A Standard Framework for Evaluating Large Health Care Data and Related Resources.

Since 2000, the availability and use of large health care data and related resources for conducting surveillance, research, and evaluations to guide clinical and public health decision-making has increased rapidly. These trends have been related to transformations in health care information technology and public as well as private-sector efforts for collecting, compiling, and supplying large volumes of data. This growing collection of robust and often timely data has enhanced the capability to increase the knowledge base guiding clinical and public health activities and also has increased the need for effective tools to assess the attributes of these resources and identify the types of scientific questions they are best suited to address. This: MMWR supplement presents a standard framework for evaluating large health care data and related resources, including constructs, criteria, and tools that investigators and evaluators can apply and adapt.

Underlying Medical Conditions and Severe Illness Among 540,667 Adults Hospitalized With COVID-19, March 2020-March 2021.

INTRODUCTION: Severe COVID-19 illness in adults has been linked to underlying medical conditions. This study identified frequent underlying conditions and their attributable risk of severe COVID-19 illness. METHODS: We used data from more than 800 US hospitals in the Premier Healthcare Database Special COVID-19 Release (PHD-SR) to describe hospitalized patients aged 18 years or older with COVID-19 from March 2020 through March 2021. We used multivariable generalized linear models to estimate adjusted risk of intensive care unit admission, invasive mechanical ventilation, and death associated with frequent conditions and total number of conditions. RESULTS: Among 4,899,447 hospitalized adults in PHD-SR, 540,667 (11.0%) were patients with COVID-19, of whom 94.9% had at least 1 underlying medical condition. Essential hypertension (50.4%), disorders of lipid metabolism (49.4%), and obesity (33.0%) were the most common. The strongest risk factors for death were obesity (adjusted risk ratio [aRR] = 1.30; 95% CI, 1.27-1.33), anxiety and fear-related disorders (aRR = 1.28; 95% CI, 1.25-1.31), and diabetes with complication (aRR = 1.26; 95% CI, 1.24-1.28), as well as the total number of conditions, with aRRs of death ranging from 1.53 (95% CI, 1.41-1.67) for patients with 1 condition to 3.82 (95% CI, 3.45-4.23) for patients with more than 10 conditions (compared with patients with no conditions). CONCLUSION: Certain underlying conditions and the number of conditions were associated with severe COVID-19 illness. Hypertension and disorders of lipid metabolism were the most frequent, whereas obesity, diabetes with complication, and anxiety disorders were the strongest risk factors for severe COVID-19 illness. Careful evaluation and management of underlying conditions among patients with COVID-19 can help stratify risk for severe illness.

Risk of Clinical Severity by Age and Race/Ethnicity Among Adults Hospitalized for COVID-19-United States, March-September 2020.

BACKGROUND: Older adults and people from certain racial and ethnic groups are disproportionately represented in coronavirus disease 2019 (COVID-19) hospitalizations and deaths. METHODS: Using data from the Premier Healthcare Database on 181 813 hospitalized adults diagnosed with COVID-19 during March-September 2020, we applied multivariable log-binomial regression to assess the associations between age and race/ethnicity and COVID-19 clinical severity (intensive care unit [ICU] admission, invasive mechanical ventilation [IMV], and death) and to determine whether the impact of age on clinical severity differs by race/ethnicity. RESULTS: Overall, 84 497 (47%) patients were admitted to the ICU, 29 078 (16%) received IMV, and 27 864 (15%) died in the hospital. Increased age was strongly associated with clinical severity when controlling for underlying medical conditions and other covariates; the strength of this association differed by race/ethnicity. Compared with non-Hispanic White patients, risk of death was lower among non-Hispanic Black patients (adjusted risk ratio, 0.96; 95% CI, 0.92-0.99) and higher among Hispanic/Latino patients (risk ratio [RR], 1.15; 95% CI, 1.09-1.20), non-Hispanic Asian patients (RR, 1.16; 95% CI, 1.09-1.23), and patients of other racial and ethnic groups (RR, 1.13; 95% CI, 1.06-1.21). Risk of ICU admission and risk of IMV were elevated among some racial and ethnic groups. CONCLUSIONS: These results indicate that age is a driver of poor outcomes among hospitalized persons with COVID-19. Additionally, clinical severity may be elevated among patients of some racial and ethnic minority groups. Public health strategies to reduce severe acute respiratory syndrome coronavirus 2 infection rates among older adults and racial and ethnic minorities are essential to reduce poor outcomes.

