Demographic and Clinical Characteristics of Mpox in Persons Who Had Previously Received 1 Dose of JYNNEOS Vaccine and in Unvaccinated Persons - 29 U.S. Jurisdictions, May 22-September 3, 2022.

As of November 14, 2022, monkeypox (mpox) cases had been reported from more than 110 countries, including 29,133 cases in the United States.* Among U.S. cases to date, 95% have occurred among males (1). After the first confirmed U.S. mpox case on May 17, 2022, limited supplies of JYNNEOS vaccine (Modified Vaccinia Ankara vaccine, Bavarian Nordic) were made available to jurisdictions for persons exposed to mpox. JYNNEOS vaccine was approved by the Food and Drug Administration (FDA) in 2019 as a 2-dose series (0.5 mL per dose, administered subcutaneously) to prevent smallpox and mpox disease.† On August 9, 2022, FDA issued an emergency use authorization to allow administration of JYNNEOS vaccine by intradermal injection (0.1 mL per dose) (2). A previous report on U.S. mpox cases during July 31-September 3, 2022, suggested that 1 dose of vaccine offers some protection against mpox (3). This report describes demographic and clinical characteristics of cases occurring ≥14 days after receipt of 1 dose of JYNNEOS vaccine and compares them with characteristics of cases among unvaccinated persons with mpox and with the vaccine-eligible vaccinated population in participating jurisdictions. During May 22-September 3, 2022, among 14,504 mpox cases reported from 29 participating U.S. jurisdictions,§ 6,605 (45.5%) had available vaccination information and were included in the analysis. Among included cases, 276 (4.2%) were among persons who had received 1 dose of vaccine ≥14 days before illness onset. Mpox cases that occurred in these vaccinated persons were associated with lower percentage of hospitalization (2.1% versus 7.5%), fever, headache, malaise, myalgia, and chills, compared with cases in unvaccinated persons. Although 1 dose of JYNNEOS vaccine offers some protection from disease, mpox infection can occur after receipt of 1 dose, and the duration of protection conferred by 1 dose is unknown. Providers and public health officials should therefore encourage persons at risk for acquiring mpox to complete the 2-dose vaccination series and provide guidance and education regarding nonvaccine-related prevention strategies (4).

Individual and community factors associated with geographic clusters of poor HIV care retention and poor viral suppression.

BACKGROUND: Previous analyses identified specific geographic areas in Philadelphia (hotspots) associated with negative outcomes along the HIV care continuum. We examined individual and community factors associated with residing in these hotspots. METHODS: Retrospective cohort of 1404 persons newly diagnosed with HIV in 2008-2009 followed for 24 months after linkage to care. Multivariable regression examined associations between individual (age, sex, race/ethnicity, HIV transmission risk, and insurance status) and community (economic deprivation, distance to care, access to public transit, and access to pharmacy services) factors and the outcomes: residence in a hotspot associated with poor retention-in-care and residence in a hotspot associated with poor viral suppression. RESULTS: In total, 24.4% and 13.7% of persons resided in hotspots associated with poor retention and poor viral suppression, respectively. For persons residing in poor retention hotspots, 28.3% were retained in care compared with 40.4% of those residing outside hotspots (P < 0.05). Similarly, for persons residing in poor viral suppression hotspots, 51.4% achieved viral suppression compared with 75.3% of those outside hotspots (P < 0.0.05). Factors significantly associated with residence in poor retention hotspots included female sex, lower economic deprivation, greater access to public transit, shorter distance to medical care, and longer distance to pharmacies. Factors significantly associated with residence in poor viral suppression hotspots included female sex, higher economic deprivation, and shorter distance to pharmacies. CONCLUSIONS: Individual and community-level associations with geographic hotspots may inform both content and delivery strategies for interventions designed to improve retention-in-care and viral suppression.

Location of HIV diagnosis impacts linkage to medical care.

: We evaluated 1359 adults newly diagnosed with HIV in Philadelphia in 2010-2011 to determine if diagnosis site (medical clinic, inpatient setting, counseling and testing center (CTC), and correctional facility) impacted time to linkage to care (difference between date of diagnosis and first CD4/viral load). A total of 1093 patients (80%) linked to care: 86% diagnosed in medical clinics, 75% in inpatient settings, 62% in CTCs, and 44% in correctional facilities. Adjusting for other factors, diagnosis in inpatient settings, CTCs, and correctional facilities resulted in a 33% (adjusted hazard ratio = 0.77; 95% confidence interval: 0.64 to 0.92), 46% (0.56; 0.42-0.72), and 75% (0.25; 0.18-0.35) decrease in the probability of linkage compared with medical clinics, respectively.

