During the COVID-19 pandemic, many public schools across the United States shifted from fully in-person learning to alternative learning modalities such as hybrid and fully remote learning. In this study, data from 14,688 unique school districts from August 2020 to June 2021 were collected to track changes in the proportion of schools offering fully in-person, hybrid and fully remote learning over time. These data were provided by Burbio, MCH Strategic Data, the American Enterprise Institute's Return to Learn Tracker and individual state dashboards. Because the modalities reported by these sources were incomplete and occasionally misaligned, a model was needed to combine and deconflict these data to provide a more comprehensive description of modalities nationwide. A hidden Markov model (HMM) was used to infer the most likely learning modality for each district on a weekly basis. This method yielded higher spatiotemporal coverage than any individual data source and higher agreement with three of the four data sources than any other single source. The model output revealed that the percentage of districts offering fully in-person learning rose from 40.3% in September 2020 to 54.7% in June of 2021 with increases across 45 states and in both urban and rural districts. This type of probabilistic model can serve as a tool for fusion of incomplete and contradictory data sources in order to obtain more reliable data in support of public health surveillance and research efforts.

BACKGROUND: HIV-infection is associated with increased mortality during multidrug-resistant tuberculosis treatment, but the extent to which the use of antiretroviral therapy (ART) and anti-tuberculosis medications modify this risk are unclear. Our objective was to evaluate how use of these treatments altered mortality risk in HIV-positive adults with multidrug-resistant tuberculosis. METHODS: We did an individual patient data meta-analysis of adults 18 years or older with confirmed or presumed multidrug-resistant tuberculosis initiating tuberculosis treatment between 1993 and 2016. Data included ART use and anti-tuberculosis medications grouped according to WHO effectiveness categories. The primary analysis compared HIV-positive with HIV-negative patients in terms of death during multidrug-resistant tuberculosis treatment, excluding those lost to follow up, and was stratified by ART use. Analyses used logistic regression after exact matching on country World Bank income classification and drug resistance and propensity-score matching on age, sex, geographic site, year of multidrug-resistant tuberculosis treatment initiation, previous tuberculosis treatment, directly observed therapy, and acid-fast-bacilli smear-positivity to obtain adjusted odds ratios (aORs) and 95% CIs. Secondary analyses were conducted among those with HIV-infection. FINDINGS: We included 11 920 multidrug-resistant tuberculosis patients. 2997 (25%) were HIV-positive and on ART, 886 (7%) were HIV-positive and not on ART, and 1749 (15%) had extensively drug-resistant tuberculosis. By use of HIV-negative patients as reference, the aOR of death was 2·4 (95% CI 2·0-2·9) for all patients with HIV-infection, 1·8 (1·5-2·2) for HIV-positive patients on ART, and 4·2 (3·0-5·9) for HIV-positive patients with no or unknown ART. Among patients with HIV, use of at least one WHO Group A drug and specific use of moxifloxacin, levofloxacin, bedaquiline, or linezolid were associated with significantly decreased odds of death. INTERPRETATION: Use of ART and more effective anti-tuberculosis drugs is associated with lower odds of death among HIV-positive patients with multidrug-resistant tuberculosis. Access to these therapies should be urgently pursued. FUNDING: American Thoracic Society, Canadian Institutes of Health Research, US Centers for Disease Control and Prevention, European Respiratory Society, Infectious Diseases Society of America.

Occupational hazards exist in the processing of seafood both in land-based facilities as well as on board vessels. Recent findings on occupational injury and respiratory health risks among seafood processing workers were presented and discussed at the IFISH5 conference. Particular emphasis was put on the challenges that im/migrant workers encounter, the greater risks onboard factory vessels, especially where processing machinery are retrofitted to older vessels not primarily designed for this purpose, and the difficulties in assessing and preventing bioaerosol exposures and associated respiratory health risks despite recent advances in characterising agents responsible for allergic and non-allergic reactions. Based on appraisal of existing knowledge in the published literature and new findings presented at the conference, recommendations for immediate actions as well as for future research have been proposed. Among these include the importance of improving extraction ventilation systems, optimising machinery performance, enclosure of bioaerosol sources, improved work organization, and making special efforts to identify and support the needs of im/migrant workers to ensure they also benefit from such improvements. There is a need for studies that incorporate longitudinal study designs, have improved exposure and diagnostic methods, and that address seafood processing in countries with high seafood processing activities such as Asia and those that involve im/migrant workers worldwide. The medical and scientific community has an important role to play in prevention but cannot do this in isolation and should cooperate closely with hygienists, engineers, and national and international agencies to obtain better health outcomes for workers in the seafood industry.

