Demographics, Birth Parameters, and Social Determinants of Health Among Opioid-Exposed Mother-Infant Dyads Affected by Neonatal Abstinence Syndrome in Pennsylvania, 2018-2019.

OBJECTIVES: To characterize demographics, birth parameters, and social determinants of health among mother-infant dyads affected by neonatal abstinence syndrome (NAS) in Pennsylvania. METHODS: We linked 2018-2019 NAS surveillance data to birth record data using probabilistic methods and then geospatially linked to local social determinants of health data based on residential address. We generated descriptive statistics and used multivariable mixed-effects logistic regression to model the association between maternal characteristics, birth parameters, social determinants of health, and NAS. RESULTS: In adjusted models maternal age > 24, non-Hispanic white race/ethnicity, low educational attainment, Medicaid as payor at delivery, inadequate or no prenatal care, smoking during pregnancy, and low median household income were associated with NAS. We found no significant associations between NAS and county-level measures of clinician supply, number of substance use treatment facilities, or urban/rural designation. CONCLUSIONS FOR PRACTICE: This study characterizes mother-infant dyads affected by NAS using linked non-administrative, population data for Pennsylvania. Results demonstrate a social gradient in NAS and inequity in prenatal care receipt among mothers of infants with NAS. Findings may inform implementation of state-based public health interventions.

Individual and Neighborhood Characteristics Associated With Confirmatory and Follow-up Blood Lead Testing Among Children With Elevated Blood Lead Levels.

OBJECTIVES: The aim of this study was to assess the proportions and likelihood of children who receive confirmatory and follow-up blood lead testing within the recommended time frames after an initial capillary elevated blood lead level (EBLL) and confirmed EBLL, respectively, by individual and neighborhood-level sociodemographic characteristics. DESIGN: We linked and used blood testing and sociodemographic characteristics data from a Pennsylvania birth cohort including children born between 2017 and 2018. Generalized linear mixed models were constructed to examine the associations between sociodemographic factors and having recommended confirmatory and follow-up testing. SETTING: A population-based, retrospective cohort study. PARTICIPANTS: In this birth cohort, children who underwent at least 1 BLL test were followed up to 24 months of age. Children with a first unconfirmed (n = 6259) and confirmed BLL (n = 4213) ≥ 5 µg/dL were included in the analysis. MAIN OUTCOME MEASURE: Children had confirmatory and follow-up testing within the recommended time frames. RESULTS: Of the children with unconfirmed and confirmed EBLLs, 3555 (56.8%) and 1298 (30.8%) received confirmatory and follow-up testing, respectively. The proportions of the 2 outcome measures were lower among children experiencing certain sociodemographic disadvantages. In the univariate analyses, lower initial BLLs, older age, non-Hispanic Blacks, lower maternal educational levels, maternal Medicaid, The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) enrollment, maternal smoking, and higher quartiles of neighborhood poverty and old housing were associated with lower odds of having confirmatory and follow-up testing. However, in multivariate models, children with lower initial BLLs, older age, maternal smoking, and non-Hispanic Blacks were significantly less likely to have confirmatory and follow-up testing. CONCLUSIONS: There were deficiencies in having recommended confirmatory and follow-up blood lead testing among children, especially those with sociodemographic disadvantages. Public health agencies and stakeholders should finetune policies to improve follow-up testing in conjunction with primary and secondary preventions for early detection and reduction of lead exposure among targeted children at risk of lead poisoning.

Adolescent Sexting, Violence, and Sexual Behaviors: An Analysis of 2014 and 2016 Pennsylvania Youth Risk Behavior Survey Data.

BACKGROUND: Sexting is common among adolescents and is associated with numerous health risk behaviors and negative psychosocial constructs. This study examined the relationships between high school students' experiences with sexual violence victimization, dating violence victimization, and engagement in risky sexual behaviors with experiences of receiving sexts. METHODS: Cross-sectional data from the 2014 to 2016 data from Pennsylvania Youth Risk Behavior. Participants were selected using an independent 2-stage cluster sample design to produce a statewide population-based sample. The pencil and paper surveys were conducted in school. Participants included 6734 Pennsylvania high school students in grades 9-12. RESULTS: Overall, 29.0% of Pennsylvania high school students had received a sext, which varied by sex, race/ethnicity, school grade, and sexual identity. Students who engaged in sexual risk behaviors, experienced dating violence, or experienced lifetime sexual violence outside of the dating context had a significantly higher prevalence of receiving a sext than students who did not engage in those behaviors or have those experiences. CONCLUSIONS: Early screening and prevention efforts that include discussions about sexting behaviors may help prevent other negative outcomes, such as risky sexual behaviors and interpersonal violence. Addressing sexting in the education and health sectors may help to prevent other related harmful health and violence experiences during adolescence.

