Philadelphia Department Of Public Health Research Articles

Adapting COVID-19 Contact Tracing Protocols to Accommodate Resource Constraints, Philadelphia, Pennsylvania, USA, 2021.

Because of constrained personnel time, the Philadelphia Department of Public Health (Philadelphia, PA, USA) adjusted its COVID-19 contact tracing protocol in summer 2021 by prioritizing recent cases and limiting staff time per case. This action reduced required staff hours to prevent each case from 21-30 to 8-11 hours, while maintaining program effectiveness.

Advancing the community plan to end the HIV Epidemic in Philadelphia: a qualitative descriptive evaluation of low-threshold PrEP services in sexual health clinics

BackgroundPre-exposure prophylaxis (PrEP) is an effective HIV prevention method and a key component of Philadelphia’s Community Plan to End the HIV Epidemic (EHE). However, significant barriers to accessing PrEP exist among people at risk for HIV. Low-threshold models for PrEP services that minimize barriers to entry and service engagement could help bolster access to PrEP through community-based clinics. This study aimed to describe the initial implementation of low-threshold PrEP services in three sexual health clinics funded by the Philadelphia Department of Public Health and explore strategies for delivering low-threshold PrEP services.MethodsWe conducted three focus groups with staff (i.e., providers, prevention navigators, and administrative staff, N = 21) at each of three participating PDPH-funded sexual health clinics from November 2021 to January 2022. Discussion topics included details about the PrEP delivery process, clinic strengths and assets, resource gaps, and PrEP implementation goals. Follow-up interviews with staff members (N = 8) between March 2022 and May 2022 focused on identifying successful strategies for PrEP delivery and adaptations needed to optimize low-threshold PrEP service delivery. Rapid qualitative methods and the Consolidated Framework for Implementation Science were used to analyze data from focus groups and interviews.ResultsParticipants collaborated to create process maps that visualized the steps involved in delivering PrEP services within their respective settings. These maps highlighted several stages in PrEP service delivery, such as connecting individuals to services, providing prevention navigation, conducting clinical encounters, and ensuring follow-up care. Participants described effective strategies for implementing PrEP, which included integrating and co-locating services on-site, strengthening staffing resources and capacity, and addressing barriers experienced by clients.ConclusionsLessons from the implementation of low-threshold PrEP service delivery in Philadelphia can guide ongoing local adaptations and future scale-up of these models to improve access to PrEP and advance the goals of the EHE initiative.

Lead exposure in childhood and historical land use: a geostatistical analysis of soil lead concentrations in South Philadelphia parks.

Elevated soil lead (Pb) concentrations in public parks and outdoor spaces continue to have a significant impact on the public health of urban communities. This study evaluated the geospatial and statistical relationships between soil Pb concentrations, the urban environment, and child blood lead levels (BLLs) in the neighborhood of South Philadelphia, PA. Soil samples (n = 240) were collected from forty (40) public parks and analyzed for Pb using a field portable X-ray fluorescence (XRF) analyzer. Geospatial mapping was used to investigate historical land use of each park, vehicular traffic on adjacent roadways, and density of residential/commercial development. Predicted child BLLs and BLL "high-risk areas" were identified using interpolation and biokinetic modeling. Childhood BLL data for South Philadelphia (n = 10,379) was provided by the Philadelphia Department of Public Health (2013-2015). Of the two hundred forty (240) soil samples collected, Pb levels for 10.8% of samples were ≥ 400ppm. Two hundred sixty-nine of 10,379 children screened were identified with BLLs ≥ 5µg/dL. Historical land use of each park was shown to be significantly correlated (p = 0.01) with soil Pb concentrations and child BLLs ≥ 5µg/dL. Approximately 13.3% of the variance in child BLLs ≥ 5µg/dL was attributed to historical site land use. Overall, undeveloped/greenspace historical land use exhibited the highest soil Pb concentrations in the study. Geospatial relationships were identified between census tracts with higher percentages of children with BLLs ≥ 5µg/dL and interpolated BLL "high-risk" areas (≥ 3.5µg/dL). The results of this study suggest soil accumulation time and historical land use may influence soil Pb concentrations and child BLLs in urban communities. Measured soil Pb concentrations were determined to effectively model community-wide contamination and childhood Pb exposure.

