Cancer Prevention Education for Providers, Staff, Parents, and Teens Improves Adolescent Human Papillomavirus Immunization Rates.

OBJECTIVE: To develop a program to educate providers, office staff, patients, and parents on life-long cancer prevention strategies, including the use of human papillomavirus (HPV) vaccine to improve adolescent HPV vaccination rates. STUDY DESIGN: A 2-phase program was implemented at 6 pediatric practices across upstate New York. Phase 1 included provider and staff education regarding practice-specific vaccination challenges and discussion of the contents of a study-specific cancer-prevention booklet, which included HPV vaccine information. Throughout phase 2, the booklets were distributed to all adolescents and their parents during office visits over a 12-month period. Practice-specific, countywide, and statewide HPV vaccination rates were assessed before phase 1, and 6 and 12 months after the launch of phase 2. RESULTS: One year after implementing phase 2 in 6 practices, adolescent HPV vaccine series initiation increased by at least 10% in 3 practices, and at least 5% in 5 practices. Similarly, adolescent vaccine series completion rates increased by more than 10% in 3 practices. The percent change in vaccine series completion rates across all study sites postintervention ranged from 12% to 20% for 11- to 12-year-olds, and from 7% to 23% for 13- to 18-year-olds. CONCLUSIONS: Cancer prevention education targeting providers, office staff, patients, and parents was modestly effective for improving adolescent HPV vaccination rates.

Self-determination theory and weight loss in a Diabetes Prevention Program translation trial.

We examined self-determination theory (SDT) and weight loss, and hypothesized that the Diabetes Prevention Program's (DPP) intervention would result in an increase in autonomous regulation of motivation (AR) in participants. Further, that those with higher AR, and those who perceived educators as supporting SDT-defined needs, would lose more weight. Support, Health Information, Nutrition and Exercise (SHINE) Study data (N = 257) were analyzed. SHINE was a randomized, controlled DPP translation trial (2-years, telephonic, primary care staff). Autonomous motivation in males increased significantly, while females showed no change. Males with high AR, but not females, lost more weight. However, the significance of these relationships varied over time. Participants who perceived educators as more supportive of psychological needs lost more weight (especially males). However, effect of support on weight loss was not mediated by AR change. Autonomous motivation and educator support are relevant to male weight loss. Future research might develop interventions to enhance autonomous motivation and educator support, and understand change pathways.

Healthy Immigrant Effect: Preterm Births Among Immigrants and Refugees in Syracuse, NY.

OBJECTIVES: The healthy immigrant effect is the phenomenon by which immigrants experience more positive health outcomes than the native-born population in developed countries. The strength of this effect appears to be related to country of origin, health outcome, healthcare and integration policies of receiving countries, as well as immigration class. This secondary analysis of birth records examines whether immigrants and mothers from refugee countries have lower adjusted risk of preterm births than US-born mothers in Syracuse, NY, a preferred refugee resettlement area. METHODS: This secondary analysis included 6354 electronic birth records for residents in the city of Syracuse, NY who gave birth to singleton infants between 2009 and 2011. Multivariate log-binomial regression was used to calculate the adjusted relative risk for preterm birth among foreign-born mothers and mothers from refugee countries, compared to US-born mothers. RESULTS: Infants born to both foreign-born women and to women from refugee countries had decreased risks of being born preterm compared to infants born to US mothers, controlling for race, late/no prenatal care, maternal age less than 18 years and smoking. CONCLUSION: Our findings support a healthy immigrant effect for preterm births both among all foreign-born immigrants and among the subsample of women from refugee countries. Mother's nativity is likely a proxy for unmeasured factors (e.g., prenatal stress, maternal diet, etc.) that may explain the relationship between mother's nativity and preterm births. Additional research is needed to better understand the underlying factors.

Incorrect Insulin Administration: A Problem That Warrants Attention.

In Brief Incorrect administration of insulin (e.g., too little, too much, or at wrong times) can result in transient and serious hypo- and hyperglycemia, wide glycemic excursions, and diabetic ketoacidosis. The authors systematically assessed the insulin-related knowledge and injection skills of a sample of adults with diabetes and found that errors in self-administering insulin, including choosing an incorrect insulin dose, were common. Injection site selection and diabetes numeracy were also concerns. Correct timing of injections and confidence in choosing correct doses, but not skills scores, related to better A1C and blood glucose levels.

