Responding to avian influenza A H5N1 detection on a hospital property in Maine-An interdisciplinary approach

BACKGROUND

The risk of infection with avian influenza A viruses currently circulating in wild and domestic birds in the Americas is considered low for the general public; however, detections in humans have been reported and warning signs of increased zoonotic potential have been identified. In December 2022, two Canada geese residing on the grounds of an urban hospital in Maine tested positive for influenza A H5N1 clade 2.3.4.4b.

AIMS

Given the opportunity for exposure to staff and hospital visitors through potentially infected faeces on the property, public health authorities determined mitigation efforts were needed to prevent the spread of disease. The ensuing response relied on collaboration between the public health and animal health agencies to guide the hospital through efforts in preventing possible zoonotic transmission to humans.

MATERIALS AND METHODS

Mitigation efforts included staff communication and education, environmental cleaning and disinfection, enhanced illness surveillance among staff and patients, and exposure and source reduction.

RESULTS

No human H5N1 cases were identified, and no additional detections in birds on the property occurred. Hospital staff identified barriers to preparedness resulting from a lack of understanding of avian influenza A viruses and transmission prevention methods, including avian influenza risk in resident wild bird populations and proper wildlife management methods.

CONCLUSION

As this virus continues to circulate at the animal-human interface, this event and resulting response highlights the need for influenza A H5N1 risk awareness and guidance for facilities and groups not traditionally involved in avian influenza responses.

Pseudomonas Infection Outbreak Associated with a Hotel Swimming Pool - Maine, March 2023

Treated recreational water venues (e.g., pools and hot tubs) located at hotels represent one third of sources of reported treated recreational water-associated outbreaks; when these outbreaks are caused by Pseudomonas aeruginosa, they predominantly occur during January-April. On March 8, 2023, the Maine Center for Disease Control and Prevention (Maine CDC) initiated an investigation in response to reports of illness among persons who had used a swimming pool at hotel A during March 4-5. A questionnaire was distributed to guests who were at hotel A during March 1-7. Among 35 guests who responded, 23 (66%) developed ear pain, rash, or pain or swelling in feet or hands within days of using the pool during March 4-5. P. aeruginosa, a chlorine-susceptible bacterium, was identified in cultures obtained from skin lesions of three patients; a difference of two single nucleotide polymorphisms was found between isolates from two patients' specimens, suggesting a common exposure. Hotel A management voluntarily closed the pool, and Maine CDC's Health Inspection Program identified multiple violations, including having no disinfectant feeder system, all of which had been identified during a previous inspection. Because chlorine had been added to the pool water after the pool was voluntary closed, environmental samples were not collected. The pool remained closed until violations were addressed. Health departments can play an important role in reducing the risk for outbreaks associated with hotel pools and hot tubs. This reduction in risk can be achieved by collaborating with operators to ensure compliance with public health codes, including maintaining chlorine concentration and otherwise vigilantly managing the pool, and by disseminating prevention messages to pool and hot tub users.

Factors associated with injury among Maine logging workers

INTRODUCTION

Despite dramatic improvements in safety, logging remains one of the most dangerous industries in the United States. The purpose of this study was to explore longitudinal injury trends among Maine logging workers.

METHODS

Loggers participated in seven quarterly surveys, over the course of 18 months. Categorical and free text data related to traumatic and acute injury, musculoskeletal disorders (MSD), and chronic pain were exported from REDCap into SAS 9.4, Excel, and NVivo, for quantitative and qualitative analysis, respectively. Time to injury was modeled using two different approaches: (1) time to the occurrence of first injury modeled by proportional hazard regression and (2) an intensity model for injury frequency. Two research team members also analyzed qualitative data using a content analysis approach.

RESULTS

During the study, 204 injuries were reported. Of the 154 participants, 93 (60.4%) reported musculoskeletal pain on at least one survey. The majority of injuries were traumatic, including fractures, sprains, and strains. Lack of health insurance was found to be related to increased risk of first injury [HR = 1.41, 95% CI = 0.97-2.04, p = 0.069]. Variables found to be related to injury intensity at the univariate level were: (1) a lack of health insurance [HR = 1.51, 95% CI = 1.04-2.20, p = 0.030], (2) age [HR for 10-year age increase;= 1.12, 95% CI = 0.99-1.27, p = 0.082], and (3) years employed in logging industry [HR for 10-year increase = 1.12, 95% CI = 0.99-1.26, p = 0.052]. Seeking medical attention for injury was not a priority for this cohort, and narratives revealed a trend for self-assessment. A variety of barriers, including finances, prevented loggers from seeking medical attention.

DISCUSSION

We found that loggers still experience serious, and sometimes disabling, injuries associated with their work. It was unsurprising that many injuries were due to slips, trips, and falls, along with contact with logging equipment and trees/logs. The narratives revealed various obstacles preventing loggers from achieving optimal health. Examples included geographic distance from healthcare, lack of time to access care, and entrenched values that prioritized independence and traditional masculinity. Financial considerations were also consistently cited as a primary barrier to adequate care.

CONCLUSION

There is a continued need to emphasize occupational health and safety in the logging industry. Implementation of relevant safety programs is key, but it is likely that the benefits of these will not be fully realized until a cultural shift takes place within this industry.

Jamestown Canyon Virus in Collected Mosquitoes, Maine, United States, 2017–2019

Jamestown Canyon virus (JCV) is a mosquito-borne arbovirus that circulates in North America. We detected JCV in 4 pools of mosquitoes collected from midcoastal Maine, USA, during 2017–2019. Phylogenetic analysis of a JCV sequence obtained from Aedes cantator mosquitoes clustered within clade A, which also circulates in Connecticut, USA.

Modeling the impact of the COVID-19 pandemic on speeding at rural roadway facilities in Maine using short-term speed and traffic count data

The COVID-19 pandemic caused a significant change in traffic operations and safety. For instance, various U.S. states reported an increase in the rate of fatal and severe injury crashes over this duration. In April and May of 2020, comprehensive stay-at-home orders were issued across the country, including in Maine. These orders resulted in drastic reductions in traffic volume. Additionally, there is anecdotal evidence that speed enforcement had been reduced during pandemic. Drivers responded to these changes by increasing their speed. More importantly, data show that speeding continues to occur, even one year after the onset of the pandemic. This study develops statistical models to quantify the impact of the pandemic on speeding in Maine. We developed models for three rural facility types (i.e., major collectors, minor arterials, and principal arterials) using a mixed effect Binomial regression model and short duration speed and traffic count data collected at continuous count stations in Maine. Our results show that the odds of speeding by more than 15 mph increased by 34% for rural major collectors, 32% for rural minor arterials, and 51% for rural principal arterials (non-Interstates) during the stay-at-home order in April and May of 2020 compared to the same months in 2019. In addition, the odds of speeding by more than 15 mph, in April and May of 2021, one year after the order, were still 27% higher on rural major collectors and 17% higher on rural principal arterials compared to the same months in 2019.

Implementation of Universal School Meals during COVID-19 and beyond: Challenges and Benefits for School Meals Programs in Maine

School meals play a major role in supporting children’s diets and food security, and policies for universal school meals (USM) have the potential to contribute to positive child health outcomes. During the COVID-19 pandemic, schools provided free school meals to all students in the United States, but this national USM policy ended in school year (SY) 2022–2023; however, a few states have adopted policies to continue USM statewide for SY 2022–2023. Research examining the challenges and strategies for successful continuation of USM is essential, along with studying pandemic-related challenges that are likely to persist in schools. Therefore, we conducted a study in Maine (with a USM policy) to evaluate the impact of COVID-19 and the concurrent implementation of USM, as well as examine differences in implementation by school characteristics, throughout the state. A total of n = 43 school food authorities (SFAs) throughout Maine completed surveys. SFAs reported multiple benefits of USM including increased school meal participation; reductions in the perceived stigma for students from lower-income households and their families; and no longer experiencing unpaid meal charges and debt. SFAs also experienced challenges due to the COVID-19 pandemic, particularly regarding costs. When considering future challenges, most respondents were concerned with obtaining income information from families, product and ingredient availability, and the costs/financial sustainability of the school meal programs. Overall, USM may have multiple important benefits for students and schools, and other states should consider implementation of a USM policy.

