Massachusetts Population Research Articles

Implementation of Neighborhood-Level Wastewater-Based Epidemiology to Measure and Mitigate Inequities in SARS-CoV-2 Infection in Boston, Massachusetts.

Starting October 2022, the Boston Public Health Commission implemented a neighborhood-level wastewater-based epidemiology program to inform strategies to reduce COVID-19 inequities. We collected samples twice weekly at 11 neighborhood sites, covering approximately 18% of Boston, Massachusetts's population. Results from the program's first year revealed inequities unobservable in regional wastewater data both between the City of Boston and the greater Boston area and between Boston neighborhoods. We report program results and neighborhood-specific recommendations and resources to help residents interpret and use our findings. (Am J Public Health. Published online ahead of print August 8, 2024:e1-e5. https://doi.org/10.2105/AJPH.2024.307749).

From admission to vaccination: COVID-19 vaccination patterns and their relationship with hospitalization in trauma patients

BackgroundCOVID-19 vaccination rates in the hospitalized trauma population are not fully characterized and may lag behind the general population. This study aimed to outline COVID-19 vaccination trends in hospitalized trauma patients and examine how hospitalization influences COVID-19 vaccination rates. MethodsWe conducted a retrospective institutional study using our trauma registry paired with the COVID-19 vaccination ENCLAVE registry. We included patients ≥18 years admitted between April 21, 2021 and November 30, 2022. Our primary outcome was the change in vaccination posthospitalization, and secondary analyzed outcomes included temporal trends of vaccination in trauma patients and predictors of non-vaccination. We compared pre and posthospitalization weekly vaccination rates. We performed joinpoint regression to depict temporal trends and multivariate regression for predictors of nonvaccination. ResultsThe rate of administration of the first vaccine dose increased in the week after hospitalization (P = .018); however, this increase was not sustained in the following weeks. The percentage of unvaccinated patients declined faster in the general population in Massachusetts compared to the hospitalized trauma population. By the conclusion of the study, 27.1% of the trauma population was unvaccinated, whereas <5% of the Massachusetts population was unvaccinated. Urban residence, having multiple hospitalizations, and experiencing moderate to severe frailty were associated with vaccination. Conversely, being in the age groups 18 to 45 years and 46 to 64 years, as well as having Medicaid or self-pay insurance, were linked to being unvaccinated. ConclusionHospitalization initially increased the rate of administration of the first vaccine dose in trauma patients, but the effect was not sustained. By the conclusion of the study period, a greater percentage of trauma patients were unvaccinated compared to the general population of Massachusetts. Strategies for sustained health care integration need to be developed to address this ongoing challenge in the high-risk trauma population.

COVID-19-Related Outcomes Among Group Home Residents with Serious Mental Illness in Massachusetts in the First Year of the Pandemic.

This study examined COVID-19 infection and hospitalizations among people with serious mental illness who resided in residential care group homes in Massachusetts during the first year of the COVID-19 pandemic. The authors analyzed data on 2261 group home residents and COVID-19 data from the Massachusetts Department of Public Health. Outcomes included positive COVID-19 tests and COVID-19 hospitalizations March 1, 2020-June 30, 2020 (wave 1) and July 1, 2020-March 31, 2021 (wave 2). Associations between hazard of outcomes and resident and group home characteristics were estimated using multi-level Cox frailty models including home- and city-level frailties. Between March 2020 and March 2021, 182 (8%) residents tested positive for COVID-19, and 51 (2%) had a COVID-19 hospitalization. Compared with the Massachusetts population, group home residents had age-adjusted rate ratios of 3.0 (4.86 vs. 1.60 per 100) for COVID infection and 13.5 (1.99 vs. 0.15 per 100) for COVID hospitalizations during wave 1; during wave 2, the rate ratios were 0.5 (4.55 vs. 8.48 per 100) and 1.7 (0.69 vs. 0.40 per 100). In Cox models, residents in homes with more beds, higher staff-to-resident ratios, recent infections among staff and other residents, and in cities with high community transmission risk had greater hazard of COVID-19 infection. Policies and interventions that target group home-specific risks are needed to mitigate adverse communicable disease outcomes in this population.Clinical Trial Registration Number This study provides baseline (i.e., pre-randomization) data from a clinical trial study NCT04726371.

Massachusetts Prevalence of Opioid Use Disorder Estimation Revisited: Comparing a Bayesian Approach to Standard Capture-Recapture Methods.

