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With increasing mpox cases in Maricopa County, Arizona, the county’s health department launched a survey on July 11, 2022, to gather eligibility and contact data and provide clinic information to those interested in JYNNEOS as postexposure prophylaxis (PEP) or expanded postexposure prophylaxis(PEP++). Survey data were matched to case and vaccination data. Overall, 343 of the 513 respondents (66.9%) who reported close contact with an mpox case patient received PEP and 1712 of the 3379 respondents (50.7%) who were unsure of their contact status received PEP++. This outreach intervention connected potential close contacts unknown to MCDPH with PEP or PEP++. (Am J Public Health. 2023;113(5):504–508. https://doi.org/10.2105/AJPH.2023.307224 )

During summer 2020, the Maricopa County Department of Public Health (MCDPH) responded to a surge in COVID-19 cases. We used internet-based platforms to automate case notifications, prioritized investigation of cases more likely to have onward transmission or severe COVID-19 based on available preinvestigation information, and partnered with Arizona State University (ASU) to scale investigation capacity. We assessed the speed of automated case notifications and accuracy of our investigation prioritization criteria. Timeliness of case notification—the median time between receipt of a case report at MCDPH and first case contact—improved from 11 days to

Background Short-term rehabilitation units present unique infection control challenges because of high turnover and medically complex residents. In June 2021, the Maricopa County Department of Public Health was notified of a severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) Delta outbreak in a skilled nursing facility short-term rehabilitation unit. We describe the outbreak and assess vaccine effectiveness (VE). Methods Facility electronic medical records were reviewed for residents who spent > 1 night on the affected unit between June 10 and July 23, 2021, to collect demographics, SARS-CoV-2 test results, underlying medical conditions, vaccination status, and clinical outcomes. Coronavirus disease 2019 VE estimates using Cox proportional hazards models were calculated. Results Forty (37%) of 109 short-stay rehabilitation unit residents who met inclusion criteria tested positive for SARS-CoV-2. SARS-CoV-2-positive case-patients were mostly male (58%) and White (78%) with a median age of 65 (range, 27-92) years; 11 (27%) were immunocompromised. Of residents, 39% (10 cases, 32 noncases) received 2 doses and 9% (4 cases, 6 noncases) received 1 dose of messenger RNA (mRNA) vaccine. Among nonimmunocompromised residents, adjusted 2-dose primary-series mRNA VE against symptomatic infection was 80% (95% confidence interval, 15-95). More cases were hospitalized (33%) or died (38%) than noncases (10% hospitalized; 16% died). Conclusions In this large SARS-CoV-2 Delta outbreak in a high-turnover short-term rehabilitation unit, a low vaccination rate and medically complex resident population were noted alongside severe outcomes. VE of 2-dose primary-series mRNA vaccine against symptomatic infection was the highest in nonimmunocompromised residents. Health departments can use vaccine coverage data to prioritize facilities for assistance in preventing outbreaks.

From May through July 2020, Arizona was a global hotspot for new COVID-19 cases. In response to the surge of cases, local public health departments looked for innovative ways to form external partnerships to address their staffing needs. In collaboration with the Maricopa County Department of Public Health, the Arizona State University Student Outbreak Response Team (SORT) created and implemented a virtual call center to conduct public health case investigations for COVID-19. SORT officially launched a dedicated COVID-19 case investigation program after 3 weeks of program design and training. From June 29 through November 8, 2020, SORT recruited and trained 218 case investigators, completed 5000 case patient interviews, and closed 10 000 cases. Our team also developed process improvements to address disparities in case investigation timeliness. A strong infrastructure designed to accommodate remote case investigations, paired with a large workforce, enabled SORT to provide additional surge capacity for the county’s high volume of cases. University-driven multidisciplinary case investigator teams working in partnership with state, tribal, and local public health staff members can be an effective tool for supporting a diverse and growing public health workforce. We discuss the essential design factors involved in building a university program to complement local COVID-19 response efforts, including workflows for case management, volunteer case investigator recruitment and training, secure technology platforms for conducting case investigations remotely, and robust data-tracking procedures for maintaining quality control and timely case reporting.

Background Coronavirus disease 2019 (COVID-19) causes a range of illness severity. Mild illness has been reported, but whether illness severity correlates with infectivity is unknown. We describe the public health investigation of a mildly ill, nonhospitalized COVID-19 case who traveled to China. Methods The case was a Maricopa County resident with multiple severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)–positive specimens collected on 22 January 2020. Contacts were persons exposed to the case on or after the day before case diagnostic specimen collection. Contacts were monitored for 14 days after last known exposure. High-risk contacts had close, prolonged case contact (≥ 10 minutes within 2 m). Medium-risk contacts wore all US Centers for Disease Control and Prevention–recommended personal protective equipment during interactions. Nasopharyngeal and oropharyngeal (NP/OP) specimens were collected from the case and high-risk contacts and tested for SARS-CoV-2. Results Paired case NP/OP specimens were collected for SARS-CoV-2 testing at 11 time points. In 8 pairs (73%), ≥ 1 specimen tested positive or indeterminate, and in 3 pairs (27%) both tested negative. Specimens collected 18 days after diagnosis tested positive. Sixteen contacts were identified; 11 (69%) had high-risk exposure, including 1 intimate contact, and 5 (31%) had medium-risk exposure. In total, 35 high-risk contact NP/OP specimens were collected for SARS-CoV-2 testing; all 35 pairs (100%) tested negative. Conclusions This report demonstrates that SARS-CoV-2 infection can cause mild illness and result in positive tests for up to 18 days after diagnosis, without evidence of transmission to close contacts. These data might inform public health strategies to manage individuals with asymptomatic infection or mild illness.