Comparison of geographic methods to assess travel patterns of persons diagnosed with HIV in Philadelphia: how close is close enough?

Travel distance to medical care has been assessed using a variety of geographic methods. Network analyses are less common, but may generate more accurate estimates of travel costs. We compared straight-line distances and driving distance, as well as average drive time and travel time on a public transit network for 1789 persons diagnosed with HIV between 2010 and 2012 to identify differences overall, and by distinct geographic areas of Philadelphia. Paired t-tests were used to assess differences across methods, and analysis of variance was used to assess between-group differences. Driving distances were significantly longer than straight-line distances (p<0.001) and transit times were significantly longer than driving times (p<0.001). Persons living in the northeast section of the city traveled greater distances, and at greater cost of time and effort, than persons in all other areas of the city (p<0.001). Persons living in the northwest section of the city traveled farther and longer than all other areas except the northeast (p<0.0001). Network analyses that include public transit will likely produce a more realistic estimate of the travel costs, and may improve models to predict medical care outcomes.

Assessing the overall quality of health care in persons living with HIV in an urban environment.

Ensuring high quality primary care for people living with HIV (PLWH) is important. We studied factors associated with meeting Health Resources and Services Administration-identified HIV performance measures, among a population-based sample of 376 PLWH in care at 24 Philadelphia clinics. Quality of care was assessed by a patient-level composite of 15 performance measures, focusing on HIV-specific care, vaccinations, and co-morbid condition screening. Adjusted incidence rate ratios (IRR) demonstrated relationships between patient and clinic factors and the performance measures score. The mean number of measures met was 8.52. Older age groups met more measures than 18- to 29-year-olds (age 40-49: adjusted IRR: 1.19, 95% CI: 1.05-1.35; age ≥50: adjusted IRR: 1.19, 95% CI: 1.03-1.35). Higher CD4 counts were associated with meeting more measures compared to CD4 <200 cells/µL (CD4 350-499 cells/µL: adjusted IRR: 1.14, 95% CI: 1.02-1.28; ≥500 cells/µL: adjusted IRR: 1.12, 95% CI: 1.01-1.26). PLWH attending clinics that provide adherence counseling or case management met more measures (adjusted IRR: 1.12, 95% CI: 1.04-1.21; adjusted IRR: 1.08, 95% CI: 1.02-1.14; respectively) than those attending clinics without these services. Limitations include potentially poor performance measure documentation and equal treatment of measures. Future work should focus on improving compliance with performance measures.

Behind the cascade: analyzing spatial patterns along the HIV care continuum.

BACKGROUND: Successful HIV treatment as prevention requires individuals to be tested, aware of their status, linked to and retained in care, and virally suppressed. Spatial analysis may be useful for monitoring HIV care by identifying geographic areas with poor outcomes. METHODS: Retrospective cohort of 1704 people newly diagnosed with HIV identified from Philadelphia's Enhanced HIV/AIDS Reporting System in 2008-2009, with follow-up to 2011. Outcomes of interest were not linked to care, not linked to care within 90 days, not retained in care, and not virally suppressed. Spatial patterns were analyzed using K-functions to identify "hot spots" for targeted intervention. Geographic components were included in regression analyses along with demographic factors to determine their impact on each outcome. RESULTS: Overall, 1404 persons (82%) linked to care; 75% (1059/1404) linked within 90 days; 37% (526/1059) were retained in care; and 72% (379/526) achieved viral suppression. Fifty-nine census tracts were in hot spots, with no overlap between outcomes. Persons residing in geographic areas identified by the local K-function analyses were more likely to not link to care [adjusted odds ratio 1.76 (95% confidence interval: 1.30 to 2.40)], not link to care within 90 days (1.49, 1.12-1.99), not be retained in care (1.84, 1.39-2.43), and not be virally suppressed (3.23, 1.87-5.59) than persons not residing in the identified areas. CONCLUSIONS: This study is the first to identify spatial patterns as a strong independent predictor of linkage to care, retention in care, and viral suppression. Spatial analyses are a valuable tool for characterizing the HIV epidemic and treatment cascade.

Adolescent sexually transmitted infections and risk for subsequent HIV.

