Public Health Reports®

Research examining the effect of changes in Medicaid dental benefits on emergency department (ED) use for dental conditions has had mixed results. We examined the effect of changes in Medicaid dental benefits on ED use for nontraumatic dental conditions (NTDCs) among adults in Massachusetts before and after Medicaid dental benefits for adults were eliminated (July 2010) and partially restored (January 2013).

We used 2009-2013 data from the Massachusetts All-Payer Claims Database. The study population included Medicaid enrollees aged ≥21 who made a visit to the ED for an NTDC that was paid for by Medicaid during the study period. We used an interrupted time-series study design and segmented regression model to assess the effect of the policy changes on ED use for NTDCs. We also conducted a subanalysis by patient age, sex, and geographic location.

During the study period, 21 731 Medicaid enrollees aged ≥21 made 35 660 NTDC ED visits. Eliminating comprehensive dental benefits led to a significant increase in the use of EDs for NTDCs. This increase occurred over time (11% increase at 15 months after elimination of comprehensive dental benefits; estimate, 0.64 [95% CI, 0.07-1.21]; P = .03) rather than immediately after the policy change took effect. The partial restoration of certain dental benefits led to a significant decrease in the rate of ED visits for NTDCs over time (15.7% decrease at 5 months after partial restoration of certain dental benefits; estimate, –0.97 [95% CI, –1.83 to –0.11]; P = .03).

Strengthening dental coverage policies for adult Medicaid enrollees could decrease their reliance on EDs for NTDCs.

With the increasing popularity of electronic cigarettes and legalization of recreational marijuana, messaging from websites and social media is shaping product perceptions and use. Quantitative research on the aesthetic appeal of these advertisements from the adolescent and young adult perspective is lacking. We evaluated (1) how adolescents and young adults perceived tobacco and marijuana messaging online and through social media platforms and (2) interactive behaviors related to these messages.

We interviewed 24 participants from the Tobacco Perceptions Study, a longitudinal study of adolescents’ and young adults’ (aged 17-21) tobacco-related perceptions and tobacco use. We collected qualitative data from October 2017 through February 2018, through individual semi-structured interviews, on participants’ experiences and interactions with online tobacco and marijuana advertisements and the advertisements’ appeal. Two analysts recorded, transcribed, and coded interviews.

Themes that emerged from the interviews focused on the direct appeal of online messaging to adolescents and young adults; the value of trusting the source; the role of general attitudes and personal decision-making related to using tobacco and/or marijuana; the appeal of messaging that includes colors, interesting packaging, and appealing flavors; and the preference of messages communicated by young people and influencers rather than by industry.

These findings suggest the need for increased regulation of social media messaging and marketing of tobacco and marijuana, with a particular focus on regulating social media, paid influencers, and marketing that appeals to adolescents and young adults. The findings also suggest the importance of prevention programs addressing the role of social media in influencing the use of tobacco and marijuana.

Hospital discharge data are a means of monitoring infectious diseases in a population. We investigated rates of infectious disease hospitalizations in New York City.

We analyzed data for residents discharged from New York State hospitals with a principal diagnosis of an infectious disease during 2001-2014 by using the Statewide Planning and Research Cooperative System. We calculated annual age-adjusted hospitalization rates and the percentage of hospitalizations in which in-hospital death occurred. We examined diagnoses by site of infection or sepsis and by pathogen type.

During 2001-2014, the mean annual age-adjusted rate of infectious disease hospitalizations in New York City was 1661.6 (95% CI, 1659.2-1663.9) per 100 000 population; the mean annual age-adjusted hospitalization rate decreased from 2001-2003 to 2012-2014 (rate ratio = 0.9; 95% CI, 0.9-0.9). The percentage of in-hospital death during 2001-2014 was 5.9%. The diagnoses with the highest mean annual age-adjusted hospitalization rates among all sites of infection and sepsis diagnoses were the lower respiratory tract, followed by sepsis. From 2001-2003 to 2012-2014, the mean annual age-adjusted hospitalization rate per 100 000 population for HIV decreased from 123.1 (95% CI, 121.7-124.5) to 40.0 (95% CI, 39.2-40.7) and for tuberculosis decreased from 10.2 (95% CI, 9.8-10.6) to 4.6 (95% CI, 4.4-4.9).

