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Two major public health evaluations of e-cigarettes—one from the National Academies of Science, Engineering, and Medicine (NASEM), the other from Public Health England (PHE)—were issued back to back in the winter of 2018. While some have read these analyses as broadly consistent, providing support for the view that e-cigarettes could play a role in smoking harm reduction, in every major respect, they come to very different conclusions about what the evidence suggests in terms of public health policy. How is that possible? The explanation rests in what the 2 reports see as the central challenge posed by e-cigarettes, which helped to determine what counted as evidence. For NASEM, the core question was how to protect nonsmokers from the potential risks of exposure to nicotine and other contaminants or from the risk of smoking combustible cigarettes through renormalization. A precautionary standard was imperative, making evidence that could speak most conclusively to the question of causality paramount. For PHE, the priority was how to reduce the burdens now borne by current smokers, burdens reflected in measurable patterns of morbidity and mortality. With a focus on immediate harms, PHE turned to evidence that was “relevant and meaningful.” Thus, competing priorities determined what counted as evidence when it came to the impact of e-cigarettes on current smokers, nonsmoking bystanders, and children and adolescents. A new clinical trial demonstrating the efficacy of e-cigarettes as a cessation tool makes understanding how values and framing shape core questions and conclusive evidence imperative.

Despite its inclusion in models of social and ecological determinants of health, work has not been explored in most health inequity research in the United States. Leaving work out of public health inequities research creates a blind spot in our understanding of how inequities are created and impedes our progress toward health equity. We first describe why work is vital to our understanding of observed societal-level health inequities. Next, we outline challenges to incorporating work in the study of health inequities, including (1) the complexity of work as a concept; (2) work’s overlap with socioeconomic position, race, ethnicity, and gender; (3) the development of a parallel line of inquiry into occupational health inequities; and (4) the dearth of precise data with which to explore the relationships between work and health status. Finally, we summarize opportunities for advancing health equity and monitoring progress that could be achieved if researchers and practitioners more robustly include work in their efforts to understand and address health inequities.

Objectives. To determine the number and causes of excess deaths in Puerto Rico after Hurricane Maria made landfall on September 20, 2017. Methods. We obtained monthly vital statistics data on all deaths from January 2008 through October 2017. We conducted a time-series analysis to estimate excess mortality in September and October 2017 overall and by age, sex, and cause of death. Results. We estimated a total of 1205 excess deaths (95% confidence interval [CI] = 707, 1702). Excess deaths were slightly higher among men than women (632 and 579 deaths, respectively) and found only among people aged 60 years or older (1038 deaths). Most excess deaths occurred from heart disease (253 deaths), “other” causes (204 deaths), diabetes (195 deaths), Alzheimer’s disease (122 deaths), and septicemia (81 deaths). Conclusions. The number of excess deaths was similar to recent government estimates. However, this study is the first to identify the causes of death that were exacerbated by the disaster. Public Health Implications. An accurate estimation of the top causes of excess mortality can help authorities plan resource allocation for the island’s recovery and for the prevention of deaths in future disasters.

Elizabeth Fee was a remarkable and influential public health historian, whose personal and professional trajectories led her to speak truth to and about power in public health, past and present. Born in Northern Ireland in 1946 to Irish–Methodist missionary parents, Liz’s childhood brought her into contact with peoples and struggles across the globe. At just five weeks of age, she was whisked away by her parents to civil war–era China, where she lost hearing in one ear from an untreated bout with scarlet fever. In midchildhood, she attended school in Malaysia, after which her family returned to Belfast. There, she came of age amid festering political and religious violence, learning firsthand that history is told and retold by protagonists and witnesses, oppressors and oppressed. (Am J Public Health. Published online ahead of print April 18, 2019: e1–e4. doi:10.2105/AJPH.2019.305065)

Objectives. To investigate the validity of the apparent downward trend in the national case–fatality rate for gunshot wounds from assault. Methods. We reanalyzed the estimated annual number of nonfatal firearm injuries the National Electronic Injury Surveillance System reported from 2003 to 2012. We adjusted the estimates for discontinuities created by the substitution of 1 hospital for another in the sample and for a downward trend in the percentage of gunshot injuries classified as “unknown circumstance.” Firearm homicide data are from the Centers for Disease Control and Prevention, Web-based Injury Statistics Query and Reporting System. Results. The unadjusted National Electronic Injury Surveillance System estimate increased by 49%, yielding a decline in the case–fatality rate from 25% to 18%. Our adjustments eliminated these trends; the case–fatality rate was 22% in both 2003 and 2012. Conclusions. With reasonable adjustments, the trend in nonfatal injuries from interpersonal firearms assault tracks the flat trend in firearms homicides, suggesting that there was no increase in firearms violence during this period. The case–fatality rate did not change, and trauma care improvements did not influence the firearms homicide trend.

