Validation of the Prevention Impacts Simulation Model (PRISM).

INTRODUCTION: Demonstrating the validity of a public health simulation model helps to establish confidence in the accuracy and usefulness of a model's results. In this study we evaluated the validity of the Prevention Impacts Simulation Model (PRISM), a system dynamics model that simulates health, mortality, and economic outcomes for the US population. PRISM primarily simulates outcomes related to cardiovascular disease but also includes outcomes related to other chronic diseases that share risk factors. PRISM is openly available through a web application. METHODS: We applied the model validation framework developed independently by the International Society of Pharmacoeconomics and Outcomes Research and the Society for Medical Decision Making modeling task force to validate PRISM. This framework included model review by external experts and quantitative data comparison by the study team. RESULTS: External expert review determined that PRISM is based on up-to-date science. One-way sensitivity analysis showed that no parameter affected results by more than 5%. Comparison with other published models, such as ModelHealth, showed that PRISM produces lower estimates of effects and cost savings. Comparison with surveillance data showed that projected model trends in risk factors and outcomes align closely with secular trends. Four measures did not align with surveillance data, and those were recalibrated. CONCLUSION: PRISM is a useful tool to simulate the potential effects and costs of public health interventions. Results of this validation should help assure health policy leaders that PRISM can help support community health program planning and evaluation efforts.

Control of Lead Sources in the United States, 1970-2017: Public Health Progress and Current Challenges to Eliminating Lead Exposure.

CONTEXT: During the past 45 years, exposure to lead has declined dramatically in the United States. This sustained decline is measured by blood and environmental lead levels and achieved through control of lead sources, emission reductions, federal regulations, and applied public health efforts. OBJECTIVE: Explore regulatory factors that contributed to the decrease in exposure to lead among the US population since 1970. DESIGN/SETTING: We present historical information about the control of lead sources and the reduction of emissions through regulatory and selected applied public health efforts, which have contributed to decreases in lead exposure in the United States. Sources of lead exposure, exposure pathways, blood lead measurements, and special populations at risk are described. RESULTS: From 1976-1980 to 2015-2016, the geometric mean blood lead level (BLL) of the US population aged 1 to 74 years dropped from 12.8 to 0.82 µg/dL, a decline of 93.6%. Yet, an estimated 500 000 children aged 1 to 5 years have BLLs at or above the blood lead reference value of 5 µg/dL established by the Centers for Disease Control and Prevention. Low levels of exposure can lead to adverse health effects. There is no safe level of lead exposure, and child BLLs less than 10 µg/dL are known to adversely affect IQ and behavior. When the exposure source is known, approximately 95% of BLLs of 25 µg/dL or higher are work-related among US adults. Despite much progress in reducing exposure to lead in the United States, there are challenges to eliminating exposure. CONCLUSIONS: There are future challenges, particularly from the inequitable distribution of lead hazards among some communities. Maintaining federal, state, and local capacity to identify and respond to populations at high risk can help eliminate lead exposure as a public health problem. The results of this review show that the use of strong evidence-based programs and practices, as well as regulatory authority, can help control or eliminate lead hazards before children and adults are exposed.

Practice-Based Evidence in Community Guide Systematic Reviews.

OBJECTIVES: To assess the relative contributions and quality of practice-based evidence (PBE) and research-based evidence (RBE) in The Guide to Community Preventive Services (The Community Guide). METHODS: We developed operational definitions for PBE and RBE in which the main distinguishing feature was whether allocation of participants to intervention and comparison conditions was under the control of researchers (RBE) or not (PBE). We conceptualized a continuum between RBE and PBE. We then categorized 3656 studies in 202 reviews completed since The Community Guide began in 1996. RESULTS: Fifty-four percent of studies were PBE and 46% RBE. Community-based and policy reviews had more PBE. Health care system and programmatic reviews had more RBE. The majority of both PBE and RBE studies were of high quality according to Community Guide scoring methods. CONCLUSIONS: The inclusion of substantial PBE in Community Guide reviews suggests that evidence of adequate rigor to inform practice is being produced. This should increase stakeholders' confidence that The Community Guide provides recommendations with real-world relevance. Limitations in some PBE studies suggest a need for strengthening practice-relevant designs and external validity reporting standards.

