Sharon Balter

New York City Department of Health and Mental Hygiene, New York, United States

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Publications (44)95.66 Total impact

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    ABSTRACT: Increases in prescription opioid misuse, injection drug use, and hepatitis C infections have been reported among youth and young adults in the USA, particularly in rural and suburban areas. To better understand these trends in New York City and to characterize demographics and risk factors among a population who, by virtue of their age, are more likely to be recently infected with hepatitis C, we analyzed routine hepatitis C surveillance data from 2009 to 2013 and investigated a sample of persons 30 and younger newly reported with hepatitis C in 2013. Between 2009 and 2013, 4811 persons 30 and younger were newly reported to the New York City Department of Health and Mental Hygiene with hepatitis C. There were high rates of hepatitis C among persons 30 and younger in several neighborhoods that did not have high rates of hepatitis C among older people. Among 402 hepatitis C cases 30 and younger investigated in 2013, the largest proportion (44 %) were white, non-Hispanic, and the most commonly reported risk factor for hepatitis C was injection drug use, mostly heroin. Hepatitis C prevention and harm reduction efforts in NYC focused on young people should target these populations, and surveillance for hepatitis C among young people should be a priority in urban as well as rural and suburban settings.
    Journal of Urban Health 12/2014; · 1.89 Impact Factor
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    ABSTRACT: In July 2014, as the Ebola virus disease (Ebola) epidemic expanded in Guinea, Liberia, and Sierra Leone, an air traveler brought Ebola to Nigeria and two American health care workers in West Africa were diagnosed with Ebola and later medically evacuated to a U.S. hospital. New York City (NYC) is a frequent port of entry for travelers from West Africa, a home to communities of West African immigrants who travel back to their home countries, and a home to health care workers who travel to West Africa to treat Ebola patients. Ongoing transmission of Ebolavirus in West Africa could result in an infected person arriving in NYC. The announcement on September 30 of an Ebola case diagnosed in Texas in a person who had recently arrived from an Ebola-affected country further reinforced the need in NYC for local preparedness for Ebola.
    MMWR. Morbidity and mortality weekly report. 10/2014; 63(41):934-936.
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    ABSTRACT: SUMMARY Using surveillance data, we describe the prevalence and characteristics of individuals in New York City (NYC) co-infected with human immunodeficiency virus (HIV) and hepatitis B virus (HBV) and/or hepatitis C virus (HCV). Surveillance databases including persons reported to the NYC Department of Health and Mental Hygiene with HIV, HBV, and HCV by 31 December 2010 and not known to be dead as of 1 January 2000, were matched with 2000-2011 vital statistics mortality data. Of 140 606 persons reported with HIV, 4% were co-infected with HBV only, 15% were co-infected with HCV only, and 1% were co-infected with HBV and HCV. In all groups, 70-80% were male. The most common race/ethnicity and HIV transmission risk groups were non-Hispanic blacks and men who have sex with men (MSM) for HIV/HBV infection, and non-Hispanic blacks, Hispanics, and injection drug users for HIV/HCV and HIV/HBV/HCV infections. The overall age-adjusted 2000-2011 mortality was higher in co-infected than HIV mono-infected individuals. Use of population-based surveillance data provided a comprehensive characterization of HIV co-infection with HBV and HCV. Our findings emphasize the importance of targeting HIV and viral hepatitis testing and prevention efforts to populations at risk for co-infection, and of integrating HIV and viral hepatitis care and testing services.