Barriers and facilitators associated with establishment of emergency department-initiated buprenorphine for opioid use disorder in rural Maine

PURPOSE

The opioid epidemic in the United States continues to grow, particularly impacting rural communities served by critical access hospitals (CAHs) in Maine. Buprenorphine is an effective medication for the treatment of opioid use disorder (OUD) that can be successfully initiated in the emergency department (ED). However, many EDs have not implemented programs to initiate buprenorphine. This study sought to identify barriers and facilitators to successful implementation of buprenorphine programs inCAH EDs.

METHODS

Semistructured interviews were conducted with ED directors of Maine CAHs regarding barriers and facilitators to developing programs for ED-initiated buprenorphine. Seventeen Maine CAH EDs exist and 11 of their directors agreed to participate and completed interviews, which were audio-recorded, transcribed, and analyzed using a thematic approach.

RESULTS

Four themes and 11 subthemes were identified, including (1) compelled to act-directors' personal experiences with patients facilitated the development of buprenorphine programs in their EDs; (2) leadership and mentorship-peer mentorship from other CAH ED directors facilitated, and senior hospital administrators facilitated, or created a barrier in some cases; (3) stigma-fear that EDs would be overcrowded by drug-seeking patients was a common barrier; and (4) follow-up-finding appropriate outpatient follow-up for OUD patients created the greatest logistical barrier.

DISCUSSION

ED directors' clinical experience with OUD patients, supportive hospital leadership, and peer mentorship facilitated ED-initiated buprenorphine programs in rural Maine CAH EDs. Overcoming stigma, developing community outreach, and appropriate follow-up were the greatest barriers. Future research should focus on enhancing peer mentorship, administrative support, community outreach, and staff education.

Not Quite Out of the Woods: Overall Health and Chronic Disease Risk Factors among Maine Logging Workers

OBJECTIVE

This research reports on the health status, including chronic disease risk factors, among Maine loggers.

METHODS

Loggers completed a survey and health screenings were held across Maine, collecting data on a variety of health endpoints.

RESULTS

Seventy-five loggers participated. The majority were men (97.1%) with a median age of 46, and a mean BMI of 30.6 kg/m2 (SD 4.9). Nearly half of those screened (45.9%) had blood pressure at the level of stage II hypertension. Loggers with at least a single joint abnormality were 38.4%. The health screening cohort was similar to the non-health screening cohort for many attributes.

CONCLUSIONS

Future research should focus on tailored interventions to improve cardiovascular and musculoskeletal risk factors among loggers.

Use of Cervid Serosurveys to Monitor Eastern Equine Encephalitis Virus Activity in Northern New England, United States, 2009-2017

Vertebrate surveillance for eastern equine encephalitis virus (EEEV) activity usually focuses on three types of vertebrates: horses, passerine birds, and sentinel chicken flocks. However, there is a variety of wild vertebrates that are exposed to EEEV infections and can be used to track EEEV activity. In 2009, we initiated a pilot study in northern New England, United States, to evaluate the effectiveness of using wild cervids (free-ranging white-tailed deer and moose) as spatial sentinels for EEEV activity. In Maine, New Hampshire, and Vermont during 2009-2017, we collected blood samples from hunter-harvested cervids at tagging stations and obtained harvest location information from hunters. U.S. Centers for Disease Control and Prevention processed the samples for EEEV antibodies using plaque reduction neutralization tests (PRNTs). We detected EEEV antibodies in 6 to 17% of cervid samples in the different states and mapped cervid EEEV seropositivity in northern New England. EEEV antibody-positive cervids were the first detections of EEEV activity in the state of Vermont, in northern Maine, and northern New Hampshire. Our key result was the detection of the antibodies in areas far outside the extent of documented wild bird, mosquito, human case, or veterinary case reports of EEEV activity in Maine, New Hampshire, and Vermont. These findings showed that cervid (deer and moose) serosurveys can be used to characterize the geographic extent of EEEV activity, especially in areas with low EEEV activity or with little or no EEEV surveillance. Cervid EEEV serosurveys can be a useful tool for mapping EEEV activity in areas of North America in addition to northern New England.

Identification of patients at risk of new onset heart failure: Utilizing a large statewide health information exchange to train and validate a risk prediction model

BACKGROUND

New-onset heart failure (HF) is associated with poor prognosis and high healthcare utilization. Early identification of patients at increased risk incident-HF may allow for focused allocation of preventative care resources. Health information exchange (HIE) data span the entire spectrum of clinical care, but there are no HIE-based clinical decision support tools for diagnosis of incident-HF. We applied machine-learning methods to model the one-year risk of incident-HF from the Maine statewide-HIE.

METHODS AND RESULTS

We included subjects aged ≥ 40 years without prior HF ICD9/10 codes during a three-year period from 2015 to 2018, and incident-HF defined as assignment of two outpatient or one inpatient code in a year. A tree-boosting algorithm was used to model the probability of incident-HF in year two from data collected in year one, and then validated in year three. 5,668 of 521,347 patients (1.09%) developed incident-HF in the validation cohort. In the validation cohort, the model c-statistic was 0.824 and at a clinically predetermined risk threshold, 10% of patients identified by the model developed incident-HF and 29% of all incident-HF cases in the state of Maine were identified.

CONCLUSIONS

Utilizing machine learning modeling techniques on passively collected clinical HIE data, we developed and validated an incident-HF prediction tool that performs on par with other models that require proactively collected clinical data. Our algorithm could be integrated into other HIEs to leverage the EMR resources to provide individuals, systems, and payors with a risk stratification tool to allow for targeted resource allocation to reduce incident-HF disease burden on individuals and health care systems.

Association of Recreational Cannabis Legalization With Maternal Cannabis Use in the Preconception, Prenatal, and Postpartum Periods

IMPORTANCE

Recent studies have revealed increases in population-level cannabis use after legalization of recreational cannabis. However, the association of cannabis legalization with maternal cannabis use during important life stages remains unknown.

OBJECTIVE

To investigate the association of legalization of recreational cannabis with maternal cannabis use during the preconception, prenatal, and postpartum periods.

DESIGN, SETTING, AND PARTICIPANTS

This repeated cross-sectional study used state-level data on women who delivered live-born infants in the US from the Pregnancy Risk Assessment Monitoring System from January 2004 to December 2018. Data from 2 states that had legalized recreational cannabis (Alaska and Maine) and 2 states that had not legalized recreational cannabis (New Hampshire and Vermont) were used. Women completed surveys 2 to 6 months after delivery, reporting preconception, prenatal, and postpartum cannabis use.

EXPOSURE

State recreational cannabis legalization.

MAIN OUTCOMES AND MEASURES

The 3 primary outcomes were self-reported cannabis use during the 12 months before pregnancy (preconception), during pregnancy (prenatal), and the 2 to 6 months after pregnancy (postpartum). A difference-in-differences analysis was used to compare changes in the prevalence of maternal cannabis use during each period before and after state legalization of recreational cannabis, controlling for maternal characteristics (age, race/ethnicity, educational level, income, cigarette smoking, and breastfeeding) and state fixed effects. State-specific survey weights were used.

RESULTS

The analytic sample included 23 082 women in the preconception period, 23 859 in the prenatal period, and 26 610 in the postpartum period. In each analysis, most women were married (range among all groups, 63.9%-64.8%), aged 25 to 34 years (preconception, 55.4%; prenatal, 55.9%; postpartum, 56.1%), and had an annual household income less than $50 000 (preconception, 55.7%; prenatal, 56.3%; postpartum, 55.5%). In adjusted analyses, preconception and postpartum cannabis use increased significantly in states that had legalized recreational cannabis compared with states that had not legalized it (preconception risk difference, 0.0457 [95% CI, 0.0013-0.0900]; P = .04; postpartum risk difference, 0.0539 [95% CI, 0.0259-0.0818]; P < .001). The risk difference for prenatal cannabis use was not significant (0.0070; 95% CI, -0.0120 to 0.0260; P = .47).

