Failure to Complete Multidose Vaccine Series in Early Childhood.

BACKGROUND: Most early childhood immunizations require 3 to 4 doses to achieve optimal protection. Our objective was to identify factors associated with starting but not completing multidose vaccine series. METHODS: Using 2019 National Immunization Survey-Child data, US children ages 19 to 35 months were classified in 1 of 3 vaccination patterns: (1) completed the combined 7-vaccine series, (2) did not initiate ≥1 of the 7 vaccine series, or (3) initiated all series, but did not complete ≥1 multidose series. Associations between sociodemographic factors and vaccination pattern were evaluated using multivariable log-linked binomial regression. Analyses accounted for the survey's stratified design and complex weighting. RESULTS: Among 16 365 children, 72.9% completed the combined 7-vaccine series, 9.9% did not initiate ≥1 series, and 17.2% initiated, but did not complete ≥1 multidose series. Approximately 8.4% of children needed only 1 additional vaccine dose from 1 of the 5 multidose series to complete the combined 7-vaccine series. The strongest associations with starting but not completing multidose vaccine series were moving across state lines (adjusted prevalence ratio [aPR] = 1.45, 95% confidence interval [CI]: 1.18-1.79), number of children in the household (2 to 3: aPR = 1.29, 95% CI: 1.05-1.58; 4 or more: aPR = 1.68, 95% CI: 1.30-2.18), and lack of insurance coverage (aPR = 2.03, 95% CI: 1.42-2.91). CONCLUSIONS: More than 1 in 6 US children initiated but did not complete all doses in multidose vaccine series, suggesting children experienced structural barriers to vaccination. Increased focus on strategies to encourage multidose series completion is needed to optimize protection from preventable diseases and achieve vaccination coverage goals.

Trends in disparities in COVID hospitalizations among community-dwelling residents of two counties in Connecticut, before and after vaccine introduction, March 2020-September 2021.

BACKGROUND: Prior to the introduction of vaccines, COVID-19 hospitalizations of non-institutionalized persons in Connecticut disproportionately affected communities of color and individuals of low socioeconomic status (SES). Whether the magnitude of these disparities changed 7-9 months after vaccine rollout during the Delta wave is not well documented. METHODS: All initially hospitalized patients with laboratory-confirmed COVID-19 during July-September 2021 were obtained from the Connecticut COVID-19-Associated Hospitalization Surveillance Network database, including patients' geocoded residential addresses. Census tract measures of poverty and crowding were determined by linking geocoded residential addresses to the 2014-2018 American Community Survey. Age-adjusted incidence and relative rates of COVID-19 hospitalization were calculated and compared with those from July to December 2020. Vaccination levels by age and race/ethnicity at the beginning and end of the study period were obtained from Connecticut's COVID vaccine registry, and age-adjusted average values were determined. RESULTS: There were 708 COVID-19 hospitalizations among community residents of the two counties, July-September 2021. Age-adjusted incidence was the highest among non-Hispanic Blacks and Hispanic/Latinx compared with non-Hispanic Whites (RR 4.10 [95% CI 3.41-4.94] and 3.47 [95% CI 2.89-4.16]). Although RR decreased significantly among Hispanic/Latinx and among the lowest SES groups, it increased among non-Hispanic Blacks (from RR 3.2 [95% CI 2.83-3.32] to RR 4.10). Average age-adjusted vaccination rates among those ≥12 years were the lowest among non-Hispanic Blacks compared with Hispanic/Latinx and non-Hispanic Whites (50.6% vs. 64.7% and 66.6%). CONCLUSIONS: Although racial/ethnic and SES disparities in COVID-19 hospitalization have mostly decreased over time, disparities among non-Hispanic Blacks increased, possibly due to differences in vaccination rates.

Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Outbreak at a College With High Coronavirus Disease 2019 (COVID-19) Vaccination Coverage-Connecticut, August 2021-September 2021.

