Maintaining a Competent Public Health Workforce: Lessons Learned From Experiences With Public Health Accreditation Domain 8 Standards and Measures.

CONTEXT: Public health accreditation is an ongoing national movement to improve the quality of public health departments and the public health system in the United States; however, calls have been made for more evidence regarding best practices in the accreditation process. OBJECTIVE: The purpose of this work is to provide evidence about best practices in the accreditation process, specifically within the workforce development domain. It is the first in-depth investigation into workforce development using data collected by Public Health Accreditation Board (PHAB). DESIGN: Using deidentified accreditation application data from PHAB, this study employs a mixed-methods approach to examining practices, lessons learned, challenges, and strategies pertaining to workforce development planning for Domain 8. SETTING: United States. PARTICIPANTS: US state (n = 19) and local health departments (n = 115). MAIN OUTCOME MEASURES: Public Health Accreditation Board assessment scores for the workforce measures and the relationship between the health department's approach to meeting a PHAB measure criteria and the PHAB assessment score. RESULTS: Of the 9 different approaches identified as ways of encouraging the development of a sufficient number of qualified public health workers (version 1, measure 8.1.1), only 1 approach (local health department internship programs with schools of public health; B = 0.25, P < .03) was significantly related to higher scores. An opportunity for improvement identified for measure 8.2.1 was that plans missing a clear identification of the gap between current staff competencies and staff needs were associated with a 0.88-point decrease in the 4-point score (P < .001). CONCLUSIONS: Findings suggest that there are approaches adopted for meeting PHAB domain 8 measures that will impact the overall conformance assessment and score of a health department pursuing accreditation. There are several opportunities for improvement that health departments might consider when planning for accreditation or assessing their activities.

Effect of exercise, heat stress and dehydration on myocardial performance.

BACKGROUND: Myocardial dysfunction is a well-documented outcome of extended periods of high cardiac output. Whether similar effects occur during firefighting, an occupation characterized by repeated periods of work compounded by dehydration and heat stress, is uncertain. AIMS: To investigate the independent and combined effects of moderate heat stress and dehydration on indicators of myocardial performance following intermittent, submaximal treadmill exercise while wearing personal protective equipment (PPE). METHODS: Twelve aerobically fit young men (age 21.5±2.6 years; maximal oxygen uptake [VO2max] 60.3±4.4ml kg(-1) min(-1)) performed intermittent treadmill walking exercise consisting of three 20min bouts at an intensity of ~40% VO2max separated by two periods of rest in four different conditions in random order: (i) no heat stress-euhydrated, (ii) heat stress-euhydrated (heat stress created by wearing PPE, (iii) no heat stress-dehydrated and (iv) heat stress-dehydrated. We measured core temperature by a telemetric gastrointestinal pill. We determined cardiac variables by standard echocardiographic techniques immediately before and ~30min after exercise. RESULTS: We recorded no significant changes in markers of systolic (ejection fraction, shortening fraction, tissue Doppler-S) or diastolic (mitral peak E velocity, tissue Doppler-E' and E/E') function following exercise in any of the four conditions. CONCLUSIONS: In this model of exercise designed to mimic the work, heat stress and dehydration associated with firefighting activities, we observed no negative effects on myocardial inotropic or lusitropic function.

Right ventricular myocardial responses to progressive exercise in young adult males.

Recent attention has been focused on possible unique features of the right ventricular response to exercise. This study investigated a) the responses of right ventricular cardiac dynamics and myocardial function to a standard bout of progressive cycle exercise in healthy young males, and b) the effect of level of aerobic fitness on these responses. 14 athletically-trained males (20.4±1.5 years) and 11 normally-active males (21.1±1.3 years) underwent a progressive upright cycle test to exhaustion with measurement of gas exchange variables and assessment of right ventricular stroke volume, systolic and diastolic myocardial velocities, and tricuspid inflow velocities by standard Doppler echocardiographic techniques at rest, submaximal and peak exercise. Stroke volume rose initially by approximately 27% in each group, followed by stable values to exhaustion. Values of maximal stroke index and maximal oxygen uptake were significantly greater in the trained group than the normally-active males (62±10 ml m(-2), 54.3±4.0 ml kg(-1) min(-1); 49±7 ml m(-2), 40.3±5.6 ml kg(-1) min(-1), respectively). No significant differences were observed in increases in systolic or diastolic myocardial velocities, peak pulmonary outflow velocity, systolic ejection rate, or tricuspid inflow velocity between the 2 groups. The magnitude of change of these variables was similar to those previously described for left ventricular responses to similar exercise. This study revealed no unique features of right ventricular functional responses to an acute exercise challenge in young males.