Although hospital discharge data are subject to limitations, particularly for tracking sepsis, lower respiratory tract infections and sepsis are important causes of infectious disease hospitalizations in New York City. Hospitalizations for HIV infection and tuberculosis appear to be declining.

We estimated the caseload of providers, practices, and clinics for psychosocial services (including psychotherapy) to Medicaid-insured children to improve the understanding of the current supply of such services and to inform opportunities to increase their accessibility.

We used 2012-2013 Medicaid claims data and data from the 2013 National Plan and Provider Enumeration System to identify and locate therapists, psychiatrists, and mental health centers along with primary, rehabilitative, and developmental care providers in the United States who provided psychosocial services to Medicaid-insured children. We estimated the per-provider, per-location, and state-level caseloads of providers offering these services to Medicaid-insured children in 34 states with sufficiently complete data to perform this analysis, by using the most recent year of Medicaid claims data available for each state. We measured caseload by calculating the number of psychosocial visits delivered by each provider in the selected year. We compared caseloads across states, urbanicity, provider specialty (eg, psychiatry, psychology, primary care), and practice setting (eg, mental health center, single practitioner).

We identified 63 314 providers, practices, or centers in the Medicaid claims data that provided psychosocial services to Medicaid-insured children in either 2012 or 2013. The median provider-level per-year caseload was <25 children and <250 visits across all provider types. Providers with a mental health center–related taxonomy accounted for >40% of visits for >30% of patients. Fewer than 10% of providers and locations accounted for >50% of patients and visits.

Psychosocial services are concentrated in a few locations, thereby reducing geographic accessibility of providers. Providers should be incentivized to offer care in more locations and to accept more Medicaid-insured patients.

Although some studies have reported a higher incidence of HIV infection among non–US-born people than among US-born people, national data on this topic are scarce. We compared the epidemiology of HIV infection between US-born and non–US-born residents of the United States and examined the characteristics of non–US-born people with diagnosed HIV infection by region of birth (ROB).

We used a cross-sectional study design to produce national, population-based data describing HIV infection among US-born and non–US-born people. We analyzed National HIV Surveillance System data for people with HIV infection diagnosed during 2010-2017 and reported to the Centers for Disease Control and Prevention (CDC). We compared data on demographic characteristics, transmission risk category, and stage 3 infection (AIDS) classification within 3 months of HIV diagnosis, by nativity and ROB.

During 2010-2017, 328 317 children and adult US residents were diagnosed with HIV infection and were reported to CDC: 214 973 (65.5%) were US-born, 50 301 (15.3%) were non–US-born, and 63 043 (19.2%) were missing data on country of birth. After adjusting for missing country of birth, 266 147 (81.1%) people were US-born and 62 170 (18.9%) were non–US-born. This group accounted for 15 928 of 65 645 (24.2%) HIV diagnoses among girls and women and 46 242 of 262 672 (17.6%) HIV diagnoses among boys and men. A larger percentage of non–US-born people than US-born people had stage 3 infection (AIDS) at HIV diagnosis (31.2% vs 23.9%). Among non–US-born people with HIV diagnoses, 19 876 (39.5%) resided in the South.

Characterizing non–US-born people with HIV infection is essential for developing effective HIV interventions, particularly in areas with large immigrant populations.

Electronic health records (EHRs) hold promise as a public health surveillance tool, but questions remain about how EHR patients compare with populations in health and demographic surveys. We compared population characteristics from a regional distributed data network (DDN), which securely and confidentially aggregates EHR data from multiple health care organizations in the same geographic region, with population characteristics from health and demographic surveys.

Ten health care organizations participating in a Colorado DDN contributed data for coverage estimation. We aggregated demographic and geographic data from 2017 for patients aged ≥18 residing in 7 counties. We used a cross-sectional design to compare DDN population size, by county, with the following survey-estimated populations: the county population, estimated by the American Community Survey (ACS); residents seeking any health care, estimated by the Colorado Health Access Survey; and residents seeking routine (eg, primary) health care, estimated by the Behavioral Risk Factor Surveillance System. We also compared data on the DDN and survey populations by sex, age group, race/ethnicity, and poverty level to assess surveillance system representativeness.

