Rilpivirine versus efavirenz in HIV-1-infected subjects receiving emtricitabine/tenofovir DF: pooled 96-week data from ECHO and THRIVE Studies.

OBJECTIVES: Week 96 efficacy and safety of the non-nucleoside reverse transcriptase inhibitor (NNRTI) rilpivirine (RPV) was compared to efavirenz (EFV) in subset of 1,096 subjects who received emtricitabine/tenofovir disoproxil fumarate (FTC/TDF) in pooled data from 2 phase 3 studies. METHODS: ECHO and THRIVE are double-blind, double-dummy, randomized, active-controlled, non-inferiority phase 3 studies of RPV versus EFV plus 2 NRTIs in antiretroviral-naïve adult subjects. The primary and secondary endpoints were the proportion of subjects with HIV-1 RNA <50 copies/ mL using an intent-to-treat, time to loss of virologic response (ITT-TLOVR) analysis at weeks 48 and 96, respectively. Safety, tolerability, immunologic response, adherence level, and other measures were also evaluated. RESULTS: At week 48, noninferior efficacy of RPV+FTC/TDF over EFV+FTC/TDF was established, and at week 96 RPV+FTC/TDF remained noninferior (77% overall response rate in both groups). Through week 96, rates of virologic failure were higher in the RPV+FTC/ TDF group, with low and similar rates of virologic failure and resistance mutations occurring during the second year of follow-up. Treatment with RPV+FTC/TDF was associated with a lower rate of discontinuation due to adverse events and grade 2-4 adverse events including dizziness, abnormal dreams/nightmares, rash, and lipid abnormalities. CONCLUSIONS: The pooled ECHO and THRIVE studies demonstrated noninferiority of RPV+FTC/TDF in achieving virologic response with safety and tolerability advantages over EFV+FTC/TDF through 96 weeks. Higher rates of virologic failure in the RPV+FTC/TDF group were balanced with higher rates of discontinuations due to adverse events in the EFV+FTC/TDF group.

SWIFT: prospective 48-week study to evaluate efficacy and safety of switching to emtricitabine/tenofovir from lamivudine/abacavir in virologically suppressed HIV-1 infected patients on a boosted protease inhibitor containing antiretroviral regimen.

BACKGROUND: In the United States, emtricitabine/tenofovir disoproxil fumarate (FTC/TDF) is a preferred nucleoside reverse transcriptase inhibitor (NRTI) backbone with lamivudine/abacavir (3TC/ABC) as a commonly used alternative. For patients infected with human immunodeficiency virus (HIV-1) virologically suppressed on a boosted protease inhibitor (PI) + 3TC/ABC regimen, the merits of switching to FTC/TDF as the NRTI backbone are unknown. METHODS: SWIFT was a prospective, randomized, open-label 48-week study to evaluate efficacy and safety of switching to FTC/TDF. Subjects receiving 3TC/ABC + PI + ritonavir (RTV) with HIV-1 RNA < 200 c/mL ≥3 months were randomized to continue 3TC/ABC or switch to FTC/TDF. The primary endpoint was time to loss of virologic response (TLOVR) with noninferiority measured by delta of 12%. Virologic failure (VF) was defined as confirmed rebound or the last HIV-1 RNA measurement on study drug ≥200 c/mL. RESULTS: In total, 311 subjects were treated in this study (155 to PI + RTV + FTC/TDF, 156 to PI + RTV + 3TC/ABC). Baseline characteristics were similar between the arms: 85% male, 28% black, median age, 46 years; and median CD4 532 cells/mm(3). By TLOVR through week 48, switching to FTC/TDF was noninferior compared to continued 3TC/ABC (86.4% vs 83.3%, treatment difference 3.0% (95% confidence interval, -5.1% to 11.2%). Fewer subjects on FTC/TDF experienced VF (3 vs 11; P = .034). FTC/TDF showed greater declines in fasting low-density lipoproteins (LDL), total cholesterol (TC), and triglycerides (TG) with significant declines in LDL and TC beginning at week 12 with no TC/HDL ratio change. Switching to FTC/TDF showed improved NCEP thresholds for TC and TG and improved 10-year Framingham TC calculated scores. Decreased estimated glomerular filtration rate [corrected] (eGFR) was observed in both arms with a larger decrease in the FTC/TDF arm. CONCLUSIONS: Switching to FTC/TDF from 3TC/ABC maintained virologic suppression, had fewer VFs, improved lipid parameters and Framingham scores but decreased eGFR. CLINICALTRIALS.GOV IDENTIFIER: NCT00724711.

