Individual-level determinants of COVID-19 vaccination in pregnant people in East Tennessee.

OBJECTIVE: Coronavirus disease 2019 (COVID-19) infection during pregnancy increases the risk of severe illness and death. This study describes individual-level determinants of COVID-19 vaccination among pregnant people in East Tennessee. METHODS: Advertisements for the online Moms and Vaccines survey were placed in prenatal clinics in Knoxville, Tennessee. Determinants were compared between unvaccinated individuals and those partially or fully vaccinated for COVID-19. RESULTS: Wave 1 of the Moms and Vaccines study included 99 pregnant people: 21 (21.2%) were unvaccinated and 78 (78.8%) were partially or fully vaccinated. Compared with the unvaccinated individuals, the partially or fully vaccinated patients more often obtained information about COVID-19 from their prenatal care provider (8 [38.1%] vs. 55 [70.5%], P = 0.006) and indicated higher levels of trust in that information (4 [19.1] vs. 69 [88.5%], P < 0.0001). Misinformation was higher in the unvaccinated group overall, although there was no difference in concern for the severity of COVID-19 infection during pregnancy by vaccination status (1 [5.0%] of the unvaccinated vs. 16 [20.8%] of the partially or fully vaccinated, P = 0.183). CONCLUSION: Strategies to counter misinformation are of the utmost importance, particularly pregnancy- and reproductive health-related misinformation, because of the increased risk of severe disease faced by unvaccinated pregnant individuals.

Association of Culturable-Virus Detection and Household Transmission of SARS-CoV-2, California and Tennessee, 2020-2022.

From 2 severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) household transmission studies (enrolling April 2020 to January 2022) with rapid enrollment and specimen collection for 14 days, 61% (43/70) of primary cases had culturable virus detected ≥6 days post-onset. Risk of secondary infection among household contacts tended to be greater when primary cases had culturable virus detected after onset. Regardless of duration of culturable virus, most secondary infections (70%, 28/40) had serial intervals <6 days, suggesting early transmission. These data examine viral culture as a proxy for infectiousness, reaffirm the need for rapid control measures after infection, and highlight the potential for prolonged infectiousness (≥6 days) in many individuals.

Crash harm before and during the COVID-19 pandemic: Evidence for spatial heterogeneity in Tennessee.

Major concerns have been raised about road safety during the COVID-19 pandemic in the US, as the crash fatalities have increased, despite the substantial reduction in traffic. However, a comprehensive analysis of safety-critical events on roadways based on a broader set of traffic safety metrics and their correlates is needed. In addition to fatalities, this study uses changes in total crashes and total monetary harm as additional measures of safety. A comprehensive and unique time-series database of crashes and socio-economic variables is created at the county level in Tennessee. Statistics show that while fatal crashes increase by 8.2%, total crashes decrease by 15.3%, and the total harm cost is lower by about $1.76 billion during COVID-19 (2020) compared with pre-COVID-19 conditions (2019). Several models, including generalized least squares linear, Poisson, and geographically weighted regression models using the differences between 2020 and 2019 values, are estimated to rigorously quantify the correlates of fatalities, crashes, and crash harm. The results indicate that compared to the pre-pandemic periods, fatal crashes that occurred during the pandemic are associated with more speeding & reckless behaviors and varied across jurisdictions. Fatal crashes are more likely to happen on interstates and dark-not-lighted roads and involve commercial trucks. These same factors largely contribute to crash harm. In addition, a greater number of long trips per person not staying home during COVID-19 is found to be associated with more crashes and crash harm. These results can inform policymaking to strengthen traffic law enforcement through appropriate countermeasures, such as the placement of warning signs and the reduction of the speed limit in hotspots.

Healthcare professionals' perceptions and recommendations regarding adolescent vaccinations in Georgia and Tennessee during the COVID-19 pandemic: A qualitative research.

