CONTEXT: Many people living in the 5 inhabited US territories experience high rates of natural hazard exposure and social vulnerability to disaster impacts. Public health workforce development and evidence-based, culturally competent approaches to disaster preparedness, response, and recovery are needed in these regions. PROGRAM: In 2020, the Natural Hazards Center established the Public Health Disaster Research Award Program with funding from the Centers for Disease Control and Prevention. The program's goal is to advance public health disaster research and practice by funding, training, mentoring, and connecting researchers, students, and practitioners in historically underserved areas with high natural hazard risk. Between 2020 and 2022, 26 research teams received up to $50 000 each to investigate public health disasters in 1 or more US territories. The program also supported awardees by providing individual consultations, online trainings, feedback on report drafts, and a virtual group workshop on the public health implications of research. Awardees authored final reports and presented at a public webinar. EVALUATION: In 2023, the Natural Hazards Center developed and distributed an online survey to all principal investigators. The survey evaluated how awardees advanced knowledge about public health disasters in the US territories; what skills, resources, and connections they acquired; and how they translated their research into public health applications and otherwise disseminated their findings. DISCUSSION: Our evaluation showed that the program is advancing knowledge of understudied hazard contexts and socially vulnerable populations in the US territories and supports awardees in sharing their findings with academics, policymakers, and practitioners. Moreover, it expanded the public health disaster workforce by bringing professionals from a diverse range of disciplines and institutions into the field, and by investing in students, early career scholars, and investigators based in US territories. Researchers are working with local partners to apply their findings to practice.

Of 319 children with invasive candidiasis, 67 (21%) transitioned from intravenous to enteral antifungal therapy. Eight (12%) transitioned back to intravenous antifungal therapy, one due to perceived treatment failure defined by clinical progression or worsening. Global treatment response at study completion was success in 66 participants transitioned to enteral therapy.

OBJECTIVE: Limited guidance exists for public health agencies to use existing data sources to conduct monitoring and surveillance of behavioral health (BH) in the context of public health emergencies (PHEs). METHODS: We conducted a literature review and environmental scan to identify existing data sources, indicators, and analytic methods that could be used for BH surveillance in PHEs. We conducted exploratory analyses and interviews with public health agencies to examine the utility of a subset of these data sources for BH surveillance in the PHE context. RESULTS: Our comprehensive search revealed no existing dedicated surveillance systems to monitor BH in the context of PHEs. However, there are a few data sources designed for other purposes that public health agencies could use to conduct BH surveillance at the substate level. Some of these sources contain lagging indicators of BH impacts of PHEs. Most do not consistently collect the sociodemographic data needed to explore PHEs' inequitable impacts on subpopulations, including at the intersection of race, gender, and age. CONCLUSIONS: Public health agencies have opportunities to strengthen BH surveillance in PHEs and build partnerships to act based on timely, geographically granular existing data.

BACKGROUND: Adjunctive diagnostic studies (aDS) are recommended to identify occult dissemination in patients with candidemia. Patterns of evaluation with aDS across pediatric settings are unknown. METHODS: Candidemia episodes were included in a secondary analysis of a multicenter comparative effectiveness study that prospectively enrolled participants age 120 days -17 years with invasive candidiasis (predominantly candidemia) from 2014-2017. Ophthalmologic examination, abdominal imaging, echocardiogram, neuroimaging, and lumbar puncture were performed per clinician discretion. aDS performance and positive results were determined per episode, within 30 days from candidemia onset. Associations of aDS performance with episode characteristics were evaluated via mixed effects logistic regression. RESULTS: In 662 pediatric candidemia episodes, 490 (74%) underwent abdominal imaging, 450 (68%) ophthalmologic examination, 426 (64%) echocardiogram, 160 (24%) neuroimaging, and 76 (11%) lumbar puncture; performance of each aDS per episode varied across sites up to 16-fold. Longer durations of candidemia were associated with undergoing ophthalmologic examination, abdominal imaging, and echocardiogram. Immunocompromised status (58% of episodes) was associated with undergoing abdominal imaging (aOR 2.38; 95% CI 1.51-3.74). Intensive care at candidemia onset (30% of episodes) was associated with undergoing echocardiogram (aOR 2.42; 95% CI 1.51-3.88). Among evaluated episodes, positive ophthalmologic examination was reported in 15 (3%), abdominal imaging in 30 (6%), echocardiogram in 14 (3%), neuroimaging in 9 (6%) and lumbar puncture in 3 (4%). CONCLUSIONS: Our findings show heterogeneity in practice, with some clinicians performing aDS selectively, potentially influenced by clinical factors. The low frequency of positive results suggests that targeted application of aDS is warranted.

