Assessment of census-tract level socioeconomic position as a modifier of the relationship between short-term PM2.5 exposure and cardiovascular emergency department visits in Missouri

INTRODUCTION

Ambient particulate matter ≤ 2.5 µm in aerodynamic diameter (PM2.5) exposure elevates the risk for cardiovascular disease morbidity (CVDM). The aim of this study is to characterise which area-level measures of socioeconomic position (SEP) modify the relationship between PM2.5 exposure and CVDM in Missouri at the census-tract (CT) level.

METHODS

We use individual level Missouri emergency department (ED) admissions data (n=3 284 956), modelled PM2.5 data, and yearly CT data from 2012 to 2016 to conduct a two-stage analysis. Stage one uses a case-crossover approach with conditional logistic regression to establish the baseline risk of ED visits associated with IQR changes in PM2.5. In the second stage, we use multivariate metaregression to examine how CT-level SEP modifies the relationship between ambient PM2.5 exposure and CVDM.

RESULTS

We find that overall, ambient PM2.5 exposure is associated with increased risk for CVDM. We test effect modification in statewide and urban CTs, and in the warm season only. Effect modification results suggest that among SEP measures, poverty is most consistently associated with increased risk for CVDM. For example, across Missouri, the highest poverty CTs are at an elevated risk for CVDM (OR=1.010 (95% CI 1.007 to 1.014)) compared with the lowest poverty CTs (OR=1.004 (95% CI 1.000 to 1.008)). Other SEP modifiers generally display an inconsistent or null effect.

CONCLUSION

Overall, we find some evidence that area-level SEP modifies the relationship between ambient PM2.5 exposure and CVDM, and suggest that the relationship between air-pollution, area-level SEP and CVDM may be sensitive to spatial scale.

Emergency department visits for dog bite injuries in Missouri municipalities with and without breed-specific legislation: a propensity score-matched analysis

Breed-Specific Legislation is a type of law that bans or restricts ownership of specific dog breeds. Some local governments - including over seventy municipalities in the state of Missouri - have enacted Breed-Specific Legislation to prevent injuries from dog bites. Several studies from the peer-reviewed literature have found that aggressive behavior is not associated with any particular dog breeds and, since 2018, at least a dozen municipalities in Missouri have repealed these laws. To evaluate the impact of Breed-Specific Legislation on public safety, the 2010-2015 rates of emergency department visits for dog bite-related injuries in Missouri municipalities with and without Breed-Specific Legislation were compared. Propensity-score matched negative binomial regression models were used to assess the effect of breed restrictions on injury rates while balancing the samples on population characteristics and estimates of dog ownership. After matching the sample on population, housing and dog ownership estimates, no association was found between emergency department visits for dog bite injuries and whether the municipality enacted Breed-Specific Legislation. However, the incidence rate ratio of emergency room visits for dog bite-related injuries increased by 13.8% for every 1% increase in the percentage of males aged 5 to 9 in the population (p < 0.01). This study has found breed discriminatory laws have not reduced the risk of emergency department visits for injury from dog bites in Missouri. There appears to be no greater risk to public safety as local governments move to repeal existing breed bans.

Geographic disparities and predictors of COVID-19 vaccination in Missouri: a retrospective ecological study

Background

Limited information is available on geographic disparities of COVID-19 vaccination in Missouri and yet this information is essential for guiding efforts to improve vaccination coverage. Therefore, the objectives of this study were to (a) investigate geographic disparities in the proportion of the population vaccinated against COVID-19 in Missouri and (b) identify socioeconomic and demographic predictors of the identified disparities.

Methods

The COVID-19 vaccination data for time period January 1 to December 31, 2021 were obtained from the Missouri Department of Health. County-level data on socioeconomic and demographic factors were downloaded from the 2020 American Community Survey. Proportions of county population vaccinated against COVID-19 were computed and displayed on choropleth maps. Global ordinary least square regression model and local geographically weighted regression model were used to identify predictors of proportions of COVID-19 vaccinated population.

Results

Counties located in eastern Missouri tended to have high proportions of COVID-19 vaccinated population while low proportions were observed in the southernmost part of the state. Counties with low proportions of population vaccinated against COVID-19 tended to have high percentages of Hispanic/Latino population (p = 0.046), individuals living below the poverty level (p = 0.049), and uninsured (p = 0.015) populations. The strength of association between proportion of COVID-19 vaccinated population and percentage of Hispanic/Latino population varied by geographic location.

Conclusion

The study findings confirm geographic disparities of proportions of COVID-19 vaccinated population in Missouri. Study findings are useful for guiding programs geared at improving vaccination coverage and uptake by targeting resources to areas with low proportions of vaccinated individuals.

The Relationship of Vaccine Uptake and COVID-19 Infections Among Nursing Home Staff and Residents in Missouri: A Measure of Risk by Community Mobility

BACKGROUND

As the COVID-19 pandemic progressed across the United States, older adults living in nursing home (NH) facilities were disproportionately affected because of living in communal spaces with close proximity to others, age-related medical conditions, and constant contact with staff who may support multiple clients and facilities. While these populations are particularly at risk, there has been limited research focused on the management of the potential vectors of COVID-19 infection.

METHODS

Data from the Centers for Medicare & Medicaid Services (CMS) COVID-19 reporting system assessing weekly observations of COVID-19 case counts among NH residents and COVID-19 vaccination rates among NH staff and residents in the states of Missouri and Illinois (n = 877) from May 24, 2021, to August 28, 2021, were used. This ecological study, using results from the CMS COVID-19 reporting system, local COVID-19 rates, and NH-level demographic characteristics, conducted a zero inflation mode to determine the association between NH staff vaccine uptake and COVID-19 cases among NH residents.

RESULTS

Among the total 11 195 weekly observations within the NH facilities, zero cases of COVID-19 were reported during 10 683 (95%) of those weeks, supporting the use of a zero-inflated model. Results show that staff vaccination rates were significantly associated with a decrease in COVID-19 mortality. This study identified that for every percentage increase in staff vaccine coverage, the rate of COVID-19 among residents decreased by 2%.

DISCUSSION

These findings suggest that NH staff vaccination rates are significantly associated with the rate of COVID-19 outbreaks among NH residents. Community median income was associated with an increased likelihood of infection. Future research that explores associations with employment benefits and staff mobility, particularly in vulnerable populations, should be implemented in future vaccination strategic planning.

Ranavirus (Frog Virus 3) Infection in Free-Living Three-Toed Box Turtles (Terrapene mexicana triunguis) in Missouri, USA

Frog virus 3 (FV3) and related ranaviruses are emerging infectious disease threats to ectothermic vertebrate species globally. Although the impact of these viruses on amphibian health is relatively well studied, less is understood about their effects on reptile health. We report two cases of FV3 infection, 11 mo apart, in three-toed box turtles (Terrapene mexicana triunguis) from a wildlife rehabilitation center. Case 1 had upper respiratory signs upon intake but had no clinical signs at the time of euthanasia 1 mo later. Case 2 presented for vehicular trauma, had ulcerative pharyngitis and glossitis, and died overnight. In case 1, we detected FV3 nucleic acid with qPCR in oral swabs, kidney, liver, spleen, and tongue. In case 2, we detected FV3 in an oral swab, an oral plaque, heart, kidney, lung, liver, spleen, and tongue. We also detected FV3 nucleic acid with in situ hybridization for case 2. For both cases, FV3 was isolated in cell culture and identified with DNA sequencing. Histopathologic examination of postmortem tissue from case 1 was unremarkable, whereas acute hemorrhagic pneumonia and splenic necrosis were noted in case 2. The difference in clinical signs between the two cases may have been due to differences in the temporal course of FV3 disease at the time of necropsy. Failure to detect this infection previously in Missouri reptiles may be due to lack of surveillance, although cases may also represent a novel spillover to box turtles in Missouri. Our findings reiterate previous suggestions that the range of FV3 infection may be greater than previously documented and that infection may occur in host species yet to be tested.

