The Youth Risk Behavior Surveillance System (YRBSS) is a set of surveys that tracks a broad range of behaviors, experiences, and conditions that can lead to poor health among high school students. The system includes a nationally representative Youth Risk Behavior Survey (YRBS) and separate school-based YRBSs conducted by states, tribes, territories, and local school districts. For the 2023 national YRBS, CDC made changes to the sampling method, survey administration mode, and questionnaire. Specifically, the sampling design added an American Indian or Alaska Native (AI/AN) supplemental sample so that separate, precise estimates could be made for AI/AN high school students, in addition to the usual sample designed to provide nationally representative data for the population of students in grades 9-12. To decrease the time needed to collect and process data, CDC changed the survey administration mode from paper-and-pencil scannable booklets to a tablet-based electronic survey. To provide national data on topics of emerging interest, CDC added new questions to the questionnaire. These new questions assessed social media use, experiences of racism at school, adverse childhood experiences, transgender identity, consent for sexual contact, and unfair discipline at school. Public health practitioners and researchers can use YRBSS data to examine the prevalence of youth health behaviors, experiences, and conditions; monitor trends; and guide interventions. This overview report describes 2023 YRBSS survey methodology, including sampling, data collection, data processing, weighting, and data analyses. The 2023 YRBS participation map, survey response rates, and a detailed examination of student demographic characteristics are included in this report. During 2023, in addition to the national YRBS, 68 site-level surveys were administered to high school students in 39 states, three tribal governments, five territories, and 21 local school districts. These site-level surveys use site-specific questionnaires that are similar to the national YRBS questionnaire but are modified to meet sites' needs. This overview and methods report is one of 11 featured in this MMWR supplement, which reports results from the 2023 national YRBS but does not include data from the 68 site-level surveys. Each report is based on data collected using methods presented in this overview report. A full description of YRBSS results and downloadable data are available (https://www.cdc.gov/yrbs/index.html).

The strength of American Indian and Alaska Native (AI/AN) communities comes from generations of Indigenous traditions, language, culture, and knowledge. These strengths have been challenged by a complex set of systemic, structural, and social factors related to historical and intergenerational trauma that affects the health of AI/AN communities. Furthermore, AI/AN population health data often are inaccurate because of analytic coding practices that do not account for multiracial and ethnic AI/AN identification and inadequate because of statistical suppression. The 2023 national Youth Risk Behavior Survey included a supplemental sample of AI/AN high school students. Coding of race and ethnicity was inclusive of all AI/AN students, even if they also identified as another race or as Hispanic or Latino, providing comprehensive data on health behaviors and experiences among AI/AN high school students nationwide. Adult caretaker engagement and school connectedness and their association with 13 health behaviors and experiences were examined, including five types of current substance use, four indicators of emotional well-being and suicide risk, and four types of violence. Pairwise t-tests and adjusted prevalence ratios from logistic regression models identified significant associations between exposure and outcome variables. Among AI/AN students, having an adult who always tried to meet their basic needs, high parental monitoring, and high school connectedness were associated with lower prevalence of certain measures of substance use, poor emotional well-being and suicide risk, and violence. Compared with non-AI/AN students, the prevalence of current electronic vapor product use, current marijuana use, attempted suicide, and experience of sexual violence was higher among AI/AN students.This report presents the most comprehensive, up-to-date data on substance use, indicators of emotional well-being and suicide risk, and experiences with violence among AI/AN high school students nationwide. The findings suggest the importance of engaged household adults and school connectedness in promoting emotional well-being and preventing substance use, suicide-related behavior, and experiences of violence among AI/AN students. Understanding the historical context and incorporating Indigenous knowledge when developing interventions focused on AI/AN youths are critical to ensure such interventions are successful in improving AI/AN health and well-being.

Black gay, bisexual, and other men who have sex with men (GBM) are disproportionately affected by HIV and STIs. Safe Spaces 4 Sexual Health (SS4SH), a community-informed, status-neutral HIV/STI testing intervention combines online outreach via geo-social networking apps and social media with mobile van testing. During 2018-2019, we recruited 25 participants for interviews about their perceptions of SS4SH compared to clinic-based testing. Participants were aged 21-65 years (mean 35); 22 (88%) identified as Black/African American; 20 (80%) identified as gay; and 10 (40%) were living with HIV. Interviews were transcribed, coded, and analyzed using a modified thematic constant comparative approach. Five themes emerged; two related to perceptions of online outreach materials (participants were drawn to eye-catching and to-the-point messages and desired more diversity and representation in messages), and three related to preference for the mobile van (participants found SS4SH provided more comfort, more privacy/confidentiality, and increased accessibility and efficiency). GBM is increasingly using geo-social networking apps to meet sexual partners, and tailored online outreach has the potential to reach historically underserved populations. SS4SH is a barrier-reducing strategy that may serve as an entry to a status-neutral approach to services and help reduce stigma and normalize accessing HIV services.

