The role of epidemiology in informing United States childhood immunization policy and practice.

One of the ten greatest public health achievements is childhood vaccination because of its impact on controlling and eliminating vaccine-preventable diseases (VPDs). Evidence-based immunization policies and practices are responsible for this success and are supported by epidemiology that has generated scientific evidence for informing policy and practice. The purpose of this report is to highlight the role of epidemiology in the development of immunization policy and successful intervention in public health practice that has resulted in a measurable public health impact: the control and elimination of VPDs in the United States. Examples in which epidemiology informed immunization policy were collected from a literature review and consultation with experts who have been working in this field for the past 30 years. Epidemiologic examples (e.g., thimerosal-containing vaccines and the alleged association between the measles, mumps, and rubella (MMR) vaccine and autism) are presented to describe challenges that epidemiologists have addressed. Finally, we describe ongoing challenges to the nation's ability to sustain high vaccination coverage, particularly with concerns about vaccine safety and effectiveness, increasing use of religious and philosophical belief exemptions to vaccination, and vaccine hesitancy. Learning from past and current experiences may help epidemiologists anticipate and address current and future challenges to respond to emerging infectious diseases, such as COVID-19, with new vaccines and enhance the public health impact of immunization programs for years to come.

Characterizing a "Big Data" Cohort of Over 200,000 Low-Income U.S. Infants and Children for Obesity Research: The ADVANCE Early Life Cohort.

Introduction Low-income populations have elevated exposure to early life risk factors for obesity, but are understudied in longitudinal research. Our objective was to assess the utility of a cohort derived from electronic health record data from safety net clinics for investigation of obesity emerging in early life. Methods We examined data from the PCORNet ADVANCE Clinical Data Research Network, a national network of Federally-Qualified Health Centers serving >1.7 million safety net patients across the US. This cohort includes patients who, in 2012-2014, had ≥1 valid body mass index measure when they were 0-5 years of age. We characterized the cohort with respect to factors required for early life obesity research in vulnerable subgroups: sociodemographic diversity, weight status based on World Health Organization (<2 years) or Centers for Disease Control (≥2 years) growth curves, and data longitudinality. Results The cohort includes 216,473 children and is racially/ethnically diverse (e.g., 17.9% Black, 45.4% Hispanic). A majority (56.9%) had family incomes below the Federal Poverty Level (FPL); 32% were <50% of FPL. Among children <2 years, 7.6 and 5.3% had high and low weight-for-length, respectively. Among children 2-5 years, 15.0, 12.7 and 2.4% were overweight, obese, and severely obese, respectively; 5.3% were underweight. In the study period, 79.2% of children had ≥2 BMI measures. Among 4-5 year olds, 21.9% had >1 BMI measure when they were <2 years. Discussion The ADVANCE Early Life cohort offers unique opportunities to investigate early life determinants of obesity in the understudied population of low income and minority children.

No fathers' names: a risk factor for infant mortality in the State of Georgia, USA.

Many studies have explored maternal and infant factors as risks for infant mortality, but little attention is given to paternal factors. In Georgia, listing a father's name on the birth certificate is optional for married couples and possible after paternal acknowledgment for unmarried couples. The authors evaluated father's name reporting as a paternity measure and risk for infant mortality. Using the linked 1989-1990 birth and death certificates of singleton Georgia infants to calculate relative risks (RRs), infant mortality rates for 38,943 infants with no father's names listed were compared to rates for 178,100 with father's names listed. Compared with the rate for married women listing names, the death rates were higher for unmarried mothers not listing fathers (relative risk, RR = 2.5; 95% CI 2.3-2.7), unmarried mothers listing fathers (RR = 1.4; 95% CI 1.3-1.6), and married women not listing fathers (RR = 2.3; 95% CI 1.6-3.1). Increased risks remained after stratifying by maternal race, age, adequacy of prenatal care and medical risks; and congenital malformations, birthweight, gestational age, and small-for-gestational age. Using logistic regression to examine for effect modification and to adjust for these factors together, the adjusted relative risks for death varied across different groups without fathers' names, regardless of marital status. For example, it remained statistically higher for infants with no father listed and without effect-modifying conditions such as low birthweight (estimated RR = 2.0; 95% CI 1.6-2.4). Although these findings suggest paternal involvement, as measured by listing fathers' names, is protective against low birthweight and infant mortality, further evaluation is needed.