Blood Lead Level Testing and Retesting Among Newly Arriving Refugee Children, Pennsylvania, 2015-2019.

Objectives. To (1) determine the prevalence of elevated blood lead levels (EBLLs; ≥ 5 µg/dL) among newly arrived refugee children, (2) understand the demographic characteristics of refugee children with EBLLs, and (3) assess health care providers' compliance with Centers for Disease Control and Prevention (CDC) recommendations for retesting. Methods. We matched refugee demographic data (2015-2019) from the CDC's Electronic Disease Notification (EDN) system with lead-testing laboratory report data from the Pennsylvania National Electronic Disease Surveillance System using Match*Pro software. Results. Of 3833 refugee children 16 years or younger in the EDN system, matching identified 3142 children with blood lead level data. Among children with blood lead level data, 578 (18.4%) had EBLLs. Among children with EBLLs, 341 (59.0%) were male. Of the 1370 children aged 6 years or younger with blood level test results, 335 (24.5%) had initial EBLLs, and only 78 (5.7%) were retested within 3 to 6 months. Of the 335 children 6 years or younger with an initial EBLL, only 44 (13.1%) were retested within 3 to 6 months. Conclusions. Following up on refugee children with EBLLs is necessary to ensure that they do not have continued lead exposure. (Am J Public Health. 2022;112(S7):S706-S714. https://doi.org/10.2105/AJPH.2022.306856).

Effect of HCV or HIV infection on mortality among hospitalized persons who used opioids, 2000-2010.

Mortality due to opioid misuse and overdose has increased substantially in the United States over the past two decades. The study objective was to describe the causes of death among persons with opioid-related hospitalizations and examine survival by Hepatitis C virus (HCV) or HIV. Opioid-related hospitalization records in Pennsylvania from 2000 to 2010 were linked to death registry files to assess cause of death, and survival from first hospital discharge date to death date, or December 31, 2010. Accelerated failure time models were used to compare survival between persons with and without HCV or HIV diagnoses. Among the 136,416 individuals with an opioid-related hospitalization, 13.0% died over a median of 56 months of follow-up; the most common causes of death were circulatory diseases (26.4%) and drug overdose (23.5%). There were 27,122 (19.9%) and 3662 (2.7%) persons who had an HCV and HIV diagnosis, respectively. Among patients aged ≥20 years, those with HCV had shorter survival time compared to those without HCV, with discrepancies more pronounced at older ages. Patients with HIV also had shorter survival time (time ratio: 0.29 [95% CI: 0.26, 0.34]) compared to without HIV. These findings show that in a cohort of patients with opioid-related hospitalizations, those with HCV or HIV diagnoses have shorter survival. This has public health implications, providing further evidence that medical providers should educate patients who use opioids about the risks of HCV and HIV infection and focus prevention and treatment to decrease mortality among patients hospitalized for opioid use.

Effects of Individual and Neighborhood Characteristics on Childhood Blood Lead Testing and Elevated Blood Lead Levels, A Pennsylvania Birth Cohort Analysis.

BACKGROUND: Despite declining lead exposure among U.S. children, childhood blood lead level (BLL) undertesting and elevation remains a public health issue. This study explores the impacts of maternal, infant, and neighborhood characteristics on the receipt of lead testing and having elevated BLLs (EBLLs) among children under age two. METHODS: Pennsylvania infants born in 2015 and 2016 were followed to 24 months. Birth certificate data were linked to 2015 through 2018 blood lead surveillance data and neighborhood data on household income, poverty, and the burden of houses built before 1970. Generalized linear mixed models were used to examine the individual and neighborhood characteristics independently and/or interactively affecting the likelihood of lead testing and of having EBLLs. RESULTS: A total of 48.6% of children were tested for BLLs, and 2.6% of them had confirmed EBLLs. The likelihood of lead testing and of having EBLLs among non-Hispanic black children was respectively 7% and 18% higher than white children. Children born to mothers with the lowest educational attainment (

Demographic and exposure characteristics as predictors of serum per- and polyfluoroalkyl substances (PFASs) levels - A community-level biomonitoring project in Pennsylvania.