Opioid Use Disorder in Missouri: An Evidence-Based, Public Health-Oriented Approach

Opioid use disorder (OUD) represents a growing public health crisis in Missouri and nationwide. Reversing the trend of rising OUD-associated morbidity and mortality will require implementing evidence-based approaches grounded in public health principles. Key evidence-based interventions include medications for opioid use disorder, naloxone distribution, overdose education, and syringe services programs. The increasing presence of fentanyl and xylazine in the drug supply represent new challenges to the OUD crisis in Missouri. Optimal implementation of evidence-based interventions will require action at the individual physician, community, and state policy level.

Continued selection on cryptic SARS-CoV-2 observed in Missouri wastewater

Deep sequencing of wastewater to detect SARS-CoV-2 has been used during the COVID-19 pandemic to monitor viral variants as they appear and circulate in communities. SARS-CoV-2 lineages of an unknown source that have not been detected in clinical samples, referred to as cryptic lineages, are sometimes repeatedly detected from specific locations. We have continued to detect one such lineage previously seen in a Missouri site. This cryptic lineage has continued to evolve, indicating continued selective pressure similar to that observed in Omicron lineages.

Firearm injuries in Missouri

Firearm deaths continue to be a major public health problem, but the number of non-fatal firearm injuries and the characteristics of patients and injuries is not well known. The American College of Surgeons Committee on Trauma, with support from the National Collaborative on Gun Violence Research, leveraged an existing data system to capture lethal and non-lethal injuries, including patients treated and discharged from the emergency department and collect additional data on firearm injuries that present to trauma centers. In 2020, Missouri had the 4th highest firearm mortality rate in the country at 23.75/100,000 population compared to 13.58/100,000 for the US overall. We examined the characteristics of patients from Missouri with firearm injuries in this cross-sectional study. Of the overall 17,395 patients, 1,336 (7.7%) were treated at one of the 11 participating trauma centers in Missouri during the 12-month study period. Patients were mostly male and much more likely to be Black and uninsured than residents in the state as a whole. Nearly three-fourths of the injuries were due to assaults, and overall 7.7% died. Few patients received post-discharge services.

Development, construct validity, and measurement invariance of the Modified Classes of Racism Frequency of Racial Experiences Measure (M-CRFRE) to capture direct and indirect exposure to perceived racism-based police use of force for Black emerging adults

OBJECTIVES

To utilize focus groups, cognitive interviews, content expert panel, and computer-assisted surveys to develop and pilot survey items assessing exposure to perceived racism-based police violence to enhance the Classes of Racism Frequency of Racial Experiences (CRFRE).

METHOD

Focus groups and cognitive interviews were conducted with Black emerging adults (n = 44) in St. Louis, Missouri. Utilizing a grounded theory approach, a thematic analysis of the focus group and cognitive interview transcripts was conducted to identify key items to be added to the CRFRE. Three content experts assessed the face and content validity of survey items. Computer-assisted surveys were conducted to pilot the modified CRFRE with a sample of Black emerging adults (n = 300). Confirmatory factor analyses and structural paths were used to examine the construct validity of the modified CRFRE.

RESULTS

Participant's qualitative data and suggestions from content experts resulted in the development of 16 additional survey items regarding exposure to perceived racism-based police violence across three domains (victim, witness in person, and seen in media). The modified CRFRE measure showed construct validity, internal reliability, and measurement invariance between men and women.

CONCLUSIONS

This study advances our epidemiological methodology for quantifying exposure to perceived racism-based police violence. Future research is necessary to assess the prevalence of exposure to perceived racism-based police violence and associated mental and behavioral outcomes for Black emerging adults in the U.S. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Associations between rurality and regional differences in sociodemographic factors and the 1918-20 influenza and 2020-21 COVID-19 pandemics in Missouri counties: An ecological study

This study compares pandemic experiences of Missouri's 115 counties based on rurality and sociodemographic characteristics during the 1918-20 influenza and 2020-21 COVID-19 pandemics. The state's counties and overall population distribution have remained relatively stable over the last century, which enables identification of long-lasting pandemic attributes. Sociodemographic data available at the county level for both time periods were taken from U.S. census data and used to create clusters of similar counties. Counties were also grouped by rural status (RSU), including fully (100%) rural, semirural (1-49% living in urban areas), and urban (>50% of the population living in urban areas). Deaths from 1918 through 1920 were collated from the Missouri Digital Heritage database and COVID-19 cases and deaths were downloaded from the Missouri COVID-19 dashboard. Results from sociodemographic analyses indicate that, during both time periods, average farm value, proportion White, and literacy were the most important determinants of sociodemographic clusters. Furthermore, the Urban/Central and Southeastern regions experienced higher mortality during both pandemics than did the North and South. Analyses comparing county groups by rurality indicated that throughout the 1918-20 influenza pandemic, urban counties had the highest and rural had the lowest mortality rates. Early in the 2020-21 COVID-19 pandemic, urban counties saw the most extensive epidemic spread and highest mortality, but as the epidemic progressed, cumulative mortality became highest in semirural counties. Additional results highlight the greater effects both pandemics had on county groups with lower rates of education and a lower proportion of Whites in the population. This was especially true for the far southeastern counties of Missouri ("the Bootheel") during the COVID-19 pandemic. These results indicate that rural-urban and socioeconomic differences in health outcomes are long-standing problems that continue to be of significant importance, even though the overall quality of health care is substantially better in the 21st century.

Understanding disruptions in cancer care to reduce increased cancer burden

Background

This study seeks to understand how and for whom COVID-19 disrupted cancer care to understand the potential for cancer health disparities across the cancer prevention and control continuum.

Methods

In this cross-sectional study, participants age 30+residing in an 82-county region in Missouri and Illinois completed an online survey from June-August 2020. Descriptive statistics were calculated for all variables separately and by care disruption status. Logistic regression modeling was conducted to determine the correlates of care disruption.

Results

Participants (N=680) reported 21% to 57% of cancer screening or treatment appointments were canceled/postponed from March 2020 through the end of 2020. Approximately 34% of residents stated they would need to know if their doctor's office is taking the appropriate COVID-related safety precautions to return to care. Higher education (OR = 1.26, 95% CI:1.11-1.43), identifying as female (OR = 1.60, 95% CI:1.12-2.30), experiencing more discrimination in healthcare settings (OR = 1.40, 95% CI:1.13-1.72), and having scheduled a telehealth appointment (OR = 1.51, 95% CI:1.07-2.15) were associated with higher odds of care disruption. Factors associated with care disruption were not consistent across races. Higher odds of care disruption for White residents were associated with higher education, female identity, older age, and having scheduled a telehealth appointment, while higher odds of care disruption for Black residents were associated only with higher education.

Conclusions

This study provides an understanding of the factors associated with cancer care disruption and what patients need to return to care. Results may inform outreach and engagement strategies to reduce delayed cancer screenings and encourage returning to cancer care.

