. Veterans Health Administration (VHA) system, we plan to enroll older patients (≥ 65 years of age) who utilize both VHA and non-VHA providers. Patients will be enrolled into one of three arms: 1) usual care; 2) event notifications only; or 3) event notifications plus a care transitions intervention. In the event notification arms, following a non-VHA acute care encounter, an HIE-based intervention will send an event notification to VHA providers. Patients in the event notification plus care transitions arm will also receive 30 days of care transition support from a social worker. The primary outcome measure is 90-day readmission rate. Secondary outcomes will be high risk medication discrepancies as well as care transitions processes within the VHA health system. Qualitative assessments of the intervention will inform VHA system-wide implementation. Discussion While HIE has been evaluated in other contexts, little evidence exists on HIE-enabled event notification interventions. Furthermore, this trial offers the opportunity to examine the use of event notifications that trigger a care transitions intervention to further support coordination of care. Trial registration ClinicalTrials.gov NCT02689076. “Regional Data Exchange to Improve Care for Veterans After Non-VA Hospitalization.” Registered 23 February 2016.

Abstract Background Given the widespread adoption of electronic health record (EHR) systems in health care organizations, public health agencies are interested in accessing EHR data to improve health assessment and surveillance. Yet there exist few examples in the U.S. of governmental health agencies using EHR data routinely to examine disease prevalence and other measures of community health. The objective of this study was to explore local health department (LHD) professionals’ perceptions of the usefulness of EHR-based community health measures, and to examine these perceptions in the context of LHDs’ current access and use of sub-county data, data aggregated at geographic levels smaller than county. Methods To explore perceived usefulness, we conducted an online survey of LHD professionals in Indiana. One hundred and thirty-three (133) individuals from thirty-one (31) LHDs participated. The survey asked about usefulness of specific community health measures as well as current access to and uses of sub-county population health data. Descriptive statistics were calculated to examine respondents’ perceptions, access, and use. A one-way ANOVA (with pairwise comparisons) test was used to compare average scores by LHD size. Results Respondents overall indicated moderate agreement on which community health measures might be useful. Perceived usefulness of specific EHR-based community health measures varied by size of respondent’s LHD [F(3, 88) = 3.56, p = 0.017]. Over 70% of survey respondents reported using community health data, but of those

Abstract Background Human Papillomavirus (HPV) leads to serious health issues and remains the most common sexually transmitted infection. Despite availability of effective vaccines, HPV vaccination rates are suboptimal. Furthermore, providers recommend the HPV vaccine less than half the time for eligible patients. Prior informatics research has demonstrated the effectiveness of computer-based clinical decision support (CDS) in changing provider behavior, especially in the area of preventative services. Methods Following a randomized clinical trial to test the effect of a CDS intervention on HPV vaccination rates, we conducted semi-structured interviews with health care providers to understand whether they noticed the CDS reminders and why providers did or did not respond to the prompts. Eighteen providers, a mix of medical doctors and nurse practitioners, were interviewed from five publicly-funded, urban health clinics. Interview data were qualitatively analyzed by two independent researchers using inductive content analysis. Results While most providers recalled seeing the CDS reminders, few of them perceived the intervention as effective in changing their behavior. Providers stated many reasons for why they did not perceive a change in their behavior, yet the results of the trial showed HPV vaccination rates increased as a result of the intervention. Conclusions CDS reminders may be effective at changing provider behavior even if providers perceive them to be of little use. Trial registration ClinicalTrials.gov Identifier: NCT02551887 Registered on September 15, 2015

Abstract Background Most public health agencies expect reporting of diseases to be initiated by hospital, laboratory or clinic staff even though so-called passive approaches are known to be burdensome for reporters and produce incomplete as well as delayed reports, which can hinder assessment of disease and delay recognition of outbreaks. In this study, we analyze patterns of reporting as well as data completeness and timeliness for traditional, passive reporting of notifiable disease by two distinct sources of information: hospital and clinic staff versus clinical laboratory staff. Reports were submitted via fax machine as well as electronic health information exchange interfaces. Methods Data were extracted from all submitted notifiable disease reports for seven representative diseases. Reporting rates are the proportion of known cases having a corresponding case report from a provider, a faxed laboratory report or an electronic laboratory report. Reporting rates were stratified by disease and compared using McNemar’s test. For key data fields on the reports, completeness was calculated as the proportion of non-blank fields. Timeliness was measured as the difference between date of laboratory confirmed diagnosis and the date the report was received by the health department. Differences in completeness and timeliness by data source were evaluated using a generalized linear model with Pearson’s goodness of fit statistic. Results We assessed 13,269 reports representing 9034 unique cases. Reporting rates varied by disease with overall rates of 19.1% for providers and 84.4% for laboratories (p

