Evaluation of a Suspected Overdose Form for Timely Surveillance of Fatal Drug Overdoses, Multnomah County, OR, 2020-2021.

OBJECTIVES: There is a significant delay in finalization of drug overdose deaths, and a need to more quickly identify suspected overdoses to improve public health response. The objective of our study was to describe creation of a suspect overdose form and evaluate its use. DESIGN: Evaluation of a suspected overdose form used to record information related to death investigation with matching to state vital records. We calculated the toxicology turnaround time for matched records, and also calculated sensitivity, specificity, positive predictive value, and negative predictive value of the form compared to vital records as the gold standard. SETTING: Multnomah County, Oregon, deaths investigated by the County Medical Examiner between January 2020 and December 2021. MAIN OUTCOME MEASURE: Sensitivity of the suspected overdose form. RESULTS: We analyzed 2818 matched death records in total during the study period. The average turnaround time for the 1673 records with toxicology results was 101 days. In 2020, sensitivity of the form was 74%, but this increased to nearly 95% in 2021. CONCLUSIONS: Multnomah County's suspected evaluation form provides a timelier indicator of deaths suspected to be from drug overdose, has good sensitivity to detect true overdoses, and can help guide more rapid public health and public safety response activities.

Alcohol and drug presence in traffic crash fatalities before and after the COVID-19 pandemic: Evaluation of the fatality analysis reporting system (FARS) and linked medical examiner-vital records data in Clackamas, Multnomah, and Washington County, Oregon, 2019-2021.

Traffic fatalities, with and from increased risky behaviors (reduced seat belt use, increased impairment from licit and illicit substances), have been increasing, especially during the COVID-19 pandemic. Death certificates are a major source of epidemiologic data in the United States, but have known underreporting of drug and alcohol presence. The Fatality Analysis Reporting System (FARS) is one major source of data on fatal crashes with intoxication. This study links FARS data for three counties in Oregon (2019-2021) with local medical examiner and death certificate data (FARS source data) and compares their concordance with blood alcohol concentration and toxicology for three major drug classes by year. For drivers only, our study finds good concordance between FARS and its source data in 2019 but poor concordance in 2020. This discordance may impact future analysis of impaired crash deaths, and we list some suggestions for amelioration.

Transgender and Nonbinary Deaths Investigated by the State Medical Examiner in the Portland, Oregon, Metro Area and Their Concordance With Vital Records, 2011-2021.

OBJECTIVES: To illustrate possible improvements in recording of gender identity, we investigated discrepancies between gender identity from medical examiner (ME) death investigations and sex as recorded in the final death record. DESIGN: Evaluation of a database used to record information related to medicolegal death investigation with matching to state vital records. Kappa analysis was used to measure concordance between both systems. SETTING: The Portland, Oregon, metro area (Clackamas, Multnomah, and Washington Counties) and deaths investigated by the Offices of each County Medical Examiner between January 2011 and September 2020. INTERVENTION: Epidemiologists identified incongruous data that have significant negative implications for transgender populations. Epidemiologists identified key actions that, if taken by death investigators, death record software, and the federal death certificate form, will rectify harmful data discrepancies. MAIN OUTCOME MEASURE: Concordance of gender identity and sex in ME data and death record, respectively. RESULTS: We identified 51 deaths in transgender persons; the majority were classified as transgender female (71%). The κ statistic was -0.0657, indicating poor concordance between the gender identity in ME investigation and the death certificate in vital records. CONCLUSIONS: Information gathered via medicolegal death investigations is foundational to effective public health/public safety response; MEs and coroners are often the first to document emerging health threats. Discrepancies in official death records impede accurate surveillance of a population disproportionately at risk of violent death.

Use of Injection Drugs and Any Form of Methamphetamine in the Portland, OR Metro Area as a Driver of an HIV Time-Space Cluster: Clackamas, Multnomah, and Washington Counties, 2018-2020.

We describe the response to detection of a time-space cluster of new HIV infection in the Portland, OR metro area among people who inject drugs (PWID) and/or people who use any form of methamphetamine. This time-space cluster took place in a region with a syndemic of homelessness and drug use. The investigation included new HIV diagnoses in 2018, 2019, and 2020 in Clackamas, Multnomah, and Washington Counties. Public health response included activating incident command, development and implementation of an enhanced interview tool, outreach testing, and stakeholder engagement. We identified 396 new cases of HIV infection, 116 (29%) of which met the cluster definition. Most cluster cases had no molecular relationships to previous cases. Persons responding to the enhanced interview tool reported behaviors associated with HIV acquisition. Field outreach testing did not identify any new HIV cases but did identify hepatitis C and syphilis infections. We show the importance of a robust public health response to a time-space cluster of new HIV infections in an urban area.

