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Hereditary factors contribute to disease development and drug pharmacokinetics. The risk of hereditary disease development can be attenuated or eliminated by early screening or risk reducing interventions. The purpose of this study was to assess the clinical utility of germline medical exome sequencing in patients recruited from a family medicine clinic and compare the mutation frequency of hereditary predisposition genes to established general population frequencies. At the University of Kentucky, 205 family medicine patients underwent sequencing in a Clinical Laboratory Improvement Amendments of 1988-compliant laboratory to identify clinically actionable genomic findings. The study identified pathogenic or likely pathogenic genetic variants—classified according to the American College of Medical Genetics and Genomics variant classification guidelines—and actionable pharmacogenomic variants, as defined by the Clinical Pharmacogenetics Implementation Consortium. Test results for patients with pharmacogenomic variants and pathogenic or likely pathogenic variants were returned to the participant and enrolling physician. Hereditary disease predisposition gene mutations in APOB, BRCA2, MUTYH, CACNA1S, DSC2, KCNQ1, LDLR, SCN5A, or SDHB were identified in 6.3% (13/205) of the patients. Nine of 13 (69.2%) underwent subsequent clinical interventions. Pharmacogenomic variants were identified in 76.1% (156/205) of patients and included 4.9% (10/205) who were prescribed a medication that had pharmacogenomic implications. Family physicians changed medications for 1.5% (3/205) of patients to prevent toxicity. In this pilot study, we found that with systemic support, germline genetic screening initiatives were feasible and clinically beneficial in a primary care setting.

COVID-19 has heavily impacted the refugee population in the United States due to exposure risks, living and working conditions, and healthcare access, but little is known about outcomes. We reviewed emergency department visits to a Kentucky hospital among 2163 patients from March-December 2020, studying incidence of COVID-19 diagnosis for patients with a primary refugee-associated language compared to English speakers, and outcomes after diagnosis including hospitalization, length of stay, and in-hospital mortality. Patients in the population of interest had higher odds of COVID-19 diagnosis in the hospital (OR = 12.31, 95% CI 7.80-19.40), but, among those with COVID-19, lower odds of hospital admission (OR = 0.58, 95% CI 0.37-0.90) and shorter median length of stay (4.1 vs. 10.5 days) compared to English speakers. The study corroborates reports of comparatively higher COVID-19 incidence in patients speaking a primary refugee-associated language, but implies milder illness severity, possibly reflecting this population's baseline health.

Background Altered sense of smell is a commonly reported COVID-19 symptom. The performance of smell testing to identify SARS-CoV-2 infection status is unknown. We measured the ability of formal smell testing to identify SARS-CoV-2 infection and compared its performance with symptom screening. Methods A convenience sample of emergency department patients with COVID-19 symptom screening participated in smell testing using an eight odor Pocket Smell Test (PST). Participants received a SARS-CoV-2 viral PCR test after smell testing and completed a health conditions survey. Descriptive analysis and receiver operating characteristic (ROC) curve models compared the accuracy of smell testing versus symptom screening in identifying SARS-CoV-2 infection. Results Two hundred and ninety-five patients completed smell testing and 87 (29.5%) had a positive SARS-CoV-2 PCR test. Twenty-eight of the SARS-CoV-2 positive patients (32.2%) and 49 of the SARS-CoV-2 negative patients (23.6%) reported at least one of seven screening symptoms (OR = 1.54, P = 0.13). SARS-CoV-2 positive patients were more likely to have hyposmia (≤5 correctly identified odors) than SARS-CoV-2 negative patients (56.1% vs. 19.3%, OR = 5.36, P Conclusion Smell testing was superior to symptom screening for identifying SARS-CoV-2 infection in our study.

