Nicotine replacement therapy and other interventions for pregnant smokers: Pregnancy Risk Assessment Monitoring System, 2009–2010

BackgroundCurrent U.S. guidelines recommend consideration of nicotine replacement therapy (NRT) for pregnant smokers if behavioral therapies fail, only under close supervision of a provider, and after discussion of known risks of continued smoking and possible risks of NRT. The percentage of pregnant smokers offered NRT by their prenatal care providers is unknown.PurposeThe study aims to calculate the percentage of pregnant smokers offered cessation intervention and NRT and assess independent associations between selected maternal characteristics and being offered NRT.MethodsData were analyzed from the 2009–2010 Pregnancy Risk Assessment Monitoring System from four states that asked about provider practices for prenatal smoking cessation. Adjusted prevalence ratios were calculated to examine associations between being offered NRT, selected maternal characteristics, and smoking level. Variables used in adjusted models were based on factors associated with smoking cessation during pregnancy from prior literature and included race, age, education, insurance type, and stress.ResultsOf 3559 women who smoked 3 months before pregnancy, 77.4% (95% CI: 74.2, 80.3) of 3rd trimester smokers and 42% (95% CI: 38.5, 46.4) of women who quit smoking during pregnancy were offered at least one cessation method. Among smokers, 19.1% (95% CI: 16.5, 22.1) were offered NRT and of these, almost all (94%) were offered another cessation method.ConclusionsOne in five pregnant smokers was offered NRT. About a quarter of pregnant smokers did not receive any interventions to stop smoking. There may still be reluctance to provide NRT to pregnant women, despite known harms of continued smoking during pregnancy.     

Community screening for cardiovascular risk factors and levels of treatment in a rural Māori cohort

Objectives : To document levels of cardiovascular disease (CVD), diagnosed and undiagnosed risk factors and clinical management of CVD risk in rural Māori. Methods : Participants (aged 20–64 years), of Māori descent and self‐report, were randomly sampled to be representative of age and gender profiles of the community. Screening clinics included health questionnaires, fasting blood samples, blood pressure and anthropometric measures. Data were obtained from participants’ primary care physicians regarding prior diagnoses and current clinical management. New Zealand Cardiovascular Guidelines were used to identify new diagnoses at screening and Bestpractice© electronic‐decision support software used to estimate 5‐year CVD risk. Results : Mean age of participants (n=252) was 45.7±0.7, 8% reported a history of cardiac disease, 43% were current smokers, 22% had a healthy BMI, 30% were overweight and 48% obese. Hypertension was previously diagnosed in 25%; an additional 22% were hypertensive at screening. Dyslipidaemia was previously diagnosed in 14% and an additional 43% were dyslipidaemic at screening. Type‐2 diabetes was previously diagnosed in 11%. Glycaemic control was achieved in only 21% of those with type‐2 diabetes. Blood pressure and cholesterol were above recommended targets in more than half of those with diagnosed CVD risk factors. Conclusions : High levels of diagnosed and undiagnosed CVD risk factors, especially hypertension, dyslipidaemia and diabetes were identified in this rural Māori community. Implications : There is a need for opportunistic screening and intensified management of CVD risk factors in this indigenous population group.     

Association Between Maternal Multivitamin Use and Preterm Birth in 24 States,Pregnancy Risk Assessment Monitoring System, 2009–2010

Objectives The study objective was to examine the prevalence of maternal multivitamin use and associations with preterm birth (<37 weeks gestation) in the United States. We additionally examined whether associations differed by race/ethnicity. Methods Using the Pregnancy Risk Assessment Monitoring System, we analyzed 2009–2010 data among women aged ≥18 years with a singleton live birth who completed questions on multivitamin use 1 month prior to pregnancy (24 states; n = 57,348) or in the last 3 months of pregnancy (3 states, n = 5095). Results In the month prior to pregnancy, multivitamin use ≥4 times/week continued to remain low (36.8 %). In the last 3 months of pregnancy, 79.6 % of women reported using multivitamins ≥4 times/week. Adjusting for confounders, multivitamin use 1–3 times/week or ≥4 times/week prior to pregnancy was not associated with preterm birth overall. Though there was no evidence of dose response, any multivitamin use in the last 3 months of pregnancy was associated with a significant reduction in preterm birth among non-Hispanic black women. Conclusions for Practice Multivitamin use during pregnancy may help reduce preterm birth, particularly among populations with the highest burden, though further investigations are warranted.     