Prevalence of Self-reported Neurologic and Ocular Symptoms in Early Syphilis Cases.

BACKGROUND: Neurosyphilis, a complication of syphilis, can occur at any stage of infection. Measuring the prevalence of neurosyphilis is challenging, and there are limited data on the prevalence of neurologic or ocular symptoms among patients with syphilis. We sought to describe the prevalence of neurologic and/or ocular symptoms among early syphilis (ES) cases and the clinical management of symptomatic cases enrolled in the STD Surveillance Network (SSuN) Neuro/Ocular Syphilis Surveillance project. METHODS: Persons diagnosed with ES were selected for interviews based on current health department protocols in 5 participating SSuN jurisdictions from November 2016 through October 2017. All interviewed ES cases were screened for self-reported neurologic and/or ocular symptoms. Additional clinical information on diagnostic testing and treatment for cases concerning for neurosyphilis/ocular syphilis was obtained from providers. RESULTS: Among 9123 patients with ES who were interviewed, 151 (1.7%; 95% confidence interval [CI], 1.4%-1.9%) reported ≥ 1 neurologic or ocular symptom. Of the 53 (35%) who underwent lumbar puncture, 22 (42%) had documented abnormal cerebrospinal fluid, of which 21 (95%) were treated for neurosyphilis/ocular syphilis. Among the remaining 98 symptomatic patients with no documented lumbar puncture (65%), 12 (12%) were treated for and/or clinically diagnosed with neurosyphilis/ocular syphilis. CONCLUSIONS: We observed a low prevalence of self-reported neurologic and/or ocular symptoms in interviewed ES cases. Approximately one-third of ES cases who self-reported symptoms underwent further recommended diagnostic evaluation. Understanding barriers to appropriate clinical evaluation is important to ensuring appropriate management of patients with possible neurologic and/or ocular manifestations of syphilis.

Firearm-Related Deaths in Multnomah County, Oregon, 2010-2016: Linking Medical Examiner Data to State Vital Records Data.

OBJECTIVES: Violence due to firearms is a substantial public health problem. Death data from medical examiner and vital records were linked to evaluate the use of medical examiner data to augment routine surveillance and determine any differences in sex, age, manner of death, or race and ethnicity between the 2 data systems. MATERIALS AND METHODS: Medical examiner data were searched for keywords of interest, and vital records data were obtained and linked for deaths occurring in Multnomah County, Oregon, from January 1, 2010, through December 31, 2016. Both data sets were compared for the number and proportion of firearm-related deaths by sex, age, manner of death, and race/ethnicity. Sensitivity and positive predictive values were calculated for variables that had discordant results. RESULTS: A total of 568 firearm-related deaths were identified in the medical examiner data. After matching with manual review, the 2 data systems had 100% case agreement. A reverse match showed that most cases not found in medical examiner data were due to transfer of case jurisdiction. The 2 systems matched nearly perfectly in sex, age, and manner of death but differed in characterization of race and ethnicity. Sensitivity was 62% for Hispanic ethnicity but 93% for white and black race. PRACTICE IMPLICATIONS: Using medical examiner data was a useful way to augment routine surveillance of firearm-related deaths in our jurisdiction in close to real time. However, caution is needed when analyzing data by subgroups because of discordant classifications of race between the data systems.

Prescription of Preexposure Prophylaxis to Men Who Have Sex With Men Diagnosed and Reported With Gonorrhea, STD Surveillance Network, 2016.

Using a representative sample of gonorrhea cases in select jurisdictions, we estimated the proportion of eligible men who have sex with men reporting being prescribed preexposure prophylaxis (PrEP) to prevent HIV infection. In 2016, half (51.3%) of the estimated 33,165 eligible men who have sex with men reported being prescribed PrEP by their health care provider.

Early Syphilis Among Men Who Have Sex with Men in the US Pacific Northwest, 2008-2013: Clinical Management and Implications for Prevention.

Substantial increases in syphilis during 2008-2013 were reported in the US Pacific Northwest state of Oregon, especially among men who have sex with men (MSM). The authors aimed to characterize the ongoing epidemic and identify possible gaps in clinical management of early syphilis (primary, secondary, and latent syphilis ≤1 year) among MSM in Multnomah County, Oregon to inform public health efforts. Administrative databases were used to examine trends in case characteristics during 2008-2013. Medical records were abstracted for cases occurring in 2013 to assess diagnosis, treatment, and screening practices. Early syphilis among MSM increased from 21 cases in 2008 to 229 in 2013. The majority of cases occurred in HIV-infected patients (range: 55.6%-69.2%) diagnosed with secondary syphilis (range: 36.2%-52.4%). In 2013, 119 (51.9%) cases were diagnosed in public sector medical settings and 110 (48.0%) in private sector settings. Over 80% of HIV-infected patients with syphilis were in HIV care. Although treatment was adequate and timely among all providers, management differed by provider type. Among HIV-infected patients, a larger proportion diagnosed by public HIV providers than private providers were tested for syphilis at least once in the previous 12 months (89.6% vs. 40.0%; p < 0.001). The characteristics of MSM diagnosed with early syphilis in Multnomah County remained largely unchanged during 2008-2013. Syphilis control measures were well established, but early syphilis among MSM continued to increase. The results suggest a need to improve syphilis screening among private clinics, but few gaps in clinical management were identified.

