Public Health Reports®

From 2012 through 2015, the Centers for Disease Control and Prevention (CDC) provided funding to 5 health departments for demonstration projects using HIV surveillance data to link people with newly diagnosed HIV to care. We assessed how well these health departments established linkage to care, how the demonstration projects helped them with this work, and if they sustained these activities after CDC funding ended.

We obtained quantitative and qualitative data on linkage-to-care activities from health department communications and progress reports submitted to CDC. We calculated and combined linkage-to-care results for the 5 health departments, and we compared these results with the combined linkage-to-care results for 61 health departments that received CDC funding for routine HIV prevention activities (eg, HIV testing, linkage to and reengagement in HIV care, HIV partner services) and for the same 5 health departments when they used only routine HIV prevention activities for linkage to care.

Of 1269 people with a new HIV diagnosis at the 5 health departments, 1124 (89%) were linked to care, a result that exceeded the 2010-2015 National HIV/AIDS Strategy goal (85%), the CDC Funding Opportunity Announcement performance standard (80%), and combined results for the 61 health departments (63%) and the same 5 health departments (66%) using routine HIV prevention activities. Benefits of the projects were improved collaboration and coordination and more accurate, up-to-date surveillance data. All health departments continued linkage-to-care activities after funding ended.

Using HIV surveillance data to link people with HIV to care resulted in substantial clinical and public health benefits. Our observations underscore the importance of collaboration among medical providers, public health staff members, community-based organizations, and people with HIV to ensure the best possible clinical and public health outcomes.

Social determinants of health (SDHs) are the complex, structural, and societal factors that are responsible for most health inequities. Since 2003, the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) has researched how SDHs place communities at risk for communicable diseases and poor adolescent health. We described the frequency and types of SDHs discussed in articles authored by NCHHSTP.

We used the MEDLINE/PubMed search engine to systematically review the frequency and type of SDHs that appeared in peer-reviewed publications available in PubMed from January 1, 2009, through December 31, 2014, with a NCHHSTP affiliation. We chose search terms to identify articles with a focus on the following SDH categories: income and employment, housing and homelessness, education and schooling, stigma or discrimination, social or community context, health and health care, and neighborhood or built environment. We classified articles based on the depth of topic coverage as “substantial” (ie, one of ≤3 foci of the article) or “minimal” (ie, one of ≥4 foci of the article).

Of 862 articles authored by NCHHSTP, 366 (42%) addressed the SDH factors of interest. Some articles addressed >1 SDH factor (366 articles appeared 568 times across the 7 categories examined), and we examined them for each category that they addressed. Most articles that addressed SDHs (449/568 articles; 79%) had a minimal SDH focus. SDH categories that were most represented in the literature were health and health care (190/568 articles; 33%) and education and schooling (118/568 articles; 21%).

This assessment serves as a baseline measurement of inclusion of SDH topics from NCHHSTP authors in the literature and creates a methodology that can be used in future assessments of this topic.

In the United States, universal screening for latent tuberculosis (TB) infection among people with HIV is recommended, but the percentage receiving screening is unknown. This study assessed screening for latent TB infection among people with HIV enrolled in Medicaid during 2006-2010.

We used nationwide fee-for-service Medicaid records to identify people with HIV, measure screening for latent TB infection, and examine associated demographic, social, and clinical factors. We used logistic regression analysis to calculate odds ratios (ORs) and 95% confidence intervals (CIs). We created 2 multivariate models to prevent collinearity between variables for length of HIV infection.

Of 152 831 people with HIV, 26 239 (17.2%) were screened for latent TB infection. The factor most strongly associated with screening was TB exposure or suspected TB (OR = 3.78; 95% CI, 3.27-4.37). Significant demographic characteristics associated with screening included being African American (OR = 1.28; 95% CI, 1.24-1.32) or ≤20 years of age (OR = 1.35; 95% CI, 1.28-1.42). Significant clinical and social factors associated with screening included poor housing conditions, low body mass index, chemotherapy treatment, and use of certain substances (ORs ranged from 1.24 [95% CI, 1.20-1.27] to 1.47 [95% CI, 1.22-1.76]). The screening rate for latent TB infection was higher among people with newly diagnosed HIV infection than among those with established infection (OR = 1.37; 95% CI, 1.32-1.41) and among people with a longer established HIV infection than among those with shorter HIV infection (OR = 1.24; 95% CI, 1.23-1.26 for each additional year).