CDC grand rounds: Creating a healthier future through prevention of child maltreatment.

Child maltreatment is abuse or neglect of a child by a parent or other caregiver that results in potential or actual harm or threats of harm to a child. Maltreatment encompasses both acts of commission (abuse) and omission (neglect). Child maltreatment is divided into four types: 1) physical abuse (e.g., hitting, kicking, shaking, or burning); 2) sexual abuse (e.g., rape or fondling); 3) psychological abuse (e.g., terrorizing or belittling); and 4) neglect, which involves the failure to meet a child's basic physical, emotional, or educational needs (e.g., not providing nutrition, shelter, or medical or mental health care) or the failure to supervise the child in a way that ensures safety (e.g., not taking reasonable steps to prevent injury). In 2012, a total of 1,593 children were reported to have died as a result of maltreatment in the United States. Also in 2012, state child protective service (CPS) agencies received an estimated 3.4 million reports of alleged maltreatment, involving an estimated 6.3 million children. Following the CPS investigation or other response, nearly 700,000 children were confirmed as having been maltreated. However, many cases are never reported to authorities; the actual scope of child maltreatment is greater. For example, data from a nationally representative survey in 2011 of children and adult caregivers (usually parents) suggest that 13.8% of children are maltreated each year and 25.6% experienced maltreatment at some point during childhood.

Trends in tobacco smoke exposure and blood lead levels among youths and adults in the United States: the National Health and Nutrition Examination Survey, 1999-2008.

INTRODUCTION: Tobacco smoke is a source of exposure to thousands of toxic chemicals including lead, a chemical of longstanding public health concern. We assessed trends in blood lead levels in youths and adults with cotinine-verified tobacco smoke exposure by using 10 years of data from the National Health and Nutrition Examination Survey. METHODS: Geometric mean levels of blood lead are presented for increasing levels of tobacco smoke exposure. Regression models for lead included age, race/ethnicity, poverty, survey year, sex, age of home, birth country, and, for adults, alcohol consumption. Lead levels were evaluated for smokers and nonsmokers on the basis of age of residence and occupation. RESULTS: Positive trend tests indicate that a linear relationship exists between smoke exposure and blood lead levels in youths and adults and that secondhand smoke exposure contributes to blood lead levels above the level caused by smoking. CONCLUSION: Youths with secondhand smoke exposure had blood lead levels suggestive of the potential for adverse cognitive outcomes. Despite remediation efforts in housing and the environment and declining smoking rates and secondhand smoke exposure in the United States, tobacco smoke continues to be a substantial source of exposure to lead in vulnerable populations and the population in general.

Introduction: CDC Health Disparities and Inequalities Report - United States, 2013.

This supplement is the second CDC Health Disparities and Inequalities Report (CHDIR). The 2011 CHDIR was the first CDC report to assess disparities across a wide range of diseases, behavioral risk factors, environmental exposures, social determinants, and health-care access (CDC. CDC Health Disparities and Inequalities Report-United States, 2011. MMWR 2011;60[Suppl; January 14, 2011]). The 2013 CHDIR provides new data for 19 of the topics published in 2011 and 10 new topics. When data were available and suitable analyses were possible for the topic area, disparities were examined for population characteristics that included race and ethnicity, sex, sexual orientation, age, disability, socioeconomic status, and geographic location. The purpose of this supplement is to raise awareness of differences among groups regarding selected health outcomes and health determinants and to prompt actions to reduce disparities. The findings in this supplement can be used by practitioners in public health, academia and clinical medicine; the media; the general public; policymakers; program managers; and researchers to address disparities and help all persons in the United States live longer, healthier, and more productive lives.

Medicaid coverage for tobacco dependence treatments in Massachusetts and associated decreases in smoking prevalence.

