INTRODUCTION: Approximately 49,000 persons died by suicide in the United States in 2022, and provisional data indicate that a similar number died by suicide in 2023. A comprehensive approach that addresses upstream community risk and protective factors is an important component of suicide prevention. A better understanding of the role of these factors is needed, particularly among disproportionately affected populations. METHODS: Suicide deaths were identified in the 2022 National Vital Statistics System. County-level factors, identified from federal data sources, included health insurance coverage, household broadband Internet access, and household income. Rates and levels of factors categorized by tertiles were calculated and presented by race and ethnicity, sex, age, and urbanicity. RESULTS: In 2022, the overall suicide rate was 14.2 per 100,000 population; rates were highest among non-Hispanic American Indian or Alaska Native (AI/AN) persons (27.1), males (23.0), and rural residents (20.0). On average, suicide rates were lowest in counties in the top one third of percentage of persons or households with health insurance coverage (13.0), access to broadband Internet (13.3), and income >100% of the federal poverty level (13.5). These factors were more strongly associated with lower suicide rates in some disproportionately affected populations; among AI/AN persons, suicide rates in counties in the highest tertile of these factors were approximately one half the rates of counties in the lowest tertile. CONCLUSIONS AND IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: Higher levels of health insurance coverage, household broadband Internet access, and household income in communities might play a role in reducing suicide rates. Upstream programs, practices, and policies detailed in CDC's Suicide Prevention Resource for Action can be implemented by decision-makers, government agencies, and communities as they work together to address community-specific needs and save lives.

This article summarizes what is currently known about the 2019 novel coronavirus and offers interim guidance.

BACKGROUND: Data on medium-term outcomes in indivduals with myocarditis after mRNA COVID-19 vaccination are scarce. We aimed to assess clinical outcomes and quality of life at least 90 days since onset of myocarditis after mRNA COVID-19 vaccination in adolescents and young adults. METHODS: In this follow-up surveillance study, we conducted surveys in US individuals aged 12-29 years with myocarditis after mRNA COVID-19 vaccination, for whom a report had been filed to the Vaccine Adverse Event Reporting System between Jan 12 and Nov 5, 2021. A two-component survey was administered, one component to patients (or parents or guardians) and one component to health-care providers, to assess patient outcomes at least 90 days since myocarditis onset. Data collected were recovery status, cardiac testing, and functional status, and EuroQol health-related quality-of-life measures (dichotomised as no problems or any problems), and a weighted quality-of-life measure, ranging from 0 to 1 (full health). The EuroQol results were compared with published results in US populations (aged 18-24 years) from before and early on in the COVID-19 pandemic. FINDINGS: Between Aug 24, 2021, and Jan 12, 2022, we collected data for 519 (62%) of 836 eligible patients who were at least 90 days post-myocarditis onset: 126 patients via patient survey only, 162 patients via health-care provider survey only, and 231 patients via both surveys. Median patient age was 17 years (IQR 15-22); 457 (88%) patients were male and 61 (12%) were female. 320 (81%) of 393 patients with a health-care provider assessment were considered recovered from myocarditis by their health-care provider, although at the last health-care provider follow-up, 104 (26%) of 393 patients were prescribed daily medication related to myocarditis. Of 249 individuals who completed the quality-of-life portion of the patient survey, four (2%) reported problems with self-care, 13 (5%) with mobility, 49 (20%) with performing usual activities, 74 (30%) with pain, and 114 (46%) with depression. Mean weighted quality-of-life measure (0·91 [SD 0·13]) was similar to a pre-pandemic US population value (0·92 [0·13]) and significantly higher than an early pandemic US population value (0·75 [0·28]; p<0·0001). Most patients had improvements in cardiac diagnostic marker and testing data at follow-up, including normal or back-to-baseline troponin concentrations (181 [91%] of 200 patients with available data), echocardiograms (262 [94%] of 279 patients), electrocardiograms (240 [77%] of 311 patients), exercise stress testing (94 [90%] of 104 patients), and ambulatory rhythm monitoring (86 [90%] of 96 patients). An abnormality was noted among 81 (54%) of 151 patients with follow-up cardiac MRI; however, evidence of myocarditis suggested by the presence of both late gadolinium enhancement and oedema on cardiac MRI was uncommon (20 [13%] of 151 patients). At follow-up, most patients were cleared for all physical activity (268 [68%] of 393 patients). INTERPRETATION: After at least 90 days since onset of myocarditis after mRNA COVID-19 vaccination, most individuals in our cohort were considered recovered by health-care providers, and quality of life measures were comparable to those in pre-pandemic and early pandemic populations of a similar age. These findings might not be generalisable given the small sample size and further follow-up is needed for the subset of patients with atypical test results or not considered recovered. FUNDING: US Centers for Disease Control and Prevention.

