Digital Commons Network^™

A Multi-Ancestry Genetic Study Of Pain Intensity In 598,339 Veterans., Sylvanus Toikumo, Rachel Vickers-Smith, Zeal Jinwala, Heng Xu, Divya Saini, Emily E Hartwell, Mirko Pavicic, Kyle A Sullivan, Ke Xu, Daniel A Jacobson, Joel Gelernter, Christopher T Rentsch, Million Veteran Program, Eli Stahl, Martin Cheatle, Hang Zhou, Stephen G Waxman, Amy C Justice, Rachel L Kember, Henry R Kranzler

Epidemiology and Environmental Health Faculty Publications

Chronic pain is a common problem, with more than one-fifth of adult Americans reporting pain daily or on most days. It adversely affects the quality of life and imposes substantial personal and economic costs. Efforts to treat chronic pain using opioids had a central role in precipitating the opioid crisis. Despite an estimated heritability of 25-50%, the genetic architecture of chronic pain is not well-characterized, in part because studies have largely been limited to samples of European ancestry. To help address this knowledge gap, we conducted a cross-ancestry meta-analysis of pain intensity in 598,339 participants in the Million Veteran Program, …

Exploring The Associations Between Drug Resistant Mutations, Low-Level Viremia, And Virological Failure In Persons With Hiv In Florida, Adriana Campos

USF Tampa Graduate Theses and Dissertations

Virologic suppression is an essential part to a successful regimen for Persons with HIV (PWH) and the 95-95-95 initiative. Yet, PWH experiencing episodes of low-level viremia (LLV) may be more prone to experience virological failure (VF). Currently, studies debate the clinical relevance of LLV and its effect on virological outcomes, but none have explored its interconnectedness with drug resistant mutations (DRM) and antiretroviral treatment (ART) adherence – all integral elements in predicting virological outcomes.

The goal of the proposed study was to contribute to the knowledge gap regarding the interconnectivity of drug resistant mutations, low-level viremia, adherence, and virological failure …

Community-Centered Early Warning For Outbreaks In Humanitarian Emergencies: Evaluating Community-Based Surveillance For Priority Communicable Diseases Among Internally Displaced Populations In Iraq, Caitlin M. Wolfe

USF Tampa Graduate Theses and Dissertations

Background: Community based surveillance (CBS) is the organized and rapid collection of information from health events identified in the community and includes the systematic detection and reporting of events of public health significance. While used globally to enhance the detection of priority diseases, CBS has not been routinely deployed in Iraq, where a once-robust health system has been devastated by decades of war, international sanctions, and large-scale population displacement. During infectious disease outbreaks, it is imperative to quickly detect and isolate suspect cases, investigate confirmed cases, and trace and monitor the contacts of confirmed cases. The COVID-19 pandemic underscored the …

Individual Risk Factors Associated With Cesarean Section Surgical Site Infections Among African American Women In California, Paula St Hill

Walden Dissertations and Doctoral Studies

No abstract provided.

Tissue-Resident Memory T Cell Signatures From Single-Cell Analysis Associated With Better Melanoma Prognosis, Chongming Jiang, Cheng-Chi Chao, Jianrong Li, Xin Ge, Aidan Shen, Vadim Jucaud, Chao Cheng, Xiling Shen

Faculty, Staff and Students Publications

Tissue-resident memory T cells (TRM) are a specialized T cell population residing in peripheral tissues. The presence and potential impact of TRM in the tumor immune microenvironment (TIME) remain to be elucidated. Here, we systematically investigated the relationship between TRM and melanoma TIME based on multiple clinical single-cell RNA-seq datasets and developed signatures indicative of TRM infiltration. TRM infiltration is associated with longer overall survival and abundance of T cells, NK cells, M1 macrophages, and memory B cells in the TIME. A 22-gene TRM–derived risk score was further developed to effectively classify patients into low- and high-risk categories, distinguishing overall …

Wastewater Surveillance For Identifying Sars-Cov-2 Infections In Long-Term Care Facilities, Kentucky, Usa, 2021–2022, James W. Keck, Reuben Adatorwovor, Matthew Liversedge, Blazan Mijotavich, Cullen Olsson, William D. Strike, Atena Amirsoleimani, Ann Noble, Soroosh Torabi, Alexus Lori Rockward, Mohammad Dehghan Banadaki, Ted Smith, Parker Lacy, Scott M. Berry