BACKGROUND: During August 2021-September 2021, a Connecticut college experienced a severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) Delta variant outbreak despite high (99%) vaccination coverage, indoor masking policies, and twice-weekly testing. The Connecticut Department of Public Health investigated characteristics associated with infection and phylogenetic relationships among cases. METHODS: A case was a SARS-CoV-2 infection diagnosed by a viral test during August 2021-September 2021 in a student. College staff provided enrollment and case information. An anonymous online student survey collected demographics, SARS-CoV-2 case and vaccination history, and activities preceding the outbreak. Multivariate logistic regression identified characteristics associated with infection. Phylogenetic analyses compared 115 student viral genome sequences with contemporaneous community genomes. RESULTS: Overall, 199 of 1788 students (11%) had laboratory-confirmed SARS-CoV-2 infection; most were fully vaccinated (194 of 199, 97%). Attack rates were highest among sophomores (72 of 414, 17%) and unvaccinated students (5 of 18, 28%). Attending in-person classes with an infectious student was not associated with infection (adjusted odds ratio [aOR], 1.0; 95% confidence interval [CI], .5-2.2). Compared with uninfected students, infected students were more likely to be sophomores (aOR, 3.3; 95% CI, 1.1-10.7), attend social gatherings before the outbreak (aOR, 2.8; 95% CI, 1.3-6.4), and complete a vaccine series ≥180 days prior (aOR, 5.5; 95% CI, 1.8-16.2). Phylogenetic analyses suggested a common viral source for most cases. CONCLUSIONS: SARS-CoV-2 infection in this highly vaccinated college population was associated with unmasked off-campus social gatherings, not in-person classes. Students should stay up to date on vaccination to reduce infection.

Persistence of racial/ethnic and socioeconomic status disparities among non-institutionalized patients hospitalized with COVID-19 in Connecticut, July to December 2020.

BACKGROUND: COVID-19 hospitalizations of non-institutionalized persons during the first COVID-19 wave in Connecticut disproportionately affected the elderly, communities of color, and individuals of low socioeconomic status (SES). Whether the magnitude of these disparities changed after the initial lockdown and before vaccine rollout is not well documented. METHODS: All first-time hospitalizations with laboratory-confirmed COVID-19 during July to December 2020, including patients' geocoded residential addresses, were obtained from the Connecticut Department of Public Health. Those living in congregate settings, including nursing homes, were excluded. Community-dwelling patients were assigned census tract-level poverty and crowding measures from the 2014-2018 American Community Survey by linking their geocoded addresses to census tracts. Age-adjusted incidence and relative rates were calculated across demographic and SES measures and compared with those from a similar analysis of hospitalized cases during the initial wave. RESULTS: During July to December 2020, there were 5652 COVID-19 hospitalizations in community residents in Connecticut. Incidence was highest among those >85 years, non-Hispanic Blacks and Hispanic/Latinx compared with non-Hispanic Whites {relative rate (RR) 3.1 (95% confidence interval [CI] 2.83-3.32) and 5.9 (95% CI 5.58-6.28)}, and persons living in high poverty and high crowding census tracts. Although racial/ethnic and SES disparities during the study period were substantial, they were significantly decreased compared with the first wave of COVID-19. CONCLUSIONS: The finding of persistent, if reduced, large racial/ethnic disparities in COVID-19 hospitalizations 2-7 months after the initial lockdown was relaxed and before vaccination was widely available is of concern. These disparities cause a challenge to achieving health equity and are relevant for future pandemic planning.

Census tract socioeconomic indicators and COVID-19-associated hospitalization rates-COVID-NET surveillance areas in 14 states, March 1-April 30, 2020.