BACKGROUND: Systematic Reviews (SR), studies of studies, use a formal process to evaluate the quality of scientific literature and determine ensuing effectiveness from qualifying articles to establish consensus findings around a hypothesis. Their value is increasing as the conduct and publication of research and evaluation has expanded and the process of identifying key insights becomes more time consuming. Text analytics and machine learning (ML) techniques may help overcome this problem of scale while still maintaining the level of rigor expected of SRs. METHODS: In this article, we discuss an approach that uses existing examples of SRs to build and test a method for assisting the SR title and abstract pre-screening by reducing the initial pool of potential articles down to articles that meet inclusion criteria. Our approach differs from previous approaches to using ML as a SR tool in that it incorporates ML configurations guided by previously conducted SRs, and human confirmation on ML predictions of relevant articles during multiple iterative reviews on smaller tranches of citations. We applied the tailored method to a new SR review effort to validate performance. RESULTS: The case study test of the approach proved a sensitivity (recall) in finding relevant articles during down selection that may rival many traditional processes and show ability to overcome most type II errors. The study achieved a sensitivity of 99.5% (213 out of 214) of total relevant articles while only conducting a human review of 31% of total articles available for review. CONCLUSIONS: We believe this iterative method can help overcome bias in initial ML model training by having humans reinforce ML models with new and relevant information, and is an applied step towards transfer learning for ML in SR.

AIMS: To estimate the prevalence and medical expenditures of diabetes-related complications (DRCs) among adult Medicaid enrollees with diabetes. METHODS: We estimated the prevalence and medical expenditures for 12 diabetes-related complications by Medicaid eligibility category (disability-based vs. non-disability-based) in eight states. We used generalized linear models with log link and gamma distribution to estimate the total per-person annual medical expenditures for DRCs, controlling for demographics, and other comorbidities. RESULTS: Among non-disability-based enrollees (NDBEs), 40.1% (in California) to 47.5% (in Oklahoma) had one or more DRCs, compared to 53.6% (in Alabama) to 64.8% (in Florida) among disability-based enrollees (DBEs). The most prevalent complication was neuropathy (16.1%-27.1% for NDBEs; 20.2%-30.4% for DBEs). Lower extremity amputation (<1% for both eligibilities) was the least prevalent complication. The costliest per-person complication was dialysis (per-person excess annual expenditure of $22,481-$41,298 for NDBEs; $23,569-$51,470 for DBEs in 2012 USD). Combining prevalence and per-person excess expenditures, the three costliest complications were nephropathy, heart failure, and ischemic heart disease (IHD) for DBEs, compared to neuropathy, nephropathy, and IHD for NDBEs. CONCLUSIONS: Our study provides data that can be used for assessing the health care resources needed for managing DRCs and evaluating cost-effectiveness of interventions to prevent and management DRCs.

PURPOSE: The purpose of the study was to examine how gender was related to enrollment and number of sessions attended in the National Diabetes Prevention Program's Lifestyle Change Program (DPP LCP). METHODS: To better understand program uptake, a population of those who would be eligible for the LCP was compared to those who enrolled. Estimates of those eligible were computed using data from the National Health and Nutrition Examination Survey, whereas enrollment and sessions attended were computed using data from the Centers for Disease Control and Prevention's Diabetes Prevention Recognition Program. RESULTS: Results revealed that although similar numbers of males and females were eligible for the program, only 39 321 males versus 121 007 females had enrolled in the National DPP LCP by the end of 2017 (odds ratio = 3.20; 95% CI, 3.17-3.24). The gender differences persisted even when stratifying by age or race/ethnicity. In contrast, no significant gender differences were found between the average number of sessions attended for males (14.0) and females (13.8). DISCUSSION: Results of the study can help inform efforts to market and tailor programs to appeal more directly to men and other groups that are underrepresented in the National DPP LCP.

