The role and limitations of electronic medical records versus patient interviews for determining symptoms, underlying comorbidities, and medication usage for patients with COVID-19.

Electronic medical records (EMR) are important for rapidly compiling information to determine disease characteristics (e.g., symptoms) and risk factors (e.g., underlying comorbidities, medications) for disease-related outcomes. To assess EMR data accuracy, agreement between EMR abstractions and patient interviews was evaluated. Symptoms, medical history, and medication usage among COVID-19 patients collected from EMR and patient interviews were compared using overall agreement (same answer in EMR and interview), reported agreement (yes answer in both EMR and interview among those who reported yes in either), and Kappa statistics. Overall, patients reported more symptoms in interviews than in EMR abstractions. Overall agreement was high (≥50% for 20/23 symptoms), but only subjective fever and dyspnea had reported agreement of ≥50%. Kappa statistics for symptoms were generally low. Reported medical conditions had greater agreement with all condition categories (10/10) having ≥50% overall agreement and half (5/10) having ≥50% reported agreement. More non-prescription medications were reported in interviews than in EMR abstractions leading to low reported agreement (28%). Discordance was observed for symptoms, medical history, and medication usage between EMR abstractions and patient interviews. Investigations utilizing EMR to describe clinical characteristics and identify risk factors should consider the potential for incomplete data, particularly for symptoms and medications.

Increase in Colorado Tick Fever Virus Disease Cases and Effect of COVID-19 Pandemic on Behaviors and Testing Practices, Montana, 2020.

In 2020, Montana, USA, reported a large increase in Colorado tick fever (CTF) cases. To investigate potential causes of the increase, we conducted a case-control study of Montana residents who tested positive or negative for CTF during 2020, assessed healthcare providers' CTF awareness and testing practices, and reviewed CTF testing methods. Case-patients reported more time recreating outdoors on weekends, and all reported finding a tick on themselves before illness. No consistent changes were identified in provider practices. Previously, only CTF serologic testing was used in Montana. In 2020, because of SARS-CoV-2 testing needs, the state laboratory sent specimens for CTF testing to the Centers for Disease Control and Prevention, where more sensitive molecular methods are used. This change in testing probably increased the number of CTF cases detected. Molecular testing is optimal for CTF diagnosis during acute illness. Tick bite prevention measures should continue to be advised for persons doing outdoor activities.

Tick bite risk factors and prevention measures in an area with emerging Powassan virus disease.

Background: In the United States (U.S.), Powassan virus is primarily transmitted to humans by the black-legged tick (Ixodes scapularis). Rarely, infections can present as severe neuroinvasive disease. In 2019, four neuroinvasive disease cases were reported in Sussex County, New Jersey, U.S. We administered a survey to county residents to better understand tick bite risk factors and the performance of personal prevention measures. Methods: A survey was administered in October 2019 to adult residents of randomly selected households. Questions focused on tick bite prevention and risk factors. Crude and adjusted odds ratios (ORs) and 95% confidence intervals were calculated for various outcomes. Results: Of 274 participants, 25% were previously diagnosed with a tick-borne disease, and 42% reported finding an attached tick in 2019. Yardwork and gardening (OR = 7.38) and spending >50 hours outdoors per week (OR = 8.15) were associated with finding an attached tick. Finding an attached tick was inversely associated with the number of prevention measures used, indicating that a layered approach could reduce the risk of tick bites. Those who performed post-outdoor activity prevention measures (e.g., tick checks) were less likely to have a tick attached compared to finding a crawling tick. Conclusion: Compliance with prevention recommendations was low, despite a high prevalence of reported tick bites and significant outdoor exposures. Older adults and persons who spend significant time outdoors or engage in yardwork or gardening were at the highest risk of tick bites. Additional research is needed to further understand the barriers to tick bite prevention.

Seroprevalence of Powassan Virus Infection in an Area Experiencing a Cluster of Disease Cases: Sussex County, New Jersey, 2019.

In 2019, a geographically focal cluster of 3 Powassan virus neuroinvasive disease cases occurred in New Jersey. We conducted a serosurvey of 273 adult area residents and estimated that immunoglobulin M seroprevalence was 0.31% (95% confidence interval [CI], .04%-1.00%) and 23% (95% CI, 7%-100%) of infections result in neuroinvasive disease.

Risk factors for hospitalization among persons with COVID-19-Colorado.

