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In June 2021, a task force commissioned by the Board of Directors of the Association for Professionals in Infection Prevention and Epidemiology (APIC) evaluated the landscape of health inequity and health disparities as they apply to infection prevention in health care settings. This task force, consisting of infection preventionists across the country, convened to evaluate current literature, identify relevant issues and make recommendations to the APIC Board of Directors for action steps to be taken.

We aimed to determine absolute and relative risks of either symptomatic or asymptomatic SARS-CoV-2 infection for late cardiovascular (CV) events and all-cause mortality. We conducted a retrospective double cohort study of patients with either symptomatic or asymptomatic SARS-CoV-2 infection (COVID-19+ cohort) and its documented absence (COVID-19- cohort). The study investigators drew a simple random sample of records from all patients under the Oregon Healthamp; Science University Healthcare (n = 65,585), with available COVID-19 test results, performed March 1, 2020 to September 13, 2020. Exclusion criteria were agelt;18 years and no established Oregon Healthamp; Science University care. The primary outcome was a composite of CV morbidity and mortality. All-cause mortality was the secondary outcome. The study population included 1,355 patients (mean age 48.7 ± 20.5 years; 770 women [57%], 977 White non-Hispanic [72%]; 1,072 ensured [79%]; 563 with CV disease history [42%]). During a median 6 months at risk, the primary composite outcome was observed in 38 of 319 patients who were COVID-19+ (12%) and 65 of 1,036 patients who were COVID-19- (6%). In the Cox regression, adjusted for demographics, health insurance, and reason for COVID-19 testing, SARS-CoV-2 infection was associated with the risk for primary composite outcome (hazard ratio 1.71, 95% confidence interval 1.06 to 2.78, p = 0.029). Inverse probability-weighted estimation, conditioned for 31 covariates, showed that for every patient who was COVID-19+, the average time to all-cause death was 65.5 days less than when all these patients were COVID-19-: average treatment effect on the treated -65.5 (95% confidence interval -125.4 to -5.61) days, p = 0.032. In conclusion, either symptomatic or asymptomatic SARS-CoV-2 infection is associated with an increased risk for late CV outcomes and has a causal effect on all-cause mortality in a late post-COVID-19 period.

ObjectiveTo determine absolute and relative risks of either symptomatic or asymptomatic SARS-CoV-2 infection for late cardiovascular events and all-cause mortality.MethodsWe conducted a retrospective double-cohort study of patients with either symptomatic or asymptomatic SARS-CoV-2 infection [COVID-19(+) cohort] and its documented absence [COVID-19(-) cohort]. The study investigators drew a simple random sample of records from all Oregon Health & Science University (OHSU) Healthcare patients (N=65,585) with available COVID-19 test results, performed 03.01.2020 - 09.13.2020. Exclusion criteria were age < 18y and no established OHSU care. The primary outcome was a composite of cardiovascular morbidity and mortality. All-cause mortality was the secondary outcome.ResultsThe study population included 1355 patients (mean age 48.7±20.5 y; 770(57%) female, 977(72%) white non-Hispanic; 1072(79%) insured; 563(42%) with cardiovascular disease (CVD) history). During a median 6 months at risk, the primary composite outcome was observed in 38/319 (12%) COVID-19(+) and 65/1036 (6%) COVID-19(-) patients (p=0.001). In Cox regression adjusted for demographics, health insurance, and reason for COVID-19 testing, SARS-CoV-2 infection was associated with the risk of the primary composite outcome (HR 1.71; 95%CI 1.06-2.78; p=0.029). Inverse-probability-weighted estimation, conditioned for 31 covariates, showed that for every COVID-19(+) patient, the average time to all-cause death was 65.5 days less than when all these patients were COVID-19(-): average treatment effect on the treated -65.5 (95%CI -125.4 to -5.61) days; p=0.032.ConclusionsEither symptomatic or asymptomatic SARS-CoV-2 infection is associated with increased risk of late cardiovascular outcomes and has causal effect on all-cause mortality in a late post-COVID-19 period.ClinicalTrials.gov Identifier: NCT04555187Key messagesWhat is already known about this subjectAcute, symptomatic COVID-19 can cause acute cardiovascular manifestations.Post-acute or “long” COVID-19 can be a debilitating disease following acute infection with a heterogenous presentation.What might this study add?Either symptomatic or asymptomatic SARS-CoV-2 infection is associated with increased risk of late cardiovascular outcomes.Either symptomatic or asymptomatic SARS-CoV-2 infection has causal effect on all-cause mortality in a late post-COVID-19 period.How might this impact on clinical practice?As we begin to care for more survivors of COVID-19, we will need to better understand not only how to care for their acute symptoms and complications following infection, but also recognize future cardiovascular risk and mitigate such risk with appropriate screening and preventative measures.

