Racial Disparities in Incidence of Legionnaires' Disease and Social Determinants of Health: A Narrative Review.

OBJECTIVES: Racial and socioeconomic disparities in the incidence of Legionnaires' disease have been documented for the past 2 decades; however, the social determinants of health (SDH) that contribute to these disparities are not well studied. The objective of this narrative review was to characterize SDH to inform efforts to reduce disparities in the incidence of Legionnaires' disease. METHODS: We conducted a narrative review of articles published from January 1979 through October 2019 that focused on disparities in the incidence of Legionnaires' disease and pneumonia (inclusive of bacterial pneumonia and/or community-acquired pneumonia) among adults and children (excluding articles that were limited to people aged <18 years). We identified 220 articles, of which 19 met our criteria: original research, published in English, and examined Legionnaires' disease or pneumonia, health disparities, and SDH. We organized findings using the Healthy People 2030 SDH domains: economic stability, education access and quality, social and community context, health care access and quality, and neighborhood and built environment. RESULTS: Of the 19 articles reviewed, multiple articles examined disparities in incidence of Legionnaires' disease and pneumonia related to economic stability/income (n = 13) and comorbidities (n = 10), and fewer articles incorporated SDH variables related to education (n = 3), social support (none), health care access (n = 1), and neighborhood and built environment (n = 6) in their analyses. CONCLUSIONS: Neighborhood and built-environment factors such as housing, drinking water infrastructure, and pollutant exposures represent critical partnership and research opportunities. More research that incorporates SDH and multilevel, cross-sector interventions is needed to address disparities in Legionnaires' disease incidence.

A Methodology for Classifying Root Causes of Outbreaks of Legionnaires' Disease: Deficiencies in Environmental Control and Water Management.

We piloted a methodology for collecting and interpreting root cause-or environmental deficiency (ED)-information from Legionnaires' disease (LD) outbreak investigation reports. The methodology included a classification framework to assess common failures observed in the implementation of water management programs (WMPs). We reviewed reports from fourteen CDC-led investigations between 1 January 2015 and 21 June 2019 to identify EDs associated with outbreaks of LD. We developed an abstraction guide to standardize data collection from outbreak reports and define relevant parameters. We categorized each ED according to three criteria: ED type, WMP-deficiency type, and source of deficiency. We calculated the prevalence of EDs among facilities and explored differences between facilities with and without WMPs. A majority of EDs identified (81%) were classified as process failures. Facilities with WMPs (n = 8) had lower prevalence of EDs attributed to plumbed devices (9.1%) and infrastructure design (0%) than facilities without WMPs (n = 6; 33.3% and 24.2%, respectively). About three quarters (72%) of LD cases and 81% of the fatalities in our sample originated at facilities without a WMP. This report highlights the importance of WMPs in preventing and mitigating outbreaks of LD. Building water system process management is a primary obstacle toward limiting the root causes of LD outbreaks. Greater emphasis on the documentation, verification, validation, and continuous program review steps will be important in maximizing the effectiveness of WMPs.

Surveillance for certain health behaviors among States and selected local areas - United States, 2010.