Funding

This study was supported by the National Cancer Institute's Administrative Supplements for P30 Cancer Center Support Grants (P30CA091842-18S2 and P30CA091842-19S4). Kia L. Davis, Lisa Klesges, Sarah Humble, and Bettina Drake were supported by the National Cancer Institute's P50CA244431 and Kia L. Davis was also supported by the Breast Cancer Research Foundation. Callie Walsh-Bailey was supported by NIMHD T37 MD014218. The content does not necessarily represent the official view of these funding agencies and is solely the responsibility of the authors.

Spatial Epidemiologic Analysis and Risk Factors for Nontuberculous Mycobacteria Infections, Missouri, USA, 2008-2019

Nontuberculous mycobacteria (NTM) infections are caused by environmental exposure. We describe spatial distribution of NTM infections and associations with sociodemographic factors and flooding in Missouri, USA. Our retrospective analysis of mycobacterial cultures reported to the Missouri Department of Health and Social Services surveillance system during January 1, 2008-December 31, 2019, detected geographic clusters of infection. Multilevel Poisson regression quantified small-area geographic variations and identified characteristics associated with risk for infection. Median county-level NTM infection rate was 66.33 (interquartile range 51-91)/100,000 persons. Risk of clustering was significantly higher in rural areas (rate ratio 2.82, 95% CI 1.90-4.19) and in counties with >5 floodings per year versus no flooding (rate ratio 1.38, 95% CI 1.26-1.52). Higher risk for NTM infection was associated with older age, rurality, and more flooding. Clinicians and public health professionals should be aware of increased risk for NTM infections, especially in similar environments.

Supporting the Resilience and Mental Health of Missouri Healthcare Workers Through COVID-19 and Beyond: the Gateway2Wellness Program

The COVID-19 pandemic is over, but US healthcare workers (HCWs) continue to report high levels of work-related exhaustion and burnout but are unlikely to seek help. Digital tools offer a scalable solution. Between February and June 2022, we surveyed Missouri hospital administrators to assess HCW mental health and identify related evidence-based or evidence-informed resources. Simultaneously, we conducted a digital survey and focus groups with HCWs and leaders at Washington University School of Medicine (WUSOM) in St. Louis to evaluate HCW mental health needs, and preferences for digital support. Here, we describe the results and subsequent development of the Gateway to Wellness (G2W) program, a digital precision engagement platform that links HCWs to the most effective tailored resources for their mental health needs.

Examining Increasing Racial Inequities in Opioid Overdose Deaths: a Spatiotemporal Analysis of Black and White Decedents in St. Louis, Missouri, 2011-2021

The third wave of the opioid overdose crisis-defined by the proliferation of illicit fentanyl and its analogs-has not only led to record numbers of overdose deaths but also to unprecedented racial inequities in overdose deaths impacting Black Americans. Despite this racialized shift in opioid availability, little research has examined how the spatial epidemiology of opioid overdose death has also shifted. The current study examines the differential geography of OOD by race and time (i.e., pre-fentanyl versus fentanyl era) in St. Louis, Missouri. Data included decedent records from the local medical examiners suspected to involve opioid overdose (N = 4420). Analyses included calculating spatial descriptive analyses and conducting hotspot analyses (i.e., Gettis-Ord Gi*) stratified by race (Black versus White) and time (2011-2015 versus 2016-2021). Results indicated that fentanyl era overdose deaths were more densely clustered than pre-fentanyl era deaths, particularly those among Black decedents. Although hotspots of overdose death were racially distinct pre-fentanyl, they substantially overlapped in the fentanyl era, with both Black and White deaths clustering in predominantly Black neighborhoods. Racial differences were observed in substances involved in cause of death and other overdose characteristics. The third wave of the opioid crisis appears to involve a geographic shift from areas where White individuals live to those where Black individuals live. Findings demonstrate racial differences in the epidemiology of overdose deaths that point to built environment determinants for future examination. Policy interventions targeting high-deprivation communities are needed to reduce the burden of opioid overdose on Black communities.

Deaths of Despair and Population Aging in Missouri

Recent declines in life expectancy in the US, especially for middle-aged White persons, have called attention to mortality from deaths of despair - deaths due to alcohol, drugs, and suicide. Using data from the Centers for Disease Control and the U.S. Census Bureau, this paper examined deaths of despair by race/ethnicity, age, cause of death, birth cohort, and sex in Missouri. We focused on Area Agencies on Aging as geographic units of interest to increase usefulness of our findings to public administrators. Deaths of despair began trending up for all age groups beginning in 2007-2009, with the sharpest increases occurring for Black or African American non-Hispanics beginning in 2013-2015. The most dramatic increases occurred for the population age 50-59 in St. Louis City and Area Agency on Aging regions in southern Missouri. For older adults, considerable variation in rates, trends, and cause of deaths of despair is evident across the state.

The Effects of COVID-19 Pandemic Policy on Social Needs Across the State of Kansas and Western Missouri: Paired Survey Response Testing

BACKGROUND

Studying patients' social needs is critical to the understanding of health conditions and disparities, and to inform strategies for improving health outcomes. Studies have shown that people of color, low-income families, and those with lower educational attainment experience greater hardships related to social needs. The COVID-19 pandemic represents an event that severely impacted people's social needs. This pandemic was declared by the World Health Organization on March 11, 2020, and contributed to food and housing insecurity, while highlighting weaknesses in the health care system surrounding access to care. To combat these issues, legislators implemented unique policies and procedures to help alleviate worsening social needs throughout the pandemic, which had not previously been exerted to this degree. We believe that improvements related to COVID-19 legislature and policy have positively impacted people's social needs in Kansas and Missouri, United States. In particular, Wyandotte County is of interest as it suffers greatly from issues related to social needs that many of these COVID-19-related policies aimed to improve.

OBJECTIVE

The research objective of this study was to evaluate the change in social needs before and after the COVID-19 pandemic declaration based on responses to a survey from The University of Kansas Health System (TUKHS). We further aimed to compare the social needs of respondents from Wyandotte County from those of respondents in other counties in the Kansas City metropolitan area.

METHODS

Social needs survey data from 2016 to 2022 were collected from a 12-question patient-administered survey distributed by TUKHS during a patient visit. This provided a longitudinal data set with 248,582 observations, which was narrowed down into a paired-response data set for 50,441 individuals who had provided at least one response before and after March 11, 2020. These data were then bucketed by county into Cass (Missouri), Clay (Missouri), Jackson (Missouri), Johnson (Kansas), Leavenworth (Kansas), Platte (Missouri), Wyandotte (Kansas), and Other counties, creating groupings with at least 1000 responses in each category. A pre-post composite score was calculated for each individual by adding their coded responses (yes=1, no=0) across the 12 questions. The Stuart-Maxwell marginal homogeneity test was used to compare the pre and post composite scores across all counties. Additionally, McNemar tests were performed to compare responses before and after March 11, 2020, for each of the 12 questions across all counties. Finally, McNemar tests were performed for questions 1, 7, 8, 9, and 10 for each of the bucketed counties. Significance was assessed at P<.05 for all tests.