Background The once-in-a-lifetime recommendation for vaccination against yellow fever virus (YFV) has been controversial, leading to increased scrutiny of the durability of immunity after 17D vaccination. Methods This is a cross-sectional analysis of 17D vaccinees living in nonendemic Portland, Oregon. Neutralization assays were used to determine YFV immunity. The relationships between 17D immunity and vaccination history, demographics, and travel were evaluated using nominal logistic regression. Results Seventy-one of 92 (77.2%) subjects were YFV seropositive (90 percent plaque reduction neutralization test ≥1:10) at all timepoints, and 24 of 38 (63.8%) were YFV seropositive at ≥10 years after single-dose vaccination. No relationship was found between YFV immunity and time in endemic countries, other flavivirus immunity, or demographics. Subjects were most likely to become seronegative between 3 and 12 years postvaccination (logistic regression, odds ratio [OR] = 1.75; 95% confidence interval [CI], 1.12–2.73). A comparison of our results and 4 previous studies of YFV nonendemic vaccinees found that overall, 79% (95% CI, 70%–86%) of vaccinees are likely to be seropositive ≥10 years postvaccination. Conclusions These results suggest that 1 in 5 17D vaccinees will lack neutralizing antibodies at ~10 years postvaccination, and a booster vaccination should be considered for nonendemic vaccinees before travel to regions where there is a high risk of YFV transmission.

Background The prescribing of pre-exposure prophylaxis (PrEP) remains a major means of reducing the incidence of HIV infection in the United States. Many individuals are unaware of their HIV status until further symptom progression has ensued or continue to engage in high-risk behavior despite awareness of the risk of HIV transmission. Primary care providers are instrumental in identifying patients who are at high risk of HIV acquisition and prescribing PrEP with appropriate counseling and monitoring. Methods In order to identify existing barriers to prescribing HIV PrEP at a single academic medical center, a voluntary 14-question de-identified survey was administered electronically to ambulatory care providers in the following departments: family medicine, internal medicine and geriatrics, adolescent and young adult health, student health, and women’s health clinics. Results Following survey dissemination, the response rate was 28% (82/286). The results are displayed in Tables 1-3. Notably, though 74% of survey respondents reported being familiar with CDC 2017 and USTPF 2019 clinical practice guidelines for PrEP prescribing, only 36% (22/61) were able to correctly identify the clinical scenarios in the survey whereby an individual is eligible for HIV PrEP. 57% (47/82) reported that they discuss HIV PrEP with less than 25% of eligible patients. Conclusion A significant proportion of healthcare providers at a major regional academic medical center are either not familiar with HIV PrEP prescribing clinical practice guidelines or are unable to appropriately identify situations whereby an individual meets eligibility for PrEP. In addition, a significant proportion do not discuss HIV PrEP with eligible patients. As such, data from the conducted survey will be used to inform the creation of clinical decision support tool to identify risk factors for HIV acquisition in patients, educate providers on guideline-based indications, and provide the option of a telePrEP referral service. Downstream effects anticipated from this intervention include increased HIV/STI testing, case identification, and increased rates of PrEP counseling and prescribing. Disclosures All Authors: No reported disclosures

