Low Seroprevalence of SARS-CoV-2 in Rhode Island blood donors during may 2020 as determined using multiple serological assay formats

BACKGROUND

Epidemic projections and public health policies addressing Coronavirus disease (COVID)-19 have been implemented without data reporting on the seroconversion of the population since scalable antibody testing has only recently become available.

METHODS

We measured the percentage of severe acute respiratory syndrome- Coronavirus-2 (SARS-CoV-2) seropositive individuals from 2008 blood donors drawn in the state of Rhode Island (RI). We utilized multiple antibody testing platforms, including lateral flow immunoassays (LFAs), enzyme-linked immunosorbent assays (ELISAs) and high throughput serological assays (HTSAs). To estimate seroprevalence, we utilized the Bayesian statistical method to adjust for sensitivity and specificity of the commercial tests used.

RESULTS

We report than an estimated seropositive rate of RI blood donors of approximately 0.6% existed in April-May of 2020. Daily new case rates peaked in RI in late April 2020. We found HTSAs and LFAs were positively correlated with ELISA assays to detect antibodies specific to SARS-CoV-2 in blood donors.

CONCLUSIONS

These data imply that seroconversion, and thus infection, is likely not widespread within this population. We conclude that IgG LFAs and HTSAs are suitable to conduct seroprevalence assays in random populations. More studies will be needed using validated serological tests to improve the precision and report the kinetic progression of seroprevalence estimates.

Low Seroprevalence of SARS-CoV-2 in Rhode Island blood donors during may 2020 as determined using multiple serological assay formats

BACKGROUND

Epidemic projections and public health policies addressing Coronavirus disease (COVID)-19 have been implemented without data reporting on the seroconversion of the population since scalable antibody testing has only recently become available.

METHODS

We measured the percentage of severe acute respiratory syndrome- Coronavirus-2 (SARS-CoV-2) seropositive individuals from 2008 blood donors drawn in the state of Rhode Island (RI). We utilized multiple antibody testing platforms, including lateral flow immunoassays (LFAs), enzyme-linked immunosorbent assays (ELISAs) and high throughput serological assays (HTSAs). To estimate seroprevalence, we utilized the Bayesian statistical method to adjust for sensitivity and specificity of the commercial tests used.

RESULTS

We report than an estimated seropositive rate of RI blood donors of approximately 0.6% existed in April-May of 2020. Daily new case rates peaked in RI in late April 2020. We found HTSAs and LFAs were positively correlated with ELISA assays to detect antibodies specific to SARS-CoV-2 in blood donors.

CONCLUSIONS

These data imply that seroconversion, and thus infection, is likely not widespread within this population. We conclude that IgG LFAs and HTSAs are suitable to conduct seroprevalence assays in random populations. More studies will be needed using validated serological tests to improve the precision and report the kinetic progression of seroprevalence estimates.

A Community-Adapted Approach to SARS-CoV-2 Testing for Medically Underserved Populations, Rhode Island, USA

We developed a testing program for severe acute respiratory syndrome coronavirus 2 in an urban Latinx neighborhood in Providence, Rhode Island, USA. Approximately 11% of Latinx participants (n = 180) tested positive. Culturally tailored, community-based programs that reduce barriers to testing help identify persons at highest risk for coronavirus disease.

First hemispheric report of invasive tick species Haemaphysalis punctata, first state report of Haemaphysalis longicornis, and range expansion of native tick species in Rhode Island, USA

BACKGROUND

Invasive arthropod vectors and the range expansions of native vectors can lead to public and veterinary health concerns, as these vectors may introduce novel pathogens or spread endemic pathogens to new locations. Recent tick invasions and range expansion in the USA has been attributed to climate and land use change, an increase in global travel, and importations of exotic animals.

METHODS

A 10-year surveillance study was conducted on Block Island, Rhode Island, from 2010 to 2020 including sampling ticks from small mammal and avian hosts.

RESULTS

We report the discovery and establishment of the red sheep tick (Haemaphysalis punctata) for the first time in the western hemisphere and in the US. This invasive species was first collected in 2010 on Block Island, was collected continuously throughout the study, and was collected from an avian host. We document the first report of the invasive Asian longhorned tick (Haemaphysalis longicornis) in the state of Rhode Island, first observed at our sites in 2018. Finally, we present data on the range expansion and establishment of two native tick species, the lone star tick and the rabbit tick, on Block Island.