On May 17, 2022, the Massachusetts Department of Public Health (MDPH) Laboratory Response Network (LRN) laboratory confirmed the presence of orthopoxvirus DNA via real-time polymerase chain reaction (PCR) from lesion swabs obtained from a Massachusetts resident. Orthopoxviruses include Monkeypox virus, the causative agent of monkeypox. Subsequent real-time PCR testing at CDC on May 18 confirmed that the patient was infected with the West African clade of Monkeypox virus. Since then, confirmed cases* have been reported by nine states. In addition, 28 countries and territories,(†) none of which has endemic monkeypox, have reported laboratory-confirmed cases. On May 17, CDC, in coordination with state and local jurisdictions, initiated an emergency response to identify, monitor, and investigate additional monkeypox cases in the United States. This response has included releasing a Health Alert Network (HAN) Health Advisory, developing interim public health and clinical recommendations, releasing guidance for LRN testing, hosting clinician and public health partner outreach calls, disseminating health communication messages to the public, developing protocols for use and release of medical countermeasures, and facilitating delivery of vaccine postexposure prophylaxis (PEP) and antivirals that have been stockpiled by the U.S. government for preparedness and response purposes. On May 19, a call center was established to provide guidance to states for the evaluation of possible cases of monkeypox, including recommendations for clinical diagnosis and orthopoxvirus testing. The call center also gathers information about possible cases to identify interjurisdictional linkages. As of May 31, this investigation has identified 17(§) cases in the United States; most cases (16) were diagnosed in persons who identify as gay, bisexual, or men who have sex with men (MSM). Ongoing investigation suggests person-to-person community transmission, and CDC urges health departments, clinicians, and the public to remain vigilant, institute appropriate infection prevention and control measures, and notify public health authorities of suspected cases to reduce disease spread. Public health authorities are identifying cases and conducting investigations to determine possible sources and prevent further spread. This activity was reviewed by CDC and conducted consistent with applicable federal law and CDC policy.(¶).

Rabies transmitted by common vampire bats (Desmodus rotundus) has been known since the early 1900s but continues to expand geographically and in the range of species and environments affected. In this review, we present current knowledge of the epidemiology and management of rabies in D. rotundus and argue that it can be reasonably considered an emerging public health threat. We identify knowledge gaps related to the landscape determinants of the bat reservoir, reduction in bites on humans and livestock, and social barriers to prevention. We discuss how new technologies including autonomously-spreading vaccines and reproductive suppressants targeting bats might manage both rabies and undesirable growth of D. rotundus populations. Finally, we highlight widespread under-reporting of human and animal mortality and the scarcity of studies that quantify the efficacy of control measures such as bat culling. Collaborations between researchers and managers will be crucial to implement the next generation of rabies management in Latin America.

BACKGROUND: Although Peru provides safe and effective influenza vaccines free-of-charge, coverage among vaccine target groups like pregnant women and older adults remains low. To improve risk communication messages and vaccine uptake, we explored knowledge, perceptions and practices about influenza illness and vaccination. METHODS: A cross-sectional, community-based survey with a three-stage cluster sampling design was conducted in three cities in Peru. We included mothers of young children, pregnant women and persons >/=65 years. Participants completed a questionnaire about knowledge, perceptions and practices about influenza illness and vaccination against influenza during the past year. Generalized linear models were used to explore factors associated with vaccination in the past year. RESULTS: 624/645 (97%) mothers, 54/55 (98%) pregnant women and 622/673 (92%) older adults approached provided informed consent and were surveyed. While most mothers, pregnant women and older adults (94%, 96% and 91%, respectively) perceived influenza as a potentially serious illness, few pregnant women (13%) and older adults (34%) self-identified themselves as a target group for influenza vaccination. Only 28% of mothers, 19% pregnant women, and 27% older adults were vaccinated against influenza during the previous year. Among the participants that did not get vaccinated against influenza in the previous year, "being afraid of vaccination and its effects" was the most commonly cited barrier. Knowledge of the recommendation for annual vaccination was significantly associated with vaccination status among pregnant women (p = 0.048) and older adults (p = 0.004). CONCLUSION: Despite a government subsidized vaccine program, vaccine utilization remained low among pregnant women and older adults, who seemed typically unaware of their status as high-risk groups targeted for vaccination. Those aware of the recommendations for annual vaccination were more likely to be vaccinated. Information campaigns addressing fears and highlighting populations at risk for severe influenza illness that are targeted for vaccination might increase vaccine coverage in Peru.

Unrecognized transmission of pathogens in healthcare settings can lead to colonization and infection of both patients and healthcare personnel. The use of personal protective equipment (PPE) is an important strategy to protect healthcare personnel from contamination and to prevent the spread of pathogens to subsequent patients. However, optimal PPE use is difficult, and healthcare personnel may alter delivery of care because of the PPE. Here, we summarize recent research from the Prevention Epicenters Program on healthcare personnel contamination and improvement of the routine use of PPE as well as Ebola-specific PPE. Future efforts to optimize the use of PPE should include increasing adherence to protocols for PPE use, improving PPE design, and further research into the risks, benefits, and best practices of PPE use.

