Trends and Characteristics of CDC Global Rapid Response Team Deployments-A 6-Month Report, October 2018-March 2019.

The Centers for Disease Control and Prevention (CDC) Global Rapid Response Team (GRRT) was launched in June 2015 to strengthen the capacity for international response and to provide an agency-wide roster of qualified surge-staff members who can deploy on short notice and for long durations. To assess GRRT performance and inform future needs for CDC and partners using rapid response teams, we analyzed trends and characteristics of GRRT responses and responders, for deployments of at least 1 day during October 1, 2018, through March 31, 2019. One hundred twenty deployments occurred during the study period, corresponding to 2645 person-days. The median deployment duration was 19 days (interquartile range, 5-30 days). Most deployments were related to emergency response (n = 2367 person-days, 90%); outbreaks of disease accounted for almost all deployment time (n = 2419 person-days, 99%). Most deployments were to Africa (n = 1417 person-days, 54%), and epidemiologists were the most commonly deployed technical advisors (n = 1217 person-days, 46%). This case study provides useful information for assessing program performance, prioritizing resource allocation, informing future needs, and sharing lessons learned with other programs managing rapid response teams. GRRT has an important role in advancing the global health security agenda and should continuously be assessed and adjusted to new needs.

Applied Epidemiology Training Needs for the Modern Epidemiologist.

Applied epidemiology training occurs throughout an epidemiologist's career, beginning with academic instruction before workforce entry, continuing as professional development while working, and culminating with mentoring the next generation. Epidemiologists need ongoing training on advancements in the field and relevant topics (e.g., informatics, laboratory science, emerging topics) to maintain and improve their skills. Even epidemiologists with advanced skills often want training on methodologic innovations or to practice a skill. Effective applied epidemiology training includes blended learning components of instruction that incorporate hands-on experiences such as simulations and experiential learning, allowing for real-time workflows and incorporation of feedback. To prepare epidemiologists for the future, public health training courses in applied epidemiology must consider the evolution in public health toward a focus on including informatics, technologic innovation, molecular epidemiology, multidisciplinary teams, delivery of population health services, and global health security. Supporting efforts by epidemiologists to increase their skills as part of their career paths ensures a strong workforce that able to tackle public health issues. We explore how to meet current training challenges for the epidemiology workforce, especially given limited resources, based on research and our experience in workforce development across federal agencies and state/local health departments, as well as with international governments and organizations.

Building the pipeline: programs to introduce middle school, high school, medical, and veterinary students to careers in epidemiology and public health.

PURPOSE: This report describes Centers for Disease Control and Prevention programs that expose students to epidemiology and public health sciences (EPHS). METHODS: The Science Ambassador workshop targets middle and high school teachers and promotes teaching EPHS in the classroom. The National Science Olympiad Disease Detectives event is an extracurricular science competition for middle and high school students based on investigations of outbreaks and other public health problems. The Epidemiology Elective Program provides experiential learning activities for veterinary and medical students. RESULTS: As of 2016, 234 teachers from 37 states and territories and three other countries participated in SA workshops. Several are teaching units or entire courses in EPHS. The National Science Olympiad Disease Detectives event exposed approximately 15,000 middle and high school students to EPHS during the 2015-2016 school year. The Epidemiology Elective Program has exposed 1,795 veterinary and medical students to EPHS. CONCLUSIONS: Students can master fundamental concepts of EPHS as early as middle school and educators are finding ways to introduce this material into their classrooms. Programs to introduce veterinary and medical students to EPHS can help fill the gap in exposing older students to the field. Professional organizations can assist by making their members aware of these programs.

Applied epidemiology and public health: are we training the future generations appropriately?

To extend the reach and relevance of epidemiology for public health practice, the science needs be broadened beyond etiologic research, to link more strongly with emerging technologies and to acknowledge key societal transformations. This new focus for epidemiology and its implications for epidemiologic training can be considered in the context of macro trends affecting society, including a greater focus on upstream causes of disease, shifting demographics, the Affordable Care Act and health care system reform, globalization, changing health communication environment, growing centrality of team and transdisciplinary science, emergence of translational sciences, greater focus on accountability, big data, informatics, high-throughput technologies ("omics"), privacy changes, and the evolving funding environment. This commentary describes existing approaches to and competencies for training in epidemiology, maps macro trends with competencies, highlights an example of competency-based education in the Epidemic Intelligence Service of Centers for Disease Control and Prevention, and suggests expanded and more dynamic training approaches. A reexamination of current approaches to epidemiologic training is needed.