CONCLUSIONS AND RELEVANCE

In this repeated cross-sectional study, recreational cannabis legalization was associated with changes in maternal cannabis use before and after pregnancy. The findings suggest that future studies should undertake an interdisciplinary approach to maximize benefit and application of findings to future public health, health care, and policy sectors.

A Generalized Additive Model Correlating Blacklegged Ticks With White-Tailed Deer Density, Temperature, and Humidity in Maine, USA, 1990-2013

Geographical range expansions of blacklegged tick [Ixodes scapularis Say (Acari: Ixodidae)] populations over time in the United States have been attributed to a mosaic of factors including 20th century reforestation followed by suburbanization, burgeoning populations of the white-tailed deer [Odocoileus virginianus Zimmerman (Artiodactyla: Cervidae)], and, at the northern edge of I. scapularis' range, climate change. Maine, a high Lyme disease incidence state, has been experiencing warmer and shorter winter seasons, and relatively more so in its northern tier. Maine served as a case study to investigate the interacting impacts of deer and seasonal climatology on the spatial and temporal distribution of I. scapularis. A passive tick surveillance dataset indexed abundance of I. scapularis nymphs for the state, 1990-2013. With Maine's wildlife management districts as the spatial unit, we used a generalized additive model to assess linear and nonlinear relationships between I. scapularis nymph abundance and predictors. Nymph submission rate increased with increasing deer densities up to ~5 deer/km2 (13 deer/mi2), but beyond this threshold did not vary with deer density. This corroborated the idea of a saturating relationship between I. scapularis and deer density. Nymphs also were associated with warmer minimum winter temperatures, earlier degree-day accumulation, and higher relative humidity. However, nymph abundance only increased with warmer winters and degree-day accumulation where deer density exceeded ~2 deer/km2 (~6/mi2). Anticipated increases in I. scapularis in the northern tier could be partially mitigated through deer herd management.

Surge in Anaplasmosis Cases in Maine, USA, 2013-2017

Incidence of human granulocytic anaplasmosis is rising in Maine, USA. This increase may be explained in part by adoption of tick panels as a frequent diagnostic test in persons with febrile illness and in part by range expansion of Ixodes scapularis ticks and zoonotic amplification of Anaplasma phagocytophilum.

Fentanyl and fentanyl analogs in the illicit stimulant supply: Results from U.S. drug seizure data, 2011-2016

BACKGROUND

U.S. research examining the illicit drug supply remains rare even though the information could help reduce overdoses. Relatively little is known regarding how often opioids are found in stimulants and whether temporal and geographic trends exist. We examined trends in fentanyl-cocaine and fentanyl-methamphetamine combinations in the national illicit drug supply.

METHODS

We analysed serial cross-sectional data from the National Forensic Laboratory Information System (NFLIS) collected between January 2011 and December 2016. We restricted the analysis to cocaine (N = 1,389,968) and methamphetamine (n = 1,407,474) samples and calculated proportions containing fentanyl (including 23 related analogs) over time.

RESULTS

The combined presence of fentanyl and cocaine steadily increased nationally between 2012-2016 (p = 0.01), and the number of such samples tripled from 2015 to 2016 (n = 423 to n = 1,325). Similarly, the combined presence of fentanyl and methamphetamine increased 179 % from 2015 to 2016 (n = 82-n = 272). Patterns varied widely by state; in 2016, fentanyl-cocaine samples were most common in New Hampshire (7.2 %), Connecticut (5.4 %), Ohio (2.6 %) and Massachusetts (2.1 %), whereas fentanyl-methamphetamine samples were most often in New Hampshire (6.1 %), Massachusetts (5.6 %), Vermont (2.4 %) and Maine (1.2 %).

CONCLUSIONS

Although relatively uncommon, the presence of fentanyl in the stimulant supply increased significantly between 2011 and 2016, with the greatest increases occuring between 2015-2016; the presence of these products was concentrated in the U.S. Northeast. Given these trends, strengthening community-based drug checking programs and surveillance within the public health infrastructure could help promote timely responses to novel threats posed by rapid shifts in the drug supply that may lead to inadvertent exposures.

Stall in Heart Disease Death Rates, Evidence From Maine, 1999-2017

INTRODUCTION

Since the 1950s, heart disease deaths have declined in the United States, but recent reports indicate a plateau in this decline. Heart disease death rates increased in Maine from 2011-2015. We examined reasons for the trend change in Maine's heart disease death rates, including the contributing types of heart disease.

METHODS

We obtained Maine's annual heart disease death data for 1999-2017 from CDC's Wide-ranging Online Data for Epidemiologic Research (CDC WONDER). We used joinpoint regression to determine changes in trend and annual percentage change (APC) in death rates for heart disease overall and by demographic groups, types of heart disease, and geographic area.

RESULTS

Joinpoint modeling showed that Maine's age-adjusted heart disease death rates decreased during 1999-2010 (-4.2% APC), then plateaued during 2010-2017 (-0.1% APC). Death rates flattened for both sexes and age groups ≥45 years. Although death rates for acute myocardial infarction (AMI) decreased through 2017, hypertensive heart disease (HHD) and heart failure death rates increased. Death rates attributable to diabetes-related heart disease and non-AMI ischemic heart disease (IHD) plateaued.

CONCLUSION

Declines in Maine's heart disease death rates have plateaued, similar to national trends. Flattening rates appear to be driven by adverse trends in HHD, heart failure, diabetes-related heart disease, and non-AMI IHD. Increased efforts to address cardiovascular disease risk factors, chronic heart disease, and access to care are necessary to continue the decrease in heart disease deaths in Maine.

Outbreaks Associated with Untreated Recreational Water - California, Maine, and Minnesota, 2018-2019

Outbreaks associated with fresh or marine (i.e., untreated) recreational water can be caused by pathogens or chemicals, including toxins. Voluntary reporting of these outbreaks to CDC's National Outbreak Reporting System (NORS) began in 2009. NORS data for 2009-2017 are finalized, and data for 2018-2019 are provisional. During 2009-2019 (as of May 13, 2020), public health officials from 31 states voluntarily reported 119 untreated recreational water-associated outbreaks, resulting at least 5,240 cases; 103 of the outbreaks (87%) started during June-August. Among the 119 outbreaks, 88 (74%) had confirmed etiologies. The leading etiologies were enteric pathogens: norovirus (19 [22%] outbreaks; 1,858 cases); Shiga toxin-producing Escherichia coli (STEC) (19 [22%]; 240), Cryptosporidium (17 [19%]; 237), and Shigella (14 [16%]; 713). This report highlights three examples of outbreaks that occurred during 2018-2019, were caused by leading etiologies (Shigella, norovirus, or STEC), and demonstrate the wide geographic distribution of such outbreaks across the United States. Detection and investigation of untreated recreational water-associated outbreaks are challenging, and the sources of these outbreaks often are not identified. Tools for controlling and preventing transmission of enteric pathogens through untreated recreational water include epidemiologic investigations, regular monitoring of water quality (i.e., testing for fecal indicator bacteria), microbial source tracking, and health policy and communications (e.g., observing beach closure signs and not swimming while ill with diarrhea).

Feasibility and Acceptability of a Checklist and Learning Collaborative to Promote Quality and Safety in the Perinatal Care of Women with Opioid Use Disorders

INTRODUCTION

Perinatal opioid use disorder (OUD) represents a maternal-child health crisis in the United States. Untreated, OUD is associated with maternal and neonatal morbidity due to infectious disease, polysubstance use, co-occurring mental health conditions, prematurity, neonatal opioid withdrawal, and maternal mortality from overdose. Although national guidelines exist to optimize perinatal care for women with OUD, wide variation persists in health care providers' experience caring for this population and in the quality of care delivered.

PROCESS

We conducted a pilot study to determine whether the use of a checklist summarizing best practice could improve perinatal care for women with OUD. Implementation was supported by a learning collaborative of maternity care providers at 8 diverse sites across Vermont, New Hampshire, and Maine. Outcomes before and after implementation were compared to determine whether practice change occurred.

