An exploratory study of the prevalence and adverse associations of in-school traditional bullying and cyberbullying among adolescents in Connecticut.

Bullying, traditional or cyber, among adolescents, is a public health concern. In this study, we explored frequencies and correlates of different forms of bullying among Connecticut high-school students. Youth Risk Behavior Survey data from 2019 from Connecticut adolescents (N = 1814) were used. χ2 tests and survey-weighted logistic regressions examined relationships between bullying subgroups (in-school traditional bullying (ISTB) only, cyberbullying only, and both) and mental concerns, risk behaviors, academic performance, physical health, and receipt of social support, with the logistic regressions adjusted for demographics. The past-12-month frequency of having experienced only cyberbullying was 5.6%, only ISTB was 9.1%, and both forms was 8.7%. Between-group differences were observed by bullying status in terms of sex and race/ethnicity. In adjusted models, bullying status was associated with suicide attempts, suicidal ideation, self-harm, depression/dysphoria, mental health, use of alcohol, marijuana, injection drugs, tobacco, and e-vapor, gambling, driving under influence of alcohol, high-risk sexual behavior, physical fights, weapon-carrying, injuries/threats at school, feeling unsafe at school, dating violence, obesity, poor general health, insecure housing, less perceived family support, and poor academic performance. People experiencing both types of bullying were typically more likely to report adverse measures. High-school students commonly report bullying. The findings that both forms (traditional and cyber) were more robustly linked to negative experiences highlight the need for examining further relationships between types and patterns of bullying and mental health and functioning. Better understanding may help improve preventive anti-bullying interventions.

Linking crash and breathalyzer data in Connecticut.

OBJECTIVES: To document the process of linking breathalyzer and motor vehicle crash (MVC) data for the State of Connecticut using a unique identifier in the place of personal and private information. METHODS: Deterministic linkage methodologies were utilized in Microsoft SQL Server to join 5,634 (of 6,650) breathalyzer records to corresponding MVC driver records for the period of January 1, 2017 to December 31, 2022. Differences between the linked and original datasets were documented by comparing the consistency of frequency and proportion distributions of key variables. RESULTS: Proportions of annual records, alcohol breath tests, and refusals were nearly unchanged when comparing linked and original breathalyzer data. When examining variables in the original MVC driver records, there were differences in the within-group proportions for sex and age, with an overrepresentation of males and drivers aged 26-to-40 years old. For crash and injury severity, the linked dataset had lower proportions of more severe injury records when compared to the original MVC data. Additionally, 1,007 breathalyzer records were not matched with an associated MVC record. CONCLUSIONS: Linkage methodology is sound and produced quality matches. The use of a unique identifier provided a strong match qualifier in the absence of personal and private data. Changes in proportions for age, sex, crash and injury severity align with previous research. Potential missed matches may be attributed to several factors outside of the linkage process, including data discrepancies and varied reporting practices. Future studies will further explore these differences and incorporate additional toxicology data as part of a continued effort to fuze crash, citation, toxicology, and public health data. The end result will be a holistic, comprehensive, and multifaceted database for transportation research and education.

Implementing a Surveillance-Based Approach to Create a Statewide Viral Clearance Cascade for Hepatitis C Among People With HIV and HCV Coinfection in Connecticut.