How willing are parents to improve pedestrian safety in their community?

STUDY OBJECTIVE: To determine how likely parents would be to contribute to strategies to reduce pedestrian injury risks and how much they valued such interventions. DESIGN: A single referendum willingness to pay survey. Each parent was randomised to respond to one of five requested contributions towards each of the following activities: constructing speed bumps, volunteering as a crossing guard, attending a neighbourhood meeting, or attending a safety workshop. SETTING: Community survey. PARTICIPANTS: A sample of 723 Baltimore parents from four neighbourhoods stratified by income and child pedestrian injury risk. Eligible parents had a child enrolled in one of four elementary schools in Baltimore City in May 2001. MAIN RESULTS: The more parents were asked to contribute, the less likely they were to do so. Parents were more likely to contribute in neighbourhoods with higher ratings of solidarity. The median willingness to pay money for speed bumps was conservatively estimated at $6.43. The median willingness to contribute time was 2.5 hours for attending workshops, 2.8 hours in community discussion groups, and 30 hours as a volunteer crossing guard. CONCLUSIONS: Parents place a high value on physical and social interventions to improve child pedestrian safety.

Annual summary of vital statistics: 2000.

The birth rate in 2000 (preliminary data) was 14.8 births per 1000 population, an increase of 2% from 1999 (14.5). The fertility rate, births per 1000 women aged 15 to 44 years, increased 3% to 67.6 in 2000, compared with 65.9 in 1999. The 2000 increases in births and the fertility rate were the third consecutive yearly increases, the largest in many years, halting the steady decline in the number of births and fertility rates in the 1990s. Fertility rates for total white, non-Hispanic white, black, and Native American women each increased about 2% in 2000. The fertility rate for black women, which declined 19% from 1990 to 1996, has changed little since 1996. The rate for Hispanic women rose 4% in 2000 to reach the highest level since 1993. Birth rates for women 30 years or older continued to increase. The proportion of births to unmarried women remained about the same at one third, but the number of births rose 3%. The birth rate for teen mothers declined again for the ninth consecutive year. The use of timely prenatal care (83.2%) remained unchanged in 2000, and was essentially unchanged for non-Hispanic white (88.5%), black (74.2%), and Hispanic (74.4%) mothers. The number and rate of multiple births continued their dramatic rise, but all of the increase was confined to twins; for the first time in more than a decade, the number of triplet and higher-order multiple births declined (4%) between 1998 and 1999 (multiple birth information is not available in preliminary 2000 data). The overall increases in multiple births account, in part, for the lack of improvement in the percentage of low birth weight (LBW) births. LBW remained at 7.6% in 2000. The infant mortality rate (IMR) dropped to 6.9 per 1000 live births (preliminary data) in 2000 (the rate was 7.1 in 1999). The ratio of the IMR among black infants to that for white infants was 2.5 in 2000, the same as in 1999. Racial differences in infant mortality remain a major public health concern. The role of low birth weight in infant mortality remains a major issue. Among all of the states, Utah and Maine had the lowest IMRs. State-by-state differences in IMR reflect racial composition, the percentage LBW, and birth weight-specific neonatal mortality rates for each state. The United States continues to rank poorly in international comparisons of infant mortality. Expectation of life at birth reached a record high of 76.9 years for all gender and race groups combined. Death rates in the United States continue to decline. The age-adjusted death rate for suicide declined 4% between 1999 and 2000; homicide declined 7%. Death rates for children 19 years of age or less declined for 3 of the 5 leading causes in 2000; cancer and suicide levels did not change for children as a group. A large proportion of childhood deaths, however, continue to occur as a result of preventable injuries.

