Surveillance Indicators Research Articles

Executive function predict the quality of life and negative emotion in older adults with diabetes: A longitudinal study

AimsTo investigate the influence of executive function (EF) on current and future quality of life (QoL) and negative emotion (NE) in older adults with diabetes. MethodsA total of 128 older adults with diabetes were recruited. Independent variables (demographic information, health and medical conditions, cognitive function, life function) were collected in the first year. Dependent variables (QoL and NE) were collected for 3 years. Pearson's correlation coefficient analysis and stepwise multiple linear regression analysis were performed to identify the predictors of QoL and NE. ResultsEF was the strongest predictor for overall QoL and NE in all 3 years, and accounted for 23.0–36.2% and 11.1–17.1% of the variance, respectively. The second strongest predictor for overall QoL in all 3 years was pain interference, which accounted for 3.2–5.8% of the variance. Pain interference was also the second strongest predictor for NE in the second year, accounting for 5.5% of the variance. ConclusionsThe present study revealed that EF is more predictive than pain for current and future QoL and NE in older adults with diabetes. We recommend that EF be included as an indicator for diabetes surveillance, and that prevention of EF decline be a part of diabetes management plans.

The Associations Between Racially/Ethnically Stratified COVID-19 Tweets and COVID-19 Cases and Deaths: Cross-sectional Study.

BackgroundThe COVID-19 pandemic exacerbated existing racial/ethnic health disparities in the United States. Monitoring nationwide Twitter conversations about COVID-19 and race/ethnicity could shed light on the impact of the pandemic on racial/ethnic minorities and help address health disparities.ObjectiveThis paper aims to examine the association between COVID-19 tweet volume and COVID-19 cases and deaths, stratified by race/ethnicity, in the early onset of the pandemic.MethodsThis cross-sectional study used geotagged COVID-19 tweets from within the United States posted in April 2020 on Twitter to examine the association between tweet volume, COVID-19 surveillance data (total cases and deaths in April), and population size. The studied time frame was limited to April 2020 because April was the earliest month when COVID-19 surveillance data on racial/ethnic groups were collected. Racially/ethnically stratified tweets were extracted using racial/ethnic group–related keywords (Asian, Black, Latino, and White) from COVID-19 tweets. Racially/ethnically stratified tweets, COVID-19 cases, and COVID-19 deaths were mapped to reveal their spatial distribution patterns. An ordinary least squares (OLS) regression model was applied to each stratified dataset.ResultsThe racially/ethnically stratified tweet volume was associated with surveillance data. Specifically, an increase of 1 Asian tweet was correlated with 288 Asian cases (P<.001) and 93.4 Asian deaths (P<.001); an increase of 1 Black tweet was linked to 47.6 Black deaths (P<.001); an increase of 1 Latino tweet was linked to 719 Latino deaths (P<.001); and an increase of 1 White tweet was linked to 60.2 White deaths (P<.001).ConclusionsUsing racially/ethnically stratified Twitter data as a surveillance indicator could inform epidemiologic trends to help estimate future surges of COVID-19 cases and potential future outbreaks of a pandemic among racial/ethnic groups.

Health surveillance indicators for diet and physical activity: what is available in European data sets for policy evaluation?

BackgroundPolicies targeting diet and physical activity have the potential to improve health and well-being at a population level. However, the impact of these policies in Europe is currently unknown. Based on existing data, as well as on a needs assessment, we derived a catalogue of indicators that can be employed to evaluate such policies. These indicators may also inform the further development and harmonization of surveillance systems.MethodsForty EU experts agreed on a list of key indicators and ranked their priority for future surveillance. We mapped these indicators onto variables provided by ongoing European surveillance systems. Using a Likert scale (well matched, somewhat matched, poorly matched, unmatched), we assessed the suitability of these variables as measures for the indicators.ResultsKey indicators included behaviour outcome indicators relating to diet (n = 72) and physical activity and sedentary behaviour (n = 67) as well as upstream determinants of these behaviours. It was possible to map 72% of diet indicators and 86% of physical activity and sedentary behaviour indicators onto at least one variable in an ongoing surveillance system.ConclusionsCurrent monitoring and surveillance systems focus mainly on measuring ‘downstream’ indicators, while gaps exist in policy and environmental level data in dimensions such as inequality, funding and resources and governance.