During a pandemic caused by a novel strain of influenza virus, it is estimated that more than 68 million people in the United States may seek acute medical care.1-3 Providing protection for healthcare personnel who care for patients is essential to ensure continuity of healthcare services during a public health emergency, including a pandemic.4 However, at the onset of a pandemic, a well-matched vaccine may not be available, and limited supplies of antiviral medications will likely be reserved primarily for treatment of ill patients, instead of prophylaxis. While a hierarchy of infection prevention measures will be widely used, surges of infectious patients may leave many healthcare personnel to use respiratory protective devices (RPDs) as a primary means of self-protection.5 To promote healthcare worker protection against occupational exposures, the Centers for Disease Control and Prevention (CDC) has sought to understand the optimal roles of RPDs, such as N95 filtering facepiece respirators (N95) and surgical masks (sometimes called medical masks), in the context of a pandemic. Prioritization of RPD allocation to healthcare personnel to limit exposures will require critical deliberation as demand outstrips RPD availability. To arrive at a rational, equitable, and transparent allocation process, stakeholders should build on lessons learned about personal protective equipment (PPE) supply chain from recent outbreaks, such as the 2009 H1N1 influenza pandemic, the 2013-14 H7N9 influenza outbreak, and the 2014 Ebola epidemic.6

Hypertension affects about one in three US adults, from recent surveillance, or four in nine based on the 2017 ACC/AHA Hypertension Guideline; about half of them have their blood pressure controlled, and nearly one in six are unaware of their hypertension status. National estimates of hypertension awareness, treatment, and control in the United States are traditionally based on measured BP from National Health and Nutrition Examination Survey (NHANES); however, at the state level, only self-reported hypertension awareness and treatment are available from BRFSS. We used national- and state-level representative samples of adults (>/=20 years) from NHANES 2011-2014 and BRFSS 2013 and 2015, respectively. The authors generated multivariable logistic regression models using NHANES to predict the probability of hypertension and undiagnosed hypertension and then applied the fitted model parameters to BRFSS to generate state-level estimates. The predicted prevalence of hypertension was highest in Mississippi among adults (42.4%; 95% CI: 41.8-43.0) and among women (42.6%; 41.8-43.4) and highest in West Virginia among men (43.4%; 42.2-44.6). The predicted prevalence was lowest in Utah 23.7% (22.8-24.6), 26.4% (25.0-27.7), and 21.0% (20.0-22.1) for adults, men, and women, respectively. Hypertension predicted prevalence was higher in most Southern states and higher among men than women in all states except Mississippi and DC. The predicted prevalence of undiagnosed hypertension ranged from 4.1% (3.4-4.8; Kentucky) to 6.5% (5.5-7.5; Hawaii) among adults, from 5.0% (4.0-5.9; Kentucky) to 8.3% (6.9-9.7; Hawaii) among men, and from 3.3% (2.5-4.1; Kentucky) to 4.8% (3.4-6.1; Vermont) among women. Undiagnosed hypertension was more prevalent among men than women in all states and DC.

Melioidosis, a disease caused by the pathogen Burkholderia pseudomallei, is a significant underreported endemic disease found in tropical countries worldwide. Recent studies have demonstrated that human melioidosis cases have been increasingly recognized in the Americas. Therefore, the first Scientific Reunion of Melioidosis in the Americas was organized in Colombia, with the participation of health authorities of 11 Latin American countries and the United States. This report summarizes the topics reviewed during the meeting, including how to identify human infections and properly diagnose them, with the goal of increasing recognition of the disease in the Americas.

Anticipating how epidemics will spread across landscapes requires understanding host dispersal events that are notoriously difficult to measure. Here, we contrast host and virus genetic signatures to resolve the spatiotemporal dynamics underlying geographic expansions of vampire bat rabies virus (VBRV) in Peru. Phylogenetic analysis revealed recent viral spread between populations that, according to extreme geographic structure in maternally inherited host mitochondrial DNA, appeared completely isolated. In contrast, greater population connectivity in biparentally inherited nuclear microsatellites explained the historical limits of invasions, suggesting that dispersing male bats spread VBRV between genetically isolated female populations. Host nuclear DNA further indicated unanticipated gene flow through the Andes mountains connecting the VBRV-free Pacific coast to the VBRV-endemic Amazon rainforest. By combining Bayesian phylogeography with landscape resistance models, we projected invasion routes through northern Peru that were validated by real-time livestock rabies mortality data. The first outbreaks of VBRV on the Pacific coast of South America could occur by June 2020, which would have serious implications for agriculture, wildlife conservation, and human health. Our results show that combining host and pathogen genetic data can identify sex biases in pathogen spatial spread, which may be a widespread but underappreciated phenomenon, and demonstrate that genetic forecasting can aid preparedness for impending viral invasions.

Against the backdrop of late 20th century declines in heart disease mortality in the United States, race-specific rates diverged because of slower declines among blacks compared with whites. To characterize the temporal dynamics of emerging black-white racial disparities in heart disease mortality, we decomposed race-sex-specific trends in an age-period-cohort (APC) analysis of US mortality data for all diseases of the heart among adults aged ≥35 years from 1973 to 2010. The black-white gap was largest among adults aged 35-59 years (rate ratios ranged from 1.2 to 2.7 for men and from 2.3 to 4.0 for women) and widened with successive birth cohorts, particularly for men. APC model estimates suggested strong independent trends across generations ("cohort effects") but only modest period changes. Among men, cohort-specific black-white racial differences emerged in the 1920-1960 birth cohorts. The apparent strength of the cohort trends raises questions about life-course inequalities in the social and health environments experienced by blacks and whites which could have affected their biomedical and behavioral risk factors for heart disease. The APC results suggest that the genesis of racial disparities is neither static nor restricted to a single time scale such as age or period, and they support the importance of equity in life-course exposures for reducing racial disparities in heart disease.

