CDC Case Definition Research Articles

Psychosocial stressors of adolescents with E-cigarette, or vaping, product-use associated lung injury: A qualitative study

Background and objectivesAdolescent electronic cigarette (EC) use has reached epidemic rates and has been linked to numerous mental health and psychosocial stressors (PS). There is limited qualitative data on PS for adolescents with e-cigarette, or vaping, product-use associated lung injury (EVALI), a severe complication of EC use. MethodsAll patients hospitalized at Children’s Medical Center in Dallas, Texas from 2018 to 2022 and met CDC case definitions for EVALI were included in the analysis. PS were extracted from the electronic health record and analyzed for recurring themes using the HEADSS assessment as a framework. Results were summarized using descriptive statistics, and representative quotations were selected to highlight each theme. ResultsForty-three adolescents (mean age 16.3 years; 62.8 % male; 39.5 % Non-Hispanic White, 60.5 % Hispanic) were included in the analysis, and 40 (93 %) reported PS. The most common themes were family (51 %; “restraining order issued against 28-year-old brother”), polysubstance use (77 %; “experimenting with…ecstasy, LSD, CCC, misusing Adderall”), and mental health (63 %; “has been suicidal since he was ‘a toddler’”). Less commonly, patients reported PS related to peers (28 %; “spending the entire day at the cemetery where his best friend was buried”), school (49 %; “attending his second alternative school”), and the legal system (19 %; “placed in juvenile detention, released, and will be on probation”). ConclusionsAdolescents with EVALI had PS that were chronic, severe, and involving multiple domains. These findings emphasize the importance of psychosocial screening in adolescents and coordinating interdisciplinary care with mental health and social services.

Characterizing Deficit Accumulation Among Gulf War Era Veterans.

Veterans of the first Gulf War (1990-1991) are reaching middle and older adulthood in differing degrees of health and biological age. Many Gulf War veterans report myriad negative symptoms classified as Gulf War illness (GWI), a chronic multi-symptom illness. To describe and analyze deficit accumulation, among veterans with Severe GWI (SGWI+) and those without Severe GWI (SGWI-), to assess the association between a medically unexplained illness and aging. This study uses a retrospective cohort design with quasi-longitudinal data. The recruitment sample included 10,042 Gulf War era veterans across all four US Census regions. The analytic sample included 1,054 participants of the GWECB for whom SGWI case status could be determined and who had valid responses for at least 90% of the deficits included in the deficit accumulation index. Chronic health conditions were retroactively reported, including year of diagnosis, enabling us to create a longitudinal measure of deficit accumulation. This deficit accumulation index (DAI) ranged from 0-1 for each respondent in each year between 1991-2013. We compare veterans with SGWI+ to those with SGWI- using the CDC case definition. Most veterans in our sample could expect to spend more years with moderate or substantial deficits than without deficits. SGWI+ was associated with spending more years with substantial deficits than those with SGWI-. Veterans in middle age (age 35-65) experienced more years with substantial deficits than younger veterans. Individuals with SGWI+ had 13 times the hazard of accumulating substantial deficits than those without. This study demonstrated that veterans with SGWI+, even those in midlife, experienced aging as measured by accumulating deficits. Practitioners should consider patients with multi-symptom illnesses as at risk of accelerated aging, tailoring treatments to address patients' holistic needs.

Evaluating the performance of WHO and CDC case definitions for influenza-like illness in diagnosing influenza during the 2022–2023 flu season in Mexico

ObjectiveThis study aimed to evaluate the performance of the World Health Organization (WHO) and Centers for Disease Control and Prevention (CDC) case definitions for influenza-like illness (ILI) in diagnosing influenza during the 2022–2023 flu season in Mexico. Study designWe conducted a cross-sectional analysis of national epidemiological surveillance data in Mexico, focusing on respiratory viral pathogens. MethodsWe analyzed data from 6027 non-hospitalized patients between 5 and 65 years old who underwent molecular testing for respiratory viral pathogens. The performance of both case definitions was evaluated in terms of sensitivity, specificity, and the area under the receiver operating characteristic (AUROC) curve. ResultsOverall, the diagnostic accuracy of the evaluated ILI definitions in identifying influenza patients was low, particularly among older patients. When compared to the CDC, the WHO definition had a lower sensitivity but a higher specificity, resulting in a higher AUROC (P = 0.031) for the WHO criteria. ConclusionsOur findings suggest that the WHO and CDC ILI case definitions have limited accuracy for diagnosing influenza in non-hospitalized patients and highlight the need for more specific diagnostic tools to improve the detection of influenza cases during the flu season.

Serologic Testing for Rocky Mountain Spotted Fever in a Low-Incidence Region.

