Cardiac Arrest During Delivery Hospitalization : A Cohort Study.

BACKGROUND: Estimates of cardiac arrest occurring during delivery guide evidence-based strategies to reduce pregnancy-related death. OBJECTIVE: To investigate rate of, maternal characteristics associated with, and survival after cardiac arrest during delivery hospitalization. DESIGN: Retrospective cohort study. SETTING: U.S. acute care hospitals, 2017 to 2019. PARTICIPANTS: Delivery hospitalizations among women aged 12 to 55 years included in the National Inpatient Sample database. MEASUREMENTS: Delivery hospitalizations, cardiac arrest, underlying medical conditions, obstetric outcomes, and severe maternal complications were identified using codes from the International Classification of Diseases, 10th Revision, Clinical Modification. Survival to hospital discharge was based on discharge disposition. RESULTS: Among 10 921 784 U.S. delivery hospitalizations, the cardiac arrest rate was 13.4 per 100 000. Of the 1465 patients who had cardiac arrest, 68.6% (95% CI, 63.2% to 74.0%) survived to hospital discharge. Cardiac arrest was more common among patients who were older, were non-Hispanic Black, had Medicare or Medicaid, or had underlying medical conditions. Acute respiratory distress syndrome was the most common co-occurring diagnosis (56.0% [CI, 50.2% to 61.7%]). Among co-occurring procedures or interventions examined, mechanical ventilation was the most common (53.2% [CI, 47.5% to 59.0%]). The rate of survival to hospital discharge after cardiac arrest was lower with co-occurring disseminated intravascular coagulation (DIC) without or with transfusion (50.0% [CI, 35.8% to 64.2%] or 54.3% [CI, 39.2% to 69.5%], respectively). LIMITATIONS: Cardiac arrests occurring outside delivery hospitalizations were not included. The temporality of arrest relative to the delivery or other maternal complications is unknown. Data do not distinguish cause of cardiac arrest, such as pregnancy-related complications or other underlying causes among pregnant women. CONCLUSION: Cardiac arrest was observed in approximately 1 in 9000 delivery hospitalizations, among which nearly 7 in 10 women survived to hospital discharge. Survival was lowest during hospitalizations with co-occurring DIC. PRIMARY FUNDING SOURCE: None.

Vaccination Coverage Among Adolescents Aged 13-17 Years - National Immunization Survey-Teen, United States, 2022.

Three vaccines are routinely recommended for adolescents to prevent pertussis, meningococcal disease, and cancers caused by human papillomavirus (HPV). CDC analyzed data from the 2022 National Immunization Survey-Teen for 16,043 adolescents aged 13-17 years to assess vaccination coverage. Birth cohort analyses were conducted to assess trends in vaccination coverage by age 13 years (i.e., before the 13th birthday) and by age 14 years (i.e., before the 14th birthday) among adolescents who were due for routine vaccination before and during the COVID-19 pandemic. Cross-sectional analysis was used to assess coverage estimates among adolescents aged 13-17 years. In 2022, vaccination coverage by age 14 years among adolescents born in 2008 continued to lag that of earlier birth cohorts and varied by sociodemographic factors and access to health care compared with coverage among earlier birth cohorts. Vaccination coverage by age 13 years among adolescents born in 2009 was similar to coverage estimates obtained before the COVID-19 pandemic. Among all adolescents aged 13-17 years, 2022 vaccination coverage levels did not differ from 2021 levels; however, initiation of the HPV vaccination series decreased among those who were insured by Medicaid. Coverage with ≥1 dose of tetanus, diphtheria, and acellular pertussis vaccine and ≥1 dose meningococcal conjugate vaccine was high and stable (around 90%). Providers should review adolescent vaccination records, especially among those born in 2008 and those in populations eligible for the Vaccines for Children program, to ensure adolescents are up to date with all recommended vaccines.

Explaining the Link Between Paternal Socioeconomic Position and Small for Gestational Age Birth: The Effect of Maternal Unhealthy Behaviors.

