Colorado Department Of Public Health And Environment Research Articles

Multistate Outbreak of Salmonella Thompson Infections Linked to Seafood Exposure — United States, 2021

In July 2021, the Colorado Department of Public Health and Environment (CDPHE) laboratory identified a cluster of five Salmonella enterica serotype Thompson isolates related to one another within one allele difference, using whole genome multilocus sequence typing (wgMLST). These five isolates, submitted to the public health laboratory as is routine process for confirmatory testing of Salmonella, were highly related to those identified in a 2020 multistate investigation, during which traceback was conducted for sushi-grade tuna and salmon; a common supplier was not identified. The 2021 investigation commenced on August 5, 2021, with five patients living in Colorado, and one each in Missouri, Washington, and Wisconsin. During August-December 2021, CDC, CDPHE, public health and regulatory officials in several states, and the Food and Drug Administration (FDA) conducted epidemiologic, environmental, and laboratory investigations of this multistate outbreak of Salmonella Thompson. Isolates were genetically related to one another and to 2020 isolates within zero to one allele difference. Implicated seafood products were traced to a single seafood distributor, in which the outbreak strain was identified through environmental sampling, and in which inspection identified inadequate sanitization and opportunities for cross-contamination of raw fish. The distributor issued a voluntary recall of 16 seafood items with high potential for contamination and completed remediation actions. This outbreak illustrated the importance of effective cleaning and sanitizing procedures and implementation of controls. When multiple products are recalled during an outbreak investigation, collaboration between public health agencies and implicated facilities can help provide food safety information to restaurants, retailers, and consumers, and to ensure disposal of all recalled products.

Health Care Personnel Exposures to Subsequently Laboratory-Confirmed Monkeypox Patients - Colorado, 2022.

The risk for monkeypox transmission to health care personnel (HCP) caring for symptomatic patients is thought to be low but has not been thoroughly assessed in the context of the current global outbreak (1). Monkeypox typically spreads through close physical (often skin-to-skin) contact with lesions or scabs, body fluids, or respiratory secretions of a person with an active monkeypox infection. CDC currently recommends that HCP wear a gown, gloves, eye protection, and an N95 (or higher-level) respirator while caring for patients with suspected or confirmed monkeypox to protect themselves from infection† (1,2). The Colorado Department of Public Health and Environment (CDPHE) evaluated HCP exposures and personal protective equipment (PPE) use in health care settings during care of patients who subsequently received a diagnosis of Orthopoxvirus infection (presumptive monkeypox determined by a polymerase chain reaction [PCR] DNA assay) or monkeypox (real-time PCR assay and genetic sequencing performed by CDC). During May 1-July 31, 2022, a total of 313 HCP interacted with patients with subsequently diagnosed monkeypox infections while wearing various combinations of PPE; 23% wore all recommended PPE during their exposures. Twenty-eight percent of exposed HCP were considered to have had high- or intermediate-risk exposures and were therefore eligible to receive postexposure prophylaxis (PEP) with the JYNNEOS vaccine§; among those, 48% (12% of all exposed HCP) received the vaccine. PPE use varied by facility type: HCP in sexually transmitted infection (STI) clinics and community health centers reported the highest adherence to recommended PPE use, and primary and urgent care settings reported the lowest adherence. No HCP developed a monkeypox infection during the 21 days after exposure. These results suggest that the risk for transmission of monkeypox in health care settings is low. Infection prevention training is important in all health care settings, and these findings can guide future updates to PPE recommendations and risk classification in health care settings.

Terpene exhaust emissions and impact ozone modeling from cannabis plants at commercial indoor cultivation facilities in Colorado