INTRODUCTION: Despite its benefits, HPV vaccine uptake has been historically lower than other recommended adolescent vaccines in the United States (US). While hesitancy and misinformation have threatened vaccinations for many years, the adverse impacts from COVID-19 pandemic on preventive services have been far-reaching. OBJECTIVES: To explore the perceptions and experiences of adolescent healthcare providers regarding routine vaccination services during the COVID-19 pandemic. METHODOLOGY: Between December 2020 and May 2021, in-depth qualitative interviews were conducted via Zoom video conferencing among a purposively selected, diverse group of adolescent healthcare providers (n = 16) within 5 healthcare practices in the US southeastern states of Georgia and Tennessee. Audio recordings were transcribed verbatim and analyzed using a rapid qualitative analysis framework. Our analysis was guided by the grounded theory and inductive approach. RESULTS: Participants reported that patient-provider communications; effective use of presumptive languaging; provider's continuing education/training; periodic reminders/recall messages; provider's personal conviction on vaccine safety/efficacy; early initiation of HPV vaccination series at 9 years; community partnerships with community health navigators/vaccine champions/vaccine advocates; use of standardized forms/prewritten scripts/standard operating protocols for patient-provider interactions; and vaccine promotion through social media, brochures/posters/pamphlets as well as outreaches to schools and churches served as facilitators to adolescent HPV vaccine uptake. Preventive adolescent services were adversely impacted by the COVID-19 pandemic at all practices. Participants highlighted an initial decrease in patients due to the pandemic, while some practices avoided the distribution of vaccine informational materials due to sanitary concerns. CONCLUSION: As part of a larger study, we provided contextual information to refine an intervention package currently being developed to improve adolescent preventive care provision in healthcare practices. Our results could inform the implementation of comprehensive intervention strategies that improve HPV vaccination rates. Additionally, lessons learned (e.g. optimizing patient- provider interactions) could be adopted to expand COVID-19 vaccine acceptance on a sizable scale.

Association Between Neighborhood Factors and Adult Obesity in Shelby County, Tennessee: Geospatial Machine Learning Approach.

BACKGROUND: Obesity is a global epidemic causing at least 2.8 million deaths per year. This complex disease is associated with significant socioeconomic burden, reduced work productivity, unemployment, and other social determinants of health (SDOH) disparities. OBJECTIVE: The objective of this study was to investigate the effects of SDOH on obesity prevalence among adults in Shelby County, Tennessee, the United States, using a geospatial machine learning approach. METHODS: Obesity prevalence was obtained from the publicly available 500 Cities database of Centers for Disease Control and Prevention, and SDOH indicators were extracted from the US census and the US Department of Agriculture. We examined the geographic distributions of obesity prevalence patterns, using Getis-Ord Gi* statistics and calibrated multiple models to study the association between SDOH and adult obesity. Unsupervised machine learning was used to conduct grouping analysis to investigate the distribution of obesity prevalence and associated SDOH indicators. RESULTS: Results depicted a high percentage of neighborhoods experiencing high adult obesity prevalence within Shelby County. In the census tract, the median household income, as well as the percentage of individuals who were Black, home renters, living below the poverty level, 55 years or older, unmarried, and uninsured, had a significant association with adult obesity prevalence. The grouping analysis revealed disparities in obesity prevalence among disadvantaged neighborhoods. CONCLUSIONS: More research is needed to examine links between geographical location, SDOH, and chronic diseases. The findings of this study, which depict a significantly higher prevalence of obesity within disadvantaged neighborhoods, and other geospatial information can be leveraged to offer valuable insights, informing health decision-making and interventions that mitigate risk factors of increasing obesity prevalence.

Respiratory pathogens during the COVID-19 pandemic: Alterations in detection and seasonality in Nashville, Tennessee.

Shortly after the implementation of community mitigation measures in response to severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), sharp declines in respiratory syncytial virus and influenza circulation were noted; post-mitigation circulation of other respiratory pathogens has gone unexplored. We retrospectively analyzed all records of a provider-ordered multiplex test between April 1, 2018, and July 31, 2021, in Nashville, Tennessee, and we noted disrupted historical seasonal patterns for common respiratory pathogens during the SARS-CoV-2 pandemic.

Clinical presentations of adult and pediatric SARS-CoV-2-positive cases in a community cohort, Nashville, Tennessee.

