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Background The Centers for Disease Control and Prevention recommends serial rapid antigen assay collection within congregate facilities. Although modeling and observational studies from communities and long-term care facilities have shown serial collection provides adequate sensitivity and specificity, the accuracy within correctional facilities remains unknown. Methods Using Connecticut Department of Correction data from 21 November 2020 to 15 June 2021, we estimated the accuracy of a rapid assay, BinaxNOW (Abbott), under 3 collection strategies: single test collection and serial collection of 2 and 3 tests separated by 1–4 days. The sensitivity and specificity of the first (including single), second, and third serially collected BinaxNOW tests were estimated relative to RT-PCRs collected ≤1 day of the BinaxNOW test. The accuracy metrics of the testing strategies were then estimated as the sum (sensitivity) and product (specificity) of tests in each strategy. Results Of the 13 112 residents who contributed ≥1 BinaxNOW test during the study period, 3825 contributed ≥1 RT-PCR paired BinaxNOW test. In relation to RT-PCR, the 3-rapid-antigen-test strategy had a sensitivity of 95.9% (95% CI: 93.6–97.5%) and specificity of 98.3% (95% CI: 96.7–99.1%). The sensitivities of the 2- and 1-rapid-antigen-test strategies were 88.8% and 66.8%, and the specificities were 98.5% and 99.4%, respectively. The sensitivity was higher among symptomatic residents and when RT-PCRs were collected before BinaxNOW tests. Conclusions We found serial antigen test collection resulted in high diagnostic accuracy. These findings support serial collection for outbreak investigation, screening, and when rapid detection is required (such as intakes or transfers).

Whether SARS-CoV-2 infection and COVID-19 vaccines confer exposure-dependent (“leaky”) protection remains unknown. We examined the effect of prior infection and vaccination on infection risk among residents of Connecticut correctional facilities during periods of predominant Omicron and Delta transmission. Residents with cell, unit, and no documented exposures to SARS-CoV-2 infected residents were matched by facility and date. During the Omicron period, prior infection and vaccination reduced the infection risk of residents without a documented exposure (Hazards ratio: infection, 0.36 [0.25-0.54]; vaccination, 0.57 [0.42-0.78]) and with cellblock exposures (infection, 0.61 [0.49-0.75]; vaccination, 0.69 [0.58-0.83]) but not with cell exposures (infection, 0.89 [0.58-1.35]; vaccination, 0.96 [0.64-1.46]). Associations were similar during the Delta period and when analyses were restricted to residents who underwent testing. These findings suggest that SARS-CoV-2 infection and COVID-19 vaccination may be leaky, highlighting the potential benefits of pairing vaccination with non-pharmaceutical interventions in densely crowded settings.

ObjectiveTo assess the Connecticut Department of Correction’s (DOC) COVID-19 vaccine program within jails.MethodsWe conducted a retrospective cohort analysis among people who were incarcerated in a DOC-operated jail between February 2 and November 8, 2021, and were eligible for vaccination at the time of incarceration (intake). We compared the vaccination rates before and after incarceration using an age-adjusted survival analysis with a time-varying exposure of incarceration and an outcome of vaccination.ResultsDuring the study period, 3,716 people spent ≥1 night in jail and were eligible for vaccination at intake. Of these residents, 136 were vaccinated prior to incarceration, 2,265 had a recorded vaccine offer, and 476 were vaccinated while incarcerated. The age-adjusted hazard of vaccination following incarceration was significantly higher than prior to incarceration (12.5; 95% CI: 10.2-15.3).ConclusionsWe found that residents were more likely to become vaccinated in jail than the community. Though these findings highlight the utility of vaccination programs within jails, the low level of vaccination in this population speaks to the need for additional program development within jails and the community.

BackgroundThe CDC recommends serial rapid antigen assay collection within congregate facilities for screening and outbreak testing. Though modeling and observational studies from community and long-term care facilities have shown serial collection provides adequate sensitivity and specificity, the diagnostic accuracy of this testing strategy within correctional facilities remains unknown.MethodsUsing Connecticut Department of Corrections (DOC) data from November 21st2020 to June 15th2021, we estimated the accuracy of a rapid assay, BinaxNOW, under three collection strategies, a single test in isolation and two and three serial tests separated by 1-4 day intervals. Diagnostic accuracy metrics were estimated in relation to RT-PCRs collected within one day before the first or after the last included rapid antigen tests in a series.ResultsOf the 17,669 residents who contributed at least one RT-PCR or rapid antigen during the study period, 3,979 contributed ≥1 paired rapid antigen test series. In relation to RT-PCR, the three-rapid antigen test strategy had a sensitivity of 89.6% (95% confidence intervals: 86.1-92.6%) and specificity of 97.2% (CI: 95.1-98.3%). The sensitivities for two and one-rapid antigen test strategy were 75.2% and 52.8%, respectively, and the specificities were 98.5% and 99.4%, respectively. The sensitivity was higher among symptomatic residents and when the RT-PCR was collected before the rapid antigen tests.ConclusionsWe found the serial collection of an antigen test resulted in high diagnostic accuracy. These findings support serial testing within correctional facilities for outbreak investigation, screening, and when rapid detection is required (such as intakes or transfers).

