Multiple COVID-19 Outbreaks Linked to a Wedding Reception in Rural Maine - August 7-September 14, 2020.

Large indoor gatherings pose a high risk for transmission of SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19), and have the potential to be super-spreading events (1,2). Such events are associated with explosive growth, followed by sustained transmission (3). During August 7-September 14, 2020, the Maine Center for Disease Control and Prevention (MeCDC) investigated a COVID-19 outbreak linked to a wedding reception attended by 55 persons in a rural Maine town. In addition to the community outbreak, secondary and tertiary transmission led to outbreaks at a long-term care facility 100 miles away and at a correctional facility approximately 200 miles away. Overall, 177 COVID-19 cases were epidemiologically linked to the event, including seven hospitalizations and seven deaths (four in hospitalized persons). Investigation revealed noncompliance with CDC's recommended mitigation measures. To reduce transmission, persons should avoid large gatherings, practice physical distancing, wear masks, stay home when ill, and self-quarantine after exposure to a person with confirmed SARS-CoV-2 infection. Persons can work with local health officials to increase COVID-19 awareness and determine the best policies for organizing social events to prevent outbreaks in their communities.

Characteristics and Outcomes of Contacts of COVID-19 Patients Monitored Using an Automated Symptom Monitoring Tool - Maine, May-June 2020.

SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19), is spread from person to person (1-3). Quarantine of exposed persons (contacts) for 14 days following their exposure reduces transmission (4-7). Contact tracing provides an opportunity to identify contacts, inform them of quarantine recommendations, and monitor their symptoms to promptly identify secondary COVID-19 cases (7,8). On March 12, 2020, Maine Center for Disease Control and Prevention (Maine CDC) identified the first case of COVID-19 in the state. Because of resource constraints, including staffing, Maine CDC could not consistently monitor contacts, and automated technological solutions for monitoring contacts were explored. On May 14, 2020, Maine CDC began enrolling contacts of patients with reported COVID-19 into Sara Alert (MITRE Corporation, 2020),* an automated, web-based, symptom monitoring tool. After initial communication with Maine CDC staff members, enrolled contacts automatically received daily symptom questionnaires via their choice of e-mailed weblink, text message, texted weblink, or telephone call until completion of their quarantine. Epidemiologic investigations were conducted for enrollees who reported symptoms or received a positive SARS-CoV-2 test result. During May 14-June 26, Maine CDC enrolled 1,622 contacts of 614 COVID-19 patients; 190 (11.7%) eventually developed COVID-19, highlighting the importance of identifying, quarantining, and monitoring contacts of COVID-19 patients to limit spread. In Maine, symptom monitoring was not feasible without the use of an automated symptom monitoring tool. Using a tool that permitted enrollees to specify a method of symptom monitoring was well received, because the majority of persons monitored (96.4%) agreed to report using this system.

Stall in Heart Disease Death Rates, Evidence From Maine, 1999-2017.

INTRODUCTION: Since the 1950s, heart disease deaths have declined in the United States, but recent reports indicate a plateau in this decline. Heart disease death rates increased in Maine from 2011-2015. We examined reasons for the trend change in Maine's heart disease death rates, including the contributing types of heart disease. METHODS: We obtained Maine's annual heart disease death data for 1999-2017 from CDC's Wide-ranging Online Data for Epidemiologic Research (CDC WONDER). We used joinpoint regression to determine changes in trend and annual percentage change (APC) in death rates for heart disease overall and by demographic groups, types of heart disease, and geographic area. RESULTS: Joinpoint modeling showed that Maine's age-adjusted heart disease death rates decreased during 1999-2010 (-4.2% APC), then plateaued during 2010-2017 (-0.1% APC). Death rates flattened for both sexes and age groups ≥45 years. Although death rates for acute myocardial infarction (AMI) decreased through 2017, hypertensive heart disease (HHD) and heart failure death rates increased. Death rates attributable to diabetes-related heart disease and non-AMI ischemic heart disease (IHD) plateaued. CONCLUSION: Declines in Maine's heart disease death rates have plateaued, similar to national trends. Flattening rates appear to be driven by adverse trends in HHD, heart failure, diabetes-related heart disease, and non-AMI IHD. Increased efforts to address cardiovascular disease risk factors, chronic heart disease, and access to care are necessary to continue the decrease in heart disease deaths in Maine.