Association between in utero perfluoroalkyl substance exposure and anti-Müllerian hormone levels in adolescent females in a British cohort.

Evidence indicates that in utero environmental exposures could influence reproduction in female offspring. Perfluoroalkyl substances (PFAS) are synthetic, ubiquitous endocrine disrupting chemicals that can cross the placental barrier. Lower levels of anti-Müllerian hormone (AMH), a biomarker of ovarian reserve, are associated with reduced fertility. We investigated the association between in utero PFAS exposure and AMH levels in female adolescents using data from the Avon Longitudinal Study of Parents and Children, a British pregnancy cohort recruited between 1991 and 1992. Maternal serum samples were collected during pregnancy and analyzed for concentrations of commonly found PFAS-perfluorooctane sulfonate (PFOS), perfluorooctanoic acid (PFOA), perfluorohexane sulfonate (PFHxS), and perfluorononanoic acid (PFNA). AMH levels were measured in serum of female offspring (mean age, 15.4 years) and log-transformed for analyses. We used a sample of 446 mother-daughter dyads for multivariable linear regression analyses, controlling for maternal age at delivery, pre-pregnancy body-mass index, and maternal education. Multiple imputation was utilized to impute missing values of AMH (61.2%) and covariates. Median PFAS concentrations (ng/mL) were as follows: PFOS 19.8 (IQR:15.1, 24.9), PFOA 3.7 (IQR: 2.8, 4.8), PFHxS 1.6 (IQR: 1.2, 2.2), PFNA 0.5 (IQR: 0.4, 0.7). The geometric mean AMH concentration was 3.9 ng/mL (95% CI: 3.8, 4.0). After controlling for confounders, mean differences in AMH per one ng/mL higher PFOA, PFOS, PFHxS, and PFNA were 3.6% (95% CI: 1.4%, 8.6%), 0.7% (95% CI: 0.2%, 1.5%), 0.9% (95% CI: 0.4%, 2.2%), and 12.0% (95% CI: 42.8%, 66.8%) respectively. These findings suggest there is no association between in utero PFAS exposure and AMH levels in female adolescents.

Prenatal exposure to organochlorine pesticides and early childhood communication development in British girls.

BACKGROUND: The developing brain is susceptible to exposure to neurodevelopmental toxicants such as pesticides. AIMS: We explored associations of prenatal serum concentrations of hexachlorobenzene (HCB), beta-Hexachlorocyclohexane (ß-HCH), 2,2-Bis(4-chlorophenyl)-1,1-dichloroethene (p,p'-DDE) and 2,2-Bis(4-chlorophenyl-1,1,1-trichloroethane (p,p'-DDT) with maternal-reported measures of verbal and non-verbal communication in young girls. STUDY DESIGN AND METHODS: We studied a sample of 400 singleton girls and their mothers participating in the Avon Longitudinal Study of Parents and Children (ALSPAC) using multivariable linear regression models adjusting for parity, Home Observation Measurement of the Environment (HOME) score, maternal age and education status, and maternal tobacco use during the first trimester of pregnancy. EXPOSURE AND OUTCOME MEASURES: Maternal serum samples (collected at median 15 wks. gestation [IQR 10, 28]) were assessed for selected organochlorine pesticide levels. Communication was assessed at 15 and 38 months, using adapted versions of the MacArthur Bates Communicative Development Inventories for Infants and Toddlers (MCDI). RESULTS: At 15 months, girls born to mothers with prenatal concentrations of HCB in the highest tertile had vocabulary comprehension and production scores approximately 16% (p = 0.007) lower than girls born to mothers with concentrations in the lowest tertile. This association varied by maternal parity in that the evidence was stronger for daughters of nulliparous mothers. At 38 months, girls born to mothers with prenatal concentrations of HCB in the highest tertile had mean adjusted intelligibility scores that were 3% (p = 0.03) lower than those born to mothers with concentrations in the lowest tertile; however, results did not vary significantly by parity. Maternal concentrations of ß-HCH and p,p'-DDE were not significantly associated with MCDI scores at 15 or 36 months. p,p'-DDT had an inconsistent pattern of association; a significant positive association was observed between p,p'-DDT with verbal comprehension scores at 15 months; however, at 38 months a significant inverse association was observed for p,p'-DDT with communicative scores. This inverse association for p,p'-DDT among older girls tended to be stronger among daughters of mothers who had lower depression scores. CONCLUSIONS: Organochlorine pesticide exposure in utero may affect communication development.