The Youth Risk Behavior Surveillance System (YRBSS) is the largest public health surveillance system in the United States, monitoring a broad range of health-related behaviors among high school students. The system includes a nationally representative Youth Risk Behavior Survey (YRBS) and separate school-based YRBSs conducted by states, tribes, territories, and local school districts. In 2021, these surveys were conducted during the COVID-19 pandemic. The pandemic underscored the importance of data in understanding changes in youth risk behaviors and addressing the multifaceted public health needs of youths. This overview report describes 2021 YRBSS survey methodology, including sampling, data collection procedures, response rates, data processing, weighting, and analyses. The 2021 YRBS participation map, survey response rates, and a detailed examination of student demographic characteristics are included in this report. During 2021, in addition to the national YRBS, a total of 78 surveys were administered to high school students across the United States, representing the national population, 45 states, two tribal governments, three territories, and 28 local school districts. YRBSS data from 2021 provided the first opportunity since the onset of the COVID-19 pandemic to compare youth health behaviors using long-term public health surveillance. Approximately half of all student respondents represented racial and ethnic minority groups, and approximately one in four identified as lesbian, gay, bisexual, questioning, or other (a sexual identity other than heterosexual) (LGBQ+). These findings reflect shifts in youth demographics, with increased percentages of racial and ethnic minority and LGBQ+ youths compared with previous YRBSS cycles. Educators, parents, local decision makers, and other partners use YRBSS data to monitor health behavior trends, guide school health programs, and develop local and state policy. These and future data can be used in developing health equity strategies to address long-term disparities so that all youths can thrive in safe and supportive environments. This overview and methods report is one of 11 featured in this MMWR supplement. Each report is based on data collected using methods presented in this overview. A full description of YRBSS results and downloadable data are available (https://www.cdc.gov/healthyyouth/data/yrbs/index.htm).

Many U.S. schools closed nationwide in March 2020 to prevent the spread of COVID-19. School closures and online-only instruction have negatively affected certain students, with studies showing adverse effects of the pandemic on mental health. However, little is known about other experiences such as economic and food insecurity and abuse by a parent, as well as risk behaviors such as alcohol and drug use among youths across the United States during the pandemic. To address this gap, CDC developed the one-time, online Adolescent Behaviors and Experiences Survey (ABES), which was conducted during January-June 2021 to assess student behaviors and experiences during the COVID-19 pandemic among high school students, including unintentional injury, violence, tobacco product use, sexual behaviors, and dietary behaviors. This overview report of the ABES MMWR Supplement describes the ABES methodology, including the student questionnaire and administration, sampling, data collection, weighting, and analysis. ABES used a stratified, three-stage cluster probability-based sampling approach to obtain a nationally representative sample of students in grades 9-12 attending public and private schools. Teachers of selected classes provided students with access to the anonymous online survey while following local consent procedures. Data were collected using a 110-item questionnaire during January-June 2021 in 128 schools. A total of 7,998 students submitted surveys, and 7,705 of these surveys had valid data (i.e., ≥20 questions answered). The school response rate was 38%, the student response rate was 48%, and the overall response rate was 18%. Information on mode of instruction and school-provided equipment was also collected from all sampled schools. This overview report provides student- and school-level characteristics obtained from descriptive analyses, and the other reports in the ABES MMWR Supplement include information on substance use, mental health and suicidality, perceived racism, and disruptions to student life among high school students. Findings from ABES during the COVID-19 pandemic can help guide parents, teachers, school administrators, community leaders, clinicians, and public health officials in decision-making for student support and school health programs.

Health risk behaviors practiced during adolescence often persist into adulthood and contribute to the leading causes of morbidity and mortality in the United States. Youth health behavior data at the national, state, territorial, tribal, and local levels help monitor the effectiveness of public health interventions designed to promote adolescent health. The Youth Risk Behavior Surveillance System (YRBSS) is the largest public health surveillance system in the United States, monitoring a broad range of health-related behaviors among high school students. YRBSS includes a nationally representative Youth Risk Behavior Survey (YRBS) and separate state, local school district, territorial, and tribal school-based YRBSs. This overview report describes the surveillance system and the 2019 survey methodology, including sampling, data collection procedures, response rates, data processing, weighting, and analyses presented in this MMWR Supplement. A 2019 YRBS participation map, survey response rates, and student demographic characteristics are included. In 2019, a total of 78 YRBSs were administered to high school student populations across the United States (national and 44 states, 28 local school districts, three territories, and two tribal governments), the greatest number of participating sites with representative data since the surveillance system was established in 1991. The nine reports in this MMWR Supplement are based on national YRBS data collected during August 2018-June 2019. A full description of 2019 YRBS results and downloadable data are available (https://www.cdc.gov/healthyyouth/data/yrbs/index.htm).Efforts to improve YRBSS and related data are ongoing and include updating reliability testing for the national questionnaire, transitioning to electronic survey administration (e.g., pilot testing for a tablet platform), and exploring innovative analytic methods to stratify data by school-level socioeconomic status and geographic location. Stakeholders and public health practitioners can use YRBS data (comparable across national, state, tribal, territorial, and local jurisdictions) to estimate the prevalence of health-related behaviors among different student groups, identify student risk behaviors, monitor health behavior trends, guide public health interventions, and track progress toward national health objectives.

