- [Show abstract] [Hide abstract] ABSTRACT: Findings from the field of Developmental Origins of Health and Disease (DOHaD) suggest that some of the most pressing public health problems facing communities today may begin much earlier than previously understood. In particular, this body of work provides evidence that social, physical, chemical, environmental, and behavioral influences in early life play a significant role in establishing vulnerabilities for chronic disease later in life. Further, because this work points to the importance of adverse environmental exposures that cluster in population groups, it suggests that existing opportunities to intervene at a population level may need to refocus their efforts “upstream” to sufficiently combat the fundamental causes of disease. To translate these findings into improved public health, however, the distance between scientific discovery and population application will need to be bridged by conversations across a breadth of disciplines and social roles. And importantly, those involved will likely begin without a shared vocabulary or conceptual starting point. The purpose of this paper is to support and inform the translation of DOHaD findings from the bench to population-level health promotion and disease prevention, by: (1) discussing the unique communication challenges inherent to translation of DOHaD for broad audiences, (2) introducing the First-hit/Second-hit Framework with an epidemiologic planning matrix as a model for conceptualizing and structuring communication around DOHaD, and (3) discussing the ways in which patterns of communicating DOHaD findings can expand the range of solutions considered and encourage discussion of population-level solutions in relation to one another, rather than in isolation.
- [Show abstract] [Hide abstract] ABSTRACT: Orphans and separated children (OSC) are a vulnerable population whose numbers are increasing, particularly in sub-Saharan Africa and Asia. Over 153 million children worldwide have lost one or both parents, including 17 million orphaned by AIDS, and millions more have been separated from their parents. As younger orphans enter adolescence, their sexual health and HIV-related risk behaviors become key considerations for their overall health. Importantly, their high prevalence of exposure to potentially traumatic events (PTEs) may put OSC at additional risk for adverse sexual health outcomes. The Positive Outcomes for Orphans study followed OSC randomly sampled from institution-based care and from family-based care, as well as a convenience sample of non-OSC, at six sites in five low-and middle-income countries. This analysis focused on the 90-month follow-up, during which adolescents 16 and older were assessed for sexual health, including age at sexual debut, past-year sex, past-year condom use, and perceptions of condom use. We specifically examined the relationship between PTEs and sexual health outcomes. Of the 1258 OSC and 138 non-OSC assessed, 11% reported ever having sex. Approximately 6% of participants reported recent sex and 5% reported having recent unprotected sex. However, 70% of those who had recent sex reported that they did not use a condom every time, and perceptions of condom use tended to be unfavorable for protection against sexual risk behavior. Nearly all (90%) of participants reported experiencing at least one lifetime PTE. For those who experienced “any” PTE, we found increased prevalence of recent sex (PR = 1.39 [0.47, 4.07]) and of recent unprotected sex (PR = 3.47 [0.60, 19.91]). This study highlights the need for caregivers, program managers, and policymakers to promote condom use for sexually active OSC and identify interventions for trauma support services. Orphans living in family-based care may also be particularly vulnerable to early sexual debut and unprotected sexual activity.
- [Show abstract] [Hide abstract] ABSTRACT: In this review, we considered how disparities in obesity emerge between birth, when socially disadvantaged infants tend to be small, and later in childhood, when socially disadvantaged groups have high risk of obesity. We reviewed epidemiologic evidence of socioeconomic and racial/ethnic differences in growth from infancy to pre-adolescence. Minority race/ethnicity and lower socioeconomic status was associated with rapid weight gain in infancy but not in older age groups, and social differences in linear growth and relative weight were unclear. Infant feeding practices was the most consistent mediator of social disparities in growth, but mediation analysis was uncommon and other factors have only begun to be explored. Complex life course processes challenge the field of social epidemiology to develop innovative study designs and analytic techniques with which to pose and test challenging yet impactful research questions about how obesity disparities evolve throughout childhood.
