Acute cardiac injury events ≤30 days after laboratory-confirmed influenza virus infection among U.S. veterans, 2010–2012

<div><p>The Rnd family of proteins, Rnd1, Rnd2 and Rnd3, are atypical Rho family GTPases, which bind to but do not hydrolyse GTP. They interact with plexins, which are receptors for semaphorins, and are hypothesised to regulate plexin signalling. We recently showed that each Rnd protein has a distinct profile of interaction with three plexins, Plexin-B1, Plexin-B2 and Plexin-B3, in mammalian cells, although it is unclear which region(s) of these plexins contribute to this specificity. Here we characterise the binary interactions of the Rnd proteins with the Rho-binding domain (RBD) of Plexin-B1 and Plexin-B2 using biophysical approaches. Isothermal titration calorimetry (ITC) experiments for each of the Rnd proteins with Plexin-B1-RBD and Plexin-B2-RBD showed similar association constants for all six interactions, although Rnd1 displayed a small preference for Plexin-B1-RBD and Rnd3 for Plexin-B2-RBD. Furthermore, mutagenic analysis of Rnd3 suggested similarities in its interaction with both Plexin-B1-RBD and Plexin-B2-RBD. These results suggest that Rnd proteins do not have a clear-cut specificity for different Plexin-B-RBDs, possibly implying the contribution of additional regions of Plexin-B proteins in conferring functional substrate selection.</p></div

Acute Hepatitis A Infection and Vaccination in the Veterans Health Administration