"The Embarrassment of Riches;" an historical theme for a children's health agenda in 21st century America.

How can the United States use its immense wealth to create an agenda for children in the 21st century? The field of maternal and child health must strengthen and broaden the social strategies needed to overcome the changing demography and diminished political place of children in society, globally. Four approaches are proposed: First, adopting a life-course orientation emphasizes the continuities of the early part of life with the conditions, developmental tasks, and health problems of the rest of the life cycle; it makes maternal and child health relevant to health and well being across the entire life span. Second, shifting to a focus on the multiple determinants of population health will overcome the limitations of a medical model that is narrowly concerned with etiological risk factors for disease and medical interventions; in particular, poverty among children must be addressed on a global scale. Third, promoting social justice for children demands an open political discussion of the moral and ethical foundations of child health. Finally, preventing health problems across the life span requires a new set of population level, univeral intervention strategies. These fundamental principles are proposed to stimulate a discussion of how to make our field more influential in the 21st century.

Some unresolved issues with botulinum toxin.

Issues concerning botulinum toxin still need resolution in the laboratory and clinic. Assay nomenclature is unsatisfactory and attempts to establish common units and/or equivalents are misguided and dangerous. Optimum toxin concentrations for most indications are unknown. Loss of response is too readily ascribed to antibody formation. New therapeutic indications for toxin raise the possibility of additional mechanisms of action.

Early effects of the healthy steps for young children program.

OBJECTIVE: The Healthy Steps for Young Children Program (HS) incorporates early child development specialists and enhanced developmental services into routine pediatric care. An evaluation of HS is being conducted at 6 randomization and 9 quasi-experimental sites. Services received, satisfaction with services, and parent practices were assessed when infants were aged 2 to 4 months. METHODS: Telephone interviews with mothers were conducted for 2631 intervention (response rate, 89%) and 2265 control (response rate, 87%) families. Analyses were conducted separately for randomization and quasi-experimental sites and adjusted for baseline differences between intervention and control groups. Hierarchical linear models assessed overall adjusted effects, while accounting for within-site correlation of outcomes. RESULTS: Intervention families were considerably more likely than controls to report receiving 4 or more developmental services and home visits and discussing 5 infant development topics. They also were more likely to be satisfied and less likely to be dissatisfied with care from their pediatric provider and were less likely to place babies in the prone sleep position or feed them water. The program did not affect breastfeeding continuation. Differences in the percentage of parents who showed picture books to their infants, fed them cereal, followed routines, and played with them daily were found only at the quasi-experimental sites and may reflect factors unrelated to HS. CONCLUSIONS: Intervention families received more developmental services during the first 2 to 4 months of their child's life and were happier with care received than were control families. Future surveys and medical record reviews will address whether these findings persist and translate into improved language development, better utilization of well-child care, and an effect on costs.

Botulinum toxin type A and other botulinum toxin serotypes: a comparative review of biochemical and pharmacological actions.

Botulinum toxin type A is an important therapeutic agent for the treatment of movement and other disorders. As the clinical uses of botulinum toxin type A expand, it is increasingly important to understand the biochemical and pharmacological actions of this toxin, as well as those of other botulinum toxin serotypes (B-G). Botulinum neurotoxin serotypes exhibit differences in neurotoxin complex protein size, percentage of neurotoxin in the activated or nicked form, intracellular protein target, and potency. These properties differ even between preparations that contain the same botulinum toxin serotype due to variations in product formulations. As demonstrated in preclinical and clinical studies, these differences result in a unique combination of efficacy, duration of action, safety, and antigenic potential for each botulinum neurotoxin preparation.

Calling the shots: immunization finance policies and practices. Executive summary of the report of the Institute of Medicine.