Per- and polyfluoroalkyl substances (PFASs) are widely used in industrial and consumer products and have been linked to various adverse health effects. Communities near two former military bases in Pennsylvania were exposed to PFAS through contaminated drinking water for several decades. The Pennsylvania Department of Health (DOH) conducted biomonitoring of 235 randomly selected community members living in four public water system (PWS) service areas to evaluate a toolkit developed by the Centers for Disease Control and Prevention (CDC) and the Agency for Toxic Substances and Disease Registry (ATSDR). DOH also collected data on participants' demographics, exposure history and self-reported health conditions. Serum PFAS levels were compared with the national averages for 2013-2014 and their relationships with demographic and exposure characteristics were analyzed. Of the 11 PFASs analyzed for, only perfluorooctanoic acid (PFOA), perfluorooctanesulfonic acid (PFOS), perfluorohexanesulfonic acid (PFHxS) and perfluorononanoic acid (PFNA) were consistently detected in the serum samples. The average levels of PFOA, PFOS, PFHxS and PFNA among the study participants were 3.13, 10.24, 6.64 and 0.74 µg per liter (µg/L), respectively. Overall, 75, 81, 94 and 59 percent of the study participants had levels exceeding the national average for PFOA (1.94 µg/L), PFOS (4.99 µg/L), PFHxS (1.35 µg/L) and PFNA (0.66 µg/L), respectively. Results indicated associations between serum levels of some PFAS compounds and sex, age, employment in the study area, PWS area, quantity of daily tap water consumption, and length of residence in the study area.

Maternal Obesity, Birth Size, and Risk of Childhood Cancer Development.

Infants and children are particularly vulnerable to in utero and early-life exposures. Thus, a mother's exposures before and during pregnancy could have important consequences for her child's health, including cancer development. We examined whether birth certificate-derived maternal anthropometric characteristics were associated with increased risk of subsequent childhood cancer development, accounting for established maternal and infant risk factors. Pennsylvania birth and cancer registry files were linked by the state Department of Health, yielding a virtual cohort of births and childhood cancers from 2003 through 2016. The analysis included 1,827,875 infants (13,785,309 person-years at risk), with 2,352 children diagnosed with any cancer and 747 with leukemia before age 14 years. Children born to mothers with a body mass index (weight (kg)/height (m)2) of ≥40 had a 57% (95% confidence interval: 12, 120) higher leukemia risk. Newborn size of ≥30% higher than expected was associated with 2.2-fold and 1.8-fold hazard ratios for total childhood cancer and leukemia, respectively, relative to those with expected size. Being <30% below expected size also increased the overall cancer risk (P for curvilinearity < 0.0001). Newborn size did not mediate the association between maternal obesity and childhood cancer. The results suggest a significant role of early-life exposure to maternal obesity- and fetal growth-related factors in childhood cancer development.

Incorrect inference in prevalence trend analysis due to misuse of the odds ratio.

Because public health agencies usually monitor health outcomes over time for surveillance, program evaluation, and policy decisions, a correct health outcome trend analysis is vital. If the analysis is done incorrectly and/or results are misinterpreted, a faulty trend analysis could jeopardize key aspects of public health initiatives such as program planning, implementations, policy development, and clinical decision making. It is essential then that accurate health outcome trend analysis be implemented in any data-driven decision-making process. Unfortunately, there continues to be common statistical mistakes in prevalence trend analysis. In this article, using recently published results from the Pediatric Nutrition Surveillance System, we will show the effect that an incorrect trend analysis and subsequent interpretation of results can have. We will also propose more appropriate statistical processes, such as the log-binomial model, for these situations.

Characteristics driving higher diabetes-related hospitalization charges in Pennsylvania.