Racial differences in the patterns of singleton preterm delivery in the 1988 National Maternal and Infant Health Survey.

OBJECTIVES: To determine if the association between race and preterm delivery would persist when preterm delivery was partitioned into two etiologic pathways. METHODS: We evaluated perinatal and obstetrical data from the 1988 National Maternal and Infant Health Survey and classified preterm delivery as spontaneous or medically indicated. Discrete proportional hazard models were fit to assess the risk of preterm delivery for Black women compared with White women adjusting for potential demographic and behavioral confounding variables. RESULTS: Preterm delivery occurred among 17.4% of Black births and 6.7% of White births with a Black versus White unadjusted hazard ratio (HR) of 2.8 (95% CI = 2.4-3.3). The adjusted HR for a medically indicated preterm delivery showed no racial difference in risk (HR = 1.0, 95% CI = 0.4-2.6). However, for spontaneous preterm delivery between 20 and 28 weeks gestation, the Black versus White adjusted hazard ratio (HR) was 4.9 (95% CI = 3.4-7.1). CONCLUSIONS: Although we found an increased unadjusted HR for preterm delivery among Black women compared with White women, the nearly fivefold increase in adjusted HR for the extremely preterm births and the absence of a difference for medically indicated preterm delivery was unexpected. Given the differences in the risks of preterm birth between Black and White women, we recommend to continue examining risk factors for preterm delivery after separating spontaneous from medically indicated preterm birth and subdividing preterm delivery by gestational age to shed light on the reasons for the racial disparity.

Quality assessment of fetal death records in Georgia: a method for improvement.

OBJECTIVES: Although more fetal deaths than neonatal deaths occur, routinely collected fetal death data are seldom used for perinatal epidemiologic research because of data quality concerns. We developed a strategy for identifying and correcting errors in birthweight and gestational age in fetal death records. METHODS: Using data from Georgia for 1989 and 1990, we detected singleton fetal death records having improbable or missing birthweight or gestational age by comparing these values with referent values. To verify the questionable values, we contacted 100 reporting hospitals in 1992. RESULTS: In 817 of 2226 records, values were either improbable (60.1%) or missing (39.9%). We were able to contact the hospitals to verify data for 716 (88%) of these records. Verification resulted in corrections to 405 (57%) records, and 48% of unreported birthweights were obtained. CONCLUSIONS: Many errors in recorded gestational age and birthweight were identified by this method. Rather than deleting or inputting problem data for analyses, researchers should consider efforts to verify them. Efforts to improve this information should include improved reporting, strict quality assurance, and procedures for routine verification and correction of records.

Constructing reproductive histories by linking vital records.

Certificates of 1,449,287 live births and fetal deaths filed in Georgia from 1980 through 1992 were linked to create chronologies that, excluding induced abortions and ectopic pregnancies, constituted the reproductive experience of individual women. The authors initially used a deterministic method (whereby linking rules were not based on probability theory) to link as many records as possible, knowing that some of the linkages would be incorrect. They subsequently used a probabilistic method (whereby evaluation of linkages was developed from probability theory) to evaluate each linkage, and they broke those that were judged to be incorrect. Of the 1.4 million records, 38% did not link to another record. From the remaining records, 369,686 chains of two or more events were constructed. The longest chain included 12 events. Of the chains, 69% included two events; 22% included three events. Longer chains tended to have lower scores for probable validity. The probability-based evaluation of chains affected 3.0% of the records that had been in chains at the end of the deterministic linkage. A greater percentage of records in longer chains were affected by the evaluation. Unfortunately, the small subset of records that were the most difficult to link tended to overrepresent groups with the greatest risk of adverse pregnancy outcomes. Researchers contemplating a similar linkage can anticipate that, for the majority of records, linkage can be accomplished with a relatively straightforward, deterministic approach.