Indicators for chronic disease surveillance - United States, 2013.

Chronic diseases are an important public health problem, which can result in morbidity, mortality, disability, and decreased quality of life. Chronic diseases represented seven of the top 10 causes of death in the United States in 2010 (Murphy SL, Xu J, Kochanek KD. Deaths: final data for 2010. Natl Vital Stat Rep 2013;6. Available at http://www.cdc.gov/nchs/data/nvsr/nvsr61/nvsr61_04.pdf Adobe PDF file). Chronic diseases and risk factors vary by geographic area such as state and county, where essential public health interventions are implemented. The chronic disease indicators (CDIs) were established in the late 1990s through collaboration among CDC, the Council of State and Territorial Epidemiologists, and the Association of State and Territorial Chronic Disease Program Directors (now the National Association of Chronic Disease Directors) to enable public health professionals and policymakers to retrieve data for chronic diseases and risk factors that have a substantial impact on public health. This report describes the latest revisions to the CDIs, which were developed on the basis of a comprehensive review during 2011-2013. The number of indicators is increasing from 97 to 124, with major additions in systems and environmental indicators and additional emphasis on high-impact diseases and conditions as well as emerging topics.

Awareness, treatment, and control of hypertension and hypercholesterolemia among insured residents of New York City, 2004.

INTRODUCTION: Health care access and sociodemographic characteristics may influence chronic disease management even among adults who have health insurance. The objective of this study was to examine awareness, treatment, and control of hypertension and hypercholesterolemia, by health care access and sociodemographic characteristics, among insured adults in New York City. METHODS: Using data from the 2004 New York City Health and Nutrition Examination Survey, we investigated inequalities in the diagnosis and management of hypertension and hypercholesterolemia among insured adults aged 20 to 64 years (n = 1,334). We assessed differences in insurance type (public, private) and routine place of care (yes, no), by sociodemographic characteristics. RESULTS: One in 10 participants with hypertension and 3 in 10 with hypercholesterolemia were unaware and untreated. Having a routine place of care was associated with treatment and control of hypertension and with awareness, treatment, and control of hypercholesterolemia, after adjusting for insurance type, age, sex, race/ethnicity, foreign birth, income, and education. Differences in systolic blood pressure and total cholesterol between people with versus without a routine place of care were 2 to 3 times the difference found between people with public versus private insurance. Few differences were associated with sociodemographic characteristics after adjusting for routine place of care and insurance type; however, male sex, younger age, Asian race, and foreign birth with short-term US residence reduced the odds of having a routine place of care. Neither income nor education predicted having a routine place of care. CONCLUSION: Sociodemographic characteristics may influence chronic disease management among the insured through health care access factors such as having a routine place of care.

Racial disparities in blood pressure control and treatment differences in a Medicaid population, North Carolina, 2005-2006.

INTRODUCTION: Racial disparities in prevalence and control of high blood pressure are well-documented. We studied blood pressure control and interventions received during the course of a year in a sample of black and white Medicaid recipients with high blood pressure and examined patient, provider, and treatment characteristics as potential explanatory factors for racial disparities in blood pressure control. METHODS: We retrospectively reviewed the charts of 2,078 black and 1,436 white North Carolina Medicaid recipients who had high blood pressure managed in primary care practices from July 2005 through June 2006. Documented provider responses to high blood pressure during office visits during the prior year were reviewed. RESULTS: Blacks were less likely than whites to have blood pressure at goal (43.6% compared with 50.9%, P = .001). Blacks above goal were more likely than whites above goal to have been prescribed 4 or more antihypertensive drug classes (24.7% compared with 13.4%, P < .001); to have had medication adjusted during the prior year (46.7% compared with 40.4%, P = .02); and to have a documented provider response to high blood pressure during office visits (35.7% compared with 30.0% of visits, P = .02). Many blacks (28.0%) and whites (34.3%) with blood pressure above goal had fewer than 2 antihypertensive drug classes prescribed. CONCLUSION: In this population with Medicaid coverage and access to primary care, blacks were less likely than whites to have their blood pressure controlled. Blacks received more frequent intervention and had greater use of combination antihypertensive therapy. Care patterns observed in the usual management of high blood pressure were not sufficient to achieve treatment goals or eliminate disparities.

