Coproduction of Low-Barrier Hepatitis C Virus and HIV Care for People Who Use Drugs in a Rural Community: Brief Qualitative Report

BACKGROUND

People who inject drugs are experiencing syndemic conditions with increasing risk of infection with hepatitis C (HCV) and HIV. However, rates of accessing HCV and HIV testing and treatment among people who inject drugs are low for various reasons, including the criminalization of drug use, which leads to a focus on treating drug use rather than caring for drug users. For many people who inject drugs, health care becomes a form of structural violence, resulting in traumatic experiences, fear of police violence, unmet needs, and avoidance of medical care. There is a clear need for novel approaches to health care delivery for people who inject drugs.

OBJECTIVE

This study aimed to analyze the process of a multidisciplinary team-encompassing health care professionals, community representatives, researchers, and people with lived experience using drugs-that was formed to develop a deep understanding of the experiences of people who inject drugs and local ecosystem opportunities and constraints to inform the cocreation of low-barrier, innovative HCV or HIV care in a rural community. Given the need for innovative approaches to redesigning health care, we sought to identify challenges and tensions encountered in this process and strategies for overcoming these challenges.

METHODS

Analysis was based on an in-depth review of meeting notes from the project year, followed by member-checking with the project team to revise and expand upon the challenges encountered and strategies identified to navigate these challenges.

RESULTS

Challenges and tensions included: scoping the project, setting the pace and urgency of the work, adapting to web-based work, navigating ethics and practice of payment, defining success, and situating the project for sustainability. Strategies to navigate these challenges included: dedicated effort to building personal and meaningful connections, fostering mutual respect, identifying common ground to make shared decisions, and redefining successes.

CONCLUSIONS

While cocreated care presents challenges, the resulting program is strengthened by challenging assumptions and carefully considering various perspectives to think creatively and productively about solutions.

Methamphetamine use and utilization of medications for opioid use disorder among rural people who use drugs

BACKGROUND

Methamphetamine use is common among persons with opioid use disorder. This study evaluated associations between methamphetamine use and treatment with agonist medications for opioid use disorder (MOUD, specifically buprenorphine, and/or methadone) in U.S. rural communities.

METHODS

The Rural Opioid Initiative (ROI) is a consortium spanning 10 states and 65 rural counties that included persons who reported past 30-day use of opioids and/or injection drug use between 1/2018 and 3/2020. Analyses were restricted to participants who had ever used opioids and had data on past 30-day methamphetamine use. Multivariable models examined the relationship between methamphetamine use and utilization of agonist MOUD.

RESULTS

Among 2899 participants, 2179 (75.2%) also reported recent methamphetamine use. Persons with methamphetamine use compared to those without were younger, more likely to have injected drugs, be unhoused, criminal justice involved, and less likely to have health insurance. Adjusted for age, sex, race, and study site, recent methamphetamine use was associated with lower relative odds of past 30-day methadone treatment (aOR=0.66; 95% CI: 0.45-0.99) and fewer methadone treatment days (aIRR=0.76; 0.57-0.99), but not past 30-day buprenorphine receipt (aOR=0.90; 0.67-1.20), buprenorphine treatment days in past 6 months: aIRR=0.88; 0.69-1.12) or perceived inability to access buprenorphine (aOR=1.12; 0.87-1.44) or methadone (aOR=1.06; 0.76-1.48).

CONCLUSION

Methamphetamine use is common among persons who use opioids in rural U.S. areas and negatively associated with current treatment and retention on methadone but not buprenorphine. Future studies should examine reasons for this disparity and reduce barriers to methadone for persons who use opioids and methamphetamine.

An unusual presentation of a rare disease: acute upper limb ischemia as the presenting symptom of Whipple's Endocarditis, a case report

BACKGROUND

Whipple's disease is known to cause multiple varied systemic symptoms, and is a well-documented cause of culture-negative endocarditis. Endocarditis secondary to Whipple disease, however, has rarely been known to present primarily as a cause of acute limb ischemia. We describe such a case here.

CASE PRESENTATION

A previously healthy 40 year old man presented to the emergency department with acute-onset right arm paresthesias. On exam, he was found to be tachycardic with a VI/VI systolic ejection murmur. He was diagnosed with critical limb ischemia and severe aortic regurgitation, and echocardiography showed a large mass on his bicuspid aortic valve. Thrombectomy was performed urgently, with aortic valve repair the following day. As blood cultures and valvular tissue culture remained unrevealing, the patient remained on empiric vancomycin and ceftriaxone for culture-negative endocarditis. 16 s rRNA nucleic acid amplification testing (NAAT) of his formalin-fixed, paraffin-embedded valvular tissue detected T. whipplei, after which the patient was transitioned to ceftriaxone and trimethoprim-sulfamethoxazole for a year of therapy. He continues to do clinically well.

CONCLUSIONS

We report an unusual presentation of Whipple endocarditis as an acute upper limb ischemia, absent other classic symptoms of Whipple's disease, and with diagnosis made by 16 s rRNA NAAT of valvular tissue in the setting of culture-negative endocarditis.

Comparison of Two Automated Immunoassays for the Detection of SARS-CoV-2 Nucleocapsid Antibodies

Background

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a novel member of the coronavirus family that caused the global coronavirus 2019 (COVID-19) pandemic. The prevalence remains largely unknown because of early testing supply shortages. Although it cannot currently be used to determine level of immunity, antibody testing can contribute to epidemiological studies, identify convalescent plasma donors, or satisfy curiosity about previous exposure to the virus.