Experiences of teen dating violence (TDV), sexual violence, and bullying during adolescence are all forms of interpersonal violence victimization (IVV) and are associated with health and behavioral issues during adulthood. Data from the nationally representative 2011-2021 Youth Risk Behavior Surveys were used to estimate the 2021 prevalence of IVV reported by U.S. high school students. IVV included past-year sexual TDV, physical TDV, sexual violence by anyone, electronic bullying, being bullied on school property, and lifetime forced sex and was analyzed by demographic characteristics and sex of sexual contacts. This report also explored trends in IVV over this 10-year period among U.S. high school students. In 2021, a total of 8.5% of students reported physical TDV, 9.7% reported sexual TDV, 11.0% reported sexual violence by anyone (with 59.5% of those also reporting sexual TDV), 15.0% reported bullying on school property, and 15.9% reported electronic bullying victimization during the past 12 months; 8.5% also reported experiencing forced sex in their lifetime. Disparities were observed for each form of IVV assessed for females and for most forms of IVV among racial and ethnic minority students; students who identified as lesbian, gay, bisexual, questioning, or other (LGBQ+); and students who reported their sexual contacts as same sex only or both sexes. Trend analyses indicated that physical TDV, sexual TDV, any physical or sexual TDV, and both physical and sexual TDV victimization decreased from 2013 to 2021 (although sexual TDV increased from 2019 to 2021). Any bullying victimization decreased from 2011 to 2021. Lifetime forced sexual intercourse decreased from 2011 to 2015, then increased from 2015 to 2021. Being bullied on school property was unchanged from 2011 to 2017, then decreased from 2017 to 2021. Sexual violence by anyone increased from 2017 to 2021. This report highlights disparities in IVV and provides the first national estimates among Native Hawaiian or other Pacific Islander youths. Findings, including trend analyses indicating recent increases in certain forms of IVV, point to the continued urgency of violence prevention efforts for all U.S. youths and especially those who are disproportionately affected by IVV.

Disruptions and consequences related to the COVID-19 pandemic, including school closures, social isolation, family economic hardship, family loss or illness, and reduced access to health care, raise concerns about their effects on the mental health and well-being of youths. This report uses data from the 2021 Adolescent Behaviors and Experiences Survey, an online survey of a probability-based, nationally representative sample of U.S. public- and private-school students in grades 9-12 (N = 7,705), to assess U.S. high school students' mental health and suicidality during the COVID-19 pandemic. The study also examines whether mental health and suicidality are associated with feeling close to persons at school and being virtually connected to others during the pandemic. Overall, 37.1% of students experienced poor mental health during the pandemic, and 31.1% experienced poor mental health during the preceding 30 days. In addition, during the 12 months before the survey, 44.2% experienced persistent feelings of sadness or hopelessness, 19.9% had seriously considered attempting suicide, and 9.0% had attempted suicide. Compared with those who did not feel close to persons at school, students who felt close to persons at school had a significantly lower prevalence of poor mental health during the pandemic (28.4% versus 45.2%) and during the past 30 days (23.5% versus 37.8%), persistent feelings of sadness or hopelessness (35.4% versus 52.9%), having seriously considered attempting suicide (14.0% versus 25.6%), and having attempted suicide (5.8% versus 11.9%). The same pattern was observed among students who were virtually connected to others during the pandemic (i.e., with family, friends, or other groups by using a computer, telephone, or other device) versus those who were not. Comprehensive strategies that improve feelings of connectedness with others in the family, in the community, and at school might foster improved mental health among youths during and after the COVID-19 pandemic.

Pre-exposure prophylaxis (PrEP) is an effective tool in protecting persons from acquiring HIV infection through sex or injection drug use. However, awareness and willingness to use PrEP among Black gay, bisexual, and other men who have sex with men (BMSM) remain suboptimal compared to White MSM (WMSM) in the United States. Our aims were to (1) assess the factors associated with PrEP awareness and willingness to use PrEP among MSM and (2) compare the PrEP perceptions among BMSM versus non-Black MSM. Data were drawn from two cross-sectional behavioral surveys in Baltimore, MD: Behavioral Surveillance Research (BESURE) conducted in 2017, and Safe Spaces 4 Sexual Health (SS4SH), conducted in 2018 and 2019. Descriptive statistics were used to summarize the study population. We used Poisson regression models to identify variables associated with awareness of PrEP and willingness to use PrEP. PrEP perceptions were assessed via 13 items scored on a 5-point Likert scale. Finally, we conducted a post-hoc exploratory bivariate analysis of the relationship between PrEP perception and willingness to use PrEP, stratified by race/ethnicity. A total of 261 MSM participated in this study. Many of the participants were aware of PrEP (75.1%). Factors associated with greater PrEP awareness included having greater than a high school education (aRR 1.22, 95% CI 1.04, 1.43); and earning more than $25,000 annually (aRR 1.24, 95% CI 1.08, 1.42). Participants who had received money in exchange for sex one or more times were less likely to be aware of PrEP (aRR 0.59, 95% CI 0.36, 0.95). More than half of the participants were willing to use PrEP (55.3%). In bivariate and multivariable analyses, demographic or behavioral characteristics were not significantly associated with willingness to use PrEP. Higher agreement with the following statements was associated with lower willingness to use PrEP: "Having to take a pill every day is difficult" (RR 0.89, 95% CI 0.82-0.97) and, "I am concerned about the side effects of PrEP" (RR 0.89, 95% CI 0.82-0.96), and "PrEP is for people who have riskier sex lives than I do" (RR 0.86, 95% CI 0.78-0.95). Conversely, higher willingness to use PrEP was associated with comfortable having sex without a condom (RR 1.11, 95% CI 1.02-1.21), less anxious about sex (RR 1.12, 95% CI 1.02-1.24), and my friends think that I should take PrEP (RR 1.19, 95% CI 1.07-1.32). We found BMSM compared to non-Black MSM had higher mean scores related to taking a daily pill (p = 0.041), concerns about side effects (p = 0.012), concerns about people thinking they had HIV (p = 0.001), concerns about the financial costs of PrEP (p = 0.038) and caution when dealing with healthcare organizations/medical mistrust (p = 0.019). Perceptions with a statistically significant lower score among BMSM versus non-Black MSM included statements such as, comfortable having sex without a condom (p = 0.003) and less anxious about sex (p < 0.001). We conclude HIV prevention strategies, programs, and interventions should be cognizant of PrEP perceptions that facilitate or hinder PrEP uptake in Baltimore City, MD.