OBJECTIVES: Some studies suggested more COVID-19-associated hospitalizations among racial and ethnic minorities. To inform public health practice, the COVID-19-associated Hospitalization Surveillance Network (COVID-NET) quantified associations between race/ethnicity, census tract socioeconomic indicators, and COVID-19-associated hospitalization rates. METHODS: Using data from COVID-NET population-based surveillance reported during March 1-April 30, 2020 along with socioeconomic and denominator data from the US Census Bureau, we calculated COVID-19-associated hospitalization rates by racial/ethnic and census tract-level socioeconomic strata. RESULTS: Among 16,000 COVID-19-associated hospitalizations, 34.8% occurred among non-Hispanic White (White) persons, 36.3% among non-Hispanic Black (Black) persons, and 18.2% among Hispanic or Latino (Hispanic) persons. Age-adjusted COVID-19-associated hospitalization rate were 151.6 (95% Confidence Interval (CI): 147.1-156.1) in census tracts with >15.2%-83.2% of persons living below the federal poverty level (high-poverty census tracts) and 75.5 (95% CI: 72.9-78.1) in census tracts with 0%-4.9% of persons living below the federal poverty level (low-poverty census tracts). Among White, Black, and Hispanic persons living in high-poverty census tracts, age-adjusted hospitalization rates were 120.3 (95% CI: 112.3-128.2), 252.2 (95% CI: 241.4-263.0), and 341.1 (95% CI: 317.3-365.0), respectively, compared with 58.2 (95% CI: 55.4-61.1), 304.0 (95%: 282.4-325.6), and 540.3 (95% CI: 477.0-603.6), respectively, in low-poverty census tracts. CONCLUSIONS: Overall, COVID-19-associated hospitalization rates were highest in high-poverty census tracts, but rates among Black and Hispanic persons were high regardless of poverty level. Public health practitioners must ensure mitigation measures and vaccination campaigns address needs of racial/ethnic minority groups and people living in high-poverty census tracts.

Multiple Transmission Chains within COVID-19 Cluster, Connecticut, USA, 20201.

In fall 2020, a coronavirus disease cluster comprising 16 cases occurred in Connecticut, USA. Epidemiologic and genomic evidence supported transmission among persons at a school and fitness center but not a workplace. The multiple transmission chains identified within this cluster highlight the necessity of a combined investigatory approach.

Deaths, Hospitalizations, and Emergency Department Visits From Food-Related Anaphylaxis, New York City, 2000-2014: Implications for Fatality Prevention.

CONTEXT: Food-induced anaphylaxis is potentially fatal but preventable by allergen avoidance and manageable through immediate treatment. Considerable effort has been invested in preventing fatalities from nut exposure among school-aged children, but few population-based studies exist to guide additional prevention efforts. OBJECTIVES: To describe the epidemiology and trends of food-related anaphylaxis requiring emergency treatment during a 15-year span in New York City when public health initiatives to prevent deaths were implemented and to understand the situational circumstances of food-related deaths. DESIGN/SETTING/PARTICIPANTS: Retrospective death record review and analysis of inpatient hospital discharges and emergency department (ED) visits in New York City residents, 2000-2014. MAIN OUTCOME: Vital statistics data, medical examiner reports, ED, and hospital discharge data were used to examine risk for death and incidence trends in medically attended food-related anaphylaxis. Potentially preventable deaths were those among persons with a known allergy to the implicated food or occurring in public settings. RESULTS: There were 24 deaths, (1.6 deaths/year; range: 0-5), 3049 hospitalizations, and 4014 ED visits, including 7 deaths from crustacean, 4 from peanut, and 2 each from tree nut or seeds and fish exposures. Risk for death among those hospitalized or treated in the ED was highest for persons older than 65 years and for those treated for crustacean reactions (relative risk 6.5 compared with those treated for peanuts, 95% confidence interval = 1.9-22.1). Eleven of 16 deaths with medical examiner data were potentially preventable. Hospitalizations (2000-2014) and ED visit rates (2005-2014) were highest for children and those with peanut exposure and increased across periods. CONCLUSIONS: Deaths from food-related anaphylaxis were rare; however, rates of hospitalization and ED visits increased. Prevention efforts related to peanut allergies among children should continue, and additional attention is needed to prevent and treat anaphylaxis among adults, particularly those with known crustacean allergies where case fatality is highest.