Electronic health record case studies to advance environmental public health tracking.

Data from traditional public health surveillance systems can have some limitations, e.g., timeliness, geographic level, and amount of data accessible. Electronic health records (EHRs) could present an opportunity to supplement current sources of routinely collected surveillance data. The National Environmental Public Health Tracking Program (Tracking Program) sought to explore the use of EHRs for advancing environmental public health surveillance practices. The Tracking Program funded four state/local health departments to obtain and pilot the use of EHR data to address several issues including the challenges and technical requirements for accessing EHR data, and the core data elements required to integrate EHR data within their departments' Tracking Programs. The results of these pilot projects highlighted the potential of EHR data for public health surveillance of rare diseases that may lack comprehensive registries, and surveillance of prevalent health conditions or risk factors for health outcomes at a finer geographic level. EHRs therefore, may have potential to supplement traditional sources of public health surveillance data.

In utero exposure to atrazine analytes and early menarche in the Avon Longitudinal Study of Parents and Children Cohort.

BACKGROUND: Evidence from experimental studies suggests that atrazine and its analytes alter the timing of puberty in laboratory animals. Such associations have not been investigated in humans. OBJECTIVE: To determine the association between in utero exposure to atrazine analytes and earlier menarche attainment in a nested case-control study of the population-based Avon Longitudinal Study of Parents and Children. METHODS: Cases were girls who reported menarche before 11.5 years while controls were girls who reported menarche at or after 11.5 years. Seven atrazine analyte concentrations were measured in maternal gestational urine samples (sample gestation week median (IQR): 12 (8-17)) during the period 1991-1992, for 174 cases and 195 controls using high performance liquid chromatography-tandem mass spectrometry. We evaluated the study association using multivariate logistic regression, adjusting for potential confounders. We used multiple imputation to impute missing confounder data for 29% of the study participants. RESULTS: Diaminochlorotriazine (DACT) was the most frequently detected analyte (58%>limit of detection [LOD]) followed by desethyl atrazine (6%), desethyl atrazine mercapturate (3%), atrazine mercapturate (1%), hydroxyl atrazine (1%), atrazine (1%) and desisopropyl atrazine (0.5%). Because of low detection of other analytes, only DACT was included in the exposure-outcome analyses. The adjusted odds of early menarche for girls with DACT exposures≥median was 1.13 (95% Confidence Interval [95% CI]:0.82, 1.55) and exposure

Acute Nonoccupational Pesticide-Related Illness and Injury - United States, 2007-2011.

CDC's National Institute for Occupational Safety and Health (NIOSH) collects data on acute pesticide-related illness and injury reported by 12 states (California, Florida, Iowa, Louisiana, Michigan, North Carolina, Nebraska, New Mexico, New York, Oregon, Texas, and Washington). This report summarizes the data on illnesses and injuries arising from nonoccupational exposure to conventional pesticides that were reported during 2007-2011. Conventional pesticides include insecticides, herbicides, fungicides, and fumigants. They exclude disinfectants (e.g., chlorine and hypochlorites) and biological pesticides (1). This report is a part of the Summary of Notifiable Noninfectious Conditions and Disease Outbreaks - United States, which encompasses various surveillance years but is being published in 2016 (2). The Summary of Notifiable Noninfectious Conditions and Disease Outbreaks appears in the same volume of MMWR as the annual Summary of Notifiable Infectious Diseases (3). In a separate report, data on illnesses and injuries from occupational exposure to conventional pesticides during 2007-2011 are summarized (4).

In utero exposure to organochlorine pesticides and early menarche in the Avon Longitudinal Study of Parents and Children.

INTRODUCTION: Epidemiologic data supporting the role of organochlorine pesticides in pubertal development are limited. METHODS: Using a nested case-control design, serum collected during pregnancy from mothers of 218 girls who reported menarche before 11.5years of age (cases) and 230 girls who reported menarche at or after 11.5years of age (controls) was analyzed for 9 organochlorines and metabolites. We analyzed the association between in utero organochlorine concentrations and early menarche using multivariate logistic regression controlling for mother's age at menarche, or mother's prenatal BMI. RESULTS: We did not observe an association between in utero exposure to HCB, ß-HCH, ϒ-HCH, p,p'-DDT, p,p'-DDE, oxychlordane or trans-nonachlor and early menarche. CONCLUSIONS: This study is the first to examine the association between in utero exposure to HCB, ß-HCH, ϒ-HCH, oxychlordane or trans-nonachlor and early menarche. In utero exposure to organochlorine pesticides does not appear to have a role in the timing of menarche in this study.

