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The advent of domestic bioterrorism has emphasized the need for enhanced detection of clusters of acute illness. We describe a monitoring system operational in eastern Massachusetts, based on diagnoses obtained [...]

The Middle Atlantic raccoon rabies epidemic began in West Virginia in the late 1970s and has spread inexorably north and south to encompass all states on the Atlantic coast as […]

We propose an analytical and conceptual framework for a systematic and comprehensive assessment of disease seasonality to detect changes and to quantify and compare temporal patterns. To demonstrate the proposed technique, we examined seasonal patterns of six enterically transmitted reportable diseases (EDs) in Massachusetts collected over a 10-year period (1992-2001). We quantified the timing and intensity of seasonal peaks of ED incidence and examined the synchronization in timing of these peaks with respect to ambient temperature. All EDs, except hepatitis A, exhibited well-defined seasonal patterns which clustered into two groups. The peak in daily incidence of Campylobacter and Salmonella closely followed the peak in ambient temperature with the lag of 2-14 days. Cryptosporidium, Shigella, and Giardia exhibited significant delays relative to the peak in temperature (approximately 40 days, P<0.02). The proposed approach provides a detailed quantification of seasonality that enabled us to detect significant differences in the seasonal peaks of enteric infections which would have been lost in an analysis using monthly or weekly cumulative information. This highly relevant to disease surveillance approach can be used to generate and test hypotheses related to disease seasonality and potential routes of transmission with respect to environmental factors. [ABSTRACT FROM AUTHOR]

In November 2015, a neurologist in the Boston, Massachusetts, area reported four cases of an uncommon amnestic syndrome involving acute and complete ischemia of both hippocampi, as identified by magnetic resonance imaging (MRI), to the Massachusetts Department of Public Health (MDPH) (1). A subsequent e-mail alert, generated by the Massachusetts Board of Registration in Medicine and sent to relevant medical specialists (including neurologists, neuroradiologists, and emergency physicians), resulted in the identification of 10 additional cases that had occurred during 2012-2016. All 14 patients (mean and median age = 35 years) had been evaluated at hospitals in eastern Massachusetts. Thirteen of the 14 patients underwent routine clinical toxicology screening at the time of initial evaluation; eight tested positive for opioids, two for cocaine, and two for benzodiazepines. Apart from sporadic cases (2-6), this combination of clinical and imaging findings has been reported rarely. The apparent temporospatial clustering, relatively young age at onset (19-52 years), and associated substance use among these patients should stimulate further case identification to determine whether these observations represent an emerging syndrome related to substance use or other causes (e.g., a toxic exposure). [ABSTRACT FROM AUTHOR]

Background and Purpose: Opioid-associated amnestic syndrome (OAS) and transient global amnesia (TGA) are conditions with clinical overlap. We therefore sought to determine whether opioid use might be associated with TGA., Methods: Data from the Massachusetts Department of Public Health Syndromic Surveillance program were queried to ascertain the frequency of opioid use among emergency department (ED) encounters for TGA compared to that for all other ED visits between January 2019 and June 2023., Results: A total of 13,188,630 ED visits were identified during the study period. Of 1417 visits for TGA, one visit met the exposure definition for opioid use. There were 13,187,213 visits for other indications, 57,638 of which were considered opioid-exposed. The odds ratio for the relationship between opioid use and TGA was 0.16 (95% confidence interval 0.02, 1.14)., Conclusion: Despite the clinical overlap between OAS and TGA, surveillance data from ED visits in Massachusetts do not suggest that opioid use is a risk factor for TGA, indicating that OAS and TGA are distinct entities., (© 2023 The Authors. European Journal of Neurology published by John Wiley & Sons Ltd on behalf of European Academy of Neurology.)