Intendedness of pregnancy and other predictive factors for symptoms of prenatal depression in a population-based study.

Prenatal depression (PD) as a risk factor for adverse birth outcomes is well documented. Less is known about maternal risks for PD, which could inform preventive strategies for perinatal and interconceptional care. This exploratory study investigates associations between prenatal depression symptoms and unintended and mistimed pregnancies and other maternal risk factors for PD. A subset of birth records from the New York Statewide Perinatal Data System (n = 19,219) was used in this secondary analysis of cross-sectional data. Univariate and multivariate multinomial regression was used to identify factors that are independently associated with four self-reported levels of prenatal depression symptoms. Women with unintended pregnancies were more likely (AOR, 95 % CI) to report severe (3.6, 2.6-5.1) or moderate (2.0, 1.6-2.5) prenatal depression symptoms and less likely to report no symptoms, compared to women with intended pregnancies. Likewise, women with mistimed pregnancies were more likely to report severe (2.7, 2.2-3.5) or moderate (1.7, 1.5-2.1) prenatal depression symptoms than no symptoms, compared to women with intended pregnancies. Low education, drug use, smoking, minority race, being unmarried and having Medicaid insurance were also significant, independent predictors of PD symptoms. Results suggest that routine screening for depression, intendedness of pregnancy and other associated risk factors such as smoking and drug use during prenatal and interconceptional care visits may enable coordinated interventions that can reduce prenatal depression and unintended and mistimed pregnancies and improve pregnancy outcomes.

Weight loss success in metabolic syndrome by telephone interventions: results from the SHINE Study.

BACKGROUND: The Diabetes Prevention Program (DPP) intensive lifestyle intervention resulted in significant weight loss, reducing the development of diabetes, but needs to be adapted to primary care provider (PCP) practices. OBJECTIVES: To compare a DPP-translation using individual (IC) vs. conference (CC) calls delivered by PCP staff for the outcome of percent weight loss over 2 years. DESIGN: Randomized clinical trial. SETTING: Five PCP sites. PARTICIPANTS: Obese patients with metabolic syndrome, without diabetes (IC, n = 129; CC, n = 128). INTERVENTION: Telephone delivery of the DPP Lifestyle Balance intervention [16-session core curriculum in year 1, 12-session continued telephone contact in year 2 plus telephone coaching sessions (dietitians). MAIN MEASURES: Weight (kg), body mass index (BMI), and waist circumference. BASELINE DATA: age = 52 years, BMI = 39 kg/m(2), 75 % female, 85 % non-Hispanic White, 13 % non-Hispanic Black, and 48 % annual incomes <$40,000/year. In the intention-to-treat analyses at year 2, mean percent weight loss was -5.6 % (CC, p < 0.001) and -1.8 % (IC, p = 0.046) and was greater for CC than for IC (p = 0.016). At year 2, mean weight loss was 6.2 kg (CC) and 2.2 kg (IC) (p < 0.001). There was similar weight loss at year 1, but between year 1 and year 2 CC participants continued to lose while IC participants regained. At year 2, 52 % and 43 % (CC) and 29 % and 22 % (IC) of participants lost at least 5 % and 7 % of initial weight. BMI also decreased more for CC than IC (-2.1 kg/m(2) vs. -0.8 kg/m(2) p < 0.001). Waist circumference decreased by 3.1 cm (CC) and 2.4 cm (IC) at year 2. Completers (≥9 of 16 sessions; mean 13.3 sessions) lost significantly more weight than non-completers (mean 4.3 sessions). CONCLUSIONS: PCP staff delivery of the DPP lifestyle intervention by telephone can be effective in achieving weight loss in obese people with metabolic syndrome. Greater weight loss may be attained with a group telephone intervention.

Predictors for return to work for those with occupational respiratory disease: clinical and structural factors.

BACKGROUND: Few occupational researchers have examined "return to work" among patients with work-related respiratory diseases. In addition, prior studies have emphasized individual patient characteristics rather than a more multi-dimensional approach that includes both clinical and structural factors. METHODS: A retrospective chart review identified patients with occupational respiratory diseases in the Occupational Health Clinical Center, Syracuse, NY between 1991 and 2009. We assessed predictors of work status using an exploratory, sequential mixed methods research design, multinomial (n = 188) and Cox regressions (n = 130). RESULTS: The findings suggest that patients with an increased number of diagnoses, non-union members, and those who took more than a year before clinical presentation had significantly poorer work status outcomes, after adjusting for age, education level, and relevant diagnoses. CONCLUSIONS: Efforts to prevent slow return to work after developing occupational respiratory disease should recognize the importance of timely access to occupational health services, disease severity, union membership, and smoking status.