    Epidemiology and infection. 08/2014;
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    ABSTRACT: Since 2009, the New York City Department of Health and Mental Hygiene (DOHMH) has received FoodCORE funding to hire graduate students to conduct in-depth food exposure interviews of salmonellosis case patients. In 2011, an increase in the number of Salmonella Heidelberg infections with pulsed-field gel electrophoresis Xba I pattern JF6X01.0022 among observant Jewish communities in New York and New Jersey was investigated. As this pattern is common nationwide, some cases identified were not associated with the outbreak. To reduce the number of background cases, DOHMH focused on the community initially identified in the outbreak and defined a case as a person infected with the outbreak strain of Salmonella Heidelberg with illness onset from 1 April to 17 November 2011 and who consumed a kosher diet, spoke Yiddish, or self-identified as Jewish. Nationally, 190 individuals were infected with the outbreak strain of Salmonella Heidelberg; 63 New York City residents met the DOHMH case definition. In October 2011, the graduate students (Team Salmonella) interviewed three case patients who reported eating broiled chicken livers. Laboratory testing of chicken liver samples revealed the outbreak strain of Salmonella Heidelberg. Although they were only partially cooked, the livers appeared fully cooked, and consumers and retail establishment food handlers did not cook them thoroughly before eating or using them in a ready-to-eat spread. This investigation highlighted the need to prevent further illnesses from partially cooked chicken products. Removing background cases helped to focus the investigation. Training graduate students to collect exposure information can be a highly effective model for conducting foodborne disease surveillance and outbreak investigations for local and state departments of public health.
    Journal of food protection 08/2014; · 1.83 Impact Factor
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    ABSTRACT: BACKGROUND: Increases in hepatitis C (HCV) infections among youth have recently been observed in some jurisdictions. The New York City (NYC) Department of Health and Mental Hygiene (DOHMH) analyzed trends in routine HCV surveillance data and investigated reports among 0 to 30 year-olds. METHODS: We evaluated trends in the number of 0 to 30 year-olds newly reported with HCV from 2000-2012. We investigated all new HCV reports for 0 to 21 year-olds from October 2012-July 2013, and 50% of new reports for 22 to 30 year-olds from April 2013-July 2013. We collected clinical, demographic, and risk factor information from the ordering provider or medical record. RESULTS: New HCV reports among 0 to 21 year-olds stayed constant at around 200 reports/year. Reports among 22 to 25 year-olds increased from 119 reports in 2000 to 273 reports in 2012. Among 26 to 30 year-olds, reports increased from 351 in 2000 to a peak of 780 in 2007, then decreased to 507 in 2012. Neighborhoods with high rates of youth HCV were identified, which mostly overlapped with neighborhoods with high overall HCV rates. We investigated 95 cases ages 0 to 21 and 73 cases ages 22 to 30. Most were male (52% of 0 to 21 year-olds and 59% of 22 to 30 year-olds). The most common race/ethnicity was white non-Hispanic (44% of 78 cases ages 0 to 21 and 58% of 64 cases ages 22 to 30 with known race/ethnicity). The most common risk factor was ever injection drug use (IDU), reported for 32% of 0 to 21 year-olds and 49% of 22 to 30 year-olds. The most common drug injected was heroin. No risk factors were identified for 32% of 0 to 21 year-olds and 29% of 22 to 30 year-olds. CONCLUSIONS: From 2000-2012, HCV reports in NYC increased among 22 to 30 year-olds. This could be due to increased incidence, increased testing, and/or increased reporting of HCV to DOHMH. Regardless, these cases most likely represent recent infections and recent IDU initiation. Cases ages 0 to 30 were most likely to be non-Hispanic whites, unlike the overall HCV population in NYC, who are most likely to be black or Hispanic. HCV and IDU prevention activities should focus on white non-Hispanic youths in neighborhoods with high rates of new HCV infections. Future research should focus on this population, to better understand their HCV risk factors and their pathway to injection initiation, including use of prescription opioids.