Under-recognition of dengue infection may lead to increased morbidity and mortality, whereas early detection is shown to help improve patient outcomes. Recent incidence and outbreak reports of dengue virus in the United States and other temperate regions where dengue was not typically seen have raised concerns regarding appropriate diagnosis and management by healthcare providers unfamiliar with the disease. This study aimed to describe self-reported clinical symptoms of dengue fever in a non-endemic cohort and to establish a clinically useful predictive algorithm based on presenting features that can assist in the early evaluation of potential dengue infection. Volunteers who experienced febrile illness while traveling in dengue-endemic countries were recruited for this study. History of illness and blood samples were collected at enrollment. Participants were classified as dengue naive or dengue exposed based on neutralizing antibody titers. Statistical analysis was performed to compare characteristics between the two groups. A regression model including joint/muscle/bone pain, rash, dyspnea, and rhinorrhea predicts dengue infection with 78% sensitivity, 63% specificity, 80% positive predictive value, and 61% negative predictive value. A decision tree model including joint/muscle/bone pain, dyspnea, and rash yields 77% sensitivity and 67% specificity. Diagnosis of dengue fever is challenging because of the nonspecific nature of clinical presentation. A sensitive predicting model can be helpful to triage suspected dengue infection in the non-endemic setting, but specificity requires additional testing including laboratory evaluation.

Chikungunya virus (CHIKV) and Zika virus (ZIKV) have recently emerged as globally important infections. This study aimed to explore the spatiotemporal heterogeneity in the occurrence of CHIKV and ZIKV outbreaks throughout the major international seaport city of Barranquilla, Colombia in 2014 and 2016 and the potential for clustering. Incidence data were fitted using multiple Bayesian Poisson models based on multiple explanatory variables as potential risk factors identified from other studies and options for random effects. A best fit model was used to analyse their case incidence risks and identify any risk factors during their epidemics. Neighbourhoods in the northern region were hotspots for both CHIKV and ZIKV outbreaks. Additional hotspots occurred in the southwestern and some eastern/southeastern areas during their outbreaks containing part of, or immediately adjacent to, the major circular city road with its import/export cargo warehouses and harbour area. Multivariate conditional autoregressive models strongly identified higher socioeconomic strata and living in a neighbourhood near a major road as risk factors for ZIKV case incidences. These findings will help to appropriately focus vector control efforts but also challenge the belief that these infections are driven by social vulnerability and merit further study both in Barranquilla and throughout the world&rsquo, s tropical and subtropical regions.

Background: During a 2-month period at an academic medical system, 4 cases of pansusceptible P. aeruginosa (PsA) meningitis were identified among neuroscience intensive care unit (NSICU) patients with an external ventricular device (EVD). Methods: We reviewed microbiology data for the previous 2 years to determine background PsA rates and to identify additional cases of PsA meningitis. A case was defined as the isolation of PsA from a CSF specimen. We convened a multidisciplinary group of stakeholders to review medical records of case patients and to conduct a series of observational rounds. Scalp swab specimens were collected from NSICU patients to detect possible skin colonization. Pulsed-field gel electrophoresis (PFGE) analyses were performed on PsA isolates from the 4 case patients and 5 patients with PsA isolates from other body sites. Results: There was no hospital-wide increase in PsA incidence, and no patient without an EVD had PsA cultured from CSF. Infections occurred, on average, 10 days (range, 6–15 days) after EVD insertion. Cases were geographically dispersed in the NSICU and did not share common staff. None of the PsA isolates were genetically related and all scalp cultures were negative. Observations included multiple opportunities for contact with water sources: sinks in proximity to the head of the bed, storage of supplies next to sinks, reuse of bath basins, and use of dilute peroxide to clean surgical wounds. Multiuse shampoos, conditioners and lotions, not approved for hospital use, were found on the unit. Furthermore, 3 of 4 patients received cefazolin >24 hours after 6 of their 7 neurosurgeries for an average of 4.7 days (range, 0.8–4 days). Care practices were changed to mitigate contact between EVD sites and environmental water sources, and extended cefazolin surgical prophylaxis was discontinued. EVD practices were revised, and clinical teams had their competency confirmed. No additional cases have been identified in the 16 months following these interventions. Conclusions: This cluster of EVD infections was likely caused by patient care practices that resulted in independent introductions of PsA from multiple nonsterile or contaminated water sources. Antibiotic selection of PsA by extended use of cefazolin perioperative prophylaxis may have also contributed. EVD care practices should be designed to limit contact between and EVD insertion sites and nonsterile water sources or potentially contaminated care supplies. To substantiate performance improvement efforts and ensure interinstitutional comparability, a practical, standardized EVD-associated infection surveillance definition is needed.Funding: NoneDisclosures: None

