Improving COVID-19 Disease Severity Surveillance Measures: Statewide Implementation Experience.

Measurement of the burden of COVID-19 on U.S. hospitals has been an important element of the public health response to the pandemic. However, because of variation in testing density and policies, the metric is not standardized across facilities. Two types of burdens exist, one related to the infection control measures that patients who test positive for SARS-CoV-2 require and one from the care of severely ill patients receiving treatment of COVID-19. With rising population immunity from vaccination and infection, as well as the availability of therapeutics, severity of illness has declined. Prior research showed that dexamethasone administration was highly correlated with other disease severity metrics and sensitive to the changing epidemiology associated with the emergence of immune-evasive variants.On 10 January 2022, the Massachusetts Department of Public Health began requiring hospitals to expand surveillance to include reports of both the total number of "COVID-19 hospitalizations" daily and the number of inpatients who received dexamethasone at any point during their hospital stay. All 68 acute care hospitals in Massachusetts submitted COVID-19 hospitalization and dexamethasone data daily to the Massachusetts Department of Public Health over a 1-year period. A total of 44 196 COVID-19 hospitalizations were recorded during 10 January 2022 to 9 January 2023, of which 34% were associated with dexamethasone administration. The proportion of patients hospitalized with COVID-19 who had received dexamethasone was 49.6% during the first month of surveillance and decreased to a monthly average of approximately 33% by April 2022, where it has remained since (range, 28.7% to 33%).Adding a single data element to mandated reporting to estimate the frequency of severe COVID-19 in hospitalized patients was feasible and provided actionable information for health authorities and policy makers. Updates to surveillance methods are necessary to match data collection with public health response needs.

The next 'pandemic playbook' needs to prioritize the needs of children-and a clear roadmap for opening schools.

The national influenza pandemic response plan includes short-term school closures as an infection mitigation measure, based on modeling data regarding the role of pediatric populations and schools as drivers of disease spread. Modeled estimates regarding the role of children and their in-school contacts as drivers of community transmission of endemic respiratory viruses were used in part to justify prolonged school closures throughout the United States. However, disease transmission models extrapolated from endemic pathogens to novel ones may underestimate the degree to which spread is driven by population immunity and overestimate the impact of school closures as a means of reducing child contacts, particularly in the longer-term. These errors, in turn, may have caused incorrect estimations about the potential benefits of closing schools on a society level while simultaneously failing to account for the significant harms of long-term educational disruption. Pandemic response plans need to be updated to include nuances regarding drivers of transmission such as pathogen type, population immunity, and contact patterns, and disease severity in different groups. Expected duration of impact also needs to be considered, recognizing that effectiveness of different interventions, particularly those focused on limiting social interactions, are short-lived. Additionally, future iterations should include risk-benefit assessments. Interventions that are particularly harmful to certain groups, such as school closures are on children, should be de-emphasized and time limited. Finally, pandemic responses should include ongoing and continuous policy re-evaluation and should include a clear plan for de-implementation and de-escalation.

Medical appropriateness and economics of nucleic acid amplification testing for infectious diseases.

It has become commonplace to assume that nucleic acid amplification tests (NAATs) represent the gold standard for all infectious disease diagnostic testing. This proposition has become increasingly entrenched recently, as these tests can now be done, in comparison to even just a few years ago, relatively inexpensively and with rapid analytic turnaround times. Many can even be performed at the point of care by individuals without technical backgrounds. But there may be a dark underside to this proposition. Could these tests be too sensitive? Are they always "fit for purpose"? Should they trump clinical judgement? Do they have untoward impacts on antimicrobial therapy? Could the profit motive - by manufacturers and by laboratories - be fueling the explosive expansion of NAATs? In this article, we will explore these questions in regard to several specific NAAT examples - Group A Streptococcus, Influenza, SARS-CoV-2, respiratory panels, and sexually transmitted disease panels.

Use of expert consensus to develop a shared list of procedures with potential for aerosol generation during the coronavirus disease 2019 (COVID-19) pandemic.

The coronavirus disease 2019 (COVID-19) pandemic highlighted the lack of agreement regarding the definition of aerosol-generating procedures and potential risk to healthcare personnel. We convened a group of Massachusetts healthcare epidemiologists to develop consensus through expert opinion in an area where broader guidance was lacking at the time.

Effecting the culture: Impact of changing urinalysis with reflex to culture criteria on culture rates and outcomes.