- [Show abstract] [Hide abstract] ABSTRACT: Background: Emerging evidence suggests potential links between some dietary fatty acids and improved fertility, because specific fatty acids may affect prostaglandin synthesis and steroidogenesis. Objective: The objective of this exploratory study was to evaluate associations between total and specific types of dietary fat intake and 1) hormone concentrations and 2) the risk of sporadic anovulation in a cohort of 259 regularly menstruating women in the BioCycle Study. Design: Endogenous reproductive hormones were measured up to 8 times/cycle for up to 2 cycles, with visits scheduled with the use of fertility monitors. Dietary intake was assessed with up to four 24-h recalls/cycle. Linear mixed models and generalized linear models were used to evaluate the associations between dietary fatty acids and both reproductive hormone concentrations and ovulatory status. All models were adjusted for total energy intake, age, body mass index, and race. Results: Relative to the lowest levels of percentage of energy from total fat, the highest tertile was associated with increased total and free testosterone concentrations (total: percentage change of 4.0%; 95% CI: 0.7%, 7.3%; free: percentage change of 4.1%; 95% CI: 0.5%, 7.7%). In particular, the percentage of energy from polyunsaturated fatty acids (PUFAs) in the highest tertile was associated with increases in total and free testosterone (total: percentage change of 3.7%; 95% CI: 0.6%, 6.8%; free: percentage change of 4.0%; 95% CI: 0.5%, 7.5%). The PUFA docosapentaenoic acid (22:5n-3) was not significantly associated with testosterone concentrations (P-trend = 0.86 in energy substitution models) but was associated with increased progesterone and a reduced risk of anovulation (highest tertile compared with the lowest tertile: RR: 0.42; 95% CI: 0.18, 0.95). Fat intakes were not associated with other reproductive hormone concentrations. Conclusions: These results indicate that total fat intake, and PUFA intake in particular, is associated with very small increases in testosterone concentrations in healthy women and that increased docosapentaenoic acid was associated with a lower risk of anovulation.
- [Show abstract] [Hide abstract] ABSTRACT: Background: Evidence is growing that the equilibrium between reactive oxygen species and antioxidants plays a vital role in women's reproductive health. Objective: The objective of this study was to evaluate variations in serum antioxidant concentrations across the menstrual cycle and associations between antioxidants and reproductive hormones and anovulation among healthy women. Methods: The BioCycle Study, a prospective cohort, followed 259 women aged 18-44 y for up to 2 menstrual cycles. Serum fat-soluble vitamin and micronutrient (α-tocopherol, γ-tocopherol, retinol, lutein, lycopene, and β-carotene), ascorbic acid, and reproductive hormone concentrations were measured 5-8 times/cycle. We used weighted linear mixed models to assess associations between antioxidants and hormone concentrations, after adjustment for age, race, body mass index, parity, sleep, pain medication use, total energy intake, concurrent hormones, serum cholesterol, F2-isoprostanes, and other antioxidants. Generalized linear models were used to identify associations with anovulation. Results: Serum antioxidant concentrations varied across the menstrual cycle. Retinol and α-tocopherol were associated with higher estradiol [RR: 1.00 pg/mL (95% CI: 0.67, 1.34 pg/mL); RR: 0.02 pg/mL (95% CI: 0.003, 0.03 pg/mL), respectively] and testosterone [RR: 0.61 ng/dL (95% CI: 0.44, 0.78 ng/dL); RR: 0.01 ng/dL (95% CI: 0.001, 0.01 ng/dL), respectively]. Ascorbic acid was associated with higher progesterone (RR: 0.15 ng/mL; 95% CI: 0.05, 0.25 ng/mL) and with lower follicle-stimulating hormone (RR: -0.06 mIU/mL; 95% CI: -0.09, -0.03 mIU/mL). The ratio of α- to γ-tocopherol was associated with an increased risk of anovulation (RR: 1.03; 95% CI: 1.01, 1.06). Conclusions: These findings shed new light on the intricate associations between serum antioxidants and endogenous hormones in healthy premenopausal women and support the hypothesis that concentrations of serum vitamins affect steroidogenesis even after adjustment for oxidative stress.