ObjectiveTo describe the epidemiology of hepatitis A virus (HAV) within the Veterans Health Administration (VHA).IntroductionSince hepatitis A vaccination became widely recommended in the US in the mid-1990’s, rates of acute hepatitis A virus (HAV) infection have steadily declined, however, since 2011, incidence of new cases of HAV appears to be increasing1, often linked with foodborne outbreaks and socio-economic trends such as homelessness and substance abuse.2 In 2016, the CDC reported vaccination coverage among adults aged &gt; 19 was 9.5%, 19-49 was 13.4%, and &gt; 50 was 5.4%3. CDC issued a Health Alert Network Advisory in June 2018 with additional guidance on identification and prevention of HAV and updates on outbreaks in multiple states4 which prompted our program to conduct a more formal review of HAV infections in VHA. Herein we describe recent trends in HAV infection, vaccination and associated risk factors among Veterans.MethodsWe queried VA data sources from October 1, 2016 – June 30, 2018 for HAV IgM laboratory tests, HAV-coded outpatient encounters and hospitalizations (ICD-10-CM: B15), and pharmacy data for hepatitis A vaccinations administered in VHA outpatient and inpatient settings. Patients with coded HAV encounter or hospitalization were compared to individuals with HAV IgM positive results to determine Positive Predictive Value (PPV) of HAV outpatient and inpatient diagnostic codes. A total of 30 (20 outpatient and 10 inpatient HAV encounters across both fiscal years) were randomly selected for detailed chart review to determine if patients were properly coded. Additionally, patients with positive HAV IgM results were analyzed for ICD-10-CM coded outpatient and inpatient encounters indicative of homelessness (ICD-10-CM: Z59.0) and/or substance abuse (ICD-10-CM: F1x, excluding nicotine and cannabis). Rates were calculated using total unique users of VHA care for matching fiscal year time frames and geographic area as denominators. We reviewed a sample of 10 electronic medical records (EMR) of patients from Hawaii to determine vaccine indications in the setting of a state-wide outbreak.ResultsA total of 136,970 HAV IgM tests were performed between October 1, 2016 – June 30, 2018. We identified 247 unique patients with positive HAV IgM. The overall incidence during the study time period was 2.05 per 100,000 population of unique users of VHA care. The state with the highest incidence was West Virginia (9.49 per 100,000) (Figure 1). The overall percent positivity of patients tested for HAV IgM was 0.18% (highest of 1.16% for Kentucky). There were 1,085 HAV-coded outpatient encounters (680 unique patients) but only 58 patients had a positive HAV IgM result (PPV= 8.5%). There were 371 HAV-coded hospitalizations (335 unique patients) but only 39 patients had a positive HAV IgM result (PPV=11.6%). Among these encounters, 270 outpatients had HAV documented as the principal diagnosis for the visit (40 of these were HAV IgM+) and 38 hospitalized patients had HAV as the principal discharge diagnosis code (25 of these were HAV IgM+). Therefore, the PPV when HAV was the principal diagnosis code improved to 14.8% for outpatient encounters and 65.8% for inpatients. Chart review of 30 randomly selected outpatient and inpatient HAV-coded EMR found that only 3 (10%) were correctly coded. Of the remaining 27, 14 (47%) had a positive HAV IgG or HAV Total test result, but negative or no HAV IgM testing, 3 (10%) had a remote history of HAV, 3 (10%) were rule-out HAV but testing was negative, 2 (7%) were miscodes of hepatitis B (HBV) or hepatitis C Virus (HCV) infections, and 5 (17%) were other miscodes. The median vaccination rate during the study time frame was 0.31% [range: 0.11% (Puerto Rico) to 3.48% (Hawaii)]. Additional states with vaccination rates above the median included Kentucky, Michigan, West Virginia, and California (1.05%, 1.02%, 0.93%, 0.67%, respectively). Review of 10 sample EMR of patients from Hawaii, the state with highest vaccination rate, indicated that during their vaccination peak, patients were receiving the 2nd in their 2-dose HAV series, the first having been given in August 2016 at the time of a state-wide outbreak associated with raw scallops. Of 247 patients with positive HAV IgM, 91 (37%) had presence of ICD-10-CM encounter codes for one or more of the following risk factors associated with HAV outbreaks (in order of frequency): substance abuse (63/247; 26%), homelessness (36/247; 15%), HCV (30/247; 12%), and HBV (2/247; 0.8%). Wayne County, MI, Jefferson County, KY, and San Diego County, CA all had clustering of 4 or more cases of acute HAV with risk factors of homelessness, substance abuse, and HCV.ConclusionsAcute HAV was identified in the VHA patient population in states associated with recognized outbreaks during the study time frame. Associated risk factors of substance abuse, homelessness, and HCV found in the Veteran population also matched national HAV outbreak data, including clustering in specific counties where outbreaks occurred. Overall, PPV for HAV-coded encounters was low for both inpatients and outpatients due to frequent miscoding. PPV was improved among inpatients with a principal discharge diagnosis of acute HAV. Vaccination rates were likely underestimated as data prior to the study time period was not evaluated and patients may have received vaccine outside of VA, however rates tended to be above the median in states with known outbreaks, possibly indicating ongoing response. In the case of Hawaii, EMR review indicated that a strong public health response demonstrated by a high post-outbreak vaccination rate with Veterans being monitored and brought back for their 2nd of 2 vaccine series occurred following the August 2016 HAV outbreak associated with raw scallops.2 Additional education of VA providers is warranted regarding the timely recognition of, proper testing for, and coding of acute HAV infections and improving vaccination rates, particularly among individuals who are at increased risk for infection or complications from HAV.References1. CDC. Progress Toward Eliminating Hepatitis A Disease in the United States. MMWR Morb Mortal Wkly Rep. 2016; 65(1): 29-31.2. CDC. Hepatitis A Outbreaks. https://www.cdc.gov/hepatitis/outbreaks/hepatitisaoutbreaks.htm. Accessed September 6, 2018.3. CDC. National Health Interview Survey, Atlanta, GA: US Department of Health and Human Services, CDC; 2016. https://www.cdc.gov/vaccines/imz-managers/coverage/adultvaxview/pubs-resources/NHIS-2016.html#hepA. Accessed September 12, 2018.4. CDC. Health Alert Network Advisory: Outbreak of Hepatitis A Virus (HAV) Infections among Persons Who Use Drugs and Persons Experiencing Homelessness. June 11, 2018. https://emergency.cdc.gov/han/han00412.asp. Accessed September 6, 2018.