Objective We sought to determine the associations of total, cognitive/affective, and somatic depressive symptoms and antidepressant use with biomarkers of processes implicated in cardiovascular disease in HIV (HIV-CVD). Methods We examined data from 1546 HIV-positive and 843 HIV-negative veterans. Depressive symptoms were assessed using the Patient Health Questionnaire-9, and past-year antidepressant use was determined from Veterans Affair pharmacy records. Monocyte (soluble CD14 [sCD14]), inflammatory (interleukin-6 [IL-6]), and coagulation (D-dimer) marker levels were determined from previously banked blood specimens. Linear regression models with multiple imputation were run to estimate the associations between depression-related factors and CVD-relevant biomarkers. Results Among HIV-positive participants, greater somatic depressive symptoms were associated with higher sCD14 (exp[b] = 1.02, 95% confidence interval [CI] = 1.00-1.03) and D-dimer (exp[b] = 1.06, 95% CI = 1.00-1.11) after adjustment for demographics and potential confounders. Further adjustment for antidepressant use and HIV factors slightly attenuated these relationships. Associations were also detected for antidepressant use, as selective serotonin reuptake inhibitor use was related to lower sCD14 (exp[b] = 0.95, 95% CI = 0.91-1.00) and IL-6 (exp[b] = 0.86, 95% CI = 0.76-0.96), and tricyclic antidepressant use was related to higher sCD14 (exp[b] = 1.07, 95% CI = 1.03-1.12) and IL-6 (exp[b] = 1.14, 95% CI = 1.02-1.28). Among HIV-negative participants, total, cognitive/affective, and somatic depressive symptoms were associated with higher IL-6, and tricyclic antidepressant use was related to higher sCD14. Conclusions Our novel findings suggest that a) monocyte activation and altered coagulation may represent two pathways through which depression increases HIV-CVD risk and that b) tricyclic antidepressants may elevate and selective serotonin reuptake inhibitors may attenuate HIV-CVD risk by influencing monocyte and inflammatory activation.

Rabies postexposure prophylaxis (PEP) is administered for rabies prevention after a human exposure to a potentially rabid animal, such as a bite. Previous studies have reported that rabies PEP is often inappropriately administered. Health professional education was proposed as one potential solution to address inappropriate PEP use. We assessed baseline knowledge, knowledge gain, and knowledge retention among health professionals in Arizona of rabies epidemiology and appropriate PEP administration. Maricopa County Department of Public Health created an online rabies PEP continuing education module and measured knowledge before and after module completion using a 10-question test. The same test was administered three times (pretest, posttest, and retention test at ≥3 months). To assess knowledge gain and retention, we compared median scores using nonparametric methods. A total of 302 respondents completed the pretest (median score, 60%) and posttest (median score, 90%; p < .001); 98 respondents completed all three tests with median scores 60% (pretest), 90% (posttest, p < .01), and 80% (retention test and compared with pretest, p < .01). Sixty-nine (70%) respondents improved their pretest to retention test score by a mean of 2.4 points out of a total 10 points (median: 2 points; range: −5 to 7 points). Only 48% of pretest respondents correctly answered that PEP should not be administered immediately to anyone bitten by a healthy dog. However, 81% and 70% answered correctly on the posttest ( p < .0001) and retention test ( p = .002), respectively. Respondents demonstrated rabies epidemiology and PEP knowledge gain and ≥3-month knowledge retention after completing the online continuing education module.

Preventing heat-associated morbidity and mortality is a public health priority in Maricopa County, Arizona (United States). The objective of this project was to evaluate Maricopa County cooling centers and gain insight into their capacity to provide relief for the public during extreme heat events. During the summer of 2014, 53 cooling centers were evaluated to assess facility and visitor characteristics. Maricopa County staff collected data by directly observing daily operations and by surveying managers and visitors. The cooling centers in Maricopa County were often housed within community, senior, or religious centers, which offered various services for at least 1500 individuals daily. Many visitors were unemployed and/or homeless. Many learned about a cooling center by word of mouth or by having seen the cooling center’s location. The cooling centers provide a valuable service and reach some of the region’s most vulnerable populations. This project is among the first to systematically evaluate cooling centers from a public health perspective and provides helpful insight to community leaders who are implementing or improving their own network of cooling centers.