Screening for latent TB infection among fee-for-service Medicaid beneficiaries with HIV was suboptimal, despite the presence of demographic, social, or clinical characteristics that should have increased the likelihood of screening. The lack of certain data in Medicaid may have resulted in an underestimation of screening.

A complete and accurate count of the number of opioid-related overdose deaths is essential to properly allocate resources. We determined the rate of unintentional overdose deaths (non–opioid-related, opioid-related, or unspecified) in the United States and by state from 1999 to 2015 and the possible effects of underreporting on national estimates of opioid abuse.

We abstracted unintentional drug overdose deaths (International Classification of Diseases, 10th Revision, codes X40-X44) with contributory drug-specific T codes (T36.0-T50.9) from the Mortality Multiple Cause Micro-Data Files. We assumed that the proportion of unspecified overdose deaths that might be attributed to opioids would be the same as the proportion of opioid-related overdose deaths among all overdose deaths and calculated the number of deaths that could be reallocated as opioid-related for each state and year. We then added these reallocated deaths to the reported deaths to determine their potential effect on total opioid-related deaths.

From 1999 to 2015, a total of 438 607 people died from unintentional drug overdoses. Opioid-related overdose deaths rose 401% (from 5868 to 29 383), non–opioid-related overdose deaths rose 150% (from 3005 to 7505), and unspecified overdose deaths rose 220% (from 2255 to 29 383). In 5 states (Alabama, Indiana, Louisiana, Mississippi, and Pennsylvania), more than 35% of unintentional overdose deaths were coded as unspecified. Our reallocation resulted in classifying more than 70 000 unspecified overdose deaths as potential additional opioid-related overdose deaths.

States may be greatly underestimating the effect of opioid-related overdose deaths because of incomplete cause-of-death reporting, indicating that the current opioid overdose epidemic may be worse than it appears.

American Indian adolescents who reside on or near reservations report higher levels of substance use than adolescents in other racial/ethnic groups. Little research has addressed patterns of use, which have important implications for prevention and treatment planning. The objective of our study was to describe substance use among a large, population-based sample of American Indian and white students who lived on or near reservations.

We obtained data from 4964 students in grades 7-12 attending 46 schools on or near reservations throughout the United States during 4 academic years (2009-2013). Measures assessed current substance use for alcohol, heavy drinking, marijuana, cigarettes, inhalants, and other drugs. We used latent class analysis to identify patterns of substance use by grade group (grades 7-8 and grades 9-12) and race (American Indian or white).

For American Indians in both grade groups, we found 4 classes of substance use (in order of size): (1) nonusers; (2) marijuana and cigarette users; (3) alcohol, marijuana, and cigarette users; and (4) polysubstance users. For white students, we found 2 classes (nonusers and polysubstance users) among younger students and 4 classes (nonusers; alcohol, marijuana, and cigarette users; alcohol and cigarette users; and polysubstance users) among older students.

We found significant differences in substance use patterns, especially at younger ages, between reservation American Indian students and white students attending the same schools. Combinations of substances used by American Indian adolescents were most likely to include marijuana, as compared with alcohol for white adolescents. Identifying subpopulations of users allows the design of interventions that will more efficiently and effectively address prevention and treatment needs of groups of individuals than would a one-size-fits-all approach.

To understand trends in health care use among people living with HIV/AIDS (PLWHA), this study compared trends in hospitalization rates, comorbidities, and hospital death rates of hospitalized PLWHA with the overall hospitalized population in Illinois during 2008-2014.