Background: A collaborative, data-to-care strategy to identify persons with HIV (PWH) newly out-of-care, combined with an active public health intervention, significantly increases the proportion of PWH re-engaged in HIV care. We assessed this strategy's impact on durable viral suppression (DVS)., Methods: A multisite, prospective randomized controlled trial for out-of-care individuals using a data-to-care strategy and comparing public health field services to locate, contact, and facilitate access to care versus the standard of care. DVS was defined as the last viral load, the viral load at least 3 months before, and any viral load between the 2 were all <200 copies/mL during the 18-month postrandomization. Alternative definitions of DVS were also analyzed., Results: Between August 1, 2016-July 31, 2018, 1893 participants were randomized from Connecticut (n = 654), Massachusetts (n = 630), and Philadelphia (n = 609). Rates of achieving DVS were similar in the intervention and standard-of-care arms in all jurisdictions (all sites: 43.4% vs 42.4%, P = 0.67; Connecticut: 46.7% vs 45.0%, P = 0.67; Massachusetts: 40.7 vs 44.4%, P = 0.35; Philadelphia: 42.4% vs 37.3%, P = 0.20). There was no association between DVS and the intervention (RR: 1.01, CI: 0.91-1.12; P = 0.85) adjusting for site, age categories, race/ethnicity, birth sex, CD4 categories, and exposure categories., Conclusion: A collaborative, data-to-care strategy, and active public health intervention did not increase the proportion of PWH achieving DVS, suggesting additional support to promote retention in care and antiretroviral adherence may be needed. Initial linkage and engagement services, through data-to-care or other means, are likely necessary but insufficient for achieving DVS for all PWH., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: We conducted a medical record review for healthcare utilization, risk factors, and clinical data among people who inject drugs (PWID) in Massachusetts to aid HIV outbreak response decision-making and strengthen public health practice., Setting: Two large community health centers (CHCs) that provide HIV and related services in northeastern Massachusetts., Methods: Between May and July 2018, we reviewed medical records for 88 people with HIV (PWH) connected to the outbreak. The review period included care received from May 1, 2016, through the date of review. Surveillance data were used to establish date of HIV diagnosis and assess viral suppression., Results: Sixty-nine (78%) people had HIV infection diagnosed during the review period, including 10 acute infections. Persons had a median of 3 primary care visits after HIV diagnosis and zero before diagnosis. During the review period, 72% reported active drug or alcohol use, 62% were prescribed medication assisted treatment, and 41% were prescribed antidepressants. The majority (68, 77%) had a documented ART prescription. HIV viral suppression at < 200 copies/mL was more frequent (73%) than the overall across the State (65%); it did not correlate with any of the sociodemographic characteristics studied in our population. Over half (57%) had been hospitalized at least once during the review period, and 36% had a bacterial infection at hospitalization., Conclusions: Medical record review with a field investigation of an outbreak provided data about patterns of health care utilization and comorbidities not available from routine HIV surveillance or case interviews. Integration of HIV screening with treatment for HIV and SUD can strengthen prevention and care services for PWID in northeastern Massachusetts., (© 2022. The Author(s).)

Following the uniquely coincident Year of the Nurse and the year of the pandemic, striking similarities between the principles and innovations that Florence Nightingale introduced to nursing and the inclusion of nurses in the pursuit of antimicrobial stewardship have become evident. Issues of universal healthcare, the treatment of infections, workforce collaboration, and quality of care are as critical in the 21st century as they were in Nightingale's lifetime. The importance of nursing involvement in each of these areas is compared and discussed with their relevance to past, present, and future healthcare.

Background: There are a wide variety of infectious complications of injection drug use. Understanding the trajectory of these complications might inform the development of an early warning system for human immunodeficiency virus (HIV) outbreaks that occur regularly among people who inject drugs (PWID)., Methods: A distributed lag Poisson regression model in the Bayesian setting was used to examine temporal patterns in the incidence of injection-associated infectious diseases and their association with HIV cases in Lawrence and Lowell, Massachusetts between 2005 and 2018., Results: Current-month HIV counts are associated with fatal overdoses approximately 8 months prior, cases of infective endocarditis 10 months prior, and cases of skin and soft tissue infections and incision and drainage procedures associated with these infections 12 months prior., Conclusions: Collecting data on these other complications associated with injection drug use by public health departments may be important to consider because these complications may serve as input to a sentinel system to trigger early intervention and avert potential outbreaks of HIV., (© The Author(s) 2021. Published by Oxford University Press on behalf of Infectious Diseases Society of America.)