UK CARES Faculty Publications

Persons living in long-term care facilities (LTCFs) were disproportionately affected by COVID-19. We used wastewater surveillance to detect SARS-CoV-2 infection in this setting by collecting and testing 24-hour compos- ite wastewater samples 2–4 times weekly at 6 LTCFs in Kentucky, USA, during March 2021–February 2022. The LTCFs routinely tested staff and symptomatic and exposed residents for SARS-CoV-2 using rapid antigen tests. Of 780 wastewater samples analyzed, 22% (n = 173) had detectable SARS-CoV-2 RNA. The LTCFs reported 161 positive (of 16,905) SARS-CoV-2 clinical tests. The wastewater SARS-CoV-2 signal showed vari- able correlation with clinical test data; we observed the strongest …

Tuberculosis In People Of Ukrainian Origin In The European Union And The European Economic Area, 2019 To 2022, Krista Stoycheva, Veronica Cristea, Csaba Ködmön, Senia Rosales-Klintz, Dominik Zenner, Anca Vasiliu, Marieke Van Der Werf, Christoph Lange

Faculty, Staff and Students Publications

Approximately five million Ukrainians were displaced to the EU/EEA following the Russian invasion of Ukraine. While tuberculosis (TB) notification rates per 100,000 Ukrainians in the EU/EEA remained stable, the number of notified TB cases in Ukrainians increased almost fourfold (mean 2019-2021: 201; 2022: 780). In 2022, 71% cases were notified in three countries, and almost 20% of drug-resistant TB cases were of Ukrainian origin. Targeted healthcare services for Ukrainians are vital for early diagnosis and treatment, and preventing transmission.

Description Of Cryptococcosis Following Sars-Cov-2 Infection: A Disease Survey Through The Mycosis Study Group Education And Research Consortium (Msg-19), Jeremey Walker, Todd Mccarty, Gerald Mcgwin, Eloy E Ordaya, Paschalis Vergidis, Luis Ostrosky-Zeichner, Mehriban Mammadova, Andrej Spec, Adriana M Rauseo, John Perfect, Julia Messina, Gabriel Vilchez, Rachel Mcmullen, Carolynn T Jones, Peter G Pappas

Faculty, Staff and Student Publications

BACKGROUND: Invasive fungal infections have been described throughout the COVID-19 pandemic. Cryptococcal disease after infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been reported in several isolated case reports and 1 larger case series. We sought to describe cryptococcal infections following SARS-CoV-2 through establishing a database to investigate underlying risk factors, disease manifestations, and outcomes.

METHODS: We created a crowdsourced call for cases solicited through the Mycoses Study Group Education and Research Consortium, the Centers for Disease Control and Prevention Emerging Infectious Diseases Network, and infectious diseases Twitter groups. Data were collected in a web-based and secure REDCap …

Design, Synthesis, X-Ray Crystallography, And Biological Activities Of Covalent, Non-Peptidic Inhibitors Of Sars-Cov-2 Main Protease, Md Ashraf-Uz-Zaman, Teck Khiang Chua, Xin Li, Yuan Yao, Bala Krishna Moku, Chandra Bhushan Mishra, Vasanthi Avadhanula, Pedro A Piedra, Yongcheng Song

Faculty, Staff and Students Publications

Highly contagious SARS-CoV-2 coronavirus has infected billions of people worldwide with flu-like symptoms since its emergence in 2019. It has caused deaths of several million people. The viral main protease (Mpro) is essential for SARS-CoV-2 replication and therefore a drug target. Several series of covalent inhibitors of Mpro were designed and synthesized. Structure-activity relationship studies show that 1) several chloroacetamide- and epoxide-based compounds targeting Cys145 are potent inhibitors with IC50 values as low as 0.49 μM, and 2) Cys44 of Mpro is not nucleophilic for covalent inhibitor design. High resolution X-ray studies revealed the protein-inhibitor interactions and mechanisms of inhibition. …

Covid-19 Hospital Mortality Among Patients With Invasive Mechanical Ventilation: A Comparison Between Public And Private Healthcare Services In San Luis Potosí 2020–2022, María E. Torres-Acosta, Rocío M. Cubos-Moncada, Alan Y. Martínez-Castellanos

The University of Louisville Journal of Respiratory Infections

Background: During 2019, México’s total public spending on health was 5.43% of the national gross domestic product, making it one of the countries of the Organisation for Economic Co-operation and Development that invested the least in developing public health systems. This study analyzes hospital mortality among intubated patients with laboratory-confirmed COVID-19 according to type of institution in San Luis Potosí, México, from March 18, 2020, to April 7, 2022.