- [Show abstract] [Hide abstract] ABSTRACT: Prenatal development is recognized as a critical period in the etiology of obesity and cardiometabolic disease. Potential strategies to reduce maternal obesity-induced risk later in life have been largely overlooked. In this paper, we first propose a conceptual framework for the role of public health and preventive medicine in mitigating the effects of fetal programming. Second, we review a small but growing body of research (through August 2015) that examines interactive effects of maternal obesity and two public health foci - diet and physical activity - in the offspring. Results of the review support the hypothesis that diet and physical activity after early life can attenuate disease susceptibility induced by maternal obesity, but human evidence is scant. Based on the review, we identify major gaps relevant for prevention research, such as characterizing the type and dose response of dietary and physical activity exposures that modify the adverse effects of maternal obesity in the offspring. Third, we discuss potential implications of interactions between maternal obesity and postnatal dietary and physical activity exposures for interventions to mitigate maternal obesity-induced risk among children. Our conceptual framework, evidence review, and future research directions offer a platform to develop, test, and implement fetal programming mitigation strategies for the current and future generations of children.
- [Show abstract] [Hide abstract] ABSTRACT: Background/Question/Methods Many environmental factors influence human mortality simultaneously. However, assessing their cumulative effects remains a challenging task. In this study we used the Environmental Quality Index (EQI), developed by the U.S. EPA, as a measure of overall environmental exposure for 2000-2005. We investigated the relative contributions of five different environmental domains (air, water, land, sociodemographic and built environment) on human mortality and their spatial variations across the U.S. The domain-specific effects were simultaneously modeled on county-level using a Bayesian hierarchical structure. The 2000-2005 mortality data for all U.S. counties (n = 3141) were obtained from the National Center for Health Statistics. We additionally stratified by Rural-Urban Continuum Codes (RUCC), Koppen climate region, states and their combinations, to account for spatial variations in the effect. Separate models were built for all-cause (non-accidental) and cause-specific death rates (neoplasms, circulatory diseases and respirational diseases). Models were adjusted for county-level characteristics including median age, percent white and population density obtained from the U.S. census. Results/Conclusions The estimated effects of environmental quality on mortality varied by spatial location and by domain. We found that stratification by the combination of RUCC and climate regions to be most informative. Among the five domains, air had the strongest effects on all-cause death rate, where 1 standard deviation increase in air-EQI, a worsening of air quality, was associated with a 0.32±0.07 increase in deaths per 1000 people on average. Spatially, the highest adverse effects of worse air (0.84±0.22 deaths/1000) and water (0.23±0.07 deaths/1000) environmental quality were found in the northwestern U.S. The adverse effects of worse land and built environmental quality were found in most parts of the U.S. except in the western mountainous area. Finally, adverse effects of poor sociodemographic quality were found mostly in urbanized areas, e.g., in these areas higher poverty, lower education, and larger non-English speaking population were associated with higher mortality rate. Similar results were observed in the cause-specific models. This study assessed the cumulative effect of overall environmental quality on human mortality rates across the U.S. The relative impact of the effects and their spatial variation can provide further reference for environmental management of cumulative exposures. This abstract does not represent EPA policy.
- [Show abstract] [Hide abstract] ABSTRACT: Many environmental factors have been independently associated with preterm birth (PTB). However, exposure is not isolated to a single environmental factor, but rather to many positive and negative factors that co-occur. The environmental quality index (EQI), a measure of cumulative environmental exposure across all US counties from 2000-2005, was used to investigate associations between ambient environment and PTB. With 2000-2005 birth data from the National Center for Health Statistics for the United States (n = 24,483,348), we estimated the association between increasing quintiles of the EQI and county-level and individual-level PTB; we also considered environmental domain-specific (air, water, land, sociodemographic and built environment) and urban-rural stratifications. Effect estimates for the relationship between environmental quality and PTB varied by domain and by urban-rural strata but were consistent across county- and individual-level analyses. The county-level prevalence difference (PD (95 % confidence interval) for the non-stratified EQI comparing the highest quintile (poorest environmental quality) to the lowest quintile (best environmental quality) was -0.0166 (-0.0198, -0.0134). The air and sociodemographic domains had the strongest associations with PTB; PDs were 0.0196 (0.0162, 0.0229) and -0.0262 (-0.0300, -0.0224) for the air and sociodemographic domain indices, respectively. Within the most urban strata, the PD for the sociodemographic domain index was 0.0256 (0.0205, 0.0307). Odds ratios (OR) for the individual-level analysis were congruent with PDs. We observed both strong positive and negative associations between measures of broad environmental quality and preterm birth. Associations differed by rural-urban stratum and by the five environmental domains. Our study demonstrates the use of a large scale composite environment exposure metric with preterm birth, an important indicator of population health and shows potential for future research.