The CDC recommends serial rapid antigen assay collection within congregate facilities. Though modeling and observational studies from communities and long-term care facilities have shown serial collection provides adequate sensitivity and specificity, the accuracy within correctional facilities remains unknown.Using Connecticut Department of Corrections (DOC) data from November 21st 2020 to June 15th 2021, we estimated the accuracy of a rapid assay, BinaxNOW, under three collection strategies, single test collection and serial collection of two and three tests separated by 1-4 days. The sensitivity and specificity of the first (including single), second, and third serially collected BinaxNOW tests were estimated relative to RT-PCRs collected within one day of the BinaxNOW test. The accuracy metrics of the testing strategies were then estimated as the sum (sensitivity) and product (specificity) of tests in each strategy.Of the 13,112 residents who contributed ≥1 BinaxNOW test during the study period, 3,825 contributed ≥1 RT-PCR paired BinaxNOW test. In relation to RT-PCR, the three-rapid antigen test strategy had a sensitivity of 95.9% (95% confidence intervals (CI): 93.6-97.5%) and specificity of 98.3% (CI: 96.7-99.1%). The sensitivity of the two- and one-rapid antigen test strategies were 88.8% and 66.8%, respectively, and the specificities were 98.5% and 99.4%, respectively. The sensitivity was higher among symptomatic residents and when RT-PCRs were collected before BinaxNOW tests.We found serial antigen test collection resulted in high diagnostic accuracy. These findings support serial collection for outbreak investigation, screening, and when rapid detection is required (such as intakes or transfers).

SARS-CoV-2 in a State Correctional System In the Connecticut correctional system, 13% of the male population tested positive for SARS-CoV-2 infection from March through June 2020. Infection risks w...

PurposeThe purpose of this paper is to determine the morbidity ofGiardiain Monroe County, New York attributed to refugees, foreign adoptees and immigrants, and to examine factors related to asymptomaticGiardiainfection.Design/methodology/approachA retrospective epidemiological analysis was conducted ofGiardiacase investigations submitted to the New York State Department of Health on the Communicable Disease Electronic Surveillance System, between January 1, 2003 and December 31, 2013 from Monroe County Department of Public Health. Univariate and multivariate logistic regression models were used to assess odds for asymptomaticGiardia.FindingsOf the 1,221Giardiacases reported in Monroe County during that time, 38 percent (n=467) were refugees, 6 percent (n=77) were foreign adoptees and 1.4 percent (n=17) were immigrants. In total, 95 percent of the refugees and 89 percent of the adoptees/immigrants were asymptomatic, compared to 15 percent of the non-refugee/adoptee/immigrant cases. Unadjusted odds for asymptomatic infection were 113.4 (95 percent CI: 70.6-183.7) for refugees, and 45.6 (95 percent CI: 22.9-91) for adoptees/immigrants.Originality/valueThis study demonstrates the importance of routine screening forGiardiaduring refugees’ initial health assessment.

Objectives. Smartphone applications (apps) are increasingly used to facilitate casual sexual relationships, increasing the risk of sexually transmitted diseases (STDs). In STD investigations, traditional contact elicitation methods can be enhanced with smartphone technology during field interviews. Methods. In 2013, the Monroe County Department of Public Health conducted a large, multi-infection STD investigation among men who have sex with men (MSM) using both index case and cluster interviews. When patients indicated meeting sexual partners online, disease intervention specialists (DISs) had access to smartphone apps and were able to elicit partners through access to inboxes and profiles where traditional contact information was lacking. Social network mapping was used to display the extent of the investigation and the impact of access to smartphones on the investigation. Results. A total of 14 index patient interviews and two cluster interviews were conducted; 97 individuals were identified among 117 sexual dyads. On average, eight partners were elicited per interview (range: 1–31). The seven individuals who used apps to find partners had an average of three Internet partners (range: 1–5). Thirty-six individuals either had a new STD ( n=7) or were previously known to be HIV-positive ( n=29). Of the 117 sexual dyads, 21 (18%) originated either online ( n=8) or with a smartphone app ( n=13). Of those originating online or with a smartphone app, six (29%) partners were located using the smartphone and two (10%) were notified of their exposure via a website. Three of the new STD/HIV cases were among partners who met online. Conclusion. Smartphone technology used by DISs in the field improved contact elicitation and resulted in successful partner notification and case finding.