BACKGROUND: Most current evidence on risk factors for hospitalization because of coronavirus disease 2019 (COVID-19) comes from studies using data abstracted primarily from electronic health records, limited to specific populations, or that fail to capture over-the-counter medications and adjust for potential confounding factors. Properly understanding risk factors for hospitalization will help improve clinical management and facilitate targeted prevention messaging and forecasting and prioritization of clinical and public health resource needs. OBJECTIVES: To identify risk factors for hospitalization using patient questionnaires and chart abstraction. METHODS: We randomly selected 600 of 1,738 laboratory-confirmed Colorado COVID-19 cases with known hospitalization status and illness onset during March 9-31, 2020. In April 2020, we collected demographics, social history, and medications taken in the 30 days before illness onset via telephone questionnaire and collected underlying medical conditions in patient questionnaires and medical record abstraction. RESULTS: Overall, 364 patients participated; 128 were hospitalized and 236 were non-hospitalized. In multivariable analysis, chronic hypoxemic respiratory failure with oxygen requirement (adjusted odds ratio [aOR] 14.64; 95% confidence interval [CI] 1.45-147.93), taking opioids (aOR 8.05; CI 1.16-55.77), metabolic syndrome (aOR 5.71; CI 1.18-27.54), obesity (aOR 3.35; CI 1.58-7.09), age ≥65 years (aOR 3.22; CI 1.20-7.97), hypertension (aOR 3.14; CI 1.47-6.71), arrhythmia (aOR 2.95; CI 1.00-8.68), and male sex (aOR 2.65; CI 1.44-4.88), were significantly associated with hospitalization. CONCLUSION: We identified patient characteristics, medications, and medical conditions, including some novel ones, associated with hospitalization. These data can be used to inform clinical and public health resource needs.

West Nile Virus and Other Domestic Nationally Notifiable Arboviral Diseases - United States, 2019.

Arthropod-borne viruses (arboviruses) are transmitted to humans primarily through the bites of infected mosquitoes and ticks. West Nile virus (WNV) is the leading cause of domestically acquired arboviral disease in the United States (1). Other arboviruses, including La Crosse, Jamestown Canyon, Powassan, eastern equine encephalitis, and St. Louis encephalitis viruses, cause sporadic disease and occasional outbreaks. This report summarizes surveillance data for nationally notifiable domestic arboviruses reported to CDC for 2019. For 2019, 47 states and the District of Columbia (DC) reported 1,173 cases of domestic arboviral disease, including 971 (83%) WNV disease cases. Among the WNV disease cases, 633 (65%) were classified as neuroinvasive disease, for a national incidence of 0.19 cases per 100,000 population, 53% lower than the median annual incidence during 2009-2018. More Powassan and eastern equine encephalitis virus disease cases were reported in 2019 than in any previous year. Health care providers should consider arboviral infections in patients with aseptic meningitis or encephalitis, perform recommended diagnostic testing, and promptly report cases to public health authorities. Because arboviral diseases continue to cause serious illness, and annual incidence of individual viruses continues to vary with sporadic outbreaks, maintaining surveillance is important in directing prevention activities. Prevention depends on community and household efforts to reduce vector populations and personal protective measures to prevent mosquito and tick bites such as use of Environmental Protection Agency-registered insect repellent and wearing protective clothing.*,†.

La Crosse Virus Disease in the United States, 2003-2019.

La Crosse virus (LACV) is an arthropod-borne virus that can cause a nonspecific febrile illness, meningitis, or encephalitis. We reviewed U.S. LACV surveillance data for 2003-2019, including human disease cases and nonhuman infections. Overall, 318 counties in 27 states, principally in the Great Lakes, mid-Atlantic, and southeastern regions, reported LACV activity. A total of 1,281 human LACV disease cases were reported, including 1,183 (92%) neuroinvasive disease cases. The median age of cases was 8 years (range: 1 month-95 years); 1,130 (88%) were aged < 18 years, and 754 (59%) were male. The most common clinical syndromes were encephalitis (N = 960; 75%) and meningitis (N = 219, 17%). The case fatality rate was 1% (N = 15). A median of 74 cases (range: 35-130) was reported per year. The average annual national incidence of neuroinvasive disease cases was 0.02 per 100,000 persons. West Virginia, North Carolina, Tennessee, and Ohio had the highest average annual state incidences (0.16-0.61 per 100,000), accounting for 80% (N = 1,030) of cases. No animal LACV infections were reported. Nine states reported LACV-positive mosquito pools, including three states with no reported human disease cases. La Crosse virus is the most common cause of pediatric neuroinvasive arboviral disease in the United States. However, surveillance data likely underestimate LACV disease incidence. Healthcare providers should consider LACV disease in patients, especially children, with febrile illness, meningitis, or encephalitis in areas where the virus circulates and advise their patients on ways to prevent mosquito bites.

