Faculty Bibliography

Similar to the early phases of the COVID-19 pandemic, New York City was the national epicenter of the ongoing 2022 mpox (formerly monkeypox) outbreak. Cases quickly began to rise in July 2022, primarily in gay, bisexual, or other men who have sex with men. Tools in the form of a reliable diagnostic test, an effective vaccine, and a viable treatment option have been available from the onset, although logistically complex to roll out. The special pathogens program at NYC Health + Hospitals/Bellevue, the flagship facility for the largest public hospital system in the United States, collaborated with multiple departments within Bellevue, the hospital system, and the NYC Department of Health and Mental Hygiene, to swiftly establish ambulatory testing, immunizations, patient-centered inpatient care, and outpatient therapeutics. With the ongoing mpox outbreak, hospitals and local health departments must prepare a systemwide response to identify and isolate patients and provide high-quality care. Findings from our experience can help guide institutions in developing a multipronged, comprehensive response to the ongoing mpox outbreak.

PURPOSE OF REVIEW:The purpose of this review is to summarize recent literature on nontuberculous mycobacteria in water of healthcare systems. Despite improvement in identification techniques and emergence of infection prevention and control programs, nontuberculous mycobacteria remain present in hospital water systems, causing outbreaks and pseudo-outbreaks in healthcare settings. RECENT FINDINGS:Waterborne outbreaks and pseudo-outbreaks of nontuberculous mycobacteria continue to affect hospitals. Improvements in methods of identification and investigation, including MALDI-TOF and whole genome sequencing with evaluation of single nucleotide polymorphisms, have been used successfully in outbreak and pseudo-outbreak investigations. Recent studies have shown control of outbreaks in immunocompromised patients through the use of sterile water for consumption, as well as control of pseudo-outbreaks by using sterile water for procedures. Construction activities have been implicated in outbreaks and pseudo-outbreaks of nontuberculous mycobacteria. Water management programs are now required by the Joint Commission, which will likely improve water risk mitigation. SUMMARY:Improvement in detection and identification of nontuberculous mycobacteria has led to increasing recognition of waterborne outbreaks and pseudo-outbreaks. Water management programs are of vital importance in infection prevention.

OBJECTIVES/OBJECTIVE:People detained in correctional facilities are at high risk for infection with severe acute respiratory syndrome coronavirus 2, the virus that causes coronavirus disease 2019 (COVID-19). We described the epidemiology of the COVID-19 outbreak in a large urban jail system, including signs and symptoms at time of testing and risk factors for hospitalization. METHODS:This retrospective observational cohort study included all patients aged ≥18 years who were tested for COVID-19 during March 11-April 28, 2020, while in custody in the New York City jail system (N = 978). We described demographic characteristics and signs and symptoms at the time of testing and performed Cox regression analysis to identify factors associated with hospitalization among those with a positive test result. RESULTS:Of 978 people tested for COVID-19, 568 received a positive test result. Among symptomatic patients, the most common symptoms among those who received a positive test result were cough (n = 293 of 510, 57%) and objective fever (n = 288 of 510, 56%). Of 257 asymptomatic patients who were tested, 58 (23%) received a positive test result. Forty-five (8%) people who received a positive test result were hospitalized for COVID-19. Older age (aged ≥55 vs 18-34) (adjusted hazard ratio [aHR] = 13.41; 95% CI, 3.80-47.33) and diabetes mellitus (aHR = 1.99; 95% CI, 1.00-3.95) were significantly associated with hospitalization. CONCLUSIONS:A substantial proportion of people tested in New York City jails received a positive test result for COVID-19, including a large proportion of people tested while asymptomatic. During periods of ongoing transmission, asymptomatic screening should complement symptom-driven COVID-19 testing in correctional facilities. Older patients and people with diabetes mellitus should be closely monitored after COVID-19 diagnosis because of their increased risk for hospitalization.

