BACKGROUND: The clinical and genomic epidemiology of human metapneumovirus (hMPV) infections in community settings is not well understood. METHODS: From 2018 to 2022, individuals with respiratory symptoms were recruited and enrolled from the greater Seattle, Washington community in the United States. Residual clinical specimens from individuals presenting with respiratory symptoms were additionally collected. Specimens were tested for hMPV by reverse-transcription polymerase chain reaction, with whole genome sequencing performed on a subset (209/1002). RESULTS: hMPV positivity was higher among clinical specimens (835/21 539 [3.9%]) compared to community specimens (167/28 348 [0.6%]). Children aged 0-4 years had the highest percent positivity across both clinical and community settings (497/10 213 [4.9%] and 28/1640 [1.7%], respectively). In multivariate analysis, a household income of ≤US$100 000 (adjusted odds ratio [aOR], 1.72 [95% confidence interval {CI}, 1.07-2.85]), and recent international travel (aOR, 6.51 [95% CI, 3.11-12.22]) were associated with hMPV positivity. A subset of 209 of 1002 samples (21%) was sequenced; the distribution of subtypes A2b, A2c, B1, and B2 were similar across both community and clinical settings, with an increase in the proportion of subtype B1 after the start of the pandemic. CONCLUSIONS: Risk factors of testing positive for hMPV in a community setting included lower household income and recent international travel. Co-circulation of hMPV subtypes was observed across community and clinical settings.

Introduction: The 2022 Behavioral Risk Factor Surveillance System introduced an optional module called social determinants and health equity to address health-related social needs, thereby supporting studies of social determinants of health. There were nonignorable nonresponses to the social determinants and health equity module. Methods: Nonresponse referred to an interviewee who completed the Behavioral Risk Factor Surveillance System core survey but chose not to answer any of the social determinants and health equity module questions. The study included 2022 Behavioral Risk Factor Surveillance System participants from 39 states; Washington, DC; and 2 territories. The sequential multiple imputation approach was used to impute the household income. Multivariable logistic regression was used to estimate the propensity of not answering any questions in social determinants and health equity. A nonresponse adjustment factor was developed for each state using a propensity score estimated from the logistic regression model. Results: Florida, California, and New Jersey had the highest nonresponse rates at 29.3%, 26.4%, and 25.6%, respectively. After excluding the outlier Puerto Rico, the median value of nonresponse adjustment factors for states ranged from 1.09 in Idaho to 1.67 in Florida. Conclusions: The nonresponse adjustment will mitigate the nonresponse bias in the analysis of social determinants and health equity data. The adjustment factor developed by the authors will be useful for analysts from various states, programs, and institutions studying social determinants and health equity. © 2025

Recommendations to use deer-excluding fencing as a method to reduce blacklegged ticks (Ixodes scapularis Say) in residential settings are based primarily upon studies excluding deer from large areas (≥3.5 hectares), often in undeveloped woodland settings. Evidence is still needed on the efficacy of deer-excluding fences for tick management at smaller suburban residential properties common to tick-endemic areas of the northeastern United States. We measured I. scapularis abundance at 16 fenced and 16 unfenced properties in Fairfield County, Connecticut, Westchester County, New York, and Washington County, Rhode Island. Overall, adult and nymphal I. scapularis encounter rates (ticks per sampling meter) were slightly higher on unfenced properties compared to within fenced properties, but differences were not significant (P > 0.05). Among fenced properties alone, tick encounter rates were significantly higher in areas immediately outside of fences compared with inside of fences for nymphs (P = 0.005), but not for adults (P > 0.05). Prevalence of tick pathogen infection with Borrelia burgdorferi sensu stricto, Borrelia miyamotoi, Babesia microti, Babesia odocoilei, or Anaplasma phagocytophilum did not differ significantly between fenced and unfenced properties (P > 0.05). Irrespective of fencing, adult tick abundance was higher at properties with stonewalls, dense herbaceous ecotone vegetation, and an absence of bird feeders. Nymphal tick encounter rates were associated with stonewalls, an absence of bird feeders, and presence of dense herbaceous understory vegetation. Household survey data revealed that deer were observed within some fenced areas. Our findings do not provide strong evidence that deer-excluding fences at properties smaller than 3.5 hectares surpress blacklegged ticks.

OBJECTIVE: Describe work-related asthma (WRA) cases and associated exposures in the legalized cannabis industry. METHODS: Using data from four state-based surveillance systems (California, Massachusetts, Michigan, and Washington), WRA cases within the cannabis industry were identified and classified as new-onset asthma (NOA) or work-aggravated asthma (WAA). RESULTS: From legalization dates (1996 in California, 2012 in Massachusetts, 2008 in Michigan, 1998 in Washington) through 2023, 30 WRA cases were identified. A majority were aged 18-34 (66.7%) and were male (60.0%). Thirteen (52.0%) cases were NOA and 12 (48.0%) were WAA, with two fatalities. The most frequently reported exposure was plant materials (40.4%), of which 94.7% were cannabis dust and/or marijuana plant. Most cases (69.0%) worked in indoor cultivation/processing. CONCLUSIONS: Cannabis industry workers are at risk for WRA, emphasizing the need for interventions to address workplace respiratory hazards.