COVID-19 Restrictions and Adolescent Cigarette and E-cigarette Use in California.

INTRODUCTION: Shelter-in-place orders altered facilitators and barriers to tobacco use (e.g., outlet closures, restricted social gatherings). This study examined whether the duration of time in shelter in place and compliance with different shelter-in-place orders influenced adolescent cigarette and E-cigarette use and how the use may differ by demographic characteristics. METHODS: Shelter-in-place policy data obtained from government websites were merged with cross-sectional 2020 survey data on adolescents in California. Treatment variables included the proportion of time in shelter in place and self-reported compliance with shelter-in-place orders (for essential businesses and retail spaces and social and outdoor contexts). Multilevel logit models for dichotomous past 6-month cigarette and E-cigarette use and multilevel negative binomial regression models for past 6-month frequency of use were used. Moderation analyses were conducted on demographic measures. The sample included 1,196 adolescents (mean age=15.8 years, age range=13-19 years, 49.2% female, 50.0% White). Analyses were conducted in 2022. RESULTS: No associations were found between the proportion of time in shelter in place and outcomes. Shelter-in-place compliance with essential business and retail space orders was associated with lower odds of using cigarettes and E-cigarettes in the past 6 months. Compliance with social and outdoor context-related orders were associated with lower odds of using E-cigarettes and fewer days using cigarettes and E-cigarettes. Being aged ≥18 years moderated the associations between essential business/retail space and social/outdoor context-related shelter-in-place compliance orders and past 6-month frequency of cigarette smoking. CONCLUSIONS: Findings support tailored interventions for less compliant and older adolescents for future pandemic mitigation measures.

Lesbian, Gay, Bisexual, Queer, Questioning and Transgender, Nonbinary, Genderqueer, and Gender Questioning Adult Alcohol Use Outcomes Associated with State Alcohol-Related Laws During the Coronavirus Pandemic in the United States.

Purpose: We assessed how COVID-19-related alcohol sales policies influenced alcohol use behaviors during the pandemic for U.S. adults of diverse sexual (lesbian, gay, bisexual, queer, questioning [LGBQ]) and gender identities (transgender, nonbinary, genderqueer, and gender questioning [T/NB/GQ]). Methods: Time-specific, state-level, restaurant, bar, and off-premise alcohol policy data were collected from the National Institute on Alcohol Abuse and Alcoholism-sponsored Alcohol Policy Information System and merged with the 2020 Behavioral Risk Factor Surveillance System survey data. Treatments included bar, restaurant, and delivery alcohol sales policies. Outcomes included past 30-day drinking frequency, quantity, and heavy episodic drinking (HED). We fitted negative binomial regression models for all outcomes, clustered standard errors by state and used sample weights. We also controlled for seasonality, state Alcohol Policy Scale scores, pre-/postpandemic time period, and included demographic control variables in our cross-sectional analyses. Results: The sample included 10,505 adults identifying as LGBQ and 809 as T/NB/GQ from 32 states. Restaurant and bar closures were associated with less alcohol use for LGBQ respondents. Outdoor-only policies at bars were also associated with significantly less quantity of use and HED for T/NB/GQ adults in the sample. Off-premise home delivery was associated with greater quantity of use for LGBQ respondents and less frequency for T/NB/GQ respondents. Conclusion: The COVID-19-related alcohol sales policy changes offer an opportunity to better understand alcohol policy and availability's influence on drinking behaviors among sexual and gender-diverse populations in the United States.