OBJECTIVE: To assess retention in the National Diabetes Prevention Program (DPP) lifestyle change program, which seeks to prevent type 2 diabetes in adults at high risk. RESEARCH DESIGN AND METHODS: We analyzed retention among 41,203 individuals who enrolled in Centers for Disease Control and Prevention (CDC)-recognized in-person lifestyle change programs at organizations that submitted data to CDC's Diabetes Prevention Recognition Program during January 2012-February 2017. RESULTS: Weekly attrition rates were typically <1-2% but were between 3.5% and 5% at week 2 and at weeks 17 and 18, where session frequency typically transitions from weekly to monthly. The percent of participants retained through 18 weeks varied by age (45.9% for 18-29 year olds, 53.4% for 30-44 year olds, 60.2% for 45-54 year olds, 66.7% for 55-64 year olds, and 67.6% for >/=65 year olds), race/ethnicity (70.5% for non-Hispanic whites, 60.5% for non-Hispanic blacks, 52.6% for Hispanics, and 50.6% for other), mean weekly percentage of body weight lost (41.0% for </=0% lost, 66.2% for >0 to <0.25% lost, 72.9% for 0.25 to <0.5% lost, and 73.9% for >/=0.5% lost), and mean weekly physical activity minutes (12.8% for 0 min, 56.1% for >0 to <60 min, 74.8% for 60 to <150 min, and 82.8% for >/=150 min) but not by sex (63.0% for men and 63.1% for women). CONCLUSIONS: Our results demonstrate the need to identify strategies to improve retention, especially among individuals who are younger or are members of racial/ethnic minority populations and among those who report less physical activity or less early weight loss. Strategies that address retention after the first session and during the transition from weekly to monthly sessions offer the greatest opportunity for impact.

CONTEXT: The Centers for Disease Control and Prevention supports the engagement of community health workers (CHWs) to help vulnerable populations achieve optimum health through a variety of initiatives implemented in several organizational units. PROGRAM: This article provides a unified and comprehensive logic model for these initiatives that also serves as a common framework for monitoring and evaluation. IMPLEMENTATION: We developed a logic model to fully describe the levels of effort needed to effectively and sustainably engage CHWs. We mapped monitoring and evaluation metrics currently used by federally funded organizations to the logic model to assess the extent to which measurement and evaluation are aligned to programmatic efforts. EVALUATION: We found that the largest proportion of monitoring and evaluation metrics (61%) currently used maps to the "CHW intervention level" of the logic model, a smaller proportion (37%) maps to the "health system and community organizational level," and a minimal proportion (3%) to the "statewide infrastructure level." DISCUSSION: Organizations engaging CHWs can use the logic model to guide the design as well as performance measurement and evaluation of their CHW initiatives.

INTRODUCTION: Public health focuses on a range of evidence-based approaches for addressing chronic conditions, from individual-level clinical interventions to broader changes in policies and environments that protect people's health and make healthy living easier. This study examined the potential long-term impact of clinical and community interventions as they were implemented by Community Transformation Grant (CTG) program awardees. METHODS: We used the Prevention Impacts Simulation Model, a system dynamics model of cardiovascular disease prevention, to simulate the potential 10-year and 25-year impact of clinical and community interventions implemented by 32 communities receiving a CTG program award, assuming that program interventions were sustained during these periods. RESULTS: Sustained clinical interventions implemented by CTG awardees could potentially avert more than 36,000 premature deaths and $3.2 billion in discounted direct medical costs (2017 US dollars) over 10 years and 109,000 premature deaths and $8.1 billion in discounted medical costs over 25 years. Sustained community interventions could avert more than 24,000 premature deaths and $3.4 billion in discounted direct medical costs over 10 years and 88,000 premature deaths and $9.1 billion in discounted direct medical costs over 25 years. CTG clinical activities had cost-effectiveness of $302,000 per death averted at the 10-year mark and $188,000 per death averted at the 25-year mark. Community interventions had cost-effectiveness of $169,000 and $57,000 per death averted at the 10- and 25-year marks, respectively. CONCLUSION: Clinical interventions have the potential to avert more premature deaths than community interventions. However, community interventions, if sustained over the long term, have better cost-effectiveness.

The National Diabetes Prevention Program lifestyle change program demonstrated health benefits and potential for health care cost-savings. For many states, employers, and insurers, there is a strong business case for paying for type 2 diabetes prevention, which will likely result in medical and nonmedical cost-savings as well as improved quality of life after a few years. Using an iterative feedback process with multiple stakeholders, the Centers for Disease Control and Prevention developed the Diabetes Prevention Impact Tool kit, https://nccd.cdc.gov/toolkit/diabetesimpact, which forecasts the cost impact the lifestyle change program can have for states, employers, and health insurers. We conducted key informant interviews and a qualitative analysis to evaluate the tool kit. We found that end users recognized its utility for decision making. They valued the detail of the tool kit's underlying calculations and appreciated the option of either using the default settings or revising assumptions based on their own data. The Diabetes Prevention Impact Tool kit can be a helpful tool for organizations that wish to forecast the economic costs and benefits of implementing or covering the National Diabetes Prevention Program lifestyle change program.

