Success Of The Rollins Epidemiology Fellowship In Rebuilding Georgia's Epidemiologic Workforce.

Over the course of the past two decades, attrition within the US governmental public health workforce has passed concerning and become dire. The practice sector has struggled to recruit and retain new talent, despite the infusion of considerable federal investment in workforce expansion initiatives. In 2020, Emory University's Rollins School of Public Health partnered with the Georgia Department of Public Health to establish the Rollins Epidemiology Fellowship Program. Initially created to recruit and place early-career master of public health-level epidemiologists into Georgia's public health system for COVID-19 pandemic response, the two-year service-learning program has evolved into an effective and replicable model of direct academic involvement in strengthening the governmental public health workforce. Here we describe the program's structure and early results, spotlighting it for consideration by the federal government and other jurisdictions interested in directly engaging academia in efforts to revitalize the public health workforce.

Comparative effectiveness of alternative intervals between first and second doses of the mRNA COVID-19 vaccines.

The optimal interval between the first and second doses of COVID-19 mRNA vaccines has not been thoroughly evaluated. Employing a target trial emulation approach, we compared the effectiveness of different interdose intervals among >6 million mRNA vaccine recipients in Georgia, USA, from December 2020 to March 2022. We compared three protocols defined by interdose interval: recommended by the Food and Drug Administration (FDA) (17-25 days for Pfizer-BioNTech; 24-32 days for Moderna), late-but-allowable (26-42 days for Pfizer-BioNTech; 33-49 days for Moderna), and late ( ≥ 43 days for Pfizer-BioNTech; ≥50 days for Moderna). In the short-term, the risk of SARS-CoV-2 infection was lowest under the FDA-recommended protocol. Longer-term, the late-but-allowable protocol resulted in the lowest risk (risk ratio on Day 120 after the first dose administration compared to the FDA-recommended protocol: 0.83 [95% confidence interval: 0.82-0.84]). Here, we showed that delaying the second dose by 1-2 weeks may provide stronger long-term protection.

Prevalence and Correlates of COVID-19 Vaccine Information on Family Medicine Practices' Websites in the United States: Cross-sectional Website Content Analysis.

BACKGROUND: Primary care providers are regarded as trustworthy sources of information about COVID-19 vaccines. Although primary care practices often provide information about common medical and public health topics on their practice websites, little is known about whether they also provide information about COVID-19 vaccines on their practice websites. OBJECTIVE: This study aimed to investigate the prevalence and correlates of COVID-19 vaccine information on family medicine practices' website home pages in the United States. METHODS: We used the Centers for Medicare and Medicaid National Provider Identifier records to create a sampling frame of all family medicine providers based in the United States, from which we constructed a nationally representative random sample of 964 family medicine providers. Between September 20 and October 8, 2021, we manually examined the practice websites of these providers and extracted data on the availability of COVID-19 vaccine information, and we implemented a 10% cross-review quality control measure to resolve discordances in data abstraction. We estimated the prevalence of COVID-19 vaccine information on practice websites and website home pages and used Poisson regression with robust error variances to estimate crude and adjusted prevalence ratios for correlates of COVID-19 vaccine information, including practice size, practice region, university affiliation, and presence of information about seasonal influenza vaccines. Additionally, we performed sensitivity analyses to account for multiple comparisons. RESULTS: Of the 964 included family medicine practices, most (n=509, 52.8%) had ≥10 distinct locations, were unaffiliated with a university (n=838, 87.2%), and mentioned seasonal influenza vaccines on their websites (n=540, 56.1%). In total, 550 (57.1%) practices mentioned COVID-19 vaccines on their practices' website home page, specifically, and 726 (75.3%) mentioned COVID-19 vaccines anywhere on their practice website. As practice size increased, the likelihood of finding COVID-19 vaccine information on the home page increased (n=66, 27.7% among single-location practices, n=114, 52.5% among practices with 2-9 locations, n=66, 56.4% among practices with 10-19 locations, and n=304, 77.6% among practices with 20 or more locations, P<.001 for trend). Compared to clinics in the Northeast, those in the West and Midwest United States had a similar prevalence of COVID-19 vaccine information on website home pages, but clinics in the south had a lower prevalence (adjusted prevalence ratio 0.8, 95% CI 0.7 to 1.0; P=.02). Our results were largely unchanged in sensitivity analyses accounting for multiple comparisons. CONCLUSIONS: Given the ongoing COVID-19 pandemic, primary care practitioners who promote and provide vaccines should strongly consider utilizing their existing practice websites to share COVID-19 vaccine information. These existing platforms have the potential to serve as an extension of providers' influence on established and prospective patients who search the internet for information about COVID-19 vaccines.

