Racial and ethnic disparities in infant mortality: risk in social context.

This article presents the multifaceted efforts of Syracuse Healthy Start, a federally funded initiative of the Onondaga County Health Department and over 20 partnering agencies to reduce racial and ethnic disparities in infant mortality. The analyses presented in this article demonstrate that many women--Caucasian, African American, and Hispanic--have serious risks for low birth weight and infant death. In many cases, multiple, simultaneous risks complicate a pregnant woman's situation and in other cases the longitudinal cumulative risks impact health across generations. Infant mortality decreased overall, and for both Caucasian and African American infants during the first 3 years of the project.

Developing the Guide to Community Preventive Services--overview and rationale. The Task Force on Community Preventive Services.

When the GUIDE TO COMMUNITY PREVENTIVE SERVICES: Systematic Reviews and Evidence-Based Recommendations (the Guide) is published in 2001, it will represent a significant national effort in encouraging evidence-based public health practice in defined populations (e.g., communities or members of specific managed care plans). The Guide will make recommendations regarding public health interventions to reduce illness, disability, premature death, and environmental hazards that impair community health and quality of life. The Guide is being developed under the guidance of the Task Force on Community Preventive Services (the Task Force)-a 15-member, nonfederal, independent panel of experts. Subject matter experts, methodologists, and scientific staff are supporting the Task Force in using explicit rules to conduct systematic literature reviews of evidence of effectiveness, economic efficiency, and feasibility on which to base recommendations for community action. Contributors to the Guide are building on the experience of others to confront methodologic challenges unique to the assessment of complex multicomponent intervention studies with nonexperimental or nonrandomized designs and diverse measures of outcome and effectiveness. Persons who plan, fund, and implement population-based services and policies to improve health at the state and local levels are invited to scrutinize the work in progress and to communicate with contributors. When the Guide is complete, readers are encouraged to consider critically the value and relevance of its contents, the implementation of interventions the Task Force recommends, the abandonment of interventions the Task Force does not recommend, and the need for rigorous evaluation of the benefits and harms of promising interventions of unknown effectiveness.

Analysis of Mycobacterium tuberculosis transmission patterns in a homeless shelter outbreak.

SETTING: From July 1997 through May 1998, ten tuberculosis (TB) cases were reported among men in a Syracuse New York homeless shelter for men. OBJECTIVE AND DESIGN: Investigation to determine extent of, and prevent further, transmission of Mycobacterium tuberculosis. RESULTS: Epidemiologic and laboratory evidence suggests that eight of the ten cases were related. Seven cases had isolates with matching six-band IS6110 DNA fingerprints; the isolate from another case had a closely related fingerprint pattern and this case was considered to be caused by a variant of the same strain. Isolates from eight cases had identical spoligotypes. The source case had extensive cavitary disease and stayed at the shelter nightly, while symptomatic, for almost 8 months before diagnosis. A contact investigation was conducted among 257 shelter users and staff, 70% of whom had a positive tuberculin skin test, including 21 with documented skin test conversions. CONCLUSIONS: An outbreak of related TB cases in a high-risk setting was confirmed through the use of IS6110 DNA fingerprinting in conjunction with spoligotyping and epidemiologic evidence. Because of the high rate of infection in the homeless population, routine screening for TB and preventive therapy for eligible persons should be considered in shelters.

Tracking sexual contacts of HIV patients: a study of physician practices.

Notification of sexual partners of HIV-infected individuals has become a focus of debate at local, state, and national levels. Issues of confidentiality and ethical concerns continue to pose challenges to state and local health departments addressing this issue. We conducted a telephone survey with physicians in Syracuse, New York to ascertain opinions about HIV partner notification and the role of public health agencies in that notification process. In general, physicians mostly relied upon the HIV-infected individuals to notify their own partners but were supportive of enhanced efforts regarding partner notification.

Tuberculosis control in New York City hospitals.

OBJECTIVES: To assess the implementation of tuberculosis (TB) control measures in New York City hospitals in 1992 and determine trends during the subsequent 2 years. METHODS: The 22 acute care facilities with the largest number of hospitalized TB patients in 1991 were selected for inclusion in the study. Medical and laboratory records of the 10 most recent acid fast bacilli (AFB) smear-positive patients in each of the selected facilities in 1992, 1993, and 1994 were reviewed by using a standardized questionnaire to determine risk factors for TB, previous history of TB, clinical signs and symptoms, AFB laboratory turnaround times, emergency department contact, timing of isolation, timing of treatment, case reporting, and status on discharge. The patients' rooms were evaluated for TB environmental control measures if the patient was still on respiratory isolation precautions. RESULTS: More than one third of patients were admitted with a previous history of TB, 31% were admitted with a cavitary lesion on chest x-ray examination, and 48% were known to have HIV infection. Eighty-five percent were admitted from the emergency department where they stayed for up to 116 hours (mean stay: 17 hours). The proportion of patients placed in AFB isolation on admission to the floor increased from 75% in 1992 to 84% in 1994. The proportion of patients given a minimum of four anti-TB drugs increased from 88% in 1992 to 94% in 1994. Patients "on isolation" were sharing rooms with up to nine other patients in 1992, whereas no patients were sharing rooms in the 1994 survey. In 1992, 51% of the rooms were under negative air flow with respect to the corridor. During the 1994 survey, 80% of rooms were under negative air flow. Between 1992 and 1994, the proportion of AFB isolation rooms with dust/mist respirators increased from 28% to 76% (p < 0.00001). Approximately 25% of discharged patients left against medical advice (no trend over time). The proportion of medically discharged patients with three negative AFB smears before discharge increased from 26% to 48% (p = 0.03) and the proportion referred for directly observed therapy increased from 15% to 53% (p = 0.00001). CONCLUSION: TB control efforts in New York City hospitals improved dramatically between 1992 and 1994. The ultimate control of TB will continue to depend on the coordinated efforts within and between health care facilities, providers, and the community.

False positive tuberculosis skin test results.

The re-emergence of tuberculosis as a significant public health threat has led to greatly renewed activity in tuberculin skin testing to identify infected persons. However, even use of the preferred skin test technique (intradermal injection of purified protein derivative via the Mantoux method) can lead to either false positive or false negative results. Interpretation of a Mantoux test can be influenced by cross reactions with other mycobacteria, intertester variation, host-response variation, and product related problems. At least 25 apparent false positive purified protein derivative skin test reactions in New York State in 1992 appeared to be associated with lots of the derivative produced by one manufacturer. These unexpected skin test results led to examination of a product with an altered appearance that may have caused the unanticipated responses. After announcement of these false positive results to the press, the company removed the product from the market. Food and Drug Administration analysis later revealed particulate matter in vials of the suspected lots of purified protein derivative.

The development of integrated public health information systems: a statement by the Joint Council of Governmental Public Health Agencies.

To truly enjoy the benefits of the information age, public health agencies at each level of government must work together to plan and implement integrated information systems that meet the needs of our dynamic profession. The Joint Council of Governmental Public Health Agencies, comprised of state and local health officials, has worked to identify the solutions to public health's information needs. Investments in integrated systems that support service delivery to clients will improve program management and enhance accountability for public funds. The ability to produce good, client-centered data will be essential as the nation's health and welfare systems change.