Methods: This is a secondary data analysis of publicly available information about mortality among intubated patients with a laboratory-confirmed diagnosis of COVID-19 with respect to the type of hospitalization institution.

Results: …

Covid-19 Vaccine And Survival Of Diabetes Patient On Dialysis, Luis Guillermo De Jesús Iii Vega

Walden Dissertations and Doctoral Studies

No abstract provided.

Association Between Malaria Educational Message Exposure And Malaria Prevalence Among Children In Nigeria, Eberechukwu Jacob Ajiwe

Walden Dissertations and Doctoral Studies

No abstract provided.

Virology-The Path Forward, Angela L Rasmussen, Gigi K Gronvall, Anice C Lowen, Felicia Goodrum, James Alwine, Kristian G Andersen, Simon J Anthony, Joel Baines, Arinjay Banerjee, Andrew J Broadbent, Christopher B Brooke, Samuel K Campos, Patrizia Caposio, Arturo Casadevall, Gary C Chan, Anna R Cliffe, Donna Collins-Mcmillen, Nancy Connell, Blossom Damania, Matthew D Daugherty, Kari Debbink, Terence S Dermody, Daniel Dimaio, W Paul Duprex, Michael Emerman, Denise A Galloway, Robert F Garry, Stephen A Goldstein, Alexander L Greninger, Amy L Hartman, Brenda G Hogue, Stacy M Horner, Peter J Hotez, Jae U Jung, Jeremy P Kamil, Stephanie M Karst, Lou Laimins, Seema S Lakdawala, Igor Landais, Michael Letko, Brett Lindenbach, Shan-Lu Liu, Micah Luftig, Grant Mcfadden, Andrew Mehle, Juliet Morrison, Anne Moscona, Elke Mühlberger, Joshua Munger, Karl Münger, Eain Murphy, Christopher J Neufeldt, Janko Z Nikolich, Christine M O'Connor, Andrew Pekosz, Sallie R Permar, Julie K Pfeiffer, Saskia V Popescu, John G Purdy, Vincent R Racaniello, Charles M Rice, Jonathan A Runstadler, Martin J Sapp, Rona S Scott, Gregory A Smith, Erin M Sorrell, Emily Speranza, Daniel Streblow, Scott A Tibbetts, Zsolt Toth, Koenraad Van Doorslaer, Susan R Weiss, Elizabeth A White, Timothy M White, Christiane E Wobus, Michael Worobey, Satoko Yamaoka, Andrew Yurochko

Faculty, Staff and Students Publications

In the United States (US), biosafety and biosecurity oversight of research on viruses is being reappraised. Safety in virology research is paramount and oversight frameworks should be reviewed periodically. Changes should be made with care, however, to avoid impeding science that is essential for rapidly reducing and responding to pandemic threats as well as addressing more common challenges caused by infectious diseases. Decades of research uniquely positioned the US to be able to respond to the COVID-19 crisis with astounding speed, delivering life-saving vaccines within a year of identifying the virus. We should embolden and empower this strength, which is …

Contrasting Tick Species Behaviors: A Course-Based Undergraduate Research Experience (Cure), Sara Benham, Shovan Dutta, Rohan Maddamsetti, Clayton Wright, Alena Anderson, David T. Gauthier, Holly D. Gaff

Spora: A Journal of Biomathematics

Tick-borne diseases are on the rise throughout the world, and there is a need to better understand tick behavior in order to identify potential new interventions. Ticks have a complex life history and can survive months off-host. There is a lack of large-scale data on off-host tick behavior, which leaves a gap in understanding of tick biology outside of tick-host interactions. Introducing undergraduate students to authentic research early in their studies can help prepare them for independent inquiry in upper-level classes. To address the student needs and fill gaps in tick research, students in introductory biology courses recorded observations of …

Resilience Of Mental Health Services Amidst Ebola Disease Outbreaks In Africa, Frankline Sevidzem Wirsiy, Nancy B. Tahmo, Lambed Tatah, David Brett-Major