MomsTalkShots, tailored educational app, improves vaccine attitudes: a randomized controlled trial.

BACKGROUND: Many pregnant women and parents have concerns about vaccines. This analysis examined the impact of MomsTalkShots, an individually tailored educational application, on vaccine attitudes of pregnant women and mothers. METHODS: MomsTalkShots was the patient-level component of a multi-level intervention to improve maternal and infant vaccine uptake that also included provider- and practice-level interventions. The impact of these interventions was studied using a two-by-two factorial design, randomizing at both the patient- and the practice-level. Study staff recruited pregnant women from a diverse set of prenatal care practices in Colorado and Georgia between June 2017 and July 2018. All participants (n = 2087) received a baseline survey of maternal and infant vaccine intentions and attitudes, and two follow-up surveys at least 1 month and 1 year after their infant's birth, respectively. Half of participants (n = 1041) were randomly assigned to receive educational videos through MomsTalkShots, algorithmically tailored to their vaccine intentions, attitudes, and demographics. Since the practice/provider intervention did not appear impactful, this analysis focused on MomsTalkShots regardless of the practice/provider intervention. RESULTS: By 1 month post-birth, MomsTalkShots increased perceived risk of maternal influenza disease (61% among MomsTalkShots recipients vs 55% among controls; Odds Ratio: 1.61, 95% Confidence Interval: 1.23-2.09), confidence in influenza vaccine efficacy (73% vs 63%; OR: 1.97, 95%CI: 1.47-2.65), and perceived vaccine knowledge (55% vs 48%; OR: 1.39, 95%CI: 1.13-1.72). Among those intending not to vaccinate at baseline, MomsTalkShots increased perceived risk of maternal influenza disease (38% vs 32%; OR: 2.07, 95%CI: 1.15-3.71) and confidence in influenza vaccine efficacy (44% vs 28%; OR: 2.62, 95%CI: 1.46-4.69). By 1 year post-birth, MomsTalkShots increased perceived vaccine knowledge (62% vs 50%; OR: 1.74, 95%CI: 1.36-2.24) and trust in vaccine information from obstetricians and pediatricians (64% vs 55%; OR: 1.53, 95%CI: 1.17-2.00). Among those uncertain about vaccinating at baseline, MomsTalkShots increased perceived vaccine knowledge (47% vs 12%; OR: 6.89, 95%CI: 1.52-31.25) and reduced infant vaccine safety concerns (71% vs 91%; OR: 0.24, 95%CI: 0.06-0.98). CONCLUSIONS: MomsTalkShots improved pregnant women's and mothers' knowledge and perceptions of maternal and infant vaccines and the diseases they prevent, and offers a scalable tool to address vaccine hesitancy. TRIAL REGISTRATION: Registered at Clinicaltrials.gov on 13/09/2016 (registration number: NCT02898688).

Use of surveillance data to elucidate household clustering of SARS-CoV-2 in Fulton County, Georgia a major metropolitan area.

BACKGROUND: Households are important for SARS-CoV-2 transmission due to high intensity exposure in enclosed spaces over prolonged durations. We quantified and characterized household clustering of COVID-19 cases in Fulton County, Georgia. METHODS: We used surveillance data to identify all confirmed COVID-19 cases in Fulton County. Household clustered cases were defined as cases with matching residential address. We described the proportion of COVID-19 cases that were clustered, stratified by age over time and explore trends in age of first diagnosed case within households and subsequent household cases. RESULTS: Between June 1, 2020 and October 31, 2021, 31,449(37%) of 106,233 cases were clustered in households. Children were the most likely to be in household clusters than any other age group. Initially, children were rarely (∼ 10%) the first cases diagnosed in the household but increased to almost 1 of 3 in later periods. DISCUSSION: One-third of COVID-19 cases in Fulton County were part of a household cluster. Increasingly children were the first diagnosed case, coinciding with temporal trends in vaccine roll-out among the elderly and the return to in-person schooling in Fall 2021. Limitations include restrictions to cases with a valid address and unit number and that the first diagnosed case may not be the infection source for the household.