COVID-19 Vaccine Equity: Codesigning Public Health Interventions with Community Partners.

COVID-19 Vaccine Equity: Codesigning Public Health Interventions with Community Partners.

Strengthening HIV Prevention Services Through an Implementation Science Approach: Perspectives From the HIV Testers in Philadelphia.

Strengthening HIV prevention services is a key priority of the Ending the HIV Epidemic plan. Informed by the Consolidated Framework for Implementation Research, we examined HIV testers' perceived barriers and facilitators to implementing HIV prevention services, including testers' strengths and weaknesses; enabling factors within the inner and outer settings; and willingness to adopt potential implementation strategies. In 2019, the Penn Center for AIDS Research (CFAR) partnered with the Philadelphia Department of Public Health (PDPH) to examine system-level challenges and opportunities experienced by PDPH-funded HIV testers (individuals conducting HIV testing) in Philadelphia. We recruited HIV testers to complete 2 web surveys (n ≈ 40 each) and in-depth interviews (n = 11). Testers self-reported high HIV testing self-efficacy and competence, despite identifying gaps in their knowledge of STI testing, reporting moderate willingness to recommend pre-exposure prophylaxis, and having insufficient cultural competency when working with priority populations. Testers indicated that educational materials and policies within their agencies might require realignment to affirm sexual and gender minority clients. In qualitative interviews, testers noted challenges to implementing PDPH priorities because limited funding fueled competition between local agencies, deterred interagency partnerships, and limited their ability to serve key populations locally. HIV testers are critical partners in addressing agency-level barriers to HIV prevention service provision through multilevel implementation strategies. In partnership with PDPH, we will create and implement a train-the-trainers program consisting of skill-building activities, technical assistance, and capacity-building for all agency personnel to address missed opportunities in HIV prevention. These activities will reinforce scalability and sustainability of PDPH-supported HIV prevention programs.

Enhancing respiratory protection in skilled nursing facilities during the COVID-19 pandemic: A public health fit-test training program

Background: The Occupational Safety and Health Administration (OSHA) Respiratory Protection standard (29 CFR 1910.134) states that it is an employer’s responsibility to establish and maintain a respiratory protection program when a respirator is necessary to protect the health of employees, including annual assessment of adequate respirator fit. Prior to the COVID-19 pandemic, N95 respirators were rarely used in Philadelphia skilled-nursing facilities (SNFs), and many facilities did not have programs in place or materials to fit test their staff. Methods: The Philadelphia Department of Public Health’s (PDPH) Healthcare Associated Infections/Antimicrobial Resistance (HAI/AR) Program designed and pilot-tested 1.5-hour “train-the-trainer” sessions on OSHA-compliant fit-testing requirements and qualitative procedures. This training was offered to all 47 SNFs beginning May 2021. Training covered the role N95 respirators play in healthcare, proper donning and doffing, OSHA training requirements, medical clearances, record keeping, fit-testing procedure, and demonstrated competency to perform fit testing. Resources that were provided after training included templates of a respiratory protection policy for SNFs, a fit-test record, the OSHA medical clearance form, and a competency checklist. This bundle was designed to help SNFs establish self-sustaining respiratory protection programs. Post-training evaluations were administered on a 6-point Likert scale as well as qualitative, open-ended questions to evaluate the overall quality and effectiveness of the training session. Results: In total, 50 employees (clinical and nonclinical) from 13 Philadelphia SNFs received N95 fit-test training from June through December 2021. The average rating for the training overall was very high (5.9 of 6 points). On average, participants strongly agreed that content presented was directly applicable to their work (5.9 of 6 points), and most strongly agreed that information they learned would alter practices and procedures (5.79 of 6 points). When asked qualitatively what the participant would do differently in practice as a result of the training, the most frequent responses were fit test staff (58%) and educate staff on proper N95 use (60%). Conclusions: The PDPH HAI/AR program created a successful pilot fit-test training program for SNFs, demonstrated by program enrollment and high ratings by participants. This relatively low-cost intervention has provided tools to enhance respiratory protection during the COVID-19 pandemic and has increases the capacity of SNFs to provide essential services for their staff and residents. The PDPH will continue to offer these training sessions to SNFs, with plans to expand to other care settings, such as inpatient behavioral health facilities, outpatient clinics, and emergency medical services.Funding: Funded by the CDC ELC Project FirstlineDisclosures: None