The National Survey on Drug Use and Health (NSDUH) estimated the prevalence of opioid use disorder (OUD) among the civilian, noninstitutionalized people aged 12 years or older in Massachusetts as 1.2% between 2015 and 2017. Accurate estimation of the prevalence of OUD is critical to the success of treatment and resource planning. Various indirect estimation approaches have been used but are subject to data availability and infrastructure-related issues. We used 2015 data from the Massachusetts Public Health Data Warehouse (PHD) to compare the results of two approaches to estimating OUD prevalence in the Massachusetts population. First, we used a seven-dataset capture-recapture analysis under log-linear model parameterization, controlling for the source dependence and effects of age, sex, and county through stratification. Second, we applied a benchmark-multiplier method in a Bayesian framework by linking health care claims data to death certificate data assuming an extrapolation of death rates from observed untreated OUD to unobserved OUD. Our estimates for OUD prevalence among Massachusetts residents (aged 18-64 years) were 4.62% (95% CI = 4.59%, 4.64%) in the capture-recapture approach and 4.29% (95% CrI = 3.49%, 5.32%) in the Bayesian model. Both estimates were approximately four times higher than NSDUH estimates. The synthesis of our findings suggests that the disease surveillance system misses a large portion of the population with OUD. Our study also suggests that concurrent use of multiple methods improves the justification and facilitates the triangulation and interpretation of the resulting estimates. ClinicalTrials.gov Identifier: NCT04111939.

Sociocultural factors associated with persistent prescription opioid use (PPOU) among Puerto Rican adults in Massachusetts.

Increasing numbers of opioid-overdose deaths have been witnessed among Hispanics and other underserved populations in Massachusetts. Puerto Rican adults (PRs) have a disproportionately higher prevalence of chronic diseases than non-Hispanic White adults-conditions linked to increased prescription opioid use and misuse. Stress indicators, including low acculturation, low social support, and perceived discrimination, have been recognized as correlates of chronic diseases. However, little research has been undertaken on how these socio-cultural factors relate to persistent prescription opioid use among PRs. This study evaluated the prevalence of prescription opioid use and socio-cultural factors associated with persistent prescription opioid use among PRs. Data from the prospective population-based Boston Puerto Rican Health Study, at baseline, ~2-year, and ~ 6-year follow-up, were used to estimate prescription opioid use prevalence and its associations with acculturation, social support, and perceived discrimination. Analyses were conducted using multivariable binary logistic regression modeling. The study sample was comprised of 798 PRs (age 56.5 ± 7.5y) with data at all three-time points. A high prevalence of prescription opioid use was observed and was associated with lower household income. PRs with experiences of perceived discrimination had higher odds of persistent prescription opioid use (y/n; OR = 2.85, 95% CI: 1.46-5.58). No significant associations were found between acculturation, social support, and persistent prescription opioid use. Our study reported a high prevalence of prescription opioid use in PRs, with persistent prescription opioid use significantly associated with perceived discrimination. Future programs to limit discrimination practices may reduce persistent prescription opioid use and opioid-related complications among PRs.

Impacts of census differential privacy for small-area disease mapping to monitor health inequities.

The U.S. Census Bureau will implement a modernized privacy-preserving disclosure avoidance system (DAS), which includes application of differential privacy, on publicly released 2020 census data. There are concerns that the DAS may bias small-area and demographically stratified population counts, which play a critical role in public health research, serving as denominators in estimation of disease/mortality rates. Using three DAS demonstration products, we quantify errors attributable to reliance on DAS-protected denominators in standard small-area disease mapping models for characterizing health inequities. We conduct simulation studies and real data analyses of inequities in premature mortality at the census tract level in Massachusetts and Georgia. Results show that overall patterns of inequity by racialized group and economic deprivation level are not compromised by the DAS. While early versions of DAS induce errors in mortality rate estimation that are larger for Black than non-Hispanic white populations in Massachusetts, this issue is ameliorated in newer DAS versions.

Evaluation of Host Fishes for the Brook Floater (Alasmidonta varicosa) from Populations in Massachusetts and Maine, USA

The Brook Floater (Alasmidonta varicosa) mussel is globally vulnerable and has disappeared from much of its historical range. Information on Brook Floater host fish use is needed for ecological and conservation purposes, but previous laboratory studies provide conflicting results. We evaluated host fish use by Brook Floater from populations in Massachusetts and Maine, USA. We conducted three experiments using a total of 10 fish species from six families, and we estimated glochidial attachment rate and juvenile metamorphosis rate. Across fish species, attachment ranged from 51.0% to 84.6% and metamorphosis ranged from 4.9% to 80.9%. Fish species and inoculation density (viable glochidia/mL) only weakly predicted attachment, and the number of glochidia that attached to fish did not affect metamorphosis rate. Juvenile metamorphosis was successful on all fish species tested, supporting evidence that Brook Floater is a host generalist. Fish species was an important factor in predicting metamorphosis rates in all experiments. The highest metamorphosis was on Slimy Sculpin (Cottus cognatus) (80.9% ± 2.6 SD) and Brook Trout (Salvelinus fontinalis) (71.6%), but metamorphosis on Brook Trout varied according to source and was lowest on hatchery-raised fish (12.8% ± 0.3 SD). These data contribute to our understanding of the life history of Brook Floater by identifying potential host fishes, and our results can inform propagation efforts for this species in the northeastern USA.