This study identified principal hospitalizations (the principal discharge diagnosis coded with an HIV-related billing code) and secondary HIV hospitalizations (a non-principal discharge diagnosis coded with an HIV-related billing code) from 2008-2014 Illinois hospital discharge data. Hospitalization rates among PLWHA were calculated using prevalence data from the Illinois Electronic HIV/AIDS Registry; US Census population estimates were used to calculate overall Illinois hospitalization rates. Joinpoint regression analysis was used to assess trends overall and among demographic subgroups. Comorbidities and discharge status for all hospitalizations were identified.

In 2014, the hospitalization rate was 2.2 times higher among PLWHA than among the overall Illinois hospitalized population. From 2008 to 2014, principal HIV hospitalization rates per 1000 PLWHA decreased by 48% (from 71 to 37) and secondary HIV hospitalization rates declined by 26% (from 296 to 218). The decline in the principal HIV hospitalization rate was steepest from 2008 to 2011 (annual percentage change = –16.0%; P = .003). Mood disorders, substance-related diagnoses, and schizophrenia accounted for 18% to 22% of principal hospitalizations among PLWHA compared with 7% to 8% of overall Illinois hospitalizations. Hepatitis as a comorbidity was more common among hospitalized PLWHA (18%-22%) than among the overall Illinois hospitalized population (1.4%-1.5%). Hospitalized PLWHA were 3 times more likely than the overall Illinois hospitalized population to die while hospitalized.

HIV hospitalizations are largely preventable with appropriate treatment and adherence. Additional efforts to improve retention in HIV care that address comorbidities of PLWHA are needed.

The cost of direct-acting antiviral agents (DAAs) for hepatitis C virus (HCV) infection may contribute to treatment disparities. However, few data exist on factors associated with DAA initiation.

We conducted a retrospective cohort study of HCV-infected Kaiser Permanente Northern California members aged ≥18 during October 2014 to December 2016, using Poisson regression models to evaluate demographic, behavioral, and clinical factors associated with DAA initiation.

Of 14 790 HCV-infected patients aged ≥18 (median age, 60; interquartile range, 53-64), 6148 (42%) initiated DAAs. DAA initiation was less likely among patients who were non-Hispanic black (adjusted rate ratio [aRR] = 0.7; 95% confidence interval [CI], 0.7-0.8), Hispanic (aRR = 0.8; 95% CI, 0.7-0.9), and of other minority races/ethnicities (aRR = 0.9; 95% CI, 0.8-1.0) than among non-Hispanic white people and among those with lowest compared with highest neighborhood deprivation index (ie, a marker of socioeconomic status) (aRR = 0.8; 95% CI, 0.7-0.8). Having maximum annual out-of-pocket health care costs >$3000 compared with ≤$3000 (aRR = 0.9; 95% CI, 0.8-0.9) and having Medicare (aRR = 0.8; 95% CI, 0.8-0.9) or Medicaid (aRR = 0.7; 95% CI, 0.6-0.8) compared with private health insurance were associated with a lower likelihood of DAA initiation. Behavioral factors (eg, drug abuse diagnoses, alcohol use, and smoking) were also significantly associated with a lower likelihood of DAA initiation (all P < .001). Clinical factors associated with a higher likelihood of DAA initiation were advanced liver fibrosis, HCV genotype 1, previous HCV treatment (all P < .001), and HIV infection (P = .007).

Racial/ethnic and socioeconomic disparities exist in DAA initiation. Substance use may also influence patient or provider decision making about DAA initiation. Strategies are needed to ensure equitable access to DAAs, even in insured populations.

We assessed sociodemographic and health care factors of mothers and newborns during a 2015-2016 outbreak of microcephaly in Recife, Brazil, and we analyzed the spatial distribution and incidence risk of newborns with microcephaly in relation to socio-environmental indicators.

