Population-Level Study on Fetal Deaths and Preterm Births during SARS-CoV-2 Pandemic in the State of Michigan.

OBJECTIVE: The aim of the study is to explore the effect of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic on preterm birth at different gestational ages and fetal death in the state of Michigan. STUDY DESIGN: Data on live births and fetal deaths in the state of Michigan from March to November in the years 2017 through 2020 were obtained from Michigan Department of Health and Human Services (MDHHS). Preterm birth rate, fetal death rate (per 1,000 live births) overall and stratified by race and maternal comorbidities during the period of pandemic (March-November 2020) were compared with the same period (March-November) in the prepandemic years (2017-2019). RESULTS: Of 328,879 live births and 1,470 fetal deaths during the study period, 77,983 live births and 242 fetal deaths were reported in 2020. Compared with prepandemic years, fetal death rate per 1,000 live births was significantly lower in 2020 (3.1 vs. 4.7 [2017], 5.2 [2018], 4.4 [2019], p-value <0.001). The adjusted risk for fetal death in 2020 was decreased (odds ratio [OR] = 0.64 [95% confidence interval (CI): 0.56-0.74], p <0.0001), compared with prepandemic years. Fetal death was significantly associated with African-American race, pregnancy hypertension and prepregnancy diabetes. No significant difference in the proportion of preterm births (<37 weeks' gestation) was noted between pandemic and prepandemic years (9.9 vs. 10.0%, p = 0.50). There was no significant difference in the risk of preterm birth across gestational age strata (<28, 28-316/7, 32-366/7, 37-416/7, and >42 weeks) between pandemic and prepandemic years on multinomial analysis. Significant associations with preterm birth across all years included African American race, lower level of maternal education, pregnancy-induced hypertension, chronic hypertension, prepregnancy diabetes, congenital anomalies, previous preterm birth, and prolonged rupture of membranes >12 hours. CONCLUSION: Fetal death rate was significantly lower whereas preterm births remained unchanged during pandemic in comparison with prepandemic years in the state of Michigan. KEY POINTS: · A decrease in fetal death rate was noted during SARS CoV-2 pandemic in the State of Michigan.. · Overall state-wide rates of preterm birth did not change in 2020, compared to previous years.. · Significant risk factors associated with preterm birth and fetal deaths did not differ between prepandemic and pandemic years..

Racial disparities in COVID-19 mortality across Michigan, United States.

BACKGROUND: Black populations in the United States are being disproportionately affected by the COVID-19 pandemic, but the increased mortality burden after accounting for health and other demographic characteristics is not well understood. We examined characteristics of individuals who died from COVID-19 in Michigan by race stratified by their age, sex and comorbidity prevalence to illustrate and understand this disparity in mortality risk. METHODS: We evaluate COVID-19 mortality in Michigan by demographic and health characteristics, using individual-level linked death certificate and surveillance data collected by the Michigan Department of Health and Human Services from March 16 to October 26, 2020. We identified differences in demographics and comorbidity prevalence across race among individuals who died from COVID-19 and calculated mortality rates by age, sex, race, and number of comorbidities. FINDINGS: Among the 6,065 COVID-19 related deaths in Michigan, Black individuals are experiencing 3·6 times the mortality rate of White individuals (p<0.001), with a mortality rate for Black individuals under 65 years without comorbidities that is 12·6 times that of their White counterparts (p<0.001). After accounting for age, race, sex, and number of comorbidities, we find that Black individuals in all strata are at higher risk of COVID-19 mortality than their White counterparts. INTERPRETATION: Our findings demonstrate that Black populations are disproportionately burdened by COVID-19 mortality, even after accounting for demographic and underlying health characteristics. We highlight how disparities across race, which result from systemic racism, are compounded in crises. FUNDING: ASP, AP and APG were funded by NSF Expeditions grant 1918784, NIH grant 1R01AI151176-01, NSF Rapid Response Research for COVID-19 grant RAPID-2027755, and the Notsew Orm Sands Foundation. MCF was supported by NIH grant K01AI141576.

Genetic and Virulence Profiles of Enteroaggregative Escherichia coli (EAEC) Isolated From Deployed Military Personnel (DMP) With Travelers' Diarrhea.

