Lessons Learned From a Sequential Mixed-Mode Survey Design to Recruit and Collect Data From Case-Control Study Participants: Formative Evaluation.

BACKGROUND: Sequential mixed-mode surveys using both web-based surveys and telephone interviews are increasingly being used in observational studies and have been shown to have many benefits; however, the application of this survey design has not been evaluated in the context of epidemiological case-control studies. OBJECTIVE: In this paper, we discuss the challenges, benefits, and limitations of using a sequential mixed-mode survey design for a case-control study assessing risk factors during the COVID-19 pandemic. METHODS: Colorado adults testing positive for SARS-CoV-2 were randomly selected and matched to those with a negative SARS-CoV-2 test result from March to April 2021. Participants were first contacted by SMS text message to complete a self-administered web-based survey asking about community exposures and behaviors. Those who did not respond were contacted for a telephone interview. We evaluated the representativeness of survey participants to sample populations and compared sociodemographic characteristics, participant responses, and time and resource requirements by survey mode using descriptive statistics and logistic regression models. RESULTS: Of enrolled case and control participants, most were interviewed by telephone (308/537, 57.4% and 342/648, 52.8%, respectively), with overall enrollment more than doubling after interviewers called nonresponders. Participants identifying as female or White non-Hispanic, residing in urban areas, and not working outside the home were more likely to complete the web-based survey. Telephone participants were more likely than web-based participants to be aged 18-39 years or 60 years and older and reside in areas with lower levels of education, more linguistic isolation, lower income, and more people of color. While there were statistically significant sociodemographic differences noted between web-based and telephone case and control participants and their respective sample pools, participants were more similar to sample pools when web-based and telephone responses were combined. Web-based participants were less likely to report close contact with an individual with COVID-19 (odds ratio [OR] 0.70, 95% CI 0.53-0.94) but more likely to report community exposures, including visiting a grocery store or retail shop (OR 1.55, 95% CI 1.13-2.12), restaurant or cafe or coffee shop (OR 1.52, 95% CI 1.20-1.92), attending a gathering (OR 1.69, 95% CI 1.34-2.15), or sport or sporting event (OR 1.05, 95% CI 1.05-1.88). The web-based survey required an average of 0.03 (SD 0) person-hours per enrolled participant and US $920 in resources, whereas the telephone interview required an average of 5.11 person-hours per enrolled participant and US $70,000 in interviewer wages. CONCLUSIONS: While we still encountered control recruitment challenges noted in other observational studies, the sequential mixed-mode design was an efficient method for recruiting a more representative group of participants for a case-control study with limited impact on data quality and should be considered during public health emergencies when timely and accurate exposure information is needed to inform control measures.

Exploring the association of weather variability on Campylobacter - A systematic review.

BACKGROUND: Previous work has found climate change-induced weather variability is suspected to increase the transmission of enteric pathogens, including Campylobacter, a leading cause of bacterial gastroenteritis. While the relationship between extreme weather events and diarrheal diseases has been documented, the specific impact on Campylobacter infections remains underexplored. OBJECTIVE: To synthesize the peer-reviewed literature exploring the effect of weather variability on Campylobacter infections in humans. METHODS: The review included English language, peer-reviewed articles, published up to September 1, 2022 in PubMed, Embase, GEOBASE, Agriculture and Environmental Science Database, and CABI Global Health exploring the effect of an antecedent weather event on human enteric illness caused by Campylobacter (PROSPERO Protocol # 351884). We extracted study information including data sources, methods, summary measures, and effect sizes. Quality and weight of evidence reported was summarized and bias assessed for each article. RESULTS: After screening 278 articles, 47 articles (34 studies, 13 outbreak reports) were included in the evidence synthesis. Antecedent weather events included precipitation (n = 35), temperature (n = 30), relative humidity (n = 7), sunshine (n = 6), and El Niño and La Niña (n = 3). Reviewed studies demonstrated that increases in precipitation and temperature were correlated with Campylobacter infections under specific conditions, whereas low relative humidity and sunshine were negatively correlated. Articles estimating the effect of animal operations (n = 15) found presence and density of animal operations were significantly associated with infections. However, most of the included articles did not assess confounding by seasonality, presence of animal operations, or describe estimates of risk. DISCUSSION: This review explores what is known about the influence of weather events on Campylobacter and identifies previously underreported negative associations between low relative humidity and sunshine on Campylobacter infections. Future research should explore pathogen-specific estimates of risk, which can be used to influence public health strategies, improve source attribution and causal pathways, and project disease burden due to climate change.

