Colorado Department of Public Health and Environment

Outdoor workers are at increased risk of tick-borne diseases, yet we poorly understand the interaction between occupational risk factors and worker behavior. This study integrates active tick surveillance with worker-reported survey data to assess how occupational behaviors, demographic characteristics, and tick-prevention knowledge influence exposure to infected ticks. We collected blacklegged ticks (Ixodes scapularis) from three Minnesota counties to determine the infection prevalence and density of infected ticks for Borrelia burgdorferi and Anaplasma phagocytophilum. Molecular surveillance was coupled with outdoor worker surveys that ascertained exposure characteristics to model individual-specific probabilities of encountering infected ticks during their job responsibilities. From May to July 2023-2024, 872 ticks were collected, where 45.6% (n = 398) were infected with B. burgdorferi and 7.2% (n = 78) were infected with A. phagocytophilum. Across both years, maximum infected tick densities peaked in Carlos Avery Wildlife Management Area at 0.80 (0.22 [IQR 0.16, 0.48]) per 100m2, were intermediate in Lake Elmo Park Reserve at 0.35 (0.12 [IQR 0.05, 0.18]) per 100m2, and lowest in Whitewater Wildlife Management Area at 0.25 (0.04 [IQR 0.02, 0.13]) per 100m2. Forty-two survey responses revealed individual probabilities of encountering infected ticks ranged from ~ 5 to 65% for B. burgdorferi and ~ 0-25% for A. phagocytophilum. Our results suggest that outdoor workers have a high probability of encountering infected ticks through occupational exposure, which was marginally associated with demographic factors (e.g., age) and preventive behaviors (e.g., tick checks, repellent use). This study reports elevated B. burgdorferi infection prevalence from adult (62.1%) and nymphal (36.5%) blacklegged ticks within Minnesota.

BackgroundCDC Core Elements of Hospital Antibiotic Stewardship (AS) and national accreditation bodies prioritize the implementation of facility-specific treatment recommendations and monitoring of adherence to those recommendations. These activities are a challenge for resource-limited hospitals, which we sought to overcome with the Colorado Antimicrobial Resources, Education, and Pathway Adherence Tools for Hospitals (CARE PATH) initiative. Here we report interim findings.Table 1:Adherence RatesBreakdown of adherence rates to clinical pathways by hospital typeFigure 1:Local vs Firstline Pathway Adherence Rates Quarters 1 and 2 by Facility TypeGraphic representation of pathway adherence rates by disease state, pathway type, and facility typeMethodsChildren’s Hospital Colorado, in partnership with Denver Health, created a free mobile application using Firstline (Firstline.org) to share evidence-based clinical pathways across Colorado, which could be adapted for use as facility-specific treatment recommendations.From July 2024-March 2025 hospitals voluntarily submitted antibiotic use data for cases of pediatric or adult community acquired pneumonia (CAP), urinary tract infection (UTI), and/or skin/soft tissue infection (SSTI) via a web-based REDCap survey. AS experts assessed prescribing compared to local clinical pathways (LCPs) and Firstline. LCP adherence was based on self-report of antibiotic selection. Firstline adherence was met if 3 criteria were consistent with app recommendations: antibiotic selection, treatment duration, and clinical indication. Facilities received quarterly reports with feedback and recommendations for AS. To supplement the reports, our team hosted a series of interactive webinars and 1-on-1 mentorship sessions.Results26 facilities registered for CARE PATH, 11 critical access (42%) and 15 acute care (58%). 22 (85%) reported having a local adult or pediatric CAP pathway, 21 (81%) a UTI, and 21 (81%) a SSTI LCP. 12 (46%) did not monitor adherence prior to CARE PATH. 13 (50%) facilities reported data on at least one condition in quarter 1, and 8 (30%) for quarter 2. Adherence rates to LCPs and Firstline are presented in Table 1 and Figure 1.ConclusionCARE PATH has helped 13 Colorado hospitals meet priority core elements. Adherence rates varied, with SSTI the lowest. CAP adherence increased Q1 to Q2, though UTI and SSTI changes were variable. These findings represent a novel hospital-state health collaboration and inform state-wide antimicrobial stewardship efforts.DisclosuresLeigh Anne Bakel, MD, Colorado Department of Public Health and Environment: Grant/Research Support|Pfizer: Grant/Research Support Sarah K. Parker, MD, Colorado Department of Health and Environment: Advisor/Consultant|Infectious Diseases Society of America: Reimbursement for Program Committee|Pfizer Global Bridges: Grant/Research Support|Society for Healthcare Epidemiology of America: Honoraria|Society of Infectious Diseases Pharmacists: Honoraria