RESULTS

The Stuart-Maxwell test for marginal homogeneity was significant (P<.001), indicating that respondents were overall less likely to identify an unmet social need after the COVID-19 pandemic. McNemar tests for individual questions indicated that after the COVID-19 pandemic, respondents across all counties were less likely to identify unmet social needs related to food availability (odds ratio [OR]=0.4073, P<.001), home utilities (OR=0.4538, P<.001), housing (OR=0.7143, P<.001), safety among cohabitants (OR=0.6148, P<.001), safety in their residential location (OR=0.6172, P<.001), child care (OR=0.7410, P<0.01), health care access (OR=0.3895, P<.001), medication adherence (OR=0.5449, P<.001), health care adherence (OR=0.6378, P<.001), and health care literacy (0.8729, P=.02), and were also less likely to request help with these unmet needs (OR=0.7368, P<.001) compared with prepandemic responses. Responses from individual counties were consistent with the overall results for the most part. Notably, no individual county demonstrated a significant reduction in social needs relating to a lack of companionship.

CONCLUSIONS

Post-COVID-19 responses showed improvement across almost all social needs-related questions, indicating that the federal policy response possibly had a positive impact on social needs across the populations of Kansas and western Missouri. Some counties were impacted more than others and positive outcomes were not limited to urban counties. The availability of resources, safety net services, access to health care, and educational opportunities could play a role in this change. Future research should focus on improving survey response rates from rural counties to increase their sample size, and to evaluate other explanatory variables such as food pantry access, educational status, employment opportunities, and access to community resources. Government policies should be an area of focused research as they may affect the social needs and health of the individuals considered in this analysis.

A Spatial Examination of COVID-19 Policies among Missouri School Districts

BACKGROUND

As the COVID-19 pandemic spread, school district administrators in the United States were faced with difficult decisions regarding the implementation of virtual or in-person learning to reduce risk of infection throughout student and staff populations. While a coordinated effort with surrounding districts would be most beneficial when encountering a highly infectious respiratory-based infectious disease, the determinants of type of education delivery is unclear.

METHODS

Data from the Missouri Department of Elementary and Secondary Education assessing education delivery method at each school district across the state of Missouri (n = 514) from August 2020 were used. This cross-sectional study, using results from a school district-level survey, local COVID-19 rates, and community-level sociodemographic characteristics, conducted a spatially adjusted analysis of variance (ANOVA) to determine associations between education delivery type and geographic-level sociogeographic characteristics.

RESULTS

Among Missouri school districts, 172 (33.4%) reported starting the 2020-2021 academic year with an in-person policy, 52 (10.1%) with a distant/virtual policy, 242 (47.1%) in-person with a distance option, and 48 (9.3%) with a blended policy. This study found districts with lower household income levels were less likely to offer students any virtual learning options. Additionally, community COVID-19 infection rates were not associated with the selection of virtual or in-person education delivery.

CONCLUSIONS

These findings suggest the presence of a specific school policy was spatially random in regard to neighboring community policies, even when accounting for community characteristics. The efficacy of policy is likely to benefit upon application of a spatial framework when addressing a crisis fundamentally tied to location. Future planning that highlights and focuses on regional coordination for community resilience in the face of a pandemic should incorporate data sources that inform decisions made for families, students, and communities.

Sharing Lessons From Successes: Long-term Care Facilities That Weathered the Storm of COVID-19 and Staffing Crises

PURPOSE

To identify leadership styles and staffing strategies in Missouri long-term care (LTC) facilities that stood out among their peers as "positive deviants" with regard to COVID-19 infections and staffing shortages.

METHODS

Statewide survey of all LTC facilities to identify exemplar facilities with stable staffing and low rates of COVID-19. Interviews with senior leaders were conducted in 10 facilities in the state to understand the strategies employed that led to these "positive outliers." A result-based educational program was designed to describe their actions and staff reactions.

RESULTS

Exemplar leaders used transformational leadership style. Top reasons for their success were as follows: (1) trusting and supportive staff relationships; (2) positive presence and communication; and (3) use of consistent staffing assignments. Strong statewide participation was noted in the educational programs.

Prevalence of Bourbon and Heartland viruses in field collected ticks at an environmental field station in St. Louis County, Missouri, USA

Heartland and Bourbon viruses are pathogenic tick-borne viruses putatively transmitted by Amblyomma americanum, an abundant tick species in Missouri. To assess the prevalence of these viruses in ticks, we collected 2778 ticks from eight sampling sites at Tyson Research Center, an environmental field station within St. Louis County and close to the City of St. Louis, from May - July in 2019 and 2021. Ticks were pooled according to life stage and sex, grouped by year and sampling site to create 355 pools and screened by RT-qPCR for Bourbon and Heartland viruses. Overall, 14 (3.9%) and 27 (7.6%) of the pools were positive for Bourbon virus and Heartland virus respectively. In 2019, 11 and 23 pools were positive for Bourbon and Heartland viruses respectively. These positives pools were of males, females and nymphs. In 2021, there were 4 virus positive pools out of which 3 were positive for both viruses and were comprised of females and nymphs. Five out of the 8 sampling sites were positive for at least one virus. This included a site that was positive for both viruses in both years. Detection of these viruses in an area close to a relatively large metropolis presents a greater public health threat than previously thought.

A Summary of Maternal Mortality in Missouri: A Historical Perspective (1999-2018)

The rate of maternal mortality in the United States (U.S.) is higher than any other industrialized nation, at 23.8 per 100,000 deliveries from 2000-2014. Although maternal mortality ratios decreased by 44% globally from 1990 to 2015, emerging evidence suggests that maternal mortality in the U.S. has been increasing.2-4 One study quotes 700 maternal deaths every year, with 50,000 "near misses."1 By one metric, Missouri ranks as the 44th-worst state for maternal mortality in the U.S.5.

Emergency Medicine Telehealth: A Pandemic Becomes a Gateway for Virtual Care in Missouri

Telehealth provides a novel bridge between patient needs and available resources. On-demand telehealth visits provide urgent medical services in a virtual setting. Telehealth can be used to provide care for patients despite geographical distance. Emergency Medicine quickly adapted in response to the COVID-19 pandemic through utilization of telehealth to solve various problems. Tele-triage was used to coordinate COVID-19 testing and treatment. Greater utilization of all current and emerging telehealth modalities could increase access and quality of care for all Missourians.

The Tip of the Spear: Emergency Medicine and Missouri's Response to the COVID-19 Pandemic

The COVID-19 pandemic provided the specialty of emergency medicine the opportunity to showcase what many knew all along: emergency physicians (EP) are well suited to deal with the unknown and can quickly adapt even with incomplete or limited information and resources. Emergency physicians in Missouri served in integral positions locally, nationally and internationally. Missouri EPs published numerous manuscripts on topics from basic science to clinical care. Device innovation also occurred with the development of protective devices for health care workers. As we approach the three-year mark of the COVID-19 pandemic, the burden of clinical care still weighs heavily on EPs. Each wave of the pandemic has brought challenges and spurred EPs to innovate in new ways. As Michigan EP Brian Zink, MD once said "Anyone, Anything, Anytime". These words correctly sum up emergency medicine. When others hesitated to care for COVID-19 patients, EPs stepped up despite uncertainty and risks to their own health. Emergency medicine has led the way and continues to innovate and push the envelope of emergency care.

Burnout Among Missouri Primary Care Clinicians in 2021: Roadmap for Recovery?

