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The availability of a well-established immunization registry to provide vaccination information, a school-located vaccination campaign followed by continued 2009 influenza A (H1N1) (pH1N1) activity, and a requirement to report hospitalized influenza cases provided an opportunity to estimate vaccine effectiveness (VE) of an initial dose of pH1N1 monovalent vaccine in children aged 7 months-9 years. Seventy-eight case children and 729 date-of-birth- and zipcode-matched controls were studied. The VE of a single vaccine dose in preventing pH1N1 hospitalization >=14 days after vaccination was 82% (95% confidence interval [CI], 0%-100%; P = .04) in children aged 3-9 years but was zero (-3%; 95% CI, <0%-75%) in children aged 7-35 months. These findings are consistent with those from prelicensure immunogenicity studies and have implications for interpretation of immunogenicity studies and setting priorities for vaccination of young children in future pandemics. Immunization registries can provide a simple, rapid assessment of VE to evaluate and inform vaccination policy. [ABSTRACT FROM AUTHOR]

In 2006, the Advisory Committee on Immunization Practices recommended that children routinely receive 2 varicella vaccine doses in place of the 1 dose previously recommended. This recommendation's initial impact on varicella epidemiology in Connecticut was assessed. Reported incidence and case-specific data were compared for 2005 and 2008. Varicella incidence decreased from 48.7 cases/100,000 persons in 2005 to 24.5 in 2008. Age-specific incidence decreased significantly (P < .05) among children aged 1-14 years. Reported varicella incidence has declined in Connecticut after implementation of routine 2-dose varicella vaccination for children. Continued surveillance is needed to determine the recommendation's full impact. [ABSTRACT FROM AUTHOR]

OBJECTIVE: The goal was to evaluate risk factors for invasive Escherichia coli infections in the first week of life (early onset), focusing on the role of intrapartum antibiotic use. METHODS: We conducted a retrospective case-control study. Between 1997 and 2001, case infants, defined as infants < 7 days of age with E coli isolated from blood or cerebrospinal fluid, were identified in selected counties of California, Georgia, and Connecticut by the Active Bacterial Core Surveillance/Emerging Infections Program Network. Control infants (N = 1212) were identified from a labor and delivery record review of a stratified random sample of live births at the same hospitals in 1998 and 1999. RESULTS: Surveillance identified 132 E coli cases, including 68 ampicillin-resistant cases. The case fatality rate was 16% (21 of 132 cases). Two thirds of case infants were preterm, and 49% (64 of 132 infants) were born at < or = 33 weeks of gestation. Fifty-three percent of case mothers (70 of 132 mothers) received intrapartum antibiotic therapy; 70% of those received ampicillin or penicillin. Low gestational age (< or = 33 weeks), intrapartum fever, and membrane rupture of > or = 18 hours were associated with increased odds of early-onset E coli infection. Results were similar when case subjects were limited to those infected with ampicillin-resistant strains. Exposure to any intrapartum antibiotic treatment, beta-lactam antibiotic treatment, or > or = 4 hours of intrapartum antibiotic therapy was associated with increased odds of E coli infection and ampicillin-resistant infection in univariate analyses. Among preterm infants, intrapartum antibiotic exposure did not remain associated with either outcome in multivariable models. Among term infants, exposure to > or = 4 hours of intrapartum antibiotic therapy was associated with decreased odds of early-onset E coli infection. CONCLUSIONS: Exposure to intrapartum antibiotic therapy did not increase the odds of invasive, early-onset E coli infection. Intrapartum antibiotic therapy was effective in preventing E coli infection only among term infants. [ABSTRACT FROM AUTHOR]

Introduction: The Connecticut Department of Public Health (CDPH) has continuously monitored daily nonelective hospital admissions through a syndromic surveillance reporting system (HASS) since September 2001. Admission diagnoses are categorized into 11 syndromes including one possible indicator of smallpox, fever with rash, and one possible indicator of influenza and pneumonia.Objectives: The objectives are to describe findings from systematic investigation of individual admissions attributed to fever and rash and to determine the utility of monitoring pneumonia admissions as an indictor of severe influenza activity during the 2003--04 influenza season.Methods: The incidence of admissions for fever and rash illness was determined for a 12-month period, and results of clinical discharge diagnoses were tabulated. Excess admissions for pneumonia by week during the influenza seasons beginning 2001--03 were determined and compared. Trends in admissions from the 2003--04 season were compared with trends from laboratory and sentinel physician surveillance.Results: A total of 57 admissions for fever and rash illness were reported from 32 acute-care hospitals and verified for an incidence of 1.7 per 100,000 population. Specific clinical diagnoses were made for 29. Many were compatible with the initial clinical presentation ofsmallpox. Excess admissions for pneumonia during the 2003--04 season occurred concurrently with sharp increases in positive laboratory reports and percentages of visits to physician's offices attributed to influenza-like illness. The 2003--04 influenza season had many more excess admissions than the 2001--02 and 2002--03 seasons.Conclusion: HASS is a useful surveillance tool for rapid detection of sentinel cases of smallpox. Monitoring excess pneumonia admissions during the influenza season appears to be an effective and specific method for determining of influenza activity and for quantification of influenza-related morbidity and impact on the hospital system. [ABSTRACT FROM AUTHOR]

THE PAST DECADE has witnessed an unprecedented upturn in tuberculosis morbidity and outbreaks of difficult-to treat and highly lethal multidrug-resistant tuberculosis. In the early 1990s, a national consensus developed among public health officials to define more comprehensively the problem, and in January 1993 expanded tuberculosis surveillance was implemented nationwide. Carefully selected epidemiologic and case management variables were added to the Report of Verified Case of Tuberculosis form. Information is collected on the health status and treatment of patients, including human immunodeficiency virus status, drug susceptibility test results, and the initial drug regimen. Completion of therapy and use of directly observed therapy are also monitored. The new surveillance system allows a comparison of the quality of care of patients in the public and private sectors. Additional epidemiologic variables include membership in high-risk groups (the homeless, residents of correctional or long-term care facilities, migrant workers, health care workers, and correctional employees) and substance abuse (injecting drug use, non-injecting drug use, and excess alcohol use). The additional information derived from expanded tuberculosis surveillance is crucial to optimal patient management, policy development, resource allocation, as well as program planning, implementation, and evaluation at Federal, State, and local levels. [ABSTRACT FROM AUTHOR]

Describes the continued decline of reported Haemophilus influenzae type b (Hib) disease cases and underscores the need for investigation of Hi invasive disease cases. Information on the national surveillance made by several countries; Purpose of some state for conducting active laboratory-based surveillance in selected areas; Vaccination history of children with Hib invasive disease in 1996 and 1997.

