Understanding factors associated with COVID-19 vaccination among health care workers using the Diffusion of Innovation Theory

BACKGROUND

The COVID-19 vaccine was initially offered to frontline health care workers (HCWs), due to the high risk of contracting COVID-19 through occupational exposure to patients. Low HCW vaccine uptake can impact overall community-level vaccine uptake. This study used the Diffusion of Innovation (DOI) Theory to understand factors related to COVID-19 vaccine uptake in HCWs.

METHODS

We surveyed Pennsylvanian HCWs (excluding Philadelphia) from August 2022 to February 2023. Survey questions inquired about demographics, COVID-19 vaccination status, reasons for receiving/declining the COVID-19 vaccine, and sources of information about the vaccine.

RESULTS

Participants (n = 3,490) were 85% female, 89% White, and 93% (n = 3,255) reported receiving at least one dose of a COVID-19 vaccine. HCWs were categorized into adopter categories of the DOI Theory: innovators (56%), early adopters (9%), early majority (11%), late majority (7%), and laggards (17%). The major reason that prompted participants to get the vaccine was to protect them against COVID-19 infection (78%), while the major reason for declining the vaccine was due to concern about possible side effects from the vaccine (78%).

CONCLUSIONS

We applied the DOI Theory to characterize adopters and identify factors related to COVID-19 vaccine uptake in HCWs. As updated COVID-19 vaccines are approved for the United States market, our findings may be used to improve vaccine education and communication among HCWs to support vaccine uptake.

Potential Sexual Transmission of Antifungal-Resistant Trichophyton indotineae

We describe a case of tinea genitalis in an immunocompetent woman in Pennsylvania, USA. Infection was caused by Trichophyton indotineae potentially acquired through sexual contact. The fungus was resistant to terbinafine (first-line antifungal) but improved with itraconazole. Clinicians should be aware of T. indotineae as a potential cause of antifungal-resistant genital lesions.

Adapting COVID-19 Contact Tracing Protocols to Accommodate Resource Constraints, Philadelphia, Pennsylvania, USA, 2021

Because of constrained personnel time, the Philadelphia Department of Public Health (Philadelphia, PA, USA) adjusted its COVID-19 contact tracing protocol in summer 2021 by prioritizing recent cases and limiting staff time per case. This action reduced required staff hours to prevent each case from 21-30 to 8-11 hours, while maintaining program effectiveness.

The impact of syringe decriminalization within the Pennsylvania harm reduction community

INTRODUCTION

Syringe decriminalization is a harm reduction approach to decrease deaths and disease related to drug use. The purpose of this study was to develop an understanding of the impact of syringe decriminalization on the harm reduction community in Pennsylvania.

METHODS

Semi-structured interviews were conducted with ten participants identified as harm reduction experts.

ANALYSIS

Narrative content analysis to the point of thematic saturation was used to generate themes around harm reduction and syringe decriminalization in Pennsylvania, specifically the meaning of harm reduction, the importance of harm reduction, and the opinions on syringe decriminalization.

RESULTS

The following themes reflect the meaning of harm reduction: human compassion; meeting people where they are at; minimizing the risk; and shifting power to the person. The themes of being personally impacted, human compassion, innate imperfection, and respecting human autonomy reflect why participants care about harm reduction. All ten participants support syringe decriminalization in Pennsylvania citing the following rationales: improved health outcomes; decreased costs to society; less involvement of the criminal justice system; and increased engagement into treatment.

CONCLUSIONS

Harm reduction is a pioneering approach to drug use that empowers individuals to make positive impacts in their lives. Harm reduction experts in Pennsylvania support syringe decriminalization as a cost-effective way to increase the engagement and improve health outcomes of people who use drugs.

The Impact of the COVID-19 Pandemic on Cancer Mortality in Pennsylvania: A Retrospective Study with Geospatial Analysis

BACKGROUND

We sought to quantify the impact of the COVID-19 pandemic on cancer mortality and identify associated factors in Pennsylvania.

METHODS

The retrospective study analyzed cross-sectional cancer mortality data from CDC WONDER for 2015 through 2020 for Pennsylvania and its 67 counties. The spatial distributions of 2019, 2020, and percentage change in age-adjusted mortality rates by county were analyzed via choropleth maps and spatial autocorrelation. A Wilcoxon Signed Rank Test was used to analyze whether the rates differed between 2019 and 2020. Quasi-Poisson and geographically weighted regression at the county level were used to assess the association between the 2019 rates, sex (percent female), race (percent non-White), ethnicity (percent Hispanic/Latino), rural-urban continuum codes, and socioeconomic status with the 2020 rates.

RESULTS

At the state level, the rate in 2020 did not reflect the declining annual trend (-2.7 per 100,000) in the rate since 2015. Twenty-six counties had an increase in the rate in 2020. Of the factors examined, the 2019 rates were positively associated with the 2020 rates, and the impact of sociodemographic and geographic factors on the 2020 rates varied by county.

CONCLUSIONS

In Pennsylvania, the 2020 cancer mortality rates did not decline as much as reported before the COVID-19 pandemic. The top five cancer types by rate were the same type for 2019 and 2020. Future cancer control efforts may need to address the impact of the COVID-19 pandemic on trends and geospatial distribution in cancer mortality.

A Needs Assessment of Women Veterans in Western Pennsylvania: Final Report to Adagio Health

Women make up an increasingly large share of the U.S. veteran population, and their numbers continue to grow while the overall number of veterans is on the decline. Yet programs designed to support veterans' health and well-being have largely focused on men. Women's military experiences and postservice needs often differ from those of men, and women veterans also differ in significant ways from their nonveteran counterparts. Few studies have explored these variations, and this has translated to potentially missed opportunities to improve support for women during and after their transition from military to civilian life. Adagio Health, a provider of health, wellness, and nutrition services based in Western Pennsylvania, has taken steps to improve care for women veterans in its service area. To identify opportunities to further expand and enhance Adagio Health's efforts to support women veterans' health and wellness, the authors quantitatively and qualitatively assessed the needs of women veterans in the Adagio Health service area. The assessment provides a clearer picture of this often-underserved population, available services and resources, gaps in support, barriers to access, and areas to prioritize to provide the best support possible for the health and well-being of women who served. With the approaches recommended in this assessment, Adagio Health can continue increasing its capacities and capabilities for supporting its women veteran patients and making progress toward its goal of advancing their health and well-being.

A comparison of critical access hospitals and other rural acute care hospitals in Pennsylvania

PURPOSE

As the Flex Program celebrates its 25th anniversary, we examined changes in critical access hospital (CAH) financial performance, investigated whether CAH status has reduced hospitals' financial vulnerability, and identified factors influencing financial performance.

METHODS

We collected data on acute care hospitals in Pennsylvania's rural counties for 2000-20. Our sample contained 1,444 hospital-year observations. We used trend analysis to compare the financial performance of CAHs and rural prospective payment system (PPS) hospitals (non-CAHs). We investigated the effect of CAH status on financial performance and identified the time-variant factors impacting financial performance using fixed-effects regression analysis.

RESULTS

The median total margin of CAHs lagged behind that of non-CAHs. When compared to non-CAH costs over the same period, the median cost per patient day incurred by CAHs has increased, with the rate of increase being significantly higher in the most recent decade. Our findings show that while CAH status does not appear to have a direct impact on the total margin, it is significantly associated with a higher cost per patient day.

CONCLUSIONS

CAHs in Pennsylvania appear to be facing a double whammy of declining margins and rising costs compared to non-CAHs. Our findings demonstrate how crucial the Flex program has been in sustaining CAHs in Pennsylvania ever since its inception. Our findings have implications for rural health care delivery as well. While providing financial support and operational flexibility to CAHs should be a continuing policy priority, a long-term policy goal should be to envision an economic development strategy that capitalizes on the unique strengths of each of the rural archetypes.

Physicians' Perspectives on Their Training for and Role Within Pennsylvania's Medical Cannabis Program

BACKGROUND

Physicians' ability to guide their patients on the use of medical cannabis can vary widely and is often shaped by their training, experiences, and the regulations and policies of their state. The goal of this qualitative study is to understand how prepared physicians are to certify and advise their patients to use medical cannabis. A secondary goal is to explore how physicians integrate certification into their clinical practices, and what factors shape their decisions and behaviors around certification.