BACKGROUND: Approximately 50% of smokers die prematurely from tobacco-related diseases. In July 2006, the Massachusetts health care reform law mandated tobacco cessation coverage for the Massachusetts Medicaid population. The new benefit included behavioral counseling and all medications approved for tobacco cessation treatment by the U.S. Food and Drug Administration (FDA). Between July 1, 2006 and December 31, 2008, a total of 70,140 unique Massachusetts Medicaid subscribers used the newly available benefit, which is approximately 37% of all Massachusetts Medicaid smokers. Given the high utilization rate, the objective of this study is to determine if smoking prevalence decreased significantly after the initiation of tobacco cessation coverage. METHODS AND FINDINGS: Smoking prevalence was evaluated pre- to post-benefit using 1999 through 2008 data from the Massachusetts Behavioral Risk Factor Survey (BRFSS). The crude smoking rate decreased from 38.3% (95% C.I. 33.6%-42.9%) in the pre-benefit period compared to 28.3% (95% C.I.: 24.0%-32.7%) in the post-benefit period, representing a decline of 26 percent. A demographically adjusted smoking rate showed a similar decrease in the post-benefit period. Trend analyses reflected prevalence decreases that accrued over time. Specifically, a joinpoint analysis of smoking prevalence among Massachusetts Medicaid benefit-eligible members (age 18-64) from 1999 through 2008 found a decreasing trend that was coincident with the implementation of the benefit. Finally, a logistic regression that controlled for demographic factors also showed that the trend in smoking decreased significantly from July 1, 2006 to December 31, 2008. CONCLUSION: These findings suggest that a tobacco cessation benefit that includes coverage for medications and behavioral treatments, has few barriers to access, and involves broad promotion can significantly reduce smoking prevalence.

Surveillance for cancers associated with tobacco use--United States, 1999-2004.

PROBLEM/CONDITION: Tobacco use is the leading preventable cause of disease and premature death in the United States. The 2004 Surgeon General report found convincing evidence for a direct causal relationship between tobacco use and the following cancers: lung and bronchial, laryngeal, oral cavity and pharyngeal, esophageal, stomach, pancreatic, kidney and renal pelvis, urinary bladder, and cervical cancers and acute myelogenous leukemia (AML). This report provides state-level cancer incidence data and recent trends for cancers associated with tobacco use. Because information on tobacco use was not available in the databases of the National Program of Cancer Registries (NPCR) and Surveillance, Epidemiology, and End Results (SEER) program, cases of cancer included in this report might or might not be in persons who used tobacco; however, the cancer types included in this report are those defined by the U.S. Surgeon General as having a direct causal relationship with tobacco use (i.e., referred to as tobacco-related cancer in this report). These data are important for initiation, monitoring, and evaluation of targeted tobacco prevention and control measures. REPORTING PERIOD COVERED: 1999--2004. DESCRIPTION OF SYSTEMS: Data were obtained from cancer registries affiliated with CDC's NPCR and the National Cancer Institute's SEER program; combined, these data cover approximately 92% of the U.S. population. Combined data from the NPCR and SEER programs provide the best source of information on population-based cancer incidence for the nation and are the only source of information for 41 states (including the District of Columbia) with cancer surveillance programs that are funded solely by NPCR. This report provides age-adjusted cancer incidence rates by demographic and geographic characteristics, percentage distributions for tumor characteristics, and trends in cancer incidence by sex. RESULTS: Approximately 2.4 million cases of tobacco-related cancer were diagnosed during 1999--2004. Age-adjusted incidence rates ranged from 4.0 per 100,000 persons (for AML) to 69.4 (for lung and bronchial cancer). High rates occurred among men, black and non-Hispanic populations, and older adults. Higher incidence rates of lung and laryngeal cancer occurred in the South compared with other regions, particularly the West, consistent with high smoking patterns in the South. INTERPRETATION: The high rates of tobacco-related cancer observed among men, blacks, non-Hispanics, and older adults reflect overall demographic patterns of cancer incidence in the United States and reflect patterns of tobacco use. PUBLIC HEALTH ACTION: The findings in this report emphasize the need for ongoing surveillance and reporting to monitor cancer incidence trends, identify populations at greatest risk for developing cancer related to tobacco use, and evaluate the effectiveness of targeted tobacco control programs and policies.

