An Examination of SARS-CoV-2 Transmission Based on Classroom Distancing in Schools With Other Preventive Measures in Place-Missouri, January-March 2021.

OBJECTIVES: Classroom layout plays a central role in maintaining physical distancing as part of a multicomponent prevention strategy for safe in-person learning during the COVID-19 pandemic. We conducted a school investigation to assess layouts and physical distancing in classroom settings with and without in-school SARS-CoV-2 transmission. METHODS: We assessed, measured, and mapped 90 K-12 (kindergarten through grade 12) classrooms in 3 Missouri public school districts during January-March 2021, prior to widespread prevalence of the Delta variant; distances between students, teachers, and people with COVID-19 and their contacts were analyzed. We used whole-genome sequencing to further evaluate potential transmission events. RESULTS: The investigation evaluated the classrooms of 34 students and staff members who were potentially infectious with COVID-19 in a classroom. Of 42 close contacts (15 tested) who sat within 3 ft of possibly infectious people, 1 (2%) probable transmission event occurred (from a symptomatic student with a longer exposure period [5 days]); of 122 contacts (23 tested) who sat more than 3 ft away from possibly infectious people with shorter exposure periods, no transmission events occurred. CONCLUSIONS: Reduced student physical distancing is one component of mitigation strategies that can allow for increased classroom capacity and support in-person learning. In the pre-Delta variant period, limited physical distancing (<6 ft) among students in K-12 schools was not associated with increased SARS-CoV-2 transmission.

California ACEP Firearm Injury Prevention Policy.

Firearm-related deaths and injuries are a serious public health problem in California and the United States. The rate of firearm-related deaths is many times higher in the US than other democratic, industrialized nations, yet many of the deaths and injuries are preventable. The California American College of Emergency Physicians Firearm Injury Prevention Policy was approved and adopted in 2013 as an evidence-based, apolitical statement to promote harm reduction. It recognizes and frames firearm injuries as a public health epidemic requiring allocation of robust resources, including increased governmental funding of high-quality research and the development of a national database system. The policy further calls for relevant legislation to be informed by best evidence and expert consensus, and advocates for legislation regarding the following: mandatory universal background checks; mandatory reporting of firearm loss/theft; restrictions against law-enforcement or military-style assault weapons and high capacity magazines; child-protective safety and storage systems; and prohibitions for high-risk individuals. It also strongly defends the right of physicians to screen and counsel patients about firearm-related risk factors and safety. Based upon best-available evidenced, the policy was recently updated to include extreme risk protection orders, which are also known as gun violence restraining orders.

Vital Signs: Pharmacy-Based Naloxone Dispensing - United States, 2012-2018.

BACKGROUND: The CDC Guideline for Prescribing Opioids for Chronic Pain recommends considering prescribing naloxone when factors that increase risk for overdose are present (e.g., history of overdose or substance use disorder, opioid dosages ≥50 morphine milligram equivalents per day [high-dose], and concurrent use of benzodiazepines). In light of the high numbers of drug overdose deaths involving opioids, 36% of which in 2017 involved prescription opioids, improving access to naloxone is a public health priority. CDC examined trends and characteristics of naloxone dispensing from retail pharmacies at the national and county levels in the United States. METHODS: CDC analyzed 2012-2018 retail pharmacy data from IQVIA, a health care, data science, and technology company, to assess U.S. naloxone dispensing by U.S. Census region, urban/rural status, prescriber specialty, and recipient characteristics, including age group, sex, out-of-pocket costs, and method of payment. Factors associated with naloxone dispensing at the county level also were examined. RESULTS: The number of naloxone prescriptions dispensed from retail pharmacies increased substantially from 2012 to 2018, including a 106% increase from 2017 to 2018 alone. Nationally, in 2018, one naloxone prescription was dispensed for every 69 high-dose opioid prescriptions. Substantial regional variation in naloxone dispensing was found, including a twenty-fivefold variation across counties, with lowest rates in the most rural counties. A wide variation was also noted by prescriber specialty. Compared with naloxone prescriptions paid for with Medicaid and commercial insurance, a larger percentage of prescriptions paid for with Medicare required out-of-pocket costs. CONCLUSION: Despite substantial increases in naloxone dispensing, the rate of naloxone prescriptions dispensed per high-dose opioid prescription remains low, and overall naloxone dispensing varies substantially across the country. Naloxone distribution is an important component of the public health response to the opioid overdose epidemic. Health care providers can prescribe or dispense naloxone when overdose risk factors are present and counsel patients on how to use it. Efforts to improve naloxone access and distribution work most effectively with efforts to improve opioid prescribing, implement other harm-reduction strategies, promote linkage to medications for opioid use disorder treatment, and enhance public health and public safety partnerships.