We analyzed varicella surveillance data in Connecticut for 2001-2005, to describe the epidemiology of varicella in a highly vaccinated population after the introduction of varicella vaccine and to determine the number of preventable cases that had occurred during school-related outbreaks. Overall, the incidence of varicella did not change during the surveillance period. Vaccination rates among reported case patients increased, and the severity of infection decreased. An annual median of 2.5 cases/outbreak was identified as being preventable, with a majority of these cases being preventable by revaccination of previously vaccinated persons. Continued surveillance is needed in order to monitor changing trends in varicella epidemiology. Copyright © 2008 Infectious Diseases Society of America [ABSTRACT FROM AUTHOR]

Background: Most early childhood immunizations require 3 to 4 doses to achieve optimal protection. Our objective was to identify factors associated with starting but not completing multidose vaccine series., Methods: Using 2019 National Immunization Survey-Child data, US children ages 19 to 35 months were classified in 1 of 3 vaccination patterns: (1) completed the combined 7-vaccine series, (2) did not initiate ≥1 of the 7 vaccine series, or (3) initiated all series, but did not complete ≥1 multidose series. Associations between sociodemographic factors and vaccination pattern were evaluated using multivariable log-linked binomial regression. Analyses accounted for the survey's stratified design and complex weighting., Results: Among 16 365 children, 72.9% completed the combined 7-vaccine series, 9.9% did not initiate ≥1 series, and 17.2% initiated, but did not complete ≥1 multidose series. Approximately 8.4% of children needed only 1 additional vaccine dose from 1 of the 5 multidose series to complete the combined 7-vaccine series. The strongest associations with starting but not completing multidose vaccine series were moving across state lines (adjusted prevalence ratio [aPR] = 1.45, 95% confidence interval [CI]: 1.18-1.79), number of children in the household (2 to 3: aPR = 1.29, 95% CI: 1.05-1.58; 4 or more: aPR = 1.68, 95% CI: 1.30-2.18), and lack of insurance coverage (aPR = 2.03, 95% CI: 1.42-2.91)., Conclusions: More than 1 in 6 US children initiated but did not complete all doses in multidose vaccine series, suggesting children experienced structural barriers to vaccination. Increased focus on strategies to encourage multidose series completion is needed to optimize protection from preventable diseases and achieve vaccination coverage goals., (Copyright © 2023 by the American Academy of Pediatrics.)

Background: Prior to the introduction of vaccines, COVID-19 hospitalizations of non-institutionalized persons in Connecticut disproportionately affected communities of color and individuals of low socioeconomic status (SES). Whether the magnitude of these disparities changed 7-9 months after vaccine rollout during the Delta wave is not well documented., Methods: All initially hospitalized patients with laboratory-confirmed COVID-19 during July-September 2021 were obtained from the Connecticut COVID-19-Associated Hospitalization Surveillance Network database, including patients' geocoded residential addresses. Census tract measures of poverty and crowding were determined by linking geocoded residential addresses to the 2014-2018 American Community Survey. Age-adjusted incidence and relative rates of COVID-19 hospitalization were calculated and compared with those from July to December 2020. Vaccination levels by age and race/ethnicity at the beginning and end of the study period were obtained from Connecticut's COVID vaccine registry, and age-adjusted average values were determined., Results: There were 708 COVID-19 hospitalizations among community residents of the two counties, July-September 2021. Age-adjusted incidence was the highest among non-Hispanic Blacks and Hispanic/Latinx compared with non-Hispanic Whites (RR 4.10 [95% CI 3.41-4.94] and 3.47 [95% CI 2.89-4.16]). Although RR decreased significantly among Hispanic/Latinx and among the lowest SES groups, it increased among non-Hispanic Blacks (from RR 3.2 [95% CI 2.83-3.32] to RR 4.10). Average age-adjusted vaccination rates among those ≥12 years were the lowest among non-Hispanic Blacks compared with Hispanic/Latinx and non-Hispanic Whites (50.6% vs. 64.7% and 66.6%)., Conclusions: Although racial/ethnic and SES disparities in COVID-19 hospitalization have mostly decreased over time, disparities among non-Hispanic Blacks increased, possibly due to differences in vaccination rates., (© 2022 The Authors. Influenza and Other Respiratory Viruses published by John Wiley & Sons Ltd.)

