Many school nurses experienced increased work burden and stress during the COVID-19 pandemic. This analysis examined data from a Centers for Disease Control and Prevention cross-sectional, nationwide survey of school nurses in March 2022 to examine associations between school nurses' ability to conduct their core responsibilities and selected nurse and school factors among school nurses during the 2021-2022 school year and COVID-19 pandemic. Perceived adequate staffing and financial compensation reduced the odds of reported difficulties across all core school nursing tasks. Nurses without a registered nurse license and with higher caseloads were more likely to report difficulty in implementing specific tasks. The impact of these factors varied, with inadequate financial compensation having the largest association with school nurses' difficulty implementing all the core responsibilities. The study results improve our understanding of school nurses' challenges in implementing core school nursing responsibilities during the COVID-19 pandemic in the 2021-2022 school year.

BACKGROUND: Cancer is a leading cause of death by disease among children and adolescents in the United States. This study updates cancer incidence rates and trends using the most recent and comprehensive US cancer registry data available. METHODS: We used data from US Cancer Statistics to evaluate counts, age-adjusted incidence rates, and trends among children and adolescents aged <20 years diagnosed with malignant tumors during 2003-2019. We calculated average annual percent change and annual percent change (APC) using joinpoint regression. Rates and trends were stratified by demographic and geographic characteristics and by cancer type. RESULTS: With 248,749 cases reported during 2003-2019, the overall cancer incidence rate was 178.3 per 1 million; incidence rates were highest for leukemia (46.6), central nervous system (CNS) neoplasms (30.8), and lymphoma (27.3). Rates were highest for males, children aged 0-4 years, Non-Hispanic White children and adolescents, those in the Northeast census region, top 25% of counties by economic status, and metropolitan counties with population ≥1 million. While the overall incidence rate of pediatric cancer increased 0.5% per year on average during 2003-2019, the rate increased during 2003-2016 (APC = 1.1%) and then decreased during 2016-2019 (APC = -2.1%). During 2003-2019, rates of leukemia, lymphoma, hepatic tumors, bone tumors, and thyroid carcinomas increased, while melanoma rates decreased. CNS neoplasms rates increased until 2017 and then decreased. Other cancer types remained stable. CONCLUSIONS: Incidence of pediatric cancer increased overall, although increases were limited to certain cancer types. These findings may guide future public health and research priorities.

This study assessed support for commercial tobacco retail policies among adults. Data came from SpringStyles 2021, a web panel survey of adults in the US aged 18 years or older (N = 6,455). Overall, 62.3% of adults supported a policy prohibiting the sale of menthol cigarettes, and 57.3% supported a policy prohibiting the sale of all tobacco products. A majority of adults supported tobacco retail policies aimed at preventing initiation, promoting quitting, and reducing tobacco-related disparities. These findings can help inform federal, state, and local efforts to prohibit the sale of tobacco products, including menthol cigarettes.

INTRODUCTION: Many in the U.S. are not up to date with cancer screening. This systematic review examined the effectiveness of interventions engaging community health workers to increase breast, cervical, and colorectal cancer screening. METHODS: Authors identified relevant publications from previous Community Guide systematic reviews of interventions to increase cancer screening (1966 through 2013) and from an update search (January 2014-November 2021). Studies written in English and published in peer-reviewed journals were included if they assessed interventions implemented in high-income countries; reported screening for breast, cervical, or colorectal cancer; and engaged community health workers to implement part or all of the interventions. Community health workers needed to come from or have close knowledge of the intervention community. RESULTS: The review included 76 studies. Interventions engaging community health workers increased screening use for breast (median increase=11.5 percentage points, interquartile interval=5.523.5), cervical (median increase=12.8 percentage points, interquartile interval=6.421.0), and colorectal cancers (median increase=10.5 percentage points, interquartile interval=4.517.5). Interventions were effective whether community health workers worked alone or as part of a team. Interventions increased cancer screening independent of race or ethnicity, income, or insurance status. DISCUSSION: Interventions engaging community health workers are recommended by the Community Preventive Services Task Force to increase cancer screening. These interventions are typically implemented in communities where people are underserved to improve health and can enhance health equity. Further training and financial support for community health workers should be considered to increase cancer screening uptake.

CONTEXT: Schools can play an important role in supporting a healthy lifestyle by offering nutritious foods and beverages and providing opportunities for physical activity. A healthy diet and regular physical activity may reduce the risk of obesity. This manuscript reports on a Community Guide systematic review examining the effectiveness of interventions in schools combining school meal or fruit and vegetable snack programs and physical activity. EVIDENCE ACQUISITION: Studies meeting the intervention definition were identified from a literature search (search period: January 1990-November 2019). Community Guide systematic review methods were used to assess effectiveness as measured by dietary behavior, physical activity, and weight changes; analyses were conducted in 2020. EVIDENCE SYNTHESIS: Interventions (n=24 studies) were considered effective for increasing physical activity (median increase=21.8 minutes/day; interquartile interval= -0.8 to 27.4 minutes/day), modestly increasing fruit and vegetable intake (median relative increase=12.1%; interquartile interval= -4.6%, 73.4%), and decreasing the prevalence of overweight and obesity (median decrease=2.5 percentage points; interquartile interval= -8.1, -1.6 percentage points) among elementary school students through sixth grade. There were not enough studies to determine the effectiveness of interventions for middle- and high-school students. CONCLUSIONS: School meal or fruit and vegetable snack interventions combined with physical activity were effective in increasing physical activity, with modest effects for improving fruit and vegetable consumption and reducing the prevalence of overweight and obesity among elementary students. These results may inform researchers and school administrators about healthy eating and physical activity interventions.