BACKGROUND: Amalgam has been used for more than 150 years as a safe and reliable restorative material. The authors described the occurrence of amalgam and nonamalgam restorations in the United States in primary and permanent teeth across age groups and according to sociodemographic characteristics. METHODS: The authors used clinical examination data from the National Health and Nutrition Examination Survey 2015-2018 for participants 2 years and older (n = 17,040). The authors estimated the prevalence and mean number of amalgam and nonamalgam restorations in primary and permanent teeth according to age groups (2-5 years, 6-11 years, 12-15 years, 16-19 years, 20-39 years, 40-59 years, 60-79 years, and ≥ 80 years), race and ethnicity, federal poverty guideline, education, and pregnancy status. RESULTS: The prevalence of amalgam restorations ranged from 4% through 69%. Overall, amalgam restorations were more prevalent in children and adolescents from racial and ethnic minority groups and families at lower poverty levels and with lower education. The mean number of teeth with nonamalgam restorations was higher than those with amalgam restorations in primary teeth of children aged 6 through 11 years, permanent teeth of those 12 through 15 years and 20 through 39 years, and women aged 20 through 49 years, regardless of pregnancy status. The mean number of amalgam restorations was higher than that for nonamalgam restorations in older age groups. CONCLUSIONS: Nonamalgam restorations were the most common in the primary teeth of children older than 5 years and in the permanent teeth of adults younger than 40 years. Amalgam restorations were more common in older adults. Amalgam and nonamalgam restorations were equally common in children younger than 5 years. PRACTICAL IMPLICATIONS: The study findings suggest a shift from amalgam to alternative restorative materials in the United States.

BACKGROUND: National data indicate that working-aged adults (20-64 years) are more likely to report financial barriers to receiving needed oral health care relative to other age groups. The aim of this study was to examine the burden of untreated caries (UC) and its association with reporting an unmet oral health care need among working-aged adults. METHODS: The authors used National Health and Nutrition Examination Survey data from 2011 through 2016 for 10,286 dentate adults to examine the prevalence of mild to moderate (1-3 affected teeth) and severe (≥ 4 affected teeth) UC. The authors used multivariable logistic regression to identify factors that were associated with reporting an unmet oral health care need. RESULTS: Low-income adults had mild to moderate UC (26.2%) 2 times more frequently and severe UC (13.2%) 3 times more frequently than higher-income adults. After controlling for covariates, the variables most strongly associated with reporting an unmet oral health care need were UC, low income, fair or poor general health, smoking, and no private health insurance. The model-adjusted prevalence of reporting an unmet oral health care need among low-income adults with mild to moderate and severe UC were 35.7% and 45.1%, respectively. CONCLUSIONS: The burden of UC among low-income adults is high; prevalence was approximately 40% with approximately 3 affected teeth per person on average. Reporting an unmet oral health care need appears to be capturing primarily differences in UC, health, and financial access to oral health care. PRACTICAL IMPLICATIONS: Data on self-reported unmet oral health care need can have utility as a surveillance tool for monitoring UC and targeting resources to decrease UC among low-income adults.

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.

OBJECTIVE: Treatment for hepatitis C virus (HCV) infection is highly effective; however, people who inject drugs (PWID), the population most affected by HCV, may encounter barriers to treatment. We examined the cascade of care for HCV infection among young adult PWID in northern New Mexico, to help identify gaps and opportunities for HCV treatment intervention. METHODS: Young adults (aged 18-29 y) who self-reported injection drug use in the past 90 days were tested for HCV antibodies (anti-HCV) and HCV RNA. We asked participants with detectable RNA to participate in an HCV education session, prior to a referral to a local health care provider for treatment follow-up, and to return for follow-up HCV testing quarterly for 1 year. We measured the cascade of care milestones ranging from the start of screening to achievement of sustained virologic response (SVR). RESULTS: Among 238 participants, the median age was 26 years and 133 (55.9%) were men. Most (90.3%) identified as Hispanic. Of 109 RNA-positive participants included in the cascade of care assessment, 84 (77.1%) received their results, 82 (75.2%) participated in the HCV education session, 61 (56.0%) were linked to care through a medical appointment, 27 (24.8%) attended the HCV treatment appointment, 13 (11.9%) attended their follow-up appointment, 6 (5.5%) initiated treatment, 3 (2.8%) completed treatment, and 1 (0.9%) achieved SVR. CONCLUSIONS: We observed a steeply declining level of engagement at each milestone step of the cascade of care after detection of HCV infection, resulting in a suboptimal level of HCV treatment and cure. Programs that can streamline testing and expand access to treatment from trusted health care providers are needed to improve the engagement of PWID in HCV treatment.

