Catherine A. Okoro

Intussusception among Infants Given an Oral Rotavirus Vaccine

BACKGROUND Intussusception is a form of intestinal obstruction in which a segment of the bowel prolapses into a more distal segment. Our investigation began on May 27, 1999, after nine cases of infants who had intussusception after receiving the tetravalent rhesus-human reassortant rotavirus vaccine (RRV-TV) were reported to the Vaccine Adverse Event Reporting System. METHODS In 19 states, we assessed the potential association between RRV-TV and intussusception among infants at least 1 but less than 12 months old. Infants hospitalized between November 1, 1998, and June 30, 1999, were identified by systematic reviews of medical and radiologic records. Each infant with intussusception was matched according to age with four healthy control infants who had been born at the same hospital as the infant with intussusception. Information on vaccinations was verified by the provider. RESULTS Data were analyzed for 429 infants with intussusception and 1763 matched controls in a case-control analysis as well as for 432 infants with intussusception in a case-series analysis. Seventy-four of the 429 infants with intussusception (17.2 percent) and 226 of the 1763 controls (12.8 percent) had received RRV-TV (P=0.02). An increased risk of intussusception 3 to 14 days after the first dose of RRV-TV was found in the case-control analysis (adjusted odds ratio, 21.7; 95 percent confidence interval, 9.6 to 48.9). In the case-series analysis, the incidence-rate ratio was 29.4 (95 percent confidence interval, 16.1 to 53.6) for days 3 through 14 after a first dose. There was also an increase in the risk of intussusception after the second dose of the vaccine, but it was smaller than the increase in risk after the first dose. Assuming full implementation of a national program of vaccination with RRV-TV, we estimated that 1 case of intussusception attributable to the vaccine would occur for every 4670 to 9474 infants vaccinated. CONCLUSIONS The strong association between vaccination with RRV-TV and intussusception among otherwise healthy infants supports the existence of a causal relation. Rotavirus vaccines with an improved safety profile are urgently needed.

Influenza vaccination in children with asthma in Health Maintenance Organizations

We assessed vaccination coverage and predictors of influenza vaccination in asthmatic children in four large Health Maintenance Organizations. We studied 68,839 children with asthma at four Health Maintenance Organizations (HMOs) in the 1995-1996 influenza season and 34,032 children at two HMOs in the 1996-1997 influenza season. In both seasons only 9-10% were vaccinated against influenza. Children who were hospitalized, had an emergency department visit for asthma or a prescription for a beta-agonist prior to the influenza season, were more likely to be vaccinated. Overall, 61% of the unvaccinated asthmatic children had made an outpatient clinic visit during months when influenza vaccination would have been appropriate. Vaccination coverage could be increased by taking advantage of all opportunities to vaccinate children with asthma whenever they make clinic visits in the fall and early winter.

A comparison of prevalence estimates for selected health indicators and chronic diseases or conditions from the Behavioral Risk Factor Surveillance System, the National Health Interview Survey, and the National Health and Nutrition Examination Survey, 2007–2008

OBJECTIVE To compare the prevalence estimates of selected health indicators and chronic diseases or conditions among three national health surveys in the United States. METHODS Data from adults aged 18 years or older who participated in the Behavioral Risk Factor Surveillance System (BRFSS) in 2007 and 2008 (n=807,524), the National Health Interview Survey (NHIS) in 2007 and 2008 (n=44,262), and the National Health and Nutrition Examination Survey (NHANES) during 2007 and 2008 (n=5871) were analyzed. RESULTS The prevalence estimates of current smoking, obesity, hypertension, and no health insurance were similar across the three surveys, with absolute differences ranging from 0.7% to 3.9% (relative differences: 2.3% to 20.2%). The prevalence estimate of poor or fair health from BRFSS was similar to that from NHANES, but higher than that from NHIS. The prevalence estimates of diabetes, coronary heart disease, and stroke were similar across the three surveys, with absolute differences ranging from 0.0% to 0.8% (relative differences: 0.2% to 17.1%). CONCLUSION While the BRFSS continues to provide invaluable health information at state and local level, it is reassuring to observe consistency in the prevalence estimates of key health indicators of similar caliber between BRFSS and other national surveys.