ABSTRACT In 2019, an air emission field sampling study was conducted by the Colorado Department of Public Health and Environment (CDPHE) Air Pollution Control Division (APCD) at three commercial cannabis cultivation facilities. The goal of the study was to quantify biogenic-terpene volatile organic compound (VOC) emissions from growing cannabis at cultivation facility exhaust points to estimate a VOC emission rate by a top-down approach. The resulting VOC emission rates were then used in combination with 2019 commercial cannabis cultivation facility biomass production volumes (harvest weight) and cultivation locations from the Colorado Department of Revenue’s Marijuana Enforcement Division (MED) to model the potential ozone and PM2.5 formation impacts of the cannabis industry in the Denver Metro North Front Range (DM/NFR) Ozone Nonattainment Area (NAA). Despite cannabis cultivation facilities’ high nuisance odors, this study found the biogenic VOC emission rate from the sampled indoor facilities to be low (2.13 lbs to 11.12 lbs of VOC/ton of cannabis harvested), even at large production facilities. The dominant terpenes from this sampling study present in most samples were β-caryophyllene, D-limonene, terpinolene, α-pinene, β-pinene, and β-myrcene, respectively, by concentration. Interestingly, the cannabis emissions exhaust profile lacked isoprene, a terpene commonly emitted from other plants that is highly reactive and has great potential to contribute to ozone formation (Sharkey et al. 2008). The low biogenic VOC emission rate and the lack of isoprene from the cannabis cultivation facilities sampled resulted in a very low to negligible impact on both ozone formation (0.005–0.009% increase in ozone from cannabis cultivation) and PM2.5 formation (largest maximum 24-hr PM2.5 difference of 0.009 µg/m3) in the DM/NFR NAA. Implications: This study concluded that even though cannabis cultivation facilities can have overwhelming nuisance odor impacts, based on samples collected and production rates they actually have a low VOC emission rate (2.13 to 11.12 lbs of VOC/ton of cannabis harvested), even at large high-volume production facilities. Additionally, the dominant VOC emissions from samples collected at the three cannabis cultivation facilities were β-caryophyllene, D-limonene, terpinolene, α-pinene, β-pinene, and β-myrcene. The low biogenic VOC emission rate and the lack of isoprene from the cannabis cultivation facilities sampled resulted in a very low to negligible impact on both ozone formation (0.005%–0.009% increase in ozone from cannabis cultivation) and PM2.5 formation (largest maximum 24-hr PM2.5 difference of 0.009 µg/m3) in the DM/NFR NAA.

Current Marijuana Use and Alcohol Consumption Among Adults Following the Legalization of Nonmedical Retail Marijuana Sales - Colorado, 2015-2019.

In Colorado, excessive alcohol use* contributed to $5 billion in economic costs in 2010 (1) and >1,800 deaths annually during 2011-2015 (2). The most common pattern of excessive drinking is binge drinking (consumption of four or more drinks on an occasion for women or five or more drinks for men) (3), which is associated with increased likelihood of using other substances, including marijuana (4). Retail (i.e., nonmedical) marijuana sales began in Colorado on January 1, 2014. The Colorado Department of Public Health and Environment (CDPHE) and CDC used data from Colorado's 2015-2019 Behavioral Risk Factor Surveillance System (BRFSS) to examine current use of marijuana (including hashish) by drinking patterns among 45,991 persons aged ≥18 years who responded to questions about alcohol and marijuana use. The age-standardized, weighted prevalence of current marijuana use among persons who reported binge drinking (34.4%) was significantly higher than the prevalence among current non-binge drinkers (14.8%) and nondrinkers (9.9%). Evidence-based strategies recommended by the Community Preventive Services Task Force to reduce excessive alcohol use and tobacco use (e.g., increasing prices or reducing access) can reduce alcohol- and tobacco-related harms. Similar strategies might be effective in reducing marijuana use and its potential harms as well.

Rapid Increase in Circulation of the SARS-CoV-2 B.1.617.2 (Delta) Variant - Mesa County, Colorado, April-June 2021.