OBJECTIVE: To evaluate the impact of changes to urinalysis with reflex to culture (UARC) reflex criteria on culture performance and clinical decision outcomes. DESIGN: Retrospective study utilizing interrupted time series analysis from December 2018 to November 2020. Primary outcomes were measures of culture performance. Secondary outcomes were rates of antimicrobial prescription for suspected urinary tract infection (UTI) and catheter-associated urinary tract infection (CAUTI). We also assessed harmful events related to antimicrobial prescription for all causes and UTI, UTI symptoms, and sepsis. SETTING: A 415-bed, academic, tertiary-care, medical center. PATIENTS: Hospitalized adult patients with urine testing performed. INTERVENTION: UARC reflex criteria were changed on October 22, 2019, from ≥5×109/L white blood cells (WBCs) or trace leukocyte esterase or positive nitrite units on urinalysis to only ≥15×109/L WBCs. RESULTS: The study included 11,322 unique UARC tests. We detected a significant decrease in the rate of urine cultures performed from UARC after the intervention (32.5-8.7 cultures per 1,000 patient days; P < .001), with improved diagnostic efficacy (ie, culture positivity increased from 34.8% to 62.1%). CAUTI rates did not change. We detected a significant decrease in antimicrobial prescription rates (P = .05), this was primarily driven by preintervention changes. One case of sepsis occurred secondary to a missed UTI, and UTIs were rarely missed after the intervention. CONCLUSIONS: Implementation of a stricter UARC reflex criterion was associated with a decrease in culture rates with improved diagnostic efficacy without significant adverse events. Continued education is needed to change antimicrobial prescribing practices.

Sources of exposure and risk among employees infected with severe acute respiratory coronavirus virus 2 (SARS-CoV-2) in a large, urban, tertiary-care hospital in the United States.

Objective: Hospital employees are at risk of SARS-CoV-2 infection through transmission in 3 settings: (1) the community, (2) within the hospital from patient care, and (3) within the hospital from other employees. We evaluated probable sources of infection among hospital employees based on reported exposures before infection. Design: A structured survey was distributed to participants to evaluate presumed COVID-19 exposures (ie, close contacts with people with known or probable COVID-19) and mask usage. Participants were stratified into high, medium, low, and unknown risk categories based on exposure characteristics and personal protective equipment. Setting: Tertiary-care hospital in Boston, Massachusetts. Participants: Hospital employees with a positive SARS-CoV-2 PCR test result between March 2020 and January 2021. During this period, 573 employees tested positive, of whom 187 (31.5%) participated. Results: We did not detect a statistically significant difference in the proportion of employees who reported any exposure (ie, close contacts at any risk level) in the community compared with any exposure in the hospital, from either patients or employees. In total, 131 participants (70.0%) reported no known high-risk exposure (ie, unmasked close contacts) in any setting. Among those who could identify a high-risk exposure, employees were more likely to have had a high-risk exposure in the community than in both hospital settings combined (odds ratio, 1.89; P = .03). Conclusions: Hospital employees experienced exposure risks in both community and hospital settings. Most employees were unable to identify high-risk exposures prior to infection. When respondents identified high-risk exposures, they were more likely to have occurred in the community.

The COVID-19 Hospitalization Metric in the Pre- and Post-vaccination Eras as a Measure of Pandemic Severity: A Retrospective, Nationwide Cohort Study.

BACKGROUND: COVID-19 hospitalization definitions do not include a disease severity assessment. Thus, we sought to identify a simple and objective mechanism for identifying hospitalized severe cases and to measure the impact of vaccination on trends. METHODS: All admissions to a Veterans Affairs (VA) hospital, where routine screening is recommended, between 3/1/2020-11/22/2021 with SARS-CoV-2 were included. Moderate-to-severe COVID-19 was defined as any oxygen supplementation or any SpO2 <94% between one day before and two weeks after the positive SARS-CoV-2 test. Admissions with moderate-to-severe disease were divided by the total number of admissions, and the proportion of admissions with moderate-to-severe COVID-19 was modelled using a penalized spline in a Poisson regression and stratified by vaccination status. Dexamethasone receipt and its correlation with moderate-to-severe cases was also assessed. RESULTS: Among 67,025 admissions with SARS-CoV-2, the proportion with hypoxemia or supplemental oxygen fell from 64% prior to vaccine availability to 56% by November 2021, driven in part by lower rates in vaccinated patients (vaccinated, 52% versus unvaccinated, 58%). The proportion of cases of moderate-to-severe disease identified using SpO2 levels and oxygen supplementation was highly correlated with dexamethasone receipt (correlation coefficient, 0.95), and increased after 7/1/2021, concurrent with delta variant predominance. CONCLUSIONS: A simple and objective definition of COVID-19 hospitalizations using SpO2 levels and oxygen supplementation can be used to track pandemic severity. This metric could be used to identify risk factors for severe breakthrough infections, to guide clinical treatment algorithms, and to detect trends in changes in vaccine effectiveness over time and against new variants.