Trends and Patterns of Geographic Variation in Opioid Prescribing Practices by State, United States, 2006-2017.

Importance: Risk of opioid use disorder, overdose, and death from prescription opioids increases as dosage, duration, and use of extended-release and long-acting formulations increase. States are well suited to respond to the opioid crisis through legislation, regulations, enforcement, surveillance, and other interventions. Objective: To estimate temporal trends and geographic variations in 6 key opioid prescribing measures in 50 US states and the District of Columbia. Design, Setting, and Participants: Population-based cross-sectional analysis of opioid prescriptions filled nationwide at US retail pharmacies between January 1, 2006, and December 31, 2017. Data were obtained from the IQVIA Xponent database. All US residents who had an opioid prescription filled at a US retail pharmacy were included. Main Outcomes and Measures: Primary outcomes were annual amount of opioids prescribed in morphine milligram equivalents (MME) per person; mean duration per prescription in days; and 4 separate prescribing rates-for prescriptions 3 or fewer days, those 30 days or longer, those with a high daily dosage (≥90 MME), and those with extended-release and long-acting formulations. Results: Between 2006 and 2017, an estimated 233.7 million opioid prescriptions were filled in retail pharmacies in the United States each year. For all states combined, 4 measures decreased: (1) mean (SD) amount of opioids prescribed (mean [SD] decrease, 12.8% [12.6%]) from 628.4 (178.0) to 543.4 (158.6) MME per person, a statistically significant decrease in 23 states; (2) high daily dosage (mean [SD] decrease, 53.1% [13.6%]) from 12.3 (3.4) to 5.6 (1.7) per 100 persons, a statistically significant decrease in 49 states; (3) short-term (≤3 days) duration (mean [SD] decrease, 43.1% [9.4%]) from 18.0 (5.4) to 10.0 (2.5) per 100 persons, a statistically significant decrease in 48 states; and (4) extended-release and long-acting formulations (mean [SD] decrease, 14.7% [13.7%]) from 7.2 (1.9) to 6.0 (1.7) per 100 persons, a statistically significant decrease in 27 states. Two measures increased, each associated with the duration of prescription dispensed: (1) mean (SD) prescription duration (mean [SD] increase, 37.6% [6.9%]) from 13.0 (1.2) to 17.9 (1.4) days, a statistically significant increase in every state; and (2) prescriptions for a term of 30 days or longer (mean [SD] increase, 37.7% [28.9%]) from 18.3 (7.7) to 24.9 (10.7) per 100 persons, a statistically significant increase in 39 states. Two- to 3-fold geographic differences were observed across states, measured by comparing the ratio of each state's 90th to 10th percentile for each measure. Conclusions and Relevance: In this study, across 12 years, the mean duration and prescribing rate for long-term prescriptions of opioids increased, whereas the amount of opioids prescribed per person and prescribing rate for high-dosage prescriptions, short-term prescriptions, and extended-release and long-acting formulations decreased. Some decreases were significant, but results were still high. Two- to 3-fold state variation in 5 measures occurred in most states. This information may help when state-specific intervention programs are being designed.

Infections of the Ear.

Infections of the ear are a common presentation to an acute care environment. In this article, the authors aim to summarize the most common presentations, and diagnostic and treatment options for typical infections of the ear. This article is geared toward the emergency physician, urgent care provider, and primary care provider who will likely be the initial evaluating and treating provider to assist them in determining what treatment modalities can be managed in a clinic and what needs to be referred for admission or specialty consultation.