CONTEXT: Unaffordable or insecure housing is associated with poor health in children and adults. Tenant-based housing voucher programs (voucher programs) limit rent to 30% or less of household income to help households with low income obtain safe and affordable housing. OBJECTIVE: To determine the effectiveness of voucher programs in improving housing, health, and other health-related outcomes for households with low income. DESIGN: Community Guide systematic review methods were used to assess intervention effectiveness and threats to validity. An updated systematic search based on a previous Community Guide review was conducted for literature published from 1999 to July 2019 using electronic databases. Reference lists of included studies were also searched. ELIGIBILITY CRITERIA: Studies were included if they assessed voucher programs in the United States, had concurrent comparison populations, assessed outcomes of interest, were written in English, and published in peer-reviewed journals or government reports. MAIN OUTCOME MEASURES: Housing quality and stability, neighborhood opportunity (safety and poverty), education, income, employment, physical and mental health, health care use, and risky health behavior. RESULTS: Seven studies met inclusion criteria. Compared with low-income households not offered vouchers, voucher-using households reported increased housing quality (7.9 percentage points [pct pts]), decreased housing insecurity or homelessness (-22.4 pct pts), and decreased neighborhood poverty (-5.2 pct pts).Adults in voucher-using households had improved health care access and physical and mental health. Female youth experienced better physical and mental health but not male youth. Children who entered the voucher programs under 13 years of age had improved educational attainment, employment, and income in their adulthood; children's gains in these outcomes were inversely related to their age at program entry. CONCLUSION: Voucher programs improved health and several health-related outcomes for voucher-using households, particularly young children. Research is still needed to better understand household's experiences and contextual factors that influence achievement of desired outcomes.

We report an outbreak of severe acute respiratory syndrome coronavirus 2 involving 3 Malayan tigers (Panthera tigris jacksoni) at a zoo in Tennessee, USA. Investigation identified naturally occurring tiger-to-tiger transmission; genetic sequence change occurred with viral passage. We provide epidemiologic, environmental, and genomic sequencing data for animal and human infections.

OBJECTIVE: Researchers at the Centers for Disease Control and Prevention monitor unplanned school closure (USC) reports through online systematic searches (OSS) to assist public health emergency responses. We counted the additional reports identified through social media along with OSS to improve USC monitoring. METHODS: Facebook and Twitter data of public-school districts and private schools in counties affected by California wildfires in October and December of 2017 and January of 2018 were retrieved. We computed descriptive statistics and performed multivariable logistic regression for both OSS and social media data. RESULTS: Among the 362 public-school districts in wildfire-affected counties, USCs were identified for 115 (32%) districts, of which OSS identified 104 (90%), Facebook, 59 (52%), and Twitter, 37 (32%). These data correspond to 4622 public schools, among which USCs were identified for 888 (19.2%) schools, of which OSS identified 722 (81.3%), Facebook, 496 (55.9%), and Twitter, 312 (35.1%). Among 1289 private schools, USCs were identified for 104 schools, of which OSS identified 47 (45.2%), Facebook, 67 (64.4%), and Twitter, 29 (27.9%). USC announcements identified via social media, in addition to those via OSS, were 11 public school districts, 166 public schools, and 57 private schools. CONCLUSION: Social media complements OSS as additional resources for USC monitoring during disasters.

INTRODUCTION: Intimate partner violence and sexual violence are widespread and often occur early in life. This systematic review examines the effectiveness of interventions for primary prevention of intimate partner violence and sexual violence among youth. METHODS: Studies were identified from 2 previous systematic reviews and an updated search (January 2012-June 2016). Included studies were implemented among youth, conducted in high-income countries, and aimed to prevent or reduce the perpetration of intimate partner violence or sexual violence. In 2016-2017, Guide to Community Preventive Services (Community Guide) methods were used to assess effectiveness as determined by perpetration, victimization, or bystander action. When heterogeneity of outcomes prevented usual Community Guide methods, the team systematically applied criteria for favorability (statistically significant at p<0.05 or approaching significance at p<0.10) and consistency (75% of results in the same direction). RESULTS: A total of 28 studies (32 arms) met inclusion and quality of execution criteria. Interventions used combinations of teaching healthy relationship skills, promoting social norms to protect against violence, or creating protective environments. Overall, 18 of 24 study arms reported favorable results on the basis of the direction of effect for decreasing perpetration; however, favorability for bystander action diminished with longer follow-up. Interventions did not demonstrate consistent results for decreasing victimization. A bridge search conducted during Fall 2020 confirmed these results. DISCUSSION: Interventions for the primary prevention of intimate partner violence and sexual violence are effective in reducing perpetration. Increasing bystander action may require additional follow-up as effectiveness diminishes over time. Findings may inform researchers, school personnel, public health, and other decision makers about effective strategies to prevent intimate partner violence and sexual violence among youth.