Methods

407 samples collected from hospitalized inpatients with and without a confirmed SARS-CoV-2 infection, 170 remnant clinical specimens collected and frozen prior to the COVID-19 outbreak, and paired serum and plasma samples from 23 convalescent plasma donors were used to determine performance characteristics of the Abbott SARS-CoV-2 IgG and Roche Elecsys Anti-SARS-CoV-2 assays. The sensitivity, specificity, imprecision, interferences, and sample stability were determined. These assays were then used to characterize the antibody response in serial samples from 20 SARS-CoV-2 positive inpatients.

Results

Both assays exhibited 100% specificity (95% CI; 99.05 – 100.00), giving no positive results in 170 specimens collected before July 2019 and 215 specimens from patients without a confirmed SARS-CoV-2 infection. Differences between platforms were most notable in SARS-CoV-2 positive samples. Roche offered higher sensitivity in convalescent plasma donors at 95.7% (95% CI; 78.1 – 99.9) versus 91.3% (95% CI; 72.0 – 98.9) but Abbott detected antibodies in two immunocompromised patients whereas Roche did not. The Roche and Abbott platforms also exhibited different trends in antibody signal for a subset of patients.

Conclusions

Both the Abbott and Roche platforms offer excellent specificity but different trends in antibody signal may reflect qualitative differences in the types of antibodies recognized by the two assays. Negative serologic results do not exclude previous SARS-CoV-2 infection.

Tracking Substance Use Complications: A Collaborative Analysis of Public Health and Academic Medical Center Records on Drug Use-Associated Infective Endocarditis

BACKGROUND

Healthcare systems and public health agencies use different methods to measure the impact of substance use (SU) on population health. We studied the ability of systems to accurately capture data on drug use-associated infective endocarditis (DUA-IE).

METHODS

We conducted a retrospective analysis of patients with IE discharge diagnosis from an academic medical center, 2011-2017, comparing data from hospital Electronic Health Record (EHR) to State Uniform Hospital Discharge Data Set (UHDDS). To identify SU we developed a composite measure.

RESULTS

EHR identified 472 IE discharges (430 of these were captured in UHDDS); 406 (86.0%) were correctly coded based on chart review. IE discharges increased from 57 to 92 (62%) from 2012 to 2017. Hospitalizations for the subset of DUA-IE identified by any measure of SU increased from 10 to 54 (440%). Discharge diagnosis coding identified 128 (60.7%) of total DUA-IE hospitalizations. The composite measure identified an additional 65 (30.8%) DUA-IE hospitalizations and chart review an additional 18 (8.5%).

CONCLUSIONS

The failure of discharge diagnosis coding to identify DUA-IE in 40% of hospitalizations demonstrates the need for better systems to capture the impact of SU. Collaborative data sharing could help improve surveillance responsiveness to address an emerging public health crises.

140. Trends of Infective Endocarditis at a Northern New England Academic Medical Center, From 2011 to 2017: A Case for Improved Methods to Reliably Identify Associated Substance Use

Background

Infective endocarditis (IE) is a morbid and often lethal complication of injection drug use. There is an urgent need for accurate surveillance for IE related to substance use (SU) to support control strategies.

Methods

We conducted a retrospective comparative analysis of 3 datasets evaluating patients aged ≥16 years admitted to an academic medical center in New England with an ICD-9/10 discharge diagnosis of IE from April 2011 to December 2017. The 3 datasets included the hospital’s electronic medical record (EMR); the hospital’s Outpatient Parenteral Antibiotic Therapy (OPAT) program dataset; and the New Hampshire Uniform Hospital Discharge Data Set (UHDDS). We analyzed the number of admissions for IE per year, stratified by SU. We developed a SU composite measure by incorporating multiple sources of data from the EMR, and then verified accuracy of both the SU and IE diagnoses through manual chart review.

Results

The EMR documented 472 hospital admissions for IE, representing 385 unique patients. The median age was 56 years and 59% were men. Admissions increased 67%, from 56 in 2012 to 84 in 2017. SU was coded as a discharge diagnosis in 27% of these admissions; however, based on our composite measure of SU, 45% IE admissions were possibly associated with SU. The proportion of IE patients who had evidence of SU increased from 20% in 2011 to 49% in 2017 (P = 0.002). Patients with SU compared with those without were younger (40.5 vs. 65.2 years, P < 0.001) and more likely to be on Medicaid (59% vs. 8%, P < 0.001). They had higher average charges ($146,633 vs. $107,223, P = 0.002) and lengths of stay (19.1 vs. 13.4 days, P < 0.001). The UHDDS and EMR datasets identified a similar numbers of patients with a diagnosis of IE; however, manual chart review revealed that IE was over-coded in ~one-fifth of admissions.

Conclusion

The rate of IE in our hospital increased dramatically between 2011 and 2017, with a rising proportion associated with SU. Despite these trends, we found that discharge diagnosis coding alone substantially underestimated associated SU and overestimated IE disease burden. Our findings suggest public health administrative datasets, such as the UHDDS, can contribute to surveillance of IE disease burden with consideration of these important limitations, especially for assessing disease trends.

Disclosures

All authors: No reported disclosures.

A Breath of Fresh Air: BCG Prevents Adult Pulmonary Tuberculosis

OBJECTIVES

The efficacy of childhood BCG vaccination in the prevention of adult pulmonary tuberculosis is not universally accepted.

METHODS

We reviewed the published literature and summarized studies of BCG vaccination reporting long-term protection against pulmonary TB.

RESULTS

We identified 15 papers reporting prospective studies and their long-term follow up, retrospective studies or systematic reviews.

CONCLUSIONS

Good quality evidence supports the efficacy of BCG vaccination in the prevention of adult pulmonary tuberculosis.