Using the essential services as a foundation for performance measurement and assessment of local public health systems.

Efforts are under way to develop a performance measurement monitoring system for state and local public health systems and to develop a strategic planning tool for local public health systems. The development of these measures is being based on the Essential Public Health Services. This article provides the rationale for why the Essential Services offer a good framework for identifying, analyzing, and evaluating public health activities. The article also reviews the history of local public health and the development and application of the Essential Public Health Services and their predecessor frameworks such as the core functions, the organizational practices, and the essential elements.

Disparities in hospital utilization in an urban county: use of local consumer marketing data for priority setting.

National data sets are often insufficient for priority setting by local public health systems and the communities they serve. We used marketing data to conduct an ecological analysis of hospital discharge rates in DeKalb County, Georgia, during 1996. Persons living in poorer areas had significantly higher discharge rates for the following conditions: hypertensive disease, blood-related conditions, pneumonia/influenza, diabetes, and chronic obstructive pulmonary diseases. Local marketing data helped identify conditions associated with higher hospital utilization in poorer areas of this urban county. This identification of priority issues informs plans for behavior modification, access to primary care and a healthy environment.

Taking training seriously: a policy statement on public health training by the Joint Council of Governmental Public Health Agencies.

Continuing education and on-the-job training in public health has suffered serious neglect over the past years. As a result, many state and local public health entities have failed to keep step with emerging challenges facing the public's health--challenges that require new and innovative approaches to prevention and treatment. In this article, the Joint Council of Governmental Public Health Agencies seeks to affirm the importance of public health training by examining barriers to training; identifying areas in which training should be emphasized; providing examples of successful training programs; and recommending ways in which public health leaders can revitalize training programs.

Evaluation of the Consensus Health Status Indicator for assessing adolescent pregnancies and births.

The authors used vital statistics and population data for DeKalb County, GA, in an evaluation of the accuracy of the Consensus Health Status Indicator for assessing adolescent pregnancies and births. The indicator used was the number of births to females 10-17 years of age, expressed as a percentage of all births in the population. The investigators found no significant changes in the proportions of births to adolescents for the period 1982-90. Births to adolescents were 5.3 percent of all births during 1982-84 and 5.2 percent during 1988-90. However, the pregnancy rate for adolescents in those years increased significantly, from 27.9 per 1,000 births for 1982-84 to 33.1 per 1,000 for 1988-90. The results indicate that, in localities with substantial changes in the age distribution of the population, the health status indicator does not adequately reflect trends in pregnancies among those 10-17 years of age.

Tuberculosis prevention practices and perspectives of physicians in DeKalb County, GA.

Knowing the reasons some physicians do not adhere to the disease prevention and treatment recommendations of expert committees can assist in the development of future recommendations more likely to be adopted by physicians. The authors describe the attitudes and practices of physicians relative to tuberculosis prevention in DeKalb County, GA. Tuberculosis is an important problem in the county, which includes part of the City of Atlanta, as well as suburban areas. Questionnaires for anonymous reply were mailed to 1,621 physicians in the county in 1991, and 848 (53 percent) were completed and returned. The final sample was 793 physicians, who were grouped into 5 specialty areas. Primary care physicians were the group most commonly involved in specific tuberculosis screening and prevention activities. Medical and pediatric specialists, surgeons, obstetricians-gynecologists, and other physicians were significantly less likely to be involved in such activities. Given that primary care physicians constitute a decreasing proportion of physicians in the United States, the findings suggest the importance of ensuring that future strategies for tuberculosis prevention take into account the increasingly specialized nature of the medical practice environment.

Four diseases of disarray in public health.

The Institute of Medicine's report The Future of Public Health stated that "public health is in disarray" (Washington, DC: National Academy Press, 1988). I describe four "diseases" of this disarray: "hardening of the categories," "hypocommitment to training," "tension headache between prevention and treatment," and "cultural incompetence." We must step outside the focus on problems and risk factors to use epidemiology to define health status positively and to identify health enhancing factors. This conference should catalyze innovative, holistic, culturally competent studies that will improve our well-being.

The epidemiology of cytomegaloviral infection in women attending a sexually transmitted disease clinic.

To test the hypothesis that cytomegalovirus (CMV) is sexually transmitted, we examined the association of CMV infection with indices of sexual activity in 347 women attending a sexually transmitted disease (STD) clinic. Stepwise multivariate logistic regression analysis showed that seropositivity to CMV (complement-fixation antibody titer, greater than or equal to 1:8) was most closely associated with number of sex partners in the subjects' lifetime (P less than .0001), young age at first sexual intercourse (P = .0002), and nonwhite race (P = .0007). Among seropositive women, cervical shedding of CMV was most strongly associated with younger age (P = .0001) and the presence of cervical chlamydial infection (P = .016). Among 84 seronegative women followed up for a mean of 18.4 weeks, 11 (13%) developed primary CMV infections, an annual incidence of 37%. Sexual contact seems to be an important mode of acquisition of CMV in some young women.