OBJECTIVES: To evaluate the characteristics driving higher diabetes-related hospitalization charges. METHODS: Hospital discharge data on 216,858 hospitalizations from 2001 to 2011 with primary discharge diagnosis of diabetes were linked to the Pennsylvania death registry. Multiple linear regression analysis was used to evaluate the association between inpatient hospitalization charges and complications, sociodemographic status, comorbidities, readmission, length of stay, admission type, region, procedures, payer type, and hospitalization misadventures. RESULTS: Diabetes-related adjusted hospitalization charges were higher for those with long-term complications [renal manifestations (75%), peripheral circulatory disorders (38%), neurological manifestations (30%), ophthalmic manifestations (16%)], acute complications [ketoacidosis (48%), hyperosmolarity (41%), coma (40%)], amputations (91%) or other medical procedure(s) (70%), emergency/urgent admissions (7%), comorbidity (3% per modified Charlson Comorbidity Index score item), medical misadventure (20%), different regions [Philadelphia (135%), and Pittsburgh (8%)], and for minorities [non-Hispanic black (12%), Hispanic (21%), and non-Hispanic other (14%)]. Readmission adjusted charges were not different from the initial admission charges. CONCLUSIONS: To reduce diabetes-related hospitalizations and curb hospitalization charges, public health and healthcare policy makers should be cognizant of high-impact drivers: diabetes-related complications, unnecessary procedures, race/ethnicity, and region. Inpatient are should focus on preventing unnecessary readmissions and misadventures. These findings are timely as the Affordable Care Act reduces Medicare payments to hospitals with high readmission rates, and as states consider Medicaid expansion.

School-based HIV/AIDS education is associated with reduced risky sexual behaviors and better grades with gender and race/ethnicity differences.

Although studies indicate school-based HIV/AIDS education programs effectively reduce risky behaviors, only 33 states and the District of Columbia in US mandate HIV/AIDS education. Ideally, school-based HIV/AIDS education should begin before puberty, or at the latest before first sexual intercourse. In 2011, 20% US states had fewer schools teaching HIV/AIDS prevention than during 2008; this is worrisome, especially for more vulnerable minorities. A nationally representative sample of 16 410 US high-school students participating in 2009 Youth Risk Behavior Survey was analyzed. Multiple regression models assessed the association between HIV/AIDS education and risky sexual behaviors, and academic grades. HIV/AIDS education was associated with delayed age at first sexual intercourse, reduced number of sex partners, reduced likelihood to have forced sexual intercourse and better academic grades, for sexually active male students, but not for female students. Both male and female students who had HIV/AIDS education were less likely to inject drugs, drink alcohol or use drugs before last sexual intercourse, and more likely to use condoms. Minority ethnic female students were more likely to have HIV testing. The positive effect of HIV/AIDS education and different gender and race/ethnicity effects support scaling up HIV/AIDS education and further research on the effectiveness of gender-race/ethnicity-specific HIV/AIDS curriculum.

Multiple chronic conditions: diabetes associated with comorbidity and shared risk factors using CDC WEAT and SAS analytic tools.

BACKGROUND: Multiple chronic conditions (MCCs) are significant public health problems receiving much attention, and rightly so, because of the substantial morbidity, mortality, and cost burden. OBJECTIVES: To report the prevalence of selected frequent MCCs with shared risk factors that are leading causes of death; and to quantify the association between diabetes and its comorbidity and shared risk factors. METHODS: This is a cross-sectional study of 9172 participants in Pennsylvania's 2009 Behavioral Risk Factor Surveillance System (BRFSS). Centers for Disease Control and Prevention's Web Enabled Analysis Tool (WEAT) and SAS Proc Survey were used for all analyses, to account for BRFSS's multistage complex survey design and sample weights. RESULTS: SAS estimated prevalence among ≥35-year-olds were as follows: diabetes (11.9%), heart disease (9.5%), stroke (3.3%), diabetes and heart disease (2.9%), diabetes and stroke (1.0%), heart disease and stroke (1.1%), and diabetes, heart disease, and stroke (0.4%). Adults ≥35 years old with the following characteristics were more likely to have diabetes when self-reporting: obese (adjusted odds ratio [ORAdj] = 4.63, 95% confidence interval [95% CI] = 3.41-6.30); low income (<$15 000 ORAdj = 2.85, 95% CI = 1.90-4.27; $15 000-$24 999 ORAdj = 2.07, 95% CI = 1.50-2.86; $25 000-$34 999 ORAdj = 2.06, 95% CI = 1.47-2.88; $35 000-$49 999 ORAdj = 1.51, 95% CI = 1.08-2.12); elderly ≥65 years old (ORAdj = 2.84, 95% CI = 1.76-4.56); non-Hispanic black (ORAdj = 2.54, 95% CI = 1.08-6.00); overweight (ORAdj = 1.99, 95% CI = 1.47-2.68); heart disease (ORAdj = 1.94, 95% CI = 1.47-2.56); 45 to 64 years old (ORAdj = 1.88 95%, CI = 1.21-2.93); hypertension (ORAdj = 1.78, 95% CI = 1.39-2.29); stroke (ORAdj = 1.62, 95% CI = 1.05-2.50); high cholesterol (ORAdj = 1.49, 95% CI = 1.18-1.88); physically inactive (ORAdj = 1.33 95% CI = 1.06-1.67); and men (ORAdj = 1.32, 95% CI = 1.04-1.67). CONCLUSION: Adults with comorbidity and risk factors were 1.3 to 4.6 times more likely to have diabetes, with obesity consistently the strongest risk factor. WEAT's limitations are the predefined categories, inability to restrict to specific age groups and to estimate the prevalence of >2 MCCs. WEAT has considerable potential to advance evidence-based primary care practice and community health programs, such as state-wide programs that target obesity and physical inactivity. The robust capability of SAS to calculate MCC prevalence and adjusted associations with risk factors provides the fundamentals for developing and evaluating primary care services and community health programs.

