Public Health Reports®

The Laboratory Response Network (LRN) consists of US and international laboratories that respond to public health emergencies, such as biothreats. We used a qualitative approach to assess the successes and challenges of the LRN during the initial 10 weeks of the 2022 mpox outbreak (May 17–July 31, 2022).

We conducted 9 unstructured interviews, which included 3 interviews with subject matter experts from the Centers for Disease Control and Prevention (CDC) and 6 interviews with state and local public health laboratories and epidemiologists and Association of Public Health Laboratories (APHL) staff. We asked guiding questions on investments in preparedness, successes, and challenges during the initial mpox response and asked for suggestions to improve future LRN responses to infectious disease outbreaks. We also reviewed data from 2 contemporaneous APHL surveys conducted in June and July 2022 in 84 LRN public health laboratories.

Notable successes included availability of an assay that had received clearance from the US Food and Drug Administration (FDA) for testing orthopoxviruses (non-variola Orthopoxvirus [NVO] assay) and a trained workforce; strong relationships among FDA, CDC, and the LRN; and strong communications between LRN laboratories and CDC. Challenges included variability among LRN laboratories in self-reported testing capacity, barriers to accessing the NVO assay for health care providers, and gaps in LRN function during surges of testing needs.

The LRN system plays an essential role in the response to emerging infectious disease outbreaks in the United States. Lessons learned from the LRN’s initial response to the mpox outbreak can help guide improvements to better position the LRN for future responses, including continued engagement with health care providers, commercial laboratories, and laboratories in health care settings.

Occupational health surveillance programs have rarely incorporated syndromic surveillance. We documented a process for evaluating and revising syndromic surveillance definitions, using the example of work-related emergency department (ED) visits.

Of 140 331 481 ED visits in the National Syndromic Surveillance Program from May 15, 2016, through October 31, 2017, we extracted 391 827 records for phase 1 that met the previously unevaluated original work-related definition or included a work-related employment status ICD-10-CM code (Y99.0/Y99.1; International Classification of Diseases, Tenth Revision, Clinical Modification). Also for phase 1, we evaluated the performance of the original work-related definition using ICD-10-CM work-related employment status codes as a reference standard. In phase 2, we extracted 99 109 records containing candidate work-related keywords. Finally, in phase 3, we examined individual keywords and developed and evaluated a revised definition.

The revised work-related definition identified 259 153 visits by keyword alone, 104 342 visits by ICD-10-CM work-related employment status codes alone, and 16 385 ED visits by both methods. Sensitivity (13.6% vs 11.3%) and positive predictive value (5.9% vs 4.8%) were higher for the revised definition than for the original work-related definition. Manual review indicated that 91.3% (95% CI, 89.6%-93.0%) of visits identified by the revised definition keywords met the study criteria for work-related visits as compared with 75.5% (95% CI, 73.0%-78.4%) of visits for the original work-related definition.

The original work-related definition performed suboptimally because keywords were not sufficiently specific. The revised definition is an improvement but requires testing in real-world scenarios. The presented methods for developing a syndromic surveillance definition are useful, not only for occupational health, but for identification of other subpopulations treated in the ED.

Although enteric disease case interviews are critical for control measures and education, not all case-patients are interviewed. We evaluated systematic differences between people with an enteric disease in Colorado who were and were not interviewed to identify ways to increase response rates and reduce biases in the surveillance data used to guide public health interventions.

We obtained data from the Colorado Electronic Disease Reporting System from March 1, 2017, through December 31, 2019. Among case-patients not interviewed and interviewed, we used univariate analyses to describe sociodemographic characteristics, timing of contact attempts, and effect of additional funding.

As compared with case-patients who were interviewed, case-patients who were not interviewed were significantly more likely to be aged 18 to 39 years (35.7% vs 31.7%; P < .001); identify as male, Hispanic, or Black; be experiencing homelessness or hospitalization; reside in rural/frontier areas or an institution; or live in areas with lower levels of education, life expectancy, and income. Time to first contact attempt was longer for case-patients who were not interviewed than for those who were (mean days from specimen collection to first contact attempt, 9.8 vs 6.8; P < .001). Residing in a jurisdiction with additional funding for interviewing was associated with increased interview rates (87.7% vs 68.8%) and timeliness of public health report and first contact attempt (2.3 vs 4.4 days; P < .001).

Findings can guide efforts to improve response rates in groups least likely to be interviewed, resulting in reduced biases in surveillance data, better disease mitigation, and increased efficiency in case investigations. Timeliness of case interviews and additional funding to conduct case investigations were factors in increasing response rates.