The DDN population included 609 840 people in 7 counties, corresponding to 25% coverage of the general adult population. Population coverage ranged from 15% to 35% across counties. Demographic distributions generated by DDN and surveys were similar for many groups. Overall, the DDN and surveys assessing care-seeking populations had a higher proportion of women and older adults than the ACS population. The DDN included higher proportions of Hispanic people and people living in high-poverty neighborhoods compared with the surveys.

The DDN population is not a random sample of the regional adult population; it is influenced by health care use patterns and organizations participating in the DDN. Strengths and limitations of DDNs complement those of survey-based approaches. The regional DDN is a promising public health surveillance tool.

Maricopa County, Arizona (2017 population about 4.3 million), is located in the Sonoran Desert. In 2005, the Maricopa County Department of Public Health (MCDPH) established a heat-associated mortality surveillance system that captures data on circumstances of death for Maricopa County residents and visitors. We analyzed 2006-2016 surveillance system data to understand the characteristics and circumstances of heat-associated deaths.

We classified heat-associated deaths based on International Classification of Diseases, Tenth Revision codes (X30, T67.X, and P81.0) and phrases (heat exposure, environ, exhaustion, sun, heat stress, heat stroke, or hyperthermia) in part I or part II of the death certificate. We summarized data on decedents’ demographic characteristics, years lived in Arizona, location of death (indoors vs outdoors), presence and functionality of air conditioning, and whether the decedent had been homeless. We examined significant associations between variables by using the Pearson χ² tests and logistic regression.

During 2006-2016, MCDPH recorded data on 920 heat-associated deaths, 912 of which included location of injury. Of 565 (62%) heat-associated deaths that occurred outdoors, 458 (81%) were among male decedents and 243 (43%) were among decedents aged 20-49. Of 347 (38%) heat-associated deaths that occurred indoors, 201 (58%) were among decedents aged ≥65. Non-Arizona residents were 5 times as likely as Arizona residents to have a heat-associated death outdoors (P < .001). Of 727 decedents with data on duration of Arizona residency, 438 (60%) had resided in Arizona ≥20 years.

Ongoing evaluation of interventions that target populations at risk for both outdoor and indoor heat-associated deaths can further inform refinement of the surveillance system and identify best practices to prevent heat-associated deaths.

The objective was to compare estimates of childhood influenza vaccination across 7 consecutive influenza seasons based on 2 survey systems.

We analyzed data from the National Health Interview Survey (NHIS) and the National Immunization Survey–Flu (NIS-Flu) using Kaplan-Meier survival analysis to estimate receipt, based on parental report, of at least 1 dose of influenza vaccine among children aged 6 months to 17 years.

We found no significant increasing trend in influenza vaccination coverage among children overall from 2012 to 2018 based on the NHIS or from 2012 to 2019 based on the NIS-Flu. We found 4 seasons with a significant increase in influenza vaccination coverage compared with the previous season (2012-2013 [NHIS, NIS-Flu], 2013-2014 [NIS-Flu], 2017-2018 [NHIS], and 2018-2019 [NIS-Flu]). As of the 2018-2019 season, based on NIS-Flu, influenza vaccination coverage was only 62.6%. Children with health conditions that put them at increased risk for complications from influenza had higher influenza vaccination coverage than children without these health conditions for all the seasons studied except 2014-2015. For all seasons studied, influenza vaccination coverage estimates for children were higher based on NIS-Flu data compared with NHIS data. Trends across seasons and differences in vaccination coverage between age groups were similar between the 2 surveys.

Influenza vaccination coverage among children appears to have plateaued. Only about half of the children in the United States were vaccinated against influenza. Improvements in measurement of influenza vaccination and development and review of strategies to increase childhood influenza vaccination coverage are needed.

More than 16 000 graduate degrees in public health are awarded annually. Yet only 14% of the governmental public health workforce has formal public health training of any kind, and 8% has a master of public health (MPH) degree. We characterized the differences among governmental staff members with master’s degrees across US health departments.

We used data from the 2017 Public Health Workforce Interests and Needs Survey, a national survey of state and local public health departments (43 669 responses; response rate, 48%). We examined the characteristics of the workforce by educational attainment and compared respondents who had obtained a “terminal” (ie, highest degree obtained) MPH degree with respondents who had obtained a terminal non–public health (non-PH) master’s degree.