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INTRODUCTION: The COVID-19 pandemic has had unprecedented socioeconomic and health impacts in the U.S. This study examined racial/ethnic and school poverty status differences in the relationship between parent job loss, experiences with hunger, and indicators of mental health problems among public high-school students nationwide during the COVID-19 pandemic. METHODS: The study analyzed data from the Adolescent Behaviors and Experiences Survey, conducted in January-June 2021. The Adolescent Behaviors and Experiences Survey was a 1-time, cross-sectional, online survey that used a stratified, 3-stage cluster sample to obtain a nationally representative sample of high-school students in the U.S. This study was limited to public-school students (n=7,379). RESULTS: Among public high-school students nationwide, 36.9% experienced poor mental health during the pandemic, and during the past year, 43.9% experienced persistent feelings of sadness or hopelessness, 19.8% seriously considered attempting suicide, and 9.1% attempted suicide. Parent job loss and having gone hungry were associated with indicators of mental health problems overall and across racial/ethnic groups and school poverty status levels. CONCLUSIONS: Students who experience parent job loss and hunger are likely to also experience poor mental health and may be at higher risk for suicide.

The Centers for Disease Control and Prevention's (CDC) Division of Adolescent and School Health (DASH) works with local decision makers, schools, youth-serving organizations, and parents across the nation to equip youth with knowledge, skills, and resources needed for healthy adolescence and adulthood. Aligned with this effort, DASH maintains high-quality surveillance systems to understand youth health behaviors and assess school health programs and policies. The Youth Risk Behavior Surveillance System (YRBSS) is a system of surveys administered every other year to high school students. In addition to the national Youth Risk Behavior Survey conducted by CDC, YRBSS features Youth Risk Behavior Surveys (YRBS) conducted by state, territorial, and local education and health agencies and tribal governments across the nation.1 Local decision makers collaborate with partners to develop questionnaires for their respective YRBS, then coordinate data dissemination and utilization. Since its inception in 1991, YRBSS has collected data from more than 5 million high school students in approximately 2200 separate surveys across the United States.1 The School Health Profiles (Profiles) is a system of surveys conducted by state, territorial, and local education and health agencies and tribal governments. These surveys collect data every other year from principals and lead health education teachers to assess school-implemented health programs and policies.2 Since 1994, Profiles data have helped evaluate health programs and informed professional development needs for educators in middle and high schools.2 Together, YRBSS and Profiles offer metrics to inform public health needs, which are then translated into evidence-based programs to protect youth.

Social determinants of health (SDOH) are not new. For example, observational data over 40 years have shown consistent—and often heart-wrenching—differences in diabetes outcomes across populations, where populations at socioeconomic disadvantage, in terms of lower education and income levels, experience less access to care and preventive services,1 lower rates of diagnosis, poorer health behaviors and control,2 worse cardiometabolic outcomes,3 and shorter life expectancy as compared with more advantaged populations of higher socioeconomic status.4 These findings suggest that diabetes is not a purely biological issue; its onset and progression are heavily influenced by the broader social context. In particular, type 2 diabetes is in large part the result of choices that people are unable to make based on the health-promoting resources and opportunities available and accessible to them.5 In in the USA, social and economic stressors and related disparities are patterned by geography and race/ethnicity.6 Type 2 diabetes, therefore, is as much an issue of where you live, as it is an issue of how you live.

Soil-transmitted helminth (STH) infections and diarrheal illness affect billions of people yearly. We conducted a cross-sectional survey in Nueva Santa Rosa, Guatemala to identify factors associated with STH infections and diarrhea using univariable and multivariable logistic regression models. On multivariable analyses, we found associations between STH infections and two factors: school-aged children (odds ratio (OR) vs. adults: 2.35, 95% CI 1.10–4.99) and household drinking water supply classified as ‘other improved’ (OR vs. ‘improved’: 7.00, CI 1.22–40.14). Finished floors in the household vs. natural floors were highly protective (OR 0.16, CI 0.05–0.50) for STH infection. In crowded households (>2.5 people/bedroom), observing water present at handwashing stations was also protective (OR 0.32, CI 0.11–0.98). When adjusted for drying hands, diarrhea was associated with preschool-age children (OR vs. adults: 3.33, CI 1.83–6.04), spending >10 min per round trip collecting water (OR 1.90, CI 1.02–3.56), and having a handwashing station ≤10 m near a sanitation facility (OR 3.69, CI 1.33–10.21). Our study indicates that familiar WASH interventions, such as increasing drinking water quantity and water at handwashing stations in crowded homes, coupled with a hygiene intervention like finished flooring may hold promise for STH and diarrhea control programs. © 2021 The Authors.

More than 19% of third-graders in Georgia had untreated dental caries (tooth decay) in 2016–2017 (1). The national average among children of similar age (6–9 y) was 15.5% in 2013–2016 (2). Untreated tooth decay can cause pain and infection and impair eating, speaking, and learning. Among children it can lead to missed school days and lower academic performance (3). The most recent US data indicated that 34 million school hours were missed in 2007 as a result of acute unplanned dental care needs (4). | | Dental sealants (5), topical fluoride (6), and restorative care are effective in preventing tooth decay. Most caries-prevention programs are implemented at the local level. The prevalence of untreated tooth decay, however, varies by geographic area — ranging from 8.2% to 32% among third-graders across 29 states during 2013–2016 (1). By county, modeled estimates among children aged 6 to 9 years nationwide ranged from 4.9% to 65.2% (7). Thus, having local data on the risk of untreated tooth decay and dental workforce capacity is critical to effectively target dental safety-net programs for children at highest risk of untreated tooth decay. | | We developed a data visualization tool that maps county-level need for caries prevention and treatment programs and the distribution of dental safety-net programs in Georgia. This tool can be used by public health decision makers to 1) assess how well dental safety-net programs are currently allocated and 2) plan and target future programs.