Range-Wide Population Projections for Northern Red-Bellied Cooters (Pseudemys rubriventris)

Northern Red-Bellied Cooters (Pseudemys rubriventris) have a disjunct distribution with a relictual population in southeastern Massachusetts and a larger range across the mid-Atlantic United States. The relictual population is currently listed with protections under the U.S. Endangered Species Act but the status of the population in the remainder of the species' range has not been assessed, and there is concern that it may be at risk of extinction without protection. The U.S. Fish and Wildlife Service requires scientific information of the species' status to inform conservation decisions. There is little empirical information available from P. rubriventris populations and, furthermore, the majority of what exists comes from the disjunct northern subpopulation. To fill data gaps in the species' life history and reduce geographic bias, we supplement available data from P. rubriventris with demographic rate estimates from other Pseudemys species to parameterize an age-structured population projection model. Our estimate of mean population growth rate was 0.987 (0.92–1.04), indicating that P. rubriventris populations may be in decline. However, there was considerable uncertainty in our results, with 35% of projections resulting in stable or increasing populations. Additional uncertainty about parameter values, geographic variation, and current threats limit the assessment. We discuss the merits and limitations of our population projection modeling (PPM) approach where other analytical methods are precluded by lack of available data.

Implementing expanded COVID-19 testing in Massachusetts community health centers through community partnerships: Protocol for an interrupted time series and stepped wedge study design

BackgroundCommunity Health Centers (CHCs) are a critical source of care for low-income and non-privately insured populations. During the pandemic, CHCs have leveraged their infrastructure and role as a trusted source of care to engage the communities they serve in COVID-19 testing. MethodsTo directly address the impact that COVID-19 has had on historically marginalized populations in Massachusetts, we designed a study of community-engaged COVID-19 testing expansion: (1) leveraging existing partnerships to accelerate COVID-19 testing and rapidly disseminate effective implementation strategies; (2) incorporating efforts to address key barriers to testing participation in communities at increased risk for COVID-19; (3) further developing partnerships between communities and CHCs to address testing access and disparities; (4) grounding the study in the development of a shared ethical framework for advancing equity in situations of scarcity; and (5) developing mechanisms for communication and science translation to support community outreach. We use a controlled interrupted time series design, comparing number of COVID-19 tests overall and among people identified as members of high-risk groups served by intervention CHCs compared with six matched control CHCs in Massachusetts, followed by a stepped wedge design to pilot test strategies for tailored outreach by CHCs. ConclusionsHere, we describe a community-partnered strategy to accelerate COVID-19 testing in historically marginalized populations that provides ongoing resources to CHCs for addressing testing needs in their communities. The study aligns with principles of community-engaged research including shared leadership, adequate resources for community partners, and the flexibility to respond to changing needs over time.

Addressing COVID-19 Testing Inequities Among Underserved Populations in Massachusetts: A Rapid Qualitative Exploration of Health Center Staff, Partner, and Resident Perceptions.

IntroductionAccess to COVID-19 testing has been inequitable and misaligned with community need. However, community health centers have played a critical role in addressing the COVID-19 testing needs of historically disadvantaged communities. The aim of this paper is to explore the perceptions of COVID-19 testing barriers in six Massachusetts communities that are predominantly low income and describe how these findings were used to build tailored clinical-community strategies to addressing testing inequities.MethodsBetween November 2020 and February 2021, we conducted 84 semi-structured qualitative interviews with 107 community health center staff, community partners, and residents. Resident interviews were conducted in English, Spanish, Vietnamese, and Arabic. We used a 2-phase framework analysis to analyze the data, including deductive coding to facilitate rapid analysis for action and an in-depth thematic analysis applying the Social Ecological Model.ResultsThrough the rapid needs assessment, we developed cross-site suggestions to improve testing implementation and communications, as well as community-specific recommendations (e.g., locations for mobile testing sites and local communication channels). Upstream barriers identified in the thematic analysis included accessibility of state-run testing sites, weak social safety nets, and lack of testing supplies and staffing that contributed to long wait times. These factors hindered residents' abilities to get tested, which was further exacerbated by individual fears surrounding the testing process and limited knowledge on testing availability.DiscussionOur rapid, qualitative approach created the foundation for implementing strategies that reached underserved populations at the peak of the COVID-19 pandemic in winter 2021. We explored perceptions of testing barriers and created actionable summaries within 1–2 months of data collection. Partnering community health centers in Massachusetts were able to use these data to respond to the local needs of each community. This study underscores the substantial impact of upstream, structural disparities on the individual experience of COVID-19 and demonstrates the utility of shifting from a typical years' long research translation process to a rapid approach of using data for action.