Risk factors for tuberculosis among health care workers in South India: a nested case–control study

ObjectiveThe epidemiology of tuberculosis (TB) among health care workers (HCWs) in India remains under-researched. This study is a nested case–control design assessing the risk factors for acquiring TB among HCWs in India.Study Design and SettingsIt is a nested case–control study conducted at a tertiary teaching hospital in India. Cases (n = 101) were HCWs with active TB. Controls (n = 101) were HCWs who did not have TB, randomly selected from the 6,003 subjects employed at the facility. Cases and controls were compared with respect to clinical and demographic variables.ResultsThe cases and controls were of similar age. Logistic regression analysis showed that body mass index (BMI) <19 kg/m² (odds ratio [OR]: 2.96, 95% confidence interval [CI]: 1.49–5.87), having frequent contact with patients (OR: 2.83, 95% CI: 1.47–5.45) and being employed in medical wards (OR: 12.37, 95% CI: 1.38–110.17) or microbiology laboratories (OR: 5.65, 95% CI: 1.74–18.36) were independently associated with increased risk of acquiring TB.ConclusionHCWs with frequent patient contact and those with BMI <19 kg/m² were at high risk of acquiring active TB. Nosocomial transmission of TB was pronounced in locations, such as medical wards and microbiology laboratories. Surveillance of high-risk HCWs and appropriate infrastructure modifications may be important to prevent interpersonal TB transmission in health care facilities.     

Rates of admission for ambulatory care sensitive conditions in France in 2009–2010: trends,geographic variation,costs, and an international comparison

Background

Admissions for ambulatory care sensitive conditions (ACSCs) are considered preventable and indicators of poor access to primary care. We wondered whether per-capita rates of admission for ACSCs in France demonstrated geographic variation, were changing, were related to other independent variables, or were comparable to those in other countries; further, we wanted to quantify the resources such admissions consume.

Methods

We calculated per-capita rates of admission for five categories (chronic, acute, vaccination preventable, alcohol-related, and other) of ACSCs in 94 departments in mainland France in 2009 and 2010, examined measures and causes of geographic variation in those rates, computed the costs of those admissions, and compared rates of admission for ACSCs in France to those in several other countries.

Results

The highest ACSC admission rates generally occurred in the young and the old, but rates varied across French regions. Over the 2-year period, rates of most categories of ACSCs increased; higher ACSC admission rates were associated with lower incomes and a higher supply of hospital beds. We found that the local supply of general practitioners was inversely associated with rates of chronic and total ACSC admission rates, but that this relationship disappeared if we accounted for patients’ use of general practitioners in neighboring departments. ACSC admissions cost 4.755 billion euros in 2009 and 5.066 billion euros in 2010; they consumed 7.86 and 8.74 million bed days of care, respectively. France had higher rates of ACSC admissions than most other countries examined.

Conclusions

Because admissions for ACSCs are generally considered a failure of outpatient care, cost French taxpayers substantial monetary and hospital resources, and appear to occur more frequently in France than in other countries, policymakers should prioritize targeted efforts to reduce them.

     

Racial–ethnic disparities in the association between risk factors and diabetes: The Northern Manhattan Study