BACKGROUND: Comparing the characteristics of patients with long COVID to those with other post-acute infection syndromes (PAIS) could potentially provide clues to common underlying disease processes that may affect patient recovery. METHODS: We identified records of patients who had documented SARS-CoV-2 tests in the University of Washington Medicine electronic health record (EHR) database from January 1, 2019, through January 31, 2022 (n = 139,472). Patients were classified into three groups: 1) long COVID defined by a positive SARS-CoV-2 test and a long COVID-related diagnosis code (n = 580); 2) recovered COVID defined by a positive test and no long COVID associated diagnosis codes (n = 7,437); and 3) non-COVID PAIS defined by a negative test, non-SARS-CoV-2 related PAIS diagnosis codes, and no COVID related codes (n = 106). Using multivariate logistic regression, we compared the clinical characteristics of these groups at three timeframes to address preclinical, acute and post-acute diagnoses: before index SARS-CoV-2 test, within 30 days of index test, and > 30 days after index test. RESULTS: The long COVID group had a higher Charlson comorbidity index [median (IQR), 2 (0-4)] than the other two patient groups [median (IQR), 1 (0-3) and 1 (0-3)]. The long COVID and non-COVID PAIS patients were older and had greater smoking exposure than the recovered COVID group. Compared to the recovered COVID control group, the long COVID group had more health problems prior to the infection, including respiratory and metabolic as well as more severe infections and comorbidities based on the ICD codes found in the acute phase records. In the post-acute timeframe, many symptoms were more likely to be associated with long COVID than recovered patients with COVID-19 including abnormalities of heart beat [OR (95% CI), 5.31 (3.96-7.13)], cognition, perception, or emotional state symptoms [OR (95% CI), 5.14 (3.81-6.92)], malaise and fatigue [OR (95% CI), 4.20 (3.13-5.63)], and sleep disorders [OR (95% CI), 2.47, (1.79-3.43)], all p < 0.05. In contrast, the non-COVID PAIS group shared many similarities with the long COVID group across all three timeframes. CONCLUSIONS: Patients diagnosed with long COVID were more similar to patients with a non-COVID-related PAIS than to recovered patients with COVID-19. This suggests risk factors for PAIS may be similar and independent of the infectious agent.

Disease burden studies commonly use data from electronic health records (EHRs) or community surveys. Quantitative bias assessments of these study designs are needed. We compared two studies on acute gastroenteritis (AGE) burden conducted in an integrated healthcare system in Oregon and Washington, USA. EHRs were used to identify AGE patients who sought care during July 2014 - June 2016 and determine the incidence of medically attended AGE (MAAGE). Members from the same health care system were surveyed during September 2016 - September 2017 to estimate community AGE incidence. MAAGE incidence was calculated using the rate of reported healthcare seeking among survey respondents and compared to the estimate derived from the EHR study. Survey respondents' EHR data were used to conduct a bias analysis. MAAGE incidence from survey respondents was 6.1 times higher than the EHR derived MAAGE estimate. Among survey respondents who self-reported contacting KPNW for an AGE episode, 36.3% had an AGE-coded encounter in the EHR during the same timeframe, and among those who reported no contact (either no AGE or AGE without medical attention), 2.6% did have an AGE-coded encounter. Potential noninfectious explanations for symptoms were reported by 35% of ill survey respondents. We quantify misclassification bias in both studies and discuss other potential sources of bias. Researchers should consider these biases when designing disease burden studies and consider including sensitivity analyses in published work.

Histoplasmosis is a fungal infection that primarily affects the lungs. The condition is caused by Histoplasma organisms, which are often found in soil contaminated with bird or bat droppings. On January 17, 2025, a Georgia infectious disease physician notified CDC of suspected histoplasmosis cases among 12 members of an extended family from households in Georgia, Texas, and Washington. The ill family members included six adults aged 42-49 years and six children aged 8-16 years. They had recently returned from Costa Rica, where they toured a cave linked to a previous histoplasmosis outbreak (1).