On May 5, 2021, the Colorado Department of Public Health and Environment (CDPHE) identified the first five COVID-19 cases caused by the SARS-CoV-2 B.1.617.2 (Delta) variant in Mesa County in western Colorado (population 154,933, <3% of the state population). All five initial cases were associated with school settings. Through early June, Mesa County experienced a marked increase in the proportion of Delta variant cases identified through sequencing: the 7-day proportion of sequenced specimens identified as B.1.617.2 in Mesa County more than doubled, from 43% for the week ending May 1 to 88% for the week ending June 5. As of June 6, more than one half (51%) of sequenced B.1.617.2 specimens in Colorado were from Mesa County. CDPHE assessed data from surveillance, vaccination, laboratory, and hospital sources to describe the preliminary epidemiology of the Delta variant and calculate crude vaccine effectiveness (VE). Vaccination coverage in early May in Mesa County was lower (36% of eligible residents fully vaccinated) than that in the rest of the state (44%). Compared with that in all other Colorado counties, incidence, intensive care unit (ICU) admissions, and COVID-19 case fatality ratios were significantly higher in Mesa County during the analysis period, April 27-June 6, 2021. In addition, during the same time period, the proportion of COVID-19 cases in persons who were fully vaccinated (vaccine breakthrough cases) was significantly higher in Mesa County compared with that in all other Colorado counties. Estimated crude VE against reported symptomatic infection for a 2-week period ending June 5 was 78% (95% confidence interval [CI]=71%-84%) for Mesa County and 89% (95% CI=88%-91%) for other Colorado counties. Vaccination is a critical strategy for preventing infection, serious illness, and death from COVID-19. Enhanced mitigation strategies, including masking in indoor settings irrespective of vaccination status, should be considered in areas with substantial or high case rates.

Identification of and Surveillance for the SARS-CoV-2 Variants B.1.427 and B.1.429 - Colorado, January-March 2021.

The B.1.427 and B.1.429 variants of SARS-CoV-2, the virus that causes COVID-19, were first described in Southern California on January 20, 2021 (1); on March 16 they were designated variants of concern* (2). Data on these variants are limited, but initial reports suggest that, compared with other lineages, they might be more infectious (1,2), cause more severe illness (2), and be less susceptible to neutralizing monoclonal antibody products such as bamlanivimab, an investigational treatment for mild-to-moderate COVID-19 (1-3). On January 24, the Colorado Department of Public Health and Environment (CDPHE) identified the first Colorado case of COVID-19 attributed to these variants. B.1.427 and B.1.429 were considered a single variant described as CAL.20C or B.1.427/B.1.429 in the 20C clade (1,3); in this report "B.1.427/B.1.429" refers to B.1.427 or B.1.429 lineage, including those reported as B.1.427/B.1.429 without further differentiation.

Investigation of a Prolonged Group A Streptococcus Outbreak Among Residents and Outpatients Receiving Wound Care at a Long-Term Care Facility (LTCF)

Background: In February 2019, the Colorado Department of Public Health and Environment (CDPHE) identified a cluster of 3 invasive group A Streptococcus (GAS) infections in residents receiving wound care in a long-term care facility (LTCF). An investigation revealed a larger outbreak that extended to nonresidents receiving outpatient wound care at the LTCF. Methods: A case was defined as a positive culture for GAS emm type 82 from an individual with exposure to the LTCF between January and June 2019. Cases were categorized as clinical (symptoms of GAS disease or GAS isolated from a wound or sterile site) or carriage (no symptoms). Carriers were identified via samples collected from throat and skin lesions. Screening occurred in 2 rounds and included residents of affected units followed by screening of all wound-care staff and residents facility-wide. Available isolates were sent for emm type testing and whole-genome sequencing (WGS) at the CDC. CDPHE staff performed infection control observations. Results: We identified 14 cases: 8 clinical and 6 carriage (from 5 residents and 1 staff member). Two patients with invasive GAS died. Of 8 patients with clinical GAS, 6 resided in the facility on or 1 day prior to symptom onset; 2 were not residents but received outpatient therapy at the LTCF. All 8 patients with clinical GAS (100%) and 3 carriers had received wound care. The staff member with emm 82 carriage had provided wound care and occupational therapy to the affected residents and the 2 outpatients. Two additional cases were detected with onset dates following staff member decolonization. Moreover, 13 of the 14 emm 82 isolates were found to be identical by WGS. Infection control observations identified lapses in staff wound care and hand hygiene practices in the residential and outpatient settings of the facility. Conclusions: This investigation details a large GAS outbreak in an LTCF associated with asymptomatic carriage in residents and staff that included patients who had only received care in the outpatient portion of the facility. The outbreak was halted following decolonization of a staff member and improvements in infection control, including in the outpatient setting. Outpatient services, particularly wound care, provided by LTCFs should be considered when investigating LTCF-related GAS cases and outbreaks.Funding: NoneDisclosures: None