Cycle threshold values and SARS-CoV-2: Relationship to demographic characteristics and disease severity.

Cycle threshold (Ct), or the number of cycles required to amplify viral RNA to a detectable level, provides an estimate of viral load. Previous studies have demonstrated mixed results in regard to the association between SARS-CoV-2 Ct from real-time reverse transcriptase PCR (rRT-PCR) testing to patient outcomes, and there is less data on the relationship between Ct and patient characteristics. This was a retrospective study of 256 patients tested at a tertiary care emergency department from March to July 2020 via nasopharyngeal rRT-PCR testing utilizing the Abbott M2000 SARS-CoV-2 assay. Kruskal-Wallis, univariable, and multivariable logistic regression were used where appropriate for analysis. There were no significant differences in Ct value by demographic characteristics including age, sex, race, or ethnicity. Ct increased with time since symptom onset (p < 0.001), and increasing Ct was associated with increased odds of severe disease (odds ratio: 1.05, 95% confidence interval: 1.0-1.11). Ct was not found to be associated with patient demographic characteristics and increasing Ct was found to be associated with increased odds of severe disease. Continued study will allow us to better comprehend the complex factors that contribute to the risk for severe outcomes due to SARS-CoV-2 infection.

Racial/ethnic disparities in antibiotic-resistant infections: Knowledge gaps and opportunities for educational interventions

IMPACT: By identifying clear gaps in our knowledge of racial and ethnic disparities in antibiotic-resistant infections, this research is informing the design of (a) community-based interventions and (b) patient-centered research studies that we are currently leading to address these disparities and improve human health. OBJECTIVES/GOALS: Antibiotic resistance (AR) is widely considered to be the next global pandemic. As with COVID-19, the potential for AR to disproportionately impact racial/ethnic minorities is a major concern. Our goal was to identify gaps in knowledge of AR disparities in order to inform the types of interventions that might be most appropriate to address this. METHODS/STUDY POPULATION: We reviewed the literature to examine evidence of racial/ethnic disparities in (a) infections with the most concerning drug-resistant bacteria in the United States, and (b) underlying social-economic or behavioral factors that could contribute to such infections. We searched PubMed and Google Scholar to identify studies published in English between August 1973 - August 2020. We used keywords that included: antibiotic resistance, antibiotic-resistant infections, antibiotic-seeking behavior, prescription/non-prescription antibiotic use, antibiotic education, or health literacy AND race, ethnicity, or socioeconomic status. We screened all s to identify US-based studies that assessed (a) or (b) above. RESULTS/ANTICIPATED RESULTS: We identified 11 studies investigating racial/ethnic disparities for 5 of the 17 drug-resistant bacteria flagged in the CDC’s 2019 Antibiotic Resistance Threats Report. Black, Hispanic, and lower-income individuals were found to be at higher risk of some community-acquired antibiotic-resistant infections. We identified multiple factors that may contribute to disparities in AR-related morbidity and mortality, including reported differences in antibiotic use, higher likelihood of living in crowded/multigenerational homes, more frequent employment in potentially high exposure settings (e.g. slaughterhouses), lower health literacy, and more frequent underlying comorbidities, which increases risks for hospitalization and subsequent acquisition of drug-resistant infections. DISCUSSION/SIGNIFICANCE OF FINDINGS: Given the small number of studies on this topic, educational interventions that aim to raise awareness of this issue must target not only the public but also researchers. Community-based interventions that seek to address disparities in ‘antibiotic resistance literacy’ among minority and underserved groups could be particularly impactful.

A Test-to-Stay Modified Quarantine Program for COVID-19 in Schools.