Background: During August 2021-September 2021, a Connecticut college experienced a severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) Delta variant outbreak despite high (99%) vaccination coverage, indoor masking policies, and twice-weekly testing. The Connecticut Department of Public Health investigated characteristics associated with infection and phylogenetic relationships among cases., Methods: A case was a SARS-CoV-2 infection diagnosed by a viral test during August 2021-September 2021 in a student. College staff provided enrollment and case information. An anonymous online student survey collected demographics, SARS-CoV-2 case and vaccination history, and activities preceding the outbreak. Multivariate logistic regression identified characteristics associated with infection. Phylogenetic analyses compared 115 student viral genome sequences with contemporaneous community genomes., Results: Overall, 199 of 1788 students (11%) had laboratory-confirmed SARS-CoV-2 infection; most were fully vaccinated (194 of 199, 97%). Attack rates were highest among sophomores (72 of 414, 17%) and unvaccinated students (5 of 18, 28%). Attending in-person classes with an infectious student was not associated with infection (adjusted odds ratio [aOR], 1.0; 95% confidence interval [CI], .5-2.2). Compared with uninfected students, infected students were more likely to be sophomores (aOR, 3.3; 95% CI, 1.1-10.7), attend social gatherings before the outbreak (aOR, 2.8; 95% CI, 1.3-6.4), and complete a vaccine series ≥180 days prior (aOR, 5.5; 95% CI, 1.8-16.2). Phylogenetic analyses suggested a common viral source for most cases., Conclusions: SARS-CoV-2 infection in this highly vaccinated college population was associated with unmasked off-campus social gatherings, not in-person classes. Students should stay up to date on vaccination to reduce infection., Competing Interests: Potential conflicts of interest. N. D. G. is a paid consultant for Tempus Labs and the National Basketball Association and claims a CDC contract (75D30120C09570), a sponsored research agreement with Tempus Labs, a sponsored research agreement with the National Basketball Association, and a sponsored research agreement with the National Football League. J. L. H. received payments for their institution from the State of Connecticut Department of Public Health for COVID-19 (coronavirus disease 2019) research; received payments for their institution from the CDC for surveillance of emerging infections and for Yale School of Public Health staff support; and is chair of the New Haven City Board of Health. L. E. S. received funding for their institution from the CDC and serves on the advisory council for the elimination of tuberculosis. All remaining authors: No reported conflicts of interest. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed., (Published by Oxford University Press on behalf of the Infectious Diseases Society of America 2022.)

Background: COVID-19 hospitalizations of non-institutionalized persons during the first COVID-19 wave in Connecticut disproportionately affected the elderly, communities of color, and individuals of low socioeconomic status (SES). Whether the magnitude of these disparities changed after the initial lockdown and before vaccine rollout is not well documented., Methods: All first-time hospitalizations with laboratory-confirmed COVID-19 during July to December 2020, including patients' geocoded residential addresses, were obtained from the Connecticut Department of Public Health. Those living in congregate settings, including nursing homes, were excluded. Community-dwelling patients were assigned census tract-level poverty and crowding measures from the 2014-2018 American Community Survey by linking their geocoded addresses to census tracts. Age-adjusted incidence and relative rates were calculated across demographic and SES measures and compared with those from a similar analysis of hospitalized cases during the initial wave., Results: During July to December 2020, there were 5652 COVID-19 hospitalizations in community residents in Connecticut. Incidence was highest among those >85 years, non-Hispanic Blacks and Hispanic/Latinx compared with non-Hispanic Whites {relative rate (RR) 3.1 (95% confidence interval [CI] 2.83-3.32) and 5.9 (95% CI 5.58-6.28)}, and persons living in high poverty and high crowding census tracts. Although racial/ethnic and SES disparities during the study period were substantial, they were significantly decreased compared with the first wave of COVID-19., Conclusions: The finding of persistent, if reduced, large racial/ethnic disparities in COVID-19 hospitalizations 2-7 months after the initial lockdown was relaxed and before vaccination was widely available is of concern. These disparities cause a challenge to achieving health equity and are relevant for future pandemic planning., (© 2021 The Authors. Influenza and Other Respiratory Viruses published by John Wiley & Sons Ltd.)

Objectives: Some studies suggested more COVID-19-associated hospitalizations among racial and ethnic minorities. To inform public health practice, the COVID-19-associated Hospitalization Surveillance Network (COVID-NET) quantified associations between race/ethnicity, census tract socioeconomic indicators, and COVID-19-associated hospitalization rates., Methods: Using data from COVID-NET population-based surveillance reported during March 1-April 30, 2020 along with socioeconomic and denominator data from the US Census Bureau, we calculated COVID-19-associated hospitalization rates by racial/ethnic and census tract-level socioeconomic strata., Results: Among 16,000 COVID-19-associated hospitalizations, 34.8% occurred among non-Hispanic White (White) persons, 36.3% among non-Hispanic Black (Black) persons, and 18.2% among Hispanic or Latino (Hispanic) persons. Age-adjusted COVID-19-associated hospitalization rate were 151.6 (95% Confidence Interval (CI): 147.1-156.1) in census tracts with >15.2%-83.2% of persons living below the federal poverty level (high-poverty census tracts) and 75.5 (95% CI: 72.9-78.1) in census tracts with 0%-4.9% of persons living below the federal poverty level (low-poverty census tracts). Among White, Black, and Hispanic persons living in high-poverty census tracts, age-adjusted hospitalization rates were 120.3 (95% CI: 112.3-128.2), 252.2 (95% CI: 241.4-263.0), and 341.1 (95% CI: 317.3-365.0), respectively, compared with 58.2 (95% CI: 55.4-61.1), 304.0 (95%: 282.4-325.6), and 540.3 (95% CI: 477.0-603.6), respectively, in low-poverty census tracts., Conclusions: Overall, COVID-19-associated hospitalization rates were highest in high-poverty census tracts, but rates among Black and Hispanic persons were high regardless of poverty level. Public health practitioners must ensure mitigation measures and vaccination campaigns address needs of racial/ethnic minority groups and people living in high-poverty census tracts., Competing Interests: Dr. Anderson reports consulting for AbbVie, Pfizer, and Sanofi-Pasteur and clinical trials research funding from MedImmune, Regeneron, PaxVax, Pfizer, GSK, Merck, Novavax, Sanofi Pasteur, Micron, and Janssen. He also works on a safety monitoring board for Kentucky Bioprocessing, Inc. All are outside of the submitted work. No other disclosures were reported. Nonetheless, this does not alter our adherence to PLOS ONE policies on sharing data and materials.

In fall 2020, a coronavirus disease cluster comprising 16 cases occurred in Connecticut, USA. Epidemiologic and genomic evidence supported transmission among persons at a school and fitness center but not a workplace. The multiple transmission chains identified within this cluster highlight the necessity of a combined investigatory approach.

