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.

Cigarettes point of purchase patterns in 19 low-income and middle-income countries: Global Adult Tobacco Survey, 2008-2012.

BACKGROUND: There is little information on cigarette-purchasing behaviour among smokers globally. Understanding cigarette purchase and point-of-sale patterns can help guide the development and implementation of tobacco-control strategies in retail environments. OBJECTIVE: The purpose of this study was to identify where adults in 19 countries last purchased cigarettes. METHODS: Data were from 19 low-income and middle-income countries that conducted the Global Adult Tobacco Survey (GATS) during 2008-2012. GATS is a nationally representative household survey of adults aged 15 years or older using a standardised protocol to measure tobacco-related behaviours. Data were weighted to yield nationally representative estimates within each country and summarised by using descriptive statistics. RESULTS: Overall prevalence of current cigarette smoking ranged from 3.7% in Nigeria to 38.5% in the Russian Federation. Among current cigarette smokers, locations of last purchase were as follows: stores, from 14.6% in Argentina to 98.7% in Bangladesh (median=66.8%); street vendors, from 0% in Thailand to 35.7% in Vietnam (median=3.0%); kiosks, from 0.1% in Thailand to 77.3% in Argentina (median=16.1%); other locations, from 0.3% in China and Egypt to 57.5% in Brazil (median=2.6%). CONCLUSION: Cigarettes are purchased at various retail locations globally. However, stores and kiosks were the main cigarette purchase locations in 18 of the 19 countries assessed. Knowledge of where cigarette purchases occur could help guide interventions to reduce cigarette accessibility and use.

Preventing tobacco epidemic in LMICs with low tobacco use - Using Nigeria GATS to review WHO MPOWER tobacco indicators and prevention strategies.

INTRODUCTION: Tobacco is a major preventable cause of disease and death globally and increasingly shifting its burden to low and middle-income countries (LMICs) including African countries. We use Nigeria Global Adult Tobacco Survey data to examine indications of a potential tobacco epidemic in a LMIC setting and provide potential interventions to prevent the epidemic. METHODOLOGY: Global Adult Tobacco Survey data from Nigeria (2012; sample=9765) were analyzed to examine key tobacco indicators. Estimates and confidence intervals for each indicator were computed using SPSS software version 21 for complex samples. RESULTS: 5.5% of adult Nigerians use any tobacco and exposure to secondhand smoke was mainly high in bars (80.0%) and restaurants (29.3%). Two-thirds of smokers (66.3%) are interested in quitting. Among those who attempted to quit, 15.0% used counseling/advice and 5.2% pharmacotherapy. Awareness was high that tobacco use causes serious illnesses (82.4%), heart attack (76.8%) and lung cancer (73.0%) but only 51.4% for stroke. Awareness that secondhand smoke can cause serious illness was also high (74.5%). Overall 88.5% support tobacco products tax increase. CONCLUSION: Although tobacco use is relatively low in Nigeria as in other African countries, high smoking rate among men compared to women might indicate potential increase in prevalence. Challenges to preventing increasing smoking rate include limited use of evidence-based cessation methods among quit attempters, social acceptability of smoking particularly in bars and restaurants, and gap in knowledge on tobacco-related diseases. However, ratification of WHO FCTC and signing into law of the Tobacco Control law provide the impetus to implement evidence-based interventions.

Surveillance for certain health behaviors among states and selected local areas--Behavioral Risk Factor Surveillance System, United States, 2011.