OBJECTIVE: Consider all metabolic syndrome (MetS) components [systolic (SBP) and diastolic (DBP) blood pressures, waist circumference, HDL cholesterol, triglycerides (TG), and fasting glucose] and gender/race differential risk when assessing cardiovascular disease (CVD) risk. METHODS: We estimated a gender- and race-specific continuous MetS score using structural equation modeling and tested its association with CVD mortality using data from National Health and Nutrition Examination Survey III linked with the National Death Index. Cox proportional hazard regression tested the association adjusted for sociodemographic and behavior characteristics. RESULTS: For men, continuous MetS components associated with CVD mortality were SBP (hazard ratio = 1.50, 95% confidence interval = 1.14-1.96), DBP (1.48, 1.16-1.90), and TG (1.15, 1.12-1.16). In women, SBP (1.44, 1.27-1.63) and DBP (1.24, 1.02-1.51) were associated with CVD mortality. MetS score was not significantly associated with CVD mortality in men; but significant associations were found for all women (1.34, 1.06-1.68), non-Hispanic white women (1.29, 1.01-1.64), non-Hispanic black women (2.03, 1.12-3.69), and Mexican-American women (3.57, 2.21-5.76). Goodness-of-fit and concordance were overall better for models with the MetS score than MetS (yes/no). CONCLUSIONS: When assessing CVD mortality risk, MetS score provided additional information than MetS (yes/no).

BACKGROUND: Limited data are available on the accuracy of 24-h dietary recalls used to monitor US sodium and potassium intakes. OBJECTIVE: We examined the difference in usual sodium and potassium intakes estimated from 24-h dietary recalls and urine collections. DESIGN: We used data from a cross-sectional study in 402 participants aged 18-39 y ( approximately 50% African American) in the Washington, DC, metropolitan area in 2011. We estimated means and percentiles of usual intakes of daily dietary sodium (dNa) and potassium (dK) and 24-h urine excretion of sodium (uNa) and potassium (uK). We examined Spearman's correlations and differences between estimates from dietary and urine measures. Multiple linear regressions were used to evaluate the factors associated with the difference between dietary and urine measures. RESULTS: Mean differences between diet and urine estimates were higher in men [dNa - uNa (95% CI) = 936.8 (787.1, 1086.5) mg/d and dK - uK = 571.3 (448.3, 694.3) mg/d] than in women [dNa - uNa (95% CI) = 108.3 (11.1, 205.4) mg/d and dK - uK = 163.4 (85.3, 241.5 mg/d)]. Percentile distributions of diet and urine estimates for sodium and potassium differed for men. Spearman's correlations between measures were 0.16 for men and 0.25 for women for sodium and 0.39 for men and 0.29 for women for potassium. Urinary creatinine, total caloric intake, and percentages of nutrient intake from mixed dishes were independently and consistently associated with the differences between diet and urine estimates of sodium and potassium intake. For men, body mass index was also associated. Race was associated with differences in estimates of potassium intake. CONCLUSIONS: Low correlations and differences between dietary and urinary sodium or potassium may be due to measurement error in one or both estimates. Future analyses using these methods to assess sodium and potassium intake in relation to health outcomes may consider stratifying by factors associated with the differences in estimates from these methods. This trial was registered at clinicaltrials.gov as NCT01631240.

OBJECTIVES: We evaluated trends and disparities in stroke death rates for American Indians and Alaska Natives (AI/ANs) and White people by Indian Health Service region. METHODS: We identified stroke deaths among AI/AN persons and Whites (adults aged 35 years or older) using National Vital Statistics System data for 1990 to 2009. We used linkages with Indian Health Service patient registration data to adjust for misclassification of race for AI/AN persons. Analyses excluded Hispanics and focused on Contract Health Service Delivery Area (CHSDA) counties. RESULTS: Stroke death rates among AI/AN individuals were higher than among Whites for both men and women in CHSDA counties and were highest in the youngest age groups. Rates and AI/AN:White rate ratios varied by region, with the highest in Alaska and the lowest in the Southwest. Stroke death rates among AI/AN persons decreased in all regions beginning in 2001. CONCLUSIONS: Although stroke death rates among AI/AN populations have decreased over time, rates are still higher for AI/AN persons than for Whites. Interventions that address reducing stroke risk factors, increasing awareness of stroke symptoms, and increasing access to specialty care for stroke may be more successful at reducing disparities in stroke death rates.

INTRODUCTION: Preventable hospitalizations for angina have been decreasing since the late 1980s - most likely because of changes in guidance, physician coding practices, and reimbursement. We asked whether this national decline has continued and whether preventable emergency department visits for angina show a similar decline. METHODS: We used National Hospital Discharge Survey data from 1995 through 2010 and National Hospital Ambulatory Medical Care Survey data from 1995 through 2009 to study preventable hospitalizations and emergency department visits, respectively. We calculated both crude and standardized rates for these visits according to technical specifications published by the Agency for Healthcare Research and Quality, which uses population estimates from the US Census Bureau as the denominator for the rates. RESULTS: Crude hospitalization rates for angina declined from 1995-1998 to 2007-2010 for men and women in all 3 age groups (18-44, 45-64, and ≥65) and age- and sex-standardized rates declined in a linear fashion (P = .02). Crude rates for preventable emergency department visits for angina declined for men and women aged 65 or older from 1995-1998 to 2007-2009. Age- and sex-standardized rates for these visits showed a linear decline (P = .05). CONCLUSION: We extend previous research by showing that preventable hospitalization rates for angina have continued to decline beyond the time studied previously. We also show that emergency department visits for the same condition have also declined during the past 15 years. Although these declines are probably due to changes in diagnostic practices in the hospitals and emergency departments, more studies are needed to fully understand the reasons behind this phenomenon.