Context: Food-induced anaphylaxis is potentially fatal but preventable by allergen avoidance and manageable through immediate treatment. Considerable effort has been invested in preventing fatalities from nut exposure among school-aged children, but few population-based studies exist to guide additional prevention efforts., Objectives: To describe the epidemiology and trends of food-related anaphylaxis requiring emergency treatment during a 15-year span in New York City when public health initiatives to prevent deaths were implemented and to understand the situational circumstances of food-related deaths., Design/setting/participants: Retrospective death record review and analysis of inpatient hospital discharges and emergency department (ED) visits in New York City residents, 2000-2014., Main Outcome: Vital statistics data, medical examiner reports, ED, and hospital discharge data were used to examine risk for death and incidence trends in medically attended food-related anaphylaxis. Potentially preventable deaths were those among persons with a known allergy to the implicated food or occurring in public settings., Results: There were 24 deaths, (1.6 deaths/year; range: 0-5), 3049 hospitalizations, and 4014 ED visits, including 7 deaths from crustacean, 4 from peanut, and 2 each from tree nut or seeds and fish exposures. Risk for death among those hospitalized or treated in the ED was highest for persons older than 65 years and for those treated for crustacean reactions (relative risk 6.5 compared with those treated for peanuts, 95% confidence interval = 1.9-22.1). Eleven of 16 deaths with medical examiner data were potentially preventable. Hospitalizations (2000-2014) and ED visit rates (2005-2014) were highest for children and those with peanut exposure and increased across periods., Conclusions: Deaths from food-related anaphylaxis were rare; however, rates of hospitalization and ED visits increased. Prevention efforts related to peanut allergies among children should continue, and additional attention is needed to prevent and treat anaphylaxis among adults, particularly those with known crustacean allergies where case fatality is highest.

Background: The relationships between socioeconomic status and domestically acquired salmonellosis and leading Salmonella serotypes are poorly understood., Methods: We analyzed surveillance data from laboratory-confirmed cases of salmonellosis from 2010-2016 for all 10 Foodborne Disease Active Surveillance Network (FoodNet) sites, having a catchment population of 47.9 million. Case residential data were geocoded, linked to census tract poverty level, and then categorized into 4 groups according to census tract poverty level. After excluding those reporting international travel before illness onset, age-specific and age-adjusted salmonellosis incidence rates were calculated for each census tract poverty level, overall and for each of the 10 leading serotypes., Results: Of 52 821geocodable Salmonella infections (>96%), 48 111 (91.1%) were domestically acquired. Higher age-adjusted incidence occurred with higher census tract poverty level (P < .001; relative risk for highest [≥20%] vs lowest [<5%] census tract poverty level, 1.37). Children <5 years old had the highest relative risk (2.07). Although this relationship was consistent by race/ethnicity and by serotype, it was not present in 5 FoodNet sites or among those aged 18-49 years., Conclusion: Children and older adults living in higher-poverty census tracts have had a higher incidence of domestically acquired salmonellosis. There is a need to understand socioeconomic status differences for risk factors for domestically acquired salmonellosis by age group and FoodNet site to help focus prevention efforts., (Published by Oxford University Press for the Infectious Diseases Society of America 2019. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Background: The relationship between socioeconomic status and Shiga toxin-producing Escherichia coli (STEC) is not well understood. However, recent studies in Connecticut and New York City found that as census tract poverty (CTP) decreased, rates of STEC increased. To explore this nationally, we analyzed surveillance data from laboratory-confirmed cases of STEC from 2010-2014 for all Foodborne Disease Active Surveillance Network (FoodNet) sites, population 47.9 million., Methods: Case residential data were geocoded and linked to CTP level (2010-2014 American Community Survey). Relative rates were calculated comparing incidence in census tracts with <20% of residents below poverty with those with ≥20%. Relative rates of age-adjusted 5-year incidence per 100 000 population were determined for all STEC, hospitalized only and hemolytic-uremic syndrome (HUS) cases overall, by demographic features, FoodNet site, and surveillance year., Results: There were 5234 cases of STEC; 26.3% were hospitalized, and 5.9% had HUS. Five-year incidence was 10.9/100 000 population. Relative STEC rates for the <20% compared with the ≥20% CTP group were >1.0 for each age group, FoodNet site, surveillance year, and race/ethnic group except Asian. Relative hospitalization and HUS rates tended to be higher than their respective STEC relative rates., Conclusions: Persons living in lower CTP were at higher risk of STEC than those in the highest poverty census tracts. This is unlikely to be due to health care-seeking or diagnostic bias as it applies to analysis limited to hospitalized and HUS cases. Research is needed to better understand exposure differences between people living in the lower vs highest poverty-level census tracts to help direct prevention efforts.

