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Zika virus (ZIKV) is an important flavivirus infection. Although ZIKV infection is rarely fatal, risk for severe disease in adults is not well described. Our objective was to describe the spectrum of illness in U.S. Veterans with ZIKV infection. Case series study including patients with laboratory-confirmed or presumed positive ZIKV infection in all Veterans Health Administration (VHA) medical centers. Adjusted odds ratios of clinical variables associated with hospitalization and neurologic complications was performed. Of 1,538 patients tested between 12/2015-10/2016 and observed through 3/2017, 736 (48%) were RT-PCR or confirmed IgM positive; 655 (89%) were male, and 683 (93%) from VA Caribbean Healthcare System (VACHCS). Ninety-four (13%) were hospitalized, 91 (12%) in the VACHCS. Nineteen (3%) died after ZIKV infection. Hospitalization was associated with increased Charlson co-morbidity index (adjusted odds ratio [OR] 1.2; 95% confidence interval [CI], 1.1-1.3), underlying connective tissue disease (OR, 29.5; CI, 3.6-244.7), congestive heart failure (OR, 6; CI, 2-18.5), dementia (OR, 3.6; CI, 1.1-11.2), neurologic symptom presentation (OR, 3.9; CI, 1.7-9.2), leukocytosis (OR, 11.8; CI, 4.5-31), thrombocytopenia (OR, 7.8; CI, 3.3-18.6), acute kidney injury (OR, 28.9; CI, 5.8-145.1), or using glucocorticoids within 30 days of testing (OR, 13.3; CI 1.3-133). Patients presenting with rash were less likely to be hospitalized (OR, 0.29; CI, 0.13-0.66). Risk for neurologic complications increased with hospitalization (OR, 5.9; CI 2.9-12.2), cerebrovascular disease (OR 4.9; CI 1.7-14.4), and dementia (OR 2.8; CI 1.2-6.6). Older Veterans with multiple comorbidities or presenting with neurologic symptoms were at increased risk for hospitalization and neurological complications after ZIKV infection.

During December 2013, the first locally transmitted chikungunya virus (CHIKV) infections in the Americas were reported in the Caribbean. Although CHIKV infection is rarely fatal, risk for severe disease increases with age and medical comorbidities. Herein we describe characteristics of Veterans Health Administration (VHA) patients with CHIKV infection and, among those with infections diagnosed in Puerto Rico, investigated risk factors for hospitalization. We queried VHA's national electronic medical records to identify patients with CHIKV testing during 2014. Demographics, clinical history, laboratory results, and outcomes were abstracted. We investigated risk factors for hospitalization among patients with laboratory-confirmed CHIKV infection in Puerto Rico. We identified 180 laboratory-confirmed CHIKV infections; 148 (82.2%) were diagnosed in Puerto Rico, and 32 (17.8%) were diagnosed among returning travelers elsewhere in the United States. In Puerto Rico, where more patients were hospitalized (55.4% versus 20.0%) and died (4.1% versus 0%), risk for hospitalization increased with age (relative risk [RR]/each 10-year increase, 1.19; 95% confidence interval [CI], 1.06-1.32) and, adjusted for age, increased among patients with congestive heart failure (RR, 1.58; 95% CI, 1.25-1.99), chronic kidney disease (RR, 1.52; 95% CI, 1.19-1.94), diabetes mellitus (RR, 1.39; 95% CI, 1.06-1.84), or chronic lung disease (RR, 1.37; 95% CI, 1.03-1.82). CHIKV infection is an emerging problem among Veterans residing in or visiting areas with CHIKV transmission. Although overall mortality rates are low, clinicians in affected areas should be aware that older patients and patients with comorbidities may be at increased risk for severe disease.