Trends in Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Seroprevalence in Massachusetts Estimated from Newborn Screening Specimens.

BackgroundEstimating the cumulative incidence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is essential for setting public health policies. We leveraged deidentified Massachusetts newborn screening specimens as an accessible, retrospective source of maternal antibodies for estimating statewide seroprevalence in a nontest-seeking population.MethodsWe analyzed 72 117 newborn specimens collected from November 2019 through December 2020, representing 337 towns and cities across Massachusetts. Seroprevalence was estimated for the Massachusetts population after correcting for imperfect test specificity and nonrepresentative sampling using Bayesian multilevel regression and poststratification.ResultsStatewide seroprevalence was estimated to be 0.03% (90% credible interval [CI], 0.00–0.11) in November 2019 and rose to 1.47% (90% CI: 1.00–2.13) by May 2020, following sustained SARS-CoV-2 transmission in the spring. Seroprevalence plateaued from May onward, reaching 2.15% (90% CI: 1.56–2.98) in December 2020. Seroprevalence varied substantially by community and was particularly associated with community percent non-Hispanic Black (β = .024; 90% CI: 0.004–0.044); i.e., a 10% increase in community percent non-Hispanic Black was associated with 27% higher odds of seropositivity. Seroprevalence estimates had good concordance with reported case counts and wastewater surveillance for most of 2020, prior to the resurgence of transmission in winter.ConclusionsCumulative incidence of SARS-CoV-2 protective antibody in Massachusetts was low as of December 2020, indicating that a substantial fraction of the population was still susceptible. Maternal seroprevalence data from newborn screening can inform longitudinal trends and identify cities and towns at highest risk, particularly in settings where widespread diagnostic testing is unavailable.

Drug Overdose Mortality Among People Experiencing Homelessness, 2003 to 2018

Despite high rates of drug overdose death among people experiencing homelessness, patterns in drug overdose mortality, including the types of drugs implicated in overdose deaths, remain understudied in this population. To describe the patterns in drug overdose mortality among a large cohort of people experiencing homelessness in Boston vs the general adult population of Massachusetts and to evaluate the types of drugs implicated in overdose deaths over a continuous 16-year period of observation. This cohort study analyzed adults aged 18 years or older who received care at Boston Health Care for the Homeless Program (BHCHP) between January 1, 2003, and December 31, 2017. Individuals were followed up from the date of their initial BHCHP encounter during the study period until the date of death or December 31, 2018. Data were analyzed from December 1, 2020, to June 6, 2021. Drug overdose deaths and the types of drugs involved in each overdose death were ascertained by linking the BHCHP cohort to the Massachusetts Department of Public Health death records. In this cohort of 60 092 adults experiencing homelessness (mean [SD] age at entry, 40.4 [13.1] years; 38 084 men [63.4%]), 7130 individuals died by the end of the study period. A total of 1727 individuals (24.2%) died of a drug overdose. Of the drug overdose decedents, 456 were female (26.4%), 194 were Black (11.2%), 202 were Latinx (11.7%), and 1185 were White (68.6%) individuals, and the mean (SD) age at death was 43.7 (10.8) years. The age- and sex-standardized drug overdose mortality rate in the BHCHP cohort was 278.9 (95% CI, 266.1-292.3) deaths per 100 000 person-years, which was 12 times higher than the Massachusetts adult population. Opioids were involved in 91.0% of all drug overdose deaths. Between 2013 and 2018, the synthetic opioid mortality rate increased from 21.6 to 327.0 deaths per 100 000 person-years. Between 2004 and 2018, the opioid-only overdose mortality rate decreased from 117.2 to 102.4 deaths per 100 000 person-years, whereas the opioid-involved polysubstance mortality rate increased from 44.0 to 237.8 deaths per 100 000 person-years. Among opioid-involved polysubstance overdose deaths, cocaine-plus-opioid was the most common substance combination implicated throughout the study period, with Black individuals having the highest proportion of cocaine-plus-opioid involvement in death (0.72 vs 0.62 in Latinx and 0.53 in White individuals; P < .001). In this cohort study of people experiencing homelessness, drug overdose accounted for 1 in 4 deaths, with synthetic opioid and polysubstance involvement becoming predominant contributors to mortality in recent years. These findings emphasize the importance of increasing access to evidence-based opioid overdose prevention strategies and opioid use disorder treatment among people experiencing homelessness, while highlighting the need to address both intentional and unintentional polysubstance use in this population.