We collected data from August 2015 through May 2016 from Brazil’s Live Birth Information System and Bulletin of Microcephaly Notification, and we geocoded the data by maternal residence. We constructed thematic maps of districts, according to socio-environmental and vector indicators. We identified spatial aggregates of newborns with microcephaly by using the Bernoulli model. We performed logistic regression analyses to compare the incidence risk of microcephaly within socio-environmental indicator groups.

We geocoded 17 990 of 19 554 (92.0%) live births in Recife, of which 202 (1.1%) newborns were classified as having microcephaly, based on a head circumference of ≥2 standard deviations below the mean. Larger proportions of newborns with microcephaly (compared with newborns without microcephaly) were born to mothers who delivered in a public hospital, did not attend college, were aged ≤19, or were black or mixed race. A higher risk of microcephaly (incidence rate ratio [IRR] = 3.90; 95% confidence interval [CI], 1.88-8.06) occurred in districts with the lowest (vs highest) Municipal Human Development Index (ie, an index that assesses longevity, education, and income). The risk of microcephaly was significantly higher where rates of larvae density (IRR = 2.31; 95% CI, 1.19-4.50) and larvae detection (IRR = 2.04; 95% CI, 1.05-4.00) were higher and rates of sewage system (IRR = 2.20; 95% CI, 1.16-4.18) and garbage collection (IRR = 1.96; 95% CI, 0.99-3.88) were lower. Newborns with microcephaly lived predominantly in the poorest areas and in a high-risk cluster (relative risk = 1.89, P = .01) in the north.

The disproportionate incidence of microcephaly in newborns in poor areas of Recife reinforces the need for government and public health authorities to formulate policies that promote social equity and support for families and their children with microcephaly.

Sodium reduction in restaurant foods is important because 77% of sodium in the United States is consumed by eating prepared and restaurant foods. We evaluated a sodium-reduction intervention, Healthy Chinese Take-Out Initiative, among Chinese take-out restaurants in low-income neighborhoods in Philadelphia, Pennsylvania. Our objectives were to (1) analyze changes in the sodium content of food samples and (2) collect data on changes in chefs’ and owners’ knowledge about the health risks of sodium overconsumption, perceptions of the need for sodium reduction, self-efficacy for lowering sodium use, and perceptions of training needs for sodium-reduction strategies.

The initiative trained chefs from 206 Chinese take-out restaurants on strategies to reduce sodium in prepared dishes. We analyzed changes in the sodium content of the 3 most frequently ordered dishes—shrimp and broccoli, chicken lo mein, and General Tso’s chicken—from baseline (July-September 2012) to 36 months after baseline (July-September 2015) among 40 restaurants. We conducted a survey to examine the changes in chefs’ and owners’ knowledge, perceptions, and self-efficacy of sodium reduction. We used multilevel analysis and repeated-measures analysis of variance to examine effects of the intervention on various outcomes.

We found significant reductions in the sodium content of all 3 dishes 36 months after a low-sodium cooking training intervention (coefficients range, –1.06 to –1.69, P < .001 for all). Mean knowledge (range, 9.2-11.1), perceptions (range, 4.6-6.0), and self-efficacy (range, 4.2-5.9) (P < .001 for all) of sodium reduction improved significantly from baseline (August 2012) to posttraining (also August 2012), but perceptions of the need for sodium reduction and self-efficacy for lowering sodium use returned to baseline levels 36 months later (August 2015).

The intervention was a useful population health approach that led to engaging restaurants in sodium-reduction practices. Local public health agencies and professionals could partner with independent restaurants to introduce environmental changes that can affect population health on a broad scale, particularly for vulnerable populations.

Mortality due to rare diseases, which are substantial sources of premature mortality, is underreported in mortality studies. The objective of this study was to determine the completeness of reporting systemic lupus erythematosus (SLE) as a cause of death.

In 2017, we linked data on a Swedish population-based cohort (the Swedish Lupus Linkage, 2001-2013) comprising people with SLE (n = 8560) and their matched general population comparators (n = 37 717) to data from the Cause of Death Register. We reviewed death records of deceased people from the cohort (n = 5110) and extracted data on patient demographic characteristics and causes of death. We estimated odds ratios (ORs) and 95% confidence intervals (CIs) for not reporting SLE as a cause of death by using multivariable-adjusted logistic regression models.

