Representativeness of Tuberculosis Genotyping Surveillance in the United States, 2009–2010

Genotyping of Mycobacterium tuberculosis isolates contributes to tuberculosis (TB) control through detection of possible outbreaks. However, 20% of U.S. cases do not have an isolate for testing, and 10% of cases with isolates do not have a genotype reported. TB outbreaks in populations with incomplete genotyping data might be missed by genotyping-based outbreak detection. Therefore, we assessed the representativeness of TB genotyping data by comparing characteristics of cases reported during January 1, 2009–December 31, 2010, that had a genotype result with those cases that did not. Of 22,476 cases, 14,922 (66%) had a genotype result. Cases without genotype results were more likely to be patients <19 years of age, with unknown HIV status, of female sex, U.S.-born, and with no recent history of homelessness or substance abuse. Although cases with a genotype result are largely representative of all reported U.S. TB cases, outbreak detection methods that rely solely on genotyping data may underestimate TB transmission among certain groups.Since 2004, the Centers for Disease Control and Prevention (CDC) has offered routine genetic characterization (i.e., genotyping) of all U.S. tuberculosis (TB) cases with Mycobacterium tuberculosis (M. tuberculosis) isolates.¹ Genotyping is a laboratory method used to determine the relatedness of isolates; although not a perfect measure of transmission,² this tool contributes to TB control in multiple ways. Genotyping data contribute to TB control, including the detection of genotype clusters that might represent remote or recent transmission (including outbreaks).^3–6 TB genotyping data are also important for defining the scope of outbreaks,⁷ monitoring outbreaks over time,⁸ distinguishing relapse from reinfection,⁹ detecting or confirming false-positive culture results,^10,11 confirming known epidemiologic links, and finding unknown links between cases.^3,4,12 The utility of genotyping is limited in populations for which few cases are genotyped, because potential transmission relationships between cases might be missed. TB genotyping is most effective when data are representative of the entire population of TB cases.^13–15Applying TB genotyping data to TB control requires that an isolate be submitted for genotyping and that the genotyping result be linked to the patient''s demographic and clinical information. While some states have independent systems for generating and linking genotyping data, most states rely on the national CDC-funded system. In this system, an isolate is submitted for genotyping to the CDC-funded national genotyping laboratory, and genotyping results are linked to the patient''s demographic and clinical data, which are reported to the National Tuberculosis Surveillance System (NTSS).¹⁶ This linkage is facilitated by a CDC-developed and -funded national Web-based genotyping database, which includes both NTSS and genotyping data.First, specimens are collected from a suspected TB patient. Specimens are generally sent to a jurisdictional public health laboratory for culturing and processing and, when a specimen yields a culture that is positive for M. tuberculosis, an isolate is sent to the national genotyping laboratory. In some cases, a viable culture might not be available to be submitted for genotyping. In other cases, a viable culture might be available but not submitted to the genotyping laboratory. These latter cases represent a missed opportunity for genotyping. Although it is not possible to determine whether or not a viable culture was available for submission from nationally reported data, we can use the presence of drug susceptibility testing (DST) results, testing that requires a viable culture, to identify cases for which a viable culture was likely available to be submitted for genotyping.Once the isolate is genotyped, the result is entered into the national Web-based genotyping database. In parallel with this process, the patient''s demographic and clinical data are submitted to jurisdictional public health authorities for reporting to NTSS; these data are then uploaded into the national Web-based genotyping database. The state TB program is responsible for the critical step of linking the surveillance report to the genotyping result, using a state-assigned identification number. Failure to link the genotyping and surveillance records will result in the case appearing to have not been genotyped. Because surveillance and genotyping data are linked by the state, it is not possible at CDC to distinguish between cases that have not been genotyped and cases that have been genotyped but not linked.National TB genotyping coverage is defined as the proportion of TB cases with a culture yielding M. tuberculosis (referred to as “culture-positive cases”) that are linked to a genotype result in the national Web-based genotyping database. In 2010, national genotyping coverage was 88%. However, approximately 20% of TB cases in the United States are not culture positive and, therefore, do not have an isolate available for genotyping.¹⁷ A case could be missing a genotype result for three general reasons: it did not have an M. tuberculosis isolate, it had an isolate that was not genotyped, or the genotyping result was not linked to NTSS data in the national Web-based genotyping database. Our aim was to characterize cases that did not have a genotype result for any of these reasons to identify populations in which outbreaks might be missed by genotype-based outbreak detection methods, and to identify opportunities to increase genotyping.     