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.

BACKGROUND: A safe and effective vaccine to prevent chronic hepatitis C virus (HCV) infection is a critical component of efforts to eliminate the disease. METHODS: In this phase 1-2 randomized, double-blind, placebo-controlled trial, we evaluated a recombinant chimpanzee adenovirus 3 vector priming vaccination followed by a recombinant modified vaccinia Ankara boost; both vaccines encode HCV nonstructural proteins. Adults who were considered to be at risk for HCV infection on the basis of a history of recent injection drug use were randomly assigned (in a 1:1 ratio) to receive vaccine or placebo on days 0 and 56. Vaccine-related serious adverse events, severe local or systemic adverse events, and laboratory adverse events were the primary safety end points. The primary efficacy end point was chronic HCV infection, defined as persistent viremia for 6 months. RESULTS: A total of 548 participants underwent randomization, with 274 assigned to each group. There was no significant difference in the incidence of chronic HCV infection between the groups. In the per-protocol population, chronic HCV infection developed in 14 participants in each group (hazard ratio [vaccine vs. placebo], 1.53; 95% confidence interval [CI], 0.66 to 3.55; vaccine efficacy, -53%; 95% CI, -255 to 34). In the modified intention-to-treat population, chronic HCV infection developed in 19 participants in the vaccine group and 17 in placebo group (hazard ratio, 1.66; 95% CI, 0.79 to 3.50; vaccine efficacy, -66%; 95% CI, -250 to 21). The geometric mean peak HCV RNA level after infection differed between the vaccine group and the placebo group (152.51×10(3) IU per milliliter and 1804.93×10(3) IU per milliliter, respectively). T-cell responses to HCV were detected in 78% of the participants in the vaccine group. The percentages of participants with serious adverse events were similar in the two groups. CONCLUSIONS: In this trial, the HCV vaccine regimen did not cause serious adverse events, produced HCV-specific T-cell responses, and lowered the peak HCV RNA level, but it did not prevent chronic HCV infection. (Funded by the National Institute of Allergy and Infectious Diseases; ClinicalTrials.gov number, NCT01436357.).

AIMS: We assessed prevalence and correlates for hepatitis C virus (HCV) infection in young adult people who inject drugs (PWID) in rural New Mexico, where opioid use has been historically problematic. METHODS: Participants were 18-29 years old with self-reported injection drug use in the past 90 days. We conducted testing for HCV antibodies (anti-HCV) and HCV ribonucleic acid (RNA) and assessed sociodemographic and risk exposures. We provided counseling and referrals to prevention services and drug treatment. We estimated prevalence ratios (PR) to assess bivariate associations with HCV infection; and adjusted PRs using modified Poisson regression methods. RESULTS: Among 256 participants tested for anti-HCV, 156 (60.9 %) had been exposed (anti-HCV positive), and of 230 tested for both anti-HCV and HCV RNA, 103 (44.8 %) had current infection (RNA-positive). The majority (87.6 %) of participants were Hispanic. Almost all (96.1 %) had ever injected heroin; 52.4 % and 52.0 % had ever injected methamphetamine or cocaine, respectively. Polysubstance injecting (heroin and any other drug) was associated with significantly higher prevalence of HCV infection (76.0 %) compared to injecting only heroin (24.0 %) (PR: 3.17 (95 % CI:1.93, 5.23)). Years of injecting, history of non-fatal opioid-involved overdose, polysubstance injecting, and stable housing were independently associated with HCV infection. CONCLUSIONS: HCV is highly prevalent among young adult PWID in rural NM. The high reported prevalence of polysubstance injecting and its association with HCV infection should be considered in prevention planning.

OBJECTIVE: To measure the association between dental and medical insurance with the receipt of dental cleaning during pregnancy. METHODS: We analyzed Pregnancy Risk Assessment Monitoring System (PRAMS) data from 2012 to 2015 on 145,051 women with a recent live birth from 36 states. We used adjusted prevalence ratios [aPR] from multivariable regression to examine the association of dental and medical insurance with receipt of dental cleaning during pregnancy, controlling for selected covariates that influence dental care utilization. RESULTS: Seventy-seven percent (77%) of all women reported having dental insurance during pregnancy. Receipt of dental cleaning before pregnancy was strongly associated with dental cleaning during pregnancy. Among women without pre-pregnancy dental cleaning who had dental insurance, those with Medicaid medical insurance had a significantly higher prevalence of dental cleaning during pregnancy [aPR = 1.42, 95% CI (1.32 - 1.52)], compared to those private medical insurance. Among women without pre-pregnancy dental cleaning, those without dental insurance but with Medicaid medical insurance were about 70% less likely to have dental cleaning during pregnancy compared to those with dental and private medical insurance. CONCLUSIONS FOR PRACTICE: With or without dental insurance, pre-pregnancy dental cleaning was strongly associated with dental cleaning during pregnancy. Dental insurance was an important determinant of dental utilization. Medical insurance had an independent and positive effect. This effect varied by private versus Medicaid medical insurance. Programs which provide women with dental insurance both before and during pregnancy could improve the oral health of maternal and infant populations.

