Population-based study of risk factors for severe maternal morbidity.

BACKGROUND: Severe maternal morbidity (SMM) is a serious health condition potentially resulting in death without immediate medical attention, including organ failure, obstetric shock and eclampsia. SMM affects 20000 US women every year; however, few population-based studies have examined SMM risk factors. METHODS: We conducted a population-based case-control study linking birth certificate and hospital discharge data from Washington State (1987-2008), identifying 9485 women with an antepartum, intrapartum or postpartum SMM with ≥3-day hospitalisation or transfer from another facility and 41 112 random controls. Maternal age, race, smoking during pregnancy, parity, pre-existing medical condition, multiple birth, prior caesarean delivery, and body mass index were assessed as risk factors with logistic regression to estimate odds ratios (OR) and 95% confidence intervals [CI], adjusted for education and delivery payer source. RESULTS: Older women (35-39: OR 1.65 [CI 1.52, 1.79]; 40+: OR 2.48 [CI 2.16, 2.81]), non-White women (Black: OR 1.82 [CI 1.64, 2.01]; American Indian: OR 1.52 [CI 1.32, 1.73]; Asian/Pacific Islander: OR 1.30 [CI 1.19, 1.41]; Hispanic: OR 1.17 [CI 1.07, 1.27]) and women at parity extremes (nulliparous: OR 1.83 [CI 1.72, 1.95]; parity 3+: OR 1.34 [CI 1.23, 1.45]) were at greater risk of SMM. Women with a pre-existing medical condition (OR 2.10 [CI 1.88, 2.33]), a multiple birth (OR 2.54 [CI 2.26, 2.82]) and a prior caesarean delivery (OR 2.08 [CI 1.93, 2.23]) were also at increased risk. CONCLUSION: The risk factors identified are not modifiable at the individual level; therefore, provider and system-level factors may be the most appropriate target for preventing SMM.

Public health emergency preparedness and response communications with health care providers: a literature review.

BACKGROUND: Health care providers (HCPs) play an important role in public health emergency preparedness and response (PHEPR) so need to be aware of public health threats and emergencies. To inform HCPs, public health issues PHEPR messages that provide guidelines and updates, and facilitate surveillance so HCPs will recognize and control communicable diseases, prevent excess deaths and mitigate suffering. Public health agencies need to know that the PHEPR messages sent to HCPs reach their target audience and are effective and informative. Public health agencies need to know that the PHEPR messages sent to HCPs reach their target audience and are effective and informative. We conducted a literature review to investigate the systems and tools used by public health to generate PHEPR communications to HCPs, and to identify specific characteristics of message delivery mechanisms and formats that may be associated with effective PHEPR communications. METHODS: A systematic review of peer- and non-peer-reviewed literature focused on the following questions: 1) What public health systems exist for communicating PHEPR messages from public health agencies to HCPs? 2) Have these systems been evaluated and, if yes, what criteria were used to evaluate these systems? 3) What have these evaluations discovered about characterizations of the most effective ways for public health agencies to communicate PHEPR messages to HCPs? RESULTS: We identified 25 systems or tools for communicating PHEPR messages from public health agencies to HCPs. Few articles assessed PHEPR communication systems or messaging methods or outcomes. Only one study compared the effectiveness of the delivery format, device or message itself. We also discovered that the potential is high for HCPs to experience "message overload" given redundancy of PHEPR messaging in multiple formats and/or through different delivery systems. CONCLUSIONS: We found that detailed descriptions of PHEPR messaging from public health to HCPs are scarce in the literature and, even when available are rarely evaluated in any systematic fashion. To meet present-day and future information needs for emergency preparedness, more attention needs to be given to evaluating the effectiveness of these systems in a scientifically rigorous manner.

Impact of the Hepatitis Testing and Linkage to Care (HepTLC) Initiative on Linkage to Care for Minnesota Refugees with Hepatitis B, 2012-2014.

OBJECTIVE: The Hepatitis Testing and Linkage to Care (HepTLC) initiative promoted viral hepatitis B and hepatitis C screening, posttest counseling, and linkage to care at 34 U.S. sites from 2012 to 2014. Through the HepTLC initiative, the Minnesota Department of Health (MDH) and clinic partners began conducting linkage-to-care activities with hepatitis B-positive refugees in October 2012. This intervention provided culturally appropriate support to link refugees to follow-up care for hepatitis B. METHODS: MDH refugee health and viral hepatitis surveillance programs, along with clinics that screened newly arrived refugees in Hennepin and Ramsey counties in Minnesota, collaborated on the project, which took place from October 1, 2012, through September 30, 2014. Bilingual care navigators contacted refugees to provide education, make appointments, and arrange transportation. We compared the linkage-to-care rate for participants with the rates for refugees screened the year before project launch using a two-sample test of proportions. RESULTS: In the year preceding the project (October 2011 through September 2012), 87 newly arrived refugees had a positive hepatitis B surface antigen (HBsAg) test. Fifty-six (64%) refugees received follow-up care, 12 (14%) refugees did not receive follow-up care, and 19 (22%) refugees could not be located and had no record of follow-up care. During the project, 174 HBsAg-positive, newly arrived refugees were screened. Of those 174 refugees, 162 (93%) received follow-up care, seven (4%) did not receive follow-up care, and five (3%) could not be located and had no record of follow-up care. The one-year linkage-to-care rate for project participants (93%) was significantly higher than the rate for refugees screened the previous year (64%) (p<0.001). CONCLUSION: In the context of a strong screening and surveillance infrastructure, a simple intervention improved the linkage-to-care rate for HBsAg-positive refugees.