All survey items reflect some conceptual framework that might or might not be accepted by subgroups with certain personal identities. For example, respondents with certain religious identities may reject the scientific framework of questions about the development of life and origins of the universe since there are competing truth claims between religion and science on these topics. Since the late 1970s, the National Science Foundation has sponsored a series of surveys to gauge public attitudes toward and understanding of science and technology. Items that simultaneously measure knowledge and acceptance of two concepts-evolution and the "big bang"-appear to raise measurement problems for a specific subgroup that rejects the premise of the items. This paper focuses on alternative versions of the survey questions that attempt to remove the effect of religious belief on answers to these items. We investigate two approaches for removing this confounding of knowledge and acceptance. One approach is to ask what scientists think rather than what the respondents believe; the other is to remove "hot-button" features of the question likely to trigger conflicts between the religious and scientific views. We also illustrate how psychometric methods (such as confirmatory factor analysis) can help sort out which version of the questions produces the most valid answers.

BACKGROUND: Treatment outcomes for multidrug-resistant tuberculosis remain poor. We aimed to estimate the association of treatment success and death with the use of individual drugs, and the optimal number and duration of treatment with those drugs in patients with multidrug-resistant tuberculosis. METHODS: In this individual patient data meta-analysis, we searched MEDLINE, Embase, and the Cochrane Library to identify potentially eligible observational and experimental studies published between Jan 1, 2009, and April 30, 2016. We also searched reference lists from all systematic reviews of treatment of multidrug-resistant tuberculosis published since 2009. To be eligible, studies had to report original results, with end of treatment outcomes (treatment completion [success], failure, or relapse) in cohorts of at least 25 adults (aged >18 years). We used anonymised individual patient data from eligible studies, provided by study investigators, regarding clinical characteristics, treatment, and outcomes. Using propensity score-matched generalised mixed effects logistic, or linear regression, we calculated adjusted odds ratios and adjusted risk differences for success or death during treatment, for specific drugs currently used to treat multidrug-resistant tuberculosis, as well as the number of drugs used and treatment duration. FINDINGS: Of 12 030 patients from 25 countries in 50 studies, 7346 (61%) had treatment success, 1017 (8%) had failure or relapse, and 1729 (14%) died. Compared with failure or relapse, treatment success was positively associated with the use of linezolid (adjusted risk difference 0.15, 95% CI 0.11 to 0.18), levofloxacin (0.15, 0.13 to 0.18), carbapenems (0.14, 0.06 to 0.21), moxifloxacin (0.11, 0.08 to 0.14), bedaquiline (0.10, 0.05 to 0.14), and clofazimine (0.06, 0.01 to 0.10). There was a significant association between reduced mortality and use of linezolid (-0.20, -0.23 to -0.16), levofloxacin (-0.06, -0.09 to -0.04), moxifloxacin (-0.07, -0.10 to -0.04), or bedaquiline (-0.14, -0.19 to -0.10). Compared with regimens without any injectable drug, amikacin provided modest benefits, but kanamycin and capreomycin were associated with worse outcomes. The remaining drugs were associated with slight or no improvements in outcomes. Treatment outcomes were significantly worse for most drugs if they were used despite in-vitro resistance. The optimal number of effective drugs seemed to be five in the initial phase, and four in the continuation phase. In these adjusted analyses, heterogeneity, based on a simulated I(2) method, was high for approximately half the estimates for specific drugs, although relatively low for number of drugs and durations analyses. INTERPRETATION: Although inferences are limited by the observational nature of these data, treatment outcomes were significantly better with use of linezolid, later generation fluoroquinolones, bedaquiline, clofazimine, and carbapenems for treatment of multidrug-resistant tuberculosis. These findings emphasise the need for trials to ascertain the optimal combination and duration of these drugs for treatment of this condition. FUNDING: American Thoracic Society, Canadian Institutes of Health Research, US Centers for Disease Control and Prevention, European Respiratory Society, Infectious Diseases Society of America.