OBJECTIVES: Highly effective direct-acting antiviral medications have made it feasible to achieve elimination of hepatis C virus (HCV), including for people with HIV and HCV coinfection. The Centers for Disease Control and Prevention offers guidance for a laboratory surveillance-based HCV viral clearance cascade, which allows public health departments to track the outcomes of people with HCV based on the following steps: ever infected, virally tested, initial infection, and cured or cleared. We examined the feasibility of this approach among people with HIV and HCV coinfection in Connecticut. METHODS: We matched an HIV surveillance database, which included cases from the enhanced HIV/AIDS Reporting System as of December 31, 2019, and the HCV surveillance database, the Connecticut Electronic Disease Surveillance System, to define a cohort of coinfected people. We used HCV laboratory results obtained from January 1, 2016, through August 3, 2020, to determine HCV status. RESULTS: Of 1361 people who were ever infected with HCV as of December 31, 2019, 1256 (92.3%) received HCV viral testing, 865 of 1256 people tested (68.9%) were HCV infected, and 336 of 865 infected people (38.8%) were cleared or cured. People who had undetectable HIV viral loads at most recent HIV test (<200 copies/mL) were more likely than those with detectable HIV viral loads to achieve HCV cure (P = .02). CONCLUSIONS: A surveillance-based approach that includes data based on the Centers for Disease Control and Prevention HCV viral clearance cascade is feasible to implement, can help track population-level outcomes longitudinally, and can help identify gaps to inform HCV elimination strategies.

Suburban Population of Bobcats (Lynx rufus) in Connecticut, USA, Tested Negative for SARS-CoV-2, November 2021-February 2022.

A SARS-CoV-2 genomic and serologic survey was performed in a population of bobcats (Lynx rufus) inhabiting the state of Connecticut, USA. Wild animal populations are becoming established in densely populated cities with increased likelihood of direct or indirect contact with humans, as well as with household cats and dogs. Wild-caught bobcats (n=38) tested negative for SARS-CoV-2 genomic RNA by reverse-transcription quantitative PCR and for virus-neutralizing antibodies by ELISA, suggesting that either the species is not susceptible to SARS-CoV-2 or that the surveyed population has not yet been exposed to a source of infectious virus. However, this limited survey cannot rule out that human-to-bobcat or unknown reservoir-to-bobcat transmission of the virus occurs in nature.

Lymphocytic Choriomeningitis Virus in Person Living with HIV, Connecticut, USA, 2021.

Lymphocytic choriomeningitis virus is an underreported cause of miscarriage and neurologic disease. Surveillance remains challenging because of nonspecific symptomatology, inconsistent case reporting, and difficulties with diagnostic testing. We describe a case of acute lymphocytic choriomeningitis virus disease in a person living with HIV in Connecticut, USA, identified by using quantitative reverse transcription PCR.

Acceptability of 4-poster deer treatment devices for community-wide tick control among residents of high Lyme disease incidence counties in Connecticut and New York, USA.

The 4-Poster Tick Control Deer Feeder (4-poster) device applies acaricide to white-tailed deer (Odocoileus virginianus) and can reduce populations of the blacklegged tick (Ixodes scapularis), which transmits the agents of Lyme disease, anaplasmosis, babesiosis, and Powassan virus disease in the Northeastern United States. While 4-poster devices have the potential to provide community-wide management of blacklegged ticks in Lyme disease endemic areas, no recent study has assessed their acceptability among residents. We conducted a survey of residents from 16 counties with high annual average Lyme disease incidence (≥ 10 cases per 100,000 persons between 2013 and 2017) in Connecticut and New York to understand perceptions and experiences related to tickborne diseases, support or concerns for placement of 4-poster devices in their community, and opinions on which entities should be responsible for tick control on private properties. Overall, 37% of 1652 respondents (5.5% response rate) would support placement of a 4-poster device on their own property, 71% would support placement on other private land in their community, and 90% would support placement on public land. Respondents who were male, rented their property, resided on larger properties, or were very or extremely concerned about encountering ticks on their property were each more likely to support placement of 4-poster devices on their own property. The primary reason for not supporting placement of a 4-poster device on one's own property was the need for weekly service visits from pest control professionals, whereas the top reason for not supporting placement on other land (private or public) was safety concerns. Most respondents (61%) felt property owners should be responsible for tick control on private properties. Communities considering 4-poster devices as part of a tick management strategy should consider targeting owners of larger properties and placing devices on public lands.