Purpose: Lifestyle change programs are an effective but underutilized approach to prevent or delay type 2 diabetes in people with prediabetes. Understanding clinician prediabetes knowledge, attitudes, and practices can inform implementation efforts to increase lifestyle change program referrals. Methods: We surveyed clinicians at an academic family medicine clinic about their prediabetes knowledge, attitudes, and practices. From the same clinic, we reviewed electronic health records to assess prediabetes screening, diagnosis, and treatment coverage in the cohort of adults seen from 2015 to 2017. Results: Thirty-one clinicians (69.6%) completed the survey. Clinicians believed prediabetes was an important health issue (n = 29; 93.7%) and that prediabetes screening (n = 20, 64.5%) and diagnosis (n = 31, 100%) were important for prediabetes management. About half of the respondents (n = 14; 45.2%) reported familiarity with the National Diabetes Prevention Program (DPP). Electronic chart review included 15,520 adult patients. Most of the 5360 nondiabetic patients meeting US Preventive Services Task Force diabetes screening guidelines (n = 4068; 75.9%) received a hemoglobin A1c test. Of the 1437 patients with an A1c result diagnostic of prediabetes, 729 (50.7%) had the diagnosis in their chart. Prediabetes patients receiving point-of-care A1c testing instead of laboratory testing had 4.7 increased odds (95% CI, 3.5 to 6.4) of metformin prescription. No patients were referred to a DPP. Conclusions: Clinicians9 positive attitudes toward prediabetes screening, moderate knowledge of prediabetes management, and low awareness of DPPs were reflected by high diabetes screening coverage, limited prediabetes diagnosis, and no DPP referrals. We will tailor our implementation strategy to overcome these prediabetes care barriers.

Purpose The purpose of the study was to assess patient and clinician perceptions of prediabetes in an academic family medicine practice. Data were collected in preparation for an implementation study to increase utilization of the National Diabetes Prevention Program (N-DPP). Methods In this mixed-methods study, discussions from 3 focus groups composed of patients with prediabetes were evaluated using thematic analysis for their understanding of and beliefs about prediabetes, care experiences, and attitudes toward N-DPP. Clinicians completed a Likert-scaled survey assessing attitudes and perceived barriers to providing prediabetes care. Results Among the 15 focus group participants, more than half were not aware of their diagnosis. Attitudes toward prediabetes were mixed: while many believed it was serious and elicited more fear than being “at risk,” others thought there were varying degrees of risk within the same diagnosis, making the diagnosis less impactful. Patients repeatedly expressed the perception that clinicians were not forthcoming about necessary behavior changes. Patients agreed on barriers to N-DPP, including scheduling and transportation. Clinicians (N = 31) concurred that patients lack awareness of their prediabetes diagnosis. They reported that time is available to screen all patients and that a prediabetes diagnosis is effective for advising patients of the need for lifestyle modification. There was consensus from both patients and clinicians that prediabetes is curable. Conclusions Increased patient awareness and patient-centered education is needed to overcome barriers to prediabetes care. To facilitate implementation of N-DPP referral processes, clinicians should clearly communicate risk, treatment information, and linkage to N-DPP as the suggested treatment plan.

Introduction The optimal length of Family Medicine Residency is unknown. As part of the American Board of Family Medicine 4-year Length of Training (LoT) pilot project, Naval Hospital Jacksonville (NHJ) maintained a dual-track 3- and 4-year Family Medicine Residency, graduating seven 4-year residents over consecutive 4 years of the LoT program. One measure of success regarding the impact of 4-year residents on program outcomes is scholarly output during residency. Materials and Methods Cumulative scholarly activity points are tracked for all NHJ residents. Cumulative scholarly activity points, points per year per, and raw percentile USMLE/COMLEX scores from academic years 2016–17 to 2019–20 were compared between PGY3 and PGY4 graduates using one-way ANOVA to 95% confidence with post hoc Tukey honestly significant difference pairwise comparison to evaluate pairwise significance between groups where multi-group differences were found. Results During the 2016–17 through 2019–20 academic years, NHJ had 28 residents complete 3 years of training without interruption (3 Years), 11 residents complete 3 years of training interrupted by general medical officer tours (Resiterns), and 7 residents complete 4 years of training without interruption (4 Years). There were no significant differences in average raw USMLE and COMLEX scores between 3 Year (71%), Resitern (68%), and 4 Year (76%) residents (P = .335). 4-Year residents had significantly more cumulative scholarly points (103) than 3-Year residents (32.6, P Conclusions An observed benefit of a 4-year Family Medicine Residency was a marked increase in scholarly output at this program.