Multi-component cancer prevention awareness program to improve adolescent HPV vaccine uptake.

OBJECTIVE: We introduced a multi-component cancer prevention awareness program to primary care practices across New York State to evaluate its impact on adolescent human papillomavirus (HPV) vaccination rates. METHODS: Eight pediatric and three family medicine practices were recruited to participate in this program. On-site training sessions were provided for all practice providers and staff to discuss the importance of HPV vaccine and cancer prevention and teach strategies for delivering a strong vaccine recommendation. Each practice received a study-specific booklet that included HPV vaccine information and other commonly provided cancer prevention guidance. These booklets were distributed to all adolescents and their parents during well visits over a one-year period. Practice specific and county-wide HPV vaccination rates were assessed before and 12 months after the program training session. RESULTS: One year after program initiation, aggregate data show statistically higher vaccine series initiation rates among 11-12 and 13-18-year-olds and higher vaccine series completion rates among 13-18-year-olds. The greatest and most consistent improvements were seen in vaccine initiation rates for the 11-12-year-old cohort. Disparities in vaccine uptake were observed by gender and medical specialty. CONCLUSION: Cancer prevention education targeting providers, office staff, patients, and parents, improved adolescent HPV vaccine series initiation rates.

Barriers to Weight Loss and Physical Activity, and Coach Approaches to Addressing Barriers, in a Real-World Adaptation of the DPP Lifestyle Intervention: A Process Analysis.

PURPOSE: The purpose of this study is to identify barriers to weight loss and physical activity, as well as approaches used by coaches, in a real-world, community sample of adults with metabolic syndrome (at risk for type 2 diabetes) who participated in a Diabetes Prevention Program (DPP)-adapted weight loss intervention and compare findings to data from the screened and highly selected DPP sample. METHODS: SHINE (Support, Health Information, Nutrition, and Exercise) was a telephonic DPP adaptation. Primary care staff delivered the DPP curriculum, and lifestyle coaches provided monthly direction to achieve weight loss. For this substudy, barriers to weight loss and physical activity described by participants, as well as approaches coaches used to address them, were gathered. Groupings of barriers (DPP defined) were analyzed in relation to demographic characteristics and compared to data from the DPP sample. RESULTS: Top weight loss barriers were problems with self-monitoring, too little physical activity, internal thought/mood cues, vacation/holidays, and social cues. Percentages reporting a barrier were much higher in SHINE. Top physical activity barriers were problems with self-monitoring, access/weather, time management, aches/pains, and vacation/holidays. These did not correspond closely to DPP data. Coaches used problem solving, self-monitoring skills review, increased physical activity, and motivational strategies. SHINE coaches were more likely than DPP coaches to use alternative approaches. CONCLUSIONS: Barriers to weight loss and physical activity in a community sample of persons at risk for diabetes occurred at much higher rates than in the highly screened DPP sample. Training coaches in a variety of patient-centered approaches may maximize their positive impact.

Associations between population based voting trends during the 2016 US presidential election and adolescent vaccination rates.

BACKGROUND: Politics play a role in the dissemination of public health information, including immunization-related issues. We aim to describe relationships between HPV vaccination rates and state voting patterns during the 2016 US presidential election. METHODS: We classified each of the 50 states as either "Red" or "Blue," based on whether a higher proportion of the state's casted votes were for the Republican or Democratic nominee during the 2016 US presidential election. State-specific HPV, Tdap, and meningococcal vaccination rates were obtained from the 2016-National Immunization Survey-Teen. State socio-demographic factors and HPV vaccine legislation were obtained from the US Census Bureau and National Conference of State Legislatures. Vaccination rates and socio-demographic variables were compared using independent t-tests. Multiple linear regression compared vaccination rates between "Red" and "Blue" states, adjusting for percentage of both uninsured children and educational attainment. RESULTS: Compared to "Blue" states, "Red" states had significantly lower unadjusted HPV vaccine series initiation (56% vs 66%, p < 0.05) and completion (39% vs 50%, p < 0.05) rates; yet had similar rates of Tdap (88% vs 89%, p > 0.05) and meningococcal (79% vs 83%, p > 0.05) vaccinations. After adjusting for potential confounders, the regression-adjusted mean rate for HPV vaccine initiation and completion remained significantly lower for "Red" states compared to "Blue" states (57% vs 65%, p < 0.05, and 41% vs 48%, p < 0.05, respectively). CONCLUSION: HPV vaccination rates are associated with statewide-level voting patterns. Future interventions aimed at improving HPV vaccination rates should consider engaging local and national elected leaders to be proactive in disseminating accurate and authoritative immunization information.

