Availability of Naloxone in 2 Underserved Urban Communities in Georgia.

In 2016, unintentional injuries became the third leading cause of death in the United States. In 2018, 54% of 103 672 unintentional injury deaths were due to drug overdoses among adults 19 to 64 years of age. In Georgia, opioid overdose deaths continued to increase, despite a 2014 state law for naloxone use to prevent deaths, and a 2017 amendment for more widespread community use without a prescription. Given these policies, naloxone availability in pharmacies in underserved communities remains unclear. Our objective is to explore naloxone availability in such communities. Three Public Health and Preventive Medicine residents during a social-cultural-behavioral longitudinal rotation conducted interviews of 9 community pharmacists. Several themes emerged: more education was needed, and naloxone was available only by prescription in certain pharmacies or in limited amounts. Additional assessments among community members and sectors can examine the extent to which policies to expand naloxone availability and accessibility are implemented, including reduced naloxone costs.

Vaccination differences among U.S. adults by their self-identified sexual orientation, National Health Interview Survey, 2013-2015.

INTRODUCTION: Very few studies have explored the associations between self-identified sexual orientation and comprehensive vaccination coverage. Most of the previous studies that reported health disparities among lesbian, gay and bisexual populations were not based on a nationally representative sample of U.S. adults, limiting the generalizability of the findings. Starting in 2013, the National Health Interview Survey (NHIS) included questions to ascertain the adult's self-identified sexual orientation that allowed national level vaccination estimation by sexual orientation. This study examined associations of self-reported vaccination coverage for selected vaccines among U.S. adults by their sexual orientation. METHODS: We analyzed combined data from 2013-2015 NHIS, a nationally representative probability-based health survey of the noninstitutionalized U.S. population ≥18 years. For vaccines other than influenza, weighted proportions were calculated. Influenza coverage was calculated using the Kaplan-Meier procedure. Multivariable logistic regression models were used to calculate adjusted prevalence differences for each vaccine overall and stratified by sexual orientation and to identify factors independently associated with vaccination. RESULTS: Significant differences were observed by sexual orientation for self-reported receipt of human papillomavirus (HPV), hepatitis A (HepA), hepatitis B (HepB), and influenza vaccination. Bisexual females (51.6%) had higher HPV coverage than heterosexual females (40.2%). Gay males (40.3% and 53.6%, respectively) had higher HepA and HepB coverage than heterosexual males (25.4% and 32.6%, respectively). Bisexual females (33.9% and 58.5%, respectively) had higher HepA and HepB coverage than heterosexual females (23.5% and 38.4%, respectively) and higher HepB coverage than lesbian females (45.4%). Bisexual adults (34.1%) had lower influenza coverage than gay/lesbian (48.5%) and heterosexual adults (43.8%). Except for the association of having self-identified as gay/lesbian orientation with greater likelihood of HepA, HepB, and influenza vaccination, sexual orientation was not associated with higher or lower likelihood of vaccination. Health status or other behavioral characteristics studied had no consistent relationship with vaccination among all populations. CONCLUSION: Differences were identified in vaccination coverage among the U.S. adult population by self-reported sexual orientation. This study is the first to assess associations of sexual orientation with a comprehensive list of vaccinations. Findings from this study can serve as a baseline for monitoring changes over time. All populations could benefit from improved vaccination.

Public Health Agency Responses and Opportunities to Protect Against Health Impacts of Climate Change Among US Populations with Multiple Vulnerabilities.

During the past several decades, unprecedented global changes in climate have given rise to an increase in extreme weather and other climate events and their consequences such as heavy rainfall, hurricanes, flooding, heat waves, wildfires, and air pollution. These climate effects have direct impacts on human health such as premature death, injuries, exacerbation of health conditions, disruption of mental well-being, as well as indirect impacts through food- and water-related infections and illnesses. While all populations are at risk for these adverse health outcomes, some populations are at greater risk because of multiple vulnerabilities resulting from increased exposure to risk-prone areas, increased sensitivity due to underlying health conditions, and limited adaptive capacity primarily because of a lack of economic resources to respond adequately. We discuss current governmental public health responses and their future opportunities to improve resilience of special populations at greatest risk for adverse health outcomes. Vulnerability assessment, adaptation plans, public health emergency response, and public health agency accreditation are all current governmental public health actions. Governmental public health opportunities include integration of these current responses with health equity initiatives and programs in communities.

Value of a small control group for estimating intervention effectiveness: results from simulations of immunization effectiveness studies.

