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The Amish lead a very simplistic lifestyle free of modern conveniences. They have unique perceptions and beliefs regarding health and illness and generally do not adhere to conventional preventive measures such as immunizations, which can result in un- or under-immunized populations. Populations with low vaccination coverage are at greater risk of outbreaks compared to vaccinated populations as a result of low herd immunity. Over the past two decades, the Delaware Division of Public Health (DPH) has recorded three distinct outbreaks of pertussis in Delaware's Amish community. The third, and most recent, outbreak was detected in May 2018. DPH conducted an outbreak investigation in the Amish community to identify cases, estimate the burden of disease in the community, and implement control measures including vaccination, treatment, and post-exposure prophylaxis. Through the conduct of active surveillance activities, DPH interviewed 134 families and identified 181 confirmed and probable cases of pertussis. The majority of pertussis cases (77%) occurred among children ≤10 years of age, of which 87% were unvaccinated. DPH engaged the Amish community in meetings, distributed educational materials, and provided medication and vaccines in the community to encourage prevention and implement control measures. DPH officially closed the outbreak investigation on December 20, 2018 following three full incubation periods (63 days) without any new pertussis cases identified in the community.

Competing Interests: All authors have completed and submitted the ICMJE form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.

The environment impacts health and contributes to factors that not only protect us from disease but also increase our risk for certain negative health outcomes. The Delaware Division of Public Health (DPH) embarked on an endeavor in 2014 to provide its communities with timely, high-quality data on the environment, risk and protective factors, and health outcomes through a data sharing platform. Through strong partnerships with the Department of Natural Resources and Environmental Control and key opportunities, these efforts coalesced into the development of Delaware's Environmental Public Health Tracking Network. We share our analyses and presentation of asthma hospitalization and air quality data and describe our path towards creating Delaware's Environmental Tracking Network.

Objectives: We explored whether collective concerns about the safety, effectiveness, and necessity of influenza vaccines mediate racial/ethnic disparities in vaccine uptake among health care workers (HCWs)., Methods: We used a self-administered Web-based survey to assess race/ethnicity (exposure), concerns about influenza vaccination (mediator; categorized through latent class analysis), and influenza vaccine uptake (outcome) for the 2012 to 2013 influenza season among HCWs at St. Jude Children's Research Hospital in Memphis, Tennessee. We used mediation analysis to estimate prevalence ratios (PRs) and 95% confidence intervals (CIs) for the total, direct, and indirect effects of race/ethnicity on influenza vaccine uptake., Results: Non-Hispanic Blacks had lower influenza vaccine uptake than non-Hispanic Whites (total effect: PR = 0.87; 95% CI = 0.75, 0.99), largely mediated by high concern about influenza vaccines (natural indirect effect: PR = 0.89; 95% CI = 0.84, 0.94; controlled direct effect: PR = 0.98; 95% CI = 0.85, 1.1). Hispanic and Asian HCWs had modestly lower uptake than non-Hispanic Whites, also mediated by high concern about influenza vaccines., Conclusions: Racial/ethnic disparities among HCWs could be attenuated if concerns about the safety, effectiveness, and necessity of influenza vaccines were reduced.