The effect of Philadelphia and Pennsylvania Clean Indoor Air Act on food services and drinking places sales and numbers, 1998-2011.

INTRODUCTION: Philadelphia enacted its Clean Indoor Air Act (CIAA) nearly 2 years before the statewide CIAA. In this study, we assessed the economic impact of CIAAs on 4 types of food services and drinking places and addressed the predominant limitation of previous pre-post ban studies, namely the lack of control for confounders and changes in secular trends over time. METHODS: We analyzed data from Pennsylvania Department of Revenue Quarterly 1998-2011 taxable county-level revenue sales and number of food services and drinking places. Region-specific and type-specific adjusted sales and number of food services and drinking places accounted for consumer spending as a general economic indicator. Segmented regression analysis of interrupted time-series methodology assessed changes in trend and level. RESULTS: Pennsylvania CIAA had no significant effect on adjusted sales or numbers except for an increase in sales in Philadelphia for limited-service eating places and in the surrounding 4 counties for special food services. Philadelphia CIAA was associated with an increase in adjusted numbers of full-service restaurants in Philadelphia and the rest of the state, special food services in Philadelphia, and drinking places in the rest of the state, and a decrease in the number of special food services in the surrounding counties. Philadelphia CIAA had no significant effect on adjusted sales except for an increase in special food services in the rest of the state. CONCLUSION: Overall, CIAAs had no negative business-related impact and, for the most part, suggest a positive impact on restaurant sales and numbers. Our results provide further support for comprehensive CIAA ordinance for restaurants.

Use of interrupted time-series method to evaluate the impact of cigarette excise tax increases in Pennsylvania, 2000-2009.

INTRODUCTION: Scientific evidence shows that cigarette price increases can significantly reduce smoking prevalence and smoking initiation among adolescents and young adults. However, data are lacking regarding the effectiveness of increasing Pennsylvania's cigarette tax to reduce smoking and/or adverse health effects of smoking. The objective of our study was to assess the impact of cigarette tax increases and resulting price increases on smoking prevalence, acute myocardial infarction (AMI) and asthma hospitalization rates, and sudden cardiac death (SCD) rates in Pennsylvania. METHODS: We used segmented regression analyses of interrupted time series to evaluate the level and trend changes in Pennsylvania adults' current smoking prevalence, age-adjusted AMI and asthma hospitalization rates, age-specific asthma hospitalization rates, and age-adjusted SCD rates following 2 cigarette excise tax increases. RESULTS: After the first excise tax increase, no beneficial effects were noted on the outcomes of interest. The second tax increase was associated with significant declines in smoking prevalence for people aged 18 to 39, age-adjusted AMI hospitalization rates for men, age-adjusted asthma hospitalizations rates, and SCD rates among men. Overall smoking prevalence declined by 5.2% (P = .01), with a quarterly decrease of 1.4% (P = .01) for people aged 18 to 39 years. The age-adjusted AMI hospitalization rate for men showed a decline of 3.87/100,000 population (P = .04). The rate of age-adjusted asthma hospitalizations decreased by 10.05/100,000 population (P < .001), and the quarterly trend decreased by 3.21/100,000 population (P < .001). Quarterly SCD rates for men decreased by 1.34/100,000 population (P < .001). CONCLUSION: An increase in the price of cigarettes to more than $4 per 20-cigarette pack was associated with a significant decrease in smoking among younger people (aged 18-39). Decreases were also seen in asthma hospitalizations and men's age-adjusted AMI hospitalization and SCD rates. Further research and policy development regarding the effect of cigarette taxes on tobacco consumption should be cognizant of the psychological tipping points at which overall price affects smoking patterns.