Multi-tiered intervention to increase maternal immunization coverage: A randomized, controlled trial.

OBJECTIVE: To evaluate the impact of a multi-component intervention package of maternal immunization uptake in obstetric care clinics. METHODS: In a multi-level, cluster- and individually-randomized controlled trial we implemented an evidence-based intervention that targeted practice-, provider- and patient-level barriers to vaccine uptake. Obstetric practices were randomized to receive the practice and provider-level interventions or continue their normal standard of care. We enrolled pregnant women at practices in Georgia and Colorado and randomized women into patient-level intervention and control groups, resulting in four study arms. The primary outcomes were receipt of the influenza and tetanus, diphtheria and acellular pertussis (Tdap) vaccines during pregnancy. A sample size of 550 women per arm (2200 total) was planned and enrolled to compare the intervention between the four study arms. RESULTS: Between June 2017 and July 2018, 4907 women were screened and 2200 women were randomized, 550 to each of the four study arms. We were unable to follow-up with 108 women, for a final sample size of 2092. Sample characteristics and sample size were similar among study arms. There was no significant increase in Tdap or influenza vaccine uptake overall. Among women who had no intention of or were unsure about receiving the influenza vaccine during pregnancy, those who received just the patient-level intervention were 61% more likely to receive the influenza vaccine than those in the control arm (Relative risk: 1.61; 95% Confidence Interval: 1.18-2.21). There was no significant difference in vaccine uptake for either influenza or tetanus, diphtheria and acellular pertussis between the four arms of the study. CONCLUSIONS: This trial highlights the need for more targeted interventions to improve vaccine uptake. Future work should focus on clinics with low baseline vaccine uptake and the patient-level intervention should be expanded and targeted towards women with low vaccine confidence.

Characteristics and Risk Factors for Mortality by Coronavirus Disease 2019 Pandemic Waves in Fulton County, Georgia: A Cohort Study March 2020-February 2021.

Background: We examined differences in mortality among coronavirus disease 2019 (COVID-19) cases in the first, second, and third waves of the COVID-19 pandemic. Methods: A retrospective cohort study of COVID-19 cases in Fulton County, Georgia, USA, reported to a public health surveillance from March 2020 through February 2021. We estimated case-fatality rates (CFR) by wave and used Cox proportional hazards random-effects models in each wave, with random effects at individual and long-term-care-facility level, to determine risk factors associated with rates of mortality. Results: Of 75 289 confirmed cases, 4490 (6%) were diagnosed in wave 1 (CFR 31 deaths/100 000 person days [pd]), 24 293 (32%) in wave 2 (CFR 7 deaths/100 000 pd), and 46 506 (62%) in wave 3 (CFR 9 deaths/100 000 pd). Compared with females, males were more likely to die in each wave: wave 1 (adjusted hazard ratio [aHR], 1.5; 95% confidence interval [CI], 1.2-1.8), wave 2 (aHR 1.5, 95% CI, 1.2-1.8), and wave 3 (aHR 1.7, 95% CI, 1.5-2.0). Compared with non-Hispanic whites, non-Hispanic blacks were more likely to die in each wave: wave 1 (aHR, 1.4; 95% CI, 1.1-1.8), wave 2 (aHR, 1.5; 95% CI, 1.2-1.9), and wave 3 (aHR, 1.7; 95% CI, 1.4-2.0). Cases with any disability, chronic renal disease, and cardiovascular disease were more likely to die in each wave compared with those without these comorbidities. Conclusions: Our study found gender and racial/ethnic disparities in COVID-19 mortality and certain comorbidities associated with COVID-19 mortality. These factors have persisted throughout the COVID-19 pandemic waves, despite improvements in diagnosis and treatment.