A decade of environmental public health tracking (2002-2012): progress and challenges.

BACKGROUND: The creation of the Centers for Disease Control and Prevention Environmental Public Health Tracking Program spawned an invigorating and challenging approach toward implementing the nation's first population-based, environmental disease tracking surveillance system. More than 10 years have passed since its creation and an abundance of peer-reviewed articles have been published spanning a broad variety of public health topics related primarily to the goal of reducing diseases of environmental origin. OBJECTIVE: To evaluate peer-reviewed literature related to Environmental Public Health Tracking during 2002-2012, recognize major milestones and challenges, and offer recommendations. DESIGN: A narrative overview was conducted using titles and abstracts of peer-reviewed articles, key word searches, and science-based search engine databases. MAIN OUTCOMES: Eighty published articles related to "health tracking" were identified and categorized according to 4 crossed-central themes. The Science and Research theme accounted for the majority of published articles, followed by Policy and Practice, Collaborations Among Health and Environmental Programs, and Network Development. CONCLUSIONS: Overall, progress was reported in the areas of data linkage, data sharing, surveillance methods, and network development. Ongoing challenges included formulating better ways to establish the connections between health and the environment, such as using biomonitoring, public water systems, and private well water data. Recommendations for future efforts include use of data to inform policy and practice and use of electronic health records data for environmental health surveillance.

Describing environmental public health data: implementing a descriptive metadata standard on the environmental public health tracking network.

The Environmental Public Health Tracking (EPHT) Network provides an opportunity to bring together diverse environmental and health effects data by integrating}?> local, state, and national databases of environmental hazards, environmental exposures, and health effects. To help users locate data on the EPHT Network, the network will utilize descriptive metadata that provide critical information as to the purpose, location, content, and source of these data. Since 2003, the Centers for Disease Control and Prevention's EPHT Metadata Subgroup has been working to initiate the creation and use of descriptive metadata. Efforts undertaken by the group include the adoption of a metadata standard, creation of an EPHT-specific metadata profile, development of an open-source metadata creation tool, and promotion of the creation of descriptive metadata by changing the perception of metadata in the public health culture.

Hurricane Katrina deaths, Louisiana, 2005.

OBJECTIVE: Hurricane Katrina struck the US Gulf Coast on August 29, 2005, causing unprecedented damage to numerous communities in Louisiana and Mississippi. Our objectives were to verify, document, and characterize Katrina-related mortality in Louisiana and help identify strategies to reduce mortality in future disasters. METHODS: We assessed Hurricane Katrina mortality data sources received in 2007, including Louisiana and out-of-state death certificates for deaths occurring from August 27 to October 31, 2005, and the Disaster Mortuary Operational Response Team's confirmed victims' database. We calculated age-, race-, and sex-specific mortality rates for Orleans, St Bernard, and Jefferson Parishes, where 95% of Katrina victims resided and conducted stratified analyses by parish of residence to compare differences between observed proportions of victim demographic characteristics and expected values based on 2000 US Census data, using Pearson chi square and Fisher exact tests. RESULTS: We identified 971 Katrina-related deaths in Louisiana and 15 deaths among Katrina evacuees in other states. Drowning (40%), injury and trauma (25%), and heart conditions (11%) were the major causes of death among Louisiana victims. Forty-nine percent of victims were people 75 years old and older. Fifty-three percent of victims were men; 51% were black; and 42% were white. In Orleans Parish, the mortality rate among blacks was 1.7 to 4 times higher than that among whites for all people 18 years old and older. People 75 years old and older were significantly more likely to be storm victims (P < .0001). CONCLUSIONS: Hurricane Katrina was the deadliest hurricane to strike the US Gulf Coast since 1928. Drowning was the major cause of death and people 75 years old and older were the most affected population cohort. Future disaster preparedness efforts must focus on evacuating and caring for vulnerable populations, including those in hospitals, long-term care facilities, and personal residences. Improving mortality reporting timeliness will enable response teams to provide appropriate interventions to these populations and to prepare and implement preventive measures before the next disaster.

Developing a process for a metadata standard for environmental public health tracking.

The National Environmental Public Health Tracking Network provides an opportunity for public health practitioners to access more data than previously possible. The availability of metadata about the Tracking Network would enable users to search for and discover data for public health action and decision-making. Specifically, the metadata will be used to establish keyword search terms for data mining and will also provide a description of the content of data sets to point out their uses and limitations.