Early childhood lead exposure is associated with numerous adverse health effects. Eliminating blood lead poisoning is a national health objective for 2020.To assess temporal trends in childhood elevated blood lead level (EBLL) rates.Laboratory surveillance data were collected from 1997 to 2011 and analyzed in 2013 using linear regression to assess trends in confirmed EBLL rates among children aged6 years in the U.S., New York State ([NYS], excluding New York City), and Monroe County NY. Monroe County was also examined as a case study of local public health efforts to reduce childhood lead exposures. Blood lead screening and home lead hazard inspection data were collected from 1990 to 2012 and analyzed in 2013.The prevalence of EBLL≥10 μg/dL per 100 tested children decreased from 13.4 to 1.1 in Monroe County, 6.3 to 1.0 in NYS, and 7.6 to 0.6 in the U.S. between 1997 and 2011. The absolute yearly rate of decline in Monroe County (slope=-0.0083, p0.001) occurred 2.4-fold faster than that in NYS (slope=-0.0034, p0.001) and 1.8-fold faster than that in the U.S. (slope=-0.0046, p0.001). The childhood blood lead testing rate was consistently higher in Monroe County than in NYS and the U.S.; however, testing increased for all three areas (all slopes0, p0.05), with greater improvements observed for U.S. children overall (slope=0.0075, p0.001).In addition to national and statewide policies, local efforts may be important drivers of population-based declines in childhood EBLL rates.

SUMMARYIn 2011, from August to November, the Monroe County Department of Public Health (MCDPH) investigated 47 salmonellosis cases. Geographical information software (GIS) was used to map the address locations of these cases. The resulting GIS analysis and culture information indicated that there were two distinct clusters of Salmonella that were geographically different. Pulsed-field gel electrophoresis (PFGE) testing was run at the New York State Department of Health Wadsworth Laboratory and identified S. Enteritidis (23 cases) and S. Typhimurium (10 cases). The epidemiological investigation identified Turkish pine nuts as the link between ill S. Enteritidis cases. Pine nut samples sent for laboratory testing were a PFGE match to human isolates with S. Enteritidis. A national recall of Turkish pine nuts ensued. A multistate outbreak was identified as a result of the initial investigation of MCDPH, in which 43 people were infected with the outbreak strain from five states. GIS software and shopper card data provided important tools in the epidemiological investigation.

In late October 2011, the Monroe County Department of Public Health (MCDPH) was notified of a suspected case of meningitis in a 9-year old girl from Monroe County, NY. Laboratory testing at the New York State Department of Health (NYSDOH) Wadsworth Center confirmed the identification of Haemophilus influenzae serotype e (Hie) isolated from the patient's cerebrospinal fluid (CSF) using real-time polymerase chain reaction (RT-PCR). The universal immunization of infants with conjugate H. influenzae type b (Hib) vaccine has significantly reduced the incidence of invasive Hib disease, including meningitis, one of the most serious complications for infected children. Not surprisingly, as the epidemiology of invasive H. influenzae continues to change, non-Hib serotypes will likely become more common. The findings reported here underscore the importance for clinicians, public health officials, and laboratory staff to consider non-Hib pathogens in pediatric cases of meningitis, especially when initial investigations are inconclusive.

Background: While routine HIV testing in the general population is a national recommendation, actual practice may vary.Purpose: To determine risk factors associated with HIV testing after the adoption of a New York State law in 2010 mandating that healthcare providers offer HIV testing in all clinical settings.Methods.: Survey data from Monroe County, New York, were collected in 2012 for adults aged 18-64 years and analyzed in 2014. Logistic regression was used to identify risk factors independently associated with HIV testing and high-risk behavior.Results: Among adults aged 18-34 years, fewer Whites were offered HIV testing in the past year by their doctors compared with Blacks (34% vs 64%) despite having similar rates of any HIV high-risk behavior (20% overall). For adults aged 35-64 years, fewer Whites than Blacks were ever tested for HIV (42% vs 71%), offered HIV testing in past year (17% vs 40%), and reported any HIV high-risk behavior (3% vs 13%). Latinos showed intermediate levels. With logistic regression analysis, ever tested for HIV was independently associated with only race/ethnicity; offered HIV testing in the past year was associated with females, Blacks and Latinos, aged 18-34 years, and having a routine health checkup in past year; any HIV high-risk behavior was associated with only younger age. Conclusions: To improve HIV testing rates as well as compliance with state laws and national guidelines, targeted efforts should be considered that improve perceptions of risk and emphasize the value of routine HIV screening, including those directed at white adults and their health care providers. Ethn Dis. 2016;26(1):91-98; doi:10.18865/ed.26.1.91