Background and Objectives: Scholarly activity (SA) is an Accreditation Council of Graduate Medical Education (ACGME) requirement for family medicine residents. Engaging residents in scholarly activity can be challenging. Naval Hospital Jacksonville Family Medicine Residency (NHJ) pioneered a curriculum that led to a dramatic, sustained increase in resident SA. We sought to implement the curriculum in other family medicine residency programs. Methods: The curriculum was implemented at two additional family medicine residencies. Three curricular interventions were identified: a 3-hour case report workshop, a written practical guide to scholarly activity, and a resident peer research leader. One program implemented all three elements. The other implemented the workshop and written guide, but did not identify a resident peer leader. SA was measured using the annual ACGME program director report and compared the intervention year to the previous 3 years of SA using a 2-sample test for equality of proportions with continuity correction. We used pre- and postintervention surveys to evaluate resident attitudes about SA. Results: The program implementing all three interventions increased residents’ conference presentation 302% (n=34, P

Introduction The Diabetes Prevention Program, an intensive lifestyle change program, effectively reduces the risk of progression from prediabetes to type 2 diabetes but is underutilized. An implementation study using formative research was undertaken to increase Diabetes Prevention Program referrals at a primary care clinic. Study design A pragmatic, cluster randomized, mixed-methods study. Setting/particpants Clusters were teams of primary care clinicians from 2 primary care clinics. The 3 intervention clusters had 8–11 clinicians, and the 3 control clusters had 7–20 clinicians. Intervention Implementation activities occurred from December 2017 to February 2019. The activities included targeted clinician education, a prediabetes clinician champion, and a custom electronic health record report identifying patients with prediabetes. Main outcome measures The primary outcome was referral of patients with prediabetes to the institutional Diabetes Prevention Program. Study data, including patient demographic and clinical variables, came from electronic health record. Interviews with clinicians evaluated the implementation strategies. Generalized estimating equation analyses that accounted for multiple levels of correlation and interview content analysis occurred in 2019. Results Study clinicians cared for 2,992 patients with a prediabetes diagnosis or HbA1c indicative of prediabetes (5.7%–6.4%). Clinicians in the intervention clusters referred 6.9% (87 of 1,262) of patients with prediabetes to the Diabetes Prevention Program and those in the control clusters referred 1.5% (26 of 1,730). When adjusted for patient age, sex, race, HbA1c value, HbA1c test location, and insurance type, intervention clinicians had 3.85 (95% CI=0.40, 36.78) greater odds of referring a patient with prediabetes to the Diabetes Prevention Program. The 11 interviewed intervention clinicians had mixed opinions about the utility of the interventions, reporting the prediabetes clinic champion (n=7, 64%) and educational presentations (n=6, 55%) as most helpful. Conclusions Intervention clinicians were more likely to make Diabetes Prevention Program referrals; however, the study lacked power to achieve statistical significance. Clinician interviews suggested that intervention components that triggered Diabetes Prevention Program referrals varied among clinicians.