Association between having a regular healthcare provider and pre-exposure prophylaxis use among men who have sex with men: a cross-sectional survey.

Healthcare providers whom people see regularly (e.g., primary care providers [PCPs]) are likely to interact with individuals at risk of human immunodeficiency virus (HIV). However, most PCPs report never prescribing pre-exposure prophylaxis (PrEP), a medication that prevents HIV infection. This study examined the association between having a regular healthcare provider and PrEP use among men who have sex with men (MSM). We analyzed health survey data from Black (n = 151) and White (n = 113) MSM in Atlanta, GA using log binomial regressions. Among Black MSM, the proportion who used PrEP was nearly three times higher for those with a regular provider compared to those without one (aPR 2.58; 95% CI: 0.96, 6.93). Conversely, the proportion of White MSM who used PrEP was slightly lower among those with a regular provider (aPR 0.67; 95% CI: 0.36, 1.27). Findings suggest having a regular provider may be more strongly associated with PrEP among Black MSM.

Assessment of US Public School District Policies for Pandemic Preparedness and Implications for COVID-19 Response Activities.

OBJECTIVES: To describe school district preparedness for school closures and other relevant strategies before the coronavirus disease 2019 (COVID-19) pandemic. METHODS: A stratified random sample of 957 public school districts from the 50 US states and the District of Columbia were surveyed between October 2015 and August 2016. The response rates for the questionnaires were as follows: Healthy and Safe School Environment, Crisis Preparedness Module (60%; N = 572), Nutrition Services (63%; N = 599), and Health Services (64%; N = 613). Data were analyzed using descriptive and regression techniques. RESULTS: Most school districts had procedures that would facilitate the implementation of school closures (88.7%). Fewer districts had plans for ensuring continuity of education (43.0%) or feeding students during closure (33.8%). The prevalence of continuity of education plans was lower in the Midwest than the Northeast (adjusted prevalence ratio [aPR] = 0.68; 95% confidence interval [CI]: 0.51-0.90). Presence of plans for feeding students was higher in high-poverty than low-poverty districts (aPR = 1.41; 95% CI: 1.01-1.99) and in large districts than small districts (aPR = 2.06; 95% CI: 1.37-3.09). CONCLUSIONS: Understanding factors associated with having comprehensive emergency plans could help decision makers to target assistance during the current COVID-19 pandemic and for future planning purposes.

Cumulative Incidence of SARS-CoV-2 Infections Among Adults in Georgia, United States, August to December 2020.

BACKGROUND: Reported coronavirus disease 2019 (COVID-19) cases underestimate true severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections. Data on all infections, including asymptomatic infections, are needed. To minimize biases in estimates from reported cases and seroprevalence surveys, we conducted a household-based probability survey and estimated cumulative incidence of SARS-CoV-2 infections adjusted for antibody waning. METHODS: From August to December 2020, we mailed specimen collection kits (nasal swabs and blood spots) to a random sample of Georgia addresses. One household adult completed a survey and returned specimens for virus and antibody testing. We estimated cumulative incidence of SARS-CoV-2 infections adjusted for waning antibodies, reported fraction, and infection fatality ratio (IFR). Differences in seropositivity among demographic, geographic, and clinical subgroups were explored with weighted prevalence ratios (PR). RESULTS: Among 1370 participants, adjusted cumulative incidence of SARS-CoV-2 was 16.1% (95% credible interval [CrI], 13.5%-19.2%) as of 16 November 2020. The reported fraction was 26.6% and IFR was 0.78%. Non-Hispanic black (PR, 2.03; 95% confidence interval [CI], 1.0-4.1) and Hispanic adults (PR, 1.98; 95% CI, .74-5.31) were more likely than non-Hispanic white adults to be seropositive. CONCLUSIONS: As of mid-November 2020, 1 in 6 adults in Georgia had been infected with SARS-CoV-2. The COVID-19 epidemic in Georgia is likely substantially underestimated by reported cases.

Racial/Ethnic Disparities in Maternal Vaccine Knowledge, Attitudes, and Intentions.