In January 2012, on the basis of an initial report from a dermatologist, we began to investigate an outbreak of tattoo-associated Mycobacterium chelonae skin and soft-tissue infections in Rochester, New York. The main goals were to identify the extent, cause, and form of transmission of the outbreak and to prevent further cases of infection.We analyzed data from structured interviews with the patients, histopathological testing of skin-biopsy specimens, acid-fast bacilli smears, and microbial cultures and antimicrobial susceptibility testing. We also performed DNA sequencing, pulsed-field gel electrophoresis (PFGE), cultures of the ink and ingredients used in the preparation and packaging of the ink, assessment of source water and faucets at tattoo parlors, and investigation of the ink manufacturer.Between October and December 2011, a persistent, raised, erythematous rash in the tattoo area developed in 19 persons (13 men and 6 women) within 3 weeks after they received a tattoo from a single artist who used premixed gray ink; the highest occurrence of tattooing and rash onset was in November (accounting for 15 and 12 patients, respectively). The average age of the patients was 35 years (range, 18 to 48). Skin-biopsy specimens, obtained from 17 patients, showed abnormalities in all 17, with M. chelonae isolated from 14 and confirmed by means of DNA sequencing. PFGE analysis showed indistinguishable patterns in 11 clinical isolates and one of three unopened bottles of premixed ink. Eighteen of the 19 patients were treated with appropriate antibiotics, and their condition improved.The premixed ink was the common source of infection in this outbreak. These findings led to a recall by the manufacturer.

Background: It is generally assumed that initial and recurrent strokes are of the same type, but data from South London, United Kingdom; Lausanne, Switzerland; and other studies suggest this may not be true for certain subtypes. In these studies, however, the number of recurrent strokes observed during the follow-up period was small, thereby limiting the ability of these studies to provide reliable estimates of stroke type concordance. Methods: Using a large, diverse, inpatient database, this study sought to: (1) estimate the relative agreement (Cohen's kappa) between initial and recurrent stroke types for blacks and whites; and (2) develop a risk-adjusted logistic model for readmission stroke type, with the initial admission stroke type as the main predictor and race, other sociodemographic variables, and clinical and hospital characteristics as potential covariates. Results: Stroke type concordance was similar for blacks (kappa = 0.77, 95% confidence interval [CI] = 0.71-0.83) and whites (kappa = 0.77, 95% CI=0.74-0.79). In the adjusted logistic regression models, the initial admission stroke type strongly predicted the readmission stroke type (subarachnoid hemorrhage: odds ratio [OR] = 738.31, 95% CI=422.58-1289.93; intracerebral hemorrhage [ICH]: OR=80.86, 95% CI=61.57-106.19; ischemic: OR=125.81, 95% CI=96.12-164.67). Other patient factors, but not race, also predicted readmission stroke type (e.g., younger age increased the odds of having an subarachnoid hemorrhage readmission; atrial fibrillation increased the odds of having an ICH readmission; older age, diabetes mellitus, and heart failure increased the odds of having an ischemic stroke readmission). Conclusion: This study showed that the initial stroke type and other factors were independently associated with the readmission stroke type and that patterns of stroke type concordance were similar for blacks and whites. These results may help to identify patients in high-risk subgroups who are more likely to have a recurrent hemorrhagic stroke, which could inform patient treatment decisions. For example, patients with atrial fibrillation may be at greater risk for having an ICH readmission because of the adverse effects of anticoagulant therapy, antiplatelet treatment, or both, which should be investigated further.