OBJECTIVE: To determine the proportion of small for gestational age (weight < 10th percentile, SGA) births among fathers with lifelong low (compared to high) socioeconomic position (SEP) attributable to white and African-American women's unhealthy pregnancy-related behaviors. METHODS: Oaxaca-Blinder decomposition methods were conducted on the Illinois transgenerational dataset of infants (1989-1991) and their Chicago-born parents (1956-1976) with appended US census income data. The neighborhood income of father's residence at the time of his birth and at the time of his infant's birth were used to estimate his lifetime SEP. Maternal unhealthy pregnancy-related behaviors were defined as cigarette smoking, inadequate prenatal care, and/or low weight gain during pregnancy. RESULTS: Among African-American women, births (n = 4426) to fathers with lifetime low SEP had an SGA rate of 14.8% compared to 12.1% for those (n = 365) born to fathers with lifetime high SEP (p < 0.0001). Among white women, births (n = 1430) to fathers with lifetime low SEP had an SGA rate of 9.8% compared to 6.2% for those (n = 9141) born to fathers with lifetime high SEP (p < 0.0001). Adjusting for maternal age, marital status, education, and parity, African-American and white women's unhealthy pregnancy behaviors accounted for 25% and 33%, respectively, of the disparity in SGA rates among infants of lifetime low (compared to high) SEP fathers. CONCLUSION: A significant proportion of the disparity in SGA rates between fathers with lifelong low (compared to high) SEP is explained in both races by maternal unhealthy pregnancy behaviors.

Use of a Learning Community to Expand Access to Contraception.

The Increasing Access to Contraception Learning Community was established to disseminate strategies and best practices to support 27 jurisdictions in the development of policies and programs to increase access to the full range of reversible contraceptives. We describe Learning Community activities and identify those that were most useful to participants. Although participation in Learning Community provided jurisdictional teams with structured activities such as virtual learning and peer networking opportunities, some teams struggled with full participation because of staffing turnover and shifts in priorities. (Am J Public Health. 2022;112(S5):S523-S527. https://doi.org/10.2105/AJPH.2022.306823).

Teen Birth Across Generations Among Non-Latino Whites and African-American Women: The Effect of Race and Neighborhood Income.

OBJECTIVES: To examine the extent to which lifelong neighborhood income modifies the generational association of teen birth among White and AA women in Cook County, IL. METHODS: Stratified and multilevel logistic regression analyses were conducted on the Illinois transgenerational dataset of singleton births (1989-1991) to non-Latina White and AA mothers (born 1956-1976) with appended U.S. census income information. We calculated rates and risks of teen births according to race, maternal age, and lifelong neighborhood economic environment. RESULTS: Teen birth occurred at a rate of 9.5% and 52.9% for White and AA women, respectively. White women whose mothers were teens when they were born had an over five-fold increased risk of becoming teen mothers themselves. For AA women, the risk was smaller, but statistically significant. For both races, women who experienced downward economic mobility had the highest risk of teen birth, while women with upward mobility had the lowest risk, even compared to women in lifelong high income neighborhoods. While White women exposed to lifelong low income had almost threefold increased risk of teen birth compared to those in lifelong high income neighborhoods, AA women in lifelong high and lifelong low income neighborhoods had similar risk of teen birth. CONCLUSIONS FOR PRACTICE: Understanding the racial differences in intergenerational patterns of teen birth is important for effective program planning and policy making, given that interventions targeted at daughters of teen mothers may differ in effectiveness for White and AA teens.

The Excess Preterm Birth Rate Among US-Born (Compared to Foreign-Born) Black Women: The Role of Father's Education.

OBJECTIVE: To ascertain the component of the excess preterm birth (< 37 weeks, PTB) rate among US-born (compared to foreign-born) Black women attributable to differences in acknowledged father's education attainment. METHODS: Stratified analyses and Oaxaca-Blinder decomposition methods were performed on the 2013 National Center for Health Statistics birth certificate files of singleton infants with acknowledged fathers. RESULTS: US-born Black women (N = 196,472) had a PTB rate of 13.3%, compared to 10.8% for foreign-born Black women (N = 51,334; Risk Difference (95% confidence interval) = 2.5 (2.3, 2.8). Infants of US-born black women had a greater a percentage of fathers with a high school diploma or less and a lower percentage of fathers with bachelor's degrees or higher than their counterparts of foreign-born women. In both subgroups, PTB rates tended to decline as the level of paternal education attainment rose. In an Oaxaca model (controlling for maternal age, education, marital status, parity, adequacy of prenatal care utilization, and chronic medical conditions), differences in paternal education attainment explained 15% of the maternal nativity disparity in PTB rates. In contrast, maternal education attainment accounted for approximately 4% of the disparity in PTB rates. CONCLUSIONS FOR PRACTICE: Acknowledged father's low level of education attainment, or something closely related to it, explains a notable proportion of the disparity in PTB rates between US-born and foreign-born Black women.