In 2010, the Centers for Disease Control and Prevention (CDC) funded communities to implement policy, systems, and environmental (PSE) changes under the Communities Putting Prevention to Work (CPPW) program to make it easier for people to make healthier choices to prevent chronic disease. Twenty-one of 50 funded communities implemented interventions intended to reduce tobacco use. To examine the potential cost-effectiveness of tobacco control changes implemented under CPPW from a healthcare system perspective, we compared program cost estimates with estimates of potential impacts. We used an existing simulation model, the Prevention Impacts Simulation Model (PRISM), to estimate the potential cumulative impact of CPPW tobacco interventions on deaths and medical costs averted through 2020. We collected data on the costs to implement CPPW tobacco interventions from 2010 to 2013. We adjusted all costs to 2010 dollars. CPPW tobacco interventions cost $130.5 million across all communities, with an average community cost of $6.2 million. We found $735 million in potentially averted medical costs cumulatively from 2010 through 2020 because of the CPPW-supported interventions. If the CPPW tobacco control PSE changes are sustained through 2020 without additional funding after 2013, we find that medical costs averted will likely exceed program costs by $604 million. Our results suggest that the medical costs averted through 2020 may more than offset the initial investment in CPPW tobacco control interventions, implying that such interventions may be cost saving, especially over the long term.

Invasive Scedosporium spp. and Lomentospora prolificans infections are an emerging threat in immunocompromised and occasionally in healthy hosts. Scedosporium spp. is intrinsically resistant to most, L. prolificans to all the antifungal drugs currently approved, raising concerns about appropriate treatment decisions. High mortality rates of up to 90% underline the need for comprehensive diagnostic workup and even more for new, effective antifungal drugs to improve patient outcome. For a comprehensive analysis, we identified cases of severe Scedosporium spp. and L. prolificans infections from the literature diagnosed in 2000 or later and the FungiScope((R)) registry. For 208 Scedosporium spp. infections solid organ transplantation (n = 58, 27.9%) and for 56 L. prolificans infection underlying malignancy (n = 28, 50.0%) were the most prevalent risk factors. L. prolificans infections frequently presented as fungemia (n = 26, 46.4% versus n = 12, 5.8% for Scedosporium spp.). Malignancy, fungemia, CNS and lung involvement predicted worse outcome for scedosporiosis and lomentosporiosis. Patients treated with voriconazole had a better overall outcome in both groups compared to treatment with amphotericin B formulations. This review discusses the epidemiology, prognostic factors, pathogen susceptibility to approved and investigational antifungals, and treatment strategies of severe infections caused by Scedosporium spp. and L. prolificans.

IN BRIEF In 2017, 30 million Americans had diabetes, and 84 million had prediabetes. In this article, the authors focus on the journey people at risk for type 2 diabetes take when they become fully engaged in an evidence-based type 2 diabetes prevention program. They highlight potential drop-off points along the journey, using behavioral economics theory to provide possible reasons for most of the drop-off points, and propose solutions to move people toward making healthy decisions.

Limited data are available on the costs of evidence-based community-wide prevention programs. The objective of this study was to estimate the per-person costs of strategies that support policy, systems, and environmental changes implemented under the Community Transformation Grants (CTG) program. We collected cost data from 29 CTG awardees and estimated program costs as spending on labor; consultants; materials, travel, and services; overhead activities; partners; and the value of in-kind contributions. We estimated costs per person reached for 20 strategies. We assessed how per-person costs varied with the number of people reached. Data were collected in 2012-2015, and the analysis was conducted in 2015-2016. Two of the tobacco-free living strategies cost less than $1.20 per person and reached over 6 million people each. Four of the healthy eating strategies cost less than $1.00 per person, and one of them reached over 6.5 million people. One of the active living strategies cost $2.20 per person and reached over 7 million people. Three of the clinical and community preventive services strategies cost less than $2.30 per person, and one of them reached almost 2 million people. Across all 20 strategies combined, an increase of 10,000 people in the number of people reached was associated with a $0.22 reduction in the per-person cost. Results demonstrate that interventions, such as tobacco-free indoor policies, which have been shown to improve health outcomes have relatively low per-person costs and are able to reach a large number of people.