PROBLEM/CONDITION: An estimated 450,000 enteric illnesses, 5,000 hospitalizations, and 76 deaths associated with animal contact occur each year in the United States. Enteric illnesses are diseases that affect the stomach or intestines and cause symptoms, such as diarrhea, nausea, or vomiting, and are typically transmitted from animals to humans through the fecal-oral route. Humans might encounter animal feces or bodily fluids through contact with the animal itself, the animal's environment, or the animal's food or water. Although outbreak-associated illnesses account for a small subset of all enteric illnesses linked to animal contact, data obtained from outbreak surveillance offer insights into the underlying epidemiologic factors contributing to illnesses, including the pathogens, animals, pathogen-animal category pairs, and settings of outbreaks associated with animal contact. PERIOD COVERED: 2009-2021. DESCRIPTION OF SYSTEM: The Animal Contact Outbreak Surveillance System (ACOSS) was launched in 2009 in conjunction with the National Outbreak Reporting System (NORS), a web-based platform that includes reports of foodborne and waterborne outbreaks as well as enteric disease outbreaks transmitted by contact with environmental sources, infected persons or animals, or unknown modes. ACOSS encompasses animal contact outbreaks that are reported to CDC through NORS. Local, state, and territorial health departments voluntarily report animal contact outbreaks, which are defined as two or more enteric illnesses associated with a common animal source. Outbreaks can involve single or multiple states; CDC staff typically report multistate outbreaks on behalf of state and territorial health departments. ACOSS defines an animal source as an animal (including domestic and wild animals); an animal's feces or bodily fluids (except milk and other fluids consumed as food, which are defined as foodborne sources); an animal's fur, hair, feathers, scales, or skin; an animal's food; or an animal's environment, which includes places in which it lives and roams. RESULTS: During 2009-2021, a total of 557 animal contact outbreaks of enteric disease were reported in the United States through ACOSS, accounting for 14,377 illnesses, 2,656 hospitalizations, and 22 deaths. Exposures were reported in all 50 states, Washington, DC, and Puerto Rico. During the period there were 393 single-state outbreaks and 164 multistate outbreaks. Although multistate outbreaks comprised 29% of all outbreaks reported through ACOSS, they accounted for 80% of illnesses, 88% of hospitalizations, and 82% of deaths. Among 474 outbreaks with a confirmed single etiology, Salmonella was the most common cause of outbreaks (248 outbreaks [52%]); these outbreaks accounted for the most outbreak-associated illnesses (11,822 [85%]), hospitalizations (2,393 [91%]), and deaths (17 [77%]). Cryptosporidium (108 outbreaks [23%]) was the second leading cause of confirmed, single etiology outbreaks, followed by Escherichia coli (63 [13%]) and Campylobacter (52 [11%]). The most common exposure locations among outbreaks with a single location reported were private home (168 [40%]) and farm or dairy (89 [21%]). Among 467 outbreaks for which an animal source could be attributed to a single animal category, ruminants (171 [37%]) were the most implicated animal category (with 75% of ruminant outbreaks attributed to cattle), followed by poultry (155 [33%]) and turtles (39 [12%]). Poultry were associated with the most outbreak-associated illnesses (9,095 [66% of illnesses resulting from outbreaks attributed to a single animal category]), hospitalizations (1,804 [70%]), and deaths (15 [83%]). Most outbreaks (130 [84% of all poultry outbreaks]) attributed to poultry had private home reported as at least one of the exposure locations (i.e., backyard poultry) and were responsible for nearly all poultry-associated illnesses (8,897 [98%]). The most common confirmed pathogen-animal pair was Salmonella and poultry (132 outbreaks), followed by Cryptosporidium and ruminants (88), and Salmonella and turtles (37). Salmonella and poultry accounted for the highest number of outbreak-associated illnesses (8,965), hospitalizations (1,790), and deaths (15). INTERPRETATION: Animal contact outbreaks of enteric disease reported through ACOSS provide insights into the animals and etiologies causing outbreak-associated enteric illnesses as well as other outbreak characteristics, such as settings in which outbreaks occur. These findings can guide public health actions, developed in collaboration with specific populations (e.g., backyard poultry owners) and including interventions tailored to settings, such as private homes and farms or dairies, that are more commonly associated with animal contact outbreaks. The high proportion of outbreaks occurring in private homes identifies a potential gap in proper hygiene and enteric disease prevention knowledge among animal owners, including owners of backyard poultry, which might be considered by owners to be pets rather than livestock. Settings and populations linked to ruminants, poultry, and turtles (particularly cattle, backyard poultry, and small turtles, respectively) are important targets for public health interventions because of the high number of outbreaks and outbreak-associated illnesses associated with these animal sources. Furthermore, the disproportionate impact of multistate outbreaks reiterates the importance of a collaborative national response but also might reflect limited resources to investigate or report animal contact outbreaks at state and local levels. PUBLIC HEALTH ACTION: Public health partners should continue to report animal contact outbreaks through ACOSS to inform evidence-based interventions tailored to specific animals, pathogens, populations, and settings. Strengthening the capacity of local, state, and territorial health departments to investigate and report animal contact outbreaks is critical to improving surveillance of animal contact outbreaks. Close collaboration between state, local, and Federal public health and agricultural partners nationwide is also key in investigating and responding to multistate outbreaks. An integrated One Health approach that leverages the expertise of animal, environmental, and public health partners can facilitate successful public health interventions aimed at preventing animal contact outbreaks.

INTRODUCTION: This paper is a systematic review of evidence from economic evaluations of family-based interventions that was recommended by the Community Preventive Services Task Force (CPSTF) to prevent substance use among youth. METHODS: The search covered studies published from inception of databases through October 2023 and was limited to those based in the United States (U.S.) and other high-income countries. The present review reports results from peer-reviewed studies and government reports as separate sources of evidence. Analyses were conducted during June 2023 through September 2024. Monetary values are in 2023 U.S. dollars. RESULTS: The search yielded 11 peer-reviewed studies and two government reports, one from the Washington State Institute for Public Policy (WSIPP) that evaluated 14 programs and one from the Substance Abuse and Mental Health Administration (SAMHSA) that evaluated 8 programs. The median intervention cost ranged from $655 to $1,672 per family and $677 to $753 per youth or participant across the 3 sources of evidence. The median benefit to cost ratio were 5.8, 3.9, and 8.9 from peer-reviewed studies, WSIPP, and SAMHSA, respectively, with all three estimates indicating that benefits exceed cost. SAMHSA's report found some interventions to be cost-saving and the others to have a median cost per quality-adjusted life years (QALY) gained of $21,426. DISCUSSION: CPSTF determined cost-benefit evidence across the three sources showed societal benefits exceeded cost of family-based interventions to prevent substance use among youth. CPSTF determined there were not enough peer-reviewed studies to reach a conclusion about cost-effectiveness.