Symptom Profiles and Progression in Hospitalized and Nonhospitalized Patients with Coronavirus Disease, Colorado, USA, 2020.

To improve recognition of coronavirus disease (COVID-19) and inform clinical and public health guidance, we randomly selected 600 COVID-19 case-patients in Colorado. A telephone questionnaire captured symptoms experienced, when symptoms occurred, and how long each lasted. Among 128 hospitalized patients, commonly reported symptoms included fever (84%), fatigue (83%), cough (73%), and dyspnea (72%). Among 236 nonhospitalized patients, commonly reported symptoms included fatigue (90%), fever (83%), cough (83%), and myalgia (74%). The most commonly reported initial symptoms were cough (21%-25%) and fever (20%-25%). In multivariable analysis, vomiting, dyspnea, altered mental status, dehydration, and wheezing were significantly associated with hospitalization, whereas rhinorrhea, headache, sore throat, and anosmia or ageusia were significantly associated with nonhospitalization. General symptoms and upper respiratory symptoms occurred earlier in disease, and anosmia, ageusia, lower respiratory symptoms, and gastrointestinal symptoms occurred later. Symptoms should be considered alongside other epidemiologic factors in clinical and public health decisions regarding potential COVID-19 cases.

Exposures Before Issuance of Stay-at-Home Orders Among Persons with Laboratory-Confirmed COVID-19 - Colorado, March 2020.

On March 26, 2020, Colorado instituted stay-at-home orders to reduce community transmission of SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19). To inform public health messaging and measures that could be used after reopening, persons with laboratory-confirmed COVID-19 during March 9-26 from nine Colorado counties comprising approximately 80% of the state's population† (Adams, Arapahoe, Boulder, Denver, Douglas, El Paso, Jefferson, Larimer, and Weld) were asked about possible exposures to SARS-CoV-2 before implementation of stay-at-home orders. Among 1,738 persons meeting the inclusion criteria§ in the Colorado Electronic Disease Surveillance System, 600 were randomly selected and interviewed using a standardized questionnaire by telephone. Data collection during April 10-30 included information about demographic characteristics, occupations, and selected activities in the 2 weeks preceding symptom onset. During the period examined, SARS-CoV-2 molecular testing was widely available in Colorado; community transmission was documented before implementation of the stay-at-home order. At least three attempts were made to contact all selected patients or their proxy (for deceased patients, minors, and persons unable to be interviewed [e.g., those with dementia]) on at least 2 separate days, at different times of day. Data were entered into a Research Electronic Data Capture (version 9.5.13; Vanderbilt University) database, and descriptive analyses used R statistical software (version 3.6.3; The R Foundation).

Investigation and Serologic Follow-Up of Contacts of an Early Confirmed Case-Patient with COVID-19, Washington, USA.

We describe the contact investigation for an early confirmed case of coronavirus disease (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), in the United States. Contacts of the case-patient were identified, actively monitored for symptoms, interviewed for a detailed exposure history, and tested for SARS-CoV-2 infection by real-time reverse transcription PCR (rRT-PCR) and ELISA. Fifty contacts were identified and 38 (76%) were interviewed, of whom 11 (29%) reported unprotected face-to-face interaction with the case-patient. Thirty-seven (74%) had respiratory specimens tested by rRT-PCR, and all tested negative. Twenty-three (46%) had ELISA performed on serum samples collected ≈6 weeks after exposure, and none had detectable antibodies to SARS-CoV-2. Among contacts who were tested, no secondary transmission was identified in this investigation, despite unprotected close interactions with the infectious case-patient.

Impaired Hematologic Status in Relation to Clinical Outcomes among HIV-Infected Adults from Uganda: A Prospective Cohort Study.