Jamestown Canyon virus (JCV) is a neuroinvasive arbovirus that is found throughout North America and increasingly recognized as a public health concern. From 2004 to 2012, an average of 1.7 confirmed cases were reported annually in the United States, whereas from 2013 to 2018 this figure increased over seventeen-fold to 29.2 cases per year. The rising number of reported human infections highlights the need for better understanding of the clinical manifestations and epidemiology of JCV. Here, we describe nine patients diagnosed with neuroinvasive JCV infection in Massachusetts from 2013, the year of the first reported case in the state, to 2017. Because current diagnostic testing relies on serology, which is complicated by cross-reactivity with related orthobunyaviruses and can be negative in immunosuppressed patients, we developed and evaluated an RT-qPCR assay for detection of JCV RNA. We tested this on the available archived serum from two patients, but did not detect viral RNA. JCV is transmitted by multiple mosquito species and its primary vector in Massachusetts is unknown, so we additionally applied the RT-qPCR assay and confirmatory RNA sequencing to assess JCV prevalence in a vector candidate, Ochlerotatus canadensis. We identified JCV in 0.6% of mosquito pools, a similar prevalence to neighboring Connecticut. We assembled the first Massachusetts JCV genome directly from a mosquito sample, finding high identity to JCV isolates collected over a 60-year period. Further studies are needed to reconcile the low vector prevalence and low rate of viral evolutionary change with the increasing number of reported cases.

Background/UNASSIGNED:High patient turnover presents challenges and opportunity to provide hepatitis C virus (HCV) care in US jails (remand facilities). This study describes the HCV care cascade in the New York City (NYC) jail system during the direct-acting antiviral (DAA) treatment era. Methods/UNASSIGNED:Patients admitted to the NYC jail system from January 2014 through December 2017 were included in this retrospective cohort analysis. We describe rates of screening, diagnosis, linkage to jail-based care, and treatment among the overall cohort, and among subgroups with long jail stays (≥120 days) or frequent stays (≥10 admissions). The study protocol was approved by a third-party institutional review board (BRANY, Lake Success, NY). Findings/UNASSIGNED:Among the 121,371 patients in our analysis, HCV screening was performed in 40,219 (33%), 4665 (12%) of whom were viremic, 1813 (39%) seen by an HCV clinician in jail, and 248 (5% of viremic patients) started on treatment in jail. Having a long stay (adjusted risk ratio [aRR] 8·11, 95% confidence interval [CI] 6·98, 9·42) or frequent stays (aRR 1·51, 95% CI 1·04, 2·18) were significantly associated with being seen by an HCV clinician. Patients with long stays had a higher rate of treatment (14% of viremic patients). Sustained virologic response at 12 weeks was achieved in 147/164 (90%) of patients with available virologic data. Interpretation/UNASSIGNED:Jail health systems can reach large numbers of HCV-infected individuals. The high burden of HCV argues for universal screening in jail settings. Length of stay was strongly associated with being seen by an HCV clinician in jail. Treatment is feasible among those with longer lengths of stay. Funding/UNASSIGNED:None.

Background/UNASSIGNED:The population detained in the New York City (NYC) jail system bears a high burden of hepatitis C virus (HCV) infection. Challenges to scaling up treatment include short and unpredictable lengths of stay. We report on the clinical outcomes of direct-acting antiviral (DAA) treatment delivered by NYC Health + Hospitals/Correctional Health Services in NYC jails from 2014 to 2017. Methods/UNASSIGNED:We performed a retrospective observational cohort study of HCV patients with detectable HCV ribonucleic acid treated with DAA therapy while in NYC jails. Some patients initiated treatment in jail, whereas others initiated treatment in the community and were later incarcerated. Our primary outcome was sustained virologic response at 12 weeks (SVR12). Results/UNASSIGNED:There were 269 patients included in our cohort, with 181 (67%) initiating treatment in jail and 88 (33%) continuing treatment started in the community. The SVR12 virologic outcome data were available for 195 (72%) individuals. Of these, 172 (88%) achieved SVR12. Patients who completed treatment in jail were more likely to achieve SVR12 relative to those who were released on treatment (adjusted risk ratio, 2.93; 95% confidence interval, 1.35-6.34). Of those who achieved SVR12, 114 (66%) had a subsequent viral load checked. We detected recurrent viremia in 18 (16%) of these individuals, which corresponded to 10.6 cases per 100 person-years of follow-up. Conclusions/UNASSIGNED:Hepatitis C virus treatment with DAA therapy is effective in a jail environment. Future work should address challenges related to discharging patients while they are on treatment, loss to follow-up, and a high incidence of probable reinfection.