BACKGROUND: Isoniazid-resistant, rifampicin-susceptible (INH-R) tuberculosis is the most common form of drug resistance, and is associated with failure, relapse, and acquired rifampicin resistance if treated with first-line anti-tuberculosis drugs. The aim of the study was to compare success, mortality, and acquired rifampicin resistance in patients with INH-R pulmonary tuberculosis given different durations of rifampicin, ethambutol, and pyrazinamide (REZ); a fluoroquinolone plus 6 months or more of REZ; and streptomycin plus a core regimen of REZ. METHODS: Studies with regimens and outcomes known for individual patients with INH-R tuberculosis were eligible, irrespective of the number of patients if randomised trials, or with at least 20 participants if a cohort study. Studies were identified from two relevant systematic reviews, an updated search of one of the systematic reviews (for papers published between April 1, 2015, and Feb 10, 2016), and personal communications. Individual patient data were obtained from authors of eligible studies. The individual patient data meta-analysis was performed with propensity score matched logistic regression to estimate adjusted odds ratios (aOR) and risk differences of treatment success (cure or treatment completion), death during treatment, and acquired rifampicin resistance. Outcomes were measured across different treatment regimens to assess the effects of: different durations of REZ (</=6 months vs >6 months); addition of a fluoroquinolone to REZ (fluoroquinolone plus 6 months or more of REZ vs 6 months or more of REZ); and addition of streptomycin to REZ (streptomycin plus 6 months of rifampicin and ethambutol and 1-3 months of pyrazinamide vs 6 months or more of REZ). The overall quality of the evidence was assessed using GRADE methodology. FINDINGS: Individual patient data were requested for 57 cohort studies and 17 randomised trials including 8089 patients with INH-R tuberculosis. We received 33 datasets with 6424 patients, of which 3923 patients in 23 studies received regimens related to the study objectives. Compared with a daily regimen of 6 months of (H)REZ (REZ with or without isoniazid), extending the duration to 8-9 months had similar outcomes; as such, 6 months or more of (H)REZ was used for subsequent comparisons. Addition of a fluoroquinolone to 6 months or more of (H)REZ was associated with significantly greater treatment success (aOR 2.8, 95% CI 1.1-7.3), but no significant effect on mortality (aOR 0.7, 0.4-1.1) or acquired rifampicin resistance (aOR 0.1, 0.0-1.2). Compared with 6 months or more of (H)REZ, the standardised retreatment regimen (2 months of streptomycin, 3 months of pyrazinamide, and 8 months of isoniazid, rifampicin, and ethambutol) was associated with significantly worse treatment success (aOR 0.4, 0.2-0.7). The quality of the evidence was very low for all outcomes and treatment regimens assessed, owing to the observational nature of most of the data, the diverse settings, and the imprecision of estimates. INTERPRETATION: In patients with INH-R tuberculosis, compared with treatment with at least 6 months of daily REZ, addition of a fluoroquinolone was associated with better treatment success, whereas addition of streptomycin was associated with less treatment success; however, the quality of the evidence was very low. These results support the conduct of randomised trials to identify the optimum regimen for this important and common form of drug-resistant tuberculosis. FUNDING: World Health Organization and Canadian Institutes of Health Research.

BACKGROUND: Better treatment during early stages of chronic kidney disease (CKD) may slow progression to end-stage renal disease and decrease associated complications and medical costs. Achieving early treatment of CKD is challenging, however, because a large fraction of persons with CKD are unaware of having this disease. Screening for CKD is one important method for increasing awareness. We examined the cost-effectiveness of identifying persons for early-stage CKD screening (i.e., screening for moderate albuminuria) using published CKD risk scores. METHODS: We used the CKD Health Policy Model, a micro-simulation model, to simulate the cost-effectiveness of using CKD two published risk scores by Bang et al. and Kshirsagar et al. to identify persons in the US for CKD screening with testing for albuminuria. Alternative risk score thresholds were tested (0.20, 0.15, 0.10, 0.05, and 0.02) above which persons were assigned to receive screening at alternative intervals (1-, 2-, and 5-year) for follow-up screening if the first screening was negative. We examined incremental cost-effectiveness ratios (ICERs), incremental lifetime costs divided by incremental lifetime QALYs, relative to the next higher screening threshold to assess cost-effectiveness. Cost-effective scenarios were determined as those with ICERs less than $50,000 per QALY. Among the cost-effective scenarios, the optimal scenario was determined as the one that resulted in the highest lifetime QALYs. RESULTS: ICERs ranged from $8,823 per QALY to $124,626 per QALY for the Bang et al. risk score and $6,342 per QALY to $405,861 per QALY for the Kshirsagar et al. risk score. The Bang et al. risk score with a threshold of 0.02 and 2-year follow-up screening was found to be optimal because it had an ICER less than $50,000 per QALY and resulted in the highest lifetime QALYs. CONCLUSIONS: This study indicates that using these CKD risk scores may allow clinicians to cost-effectively identify a broader population for CKD screening with testing for albuminuria and potentially detect people with CKD at earlier stages of the disease than current approaches of screening only persons with diabetes or hypertension.

