Castle County Research Articles

Development of Sub-County Cancer Reporting Zones in Delaware and Example Use Case for Targeted Interventions.

To describe the Delaware Cancer Registry (DCR)'s participation in the National Cancer Institute (NCI)/North American Association of Central Cancer Registries (NAACCR) Zone Design Project to create sub-county geographic areas ("zones") for use in cancer reporting and geospatial analysis. DCR and other stakeholders reviewed up to ten unique zone configurations for each of Delaware's three counties. The zone configurations were created using AZTool and were set to optimize three objectives: create zones that have a minimum and target population of 50,000; are homogenous based on the variables of percent minority, percent below poverty, and percent urban; and are as compact as possible. The DCR sent a survey to stakeholders to provide input on their preferred zone configuration for each county. Following the final selection of zones, the DCR utilized the geographies for calculating overall and late-stage breast cancer incidence statistics and created choropleth maps to visualize the rates by quintiles. The final selections resulted in a total of 15 zones for Delaware, with three in Kent County, nine in New Castle County, and three in Sussex County. The zones ranged in population size from 54,013 to 67,693 people. Zones with higher late-stage breast cancer incidence rates included those near the areas of Wilmington, Middletown, and between Milford and Georgetown. Comparing results of overall breast cancer incidence rates by zone with late-stage rates by zone, there were areas that had lower relative overall breast cancer incidence rates but were relatively higher for late-stage rates by zones or vice versa. Aggregating census tracts into zones allows for reporting reliable cancer rates at sub-county levels, which is instrumental in conveying meaningful information about regional cancer trends to stakeholders and the public. Delaware will be able to utilize zone-level cancer information to provide targeted interventions and outreach initiatives.

First Report of Chagas Disease Vector Species Triatoma sanguisuga (Hemiptera: Reduviidae) Infected with Trypanosoma cruzi in Delaware.

In July and October 2023, two live triatomine bugs were found inside a home in New Castle County, Delaware. The bugs were identified as Triatoma sanguisuga, the most widespread triatomine bug species in the United States. Triatoma sanguisuga is a competent vector of Trypanosoma cruzi, the causative agent of Chagas disease. The two specimens were tested via real-time PCR (qPCR) for infection with T. cruzi, and one of the specimens was positive. Despite T. sanguisuga being endemic to the area, attainment of accurate species identification and T. cruzi testing of the bugs required multiple calls to federal, state, private, and academic institutions over several months. This constitutes the first report of T. sanguisuga infected with T. cruzi in Delaware. In addition, this is the first published report of T. sanguisuga in New Castle County, the northernmost and most densely populated county in Delaware. New Castle County still conforms to the described geographic range of T. sanguisuga, which spans from Texas to the East Coast of the United States. The T. cruzi infection prevalence of the species has not been studied in the northeastern United States, but collections in southern states have found prevalences as high as 60%. The Delaware homeowner's lengthy pursuit of accurate information about the vector highlights the need for more research on this important disease vector in Delaware.

Paving the Way to Active Living for People with Disabilities:: Evaluating Park and Playground Accessibility and Usability in Delaware.

To evaluate the accessibility and usability of parks and playgrounds in New Castle County, Delaware, for people with disabilities, with a particular focus on identifying environmental barriers that may impede access to these public spaces and potentially affect physical activity (PA) participation for the chronic disease prevention and mitigation. Using a cross-sectional observational design, teams of trained University of Delaware students utilized the Community Health Inclusion Index (CHII) Tool to assess the accessibility of ten suburban and urban parks and playgrounds from April to November 2023. The tool evaluated various elements of public spaces, including public transit, parking, pathways and multi-use trails, entrances, playground equipment, and health promotional materials. Descriptive statistics were calculated for the accessibility and usability of each element. Significant barriers to accessibility and usability were identified. Over half of the sites lacked nearby public transit stops, and many trails and playgrounds were not fully accessible to people with disabilities. While some areas demonstrated good accessibility, such as well-maintained pathways and appropriately designed crosswalks, barriers like uneven surfaces, insufficient curb cuts, and inadequate van-accessible parking spaces were common. Most playgrounds lacked equitable play equipment, with less than half having ground materials suitable for mobility devices. The study underscores the need for substantial improvements in the design, construction, and maintenance of Delaware parks and playgrounds to better support people with disabilities. Enhancing accessibility is crucial for promoting PA participation. The findings support the development of inclusive recreational and PA environments, aligning with the Americans with Disabilities Act, to reduce chronic disease health disparities faced by people with disabilities. This study highlights the need for revised policy measures to enhance park accessibility, advocating for infrastructure improvements and inclusive designs to ensure equitable recreation and physical activity opportunities for people with disabilities.