PROBLEM/CONDITION: Autism spectrum disorder (ASD). PERIOD COVERED: 2022. DESCRIPTION OF SYSTEM: The Autism and Developmental Disabilities Monitoring Network is an active surveillance program that estimates prevalence and characteristics of ASD and monitors timing of ASD identification among children aged 4 and 8 years. In 2022, a total of 16 sites (located in Arizona, Arkansas, California, Georgia, Indiana, Maryland, Minnesota, Missouri, New Jersey, Pennsylvania, Puerto Rico, Tennessee, Texas [two sites: Austin and Laredo], Utah, and Wisconsin) conducted surveillance for ASD among children aged 4 and 8 years and suspected ASD among children aged 4 years. Surveillance included children who lived in the surveillance area at any time during 2022. Children were classified as having ASD if they ever received 1) an ASD diagnostic statement in a comprehensive developmental evaluation, 2) autism special education eligibility, or 3) an ASD International Classification of Diseases, Ninth Revision (ICD-9) code in the 299 range or International Classification of Diseases, Tenth Revision (ICD-10) code of F84.0, F84.3, F84.5, F84.8, or F84.9. Children aged 4 years were classified as having suspected ASD if they did not meet the case definition for ASD but had an evaluator's suspicion of ASD documented in a comprehensive developmental evaluation. RESULTS: Among children aged 8 years in 2022, ASD prevalence was 32.2 per 1,000 children (one in 31) across the 16 sites, ranging from 9.7 in Texas (Laredo) to 53.1 in California. The overall observed prevalence estimate was similar to estimates calculated using Bayesian hierarchical and random effects models. ASD was 3.4 times as prevalent among boys (49.2) than girls (14.3). Overall, ASD prevalence was lower among non-Hispanic White (White) children (27.7) than among Asian or Pacific Islander (A/PI) (38.2), American Indian or Alaska Native (AI/AN) (37.5), non-Hispanic Black or African American (Black) (36.6), Hispanic or Latino (Hispanic) (33.0), and multiracial children (31.9). No association was observed between ASD prevalence and neighborhood median household income (MHI) at 11 sites; higher ASD prevalence was associated with lower neighborhood MHI at five sites.Record abstraction was completed for 15 of the 16 sites for 8,613 children aged 8 years who met the ASD case definition. Of these 8,613 children, 68.4% had a documented diagnostic statement of ASD, 67.3% had a documented autism special education eligibility, and 68.9% had a documented ASD ICD-9 or ICD-10 code. All three elements of the ASD case definition were present for 34.6% of children aged 8 years with ASD.Among 5,292 (61.4% of 8,613) children aged 8 years with ASD with information on cognitive ability, 39.6% were classified as having an intellectual disability. Intellectual disability was present among 52.8% of Black, 50.0% of AI/AN, 43.9% of A/PI, 38.8% of Hispanic, 32.7% of White, and 31.2% of multiracial children with ASD. The median age of earliest known ASD diagnosis was 47 months and ranged from 36 months in California to 69.5 months in Texas (Laredo).Cumulative incidence of ASD diagnosis or eligibility by age 48 months was higher among children born in 2018 (aged 4 years in 2022) than children born in 2014 (aged 8 years in 2022) at 13 of the 15 sites that were able to abstract records. Overall cumulative incidence of ASD diagnosis or eligibility by age 48 months was 1.7 times as high among those born in 2018 compared with those born in 2014 and ranged from 1.4 times as high in Arizona and Georgia to 3.1 times as high in Puerto Rico. Among children aged 4 years, for every 10 children meeting the case definition of ASD, one child met the definition of suspected ASD.Children with ASD who were born in 2018 had more evaluations and identification during ages 0-4 years than children with ASD who were born in 2014 during the 0-4 years age window, with an interruption in the pattern in early 2020 coinciding with onset of the COVID-19 pandemic.Overall, 66.5% of children aged 8 years with ASD had a documented autism test. Use of autism tests varied widely across sites: 24.7% (New Jersey) to 93.5% (Puerto Rico) of children aged 8 years with ASD had a documented autism test in their records. The most common tests documented for children aged 8 years were the Autism Diagnostic Observation Schedule, Autism Spectrum Rating Scales, Childhood Autism Rating Scale, Gilliam Autism Rating Scale, and Social Responsiveness Scale. INTERPRETATION: Prevalence of ASD among children aged 8 years was higher in 2022 than previous years. ASD prevalence was higher among A/PI, Black, and Hispanic children aged 8 years than White children aged 8 years, continuing a pattern first observed in 2020. A/PI, Black, and Hispanic children aged 8 years with ASD were also more likely than White or multiracial children with ASD to have a co-occurring intellectual disability. Identification by age 48 months was higher among children born in 2018 compared with children born in 2014, suggesting increased early identification consistent with historical patterns. PUBLIC HEALTH ACTION: Increased identification of autism, particularly among very young children and previously underidentified groups, underscores the increased demand and ongoing need for enhanced planning to provide equitable diagnostic, treatment, and support services for all children with ASD. The substantial variability in ASD identification across sites suggests opportunities to identify and implement successful strategies and practices in communities to ensure all children with ASD reach their potential.

Same-day pre-exposure prophylaxis for HIV (PrEP) is recommended to improve access to this important HIV prevention tool. A PrEP program at a community-based LGBTQ+ clinic in Seattle, Washington provided PrEP via telemedicine with a focus on converting testing-only visits to same-day 'Insta-PrEP' visits. We identified three key barriers to same-day PrEP for clients who present to clinic for testing-only visits: delays related to health insurance; longer counseling times; and disruption of clinic flow following Insta-PrEP visits. Copyright © 2025 Wolters Kluwer Health, Inc. All rights reserved.

BACKGROUND: Monitoring temporal trends in firearm injury-related emergency department (ED) visits is challenging because traditional surveillance systems lack detailed temporal information. OBJECTIVE: To describe temporal patterns of ED visits for firearm injury using data from the Centers for Disease Control and Prevention's (CDC) Firearm Injury Surveillance Through Emergency Rooms (FASTER) program. DESIGN: Cross-sectional analysis of firearm injury-related ED visits. SETTING: 9 states (Florida, Georgia, New Mexico, North Carolina, Oregon, Utah, Virginia, Washington, and West Virginia) and the District of Columbia from 1 January 2018 to 31 August 2023. PATIENTS: ED visits for firearm injury (n = 93 022) from CDC's FASTER program. MEASUREMENTS: ED visits for firearm injury per 100 000 ED visits, analyzed by time of day (in 30-minute intervals), day of the week, day of the year, and holidays. RESULTS: From January 2018 through August 2023, there were 93 022 firearm injury ED visits (73.9 per 100 000 ED visits), or approximately 1 firearm injury every 30 minutes overall. Rates of firearm injury ED visits were highest between 2:30 and 3:00 a.m. and lowest between 10:00 and 10:30 a.m. Nighttime peaks and daily rates were highest on Friday and Saturday. Monthly rates were highest in July and lowest in February; daily rates were disproportionately high on most holidays, especially Independence Day and New Year's Eve. LIMITATIONS: Data are limited to 9 states and the District of Columbia and are not nationally representative. The analysis of ED visits for firearm injury does not distinguish injury intent and is based on arrival time rather than actual injury time. CONCLUSION: Distinct temporal patterns in firearm injury ED visits highlight resource allocation considerations for prevention and response efforts. PRIMARY FUNDING SOURCE: Centers for Disease Control and Prevention.