Arsenic in drinking-water and reproductive health outcomes: a study of participants in the Bangladesh Integrated Nutrition Programme.

This study examined 2,006 pregnant women chronically exposed to a range of naturally-occurring concentrations of arsenic in drinking-water in three upazilas in Bangladesh to find out relationships between arsenic exposure and selected reproductive health outcomes. While there was a small but statistically significant association between arsenic exposure and birth-defects (odds ratio=1.005, 95% confidence interval 1.001-1.010), other outcomes, such as stillbirth, low birth-weight, childhood stunting, and childhood under-weight, were not associated with arsenic exposure. It is possible that the association between arsenic exposure from drinking-water and birth-defects may be a statistical anomaly due to the small number of birth-defects observed. Future studies should look more closely at birth-defects, especially neural tube defects, to elucidate any potential health effects associated with arsenic exposure from drinking-water. Further, given the knowledge that serious health effects can result from chronic arsenic exposure, efforts to find alternatives of safe drinking-water for the population must continue.

Water, sanitation, and hygiene interventions to reduce diarrhoea in less developed countries: a systematic review and meta-analysis.

Many studies have reported the results of interventions to reduce illness through improvements in drinking water, sanitation facilities, and hygiene practices in less developed countries. There has, however, been no formal systematic review and meta-analysis comparing the evidence of the relative effectiveness of these interventions. We developed a comprehensive search strategy designed to identify all peer-reviewed articles, in any language, that presented water, sanitation, or hygiene interventions. We examined only those articles with specific measurement of diarrhoea morbidity as a health outcome in non-outbreak conditions. We screened the titles and, where necessary, the abstracts of 2120 publications. 46 studies were judged to contain relevant evidence and were reviewed in detail. Data were extracted from these studies and pooled by meta-analysis to provide summary estimates of the effectiveness of each type of intervention. All of the interventions studied were found to reduce significantly the risks of diarrhoeal illness. Most of the interventions had a similar degree of impact on diarrhoeal illness, with the relative risk estimates from the overall meta-analyses ranging between 0.63 and 0.75. The results generally agree with those from previous reviews, but water quality interventions (point-of-use water treatment) were found to be more effective than previously thought, and multiple interventions (consisting of combined water, sanitation, and hygiene measures) were not more effective than interventions with a single focus. There is some evidence of publication bias in the findings from the hygiene and water treatment interventions.

Elevated blood lead levels associated with the consumption of moonshine among emergency department patients in Atlanta, Georgia.

STUDY OBJECTIVES: In February and March 2000, 4 adult emergency care patients were identified with potentially lethal lead toxicity at Grady Memorial Hospital, an urban Atlanta, GA, hospital. All were moonshine drinkers, prompting concern that lead exposure from moonshine was underrecognized in this setting. METHODS: We conducted a 2-phased, nested, cross-sectional study throughout a 14-day period in the emergency care center of Grady Memorial Hospital. The prevalence phase consisted of demographic data collection, eligibility screening, and a brief interview pertaining to alcohol and moonshine consumption. During the nested phase, a full interview and blood lead analyses were conducted on all consenting moonshine drinkers and a time-matched comparison group of non-moonshine drinkers. RESULTS: In the prevalence phase, of 581 patients interviewed, 8.6% reported consuming moonshine in the past 5 years. Moonshine drinkers were predominantly men between the ages of 40 and 59 years. In the nested phase, the median blood lead levels among moonshine drinkers and nondrinkers were 11.0 microg/dL (0.531 micromol/L) and 2.5 microg/dL (0.121 micromol/L), respectively. Moonshine drinkers were significantly more likely to have blood lead levels of 10 microg/dL (0.483 micromol/L) or greater (odds ratio [OR] 10.94; 95% confidence interval 3.76 to 31.85). Patients who consumed moonshine in the previous week were significantly more likely to have a blood lead level of 10 microg/dL (0.483 micromol/L) or greater than were individuals who reported less recent consumption. Patients who consumed moonshine more than once a month were significantly more likely to have a blood lead level of 10 microg/dL (0.483 micromol/L) or greater than were those reporting less frequent use. Moonshine users were more likely to report heavy alcohol use. CONCLUSION: Moonshine consumption was more prevalent than expected in our patient population and was strongly associated with elevated blood lead levels, particularly among recent moonshine drinkers.