Vital Signs: Changes in Opioid Prescribing in the United States, 2006-2015.

BACKGROUND: Prescription opioid-related overdose deaths increased sharply during 1999-2010 in the United States in parallel with increased opioid prescribing. CDC assessed changes in national-level and county-level opioid prescribing during 2006-2015. METHODS: CDC analyzed retail prescription data from QuintilesIMS to assess opioid prescribing in the United States from 2006 to 2015, including rates, amounts, dosages, and durations prescribed. CDC examined county-level prescribing patterns in 2010 and 2015. RESULTS: The amount of opioids prescribed in the United States peaked at 782 morphine milligram equivalents (MME) per capita in 2010 and then decreased to 640 MME per capita in 2015. Despite significant decreases, the amount of opioids prescribed in 2015 remained approximately three times as high as in 1999 and varied substantially across the country. County-level factors associated with higher amounts of prescribed opioids include a larger percentage of non-Hispanic whites; a higher prevalence of diabetes and arthritis; micropolitan status (i.e., town/city; nonmetro); and higher unemployment and Medicaid enrollment. CONCLUSIONS AND IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: Despite reductions in opioid prescribing in some parts of the country, the amount of opioids prescribed remains high relative to 1999 levels and varies substantially at the county-level. Given associations between opioid prescribing, opioid use disorder, and overdose rates, health care providers should carefully weigh the benefits and risks when prescribing opioids outside of end-of-life care, follow evidence-based guidelines, such as CDC's Guideline for Prescribing Opioids for Chronic Pain, and consider nonopioid therapy for chronic pain treatment. State and local jurisdictions can use these findings combined with Prescription Drug Monitoring Program data to identify areas with prescribing patterns that place patients at risk for opioid use disorder and overdose and to target interventions with prescribers based on opioid prescribing guidelines.

Geographic Disparities in Access to Syringe Services Programs Among Young Persons With Hepatitis C Virus Infection in the United States.

Using commercial laboratory data, we found 80% of 29382 young persons currently infected with hepatitis C virus lived >10 miles from a syringe services program. The median distance was 37 miles, with greater distances in rural areas and Southern and Midwestern states. Strategies to improve access to preventive services are warranted.

Intermittent Ovarian Torsion in Pregnancy.

Ovarian torsion during pregnancy is a fairly uncommon complication with a high patient morbidity and fetal mortality if not immediately treated. Ovarian torsion should be considered a clinical diagnosis, and a high level of clinical suspicion is needed by the practitioner to ensure that this diagnosis is not missed. We present an unusual case of intermittent ovarian torsion discussing both the presentation and the operative and post-operative management.

Park Access Among School-Age Youth in the United States.

BACKGROUND: Fewer than 30% of U.S. youth meet the recommendation to be active ≥ 60 minutes/day. Access to parks may encourage higher levels of physical activity. PURPOSE: To examine differences in park access among U.S. school-age youth, by demographic characteristics and urbanicity of block group. METHODS: Park data from 2012 were obtained from TomTom, Incorporated. Population data were obtained from the 2010 U.S. Census and American Community Survey 2006-2010. Using a park access score for each block group based on the number of national, state or local parks within one-half mile, we examined park access among youth by majority race/ethnicity, median household income, median education, and urbanicity of block groups. RESULTS: Overall, 61.3% of school-age youth had park access--64.3% in urban, 36.5% in large rural, 37.8% in small rural, and 35.8% in isolated block groups. Park access was higher among youth in block groups with higher median household income and higher median education. CONCLUSION: Urban youth are more likely to have park access. However, park access also varies by race/ethnicity, median education, and median household. Considering both the demographics and urbanicity may lead to better characterization of park access and its association with physical activity among youth.

Geographic distribution of acute chemical incidents­Hazardous Substances Emergency Events Surveillance, nine states, 1999-2008.