Collecting a Sexual History During Shigellosis Case Investigations: Nationwide Practices and an Assessment of Data Quality.

Shigellosis is spread through the fecal-oral route, including sexual activity. The Centers for Disease Control and Prevention recommends collecting a sexual history from people diagnosed with shigellosis to enhance the understanding of its epidemiology and outbreak detection and the design of disease prevention messaging, although individual jurisdictions decide if and how this is done. Moreover, enteric disease interviewers typically receive in-depth general interviewing training, but often not sexual history question training. The goal of this project was to inform national practices around sexual history questions asked during shigellosis interviews by collecting information from U.S. state health agencies and evaluating sexual history data from people diagnosed with shigellosis in Colorado. From November 2021 to January 2022, information on sexual history questions asked of persons with reported shigellosis and accompanying training resources were collected from U.S. state health departments. Data completeness and quality of shigellosis sexual history questions from Colorado's notifiable disease database from 2018 to 2022 were also evaluated. Of 48 states, 54% reported routinely asking all adults about their sexual history during shigellosis interviews. Of 44 states, 18% indicated having accompanying training materials for interviewers. In Colorado, the proportion of unknown/missing responses to questions about recent sexual contact with male and female partners was lower for males (3.3% unknown and 3.3% missing) than females (5.4% and 6.2%) and highest among those 66 years and older (6.7% and 10%). Among those reporting new sexual partners, 93.5% indicated how they met. The evaluation of Colorado data demonstrates that routine collection of complete, high-quality, actionable sexual history data from all adults with reported shigellosis is feasible. Nearly half of the responding states indicated not doing so, and few had training resources. We recommend training enteric disease interviewers to routinely ask all adults with reported shigellosis about their sexual history, including new partner meeting location.

Improving occupational health surveillance for enteric infections.

AIMS: Enteric pathogens with a livestock reservoir pose a unique risk to people in occupations with regular contact with animals. However, public health surveillance of occupational exposures is inadequate, with surveillance for occupation typically focusing on the risk of transmission and the need for worker exclusion, rather than workplace exposures. To improve surveillance for occupational zoonoses, the Colorado Integrated Food Safety Center of Excellence convened a group of subject matter experts who developed a set of variables on occupation, industry, and exposures, which were integrated into Colorado's surveillance system in 2017. We evaluated the quality and completeness of these new occupational fields for interviewed cases with laboratory-confirmed zoonotic infections and compared occupations to cases with a non-zoonotic infection (Shigella) and to employment data from the Bureau of Labor Statistics. METHODS AND RESULTS: From March 2017 through December 2019, 3668 domestically acquired, laboratory-confirmed sporadic infections of Campylobacter, Cryptosporidium, Shiga toxin-producing Escherichia coli, and non-typhoidal Salmonella among individuals ≥14 years of age were interviewed by public health. We found asking explicitly about occupational exposure risks and focusing on animal exposures, improved data quality and accuracy. Of the cases who stated that they were employed, 262 (13%) reported working in an occupation with regular animal exposure, and 254 (14%) reported an industry with regular animal exposure. Cases with an animal exposure occupation were more likely to be male and live in a rural or frontier county compared to other occupations. All occupations with regular animal contact were reported at a higher frequency than among Shigella cases or the general population. CONCLUSIONS: Public health efforts, both in occupational health and communicable disease sectors, should be made to improve surveillance for enteric zoonoses and identify opportunities for prevention strategies.

A Prediction Tool to Identify the Causative Agent of Enteric Disease Outbreaks Using Outbreak Surveillance Data.