OUTCOMES

Data were collected from the records of 223 women with OUD who received prenatal care at pilot sites. All sites endorsed use of the checklist as a practice guide, and it was integrated in 78% of records reviewed. Across sites, significant improvement occurred in key elements of care, including increasing the proportion of women with access to the lifesaving drug naloxone (10.9% vs 36.3%, P < .001), receiving counseling about the benefits of breastfeeding (50.9% vs 72.0%, P < .01), and treating with nicotine replacement when indicated (9.1% vs 26.8%, P = .01). No significant change occurred in rates of prematurity, low birth weight, or breastfeeding at hospital discharge.

DISCUSSION

Implementation of a checklist to facilitate best practice in the care of pregnant women with OUD is feasible, acceptable to maternity care providers, and represents a promising approach to improving quality of care for this vulnerable population. Additional research is needed to determine whether improvement in quality can transform perinatal outcomes.

Decoupling of Blacklegged Tick Abundance and Lyme Disease Incidence in Southern Maine, USA

Lyme disease is caused by the bacterial spirochete Borrelia burgdorferi Johnson, Schmid, Hyde, Steigerwalt, and Brenner (Spirocheatales: Spirochaetaceae) which is transmitted through the bite of an infected blacklegged tick Ixodes scapularis Say (Ixodida: Ixodidae). Maine, USA, is a high Lyme disease incidence state, with rising incidence of Lyme disease and other tick-borne illnesses associated with increasing I. scapularis abundance and northward range expansion. Members of the public submitted ticks to a tick identification program (1990-2013). From these passive surveillance data, we characterized temporal trends in I. scapularis submission rate (an index of abundance), comparing Maine's northern tier (seven counties) versus southern tier (nine counties). In the northern tier, the I. scapularis submission rate increased throughout the duration of the time series, suggesting I. scapularis was emergent but not established. By contrast, in the southern tier, submission rate increased initially but leveled off after 10-14 yr, suggesting I. scapularis was established by the mid-2000s. Active (field) surveillance data from a site in the southern tier-bird tick burdens and questing adult tick collections-corroborated this leveling pattern. Lyme disease incidence and I. scapularis submission rate were temporally correlated in the northern but not southern tier. This suggested a decoupling of reported disease incidence and entomological risk.

Seroprevalence of Borrelia burgdorferi, B. miyamotoi, and Powassan Virus in Residents Bitten by Ixodes Ticks, Maine, USA

We conducted a serosurvey of 230 persons in Maine, USA, who had been bitten by Ixodes scapularis or I. cookei ticks. We documented seropositivity for Borrelia burgdorferi (13.9%) and B. miyamotoi (2.6%), as well as a single equivocal result (0.4%) for Powassan encephalitis virus.

Lifejackets and Lobstermen: Giving Safety Equipment a Competitive Advantage

Background: Falls overboard are the most frequent cause of death in the Northeast lobster fishing industry. National Institute for Occupational Safety and Health (NIOSH) surveillance indicates every victim of a fall overboard who has been found was not wearing a lifejacket. Preliminary research conducted in Maine and Massachusetts indicates lifejacket use is relatively uncommon among lobstermen due to barriers such as comfort, practicality, and social norms.Methods: This study highlights an initiative to: (1) trial various lifejacket designs with lobstermen; (2) identify the most popular designs; and (3) identify other features that could encourage use of lifejackets. In 2017, nine designs were trialed with lobstermen in Maine and Massachusetts during the winter and summer fishing seasons. Participants were recruited dockside, and lifejackets were randomly assigned. Participants completed surveys at 1 week and 4 weeks to assess positive and negative design features and to understand the importance of survival technology that can be used in conjunction with lifejackets.Results: 181 lobstermen in Maine and Massachusetts agreed to participate. Recruitment rates were 90.5%, while the survey completion rate was 88.4%. Survey results identified no clear preference for a specific lifejacket design; however, the ability to choose from many options appeared to be an important factor.Conclusion: Previous studies have indicated that lifejacket preferences are fisheries specific. In the Northeast lobster fishery, however, individual preferences varied. Our research demonstrates that a range of devices covering different buoyancies, wear type, and retrieval systems should be made more available to lobstermen.

The Three-spined Stickleback, Gasterosteus aculeatus Linnaeus 1758, plays a minor role as a host of Lepeophtheirus salmonis (Krøyer 1837) in the Gulf of Maine

The sea louse, Lepeophtheirus salmonis (Krøyer 1837), is a significant parasite of farmed salmon throughout the Northern Hemisphere. Management of on-farm louse populations can be improved by understanding the role that wild fish play in sustaining and providing refuge for the local population of sea lice. In this study, 1,064 sticklebacks were captured. Of these animals, 176 individuals were carrying a total of 238 sea lice, yielding a prevalence and intensity of 16.5% and 1.4 lice per fish, respectively. Detailed examination of the sea lice on the three-spined sticklebacks captured in Cobscook Bay found two L. salmonis individuals using three-spined sticklebacks as hosts. A 2012 survey of wild fish in Cobscook Bay, Maine, found multiple wild hosts for Caligus elongatus (von Nordmann 1832), including three-spined sticklebacks (Gasterosteus aculeatus L.), but no L. salmonis were found in this earlier study.

Assessment of Mortality and Smoking Rates Before and After Reduction in Community-wide Prevention Programs in Rural Maine

IMPORTANCE

It is unclear whether effective population-wide interventions that reduce risk factors and improve health result in sustained benefits to a community's health. If benefits do persist after a program is ended, interventions could be brief rather than maintained long term.

OBJECTIVE

To measure mortality and smoking rates in a rural community over decades before, during, and after prevention program reductions.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study compared smoking and mortality rates in a rural Maine county with other Maine counties over time by 5-year intervals. Multiple changes occurred between 2001 and 2015 in the physiological and behavioral risk factor reduction programs offered in the county. They included reductions in leadership, staff, institutional resources, data monitoring, and the programs themselves. Data were analyzed from May 2018 to March 2019.

INTERVENTION

Previous multifaceted interventions and outcome monitoring were withdrawn or diminished in the past decade.

MAIN OUTCOMES AND MEASURES

Smoking and age-adjusted mortality rates vs household income.

RESULTS

Reduced mortality rates in Franklin County in 1986 to 2005 reverted to those predicted by household incomes, relative to other Maine counties, by 2006 to 2015 (1986-1990 T score = -2.86 [P = .01] and 2001-2005 T score = -3.00 [P = .01] to 2006 to 2010 T score = -0.43 [P = .67] and 2011-2015 T score = -0.72 [P = .48]). Analysis of County Health Rankings data from 2010 to 2018 also showed that Franklin County's outcomes have reverted to no better than predicted by socioeconomic status. The county's T scores increased from -3.62 (P = .003) in 2010 to -0.41 (P = .69) in 2015 to 0.13 (P = .90) in 2018. Statewide association of income with mortality by analyses of variance showed that the R2 values have increased from the decades preceding 2000 (1976-1980, R2 = 0.21; P = .08; 1986-1990, R2 = 0.32; P = .02) to 2006 to 2010 (R2 = 0.73; P < .001) and 2011 to 2015 (R2 = 0.70; P < .001).

CONCLUSIONS AND RELEVANCE

This study suggests that gains associated with population health interventions may be lost when the interventions are reduced. Adjusting outcome measures for socioeconomic status may allow quicker and more sensitive monitoring of intervention adequacy and success. The increasing trend of age-adjusted mortality in Maine and nationally to correlate inversely with incomes may warrant further community interventions, especially for poorer populations.

Descriptive, observational study of pharmaceutical and non-pharmaceutical arrests, use, and overdoses in Maine

OBJECTIVES

The Maine Diversion Alert Program grants healthcare providers access to law enforcement data on drug charges. The objectives of this report were to analyse variations in drug charges by demographics and examine recent trends in arrests, prescriptions of controlled substances and overdoses.

DESIGN

Observational.

SETTING

Arrests, controlled prescription medication distribution and overdoses in Maine.

PARTICIPANTS

Drug arrestees (n=1272) and decedents (n=2432).

PRIMARY OUTCOME MEASURES

Arrestees were analysed by sex and age. Substances involved in arrests were reported by schedule (I-V or non-controlled prescription) and into opioids, stimulants or other classes. Controlled substances reported to the Drug Enforcement Administration (2007-2017) were evaluated. Drug-induced deaths (2007-2017) reported to the medical examiner were examined by the substance(s) identified.