Trends in Retinopathy of Prematurity over 12 Years in a Colorado Cohort

ABSTRACT Purpose To determine trends in retinopathy of prematurity (ROP) in a Colorado cohort between 2006 and 2017 and compare trends in risk factors between our cohort and statewide data. Methods A retrospective cohort study was conducted by the use of records from two registry databases: 1) an academic center’s ROP registry, and 2) vital statistics birth data from the Colorado Department of Public Health and Environment (CDPHE). ROP was categorized as severe (type 1 or type 2), low grade (not type 1 or type 2), or no ROP. Other variables included in the analyses were gestational age and birth weight at delivery, and infant mortality. Trends over time were evaluated for both registry databases using generalized linear models. Results In our ROP registry cohort of 1,267 eligible infants, 134 (10.6%) developed severe ROP and 279 (22%) developed low-grade ROP. We found no overall trend in severe ROP rates (p = .23), and a decreasing trend in rates of low-grade ROP (p < .01) over the study period. Trends in gestational age, birth weight, and mortality rates remained stable during the study period in both the ROP registry and the CDPHE cohorts. Conclusion The rate of severe ROP in our ROP registry cohort did not change over time. There was evidence of a decreasing trend in low grade ROP during the 12-year study period that was not explained by a change in the primary ROP risk factors in either the ROP registry cohort or the Colorado statewide data.

1891. Invasive Group A Streptococcus Infections Among Residents of Multiple Nursing Homes—Denver, Colorado, 2017–2018

BackgroundOlder adults residing in nursing homes (NH) are at increased risk for invasive group A Streptococcus (GAS) infections due to advanced age, presence of wounds, and comorbidities; approximately one-third of infected patients die. Beginning in 2015, increasing numbers of GAS infections in NH residents and several NH clusters were reported from the Denver metropolitan area. Colorado Department of Public Health and Environment (CDPHE) and CDC investigated to characterize cases and assess if outbreaks resulted from interfacility transmission.MethodsWe reviewed data from Active Bacterial Core surveillance (ABCs) in the 5-county Denver area from January 2017 to June 2018. We defined a case as isolation of GAS from a normally sterile site in an NH resident. GAS isolates underwent whole-genome sequencing (WGS) at CDC’s Streptococcus Laboratory to determine emm types for genotyping. Among isolates with the same emm type, pairwise single-nucleotide polymorphism (SNP) distances were calculated using Nucmer software. In October 2018, a CDPHE-CDC team assessed infection control at NHs with cases of the most common emm type.ResultsOver 18 months, among >100 NHs in the Denver area, ≥1 GAS case was identified in 29 NHs, with 6 having ≥3 cases. During this period, 68 cases in NH residents were identified. WGS identified 17 emm types among isolates from these cases; most common was emm11.10 (34%, n = 22), a rare subtype in ABCs. All emm11.10 isolates had nearly identical genomes (average pairwise SNP distance: 3.2), and were isolated from 10 NHs, with 2 NHs having ≥ 4 cases. Multiple infection control lapses were noted during site visits to 8 NHs.ConclusionMultiple outbreaks due to GAS were noted in 5-county Denver area NHs in 2017–2018. WGS of surveillance isolates identified a rarely seen emm subtype 11.10 from multiple facilities with temporal and genomic clustering suggesting interfacility GAS transmission. Disclosures All Authors: No reported Disclosures.

Candida Bloodstream Infections Among Persons Who Inject Drugs - Denver Metropolitan Area, Colorado, 2017-2018.