283. Population-Based Co-infection of Carbapenem-Resistant Organisms and SARS-CoV-2 in Massachusetts

BackgroundConcerns about antibiotic resistance are exacerbated in COVID-19 patients due to frequent antibiotic use, increase in mechanical ventilation and reusable equipment, conservation of PPE, and strain on hospital staff. We described cases with co-infection of carbapenem-resistant organisms (CRO) and SARS-CoV-2 and compared rates in the Massachusetts population.MethodsAll providers and hospitals are required to report CROs and SARS-CoV-2 to the Massachusetts Virtual Epidemiologic Network (MAVEN). We selected cases with both a positive SARS-CoV-2 test and a laboratory confirmed CRO from January through July 2020. We classified by which result occurred first and described demographic and clinical characteristics. We standardized the CRO case definition by excluding CR-Pseudomonas aeruginosa and calculated rates per 100,000 to assess the impact of SARS-CoV-2 on the population-based frequency of CROs. Analyses were conducted in SAS 9.4.Results28 confirmed cases of SARS-CoV-2 infection were also diagnosed with a CRO. They were an average age of 71.8, 60.7% male, 67.9% white, and 64.3% were in congregate care prior to their diagnoses. Mortality was 5/28 (17.9%). The 23 (82.1%) with a positive SARS-CoV-2 result first were all hospitalized at least once compared to 40% in the CRO first group (p=0.003). 11 (47.8%) of the SARS-CoV-2 first were already admitted when they tested CRO positive; 7 (30.4%) were admitted for the CRO separately from COVID-19 treatment. None of the CRO first group were admitted for CRO infection. Average length of stay for the SARS-CoV-2 first group was higher than the CRO first group (62.3 days vs 11.0 days; p=0.049). Cases positive for CRO first were all infected with CR-Escherichia coli whereas those positive for SARS-CoV-2 first were infected with CRAB, CRPA, or a CRE (Klebsiella oxytoca or Klebsiella pneumoniae) (p< 0.0001). The rate of CRO/COVID coinfection was 0.203 per 100,000 population; the rates for January through July of CRO alone were 2.5 per 100,000 in 2020 and 2.4 per 100,000 in 2019. ConclusionCharacteristics of individuals co-infected with CRO and SARS-CoV-2 differed by which diagnosis was made first; however, the SARS-CoV-2 pandemic did not impact the CRO population rate during the time frame studied.Disclosures All Authors: No reported disclosures

Associations between SARS-CoV-2 concentration in wastewater and sludge and measures of COVID-19 cases in three communities

BACKGROUND AND AIM: COVID-19 is an ongoing public health crisis in the United States, and wastewater-based epidemiology has evolved as a form of surveillance that can capture both symptomatic and asymptomatic cases. The aim of this study is to determine the association among concentrations of SARS-CoV-2 in wastewater and sludge and epidemiological measures of COVID-19. METHODS: We used data from the Boston, Massachusetts (8/19/2020 to 1/19/2021), Portland, Maine (9/1/2020 to 3/2/2021), and New Haven, Connecticut (3/1/2020 to 7/1/2020) metropolitan areas. Massachusetts (population of approximately 3.1 million) and Maine (population of approximately 77,000) SARS-CoV-2 concentrations were measured from weekly or biweekly 24-hour composite samples of wastewater. The Connecticut SARS-CoV-2 concentrations were measured from daily primary sludge samples (copies/mL) from a facility that serves roughly 200,000 residents. Maine samples were not normalized to population size and values below the limit of detection (0.762 copies/mL) were determined to be half the detection limit. Massachusetts samples were normalized to the population using Pepper mild mottle virus. All samples were quantified using RT-qPCR. We used linear regression to assess the association between SARS-CoV-2 concentration in wastewater and sludge and COVID-19 regional incidence. All analyses were adjusted for day of week, temperature (Fahrenheit), precipitation (inches), and flow rate (millions of gallons per day; Massachusetts and Maine only). SARS-CoV-2 concentrations and COVID-19 cases were log-transformed. RESULTS:The median (IQR) concentrations of SARS-CoV-2 were 312.0 (74.0, 858.2), 17.4 (5.5, 63.5), and 70996.87 (37911.53, 124461.7) copies/mL in Massachusetts, Maine, and Connecticut, respectively. SARS-CoV-2 concentrations in wastewater and sludge were significantly associated with incidence in Massachusetts (β=0.56; 95%CI=0.50, 0.63) and Connecticut (β=0.74; 95%CI=0.34, 1.14) and marginally significant in Maine (β=0.22; 95%CI=-0.002, 0.44; p=0.05). CONCLUSIONS:SARS-CoV-2 concentrations in wastewater and sludge were associated with incidence in three communities in the Northeast of the United States. KEYWORDS: SARS-CoV-2, wastewater-based epidemiology, COVID-19, sludge