Objective To determine whether data from the Office of the Medical Examiner are useful for conducting injection drug use surveillance in Maricopa County, Arizona, and to describe the characteristics of decedents who died from a drug overdose, were investigated by the county’s medical examiner, and had an indication of injection drug use. Introduction The rate of drug overdose deaths in the United States has increased steadily since 2000. Injection drug use, a practice associated with infectious disease transmission, has likely increased along with this upward trend in drug overdoses. Injection drug use surveillance is difficult to conduct at a public health department because there are no specific Internal Classification of Diseases codes to identify this risk behavior in hospital discharge or vital registration data. Maricopa County Department of Public Health Office of Epidemiology aimed to identify indications of injection drug use within data from the Office of the Medical Examiner Methods The Office of Epidemiology receives toxicology results for deaths which were ruled by the Maricopa County’s medical examiner as substance use related, also referred to as overdose deaths. We explored data from decedents who were investigated by the Maricopa County’s medical examiner between 7/1/2016-6/30/2017, had a cause of death from a drug overdose, and screened positive for at least one commonly injected drug (i.e., opioids - general, heroin, methamphetamine, or cocaine). To narrow our search for indications of injection drug use, we requested preliminary investigation reports and medical examiner reports for a random sample of reports (10% from each drug class) from the Office of the Medical Examiner. Preliminary investigation reports, produced by a scene investigator, included the decedent’s medical history, risk factors, circumstances of death, circumstances of death discovery, and scene characteristics. Medical examiner reports included toxicology screen results, autopsy findings, and the cause of death. The Office of the Medical Examiner provided these reports to the Office of Epidemiology in portable document format (PDF) for this analysis. We built a query to identify keywords related to injection drug use (e.g. inject, syringe, needle) and injection injuries (e.g. cellulitis, abscess). We used PDF XChangeViewer’s Optical Character Recognition (OCR) function to convert the PDF reports to text data and used Python’s String and Collections modules to parse text data for occurrences of keywords within the reports. Reports that included at least one keyword were manually reviewed and classified as probable or ruled out for injection drug use, and characteristics of those with a probable indication of injection drug use were described. Results During the period of interest, 1,127 deaths were caused by drug overdose, of which 930 decedents screened positive for opioids (N=673, 59.7% of drug overdose deaths), heroin (358, 38.5%), methamphetamine (445, 39.5%), and/or cocaine (100, 11%). Indications of injection drug use were identified within 48 (32.7%) of the 147 preliminary investigation and medical examiner reports that were reviewed (Table). Common indicators of injection drug use included: history of drug use as a reported risk factor; presence of prescription drugs, illicit drugs, or drug paraphernalia at the scene; body position at the scene; and injuries associated with needle use identified during the autopsy. The most common terms that indicated injection drug use were “syringe”, “intravenous”, “needle”, and “inject”. Among persons who had an indication of injection drug use, 85.4% were male, 52.1% were between the ages of 20 and 39 years, and 85.4% were white. Conclusions Data from the Office of the Medical Examiner’s preliminary investigation and medical examiner reports provided rich context for understating the underlying risk factors and circumstances that contributed to drug overdose deaths. Injection drug use paraphernalia found at the scene of death and injuries found during autopsy were well-documented in these reports, which helped us quantify the proportion of decedents who died from overdose that may have injected drugs, by drug class. We were able to describe basic characteristics of this sample, which were consistent with previously published reports describing people who inject drugs. This surveillance method has limitations, however. Decedents reviewed by a medical examiner represent a subset of the drug using population, and findings may not be generalized to the full population. Other data sources and analytical methods must be employed to accurately estimate the number of people who inject drugs in Maricopa County and to describe their characteristics and experiences.

Background Hematologic variables are often analyzed in animal analogs during the investigation of complex disease etiologies such as necrotizing enterocolitis. However, reference intervals (RI) can vary depending on animal strain, age, and sampling site. Reference intervals have been published for adult C57BL/6J mice, but not newborn C57BL/6J mice. Objectives The purpose of the present study was to determine hematologic RI in newborn C57BL/6J mice up to day 35. Methods C57BL/6J mice founders from The Jackson Laboratory were bred at the University of Iowa. Blood samples were obtained via facial vein sampling at postnatal days 0 (p0), p7, p14, p21, p28, or young adulthood (p35). CBCs were determined with the Sysmex XT-2000iV analyzer within 30 minutes of blood collection at a 1:10 dilution. Statistics were determined using nonparametric methods following ASVCP guidelines. Results Hematologic RI were determined for each of the 6 groups (n = 247, n ≥ 39 per group). Significantly higher values for HGB, RBC, and PLT counts were observed with advancing developmental age. Total WBC counts remained relatively stable during the first 35 days of life. However, WBC differential counts were dominated by neutrophils and lymphocytes in the younger mice, with a trend toward a lymphocytic leukogram on day 35. Conclusions These results illustrate the dynamic changes in hematologic variables during murine development after birth. Utilization of age-specific RI is advised when evaluating data derived from experimental perinatal mouse models.

