High-risk Counties Research Articles

Impact of Supplementary Immunization Activities in Measles-Endemic Areas: A Case Study From Guangxi, China

Because of limited resources, each year during the period from 1999 through 2007, only about one-quarter of the 111 counties in Guangxi province were selected by means of risk assessment to participate in Supplementary Immunization Activities (SIAs), targeting children aged 8 months to 14 years during 1999-2003 and 8 months to 10 years during 2004-2007. Approximately 2 million doses of measles vaccines were administrated each year during SIAs. Estimated from the National Notifiable Diseases Surveillance System, with a reliable internal consistency over years, the average annual incidences of measles before SIAs (1993-1998), during the first phase (1999-2003), and during the second phase (2004-2007) were 16.05, 9.10, and 2.46 cases per 100,000, respectively. The overall provincewide annual incidence decreased by 84.67%, from 12.12 cases per 100,000 in 2000 to 2.10 cases per 100,000 in 2007. The percentage of counties with annual incidence ≥10 cases per 100,000 decreased from 55% in 1993 to <1% in 2007. Compared with the pre-SIA period, the greatest decrease in annual incidence was 83.93% for the 10-14.9-year-old group and the smallest decrease was 46.16% for children <1 year old. The multiple-year SIAs targeting children in selected high-risk counties were effective in controlling measles in mountainous, impoverished, and multiethnic measles-endemic areas.

A regionalised strategy for improving motor vehicle-related highway driver deaths using a weighted averages method

ObjectiveThe state of Florida has some of the most dangerous highways in the USA. In 2006, Florida averaged 1.65 fatalities per 100 million vehicle miles travelled (VMT) compared with the...

Integrating Spatial Epidemiology Into a Decision Model for Evaluation of Facial Palsy in Children

To develop a novel diagnostic algorithm for Lyme disease among children with facial palsy by integrating public health surveillance data with traditional clinical predictors. Retrospective cohort study. Children's Hospital Boston emergency department, 1995-2007. Two hundred sixty-four children (aged <20 years) with peripheral facial palsy who were evaluated for Lyme disease. Multivariate regression was used to identify independent clinical and epidemiologic predictors of Lyme disease facial palsy. Lyme diagnosis was positive in 65% of children from high-risk counties in Massachusetts during Lyme disease season compared with 5% of those without both geographic and seasonal risk factors. Among patients with both seasonal and geographic risk factors, 80% with 1 clinical risk factor (fever or headache) and 100% with 2 clinical factors had Lyme disease. Factors independently associated with Lyme disease facial palsy were development from June to November (odds ratio, 25.4; 95% confidence interval, 8.3-113.4), residence in a county where the most recent 3-year average Lyme disease incidence exceeded 4 cases per 100,000 (18.4; 6.5-68.5), fever (3.9; 1.5-11.0), and headache (2.7; 1.3-5.8). Clinical experts correctly treated 68 of 94 patients (72%) with Lyme disease facial palsy, but a tool incorporating geographic and seasonal risk identified all 94 cases. Most physicians intuitively integrate geographic information into Lyme disease management, but we demonstrate quantitatively how formal use of geographically based incidence in a clinical algorithm improves diagnostic accuracy. These findings demonstrate potential for improved outcomes from investments in health information technology that foster bidirectional communication between public health and clinical settings.

Iodine deficiency disorders in high-risk areas of Hainan province from 2007 to 2009: an analysis of survey results