INTRODUCTION: Untreated dental caries (UC), although preventable, is the most prevalent disease in the United States. UC diminishes quality of life and lowers productivity for millions of Americans and is notably higher among lower-income compared to higher-income persons. OBJECTIVE: This study examines changes in disparities by income in past-year dental use (DU) and UC in 4 life stages (2-5, 6-19, 20-64, and >/=65 y) between 1999-2004 and 2011-2016. We also examined changes in dental safety net policies during this time. METHODS: We obtained data on dependent variables, UC and DU, from cross-sectional, nationally representative surveys for 1999-2004 and 2011-2016. We used multivariable regression models with 3 main-effect explanatory variables: income (<200% or >/=200% federal poverty level), life stage, and survey period (1999-2004 or 2011-2016) and sociodemographic variables. We included 2-way interaction terms among main-effect variables to test whether disparities had changed over time in each life stage and a 3-way term to test changes in disparities differed across life stages. RESULTS: Model-adjusted disparities in DU decreased for both preschool-age and school-age children, and disparities in UC decreased for school-age children. Changes in DU and UC disparities were not detectable for working-age adults and increased for retirement-age adults. Changes in DU and UC among preschool and school-age children were not significantly different from one another and were significantly different from changes among retirement-age adults. Compared to working-age adults, changes in disparities for DU and UC were significantly different for school-age children, and changes in DU were significantly different for preschool-age children. Between surveys, the dental safety net was expanded for youth but remained largely unchanged for adults. CONCLUSIONS: Expanding the dental safety net for youth could have contributed to increased access to dental care among children relative to adults and contributed to the decrease in disparities in DU and UC among youth. Knowledge Transfer Statement: Between 1999-2004 and 2011-2016, the dental safety net was expanded for youth but remained largely unchanged for adults. Using national survey data to compare changes in disparities in past-year dental use and untreated dental caries by income between adults and youth sheds light on the potential impact of expanding the dental safety net.

In Zambia limited access to adequate water and sanitation is a key developmental challenge, particularly for rapidly expanding peri-urban areas. During 20162017, a cross-sectional household survey was conducted among 12,500 households representing ~60,000 individuals to assess the burden of household diarrheal and respiratory disease and to measure water, sanitation, and hygiene (WASH) characteristics in Lusaka, Zambia. We found that socio-economic factors, including having an additional household member, having children <5 years old in the household, living in a rental home, and higher annual household expenditure were associated with diarrhea and respiratory illness. We also found an increased risk for diarrhea associated with a number of WASH-related factorssuch as not covering all water storage containers, not using soap for handwashing, having an unimproved sanitation facility, and utilizing a heavily shared toilet (18 people). Detectable free chlorine residual in household stored water and more hours of water availability per day were associated with reduced odds of waterborne illness. In all, 75% of household stored water was contaminated with E. coli and households consuming less water (<20 L/day per person) for all purposes had lower odds of diarrhea than households consuming more waterthese findings highlight the need for enhanced WASH services within densely populated peri-urban areas and the importance of achieving universal access to safely managed water and sanitation services.

Extensive tooth loss can lead to poor diet resulting in weight loss or obesity (1). It can also detract from physical appearance and impede speech, factors that can restrict social contact, inhibit intimacy, and lower self-esteem (1). Chronic medical conditions and oral conditions share common risk factors (2). Persons with chronic conditions are more likely to have untreated dental disease, which can result in tooth loss. Three measures of tooth loss during 1999-2004 and 2011-2016 were estimated by comparing data from the National Health and Nutrition Examination Survey (NHANES) for each period among adults aged >/=50 years with selected chronic conditions.* The three measures were 1) edentulism (having no teeth); 2) severe tooth loss (having eight or fewer teeth) (3); and 3) lacking functional dentition (having <20 teeth out of 28, which is considered a full set for the purpose of NHANES assessments) (4). During 2011-2016, prevalences of edentulism and severe tooth loss were >/=50% higher among adults with fair or poor general health, rheumatoid arthritis, asthma, diabetes, emphysema, heart disease, liver condition, or stroke than among those with those adults without the chronic condition. Lack of functional dentition was also more prevalent among adults with chronic conditions than among persons without these conditions. Tooth loss is preventable with self-care and routine dental visits (1). To encourage these behaviors, public health professionals can educate the public about the association between having a chronic condition and tooth loss, and primary care providers can educate their patients about the importance of healthy behaviors and screen and refer them for needed dental care.