Characteristics of Veterans Accessing the Veterans Affairs Telephone Triage Who Have Depression or Suicidal Ideation: Opportunities for Intervention

Veterans accessing Veterans Affairs (VA) health care have more characteristics associated with suicide risk compared with the general U.S. population. Telephone triage is a national telephone-based system used to assess Veterans with acute medical or mental health complaints. We used a biosurveillance application to characterize Veterans who call telephone triage because of suicidal ideation or depression. >2,000 Veterans called during January-June 2012. Suicide prevention training should be prioritized for operators working during off-hours and weekends. Standard notification of clinical staff regarding calls to prevent loss to follow-up and investigation into increased call burden in identified geographic areas is recommended

Improving the Value Proposition of Surveillance Tools: Innovative Uses for VA ESSENCE

We describe VA's experience developing innovative and alternative uses for a surveillance system. We reviewed use cases for new data elements; enhancements to system analytics and functionality; and novel use cases for original outpatient data elements. Enhancements and innovations to influenza surveillance (immunization tracking, %ILI for primary care settings, telephone triage data, inpatient influenza data, geospatial mapping); epidemiologic reviews and lookbacks (identifying ERCP procedures for a CRE review); and infection control activities (SSI procedure dominators, pneumonia hospitalizations for Legionella testing review and needlestick injury queries) were highlighted. These activities were essential for demonstrating usefulness and maintaining system support within VA

Characteristics of Veterans Accessing the Veterans Affairs Telephone Triage Who Have Depression or Suicidal Ideation: Opportunities for Intervention

OBJECTIVE: To characterize Veterans who call telephone triage because of suicidal ideation (SI) or depression and to identify opportunities for suicide prevention efforts among these telephone triage users using a biosurveillance application. INTRODUCTION: Veterans accessing Veterans Affairs (VA) health care have higher suicide rates and more characteristics associated with suicide risk, including being male, having multiple medical and psychiatric comorbidities, and being an older age, compared with the general U.S. population. The Veterans Crisis Line is a telephone hotline available to Veterans with urgent mental health concerns; however, not all Veterans are aware of this resource. By contrast, telephone triage is a national telephone-based triage system used by the VA to assess and triage all Veterans with acute medical or mental health complaints. METHODS: The VA Electronic Surveillance System for Early Notification of Community-based Epidemics (ESSENCE) was queried for telephone triage calls during January 1–June 30, 2012. Calls were classified as SI or depression when the triage nurse selected SI or depression as the Veteran’s chief complaint from a set of fixed options. Demographic and recommended follow-up time and location information was reviewed. A random sample of 20 SI calls and 50 depression calls were selected for chart review to determine whether Veterans were examined in a clinic or followed up by a clinician by telephone within 2 weeks of the veteran’s call. RESULTS: During January 1–June 30, 2012, 253,573 total calls were placed to telephone triage. Among these calls, 2,460 unique Veterans placed 417 calls for SI and 2,290 calls for depression. This represents 1% (2,707/253,573) of all calls placed during the period. All encounter information is available in the surveillance application within 24 hours of the call being placed. Median age of callers was 55 years (range: 19–94); 86% were male; and 6% placed repeat calls. The median number of repeat calls was 2 (range: 2–10). Among the 2,707 calls for SI or depression, 1,286 (48%) were made after routine business hours (5:00 p.m.–8:00 a.m.), and 646 (24%) were made on weekends. The greatest proportion of calls were from Wisconsin and Northern Illinois (17%) and the Southeastern United States (14%). Among the 2,290 calls for depression, 1,401 callers (61%) were recommended for urgent follow up or within 24 hours. 771 (34%) were assigned a follow up location of an emergency department; 117 (5%) an urgent care; 1,332 (58%) a physician’s office or clinic; 52 (2%) self-care at home; and 18 (1%) were unspecified. Among the 417 calls for SI, callers 410 (98%) were recommended for urgent follow-up or within 24 hours. 330 (79%) were assigned a follow-up location of an emergency department; 38 (9%) an urgent care; 43 (10%) a physician’s office or clinic; 3 (1%) self-care at home; and 3 (1%) unspecified. Among the 20 SI and 50 depression calls for which the charts were reviewed, 1 (5%) SI call and 6 (12%) depression calls had no documented follow-up by telephone or in person with a clinician within 2 weeks of initial call. CONCLUSIONS: Telephone triage represents an additional data source available to surveillance applications. Although telephone triage is not the traditional method provided by the VA for triage of urgent mental health concerns, >2,000 Veterans called it with acute symptoms of SI or depression during January–June 2012. Training for suicide prevention should be prioritized for operators working during the high-volume periods of off-hours and weekends when approximately half and one-quarter of calls were received, respectively. We recommend standard notification of suicide prevention coordinators regarding calls to telephone triage for SI or depression to prevent loss to follow-up among Veterans at risk for suicide. Further investigation into reasons for increased call burden in identified geographic areas also is recommended

