Toward a New Strategic Public Health Science for Policy, Practice, Impact, and Health Equity.

The COVID-19 pandemic and its social and health impact have underscored the need for a new strategic science agenda for public health. To optimize public health impact, high-quality strategic science addresses scientific gaps that inform policy and guide practice. At least 6 scientific gaps emerge from the US experience with COVID-19: health equity science, data science and modernization, communication science, policy analysis and translation, scientific collaboration, and climate science. Addressing these areas within a strategic public health science agenda will accelerate achievement of public health goals. Public health leadership and scientists have an unprecedented opportunity to use strategic science to guide a new era of improved and equitable public health.

Community-Based Interventions to Decrease Obesity and Tobacco Exposure and Reduce Health Care Costs: Outcome Estimates From Communities Putting Prevention to Work for 2010-2020.

INTRODUCTION: In 2010, the Centers for Disease Control and Prevention (CDC) launched Communities Putting Prevention to Work (CPPW), a $485 million program to reduce obesity, tobacco use, and exposure to secondhand smoke. CPPW awardees implemented evidence-based policy, systems, and environmental changes to sustain reductions in chronic disease risk factors. This article describes short-term and potential long-term benefits of the CPPW investment. METHODS: We used a mixed-methods approach to estimate population reach and to simulate the effects of completed CPPW interventions through 2020. Each awardee developed a community action plan. We linked plan objectives to a common set of interventions across awardees and estimated population reach as an early indicator of impact. We used the Prevention Impacts Simulation Model (PRISM), a systems dynamics model of cardiovascular disease prevention, to simulate premature deaths, health care costs, and productivity losses averted from 2010 through 2020 attributable to CPPW. RESULTS: Awardees completed 73% of their planned objectives. Sustained CPPW improvements may avert 14,000 premature deaths, $2.4 billion (in 2010 dollars) in discounted direct medical costs, and $9.5 billion (in 2010 dollars) in discounted lifetime and annual productivity losses through 2020. CONCLUSION: PRISM results suggest that large investments in community preventive interventions, if sustained, could yield cost savings many times greater than the original investment over 10 to 20 years and avert 14,000 premature deaths.

The Program Cost of a Brief Video Intervention Shown in Sexually Transmitted Disease Clinic Waiting Rooms.

BACKGROUND: Patients in sexually transmitted disease (STD) clinic waiting rooms represent a potential audience for delivering health messages via video-based interventions. A controlled trial at 3 sites found that patients exposed to one intervention, Safe in the City, had a significantly lower incidence of STDs compared with patients in the control condition. An evaluation of the intervention's cost could help determine whether such interventions are programmatically viable. MATERIALS AND METHODS: The cost of producing the Safe in the City intervention was estimated using study records, including logs, calendars, and contract invoices. Production costs were divided by the 1650 digital video kits initially fabricated to get an estimated cost per digital video. Clinic costs for showing the video in waiting rooms included staff time costs for equipment operation and hardware depreciation and were estimated for the 21-month study observation period retrospectively. RESULTS: The intervention cost an estimated $416,966 to develop, equaling $253 per digital video disk produced. Per-site costs to show the video intervention were estimated to be $2699 during the randomized trial. CONCLUSIONS: The cost of producing and implementing Safe in the City intervention suggests that similar interventions could potentially be produced and made available to end users at a price that would both cover production costs and be low enough that the end users could afford them.

Reduced Disparity in Vegetable Consumption in 16 Disadvantaged Black Communities: A Successful 5-Year Community-Based Participatory Intervention.

BACKGROUND: Data on large scale community-level interventions on fruit and vegetable consumption targeting minority communities are lacking. This study examined whether a multicommunity intervention decreased disparities in fruit and vegetable consumption. MATERIALS AND METHODS: The Racial and Ethnic Approaches to Community Health (REACH) 2010 program was conducted among 16 black communities. Five-year trends (2001-2006) in self-reported fruit and vegetable consumption among the target population were compared with trends among white and black populations in 14 states where communities were located. RESULTS: The geometric mean of combined fruit and vegetable consumption in the REACH communities increased 7.4 % (P0.001) but did not change among white and black populations in comparison states (P0.05). Increased consumption in REACH communities was higher in the lower quintiles of consumptions. The disparity in fruits and vegetables consumption between comparison white population and blacks in REACH communities decreased by 33 %-from 0.66 to 0.44 times per day. The target population of 1.2 million people consumed fruits and vegetables about 21.9 million additional times per year as a result of the REACH program. CONCLUSION: This large community-based participatory intervention successfully reduced isparities in fruit and vegetable consumption between comparison white population and 16 disadvantaged black communities.