Rediscoveries of Dichanthelium scoparium (Poaceae) in Southern New England and Evaluation of Past Records from New England and New York

Dichanthelium scoparium (Poaceae) is a robust, rhizomatous panic-grass of the eastern United States. Most common in the southeast, it is considered rare in New York and had not been observed in New England since 1931. In recent years, we have discovered four new populations in Massachusetts and Rhode Island, reestablishing the species as extant in New England. To establish context for these discoveries, we evaluated past records from New England and New York, principally by inspecting digital images of voucher specimens, relying on the readily discernible diagnostic characters of the species. Using the subset of 22 verified records, we elucidate the regional distribution of the species and discuss patterns of habitat and ecological processes that may affect its presence and persistence on the landscape.

Patterns of patient discontinuation from buprenorphine/naloxone treatment for opioid use disorder: A study of a commercially insured population in Massachusetts

BackgroundResearch has shown buprenorphine/naloxone to be an effective medication for treating individuals with opioid use disorder. At the same time, treatment discontinuation rates are reportedly high though much of the extant evidence comes from studies of the Medicaid population. ObjectivesTo examine the pattern and determinants of buprenorphine/naloxone treatment discontinuation in a population of commercially insured individuals. Research designWe performed a retrospective observational analysis of Massachusetts All Payer Claims Data (MA APCD) covering years 2013 through 2017. We defined treatment discontinuation as a gap of 60 consecutive days without a prescription for buprenorphine/naloxone within a time frame of 24 months from the initiation of treatment. A mixed-effect Cox proportional hazard model examined the associated risk of discontinuing treatment with baseline predictors. SubjectsA total of 5134 individuals who were commercially insured during the study period. MeasuresBuprenorphine/naloxone treatment discontinuation. ResultsOverall 75% of individuals had discontinued treatment within two years of initiating treatment, and median time to discontinuation was 300 days. Patients aged between 18 and 24 years (HR = 1.436, 95%, CI = 1.240–1.663) and receiving treatment from prescribers with high panel-size (HR = 1.278, 95% CI = 1.112–1.468) had higher risk of discontinuing treatment. On the contrary, patients receiving treatment from multiple prescribers had lower associated risk of treatment discontinuation. ConclusionsA substantial percentage of patients discontinue treatment well before they can typically meet criteria for sustained remission. Further investigations should assess the clinical outcomes following premature discontinuation and identify strategies for retaining patients in treatment.

Geographic distribution and environmental triggers of systemic sclerosis cases from 2 large academic tertiary centers in Massachusetts