Background: Intensive lifestyle change programs effectively prevent or delay type 2 diabetes but are underutilized. We evaluated patient and clinician prediabetes attitudes and practices and implemented strategies to increase National Diabetes Prevention Program (DPP) referrals. Methods: The Tailored Implementation for Chronic Diseases framework guided data collection and the interventional approach of our cluster randomized implementation study across two large primary care clinics. Formative data came from clinician surveys, patient focus groups, and electronic health record (EHR) review. Thematic qualitative and descriptive quantitative analyses identified implementation opportunities. Intervention clusters (family medicine teams) received clinician detailing and EHR-guided prediabetes patient identification. All clusters (family medicine and internal medicine) had access to an electronic DPP referral process. The primary outcome was DPP referral. Results: Focus group participants (3 groups, 15 participants) had mixed perceptions of prediabetes risk and desired personalized behavior change guidance. Surveyed clinicians (31 respondents of 45 invited) viewed prediabetes care positively, but had low DPP awareness. Baseline pre-implementation EHR data for two years (15,520 adult patients) revealed A1c screening coverage of 75.9% per national guidelines. Documentation of prediabetes occurred in 50.7% (729/1,437) of patients meeting A1c criteria. Interim analysis of DPP referrals 8 months post-intervention found 4.8% (69/1,423) of diagnosed prediabetes patients received DPP referral in intervention clusters versus 0.7% (17/2,357) of diagnosed prediabetes patients in control clusters. Patients with prediabetes in intervention clusters had 3.32 (95% CI: 0.89, 12.35) odds of receiving DPP referral after covariate and clustered data adjustments. Conclusions: Clinician detailing and EHR patient identification increased DPP referrals. Disclosure J.W. Keck: None. K.L. Roper: None. A. Thomas: None. L. Hieronymus: None. Funding National Center for Research Resources; National Center for Advancing Translational Sciences (UL1TR001998)

BACKGROUND: Invasive infections from Haemophilus influenzae serotype a (Hia) have been reported with increasing frequency, especially among indigenous populations. However there are limited population-based-studies of clinical severity. We studied invasive Hia infections in Alaska to determine clinical characteristics, mortality, and sequelae. METHODS: We defined an invasive Hia infection as the first detection of Hia from a usually sterile site in a child

Encouraging resident scholarly activity has been a longstanding challenge for medical educators. The Accreditation Council for Graduate Medical Education (ACGME) has been increasing its emphasis on scholarly activity, forcing programs to evaluate their existing processes. This study sought to evaluate the impact of a scholarly activity point system on the resident scholarly productivity at multiple programs.Five military family medicine residencies evaluated resident outcomes 2 years before and 2 years after the introduction of a scholarly activity point system. Outcome measures included peer-reviewed publications with a resident as first author, peer-reviewed publications with a resident as any author, resident presentation of scholarship at a regional, national, and international conference, IRB-approved protocols with a resident as principal investigator, and IRB-approved protocols with a resident in any role.Four of the five programs experienced substantial increases in nearly every outcome. The fifth program, which had a more robust culture of inquiry at baseline, did not experience an increase in resident scholarly productivity.A scholarly activity point system was associated with an increase in resident scholarly production in family medicine programs. It appears to work best in programs that start from a lower level of scholarly productivity at baseline. A point system appears to be a useful addition to scholarly activity curricula.

Objective: To evaluate the correlation between medical resident scholarly activity (SA) and in-training exam scores (ITEs). Methods: We conducted a five year (2013-14 through 2017-18) retrospective comparison of resident ITE scores and their cumulative SA. Each resident’s final ITE score was compared to their cumulative SA. Residents who began and ended their residency within this period were also evaluated with a comparison of their cumulative SA to their post-graduate year 1 (PGY1) ITE score and their change in ITE score. Results: 49 of 51 residents (96%) were evaluated. 26 of these were tracked from PGY1 through graduation. Spearman rank correlation shows a moderate positive correlation between scholarly activity and PGY1 ITE score (r=0.43, P=0.029), a weak positive correlation between scholarly activity and senior ITE score (r=0.29, P=0.046), and no correlation between scholarly activity and change in ITE score (r=-0.09, P=0.660). Conclusions: Our results provide evidence that higher scoring students tend to perform more scholarly activity. This finding warrants further study to determine the nature of this correlation – in particular the extent to which effort to increase one may also increase the other.