CONCLUSION

This study emphasized the importance of long-term surveillance to detect changes in tick host communities, including invasive and expanding native vectors of potential significance to humans and wildlife.

Clinical Outcomes of Free, Public Skin Cancer Screening Events, Rhode Island, 2015-2019

BACKGROUND

In Rhode Island, malignant melanoma of skin causes about 30 deaths a year. Early detection has been shown to reduce mortality risk.

METHODS

Dermatology volunteers and public health professionals convened 27 free skin cancer screenings at public beaches in 2015-2019 to raise skin cancer awareness and screen patients for malignancy. Participants with suspicious lesions were referred for follow-up and later telephoned to ascertain outcomes.

RESULTS

Of 2354 people screened, 597 (25%) were referred. 319 of 597 (53%) were later reached by telephone. 196 of 319 (61%) who had kept appointments by the time of the telephone call reported the following diagnoses: 7 malignant melanomas, 32 keratinocyte carcinomas, and 34 actinic keratoses, yielding 3.0 as number needed to biopsy (NNB), and 18.3 as number needed to screen (NNS).

CONCLUSIONS

Our results demonstrate the value of convenient skin cancer screening events, suggesting the desirability of additional interventions of this type.

Optimal SARS-CoV-2 vaccine allocation using real-time attack-rate estimates in Rhode Island and Massachusetts

BACKGROUND

When three SARS-CoV-2 vaccines came to market in Europe and North America in the winter of 2020-2021, distribution networks were in a race against a major epidemiological wave of SARS-CoV-2 that began in autumn 2020. Rapid and optimized vaccine allocation was critical during this time. With 95% efficacy reported for two of the vaccines, near-term public health needs likely require that distribution is prioritized to the elderly, health care workers, teachers, essential workers, and individuals with comorbidities putting them at risk of severe clinical progression.

METHODS

We evaluate various age-based vaccine distributions using a validated mathematical model based on current epidemic trends in Rhode Island and Massachusetts. We allow for varying waning efficacy of vaccine-induced immunity, as this has not yet been measured. We account for the fact that known COVID-positive cases may not have been included in the first round of vaccination. And, we account for age-specific immune patterns in both states at the time of the start of the vaccination program. Our analysis assumes that health systems during winter 2020-2021 had equal staffing and capacity to previous phases of the SARS-CoV-2 epidemic; we do not consider the effects of understaffed hospitals or unvaccinated medical staff.

RESULTS

We find that allocating a substantial proportion (>75%) of vaccine supply to individuals over the age of 70 is optimal in terms of reducing total cumulative deaths through mid-2021. This result is robust to different profiles of waning vaccine efficacy and several different assumptions on age mixing during and after lockdown periods. As we do not explicitly model other high-mortality groups, our results on vaccine allocation apply to all groups at high risk of mortality if infected. A median of 327 to 340 deaths can be avoided in Rhode Island (3444 to 3647 in Massachusetts) by optimizing vaccine allocation and vaccinating the elderly first. The vaccination campaigns are expected to save a median of 639 to 664 lives in Rhode Island and 6278 to 6618 lives in Massachusetts in the first half of 2021 when compared to a scenario with no vaccine. A policy of vaccinating only seronegative individuals avoids redundancy in vaccine use on individuals that may already be immune, and would result in 0.5% to 1% reductions in cumulative hospitalizations and deaths by mid-2021.

CONCLUSIONS

Assuming high vaccination coverage (>28%) and no major changes in distancing, masking, gathering size, hygiene guidelines, and virus transmissibility between 1 January 2021 and 1 July 2021 a combination of vaccination and population immunity may lead to low or near-zero transmission levels by the second quarter of 2021.

Patients with borderline personality disorder and bipolar disorder: a descriptive and comparative study

BACKGROUND

Bipolar disorder and borderline personality disorder (BPD) are each significant public health problems. It has been frequently noted that distinguishing BPD from bipolar disorder is challenging. Consequently, reviews and commentaries have focused on differential diagnosis and identifying clinical features to distinguish the two disorders. While there is a burgeoning literature comparing patients with BPD and bipolar disorder, much less research has characterized patients with both disorders. In the current report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we compare psychiatric outpatients with both BPD and bipolar disorder to patients with BPD without bipolar disorder and patients with bipolar disorder without BPD.