Tick-borne diseases have grown in incidence over recent decades. As a result, diagnostic testing has become more common, often performed as broad antibody-based panels for multiple tick-transmitted pathogens. Rocky Mountain spotted fever (RMSF) is rare in our region yet may cause severe morbidity, leading to diagnostic screening in low-risk patients. We sought to describe trends in RMSF diagnostic testing, rate of IgG seropositivity, and clinical features of those tested. We performed a retrospective chart review of patients ≤21 years old undergoing testing for RMSF and/or with an ICD-9/10 code for RMSF. Patients were categorized by infection likelihood based on clinical and laboratory criteria adapted from Centers for Disease Control and Prevention's (CDC) case definition of spotted fever rickettsioses. Clinical data were collected and analyzed with descriptive statistics. One hundred and seventy patients were included. 5.8% met CDC criteria for rickettsial infection, 6.5% had an elevated IgG titer but lacked suggestive symptoms, and 87.6% had a negative IgG titer. Many patients tested were unlikely to have RMSF, including 50% lacking fever, 20% lacking any RMSF "classic triad" symptoms, 13% without acute illness, and 22% tested during months with low tick activity. Convalescent serology was performed in 7.6% of patients and none underwent Rickettsia rickettsii polymerase chain reaction (PCR) testing. Diagnostic testing was frequently performed in patients unlikely to have RMSF. We identified many opportunities for improving test utilization. Reserving testing for those with higher pretest probability, performing convalescent serology, and utilizing PCR may improve the accuracy of RMSF diagnosis and reduce clinical challenges stemming from inappropriate testing.

Examination of the Accuracy of Existing Overdose Surveillance Systems

Health departments have used a variety of methods for overdose surveillance, and the Centers for Disease Control and Prevention (CDC) is implementing a standardized case definition to improve overdose surveillance nationally. The comparative accuracy of the CDC opioid overdose case definition vs existing state opioid overdose surveillance systems is unknown. To evaluate the accuracy of the CDC opioid overdose case definition and existing Rhode Island Department of Health (RIDOH) state opioid overdose surveillance system. This cross-sectional study of ED opioid overdose visits was conducted at 2 EDs in Providence, Rhode Island, at the state's largest health system from January to May 2021. Electronic health records (EHRs) were reviewed for opioid overdoses identified by the CDC case definition and opioid overdoses reported to the RIDOH state surveillance system. Included patients were those at study EDs whose visit met the CDC case definition, was reported to the state surveillance system, or both. True overdose cases were confirmed by EHR review using a standard case definition; 61 of 460 EHRs (13.3%) were double reviewed to estimate classification accuracy. Data were analyzed from January through May 2021. Accurate identification of an opioid overdose was assessed by estimating the positive predictive value of the CDC case definition and state surveillance system using results from the EHR review. Among 460 ED visits that met the CDC opioid overdose case definition, were reported to the RIDOH opioid overdose surveillance system, or both (mean [SD] age, 39.7 [13.5] years; 313 males [68.0%]; 61 Black [13.3%], 308 White [67.0%], and 91 other race [19.8%]; and 97 Hispanic or Latinx [21.1%] among each patient visit), 359 visits (78.0%) were true opioid overdoses. For these visits, the CDC case definition and RIDOH surveillance system agreed that 169 visits (36.7%) were opioid overdoses. Of 318 visits meeting the CDC opioid overdose case definition, 289 visits (90.8%; 95% CI, 87.2%-93.8%) were true opioid overdoses. Of 311 visits reported to the RIDOH surveillance system, 235 visits (75.6%; 95% CI, 70.4%-80.2%) were true opioid overdoses. This cross-sectional study found that the CDC opioid overdose case definition more often identified true opioid overdoses compared with the Rhode Island overdose surveillance system. This finding suggests that using the CDC case definition for opioid overdose surveillance may be associated with improved data efficiency and uniformity.

Severity of multisystem inflammatory syndrome in children (MIS-C) in patients with and without mucocutaneous findings.

There are few studies comparing severity of MIS-C disease with mucocutaneous symptoms, age, race, and ethnicity. To describe the mucocutaneous symptoms present on admission and evaluate whether these symptoms are correlated with a more severe MIS-C disease course. Retrospective cohort study of hospitalized patients with suspected MIS-C between May 13, 2020 to April 21, 2021. Of the 66 patients who met the inclusion criteria, 84.8% (56/66) exhibited mucocutaneous findings. The most common mucocutaneous symptoms were rash, conjunctivitis, cracked lips, and sore throat. Children with mucocutaneous symptoms were younger (median 9.8 years) compared to those without (11.4 years), p=.39. The groups had similar proportions of pediatric intensive care unit admission, abnormal cardiology studies, and necessity of pressors. The presence of mucocutaneous findings on admission was associated with a lower troponin level on admission (median 0.08 ng/ml vs. 0.52, p=.003). Black children had higher odds of severe MIS-C compared to White children (odds ratio [95% CI]: 3.30 [1.02, 10.72], p=.047). Children ≥5 years of age had greater odds of severe MIS-C compared to children <5 years of age (odds ratio [95% CI]: 5.43 [1.39, 21.23], p=.02). The sample size was relatively small, there was no dermatologist present on admission, initial diagnostic testing and management varied if patients presented at outside hospitals, and the CDC case definition for MIS-C was highly sensitive. The presence of mucocutaneous symptoms negatively correlated with troponin levels, but there was no significant association between these symptoms and other markers of cardiac involvement (echocardiogram, ejection fraction, electrocardiogram).