    2014 Council of State and Territorial Epidemiologists Annual Conference; 06/2014
  • Katherine Bornschlegel, Sharon Balter
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    ABSTRACT: Brief Summary Diagnosing hepatitis C (HCV) infection requires two tests, a screening antibody test followed by an RNA test. At the New York City Department of Health and Mental Hygiene (DOHMH), HCV surveillance data show that many patients with a positive antibody test do not receive the recommended RNA test to determine infection status. For the roundtable discussion, the presenter will describe strategies used at NYCDOHMH to increase HCV RNA testing. We will also hear about strategies in place at other health departments. HCV infection is a major public health issue. Recent increases in morbidity and mortality, along with improved antiviral treatments with much better cure rates, make HCV diagnosis and linkage to care a priority. In NYC, at least 1/3 of persons with a positive antibody test do not receive RNA testing. DOHMH is pursuing several strategies to increase RNA testing: 1)We mail educational booklets to all persons newly reported to the surveillance system. The booklet explains HCV tests, complications, transmission and antiviral treatment, and provides resources. For persons with no report of RNA testing, the cover letter advises patients to ask their clinician about the RNA test. 2) For each patient with a positive antibody test but no RNA result, we mail a letter to the ordering clinician, recommending they order the RNA test and including a copy of HCV testing guidelines. 3) We encourage laboratories to stress the importance of RNA testing when providing positive antibody results. 4) We educate clinicians on the availability of HCV reflex test, where the laboratory immediately performs the RNA test on the same specimen if the antibody result is positive. 5) We surveyed a sample of Federally Qualified Health Centers about HCV RNA testing practices, and provide technical assistance to improve RNA testing rates based on the results. 6) We discuss the issue at the Hep C Task Force (community advisory group) meetings to explore challenges and solutions to RNA testing in various settings (e.g., correctional facilities, drug treatment facilities). 7) We mailed a letter from NYC’s Commissioner of Health to over 35,000 clinicians, highlighting the need for RNA testing, along with other key updates on hepatitis C diagnosis and management. To evaluate these efforts, we are monitoring the proportion of patients with a positive antibody test who also have a positive RNA test reported to our surveillance system.
    2014 Council of State and Territorial Epidemiologists Annual Conference; 06/2014
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    ABSTRACT: BACKGROUND: Hepatitis A virus (HAV) infections are reportable by law in New York City (NYC), and, in 2006, electronic laboratory reporting for hepatitis A was mandated. Diagnostic tests for HAV lack specificity, which can lead to false positives. In 2006, the Advisory Committee on Immunization Practices (ACIP) recommended all children receive hepatitis A vaccine as part of routine immunizations at 12 months. METHODS: Clinicians and laboratories are required to report patients who have positive HAV tests. All reports are investigated to determine if they meet the CDC case definition. The NYC Department of Health and Mental Hygiene (DOHMH) routinely investigates all hepatitis A reports, and confirmed cases are interviewed to assess symptoms, risk factors, and occupation. Reports from 2006-2013 were analyzed. We evaluated the surveillance system for timeliness of case investigations, positive predictive value (PPV), and usefulness in identifying contacts to offer post-exposure prophylaxis (PEP). RESULTS: From 2006-2013, 5,738 reports of hepatitis A were received, and 888 (15%) met the case definition. Of 448 reports received in 2006, 126 (PPV=28%) met the case definition, compared with 838 reports received in 2013 of which 90 (PPV=11%) met the case definition (p<0.0001). The median number of days from report date to patient interview was 0 days for every year except 2011, which was 1 day, and the median number of days from diagnosis date to patient interview declined from 6 days in 2006 to 4 days in 2013. The median age for confirmed cases in 2006 was 23 years versus 31 years in 2013 (p<0.0003); 17% of cases were<10 years in 2006 compared with 3% in 2013. From 2006-2013, PEP was recommended for contacts of 420 cases for which 350 (83%) had at least one contact who was successfully treated for exposure, and a total of 1,243 contacts received PEP. CONCLUSIONS: The NYC HAV surveillance system is timely with the majority of cases interviewed the day they are reported and useful in allowing for rapid identification and treatment of contacts. The number of confirmed cases reported to DOHMH appears to have decreased, while the age of cases has risen, possibly due to the 2006 vaccine recommendations for children. At the same time, the absolute number of tests and the false positive rate have increased, contributing to greater burden on staff and misdirected resources. Improving the specificity of the test or decreasing testing of patients with low probability of infection could decrease the burden on health departments.