On June 30, 2021, the Illinois Department of Public Health (IDPH) contacted CDC concerning COVID-19 outbreaks at two events sponsored by the same organization: a 5-day overnight church camp for persons aged 14-18 years and a 2-day men's conference. Neither COVID-19 vaccination nor COVID-19 testing was required before either event. As of August 13, a total of 180 confirmed and probable cases had been identified among attendees at the two events and their close contacts. Among the 122 cases associated with the camp or the conference (primary cases), 18 were in persons who were fully vaccinated, with 38 close contacts. Eight of these 38 close contacts subsequently became infected with SARS-CoV-2, the virus that causes COVID-19 (secondary cases); among the eight close contacts with secondary cases, one half (four) were fully vaccinated. Among the 180 total persons with outbreak-associated cases, five (2.8%) were hospitalized; no deaths occurred. None of the vaccinated persons with cases were hospitalized. Approximately 1,000 persons across at least four states were exposed to SARS-CoV-2 through attendance at these events or through close contact with a person who had a primary case. This investigation underscores the impact of secondary SARS-CoV-2 transmission during large events, such as camps and conferences, when COVID-19 prevention strategies are not implemented. In Los Angeles County, California, during July 2021, when the SARS-CoV-2 B.1.617.2 (Delta) variant was predominant, unvaccinated residents were five times more likely to be infected and 29 times more likely to be hospitalized from infection than were vaccinated residents (1). Implementation of multiple prevention strategies, including vaccination and nonpharmaceutical interventions such as masking, physical distancing, and screening testing, are critical to preventing SARS-CoV-2 transmission and serious complications from COVID-19.

BACKGROUND: Although pediatric cancer mortality and survival have improved in the United States over the past 40 years, differences exist by age, race/ethnicity, cancer site, and economic status. To assess progress, this study examined recent mortality and survival data for individuals younger than 20 years. METHODS: Age-adjusted death rates were calculated with the National Vital Statistics System for 2002-2016. Annual percent changes (APCs) and average annual percent changes (AAPCs) were calculated with joinpoint regression. Five-year relative survival was calculated on the basis of National Program of Cancer Registries data for 2001-2015. Death rates and survival were estimated overall and by sex, 5-year age group, race/ethnicity, cancer type, and county-based economic markers. RESULTS: Death rates decreased during 2002-2016 (AAPC, -1.5), with steeper declines during 2002-2009 (APC, -2.6), and then plateaued (APC, -0.4). Leukemia and brain cancer were the most common causes of death from pediatric cancer, and brain cancer surpassed leukemia in 2011. Death rates decreased for leukemia and lymphoma but were unchanged for brain, bone, and soft-tissue cancers. From 2001-2007 to 2008-2015, survival improved from 82.0% to 85.1%. Survival was highest in both periods among females, those aged 15 to 19 years, non-Hispanic Whites, and those in counties in the top 25% by economic status. Survival improved for leukemias, lymphomas, and brain cancers but plateaued for bone and soft-tissue cancers. CONCLUSIONS: Although overall death rates have decreased and survival has increased, differences persist by sex, age, race/ethnicity, cancer type, and economic status. Improvements in pediatric cancer outcomes may depend on improving therapies, access to care, and supportive and long-term care.

CONTEXT: Healthy eating during childhood is important for optimal growth and helps reduce the risk of obesity, which has potentially serious health consequences. Changing the school food environment may offer one way to improve students' dietary intake. This manuscript reports 4 Community Guide systematic reviews examining the effectiveness of interventions in schools promoting healthy eating and weight. EVIDENCE ACQUISITION: School obesity prevention programs aiming to improve diet were identified from a 2013 Agency for Health Care Research and Quality systematic review and an updated search (August 2012-January 4, 2017). In 2017-2018, Community Guide systematic review methods were used to assess effectiveness as determined by dietary behavior and weight changes. EVIDENCE SYNTHESIS: Interventions improving school meals or offering fruits and vegetables (n=27 studies) are considered effective. Evidence is insufficient to determine the effectiveness of interventions supporting healthier snack foods and beverages outside of school meal programs given inconsistent findings (n=13 studies). Multicomponent interventions to increase availability of healthier foods and beverages are considered effective. These interventions must include 1 component from school meals or fruit and vegetable programs and interventions supporting healthier snack foods and beverages (n=12 studies). There is insufficient evidence to determine the effectiveness of interventions to increase water access because only 2 studies met inclusion criteria. CONCLUSIONS: A total of 2 school-based dietary interventions have favorable effects for improving dietary habits and modest effects for improving or maintaining weight. More evidence is needed regarding interventions with insufficient findings. These reviews may inform researchers and school administrators about healthy eating and obesity prevention interventions.