OBJECTIVES: For the first time ever, as emphasized by inclusion in the Healthy People 2020 goals, sleep health is an emphasis of national health aims. The National Healthy Sleep Awareness Project (NHSAP) was tasked to propose questions for inclusion in the next Behavioral Risk Factor Surveillance System (BRFSS), a survey that includes a number of questions that target behaviors thought to impact health, as a means to measure community sleep health. The total number of questions could not exceed five, and had to include an assessment of the risk for obstructive sleep apnea (OSA). METHODS: An appointed workgroup met via teleconference and face-to-face venues to develop an inventory of published survey questions being used to identify sleep health, to develop a framework on which to analyze the strengths and weaknesses of current survey questions concerning sleep, and to develop recommendations for sleep health and disease surveillance questions going forward. RESULTS: The recommendation was to focus on certain existing BRFSS questions pertaining to sleep duration, quality, satisfaction, daytime alertness, and to add to these other BRFSS existing questions to make a modified STOP-BANG questionnaire (minus the N for neck circumference) to assess for risk of OSA. CONCLUSIONS: Sleep health is an important dimension of health that has previously received less attention in national health surveys. We believe that 5 questions recommended for the upcoming BRFSS question banks will assist as important measures of sleep health, and may help to evaluate the effectiveness of interventions to improve sleep health in our nation.

OBJECTIVE: To describe scientific information usage and publication patterns of the Centers for Disease Control and Prevention (CDC) Public Health Library and Information Center patrons. DESIGN: Administratively collected patron usage data and aggregate data on CDC-authored publications from the CDC Library for 3 consecutive years were analyzed. SETTING: The CDC Public Health Library and Information Center, which serves CDC employees nationally and internationally. PARTICIPANTS: Internal patrons and external users of the CDC Library. MAIN OUTCOME MEASURE(S): Three-year trends in full-text article publication and downloads including most common journals used for each purpose, systematic literature searches requested and completed, and subscriptions to a weekly public health current literature awareness service. RESULTS: From 2011 to 2013, CDC scientists published a total of 7718 articles in the peer-reviewed literature. During the same period, article downloads from the CDC Library increased 25% to more than 1.1 million, completed requests for reviews of the scientific literature increased by 34%, and electronic subscriptions to literature compilation services increased by 23%. CONCLUSIONS: CDC's scientific output and information use via the CDC Library are both increasing. Researchers and field staff are making greater use of literature review services and other customized information content delivery. Virtual public health library access is an increasingly important resource for the scientific practice of public health.

As of December 2012, an estimated 35.3 million persons were living with HIV; approximately two thirds of these people were living in sub-Saharan Africa.1 The response to the HIV pandemic in Africa and in other low-and middle-income regions of the world has consisted of a variety of bilateral and multi-lateral support from donor agencies, as well as local support from countries that have been able to afford it. A majority of the support has been directed towards HIV care and treatment. | Accordingly, the past ten years have witnessed a remarkable increase in the number of HIV-infected persons receiving antiretroviral therapy (ART) in low- and middle-income countries--from 300,000 in 2003 to 9.7 million in 20121,2. Expanded access to ART in these countries has led to significant proportions of eligible persons enrolled on ART, reaching coverage rates as high as 61% based on the World Health Organization (WHO) treatment guidelines eligibility criteria of CD4 <350 cells/uL) in 2012.1 In 2013, WHO revised its guidelines to indicate eligibility at CD4 <500 cells/uL; under these criteria, only 34% of eligible persons were on ART in 2013.1 Nevertheless, these changes in access to ART were estimated to have averted 4.2 million deaths through 20122.1 | HIV treatment programs in low- and middle-income countries have been supported by a variety of sources, including over $50 billion through the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) from 2004 to 20133. PEPFAR programs are coordinated by the U.S. Department of State’s Office of the U.S. Global AIDS Coordinator (OGAC) in Washington, D.C.,; oversight of in-country expenditures is supported by additional U.S. government(USG) agencies with the majority of funds concentrated in 36 countries and regions 4 in sub-Saharan Africa, South and Central Asia, Eastern Europe, Central America and the Caribbean. PEPFAR supports a range of HIV care and treatment services besides ART including clinical (e.g. monitoring to determine eligibility for ART and prevention and treatment of opportunistic infections) and non-clinical services (e.g. psychological, social, and preventive)4. Services implemented through PEPFAR support in each country are determined through a dialogue between the USG, and host governments. PEPFAR country operating plans and budgets are submitted annually and reviewed by USG staff.