Lyme Disease in Hispanics,United States, 2000–2013

Hispanics comprise a growing portion of the US population and might have distinct risk factors for tickborne diseases. During 2000–2013, a total of 5,473 Lyme disease cases were reported among Hispanics through national surveillance. Hispanics were more likely than non-Hispanics to have signs of disseminated infection and onset during fall months.     

Asbestosis Mortality Surveillance in the United States, 1970–2004

Abstract

To describe the demographic, geographic, and occupational distribution of asbestosis mortality in the United States during 1970–2004, we identified a total of 25,413 asbestosis deaths. We calculated national, state, and county death rates, age-adjusted to the 2000 U.S. standard population. We also calculated industry- and occupation-specific proportionate mortality ratios (PMRs), adjusted for age, sex, and race, and corresponding confidence intervals (CIs) using available data. The overall U.S. age-adjusted asbestosis death rate was 4.1 per million population per year; the rate for males (10.4) was nearly 35-fold higher than that for females (0.3). It increased significantly from 0.6 to 6.9 per million population from 1970 to 2000 (p<0.001),and then declined to 6.3 in 2004 (p=0.014). High asbestosis death rates occurred predominantly, though not exclusively, in coastal areas. Industries with highest PMRs included ship and boat building and repairing (18.5; 95% CI 16.3–20.9) and miscellaneous nonmetallic mineral and stone products (15.9; 95% CI 13.0–19.5). Occupations with highest PMRs included insulation workers (109.2; 95% CI 93.8-127.2) and boilermakers (21.3; 95% CI 17.0–26.6).     

Tuberculosis Among Africans Living in the United States, 2000–2009

The incidence of tuberculosis (TB) has declined steadily in the United States; however, foreign-born persons are disproportionately affected. The aim of our study was to describe characteristics of TB patients diagnosed in the United States who originated from the African continent. Using data from the U.S. National Tuberculosis Surveillance System, we calculated TB case rates and analyzed differences between foreign-born patients from Africa compared with other foreign-born and U.S.-born patients. The 2009 TB case rate among Africans (48.1/100,000) was 3 times as high as among other foreign-born and 27 times as high as among U.S.-born patients. Africans living in the United States have high rates of TB disease; they are more likely to be HIV-positive and to have extrapulmonary TB. Identification and treatment of latent TB infection, HIV testing and treatment, and a high index of suspicion for extrapulmonary TB are needed to better address TB in this population.     

Cat-Scratch Disease in the United States, 2005–2013

Cat-scratch disease (CSD) is mostly preventable. More information about the epidemiology and extent of CSD would help direct prevention efforts to those at highest risk. To gain such information, we reviewed the 2005–2013 MarketScan national health insurance claims databases and identified patients <65 years of age with an inpatient admission or outpatient visit that included a CSD code from the International Classification of Diseases, Ninth Revision, Clinical Modification. Incidence of CSD was highest among those who lived in the southern United States (6.4 cases/100,000 population) and among children 5–9 years of age (9.4 cases/100,000 population). Inpatients were significantly more likely than outpatients to be male and 50–64 years of age. We estimate that each year, 12,000 outpatients are given a CSD diagnosis and 500 inpatients are hospitalized for CSD. Prevention measures (e.g., flea control for cats) are particularly helpful in southern states and in households with children.     