Combination of serological biomarkers and clinical features to predict mucosal healing in Crohn’s disease: a multicenter cohort study

PurposeMucosal healing (MH) has become the treatment goal of patients with Crohn’s disease (CD). This study aims to develop a noninvasive and reliable clinical tool for individual evaluation of mucosal healing in patients with Crohn’s disease.MethodsA multicenter retrospective cohort was established. Clinical and serological variables were collected. Separate risk factors were incorporated into a binary logistic regression model. A primary model and a simple model were established, respectively. The model performance was evaluated with C-index, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy. Internal validation was performed in patients with small intestinal lesions.ResultsA total of 348 consecutive patients diagnosed with CD who underwent endoscopic examination and review after treatment from January 2010 to June 2021 were composed in the derivation cohort, and 112 patients with small intestinal lesions were included in the validation cohort. The following variables were independently associated with the MH and were subsequently included into the primary prediction model: PLR (platelet to lymphocyte ratio), CAR (C-reactive protein to albumin ratio), ESR (erythrocyte sedimentation rate), HBI (Harvey-Bradshaw Index) score and infliximab treatment. The simple model only included factors of PLR, CAR and ESR. The primary model performed better than the simple one in C-index (87.5% vs. 83.0%, p = 0.004). There was no statistical significance between these two models in sensitivity (70.43% vs. 62.61%, p = 0.467), specificity (87.12% vs. 80.69%, p = 0.448), PPV (72.97% vs. 61.54%, p = 0.292), NPV (85.65% vs. 81.39%, p = 0.614), and accuracy (81.61% vs. 74.71%, p = 0.303). The primary model had good calibration and high levels of explained variation and discrimination in validation cohort.ConclusionsThis model can be used to predict MH in post-treatment patients with CD. It can also be used as an indication of endoscopic surveillance to evaluate mucosal healing in patients with CD after treatment.

Evolution of the epidemiological surveillance indicators of the main sexually transmitted infections in Spain: A retrospective observational study (2011-2019)

IntroductionOne of the most relevant aspects of sexual health promotion is the need to carry out health education by promoting a healthy affective-sexual education, with the capacity and resources to prevent sexually transmitted infections (STIs) and unwanted pregnancies. The aim of this study was to collect the evolution of epidemiological surveillance indicators of the main STIs, stratified by autonomous community after the publication of the Sexual and Reproductive Health Strategy in Spain in 2011 and until 2019. MethodsA retrospective observational study of the Spanish population with STIs from 2011-2019. The study variables were indicators of the main STIs, including annual rates of notification of infections per 100,000 inhabitants. ResultsThere is a lack of homogeneous and systematic epidemiological surveillance records for STIs. Overall, in Spain there was an upward trend in STIs, except for HIV, which showed a clear decrease. DiscussionDespite existing regulations, strategies, and sex education programs in Spain, the main STIs have been increasing over the years, and Spain is one of the countries with the highest rates in Europe.

Beyond comorbidities, sex and age have no effect on COVID-19 health care demand.

This paper explores the associations between sex, age and hospital health care pressure in the context of the COVID-19 pandemic in Portuguese mainland municipalities. To represent the impact of sex and age, we calculated COVID-19 standardised incidence ratios (SIR) in Portuguese mainland municipalities over fourteen months daily, especially focusing on the Porto metropolitan area. A daily novel indicator was devised for hospital health care pressure, consisting of an approximation to the ratio of hospitalisations per available hospital medical doctor (HPI). In addition, 14-day incidence rates were also calculated daily (DIR14), both as an approach and an alternative to the current national pandemic surveillance indicator (which is not calculated with such regularity). Daily maps were first visualised to evaluate spatial patterns. Pearson's correlation coefficients were then calculated between each proposed surveillance indicator (SIR and DIR14) and the HPI. Our results suggest that hospital pressure is not strongly associated with SIR (r = 0.34, p value = 0.08). However, DIR14 bears a stronger correlation with hospital pressure (r = 0.84, p value < 0.001). By establishing the importance of tackling sex and age through the inclusion of these factors explicitly in an epidemiological monitoring indicator, and assessing its relationship with a hospital pressure indicator, our findings have public policy implications that could improve COVID-19 incidence surveillance in Portugal and elsewhere, contributing to advancing the management of potential pandemics in the near future, with a particular focus on local and regional territorial scales.