METHOD

Using semi-structured interviews with 24 physicians authorized to certify patients to use medical cannabis in Pennsylvania, a state with a medical access only program, we explored how physicians are trained and set up their practices. Interviews were analyzed using a blend of directed and conventional, and summative content analysis.

RESULTS

Three main themes emerged from the data around training, system-level factors, and practice-level factors that shaped how physicians are trained and practice medical cannabis certification. Although participants were largely satisfied with their CME training, they noted areas for improvement and a need for more high-quality research. Participants also noted system-level factors that prohibited treating cannabis as a traditional medical therapy, including communication barriers between physicians and dispensaries and confusion about insurance coverage for certification exams.

CONCLUSION

Physicians require additional training to improve the operation of the medical cannabis program in Pennsylvania. Participants suggested that the program could be improved by reducing communication barriers between them, their patients, and the dispensaries around the product purchase, selection, use, and effectiveness of medical cannabis.

Enrollee characteristics and receipt of colorectal cancer testing in Pennsylvania after adoption of the Affordable Care Act Medicaid expansion

BACKGROUND

Colorectal cancer (CRC) is the fourth most common cancer and the second leading cause of cancer-related death in the U.S. Despite increased CRC screening rates, they remain low among low-income non-older adults, including Medicaid enrollees who are more likely to be diagnosed at advanced stages.

OBJECTIVES

Given limited evidence regarding CRC screening service use among Medicaid enrollees, we examined multilevel factors associated with CRC testing among Medicaid enrollees in Pennsylvania after Medicaid expansion in 2015.

RESEARCH DESIGN

Using the 2014-2019 Medicaid administrative data, we performed multivariable logistic regression models to assess factors associated with CRC testing, adjusting for enrollment length and primary care services use.

SUBJECTS

We identified 15,439 adults aged 50-64 years newly enrolled through Medicaid expansion.

MEASURES

Outcome measures include receiving any CRC testing and by modality.

RESULTS

About 32% of our study population received any CRC testing. Significant predictors for any CRC testing include being male, being Hispanic, having any chronic conditions, using primary care services ≤4 times annually, and having a higher county-level median household income. Being 60-64 years at enrollment, using primary care services >4 times annually, and having higher county-level unemployment rates were significantly associated with a decreased likelihood of receiving any CRC tests.

CONCLUSIONS

CRC testing rates were low among adults newly enrolled in Medicaid under the Medicaid expansion in Pennsylvania relative to adults with high income. We observed different sets of significant factors associated with CRC testing by modality. Our findings underscore the urgency to tailor strategies by patients' racial, geographic, and clinical conditions for CRC screening.

Exploring Prenatal Care Quality and Access During the COVID-19 Pandemic Among Pregnant Immigrants in Philadelphia Through the Lens of Community-Based Organizations

Background

The peak of the COVID-19 pandemic led to decreased maternal and child health care engagement, especially among marginalized populations. Existing disparities in prenatal care access and quality faced by pregnant immigrant people are likely to be amplified by the pandemic.

Materials and Methods

We conducted a study with direct service providers (DSPs) at community-based organizations (CBOs) serving pregnant immigrant families in the Philadelphia region. Semistructured interviews addressed barriers and facilitators to prenatal health care access and engagement among immigrant families both before and then after the onset of the pandemic in March 2020. Additional questions elicited context about the demographics of service populations, organizational connectedness to health care providers, and pandemic-related operational changes.

Results

Between June and November 2021, 10 interviews were conducted in English and Spanish with DSPs at 5 CBOs. Primary themes included diminished access and quality of care received due to decreased language accessibility, increased restrictions around support persons, shifts to telemedicine, and changes to appointment scheduling. Additional themes included heightened hesitancy engaging with services due to documentation status, confusion around legal rights, financial strain, and health insurance status. Interviewees provided suggestions for improving service access during and postpandemic for immigrant pregnant people, including implementation of culturally responsive group prenatal care, institutional policies to improve understanding of legal rights, and increased financial supports.

Conclusions

Understanding emergent and exacerbated barriers to prenatal care access and quality during the COVID-19 pandemic provides context for how to improve health equity for immigrant pregnant people through public health and health care policies as the pandemic continues, and once it has subsided.

USE OF A POINT OF CARE TEST TO DETERMINE THE PREVALENCE OF ANTIBODIES TO TOXOPLASMA GONDII IN BLACK BEARS FROM NORTH CAROLINA AND PENNSYLVANIA

Toxoplasma gondii is an important protozoan parasite of humans and animals throughout the world. Black bears are among the animals with the highest seroprevalence of T. gondii in the United States. A rapid point of care (POC) test is commercially available to detect antibodies to T. gondii in humans. We evaluated the utility of the POC test to detect anti-T. gondii antibodies in 100 wild black bears from North Carolina (n = 50) and Pennsylvania (n = 50). In a blind study, sera were tested by the POC test, and results were compared to the modified agglutination test (MAT). Overall, anti-T. gondii antibodies were detected in 76% (76/100) black bears by both MAT and POC tests. One false positive and one false negative result in the POC test were obtained in bears from Pennsylvania. The sensitivity and specificity of the POC test were both 99% when compared to the MAT. Results from our study indicate the POC test could be a useful screening tool for serological surveillance of T. gondii in black bears.

Echinococcus Species Infections among Wild Canids in Pennsylvania, USA

Echinococcus species are zoonotic tapeworms that can impact the health of wildlife, domestic animals, livestock, and humans. Two species of interest in North America are Echinococcus multilocularis and Echinococcus canadensis (Echinococcus granulosus sensu lato). The primary wildlife definitive hosts for E. multilocularis and E. canadensis are similar, including red foxes (Vulpes vulpes), gray foxes (Urocyon cinereoargenteus), coyotes (Canis latrans), and wolves (Canis lupus). These two Echinococcus spp. use different intermediate hosts, including small mammals for E. multilocularis and artiodactylids for E. canadensis. Although historically absent from much of the eastern US, recent reports in new US states (e.g., Virginia, Vermont, Maine, Missouri) highlight the need for Echinococcus spp. surveillance in this region. During 2019-2020, 308 gastrointestinal tracts were collected from wild canids in Pennsylvania and microscopically screened for adult Echinococcus species. Two coyotes (2/155) were co-infected with both E. multilocularis and E. canadensis as determined by molecular confirmation. No red foxes (n=137) or gray foxes (n=16) were positive. These data indicate both Echinococcus species are present in Pennsylvanian coyotes, highlighting the need to understand the ecological and epidemiological consequences for human and animal health better.

First Report of Pectobacterium brasiliense Causing Bacterial Blackleg and Soft Rot of Potato in Pennsylvania

Potato (Solanum tuberosum) plants showing blackleg and soft rot symptoms were collected at a commercial vegetable farm near Newmanstown, PA in August 2021 (Fig. S1). The incidence of potato blackleg in the unirrigated field was about 5 to 8%, but approximately 30% in the irrigated field. The diseased stems were cut into 5 cm and surface disinfected. The stem segments were placed into a 50-mL tube containing 15 mL of sterile water for 15 min for bacterial release. The bacterial suspension was streaked on crystal violet polypectate (CVP) (Hélias et al. 2012) plates and incubated at 28°C for 48 h. Three single colonies produced pits on CVP were picked and purified. Genomic DNA of all three isolates were extracted using the FastDNA Spin Kit (MP Biomedicals, Santa Ana, CA). Polymerase chain reaction (PCR) was performed using all three extracted DNAs as a template with the primer pairs gapA 7F/938R (Cigna et al. 2017), recA F/R (Waleron et al. 2001), dnaA F/R (Schneider et al. 2011) and dnaX F/R (Sławiak et al. 2009) targeting the gapA, recA, dnaA and dnaX genes, respectively. Isolate 21PA01 was further studied as a representative isolate. PCR amplicons derived from both forward and reverse primers were sequenced and analyzed using the BLAST algorithm against the NCBI database (https://www.ncbi.nlm.nih.gov). The regions of gapA (GenBank accession No. ON989738), recA (ON989739), dnaA (OP121183), and dnaX (OP121184) had 99.86%, 100%, 98.88%, and 100% identities with Pectobacterium brasiliense strains S1.16.01.3M (MN167062.1), BL-2 (MW721598.1), IPO:4132 (CP059956.1), and BL-2 (MW721603.1), respectively. A phylogenetic maximum-likelihood tree of the concatenated genes with the length of 2551 bp was constructed to visualize the relationship among different species of Dickeya and Pectobacterium. As a result, 21PA01 was in a single monophyletic cluster with other Pectobacterium brasiliense reference strains (Fig. S2 C). To confirm the pathogen, Koch's postulates were performed. Seed pieces of potato 'Lamoka' were planted in potting mix in one-gallon plastic pots in a greenhouse. Three weeks after emergence, the stems of three plants were each injected with 10 µL of bacteria suspension of either 21PA01 at 107 CFU/mL, P. parmentieri ME175 in tryptic soy broth (TSB) at 107 CFU/mL or TSB at 2 cm above the soil line. Seven days after inoculation, stems inoculated with 21PA01 and ME175 showed black and rotten symptoms, whereas the TSB-injected control plants remained symptomless. In addition, 'Lamoka' tubers were inoculated by placing 10 µL 21PA01 and ME175 suspensions at 107 CFU/mL, and TSB in a 1-cm-deep hole poked in a tuber separately and then sealed with petroleum gel, followed by incubation in a moist chamber at 22 °C for 4 d. The 21PA01 and ME175 inoculated tubers showed soft rot symptoms, but the TSB treatment had no symptoms. Bacterial colonies were isolated from the infected stems and confirmed by the DNA sequences as described above. PCR result was negative on control plant samples. Both stem and tuber inoculation trials were repeated two times, and the results were consistent. Thus, 21PA01 was identified as Pectobacterium brasiliense. To our knowledge, this is the first report of P. brasiliense infecting potatoes in Pennsylvania, USA, although it has been reported somewhere else (van der Merwe et al. 2010, Zhao et al. 2018). This could be a new species in Northeastern US.

