The study aims were (1) to explore whether "periodontal treatment" consisting of surgical therapy (flap, resective, or regenerative) or scaling and root planing treatment with long-term periodontal maintenance treatment, is cost-effective in terms of preventing periodontitis-attributable tooth extraction and replacement by implant-supported crowns ("extraction/replacement"); (2) to assess the effect of cigarette smoking on this cost-effectiveness. Data for this observational retrospective study were collected from dental charts of patients who had received periodontal therapy and at least annual follow-up visits for >10 years were analyzed by linear regression generalized estimating equations and generalized linear models. Among 399 adults (199 males, 200 females), those with the least mean annual treatment cost experienced the greatest mean annual costs for extraction/replacement, indicating general cost-effectiveness. Cigarette smoking adversely impacted this cost-effectiveness, with current heavy smokers experiencing no cost-effectiveness. Former smokers with Grade C periodontitis benefitted most, whereas smoking did not influence cost-effectiveness for Grade B periodontitis. Assessed by mean annual costs of "extraction/replacement," periodontal treatment was cost-effective, which decreased in a dose-response manner by former and current smoking intensity. Cigarette smoking should be factored into treatment planning and cost-effective analyses of periodontal treatment. Smoking cessation should be encouraged.

Studies on epilepsy mortality in the United States are limited. We used the National Vital Statistics System Multiple Cause of Death data to investigate mortality rates and trends during 2011-2021 for epilepsy (defined by the International Classification of Diseases, 10th Revision, codes G40.0-G40.9) as an underlying, contributing, or any cause of death (i.e., either an underlying or contributing cause) for U.S. residents. We also examined epilepsy as an underlying or contributing cause of death by selected sociodemographic characteristics to assess mortality rate changes and disparities in subpopulations. During 2011-2021, the overall age-standardized mortality rates for epilepsy as an underlying (39 % of all deaths) or contributing (61 % of all deaths) cause of death increased 83.6 % (from 2.9 per million to 6.4 per million population) as underlying cause and 144.1 % (from 3.3 per million to 11.0 per million population) as contributing cause (P < 0.001 for both based on annual percent changes). Compared to 2011-2015, in 2016-2020 mortality rates with epilepsy as an underlying or contributing cause of death were higher overall and in nearly all subgroups. Overall, mortality rates with epilepsy as an underlying or contributing cause of death were higher in older age groups, among males than females, among non-Hispanic Black or non-Hispanic American Indian/Alaska Native persons than non-Hispanic White persons, among those living in the West and Midwest than those living in the Northeast, and in nonmetro counties compared to urban regions. Results identify priority subgroups for intervention to reduce mortality in people with epilepsy and eliminate mortality disparity.

Social determinants of health (SDOH) are a broad array of social and contextual conditions where persons are born, live, learn, work, play, worship, and age that influence their physical and mental wellbeing and quality of life. Using 2022 Behavioral Risk Factor Surveillance System data, this study assessed measures of adverse SDOH and health-related social needs (HRSN) among U.S. adult populations. Measures included life satisfaction, social and emotional support, social isolation or loneliness, employment stability, food stability/security, housing stability/security, utility stability/security, transportation access, mental well-being, and health care access. Prevalence ratios were adjusted for age, sex, education, marital status, income, and self-rated health. Social isolation or loneliness (31.9%) and lack of social and emotional support (24.8%) were the most commonly reported measures, both of which were more prevalent among non-Hispanic (NH) American Indian or Alaska Native, NH Black or African American, NH Native Hawaiian or other Pacific Islander, NH multiracial, and Hispanic or Latino adults than among NH White adults. The majority of prevalence estimates for other adverse SDOH and HRSN were also higher across all other racial and ethnic groups (except for NH Asian) compared with NH White adults. SDOH and HRSN data can be used to monitor needed social and health resources in the U.S. population and help evaluate population-scale interventions.

INTRODUCTION: Cardiovascular disease (CVD) is the leading cause of death in the United States. Certain demographic characteristics are associated with disparities in CVD and its risk factors, which may interact with specific social determinants of health (SDOH). We examined the association of a single SDOH (ie, poverty level) with diagnosed CVD morbidity and the joint influence of poverty and hypertension on the prevalence of CVD morbidity among non-Hispanic Black, non-Hispanic White, and Hispanic people aged 30 years or older. METHODS: We used data from the National Health and Nutrition Examination Survey collected during 1999 to 2018. We assessed the prevalence of diagnosed CVD morbidity (eg, self-reported coronary heart disease, angina, myocardial infarction, or stroke) by using a Poisson family with a log link regression model. We calculated the additive interaction of poverty level with hypertension on diagnosed CVD morbidity for each race and ethnicity. RESULTS: We found excess CVD morbidity among non-Hispanic Black and Hispanic people experiencing poverty and diagnosed with hypertension compared with their non-Hispanic White counterparts. Multivariate analysis found a higher prevalence of CVD among participants of all races and ethnicities who were experiencing poverty and among non-Hispanic White people who had less than a college education. In addition, age, hypertension, poverty, smoking, and weight were significant predictors of the prevalence of CVD morbidity among all racial and ethnic groups. CONCLUSION: Changes to interventions, policies, and research may be needed to address the effect of key indicators of health disparities and specific SDOH, such as poverty level, that intersect with hypertension and contribute to excess CVD morbidity among people of some racial and ethnic groups, particularly non-Hispanic Black and Hispanic populations.

Depression is a major contributor to mortality, morbidity, disability, and economic costs in the United States (1). Examining the geographic distribution of depression at the state and county levels can help guide state- and local-level efforts to prevent, treat, and manage depression. CDC analyzed 2020 Behavioral Risk Factor Surveillance System (BRFSS) data to estimate the national, state-level, and county-level prevalence of U.S. adults aged ≥18 years self-reporting a lifetime diagnosis of depression (referred to as depression). During 2020, the age-standardized prevalence of depression among adults was 18.5%. Among states, the age-standardized prevalence of depression ranged from 12.7% to 27.5% (median = 19.9%); most of the states with the highest prevalence were in the Appalachian* and southern Mississippi Valley(†) regions. Among 3,143 counties, the model-based age-standardized prevalence of depression ranged from 10.7% to 31.9% (median = 21.8%); most of the counties with the highest prevalence were in the Appalachian region, the southern Mississippi Valley region, and Missouri, Oklahoma, and Washington. These data can help decision-makers prioritize health planning and interventions in areas with the largest gaps or inequities, which could include implementation of evidence-based interventions and practices such as those recommended by The Guide to Community Preventive Services Task Force (CPSTF) and the Substance Abuse and Mental Health Services Administration (SAMHSA).