Spatial Analysis and Lead-Risk Assessment of Philadelphia, USA.

Childhood lead poisoning is an issue that continues to plague major U.S. cities. Despite efforts by the Philadelphia Department of Public Health to curtail systemic childhood lead poisoning, children continue to be identified with elevated blood lead levels. The persistence of elevated blood lead levels in children is concerning because lead poisoning has been linked to decreases in academic achievement and IQ, with associated repercussions for entire communities. This paper reports the results of an analysis of the spatial distribution of houses with lead paint (i.e., pre‐1978), demolitions, and occurrence of historic smelters, in West and North Philadelphia, relative to elevated blood lead level data, to determine which lead sources act as primary lead‐risk factors. The presence of lead paint in homes and the number of demolitions of older properties were found to have the highest correlations to elevated blood lead levels for children in Philadelphia. Using lead‐risk factors including lead paint, housing code violations, demolitions, and owner‐occupied housing units, a lead‐risk assessment was performed at the census tract level to identify future soil sampling sites and high‐risk neighborhoods in Philadelphia. These sites of high risk for lead exposure, and in particular the census tracts 175 and 172, should be prioritized for lead poisoning prevention initiatives.

SARS-CoV-2 Infection in Public School District Employees Following a District-Wide Vaccination Program - Philadelphia County, Pennsylvania, March 21-April 23, 2021.

The School District of Philadelphia reopened for in-school instruction the week of March 21, 2021, and required weekly testing for SARS-CoV-2, the virus that causes COVID-19, for all employees returning to in-school responsibilities. The resumption of in-school instruction followed a mass vaccination program using the Pfizer-BioNTech 2-dose vaccine offered under a partnership between the Philadelphia Department of Public Health and Children's Hospital of Philadelphia to all 22,808 School District of Philadelphia employees during February 23-April 3, 2021.* The subsequent mandatory testing program provided an opportunity to assess the percentage of positive BinaxNow point-of-care antigen tests (Abbott Laboratories) identified among school staff members based on their self-reported vaccination status (i.e., received zero, 1, or 2 vaccine doses) at the time of testing. During the initial 5 weeks after schools reopened, 34,048 screening tests were performed. Overall, 0.70% of tests returned a positive result. The percentage of positive test results was lower among persons who reported receipt of 2 vaccine doses (0.09%) compared with those who reported receipt of 1 dose (1.21%) or zero doses (1.76%) (p<0.001) representing a 95% reduction in percentage of positive SARS-CoV-2 test results among persons reporting receipt of 2 compared with zero doses of Pfizer-BioNTech vaccine. Vaccination of school staff members has been highlighted as an important strategy to maximize the safety of in-person education of K-12 students this fall (1). These findings reinforce the importance of promoting COVID-19 vaccination among school staff members before commencement of the 2021-22 school year.