Pregnancy Outcomes in Patients Enrolled in the Healthy Beginnings Plus Program

OBJECTIVE

To evaluate the effectiveness of enrollment in the Healthy Beginnings Plus Program (HB) on pregnancy outcomes.

DESIGN

Retrospective cohort study of 12,299 singleton pregnancies birthed between January 2007 and December 2018.

SETTING/LOCAL PROBLEM

Individuals of low socioeconomic status are at increased risk for adverse pregnancy outcomes, such as preterm birth (PTB) and low-birth-weight (LBW) neonates. Pennsylvania offers HB to pregnant individuals with Medical Assistance insurance to provide additional psychosocial and obstetric resources to routine prenatal care to minimize risk.

PARTICIPANTS

Individuals with Medical Assistance insurance enrolled in HB (n = 4,645), individuals with Medical Assistance insurance not enrolled in HB (n = 2,874), and individuals with private insurance (n = 4,780).

MEASUREMENTS

Primary outcomes were rates of PTB and LBW neonates. Secondary outcomes included rates of gestational diabetes, gestational hypertension, small-for-gestational-age neonates, and admission to the NICU.

RESULTS

There were no differences in PTB (adjusted OR [aOR] = 0.93, 95% confidence interval [CI] [0.76, 1.13]) or LBW neonates (aOR = 1.06, 95% CI [0.86, 1.31]) between individuals with Medical Assistance enrolled in HB versus those with Medical Assistance insurance not enrolled in HB. Individuals with Medical Assistance enrolled in HB were less likely to develop gestational hypertension compared to individuals with Medical Assistance insurance not enrolled in HB (aOR = 1.41, 95% CI [1.25, 1.59]) and individuals with private insurance (aOR = 0.85, 95% CI [0.76, 0.96]). They also attended more prenatal visits than individuals with Medical Assistance insurance not enrolled in HB (12.0 vs. 14.0, p < .01).

CONCLUSION

Although there was no significant difference between groups for the primary outcomes studied, individuals with Medical Assistance insurance enrolled in HB attended more prenatal visits than those who did not enroll in HB. Similar programs should evaluate outcomes and consider whether changes are needed.

Estimated Cases Averted by COVID-19 Digital Exposure Notification, Pennsylvania, USA, November 8, 2020-January 2, 2021

We combined field-based data with mathematical modeling to estimate the effectiveness of smartphone-enabled COVID-19 exposure notification in Pennsylvania, USA. We estimated that digital notifications potentially averted 7-69 cases/1,000 notifications during November 8, 2020-January 2, 2021. Greater use and increased compliance could increase the effectiveness of digital notifications.

Geographic variations in opioid overdose patterns in Pennsylvania during the COVID-19 pandemic

The convergence of the opioid epidemic and the COVID-19 pandemic has created new health challenges throughout the United States. Since the onset of the pandemic, media attention and scholarly research have drawn attention to the intersections of addiction and COVID-19. However, there remain few empirical studies that examine the direct impacts of the COVID-19 pandemic for opioid overdose patterns. Even fewer have integrated quantitative and qualitative methods to detail the place-specific dynamics shaping opioid overdose and addiction treatment during the COVID-19 pandemic. This article measures and maps change in the age-adjusted rate of opioid-related overdose incidents at the county level from 2018 to 2020. These analyses are combined with interviews conducted since December 2020 with public health providers in the state of Pennsylvania to identify the key factors influencing opioid misuse and transformations in addiction treatment practices.

Alcohol, nicotine, and COVID-19: A retrospective study of health outcomes in central Pennsylvania

Individuals with substance abuse disorder are at increased risk for the development of severe disease following COVID-19 infection. Furthermore, individuals in rural populations where access to healthcare is limited and rates of substance abuse tend to be higher are at increased risk compared to other regions. The Penn State Health Network serves 29 counties in central Pennsylvania that are largely rural. The current study assessed the electronic medical records for individuals in this population that were reported as having alcohol dependence, nicotine dependence or both (co-users) in addition to individuals with no history of drug use and the rate of developing primary and secondary health outcomes following COVID-19 infection. All patients in this study were determined to be COVID+ while in care. We found that overall, risk for requiring ventilation, developing pneumonia, and mortality within 30 days of diagnosis all increased with any substance use history, across both males and females and across all age groups. Moreover, rates of these outcomes were considerably higher in patients that were both alcohol and nicotine dependent suggesting additive effects of co-use. Rates of secondary effects also increased substantially across all use categories with these patients showing greater risk of developing liver, kidney, and pancreas maladies compared to patients with no history of substance use. Taken together, these findings reinforce previous studies showing that substance use increases the risks of significant disease following COVID-19 infection, giving insights into the health disparities that exist in rural populations.

Development and Validation of Simple Risk Scores to Predict Hospitalization in Outpatients with COVID-19 Including the Omicron Variant

Outpatient physicians need guidance to support decisions regarding hospitalization of COVID-19 patients and how closely to follow outpatients. Thus, we sought to develop and validate simple risk scores to predict hospitalization for outpatients with COVID-19 that do not require laboratory testing or imaging. METHODS: We identified outpatients 12 years and older who had a positive polymerase chain reaction test for SARS-CoV-2. Logistic regression was used to derive a risk score in patients presenting before March, 2021, and it was validated in a cohort presenting from March to September 2021 and an Omicron cohort from December, 2021 to January, 2022. RESULTS: Overall, 4.0% of 5843 outpatients in the early derivation cohort (before 3/1/21), 4.2% of 3806 outpatients in the late validation cohort, and 1.2% in an Omicron cohort were hospitalized. The base risk score included age, dyspnea, and any comorbidity. Other scores added fever, respiratory rate and/or oxygen saturation. All had very good overall accuracy (AUC 0.85-0.87) and classified about half of patients into a low-risk group with < 1% hospitalization risk. Hospitalization rates in the Omicron cohort were 0.22%, 1.3% and 8.7% for the base score. Two externally derived risk scores identified more low risk patients, but with a higher overall risk of hospitalization than our novel risk scores. CONCLUSIONS: A simple risk score suitable for outpatient and telehealth settings can classify over half of COVID-19 outpatients into a very low risk group with a 0.22% hospitalization risk in the Omicron cohort. The Lehigh Outpatient COVID Hospitalization (LOCH) risk score is available online as a free app: https://ebell-projects.shinyapps.io/LehighRiskScore/.

An Observational Cross-Sectional Survey Exploring the Indications for and Responses to Medical Marijuana Use in Certified Patients in Pennsylvania

INTRODUCTION/OBJECTIVES

Medical cannabis programs across the country vary and differ in their qualifying conditions for medical cannabis use. This has led to a gap in knowledge regarding the specific needs of cannabis patients, including the most common reason patients seek medical cannabis. The purpose of this study was to examine the current needs of medical cannabis patients in order to better inform future research, and to evaluate potential needs in policy changes in states with more restrictive qualifying conditions for medical cannabis use.