Acute Hepatitis A Infections among Veterans in Outbreak States, 2016-2018

ObjectiveTo conduct surveillance for acute Hepatitis A virus (HAV) infections in Veterans from states reporting outbreaks among high-risk individuals beginning in fiscal year (FY) 2017.IntroductionAlthough cases of acute HAV have declined in recent years, elevated numbers of HAV infections began to be reported by California and Michigan in the fall of 2016.1,2 Since this time, associated outbreaks have been reported in 9 additional states (Arizona, Utah, Kentucky, Missouri, Tennessee, Indiana, Ohio, Arkansas, and West Virginia).3 No common source of food, beverages or drugs have been identified and transmission appears to be primarily person-to-person with high-risk individuals including people experiencing homelessness, those who use illicit drugs and their close direct contacts. In June 2018, CDC issued a Health Alert Network Advisory providing additional guidance on identification and prevention of HAV and updates on the outbreaks.4 This prompted our office to more closely review our HAV surveillance, to identify Veterans who may be part of these outbreaks, and assess risk factors and outcomes of HAV infection.MethodsWe queried VA data sources starting in FY 2017 (October 1, 2016 – June 30, 2018) for HAV IgM laboratory tests and HAV-coded outpatient encounters and hospitalizations (ICD-10-CM: B15) to identify potential case patients. We performed a detailed chart review on all HAV IgM positive Veterans residing in or treated in an outbreak state during the identified outbreak time frame as reported by each state health department. Data elements collected included: (1) demographics; (2) risk factors, exposures and Hepatitis A vaccination status; (3) treatment locations (i.e. outpatient, Emergency Department, inpatient, intensive care unit); (4) presenting signs and symptoms; (5) laboratory data (including liver function tests (LFTs) and hepatitis testing); and (6) outcomes (i.e. deaths). County-level rates for positive HAV IgM test results were calculated using total unique users of VHA care for matching fiscal year time frames in each county as denominators.ResultsA total of 247 HAV IgM positive individuals were identified among 136,970 HAV IgM tests performed during the study period. Among these, 67 individuals resided in an outbreak state and were identified for further chart review. Additional laboratory review revealed that 5 of the 67 were positive for HAV Total Ab with no HAV IgM performed (all five patients came from a single facility and were asymptomatic at the time of testing). Based on review of clinical data for the remaining 62 HAV IgM positive patients, 22 (35%) did not meet the CSTE clinical case definition criteria5 of having signs or symptoms consistent with acute viral hepatitis plus either jaundice or elevated ALT/AST levels. These patients were either asymptomatic or had relevant symptoms that could be explained by other diagnoses. None had documented jaundice and only 4 had any LFT elevation, which was mild (ALT: 60-83 IU/L, AST: 36-103 IU/L). There was often no mention of the positive HAV IgM test result in the patient visit records. In the cases where the results were documented, it was thought to be a false positive or cross reactivity, related to recent receipt of HAV vaccination, or prolonged persistence of HAV IgM from a prior infection. Patient characteristics of the 40 patients meeting the case definition are summarized in Table 1. None of confirmed cases had documentation of HAV vaccination prior to their acute infection. The top 5 counties of residence among confirmed cases were Jefferson, KY (7, 18%), San Diego, CA (6, 15%), Wayne, MO (4, 10%), Butler, MO (3, 8%) and