Objective To know the prevalence of iodine deficiency disorders(IDD) and the implementation of control measures against the disorders in high-risk areas of Hainan province. Methods Typical sampling principle was used. Eight townships with lower coverage rate of iodized salt were chosen in IDD high-risk counties of Hainan. New cretinism cases were screened among children aged 10 years and under. Intelligence quotient (IQ)value, urinary iodine (UI) concentration and thyroid gland size (by palpation and B ultrasonic) were investigated in children aged 8 to 10 years and questionnaire was also carried out among students from grade 5 in elementary school. Edible salt and urine of women of childbearing age were collected to detect iodine levels, respectively,questionnaire was also carried out among the women of childbearing age. The UI was determined by As3-Ce4+ catalytic spectrophotometer, the salt iodine level was determined using self-quantitative kit. IQ values were measured by the Combined Raven Test in China (CRT-C2). Results Seventy-two townships were investigated in three consecutive years, 7937 children aged 8 to 10 years, 1797 women of childbearing age and 4128 students of grade 5 were included in the survey. One child was diagnosed as suspected new cretinism case. The coverage rate of iodized salt was increased from 44.6%(629/1411) in 2007 to 92.1%(1688/1832) in 2009. The goiter rate was dropped from 5.9% (269/4548), 6.0% (274/4548) in 2007 to 1.6% (24/1461), 0.1% (2/1461) in 2009 bypalpation, and by B-ultrasound, respectively, in children aged 8 to 10 years. The median urinary iodine(MUI) was found to be increased from 97.4 μg/L in 2007 to 165.0 μg/L in 2009, and the percentage of UI less than 50.0 μg/L, and 100.0 μg/L were dropped from 21.4%(973/4548), 51.2%(2329/4548) in 2007 to 7.5 %(110/1461), 23.4%(342/1461) in 2009, respectively. The MUI of women of childbearing age was found to be elevated from 73.7 μg/L in 2007 to 126.1 μg/L in 2009, and the value was also increased from 55.7 μg/L to 121.5 μg/L in pregnant women, but these values were still lower than 150.0 μg/L The pass rate of the questionnaire of IDD controlling among the students of grade 5 and the women of childbearing age was raised from 29.8% (446/1495) ,24.1% (179/742) in 2007 to 65.8%(732/1112), 72.1%(264/366) in 2009, respectively. The mean IQ of children was 90.4±16.0, and the percentage of IQ value less than 69 was 12.6% (1000/7937). Conclusions The diseased state of IDD has improved in the high-risk counties of disorders in Hainan province, but the pregnant women are still iodine deficient. Iodine supplimentation should be promoted among pregnant women. Key words: Iodine; Deficiency disorders; Goiter, Endemic; Data collection

Examining Barriers to Cervical Cancer Screening and Treatment in Florida through a Socio-Ecological Lens

Cervical cancer incidence and mortality have declined in the U.S. over the past 50 years because of broad screening efforts; however, some states continue to bear a greater burden due to under-screened and -treated populations. The purpose of this study was to utilize the socio-ecological model to examine barriers to cervical cancer screening and treatment in Florida. A qualitative semi-structured interview guide was used to conduct telephone interviews with 21 purposively sampled health care professionals from 13 high-risk counties. Interviews were transcribed and coded using themes identified a priori based on levels of the socio-ecological model. Investigators identified barriers to cervical cancer screening and treatment in Florida across four levels: (1) regulations and funding issues at the policy level are inconsistent between federal, state and local levels; (2) community level barriers range from cultural differences and fear of deportation, to transportation issues; (3) institutional level barriers complicate the administration of screening and treatment services; and (4) individual beliefs, behaviors, and stressors due to poverty hinder women's ability to access services. Many of our findings are consistent with previous studies that identified constraints to screening and treatment of cervical cancer, such as poverty and lack of access to care. This study adds to the literature by examining barriers from the viewpoint of service providers and program coordinators, and through the utilization of the socio-ecological model to provide a comprehensive framework for identifying and understanding these challenges.

Burn Injury in Utah: Demographic and Geographic Risks

Burns are preventable injuries, and prevention campaigns have been conducted with varying success. To develop successful prevention programs, it is imperative that burn risk be identified and factors associated with increased risk elucidated. The aims of this study were to determine the risk of burn injury to Utah residents, identify demographic and geographic subgroups at increased risk, and to examine sociodemographic factors associated with risk. Probabilistic record linkage of databases from five states was performed to identify Utah residents burned over a 5-year period and to calculate the burn rates and risk. Geographic Information Systems mapping allowed for the identification and characterization of high risk areas. Men had a higher rate of injury than women. Children under the age of 5 years had the highest rate of burn injury. Adults aged > 65 years had the lowest rate. Seven Utah counties were identified as high-risk counties. The counties were predominantly rural and tended to have higher rates of American-Indian populations, increased poverty levels, lower percentages of individuals with high school degrees, and lower employment rates. The characteristics of these high-risk counties do not imply causality, and further research is warranted to determine whether these factors contribute to burn risk. The results of this study provide the foundation for future research and prevention programs targeted toward populations and geographic areas with the greatest risk of burn injury.