Federal, state, and private-sector investments in vaccine purchases and immunization programs are lagging behind emerging opportunities to reduce the risks of vaccine-preventable disease. Although federal assistance to the states for immunization programs and data collection efforts rapidly expanded in the early part of the 1990s, significant cutbacks have occurred in the last 5 years that have reduced the size of state grant awards by more than 50% from their highest point. During this same period, the vaccine delivery system for children and adults has become more complex and fragmented. This combination of new challenges and reduced resources has led to instability in the public health infrastructure that supports the U. S. immunization system. Many states have reduced the scale of their immunization programs and currently lack adequate strength in areas such as data collection among at-risk populations, strategic planning, program coordination, and assessment of immunization status in communities that are served by multiple health care providers. If unmet immunization needs are not identified and addressed, states will have difficulty in achieving the national goal of 90% coverage by the year 2010 for completion of the childhood immunization series for young children. Furthermore, state and national coverage rates, which reached record levels for vaccines in widespread use (79%, 1998), can be expected to decline and preventable disease outbreaks may occur as a result, particularly among persons who are vulnerable to vaccine-preventable disease because of their underimmunization status. The Institute of Medicine (IOM) Committee on Immunization Finance Policies and Practices has therefore concluded that a renewal and strengthening of the federal and state immunization partnership is necessary. The goal of this renewed partnership is to prevent infectious disease; to monitor, sustain, and improve vaccine coverage rates for child and adult populations within more numerous and increasingly diversified health care settings; and to respond to vaccine-safety concerns. To achieve this renewal, states require a consistent strategy, additional funds, and a multiyear finance plan that can help expedite the delivery of new vaccines; strengthen the immunization assessment, assurance, and policy development functions in each state; and adapt childhood immunization programs to serve the needs of new age groups (especially adults with chronic diseases) in different health care environments. The IOM committee recommends that federal and state governments adopt a national finance strategy that would allocate $1.5 billion in federal and state resources over the first 5 years to strengthen the infrastructure for child and adult immunization-an annual increase of $175 million over current spending levels. These resources would consist of $200 million per year in state infrastructure grants awarded by the Centers for Disease Control and Prevention (the Section 317 program) and an additional $100 million per year in increased state contributions. The committee also recommends that the Congress replace the current discretionary Section 317 grants with a formula approach for state immunization grant awards to improve the targeting and stability of federal immunization grants. The formula should provide a base level of support to all states, as well as additional amounts related to each state's need, capacity, and performance. The committee further recommends that Congress introduce a state match requirement for the receipt of increased federal funds to help strengthen and stabilize the infrastructure that supports long-term public health assessment, assurance, and policy development efforts. (ABSTRACT TRUNCATED)

Assessing the impact of pediatric-based development services on infants, families, and clinicians: challenges to evaluating the Health Steps Program.