Macomb, MI (3, 8%). Additionally, the top three counties (Jefferson, San Diego and Wayne) were each noted to have clustering of cases of acute HAV with risk factors of homelessness, substance abuse and/or needle exposure. Incidence rates for HAV IgM+ test results were calculated for all reported outbreak counties and the 25 counties with the highest rates are shown in Figure 1.ConclusionsOccurrence of acute HAV infections among Veterans during October 2016 – June 2018 followed patterns reported by states with outbreaks during the same time frame, including high hospitalization rates. Risk factors of homelessness, substance abuse and/or needle exposures were noted in the Veteran population, similar to national HAV outbreak data. County-level clustering of cases in states with outbreaks was also observed among Veterans, with incidence rates of HAV IgM+ as high as 13 per 10,000 Veterans. Additional education of VA providers is needed regarding recognition of and appropriate testing for acute HAV infections. HAV IgM should not be ordered in asymptomatic patients with normal LFTs as the pretest probability of HAV infection is low, leading to false positives and confusion in interpreting test results. Improving Hepatitis A vaccination rates among Veterans is important, particularly among individuals who are at increased risk for infection or complications from HAV and in outbreak states to limit further spread of this outbreak.References1. Hepatitis A Outbreak in California. Available at: &lt;a href="https://www.cdph.ca.gov/Programs/CID/DCDC/Pages/Immunization/Hepatitis-A-Outbreak.aspx"&gt;https://www.cdph.ca.gov/Programs/CID/DCDC/Pages/Immunization/Hepatitis-A-Outbreak.aspx&lt;/a&gt;. Accessed September 18, 2018.2. Michigan Hepatitis A Outbreak. Available at: &lt;a href="https://www.michigan.gov/mdhhs/0,5885,7-339-71550_2955_2976_82305_82310-447907--,00.html"&gt;https://www.michigan.gov/mdhhs/0,5885,7-339-71550_2955_2976_82305_82310-447907--,00.html&lt;/a&gt;. Accessed September 18, 2018.3. CDC. 2017 – Outbreaks of hepatitis A in multiple states among people who use drugs and/or people who are homeless. Available at: &lt;a href="https://www.cdc.gov/hepatitis/outbreaks/2017March-HepatitisA.htm"&gt;https://www.cdc.gov/hepatitis/outbreaks/2017March-HepatitisA.htm&lt;/a&gt;. Accessed September 18, 2018.4. CDC . Health Alert Network Advisory: Outbreak of Hepatitis A Virus (HAV) Infections among Persons Who Use Drugs and Persons Experiencing Homelessness. June 11, 2018. Available at: &lt;a href="https://emergency.cdc.gov/han/han00412.asp"&gt;https://emergency.cdc.gov/han/han00412.asp&lt;/a&gt;. Accessed September 18, 2018.5. CSTE Position Statement. Hepatitis A, Acute 2012 Case Definition. Available at: &lt;a href="https://wwwn.cdc.gov/nndss/conditions/hepatitis-a-acute/case-definition/2012/"&gt;https://wwwn.cdc.gov/nndss/conditions/hepatitis-a-acute/case-definition/2012/&lt;/a&gt;. Accessed September 18, 2018

Challenges in Surveillance for Chikungunya Virus (CHIKV) Infection

We describe challenges and lessons learned using biosurveillance methods for identifying Chikungunya (CHIKV) infections. Surveillance was performed using VA ESSENCE, electronic laboratory data and facility reports. As of Aug. 14, 2014, 21 confirmed/probable cases were identified at 10 hospitals. The principal challenges were lack of a specific ICD-9 code for CHIKV, use of non-specific symptom codes at initial and subsequent encounters, lack of CHIKV testing, long turn-around times for results, poor uniformity in test names, and infection control not being notified of  suspected/confirmed CHIKV cases.  Based on our experience, a combination surveillance strategy using multiple data sources is essential for CHIKV detection