Background: Multiple chronic health conditions have been associated with exposure to the September 11, 2001 World Trade Center (WTC) terrorist attacks (9/11). We assessed whether excess deaths occurred during 2003-2014 among persons directly exposed to 9/11, and examined associations of 9/11-related exposures with mortality risk., Materials and Methods: Deaths occurring in 2003-2014 among members of the World Trade Center Health Registry, a cohort of rescue/recovery workers and lower Manhattan community members who were exposed to 9/11, were identified via linkage to the National Death Index. Participants' overall levels of 9/11-related exposure were categorized as high, intermediate, or low. We calculated standardized mortality ratios (SMR) using New York City reference rates from 2003 to 2012. Proportional hazards were used to assess associations of 9/11-related exposures with mortality, accounting for age, sex, race/ethnicity and other potential confounders., Results: We identified 877 deaths among 29,280 rescue/recovery workers (3.0%) and 1694 deaths among 39,643 community members (4.3%) during 308,340 and 416,448 person-years of observation, respectively. The SMR for all causes of death was 0.69 [95% confidence interval (CI) 0.65-0.74] for rescue/recovery workers and 0.86 (95% CI 0.82-0.90) for community members. SMRs for diseases of the cardiovascular and respiratory systems were significantly lower than expected in both groups. SMRs for several other causes of death were significantly elevated, including suicide among rescue recovery workers (SMR 1.82, 95% CI 1.35-2.39), and brain malignancies (SMR 2.25, 95% CI 1.48-3.28) and non-Hodgkin's lymphoma (SMR 1.79, 95% CI 1.24-2.50) among community members. Compared to low exposure, both intermediate [adjusted hazard ratio (AHR) 1.36, 95% CI 1.10-1.67] and high (AHR 1.41, 95% CI 1.06-1.88) levels of 9/11-related exposure were significantly associated with all-cause mortality among rescue/recovery workers (p-value for trend 0.01). For community members, intermediate (AHR 1.13, 95% CI 1.01-1.27), but not high (AHR 1.14, 95% CI 0.94-1.39) exposure was significantly associated with all-cause mortality (p-value for trend 0.03). AHRs for associations of overall 9/11-related exposure with heart disease- and cancer-related mortality were similar in magnitude to those for all-cause mortality, but with 95% CIs crossing the null value., Conclusions: Overall mortality was not elevated. Among specific causes of death that were significantly elevated, suicide among rescue/recovery workers is a plausible long-term consequence of 9/11 exposure, and is potentially preventable. Elevated mortality due to other causes, including non-Hodgkin's lymphoma and brain cancer, and small but statistically significant associations of 9/11-related exposures with all-cause mortality hazard warrant additional surveillance., (Copyright © 2018 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Trends in human papillomavirus (HPV)-associated cervical lesions can provide an indication of vaccine impact. Our purpose was to measure trends in cervical lesions during 2008-2015 and to consider possible explanations including vaccination coverage, changes in screening for cervical cancer, and risk behaviors for acquiring HPV., Methods: Connecticut (CT) implemented mandatory reporting of cervical intraepithelial neoplasia grades 2/3 and adenocarcinoma in situ (cervical intraepithelial neoplasia grade 2 or higher [CIN2+]) in 2008. Trends by age and birth cohort were modeled using negative binomial regression and change-point methods. To evaluate possible explanations for changes, these trends were compared to changes in HPV vaccination coverage, cervical cancer screening, an antecedent event to detection of a high-grade lesion, and changes in sexual behaviors and Chlamydia trachomatis, an infection with similar epidemiology to and shared risk factors for HPV., Results: A significant decline in CIN2+ was first evident among women aged 21 years in 2010, followed by successive declines in women aged 22-26 years during 2011-2012. During 2008-2015, the rates of CIN2+ declined by 30%-74% among women aged 21-26 years, with greater declines observed in the younger women. Birth cohorts between 1985 and 1994 all experienced significant declines during the surveillance period, ranging from 25% to 82%. Ecological comparisons revealed substantial increases in HPV vaccination during this time period, and more modest reductions in cervical cancer screening and sexual risk behaviors., Conclusions: The age and cohort patterns in our data suggest that declines in CIN2+ during 2008-2015 are more likely driven by HPV vaccination, introduced in 2006, than by changes in screening or risk behavior., (© The Author 2017. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com)

Introduction: Previous FluSurv-NET studies found that adult females had a higher incidence of influenza-associated hospitalizations than males. To identify groups of women at higher risk than men, we analyzed data from 14 FluSurv-NET sites that conducted population-based surveillance for laboratory-confirmed influenza-associated hospitalizations among residents of 78 US counties., Methods: We analyzed 6292 laboratory-confirmed, geocodable (96%) adult cases collected by FluSurv-NET during the 2010-12 influenza seasons. We used 2010 US Census and 2008-2012 American Community Survey data to calculate overall age-adjusted and age group-specific female:male incidence rate ratios (IRR) by race/ethnicity and census tract-level poverty. We used national 2010 pregnancy rates to estimate denominators for pregnant women aged 18-49. We calculated male:female IRRs excluding them and IRRs for pregnant:non-pregnant women., Results: Overall, 55% of laboratory-confirmed influenza cases were female. Female:male IRRs were highest for females aged 18-49 of high neighborhood poverty (IRR 1.50, 95% CI 1.30-1.74) and of Hispanic ethnicity (IRR 1.70, 95% CI 1.34-2.17). These differences disappeared after excluding pregnant women. Overall, 26% of 1083 hospitalized females aged 18-49 were pregnant. Pregnant adult females were more likely to have influenza-associated hospitalizations than their non-pregnant counterparts (relative risk [RR] 5.86, 95% CI 5.12-6.71), but vaccination levels were similar (25.5% vs 27.8%)., Conclusions: Overall rates of influenza-associated hospitalization were not significantly different for men and women after excluding pregnant women. Among women aged 18-49, pregnancy increased the risk of influenza-associated hospitalization sixfold but did not increase the likelihood of vaccination. Improving vaccination rates in pregnant women should be an influenza vaccination priority., (Published 2017. This article is a U.S. Government work and is in the public domain in the USA. Influenza and Other Respiratory Viruses Published by John Wiley & Sons Ltd.)

Objectives: Despite increased funding and efforts to prevent and control HIV infections in the black and Hispanic communities, racial disparities persist in the USA. We used a mathematical model to explain the phenomena., Methods: A mathematical model was constructed to project HIV prevalence ratio (PR), incidence rate ratio (IRR), and HIV-specific mortality rate ratio (MRR) among blacks and Hispanics vs. whites in two scenarios: (1) an annual reduction in HIV incidence rate at the 2007-2010 level and (2) an annual reduction in HIV incidence rate at the 2007-2010 level among whites (4.2 %) and twice that of whites among blacks and Hispanics (8.4 %)., Results: In scenario no. 1, the PR, IRR, and MRR among blacks would decrease from 7.6 to 5.8, 7.9 to 5.9, and 11.3 to 5.3 and among Hispanics from 2.8 to 1.8, 3.1 to 1.9, and 2.3 to 1.0, respectively. In scenario no. 2, the PR, IRR, and MRR among blacks would decrease from 7.6 to 5.1, 7.9 to 2.5, and 11.3 to 4.7 and among Hispanics from 2.8 to 1.6, 3.1 to 0.8, and 2.3 to 0.9, respectively., Conclusions: Much of the persistent racial disparities in HIV infection in the USA, as measured by PR, IRR, and MRR, can be explained by higher HIV prevalence among blacks and Hispanics. The public health community should continue its efforts to reduce racial disparities, but also need to set realistic goals and measure progress with sensitive indicators.