- [Show abstract] [Hide abstract] ABSTRACT: Particulate matter ≤2.5 micrometers in aerodynamic diameter (PM2.5) has been consistently associated with preterm birth (PTB) to varying degrees, but roles of PM2.5 species have been less studied. We estimated risk differences (RD) of PTB (reported per 10(6) pregnancies) associated with change in ambient concentrations of elemental carbon (EC), organic carbon (OC), nitrates (NO3), and sulfates (SO4). From live birth certificates from three states, we constructed a cohort of singleton pregnancies at or beyond 20 weeks of gestation from 2000-2005 (n=1,771,225; 8% PTB). We estimated mean species exposures for each week of gestation from monitor-corrected Community Multi-Scale Air Quality modeling data. RDs and 95% confidence intervals (CI) for 4 PTB categories were estimated for each exposure using linear regression, adjusted for maternal race/ethnicity, marital status, education, age, smoking, maximum temperature, ozone, and season of conception. We also adjusted for other species in multi-species models. RDs varied by exposure window and outcome period. EC was positively associated with PTB after 27 and before 35 weeks of gestation. For example, for a 0.25 µg/m(3) increase in EC exposure during gestational week 9, RD = 96 (95% CI: -20, 213) and RD = 145 (95% CI: -50, 341) for PTB during weeks 28-31 and 32-34, respectively. Associations with OCs were null or negative. RDs for NO3 were elevated with exposure in early weeks of gestation, and null in later weeks. RDs for SO4 exposure were positively associated with PTB though magnitude varied across gestational weeks. We observed effect measure modification for associations between EC and PTB by race/ethnicity and smoking status. EC and SO4 may contribute to associations between PM2.5 and PTB. Associations varied according to the timing of exposure and the timing of PTB.
- [Show abstract] [Hide abstract] ABSTRACT: Racial and/or ethnic minorities carry the highest burden of many adverse health outcomes intergenerationally. We propose a paradigm in which developmental programming exacerbates the effects of racial patterning of adverse environmental conditions, thereby contributing to health disparity persistence. Evidence that developmental programming induces a heightened response to adverse exposures (“second hits”) encountered later in life is considered. We evaluated the evidence for the second hit phenomenon reported in animal and human studies from three domains (air, stress, nutrition). Original research including a gestational exposure and a childhood or adulthood second hit exposure was reviewed. Evidence from animal studies suggest that prenatal exposure to air pollutants is associated with an exaggerated reaction to postnatal air pollution exposure, which results in worse health outcomes. It also indicates offspring exposed to prenatal maternal stress produce an exaggerated response to subsequent stressors, including anxiety and hyper-responsiveness of the hypothalamic–pituitary–adrenal axis. Similarly, prenatal and postnatal Western-style diets induce synergistic effects on weight gain, metabolic dysfunction, and atherosclerotic risk. Cross-domain second hits (e.g., gestational air pollution followed by childhood stressor) were also considered. Suboptimal gestational environments induce exaggerated offspring responses to subsequent environmental and social exposures. These developmental programming effects may result in enhanced sensitivity of ongoing, racially patterned, adverse exposures in race/ethnic minorities, thereby exacerbating health disparities from one generation to the next. Empirical assessment of the hypothesized role of priming processes in the propagation of health disparities is needed. Future social epidemiology research must explicitly consider synergistic relationships among social environmental conditions to which gestating females are exposed and offspring exposures when assessing causes for persistent health disparities.
