COVID Community-Engaged Testing in Alabama: Reaching Underserved Rural Populations Through Collaboration

Rural communities are often underserved by public health testing initiatives in Alabama. As part of the National Institutes of Health's Rapid Acceleration of Diagnostics‒Underserved Populations initiative, the University of Alabama at Birmingham, along with community partners, sought to address this inequity in COVID-19 testing. We describe the participatory assessment, selection, and implementation phases of this project, which administered more than 23 000 COVID-19 tests throughout the state, including nearly 4000 tests among incarcerated populations. (Am J Public Health. 2022;112(10):1399-1403. https://doi.org/10.2105/AJPH.2022.306985).

The Association Between Neighborhood Social Vulnerability and COVID-19 Testing, Positivity, and Incidence in Alabama and Louisiana

Racial/ethnic and socioeconomic disparities in COVID-19 burden have been widely reported. Using data from the state health departments of Alabama and Louisiana aggregated to residential Census tracts, we assessed the relationship between social vulnerability and COVID-19 testing rates, test positivity, and incidence. Data were cumulative for the period of February 27, 2020 to October 7, 2020. We estimated the association of the 2018 Social Vulnerability Index (SVI) overall score and theme scores with COVID-19 tests, test positivity, and cases using multivariable negative binomial regressions. We adjusted for rurality with 2010 Rural-Urban Commuting Area codes. Regional effects were modeled as fixed effects of counties/parishes and state health department regions. The analytical sample included 1160 Alabama and 1105 Louisiana Census tracts. In both states, overall social vulnerability and vulnerability themes were significantly associated with increased COVID-19 case rates (RR 1.57, 95% CI 1.45-1.70 for Alabama; RR 1.36, 95% CI 1.26-1.46 for Louisiana). There was increased COVID-19 testing with higher overall vulnerability in Louisiana (RR 1.26, 95% CI 1.14-1.38), but not in Alabama (RR 0.95, 95% CI 0.89-1.02). Consequently, test positivity in Alabama was significantly associated with social vulnerability (RR 1.66, 95% CI 1.57-1.75), whereas no such relationship was observed in Louisiana (RR 1.05, 95% CI 0.98-1.12). Social vulnerability is a risk factor for COVID-19 infection, particularly among racial/ethnic minorities and those in disadvantaged housing conditions without transportation. Increased testing targeted to vulnerable communities may contribute to reduction in test positivity and overall COVID-19 disparities.

A state-based approach to genomics for rare disease and population screening

PURPOSE

The Alabama Genomic Health Initiative (AGHI) is a state-funded effort to provide genomic testing. AGHI engages two distinct cohorts across the state of Alabama. One cohort includes children and adults with undiagnosed rare disease; a second includes an unselected adult population. Here we describe findings from the first 176 rare disease and 5369 population cohort AGHI participants.

METHODS

AGHI participants enroll in one of two arms of a research protocol that provides access to genomic testing results and biobank participation. Rare disease cohort participants receive genome sequencing to identify primary and secondary findings. Population cohort participants receive genotyping to identify pathogenic and likely pathogenic variants for actionable conditions.

RESULTS

Within the rare disease cohort, genome sequencing identified likely pathogenic or pathogenic variation in 20% of affected individuals. Within the population cohort, 1.5% of individuals received a positive genotyping result. The rate of genotyping results corroborated by reported personal or family history varied by gene.

CONCLUSIONS

AGHI demonstrates the ability to provide useful health information in two contexts: rare undiagnosed disease and population screening. This utility should motivate continued exploration of ways in which emerging genomic technologies might benefit broad populations.

Development of a Multifaceted Health Disparities Curriculum for Medical Residents

BACKGROUND AND OBJECTIVES

Health disparities education is required during residency training. However, residency program directors cite numerous barriers to implementing disparities curricula, and few publications describing successful disparities curricula exist in the literature. In this report, we describe the development, implementation, and early evaluation of a longitudinal health disparities curriculum for resident physicians. We provide resource references, process, and didactic toolkits to facilitate use by other residency programs.

METHODS

We used a standard, six-step model for curricular design, implementation, and evaluation. We assessed feasibility of curricular development including practicality (program cost and time requirements) and demand (resident engagement). We also assessed program and learner outcomes, including number of didactic and clinic sessions delivered and resident preparedness, attitudes, and skill in caring for vulnerable patients.

RESULTS

We designed, implemented, and evaluated our curriculum in less than 1 year, with no external funding. Time costs included 100 chief resident and 20 faculty hours for curricular development, followed by 20 chief resident and 16 faculty hours for implementation. In the first year of our curriculum, 21% of residents (16 of 75) participated. We created eight didactic sessions and delivered four as intended. Residents provided 84 free clinic sessions for uninsured patients and reported increased preparedness and skill caring for vulnerable patients in 15 of 20 measured domains. Residents also reported 20 commitments to change on themes that comprehensively reflected the content of our first curricular year.

CONCLUSIONS

It is possible to design a disparities curriculum, overcome cited barriers, and improve educational outcomes related to the care of vulnerable patients.

Nicotine replacement therapy-associated syndrome of inappropriate antidiuretic hormone

Nicotine has been documented to regulate the release of plasma arginine vasopressin (AVP). The literature is inconclusive about the effects of nicotine replacement therapy on AVP release, although cigarette smoking has been shown to increase the release of AVP. No clinical case reports have documented the possible association between nicotine replacement and hyponatremia through AVP release. We report a case of a 39-year-old man who experienced syndrome of inappropriate antidiuretic hormone while on nicotine patch therapy. We theorize that the constant serum concentration of nicotine levels provided through the patch may cause hyponatremia through the continuous stimulation of vasopressin.

Necrotizing arteritis associated with blastomycosis

We have described a patient with cavitary pulmonary fungal infection, probably blastomycosis, with necrotizing arteritis of the skin. The pulmonary and skin lesions resolved with amphotericin B therapy.

Neurogenic bladder in Rocky Mountain spotted fever

A previously healthy 29-year-old man who had verified Rocky Mountain spotted fever had a flaccid neurogenic bladder that resolved as he recovered from his infection. The neurologic complications of this disease are presumed to be related to vasculitis with resulting ischemia or infarction of nervous tissue.

Klinefelter's syndrome and mediastinal germ cell neoplasms

We describe 2 patients with Klinefelter's syndrome in whom mediastinal germ cell neoplasms developed. This association also has been noted in the literature in 6 other cases. The pathogenesis of these otherwise rare neoplasms probably is related to the genetic abnormality and the abnormal hormonal status in Klinefelter's syndrome. Patients with Klinefelter's syndrome appear to have an increased risk of development of extragonadal mediastinal germ cell neoplasms and should be followed closely, while patients with mediastinal germ cell neoplasms should have karyotypes performed.

Human nocardiosis. A clinical review with selected case reports

Nocardiosis is an illness caused by several species of the genus Nocardia. Although it is seen in immunocompromised hosts, infection frequently occurs in persons with no recognized predisposition. Infection may be localized to the skin, or it may involve the lungs, disseminating to virtually any organ. Pathogenesis is only beginning to be understood, but, at least in laboratory animals, there seems to be a host-parasite relationship that depends on inadequate clearing of the organism by processes of cell-mediated immunity. Clinical manifestation varies widely according to the sites involved. Diagnosis is principally by culture and may require an aggressive approach. Although sulfonamides remain the mainstay of therapy, preliminary data for other antimicrobial agents are promising.