1462. Validating a claims-based algorithm for Lyme Disease in Massachusetts

Abstract Background Lyme disease (LD) is the fifth most reported notifiable disease in the US, but the true disease burden remains unknown due to inconsistent reporting. Claims-based algorithms estimate a ≥10-fold higher incidence compared to notifiable-disease surveillance, but these algorithms are unvalidated. Methods We evaluated a claims-based LD algorithm based on ICD codes (ICD-9-CM 088.81 or ICD-10-CM A69.2X) and a ≥7-day course of an antibiotic used to treat LD dispensed ±30 days of diagnosis. We applied the LD algorithm to Harvard Pilgrim Health Care (HPHC) claims data for Massachusetts (MA) residents. We sought health records for patients who met the algorithm between Jan 2015 and June 2019 and received care within the Massachusetts General Brigham (MGB) system at diagnosis. Three clinicians received training on case classification and conducted chart abstractions and adjudications. Cases were classified as confirmed, probable, suspect, or ruled out using 2017 CDC case definitions. To assess inter-rater reliability, the clinicians abstracted and adjudicated the same 20 charts; we computed the mean of kappa for each clinician-pair. We calculated the positive predictive value (PPV) of the algorithm for identifying confirmed, probable, or suspect LD cases, all of which required at least erythema migrans (EM) or clinical diagnosis with confirmatory serology and antibiotics prescription. Results We identified 11,823 HPHC members who met the LD algorithm. Of these members, 171 cases occurred within the study period among MGB patients; we obtained 128 (75%) patients’ charts for review. The average weighted kappa statistic of adjudicator agreement was 0.94. Of the reviewed charts, 103 (80.5%) were adults ≥ 18 years old. 71 patients (55.5%) were clinically diagnosed with LD, among whom 62 (48.4%) presented with EM rash. 24 reviewed cases (18.8%) had laboratory-confirmed LD. LD was ruled out for 8 cases. The overall algorithm PPV was 93.8% (95% CI 89.6-97.9%). Limited to confirmed and probable cases only, the PPV was 66.4% (95% CI 57.5-74.5%). Conclusion A claims-based algorithm combining diagnosis codes and antibiotic prescriptions identified LD cases in MA with high PPV. This algorithm could be used to describe the incidence of LD in regions with similar diagnostic, treatment, and coding practices. Disclosures Sheryl A. Kluberg, PhD, SM, GlaxoSmithKline: Grant/Research Support|Pfizer, Inc.: Support for the project described in the abstract Sarah J. Willis, PhD, MPH, Pfizer: Employment|Pfizer: Conducted Pfizer funded research while employed by Harvard Pilgrim Health Care Institute Noelle M. Cocoros, DSc, MPH, Pfizer: PI on study Bradford D. Gessner, M.D., M.P.H., Pfizer Inc.: Employee|Pfizer Inc.: Stocks/Bonds Sarah J. Pugh, PhD, MPH, Pfizer, Inc: Employee|Pfizer, Inc: Stocks/Bonds James H. Stark, PhD, Pfizer: Employee|Pfizer: Stocks/Bonds Chanu Rhee, MD, MPH, Cytovale: Advisor/Consultant|Pfizer: Advisor/Consultant|UpToDate, Inc.: Royalties.