BACKGROUND: In this study, the authors report on the geospatial distributions of periodontists and adults with severe periodontitis in the United States. METHODS: The authors used geospatial analysis to describe the distribution of periodontists and adults, periodontists vis-à-vis estimated density of adults with severe periodontitis, and their ratios to adults with severe periodontitis. The authors identified locations of 5,415 practicing periodontists through the 2014 National Provider Identifier Registry, linked them with the weighted census number of adults, and estimated the number of adults within a series of circular distance zones. RESULTS: Approximately 60% of adults 30 through 79 years lived within 5 miles of a periodontist, 73% within 10 miles, 85% within 20 miles, and 97% within 50 miles. Proximity to a periodontist varied widely. In urban areas, 95% of adults resided within 10 miles of a periodontist and 100% within 20 miles. Only 24% of adults in rural areas lived within 10 miles of a periodontist. Most periodontists (96.1%) practiced in urban areas, clustering along the eastern and western coasts and in the Midwest, 3.1% in urban clusters elsewhere, and 0.8% in rural areas. Ratios of fewer than 8,000 adults with periodontitis to 1 or more periodontists within 10 miles were clustered mostly in the Northeast, central East Coast, Florida, West Coast, Arizona, and Midwest. CONCLUSIONS: In this study, the authors identified wide variations in geographic proximity to a practicing periodontist for adults with severe periodontitis. PRACTICAL IMPLICATIONS: Dental practitioners may provide preventive care and counseling for periodontitis and referrals for specialty care. Geographic proximity to specialized periodontal care may vary widely by locality.

Chronic conditions are common, costly, and major causes of death and disability.* Addressing chronic conditions and their determinants in young adulthood can help slow disease progression and improve well-being across the life course (1); however, recent prevalence estimates examining chronic conditions in young adults overall and by subgroup have not been reported. CDC analyzed data from the Behavioral Risk Factor Surveillance System (BRFSS) to measure prevalence of 11 chronic conditions among adults aged 18-34 years overall and by selected characteristics, and to measure prevalence of health-related risk behaviors by chronic condition status. In 2019, more than one half (53.8%) of adults aged 18-34 years reported having at least one chronic condition, and nearly one quarter (22.3%) reported having more than one chronic condition. The most prevalent conditions were obesity (25.5%), depression (21.3%), and high blood pressure (10.7%). Differences in the prevalence of having a chronic condition were most noticeable between young adults with a disability (75.8%) and without a disability (48.3%) and those who were unemployed (62.3%) and students (45.8%). Adults aged 18-34 years with a chronic condition were more likely than those without one to report binge drinking, smoking, or physical inactivity. Coordinated efforts by public and private sectors might help raise awareness of chronic conditions among young adults and help improve the availability of evidence-based interventions, policies, and programs that are effective in preventing, treating, and managing chronic conditions among young adults (1).

OBJECTIVES: To examine the association between chronic obstructive pulmonary disease status and indicators of economic instability and stress to better understand the magnitude of these issues in persons with chronic obstructive pulmonary disease. METHODS: Analyzed 2017 Behavioral Risk Factor Surveillance System data from 16 states that administered the 'Social Determinants of Health' module, which included economic instability and stress measures (N = 101,461). Associations between self-reported doctor-diagnosed chronic obstructive pulmonary disease status and each measure were examined using multinomial logistic models. RESULTS: Adults with chronic obstructive pulmonary disease were more likely (p < 0.001) than adults without to report not having enough money at month end (21.0% vs. 7.9%) or just enough money (44.9% vs. 37.2%); being unable to pay mortgage, rent, or utility bills (19.2% vs. 8.8%); and that often or sometimes food did not last or could not afford to eat balanced meals (37.9% vs. 20.6%), as well as stress all or most of the time (27.3% vs. 11.6%). Associations were attenuated although remained significant after adjustments for sociodemographic and health characteristics. DISCUSSION: Financial, housing, and food insecurity and frequent stress were more prevalent in adults with chronic obstructive pulmonary disease than without. Findings highlight the importance of including strategies to address challenges related to economic instability and stress in chronic obstructive pulmonary disease management programs.

CONTEXT: HIV testing is a critically important first step in preventing and reducing HIV transmission. Community-based organizations (CBOs) are uniquely positioned to provide HIV testing and other prevention services to populations disproportionately affected by HIV infection. OBJECTIVE: The purpose of this analysis was to assess CDC-funded health department (HD) and CBO testing programs during 2012-2017, including the number of tests and HIV positivity. DESIGN: This is an analysis of National HIV Prevention Program Monitoring and Evaluation HIV testing data submitted between 2012 and 2017 to CDC. SETTING: Sixty-one CDC-funded state and local HDs in the United States, Puerto Rico, and the US Virgin Islands and between 122 and 175 CDC-funded CBOs, depending on the year. PARTICIPANTS: Persons who received HIV testing at CDC-funded CBOs and HDs. MAIN OUTCOME MEASURE: The number of HIV tests and positivity at CBOs were compared with HDs overall and to HDs in non-health care settings that, like CBOs, include HIV risk data and are in similar locations. RESULTS: CBOs accounted for 7625 (8%) new diagnoses but conducted only 3% of the almost 19 million CDC-funded HIV tests from 2012 to 2017. Newly diagnosed HIV positivity at CBOs (1.4%) was nearly 3 times the new positivity at HDs overall (0.5%) and twice that of new positivity at HDs in non-health care settings (0.7%). A higher proportion of tests at CBOs were conducted among groups at risk, and new HIV positivity was higher for most demographic and population groups than new HIV positivity at HDs in non-health care settings. CONCLUSION: These findings demonstrate the essential role CDC-funded CBOs have in reaching, testing, and diagnosing groups at high risk for acquiring HIV infection.

