Public Health Reports®

We examined behavioral trends associated with cancer risk and cancer screening use from 1997 through 2006 among American Indians/Alaska Natives (AI/ANs) in the Northern Plains region (North Dakota, South Dakota, Nebraska, and Iowa) of the United States. We also examined disparities between that population and non-Hispanic white (NHW) people in the Northern Plains and AI/ANs in other regions.

We analyzed Behavioral Risk Factor Surveillance System data from the Centers for Disease Control and Prevention for 1997–2000 and 2003–2006. We used age-adjusted Wald Chi-square tests to test the difference between these two periods for AI/ANs and the difference between AI/ANs and NHW people during 2003–2006.

There was no statistically significant improvement among AI/ANs in the Northern Plains region for behaviors associated with cancer risk or cancer screening use, and there was a significant increase in the obesity rate. The prevalence of binge drinking, obesity, and smoking among AI/ANs in the Northern Plains was significantly higher than among NHW people in the same region and among AI/AN populations in other regions. Although the percentage of cancer screening use was similar for all three groups, the use of sigmoidoscopy/colonoscopy was significantly lower among the Northern Plains AI/ANs than among NHW people.

These results indicate a need for increased efforts to close the gaps in cancer health disparities between AI/ANs and the general population. Future efforts should focus not only on individual-level changes, but also on system-level changes to build infrastructure to promote healthy living and to increase access to cancer screening.

We described prevalence estimates of high-risk human papillomavirus (HR-HPV), HPV types 16 and 18, and abnormal Papanicolaou (Pap) smear tests among American Indian/Alaska Native (AI/AN) women compared with women of other races/ethnicities.

A total of 9,706 women presenting for cervical screening in a sentinel network of 26 clinics (sexually transmitted disease, family planning, and primary care) received Pap smears and HR-HPV type-specific testing. We compared characteristics of 291 women self-identified as AI/AN with other racial/ethnic minority groups.

In our population, AI/AN and non-Hispanic white (NHW women had similar age- and clinic-adjusted prevalences of HR-HPV (29.1%, 95% confidence interval [CI] 23.9, 34.3 for AI/AN women vs. 25.8%, 95% CI 24.4, 27.2 for NHW women), HPV 16 and 18 (6.7%, 95% CI 3.9, 9.6 for AI/AN women vs. 8.8%, 95% CI 7.9, 9.7 for NHW women), and abnormal Pap smear test results (16%, 95% CI 11.7, 20.3 for AI/AN women vs. 14.9%, 95% CI 13.7, 16.0 for NHW women). AI/AN women had a higher prevalence of HR-HPV than Hispanic women, and a similar prevalence of HPV 16 and 18 as compared with Hispanic and African American women.

We could not demonstrate differences in the prevalence of HR-HPV, HPV 16 and 18, or abnormal Pap smear test results between AI/AN and NHW women. This finding should improve confidence in the benefit of HPV vaccine and Pap smear screening in the AI/AN population as an effective strategy to reduce rates of cervical cancer.

Late HIV testing leads to preventable, severe clinical and public health outcomes. California, lacking a mature HIV surveillance system, has been excluded from documented analyses of late HIV testers in the United States. We identified factors associated with late HIV testing in the California AIDS surveillance data to inform programs of HIV testing and access to treatment.

We analyzed data from California AIDS cases diagnosed between 2000 and 2006 and reported through November 1, 2007. Late testers were people diagnosed with HIV within 12 months before their AIDS diagnosis. We identified factors significantly associated with late HIV testing using multivariable logistic regression.

Among 28,382 AIDS cases, 61.2% were late HIV testers. Late testing was significantly associated with those ≥35 years of age, heterosexual contact or unknown/other reported transmission risk, and being born outside of the U.S. When further classified by country of birth, people born in Mexico were most likely to be HIV late testers who progressed to AIDS.

Our findings support wider implementation of opt-out HIV testing and HIV testing based in emergency departments. Services for HIV testing and treatment should be inclusive of all populations, but especially targeted to populations that may have more limited access.

Both HIV and hepatitis C virus (HCV) can be transmitted through percutaneous exposure to blood in similar high-risk populations. HCV and HIV/AIDS surveillance databases were matched in Colorado, Connecticut, and Oregon to measure the frequency of co-infection and to characterize co-infected people.

We defined a case of HCV infection as a person with a reactive antibody for hepatitis C, medical diagnosis, positive viral-load test result, or positive genotype reported to any of three state health departments from the start of each state's hepatitis C registry through June 30, 2008. We defined a case of HIV/AIDS as a person diagnosed and living with HIV/AIDS at the start of each state's respective hepatitis C registry through June 30, 2008. HIV/AIDS and hepatitis C datasets were matched using Link King, public domain record linkage and consolidation software, and all potential matches were manually reviewed before acceptance as a match.

