A cohort study measuring SARS-CoV-2 seroconversion and serial viral testing in university students.

BACKGROUND: To improve understanding of the antibody response to SARS-CoV-2 infection, we examined seroprevalence, incidence of infection, and seroconversion among a cohort of young adults living on university campuses during the fall of 2020. METHODS: At the beginning (semester start) and end (semester end) of an 11-week period, serum collected from 107 students was tested using the qualitative Abbott Architect SARS-CoV-2 IgG and AdviseDx SARS-CoV-2 IgG II assays. Results were matched to interim weekly surveillance viral testing and symptom data. RESULTS: With the SARS-CoV-2 IgG assay, 15 (14.0%) students were seropositive at semester start; 29 (27.1%) students were seropositive at semester end; 10 (9.3%) were seropositive at both times. With the AdviseDx SARS-CoV-2 IgG II assay, 17 (16.3%) students were seropositive at semester start, 37 (35.6%) were seropositive at semester end, and 16 (15.3%) were seropositive at both times. Overall, 23 students (21.5%) had positive viral tests during the semester. Infection was identified by serial testing in a large majority of individuals who seroconverted using both assays. Those seropositive at semester end more frequently reported symptomatic infections (56.5%) than asymptomatic infections (30.4%). CONCLUSION: Differences between antibody targets were observed, with more declines in antibody index values below the threshold of positivity with the anti-nucleocapsid assay compared to the anti-spike assay. Serology testing, combined with serial viral testing, can detect seroconversions, and help understand the potential correlates of protection provided by antibodies to SARS-CoV-2.

The Epidemic of Despair Among White Americans: Trends in the Leading Causes of Premature Death, 1999-2015.

OBJECTIVES: To evaluate trends in premature death rates by cause of death, age, race, and urbanization level in the United States. METHODS: We calculated cause-specific death rates using the Compressed Mortality File, National Center for Health Statistics data for adults aged 25 to 64 years in 2 time periods: 1999 to 2001 and 2013 to 2015. We defined 48 subpopulations by 10-year age groups, race/ethnicity, and county urbanization level (large urban, suburban, small or medium metropolitan, and rural). RESULTS: The age-adjusted premature death rates for all adults declined by 8% between 1999 to 2001 and 2013 to 2015, with decreases in 39 of the 48 subpopulations. Most decreases in death rates were attributable to HIV, cardiovascular disease, and cancer. All 9 subpopulations with increased death rates were non-Hispanic Whites, largely outside large urban areas. Most increases in death rates were attributable to suicide, poisoning, and liver disease. CONCLUSIONS: The unfavorable recent trends in premature death rate among non-Hispanic Whites outside large urban areas were primarily caused by self-destructive health behaviors likely related to underlying social and economic factors in these communities.

Combined Diet and Physical Activity Promotion Programs for Prevention of Diabetes: Community Preventive Services Task Force Recommendation Statement.

DESCRIPTION: Community Preventive Services Task Force recommendation on the use of combined diet and physical activity promotion programs to reduce progression to type 2 diabetes in persons at increased risk. METHODS: The Task Force commissioned an evidence review that assessed the benefits and harms of programs to promote and support individual improvements in diet, exercise, and weight and supervised a review on the economic efficiency of these programs in clinical trial, primary care, and primary care-referable settings. POPULATION: Adolescents and adults at increased risk for progression to type 2 diabetes. RECOMMENDATION: The Task Force recommends the use of combined diet and physical activity promotion programs by health care systems, communities, and other implementers to provide counseling and support to clients identified as being at increased risk for type 2 diabetes. Economic evidence indicates that these programs are cost-effective.

Combined Diet and Physical Activity Promotion Programs to Prevent Type 2 Diabetes Among Persons at Increased Risk: A Systematic Review for the Community Preventive Services Task Force.