Hepatitis B antibody persistence was assessed in individuals who had previously received a vaccine booster. We measured hepatitis B surface antigen antibody (anti-HBs) levels 7 to 9 years post-hepatitis B booster in individuals with primary vaccination at birth. While 95 (91.3%) of 104 participants had detectable anti-HBs (minimum, 0.1 mIU/ml; maximum, 1,029 mIU/ml), only 43 (41%) had protective levels of ≥10 mIU/ml. Pre- and week 4 postbooster anti-HBs levels were significant predictors of hepatitis B immunity at follow-up (P< 0.001). Almost all participants had detectable anti-HBs 7 to 9 years after the hepatitis B vaccine booster, but less than half had levels ≥10 mIU/ml.

Alaska Native people have suffered disproportionately from previous influenza pandemics. We evaluated 3 separate syndromic data sources to determine temporal and geographic patterns of spread of 2009 pandemic influenza A H1N1 (pH1N1) in Alaska, and reviewed records from persons hospitalized with pH1N1 disease in 3 areas in Alaska to characterize clinical and epidemiologic features of disease in Alaskans. A wave of pH1N1 disease swept through Alaska beginning in most areas in August or early September. In rural regions, where Alaska Native people comprise a substantial proportion of the population, disease occurred earlier than in other regions. Alaska Native people and Asian/Pacific Islanders (A/PI) were 2-4 times more likely to be hospitalized than whites. Alaska Native people and other minorities remain at high risk for early and substantial morbidity from pandemic influenza episodes. These findings should be integrated into plans for distribution and use of vaccine and antiviral agents.

SUMMARYEnterotoxigenicEscherichia coli(ETEC) is a common cause of profuse watery diarrhoea in the developing world, often leading to severe dehydration or death. We found only 15 population-based studies in low and medium human development index (HDI) countries from 1984 to 2005 that evaluate disease incidence. Reported incidence ranged from 39 to 4460 infections/1000 persons per year. The peak incidence of ETEC appeared to occur between ages 6 and 18 months. A median of 14% (range 2–36%) of diarrhoeal specimens were positive for ETEC in 19 facility- and population-based studies conducted in all age groups and 13% (range 3–39%) in 51 studies conducted in children only. Heat-labile toxin (LT)-ETEC is thought to be less likely to cause disease than heat-stable toxin (ST)-ETEC or LT/ST-ETEC. Because population-based studies involve enhanced clinical management of patients and facility-based studies include only the most severe illnesses, reliable data on complications and mortality from ETEC infections was unavailable. To reduce gaps in the current understanding of ETEC incidence, complications and mortality, large population-based studies combined with facility-based studies covering a majority of the corresponding population are needed, especially in low-HDI countries. Moreover, a standard molecular definition of ETEC infection is needed to be able to compare results across study sites.

Introduction: HIV-associated Kaposi sarcoma (HIV-KS) is the most common cancer in Malawi. In 2008, the non-governmental organization, Partners In Health, and the Ministry of Health established the Neno Kaposi Sarcoma Clinic (NKSC) to treat HIV-KS in rural Neno district. We aimed to evaluate 12-month clinical outcomes and retention in care for HIV-KS patients in the NKSC, and to describe our implementation model, which featured protocol-guided chemotherapy, integrated antiretroviral therapy (ART) and psychosocial support delivered by community health workers. Methods: We conducted a retrospective cohort study using routine clinical data from 114 adult HIV-KS patients who received ART and )1 chemotherapy cycle in the NKSC between March 2008 and February 2012. Results: At enrolment 97% of patients (n/N� 103/106) had advanced HIV-KS (stage T1). Most patients were male (n/N � 85/ 114, 75%) with median age 36 years (interquartile range, IQR: 29� 42). Patients started ART a median of 77 days prior to chemotherapy (IQR: 36� 252), with 97% (n/N � 105/108) receiving nevirapine/lamivudine/stavudine. Following standardized protocols, we treated 20 patients (18%) with first-line paclitaxel and 94 patients (82%) with bleomycin plus vincristine (BV). Of the 94 BV patients, 24 (26%) failed to respond to BV requiring change to second-line paclitaxel. A Division of AIDS grade 3/4 adverse event occurred in 29% of patients (n/N � 30/102). Neutropenia was the most common grade 3/4 event (n/N � 17/102, 17%).Twelve months after chemotherapy initiation, 83% of patients (95% CI: 74� 89%) were alive, including 88 (77%) retained in care. Overall survival (OS) at 12 months did not differ by initial chemotherapy regimen (p� 0.6). Among patients with T1 disease, low body mass index (BMI) (adjusted hazard ratio, aHR � 4.10, 95% CI: 1.06� 15.89) and 1 g/dL decrease in baseline haemoglobin (aHR � 1.52, 95% CI: 1.03� 2.25) were associated with increased death or loss to follow-up at 12 months. Conclusions: The NKSC model resulted in infrequent adverse events, low loss to follow-up and excellent OS. Our results suggest it is safe, effective and feasible to provide standard-of-care chemotherapy regimens from the developed world, integrated with ART, to treat HIV-KS in rural Malawi. Baseline BMI and haemoglobin may represent important patient characteristics associated with HIV-KS survival in rural sub-Saharan Africa.