New street drug detected in fatal overdose cases

New street drug detected in fatal overdose cases

Prevalence and Correlates of Syringe Disposal Box Use in a Philadelphia Neighborhood with High Levels of Public Drug Injection

Background: Philadelphia (Pennsylvania, USA) is facing an unprecedented public health crisis due to fentanyl use. To combat drug-related litter, the Philadelphia Department of Public Health installed 7 public syringe disposal boxes (SDB) in Kensington, the neighborhood most impacted by the opioid crisis and home to a syringe exchange. Methods: We used street- and business-intercepts to recruit residents (N=358) and business owners/staff (N=78) who completed a brief survey with two binary items measuring observing and using SDB. Multivariable logistic regression was used to assess factors independently associated with SDB observance and use. Results: 78% (340/436) observed SDB and 34.1% (116/340) had ever used SDB among those who had seen them. Unstably housed persons had 4.3 times greater odds of observing SDB (Adjusted odds ratio [aOR= 4.29; 95% confidence interval [CI]: 1.56, 11.82) and had 2.5 times greater odds of using SDB (aOR = 2.51; 95% CI: 1.33, 4.74) as did people who use opioids (aOR = 2.61; 95% CI: 1.45, 4.72). Among individuals reporting opioid use who also saw SDB (n=123), those who were unstably housed were more likely to use SDB than those with stable housing (67.8% vs 45.3%, p=.012). Conclusion: These results suggest Kensington residents, especially those who are unstably housed, use SDB once they see them in the neighborhood.

From Salt to Stroke-Evaluation of a Media Campaign for Sodium Reduction in Philadelphia.

Excess dietary sodium contributes to the burden of chronic disease, including cardiovascular disease and stroke. Media-based health education campaigns are one strategy to raise awareness among populations at greater risk for stroke, including African Americans. During 2014–2015, the Philadelphia Department of Public Health conducted a health education campaign using radio, print news, and transit ads, to promote awareness of the link between dietary sodium, hypertension and stroke, and encourage reduced consumption of high sodium foods. Using a repeated cross-sectional design, street intercept surveys were conducted with ~400 Philadelphia residents representing the campaign's priority audience (African Americans ages 35–55) before and 6–13 weeks after the campaign, to evaluate both process (campaign exposure) and impact (recall of key health messages). Thirty percent of post-campaign respondents reported familiarity with one of the most engaging radio spots, and 17% provided accurate unaided recall of its key content, with greater recall among older respondents and frequent radio listeners. Forty-one percent of post-campaign respondents named stroke as a consequence of excess salt consumption, compared to only 17% of pre-campaign respondents, with greater awareness of the salt-stroke connection among those accurately recalling the radio spot from the campaign. Results suggest that priority populations for sodium reduction can be effectively reached through radio and transit campaigns. From a pragmatic perspective, street intercept surveys may offer one low resource strategy for evaluating public health education campaigns conducted by local health departments, especially among urban populations.

872. Burden of Influenza Outbreaks in Long-Term Care Facilities in Philadelphia, 2012-2020

BackgroundIn the United States, influenza and other acute respiratory viruses contribute to a high burden of disease in long-term care facility (LTCF) residents. We aim to characterize the disease patterns and inter-seasonal variation of influenza virus outbreaks in LTCFs and identify institutional, environmental, and public health interventions associated with differences in outbreak outcomes and characteristics.MethodsWe conducted a retrospective, longitudinal study of influenza outbreaks in LTCFs reported to the Philadelphia Department of Public Health (PDPH) over eight consecutive seasons (November 2012 through March 2020). Characteristics of individual outbreaks, facilities, and infection control measures were reported in the PDPH Influenza Outbreak database, while quality measures and other facility-level data were extracted from the CMS Nursing Home Compare (NHC) database. Cases of influenza-like illness (ILI) in residents and staff were reported.Results131 influenza outbreaks were reported among 56 facilities, leading to 1196 cases of ILI, 227 influenza-related hospitalizations and 20 deaths. The median number of facility residents affected per outbreak was 4 (range, 0-52), and the resident attack rate was 3.0% (IQR, 1.6-7.4). Facility staff were affected in 56 (43%) of outbreaks. A greater number of facility beds was associated with sites reporting 3 or more outbreaks compared to those that did not (180 vs 133 beds, p=0.019). Public health measures were associated with lower total attack rates for surveillance (1.9% vs 4.3%, p=0.0015), education (1.9% vs 5.1%, p=0.0004), visitation restrictions (1.8% vs 3.1%, p=0.049), and vaccination policies of staff and/or residents (1.6% vs 2.7%, p=0.047). Smaller outbreaks were associated with the implementation of droplet precautions (3 vs 6, p=0.0071), antiviral treatment and prophylaxis (3 vs 6, p=0.024), and admission restrictions (4 vs 7, p=0.015).ConclusionLarger facility size was associated with an increased frequency of outbreaks. Public health measures may reduce the size and severity of influenza outbreaks in LTCFs. These results emphasize the importance of ensuring consistent utilization of recommended infection prevention strategies.Disclosures All Authors: No reported disclosures