    2014 Council of State and Territorial Epidemiologists Annual Conference; 06/2014
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    ABSTRACT: We analyzed and evaluated enhanced chronic hepatitis C virus (HCV) surveillance in New York City (NYC), which involved detailed investigations on a sample of newly reported HCV patients. Beginning in July 2009, we generated a simple random sample bimonthly from all patients newly reported with a positive HCV test. We administered questionnaires to clinicians and patients to collect clinical and epidemiological information on patients diagnosed from April 2009 to January 2011 and evaluated the staff resources required to conduct enhanced surveillance. Of 205 patients meeting inclusion criteria, 40 (19.5%) tested HCV ribonucleic acid (RNA) negative. For the remaining 165 patients, questionnaires were completed by 164 clinicians (99.4%) and 77 patients (46.7%). Many patients (54.0%) were born between 1945 and 1964, and most patients were Hispanic (32.7%) or non-Hispanic black (32.7%). Common risk factors were injection (43.0%) and intranasal (33.9%) drug use. One-third of patients were diagnosed in nontraditional medical settings including substance abuse/detoxification centers (25.0%), jail/prison (6.7%), and psychiatric facilities (1.8%). Of 98 patients with positive HCV RNA tests, 38.8% were immune to hepatitis A and 39.8% were immune to hepatitis B. Investigators required approximately 3.5 hours to complete each investigation and averaged 50 days from assignment to completion. Although conducting enhanced HCV surveillance requires significant resources, investigating a representative sample provides detailed information about NYC's HCV population. Surveillance data have been used to plan educational initiatives for clinicians and patients, which may have led to increased awareness of HCV status, improved patient support, and better overall care.
    Public Health Reports 11/2013; 128(6):510-8. · 1.42 Impact Factor
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    ABSTRACT: To survey anesthesiologists to assess medication injection safety knowledge and practices, and to improve infection control programs of the New York City Department of Health and Mental Hygiene and the New York State Society of Anesthesiologists (NYSSA). Survey instrument. Scientific Educational and Professional Development Program Office, Centers for Disease Control and Prevention, Atlanta, GA, USA. A confidential, 23-question survey was emailed to a total of 2,310 NYSSA members. Data from the survey were culled from the responses of NYSSA members who practiced in New York State only. Of the 607 survey respondents, 595 met inclusion criteria (response rate 26%). Of these, 94% to 99% correctly answered 4 questions about injection-contamination mechanisms. Respondents reported unacceptable practices (eg, not using a new needle and syringe for each new patient [3%]; not using a new needle and syringe to access medication vials [28%]; and combining vial content leftovers [11%]). Resident physicians reported these unacceptable practices more often than attending physicians. Use of medication vials for multiple patients (permitted for multi-dose vials but a potentially high-risk practice) was reported by 49% of respondents and was more common among those who worked in outpatient settings. Reported barriers to using a new medication vial for each new patient were medication shortages (44%), reduction of waste (44%), and cost (27%). Unacceptable or potentially high-risk practices were more common among respondents who reported ≥ one barrier. Although they were not necessarily representative of all anesthesiologists in New York State, unacceptable or high-risk injection practices were common among respondents despite widespread knowledge regarding injection-contamination mechanisms. Systemic barriers contribute to the use of medication vials for multiple patients.
    Journal of clinical anesthesia 09/2013; · 1.32 Impact Factor
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    ABSTRACT: Recent guidelines recommend testing all individuals born during 1945-1965 for hepatitis C virus (HCV) antibody. For antibody-positive patients, subsequent RNA testing is necessary to determine current infection status. This study aimed to assess whether clinicians order HCV RNA tests as recommended for antibody-positive patients and to identify barriers to such testing. We sampled individuals newly reported to the New York City Department of Health and Mental Hygiene's HCV surveillance system and collected information from clinicians. For patients without RNA test results, we asked the reason an RNA test was not ordered and requested that the clinician order the test. Of 245 antibody-positive patients, 67% were tested for HCV RNA (for 21% of these, the test was ordered only after our request); 33% had no RNA testing despite our request. Patients without RNA testing were seen in medical facilities (47%), detox facilities (30%), and jail/prison (15%). Reasons RNA testing was not done were that the patient did not return for follow-up (35%), the facility does not do RNA testing (22%), and the patient was tested in jail (15%). In our study, one third of patients did not get complete testing for accurate diagnosis of HCV, which is essential for medical management. Additional education for clinicians about the importance of RNA testing may help. However, with improved antiviral treatments now available for HCV, it is time for reflex HCV RNA testing for positive antibody tests to become routine, just as reflex Western blot testing is standard for human immunodeficiency virus.