Urban-Rural Differences in Coronary Heart Disease Mortality in the United States: 1999–2009

Objective

Coronary heart disease (CHD) mortality has declined in the past few decades; however, it is unclear whether the reduction in CHD deaths has been similar across urbanization levels and in specific racial groups. We describe the pattern and magnitude of urban-rural variations in CHD mortality in the U.S.

Methods

Using data from the National Center for Health Statistics, we examined trends in death rates from CHD from 1999 to 2009 among people aged 35–84 years, in each geographic region (Northeast, Midwest, West, and South) and in specific racial-urbanization groups, including black and white people in large and medium metropolitan (urban) areas and in non-metropolitan (rural) areas. We also examined deaths from early-onset CHD in females aged <65 years and males aged <55 years.

Results

From 1999 to 2009, there was a 40% decline in age-adjusted CHD mortality. The trend was similar in black and white people but was more pronounced in urban than in rural areas, resulting in a crossover in 2007, when rural areas began showing a higher CHD mortality than urban areas. White people in large metropolitan areas had the largest decline (43%). Throughout the study period, CHD mortality remained higher in black people than in white people, and, in the South, it remained higher in rural than in urban areas. For early-onset CHD, the mortality decline was more modest (30%), but overall trends by urbanization and region were similar.

Conclusion

Favorable national trends in CHD mortality conceal persisting disparities for some regions and population subgroups (e.g., rural areas and black people).Coronary heart disease (CHD) is the leading cause of death for most racial groups in the United States, accounting for approximately 600,000 total deaths annually.¹ CHD remains the leading cause of morbidity and mortality despite the fact that CHD death rates have declined by more than 30% since the 1990s.² This decline has been attributed to a combination of primary and secondary prevention efforts, with a reduction in the level of risk factors, such as blood pressure, smoking, and blood cholesterol, and continuing improvements in diagnosis and treatment.^3–6Although encouraging, the overall decline in CHD mortality rates in the U.S. may conceal less favorable trends in certain regions and demographic groups. Urbanization level is a key characteristic when studying health disparities. One-fifth of the U.S. population resides in rural areas, which rank poorly on 21 of 23 selected population health indicators, behaviors, and risk factors.^7–9 Urban-rural differences provide opportunities for optimizing health-care resources and improving prevention targeting areas of highest need.Few previous studies have described regional differences in CHD mortality in the U.S. and trends over time in recent years.^10–12 There is an ongoing need to monitor the distribution of death rates from specific causes to help reduce preventable diseases and deaths and improve the health of all groups.¹³ This study describes the pattern and magnitude of urban-rural differences in CHD mortality rates by geographic region in the U.S. from 1999 to 2009. The extent to which the decline applies to early CHD mortality is also examined. Deaths from early-onset CHD translate into a large number of years of potential life lost with substantial impact on families and society. Thus, the study of potential determinants of early-onset CHD is important but often neglected.     

Infectious Disease in a Warming World: How Weather Influenced West Nile Virus in the United States (2001–2005)

Background

The effects of weather on West Nile virus (WNV) mosquito populations in the United States have been widely reported, but few studies assess their overall impact on transmission to humans.

Objectives

We investigated meteorologic conditions associated with reported human WNV cases in the United States.

Methods

We conducted a case–crossover study to assess 16,298 human WNV cases reported to the Centers for Disease Control and Prevention from 2001 to 2005. The primary outcome measures were the incidence rate ratio of disease occurrence associated with mean weekly maximum temperature, cumulative weekly temperature, mean weekly dew point temperature, cumulative weekly precipitation, and the presence of ≥ 1 day of heavy rainfall (≥ 50 mm) during the month prior to symptom onset.

Results

Increasing weekly maximum temperature and weekly cumulative temperature were similarly and significantly associated with a 35–83% higher incidence of reported WNV infection over the next month. An increase in mean weekly dew point temperature was significantly associated with a 9–38% higher incidence over the subsequent 3 weeks. The presence of at least 1 day of heavy rainfall within a week was associated with a 29–66% higher incidence during the same week and over the subsequent 2 weeks. A 20-mm increase in cumulative weekly precipitation was significantly associated with a 4–8% increase in incidence of reported WNV infection over the subsequent 2 weeks.