Objective To evaluate Arizona’s arboviral syndromic surveillance protocol in Maricopa County. Introduction Timely identification of arboviral disease is key to prevent transmission in the community, but traditional surveillance may take up to 14 days between specimen collection and health department notification. Arizona state and county health agencies began monitoring National Syndromic Surveillance Program BioSense 2.0 data for patients infected with West Nile virus (WNV), St. Louis encephalitis virus (SLEV), chikungunya, or dengue virus in August 2015. Zika virus was added in April 2016. Our novel methods were presented at the International Society for Disease Surveillance 2015 Annual Conference. [1] Twice per week, we queried patient records from 15 Maricopa County BioSense-enrolled emergency department and inpatient hospitals for chief complaint keywords and discharge diagnosis codes. Our “Case Investigation Decision Tree” helped us determine whether records had a high or low degree of evidence for arboviral disease and necessitated further investigation. This study evaluated how Arizona’s protocol for conducting syndromic surveillance compared to traditional arboviral surveillance in terms of accuracy and timeliness in Maricopa County from August 2015 through December 2016. Methods We followed guidelines from the Centers for Disease Control and Prevention (CDC) to evaluate two major attributes of the protocol: accuracy [measured as positive predictive value (PPV) and sensitivity] and timeliness. [2] Arizona’s Medical Electronic Disease Surveillance Intelligence System (MEDSIS) was considered the “gold standard” system and BioSense was the test system. PPV was calculated as the proportion of records identified by BioSense that were reported to MEDSIS, regardless of final case classification. Sensitivity was the proportion of confirmed or probable cases in MEDSIS identified by BioSense. Though not all MEDSIS cases were seen at BioSense-reporting facilities, the sensitivity demonstrates how each query contributed to arboviral surveillance overall. We assessed timeliness in two ways: (1) the difference between the date when keywords or diagnosis codes were first identified by BioSense and the date the same patient was first reported to MEDSIS; and (2) the difference between the date the BioSense record was first reviewed by the Maricopa County Department of Public Health (MCDPH) syndromic surveillance team and the date the same patient was first investigated through MEDSIS by the MCDPH disease investigators. We assessed whether timeliness was affected by the method in which a record was identified in BioSense (i.e., chief complaint keyword or discharge diagnosis code). Results The arboviral syndromic surveillance queries identified 62 records during the evaluation period (Table). For each arboviral query, the proportion of BioSense records that were also reported through MEDSIS ranged from 25.0% to 32.4%, except chikungunya, which had a PPV of 0%. BioSense records that had a high degree of evidence for arboviral disease tended to have a higher PPV compared to those with low evidence. BioSense records that were not already reported to MEDSIS met neither clinical nor exposure criteria for the arboviral diseases and were not deemed a public health risk. The sensitivities of the WNV and Zika queries to detect confirmed or probable cases in MEDSIS were 8.2% and 5.6%, respectively, while SLEV, chikungunya, and dengue queries were 0%. On average, patients were reported to MEDSIS 7 days prior to BioSense identifying keywords or diagnosis codes. In addition, MEDSIS cases were investigated by MCDPH disease investigators 10 days prior to MCDPH syndromic surveillance team review of BioSense records, on average. The average time between MEDSIS report date and BioSense identification date was shorter for BioSense records identified by chief complaint keywords than by diagnosis codes (4 and 8 days after MEDSIS, respectively). Conclusions Arizona’s arboviral syndromic surveillance protocol provided MCDPH with situational awareness, but BioSense data were not available more quickly than traditional mandated reporting. Through this process, we reviewed patient records that mentioned arboviral diseases and confirmed that these reportable conditions were captured in our traditional surveillance system. The decision tree was effective at prioritizing records for further investigation. Timeliness may be improved by updating the queries to include more chief complaint keywords and reviewing BioSense more than twice per week. MCDPH plans to evaluate Arizona’s updated arboviral syndromic surveillance protocol, which was adapted for BioSense Platform’s Electronic Surveillance System for Early Notification of Community-based Epidemics (ESSENCE). References 1. White, J. R., Imholte, S., & Collier, K. (2016). Using Syndromic Surveillance to Enhance Arboviral Surveillance in Arizona. Online J Public Health Inform, 8 (1), e81. 2. German, R. R., et al. (2001). Updated guidelines for evaluating public health surveillance systems: recommendations from the Guidelines Working Group. MMWR Recomm Rep, 50 (RR-13), 1-35.

Objective To demonstrate the utility of the National Syndromic Surveillance Program’s (NSSP) version of the Electronic Surveillance System for Early Notification of Community-based Epidemics (ESSENCE) for case detection during a 2017 outbreak of hepatitis A virus (HAV) infection among persons experiencing homelessness in Maricopa County, Arizona. Introduction On 3/29/2017, the Maricopa County Department of Public Health (MCDPH) received three reports of confirmed HAV infection from an onsite clinic at Campus A that assists individuals experiencing homelessness, a population at risk for HAV transmission. To identify the scope of the problem, the department initiated rapid HAV infection case detection using NSSP ESSENCE. Methods MCDPH created a myESSENCE dashboard that searched for chief complaint keywords and discharge diagnosis codes from 15 Maricopa County emergency department and inpatient hospital records using three separate queries: (1) HAV infection; (2) hepatitis virus infection; and (3) HAV infection symptoms combined with terms for homelessness. The dashboard was reviewed retrospectively for the 90 days prior to the initial report of the cluster (12/28/2016 – 3/29/2017). Based on this review, MCDPH epidemiologists decided to use the first query (HAV infection-specific) only, because reviewing the line list for all three queries was resource-intensive and resulted in duplicate cases. The query was monitored every weekday morning from 3/30/2017 to the close of the outbreak on 7/22/2017. Results From 3/30/2017 – 7/22/2017, MCDPH identified 37 potential HAV infection cases in ESSENCE. Eleven cases were classified as outbreak cases, while the other 26 patients lacked recent HAV infection symptoms, laboratory confirmation, or association with Campus A. All 11 outbreak cases’ records included the ICD-CM-10 code B15.9 (Hepatitis A without hepatic coma), and 3 records included the code Z59 (Problems related to housing and economic circumstances). The HAV infection-specific query in ESSENCE identified 11 (73%) of the 15 total outbreak cases; however, all cases were reported in MEDSIS prior to a being flagged in ESSENCE. On average, cases were reported to MEDSIS 9 days earlier than identified in ESSENCE (range, 0 - 21 days). Of note, ESSENCE helped identify the outbreak index case, previously lost to follow-up, as an individual experiencing homelessness. This information helped MCDPH perform additional follow-up, which revealed that the individual had arrived from San Diego, CA, a city with an ongoing outbreak of HAV infection in their homeless and drug-using population. This epidemiologic link was identified on 3/30/2017, over a month before the Centers for Disease Control and Prevention confirmed a match by genome sequencing between the index case and the neighboring outbreak on 5/5/2017. Conclusions Use of ESSENCE identified most of the HAV infection cases from this outbreak among individuals experiencing homelessness but no sooner than traditional surveillance methods. However, use of ESSENCE allowed for identification of the outbreak index case, leading to epidemiological linkage to outbreak origin approximately one month prior to molecular laboratory confirmation.