OBJECTIVES: To aid emergency response, Centers for Disease Control and Prevention (CDC) researchers monitor unplanned school closures (USCs) by conducting online systematic searches (OSS) to identify relevant publicly available reports. We examined the added utility of analyzing Twitter data to improve USC monitoring. METHODS: Georgia public school data were obtained from the National Center for Education Statistics. We identified school and district Twitter accounts with 1 or more tweets ever posted ("active"), and their USC-related tweets in the 2015-16 and 2016-17 school years. CDC researchers provided OSS-identified USC reports. Descriptive statistics, univariate, and multivariable logistic regression were computed. RESULTS: A majority (1,864/2,299) of Georgia public schools had, or were in a district with, active Twitter accounts in 2017. Among these schools, 638 were identified with USCs in 2015-16 (Twitter only, 222; OSS only, 2015; both, 201) and 981 in 2016-17 (Twitter only, 178; OSS only, 107; both, 696). The marginal benefit of adding Twitter as a data source was an increase in the number of schools identified with USCs by 53% (222/416) in 2015-16 and 22% (178/803) in 2016-17. CONCLUSIONS: Policy-makers may wish to consider the potential value of incorporating Twitter into existing USC monitoring systems.

OBJECTIVE: Informal caregiving may likely increase as the number of cancer survivors grows. Caregiving responsibilities can impact caregivers' quality of life (QOL). Understanding the current state of the science regarding caregiving QOL could help inform future research and intervention development. METHODS: A systematic literature review in PubMed/Medline examined research on QOL among informal cancer caregivers and related psychosocial health outcomes. Original research articles in English, published between 2007 and 2017 about caregivers (aged >18 years) of adult cancer patients in the United States were included. Abstracted articles were categorized according to caregiving recipient's phase of survivorship (acute, middle to long-term, end of life/bereavement). RESULTS: Of 920 articles abstracted, 60 met inclusion criteria. Mean caregiver age ranged from 37 to 68 with the majority being female, non-Hispanic white, with at least a high school degree, and middle income. Almost half of the studies focused on caregivers who provided care for survivors from diagnosis through the end of active treatment. Studies examined physical health, spirituality, psychological distress, and social support. Differences in QOL were noted by caregiver age, sex, and employment status. SIGNIFICANCE OF RESULTS: Additional research includes the examination of the needs of diverse cancer caregivers and determines how additional caregiver characteristics (e.g., physical functioning, financial burden, etc.) affect QOL. This includes studies examining caregiver QOL in the phases following the cessation of active treatment and assessments of health systems, support services, and insurance to determine barriers and facilitators needed to meet the immediate and long-term needs of cancer caregivers.

Objective: Methods for developing mobile health (mHealth) interventions are not well described. To guide the development of future mHealth interventions, we describe the application of the agile science framework to iteratively develop an mHealth intervention for adolescent and young adult (AYA) survivors of childhood cancer. Method: We created the AYA STEPS mobile app (AYA Self-management via Texting, Education, and Plans for Survivorship) by modifying and integrating 2 existing programs: an online survivorship care plan (SCP) generator and a text messaging self-management intervention for AYA off treatment. The iterative development process involved 3 stages of agile science: (1) formative work, (2) obtaining feedback about the first AYA STEPS prototype, and (3) pilot testing and finalization of a prototype. We determined preferences of AYA stakeholders as well as discovered and addressed technology problems prior to beginning a subsequent randomized controlled trial. Results: AYA survivors reported that the app and the embedded tailored messages related to their health and SCP were easy to use and generally satisfying and beneficial. Usage data supported that AYA were engaged in the app. Technology glitches were discovered in the pilot and addressed. Conclusion: The iterative development of AYA STEPS was essential for creating a consistent and acceptable end user experience. This study serves as one example of how behavioral scientists may apply agile science to their own mHealth research.

INTRODUCTION: Nearly 5 million people are treated for skin cancer each year in the United States. Agricultural and construction workers (ACWs) may be at increased risk for skin cancer because of high levels of ultraviolet radiation exposure from the sun. This is the first study that uses nationally representative data to assess sun-protection behaviors among ACWs. METHODS: We analyzed data from the 2015 National Health Interview Survey Cancer Control Supplement to examine the prevalence of sun-protection behaviors among ACWs. We calculated national, weighted, self-reported prevalence estimates. We used chi(2) tests to assess differences between ACWs by industry and occupation. RESULTS: Most of the 2,298 agricultural and construction workers studied were male (by industry, 72.4% in agriculture and 89.3% in construction; by occupation, 66.1% in agriculture and 95.6% in construction) and non-Hispanic white. About one-third had at least 1 sunburn in the past year. The prevalence of sunscreen use and shade seeking was low and did not significantly differ among groups, ranging from 15.1% to 21.4% for sunscreen use and 24.5% to 29.1% for shade seeking. The prevalence of wearing protective clothing was significantly higher among agricultural workers than among construction workers by industry (70.9% vs 50.7%) and occupation (70.5% vs 53.0%). CONCLUSION: Our findings could be used to improve occupational health approaches to reducing skin cancer risk among ACWs and to inform education and prevention initiatives addressing skin cancer. Sun-safety initiatives may include modifying work sites to increase shade and adding sun safety to workplace policies and training. Employers can help reduce occupational health inequities and protect workers by creating workplaces that facilitate sun protection.