METHODS

A cross-sectional survey study was administered (n = 207) at a Laurel Harvest Labs dispensary in Pennsylvania. Participants were qualified medical cannabis users and were recruited as a convenience sample when entering the dispensary. The survey asked questions regarding participant demographics, medical cannabis qualifying conditions, usage, methods of administration, adverse effects, tolerance, and impact of medical cannabis on medication, alcohol, and tobacco use. Chi-squared or Fisher's exact tests were conducted for analyses involving categorical data.

RESULTS

The mean age of respondents was 36.7 years (SD = 12.8), and the majority were male (61.4%) and white (84.7%). Respondents self-reported that anxiety disorder was the most common qualifying medical condition and the most common comorbid condition (50.1%; 69.3%) for medical cannabis use. Additionally, approximately 95% of users reported having no adverse effects from using medical cannabis, and 90% of users preferred inhalation through vaporization as the preferred method of consumption. More than 50% of participants reported an improvement in their symptoms where only 20% of users reported being tolerant to their current dose. More than 70% of respondents reported that obtaining medical cannabis was "easy" and 54% of users reported that the cost of medical cannabis was not a barrier to access.

CONCLUSIONS

Anxiety disorder is a prevalent condition for which medical cannabis is used; however, many states do not recognize anxiety disorder as a qualifying condition for medical cannabis. Further research on medical cannabis use for anxiety disorders is needed to evaluate proper dosing and responses to treatment.

Development and Validation of Simple Risk Scores to Predict Hospitalization in Outpatients with COVID-19 Including the Omicron Variant

INTRODUCTION

Outpatient physicians need guidance to support decisions regarding hospitalization of COVID-19 patients and how closely to follow outpatients. Thus, we sought to develop and validate simple risk scores to predict hospitalization for outpatients with COVID-19 that do not require laboratory testing or imaging. METHODS: We identified outpatients 12 years and older who had a positive polymerase chain reaction test for SARS-CoV-2. Logistic regression was used to derive a risk score in patients presenting before March, 2021, and it was validated in a cohort presenting from March to September 2021 and an Omicron cohort from December, 2021 to January, 2022. RESULTS: Overall, 4.0% of 5843 outpatients in the early derivation cohort (before 3/1/21), 4.2% of 3806 outpatients in the late validation cohort, and 1.2% in an Omicron cohort were hospitalized. The base risk score included age, dyspnea, and any comorbidity. Other scores added fever, respiratory rate and/or oxygen saturation. All had very good overall accuracy (AUC 0.85-0.87) and classified about half of patients into a low-risk group with < 1% hospitalization risk. Hospitalization rates in the Omicron cohort were 0.22%, 1.3% and 8.7% for the base score. Two externally derived risk scores identified more low risk patients, but with a higher overall risk of hospitalization than our novel risk scores. CONCLUSIONS: A simple risk score suitable for outpatient and telehealth settings can classify over half of COVID-19 outpatients into a very low risk group with a 0.22% hospitalization risk in the Omicron cohort. The Lehigh Outpatient COVID Hospitalization (LOCH) risk score is available online as a free app: https://ebell-projects.shinyapps.io/LehighRiskScore/.

Infection with SARS-CoV-2 Omicron Variant 24 Days after Non-Omicron Infection, Pennsylvania, USA

A 42-year-old man, with up-to-date COVID-19 vaccination, experienced symptomatic SARS-CoV-2 infection in December 2021. Mutation tests suggested a non-Omicron variant. After his recovery, and 24 days after the first positive SARS-CoV-2 test, he had onset of symptomatic infection with the BA.1.1 (Omicron) variant, which was confirmed by whole-genome sequencing.

Fatal Fungicide-Associated Triazole-Resistant Aspergillus fumigatus Infection, Pennsylvania, USA

We report a fatal infection in a 65-year-old immunocompromised male patient caused by pan-triazole-resistant Aspergillus fumigatus containing a TR₃₄/L98H genetic mutation linked to agricultural fungicide use. Clinical and environmental surveillance of triazole-resistant A. fumigatus is needed in the United States to prevent spread and guide healthcare and agricultural practices.

Identification of spatio-temporal clusters of lung cancer cases in Pennsylvania, USA: 2010-2017

Background

It is known that geographic location plays a role in developing lung cancer. The objectives of this study were to examine spatio-temporal patterns of lung cancer incidence in Pennsylvania, to identify geographic clusters of high incidence, and to compare demographic characteristics and general physical and mental health characteristics in those areas.

Method

We geocoded the residential addresses at the time of diagnosis for lung cancer cases in the Pennsylvania Cancer Registry diagnosed between 2010 and 2017. Relative risks over the expected case counts at the census tract level were estimated using a log-linear Poisson model that allowed for spatial and temporal effects. Spatio-temporal clusters with high incidence were identified using scan statistics. Demographics obtained from the 2011–2015 American Community Survey and health variables obtained from 2020 CDC PLACES database were compared between census tracts that were part of clusters versus those that were not.

Results

Overall, the age-adjusted incidence rates and the relative risk of lung cancer decreased from 2010 to 2017 with no statistically significant space and time interaction. The analyses detected 5 statistically significant clusters over the 8-year study period. Cluster 1, the most likely cluster, was in southeastern PA including Delaware, Montgomery, and Philadelphia Counties from 2010 to 2013 (log likelihood ratio = 136.6); Cluster 2, the cluster with the largest area was in southwestern PA in the same period including Allegheny, Fayette, Greene, Washington, and Westmoreland Counties (log likelihood ratio = 78.6). Cluster 3 was in Mifflin County from 2014 to 2016 (log likelihood ratio = 25.3), Cluster 4 was in Luzerne County from 2013 to 2016 (log likelihood ratio = 18.1), and Cluster 5 was in Dauphin, Cumberland, and York Counties limited to 2010 to 2012 (log likelihood ratio = 17.9). Census tracts that were part of the high incidence clusters tended to be densely populated, had higher percentages of African American and residents that live below poverty line, and had poorer mental health and physical health when compared to the non-clusters (all p < 0.001).

Conclusions

These high incidence areas for lung cancer warrant further monitoring for other individual and environmental risk factors and screening efforts so lung cancer cases can be identified early and more efficiently.

Covid-19 vaccine acceptance and associated factors among pregnant women in Pennsylvania 2020

Data on factors associated with vaccine acceptance among pregnant women are critical to the rapid scale up of interventions to improve vaccine uptake. When COVID-19 vaccines were still in the testing phases of research, we surveyed pregnant women accessing prenatal care at an academic medical institution in Central Pennsylvania, United States to examine factors associated with vaccine acceptance. Willingness to receive a COVID-19 vaccine once a vaccine became available was asked as part of an ongoing study on the COVID-19 pandemic and pregnancy (n = 196). Overall, 65% of women reported they would be willing or somewhat willing to receive the COVID-19 vaccine. Women who had received an influenza vaccine within the past year were more likely to be willing to receive the COVID-19 vaccine than women who had never received an influenza vaccine or those who received it over one year ago (aOR 4.82; 95% CI 2.17, 10.72). Similarly, women who were employed full-time were more willing to receive the COVID-19 vaccine than women who were not employed full time (aOR 2.22; 95% CI 1.02, 4.81), and women who reported feeling overloaded were more willing to receive the COVID-19 vaccine than women who did not feel overloaded (aOR 2.18; 95% CI 1.02, 4.68). Our findings support the need to increase vaccination education among pregnant women before vaccines are rolled out, especially those who have not received an influenza vaccine within the past year. Improved understanding of willingness to vaccinate among pregnant women will improve future pandemic responses and current vaccination efforts.

