Community-Based Outbreak Investigation And Response: Enhancing Preparedness, Public Health Capacity, And Equity.

Throughout the COVID-19 pandemic, the US has struggled with many aspects of the public health response, from determining where transmission is occurring to building trust with communities and implementing interventions. Three factors have contributed to these challenges: insufficient local public health capacity, siloed interventions, and underuse of a cluster-based approach to outbreak response. In this article we introduce Community-based Outbreak Investigation and Response (COIR), a local public health strategy developed during the COVID-19 pandemic that addresses these shortcomings. COIR can help local public health entities conduct disease surveillance more effectively, take a more proactive and efficient approach to mitigating transmission, coordinate response efforts, build community trust, and advance equity. We offer a practitioner's lens, informed through on-the-ground experience and engagement with policy makers, to highlight the financing, workforce, data system, and information-sharing policy changes needed to scale up COIR throughout the country. COIR can enable the US public health system to develop effective solutions to many of today's public health challenges and improve the nation's preparedness for public health crises in the years to come.

National, regional, and state-level all-cause and cause-specific under-5 mortality in India in 2000-15: a systematic analysis with implications for the Sustainable Development Goals.

BACKGROUND: India had the largest number of under-5 deaths of all countries in 2015, with substantial subnational disparities. We estimated national and subnational all-cause and cause-specific mortality among children younger than 5 years annually in 2000-15 in India to understand progress made and to consider implications for achieving the Sustainable Development Goal (SDG) child survival targets. METHODS: We used a multicause model to estimate cause-specific mortality proportions in neonates and children aged 1-59 months at the state level, with causes of death grouped into pneumonia, diarrhoea, meningitis, injury, measles, congenital abnormalities, preterm birth complications, intrapartum-related events, and other causes. AIDS and malaria were estimated separately. The model was based on verbal autopsy studies representing more than 100 000 neonatal deaths globally and 16 962 deaths among children aged 1-59 months at the subnational level in India. By applying these proportions to all-cause deaths by state, we estimated cause-specific numbers of deaths and mortality rates at the state, regional, and national levels. FINDINGS: In 2015, there were 25·121 million livebirths in India and 1·201 million under-5 deaths (under-5 mortality rate 47·81 per 1000 livebirths). 0·696 million (57·9%) of these deaths occurred in neonates. There were disparities in child mortality across states (from 9·7 deaths [Goa] to 73·1 deaths [Assam] per 1000 livebirths) and regions (from 29·7 deaths [the south] to 63·8 deaths [the northeast] per 1000 livebirths). Overall, the leading causes of under-5 deaths were preterm birth complications (0·330 million [95% uncertainty range 0·279-0·367]; 27·5% of under-5 deaths), pneumonia (0·191 million [0·168-0·219]; 15·9%), and intrapartum-related events (0·139 million [0·116-0·165]; 11·6%), with cause-of-death distributions varying across states and regions. In states with very high under-5 mortality, infectious-disease-related causes (pneumonia and diarrhoea) were among the three leading causes, whereas the three leading causes were all non-communicable in states with very low mortality. Most states had a slower decline in neonatal mortality than in mortality among children aged 1-59 months. Ten major states must accelerate progress to achieve the SDG under-5 mortality target, while 17 are not on track to meet the neonatal mortality target. INTERPRETATION: Efforts to reduce vaccine-preventable deaths and to reduce geographical disparities should continue to maintain progress achieved in 2000-15. Enhanced policies and programmes are needed to accelerate mortality reduction in high-burden states and among neonates to achieve the SDG child survival targets in India by 2030. FUNDING: Bill & Melinda Gates Foundation.

The promise of prevention: the effects of four preventable risk factors on national life expectancy and life expectancy disparities by race and county in the United States.