Human metapneumovirus (hMPV) is an important cause of respiratory illness. However, information about hMPV incidence, patient characteristics, and symptoms outside hospital settings is limited. During June 2022-March 2024, participants aged 6 months-49 years who were enrolled in the CASCADIA community-based cohort study submitted weekly illness surveys and nasal swabs, and completed follow-up illness surveys. Swabs collected 0-3 days before reporting new or worsening symptoms were tested for hMPV and other respiratory viruses by multiplex polymerase chain reaction. Incidence was analyzed using an exponential survival model. Among 3,549 participants, 306 had symptomatic hMPV infection, representing an average of 7.5 cases per 100 persons per year (95% CI = 6.7-8.4). Incidence was highest during January-March (adjusted hazard ratio [aHR] = 4.3; 95% CI = 3.0-6.0) compared with October-December, and among those aged 2-4 years (aHR = 5.8; 95% CI = 3.8-9.0) compared with those aged ≥40 years. The most frequently reported symptoms were cough (80.4%) and nasal congestion (71.9%). Among 252 (82.4%) participants who completed a post-illness follow-up survey, 68 (27.0%) missed work, school, or child care facility attendance. Together, these findings indicate that hMPV is a common cause of respiratory illness during late winter to spring, particularly among young children, and frequently disrupts daily activities. Understanding hMPV epidemiology can guide surveillance definitions, clinical testing, and prioritization of prevention strategies.

We describe a case of alpha-gal syndrome (AGS) in a resident of Washington, USA, after local Ixodes pacificus tick bites, which were associated with IgE increases after diagnosis. AGS should be considered a potential cause of anaphylactic and allergic reactions in persons with tick exposures, regardless of geographic residence.

Seroprevalence studies play an important role in estimating the number of children infected with SARS-CoV-2. We report SARS-CoV-2 seroprevalence in children seeking medical care for any reason at a free-standing pediatric hospital in Seattle, WA over a 2.5-year period and four distinct pandemic waves. We randomly selected residual serum samples from children and young adults seeking medical care as inpatients and outpatients at Seattle Children's Hospital between June 2020 and December 2022 to test for the presence of anti-nucleocapsid (N) antibodies. Samples were categorized into four distinct pandemic waves based on Washington State epidemiology: Wave 1 (June 2020-October 2020), Wave 2 (November 2020-June 2021), Wave 3 (July 2021-November 2021), and Wave 4 (December 2021-December 2022). Patient characteristics and COVID-19 vaccine status were obtained, and zip codes were used to ascertain the Social Vulnerability Index (SVI). Multivariable Poisson regression models with robust variance estimates were used to examine the relationship between patient characteristics and anti-N-positivity for each wave. Among 8,040 samples from 7,102 patients included in the analyses, seroprevalence rose from 2.4% (95% CI, 2.0%-3.1%) in Wave 1 to 25.5% (95% CI 23.3%-27.8%) in Wave 4 (following the Omicron surge). High SVI, Hispanic ethnicity, or use of government insurance was associated with increased anti-N positivity in most waves. We observed a steady increase in anti-N seroprevalence followed by a sharp increase after the Omicron surge in early 2022. Our data demonstrate the burden of COVID-19 on specific groups with health disparities within our region throughout the pandemic.IMPORTANCEOur results highlight the importance of seropositivity studies as essential tools to provide information on the incidence and prevalence of SARS-CoV-2 seropositivity. Our results also reinforce other reports demonstrating the inequitable burden of COVID-19 on groups with health disparities and that this inequitable burden continued to persist throughout the pandemic, even in a region with high adherence to COVID-19 mitigation efforts. It also highlights SVI's value in identifying communities that must be part of pandemic research, and public health and vaccination strategies.

Background: Guidelines recommend tailored reproductive health counseling for women with congenital heart defects (CHDs) beginning in adolescence, yet provider adherence to recommendations remains understudied, particularly outside specialized cardiac care settings. Study Design: We conducted a cross-sectional cohort study among women aged 19 to 38 with CHDs, identified from active population-based birth defects registries in three states. Participants completed surveys from 2016 to 2019, including questions about contraception, pregnancy counseling, concerns, and experiences. Multivariable Poisson regression, adjusted for sociodemographic and health characteristics, assessed associations between CHD severity, counseling, and reproductive health outcomes. Results: Of 765 women, those with severe CHDs, compared with non-severe, were more likely to report receiving clinician counseling about safe contraceptive methods (44.0% and 13.7%; adjusted prevalence ratio [aPR] = 3.0; 95% confidence interval [95% CI] [2.2, 4.0]), pregnancy, (63.3% and 16.5%; aPR = 3.6; 95% CI [2.7, 4.6]), and pregnancy avoidance (32.0% and 6.4%; aPR = 4.3; 95% CI [2.9, 6.6]); be concerned about ability to have children (40.9% and 31.2%; aPR = 1.4; 95% CI [1.1, 1.8]), and delay/avoid pregnancy (26.6% and 10.7%; aPR = 2.2; 95% CI [1.5, 3.2]). No disparity was found in ever being pregnant (30.0% vs. 37.2%; aPR = 1.0; 95% CI [0.7, 1.2]). One-third of the respondents with any CHD reported concerns about their ability to have children (33.6%). Conclusion: We found that only a minority of women with CHDs reported receiving counseling on safe contraception and pregnancy, and about a third reported concerns about their ability to have children. These findings highlight a gap between guideline recommendations and clinical practice, underscoring the need for improved reproductive health discussions for women with CHDs. © 2025 Jacobs Institute of Women's Health, George Washington University