Background: Pediatric and young adult (PAYA) cancer survivors may have an earlier onset of chronic diseases compared with the general population. We compared the age at cervical cancer diagnosis between PAYA cancer survivors and females in the general US population., Methods: We used longitudinal data from 9 population-based registries of the Surveillance, Epidemiology, and End Results program collected between 1973 and 2010. PAYA cancer survivors were females diagnosed with any cancer before age 30 years, survived at least 5 years post-diagnosis, and were subsequently diagnosed with invasive cervical cancer (n=46). The general US population comprised females who were diagnosed with invasive cervical cancer as the primary malignancy (n=26,956). We estimated the difference in median age at diagnosis (ß₅₀) and bootstrap 95% confidence limits (CL) of invasive cervical cancer after adjustment for year of diagnosis and race., Results: The median age at diagnosis of invasive cervical cancer was 33 years for female PAYA cancer survivors and 40 years for females in the general US population (ß50=-7.0, 95% CL: -11, -3.2). Similar differences were observed across subgroups of stage and histologic subtype of invasive cervical cancer., Conclusion: Our results suggest that PAYA cancer survivors are diagnosed with invasive cervical cancer at a substantially younger age compared with females without a prior cancer diagnosis in the general US population. This issue warrants further study, and could have implications for determining age at initiation or frequency of cervical cancer screening if younger age at diagnosis is attributable to an underlying biological phenomenon., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: A large proportion of long-term survivors of childhood cancer have treatment-related adverse cardiac and pulmonary late-effects, with related mortality. Consequently, this population of approximately 379,000 individuals in the U.S. is at high risk of complications from influenza infections., Purpose: To estimate influenza vaccination coverage overall and among subgroups of adult survivors of pediatric cancer aged 18-64 years and to compare coverage with the general adult U.S. population., Methods: Data from the 2009 Behavioral Risk Factor Surveillance System were analyzed in 2013 using binomial regression to estimate influenza vaccination coverage differences (CDs) and corresponding 95% confidence limits (CLs) between adult survivors of pediatric cancer and the general U.S. population. Analyses were stratified by demographic characteristics and adjusted for design effects, non-coverage, and non-response., Results: Influenza vaccination coverage was 37% for adult pediatric cancer survivors overall and 31% for the general adult U.S. population (CD=6.3%, 95% CL=0.04%, 13%). Dramatically lower coverage was observed for non-Hispanic black survivors (6%) than for non-Hispanic blacks in the general U.S. population (26%; CD=-18%, 95% CL=-25%, -11%)., Conclusions: Although influenza vaccination coverage was modestly higher among adult survivors of pediatric cancer than the general U.S. population, coverage was less than desirable for a population with a high prevalence of cardiopulmonary conditions and early mortality, and far lower than the Healthy People 2010 goal of 60% or Healthy People 2020 goal of 80% for the general population., (Copyright © 2014 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To systematically review the published literature in order to estimate the incidence and describe the variability of human papillomavirus (HPV) infection in women following treatment for cervical neoplasia., Methods: Several scientific literature databases (e.g. PubMed, ISI Web of Science) were searched through January 31, 2012. Eligible articles provided data on (i) baseline HPV infection status within 6 months prior to or at time of treatment (pre-treatment); and (ii) HPV test results for women's first visit after treatment occurring within 36 months (post-treatment). We abstracted and summarized the post-treatment incidence of newly detected HPV genotypes that were not present at pre-treatment, overall and stratified by study and other population characteristics., Results: A total of 25 studies were included, reporting post-treatment HPV incidence in nearly 2000 women. Mean patient age ranged from 31 to 43 years (median 36). Most studies used cervical exfoliated cell specimens to test for HPV DNA (n=20; 80%), using polymerase chain reaction (n=21; 84%). Cervical neoplasia treatment included loop electrical excision procedure (n=11; 44%); laser conization (n=2; 8%); laser ablation, surgical conization, cryotherapy, alpha-interferon (n=1; 4% each); or multiple treatment regimens (n=8; 32%). Follow-up times post-treatment ranged from 1.5 to 36 months (median 6). More than half of studies (n=17; 68%) estimated the incidence of any HPV type following treatment, while 7 (28%) focused specifically on high-risk (HR) HPV. HPV incidence after treatment varied widely, ranging from 0 to 47% (interquartile range: 0%-15%) in up to 3 years of follow-up after treatment. Lower HPV incidence was observed among studies that included relatively younger women, used laser conization, focused on HR-HPV rather than overall HPV infection, and had a lower proportion of recurrent cervical disease., Conclusions: These modest summary incidence estimates from the published literature can guide clinicians, epidemiologists and health economists in developing best practices for post-treatment cervical cancer prevention., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Post-marketing surveillance studies provide conflicting evidence about whether Guillain-Barre syndrome occurs more frequently following quadrivalent human papillomavirus (HPV4) vaccination. We aimed to assess whether Guillain-Barre syndrome is reported more frequently following HPV4 vaccination than other vaccinations among females and males aged 9 to 26 y in the United States. We used adverse event reports received by the United States Vaccine Adverse Event Reporting System (VAERS) between January 1, 2010 and December 31, 2012 to estimate overall, age-, and sex-specific proportional reporting ratios (PRRs) and corresponding Χ2 values for reports of Guillain-Barre syndrome between 5 and 42 d following HPV vaccination. Minimum criteria for a signal using this approach are 3 or more cases, PRR≥2, and Χ2≥4. Guillain-Barre syndrome was listed as an adverse event in 45 of 14,822 reports, of which 9 reports followed HPV4 vaccination and 36 reports followed all other vaccines. The overall, age-, and sex-specific PRR estimates were uniformly below 1. In addition, the overall, age-, and sex-specific Χ2 values were uniformly below 3. Our analysis of post-marketing surveillance data does not suggest that Guillain-Barre syndrome is reported more frequently following HPV4 vaccination than other vaccinations among vaccine-eligible females or males in the United States. Our findings may be useful when discussing the risks and benefits of HPV4 vaccination.