The HealthPartners’ Vaccine Safety Datalink (VSD) team maintains standardized files of vaccines from medical and pharmacy claims and electronic health records (established data sources) for safety surveillance. Since 2021, for selected vaccines, data from the Minnesota Immunization Information Connection (MIIC), Minnesota’s immunization information system, have been added to the HealthPartners’ VSD files. We examined how MIIC data have enhanced the identification of novel and routine vaccines.

We describe the approach to incorporating MIIC data. We determined and compared the number and proportion of vaccines identified from established data sources with the additional capture of vaccine data identified from MIIC, in which age group and period of observation varied by vaccine.

As of December 31, 2023, of 1 099 411 people in the HealthPartners’ VSD cohort, 1 001 400 people (91%) were linked with an MIIC record. Across all data sources, for the full cohort, >2.7 million COVID-19 vaccine doses were recorded since 2020, >4000 mpox vaccine doses since 2022, >7.3 million influenza vaccine doses since 2004, >600 000 human papillomavirus (HPV) vaccine doses since 2006, and >1.1 million diphtheria and tetanus toxoids and acellular pertussis (DTaP) vaccine doses since 2004. For COVID-19 vaccines, about 30% of vaccine doses were exclusively captured from MIIC, with the remaining 70% from established data sources. For the mpox vaccine, about 42% were exclusively from MIIC. For influenza, HPV, and DTaP vaccines, about 20%, 14%, and 17%, respectively, were exclusively identified from MIIC.

Incorporation of data from state immunization information systems into existing vaccine data files can enhance monitoring on the safety of novel vaccines administered outside traditional health care settings and can enhance data quality for routine childhood and adult vaccines.

Prenatal alcohol exposure poses a substantial risk to fetal development. Efforts were made in 2011-2020 to increase public awareness of and prevent alcohol consumption during pregnancy. We conducted a cross-sectional survey in Israel of pregnant women’s alcohol consumption from January 2021 through June 2023 and compared our results with the results of a survey conducted during 2009-2010 to assess changes over time.

We conducted cross-sectional surveys at 3 public hospitals in central and northern Israel. Surveyors visited hospitals twice weekly and used a questionnaire consistent with one used in 2009-2010 that focused on alcohol consumption 3 months before pregnancy and during pregnancy. We conducted a stratified analysis of the prevalence of alcohol consumption during pregnancy by demographic characteristics. We also used a multivariable logistic regression model to examine variables associated with receiving guidance on alcohol consumption during pregnancy.

Of 1915 women in the 2021-2023 survey (mean [SD] age, 30.8 [5.6] y), 1204 (62.9%) reported never consuming alcohol before pregnancy and 1708 (89.2%) reported no alcohol consumption during pregnancy. During pregnancy, 157 (8.2%) women reported consuming alcohol weekly or less, 12 (0.6%) more frequently, and 52 (2.7%) binge drinking. We found a significant decrease in alcohol consumption during pregnancy in 2021-2023 as compared with 2009-2010 (odds ratio, 0.68; 95% CI, 0.52-0.88; P = .03). Predictors of alcohol consumption during pregnancy included alcohol consumption before pregnancy, parity, and smoking. Significantly more women in the 2021-2023 sample (n = 569; 29.7%) than in the 2009-2010 sample received guidance on alcohol consumption during pregnancy (P < .001).

Educational efforts should continue to increase awareness of the risks of prenatal alcohol exposure in the general population and among health professionals.

Studies have demonstrated that people with disabilities are more likely to use cannabis than people without disabilities. However, less is known about novel forms of use, such as cannabis vaping, in this population. We examined the correlates of cannabis vaping among people with disabilities and the association between cannabis vaping and the frequency of cannabis use in any form.

We used data from the 2022 Behavioral Risk Factor Surveillance System to examine the association between disabilities and past-month cannabis vaping, as well as the number of days that cannabis was used in the past month, among US adults. We used weighted multivariable logistic and modified Poisson regression models with incidence rate ratios to examine the associations.

The prevalence of cannabis vaping was higher among adults with any disability (4.6%) than among adults without disabilities (2.8%); adults with only cognitive disabilities had the highest prevalence (8.2%). Daily nicotine vaping (adjusted odds ratio [AOR] = 6.04; 95% CI, 4.14-8.80), former cigarette smoking status (AOR = 1.67; 95% CI, 1.25-2.25), and being aged 18-24 years (vs ≥65 y) (AOR = 11.07; 95% CI, 7.05-17.38) were associated with higher odds of cannabis vaping among adults with any disability. Disability status modified the relationship between cigarette smoking and cannabis vaping (P < .001). Additionally, among adults with disabilities, the rate of cannabis-use days was higher among adults who vaped cannabis (adjusted incidence rate ratio = 1.28; 95% CI, 1.19-1.36) than among adults who did not vape cannabis.