To discern if there was a particular genotype associated with clinical enteroaggregative Escherichia coli (EAEC) strains isolated from deployed military personnel (DMP) with travelers' diarrhea (TD), we characterized a collection of EAEC from DMP deployed to Afghanistan, Djibouti, Kenya, or Honduras. Although we did not identify a specific EAEC genotype associated with TD in DMP, we found that EAEC isolated at the first clinic visit were more likely to encode the dispersin gene aap than EAEC collected at follow-up visits. A majority of the EAEC isolates were typical EAEC that adhered to HEp-2 cells, formed biofilms, and harbored genes for aggregative adherence fimbriae (AAF), AggR, and serine protease autotransporters of Enterobacteriaceae (SPATEs). A separate subset of the EAEC had aggR and genes for SPATEs but encoded a gene highly homologous to that for CS22, a fimbriae more commonly found in enterotoxigenic E. coli. None of these CS22-encoding EAEC formed biofilms in vitro or adhered to HEp-2 cells. Whole genome sequence and single nucleotide polymorphism analyses demonstrated that most of the strains were genetically diverse, but that a few were closely related. Isolation of these related strains occurred within days to more than a year apart, a finding that suggests a persistent source and genomic stability. In an ampicillin-treated mouse model we found that an agg4A+ aar- isolate formed a biofilm in the intestine and caused reduced weight gain in mice, whereas a strain that did not form an in vivo biofilm caused no morbidity. Our diverse strain collection from DMP displays the heterogeneity of EAEC strains isolated from human patients, and our mouse model of infection indicated the genotype agg4A+ aar- and/or capacity to form biofilm in vivo may correlate to disease severity.

Exposure and potential effects of pesticides and pharmaceuticals in protected streams of the US National park Service southeast region.

Globally, protected areas offer refugia for a broad range of taxa including threatened and endangered species. In the United States (US), the National Park Service (NPS) manages public lands to preserve biodiversity, but increasing park visitation and development of surrounding landscapes increase exposure to and effects from bioactive contaminants. The risk (exposure and hazard) to NPS protected-stream ecosystems within the highly urbanized southeast region (SER) from bioactive contaminants was assessed in five systems based on 334 pesticide and pharmaceutical analytes in water and 119 pesticides in sediment. Contaminant mixtures were common across all sampled systems, with approximately 24% of the unique analytes (80/334) detected at least once and 15% (49/334) detected in half of the surface-water samples. Pharmaceuticals were observed more frequently than pesticides, consistent with riparian buffers and concomitant spatial separation from non-point pesticide sources in four of the systems. To extrapolate exposure data to biological effects space, site-specific cumulative exposure-activity ratios (ΣEAR) were calculated for detected surface-water contaminants with available ToxCast data; common exceedances of a 0.001 ΣEAR effects-screening threshold raise concerns for molecular toxicity and possible, sub-lethal effects to non-target, aquatic vertebrates. The results illustrate the need for continued management of protected resources to reduce contaminant exposure and preserve habitat quality, including prioritization of conservation practices (riparian buffers) near stream corridors and increased engagement with upstream/up-gradient property owners and municipal wastewater facilities.

Discovering the Unclassified Suicide Cases Among Undetermined Drug Overdose Deaths Using Machine Learning Techniques.

OBJECTIVE: The Centers for Disease Control and Prevention (CDC) monitor accidental and intentional deaths to answer questions that are critical for the development of effective prevention and resource allocation. CDC's National Violent Death Reporting System (NVDRS) is a major innovation in surveillance linking individual-level data from multiple sources. However, suicide underreporting is common, particularly from drug overdose deaths. This study sought to assess machine learning (ML) techniques in quantifying drug overdose suicide underreporting rates. METHODS: Clinical, sociodemographic, toxicological, and proximal stressor data on overdose decedents (n = 2,665) were extracted from Utah's NVDRS from 2012 to 2015. The existing well-determined cases were used to train and test our ML models. We assessed and compared multiple machine learning methods including Logistic Regression, Random Forest Classifier, Support Vector Machines, and Artificial Neural Networks. We applied a majority voting methodology to classify undetermined drug overdose deaths. RESULTS: Overdose suicide rates were estimated to be underreported by 33% across all years, increasing yearly from 29% in 2012 to 37% in 2015. The overall test accuracies for all models ranged from 92.3% to 94.6%. CONCLUSIONS: This research identifies a cost-effective, replicable, and expandable ML-based methodology to estimate the true rates of suicide which may be partially masked during the opioid epidemic.

Activation of Shigella flexneri type 3 secretion requires a host-induced conformational change to the translocon pore.