Abstract Mobile device data has the potential to capture fluctuations in populations contributing to a wastewater catchment area, which can aid in interpreting pathogen concentrations. As an alternative to flow rates which are commonly used to normalize pathogen concentrations, we evaluated the use of mobile device data to characterize population dynamics at the daily and monthly scale across 66 sewersheds in Colorado from August 2020 to December 2024. We compared monthly device counts to monthly average flow rates where available and evaluated the extent to which rainfall and snowmelt explained periods of decoupling between device counts and flow rates. Using K-Means clustering, we identified two distinct patterns of population dynamics, one comprised of high-tourism regions. There were significant temporal fluctuations in daily and monthly device counts, with more pronounced patterns at the monthly level. Flow and mobile device counts were not consistently well-correlated. Using mixed effects regression, we found that rainfall and snowmelt, in addition to device counts, were significantly associated with flow rates. Mobile device data can characterize dynamic populations over multiple geographical areas and over short and long timescales in ways that are distinct from flow. It should be considered in efforts to improve normalization algorithms for wastewater-based epidemiology.

Abstract Wastewater based epidemiology has emerged as a compelling tool to monitor the spread and evolution of pathogens of public health concern. Next generation sequencing (NGS) of pathogens detected in wastewater enables sequence characterization which is essential for monitoring the changing genomic landscape of pathogens. Influenza virus, with its potential to cause epidemics and pandemics, poses a serious risk to human health. Genomic surveillance of the virus is essential for safeguarding public health by monitoring the virus’s evolution, and developing preventive vaccines and therapeutics. As such, methods for successfully sequencing influenza virus at a consistent high depth of coverage across the genome can aid in this endeavor. Here, we present a novel targeted tiled amplicon based sequencing protocol that uses short tiled amplicons (<250 bp in length) to successfully capture the Hemagglutinin (HA) gene segment of seasonal influenza A subtypes (H1 and H3) and Influenza B at high depth of coverage. We observed near consistent coverage across the HA gene segment for wastewater samples that had influenza viral target dPCR detections of at least 10 3 copies/L. We were able to successfully detect low frequency single nucleotide variants (SNVs) at high depth of coverage demonstrating the utility of the data to characterize the diversity of circulating influenza A and B viruses at the community level. Our approach is flexible and future directions include expanding this approach to sequence additional influenza virus HA subtypes and gene segments.

Background: The association between social determinants of health (SDOH) and healthcare-associated infections is underappreciated. We evaluated disparities in rates of candidemia associated with the social vulnerability index in Denver area census tracts. Methods: We conducted an ecologic study of the 664 census tracts within Adams, Arapahoe, Denver, Douglas, and Jefferson Counties, Colorado in 2021 and 2022. The outcome of interest was census tract rates of candidemia, with cases captured by population-based surveillance of the Centers for Disease Control and Prevention’s (CDC) Emerging Infections Program and geocoded to census tract of residence. The primary explanatory variable was the CDC and Agency for Toxic Substances and Disease Registry Social Vulnerability Index (SVI) from 2022 and its four themes: socioeconomic status, household characteristics, race and ethnic minority status, and housing type and transportation. Population denominators were taken from the 2018-2022 American Community Survey, and census tract boundaries from the 2020 US Census. We used bayesian conditional autoregressive models to map smoothed rate ratios (RRs) of candidemia relative to the five-county catchment area rate and to estimate RRs and 95% credible intervals (CIs) associated with a 0.1 unit increase in SVI and each SVI theme. Analyses were conducted using SAS 9.4, RStudio 2023.06.0, and OpenBUGS 3.2.3 software. Results: Of 664 census tracts, 658 (99%) had a greater than zero population for which rates could be calculated. There were 333 candidemia cases in 5,652,254 person-years, of which 321 (96%) were geocoded and included in the analysis. Disease mapping indicated clusters of census tracts with higher than expected rates of candidemia relative to the five-county catchment area after adjusting for sex and age (Figure). For every 0.1 unit increase in census tract SVI, there was a 15% increase in the rate of candidemia (RR 1.15, 95% CI, 1.10, 1.20) after adjusting for sex and age. There were similar, modest associations with each SVI theme. Discussion: We demonstrated clustering of census tracts with higher than expected rates of candidemia and a modest association with SVI. Healthcare and public health epidemiologists should consider the contribution of SDOH to population rates of candidemia with an eye toward identifying opportunities to improve health equity.