Measles transmission during air travel, United States, December 1, 2008-December 31, 2011.

BACKGROUND: Flight-related measles contact investigations in the United States are coordinated by the Centers for Disease Control and Prevention (CDC). To evaluate the efficiency of CDC's measles protocol, we analyzed data from contact investigations conducted December 2008-December 2011. METHODS: Cases were defined as travelers diagnosed with measles that were infectious at the time of the flight. Passengers seated within 2 rows of the case-traveler and all babies-in-arms were defined as contacts. Contact information obtained from airlines was distributed to US health departments; reporting of outcomes was requested. We cross-referenced the National Notifiable Diseases Surveillance System and CDC's National Center for Immunization and Respiratory Diseases to identify unreported cases in passenger-contacts and in passengers not identified as contacts. RESULTS: Our evaluation included 74 case-travelers on 108 flights. Information for 2673 (79%) of 3399 passenger-contacts was provided to health departments; 9 cases of secondary measles were reported. No additional cases were identified. CONCLUSION: Our evaluation provided evidence of measles transmission related to air travel. CDC's protocol efficiently identifies passengers most at risk of exposure and infection for flights into and within the United States.

No evidence of mumps transmission during air travel, United States, November 1, 2006-October 31, 2010.

Since November 2006, flight-related mumps contact investigations were conducted in the United States only for flights ≥5 h long after an investigation showed minimal risk of mumps transmission on flights <5 h. Because the transmission risk on longer flights had not been evaluated, we investigated whether there was evidence to support the guidelines. We examined data from mumps contact investigations that were initiated by the US Centers for Disease Control and Prevention (CDC) from November 2006 to October 2010. We also cross-referenced passenger-contact data with data on mumps cases in the National Notifiable Diseases Surveillance System (NNDSS). Twenty-seven cases met inclusion criteria. Of 246 passengers identified as contacts, 166 (67%) were distributed to a US health department for contact tracing. Outcomes were reported for 21 (13%) of those 166 passengers. No secondary cases of mumps among passenger contacts were reported or identified by cross-referencing NNDSS data. The findings suggested that in-flight risk of mumps transmission is not high. Furthermore, these investigations have low yield, are resource intensive, there is no post-exposure prophylaxis, and mumps transmission has not been eliminated in the United States. Therefore, CDC discontinued conducting flight-related mumps contact investigations in May 2011.

HIV/AIDS and associated conditions among HIV-infected refugees in Minnesota, 2000­2007.

In 2010, the requirement for human immunodeficiency virus (HIV) testing of adult refugees prior to US resettlement was removed, thus leading to a potential for missed diagnosis. We reviewed refugee health assessment data and medical charts to evaluate the health status of HIV-infected refugees who arrived in Minnesota during 2000-2007, prior to this 2010 policy change. Among 19,292 resettled adults, 174 were HIV-infected; 169 (97%) were African (median age 26.4 (range: 17-76) years). Charts were abstracted for 157 (124 (79%) with ≥ 1 year of follow-up). At initial presentation, two of 74 (3%) women were pregnant; 27% became pregnant during follow-up. HIV clinical stage varied (59%, asymptomatic; 11%, mild symptoms; 10%, advanced symptoms; 3%, severe symptoms; 17%, unknown); coinfections were common (51 tuberculosis, 13 hepatitis B, 13 parasites, four syphilis). Prior to arrival 4% had received antiretrovirals. Opportunistic infections were diagnosed among 13%; 2% died from AIDS-related causes. Arrival screening may be needed to identify these HIV-infected refugees and prevent HIV-related morbidity and mortality.

Preterm Delivery Risk in Relation to Maternal Occupational and Leisure Time Physical Activity Among Thai Women.

BACKGROUND: Little is known about the relationship between maternal occupational physical exertion and leisure time physical activity (LTPA) with preterm delivery (PTD) among Thai women, a population that differs in many respects from women in Western countries. OBJECTIVES: To evaluate associations of maternal occupational physical exertion and LTPA with PTD in aggregate and in subgroups (i.e., spontaneous preterm labor, preterm premature rupture of membrane, medically indicated preterm delivery, moderate preterm delivery [gestational age 32-36 weeks], and very preterm delivery [<32 weeks]) among Thai women. METHODS: This case-control study included 467 PTD cases and 467 term controls. Maternal occupational exertion during pregnancy, as well as habitual engagement in LTPA before and during pregnancy was assessed using a structured questionnaire administered after delivery. Logistic regression procedures were used to examine relationships between both occupational and leisure time physical activity and PTD. RESULTS: After controlling for potential confounders, women who reported heavy physical occupational exertion during pregnancy, compared with other women, had a 2.42-fold increased risk of PTD overall [OR=2.42, 95% CI: 1.15, 5.09]. Very PTD [OR=4.57, 95% CI: 1.65, 12.64] and medically indicated PTD [OR=3.79, 95% CI: 1.54, 9.32] were particularly strongly associated with heavy occupational exertion. Maternal participation in LTPA before pregnancy was associated with a 24% reduction in PTD risk overall [OR=0.76, 95% CI: 0.57, 1.00], though no similar pattern in risk reduction was observed for LTPA performed during the first 6 months of pregnancy [OR=0.96, 95% CI: 0.68, 1.36]. CONCLUSION: Consistent with some previous reports, we noted that heavy occupational physical exertion is associated with at least a doubling in PTD risk. Patterns of associations of PTD risk with LTPA were less well delineated in this Thai population.