Examining the Ratio of Obstetric Beds to Births, 2000-2019.

The number of U.S. births has been declining. There is also concern about rural obstetric units closing. To better understand the relationship between births and obstetric beds during 2000-2019, we examined changes over time in births, birth hospital distributions (i.e., hospital birth volume, ownership, and urban-rural designation), and the ratio of births to obstetric beds. We analyzed American Hospital Association Annual Survey data from 2000 to 2019. We included U.S. hospitals with at least 25 reported births during the year and at least 1 reported obstetric bed. We categorized birth volume to identify and describe hospitals with maternity services using seven categories. We calculated ratios of number of births to number of obstetric beds overall, by annual birth volume category, by three categories of hospital ownership, and by six urban-rural categories. The ratio of births to obstetric beds, which may represent need for maternity services, has stayed relatively consistent at 65 over the past two decades, despite the decline in births and changes in birth hospital distributions. The ratios were smallest in hospitals with < 250 annual births and largest in hospitals with ≥ 7000 annual births. The largest ratios of births to obstetric beds were in large metro areas and the smallest ratios were in noncore areas. At a societal level, the reduction in obstetric beds corresponds with the drop in the U.S. birth rate. However, consistency in the overall ratio can mask important differences that we could not discern, such as the impact of closures on distances to closest maternity care.

Adverse Pregnancy Outcomes, Maternal Complications, and Severe Illness Among US Delivery Hospitalizations With and Without a Coronavirus Disease 2019 (COVID-19) Diagnosis.

BACKGROUND: Evidence on risk for adverse outcomes from coronavirus disease 2019 (COVID-19) among pregnant women is still emerging. We examined the association between COVID-19 at delivery and adverse pregnancy outcomes, maternal complications, and severe illness, and whether these associations differ by race/ethnicity, and describe discharge status by COVID-19 diagnosis and maternal complications. METHODS: Data from 703 hospitals in the Premier Healthcare Database during March-September 2020 were included. Adjusted risk ratios (aRRs) overall and stratified by race/ethnicity were estimated using Poisson regression with robust standard errors. Proportion not discharged home was calculated by maternal complications, stratified by COVID-19 diagnosis. RESULTS: Among 489 471 delivery hospitalizations, 6550 (1.3%) had a COVID-19 diagnosis. In adjusted models, COVID-19 was associated with increased risk for acute respiratory distress syndrome (aRR, 34.4), death (aRR, 17.0), sepsis (aRR, 13.6), mechanical ventilation (aRR, 12.7), shock (aRR, 5.1), intensive care unit admission (aRR, 3.6), acute renal failure (aRR, 3.5), thromboembolic disease (aRR, 2.7), adverse cardiac event/outcome (aRR, 2.2), and preterm labor with preterm delivery (aRR, 1.2). Risk for any maternal complications or for any severe illness did not significantly differ by race/ethnicity. Discharge status did not differ by COVID-19; however, among women with concurrent maternal complications, a greater proportion of those with (vs without) COVID-19 were not discharged home. CONCLUSIONS: These findings emphasize the importance of implementing recommended prevention strategies to reduce risk for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and further inform counseling and clinical care for pregnant women during the COVID-19 pandemic.

Risk for Stillbirth Among Women With and Without COVID-19 at Delivery Hospitalization - United States, March 2020-September 2021.