Relationship Between Census Tract-Level Poverty and Domestically Acquired Salmonella Incidence: Analysis of Foodborne Diseases Active Surveillance Network Data, 2010-2016.

BACKGROUND: The relationships between socioeconomic status and domestically acquired salmonellosis and leading Salmonella serotypes are poorly understood. METHODS: We analyzed surveillance data from laboratory-confirmed cases of salmonellosis from 2010-2016 for all 10 Foodborne Disease Active Surveillance Network (FoodNet) sites, having a catchment population of 47.9 million. Case residential data were geocoded, linked to census tract poverty level, and then categorized into 4 groups according to census tract poverty level. After excluding those reporting international travel before illness onset, age-specific and age-adjusted salmonellosis incidence rates were calculated for each census tract poverty level, overall and for each of the 10 leading serotypes. RESULTS: Of 52 821geocodable Salmonella infections (>96%), 48 111 (91.1%) were domestically acquired. Higher age-adjusted incidence occurred with higher census tract poverty level (P < .001; relative risk for highest [≥20%] vs lowest [<5%] census tract poverty level, 1.37). Children <5 years old had the highest relative risk (2.07). Although this relationship was consistent by race/ethnicity and by serotype, it was not present in 5 FoodNet sites or among those aged 18-49 years. CONCLUSION: Children and older adults living in higher-poverty census tracts have had a higher incidence of domestically acquired salmonellosis. There is a need to understand socioeconomic status differences for risk factors for domestically acquired salmonellosis by age group and FoodNet site to help focus prevention efforts.

The Relationship Between Census Tract Poverty and Shiga Toxin-Producing E. coli Risk, Analysis of FoodNet Data, 2010-2014.

BACKGROUND: The relationship between socioeconomic status and Shiga toxin-producing Escherichia coli (STEC) is not well understood. However, recent studies in Connecticut and New York City found that as census tract poverty (CTP) decreased, rates of STEC increased. To explore this nationally, we analyzed surveillance data from laboratory-confirmed cases of STEC from 2010-2014 for all Foodborne Disease Active Surveillance Network (FoodNet) sites, population 47.9 million. METHODS: Case residential data were geocoded and linked to CTP level (2010-2014 American Community Survey). Relative rates were calculated comparing incidence in census tracts with <20% of residents below poverty with those with ≥20%. Relative rates of age-adjusted 5-year incidence per 100 000 population were determined for all STEC, hospitalized only and hemolytic-uremic syndrome (HUS) cases overall, by demographic features, FoodNet site, and surveillance year. RESULTS: There were 5234 cases of STEC; 26.3% were hospitalized, and 5.9% had HUS. Five-year incidence was 10.9/100 000 population. Relative STEC rates for the <20% compared with the ≥20% CTP group were >1.0 for each age group, FoodNet site, surveillance year, and race/ethnic group except Asian. Relative hospitalization and HUS rates tended to be higher than their respective STEC relative rates. CONCLUSIONS: Persons living in lower CTP were at higher risk of STEC than those in the highest poverty census tracts. This is unlikely to be due to health care-seeking or diagnostic bias as it applies to analysis limited to hospitalized and HUS cases. Research is needed to better understand exposure differences between people living in the lower vs highest poverty-level census tracts to help direct prevention efforts.

Mortality among rescue and recovery workers and community members exposed to the September 11, 2001 World Trade Center terrorist attacks, 2003-2014.