Mapping Cumulative Risk in Delaware: Approach and Implications for Health Equity.

Addressing health equity requires attention to upstream determinants of health, including environmental and social factors that act in tandem to increase communities' exposure to and vulnerability to toxicants. Cumulative risk assessment, which evaluates combined risks from environmental and social factors, is a useful approach for estimating potential drivers of health disparities. We developed a cumulative risk score of multiple indices of environmental and social conditions and assessed block group-level differences in New Castle County, Delaware. This cross-sectional study used choropleth maps to visualize the distribution of environmental, social, and cumulative risks and Moran's I statistics to assess spatial clustering of cumulative risk across the county and among individual block groups. Findings indicate that environmental risk rarely occurs without social risk and that environmental and social risks co-occur in distinct areas, resulting in large-scale clustering of cumulative risk. Areas of higher cumulative risk had more Black residents and people of lower socioeconomic status. Replicable measures of cumulative risk can show how environmental and social risks are inequitably distributed by race and socioeconomic status, as seen here in New Castle County. Such measures can support upstream approaches to reduce health disparities resulting from histories of environmental racism.

Neighborhood factors and triple negative breast cancer: The role of cumulative exposure to area-level risk factors.

Despite similar incidence rates among Black and White women, breast cancer mortality rates are 40% higher among Black women. More than half of the racial difference in breast cancer mortality can be attributed to triple negative breast cancer (TNBC), an aggressive subtype of invasive breast cancer that disproportionately affects Black women. Recent research has implicated neighborhood conditions in the etiology of TNBC. This study investigated the relationship between cumulative neighborhood-level exposures and TNBC risk. This single-institution retrospective study was conducted on a cohort of 3316 breast cancer cases from New Castle County, Delaware (from 2012 to 2020), an area of the country with elevated TNBC rates. Cases were stratified into TNBC and "Non-TNBC" diagnosis and geocoded by residential address. Neighborhood exposures included census tract-level measures of unhealthy alcohol use, metabolic dysfunction, breastfeeding, and environmental hazards. An overall cumulative risk score was calculated based on tract-level exposures. Univariate analyses showed each tract-level exposure was associated with greater TNBC odds. In multivariate analyses that controlled for patient-level race and age, tract-level exposures were not associated with TNBC odds. However, in a second multivariate model that included patient-level variables and considered tract-level risk factors as a cumulative exposure risk score, each one unit increase in cumulative exposure was significantly associated with a 10% increase in TNBC odds. Higher cumulative exposure risk scores were found in census tracts with relatively high proportions of Black residents. Cumulative exposure to neighborhood-level risk factors that disproportionately affect Black communities was associated with greater TNBC risk.

Abstract C095: Deconstructing the link between neighborhood disadvantage and triple negative breast cancer: Preliminary evidence in support of cumulative exposure to area-level risk factors