    The American journal of medicine 06/2013; · 5.30 Impact Factor
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    ABSTRACT: Brief Summary Chronic hepatitis B (HBV) and C (HCV) are major public health problems affecting millions of people in the United States. In New York City, laboratories and clinicians are required to report positive HBV and HCV tests, which we automatically import into our surveillance database; we receive over 90,000 reports of each disease annually. Because patients with chronic hepatitis may be tested frequently, there are often multiple reports of positive tests per patient. To handle this large volume, we have automated our matching process for identifying which reports belong to the same patient. Managing and reporting hepatitis surveillance data is complex because patient-level information must be pulled and summarized from these multiple reports. Therefore, we use a variety of methods to structure datasets for analysis and reporting in a standardized way. First, our surveillance database creates one single “event” of disease per patient, which includes demographic information taken from the earliest report for that disease. For diagnosis date (the date we use for structuring all our datasets), we use the specimen date of the earliest positive test. Second, customized SAS code is used to create tables summarizing multiple laboratory test results for each patient. Four test types are reportable for HCV (two types of antibody tests, RNA, and genotype): we create four variables to capture whether a positive result was ever reported for each test type to determine whether the patient met the case definition and also received recommended follow up testing. For HBV, we calculate case definition status (two positive tests greater than six months apart) by subtracting the date of the earliest positive test from the date of the most recent positive test. Finally, for summary data published in our Hepatitis Surveillance Report, we analyze and report patients newly reported that calendar year, rather than all patients who had a positive test reported that year. Although these are decisions we have made in order to maintain and present our data uniformly, other health departments have their own methods for data management. Therefore, comparing chronic hepatitis data across jurisdictions is challenging. Agreement on national standards for data management could improve comparability of published surveillance data.
    2013 Council of State and Territorial Epidemiologists Annual Conference; 06/2013
  • 2013 Council of State and Territorial Epidemiologists Annual Conference; 06/2013
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    ABSTRACT: Brief Summary Hepatitis B and C are the most commonly reported infectious diseases in NYC; in part because both are highly prevalent and patients are tested repeatedly over time. Annually, for each infection, the NYC Department of Health and Mental Hygiene (DOHMH) receives over 90,000 reports, representing over 40,000 persons, of whom about 10,000 are newly reported. Laboratory electronic reporting has been mandatory since 2006 and has created many data management challenges. These include ensuring completeness of laboratory reporting, improving standardization of test types and test results, interpreting complex test methodologies, and matching multiple reports for a given patient. We present our solutions to these challenges. Although both laboratories and providers are required to report, 93% of all hepatitis reports submitted to DOHMH are from laboratories. With limited resources, focusing on complete laboratory reporting is our highest priority. To identify gaps in laboratory reporting, we review all hepatitis B core IgM (HBcIgM) events that were reported by providers, but not by laboratories; we follow-up with the laboratory to resolve reporting barriers. Because reporting is done by over 100 laboratories and is not standardized, we developed a web application that electronically standardizes three variables: test type, test result and specimen source. Only standardized data is imported into our surveillance database. Reporting hepatitis test results is complex, especially for hepatitis B surface antigen (HBsAg) and hepatitis C antibody. HBsAg positive must be confirmed by the laboratory; hepatitis C antibody signal to cut off (s/co) ratio must be high to be reported to the NYC DOHMH. We track each laboratory’s HBsAg confirmation method and hepatitis C s/co threshold to ensure we import only reportable positive tests. Lastly, with multiple reports for the same patient, matching persons is a key concern; automated algorithms minimize the number of possible matches requiring manual review. With highly prevalent conditions like hepatitis B and C, if the algorithm is too sensitive, persons with common names may be called matches when they are not. In NYC, this is especially true with our hepatitis B surveillance database, half of whom are East Asians. East Asian names are especially prone to being misclassified as duplicates because of differences in character transliteration and shortness of names. To reduce these problems, in partnership with our vendor, we developed a special matching program for East Asian names. NYC DOHMH’s experience may be useful for other health departments facing similar challenges.