BACKGROUND: There has been substantial research on psychosocial and health care determinants of health disparities in the United States (US) but less on the role of modifiable risk factors. We estimated the effects of smoking, high blood pressure, elevated blood glucose, and adiposity on national life expectancy and on disparities in life expectancy and disease-specific mortality among eight subgroups of the US population (the "Eight Americas") defined on the basis of race and the location and socioeconomic characteristics of county of residence, in 2005. METHODS AND FINDINGS: We combined data from the National Health and Nutrition Examination Survey and the Behavioral Risk Factor Surveillance System to estimate unbiased risk factor levels for the Eight Americas. We used data from the National Center for Health Statistics to estimate age-sex-disease-specific number of deaths in 2005. We used systematic reviews and meta-analyses of epidemiologic studies to obtain risk factor effect sizes for disease-specific mortality. We used epidemiologic methods for multiple risk factors to estimate the effects of current exposure to these risk factors on death rates, and life table methods to estimate effects on life expectancy. Asians had the lowest mean body mass index, fasting plasma glucose, and smoking; whites had the lowest systolic blood pressure (SBP). SBP was highest in blacks, especially in the rural South--5-7 mmHg higher than whites. The other three risk factors were highest in Western Native Americans, Southern low-income rural blacks, and/or low-income whites in Appalachia and the Mississippi Valley. Nationally, these four risk factors reduced life expectancy at birth in 2005 by an estimated 4.9 y in men and 4.1 y in women. Life expectancy effects were smallest in Asians (M, 4.1 y; F, 3.6 y) and largest in Southern rural blacks (M, 6.7 y; F, 5.7 y). Standard deviation of life expectancies in the Eight Americas would decline by 0.50 y (18%) in men and 0.45 y (21%) in women if these risks had been reduced to optimal levels. Disparities in the probabilities of dying from cardiovascular diseases and diabetes at different ages would decline by 69%-80%; the corresponding reduction for probabilities of dying from cancers would be 29%-50%. Individually, smoking and high blood pressure had the largest effect on life expectancy disparities. CONCLUSIONS: Disparities in smoking, blood pressure, blood glucose, and adiposity explain a significant proportion of disparities in mortality from cardiovascular diseases and cancers, and some of the life expectancy disparities in the US. Please see later in the article for the Editors' Summary.

Are Americans feeling less healthy? The puzzle of trends in self-rated health.

Although self-rated health is proposed for use in public health monitoring, previous reports on US levels and trends in self-rated health have shown ambiguous results. This study presents a comprehensive comparative analysis of responses to a common self-rated health question in 4 national surveys from 1971 to 2007: the National Health and Nutrition Examination Survey, Behavioral Risk Factor Surveillance System, National Health Interview Survey, and Current Population Survey. In addition to variation in the levels of self-rated health across surveys, striking discrepancies in time trends were observed. Whereas data from the Behavioral Risk Factor Surveillance System demonstrate that Americans were increasingly likely to report "fair" or "poor" health over the last decade, those from the Current Population Survey indicate the opposite trend. Subgroup analyses revealed that the greatest inconsistencies were among young respondents, Hispanics, and those without a high school education. Trends in "fair" or "poor" ratings were more inconsistent than trends in "excellent" ratings. The observed discrepancies elude simple explanations but suggest that self-rated health may be unsuitable for monitoring changes in population health over time. Analyses of socioeconomic disparities that use self-rated health may be particularly vulnerable to comparability problems, as inconsistencies are most pronounced among the lowest education group. More work is urgently needed on robust and comparable approaches to tracking population health.

Trends and cardiovascular mortality effects of state-level blood pressure and uncontrolled hypertension in the United States.