Objectives. To describe and control an outbreak of HIV infection among people who inject drugs (PWID). Methods. The investigation included people diagnosed with HIV infection during 2015 to 2018 linked to 2 cities in northeastern Massachusetts epidemiologically or through molecular analysis. Field activities included qualitative interviews regarding service availability and HIV risk behaviors. Results. We identified 129 people meeting the case definition; 116 (90%) reported injection drug use. Molecular surveillance added 36 cases to the outbreak not otherwise linked. The 2 largest molecular groups contained 56 and 23 cases. Most interviewed PWID were homeless. Control measures, including enhanced field epidemiology, syringe services programming, and community outreach, resulted in a significant decline in new HIV diagnoses. Conclusions. We illustrate difficulties with identification and characterization of an outbreak of HIV infection among a population of PWID and the value of an intensive response. Public Health Implications. Responding to and preventing outbreaks requires ongoing surveillance, with timely detection of increases in HIV diagnoses, community partnerships, and coordinated services, all critical to achieving the goal of the national Ending the HIV Epidemic initiative.

Competing Interests: All authors have completed and submitted the ICMJE form for disclosure of potential conflicts of interest. Nivedha Panneer reports stock ownership in Gilead. Shauna Onofrey reports that a family member works for and owns stock in Emergent Biosolutions. No other potential conflicts of interest were disclosed.

Techniques of data mining and machine learning were applied to a large database of medical and facility claims from commercially insured patients to determine the prevalence, gender demographics, and costs for individuals with provider-assigned diagnosis codes for myalgic encephalomyelitis (ME) or chronic fatigue syndrome (CFS). The frequency of diagnosis was 519-1,038/100,000 with the relative risk of females being diagnosed with ME or CFS compared to males 1.238 and 1.178, respectively. While the percentage of women diagnosed with ME/CFS is higher than the percentage of men, ME/CFS is not a "women's disease." Thirty-five to forty percent of diagnosed patients are men. Extrapolating from this frequency of diagnosis and based on the estimated 2017 population of the United States, a rough estimate for the number of patients who may be diagnosed with ME or CFS in the U.S. is 1.7 million to 3.38 million. Patients diagnosed with CFS appear to represent a more heterogeneous group than those diagnosed with ME. A machine learning model based on characteristics of individuals diagnosed with ME was developed and applied, resulting in a predicted prevalence of 857/100,000 ( p > 0.01), or roughly 2.8 million in the U.S. Average annual costs for individuals with a diagnosis of ME or CFS were compared with those for lupus (all categories) and multiple sclerosis (MS), and found to be 50% higher for ME and CFS than for lupus or MS, and three to four times higher than for the general insured population. A separate aspect of the study attempted to determine if a diagnosis of ME or CFS could be predicted based on symptom codes in the insurance claims records. Due to the absence of specific codes for some core symptoms, we were unable to validate that the information in insurance claims records is sufficient to identify diagnosed patients or suggest that a diagnosis of ME or CFS should be considered based solely on looking for presence of those symptoms. These results show that a prevalence rate of 857/100,000 for ME/CFS is not unreasonable; therefore, it is not a rare disease, but in fact a relatively common one.

Objectives: To describe secular trends in reported HIV diagnoses in Massachusetts concurrent with treatment access expansion., Methods: We characterized cases of HIV infection reported to the Massachusetts HIV/AIDS Surveillance Program between 2000 and 2014 by sex, age, race/ethnicity, and exposure mode. We used Poisson regression to test the statistical significance of trends in diagnoses., Results: Between 2000 and 2014, annual new HIV infections diagnosed in Massachusetts decreased by 47% (P < .001 for trend). We observed significant reductions in diagnoses among women (58% when comparing 2000 with 2014), men (42%), Whites (54%), Blacks (51%), and Hispanics (35%; P < .001 for trend). New diagnoses decreased significantly among men who have sex with men (19%), persons who inject drugs (91%), and heterosexuals (86%; P < .001 for trend). We saw statistically significant downward trends among all men by race/ethnicity, but the trend among Black men who have sex with men was nonsignificant., Conclusions: Sustained reduction in new HIV diagnoses was concurrent with Massachusetts's Medicaid expansion, state health care reform, and public health strategies to improve care access. A contributory effect of expanded HIV treatment and population-level viral suppression is hypothesized for future research.