Objectives. To quantify the inflation-adjusted costs associated with initial hospitalizations for firearm-related injuries in the United States. Methods. We used the Healthcare Cost and Utilization Project Nationwide Inpatient Sample to identify patients admitted for firearm-related injuries from 2006 to 2014. We converted charges from hospitalization to costs, which we inflation-adjusted to 2014 dollars. We used survey weights to create national estimates. Results. Costs for the initial inpatient hospitalization totaled $6.61 billion. The largest proportion was for patients with governmental insurance coverage, totaling $2.70 billion (40.8%) and was divided between Medicaid ($2.30 billion) and Medicare ($0.40 billion). Self-pay individuals accounted for $1.56 billion (23.6%) in costs. Conclusions. From 2006 to 2014, the cost of initial hospitalizations for firearm-related injuries averaged $734.6 million per year. Medicaid paid one third and self-pay patients one quarter of the financial burden. These figures substantially underestimate true health care costs. Public health implications. Firearm-related injuries are costly to the US health care system and are particularly burdensome to government insurance and the self-paying poor.

Objectives. To estimate the lifetime prevalence of official investigations for child maltreatment among children in the United States. Methods. We used the National Child Abuse and Neglect Data System Child Files (2003–2014) and Census data to develop synthetic cohort life tables to estimate the cumulative prevalence of reported childhood maltreatment. We extend previous work, which explored only confirmed rates of maltreatment, and we add new estimations of maltreatment by subtype, age, and ethnicity. Results. We estimate that 37.4% of all children experience a child protective services investigation by age 18 years. Consistent with previous literature, we found a higher rate for African American children (53.0%) and the lowest rate for Asians/Pacific Islanders (10.2%). Conclusions. Child maltreatment investigations are more common than is generally recognized when viewed across the lifespan. Building on other recent work, our data suggest a critical need for increased preventative and treatment resources in the area of child maltreatment.

Objectives. To estimate potential impacts of California Assembly Bill (AB) 1316: a requirement for universal screening and insurance coverage for child blood lead testing. Methods. In April 2017 the California Health Benefits Review Program (Oakland, CA) analyzed AB 1316 for the California legislature, including a systematic review of lead screening effectiveness, commercial insurer surveys regarding screening coverage, and actuarial utilization and cost implication assessments. Results. Universal screening requirements would increase child lead testing by 273%, raise affected populations’ premiums by 0.0043%, and detect an additional 4777 exposed children 1 year after implementation. Conclusions. The evidence for a net societal benefit of universal screening approach is limited and is not supported by prominent medical professional groups. Public Health Implications. California expanded targeted screening to identify additional children at higher risk for lead poisoning on the basis of California-specific risk factors, while mitigating the potential harms of universal screening such as an increase in false positive tests and health care costs.

Fear is now commonly used in public health campaigns, yet for years ethical and efficacy-centered concerns provided a challenge to using fear in such efforts. From the 1950s through the 1970s, the field of public health believed that using fear to influence individual behavior would virtually always backfire. Yet faced with the limited effectiveness of informational approaches to cessation, antitobacco campaigns featured fear in the 1960s. These provoked little protest outside the tobacco industry. At the outset of the AIDS epidemic, fear was also employed. However, activists denounced these messages as stigmatizing, halting use of fear for HIV/AIDS until the 21st century. Opposition began to fracture with growing concerns about complacency and the risks of HIV transmission, particularly among gay men. With AIDS, fear overcame opposition only when it was framed as fair warning with the potential to correct misperceptions.

Objectives. To illustrate the effects that minor social or environmental disruptions could have on the food access of low-income households in Philadelphia, Pennsylvania, and provide suggestions for how cities can better incorporate food into emergency planning. Methods. Using publicly available data and stakeholder interviews (n = 8) in 2017, we projected the number of meals that would be missed during environmental and social disruptions in Philadelphia, a major US city with a high poverty rate. Results. As our projections in Philadelphia indicate, even just 3 days of school closures could result in as many as 405 600 missed meals for school-aged children. Conclusions. These scenarios provide valuable lessons for other cities to proactively plan for food access continuity in times of uncertainty. Public Health Implications. City planners and other city agencies need to include food as a routine part of emergency planning and redefine the threshold at which emergency response protocols are triggered to better ensure protection of low-income and underserved populations.

We provide an overview of classical and newer methods for the control of confounding of time-invariant interventions to permit causal inference in public health evaluations. We estimated the causal effect of gender on all-cause mortality in a large HIV care and treatment program supported by the President's Emergency Program for AIDS Relief in Dar es Salaam, Tanzania, between 2004 and 2012. We compared results from multivariable modeling, three propensity score methods, inverse-probability weighting, doubly robust methods, and targeted maximum likelihood estimation. Considerable confounding was evident, and, as expected by theory, all methods considered gave the same result, a statistically significant approximately 20% increased mortality rate in men. In general, there is no clear advantage of any of these methods for causal inference over classical multivariable modeling, from the point of view of either bias reduction or efficiency. Rather, given sufficient data to adequately fit the multivariable model to the data, multivariable modeling will yield causal estimates with the greatest statistical efficiency. All methods can adjust only for well-measured confounders-if there are unmeasured or poorly measured confounders, none of these methods will yield causal estimates.