OBJECTIVES: Although disparities in maternal vaccine acceptance among racial/ethnic groups are well documented, the reasons for these disparities are unclear. The objective of this study was to describe differences in pregnant women's knowledge, attitudes, beliefs, intentions, and trust regarding maternal and infant vaccines by race/ethnicity. METHODS: We collected survey data from 1862 pregnant women from diverse prenatal care practices in Georgia and Colorado from June 2017 through July 2018. We performed multiple logistic regressions to determine differences in intentions, knowledge, attitudes, beliefs, and trust by race/ethnicity and calculated odds ratios (ORs) and 95% CIs. RESULTS: Compared with White women, Black and Hispanic women were less confident in vaccine safety and efficacy and less likely to perceive risk of acquiring vaccine-preventable diseases, report provaccine social norms, indicate having enough vaccine knowledge, and trust vaccine information from health care providers and public health authorities. Black women were the least confident in the safety of the maternal influenza vaccine (OR = 0.37; 95% CI, 0.27-0.49); maternal tetanus, diphtheria, and acellular pertussis vaccine (OR = 0.37; 95% CI, 0.27-0.52); and infant vaccines overall (OR = 0.40; 95% CI, 0.28-0.58), and were least likely to intend to receive both maternal vaccines (OR = 0.35; 95% CI, 0.27-0.47) or all infant vaccines on time (OR = 0.45; 95% CI, 0.34-0.61) as compared with White women. CONCLUSIONS: Understanding differences in behavioral constructs integral to vaccine decision making among women of different races/ethnicities can lead to tailored interventions to improve vaccine acceptance.

Health after Legionnaires' disease: A description of hospitalizations up to 5 years after Legionella pneumonia.

BACKGROUND AND OBJECTIVES: Research on Legionnaires' Disease (LD) suggests there may be long-term health complications, but data are limited. This study investigated whether Intensive Care Unit (ICU) admission during LD hospitalization may be associated with adverse health outcomes and characterized subsequent discharge diagnoses in patients with LD up to 5 years post-LD. METHODS: We conducted a retrospective case series study with follow up for 5 years among patients hospitalized at a Department of Veterans Affairs (VA) Medical Center between 2005 and 2010 with LD. Data were collected from medical records on health history, LD severity (including ICU admission), and discharge diagnoses for 5 years post-LD or until death. We used ordinal logistic regression to explore associations between ICU admission and hospitalizations post-LD. Frequency counts were used to determine the most prevalent discharge diagnoses in the 5 years post-LD. RESULTS: For the 292 patients with laboratory-confirmed LD, those admitted to the ICU during LD hospitalization were more likely to have a greater number of hospitalizations within 5 years compared to non-ICU patients (ORHosp 1.92 CI95% 1.25, 2.95). Fifty-five percent (161/292) had ≥ 1 hospitalization within 5 years post-LD. After accounting for pre-existing diagnosis codes in patients with at least one hospitalization in the 2 years prior to LD (n = 77/161 patients, 47.8%), three of the four most frequent new diagnoses in the 5 years post-LD were non-chronic conditions: acute renal failure (n = 22, 28.6%), acute respiratory failure (n = 17, 22.1%) and unspecified pneumonia (n = 15, 19.5%). CONCLUSIONS: Our findings indicate that LD requiring ICU admission is associated with more subsequent hospitalizations, a factor that could contribute to poorer future health for people with severe LD. In addition to chronic conditions prevalent in this study population, we found new diagnoses in the 5-year post-LD period including acute renal failure. With LD incidence increasing, more research is needed to understand conditions and factors that influence long term health after LD.

The 6 E Framework of Public Health Preparedness for Mass Gatherings-Lessons Learned From Super Bowl LIII, Fulton County, Georgia, 2019.