Pregnant women are at increased risk for severe COVID-19-related illness, and COVID-19 is associated with an increased risk for adverse pregnancy outcomes and maternal and neonatal complications (1-3). To date, studies assessing whether COVID-19 during pregnancy is associated with increased risk for stillbirth have yielded mixed results (2-4). Since the B.1.617.2 (Delta) variant of SARS-CoV-2 (the virus that causes COVID-19) became the predominant circulating variant,* there have been anecdotal reports of increasing rates of stillbirths in women with COVID-19.† CDC used the Premier Healthcare Database Special COVID-19 Release (PHD-SR), a large hospital-based administrative database,§ to assess whether a maternal COVID-19 diagnosis documented at delivery hospitalization was associated with stillbirth during March 2020-September 2021 as well as before and during the period of Delta variant predominance in the United States (March 2020-June 2021 and July-September 2021, respectively). Among 1,249,634 deliveries during March 2020-September 2021, stillbirths were rare (8,154; 0.65%): 273 (1.26%) occurred among 21,653 deliveries to women with COVID-19 documented at the delivery hospitalization, and 7,881 (0.64%) occurred among 1,227,981 deliveries without COVID-19. The adjusted risk for stillbirth was higher in deliveries with COVID-19 compared with deliveries without COVID-19 during March 2020-September 2021 (adjusted relative risk [aRR] = 1.90; 95% CI = 1.69-2.15), including during the pre-Delta (aRR = 1.47; 95% CI = 1.27-1.71) and Delta periods (aRR = 4.04; 95% CI = 3.28-4.97). COVID-19 documented at delivery was associated with increased risk for stillbirth, with a stronger association during the period of Delta variant predominance. Implementing evidence-based COVID-19 prevention strategies, including vaccination before or during pregnancy, is critical to reducing the impact of COVID-19 on stillbirths.

Comparing Postpartum Care Utilization from Medicaid Claims and the Pregnancy Risk Assessment Monitoring System in Wisconsin, 2011-2015.

OBJECTIVE: To compare two data sources from Wisconsin-Medicaid claims and Pregnancy Risk Assessment Monitoring System (PRAMS) surveys-for measuring postpartum care utilization and to better understand the incongruence between the sources. METHODS: We used linked Medicaid claims and PRAMS surveys of Wisconsin residents who delivered a live birth during 2011-2015 to assess women's postpartum care utilization. Three different definitions of postpartum care from Medicaid claims were employed to better examine bundled service codes and timing of care. We used one question from the PRAMS survey that asks women if they have had a postpartum checkup. Concordance between the two data sources was examined using Cohen's Kappa value. For women who reported having a postpartum checkup on PRAMS but did not have a Medicaid claim for a traditional postpartum visit, we determined the other types of health care visits these women had after delivery documented in the Medicaid claims. RESULTS: Among the 2313 women with a Medicaid-paid delivery and who completed a PRAMS survey, 86.6% had claims for a postpartum visit during the first 12 weeks postpartum and 90.5% self-reported a postpartum checkup on PRAMS (percent agreement = 79.9%, Kappa = 0.015). The percent agreement and Kappa values varied based on the definition of postpartum care derived from the Medicaid claims data. CONCLUSIONS: There was slight agreement between Medicaid claims and PRAMS data. Most women had Medicaid claims for postpartum care at some point in the first 12 weeks postpartum, although the timing of these visits was somewhat unclear due to the use of bundled service codes.

Characteristics of Hospitalized COVID-19 Patients Discharged and Experiencing Same-Hospital Readmission - United States, March-August 2020.

Coronavirus disease 2019 (COVID-19) is a complex clinical illness with potential complications that might require ongoing clinical care (1-3). Few studies have investigated discharge patterns and hospital readmissions among large groups of patients after an initial COVID-19 hospitalization (4-7). Using electronic health record and administrative data from the Premier Healthcare Database,* CDC assessed patterns of hospital discharge, readmission, and demographic and clinical characteristics associated with hospital readmission after a patient's initial COVID-19 hospitalization (index hospitalization). Among 126,137 unique patients with an index COVID-19 admission during March-July 2020, 15% died during the index hospitalization. Among the 106,543 (85%) surviving patients, 9% (9,504) were readmitted to the same hospital within 2 months of discharge through August 2020. More than a single readmission occurred among 1.6% of patients discharged after the index hospitalization. Readmissions occurred more often among patients discharged to a skilled nursing facility (SNF) (15%) or those needing home health care (12%) than among patients discharged to home or self-care (7%). The odds of hospital readmission increased with age among persons aged ≥65 years, presence of certain chronic conditions, hospitalization within the 3 months preceding the index hospitalization, and if discharge from the index hospitalization was to a SNF or to home with health care assistance. These results support recent analyses that found chronic conditions to be significantly associated with hospital readmission (6,7) and could be explained by the complications of underlying conditions in the presence of COVID-19 (8), COVID-19 sequelae (3), or indirect effects of the COVID-19 pandemic (9). Understanding the frequency of, and risk factors for, readmission can inform clinical practice, discharge disposition decisions, and public health priorities such as health care planning to ensure availability of resources needed for acute and follow-up care of COVID-19 patients. With the recent increases in cases nationwide, hospital planning can account for these increasing numbers along with the potential for at least 9% of patients to be readmitted, requiring additional beds and resources.