METHODS

Psychiatric outpatients presenting for treatment were evaluated with semi-structured interviews. The focus of the current study is the 517 patients with both BPD and bipolar disorder (n = 59), BPD without bipolar disorder (n = 330), and bipolar disorder without BPD (n = 128).

RESULTS

Compared to patients with bipolar disorder, the patients with bipolar disorder and BPD had more comorbid disorders, psychopathology in their first-degree relatives, childhood trauma, suicidality, hospitalizations, time unemployed, and likelihood of receiving disability payments. The added presence of bipolar disorder in patients with BPD was associated with more posttraumatic stress disorder in the patients as well as their family, more bipolar disorder and substance use disorders in their relatives, more childhood trauma, unemployment, disability, suicide attempts, and hospitalizations.

CONCLUSIONS

Patients with both bipolar disorder and BPD have more severe psychosocial morbidity than patients with only one of these disorders.

Predictors of severity and mortality among patients hospitalized with COVID-19 in Rhode Island

BACKGROUND

In order for healthcare systems to prepare for future waves of COVID-19, an in-depth understanding of clinical predictors is essential for efficient triage of hospitalized patients.

METHODS

We performed a retrospective cohort study of 259 patients admitted to our hospitals in Rhode Island to examine differences in baseline characteristics (demographics and comorbidities) as well as presenting symptoms, signs, labs, and imaging findings that predicted disease progression and in-hospital mortality.

RESULTS

Patients with severe COVID-19 were more likely to be older (p = 0.02), Black (47.2% vs. 32.0%, p = 0.04), admitted from a nursing facility (33.0% vs. 17.9%, p = 0.006), have diabetes (53.9% vs. 30.4%, p<0.001), or have COPD (15.4% vs. 6.6%, p = 0.02). In multivariate regression, Black race (adjusted odds ratio [aOR] 2.0, 95% confidence interval [CI]: 1.1-3.9) and diabetes (aOR 2.2, 95%CI: 1.3-3.9) were independent predictors of severe disease, while older age (aOR 1.04, 95% CI: 1.01-1.07), admission from a nursing facility (aOR 2.7, 95% CI 1.1-6.7), and hematological co-morbidities predicted mortality (aOR 3.4, 95% CI 1.1-10.0). In the first 24 hours, respiratory symptoms (aOR 7.0, 95% CI: 1.4-34.1), hypoxia (aOR 19.9, 95% CI: 2.6-152.5), and hypotension (aOR 2.7, 95% CI) predicted progression to severe disease, while tachypnea (aOR 8.7, 95% CI: 1.1-71.7) and hypotension (aOR 9.0, 95% CI: 3.1-26.1) were associated with increased in-hospital mortality.

CONCLUSIONS

Certain patient characteristics and clinical features can help clinicians with early identification and triage of high-risk patients during subsequent waves of COVID-19.

Presentations and Outcomes of Severe Cardiac Complications in COVID-19: Rhode Island Experience

Forty-one (41) patients admitted to Rhode Island hospitals with COVID-19 from April to November 2020 were identified to have severe cardiac complications. Clinical presentations of cardiovascular system toxicity in COVID-19 included myocarditis, pericarditis, cardiomyopathy, ACS and cardiac arrhythmia. Clinical features, hospital outcomes and post-discharge outcomes were characterized. Acute myocarditis (46.3%) and cardiomyopathy (29.3%) were the most common findings followed by cardiac arrhythmia, acute coronary syndrome, and pericardial disease. Pulmonary involvement of COVID-19 was absent in 41.5% of patients. Comorbid cardiovascular conditions were absent in 29.3% of patients. Severe cardiac complications in COVID-19 were associated with an in-hospital mortality rate of 61%. Among survivors with COVID-19-related cardiomyopathy, only 20% demonstrated recovery of LV function on follow-up echocardiography done within 12 weeks after initial diagnosis. Identification, diagnosis and management of severe cardiac complications in COVID-19 are discussed.

Epidemiology and Clinical Characteristics of Emergency Department Patients with COVID-19 in a Rhode Island Healthcare System

BACKGROUND

Rhode Island (RI) has been severely impacted by the COVID-19 pandemic. This study aims to describe emergency department (ED) patients with COVID-19 within the largest healthcare system in RI.