Candidemia, a bloodstream infection caused by Candida species, is typically considered a health care-associated infection, with known risk factors including the presence of a central venous catheter, receipt of total parenteral nutrition or broad-spectrum antibiotics, recent abdominal surgery, admission to an intensive care unit, and prolonged hospitalization (1,2). Injection drug use (IDU) is not a common risk factor for candidemia; however, in the context of the ongoing opioid epidemic and corresponding IDU increases, IDU has been reported as an increasingly common condition associated with candidemia (3) and methicillin-resistant Staphylococcus aureus bacteremia (4). Little is known about the epidemiology of candidemia among persons who inject drugs. The Colorado Department of Public Health and Environment (CDPHE) conducts population-based surveillance for candidemia in the five-county Denver metropolitan area, encompassing 2.7 million persons, through CDC's Emerging Infections Program (EIP). As part of candidemia surveillance, CDPHE collected demographic, clinical, and IDU behavior information for persons with Candida-positive blood cultures during May 2017-August 2018. Among 203 candidemia cases reported, 23 (11%) occurred in 22 patients with a history of IDU in the year preceding their candidemia episode. Ten (43%) of the 23 cases were considered community-onset infections, and four (17%) cases were considered community-onset infections with recent health care exposures. Seven (32%) of the 22 patients had disseminated candidiasis with end-organ dysfunctions; four (18%) died during their hospitalization. In-hospital IDU was reported among six (27%) patients, revealing that IDU can be a risk factor in the hospital setting as well as in the community. In addition to community interventions, opportunities to intervene during health care encounters to decrease IDU and unsafe injection practices might prevent infections, including candidemia, among persons who inject drugs.

1173. A Cluster of Carbapenemase-Producing Acinetobacter baumannii

BackgroundCarbapenem-resistant A. baumannii (CRAB) is reportable in Colorado with three to 11 cases detected annually. Between December 2017 and February 2018, Denver Health Medical Center (DHMC) detected two inpatients with CRAB in urine. The hospital and the Colorado Department of Public Health and Environment (CDPHE) conducted an investigation to determine epidemiologic links and molecular relatedness of the isolates.MethodsWe reviewed medical records and performed infection control observations among staff. Pulsed-field gel electrophoresis (PFGE) was performed at CDPHE; antimicrobial susceptibility (AST) and carbapenemase testing was performed at CDC.Results Epidemiologic investigation: Both patients had neurogenic bladders managed by suprapubic catheters, stage IV decubitus ulcers, and recent surgery. Neither had traveled outside of Colorado. Although both received recent antibiotics, neither received a carbapenem in the 6 previous months. Both isolates were regarded to be asymptomatic bacteriuria. In November 2017, the patients overlapped for 7 days at DHMC on different units. During this week, the same nurse provided wound care for both patients on the same day. Observations of the wound care team revealed opportunities to improve hand hygiene prior to donning and after doffing gloves, the use of single-use scissors on multiple patients, and inconsistent cleaning of a mobile device used to photograph wounds. Microbiologic and molecular investigations: Isolates from the two patients were indistinguishable by PFGE. AST found both isolates susceptible to colistin, but resistant to all other antimicrobials tested (Table 1); both harbored OXA-23-like genes by a Research Use Only assay performed at CDC.ConclusionThese are the first carbapenemase-producing A. baumannii strains identified in Colorado. We suspect that they were transmitted during the overlapping hospital admission, although we could not determine where the organism originated or the route of transmission. Opportunities to improve hand hygiene and low-level disinfection were identified. The emergence of previously undetected carbapenemases in Colorado is of great public health concern; collaboration between public health and healthcare facilities is critical to halt transmission of novel regional pathogens. Disclosures All authors: No reported disclosures.

Mumps Outbreak in a Marshallese Community - Denver Metropolitan Area, Colorado, 2016-2017.

In January 2017, the Colorado Department of Public Health and Environment (CDPHE) identified four epidemiologically linked cases of mumps among persons from a Marshallese community who were members of the same church in the Denver metropolitan area. During 2016-2017, sizable outbreaks of mumps reported in Arkansas, Hawaii, and Washington also affected the Marshallese population (1). CDPHE, the Tri-County Health Department (TCHD), and Denver Public Health collaborated to conduct an outbreak investigation during January-March 2017 using active and passive surveillance that identified 17 confirmed and 30 probable cases. Public health actions included conducting measles-mumps-rubella (MMR) vaccination clinics at local Marshallese churches; these resulted in the vaccination of 126 persons with ≥1 doses of MMR vaccine. Implementation of active surveillance and support from local Marshallese church leaders in promoting vaccination programs likely contributed to interruption of the outbreak.