Characterizing Persons With HIV/HCV Coinfection Who Remain Untreated for Hepatitis C at Four HIV Clinics in Connecticut (CT): Role of Multiple Overlapping Barriers at the Individual and Clinic System Levels.

Introduction. Direct-acting antiviral medications have made hepatitis C virus (HCV) cure possible for >95% of persons with chronic HCV infection, including those coinfected with HIV. Achieving strategic HCV elimination targets requires an understanding of system, provider, and patient-level barriers to treatment. We explored such barriers among persons with HIV/HCV coinfection who remained untreated for HCV. Methods. Among four primary care HIV clinics in CT with high rates of HCV cure, 25 patients with HIV/HCV coinfection were eligible (no HCV treatment as of March 31, 2021). We conducted retrospective chart reviews of demographics, clinical practice patterns, patient-specific issues such as housing, transportation, food security, and presence of mental health and substance use problems. Results. Among untreated patients, 13 (51%) were female; 17 (68%) were Black; median age was 62 years old. The majority (84%) had injecting drug use (IDU) as HIV transmission risk factor; 14 (56%) were prescribed medication-assisted treatment. Median time since HIV and HCV diagnosis was 25 and 19 years, respectively. Clinic-level barriers were noted in 19 (76%) and included lack of evaluation, treatment not recommended or implemented. Concomitant structural barriers included unstable housing for 11 (44%) and lack of transportation for eight (32%). Most patients had history of illicit substance use (84%) and mental health issues (68%). Many (76%) had multiple potential barriers. Conclusions. Multiple overlapping barriers spanning clinic and patient level domains including social determinants of health were the norm in persons with long-standing HIV/HCV coinfection who have not received HCV treatment. Interventions will require innovative, multi-disciplinary and personalized approaches.

Gambling participation among Connecticut adolescents from 2007 to 2019: Potential risk and protective factors.

Background and aims: Gambling in adolescents is a public health concern. This study sought to examine patterns of gambling among Connecticut high-school students using seven representative samples covering a 12-year period. Methods: Data were analyzed from N = 14,401 participants in cross-sectional surveys conducted every two years based on random sampling from schools in the state of Connecticut. Anonymous self-completed questionnaires included socio-demographic data, current substance use, social support, and traumatic experiences at school. Chi-square tests were used to compare socio-demographic characteristics between gambling and non-gambling groups. Logistic regressions were used to assess changes in the prevalence of gambling over time and effects of potential risk factors on the prevalence, adjusted for age, sex, and race. Results: Overall, the prevalence of gambling largely decreased from 2007 to 2019, although the pattern was not linear. After steadily declining from 2007 to 2017, 2019 was associated with increased rates of gambling participation. Consistent statistical predictors of gambling were male gender, older age, alcohol and marijuana use, higher levels of traumatic experiences at school, depression, and low levels of social support. Discussion and conclusion: Among adolescents, older males may be particularly vulnerable to gambling that relates importantly to substance use, trauma, affective concerns, and poor support. Although gambling participation appears to have declined, the recent increase in 2019 that coincides with increased sports gambling advertisements, media coverage and availability warrants further study. Our findings suggest the importance of developing school-based social support programs that may help reduce adolescent gambling.

Activity Space Assessments to Investigate Neighborhood Exposure to Racism-Related Stress and Related Substance Use Among Young Black Men: Connecticut, 2019.

Objectives. To use activity space assessments to investigate neighborhood exposures that may heighten young Black men's vulnerability to substance use and misuse. Methods. We surveyed young Black men in New Haven, Connecticut in 2019 on the locations (activity spaces) they traveled to in a typical week and their experiences of racism and any alcohol and cannabis use at each location. Results. A total of 112 young Black men (mean age = 23.57 years; SD = 3.20) identified 583 activity spaces. There was significant overlap between racism-related events and substance use (alcohol and cannabis use) at specific locations. Areas with a higher prevalence of violent crime also had a greater frequency of racism-related events and substance use. Conclusions. An activity space approach is a promising method for integrating objective and subjective experiences within neighborhood contexts to better understand the frequency and co-occurrence of racism-related stress and substance use among young Black men. (Am J Public Health. 2023;113(S2):S136-S139. https://doi.org/10.2105/AJPH.2023.307254).