Forewarning of poliovirus outbreaks in the Horn of Africa: an assessment of acute flaccid paralysis surveillance and routine immunization systems in Kenya.

BACKGROUND: Although the Horn of Africa region has successfully eliminated endemic poliovirus circulation, it remains at risk for reintroduction. International partners assisted Kenya in identifying gaps in the polio surveillance and routine immunization programs, and provided recommendations for improved surveillance and routine immunization during the health system decentralization process. METHODS: Structured questionnaires collected information about acute flaccid paralysis (AFP) surveillance resources, training, data monitoring, and supervision at provincial, district, and health facility levels. The routine immunization program information collected included questions about vaccine and resource availability, cold chain, logistics, health-care services and access, outreach coverage data, microplanning, and management and monitoring of AFP surveillance. RESULTS: Although AFP surveillance met national performance standards, widespread deficiencies and limited resources were observed and reported at all levels. Deficiencies were related to provider knowledge, funding, training, and supervision, and were particularly evident at the health facility level. CONCLUSIONS: Gap analysis assists in maximizing resources and capacity building in countries where surveillance and routine immunization lag behind other health priorities. Limited resources for surveillance and routine immunization systems in the region indicate a risk for additional outbreaks of wild poliovirus and other vaccine-preventable illnesses. Monitoring and evaluation of program strengthening activities are needed.

A longitudinal study of youth assets, neighborhood conditions, and youth sexual behaviors.

PURPOSE: To prospectively determine whether individual, family, and community assets help youth to delay initiation of sexual intercourse (ISI); and for youth who do initiate intercourse, to use birth control and avoid pregnancy. The potential influence of neighborhood conditions was also investigated. METHODS: The Youth Asset Study was a 4-year longitudinal study involving 1,089 youth (mean age = 14.2 years, standard deviation = 1.6; 53% female; 40% white, 28% Hispanic, 23% African American, 9% other race) and their parents. Participants were living in randomly selected census tracts. We accomplished recruitment via door-to-door canvassing. We interviewed one youth and one parent from each household annually. We assessed 17 youth assets (e.g., responsible choices, family communication) believed to influence behavior at multiple levels via in-person interviews methodology. Trained raters who conducted annual windshield tours assessed neighborhood conditions. RESULTS: Cox proportional hazard or marginal logistic regression modeling indicated that 11 assets (e.g., family communication, school connectedness) were significantly associated with reduced risk for ISI; seven assets (e.g., educational aspirations for the future, responsible choices) were significantly associated with increased use of birth control at last sex; and 10 assets (e.g., family communication, school connectedness) were significantly associated with reduced risk for pregnancy. Total asset score was significantly associated with all three outcomes. Positive neighborhood conditions were significantly associated with increased birth control use, but not with ISI or pregnancy. CONCLUSIONS: Programming to strengthen youth assets may be a promising strategy for reducing youth sexual risk behaviors.

Reasons for the increasing Hispanic infant mortality rate: Florida, 2004-2007.