68 The confounder in time of confusion: a case report on Multisystem Inflammatory Syndrome in Children (MIS-C)

68 The confounder in time of confusion: a case report on Multisystem Inflammatory Syndrome in Children (MIS-C)

P303 A CASE OF MYOPERICARDITIS AFTER II DOSE COVID 19 MRNA VACCINE IN YOUNG MALE

COVID 19 disease caused devasting health consequences from March 2020. The development of effective vaccines against SARs COV 2 is an important weapon to defeat this virus. However rare cases of vaccines complications have been reported including myopericarditis above all in young males that we have to follow strictly and to begin right therapy as soon as possible. Data regarding specific therapy about mypericarditis after COVid 19 vaccine are scanty. We report a case of 16 years old male with no health problems, admitted in emergency department with chest pain relieved by sitting posistion and persistent fever rised 24 h after receiving his second dose of mRNA COVID 19 vaccineA 12 lead ECG showed normal sinusal rhythm without ST changes. On admission the complete blood cells count was normal, PCR was high: 5,92 mg/dl and troponin I at high sensivity was elevated: 9249 ml/L. The patient was hospitalized in our cardiology department with suspected myopericarditis. Ecocardiography TT showed normal left ventricular ejection fraction and no pericardial effusion. We began immediately non steroidal anti inflammatory therapy at high dose (ibuprofen 600 mg x 3/die and colchicine 1 mg/die) with conseguently reduction of chest painfuls symptoms. We also began ACEi therapy. On the advice of of the infectious disease specialist we added in the 5 th day methilprednisolone 25 mg/die in consideration of an excessive acute inflammatory response and we observed a clinical improvement with an indices of inflammation reduction. Cardiac magnetic resonance (CMR) performed after 3 day in T2 weighted images showed intramyocardial and subepicardial hyperintensity localized to the mid and apical lateral, basal infero lateral, distal anterior segment, as myocardial edema. Furthermore after Injection of contrast: subepicardial late gadolinium enhancement in the same segment. Minimum (4 mm) pericardial effusion. The clinical setting was attributable as symptoms, elevated troponin above upper limit of normal, in absence of other identifiable cause of symptoms and findings, to confirmed case of acute myocarditis after vaccine in according to the “CDC case definitions”. Myocarditis after mRNA COVID 19 vaccination affect above all young males with mild and multifocal forms with risks and benefits in favour of vaccines. However we need to identify them for an early therapy. In these setting of myocarditis an early use of corticosteroids can be provided.

Risk of myopericarditis following COVID-19 mRNA vaccination in a large integrated health system: A comparison of completeness and timeliness of two methods.

PurposeHow completely do hospital discharge diagnoses identify cases of myopericarditis after an mRNA vaccine?MethodsWe assembled a cohort 12–39 year‐old patients, insured by Kaiser Permanente Northwest, who received at least one dose of an mRNA vaccine (Pfizer‐BioNTech or Moderna) between December 2020 and October 2021. We followed them for up to 30 days after their second dose of an mRNA vaccine to identify encounters for myocarditis, pericarditis or myopericarditis. We compared two identification methods: A method that searched all encounter diagnoses using a brief text description (e.g., ICD‐10‐CM code I40.9 is defined as ‘acute myocarditis, unspecified’). We searched the text description of all inpatient or outpatient encounter diagnoses (in any position) for “myocarditis” or “pericarditis.” The other method was developed by the Centers for Disease Control and Prevention's Vaccine Safety Datalink (VSD), which searched for emergency department visits or hospitalizations with a select set of discharge ICD‐10‐CM diagnosis codes. For both methods, two physicians independently reviewed the identified patient records and classified them as confirmed, probable or not cases using the CDC's case definition.ResultsThe encounter methodology identified 14 distinct patients who met the confirmed or probable CDC case definition for acute myocarditis or pericarditis with an onset within 21 days of receipt of COVID‐19 vaccination. When we extended the search for relevant diagnoses to 30 days since vaccination, we identified two additional patients (for a total of 16 patients) who met the case definition for acute myocarditis or pericarditis, but those patients had been misdiagnosed at the time of their original presentation. Three of these patients had an ICD‐10‐CM code of I51.4 “Myocarditis, Unspecified;” that code was omitted by the VSD algorithm (in the late fall of 2021). The VSD methodology identified 11 patients who met the CDC case definition for acute myocarditis or pericarditis. Seven (64%) of the 11 patients had initial care for myopericarditis outside of a KPNW facility and their diagnosis could not be ascertained by the VSD methodology until claims were submitted (median delay of 33 days; range of 12–195 days). Among those who received a second dose of vaccine (n = 146 785), we estimated a risk as 95.4 cases of myopericarditis per million second doses administered (95% CI, 52.1–160.0).ConclusionWe identified additional valid cases of myopericarditis following an mRNA vaccination that would be missed by the VSD's search algorithm, which depends on select hospital discharge diagnosis codes. The true incidence of myopericarditis is markedly higher than the incidence reported to US advisory committees in the fall of 2021. The VSD should validate its search algorithm to improve its sensitivity for myopericarditis.

Risk of COVID-19 infection and severe disease in MS patients on different disease-modifying therapies