AIM: To improve evidence for public health practice, the conduct of effectiveness studies by practitioners is needed and may be stimulated if knowledge that smaller than usual samples may provide the same reliability of intervention effect size as larger samples. MATERIALS & METHODS: We examined reliability of intervention effect using computerized simulations of 2000 hypothetical immunization effectiveness studies from an actual study population and by small (30 and 60) and larger (100 and 200) control groups compared with an intervention group of 200 participants. RESULTS & CONCLUSION: Across simulated studies, the mean intervention effect (14%) and effect sizes were equivalent regardless of control group size and equal to the actual study effect. These results are relevant for similarly designed and executed studies and indicate that studies with smaller control groups can generate valid and accurate evidence for effective public health practice in communities.

Protecting vulnerable populations from pandemic influenza in the United States: a strategic imperative.

Protecting vulnerable populations from pandemic influenza is a strategic imperative. The US national strategy for pandemic influenza preparedness and response assigns roles to governments, businesses, civic and community-based organizations, individuals, and families. Because influenza is highly contagious, inadequate preparedness or untimely response in vulnerable populations increases the risk of infection for the general population. Recent public health emergencies have reinforced the importance of preparedness and the challenges of effective response among vulnerable populations. We explore definitions and determinants of vulnerable, at-risk, and special populations and highlight approaches for ensuring that pandemic influenza preparedness includes these populations and enables them to respond appropriately. We also provide an overview of population-specific and cross-cutting articles in this theme issue on influenza preparedness for vulnerable populations.

Protection of racial/ethnic minority populations during an influenza pandemic.

Racial/ethnic minority populations experience worse health outcomes than do other groups during and after disasters. Evidence for a differential impact from pandemic influenza includes both higher rates of underlying health conditions in minority populations, increasing their risk of influenza-related complications, and larger socioeconomic (e.g., access to health care), cultural, educational, and linguistic barriers to adoption of pandemic interventions. Implementation of pandemic interventions could be optimized by (1) culturally competent preparedness and response that address specific needs of racial/ethnic minority populations, (2) improvements in public health and community health safety net systems, (3) social policies that minimize economic burdens and improve compliance with isolation and quarantine, and (4) relevant, practical, and culturally and linguistically tailored communications.

Public health surveillance for suspected smallpox in the United States, 2003-2005: results of a national survey.

In 2005, a Web-based survey of chief epidemiologists of 50 states, the District of Columbia, 9 large cities, and 8 territories examined the status of US smallpox surveillance after the Council of State and Territorial Epidemiologists recommended that smallpox be reportable. Of 55 respondents, 95% reported state or territory laws or regulations governing smallpox reporting; 70% of states required laboratories to report variola virus. All respondents could investigate reported suspected patients; 70%-89% would investigate initially by telephone or fax. In 2004, 11 states reported 33 patients suspected of having smallpox. Reports were more likely in states that provided >/=2 educational and training sessions (67% vs. 21%; prevalence odds ratio, 7.60; 95% confidence interval, 1.07-60.45). The goal is a public health surveillance system in which all states, cities, and territories can detect and manage suspected smallpox cases urgently and in which overall surveillance for other infectious diseases is strengthened.

Performance of an algorithm for assessing smallpox risk among patients with rashes that may be confused with smallpox.

After the 2001 anthrax bioterror attacks, the Centers for Disease Control and Prevention developed an algorithm to evaluate patients rapidly for suspected smallpox. A prospective, multicenter study examined the performance of this algorithm in assessing patients with an acute, generalized vesicular or pustular rash (AGVPR) admitted to emergency departments and inpatient units of 12 acute-care hospitals in 6 states. Of 26,747 patients (3.5% of all admissions) with rashlike conditions screened, 89 (1.2 patients per 10,000 admissions) had an AGVPR. Physicians or study staff classified none of 73 enrolled patients as being at high risk for having smallpox; 72 (99%) were classified as being at low risk, and 1 was classified as being at moderate risk. The discharge diagnosis for 55 (75%) of these 73 participants was varicella illness. Use of the algorithm did not result in misclassification of AGVPR as high risk for smallpox. The algorithm is a highly specific tool for clinical evaluation of suspected smallpox disease.

Population immunity to measles in the United States, 1999.

To estimate population immunity, we examined measles immunity among residents of the United States in 1999 from serological and vaccine coverage surveys. For persons aged >or=20 years, serological data from the third National Health and Nutrition Examination Survey (1988-1994) were used. For persons <20 years of age, immunity was estimated from results of the National Immunization Survey (1994-1998), state surveys of school entrants (1990-2000), and vaccine coverage surveys of adolescents (1997). To estimate immunity from vaccine coverage data, 95% vaccine efficacy was used for recipients of a single dose at >or=12 years of age and 99% vaccine efficacy was used for those with failure of a first dose who were revaccinated. Overall, calculated population immunity was found to be 93%. Although there was not much variation in immunity by region and state, in some large urban centers immunity among preschool-aged children was as low as 86%. Overall, geographic- and age-specific estimates of a high population immunity support the epidemiological evidence that measles disease is no longer endemic in the United States.