Background: Cancer incidence in exposed rescue/recovery workers (RRWs) and civilians (non-RRWs) was previously reported through 2008., Methods: We studied occurrence of first primary cancer among World Trade Center Health Registry enrollees through 2011 using adjusted standardized incidence ratios (SIRs), and the WTC-exposure-cancer association, using Cox proportional hazards models., Results: All-cancer SIR was 1.11 (95% confidence interval (CI) 1.03-1.20) in RRWs, and 1.08 (95% CI 1.02-1.15) in non-RRWs. Prostate cancer and skin melanoma were significantly elevated in both populations. Thyroid cancer was significantly elevated only in RRWs while breast cancer and non-Hodgkin's lymphoma were significantly elevated only in non-RRWs. There was a significant exposure dose-response for bladder cancer among RRWs, and for skin melanoma among non-RRWs., Conclusions: We observed excesses of total and specific cancers in both populations, although the strength of the evidence for causal relationships to WTC exposures is somewhat limited. Continued monitoring of this population is indicated. Am. J. Ind. Med. 59:709-721, 2016. © 2016 Wiley Periodicals, Inc., (© 2016 Wiley Periodicals, Inc.)

Residing in a high-poverty area has consistently been associated with higher mortality rates, but the association between poverty and mortality can change over time. We examine the association between neighborhood poverty and mortality in New York City (NYC) during 1990-2010 to document mortality disparity changes over time and determine causes of death for which disparities are greatest. We used NYC and New York state mortality data for years 1990, 2000, and 2010 to calculate all-cause and cause-specific age-adjusted death rates (AADRs) by census tract poverty (CTP), which is the proportion of persons in a census tract living below the federal poverty threshold. We calculated mortality disparities, measured as the difference in AADR between the lowest and highest CTP groups, within and across race/ethnicity, nativity, and sex categories by year. We observed higher all-cause AADRs with higher CTP for each year for all race/ethnicities, both sexes, and US-born persons. Mortality disparities decreased progressively during 1990-2010 for the NYC population overall, for each race/ethnic group, and for the majority of causes of death. The overall mortality disparity between the highest and lowest CTP groups during 2010 was 2.55 deaths/1000 population. The largest contributors to mortality disparities were heart disease (51.52 deaths/100,000 population), human immunodeficiency virus (19.96/100,000 population), and diabetes (19.59/100,000 population). We show that progress was made in narrowing socioeconomic disparities in mortality during 1990-2010, but substantial disparities remain. Future efforts toward achieving health equity in NYC mortality should focus on areas contributing most to disparities.

Objectives: To assess potential reductions in premature mortality that could have been achieved in 2008 to 2012 if the minimum wage had been $15 per hour in New York City., Methods: Using the 2008 to 2012 American Community Survey, we performed simulations to assess how the proportion of low-income residents in each neighborhood might change with a hypothetical $15 minimum wage under alternative assumptions of labor market dynamics. We developed an ecological model of premature death to determine the differences between the levels of premature mortality as predicted by the actual proportions of low-income residents in 2008 to 2012 and the levels predicted by the proportions of low-income residents under a hypothetical $15 minimum wage., Results: A $15 minimum wage could have averted 2800 to 5500 premature deaths between 2008 and 2012 in New York City, representing 4% to 8% of total premature deaths in that period. Most of these avertable deaths would be realized in lower-income communities, in which residents are predominantly people of color., Conclusions: A higher minimum wage may have substantial positive effects on health and should be considered as an instrument to address health disparities.

Annual influenza vaccine is recommended for all persons aged ≥6 months in the United States, with recognition that some persons are at risk for more severe disease (1). However, there might be previously unrecognized demographic groups that also experience higher rates of serious influenza-related disease that could benefit from enhanced vaccination efforts. Socioeconomic status (SES) measures that are area-based can be used to define demographic groups when individual SES data are not available (2). Previous surveillance data analyses in limited geographic areas indicated that influenza-related hospitalization incidence was higher for persons residing in census tracts that included a higher percentage of persons living below the federal poverty level (3-5). To determine whether this association occurs elsewhere, influenza hospitalization data collected in 14 FluSurv-NET sites covering 27 million persons during the 2010-11 and 2011-12 influenza seasons were analyzed. The age-adjusted incidence of influenza-related hospitalizations per 100,000 person-years in high poverty (≥20% of persons living below the federal poverty level) census tracts was 21.5 (95% confidence interval [CI]: 20.7-22.4), nearly twice the incidence in low poverty (<5% of persons living below the federal poverty level) census tracts (10.9, 95% CI: 10.3-11.4). This relationship was observed in each surveillance site, among children and adults, and across racial/ethnic groups. These findings suggest that persons living in poorer census tracts should be targeted for enhanced influenza vaccination outreach and clinicians serving these persons should be made aware of current recommendations for use of antiviral agents to treat influenza (6).