Rates of burnout among clinicians have been exacerbated by the COVID-19 (COVID)pandemic. A survey of Missouri primary care professionals at federally qualified health centers was conducted during a COVID surge in August 2021 to assess burnout, stress, and job satisfaction as well as if respondents had sought assistance for burnout or attended resiliency training. Despite respondents reporting rates of burnout (56%) that exceed those reported nationally (48%), only 17% sought help for burnout. Most (81%) had not attended resiliency training; of those who did, 16% said sessions "make me feel less alone," while an equivalent number found sessions not useful, identifying an absence of resources within their organization. Comments focused on the need for dedicated time to receive support, including time to seek assistance during working hours, time to take breaks, and time for self-care. The data suggest one path forward to remediate burnout: provide the workforce with time to access support.

Neutralizing Enterovirus D68 Antibodies in Children after 2014 Outbreak, Kansas City, Missouri, USA

Antibodies to B1, B2, and D clade viruses were detected.

Enterovirus D68 (EV-D68) causes severe respiratory illness outbreaks among children, particularly those with asthma. We previously detected neutralizing antibodies against the predominant EV-D68 B1 clade in the 2014 outbreak in serum collected before the outbreak (2012–2013) from persons 24 months to 85 years of age. We recently detected neutralizing antibodies to the 2014 B1, B2, and D clade viruses in serum collected after the 2014 outbreak (April–May 2017) from 300 children 6 months to 18 years of age. B1 virus neutralizing antibodies were found in 100% of patients, even children born after 2014; B2 in 84.6%, and D in 99.6%. In 2017, titers increased with patient age and were higher than titers in 2012–2013 from comparably aged children. Rate of seronegativity was highest (15.3%) for B2 virus. Multivariate analysis revealed an association between asthma and higher titers against B2 and D viruses. EV-D68 seems to have circulated during 2014–2017.

Understanding contributors to racial and ethnic inequities in COVID-19 incidence and mortality rates

Background

Racial inequities in Coronavirus 2019 (COVID-19) have been reported over the course of the pandemic, with Black, Hispanic/Latinx, and Native American individuals suffering higher case rates and more fatalities than their White counterparts.

Methods

We used a unique statewide dataset of confirmed COVID-19 cases across Missouri, linked with historical statewide hospital data. We examined differences by race and ethnicity in raw population-based case and mortality rates. We used patient-level regression analyses to calculate the odds of mortality based on race and ethnicity, controlling for comorbidities and other risk factors.

Results

As of September 10, 2020 there were 73,635 confirmed COVID-19 cases in the State of Missouri. Among the 64,526 case records (87.7% of all cases) that merged with prior demographic and health care utilization data, 12,946 (20.1%) were Non-Hispanic (NH) Black, 44,550 (69.0%) were NH White, 3,822 (5.9%) were NH Other/Unknown race, and 3,208 (5.0%) were Hispanic. Raw cumulative case rates for NH Black individuals were 1,713 per 100,000 population, compared with 2,095 for NH Other/Unknown, 903 for NH White, and 1,218 for Hispanic. Cumulative COVID-19-related death rates for NH Black individuals were 58.3 per 100,000 population, compared with 38.9 for NH Other/Unknown, 19.4 for NH White, and 14.8 for Hispanic. In a model that included insurance source, history of a social determinant billing code in the patient’s claims, census block travel change, population density, Area Deprivation Index, and clinical comorbidities, NH Black race (OR 1.75, 1.51–2.04, p<0.001) and NH Other/Unknown race (OR 1.83, 1.36–2.46, p<0.001) remained strongly associated with mortality.

Conclusions

In Missouri, COVID-19 case rates and mortality rates were markedly higher among NH Black and NH Other/Unknown race than among NH White residents, even after accounting for social and clinical risk, population density, and travel patterns during COVID-19.

Geographic disparities and determinants of COVID-19 incidence risk in the greater St. Louis Area, Missouri (United States)

BACKGROUND

Evidence seems to suggest that the risk of Coronavirus Disease 2019 (COVID-19) might vary across communities due to differences in population characteristics and movement patterns. However, little is known about these differences in the greater St Louis Area of Missouri and yet this information is useful for targeting control efforts. Therefore, the objectives of this study were to investigate (a) geographic disparities of COVID-19 risk and (b) associations between COVID-19 risk and socioeconomic, demographic, movement and chronic disease factors in the Greater St. Louis Area of Missouri, USA.

METHODS

Data on COVID-19 incidence and chronic disease hospitalizations were obtained from the Department of Health and Missouri Hospital Association, respectively. Socioeconomic and demographic data were obtained from the 2018 American Community Survey while population mobility data were obtained from the SafeGraph website. Choropleth maps were used to identify geographic disparities of COVID-19 risk and several sociodemographic and chronic disease factors at the ZIP Code Tabulation Area (ZCTA) spatial scale. Global negative binomial and local geographically weighted negative binomial models were used to investigate associations between ZCTA-level COVID-19 risk and socioeconomic, demographic and chronic disease factors.

RESULTS

There were geographic disparities found in COVID-19 risk. Risks tended to be higher in ZCTAs with high percentages of the population with a bachelor's degree (p<0.0001) and obesity hospitalizations (p<0.0001). Conversely, risks tended to be lower in ZCTAs with high percentages of the population working in agriculture (p<0.0001). However, the association between agricultural occupation and COVID-19 risk was modified by per capita between ZCTA visits. Areas that had both high per capita between ZCTA visits and high percentages of the population employed in agriculture had high COVID-19 risks. The strength of association between agricultural occupation and COVID-19 risk varied by geographic location.

CONCLUSIONS

Geographic disparities of COVID-19 risk exist in the St. Louis area and are associated with sociodemographic factors, population movements, and obesity hospitalization risks. The latter is particularly concerning due to the growing prevalence of obesity and the known immunological impairments among obese individuals. Therefore, future studies need to focus on improving our understanding of the relationships between COVID-19 vaccination efficacy, obesity and waning of immunity among obese individuals so as to better guide vaccination regimens and reduce disparities.

Assessment of Retrospective COVID-19 Spatial Clusters with Respect to Demographic Factors: Case Study of Kansas City, Missouri, United States

Coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The United States (U.S.) has the highest number of reported COVID-19 infections and related deaths in the world, accounting for 17.8% of total global confirmed cases as of August 2021. As COVID-19 spread throughout communities across the U.S., it became clear that inequities would arise among differing demographics. Several researchers have suggested that certain racial and ethnic minority groups may have been disproportionately impacted by the spread of COVID-19. In the present study, we used the daily data of COVID-19 cases in Kansas City, Missouri, to observe differences in COVID-19 clusters with respect to gender, race, and ethnicity. Specifically, we utilized a retrospective Poisson spatial scan statistic with respect to demographic factors to detect daily clusters of COVID-19 in Kansas City at the zip code level from March to November 2020. Our statistical results indicated that clusters of the male population were more widely scattered than clusters of the female population. Clusters of the Hispanic population had the highest prevalence and were also more widely scattered. This demographic cluster analysis can provide guidance for reducing the social inequalities associated with the COVID-19 pandemic. Moreover, applying stronger preventive and control measures to emerging clusters can reduce the likelihood of another epidemic wave of infection.

Association of Ambient Fine Particulate Matter Air Pollution With Kidney Transplant Outcomes

IMPORTANCE

Increased levels of ambient fine particulate matter (PM2.5) air pollution are associated with increased risks for detrimental health outcomes, but risks for patients with kidney transplants (KTs) remain unknown.