Background: The NHSN does not have a published surveillance definition for central-line–associated bloodstream infections (CLABSIs) related to healthcare in ambulatory settings. With the increasing reliance on services involving central-line care in the ambulatory setting, there is opportunity to improve healthcare performance by developing standardized surveillance. Methods: Chart review was performed on 320 patients who had a visit at an infusion clinic and a positive blood culture in 2018. A qualifying infusion clinic visit involved accessing of the central line during the encounter. Ambulatory-associated cases were defined as having a qualifying infusion clinic encounter within 7 days prior to blood culture collection. Cases were excluded if the patient’s central line had been accessed in an inpatient setting between the positive blood culture and infusion clinic visit. All other criteria were based on the NHSN inpatient CLABSI case definition. Results: Application of the proposed surveillance definition revealed 17 of 320 (5.3%) patients who met criteria for an ambulatory CLABSI. All 16 patients who met criteria (94%) had an inpatient hospital stay within 7 days of the qualifying infusion clinic encounter, for an average of 8.8 hospital days (range, 2–20). Positive blood cultures were collected on average 3.2 days after the patient’s qualifying infusion clinic encounter (range, 0–7). Moreover, 20 causative organisms were identified: 6 common commensals, 2 Staphylococcus aureus, and 12 gram-negative bacteria. Also, positive blood cultures for 7 patients (41%) were collected in ambulatory clinics. Patients reported symptom onset on average 1.2 days prior to telling a healthcare professional (range, 0–5) and an average of 2 days from their last qualifying infusion clinic visit (range, 0–6). In addition, 1 patient (6%) met for a site-specific infection outside of the defined window period during their subsequent admission. Conclusions: Application of the surveillance definition resulted in the identification of 17 CLABSIs. These results highlight important limitations in ambulatory CLABSI surveillance: Patients who access emergency services closer to their residence may have had their bloodstream infection (BSI) identified elsewhere. Ensuring comprehensive interfacility communication would increase the value of an institution’s surveillance. Additionally, ambulatory surveillance for BSI should include all possible collection locations. Although subject to recall bias, the event date could be based on symptom onset to allow for variation in healthcare-seeking behavior. In the ambulatory setting, because diagnostics are not readily available, delayed diagnosis of site-specific infections could result in an inflated ambulatory CLABSI rate.Funding: NoneDisclosures: None

Chikungunya virus (CHIKV) and Zika virus (ZIKV) have recently emerged as global infections with consequential disability adjusted life years (DALYs) and economic burden. This study aimed to explore the spatiotemporal heterogeneity in the occurrence of CHIKV and ZIKV outbreaks throughout Barranquilla, Colombia during 2014 and 2016 and explored the potential for clustering. Incidence data were fitted using multiple Bayesian Poisson models based on a suite of explanatory variables as potential risk factors and multiple options for random effects. A best fit model was used to analyse the case incidence risk for both epidemics to identify any risk factors during their epidemics. Neighbourhoods in the northern region of Barranquilla were hotspots for the outbreaks of both CHIKV and ZIKV. Additional hotspots occurred in the south-western and central regions of the CHIKV and ZIKV outbreaks, respectively. Multivariate conditional autoregressive models strongly identified higher socioeconomic strata (SES) and residing in detached houses as risk factors for ZIKV case incidences. These novel findings challenge the belief that these infections are driven by social vulnerability and merits further study both in Barranquilla and throughout the tropical and subtropical regions of the world.&nbsp