To treat a cluster of tuberculosis (TB) transmission cases in a long-term care facility for cognitively impaired adults located in Puerto Rico (facility A), the Puerto Rico TB Control Program used a novel video directly observed therapy (VDOT) application. In 2016, active TB disease was diagnosed in 11 residents and latent TB infection (LTBI) was diagnosed in six residents of facility A. Asynchronous VDOT was used to monitor treatment for these 17 residents. One of the patients with active TB disease had received a diagnosis of LTBI during an investigation at facility A during 2011–2012.

Purpose: Multiple studies have demonstrated significant disparities in the relationship between individual sociodemographic characteristics and risk of overweight or obesity. However, little information is available for assessing the complex associations among being overweight or obese with neighborhood and individual sociodemographic factors and the measured and perceived community food environment. Methods: Using 2014 national evaluation data from 20 communities (analyzed 2015-2016) that participated in the U.S. Centers for Disease Control and Prevention Community Transformation Grants Program, we used multilevel multivariable models to assess associations among factors at the individual, census tract, and county levels with being overweight or obese and with the perceived home food environment. Results: Individual level factors (age, sex, race/ethnicity, household income, and education) were significantly associated with the likelihood of being overweight or obese in every model tested. Census tract level poverty and education were significantly associated with the likelihood of being overweight or obese in univariate but not multivariable analyses. Perceived community food environment was a significant predictor of the perceived home food environment; the objective measure of county-level grocery store access was not. Neither perceived nor objective community food environment measures were significantly associated with overweight/obesity in multivariable analyses. Conclusion: Individual-level sociodemographic characteristics are more strongly associated with obesity-related outcomes than are area-level measures. Future interventions designed to address health equity issues in obesity among underserved populations may benefit from focusing on nutrition education tailored to individuals, to encourage purchase and consumption of healthy food. Improving healthy food availability in underserved communities may also be critical for nutrition education to have a meaningful impact.

Lesbian, gay, and bisexual (LGB) adults in the United States have a higher prevalence of smoking than their heterosexual counterparts. In 2013, the Los Angeles County Department of Public Health launched a social marketing and outreach campaign called Break Up to reduce the prevalence of smoking in LGB communities. Break Up was evaluated using cross-sectional, street-intercept surveys before and near the end of campaign. Surveys measured demographics, campaign awareness, and self-reported smoking-related outcomes. Bivariate statistics and logistic regression models were used to identify whether campaign awareness was associated with smoking-related outcomes. Calls by LGB persons to a smokers' helpline were also measured. Among those interviewed at endline, 32.7% reported Break Up awareness. Awareness was associated with thinking of quitting smoking and ever taking steps to quit but not with smoking cessation (defined as not smoking in the past 30 days among those who had smoked in the past 6 months). There was a 0.7% increase in the percentage of weekly calls by LGB persons to the helpline in the year after the campaign. Break Up reached about a third of its intended audience. The campaign was associated with smoking cessation precursors and may have led to an increase in helpline utilization, but there is no evidence it affected quit attempts. This study adds to the limited literature on tobacco programs for LGB persons and, as far as we know, is one of the first to evaluate tobacco-free social marketing in this important yet understudied population.

OBJECTIVE: To examine the elements of capacity, a measure of organizational resources supporting program implementation that result in successful completion of public health program objectives in a public health initiative serving 50 communities. DESIGN: We used crisp set Qualitative Comparative Analysis (QCA) to analyze case study and quantitative data collected during the evaluation of the Communities Putting Prevention to Work (CPPW) program. SETTING: CPPW awardee program staff and partners implemented evidence-based public health improvements in counties, cities, and organizations (eg, worksites, schools). PARTICIPANTS: Data came from case studies of 22 CPPW awardee programs that implemented evidence-based, community- and organizational-level public health improvements. INTERVENTION: Program staff implemented a range of evidence-based public health improvements related to tobacco control and obesity prevention. MAIN OUTCOME MEASURE: The outcome measure was completion of approximately 60% of work plan objectives. RESULTS: Analysis of the capacity conditions revealed 2 combinations for completing most work plan objectives: (1) having experience implementing public health improvements in combination with having a history of collaboration with partners; and (2) not having experience implementing public health improvements in combination with having leadership support. CONCLUSION: Awardees have varying levels of capacity. The combinations identified in this analysis provide important insights into how awardees with different combinations of elements of capacity achieved most of their work plan objectives. Even when awardees lack some elements of capacity, they can build it through strategies such as hiring staff and engaging new partners with expertise. In some instances, lacking 1 or more elements of capacity did not prevent an awardee from successfully completing objectives. IMPLICATIONS FOR POLICY & PRACTICE: These findings can help funders and practitioners recognize and assemble different aspects of capacity to achieve more successful programs; awardees can draw on extant organizational strengths to compensate when other aspects of capacity are absent.