BACKGROUND: Multiple chronic health conditions have been associated with exposure to the September 11, 2001 World Trade Center (WTC) terrorist attacks (9/11). We assessed whether excess deaths occurred during 2003-2014 among persons directly exposed to 9/11, and examined associations of 9/11-related exposures with mortality risk. MATERIALS AND METHODS: Deaths occurring in 2003-2014 among members of the World Trade Center Health Registry, a cohort of rescue/recovery workers and lower Manhattan community members who were exposed to 9/11, were identified via linkage to the National Death Index. Participants' overall levels of 9/11-related exposure were categorized as high, intermediate, or low. We calculated standardized mortality ratios (SMR) using New York City reference rates from 2003 to 2012. Proportional hazards were used to assess associations of 9/11-related exposures with mortality, accounting for age, sex, race/ethnicity and other potential confounders. RESULTS: We identified 877 deaths among 29,280 rescue/recovery workers (3.0%) and 1694 deaths among 39,643 community members (4.3%) during 308,340 and 416,448 person-years of observation, respectively. The SMR for all causes of death was 0.69 [95% confidence interval (CI) 0.65-0.74] for rescue/recovery workers and 0.86 (95% CI 0.82-0.90) for community members. SMRs for diseases of the cardiovascular and respiratory systems were significantly lower than expected in both groups. SMRs for several other causes of death were significantly elevated, including suicide among rescue recovery workers (SMR 1.82, 95% CI 1.35-2.39), and brain malignancies (SMR 2.25, 95% CI 1.48-3.28) and non-Hodgkin's lymphoma (SMR 1.79, 95% CI 1.24-2.50) among community members. Compared to low exposure, both intermediate [adjusted hazard ratio (AHR) 1.36, 95% CI 1.10-1.67] and high (AHR 1.41, 95% CI 1.06-1.88) levels of 9/11-related exposure were significantly associated with all-cause mortality among rescue/recovery workers (p-value for trend 0.01). For community members, intermediate (AHR 1.13, 95% CI 1.01-1.27), but not high (AHR 1.14, 95% CI 0.94-1.39) exposure was significantly associated with all-cause mortality (p-value for trend 0.03). AHRs for associations of overall 9/11-related exposure with heart disease- and cancer-related mortality were similar in magnitude to those for all-cause mortality, but with 95% CIs crossing the null value. CONCLUSIONS: Overall mortality was not elevated. Among specific causes of death that were significantly elevated, suicide among rescue/recovery workers is a plausible long-term consequence of 9/11 exposure, and is potentially preventable. Elevated mortality due to other causes, including non-Hodgkin's lymphoma and brain cancer, and small but statistically significant associations of 9/11-related exposures with all-cause mortality hazard warrant additional surveillance.

Impact of pregnancy on observed sex disparities among adults hospitalized with laboratory-confirmed influenza, FluSurv-NET, 2010-2012.

INTRODUCTION: Previous FluSurv-NET studies found that adult females had a higher incidence of influenza-associated hospitalizations than males. To identify groups of women at higher risk than men, we analyzed data from 14 FluSurv-NET sites that conducted population-based surveillance for laboratory-confirmed influenza-associated hospitalizations among residents of 78 US counties. METHODS: We analyzed 6292 laboratory-confirmed, geocodable (96%) adult cases collected by FluSurv-NET during the 2010-12 influenza seasons. We used 2010 US Census and 2008-2012 American Community Survey data to calculate overall age-adjusted and age group-specific female:male incidence rate ratios (IRR) by race/ethnicity and census tract-level poverty. We used national 2010 pregnancy rates to estimate denominators for pregnant women aged 18-49. We calculated male:female IRRs excluding them and IRRs for pregnant:non-pregnant women. RESULTS: Overall, 55% of laboratory-confirmed influenza cases were female. Female:male IRRs were highest for females aged 18-49 of high neighborhood poverty (IRR 1.50, 95% CI 1.30-1.74) and of Hispanic ethnicity (IRR 1.70, 95% CI 1.34-2.17). These differences disappeared after excluding pregnant women. Overall, 26% of 1083 hospitalized females aged 18-49 were pregnant. Pregnant adult females were more likely to have influenza-associated hospitalizations than their non-pregnant counterparts (relative risk [RR] 5.86, 95% CI 5.12-6.71), but vaccination levels were similar (25.5% vs 27.8%). CONCLUSIONS: Overall rates of influenza-associated hospitalization were not significantly different for men and women after excluding pregnant women. Among women aged 18-49, pregnancy increased the risk of influenza-associated hospitalization sixfold but did not increase the likelihood of vaccination. Improving vaccination rates in pregnant women should be an influenza vaccination priority.