Information on the causative agent in an enteric disease outbreak can be used to generate hypotheses about the route of transmission and possible vehicles, to guide environmental assessments, and to target outbreak control measures. However, only about 40% of outbreaks reported in the United States include a confirmed etiology. The goal of this project was to identify clinical and demographic characteristics that can be used to predict the causative agent in an enteric disease outbreak and to use these data to develop an online tool for investigators to use during an outbreak when hypothesizing about the causative agent. Using data on enteric disease outbreaks from all transmission routes (animal contact, environmental contamination, foodborne, person-to-person, waterborne, unknown) reported to the U.S. Centers for Disease Control and Prevention, we developed random forest models to predict the etiology of an outbreak based on aggregated clinical and demographic characteristics at both the etiology category (i.e., bacteria, parasites, toxins, viruses) and individual etiology (Clostridium perfringens, Campylobacter, Cryptosporidium, norovirus, Salmonella, Shiga toxin-producing Escherichia coli, and Shigella) levels. The etiology category model had a kappa of 0.85 and an accuracy of 0.92, whereas the etiology-specific model had a kappa of 0.75 and an accuracy of 0.86. The highest sensitivities in the etiology category model were for bacteria and viruses; all categories had high specificities (>0.90). For the etiology-specific model, norovirus and Salmonella had the highest sensitivity and all etiologies had high specificities. When laboratory confirmation is unavailable, information on the clinical signs and symptoms reported by people associated with the outbreak, with other characteristics including case demographics and illness severity, can be used to predict the etiology or etiology category. An online publicly available tool was developed to assist investigators in their enteric disease outbreak investigations.

The Need for Responsive Workforce Development During the Pandemic and Beyond: A Case Study of the Regional Public Health Training Centers.

CONTEXT: The COVID-19 pandemic underscored the importance of a strong public health infrastructure for protecting and supporting the health of communities. This includes ensuring an adaptive workforce capable of leading through rapidly changing circumstances, communicating effectively, and applying systems thinking to leverage cross-sector partnerships that help promote health equity. The 10 Regional Public Health Training Centers (PHTCs) advance the capacity of the current and future public health workforce through skill development and technical assistance in these and other strategic areas. PROGRAM: This study examines activities through which the Regional PHTCs and their partners supported the public health workforce during the pandemic. Representatives of the 10 Regional PHTCs completed a survey in the spring of 2022. The survey included (1) pulling trends in training usage from 2018-2021 annual performance reports and (2) questions assessing the type, content, and reach of training needs assessments, training and technical assistance, student placements, and PHTC Network collaborative activities that occurred from January 1, 2020, to December 31, 2021. Respondents also reflected on trends in use, challenges, lessons learned, stories of impact, and future PHTC practice. EVALUATION: During the pandemic, the Regional PHTCs engaged in numerous efforts to assess needs, provide training and technical assistance to the practice community, facilitate projects that built student competency to support public health agency efforts, and collaborate as the PHTC Network on national-level initiatives. Across these activities, the Regional PHTCs adjusted their approaches and learned from each other in order to meet regional needs. DISCUSSION: The Regional PHTCs provided student and professional development in foundational public health knowledge and skills within their regions and nationally while being flexible and responsive to the changing needs of the field during the pandemic. Our study highlights opportunities for collaboration and adaptive approaches to public health workforce development in a postpandemic environment.

Competencies for Public Health Professionals and Epidemiologists Who Detect and Investigate Enteric Disease Outbreaks.