Abstract Background: Triple negative breast cancer (TNBC) is an aggressive subtype of invasive breast cancer that disproportionately affects Black women and contributes to racial disparities in breast cancer mortality. Prior research has found evidence of a link between TNBC risk and neighborhood/area-level measures of disadvantage, including socioeconomic status and racial segregation. This study evaluated additional area-level exposures as potential mediators of the relationship between neighborhood disadvantage and TNBC risk in New Castle County, DE, a region with elevated rates of TNBC. Methods: The study population included 3,316 Black and White adult female residents of New Castle County who were diagnosed with invasive breast cancer at the Helen F. Graham Cancer Center & Research Institute (HFGCCRI) in Newark, DE from 2012-2020. Patient addresses were geocoded, and demographic and clinical measures were abstracted from the HFGCCRI cancer registry. Neighborhood and environmental exposure measures were generated from electronic health records (EHR), the US Census Bureau American Community Survey, and Environmental Protection Agency (EPA) Risk-Screening Environmental Indicator (RSEI) data; these measures were aggregated to the census tract and linked to patient geocodes. Included neighborhood exposure measures were factors that may influence patient-level exposure to well-known breast cancer risk factors, including alcohol use disorder (AUD) and diabetes prevalence, breastfeeding (assessed with the proxy measure ‘% single female-headed households with children’), and toxic environmental indicators (e.g., toxic release inventory sites). The relationships between these exposures and the odds of TNBC (relative to other subtypes of invasive breast cancer) were first evaluated on a univariate basis. Next, to estimate the relationship between cumulative exposure and TNBC odds, census tract risk scores were calculated by dichotomizing each exposure into low- and high-risk categories and summing the total of high-risk exposures. A multilevel logistic regression model was used to test the association between this risk score and TNBC odds while adjusting for patient-level age and race.Results: TNBC cases accounted for 14% (n = 453) of invasive breast cancer cases. Significantly higher odds of TNBC were observed for patients who reside in census tracts characterized by higher rates of AUD, diabetes, % single female-headed households with children, and RSEI scores. In the multilevel logistic regression model that adjusted for patient demographics, the cumulative exposure risk score was significantly associated with greater odds of TNBC. Conclusion: Results provide preliminary support for a link between TNBC odds and cumulative, area-level exposure to disordered alcohol use, metabolic disorders, lower breastfeeding rates, and toxic environmental indicators. Additional research evaluating the cumulative exposure risk score as a potentially modifiable mediator of the relationship between neighborhood disadvantage and TNBC risk will be presented. Citation Format: Scott D. Siegel, Madeline M. Brooks, Jesse D. Berman, Shannon M. Lynch, Jennifer Sims-Mourtada, Zachary T. Schug, Frank C. Curriero. Deconstructing the link between neighborhood disadvantage and triple negative breast cancer: Preliminary evidence in support of cumulative exposure to area-level risk factors [abstract]. In: Proceedings of the 15th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2022 Sep 16-19; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr C095.

Law Enforcement-Based Outreach and Treatment Referral as a Response to Opioid Misuse: Assessing Reductions in Overdoses and Costs

To reduce opioid-involved overdoses, law enforcement agencies have taken proactive steps to connect people to treatment and supportive services. This study evaluates the impact of a law enforcement-based outreach and treatment referral program known as Hero Help on the incidence and costs of overdoses occurring in the jurisdiction of Delaware’s New Castle County Division of Police (NCCPD). It first compares observed and predicted fatal and nonfatal overdoses between 2013 and 2021. A time series analysis shows an average decrease of 7.25 nonfatal and 1.85 fatal overdoses per month since the program’s two expansions of its civilian care team. It then adapts Centers for Disease Control and Prevention and health care cost data to estimate the cost reductions of fewer overdoses. These metrics suggest Hero Help saved the community $21.5 million per month. Police departments can then reduce the incidence and economic burden of overdoses through outreach and referrals to treatment.