Non-Hispanic White Women's Exposure to Decreased Neighborhood Income and Small for Gestational Age Births: A Population-Based Study.

BACKGROUND: The relationship between non-Hispanic White (NHW) women's decreased neighborhood income between early-life and adulthood, individual risk-status at delivery, and small for gestational age (weight for gestation < 10th percentile, SGA) rates is unknown. OBJECTIVE: To determine the extent to which NHW women's exposure to decreased neighborhood income is a risk factor for SGA births, and whether their own birth weight modifies this relationship. METHODS: Stratified and multilevel logistic regression analyses were executed on the Illinois transgenerational dataset of mothers (born 1956-1976) and their infants (born 1989-1991) with appended U.S. census income information. Only NHW women with an early-life residence in top income quartile Chicago neighborhoods were studied. RESULTS: NHW women (n = 4889) unexposed to decreased neighborhood income between early-life and adulthood had an SGA rate of 7.1%. In contrast, NHW women exposed to slightly (n = 5112), modestly (n = 2158), or severely (n = 339) decreased neighborhood income by the time of delivery had SGA rates of 8.2%, 10.8%, and 10.8%, respectively; RR (95% CI) equaled 1.2 (1.0-1.3), 1.5 (1.3-1.8) and 1.5 (1.1-2.1), respectively. The relationship between maternal exposure to modestly decreased neighborhood income and SGA rates was present only among former non-low birth weight (> 2500 g, non-LBW) mothers. In multilevel logistic regression models, the adjusted (controlling for age, parity, prenatal care usage, and cigarette smoking) OR of SGA birth for former low birth weight (< 2500 g, LBW) and non-LBW NHW women exposed to modestly (compared to no) decreased neighborhood income equaled 0.7 (0.4, 1.4) and 1.3 (1.1-1.6), respectively. CONCLUSIONS FOR PRACTICE: NHW women's exposure to modestly decreased neighborhood income is associated with an increased risk of SGA birth; this phenomenon is absent among former low birth weight women.

Excess Early (< 34 weeks) Preterm Rates Among Non-acknowledged and Acknowledged Low Socioeconomic Position Fathers: The Role of Women's Selected Pregnancy-Related Risk Factors.

OBJECTIVE: To determine the proportion of the excess early preterm birth (< 34 weeks, PTB) rates among non-acknowledged and acknowledged low socioeconomic position (SEP) fathers attributable to White and African-American women's selected pregnancy-related risk factors for PTB. METHODS: Oaxaca-Blinder decomposition methods were performed on the Illinois transgenerational birth-file of infants (1989-1991) and their parents (1956-1976) with appended U.S. census income information. The neighborhood income of father's place of residence at the time of his birth and at the time of his infant's birth were used to measure lifetime SEP. RESULTS: Among non-Latina White women, the early PTB rate for non-acknowledged (n = 3260), acknowledged low SEP (n = 1430), and acknowledged high SEP (n = 9141) fathers equaled 4.02%, 1.82%, and 1.19, respectively; p < 0.001. White women's selected pregnancy-related risk factors for PTB (inadequate prenatal usage, suboptimal weight gain, and/or cigarette smoking) were responsible for 19.3% and 41.2% of the explained disparities in early PTB rates for non-acknowledged and acknowledged low (compared to acknowledged high) SEP fathers, respectively. Among African-American women, the early PTB rate for non-acknowledged (n = 22,727), acknowledged low SEP (n = 4426), and acknowledged high SEP (n = 365) fathers equaled 6.72%, 4.34%, and 3.29%, respectively; p < 0.001. African-American women's selected pregnancy-related risk factors for PTB were responsible for 21.4% and 20.2% of the explained disparities in early PTB rates for non-acknowledged and acknowledged low SEP fathers, respectively. CONCLUSIONS: Non-Latina White and African-American women's selected pregnancy-related risk factors for PTB explain a significant percentage of excess early PTB rates among non-acknowledged and acknowledged low (compared to acknowledged high) SEP fathers.