INTRODUCTION: In 2010, the Centers for Disease Control and Prevention (CDC) launched Communities Putting Prevention to Work (CPPW), a $485 million program to reduce obesity, tobacco use, and exposure to secondhand smoke. CPPW awardees implemented evidence-based policy, systems, and environmental changes to sustain reductions in chronic disease risk factors. This article describes short-term and potential long-term benefits of the CPPW investment. METHODS: We used a mixed-methods approach to estimate population reach and to simulate the effects of completed CPPW interventions through 2020. Each awardee developed a community action plan. We linked plan objectives to a common set of interventions across awardees and estimated population reach as an early indicator of impact. We used the Prevention Impacts Simulation Model (PRISM), a systems dynamics model of cardiovascular disease prevention, to simulate premature deaths, health care costs, and productivity losses averted from 2010 through 2020 attributable to CPPW. RESULTS: Awardees completed 73% of their planned objectives. Sustained CPPW improvements may avert 14,000 premature deaths, $2.4 billion (in 2010 dollars) in discounted direct medical costs, and $9.5 billion (in 2010 dollars) in discounted lifetime and annual productivity losses through 2020. CONCLUSION: PRISM results suggest that large investments in community preventive interventions, if sustained, could yield cost savings many times greater than the original investment over 10 to 20 years and avert 14,000 premature deaths.

All regions of the US experience disasters which result in a number of negative public health consequences. Some populations have higher levels of social vulnerability and, thus, are more likely to experience negative impacts of disasters including emotional distress, loss of property, illness, and death. To mitigate the impact of disasters on at-risk populations, emergency managers must be aware of the social vulnerabilities within their community. This paper describes a qualitative study which aimed to understand how emergency managers identify social vulnerabilities, also referred to as at-risk populations, in their populations and barriers and facilitators to current approaches. Findings suggest that although public health tools have been developed to aid emergency managers in identifying at-risk populations, they are not being used consistently. Emergency managers requested more information on the availability of tools as well as guidance on how to increase ability to identify at-risk populations.

CONTEXT: Lesbian, gay, and bisexual (LGB) populations experience significant health inequities in preventive behaviors and chronic disease compared with non-LGB populations. OBJECTIVES: To examine differences in physical activity and diet by sexual orientation and sex subgroups and to assess the influences of home and neighborhood environments on these relationships. DESIGN: A population-based survey conducted in 2013-2014. SETTING: A stratified, simple, random sample of households in 20 sites in the United States. PARTICIPANTS: A total of 21 322 adult LGB and straight-identified men and women. OUTCOME MEASURES: Any leisure-time physical activity in the past month; physical activity 150 min/wk or more; daily frequency of consumption of vegetables, fruit, water, and sugar-sweetened beverages; and the number of meals prepared away from home in the past 7 days. RESULTS: Physical activity and diet varied by sexual orientation and sex; differences persisted after adjusting for sociodemographic factors and household and community environments. Bisexual men reported a higher odds of engaging in frequent physical activity than straight men (odds ratio [OR] = 3.10; 95% confidence interval [CI], 1.57-6.14), as did bisexual women compared with straight women (OR = 1.84; 95% CI, 1.20-2.80). LGB subgroups reported residing in more favorable walking and cycling environments. In contrast, gay men and lesbian and bisexual women reported a less favorable community eating environment (availability, affordability, and quality of fruit and vegetables) and a lower frequency of having fruit or vegetables in the home. Lesbian women reported lower daily vegetable consumption (1.79 vs 2.00 mean times per day; difference = -0.21; 95% CI, -0.03 to -0.38), and gay men reported consumption of more meals prepared away from home (3.17 vs 2.63; difference = 0.53; 95% CI, 0.11-0.95) than straight women and men, respectively. Gay men and lesbian and bisexual women reported a higher odds of sugar-sweetened beverage consumption than straight men and women. CONCLUSIONS: Findings highlight opportunities for targeted approaches to promote physical activity and mitigate differences in diet to reduce health inequities.

