|| Depression Trajectories in Bereaved Caregivers of Elders with Dementia
|| Influenza Surveillance: Linking Public Health and Clinical Medicine
||Effects of Nutritional Status on Diarrhea in Peruvian Children
||Remote Sensing and GIS as Decision-Making Tools for Control of Malaria in the Republic of Korea
||Impact of Hepatitis C Virus Infection Among Persons with Hemophilia in New York State
||When Ethics and Managed Care Collide: The Right of Patients to Informed Consent
||Cost-effectiveness Evaluation of Syphilis Screening Among Women at Cook County Jail (Chicago, IL)
||Stage Specific Toxicity and Hormetic Effects Induced by Cadmium in the Black Blowfly Phormia regina
||A Case-Control Study Evaluating the Association Between Infant Mortality and Mothers' Participation in Medicaid, WIC and Food Stamps Program During Pregnancy in Missouri During 1989-1997
||Migration Status of U.S.-born Women: What Difference Does it Make in Pregnancy Outcomes?
Depression Trajectories in Bereaved Caregivers of Elders with Dementia
Amanda L. Botticello, University of California at Los Angeles
The emotional cost of caregiving by family members for cognitively impaired elders is one of increasing interest in light of the aging US population. Few studies have examined the fate of these individuals when their caregiving responsibilities cease with the death of their relative. The data used for this analysis were part of a 6-year longitudinal study of caregivers for relatives with dementia. The sample consisted of a subgroup of caregivers who became bereaved over the course of the study (n=291) and participated in post-bereavement interviews up to five years after the death of their relative. A semi-parametric, group-based method using a latent class mixture model yielded four distinctive pathways of depression following bereavement among this sample. Two paths emerged indicating a low level of depression that remained stable over time; in contrast, one trajectory indicated a high level of depression that decreased, while a fourth indicated that moderate symptoms of depression increased for some caregivers over time. Preliminary analyses of covariates of these depression trajectories have implicated several select caregiver characteristics and expressions of related depressive symptomatology in these trajectories. In particular, gender, caregiver type (spouse or adult child), age, and socioeconomic status (employment, income and years of education) have been identified as prospective factors related to the depression trajectories as well as selected expressions of grieving related to loss of the relative. These findings have implications for identifying the both risk and protective factors related to course of depression following prolonged caregiving activities and subsequent disengagement from the caregiver role.
Influenza Surveillance: Linking Public Health and Clinical Medicine
Mary Bragg , Utah University
Other Authors: Laurie Johnson and Steve Alder
Often there is little linkage between public health surveillance systems and primary care practices.Current public health surveillance systems do not provide rapid identification of viral epidemics to providers. A typical system uses school absenteeism, sentinel practices, and laboratory data.This is less effective because the epidemic detection takes place weeks after the actual occurrence.
During the 2000-2001 influenza season, we teamed with the Utah Department of Health (UDOH), Bureau of Epidemiology and Laboratory Services, to test a new influenza surveillance system.The approach uses Statistical Process Control (SPC), a simple technique for detecting non-random variation in routine events such as clinic visits. We tracked increases in daily patient visits at urgent care, outpatient clinics, and emergency rooms, to signal the onset of a respiratory epidemic. Once a signal is detected through SPC, a sample of clinic patients with respiratory infection symptoms is cultured. Cultures are sent to UDOH, Infectious Disease Laboratory where they are tested for influenza or other respiratory pathogens. Patient loads, laboratory results, and UDOH influenza surveillance are used to characterize the status of influenza in Utah . Results from individual cultures are returned to the submitting clinician.
Early intervention reduces the health impact of infectious agents and exposures.With increasing availability of electronic means for gathering surveillance data from urgent care, outpatient clinics, and emergency rooms, improved detection of disease outbreaks and epidemics is possible.Developing stronger links between public health and clinical medicine provides a synergy to improve health, both at the population and individual level.