Genome-wide Association Study in a High-Risk Isolate for Multiple Sclerosis Reveals Associated Variants in STAT3 Gene

Genetic risk for multiple sclerosis (MS) is thought to involve both common and rare risk alleles. Recent GWAS and subsequent meta-analysis have established the critical role of the HLA locus and identified new common variants associated to MS. These variants have small odds ratios (ORs) and explain only a fraction of the genetic risk. To expose potentially rare, high-impact alleles, we conducted a GWAS of 68 distantly related cases and 136 controls from a high-risk internal isolate of Finland with increased prevalence and familial occurrence of MS. The top 27 loci with p < 10(-4) were tested in 711 cases and 1029 controls from Finland, and the top two findings were validated in 3859 cases and 9110 controls from more heterogeneous populations. SNP (rs744166) within the STAT3 gene was associated to MS (p = 2.75 x 10(-10), OR 0.87, confidence interval 0.83-0.91). The protective haplotype for MS in STAT3 is a risk allele for Crohn disease, implying that STAT3 represents a shared risk locus for at least two autoimmune diseases. This study also demonstrates the potential of special isolated populations in search for variants contributing to complex traits.

Analysis of field survey results for iodine deficiency disorders in high-risk areas of China

Objective To investigate the occurrence of new cretinism cases and the prevalence of endemic goiter, and the reason of lower coverage rate of iodized salt in the iodine deficiency disorders(IDD) high-risk areas of China, so as to put forward target prevention measures for these areas. Methods A hundred and one counties from 11 provinces(autonomous regions, municipality), such as Tibet, Qinghai, Xinjiang, Gansu, Ningxia, Sichuan, Hainan, Chongqing, Yunnan, Guangxi, Inner Mongolia, were chosen into the survey by simple random sampling. In the counties of high risk, typical sampling principle was used. In the selected townships, searching for new cretinism cases were carried out in the children under 10 years old, the thyroid volume of children aged 8-10 years old were determined by B-ultrasonography methods and their urinary iodine (UI) were determined by As3-Ce catalytic spectrophotometry, the intelligence quotient(IQ) values of children aged 8-10 years old were measured by the combined Raven Test in China. In the household survey, the housewives were asked to fill in the questionnaire, the iodized salt coverage rates and the UI levels of child-bearing age women were investigated, the salt iodine content was determined using self-quantitative kit. Epi Info software was used to analyze the determination results. Results In the 101 high-risk counties, 249 were diagnosed as new cretinism cases from 4122 suspected cases searched. The goiter rate of children aged 8-10 years old by B-ultrasound was 8.28% (4434/53 541), 44 counties had goiter rates in the range of 5%-20%, 5 counties had goiter rates in the range of 20%-30%, and 3 counties had goiter rates of 30%. The mean IQ of children was 85.44, and the percentage of IQ value less than 70 was 16.52%(8713/52 745). The median urinary iodine(MUI) of children was 154.69 μg/L, the percentage of UI less than 50 μg/L was 17.26% (9069/52 558). Twenty-five counties had a MUI of children less than 100 μg/L. The MUI of housewives was 107.14 μg/L, the percentage of UI less than 50 μg/L was 27.50% (3722/13 534). MUI of housewives in 46 counties were less than 100.0 μg/L. The coverage rate of iodized salt at household level was 77.85%(13 150/16 891). The coverage rate of iodized salt was 52.80%(1585/3002), 44.72% (631/1411) and 72.82% (1850/2506) in Tibet, Hainan and Qinghai, respectively. More than 10% residents of Tibet, Sichuan, Hainan, Gansu and Qinghai complained that iodized salt was not convenient to buy. There were 71.39%(7652/10 719) of observed people ate crude salt. The average price of crude salt price(0.30-1.20 Yuan/kg) was lower than iodized salt(1.20-3.00 Yuan/kg). Conclusions In these IDD high-risk areas, the risk of endemic goiter and cretinism prevalence is threatening. The IDD monitoring should be carried out successively in these high-risk areas. The prevention measures, increasing iodized salt coverage rate and establishing the sustainable mechanism for eliminating IDD should be strengthened. Emergent iodine fortification measure for high risk region people should be implemented as soon as possible, a long term effective mechanism of eliminating IDD should be established. Key words: Iodine; Deficiency diseases; Goiter, Endemic; Data collection