Biological and Environmental Sampling at ATSDR PFAS Exposure Assessment Sites

BACKGROUND AND AIM The Agency for Toxic Substances and Disease Registry (ATSDR) conducted biomonitoring exposure assessments (EAs) in communities near U.S. military installations that have documented PFAS in drinking water. PFAS in drinking water were mitigated prior to initiation of the EAs. METHODS EAs were conducted in ten communities using a community sampling design to evaluate PFAS serum concentrations in communities with PFAS in drinking water. PFAS in urine was measured in a subset of participants. PFAS in indoor dust and tap water were evaluated in a subset of households. All participants completed a questionnaire to gather information to characterize exposure and the responses were evaluated to identify demographic and exposure characteristics associated with PFAS levels in serum. RESULTS The relationships between PFAS levels in drinking water and concentrations of PFAS in serum will be presented for two locations, Hampden County Massachusetts and New Castle County Delaware. The primary PFAS elevated in serum included PFHxS, PFOS, and PFOA which were associated with drinking water exposure. PFAS levels in serum were compared to CDC’s National Health and Nutritional Examination Survey (NHANES). Males had higher PFAS serum levels than females at both locations; additional site-specific findings regarding serum levels and demographic and exposure characteristics information will be presented. Dust sampling results indicated that non-drinking water sources of PFAS may contribute to exposure. CONCLUSIONS The results of testing at the PFAS EA locations presented indicate that levels of PFAS in drinking water are associated with increased levels of PFAS in serum. Additional environmental sampling is being conducted in partnership with U.S. EPA in Delaware and Massachusetts to evaluate potential non-drinking water exposures to PFAS. KEYWORDS: Exposure, PFAS The findings and conclusions in this presentation have not been formally disseminated by CDC/ATSDR and should not be construed to represent any agency determination or policy.

What shapes People Living With HIV's experiences of HIV stigma in Delaware?: A qualitative exploration of place and social position.

ObjectivesTo understand how place and social position shape experiences of HIV stigma among people living with HIV (PLWH) in Delaware. HIV stigma impedes the health and wellbeing of PLWH. Yet, HIV stigma is often studied through psychosocial perspectives without considering social-structural conditions. Recent theorists have hypothesized that place and social position, two key social-structural conditions, fundamentally shape PLWH’s experiences of stigma. Due to residential segregation of racial/ethnic and lesbian, gay, bisexual, transgender, and queer (LGBTQ) populations, place and social position are often inextricably intertwined within the U.S.MethodsQualitative interviews were conducted with 42 PLWH and 14 care providers in 2017. Interviews were conducted with English- and Spanish-speaking PLWH in all three counties in Delaware, including: Wilmington in New Castle County, Smyrna in Kent County, and Georgetown in Sussex County.ResultsResults suggest that PLWH’s experiences of HIV stigma are shaped by place and social position. Although HIV stigma is still prevalent across Delaware, participants reported that HIV stigma is more pronounced in Kent and Sussex counties and in rural areas. Latinx and Haitian PLWH are at greater risk of experiencing HIV stigma than other racial/ethnic groups, with participants identifying misinformation within Latinx and Haitian communities as a key driver of HIV stigma. HIV stigma is further compounded by medical mistrust in the Haitian community. In contrast, participants noted that LGBTQ PLWH in Sussex County are somewhat buffered from HIV stigma by the LGBTQ community, which is reported to be more knowledgeable about HIV and accepting of PLWH.ConclusionsMulti-level interventions that address social-structural conditions in addition to individual-level factors are recommended to best address HIV stigma in Delaware. Interventions should target drivers of stigma, such as lack of knowledge, and consider how place and social position uniquely shape PLWH’s experiences of stigma.

Dragonfly Biodiversity at Abandoned Work Sites: Dredge-spoil Ponds of the Chesapeake and Delaware Canal, New Castle County, Delaware

There are few undisturbed, freshwater habitats remaining in the populated areas of the United States. Aquatic organisms, such as dragonflies (Odonata), have therefore either had to adapt to disturbed and modified secondary habitats, such as farms, golf courses, storm-water remediation basins, and community-park ponds, or risk extirpation. The species that readily adapt to these habitats are usually widespread common species. However, other aquatic habitats inadvertently created at abandoned work sites often evolve distinctive characteristics over time that provide refuge for species rarely or never found at deliberately created pond habitats. For 17 years, we have monitored the diverse Odonata fauna at several floristically distinct ponds formed in depressions left from the dredging of the Chesapeake and Delaware Canal in the 1960s. Among the species found are ones not known elsewhere locally or ones found in unusual abundance at 1 or more of the ponds, though infrequently encountered regionally. These dredge-spoil ponds are important for conserving regional Odonata biodiversity by providing unique habitats in an increasingly urbanized environment.