    2013 Council of State and Territorial Epidemiologists Annual Conference; 06/2013
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    ABSTRACT: BACKGROUND: Several United States jurisdictions have reported increasing hepatitis C infections among youth. The New York City (NYC) Department of Health piloted a surveillance project to investigate whether this was occurring locally and help plan for a sustainable surveillance system for investigating hepatitis C reports in youth. We evaluated this pilot based on CDC surveillance evaluation guidelines. METHODS: We investigated individuals who were reported from March 15-May 15, 2011 through routine surveillance to be NYC residents aged 1-25 with hepatitis C. We collected clinical, demographic, and risk factor information by contacting clinicians; we also interviewed cases 18 years or older. We analyzed these data to evaluate resources required, data quality, and representativeness. We assessed resource use by determining the time required for investigations. We assessed data quality by determining questionnaire completion rates and percentages of missing/unknown responses; for questions asked of clinicians and patients, we compared clinician and patient responses. We assessed representativeness by comparing cases for which patient questionnaires were and were not completed. RESULTS: Of 81 cases identified, 34 (42%) were excluded because they did not have hepatitis C infection (n=17), were older than 25 (n=10), lived outside NYC (n=3), or the clinician could not be reached (n=4). Thus, clinician questionnaires were completed for 47 cases. The most common risk factors for infection were injection (18 (38%) cases) and intranasal (16 (34%) cases) drug use. The median investigation time was 54 days for clinician and patient qestionnaire completion, and 23 days for clinician questionnaire completion only. Patient questionnaires were completed for 10 (24%) of 41 cases 18 years of age or older. The mean percentage of missing/unknown responses was 34% for the clinician and 7% for the patient questionnaire. For questions asked of clinicians and patients, the mean percentage of responses with information from the patient only was 40% and the mean percentage of responses with disagreement between clinician and patient responses was 5%. There were no significant demographic differences between cases with and without completed patient questionnaires. CONCLUSIONS: This pilot provided useful data on characteristics and correlates of hepatitis C infection among NYC youth. Though data from patient questionnaires were of higher quality than data from physician questionnaires, the completion rate was low, and interviewing cases more than doubled investigation time. Cases with completed patient questionnaires were representative of all cases. Given limited staff resources, we recommend that ongoing surveillance should eliminate the patient questionnaire and collect information only from clinicians.
    2013 Council of State and Territorial Epidemiologists Annual Conference; 06/2013
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    ABSTRACT: BACKGROUND: The NYC Department of Health and Mental Hygiene (DOHMH) receives approximately 2,800 complaints about restaurants annually through the City’s non-emergency call number and website known as “311.” During a recent outbreak, DOHMH noted that many patrons had reported illness on restaurant review website X but had not notified 311. To detect outbreaks not previously identified and potentially prevent further illness, DOHMH collaborated with website X and Columbia University on systematically analyzing restaurant reviews for foodborne illness complaints. METHODS: Using website X’s NYC data, we trained a program to automatically analyze the text of reviews for foodborne illness complaints (e.g., sick, vomiting, diarrhea), and other criteria including number of people ill and relevant incubation period (>10 hours). DOHMH used this program to download and analyze new reviews weekly. Flagged reviews were then examined to determine if they 1) indicated an episode of gastrointestinal illness related to a restaurant, 2) suggested the illness occurred recently (within four weeks of the review if a time period was provided), and 3) warranted further investigation because two or more people were ill or severe illness occurred. For all reviews with a recent illness or no time period specified, the reviews were compared with the 311 database to identify duplicate complaints. For reviews requiring further investigation, DOHMH contacted the reviewers through website X’s messaging service. RESULTS: From July 2012 - November 2012, 309 reviews were flagged by the classifier program; 165 (53%) described an episode of gastrointestinal illness, and 150 reviews suggested the illness had occurred recently or did not provide a time period. Comparison of these 150 reviews with the 311 database revealed that only five (3%) reviewers had also submitted a complaint to 311. Thirty-one reviews required further investigation, and six (19%) of these reviewers completed a phone interview. In response to the six complaint interviews, representing approximately 13 illnesses, DOHMH reviewed the food inspection history of all six restaurants and conducted environmental investigations at two restaurants. CONCLUSIONS: Many restaurant-related foodborne illness episodes are not reported to city agencies, but are posted to restaurant review websites. By analyzing reviews on a regular basis, DOHMH was able to detect unreported restaurant-related illnesses and further investigate these establishments. Although no additional outbreaks were detected, DOHMH will continue to explore this tool by refining the mechanics used in the classifier program and expanding the analysis to include additional review websites.