Racial and ethnic disparities in the treatment and outcomes for witnessed out-of-hospital cardiac arrest in Connecticut.

BACKGROUND: Racial and ethnic disparities in the treatment and outcomes for witnessed out-of-hospital cardiac arrest (OHCA) in the United States have been previously described. We sought to characterize disparities in pre-hospital care, overall survival, and survival with favorable neurological outcomes following witnessed OHCA in the state of Connecticut. METHODS: We performed a cross-sectional study to compare pre-hospital treatment and outcomes for White versus Black and Hispanic (Minority) OHCA patients submitted from Connecticut to the Cardiac Arrest Registry to Enhance Survival (CARES) between 2013 and 2021. Primary outcomes included bystander CPR use, bystander automated external defibrillator (AED) use with attempted defibrillation, overall survival, and survival with favorable cerebral function. RESULTS: 2,809 patients with witnessed OHCA were analyzed (924 Black or Hispanic; 1885 White). Minorities had lower rates of bystander CPR (31.4% vs 39.1%, P = 0.002) and bystander AED placement with attempted defibrillation (10.5% vs 14.4%, P = 0.004), with lower rates of survival to hospital discharge (10.3% vs 14.8%, P = 0.001) and survival with favorable cerebral function (65.3% vs 80.2%, P = 0.003). Minorities were less likely to receive bystander CPR in communities with median annual household income >$80, 000 (OR, 0.56; 95% CI, 0.33-0.95; P = 0.030) and in integrated neighborhoods (OR, 0.70; 95% CI, 0.52-0.95; P = 0.020). CONCLUSIONS: Black and Hispanic Connecticut patients with witnessed OHCA have lower rates of bystander CPR, attempted AED defibrillation, overall survival, and survival with favorable neurological outcomes compared to White patients. Minorities were less likely to receive bystander CPR in affluent and integrated communities.

Neurologic Complications of Babesiosis, United States, 2011-2021.

Babesiosis is a globally distributed parasitic infection caused by intraerythrocytic protozoa. The full spectrum of neurologic symptoms, the underlying neuropathophysiology, and neurologic risk factors are poorly understood. Our study sought to describe the type and frequency of neurologic complications of babesiosis in a group of hospitalized patients and assess risk factors that might predispose patients to neurologic complications. We reviewed medical records of adult patients who were admitted to Yale-New Haven Hospital, New Haven, Connecticut, USA, during January 2011-October 2021 with laboratory-confirmed babesiosis. More than half of the 163 patients experienced >1 neurologic symptoms during their hospital admissions. The most frequent symptoms were headache, confusion/delirium, and impaired consciousness. Neurologic symptoms were associated with high-grade parasitemia, renal failure, and history of diabetes mellitus. Clinicians working in endemic areas should recognize the range of symptoms associated with babesiosis, including neurologic.

Mapping Heat Vulnerability of a Community Mental Health Center Population.

Individuals with serious mental illness are vulnerable to extreme heat due to biological, social, and place-based factors. We examine the spatial correlation of prevalence of individuals treated at a community mental health center to heat vulnerability. We applied a heat vulnerability index (HVI) to the catchment of the Connecticut Mental Health Center in New Haven, Connecticut. Geocoded addresses were mapped to correlate patient prevalence with heat vulnerability of census tracts. Census tracts closer to the city center had elevated vulnerability scores. Patient prevalence was positively correlated with HVI score (Pearson's r(44) = 0.67, p < 0.01). Statistical significance persists after correction for spatial autocorrelation (modified t-test p < 0.01). The study indicates that individuals treated at this community mental health center are more likely to live in census tracts with high heat vulnerability. Heat mapping strategies can help communicate risk and target resources at the local scale.