BackgroundThe risk of SARS-CoV-2 infection and severity with disease modifying therapies (DMTs) in multiple sclerosis (MS) remains unclear, with some studies demonstrating increased risks of infection with B-cell-depleting (anti-CD20) therapies and severity, while others fail to observe an association. Most existing studies are limited by a reliance on ‘numerator’ data (i.e., COVID-19 cases) only. ObjectiveTo assess the risks of COVID-19 by DMT, this study aimed to assess both ‘numerator’ (patients with SARS-CoV-2 infection) and ‘denominator’ data (all patients treated with DMTs of interest) to determine if any DMTs impart an increased risk of SARS-CoV-2 infection or disease severity. MethodsWe systematically reviewed charts and queried patients during clinic encounters in the NYU MS Comprehensive Care Center (MSCCC) for evidence of COVID-19 in all patients who were on the most commonly used DMTs in our clinic (sphingosine-1-phosphate receptor (S1P) modulators (fingolimod/siponimod), rituximab, ocrelizumab, fumarates (dimethyl fumarate/diroximel fumarate), and natalizumab). COVID-19 status was determined by clinical symptoms (CDC case definition) and laboratory testing where available (SARS-CoV-2 PCR, SARS-CoV-2 IgG). Multivariable analyses were conducted to determine predictors of infection and severe disease (hospitalization or death) using SARS-CoV-2 infected individuals per DMT group and all individuals on a given DMT as denominator. ResultsWe identified 1,439 MS patients on DMTs of interest, of which 230 had lab-confirmed (n = 173; 75.2%) or suspected (n = 57; 24.8%) COVID-19. Infection was most frequent in those on rituximab (35/138; 25.4%), followed by fumarates (39/217; 18.0%), S1P modulators (43/250; 17.2%), natalizumab (36/245; 14.7%), and ocrelizumab (77/589; 13.1%). There were 14 hospitalizations and 2 deaths. No DMT was found to be significantly associated with increased risk of SARS-CoV-2 infection. Rituximab was a predictor of severe SARS-CoV-2 infection among patients with SARS-CoV-2 infection (OR 6.7; 95% CI 1.1-41.7) but did not reach statistical significance when the entire patient population on DMT was used (OR 2.8; 95% CI 0.6-12.2). No other DMT was associated with an increased risk of severe COVID-19. ConclusionsAnalysis of COVID-19 risk among all patients on the commonly used DMTs did not demonstrate increased risk of infection with any DMT. Rituximab was associated with increased risk for severe disease.

The Impact of COVID-19 Pandemic on Health Care-Associated Infections in Intensive Care Units: Results From the Egypt National Health Care-Associated Infections Surveillance, 2019-2020

Background The COVID-19 pandemic resulted in the unexpected influx of patients leading to high rates of hospitalization. Focusing resources to mitigate the pandemic unintentionally reduced attention to health care-associated infections (HAIs) prevention programs. Intensive care units (ICUs) have suffered the most burden due to requirement of ventilation. Objective In this paper, we aimed to estimate the national HAI rates at ICUs before and during the COVID-19 pandemic to better identify the pandemic’s impact on HAIs. Methods Egypt’s HAI Surveillance was established in 2016 in 177 governmental ICUs. CDC case definitions and questionnaire were used to collect patients’ data. The types of HAIs targeted included bloodstream infections, pneumonia, and urinary tract infections. Pathogen identification and antimicrobial resistance were performed at the central laboratory. Surveillance data 2019-2020 were obtained, and a descriptive data analysis was performed. HAI rates per 100 patient days and device-associated infections (DAIs) per 1000 device days were compared between 2019 and 2020. Results In 2020, 4028 HAIs were reported, including 777 (19.3%) ICU-acquired reports; however, in 2019, 6242 were reported, including 1084 (17.4%) ICU-acquired ones. Incidence significantly decreased in 2020 compared with 2019 (2.67 vs 2.72, P&lt;.001). The percentages of bloodstream infections, pneumonia, and urinary tract infection in 2020, compared with 2019, were 64.0% versus 61.6%, 10.9% versus 12.1%, and 25.1% versus 23.8%, respectively. DAIs decreased significantly, including CLABSI (2.6 vs 2.5, P&lt;.001), VAP (0.75 vs 0.87, P=.04), and CAUTI (1.5 vs 1.6, P=.02). Klebsiella spp. was the predominant pathogen in both years representing (35.6% and 38.1%), followed by S. aureus (11.2% and 15.4%). The rate of carbapenem-resistant K. pneumoniae insignificantly increased (25% vs 23%, P=0.3), and that of Methicillin-resistant S. aureus decreased (68% vs 70%, P=0.4). Conclusions Egypt’s HAI Surveillance successfully described the impact of COVID-19 pandemic on HAIs. It identified a significant decrease in ICU-acquired HAIs and DAIs at the first pandemic year, which could reflect better the infection control measures. The types of HAIs, causative pathogens, and antimicrobial resistance pattern did not change significantly. Surveillance should be maintained to guide HAIs’ preventive and control measures.

449. Performance of the Brighton Case Definition for Multisystem Inflammatory Syndrome in Children (MIS-C) Among a Large Single Center Cohort