CONTEXT: On February 3, 2019, Atlanta, Georgia, hosted Super Bowl LIII, which is classified as a National Special Security Event. The festivities comprising this major sporting event brought approximately half a million people to Atlanta, which posed significant challenges to the local public health community. As the lead local agency for public health planning, preparedness, and response efforts, Fulton County Board of Health (FCBOH) needed to address multiple specific tasks based on core functional areas outlined in the Emergency Support Function (ESF) 8 (eg, bioterrorism preparedness and epidemiological surveillance). PROGRAM: To prepare for the Super Bowl, FCBOH developed a systematic approach to ensure community-wide public health preparedness for mass gatherings. This approach came to be known as the 6 E framework, which consists of (1) engaging stakeholders, (2) examining current capabilities and identifying gaps, (3) establishing roles and responsibilities, (4) executing plans to fill gaps, (5) exercising plans, and (6) evaluating impact. IMPLEMENTATION: We define each step of the 6 E framework and present practical examples of how FCBOH implemented each step when preparing for the Super Bowl. Challenges that FCBOH faced and the lessons learned in the process are illustrated. The 6 E framework provides a systematic approach to community preparedness and allows local health departments to tailor the approach to serve local public health needs. EVALUATION: The successful implementation of the 6 E framework allowed for stakeholders at the federal, state, and local levels (including law enforcement) to effectively coordinate an epidemiological investigation and response when 4 staff members reported gastrointestinal symptoms after eating at a feeding station. DISCUSSION: Preparation for the Super Bowl required months of diligent cross-sectoral and cross-jurisdictional partnership building, and the 6 E framework can help other local public health jurisdictions prepare to host major mass gatherings.

Retrospective cohort study of COVID-19 among children in Fulton County, Georgia, March 2020-June 2021.

OBJECTIVE: To describe case rates, testing rates and percent positivity of COVID-19 among children aged 0-18 years by school-age grouping. DESIGN: We abstracted data from Georgia's State Electronic Notifiable Disease Surveillance System on all 10 437 laboratory-confirmed COVID-19 cases among children aged 0-18 years during 30 March 2020 to 6 June 2021. We examined case rates, testing rates and percent positivity by school-aged groupings, namely: preschool (0-4 years), elementary school (5-10 years), middle school (11-13 years), and high school (14-18 years) and compared these data among school-aged children with those in the adult population (19 years and older). SETTING: Fulton County, Georgia. MAIN OUTCOME MEASURES: COVID-19 case rates, testing rates and percent positivity. RESULTS: Over time, the proportion of paediatric cases rose substantially from 1.1% (April 2020) to 21.6% (April 2021) of all cases in the county. Age-specific case rates and test rates were consistently highest among high-school aged children. Test positivity was similar across school-age groups, with periods of higher positivity among high-school aged children. CONCLUSIONS: Low COVID-19 testing rates among children, especially early in the pandemic, likely underestimated the true burden of disease in this age group. Despite children having lower measured incidence of COVID-19, we found when broader community incidence increased, incidence also increased among all paediatric age groups. As the COVID-19 pandemic continues to evolve, it remains critical to continue learning about the incidence and transmissibility of COVID-19 in children.

Characteristics and Risk Factors for Hospitalization and Mortality among Persons with COVID-19 in Atlanta Metropolitan Area.

Background: We present data on risk factors for severe outcomes among patients with coronavirus disease 2019 (COVID-19) in the southeast United States (U.S.). Objective: To determine risk factors associated with hospitalization, intensive care unit (ICU) admission, and mortality among patients with confirmed COVID-19. Design: A retrospective cohort study. Setting: Fulton County in Atlanta Metropolitan Area, Georgia, U.S. Patients: Community-based individuals of all ages that tested positive for SARS-CoV-2. Measurements: Demographic characteristics, comorbid conditions, hospitalization, ICU admission, death (all-cause mortality), and severe COVID-19 disease, defined as a composite measure of hospitalization and death. Results: Between March 2 and May 31, 2020, we included 4322 individuals with various COVID-19 outcomes. In a multivariable logistic regression random-effects model, patients in age groups ≥45 years compared to those <25 years were associated with severe COVID-19. Males compared to females (adjusted odds ratio [aOR] 1.4, 95% confidence interval [CI]: 1.1-1.6), non-Hispanic blacks (aOR 1.9, 95%CI: 1.5-2.4) and Hispanics (aOR 1.7, 95%CI: 1.2-2.5) compared to non-Hispanic whites were associated with increased odds of severe COVID-19. Those with chronic renal disease (aOR 3.6, 95%CI: 2.2-5.8), neurologic disease (aOR 2.8, 95%CI: 1.8-4.3), diabetes (aOR 2.0, 95%CI: 1.5-2.7), chronic lung disease (aOR 1.7, 95%CI: 1.2-2.3), and "other chronic diseases" (aOR 1.8, 95%CI: 1.3-2.6) compared to those without these conditions were associated with increased odds of having severe COVID-19. Conclusions: Multiple risk factors for hospitalization, ICU admission, and death were observed in this cohort from an urban setting in the southeast U.S. Improved screening and early, intensive treatment for persons with identified risk factors is urgently needed to reduce COVID-19 related morbidity and mortality.