Structural violence, urban retail food markets, and low birth weight.

This paper investigates urban retail food markets and health in Syracuse, New York. A structured observational analysis found that a majority of corner markets do not sell fresh produce or low fat dairy products, but conduct a lively business selling lottery tickets, cigarettes, and liquor. A comparison of census tracts with and without access to supermarkets that sell fresh produce and other healthy food found that pregnant women living in proximity to a supermarket had significantly fewer low birth weight births than other pregnant women regardless of income level.

Immunization attitudes and practices among family medicine providers.

OBJECTIVE: To describe immunization attitudes and practices among family medicine providers across New York State. METHODS: In this cross-sectional survey study, family medicine providers across New York State completed a questionnaire to assess vaccine beliefs and barriers and immunization practices. STATISTICAL ANALYSIS: Descriptive statistical methods were used to define provider characteristics, knowledge and vaccine practices. RESULTS: Completed questionnaires from 226 family medicine providers were included for analysis. As a group, 207/218 (95%) of providers who answered the question state they always recommend standard pediatric vaccines. Of the 209 providers who answered both questions, 47 (22%) state they always recommend standard pediatric vaccines but do not always recommend HPV vaccine to eligible 11-12 year-old patients. Only 75% of providers strongly disagreed with the statement 'vaccinating adolescents against HPV increases the likelihood of unprotected sex'. Even though 178/190 (94%) and 164/188 (87%) of surveyed family medicine providers reported recommending that their pregnant patients receive influenza vaccine and Tdap vaccine, respectively, only 134/185 (72%) routinely do so in their office. CONCLUSION: Most family medicine providers self-report always recommending standard pediatric vaccines, however only a minority are following ACIP recommendations. Educational sessions to update family medicine providers on ACIP recommendations and address individual provider concerns may improve provider vaccine confidence and uptake of vaccines by their patients.

Parental literacy and infant health: an evidence-based healthy start intervention.

Syracuse Healthy Start, a federally funded infant mortality prevention project in Onondaga County, New York, has undertaken a range of interventions to address parental low literacy as a risk factor for infant mortality. A growing number of studies advocate for health-related information that is easy to read, of a low literacy level, and culturally appropriate. Creation of an evidence-based public health intervention involves analyzing local data, reviewing published studies, assessing available materials, initiating programmatic interventions, and evaluating the outcomes. Preparing health educational materials that are clear, culturally sensitive, and at appropriate reading levels follows Paulo Freire's lead in empowering the disadvantaged to positively affect their health and the health of their infants toward the reduction of infant mortality.

Cost-effectiveness of SHINE: A Telephone Translation of the Diabetes Prevention Program.

BACKGROUND: The Support, Health Information, Nutrition, and Exercise (SHINE) trial recently showed that a telephone adaptation of the Diabetes Prevention Program (DPP) lifestyle intervention was effective in reducing weight among patients with metabolic syndrome. The aim of this study is to determine whether a conference call (CC) adaptation was cost effective relative to an individual call (IC) adaptation of the DPP lifestyle intervention in the primary care setting. METHODS: We performed a stochastic cost-effectiveness analysis alongside a clinical trial comparing two telephone adaptations of the DPP lifestyle intervention. The primary outcomes were incremental cost-effectiveness ratios estimated for weight loss, body mass index (BMI), waist circumference, and quality-adjusted life years (QALYs). Costs were estimated from the perspective of society and included direct medical costs, indirect costs, and intervention costs. RESULTS: After one year, participants receiving the CC intervention accumulated fewer costs ($2,831 vs. $2,933) than the IC group, lost more weight (6.2 kg vs. 5.1 kg), had greater reduction in BMI (2.1 vs. 1.9), and had greater reduction in waist circumference (6.5 cm vs. 5.9 cm). However, participants in the CC group had fewer QALYs than those in the IC group (0.635 vs. 0.646). The incremental cost-effectiveness ratio for CC vs. IC was $9,250/QALY, with a 48% probability of being cost-effective at a willingness-to-pay of $100,000/QALY. CONCLUSIONS: CC delivery of the DPP was cost effective relative to IC delivery in the first year in terms of cost per clinical measure (weight lost, BMI, and waist circumference) but not in terms of cost per QALY, most likely because of the short time horizon.