Among adults with disabilities, nicotine consumption by vaping was associated with cannabis vaping. Our findings highlight the need for interventions that reduce the risk of polysubstance use (ie, nicotine and cannabis) in this population.

To improve rapid detection and response to spikes in suspected nonfatal opioid overdoses in the community, the Rhode Island Department of Health (RIDOH) sought to modify its case definition to align with newly released guidance from the Council of State and Territorial Epidemiologists (CSTE).

RIDOH used CSTE guidance to create 2 alternative criteria (CSTE-guided and RIDOH-modified CSTE) to replace one of RIDOH’s original criteria. We gathered emergency medical services (EMS) records from 4 months in 2022 to determine whether they met any criteria, and we reviewed them to determine the accuracy of identifying an opioid overdose. We calculated the positive predictive value for each criterion individually and as a complete case definition (RIDOH original definition, CSTE-guided definition, and RIDOH-modified CSTE definition).

The RIDOH-modified CSTE case definition was adopted because it had a positive predictive value of 91.5% in identifying nonfatal opioid overdose–related EMS incidents, similar to the original definition (91.3%) and higher than the CSTE-guided definition (82.2%). The RIDOH-modified CSTE case definition identified 624 additional nonfatal opioid overdoses in EMS data from 2018 through 2022, a 7% increase from the original definition.

The RIDOH-modified CSTE case definition increased RIDOH’s ability to detect suspected nonfatal opioid overdoses while maintaining the accuracy of the case definition. With the new case definition, RIDOH aims to improve allocation of resources to communities experiencing increased overdose burden.

Serologic testing is a useful adjunct for the diagnosis of Lyme disease, a major public health problem in certain US regions. We aimed to determine whether Lyme disease serologic testing and results differed by sex and age group.

We identified 2 cohorts of individuals across all ages who underwent serologic testing for Lyme disease at a national reference laboratory in 2019 (cohort 1) and 2022 (cohort 2). If an individual had multiple tests in the same year, we included only the first test. We excluded individuals who had been tested in the previous 5 years.

Cohorts 1 and 2 consisted of 578 052 and 550 674 people, respectively. Fewer males than females were tested in cohort 1 (42.7% vs 57.3%) and cohort 2 (42.3% vs 57.7%), although similar numbers were tested for both sexes among nonadults. More males than females had a positive test result in cohort 1 (53.9% more males) and cohort 2 (52.9% more males). The odds ratio of receiving a positive test result among males versus females was 2.09 (95% CI, 2.01-2.17) in cohort 1 and 2.12 (95% CI, 2.05-2.19) in cohort 2. Among people with positive test results, females (except children) were more likely than males to have positive immunoglobulin M and negative immunoglobulin G results, which can serve as a marker of early infection (odds ratio = 1.43 [95% CI, 1.31-1.55] in cohort 1 and 1.38 [95% CI, 1.29-1.47] in cohort 2).

Further studies are needed to understand whether the observed differences in Lyme disease testing and positivity result from sex- and age-associated disparities in social behavior, health care seeking, clinical practice, or other factors.

Alaska has among the highest traumatic brain injury (TBI) mortality rates in the United States. We characterized the epidemiology of TBIs in the country’s largest and most sparsely populated state to guide prevention efforts.

This cross-sectional study analyzed TBI-associated hospitalization and mortality rates in Alaska from 2016 through 2021. Data included people with TBI-associated hospitalization or death in Alaska. We compared age-adjusted rates using national data, with analysis by age, sex, race and ethnicity, and injury mechanism. Logistic regression explored factors influencing mortality among hospitalized patients with TBI.

TBI-associated hospitalization rates per 100 000 population in Alaska were highest among adults aged ≥75 years (310.4), by sex among males (123.3), and by race among American Indian and Alaska Native (AI/AN) people (186.7). Patients with TBI-associated hospitalizations due to self-harm were approximately 8.6 times as likely to die as patients with unintentional injuries. Alaska’s age-adjusted TBI-associated mortality rate per 100 000 population was twice the national rate (36.2 vs 17.3). TBI-associated mortality rates in Alaska exceeded national averages across all demographic characteristics and injury mechanisms. Adults aged ≥75 years, males, and AI/AN people in Alaska had TBI-associated death rates that were 1.3, 1.9, and 2.0 times higher, respectively, than national rates. Alaska’s TBI-associated mortality rate from suicide was 2.6 times the national average, with notable racial disparities for AI/AN people.

TBIs are a considerable source of morbidity and mortality in Alaska, with disproportionate effects observed among population groups. These findings underscore the need for increased focus on mechanism-specific TBI prevention activities, particularly for older adults and AI/AN people.