The role of neighborhood walkability and safety in mediating the association between education and physical activity has not been quantified. We used data from the 2010 and 2012 Communities Putting Prevention to Work Behavioral Risk Factor Surveillance System and structural equation modeling to estimate how much of the effect of education level on physical activity was mediated by perceived neighborhood walkability and safety. Neighborhood walkability accounts for 11.3% and neighborhood safety accounts for 6.8% of the effect. A modest proportion of the important association between education and physical activity is mediated by perceived neighborhood walkability and safety, suggesting that interventions focused on enhancing walkability and safety could reduce the disparity in physical activity associated with education level.

This introduction is an overview of the articles presented in this supplement that describe implementation and evaluation activities conducted as part of the Centers for Disease Control and Prevention's (CDC's) Communities Putting Prevention to Work (CPPW) initiative. CPPW was one of the largest federal investments ever to combat chronic diseases in the United States. CPPW supported high-impact, jurisdiction-wide policy, systems, and environmental changes to improve health by increasing access to physical activity and healthy foods, and by decreasing tobacco use and exposure to secondhand smoke. The articles included in this supplement describe implementation and evaluation efforts of strategies implemented as part of CPPW by local awardees. This supplement is intended to guide the evidence base for public health interventions on the basis of jurisdiction-wide policy and environmental-level improvements and to encourage rigorous evaluation of the public health interventions.

INTRODUCTION: Computer simulation offers the ability to compare diverse interventions for reducing cardiovascular disease risks in a controlled and systematic way that cannot be done in the real world. METHODS: We used the Prevention Impacts Simulation Model (PRISM) to analyze the effect of 50 intervention levers, grouped into 6 (2 x 3) clusters on the basis of whether they were established or emerging and whether they acted in the policy domains of care (clinical, mental health, and behavioral services), air (smoking, secondhand smoke, and air pollution), or lifestyle (nutrition and physical activity). Uncertainty ranges were established through probabilistic sensitivity analysis. RESULTS: Results indicate that by 2040, all 6 intervention clusters combined could result in cumulative reductions of 49% to 54% in the cardiovascular risk-related death rate and of 13% to 21% in risk factor-attributable costs. A majority of the death reduction would come from Established interventions, but Emerging interventions would also contribute strongly. A slim majority of the cost reduction would come from Emerging interventions. CONCLUSION: PRISM allows public health officials to examine the potential influence of different types of interventions - both established and emerging - for reducing cardiovascular risks. Our modeling suggests that established interventions could still contribute much to reducing deaths and costs, especially through greater use of well-known approaches to preventive and acute clinical care, whereas emerging interventions have the potential to contribute significantly, especially through certain types of preventive care and improved nutrition.

CONTEXT: Health communication campaigns including mass media and health-related product distribution have been used to reduce mortality and morbidity through behavior change. The intervention is defined as having two core components reflecting two social marketing principles: (1) promoting behavior change through multiple communication channels, one being mass media, and (2) distributing a free or reduced-price product that facilitates adoption and maintenance of healthy behavior change, sustains cessation of harmful behaviors, or protects against behavior-related disease or injury. EVIDENCE ACQUISITION: Using methods previously developed for the Community Guide, a systematic review (search period, January 1980-December 2009) was conducted to evaluate the effectiveness of health communication campaigns that use multiple channels, including mass media, and distribute health-related products. The primary outcome of interest was use of distributed health-related products. EVIDENCE SYNTHESIS: Twenty-two studies that met Community Guide quality criteria were analyzed in 2010. Most studies showed favorable behavior change effects on health-related product use (a median increase of 8.4 percentage points). By product category, median increases in desired behaviors ranged from 4.0 percentage points for condom promotion and distribution campaigns to 10.0 percentage points for smoking-cessation campaigns. CONCLUSIONS: Health communication campaigns that combine mass media and other communication channels with distribution of free or reduced-price health-related products are effective in improving healthy behaviors. This intervention is expected to be applicable across U.S. demographic groups, with appropriate population targeting. The ability to draw more specific conclusions about other important social marketing practices is constrained by limited reporting of intervention components and characteristics.