PURPOSE: To provide estimates for prevalence of health care provider advice offered to reproductive-aged women and to assess their association with behavior change. DESIGN: Cross-sectional study using the 2009 Behavioral Risk Factor Surveillance System. SETTING: Nineteen states/areas. SUBJECTS: Women aged 18 to 44 years with a self-reported history of hypertension or current antihypertensive medication use (n = 2063). MEASURES: Self-reported hypertension; sociodemographic and health care access indicators; and provider advice and corresponding self-reported behavior change to improve diet, limit salt intake, exercise, and reduce alcohol use. ANALYSIS: We estimated prevalence and prevalence ratios for receipt of provider advice and action to change habits. We calculated 95% confidence interval (CI) and used chi(2) tests to assess associations. RESULTS: Overall, 9.8% of reproductive-aged women had self-reported hypertension; most reported receiving advice to change eating habits (72.9%), reduce salt intake (74.6%), and exercise (82.1%), and most reported making these changes. Only 44.7% reported receiving advice to reduce alcohol intake. Women who received provider advice were more likely to report corresponding behavior change compared to those who did not (prevalence ratios ranged from 1.3 [95% CI, 1.2-1.5, p < .05] for exercise to 1.6 [95% CI, 1.4-1.8, p < .05] for reducing alcohol use. CONCLUSION: Health care providers should routinely advise hypertensive reproductive-aged women about lifestyle changes to reduce blood pressure and improve pregnancy outcomes.

OBJECTIVE: The purpose of this analysis was to determine whether there is an association between type of emergency medical services (EMS) medical direction and local EMS agency practices and characteristics specifically related to emergency response for acute cardiovascular events. METHODS: We surveyed 1,292 EMS agencies in nine states. For each cardiovascular prehospital procedure or practice, we compared the proportion of agencies that employed paid (full- or part-time) medical directors with the proportion of agencies that employed volunteer medical directors. We also compared the proportion of EMS agencies who reported direct interaction between emergency medical technicians (EMTs) and their medical director within the previous four weeks with the proportion of agencies who reported no direct interaction. Chi-square tests were used to assess statistical differences in proportion of agencies with a specific procedure by medical director employment status and medical director interaction. We repeated these comparisons using t-tests to evaluate mean differences in call volume. RESULTS: The EMS agencies with prehospital cardiovascular response policies were more likely to report employment of a paid medical director and less likely to report employment of a volunteer medical director. Similarly, agencies with prehospital cardiovascular response practices were more likely to report recent medical director interaction and less likely to report absence of recent medical director interaction. Mean call volumes for chest pain, cardiac arrest, and stroke were higher among agencies having paid medical directors (compared with agencies having volunteer medical directors) and agencies having recent medical director interaction (compared with agencies not having recent medical director interaction). CONCLUSIONS: Our study demonstrated that EMS agencies with a paid medical director and agencies with medical director interaction with EMTs in the previous four weeks were more likely to have prehospital cardiovascular procedures in place. Given the strong relationship that both employment status and direct interaction have with the presence of these practices, agencies with limited resources to provide a paid medical director or a medical director that can be actively involved with EMTs should be supported through partnerships and other interventions to ensure that they receive the necessary levels of medical director oversight.

OBJECTIVE: The role of occupation in the management of cardiovascular risk factors including hypertension is not well known. METHODS: We analyzed the 1999-2004 National Health and Nutrition Examination Survey data of 6928 workers aged 20 years or older from 40 occupational groups. Hypertension was defined as measured blood pressure of 140/90 mm Hg or greater or self-reported use of antihypertensive medication, treatment as use of antihypertensive medication, awareness as ever being told by a doctor about having hypertension, and control as having blood pressure of less than 140/90 mm Hg among treated participants. RESULTS: Protective service workers ranked among the lowest in awareness (50.6%), treatment (79.3%), and control (47.7%) and had lower odds of hypertension control and treatment compared with executive/administrative/managerial workers, adjusting for sociodemographic, body-weight, smoking, and alcohol. CONCLUSIONS: Protective service workers may benefit the most from worksite hypertension management programs.

Despite extensive culling of common vampire bats in Latin America, lethal human rabies outbreaks transmitted by this species are increasingly recognized, and livestock rabies occurs with striking frequency. To identify the individual and population-level factors driving rabies virus (RV) transmission in vampire bats, we conducted a longitudinal capture-recapture study in 20 vampire bat colonies spanning four regions of Peru. Serology demonstrated the circulation of RV in vampire bats from all regions in all years. Seroprevalence ranged from 3 to 28 per cent and was highest in juvenile and sub-adult bats. RV exposure was independent of bat colony size, consistent with an absence of population density thresholds for viral invasion and extinction. Culling campaigns implemented during our study failed to reduce seroprevalence and were perhaps counterproductive for disease control owing to the targeted removal of adults, but potentially greater importance of juvenile and sub-adult bats for transmission. These findings provide new insights into the mechanisms of RV maintenance in vampire bats and highlight the need for ecologically informed approaches to rabies prevention in Latin America.