Journal Articles: Epidemiology

INTRODUCTION: Health systems including mental health (MH) systems are resilient if they protect human life and produce better health outcomes for all during disease outbreaks or epidemics like Ebola disease and their aftermaths. We explored the resilience of MH services amidst Ebola disease outbreaks in Africa; specifically, to (i) describe the pre-, during-, and post-Ebola disease outbreak MH systems in African countries that have experienced Ebola disease outbreaks, (ii) determine the prevalence of three high burden MH disorders and how those prevalences interact with Ebola disease outbreaks, and, (iii) describe the resilience of MH systems in the context of these …

Feasibility Assessment Of A Novel Isolation Care Tent In Uganda During The 2022, M. Jana Broadhurst, Rodgers R. Ayebare, David Brett-Major, Sean M. Carroll, Jacob Lacore, Alexander D. Laskey, James V. Lawler, Patricia Lord, Ruben M. Vazquez, Peter Waitt, Mohammed Lamorde

Journal Articles: Epidemiology

This case study describes a feasibility assessment of a novel isolation care tent used in health facilities in Uganda during the 2022 Sudan ebolavirus outbreak. The Isolation System for Treatment and Agile Response to High-Risk Infections Model 1B (ISTARI 1B) is a single-occupancy, portable, negative-pressure isolation tent designed for the safe delivery of standard care to patients with a communicable disease, including Ebola disease (Sudan). At the request of the Uganda Ministry of Health, the Makerere University Infectious Diseases Institute and University of Nebraska Medical Center partnered to evaluate 7 health facilities across 4 districts in Uganda for infrastructure, case …

Redesigning Surveillance Through The Global Emerging Infections Surveillance Program, David Brett-Major

Journal Articles: Epidemiology

No abstract provided.

Population Burden Of Rare Infectious And Inflammatory Diseases Of The Heart, Meera Marji

Theses and Dissertations--Epidemiology and Biostatistics

Rare diseases of the heart, such as infective endocarditis (IE), myocarditis, and pericarditis, have earned limited attention in cardiovascular research despite their potential for severe morbidity and mortality. Amidst the opioid crisis in the United States, there has been a notable increase in endocarditis hospitalizations among people who inject drugs. Kentucky, at the epicenter of the opioid epidemic, lacks available data on IE hospitalizations. Moreover, the COVID-19 pandemic has introduced unprecedented challenges to healthcare systems, influencing hospitalizations and healthcare utilization patterns. While trends before, during, and after the pandemic have been extensively studied for common cardiovascular diseases, such as heart …

Impacts Of Climate Change On Vector-Borne Disease Burden In The United States: Exploring The Epidemiological Evidence, Leah V. Loetman

Honors Theses

Climate change models predict shifts in vector-borne diseases (VBDs) around the world, including in the United States. However, to my knowledge there has yet to be a comprehensive descriptive epidemiological study examining prevalence, geographic distribution, and trends for all tick- and mosquito-borne diseases in the United States. I compiled data from the U.S. Centers for Disease Control (CDC), which publishes yearly case numbers for 17 vector-borne diseases. However, these publications depend on a scattered framework of state regulations regarding disease reporting. I compiled data from the CDC to determine the current geographic distribution, prevalence, and trends of tick- and mosquito-borne …

High Prevalence Of Trypanosoma Cruzi Infection In Raccoons (Procyon Lotor) And Associated Risk To Humans In Central Illinois, Esther Onuselogu

Masters Theses

Chagas disease, caused by the protozoan parasite Trypanosoma cruzi, remains a neglected tropical disease and a growing health threat in the United States. Raccoons (Procyon lotor) often coexist with humans in urban and suburban areas and serve as reservoir hosts for T. cruzi. While T. cruzi is rare in humans and domestic animals in the U.S., it is common in wildlife species, particularly raccoons and Virginia opossums (Didelphis virginiana). This study aimed to assess the prevalence of T. cruzi infection in the raccoon population of Central Illinois and evaluate the risk of transmission to humans. …

Evaluating The Performance Of Flukecatcher At Detecting Urogenital Schistosomiasis, Louis Fok, Berhanu Erko, David Brett-Major, Abebe Animut, M. Jana Broadhurst, Daisy Dai, John Linville, Bruno Levecke, Yohannes Negash, Abraham Degarege