Little information is available about perceptions of influenza vaccination of parents with healthy children in daycare. Therefore, we systematically explored the relationship between parental risk perception and influenza vaccination in children attending daycare. We distributed a self-administered paper survey to parents of children aged 6-59 months attending licensed daycare centres in Tarrant County, Texas. We used conditional logistic regression with penalized conditional likelihood to estimate odds ratios (ORs) and 95% profile likelihood confidence limits (PL) for parental risk-perception factors and influenza vaccination. A high level of parental prevention behaviours (OR 9.1, 95% PL 3.2, 31) and physician recommendation (OR 8.2, 95% PL 2.7, 30) had the highest magnitudes of association with influenza vaccination of healthy children in daycare. Our results provide evidence about critical determinants of influenza vaccination of healthy children in daycare, which could help inform public health interventions aimed at increasing influenza vaccination coverage in this population.

The effects of caregiver strain and stress on preventive health service utilization among adult family members are well-established, but the effects of informal caregiving on children of caregivers are unknown. We aimed to assess whether inequalities in vaccination coverage (specifically human papillomavirus [HPV] and influenza) exist for females aged 9 to 17 years whose parents are informal caregivers (i.e., care providers for family members or others who are not functionally independent) compared with females whose parents are not informal caregivers. Data from the 2009 Behavioral Risk Factor Surveillance System were analyzed using Poisson regression with robust variance to estimate overall and subgroup-specific HPV and influenza vaccination prevalence ratios (PRs) and corresponding 95% confidence limits (CL) comparing females whose parents were informal caregivers with females whose parents were not informal caregivers. Our unweighted study populations comprised 1645 and 1279 females aged 9 to 17 years for the HPV and influenza vaccination analyses, respectively. Overall, both HPV and influenza vaccination coverage were lower among females whose parents were informal caregivers (HPV: PR = 0.72, 95% CL: 0.53, 0.97; Influenza: PR = 0.89, 95% CL: 0.66, 1.2). Our results suggest consistently lower HPV and influenza vaccination coverage for young females whose parents are informal caregivers. Our study provides new evidence about the potential implications of caregiving on the utilization of preventive health services among children of caregivers.