Hispanic or Latino* (Hispanic) persons are disproportionately affected by HIV in the United States. In 2019, Hispanic persons accounted for 18% of the U.S. population, but for 29% of new diagnoses of HIV infection (1). The Ending the HIV Epidemic in the U.S. (EHE) initiative aims to reduce new HIV infections by 90% by 2030 (2). Preexposure prophylaxis (PrEP), medication taken to prevent acquisition of HIV, is an effective strategy for preventing HIV infection.(†) To examine PrEP awareness and referral to providers among Hispanic persons, CDC analyzed 2019 National HIV Prevention Program Monitoring and Evaluation HIV testing data. Approximately one quarter (27%) of Hispanic persons tested for HIV at CDC-funded sites (n = 310,954) were aware of PrEP, and 22% of those who received a negative HIV test result and were eligible for referral (111,644) were referred to PrEP providers. PrEP awareness and referrals among Hispanic persons were lower compared with those among non-Hispanic White persons. Among Hispanic persons, significant differences were found in PrEP awareness and referrals by age, gender, race, population group, geographic region, and test setting. HIV testing programs can expand PrEP services for Hispanic persons by implementing culturally and linguistically appropriate strategies that routinize PrEP education and referral, collaborating with health care and other providers, and addressing social and structural barriers.

Approximately 60 million persons in the United States live in rural counties, representing almost one fifth (19.3%) of the population.* In September 2020, COVID-19 incidence (cases per 100,000 population) in rural counties surpassed that in urban counties (1). Rural communities often have a higher proportion of residents who lack health insurance, live with comorbidities or disabilities, are aged ≥65 years, and have limited access to health care facilities with intensive care capabilities, which places these residents at increased risk for COVID-19-associated morbidity and mortality (2,3). To better understand COVID-19 vaccination disparities across the urban-rural continuum, CDC analyzed county-level vaccine administration data among adults aged ≥18 years who received their first dose of either the Pfizer-BioNTech or Moderna COVID-19 vaccine, or a single dose of the Janssen COVID-19 vaccine (Johnson & Johnson) during December 14, 2020-April 10, 2021 in 50 U.S. jurisdictions (49 states and the District of Columbia [DC]). Adult COVID-19 vaccination coverage was lower in rural counties (38.9%) than in urban counties (45.7%) overall and among adults aged 18-64 years (29.1% rural, 37.7% urban), those aged ≥65 years (67.6% rural, 76.1% urban), women (41.7% rural, 48.4% urban), and men (35.3% rural, 41.9% urban). Vaccination coverage varied among jurisdictions: 36 jurisdictions had higher coverage in urban counties, five had higher coverage in rural counties, and five had similar coverage (i.e., within 1%) in urban and rural counties; in four jurisdictions with no rural counties, the urban-rural comparison could not be assessed. A larger proportion of persons in the most rural counties (14.6%) traveled for vaccination to nonadjacent counties (i.e., farther from their county of residence) compared with persons in the most urban counties (10.3%). As availability of COVID-19 vaccines expands, public health practitioners should continue collaborating with health care providers, pharmacies, employers, faith leaders, and other community partners to identify and address barriers to COVID-19 vaccination in rural areas (2).

Purpose of Review: This review provides an overview of the objectives, activities, and accomplishments of the CDC-AAP collaboration on public health aspects of periodontitis focusing mostly on surveillance. Dr. Robert Genco was co-chair of this effort. Recent Findings: This initiative developed new standard periodontitis case definitions for surveillance and implemented for the first time a full-mouth periodontal examination protocol for NHANES 2009–2014. Measurements from this survey resulted in a significantly greater estimate of the national prevalence of periodontitis in US adults and improved our understanding of population risk factors associations with periodontitis. Notably, this initiative also developed, and validated by field-testing, a battery of eight questions for multivariable modeling of self-report measures for predicting periodontitis in populations. Summary: This initiative resulted in significant improvements of surveillance of periodontitis and produced unique findings with important implications for advancing our understanding of population aspects of periodontitis in US adults at the national, state, and local levels. At long last, the world finally had a set of periodontitis case definitions that applied globally would enable valid comparisons between populations in different geographic settings and at different times.

Behavioral interventions have been a crucial tool for the prevention of HIV transmission since early in the epidemic. The Centers for Disease Control and Prevention (CDC) has provided funding for evidence-based behavioral interventions (EBIs) at health departments and community-based organizations (CBOs) since 2004. From 2006 to 2015, CDC funded 25 CBOs to evaluate one or more of seven EBIs designed to prevent HIV through the Community-based Organization Behavioral Outcomes Project (CBOP) as implemented outside of a research setting. For each EBI, CBOP showed that most HIV risk behaviors improved after the intervention, and improvements were similar to those observed in research studies. Our findings show that behavioral interventions can be successfully implemented in real-world settings. Although the focus of HIV prevention has largely shifted toward biomedical interventions in recent years, successful implementation often depends on behavioral components. Lessons from CBOP can inform future efforts to develop and implement behavioral interventions for HIV and other areas of public health.