Blood lead, blood pressure, and hypertension in perimenopausal and postmenopausal women.

CONTEXT: Lead exposures have been shown to be associated with increased blood pressure and risk of hypertension in older men. In perimenopausal women, skeletal lead stores are an important source of endogenous lead exposure due to increased bone demineralization. OBJECTIVE: To examine the relationship of blood lead level with blood pressure and hypertension prevalence in a population-based sample of perimenopausal and postmenopausal women in the United States. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional sample of 2165 women aged 40 to 59 years, who participated in a household interview and physical examination, from the Third National Health and Nutrition Examination Survey conducted from 1988 to 1994. MAIN OUTCOME MEASURES: Associations of blood lead with blood pressure and hypertension, with age, race and ethnicity, cigarette smoking status, body mass index, alcohol use, and kidney function as covariates. RESULTS: A change in blood lead levels from the lowest (quartile 1: range, 0.5-1.6 micro g/dL) to the highest (quartile 4: range, 4.0-31.1 microg/dL) was associated with small statistically significant adjusted changes in systolic and diastolic blood pressures. Women in quartile 4 had increased risks of diastolic (>90 mm Hg) hypertension (adjusted odds ratio [OR], 3.4; 95% confidence interval [CI], 1.3-8.7), as well as moderately increased risks for general hypertension (adjusted OR, 1.4; 95% CI, 0.92-2.0) and systolic (>140 mm Hg) hypertension (adjusted OR, 1.5; 95% CI, 0.72-3.2). This association was strongest in postmenopausal women, in whom adjusted ORs for diastolic hypertension increased with increasing quartile of blood lead level compared with quartile 1 (adjusted OR, 4.6; 95% CI, 1.1-19.2 for quartile 2; adjusted OR, 5.9; 95% CI, 1.5-23.1 for quartile 3; adjusted OR, 8.1; 95% CI, 2.6-24.7 for quartile 4). CONCLUSIONS: At levels well below the current US occupational exposure limit guidelines (40 microg/dL), blood lead level is positively associated with both systolic and diastolic blood pressure and risks of both systolic and diastolic hypertension among women aged 40 to 59 years. The relationship between blood lead level and systolic and diastolic hypertension is most pronounced in postmenopausal women. These results provide support for continued efforts to reduce lead levels in the general population, especially women.

Deaths related to lead poisoning in the United States, 1979-1998.

This study was conducted to describe trends in US lead poisoning-related deaths between 1979 and 1998. The predictive value of relevant ICD-9 codes was also evaluated. Multiple cause-of-death files were searched for records containing relevant ICD-9 codes, and underlying causes and demographic characteristics were assessed. For 1979-1988, death certificates were reviewed; lead source information was abstracted and accuracy of coding was determined. An estimated 200 lead poisoning-related deaths occurred from 1979 to 1998. Most were among males (74%), Blacks (67%), adults of age >/=45 years (76%), and Southerners (70%). The death rate was significantly lower in more recent years. An alcohol-related code was a contributing cause for 28% of adults. Only three of nine ICD-9 codes for lead poisoning were highly predictive of lead poisoning-related deaths. In conclusion, lead poisoning-related death rates have dropped dramatically since earlier decades and are continuing to decline. However, the findings imply that moonshine ingestion remains a source of high-dose lead exposure in adults.

Is home renovation or repair a risk factor for exposure to lead among children residing in New York City?

Children can be lead poisoned when leaded paint is disturbed during home renovation or repair. We conducted a case-control study to assess the association between elevated blood lead levels (BLLs) in children younger than 5 years of age and renovation or repair of homes built before 1950 in New York City. In 1998, we interviewed parents of 106 case children (BLLs >/= 10 micro g/dL) and 159 control children (BLLs