Silicosis is a preventable occupational lung disease caused by the inhalation of respirable crystalline silica dust and can progress to respiratory failure and death. No effective specific treatment for silicosis is available; patients are provided supportive care, and some patients may be considered for lung transplantation. Chronic silicosis can develop or progress even after occupational exposure has ceased. The number of deaths from silicosis declined from 1,065 in 1968 to 165 in 2004. Hazardous occupational exposures to silica dust have long been known to occur in a variety of industrial operations, including mining, quarrying, sandblasting, rock drilling, road construction, pottery making, stone masonry, and tunneling operations. Recently, hazardous silica exposures have been newly documented during hydraulic fracturing of gas and oil wells and during fabrication and installation of engineered stone countertops. To describe temporal trends in silicosis mortality in the United States, CDC analyzed annual multiple cause-of-death data for 2001-2010 for decedents aged ≥15 years. During 2001-2010, a total of 1,437 decedents had silicosis coded as an underlying or contributing cause of death. The annual number of silicosis deaths declined from 164 (death ratedagger = 0.74 per 1 million population) in 2001 to 101 (0.39 per 1 million) in 2010 (p = 0.002). Because of new operations and tasks placing workers at risk for silicosis, efforts to limit workplace exposure to crystalline silica need to be maintained.

OBJECTIVE: To estimate the prevalence of obesity and the change of prevalence of obesity between 2004-2007 and 2008-20011 by occupation among US workers in the National Health Interview Survey. METHODS: Self-reported weight and height were collected and used to assess obesity (body mass index ≥ 30 kg/m). Gender-, race/ethnicity-, and occupation-specific prevalence of obesity were calculated. RESULTS: Prevalence of obesity steadily increased from 2004 through 2008 across gender and race/ethnicity but leveled off from 2008 through 2011. Non-Hispanic black female workers in health care support (49.2%) and transportation/material moving (46.6%) had the highest prevalence of obesity. Prevalence of obesity in relatively low-obesity (white-collar) occupations significantly increased between 2004-2007 and 2008-2011, whereas it did not change significantly in high-obesity (blue-collar) occupations. CONCLUSIONS: Workers in all occupational categories are appropriate targets for health promotion and intervention programs to reduce obesity.

BACKGROUND: Although asbestos use has been restricted in recent decades, asbestos-associated deaths continue to occur in the United States. OBJECTIVES: We evaluated premature mortality and loss of potentially productive years of life attributable to asbestos-associated diseases. METHODS: Using 1999-2010 National Center for Health Statistics mortality data, we identified decedents aged ≥25 years whose death certificate listed asbestosis and malignant mesothelioma as the underlying cause of death. We computed years of potential life lost to life expectancy (YPLL) and to age 65 (YPLL65 ). RESULTS: During 1999-2010, a total of 427,005 YPLL and 55,184 YPLL65 were attributed to asbestosis (56,907 YPLL and 2,167 YPLL65 ), malignant mesothelioma (370,098 YPPL and 53,017 YPLL65 ). Overall and disease-specific asbestos-attributable total YPLL and YPLL65 and median YPLL and YPLL65 per decedent did not change significantly from 1999 to 2010. CONCLUSIONS: The continuing occurrence of asbestos-associated diseases and their substantial premature mortality burden underscore the need for maintaining prevention efforts and for ongoing surveillance to monitor temporal trends in these diseases.

OBJECTIVE: To examine the prevalence of chronic obstructive pulmonary disease (COPD) among nonsmokers by occupation in the United States. METHODS: The 1997 to 2004 National Health Interview Survey data for working adults aged 25 years or more were used to estimate the COPD prevalence and to examine change in COPD prevalence between 1997 to 2000 and 2001 to 2004 by occupational groups. RESULTS: During 1997 to 2004, COPD prevalence was 2.8%. The COPD prevalence was highest in financial records processing (4.6%) occupations. There was a slight increase in COPD prevalence during the two survey periods from 2.8% during 1997 to 2000 compared with 2.9% during 2001 to 2004. CONCLUSIONS: No significant changes in the COPD prevalence between the two periods were found. Nevertheless, the elevated COPD prevalence in certain occupational groups suggests that other risk factors play a role in developing COPD.