Excess Pneumonia Mortality During a 2014-2015 Legionnaires' Disease Outbreak in Genesee County, Michigan.

BACKGROUND: From June 2014 to October 2015, the Michigan Department of Health and Human Services reported an outbreak of 90 cases of Legionnaires' disease, including 10 deaths, in Genesee County, Michigan. As Legionnaires' disease is not routinely tested for as a cause of community-acquired pneumonia, we hypothesized that the size of the outbreak was underestimated. METHODS: We used Centers for Disease Control and Prevention (CDC) Wide-ranging ONline Data for Epidemiologic Research data to compare pneumonia mortality in Genesee to similar counties from 2011 to 2017. We used data from the Genesee County Vital Records Division to assess geographic overlap of pneumonia mortality with reported Legionnaires disease cases by census tract. RESULTS: We estimated 70.0 excess pneumonia deaths (90% uncertainty interval: 36-103) in Genesee County during the outbreak. Areas of high pneumonia mortality overlapped with those with high Legionnaires' disease incidence. CONCLUSIONS: These findings are consistent with the hypothesis that the Legionnaires' disease outbreak was larger than reported. Earlier outbreak detection and response may have facilitated identification of additional cases.

Adapting Center for Disease Control and Prevention's immunization quality improvement program to improve maternal vaccination uptake in obstetrics.

INTRODUCTION: Maternal vaccination is critical for improving maternal and child health. Quality Improvement (QI) models1, such as the Centers for Disease Control and Prevention's (CDC) Assessment, Feedback, Incentives, eXchange (AFIX)2 model, have not yet been adapted to maternal vaccinations. This study assesses the impact of AFIX-OB, an adapted version of AFIX for obstetric settings, on maternal vaccination rates. METHODS: Between December 2016 and May 2018, state health departments and obstetric practices in Colorado and Georgia implemented the adapted AFIX-OB model. The model addressed unique patterns in patient encounters, practice flow, health records systems and competing clinical priorities in the obstetric setting through a menu of clearly-defined QI strategies, bi-weekly technical assistance meetings with designated immunization champions, incentives for champions/staff, and adapted tools to aid each practice during implementation. Vaccination rates were assessed by random chart reviews pre- and post-intervention. RESULTS: The AFIX-OB model was evaluated in eleven obstetric practices in two states as part of a multi-level intervention to increase maternal vaccination. Post AFIX-OB implementation, documented influenza vaccination rates increased from 56% at baseline to 65% (p < 0.01); and tetanus, diphtheria, and acellular pertussis (Tdap) vaccination rates increased from 77% at baseline to 84% (p < 0.02) across all practices. CONCLUSIONS: The AFIX-OB model showed improvement in maternal vaccination rates for both influenza and Tdap vaccines. AFIX-OB may provide a useful framework for obstetric practices, as well as for other health care specialties. The focused goal should be on broader dissemination among those interested in adopting an evidence-based model for increasing vaccine uptake.

Latent Class Analysis of Maternal Vaccine Attitudes and Beliefs.