The proportion of reported hepatitis C cases co-infected with HIV/AIDS was 1.8% in Oregon, 1.9% in Colorado, and 4.9% in Connecticut. Conversely, the proportion of HIV/AIDS cases co-infected with hepatitis C was consistently higher in the three states: 4.4% in Oregon, 9.7% in Colorado, and 23.6% in Connecticut.

Electronic matching of registries is a potentially useful and efficient way to transfer information from one registry to another. In addition, it can provide a measure of the public health burden of HIV/AIDS and hepatitis C co-infection and provide insight into prevention and medical care needs for respective states.

This study evaluated risk factors for intensive care unit (ICU) admission or death among people hospitalized with 2009 pandemic influenza A (pH1N1) virus infection.

We based analyses on data collected in Washington State from April 27 to September 18, 2009, on deceased or hospitalized people with laboratory-confirmed pH1N1 infection reported by health-care providers and hospitals as part of enhanced public health surveillance. We used bivariate analyses and multivariable logistic regression to identify risk factors associated with ICU admission or death due to pH1N1.

We identified 123 patients admitted to the hospital but not an ICU and 61 patients who were admitted to an ICU or died. Independent of high-risk medical conditions, both older age and delayed time to hospital admission were identified as risk factors for ICU admission or death due to pH1N1. Specifically, the odds of ICU admission or death were 4.44 times greater among adults aged 18–49 years (95% confidence interval [CI] 1.97, 10.02) and 5.93 times greater among adults aged 50–64 years (95% CI 2.24, 15.65) compared with pediatric patients <18 years of age. Likewise, hospitalized cases admitted more than two days after illness onset had 2.17 times higher odds of ICU admission or death than those admitted within two days of illness onset (95% CI 1.10,4.25).

Although certain medical conditions clearly influence the need for hospitalization among people infected with pH1N1 virus, older age and delayed time to admission each played an independent role in the progression to ICU admission or death among hospitalized patients.

Antibiotic resistance is a significant global problem, but the trends in prevalence and impact of antibiotic resistance in hospitalizations in the United States are unclear. We evaluated the trends in hospitalizations associated with antibiotic-resistant infections in U.S. hospitals from 1997 to 2006.

We analyzed the National Hospital Discharge Survey (NHDS) during 1997–2006 (unweighted n=3.3 million hospitalizations; weighted n=370.3 million hospitalizations) and examined trends in prevalence of hospitalizations with antibiotic-resistant infections, length of stay, and discharge status.

The number of infection-related hospitalizations with antibiotic resistance increased 359% during the 10-year period, from 37,005 in 1997 to 169,985 in 2006. The steepest rise was seen among individuals <18 years of age. The mean age of individuals with infection-related hospitalizations that had antibiotic-resistant infections decreased substantially, from 65.7 years (standard error [SE] = 2.01) in 1997 to 44.2 years (SE = 1.47) in 2006. As the proportion of patients with antibiotic-resistant infections who did not have insurance increased, the length of stay for those hospitalizations had a corresponding decrease (r=0.91, p<0.01).

Antibiotic-resistant infections are becoming increasingly commonplace in hospitalizations in the U.S., with a steady upward trend between 1997 and 2006. Antibiotic-resistant infections are increasingly being seen in younger patients and those without health insurance.

We tested whether positive selection on childhood predictors of adult mental and physical health contributed to health advantages of Mexican-born immigrants to the United States relative to U.S.-born Mexican Americans.

We combined data from surveys conducted during 2000–2003 in Mexico and the U.S. with the same structured interview. We examined retrospective reports of childhood (i.e., <16 years of age) predictors of adult health—education, height, childhood physical illness, childhood mental health, early substance use, and childhood adversities—as predictors of migration from Mexico to the U.S. at ≥16 years of age. We estimated overall selection by comparing migrants to all non-migrants. We also examined selection at the family (members of families of migrants vs. members of families without a migrant) and individual (migrants vs. non-migrants within families of migrants) levels.

Distinguishing between family and individual selection revealed evidence of positive health selection that is obscured in the overall selection model. In particular, respondents in families with migrants were more likely to have ≥12 years of education (odds ratio [OR] = 1.60) and be in the tallest height quartile (OR=1.72) than respondents in families without migrants. At both the family and individual levels, migrants are disadvantaged on mental health profiles, including a higher prevalence of conduct problems, phobic fears, and early substance use.

Positive health selection may contribute to physical health advantages among Mexican immigrants in the U.S. relative to their U.S.-born descendants. Mental health advantages likely reflect a lower prevalence of psychiatric disorders in Mexico, rather than protective factors that distinguish migrants.

We examined the association of physical activity with prospectively assessed posttraumatic stress disorder (PTSD) symptoms in a military cohort.

Using baseline and follow-up questionnaire data from a large prospective study of U.S. service members, we applied multivariable logistic regression to examine the adjusted odds of new-onset and persistent PTSD symptoms associated with light/moderate physical activity, vigorous physical activity, and strength training at follow-up.