Respiratory syncytial virus (RSV) is a leading cause of hospitalization among young children. Nirsevimab is recommended for all infants younger than 8 months and children aged 8 to 19 months who are at increased risk of severe RSV entering their second RSV season. Additional data are necessary to identify children aged 8 to 19 months at increased risk for severe disease. The Respiratory Syncytial Virus Hospitalization Surveillance Network, a population-based surveillance system, captures laboratory-confirmed RSV-associated hospitalizations in 12 states. We compared demographics and clinical characteristics of children aged 0 to 23 months by age category, and of children aged 12 to 23 months by severity (not admitted to the intensive care unit [ICU], admitted to the ICU, or with prolonged [≥3days] ICU admission) during the 2022-2023 season using χ2 tests and logistic regression. Among 3659 randomly sampled hospitalized children in 2022-2023, 31.2%, 40.0%, and 28.9% were aged 0 to 2, 3 to 11, and 12 to 23 months, respectively. Compared with children aged 0 to 2 months, children 3 to 11 and 12 to 23 months were more likely to have at least 1 underlying medical condition (UMC) (3.4%, 12.6%, 23.4%, respectively; P < .05). Children aged 12 to 23 months with prolonged ICU admission were more likely to have airway abnormalities, cardiovascular disease (CVD), Down syndrome (with or without concomitant CVD), and feeding tube dependence than those without ICU admission (P < .05 for all). UMCs were more frequently identified among hospitalized children aged 12 to 23 months compared with children 0 to 2 months; prolonged ICU admission was associated with airway abnormalities, CVD, Down syndrome, and feeding tube dependence.

Aim:Identify desired training content for shift-working nurses to improve their sleep and fatigue.Design:A descriptive qualitative design.Methods:We recruited night shift nurses (N = 23) to provide feedback during virtual focus groups/interviews. Data collection occurred in the U.S. between March and June 2024. Participants were presented with sleep and fatigue topics derived from the literature. Focus group/interview data were collected and transcribed. Data were analysed using a hybrid deductive-inductive manifest content analysis with an a priori coding schema based on topics shared during data collection. Data not fitting the schema, yet informing content, were analysed inductively.Results:Three themes aligned with literature-derived topics. Theme 1, Why We Sleep and Why Should Nurses Care, explains the importance of sleep to health. Theme 2, Sleep Practices for Nurses to Support Health and Social Relationships, describes healthy strategies to promote sleep for enhanced quality of life. Theme 3, Fatigue and Work, illustrates the significance of nurse sleep and fatigue risk mitigation to safe working conditions and patient care.Conclusions:Study findings highlight night shift nurses’ interest in gaining evidence-based information to promote their sleep. Sleep education and training could fill a knowledge and skills gap, not often offered in school or workplace.Implications for the Profession:Identifying themes relevant to nurses may help increase the development and availability of sleep education and training currently tailored for nurses.Impact:Study findings describe content night shift nurses’ desire for sleep and fatigue training, serving as an important first step in developing programmes most relevant to shift-working nurses.Our analysis found the findings largely align with key components workers should receive in sleep education and training and reinforced the need for employers to offer such training.This study could benefit the nursing workforce and employers who expect rested, high-functioning nurses to care for patients.Reporting Method:Standards for Reporting Qualitative Research.Patient or Public Contribution:No patient or public contribution.Trial and Protocol Registration:Clinicaltrials.gov, NCT06105307