The most important development in the epidemiology of periodontitis in the USA during the last decade is the result of improvements in survey methodologies and statistical modeling of periodontitis in adults. Most of these advancements have occurred as the direct outcome of work by the joint initiative known as the Periodontal Disease Surveillance Project by the Centers for Disease Control and Prevention and the American Academy of Periodontology that was established in 2006. This report summarizes some of the key findings of this important initiative and its impact on our knowledge of the epidemiology of periodontitis in US adults. This initiative first suggested new periodontitis case definitions for surveillance in 2007 and revised them slightly in 2012. This classification is now regarded as the global standard for periodontitis surveillance and is used worldwide. First, application of such a standard in reporting finally enables results from different researchers in different countries to be meaningfully compared. Second, this initiative tackled the concern that prior national surveys, which used partial-mouth periodontal examination protocols, grossly underestimated the prevalence of periodontitis of potentially more than 50%. Consequently, because previous national surveys significantly underestimated the true prevalence of periodontitis, it is not possible to extrapolate any trend in periodontitis prevalence in the USA over time. Any difference calculated may not represent any actual change in periodontitis prevalence, but rather is a consequence of using different periodontal examination protocols. Finally, the initiative addressed the gap in the need for state and local data on periodontitis prevalence. Through the direct efforts of the Centers for Disease Control and Prevention and the American Academy of Periodontology initiative, full-mouth periodontal probing at six sites around all nonthird molar teeth was included in the 6 years of National Health and Nutrition Examination Surveys from 2009-2014, yielding complete data for 10 683 dentate community-dwelling US adults aged 30 to 79 years. Applying the 2012 periodontitis case definitions to the 2009-2014 National Health and Nutrition Examination Surveys data, the periodontitis prevalence turned out to be much greater than previously estimated, namely affecting 42.2% of the population with 7.8% of people experiencing severe periodontitis. It was also discovered that only the moderate type of periodontitis is driving the increase in periodontitis prevalence with age, not the mild or the severe types whose prevalence do not increase consistently with age, but remain ~ 10%-15% in all age groups of 40 years and older. The greatest risk for having periodontitis of any type was seen in older people, in males, in minority race/ethnic groups, in poorer and less educated groups, and especially in cigarette smokers. The Centers for Disease Control and Prevention and the American Academy of Periodontology initiative reported, for the first time, the periodontitis prevalence estimated at both local and state levels, in addition to the national level. Also, this initiative developed and validated in field studies a set of eight items for self-reported periodontitis for use in direct survey estimates of periodontitis prevalence in existing state-based surveys. These items were also included in the 2009-2014 National Health and Nutrition Examination Surveys for validation against clinically determined cases of periodontitis. Another novel result of this initiative is that, for the first time, the geographic distribution of practicing periodontists in relation to the geographic distribution of people with severe periodontitis is illustrated. In summary, the precise periodontitis prevalence and distribution among subgroups in the dentate US noninstitutionalized population aged 30-79 years is better understood because of application of valid periodontitis case definitions to full-mouth periodontal examination, in combination with reliable information on demographic and health-related measures. We now can monitor the trend of periodontitis prevalence over time as well as guide public health preventive and intervention initiatives for the betterment of the health of the adult US population.

Reducing HIV among men who have sex with men (MSM) is a national goal, and early diagnosis, timely linkage to HIV medical care, and ongoing care and treatment are critical for improving health outcomes for MSM with HIV and preventing transmission to others. We assessed demographic, social, and economic factors associated with HIV antiretroviral treatment among HIV-infected MSM. Data are from the National HIV Behavioral Surveillance (NHBS) collected in 2014 among MSM. We estimated prevalence ratios and 95% confidence intervals using average marginal predictions from logistic regression. Overall, 89% of HIV-positive MSM reported currently taking antiretroviral therapy (ART). After controlling for other variables, we found that higher perceived community stigma and not having health insurance were significant risk factors for not taking ART. We also found that high socioeconomic status (SES) was associated with taking ART. Race/ethnicity was not significantly associated with taking ART in either the unadjusted or adjusted analyses. Findings suggest that to increase ART use for MSM with HIV, we need to move beyond individual-level approaches and move towards the development, dissemination, and evaluation of structural and policy interventions that respond to these important social and economic factors.

In contrast to intervention studies that assess psychosocial factors only as mediators or moderators of HIV risk, the present study assessed the effects of an Mpowerment-based community-level intervention on psychosocial determinants (e.g., depressive symptoms, sexual stigma) of HIV risk behavior among young black MSM. Approximately 330 respondents were surveyed annually for 4 years in each of two sites. General linear models examined change across time between the intervention and comparison communities, and participation effects in the intervention site. Social diffusion (spreading information within networks) of safer sex messages (p < 0.01) and comfort with being gay (p < 0.05) increased with time in intervention versus control. Cross-sectionally, intervention participants responded more favorably (p < 0.05) on social diffusion and depressive symptoms, but less favorably (p < 0.01) on sex in difficult situations and attitudes toward condom use. Findings suggest a need to address broader health issues of MSM as well as sexual risk.

Water, sanitation, and hygiene (WASH) services in healthcare facilities are essential to ensure quality health care and to facilitate infection, prevention, and control practices. They are critical to responding to outbreaks and preventing healthcare-associated infections and, therefore, critical to global health security. Many healthcare facilities in low- and middle-income settings have limited WASH services. One tool to address this issue is the World Health Organization (WHO) and United Nations Children's Fund (UNICEF) Water and Sanitation for Health Facility Improvement Tool, or "WASH FIT." WASH FIT is a continuous improvement tool based on key WHO environmental health and infection, prevention, and control standards. While using WASH FIT, internal teams regularly perform self-assessments at their facilities, using up to 65 WASH indicators to develop and implement an improvement plan. The Ministry of Health and Social Protection (MSPS) in Togo, with support from WHO and the US Centers for Disease Control and Prevention (CDC), piloted this tool in 3 healthcare facilities. The pilot included facility assessments at 3 time points and in-depth interviews and document review 7 months after initiating WASH FIT. Facilities made improvements without significant external financial or material support. On average, pilot facilities improved from 18% of total indicators meeting standards at baseline to 44% after 7 months. Examples included improved drinking water supply, medical waste segregation, and increased soap at handwashing stations. Participants reported improvements in staff and patient satisfaction, hand hygiene, and occupational safety. Findings suggest that WASH FIT, coupled with training and supervision, may help facilities improve WASH services and practices, thus contributing to global health security. Based on these findings, the Togolese MSPS plans to scale up nationwide. Les services d'eau, d'assainissement, et d'hygiene (WASH) dans les etablissements de sante sont essentiels pour assurer des soins de qualite et faciliter les pratiques de prevention et controle des infections. Ils sont essentiels pour repondre aux epidemies et prevenir les infections associees aux soins de sante, et donc a la securite sanitaire mondiale. De nombreux pays a revenu faible ou intermediaire ont des services WASH limites dans les etablissements de soins. Un outil recemment publie pour remedier cette situation est l'outil WASH FIT [Water and Sanitation for Health Facility Improvement Tool] de l'Organisation mondiale de la Sante (OMS) et le Fonds des Nations Unies (UNICEF) pour l'amelioration de l'eau et l'assainissement dans les formations sanitaires. WASH FIT est un outil d'amelioration continue base sur les normes de l'OMS en matiere de sante environnementale et de prevention et controle des infections. Lors de l'utilisation de WASH FIT, les equipes internes effectuent regulierement des auto-evaluations dans leurs installations en utilisant jusqu'a 65 indicateurs pour elaborer et mettre en oeuvre leur plan d'amelioration. Le ministere de la Sante et de la Protection Sociale (MSPS) du Togo, avec le soutien de l'OMS et les Centres pour le controle et la prevention des maladies (CDC), a fait un pilotage de cet outil dans 3 centres de sante. Ce pilotage comprenait 3 evaluations dans chaque formation sanitaire, des interviews approfondies, et une revue documentaire, 7 mois apres l'initiation du WASH FIT. Les formations sanitaires ont realise des progres, sans aide financiere ou materielle exterieure. En moyenne, les formations sanitaires sont passees de 18% des indicateurs atteignant les standards au depart, a 44% apres 7 mois. Les exemples incluent l'approvisionnement en eau potable, le tri des dechets medicaux, et le savon aux points de lavage des mains. Les participants ont signale des ameliorations dans la satisfaction du personnel et des patients, l'hygiene des mains, et la securite au travail. Les resultats indiquent que WASH FIT, associe a la formation et a la supervision, pourrait etre un outil pour aider les formations sanitaires a ameliorer les services et pratiques WASH, contribuant ainsi a la securite sanitaire mondiale. Sur la base de ces resultats, le MSPS prevoit une extension a l'echelle nationale.