BACKGROUND: Trials have shown efficacy of rigorous diet and physical activity promotion programs to reduce diabetes incidence and improve glycemic measures in adults at increased risk for type 2 diabetes. PURPOSE: To evaluate diet and physical activity promotion programs for persons at increased risk for type 2 diabetes, primarily to reduce diabetes risk and decrease body weight and glycemia. DATA SOURCES: MEDLINE, the Cochrane Central Register of Controlled Trials, CAB Abstracts, Global Health, and Ovid HealthSTAR from 1991 through 27 February 2015, with no language restriction. STUDY SELECTION: 8 researchers screened articles for single-group or comparative studies of combined diet and physical activity promotion programs with at least 2 sessions over at least 3 months in participants at increased risk for type 2 diabetes. DATA EXTRACTION: 7 researchers extracted data on study design; participant, intervention, and outcome descriptions; and results and assessed study quality. DATA SYNTHESIS: 53 studies (30 of diet and physical activity promotion programs vs. usual care, 13 of more intensive vs. less intensive programs, and 13 of single programs) evaluated 66 programs. Compared with usual care, diet and physical activity promotion programs reduced type 2 diabetes incidence (risk ratio [RR], 0.59 [95% CI, 0.52 to 0.66]) (16 studies), decreased body weight (net change, -2.2% [CI, -2.9% to -1.4%]) (24 studies) and fasting blood glucose level (net change, -0.12 mmol/L [-2.2 mg/dL] [CI, -0.20 to -0.05 mmol/L {-3.6 to -0.9 mg/dL}]) (17 studies), and improved other cardiometabolic risk factors. Evidence for clinical events was limited. More intensive programs were more effective. LIMITATIONS: Wide variation in diet and physical activity promotion programs limited identification of features most relevant to effectiveness. Evidence on clinical outcomes and in children was sparse. CONCLUSION: Combined diet and physical activity promotion programs are effective at decreasing diabetes incidence and improving cardiometabolic risk factors in persons at increased risk. More intensive programs are more effective. PRIMARY FUNDING SOURCE: Centers for Disease Control and Prevention Community Preventive Services Task Force.

A Qualitative Pilot Study of Pediatricians' Approach to Childhood Obesity.

IMPORTANCE: Over the past 3 decades, rates of childhood obesity have tripled. Given the gravity of this health concern, it is important that physicians intervene early. However, physicians continue to underdiagnose and undertreat childhood overweight and obesity. OBJECTIVE: The aim of this pilot study was to identify current tools and strategies used by pediatricians in regard to childhood obesity, as well as to reassess barriers to success, and to uncover areas for improvement. DESIGN: One-on-one interviews were conducted with pediatricians during the summer of 2013. Seven of the interviews occurred in person, and 10 occurred via telephone. Each interview lasted 30 to 60 minutes. All interviewees (n = 17, 13.2% response rate) were Wisconsin pediatricians, representing 7 different health systems. MAIN OUTCOMES: Themes relating to pediatrician's experiences in addressing and managing childhood obesity. RESULTS: Pediatricians interviewed in this survey are comfortable identifying and diagnosing pediatric obesity with the widespread use of electronic health records. They have several tools and strategies at their disposal for the treatment and management of obesity, but do not often achieve the desired outcome of achieving healthy body weight. Most of them lack connections to community resources and the ability to effectively communicate with referral systems outside of their clinic, such as with dietitians. CONCLUSIONS: Building stronger connections between physicians and dietitians, as well as between physicians and the local community, may allow physicians to feel more empowered when it comes to managing childhood obesity.

Variation in Breast Cancer-Risk Factor Associations by Method of Detection: Results From a Series of Case-Control Studies.

Concerns about breast cancer overdiagnosis have increased the need to understand how cancers detected through screening mammography differ from those first detected by a woman or her clinician. We investigated risk factor associations for invasive breast cancer by method of detection within a series of case-control studies (1992-2007) carried out in Wisconsin, Massachusetts, and New Hampshire (n=15,648 invasive breast cancer patients and 17,602 controls aged 40-79 years). Approximately half of case women reported that their cancer had been detected by mammographic screening and half that they or their clinician had detected it. In polytomous logistic regression models, parity and age at first birth were more strongly associated with risk of mammography-detected breast cancer than with risk of woman/clinician-detected breast cancer (P≤0.01; adjusted for mammography utilization). Among postmenopausal women, estrogen-progestin hormone use was predominantly associated with risk of woman/clinician-detected breast cancer (odds ratio (OR)=1.49, 95% confidence interval (CI): 1.29, 1.72), whereas obesity was predominantly associated with risk of mammography-detected breast cancer (OR=1.72, 95% CI: 1.54, 1.92). Among regularly screened premenopausal women, obesity was not associated with increased risk of mammography-detected breast cancer (OR=0.99, 95% CI: 0.83, 1.18), but it was associated with reduced risk of woman/clinician-detected breast cancer (OR=0.53, 95% CI: 0.43, 0.64). These findings indicate important differences in breast cancer risk factors according to method of detection.