Assess whether the 55% increase in Florida's Hispanic infant mortality rate (HIMR) during 2004-2007 was real or artifactual. Using linked data from Florida resident live births and infant deaths for 2004-2007, we calculated traditional (infant Hispanic ethnicity from death certificates and maternal Hispanic ethnicity from birth certificates) and nontraditional (infant and maternal Hispanic ethnicity from birth certificate maternal ethnicity) HIMRs. We assessed trends in HIMRs (per 1,000 live births) using Chi-square statistics. We tested agreement in Hispanic ethnicity after implementation of a revised 2005 death certificate by using kappa statistics and used logistic regression to test the associations of infant mortality risk factors. Hispanic was defined as being of Mexican, Puerto Rican, Cuban, Central/South American, or other/unknown Hispanic origin. During 2004-2007 traditional HIMR increased 55%, from 4.0 to 6.2 (Chi-square, P < 0.001) and nontraditional HIMR increased 20%, from 4.5 to 5.4 (Chi-square, P = 0.03). During 2004-2005, agreement in Hispanic ethnicity did not change with use of the revised certificate (kappa = 0.70 in 2004; kappa = 0.76 in 2005). Birth weight was the most significant risk factor for trends in Hispanic infant mortality (OR = 1.33, 95% CI = 1.10-1.61). Differences in Hispanic reporting on revised death certificates likely accounted for the majority of traditional HIMR increase, indicating a primarily artifactual increase. Reasons for the 20% increase in nontraditional HIMR during 2004-2007 should be further explored through other individual and community factors. Use of nontraditional HIMRs, which use a consistent source of Hispanic classification, should be considered.

Racial and ethnic disparities in hospitalizations and deaths associated with 2009 pandemic Influenza A (H1N1) virus infections in the United States.

PURPOSE: Concerns have been raised regarding possible racial-ethnic disparities in 2009 pandemic influenza A (H1N1) (pH1N1) illness severity and health consequences for U.S. minority populations. METHODS: Using data from the Centers for Disease Control and Prevention's Behavioral Risk Factor Surveillance System, Emerging Infections Program Influenza-Associated Hospitalization Surveillance, and Influenza-Associated Pediatric Mortality Surveillance, we calculated race-ethnicity-specific, age-adjusted rates of self-reported influenza-like illness (ILI) and pH1N1-associated hospitalizations. We used χ(2) tests to evaluate racial-ethnic disparities in ILI-associated health care-seeking behavior and pH1N1 hospitalization. To evaluate pediatric deaths, we compared racial-ethnic proportions of deaths against U.S. population distributions. RESULTS: Prevalence of self-reported ILI was lower among Hispanics (6.5%), higher among American Indians/Alaska Natives (16.2%), and similar among non-Hispanic blacks (7.7%) compared with non-Hispanic whites (8.5%). No racial-ethnic differences were identified in ILI-associated health care-seeking behavior. Age-adjusted pH1N1-associated Emerging Infections Program hospitalization rates were higher among all minority populations (range: 8.1-10.9/100,000 population) compared with non-Hispanic whites (3.0/100,000). The proportion of pH1N1-associated pediatric deaths was higher than expected among Hispanics (31%) and lower than expected among non-Hispanic whites (45%) given the proportions of the U.S. population they comprise (22% and 58%, respectively). CONCLUSIONS: Racial-ethnic disparities in pH1N1-associated hospitalizations and pediatric deaths were identified. Vaccination remains the primary intervention for preventing influenza.

Associations between youth assets and sexual intercourse by household income.

PURPOSE: Evaluate youth assets or potential strengths and sexual intercourse associations by household income. DESIGN: Data consisted of youth and parent responses from randomly selected households from a cross-sectional study and wave one of a longitudinal extension of that study. Youth assets and sexual intercourse were compared for four income categories. SETTING: Midwestern racially diverse, inner-city neighborhoods. SUBJECTS: One adolescent (12-19 years) and one parent (2335 pairs). MEASURES: Adjusted odds ratios (ORs) were calculated using logistic regression. Variables assessed included parent and youth demographics, youth sexual intercourse, and youth assets (adult and peer role models, family communication, use of time [religion or sports], community involvement, future aspirations, responsible choices, and health practices). RESULTS: Youths' mean age was 14.9 (± 1.8) years, and 52% were female; 44% of respondents were white. Use of time (religion) was significantly associated with never having sex for all but the lowest income youth (OR range=1.79-2.64). The variable peer role models was significant for the lowest income (O =2.01) and two upper income groups (ORs=2.52 and 4.27, respectively). The variable future aspirations was significant for the lowest income youth (OR=1.77). CONCLUSION: The youth asset variable future aspirations was critical for the lowest income households. Other asset variables, such as peer role models and use of time (religion) were critical regardless of income.

Assessment of the Institute of Medicine recommendations for weight gain during pregnancy: Florida, 2004-2007.