OBJECTIVE: Food safety progress depends on the ability of public health agencies to detect and investigate foodborne disease outbreaks. The Integrated Food Safety Centers of Excellence identify and implement best practices and serve as resources for public health professionals who investigate enteric disease outbreaks. To target the needs of this diverse workforce, the Integrated Food Safety Centers of Excellence developed and assessed a professional tier framework and competencies. METHODS: We described the characteristics of public health professionals who investigate enteric disease outbreaks in the epidemiology role in a conceptual tiered framework. We mapped core competencies to each tier and disseminated a survey to practitioners at local (June 2019) and state (August 2018) US public health agencies to evaluate the importance and frequency of each competency. RESULTS: We developed 15 competencies on surveillance, outbreak detection, interview skills, investigation team, specimen testing, data analysis, hypothesis generation, study design, communication, enteric disease biology, control measures, legal authority, quality improvement, environmental health, and reporting to surveillance. The 286 survey respondents selected interview skills, surveillance, control measures, and hypothesis generation as the competencies most important to their work and most frequently performed. CONCLUSION: The Integrated Food Safety Centers of Excellence created the first published workforce framework and competencies for public health professionals who detect and investigate enteric disease outbreaks in the epidemiology role, in collaboration with local, state, and federal public health agencies and national organizations. These tools have been integrated into existing programs and can be used to develop training curricula, assess workforce competency over time, and identify priorities for continuing education and training.

Preliminary Incidence and Trends of Infections Caused by Pathogens Transmitted Commonly Through Food - Foodborne Diseases Active Surveillance Network, 10 U.S. Sites, 2022.

Each year, infections from major foodborne pathogens are responsible for an estimated 9.4 million illnesses, 56,000 hospitalizations, and 1,350 deaths in the United States (1). To evaluate progress toward prevention of enteric infections in the United States, the Foodborne Diseases Active Surveillance Network (FoodNet) conducts surveillance for laboratory-diagnosed infections caused by eight pathogens transmitted commonly through food at 10 U.S. sites. During 2020-2021, FoodNet detected decreases in many infections that were due to behavioral modifications, public health interventions, and changes in health care-seeking and testing practices during the COVID-19 pandemic. This report presents preliminary estimates of pathogen-specific annual incidences during 2022, compared with average annual incidences during 2016-2018, the reference period for the U.S. Department of Health and Human Services' Healthy People 2030 targets (2). Many pandemic interventions ended by 2022, resulting in a resumption of outbreaks, international travel, and other factors leading to enteric infections. During 2022, annual incidences of illnesses caused by the pathogens Campylobacter, Salmonella, Shigella, and Listeria were similar to average annual incidences during 2016-2018; however, incidences of Shiga toxin-producing Escherichia coli (STEC), Yersinia, Vibrio, and Cyclospora illnesses were higher. Increasing culture-independent diagnostic test (CIDT) usage likely contributed to increased detection by identifying infections that would have remained undetected before widespread CIDT usage. Reducing pathogen contamination during poultry slaughter and processing of leafy greens requires collaboration among food growers and processors, retail stores, restaurants, and regulators.

Advancing antimicrobial stewardship in companion animal veterinary medicine: a qualitative study on perceptions and solutions to a One Health problem.

OBJECTIVE: The term antimicrobial stewardship (AMS) is used to describe the coordinated efforts and programs required to sustain the clinical efficacy of antimicrobials and slow the development of antimicrobial resistance. However, companion animal veterinarians are provided with few "cage-side" resources to achieve these goals. The aims of our study were to understand the current perceptions, attitudes, and knowledge of AMS among companion animal veterinarians and to source technology-based solutions that reduce barriers to judicious antimicrobial drug prescribing. PROCEDURES: 6 focus groups were conducted via a teleconference platform. The focus group recordings were transcribed and coded thematically using a grounded theory approach and inductive coding. RESULTS: A total of 25 companion animal veterinarians participated in 6, 1-hour focus groups. Two themes emerged from the data: (1) Veterinarians feel that AMS is important and understand the principles of AMS, but experience barriers to practicing judicious AMD use principles. (2) Veterinarians agree that technology can promote AMS, but express that a tool needs to support their prescribing decisions, provide accurate and concise stewardship information, and be integrated into the existing workflow. CLINICAL RELEVANCE: For an AMS technology tool to be successful in improving AMS in companion animal medicine, veterinarians need centralized information on antimicrobial use, improved access to geographical AMR patterns, and communication support with clients and their hospital teams.

Community exposures among Colorado adults who tested positive for SARS-CoV-2 -A case-control study, March-December 2021.