The County Health Rankings: rationale and methods.

BACKGROUND: Annually since 2010, the University of Wisconsin Population Health Institute and the Robert Wood Johnson Foundation have produced the County Health Rankings-a "population health checkup" for the nation's over 3,000 counties. The purpose of this paper is to review the background and rationale for the Rankings, explain in detail the methods we use to create the health rankings in each state, and discuss the strengths and limitations associated with ranking the health of communities. METHODS: We base the Rankings on a conceptual model of population health that includes both health outcomes (mortality and morbidity) and health factors (health behaviors, clinical care, social and economic factors, and the physical environment). Data for over 30 measures available at the county level are assembled from a number of national sources. Z-scores are calculated for each measure, multiplied by their assigned weights, and summed to create composite measure scores. Composite scores are then ordered and counties are ranked from best to worst health within each state. RESULTS: Health outcomes and related health factors vary significantly within states, with over two-fold differences between the least healthy counties versus the healthiest counties for measures such as premature mortality, teen birth rates, and percent of children living in poverty. Ranking within each state depicts disparities that are not apparent when counties are ranked across the entire nation. DISCUSSION: The County Health Rankings can be used to clearly demonstrate differences in health by place, raise awareness of the many factors that influence health, and stimulate community health improvement efforts. The Rankings draws upon the human instinct to compete by facilitating comparisons between neighboring or peer counties within states. Since no population health model, or rankings based off such models, will ever perfectly describe the health of its population, we encourage users to look to local sources of data to understand more about the health of their community.

The Development of a Summary Measure to Estimate the Relative Burden of Smoking in Wisconsin Counties.

BACKGROUND: The rate of cigarette smoking among US adults has declined over the past 50 years. Yet smoking remains the leading cause of preventable death and marked disparities now exist in smoking rates based on education level, socioeconomic status, race/ethnicity, and geographic location. In order to target resources to reduce these disparities, a summary measure comparing the relative burden of smoking among smaller populations is needed. OBJECTIVE: To create a single summary measure that assesses the relative health burden from smoking in Wisconsin counties using age-adjusted mortality rates for smoking-attributable diseases, current adult smoking prevalence, and the current rate of mothers who smoked during pregnancy. RESULTS: Rates varied significantly between counties for smoking-attributable deaths (2-fold), adult smoking prevalence (5-fold), and smoking in pregnancy (5-fold). The summary measure of relative smoking burden was highest in rural counties and in counties with less education, higher rates of poverty, and more veterans. The ranking of a county's smoking burden was highly correlated with its overall health ranking from the County Health Rankings. DISCUSSION: The burden from smoking varied markedly across Wisconsin and was highest in the least advantaged counties in the state. Additional public health efforts must be directed toward the counties with the greater relative smoking burden in order to reduce these disparities.

Incidence, Survival, and Mortality of Malignant Cutaneous Melanoma in Wisconsin, 1995-2011.