BACKGROUND: This report presents weighted average estimates of the prevalence of periodontitis in the adult US population during the 6 years 2009-2014 and highlights key findings of a national periodontitis surveillance project. METHODS: Estimates were derived for dentate adults 30 years or older from the civilian noninstitutionalized population whose periodontitis status was assessed by means of a full-mouth periodontal examination at 6 sites per tooth on all non-third molar teeth. Results are reported according to a standard format by applying the Centers for Disease Control and Prevention/American Academy of Periodontology periodontitis case definitions for surveillance, as well as various thresholds of clinical attachment loss and periodontal probing depth. RESULTS: An estimated 42% of dentate US adults 30 years or older had periodontitis, with 7.8% having severe periodontitis. Overall, 3.3% of all periodontally probed sites (9.1% of all teeth) had periodontal probing depth of 4 millimeters or greater, and 19.0% of sites (37.1% of teeth) had clinical attachment loss of 3 mm or greater. Severe periodontitis was most prevalent among adults 65 years or older, Mexican Americans, non-Hispanic blacks, and smokers. CONCLUSIONS: This nationally representative study shows that periodontitis is a highly prevalent oral disease among US adults. PRACTICAL IMPLICATIONS: Dental practitioners should be aware of the high prevalence of periodontitis in US adults and may provide preventive care and counselling for periodontitis. General dentists who encounter patients with periodontitis may refer these patients to see a periodontist for specialty care.

Diagnoses of human immunodeficiency virus (HIV) infection among women declined 17% during 2011-2015, and a total of 7,498 women received a diagnosis of HIV infection in 2015 (1). Although black or African American (black) women accounted for only 12% of the U.S. female population, 60% of women with newly diagnosed HIV infection were black (1,2). By the end of 2014, an estimated 255,900 women were living with HIV infection (3), including approximately 12% who did not know they were infected; in addition, approximately 45% of women who had received a diagnosis had not achieved viral suppression (3). HIV testing is an important public health strategy for identifying women with HIV infection and linking them to HIV medical care. Analysis of CDC-funded program data submitted by 61 health departments in 2015 indicated that among 4,749 women tested who received a diagnosis of HIV infection, 2,951 (62%) had received a diagnosis in the past (previous diagnosis), and 1,798 (38%) were receiving a diagnosis for the first time (new diagnosis). Of those who had received a previous diagnosis, 87% were not in HIV medical care at the time of the current test. Testing and identifying women who are living with HIV infection but who are not in care (regardless of when they received their first diagnosis) and rapidly linking them to care so they can receive antiretroviral therapy and become virally suppressed are essential for reducing HIV infection among all women.

BACKGROUND: Although the overall life expectancy at birth has increased for both blacks and whites and the gap between these populations has narrowed, disparities in life expectancy and the leading causes of death for blacks compared with whites in the United States remain substantial. Understanding how factors that influence these disparities vary across the life span might enhance the targeting of appropriate interventions. METHODS: Trends during 1999-2015 in mortality rates for the leading causes of death were examined by black and white race and age group. Multiple 2014 and 2015 national data sources were analyzed to compare blacks with whites in selected age groups by sociodemographic characteristics, self-reported health behaviors, health-related quality of life indicators, use of health services, and chronic conditions. RESULTS: During 1999-2015, age-adjusted death rates decreased significantly in both populations, with rates declining more sharply among blacks for most leading causes of death. Thus, the disparity gap in all-cause mortality rates narrowed from 33% in 1999 to 16% in 2015. However, during 2015, blacks still had higher death rates than whites for all-cause mortality in all groups aged <65 years. Compared with whites, blacks in age groups <65 years had higher levels of some self-reported risk factors and chronic diseases and mortality from cardiovascular diseases and cancer, diseases that are most common among persons aged ≥65 years. CONCLUSIONS AND IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: To continue to reduce the gap in health disparities, these findings suggest an ongoing need for universal and targeted interventions that address the leading causes of deaths among blacks (especially cardiovascular disease and cancer and their risk factors) across the life span and create equal opportunities for health.

HIV affects African American gay and bisexual men (AAGBM) more disproportionately than any other group in the USA. The Black Church, which has been a historic mainstay for African American empowerment and well-being, has the potential to be a public health partner for HIV prevention with AAGBM. Public health partnerships with the Black Church can strengthen HIV prevention efforts with AAGBM by [1] adapting church-based prevention strategies developed for other African American subgroups [2], providing prevention and referral services [3], considering how scripture supports prevention efforts, and [4] emphasizing the tenets of liberation theology. Public health should consider how thoughtful engagement, research, and interventions can support these approaches. Developing partnerships with the Black Church and African American clergy can promote effective HIV prevention efforts for AAGBM.