We describe influenza activity in the US Veterans Affairs (VA) population for the 2010‐2011 through 2015‐2016 seasons and compare with national CDC FluView data. VA confirmed influenza cases ranged from 1005 to 11 506 per season; triage calls from 6090 to 10 346; outpatient visits from 3849 to 13 406; antiviral prescriptions from 3650 to 32 826; hospitalizations from 546 to 4673; and deaths in hospitalized patients from 17 to 139. Peak activity was generally the same as observed nationally by the CDC. For the seasons analyzed, correlation between VA and CDC %ILI visits (r = .863), influenza hospitalizations (r = .953), positive tests (r = .948), and percent of tests positive (r = .938) was strong. Understanding influenza burden is important for evaluating prevention priorities and resource allocation within VA.

Background Early threat detection and situational awareness are vital to achieving a comprehensive and accurate view of health-related events for federal, state, and local health agencies. Key to this are public health and syndromic surveillance systems that can analyze large data sets to discover patterns, trends, and correlations of public health significance. In 2020, Department of Veterans Affairs (VA) evaluated its public health surveillance system and identified areas for improvement. Methods Using the Centers for Disease Control and Prevention (CDC) Guidelines for Evaluating Public Health Surveillance Systems, we assessed the ability of the Praedico Surveillance System to perform public health surveillance for a variety of health issues and evaluated its performance compared to an enterprise data solution (VA Corporate Data Warehouse), legacy surveillance system (VA ESSENCE) and a national, collaborative syndromic surveillance platform (CDC NSSP BioSense). Results Review of system attributes found that the system was simple, flexible, and stable. Representativeness, timeliness, sensitivity, and Predictive Value Positive were acceptable but could be further improved. Data quality issues and acceptability present challenges that potentially affect the overall usefulness of the system. Conclusions Praedico is a customizable surveillance and data analytics platform built on big data technologies. Functionality is straightforward, with rapid query generation and runtimes. Data can be graphed, mapped, analyzed, and shared with key decision makers and stakeholders. Evaluation findings suggest that future development and system enhancements should focus on addressing Praedico data quality issues and improving user acceptability. Because Praedico is designed to handle big data queries and work with data from a variety of sources, it could be enlisted as a tool for interdepartmental and interagency collaboration and public health data sharing. We suggest that future system evaluations include measurements of value and effectiveness along with additional organizations and functional assessments.

Background Cardiac injury is a known potential complication of influenza infection. Because U.S. veterans cared for at the U.S. Department of Veterans Affairs are older and have more cardiovascular disease (CVD) risk factors than the general U.S. population, veterans are at risk for cardiac complications of influenza infection. We investigated biomarkers of cardiac injury characteristics and associated cardiac events among veterans who received cardiac biomarker testing ≤30 days after laboratory-confirmed influenza virus infection. Methods Laboratory-confirmed influenza cases among veterans cared for at U.S. Department of Veterans Affairs’ facilities for October 2010–December 2012 were identified using electronic medical records (EMRs). Influenza confirmation was based on respiratory specimen viral culture or antigen or nucleic acid detection. Acute cardiac injury (ACI) was defined as an elevated cardiac biomarker (troponin I or creatinine kinase isoenzyme MB) >99 % of the upper reference limit occurring ≤30 days after influenza specimen collection. EMRs were reviewed for demographics, CVD history and risk factors, and ACI-associated cardiac events. Results Among 38,197 patients with influenza testing results, 4,469 (12 %) had a positive result; 600 of those patients had cardiac biomarker testing performed ≤30 days after influenza testing, and 143 (24 %) had one or more elevated cardiac biomarkers. Among these 143, median age was 73 years (range 44–98 years), and 98 (69 %) were non-Hispanic white. All patients had one or more CVD risk factors, and 98 (69 %) had a history of CVD. Eighty-six percent of ACI-associated events occurred within 3 days of influenza specimen collection date. Seventy patients (49 %) had documented or probable acute myocardial infarction, 8 (6 %) acute congestive heart failure, 6 (4 %) myocarditis, and 4 (3 %) atrial fibrillation. Eleven (8 %) had non-cardiac explanations for elevated cardiac biomarkers, and 44 (31 %) had no documented explanation. Sixty-eight (48 %) patients had received influenza vaccination during the related influenza season. Conclusion Among veterans with laboratory-confirmed influenza infection and cardiac biomarker testing ≤30 days after influenza testing, approximately 25 % had evidence of ACI, the majority within 3 days. Approximately half were myocardial infarctions. Our findings emphasize the importance of considering ACI associated with influenza infection among patients at high risk, including this older population with prevalent CVD risk factors.