To the Editor: Systemic sclerosis (SSc) is a chronic autoimmune sclerosing disease with the highest case fatality rate among connective tissue diseases.1Feghali-Bostwick C.A. Varga J. Systemic Sclerosis.in: Bradshaw R.A. Dennis E.A. Handbook of Cell Signaling. 2nd ed. Academic Press, 2010: 2913-2917Crossref Scopus (1) Google Scholar Since the 1980s, the annual incidence rates in North America have increased from 1.7 to 2.7 per 100,000 individuals.2Bergamasco A. Hartmann N. Wallace L. Verpillat P. Epidemiology of systemic sclerosis and systemic sclerosis-associated interstitial lung disease.Clin Epidemiol. 2019; 11: 257-273Crossref PubMed Scopus (66) Google Scholar Although the exact pathogenesis of SSc remains unclear, environmental triggers have been hypothesized to provoke disease development among genetically predisposed hosts.3Barnes J. Mayes M.D. Epidemiology of systemic sclerosis: incidence, prevalence, survival, risk factors, malignancy, and environmental triggers.Curr Opin Rheumatol. 2012; 24: 165-170Crossref PubMed Scopus (212) Google Scholar,4McCormic Z.D. Khuder S.S. Aryal B.K. Ames A.L. Khuder S.A. Occupational silica exposure as a risk factor for scleroderma: a meta-analysis.Int Arch Occup Environ Health. 2010; 83: 763-769Crossref PubMed Scopus (82) Google Scholar The assessment of high-prevalence geographic clusters may be a crucial first step in cause identification. Our objectives were to analyze SSc hotspots in Massachusetts and identify possible environmental triggers. The research patient data registry was utilized to identify 4579 potential SSc cases and zip codes from medical records between 1989 and 2019 of Massachusetts General Hospital and Brigham and Women's Hospital. Cases confirmed by dermatologists or rheumatologists were included (n = 2196). The period prevalence was calculated based on the population per zip code. QGIS3.10, a geospatial program, was used to create and analyze SSc distribution and prevalence maps (Fig 1). These maps were compared to environmental toxins and social justice maps to determine trends in etiologic triggers and demographic clusters. Statistical analysis was performed using 2 sample t tests. Hazardous waste facilities (P = .0039) and oil release or disposal sites (P = .0203) were significantly associated with a higher SSc prevalence (Fig 2). Although the association between chemical release sites and SSc prevalence was not independently significant (P = .3166), a spatial correlation was found to exist. Exposure to all 3 sites together posed a significantly increased SSc risk (P = .0002). Disease hotspots showed greater particulate pollution levels and were in proximity to ash pollution and combustion facilities (Supplemental Fig 1 available via Mendeley at https://data.mendeley.com/datasets/59zfn6fdb2/2). The maps of low-income and minority communities demonstrated a spatial relationship with SSc hotspots, suggesting a possible association between socioeconomic factors and disease (Supplemental Fig 2 available via Mendeley at https://data.mendeley.com/datasets/59zfn6fdb2/2).5Environmental justice populations in Massachusetts | Mass.gov.https://www.mass.gov/info-details/environmental-justice-populations-in-massachusettsDate accessed: January 27, 2021Google Scholar The presence of SSc regional clustering and increased density of industry and waste sites in these areas suggest that environmental pollutants play a critical role in disease development. Additionally, the clustering of SSc hotspots and environmental pollutants around low-income and minority neighborhoods indicates that these residents face a disproportionate burden of toxin exposure and disease. High-SSc prevalence pockets in Central and Western Massachusetts with few or no direct toxin sites may be impacted by their surrounding environmental factors, such as water sources collecting precipitated pollutants from nearby facilities or by cross-state pollution, both waterborne and airborne. Another possible explanation for SSc regional clustering is the social drift hypothesis, suggesting that those with chronic diseases are more likely to reside in low-income areas because of disease burden. The study limitations include potential confounders contributing to disease, such as genetic predispositions, sociodemographic factors, and proximity bias. Finally, our study demonstrated a correlation but could not prove causation, making further study of this important topic crucial. Further investigations, including wider geographies and more diverse patient populations, are warranted. Ultimately, this research may provide a greater understanding of the potential role of environmental toxins in SSc onset. Furthermore, it may be used as an advocate for environmental and health policy reforms to protect communities disproportionately burdened by their exposure to environmental toxins and their adverse health effects. None disclosed.

Community Solar Governance: Institutional Design and Collective Choice Options: Implications for U.S. Markets

To assess market development, and governance and equity implications in detail, the research team investigates programs in California, Massachusetts, and New York. The analysis yields insight into the current and future operation of Community Clean Energy authorities (CCEs) in these three states. We estimate that the CCEs in operation in the three states in question now represent over 15 million people. In particular, we identify 471 cities, towns, and counties that have embarked on the community solar choice and CCE authority trajectory. For each state, we assess market conditions by evaluating solar sales, contracts, CCE coverage, and CCE market scale. We find that 55%+ of the Massachusetts population now resides in jurisdictions with active CCE efforts and the same is true for ~41% of the California population. Rapid growth of the CCE model is expected to continue in all three states. We find that CCEs spur substantial solar energy deployment. For example, we were able to examine 85 solar energy transactions by California CCEs that together exceed 3.8 GWp of solar capacity. Our analysis of governance and equity considerations finds that operational CCEs can be classified into two main types: a) a City/County model where individual municipalities embark on community-wide energy decision-making; and b) a joint powers agency (JPA) model where municipalities engage in a collaborative framework to make joint decisions affecting their energy futures. We find both models in all three states. We observe a tendency for JPA strategies to emerge after City/County models have been in operation in the state. We further find that larger, more mature CCE efforts typically emphasize a more sophisticated level of community inputs. CCEs are realizing lower solar-generated electricity prices compared to incumbent utility offerings. The benefits are often explicitly shared with low- and moderate- income families that receive, for instance, temporary relief due to emergencies like the COVID-19 pandemic and permanent discounts on their electricity bills through bill offsets and shared savings. CCEs in California, Massachusetts, and New York are earmarking solar energy deployment that directly serves LMI households through discounted electricity offerings. The solar energy programs and projects initiated by CCEs in the three states are managed and overseen by local governments. While the extent and depth of local government participation varies, we see evidence in all three states that local government oversight produces benefits for the community as a whole that would otherwise be unavailable in utility or private developer-based subscriber programs. CCE authorities provided rights and consumer protection not often found in utility and private developer-based subscriber models. This governance benefit leverages community-wide interests and power. The observed CCEs are engaged in a process of innovation where more and more services and functions are initiated in service to the community. No longer is it the case that these entities are solely motivated to deliver lower electricity prices for their community.