Perspectives on Engagement With Youth Physical Activity Opportunities in Low-Income, African American, Urban Neighborhoods.

To identify and describe factors related to low-income, African American youth's participation in neighborhood youth physical activity opportunities (YPAO). Formative research. Face-to-face focus groups in New Castle County, Delaware. Fifty-five adults (parents/guardians of youth, YPAO providers, small business representatives) living and/or working in low-income, African American neighborhoods. Nine, 60-90minute focus groups were conducted from December 2018 through March 2019. Focus group questions were developed a priori and included domains related to neighborhood YPAOs. The domains were awareness of YPAOs, benefits and barriers to providing YPAOs, ways to increase youth participation in YPAOs, and strategies for creating, improving, and sustaining YPAOs. Focus group recordings were transcribed, and thematic analysis was performed to identify themes related to increasing youth participation in YPAOs. Four major themes related to YPAOs emerged: 1) exposure/access, 2) parent buy-in/accountability (e.g., personal values and trust with YPAOs), 3) technology, and 4) increasing a sense of community. Three minor themes included liability, advertising, and schools. Small businesses desired to support YPAOs mainly through non-monetary means, while mutually benefitting from receiving local recognition. Developing strategies to incorporate effective community partnerships, creative program ideas with advertising, and active, multisector involvement including small businesses into practice has the potential to increase engagement of low-income, African American youth in YPAOs.

Racial disparities in triple negative breast cancer: toward a causal architecture approach

BackgroundTriple negative breast cancer (TNBC) is an aggressive subtype of invasive breast cancer that disproportionately affects Black women and contributes to racial disparities in breast cancer mortality. Prior research has suggested that neighborhood effects may contribute to this disparity beyond individual risk factors.MethodsThe sample included a cohort of 3316 breast cancer cases diagnosed between 2012 and 2020 in New Castle County, Delaware, a geographic region of the US with elevated rates of TNBC. Multilevel methods and geospatial mapping evaluated whether the race, income, and race/income versions of the neighborhood Index of Concentration at the Extremes (ICE) metric could efficiently identify census tracts (CT) with higher odds of TNBC relative to other forms of invasive breast cancer. Odds ratios (OR) and 95% confidence intervals (CI) were reported; p-values < 0.05 were significant. Additional analyses examined area-level differences in exposure to metabolic risk factors, including unhealthy alcohol use and obesity.ResultsThe ICE-Race, -Income-, and Race/Income metrics were each associated with greater census tract odds of TNBC on a bivariate basis. However, only ICE-Race was significantly associated with higher odds of TNBC after adjustment for patient-level age and race (most disadvantaged CT: OR = 2.09; 95% CI 1.40–3.13), providing support for neighborhood effects. Higher counts of alcohol and fast-food retailers, and correspondingly higher rates of unhealthy alcohol use and obesity, were observed in CTs that were classified into the most disadvantaged ICE-Race quintile and had the highest odds of TNBC.ConclusionThe use of ICE can facilitate the monitoring of cancer inequities and advance the study of racial disparities in breast cancer.

Aggregated spatial intensity as a method for estimating point-level exposures within area-level units: The case of tobacco retailer exposure in census tracts

BackgroundAggregating point-level events to area-level units can produce misleading interpretations when displayed via choropleth maps. We developed the aggregated intensity method to share point-level location information across unit boundaries prior to aggregation. This method was applied to tobacco retailers among census tracts in New Castle County, DE. MethodsAggregated intensity uses kernel density estimation to generate spatially continuous expected counts of events per unit area, then aggregates these results to area-level units. We calculated a relative difference measure to compare aggregated intensity to observed counts. ResultsAggregated intensity produces estimates of event exposure unconstrained by boundaries. The relative difference between aggregated intensity and counts is greater for units with many events proximal to their borders. The appropriateness of aggregated intensity depends on events’ spatial influence and proximity to unit boundaries, as well as computational inputs. ConclusionsAggregated intensity may facilitate more spatially realistic estimates of exposure to point-level events.