BACKGROUND: Begun in 1996, the Healthy Steps for Young Children Program (HS) is a new model of pediatric practice that incorporates child development specialists and enhanced developmental services for families of young children. HS is for all families, not just those at high-risk. It is expected to strengthen parents' knowledge, attitudes, and behaviors in ways that promote child health and development, and in turn, to lead to improved child outcomes, such as improved language development, increased utilization of well child care, and decreased problem behaviors, hospitalizations, and injuries. The HS evaluation is designed to assess whether HS is successful in achieving the desired outcomes, measure the program's costs, and determine the relation of the program's costs to its outcomes. OBJECTIVE: This article is the first report of the HS evaluation. It describes the evaluation design and characteristics of the HS sites and sample for the evaluation. METHODS: The evaluation is following a cohort of children from birth to age 3 at 15 evaluation sites across the country. The sites represent a range of organizational practice settings that include group practices, hospital-based clinics, and health maintenance organization pediatric clinics. The evaluation design relies on 2 comparison strategies. At 6 randomization design sites, 400 children were randomized to the intervention or control group. At 9 quasi-experimental design sites, a comparison location with a similar organizational setting and patient profile has been selected and up to 200 children are being followed at each of these sites. At each site, 2 developmental specialists (or their full-time equivalents) work as a team with 4 to 8 pediatricians and pediatric nurse practitioners. The specialist conducts office visits (jointly or sequentially with the pediatric clinician) and home visits, assesses children's developmental progress, provides referrals and follow-up to resources in the community, organizes and conducts parent discussion groups, coordinates early reading activities, and maintains a telephone information line for questions about child development and behavior. The evaluation relies on many data sources including self-administered provider surveys, key informant interviews, forms completed by parents at office visits, telephone interviews with parents, medical record reviews, data from each site on program costs and health services use, and an ongoing log of family contacts maintained by each developmental specialist. Analyses for this article are based on enrollment data for the Healthy Steps sample and national data on 1997 US live births. The chi2 goodness-of-fit test was used to evaluate whether the distribution of selected demographic variables, insurance, and infant's birth weight for the Healthy Steps sample was similar to the distributions for US births in 1997. In addition, comparisons were made between intervention and comparison families at the randomization and quasi-experimental evaluation sites. The chi2 test of independence was used to evaluate differences in variables across groups. RESULTS: Throughout a 26-month period, 5565 children enrolled in the evaluation, 2963 (53.2%) children in the intervention group and 2602 (46.8%) in the comparison group. More than 10% of mothers in the Healthy Steps sample are teenagers; 18% have 11 years of education or less; 27% have completed college; 18% are black or African-American; slightly >20% are of Hispanic origin; 36% are single; and close to one-third used Medicaid for their prenatal care. Approximately 7% of infants were low birth weight. When compared with national birth data for the United States as a whole, the Healthy Steps sample seems similarly diverse. However, with the exception of maternal age, the distribution of variables was significantly different from the distribution for US births. There are no differences between intervention and comparison families at randomization sites on any of

Recommendations for the use of botulinum toxin type A in the management of cerebral palsy.

Botulinum toxin type A (BTX-A) is increasingly being used for the treatment of childhood spasticity, particularly cerebral palsy. However, until very recently, all such use in this indication has been unapproved with no generally accepted treatment protocols, resulting in considerable uncertainty and variation in its use as a therapeutic agent. In view of the increasing awareness of, and interest in, this approach to the treatment of spasticity, and also the recent licensing in a number of countries of a BTX-A preparation for treating equinus deformity in children, it would seem timely to establish a framework of guidelines for the safe and efficacious use of BTX-A for treating spasticity in children. This paper represents an attempt, by a group of 15 experienced clinicians and scientists from a variety of disciplines, to arrive at a consensus and produce detailed recommendations as to appropriate patient selection and assessment, dosage, injection technique and outcome measurement. The importance of adjunctive physiotherapy, orthoses and casting is also stressed.

Annual summary of vital statistics: trends in the health of Americans during the 20th century.