Ecoepidemiology of Tularemia in the Southcentral United States

We combined county-based data for tularemia incidence from 1990 to 2003 for a nine-state region (Arkansas, Illinois, Indiana, Kansas, Kentucky, Missouri, Nebraska, Oklahoma, and Tennessee) in the southcentral United States with Geographic Information System (GIS)-based environmental data to determine associations between coverage by different habitats (especially dry forest representing suitable tick habitat) and tularemia incidence. High-risk counties (> 1 case per 100,000 person-years) clustered in Arkansas-Missouri and far eastern Oklahoma and Kansas. County tularemia incidence was positively associated with coverage by dry forested habitat suitable for vector ticks for Oklahoma-Kansas-Nebraska and Arkansas-Missouri but not for Illinois-Indiana-Kentucky-Tennessee. A multivariate logistic regression model predicting presence of areas with risk of tularemia based on GIS-derived environmental data was developed for the Arkansas-Missouri tularemia focus. The study shows the potential for research on tularemia ecoepidemiology and highlights the need for further modeling efforts based on acarologic data and more fine-scale point or zip code/census tract epidemiologic data.

Factors Associated with Hurricane Preparedness: Results of a Pre-Hurricane Assessment

Previous studies of hurricane preparedness have generally used indirect measures to ascertain household preparedness, including time intervals between preparation and hurricane landfall and past evacuation. This study sought to directly measure hurricane preparedness by asking residents of a high-risk coastal North Carolina county to report whether their household had an evacuation plan and a disaster supply kit with at least 3 days of food and water for each family member and pet as recommended by the American Red Cross. The survey was conducted six weeks prior to the start of the 2007 Atlantic hurricane season. Past hurricane experience increased the likelihood of a household having a disaster supply kit. However, living in multi-unit housing or a mobile home significantly decreased the likelihood of having a disaster supply kit. Past hurricane experience, past evacuation experience and anticipated evacuation under a mandatory evacuation order were important factors related to a household having an evacuation plan. Residence in a designated flood zone, demographic characteristics of the household, pet ownership, and perceived risk were not significantly related to preparedness. Public health and emergency management officials should work together to determine effective interventions that can improve personal preparedness based on factors other than personal hurricane experience.

Environmental Perceptions Related to Physical Activity in High- and Low-Risk Counties

To identify whether perceptions about the physical activity environment were related to the prevalence of sedentary lifestyle, residents from high-risk (n = 153) or low-risk (n = 100) counties were interviewed. County risk status was determined by the prevalence of cardiovascular mortality, overweight, and sedentary lifestyle. Key public officials in the same counties were also interviewed. Residents in the low-risk county were more likely to report having sidewalks in their community and that these sidewalks were safe and well lit than residents living in the high-risk counties. Low-risk county residents also reported more indoor recreation facilities being available than the residents in the high-risk counties. Residents supported allocating tax dollars toward improving sidewalks, lighting, and so on. Thus a more conducive environment for physical activity was found in the low-risk county. Improving physical environments and individual perceptions could help increase physical activity behavior.

Neonatal tetanus incidence in China, 1996-2001, and risk factors for neonatal tetanus, Guangxi Province, China.