Carbon Monoxide Poisoning in the Veterans Health Administration, 2010 - 2016

ObjectiveTo describe characteristics of Veterans Health Administration(VHA) patients with ICD 9/10 CM inpatient discharge and/oremergency department (ED)/urgent care outpatient encounter codesfor carbon monoxide (CO) poisoning.IntroductionIt is estimated that in the United States (US), unintentional non-firerelated CO poisoning causes an average of 439 deaths annually, and in2007 confirmed CO poisoning cases resulted in 21,304 ED visits and2,302 hospitalizations (71 per million and 8 per million population,respectively)1. Despite the significant risk of morbidity and mortalityassociated with CO poisoning, existing surveillance systems in theUnited States are limited. This study is the first to focus specificallyon CO poisoning trends within the VHA population.MethodsQueries were performed in VA PraedicoTMPublic HealthSurveillance System for inpatient discharges and emergency roomand urgent care outpatient visits with ICD 9/10 CM codes for COpoisoning from 1/1/2010 – 6/30/2016. A dataset of unique patientencounters with CO poisoning was compiled and further classified asaccidental, self-harm or unspecified. Patients with carboxyhemoglobin(COHb) blood level measurements≥10%2for the same timeframewere extracted and merged with the CO poisoning dataset.We analyzed for demographic, geographic and seasonal variables.Rates were calculated using total unique users of VHA care formatching time frame and geographic area as denominators.ResultsThere were a total of 671 unique VHA patients identified with COpoisoning. Of these, 298 (44%) were classified as accidental, 104(15%) self-harm, and 269 (40%) unspecified. A total of 6 patientsdied within 30 days of their coded diagnosis, however only 1 ofthese was directly attributable to CO poisoning. The overall rate ofCO poisoning over the study time frame was 18 per million uniqueusers of VHA care. CO poisoning diagnoses were obtained from396 (59%) outpatients, 216 (32%) inpatients, and 59 (9%) patientswith both and outpatient visit and inpatient admission. Patientswith self-harm classification were less likely to be seen in the ED(only 24 (6%) unique patients compared to 190 (48%) accidental and182 (46%) unspecified classifications). Of patients seen in the ED andsubsequently admitted, patients with the classification of accidentalpoisoning made up the largest percentage with 36 unique patients(61%). There were 71 (11%) females compared to 600 (89%) males.The highest represented age group was 45-64 with 342 unique patients(51%). Rates by US Census Region were highest in the Midwestand Northeast (27 and 23 per million unique users, respectively)compared to the West and South (15 and 13 per million uniqueusers, respectively) (Figure 1). Accidental CO poisonings showed aseasonal pattern with peaks occurring in late fall, winter, and earlyspring months (Figure 2). CO poisonings classified as unspecifiedhad a similar but less pronounced pattern, while those classified asself-harm were too few to observe any pattern over time. COHb bloodlevels≥10% were present in 111 (17%) of patients with CO poisoningcodes. Of patients with COHb measures≥10%, those with self-harmclassification were least represented with only 7 unique patients (6%).Accidental and unspecified classifications were equally representedwith 53 (48%) and 51 (46%) unique patients, respectively.ConclusionsThe impact of CO poisoning on the VHA patient population hasnot been well studied. The geographic distribution of the majorityof cases in the Midwest and Northeast, and the seasonal distributionof accidental cases in colder months seems to be appropriate withrespect to what is known of unintentional CO poisoning as oftenassociated with heat-generating sources3. Opportunities for furtherinvestigation include how potential CO poisoning cases are evaluatedin VHA given the low percentage of cases with COHb blood levelmeasurements

