COVID-19 Case Investigation and Contact Tracing in New York City, June 1, 2020, to October 31, 2021.

Importance: Contact tracing is a core strategy for preventing the spread of many infectious diseases of public health concern. Better understanding of the outcomes of contact tracing for COVID-19 as well as the operational opportunities and challenges in establishing a program for a jurisdiction as large as New York City (NYC) is important for the evaluation of this strategy. Objective: To describe the establishment, scaling, and maintenance of Trace, NYC's contact tracing program, and share data on outcomes during its first 17 months. Design, Setting, and Participants: This cross-sectional study included people with laboratory test-confirmed and probable COVID-19 and their contacts in NYC between June 1, 2020, and October 31, 2021. Trace launched on June 1, 2020, and had a workforce of 4147 contact tracers, with the majority of the workforce performing their jobs completely remotely. Data were analyzed in March 2022. Main Outcomes and Measures: Number and proportion of persons with COVID-19 and contacts on whom investigations were attempted and completed; timeliness of interviews relative to symptom onset or exposure for symptomatic cases and contacts, respectively. Results: Case investigations were attempted for 941 035 persons. Of those, 840 922 (89.4%) were reached and 711 353 (75.6%) completed an intake interview (women and girls, 358 775 [50.4%]; 60 178 [8.5%] Asian, 110 636 [15.6%] Black, 210 489 [28.3%] Hispanic or Latino, 157 349 [22.1%] White). Interviews were attempted for 1 218 650 contacts. Of those, 904 927 (74.3%) were reached, and 590 333 (48.4%) completed intake (women and girls, 219 261 [37.2%]; 47 403 [8.0%] Asian, 98 916 [16.8%] Black, 177 600 [30.1%] Hispanic or Latino, 116 559 [19.7%] White). Completion rates were consistent over time and resistant to changes related to vaccination as well as isolation and quarantine guidance. Among symptomatic cases, median time from symptom onset to intake completion was 4.7 days; a median 1.4 contacts were identified per case. Median time from contacts' last date of exposure to intake completion was 2.3 days. Among contacts, 30.1% were tested within 14 days of notification. Among cases, 27.8% were known to Trace as contacts. The overall expense for Trace from May 6, 2020, through October 31, 2021, was approximately $600 million. Conclusions and Relevance: Despite the complexity of developing a contact tracing program in a diverse city with a population of over 8 million people, in this case study we were able to identify 1.4 contacts per case and offer resources to safely isolate and quarantine to over 1 million cases and contacts in this study period.

The Legacy of 1987 Boreali v. Axelrod: Board of Health Rule-Making Under Siege.

We explore how a 1987 New York State court decision-Boreali v. Axelrod-affected public health rule-making nationally and, with considerable impact, locally in New York City (NYC).We discuss the history of the origin of the NYC Board of Health (BOH), and establish that legislatures can be challenging venues in which to enact public health-related laws. We describe how, as the NYC Department of Health and Mental Hygiene began to tackle modern public health problems (e.g., chronic diseases caused by food and tobacco), the regulatory power of its BOH was challenged.In an era when industry funds political causes and candidates, the weakening of the independence of rule-making boards of health, such as the NYC BOH, might result in illness and death.

Making it harder to smoke and easier to quit: the effect of 10 years of tobacco control in New York City.

In 2002, New York City implemented a comprehensive tobacco control plan that discouraged smoking through excise taxes and smoke-free air laws and facilitated quitting through population-wide cessation services and hard-hitting media campaigns. Following the implementation of these activities through a well-funded and politically supported program, the adult smoking rate declined by 28% from 2002 to 2012, and the youth smoking rate declined by 52% from 2001 to 2011. These improvements indicate that local jurisdictions can have a significant positive effect on tobacco control.

Changes in smoking prevalence and number of cigarettes smoked per day following the implementation of a comprehensive tobacco control plan in New York City.

The New York City (NYC) Health Department has implemented a comprehensive tobacco control plan since 2002, and there was a 27% decline in adult smoking prevalence in NYC from 2002 to 2008. There are conflicting reports in the literature on whether residual smoker populations have a larger or smaller share of "hardcore" smokers. Changes in daily consumption and daily and nondaily smoking prevalence, common components used to define hardcore smokers, were evaluated in the context of the smoking prevalence decline. Using the NYC Community Health Survey, an annual random digit dial, cross-sectional survey that samples approximately 10,000 adults, the prevalence of current heavy daily, light daily, and nondaily smokers among NYC adults was compared between 2002 and 2008. A five-level categorical cigarettes per day (CPD) variable was also used to compare the population of smokers between the 2 years. From 2002 to 2008, significant declines were seen in the prevalence of daily smoking, heavy daily smoking, and nondaily smoking. Among daily smokers, there is also evidence of population declines in all but the lowest smoking category (one to five CPD). The mean CPD among daily smokers declined significantly, from 14.6 to 12.5. After an overall decline in smoking since 2002, the remaining smokers may be less nicotine dependent, based on changes in daily consumption and daily and nondaily smoking prevalence. These findings suggest the need to increase media and cessation efforts targeted towards lighter smokers.

