Overdose Deaths and Acute Hepatitis Infections among American Indians in North Carolina.

BACKGROUND Like the rest of the nation, North Carolina is experiencing the worst drug crisis in United States history, as deaths related to medication and drug overdoses are at an all-time high. Although the absolute numbers of deaths are highest among white populations, American Indians (AIs) experience disproportionally high rates.METHOD Using death certificate data, death rates due to unintentional medication and drug overdose were calculated for various races and ethnicities. Acute hepatitis B (HBV) and acute hepatitis C (HCV) rates were also calculated across racial and ethnic groups using data from the North Carolina Electronic Disease Surveillance System.RESULTS After adjusting for population size, AIs have as high or higher overdose death rates for all types of drugs except heroin, compared to other racial and ethnic groups. During the most recent 5 years of data (2012-2016), the highest rate of acute HCV infection occurred among AIs.LIMITATIONS Race/ethnicity data recorded on death certificates is often provided by family members and is difficult to verify independently. Another potential limitation is use of small numbers to calculate rates. Additionally, HBV and HCV are thought to be underreported.CONCLUSION Overdose death rates and rates of communicable diseases associated with injection drug use among AIs residing in North Carolina are as high as or higher than the overall North Carolina population. It is important to recognize and address these differences and provide prevention, harm reduction, and treatment services to all groups being impacted by the overdose epidemic.

Ocular Syphilis and Human Immunodeficiency Virus Coinfection Among Syphilis Patients in North Carolina, 2014-2016.

BACKGROUND: Ocular syphilis (OS) has been associated with human immunodeficiency virus (HIV) coinfection previously. We compared demographic and clinical characteristics of syphilis patients with and without HIV to identify risk factors for developing OS. METHODS: We reviewed all syphilis cases (early and late) reported to the North Carolina Division of Public Health during 2014 to 2016 and categorized HIV status (positive, negative, unknown) and OS status based on report of ocular symptoms with no other defined etiology. We estimated prevalence ratios (PR) and 95% confidence intervals (CI) for OS by HIV status. Among syphilis patients with HIV, we compared viral loads and CD4 cell counts by OS status. We compared symptom resolution by HIV status for a subset of OS patients. RESULTS: Among 7123 confirmed syphilis cases, 2846 (39.9%) were living with HIV, 109 (1.5%) had OS, and 59 (0.8%) had both. Ocular syphilis was more prevalent in syphilis patients with HIV compared to HIV-negative/unknown-status patients (PR, 1.8; 95% CI, 1.2-2.6). Compared with other patients with HIV, the prevalence of OS was higher in patients with viral loads greater than 200 copies/mL (1.7; 1.0-2.8) and in patients with a CD4 count of 200 cells/mL or less (PR, 2.3; 95% CI, 1.3-4.2). Among 11 patients with severe OS, 9 (81.8%) were HIV-positive. Among 39 interviewed OS patients, OS symptom resolution was similar for HIV-positive (70.0%) and HIV-negative/unknown-status (68.4%) patients. CONCLUSIONS: Syphilis patients with HIV were nearly twice as likely to report OS symptoms as were patients without documented HIV. Human immunodeficiency virus-related immunodeficiency possibly increases the risk of OS development in co-infected patients.

Depression, ART Adherence, and Receipt of Case Management Services by Adults with HIV in North Carolina, Medical Monitoring Project, 2009-2013.

Depression among persons with HIV is associated with antiretroviral therapy (ART) interruption and discontinuation, virological failure, and poor clinical and survival outcomes. Case management services can address needs for emotional counseling and other supportive services to facilitate HIV care engagement. Using 2009-2013 North Carolina Medical Monitoring Project data from 910 persons engaged in HIV care, we estimated associations of case management utilization with "probable current depression" and with 100% ART dose adherence. After weighting, 53.2% of patients reported receiving case management, 21.7% reported depression, and 87.0% reported ART adherence. Depression prevalence was higher among those reporting case management (24.9%) than among other patients (17.6%) (p < 0.01). Case management was associated with depression among patients living above the poverty level [adjusted prevalence ratio (aPR), 2.05; 95% confidence interval (CI) 1.25-3.36], and not among other patients (aPR, 1.01; 95% CI 0.72-1.43). Receipt of case management was not associated with ART adherence (aPR, 1.00; 95% CI 0.95-1.05). Our analysis indicates a need for more effective depression treatment, even among persons receiving case management services. Self-reported ART adherence was high overall, though lower among persons experiencing depression (unadjusted prevalence ratio, 0.92; 95% CI 0.86-0.99). Optimal HIV clinical and prevention outcomes require addressing psychological wellbeing, monitoring of ART adherence, and effective case management services.

A Comparison of Syphilis Partner Notification Outcomes by Reported Use of Internet-based Apps to Meet Sex Partners in North Carolina, 2013-2016.