BACKGROUND: Spirituality and religiosity may serve as both a resource and a barrier to HIV prevention with young black men who have sex with men (YBMSM). We examined indices of spirituality/religiosity as correlates of binge drinking, stimulant use, and recent HIV testing in a sample of YBMSM. METHODS: From 2011-2013, annual venue-based surveys of sexually active YBMSM ages 18-29 were conducted in Dallas and Houston, Texas. Binge drinking and stimulant use were assessed in the past two months. Participants recently tested for HIV (i.e., within the past six months) were compared to those without recent HIV testing (i.e., never tested or tested more than six months ago). RESULTS: Among the 1565 HIV-negative or HIV-unknown YBMSM enrolled, more engagement in spiritual and religious activities was associated with greater odds of reporting stimulant use (Adjusted Odds Ratio [AOR]=1.20; 95% CI=1.04-1.40) while higher spiritual coping was associated with lower odds of reporting stimulant use (AOR=0.66; 95% CI=0.56-0.78). Binge drinking was independently associated with 29% lower odds of recent HIV testing (AOR=0.71; 95% CI=0.55-0.92), but lower odds of binge drinking did not mediate the association of engagement in spiritual and religious activities with 27% greater odds of recent HIV testing (AOR=1.27; 95% CI=1.11-1.46). CONCLUSIONS: Among YBMSM, culturally tailored approaches addressing spirituality/religiosity could support prevention of stimulant use and increase HIV testing. In particular, expanded efforts are needed to promote HIV testing in binge drinkers.

PROBLEM/CONDITION: As a result of the 2010 Patient Protection and Affordable Care Act, millions of U.S. adults attained health insurance coverage. However, millions of adults remain uninsured or underinsured. Compared with adults without barriers to health care, adults who lack health insurance coverage, have coverage gaps, or skip or delay care because of limited personal finances might face increased risk for poor physical and mental health and premature mortality. PERIOD COVERED: 2014. DESCRIPTION OF SYSTEM: The Behavioral Risk Factor Surveillance System (BRFSS) is an ongoing, state-based, landline- and cellular-telephone survey of noninstitutionalized adults aged ≥18 years residing in the United States. Data are collected from states, the District of Columbia, and participating U.S. territories on health risk behaviors, chronic health conditions, health care access, and use of clinical preventive services (CPS). An optional Health Care Access module was included in the 2014 BRFSS. This report summarizes 2014 BRFSS data from all 50 states and the District of Columbia on health care access and use of selected CPS recommended by the U.S. Preventive Services Task Force or the Advisory Committee on Immunization Practices among working-aged adults (aged 18-64 years), by state, state Medicaid expansion status, expanded geographic region, and federal poverty level (FPL). This report also provides analysis of primary type of health insurance coverage at the time of interview, continuity of health insurance coverage during the preceding 12 months, and other health care access measures (i.e., unmet health care need because of cost, unmet prescription need because of cost, medical debt [medical bills being paid off over time], number of health care visits during the preceding year, and satisfaction with received health care) from 43 states that included questions from the optional BRFSS Health Care Access module. RESULTS: In 2014, health insurance coverage and other health care access measures varied substantially by state, state Medicaid expansion status, expanded geographic region (i.e., states categorized geographically into nine regions), and FPL category. The following proportions refer to the range of estimated prevalence for health insurance and other health care access measures by examined geographical unit (unless otherwise specified), as reported by respondents. Among adults with health insurance coverage, the range was 70.8%-94.5% for states, 78.8%-94.5% for Medicaid expansion states, 70.8%-89.1% for nonexpansion states, 73.3%-91.0% for expanded geographic regions, and 64.2%-95.8% for FPL categories. Among adults who had a usual source of health care, the range was 57.2%-86.6% for states, 57.2%-86.6% for Medicaid expansion states, 61.8%-83.9% for nonexpansion states, 64.4%-83.6% for expanded geographic regions, and 61.0%-81.6% for FPL categories. Among adults who received a routine checkup, the range was 52.1%-75.5% for states, 56.0%-75.5% for Medicaid expansion states, 52.1%-71.1% for nonexpansion states, 56.8%-70.2% for expanded geographic regions, and 59.9%-69.2% for FPL categories. Among adults who had unmet health care need because of cost, the range was 8.0%-23.1% for states, 8.0%-21.9% for Medicaid expansion states, 11.9%-23.1% for nonexpansion states, 11.6%-20.3% for expanded geographic regions, and 5.3%-32.9% for FPL categories. Estimated prevalence of cancer screenings, influenza vaccination, and having ever been tested for human immunodeficiency virus also varied by state, state Medicaid expansion status, expanded geographic region, and FPL category. The prevalence of insurance coverage varied by approximately 25 percentage points among racial/ethnic groups (range: 63.9% among Hispanics to 88.4% among non-Hispanic Asians) and by approximately 32 percentage points by FPL category (range: 64.2% among adults with household income <100% of FPL to 95.8% among adults with household income >400% of FPL). The prevalence of unmet health care need because of cost varied by nearly 14 percentage points among racial/ethnic groups (range: 11.3% among non-Hispanic Asians to 25.0% among Hispanics), by approximately 17 percentage points among adults with and without disabilities (30.8% versus 13.7%), and by approximately 28 percentage points by FPL category (range: 5.3% among adults with household income >400% of FPL to 32.9% among adults with household income <100% of FPL). Among the 43 states that included questions from the optional module, a majority of adults reported private health insurance coverage (63.4%), followed by public health plan coverage (19.4%) and no primary source of insurance (17.1%). Financial barriers to health care (unmet health care need because of cost, unmet prescribed medication need because of cost, and medical bills being paid off over time [medical debt]) were typically lower among adults in Medicaid expansion states than those in nonexpansion states regardless of source of insurance. Approximately 75.6% of adults reported being continuously insured during the preceding 12 months, 12.9% reported a gap in coverage, and 11.5% reported being uninsured during the preceding 12 months. The largest proportion of adults reported ≥3 visits to a health care professional during the preceding 12 months (47.3%), followed by 1-2 visits (37.1%), and no health care visits (15.6%). Adults in expansion and nonexpansion states reported similar levels of satisfaction with received health care by primary source of health insurance coverage and by continuity of health insurance coverage during the preceding 12 months. INTERPRETATION: This report presents for the first time estimates of population-based health care access and use of CPS among adults aged 18-64 years. The findings in this report indicate substantial variations in health insurance coverage; other health care access measures; and use of CPS by state, state Medicaid expansion status, expanded geographic region, and FPL category. In 2014, health insurance coverage, having a usual source of care, having a routine checkup, and not experiencing unmet health care need because of cost were higher among adults living below the poverty level (i.e., household income <100% of FPL) in states that expanded Medicaid than in states that did not. Similarly, estimates of breast and cervical cancer screening and influenza vaccination were higher among adults living below the poverty level in states that expanded Medicaid than in states that did not. These disparities might be due to larger differences to begin with, decreased disparities in Medicaid expansion states versus nonexpansion states, or increased disparities in nonexpansion states. PUBLIC HEALTH ACTION: BRFSS data from 2014 can be used as a baseline by which to assess and monitor changes that might occur after 2014 resulting from programs and policies designed to increase access to health care, reduce health disparities, and improve the health of the adult population. Post-2014 changes in health care access, such as source of health insurance coverage, attainment and continuity of coverage, financial barriers, preventive care services, and health outcomes, can be monitored using these baseline estimates.