Background: In New Haven County, CT (NHC), influenza hospitalization rates have been shown to increase with census tract poverty in multiple influenza seasons. Though multiple factors have been hypothesized to cause these inequalities, including population structure, differential vaccine uptake, and differential access to healthcare, the impact of each in generating observed inequalities remains unknown. We can design interventions targeting factors with the greatest explanatory power if we quantify the proportion of observed inequalities that hypothesized factors are able to generate. Here, we ask if population structure is sufficient to generate the observed area-level inequalities in NHC. To our knowledge, this is the first use of simulation models to examine the causes of differential poverty-related influenza rates., Methods: Using agent-based models with a census-informed, realistic representation of household size, age-structure, population density in NHC census tracts, and contact rates in workplaces, schools, households, and neighborhoods, we measured poverty-related differential influenza attack rates over the course of an epidemic with a 23 % overall clinical attack rate. We examined the role of asthma prevalence rates as well as individual contact rates and infection susceptibility in generating observed area-level influenza inequalities., Results: Simulated attack rates (AR) among adults increased with census tract poverty level (F = 30.5; P < 0.001) in an epidemic caused by a virus similar to A (H1N1) pdm09. We detected a steeper, earlier influenza rate increase in high-poverty census tracts-a finding that we corroborate with a temporal analysis of NHC surveillance data during the 2009 H1N1 pandemic. The ratio of the simulated adult AR in the highest- to lowest-poverty tracts was 33 % of the ratio observed in surveillance data. Increasing individual contact rates in the neighborhood did not increase simulated area-level inequalities. When we modified individual susceptibility such that it was inversely proportional to household income, inequalities in AR between high- and low-poverty census tracts were comparable to those observed in reality., Discussion: To our knowledge, this is the first study to use simulations to probe the causes of observed inequalities in influenza disease patterns. Knowledge of the causes and their relative explanatory power will allow us to design interventions that have the greatest impact on reducing inequalities., Conclusion: Differential exposure due to population structure in our realistic simulation model explains a third of the observed inequality. Differential susceptibility to disease due to prevailing chronic conditions, vaccine uptake, and smoking should be considered in future models in order to quantify the role of additional factors in generating influenza inequalities.

The Emerging Infections Program (EIP) is a collaboration between the Centers for Disease Control and Prevention and 10 state health departments working with academic partners to conduct active population-based surveillance and special studies for several emerging infectious disease issues determined to need special attention. The Centers for Disease Control and Prevention funds the 10 EIP sites through cooperative agreements. Our objective was to highlight 1) what being an EIP site has meant for participating health departments and associated academic centers, including accomplishments and challenges, and 2) the synergy between the state and federal levels that has resulted from the collaborative relationship. Sharing these experiences should provide constructive insight to other public health programs and other countries contemplating a collaborative federal-local approach to collective public health challenges.

Foodborne pathogens cause >9 million illnesses annually. Food safety efforts address the entire food chain, but an essential strategy for preventing foodborne disease is educating consumers and food preparers. To better understand the epidemiology of foodborne disease and to direct prevention efforts, we examined incidence of Salmonella infection, Shiga toxin-producing Escherichia coli infection, and hemolytic uremic syndrome by census tract-level socioeconomic status (SES) in the Connecticut Foodborne Diseases Active Surveillance Network site for 2000-2011. Addresses of case-patients were geocoded to census tracts and linked to census tract-level SES data. Higher census tract-level SES was associated with Shiga toxin-producing Escherichia coli, regardless of serotype; hemolytic uremic syndrome; salmonellosis in persons ≥5 years of age; and some Salmonella serotypes. A reverse association was found for salmonellosis in children <5 years of age and for 1 Salmonella serotype. These findings will inform education and prevention efforts as well as further research.

Objectives: We described disparities in selected communicable disease incidence across area-based poverty levels in New York City, an area with more than 8 million residents and pronounced household income inequality., Methods: We geocoded and categorized cases of 53 communicable diseases diagnosed during 2006 to 2013 by census tract-based poverty level. Age-standardized incidence rate ratios (IRRs) were calculated for areas with 30% or more versus fewer than 10% of residents below the federal poverty threshold., Results: Diseases associated with high poverty included rickettsialpox (IRR = 3.69; 95% confidence interval [CI] = 2.29, 5.95), chronic hepatitis C (IRR for new reports = 3.58; 95% CI = 3.50, 3.66), and malaria (IRR = 3.48; 95% CI = 2.97, 4.08). Diseases associated with low poverty included domestic tick-borne diseases acquired through travel to areas where infected vectors are prevalent, such as human granulocytic anaplasmosis (IRR = 0.08; 95% CI = 0.03, 0.19) and Lyme disease (IRR = 0.34; 95% CI = 0.32, 0.36)., Conclusions: Residents of high poverty areas were disproportionately affected by certain communicable diseases that are amenable to public health interventions. Future work should clarify subgroups at highest risk, identify reasons for the observed associations, and use findings to support programs to minimize disparities.

Accomplishments of this program have provided numerous dividends and might benefit areas outside infectious diseases.

The Emerging Infections Program (EIP), a collaboration between (currently) 10 state health departments, their academic center partners, and the Centers for Disease Control and Prevention, was established in 1995. The EIP performs active, population-based surveillance for important infectious diseases, addresses new problems as they arise, emphasizes projects that lead to prevention, and develops and evaluates public health practices. The EIP has increasingly addressed the health equity challenges posed by Healthy People 2020. These challenges include objectives to increase the proportion of Healthy People-specified conditions for which national data are available by race/ethnicity and socioeconomic status as a step toward first recognizing and subsequently eliminating health inequities. EIP has made substantial progress in moving from an initial focus on monitoring social determinants exclusively through collecting and analyzing data by race/ethnicity to identifying and piloting ways to conduct population-based surveillance by using area-based socioeconomic status measures.

Before 1999, the United States had no appropriated funding for arboviral surveillance, and many states conducted no such surveillance. After emergence of West Nile virus (WNV), federal funding was distributed to state and selected local health departments to build WNV surveillance systems. The Council of State and Territorial Epidemiologists conducted assessments of surveillance capacity of resulting systems in 2004 and in 2012; the assessment in 2012 was conducted after a 61% decrease in federal funding. In 2004, nearly all states and assessed local health departments had well-developed animal, mosquito, and human surveillance systems to monitor WNV activity and anticipate outbreaks. In 2012, many health departments had decreased mosquito surveillance and laboratory testing capacity and had no systematic disease-based surveillance for other arboviruses. Arboviral surveillance in many states might no longer be sufficient to rapidly detect and provide information needed to fully respond to WNV outbreaks and other arboviral threats (e.g., dengue, chikungunya).