Mental health emergency department visits: An exploration of case definitions in North Carolina

BackgroundMental health (MH) disorders comprise a high disease burden and have long-lasting impacts. To improve MH, it is important to define public health MH surveillance. MethodsWe compared MH related definitions using ICD-10-CM codes: The Council of State and Territorial Epidemiologists' (CSTE) surveillance indicators for all MH, mood or depressive, schizophrenic, and drug/alcohol-induced disorders; and North Carolina's (NC) syndromic surveillance system's definition for anxiety/mood/psychotic disorders, and suicide/self-harm. We compared code definitions and frequent codes in 2019 emergency department (ED) data for those age ≥ 10 years. ResultsCSTE's definition resulted in over one million MH-related visits (23% of all ED visits) and NC's definitions in 451,807 MH-related visits (9% of all ED visits). Using CSTE's broadest definition, nicotine use was the most common visit type; using NC's definitions, it was major depressive disorder. ConclusionsStandardizing population-level MH indicators benefits surveillance efforts. Given its prevalence, efforts should focus on documenting MH to improve treatment and prevention.

Lessons from COVID-19 syndromic surveillance through emergency department activity: a prospective time series study from western Switzerland

ObjectiveWe aimed to assess if emergency department (ED) syndromic surveillance during the first and second waves of the COVID-19 outbreak could have improved our surveillance system.Design and settingsWe did an...

Taly physical activity country profile: results from the first set of country cards of the Global Observatory for Physical Activity-GoPA!

The Global Observatory for Physical Activity – GoPA! country cards were launched last Dec 4th in London [1]. GoPA! was created in response to the urgent call to action to prevent the physical inactivity pandemic described in the Lancet physical activity series back in 2012 [2,3]. These population, researcher and policy maker friendly profiles aim to contribute promoting physical activity worldwide. Each profile put together a set of prevalence, health burden, research, surveillance and policy indicators. Each country has a representative that reviews the content presented in the card. Italy was launched in the first set of cards and it has an interesting profile. Main questions that were answered:

Surveillance to Track Progress Toward Polio Eradication - Worldwide, 2020-2021.

Since the Global Polio Eradication Initiative (GPEI) was established in 1988, the number of reported poliomyelitis cases worldwide has declined by approximately 99.99%. By the end of 2021, wild poliovirus (WPV) remained endemic in only two countries (Pakistan and Afghanistan). However, a WPV type 1 (WPV1) case with paralysis onset in 2021, was reported by Malawi a year after the World Health Organization (WHO) African Region (AFR) was certified as WPV-free and circulating vaccine-derived poliovirus (cVDPV) cases were reported from 31 countries during 2020-2021 (1,2). cVDPVs are oral poliovirus vaccine-derived viruses that can emerge after prolonged circulation in populations with low immunity and cause paralysis. The primary means of detecting poliovirus transmission is through surveillance for acute flaccid paralysis (AFP) among persons aged <15 years, with confirmation through stool specimen testing by WHO-accredited laboratories, supplemented by systematic sampling of sewage and testing for the presence of poliovirus (environmental surveillance). The COVID-19 pandemic caused disruptions in polio vaccination and surveillance activities across WHO regions in 2020; during January-September 2020, the number of reported cases of AFP declined and the interval between stool collection and receipt by laboratories increased compared with the same period in 2019 (3). This report summarizes surveillance performance indicators for 2020 and 2021 in 43 priority countries* and updates previous reports (4). In 2021, a total of 32 (74%) priority countries† met two key surveillance performance indicator targets nationally, an improvement from 2020 when only 23 (53%) met both targets; however, substantial national and subnational gaps persist. High-performing poliovirus surveillance is critical to tracking poliovirus transmission. Frequent monitoring of surveillance indicators could help identify gaps, guide improvements, and enhance the overall sensitivity and timelines of poliovirus detection to successfully achieve polio eradication.

The use of electronic health records to inform cancer surveillance efforts: a scoping review and test of indicators for public health surveillance of cancer prevention and control