- [Show abstract] [Hide abstract] ABSTRACT: The relationship between environmental conditions and human health varies by urbanicity. To estimate ambient environmental conditions, an Environmental Quality Index (EQI) for 2000-2005 was constructed by the Environmental Protection Agency using county-level data representing five environmental domains (air, water, land, built and sociodemographic) for each U.S. county (n=3141). Annual county-level, age-adjusted, cancer incidence rate data for 2006-2010 from Surveillance, Epidemiology, and End Results Program (SEER) was modeled with EQI quintiles. A random intercept multi-level linear regression clustered by state estimated fixed effects of EQI quintiles on all-site cancer incidence by sex, adjusted for percentage of population ever smoked (both sexes), and percentage to have had a mammogram and a pap smear (females). Results are reported as incidence rate difference (IRD) (95% confidence interval) comparing highest quintile/worst environmental quality to lowest/best environmental quality. All cause cancer was strongly positively associated with EQI in both sexes (males: 32.60 (16.28, 48.91), females: 30.34 (20.47, 40.21)). Models were also stratified by four rural-urban continuum codes (RUCC) ranging from metropolitan urbanized (RUCC1) to rural (RUCC4). We observed positive associations between all cause cancer and EQI for most strata for males (RUCC1: 27.01 (11.29, 42.74); RUCC2: 11.29 (-18.10, 40.67), RUCC3: 25.66 (3.85, 47.47), RUCC4: -12.12 (-50.65, 26.42)) and across all strata for females (RUCC1: 21.76 (8.26, 35.26); RUCC2: 2.34 (1.62, 3.06), RUCC3: 1.77 (1.19, 2.35), RUCC4: 2.06 (0.93, 3.19)). The strength of association varied by urbanization with the strongest observed in the most urbanized areas for both sexes. In addition, we assessed associations with the top three causes of cancer for both sexes. Cancer incidence is associated with ambient environmental quality and the strength of association varies by level of urbanization, which has implications for public health programs intervention planning in more or less urban areas. This abstract does not necessarily reflect EPA policy.
- [Show abstract] [Hide abstract] ABSTRACT: Physical inactivity has been associated with numerous adverse health outcomes including obesity, heart disease, and depression, and is considered a major contributor to all-cause mortality worldwide. Many studies have shown associations between specific environmental features (lack of sidewalks, safe surroundings, clean air) and physical inactivity. Yet, exposures affecting inactivity do not occur in isolation. Understanding the role of the overall ambient environment in population inactivity levels is essential. A novel county-level Environmental Quality Index (EQI) was developed by the Environmental Protection Agency (EPA) for all US counties from 2000-2005 representing 5 environmental domains: air, water, land, built, and sociodemographic. We linked the EQI to 2006 Behavioral Risk Factor Surveillance System county-level prevalence of age-adjusted physical inactivity in US counties (N=3,141). We used random intercept multi-level linear regression, clustering by state, to estimate fixed effects of EQI quintiles on physical inactivity prevalence. Analyses were stratified by 4 modified United States Department of Agriculture rural-urban continuum codes (RUCC) ranging from metropolitan urbanized (RUCC1) to rural (RUCC4). Results are reported as prevalence difference (PD) (95% confidence interval) comparing highest quintile/worst quality to lowest/best. For the overall EQI, negative quality environments were associated with reduced physical inactivity (RUCC1: -5.07(-5.65, -4.49); RUCC2: -3.36(-4.70, -2.01), RUCC3: -3.35(-4.00, -2.71); RUCC4: -2.55(-3.18, -1.92). However, in domain-specific EQI analyses, patterns of association (strength and direction) varied by RUCC: RUCC1, sociodemographic domain PD=4.56 (4.04, 5.08) and built PD=-4.07(-4.66, -3.48); RUCC2, air PD=1.96 (0.78, 3.13) and sociodemographic PD=-5.03, (-6.18, -3.89); RUCC3, air PD=1.24 (0.64, 1.84) and built PD=-1.23(-1.74, -0.71); RUCC4, sociodemographic PD=-3.00(-3.64, -2.37) and air PD=1.86 (0.98, 2.75). Physical inactivity was influenced by multiple domains of environmental quality depending on the extent of urbanization. These results provide useful information for environmental research and programs aimed at reducing county-level physical inactivity. This abstract does not necessarily reflect EPA policy.