The overall improvement in the health of Americans over the 20th century is best exemplified by dramatic changes in 2 trends: 1) the age-adjusted death rate declined by about 74%, while 2) life expectancy increased 56%. Leading causes of death shifted from infectious to chronic diseases. In 1900, infectious respiratory diseases accounted for nearly a quarter of all deaths. In 1998, the 10 leading causes of death in the United States were, respectively, heart disease and cancer followed by stroke, chronic obstructive pulmonary disease, accidents (unintentional injuries), pneumonia and influenza, diabetes, suicide, kidney diseases, and chronic liver disease and cirrhosis. Together these leading causes accounted for 84% of all deaths. The size and composition of the American population is fundamentally affected by the fertility rate and the number of births. From the beginning of the century there was a steady decline in the fertility rate to a low point in 1936. The postwar baby boom peaked in 1957, when 123 of every 1000 women aged 15 to 44 years gave birth. Thereafter, fertility rates began a steady decline. Trends in the number of births parallel the trends in the fertility rate. Beginning in 1936 and continuing to 1956, there was precipitous decline in maternal mortality from 582 deaths per 100 000 live births in 1935 to 40 in 1956. Since 1950 the maternal mortality ratio dropped by 90% to 7.1 in 1998. The infant mortality rate has shown an exponential decline during the 20th century. In 1915, approximately 100 white infants per 1000 live births died in the first year of life; the rate for black infants was almost twice as high. In 1998, the infant mortality rate was 7.2 overall, 6.0 for white infants, and 14.3 for black infants. For children older than 1 year of age, the overall decline in mortality during the 20th century has been spectacular. In 1900, >3 in 100 children died between their first and 20th birthday; today, <2 in 1000 die. At the beginning of the 20th century, the leading causes of child mortality were infectious diseases, including diarrheal diseases, diphtheria, measles, pneumonia and influenza, scarlet fever, tuberculosis, typhoid and paratyphoid fevers, and whooping cough. Between 1900 and 1998, the percentage of child deaths attributable to infectious diseases declined from 61.6% to 2%. Accidents accounted for 6.3% of child deaths in 1900, but 43.9% in 1998. Between 1900 and 1998, the death rate from accidents, now usually called unintentional injuries, declined two-thirds, from 47. 5 to 15.9 deaths per 100 000. The child dependency ratio far exceeded the elderly dependency ratio during most of the 20th century, particularly during the first 70 years. The elderly ratio has gained incrementally since then and the large increase expected beginning in 2010 indicates that the difference in the 2 ratios will become considerably less by 2030. The challenge for the 21st century is how to balance the needs of children with the growing demands for a large aging population of elderly persons.

The effect of parental monetary sanctions on the vaccination status of young children: an evaluation of welfare reform in Maryland.

OBJECTIVE: To determine whether financial sanctions to Aid to Families With Dependent Children (AFDC) recipients can be used to improve vaccination coverage of young children. DESIGN: Randomized controlled trial. SETTING: Six AFDC jurisdictions in Maryland. INTERVENTION: Recipients of AFDC were randomized to the experimental or control group of the Primary Prevention Initiative. Families in the experimental group were penalized financially for failing to verify that their children received preventive health care, including vaccinations; control families were not. PARTICIPANTS: Children aged 3 to 24 months from assigned families were randomly selected for the evaluation (911 in the experimental, 864 in the control, and 471 in the baseline groups). MAIN OUTCOME MEASURES: Up-to-date for age for diphtheria and tetanus toxoids and pertussis (DTP), polio, and measles-mumps-rubella (MMR) vaccines; missed opportunities to vaccinate; and number of visits per year. ANALYSIS: Comparisons among baseline and postimplementation years 1 and 2. RESULTS: Vaccination coverage of children was low. Less than 70% of children were up-to-date for age for polio and MMR vaccines; slightly more than 50% were up-to-date for DTP vaccine. Up-to-date rates differed little among baseline, experimental, and control groups. Over time, there was a decrease in missed opportunities, and more children made at least 1 well-child visit; however, neither improvement resulted in a change in vaccination status. CONCLUSIONS: The Primary Prevention Initiative did not contribute to an increase in vaccination coverage among these children. Minimal economic sanctions alone levied against parents should not be expected substantially to affect vaccination rates.

Annual summary of vital statistics--1998.