Compared to adults, the prevalence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) illness in children has been lower and less severe. However, reports comparing SARS-CoV-2 infection among children and adults are limited. As part of our longitudinal cohort study of adults and children with SARS-CoV-2 infection and their household contacts in Nashville, Tennessee, we compared the clinical characteristics and outcomes of SARS-CoV-2 infections between children and adults. Children were more likely to be asymptomatically infected and had a shorter illness duration compared to adults. The differences observed in clinical presentation across ages may inform symptom-specific testing, screening, and management algorithms.

SARS-CoV-2 Outbreak among Malayan Tigers and Humans, Tennessee, USA, 2020.

We report an outbreak of severe acute respiratory syndrome coronavirus 2 involving 3 Malayan tigers (Panthera tigris jacksoni) at a zoo in Tennessee, USA. Investigation identified naturally occurring tiger-to-tiger transmission; genetic sequence change occurred with viral passage. We provide epidemiologic, environmental, and genomic sequencing data for animal and human infections.

Access to In-Network Hospitals in Tennessee During the COVID-19 Pandemic.

This cross-sectional study assesses the daily percentage of floor and intensive care unit bed available at in-network hospitals for patients with COVID-19 in Tennessee.

Household Transmission and Clinical Features of SARS-CoV-2 Infections.

OBJECTIVES: Examine age differences in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission risk from primary cases and infection risk among household contacts and symptoms among those with SARS-CoV-2 infection. METHODS: People with SARS-CoV-2 infection in Nashville, Tennessee and central and western Wisconsin and their household contacts were followed daily for 14 days to ascertain symptoms and secondary transmission events. Households were enrolled between April 2020 and April 2021. Secondary infection risks (SIR) by age of the primary case and contacts were estimated using generalized estimating equations. RESULTS: The 226 primary cases were followed by 198 (49%) secondary SARS-CoV-2 infections among 404 household contacts. Age group-specific SIR among contacts ranged from 36% to 53%, with no differences by age. SIR was lower in primary cases age 12 to 17 years than from primary cases 18 to 49 years (risk ratio [RR] 0.42; 95% confidence interval [CI] 0.19-0.91). SIR was 55% and 45%, respectively, among primary case-contact pairs in the same versus different age group (RR 1.47; 95% CI 0.98-2.22). SIR was highest among primary case-contact pairs age ≥65 years (76%) and 5 to 11 years (69%). Among secondary SARS-CoV-2 infections, 19% were asymptomatic; there was no difference in the frequency of asymptomatic infections by age group. CONCLUSIONS: Both children and adults can transmit and are susceptible to SARS-CoV-2 infection. SIR did not vary by age, but further research is needed to understand age-related differences in probability of transmission from primary cases by age.

Sensitivity of Pregnancy Field on the COVID-19 Case Report Form Among Pregnancies Completed Through December 31, 2020: Illinois and Tennessee.

PURPOSE: The considerable volume of infections from SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19), has made it challenging for health departments to collect complete data for national disease reporting. We sought to examine sensitivity of the COVID-19 case report form (CRF) pregnancy field by comparing CRF data to the gold standard of CRF data linked to birth and fetal death certificates. DESCRIPTION: CRFs for women aged 15-44 years with laboratory-confirmed SARS-CoV-2 infection were linked to birth and fetal death certificates for pregnancies completed during January 1-December 31, 2020 in Illinois and Tennessee. Among linked records, pregnancy was considered confirmed for women with a SARS-CoV-2 specimen collection date on or prior to the delivery date. Sensitivity of the COVID-19 CRF pregnancy field was calculated by dividing the number of confirmed pregnant women with SARS-CoV-2 infection with pregnancy indicated on the CRF by the number of confirmed pregnant women with SARS-CoV-2 infection. ASSESSMENT: Among 4276 (Illinois) and 2070 (Tennessee) CRFs that linked with a birth or fetal death certificate, CRF pregnancy field sensitivity was 45.3% and 42.1%, respectively. In both states, sensitivity varied significantly by maternal race/ethnicity, insurance, trimester of prenatal care entry, month of specimen collection, and trimester of specimen collection. Sensitivity also varied by maternal education in Illinois but not in Tennessee. CONCLUSION: Sensitivity of the COVID-19 CRF pregnancy field varied by state and demographic factors. To more accurately assess outcomes for pregnant women, jurisdictions might consider utilizing additional data sources and linkages to obtain pregnancy status.