Declines in Human Papillomavirus (HPV)-Associated High-Grade Cervical Lesions After Introduction of HPV Vaccines in Connecticut, United States, 2008-2015.

BACKGROUND: Trends in human papillomavirus (HPV)-associated cervical lesions can provide an indication of vaccine impact. Our purpose was to measure trends in cervical lesions during 2008-2015 and to consider possible explanations including vaccination coverage, changes in screening for cervical cancer, and risk behaviors for acquiring HPV. METHODS: Connecticut (CT) implemented mandatory reporting of cervical intraepithelial neoplasia grades 2/3 and adenocarcinoma in situ (cervical intraepithelial neoplasia grade 2 or higher [CIN2+]) in 2008. Trends by age and birth cohort were modeled using negative binomial regression and change-point methods. To evaluate possible explanations for changes, these trends were compared to changes in HPV vaccination coverage, cervical cancer screening, an antecedent event to detection of a high-grade lesion, and changes in sexual behaviors and Chlamydia trachomatis, an infection with similar epidemiology to and shared risk factors for HPV. RESULTS: A significant decline in CIN2+ was first evident among women aged 21 years in 2010, followed by successive declines in women aged 22-26 years during 2011-2012. During 2008-2015, the rates of CIN2+ declined by 30%-74% among women aged 21-26 years, with greater declines observed in the younger women. Birth cohorts between 1985 and 1994 all experienced significant declines during the surveillance period, ranging from 25% to 82%. Ecological comparisons revealed substantial increases in HPV vaccination during this time period, and more modest reductions in cervical cancer screening and sexual risk behaviors. CONCLUSIONS: The age and cohort patterns in our data suggest that declines in CIN2+ during 2008-2015 are more likely driven by HPV vaccination, introduced in 2006, than by changes in screening or risk behavior.

Persistent Racial Disparities in HIV Infection in the USA: HIV Prevalence Matters.

OBJECTIVES: Despite increased funding and efforts to prevent and control HIV infections in the black and Hispanic communities, racial disparities persist in the USA. We used a mathematical model to explain the phenomena. METHODS: A mathematical model was constructed to project HIV prevalence ratio (PR), incidence rate ratio (IRR), and HIV-specific mortality rate ratio (MRR) among blacks and Hispanics vs. whites in two scenarios: (1) an annual reduction in HIV incidence rate at the 2007-2010 level and (2) an annual reduction in HIV incidence rate at the 2007-2010 level among whites (4.2 %) and twice that of whites among blacks and Hispanics (8.4 %). RESULTS: In scenario no. 1, the PR, IRR, and MRR among blacks would decrease from 7.6 to 5.8, 7.9 to 5.9, and 11.3 to 5.3 and among Hispanics from 2.8 to 1.8, 3.1 to 1.9, and 2.3 to 1.0, respectively. In scenario no. 2, the PR, IRR, and MRR among blacks would decrease from 7.6 to 5.1, 7.9 to 2.5, and 11.3 to 4.7 and among Hispanics from 2.8 to 1.6, 3.1 to 0.8, and 2.3 to 0.9, respectively. CONCLUSIONS: Much of the persistent racial disparities in HIV infection in the USA, as measured by PR, IRR, and MRR, can be explained by higher HIV prevalence among blacks and Hispanics. The public health community should continue its efforts to reduce racial disparities, but also need to set realistic goals and measure progress with sensitive indicators.