In China during 1995-1996 widespread tetanus toxoid (TT) mass vaccination of women of childbearing age in high-risk areas was conducted and neonatal tetanus (NT) surveillance was initiated as part of NT elimination efforts. Despite a subsequent decrease in the estimated rate of NT, the NT disease burden remains high in poorer areas of China. To describe the recent epidemiology of NT in China and estimate its risk, we analysed national surveillance data in China 1996-2001 and conducted a case-control study in one high-risk county (Bobai): 60 hospitalized cases were sex- and calendar-birth year matched to 60 controls from the same or neighbouring villages. Reported national annual NT incidence decreased from 0.21/1000 live births (LB) in 1997 to 0.16/1000 LB in 2001. Case mothers were more likely to be aged >30 years (odds ratio [OR] = 6; 95% CI: 2.2, 20.2), unschooled (OR = 3.2; 95% CI: 1.1, 11.6), and with an annual income of <1000 yuan ($125 USD) (OR = 6.0; 95% CI: 1.9, 25.6). Only 28% of control mothers and 12% of case mothers reported any TT vaccination. In multivariate analysis, relative to hospital delivery, cases had a 64-fold increased odds of home delivery by a family member or neighbour (95% CI: 8.4, 982.2), and a 13-fold increased odds of home delivery by a traditional birth attendant (95% CI: 1.6, 322.6). Improved access to clean deliveries in high-risk areas is critically needed in China. Nonetheless, targeted TT vaccination appears to have helped reduce NT incidence in China.

Incidence patterns of vivax malaria in civilians residing in a high-risk county of Kyonggi-do (province), Republic of Korea.

The characteristics of vivax malaria epidemics along the demilitarized zone (DMZ) in the Republic of Korea has been established by the early surveillance data. To further characterize the epidemic, data of civilian patients microscopically diagnosed with malaria from 1995 through 2000 were analyzed in Yonchon-gun (county). Malaria incidence was greater in male civilians > 30 years of age (p < 0.05). The annual parasite index was significantly higher in those living in the administrative areas (Myeon) traversed by DMZ than those living in Myons not traversed by DMZ (p < 0.05). Analysis according to the distance (4 to 14 km) from DMZ showed that people living in villages close to DMZ had higher annual parasite indices than those living in villages remote from DMZ (p for trend < 0.05). Civilians living in Myeons with plains and located in northwestern part of the county had higher annual parasite indices than those living in hilly Myeons located in southeastern part of the county (p for trend < 0.05). These findings suggest that the contraction of vivax malaria is related with night-time outdoor activities, and that the distance from DMZ is a risk factor. In this area, the flying distance of infected vector mosquitos can explain the annually repeating occurrence of civilian cases.

The examination of an EBV-DNase gene fragment in the paraffin-embedded NPC, precancerous and from high-risk population nasopharyngeal tissues

To examine if EB virus enters nasopharyngeal epithelial cells in the course of the tumorigenesis in nasopharyngeal carcinoma (NPC). Based on the annual investigation of Si-Hui county, a cancer-prevention base of the Sun Yet-sen University of Medical Sciences and Tumour Hospital outpatient clinic, more than 450 paraffin-embedded tissues with NPC, and with pre-cancerous lesions in high risk populations were collected for the detection of EBV-DNase gene fragment by an optimized PCR method. In 145 of the 149(97.3%) cases with invasive NPC, and 2 of 4 cases with in situ NPC, EBV-DNase gene was detected. However, in Sihui, Canton, a high-risk county for NPC, only 2 of the 155 subjects with nasopharyngeal precancerous state was the gene positive, and none of the 47 cases examined in the out-patient department of the Tumor Hospital with precancerous lesions in the nasopharynx was positive. EBV is seldomly detected in the non-malignant and precancerous lesions in the nasopharynx in high-risk populations. It implies that EBV is probably not etiologically involved in the genesis of NPC.

A cost-of-illness study of lyme disease in the United States

Lyme disease produces a diverse clinical picture that can include serious and potentially debilitating cardiac, neurologic, joint, and skin involvement. It is characterized in three stages—early localized (stage I), early disseminated (stage II), and late disseminated (stage III)—and medical management is highly dependent on the stage at which the patient presents and the physician's awareness of available treatment options. This study was conducted to establish the medical and economic burden of Lyme disease in the overall US population, which included determining its endemicity in high-risk states and counties, describing current treatment patterns, measuring direct and indirect costs, and defining the cost burden by age group (<18 years and ≥18 years of age). Medical, epidemiologic, and economic data were collected, and an algorithm was developed representing the natural course of Lyme disease and the progress of health states over time following medical intervention. Using an annual mean incidence of 4.73 cases of Lyme disease per 100,000 population in the decision analysis model yielded an expected national expenditure of $2.5 billion (1996 dollars) over 5 years for therapeutic interventions to prevent 55,626 cases of Lyme disease sequelae. This estimate included both direct medical and indirect costs. However, there is evidence of considerable variation in incidence within states. Our findings support development of vaccination strategies for specific target groups.