OBJECTIVES: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, which causes coronavirus disease 2019 (COVID-19), is spread primarily through exposure to respiratory droplets from close contact with an infected person. To inform prevention measures, we conducted a case-control study among Colorado adults to assess the risk of SARS-CoV-2 infection from community exposures. METHODS: Cases were symptomatic Colorado adults (aged ≥18 years) with a positive SARS-CoV-2 test by reverse transcription-polymerase chain reaction (RT-PCR) reported to Colorado's COVID-19 surveillance system. From March 16 to December 23, 2021, cases were randomly selected from surveillance data ≤12 days after their specimen collection date. Cases were matched on age, zip code (urban areas) or region (rural/frontier areas), and specimen collection date with controls randomly selected among persons with a reported negative SARS-CoV-2 test result. Data on close contact and community exposures were obtained from surveillance and a survey administered online. RESULTS: The most common exposure locations among all cases and controls were place of employment, social events, or gatherings and the most frequently reported exposure relationship was co-worker or friend. Cases were more likely than controls to work outside the home (adjusted odds ratio (aOR) 1.18, 95% confidence interval (CI): 1.09-1.28) in industries and occupations related to accommodation and food services, retail sales, and construction. Cases were also more likely than controls to report contact with a non-household member with confirmed or suspected COVID-19 (aOR 1.16, 95% CI: 1.06-1.27). CONCLUSIONS: Understanding the settings and activities associated with a higher risk of SARS-CoV-2 infection is essential for informing prevention measures aimed at reducing the transmission of SARS-CoV-2 and other respiratory diseases. These findings emphasize the risk of community exposure to infected persons and the need for workplace precautions in preventing ongoing transmission.

Barriers to stool specimen collection during foodborne and enteric illness outbreak investigations in Arizona and Colorado.

Stool specimen collection during a foodborne or enteric illness outbreak investigation is essential for determining the outbreak etiology and for advancing the epidemiologic understanding of the pathogens and food vehicles causing illness. However, public health professionals face multifaceted barriers when trying to collect stool specimens from ill person during an outbreak investigation. The Colorado Integrated Food Safety Center of Excellence (Colorado IFS CoE) and the Arizona Department of Health Services surveyed local public health agencies (LPHAs) to identify barriers to collecting ≥2 clinical specimens in foodborne and enteric illness outbreaks. The most commonly selected patient-related barrier was that the patient did not think it is important to provide a stool sample because they are well by the time the LPHA follows-up (61%). The most frequently selected outbreak-related barrier was the LPHA did not learn about the outbreak until after symptoms had resolved (61%). Time/personnel not being available for stool collection was the most frequently chosen health department-related barrier (51%). Timing of the outbreak (e.g., on a weekend or holiday) was the most frequently selected transportation-related barrier (51%) to collecting ≥2 stool specimens. Many of the frequently cited barriers in this survey were similar to those previously reported, such as workforce capacity and patient privacy concerns, indicating that these barriers are ongoing. Reducing barriers to stool collection during outbreaks will require efforts led at the national and state levels, such as increased enteric illness program funding, educating public health staff on the importance of specimen collection during every enteric illness outbreak, and providing specimen collection resources to LPHA staff.

Colorado pet owners' perceptions of and attitudes towards antimicrobial drug use and resistance.

BACKGROUND: Antimicrobial drug (AMD) use in companion animal medicine may contribute to antimicrobial resistance (AMR) in both pets and humans. However, pet owners' attitudes and perceptions regarding AMD use and AMR have not been extensively studied in the United States. METHODS: A cross-sectional survey at five Colorado veterinary hospitals collected information about pet owners' knowledge and perceptions of AMD use and AMR, adherence with AMD treatment instructions and the role of the veterinarian in the AMD prescribing process. RESULTS: The pet owners surveyed did not have an adequate understanding of AMR and were unaware of the potential human health impact of AMD use in pets. However, most pet owners reported adherence with veterinary prescription instructions and indicated that they trusted their veterinarian to make appropriate decisions for their pets. LIMITATIONS: The cross-sectional design focusing on Colorado pet owners limits the generalisability of the results. Selection and social desirability biases may have occurred, which could have affected who participated and how participants responded to statements. CONCLUSIONS: Pet owners play an important role in the AMD prescription process, and their lack of AMR understanding should be addressed in antimicrobial stewardship plans. Further research on how to effectively incorporate pet owners into  stewardship interventions is needed.