Evaluation of reproductive histories constructed by linking vital records.

We used 1.4 million fetal death and birth certificates filed in Georgia between 1980 and 1992 to construct 369,686 chains of two or more reproductive events occurring to the same woman. We evaluated these chains using both information on the certificates and information independently collected in interviews with 1311 women. Overall, 86.6% of the chains had the expected number of events, based on the certificate's information about previous pregnancies. Seventy-nine per cent of the chains had the expected number of events based on the maternal interviews. Consistency between the observed number of events in the chain and the number expected, based either on data from the certificates or from the maternal interviews, was greatest for chains with two or three events. Mothers born in Georgia were more likely to have complete chains than mothers born elsewhere. Among the 551,391 non-linked certificates, 48.7% were the mother's first birth, 40.2% were second or higher-order births to women whose previous pregnancy occurred before 1980, and 11.1% were second or higher-order births to women whose previous pregnancy occurred after 1980. Fetal death and livebirth certificates can be linked to construct pregnancy histories with reasonably low levels of underlinkage and overlinkage.

Ligand interactions with E-selectin. Identification of a new binding site for recognition of N-acyl aromatic glucosamine substituents of sialyl Lewis X.

Several N-acylglucosamine derivatives of sialyl Lewis X (1-3) were prepared using a combined chemical enzymatic approach and evaluated as an inhibitor of E-selectin-mediated cellular adhesion. Compounds with aromatic functionality, 1 and 2, were found to be 3-10 times more potent than the N-acetyl derivative (14) in an ELISA E-selectin cell adhesion assay. Conformational analysis with NMR indicated that the sialyl Lewis x domain of 1 retained the conformation of the N-acetyl derivative (14) despite the presence of the N-naphthamido group. The dramatic order of magnitude increase in potency of these monovalent structures can be utilized to design more potent selectin-based cell adhesion inhibitors.

Definitive treatment of colon injuries: a prospective study.

The results of a prospective protocol for penetrating injuries of the colon in 252 patients are presented. The protocol emphasized definitive management of the injury by repair, resection and anastomosis or exteriorized repair. Colostomy was reserved for left colon injuries requiring resection or for delayed treatment. Two hundred nineteen patients (86.9%) had definitive treatment by repair (N = 159), resection and anastomosis (N = 26), or exteriorized repair. This was successful in 205 patients (93.6%). Three patients had anastomotic leak after repair or ileocolostomy. Eight of the 34 patients with exteriorized repair had suture-line breakdown and 26 (76.5%) patients avoided a colostomy. Injury severity indices (anatomic: Abdominal Trauma Index and Flint grading of colon injury) were higher in the exteriorized repair than in the repair group. Postoperative abdominal abscesses occurred in 43 patients (17.1%). A multiple regression analysis identified the Abdominal Trauma Index (P < 0.0001) and the presence of colostomy (P < 0.0004) as significant independent factors in association with this complication. Mortality from sepsis was 2.4 per cent (6 patients) and in only one patient was the death directly related to colon injury management. We conclude that the majority of colon injuries can be managed by repair or resection with anastomosis. End colostomy is unavoidable in Flint 3 injuries of the left colon. In other situations, ileocolic or colocolic anastomoses appear to be safe in hemodynamically stable patients. Loop colostomy has a role in delayed treatment, but can be replaced by an exteriorized repair in Grade 2 colon injuries that do not require resection.

"Directed" emergency room thoracotomy: a prognostic prerequisite for survival.