The 1990 objectives for the nation for injury prevention: a progress review.

Unintentional injuries are the principal cause of preventable early death. Beyond terms of human suffering and death, injuries place enormous burdens on this country's economic and health care resources. Demographic, sociological, environmental, and behavioral factors that influence our society contribute to the complexity and scope of the injury problem. Progress in injury prevention will be achieved only through the combined efforts of individuals, organizations, and government at every level of our society. The Federal Government is an important contributor to this process through its role of leading, catalyzing, and providing strategic support. Within the Department of Health and Human Services, numerous agencies have major injury prevention components with a broad range of responsibilities, including the direct delivery of services, establishment of safety standards, sponsorship of education and information efforts, building of the capacity of other sectors, basic and applied research, and surveillance. The Centers for Disease Control, as the lead agency, assists State and local health departments in their injury prevention efforts and coordinates activities undertaken jointly by Federal agencies, State and local governments, and private-sector organizations. To meet the 1990 Objectives for the Nation with respect to injury prevention, both the public health and private-sector providers must recognize the injury problem of the 1980s. Without the support and involvement of the public health and provider communities and of the private sector, injuries and their costs will continue at their present alarming rates. The opportunity is great for promoting health, preventing injuries, and reducing associated costs to society. Making the best of this opportunity is our challenge during this decade.

Sexually transmitted diseases: meeting the 1990 objectives--a challenge for the 1980s.

Sexually transmitted diseases (STDs) represent a major public health problem in the country, cause patients enormous suffering, and cost the nation billions of dollars annually. Demographic, sociological, and behavioral changes in our society during the past decade are important contributors to the growing complexity and scope of the STD problem. Several agencies in the Public Health Service are engaged in the Federal effort against STDs. The Centers for Disease Control, as the lead agency, assists State and local health departments in their STD control efforts. In fiscal year 1981, federally supported syphilis and gonorrhea control efforts--based on prevention of an estimated 209,400 new cases--saved the taxpayers approximately $150 million. To meet the 1990 objectives, both the public and private medical sectors must recognize the STD problem of the 1980s. Without the support of the professional community and involvement of the private sector, the incidence of STDs will continue to increase at alarming proportions during this decade. The opportunity for promoting health, preventing human suffering, and reducing costs to society is great. Making the best of this opportunity is our challenge during this decade.

STD education: challenge for the 80s.

PIP: Discussion focuses on 3 aspects of sexually transmitted diseases (STD) education: the need for and appropriateness of school-based STD education; some elements of timely, high quality STD education; and strategies for dealing constructively with controversy. More than half of the estimated 20 million STD victims in the US this year will be persons under age 25. Almost 1/4 will be victims of STD before they receive their high school diplomas. STD are the most pervasive, destructive, and expensive communicable disease problems facing American youth. If the twin criteria of true experimental design and of measuring appropriate outcomes are applied to published studies, then the effectiveness of classroom STD education has not as yet been properly evaluated. The evaluation criteria which should be applied to health education programs are uniquely based on nonacademic goals, that is, ultimate outcomes are generally not observable in the academic environment. The federal government has been virtually precluded from supporting or conducting appropriate behavioral studies because of laws protecting individual privacy, and most school systems are similarly restricted when it comes to asking students about their personal or family lives, of which sexual matters are among the most intimate. Programs designed according to accepted concepts of learning and decision making need to be implemented, even if their benefits must be regarded as potential, until such time as research obstacles can be resolved. STD education objectives should be drawn from the behaviors relevant to the prevention, acquisition, transmission, and disposition of an STD. The behaviors are organized into 5 behavioral sets and described here as decision steps: decisions about when, how, and with whom to engage in sexual behavior; decisions specific to health protection if sexual behavior includes genital contact; decisions in response to suspected illness; decisions in response to diagnosed disease; and decisions related to other people. Within each decision step are various alternative choices, some that enhance health and others that jeopardize it. Once behavioral objectives have been formulated, decisions about content should be directed toward predisposing, enabling, or reinforcing those behaviors. Emphasis should be on the following: risk reduction; recognition; response; referral; and responsible resource. No particular instructional methods possess inherent superiority. It is questionable whether young people derive a maximum benefit from STD instruction if they have not initially learned rudimentary physiological and sociological facts of sexual life and how to discuss such matters. School systems should not delay efforts to meet the 1990 goal of high quality, timely STD education for every child in the US. Guidelines for community leaders who plan education programs are listed.^ieng

Gonorrhea.