PurposeTo identify risk factors (RF) for diabetes within a multiethnic cohort and to examine whether race–ethnicity modified their effects.MethodsParticipants in the Northern Manhattan Study without diabetes at baseline were studied from 1993 to 2014 (n = 2430). Weibull regression models with interval censoring data were fit to calculate hazard ratios and 95% confidence intervals for incident diabetes. We tested for interactions between RF and race–ethnicity.ResultsDuring a mean follow-up period of 11 years, there were 449 diagnoses of diabetes. Being non-Hispanic black (HR 1.69 95% CI 1.11–2.59) or Hispanic (HR 2.25 95% CI 1.48–3.40) versus non-Hispanic white, and body mass index (BMI; HR 1.34 per SD 95% CI 1.21–1.49) were associated with greater risk of diabetes; high-density lipoprotein cholesterol (HR 0.75 95% CI 0.66–0.86) was protective. There were interactions by race–ethnicity. In stratified models, the effects of BMI, current smoking, and C-reactive protein (CRP) on risk of diabetes differed by race–ethnicity (p for interaction < 0.05). The effects were greater among non-Hispanic whites than non-Hispanic blacks and Hispanics.ConclusionsAlthough Hispanics and non-Hispanic blacks had a greater risk of diabetes than whites, there were variations by race–ethnicity in the association of BMI, smoking, and CRP with risk of diabetes. Unique approaches should be considered to reduce diabetes as traditional RF may not be as influential in minority populations.     

Risk factors for tuberculosis in older children and adolescents: a matched case–control study in Recife,Brazil

Background

Tuberculosis is a major disease worldwide and most research focus on risk factors for adults, although there is a marked adolescent peak in incidence. The objective of this study was to identify risk factors for tuberculosis in children aged 7 to 19.

Methods

A case control study matched by age with 169 cases and 477 controls. The study population consisted of adolescents and older children from Recife, Brazil. Cases were individuals diagnosed with tuberculosis in the control programme and controls were selected in the neighborhood of cases. Conditional logistic regression was used to identify risk factors.

Results

Cigarette smoking increased by 50% the risk of tuberculosis but that this was not statistically significant (OR?=?1.6). Other risk factors were sleeping in the same house as a case of tuberculosis (OR?=?31.6), living in a house with no piped water (OR?=?7.7) (probably as a proxy for bad living conditions), illiteracy (OR?=?3.7) and male sex (OR?=?1.8). The increase in risk with living in houses with no piped water was much more marked in males. The proportion of cases of tuberculosis attributed to contact with someone with TB was 38% and to illiteracy, lack of piped water and smoking, 20%.

Conclusion

Household contact with tuberculosis, social factors and male sex play the biggest role in determining risk of TB disease among children and adolescents in the study. We recommend further research on the relationship of cigarette smoking on tuberculosis in adolescents, and on whether the sex differentials are more marked in bad living conditions. Separate studies should be conducted in older children and in adolescents.

     

8th International Symposium on Biological Monitoring in Occupational and Environmental Health: 6–8 September 2010, Espoo, Finland

Announcement

8th International Symposium on Biological Monitoring in Occupational and Environmental Health: 6–8 September 2010, Espoo, Finland     

Unemployment and stillbirth risk among foreign-born and Spanish pregnant women in Spain, 2007–2010: a multilevel analysis study

We describe stillbirth and unemployment rates by autonomous region in Spain and analyse whether women who gave birth in regions with high unemployment rates were more likely to have a stillborn. We designed a multilevel population-based observational study of births from 2007 to 2010. We defined stillbirth as the outcome, individual maternal socioeconomic and pregnancy-related characteristics as covariates, and maternal autonomous region of residence as the contextual covariate. We used mixed-logistic regression models to account for differences across regions. In total, 1,920,235 singleton births and 5,560 stillbirths were included in the study. Women residing in autonomous regions with the highest rates of unemployment had a two-times-greater chance of delivering a stillborn (adjusted OR 2.60; 95 % CI 2.08–3.21). The region where women resided explained 14 % of the total individual differences in the risk of delivering a stillborn. The odds of stillbirth were 1.82 (95 % CI 1.62–2.05) times higher for African-born women than for Spanish-born women and 1.90 (95 % CI 1.68–2.15) times higher for women with low educational attainment than for women with higher education. In conclusion, regional disparities in stillbirth rates in Spain in the period 2007–2010 were mainly associated with mothers who had low levels of education, were African-born, and lived in regions with higher unemployment.     