The results of 163 patients (49 SWs, 85 GSWs, 29 blunt trauma) who had resuscitative thoracotomy in the emergency room (ERT) were reviewed to reassess the indications for the procedure. The Revised Trauma Score (RTS) of the patients ranged from 0 to 3 in 138, 4 to 8 in 21, and greater than 8 in four. No patient with blunt trauma survived. Sixteen patients [12 (24.5%) with stab wounds and 4 (4.7%) with gunshot wounds] were eventually discharged, an overall survival of 9.8%. Eight of the survivors were without vital signs on arrival at the emergency center and one of them had only signs of life at the scene. Survival was best when the site of penetration was thoracic (n = 84) and the ERT was "directed" at potential cardiac injury. Fifty-six of these patients (66.6%) did have cardiac wounds with tamponade and 12 of them survived (21.4%). Two of the remaining 28 patients, both with pulmonary injury, were salvaged. This was significantly (p less than 0.001) higher than in patients with head and neck (n = 4), abdominal (n = 19), or multiple site (n = 40) injury when the ERT was nondirected. Two of the five patients (40%) with extremity vascular injuries survived after ERT was successful in restoring a cardiac rhythm. These data suggest that in patients without vital signs, ERT "directed" at potential cardiac injury based on thoracic penetration is an important prognostic prerequisite for survival. Emergency room thoracotomy is not beneficial in blunt trauma and its role in penetrating abdominal injuries remains unproven.

Human T-cell lymphotrophic virus in California's injection drug users.

Human T-cell lymphotrophic virus I (HTLV-I) and human T-cell lymphotrophic virus II (HTLV-II) are closely related retroviruses that are highly prevalent in injection drug users (IDUs). The bulk of infection in this group probably occurs with HTLV-II, with a lower prevalence of HTLV-I. HTLV-I is known to cause adult T-cell leukemia/lymphoma and tropical spastic paraparesis. HTLV-II has not been proven to cause any human pathology, but may be immunosuppressive and is almost indistinguishable serologically from HTLV-I. As with human immunodeficiency virus (HIV), infection with these viruses is likely to be lifelong and the disease may have a latent period of many years. Unlike HIV, HTLV-I and/or HTLV-II are not likely to be transmitted from mother to child prenatally, and usually require breast-feeding for vertical transmission. It is likely that HTLV-I and/or HTLV-II has been prevalent in IDUs for far longer than the HIV epidemic. HTLV-I and/or HTLV-II are relevant to the AIDS epidemic in that they may function as biologic markers of behavioral risk status for HIV infection in IDUs or their sexual partners, and they may accelerate the course of HIV infection in persons coinfected with HTLV-I and/or HTLV-II and HIV. Coinfection will be more likely as the HIV epidemic progresses. Pregnant addicts entering outpatient methadone maintenance treatment in San Francisco County or Contra Costa County during 1990 were found to have an HTLV-II prevalence of 21% (n = 24). Important issues in counseling infected methadone patients are described.

A general approach to carbocyclic sugar analogs: preparation of a carbocyclic analog of beta-D-fructofuranose.

The development and execution of the first examples of a new and general approach to carbocyclic analogs of carbohydrates ("pseudo-sugars") is presented. Complete experimental details for the preparation of the carbocyclic analog of beta-D-fructofuranose 6-phosphate are described for the first time. In the conclusion, the success of the synthetic strategy is analyzed and an approach to retrosynthetic analysis based on "unitive synthons" is offered for consideration.

Sensitivity and specificity of pooled versus individual sera in a human immunodeficiency virus antibody prevalence study.

We evaluated the efficacy of testing pooled versus individual sera for the detection of human immunodeficiency virus antibody. A total of 5,000 individual specimens and 500 pools of 10 specimens each were assayed by an enzyme-linked immunosorbent assay. There was complete agreement in human immunodeficiency virus enzyme-linked immunosorbent assay reactivity for pooled versus individual specimens. An estimated savings of 60 to 80% (labor and supplies) can be realized dependent upon pooling and assay format.

Latent mammary tuberculosis: a case report.

Tuberculosis of the breast was diagnosed in this 63-year-old woman 14 years after she was treated for tuberculous pericarditis. Case history and a review of the literature are presented.

Penetrating duodenal injuries. Analysis of 100 consecutive cases.