We investigated the association between 2009 IOM recommendations and adverse infant outcomes by maternal prepregnancy body mass index (BMI). Birth outcomes for 570,672 women aged 18-40 years with a singleton full-term live-birth were assessed using 2004-2007 Florida live-birth certificates. Outcomes included large-for-gestational-age (LGA) and small-for-gestational-age (SGA). Associations between gestational weight change and outcomes were assessed for 10 BMI groups by calculating proportions, and logistic regression modeling was used to produce adjusted odds ratios (aORs) to account for the effect of confounders. We created comparison categories below and above recommendations using 2009 IOM recommendations as a reference. Of importance, 41.6% of women began pregnancy as overweight and obese and 51.2% gained weight excessively during pregnancy on the basis of 2009 IOM recommendations. Proportions of LGA were higher among obese women and increased with higher weight gain. Compared with recommended weight gain, aORs for LGA were lower with less than recommended gain (aOR range: 0.27-0.77) and higher with more than recommended gain (aOR range: 1.27-5.99). However, SGA was less prevalent among obese women, and the proportion of SGA by BMI was similar with higher weight gain. Gain less than recommended was associated with increased odds of SGA (aOR range: 1.11-2.97), and gain greater than recommended was associated with decreased odds of SGA (aOR range: 0.38-0.83). Gestational weight gain influenced the risk for LGA and SGA in opposite directions. Minimal weight gain or weight loss lowered risk for LGA among obese women. Compared with 1990 IOM recommendations, 2009 recommendations include weight gain ranges that are associated with lower risk of LGA and higher risk of SGA. Awareness of these tradeoffs may assist with clinical implementation of the 2009 IOM gestational weight gain recommendations. However, our results did not consider other maternal and infant outcomes related to gestational weight gain; therefore, the findings should be interpreted with caution.

Reliability and validity of birth certificate prepregnancy weight and height among women enrolled in prenatal WIC program: Florida, 2005.

To investigate the reliability and validity of weight, height, and body mass index (BMI) from birth certificates with directly measured values from the Women, Infants, and Children (WIC) Program. Florida birth certificate data were linked and compared with first trimester WIC data for women with a live birth during the last quarter of calendar year 2005 (n = 23,314 women). Mean differences for weight, height, and BMI were calculated by subtracting birth certificate values from WIC values. Reliability was estimated by Pearson's correlation. Validity was measured by sensitivity and specificity using WIC data as the reference. Overall mean differences plus or minus standard error (SE) were 1.93 ± 0.04 kg for weight, -1.03 ± 0.03 cm for height, and 1.07 ± 0.02 kg/m(2) for BMI. Pearson's correlation ranged from 0.83 to 0.95, which indicates a strong positive association. Compared with other categories, women in the second weight group (56.7-65.8 kg), the highest height group (≥167.6 cm), or BMI < 18.5 had the greatest mean differences for weight (2.2 ± 0.08 kg), height (-2.4 ± 0.05 cm), and BMI (1.5 ± 0.06), respectively. Mean differences by maternal characteristics were similar, but statistically significant, likely in part from the large sample size. The sensitivity for birth certificate data was 77.3% (±1.42) for underweight (BMI < 18.5) and 76.4% (±0.51) for obesity (BMI ≥ 30). Specificity was 96.8% (±0.12) for underweight and 97.5% (±0.12) for obesity. Birth certificate data had higher underweight prevalence (6 vs. 4%) and lower obesity prevalence (24 vs. 29%), compared with WIC data. Although birth certificate data overestimated underweight and underestimated obesity prevalence, the difference was minimal and has limited impact on the reliability and validity for population-based surveillance and research purposes related to recall or reporting bias.

The impact of the availability of school vending machines on eating behavior during lunch: the Youth Physical Activity and Nutrition Survey.