RESULTS

Males were more commonly arrested for stimulants and schedule II substances. More than two-thirds of arrests involved individuals under the age of 40. Individuals age >60 were elevated for oxycodone arrests. Over three-fifths (63.38%) of arrests involved schedule II-IV substances. Opioids accounted for almost half (44.6%) of arrests followed by stimulants (32.5%) and sedatives (9.1%). Arrests involving buprenorphine exceeded those for oxycodone, hydrocodone, methadone, tramadol and morphine, combined. Prescriptions for hydrocodone (-56.0%) and oxycodone (-46.9%) declined while buprenorphine increased (+58.1%) between 2012 and 2017. Deaths from 2007 to 2017 tripled. Acetylfentanyl and furanylfentanyl were the most common fentanyl analogues identified.

CONCLUSIONS

Although the overall profile of those arrested for drug crimes in 2017 involve males, age <40 and heroin, exceptions (oxycodone for older adults) were observed. Most prescription opioids are decreasing while deaths involving opioids continue to increase in Maine.

Echinococcus in wild canids in Québec (Canada) and Maine (USA)

Zoonotic Echinococcus spp. cestodes (E. canadensis and E. multilocularis) infect domestic animals, wildlife, and people in regions of Canada and the USA. We recovered and quantified Echinococcus spp. cestodes from 22 of 307 intestinal tracts of wild canids (23 wolves, 100 coyotes, 184 red and arctic foxes) in the state of Maine and the province of Québec. We identified the species and genotypes of three Echinococcus spp. cestodes per infected animal by sequencing mitochondrial DNA at two loci. We further confirmed the absence of E. multilocularis by extracting DNA from pools of all cestodes from each animal and running a duplex PCR capable of distinguishing the two species. We detected E. canadensis (G8 and G10), but not E. multilocularis, which is emerging as an important human and animal health concern in adjacent regions. Prevalence and median intensity of E. canadensis was higher in wolves (35%, 460) than coyotes (14%, 358). This parasite has historically been absent in Atlantic regions of North America, where suitable intermediate hosts, but not wolves, are present. Our study suggests that coyotes are serving as sylvatic definitive hosts for E. canadensis in Atlantic regions, and this may facilitate eastward range expansion of E. canadensis in the USA and Canada. As well, compared to wolves, coyotes are more likely to contaminate urban green spaces and peri-urban environments with zoonotic parasites.

Echinococcosis is a zoonosis caused by ingestion of tapeworm eggs in feces of wild or domestic canids (e.g. foxes, wolves, coyotes, and dogs). In North America, the number of new human echinococcosis cases reported annually is low; however, recent reports of these parasites in unusual presentations, in new locations, and in wildlife near urban areas have caused renewed interest by veterinary and human health professionals. In a cross-border collaboration, we examined the intestines of wolves (Canis lupus), coyotes (C. latrans) and foxes (Vulpes vulpes, V. lagopus) trapped in Québec (Canada) and neighboring Maine (USA), using genetic tools to identify Echinococcus tapeworms. We did not detect E. multilocularis, a serious threat to human health that has recently emerged in southern Ontario. We did identify E. canadensis in wolves and coyotes, in both Quebec and Maine. The presence of this parasite in coyotes is especially concerning because coyotes are more likely to come into close proximity with human communities. This information is relevant to veterinarians who should promote regular fecal examination and/or deworming of high risk dogs (dogs that scavenge or hunt cervids, such as moose), to physicians who might encounter this relatively rare disease, and to public health agencies who should promote surveillance and develop precautions for high risk people.

Characterizing the demographics of chronic pain patients in the state of Maine using the Maine all payer claims database

BACKGROUND

Chronic pain is currently a significant health problem in the United States. A comprehensive strategy is needed to increase prevention of chronic pain and to improve care for chronic pain patients. However, development of a successful strategy relies, in part, on a better understanding of the demographics and socioeconomics of patients living with chronic pain conditions. The current study was designed to understand the burden of chronic pain in the state of Maine by identifying the prevalence of chronic pain and its relationship with selected demographic and socioeconomic factors in Maine.

METHODS

The Maine All Payer Claims Database (MEAPCD) (2006-2011) was used in the secondary data analysis to assess the demographic characteristics (such as age, sex, insurance type, and county of residence) of chronic pain patients in Maine. Chronic pain patients were identified based on the presence of pre-identified chronic pain-associated ICD-9 code(s) and opioid prescription information. Potential associations between the prevalence of chronic pain and a number of socioeconomic factors were determined by comparisons to Maine Census data.

RESULTS

More women in the state were identified as having chronic pain across all counties and all age groups (> 10 years old). Surprisingly, the majority of chronic pain patients were identified based on the diagnostic code criteria and not the opioid prescription criteria. A greater utilization of public health insurance was seen within the chronic pain patients. At the county level, although neither education level nor income were associated with the prevalence of chronic pain, these factors significantly correlated with the usage of public health insurance.

CONCLUSIONS

Further detailed characterization of the chronic pain patient population in the state of Maine, using multiple data sources, can help design population-targeted strategies to prevent and manage chronic pain.

The Impact of Maternal Obesity and Excessive Gestational Weight Gain on Maternal and Infant Outcomes in Maine: Analysis of Pregnancy Risk Assessment Monitoring System Results from 2000 to 2010

The objective of this study is to understand the relationships between prepregnancy obesity and excessive gestational weight gain (GWG) and adverse maternal and fetal outcomes. Pregnancy risk assessment monitoring system (PRAMS) data from Maine for 2000-2010 were used to determine associations between demographic, socioeconomic, and health behavioral variables and maternal and infant outcomes. Multivariate logistic regression analysis was performed on the independent variables of age, race, smoking, previous live births, marital status, education, BMI, income, rurality, alcohol use, and GWG. Dependent variables included maternal hypertension, premature birth, birth weight, infant admission to the intensive care unit (ICU), and length of hospital stay of the infant. Excessive prepregnancy BMI and excessive GWG independently predicted maternal hypertension. A high prepregnancy BMI increased the risk of the infant being born prematurely, having a longer hospital stay, and having an excessive birth weight. Excessive GWG predicted a longer infant hospital stay and excessive birth weight. A low pregnancy BMI and a lower than recommended GWG were also associated with poor outcomes: prematurity, low birth weight, and an increased risk of the infant admitted to ICU. These findings support the importance of preconception care that promotes achievement of a healthy weight to enhance optimal reproductive outcomes.

Elevated Bladder Cancer in Northern New England: The Role of Drinking Water and Arsenic

BACKGROUND

Bladder cancer mortality rates have been elevated in northern New England for at least five decades. Incidence rates in Maine, New Hampshire, and Vermont are about 20% higher than the United States overall. We explored reasons for this excess, focusing on arsenic in drinking water from private wells, which are particularly prevalent in the region.

METHODS

In a population-based case-control study in these three states, 1213 bladder cancer case patients and 1418 control subjects provided information on suspected risk factors. Log transformed arsenic concentrations were estimated by linear regression based on measurements in water samples from current and past homes. All statistical tests were two-sided.

RESULTS

Bladder cancer risk increased with increasing water intake (Ptrend = .003). This trend was statistically significant among participants with a history of private well use (Ptrend = .01). Among private well users, this trend was apparent if well water was derived exclusively from shallow dug wells (which are vulnerable to contamination from manmade sources, Ptrend = .002) but not if well water was supplied only by deeper drilled wells (Ptrend = .48). If dug wells were used pre-1960, when arsenical pesticides were widely used in the region, heavier water consumers (>2.2 L/day) had double the risk of light users (<1.1 L/day, Ptrend = .01). Among all participants, cumulative arsenic exposure from all water sources, lagged 40 years, yielded a positive risk gradient (Ptrend = .004); among the highest-exposed participants (97.5th percentile), risk was twice that of the lowest-exposure quartile (odds ratio = 2.24, 95% confidence interval = 1.29 to 3.89).