Objective: To evaluate the effect and implications of changing the chief complaint field during the National Syndromic Surveillance Program (NSSP) transition from BioSense 2.0 analytical tools to BioSense Platform – ESSENCE Introduction: In January 2017, the NSSP transitioned their BioSense analytical tools to Electronic Surveillance System for Early Notification of Community-Based Epidemics (ESSENCE). The chief complaint field in BioSense 2.0 was a concatenation of the record’s chief complaint, admission reason, triage notes, and diagnostic impression. Following the transition to ESSENCE, the chief complaint field was comprised of the first chief complaint entered or the first admission reason, if the chief complaint was blank. Furthermore, the ESSENCE chief complaint field was electronically parsed (i.e., the original chief complaint text was altered to translate abbreviations and remove punctuation). This abstract highlights key findings from Maricopa County Department of Public Health’s evaluation of the new chief complaint field, its impact on heat-related illness syndromic surveillance, and implications for ongoing surveillance efforts. Methods: For this evaluation, we used the heat-related illness query recommended in Council of State and Territorial Epidemiologists’ (CSTE) 2016 Guidance Document for Implementing Heat-Related Illness Syndromic Surveillance . Before the transition, we used BioSense 2.0’s, phpMyAdmin analytical tool to generate a list of patients who visited Maricopa County emergency departments or inpatient hospitals between 5/1/2016 – 9/30/2016 due to heat-related illness. After the transition, we used the CC and DD Category “Heat-related Illness, v1” in ESSENCE, which was based on the CSTE heat-related illness query, to generate a list of patients for the same time period. We compared the line-lists and time-series trends from phpMyAdmin and ESSENCE. Results: The phpMyAdmin analytical tool identified 785 heat-related illness records with the query (Figure). 642 (82%) of these heat-related illness records were also captured by ESSENCE. Reasons for 143 (18%) records not being identified by ESSENCE included: the patient’s admission reason field contained keywords that were not available in the ESSENCE chief complaint field (n=94, 66%); data access changed, which disabled access to patients who resided in zip codes that crossed a county border (30, 21%); discrepancies between ESSENCE parsing and text in the original chief complaint (11, 8%); heat-related illness discharge diagnoses were removed by the facility after the phpMyAdmin line-list for heat-related illness was extracted (7, 5%); and one record was undetermined. Conversely, ESSENCE captured 36 additional heat-related illness records, not previously captured by phpMyAdmin. Reasons included: a query exclusion term was located in the patient’s admission reason but not the ESSENCE chief complaint field (16, 44%); a heat-related illness discharge diagnosis code was added by the facility after the data were extracted by phpMyAdmin (4, 11%); and 16 (44%) were undetermined. Time-series trend evaluation revealed a significant correlation between the two surveillance tools (Pearson coefficient = 0.97, p < 0.01). Conclusions: Though the data trends over time were not significantly affected by changes in the chief complaint field, differences in the field’s composition have important implications for syndromic surveillance practitioners. Free-text queries designed to search the chief complaint field in ESSENCE may not retrieve records previously identified with BioSense 2.0 analytical tools, which may limit individual case-finding capacity. The elimination of admission reason from the chief complaint field in ESSENCE has the greatest effect on case-finding capacity. Furthermore, surveillance reports produced by ESSENCE cannot be directly compared to reports that were previously published with data from BioSense 2.0. These limitations may be addressed if ESSENCE creates a feature that allows users to easily query fields (e.g., admission reason) in addition to the chief compliant field.