    2013 Council of State and Territorial Epidemiologists Annual Conference; 06/2013
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    ABSTRACT: BACKGROUND: Shigellosis is the third most common enteric bacterial infection in the United States. Risk groups for infection include young children, men who have sex with men (MSM), and international travelers. Although shigellosis is generally self-limiting, patients with diarrhea frequently receive empiric ciprofloxacin treatment. The New York City Department of Health and Mental Hygiene (DOHMH) began monitoring antimicrobial resistance among Shigella isolates after detecting high levels of antibiotic resistance, including 5 ciprofloxacin-resistant Shigella isolates among non-travelers from 2006-2009, the first such strains detected in the US. METHODS: In NYC, clinicians and laboratories are required to report laboratory-confirmed shigellosis to DOHMH. Isolates are forwarded to DOHMH for confirmation, serogrouping, and antibiotic susceptibility testing. When appropriate, pulsed field gel electrophoresis (PFGE) is performed. All patients with ciprofloxacin-resistant isolates or their providers were interviewed with a standard questionnaire to assess antibiotic use and international travel before illness. RESULTS: Among 879 Shigella isolates tested from January 2011-October 2012, 22 (2.5%) were resistant to ciprofloxacin. The age of patients with ciprofloxacin-resistant shigellosis ranged from 1-71 years; 14 (64%) were male. Twelve case patients reported international travel to areas of endemic resistance, most commonly India and Bangladesh. Of these, 2 were treated with antibiotics while abroad and 8 upon return; antibiotic use was unknown for 2 patients. Of four ciprofloxacin-resistant isolates associated with travel to South Asia, PFGE patterns (using XbaI digest) of three were indistinguishable and the fourth was very similar. Of the 10 remaining patients, six were MSM and reported no known travel; the other 4 were not MSM and reported no travel, and one of those four reported antibiotic use before illness though the antibiotic was not ciprofloxacin. Three of the non-travel cases were <6 years of age and unrelated. CONCLUSIONS: In New York City, ciprofloxacin-resistant Shigella has emerged as a cause of infection among people with no travel history to endemic regions and no recent antibiotic use. Other jurisdictions, especially urban centers with high-risk groups such as MSM and international travelers, should consider monitoring ciprofloxacin resistance in Shigella isolates.
    2013 Council of State and Territorial Epidemiologists Annual Conference; 06/2013
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    ABSTRACT: SUMMARY Hepatitis C virus is the most common chronic blood-borne infection in the USA. Based on results of a serosurvey, national prevalence is estimated to be 1·3% or 3·2 million people. Sub-national estimates are not available for most jurisdictions. Hepatitis C surveillance data was adjusted for death, out-migration, under-diagnosis, and undetectable blood RNA, to estimate prevalence in New York City (NYC). The prevalence of hepatitis C infection in adults aged ⩾20 years in NYC is 2·37% (range 1·53-4·90%) or 146 500 cases of hepatitis C. This analysis presents a mechanism for generating prevalence estimates using local surveillance data accounting for biases and difficulty in accessing hard to reach populations. As the cohort of patients with hepatitis C age and require additional medical care, local public health officials will need a method to generate prevalence estimates to allocate resources. This approach can serve as a guideline for generating local estimates using surveillance data that is less resource prohibitive.