Racial Segregation, Testing Site Access, and COVID-19 Incidence Rate in Massachusetts, USA.

The U.S. has merely 4% of the world population, but contains 25% of the world’s COVID-19 cases. Since the COVID-19 outbreak in the U.S., Massachusetts has been leading other states in the total number of COVID-19 cases. Racial residential segregation is a fundamental cause of racial disparities in health. Moreover, disparities of access to health care have a large impact on COVID-19 cases. Thus, this study estimates racial segregation and disparities in testing site access and employs economic, demographic, and transportation variables at the city/town level in Massachusetts. Spatial regression models are applied to evaluate the relationships between COVID-19 incidence rate and related variables. This is the first study to apply spatial analysis methods across neighborhoods in the U.S. to examine the COVID-19 incidence rate. The findings are: (1) Residential segregations of Hispanic and Non-Hispanic Black/African Americans have a significantly positive association with COVID-19 incidence rate, indicating the higher susceptibility of COVID-19 infections among minority groups. (2) Non-Hispanic Black/African Americans have the shortest drive time to testing sites, followed by Hispanic, Non-Hispanic Asians, and Non-Hispanic Whites. The drive time to testing sites is significantly negatively associated with the COVID-19 incidence rate, implying the importance of the accessibility of testing sites by all populations. (3) Poverty rate and road density are significant explanatory variables. Importantly, overcrowding represented by more than one person per room is a significant variable found to be positively associated with COVID-19 incidence rate, suggesting the effectiveness of social distancing for reducing infection. (4) Different from the findings of previous studies, the elderly population rate is not statistically significantly correlated with the incidence rate because the elderly population in Massachusetts is less distributed in the hotspot regions of COVID-19 infections. The findings in this study provide useful insights for policymakers to propose new strategies to contain the COVID-19 transmissions in Massachusetts.

Clinical Impact, Costs, and Cost-effectiveness of Expanded Severe Acute Respiratory Syndrome Coronavirus 2 Testing in Massachusetts.

BackgroundWe projected the clinical and economic impact of alternative testing strategies on coronavirus disease 2019 (COVID-19) incidence and mortality in Massachusetts using a microsimulation model. MethodsWe compared 4 testing strategies: (1) hospitalized: polymerase chain reaction (PCR) testing only for patients with severe/critical symptoms warranting hospitalization; (2) symptomatic: PCR for any COVID-19–consistent symptoms, with self-isolation if positive; (3) symptomatic + asymptomatic once: symptomatic and 1-time PCR for the entire population; and (4) symptomatic + asymptomatic monthly: symptomatic with monthly retesting for the entire population. We examined effective reproduction numbers (Re = 0.9–2.0) at which policy conclusions would change. We assumed homogeneous mixing among the Massachusetts population (excluding those residing in long-term care facilities). We used published data on disease progression and mortality, transmission, PCR sensitivity/specificity (70%/100%), and costs. Model-projected outcomes included infections, deaths, tests performed, hospital-days, and costs over 180 days, as well as incremental cost-effectiveness ratios (ICERs, $/quality-adjusted life-year [QALY]). ResultsAt Re = 0.9, symptomatic + asymptomatic monthly vs hospitalized resulted in a 64% reduction in infections and a 46% reduction in deaths, but required >66-fold more tests/day with 5-fold higher costs. Symptomatic + asymptomatic monthly had an ICER <$100 000/QALY only when Re ≥1.6; when test cost was ≤$3, every 14-day testing was cost-effective at all Re examined. ConclusionsTesting people with any COVID-19–consistent symptoms would be cost-saving compared to testing only those whose symptoms warrant hospital care. Expanding PCR testing to asymptomatic people would decrease infections, deaths, and hospitalizations. Despite modest sensitivity, low-cost, repeat screening of the entire population could be cost-effective in all epidemic settings.