Conclusions

Warmer temperatures, elevated humidity, and heavy precipitation increased the rate of human WNV infection in the United States independent of season and each others’ effects.     

Cervical Cancer Screening in the US–Mexico Border Region: A Binational Analysis

Cervical cancer mortality is high along the US–Mexico border. We describe the prevalence of a recent Papanicolaou screening test (Pap) among US and Mexican border women. We analyzed 2006 cross-sectional data from Mexico’s National Survey of Health and Nutrition and the US Behavioral Risk Factor Surveillance System. Women aged 20–77 years in 44 US border counties (n = 1,724) and 80 Mexican border municipios (n = 1,454) were studied. We computed weighted proportions for a Pap within the past year by age, education, employment, marital status, health insurance, health status, risk behaviors, and ethnicity and adjusted prevalence ratios (APR) for the US, Mexico, and the region overall. Sixty-five percent (95 %CI 60.3–68.6) of US women and 32 % (95 %CI 28.7–35.2) of Mexican women had a recent Pap. US residence (APR = 2.01, 95 %CI 1.74–2.33), marriage (APR = 1.31, 95 %CI 1.17–1.47) and insurance (APR = 1.38, 95 %CI 1.22–1.56) were positively associated with a Pap test. Among US women, insurance and marriage were associated (APR = 1.21, 95 %CI 1.05–1.38 and 1.33, 95 %CI 1.10–1.61, respectively), and women aged 20–34 years were about 25 % more likely to have received a test than older women. Insurance and marriage were also positively associated with Pap testing among Mexican women (APR = 1.39, 95 %CI 1.17–1.64 and 1.50; 95 %CI 1.23–1.82, respectively), as were lower levels of education (≤8th grade or 9th–12th grade versus some college) (APR = 1.74; 95 %CI 1.21–2.52 and 1.60; 95 %CI 1.03–2.49, respectively). Marriage and insurance were associated with a recent Pap test on both sides of the border. Binational insurance coverage increases and/or cost reductions might bolster testing among unmarried and uninsured women, leading to earlier cervical cancer diagnosis and potentially lower mortality.     

Hot spots in mortality from drug poisoning in the United States, 2007–2009

Over the past several years, the death rate associated with drug poisoning has increased by over 300% in the U.S. Drug poisoning mortality varies widely by state, but geographic variation at the substate level has largely not been explored. National mortality data (2007–2009) and small area estimation methods were used to predict age-adjusted death rates due to drug poisoning at the county level, which were then mapped in order to explore: whether drug poisoning mortality clusters by county, and where hot and cold spots occur (i.e., groups of counties that evidence extremely high or low age-adjusted death rates due to drug poisoning). Results highlight several regions of the U.S. where the burden of drug poisoning mortality is especially high. Findings may help inform efforts to address the growing problem of drug poisoning mortality by indicating where the epidemic is concentrated geographically.     

State Medicaid Expansion,Community Interventions,and Health Care Disparities in a United States–Mexico Border Community