METHODS

A retrospective electronic medical record review of 1,209 adult patients evaluated and diagnosed with COVID-19 in 4 EDs during the first peak (March 15, 2020 to May 16, 2020) was conducted. Sociodemographic, clinical, management, and ED disposition information were summarized. RESULTS: Median age of patients was 55 years (IQR 40-69), 55.2% were male, and 47.8% were Hispanic/Latinx. Over half of the patients (60.5%) were admitted to the hospital. Supplemental oxygen was used by 32.2%.

CONCLUSION

This study presents the clinical and sociodemographic characteristics of ED patients with COVID-19 presenting to the largest healthcare system in Rhode Island. Continued analysis is warranted to provide further insight into the trends in this pandemic.

Residential proximity to roadways and placental-associated stillbirth: a case-control study

We conducted a retrospective case-control study of 1,097 women in Massachusetts and Rhode Island, USA, to examine the association between stillbirth related to placental abruption or placental insufficiency and maternal exposure to traffic-related air pollution. We utilized distance to nearest roadway proximity metrics as a proxy for traffic-related air pollution exposure. No meaningful increase in the overall odds of placental-associated stillbirths was observed (adjusted OR: 1.1, 95% CI: 0.5-2.8). However, mothers living within 50 m of a roadway had a 60% increased odds of experiencing a stillbirth related to placental abruption compared to mothers living greater than 200 m away. This suggestive finding was imprecise due to the small case number in the highest exposure category (95% CI: 0.6-4.0). Future studies of placental abruption with more precise exposure assessments are warranted.

Decision Making Regarding Trauma Patients in Rhode Island who Present on Anticoagulants and Antiplatelet Agents: A Multidisciplinary and Collaborative Approach

OBJECTIVES

Use of anticoagulant and antiplatelet medications (AAMs) is increasing significantly with our growing population of older adults. AAMs worsen outcomes in trauma patients. Our goal was to improve collaboration between trauma and outpatient providers and to improve safety in making decisions on anticoagulant and antiplatelet medications(AAMs) after injuries.

DESIGN

A risk management initiative.

SETTING AND PARTICIPANTS

Patients that suffered traumatic injury while on anticoagulation or antiplatelets medications at a level I university trauma center.

METHODS

IRB approval was obtained to review records for medications, demographics, mechanism and type of injury, and indication for preinjury AAM use. Inpatient trauma team providers contacted the primary prescriber. A collaborative decision was made regarding AAM plans.

RESULTS

One hundred and five patients, mean age 79 years, were followed. The three most common AAMs were warfarin (69 patients), clopidogrel (24), and Factor Xa inhibitors (16). Atrial fibrillation was the most common indication for AAMs (70 patients), venous thrombosis (14) and TIA/CVA (11). Falls were the most frequent injury mechanism, 79.4%. Soft tissue hematomas (27.4%), TBI (16%), and pelvic fractures (12.3%) were the most common injuries. In 56.6% AAMs were held until follow-up, 31.1% had AAMs resumed at discharge, and AAMs were held indefinitely in 12.3%. Patients discharged to home versus facility (37 vs 18% p<0.05), <75 years of age (47 vs 27% p<0.05) were more likely to have AAMs resumed at discharge. Patients who suffered falls versus MVC mechanism were less likely to have AAMs resumed at discharge (28 vs 82% p<0.05). CHA2DS2-VASc scores were similar between decision groups.

CONCLUSIONS AND IMPLICATIONS

This is the first description of mandatory communication between trauma and outpatient providers to guide decision making on AAMs after injury. Efforts should be made to determine if this mitigates risk by following patients longterm. This communication should become standard for a population that is often elderly, frail, and at risk of repeat injuries.

Characterizing the Symptoms of Patients with Persistent Post-Treatment Lyme Symptoms: A Survey of Patients at a Lyme Disease Clinic in Rhode Island

BACKGROUND

10-20% of individuals diagnosed with Lyme disease develop chronic symptoms after antibiotic treatment.