The Disproportionate Rate of Acute Clinical Illness Associated with Cannabis Edible Use

Background: Cannabis-associated emergency department (ED) visits have risen due to increased availability of the drug in Colorado. Edible cannabis products have been associated with pediatric ED visits and emergency providers report a high incidence of edible related visits in adults. We sought to determine if edible cannabis products result in more ED visits than inhaled products when standardized for product availability. Methods: This was a retrospective chart review study at a large academic hospital. Cases were identified by cannabis ICD-9 and ICD-10 codes. All ED visits with a cannabis ICD-9/10 code between January 1, 2012 and December 31, 2016 were reviewed. Rates of inhaled cannabis-attributed visits and edible-attributed visits were standardized by inhaled and edible product sales provided by the Colorado Department of Revenue over the study period. Findings: There were 9,973 visits with an ICD-9 or ICD-10 code for cannabis use. 2,567 (25·7%) visits were deemed to be at least partially cannabis-attributable; 238 of those (9·3%) were related to edibles ingestion. When standardized for product sales, edibles had a cannabis-attributable ED visit rate 269 times the rate of inhaled cannabis. Inhaled cannabis-attributed visits were more likely to be for cannabinoid hyperemesis syndrome (p<0·0001) and patients with edible-attributed visits were more likely to be due to acute psychiatric symptoms (p<0·0001). Interpretation: Inhaled cannabis-attributable visits are more frequent than edible cannabis-attributable visits though when standardized for sales data, edible cannabis products are associated with a higher rate of emergency department visits than inhaled products. Funding Statement: NIH K23 GM110516, NIH CTSI UL1 TR001082, and CDPHE 17 FHHA 96950. Declaration of Interests: Andrew A. Monte received support from NIH K23 GM110516, NIH CTSI UL1 TR001082, and CDPHE 17 FHHA 96950. The contents of this work are the sole responsibility of the authors and do not necessarily represents the views of the National Institutes of Health (NIH) or the Colorado Department of Public Health and Environment (CDPHE). Ethics Approval Statement: This study protocol was approved by the Colorado Multiple Institution Review Board.

Current Marijuana Use by Industry and Occupation - Colorado, 2014-2015.

The effects of marijuana use on workplace safety are of concern for public health and workplace safety professionals. Twenty-nine states and the District of Columbia have enacted laws legalizing marijuana at the state level for recreational and/or medical purposes. Employers and safety professionals in states where marijuana use is legal have expressed concerns about potential increases in occupational injuries, such as on-the-job motor vehicle crashes, related to employee impairment. Data published in 2017 by the Colorado Department of Public Health and Environment (CDPHE) showed that more than one in eight adult state residents aged ≥18 years currently used marijuana in 2014 (13.6%) and 2015 (13.4%) (1). To examine current marijuana use by working adults and the industries and occupations in which they are employed, CDPHE analyzed data from the state's Behavioral Risk Factor Surveillance System (BRFSS) regarding current marijuana use (at least 1 day during the preceding 30 days) among 10,169 persons who responded to the current marijuana use question. During 2014 and 2015, 14.6% of these 10,169 Colorado workers reported current marijuana use, with the highest reported prevalence among workers in the Accommodation and Food Services industry (30.1%) and Food Preparation and Serving (32.2%) occupations. Understanding the industries and occupations of adults with reported marijuana use can help direct and maximize impact of public health messaging and potential safety interventions for adults.

Outbreak of Fluoroquinolone-Resistant Campylobacter jejuni Infections Associated with Raw Milk Consumption from a Herdshare Dairy - Colorado, 2016.

In August 2016, a local public health agency (LPHA) notified the Colorado Department of Public Health and Environment (CDPHE) of two culture-confirmed cases of Campylobacter infection among persons who consumed raw (unpasteurized) milk from the same herdshare dairy. In Colorado, the sale of raw milk is illegal; however, herdshare programs, in which a member can purchase a share of a herd of cows or goats, are legal and are not regulated by state or local authorities. In coordination with LPHAs, CDPHE conducted an outbreak investigation that identified 12 confirmed and five probable cases of Campylobacter jejuni infection. Pulsed-field gel electrophoresis (PFGE) patterns for the 10 cases with available isolates were identical using the enzyme Sma. In addition, two milk samples (one from the dairy and one obtained from an ill shareholder) also tested positive for the outbreak strain. Five C. jejuni isolates sent to CDC for antimicrobial susceptibility testing were resistant to ciprofloxacin, tetracycline, and nalidixic acid (1). Although shareholders were notified of the outbreak and cautioned against drinking the milk on multiple occasions, milk distribution was not discontinued. Although its distribution is legal through herdshare programs, drinking raw milk is inherently risky (2). The role of public health in implementing control measures associated with a product that is known to be unsafe remains undefined.