Early Identification and Linkage to Care of Foreign-Born People with Chronic Hepatitis B Virus Infection, Multnomah County, Oregon, 2012-2014.

OBJECTIVE: Hepatitis B virus (HBV) infection is a global health concern, with a large proportion of high-risk individuals unaware of their infection status. People born in countries with medium to high endemicity of HBV should be tested and linked to care. We describe a program that improved identification and linkage to care for refugees and immigrants at the Multnomah County Health Department in Oregon. METHODS: We instituted outreach clinics and community referrals and expanded refugee screening to identify foreign-born people at risk for HBV. We obtained data from electronic health records and electronic laboratory reporting, including patient demographics, hepatitis B testing variables, vaccination history, and-for positive cases-risk-factor and linkage-to-care data. All results were entered into an Internet-based data collection tool. For this analysis, we only used results for testing performed from October 2012 through June 2014. RESULTS: We screened 2,087 foreign-born people for HBV infection and identified 77 (4%) people with positive results. HBV infection prevalence varied by site, with 7% of HBV-positive people identified through the outreach and voucher program and 3% identified through refugee screening. Of the 77 people testing positive for HBV, 72 (94%) were successfully linked to care, of whom 68 (94%) attended their first follow-up visit. CONCLUSION: Implementation of a culturally competent screening program among immigrants and refugees in Multnomah County improved case finding and subsequent linkage to care.

Impact of Routine Quantiferon Testing on Latent Tuberculosis Diagnosis and Treatment in Refugees in Multnomah County, Oregon, November 2009-October 2012.

Interferon-gamma release assays have potentially been transformative to screening programs focused on latent tuberculosis infection (LTBI) in foreign-born persons. We sought to add to this assessment by presenting the impact of a well-established refugee screening and treatment program switching from skin testing to Quantiferon(®)-TB Gold (QFT). We completed a retrospective cohort of refugees screened for tuberculosis between November 1, 2009-April 30, 2011 (pre-QFT) and May 1, 2011-October 31, 2012 (post-QFT). Among 2244 refugees screened that met the inclusion criteria, there was a significant difference in the proportion of refugees diagnosed with LTBI between the two time periods (p = <0.0001). In multivariate analysis, refugees tested with QFT had a greater odds of treatment initiation (adjusted odds ratio 1.53; 95% CI 1.02-2.29, p = 0.040). However, test type had no impact on treatment completion (odds ratio 0.88; 95% CI 0.57-1.36, p = 0.560). Although we demonstrated increased efficiency in LTBI diagnosis in this group, treatment completion rates indicate other barriers to treatment that must be addressed.

Elevated occupational transportation fatalities among older workers in Oregon: an empirical investigation.

Older workers have an elevated risk of being killed on the job, and transportation incidents involving vehicles or mobile machinery are especially deadly for this group. The present study was designed to address the research gap in understanding contributing factors to these incidents and recommend evidence-based guidelines for interventions. We gathered and analyzed data from several sources, including the Oregon Fatality Assessment and Control Evaluation program, the Oregon Workers' Compensation system, the Census of Fatal Occupational Injuries, the Bureau of Labor Statistics, and peer reviewed research literatures. Rates and rate ratios (RR) were used to evaluate excess risk among groups. The results of this study show that older workers in Oregon have an elevated risk of fatality both in all events (RR=3.0, 95% CI 2.2-4.0) and transportation events (RR=3.6, 95% CI 2.4-5.4). Additional analyses and extant literature supports our hypotheses that multiple risk factors contribute to the phenomenon, including (a) hazard exposure, (b) organization of work, (c) physical fragility, and (d) normative cognitive, sensory, and psychomotor changes that occur with age. The evidence-based framework proposed may provide valuable guidance for developing safety interventions that protect older workers.

Occupational injuries to Oregon workers 24 years and younger: An analysis of workers' compensation claims, 2000-2007.