- [Show abstract] [Hide abstract] ABSTRACT: Abstract The combined epidemics of substance abuse, violence, and HIV/AIDS, known as the SAVA syndemic, contribute to the disproportionate burden of disease among people of color in the U.S. To examine the association between HIV viral load suppression and SAVA syndemic variables, we used baseline data from 563 HIV+ women of color treated at nine HIV medical and ancillary care sites participating in HRSA's Special Project of National Significance Women of Color (WOC) Initiative. Just under half the women (n=260) were virally suppressed. Five psychosocial factors contributing to the SAVA syndemic were examined in this study: substance abuse, binge drinking, intimate partner violence, poor mental health, and sexual risk taking. Associations among the psychosocial factors were assessed and clustering confirmed. A SAVA score was created by summing the dichotomous (present/absent) psychosocial measures. Using generalized estimating equation (GEE) models to account for site-level clustering and individual-covariates, a higher SAVA score (0 to 5) was associated with reduced viral suppression; OR (adjusted)=0.81, 95% CI: 0.66, 0.99. The syndemic approach represents a viable framework for understanding viral suppression among HIV positive WOC, and suggests the need for comprehensive interventions that address the social/environmental contexts of patients' lives.
- [Show abstract] [Hide abstract] ABSTRACT: Irregular participation in HIV medical care hinders HIV RNA suppression and impacts health among people living with HIV. Cluster analysis of clinical data from 1,748 patients attending a large academic medical center yielded three HIV service usage patterns, namely: 'engaged in care', 'sporadic care', and 'frequent use'. Patients 'engaged in care' exhibited most consistent retention (on average, >88 % of each patient's observation years had ≥2 visits 90 days apart), annualized visit use (2.9 mean visits/year) and viral suppression (>73 % HIV RNA tests <400 c/mL). Patients in 'sporadic care' demonstrated lower retention (46-52 %), visit use (1.7 visits/year) and viral suppression (56 % <400 c/mL). Patients with 'frequent use' (5.2 visits/year) had more inpatient and emergency visits. Female, out-of-state residence, low attendance during the first observation year and detectable first-observed HIV RNA were early predictors of subsequent service usage. Patients 'engaged in care' were more likely to have HIV RNA <400 than those receiving sporadic care. Results confirm earlier findings that under-utilization of services predicts poorer viral suppression and health outcomes and support recommendations for 2-3 visits/year.
- [Show abstract] [Hide abstract] ABSTRACT: Neighborhood deprivation is consistently associated with greater risk of low birthweight. However, large birth size is increasingly relevant but overlooked in neighborhood health research, and proximity within which neighborhood deprivation may affect birth outcomes is unknown. We estimated race/ethnic-specific effects of neighborhood deprivation index (NDI) within 1, 3, 5, and 8km buffers around Oregon Pregnancy Risk Assessment Monitoring System (n=3716; 2004-2007) respondents׳ homes on small and large for gestational age (SGA, LGA). NDI was positively associated with LGA and SGA in most race/ethnic groups. The results varied little across the four buffer sizes.