The cost-effectiveness of screening men who have sex with men for rectal chlamydial and gonococcal infection to prevent HIV Infection.

BACKGROUND: Men who have sex with men (MSM) who have a current or recent history of rectal Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) infection are at greater risk for HIV than MSM with no history of rectal infection. Screening and treating MSM for rectal CT/GC infection may help reduce any increased biological susceptibility to HIV infection. METHODS: We used 2 versions of a Markov state-transition model to examine the impact and cost-effectiveness of screening MSM for rectal CT/GC infection in San Francisco: a static version that included only the benefits to those screened and a dynamic version that accounted for population-level impacts of screening. HIV prevention through reduced susceptibility to HIV was the only potential benefit of rectal CT/GC screening that we included in our analysis. Parameter values were based on San Francisco program data and the literature. RESULTS: In the base case, the cost per quality-adjusted life year gained through screening MSM for rectal CT/GC infection was $16,300 in the static version of the model. In the dynamic model, the cost per quality-adjusted life year gained was less than $0, meaning that rectal screening was cost-saving. The impact of rectal CT/GC infection on the risk of HIV acquisition was the most influential model parameter. CONCLUSIONS: Although more information is needed regarding the impact of rectal CT/GC screening on HIV incidence, rectal CT/GC screening of MSM can potentially be a cost-effective, scalable intervention targeted to at-risk MSM in certain urban settings such as San Francisco.

The association between racial disparity in income and reported sexually transmitted infections.

OBJECTIVES: We examined the association between racial disparity in income and reported race-specific county-level bacterial sexually transmitted infections (STIs) in the United States focusing on disparities between Blacks and Whites. METHODS: Data are from the US 2000 decennial census. We defined 2 race-income county groups (high and low race-income disparity) on the basis of the difference between Black and White median household incomes. We used 2 approaches to examine disparities in STI rates across the groups. In the first approach, we computed and compared race-specific STI rates for the groups. In the second approach, we used spatial regression analyses to control for potential confounders. RESULTS: Consistent with the STI literature, chlamydia, gonorrhea, and syphilis rates for Blacks were substantially higher than were those for Whites. We also found that racial disparities in income were associated with racial disparities in chlamydia and gonorrhea rates and, to a lesser degree, syphilis rates. CONCLUSIONS: Racial disparities in household income may be a more important determinant of racial disparities in reported STI morbidity than are absolute levels of household income.

Investigating the potential public health benefit of jail-based screening and treatment programs for chlamydia.

Observational studies have found mixed results on the impact of jail-based chlamydia screen-and-treat programs on community prevalence. In the absence of controlled trials or prospectively designed studies, dynamic mathematical models that incorporate movements in and out of jail and sexual contacts (including disease transmission) can provide useful information. We explored the impact of jail-based chlamydia screening on a hypothetical community's prevalence with a deterministic compartmental model focusing on heterosexual transmission. Parameter values were obtained from the published literature. Two analyses were conducted. One used national values (large community); the other used values reported among African Americans--the population with the highest incarceration rates and chlamydia burden (small community). A comprehensive sensitivity analysis was carried out. For the large-community analysis, chlamydia prevalence decreased by 13% (from 2.3% to 2.0%), and based on the ranges of parameter values (including screening coverage of 10%-100% and a postscreening treatment rate of 50%-100%) used in the sensitivity analysis, this decrease ranged from 0.1% to 58%. For the small-community analysis, chlamydia prevalence decreased by 54% (from 4.6% to 2.1%). Jail-based chlamydia screen-and-treat programs have the potential to reduce chlamydia prevalence in communities with high incarceration rates. However, the magnitude of this potential decrease is subject to considerable uncertainty.

The estimated direct medical cost of selected sexually transmitted infections in the United States, 2008.