OBJECTIVES: To investigate the association between psychological distress and obesity among law enforcement officers (LEOs) in the United States. METHODS: Self-reported data on psychological distress based on six key questions were obtained from LEOs who participated in the National Health Interview Survey (2004-2010). We used Prochaska's cut-point of a Kessler 6 score ≥ 5 for moderate/high mental distress in our analysis. Mean levels of body mass index (BMI) were compared across three levels of psychological distress. RESULTS: The average age of LEOs (n = 929) was 39.3 years; 25% were female. Overall, 8.1% of LEOs had moderate or high psychological distress; 37.5% were obese (BMI ≥ 30). Mean BMI increased with increasing psychological distress (no distress, BMI = 27.2 kg/m(2); mild distress, 27.6 kg/m(2); and moderate/high distress, 33.1 kg/m(2); p = 0.016) after adjustment for age, race, income, and education level among female officers only. Physical activity modified the association between psychological distress and BMI but only among male LEOs (interaction p = 0.002). Among male LEOs reporting low physical activity, psychological distress was positively associated with BMI (30.3 kg/m(2) for no distress, 30.7 for mild distress, 31.8 for moderate/high distress; p = 0.179) after adjustment, but not significantly. This association was not significant among males reporting high physical activity. CONCLUSION: Mean BMI significantly increased as psychological distress increased among female LEOs. A longitudinal study design may reveal the directionality of this association as well as the potential role that physical activity might play in this association.

BACKGROUND: Genetic tracking of Mycobacterium tuberculosis is a cornerstone of tuberculosis (TB) control programs. The RD(Rio)M. tuberculosis sublineage was previously associated with TB in Brazil. We investigated 3847 M. tuberculosis isolates and registry data from New York City (NYC) (2001-2005) to: (1) affirm the position of RD(Rio) strains within the M. tuberculosis phylogenetic structure, (2) determine its prevalence, and (3) define transmission, demographic, and clinical characteristics associated with RD(Rio) TB. METHODS: Isolates classified as RD(Rio) or non-RD(Rio)M. tuberculosis by multiplex PCR were further classified as clustered (2 isolates) or unique based primarily upon IS6110-RFLP patterns and lineage-specific cluster proportions were calculated. The secondary case rate of RD(Rio) was compared with other prevalent M. tuberculosis lineages. Genotype data were merged with the data from the NYC TB Registry to assess demographic and clinical characteristics. RESULTS: RD(Rio) strains were found to: (1) be restricted to the Latin American-Mediterranean family, (2) cause approximately 8% of TB cases in NYC, and (3) be associated with heightened transmission as shown by: (i) a higher cluster proportion compared to other prevalent lineages, (ii) a higher secondary case rate, and (iii) cases in children. Furthermore, RD(Rio) strains were significantly associated with US-born Black or Hispanic race, birth in Latin American and Caribbean countries, and isoniazid resistance. CONCLUSIONS: The RD(Rio) genotype is a single M. tuberculosis strain population that is emerging in NYC. The findings suggest that expanded RD(Rio) case and exposure identification could be of benefit due to its association with heightened transmission.

BACKGROUND: The elimination of rubella and prevention of congenital rubella syndrome (CRS) by 2015 are established goals for Europe. Our aim was to review the epidemiology of rubella in relation to this goal. MATERIAL AND METHODS: National surveillance institutions from 32 European countries provided information on rubella and CRS surveillance systems and data for 2000-08. We reported the number of notified rubella cases by year for countries with a national mandatory notification system for rubella covering total country population consistently throughout 2000-08 and analysed rubella surveillance data for 2008. RESULTS: Throughout 2000-08, 24 countries conducted passive routine surveillance based on mandatory reporting rubella covering total country population. Altogether these countries reported 526,751 rubella cases. The median incidence per million inhabitants declined from 7.2 in 2000 to 0.3 in 2008. By 2008, the number of countries with mandatory notification systems for rubella increased to 28. These countries reported 21,475 rubella cases of which 1.5% (n=317) were laboratory-confirmed. Most cases (n=21,075; 98%) were reported from Poland, Italy and Romania. Ten countries reported zero rubella cases and five others reported an incidence of <1 per million inhabitants. In 2008, 20 CRS cases were reported from five countries. CONCLUSION: The overall decline in rubella incidence and increase in the number of countries conducting rubella surveillance through a mandatory notification system are notable achievements toward the goal of rubella elimination in Europe. However, in a few countries with high rubella incidence the risk for CRS still exists. Achievement and maintenance of the required high vaccination coverage and high-quality surveillance of rubella and CRS including laboratory testing of all suspected cases are fundamental to eliminate rubella and prevent CRS in Europe.