BACKGROUND: Limited data are available regarding the development and durability of immune responses following COVID-19 infection or vaccination in pediatric solid-organ transplant (SOT) recipients. METHODS: Renal, liver, or intestinal transplant recipients < 21 years of age followed at Seattle Children's Hospital were enrolled from August 2020 to May 2021. Blood samples were collected at ~6-month intervals for up to 3 years and tested for antinucleocapsid (N) antibodies. COVID-19 vaccination data were collected from the Washington State Immunization Information System and/or the medical record. Semi-quantitative anti-S IgG testing was performed on all postvaccine samples using the Abbott Architect platform. We further evaluated a subset of postvaccine samples using variant-specific quantitative binding (Meso Scale Discovery, MSD) immunoassays and pseudovirus-neutralization assays. Antibody levels were compared over time and by vaccine category. RESULTS: We followed 83 SOT recipients for a median of 12.5 months (IQR 7.0, 28.3). Overall, 16 (19.3%) participants had evidence of SARS-CoV-2 infection based on anti-N antibody detection. Forty-six (55%) participants had a blood sample collected > 14 days after receipt of a vaccination. Serum IgG to spike antigens (anti-S antibody) increased following vaccination and increased with the number of vaccine doses received as assessed by both the Abbott and MSD assays. Neutralizing activity was significantly lower against the Omicron subvariants compared to the ancestral strain. CONCLUSION: Pediatric SOT recipients demonstrated strong antibody responses following SARS-CoV-2 vaccination, with higher anti-S antibody responses following > 2 doses of vaccine. Our study offers unique longitudinal immune response data in this vulnerable patient population.

BACKGROUND: Respiratory syncytial virus (RSV) is the leading cause of hospitalization among infants in the United States (US). RSV immunization, in the form of a monoclonal antibody (mAb) for infants and vaccines for pregnant people, may reduce infant RSV risk. METHODS: In April and May 2023, we surveyed adults with children in Oregon and Washington about the likelihood to accept infant mAb and maternal RSV vaccine and RSV awareness. We used multivariable logistic regression to identify predictors of self-reported likelihood of accepting RSV immunization. RESULTS: Among 1082 respondents, 68% and 70% responded they would very likely accept infant mAb or maternal RSV vaccine, respectively. Respondents had lower odds of accepting infant mAb (OR: 0.10, 95% CI: 0.07-0.15) and maternal RSV vaccine (OR: 0.16, 95% CI: 0.12-0.23) if they were somewhat or very concerned about side effects. Respondents had higher odds of accepting infant mAb if they received an influenza vaccination (OR: 3.79, 95% CI: 1.88-7.63). Respondents had higher odds of accepting maternal vaccine if they had an advanced degree (OR: 1.70, 95% CI: 1.06-2.73), had received an influenza vaccination (OR: 3.62, 95% CI: 1.80-7.25), or were aware of RSV before our survey (OR: 2.03, 95% CI: 1.03-4.01). CONCLUSION: Most respondents reported that they would likely accept RSV mAb for their infant or an RSV vaccine during pregnancy. Concerns about side effects lowered the odds of accepting immunization, however, nearly one-half of those concerned about side effects still expressed a high likelihood of accepting either immunization.

OBJECTIVES: This project aimed to understand the experiences and preferences for social risk factor screening among racially, ethnically, and linguistically diverse cancer survivors in the Washington, DC, region. METHODS: Semi-structured interviews were conducted with English, Spanish, and Amharic-speaking breast and prostate cancer survivors. Data were inductively coded to identify themes, and differences by race and preferred language were evaluated. FINDINGS: Twenty-two interviews in English (n = 14), Spanish (n = 7), and Amharic (n = 1) among participants who identified as Black (n = 8), White (n = 5), Asian (n = 1), Other (n = 6), and multiracial (n = 2) were completed. Participants reported unresolved needs during treatment including transportation, healthful food, mental health care, financial help, and employment assistance. COVID-19 exacerbated many needs. Most participants did not recall discussing needs with oncology teams, but all participants were open to having these conversations. CONCLUSION(S): This research reveals that cancer survivors might benefit from culturally appropriate strategies that address social needs.

COVID-19 vaccines mitigate severe disease, yet uptake remains low among people experiencing homelessness (PEH) despite the risk of transmission in congregate settings like homeless shelters. This study evaluated retrospective COVID-19 vaccination intent and decision-making between March 2020-October 2021 to identify modifiable factors to improve vaccine acceptance among PEH. We conducted 31 semi-structured interviews and eight focus group discussions across six homeless shelters in Seattle-King County, Washington. Residents and staff aged >= 18 years were recruited through purposive sampling for interviews and convenience sampling for focus groups. Thematic analysis was conducted. Participants reported that too much contradictory and changing information about COVID-19 vaccines led to confusion. Information deemed trustworthy contributed to individual's knowledge and in some cases changed their vaccination intent. While many intended to get vaccinated without external motivators, others were motivated by incentives and requirements. Despite intention to vaccinate, participants reported barriers to COVID-19 vaccine access including availability of vaccine doses, timely eligibility for vaccination, and availability of appointments. Participants presented recommendations to improve COVID-19 information content and dissemination, access, and use of incentives in shelter settings. Future research should test recommended vaccination strategies rooted in the voices and experiences of PEH to determine feasibility and effectiveness in shelter settings. (PsycInfo Database Record (c) 2025 APA, all rights reserved)