BACKGROUND: Blood pressure is an important risk factor for cardiovascular disease and mortality and has lifestyle and healthcare determinants that vary across states. Only self-reported hypertension status is measured at the state level in the United States. Our aim was to estimate levels and trends in state-level mean systolic blood pressure (SBP), the prevalence of uncontrolled systolic hypertension, and cardiovascular mortality attributable to all levels of higher-than-optimal SBP. METHODS AND RESULTS: We estimated the relationship between actual SBP/uncontrolled hypertension and self-reported hypertension, use of blood pressure medication, and a set of health system and sociodemographic variables in the nationally representative National Health and Nutrition Examination Survey. We applied this relationship to identical variables from the Behavioral Risk Factor Surveillance System to estimate state-specific mean SBP and uncontrolled hypertension. We used the comparative risk assessment methods to estimate cardiovascular mortality attributable to higher-than-optimal SBP. In 2001-2003, age-standardized uncontrolled hypertension prevalence was highest in the District of Columbia, Mississippi, Louisiana, Alabama, Texas, Georgia, and South Carolina (18% to 21% for men and 24% to 26% for women) and lowest in Vermont, Minnesota, Connecticut, New Hampshire, Iowa, and Colorado (15% to 16% for men and approximately 21% for women). Women had a higher prevalence of uncontrolled hypertension than men in every state by 4 (Arizona) to 7 (Kansas) percentage points. In the 1990s, uncontrolled hypertension in women increased the most in Idaho and Oregon (by 6 percentage points) and the least in the District of Columbia and Mississippi (by 3 percentage points). For men, the worst-performing states were New Mexico and Louisiana (decrease of 0.6 and 1.3 percentage points), and the best-performing states were Vermont and Indiana (decrease of 4 and 3 percentage points). Age-standardized cardiovascular mortality attributable to higher-than-optimal SBP ranged from 200 to 220 per 100,000 (Minnesota and Massachusetts) to 360 to 370 per 100,000 (District of Columbia and Mississippi) for women and from 210 per 100,000 (Colorado and Utah) to 370 per 100,000 (Mississippi) and 410 per 100,000 (District of Columbia) for men. CONCLUSIONS: Lifestyle and pharmacological interventions for lowering blood pressure are particularly needed in the South and Appalachia, and with emphasis on control among women. Self-reported data on hypertension diagnosis from the Behavioral Risk Factor Surveillance System can be used to obtain unbiased state-level estimates of blood pressure and uncontrolled hypertension as benchmarks for priority setting and for designing and evaluating intervention programs.

Improving child survival through environmental and nutritional interventions: the importance of targeting interventions toward the poor.

CONTEXT: The United Nations Millennium Development Goals (MDGs) set targets related to important global poverty, health, and sustainability issues. A critical but underinvestigated question for planning and allocating resources toward the MDGs is how interventions related to one MDG might affect progress toward other goals. OBJECTIVES: To estimate the reduction in child mortality as a result of interventions related to the environmental and nutritional MDGs (improving child nutrition and providing clean water, sanitation, and fuels) and to estimate how the magnitude and distribution of the effects of interventions vary based on the economic status of intervention recipients. DESIGN, SETTING, AND POPULATION: Population-level comparative risk assessment modeling the mortality effects of interventions on child nutrition and environmental risk factors, stratified by economic status. Data on economic status, child underweight, water and sanitation, and household fuels were from the nationally representative Demographic and Health Surveys for 42 countries in Latin America and the Caribbean, South Asia, and sub-Saharan Africa. Data on disease-specific child mortality were from the World Health Organization. Data on the hazardous effects of each MDG-related risk factor were from systematic reviews and meta-analyses of epidemiological studies. MAIN OUTCOME MEASURE: Child mortality, stratified by comparable international quintiles of economic status. RESULTS: Implementing interventions that improve child nutrition and provide clean water and sanitation and clean household fuels to all children younger than 5 years would result in an estimated annual reduction in child deaths of 49,700 (14%) in Latin America and the Caribbean, 0.80 million (24%) in South Asia, and 1.47 million (31%) in sub-Saharan Africa. These benefits are equivalent to 30% to 48% of the current regional gaps toward the MDG target on reducing child mortality. Fifty percent coverage of the same environmental and nutritional interventions, as envisioned by the MDGs, would reduce child mortality by 26,900, 0.51 million, and 1.02 million in the 3 regions, respectively, if the interventions are implemented among the poor first. These reductions are 30% to 75% larger than those expected if the same 50% coverage first reached the wealthier households, who nonetheless are in need of similar interventions. CONCLUSIONS: Interventions related to nutritional and environmental MDGs can also provide substantial gains toward the MDG of reducing child mortality. To maximize the reduction in childhood mortality, such integrated management of interventions should prioritize the poor.