Improving Foodborne Disease Surveillance and Outbreak Detection and Response Using Peer Networks-The Integrated Food Safety Centers of Excellence.

CONTEXT: Foodborne disease surveillance and outbreak investigations are foundational to the prevention and control of foodborne disease in the United States, where contaminated foods cause an estimated 48 million illnesses, 128 000 hospitalizations, and 3000 deaths each year. Surveillance activities and rapid detection and investigation of foodborne disease outbreaks require a trained and coordinated workforce across epidemiology, environmental health, and laboratory programs. PROGRAM: Under the 2011 Food Safety Modernization Act, the Centers for Disease Control and Prevention (CDC) was called on to establish Integrated Food Safety (IFS) Centers of Excellence (CoEs) at state health departments, which would collaborate with academic partners, to identify, implement, and evaluate model practices in foodborne disease surveillance and outbreak response and to serve as a resource for public health professionals. IMPLEMENTATION: CDC designated 5 IFS CoEs in August 2012 in Colorado, Florida, Minnesota, Oregon, and Tennessee; a sixth IFS CoE in New York was added in August 2014. For the August 2019-July 2024 funding period, 5 IFS CoEs were designated in Colorado, Minnesota, New York, Tennessee, and Washington. Each IFS CoE is based at the state health department that partners with at least one academic institution. EVALUATION: IFS CoEs have built capacity across public health agencies by increasing the number of workforce development opportunities (developing >70 trainings, tools, and resources), supporting outbreak response activities (responding to >50 requests for outbreak technical assistance annually), mentoring students, and responding to emerging issues, such as changing laboratory methods and the COVID-19 pandemic.

Direct Outpatient Health Care Costs Among Commercially Insured Persons for Common Foodborne Pathogens and Acute Gastroenteritis, 2012-2015.

Foodborne illness is common in the United States with most, but not all, foodborne pathogens causing symptoms of acute gastroenteritis (AGI). Outpatient care is the most frequent type of medical care sought; however, more accurate estimates of outpatient costs are needed to inform food safety policy decision. Using the U.S. MarketScan Commercial Claims and Encounters database, we quantified the per-visit cost of outpatient visits with any AGI-related diagnosis (including pathogen-specific and nonspecific or symptom-based diagnoses) and for those with a pathogen-specific diagnosis for 1 of 29 pathogens commonly transmitted through food (including pathogens that cause AGI and some that do not). Our estimates included the per-case cost of office visits and associated laboratory tests and procedures as well as the conservative estimates of prescription cost. Most AGI outpatient visits were coded using nonspecific codes (e.g., infectious gastroenteritis), rather than pathogen-specific codes (e.g., Salmonella). From 2012 to 2015, we identified more than 3.4 million initial outpatient visits with any AGI diagnosis and 45,077 with a foodborne pathogen-specific diagnosis. As is typical of treatment cost data, severe cases of illness drove mean costs above median. The mean cost of an outpatient visit with any AGI was $696 compared with the median of $162. The mean costs of visits with pathogen-specific diagnoses ranged from $254 (median $131; interquartile range [IQR]: $98-184) for Streptococcus spp. Group A (n = 22,059) to $1761 (median $161; IQR: $104-$1101) for Clostridium perfringens (n = 30). Visits with two of the most common causes of foodborne illness, nontyphoidal Salmonella and norovirus, listed as a diagnosis, had mean costs of $841 and $509, respectively. Overall, the median per-case costs of outpatient visits increased with age, with some variation by pathogen. More empirically based estimates of outpatient costs for AGI and specific pathogens can enhance estimates of the economic cost of foodborne illness used to guide food policy and focus prevention efforts.

Persisting gastrointestinal symptoms and post-infectious irritable bowel syndrome following SARS-CoV-2 infection: results from the Arizona CoVHORT.