Covid-19 shelter-in-place, modified reopening orders, and order compliance impact on adolescent alcohol use and drinking contexts in California: A longitudinal analysis.

INTRODUCTION: This study evaluated how Shelter-in-Place (SIP), modified reopening orders, and self-reported compliance with these orders have affected adolescent alcohol frequency and quantity of use across contexts during the COVID-19 pandemic. MATERIALS AND METHODS: Differences-in-differences (DID) models and multi-level modeling analyses were conducted on longitudinal data collected as part of a larger study on alcohol use among adolescents in California. 1,350 adolescents at baseline contributed 7,467 observations for a baseline and 5 six-month follow-up surveys. Analytic samples ranged from 3,577-6,245 participant observations based on models. Alcohol use outcomes included participant frequency (days) and quantity (number of whole drinks) of alcohol use in past 1-month and past 6-month periods. Context-specific alcohol use outcomes included past 6-month frequency and quantity of use at: restaurants, bars/nightclubs, outside, one's own home, another's home, and fraternities/sororities. Participant self-reported compliance with orders in essential business/retail spaces and at outdoor/social settings were also assessed. RESULTS: Our DID results indicated that being under a modified reopening order was associated with decreases in past 6-month quantity of alcohol use (IRR = 0.72, CI = 0.56-0.93, p < 0.05). Higher self-reported compliance with SIP orders related to social outdoor/social settings was associated with decreases in overall drinking frequency and quantity as well as decreases in frequency and quantity of alcohol use in all contexts in the past six months. Compliance with SIP orders impacting essential businesses and retail spaces was associated with decreased frequency and quantity of use at other's home and outdoors. CONCLUSIONS: Results suggest that SIP and modified reopening policies may not directly affect adolescent alcohol use or drinking contexts, and that individual compliance with such orders may be a protective factor for alcohol use.

Influence of sex on ventricular remodeling in collegiate athletes.

AIM: Previous reports indicate that the "athlete's heart" is more prominent in males than females, but the mechanisms responsible for this sex difference have not been elucidated. This study examined male-female differences in cardiac mass and volume in highly trained athletes and normally active individuals to assess the relative contributions of pre-existing sex differences and sports training to cardiac findings. METHODS: Echocardiographic and electrocardiographic findings were compared between 20 male and 21 female collegiate athletes and 22 male and 29 female normally-active subjects. RESULTS: Cardiac mass (per kg lean body mass) was significantly greater in the male compared to female athletes (3.62±0.55 and 3.31±0.56 g.kg-1, respectively). A similar magnitude of difference in average relative cardiac mass was observed between the normally active males and females, and cardiac mass was greater in athletic versus nonathletic groups by +14.9% in the males and +13.3% in the females. Relative left ventricular volume was greater in the male athletes (47.5±6.3 ml•BSA-1.5) compared to male nonathletes (42.9±6.1 ml•BSA-1.5); no such difference was observed in the females. CONCLUSION: These findings suggest that sex differences in both the untrained state and magnitude of training response contribute to male-female differences in the "athlete's heart"

A rapid High Performance Liquid Chromatographic (HPLC) method for the simultaneous determination of seven UV filters found in sunscreen and cosmetics.

A rapid High Performance Liquid Chromatographic (HPLC) method was developed for the simultaneous determination of seven Ultra Violet (UV) filters most commonly found in cosmetics and sunscreen. The object of the method development was to provide a reliable rapid method, that would simultaneously separate a combination of the UV Filters, most commonly found in cosmetics and sunscreen products, utilizing a minimum of environmentally friendly solvents. The compounds separated were: benzophenone 3 (BZ3), methylbenzildene camphor (MBC), octyl dimethyl PABA (ODP), octocrylene (OCR), octyl methoxycinnamate (OMC), butyl - methoxydibenzoylmethane (BDM) and octyl salicylate (OS). An adjusted mobile phase consisting of ethanol and 1% acetic acid, combined with a Thermo Hypersil C(18) BDS 3 micron column resulted in a method, which allowed the analysis of the seven compounds in seven minutes. The proposed method was validated utilising the International Congress on Harmonisation (ICH) and the Food and Drug Administration (FDA) guidelines. All parameters examined were found to be well within the stated guidelines.