Type 3 secretion systems (T3SSs) are conserved bacterial nanomachines that inject virulence proteins (effectors) into eukaryotic cells during infection. Due to their ability to inject heterologous proteins into human cells, these systems are being developed as therapeutic delivery devices. The T3SS assembles a translocon pore in the plasma membrane and then docks onto the pore. Docking activates effector secretion through the pore and into the host cytosol. Here, using Shigella flexneri, a model pathogen for the study of type 3 secretion, we determined the molecular mechanisms by which host intermediate filaments trigger docking and enable effector secretion. We show that the interaction of intermediate filaments with the translocon pore protein IpaC changed the pore's conformation in a manner that was required for docking. Intermediate filaments repositioned residues of the Shigella pore protein IpaC that are located on the surface of the pore and in the pore channel. Restricting these conformational changes blocked docking in an intermediate filament-dependent manner. These data demonstrate that a host-induced conformational change to the pore enables T3SS docking and effector secretion, providing new mechanistic insight into the regulation of type 3 secretion.

Topological Analysis of the Type 3 Secretion System Translocon Pore Protein IpaC following Its Native Delivery to the Plasma Membrane during Infection.

Many Gram-negative bacterial pathogens require a type 3 secretion system (T3SS) to deliver effector proteins into eukaryotic cells. Contact of the tip complex of the T3SS with a target eukaryotic cell initiates secretion of the two bacterial proteins that assemble into the translocon pore in the plasma membrane. The translocon pore functions to regulate effector protein secretion and is the conduit for effector protein translocation across the plasma membrane. To generate insights into how the translocon pore regulates effector protein secretion, we defined the topology of the Shigella translocon pore protein IpaC in the plasma membrane following its native delivery by the T3SS. Using single cysteine substitution mutagenesis and site-directed labeling with a membrane-impermeant chemical probe, we mapped residues accessible from the extracellular surface of the cell. Our data support a model in which the N terminus of IpaC is extracellular and the C terminus of IpaC is intracellular. These findings resolve previously conflicting data on IpaC topology that were based on nonnative delivery of IpaC to membranes. Salmonella enterica serovar Typhimurium also requires the T3SS for effector protein delivery into eukaryotic cells. Although the sequence of IpaC is closely related to the Salmonella translocon pore protein SipC, the two proteins have unique functional attributes during infection. We showed a similar overall topology for SipC and IpaC and identified subtle topological differences between their transmembrane α-helixes and C-terminal regions. Together, our data suggest that topological differences among distinct translocon pore proteins may dictate organism-specific functional differences of the T3SSs during infection.IMPORTANCE The type 3 secretion system (T3SS) is a nanomachine required for virulence of many bacterial pathogens that infect humans. The system delivers bacterial virulence proteins into the cytosol of human cells, where the virulence proteins promote bacterial infection. The T3SS forms a translocon pore in the membranes of target cells. This pore is the portal through which bacterial virulence proteins are delivered by the T3SS into the eukaryotic cytosol. The pore also regulates secretion of these virulence proteins. Our work defines the topology of translocon pore proteins in their native context during infection, resolves previously conflicting reports about the topology of the Shigella translocon pore protein IpaC, and provides new insights into how interactions of the pore with the T3SS likely produce signals that activate secretion of virulence proteins.

Building an Ontology for Identity Resolution in Healthcare and Public Health.

UNLABELLED: Integration of disparate information from electronic health records, clinical data warehouses, birth certificate registries and other public health information systems offers great potential for clinical care, public health practice, and research. Such integration, however, depends on correctly matching patient-specific records using demographic identifiers. Without standards for these identifiers, record linkage is complicated by issues of structural and semantic heterogeneity. OBJECTIVES: Our objectives were to develop and validate an ontology to: 1) identify components of identity and events subsequent to birth that result in creation, change, or sharing of identity information; 2) develop an ontology to facilitate data integration from multiple healthcare and public health sources; and 3) validate the ontology's ability to model identity-changing events over time. METHODS: We interviewed domain experts in area hospitals and public health programs and developed process models describing the creation and transmission of identity information among various organizations for activities subsequent to a birth event. We searched for existing relevant ontologies. We validated the content of our ontology with simulated identity information conforming to scenarios identified in our process models. RESULTS: We chose the Simple Event Model (SEM) to describe events in early childhood and integrated the Clinical Element Model (CEM) for demographic information. We demonstrated the ability of the combined SEM-CEM ontology to model identity events over time. CONCLUSION: The use of an ontology can overcome issues of semantic and syntactic heterogeneity to facilitate record linkage.

Completing Death Certificates from an EMR: Analysis of a Novel Public-Private Partnership.

With the objective of increasing electronic death registration, Intermountain Healthcare and the Utah Office of Vital Records and Statistics have developed a system enabling death certification from within Intermountain's electronic medical record (EMR), consisting of an EMR module and an HL7 interface. Comparison of post-intervention death certification at Intermountain Healthcare against a baseline study found a slight increase in the percentage of deaths certified electronically (73% pre vs. 77% post). Analysis of deaths certified using the EMR-module found that they were completed significantly sooner than those certified on paper or using the state's web-based electronic death registration system (EDRS) (Mean time: Paper = 114.72 hours, EDRS = 81.84 hours, EMR = 43.92 hours; p < 0.0001). EMR-certified deaths also contained significantly more causes of deaths than either alternative method (Mean number of causes: Paper = 3.9 causes, EDRS = 4.0 causes, EMR = 5.5 causes; p < 0.0001).