Impaired hematologic status (IHS) was investigated as a determinant of immune function defined as cluster of differentiation 4 (CD4) T-helper cell count, quality of life (QOL) weight and hospitalization/mortality over 18-months among 398 adult persons living with HIV/AIDS (PLWHA) on anti-retroviral therapy. IHS was defined as having anemia at baseline (Hemoglobin: <12 g/dL for women and <13 g/dL for men), time-updated anemia or having low (<30 µg/L) or high (>200 µg/L for men and >150 µg/L for women) ferritin levels at baseline. Months-to-hospitalization/death or study-end (if no event) was calculated from enrollment. Multivariable linear-mixed models quantified associations between IHS and changes in CD4 cell-count, weight gain and QOL. Cox proportional hazards models calculated hazard ratios (HR) and corresponding 95% confidence intervals (CI) for IHS-related differences in time-to-hospitalization/death. The prevalences of anemia and high and low ferritin levels at baseline were 48.7% (n = 194), 40.5% (n = 161) and 17% (n = 68), respectively. Most patients (63.4%, n = 123) remained anemic during follow-up. Weight gained (ferritin-time interaction, p < 0.01) and QOL (anemia-time interaction, p = 0.05; ferritin-time interaction, p = 0.01) were lower for PLWHA with versus without IHS. Relative to anemia-free/normal ferritin, the risk of hospitalization/death was elevated for PLWHA with anemia (HR = 2.0; 95% CI: 1.2-3.6), low or high ferritin (HR: 1.8-1.9, 95% CI: 0.9-4.1) and those that developed new/persistent/progressive anemia (HR: 2.3-6.7, 95% CI: 1.0-12.7). Among PLWHA, IHS predicted deficits in QOL, low weight gain and a high risk of hospitalization/death. Intervention to mitigate persistent IHS may be warranted among PLWHA on long-term highly active antiretroviral therapy (HAART) to improve health outcomes.

Seafood consumption habits of South Carolina shrimp baiters.

Shrimp baiting is a fishing technique used by many South Carolinians and has been regulated in the state since the late 1980s. A postcard survey was developed and included with 400 South Carolina Department of Natural Resources (SCDNR) annual surveys of registered shrimp baiters over a two-year period. The survey contained questions concerning frequency, portion size, baiting locations, and preparation techniques for shrimp as well as other species consumed and demographic information. An overall response rate of 37% was received. The majority of respondents were men over the age of 55 years. Charleston and Beaufort counties were the most common locations for shrimp baiting. Almost half (45.9%) of respondents reported eating locally caught shrimp at least 2-3 times per month. The most common portion size was ½ pound (8 oz. or 277 g), with 44.8% of respondents reporting this as their typical amount of shrimp ingested at one meal. Only 3.7% of respondents reported typically eating the whole shrimp, while all other respondents ingested shrimp with the head removed. The most commonly consumed species besides shrimp were blue crab, oysters, and flounder. According to the US Food and Drug Administration mercury (Hg) guidelines, the majority (97%) of our respondents were not at risk for consuming unsafe levels of Hg from locally caught shrimp. However, this does not take into account other local seafood eaten or other contaminants of concern. These consumption results may be used in conjunction with data on contaminant levels in shrimp to determine potential adverse health risks associated with consumption of locally caught shrimp.

Quantifying the Seafood Consumption Patterns of Recreational Anglers in Charleston and Berkeley Counties, South Carolina.

This study was designed to provide self-reported data on the frequency of fish consumption and shellfish consumption in Charleston and Berkeley (CB) counties, South Carolina. While commercial fishing and recreational fishing have played an important role in the culture and history of the area, information on the specific patterns of consumption by recreational anglers has been previously unavailable. The pilot data presented here will help determine the feasibility of a large-scale survey of seafood consumption in coastal South Carolina. The study's sampling frame consisted of CB county anglers who had purchased a recreational saltwater fishing license for the 2005/2006 year with oversampling in North Charleston. Survey recipients were asked to provide information on fish consumption and shellfish consumption, general angling habits, perception of water and fishing quality, and demographics. Of the 2500 individuals who were sent questionnaires, about one-fourth responded. Respondents were generally white, middle, or upper class and highly educated. The majority fished by boat and most often ate flounder, spotted sea trout, and red drum. Most respondents ate shrimp several times a month and also supplemented their recreational catch with seafood purchased from grocery stores, markets, and restaurants. Almost all respondents had eaten some seafood in the last year, and more than one-fourth ate seafood twice a week or more. Most anglers responded positively about the area's fishing and water qualities, but many referred to areas where they would hesitate to eat their catch. Further research may need to incorporate direct distribution of surveys to underrepresented groups and financial incentives to encompass a more diverse population of anglers.