Objectives. We investigated whether access to and use of health care services increased among residents of a low-income, predominantly Mexican American border community affected by the expansion of Arizona’s Medicaid program in 2001 and multiple community-level programs and policies.Methods. We used data from a probability sample of 1623 adult residents of Douglas, Arizona, who participated in cross-sectional health surveys in 1998 and 2010. Response rates were 83% and 86%, respectively.Results. In 2010, participants were more likely to have a usual source of care, to have visited a provider in the previous year, and to have been screened for diabetes and hypertension and less likely to have delayed needed care or to have seen a regular provider in Mexico (P < .001 for all outcomes). Improvements in access to and use of health care were most pronounced among residents with less than a high school education, which reduced or eliminated educational disparities in health care.Conclusions. Expansion of public insurance programs can effectively reduce health care disparities when paired with other community-level policies and programs that target medically underserved populations.Mexican Americans and other Latinos suffer from a high burden of chronic disease.1,2 For example, 79% of Mexican American adults and 78% of all Latino adults are overweight or obese compared with 67% of non-Hispanic Whites, and half of Latinos born in 2000 will develop diabetes in their lifetimes compared with less than one third of non-Hispanic Whites.1,2 Identifying effective programs and policies to improve the health of Mexican Americans and other Latinos is a top public health priority, both to reduce health disparities and because even small improvements can yield large health and economic benefits at the population level.Poor access, use, and quality of health care services may contribute to high rates of chronic disease among Mexican Americans and other Latinos. Latinos are less likely than are other racial/ethnic groups to have health insurance, attend regular medical checkups, have a usual source of care, or be regularly screened for several forms of cancer and other chronic conditions.3–8 Latinos are also more likely to delay needed care, have chronic conditions that go undiagnosed or are diagnosed at later stages, have negative outcomes related to their chronic conditions, and be unsatisfied with their providers.4,9,10 Health care access and use is even poorer among Mexican Americans than most other Latino subgroups.4Latinos face numerous social, economic, and structural barriers to health care. As a group, Latinos have low income, high poverty rates, and poor educational attainment, factors consistently found to affect health and health care.11–13 One third of Latinos are immigrants and 41% of Latino immigrants speak English less than very well, factors that can lead to linguistic and cultural barriers to health care.13,14 Many immigrants, including 6 million who are undocumented, are ineligible for public health insurance programs that subsidize health care for other low-income populations.15–17One potential way to reduce health care disparities faced by low-income and minority populations, including Latinos, is through public policy. The Affordable Care Act (ACA) includes several provisions expected to curb uninsurance and increase access to and use of health care services among medically underserved populations, including an individual mandate requiring most Americans to have health insurance; public health insurance exchanges that can be used to buy affordable, high-quality, and often subsidized insurance; and expanded eligibility for Medicaid to include individuals with incomes up to 138% of the federal poverty level (FPL) as set by the US Department of Health and Human Services.18 It is important to understand whether the ACA and other policy- and community-level interventions can effectively reduce health care disparities that Latinos and other low-income and minority populations face.     

Establishing a Binational Student-Run Free-Clinic in Tijuana,Mexico: A Model for US–Mexico Border States

In 2011, a bi-national student-run free clinic for the underserved, known as “Health Frontiers in Tijuana” (HFiT), was created in Tijuana, Mexico. Students and faculty from one Mexican and one US medical school staff the clinic and attend patients on Saturdays. Students from both medical schools enroll in a didactic course during the quarter/semester that they attend the free clinic. The course addresses clinical, ethical, cultural, population-specific issues and the structure, financing and delivery of medical care in Mexico. The clinic implements an electronic medical record and is developing telemedicine for consulting on complex cases. Despite challenges related to sustaining adequate funding, this program may be replicated in other border communities.     

Pap Smear Screening Among Women ≥40 years Residing at the United States–Mexico Border

Invasive cervical cancer is a preventable disease due to screening for precursor lesions using the Papanicolaou cytological testing (Pap smear). Participants were assessed regarding their access to and utilization of health care services, prevention orientation, history of chronic disease screening, and reproductive health history. Factors independently positively associated with Pap smear screening were age, clinical breast exam (CBE) in the last year, doctor recommendation of a Pap test, living in the United States, and checkup in the past year. Having a regular source of health care, as well as a doctor's recommendation for a Pap smear, appears to have a positive effect on women's Pap smear screening rates in U.S.–Mexico border communities.     