Objectives: We used area-level indicators of poverty to describe economic disparities in the incidence rate of infectious syphilis in Massachusetts to (1) determine whether methods developed in earlier AIDS analyses in Massachusetts could be applied to syphilis and (2) characterize syphilis trends during a time of increased rates of syphilis incidence., Methods: Using census tract data and population counts from the US Census Bureau and Massachusetts data on syphilis, we analyzed the incidence rate of syphilis infection from 2001 to 2013 by the poverty level of the census tract in which people with syphilis resided, stratified by age, sex, and race/ethnicity., Results: The syphilis incidence rate increased in all census tract groups in Massachusetts from 2001 to 2013, and disparities in incidence rates by area poverty level persisted over time. The overall incidence rate of syphilis increased 6.9-fold from 2001 to 2013 in all census tract poverty-level groupings (from 1.5 to 10.3 per 100 000 population), but the rise in rate was especially high in the poorest census tracts (from 5.6 to 31.0 per 100 000 population) and among men (from 2.2 to 19.4 per 100 000 population). The highest syphilis incidence rate was among non-Hispanic black people. The largest changes in incidence rate occurred after 2010. One region had a disproportionate increase in incidence rates and a disproportionate impact on the statewide trend., Conclusions: Census tract poverty analyses can inform the targeting of interventions that make progress toward reducing disparities in rates of syphilis incidence possible.

The Massachusetts Department of Public Health (MDPH) identified cases of hepatitis C virus (HCV) infection reported from 2007 through 2010 to assess evidence of appropriate follow-up testing for the diagnosis of active HCV infection. Surveillance data were used to assess the number of people with reported HCV who had an antibody test and nucleic acid test (NAT) for HCV, to determine the time between tests, and to identify demographic characteristics. Out of the 34,005 cases of HCV reported with laboratory results during the study period, 45% (n=15,279) had only an antibody test reported and 55% (n=18,726) had a NAT reported, with differences by age, gender, and region of residence. Nearly half of those with reported cases of HCV infection in Massachusetts did not have a NAT reported to MDPH, indicating that these individuals may not have received appropriate diagnostic testing. Analysis of demographics suggests differences by age, gender, and region.

We outline a framework for evaluating food- and water-borne surveillance systems using hospitalization records, and demonstrate the approach using data on salmonellosis, campylobacteriosis and giardiasis in persons aged ≥65 years in Massachusetts. For each infection, and for each reporting jurisdiction, we generated smoothed standardized morbidity ratios (SMR) and surveillance to hospitalization ratios (SHR) by comparing observed surveillance counts with expected values or the number of hospitalized cases, respectively. We examined the spatial distribution of SHR and related this to the mean for the entire state. Through this approach municipalities that deviated from the typical experience were identified and suspected of under-reporting. Regression analysis revealed that SHR was a significant predictor of SMR, after adjusting for population age-structure. This confirms that the spatial "signal" depicted by surveillance is in part influenced by inconsistent testing and reporting practices since municipalities that reported fewer cases relative to the number of hospitalizations had a lower relative risk (as estimated by SMR). Periodic assessment of SHR has potential in assessing the performance of surveillance systems.

The Massachusetts Virtual Epidemiologic Network (MAVEN) was deployed in 2006 by the Massachusetts Department of Public Health, Bureau of Infectious Disease to serve as an integrated, Web-based disease surveillance and case management system. MAVEN replaced program-specific, siloed databases, which were inaccessible to local public health and unable to integrate electronic reporting. Disease events are automatically created without human intervention when a case or laboratory report is received and triaged in real time to state and local public health personnel. Events move through workflows for initial notification, case investigation, and case management. Initial development was completed within 12 months and recent state regulations mandate the use of MAVEN by all 351 jurisdictions. More than 300 local boards of health are using MAVEN, there are approximately one million events, and 70 laboratories report electronically. MAVEN has demonstrated responsiveness and flexibility to emerging diseases while also streamlining routine surveillance processes and improving timeliness of notifications and data completeness, although the long-term resource requirements are significant.