Childhood obesity is a major public health concern and is associated with substantial morbidities. Access to less-healthy foods might facilitate dietary behaviors that contribute to obesity. However, less-healthy foods are usually available in school vending machines. This cross-sectional study examined the prevalence of students buying snacks or beverages from school vending machines instead of buying school lunch and predictors of this behavior. Analyses were based on the 2003 Florida Youth Physical Activity and Nutrition Survey using a representative sample of 4,322 students in grades six through eight in 73 Florida public middle schools. Analyses included χ2 tests and logistic regression. The outcome measure was buying a snack or beverage from vending machines 2 or more days during the previous 5 days instead of buying lunch. The survey response rate was 72%. Eighteen percent of respondents reported purchasing a snack or beverage from a vending machine 2 or more days during the previous 5 school days instead of buying school lunch. Although healthier options were available, the most commonly purchased vending machine items were chips, pretzels/crackers, candy bars, soda, and sport drinks. More students chose snacks or beverages instead of lunch in schools where beverage vending machines were also available than did students in schools where beverage vending machines were unavailable: 19% and 7%, respectively (P≤0.05). The strongest risk factor for buying snacks or beverages from vending machines instead of buying school lunch was availability of beverage vending machines in schools (adjusted odds ratio=3.5; 95% confidence interval, 2.2 to 5.7). Other statistically significant risk factors were smoking, non-Hispanic black race/ethnicity, Hispanic ethnicity, and older age. Although healthier choices were available, the most common choices were the less-healthy foods. Schools should consider developing policies to reduce the availability of less-healthy choices in vending machines and to reduce access to beverage vending machines.

Association of maternal smoking status with breastfeeding practices: Missouri, 2005.

OBJECTIVE: We sought to determine the association of smoking status as a risk factor for reduced initiation and duration of breastfeeding. METHODS: The Missouri Pregnancy Related Assessment and Monitoring System collected a stratified sample of new mothers in 2005. Surveys were mailed, with telephone follow-up, and completed within 2 to 12 months after delivery. Respondents were classified as nonsmokers, smokers who quit during pregnancy, light smokers (10 cigarettes per day). Multivariable binomial regression and Cox proportional hazards models were used to assess breastfeeding initiation and duration according to smoking status. RESULTS: Overall, 1789 women participated (weighted response rate: 61%). Approximately 74% of the women ever breastfed; 31% of the women ever smoked while pregnant. Compared with nonsmokers, the moderate/heavy smokers and light smokers were less likely to initiate breastfeeding, after controlling for sociodemographic characteristics, the presence of other smokers in the household, alcohol use, mode of delivery, and infant hospitalization. Compared with nonsmokers, the moderate/heavy smokers, light smokers, and smokers who quit during pregnancy were more likely to wean over time, controlling for the same covariates. There were no significant differences between nonsmokers and smokers regarding reasons for not initiating or ceasing breastfeeding. CONCLUSIONS: Mothers who smoked initiated breastfeeding less often and weaned earlier than nonsmoking mothers. Incorporating knowledge of the association between smoking and breastfeeding into existing smoking-cessation and breastfeeding programs could provide opportunities to reduce perinatal exposure to tobacco smoke, improve interest in breastfeeding, and address other barriers to breastfeeding that smoking mothers may face.

Contraceptive use--United States and territories, Behavioral Risk Factor Surveillance System, 2002.