PROBLEM/CONDITION: Hazardous chemicals are transported and used widely in the United States, and acute chemical releases (lasting <72 hours) are not uncommon. Characterizing acute incidents within geographic areas can help researchers identify spatial patterns and differences and enable public and environmental health and safety practitioners, members of local emergency planning committees, preparedness coordinators, industry managers, emergency responders, and others to prepare for and respond to chemical incidents. REPORTING PERIOD: 1999-2008. DESCRIPTION OF SYSTEM: The Hazardous Substances Emergency Events Surveillance (HSEES) system was operated by the Agency for Toxic Substances and Disease Registry (ATSDR) during January 1991-September 2009 to collect data on hazardous chemical releases that would enable researchers to describe the public health consequences of these acute releases and to develop activities aimed at reducing the ensuing harm to the public. This report summarizes data for the geographic distribution of reported acute incidents by states, counties, and Metropolitan Statistical Areas (MSAs) from the nine states (Colorado, Iowa, Minnesota, New York, North Carolina, Oregon, Texas, Washington, and Wisconsin) that participated in HSEES during its last 10 full years of data collection (1999-2008). RESULTS: A total of 57,975 acute incidents occurred during 1999-2008; five MSAs accounted for 40.1% of all incidents. Texas reported 41% of all incidents reported by the nine states during the 10-year study period, and Colorado reported the fewest incidents (3.4%). INTERPRETATION: Storage, use, and transport of hazardous substances often are associated with unanticipated releases. In general, releases occurred more frequently in areas that use or store more hazardous chemicals and in urbanized areas compared with rural areas. In rural areas, most incidents were related to the transport of hazardous chemicals. The primary economic activities in an area had a strong influence on the frequency and type of chemicals released in the area. PUBLIC HEALTH IMPLICATIONS: Exposure to hazardous chemicals can have immediate and serious health consequences. Harmful releases can occur wherever hazardous chemicals are used, stored, or transported. The time and location of releases is unpredictable. Taken together, these elements underscore the need for preparedness. A culture of safety, prevention, and preparedness can minimize the consequences of future incidents.

Using geographic information systems to track polio vaccination team performance: pilot project report.

The application of geospatial data to public health problems has expanded significantly with increased access to low-cost handheld global positioning system (GPS) receivers and free programs for geographic information systems analysis. In January 2010, we piloted the application of geospatial analysis to polio supplementary immunization activities (SIAs) in northern Nigeria. SIA teams carried GPS receivers to compare hand-drawn catchment area route maps with GPS tracks of actual vaccination teams. Team tracks overlaid on satellite imagery revealed that teams commonly missed swaths of contiguous households and indicated that geospatial data can improve microplanning and provide nearly real-time monitoring of team performance.

Teasing, taunting, and the politics of politeness: high sociometric status is associated with expectation-consistent behavior.

Research examining face-to-face status hierarchies suggests that individuals attain respect and admiration by engaging in behavior that influences others' judgments of their value to the group. Building on this research, we expected that high-status individuals would be less likely to engage in behaviors that violate group norms and expectations, relative to low-status individuals. Adolescent participants took part in an interaction in which they teased an opposite-gender friend (Study 1) or an experiment in which taunting or cheering expectations were manipulated (Study 2). Consistent with the hypothesis, high-status boys and girls engaged in teasing behaviors consistent with their gender roles, relative to their low status counterparts (Study 1). In Study 2, high-status boys engaged in more direct provocation and off-record commentary while taunting, and more affiliative behavior while cheering on their partner, relative to low-status boys. Discussion focused on how expectation-consistent actions help individuals maintain elevated status.

Heat illness: predictors of hospital admissions among emergency department visits-Georgia, 2002-2008.