Young men who have sex with men (MSM) of color are at increased risk for HIV infection. Mpowerment (MP) is an intervention designed to reduce risky sexual behavior and increase HIV testing among young MSM ages 18-29. From 2009 to 2012, three community-based organizations with support from the U.S. Centers for Disease Control and Prevention evaluated MP among N = 298 participants. Following a repeated measures design, data from 3- and 6-month follow-ups were compared to baseline. HIV testing and self-efficacy for safer sex increased at both follow-up time points; self-acceptance as an MSM was higher at follow-up 2. Condomless anal/vaginal sex was lower at follow-up 1 only. Frequency of exchange of safer sex messages among gay/bisexual/transgender friends was lower at follow-up 1, but similar to baseline at follow-up 2. Exposure to MP was associated with improved perceived positive social norms about safer sex and safer sex messages among gay/bisexual/transgender friends.

PROBLEM/CONDITION: Persons living in rural areas are recognized as a health disparity population because the prevalence of disease and rate of premature death are higher than for the overall population of the United States. Surveillance data about health-related behaviors are rarely reported by urban-rural status, which makes comparisons difficult among persons living in metropolitan and nonmetropolitan counties. REPORTING PERIOD: 2013. DESCRIPTION OF SYSTEM: The Behavioral Risk Factor Surveillance System (BRFSS) is an ongoing, state-based, random-digit-dialed landline- and cellular-telephone survey of noninstitutionalized adults aged ≥18 years residing in the United States. BRFSS collects data on health-risk behaviors, chronic diseases and conditions, access to health care, and use of preventive health services related to the leading causes of death and disability. BRFSS data were analyzed for 398,208 adults aged ≥18 years to estimate the prevalence of five self-reported health-related behaviors (sufficient sleep, current nonsmoking, nondrinking or moderate drinking, maintaining normal body weight, and meeting aerobic leisure time physical activity recommendations) by urban-rural status. For this report, rural is defined as the noncore counties described in the 2013 National Center for Health Statistics Urban-Rural Classification Scheme for Counties. RESULTS: Approximately one third of U.S. adults practice at least four of these five behaviors. Compared with adults living in the four types of metropolitan counties (large central metropolitan, large fringe metropolitan, medium metropolitan, and small metropolitan), adults living in the two types of nonmetropolitan counties (micropolitan and noncore) did not differ in the prevalence of sufficient sleep; had higher prevalence of nondrinking or moderate drinking; and had lower prevalence of current nonsmoking, maintaining normal body weight, and meeting aerobic leisure time physical activity recommendations. The overall age-adjusted prevalence of reporting at least four of the five health-related behaviors was 30.4%. The prevalence among the estimated 13.3 million adults living in noncore counties was lower (27.0%) than among those in micropolitan counties (28.8%), small metropolitan counties (29.5%), medium metropolitan counties (30.5%), large fringe metropolitan counties (30.2%), and large metropolitan centers (31.7%). INTERPRETATION: This is the first report of the prevalence of these five health-related behaviors for the six urban-rural categories. Nonmetropolitan counties have lower prevalence of three and clustering of at least four health-related behaviors that are associated with the leading chronic disease causes of death. Prevalence of sufficient sleep was consistently low and did not differ by urban-rural status. PUBLIC HEALTH ACTION: Chronic disease prevention efforts focus on improving the communities, schools, worksites, and health systems in which persons live, learn, work, and play. Evidence-based strategies to improve health-related behaviors in the population of the United States can be used to reach the Healthy People 2020 objectives for these five self-reported health-related behaviors (sufficient sleep, current nonsmoking, nondrinking or moderate drinking, maintaining normal body weight, and meeting aerobic leisure time physical activity recommendations). These findings suggest an ongoing need to increase public awareness and public education, particularly in rural counties where prevalence of these health-related behaviors is lowest.

The older adult population is growing rapidly in the USA and it is expected that by 2040 the number of adults ≥ 65 years of age will have increased by about 50%. With the growth of this subpopulation, oral health status, and periodontal status in particular, becomes important in the quest to maintain an adequate quality of life. Poor oral health can have a major impact, leading to tooth loss, pain and discomfort, and may prevent older adults from chewing food properly, often leading to poor nutrition. Periodontitis is monitored in the USA at the national level as part of the Healthy People 2020 initiative. In this report, we provide estimates of the overall burden of periodontitis among adults ≥ 65 years of age and after stratification according to sociodemographic factors, modifiable risk factors (such as smoking status), the presence of other systemic conditions (such as diabetes) and access to dental care. We also estimated the burden of periodontitis within this age group at the state and local levels. Data from the National Health and Nutrition Examination Survey 2009/2010 and 2011/2012 cycles were analyzed. Periodontal measures from both survey cycles were based on a full-mouth periodontal examination. Nineteen per cent of adults in this subpopulation were edentulous. The mean age was 73 years, 7% were current smokers, 8% lived below the 100% Federal Poverty Level and < 40% had seen a dentist in the past year. Almost two-thirds (62.3%) had one or more sites with ≥ 5 mm of clinical attachment loss and almost half had at least one site with probing pocket depth of ≥ 4 mm. We estimated the lowest prevalence of periodontitis in Utah (62.3%) and New Hampshire (62.6%) and the highest in New Mexico, Hawaii, and the District of Columbia each with a prevalence of higher than 70%. Overall, periodontitis is highly prevalent in this subpopulation, with two-thirds of dentate older adults affected at any geographic level. These findings provide an opportunity to determine how the overall health-care management of older adults should consider the improvement of their oral health conditions. Many older adults do not have dental insurance and are also likely to have some chronic conditions, which can adversely affect their oral health.