Objectives: We evaluated a novel syndromic surveillance query, developed by the Council of State and Territorial Epidemiologists (CSTE) Heat Syndrome Workgroup, for identifying heat-related illness cases in near real time, using emergency department and inpatient hospital data from Maricopa County, Arizona, in 2015. Methods: The Maricopa County Department of Public Health applied 2 queries for heat-related illness to area hospital data transmitted to the National Syndromic Surveillance Program BioSense Platform: the BioSense “heat, excessive” query and the novel CSTE query. We reviewed the line lists generated by each query and used the diagnosis code and chief complaint text fields to find probable cases of heat-related illness. For each query, we calculated positive predictive values (PPVs) for heat-related illness. Results: The CSTE query identified 674 records, of which 591 were categorized as probable heat-related illness, demonstrating a PPV of 88% for heat-related illness. The BioSense query identified 791 patient records, of which 589 were probable heat-related illness, demonstrating a PPV of 74% for heat-related illness. The PPV was substantially higher for the CSTE novel and BioSense queries during the heat season (May 1 to September 30; 92% and 85%, respectively) than during the cooler seasons (55% and 29%, respectively). Conclusion: A novel query for heat-related illness that combined diagnosis codes, chief complaint text terms, and exclusion criteria had a high PPV for heat-related illness, particularly during the heat season. Public health departments can use this query to meet local needs; however, use of this novel query to substantially improve public health heat-related illness prevention remains to be seen.

Necrotizing enterocolitis (NEC) remains a leading cause of morbidity and mortality in premature infants. Both human surgical specimens and animal models suggest a potential involvement of Paneth cells in NEC pathogenesis. Paneth cells play critical roles in epithelial homeostasis, innate immunity and host-microbial interactions. Yet, the complex interplay between Paneth cell disruption, epithelial barrier dysfunction and microbial-driven inflammation remains unclear in the immature intestine. In this study, mucosal intestinal injury consistent with human NEC was induced in postnatal day 14-16 (P14-P16) mice by disrupting Paneth cells, followed by gavage with Klebsiella pneumonia. Mucosal injury was determined by histology, serum cytokine levels and epithelial barrier dysfunction. Toll-like receptor 4 (TLR4) activation was examined using protein expression, gene expression, and TLR4−/− mice. Finally, the role of bacteria was evaluated using heat-killed bacteria, conditioned media, Bacillus cereus and cecal slurries. We found that live bacteria were required to induce injury; however, TLR4 activation was not required. NEC induced by Paneth cell disruption results in altered localization of tight junction proteins and subsequent loss of barrier function. Prior research has shown a requirement for TLR4 activation to induce NEC-like damage. However, many infants develop NEC in the absence of Gram-negative rod bacteremia, raising the possibility that alternative pathways to intestinal injury exist. In this study, we show a previously unknown mechanism for the development of intestinal injury equivalent to that seen in human NEC and that is not dependent on TLR4 pathways. These data are congruent with the new hypothesis that NEC may be the consequence of several disease processes ending in a final common inflammatory pathway., Summary: Paneth cell disruption and bacterial exposure in immature murine intestine induces NEC-like pathology. Importantly, this occurs independently of TLR4 activation, presenting an alternative mechanism for disease development.

Purpose People with seizure disorders experience elevated rates of psychopathology, often undiagnosed and untreated. Accurate diagnosis of psychopathology remains an important goal of quality health care for people with seizure disorders. One of the most widely used dimensional measures of psychopathology is the Minnesota Multiphasic Personality Inventory—Second Edition (MMPI-2). Research in heterogeneous mental health samples suggests that the 2008 revision of this measure, the Minnesota Multiphasic Personality Inventory—Second Edition—Restructured Form (MMPI-2-RF), offers better construct fidelity and more cost-effective administration. This study seeks to extend research on MMPI-2-RF scale elevations to a sample of people with seizure disorders. Methods In a consecutive, heterogeneous sample of people with seizure disorders, MMPI-2 and MMPI-2-RF scores were compared in terms of categorical classification agreement (clinically elevated versus not clinically elevated). Scores were also compared in terms of variance attributable to diagnosis-specific items, general demoralization, subtle items, social desirability, and demographic factors. Key findings Scores on MMPI-2 and MMPI-2-RF provided a statistically significant level of agreement between corresponding clinical diagnostic scales ranging from 68% to 84%. Most classification disagreement was attributable to MMPI-2 clinical scale elevations when MMPI-2-RF scales were not elevated. Regression analysis supported the interpretation that general demoralization, subtle items, social desirability, and demographic factors led to MMPI-2 clinical scale elevations. Significance The results provide evidence that in the context of strong psychopathology classification agreement, the MMPI-2-RF restructured clinical scales provide better construct fidelity compared with the more trait heterogeneous MMPI-2 clinical scales. These results should encourage clinicians to use the MMPI-2 Restructured Form (MMPI-2-RF) for improved psychopathology assessment compared with the MMPI-2 in patients with seizure disorders.

Aortic stiffness is being recognized as a predictor of cardiovascular disease (CVD) and all-cause mortality independent of blood pressure (BP), age, and other CVD risk factors.1 Aortic stiffness can be measured noninvasively by carotid–femoral pulse wave velocity (cfPWV), which is considered the gold standard method. In fact, the European Society of Hypertension/European Society of Cardiology added cfPWV as a factor to assess future CVD risk in recently published guidelines for the management of arterial hypertension.2 A recent meta-analysis reported that supplementation of marine n-3 fatty acids (FAs) improved aortic stiffness.3 The randomized clinical trials (RCTs) in the meta-analysis4–12 and 1 more recent RCT13 have several characteristics. First, subjects in these RCTs were individuals with type 2 diabetes,5,9 metabolic syndrome,10 hyperlipidemia,11,12 or individuals who were obese or overweight.4,6–8 Thus, the result may not be extrapolated to the general population. Second, although the differential effect of 2 major marine n-3 FAs: eicosapentaenoic (EPA; 20:5 n-3) and docosahexaenoic acids (DHA; 22:6 n-3), on CVD risk factors is a current research topic,14 only 1 RCT11 reported the effect of each of DHA and EPA on aortic stiffness separately. Third, although cfPWV is regarded as the gold standard to evaluate aortic stiffness, these RCTs, except for one study,13 used other methods. Finally, most of these RCTs examined the effect of >1 gram of fish oil on aortic stiffness,4–7,9–11,15 as compared with