Trends in and Risk Factors for Recurrent Clostridioides difficile Infection, New Haven County, Connecticut, USA, 2015-2020.

Recurrent Clostridioides difficile infection (RCDI) causes an increased burden on the healthcare system. We calculated RCDI incidence and identified factors associated with RCDI cases in New Haven County, Connecticut, USA, during 2015-2020 by using data from population-based laboratory surveillance. A subset of C. difficile cases had complete chart reviews conducted for RCDI and potentially associated variables. RCDI was defined as a positive C. difficile specimen occurring 2-8 weeks after incident C. difficile infection. We compared cases with and without RCDI by using multiple regression. RCDI occurred in 12.0% of 4,301 chart-reviewed C. difficile cases, showing a U-shaped time trend with a sharp increase in 2020, mostly because of an increase in hospital-onset cases. Malignancy (odds ratio 1.51 [95% CI 1.11-2.07]) and antecedent nitrofurantoin use (odds ratio 2.37 [95% CI 1.23-4.58]) were medical risk factors for RCDI. The 2020 increase may reflect the impact of the COVID-19 pandemic.

Leveraging probe data to model speeding on urban limited access highway segments: Examining the impact of operational performance, roadway characteristics, and COVID-19 pandemic.

Stay-at-home orders - imposed to prevent the spread of COVID-19 - drastically changed the way highways operate. Despite lower traffic volumes during these times, the rate of fatal and serious injury crashes increased significantly across the United States due to increased speeding on roads with less traffic congestion and lower levels of speed enforcement. This paper uses a mixed effect binomial regression model to investigate the impact of stay-at-home orders on odds of speeding on urban limited access highway segments in Maine and Connecticut. This paper also establishes a link between traffic density and the odds of speeding. For this purpose, hourly speed and volume probe data were collected on limited access highway segments for the U.S. states of Maine and Connecticut to estimate the traffic density. The traffic density was then combined with the roadway geometric characteristics, speed limit, as well as dummy variables denoting the time of the week, time of the day, COVID-19 phases (before, during and after stay-at-home order), and the interactions between them. Density, represented in the model as Level of Service, was found to be associated with the odds of speeding, with better levels of service such as A, or B (low density) resulting in the higher odds that drivers would speed. We also found that narrower shoulder width could result in lower odds of speeding. Furthermore, we found that during the stay-at-home order, the odds of speeding by more than 10, 15, and 20 mph increased respectively by 54%, 71% and 85% in Connecticut, and by 15%, 36%, and 65% in Maine during evening peak hours. Additionally, one year after the onset of the pandemic, during evening peak hours, the odds of speeding greater than 10, 15, and 20 mph were still 35%, 29%, and 19% greater in Connecticut and 35% 35% and 20% greater in Maine compared to before pandemic.

Trends in Reported Babesiosis Cases - United States, 2011-2019.

Babesiosis is a tickborne disease caused by intraerythrocytic Babesia parasites. In the United States, most babesiosis cases are caused by Babesia microti, transmitted from bites of blacklegged ticks, Ixodes scapularis, in northeastern and midwestern states. Transmission can also occur through blood transfusions, transplantation of organs from infected donors, or congenital (mother-to-child) transmission (1). Babesia infection can be asymptomatic or cause mild to severe illness that can be fatal. Overall, U.S. tickborne disease cases have increased 25%, from 40,795 reported in 2011 to 50,856 in 2019 (2). Babesiosis trends were assessed in 10 states* where babesiosis was reportable during 2011-2019. Incidence increased significantly in Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Rhode Island, and Vermont (p<0.001), with the largest increases reported in Vermont (1,602%, from two to 34 cases), Maine (1,422%, from nine to 138), New Hampshire (372%, from 13 to 78), and Connecticut (338%, from 74 to 328). Unlike the other seven states, Maine, New Hampshire, and Vermont, were not included as states with endemic disease in previous CDC babesiosis surveillance summaries. These three states should now be considered to have endemic transmission comparable to that in other high-incidence states; they have consistently identified newly acquired cases every year during 2011-2019 and documented presence of Babesia microti in the associated tick vector (3). Because incidence in Northeastern states, including Maine, New Hampshire, and Vermont, is increasing, tick prevention messaging, provider education, and awareness of infection risk among travelers to these states should be emphasized.