PROBLEM: Contraceptive use is an important determinant of unintended pregnancy. In the United States, approximately half of all pregnancies are unintended. Population-based information about contraceptive use patterns is limited at the state level. Information about contraceptive use for states can be used to guide the development of state programs and policies to decrease unintended pregnancy and the spread of sexually transmitted infections. Information about contraceptive use for specific subpopulations can be used to further refine state efforts to improve contraceptive use and subsequently decrease the occurrence of unintended pregnancy. REPORTING PERIOD: Data were collected in 2002 for men and women. DESCRIPTION OF SYSTEM: The Behavioral Risk Factor Surveillance System (BRFSS) is a random-digit--dialed, telephone survey of the noninstitutionalized U.S. population aged > or =18 years. All 50 states, the District of Columbia, Guam, the Commonwealth of Puerto Rico, and the U.S. Virgin Islands participated in BRFSS in 2002. These data can be used to track state progress towards the national health objectives for 2010 for responsible sexual behavior. The 2002 BRFSS data represent the first time state data on contraceptive use in all 50 states will be presented and examined by selected sociodemographic characteristics. The 2002 BRFSS also, for the first time, provided an opportunity to examine state-level contraceptive use patterns among men. RESULTS: Variation across states and territories was observed for the majority of contraceptive methods among the different demographics analyzed and among men and women. The percentage of men and women at risk for pregnancy who said they or their partner was using birth control was high overall and ranged from 67% (Guam) to 88% (Idaho). Oral contraceptives (i.e., the pill), vasectomy, tubal ligation, and condoms were the methods most frequently reported by both male and female respondents who said they or their partner was using birth control. Among female respondents using birth control, the pill was the most common method reported. Among men, vasectomy was the most commonly reported method. The prevalence of use for the four most commonly reported methods (pills, vasectomy, tubal ligation, condoms) varied as much as six-fold among states for vasectomy and three- to four-fold for condoms, pills, and tubal ligation. INTERPRETATION: The findings in this report document substantial differences among states and sociodemographic groups within states in contraceptive method use. PUBLIC HEALTH ACTION: These data can help states identify populations with an unmet need for birth control, barriers to birth control use, and gaps in the range of birth control methods offered by health-care providers. An analysis of the prevalence of birth control use by state and selected population characteristics can help states target contraceptive programs to best meet the needs of their population.

Contraceptive use by diabetic and obese women.

PURPOSE: Women with chronic medical conditions are at increased risk for adverse pregnancy outcomes, yet contraceptive use by these women has not been well described. The purpose of this study was to describe contraceptive use by diabetic and overweight/obese women compared with women without these conditions. METHODS: Using cross-sectional data from the 11 states participating in the optional Family Planning Module of the Behavioral Risk Factor Surveillance System in 2000, we analyzed contraceptive use among 7,943 sexually active women of reproductive age (18-44) who were not trying to conceive. Using logistic regression techniques, we modeled the effect of diabetes and overweight/obesity on contraceptive nonuse, controlling for age, race/ethnicity, marital status, education, income, and health insurance coverage. MAIN FINDINGS: Contraceptive nonuse was reported by 1,500 (18.9%) of the total sample, 31 (25.8%) diabetic women, 371 (20.0%) overweight women, and 385 (23.4%) obese women. In the multivariable model, obesity was significantly associated with contraceptive nonuse (adjusted odds ratio [OR] 1.34, 95% confidence interval [CI] 1.16-1.55), but there were no significant differences in contraceptive nonuse for diabetic women (adjusted OR 1.23, 95% CI 0.80-1.87) or overweight women (adjusted OR 1.14, 95% CI 0.99-1.31). Older, Black, Hispanic, married, less educated, and women without health insurance were more likely to report contraceptive nonuse. CONCLUSION: Among women with need for contraception, obese women were more likely to report contraceptive nonuse than normal weight women. Because women with chronic conditions like obesity are at higher risk of pregnancy-related complications and adverse pregnancy outcomes, proper contraceptive use and unintended pregnancy avoidance is a priority.

Alaska air carrier operator and pilot safety practices and attitudes: a statewide survey.

INTRODUCTION: Aviation crashes are a leading cause of occupational fatalities in Alaska, with Alaskan pilots having nearly 100 times the fatality rate of U.S. workers overall. A survey was designed to study pilot and company practices and attitudes in order to develop intervention strategies that would reduce aviation fatalities. METHODS: Two surveys were administered: one of air carrier operators and one of active commercial pilots. Surveys from 153 air taxi and public-use operators were received at a 79% response rate. RESULTS: There are almost 2000 pilots employed in Alaska during peak season by air taxi operators and public agencies. Surveyed operators and pilots generally agreed that improved weather information and regional hazards training would be effective ways to prevent crashes. Operators were more in favor of operator financial incentives (p < 0.05) and better pre-employment hiring checks on pilots (p < 0.05) compared with pilots' survey responses. There were 48% of pilots of large operators and 73% of pilots of small operators who considered their jobs to be at least as safe as other jobs. CONCLUSIONS: The results of operator-pilot comparisons suggest that financial pressures on operators may influence their views on what measures would be effective in preventing crashes, and that Alaskan pilots underestimate their occupational fatality risk.