Using geographic information system analyses to monitor large-scale distribution of nicotine replacement therapy in New York City.

OBJECTIVE: Since 2003, the New York City Department of Health and Mental Hygiene has distributed nicotine replacement therapy nicotine replacement therapy to adult smokers through annual large-scale distribution programs. METHODS: In 2008, the New York City Department of Health and Mental Hygiene formally integrated geographic information system analyses to track program enrollment, map the geographic density of enrollees, and assess the effects of outreach strategies. RESULTS: Geographic information system analyses provided a unique, near real-time visual method of assessing participation patterns as well as the impact of media and outreach strategies. Among neighborhoods with high smoking prevalence, lower income neighborhoods had higher enrollment compared to higher income neighborhoods. Mapping before and after a press release demonstrated that program interest increased over 700% in one area. CONCLUSION: Although geographic information system analysis is traditionally utilized for large-scale infectious disease surveillance, the New York City Department of Health and Mental Hygiene used GIS to inform and improve an annual large-scale smoking cessation program. These analyses provide unique feedback that can aid public health program planners in improving efficiency and efficacy of service delivery.

Media campaign effectiveness in promoting a smoking-cessation program.

BACKGROUND: Little is known about the perceived barriers among smokers who do not utilize phone-based, population-level smoking-cessation services. PURPOSE: The purpose of this study was to improve understanding of a media campaign's impact in promoting a phone-based, time-limited smoking-cessation program as measured by smoker awareness of the program, untapped interest in the program, perceived barriers to use of the program, and suggested methods for enhanced outreach. METHODS: A random telephone survey of New York City smokers (n=1000) was conducted in 2006 in order to assess awareness of, interest in, and barriers to using the 2006 Nicotine Patch Program. Analyses were conducted in 2006 and 2007. RESULTS: The level of program awareness was high (60% overall), although it varied by demographic subgroup. The level of program interest among smokers unaware of the program was also encouragingly high (54%). Analysis of barriers to program use indicates that enrollment may be increased by addressing hesitance about using patches, developing messages for smokers who do not self-identify as smokers, and clarifying application procedures. Specific outreach strategies suggested by smokers include promotion through direct mail and advertising on public transportation. CONCLUSIONS: These data suggest that the use of mass media is an effective method for informing smokers about cessation services and that enrollment could be improved by modifying public messages to address barriers as well as expanding outreach to specific demographic groups. Improved outreach to smokers may be feasible using the strategies suggested by smokers in this survey. These findings can aid smoking-cessation services in expanding their reach and impact.

Decline in smoking during pregnancy in New York City, 1995-2005.

OBJECTIVES: The 1998 Master Settlement Agreement (MSA) between 46 states and four major tobacco companies increased tobacco control funding and restricted tobacco marketing. In 2002, New York City (NYC) began a comprehensive tobacco control program that raised the price of cigarettes, banned indoor workplace smoking, and increased access to cessation treatment. We examined the temporal pattern of smoking during pregnancy, including ethnic variation in smoking prevalence, relative to the implementation of the MSA and NYC's comprehensive tobacco control program using birth certificate data. METHODS: Using multiple logistic regression, we analyzed NYC birth certificate data to examine prenatal smoking during three time periods: 1995-1998 (pre-MSA), 1999-2002 (post-MSA, pre-NYC tobacco control), and 2003-2005 (post-MSA, post-tobacco control). RESULTS: Overall, 3.0% of 1,136,437 births included were to smoking mothers. The proportion of smoking mothers declined from 4.5% in 1995-1998 to 1.7% in 2003-2005. Compared with non-Hispanic white women, African American women had 2.46 increased odds (95% confidence interval [CI] 2.36, 2.55) of smoking during 1995-1998, and 3.63 increased odds (95% CI 3.39, 3.88) of smoking during 2003-2005, despite an absolute reduction in smoking from 10.4% to 5.0%. Puerto Rican women also smoked considerably more than non-Hispanic white women. CONCLUSIONS: These findings document a striking temporal decline in prenatal smoking in NYC concurrent with changing tobacco control policies. Targeted efforts may be required to address the increasing disparity in prenatal smoking between non-Hispanic white and African American and Puerto Rican women.

Secondhand smoke exposure among nonsmokers nationally and in New York City.