PROBLEM: Chronic conditions (e.g., heart diseases, cerebrovascular diseases, malignant neoplasms, and diabetes), infectious diseases (e.g., influenza and pneumonia), and unintentional injuries are the leading causes of morbidity and mortality in the United States. Adopting positive health behaviors (e.g., staying physically active, quitting tobacco use, always wearing seatbelts in automobiles) and accessing preventive health-care services (e.g., getting routine physical checkups, receiving recommended vaccinations on appropriate schedules, checking blood pressure and cholesterol and maintaining them at healthy levels) can reduce morbidity and mortality from chronic and infectious diseases. Monitoring the health-risk behaviors of a community's residents as well as their participation in and access to health-care services provides information critical to the development and maintenance of intervention programs as well as the implementation of strategies and health policies that address public health problems at the levels of state and territory, metropolitan and micropolitan statistical area (MMSA), and county. REPORTING PERIOD: January-December 2011. 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. In 2011, BRFSS adopted a new weighting methodology (iterative proportional fitting, or raking) and for the first time included data from respondents who solely use cellular telephones (i.e., do not use landlines). This report presents results for the year 2011 for all 50 states, the District of Columbia, and participating U.S. territories including the Commonwealth of Puerto Rico and Guam, 198 MMSAs, and 224 counties. RESULTS: In 2011, the estimated prevalence of health-risk behaviors, chronic conditions, access to health care, and use of preventive health services substantially varied by state and territory, MMSA, and county. The following portion of this abstract summarizes selected results by some BRFSS measures. Each set of proportions refers to the range of estimated prevalence of the behaviors, diseases, or use of preventive health-care services as reported by survey respondents. Adults with good or better health: 65.5%-88.0% for states and territories, 72.0%-92.4% for MMSAs, and 74.3%-94.2% for counties. Adults aged <65 years with health-care coverage: 65.4%-92.3% for states and territories, 66.8%-94.7% for MMSAs, and 61.3%-95.6% for counties. Influenza vaccination received during the preceding 12 months among adults aged ≥65 years: 28.6%-70.2% for states and territories, 42.0% -80.0% for MMSAs, and 41.1%-78.2% for counties. Adults meeting the federal physical activity recommendations for both aerobic physical activity and muscle-strengthening activity: 8.5%-27.3% for states and territories, 7.3%-32.0% for MMSAs, and 11.0%-32.0% for counties. Current cigarette smokers: 11.8%-30.5% for states and territories, 8.4%-30.6% for MMSAs, and 8.1%-35.2% for counties. Binge drinking during the last month: 10.0%-25.0% for states and territories, 7.0%-32.5% for MMSAs, and 7.0%-32.5% for counties. Adults always wearing seatbelts while driving or riding in a car: 63.9%-94.1% for states and territories, 51.8%-96.9% for MMSAs, and 51.8%-97.0% for counties. Adults aged ≥18 who were obese: 20.7%-34.9% for states and territories, 15.1%-37.2% for MMSAs, and 15.1%-41.0% for counties. Adults with diagnosed diabetes: 6.7%-13.5% for states and territories, 3.9%-15.9% for MMSAs, and 3.5%-18.3% for counties. Adults with current asthma: 4.3%-12.1% for states and territories, 2.9%-14.1% for MMSAs, and 2.9%-15.6% for counties. Adults aged ≥45 years who have had coronary heart disease: 7.1%-16.2% for states and territories, 5.0%-19.4% for MMSAs, and 3.9%-18.5% for counties. Adults using special equipment because of any health problem: 5.1%-11.3% for states and territories, 3.9%-13.2% for MMSAs, and 2.4%-14.7% for counties. INTERPRETATION: Because of the recent change in the BRFSS methodology, the results should not be compared with those from previous years. The findings in this report indicate that substantial variations exist in the reported health-risk behaviors, chronic diseases, disabilities, access to health-care services, and the use of preventive health services among U.S. adults at state and territory, MMSA, and county levels. The findings underscore the continued need for surveillance of health-risk behaviors, chronic conditions, and use of preventive health-care services as well as surveillance-informed programs designed to help improve health-related risk behaviors, levels of chronic disease and disability, and the access to and use of preventive services and health-care resources. PUBLIC HEALTH ACTION: State and local health departments and agencies can continue to use BRFSS data to identify populations at high risk for certain unhealthy behaviors and chronic conditions. Additionally, they can use the data to inform the design, implementation, direction, monitoring, and evaluation of public health programs, policies, and use of preventive services that can lead to a reduction in morbidity and mortality among U.S. residents.

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.

Career phase of board-certified general surgeons: workload composition and outcomes.

OBJECTIVE: To examine surgeon career phase and its association with surgical workload composition and outcomes of surgery. DESIGN: Cross-sectional study. SETTING: The study used data from calendar years 2004 through 2006 from 4 Florida general surgeon (GS) cohorts determined by years since board certification. PARTICIPANTS: American Board of Surgery-certified GSs regardless of subspecialty (n = 1187) performing 460 881 operations on adults 18 years or older. MAIN OUTCOME MEASURES: Workload composition based on the Clinical Classification System, complications identified by patient safety indicators, and in-hospital mortality. Poisson regression with robust error variance estimated adjusted rate ratios (RRs) for complications and mortality. RESULTS: Compared with late-career surgeons, the rate of complications from cardiovascular procedures was higher for surgeons in the early-career phase (RR, 1.23; 95% CI, 1.06-1.44) and the late middle-career phase (1.18; 1.02-1.37). The mortality rate for cardiovascular procedures also was higher for early-career surgeons (RR, 1.23; 95% CI, 1.04-1.46). For digestive procedures, early-career surgeons had lower complication rates than late-career surgeons (RR, 0.86; 95% CI, 0.75-0.99). CONCLUSION: Late-career GSs perform both better and worse compared with early-career GSs, relative to their workload composition and proportional surgical volume. Factors such as training and case complexity may contribute to these career-phase differences.

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.