Journal Articles: Epidemiology

Urine filtration microscopy (UFM) lacks sensitivity in detecting low-intensity Schistosoma haematobium infections. In pursuit of a superior alternative, this study evaluated the performance of FlukeCatcher microscopy (FCM) at detecting S. haematobium eggs in human urine samples. Urine samples were collected from 572 school-age children in Afar, Ethiopia in July 2023 and examined using UFM and FCM approaches. Using the combined UFM and FCM results as a reference, the sensitivity, negative predictive value, and agreement levels for the two testing methods in detecting S. haematobium eggs in urine samples were calculated. The sensitivity and negative predictive value of detecting S. haematobium …

"Shut Down And Closed Off": A Routine Activity Approach To Investigating The Relationship Between Covid-19 School Closures And Child Sexual Abuse Report Characteristics In Georgia, Spencer E. Riner

College of Graduate Studies: Theses & Dissertations

The COVID-19 pandemic of 2020 created a public health crisis that led to an unprecedented number of school closures. A major concern raised by child advocates, law enforcement, and social service providers was the possible increase in undetected child abuse and maltreatment. Undergirding this concern was the belief that this mitigation effort might place child abuse victims and offenders within proximity for extended periods of time. While this was a significant concern, it has rarely been analyzed empirically. To address this gap in the literature, this thesis investigates how school closures impacted the characteristics of child sexual abuse (CSA) reports …

Recent Trends In Stimulant Prescribing In Kentucky, 2021-2023, Jordan Shannon

Theses and Dissertations--Public Health (M.P.H. & Dr.P.H.)

Abstract

Introduction

Prescription stimulants have a long history of clinical use dating as far back as the 1930s. In the United States stimulant prescribing rates have steadily climbed over the last 3 decades. The primary objective is to describe recent (2021-2023) prescribing trends of stimulant medications in the Commonwealth of Kentucky

Methods

Prescription data collected from Kentucky’s prescription drug monitoring (PDMP) database known as the Kentucky All Schedule Prescription Electronic Reporting System (KASPER). Annual and quarterly trends in stimulant prescribing between 2021-2023 were calculated, examined by age, sex, and geographic location.

Results

Stimulant prescribing increased by ~15% where the majority …

The Performance Of Marginal Modeling Methods For Rare Events With Application To Opioid Overdose Mortality And Morbidity, Shawn Nigam

Theses and Dissertations--Epidemiology and Biostatistics

Opioid misuse is a nationwide epidemic, with Kentucky having one of the highest opioid overdose-related fatality rates across all US states. These rates have increased significantly over the past decade, with particularly large increases during the COVID-19 pandemic. This dissertation aims to study the behavior of these increases and the methods for the marginal modeling of count outcomes related to opioid overdose.

Opioid overdose-related fatality rates in Kentucky increased significantly during the COVID-19 pandemic. In this chapter, we characterize the changes in opioid overdose fatality rates in Kentucky and identify associations between potential factors and fatality rates. County-level opioid overdose …

Availability, Use, And Impact Of Workplace Mental Health Supports During The Covid-19 Pandemic In A Canadian Cohort Of Healthcare Workers, Shannon Ruzycki, Anil Adisesh, Igor Burstyn, Quentin Durand-Moreau, France Labreche, Tanis Zadunayski, Nicola Cherry

Études primaires

We investigated the availability and use of workplace mental health (MH) supports during the COVID-19 pandemic in a Canadian cohort of healthcare workers (HCW) and measured anxiety and depression by the Hospital Anxiety and Depression Scale (HADS) completed at four contacts 2020–2022. Reports were available for 4400 HCW working with patients. Half the HCWs had a clinically significant HADS score at one or more contacts Access to MH supports increased during the pandemic, with 94% reporting access to some workplace support by 2022: 47% had made use of at least one support. 25% of those with high HADS scores used …

Efficacy Of Praziquantel In Treating Schistosoma Haematobium Infection Among Ethiopian Children, Louis Fok, David Brett-Major, Berhanu Erko, John Linville, Hongying Dai, Yohannes Negash, Abebe Animut, Abraham Degarege

Journal Articles: Epidemiology

Background/Objectives: Praziquantel is a cornerstone of schistosomiasis control and elimination efforts. Continued surveillance of praziquantel efficacy is needed to monitor for the development of resistance, as well as to help public health officials gauge the effect of mass praziquantel administration on schistosomiasis control in communities, since it is the only drug used in schistosomiasis control programs. The objective of this study was to assess the praziquantel cure rate and egg reduction rate against urogenital schistosomiasis.