INTRODUCTION: We describe smoking prevalence and secondhand smoke (SHS) exposure among adult nonsmokers in New York City (NYC) across key demographic strata and compare exposure estimates with those found nationally. METHODS: We used serum cotinine data from the 2004 NYC Health and Nutrition Examination Survey (n = 1,767 adults aged 20 years or older) and the 2003-2004 National Health and Nutrition Examination Survey (n = 4,476 adults aged 20 years or older) to assess and compare smoking prevalence and the prevalence of elevated cotinine levels (> or =0.05 ng/ml) among nonsmokers. We conducted multivariate logistic regression to assess independent predictors of elevated cotinine levels in NYC. RESULTS: Although the smoking prevalence in NYC was lower than that found nationally (23.3% vs. 29.7%, p < .05), the proportion of nonsmoking adults in NYC with elevated cotinine levels was greater than the national average overall (56.7% vs. 44.9%, p < .05) and was higher for most demographic subgroups. In NYC, the highest cotinine levels among nonsmokers were among adults aged 20-39 years, males, and Asians. DISCUSSION: Although NYC enacted comprehensive smoke-free workplace legislation in 2003, findings suggest that exposure to SHS remains a significant public health issue, especially among certain subgroups. The finding of a higher prevalence of SHS exposure in NYC despite lower smoking rates is puzzling but suggests that SHS exposure in dense, urban settings may pose a particular challenge.

Gender differences in smoking and cessation behaviors among young adults after implementation of local comprehensive tobacco control.

OBJECTIVES: We sought to study gender differences in young adult smoking declines and enrollment in populationwide cessation services. METHODS: The New York City (NYC) Department of Health and Mental Hygiene implemented populationwide cessation programs to distribute free nicotine replacement therapy (NRT); demographic data were collected from enrollees. Smoking prevalence was assessed using data from the Community Health Survey, an annual population-based survey. RESULTS: Between 2002 and 2005, smoking among young adults in NYC declined from 23.8% to 18.8%, which was explained entirely by a 41.8% decline among young adult women (23.2% to 13.5); prevalence remained at 24% among young adult men. More young adult women enrolled in cessation services than did men, although once enrolled, the likelihood of using NRT was high among both groups. CONCLUSIONS: Among young adults, women have been responsive to comprehensive tobacco control, but men require more-intensive strategies. Population-wide NRT distribution can be effective with young adults overall; however, additional resources need to be devoted to identifying successful outreach strategies for young adult men.

Integrating behavioral and social science into a public health agency: a case study of New York City.

In the last century, both the health and life expectancy of Americans improved dramatically. These gains were primarily the result of advances in public health. But the approaches used may not be adequate to achieve the next level of improvements in health. Because health exists in the context of social, environmental, community, religious, political, and other spheres, ecological approaches that incorporate behavioral and social science theory and methodologies may provide the best avenue for advancing health in the 21st century. In 1999, the New York City Department of Health (NYCDOH) undertook the task of integrating behavioral and social science into its public health practice. The experience serves as a case study on the integration process at a public health agency.

Use of social and behavioral sciences by public health departments in major cities.

Individual behavior and social contexts are critical determinants of health. We surveyed commissioners or their designees in 22 departments of health serving US cities of at least 500,000 people to examine their use of scientific approaches to influence individual behavior and social contexts. Each department used behavioral or social science in its work, but only four departments were judged to have integrated these approaches throughout their operations, using both centralized and decentralized structures. Degree of integration was unrelated to collaboration with universities or communities but was related to use of explicit theories. Behavioral and social sciences were employed most frequently in the areas of HIV/AIDS and maternal and child health and in the service of changing individual behavior rather than larger contexts, although across departments many health problems and approaches were involved. Commissioners generally found the approaches valuable, but articulated barriers to more widespread adoption.

The role of social and behavioral science in public health practice: a study of the New York City Department of Health.

Studies over the last decade have demonstrated the effectiveness of public health interventions based on social and behavioral science theory for many health problems. Little is known about the extent to which health departments are currently utilizing these theories. This study assesses the application of social and behavioral science to programs in the New York City Department of Health (NYCDOH). Structured open-ended interviews were conducted with executive and program management staff of the health department. Respondents were asked about the application of social and behavioral sciences within their programs, and about the benefits and barriers to increasing the use of such approaches. Themes related to the aims of the study were identified, a detailed coding manual developed, narrative data were coded independently by two investigators (kappa.85), and data analyzed. Interviews were conducted with 61 eligible individuals (response rate 88%). The most common applications of social and behavioral science were individual-level behavior change to prevent HIV transmission and community-level interventions utilizing community organizing models and/or media interventions for health promotion and disease prevention. There are generally positive attitudes about the benefits of utilizing these sciences; however, there are also reservations about expanded use because of resource constraints. While NYCDOH has successfully applied social and behavioral sciences in some areas of practice, many areas use them minimally or not at all. Increasing use will require additional resources. Partnerships with academic institutions can bring additional social and behavioral science resources to health departments and benefit researchers understanding of the health department environment.