Association Between Androgen Deprivation Therapy and Mortality Among Patients With Prostate Cancer and COVID-19.

Importance: Androgen deprivation therapy (ADT) has been theorized to decrease the severity of SARS-CoV-2 infection in patients with prostate cancer owing to a potential decrease in the tissue-based expression of the SARS-CoV-2 coreceptor transmembrane protease, serine 2 (TMPRSS2). Objective: To examine whether ADT is associated with a decreased rate of 30-day mortality from SARS-CoV-2 infection among patients with prostate cancer. Design, Setting, and Participants: This cohort study analyzed patient data recorded in the COVID-19 and Cancer Consortium registry between March 17, 2020, and February 11, 2021. The consortium maintains a centralized multi-institution registry of patients with a current or past diagnosis of cancer who developed COVID-19. Data were collected and managed using REDCap software hosted at Vanderbilt University Medical Center in Nashville, Tennessee. Initially, 1228 patients aged 18 years or older with prostate cancer listed as their primary malignant neoplasm were included; 122 patients with a second malignant neoplasm, insufficient follow-up, or low-quality data were excluded. Propensity matching was performed using the nearest-neighbor method with a 1:3 ratio of treated units to control units, adjusted for age, body mass index, race and ethnicity, Eastern Cooperative Oncology Group performance status score, smoking status, comorbidities (cardiovascular, pulmonary, kidney disease, and diabetes), cancer status, baseline steroid use, COVID-19 treatment, and presence of metastatic disease. Exposures: Androgen deprivation therapy use was defined as prior bilateral orchiectomy or pharmacologic ADT administered within the prior 3 months of presentation with COVID-19. Main Outcomes and Measures: The primary outcome was the rate of all-cause 30-day mortality after COVID-19 diagnosis for patients receiving ADT compared with patients not receiving ADT after propensity matching. Results: After exclusions, 1106 patients with prostate cancer (before propensity score matching: median age, 73 years [IQR, 65-79 years]; 561 (51%) self-identified as non-Hispanic White) were included for analysis. Of these patients, 477 were included for propensity score matching (169 who received ADT and 308 who did not receive ADT). After propensity matching, there was no significant difference in the primary end point of the rate of all-cause 30-day mortality (OR, 0.77; 95% CI, 0.42-1.42). Conclusions and Relevance: Findings from this cohort study suggest that ADT use was not associated with decreased mortality from SARS-CoV-2 infection. However, large ongoing clinical trials will provide further evidence on the role of ADT or other androgen-targeted therapies in reducing COVID-19 infection severity.

Characteristics, Comorbidities, and Data Gaps for Coronavirus Disease Deaths, Tennessee, USA.

As of March 2021, coronavirus disease (COVID-19) had led to >500,000 deaths in the United States, and the state of Tennessee had the fifth highest number of cases per capita. We reviewed the Tennessee Department of Health COVID-19 surveillance and chart-abstraction data during March 15‒August 15, 2020. Patients who died from COVID-19 were more likely to be older, male, and Black and to have underlying conditions (hereafter comorbidities) than case-patients who survived. We found 30.4% of surviving case-patients and 20.3% of deceased patients had no comorbidity information recorded. Chart-abstraction captured a higher proportion of deceased case-patients with >1 comorbidity (96.3%) compared with standard surveillance deaths (79.0%). Chart-abstraction detected higher rates of each comorbidity except for diabetes, which had similar rates among standard surveillance and chart-abstraction. Investing in public health data collection infrastructure will be beneficial for the COVID-19 pandemic and future disease outbreaks.

Impact of COVID-19 on presentation, staging, and treatment of head and neck mucosal squamous cell carcinoma.