Geographic and sociodemographic disparities in drive times to Joint Commission-certified primary stroke centers in North Carolina, South Carolina, and Georgia.

INTRODUCTION: Timely access to facilities that provide acute stroke care is necessary to reduce disabilities and death from stroke. We examined geographic and sociodemographic disparities in drive times to Joint Commission-certified primary stroke centers (JCPSCs) and other hospitals with stroke care quality improvement initiatives in North Carolina, South Carolina, and Georgia. METHODS: We defined boundaries for 30- and 60-minute drive-time areas to JCPSCs and other hospitals  by  using geographic information systems (GIS) mapping technology and calculated the proportions of the population living in these drive-time areas by sociodemographic characteristics. Age-adjusted county-level stroke death rates were overlaid onto the drive-time areas. RESULTS: Approximately 55% of the population lived within a 30-minute drive time to a JCPSC; 77% lived within a 60-minute drive time. Disparities in percentage of the population within 30-minute drive times were found by race/ethnicity, education, income, and urban/rural status; the disparity was largest between urban areas (70% lived within 30-minute drive time) and rural areas (26%). The rural coastal plains had the largest concentration of counties with high stroke death rates and the fewest JCPSCs. CONCLUSION: Many areas in this tri-state region lack timely access to JCPSCs. Alternative strategies are needed to expand provision of quality acute stroke care in this region. GIS modeling is valuable for examining and strategically planning the distribution of hospitals providing acute stroke care.

Drive-time proximity to Joint Commission Primary Stroke Centers among North Carolina residents who died of stroke.

OBJECTIVE: In developing a statewide system of stroke care, understanding the relative availability of acute stroke care at designated centers for stroke care is essential. In this article, we compare the change in availability of acute stroke care in North Carolina at Joint Commission Primary Stroke Centers (JCPSCs) between 2006 and 2008 by examining the drive-time proximity of the residential address to the nearest JCPSC among people who died of stroke. METHODS: We assigned geographic coordinates to residential addresses of North Carolinians who died of stroke and to addresses of North Carolina JCPSCs. We calculated the distance within a 40-minute drive from each JCPSC and determined whether the residential addresses of patients who died of stroke were in the areas demarcated by the drive time. In a secondary analysis, we included non-ICPSCs that participate in recognized quality-improvement programs for stroke care. RESULTS: In 2006, 37% of geocodable residences of patients who died of stroke (3,834 of 10,469) were within a 40-minute drive from a JCPSC. By the end of 2008, this percentage increased to 56% (3,482 of 6,204). Inclusion of other hospitals that participate in recognized quality-improvement programs for acute stroke care increased the 40-minute drive-time coverage to 82% (5,095 of 6,204). LIMITATIONS: As an index of the geographic distribution of the stroke burden, we used deaths due to stroke, rather incident strokes. We included several assumptions in our drive-time calculation. CONCLUSIONS: For many regions of North Carolina in which the stroke burden is high, timely care at JCPSCs for acute stroke is unavailable. To develop a statewide system for acute stroke care in North Carolina, criteria beyond JCPSC certification should be considered for designating hospitals as centers for stroke care.

Predictors of time from hospital arrival to initial brain-imaging among suspected stroke patients: the North Carolina Collaborative Stroke Registry.

BACKGROUND AND PURPOSE: We examined patient demographic and hospital characteristics and clinical predictors of delay time from hospital arrival until CT among 20 374 patients enrolled in the North Carolina Collaborative Stroke Registry (January 2005 to April 2008). METHODS: Delay time was log-transformed in linear regression analyses and dichotomized (25 minutes) in logistic regression analyses to correspond to a 1999 National Institute of Neurological Disorders and Stroke guideline. RESULTS: In multiple linear regression analyses, prehospital delay time, mode of transport, race, gender, presumptive diagnosis, time of day of arrival, weekday versus weekend arrival, and hospital type (defined by Joint Commission Primary Stroke Center certification and teaching status) were significantly associated with CT delay. In analyses of 3549 patients arriving within 2 hours of symptom onset, time of day of arrival and weekday versus weekend arrival were no longer significant. Among patients arriving within 2 hours of symptom onset, the strongest independent predictors of meeting the National Institute of Neurological Disorders and Stroke (NINDS) guideline were arrival by emergency medical services versus other modes of transportation (odds ratio, 95% CI=2.3 [1.9, 2.8]) and a presumptive diagnosis of transient ischemic attack versus unspecified stroke type (odds ratio, 95% CI=0.4 [0.3, 0.5]). CONCLUSIONS: Most patients do not arrive to the hospital in a timely manner and cannot be considered for time-dependent therapies. Among those that do, disparities exist in time to receipt of CT scan, suggesting room for improvement in hospital-level stroke systems of care.