HIV/AIDS remains the second most common cause of death in low and middle-income countries (LMICs), and only 34% of eligible patients in Africa received antiretroviral therapy (ART) in 2013. This study investigated the impact of ART decentralization on patient enrollment and retention in rural Malawi. We reviewed electronic medical records of patients registered in the Neno District ART program from August 1, 2006, when ART first became available, through December 31, 2013. We used GPS data to calculate patient-level distance to care, and examined number of annual ART visits and one-year lost to follow-up (LTFU) in HIV care. The number of ART patients in Neno increased from 48 to 3,949 over the decentralization period. Mean travel distance decreased from 7.3 km when ART was only available at the district hospital to 4.7 km when ART was decentralized to 12 primary health facilities. For patients who transferred from centralized care to nearer health facilities, mean travel distance decreased from 9.5 km to 4.7 km. Following a transfer, the proportion of patients achieving the clinic’s recommended ≥4 annual visits increased from 89% to 99%. In Cox proportional hazards regression, patients living ≥8 km from a health facility had a greater hazard of being LTFU compared to patients

BACKGROUND: Alaska Native persons experience gastric cancer incidence and mortality rates that are three to four times higher than in the general United States population.OBJECTIVE: To evaluate pepsinogen I, pepsinogen I/II ratio, anti-Helicobacter pyloriand cytotoxin-associated gene A (CagA) antibody levels, and blood group for their associations with gastric cancer development in Alaska Native people.METHODS: The present analysis was a retrospective case-control study that matched gastric cancers reported to the Alaska Native Tumor Registry from 1969 to 2008 to three controls on known demographic risk factors forH pyloriinfection, using sera from the Alaska Area Specimen Bank. Conditional logistic regression evaluated associations between serum markers and gastric cancer.RESULTS: A total of 122 gastric cancer cases were included, with sera predating cancer diagnosis (mean = 13 years) and 346 matched controls. One hundred twelve cases (91.8%) and 285 controls (82.4%) had evidence of previous or ongoingH pyloriinfection as measured by anti-H pyloriantibody levels. Gastric cancer cases had a 2.63-fold increased odds of having positive anti-H pyloriantibodies compared with their matched controls (P=0.01). In a multivariate model, non-cardia gastric cancer (n=94) was associated with anti-H pyloriantibodies (adjusted OR 3.92; P=0.004) and low pepsinogen I level (adjusted OR 6.04; P=0.04). No association between gastric cancer and blood group, anti-CagA antibodies or pepsinogen I/II ratio was found.CONCLUSION: Alaska Native people with gastric cancer had increased odds of previousH pyloriinfection. Low pepsinogen I level may function as a precancer marker for noncardia cancer.