OBJECTIVES: During the COVID-19 pandemic, maintenance of safe and timely oncologic care has been challenging. The goal of this study is to compare presenting symptoms, staging, and treatment of head and neck mucosal squamous cell carcinoma during the pandemic with an analogous timeframe one year prior. MATERIALS AND METHODS: Retrospective cohort study at a single tertiary academic center of new adult patients evaluated in a head and neck surgical oncology clinic from March -July 2019 (pre-pandemic control) and March - July 2020 (COVID-19 pandemic). RESULTS: During the pandemic, the proportion of patients with newly diagnosed malignancies increased by 5%, while the overall number of new patients decreased (n = 575) compared to the control year (n = 776). For patients with mucosal squamous cell carcinoma (SCC), median time from referral to initial clinic visit decreased from 11 days (2019) to 8 days (2020) (p = 0.0031). There was no significant difference in total number (p = 0.914) or duration (p = 0.872) of symptoms. During the pandemic, patients were more likely to present with regional nodal metastases (adjusted odds ratio (OR) 2.846, 95% CI 1.072-3.219, p = 0.028) and more advanced clinical nodal (N) staging (p = 0.011). No significant difference was seen for clinical tumor (T) (p = 0.502) or metastasis (M) staging (p = 0.278). No significant difference in pathologic T (p = 0.665), or N staging (p = 0.907) was found between the two periods. CONCLUSION: Head and neck mucosal SCC patients presented with more advanced clinical nodal disease during the early months of the COVID-19 pandemic despite no change in presenting symptoms.

Influence of social determinants of health and county vaccination rates on machine learning models to predict COVID-19 case growth in Tennessee.

INTRODUCTION: The SARS-CoV-2 (COVID-19) pandemic has exposed health disparities throughout the USA, particularly among racial and ethnic minorities. As a result, there is a need for data-driven approaches to pinpoint the unique constellation of clinical and social determinants of health (SDOH) risk factors that give rise to poor patient outcomes following infection in US communities. METHODS: We combined county-level COVID-19 testing data, COVID-19 vaccination rates and SDOH information in Tennessee. Between February and May 2021, we trained machine learning models on a semimonthly basis using these datasets to predict COVID-19 incidence in Tennessee counties. We then analyzed SDOH data features at each time point to rank the impact of each feature on model performance. RESULTS: Our results indicate that COVID-19 vaccination rates play a crucial role in determining future COVID-19 disease risk. Beginning in mid-March 2021, higher vaccination rates significantly correlated with lower COVID-19 case growth predictions. Further, as the relative importance of COVID-19 vaccination data features grew, demographic SDOH features such as age, race and ethnicity decreased while the impact of socioeconomic and environmental factors, including access to healthcare and transportation, increased. CONCLUSION: Incorporating a data framework to track the evolving patterns of community-level SDOH risk factors could provide policy-makers with additional data resources to improve health equity and resilience to future public health emergencies.

Regional COVID-19 Dynamics: Surrogate Synchrony in Case Infection Rates.

As many jurisdictions consider in-person learning strategies (including at Institutions of Higher Education, IHE), implementing travel restrictions or quarantines, and/or establishing interstate pacts to reduce COVID-19 spread, this study explores the degree to which COVID-19 case infection rates in a group of neighboring, Southern and Midwestern U.S. states (namely, Arkansas and its contiguous neighbors) are patterned in a non-random way known as synchrony. Utilizing surrogate synchrony (SUSY) to estimate the dyadic coupling between the COVID-19 case infection rate processes in this region from March to December 2020, results indicate that significant synchrony is present between Arkansas and three of its neighbors. The highest level of instantaneous synchrony occurs between Arkansas and Tennessee, with the next highest level occurring between Arkansas and Missouri. There is evidence of directionality in the synchrony, indicating that Arkansas case infection rates lead Mississippi while rates in Missouri and Tennessee lead Arkansas. The lagged cross-correlations suggest the greatest synchrony to occur between 3 and 6 days. To explore the effect of IHE reopening on COVID-19, synchrony is compared between pre- and post-reopening windows. Results suggested that, following reopening, there are gains in detectable synchrony and that COVID-19 is in-flowing to Arkansas from all of its neighboring states. Taken together, results suggest that there is spatiality to COVID-19 with neighboring states having case infection rates that are significantly synchronous at a lag time that would be expected based on symptom onset. This synchrony is potentially strengthened by the in-flow and cross-border movement of IHE students.