Nasopharyngeal pneumococcal carriage rates among HIV-infected adults following widespread pediatric use of conjugate pneumococcal vaccine-13.

BACKGROUND: Nasopharyngeal pneumococcal carriage rates among HIV-infected adults has not been described since conjugate pneumococcal vaccine-13 (PCV13) was added to the universal infant and childhood vaccination schedule in 2010. METHODS: HIV-infected adults presenting for routine health care visits to the Designated AIDS Center in Syracuse, NY between December 2013 and June 2015 were eligible for enrollment. Demographic, medical, and social history were recorded after obtaining informed consent. Nasopharyngeal samples were collected and cultured for the presence of Streptococcus pneumoniae using standard microbiologic techniques. Antibiotic susceptibility testing was performed using E-test→. RESULTS: 707 nasopharyngeal samples were collected from 414 HIV-infected adults. 18 samples were culture positive for S. pneumoniae; 1 (6%) isolate was of vaccine-type, 9 (50%) were non-vaccine types, and 8 (44%) were non-typeable. The 18 isolates were recovered from 15 different patients (4% of those enrolled). Three patients were culture positive for pneumococcus isolated from 2 consecutive samples, with non-typeable pneumococci identified consecutively from 2 patients and serotype 35B identified consecutively from 1 patient. The most commonly identified non-vaccine serotypes were 35B and 15B/C. Identified pneumococci were penicillin and cefotaxime susceptible. CONCLUSION: Four percent of HIV-infected adults in our study population were colonized with S. pneumoniae. The non-vaccine serotypes 35B and 15B/C predominated.

Health and Psychosocial Outcomes of a Telephonic Couples Behavior Change Intervention in Patients With Poorly Controlled Type 2 Diabetes: A Randomized Clinical Trial.

OBJECTIVE: To compare glycemic control and secondary outcomes of a 4-month telephonic couples behavioral intervention to individual intervention, and to education, for adults with type 2 diabetes. RESEARCH DESIGN AND METHODS: A randomized trial with the following three arms: couples calls (CC) (n = 104); individual calls (IC) (n = 94); and diabetes education (DE) (n = 82). All arms had self-management education (two calls). CC and IC had 10 additional behavior change calls. CC addressed collaboration and relationships/communication. Participants consisted of 280 couples, among whom one partner had type 2 diabetes and an A1C level ≥7.5%. Blinded assessments occurred at 4, 8, and 12 months. The primary outcome was change in A1C; and secondary outcomes were BMI, waist circumference, blood pressure, depressive symptoms, diabetes self-efficacy, and diabetes distress. RESULTS: Patients had a mean age of 56.8 years; 61.6% were male, and 30.4% were minorities. The baseline mean A1C level was 9.1%. Intention-to-treat analyses found significant A1C reductions for all (12 months: CC -0.47%, IC -0.52%, DE -0.57%), with no differences between arms. Preplanned within-arm analyses were stratified by baseline A1C tertiles: lowest tertile (7.5-8.2%), no change from baseline; middle tertile (8.3-9.2%), only CC led to significantly lower A1C level; and highest tertile (≥9.3%), significant improvement for all interventions. For BMI, CC showed significant improvement, and CC and DE led to decreased waist circumference. The IC group showed greater blood pressure improvement. Results for secondary psychosocial outcomes favored the CC group. CONCLUSIONS: In adults with poorly controlled type 2 diabetes, a collaborative couples intervention resulted in significant, lasting improvement in A1C levels, obesity measures, and some psychosocial outcomes. For those with exceedingly high A1C levels, education alone was beneficial, but additional intervention is needed to achieve glycemic targets.

Student HPV vaccine attitudes and vaccine completion by education level.