Background. Maternal vaccine coverage is suboptimal, and a substantial proportion of parents have concerns about vaccines. Most parents seek out vaccine information during and immediately after their first pregnancy. No study to our knowledge has analyzed survey data to identify homogeneous groups of pregnant women based on their vaccine attitudes and beliefs. Aims. To identify homogeneity among groups of pregnant women based on their vaccine attitudes and beliefs to facilitate audience segmentation and targeting of tailored educational interventions. Method. Between June 2017 and July 2018, we surveyed 2,196 pregnant women recruited from geographically and sociodemographically diverse prenatal care practices in Georgia and Colorado. We then performed a latent class analysis to identify homogeneity among groups of pregnant women. Results. Our latent class analysis produced three groups of pregnant women: vaccine supporters (36% of women), vaccine acceptors (41%), and vaccine skeptics (23%). Discussion. The major difference between the supporters and the acceptors were whether they mostly "strongly agreed" or just "agreed" to Likert-type scale survey items assessing their vaccine attitudes and beliefs. The skeptics most frequently chose "disagree" or "don't know" for items assessing attitudinal constructs such as confidence in vaccine safety and efficacy and disease susceptibility. However, even skeptics often chose "agree" for items assessing constructs such as disease severity and self-efficacy. Conclusions. This article provides useful insight into the homogeneity among groups of pregnant women based on their vaccine attitudes and beliefs. This knowledge should help facilitate audience segmentation and targeting of tailored educational interventions among this population.

Health Care-Seeking Behaviors and Perceptions of Provider-Initiated Discussion of Pre-exposure Prophylaxis Among PrEP-Naïve HIV-Negative Men Who Have Sex With Men in Atlanta, Georgia.

BACKGROUND: Given high rates of HIV among men who have sex with men (MSM) in the United States, there is a need to more effectively leverage the health care system to bolster promotion of pre-exposure prophylaxis (PrEP) to at-risk MSM. METHODS: Using data collected from a 2018 venue-based cross-sectional survey, we examined factors associated with health care-seeking behaviors, discussing PrEP with a provider, and barriers to PrEP uptake among MSM. Associations between outcomes and respondents' sociodemographic characteristics and sexual behaviors were assessed using log binomial regression. RESULTS: Of 478 MSM, 247 (51%) were PrEP-naïve and HIV-negative. Although 85% of PrEP-naïve MSM reported visiting a health care provider in the past year, only 31% recalled having any provider discuss PrEP. The most frequently cited reasons for not taking PrEP were low perception of personal risk of acquiring HIV (37%) and not knowing enough about PrEP (35%). Those who saw a provider in the last year were less likely than those who did not to cite lack of knowledge as a barrier to use (prevalence rate, 0.66, 95% confidence interval, 0.45-0.96). CONCLUSIONS: Despite the majority of PrEP-naïve MSM interfacing with the health care system, recollection of discussing PrEP with providers was limited. Increased efforts to equip providers with the tools to discuss PrEP and address pressing concerns with at-risk individuals may help improve PrEP uptake among priority populations.

Using PrEP to #STOPHIVATL: Findings from a Cross-Sectional Survey Among Gay Men and Transgender Women Participating in Gay Pride Events in Atlanta, Georgia, 2018.

Assessing pre-exposure prophylaxis (PrEP) coverage and identifying reasons for disproportionate uptake among the varied social and cultural sub-groups of men who have sex with men (MSM) and transgender women who have sex with men (TWSM) are necessary precursors to setting attainable local PrEP. We report on findings of a cross-sectional survey among MSM/TWSM attending Gay pride events in Atlanta, Georgia, in 2018. Associations between PrEP awareness, uptake, and respondent characteristics were assessed using logistic regression. PrEP awareness did not differ by race, but current use was significantly lower among Blacks at substantial risk of HIV (p = .008). In multivariate analysis, clinician encounter in the past year was associated with awareness while age, income, drug use, sero-discordant sex, and multiple male partners were associated with current use. Among PrEP-naïve MSM/TWSM, the most common reasons for nonuse differed by race (poor knowledge of PrEP: Black-45% vs. non-Black-27%, p = .010, low perception of risk: Black-26% vs. non-Black-52%, p = .001). Key racial and socioeconomic disparities in active PrEP use and reasons for nonuse remain despite the recent increases in PrEP awareness and use among MSM/TWSM in Atlanta. Achieving overall improvement in uptake among all MSM/TWSM sub-groups will require tailoring PrEP educational messaging, optimizing communication modalities, expanding provider outreach, and identifying ways to defray costs for high-risk, underserved sub-groups in these populations.