Objectives. To establish a validated, standardized set of core competencies for community health workers (CHWs) and a linked workforce framework. Methods. We conducted a review of the literature on CHW competency development (August 2015), completed a structured analysis of literature sources to develop a workforce framework, convened an expert panel to review the framework and write measurable competencies, and validated the competencies (August 2017) by using a 5-point Likert scale survey with 58 participants in person in Biloxi, Mississippi, and electronically across the United States. Results. The workforce framework delineates 3 categories of CHWs based upon training, workplace, and scope of practice. Each of the 27 competencies was validated with a mean of less than 3 (range = 1.12–2.27) and a simple majority of participants rated all competencies as “extremely important” or “very important.” Conclusions. Writing measurable competencies and linking the competencies to a workforce framework are significant advances for CHW workforce development. Public Health Implications. The standardized core competencies and workforce framework are important for addressing health disparities and maximizing CHW effectiveness.

Hearing loss is a leading cause of disability among older people. Yet only one in seven US adults who could benefit from a hearing aid uses one. This fraction has not increased over the past 30 years, nor have hearing aid prices dropped, despite trends of steady improvements and price reductions in the consumer electronics industry. The President’s Council on Science and Technology has proposed changes in the regulation of hearing aids, including the creation of a “basic” low-cost over-the-counter category of devices. We discuss the potential to reduce disability as well as to improve public health, stakeholder responses to the president’s council’s proposal, and public health efforts to further mitigate the burden of disability stemming from age-related hearing loss.

Objectives. To determine how urban water conservation strategies in California cities can affect water and energy conservation efforts, reduce greenhouse gas emissions, and benefit public health. Methods. We expanded upon our 2014 health impact assessment of California's urban water conservation strategies by comparing the status quo to 2 options with the greatest potential impact on the interrelated issues of water and energy in California: (1) banning landscape irrigation and (2) expanding alternative water sources (e.g., desalination, recycled water). Results. Among the water conservation strategies evaluated, expanded use of recycled water stood out as the water conservation strategy with potential to reduce water use, energy use, and greenhouse gas emissions, with relatively small negative impacts for the public’s health. Conclusions. Although the suitability of recycled water for urban uses depends on local climate, geography, current infrastructure, and finances, analyses similar to that presented here can help guide water policy decisions in cities across the globe facing challenges of supplying clean, sustainable water to urban populations.

The 2014 Ebola virus epidemic is the largest and most severe ever recorded. With no approved vaccines or specific treatments for Ebola, clinical trials were launched within months of the epidemic in an unprecedented show of global partnership. One of these trials used a highly innovative “ring vaccination” design. The design was chosen for operational, scientific, and ethical reasons—in particular, it was regarded as ethically superior to individually randomized placebo-controlled trials. We scrutinize the ethical rationale for the ring vaccination design. We argue that the ring vaccination design is ethical but fundamentally equivalent to placebo-controlled designs with respect to withholding a potentially effective intervention from the control group. We discuss the implications for the ongoing ring vaccination trial and future research.

Objectives. We analyzed differences in pediatric elevated blood lead level incidence before and after Flint, Michigan, introduced a more corrosive water source into an aging water system without adequate corrosion control. Methods. We reviewed blood lead levels for children younger than 5 years before (2013) and after (2015) water source change in Greater Flint, Michigan. We assessed the percentage of elevated blood lead levels in both time periods, and identified geographical locations through spatial analysis. Results. Incidence of elevated blood lead levels increased from 2.4% to 4.9% (P Conclusions. The percentage of children with elevated blood lead levels increased after water source change, particularly in socioeconomically disadvantaged neighborhoods. Water is a growing source of childhood lead exposure because of aging infrastructure.

Objectives. To determine age-associated changes in cardiorespiratory fitness (CRF) among firefighters. Methods. Male firefighters (n = 1169) underwent annual evaluations from 2005 to 2015 in San Diego, California. We assessed CRF, the ability to deliver and use oxygen, during a maximal graded exercise test and recorded it in metabolic equivalents (METs; 1 MET = 3.5 ml/kg/min). We investigated differences in baseline CRF among 10-year age groups and patterns of change over follow-up using cross-sectional and longitudinal analyses, respectively. Results. Both analyses support an inverse relationship between CRF and age. Mean baseline CRF decreased from 15.7 ±1.7 to 11.7 ±1.9 METs in the younger than 30 years and 50 years and older age groups, respectively. There was no interaction between body fat and age in predicting CRF (Page × body fat = .09). Longitudinally, there was a nonlinear decrease in CRF, which differed across age groups: the youngest age group demonstrated the greatest decrease in CRF. Conclusions. Results support a negative, nonlinear association between age and CRF without modification by body fatness. Public Health Implications. Fire departments should recognize the health and safety risks of declining CRF and institutionalize programs to promote firefighter fitness.