METHODS

A convenience sample of adults with self- reported, persistent post-Lyme treatment symptoms seeking treatment at the Lifespan Lyme Disease Center in Rhode Island completed a demographic and medical survey, the Patient Reported Outcomes Measurement Information System (PROMIS)-29 v2.0, and other short-form PROMIS measures of cognitive function, sleep disturbance, and fatigue.

RESULTS

Compared to average standardized scale scores (T=50; SD=10), participants had mild impairments in physical (T=41) and social (T=42) functioning, mild symptoms of depression (T=56), anxiety (T=60), and sleep disturbance (T=57), and moderate pain interference (T=62), and fatigue (T=65). Participants reported greater symptoms than some other clinical samples including those with cancer and chronic pain. Post-hoc analyses revealed that women reported higher levels of fatigue than men.

CONCLUSIONS

People with persistent post-Lyme treatment symptoms report debilitating symptoms and functional impairments which must be considered in clinical care.

COBRE on Opioid and Overdose: A Collaborative Research-Based Center Addressing the Crises in Rhode Island and Beyond

Overdose deaths across the country have spiked since the onset of the COVID-19 pandemic. It is crucial now, more than ever, to address the continuing and worsening, complex and dynamic opioid and overdose epidemics. In 2018, The Center of Biomedical Research Excellence (COBRE) on Opioids and Overdose, based at Rhode Island Hospital, launched with three major goals: 1) establish a center of scientific excellence on opioids and overdose; 2) train the next generation of scientists to become independent investigators and address the opioid and overdose crises; and 3) contribute to the scientific progress and solutions to combat these epidemics. To date, we have made substantial progress. While the opioid and overdose crises continue to evolve, the COBRE on Opioid and Overdose and its team of investigators are well poised to address the daunting task of understanding and meaningfully addressing these deadly epidemics, with the ultimate goal of saving lives.

Examining nonprescription syringe sales in Massachusetts and Rhode Island community pharmacies

Background:

The role pharmacies play in addressing the opioid crisis and drug-related risks such as injection drug use is evolving. Estimating the prevalence of injection drug use at the community level is challenging because of the stigma of drug use. Many community pharmacies sell nonprescription sterile syringes; thus, pharmacy-level sales of injection equipment may be an indicator of drug-related harms and unmet needs of high-risk populations.

Objectives:

To describe, compare, and assess the convergent validity of staff-reported nonprescription syringe (NPS) sales volume and NPS administrative sales data from community pharmacies in Massachusetts (MA) and Rhode Island (RI).

Methods:

This study employed both prospective cross-sectional survey data collection and utilization of administrative pharmacy sales data. Between November 2017 and January 2018, we administered a telephone-based survey to estimate average weekly NPS type and volume for 191 chain pharmacies (CVS Health) located in communities experiencing fatal opioid overdoses above the state’s 2015 annual median rate. For the same time period, we obtained NPS sales data from surveyed pharmacies and all CVS Health pharmacies in the 2 states. We calculated Spearman correlations to assess convergence of average weekly volume between pharmacy staff reports and sales data.

Results:

All pharmacies responded to the survey. Most (98.4%) pharmacies surveyed sold NPS, but 42.0% reported running out of stock monthly or more frequently. Pharmacy staff tended to under-report syringe sales. Staff-reported weekly NPS sales volume was 67,922 versus 70,962 syringes from administrative pharmacy sales data. Spearman correlation between reported and actual NPS sales was 0.40 (95% CI 0.27e0.51).

Conclusion:

The counts of administrative pharmacy syringe sales data in MA and RI indicate high need, substantial volume, and notable access at community pharmacies. Future research should use NPS sales data rather than self-report data to track emerging trends and tailor local responses.

Severe Acute Respiratory Syndrome Coronavirus 2 Seropositivity among Healthcare Personnel in Hospitals and Nursing Homes, Rhode Island, USA, July-August 2020

Healthcare personnel are recognized to be at higher risk for infection with severe acute respiratory syndrome coronavirus 2. We conducted a serologic survey in 15 hospitals and 56 nursing homes across Rhode Island, USA, during July 17–August 28, 2020. Overall seropositivity among 9,863 healthcare personnel was 4.6% (95% CI 4.2%–5.0%) but varied 4-fold between hospital personnel (3.1%, 95% CI 2.7%–3.5%) and nursing home personnel (13.1%, 95% CI 11.5%–14.9%). Within nursing homes, prevalence was highest among personnel working in coronavirus disease units (24.1%; 95% CI 20.6%–27.8%). Adjusted analysis showed that in hospitals, nurses and receptionists/medical assistants had a higher likelihood of seropositivity than physicians. In nursing homes, nursing assistants and social workers/case managers had higher likelihoods of seropositivity than occupational/physical/speech therapists. Nursing home personnel in all occupations had elevated seropositivity compared with hospital counterparts. Additional mitigation strategies are needed to protect nursing home personnel from infection, regardless of occupation.