We applied lymphogranuloma venereum (LGV) clinical case criteria to a cohort of 1381 Veterans positive for HIV and Chlamydia trachomatis (CT) from 2016 from 2023 and analyzed variables to ascertain risk factors for LGV and factors associated with the use of standard treatment regimens. In total, 284/1381 (20.6%) met the criteria for LGV. A total of 179/284 (63%) were probable cases, and 105/284 (37%) were possible cases (those meeting clinical criteria but with concurrent sexually transmitted infections (STI) associated with LGV-like symptoms). None had confirmatory CT L1–L3 testing. A total of 230 LGV cases (81%) presented with proctitis, 71 (25%) with ulcers, and 57 (20.1%) with lymphadenopathy. In total, 66 (23.2%) patients had >1 symptom of LGV. A total of 43 (15%) LGV cases were hospitalized. Primary risk factors for LGV were male birth sex (p = 0.004), men who have sex with men (p < 0.001), and the presence of STIs other than gonorrhea or syphilis (p = 0.011). In total, 124/284 (43.7%) LGV cases received standard recommended treatment regimens. Probable cases were more likely to receive standard treatment than possible cases (p = 0.003). We report that 20.6% of CT cases met clinical criteria for LGV among HIV-infected Veterans and that less than half of cases received recommended treatment regimens, indicating that LGV is likely underestimated and inadequately treated among this US population.

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.

Although dengue is endemic in Puerto Rico (PR), 2007 and 2010 were recognized as epidemic years. In the continental United States (US), outside of the Texas-Mexico border, there had not been a dengue outbreak since 1946 until dengue re-emerged in Key West, Florida (FL), in 2009-2010. The objective of this study was to use electronic and manual surveillance systems to identify dengue cases in Veterans Affairs (VA) healthcare facilities and then to clinically compare dengue cases in Veterans presenting for care in PR and in FL. Outpatient encounters from 1/2007-12/2010 and inpatient admissions (only available from 10/2009-12/2010) with dengue diagnostic codes at all VA facilities were identified using VA's Electronic Surveillance System for Early Notification of Community-based Epidemics (ESSENCE). Additional case sources included VA data from Centers for Disease Control and Prevention BioSense and VA infection preventionists. Case reviews were performed. Categorical data was compared using Mantel-Haenszel or Fisher Exact tests and continuous variables using t-tests. Dengue case residence was mapped. Two hundred eighty-eight and 21 PR and FL dengue cases respectively were identified. Of 21 FL cases, 12 were exposed in Key West and 9 were imported. During epidemic years, FL cases had significantly increased dengue testing and intensive care admissions, but lower hospitalization rates and headache or eye pain symptoms compared to PR cases. There were no significant differences in clinical symptoms, laboratory abnormalities or outcomes between epidemic and non-epidemic year cases in FL and PR. Confirmed/probable cases were significantly more likely to be hospitalized and have thrombocytopenia or leukopenia compared to suspected cases. Dengue re-introduction in the continental US warrants increased dengue surveillance and education in VA. Throughout VA, under-testing of suspected cases highlights the need to emphasize use of diagnostic testing to better understand the magnitude of dengue among Veterans.