Emergency department visits in Connecticut for survivors of sexual assault before and during the COVID-19 pandemic.

STUDY OBJECTIVE: We evaluate the impact of the COVID-19 pandemic on care for survivors of sexual assault in three urban Emergency Departments (ED) in the United States. METHODS: A retrospective chart review was conducted on patients who presented after sexual assault to three EDs during 6-month intervals before and during the COVID-19 pandemic. We excluded individuals <18 years old. We performed a structured chart review to ascertain demographics, ED treatments, and adherence to guidelines for care of sexual assault survivors. RESULTS: Of 105 patients who received care after a sexual assault, 57 presented during the COVID-19 pandemic. The majority were female, White/Caucasian, and presented within 120 h of sexual assault. There was an increase in ED presentations for sexual assault during the pandemic. While there was no difference in medical care, there were fewer sexual assault advocates called during the pandemic. In addition, there was an increase in non-White survivors in the first 3 months of the pandemic that did not remain at 6 months. CONCLUSION: The care of survivors in the ED was disrupted by the COVID-19 pandemic. While medical care remained similar, fewer calls to sexual assault advocates, a key component of ED and long-term care of survivors, demonstrate a disruption in their care.

Geographic and temporal trends in fentanyl-detected deaths in Connecticut, 2009-2019.

PURPOSE: Since 2012 fentanyl-detected fatal overdoses have risen from 4% of all fatal overdoses in Connecticut to 82% in 2019. We aimed to investigate the geographic and temporal trends in fentanyl-detected deaths in Connecticut during 2009-2019. METHODS: Data on the dates and locations of accidental/undetermined opioid-detected fatalities were obtained from Connecticut Office of the Chief Medical Examiner. Using a Bayesian space-time binomial model, we estimated spatiotemporal trends in the proportion of fentanyl-detected deaths. RESULTS: During 2009-2019, a total of 6,632 opioid deaths were identified. Among these, 3234 (49%) were fentanyl-detected. The modeled spatial patterns suggested that opioid deaths in northeastern Connecticut had higher probability of being fentanyl-detected, while New Haven and its neighboring towns and the southwestern region of Connecticut, primarily Greenwich, had a lower risk. Model estimates also suggested fentanyl-detected deaths gradually overtook the preceding non-fentanyl opioid-detected deaths across Connecticut. The estimated temporal trend showed the probability of fentanyl involvement increased substantially since 2014. CONCLUSIONS: Our findings suggest that geographic variation exists in the probability of fentanyl-detected deaths, and areas at heightened risk are identified. Further studies are warranted to explore potential factors contributing to the geographic heterogeneity and continuing dispersion of fentanyl-detected deaths in Connecticut.

The impact of ABO and RhD blood types on Babesia microti infection.