Long-term survivors of pediatric and young adult (PAYA) cancers have a high incidence of subsequent neoplasms, but few risk factors other than cancer treatment have been identified. We aimed to describe the burden of human papillomavirus (HPV)-associated malignancies among survivors of PAYA cancers to assess whether HPV infections might be a reasonable area of future etiologic research on subsequent malignancies in this population. We used longitudinal data from 9 population-based registries of the Surveillance, Epidemiology, and End Results program collected between 1973 and 2010 to assemble a cohort of individuals who were diagnosed with any cancer between the ages of 0 and 29 years and survived at least 5 years post-diagnosis. We estimated sex-specific standardized incidence ratios (SIRs) with corresponding 95% confidence limits (CL) of HPV-associated subsequent malignancies (cervical, vaginal, vulvar, penile, anal, tongue, tonsillar, and oropharyngeal). Our study population comprised 64,547 long-term survivors of PAYA cancers diagnosed between 1973 and 2010. Compared with females in the general US population, female PAYA cancer survivors had a 40% relative excess of HPV-associated malignancies overall (SIR = 1.4, 95% CL: 1.2, 1.8). Compared with males in the general US population, male PAYA cancer survivors had a 150% relative excess of HPV-associated malignancies overall (SIR = 2.5, 95% CL: 1.9, 3.4). Our findings suggest an excess of HPV-associated malignancies among PAYA cancer survivors compared with the general US population. We hypothesize that a portion of subsequent malignancies among PAYA cancer survivors may be directly attributable to HPV infection. This hypothesis warrants exploration in future studies.

Purpose: We assessed the accuracy of human papillomavirus (HPV) vaccination status based on adult proxy recall and household immunization records for adolescent females in the United States., Methods: We used data from the 2010 National Immunization Survey-Teen for females aged 13 to 17 years. The accuracy of HPV vaccination status (≥1 dose) based on adult proxy recall (unweighted n = 6868) and household immunization records (unweighted n = 2216) was assessed by estimating the sensitivity, specificity, and corresponding 95% confidence limits (CL) of these measures with provider-reported HPV vaccination status as the reference standard. Our analyses accounted for the complex survey design and population weights., Results: The sensitivity and specificity of adult proxy recall were 83.9% (95% CL: 81.2%, 86.6%) and 90.4% (95% CL: 88.9%, 92.0%), respectively. Conversely, the sensitivity and specificity of household immunization records were 74.2% (95% CL: 69.1%, 79.2%) and 98.0% (95% CL: 96.8%, 99.1%), respectively. The accuracy of both measures varied by race/ethnicity, proxy respondent, and maternal education., Conclusions: Our results suggest that adult proxy recall and household immunization records have reasonable accuracy for classifying HPV vaccination status for females aged 13 to 17 years in the United States, but these measures present a trade-off between sensitivity and specificity., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Purpose: Epidemiologists have long contributed to policy efforts to address health disparities. Three examples illustrate how epidemiologists have addressed health disparities in the United States and abroad through a "social determinants of health" lens., Methods: To identify examples of how epidemiologic research has been applied to reduce health disparities, we queried epidemiologists engaged in disparities research in the United States, Canada, and New Zealand, and drew upon the scientific literature., Results: Resulting examples covered a wide range of topic areas. Three areas selected for their contributions to policy were: (1) epidemiology's role in definition and measurement, (2) the study of housing and asthma, and (3) the study of food policy strategies to reduce health disparities. Although epidemiologic research has done much to define and quantify health inequalities, it has generally been less successful at producing evidence that would identify targets for health equity intervention. Epidemiologists have a role to play in measurement and basic surveillance, etiologic research, intervention research, and evaluation research. However, our training and funding sources generally place greatest emphasis on surveillance and etiologic research., Conclusions: The complexity of health disparities requires better training for epidemiologists to effectively work in multidisciplinary teams. Together we can evaluate contextual and multilevel contributions to disease and study intervention programs to gain better insights into evidenced-based health equity strategies., (Copyright © 2012 Elsevier Inc. All rights reserved.)

The objective of this study was to determine the proportion of ecologic studies published during a 20-year period regarding environmental exposures and cancer in which correlation coefficients or coefficients of determination were used as a measure of association. The authors performed a descriptive analysis of published literature by conducting a systematic review of PubMed to identify eligible ecologic studies published between 1991 and 2010. The reported measure of association was extracted for all eligible studies. During the 20-year study period, 35/105 (33%, 95% confidence limits [CL]: 25%, 43%) ecologic studies used correlation coefficients or coefficients of determination as a measure of association. These results indicate that the use of correlation coefficients and coefficients of determination as measures of association in ecologic studies of environmental exposures and cancer is relatively common, despite extensive literature discouraging their interpretation as valid measures of association.