Two decades ago, a wave of effectiveness trials demonstrating the enormous potential to reduce both diabetes and its complications gave a new stimulus to implementation research intended to find the best ways to translate, implement, and evaluate prevention through mediums of public health action.1–3 This burgeoning research portfolio largely used approaches that were limited by the available data infrastructures and study designs of the day. For example, translating primary prevention of diabetes employed pragmatic, randomized implementation studies, using the proof of concept of prevention but modifying the target population, context, dosage, or delivery mode.4 Similarly, translation studies to improve care for diabetes focused on trials or observations of the health care delivery unit and how changes in team composition and workflows, information sharing, communication, or decision support could improve real-world delivery of care.5,6 These efforts contributed to long-term reductions in diabetes complications in the United States and laid the groundwork for broader efforts to scale up primary prevention.7,8 Despite these successes, though, the impact of the diabetes epidemic is persistent and unpredictable.9 National surveillance data of diabetes complications and the cascades of care have shown that the diffusion of effective interventions is often patchwork and selective, and there has been no narrowing of the socioeconomic disparities that have characterized the diabetes epidemic.10–12 Further, there is new evidence of an increasing divide along age and socioeconomic lines.13

Obesity and type 2 diabetes disproportionately impact U.S. racial and ethnic minority communities and low-income populations. Improvements in implementing efficacious interventions to reduce the incidence of type 2 diabetes are underway (i.e., the National Diabetes Prevention Program), but challenges in effectively scaling-up successful interventions and reaching at-risk populations remain. In October 2017, the National Institutes of Health convened a workshop to understand how to (1) address socioeconomic and other environmental conditions that perpetuate disparities in the burden of obesity and type 2 diabetes; (2) design effective prevention and treatment strategies that are accessible, feasible, culturally relevant, and acceptable to diverse population groups; and (3) achieve sustainable health improvement approaches in communities with the greatest burden of these diseases. Common features of guiding frameworks to understand and address disparities and promote health equity were described. Promising research directions were identified in numerous areas, including study design, methodology, and core metrics; program implementation and scalability; the integration of medical care and social services; strategies to enhance patient empowerment; and understanding and addressing the impact of psychosocial stress on disease onset and progression in addition to factors that support resiliency and health.

BACKGROUND: In April 2015, in collaboration with U.S. CDC and Gilead Sciences, Georgia embarked on the world's first hepatitis C elimination program. We aimed to assess progress towards elimination targets after three years since the beginning of the elimination program. METHODS: We constructed an HCV care cascade for adults in Georgia, based on the estimated 150,000 persons age >/= 18 years with active HCV infection. All patients who were screened or entered the treatment program during April 2015 - March 2018 were included in the analysis. Data on the number of persons screened for HCV was extracted from the national HCV screening database. For treatment component we utilized data from the Georgia National HCV treatment program database. Available treatment options included sofosbuvir (SOF) and ledipasvir/sofosbuvir (LDV/SOF) based regimens. RESULTS: Since April 2015, a cumulative 974,817 adults were screened for HCV antibodies, 86,624 persons tested positive, of which 61,925 underwent HCV confirmatory testing. Among estimated 150,000 adults living with chronic hepatitis C in Georgia, 52,856 (35.1%) were diagnosed, 45,334 (30.2%) initiated treatment with DAA, and 29,090 (19.4%) achieved sustained virologic response (SVR). Overall 37,256 persons were eligible for SVR assessment, of these only 29,620 (79.5%) returned for evaluation. In the per-protocol analysis, SVR rate achieved was 98.2% (29,090/29,620), and 78.1% (29,090/37,256) in the intent-to-treat analysis. CONCLUSIONS: Georgia has made substantial progress in the path towards eliminating hepatitis C. Scaling-up testing and diagnosis, along with effective linkage to treatment services are needed to achieve the goal of elimination.

BACKGROUND: Following implementation in 2009-2010 to the oral health component for the National Health and Nutrition Examination Survey (NHANES), a full-mouth periodontal examination was continued during 2011-2014. Additionally, a comprehensive dental caries assessment was re-introduced in 2011 after a 6-year absence from NHANES. This report provides oral health content information and results of dental examiner reliability statistics for key intraoral assessments conducted by dentists during 2011-2014. METHODS: During the 2011-2014 NHANES 17,463 persons age 1 and older representing the US civilian, non-institutionalized population received an oral health examination. From this group, 387 individuals underwent a repeat examination conducted by the survey reference examiner. A combination of examiner training and calibration, electronic data capture, and ongoing performance evaluation with statistical monitoring was used to ensure conformance with NHANES protocols and data comparability to prior data collection periods. RESULTS: During 2011-2014, the Kappa statistics for the tooth count assessment ranged from 0.96 to 1.00, for untreated dental caries Kappa scores were 0.93 to 1.00. The overall Kappa statistics for identifying combined moderate-severe periodontitis using the CDC/AAP case definition was 0.66 and 0.69 with percent agreement of 83 to 85% during 2011-2014. When evaluating inter-examiner agreement using information collected from 3 periodontal sites for comparability to the NHANES 2003-04 periodontal examination protocols, Kappa scores for combined moderate-severe periodontitis was 0.65 and 0.80 during 2011-2014. For total mean attachment loss and pocket depth across all 6 periodontal sites, the inter-class coefficients (ICCs) ranged from 0.80-0.90 and 0.79-0.86 respectively. Site-specific mean attachment loss ICCs were generally higher for the 4 interproximal measurements compared to the 2 mid-site probing measurements and this observation was similar in 2009-2010. CONCLUSION: During 2011-2014, results overall indicate a high level of data quality and substantial examiner reliability for tooth count and dentition; reliability for periodontal disease, across various assessments, was at least moderate. When comparing the 2011-2014 examiner performance to findings from 2003 to 2004, comparable concordance between the examiners and the reference examiner exists.