Effects of Nutritional Status on Diarrhea in Peruvian Children
William Checkley, Johns Hopkins University
We conducted a four-year (1995-1998) field study in a Peruvian peri-urban community (pueblo joven) to examine the relationship between diarrheal diseases and nutritional status in 230 children less than three years of age. We followed the birth cohort daily for diarrhea and monthly for anthropometry. We modeled diarrheal incidence with a time-to-event regression model that accounted for multiple episodes per child and irregular follow-up periods, and diarrheal duration with a mixed-effects gamma regression model. During 159,551 child-days of follow-up, we identified 1,387 episodes of diarrhea. Mean diarrheal incidence was 3.2 episodes per child-year, however, infants suffered up to 8 diarrheal episodes during the summer. This effect of seasonal variation on diarrheal incidence decreased noticeably with age. Changes in nutritional status were significantly associated with diarrheal incidence. The frequency of diarrhea increased by 12 percent per standard deviation decrease in height-for-age Z-score and five percent per standard deviation decrease in weight-for-height Z-score. Diarrheal episodes in children less than six months of age were also significantly longer lasting than episodes among older children. These results identify infants and children of poor nutritional status as priority risk groups for prevention efforts aimed at reducing the burden of acute childhood diarrhea.
Remote Sensing and GIS as Decision-Making Tools for Control of Malaria in the Republic of Korea
David M. Claborn, Uniformed Services University of Health Sciences
Remote sensing and geographic information systems (GIS) were used to compare the cost of mosquito larviciding to that of chemoprophylaxis for the control of re-emerging malaria on two U.S. Army camps in South Korea . Larval surveillance showed that the primary vector, Anopheles sinensis , occurred in equal densities (p > 0.10) in rice paddies, ditches, ponds and swamps during most of the growing season. Remotely-sensed images were used to identify digitally the location and size of vector habitats within the flight range of the vector around the camps. Ground-truthing and a 1-meter resolution image were used to validate a 30-meter resolution Landsat image used for all comparisons. Cost of larvicidal treatment was based on the cost per unit area (including fuel, labor, equipment and supplies) and the size of the vector's larval habitat as determined remotely. Chemoprophylaxis cost was estimated based on the current cost of primaquine and chloroquine, a 19-week transmission season, and the size of the at-risk population. Our results showed that on one camp, 29 insecticide applications could be applied for the cost of providing chemoprophylaxis; whereas, on the other, the cost of the requisite three applications was more than the cost of chemoprophylaxis.
Remote sensing and GIS allow the user to extrapolate local mosquito surveillance data to a regional scale, thus providing cost comparisons for multiple human population centers that would not otherwise be surveyed. Such comparisons allow the choice of appropriate malaria control measures for local conditions while minimizing expense and labor.
Impact of Hepatitis C Virus Infection Among Persons with Hemophilia in New York State
Ping Du, University at Albany SUNY
Other Authors: Louise-Anne McNutt, Jeanne V. Linden, Marcia H. Kolakoski and Jennifer E. Lima
Hepatitis C virus (HCV) infection is common among persons with hemophilia (PWH). PWH having unknown HCV status are rarely studied. We want to assess the impact of HCV infection on health outcomes among PWH in New York State (NYS). From January 1, 1993, to December 31, 1997, a cohort of PWH was enrolled into a population-based study in NYS. Medical record reviews were performed annually to collect information. HCV infection status was grouped into four categories according to HCV antibody test results and risk profiles for HCV infection: Yes, No, Unknown-high risk for HCV infection (e.g., high demand of blood product usage and age), and Unknown-low risk for HCV infection. Health outcomes included death, hospitalization for infection and liver disease.