Since 2001, the Council of State and Territorial Epidemiologists (CSTE) periodically has conducted a standardized national assessment of state health departments' core epidemiology capacity (1-4). During August-September 2013, CSTE sent a web-based questionnaire to state epidemiologists in the 50 states and the District of Columbia. The questionnaire inquired into workforce capacity and technology advancements to support public health surveillance. Measures of capacity included the total number of epidemiologists, a self-assessment of the state's ability to carry out four of the 10 essential public health services* most relevant to epidemiologists, and program-specific epidemiology capacity. This report summarizes the results, which indicated that in 2013, most of these measures were at their highest level since assessments began in 2001, including the number of epidemiologists, the percentage of state health departments with substantial-to-full (>50%) capacity for three of the 10 essential public health services, and the percentage with substantial-to-full epidemiology capacity for eight of 10 program areas. However, >50% of states reported minimal-to-no (<25%) epidemiology capacity for four of 10 program areas, including occupational health (55%), oral health (59%), substance abuse (73%), and mental health (80%). Federal, state, and local agencies should work together to develop a strategy to address continued outstanding gaps in epidemiology capacity.

Background.  The introductions of the varicella vaccine in 1995 and herpes zoster (HZ) vaccine in 2006 have an ongoing potential to modify the epidemiology of both diseases. Analysis of data on hospitalizations can be conducted to examine trends in the occurrence of severe disease over time and to assess the possible impact of vaccination on the incidence of hospitalization. Methods.  Statewide hospital discharge data 1994-2012 in Connecticut were used to identify individuals discharged with a diagnosis of varicella and the initial admissions of persons with a discharge diagnosis of HZ in the first or second diagnostic position. Trends in overall age-standardized and age group-specific hospitalization rates for preselected time intervals before and after the introduction of vaccines were examined using Poisson regression models or Mantel-Haenszel χ(2) tests. Results.  Beginning in 2001, 5 years after the introduction of varicella vaccine, HZ hospitalization rates decreased significantly in individuals <15 years at an average rate of 19.4% per year through 2012. Among individuals ≥60 years, HZ hospitalization rates increased by 5.1% per year from 2001 to 2006 but decreased by 4.2% per year from 2007 to 2012. Primary varicella hospitalization rates declined 82.9% from the prevaccine era (1994-1995) to the 1-dose era (2001-2005) (P < .001). Rates further decreased significantly in the 2-dose era (2010-2012) among 5 to 9 year olds (100% decrease). Conclusions.  Varicella vaccine seems to have had an impact on both varicella and HZ hospitalizations, and introduction of the HZ vaccine may be having an impact on HZ hospitalizations.

Objectives: To help guide universal influenza vaccination efforts in the United States, it is important to know which demographic groups are currently at highest risk of costly complications of influenza infection. Few studies have examined the relationship between hospitalization with influenza and either socioeconomic status (SES) or sex. We examined associations between census tract-level SES and sex and incidence of influenza-related hospitalizations among adults., Design: Descriptive analysis of data collected by active population-based surveillance for persons >18 years old hospitalized with laboratory confirmed influenza during the 2007-2008 through 2010-2011 influenza seasons. Case residential addresses were geocoded and linked to data from the 2006-2010 American Community Survey to obtain census-tract level (neighborhood) SES measures. Census-tract level SES variables included measures of poverty, education, crowding, primary language, and median income. Four levels were created for each., Setting: New Haven, County, Connecticut., Sample: Entire New Haven County population >18 years old., Main Outcome Measures: Age-adjusted incidence of influenza hospitalizations and relative risk by sex and by each of five SES measures., Results: Crude and age-adjusted incidence progressively increased with decreasing neighborhood SES for each measure both overall and for each influenza season. Female incidence was higher than male for each age group, and female age-adjusted incidence was higher for each SES level and influenza season., Conclusions: Female sex and lower neighborhood SES were independently and consistently associated with higher incidence of hospitalization of adults with influenza. If this is more broadly the case, these findings have implications for future influenza vaccination efforts. Analysis using census tract SES measures can provide additional perspective on health disparities., (© 2014 The Authors. Influenza and Other Respiratory Viruses Published by John Wiley & Sons Ltd.)

In the first 5 years after its introduction in the United States in 1999, West Nile virus (WNV) spread to the 48 contiguous states, resulting in 667 reported deaths. To establish detection and response capacity, WNV surveillance and prevention was supported through CDC Epidemiology and Laboratory Capacity (ELC) cooperative agreements with all 50 states and six large cities/counties. In 2005, the Council of State and Territorial Epidemiologists (CSTE) conducted an assessment of ELC recipients and determined that, since 1999, all had developed WNV surveillance and control programs, resulting in a national arboviral surveillance infrastructure. From 2004 to 2012, ELC funding for WNV surveillance decreased by 61%. In 2012, the United States had its most severe WNV season since 2003, prompting a follow-up assessment of the capacity of ELC-supported WNV programs. Since the first assessment, 22% of jurisdictions had stopped conducting active human surveillance, 13% had stopped mosquito surveillance, 70% had reduced mosquito trapping and testing, and 64% had eliminated avian mortality surveillance. Reduction in early detection capacity compromises local and national ability to rapidly detect changes in WNV and other arboviral activity and to initiate prevention measures. Each jurisdiction is encouraged to review its current surveillance systems in light of the local threat of WNV and emerging arboviruses (e.g., dengue and chikungunya) and ensure it is able to rapidly detect and respond to critical changes in arbovirus activity.