Abstract Background The future of notifiable condition reporting in the United States is undergoing a transformation with the increasing development of Health Information Exchanges which support electronic data-sharing and -transfer networks and the wider adoption of electronic laboratory reporting. Communicable disease report forms originating in clinics are an important source of surveillance data for public health agencies. However, problems of poor data quality and delayed submission of reports to public health agencies are common. In addition, studies of barriers and facilitators to reporting have assumed that the primary reporter is the treating physician, although the extent to which a provider is involved in the reporting workflow is unclear. We sought to better understand the barriers to and burden of notifiable condition reporting from the perspectives of the three primary groups involved in reporting workflow: providers, clinic staff who bear the principal responsibility for reporting, and the public health workers who receive and process reports from clinics. In addition, we sought to situate these findings within the context of the future of notifiable disease reporting and the potential impacts of electronic lab and medical records on the surveillance system. Methods Seven ambulatory care clinics and 3 public health agencies that are part of a Health Information Exchange in the state of Indiana, USA, participated in the study. Data were obtained from a survey of clinic physicians (N = 29), interviews with clinic reporters (N = 11), and interviews with public health workers (N = 9). Survey data were summarized descriptively and interview transcripts underwent qualitative analysis. Results In both clinics and public health agencies, the laboratory report initiates reporting workflow. Provider involvement with reporting primarily revolves around ordering medications to treat a condition confirmed by the lab result. In clinics, reporting is typically the responsibility of clinic reporters who vary in frequency of reporting. We found an association between frequency of reporting, reporting knowledge and perceptions of reporting burden. In both clinics and public health agencies, interruptions and delays in reporting workflow are encountered due to inaccurate or missing information and impact reporting timeliness, data quality and report completeness. Both providers and clinic reporters lack clarity regarding how data submitted by their reports are used by public health agencies. It is possible that the value of reporting may be diminished when those responsible do not perceive receiving benefit in return. This may account for the low awareness of or recollection of public health communications with clinics that we observed. Despite the high likelihood that public health advisories and guidance are based, in part, on data submitted by clinics, a direct concordance may not be recognized. Conclusions Unlike most studies of notifiable condition reporting, this study included the clinic reporters who bear primary responsibility for completing and submitting reports to public health agencies. A primary barrier to this reporting is timely and easy access to data. It is possible that expanded adoption of electronic health record and laboratory reporting systems will improve access to this data and reduce reporting the burden. However, a complete reliance on automatic electronic extraction of data requires caution and necessitates continued interfacing with clinic reporters for the foreseeable future—particularly for notifiable conditions that are high-impact, uncommon, prone to false positive readings by labs, or are hard to verify. An important finding of this study is the association between frequency of reporting, reporting knowledge and perceptions of reporting burden. Increased automation could result in even lower reporting knowledge and familiarity with reporting requirements which could actually increase reporters’ perception of notifiable condition reporting as burdensome. Another finding was of uncertainty regarding how data sent to public health agencies is used or provides clinical benefit. A strong recommendation generated by these findings is that, given their central role in reporting, clinic reporters are a significant target audience for public health outreach and education that aims to alleviate perceived reporting burden and improve reporting knowledge. In particular, communicating the benefits of public health’s use of the data may reduce a perceived lack of information reciprocity between clinical and public health organizations.

Among the identified barriers to HPV vaccination is the concern that women may compensate for their reduced susceptibility to cervical cancers by reducing cervical cancer screening. This exploratory study examined the relationship between cervical cancer screening rates and HPV vaccination. We conducted a cross-sectional survey using a convenience sample of women aged 21–35 attending a local minority health fair in July 2015. Data were analyzed in 2015–2016. Outcomes assessed were: receiving a Pap test within the last three years, awareness and comfort with current Pap test recommendations, and knowledge regarding the purpose of a Pap test. A total of 291 women were included in the analyses. Mean age was 28.5 years and 62% were non-Hispanic black. 84% had received a Pap test in the last three years and 33% had received at least one HPV vaccine. Logistic regression results showed that women who had been vaccinated did not have lower odds of having a Pap test in the past three years (OR = 1.32; 95% CI = 0.66–2.65). In an adjusted regression model controlling for age and race, vaccinated women were significantly more likely to have had a Pap test (AOR = 3.06; 95% CI = 1.37–6.83). Yet only 26% of women knew the purpose of a Pap test and the proportion who answered correctly was higher among non-Hispanic white women. Women who have been vaccinated for HPV are more likely to have been screened for cervical cancer. These results suggest areas for more robust studies examining pro-health attitudes, behaviors, and communication regarding vaccination and preventive screening.

Background: Provider recommendation is a significant predictor of HPV vaccine uptake. Prior research suggests that concerns regarding risk compensation could cause some providers to hesitate recommending the HPV vaccine. Methods: During 15–30 min semi-structured interviews in early 2015, 22 U.S. pediatric providers were asked about their beliefs regarding sexual risk compensation and cervical cancer screening following HPV vaccination. Providers were asked if these beliefs result in reservations recommending the vaccine. Interviews were audio-recorded, transcribed, and analyzed using inductive content analysis. Results: None of the providers believed the HPV vaccine would result in risky sexual behavior. Half indicated it was better to start vaccination early, before sexual activity was a worry. Others noted that patients’ risky behavior decisions happen independently of vaccination. When providers were asked if they were concerned about decreased cervical cancer screening, half said they did not know and some stated they had never thought about it before. The main themes addressed were the significant time lapse between vaccination and screening and that women tend to get over-screened as opposed to under-screened. Conclusion: Providers were generally in favor of HPV vaccination and do not perceive risk compensation as a barrier to HPV recommendation. Keywords: Behavior, Risk compensation, Human Papillomavirus vaccination, Cervical cancer screening, Healthcare provider