BACKGROUND:Liver fibrosis stage determines risk of morbidity and mortality from chronic hepatitis C virus (HCV) infection. Prior data have shown long-term reversal of liver fibrosis, measured by vibration-controlled transient elastography (VCTE), in patients successfully treated with interferon-based therapies. AIM:Our study sought to determine the effect of treatment with modern HCV direct-acting antiviral (DAA) therapy on noninvasive liver fibrosis measurements. METHODS:A total of 70 patients had VCTE-based liver stiffness measurement (LSM) taken before treatment, directly after treatment completion, and at least 12 months after completion of DAA therapy. Our primary outcome was a >30% improvement in VCTE score at the end of follow-up, relative to baseline. RESULTS:The sustained virologic response rate in our cohort was 95.7%. In our cohort, 34 (48.6%) met the primary outcome. Those who had baseline elevated alanine aminotransferase (OR 3.27; 95% CI 1.13-9.47) and genotype 1 (OR 14.63; 95% CI 1.70-125.83) had higher odds of meeting that outcome, and this remained significant after adjusting for age, baseline body mass index, gender, baseline elevated alkaline phosphatase levels, treatment experience, liver transplant status, smoking, and baseline liver stiffness. CONCLUSION:Treatment of chronic HCV with modern DAA therapy was associated with a significant improvement in LSM by VCTE measurement, suggesting possible early improvement in liver fibrosis along with resolution of inflammation over the first year after treatment completion.

BACKGROUND/UNASSIGNED:Infectious diseases (ID) physicians are important for hepatitis C virus (HCV) care delivery in Canada. Our study describes their current and intended patterns of practice, attitudes, and barriers to care. METHODS/UNASSIGNED:The study population includes 372 practicing ID physicians who are members of the Association of Medical Microbiology and Infectious Disease (AMMI) Canada. A random sample from each province was invited to participate in a web-based survey. Our outcome of interest was level of HCV care provided, and related intentions for the next 12 months. Additional survey domains included attitudes toward treatment and perceived barriers to care. RESULTS/UNASSIGNED:Of 205 invitations to complete the survey, 64 (31%) physicians responded to the full survey and 81 to an abbreviated survey on the main outcomes of interest (overall response rate 71%). After adjusting for non-response, we estimate that 38% (95% CI 29% to 46%) are prescribing direct-acting antiviral (DAA) therapy, and 17% (95% CI 9% to 24%) are interested in starting to prescribe. Of full survey respondents, 100% of prescribers and 79% of non-prescribers agreed that people who inject drugs should be offered DAA therapy. Common barriers to care include patients' competing priorities, mental health comorbidities, poor access to harm reduction services, and insufficient physician training. CONCLUSIONS/UNASSIGNED:A large proportion of Canadian ID physicians are not currently prescribing DAA therapy for HCV. While some of these physicians are interested in starting to prescribe, we need strategies to improve physician training and address other barriers to care as provincial restrictions on DAA eligibility are being eliminated.

Approximately 170 million people harbor chronic infection with hepatitis C virus (HCV) worldwide, with 3-4 million in the United States. As recently as 2013, the few treatment options available were poorly tolerated and only moderately effective. That changed when the first interferon-free direct-acting antiviral (DAA) regimen was US Food and Drug Administration-approved in December 2013. There are now 10 approved DAAs, with several more deep in the pipeline to approval. There are now interferon-free regimens available for every HCV genotype, and the application of DAA combination regimens has lifted response rates for historically difficult-to-treat patient groups to levels on par with more conventional treatment groups, including persons with HIV/HCV coinfection. This review will summarize the data behind currently recommended DAA regimens, review the data for treatment of HIV/HCV-coinfected patients, and discuss important drug-drug interactions between HCV DAAs and HIV antiretrovirals.