Norovirus is the leading cause of acute gastroenteritis among all ages in the US. Older adults, including veterans, are a potential target group for future vaccination and therapeutics, and more data are needed on the economic burden of norovirus among this population. To quantify the outpatient, emergency department (ED), and inpatient health care costs associated with laboratory-confirmed norovirus episodes among veterans seeking care in the Veterans Health Administration (VHA). This economic evaluation used VHA electronic health record and health care cost data between January 1, 2010, and December 31, 2024, with costs adjusted to 2024 dollars. Participants were veterans (aged ≥18 years) with norovirus who sought care from VHA clinics and hospitals nationwide. Norovirus episodes were categorized as outpatient, ED, or inpatient. Norovirus episodes laboratory-confirmed by polymerase chain reaction assays. Outpatient, ED, and inpatient costs for encounters or admissions within 2 days of the norovirus-positive test result. Costs were extrapolated to the expected number of annual norovirus episodes with and without laboratory confirmation in the VHA using published incidence rates. A total of 7768 norovirus episodes from 7520 patients (median [IQR] age, 62 [45-74] years; 6862 males [88%]; median [IQR] Charlson Comorbidity Index [CCI], 1 [0-4]) were included in the analysis. There were 3520 outpatient, 2018 ED, and 2230 inpatient norovirus episodes, with respective median (IQR) costs of $640 ($207-$1291), $2203 ($1596-$2989), and $14 083 ($8045-$26 672). Median (IQR) inpatient costs were higher among older age groups ($12 777 [$7297-$23 737], $16 075 [$9291-$29 311], and $18 566 [$10 676-$33 582] for those aged 45-64 years, 65-84 years, and ≥85 years, respectively) than younger adults ($7751 [$4768-$14 984] and $9394 [$5474-$15 830] for those aged 18-24 years and 25-44 years, respectively; P < .001). Median (IQR) inpatient costs were also higher across CCI categories, with the highest for CCI of 5 or higher ($18 508 [$10 445-$35 900]). The overall extrapolated annual cost to the VHA was $28 438 556. This study found norovirus to be a substantial economic burden in the VHA. Developing targeted interventions, such as vaccines and antivirals, for this population may result in cost savings.

We describe the epidemiology of coccidioidomycosis among a national cohort of Veterans. Using electronic health record data from adults tested for coccidioidomycosis between 1 January 2013 and 31 December 2022, we analyzed differences in baseline demographics (age, sex, race/ethnicity, birth country, comorbidities, residence, and Charlson Comorbidity Index score) between 4204 coccidioidomycosis-test-positive and 63,322 test-negative Veterans. Log-binomial regression models with adjusted risk ratios (aRRs) were used to evaluate risk factors associated with coccidioidomycosis including dissemination, hospitalization, and mortality. Case counts and incidence rates were highest in select counties in Arizona and California where Coccidioides is endemic. Coccidioidomycosis-positive Veterans were younger, more likely to be male, and Philippine-born. The risk factors most highly associated with being coccidioidomycosis-positive included Native Hawaiian/Pacific Islander (aRR 1.068 [95%CI: 1.039–1.098]), Asian (aRR 1.060 [95%CI: 1.037–1.083]), Black (aRR 1.029 [95%CI: 1.022–1.036]), American Indian/Alaska Native (aRR 1.026 [95%CI: 1.004–1.048]) race, and Hispanic/Latino ethnicity (aRR 1.021 [95%CI: 1.013–1.028]). Black race (aRR: 1.058 [95%CI: 1.037–1.081]) and Hispanic/Latino ethnicity (aRR 1.018 [95%CI: 1.0003–1.036]) were also associated with disseminated coccidioidomycosis, strengthening the evidence for the association of coccidioidomycosis, including severe infections, with specific racial and ethnic groups. There were no statistically significant differences in hospitalization within 45 days of testing or 30-day all-cause mortality. Improving our understanding of coccidioidomycosis risk factors is important for targeted prevention strategies and to reduce delays in diagnosis and ineffective treatment.