BACKGROUND: Millions of cases of sexually transmitted infections (STIs) occur in the United States each year, resulting in substantial medical costs to the nation. Previous estimates of the total direct cost of STIs are quite dated. We present updated direct medical cost estimates of STIs in the United States. METHODS: We assembled recent (i.e., 2002-2011) cost estimates to determine the lifetime cost per case of 8 major STIs (chlamydia, gonorrhea, hepatitis B virus, human immunodeficiency virus (HIV), human papillomavirus, genital herpes simplex virus type 2, trichomoniasis and syphilis). The total direct cost for each STI was computed as the product of the number of new or newly diagnosed cases in 2008 and the estimated discounted lifetime cost per case. All costs were adjusted to 2010 US dollars. RESULTS: Results indicated that the total lifetime direct medical cost of the 19.7 million cases of STIs that occurred among persons of all ages in 2008 in the United States was $15.6 (range, $11.0-$20.6) billion. Total costs were as follows: chlamydia ($516.7 [$258.3-$775.0] million), gonorrhea ($162.1 [$81.1-$243.2] million), hepatitis B virus ($50.7 [$41.3-$55.6] million), HIV ($12.6 [$9.5-$15.7] billion), human papillomavirus ($1.7 [$0.8-$2.9] billion), herpes simplex virus type 2 ($540.7 [$270.3-$811.0] million), syphilis ($39.3 [$19.6-$58.9] million), and trichomoniasis ($24.0 [$12.0-$36.0] million). Costs associated with HIV infection accounted for more than 81% of the total cost. Among the nonviral STIs, chlamydia was the most costly infection. CONCLUSIONS: Sexually transmitted infections continue to impose a substantial cost burden on the payers of medical care in the United States. The burden of STIs would be even greater in the absence of STI prevention and control efforts.

Chlamydia testing patterns for commercially insured women, 2008.

BACKGROUND: Annual chlamydia screening for sexually active women aged ≤25 years is recommended, and chlamydia testing rates have continuously increased. However, several studies have shown that many providers screen all women of reproductive age in public settings. PURPOSE: To examine chlamydia testing patterns in private settings for women and young women aged 15-44 years (hereafter referred to as women). METHODS: A large commercial claims database was used to estimate the chlamydia testing rate for women aged 15-44 years who had reproductive health services in 2008. Such services and tests were identified using diagnostic and procedural codes in 2008. RESULTS: Of 3.2 million women aged 15-44 years who had reproductive health services in 2008, 19.2% had at least a claim for a sexually transmitted disease (STD), 29.3% for pregnancy, and 81.2% for a gynecologic exam. Of those 3.2 million, 22.3% had chlamydia testing: 34.2% aged 15-25 years vs 18.3% aged 26-44 years. Of the 0.7 million who were tested, 65% were aged 26-44 years, and the reason for the healthcare visit in which their first chlamydia test was performed was an STD for 22.7% and pregnancy for 33.5%. CONCLUSIONS: In this population of insured women, young women are undertested and older women are overtested for chlamydia. Efforts to improve screening practices should be evaluated.

A brief review of the estimated economic burden of sexually transmitted diseases in the United States: inflation-adjusted updates of previously published cost studies.

We conducted a literature review of studies of the economic burden of sexually transmitted diseases in the United States. The annual direct medical cost of sexually transmitted diseases (including human immunodeficiency virus) has been estimated to be $16.9 billion (range: $13.9-$23.0 billion) in 2010 US dollars.

Chlamydia screening of young sexually active, Medicaid-insured women by race and ethnicity, 2002-2005.

OBJECTIVE: To estimate chlamydia screening rates of young sexually active Medicaid-insured women by race and ethnicity and age from 2002 to 2005. METHODS: Using Medicaid child claims data from the MarketScan database, we estimated the proportion of sexually active women aged 15 to 21 years screened for chlamydia by race and ethnicity and by age group (15-16, 17-18, and 19-21 years) using codes for medical diagnostic and procedural claims. RESULTS: Overall, chlamydia screening increased from 34% in 2002 to 44% in 2005. In all years, black women had significantly higher screening rates compared with white women (e.g., 51% vs. 39% in 2005). When stratified by age, black women were still significantly more likely to be screened for chlamydia than white women. CONCLUSIONS: Although it is encouraging that screening has increased over time and that black women were more likely to be screened than white women, rates remain suboptimal for all women. Effective and targeted interventions are needed to improve chlamydia screening of young women. As interventions to increase screening are developed and implemented, the estimation method described in this article can be used to track chlamydia screening trends in racial and ethnic populations over time.

Estimates of the direct cost per case and overall burden of trichomoniasis for the employer-sponsored privately insured women population in the United States, 2001 to 2005.

BACKGROUND: Little is known about the direct medical cost and overall burden of trichomoniasis among women in the United States. METHODS: We extracted insurance claims for trichomoniasis for 2001 to 2005 from the MEDSTAT MarketScan database using International Classification of Diseases, ninth revision codes. The analysis was restricted to outpatient care and prescription drug claims for women in 4 age categories; under 15, 15 to 24, 25 to 34, and 35 to 64. We used Current Procedures Terminology codes to analyze diagnostic methodologies. All costs were adjusted to 2005 US dollars. RESULTS: The average outpatient and prescription drug costs per episode for all ages were 97 dollars and 9 dollars, respectively. The resulting average total cost per episode was 101 dollars (about 50% did not have drug costs). Average total cost among women aged 15 to 24 years (120 dollars) was significantly (P < 0.01) higher than all other age categories. The estimated annual economic burden was 6.8 million dollars among privately insured women and 18.9 million dollars among all women from the United States. The incidence rate for female enrollees (all ages) having claims was 91 per 100,000 enrollees. Incidence rates were highest for women aged 25 to 29 years (185 per 100,000), followed by women aged 20 to 24 years (166 per 100,000). The most common diagnostic procedure seemed to be wet mount, but nonspecificity of Current Procedures Terminology codes inhibited the analysis of diagnostic methodologies. CONCLUSION: The estimated economic burden was highest among reproductive age women (15-34 years). Our estimated economic burden represents a lower-bound estimate because it was based on direct medical costs only.