Respondents who had a non-PH master’s degree were as likely as respondents who had an MPH degree to hold a supervisory role (43% vs 41%; P = .67). We found only 1 significant difference between the 2 groups: respondents aged ≤40 with a terminal MPH degree were significantly less likely than respondents aged ≤40 with a non-PH master’s degree to earn more than the national average salary (adjusted odds ratio = 0.67; 95% CI, 0.47-0.97; P = .03).

We found only marginal differences in career outcomes for people working in governmental public health who had a terminal MPH degree vs a terminal non-PH master’s degree. This finding does not necessitate a full reconsideration of the MPH as it relates to governmental public health practice but a greater recognition that there are multiple paths into practice.

The health profile of Arab American mothers and infants may differ from that of non–Arab American mothers and infants in the United States as a result of social stigma experienced in the historical and current sociopolitical climate. The objective of our study was to compare maternal health behaviors, maternal health outcomes, and infant health outcomes of Arab American mothers and non-Hispanic white mothers in Massachusetts and to assess the role of nativity as an effect modifier.

Using data from Massachusetts birth certificates (2012-2016), we conducted adjusted logistic and linear regression models for maternal health behaviors, maternal health outcomes, and infant health outcomes. We used Arab ethnicity as the exposure of interest and nativity as an effect modifier.

Arab American mothers had higher odds than non-Hispanic white mothers of initiating breastfeeding (adjusted odds ratio [aOR] = 2.61; 95% CI, 2.39-2.86), giving birth to small-for-gestational-age infants (aOR = 1.28; 95% CI, 1.18-1.39), and having gestational diabetes (aOR = 1.31; 95% CI, 1.20-1.44). Among Arab American mothers, non–US-born mothers had higher odds than US-born mothers of having gestational diabetes (aOR = 1.80; 95% CI, 1.33-2.44) and lower odds of initiating prenatal care in the first trimester (aOR = 0.41; 95% CI, 0.33-0.50). In linear regression models, infants born to non–US-born Arab American mothers weighed 42.1 g (95% CI, −75.8 to −8.4 g) less than infants born to US-born Arab American mothers.

Although Arab American mothers engage in positive health behaviors, non–US-born mothers had poorer maternal health outcomes and access to prenatal care than US-born mothers, suggesting the need for targeted interventions for non–US-born Arab American mothers.

The Virginia Department of Health (VDH) identified an outbreak of Salmonella serotype Javiana infections in Virginia after a chili and chowder cook-off with 11 competitors and about 2500 attendees on September 30, 2017. The objectives of this study were to assess the extent of the outbreak and identify the most likely source of exposure.

To identify people with suspected Salmonella infection, VDH used press releases and social media posts to recruit event attendees to take an online survey about foods eaten at the cook-off and any gastrointestinal (GI) symptoms experienced. VDH defined a case as reported GI illness that occurred within 1 week after eating food from the cook-off. Confirmed cases required a clinical specimen culture positive for Salmonella. Probable cases reported diarrhea or related clinical symptoms. “Not ill” people did not report GI illness. Investigators calculated unadjusted relative risks of illness and performed stratified analysis to address potential confounding. Available food samples were tested for Salmonella. Environmental health specialists interviewed food handlers and inspected restaurants where 3 competitors had prepared food.

Of 438 survey responses, 171 (39%) met the case definition. Of all chilies and chowders consumed, Chowder A was associated with the highest relative risk of illness (8.9; 95% CI, 5.7-13.7). A Chowder A sample tested positive for Salmonella serotype Javiana. The environmental investigation did not identify an original contamination source but did find deficiencies in maintaining safe cooking temperatures.

Epidemiologic and laboratory findings indicated that Chowder A was the most likely cause of outbreak. Recommendations to prevent future outbreaks include preparation of all food on-site to ensure safe temperatures during food preparation and service.

Infants born to women with hepatitis B virus (HBV) infection are at high risk for chronic HBV infection and premature death. We examined epidemiologic trends among women with HBV infection who gave birth in New York City (NYC) to inform public health prevention activities.

We obtained data on HBV-infected women residing and giving birth in NYC during 1998-2015 from the NYC Perinatal HBV Prevention Program. We obtained citywide birth data from the NYC Office of Vital Statistics. We calculated the incidence of births to HBV-infected women per 100 000 live births and stratified by maternal race, birthplace, and age. We calculated annual percentage change (APC) in incidence of births to HBV-infected women by using joinpoint regression.