In this study, we aimed to examine the association between gastrointestinal (GI) symptom presence during severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and the prevalence of GI symptoms and the development of post-infectious irritable bowel syndrome (PI-IBS). We used data from a prospective cohort and logistic regression to examine the association between GI symptom status during confirmed SARS-CoV-2 infection and prevalence of persistent GI symptoms at ≥45 days. We also report the incidence of PI-IBS following SARS-CoV-2 infection. Of the 1475 participants in this study, 33.8% (n = 499) had GI symptoms during acute infection. Cases with acute GI symptoms had an odds of persisting GI symptoms 4 times higher than cases without acute GI symptoms (odds ratio (OR) 4.29, 95% confidence interval (CI) 2.45-7.53); symptoms lasted on average 8 months following infection. Of those with persisting GI symptoms, 67% sought care for their symptoms and incident PI-IBS occurred in 3.0% (n = 15) of participants. Those with acute GI symptoms after SARS-CoV-2 infection are likely to have similar persistent symptoms 45 days and greater. These data indicate that attention to a potential increase in related healthcare needs is warranted.

Training Public Health Professionals on Adaptive Challenges-An Innovative Approach Using Remote Learning Modalities.

CONTEXT: Remote learning opportunities increase access to public health training. Innovative approaches are needed to promote active engagement and learning when tackling more complex, adaptive challenges that are nuanced, lack quick and easy solutions, and require a transformation of values and beliefs. PROGRAM: The Rocky Mountain Public Health Training Center's (RM-PHTC's) training framework considers the complexity of the challenge (technical to adaptive) when selecting the learning modality. Remote learning opportunities on adaptive challenges are addressed using virtual workshops, online courses, ECHO (Extension for Community Healthcare Outcomes) series, and communities of practice that include a combination of multiple sessions, cohort-based learning, peer learning, practice-based application, and live, interactive sessions. The specific modality chosen depends on the audience and amount of content delivery. IMPLEMENTATION: Virtual workshops are single events that encourage peer learning using a blend of instruction and practice-based work. Online courses deliver content to learning cohorts through an online platform combined with multiple, facilitated "live learning sessions." ECHO series include a short delivery of content, combined with multiple, facilitated, face-to-face, case-based learning sessions with a cohort of peers. Communities of practice encourage a bidirectional peer exchange of resources, approaches, and challenges through online sharing platforms and virtual meetings. EVALUATION: Using the Kirkpatrick training evaluation model, learners of public health reported that their understanding of the subject matter improved and that they had identified actions that they would apply to their work. In qualitative feedback, learners shared feedback on elements that facilitated learning on adaptive challenges, including interactive breakout groups with peers and practice-based applications. DISCUSSION: Remote learning opportunities increase access for public health professionals in rural areas and encourage knowledge exchange region-wide. The RM-PHTC's training framework matches learning opportunities that address adaptive challenges with modalities that include elements that encourage the sharing of ideas and cocreation of solutions.

Using Outbreak Data for Hypothesis Generation: A Vehicle Prediction Tool for Disease Outbreaks Caused by Salmonella and Shiga Toxin-Producing Escherichia coli.

Hypothesis generation about potential food and other exposures is a critical step in an enteric disease outbreak investigation, helping to focus investigation efforts and use of limited resources. Historical outbreak data are an important source of information for hypothesis generation, providing data on common food- and animal-pathogen pairs and other epidemiological trends. We developed a model to predict vehicles for Shiga toxin-producing Escherichia coli and Salmonella outbreaks using demographic and outbreak characteristics from outbreaks in the Centers for Disease Control and Prevention's Foodborne Disease Outbreak Surveillance System (1998-2019) and Animal Contact Outbreak Surveillance System (2009-2019). We evaluated six algorithmic methods for prediction based on their ability to predict multiple class probabilities, selecting the random forest prediction model, which performed best with the lowest Brier score (0.0953) and highest accuracy (0.54). The model performed best for outbreaks transmitted by animal contact and foodborne outbreaks associated with eggs, meat, or vegetables. Expanding the criteria to include the two highest predicted vehicles, 83% of egg outbreaks were predicted correctly, followed by meat (82%), vegetables (74%), poultry (67%), and animal contact (62%). The model performed less well for fruit and poultry vehicles, and it did not predict any dairy outbreaks. The final model was translated into a free, publicly available online tool that can be used by investigators to provide data-driven hypotheses about outbreak vehicles as part of ongoing outbreak investigations. Investigators should use the tool for hypothesis generation along-side other sources, such as food-pathogen pairs, descriptive data, and case exposure assessments. The tool should be implemented in the context of individual outbreaks and with an awareness of its limitations, including the heterogeneity of outbreaks and the possibility of novel food vehicles.