OBJECTIVES: We estimated the risk of HIV associated with sexually transmitted infection (STI) history during adolescence. METHODS: We retrospectively studied a cohort of adolescents (n = 75 273, born in 1985-1993) who participated in the Philadelphia High School STD Screening Program between 2003 and 2010. We matched the cohort to STI and HIV surveillance data sets and death certificates and performed Poisson regression to estimate the association between adolescent STI exposures and subsequent HIV diagnosis. RESULTS: Compared with individuals reporting no STIs during adolescence, adolescents with STIs had an increased risk for subsequent HIV infection (incidence rate ratio [IRR] for adolescent girls = 2.6; 95% confidence interval [CI] = 1.5, 4.7; IRR for adolescent boys = 2.3; 95% CI = 1.7, 3.1). Risk increased with number of STIs. The risk of subsequent HIV infection was more than 3 times as high among those with multiple gonococcal infections during adolescence as among those with none. CONCLUSIONS: Effective interventions that reduce adolescent STIs are needed to avert future STI and HIV acquisition. Focusing on adolescents with gonococcal infections or multiple STIs might have the greatest impact on future HIV risk.

Accuracy of definitions for linkage to care in persons living with HIV.

OBJECTIVE: To compare the accuracy of linkage to care metrics for patients diagnosed with HIV using retention in care and virological suppression as the gold standards of effective linkage. DESIGN: A retrospective cohort study of patients aged 18 years and older with newly diagnosed HIV infection in the City of Philadelphia, 2007-2008. METHODS: Times from diagnosis to clinic visits or laboratory testing were used as linkage measures. Outcome variables included being retained in care and achieving virological suppression, 366-730 days after diagnosis. Positive predictive value (PPV), negative predictive value (NPV), and area under the curve (AUC) for each linkage measure and retention, and virological suppression outcomes are described. RESULTS: Of the 1781 patients in the study, 503 (28.2%) were retained in care in the Ryan White system and 418 (23.5%) achieved virological suppression 366-730 days after diagnosis. The linkage measure with the highest PPV for retention was having 2 clinic visits within 365 days of diagnosis, separated by 90 days (74.2%). Having a clinic visit between 21 and 365 days after diagnosis had both the highest NPV for retention (94.5%) and the highest adjusted AUC for retention (0.872). Having 2 tests within 365 days of diagnosis, separated by 90 days, had the highest adjusted AUC for virological suppression (0.780). CONCLUSIONS: Linkage measures associated with clinic visits had higher PPV and NPV for retention, whereas linkage measures associated with laboratory testing had higher PPV and NPV for retention. Linkage measures should be chosen based on the outcome of interest.

Factors associated with delayed entry into primary HIV medical care after HIV diagnosis.

The aim of the study was to assess the median time between HIV diagnosis and entry into primary HIV medical care in a large urban area and to assess the potential individual, diagnosing facility, and community level factors influencing entry into care. One thousand two hundred and sixty-six individuals diagnosed with HIV in Philadelphia between 1 July 2005 and 30 June 2006 were followed until entry into care through 15 June 2007. Time to entry into care was calculated as a survival time variable and was defined as the time in months between the date of HIV diagnosis and the date more than 3 weeks after diagnosis when a CD4 cell count or percentage and/or HIV viral load were obtained. The median time to entry into care for all individuals was 8 months, with a range of 1-26 months. Factors associated with delayed entry into care included age more than 40 years [hazard ratio (HR) = 0.85; 95% confidence interval (CI) = 0.75-0.97] and diagnosis as an inpatient in the hospital (HR = 0.37; 95% CI = 0.37-0.57). Factors associated with earlier entry into care included Hispanic ethnicity (HR = 1.39; 95% CI = 1.05-1.84), male sex with men as HIV transmission risk factor (HR = 1.27; 95% CI = 1.03-1.56), and residence in a census tract with a high poverty rate (HR = 1.68; 95% CI = 1.22-2.30). Individuals newly diagnosed with HIV in Philadelphia demonstrated marked delays in accessing care highlighting the tremendous need for interventions to improve overall linkage. These interventions should especially be targeted at those aged more than 40 years and those diagnosed in the hospital.

Outbreak of cyclosporiasis associated with imported raspberries, Philadelphia, Pennsylvania, 2000.

An outbreak of cyclosporiasis occurred in attendees of a wedding reception held in Philadelphia, Pennsylvania, on June 10, 2000. In a retrospective cohort study, 54 (68.4%) of the 79 interviewed guests and members of the wedding party met the case definition. The wedding cake, which had a cream filling that included raspberries, was the food item most strongly associated with illness (multivariate relative risk, 5.9; 95% confidence interval, 3.6 to 10.5). Leftover cake was positive for Cyclospora DNA by polymerase chain reaction analyses. Sequencing of the amplified fragments confirmed that the organism was Cyclospora cayetanensis. The year 2000 was the fifth year since 1995 that outbreaks of cyclosporiasis definitely or probably associated with Guatemalan raspberries have occurred in the spring in North America. Additionally, this is the second documented U.S. outbreak, and the first associated with raspberries, for which Cyclospora has been detected in the epidemiologically implicated food item.