High Prevalence of Antibodies against Canine Parvovirus and Canine Distemper Virus among Coyotes and Foxes from Pennsylvania: Implications for the Intersection of Companion Animals and Wildlife

Canine distemper virus (CDV) and Canine parvovirus (CPV) can cause deadly infections in wildlife and companion animals. In this report, we screened serum from free-ranging eastern coyotes (Canis latrans; N = 268), red foxes (Vulpes vulpes; N = 63), and gray foxes (Urocyon cinereoargenteus; N = 16) from Pennsylvania, USA, for antibodies (Abs) to CDV and CPV. This comprehensive screening was achieved using a commercially available enzyme-linked immunosorbent assay (ELISA)-based colorimetric assay. Abs to CDV and CPV were detected in 25.4% and 45.5% of coyotes, 36.5% and 52.4% of red foxes, and 12.5% and 68.8% of gray foxes, respectively. Abs to both viruses were detected in 9.7% of coyotes, 19.1% of red foxes, and 12.5% of gray foxes. This study demonstrates significant wildlife exposure in a northeastern state to CDV and CPV. As wildlife species continue to urbanize, the probability of spillover between domestic animals and wildlife will increase. Ongoing surveillance of wildlife for CDV and CPV exposure is warranted.

IMPORTANCECanine distemper virus (CDV) and Canine parvovirus (CPV) are significant health threats to domestic dogs (Canis familiaris) and wildlife. CDV and CPV have been identified in diverse vertebrates, including endangered wildlife species. Susceptibility to these viral pathogens varies significantly among geographic regions and between host species. High morbidity and mortality have been reported with infection by either virus in susceptible species, including dogs. As humans and companion animals encroach on wildlife habitat, and as wildlife becomes increasingly urbanized, the potential for transmission between species increases. This study assessed CPV and CDV Ab prevalence in wild canids (eastern coyotes, red foxes, and gray foxes) harvested in Pennsylvania between 2015 and 2020. High Ab prevalence was demonstrated for both viruses in each species. Ongoing monitoring of CPV and CDV in wildlife and increased efforts to vaccinate dogs and prevent spillover events are essential.

Implementation of buprenorphine initiation and warm handoff protocols in emergency departments: A qualitative study of Pennsylvania hospitals

BACKGROUND

Emergency departments (ED) are a critical touchpoint for patients with opioid use disorder (OUD). In 2019, Pennsylvania had the fifth highest drug overdose mortality rate in the United States. State efforts have focused on implementing evidence-based ED care protocols, including induction of buprenorphine and warm handoffs to community treatment.

OBJECTIVE

We examined hospital staff's perspectives on the processes, challenges, and facilitators to buprenorphine initiation and warm handoff protocols in the ED.

METHODS

We used a qualitative case study design to focus on six Pennsylvania hospitals. The study selected hospitals using purposive sampling to capture varying hospital size, rurality, teaching status, and phase of protocol implementation. The study staff interviewed hospital staff with key roles in OUD care delivery in the ED, which included administrators, physicians, nurses, recovery support professionals, care coordinators, a social worker, and a pharmacist. Guided by the Consolidated Framework for Implementation Research (CFIR), we conducted semi-structured virtual interviews with 21 key informants from June to November 2020. Interviews were transcribed, deductively coded, and analyzed using CFIR domains and constructs to summarize factors influencing implementation of OUD ED care protocols and warm handoff to care protocols, as well as suggestions that emerged between and across cases.

RESULTS

Despite variation in the local context between hospitals, we identified common themes that influenced buprenorphine and warm handoffs across sites. Attention to hospital OUD care through state-level initiatives like the Hospital Quality Improvement Program generated hospital leadership buy-in toward implementing best OUD care practices. Factors at the hospital-level that influenced implementation success included supporting interdisciplinary OUD care champions, addressing knowledge gaps and biases around patients with OUD, having data systems that capture OUD care and integrate clinical protocols, incorporating patient comorbidities and non-medical needs into care, and fostering community provider linkages and capacity for warm handoffs. Although themes were largely consistent among hospital and staff types, protocol implementation was tailored by each hospital's size, patient volume, and hospital and community resources.

CONCLUSIONS

By understanding frontline staff's perspectives around factors that impact OUD care practices in the ED, stakeholders may better optimize implementation efforts.

Characterization of Avian Pox in a Ruffed Grouse (Bonasa umbellus) from Pennsylvania

A free-ranging, adult male ruffed grouse (Bonasa umbellus) was harvested by a hunter during November 2019 in Forest County, PA. The bird was submitted for necropsy due to a skin mass on its left leg. Upon necropsy, two proliferative skin masses were grossly visible, one on the left leg and one on the cere. An additional mass was present on the oropharyngeal mucosa covering the hard palate. These masses were diagnosed as avian pox based on histopathologic and cytologic findings, including marked epithelial hypertrophy, hyperplasia, vacuolar degeneration with eosinophilic stippling, and intracytoplasmic inclusion bodies. An avipoxvirus was detected using PCR and was identified as fowlpox virus through sequencing of the 4b core gene segment. The avipoxvirus from this case showed genetic similarity to isolates from Eastern wild turkeys (Meleagris gallopavo silvestris).

Spatial and temporal variations in indoor radon concentrations in Pennsylvania, USA from 1988 to 2018

Indoor radon poses one of the most significant environmental threats to public health as it is the second leading cause of lung cancer in the United States. Developing a more thorough understanding of the factors that affect radon concentrations is key for developing risk maps, identifying where testing should be a priority, and education about indoor radon exposure. The objectives of this study are to investigate seasonal and annual variation of indoor radon concentrations in Pennsylvania, USA from 1988 to 2018, to explore the hotspot areas for high indoor radon concentrations, and to analyze the association with various factors such as weather conditions, housing types, and floor levels. Based on a total of 1,808,294 radon tests conducted from 1988 to 2018, we found that 61% of the area (by zip codes), 557,869 tests conducted in the basement and 49,141 tests conducted on the ground floor in homes in Pennsylvania had higher radon levels than the U.S. EPA action level concentration of 148 Bq/m³ (equivalent to 4 pCi/L). Winter and fall had significantly higher indoor radon concentrations than summer and spring. Case studies conducted in Pittsburgh, Philadelphia, and Harrisburg showed that there was no significant correlation of daily temperature, precipitation, or relative humidity with indoor radon concentration on the day a radon test occurred.

Borrelia burgdorferi Sensu Stricto DNA in Field-Collected Haemaphysalis longicornis Ticks, Pennsylvania, United States

We collected questing Haemaphysalis longicornis ticks from southeastern counties of Pennsylvania, USA. Of 263 ticks tested by PCR for pathogens, 1 adult female was positive for Borrelia burgdorferi sensu stricto, yielding a 0.4% infection rate. Continued monitoring of this invasive tick is essential to determine its public health role.

Rise in Babesiosis Cases, Pennsylvania, USA, 2005-2018

Babesiosis is an emerging infection in the state of Pennsylvania, and clinicians need to be made aware of its clinical manifestations as well as the risk factors associated with severe disease. Before 2010, our tertiary academic center in central Pennsylvania previously saw zero cases of babesiosis. We saw our first confirmed case of Babesia infection acquired in Pennsylvania in 2011; we recorded 2 confirmed cases in 2017 and 4 confirmed cases in 2018. All 4 cases from 2018 were thought to be acquired in southcentral Pennsylvania counties, whereas prior reports of cases were predominately in the southeast and northeast counties of the state.

Surveillance for Babesia odocoilei in Hunter-Harvested Wild-Elk (Cervus elaphus canadensis) from Pennsylvania, USA (2016-2017)

Babesia odocoilei is a tick-borne protozoal parasite which infects the erythrocytes of members of the families Cervidae and Bovidae. Infection can result in hemolytic anemia, lethargy, anorexia, and death. The reservoir host of B. odocoilei is the white-tailed deer (Odocoileus virginianus); however, infections with overt disease have only been documented in reindeer (Rangider tarandu tarandus), caribou (Rangider tarandu caribou) and captive elk (Cervus elaphus canadensis). Infected elk may remain asymptomatic, creating the risk for dissemination of the pathogen when elk are relocated. Additionally, infected asymptomatic elk may contribute to the spread of B. odocoilei in the local wildlife/captive population via feeding ticks. Information regarding endemic regions of B. odocoilei infection is limited due to frequent asymptomatic infections and a lack of targeted surveillance of B. odocoilei in wildlife. To obtain data on B. odocoilei infection in wild elk in Pennsylvania, we tested blood samples collected from 190 hunter-harvested wild elk between 2016 and 2017. Of the 190 blood samples tested, 18.4% (35/190) tested positive for Babesia spp. Genetic sequencing of the positive samples showed a 98.0–100.0% match for B. odocoilei. No other Babesia species were identified. Results of this study documents B. odocoilei infection within hunter-harvested wild elk from Pennsylvania.