Mitigating a COVID-19 Outbreak Among Major League Baseball Players - United States, 2020.

Mass gatherings have been implicated in higher rates of transmission of SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19), and many sporting events have been restricted or canceled to limit disease spread (1). Based on current CDC COVID-19 mitigation recommendations related to events and gatherings (2), Major League Baseball (MLB) developed new health and safety protocols before the July 24 start of the 2020 season. In addition, MLB made the decision that games would be played without spectators. Before a three-game series between teams A and B, the Philadelphia Department of Public Health was notified of a team A player with laboratory-confirmed COVID-19; the player was isolated as recommended (2). During the series and the week after, laboratory-confirmed COVID-19 was diagnosed among 19 additional team A players and staff members and one team B staff member. Throughout their potentially infectious periods, some asymptomatic team A players and coaches, who subsequently received positive SARS-CoV-2 test results, engaged in on-field play with teams B and C. No on-field team B or team C players or staff members subsequently received a clinical diagnosis of COVID-19. Certain MLB health and safety protocols, which include frequent diagnostic testing for rapid case identification, isolation of persons with positive test results, quarantine for close contacts, mask wearing, and social distancing, might have limited COVID-19 transmission between teams.

A Collaborative Public Health and Veterinary Facility Approach to an NDM-5 Escherichia coli Outbreak

Background: Carbapenem-resistant Enterobacteriaceae (CRE) are an important cause of healthcare-associated infections (HAIs) in human hospitals. The Philadelphia Department of Public Health (PDPH) made CRE reportable in April 2018. In May 2019, the Matthew J. Ryan Veterinary Hospital (MJRVH) reported an NDM-5 Escherichia coli cluster in companion animals to the PDPH. In total, 15 infected animals (14 dogs and 1 cat) were reported between July 2018 and June 2019, with no new infections after June 2019. Limited literature is available on the prevalence of CRE in companion animals, and recommendations for dealing with CRE infections currently target human healthcare settings. Methods: A collaborative containment response included assessing interspecies transmission to veterinary staff and a comprehensive evaluation of the infection control program at MJRVH. MJRVH notified all owners of affected animals verbally and via notification letters with PDPH recommendations for CRE colonization screening of high-risk individuals. CRE screening of exposed high-risk employees was conducted by the University of Pennsylvania Occupational Health service and PDPH. Human rectal swabs were analyzed at the Antibiotic Resistance Laboratory Network (ARLN) Maryland Laboratory. PDPH were invited to conduct an onsite infection control assessment and to suggest improvements. Results: No pet owners self-identified in high-risk groups to be screened. In total, 10 high-risk staff were screened, and no colonized individuals were detected. Recommendations made by the PDPH to MJRVH included improvement of infection prevention and control policies (eg, consolidation of the infection control manual and identification of lead staff member), improvement in hand hygiene (HH) compliance (eg, increasing amount of HH supplies), improvement of environment of care (eg, decluttering and evaluation of mulched animal relief area), and improvement of respiratory care processes (eg, standardization of care policies). MJRVH made substantial improvements across recommendation areas including revision of infection control manual, creation of a full-time infection preventionist position, individual alcohol hand sanitizers for patient cages, and environmental decluttering and decontamination. PDPH and MJRVH maintained frequent communication about infection control improvements. Conclusions: No positive transmission to high-risk staff members suggest that, like in human healthcare facilities, transmission of CRE to caretakers may not be a common event. Stronger communication and collaboration is required from Departments of Public Health (DPH) to the veterinary profession regarding the reporting requirements of emerging pathogens such as CRE. Veterinary facilities should view DPH as a valuable resource for recommendations to fill in gaps that exist in infection control “best practices,” particularly for novel pathogens in veterinary settings.Funding: NoneDisclosures: Jane M. Gould reports that her spouse receives salary from Incyte.