Ten-year cancer incidence in rescue/recovery workers and civilians exposed to the September 11, 2001 terrorist attacks on the World Trade Center.

BACKGROUND: Cancer incidence in exposed rescue/recovery workers (RRWs) and civilians (non-RRWs) was previously reported through 2008. METHODS: We studied occurrence of first primary cancer among World Trade Center Health Registry enrollees through 2011 using adjusted standardized incidence ratios (SIRs), and the WTC-exposure-cancer association, using Cox proportional hazards models. RESULTS: All-cancer SIR was 1.11 (95% confidence interval (CI) 1.03-1.20) in RRWs, and 1.08 (95% CI 1.02-1.15) in non-RRWs. Prostate cancer and skin melanoma were significantly elevated in both populations. Thyroid cancer was significantly elevated only in RRWs while breast cancer and non-Hodgkin's lymphoma were significantly elevated only in non-RRWs. There was a significant exposure dose-response for bladder cancer among RRWs, and for skin melanoma among non-RRWs. CONCLUSIONS: We observed excesses of total and specific cancers in both populations, although the strength of the evidence for causal relationships to WTC exposures is somewhat limited. Continued monitoring of this population is indicated. Am. J. Ind. Med. 59:709-721, 2016. © 2016 Wiley Periodicals, Inc.

Trends in Mortality Disparities by Area-Based Poverty in New York City, 1990-2010.

Residing in a high-poverty area has consistently been associated with higher mortality rates, but the association between poverty and mortality can change over time. We examine the association between neighborhood poverty and mortality in New York City (NYC) during 1990-2010 to document mortality disparity changes over time and determine causes of death for which disparities are greatest. We used NYC and New York state mortality data for years 1990, 2000, and 2010 to calculate all-cause and cause-specific age-adjusted death rates (AADRs) by census tract poverty (CTP), which is the proportion of persons in a census tract living below the federal poverty threshold. We calculated mortality disparities, measured as the difference in AADR between the lowest and highest CTP groups, within and across race/ethnicity, nativity, and sex categories by year. We observed higher all-cause AADRs with higher CTP for each year for all race/ethnicities, both sexes, and US-born persons. Mortality disparities decreased progressively during 1990-2010 for the NYC population overall, for each race/ethnic group, and for the majority of causes of death. The overall mortality disparity between the highest and lowest CTP groups during 2010 was 2.55 deaths/1000 population. The largest contributors to mortality disparities were heart disease (51.52 deaths/100,000 population), human immunodeficiency virus (19.96/100,000 population), and diabetes (19.59/100,000 population). We show that progress was made in narrowing socioeconomic disparities in mortality during 1990-2010, but substantial disparities remain. Future efforts toward achieving health equity in NYC mortality should focus on areas contributing most to disparities.

Estimating Potential Reductions in Premature Mortality in New York City From Raising the Minimum Wage to $15.

OBJECTIVES: To assess potential reductions in premature mortality that could have been achieved in 2008 to 2012 if the minimum wage had been $15 per hour in New York City. METHODS: Using the 2008 to 2012 American Community Survey, we performed simulations to assess how the proportion of low-income residents in each neighborhood might change with a hypothetical $15 minimum wage under alternative assumptions of labor market dynamics. We developed an ecological model of premature death to determine the differences between the levels of premature mortality as predicted by the actual proportions of low-income residents in 2008 to 2012 and the levels predicted by the proportions of low-income residents under a hypothetical $15 minimum wage. RESULTS: A $15 minimum wage could have averted 2800 to 5500 premature deaths between 2008 and 2012 in New York City, representing 4% to 8% of total premature deaths in that period. Most of these avertable deaths would be realized in lower-income communities, in which residents are predominantly people of color. CONCLUSIONS: A higher minimum wage may have substantial positive effects on health and should be considered as an instrument to address health disparities.