Most vital statistics indicators of the health of Americans were stable or showed modest improvements between 1997 and 1998. The preliminary birth rate in 1998 was 14.6 births per 1000 population, up slightly from the record low reported for 1997 (14.5). The fertility rate, births per 1000 women aged 15 to 44 years, increased 1% to 65.6 in 1998, compared with 65.0 in 1997. The 1998 increases, although modest, were the first since 1990, halting the steady decline in the number of births and birth and fertility rates in the 1990s. Fertility rates for total white, non-Hispanic white, and Native American women each increased from 1% to 2% in 1998. The fertility rate for black women declined 19% from 1990 to 1996, but has changed little since 1996. The rate for Hispanic women, which dropped 2%, was lower than in any year for which national data have been available. Birth rates for women 30 years or older continued to increase. The proportion of births to unmarried women remained about the same at one third. The birth rate for teen mothers declined again for the seventh consecutive year, and the use of timely prenatal care (82.8%) improved for the ninth consecutive year, especially for black (73.3%) and Hispanic (74.3%) mothers. The number and rate of multiple births continued their dramatic rise; the number of triplet and higher-order multiple births jumped 16% between 1996 and 1997, accounting, in part, for the slight increase in the percentage of low birth weight (LBW) births. LBW continued to increase from 1997 to 1998 to 7.6%. The infant mortality rate (IMR) was unchanged from 1997 to 1998 (7.2 per 1000 live births). The ratio of the IMR among black infants to that for white infants (2.4) remained the same in 1998 as in 1997. Racial differences in infant mortality remain a major public health concern. In 1997, 65% of all infant deaths occurred to the 7.5% of infants born LBW. Among all of the states, Maine, Massachusetts, and New Hampshire had the lowest IMRs. State-by-state differences in IMR reflect racial composition, the percentage LBW, and birth weight-specific neonatal mortality rate for each state. The United States continues to rank poorly in international comparisons of infant mortality. Expectation of life at birth increased slightly to 76.7 years for all gender and race groups combined. Death rates in the United States continue to decline, including a drop in mortality from human immunodeficiency virus. The age-adjusted death rate for suicide declined 6% in 1998; homicide declined 14%. Death rates for children from all major causes declined again in 1998. A large proportion of childhood deaths, however, continue to occur as a result of preventable injuries.

Innovative methods for monitoring perinatal health outcomes in cities and in smaller geographic areas.

OBJECTIVES: Monitoring health in small localities such as cities or local communities is important, because rates of adverse outcomes often vary widely by geographic area. This article explores the utility of CUSUM (cumulative summation), a method developed and refined in industry, for monitoring health outcomes in cities and smaller geographic areas. METHODS: CUSUM monitoring methods were applied to rates of late or no prenatal care initiation and very low birthweight for the city of Baltimore as a whole and for a cluster of high-risk areas within the city. The performance of supplementary runs criteria was also assessed. The ability of both methods to flag significant increases or decreases in prenatal care initiation and very low birthweight rates was assessed. RESULTS: CUSUM and runs criteria detected most significant rate changes. The 2 methods performed better in regard to outcomes with higher prevalence and in larger geographic areas. CONCLUSIONS: CUSUM methods are convenient and reliable for use in the monitoring of moderately low prevalence outcomes in small geographic areas. Future research should examine their applicability to other health outcomes and further refine these methods, especially for rarer outcomes.

The relation of parent and provider characteristics to vaccination status of children in private practices and managed care organizations in Maryland.

OBJECTIVES: This study sought to identify provider practices and policies in private pediatric settings that relate to vaccination status, controlling for the characteristics of the children served. METHODS: Vaccination data came from the medical records of 709 randomly selected 2-year-old children at 18 private practices and managed care organizations in Maryland, family data from 466 telephone interviews with the children's parents, and provider characteristics from 18 site questionnaires and 42 individual physician and nurse practitioner questionnaires. Logistic regression and generalized estimating equations were used to estimate the relation of provider characteristics to vaccination status. Three age-appropriate (AA) and two up-to-date (UTD) vaccination status variables characterized successful vaccination. RESULTS: Approximately 70% of the study children were up-to-date by age 2 years for the full vaccination series, excluding hepatitis B vaccine. Family demographic characteristics were the strongest correlates of undervaccination. Neither parents' knowledge and attitudes about immunization nor the children's insurance coverage was statistically related to vaccination status. Site reminder or follow-up systems and provider perceptions about appointment scheduling and receipt of vaccine information from health departments were positively related to vaccination. Concern for liability was associated with a reduced odds of age-appropriate and up-to-date vaccination. CONCLUSIONS: Family demographics strongly correlate with vaccination status; however, they are generally not modifiable. This study's findings encourage providers to operate a tracking system, to remain current on immunization recommendations, to use all clinical encounters to screen and vaccinate children, and to ensure the availability and convenience of vaccination services.