An Outbreak of New Delhi Metallo--Lactamase-5 (blaNDM-5)–Producing Escherichia coli in Companion Animals in the United States

Background: The emergence of carbapenem-resistant Enterobacteriaceae (CRE) in companion animals will be a game changer for infection prevention and control strategies in veterinary and human healthcare facilities. CRE have emerged as an important cause of human healthcare-associated infections and are a major clinical and public health problem. Although reports of CRE from animals are still very rare, they have been documented in China, Europe, and the United States. Methods: In April 2019, a passive veterinary surveillance system identified the blaNDM-5 gene in an E. coli isolated from a dog in Philadelphia in July 2018. CRE are reportable to the Philadelphia Department of Public Health (PDPH), and in May 2019, the Matthew J. Ryan Veterinary Hospital at the University of Pennsylvania (MJRVH) reported a cluster of carbapenem-resistant E. coli (CR-E. coli) isolated from 14 animals to the PDHP. This cluster of 17 isolates, that all contained a blaNDM-5 gene, was the first report of a CR-E. coli outbreak at a US veterinary facility. The first isolate, E. coli 24213-18, was sequenced on the Pacific Biosciences (PacBio) Sequel Sequencer and has been uploaded to GenBank. Whole genome sequencing was performed on all 17 isolates using the Illumina MiSeq platform. Antimicrobial resistance genes were identified from the National Center for Biotechnology Information Pathogen Detection Isolates Browser using AMRFinder. Results: PacBio sequencing confirmed E. coli ST167 and identified a circular IncFII plasmid of 139,547 bp that contained the blaNDM-5 gene, along with many additional resistance genes. In June 2019, a retrospective review of hospital records was completed and showed that, from July 2018, 17 CR- E. coli were isolated from 14 animals. Conclusions: Control of CRE infections in human healthcare settings is challenging because the organisms colonize the gastrointestinal tract and can go undetected. The same issue is to be expected with companion animals. Healthcare-associated spread of CRE E. coli in a veterinary facility emphasizes the importance of rapidly identifying and characterizing carbapenem-resistant isolates from animals. Methods to control the spread of CRE in veterinary medical settings have not yet been studied, and related investigations will be critically important to limit the transmission of these pathogens in animal populations. The risk of transmission of CRE from animals to people is currently poorly understood. CRE will be a major challenge across all health fields as these organisms become more prevalent in the community. It is likely that a ‘One Health’ approach to surveillance, infection prevention, and antimicrobial stewardship will be required to limit the spread and potential global dominance of CRE.Funding: NoneDisclosures: None

Site Visits Reveal Common Gaps in Instrument Reprocessing and Sterilization at Philadelphia Dental Clinics