    Epidemiology and Infection 05/2013; · 2.87 Impact Factor
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    ABSTRACT: In May 2001, The New York City Department of Health and Mental Hygiene was informed of a cluster of 4 patients treated at an outpatient gastroenterology center who developed acute hepatitis C virus infection. An investigation identified a total of 12 clinic-associated hepatitis C virus transmissions and the outbreak and was traced to unsafe handling of multidose anesthetic vials and possible re-use of contaminated needles. This report typifies the types of outbreaks that continue to occur despite safe injection guidelines.
    American journal of infection control 05/2012; · 3.01 Impact Factor
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    ABSTRACT: BACKGROUND: Reports of hepatitis B and hepatitis C virus transmission associated with unsafe medical practices have been increasing in the United States. However, the contribution of healthcare exposures to the burden of new infections is poorly understood outside of recognized outbreaks. METHODS: We conducted a case-control study at 3 health departments that perform enhanced viral hepatitis surveillance in New York and Oregon. Reported cases of symptomatic acute hepatitis B and hepatitis C occurring in persons aged ≥ 55 years from 2006-2008 were enrolled. Controls were identified using telephone directories and matched to individual cases by age group (55-59 years, 60-69 years, and ≥70 years) and residential ZIP code. Data collection covered exposures within 6 months prior to symptom onset (cases) or date of interview (controls). RESULTS: Forty-eight (37 hepatitis B; 11 hepatitis C) case- and 159 control-patients were enrolled. Case-patients were more likely than controls to report one or more behavioral risk exposures, including sexual or household contact with an HBV or HCV patient, >1 sex partner, illicit drug use or incarceration (21% of cases vs 4% of controls exposed; matched Odds Ratio [mOR]=7.1; 95%CI 2.1, 24.1). Case-patients were more likely than controls to report hemodialysis (8% of cases; mOR=13.0; 95%CI 1.5, 115); injections in a healthcare setting (58%; mOR=2.7; 95%CI 1.3, 5.3); and surgery (33%; mOR=2.3; 95%CI 1.1, 4.7). In a multivariate model, behavioral risks (adjusted OR [aOR]=5.4, 95%CI 1.5, 19.0; 17% attributable risk), injections (aOR=2.7, 95%CI 1.3, 5.8; 37% attributable risk) and hemodialysis (aOR=11.5, 95%CI 1.2, 107; 8% attributable risk) were associated with case status. CONCLUSION: Healthcare exposures may represent an important source of new HBV and HCV infections among older adults. (HEPATOLOGY 2012.).
    Hepatology 03/2012; · 12.00 Impact Factor
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    ABSTRACT: To describe New York City (NYC) assisted living facility (ALF) characteristics, services offered, and infection control practices and to identify infection control barriers and unmet needs. Cross-sectional. ALFs licensed or applying to be licensed in NYC. Seventy ALFs; 70 of 77 eligible facilities participated (91% participation rate). Telephone interview questions assessed ALF characteristics, services offered, and infection control practices, including glucometry practices. ALFs provided a broad range of services, such as vaccination (90%), assistance with taking medication (75%), bathing and showering (33%), and blood glucose monitoring (90%). Ninety percent of the facilities had nurses on site (directly employed or through a contract agency). Five facilities reported that residents sometimes shared glucometers, and one reported that fingerstick devices were sometimes shared. The majority of facilities wanted educational materials for staff (83%) and residents (77%) on topics including influenza, respiratory illness, norovirus, standard precautions, and general infection control. ALFs had a range of sick leave policies and infection control training requirements. Eighty-nine percent of the facilities reported having designated staff responsible for infection control, although 50% had nonclinical job titles. NYC ALFs were varied in terms of nursing services offered, characteristics, and residents' needs; therefore, public health agencies may need to be flexible in their assistance. Public health agencies should consider strengthening relationships with ALFs to identify unmet needs and gaps in services.
    Journal of the American Geriatrics Society 02/2012; 60(2):284-9. · 4.22 Impact Factor