BackgroundMultisystem Inflammatory Syndrome in Children (MIS-C) is a rare, life-threatening, hyperinflammatory condition presumed to follow SARS-CoV-2 infection. Whether MIS-C can also follow SARS-CoV-2 vaccination is not clear, making MIS-C an adverse event of special interest following immunization. Monitoring for post-vaccine MIS-C is complicated by the clinical overlap of MIS-C with numerous other inflammatory conditions including Kawasaki Disease, toxic shock syndrome, and viral myocarditis. A case definition for MIS-C was recently created with the Brighton Collaboration (BC). We aimed to determine the performance of the BC MIS-C case definition among a large, single-center MIS-C cohort.MethodsRetrospective review was performed for the first 100 MIS-C cases at our institution (May 2020-February 2021). All cases met the Centers for Disease Control and Prevention (CDC) case definition. Data on age, presentation, laboratory results and cardiac studies were collected and used to determine cases that fulfilled the BC case definition for MIS-C (see figure).Case Definition: Definite Case ResultsOf 100 children (age < 21 years) diagnosed with MIS-C using the CDC case definition, 93 patients also fulfilled the BC definition. All 100 patients had elevated laboratory markers of inflammation and positive SARS-CoV-2 antibodies. However, 1 patient was excluded for significant respiratory symptoms (pulmonary hemorrhage), 5 were excluded due to only 1 clinical feature, and an additional patient was excluded for having none of the measures of disease activity. Among the 93 patients fulfilling the revised case definition, 88 (95%) met criteria for a definite case. Five of the 93 patients (5%) were considered probable cases, 1 reported only 1 day of fever and 4 had only 1 measure of disease activity.ConclusionThe original case definitions for MIS-C were created rapidly following the first emerging reports of this hyperinflammatory state. Knowledge of the varied clinical presentations of this disorder has grown substantially. Modification of the case definition to include features truly representative of MIS-C will allow for more precise diagnosis in the face of conditions which mimic MIS-C, and for accurate and reliable monitoring for adverse events following immunization.Disclosures Flor M. Munoz, MD, Biocryst (Scientific Research Study Investigator)Gilead (Scientific Research Study Investigator)Meissa (Other Financial or Material Support, DSMB)Moderna (Scientific Research Study Investigator, Other Financial or Material Support, DSMB)Pfizer (Scientific Research Study Investigator, Other Financial or Material Support, DSMB)Virometix (Other Financial or Material Support, DSMB)

Research tool for classifying Gulf War illness using survey responses: Lessons for writing replicable algorithms for symptom-based conditions

AimsGulf War illness (GWI), a chronic symptom-based disorder, affects up to 30% of Veterans who served in the 1990-1991 Gulf War1. Because no diagnostic test or code for GWI exists, researchers typically determine case status using self-reported symptoms and conditions according to Kansas2 and CDC3 criteria. No validated algorithm has been published and case definitions have varied slightly by study. This paper aims to standardize the application of the original CDC and Kansas case definitions by defining a framework for writing reliable code for complex case definitions, implementing this framework on a sample of 1343 Gulf War Veterans (GWVs), and validating the framework by applying the code to a sample of 41,077 GWVs. Main methodsMethods were drawn from software engineering: write pseudocode, write test cases, and write code; then test code. Code was examined for accuracy, flexibility, replicability, and reusability. Key findingsThe pseudocode promoted understanding of the planned algorithm, encouraging discussion and leading to agreement on the case definition algorithms among all team members. The completed SAS code was written for and tested in the Gulf War Era Cohort and Biorepository (GWECB)4. This code was adapted and tested in the Million Veteran Program (MVP)5. The code was documented for reproducibility and reusability. SignificanceEase of reuse suggests that this method could be used to standardize the application of other case definitions, reducing time and resources spent by each study team. Documentation, code, and test cases are available through the Department of Veterans Affairs (VA) Phenomics catalog6.

#42: COVID-19 in Pediatric Hemato-Oncology Patients from Three Hispaniola Hospitals

Abstract Background In late 2019, a novel coronavirus, SARS-CoV-2, was reported in China, which rapidly spread across the globe. The WHO declared a pandemic of coronavirus disease (COVID-19) in early 2020. In March, both the Dominican Republic and Haiti reported their first cases. The three pediatric oncology units (POUs) that make up the St. Jude Global Infectious Diseases Hispaniola Project began to see COVID-19 among patients in Santo Domingo in March and in both Santiago and Port-au-Prince in June. We report the experience of managing pediatric hemato-oncology patients with COVID-19 in these three POUs. Methods We added COVID-19 data to our ongoing healthcare-associated infection surveillance in the POUs of the Hispaniola Project. The population studied included all patients tested for SARS-CoV-2 by PCR and/or serological methods. Patient data was recorded on a basic line listing. Cases were categorized using a published clinical symptom severity scale and case definition criteria from the WHO and the US Centers for Disease Control and Prevention (CDC). Results In total, 31 pediatric oncology patients met either the WHO and/or CDC case definition for COVID-19. The average age was 8 years (range: 5 months to 15 years). Just over half (17, 55%) of cases were female. The most common oncology diagnosis was acute lymphoblastic leukemia in 17 of the cases, followed by acute myeloid leukemia (5) and solid tumor (4). Five (16%) cases were in the consolidation phase, 7 (23%) in induction, and 11 (35%) in maintenance. Using the symptom severity scale, 13 (32%) cases were asymptomatic; symptoms were considered mild in 14 (45%) cases, moderate in 3 (10%), severe in 0 (0%), and critical in 1 (3%). Three deaths were attributed to COVID-19. Eighteen cases met the WHO criteria, 13 (72%) of which were confirmed, 1 probable, and 4 suspected. Twenty-six cases met the CDC criteria, 13 (50%) of which were confirmed and 13 (50%) were suspected; there were 0 probable cases. Conclusions Our findings about COVID-19 in pediatric oncology patients are consistent with data reported globally that disease presentation is mostly asymptomatic or mild but with increased mortality. The high contagiousness and unpredictable clinical response of children with cancer call for rigorous measures to prevent infections in this population. In low resource settings, the scarcity of antiviral, immunologic, and supportive medications further underscores this need. Additionally, we observed differences in our data depending on which COVID-19 case criteria were used (WHO versus CDC); this highlights the importance of standardized definitions that can be used at all resource levels to promote reliable measurement of disease burden.