A total of 1360 PWH were followed for a median of 5 years. HCV prevalence was 62% among PWH having documented HCV tests. Liver disease was the fourth leading cause of death. Compared with those without HCV infection, HCV unknown-high risk PWH had an increased risk of death with rate ratio of 2.0 (95% confidence interval: 1.1-4.0). However, persons with HCV infection did not have higher risk of death. HCV infection was associated with hospitalization for infection. Hospitalization for liver disease was slightly increasing over the study period. HCV infection had an impact on morbidity and mortality for PWH, and liver disease would be increasing with lengthening follow-up time. HCV unknown-high risk PWH could have the greatest potential for adverse outcomes, and should be further studied.
When Ethics and Managed Care Collide: The Right of Patients to Informed Consent
Katherine H. Leith, University of South Carolina
The American health care system is undergoing drastic changes, most notably the advent and subsequent expansion of managed care organizations.Health care professionals agree that the process of merging managed care and health care delivery, two potentially conflicting systems, has resulted in a number of ethical conflicts.To some degree, such ethical conflicts are rooted in the structure of today's managed care environment itself.This environment is primarily driven by for-profit and investor-owned entities, and too often, fiscal constraints and cost cutting can create ethical problems.
One particularly troubling development is the unintentional withholding of relevant information patients would need to make competent and independent choices about their medical treatment.Considered a fundamental right, the doctrine of informed consent requires health care providers to disclose to their patients the nature of procedures to be performed and the attendant risks, benefits, and alternatives. This presentation explores the ethical ramifications inherent in the right of patients to informed consent.It identifies two fundamental concepts that establish the basis for informed consent: the fiduciary relationship between provider and patient, incorporating honesty, trust, and mutual respect, and patient autonomy, or the patient's right to self-determination. Preconditions for informed consent (i.e., voluntariness, elements of disclosure, and competence or understanding) are discussed.Recommendations for creating an “ethically aware” managed care environment that encourages the delivery of high quality health services while preventing the erosion of informed consent in the name of efficiency are reviewed.
Cost-effectiveness Evaluation of Syphilis Screening Among Women at Cook County Jail (Chicago, IL)
Anne McIntyre, University of Illinois at Chicago
Other Authors: Heidi Beidinger, Julie Kraut and Kathleen Irwin
To evaluate the cost effectiveness of a pilot rapid syphilis screening program and the routine screening program for women at Cook County Jail. The number of new syphilis cases detected and treated through a pilot rapid screening program implemented during high volume processing hours were compared to those detected and treated through the routine program (all other hours) for one month in 2000. Costs for each screening program were compared using a decision analysis model. Material and overhead costs were assigned to the two screening programs. Labor costs for each screening program activity were estimated using a “time-in-motion” study conducted for the same month.
From March 7-April 3, 2000, 553 women were screened through the rapid program and 690 through the routine program. The rapid screening program detected 7 (13.2%) new cases and the routine program detected 11 (28.2%) new cases. The cost per new case detected through rapid screening was similar to the routine screening program ($304 and $341, respectively). Treatment rates prior to release were higher for the rapid program (4/7, 57%) than the routine program (4/11, 36%).
The cost to detect new cases for the two screening programs were similar. However, a greater proportion of women were treated prior to release through the rapid program. The cost of locating a woman after release from custody is high and the preliminary results indicate that the rapid screening program may be more cost-effective than the routine program.
Stage Specific Toxicity and Hormetic Effects Induced by Cadmium in the Black Blowfly Phormia regina
Marc A. Nascarella, University of Massachusetts
Other Authors: John G. Stoffolano, Jr. and Edward J. Calabrese
The primary goal of this research is to evaluate possible hormetic responses within an established insect model extensively used in developmental, nutritional, and gerontological investigations. An additional goal is to assess the existence of differential susceptibility to cadmium chloride with respect to developmental stage. This study will assess whether cadmium chloride exposure via larval feeding to Phormia regina (Blowfly)alters the developmental processes as measured by changes in larval, pupal, and adult survival compared to concurrent vehicle controls. If hormesis can be consistently replicated in this model, it will provide a relatively inexpensive, and efficient model to assess this phenomenon, with a future goal of elucidating the mechanistic underpinnings by which organisms may adapt to low levels of environmental toxicants. The stage specific susceptibility in the uptake of heavy metals may be relevant for bioavailibility studies, and may also produce useful information for conducting ecological risk assessments of environmental stressor agents. This study suggests that the blowfly larval exposure model reveal a developmental stage specific susceptibility to cadmium chloride, as well as hormetic effects with respect to larvae to emerge as pupae.