Firearm Injury Encounters in the Veterans Health Administration (VHA), 2010-2015

IntroductionFirearm violence is an issue of public health concern leading tomore than 30,000 deaths and 80,000 nonfatal injuries in the UnitedStates annually.1To date, firearm-related studies among Veteranshave focused primarily on suicide and attempted suicide.2-5Herein,we examine firearm violence among VHA enrollees for all manners/intents, including assault, unintentional, self-inflicted, undeterminedand other firearm-related injury encounters in both the inpatient andoutpatient settings.MethodsInpatient and Outpatient encounters with one or more ICD-9-CM firearm external-cause-of-injury codes (E-codes) from1/1/2010-9/30/2015 were extracted from the VHA’s Praedico™Public Health Surveillance System, including demographics, era ofservice/eligibility, encounter type, and deaths. Firearm E-codes wereclassified for manner/intent based on the CDC’s Web-based InjuryStatistics Query and Reporting System (WISQARS™) matrix.6Outpatient/emergency department (ED) data were exclusively fromVHA facilities (a single pediatric patient seen as a humanitarianemergency was excluded from the dataset). Inpatient data includedVHA facilities and some records received from non-VHA facilities.VHA rate of hospitalization for firearm-related admissions wascalculated using the total VHA acute-care admissions for the sametime period as the denominator.ResultsDuring the time frame examined, 5,205 unique individuals wereseen with a firearm E-code. Of these, 4,221 were seen in the outpatient/ED setting only, 597 in the inpatient setting only, and the remaining387 had encounters in both the outpatient/ED and inpatient settings.VHA firearm admission rate was 1.63 per 10,000 VHA admissions,compared to a national rate of 1.96 per 10,000 in 2010.7Table 1 showsthe breakdown of encounters by manner/intent. Unintentional was themost common firearm injury manner/intent. Overall, the median age atinitial encounter was 54 (range 19-100 years), and 96% were male. Thehighest percentage served in the Persian Gulf War Era (2,136, 41%),followed by Vietnam Era (1,816, 35%) and Post-Vietnam Era (716,14%). The greatest number of patients with a firearm-coded encounterresided in Texas (453), California (349), Florida (326), Arizona (214)and Ohio (212).ConclusionsUnintentional injuries were the most common form of firearminjury among VHA enrollees, representing over half of alloutpatient/ED firearm encounters and more than twice the numberof firearm hospitalizations compared with any other manner/intent.Limitations include that not all U.S. Veterans are VHA enrollees;miscoding and misclassification of firearm-related injuries may haveoccurred; and data from non-VHA outpatient/ED encounters andsome non-VHA hospitalizations are not available to our surveillancesystem for analysis. Additional study is needed to further understandthe epidemiology of firearm-related injuries among Veterans andinform VHA leadership and provider

Carbon monoxide poisoning surveillance in the Veterans Health Administration, 2010–2017

Abstract Background Exposure to carbon monoxide (CO), the odorless, colorless gas resulting from incomplete combustion of hydrocarbons, is preventable. Despite the significant risk of morbidity and mortality associated with CO poisoning, there currently exists no active national CO surveillance system in the United States (U.S.). Our study aims to use electronic health record data to describe the epidemiology of CO poisoning in the Veterans Health Administration healthcare population. Methods We identified unique inpatient and outpatient encounters coded with International Classification of Diseases (ICD) codes for CO poisoning and analyzed relevant demographic, laboratory, treatment, and death data from January 2010 through December 2017 for Veterans across all 50 U.S. states and Puerto Rico. Statistical methods used were 95% CI calculations and the two-tailed z test for proportions. Results We identified 5491 unique patients with CO poisoning, of which 1755 (32%) were confirmed/probable and 3736 (68%) were suspected. Unintentional poisoning was most common (72.9%) overall. Age less than 65 years, residence in Midwest U.S. Census region versus South or West, and winter seasonal trend were characteristics associated with confirmed/probable CO poisoning. Twenty-six deaths (1.5%) occurred within 30 days of confirmed/probable CO poisoning and were primarily caused by cardiovascular events (42%) or anoxic encephalopathy (15%). Conclusions Our findings support the use of ICD-coded data for targeted CO poisoning surveillance, however, improvements are needed in ICD coding to reduce the percentage of cases coded with unknown injury intent and/or CO poisoning source. Prevalence of CO poisoning among Veterans is consistent with other U.S. estimates. Since most cases are unintentional, opportunities exist for provider and patient education to reduce risk