The program cost and cost-effectiveness of screening men for Chlamydia to prevent pelvic inflammatory disease in women.

BACKGROUND: Because men transmit Chlamydia trachomatis to women, screening men to prevent pelvic inflammatory disease in women may be a viable strategy. However, the cost-effectiveness of this approach requires careful assessment. METHODS: Data from a demonstration project and longitudinal study that examined screening men for chlamydia were applied to a compartment-based transmission model to estimate the cost-effectiveness of screening men for chlamydia compared with alternative interventions, including expanded screening of women and combining disease investigation specialist-provided partner notification with screening. Cases of pelvic inflammatory disease and quality-adjusted life years lost were the primary outcome measures. A male screening program that screened 1% of men in the population annually was modeled. RESULTS: A program targeting high-risk men for screening (those with a larger number of partners in the previous year than the general population and a higher chlamydia prevalence) was cost saving compared with using equivalent program dollars to expand screening of lower-risk women. Combining partner notification with male screening was more effective than screening men alone. In sensitivity analyses, the male program was not always cost saving but averaged $10,520 per quality-adjusted life year saved over expanded screening of women. CONCLUSIONS: Screening men can be a cost-effective alternative to screening women, but the men screened must have a relatively high prevalence compared with the women to whom screening would be expanded (under baseline assumptions, the prevalence in screened men was 86% higher than that of screened women). These modeling results suggest that programs targeting venues that have access to high-risk men can be effective tools in chlamydia prevention.

HIV partner notification outcomes for HIV-infected patients by duration of infection, San Francisco, 2004 to 2006.

BACKGROUND: The San Francisco Department of Public Health conducts HIV third-party partner notification in the following populations based on standard Centers for Disease Control and Prevention (CDC) guidelines: (1) persons with acute and nonacute incident HIV infection tested at the municipal sexually transmitted disease (STD) clinic and the county hospital and (2) all county residents with early syphilis and long-standing HIV infection. METHODS: We reviewed routinely collected demographic and partner notification outcome data among acute and nonacute cases between 2004 and 2006 and among long-standing cases between July 2005 and December 2006. Outcomes were examined among the 3 case types. RESULTS: Most acute (n = 30), nonacute (n = 398), and long-standing cases (n = 335) occurred in gay/bisexual men (89%), and most case-patients were interviewed (80%). In acute and nonacute cases, 13% of partners tested for HIV were newly identified as HIV-infected. The number of patients interviewed per new HIV infection identified was 25 for acute cases, 21 for nonacute cases, and 39 for long-standing cases; however, half of recent new HIV infections were identified among partners of long-standing patients. Few patients or partners refused partner notification services. CONCLUSIONS: Partner notification was acceptable and successfully identified new HIV infections. Other jurisdictions should consider implementing or expanding partner notification for HIV infection. More evaluation is needed of the effectiveness of partner notification among HIV-infected persons with other STDs.

Community-based chlamydia and gonorrhea screening through the United States mail, San Francisco.

BACKGROUND: Because gonococcal and chlamydial infections are often asymptomatic, disease control requires population-based screening. This report describes the feasibility of home-based testing for sexually transmitted diseases (STDs) and of specimen transport via the US mail. GOAL: This project sought to establish the efficacy and acceptability to the public of screening by means of urine kits made available in public places and mailed in for STD testing. STUDY DESIGN: Self-selected community participants obtained STD test kits from local businesses, collected urine specimens at home, and mailed kits to the health department for nucleic acid amplification testing. RESULTS: Participants picked up 209 test kits and returned 80 (38%): 3 (3.8%) of 76 were positive for gonorrhea and 1 (1.3%) of 76 was positive for chlamydia. The majority (95%) of participants were white gay men. The cost of specimen collection and transport was similar to that of other population-based screening programs. CONCLUSION: Using the mail for home-based testing for gonorrhea and chlamydia was feasible and may be a useful addition to STD control efforts.