This review presents the epidemiologic, diagnostic, and office management of the gonorrhea patient. Better techniques in obtaining specimens from various sites are reviewed. For example, an effective method for obtaining specimens without the use of an anoscope and the utility of the Gram stain in the laboratory diagnosis of gonorrhea are described. Complications, diagnosis and predisposing factors of disseminated gonococcal infections are also discussed. Follow-up management of patients with gonorrhea with emphasis placed on test-of-cure cultures and testing for penicillinase producing Neisseria gonorrhoeae (PPNG) strains in all treatment failure cases is also presented. The cooperation between public and private health professionals and screening programs have lessened the gonorrhea reservoir in the United States. Therefore, early treatment through targeted screening, and epidemiologic treatment to sexual partners are important guidelines in gonorrhea control.

Problems and approaches to the control and surveillance of sexually transmitted agents associated with pelvic inflammatory disease in the United States.

The national gonorrhea control program has expanded since its inception in 1972 and now reflects new information and program evaluations. Initial program objectives to reduce the incidence of disease and the resistance of gonococci to antibiotics have been expanded to reduce the occurrence of pelvic inflammatory disease and to limit the sequelae of PID. The changes since 1972 in the national venereal disease control program have increased the number of people helping control programs and have enhanced our ability to control other sexually transmitted diseases.

PIP: The initial objectives of the national gonorrhea control program begun in 1972 were to reduce disease incidence and the resistance of gonococci to antibiotics. To reduce disease incidence the goal was to identify asymptomatic or unrecognized disease in women. To reduce the resistance of gonococci to antibiotics an attempt was made to minimize the use of ineffective treatments which favored the relatively resistant organisms. National gonorrhea treatment recommendations were made in 1972 and widespread use of them was promoted. By 1975 all state and local health departments had implemented a gonorrhea screening program which obtained 9.0 million cultures per year. Broad participation was encouraged to identify the maximum number of infected women, to increase provider recognition of gonorrhea, and to identify the most important providers. Laboratory, logistic, and training support was organized to ensure that the culture screening efforts were effective. Contact tracing interviews with infected men were used to identify asymptomatic women. The interview field investigation model used was that developed for syphilis. Public education was implemented to create an awareness of and support for the gonorrhea control program. The reporting of gonorrhea cases remained the primary surveillance mechanism. During the 2nd or transmitter phase, experience and theoretical consideration, which emphasized the increased importance of some disease transmitters, led to program changes. Efforts to identify patients in whom treatment failed and to limit the spread of their organisms received additional attention when penicillin producing Neisseria gonorrhoea (PPNG) was recognized. In many areas screening was targeted increasingly at patients who attended high priority providers and who attended for tests of cure and repeat testing 6-12 weeks after treatment. Patient counseling efforts began to change as many programs sought to implement tests of cure and rescreening. Clinic services received increasing attention during this period. Education efforts were directed increasingly at clinic patients and at high risk groups. In the present phase, program experiences, special studies, and analyses of national data clarified the public health importance of gonococcal pelvic inflammatory disease. Thus, program objectives were expanded to include limitation of the incidence and consequences of PID. Studies conducted in hospital emergency rooms by several programs demonstrated the feasibility of identifying women with PID, ensuring appropriate management of such women, identifying many previously untreated sexual partners. Efforts to increase the effectiveness of the gonorrhea screening program continue, but major emphasis is now placed on improved and expanded screening in hospital outpatient departments. Education efforts currently focus on providers in clinics, emergency rooms, professional schools, and private practice.

Failure of the Treponema pallidum immobilization test to provide additional diagnostic information about contemporary problem sera.

Two hundred forty-five sera submitted to the Center for Disease Control, Atlanta, Ga., (CDC) were analyzed serologically in an attempt to demonstrate the diagnostic value of the Treponema pallidum immobilization (TPI) test when performed in addition to the fluorescent treponemal antibody-absorption (FTA-Abs) test. Diagnoses for the patients whose sera were tested were based on information supplied by the referring physicians. Fifty-four per cent of the diagnostic problems were resolved merely by the finding of a negative result with the FTA-Abs test. There was agreement between the serologic results of the referring laboratory and those of the CDC for 76% of sera tested by the Venereal Disease Research Laboratory test and for 71% of sera tested by the FTA-Abs test. For patients with treponemal disease, the sensitivity of the TPI test was 56% and that of the FTA-Abs test was 78%. When the FTA-Abs test was reactive, a negative TPI test was not significantly associated with systemic lupus erythematosus (P > 0.6) or other collagen vascular disease (P > 0.6), nor was a positive TPI test associated with treponemal disease (P > 0.09). It is concluded that once the result of the FTA-Abs test is known, the TPI test does not provide additional diagnostic information.