As the amount of lead in the environment has significantly decreased with the removal of lead in gasoline and paint, the United States has made great strides in preventing lead poisoning or reducing levels of lead in young children's blood. Even so, lead exposure is not equal for all children-low-income and minority children continue to bear a disproportionate burden of exposure primarily through contact with deteriorating lead-based paint from older housing and potentially through drinking contaminated water resulting from failing leaded pipes, as evidenced by the recent events in Flint, Michigan. These facts suggest that childhood lead poisoning is an environmental justice issue worthy of public health consideration and action; "environmental justice" is focused on identifying and addressing disproportionately high and adverse effects of environmental hazards on low-income and minority communities. The question remains, however, as to whether addressing the quality-of-life "risk" factors associated with lead poisoning might eventually lead to reduction in exposure, as well as potentially resulting in adverse health effects. Utilizing an environmental justice framework and examining this issue through a multidimensional environmental justice lens, we contemplated the quality-of-life factors that may essentially predispose minority children and their families to lead poisoning. Specifically, we examined American Community Survey data (2012-2016) focused on comparing race/ethnicity with other sociodemographic variables known to be associated with risks for childhood lead poisoning. The results provide thought-provoking context for making progress toward eliminating lead poisoning as a major environmental justice concern.

Black and Hispanic populations perceive their skin cancer risk to be low and are less likely to use sun protection strategies. We conducted formative research to understand knowledge, awareness, beliefs, and behaviors among these groups. In 2017, eighteen focus groups were conducted with black and Hispanic respondents(18-44 years) in four US cities. Groups were segmented by participant characteristics associated with elevated or lower risk for skin cancer, by race/ethnicity, gender, and age. A professional moderator followed a semi-structured discussion guide, and focus group transcripts were analyzed using conventional content analysis and NVIVO 11 Software. Most participants perceived themselves to be at low skin cancer risk due to their "darker skin tone" and/or "lack of family history." Skin cancer signs and symptoms were more inconsistently reported by blacks than Hispanics. Few participants reported regular sun protection behaviors. Those who did used sunscreen, wore protective clothing, and had elevated risk based on sun sensitivity or UV exposure. While most participants recalled family discussions (as youth) about sunscreen and sun protection, the understood intent was to warn against "further skin darkening" or to "prevent aging," not to reduce sun burns or skin cancer risk. Tanning bed use was low across all segments, especially among black respondents. Tailored skin cancer prevention campaigns need to address misperceptions about risks and benefits of skin cancer prevention behaviors among black and Hispanic populations. Families, peer groups, and healthcare providers need to be engaged in the creation of educational interventions and messaging efforts that target these populations.

November marks Lung Cancer Awareness Month, and reminds us that lung cancer is the leading cause of cancer death among women in the United States. In this brief report, we highlight CDC resources that can be used to examine the most recent data on lung cancer incidence, survival, prevalence, and mortality among women. Using the U.S. Cancer Statistics Data Visualizations tool, we report that in 2015, 104,992 new cases of lung cancer and 70,073 lung cancer deaths were reported among women in the United States. The 5-year relative survival among females diagnosed with lung cancer was 22%, and as of 2015, approximately 185,759 women were living with a lung cancer diagnosis. We also describe ways CDC works to collect and disseminate quality cancer surveillance data, prevent initiation of tobacco use, promote cessation, eliminate exposure to secondhand smoke, identify and eliminate disparities, promote lung cancer screening, and help cancer survivors live longer by improving health outcomes.

INTRODUCTION: This systematic review examines healthcare costs associated with mental health conditions among cancer survivors in the United States. Areas covered: Ten published studies were identified. Studies varied substantially in terms of population, mental health conditions examined, data collection methods, and type of cost reported. Cancer survivors with mental health conditions incurred significantly higher total medical costs and costs of most service types compared to cancer survivors without a mental health condition. Additionally, the total healthcare expenditure related to mental health was higher among cancer survivors compared with people without history of cancer. Expert commentary: Mental health conditions are associated with increased healthcare costs among cancer survivors. Future examination of other components of economic burden, including patient out-of-pocket costs, non-medical costs, such as transportation, childcare, and productivity losses for patients and their caregivers, will be important. Additionally, evaluation of economic burden by cancer site, stage at diagnosis, duration of survivorship, and treatment(s) will increase understanding of the overall impact of mental health conditions on cancer survivors and on the healthcare system.