Synthetic cancer variables and the construction and testing of synthetic risk maps.

Cancer cluster investigations are usually univariate in nature; they focus on a particular cancer, such as leukaemia, and attempt to determine whether excess risk is associated with a suspected cancer-causing agent. Although several causes of death (such as leukaemia, lymphoma, Hodgkin's) may be considered, the approach is univariate because the causes of death are analysed sequentially and independently of one another. This approach is consistent with a one-cause one-effect model. Rarely, however, is the action of a carcinogen manifested at only one body site, and correlations among causes of death are the norm rather than the exception. A multiple effects model is therefore appropriate, and the multivariate nature of cancer mortality data should be exploited when exploring geographic pattern in cancer risks. This paper describes such an approach. We construct maps based on a principal components analysis of cancer mortality rates from different geographic areas. The resulting principal components are called synthetic cancer variables (SCVs), and maps of the SCV scores are synthetic risk maps (SRMs). These maps quantify geographic variation in cancer risk at several body sites simultaneously, and may be analysed for (1) spatial structure and (2) geographic association with potential risk factors. As an example, we use synthetic risk maps to determine whether high-risk counties in Illinois cluster near nuclear facilities. Much work remains to be done, but synthetic cancer risk maps appear to be a useful tool for quantifying geographic pattern and multivariate structure in cancer mortality.

Canine exposure to Borrelia burgdorferi and prevalence of Ixodes dammini (Acari: Ixodidae) on deer as a measure of Lyme disease risk in the northeastern United States.

Surveillance programs that identify areas where both the vector (Ixodes dammini) and etiologic agent (Borrelia burgdorferi) are present may identify the risk of Lyme disease and its spread earlier and more accurately than do programs relying on any single method, particularly human case reports. Hunter-killed deer (n = 1,204) from 22 counties in Maryland, Massachusetts, New Hampshire, New York, and Pennsylvania were examined in fall 1989 and all ectoparasites were identified. The following spring, canine sera (n = 884) were obtained from these sites, which included known endemic areas and those where Lyme disease is uncommon, and tested by enzyme-linked immunosorbent assay. Regression analysis of canine seroprevalence versus tick prevalence on deer from the same counties demonstrate a significant positive linear relationship. Sites were designated as low-, moderate-, or high-risk counties based upon their position on the regression curve. The geographic distribution of the sites correlated well with the distribution of known Lyme disease endemic and nonendemic areas. Locations were also identified where Lyme disease may be emerging. The positive relationship between measures of vector and pathogen abundance determined in this study permits public health workers to identify endemic and potentially endemic areas independently of human case reports.

STUDIES ON THE CLUSTERING OF MULTIPLE SCLEROSIS IN FINLAND II: MICROEPIDEMIOLOGY IN ONE HIGH-RISK COUNTY WITH SPECIAL REFERENCE TO FAMILIAL CASES

The epidemiology of multiple sclerosis (MS) was investigated in a small selected area within the western high-risk county of Finland. The investigation was extended to the level of single communes, villages and even houses, together with the search for all familial cases born in this district. The results were compared to those obtained for Helsinki, a city of medium-risk for MS. Prevalences by present domicile that exceeded 100 per 1000,000 inhabitants were recorded in several communes of the western high-risk county. The highest prevalence was 174.2. Seventy patients were born in the small high-risk area. This was 25% of the MS patients born in the whole county and much higher than expected (16%). A positive familial history of another MS patient was recorded in 8 cases (11%). They were all living, first-degree relatives. A similar history was found in only 2 cases (2%) among the 99 MS patients born in Helsinki. The birthplaces of the 123 parents of these 70 MS cases could be confirmed. All villages with high MS frequencies were located along the rivers, running through the area. The birthplaces of the patients showed a similar accumulation to the valleys. No conjugal cases were found. If the preponderance of familial cases in the small high-risk area reflects the role of genetic factors in the aetiology of MS, it is only of polygenic nature. The pronounced clustering of the birthplaces in the small high-risk area and, especially, along the rivers also suggests the importance of environmental influences in early childhood.