- [Show abstract] [Hide abstract] ABSTRACT: Background With more than 2 million children living in group homes, or “institutions”, worldwide, the extent to which institution-based caregiving negatively affects development and wellbeing is a central question for international policymakers. Methods A two-stage random sampling methodology identified community representative samples of 1,357 institution-dwelling orphaned and separated children (OSC) and 1,480 family-dwelling OSC aged 6–12 from 5 low and middle income countries. Data were collected from children and their primary caregivers. Survey-analytic techniques and linear mixed effects models describe child wellbeing collected at baseline and at 36 months, including physical and emotional health, growth, cognitive development and memory, and the variation in outcomes between children, care settings, and study sites. Findings At 36-month follow-up, institution-dwelling OSC had statistically significantly higher height-for-age Z-scores and better caregiver-reported physical health; family-dwelling OSC had fewer caregiver-reported emotional difficulties. There were no statistically significant differences between the two groups on other measures. At both baseline and follow-up, the magnitude of the differences between the institution- and family-dwelling groups was small. Relatively little variation in outcomes was attributable to differences between sites (11–27% of total variation) or care settings within sites (8–14%), with most variation attributable to differences between children within settings (60–75%). The percent of variation in outcomes attributable to the care setting type, institution- versus family-based care, ranged from 0–4% at baseline, 0–3% at 36-month follow-up, and 0–4% for changes between baseline and 36 months. Interpretation These findings contradict the hypothesis that group home placement universally adversely affects child wellbeing. Without substantial improvements in and support for family settings, the removal of institutions, broadly defined, would not significantly improve child wellbeing and could worsen outcomes of children who are moved from a setting where they are doing relatively well to a more deprived setting.
- [Show abstract] [Hide abstract] ABSTRACT: Background: Although routine HIV testing programs aim to identify persons earlier in the course of their HIV infection, the results of extant HIV testing programs are inconclusive. The objective of this study was to estimate the impact of a routine, opt-out HIV testing program in North Carolina sexually transmitted disease (STD) clinics on the risk of progression to AIDS after HIV diagnosis. Methods: North Carolina residents aged 18-64 identified as new HIV-infected cases in North Carolina STD clinics from July 1, 2005 through June 30, 2011 were included. Exposure status was dichotomized on the date of intervention implementation on November 1, 2007. Risk of progression to AIDS within 12 months of initial HIV diagnosis was analyzed using county-specific random-intercept multilevel binomial regression models to calculate risk ratios (RRs) and 95% confidence intervals (95% CIs). Results: Of the 1203 persons newly diagnosed with HIV infection, 12% and 13% were diagnosed with AIDS within 12 months of their initial HIV diagnosis in the pre- and post-intervention periods, respectively. Overall, we did not observe an association between the introduction of the expanded HIV testing program and the risk of progression to AIDS (RR=1.04, 95% CI: 0.77-1.43). The intervention was associated with an increased risk of progression to AIDS among women (RR=2.32, 95% CI: 1.06-4.83) and persons who had previously been tested for HIV (RR=1.42, 95% CI: 0.92-2.19). Conclusions: Overall, the routine, opt-out HIV testing program was not associated with a decreased risk of progression to AIDS. Among some subpopulations, the increased risk of progression to AIDS post-intervention was likely due to identification of persons who had been infected for many years but were not previously targeted for risk-based testing. If undiagnosed HIV-infected persons do not seek interactions with the healthcare system, they cannot benefit from routine HIV testing programs in clinical settings.
- [Show abstract] [Hide abstract] ABSTRACT: The impact of routine, opt-out HIV testing programs in clinical settings is inconclusive. The objective of this study was to estimate the impact of an expanded, routine HIV testing program in North Carolina sexually transmitted disease (STD) clinics on HIV testing and case detection. Adults aged 18 to 64 years who received an HIV test in a North Carolina STD clinic from July 1, 2005, through June 30, 2011, were included in this analysis, dichotomized at the date of implementation on November 1, 2007. HIV testing and case detection counts and rates were analyzed using interrupted time series analysis and Poisson and multilevel logistic regression. Preintervention, 426 new HIV-infected cases were identified from 128,029 tests (0.33%), whereas 816 new HIV-infected cases were found from 274,745 tests postintervention (0.30%). Preintervention, HIV testing increased by 55 tests per month (95% confidence interval [CI], 41-72), but only 34 tests per month (95% CI, 26-42) postintervention. Increases in HIV testing rates were most pronounced in women and non-Hispanic whites. A slight preintervention decline in case detection was mitigated by the intervention (mean difference, 0.01; 95% CI, -0.02 to 0.05). Increases in case detection rates were observed among women and non-Hispanic blacks. The impact of a routine HIV screening in North Carolina STD clinics was marginal, with the greatest benefit among persons not traditionally targeted for HIV testing. The use of a preintervention comparison period identified important temporal trends that otherwise would have been ignored.