Methods: This study enrolled 977 children from 12 villages in Afar and Gambella, Ethiopia, who provided urine samples that were checked for Schistosoma haematobium …

Implementing A Nurse-Driven Clostridium Difficile Screening Protocol, Sandrela Magnuson

Graduate Theses, Dissertations, and Problem Reports (ETD)

ABSTRACT

Background: Clostridium difficile infection (CDI) is a prevalent infection often contracted in hospitals. CDI is also increasingly originating from community settings. In addition to the health risks associated with CDI, diagnosis of a hospital-acquired CDI can have a significant financial impact on hospital systems. When hospital acquired, hospital systems are no longer reimbursed by payers. Secondary to the increasing prevalence of community-acquired CDI, mechanisms for early detection and isolation are warranted.

Local Problem: J.W. Ruby Memorial Hospital has an integrated Clostridium difficile (C. difficile) electronic health record (EHR) screening questionnaire that requires updating to align with current guidelines.

Purpose: …

Using Phosphatidylethanol As An Adjunct To Self-Reported Alcohol Use Improves Identification Of Liver Fibrosis Risk, Pamela M. Murnane, Majid Afshar, Gabriel Chamie, Robert L. Cook, Tekeda Ferguson, Lamia Y. Haque, Karen R. Jacobson, Amy C. Justice, Theresa W. Kim, Mandana Khalili, Evgeny Krupitsky, Kathleen A. Mcginnis, Patricia Molina, Winnie R. Muyindike, Bronwyn Myers, Veronica L. Richards, Kaku So-Armah, Scott Stewart, Mark S. Sulkowski, Phyllis C. Tien, Judith A. Hahn

School of Public Health Faculty Publications

Introduction: Accurate assessment of alcohol use informs prevention and management of liver disease. We examined whether phosphatidylethanol (PEth, an alcohol metabolite) blood concentrations are associated with liver fibrosis risk independently of self-reported alcohol use, among persons with and without HIV. Methods: We pooled individual-level data from 12 studies from the United States, Russia, Uganda, and South Africa with PEth, AUDIT-C (Alcohol Use Disorders Identification Test-Consumption), and FIB-4 measurements. We conducted mixed-effects logistic regression of the relationship between PEth and AUDIT-C as continuous variables (after checking linearity), with high FIB-4 ( ≥ 2.67). We divided PEth (range 0-1000) by 83.3 to …

Unraveling The Effects Of The Covid-19 Pandemic On Staphylococcus Aureus Carriage: A Comparative Research Of Pre- And Post-Pandemic Samples, Catherine G. Johnston

Honors Undergraduate Theses

The COVID-19 pandemic brought about significant changes in the epidemiology of Staphylococcus aureus carriage and disease. This study aims to assess these changes by leveraging respiratory samples collected from a longstanding cohort, comparing the genomic characteristics of S. aureus isolates from pre- and post-pandemic periods. We analyzed S. aureus genomes and phenotypically determined macrolide resistance to characterize population structure, antibiotic resistance, and virulence profiles. Changes in S. aureus carriage rates, macrolide resistance, disease occurrence, and population structure between samples collected pre- and post-pandemic were examined. By using respiratory samples, chart reviews, and risk factor questionnaires of 498 children from a …

Provider And Staff Education Surrounding Universal Hcv Screening And Linkage To Care In An Ambulatory Care Setting, Lauren Clifford

DNP Projects

Abstract

Background: In the United States, it is estimated that there are more than 2 million cases of Hepatitis C (HCV), with over 66,000 new cases since 2020 However, an estimated 75% of those with HCV go undiagnosed and less than 35% receive treatment within a year of diagnosis. In 2018, UK Healthcare (UKHC) implemented a universal HCV screening method using a Best Practice Advisory (BPA) for anyone 18 and older who presented to the Emergency Department and had labs ordered. Patients who screened positive were then referred to outpatient clinics for HCV treatment. Approximately ten percent of positive patients …