The purpose of this study was to evaluate the pre-defined "Heat, excessive" query in BioSense 2.0 using data from Maricopa County, Arizona. BioSense was used to produce a line list of 539 patient records from the period between 1/1/15 and 8/15/15. Records with a clinical diagnosis for heat-related illness (HRI) were classified as confirmed HRI cases (N = 268). The chief complaints of the remaining 271 records were reviewed manually; 148 records were probable HRI cases and 91 records were ruled out for HRI. To make the query more specific, a list of potential exclusion terms was created and evaluated.

Arizona is facing multiple threats from mosquito-borne diseases. Traditional surveillance, however, may take as long as 14 days between specimen collection and laboratory reporting to the health department. The Arizona Department of Health Services partnered with local public health jurisdictions to enhance traditional arboviral surveillance by incorporating syndromic surveillance. The objectives of this project were to develop a protocol for enhancing traditional arboviral surveillance with syndromic surveillance and to evaluate the protocol for accuracy, effectiveness, and timeliness.

In an effort to enhance situational awareness, Maricopa County Department of Public Health (Arizona) dedicated resources to begin developing a robust syndromic surveillance program. This abstract shares how the CDC Framework for Program Evaluation and a logic model were used to enhance syndromic surveillance at a local public health department.

Background— Both HIV and depression are associated with increased heart failure (HF) risk. Depression, a common comorbidity, may further increase the risk of HF among adults with HIV infection (HIV+). We assessed the association between HIV, depression, and incident HF. Methods and Results— Veterans Aging Cohort Study (VACS) participants free from cardiovascular disease at baseline (n=81 427: 26 908 HIV+, 54 519 without HIV [HIV−]) were categorized into 4 groups: HIV− without major depressive disorder (MDD) [reference], HIV− with MDD, HIV+ without MDD, and HIV+ with MDD. International Classification of Diseases, Ninth Revision codes from medical records were used to determine MDD and the primary outcome, HF. After 5.8 years of follow-up, HF rates per 1000 person-years were highest among HIV+ participants with MDD (9.32; 95% confidence interval [CI], 8.20–10.6). In Cox proportional hazards models, HIV+ participants with MDD had a significantly higher risk of HF (adjusted hazard ratio, 1.68; 95% CI, 1.45–1.95) compared with HIV− participants without MDD. MDD was associated with HF in separate fully adjusted models for HIV− and HIV+ participants (adjusted hazard ratio, 1.21; 95% CI, 1.06–1.37; and adjusted hazard ratio, 1.29; 95% CI, 1.11–1.51, respectively). Among those with MDD, baseline antidepressant use was associated with lower risk of incident HF events (adjusted hazard ratio, 0.76; 95% CI, 0.58–0.99). Conclusions— Our study is the first to suggest that MDD is an independent risk factor for HF in HIV+ adults. These results reinforce the importance of identifying and managing MDD among HIV+ patients. Future studies must clarify mechanisms linking HIV, MDD, antidepressants, and HF and identify interventions to reduce HF morbidity and mortality in those with both HIV and MDD.

Infants with intrauterine growth restriction (IUGR) are at increased risk for neonatal and lifelong morbidities affecting multiple organ systems including the intestinal tract. The underlying mechanisms for the risk to the intestine remain poorly understood. In this study, we tested the hypothesis that IUGR affects the development of goblet and Paneth cell lineages, thus compromising the innate immunity and barrier functions of the epithelium. Using a mouse model of maternal thromboxane A2-analog infusion to elicit maternal hypertension and resultant IUGR, we tested whether IUGR alters ileal maturation and specifically disrupts mucus-producing goblet and antimicrobial-secreting Paneth cell development. We measured body weights, ileal weights and ileal lengths from birth to postnatal day (P) 56. We also determined the abundance of goblet and Paneth cells and their mRNA products, localization of cellular tight junctions, cell proliferation, and apoptosis to interrogate cellular homeostasis. Comparison of the murine findings with human IUGR ileum allowed us to verify observed changes in the mouse were relevant to clinical IUGR. At P14 IUGR mice had decreased ileal lengths, fewer goblet and Paneth cells, reductions in Paneth cell specific mRNAs, and decreased cell proliferation. These findings positively correlated with severity of IUGR. Furthermore, the decrease in murine Paneth cells was also seen in human IUGR ileum. IUGR disrupts the normal trajectory of ileal development, particularly affecting the composition and secretory products of the epithelial surface of the intestine. We speculate that this abnormal intestinal development may constitute an inherent "first hit", rendering IUGR intestine susceptible to further injury, infection, or inflammation.