Severe Acute Respiratory Syndrome Coronavirus 2 Testing in Children in a Large Regional US Health System During the Coronavirus Disease 2019 Pandemic

BACKGROUND

The objective was to evaluate patterns of pediatric coronavirus disease 2019 testing in a large health system throughout the pandemic, before and after school reopening.

METHODS

This was a cross-sectional time-series study of clinical virology results from children tested for severe acute respiratory syndrome coronavirus 2 in Southern Connecticut and areas of New York and Rhode Island. Data collected include demographics, hospital admission, changes in percent positive tests over time, detection intervals in persistently positive children and cycle threshold values. The setting was the Yale New Haven Health System has 6 hospitals at 4 Connecticut locations, 1 hospital in Rhode Island and ambulatory locations in Connecticut, Rhode Island and New York. Participants included twenty-three-thousand one-hundred thirty-seven children ≤ 18 years of age, tested for coronavirus disease 2019 at an ambulatory testing site, the emergency department or on an inpatient unit within the Yale New Haven Health System.

RESULTS

Among all tests, 3.2% were positive. Older children consistently made up the larger portion of positive pediatric cases, regardless of community prevalence. Increased pediatric cases later in the pandemic when prevalence in adults was relatively low correlates with a higher number of tests performed in children and not with an increased positivity rate. No significant changes in trends of positivity were detected after the reopening of schools. Symptomatic and asymptomatic children had similar cycle threshold values regardless of age, and a subset of children demonstrated persistent viral detection, some for as long as 6 weeks.

CONCLUSION

An increase in pediatric cases documented in the late summer was predominately due to increased access to testing for children. The percent positivity in children did not change in the first 3 weeks after school opened. A subset of children has detectable severe acute respiratory syndrome coronavirus 2 RNA in the upper respiratory tract for weeks after the initial infection.

COVID-19 in Pediatric Patients: Observations from the Initial Phase of the Global Pandemic in Rhode Island

OBJECTIVE

To describe characteristics of children undergoing SARS-CoV-2 testing during the initial wave of infections in Rhode Island.

METHODS

This is a descriptive study of 729 children tested for SARS-CoV-2 at four emergency departments April 9 to May 7, 2020 in Rhode Island. Demographic information and symptoms were cataloged for those tested.

RESULTS

81 (11%) children tested positive for SARS-CoV-2. 94% of positive children were symptomatic. 74% of positive cases had constitutional symptoms and 72% had upper respiratory symptoms. While only 34% of those tested were Hispanic, 68% of the SARS-CoV-2- positive cases occurred in Hispanic children.

CONCLUSION

This study details the pediatric population's experience during the first wave of the pandemic in Rhode Island. It could inform testing allocation strategies in healthcare settings. It also highlights vulnerable populations in need of further public health support in our state.

Mental Health Comorbidity Analysis in Pediatric Patients with Autism Spectrum Disorder Using Rhode Island Medical Claims Data

Identification of comorbidity subgroups linked with Autism Spectrum Disorder (ASD) could provide promising insight into learning more about this disorder. This study sought to use the Rhode Island All-Payer Claims Database to examine mental health conditions linked to ASD. Medical claims data for ASD patients and one or more mental health conditions were analyzed using descriptive statistics, association rule mining (ARM), and sequential pattern mining (SPM). The results indicated that patients with ASD have a higher proportion of mental health diagnoses than the general pediatric population. ARM and SPM methods identified patterns of comorbidities commonly seen among ASD patients. Based on the observed patterns and temporal sequences, suicidal ideation, mood disorders, anxiety, and conduct disorders may need focused attention prospectively. Understanding more about groupings of ASD patients and their comorbidity burden can help bridge gaps in knowledge and make strides toward improved outcomes for patients with ASD.