Older patients' preferences and views related to non-face-to-face diabetes chronic care management: a qualitative study from southeast Louisiana.

Background: Management of diabetes may be uniquely challenging for older individuals with multiple chronic conditions. Health systems and policymakers have attempted to reduce barriers to chronic care management (CCM) through incentives to provide non-face-to-face care. This qualitative study aimed to investigate and present views on non-face-to-face care management held by elderly patients with diabetes and other chronic conditions in order to contribute to improved programming for this population. Materials and methods: Semi-structured interviews were conducted with patients over the age of 64 who have been diagnosed with diabetes and at least one other chronic health condition. Interview recordings were transcribed and analyzed by experienced researchers using a thematic analytic approach, and an illustrative case study was developed. Results: Thirty individuals participated in this study. Participants were drawn from three health systems in south Louisiana, an area with high rates of morbidity and mortality related to chronic diseases. We identified themes related to lived experiences with diabetes and other medical conditions, perception of personal health status, perceived value of non-face-to-face programs, and support needs for future programming. Additionally, we present one case study describing in detail an individual patient's experience with non-face-to-face CCM. Conclusion: Health systems should consider intentionally recruiting participants who would benefit most from non-face-to-face care, including higher-need, less self-sufficient patients with resource constraints, while continuing to offer in-person services. Future research should examine whether tailoring non-face-to-face programming and support to address unique barriers can further enhance diabetes care at the population level.

Ensuring access to prescription medications in the post-ACA healthcare access landscape: the essential role of FQHCs in the safety net for the underinsured.

OBJECTIVES: Federally qualified health centers (FQHCs) are essential to underinsured populations in the safety net by offering them several means of access to reduced cost medications. This study employed a 2-pronged approach to evaluate FQHCs' role, estimating both the need for patient assistance and the impact of the safety net. STUDY DESIGN: A multiyear panel data study for post-Affordable Care Act (ACA) years 2012 to 2016 and a 2016 cross-sectional analysis design were utilized to analyze FQHCs, their patient populations, and prescription assistance programs. METHODS: Publicly available Health Resources and Services Administration (HRSA) Uniform Data System data were merged with HRSA Office of Pharmacy Affairs Information System data on 340B programs. Descriptive statistics were produced to evaluate the need for patient assistance, costs, and conditions treated at FQHCs. RESULTS: There were 1337 FQHCs serving more than 2.5 million patients, nearly 29% of whom were uninsured. FQHCs utilized 2 programs to provide affordable, reduced-cost prescriptions for patients without insurance: 1) the HRSA 340B Drug Pricing Program and 2) prescription assistance programs, which rely on pharmaceutical manufacturer donations of reduced-cost medications or coupons. Although these programs were effective at providing affordable prescriptions, program accessibility varied widely by state and FQHC resources. CONCLUSIONS: Despite changes in the healthcare access landscape due to the ACA, underinsured populations remain prevalent and the need for financial assistance with medications persists. FQHCs are uniquely situated to provide access to these essential services. Further policy and funding efforts, such as expansion of 340B programs, could assist FQHCs in fulfilling the role of prescription safety-net providers.

Barriers and Facilitators in Implementing Non-Face-to-Face Chronic Care Management in an Elderly Population with Diabetes: A Qualitative Study of Physician and Health System Perspectives.

The burden of illness related to diabetes and its complications is exceedingly high and growing globally. Systematic approaches to managing chronic care are needed to address the complex nature of the disease, taking into account health system structures. This study presents data collected from interviews with physicians, health system administrators, and other healthcare staff about chronic care management for elderly people with diabetes co-morbid with other chronic conditions in light of new programs intended to reduce barriers by incentivizing care encounters that take place through telephone and electronic communications (non-face-to-face care). Results indicate that health system personnel view non-face-to-face care as potentially providing value for patients and addressing systemic needs, yet challenging to implement in practice. Barriers and facilitators to this approach for managing diabetes and chronic care management for its complications are presented, with consideration to different types of health systems, and recommendations are provided for implementation.