Of 1802 deaths among SLE patients in the study, 1071 (59%) did not have SLE reported on their death records. Most SLE decedents were aged 75-84 at death (n = 584, 32%), female (n = 1462, 81%), and born in Nordic countries (n = 1730, 96%). Decedents aged ≥85 at death were more likely to have SLE not reported on their death records than were decedents aged <50 (OR = 2.34; 95% CI, 1.48-3.68). Having renal failure listed as a cause of death decreased the likelihood of SLE not being reported on the death record (OR = 0.54; 95% CI, 0.40-0.73), whereas having cancer listed as a cause of death increased this likelihood (OR = 2.39; 95% CI, 1.85-3.07).

SLE was greatly underreported as a cause of mortality on death records of SLE patients, particularly in older decedents and those with cancer, thereby underestimating the true burden of this disease. Public health resources need to focus on improving the recording of rare diseases in order to enhance the epidemiological utility of mortality data.

Patterns of HIV transmission vary widely across demographic groups. Identifying and engaging these groups are necessary to prevent new infections and diagnose disease among people who are unaware of their infection. The objective of this study was to determine characteristics of newly diagnosed individuals across an entire state to determine patterns of HIV transmission.

We evaluated data on people with new HIV diagnoses in Rhode Island from 2013 through 2015. We performed a latent class analysis (LCA) to identify underlying demographic and behavioral characteristics of people with newly diagnosed HIV.

Of 167 people with new HIV diagnoses interviewed in Rhode Island from 2013 through 2015, 132 (79%) were male, 84 (50%) were nonwhite, 112 (67%) were men who have sex with men (MSM), 112 (67%) were born in the United States, and 61 (37%) were born in Rhode Island. LCA revealed 2 major classes. Of the 98 people in class 1, 96% were male, 85% were MSM, 80% were white, 94% were born in the United States, and 80% believed they acquired HIV in Rhode Island. Class 2 was 63% male and 69% Hispanic/Latino; 29% were born in the United States, and 61% believed they acquired HIV in Rhode Island.

Most new HIV diagnoses in Rhode Island were among MSM born in the United States, and a substantial number were likely infected in-state. People with newly diagnosed HIV who were foreign-born, including Hispanic/Latino and heterosexual groups, were less likely to have acquired HIV in Rhode Island than were MSM. HIV prevention approaches, including pre-exposure prophylaxis, should be adapted to the needs of specific groups. Rhode Island offers lessons for other states focused on eliminating HIV transmission.

The care cascade, a method for tracking population-level progression from diagnosis to cure, is an important tool in addressing and monitoring the hepatitis C virus (HCV) epidemic. However, little agreement exists on appropriate care cascade steps or how best to measure them. The New York City (NYC) Department of Health and Mental Hygiene (DOHMH) sought to construct a care cascade by using laboratory surveillance data with clinically relevant categories that can be readily updated over time.

We identified all NYC residents ever reported to the DOHMH surveillance registry with HCV through June 30, 2017 (n = 175 896). To account for outmigration, death, or treatment before negative RNA results became reportable to the health department, we limited the population to people with any test reported since July 1, 2014. Of these residents, we identified the proportion with a reported positive RNA test and estimated the proportion treated and cured since July 2014 by using DOHMH-developed surveillance-based algorithms.

Of 78 886 NYC residents ever receiving a diagnosis of HCV and tested since July 1, 2014, a total of 70 397 (89.2%) had ever been reported as RNA positive through June 30, 2017; 36 875 (46.7%) had initiated treatment since July 1, 2014, and 23 766 (30.1%) appeared cured during the same period.

A substantial gap exists between confirming HCV infection and initiating treatment, even in the era of direct-acting antivirals. Using this cascade, we will monitor progress in improved treatment and cure of HCV in NYC.