Workers' perceptions about worksite policies and environments and their association with leisure-time physical activity.

PURPOSE: To estimate the employed population's exposure to perceived worksite policies and environments hypothesized to promote physical activity and to determine their relationship to leisure-time physical activity. DESIGN: Cross-sectional, random-digit-dial telephone survey. SETTING: Community. SUBJECTS: Employed adults (n = 987) in six North Carolina counties. MEASURES: Outcomes included any leisure-time physical activity, recommended physical activity, and work-break physical activity. Perceived worksite policies and environments included on-site fitness facility at work, safe place to walk outside work, paid time for activity, subsidized health-club membership, and flexible work schedule. ANALYSIS: Descriptive statistics were used to describe the study population and exposure to perceived worksite policies and environments. Multivariable logistic regression was used to evaluate relationships between perceived worksite policies and environments and physical activity, controlling for age, race, sex, educational status, disability, and general health status. RESULTS: Various supportive worksite policies and environments were reported by 15% to 56% of employed participants. Associations between perceived worksite policies and environments and physical activity were strongest for having paid time for non-work-related physical activity, an on-site fitness facility at work, and subsidies for health clubs. Recommended activity was not associated with perceived worksite policies and environments. CONCLUSION: Worksite policies and environments are promising factors for future study in physical activity promotion. Studies should evaluate these relationships in other populations and explore measurement error in self-reported worksite policies and environments.

The relationship between leisure, walking, and transportation activity with the natural environment.

The purpose of this study was to quantify the agreement between perceived and objective measures of the natural environment and to assess their associations with physical activity. Perception of the natural environment was obtained through survey data. Objective measures of weather and hills were created using Geographic Information Systems (GIS). When objective measures were compared to respondent's perceptions little agreement was found. Objective measures were not associated with any physical activity outcomes; however, several associations were seen between perceived measures and physical activity. These results indicate that researchers should consider perceptions of the natural environment when developing physical activity interventions.

Evaluating change in physical activity with the building of a multi-use trail.

BACKGROUND: Cross-sectional studies suggest a positive association between the presence of trails and physical activity participation. Prospective evaluations of the impact of building a multi-use trail, in terms of change in physical activity levels among nearby residents, are needed. DESIGN: The study was designed as a quasi-experimental noncontrol pre-post design. SETTING/PARTICIPANTS: Participants included 366 adults aged > or =18 years living within 2 miles of the evaluated trail. INTERVENTION: A railway of >23 miles was under development for conversion to a multi-use trail in central North Carolina. A segment of the trail was evaluated by randomly selecting and telephone interviewing adults living within 2 miles of the planned trail before trail construction began and approximately 2 months after completion of construction. MAIN OUTCOME MEASURES: Outcomes were time spent in leisure activity, leisure activity near home, walking, bicycling, moderate activity, vigorous activity, and transportation activity. RESULTS: At follow-up, of the 366 adults living within 2 miles of the trail, 11.0% had not heard of the trail, and 23.1% had heard of the trail and had used it at least once. In multivariable logistic models, leisure activity, leisure activity near home, moderate activity, vigorous activity, and walking for transportation did not significantly change for those who used the trail compared to those not using the trail. CONCLUSIONS: This prospective study of the building of a multi-use trail did not demonstrate an increase in physical activity among adults living near the trail. Other prospective studies are encouraged, to take advantage of rigorously evaluating different types of trails that are to be constructed in rural and urban settings.

Statewide prevalence and correlates of walking and bicycling to school.