PROBLEM: Substantial racial/ethnic health disparities exist in the United States. Although the populations of racial and ethnic minorities are growing at a rapid pace, large-scale community-based surveys and surveillance systems designed to monitor the health status of minority populations are limited. CDC conducts the Racial and Ethnic Approaches to Community Health across the U.S. (REACH U.S.) Risk Factor Survey annually in minority communities. The survey focuses on black, Hispanic, Asian (including Native Hawaiian and Other Pacific Islander), and American Indian (AI) populations. REPORTING PERIOD COVERED: 2009. DESCRIPTION OF SYSTEM: An address-based sampling design was used in the survey in 28 communities located in 17 states (Arizona, California, Georgia, Hawaii, Illinois, Massachusetts, Michigan, New Mexico, New York, North Carolina, Ohio, Oklahoma, Pennsylvania, South Carolina, Virginia, West Virginia, and Washington). Self-reported data were collected through telephone, questionnaire mailing, and in-person interviews from an average of 900 residents aged ≥ 18 years in each community. Data from the community were compared with data derived from the Behavioral Risk Factor Surveillance System (BRFSS) for the metropolitan and micropolitan statistical area (MMSA), county, or state in which the community was located and also compared with national estimates. RESULTS: Reported education level and household income were markedly lower in black, Hispanic, and AI communities than that among the general population living in the comparison MMSA, county, or state. More residents in these minority populations did not have health-care coverage and did not see a doctor because of the cost. Substantial variations were identified in self-perceived health status and prevalence of selected chronic conditions among minority populations and among communities within the same racial/ethnic population. In 2009, the median percentage of men who reported fair or poor health was 15.8% (range: 8.3%-29.3%) among A/PI communities and 26.3% (range: 22.3%-30.8%) among AI communities. The median percentage of women who reported fair or poor health was 20.1% (range: 13.3%-37.2%) among A/PI communities, whereas it was 31.3% (range: 19.4%-44.2%) among Hispanic communities. AI and black communities had a high prevalence of self-reported hypertension, cardiovascular disease, and diabetes. For most communities, prevalence was much higher than that in the corresponding MMSA, county, or state in which the community was located. The median percentages of persons who knew the signs and symptoms of a heart attack and stroke were consistently lower in all four minority communities than the national median. Variations were identified among racial/ethnic populations in the use of preventive services. Hispanics had the lowest percentages of persons who had their cholesterol checked, of those with high blood pressure who were taking antihypertensive medication, and of those with diabetes who had a glycosylated hemoglobin (HbA1C) test in the past year. AIs had the lowest mammography screening rate within 2 years among women aged ≥40 years (median: 72.7%; range: 69.4%-76.2%). A/PIs had the lowest Pap smear screening rate within 3 years (median: 74.4%; range: 60.3%-80.8%). The median influenza vaccination rates in adults aged ≥65 years were much lower among black (57.3%) and Hispanic communities (63.3%) than the national median (70.1%) among the 50 states and DC. Pneumococcal vaccination rates also were lower in black (60.5%), Hispanic (58.5%), and A/PI (59.7%) communities than the national median (68.5%). INTERPRETATIONS: Data from the REACH U.S. Risk Factor Survey demonstrate that residents in most of the minority communities continue to have lower socioeconomic status, greater barriers to health-care access, and greater risks for and burden of disease compared with the general populations living in the same MMSA, county, or state. Substantial variations in prevalence of risk factors, chronic conditions, and use of preventive services among different minority populations and different communities within the same racial/ethnic population provide opportunities for public health intervention. These variations also indicate that different priorities are needed to eliminate health disparities for different communities. PUBLIC HEALTH ACTION: These community-level survey data are being used by CDC and community coalitions to implement, monitor, and evaluate intervention programs in each community. Continuous surveillance of health status in minority communities is necessary so that community-specific, culturally sensitive strategies that include system, environmental, and individual-level changes can be tailored to these communities.

The presence of tuberculosis (TB) in patients with silicosis increases mortality risk. To characterize silicosis-respiratory TB comortality in the United States, the authors used 1968-2006 National Center for Health Statistics multiple cause-of-death data for decedents aged ≥25 years. The authors calculated proportionate mortality ratios (PMRs) using available information on decedents' industries and occupations reported from 26 states from 1985 through 1999. Among 16,648 silicosis deaths, 2,278 (13.7%) had respiratory TB listed on the death certificate. Of silicosis-respiratory TB deaths, 1,666 decedents (73.1%) were aged ≥65 years, 2,255 (99.0%) were male, and 1,893 (83.1%) were white. Silicosis-respiratory TB deaths declined 99.5% during the study period (P < 0.001 for time-related trend), from 239.8 per year during 1968-1972 to 1.2 per year during 2002-2006, with no reported deaths in 2006. Silicosis-respiratory TB deaths reported from Pennsylvania (n = 525; 1.29 per million population), Ohio (n = 258; 0.81 per million), and West Virginia (n = 146; 2.35 per million) accounted for 40.8% of all such deaths in the United States. The highest PMR for silicosis-respiratory TB death was associated with the "miscellaneous nonmetallic mineral and stone products" industry (PMR = 73.7, 95% confidence interval: 33.8, 139.8). In the United States, 2006 marked the first year since 1968 with no silicosis-respiratory TB deaths. The substantial decline in silicosis-respiratory TB comortality probably reflects prevention and control measures for both diseases.