INTRODUCTION: On average, less than 8% of people who experience an out-of-hospital cardiac arrest survive. However, death from sudden cardiac arrest is preventable if a bystander quickly retrieves and applies an automated external defibrillator (AED). Public access defibrillation (PAD) policies have been enacted to create programs that increase the public availability of these devices. The objective of this study was to describe each state's legal requirements for recommended PAD program elements. METHODS: We reviewed state laws and described the extent to which 13 PAD program elements are mandated in each state. RESULTS: No jurisdiction requires all 13 PAD program elements, 18% require at least 10 elements, and 31% require 3 or fewer elements. All jurisdictions provide some level of immunity to AED users, 60% require PAD maintenance, 59% require emergency medical service notification, 55% impose training requirements, and 41% require medical oversight. Few jurisdictions require a quality improvement process. CONCLUSION: PAD programs in many states are at risk of failure because critical elements such as maintenance, medical oversight, emergency medical service notification, and continuous quality improvement are not required. Policy makers should consider strengthening PAD policies by enacting laws that can reduce the time from collapse to shock, such as requiring the strategic placement of AEDs in high-risk locations or mandatory PAD registries that are coordinated with local EMS and dispatch centers. Further research is needed to identify the most effective PAD policies for increasing AED use by lay persons and improving survival rates.

PROBLEM/CONDITION: Each year, approximately 300,000 persons in the United States experience an out-of-hospital cardiac arrest (OHCA); approximately 92% of persons who experience an OHCA event die. An OHCA is defined as cessation of cardiac mechanical activity that occurs outside of the hospital setting and is confirmed by the absence of signs of circulation. Whereas an OHCA can occur from noncardiac causes (i.e., trauma, drowning, overdose, asphyxia, electrocution, primary respiratory arrests, and other noncardiac etiologies), the majority (70%--85%) of such events have a cardiac cause. The majority of persons who experience an OHCA event, irrespective of etiology, do not receive bystander-assisted cardiopulmonary resuscitation (CPR) or other timely interventions that are known to improve the likelihood of survival to hospital discharge (e.g., defibrillation). Because nearly half of cardiac arrest events are witnessed, efforts to increase survival rates should focus on timely and effective delivery of interventions by bystanders and emergency medical services (EMS) personnel. This is the first report to provide summary data from an OHCA surveillance registry in the United States. REPORTING PERIOD: This report summarizes surveillance data collected during October 1, 2005-- December 31, 2010. DESCRIPTION OF THE SYSTEM: In 2004, CDC established the Cardiac Arrest Registry to Enhance Survival (CARES) in collaboration with the Department of Emergency Medicine at the Emory University School of Medicine. This registry evaluates only OHCA events of presumed cardiac etiology that involve persons who received resuscitative efforts, including CPR or defibrillation. Participating sites collect data from three sources that define the continuum of emergency cardiac care: 911 dispatch centers, EMS providers, and receiving hospitals. OHCA is defined in CARES as a cardiac arrest that occurred in the prehospital setting, had a presumed cardiac etiology, and involved a person who received resuscitative efforts, including CPR or defibrillation. RESULTS: During October 1, 2005--December 31, 2010, a total of 40,274 OHCA records were submitted to the CARES registry. After noncardiac etiology arrests and missing hospital outcomes were excluded from the analysis (n = 8,585), 31,689 OHCA events of presumed cardiac etiology (e.g., myocardial infarction or arrhythmia) that received resuscitation efforts in the prehospital setting were analyzed. The mean age at cardiac arrest was 64.0 years (standard deviation [SD]: 18.2); 61.1% of persons who experienced OHCA were male (n = 19,360). According to local EMS agency protocols, 21.6% of patients were pronounced dead after resuscitation efforts were terminated in the prehospital setting. The survival rate to hospital admission was 26.3%, and the overall survival rate to hospital discharge was 9.6%. Approximately 36.7% of OHCA events were witnessed by a bystander. Only 33.3% of all patients received bystander CPR, and only 3.7% were treated by bystanders with an automated external defibrillator (AED) before the arrival of EMS providers. The group most likely to survive an OHCA are persons who are witnessed to collapse by a bystander and found in a shockable rhythm (e.g., ventricular fibrillation or pulseless ventricular tachycardia). Among this group, survival to discharge was 30.1%. A subgroup analysis was performed among persons who experienced OHCA events that were not witnessed by EMS personnel to evaluate rates of bystander CPR for these persons. After exclusion of 3,400 OHCA events that occurred after the arrival of EMS providers, bystander CPR information was analyzed for 28,289 events. In this group, whites were significantly more likely to receive CPR than blacks, Hispanics, or members of other racial/ethnic populations (p<0.001). Overall survival to hospital discharge of patients whose events were not witnessed by EMS personnel was 8.5%. Of these, patients who received bystander CPR had a significantly higher rate of overall survival (11.2%) than those who did not (7.0%) (p<0.001). INTERPRETATION: CARES data have helped identify opportunities for improvement in OHCA care. The registry is being used continually to monitor prehospital performance and selected aspects of hospital care to improve quality of care and increase rates of survival following OHCA. CARES data confirm that patients who receive CPR from bystanders have a greater chance of surviving OHCA than those who do not. PUBLIC HEALTH ACTIONS: Medical directors and public health professionals in participating communities use CARES data to measure and improve the quality of prehospital care for persons experiencing OHCA. Tracking performance longitudinally allows communities to better understand which elements of their care are working well and which elements need improvement. Education of public officials and community members about the importance of increasing rates of bystander CPR and promoting the use of early defibrillation by lay and professional rescuers is critical to increasing survival rates. Reporting at the state and local levels can enable state and local public health and EMS agencies to coordinate their efforts to target improving emergency response for OHCA events, regardless of etiology, which can lead to improvement in OHCA survival rates.