The Health and Economic Consequences of Cigarette Smoking in Alabama, 2009–2010

While CDC reports on the health and economic burden of smoking in the United States, state-specific data are not readily available. We estimated the health and economic consequences of cigarette smoking in Alabama to provide the state legislature with the state-specific data that reveal the direct impact of smoking on their constituents. We estimated that in 2009, almost 7,900 adult deaths (18% of all adult deaths) and approximately 121,000 years of potential life lost among Alabama adults aged 35 years and older were attributable to cigarette smoking. Productivity losses due to premature death and smoking-attributable illness were estimated at $2.84 billion and $941 million, respectively. Our findings support a strong need for tobacco control and prevention programs to decrease the health and economic burden of smoking in Alabama. These results are being used by the State Health Officer to illustrate the real costs of smoking in Alabama and to advocate for improved tobacco control policies.Tobacco use is one of the most preventable causes of disease and death in the United States.¹ Cigarette smoking drastically increases the risk of disease and is associated with medical conditions that cause death, including cancer, cardiovascular disease, respiratory disease, and perinatal conditions. In the U.S., smoking accounts for approximately 443,000 deaths each year.² While the U.S. Centers for Disease Control and Prevention (CDC) and other health organizations report on the burden of cigarette smoking nationwide, state-specific data are not as readily available. Yet, providing state-specific information can have a greater impact on state policy makers than national data because it reveals the direct impact of smoking on a state''s constituents.To understand the current health and economic consequences of cigarette use in Alabama, in 2011, the Alabama Department of Public Health (ADPH) and the Institute for Social Science Research at the University of Alabama produced estimates of smoking-attributable mortality (SAM), years of potential life lost (YPLL), and productivity losses using CDC''s Smoking-Attributable Mortality, Morbidity, and Economic Costs (SAMMEC) calculator.³ The resulting estimates are being used by the State Health Officer to illustrate the real costs of smoking in Alabama to policy makers and the public. This study can be used as a model for how researchers can estimate the burden of cigarette smoking in other states.     

Prevalence of and risk factors for abdominal aortic aneurysms in a population-based study : The Tromsø Study

In a population-based study of 6,386 men and women aged 25--84 years in Troms?, Norway, in 1994--1995, the authors assessed the age- and sex-specific distribution of the abdominal aortic diameter and the prevalence of and risk factors for abdominal aortic aneurysm. Renal and infrarenal aortic diameters were measured with ultrasound. The mean infrarenal aortic diameter increased with age. The increase was more pronounced in men than in women. The age-related increase in the median diameter was less than that in the mean diameter. An aneurysm was present in 263 (8.9%) men and 74 (2.2%) women (p < 0.001). The prevalence of abdominal aortic aneurysm increased with age. No person aged less than 48 years was found with an abdominal aortic aneurysm. Persons who had smoked for more than 40 years had an odds ratio of 8.0 for abdominal aortic aneurysm (95% confidence interval: 5.0, 12.6) compared with never smokers. Low serum high density lipoprotein cholesterol was associated with an increased risk for abdominal aortic aneurysm. Other factors associated with abdominal aortic aneurysm were a high level of plasma fibrinogen and a low blood platelet count. Antihypertensive medication (ever use) was significantly associated with abdominal aortic aneurysm, but high systolic blood pressure was a risk factor in women only. This study indicates that risk factors for atherosclerosis are also associated with increased risk for abdominal aortic aneurysm.     

Role of birthplace in chronic disease in adults and very old individuals: national cohorts in the UK and USA, 2009–2010

Objectives

To understand the role of birthplace in chronic disease in adults and very old individuals.

Study design

Two national and population-based studies (UK Longitudinal Household Survey and US National Health and Nutrition Examination Surveys) in 2009–2010 were included.

Method

Information on demographics, lifestyle factors and self-reported chronic diseases was obtained by household interview. Analyses included Chi-squared test, t-test and logistic regression modelling.