- [Show abstract] [Hide abstract] ABSTRACT: Background: Particulate matter ≤ 2.5 μm in aerodynamic diameter (PM2.5) has been variably associated with preterm birth (PTB). Objective: We classified PTB into four categories (20-27, 28-31, 32-34, and 35-36 weeks completed gestation) and estimated risk differences (RDs) for each category in association with a 1-μg/m3 increase in PM2.5 exposure during each week of gestation. Methods: We assembled a cohort of singleton pregnancies that completed ≥ 20 weeks of gestation during 2000-2005 using live birth certificate data from three states (Pennsylvania, Ohio, and New Jersey) (n = 1,940,213; 8% PTB). We estimated mean PM2.5 exposures for each week of gestation from monitor-corrected Community Multi-Scale Air Quality modeling data. RDs were estimated using modified Poisson linear regression and adjusted for maternal race/ethnicity, marital status, education, age, and ozone. Results: RD estimates varied by exposure window and outcome period. Average PM2.5 exposure during the fourth week of gestation was positively associated with all PTB outcomes, although magnitude varied by PTB category [e.g., for a 1-μg/m3 increase, RD = 11.8 (95% CI: -6, 29.2); RD = 46 (95% CI: 23.2, 68.9); RD = 61.1 (95% CI: 22.6, 99.7); and RD = 28.5 (95% CI: -39, 95.7) for preterm births during 20-27, 28-31, 32-34, and 35-36 weeks, respectively]. Exposures during the week of birth and the 2 weeks before birth also were positively associated with all PTB categories. Conclusions: Exposures beginning around the time of implantation and near birth appeared to be more strongly associated with PTB than exposures during other time periods. Because particulate matter exposure is ubiquitous, evidence of effects of PM2.5 exposure on PTB, even if small in magnitude, is cause for concern.
- [Show abstract] [Hide abstract] ABSTRACT: Background A more comprehensive estimate of environmental quality would improve our understanding of the relationship between environmental conditions and human health. An environmental quality index (EQI) for all counties in the U.S. was developed. Methods The EQI was developed in four parts: domain identification; data source acquisition; variable construction; and data reduction. Five environmental domains (air, water, land, built and sociodemographic) were recognized. Within each domain, data sources were identified; each was temporally (years 2000–2005) and geographically (county) restricted. Variables were constructed for each domain and assessed for missingness, collinearity, and normality. Domain-specific data reduction was accomplished using principal components analysis (PCA), resulting in domain-specific indices. Domain-specific indices were then combined into an overall EQI using PCA. In each PCA procedure, the first principal component was retained. Both domain-specific indices and overall EQI were stratified by four rural–urban continuum codes (RUCC). Higher values for each index were set to correspond to areas with poorer environmental quality. Results Concentrations of included variables differed across rural–urban strata, as did within-domain variable loadings, and domain index loadings for the EQI. In general, higher values of the air and sociodemographic indices were found in the more metropolitan areas and the most thinly populated areas have the lowest values of each of the domain indices. The less-urbanized counties (RUCC 3) demonstrated the greatest heterogeneity and range of EQI scores (−4.76, 3.57) while the thinly populated strata (RUCC 4) contained counties with the most positive scores (EQI score ranges from −5.86, 2.52). Conclusion The EQI holds promise for improving our characterization of the overall environment for public health. The EQI describes the non-residential ambient county-level conditions to which residents are exposed and domain-specific EQI loadings indicate which of the environmental domains account for the largest portion of the variability in the EQI environment. The EQI was constructed for all counties in the United States, incorporating a variety of data to provide a broad picture of environmental conditions. We undertook a reproducible approach that primarily utilized publically-available data sources.
Durham, North Carolina, United States
- Center for Health Policy & Inequalities Research