Strong Smoke-Free Law Coverage in the United States by Race/Ethnicity: 2000–2009

Objectives. We determined whether racial/ethnic disparities existed in coverage by type of 100% smoke-free private workplace, restaurant, and bar laws from 2000 to 2009.Methods. We combined US census population data and the American Nonsmokers’ Rights Foundation US Tobacco Control Database to calculate the percentage of individuals in counties covered by each type of law by race/ethnicity from 2000 to 2009.Results. More of the US Hispanic and Asian populations were covered by 100% smoke-free restaurant and bar laws than non-Hispanic White and non-Hispanic Black populations. Asian coverage by smoke-free bars laws increased from 36% to 75%, and Hispanic coverage increased from 31% to 62%, compared with 6% to 41% for non-Hispanic Blacks and 8% to 49% for non-Hispanic Whites.Conclusions. Hispanics and Asians benefited more from the rapid spread of smoke-free law coverage, whereas non-Hispanic Blacks benefited less. These ethnic disparities suggest a likely effect of geographic region and may provide a basis for more effective, community-based, and tailored policy-related interventions, particularly regarding areas with high concentrations of non-Hispanic Blacks.Secondhand smoke causes disease, including lung cancer, heart disease, and breast cancer.1–3 Implementation of strong smoke-free laws is followed by drops in hospital admissions for heart attacks4–8 and decreased smoking prevalence.9 Regional studies have suggested that the implementation of clean indoor air and tobacco control policies is not evenly distributed across the United States; communities with high education and income are more likely to adopt 100% smoke-free laws than communities with lower education and income; disparities also exist by race/ethnicity.10–14 In Massachusetts, areas with large minority populations were less likely to have smoke-free laws,12 whereas in Texas large minority urban areas were more likely to have smoke-free coverage.13 Blue-collar and service workers were less likely to be covered by smoke-free laws than white-collar workers.15–17Although several investigators have studied the effects of smoke-free laws at a national level, there have been important limitations in how coverage was assessed. Some studies relied only on state laws,18–20 despite the fact that states with weak or no state laws often have strong local laws. Other studies relied on individual survey responses about law coverage, such as the initial outcomes index that measures clean indoor air laws in incorporated places (such as towns) that is combined with a state-level aggregate of individual responses regarding smoke-free coverage from the Tobacco Use Supplement to the Current Population Survey.21–23 Some studies have not considered the fact that some county laws cover incorporated areas inside the county,24 and other studies have not considered subcounty coverage at all.25In states in which county laws apply only to unincorporated areas in the county, the incorporated areas (cities or towns that function as administrative units that provide “governmental functions for a concentration of people”26) can pass laws. Assuming that county laws apply everywhere in these counties introduces 2 kinds of misclassification errors: (1) if a county law exists but does not cover incorporated areas, the number of people covered by the law will be overstated, and (2) if no county law exists, but laws in incorporated cities do, the number of people covered by the law will be underestimated. Because population is not evenly distributed across counties but often clustered in cities and towns, reliance on county-level laws can miss large, subcounty population clusters. For example, the largest city in Alabama, Birmingham, has a 100% smoke-free law, but neither the State of Alabama nor Jefferson County (which includes Birmingham) have 100% smoke-free laws. Thus, relying on the county law would completely miss coverage for the largest city in the state.Measures of policy coverage have varied in earlier studies. For example, in 1 study respondent zip code was used as a means of determining respondent location and thus subcounty clean indoor air law coverage. (This level of geocode information is usually available only for privately funded data sets.27) Two studies have accounted for subcounty law coverage by using the existence of a city-level law as a proxy for county coverage (in these cases, the publicly funded data sets only included county-level geocodes).28,29 Other studies accounted for subcounty smoke-free law coverage by calculating the percentage of individuals in a county covered by clean indoor air laws30,31 using state laws and local ordinances in the single years of 199232 or 200733; none accounted for changes in population over time.     