A Population Health Assessment in a Community Cancer Center Catchment Area: Triple-Negative Breast Cancer, Alcohol Use, and Obesity in New Castle County, Delaware.

The NCI requires designated cancer centers to conduct catchment area assessments to guide cancer control and prevention efforts designed to reduce the local cancer burden. We extended and adapted this approach to a community cancer center catchment area with elevated rates of triple-negative breast cancer (TNBC). Cancer registry data for 462 TNBC and 2,987 "Not-TNBC" cases diagnosed between 2012 and 2020 at the Helen F. Graham Cancer Center & Research Institute (HFGCCRI), located in New Castle County, Delaware, were geocoded to detect areas of elevated risk (hot spots) and decreased risk (cold spots). Next, electronic health record (EHR) data on obesity and alcohol use disorder (AUD) and catchment area measures of fast-food and alcohol retailers were used to assess for spatial relationships between TNBC hot spots and potentially modifiable risk factors. Two hot and two cold spots were identified for TNBC within the catchment area. The hot spots accounted for 11% of the catchment area but nearly a third of all TNBC cases. Higher rates of unhealthy alcohol use and obesity were observed within the hot spots. The use of spatial methods to analyze cancer registry and other secondary data sources can inform cancer control and prevention efforts within community cancer center catchment areas, where limited resources can preclude the collection of new primary data. Targeting community outreach and engagement activities to TNBC hot spots offers the potential to reduce the population-level burden of cancer efficiently and equitably.

Racial/Ethnic and Geo-clustering Differentials in SARS-CoV-2 (COVID-19) Cumulative Incidence, Mortality and Temporal Trend in Delaware State, USA

Purpose: COVID-19, a respiratory disease caused by SARS-CoV-2 indicates subpopulation differentials in cumulative incidence (CmI) and mortality. We aimed to assess the racial/ethnic and geo-clustering in COVID-19 CmI and mortality in Delaware. Method: A cross-sectional ecologic design was used to assess COVID-19 mortality in April, May and November 2020. The binomial and poison regression models were utilized for race/ethnic and geo-clustering risk prediction, respectively. Results: As per late April, CmI remains to be flattened in DE, with the confirmed SARS-CoV-2, n=4575 (47.5 per 10,000), Sussex county (SC), n=2,114 (111.4 per 10,000), Kent county, n=728 (41.8 per 10,000) and New Castle county, n=1,701 (28.7 per 10,000). CmI was highest for Non-Hispanic blacks (NHB), 27% (n=1250) but lowest among Asian/Pacific Islanders, n=61 (1%). The disproportionate burden of COVID-19 CmI was highest among Hispanics, 100.2 per 10,000. COVID-19 cases were more prevalent among NHB (30%) and Hispanics (19%). Mortality was higher among NHB, 1.70 per 10,000 compared to Non-Hispanic whites (NHW), 1.34 per 10,000. COVID-19 mortality differed by race, with NHB relative to NHW 27% more likely to die, risk ratio (RR)=1.27, 95%CI, 0.85-1.89. Geo-clustering indicated a significant 50% increased mortality risk in SC compared to DE, incidence rate ratio (IRR)=1.50, 95%CI, 1.11-2.03.During November, the case fatality rate (CFR) in DE was 27 per 10,000, while in the US, the CFR was 25 per 10,000. Conclusions: The Delaware COVID-19 CmI indicates disproportionate burden on NHB and Hispanics; case clustering disproportionate burden in SC; and the risk of dying was highest among NHB.

Zooarchaeology and GIS: Enslaved and Free Black Diet at a Late Eighteenth- to Mid-Nineteenth-Century Delaware Farm, New Castle County, Delaware, United States

Zooarchaeology and GIS: Enslaved and Free Black Diet at a Late Eighteenth- to Mid-Nineteenth-Century Delaware Farm, New Castle County, Delaware, United States

Addressing opioid misuse: Hero Help as a recovery and behavioural health response