PURPOSE: Adolescents with cancer have had less improvement in survival than other populations in the United States. This may be due, in part, to adolescents not receiving treatment at Children's Oncology Group (COG) institutions, which have been shown to increase survival for some cancers. The objective of this ecologic study was to examine geographic distance to COG institutions and adolescent cancer mortality. METHODS: We calculated cancer mortality among adolescents and sociodemographic and healthcare access factors in four geographic zones at selected distances surrounding COG facilities: Zone A (area within 10 miles of any COG institution), Zones B and C (concentric rings with distances from a COG institution of >10-25 miles and >25-50 miles, respectively), and Zone D (area outside of 50 miles). RESULTS: The adolescent cancer death rate was highest in Zone A at 3.21 deaths/100,000, followed by Zone B at 3.05 deaths/100,000, Zone C at 2.94 deaths/100,000, and Zone D at 2.88 deaths/100,000. The United States-wide death rate for whites without Hispanic ethnicity, blacks without Hispanic ethnicity, and persons with Hispanic ethnicity was 2.96 deaths/100,000, 3.10 deaths/100,000, and 3.26 deaths/100,000, respectively. Zone A had high levels of poverty (15%), no health insurance coverage (16%), and no vehicle access (16%). CONCLUSIONS: Geographic access to COG institutions, as measured by distance alone, played no evident role in death rate differences across zones. Among adolescents, socioeconomic factors, such as poverty and health insurance coverage, may have a greater impact on cancer mortality than geographic distance to COG institution.

INTRODUCTION: Chronic mental health problems often emerge in young adulthood, when adults begin to develop lifelong health behaviors and access preventive health services. The associations between mental health problems and modifiable cancer risk factors in young adulthood are not well understood. METHODS: In 2016, the authors analyzed 2014 Behavioral Risk Factor Surveillance System data on demographic characteristics, health service access and use, health status, and cancer risk factors (tobacco use, alcohol use, overweight or obesity, physical activity, and sleep) for 90,821 young adults aged 18-39 years with mental health problems (depressive disorder or frequent mental distress) compared to other young adults. RESULTS: Mental health problems were associated with white race; less than a high school education; lower income; being out of work or unable to work; being uninsured (for men only); poor health; previous diagnosis of asthma, skin cancer, or diabetes; and not having a recent checkup. After controlling for demographic characteristics, health service use, and health status, mental health problems among young adults were associated with smoking, binge drinking, inadequate sleep, having no leisure time physical activity, and being overweight or obese (among women only). Cervical cancer screening was not associated with mental health problems after controlling for demographic characteristics, health service use, and health status. CONCLUSIONS: Mental health problems in young adulthood were associated with potentially modifiable factors and behaviors that increase risk for cancer. Efforts to prevent cancer and promote health must attend to mental health disparities to meet the needs of young adults.

BACKGROUND: Cervical cancer is the leading cause of female cancer mortality in Kenya. Kenya's National Cervical Cancer Prevention Program Strategic Plan outlines efforts to reduce the burden; however, treatment services remain limited. This study identified male and female perspectives regarding benefits, facilitators, and barriers to treatment for precancerous lesions and cervical cancer. MATERIALS AND METHODS: Ten focus groups were conducted in Nairobi and Nyanza in 2014 with females aged 25-49 years (n = 60) and male partners (n = 40). Participants were divided into groups dependent on screening status, sex, language, and geographic location. Qualitative analytic software was used to analyze transcribed and translated data. RESULTS: Treatment was endorsed as beneficial for the prevention of death and the improvement of wellness, quality of life, symptoms, and family life. Barriers reported by males and females included the following: (a) concerns about side effects; (b) treatment-related fear and stigma; (c) marital discord; (d) financial and access issues; (e) religious and cultural beliefs; and (f) limited knowledge. Male endorsement of wanting to improve knowledge and communication with their partners, in spite of stigmatizing beliefs and misperceptions regarding females with abnormal screening results or those who have been diagnosed with cancer, was novel. CONCLUSION: Incorporating qualitative data on benefits of and barriers to treatment for precancerous lesions and cervical cancer into Kenya's national priorities and activities is important. Our findings can be used to inform the development and successful implementation of targeted, region-specific community outreach and health messaging campaigns focused on alleviating the country's cervical cancer burden. IMPLICATIONS FOR PRACTICE: This article provides important insight into female and male partner perspectives regarding benefits, facilitators, and barriers to treatment for precancerous lesions and cervical cancer. Our novel research findings can inform the development of targeted community health interventions, educational messages, and resources and aid stakeholders in strengthening strategic plans regarding treatment coverage and cervical cancer prevention. Because several treatment barriers identified in this study are similar to barriers associated with cervical cancer screening in low- and middle-resourced countries, effective messaging interventions could address barriers to receipt of both screening and treatment.