A Case-Control Study Evaluating the Association between Infant Mortality and Mothers' Participation in Medicaid, WIC and Food Stamps Program During Pregnancy in Missouri during 1989-1997
Jeya Sophia Yogaraj, Saint Louis University
Other Authors: Clay Gemmill, Louise Flick and Belinda Ireland
This study evaluated whether mothers who were enrolled in Medicaid, Special Supplemental Nutrition Program for Women, Infants and Children(WIC) and Food Stamps program during pregnancy experienced different infant mortality risks when compared to mothers who did not participate in any of these programs.
4678 infant mortality cases and 4839 controls were selected for this population-based case-control study using linked infant birth and death certificates of Missouri residents between 1989 and 1997. Association between infant mortality and government program participation was estimated using a logistic regression model.
WIC only, Medicaid only or WIC+Medicaid participants had infant mortality risks similar to non-government program participants. Mothers who participated in Food Stamps only[adjusted odds ratio(aOR)=1.4, 95% confidence interval(CI)=0.8-2.6], Food Stamps+Medicaid(aOR=2.0,CI=1.5-2.6), Food Stamps+WIC(aOR=1.7,CI=1.0-3.0), or all three government programs(aOR=1.7,CI=1.4-2.0) had higher infant mortality risks. Mother's race, education level, marital status, and inadequate prenatal care were identified as confounders. Mothers with less than 12 years of education(aOR=1.2,CI=1.1-1.4) and inadequate prenatal care(aOR=1.7,CI=1.5-1.9) had higher infant mortality risks. Conversely, white mothers(aOR=0.8,CI=0.7-0.9) and mothers married to infants' fathers(aOR=0.8,CI=0.7-0.9) had lower infant mortality risks.
WIC and/or Medicaid enrollment should be considered beneficial for low-income women since these program participants have infant mortality rates similar to those in the reference group. Food Stamps mothers, regardless of their enrollment in WIC or Medicaid, were more likely to have a child that died within the first year of life. Larger studies are needed to confirm the trends seen in this study.
Migration Status of U.S.-born Women: What Difference Does it Make in Pregnancy Outcomes?
Pattie J. Tucker, University of Alabama at Birmingham
The healthy-migrant-effect, suggest that migration has selected out healthier individuals. Few if any, published studies have examined the impact of this effect on pregnancy outcomes of non-Hispanic African American and white women.
This study hypothesizes that U.S.-born women who migrate to a region or a state different from their state of birth are at lower risk for adverse pregnancy outcomes compared to non migrant women.
The National Center for Health Statistics cohort linked birth/death 1995-1997 data files containing U.S. born non-Hispanic African American and non-Hispanic white women who delivered singleton live births in the southern region were used. Women were assigned to a migration group: non migrants, born in the south and delivered in the south; inter region migrants, born in the south and delivered in other southern state; southern region migrants, born in a non southern state and delivered in the south. The multiple logistic regression model was used to determine how and to what extent maternal migration status is related to the probability of adverse pregnancy outcomes.
Southern region migrants were found to have favorable sociodemographic characteristics and received adequate prenatal care compared to non migrants. Lower adverse pregnancy outcomes were observed among southern region migrants compared to non migrants.
These study results support the premise that migration is a selective process for U.S.-born women that move to and within the U.S. southern region. Further research is needed to better understand the complexity of migration patterns and the selectivity process of U.S.-born populations.