Distribution and Density of Haemaphysalis longicornis (Acari: Ixodidae) on Public Lands in Pennsylvania, United States

Since the recent introduction of the Asian longhorned tick (Haemaphysalis longicornis Neumann) in the United States, quantitative surveillance information remains lacking, which hinders accurate estimates of population structure and entomological risk. We conducted statewide, active tick surveillance from May to August 2019 and report data on H. longicornis geographical distribution and population density in Pennsylvania. In total, 615 H. longicornis were collected from four counties. Across samples recovering H. longicornis, mean density of H. longicornis was 9.2/100 m2, comparably greater than Ixodes scapularis Say (8.5/100 m2). Density of H. longicornis was also significantly greater in August, largely driven by larvae, and greater in recreational habitat types (12.6/100 m2) and in Bucks County (11.7/100 m2), situated adjacent to the location of the first U.S. discovery of intense infestations. These data are among the first to document H. longicornis from statewide tick surveillance and provide initial measures of population density enabling more quantitative characterizations of distributional patterns.

Impact of Coronavirus Disease 2019 Shutdown on Neurotrauma Volume in Pennsylvania

OBJECTIVE

The 2020 coronavirus disease 2019 (COVID-19) pandemic resulted in state-specific quarantine protocols and introduced the concept of social distancing into modern parlance. We assess the impact of the COVID-19 pandemic on neurotrauma presentations in the first 3 months after shutdown throughout Pennsylvania.

METHODS

The Pennsylvania Trauma Systems Foundation was queried for registry data from the Pennsylvania Trauma Outcomes Study between March 12 and June 5 in each year from 2017 to 2020.

RESULTS

After the COVID-19 shutdown, there was a 27% reduction in neurotrauma volume, from 2680 cases in 2017 to 2018 cases in 2020, and a 28.8% reduction in traumatic brain injury volume. There was no significant difference in neurotrauma phenotype incurred relative to total cases. Injury mechanism was less likely to be motor vehicle collision and more likely caused by falls, gunshot wound, and recreational vehicle accidents (P < 0.05). Location of injury was less likely on roads and public locations and more likely at indoor private locations (P < 0.05). The proportion of patients with neurotrauma with blood alcohol concentration >0.08 g/dL was reduced in 2020 (11.4% vs. 9.0%; P < 0.05). Mortality was higher during 2020 compared with pre-COVID years (7.7% vs. 6.4%; P < 0.05).

CONCLUSIONS

During statewide shutdown, neurotrauma volume and alcohol-related trauma decreased and low-impact traumas and gunshot wounds increased, with a shift toward injuries occurring in private, indoor locations. These changes increased mortality. However, there was not a change in the types of injuries sustained.

Public data from three US states provide new insights into well integrity

There are over 900,000 active oil and gas wells in the United States. Estimates of the percentage of these wells that leak during their lifetime have been limited by data availability. We mined publicly available records from state regulatory databases and synthesized the results of various well testing methods into a uniform dataset that describes the integrity of 105,031 wells. Our analysis of the dataset provides insight into regional well leakage frequencies in three US states (Colorado, New Mexico, and Pennsylvania), spatial and temporal leakage trends among vertical and directional wells, and the characteristics of leaked fluids. Our findings demonstrate the value of statewide well testing programs and highlight the challenges of interpreting disparate interjurisdictional well testing data.

Oil and gas wells with compromised integrity are a concern because they can potentially leak hydrocarbons or other fluids into groundwater and/or the atmosphere. Most states in the United States require some form of integrity testing, but few jurisdictions mandate widespread testing and open reporting on a scale informative for leakage risk assessment. In this study, we searched 33 US state oil and gas regulatory agency databases and identified records useful for evaluating well integrity in Colorado, New Mexico, and Pennsylvania. In total, we compiled 474,621 testing records from 105,031 wells across these states into a uniform dataset. We found that 14.1% of wells tested prior to 2018 in Pennsylvania exhibited sustained casing pressure (SCP) or casing vent flow (CVF)—two indicators of compromised well integrity. Data from different hydrocarbon-producing regions within Colorado and New Mexico revealed a wider range (0.3 to 26.5%) of SCP and/or CVF occurrence than previously reported, highlighting the need to better understand regional trends in well integrity. Directional wells were more likely to exhibit SCP and/or CVF than vertical wells in Colorado and Pennsylvania, and their installation corresponded with statewide increases in SCP and/or CVF occurrence in Colorado (2005 to 2009) and Pennsylvania (2007 to 2011). Testing the ground around wells for indicators of gas leakage is not a widespread practice in the states considered. However, 3.0% of Colorado wells tested and 0.1% of New Mexico wells tested exhibited a degree of SCP sufficient to potentially induce leakage outside the well.

Visualizing COVID-19 Mortality Rates and African-American Populations in the USA and Pennsylvania

The Centers for Disease Control and Prevention has identified African-Americans as having increased risk of COVID-19-associated mortality. Access to healthcare and related social determinants of health are at the core of this disparity. To explore the geographical links between race and COVID-19 mortality, we created descriptive maps of COVID-19 mortality rates in relation to the percentage of populations self-identifying as African-American across the USA, by state, and Pennsylvania (PA), by county. In addition, we used bivariate and logistic regression analyses to quantify the statistical relationship between these variables, and control for area-level demographic, healthcare access, and comorbidity risk factors. We found that COVID-19 mortality rates were generally higher in areas that had higher African-American populations, particularly in the northeast USA and eastern PA. These relationships were quantified through Pearson correlations showing significant positive associations at the state and county level. At the US state-level, percent African-American population was the only significant correlate of COVID-19 mortality rate. In PA at the county-level, higher percent African-American population was associated with higher COVID-19 mortality rate even after controlling for area-level confounders. More resources should be allocated to address high COVID-19 mortality rates among African-American populations.

Motivations for PrEP-Related Interpersonal Communication Among Women Who Inject Drugs: A Qualitative Egocentric Network Study

A qualitative egocentric social network approach was taken to explore motivations for pre-exposure prophylaxis (PrEP)-related communication between women who inject drugs and network members. Eligible participants were HIV-negative, 18 years or older, and participating in a PrEP demonstration project in Philadelphia, PA, USA. The study employed content analysis of in-depth interviews to identify themes related to contextual and relational factors impacting PrEP communication within networks. Participants (n = 20) named on average three network members, resulting in a total of 57 unique relationships. PrEP conversations occurred within 30 of the 57 relationships, and motivations were to benefit others, to benefit themselves, and due to a sense of obligation. Some conversations also occurred when a peer unexpectedly found their pills. Taking a qualitative approach to network analysis provided a nuanced understanding of how interpersonal characteristics motivated PrEP conversations. Network interventions that facilitate information diffusion and social support may increase PrEP uptake and adherence among women who inject drugs.

Impacts of Health Care Industry Consolidation in Pittsburgh, Pennsylvania: A Qualitative Study

While most studies of health care industry consolidation focus on impacts on prices or quality, these are not its only potential impacts. This exploratory qualitative study describes industry and community stakeholder perceptions of the impacts of cumulative hospital, practice, and insurance mergers, acquisitions, and affiliations in Pittsburgh, Pennsylvania. Since the 1980s, Pittsburgh’s health care landscape has been transformed and is now dominated by competition between 2 integrated payer-provider networks, health care system UPMC (and its insurance arm UPMC Health Plan) and insurer Highmark (and its health care system Allegheny Health Network). Semi-structured interviews with 20 boundary-spanning stakeholders revealed a mix of perceived impacts of consolidation: some positive, some neutral or ambiguous, and some negative. Stakeholders perceived consolidation’s positive impacts on long-term viability of health care facilities and their ability to adopt new care models, enhanced competition in health insurance, creation of foundations, and pioneering medical research and innovation. Stakeholders also believed that consolidation changed geographic access to care, physician referral behaviors, how educated patients were about their health care, the health care advertising environment, and economies of surrounding neighborhoods. Interviewees noted that consolidation raised questions about what the responsibilities of non-profit organizations are to their communities. However, stakeholders also reported their perceptions of negative outcomes, including ways in which consolidation had potentially reduced patient access to care, accountability and transparency, systems’ willingness to collaborate, and physician autonomy. As trends toward consolidation are not slowing, there will be many opportunities to experiment with policy levers to mitigate its potentially negative consequences.