Influenza-Related Hospitalizations and Poverty Levels - United States, 2010-2012.

Annual influenza vaccine is recommended for all persons aged ≥6 months in the United States, with recognition that some persons are at risk for more severe disease (1). However, there might be previously unrecognized demographic groups that also experience higher rates of serious influenza-related disease that could benefit from enhanced vaccination efforts. Socioeconomic status (SES) measures that are area-based can be used to define demographic groups when individual SES data are not available (2). Previous surveillance data analyses in limited geographic areas indicated that influenza-related hospitalization incidence was higher for persons residing in census tracts that included a higher percentage of persons living below the federal poverty level (3-5). To determine whether this association occurs elsewhere, influenza hospitalization data collected in 14 FluSurv-NET sites covering 27 million persons during the 2010-11 and 2011-12 influenza seasons were analyzed. The age-adjusted incidence of influenza-related hospitalizations per 100,000 person-years in high poverty (≥20% of persons living below the federal poverty level) census tracts was 21.5 (95% confidence interval [CI]: 20.7-22.4), nearly twice the incidence in low poverty (<5% of persons living below the federal poverty level) census tracts (10.9, 95% CI: 10.3-11.4). This relationship was observed in each surveillance site, among children and adults, and across racial/ethnic groups. These findings suggest that persons living in poorer census tracts should be targeted for enhanced influenza vaccination outreach and clinicians serving these persons should be made aware of current recommendations for use of antiviral agents to treat influenza (6).

Is population structure sufficient to generate area-level inequalities in influenza rates? An examination using agent-based models.

BACKGROUND: In New Haven County, CT (NHC), influenza hospitalization rates have been shown to increase with census tract poverty in multiple influenza seasons. Though multiple factors have been hypothesized to cause these inequalities, including population structure, differential vaccine uptake, and differential access to healthcare, the impact of each in generating observed inequalities remains unknown. We can design interventions targeting factors with the greatest explanatory power if we quantify the proportion of observed inequalities that hypothesized factors are able to generate. Here, we ask if population structure is sufficient to generate the observed area-level inequalities in NHC. To our knowledge, this is the first use of simulation models to examine the causes of differential poverty-related influenza rates. METHODS: Using agent-based models with a census-informed, realistic representation of household size, age-structure, population density in NHC census tracts, and contact rates in workplaces, schools, households, and neighborhoods, we measured poverty-related differential influenza attack rates over the course of an epidemic with a 23 % overall clinical attack rate. We examined the role of asthma prevalence rates as well as individual contact rates and infection susceptibility in generating observed area-level influenza inequalities. RESULTS: Simulated attack rates (AR) among adults increased with census tract poverty level (F = 30.5; P < 0.001) in an epidemic caused by a virus similar to A (H1N1) pdm09. We detected a steeper, earlier influenza rate increase in high-poverty census tracts-a finding that we corroborate with a temporal analysis of NHC surveillance data during the 2009 H1N1 pandemic. The ratio of the simulated adult AR in the highest- to lowest-poverty tracts was 33 % of the ratio observed in surveillance data. Increasing individual contact rates in the neighborhood did not increase simulated area-level inequalities. When we modified individual susceptibility such that it was inversely proportional to household income, inequalities in AR between high- and low-poverty census tracts were comparable to those observed in reality. DISCUSSION: To our knowledge, this is the first study to use simulations to probe the causes of observed inequalities in influenza disease patterns. Knowledge of the causes and their relative explanatory power will allow us to design interventions that have the greatest impact on reducing inequalities. CONCLUSION: Differential exposure due to population structure in our realistic simulation model explains a third of the observed inequality. Differential susceptibility to disease due to prevailing chronic conditions, vaccine uptake, and smoking should be considered in future models in order to quantify the role of additional factors in generating influenza inequalities.