BACKGROUND: Blood pressure and cholesterol screening among women of reproductive age are important for early disease detection and intervention, and because hypertension and dyslipidemia are associated with adverse pregnancy outcomes. PURPOSE: The objective of this study was to examine associations of sociodemographic characteristics, cardiovascular disease risk factors, and healthcare access indicators with blood pressure and cholesterol screening among women of reproductive age. METHODS: In 2011, prevalence estimates for self-reported blood pressure screening within 2 years and cholesterol screening within 5 years and AORs for screenings were calculated for 4837 women aged 20-44 years, using weighted 2008 National Health Interview Survey data. RESULTS: Overall, recommended blood pressure and cholesterol screening was received by 89.6% and 63.3% women, respectively. Those who were underinsured or uninsured had the lowest screening percentage at 76.6% for blood pressure (95% CI=73.4, 79.6) and 47.6% for cholesterol (95% CI=43.8, 51.5) screening. Suboptimal cholesterol screening prevalence was also found for women who smoke (54.5%, 95% CI=50.8, 58.2); obese women (69.8%, 95% CI=66.3, 73.0); and those with cardiovascular disease (70.3%, 95% CI=63.7, 76.1), prediabetes (73.3%, 95% CI= 64.1, 80.8), or hypertension (81.4%, 95% CI=76.6, 85.4). CONCLUSIONS: Most women received blood pressure screening, but many did not receive cholesterol screening. Universal healthcare access may improve screening prevalence.

OBJECTIVES: To examine prehospital emergency medical services (EMS) scope of practice for acute cardiovascular events and characteristics that may affect scope of practice; and to describe variations in EMS scope of practice for these events and the characteristics associated with that variability. METHODS: In 2008, we conducted a telephone survey of 1,939 eligible EMS providers in nine states to measure EMS agency characteristics, medical director involvement, and 18 interventions authorized for prehospital care of acute cardiovascular events by three levels of emergency medical technician (EMT) personnel. RESULTS: A total of 1,292 providers responded to the survey, for a response rate of 67%. EMS scope of practice interventions varied by EMT personnel level, with the proportion of authorized interventions increasing as expected from EMT-Basic to EMT-Paramedic. Seven of eight statistically significant associations indicated that EMS agencies in urban settings were less likely to authorize interventions (odds ratios <0.7) for any level of EMS personnel. Based on the subset of six statistically significant associations, fire department-based EMS agencies were two to three times more likely to authorize interventions for EMT-Intermediate personnel. Volunteer EMS agencies were more than twice as likely as nonvolunteer agencies to authorize interventions for EMT-Basic and EMT-Intermediate personnel but were less likely to authorize any one of the 11 interventions for EMT-Paramedics. Greater medical director involvement was associated with greater likelihood of authorization of seven of the 18 interventions for EMT-Basic and EMT-Paramedic personnel but had no association with EMT-Intermediate personnel. CONCLUSIONS: We noted statistically significant variations in scope of practice by rural vs. urban setting, medical director involvement, and type of EMS service (fire department-based/non-fire department-based; volunteer/paid). These variations highlight local differences in the composition and capacity of EMS providers and offer important information for the transition towards the implementation of a national scope of practice model.

AIM OF THE STUDY: Few studies have focused on the full complement of cardiac arrest cases seen in hospital emergency departments (ED). The aims of our study were to describe cardiac arrest visits in the ED by using a nationally representative sample of U.S. adults. METHODS: ED data from the 2001-2007 National Hospital Ambulatory Medical Care Survey (NHAMCS) were analyzed. Cardiac arrest visits were considered to be those with an International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code of 427.5 as the primary diagnosis. RESULTS AND CONCLUSIONS: From 2001 to 2007, adults in the U.S. made an estimated 600,729,000 ED visits. Of those, 1,001,000 (0.17%) had a primary diagnosis of cardiac arrest. The majority of patients with such visits were dead on arrival or died in the ED (74.0%). The mean age for cardiac arrest visits was 66.7 years (95% confidence interval [CI], 64.6-68.8 years). Women had a lower rate of cardiac arrest visits than men (age-adjusted odds ratio [AOR], 0.6; 95% CI, 0.5-0.8), and the privately insured (AOR, 0.4; 95% CI, 0.2-0.7) and those with government insurance (AOR, 0.5; 95% CI, 0.3-0.9) had a lower proportion of cardiac arrest ED visits than uninsured persons. In addition, increasing age was a significant predictor of cardiac arrest visits. Cardiac arrest visits did not vary significantly by race, geographic region, or metropolitan statistical area. ED visits classified as cardiac arrest represent 1 in 600 visits and these visits differ by age, sex, payment source, and arrival time at the ED.