COVID-19 Infection Control Measures in Long-Term Care Facility, Pennsylvania, USA

Residents of long-term care facilities are at risk for coronavirus disease. We report a surveillance exercise at such a facility in Pennsylvania, USA. After introduction of a testing strategy and other measures, this facility had a 17-fold lower coronavirus disease case rate than neighboring facilities.

Prevalence of Winter Ticks (Dermacentor albipictus) in Hunter-Harvested Wild Elk (Cervus canadensis) from Pennsylvania, USA (2017-2018)

Winter ticks (Dermacentor albipictus) are an aggressive one-host tick that infest a wide-diversity of ungulates. Infestations can result in anemia, alopecia, emaciation, and death. Most notably, the winter tick has caused negative impacts to moose (Alces alces) populations in the northeast United States and Canada. Winter ticks have been identified on other cervid species, including deer (Odocoileus virginianus) and elk (Cervus canadensis), which generally results in low tick burdens and mild or no disease. Recently, however, a wild yearling bull elk in Pennsylvania was found dead as a result of severe winter tick infestation. To obtain baseline data on winter ticks in wild elk in Pennsylvania, we collected 1453 ticks from 190 hunter-harvested wild elk between 2017-2018. Of the 204 harvested elk, 94.3% (190/204) had ticks collected for this study and none of the sampled elk had evidence of winter-tick associated disease. The average tick burden was 7.7 ticks/elk and average winter tick load on all elk was 0.5. Results of this study indicate that winter ticks do infest wild elk in Pennsylvania. However, during the fall months, the tick burden is low and rarely associated with lesions. These data herein serve as a baseline to monitor winter tick populations over time.

in Game Birds and Cage-Free, Floor-Raised Poultry in Pennsylvania

Histomoniasis is a significant disease of gallinaceous birds caused by Histomonas meleagridis. Transmission of this parasite is dependent on use of the cecal nematode Heterakis gallinarum. To define the host range of this nematode, cecal contents from 399 game birds and poultry, representing eight species, were examined for Heterakis spp. The majority of these species (five of eight) were infected with Heterakis nematodes. Heterakis gallinarum was detected in free-ranging wild turkeys (Meleagridis gallopovo), captive-raised ring-necked pheasants (Phasianus colchicus), chukars (Alectoris chukar), and domestic chickens (Gallus gallus domesticus), whereas H. isolonche was found in ruffed grouse (Bonasa umbellus). No Heterakis species were identified in the domestic turkey (Meleagridis gallopovo), American woodcock (Scolopax minor), and dabbling duck (Anas spp.) samples. Genetic characterization indicated that nematodes identified as H. gallinarum were present in two distinct clades. One clade of H. gallinarum sequenced from this study grouped with chicken-derived sequences from other countries. The other group of sequences consisted of a sister clade to a group of parasites morphologically identified as H. isolonche. Currently it is unknown if this group represents a genetic variant of H. gallinarum, a variant of H. isolonche, or a novel species. These results indicate Heterakis infection varies among poultry and game bird species but is common among select gallinaceous species in Pennsylvania.

Host distribution and pathogen infection of fleas (Siphonaptera) recovered from small mammals in Pennsylvania

The number of recognized flea-borne pathogens has increased over the past decade. However, the true number of infections related to all flea-borne pathogens remains unknown. To better understand the enzootic cycle of flea-borne pathogens, fleas were sampled from small mammals trapped in central Pennsylvania. A total of 541 small mammals were trapped, with white-footed mice (Peromyscus leucopus) and southern red-backed voles (Myodes gapperi) accounting for over 94% of the captures. Only P. leucopus were positive for examined blood-borne pathogens, with 47 (18.1%) and ten (4.8%) positive for Anaplasma phagocytophilum and Babesia microti, respectively. In addition, 61 fleas were collected from small mammals and tested for pathogens. Orchopeas leucopus was the most common flea and Bartonella vinsonii subspecies arupensis, B. microti, and a Rickettsia felis-like bacterium were detected in various flea samples. To the best of our knowledge, this is the first report of B. microti DNA detected from a flea and the first report of a R. felis-like bacterium from rodent fleas in eastern North America. This study provides evidence of emerging pathogens found in fleas, but further investigation is required to resolve the ecology of flea-borne disease transmission cycles.

A simulated patient study to assess referrals to abortion care by student health centers in Pennsylvania

OBJECTIVE

To determine college health centers' referral patterns for students seeking induced abortion.

STUDY DESIGN

We conducted a cross-sectional simulated patient study at 4-year colleges in Pennsylvania between June 2017 and May 2018. A researcher posing as a student seeking abortion referral contacted student health centers twice during the course of the study using a structured script, once as a minor (under 18 years), and once as an adult. The primary outcome was "direct referral", defined as a referral to an abortion provider. We measured proportions of student health centers who provided no referral, "indirect referral" (referral to a non-specific provider), and "inappropriate referral" (referral to a non-abortion provider). We analyzed the relationship between the proportion of direct referrals and minor status of the caller as well as college characteristics (religious affiliation, location, student body mean income, and size). We included variables found to be significant as covariates in a generalized linear model that accounted for the cluster of multiple calls to each institution.

RESULTS

We attempted contact with 115 institutions, once as a minor and once as an adult, resulting in 202 successful contacts. Direct referral was the most common outcome (49.5%), followed by inappropriate referral (33.7%) and no referral (21.8%). The proportion of direct referrals given to minors was similar when compared to adults (48.0% vs 52.0%, OR 0.82, 95% CI 0.47-1.42). Religiously affiliated institutions were less likely to provide a direct referral than non-religiously affiliated schools (aOR 0.47, 95% CI 0.30-0.75). With each increase in students' household income tertile, health centers were more likely to provide a direct referral (aOR 1.22, 95% CI 1.05-1.42).

CONCLUSIONS

Half of college student health centers in Pennsylvania do not provide direct abortion referrals, and many provide inappropriate referrals. Student health centers at religiously affiliated institutions and those with poorer students are less likely to provide direct abortion referrals.

IMPLICATIONS

Student health providers should inform themselves about fake health clinics and local abortion providers. Colleges should train staff, create accurate resources and define clear policies around referral. Professional and policymaking organizations should affirm the duty of all college health centers, regardless of religious affiliation, to provide abortion referrals.

Impact of school-entry vaccination requirement changes on clinical practice implementation and adolescent vaccination rates in metropolitan Philadelphia

In 2017, Pennsylvania amended school-entry vaccination requirements including reduction of the provisional period from eight months to the first five days of school and requirement of meningococcal-conjugate vaccine (MCV4) for students entering 12th grade. This cross-sectional study evaluates the impact of these new requirements on clinical practice and vaccination rates among requirement-eligible adolescents within a large pediatric network in metropolitan Philadelphia. We surveyed providers from 24 pediatric primary care facilities across five Southeastern Pennsylvania counties to assess strategies for timely vaccination of children, facilitators and barriers to implementation of these strategies, and attitudes toward the new school vaccine requirements. Vaccination rates post-five-day grace period among eligible 12-18-year-old adolescents were calculated using aggregate electronic health record data and compared pre- and post-policy implementation (2016 vs. 2017) using two-sample tests of proportion. Overall, providers were supportive of the new vaccination requirements and reported that their facilities were equipped to accommodate the increased demand for vaccination visits prior to the beginning of the school year. There were modest increases in Tdap and MCV4 vaccination rates among 12-13-year-old adolescents by mid-September and a significant increase for MCV4 among 17-18-year-old adolescents (p > .001) in all regions. There were also statistically significant increases (p > .001) in MenB and HPV vaccination rates in this older age group. Our results suggest that these amended school-entry vaccination requirements may help improve timely vaccination rates for both required and non-required vaccines, increasing protection among students at the beginning of the school year.

in Adult Black-Legged Ticks (Ixodes scapularis) from Pennsylvania, United States, with a Luminex Multiplex Bead Assay

Ixodes scapularis, the black-legged tick, harbors multiple organisms and transmits several pathogens to animals and humans. To determine the presence of tick-borne microorganisms carried by I. scapularis in Pennsylvania, 299 adult I. scapularis ticks were collected from across the state and tested with a multiplex bead panel targeting 20 microorganisms. The Luminex bead-based xMAP^® MultiFLEX Mega Tick Panel detected microorganisms in these ticks, including Anaplasma spp. (1.7%), Borrelia spp. (45.8%), Babesia spp. (16.1%), and Rickettsia spp. (22.1%) at the genera level and identified Anaplasma phagocytophilum (1.7%), Babesia microti (0.7%), Borrelia burgdorferi sensu stricto (45.5%), Borrelia miyamotoi (0.3%), and Rickettsia parkeri (0.7%) at the species level. Babesia spp. reactivity was found to be due to Ba. odocoilei, and Rickettsia spp. reactivity was mainly due to rickettsial endosymbionts.