CONCLUSIONS

Our findings support an association between low-to-moderate levels of arsenic in drinking water and bladder cancer risk in New England. In addition, historical consumption of water from private wells, particularly dug wells in an era when arsenical pesticides were widely used, was associated with increased bladder cancer risk and may have contributed to the New England excess.

Elevated Bladder Cancer in Northern New England: The Role of Drinking Water and Arsenic

BACKGROUND

Bladder cancer mortality rates have been elevated in northern New England for at least five decades. Incidence rates in Maine, New Hampshire, and Vermont are about 20% higher than the United States overall. We explored reasons for this excess, focusing on arsenic in drinking water from private wells, which are particularly prevalent in the region.

METHODS

In a population-based case-control study in these three states, 1213 bladder cancer case patients and 1418 control subjects provided information on suspected risk factors. Log transformed arsenic concentrations were estimated by linear regression based on measurements in water samples from current and past homes. All statistical tests were two-sided.

RESULTS

Bladder cancer risk increased with increasing water intake (Ptrend = .003). This trend was statistically significant among participants with a history of private well use (Ptrend = .01). Among private well users, this trend was apparent if well water was derived exclusively from shallow dug wells (which are vulnerable to contamination from manmade sources, Ptrend = .002) but not if well water was supplied only by deeper drilled wells (Ptrend = .48). If dug wells were used pre-1960, when arsenical pesticides were widely used in the region, heavier water consumers (>2.2 L/day) had double the risk of light users (<1.1 L/day, Ptrend = .01). Among all participants, cumulative arsenic exposure from all water sources, lagged 40 years, yielded a positive risk gradient (Ptrend = .004); among the highest-exposed participants (97.5th percentile), risk was twice that of the lowest-exposure quartile (odds ratio = 2.24, 95% confidence interval = 1.29 to 3.89).

CONCLUSIONS

Our findings support an association between low-to-moderate levels of arsenic in drinking water and bladder cancer risk in New England. In addition, historical consumption of water from private wells, particularly dug wells in an era when arsenical pesticides were widely used, was associated with increased bladder cancer risk and may have contributed to the New England excess.

Physical Activity and the Risk of Primary Hyperparathyroidism

CONTEXT

Primary hyperparathyroidism (P-HPTH) is relatively common and predominantly affects women. Prior studies have shown that physical activity (PA) can lower PTH levels.

OBJECTIVE

Our objective was to evaluate the hypothesis that lower PA is a risk factor for developing P-HPTH.

DESIGN, SETTING, AND PARTICIPANTS

This prospective cohort study included 69 621 female participants in the Nurses' Health Study I followed for 22 years.

EXPOSURES

PA and other dietary and demographic exposures were quantified via detailed, and validated, biennial questionnaires.

OUTCOMES

Incident P-HPTH was confirmed by medical record review after initial assessment by questionnaire. Adjusted Cox proportional hazards models were used to evaluate whether PA was an independent risk factor for developing P-HPTH. We also evaluated the risk of developing P-HPTH when combining low PA (<16 metabolic equivalent hours/week) with a previously identified independent risk factor for developing P-HPTH: low calcium intake (<800 mg/day). The relation between PA and PTH levels was evaluated in 625 participants.

RESULTS

We confirmed 302 incident cases of P-HPTH during 1 474 993 person-years of follow-up. Participants in the highest quintile (Q) of PA had a 50% lower risk of developing P-HPTH: age-adjusted relative risks and 95% confidence intervals for incident P-HPTH by lowest to highest of PA were Q1 = 1.0 (reference); Q2 = 0.83 (0.60–1.15); Q3 = 0.84 (0.61–1.15); Q4 = 0.50 (0.34–0.74); Q5 = 0.50 (0.35–0.73); P for trend <.001. Extensive multivariable adjustments did not materially change these findings. The adjusted relative risk for developing P-HPTH among participants with the combination lower PA and lower calcium intake was 2.37-fold (1.60–3.51) higher than in participants with higher PA and higher calcium intake. PA was inversely correlated with serum PTH (ρ = −0.09, P = .03); the mean adjusted serum PTH in Q 2–5 of PA was lower than in Q 1 (36.3 vs 39.1 pg/mL, P = .02).

CONCLUSION

Low physical activity may be a modifiable risk factor for developing P-HPTH in women.

Experiences of opioid-dependent women in their prenatal and postpartum care: Implications for social workers in health care

The prevalence of prescription opioid abuse has increased nationally in the last decade with increased incidence rates reported among pregnant women. This was a qualitative study designed to understand the role of pregnant women with an opioid use disorder participating in medical decision making regarding their prenatal care while addressing their addiction. Group interviews were conducted with postpartum women who self-identified as opioid dependent during their pregnancy, and the data were analyzed using Interpretative Phenomenological Analysis. Social workers in the health care setting are an integral part of the interdisciplinary team in caring for pregnant and postpartum opioid-dependent women. Social workers are ideal in creating stigma reduction strategies, peer and professional supports, and comprehensive coordinated care. A social justice-based practice may be a framework to utilize when caring for this unique population.

Ascariasis in humans and pigs on small-scale farms, Maine, USA, 2010-2013

Ascaris is a genus of parasitic nematodes that can cause infections in humans and pigs. During 2010-2013, we identified 14 cases of ascariasis in persons who had contact with pigs in Maine, USA. Ascaris spp. are important zoonotic pathogens, and prevention measures are needed, including health education, farming practice improvements, and personal and food hygiene.

Severity of Anemia Predicts Hospital Length of Stay but Not Readmission in Patients with Chronic Kidney Disease: A Retrospective Cohort Study

The aim of this study was to examine the relationship of severe anemia to hospital readmission and length of stay (LOS) in patients with chronic kidney disease (CKD) stage 3-5. Compared with the general population, patients with moderate CKD have a higher hospital readmission rate and LOS. Anemia in patients with moderate CKD is associated with higher morbidity and mortality. The influence of anemia on hospital outcomes in patients with moderate CKD has not been characterized.We conducted a retrospective cohort study at Maine Medical Center, a 606-bed academic tertiary care hospital. Patients with CKD stages 3-5 and not on dialysis admitted during February 2013 to January 2014 were eligible. Patients with end stage renal disease on hemodialysis or peritoneal dialysis, kidney transplant, acute kidney injury, gastrointestinal bleeding, active malignancy, pregnancy, and surgery were excluded. The cohort was split into severe anemia (hemoglobin ≤9  g/dL) versus a comparison group (hemoglobin >9 g /dL), and examined for differences in 30-day hospital readmission and LOS.In this study, the data of 1141 patients were included, out of which 156 (13.7%) had severe anemia (mean hemoglobin 8.1 g/dL, SD 0.8). Severe anemia was associated with increased hospital LOS (mean 6.4 (SD 6.0) days vs mean 4.5 (SD 4.0) days, P < 0.001). The difference was 1.7 day longer (95% CI 0.94, 2.45). There was no difference in readmission rate (mean 11.5% vs 10.2%, P = 0.7).Patients with moderate CKD and severe anemia are at risk for increased hospital LOS. Interventions targeting this high-risk population, including outpatient management of anemia, may benefit patient care and save costs through improved hospital outcomes.

Community-wide cardiovascular disease prevention programs and health outcomes in a rural county, 1970-2010

IMPORTANCE

Few comprehensive cardiovascular risk reduction programs, particularly those in rural, low-income communities, have sustained community-wide interventions for more than 10 years and demonstrated the effect of risk factor improvements on reductions in morbidity and mortality.

OBJECTIVE

To document health outcomes associated with an integrated, comprehensive cardiovascular risk reduction program in Franklin County, Maine, a low-income rural community.

DESIGN, SETTING, AND PARTICIPANTS

Forty-year observational study involving residents of Franklin County, Maine, a rural, low-income population of 22,444 in 1970, that used the preceding decade as a baseline and compared Franklin County with other Maine counties and state averages.

INTERVENTIONS

Community-wide programs targeting hypertension, cholesterol, and smoking, as well as diet and physical activity, sponsored by multiple community organizations, including the local hospital and clinicians.