Background: Most dental clinics lack resources and oversight related to infection prevention and control (IPC) practices. Few dental clinics undergo inspections by regulatory authorities unless the state licensing authorities receive a specific complaint. Many states, including Pennsylvania, do not have continuing IPC education requirements for dental providers. In 2018–2019, the Philadelphia Department of Public Health (PDPH) received and responded to multiple complaints and concerns related to IPC practices at dental clinics. Complaints were investigated in collaboration with the Pennsylvania Department of State (PADOS). Methods: Unannounced site visits were conducted at 7 Philadelphia dental clinics from December 2018 through September 2019 as part of the public health responses. Clinic evaluations and observations by PDPH certified infection preventionists focused on (1) IPC policies and procedures, (2) staff IPC training, (3) hand hygiene, (4) personal protective equipment, (5) instrument reprocessing and sterilization, (6) injection safety, and (7) environmental cleaning and disinfection. The CDC and the Organization of Safety, Antisepsis and Prevention (OSAP) checklists were adapted for this purpose. Results: Most dental practices we visited were small, unaffiliated, owner-operated clinics. The most common gaps we identified were associated with instrument reprocessing and sterilization practices, including inadequate separation between clean and dirty work areas, limited space and availability of sinks, inappropriate use of glutaraldehyde products for instrument cleaning (n = 3, 43%), extended reuse of cleaning brushes (n = 5, 71%), sterilization or storage of sterilized instruments without appropriate packaging (n = 2, 29%), lack of spore testing or reviewing results (n = 2, 29%), and lack of documentation of sterilizer run cycles and maintenance (n = 7, 100%). Additionally, most clinics did not have well-developed IPC policies and procedures, and staff IPC trainings were neither documented nor conducted annually. Alcohol-based hand sanitizer was often not available at the point of use. Conclusions: In Philadelphia, dental clinics often lacked IPC support and oversight. Lapses across multiple key IPC domains were common. These findings suggest that public health may have a role in providing IPC support to unaffiliated dental clinics. Licensing entities can also serve a role in improving IPC practices by more widely mandating continuing IPC education as part of the dental license renewal process.Funding: NoneDisclosures: None

The Burden of Gastroenteritis Outbreaks in Long-Term Care Settings in Philadelphia, 2009–2018

Background: Gastroenteritis causes significant morbidity and mortality in long-term care facility (LTCF) residents, a growing population within the United States. Methods: We conducted a retrospective cross-sectional study in LTCFs in Philadelphia County from 2009 to 2018. Outbreak characteristics and interventions were extracted from Philadelphia Department of Public Health’s (PDPH) database, and quality data on all LTCFs was extracted from the CMS Nursing Home Compare database. Results: We identified 121 gastroenteritis outbreaks in 49 facilities. Numbers of affected patients ranged from 2 to 211 patients (median patient attack rate, 17%). Staff were reported ill in 94 outbreaks (median staff attack rate, 5%). Outbreak facilities were associated with higher occupancy rates (91% vs 88%; P = .033) and total bed numbers (176 vs 122; P = .071) when compared to nonoutbreak facilities. Higher rates of staff illness were associated with prolonged outbreaks (13% vs 4%; P &lt; .001) and higher patient illness rates (9% vs 4%; P = .012). Prolonged outbreaks were associated with lower frequency of cohorting for outbreak management (13% vs 41%; P = .046). Conclusions: This study is the largest published analysis of gastroenteritis outbreaks in LTCFs. Facility characteristics and staff disease 20 activity were associated with more severe outbreaks. Heightened surveillance for gastrointestinal symptoms among staff and increased 21 use of cohorting might reduce the risk of prolonged gastroenteritis outbreaks in LTCF.Funding: NoneDisclosures: None

Understanding the Intersection of Behavioral Risk and Social Determinants of Health and the Impact on an Outbreak of Human Immunodeficiency Virus Among Persons Who Inject Drugs in Philadelphia.