OBJECTIVE: The purpose of this study is to examine hypertension and cholesterol screening, knowledge of heart attack symptoms, and cardiovascular disease (CVD) risk factors among women with a history of gestational hypertension. STUDY DESIGN: We used weighted 2008 National Health Interview Survey data to examine health indicators and modifiable CVD risk factors and to estimate prevalence and adjusted odds ratios for recommended CVD screening and knowledge of heart attack symptoms by hypertension history among 11,970 adult women. RESULTS: Among women with gestational hypertension only (n = 301), 93% received the recommended screening for hypertension; 75% received screening for dyslipidemia, and 40% correctly identified 5 of 5 heart attack symptoms. The odds of CVD screenings and knowledge did not differ between women with a history of gestational hypertension and those with no hypertension. However, women with gestational hypertension had higher rates of obesity (43%), CVD (18%), and diabetes mellitus (13%), compared with women without a history of hypertension (21%, 8%, and 3%, respectively). CONCLUSION: A history of gestational hypertension is a neglected CVD risk marker.

Consuming high amounts of dietary sodium is associated with hypertension. The authors analyzed the HealthStyles 2005 and 2008 survey for behaviors to lower blood pressure related to dietary sodium, including the reduction of sodium intake and reading food labels for sodium content among hypertensives. All estimates were based on self-reported data. The relative percent change (RPC) in the prevalence of these behaviors between 2005 and 2008 was assessed. During the 3-year period, there were increases in the prevalence of reducing dietary sodium (RPC=17.2%, 56.6% in 2008 vs 48.3% in 2005; P<.05) and reading food labels for sodium content (RPC=7.9%, 53.0% vs 49.1%; P<.05). In 2005, the proportion of hypertensive adults who reported reducing dietary sodium was higher for persons 65 years and older, for blacks, for those with income <$25,000, and for those with more than a high school education compared with those in their comparison groups. In 2008, those aged 65 years and older had the highest percentage, while Hispanics and blacks had essentially the same percentage for reducing sodium. Based on 2005 and 2008 HealthStyles surveys, about half of hypertensive patients reported reducing their intake of sodium and reading food labels for salt. Health care providers should emphasize the importance of knowing the daily recommended limit for dietary sodium to help adults lower this intake. 2010 Wiley Periodicals, Inc.

Lifestyle changes, such as changes in diet and exercise, are recommended to lower blood pressure (BP) in adults. Using data from the 2008 HealthStyles survey, the authors estimated the prevalence of self-reported hypertension, advice received from health professionals, and actions taken to reduce BP. Among 5399 respondents, 25.8% had hypertension and 79.8% of these were currently taking antihypertensive medications. Overall, 21.0% to 24.4% reported receiving advice to adopt specific behavior changes, with younger adults and women having a lower prevalence of receiving advice. Blacks had the highest prevalence among the racial/ethnic groups of receiving advice, and household income was associated with receiving advice. More than half of respondents took action following the receipt of advice. Women were more likely than men to follow advice to go on a diet. Although many patients were following advice from their health professional and making lifestyle changes to decrease BP, the proportion of patients making changes remains suboptimal. Receiving advice from health professionals and following recommendations to reduce or control high BP are essential to hypertension management. Counseling on lifestyle modification should continue to be an integral component of visits to health professionals. 2010 Wiley Periodicals, Inc.

BACKGROUND: Consuming enough fruits and vegetables and engaging in regular physical activity are believed to be two important components of several lifestyle modifications for people with hypertension. The purpose of this study was to measure the degree to which US adults with hypertension achieved recommended intakes of fruits and vegetables and engaged in recommended levels of physical activity in 2003 and 2007. METHODS: Using the Behavioral Risk Factor Surveillance System (BRFSS) data conducted in 2003 (N = 264,178) and 2007 (N = 430,082), we determined the changes in the prevalence of eating ≥5 servings of fruits and vegetables and of obtaining Healthy People 2010 recommended level of physical activity among adults with hypertension during the period. RESULTS: In 2003 and 2007, among individuals with hypertension, age-adjusted prevalences of eating ≥5 servings of fruits and vegetables were 23.8 and 24.4% (P = 0.394) and meeting a recommended physical activity level were 38.2 and 40.3% (P < 0.001). With 2003 as the reference, odds ratios (95% confidence interval) of eating ≥5 servings of fruits and vegetables and meeting a recommended physical activity for 2007 were 1.02 (0.97-1.08) and 1.06 (1.01-1.10), respectively, after adjusting for relevant factors. CONCLUSIONS: Among hypertensives, less than a quarter are eating five or more servings of fruits and vegetables per day, and less than half are meeting recommended physical activity. In 4 years, there was no statistically significant improvement in intake of fruits and vegetables and just a slight, albeit statistically significant, improvement in physical activity among US adults. American Journal of Hypertension 2010; doi:10.1038/ajh.2010.46.