Cookery method and endpoint temperature can affect the Warner-Bratzler shear force, cooking loss, and internal cooked color of beef semimembranosus and infraspinatus steaks.

Steaks from USDA Select inside rounds (Exp. 1) and shoulder clods (Exp. 2) were used to test the interactive effect of cookery method and endpoint temperature on Warner-Bratzler shear force (WBSF) and internal cooked color. Pairs of 2.5-cm-thick semimembranosus (SM) or infraspinatus (INF) steaks ( = 360/muscle) were cut from each subprimal, labeled, vacuum packaged, and frozen at -30°C in the dark for approximately 60 d before being cooked to 65.5, 71.1, or 76.6°C using 1) a forced-air convection oven (FAC); 2) a forced-air impingement oven (IMP); 3) a gas-fired, open-hearth charbroiler (CHAR); 4) an electric countertop griddle (GRID); or 5) a clam-shell grill (CLAM). Thawed steaks were cooked to their assigned endpoint temperature × cookery method combination, and, after a 5-min cooling period, steaks were weighed to calculate cooking loss percentage and subsequently sliced perpendicular to the cut surface to measure instrumental cooked color. Then, 6 cores were removed for measurement of WBSF. Cooking losses of SM steaks increased ( < 0.05) with each increase in endpoint temperature, whereas INF steaks cooked on a CHAR had the greatest ( < 0.05) cooking losses and cooking INF steaks with the GRID and the CLAM resulted in lesser ( < 0.05) cooking losses than cooking with the FAC and the IMP. Cooking SM steaks on the CHAR resulted in greater ( < 0.05) WBSF values than all other cookery methods when cooked to 65.5 and 76.6°C and greater ( < 0.05) WBSF values than those cooked on the FAC, GRID, and CLAM when cooked to 71.1°C. Shear force values were greater ( < 0.05) for INF steaks cooked to 71.1 and 76.6°C than those cooked to 65.5°C, but INF WBSF values were similar ( = 0.55) among cookery methods. At 65.5°C, FAC-cooked SM steaks were redder ( < 0.05) than those cooked with the GRID and the IMP and, at 71.1°C, CLAM-cooked SM steaks were redder ( < 0.05) than FAC- and IMP-cooked SM steaks; however, a* values were similar ( > 0.05) among cookery methods when cooked to 76.6°C. Redness did not ( > 0.05) differ among INF steaks cooked to 65.5 and 71.1°C with the FAC and the CHAR, whereas internal color of INF steaks cooked in the IMP and the FAC was redder ( < 0.05) than that of INF steaks cooked with the CLAM and the GRID to 76.6°C. Results suggest that endpoint temperature has a greater impact on cooking properties of SM and INF steaks than cookery method, yet it is apparent that internal cooked color of INF and SM steaks react differently to some cookery method-endpoint temperature combinations.

Mumps transmission in hospitals.

Although sporadic transmission of mumps within hospitals to patients and staff is well documented, outbreaks of mumps within hospitals have only rarely been reported. The widespread mumps outbreaks that occurred in Tennessee in 1986-1987 provided an opportunity to assess the extent of the problems caused by mumps in hospitals. Information was obtained from 146 (95%) of 154 infection control practitioners in the state. Infection control problems caused by mumps were reported from 17 (12%) of 146 hospitals. The 17 hospitals in which these incidents occurred were located in counties that accounted for 67% of the reported mumps cases statewide during this period. Although most cases of mumps in health care workers were community-acquired, six health care workers in three different hospitals developed mumps following nosocomial exposure. In two institutions, nine patients contracted mumps while hospitalized. Both were long-term-care facilities housing adolescents, who had substantial contact with a community where mumps outbreaks were ongoing. This study suggests that mumps poses a small but real risk to both patients and staff in hospitals, particularly in long-term-care facilities caring for adolescents and young adults. In communities where mumps activity is ongoing, hospitals should consider identifying potentially susceptible staff members at risk for infection and offering vaccine. Likewise, susceptible patients in long-term-care facilities should be immunized.