BACKGROUND: Babesiosis is an emerging infectious disease caused by intraerythrocytic Babesia parasites that can cause severe disease and death. While blood type is known to affect the mortality of Plasmodium falciparum malaria patients, associations between red blood cell (RBC) antigens and Babesia microti infection and disease severity are lacking. METHODS: We evaluated RhD and ABO blood types of Babesia-infected (18S rRNA reactive) blood donors in 10 endemic states in the Northeastern and northern Midwestern United States. We also assessed possible associations between RhD and ABO blood types and disease severity among hospitalized babesiosis patients in Connecticut. RESULTS: A total of 768 Babesia-infected blood donors were analyzed, of which 750 (97.7%) had detectable B. microti-specific antibodies. B. microti-infected blood donors were more likely to be RhD- (OR of 1.22, p-value 0.024) than RhD+ donors. Hospitalized RhD- babesiosis patients were more likely than RhD+ patients to have high peak parasitemia (p-value 0.017), which is a marker for disease severity. No differences in RhD+ blood type were noted between residents of the Northeast (OR of 0.82, p-value 0.033) and the Midwest (OR of 0.74, p-value 0.23). Overall, ABO blood type was not associated with blood donor B. microti infection, however, B. microti-infected donors in Maine and New Jersey were more likely to be blood type B compared to non-type B (OR 2.49 [p = 0.008] and 2.07 [p = 0.009], respectively), while infected donors from Pennsylvania were less likely to be type B compared to non-type B (OR 0.32 [p = 0.02]). CONCLUSIONS: People expressing RhD antigen may have a decreased risk of B. microti infection and babesiosis severity. The association of B antigen with B. microti infection is less clear because the antigen appeared to be less prevalent in infected Pennsylvania blood donors but more prevalent in Maine and New Jersey infected donors. Future studies should quantify associations between B. microti genotypes, RBC antigens, and the frequency and severity of B. microti infection to increase our understanding of human Babesia pathogenesis and improve antibody, vaccine, and RBC exchange transfusion strategies.

The effect of the COVID-19 pandemic on community violence in Connecticut.

INTRODUCTION: Natural disasters may lead to increases in community violence due to broad social disruption, economic hardship, and large-scale morbidity and mortality. The effect of the COVID-19 pandemic on community violence is unknown. METHODS: Using trauma registry data on all violence-related patient presentations in Connecticut from 2018 to 2021, we compared the pattern of violence-related trauma from pre-COVID and COVID pandemic using an interrupted time series linear regression model. RESULTS: There was a 55% increase in violence-related trauma in the COVID period compared with the pre-COVID period (IRR: 1.55; 95%CI: 1.34-1.80; p-value<0.001) driven largely by penetrating injuries. This increase disproportionately impacted Black/Latinx communities (IRR: 1.61; 95%CI: 1.36-1.90; p-value<0.001). CONCLUSION: Violence-related trauma increased during the COVID-19 pandemic. Increased community violence is a significant and underappreciated negative health and social consequence of the COVID-19 pandemic, and one that excessively burdens communities already at increased risk from systemic health and social inequities.

Model-based community health surveillance via multilevel small area estimation using state behavioral risk factor surveillance system (BRFSS): a case study in Connecticut.

PURPOSE: The main objective of state behavioral risk factor surveillance system (BRFSS) is to produce reliable state-level estimates of various population health outcomes. A multilevel Regression and Post-stratification (MRP) methodology for small area estimation has been applied to the 500 Cities Project to provide population estimates at both city-level and census tract-level using national BRFSS data. To date, MRP has not been applied to any state BRFSS to produce health data at local geographic areas. In addition, the use of single year BRFSS might produce temporary inconsistency in small area estimates (SAEs). The predicted standard errors (SEs) and confidence intervals (CIs) of SAEs using Monte Carlo simulation could be substantially underestimated or overestimated. METHODS: By extending the current MRP approach and applying a parametric bootstrapping approach to Connecticut BRFSS (CT BRFSS), we were able to produce SAEs as well as SEs and CIs of SAEs for Connecticut counties and towns. We also applied this model to 5-year CT BRFSS (2011-2015) with an aim to improve the temporary consistency of SAEs. RESULTS: Both single-year and 5-year estimates with SEs and CIs were generated for six selected population health indicators at town, county and state levels. Model-based SAEs were internally evaluated by comparing to single-year and 5-year direct BRFSS survey (2011-2015). SAEs were also externally validated when external data were available. CONCLUSIONS: Model-based SAEs are valid and could be used to characterize local geographic variations using single state BRFSS data.