Hepatitis A vaccination coverage among adolescents (13–17 years) in the United States, 2008–2016

BackgroundThe hepatitis A (HepA) vaccine was recommended by the Advisory Committee on Immunization Practices (ACIP) incrementally from 1996 to 1999. In 2006, HepA vaccine was recommended (1) universally for children aged 12–23 months, (2) for persons who are at increased risk for infection, or (3) for any person wishing to obtain immunity. Catch-up vaccination can be considered.ObjectiveTo assess HepA vaccine coverage among adolescents and factors independently associated with vaccination administration in the US.MethodsThe 2008–2016 National Immunization Survey–Teen was utilized to determine 1 and ≥2 dose HepA vaccination coverage among adolescents aged 13–17 years. Factors associated with HepA vaccine series initiation (1 dose) were determined by bivariate and multivariable analyses. Data were stratified by state groups based on ACIP recommendation: universal child vaccination recommended since 1999 (group 1); child vaccination considered since 1999 (group 2); universal child vaccination recommendation since 2006 (group 3).ResultsIn 2016, national vaccination coverage for 1 and ≥2 doses of HepA vaccine among adolescents was 73.9% and 64.4%, respectively. Nationally, a 40 percentage point increase in vaccination coverage occurred among adolescents born in 1995 compared to adolescents born in 2003. Nationally, the independent factors associated with increased vaccine initiation was race/ethnicity (Hispanic, American Indian/Alaskan Native, Asian), military payment source and provider recommendation for HepA vaccination (2008–2013). Living in a suburban or rural region, living in poverty (level <1.33–5.03), and absence of state daycare or school HepA requirement were common factors associated with decreased likelihood of vaccine initiation.ConclusionsEfforts to increase HepA vaccine coverage in adolescents in all regions of the country would strengthen population protection from hepatitis A virus (HAV).     

HIV Diagnoses and Prevalence in the Southern Region of the United States, 2007–2010

On a number of leading health indicators, including HIV disease, individuals in the southern states of the United States fare worse than those in other regions. We analyzed data on adults and adolescents diagnosed with HIV infection through December 2010, and reported to the Centers for Disease Control and Prevention (CDC) through June 2011 from 46 states with confidential name-based HIV reporting since January 2007 to describe the impact of HIV in the South. In 2010 46.0 % of all new diagnoses of HIV infection occurred in the South. Compared to other regions, a higher percentage of diagnoses in the South were among women (23.8 %), blacks/African Americans (57.2 %), and among those in the heterosexual contact category (15.0 % for males; 88.5 % for females). From 2007 to 2010 the estimated number and rate of diagnoses of HIV infection decreased significantly in the South overall (estimated annual percentage change [EAPC] = ?1.5 % [95 %CI ?2.3 %, ?0.7 %] and ?2.1 % [95 % CI ?4.0 %, ?0.2 %], respectively) and among most groups of women, but there was no change in the number or rate of diagnoses of HIV infection among men overall. Significant decreases in men 30–39 and 40–49 years of age were offset by increases in young men 13–19 and 20–29 years of age. A continued focus on this area of high HIV burden is needed to yield success in the fight against HIV disease.     

Methuselah's medicine: Pharmaceutical innovation and mortality in the United States, 1960–2000

Although there is a good deal of speculation surrounding the role of pharmaceutical innovation in late 20th century mortality improvements in the United States, there is little empirical evidence on the topic and there remains a good deal of doubt regarding whether pharmaceuticals matter at all for mortality. Using a reliable indicator of pharmaceutical innovation—yearly approvals of new molecular entities (NMEs) by the Food and Drug Administration, along with information on priority status and disease-category indication—this study examines the relationship between pharmaceutical innovation and life expectancy between 1960 and 2000. The study demonstrates a significant relationship between pharmaceutical innovation and life expectancy at birth, which is robust to controls for gross domestic product, as well as controls for various forms of medical spending. The relationship with life expectancy is robust, in part, because pharmaceutical innovation has a stronger relationship with early-life mortality (between 20 and 50) than with later-life mortality (65 and over), even though older persons consume more pharmaceuticals and many recently approved drugs target conditions more common in later life. There is, to be sure, another side to the results. There is some evidence, for example, that the relationship between pharmaceutical innovation and mortality has declined over time, suggesting a change in the kind of innovations now entering the market. Nevertheless, there is more to contemporary pharmaceutical innovation than the development of mere “halfway” technologies. The overall relationship between innovation and mortality is sufficiently strong to warrant further consideration as a key determinant of trends in mortality.