IntroductionState cancer prevention and control programs rely on public health surveillance data to set objectives to improve cancer prevention and control, plan interventions, and evaluate state-level progress towards achieving those objectives. The goal of this project was to evaluate the validity of using electronic health records (EHRs) based on common data model variables to generate indicators for surveillance of cancer prevention and control for these public health programs.MethodsFollowing the methodological guidance from the PRISMA Extension for Scoping Reviews, we conducted a literature scoping review to assess how EHRs are used to inform cancer surveillance. We then developed 26 indicators along the continuum of the cascade of care, including cancer risk factors, immunizations to prevent cancer, cancer screenings, quality of initial care after abnormal screening results, and cancer burden. Indicators were calculated within a sample of patients from the New York City (NYC) INSIGHT Clinical Research Network using common data model EHR data and were weighted to the NYC population using post-stratification. We used prevalence ratios to compare these estimates to estimates from the raw EHR of NYU Langone Health to assess quality of information within INSIGHT, and we compared estimates to results from existing surveillance sources to assess validity.ResultsOf the 401 identified articles, 15% had a study purpose related to surveillance. Our indicator comparisons found that INSIGHT EHR-based measures for risk factor indicators were similar to estimates from external sources. In contrast, cancer screening and vaccination indicators were substantially underestimated as compared to estimates from external sources. Cancer screenings and vaccinations were often recorded in sections of the EHR that were not captured by the common data model. INSIGHT estimates for many quality-of-care indicators were higher than those calculated using a raw EHR.ConclusionCommon data model EHR data can provide rich information for certain indicators related to the cascade of care but may have substantial biases for others that limit their use in informing surveillance efforts for cancer prevention and control programs.

HABs in coastal upwelling systems: Insights from an exceptional red tide of the toxigenic dinoflagellate Alexandrium minutum

Alexandrium minutum blooms generally occur in semi-enclosed sites such as estuaries, harbours and lagoons, where enhanced stratification, restricted circulation and accumulation of resting cysts in the sediment set suitable habitat conditions for the proliferation of this paralytic shellfish poisoning toxigenic species. In the Galician Rías Baixas (NW Iberian Peninsula), according to weekly time-series between 1994 and 2020, blooms of A. minutum were recurrent in small, shallow estuarine bays inside the Rías de Vigo and Pontevedra, but rarely detected, and if so at low concentrations, out of these environments. However, from May to July 2018 it developed as usual in the small inner bays but then spread over both Rías (Vigo and Pontevedra) causing discoloured waters during one month and prolonged harvesting closures. Meteorological conditions during that period (rains / runoff higher than climatological averages, sustained temperature increment and oscillating wind pattern –i.e., series of upwelling-relaxation cycles), fostered optimal circumstances for the development of that extensive and massive proliferation: strong vertical stratification and the alternation of retention and dispersion processes. Simulations from a particle tracking model portrayed the observed bloom development phases: onset and development inside a small inner bay; transport within the surface layer, from these sites towards the interior parts of the Ría; and dispersion all over the embayment. Seedbeds with high concentrations of resting cysts were detected several months after the bloom, which may have favoured flourishment of A. minutum in the following two years, markedly in 2020. The present work contributes to the general understanding of the dynamics of harmful algal blooms (HABs), from which surveillance indicators of the state of marine ecosystems and their evolution can be derived. We hypothesize that the intensity and frequency of A. minutum proliferations in the Galician Rías could increase under projected climate trends.

Rectal neuroendocrine tumors: Current advances in management, treatment, and surveillance.

Rectal neuroendocrine neoplasms (r-NENs) are considered among the most frequent digestive NENs, together with small bowel NENs. Their incidence has increased over the past few years, and this is probably due to the widespread use of endoscopic screening for colorectal cancer and the advanced endoscopic procedures available nowadays. According to the current European Neuroendocrine Tumor Society (ENETS) guidelines, well-differentiated r-NENs smaller than 10 mm should be endoscopically removed in view of their low risk of local and distant invasion. R-NENs larger than 20 mm are candidates for surgical resection because of their high risk of distant spreading and the involvement of the muscularis propria. There is an area of uncertainty regarding tumors between 10 and 20 mm, in which the metastatic risk is intermediate and the endoscopic treatment can be challenging. Once removed, the indications for surveillance are scarce and poorly codified by international guidelines, therefore in this paper, a possible algorithm is proposed.

Hospitalization with or for COVID-19: which surveillance indicator to choose?