BACKGROUND: Partner notification services (PNS) remain the backbone of syphilis control. The popularity of Internet-based apps to meet sex partners among early syphilis (ES) patients may hinder the success of PNS if partners cannot be located. METHODS: We compared demographic and clinical characteristics between male ES patients indicating sex with men (MSM) and reported in North Carolina between 2013 and 2016 by reported use of an Internet-based app to meet sex partners (app user). We used multivariable log-binomial regression to assess the association between app usage and ES exposure notification of 1 or more sex partner. RESULTS: Among 3414 MSM ES patients, 58.6% were app users. App users were more frequently white (33.2% vs 27.3%; P = 0.003), younger (median, 28 years vs 30 years; P = 0.0002) and less frequently human immunodeficiency virus coinfected (54.1% vs 58.2%; P = 0.02) compared to non-app users. Overall, 94.9% of app users and 89.6% of non-app users reported 1 or more sex partner. App users reported 2.5 times more locatable and 2.7 times more unlocatable sex partners than non-app users. Similar proportions of app (23.6%) and non-app users (25.0%) reported only unlocatable partners (P = 0.4). App usage was not associated with ES exposure notification of 1 or more sex partner (adjusted risk ratio, 0.99; 95% confidence interval, 0.87-1.13). CONCLUSIONS: We observed no difference in the proportion of locatable partners or likelihood of notifying 1 or more sex partner of exposure among MSM ES patients, by reported use of Internet-based apps to meet sex partners. Partner notification services continues to be an important mechanism to locate and assure treatment for sex partners in this population.

Changing Susceptibility of Staphylococcus aureus in a US Pediatric Population.

BACKGROUND: Staphylococcus aureus is a major cause of infection in both adult and pediatric populations. After several decades of increasing prevalence, the proportion of S aureus infections due to methicillin-resistant S aureus has been reported to be in decline in adults. Data for similar changes in pediatric populations are limited. METHODS: Evaluation of S aureus susceptibility data for pediatric patients receiving care in the US Military Health System was performed. Microbiology and demographic data were collected for years 2005 through 2014. Trends in antibiotic susceptibility results were evaluated. Clinical and demographic characteristics were explored to assess for association with antibiotic susceptibilities. RESULTS: In this study, 41 745 S aureus isolates from 39 207 pediatric patients were included. An overall increase in susceptibility of isolates to oxacillin was noted over this 10-year period; with over 60% of isolates oxacillin-susceptible in 2014. S aureus susceptibility to clindamycin declined over the study period; notably methicillin-susceptible S aureus susceptibility to clindamycin declined from 90% to 83% (P < .0001). Differences in oxacillin susceptibility between US regions decreased over time. CONCLUSIONS: Similar to recent trends seen in adults, the proportion of pediatric S aureus infections secondary to methicillin-resistant S aureus appear to be decreasing, as is variability in US geographical resistance rates. Increasing clindamycin resistance among methicillin-susceptible S aureus should raise caution in the use of empirical clindamycin in presumed S aureus infection. Clinicians should be aware of regional susceptibility patterns when choosing empirical regimens.

Relationships among cleaning, environmental DNA, and healthcare-associated infections in a new evidence-based design hospital.

OBJECTIVE: Hospital environments influence healthcare-associated infection (HAI) patterns, but the role of evidenced-based design (EBD) and residual bacterial DNA (previously thought to be clinically inert) remain incompletely understood. METHODS: In a newly built EBD hospital, we used culture-based and culture-free (molecular) assays, pulsed-field gel electrophoresis (PFGE), and whole-genome sequencing (WGS) to determine: (1) patterns of environmental contamination with target organisms (TOs) and multidrug-resistant (MDR) target organisms (MDR-TOs); (2) genetic relatedness between environmentally isolated MDR-TO and those from HAIs; and (3) correlation between surface contamination and HAIs. RESULTS: A total of 1,273 high-touch surfaces were swabbed before and after terminal cleaning during 77 room visits. Of the 2,546 paired swabs, 47% had cultivable biomaterial and 42% had PCR-amplifiable DNA. The ratios of TOs detected to surfaces assayed were 85 per 1,273 for the culture-based method and 106 per 1,273 for the PCR-based method. Sinks, toilet rails, and bedside tables most frequently harbored biomaterial. Although cleaned surfaces were less likely to have cultivable TOs than precleaned surfaces, they were not less likely to harbor bacterial DNA. The rate of MDR-TOs to surfaces swabbed was 0.1% (3/2546). Although environmental MDR-TOs and MDR-TOs from HAIs were genetically related by PFGE, WGS revealed that they were unrelated. Environmental levels of cultivable Enterococcus spp. and E. coli DNA were positively correlated with infection incidences (P<.04 and P<.005, respectively). CONCLUSION: MDR-TOs were rarely detected during surveillance and were not implicated in HAIs. The roles of environmental DNA and EBD, particularly with respect to water-associated fixtures or the potential suppression of cultivable environmental MDR-TOs, warrant multicenter investigations.