Scholarly activity is an important component of residency programs. Amidst many other professional obligations, finding time and support for resident research can be challenging. Thus, it is important to equip residents with the tools needed to perform scholarly activity both during and after residency.We studied a series of curriculum initiatives on scholarly productivity at Naval Hospital Jacksonville. Educational interventions were rolled out in three parts. First, a faculty research coordinator (FRC) was established. Second, a scholarly activity point system was adapted from one published by Seehusen et al, along with research and conference tracking systems. Third, a resident research coordinator (RRC) position was created. The FRC and RRC acted as liaisons between residents, faculty, and non-faculty staff and created an annual scholarly activity workshop. Scholarly productivity was analyzed using descriptive statistics.Prior to the roll out of these curriculum changes, the number of resident scholarly projects per resident, defined as regional or higher posters/presentations and peer-reviewed publications, was 0.07 with four residents involved. In 2012, the research per resident was 0.91, with 26 residents involved.Our analysis reveals an association between these new curricular initiatives and increased research among residents, similar to growth demonstrated by the innovations of Seehusen et al. Limitations of this study include reliance on the accuracy of past records and a small sample size. We believe this is a model that could be implemented in other residency programs to support scholarly activity requirements.

Changes in pneumococcal serotype-specific carriage and invasive pneumococcal disease (IPD) after the introduction of pneumococcal conjugate vaccine (PCV7) could inform serotype epidemiology patterns following the introduction of newer conjugate vaccines.We used data from statewide IPD surveillance and annual pneumococcal carriage studies in four regions of Alaska to calculate serotype-specific invasiveness ratios (IR; odds ratio of a carried serotype's likelihood to cause invasive disease compared to other serotypes) in children5 years of age. We describe changes in carriage, disease burden, and invasiveness between two time periods, the pre-PCV7 period (1996-2000) and the late post-PCV7 period (2006-2009).Incidence of IPD decreased from the pre- to post-vaccine period (95.7 vs. 57.2 cases per 100,000 children, P0.001), with a 99% reduction in PCV7 disease. Carriage prevalence did not change between the two periods (49% vs. 50%), although PCV7 serotype carriage declined by 97%, and non-vaccine serotypes increased in prevalence. Alaska pre-vaccine IRs corresponded to pooled results from eight pre-vaccine comparator studies (Spearman's rho=0.44, P=0.002) and to the Alaska post-vaccine period (Spearman's rho=0.28, P=0.029). Relatively invasive serotypes (IR1) caused 66% of IPD in both periods, although fewer serotypes with IR1 remained in the post-vaccine (n=9) than the pre-vaccine period (n=13).After PCV7 introduction, serotype IRs changed little, and four of the most invasive serotypes were nearly eliminated. If PCV13 use leads to a reduction of carriage and IPD for the 13 vaccine serotypes, the overall IPD rate should further decline.The findings and conclusions in this report are those of the author(s) and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Objective Increasing use of electronic health records (EHRs) provides new opportunities for public health surveillance. During the 2009 influenza A (H1N1) virus pandemic, we developed a new EHR-based influenza-like illness (ILI) surveillance system designed to be resource sparing, rapidly scalable, and flexible. 4 weeks after the first pandemic case, ILI data from Indian Health Service (IHS) facilities were being analyzed. Materials and methods The system defines ILI as a patient visit containing either an influenza-specific International Classification of Disease, V.9 (ICD-9) code or one or more of 24 ILI-related ICD-9 codes plus a documented temperature ≥100°F. EHR-based data are uploaded nightly. To validate results, ILI visits identified by the new system were compared to ILI visits found by medical record review, and the new system's results were compared with those of the traditional US ILI Surveillance Network. Results The system monitored ILI activity at an average of 60% of the 269 IHS electronic health databases. EHR-based surveillance detected ILI visits with a sensitivity of 96.4% and a specificity of 97.8% based on chart review (N=2375) of visits at two facilities in September 2009. At the peak of the pandemic (week 41, October 17, 2009), the median time from an ILI visit to data transmission was 6 days, with a mode of 1 day. Discussion EHR-based ILI surveillance was accurate, timely, occurred at the majority of IHS facilities nationwide, and provided useful information for decision makers. EHRs thus offer the opportunity to transform public health surveillance.