This study was conducted among U.S. Army soldiers to evaluate the association between exposure to o-chlorobenzylidene malononitrile (CS riot control agent) and urinary metabolite 2-chlorohippuric acid (CHA) detected in test subjects (n = 87) after completion of Mask Confidence Training. CS exposures ranged 0.086 - 4.9 mg/m(3) ([Formula: see text] = 2.7 mg/m(3)). CHA levels (corrected for creatinine) at 2, 8, 24, and 30 hours post-exposure resulted in ranges of 94.6 - 1120 mug/g-cr ([Formula: see text] = 389 mug/g-cr), 15.80 - 1170 mug/g-cr ([Formula: see text] = 341 mug/g-cr), 4.00 - 53.1 mug/g-cr ([Formula: see text] = 19.3 mug/g-cr), and 1.99 - 28.4 mug/g-cr ([Formula: see text] = 10.6 mug/g-cr), respectively. Spearman's correlation revealed CHA levels strongly correlated with time sampled (r = -0.748, p < 0.05) and weakly correlated with CS concentration (r = 0.270, p < 0.05). A linear relationship was observed between CHA, CS concentration, and time of urine sample according to the following regression equation: ln(CHA, mug/g-cr) = 5.423 + 0.316 (CS conc., mg/m(3)) - 0.002 (time sampled), (R = 0.910, R(2) = 0.827, p < 0.05). This relationship suggests that CHA has the potential to be an effective retrospective indicator of CS exposure in future biomarker developments.

Background: In response to a growing cancer burden and need for improved coordination among stakeholders in Kenya, the US National Cancer Institute and the Kenya Ministry of Health collaboratively hosted a stakeholder meeting in 2014 which identified four priority areas of need (research capacity building, pathology and cancer registries, cancer awareness and education, and health system strengthening) and developed corresponding action plans. Methods: Surveys were conducted with participants to collect input on the progress and impact of the 2014 stakeholder meeting. Findings: Of 69 eligible participants, 45 responded from academia, healthcare institutions, civil society, government, and international agencies. Of the four technical focus areas, three have continued to conduct working group meetings and two have conducted in-person meetings to review and update their respective action plans. Accomplishments linked to or enhanced by the meeting include: Kenyan and international support for expansion of population-based cancer registries, increased availability of prioritized diagnostic tests in selected regional referral hospitals, a greater focus on development of a national cancer research agenda, strategic planning for a community education strategy for cancer awareness, and improved coordination of partners through in-country technical assistance. Interpretation: The Stakeholder Program has successfully united individuals and organizations to improve cancer control planning in Kenya, and has enhanced existing efforts and programs across the country. This model of partners working in parallel on prioritized track activities has supported development of long term coordination of cancer research and control activities sustainable by the Kenyan government and Kenyan institutions.

BACKGROUND: Cervical cancer is the second most commonly diagnosed cancer in females and is a leading cause of cancer-related mortality in Kenya; limited cervical cancer screening services may be a factor. Few studies have examined men's and women's perceptions on environmental and psychosocial barriers and benefits related to screening. MATERIALS AND METHODS: In 2014, 60 women aged 25-49 years and 40 male partners participated in 10 focus groups (6 female and 4 male), in both rural and urban settings (Nairobi and Nyanza, Kenya), to explore perceptions about barriers to and benefits of cervical cancer screening. Focus groups were segmented by sex, language, geographic location, and screening status. Data were transcribed, translated into English, and analyzed by using qualitative software. RESULTS: Participants identified screening as beneficial for initiating provider discussions about cancer but did not report it as a beneficial method for detecting precancers. Perceived screening barriers included access (transportation, cost), spousal approval, stigma, embarrassment during screening, concerns about speculum use causing infertility, fear of residual effects of test results, lack of knowledge, and religious or cultural beliefs. All participants reported concerns with having a male doctor perform screening tests; however, men uniquely reported the young age of a doctor as a barrier. CONCLUSION: Identifying perceived barriers and benefits among people in low- and middle-income countries is important to successfully implementing emerging screening programs. The novel findings on barriers and benefits from this study can inform the development of targeted community outreach activities, communication strategies, and educational messages for patients, families, and providers. Implications for Practice: This article provides important information for stakeholders in clinical practice and research when assessing knowledge, beliefs, and acceptability of cervical cancer screening and treatment services in low- and middle-resourced countries. Formative research findings provide information that could be used in the development of health interventions, community education messages, and materials. Additionally, this study illuminates the importance of understanding psychosocial barriers and facilitators to cervical cancer screening, community education, and reduction of stigma as important methods of improving prevention programs and increasing rates of screening among women.