Increases in opioid-related overdoses have required law enforcement and public health officials to collectively develop new approaches that treat substance use disorders and save lives. This essay describes the Hero Help recovery and behavioural health assistance program, a Delaware-based initiative providing drug treatment to qualifying adults who contact the police and ask for treatment, or to individuals in lieu of an arrest or upon recommendation by a police officer. Led by the New Castle County Division of Police, this collaborative project has brought together stakeholders from public health and criminal justice to coordinate treatment for people suffering from a substance use disorder and/or mental health problems. This essay describes the goals, evolution, and key activities of the program. It further highlights lessons learned, including improving credibility through concerted community outreach, finding ways to overcome the stigma associated with participating in a law enforcement–based program, gaining officer buy-in, and using data to inform treatment responses. Effectively, this essay seeks to disseminate emerging lessons in creating programming responsive to substance use disorder and mental illness among police departments and their community partners.

Recovery of SARS-CoV-2 from Wastewater Using Centrifugal Ultrafiltration.

The COVID-19 pandemic is a global crisis and continues to impact communities as the disease spreads. Clinical testing alone provides a snapshot of infected individuals but is costly and difficult to perform logistically across whole populations. The virus which causes COVID-19, SARS-CoV-2, is shed in human feces and urine and can be detected in human waste. SARS-CoV-2 can be shed in high concentrations (>107 genomic copies/mL) due to its ability to replicate in the gastrointestinal tract of humans through attachment to the angiotensin-converting enzyme 2 (ACE-2) receptors there. Monitoring wastewater for SARS-CoV-2, alongside clinical testing, can more accurately represent the spread of disease within a community. This protocol describes a reliable and efficacious method to recover SARS-CoV-2 in wastewater, quantify genomic RNA levels, and evaluate concentration fluctuations over time. Using this protocol, viral levels as low as 10 genomic copies/mL were successfully detected from 30 mL of wastewater in more than seven-hundred samples collected between August 2020 and March 2021. Through the adaptation of traditional enteric virus methods used in food safety research, targets have been reliably detected with no inhibition of detection (RT-qPCR) observed in any sample processed. This protocol is currently used for surveillance of wastewater systems across New Castle County, Delaware.

Characterizing the spatial relationship between smoking status and tobacco retail exposure: Implications for policy development and evaluation.

Tobacco retail density and smoking prevalence remain elevated in marginalized communities, underscoring the need for strategies to address these place-based disparities. The spatial variation of smokers and tobacco retailers is often measured by aggregating them to area-level units (e.g., census tracts), but spatial statistical methods that use point-level data, such as spatial intensity and K-functions, can better describe their geographic patterns. We applied these methods to a case study in New Castle County, DE to characterize the cross-sectional spatial relationship between tobacco retailers and smokers, finding that current smokers experience greater tobacco retail exposure and clustering relative to former smokers. We discuss how analysis at different geographic scales can provide complementary insights for tobacco control policy.

Emergency Patient Voting Initiative in a Community Hospital During a Global Pandemic:: Lessons and a Call-to-Action for Expanded Voter Access.

The 2020 United States general election remained extremely polarized despite occurring during the midst of a global coronavirus pandemic. Acutely hospitalized persons in the days to weeks leading up to the general election are exceptionally vulnerable to voter disenfranchisement and not among the population typically discussed during election seasons. As residents in the Christiana Care Family Medicine Residency Program in Wilmington, Delaware, we organized an emergency ballot registration and absentee voting project for hospitalized patients in our community hospital during the days to weeks leading up to the 2020 general election. We experienced multiple challenges to registering and aiding patients with ballot applications, including but not limited to communication with an overworked New Castle County elections office and coordination of receiving and returning completed ballots. However, we did notice a positive trend in the number of patients acutely hospitalized in the days-weeks leading up to Election Day who had already cast their vote through the expanded mail-in voting campaign in the setting of the COVID19 pandemic. As physicians, we have a unique position and opportunity to not only educate patients and potential voters on voter registration, but also assist these members of our community in the registration process first-hand. In addition to these physician responsibilities, we feel strongly that the state of Delaware should continue the expansion of mail-in/absentee voting for all residents in addition to new initiatives such as extended voter registration period and early in-person voting.