Objectives: In the United States, firearm injuries disproportionately occur in low-income communities and among racial and ethnic minority populations. Recognizing these patterns across social conditions is vital for effective public health interventions. Using timely and localized data, we examined the association between social vulnerability and firearm injuries in King County, Washington. Methods: For this ecological, cross-sectional study, we used health reporting areas (HRAs) (n = 61), a subcounty geography of King County. We obtained HRA-level counts of firearm injuries by using responses from King County emergency medical services (EMS) from 2019 through 2023. We measured HRA-level social vulnerability by using the Social Vulnerability Index (SVI) from the Centers for Disease Control and Prevention/Agency for Toxic Substances and Disease Registry, categorized into tertiles (low, moderate, and high SVI). We used bivariate choropleth mapping to illustrate spatial associations between SVI and rates of firearm injuries per 10 000 residents. We used Bayesian spatial negative binomial regression to quantify the strength of these associations. Results: Bivariate choropleth mapping showed a correlation between SVI and rates of firearm injuries. In spatial models, HRAs categorized as high SVI had a 3 times higher rate of firearm injuries than HRAs categorized as low SVI (incidence rate ratio = 3.01; 95% credible interval, 2.02-4.47). Rates of firearm injuries were also higher in HRAs categorized as moderate versus low SVI (incidence rate ratio = 1.72; 95% credible interval, 1.23-2.40). Conclusion: In King County, areas with high social vulnerability had high rates of EMS responses to firearm injuries. SVI can help identify geographic areas for intervention and provide a framework for identifying upstream factors that might contribute to spatial disparities in firearm injuries. © 2024, Association of Schools and Programs of Public Health.

OBJECTIVE: To compare the prevalence of diagnosed diabetes among U.S. adults with and without disabilities, overall and by subgroups. RESEARCH DESIGN AND METHODS: We used data on adults aged ≥18 years from the cross-sectional 2021-2022 National Health Interview Survey to report the prevalence of diagnosed diabetes by functional disability status and for each disability type (hearing, seeing, mobility, cognition, self-care, and communication) separately. With use of the Washington Group Short Set on Functioning indicator, disability was defined according to the categories of milder (reporting some difficulty), moderate (reporting a lot of difficulty), and severe (cannot do at all) by disability type. Crude prevalence and age-standardized prevalence of diabetes were also calculated for adults with any difficulty with any disability by age, sex, race/ethnicity, education, insurance, and poverty-to-income ratio. RESULTS: Diabetes prevalence increased with number of disability types, was lower among adults with no disability (5.8%) than among those with milder (9.5%) or moderate to more severe (18.3%) disability, and was 4.0-10.3 percentage points higher among those with moderate to more severe disability than among those with milder disability for vision, hearing, mobility, and cognitive disabilities. Diabetes prevalence was similar for adults with milder and moderate to more severe self-care and communication disabilities. CONCLUSIONS: Prevalence of diabetes was higher among adults with any functional disability than without and increased with increasing number of disability types. Adults with multiple disability types, or those who have difficulty with self-care or communication or other moderate to more severe disabilities, may benefit from diabetes prevention programs.

BACKGROUND: Institutions of higher education (IHE) have been a focus of SARS-CoV-2 transmission studies but there is limited information on how viral diversity and transmission at IHE changed as the pandemic progressed. METHODS: Here we analyze 3606 viral genomes from unique COVID-19 episodes collected at a public university in Seattle, Washington from September 2020 to September 2022. RESULTS: Across the study period, we found evidence of frequent viral transmission among university affiliates with 60% (n = 2153) of viral genomes from campus specimens genetically identical to at least one other campus specimen. Moreover, viruses from students were observed in transmission clusters at a higher frequency than in the overall dataset while viruses from symptomatic infections were observed in transmission clusters at a lower frequency. Although only a small percentage of community viruses were identified as possible descendants of viruses isolated in university study specimens, phylodynamic modeling suggested a high rate of transmission events from campus into the local community, particularly during the 2021-2022 academic year. CONCLUSIONS: We conclude that viral transmission was common within the university population throughout the study period but that not all university affiliates were equally likely to be involved. In addition, the transmission rate from campus into the surrounding community may have increased during the second year of the study, possibly due to return to in-person instruction.

Rotavirus is a leading cause of diarrhea among children but less known as a cause among adults. We describe clinical, epidemiologic, and genotype characteristics of a rotavirus outbreak among adults in King County, Washington occurring January-June 2023. Adult rotavirus incidence in 2023 was ten times higher than the same period in 2022 (5% versus 0.5% samples). Disease severity was mild. G9P[4], an uncommon, non-vaccine strain in USA, was the predominant genotype. Genotyping suggested spillover from children with subsequent spread among adults. Our study highlights benefits of routine testing and genotyping during outbreaks for surveillance, tracking, and understanding implications on vaccination.

STUDY OBJECTIVE: To understand trends in nonfatal firearm injuries by examining rates of firearm injury emergency department (ED) visits stratified by individual- and county-level characteristics. METHODS: Data from participating EDs within 10 jurisdictions in the United States funded through the Centers for Disease Control and Prevention's Firearm Injury Surveillance Through Emergency Rooms program, including the District of Columbia, Florida, Georgia, New Mexico, North Carolina, Oregon, Utah, Virginia, Washington, and West Virginia, were analyzed. We examined trends in firearm injury ED visits by sex, age group, jurisdiction, county-level urbanicity, and county-level social vulnerability from January 2019 to August 2023. Mean weekly rates of firearm injury ED visits and visit ratios (or the proportion of firearm injury-related ED visits of all visits during the surveillance periods with the same period in 2019) were calculated. RESULTS: Compared with 2019, the proportion of ED visits for firearm injury was elevated each year during 2020 to 2023 overall, with the largest observed increase in 2020 (visit ratio=1.59). All 10 Firearm Injury Surveillance Through Emergency Rooms jurisdictions experienced an increase in the proportion of firearm injury ED visits in 2020 (visit ratios ranging from 1.26 in West Virginia and 2.31 in Washington, DC) when compared with 2019. By county-level social vulnerability, the mean weekly rate of firearm injury ED visits was highest in counties with the highest social vulnerability over the entire study period. CONCLUSION: Results highlight the continued burden of firearm injuries in communities with higher social vulnerability. Timely ED data by community social vulnerability can inform public health interventions and resource allocation at local, state, and national levels.