The Effect of Continuous Versus Pregnancy-Only Medicaid Eligibility on Routine Postpartum Care in Wisconsin, 2011-2015.

OBJECTIVE: To compare patterns of routine postpartum health care utilization for women in Wisconsin with continuous Medicaid eligibility versus pregnancy-only Medicaid METHODS: This analysis used Medicaid records and linked infant birth certificates for Medicaid paid births in Wisconsin during 2011-2015 (n = 105,718). We determined if women had continuous or pregnancy-only eligibility from the Medicaid eligibility file. We used a standard list of billing codes to identify if women received routine postpartum care. We examined maternal characteristics and receipt of postpartum care overall and by Medicaid eligibility category. Finally, we used a binomial model to calculate the relationship between Medicaid eligibility category and receipt of postpartum care, adjusted for maternal characteristics. RESULTS: Women with continuous Medicaid had profiles more consistent with low postpartum visit attendance rates (e.g., younger, more likely to use tobacco) than women with pregnancy-only Medicaid. However, after adjusting for maternal characteristics, women with continuous Medicaid eligibility had a postpartum visit rate that was 6 percentage points higher than the rate for women with pregnancy-only Medicaid (RD: 6.27, 95% CI 5.72, 6.82). CONCLUSIONS FOR PRACTICE: Women with pregnancy-only Medicaid were less likely to have received routine postpartum care than women with continuous Medicaid. Medicaid coverage beyond the current guaranteed 60 days postpartum could help provide more women access to postpartum care.

Adverse birth outcome across the generations: the contribution of paternal factors.

PURPOSE: There is literature suggesting an intergenerational relationship between maternal and infant size for gestational age status and preterm birth, but much less is known about the contribution of paternal birth outcome to infant birth outcome. This study seeks to determine the association between paternal and infant small-for-gestational-age status (weight for gestational age < 10th percentile, SGA) and preterm birth (< 37 weeks gestation, PTB) in a large, diverse population-based sample in the United States. METHODS: Stratified and log-binomial multivariable regression analyses were computed on the vital records of Illinois-born infants (1989-1991) and their Illinois-born parents (born 1956-1976). RESULTS: Among non-Hispanic Whites (n = 83,218), the adjusted (controlling for maternal SGA or PTB, age, parity, education, marital status, prenatal care, and cigarette smoking) relative risk (95% confidence interval) of infant SGA and PTB for former SGA (compared to non-SGA) and preterm (compared to term) fathers equaled 1.65 (1.53, 1.77) and 1.07 (0.92, 1.24), respectively. Among African-Americans (n = 8401), the adjusted relative risk (95% confidence interval) of infant SGA and PTB for former SGA (compared to non-SGA) and preterm (compared to term) fathers equaled 1.32 (1.14, 1.52) and 1.19 (0.98, 1.45), respectively. CONCLUSION: Paternal adverse birth outcome, particularly SGA, is a modest risk factor for corresponding adverse infant outcome, independent of maternal risk status. This phenomenon appears to occur similarly among non-Hispanic White and African-American women.

Characteristics of a Multistate Outbreak of Lung Injury Associated with E-cigarette Use, or Vaping - United States, 2019.