MAIN OUTCOMES AND MEASURES

Resident participation; hypertension and hyperlipidemia detection, treatment, and control; smoking quit rates; hospitalization rates from 1994 through 2006, adjusted for median household income; and mortality rates from 1970 through 2010, adjusted for household income and age.

RESULTS

More than 150,000 individual county resident contacts occurred over 40 years. Over time, as cardiovascular risk factor programs were added, relevant health indicators improved. Hypertension control had an absolute increase of 24.7% (95% CI, 21.6%-27.7%) from 18.3% to 43.0%, from 1975 to 1978; later, elevated cholesterol control had an absolute increase of 28.5% (95% CI, 25.3%-31.6%) from 0.4% to 28.9%, from 1986 to 2010. Smoking quit rates improved from 48.5% to 69.5%, better than state averages (observed - expected [O - E], 11.3%; 95% CI, 5.5%-17.7%; P < .001), 1996-2000; these differences later disappeared when Maine's overall quit rate increased. Franklin County hospitalizations per capita were less than expected for the measured period, 1994-2006 (O - E, -17 discharges/1000 residents; 95% CI -20.1 to -13.9; P < .001). Franklin was the only Maine county with consistently lower adjusted mortality than predicted over the time periods 1970-1989 and 1990-2010 (O - E, -60.4 deaths/100,000; 95% CI, -97.9 to -22.8; P < .001, and -41.6/100,000; 95% CI, -77.3 to -5.8; P = .005, respectively).

CONCLUSIONS AND RELEVANCE

Sustained, community-wide programs targeting cardiovascular risk factors and behavior changes to improve a Maine county's population health were associated with reductions in hospitalization and mortality rates over 40 years, compared with the rest of the state. Further studies are needed to assess the generalizability of such programs to other US county populations, especially rural ones, and to other parts of the world.

Human babesiosis, Maine, USA, 1995-2011

We observed an increase in the ratio of pathogenic Babesia microti to B. odocoilei in adult Ixodes scapularis ticks in Maine. Risk for babesiosis was associated with adult tick abundance, Borrelia burgdorferi infection prevalence, and Lyme disease incidence. Our findings may help track risk and increase the focus on blood supply screening.

Spatial prevalence and associations among respiratory diseases in Maine

Chronic respiratory diseases rank among the leading global disease burdens. Maine's respiratory disease prevalence exceeds the US average, despite limited urbanization/industrialization. To provide insight into potential etiologic factors among this unique, rural population, we analyzed the spatial distributions of, and potential associations among asthma, COPD, pneumonia, and URI adult outpatient data (n=47,099) from all outpatient transactions (n=5,052,900) in 2009 for Maine hospitals and affiliate clinics, using spatial scan statistic, geographic weighted regression (GWR), and a Delaunay graph algorithm. Non-random high prevalence regions were identified, the majority of which (84% of the population underlying all regions) exhibited clusters for all four respiratory diseases. GWR provided further evidence of spatial correlation (R(2)=0.991) between the communicable and noncommunicable diseases under investigation, suggesting spatial interdependence in risk. Sensitivity analyses of known respiratory disease risks did not fully explain our results. Prospective epidemiology studies are needed to clarify all contributors to risk.

An ergonomic assessment of the long handle blueberry harvesting rake

BACKGROUND

Previous work shows the superiority of the long-handled blueberry harvesting rake (LHR) for worker preference and productivity compared to the short-handle rake (SHR).

METHODS

Post-shift interviews on occurrence, location, and severity of pain, and video-based observation of body postures enabled ergonomic assessment of Maine workers harvesting blueberries. Workers randomly crossed between LHR and SHR on consecutive work days. Wilcoxon tests compared proportions of specific body postures between LHR and SHR.

RESULTS

Subjects used SHR for shorter work periods than LHR. Thirty workers provided interviews for both one LHR and one SHR shift. Assessment of these matched pairs suggested a trend toward less frequent overall pain (P = 0.07) and back pain (P = 0.11) with the LHR versus the SHR. Video tape analysis included 17 sets of observations (8 SHR and 9 LHR) on 12 individuals. Posture assessment showed more severe forward bend and squatting with the SHR and more moderate/neutral postures with the LHR.

CONCLUSION

Harvesting with the traditional SHR is likely to be associated with increased frequency of pain in general, and mid-low back pain in particular, when compared to the newer LHR. This may well relate to the work postures associated with each rake. Periodicals, Inc.

Centers for Disease Control and Prevention (CDC). Influenza outbreaks at two correctional facilities -- Maine, March 2011

On March 8, 2011, the Maine Center for Disease Control and Prevention (Maine CDC) received a laboratory report of a positive influenza specimen from an intensive-care unit patient who was an inmate at a prison (facility A). That same day, the state medical examiner notified Maine CDC of an inmate death suspected to be have been caused by influenza at another, nearby prison (facility B). On March 9, Correctional Medical Services (CMS), which provides health services to both facilities, notified Maine CDC that additional inmates and staff members from both facilities were ill with influenza-like illness (ILI). CMS reported that influenza vaccination coverage among inmates was very low (<10%), and coverage among staff members was unknown but believed to be low. Maine CDC assisted CMS and the Maine Department of Corrections (DOC) in conducting an epidemiologic investigation to gather more information about the two cases, initiate case finding, and implement control measures, which included emphasizing respiratory hygiene and cough etiquette, closing both facilities to new admissions and transfers, and offering vaccination and antiviral drugs to inmates and staff members. This report describes the public health response and highlights the importance of collaboration between public health and corrections officials to identify quickly and mitigate communicable disease outbreaks in these settings, where influenza can spread rapidly in a large and concentrated population. Correctional facilities should strongly consider implementing the following measures during each influenza season: 1) offering influenza vaccination to all inmates and staff members, 2) conducting education on respiratory etiquette, and 3) making documentation regarding the vaccination status of inmates and staff members accessible.

The effect of mixing events on the dynamics of pH1N1 outbreaks at small residential colleges

OBJECTIVE

The authors examine the dynamics and the impact of all-campus events on pH1N1 spread at Bates College in fall 2009, with comparisons to 3 other campuses.

PARTICIPANTS

Students (N = 285) presented or called in to the Bates Health Center with symptoms consistent with influenza-like illness.

METHODS

Health Center staff at Bates collected data on the outbreak; data from other colleges are from Web sites and journal articles. Data were analyzed using a mathematical model for influenza.

RESULTS

Bates held 2 vaccine clinics mid-outbreak. The data are consistent with the hypothesis that the vaccine clinics may have altered routine student interactions, facilitating transmission of pH1N1 among students who otherwise might not have encountered each other.

CONCLUSION

The vaccine clinics, held when vaccine became available, were too late to halt transmission. The disruptions to campus rhythms due to the vaccine clinics may instead have contributed to pH1N1 spread.

Estimating water supply arsenic levels in the New England Bladder Cancer Study

BACKGROUND

Ingestion of inorganic arsenic in drinking water is recognized as a cause of bladder cancer when levels are relatively high (≥ 150 µg/L). The epidemiologic evidence is less clear at the low-to-moderate concentrations typically observed in the United States. Accurate retrospective exposure assessment over a long time period is a major challenge in conducting epidemiologic studies of environmental factors and diseases with long latency, such as cancer.

OBJECTIVE

We estimated arsenic concentrations in the water supplies of 2,611 participants in a population-based case-control study in northern New England.

METHODS

Estimates covered the lifetimes of most study participants and were based on a combination of arsenic measurements at the homes of the participants and statistical modeling of arsenic concentrations in the water supply of both past and current homes. We assigned a residential water supply arsenic concentration for 165,138 (95%) of the total 173,361 lifetime exposure years (EYs) and a workplace water supply arsenic level for 85,195 EYs (86% of reported occupational years).

RESULTS

Three methods accounted for 93% of the residential estimates of arsenic concentration: direct measurement of water samples (27%; median, 0.3 µg/L; range, 0.1-11.5), statistical models of water utility measurement data (49%; median, 0.4 µg/L; range, 0.3-3.3), and statistical models of arsenic concentrations in wells using aquifers in New England (17%; median, 1.6 µg/L; range, 0.6-22.4).