Pertussis deaths: report of 23 cases in the United States, 1992 and 1993.

OBJECTIVE: To characterize pertussis deaths and to identify possible risk factors and prevention strategies. METHODS: A retrospective review of all deaths attributed to pertussis with disease onset during 1992 and 1993 reported to the Centers for Disease Control and Prevention. Hospital discharge summaries and autopsy reports were reviewed, and additional clinical information was provided by physicians involved in the care of the children. RESULTS: During 1992 and 1993, 23 deaths attributed to pertussis were reported to the Centers for Disease Control and Prevention. Cultures for Bordetella pertussis were positive in 18 (90%) of the 20 cases in which it was performed. Twenty (87%) of the 23 children who died were young than 1 year of age, and 18 (78%) of the children had received no doses orf pertussis vaccine. Among 20 children for whom gestational ages were known, 12 (60%) were born at36 weeks' gestation or earlier; in contrast, 10.7% of live births in the United States in 1992 were at 36 weeks' gestation or earlier. The median age of mothers whose children had fatal pertussis was 20 (range, 14 to 37) years in the 15 cases in which ages were known, compared with the national median age of 26.3 years in 1992. Pneumonia was a complication in all but 1 (96%) of the cases. Seizures occurred in 4 cases (17%), and acute encephalopathy occurred in 3 cases (13%). CONCLUSIONS: Pertussis continues to cause serious illness and death in the United States, particularly among infants who are not vaccinated. Preterm delivery and young maternal age may place infants at increased risk of death because of pertussis. Under the current pertussis vaccination schedule, three fourths of the infants who died were too young to have received three doses of pertussis vaccine, the minimum number of doses considered necessary for adequate protection against clinical pertussis. Additional strategies, to prevent deaths caused by pertussis in young infants, such as starting infant vaccination at an earlier age and booster doses to adolescents and adults, need to be evaluated.

Pertussis outbreak in an elementary school with high vaccination coverage.

BACKGROUND: An outbreak of pertussis in a US elementary school with high vaccination coverage was investigated to evaluate vaccine effectiveness and to identify potential contributing factors. METHODS: Survey and cohort study of all 215 students of an elementary school (including 36 case patients) and 16 secondary cases among contacts. RESULTS: Fifty-two pertussis cases were identified (attack rate among students, 17%). Receipt of <3 doses of pertussis-containing-vaccine compared with receipt of complete vaccination series was a significant risk factor for pertussis [relative risk, 5.1; 95% confidence interval (CI), 3 to 8.6]. The effectiveness of the complete vaccination series was 80% (95% CI 66 to 88). No evidence of waning immunity among students was found. The following contributing factors for the outbreak were identified: multiple introductions of pertussis from the community; delays in identification and treatment of early cases; and high contact rates among students. Antimicrobial treatment initiated >14 days after cough onset was associated with increased risk of further transmission of pertussis (relative risk, 10.1; 95% CI 1.5 to 70.3) compared with treatment within 14 days of onset. CONCLUSIONS: This investigation demonstrated the potential for pertussis outbreaks to occur in well-vaccinated elementary school populations. Aggressive efforts to identify cases and contacts and timely antimicrobial treatment can limit spread of pertussis in similar settings. High vaccination coverage should be maintained, because vaccination significantly reduces the risk of the disease throughout the elementary school years, and to ensure timely diagnosis and treatment health care providers should maintain a high index of suspicion for pertussis among elementary school age children.

Vaccine-associated paralytic poliomyelitis in the United States: no evidence of elevated risk after simultaneous intramuscular injections of vaccine.