Heat-related illnesses (HRI) are the most frequent cause of environmental exposure-related injury treated in US emergency departments (ED). While most individuals with HRI evaluated in EDs are discharged to home, understanding predictors of individuals hospitalized with HRI may help public health practitioners and medical providers identify high risk groups who would benefit from educational outreach. We analyzed data collected by the Georgia Department of Public Health, Office of Health Indicators for Planning, regarding ED and hospital discharges for HRI, as identified by ICD-9 codes, between 2002 and 2008 to determine characteristics of individuals receiving care in EDs. Temperature data from CDC's Environmental Public Health Tracking Network were linked to the dataset to determine if ED visits occurred during an extreme heat event (EHE). A multivariable logistic regression model was developed to determine characteristics predicting hospitalization versus ED discharge using demographic characteristics, comorbid conditions, socioeconomic status, the public health district of residence, and the presence of an EHE. Men represented the majority of ED visits (75 %) and hospitalizations (78 %). In the multivariable model, the odds of admission versus ED discharge with an associated HRI increased with age among both men and women, and odds were higher among residents of specific public health districts, particularly in the southern part of the state. Educational efforts targeting the specific risk groups identified by this study may help reduce the burden of hospitalization due to HRI in the state of Georgia.

Racial disparities in travel time to radiotherapy facilities in the Atlanta metropolitan area.

Low-income women with breast cancer who rely on public transportation may have difficulty in completing recommended radiation therapy due to inadequate access to radiation facilities. Using a geographic information system (GIS) and network analysis we quantified spatial accessibility to radiation treatment facilities in the Atlanta, Georgia metropolitan area. We built a transportation network model that included all bus and rail routes and stops, system transfers and walk and wait times experienced by public transportation system travelers. We also built a private transportation network to model travel times by automobile. We calculated travel times to radiation therapy facilities via public and private transportation from a population-weighted center of each census tract located within the study area. We broadly grouped the tracts by low, medium and high household access to a private vehicle and by race. Facility service areas were created using the network model to map the extent of areal coverage at specified travel times (30, 45 and 60 min) for both public and private modes of transportation. The median public transportation travel time to the nearest radiotherapy facility was 56 min vs. approximately 8 min by private vehicle. We found that majority black census tracts had longer public transportation travel times than white tracts across all categories of vehicle access and that 39% of women in the study area had longer than 1 h of public transportation travel time to the nearest facility. In addition, service area analyses identified locations where the travel time barriers are the greatest. Spatial inaccessibility, especially for women who must use public transportation, is one of the barriers they face in receiving optimal treatment.

Expanding and improving urban outreach immunization in Patna, India.

OBJECTIVES: We conducted a case study of an urban immunization outreach strategy to determine the feasibility of the intervention and to measure administrative immunization coverage outcomes. METHODS: A multipronged strategy for improving immunization coverage in Urban Patna, India, was implemented for 1 year (2009/2010). The strategy was designed to increase immunization sites, shift human resources, plan logistics, improve community mobilization, provide supervision, strengthen data flow and implement special vaccination drives. RESULTS: Over 1 year, the coverage of all primary vaccines of the Universal Immunization Program improved by over 100%. CONCLUSION: Coverage can be rapidly improved through outreach immunization in low socioeconomic areas if existing opportunities are carefully utilized.

Time and distance barriers to mammography facilities in the Atlanta metropolitan area.

To a great extent, research on geographic accessibility to mammography facilities has focused on urban-rural differences. Spatial accessibility within urban areas can nonetheless pose a challenge, especially for minorities and low-income urban residents who are more likely to depend on public transportation. To examine spatial and temporal accessibility to mammography facilities in the Atlanta metropolitan area by public and private transportation, we built a multimodal transportation network model including bus and rail routes, bus and rail stops, transfers, walk times, and wait times. Our analysis of travel times from the population-weighted centroids of the 282 census tracts in the 2-county area to the nearest facility found that the median public transportation time was almost 51 minutes. We further examined public transportation travel times by levels of household access to a private vehicle. Residents in tracts with the lowest household access to a private vehicle had the shortest travel times, suggesting that facilities were favorably located for women who have to use public transportation. However, census tracts with majority non-Hispanic black populations had the longest travel times for all levels of vehicle availability. Time to the nearest mammography facility would not pose a barrier to women who had access to a private vehicle. This study adds to the literature demonstrating differences in spatial accessibility to health services by race/ethnicity and socioeconomic characteristics. Ameliorating spatial inaccessibility represents an opportunity for intervention that operates at the population level.