Vaccination levels associated with lack of measles transmission among preschool-aged populations in the United States, 1989-1991.

Knowledge of the minimum level of vaccination capable of preventing measles transmission in an age group is helpful for establishing program targets for measles elimination. In 1990, during the measles resurgence in the United States, one-half of cases occurred in children aged <5 years. Although estimated population immunity among persons >or=6 years of age was 93%, immunity was lower and varied widely among preschool-aged children. To examine the association of vaccine coverage at 2 years of age and measles incidence among preschool-aged children, we analyzed ecological studies of measles incidence in Milwaukee (Wisconsin) census tracts, Dallas (Texas) ZIP code areas, and selected cities during the 1989-1991 measles resurgence. In each study area, measles incidence decreased rapidly with increasing measles vaccine coverage and became low or negligible when coverage was >or=80%. Regression analysis also suggested that measles would not be transmitted when vaccine coverage was at least 79%. A minimum vaccine coverage of approximately 80% at the second birthday in census tracts, ZIP code areas, and cities in the United States may be sufficient to prevent measles transmission among preschool-aged children if population immunity is >or=93% among persons >or=6 years of age.

Persistence of vaccine-induced antibody to measles 26-33 years after vaccination.

Because measles-specific antibody titer after vaccination is lower than after natural infection, there is concern that vaccinated persons may gradually lose protection from measles. To examine the persistence of vaccine-induced antibody, participants of a vaccine study in 1971, with documentation of antibody 1-7 years after vaccination, were followed up in 1997-1999 to determine the presence and titer of measles antibody. Of the 56 participants (77% were 2-dose recipients), all had antibodies detected by the plaque reduction neutralization (PRN) antibody assay an average of 26-33 years after the first or second dose of measles vaccine; 92% had a PRN titer considered protective (>1 : 120). Baseline hemagglutination inhibition antibody titer in 1971 strongly predicted follow-up PRN antibody titer (P<.001). Persistence of antibody in these primarily 2-dose recipients supports the current elimination strategy to achieve and sustain high population immunity with a 2-dose schedule.

Elimination of measles and of disparities in measles childhood vaccine coverage among racial and ethnic minority populations in the United States.

The gap in measles vaccine coverage between white and nonwhite children was as large as 18% in 1970. During the measles epidemic of 1989-1991, attack rates among nonwhite children <5 years of age were 4- to 7-fold higher than rates among white children. Because of the epidemic and of the known disparity in vaccine coverage and risk of disease, a dual strategy to eliminate measles in the United States was implemented: universal interventions likely to reach the majority of children and targeted interventions more likely to reach nonwhite children. In 1992, the gap in coverage between white and nonwhite children was reduced to 6% (from 15% in 1985); the risk of disease among nonwhite children was narrowed to

Evaluation of the measles clinical case definition.

An accurate system of identifying and classifying suspected measles cases is critical for the measles surveillance system in the United States. To examine the performance of the clinical case definition in predicting laboratory confirmation of suspected cases of measles, we reviewed 4 studies conducted between 1981 and 1994. A clinical case definition was examined that included a generalized maculopapular rash, fever (>or=38.3 degrees C, if measured), and either a cough, coryza, or conjunctivitis. Serological confirmation of measles was done either by hemagglutination inhibition assay, complement fixation assay, or enzyme immunoassays. The positive predictive value of the clinical case definition decreased from 74% to 1% as incidence decreased from 171 cases/100000 population to 1.3 cases/100000 population. Sensitivity was high, and for the larger studies with the most precise estimates, sensitivity was 76%-88%. The low positive predictive value of the clinical case definition in settings of low incidence demonstrates that serological confirmation is essential to ensure an accurate diagnosis of measles when measles is rare.

Measles hospitalizations, United States, 1985-2002.

Cases of measles that require hospitalization are a good marker of the burden of clinically severe measles in the United States. Measles hospitalizations routinely are monitored by the National Notifiable Disease Surveillance System (NNDSS). Our objectives were to describe measles hospitalizations reported to the NNDSS in 1985-2002, to use hospital discharge data from independent data sets (the National Hospital Discharge Survey [NHDS] [data available for 1985-1999] and the Health Care Investment Analysts [HCIA] hospital discharge database [data available for 1985-1996]) to provide additional estimates of total measles hospitalizations, and to compare trends in measles-associated hospitalizations. In 1985-2002, a total of 13621 patients with measles reported to the NNDSS were hospitalized (annual average, 757; range, 19-5856 patients). In 1985-1996, a total of 13472 measles hospitalizations were reported from NNDSS, compared with 28047 estimated from the NHDS and 19352 extrapolated from HCIA data. In the NNDSS, the annual total number declined after 1992 to