Results

In the UK, there were more cases of heart failure and myocardial infarction in adults (aged 20–79 years) born in Scotland, and more cases of coronary heart disease in adults born in Northern Ireland. There were fewer cases of asthma, depression and hypothyroidism in adults born in Northern Ireland and not born in the UK, and fewer cases of cancer, chronic bronchitis and epilepsy in adults not born in the UK. In USA, there were fewer cases of asthma, cancer, chronic bronchitis, heart failure and heart attack, but more cases of liver disease in adults born in Mexico. Similarly, there were fewer cases of asthma, cancer and chronic bronchitis in adults born in other Spanish or non-Spanish countries, although there were more cases of liver disease in other Spanish-born adults and more cases of diabetes in other non-Spanish-born adults. In very old (≥80 years) individuals, there were more cases of chronic bronchitis in those born in Wales, more cases of myocardial infarction in those born in Northern Ireland, and more cases of diabetes and liver disease in those not born in the UK. Overall, diabetes was more common in foreign-born adults, and respiratory illness and cancer were more common in native-born adults.

Conclusions

It is suggested that future health policy and public health programmes should consider birthplace.     

Cross sectional study of childhood obesity and prevalence of risk factors for cardiovascular disease and diabetes in children aged 11–13

Background

European and Developing Countries Clinical Trials Partnership (EDCTP) was founded in 2003 by the European Parliament and Council. It is a partnership of 14 European Union (EU) member states, Norway, Switzerland, and Developing Countries, formed to fund acceleration of new clinical trial interventions to fight the human immunodeficiency virus and acquired immune deficiency syndrome (HIV/AIDS), malaria and tuberculosis (TB) in the sub-Saharan African region. EDCTP seeks to be synergistic with other funding bodies supporting research on these diseases.

Methods

EDCTP promotes collaborative research supported by multiple funding agencies and harnesses networking expertise across different African and European countries. EDCTP is different from other similar initiatives. The organisation of EDCTP blends important aspects of partnership that includes ownership, sustainability and responds to demand-driven research. The Developing Countries Coordinating Committee (DCCC); a team of independent scientists and representatives of regional health bodies from sub-Saharan Africa provides advice to the partnership. Thus EDCTP reflects a true partnership and the active involvement and contribution of these African scientists ensures joint ownership of the EDCTP programme with European counterparts.

Results

The following have been the major achievements of the EDCTP initiative since its formation in 2003; i) increase in the number of participating African countries from two to 26 in 2008 ii) the cumulative amount of funds spent on EDCTP projects has reached € 150 m, iii) the cumulative number of clinical trials approved has reached 40 and iv) there has been a significant increase number and diversity in capacity building activities.

Conclusion

While we recognise that EDCTP faced enormous challenges in its first few years of existence, the strong involvement of African scientists and its new initiatives such as unconditional funding to regional networks of excellence in sub-Saharan Africa is envisaged to lead to a sustainable programme. Current data shows that the number of projects supported by EDCTP is increasing. DCCC proposes that this success story of true partnership should be used as model by partners involved in the fight against other infectious diseases of public health importance in the region.     

System for Rapid Assessment of Pneumonia and Influenza-Related Mortality—Ohio, 2009–2010

Rapid mortality surveillance is critical for state emergency preparedness. To enhance timeliness during the 2009–2010 influenza A H1N1 pandemic, the Ohio Department of Health activated a drop-down menu within Ohio’s Electronic Death Registration System for reporting of pneumonia- or influenza-related deaths approximately 5 days postmortem. We used International Classification of Diseases—Tenth Revision (ICD-10) codes, available 2–3 months postmortem as the standard, and assessed their agreement with drop-down-menu codes for pneumonia- or influenza-related deaths. Among 56 660 Ohio deaths during September 2009–March 2010, agreement was 97.9% for pneumonia (κ = 0.85) and 99.9% for influenza (κ = 0.79). Sensitivity was 80.2% for pneumonia and 73.9% for influenza. Drop-down menu coding enhanced timeliness while maintaining high agreement with ICD-10 codes.     