The primary romantic relationship plays a fundamental role in health maintenance, but little is known about its role in HIV care engagement among young Black men who have sex with men (MSM) living with HIV. We examined how HIV care engagement outcomes (i.e., having a primary healthcare provider, receiving HIV treatment, taking antiretroviral medication, and medication adherence) vary by partnership status (single vs. concordant-positive vs. discordant) in a sample of young Black MSM living with HIV. Results showed mixed findings. Partnership status was significantly associated with HIV care engagement, even after adjusting for individual, social, and structural factors. While partnered men were consistently more likely than their single counterparts to have a regular healthcare provider, to receive recent treatment, and to have ever taken antiretroviral medication, they were less likely to report currently receiving antiretroviral therapy. Moreover, men with a discordant partner reported better adherence compared to men with a concordant or no partner. The association between partnership status and HIV care engagement outcomes was not consistent across the stages of the HIV Care Continuum, highlighting the complexity in how and why young Black men living with HIV engage in HIV healthcare. Given the social context of HIV disease management, more research is needed to explicate underlying mechanisms involved in HIV care and treatment that differ by relational factors for young Black MSM living with HIV.

Public health researchers have used a class of statistical methods to calculate prevalence estimates for small geographic areas with few direct observations. Many researchers have used Behavioral Risk Factor Surveillance System (BRFSS) data as a basis for their models. The aims of this study were to 1) describe a new BRFSS small area estimation (SAE) method and 2) investigate the internal and external validity of the BRFSS SAEs it produced. The BRFSS SAE method uses 4 data sets (the BRFSS, the American Community Survey Public Use Microdata Sample, Nielsen Claritas population totals, and the Missouri Census Geographic Equivalency File) to build a single weighted data set. Our findings indicate that internal and external validity tests were successful across many estimates. The BRFSS SAE method is one of several methods that can be used to produce reliable prevalence estimates in small geographic areas.

OBJECTIVE: To determine population-average risk profiles for severe and non-severe periodontitis in US adults (30 years and older) using optimal surveillance measures and standard case definitions. METHODS: We used data from the 2009-2012 National Health and Nutrition Examination Survey (NHANES), which for the first time used the "gold standard" full-mouth periodontitis surveillance protocol to classify severity of periodontitis following the suggested CDC/AAP case definitions. The probabilities of periodontitis by socio-demographics, behavioral factors, and co-morbid conditions, were assessed using prevalence ratios (PR) estimated by the predicted marginal probability from multivariable generalized logistic regression models. The analyses were further stratified by gender for each classification of periodontitis. RESULTS: The likelihood of periodontitis increased with age for overall and non-severe relative to non-periodontitis. Compared to non-Hispanic whites, periodontitis was more likely among Hispanics (aPR=1.38; 1.26-1.52) and non-Hispanic blacks (aPR=1.35; 1.22-1.50), whereas severe periodontitis was most likely among non-Hispanic blacks (aPR=1.82; 1.44-2.31). There was at least a 50% greater likelihood of periodontitis among current smokers compared to non-smokers. Among males, the likelihood of periodontitis among adults 65 years and older was greater (aPR=2.07; 1.76 - 2.43) than adults 30-44 years old. This probability was even greater among women (aPR=3.15; 95% CI 2.63 - 3.77). The likelihood of periodontitis was higher among current smokers relative to non-smokers regardless of gender and periodontitis classification. Periodontitis was more likely among men with un-controlled diabetes compared to persons with no diabetes only. CONCLUSIONS: An assessment of risk profiles for periodontitis in US adults based on gold standard periodontal measures show important differences by severity of disease and gender. Cigarette smoking, specifically among current smokers remains an important modifiable risk for all levels of periodontitis severity. The higher likelihood of periodontitis in older adults and in males with uncontrolled diabetes is noteworthy. These findings could improve the identification of target populations for effective public health interventions to improve periodontal health of US adults.

The objective of the study was to estimate the prevalence of periodontitis at state and local levels across the United States by using a novel, small area estimation (SAE) method. Extended multilevel regression and poststratification analyses were used to estimate the prevalence of periodontitis among adults aged 30 to 79 y at state, county, congressional district, and census tract levels by using periodontal data from the National Health and Nutrition Examination Survey (NHANES) 2009-2012, population counts from the 2010 US census, and smoking status estimates from the Behavioral Risk Factor Surveillance System in 2012. The SAE method used age, race, gender, smoking, and poverty variables to estimate the prevalence of periodontitis as defined by the Centers for Disease Control and Prevention/American Academy of Periodontology case definitions at the census block levels and aggregated to larger administrative and geographic areas of interest. Model-based SAEs were validated against national estimates directly from NHANES 2009-2012. Estimated prevalence of periodontitis ranged from 37.7% in Utah to 52.8% in New Mexico among the states (mean, 45.1%; median, 44.9%) and from 33.7% to 68% among counties (mean, 46.6%; median, 45.9%). Severe periodontitis ranged from 7.27% in New Hampshire to 10.26% in Louisiana among the states (mean, 8.9%; median, 8.8%) and from 5.2% to 17.9% among counties (mean, 9.2%; median, 8.8%). Overall, the predicted prevalence of periodontitis was highest for southeastern and southwestern states and for geographic areas in the Southeast along the Mississippi Delta, as well as along the US and Mexico border. Aggregated model-based SAEs were consistent with national prevalence estimates from NHANES 2009-2012. This study is the first-ever estimation of periodontitis prevalence at state and local levels in the United States, and this modeling approach complements public health surveillance efforts to identify areas with a high burden of periodontitis.