OBJECTIVE

To investigate the association of PM2.5 exposure with KT outcomes.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study was conducted using data on patients who received KTs from 2004 to 2016 who were identified in the national US transplant registry and followed up through March 2021. Multiple databases were linked to obtain data on PM2.5 concentration, KT outcomes, and patient clinical, transplant, and contextual factors. Data were analyzed from April 2020 through July 2021.

EXPOSURES

Exposures included post-KT time-dependent annual mean PM2.5 level (in 10 μg/m3) and mean PM2.5 level in the year before KT (ie, baseline levels) in quartiles, as well as baseline annual mean PM2.5 level (in 10 μg/m3).

MAIN OUTCOMES AND MEASURES

Acute kidney rejection (ie, rejection within 1 year after KT), time to death-censored graft failure, and time to all-cause death. Multivariable logistic regression for kidney rejection and Cox analyses with nonlinear assessment of exposure-response for death-censored graft failure and all-cause death were performed. The national burden of graft failure associated with PM2.5 levels greater than the Environmental Protection Agency recommended level of 12 μg/m3 was estimated.

RESULTS

Among 112 098 patients with KTs, 70 522 individuals (62.9%) were older than age 50 years at the time of KT, 68 117 (60.8%) were men, and the median (IQR) follow-up was 6.0 (3.9-8.9) years. There were 37 265 Black patients (33.2%), 17 047 Hispanic patients (15.2%), 48 581 White patients [43.3%]), and 9205 patients (8.2%) of other race or ethnicity. The median (IQR) baseline PM2.5 level was 9.8 (8.3-11.9) μg/m3. Increased baseline PM2.5 level, compared with quartile 1 baseline PM2.5 level, was not associated with higher odds of acute kidney rejection for quartile 2 (adjusted odds ratio [aOR], 0.99; 95% CI, 0.92-1.06) but was associated with increased odds for quartile 3 (aOR, 1.11; 95% CI, 1.04-1.20) and quartile 4 (aOR, 1.13; 95% CI, 1.05-1.23). Nonlinear assessment of exposure-response for graft failure and death showed no evidence for nonlinearity. Increased PM2.5 levels were associated with increased risk of death-censored graft failure (adjusted hazard ratio [aHR] per 10 μg/m3 increase, 1.17; 95% CI, 1.09-1.25) and all-cause death (aHR per 10 μg/m3 increase, 1.21; 95% CI, 1.14-1.28). The national burden of death-censored graft failure associated with PM2.5 above 12 μg/m3 was 57 failures (95% uncertainty interval, 48-67 failures) per year among patients with KTs.

CONCLUSIONS AND RELEVANCE

This cohort study found that PM2.5 level was an independent risk factor associated with acute rejection, graft failure, and death among patients with KTs. These findings suggest that efforts toward decreasing levels of PM2.5 concentration may be associated with improved outcomes after KT.

Implementation of a Scalable Family-Based Behavioral Treatment for Childhood Obesity Delivered through Primary Care Clinics: Description of the Missouri Childhood Obesity Research Demonstration Study Protocol

Background: Significant gaps exist in access to evidence-based pediatric weight management interventions, especially for low-income families who are disproportionately affected by obesity. As a part of the Centers for Disease Control and Prevention's Childhood Obesity Research Demonstration project (CORD 3.0), the Missouri team (MO-CORD) aims to increase access to and dissemination of an efficacious pediatric obesity treatment, specifically family-based behavioral treatment (FBT), for low-income families. Methods/Design: The implementation pilot study is a multisite matched-comparison group pilot of packaged FBT in pediatric clinics for low-income children with obesity, of ages 5 to 12 years old. The study is implemented in two Missouri pediatric primary care clinical sites, Freeman Health System Pediatric Clinics (rural Joplin) and Children's Mercy Hospital Pediatric Clinics (urban Kansas City). The design focuses on pragmatism through utilization of PRECIS (Pragmatic Explanatory Continuum Indicator Summary) domains, such as open eligibility criteria, limited follow-up intensity, reliance on medical records for creating a usual care comparison group data, and unobtrusive measurement of participant and provider adherence. The evaluation focuses on effectiveness as well as implementation outcomes and barriers to inform implementation scale up. Conclusions: Findings from this study will advance both science and practice by providing novel and immediately useful information to families, health care providers, health care organizations, payers, and other state Medicaid plans by developing and optimizing evidence-based pediatric weight management treatment for implementation and dissemination in health systems to address health disparities among low-income populations most affected by overweight and obesity.

Monitoring SARS-CoV-2 Populations in Wastewater by Amplicon Sequencing and Using the Novel Program SAM Refiner

Sequencing Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) from wastewater has become a useful tool in monitoring the spread of viral variants. Approaches to this task have been varied, relying on differing sequencing methods and computational analyses. We used a novel computation workflow based on amplicon sequencing of SARS-CoV-2 spike domains in order to track viral populations in wastewater. As part of this workflow, we developed a program, SAM Refiner, that has a variety of outputs, including novel variant reporting as well as functions designed to remove polymerase chain reaction (PCR) generated chimeric sequences. With these methods, we were able to track viral population dynamics over time. We report here on the emergence of two variants of concern, B.1.1.7 (Alpha) and P.1 (Gamma), and their displacement of the D614G B.1 variant in a Missouri sewershed.

Monitoring SARS-CoV-2 Populations in Wastewater by Amplicon Sequencing and Using the Novel Program SAM Refiner

Sequencing Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) from wastewater has become a useful tool in monitoring the spread of viral variants. Approaches to this task have been varied, relying on differing sequencing methods and computational analyses. We used a novel computation workflow based on amplicon sequencing of SARS-CoV-2 spike domains in order to track viral populations in wastewater. As part of this workflow, we developed a program, SAM Refiner, that has a variety of outputs, including novel variant reporting as well as functions designed to remove polymerase chain reaction (PCR) generated chimeric sequences. With these methods, we were able to track viral population dynamics over time. We report here on the emergence of two variants of concern, B.1.1.7 (Alpha) and P.1 (Gamma), and their displacement of the D614G B.1 variant in a Missouri sewershed.

Public Preferences for Social Distancing Policy Measures to Mitigate the Spread of COVID-19 in Missouri

IMPORTANCE

Policies to promote social distancing can minimize COVID-19 transmission but come with substantial social and economic costs. Quantifying relative preferences among the public for such practices can inform locally relevant policy prioritization and optimize uptake.

OBJECTIVE

To evaluate relative utilities (ie, preferences) for COVID-19 pandemic social distancing strategies against the hypothetical risk of acquiring COVID-19 and anticipated income loss.

DESIGN, SETTING, AND PARTICIPANTS

This survey study recruited individuals living in the Missouri area from May to June 2020 via randomly distributed unincentivized social media advertisements and local recruitment platforms for members of minority racial and ethnic groups. Participants answered 6 questions that asked them to choose between 2 hypothetical counties where business closures, social distancing policy duration, COVID-19 infection risk, and income loss varied.

MAIN OUTCOMES AND MEASURES

Reweighted population-level relative preferences (utilities) for social distancing policies, subgroups, and latent classes.