The “timeless” use of influenza-like illness criteria for influenza detection in the tropics

ObjectiveWe assessed the performance of influenza-like illness (ILI) case definitions by the Centers for Disease Control and Prevention (CDC), European Centers for Disease Control and Prevention and World Health Organization (WHO) in the tropics where seasonal patterns of respiratory viruses in acute upper respiratory tract infections (AURTIs) are ill-defined. MethodsClinical data and samples for respiratory multiplex polymerase chain reaction test were collected from 717 consecutive patients attending an emergency department in Singapore for uncomplicated AURTI in 2016–2018. ResultsInfluenza (20.6%), rhinoviruses (14.4%), and coronaviruses (3.6%) were the most common viral pathogens identified. Biannual peaks with year-round activity were identified for influenza. Although higher rhinovirus activity was observed in inter-influenza seasonal periods, rhinoviruses and coronaviruses circulated year-round without distinct seasonal patterns. During high influenza activity months, the CDC and WHO ILI case definitions had moderate-to-high positive likelihood ratio (LR+) of 3.8–6.8 and 4.5–10.7, respectively, for ruling in influenza. They had moderately-high LR + of 3.3–3.8 and 3.9–4.6 for diagnosing influenza during other months. The ILI case definitions had high specificity (77.2%–85.4%) for rhinoviruses and coronaviruses. ConclusionThe CDC and WHO ILI case definitions can be applied to clinically diagnose influenza in the tropics, regardless of the time of the year.

Factors linked to severe outcomes in multisystem inflammatory syndrome in children (MIS-C) in the USA: a retrospective surveillance study

BackgroundMultisystem inflammatory syndrome in children (MIS-C) is a newly identified and serious health condition associated with SARS-CoV-2 infection. Clinical manifestations vary widely among patients with MIS-C, and the aim of this study was to investigate factors associated with severe outcomes.MethodsIn this retrospective surveillance study, patients who met the US Centers for Disease Control and Prevention (CDC) case definition for MIS-C (younger than 21 years, fever, laboratory evidence of inflammation, admitted to hospital, multisystem [≥2] organ involvement [cardiac, renal, respiratory, haematological, gastrointestinal, dermatological, or neurological], no alternative plausible diagnosis, and either laboratory confirmation of SARS-CoV-2 infection by RT-PCR, serology, or antigen test, or known COVID-19 exposure within 4 weeks before symptom onset) were reported from state and local health departments to the CDC using standard case-report forms. Factors assessed for potential links to severe outcomes included pre-existing patient factors (sex, age, race or ethnicity, obesity, and MIS-C symptom onset date before June 1, 2020) and clinical findings (signs or symptoms and laboratory markers). Logistic regression models, adjusted for all pre-existing factors, were used to estimate odds ratios between potential explanatory factors and the following outcomes: intensive care unit (ICU) admission, shock, decreased cardiac function, myocarditis, and coronary artery abnormalities.Findings1080 patients met the CDC case definition for MIS-C and had symptom onset between March 11 and Oct 10, 2020. ICU admission was more likely in patients aged 6–12 years (adjusted odds ratio 1·9 [95% CI 1·4–2·6) and patients aged 13–20 years (2·6 [1·8–3·8]), compared with patients aged 0–5 years, and more likely in non-Hispanic Black patients, compared with non-Hispanic White patients (1·6 [1·0–2·4]). ICU admission was more likely for patients with shortness of breath (1·9 [1·2–2·9]), abdominal pain (1·7 [1·2–2·7]), and patients with increased concentrations of C-reactive protein, troponin, ferritin, D-dimer, brain natriuretic peptide (BNP), N-terminal pro B-type BNP, or interleukin-6, or reduced platelet or lymphocyte counts. We found similar associations for decreased cardiac function, shock, and myocarditis. Coronary artery abnormalities were more common in male patients (1·5 [1·1–2·1]) than in female patients and patients with mucocutaneous lesions (2·2 [1·3–3·5]) or conjunctival injection (2·3 [1·4–3·7]).InterpretationIdentification of important demographic and clinical characteristics could aid in early recognition and prompt management of severe outcomes for patients with MIS-C.FundingNone.