PURPOSE: We describe HPV vaccine attitudes among students of different education levels. METHODS: High school, college, and graduate-level health care professional students were surveyed regarding HPV vaccine knowledge, attitudes, and receipt. Relationships between categorical variables were analyzed using chi-square tests of independence and z-tests for proportions. Means for quantitative variables were compared using t-tests and one-way analysis of variance. RESULTS: 57% and 42% of the 889 students reported starting and completing HPV vaccine series, respectively, with no statistical difference by education level. 61% of students who reported receiving a provider recommendation had completed the series, compared to 6% of those who did not receive recommendation (p<0.001). The belief that HPV vaccine prevents cancer was strongly associated with vaccine completion (p=0.003). CONCLUSION: HPV vaccine coverage rates remain suboptimal. Future interventions should focus on improving provider recommendation and patient belief that HPV vaccine prevents cancer.

Vaccine attitudes and practices among obstetric providers in New York State following the recommendation for pertussis vaccination during pregnancy.

UNLABELLED: To determine factors associated with obstetric provider recommendation of pertussis vaccine (Tdap) to their pregnant patients following the Advisory Committee on Immunization Practices (ACIP) recommendation that Tdap be given in the third trimester of each pregnancy. Obstetric providers across New York State anonymously completed a standard set of questions to assess vaccine recommendation knowledge and practice. STATISTICAL ANALYSIS: Descriptive statistical methods were used to define provider characteristics, knowledge and vaccine practices. Factors associated with recommendation were analyzed using odds ratios. 133 obstetric providers were included in the study. 11% and 13% expressed concern with pertussis vaccine safety and efficacy, respectively, in pregnant women. 92% of obstetric providers stated that they knew ACIP recommendations for Tdap during pregnancy, 80% recommended Tdap to all eligible patients, but only 67% provided Tdap vaccine in their office. Provider knowledge of recommendation (OR 23.33), routine provider recommendation of influenza vaccine (OR 12.5), and administration of pertussis vaccine in the office (OR 7.01) were all factors strongly associated with routine provider recommendation of Tdap vaccine to eligible pregnant women (P < 0.05). Providers expressed concerns with cost of Tdap, the need to administer Tdap with each pregnancy, vaccine safety, low incidence of pertussis in the area, and administration of pertussis vaccine at the hospital after delivery. Educational programs are needed to improve provider vaccine confidence and recommendation.

Pediatric provider vaccine hesitancy: An under-recognized obstacle to immunizing children.

OBJECTIVE: To describe vaccine attitudes among pediatric healthcare providers attending immunization conferences. STUDY DESIGN: Attendees of 5 American Academy of Pediatrics (AAP)-sponsored vaccine conferences held between June and November 2013 anonymously completed a questionnaire assessing vaccine attitudes and practices prior to the opening of educational sessions. Pearson's chi-square tests and Fisher's exact tests were used to analyze associations between vaccine attitudes, vaccine practices and provider characteristics. RESULTS: 680 providers attending AAP-sponsored vaccine conferences were included. 661/666 (99%) enrolled providers state they routinely recommend standard pediatric vaccines, yet, 30 (5%) state that they do not routinely recommend influenza and/or human papillomavirus (HPV) vaccines. These providers expressed vaccine safety (87/680 (13%)) and efficacy (21/680 (31%)) concerns and stated belief in vaccine misperceptions: vaccine causes autism (34/668, 5%), multiple vaccines at a single visit reduces vaccine efficacy (43/680, 6%) or overwhelms the immune system (63/680, 9%), and administering HPV vaccine will increase the likelihood of unprotected adolescent sexual activity (29/680, 4%). Six percent of providers who do not routinely recommend all pediatric vaccines correctly identified themselves as vaccine hesitant. CONCLUSION: Vaccine hesitancy is under-recognized among pediatric providers attending AAP-sponsored immunization conferences. Educational interventions tailored to address provider vaccine concerns are needed to improve provider vaccine confidence.

Outbreak of tuberculosis in a homeless men's shelter.

This case-tuberculosis in a homeless men's shelter-is one of a series of teaching cases in the Case-Based Series in Population-Oriented Prevention (C-POP). It has been developed for use in medical school and residency prevention curricula. The complete set of cases is presented in this supplement to the American Journal of Preventive Medicine. Tuberculosis presents a significant public health challenge. In this teaching case, medical students are given information about four cases of active tuberculosis that occurred over a short period of time in residents of a homeless men's shelter. The students then walk through the steps that a local health department takes to identify and screen those individuals at risk for transmission of tuberculosis during an outbreak. During this process, they learn skills in epidemiology (such as defining "epidemic" and distinguishing uses for incidence and prevalence) as well as in population-based prevention of tuberculosis. Finally students discuss health policy as it relates to the control and prevention of tuberculosis.