Background: Racial differences in stroke mortality are widely recognized, but it is unclear whether or not these differences are due mainly to blacks having a greater stroke incidence or higher case fatality rates compared to those of whites. Objectives: The aim of this study was to describe the race-specific US trends in hospital discharge rates and in-hospital mortality among stroke patients for the period 1980–1999. It was hypothesized that the hospital discharge rates and in-hospital mortality among stroke patients would be greater for blacks than for whites. Methods: Data from the National Hospital Discharge Survey for the period 1980–1999 were used to identify stroke subjects according to the codes of the International Classification of Diseases, ninth revision (codes 430–434 and 436). Direct standardization and Poisson regression were used to compare hospitalized stroke morbidity and mortality rates between blacks and whites. The main outcome measures were the number of stroke discharges and in-hospital deaths for black and white stroke patients. Results: Between the years 1980 and 1999, the hospital discharge rates for stroke increased for blacks (n = 8,700) and decreased for whites (n = 46,154); the in-hospital mortality rates decreased for both black and white stroke patients. Generally, the risk of a stroke hospitalization was greater for blacks than for whites by more than 70%, whereas both groups were similar in terms of in-hospital mortality rates among stroke patients. Conclusions: Differences between blacks and whites in terms of stroke mortality are more likely due to differences in stroke incidence rather than case fatality. These data imply that greater attention should be given to primary/secondary prevention and that additional research is needed to understand the reasons for these patterns.

Q-fever is a zoonotic disease caused by Coxiella burnetii that can create an acute or chronic form of the illness. In March 2014, Q-fever was identified by serology and Real-time Polymerase Chain Reaction (RT-PCR), in a 62 year-old male that was a Nepalese refugee. The male visited a livestock farm with a slaughterhouse in rural Central New York State, twenty-two days prior to onset of symptoms. He had direct handling of goats on this farm prior to slaughter. We describe the case presentation of his illness and the public health epidemiological investigation.

Background Few studies have examined treatment rates in patients with multiple cardiovascular risk factors. This study assessed outpatient visit and treatment patterns among patients having ≥ 1 cardiovascular conditions. Methods Nationally representative outpatient survey data were used to identify patients ≥ 25 years with hypertension, hyperlipidemia, diabetes mellitus, ischemic heart disease or congestive heart failure during the year 2005 (n=15,060 records). Prevalence and visit patterns were examined for each cardiovascular condition by race/ethnicity, sex and age. Adherence to recommended treatment was also assessed using logistic regression. Results Prevalence rates generally increased with age, and several subgroup patterns were observed for some cardiovascular conditions. Visit rates were similar, with most patients seeing their providers about 3-4 times during the year. Hypertension, the most prevalent condition, had the highest treatment rate (88%) versus ischemic heart disease, one of the least prevalent conditions, which had the lowest treatment rate (28%). Treatment rates decreased with increasing numbers of cardiovascular conditions. Appropriate treatment was independently associated with decreasing numbers of cardiovascular conditions, treatment by the primary care provider and treatment with a combination agent—but not race/ethnicity, sex or primary payment source. Conclusions While patients with multiple cardiovascular conditions visit their providers several times during the year, they are still largely undertreated, particularly as their cardiovascu lar disease burden increases. These findings may suggest that patients with multiple cardiovascular conditions are getting lower-quality care because of the greater demands placed on their physicians. Adherence to treatment guidelines may improve with adoption of a polypill and by encouraging patients to have a primary care home.

In October 2013, leptospirosis was identified in a 20-year-old male. The male was bitten on his hand by either his canine or a skunk while breaking up a fight between the two animals. Eight days after the bite, the male developed fever, headache, drowsiness, neck pain, nausea, vomiting, diarrhea, malaise and erythematous rash. Diagnosis was confirmed by amplification of Leptospira by DNA from a urine specimen. Veterinarian serology testing of the canine for Leptospira was negative. Leptospira in a human, acquired from an animal bite is a rare occurrence.

The purpose of this study was to determine to what extent a single measure, self-rated health (SRH), independently predicts long-term hospitalizations due to all causes and to cardiovascular diseases by using both the standard Cox proportional hazards model and a more robust events model. The study cohort consisted of 2,812 elderly subjects residing in New Haven, Connecticut, who were followed from 1982 to 1996 as part of the Established Populations for Epidemiologic Study of the Elderly. After adjustment for baseline risk factors, using the Cox model, a favorable SRH was associated with a significantly lowered risk for a first hospitalization for all causes (risk ratio (RR) = 0.850, 95% confidence interval (CI): 0.774, 0.934) and congestive heart failure (RR = 0.599, 95% CI: 0.426, 0.841) but not for myocardial infarction (RR = 0.882, 95% CI: 0.565, 1.379). With the adjusted robust events model, a positive SRH was associated with a decreased risk in both a first (RR = 0.813, 95% CI: 0.744, 0.889) and a second (RR = 0.870, 95% CI: 0.782, 0.968) hospitalization for any cause. These results indicate that a single measurement of SRH predicts long-term patterns of hospitalization, especially for heart failure, among older adults.