Electronic cigarettes (e-cigarettes), also called vapes, e-hookas, vape pens, tank systems, mods, and electronic nicotine delivery systems (ENDS), are electronic devices that produce an aerosol by heating a liquid typically containing nicotine, flavorings, and other additives; users inhale this aerosol into their lungs (1). E-cigarettes also can be used to deliver tetrahydrocannabinol (THC), the principal psychoactive component of cannabis (1). Use of e-cigarettes is commonly called vaping. Lung injury associated with e-cigarette use, or vaping, has recently been reported in most states (2-4). CDC, the Food and Drug Administration (FDA), state and local health departments, and others are investigating this outbreak. This report provides data on patterns of the outbreak and characteristics of patients, including sex, age, and selected substances used in e-cigarette, or vaping, products reported to CDC as part of this ongoing multistate investigation. As of September 24, 2019, 46 state health departments and one territorial health department had reported 805 patients with cases of lung injury associated with use of e-cigarette, or vaping, products to CDC. Sixty-nine percent of patients were males, and the median age was 23 years (range = 13-72 years). To date, 12 deaths have been confirmed in 10 states. Among 514 patients with information on substances used in e-cigarettes, or vaping products, in the 30 days preceding symptom onset, 76.9% reported using THC-containing products, and 56.8% reported using nicotine-containing products; 36.0% reported exclusive use of THC-containing products, and 16.0% reported exclusive use of nicotine-containing products. The specific chemical exposure(s) causing the outbreak is currently unknown. While this investigation is ongoing, CDC recommends that persons consider refraining from using e-cigarette, or vaping, products, particularly those containing THC. CDC will continue to work in collaboration with FDA and state and local partners to investigate cases and advise and alert the public on the investigation as additional information becomes available.

Update: Characteristics of Patients in a National Outbreak of E-cigarette, or Vaping, Product Use-Associated Lung Injuries - United States, October 2019.

CDC, the Food and Drug Administration, state and local health departments, and other public health and clinical stakeholders are investigating a national outbreak of electronic-cigarette (e-cigarette), or vaping, product use-associated lung injury (EVALI) (1). As of October 22, 2019, 49 states, the District of Columbia (DC), and the U.S. Virgin Islands have reported 1,604 cases of EVALI to CDC, including 34 (2.1%) EVALI-associated deaths in 24 states. Based on data collected as of October 15, 2019, this report updates data on patient characteristics and substances used in e-cigarette, or vaping, products (2) and describes characteristics of EVALI-associated deaths. The median age of EVALI patients who survived was 23 years, and the median age of EVALI patients who died was 45 years. Among 867 (54%) EVALI patients with available data on use of specific e-cigarette, or vaping, products in the 3 months preceding symptom onset, 86% reported any use of tetrahydrocannabinol (THC)-containing products, 64% reported any use of nicotine-containing products, and 52% reported use of both. Exclusive use of THC-containing products was reported by 34% of patients and exclusive use of nicotine-containing products by 11%, and for 2% of patients, no use of either THC- or nicotine-containing products was reported. Among 19 EVALI patients who died and for whom substance use data were available, 84% reported any use of THC-containing products, including 63% who reported exclusive use of THC-containing products; 37% reported any use of nicotine-containing products, including 16% who reported exclusive use of nicotine-containing products. To date, no single compound or ingredient used in e-cigarette, or vaping, products has emerged as the cause of EVALI, and there might be more than one cause. Because most patients reported using THC-containing products before symptom onset, CDC recommends that persons should not use e-cigarette, or vaping, products that contain THC. In addition, because the specific compound or ingredient causing lung injury is not yet known, and while the investigation continues, persons should consider refraining from the use of all e-cigarette, or vaping, products.

Early and Late Preterm Birth Rates Among US-Born Urban Women: The Effect of Men's Lifelong Class Status.

OBJECTIVE: To ascertain the relation of men's lifelong class status (as measured by neighborhood income) to the rates of early (< 34 weeks) and late (34-36 weeks) preterm birth (PTB). METHODS: Stratified and multilevel, multivariable binomial regression analyses were computed on the Illinois transgenerational birth-file of infants (born 1989-1991) and their parents (born 1956-1976) with appended U.S. census income information. The median family income of men's census tract residence at two-time periods were utilized to assess lifelong class status (defined by residence in either the lower or upper half of neighborhood income distribution). RESULTS: In Cook County Illinois, the preterm rate for births (n = 8115) to men with a lifelong lower class status was twice that of births (n = 10,330) to men with a lifelong upper class status: 13% versus 6.0%, RR = 2.2 (2.0, 2.4). This differential was greatest in early PTB rates: 3.9% versus 1.4%, RR = 3.0 (2.5, 3.7). The relation of men's lifelong class status to both PTB components persisted among non-teens, married, college-educated, and non-Latina White women, respectively. The adjusted (controlling for maternal demographic characteristics) RR of early and late PTB for men with a lifelong lower (versus upper) class status were 1.4 (1.1, 1.9) and 1.2 (1.0, 1.4), respectively. The population attributable risk of early PTB for men's lifelong lower class status equaled 16%. CONCLUSIONS: Men's lifelong lower (versus upper) class status is a novel risk factor for early preterm birth regardless of maternal demographic characteristics. This intriguing finding has public health relevance.