Survey of companion animal veterinarians' antimicrobial drug prescription practices and awareness of antimicrobial drug use guidelines in the United States.

Antimicrobial drug use in companion animal medicine, the subsequent development of antimicrobial resistance and the potential hazard of animals transmitting resistant bacteria to humans are of increasing concern. Antimicrobial prescription patterns among companion animal veterinarians in the United States are understudied, and the association between antimicrobial drug use guideline awareness and antimicrobial drug prescription practices is unknown. Information on antimicrobial recommendations for five hypothetical clinical scenarios, including canine pyoderma, acute canine diarrhoea, feline lower urinary tract illness, canine dental procedures and feline upper respiratory illness, was gathered using an anonymous, online cross-sectional survey. A logistic regression approach was used to assess the association between self-reported awareness of antimicrobial drug use guidelines and prescribing recommendations for the five hypothetical scenarios. Responses (n = 2,410) indicated antimicrobial drugs were commonly recommended for the five hypothetical clinical scenarios. After controlling for key demographic characteristics, prescribers who reported an awareness of existing antimicrobial drug use guidelines were significantly less likely to recommend antimicrobial drugs for the scenarios describing feline lower urinary symptoms, feline upper respiratory illness and canine acute diarrhoea. Results from hypothetical clinical scenarios point to the possibility for widespread unsupported prescribing of antimicrobial drugs in companion animal medicine. Additionally, results provide evidence of an association between awareness of antimicrobial drug use guidelines and lower prescribing levels for certain hypothetical disease presentations.

Trends in Outpatient Medical-Care Seeking for Acute Gastroenteritis During the COVID-19 Pandemic, 2020.

The rate of enteric infections reported to public health surveillance decreased during 2020 amid the coronavirus disease 2019 (COVID-19) pandemic. Changes in medical care-seeking behaviors may have impacted the diagnosis of enteric infections contributing to these declines. We examined trends in outpatient medical care-seeking behavior for acute gastroenteritis (AGE) in Colorado during 2020 compared with the that of previous 3 years using electronic health record data from the Colorado Health Observation Regional Data Service (CHORDS). Outpatient medical encounters for AGE were identified using diagnoses codes from the International Classification of Diseases 10th Revision and aggregated by year, quarter, age group, and encounter type. The rate of encounters was calculated by dividing the number of AGE encounters by the corresponding total number of encounters. There were 9064 AGE encounters in 2020 compared with an annual average of 18,784 from 2017 to 2019 (p < 0.01), representing a 52% decrease. The rate of AGE encounters declined after the first quarter of 2020 and remained significantly lower for the rest of the year. Moreover, previously observed trends, including seasonal patterns and the preponderance of pediatric encounters, were no longer evident. Telemedicine modalities accounted for 23% of all AGE encounters in 2020. AGE outpatient encounters in Colorado in 2020 were substantially lower than during the previous 3 years. Decreases remained stable over the second, third, and fourth quarters of 2020 (April-December) and were especially pronounced for children <18 years of age. Changes in medical care-seeking behavior likely contributed to declines in the number of enteric disease cases and outbreaks reported to public health. It is unclear to what extent people were ill with AGE and did not seek medical care because of concerns about the infection risk during a health care visit or to what extent there were reductions in certain exposures and opportunities for disease transmission resulting in less illness.