Depression is associated with an increased risk of heart failure (HF) among HIV infected (HIV+) and uninfected (HIV-) veterans. Antidepressants are commonly prescribed to mitigate psychosocial symptoms related to major depressive disorder (MDD). The purpose of this study was to determine whether antidepressant use was associated with lower HF risk among a large cohort of HIV+ and HIV- veterans with MDD. We analyzed data on 13,849 veterans (36.5% HIV+) from the Veterans Aging Cohort Study (VACS), a prospective study of HIV+ and matched HIV- veterans who had a diagnosis of MDD (ICD-9 codes 296.2x & 296.3x) and were free of cardiovascular disease (CVD) at baseline. Antidepressant use was defined as documentation of selective serotonin reuptake inhibitor (SSRIs), tricyclic antidepressant (TCAs), and non-SSRI, non-TCA antidepressant use from the VA pharmacy records during the baseline period (1998 - 2003). Incident HF was identified using ICD-9 codes and defined as first HF event on or after 4/1/2003 until 12/31/2009. We used Cox proportional hazards regression to assess the association between HIV infection, antidepressant use and incident HF, adjusting for covariates (Table). Most participants were on antidepressant therapy [90.2% (12,498 of 13,849)]. In the total sample, baseline antidepressant use was associated with a lower risk of HF, adjusting for all covariates including HIV (adjusted HR = 0.76, 95% CI = 0.58 - 0.99). The rates of incident HF were highest among HIV+ participants who did not use antidepressants (Table). Among the HIV+ participants, the association between antidepressant use and lower HF risk neared significance (p = 0.053). Antidepressant use was common among this cohort of veterans with MDD and was associated with a lower risk of incident HF. Our study lends support to further investigations to determine the importance of antidepressants as additional therapy for CVD prevention among MDD patients with and without HIV.

Objective: The metabolic syndrome (MetS) and subclinical CVD measures are associated with a higher risk of future cardiovascular disease (CVD) events. Furthermore, individuals with MetS have a greater burden of subclinical CVD, such as the presence of carotid plaque (CP) and larger adventitial diameter (AD). Midlife women proceeding through the menopausal transition are vulnerable to developing MetS and are also at greater risk of CVD, a risk that varies by race/ethnicity. We hypothesized that there are racial/ethnic differences in the association between MetS and measures of subclinical atherosclerosis. Methods: Participants from 6 sites of the Study of Women’s Health Across the Nation (SWAN) were analyzed if they were free of clinical CVD and had measures of CP and AD at the 12th annual visit. Women were identified as having MetS if they met the criteria defined by the International Diabetes Federation (IDF). Multivariable logistic and linear regression models were used to investigate the relationship of MetS with CP and AD overall and separately within each race/ethnicity group. Study site, age, height, LDL-C, smoking status, menopausal status, hormone use, and education level were included as covariates. Further analysis adjusted for inflammatory and metabolic biomarkers. Results: The 1454 women were, on average, 59.6 years old 43.5% had evidence of MetS, and 85.8% were postmenopausal. The race/ethnicity breakdown was 51.1% White, 30.3% Black, 12.7% Chinese, and 5.8% Hispanic. Overall, MetS was associated with the presence of CP and higher AD after adjusting for covariates (OR (95%): 1.65 (1.31, 2.08); β (SE): 0.344(0.035) mm, p< .0001, respectively). In race-specific models, MetS was significantly associated with AD in White, Black, Hispanic, and Chinese participants, adjusting for covariates (β (SE): 0.305 (0.043) p Conclusion: MetS is associated with subclinical atherosclerosis, and the association varies by race/ethnicity in midlife women. This variation may help explain differences in incidence rates of CVD events between racial/ethnic groups.

Limited data are available about risk factors for the progression of aortic stiffness in healthy population. We examined several risk factors as possible independent predictors of aortic stiffness progression among a population-based sample of US men.A total of 240 men (40-49 years) free of CVD at baseline from the Pittsburgh site of the ERA JUMP study were evaluated. Aortic stiffness was measured as carotid-femoral pulse wave velocity at baseline and after 4.6 ± 0.2 (mean ± SD) years of follow-up. Progression of aortic stiffness was evaluated as relative annual change in carotid-femoral pulse wave velocity (% change/year). Using linear regression, both baseline potential risk factors and their annual changes were evaluated as possible risk factors for aortic stiffness progression. Baseline age, follow-up time, race, heart rate, and medications use were forced in all models.During follow-up, relative to baseline level, aortic stiffness increased 0.3% ± 5.3% per year. In final models, the independent predictors of degree of aortic stiffness progression were lower levels of adiponectin (P = 0.03), higher levels of systolic blood pressure (P = 0.03), greater annual change in systolic blood pressure (P = 0.04), and alcohol consumption ≥ 2 times/week (P = 0.02). Adiponectin levels within the third (9.8 μg/Ml ≤ adiponectin13.0 μg/mL) and the fourth (adiponectin ≥ 13.0 μg/mL) quartiles were associated with an improvement in relative annual aortic stiffness progression (P = 0.02, P = 0.01, respectively) compared to levels within the first quartile (adiponectin ≤ 7.0 μg/mL).Among apparently healthy men, lower levels of baseline adiponectin could be a novel marker for greater risk of aortic stiffness progression. Longitudinal research is required to evaluate whether adiponectin change over time would have similar association with aortic stiffness progression.