One hundred consecutive patients with penetrating duodenal injuries were reviewed retrospectively to analyze the results of various methods of treatment. The severity of the abdominal injury was quantified by the Penetrating Abdominal Trauma Index (PATI). The overall mortality was 25%. Sixteen per cent of the deaths were related to extensive associated organ injury, eight per cent to sepsis, and one per cent to concurrent head trauma. Duodenal fistulas occurred in four per cent and were associated with mortality in two per cent. The complications of duodenal fistula, abdominal sepsis, and mortality from sepsis were significantly higher in those patients treated by repair and decompressive enterostomy with or without a serosal patch than in those with repair or resection. The severity of duodenal and associated organ injuries, as well as the clinical status, were similar in both groups. It is concluded that the majority of duodenal injuries from penetrating trauma may be treated effectively by primary repair, and that the use of decompressive enterostomy or serosal patch appears to contribute to an increased morbidity rate.

Treatment of penetrating duodenal injuries: primary repair vs. repair with decompressive enterostomy/serosal patch.

We analyzed 60 patients with penetrating duodenal injuries (1972-1983) treated by two operative techniques: primary repair or anastomosis after debridement, and repair with decompressive enterostomy with or without serosal patch of jejunum. The two treatment groups were comparable in terms of severity of duodenal and associated injuries and clinical status of the patients. Morbidity was significantly higher (p less than 0.001) in the enterostomy/patch group and mortality was limited to that group. Our data suggest that debridement and primary repair of duodenal wounds is the treatment of choice and that the addition of decompressive enterostomy and/or serosal patch does not improve results and may contribute to morbidity and mortality.

Exploración radisotopica de la función ventricular basal izquierda del tránsito esofágico, de la vía urinaria superior y de la función vesical en pacientes chagásicos cronicos predominantemente asintomáticos / Radioisotopic exploration of basal left ventricular function of the esophageal transit, of upper urinary duct and of bladder function of patients with chronic Chagas' disease predominantly en assymptomatic

Estudou-se em 56 pacientes chagásicos crônicos (45 assintomáticos e os restantes portadores de transtornos cardiovasculares e digestivos) a funçäo ventrícular esquerda (ejeçäo basal, motilidade parietal segmentar e o histograma); em 29 deles, o trânsito esofagiano e em outros 25 enfermos explorou-se a via urinária, respectivamente com o 99m - TC coloidal e o 99ml - TC b + PA. Observou-se que a fraçäo de ejeçäo do ventrículo esquerdo entre os indivíduos normais era de 0,66 + ou - 0,07, enquanto nos chagásicos crônicos com alteraçöes cardiovasculares (Grupo II) verificou-se 0,49 + ou - 0,21. A motilidade parietal esteve alterada em 60% do mesmo grupo de enfermos e o desvio standard do histograma foi de 1,98 + ou - 0,45, para 1,29 + ou - 0,17 no grupo de voluntários. O trânsito esofágico foi considerado normal em 9 casos e alterado em 20, sendo que em 6 foi do tipo prolongado, em 4 adinâmico e em 10 incoordenado. Nos 25 pacientes nos quais investigaram a via urinária superior, foi encontrada alteraçäo em 22 (dilataçäo piélica uni ou bilateral) e a funçäo vesical nestes pacientes foi normal em apenas quatro casos. Concluem os pesquisadores que o 99 - TC representa um grande avanço tecnológico no estudo da funçäo cardíaca, esofágica e das vias urinárias em pacientes chagásicos crônicos e assintomáticos

Aggressive definitive management of penetrating colon injuries: 136 cases with 3.7 per cent mortality.

One hundred thirty six patients with penetrating colon injuries (gunshot wounds, 95; stab wounds, 41) were retrospectively analyzed. A scoring system, the Penetrating Abdominal Trauma Index (P.A.T.I.), was employed to quantitatively assess the severity of injuries in each patient. Of 67 patients with right colon injuries, 48 (72%) were treated definitively by primary repair (32) and by resection and ileocolic anastomosis (16), with minimal morbidity. In 69 patients with left colon injuries, 47 (68%) were treated by colostomy (28) and by exteriorized repair (19). Overall, exteriorized repair was successful in 74% of patients. All five mortalities (3.7%) were related to associated injuries. It is concluded that the majority of the right colon injuries can be treated definitively. Exteriorized repair should be the preferred method whenever colostomy is considered, except in severe left colon injuries requiring resection.