Student interview teams provided essential surge capacity for the conduct of routine enteric disease surveillance and outbreak activities during the COVID-19 pandemic response, for states with that resource available. This case study describes how student interview teams based in Colorado and Washington supported enteric disease interviewing for public health agencies in Nebraska, Wyoming, Kansas, and California, and demonstrates the feasibility and value of interstate student interview team work to provide enteric and other communicable disease surge capacity. In collaboration with their respective state health agencies, the Colorado School of Public Health Enteric Disease Interview Team (EDIT) and the University of Washington Student Epidemic Action Leaders (SEAL) team amended scopes of work and procedures for hiring and onboarding, training, work management and engagement, communication, and evaluation to offer enteric disease interviewing support to the Nebraska Department of Health and Human Services, the Wyoming Department of Health, the Kansas Department of Health and Environment, and the California Department of Public Health. EDIT was assigned 467 enteric interviews in Nebraska, 193 in Wyoming, and 33 in Kansas; and the SEAL team was assigned 133 interviews from 26 clusters in California, with response rates of 68%, 79%, 58%, and 53%, respectively. The median time from case assignment to first interview for EDIT interviews was less than or equal to 1 day. The completeness of all interviews was satisfactory. Enteric disease epidemiologists from host state health departments and students reported valuing the interstate work. Establishing interstate student interview team support requires coordination but is possible and can be effective in providing essential surge capacity for states without a student interview team. It also provides intangible benefits such as strengthening relationships between states and affiliated university programs and providing professional experiences and networking opportunities for students.

Abstract Background Extraintestinal invasive Escherichia coli (iEC) is a leading cause of sepsis and hospitalization, but US surveillance for iEC has been frequently limited to multidrug-resistant (MDR) strains and hospitalized cohorts. To describe the incidence and clinical characteristics of MDR and non-MDR iEC and inform prevention and vaccine development, CDC’s Emerging Infections Program piloted active population- and laboratory-based surveillance in 9 US sites. Methods Among surveillance area residents ( &amp;gt; 7.3 million people), an incident iEC case was the first isolation of E. coli in a 30-day period from a normally sterile body site (June–August 2023). Demographic, clinical, and laboratory characteristics were assessed by chart review. Annual incidence rates by surveillance area were estimated by multiplying total case number by 4 and used 2022 US census data for denominators. Results Among 1345 iEC cases in 1334 patients, E. coli was isolated from blood in 1223 (90.9%) and from other sterile sites in 122 (9.1%). Median age was 68 years (IQR 55–79); 766 (57.0%) were female. Overall estimated annual crude incidence rate was 74.5 cases per 100,000 population (range by area 51.3–95.6) and was higher for persons aged ≥ 60 vs &amp;lt; 60 years (228.5 vs 30.4). Cases were most commonly community associated (554, 41.2%) or health care associated community onset (633, 47.1%). Most case-patients (1194, 88.8%) had comorbidities; diabetes was most common (457, 34.0%). Of all cases, 762 (56.7%) were associated with urinary tract infection (UTI), 192 (14.3%) with recurrent UTI, and 213 (15.8%) had a urinary catheter in the 2 days before collection of the iEC-defining specimen. Among 1160 hospitalized cases, median length of stay was 5 days (IQR 3–9), 103 (8.9%) died. Of reported E. coli susceptibilities, 144/500 (28.8%) were fluoroquinolone-resistant, 185/1345 (13.8%) were extended-spectrum β-lactamase producing, and 3/1345 (0.2%) carbapenem-resistant. Conclusion The burden of iEC disease was substantial compared to other invasive pathogens and primarily affected older adults. Over half of infections accompanied UTIs and involved hospitalization. Continued surveillance to monitor trends over time, inform vaccine development and evaluation, and advise prevention efforts are needed. Disclosures All Authors: No reported disclosures