OBJECTIVE: To assess trends in malignant melanoma incidence, survival, and mortality in Wisconsin. METHODS: Incidence data for Wisconsin were obtained from the Wisconsin Cancer Reporting System Bureau of Health Information using Wisconsin Interactive Statistics on Health, while incidence data for the United States were obtained from the Surveillance, Epidemiology, and End Results system (SEER). The mortality to incidence ratio [1 - (mortality/incidence)] was used as a proxy to estimate relative 5-year survival in Wisconsin, while observed 5-year survival rates for the United States were obtained from SEER. Mortality data for both Wisconsin and the United States were extracted using the Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research. RESULTS: During the past decade, malignant melanoma incidence rates increased 57% in Wisconsin (from 12.1 to 19.0 cases per 100,000) versus a 33% increase (from 20.9 to 27.7 cases per 100,000) in the United States during the same time period. The greatest Wisconsin increase in incidence was among women ages 45-64 years and among men ages 65 years and older. Overall relative percent difference in 5-year survival in Wisconsin rose 10% (from 77% to 85%) and was unchanged (82%) for the United States. Wisconsin overall mortality rates were unchanged at 2.8 deaths per 100,000, compared to a 10% increase in the United States (from 3.1 to 3.4 deaths per 100,000). Wisconsin mortality rates improved for women ages 45-64 and for men ages 25-44. CONCLUSION: Despite improvements in malignant melanoma survival rates, increases in incidence represent a major public health challenge for physicians and policymakers.

A Novel Approach for Measuring and Communicating State Health Trends Over Time.

OBJECTIVE: To develop a method to assess long-term and recent progress for leading health indicators in Wisconsin. METHODS: Data from state and national sources were compiled. Baseline (10-year) trends for 20 health indicators were measured and compared to the Healthy People 2020 improvement standard of 1% per year. Additionally, current rates were assessed by comparing the most recent year of data to the expected rate had the previous 10-year baseline trend continued. Where available, health indicator trends were reported by gender, race/ethnicity, geography, and socioeconomic status. RESULTS: Wisconsin improved on 10 of the 20 indicators over the past decade, with decreasing mortality rates for all age groups. The largest improvement was a decline of 3.0% per year in deaths among ito 24 year olds. The rates of teen births and adult excessive drinking also improved by 2.5% per year and 1.4% per year, respectively. Other indicators worsened. For example, increasing rates of low birthweight (+ 0.6% per year), adults in fair or poor health (+1.6% per year), and all socioeconomic indicators worsened (high school dropouts [+0.9% per year], unemployment [+5.9% per year], children in poverty [+5.1% per year], and violent crime [+2.3% per year]). Health indicators varied substantially across subgroups within Wisconsin. For example, African Americans were twice as likely to experience low birthweight compared to other racial subgroups, and males experienced death rates higher than females across all ages. CONCLUSION: Reporting current estimates and 10-year trends of leading health indicators helps identify areas of progress and opportunities for improvement. Despite progress in reducing death rates and several other health factors, self-reported health status is worsening in Wisconsin. Worsening socioeconomic conditions and health disparities represent significant public health challenges for Wisconsin's future.

Modification of breast cancer risk according to age and menopausal status: a combined analysis of five population-based case-control studies.

While several risk factors for breast cancer have been identified, studies have not consistently shown whether these factors operate more strongly at certain ages or for just pre- or postmenopausal women. We evaluated whether risk factors for breast cancer differ according to age or menopausal status. Data from five population-based case-control studies conducted during 1988-2008 were combined and analyzed. Cases (N = 23,959) and population controls (N = 28,304) completed telephone interviews. Logistic regression was used to estimate adjusted odds ratios and 95 % confidence intervals and tests for interaction by age and menopausal status. Odds ratios for first-degree family history of breast cancer were strongest for younger women-reaching twofold elevations-but were still statistically significantly elevated by 58-69 % among older women. Obesity was inversely associated with breast cancer among younger women and positively associated with risk for older women (interaction P < 0.0001). Recent alcohol intake was more strongly related to breast cancer risk among older women, although consumption of 3 or more drinks/day among younger women also was associated with elevated odd ratios (P < 0.0001). Associations with benign breast disease and most reproductive/menstrual factors did not vary by age. Repeating analysis stratifying by menopausal status produced similar results. With few exceptions, menstrual and lifestyle factors are associated with breast cancer risk regardless of age or menopausal status. Variation in the association of family history, obesity, and alcohol use with breast cancer risk by age and menopausal status may need to be considered when determining individual risk for breast cancer.

The association between motor vehicle injuries and health-related quality of life: a longitudinal study of a population-based sample in the United States.