In the SARS-CoV-2 epidemic, the monitoring of epidemiological surveillance indicators is a central issue. We were able to describe the monitoring of the epidemic of hospitalized patients in the department of Alpes-Maritimes from three data sources: 1)&#160;Sant&#233; Publique France (SPF) via the SI-VIC software, 2)&#160;the Regional Health Agency (ARS Paca) with conventional hospitalization or department critical care data taken from SI-VIC, adjusting them to those of the Health Establishments (ES), 3)&#160;The ES of Alpes-Maritimes associated with the ARS of Alpes-Maritimes and the Department of Public Health (DSP) of the CHU, with the collection of patients hospitalized in the conventional sector or in critical/intensive care in the dedicated COVID-19 beds. The aim of this study was to verify the&#160;consistency of these three information systems. We observed disparities between the number of cases of hospitalization of SPF and the data from ES/ARS/DSP. We did not observe any differences in patients hospitized in intensive care/critical care units. The Scientific Council uses SPF data on the number of hospitalizations or intensive/critical beds to justify its recommendations.However, SPF data from SI-VIC have associated patients hospitalized for COVID and patients who tested positive for PCR, but whose reason for hospitalization is not related to SARS-CoV2 infection (formerly infected or asymptomatic patients). We believe that hospital surveillance indicators should only take into account the number of patients in conventional hospitalization or resuscitation for a COVID-19 infection.

Total polyp number may be more important than size and histology of polyps for prediction of metachronous high-risk colorectal neoplasms

BackgroundTo evaluate whether the risk of metachronous high-risk colorectal neoplasm (HR-CRN) differs according to the indication for surveillance colonoscopy.MethodsPatients who underwent polypectomy or endoscopic resection of colorectal neoplasms were enrolled and classified into three groups according to the indication for surveillance colonoscopy: advanced colorectal neoplasm (ACRN: adenoma ≥ 10 mm, adenoma with high-degree dysplasia and/or villous component), advanced serrated polyps (ASP: hyperplastic polyp or sessile serrated lesion ≥ 10 mm, traditional serrated polyp), and high-risk polyps (HRP: 3 or more adenomas or serrated polyps). The primary outcome was the development of metachronous HR-CRN, defined as ACRN, ASP, or HRP at the first follow-up colonoscopy.ResultsIn total, 367 patients were enrolled (ACRN group: N = 264; ASP group: N = 33; HRP group: N = 70). Among the 160 patients who underwent follow-up colonoscopy, 28 (18%) had HR-CRN. In univariable analysis, indication for surveillance colonoscopy was not found to be associated with the development of metachronous HR-CRN. Instead, the total polyp number at index colonoscopy showed a positive association with the risk of metachronous HR-CRN in trend analysis (p = 0.001). In multivariable analysis, the presence of 5 or more polyps at index colonoscopy was found to be associated with the risk of metachronous HR-CRN (OR, 2.575, p = 0.049) after adjusting for risk factors, such as obesity, diabetes, and smoking.ConclusionsThe risk of metachronous HR-CRN did not differ according to the main indications for surveillance colonoscopy. The presence of 5 or more polyps at index colonoscopy was the only risk factor for metachronous HR-CRN.

Impact of the COVID-19 pandemic on gastrointestinal infection trends in England, February–July 2020

ObjectiveTo establish the impact of the first 6 months of the COVID-19 outbreak response on gastrointestinal (GI) infection trends in England.DesignRetrospective ecological study using routinely collected national and regional surveillance...

The Impact of Adulticide on Culex Abundance and Infection Rate in North Shore of Cook County, Illinois.

Mosquito surveillance is critical to reduce the risk of West Nile virus (WNV) transmission to humans. In response to surveillance indicators such as elevated mosquito abundance or increased WNV levels, many mosquito control programs will perform truck-mounted ultra-low volume (ULV) adulticide application to reduce the number of mosquitoes and associated virus transmission. Despite the common use of truck-based ULV adulticiding as a public health measure to reduce WNV prevalence, limited evidence exists to support a role in reducing viral transmission to humans. We use a generalized additive and fused ridge regression model to quantify the location-specific impact of truck-mounted ULV adulticide spray efforts from 2010 to 2018 in the North Shore Mosquito Abatement District (NSMAD) in metropolitan Chicago, IL, on commonly assessed risk factors from NSMAD surveillance gravid traps: Culex abundance, infection rate, and vector index. Our model also takes into account environmental variables commonly associated with WNV, including temperature, precipitation, wind speed, location, and week of year. Since it is unlikely ULV adulticide spraying will have the same impact at each trap location, we use a spatially varying spray effect with a fused ridge penalty to determine how the effect varies by trap location. We found that ULV adulticide spraying has an immediate temporary reduction in abundance followed by an increase after 5 days. It is estimated that mosquito abundance increased more in sprayed areas than if left unsprayed in all but 3 trap locations. The impact on infection rate and vector index were inconclusive due to the large error associated with estimating trap-specific infection rates.