In 2018, Philadelphia identified an outbreak of new human immunodeficiency virus (HIV) infections among persons who inject drugs (PWID). Although conventional HIV surveillance systems capture individual-level behavioral risk, they are not able to capture the social and environmental factors contributing to rapid transmission. HIV surveillance data were used to assess demographic, clinical, and behavioral factors for PWID with HIV diagnosed during 2017 and 2018. Social factors such as homelessness, disruption of encampments, and trends in sexual behaviors, drug use and syringe availability among PWID were captured through National HIV Behavioral Surveillance, routine hepatitis and sexually transmitted infection surveillance, and shelter and homeless outreach data. In 2018, there were 71 new infections among PWID, an increase of 115% since 2016. During this time, opioid overdose deaths peaked at 59 deaths per 100 000 persons, 85% of which involved the use of fentanyl. While overall reported homelessness increased, rates of those living unsheltered rose by 13%. The Philadelphia Department of Public Health identified increased injection frequency, encampment closures, and lack of syringe access as promoters of continued HIV transmission. The use of conventional surveillance methods only is inadequate for determining HIV risk during outbreaks. Incorporation of individual and aggregate level data on social and environmental determinants is necessary to develop effective outbreak response interventions.

The burden of gastroenteritis outbreaks in long-term care settings in Philadelphia, 2009-2018.

Gastroenteritis causes significant morbidity and mortality in long-term care facility (LTCF) residents, a growing population within the United States. We set out to better understand gastroenteritis outbreaks in LTCF by identifying outbreak and facility characteristics associated with outbreak incidence as well as outbreak duration and size. We conducted a retrospective cross-sectional study on LTCFs in Philadelphia County from 2009 to 2018. Outbreak characteristics and interventions were extracted from Philadelphia Department of Public Health (PDPH) database and quality data on all LTCFs was extracted from Centers for Medicare and Medicaid Services Nursing Home Compare database. We identified 121 gastroenteritis outbreaks in 49 facilities. Numbers of affected patients ranged from 2 to 211 patients (median patient illness rate, 17%). Staff were reported ill in 94 outbreaks (median staff illness rate, 5%). Outbreak facilities were associated with higher occupancy rates (91% vs 88%; P = .033) and total bed numbers (176 vs 122; P = .071) compared to nonoutbreak facilities. Higher rates of staff illness were associated with prolonged outbreaks (13% vs 4%; P < .001) and higher patient illness rates (9% vs 4%; P = .012). Prolonged outbreaks were associated with lower frequency of cohorting for outbreak management (13% vs 41%; P = .046). This study is the largest published analysis of gastroenteritis outbreaks in LTCFs. Facility characteristics and staff disease activity were associated with more severe outbreaks. Heightened surveillance for gastrointestinal symptoms among staff and increased use of cohorting might reduce the risk of prolonged gastroenteritis outbreaks in LTCF.

Overdose Awareness and Reversal Trainings at Philadelphia Public Libraries.

To evaluate an overdose response training program in public libraries. Mixed methods evaluation including pre- and post-intervention questionnaires and debriefing interviews. Ten Philadelphia public libraries. Overdose response training participants (library staff and community members). Public, hour-long overdose response trainings run by the Philadelphia Department of Public Health, the Free Library of Philadelphia, and the University of Pennsylvania between March and December 2018. Questionnaires assessed motivation for attending trainings, overdose response readiness, and intention to acquire and carry naloxone. Debriefing interviews elicited training feedback. We assessed changes in overdose response readiness and intention to carry naloxone and performed thematic analysis on interview data. At 29 trainings, 254 people attended, of whom 203 (80%) completed questionnaires and 23 were interviewed. 30% of participants had witnessed an overdose, but only 3% carried naloxone at baseline. Following training, overdose response readiness and intention to acquire/carry naloxone improved significantly (P < .01). Interviewees nonetheless noted that they experienced barriers to naloxone acquisition, including cost, stigma, and concern regarding future insurability. Trainings subsequently included naloxone distribution. Interviewees reported that public libraries were welcoming, nonstigmatizing venues. In Philadelphia, library-based overdose response trainings were well-attended and reached a population with prior overdose encounters. Similar trainings could be deployed as a scalable overdose prevention strategy in the nation's 16 568 public libraries.