INTRODUCTION: Occupational injuries have been associated with increased suicide mortality, but prior studies have not accounted for pre-injury depression. METHODS: We linked injuries that occurred from 1994 to 2000 in the Washington State workers' compensation system with Social Security Administration data on earnings and mortality through 2018. We estimated the subdistribution hazard ratio (sHR) and 95% confidence interval using competing risks regression of suicide deaths with lost time compared with medical-only injuries separately for men and women, adjusting for age, pre-injury annual earnings, and industry. We further adjusted for pre-injury diagnosis of major depressive disorder by using a quantitative bias analysis (QBA), with the prevalence of this disorder in workers derived from an external health insurance claims data set. RESULTS: Elevated suicide mortality was observed following lost-time injuries compared with medical-only injuries for men (sHR = 1.49, 95% CI [1.14, 1.93]) and women (sHR = 1.30, 95% CI [1.00, 1.69]), adjusting for age, pre-injury earnings, and industry. Adjusted for pre-injury depression using a QBA, elevated suicide risk in men remained statistically significant (median sHR = 1.33, simulation interval [1.18, 1.47]) but not for women. DISCUSSION: Workplace injury requiring time off work appeared to remain influential in increasing suicide risk among men, even after controlling for pre-injury depression. The relationship between mental health before and after occupational injury is complex and studies should better integrate mental health pre-injury. CONCLUSIONS: Though many questions remain on the complex relationship between work, depression, injuries, and suicide, employers should work to prevent injuries and consider implementing mental health programs, which could be helpful in reducing suicide risk.

OBJECTIVE: To determine whether differences exist in antibiotic prescribing for respiratory infections in pediatric urgent cares (PUCs) by patient race/ethnicity, insurance, and language. DESIGN: Multi-center cohort study. SETTING: Nine organizations (92 locations) from 22 states and Washington, DC. PARTICIPANTS: Patients ages 6 months-18 years evaluated April 2022-April 2023, with acute viral respiratory infections, otitis media with effusion (OME), acute otitis media (AOM), pharyngitis, community-acquired pneumonia (CAP), and sinusitis. METHODS: We compared the use of first-line (FL) therapy as defined by published guidelines. We used race/ethnicity, insurance, and language as exposures. Multivariable logistic regression models estimated the odds of FL therapy by group. RESULTS: We evaluated 396,340 ARI encounters. Among all encounters, 351,930 (88.8%) received FL therapy (98% for viral respiratory infections, 85.4% for AOM, 96.0% for streptococcal pharyngitis, 83.6% for sinusitis). OME and CAP had the lowest rates of FL therapy (49.9% and 60.7%, respectively). Adjusted odds of receiving FL therapy were higher in Black Non-Hispanic (NH) (adjusted odds ratio [aOR] 1.53 [1.47, 1.59]), Asian NH (aOR 1.46 [1.40, 1.53], and Hispanic children (aOR 1.37 [1.33, 1.41]), compared to White NH. Additionally, odds of receiving FL therapy were higher in children with Medicaid/Medicare (aOR 1.21 [1.18-1.24]) and self-pay (aOR 1.18 [1.1-1.27]) compared to those with commercial insurance. CONCLUSIONS: This multicenter collaborative showed lower rates of FL therapy for children of the White NH race and those with commercial insurance compared to other groups. Exploring these differences through a health equity lens is important for developing mitigating strategies.

OBJECTIVE: To investigate COVID-19 disparities between Hispanic/Latino persons (H/L) and non-H/L persons in an agricultural community by examining behavioral and demographic differences. METHODS: In September 2020, we conducted Community Assessments for Public Health Emergency Response in Wenatchee and East Wenatchee, Washington, to evaluate differences between H/L and non-H/L populations in COVID-19 risk beliefs, prevention practices, household needs, and vaccine acceptability. We produced weighted sample frequencies. RESULTS: More households from predominately H/L census blocks (H/L-CBHs) versus households from predominately non-H/L census blocks (non-H/L-CBHs) worked in essential services (79% versus 57%), could not telework (70% versus 46%), and reported more COVID-19 cases (19% versus 4%). More H/L-CBHs versus non-H/L-CBHs practiced prevention strategies: avoiding gatherings (81% versus 61%), avoiding visiting friends/family (73% versus 36%), and less restaurant dining (indoor 24% versus 39%). More H/L-CBHs versus non-H/L-CBHs needed housing (16% versus 4%) and food assistance (19% versus 6%). COVID-19 vaccine acceptance in H/L-CBHs and non-H/L-CBHs was 42% versus 46%, respectively. CONCLUSIONS: Despite practicing prevention measures with greater frequency, H/L-CBHs had more COVID-19 cases. H/L-CBHs worked in conditions with a higher likelihood of exposure. H/L-CBHs had increased housing and food assistance needs due to the pandemic. COVID-19 vaccine acceptability was similarly low (<50%) between groups.

Congregate homeless shelters are disproportionately affected by infectious disease outbreaks. We describe enterovirus epidemiology across 23 adult and family shelters in King County, Washington, USA, during October 2019-May 2021, by using repeated cross-sectional respiratory illness and environmental surveillance and viral genome sequencing. Among 3,281 participants >3 months of age, we identified coxsackievirus A21 (CVA21) in 39 adult residents (3.0% [95% CI 1.9%-4.8%] detection) across 7 shelters during October 2019-February 2020. We identified enterovirus D68 (EV-D68) in 5 adult residents in 2 shelters during October-November 2019. Of 812 environmental samples, 1 was EV-D68-positive and 5 were CVA21-positive. Other enteroviruses detected among residents, but not in environmental samples, included coxsackievirus A6/A4 in 3 children. No enteroviruses were detected during April 2020-May 2021. Phylogenetically clustered CVA21 and EV-D68 cases occurred in some shelters. Some shelters also hosted multiple CVA21 lineages.