Comparative efficacy of an optimal exam between ultrasound versus abbreviated MRI for HCC screening in NAFLD cirrhosis: A prospective study.

Retrospective studies report that visualisation of the liver may be severely limited using ultrasound (US), potentially contributing to diminished sensitivity for detection of hepatocellular carcinoma (HCC) among patients with nonalcoholic fatty liver disease (NAFLD) and cirrhosis, but there are limited prospective data. To compare liver visualisation scores prospectively for US and abbreviated hepatobiliary phase (HBP) magnetic resonance imaging (AMRI) in a cohort of participants with NAFLD cirrhosis and a clinical indication for HCC surveillance. This prospective multicenter study included 54 consecutive participants (67% women) with NAFLD cirrhosis who underwent contemporaneous US as well as HBP-AMRI with gadoxetic acid. Primary outcome was the proportion of imaging examinations with severe limitations in liver visualisation (visualisation score C) compared head-to-head between US and AMRI. The mean (± standard deviation) age was 63.3years (±8.4) and body mass index was 32.0kg/m2 (±6.0). Nineteen participants (35%) had severe visualisation limitations on US, compared with 10 (19%) with AMRI, p<0.0001. Nine (17%) participants had <90% of the liver visualised on US, compared with only 1 (2%) participant with AMRI, p<0.0001. Obesity was a strong and independent predictor for severe visualisation limitation on US (OR 5.1, CI 1.1-23.1, p=0.03), after adjustment for age, sex and ethnicity. More than one-third of participants with NAFLD cirrhosis had severe visualisation limitations on US for HCC screening, compared with one-sixth on AMRI. US adequacy should be reported in all clinical studies and when suboptimal then AMRI may be considered for HCC screening.

Acquired insights from the long-term surveillance of SARS-CoV-2 RNA for COVID-19 monitoring: The case of Monterrey Metropolitan Area (Mexico)

Wastewater-based epidemiology offers a time- and cost-effective way to monitor SARS-CoV-2 spread in communities and therefore represents a complement to clinical testing. WBE applicability has been demonstrated in a number of cases over short-term periods as a method for tracking the prevalence of SARS-CoV-2 and an early-warning tool for predicting outbreaks in the population. This study reports SARS-CoV-2 viral loads from wastewater treatment plants (WWTPs) and hospitals over a 6-month period (June to December 2020). Results show that the overall range of viral load in positive tested samples was between 1.2 × 103 and 3.5 × 106 gene copies/l, unveiling that secondary-treated wastewaters mirrored the viral load of influents. The interpretation suggests that the viral titers found in three out of four WWTPs were associated to clinical COVID-19 surveillance indicators preceding 2–7 days the rise of reported clinical cases. The median wastewater detection rate of SARS-CoV-2 was one out of 14,300 reported new cases. Preliminary model estimates of prevalence ranged from 0.02 to 4.6% for the studied period. This comprehensive statistical and epidemiological analysis demonstrates that the applied wastewater-based approach to COVID-19 surveillance is in general consistent and feasible, although there is room for improvements.

Donor-derived cell-free DNA and renal allograft rejection in surveillance biopsies and indication biopsies.

To evaluate the role of circulating dd-cfDNA in allograft surveillance in immunologically high-risk patients, a retrospective cross-sectional study of 261 kidney transplant recipients who underwent outpatient allograft biopsy at our center between September 2020 and August 2021 was performed. Of the 236 dd-cfDNA results included, 37 samples were obtained at the time of a surveillance biopsy in sensitized recipients and 199 at the time of a clinically indicated biopsy. The median serum creatinine at the time of the biopsy was 1.3mg/dl and 2.1mg/dl for surveillance biopsies and clinically indicated biopsies, respectively (P<.001). Rejection was diagnosed in 27% of surveillance biopsies and 29% of clinically indicated biopsies. Among surveillance biopsies, sensitivity and specificity to detect rejection were 0% and 89%, respectively, and among clinically indicated biopsies they were 28% and 96%, respectively. The sensitivity and specificity to detect antibody-mediated rejection were 0% and 91% among surveillance biopsies and 50% and 94% among clinically indicated biopsies. Nine biopsies without rejection findings had corresponding dd-cfDNA of ≥1%. Our data does not support dd-cfDNA as a biomarker for kidney allograft rejection, even in immunologically high-risk patients in the absence of graft dysfunction.