Assessment of the Quality and Accuracy of Publically Reported CLABSI Data in Colorado

Validation of healthcare-associated infection (HAI) data is essential in order to verify correct understanding of definition criteria, surveillance practices, and reporting integrity. Additionally, comparisons between facilities may not be accurate if the infection data is incorrect, which can therefore be misleading to the public. The Patient Safety Program at the Colorado Department of Public Health and Environment (CDPHE) assessed the accuracy and quality of the central line-associated bloodstream infection data reported into the National Healthcare Safety Network (NHSN) as well as the surveillance techniques utilized by infection preventionists in Colorado.

Will stringent total nitrogen wastewater treatment plant discharge regulations achieve stream water quality goals?

The Colorado Department of Public Health and Environment (CDPHE) proposed the in-stream numeric nutrient criteria as 2 mg TN per L and 0.16 mg TP per L for warm surface waters and 0.40 mg TN per L and 0.11 mg TP per L for cold surface waters. Consequently the department presented the nutrient limits for the municipal wastewater treatment plants (WWTPs) as annual averages of 0.7 mg TP per L and 5.7 mg TIN per L and quarterly averages of 1.0 mg TP per L and 9.0 mg TIN per L. Implementing stringent nutrient reduction at point sources is unlikely to result in improvements to the environment without non-point source controls. In this study, total nitrogen (TN) load inputs from known point source, WWTPs, and other non-point sources at six sub-basins of the Cache La Poudre (CLP) River Basin were estimated and compared under various hydrologic conditions. Significant loading exceedance from the proposed limits was observed during lower flow conditions and other sources dominated during events when the exceedance was observed except for one point. The point receives direct TN inputs from a WWTP which has the highest TN concentration in its effluent among all WWTPs in the study area; however, TN loads entered the point from other sources were significant during higher flow conditions. TN loads in the CLP River were simulated to determine whether the loads meet the proposed in-stream limits in a case in which all WWTPs comply with the proposed regulations for WWTPs. From this study, it was observed that reducing TN concentrations only at WWTPs merely impacts total TN loads in the river.

P5-S6.20 STIs and healthcare reform. Will it really improve America's sexual health?

BackgroundThe implementation of healthcare reform in the U.S has led to a debate on whether publicly-funded STI clinics will continue to be necessary. A large proportion of STIs are reported...

Efectividad de la vacuna antigripal en individuos de 50-64 años de edad durante una estación de baja concordancia antigénica entre las cepas de virus de la vacuna y las cepas circulantes del virus de la gripe: Colorado, Estados Unidos, 2003-2004

During the 2003-2004 influenza season, we conducted a case-control study of influenza vaccine effectiveness (VE) among Colorado residents aged 50-64 years. Cases (n = 330) were identified from laboratory-confirmed influenza reports to the Colorado Department of Public Health and Environment (CDPHE). Controls (n = 1,055) were recruited by random-digit dial telephone survey. VE was 60% (43-72%) and 48% (21-66%) among those without and with high-risk medical conditions, respectively. VE was 90% (68-97%) and 36% (0-63%) against influenza-related hospitalization for persons without and with high-risk conditions, respectively.

Influenza vaccine effectiveness among 50–64-year-old persons during a season of poor antigenic match between vaccine and circulating influenza virus strains: Colorado, United States, 2003–2004

During the 2003–2004 influenza season, we conducted a case–control study of influenza vaccine effectiveness (VE) among Colorado residents aged 50–64 years. Cases ( n = 330) were identified from laboratory-confirmed influenza reports to the Colorado Department of Public Health and Environment (CDPHE). Controls ( n = 1055) were recruited by random-digit dial telephone survey. VE was 60% (43–72%) and 48% (21–66%) among those without and with high-risk medical conditions, respectively. VE was 90% (68–97%) and 36% (0–63%) against influenza-related hospitalization for persons without and with high-risk conditions, respectively.