CONTEXT: The objective of this systematic review was to determine the costs, benefits, and overall economic value of communication campaigns that included mass media and distribution of specified health-related products at reduced price or free of charge. EVIDENCE ACQUISITION: Economic evaluation studies from a literature search from January 1980 to December 2009 were screened and abstracted following systematic economic review methods developed by The Community Guide. Data were analyzed in 2011. EVIDENCE SYNTHESIS: The economic evidence was grouped and assessed by type of product distributed and health risk addressed. A total of 15 evaluation studies were included in the economic review, involving campaigns promoting the use of child car seats or booster seats, pedometers, condoms, recreational safety helmets, and nicotine replacement therapy. CONCLUSIONS: Economic merits of the intervention could not be determined for health communication campaigns associated with use of recreational helmets, child car seats, and pedometers, primarily because available economic information and analyses were incomplete. There is some evidence that campaigns with free condom distribution to promote safer sex practices were cost-effective among high-risk populations and the cost per quit achieved in campaigns promoting tobacco cessation with nicotine replacement therapy products may translate to a cost per quality-adjusted life-year less than $50,000. Many interventions were publicly funded trials or programs, and the failure to properly evaluate their economic cost and benefit is a serious gap in the science and practice of public health.

This report augments guidelines published in 1990 for investigating clusters of health events (CDC. Guidelines for investigating clusters of health events. MMWR 1990;39[No. RR-11]). The 1990 Guidelines considered any noninfectious disease cluster, injuries, birth defects, and previously unrecognized syndromes or illnesses. These new guidelines focus on cancer clusters. State and local health departments can use these guidelines to develop a systematic approach to responding to community concerns regarding cancer clusters. The guidelines are intended to apply to situations in which a health department responds to an inquiry about a suspected cancer cluster in a residential or community setting only. Occupational or medical treatment-related clusters are not included in this report. Since 1990, many improvements have occurred in data resources, investigative techniques, and analytic/statistical methods, and much has been learned from both large- and small-scale cancer cluster investigations. These improvements and lessons have informed these updated guidelines. These guidelines utilize a four-step approach (initial response, assessment, major feasibility study, and etiologic investigation) as a tool for managing a reported cluster. Even if a cancer cluster is identified, there is no guarantee that a common cause or an environmental contaminant will be implicated. Identification of a common cause or an implicated contaminant might be an expected outcome for the concerned community. Therefore, during all parts of an inquiry, responders should be transparent, communicate clearly, and explain their decisions to the community.

CONTEXT: Adolescence marks a time when many young people engage in risky behaviors with potential implications for long-term health. Interventions focused on adolescents' parents and other caregivers have the potential to affect adolescents across a variety of risk and health-outcome areas. EVIDENCE ACQUISITION: Community Guide methods were used to evaluate the effectiveness of caregiver-targeted interventions in addressing adolescent risk and protective behaviors and health outcomes. Sixteen studies published during the search period (1966-2007) met review requirements and were included in this review. EVIDENCE SYNTHESIS: Effectiveness was assessed based on changes in whether or not adolescents engaged in specified risk and protective behaviors; frequency of risk and protective behaviors, and health outcomes, also informed the results. Results from qualifying studies provided sufficient evidence that interventions delivered person-to-person (i.e., through some form of direct contact rather than through other forms of contact such as Internet or paper) and designed to modify parenting skills by targeting parents and other caregivers are effective in improving adolescent health. CONCLUSIONS: Interventions delivered to parents and other caregivers affect a cross-cutting array of adolescent risk and protective behaviors to yield improvements in adolescent health. Analysis from this review forms the basis of the recommendation by the Community Preventive Services Task Force presented elsewhere in this issue.

The burden of preventable chronic diseases is straining our nation's health and economy. Diseases caused by obesity and tobacco use account for the largest portions of this preventable burden. CDC funded 50 communities in 2010 to implement policy, systems, and environmental (PSE) interventions in a 2-year initiative. Funded communities developed PSE plans to reduce obesity, tobacco use, and second-hand smoke exposure for their combined 55 million residents. Community outcome objectives and milestones were categorized by PSE interventions as they related to media, access, promotion, pricing, and social support. Communities estimated population reach based on their jurisdiction's census data and target populations. The average proportion of each community's population that was reached was calculated for each intervention category. Outcome objectives that were achieved within 12 months of program initiation were identified from routine program records. The average proportion of a community's jurisdictional population reached by a specific intervention varied across interventions. Mean population reach for obesity-prevention interventions was estimated at 35%, with 14 (26%) interventions covering over 50% of the jurisdictional populations. For tobacco prevention, mean population reach was estimated at 67%, with 16 (84%) interventions covering more than 50% of the jurisdictional populations. Within 12 months, communities advanced over one-third of their obesity and tobacco-use prevention strategies. Tobacco interventions appeared to have higher potential population reach than obesity interventions within this initiative. Findings on the progress and potential reach of this major initiative may help inform future chronic disease prevention efforts.