PURPOSE: As many as 3 million US residents are injured in traffic-related incidents every year leaving many victims with disabling conditions. To date, limited numbers of studies have examined the effects of traffic-related injuries on self-reported health. This study aims to examine the association between health-related quality of life (HRQOL) and traffic-related injuries longitudinally in a nationally representative sample of US adult population. METHODS/APPROACH: This is a longitudinal study of adult participants (age ≥18) from seven panels (2000-2007) of the Medical Expenditure Panel Survey. The dependent variables included the physical and mental components of the SF-12, a measure of self-reported health. The outcome was assessed twice during the follow-up period: round 2 (~4-5 months into the study) and round 4 (~18 months into the study) for 62,298 individuals. Two methods estimate the association between traffic-related injuries and HRQOL: a within person change using paired tests and a between person change using multivariable regression adjusting for age, sex, income and educational level. RESULTS: Nine hundred and ninety-three participants reported traffic-related injuries during the follow-up period. Compared to their pre-crash HRQOL, these participants lost 2.7 of the physical component score while their mental component did not change. Adjusted results showed significant deficits in the physical component (-2.84, p value = <.001) but not the mental component (-0.07, p value = .83) of HRQOL after controlling for potential confounders. CONCLUSION: Traffic injuries were significantly associated with the physical component of HRQOL. These findings highlight the individual and societal burden associated with motor vehicle crash-related disability in the United States.

Academic health departments as training sites for future public health leaders: a partnership model in Wisconsin.

BACKGROUND: In 2004, 2 Wisconsin academic health departments partnered with the School of Medicine and Public Health, University of Wisconsin-Madison to strengthen the public health workforce through a service-learning program that prepares the next generation of leaders while addressing local public health needs. The Wisconsin Population Health Service Fellowship annually provides 4 to 6 master's or doctorally trained fellows with 2-year service-learning placements in health departments and community-based organizations. PROGRAM BENEFITS: Placement communities benefit from fellows' contributions to a broad range of public health issues, including chronic and communicable disease prevention, health equity, community practice, and policy and systems change. Academic health departments and the UW School of Medicine and Public Health enjoy additional program benefits, along with the advantages that accrue to the fellows themselves. For the academic health departments, this includes increased organizational capacity, generation of resources for public health, and a stronger and more diverse public health workforce. LESSONS LEARNED: The success of the partnership depends upon shared decision making and management, written agreements to clarify partner expectations, shared financial and in-kind contributions, and collaboration on program evaluation and dissemination. CONCLUSIONS: By building upon their respective organizational strengths, Wisconsin's academic health departments and the UW School of Medicine and Public Health have developed a successful model for transforming talented, highly motivated young professionals into confident, emerging public health leaders with the cutting-edge skills and connections necessary to improve population health outcomes and advance health equity.

Evaluating the implementation of a primary care weight management toolkit.

OBJECTIVE: With over one-third of adults in the United States classified as obese, new recommendations call for screening all adults for obesity at outpatient visits. The UW Health Fox Valley Clinic does not actively screen for obesity. The objective of this project was to test the feasibility of an obesity screening and brief intervention protocol. PROCESS: A modified version of the Promoting Healthier Weight in Primary Care toolkit was implemented into a family medicine practice for 6 weeks. Patients (N = 88) were asked about visit satisfaction and acceptability of weight-focused conversation. Providers (N = 22) were asked about acceptability and feasibility of use. OUTCOME: Almost all patients (97.7%) found the conversation acceptable. Providers found the toolkit helpful, not confusing for their patients, and easy to use. Time was the greatest barrier.

The epidemiology of maternal overweight in Dane County, Wisconsin.

BACKGROUND: Research shows that maternal obesity leads not only to adverse pregnancy outcomes but also can act as a predictor of poor health of future generations. The Public Health Madison & Dane County Fetal and Infant Mortality Review Board observed poor health associated with prepregnancy BMI > or = 25, prompting further exploration of this issue in the Dane County, Wisconsin population. OBJECTIVE: This is a descriptive epidemiologic study of the problem of maternal overweight defined as prepregnancy BMI > or = 25 in Dane County. METHODS: Data were abstracted from the Secure Public Health Electronic Records Environment (SPHERE) on births in Dane County in 2011. Risk ratios were used to determine associations between race, education, parity, gravidity, and place of residence and maternal overweight. A t test was completed to determine differences in mean age of overweight and healthy weight mothers. RESULTS: Approximately half (50.6%) of Dane County mothers in 2011 were overweight or obese prepregnancy. Results showed increased risk of overweight for black mothers and multiparous/multigravidous mothers. There was no difference in mean age of overweight and healthy weight mothers. Overweight rates varied considerably by ZIP code of residence. CONCLUSION: Rates of maternal overweight vary significantly in Dane County by social and demographic factors. This information can be used to design and target interventions and monitor trends over time.