Background: Obesity was recognized as in independent risk factor for influenza during the 2009 H1N1 influenza pandemic., Objectives: We evaluated the association between body mass index (BMI) and influenza-like illness (ILI) during two non-pandemic influenza seasons (2003-2004 and 2004-2005) and during the spring and fall waves of the 2009 H1N1 pandemic., Methods: Adults with severe (inpatient) and mild (outpatient) ILI were compared to those without ILI using a case-cohort design. The study was nested among those insured by a single health insurance company, receiving care from a large multispecialty practice. Data were collected from insurance claims and the electronic health record. The primary exposure was obesity (BMI ≥ 30·0 kg/m(2) )., Results: Across three seasons, the crude and adjusted ORs for obesity and severe ILI were 1·65 (95% CI 1·31, 2·08) and 1·23 (95% CI 0·97, 1·57), respectively. An association was observed for those aged 20-59 years (adjusted OR 1·92, 95% CI 1·26, 2·90), but not for those 60 and older (adjusted OR 1·08, 95% CI 0·80, 1·46). The adjusted ORs for obesity and severe ILI in 2003-2004, 2004-2005, and during H1N1 were 1·14 (95% CI 0·80, 1·64), 1·24 (95% CI 0·86, 1·79), and 1·76 (95% CI 0·91, 3·42), respectively. Among those with a Charlson Comorbidity Index score of zero, the adjusted ORs for 2003-2004, 2004-2005, and H1N1 were 1·60 (95% CI 0·93, 2·76), 1·43 (95% CI 0·80, 2·56), and 1·90 (95% CI 0·68, 5·27), respectively., Conclusions: Our results suggest a small to moderate association between obesity and hospitalized ILI among adults., (© 2013 The Authors. Influenza and Other Respiratory Viruses Published by John Wiley & Sons Ltd.)

Objectives: This study examined the association between prenatal exposure to pandemic influenza and cardiovascular events in adulthood., Design: Using Danish surveillance data to identify months when influenza activity was highest during three previous pandemics (1918, 1957, and 1968), persons were defined as exposed/unexposed based on whether they were in utero during peak months of one of the pandemics. Episodes of acute myocardial infarction (MI) and stroke were identified in the Danish National Registry of Patients covering all Danish hospitals since 1977., Setting/sample: Information from Danish national registries on all persons with a Civil Personal Registry number and birthdates in 1915 through 1922, 1954 through 1960, and 1966 through 1972 was collected., Main Outcome Measures: Crude incidence rate ratios (IRRs) were calculated per pandemic. Generalized linear models were fit to estimate IRRs adjusted for sex., Results: For acute MI, sex-adjusted IRRs for persons in utero during peaks of the 1918, 1957, and 1968 pandemics, compared with those born afterward, were 1·02 (95% confidence interval (CI): 0·99, 1·05), 0·96 (95% CI: 0·87, 1·05), and 1·18 (95% CI: 0·96, 1·45), respectively. For stroke, the corresponding IRRs were 0·99 (95% CI: 0·97, 1·02), 0·99 (95% CI: 0·92, 1·05), and 0·85 (95% CI: 0·77, 0·94), respectively., Conclusions: There was generally no evidence of an association between prenatal influenza exposure and acute MI or stroke in adulthood. However, survivor bias and left truncation of outcomes for the 1918 pandemic are possible, and the current young ages of persons included in the analyses for the 1957 and 1968 pandemics may warrant later re-evaluation., (© 2013 The Authors. Influenza and Other Respiratory Viruses Published by John Wiley & Sons Ltd.)

Objectives: The Massachusetts Department of Public Health (MDPH) and the Barnstable County Sheriff's Department (BCSD) in Massachusetts initiated a pilot program in July 2009 offering education and hepatitis C virus (HCV) antibody testing to inmates and detainees, concurrent with routine HIV testing. The initiative was implemented to assess the feasibility of integrating HCV screening into an HIV screening program in a correctional setting and the efficacy of linking HCV antibody-positive inmates to clinical care upon release., Methods: Through the Screening for Hepatitis C as a Prevention Enhancement initiative, HCV and HIV testing were offered to inmates and detainees shortly after admission, and by request at any time during incarceration. In preparation for release, referrals were made to community-based medical providers for HCV follow-up care. Data from BCSD were compared with routine surveillance data received by MDPH. Confirmatory HCV test results received by April 15, 2012, were considered indicators of appropriate post-release clinical care., Results: From July 2009 through December 2011, 22% (n=596) and 25% (n=667) of 2,716 inmates/detainees accepted HCV and HIV testing, respectively. Of those tested for HCV antibody, 20.5% (n=122) were positive. Of those tested for HIV antibody, 0.8% (n=5) were positive. Of the inmates who tested HCV positive at BCSD and had been released, 37.8% were identified as receiving post-release medical care., Conclusions: We determined that integration of HCV education and screening into correctional facilities is feasible and reveals high rates of HCV infection. Although this model presupposes programmatic infrastructure, elements of the service design and integration could inform a range of correctional programs. Effective linkage to care, while substantial, was not routine based on our analysis, and may require additional resources given its cost and complexity.