BACKGROUND: Occupational injuries to adolescents and young adults are a known public health problem. We sought to describe and estimate rates of occupational injuries to workers younger than 25 years of age in Oregon during an 8-year period. METHODS: Oregon workers' compensation disabling claims data (n = 23,325) and one commercial insurance carrier's non-disabling claims data (n = 16,153) were analyzed. Total employment from the Local Employment Dynamics of the U.S. Census Bureau and the Oregon Labor Market Information System was used as a denominator for rates. RESULTS: Injuries were more frequent among 22-24 year olds and among males, though females accounted for a higher proportion of claims in the youngest age group. The most common injury type was a sprain or strain, but lacerations and burns were more frequently reported in the 14-18 year olds. When non-disabling claims were included, the rate of injury for 14-18 year olds doubled. The overall rate of injury was 122.7/10,000 workers, but was higher in the construction, manufacturing, and transportation sectors, and in the agriculture, forestry, fishing, and hunting sector for older teens and young adults. CONCLUSIONS: Young workers continue to be at risk for occupational injuries. Our results show that specific interventions may be needed for older teen and young adult workers to reduce their rate of injury.

Prevalence of work-related asthma in Michigan, Minnesota, and Oregon.

INTRODUCTION: Adults who have asthma that is caused or aggravated by triggers at work experience a reduced quality of life. In this study, the authors sought to estimate the proportion of asthma that is associated with work using a state-based survey of adults with asthma. METHODS: In 2005, Michigan, Minnesota, and Oregon piloted the Behavioral Risk Factor Surveillance System Adult Asthma Call-Back Survey, with sample sizes of 867, 469, and 1072, respectively. Six questions addressing work-related asthma (WRA) were analyzed to generate estimates of the proportion of adult asthma that is work-related and compare those with and without WRA. RESULTS: Over half of all adults with asthma (53%) reported that their asthma was caused or made worse by any job they ever had, and among these respondents reporting WRA, only 21.5% to 25.1% reported ever telling or being told by a health professional that their asthma was work-related. Additionally, adults with WRA consistently reported poorer asthma control and higher health care utilization than adults with non-WRA. CONCLUSIONS: WRA is a common but frequently unrecognized health problem, and this lack of recognition might contribute to poorer asthma control among adults with WRA. Because early recognition, treatment, and management of WRA are crucial for improving long-term prognosis, clinicians need to include assessment of workplace triggers in both their diagnostic and treatment plans for adult patients with asthma.

Pyrethrin and pyrethroid illnesses in the Pacific northwest: a five-year review.

OBJECTIVE: Pyrethrin and pyrethroid insecticides are commonly applied in homes and businesses and on some agricultural crops. This research used a two-state regional approach to analyze reports of acute pesticide poisonings due to pyrethrin and pyrethroid insecticides. METHODS: The Washington State Department of Health and the Oregon Public Health Division collected pesticide poisoning surveillance data from 2001 through 2005. Cases were included if they involved exposure to at least one pyrethrin or pyrethroid insecticide. Descriptive statistics were calculated; differences between categories were assessed using Chi-square analysis. RESULTS: A total of 407 cases fit our definition. Overall, the rate of poisoning in Oregon was significantly higher than in Washington (incidence rate ratio 1.70, 95% confidence interval 1.40, 2.07), and rates for both states generally increased during the time period. For both states, most exposures resulted in low severity illnesses (92%), and most were classified as possible cases (73%). Only about one-fourth of cases were related to a person's work. The most common category of clinical signs and symptoms of illness was respiratory (52% of cases), followed by neurological (40% of cases). Exposure route was predominantly inhalation; there was no association between route and case severity. There was a significant association between illness severity and losing time from work or regular activities (p<0.0001). CONCLUSIONS: Although the majority of pyrethrin and pyrethroid poisoning cases were low in severity, adverse reactions have occurred, as transpired in Oregon in 2005. Regional analysis has the potential to improve the surveillance system and provide unique opportunities for targeting preventive interventions.

Characteristics of occupational burns in Oregon, 2001-2006.

BACKGROUND: Occupational burns are known to be a serious public health concern. This article describes work-related burns in Oregon between 2001 and 2006. METHODS: Oregon Workers' Compensation (WC) burn claims were analyzed; data from a commercial insurance carrier (CIC) was used to characterize non-disabling burn claims. To ensure that our primary data source (WC) captures as many burn cases as possible, we compared hospitalized cases to a regional burn center (RBC) and Oregon hospital discharge index (HDI) data. RESULTS: The WC burn injury rate ranged from a high of 1.8 per 10,000 workers in 2001 to a low of 1.4 per 10,000 in 2004. We identified 2,165 accepted burn claims in CIC data, of which 85% were non-disabling. We matched data from a regional burn center to a subset of hospitalized claims from WC data and found an additional 44 cases of occupational hospitalized burns representing a 3% increase in total cases captured. CONCLUSIONS: Occupational burns continue to be a problem for working Oregonians, and the use of additional data sources outside of WC augments our surveillance system.