Of the 38,883 participants, 89.4% reported engaging in at least 30 minutes of physical activity per week. At follow-up, those who reported proportionately less physical activity were more likely to screen positive for PTSD. Vigorous physical activity had the most consistent relationship with PTSD. Those who reported at least 20 minutes of vigorous physical activity twice weekly had significantly decreased odds for new-onset (odds ratio [OR] = 0.58, 95% confidence interval [CI] 0.49, 0.70) and persistent (OR=0.59, 95% CI 0.42, 0.83) PTSD symptoms.

Engagement in physical activity, especially vigorous activity, is significantly associated with decreased odds of PTSD symptoms among U.S. service members. While further longitudinal research is necessary, a physical activity component may be valuable to PTSD treatment and prevention programs.

This study assessed the health effects of the 2003 Northeastern blackout, the largest one in history, on mortality and hospital admissions due to respiratory, cardiovascular, and renal diseases in New York City (NYC), and compared the disease patterns and sociodemographic profiles of cases during the blackout with those on control days.

We investigated the effects of the blackout on health using incidence rate ratios to compare the disease on blackout days (August 14 and 15, 2003) with those on normal and comparably hot days (controls). Normal days were defined as summer days (June-August) between the 25th and 75th percentiles of maximum temperature during 1991–2004. Comparably hot days were days with maximum temperatures in the same range as that of the blackout days. We evaluated the interactive effects of demographics and the blackout using a case-only design.

We found that mortality and respiratory hospital admissions in NYC increased significantly (two- to eightfold) during the blackout, but cardiovascular and renal hospitalizations did not. The most striking increases occurred among elderly, female, and chronic bronchitis admissions. We identified stronger effects during the blackout than on comparably hot days. In contrast to the pattern observed for comparably hot days, higher socioeconomic status groups were more likely to be hospitalized during the blackout.

This study suggests that power outages may have important health impacts, even stronger than the effects of heat alone. The findings provide some direction for future emergency planning and public health preparedness.

Immunization against potentially life-threatening illnesses for children and adults has proved to be one of the great public health successes of the 20th century and is extremely cost-effective. The Patient Protection and Affordable Care Act includes a number of provisions to increase coverage and access to immunizations for the consumer, including a provision for health plans to cover all Advisory Committee on Immunization Practices-recommended vaccines at first dollar, or without cost sharing. In this study, we examined payers' perspectives on first-dollar coverage of vaccines and strategies to improve vaccination rates.

This was a qualitative study, using a literature review and semistructured expert interviews with payers.

Four key themes emerged, including (7) the cost implications of the first-dollar change; (2) the importance of examining barriers to children, adolescents, and adults separately to focus interventions more strategically; (3) the importance of provider knowledge and education in increasing immunization; and (4) the effect of first-dollar coverage on those who decline vaccination for personal reasons.

We determined that, while reducing financial barriers through first-dollar coverage is an important first step to increasing immunization rates, there are structural and cultural barriers that also will require collaborative, strategic work among all vaccine stakeholders.

Post-disaster trends in alcohol consumption and cigarette smoking, as well as their predictors, were identified.

Data from cross-sectional and panel surveys of African American adults in New Orleans, Louisiana, were used from before (2004: n=1,867; 2005: n=879) and after (2006a: n=500; 2006b: n=500) Hurricane Katrina.

Alcohol consumption increased significantly from pre- to post-Hurricane Katrina, while cigarette smoking remained constant. In 2006, posttraumatic stress disorder (PTSD) was associated with cigarette smoking, whereas “news attention” and “provided social support” were inversely associated with cigarette smoking. “News attention” was also inversely associated with cigarette smoking frequency, while “neighborliness” was associated with alcohol consumption. In addition, the effects of PTSD on alcohol consumption were moderated by “neighborliness.”

In the wake of Hurricane Katrina, there were complex predictive processes of addictive behaviors involving PTSD, news information, and social capital-related measures.

We examined findings from the 2008 National Association of Local Boards of Health Survey to provide information about this understudied entity to the public health community.

The survey instrument consisted of 196 items covering five parts: (7) demographics; (2) composition and organizational structure; (3) roles, responsibilities, and authorities; (4) telecommunications infrastructure; and (5) concerns and needs. The survey was sent to chairs of local boards of health (LBHs) in 2008 (n=3,276). After six months of follow-ups and reminders, and a month of data cleaning and screening, the final sample consisted of 870 respondents, for a return rate of 27%.

LBHs tend to represent smaller communities and are primarily appointed. Governing and policy-making boards are more prevalent than advisory boards. Most boards do not have official websites or e-mail addresses of board members available to the public; however, most report the capability to receive training via webcasts. Boards express concerns and needs in a variety of areas, particularly public health law, strategic planning, and accreditation.

Little is known about the more than 3,000 LBHs across the United States that are often charged with making and enforcing public health law. This article is a first step toward providing the public health community with information about LBHs based on survey data.