Monitoring progress in population health: trends in premature death rates.

INTRODUCTION: Trends in population health outcomes can be monitored to evaluate the performance of population health systems at the national, state, and local levels. The objective of this study was to compare and contrast 4 measures for assessing progress in population health improvement by using age-adjusted premature death rates as a summary measure of the overall health outcomes in the United States and in all 50 states. METHODS: To evaluate the performance of statewide population health systems during the past 20 years, we used 4 measures of age-adjusted premature (<75 years of age) death rates: current rates (2009), baseline trends (1990s), follow-up trends (2000s), and changes in trends from baseline to the follow-up periods (ie, "bending the curve"). RESULTS: Current premature death rates varied by approximately twofold, with the lowest rate in Minnesota (268 deaths per 100,000) and the highest rate in Mississippi (482 deaths per 100,000). Rates improved the most in New York during the baseline period (-3.05% per year) and in New Jersey during the follow-up period (-2.87% per year), whereas Oklahoma ranked last in trends during both periods (-0.30%/y, baseline; +0.18%/y, follow-up). Trends improved the most in Connecticut, bending the curve downward by -1.03%; trends worsened the most in New Mexico, bending the curve upward by 1.21%. DISCUSSION: Current premature death rates, recent trends, and changes in trends vary by state in the United States. Policy makers can use these measures to evaluate the long-term population health impact of broad health care, behavioral, social, and economic investments in population health.

Using empirical Bayes methods to rank counties on population health measures.

University of Wisconsin Population Health Institute has published County Health Rankings (The Rankings) since 2010. These rankings use population-based data to highlight variation in health and encourage health assessment for all US counties. However, the uncertainty of estimates remains a limitation. We sought to quantify the precision of The Rankings for selected measures. We developed hierarchical models for 5 health outcome measures and applied empirical Bayes methods to obtain county rank estimates for a composite health outcome measure. We compared results using models with and without demographic fixed effects to determine whether covariates improved rank precision. Counties whose rank had wide confidence intervals had smaller populations or ranked in the middle of all counties for health outcomes. Incorporating covariates in the models produced narrower intervals, but rank estimates remained imprecise for many counties. Local health officials, especially in smaller population and mid-performing communities, should consider these limitations when interpreting the results of The Rankings.

Look local: the value of cancer surveillance and reporting by American Indian clinics.

INTRODUCTION: Cancer incidence and mortality rates for American Indians in the Northern Plains region of the United States are among the highest in the nation. Reliable cancer surveillance data are essential to help reduce this burden; however, racial data in state cancer registries are often misclassified, and cases are often underreported. METHODS: We used a community-based participatory research approach to conduct a retrospective ascertainment of cancer cases in clinic medical records over a 9-year period (1995-2003) and compared the results with the state cancer registry to evaluate missing or racially misclassified cases. Six tribal and/or urban Indian clinics participated in the study. The project team consisted of participating clinics, a state cancer registry, a comprehensive cancer center, an American Indian/Alaska Native Leadership Initiative on Cancer, and a set of diverse organizational partners. Clinic personnel were trained by project staff to accurately identify cancer cases in clinic records. These records were then matched with the state cancer registry to assess misclassification and underreporting. RESULTS: Forty American Indian cases were identified that were either missing or misclassified in the state registry. Adding these cases to the registry increased the number of American Indian cases by 21.3% during the study period (P = .05). CONCLUSIONS: Our results indicate that direct reporting of cancer cases by tribal and urban Indian health clinics to a state cancer registry improved the quality of the data available for cancer surveillance. Higher-quality data can advance the efforts of cancer prevention and control stakeholders to address disparities in Native communities.