Birth of identity: understanding changes to birth certificates and their value for identity resolution.

INTRODUCTION: Identity information is often used to link records within or among information systems in public health and clinical settings. The quality and stability of birth certificate identifiers impacts both the success of linkage efforts and the value of birth certificate registries for identity resolution. OBJECTIVE: Our objectives were to describe: (1) the frequency and cause of changes to birth certificate identifiers as children age, and (2) the frequency of events (ie, adoptions, paternities, amendments) that may trigger changes and their impact on names. METHODS: We obtained two de-identified datasets from the Utah birth certificate registry: (1) change history from 2000 to 2012, and (2) occurrences for adoptions, paternities, and amendments among births in 1987 and 2000. We conducted cohort analyses for births in 1987 and 2000, examining the number, reason, and extent of changes over time. We conducted cross-sectional analyses to assess the patterns of changes between 2000 and 2012. RESULTS: In a cohort of 48 350 individuals born in 2000 in Utah, 3164 (6.5%) experienced a change in identifiers prior to their 13th birthday, with most changes occurring before 2 years of age. Cross-sectional analysis showed that identifiers are stable for individuals over 5 years of age, but patterns of changes fluctuate considerably over time, potentially due to policy and social factors. CONCLUSIONS: Identities represented in birth certificates change over time. Specific events that cause changes to birth certificates also fluctuate over time. Understanding these changes can help in the development of automated strategies to improve identity resolution.

A focus area maturity model for a statewide master person index.

OBJECTIVE: The sharing of personally identifiable information across organizational boundaries to facilitate patient identification in Utah presents significant policy challenges. Our objective was to create a focus area maturity model to describe and evaluate our progress in developing a policy framework to support a statewide master person index (sMPI) for healthcare and public health operations and research in Utah. MATERIALS AND METHODS: We used various artifacts, including minutes from policy guidance committee meetings over a span of 18 months, a report from Utah's Digital Health Services Commission, and a draft technical requirements document to retrospectively analyze our work and create a focus area maturity model describing the domain of policy needed to support the sMPI. We then used our model to assess our progress and future goals. CONCLUSIONS: The focus area maturity model provides an orderly path that can guide the complex process of developing a functional statewide master person index among diverse, autonomous partners. While this paper focuses on our experience in Utah, we believe that the arguments for using a focus area maturity model to guide the development of state or regional MPIs is of general interest.

Electronic end-of-life care registry: the Utah ePOLST initiative.

As a patient's end-of-life approaches, it is typical for the disease to be the focus of treatment instead of the dying patient. There is limited congruence between the care preferred by patients and the treatment actually delivered to patients during their end-of-life. The Physician Orders for Life-Sustaining Treatment Paradigm has been endorsed or is in development in all but three states and the District of Columbia in an effort to ensure that patients are provided with adequate opportunities to specify their end-of-life care preferences. However, most states are using paper forms to document these preferences which may be inaccessible when needed. We have developed an electronic end-of-life care registry that allows authorized users to store and retrieve information pertaining to patients' end-of-life care preferences. In this paper, we describe (a) the requirements identified for the registry from the users' perspective and (b) the design and development of the electronic registry.

Population-based trends and correlates of maternal overweight and obesity, Utah 1991-2001.

OBJECTIVE: This study aims to identify recent population-based trends in maternal overweight and obesity and adverse outcomes. STUDY DESIGN: Statewide retrospective cohort study of birth certificate data for live singleton births to women in Utah between 1991 and 2001. RESULTS: Prepregnancy overweight and obesity increased from 25.1% in 1991 to 35.2% in 2001, a 40.2% increase (prevalence ratio [PR] 1.40 [1.37-1.43]), whereas maternal obesity at delivery rose 36.2% from 28.7% to 39.1% (PR 1.36 [1.33-1.39]). The attributable fraction of cesarean delivery in overweight and obese women was 0.388 (0.369-0.407). Statewide, among all women having a cesarean delivery in 2001, 1 in 7 is attributable to overweight and obesity. CONCLUSION: This is the first state-wide analysis of maternal obesity trends demonstrating a significant increase in maternal overweight and obesity. Overweight and obese women are at increased risk of cesarean delivery, preeclampsia, eclampsia, dystocia, and macrosomia, risks that increase as the body mass index rises.