Toxoplasma gondii is one of the leading foodborne pathogens in the United States. The Centers for Disease Control and Prevention (CDC) reported that T. gondii accounts for 24% of deaths due to foodborne illness in the United States. Consumption of undercooked pork products in which T. gondii has encysted has been identified as an important route of human exposure. However, little quantitative evaluation of risk due to different pork products as a function of microbial quality at the abattoir, during the production process, and due to consumer handling practices is available to inform risk management actions. The goal of this study was to develop a farm-to-table quantitative microbial risk assessment (QMRA) model to predict the public health risk associated with consumption of fresh pork in the United States. T. gondii prevalence in pigs was derived through a meta-analysis of existing data, and the concentration of the infectious life stage (bradyzoites) was calculated for each pork cut from an infected pig. Logistic regression and log-linear regression models were developed to predict the reduction of T. gondii during further processing and consumer preparation, respectively. A mouse-derived exponential dose-response model was used to predict infection risk in humans. The estimated mean probability of infection per serving of fresh pork products ranges from 3.2 × 10−7 to 9.5 × 10−6, corresponding to a predicted approximately 94,600 new infections annually in the U.S. population due to fresh pork ingestion. Approximately 957 new infections per year were estimated to occur in pregnant women, corresponding to 277 cases of congenital toxoplasmosis per year due to fresh pork ingestion. In the context of available data, sensitivity analysis suggested that cooking is the most important parameter impacting human health risk. This study provides a scientific basis for risk management and also could serve as a baseline model to quantify infection risk from T. gondii and other parasites associated with meat products.

Purpose This study used population-based data to estimate the percentage of cancer survivors in the United States reporting current medication use for anxiety and depression and to characterize the survivors taking this type of medication. Rates of medication use in cancer survivors were compared with rates in the general population. Methods We analyzed data from the National Health Interview Survey, years 2010 to 2013, identifying cancer survivors (n = 3,184) and adults with no history of cancer (n = 44,997) who completed both the Sample Adult Core Questionnaire and the Adult Functioning and Disability Supplement. Results Compared with adults with no history of cancer, cancer survivors were significantly more likely to report taking medication for anxiety (16.8% v 8.6%, P < .001), depression (14.1% v 7.8%, P < .001), and one or both of these conditions combined (19.1% v 10.4%, P < .001), indicating that an estimated 2.5 million cancer survivors were taking medication for anxiety or depression in the United States at that time. Survivor characteristics associated with higher rates of medication use for anxiety included being younger than 65 years old, female, and non-Hispanic white, and having public insurance, a usual source of medical care, and multiple chronic health conditions. Survivor characteristics associated with medication use for depression were largely consistent with those for anxiety, with the exceptions that insurance status was not significant, whereas being widowed/divorced/separated was associated with more use. Conclusion Cancer survivors in the United States reported medication use for anxiety and depression at rates nearly two times those reported by the general public, likely a reflection of greater emotional and physical burdens from cancer or its treatment.

CONTEXT: Adverse childhood experiences (ACEs) can affect health and well-being across the life course. OBJECTIVE: This systematic review summarizes the literature on associations between ACEs and risk of cancer in adulthood. DATA SOURCES: We searched PubMed to identify relevant publications published on or before May 31, 2015. STUDY SELECTION: We included original research quantifying the association between ACEs and adult cancer incidence. Case reports and reviews were excluded. DATA ABSTRACTION: Two reviewers independently abstracted and summarized key information (eg, ACE type, cancer type, risk estimates) from included studies and resolved all discrepancies. RESULTS: Twelve studies were included in the review. In studies in which ACE summary scores were calculated, significant associations were observed between the scores and an increased risk of cancer in adulthood. Of the different types of ACEs examined, physical and psychological abuse victimization were associated with risk of any cancer in 3 and 2 studies, respectively. Two studies also reported significant associations with regard to sexual abuse victimization (1 for cervical cancer and 1 for any cancer). However, 2 other studies reported no significant associations between childhood sexual or physical abuse and incidence of cervical or breast cancer. LIMITATIONS: Because of heterogeneity across studies, we were unable to compute a summary effect estimate. CONCLUSIONS: These findings suggest that childhood adversity in various forms may increase a person's cancer risk. Further research is needed to understand the mechanisms driving this relationship and to identify opportunities to prevent and mitigate the deleterious effects of early adversity on long-term health.

Compelling evidence suggests that early life exposures can affect lifetime cancer risk. In 2014, the Centers for Disease Control and Prevention's (CDC's) Cancer Prevention Across the Lifespan Workgroup hosted a series of virtual meetings with select experts to discuss the state of the evidence linking factors during the prenatal period and early childhood to subsequent risk of both pediatric and adult cancers. In this article, we present the results from a qualitative analysis of the meeting transcripts and summarize themes that emerged from our discussions with meeting participants. Themes included the state of the evidence linking early life factors to cancer risk, research gaps and challenges, the level of evidence needed to support taking public health action, and the challenges of communicating complex, and sometimes conflicting, scientific findings to the public. Opportunities for collaboration among public health agencies and other stakeholders were identified during these discussions. Potential next steps for the CDC and its partners included advancing and building upon epidemiology and surveillance work, developing and using evidence from multiple sources to inform decision-making, disseminating and communicating research findings in a clear and effective way, and expanding collaborations with grantees and other partners. As the science on early life factors and cancer risk continues to evolve, there are opportunities for collaboration to translate science into actionable public health practice.