During the past 30 years, Romania reported rates of vaccine-associated paralytic poliomyelitis (VAPP) approximately 10-fold higher than in the United States. The elevated VAPP risk was largely caused by multiple intramuscular (im) injections with antibiotics given within 30 days of onset of paralysis. Because it is not known whether im injections contribute to the VAPP risk in the United States, we examined VAPP cases reported since 1980. We reviewed injection histories of VAPP cases reported to the Centers for Disease Control and Prevention from 1980 to 1993: with vaccines for 1980 to 1987; and for all substances for 1988 to 1993. Rates of VAPP by number of im injections with vaccines were calculated from 1988 to 1993 with estimated vaccine coverage data from the National Health Interview Survey. From 1980 to 1993 a total of 119 cases of poliomyelitis were reported to the Centers for Disease Control and Prevention. Of these, 87 (73%) were vaccine-associated and immunologically normal: 41 were oral polio vaccine (OPV) recipient cases; 40 were OPV contact cases; and 6 were community-acquired cases. A history of im injections in the 45 days before onset of paralysis was obtained from 28 (72%) of 39 recipient cases reported from 1980 to 1993 for which dates of paralysis onset could be determined and from 1 (8%) of 13 contact cases reported from 1988 to 1993. With one exception all substances administered intramuscularly were routine childhood vaccines. No clustering of im injections in the "high risk" windows, 0 to 3 and 8 to 21 days before onset of paralysis, was observed.(ABSTRACT TRUNCATED AT 250 WORDS)

The epidemiology of varicella-zoster virus infections.

Historically, varicella has been a disease predominantly affecting preschool and school-aged children in the United States. The live attenuated varicella vaccine was licensed in this country in 1995 and has been recommended for routine use in immunization of children 12 to 18 months of age. As an increasing proportion of the children in the United States are protected from varicella by vaccination, changes in the current epidemiology of the disease are anticipated. This article reviews the current epidemiology of VZV infection and outlines issues related to possible changes in varicella epidemiology that may follow widespread use of the live varicella (Oka) vaccine.

Measles, mumps, and rubella vaccines.

With widespread use of the live virus vaccines for measles, mumps, and rubella, there has been a dramatic decrease in the incidence of all three diseases. At the same time, an increasing proportion of the remaining cases are occurring in adolescents and adults. Thus, vaccinations for these three diseases of childhood must be included in a comprehensive program for adult immunization. The vaccines have a proven history of safety and efficacy and are usually administered together as combined measles-mumps-rubella (MMR) vaccine. Vaccination for measles, mumps, and rubella is particularly important for susceptible adults likely to come in contact with infected children. Adults at particularly high risk for exposure may include daycare center workers, teachers and other school employees, college students, medical personnel, and those planning to travel outside the United States.

Evaluation of a method for detecting outbreaks of diseases in six states.

A new statistical method, developed for detection of changes in reporting, has proved useful in analysis of provisional data reported by state health departments to the National Notifiable Diseases Surveillance System (NNDSS). In this system, data from the current four-week period can be compared with data from the previous, same, and subsequent four-week periods from each of the preceding five years, and reports exceeding historical limits are highlighted in a horizontal bar graph. To evaluate the usefulness of this method at the state level, we applied it to weekly reports of seven notifiable diseases in six states over a four-month period. Participating state health departments investigated all events exceeding historical limits and reported known outbreaks that were not identified by the method. During the four-month period, the method identified 27 episodes of disease reports exceeding historical limits. Of these, 14 (52%) represented outbreaks. None was detectable by analysis of aggregate national surveillance data. Five outbreaks known to state health department officials were not identified by the method, because of increased disease activity during the baseline period or lack of timely provisional reporting of outbreak-related cases. Methods for detection of increases in reporting at the state level may identify events of public health importance that are obscured in aggregate national data and may supplement other local sources of information available to state health departments in the recognition of significant public health events.

TMJ diagnosis and treatment in a multidisciplinary environment--a follow-up study.

New modalities--TMJ direct parasagittal CT and MRI scans and arthroscopic visualization and surgery--along with psychological and other health professional support, are changing the approach to clinical orthodontic practice. This report presents an update on clinical experience over a period of time, with emphasis on orthodontics, psychology, and arthroscopic surgery.