Father's Lifetime Socioeconomic Status, Small for Gestational Age Infants, and Infant Mortality: A Population-Based Study.

Objective: To ascertain the association between father's lifetime socioeconomic status (SES) and rates of small for gestational age (SGA, defined as weight for gestational age <10th percentile) and infant mortality (defined as <365 days). Methods: The study sample was limited to the singleton births of African American (n=8,331), non-Latina White (n=18,200), and Latina (n=2,637) women. Stratified and multilevel, multivariable logistic regression analyses were conducted on the Illinois transgenerational dataset of infants (1989-1991) and their Chicago-born parents (1956-1976) with appended US census income data (n=29,168). The median family income of father's census tract residence during childhood and parenthood were used to assess lifetime SES. Results: Births (n=8,113) to fathers with a lifetime low SES had a SGA rate of 13.3% compared with 6.6% for those (n=10,329) born to fathers with a lifetime high SES, RR = 1.97 (1.79, 2.17). The infant mortality rate of births to fathers with a lifetime low SES exceeded that of infant mortality rate of births to fathers with a lifetime high SES: 13/1,000 vs 5/1,000, respectively; RR = 2.71 (1.94, 3.77). The adjusted (controlling for mother's age, education, marital status, and race/ethnicity) OR of SGA for fathers with childhood, parenthood, and lifetime low (vs high) SES were 1.15 (1.01, 1.31), 1.13 (1.02, 1.26), and 1.19 (1.05, 1.34), respectively. The adjusted OR of infant mortality for births to fathers with childhood, parenthood, and lifetime low (vs high) SES were 1.14 (.78, 1.67), 1.40 (.90, 2.18), and 1.31 (.90, 1.92), respectively. Conclusions: Low paternal socioeconomic status is a previously unrecognized determinant of SGA birth regardless of mother's demographic status.

Affluent-Born White Mother's Descending Neighborhood Income and Infant Mortality: A Population-Based Study.

Objectives To determine whether affluent-born White mother's descending neighborhood income is associated with infant mortality rates (< 365 day, IMR). Methods Stratified and multilevel logistic regression analyses were completed on the Illinois transgenerational dataset of singleton births (1989-1991) to non-Latina White mothers (1956-1976) with an early-life residence in affluent neighborhoods (defined as the fourth quartile of income distribution). The breadth of descending neighborhood income was defined by mother's neighborhood income at the time of delivery. Results Infants of White mothers (n = 4890) who did not suffer descending neighborhood income by the time of delivery had a first-year mortality rate of 5.1/1,000. Infants of White mothers who experienced minor (n = 5112), modest (n = 2158), or extreme (n = 339) descending neighborhood income had IMR of 6.5/1,000, 14.4/1,000, and 11.8/1,000, respectively; RR [95% CI] = 1.3 [0.8, 2.1], 2.8 [1.7, 4.8], and 2.3 [0.8, 6.6], respectively. The incidence of young maternal age, inadequate prenatal care utilization, and cigarette smoking rose as descending neighborhood income increased, p < 0.01. In multilevel logistic regression models, the adjusted (controlling for selected individual-level co-variates) OR [95% CI] of infant mortality for White women with an early-life residence in affluent neighborhoods who subsequently experienced minor or modest to extreme (versus absent) descending neighborhood income equaled 1.0 [0.6, 1.8] and 2.1 [1.1, 3.8] respectively. Conclusions White mother's modest to extreme descending neighborhood income from early-life residence in affluent neighborhoods is associated with a twofold greater risk of infant mortality independent of selected biologic, medical, and behavioral characteristics.