Of 29 896 HBV-infected women included in the study, 28 195 (94.3%) were non–US-born, of whom 16 600 (58.9%) were born in China. Overall incidence of births to HBV-infected women per 100 000 live births increased from 1156 in 1998 to 1573 in 2006 (APC = 3.1%; P < .001) but declined to 1329 in 2015 (APC = –1.4%; P = .02). Incidence among US-born women declined from 1998 to 2015 (330 to 84; APC = –7.3%; P < .001) and among non–US-born women increased from 1998 to 2007 (1877 to 2864; APC = 3.6%; P < .001) but not thereafter. Incidence among women born in China increased from 1998 to 2006 (13 275 to 16 480; APC = 1.8%; P = .02) but decreased to 12 631 through 2015 (APC = –3.3%; P < .001).

The incidence of births to HBV-infected women in NYC declined significantly among US-born women but not among non–US-born women, highlighting the need for successful vaccination programs worldwide.

Racial/ethnic disparities in HIV diagnosis rates remain despite the availability of effective treatment and prevention tools in the United States. In 2019, President Trump announced the “Ending the HIV Epidemic: A Plan for America” (EHE) initiative to reduce new HIV infections in the United States at least 75% by 2025 and at least 90% by 2030. The objective of this study was to show the potential effect of the EHE initiative on racial/ethnic disparities in HIV diagnosis rates at the national level.

We used 2017 HIV diagnoses data from the Centers for Disease Control and Prevention National HIV Surveillance System. We developed a counterfactual scenario to determine changes in racial/ethnic disparities if the 2017 HIV diagnosis rates were reduced by 75% in the geographic regions targeted by the EHE initiative. We used 4 measures to calculate results: rate ratio, population-attributable proportion (PAP), Gini coefficient, and Index of Disparity.

The relative measures of racial/ethnic disparity decreased by 9%-21% in the EHE scenario compared with the 2017 HIV diagnoses data. The largest decrease was in the Hispanic/Latino:white rate ratio (−20.6%) and in the black:white rate ratio (−18.2%). The PAP measure decreased by 11.5%. The absolute versions of the Index of Disparity (unweighted and weighted) were approximately 50% lower in the EHE scenario than in the 2017 HIV diagnoses data.

EHE efforts could reduce but will not eliminate racial/ethnic disparities in HIV diagnosis rates. Efforts to address racial/ethnic disparities should continue, and innovative approaches, specifically those that focus on social and structural factors, should be developed and implemented for populations that are disproportionately affected by HIV in the United States.

Although many people who use drugs meet criteria for vaccination against hepatitis A virus (HAV) and hepatitis B virus (HBV), estimates of susceptibility (ie, lack of immunity) are not well established. This study sought to identify the prevalence of and characteristics associated with HAV and HBV susceptibility among people who use drugs attending an urban syringe services program.

We initiated this seroprevalence study in 2018 among 438 clients of a syringe services program who met study criteria, including provision of a blood specimen and a self-reported history of drug use. We assessed HAV and HBV susceptibility and infection via serological testing. We examined associations between participant characteristics and serology status by using descriptive statistics and multivariable logistic regression models.

Of the initial 438 clients identified, 353 (80.6%) met study criteria. Of 352 participants with conclusive HAV test results, 48.6% (n = 171) were HAV susceptible; of 337 participants with conclusive HBV test results, 32.6% (n = 110) were HBV susceptible, 24.3% (n = 82) showed evidence of past or present HBV infection, and 43.0% (n = 145) had vaccine-derived immunity. Compared with participants born before 1970, participants born during 1980-1989 had 5.90 (95% CI, 2.42-14.40) times the odds of HAV susceptibility and 0.18 (95% CI, 0.06-0.53) times the odds of HBV susceptibility, and participants born during 1990-1999 had 6.31 (95% CI, 2.34-17.00) times the odds of HAV susceptibility. Decreased odds of HAV susceptibility were associated with homelessness (adjusted odds ratio = 0.48; 95% CI, 0.28-0.82).

Despite applicable HAV and HBV vaccination recommendations, substantial gaps exist in HAV and HBV susceptibility among a population of people who use drugs. These findings highlight the need for increased HAV and HBV vaccination efforts among people who use drugs.