Disseminated Metacestode Versteria Species Infection in Woman, Pennsylvania, USA1

A patient in Pennsylvania, USA, with common variable immunodeficiency sought care for fever, cough, and abdominal pain. Imaging revealed lesions involving multiple organs. Liver resection demonstrated necrotizing granulomas, recognizable tegument, and calcareous corpuscles indicative of an invasive cestode infection. Sequencing revealed 98% identity to a Versteria species of cestode found in mink.

High Seroprevalence but Low Rate of Isolation of Toxoplasma gondii from Wild Elk (Cervus Canadensis) in Pennsylvania

Toxoplasma gondii infections are prevalent in most warm-blooded animals worldwide. During the 2018 November hunting season in Pennsylvania, fresh (unfixed, not frozen) samples obtained from 99 harvested elk (Cervus canadensis) were tested for T. gondii infection. Antibodies to T. gondii were detected in 69 of 99 (69.7%) elk tested by the modified agglutination test (MAT, 1:25 cut-off). Tongues and hearts from 16 elk with high MAT titers (>1:200) were bioassayed for T. gondii by inoculation in outbred Swiss Webster (SW) and interferon-gamma gene knockout (KO) mice. Viable T. gondii was isolated from tongues of 2 elk with MAT titers of 1:200 and 1:3,200. Toxoplasma gondii from both isolates were successfully propagated in cell culture. Genetic typing on DNA extracted from culture-derived tachyzoites using the PCR restriction fragment length polymorphism with 10 genetic markers (SAG1, SAG2, SAG3, BTUB, GRA6, c22-8, c29-2, L358, PK1, and Apico) revealed that both isolates belonged to ToxoDB PCR-RFLP genotype #5 that is widely prevalent in wildlife in the United States. Our results suggest that elk may clear T. gondii organisms from their tissues.

Attendance at National Cancer Institute and Children's Oncology Group Facilities for Children, Adolescents, and Young Adults with Cancer in Pennsylvania: A Population-Based Study

Purpose: Adolescents and young adults (AYAs) with cancer are a vulnerable population with decreased attendance at National Cancer Institute (NCI) comprehensive cancer centers and Children's Oncology Group (COG) facilities. Decreased attendance at NCI/COG facilities has been associated with poor cancer outcomes. The objective of this study was to evaluate cancer care patterns of AYAs compared with children, within Pennsylvania, and factors associated with attending an NCI/COG facility. Methods: Data from the Pennsylvania Cancer Registry between 2010 and 2015 for patients aged 0-39 years at cancer diagnosis were used. Primary analyses focused on age at diagnosis, insurance status, race, ethnicity, gender, cancer type, stage, diagnosis year, and distance to the NCI/COG facility. The primary outcome was receipt of care at an NCI/COG facility. Odds ratios (ORs) were calculated using multivariable logistic regression models. Sensitivity analyses were conducted to test and estimate robustness. Results: A sample of 15,002 patients, ages 0-39, was obtained, including 8857 patients (59%) who attended an NCI/COG facility. Patients were significantly less likely to attend an NCI/COG facility if they were aged 31-39 years (OR 0.054, 95% confidence interval [CI] 0.04-0.07), non-White (OR 0.890, 95% CI 0.80-0.99), Hispanic (OR 0.701, 95% CI 0.59-0.83), female (OR 0.915, 95% CI 0.84-1.00), had Medicaid insurance (OR 0.836, 95% CI 0.75-0.93), and lived further from an NCI/COG facility. Sensitivity analyses largely corroborated the performed estimates. Conclusions: AYAs with cancer in Pennsylvania have disproportionate attendance at specialized NCI/COG facilities across a variety of demographic domains. Enhancing the attendance of AYAs with cancer at these specialized centers is crucial to improve cancer outcomes.

Associations of Opioid Prescriptions with Death and Hospitalization across the Spectrum of Estimated GFR

BACKGROUND AND OBJECTIVES

Most opioids undergo kidney excretion. The goal of this study was to evaluate opioid-associated risks of death and hospitalization across the range of eGFR.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

The study population included adult primary care patients in Geisinger Health (Danville, PA) between 2008 and 2017. People receiving their first opioid prescription were propensity matched to people receiving NSAIDS (and, in sensitivity analysis, gabapentinoids) and the risk of death and hospitalization were compared, classifying opioid medication exposure as time-varying daily oral morphine milligram equivalents (MMEs) across time-varying eGFR.

RESULTS

The propensity-matched cohort included 46,246 patients prescribed either opioids or NSAIDs between 2008 and 2017 (mean [SD] age, 54 [16] years; 56% female; 3% of black race). Prescriptions for 1-59 and ≥60 MMEs were associated with higher risk of death (HR, 1.70; 95% CI, 1.41 to 2.05 for 1-59 MMEs; HR, 2.25; 95% CI, 1.82 to 2.79 for ≥60 MMEs) and hospitalization (HR, 1.38; 95% CI, 1.30 to 1.46 for 1-59 MMEs; HR, 1.68; 95% CI, 1.56 to 1.81 for ≥60 MMEs) compared with NSAID prescriptions, when evaluated at eGFR 80 ml/min per 1.73 m². The relative risk of death associated with ≥60 MMEs was higher at lower GFR (e.g., eGFR, 40 ml/min per 1.73 m²; HR, 3.94; 95% CI, 2.70 to 5.75; P for interaction, 0.01). When gabapentinoids were used as the comparison medication, only ≥60 MMEs were significantly associated with higher risk of death (HR, 2.72; 95% CI, 1.71 to 4.34), although both 1-59 and ≥60 MMEs were associated with risk of hospitalization (HR, 1.22; 95% CI, 1.04 to 1.43 for 1-59 MMEs; HR, 1.54; 95% CI, 1.28 to 1.86 for ≥60 MMEs).

CONCLUSIONS

The receipt of prescription opioids was associated with a higher risk of death and hospitalization compared with other pain medications, particularly with higher doses and at lower eGFR.

Association of Enterovirus D68 with Acute Flaccid Myelitis, Philadelphia, Pennsylvania, USA, 2009-2018

Acute flaccid myelitis (AFM) is a polio-like disease that results in paralysis in previously healthy persons. Although the definitive cause of AFM remains unconfirmed, enterovirus D68 (EV-D68) is suspected based on 2014 data demonstrating an increase in AFM cases concomitant with an EV-D68 outbreak. We examined the prevalence in children and the molecular evolution of EV-D68 for 2009–2018 in Philadelphia, Pennsylvania, USA. We detected widespread EV-D68 circulation in 2009, rare detections in 2010 and 2011, and then biennial circulation, only in even years, during 2012–2018. Prevalence of EV-D68 significantly correlated with AFM cases during this period. Finally, whole-genome sequencing revealed early detection of the B1 clade in 2009 and continued evolution of the B3 clade from 2016 to 2018. These data reinforce the need to improve surveillance programs for nonpolio enterovirus to identify possible AFM triggers and predict disease prevalence to better prepare for future outbreaks.

Mycobacterium avium in Community and Household Water, Suburban Philadelphia, Pennsylvania, USA, 2010-2012

Attention to environmental sources of Mycobacterium avium complex (MAC) infection is a vital component of disease prevention and control. We investigated MAC colonization of household plumbing in suburban Philadelphia, Pennsylvania, USA. We used variable-number tandem-repeat genotyping and whole-genome sequencing with core genome single-nucleotide variant analysis to compare M. avium from household plumbing biofilms with M. avium isolates from patient respiratory specimens. M. avium was recovered from 30 (81.1%) of 37 households, including 19 (90.5%) of 21 M. avium patient households. For 11 (52.4%) of 21 patients with M. avium disease, isolates recovered from their respiratory and household samples were of the same genotype. Within the same community, 18 (85.7%) of 21 M. avium respiratory isolates genotypically matched household plumbing isolates. Six predominant genotypes were recovered across multiple households and respiratory specimens. M. avium colonizing municipal water and household plumbing may be a substantial source of MAC pulmonary infection.