BACKGROUND AND OBJECTIVES: Mandatory quarantine upon exposure to coronavirus disease 2019 (COVID-19) results in a substantial number of lost days of school. We hypothesized that implementation of a state-wide test-to-stay (TTS) program would allow more students to participate in in-person learning, and not cause additional clusters of COVID-19 cases due to in-school transmission. METHODS: For the 2020-2021 academic year, Massachusetts implemented an opt-in TTS program, in which students exposed to COVID-19 in school are tested each school day with a rapid antigen test. If negative, students may participate in school-related activities that day. Testing occurs daily for a duration of 7 calendar days after exposure. Here, we report the results from the first 13 weeks of the program. RESULTS: A total of 2298 schools signed up for TTS, and 504 167 individuals out of a total population of 860 457 consented. During the first 13 weeks with complete data, 1959 schools activated the program at least once for 102 373 individual, exposed students. Out of 328 271 tests performed, 2943 positive cases were identified (per person positivity rate, 2.9%, 95% confidence interval, 2.8-3.0). A minimum of 325 328 and a maximum of 497 150 days of in-person school were saved through participation in the program. CONCLUSIONS: Daily, rapid on-site antigen testing is a safe and feasible alternative to mandatory quarantine and can be used to maximize safe in-person learning time during the pandemic.

Weekly SARS-CoV-2 screening of asymptomatic kindergarten to grade 12 students and staff helps inform strategies for safer in-person learning.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission in K-12 schools was rare during in 2020-2021; few studies included Centers for Disease Control and Prevention (CDC)-recommended screening of asymptomatic individuals. We conduct a prospective observational study of SARS-CoV-2 screening in a mid-sized suburban public school district to evaluate the incidence of asymptomatic coronavirus disease 2019 (COVID-19), document frequency of in-school transmission, and characterize barriers and facilitators to asymptomatic screening in schools. Staff and students undergo weekly pooled testing using home-collected saliva samples. Identification of >1 case in a school prompts investigation for in-school transmission and enhancement of safety strategies. With layered mitigation measures, in-school transmission even before student or staff vaccination is rare. Screening identifies a single cluster with in-school staff-to-staff transmission, informing decisions about in-person learning. The proportion of survey respondents self-reporting comfort with in-person learning before versus after implementation of screening increases. Costs exceed $260,000 for assays alone; staff and volunteers spend 135-145 h per week implementing screening.

First Do No Harm: Moving Beyond Universal Preprocedural Testing for COVID-19.

Preprocedural testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was introduced early in the pandemic in an effort to protect health care workers, direct appropriate use of personal protective equipment (PPE), and improve patient outcomes. In light of our appreciation for the efficacy of PPE and the nuances associated with interpretation of polymerase chain reaction testing for SARS-CoV-2, particularly as community transmission decreases, we call for a re-evaluation of universal preprocedural testing. We propose a transition to a patient-centered approach, focusing on testing patients whose outcomes would be improved by a delayed procedure in the event of a positive test and a greater reliance on appropriate PPE rather than preprocedural test results. We recommend that a community infection rate threshold be set at which point preprocedural testing is discontinued, understanding that there is an inflection point at which testing downsides outweigh the benefits.

The prevalence of asymptomatic carriers of COVID-19 as determined by routine preoperative testing.

BACKGROUND: The coronavirus disease SARS-CoV-2 (COVID-19) has swiftly spread throughout the globe, greatly influencing all aspects of life. As in previous pandemics, concerns for limited resources and a sustainable medical workforce have been on the forefront of infrastructure modifications. Consequently, surgical specialties have needed to consider each surgical case for necessity and safety during the COVID-19 outbreak. At our institution, availability of SARS-CoV-2 assay has allowed preoperative testing of asymptomatic surgical patients. AIM/OBJECTIVE: To better define the prevalence of asymptomatic carriers in a surgical population and to better understand the impact of testing on our personal protective equipment (PPE) supply. METHODS: We began routine, preoperative testing for all asymptomatic patients coming to our academic medical centre on 30 March 2020. Scheduled surgeries were deemed urgent by the surgeon with a review for appropriateness by a novel surgical committee. A retrospective patient chart review was performed. Emergency surgeries were excluded. Asymptomatic patients with positive test results had their surgeries rescheduled at the discretion of the surgeon and patient. Patients who tested negative underwent surgery with staff using standard PPE. RESULTS: Eighty-four asymptomatic surgical patients were tested preoperatively with three (3.6%) testing positive for SARS-CoV-2. Preoperative testing saved 498 N95 respirators over this time period. DISCUSSION: This is the first report of routine COVID-19 preoperative testing in an asymptomatic surgical population. Within this population, there is a 3.6% rate of asymptomatic SARS-CoV-2 carriers. Through this practice, personnel exposure can be minimised and access to PPE can be preserved.