RESULTS

The survey had a 3% response rate (3045 of 90 320). Of the 2428 respondents who completed the survey, 1669 (75%) were 35 years and older, 1536 (69%) were women, and 1973 (89%) were White. After reweighting to match Missouri population demographic characteristics, the strongest preference was for the prohibition of large gatherings (mean preference, -1.43; 95% CI, -1.67 to -1.18), with relative indifference to the closure of social and lifestyle venues (mean preference, 0.05; 95% CI, -0.08 to 0.17). There were weak preferences to keep outdoor venues (mean preference, 0.50; 95% CI, 0.39 to 0.61) and schools (mean preference, 0.18; 95% CI, 0.05 to 0.30) open. Latent class analysis revealed 4 distinct preference phenotypes in the population: risk averse (48.9%), conflicted (22.5%), prosocial (14.9%), and back to normal (13.7%), with men twice as likely as women to belong to the back to normal group than the risk averse group (relative risk ratio, 2.19; 95% CI, 1.54 to 3.12).

CONCLUSIONS AND RELEVANCE

In this survey study using a discrete choice experiment, public health policies that prohibited large gatherings, as well as those that closed social and lifestyle venues, appeared to be acceptable to the public. During policy implementation, these activities should be prioritized for first-phase closures. These findings suggest that policy messages that address preference heterogeneity (eg, focusing on specific preference subgroups or targeting men) could improve adherence to social distancing measures for COVID-19 and future pandemics.

Patients With Symptomatic Sequelae of Slipped Capital Femoral Epiphysis Have Advanced Cartilage Wear at the Time of Surgical Intervention

BACKGROUND

Slipped capital femoral epiphysis (SCFE) is a common hip problem in children. The resulting deformity can cause impingement similar to cam-type idiopathic femoroacetabular impingement (FAI). Although there are similarities between FAI and SCFE, deformity patterns, severity, and time of onset of symptoms varies, which may impact management. The purpose of this study was to describe patterns of articular cartilage damage in patients undergoing surgical hip dislocation for sequelae of SCFE in comparison to patients undergoing arthroscopic surgery for primary FAI.

METHODS

Patients were identified who underwent surgical treatment for hip pain due to primary FAI (cam type) or sequelae of SCFE. Clinical data and radiographic measurements were recorded. Cartilage was assessed intraoperatively. Severity was classified using the modified Beck classification, while location was classified into 6 sectors. Statistical analysis was performed to test for differences in demographic and radiographic characteristics between the SCFE and FAI patients. χ2 or Fisher exact tests were used to evaluate trends in patterns of acetabular and femoral cartilage wear between SCFE and FAI groups.

RESULTS

The SCFE group had 28 hips compared with 304 in the FAI group. SCFE patients were younger (19 vs. 32, P<0.001), had higher body mass index (30±5.9 vs. 24±4.8, P<0.001), and were more often male (61% vs. 27%, P<0.001). Deformity severity based on α-angle was higher in the SCFE group [AP 74 vs. 55 (P=0.001) and Dunn 72 vs. 58 (P<0.001)]. There were no significant differences with regards to lateral center edge angle, anterior center edge angle, or Tonnis angle. In both groups the most common locations for cartilage lesions in both groups were the anterior peripheral and superolateral peripheral regions with fewer but more widely distributed femoral head lesions. The SCFE group had higher rates of femoral head and superolateral central cartilage lesions compared with the FAI group. There was no statistical difference between high-grade femoral or acetabular cartilage lesions between groups.

CONCLUSIONS

Patients with SCFE were younger at the time of surgery and presented with more severe deformity based on radiographic α-angle compared to patients with FAI. Our results suggest higher prevalence of femoral head lesions and more diffuse cartilage injury in patients with SCFE. This study can be used to support early surgical intervention in patients with symptomatic sequelae of SCFE due to risk of premature joint damage.

LEVEL OF EVIDENCE

Level III-prognostic study.

Changes In Non-COVID-19 Emergency Department Visits By Acuity And Insurance Status During The COVID-19 Pandemic

Prior studies suggest that the COVID-19 pandemic was associated with decreases in emergency department (ED) volumes, but it is not known whether these decreases varied by visit acuity or by demographic and socioeconomic risk factors. In this study of more than one million non-COVID-19 visits to thirteen EDs in a large St. Louis, Missouri, health system, we observed an overall 35 percent decline in ED visits. The decrease in medical and surgical visits ranged from 40 percent to 52 percent across acuity levels, with no statistically significant differences between higher- and lower-acuity visits after correction for multiple comparisons. Mental health visits saw a smaller decrease (-32 percent), and there was no decrease for visits due to substance use. Medicare patients had the smallest decrease in visits (-31 percent) of the insurance groups; privately insured (-46 percent) and Medicaid (-44 percent) patients saw larger drops. There were no observable differences in ED visit decreases by race. These findings can help inform interventions to ensure that people requiring timely ED care continue to seek it and to improve access to lower-risk alternative settings of care where appropriate.

Reassortant Cache Valley virus associated with acute febrile, non-neurologic illness, Missouri

An adult male from Missouri sought care for fever, fatigue, and gastrointestinal symptoms. He had leukopenia and thrombocytopenia and was treated for a presumed tickborne illness. His condition deteriorated with respiratory and renal failure, lactic acidosis, and hypotension. Next-generation sequencing and phylogenetic analysis identified a reassortant Cache Valley virus.

Seroprevalence of SARS-CoV-2 Antibodies in Children and Adults in St. Louis, Missouri, USA

Reported coronavirus disease 2019 (COVID-19) case counts likely underestimate the true prevalence because mild or asymptomatic cases often go untested. Here, we use a sero-survey to estimate the seroprevalence of IgG antibodies against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in the St. Louis, MO, metropolitan area in a symptom-independent manner. Five hundred three adult and 555 pediatric serum/plasma samples were collected from patients presenting to Barnes-Jewish Hospital or St. Louis Children's Hospital between 14 April 2020 and 12 May 2020. We developed protocols for in-house enzyme-linked immunosorbent assays (ELISAs) using spike and nucleoprotein and used the assays to estimate a seroprevalence rate based on our samples. Overall IgG seropositivity was estimated to be 1.71% (95% credible interval [CI], 0.04% to 3.38%) in pediatric samples and 3.11% (95% CI, 0.92% to 5.32%) in adult samples. Seropositivity was significantly lower in children under 5 years of age than in adults, but rates between adults and children aged 5 or older were similar. Of the 176 samples tested from children under 4 years of age, none were positive.IMPORTANCE This study determined the percentages of both children and adult samples from the greater St. Louis metropolitan area who had antibodies to SARS-CoV-2 in late April to early May 2020. Approximately 1.7 to 3.1% of the tested individuals had antibodies, indicating that they had previously been infected by SARS-CoV-2. These results demonstrate that the extent of infection was about 10 times greater than the number of confirmed cases at that time. Furthermore, it demonstrated that by 5 years of age, children were infected to an extent similar to that of adults.

Twenty-two Years of Pediatric Musculoskeletal Firearm Injuries: Adverse Outcomes for the Very Young

BACKGROUND

Firearm injuries are a significant cause of morbidity and mortality for children in the United States. The purpose of this study is to investigate the 22-year experience of pediatric firearm-related musculoskeletal injuries at a major pediatric level 1 hospital and to analyze the risk of adverse outcomes in children under 10 years of age.

METHODS

An institutional review board-approved, retrospective cohort analysis was conducted on pediatric firearm-related musculoskeletal injuries at our institution from 1995 to 2017. A total of 189 children aged 0 to 18 years were identified using International Classification of Diseases, 9th Revision/10th Revision codes, focusing on musculoskeletal injuries by firearms. Exclusion criteria were primary treatment at an outside hospital, isolated nonmusculoskeletal injuries (eg, traumatic brain injury), and death before orthopaedic intervention. Two cohorts were included: age below 10 years and age 10 years and above. Primary outcome measure was a serious adverse outcome (death, growth disturbance, amputation, or impairment). Standard statistical analysis was used for demographic data, along with linear mixed models and multivariable logistic regression for adverse outcome.