BACKGROUND: Travel to and from school can be an important and regular source of physical activity for youth. Few US studies have documented the prevalence and correlates of walking and bicycling to school. OBJECTIVE: To examine the prevalence and correlates of walking and bicycling to school among middle and high school youth. DESIGN: Cross-sectional survey. SETTING: Sixty middle schools and 62 high schools selected in North Carolina. PARTICIPANTS: Students in 6th through 8th grades (n = 2151) and in 9th through 12th grades (n = 2297) during the spring of 2001. MAIN OUTCOME MEASURES: Walking or bicycling to school in a usual week. RESULTS: Among middle school students, 9.4% usually walked to school and 4.1% usually bicycled to school at least 1 day per week. Among high school students, 4.9% usually walked to school and 2.8% usually bicycled to school at least 1 day per week. For middle school youth, walking or bicycling to school was more prevalent among boys and among nonwhites. For high school youth, walking or bicycling to school was also more prevalent among nonwhites. For middle school youth (but not high school youth), a higher body mass index (85th to less than 95th percentile) was associated with a reduced odds of walking to school. For high school youth (but not middle school youth), participating in physical education 1 to 4 days per week or never having an adult at home immediately after school was associated with walking or bicycling to school. Higher parental educational level was associated with a reduced odds of walking to school among high school youth. CONCLUSIONS: The descriptive information provided by this study broadens our limited understanding of the prevalence and correlates of walking and bicycling to school in the United States. Further qualitative and quantitative descriptive data are needed to develop successful interventions to increase walking and bicycling to school.

Change in the prevalence of leisure activity with the number of activities recalled.

PURPOSE: The purpose of this study was to examine how the estimated prevalence of leisure activity changed when respondents self-reported up to four activities, compared with using information only from the respondent's one, two, and three most commonly performed leisure activities. METHODS: Information on leisure activities, sociodemographics, and body mass index (BMI) categories was collected in the year 2000 during a telephone interview of 1813 randomly selected adults living in six North Carolina counties. Recommended activity was defined as moderate leisure activity > or =5x wk(-1) for > or =30 min per session or vigorous leisure activity > or =3x wk(-1) for > or =20 min per session. RESULTS: Among respondents, 32.1% reported participation in no leisure activity, 41.7% reported one activity, 21.5% reported two activities, 3.8% reported three activities, and 0.9% reported four activities during the past month. The largest change in prevalence occurred when using two activities compared with one activity for recommended activity, overall and by sociodemographic and BMI categories. The prevalence of recommended activity determined by using 1, 2, 3, or 4 activities was 21.0%, 26.0%, 26.5%, and 26.7%, respectively. CONCLUSION: In this study, collecting information on two leisure activities was the most efficient balance for population specific accuracy of recommended activity.

Neighborhood environment, access to places for activity, and leisure-time physical activity in a diverse North Carolina population.

PURPOSE: To examine associations between perceived neighborhood characteristics, access to places for activity, and leisure-time physical activity. DESIGN: Cross-sectional telephone survey. SETTING: Cabarrus, Henderson, Pitt, Robeson, Surry, and Wake counties in North Carolina. SUBJECTS: Population-based sample of 1796 adults at least 18 years of age residing in the six counties. MEASURES: The 133-item questionnaire assessed self-reported leisure-time physical activity and perceptions of neighborhood characteristics (sidewalks, trails, heavy traffic, streetlights, unattended dogs, and safety from crime) and general access to places for physical activity. RESULTS: Trails, streetlights, and access to places were positively associated with engaging in any leisure activity: unadjusted odds ratio (OR) (95% confidence interval [CI]); 1.62 (1.09-2.41), 1.57 (1.14-2.17), and 2.94 (1.91-4.52), respectively. Trails and access to places were positively associated with engaging in the recommended amount of leisure activity: 1.49 (1.00-2.22), and 2.28 (1.30-4.00), respectively). In multivariable logistic regression modeling including environmental factors and demographics, access to places was associated with any activity (2.23 [1.44-3.44]) and recommended activity (2.15 [1.23-3.77]), and trails were associated with recommended activity (1.51 [1.00-2.28]). CONCLUSION: Certain neighborhood characteristics, particularly trails, and access to places for physical activity may be associated with leisure activity levels. In this study, perceived neighborhood environmental factors and access to places for physical activity were strongly associated with race, education, and income.