Predictive modeling of COVID-19 case growth highlights evolving racial and ethnic risk factors in Tennessee and Georgia.

INTRODUCTION: The SARS-CoV-2 (COVID-19) pandemic has exposed the need to understand the risk drivers that contribute to uneven morbidity and mortality in US communities. Addressing the community-specific social determinants of health (SDOH) that correlate with spread of SARS-CoV-2 provides an opportunity for targeted public health intervention to promote greater resilience to viral respiratory infections. METHODS: Our work combined publicly available COVID-19 statistics with county-level SDOH information. Machine learning models were trained to predict COVID-19 case growth and understand the social, physical and environmental risk factors associated with higher rates of SARS-CoV-2 infection in Tennessee and Georgia counties. Model accuracy was assessed comparing predicted case counts to actual positive case counts in each county. RESULTS: The predictive models achieved a mean R2 of 0.998 in both states with accuracy above 90% for all time points examined. Using these models, we tracked the importance of SDOH data features over time to uncover the specific racial demographic characteristics strongly associated with COVID-19 incidence in Tennessee and Georgia counties. Our results point to dynamic racial trends in both states over time and varying, localized patterns of risk among counties within the same state. For example, we find that African American and Asian racial demographics present comparable, and contrasting, patterns of risk depending on locality. CONCLUSION: The dichotomy of demographic trends presented here emphasizes the importance of understanding the unique factors that influence COVID-19 incidence. Identifying these specific risk factors tied to COVID-19 case growth can help stakeholders target regional interventions to mitigate the burden of future outbreaks.

The COVID-19 pandemic and reproductive genetic counseling: Changes in access and service delivery at an academic medical center in the United States.

The COVID-19 pandemic widely disrupted the delivery of healthcare services, including genetic counseling. To ensure continuity of care, the reproductive genetic counselors at a large academic medical center in the United States rapidly transitioned their practice from 90% in-person patient consultations to a predominantly telehealth model. The present study describes this transition in regard to patient access to genetic counseling and genetic screening. A chart review of patients seen by the reproductive genetic counselors from January 2020 to August 2020 was completed. The time frame included the three months prior to the COVID-19 pandemic and the first five months during COVID-19. Patient demographics and clinical and appointment data were compared between the pre-COVID-19 and during-COVID-19 timeframes. Overall, 88.6% of patients were seen via telehealth during COVID-19 and there was no significant difference based upon patient age (p = .20), indication for appointment (p = .06), or gestational age (p = .06). However, non-English speaking patients were more often seen in-person than by telehealth (p < .001), and more patients residing farther from the clinic were seen via telehealth (p = .004). During-COVID-19 results for prenatal cell-free DNA screening and expanded carrier screening were delayed (p < .001). Additionally, after consenting to screening, patients seen during COVID-19 were more likely to not complete a sample collection for their intended screening when compared to those seen pre-COVID-19 (OR = 6.15, 95% CI = 1.43-26.70, p = .015). Overall, this study supports that access to genetic counseling services and genetic screening can be maintained during a global pandemic like COVID-19. Genetic counselors are well-equipped to pivot swiftly during challenging times; however, they must continue to work to address other barriers to accessing genetic services, especially for non-English speaking populations. Future studies are needed to pose solutions to the obstacles confronted in this service delivery model during a global pandemic.

Low In-School COVID-19 Transmission and Asymptomatic Infection Despite High Community Prevalence.

There is concern that in-person schooling during the coronavirus disease 2019 (COVID-19) pandemic will facilitate disease transmission. Through asymptomatic surveillance and contact tracing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), we found low rates of asymptomatic SARS-CoV-2 infection and little in-school transmission of COVID-19 when physical distancing and masking strategies were enforced despite a high community prevalence of COVID-19.