P0387 / #787: VAPING ASSOCIATED LUNG DISEASE: A CASE PRESENTATION

Aims & Objectives: Vaping is an increasing alternative to smoking and widely considered a safe alternative. This case provides an example of a paediatric patient admitted to intensive care with an acute respiratory illness that presented a number of days after vaping. Methods: KB, a 14 year old, presented with abdominal pain and malaise. Her symptoms evolved to include dizziness, headache and nausea. Over 24 hours she developed worsening respiratory distress and hypoxia despite maximal high flow oxygen therapy.CXR showed ARDS. Consideration was given to starting steroids but they were not started. Following the arrival of the transport team, KB was intubated due to work of breathing, high oxygen requirement and tachycardia. Her pressure and oxygen requirement remained high and nitic was started. She was established on ventilator settings of 30/12 rate 23, nitric 20ppm and 50 percent oxygen. Despite high ventilator pressures CO2 remained high and she was started on HFOV. A large pleural effusion was drained. She was ventilated for a total of 4 days. She recovered well and was discharged. Initial lung function showed a restrictive defect which resolved. Results: CT chest. Widespread bilateral consolidation, pleural effusions. Deranged liver function and coagulopathy- PT 22.9 APTT 29 and fibrinogen 4.5. Gamma GT 300 CRP 300. Cultures and virology negative Conclusions: CDC case definition of confirmed case of vaping associated lung disease Vaping (within 90 days) AND pulmonary infiltrates AND absence of infection AND no plausible alternative diagnosis. KB would fit CDC criteria 2019 Vaping associated lung disease can cause respiratory failure in children.

Improved Postoperative Outcomes By Utilizing A Comprehensive Perioperative Surgical Site Infection (SSI) Reduction Bundle

Background: Surgical site infections (SSIs) can be attributed to increased patient morbidity and mortality, prolonged hospital stays, and overall increased healthcare costs. The Surgical Care Improvement Project (SCIP) was implemented in 2002 but has made limited impact on SSI rates across our facilities, which has led to the creation of a bundled approach of current evidence-based strategies. Methods: In January 2019, a comprehensive SSI prevention bundle of strategies was implemented across a multihospital health system. The bundle was comprised of 8 interventions focusing on the preoperative, intraoperative, and postoperative continuum of care, and refining documentation in the electronic medical record. From January to September 2019 (preointervention period), data were collected from 7,163 adult inpatient and observation elective patients undergoing colon surgery (COLO), abdominal hysterectomy (HYST), hip arthroplasty (HPRO), knee arthroplasty (KPRO), and cardiac bypass graft (CBGB/CBGC). The preintervention period for SSI standardized infection ratios (SIRs) and retrospective review of process measures was set as January–December 2018 (postintervetnion period). Each process measure had outlined targets along with primary outcome measures of overall SSI SIRs and SIRs for each of the 5 reported procedure categories. SSIs were validated to meet CDC and NHSN surveillance case definitions. Secondary outcomes evaluated included length of stay (LOS), readmission rates, and mortality. Results: Overall SIR for all 5 monitored surgical categories decreased by 5% to 1.131 from January to September 2019, compared to SIR of 1.190 in 2018. Hip and knee arthroplasties demonstrated 40% and 38% reductions after the intervention, respectively. Completion of 7 or 8 interventions of the SSI bundle were correlated with lower readmission rates (P = .0488). When any portion of the bundle was used, this was correlated with shorter LOS (P &lt; .0001). Adherence to standardized antimicrobial prophylaxis was associated with decreased mortality (P = .017), for all 5 surgical categories. Conclusions: With the implementation of a focused SSI reduction bundle, our institution has realized reductions in surgical readmissions, length of stay, and mortality. Additionally, SSI rates in certain procedure categories have shown marked improvement. The initial success of this bundle has garnered development of additional procedure focused supplemental strategies for the future year.Funding: NoneDisclosures: Aarikha D’Souza, Banner Health

Clinical Profile of Critical Pertussis in Children at a Pediatric Intensive Care Unit in Northern India

ObjectiveTo delineate the clinical profile, complications, intensive care needs, and predictors of mortality in children with critical pertussis.MethodsRetrospective analysis of case records of children in the pediatric intensive care unit of a tertiary-care hospital, with a diagnosis of critical pertussis over 3 years. Diagnostic criteria included CDC case definition and confirmation by polymerase chain reaction (PCR), when available. Survivors and nonsurvivors were compared to identify predictors of mortality.Results36 records were analysed, most cases were infants (31, 86.1%). 10 (27.7%) were (below 6 weeks of age). In the rest, 16 (61.5%) were partially immunized or unimmunized against pertussis. Rapid breathing (88.9%), paroxysmal cough (86.1%) and apnea (41.7%) were common presenting complaints. Hypoxemia (97.2%), hyperleukocytosis (61.1%) and encephalopathy (52.8%) were common complications. Intensive care needs were mechanical ventilation in 11 (30.6%), vasoactive support in 7 (19.4%) and exchange transfusion in 3 (8.3%). Female gender, apnea, hyperleukocytosis, encephalopathy, need for vasoactive support, and mechanical ventilation predicted mortality.ConclusionPertussis demands attention due to its varied presentation, increased complications and higher mortality.