CONCLUSIONS

We used a different validation procedure for each of the three methods, and found our estimated levels to be comparable with available measured concentrations. This methodology allowed us to calculate potential drinking water exposure over long periods.

Location of food stores near schools does not predict the weight status of Maine high school students

OBJECTIVE

To examine the relationship between stores selling calorie-dense food near schools and student obesity risk, with the hypothesis that high availability predicts increased risk.

METHODS

Mail surveys determined height, weight, and calorie-dense food consumption for 552 students at 11 Maine high schools. Driving distance from all food stores within 2 km (1.24 miles) of schools (or the closest store) was computed, and the impact of food store density and proximity to schools on student body mass index was determined by logistic regression.

RESULTS

Ten schools had ≥ 1 store selling soda, and 8 schools had ≥1 fast-food restaurant within 1 km (0.62 miles). There were no significant relationships between the proximity or density of food stores around schools and student obesity risk. Students obtained sugar-sweetened beverages in many locations including at school.

CONCLUSIONS AND IMPLICATIONS

Unhealthful food choices are ubiquitous. Consequently, stores selling these food items near schools have no significant affect on student obesity.

Impact of a school health coordinator intervention on health-related school policies and student behavior

BACKGROUND

Health-related, school-based interventions may serve to prevent disease and improve academic performance. The Healthy Maine Partnerships (HMP) initiative funded local school health coordinators (SHCs) as a part of Maine's Coordinated School Health Program (CSHP) beginning in January 2001. SHCs established school health leadership teams and implemented annual work plans to address health risk behaviors. This study evaluates the impact of the Healthy Maine Partnerships SHC (HMPSHC) intervention on school policies and student risk behaviors after its first 5 years.

METHODS

Data sources include the Maine School Health Profiles Survey and the Maine Youth Drug and Alcohol Use Survey/Youth Tobacco Survey. Cross-sectional analyses were performed on 2006 data to assess physical activity, nutrition, and tobacco-related policy associations with the HMPSHC intervention. Finally, policy and student behavior analyses were conducted to assess associations.

RESULTS

Intervention schools were more likely to be associated with physical activity intramural offerings, improved nutritional offerings, and tobacco cessation programs. In intervention schools, supportive school policies were associated with decreased soda consumption, decreased inactivity, and decreased tobacco use. Required school health education curricula were more predictive of decreased risk behavior in intervention schools than in nonintervention schools.

CONCLUSIONS

In schools with SHCs, there exists a stronger association with improved school programs. Improved policies and programs were associated with decreases in risk behavior among students in intervention schools. The HMPSHC intervention may be a viable CSHP model to replicate and evaluate in other settings.

Centers for Disease Control and Prevention (CDC). Outbreaks of 2009 pandemic influenza A (H1N1) among long-term-care facility residents - three states, 2009

Hospitalization and death from seasonal influenza are more common among older adults and in long-term--care facilities (LTCFs). Early data from the 2009 pandemic influenza A (H1N1) outbreak indicated that attack rates among persons aged >or=65 years were lower than in other age groups, and anti-influenza A antibodies that cross-react with 2009 H1N1 could be detected in up to one third of healthy adults aged >60 years. Based on these early data and anticipation of limited initial supplies of 2009 H1N1 vaccine, the Advisory Committee on Immunization Practices (ACIP) identified priority groups for vaccination, which did not include persons aged >or=65 years who did not have higher risk for influenza or its complications. During October and November 2009, CDC received reports of 2009 H1N1 outbreaks in LTCFs in Colorado, Maine, and New York. This report summarizes the three outbreaks, which involved facilities primarily housing older patients. These outbreaks illustrate that, despite the lower risk for infection with 2009 H1N1 among persons aged >or=65 years compared with seasonal influenza, 2009 H1N1 outbreaks still can occur in LTCFs. These outbreaks also underscore the importance of respiratory illness surveillance and recommended infection-control procedures in LTCFs. All health-care personnel should be vaccinated against seasonal influenza and 2009 H1N1. LTCF residents should receive seasonal influenza vaccination, and should be vaccinated against 2009 H1N1 after assessment of vaccine availability at the local level indicates that demand for vaccine among younger age groups is being met.

Centers for Disease Control and Prevention (CDC). Anaplasmosis and ehrlichiosis - Maine, 2008

Anaplasmosis and ehrlichiosis are rickettsial tickborne diseases that have had at least a twofold increase in prevalence in the United States since 2000. Despite similar clinical presentations, the causative organisms are carried by different ticks with distinct geographic and ecologic associations. Surveillance efforts are complicated by ambiguous terminology and serologic testing with antibody cross-reactivity. Although anaplasmosis historically has been reported in Maine, ehrlichiosis has been reported infrequently. During 2007-2008, the number of physician-reported anaplasmosis cases nearly doubled in Maine, and ehrlichiosis cases increased more than fourfold. To examine this increase, the Maine Department of Health and Human Services (MDHHS) analyzed available data on tick burden and physician-reported cases of anaplasmosis and ehrlichiosis during 2000-2008. This report describes the results of that analysis, which indicated that Ixodes scapularis (the tick vector for Anaplasma phagocytophilum) was broadly distributed in Maine, whereas Amblyomma americanum (the tick vector for Erhlichia chaffeenisis) was scarce. Moreover, 95% of physician-reported ehrlichiosis cases lacked a concurrent serologic assessment to exclude anaplasmosis, suggesting that antibody cross-reactivity might have resulted in misclassification. In 2008, Maine modified case classification to enhance specificity; ehrlichiosis cases that lack a concurrent test for anaplasmosis are now classified as suspect rather than probable and therefore are not included in national surveillance summaries. The accuracy of case classification and surveillance can be improved by educating health-care providers regarding 1) the expected geographic distribution of tick vectors and 2) recommendations for confirmatory testing to distinguish between the causative organisms of anaplasmosis and ehrlichiosis.

Centers for Disease Control and Prevention (CDC). Childhood lead poisoning associated with lead dust contamination of family vehicles and child safety seats - Maine, 2008

Persons employed in high-risk lead-related occupations can transport lead dust home from a worksite through clothing, shoes, tools, or vehicles. During 2008, the Maine Childhood Lead Poisoning Prevention Program (MCLPPP) identified 55 new cases of elevated (>or=15 microg/dL) venous blood lead levels (BLLs) among children aged <6 years through mandated routine screening. Although 90% of childhood lead poisoning cases in Maine during 2003-2007 had been linked to lead hazards in the child's home, no lead-based paint or dust or water with elevated lead levels were found inside the homes associated with six of the 2008 cases (i.e., five families, including one family with two affected siblings). An expanded environmental investigation determined that these six children were exposed to lead dust in the family vehicles and in child safety seats. The sources of the lead dust were likely household contacts who worked in high-risk lead exposure occupations. Current recommendations for identifying and reducing risk from take-home lead poisoning include 1) ensuring that children with elevated BLLs are identified through targeted blood lead testing, 2) directing prevention activities to at-risk workers and employers, and 3) improving employer safety protocols. State and federal prevention programs also should consider, when appropriate, expanded environmental lead dust testing to include vehicles and child safety seats.

Fetal cerebral ventricular pointing as a marker of spina bifida: incidence and observational agreement

OBJECTIVE

Occipital cerebral ventricular pointing is a promising intracranial marker for spina bifida. We sought to determine (1) the incidence of pointing in fetuses with and without spina bifida and (2) inter-observer and intraobserver agreement for visualizing pointing.

METHODS

Second-trimester transverse axial images of the lateral cerebral ventricles from an equal number of affected and unaffected fetuses were independently reviewed in a blinded fashion by 2 examiners.

RESULTS

Sixty-two fetuses (31 with isolated spina bifida and 31 without) had sonographic examinations at 19.2+/-1.3 weeks (mean+/-SD). Pointing was present in 77.3% of fetuses with spina bifida and 15% of those without by the first examiner and in 78.3% of fetuses with spina bifida and 10% of those without by the second examiner. Interobserver and intraobserver agreement were substantial (kappa=0.69 and 0.78, respectively).

CONCLUSIONS

Ventricular pointing is a highly agreed-on finding that is substantially associated with but not pathognomonic for fetal spina bifida.