PROBLEM: Chronic diseases (e.g., heart disease, stroke, cancer, and diabetes) are the leading causes of morbidity and mortality in the United States. Engaging in healthy behaviors (e.g., quitting smoking and tobacco use, being more physically active, and eating a nutritious diet) and accessing preventive health-care services (e.g., routine physical checkups, screening for cancer, checking blood pressure, testing blood cholesterol, and receiving recommended vaccinations) can reduce morbidity and mortality from chronic and infectious disease and lower medical costs. Monitoring and evaluating health-risk behaviors and the use of health services is essential to developing intervention programs, promotion strategies, and health policies that address public health at multiple levels, including state, territory, metropolitan and micropolitan statistical area (MMSA), and county. REPORTING PERIOD: January-December 2010. DESCRIPTION OF THE SYSTEM: The Behavioral Risk Factor Surveillance System (BRFSS) is an ongoing, state-based, random-digit-dialed telephone survey of noninstitutionalized adults aged ≥18 years residing in the United States. BRFSS collects data on health-risk behaviors, chronic diseases and conditions, access to health care, and use of preventive health services and practices related to the leading causes of death and disabilities in the United States. This report presents results for 2010 for all 50 states, the District of Columbia, the Commonwealth of Puerto Rico, Guam, the U.S. Virgin Islands, 192 MMSAs, and 302 counties. RESULTS: In 2010, the estimated prevalence of high-risk health behaviors, chronic diseases and conditions, access to health care, and use of preventive health services varied substantially by state and territory, MMSA, and county. In the following summary of results, each set of proportions refers to the range of estimated prevalence for the disease, condition, or behaviors, as reported by survey respondents. Adults reporting good or better health: 67.9%-89.3% for states and territories, 72.2%-92.1% for MMSAs, and 72.8%-95.8% for counties. Adults with health-care coverage: 69.4%-95.7% for states and territories, 45.7%-97.0% for MMSAs, and 45.7%-97.2% for counties. Adults who had a dental visit in the past year: 57.2%-81.7% for states and territories, 47.1%-83.5% for MMSAs, and 47.1%-88.2% for counties. Adults aged ≥65 years having had all their natural teeth extracted (edentulism): 7.4%-36.0% for states and territories, 4.8%-34.8% for MMSAs, and 2.4%-39.3% for counties. A routine physical checkup during the preceding 12 months: 53.8%-80.0% for states and territories, 49.5%-82.6% for MMSAs, and 49.5%-85.3% for counties. Influenza vaccination received during the preceding 12 months among adults aged ≥65 years: 26.9%-73.4% for states and territories, 51.7%-77.1% for MMSAs, and 49.3%-87.8% for counties. Pneumococcal vaccination ever received among adults aged ≥65 years: 24.7%-74.0% for states and territories, 48.6%-79.9% for MMSAs, and 47.6%-83.1% for counties. Sigmoidoscopy or colonoscopy ever received among adults aged ≥50 years: 37.8%-75.7% for states and territories, 37.3%-79.9% for MMSAs, and 37.3%-82.5% for counties. Blood stool test received during the preceding 2 years among adults aged ≥50 years: 8.5%-27.0% for states and territories, 6.7%-51.3% for MMSAs, and 6.8%-57.2% for counties. Women who reported having had a Papanicolaou test during the preceding 3 years: 67.8%-88.9% for states and territories, 63.3%-91.2% for MMSAs, and 63.2%-95.7% for counties. Women aged ≥40 years who had a mammogram during the preceding 2 years: 63.8%-83.6% for states and territories, 60.3%-86.2% for MMSAs, and 59.3%-89.7% for counties. Current cigarette smokers: 5.8%-26.8% for states and territories, 5.8%-28.5% for MMSAs, and 5.9%-29.8% for counties. Binge drinking during the preceding month: 6.6%-21.6% for states and territories, 3.6%-23.0% for MMSAs, and 3.8%-24.0% for counties. Heavy drinking during the preceding month: 2.0%-7.2% for states and territories, 1.0%-10.0% for MMSAs, and 1.0%-14.2% for counties. Adults reporting no leisure-time physical activity: 17.5%-42.3% for states and territories, 13.1%-37.6% for MMSAs, and 8.5%-39.0% for counties. Adults who were overweight: 32.6%-40.7% for states and territories, 28.5%-42.5% for MMSAs, and 27.2%-46.4% for counties. Adults aged ≥20 years who were obese: 22.1%-35.0% for states and territories, 17.1%-42.1% for MMSAs, and 13.3%-42.1% for counties. Adults with current asthma: 5.2%-11.1% for states and territories, 3.4%-14.5% for MMSAs, and 3.3%-14.6% for counties. Adults with diagnosed diabetes: 5.3%-13.2% for states and territories, 4.6%-15.4% for MMSAs, and 2.6%-18.8% for counties. Adults with limited activities because of physical, mental or emotional problems: 10.8%-28.2% for states and territories, 13.5%-38.3% for MMSAs, and 11.7%-32.0% for counties. Adults using special equipment because of any health problem: 2.8%-10.6% for states and territories, 4.5%-15.5% for MMSAs, and 1.3%-15.5% for counties. Adults aged ≥45 years who have had coronary heart disease: 5.3%-16.7% for states and territories, 6.5%-19.6% for MMSAs, and 4.9%-19.6% for counties. Adults aged ≥45 years who have had a stroke: 2.4%-7.1% for states and territories, 2.3%-8.8% for MSMAs, and 1.7%-8.8% for counties. INTERPRETATION: The findings in this report indicate substantial variations in the health-risk behaviors, chronic diseases and conditions, access to health-care services, and the use of the preventive health services among U.S. adults at the state and territory, MMSA, and county levels. Healthy People 2010 (HP 2010) objectives were established to monitor health behaviors, conditions, and the use of preventive health services for the first decade of the 2000s. The findings in this report indicate that many of the HP 2010 objectives were not achieved by 2010. The findings underscore the continued need for surveillance of health-risk behaviors, chronic diseases, and conditions and of the use of preventive health-care services. PUBLIC HEALTH ACTION: Local and state health departments and federal agencies use BRFSS data to identify populations at high risk for certain health-risk behaviors, chronic diseases, and conditions and to evaluate the use of preventive health-care services. BRFSS data also are used to direct, implement, monitor, and evaluate public health programs and policies that can lead to a reduction in morbidity and mortality from chronic conditions and corresponding health-risk behaviors.

Exercise DVD improves exercise expectations in cardiovascular outpatients.

OBJECTIVE: To assess impact of exercise education intervention on exercise frequency and attitudes. METHODS: Cardiovascular outpatients (N=509) were randomized to receive an education DVD or standard care. Outcome measures (baseline and 6 weeks) assessed exercise frequency and cognitive variables. RESULTS: There was no difference between groups on exercise frequency change from baseline, but DVD group reported greater exercise outcome expectations than control group (P=0.01). There was a greater increase in relapse-prevention behavior in the DVD group, compared to control, for those with low relapse-prevention behavior at baseline (P=0.02). CONCLUSION: A minimal intervention improves outcome expectations for exercise.