WIC Participation and Breastfeeding in South Carolina: Updates from PRAMS 2009–2010

Few studies examined breastfeeding initiation and duration among mothers who were eligible for the Women Infants Children (WIC) program and did not participate. This study is sought to understand the role of WIC participation and poverty level in breastfeeding initiation and duration in South Carolina. The data came from the 2009–2010 South Carolina Pregnancy Risk Assessment Monitoring System (unweighted N = 1,796). All participants were classified as WIC participants, income-eligible non-WIC participants, and income-ineligible non-WIC participants. Logistic regression models were used to analyze the association between breastfeeding initiation and WIC participation. The Kaplan–Meier method and Cox proportional hazards models were used to determine whether the continuation of breastfeeding and hazards of discontinuing breastfeeding differed by WIC participation groups. In South Carolina, two out of three women (67.2 %) initiated breastfeeding. The breastfeeding initiation rate was higher among income-ineligible (84.0 %) and income-eligible (78.9 %) non-WIC participants than among WIC participants (55.5 %). Compared to WIC participants, both income-ineligible [odds ratio (OR) = 2.1, 95 % confidence interval (CI) 1.2–4.0] and income-eligible (OR = 2.6, 95 % CI 1.1–4.3) non-WIC participants were more likely to initiate breastfeeding. Among mothers who already initiated breastfeeding, after adjusting covariates, the hazard ratios for weaning within 34 weeks postpartum were not significantly different by WIC participation groups. This study confirmed WIC participants were less likely to initiate breastfeeding. Once initiated, WIC participation did not significantly impact breastfeeding duration in the early postpartum period. Poverty status may not play an important role in explaining disparities in breastfeeding initiation between WIC and non-WIC participants.     

Substance abuse treatment for women: Changes in the settings where women received treatment and types of services provided, 1987–1998

Changes in social policies during the last 2 decades have had major implications for the provision of substance abuse treatment services to women. The goal of this analysis was to examine (a) changes in the proportion of women clients served within different types of treatment facilities and (b) the services provided in these facilities. Data were analyzed from national surveys of treatment providers for the period of 1987 to 1998. Overall, there were gradual increases in the proportion of women clients across treatment facilities and greater concentrations of women in more intensive treatment modalities. The provision of childcare increased over time, particularly in programs with only women clients. Treatment facilities in which there were higher proportions of women generally had higher rates of providing services related to pregnancy, parenting, and domestic violence. These findings can be used to assess the adequacy of service delivery to women in substance abuse treatment.     

Left behind: widening disparities for males and females in US county life expectancy, 1985–2010

Background

The United States spends more than any other country on health care. The poor relative performance of the US compared to other high-income countries has attracted attention and raised questions about the performance of the US health system. An important dimension to poor national performance is the large disparities in life expectancy.

Methods

We applied a mixed effects Poisson statistical model and Gaussian Process Regression to estimate age-specific mortality rates for US counties from 1985 to 2010. We generated uncertainty distributions for life expectancy at each age using standard simulation methods.

Results

Female life expectancy in the United States increased from 78.0 years in 1985 to 80.9 years in 2010, while male life expectancy increased from 71.0 years in 1985 to 76.3 years in 2010. The gap between female and male life expectancy in the United States was 7.0 years in 1985, narrowing to 4.6 years in 2010. For males at the county level, the highest life expectancy steadily increased from 75.5 in 1985 to 81.7 in 2010, while the lowest life expectancy remained under 65. For females at the county level, the highest life expectancy increased from 81.1 to 85.0, and the lowest life expectancy remained around 73. For male life expectancy at the county level, there have been three phases in the evolution of inequality: a period of rising inequality from 1985 to 1993, a period of stable inequality from 1993 to 2002, and rising inequality from 2002 to 2010. For females, in contrast, inequality has steadily increased during the 25-year period. Compared to only 154 counties where male life expectancy remained stagnant or declined, 1,405 out of 3,143 counties (45%) have seen no significant change or a significant decline in female life expectancy from 1985 to 2010. In all time periods, the lowest county-level life expectancies are seen in the South, the Mississippi basin, West Virginia, Kentucky, and selected counties with large Native American populations.

Conclusions

The reduction in the number of counties where female life expectancy at birth is declining in the most recent period is welcome news. However, the widening disparities between counties and the slow rate of increase compared to other countries should be viewed as a call for action. An increased focus on factors affecting health outcomes, morbidity, and mortality such as socioeconomic factors, difficulty of access to and poor quality of health care, and behavioral, environmental, and metabolic risk factors is urgently required.