Zika virus (ZIKV) emerged as a global public health threat throughout the Americas since 2014. Phylogenetically, the virus is composed of three main lineages, an African, Asian, and American lineage. The recent emergence and spread of ZIKV has raised questions regarding the breadth and potency of human primary ZIKV immune sera against antigenically diverse ZIKV. Although ZIKV is thought to compose a single antigenic serotype, in-depth evaluation of the antigenic relatedness of ZIKV across genetic variants has been limited to a relatively small series of early convalescent human immune sera (4–12 weeks) against a limited number (3) of genetic variants. Using virus neutralization assays, we characterize the potency and breadth of twelve primary ZIKV immune sera from adults infected 5 to 38 months previously against a panel of 11 ZIKV isolates from the African, Asian and American lineages. We assess the variability of neutralization potency of immune sera from these subjects and the variability of susceptibility to neutralization for each virus isolate. Overall, we found all sera neutralized all viruses at FRNT50 ranging from 1:271 to 1:4271, a 15.8-fold range, with only small differences between subject geometric mean titers (GMT) against all viruses and small differences between each ZIKV isolate and sensitivity to neutralization by all sera: when pooled, African strains were 1.3-fold more sensitive to neutralization by subject immune sera compared to pooled American strains. Finally, we subjected our data to analysis using antigenic cartography, finding that ZIKV are highly antigenically similar, with only a ~4-fold range across all antigenic distances between viruses, consistent with a single serotype., Author summary The recent emergence of Zika virus as an important human pathogen has raised questions about the durability and breadth of Zika virus immunity following natural infection in humans. While global epidemic patterns suggest that Zika infection elicits a protective immune response that is likely to offer long-term protection against repeat infection by other Zika viruses, only one study to date has formally examined the ability of human Zika immune sera to neutralize different Zika viruses. That study was limited because it evaluated human immune sera no more than 13 weeks after Zika virus infection and tested a relatively small number of Zika viruses. In this study, we examine twelve human Zika immune sera as far as 3 years after infection and test the sera against a total of eleven Zika virus isolates. Our results confirm the earlier study and epidemic patterns that suggest Zika virus exists in nature as a single serotype, and infection with one Zika virus can be expected to elicit protective immunity against repeat infection by any Zika virus for years to decades after the first infection.

Background Testing for urinary tract infection (UTI) and Clostridiodes difficile infection (CDI) poses diagnostic and antimicrobial stewardship challenges. Both diagnoses hinge on local microbiology laboratory algorithms. For UTI testing, the definition of “abnormal” urinalysis and the use of reflex urine cultures, both of which alter the frequency of bacteriuria detection, likely differs between laboratories. For CDI, pretest probability, choice and sequence of diagnostic tests are likely variable and impact the chances of accurate diagnosis. Methods To understand laboratory practices and determine variations in local testing algorithms, we deployed a self-administered survey to microbiology laboratories serving Oregon healthcare facilities via SurveyMonkey in September 2018. Responses were collected through April 2019. We analyzed a subset of questions focused on UTI and CDI diagnosis. Results Of 51 surveyed laboratories, response rate was 86% (n = 44). 91% of respondents (n = 40) process bacterial cultures. 47.5% (n = 19) primarily perform urine culture when ordered, whereas the remainder primarily perform cultures in a reflex algorithm when ordered (n = 12; 30%) or a reflex algorithm automatically (n = 9; 22.5%) (Figure 1). The definition of an abnormal urinalysis varied widely (Figure 2). 15% (n = 6) of laboratories reported considering changes to their workflow; two cited a goal of reducing unnecessary testing. Of the 32 laboratories that perform in-house C. difficile testing, the assays and sequence in which they were implemented in testing algorithms varied substantially (Figure 3) and most commonly included NAAT testing. Seven (21.8%) laboratories reported recently changed practices; these changes did not favor any particular algorithm. 84.2% (n = 32) reported stool rejection criteria to limit unnecessary testing, but these criteria varied (Figure 4). Conclusion Wide variation exists in laboratory workflows for UTI and CDI diagnoses in Oregon, suggesting lack of consensus on optimal practices. Encouragingly, multiple labs described recently implemented or planned interventions to reduce unnecessary testing for both infections. This snapshot will inform statewide education and interventions to optimize testing and help prevent patient and population harm. Disclosures All authors: No reported disclosures.