RESULTS

Of the 189 children, 46 (24.3%) were below 10 years of age and 143 (75.7%) were 10 years and above. Fifty-two (27.5%) of the total group had an adverse outcome, with 19 (41.3%) aged below 10 years and 33 (23.1%) aged 10 years and above (P=0.016). Adverse outcomes were 3 deaths, 17 growth disturbances, 7 amputations, and 44 impairments. For those below 10 years of age, rural location (P=0.024), need for surgical treatment (P=0.041), femur injury (P=0.032), peripheral nerve injury (P=0.006), and number of surgeries (P=0.022) were associated with an adverse outcome.

CONCLUSIONS

Over one fourth of survivors of musculoskeletal firearm injuries had an adverse outcome. Children 10 years and above represent the majority of firearm injuries in our population; however, when injured, those below 10 years are more likely to have an adverse outcome.

LEVEL OF EVIDENCE

Level III.

Using Lorenz Curves to Measure Racial Inequities in COVID-19 Testing

This cross-sectional study uses Lorenz curves as a metric for quantifying racial inequities in coronavirus disease 2019 (COVID-19) testing.

The Pandemic's Toll-A Case for Clinician Support

Healthcare providers perform lifesaving work in unusually stressful work environments due to the challenges and related risks of battling the unprecedented COVID-19 pandemic. The potential personal and professional toll is substantial. This article describes how one healthcare facility benefited from existing peer support resources to address workforce well-being, ensuring that resources were available to support workforce resilience throughout the protracted COVID response.

Predictors of long-term opioid use and opioid use disorder among construction workers: Analysis of claims data

BACKGROUND

Construction workers have high rates of work-related musculoskeletal disorders, which lead to frequent opioid use and opioid use disorder (OUD). This paper quantified the incidence of opioid use and OUD among construction workers with and without musculoskeletal disorders.

METHODS

We conducted a retrospective study using union health claims from January 2015 to June 2018 from 19,909 construction workers. Claims for diagnoses of chronic musculoskeletal disorders, acute musculoskeletal injuries, musculoskeletal surgery, and other conditions were linked to new opioid prescriptions. We examined the effects of high doses (≥50 morphine mg equivalents per day), large supply (more than 7 days per fill), long-term opioid use (60 or more days supplied within a calendar quarter), and musculoskeletal disorders, on the odds of a future OUD.

RESULTS

There were high rates (42.8% per year) of chronic musculoskeletal disorders among workers, of whom 24.1% received new opioid prescriptions and 6.3% received long-term opioid prescriptions per year. Workers receiving opioids for chronic musculoskeletal disorders had the highest odds of future OUD: 4.71 (95% confidence interval 3.09-7.37); workers prescribed long-term opioids in any calendar quarter had a nearly 10-fold odds of developing an OUD.

CONCLUSIONS

Among construction workers, opioids initiated for musculoskeletal pain were strongly associated with incident long-term opioid use and OUD. Musculoskeletal pain from physically demanding work is likely one driver of the opioid epidemic in occupations like construction. Prevention of work injuries and alternative pain management are needed for workers at risk for musculoskeletal injuries.

Lessons from Contact Tracing in Mid-Missouri

The public health community has used contact tracing to address pandemics since the eighteenth century. With the emergence of COVID-19, these classical skills are the primary defense for communities to limit morbidity and mortality during the pandemic. Here we describe the methods, strengths, and challenges of contact tracing.

Association of Changes in Missouri Firearm Laws With Adolescent and Young Adult Suicides by Firearms

IMPORTANCE

Suicide by firearm is a major cause of mortality in young Missouri residents. Changes in statewide firearm policy may have contributed to changes in suicide rates.

OBJECTIVE

To evaluate if changes in Missouri permit-to-purchase (PTP) and concealed carry firearm laws were associated with changes in rates of suicide by firearms in young Missouri residents.

DESIGN, SETTINGS, AND PARTICIPANTS

This cross-sectional study examined rates of suicide by firearm in Missouri among adolescents (ages 14-18 years) and young adults (ages 19-24 years) from January 1999 to December 2018, following changes to state PTP and concealed carry law, in comparison with a donor state pool with existing firearm laws (13 states in PTP pool; 42 states in concealed carry pool) that did not make changes during this period. This study used a quasiexperimental, synthetic control design at the state level that defined Missouri as the treated state and treatment as changes in firearm laws.

EXPOSURES

Legislative changes to Missouri's PTP and concealed carry firearm laws.

MAIN OUTCOMES AND MEASURES

Age-adjusted annual rates of firearm-related suicide mortality per 100 000 people for adolescents (aged 14-18 years) and young adults (aged 19-24 years).

RESULTS

Repeal of the PTP law was associated with a 21.8% increase in firearm suicide rates in young adults aged 19 to 24 years in Missouri. Lowering the minimum age of concealed carry to 19 years in Missouri was associated with a 32.0% increase in firearm suicide rates and a 29.7% increase in nonfirearm suicide rates in adolescents aged 14 to 18 years, and a 7.2% increase in firearm suicide rates in young adults aged 19 to 24 years.

CONCLUSIONS AND RELEVANCE

Increases in rates of suicide by firearms in adolescents and young adults were seen following repeal of Missouri's PTP law and lowering of the minimum age for concealed carry in 2014. Changes in Missouri's firearm policies may be an important contributor to rates of suicide by firearm in young Missouri residents.

Prior Interpersonal Violence Exposure and Experiences During and After a Disaster as Predictors of Posttraumatic Stress Disorder and Depression Among Adolescent Victims of the Spring 2011 Tornadoes

The purpose of the current report was to examine prior history of exposure to interpersonal violence (IPV), as compared with prior accident or prior disaster exposure, experiences during and after a disaster, and demographic variables as predictors of past month posttraumatic stress disorder (PTSD) and depression severity among adolescents exposed to the tornadoes in Alabama and Missouri. IPV exposure has been consistently identified as a unique category of potentially traumatic events (PTE) that significantly increases risk for development of PTSD and other difficulties relative to other event types among adolescents. A population-based sample of adolescents and caregivers (N = 2,000) were recruited randomly from tornado-affected communities in Alabama and Joplin, Missouri. Participants completed structured telephone interviews on an average of 8.8 months posttornado. Prior history of IPV was prevalent (36.5%), as was reported history of accidents (25.9%) and prior disaster exposure (26.9%). Negative binomial regression analyses with PTSD and depression symptom counts for past month as outcome variables indicated that history of predisaster IPV was most robustly related to PTSD and depression symptoms, such that those with a history of IPV endorsed over 3 times the number of symptoms than those without IPV history. Final model statistics indicated that female gender, physical injury to caregiver, concern about others' safety, prior disaster, prior accident, and prior IPV exposure were also related to PTSD. Predictors of depression symptoms were similar with the exception that concern about others' safety was not a predictor and age was a predictor in the final model. It is important to evaluate potential additive effects of IPV history in addition to recent disaster exposure variables and to consider such history when developing interventions aimed to reduce or prevent symptoms of PTSD and depression among adolescents recently exposed to disaster.