BACKGROUND: The World Health Organization European Region has a goal for rubella elimination and congenital rubella syndrome (CRS) prevention. Although all Member States recommend a rubella-containing vaccine in their national immunization programs, rubella and CRS continue to occur, and surveillance quality varies throughout the region. METHODS: To describe the status of regional rubella and CRS surveillance and assess progress toward elimination, we reviewed surveillance practices by surveying all 53 Member States and analyzed rubella and CRS surveillance data during 2005-2009. RESULTS: Overall, 41 (91%) of 45 responding Member States have nationwide rubella surveillance, and 39 (87%) have nationwide CRS surveillance. During 2005-2009, rubella cases reported in the region decreased by 94% from 206,359 cases to 11,623 cases. The greatest decrease (99%) was observed in newly independent states of the former Soviet Union. In the rest of the region, high rubella incidence was observed in Poland, Romania, Italy, and San Marino during 2005-2008 and in Poland, Bosnia and Herzegovina, and Austria in 2009. A total of 68 CRS cases were reported during 2005-2009. CONCLUSIONS: As the foundation to achieving and verifying rubella elimination, high-quality rubella and CRS surveillance needs to be implemented and sustained in all Member States.

Poor people and people of color are more likely to live shorter and sicker lives and are less likely to survive a host of chronic illnesses. Policies and organizational practices that improve the environments in which people live, work, learn, and play can reduce these disparities. Using the World Health Organization's "Call to Action" principles as a discussion framework, we highlight the Centers for Disease Control and Prevention's Racial and Ethnic Approaches to Community Health programs that have developed and applied such strategies to address chronic illnesses. Several, in turn, foster health equity.

To estimate the prevalence and the population attributable fraction of chronic obstructive pulmonary disease (COPD) in the U.S. adult workers, we analyzed data obtained from the National Health Interview Surveys for the period 1997-2004. The overall COPD prevalence was 4.0% (95% confidence interval [CI] 3.9-4.1%). The prevalence was higher in females (5.4%, 95% CI 5.3-5.6%) than in males (2.8%, 95% CI 2.7-2.9%); in Whites (4.2%, 95% CI 4.1-4.3%) than in Blacks (3.4%, 95% CI 3.1-3.7%) and other races (2.4%, 95% CI 2.1-2.8%). Compared with insurance, real estate and other finance industry, the top three industries associated with significantly higher prevalence odds ratios (PORs) (adjusted for age, sex, race, and smoking) were other educational services (POR = 1.5, 95% CI 1.0-2.3); transportation equipment (POR = 1.4, 95% CI 1.1-1.8); and social services, religious and membership organizations (POR = 1.4, 95% CI 1.1-1.7). Compared with managers and administrators, except public administration occupation, the top three occupations with significantly higher PORs were health service (1.8, 95% CI 1.5-2.1), other protective service (POR = 1.6, 95% CI 1.2-2.2), and material moving equipment operators (POR = 1.6, 95% CI 1.1-2.3). The overall population attributable fraction for association of COPD with employment was 12.2% for industry and 17.4% for occupation. Further studies are needed to determine specific risk factors associated with COPD in industries and occupations with elevated prevalence and POR.

OBJECTIVE: To estimate national prevalences of lifetime asthma and asthma attacks among workers by age, sex, race, occupation and industry, and estimate population attributable fraction to employment for asthma attacks in the United States. METHODS: The 1997-2004 National Health Interview Survey data for currently working adults aged > or = 18 years were analyzed. RESULTS: Lifetime asthma prevalence was 9.2%; the social services religious and membership organizations industry and the health service occupation had the highest asthma prevalence. Asthma attack prevalence among workers with asthma was 35.4%; the primary metal industry and the health assessment and treating occupation had the highest attack prevalence. Approximately, 5.9% of cases reporting an asthma attack were attributed to employment when considering industries and 3.8% when considering occupations. CONCLUSIONS: Future studies and intervention strategies should address the higher prevalence of asthma in certain industries and occupations.