The associations among childhood headaches, emotional and behavioral difficulties, and health care use

BACKGROUND. Headaches are common among children and adolescents, particularly migraine and tension-type headaches. They contribute to missed school days, affect childrens peer and family relationships, and significantly impact childrens quality of life, often times into adulthood. OBJECTIVES. This study, based on responses to the Strengths and Difficulties Questionnaire, was designed to examine difficulties and impairments related to emotions, concentration, behavior, and social functioning among children with frequent or severe headaches (FSH). METHODS. We used a cross-sectional study of 9264 children aged 4–17 years from the 2003 National Health Interview Survey, an ongoing, computer-assisted personal interview survey of the noninstitutionalized US population. RESULTS. Approximately 6.7% of children experienced FSH during the previous 12 months. Overall, children with FSH were 3.2 times more likely than children without FSH to have a high level of difficulties and 2.7 times more likely to have a high level of impairment, suggesting potential mental health issues. More specifically, analyses revealed that children with FSH were significantly more likely than those without FSH to exhibit high levels of emotional, conduct, inattention-hyperactivity, and peer problems and were significantly more likely than children without FSH to be upset or distressed by their difficulties and to have their difficulties interfere with home life, friendships, classroom learning, and leisure activities. CONCLUSION. Because children with FSH experience notable pain, mental health issues, and functional limitations, integrated care using a biopsychosocial approach is warranted.

Health-related quality of life, health risk behaviors, and disability among adults with pain-related activity difficulty

OBJECTIVES We examined the association between pain-related activity difficulty (PRAD) in the past 30 days and health-related quality of life, health behaviors, disability indices, and major health impairments in the general US population. METHODS We obtained data from 18 states in the 2002 Behavioral Risk Factor Surveillance System, an ongoing, cross-sectional, state-based, random-digit-dialed telephone survey of noninstitutionalized adults aged 18 years or older. RESULTS Nearly one quarter of people in the 18 states and the District of Columbia reported at least 1 day of PRAD in the past 30 days. PRAD was associated with obesity, smoking, physical inactivity, impaired general health, infrequent vitality, and frequent occurrences of physical distress, mental distress, depressive symptoms, sleep insufficiency, and anxiety symptoms. Moreover, a general dose-response relationship was noted between increased days of PRAD and increased prevalence of impaired health-related quality of life, disability indices, and health risk behaviors. CONCLUSION Pain negatively influences various domains of health, not only among clinical populations, but also in the general community, suggesting a critical need for the dissemination of targeted interventions to enhance recognition and treatment of pain among adult community-dwellers.

The association between depression and anxiety and use of oral health services and tooth loss

OBJECTIVE The purpose of this study is to examine the associations among depression, anxiety, use of oral health services, and tooth loss. METHODS Data were analysed for 80 486 noninstitutionalized adults in 16 states who participated in the 2008 Behavioral Risk Factor Surveillance System. Binomial and multinomial logistic regression analyses were used to estimate predicted marginals, adjusted prevalence ratios, adjusted odds ratios (AOR) and their 95% confidence intervals (CI). RESULTS The unadjusted prevalence for use of oral health services in the past year was 73.1% [standard error (SE), 0.3%]. The unadjusted prevalence by level of tooth loss was 56.1% (SE, 0.4%) for no tooth loss, 29.6% (SE, 0.3%) for 1-5 missing teeth, 9.7% (SE, 0.2%) for 6-31 missing teeth and 4.6% (SE, 0.1%) for total tooth loss. Adults with current depression had a significantly higher prevalence of nonuse of oral health services in the past year than those without this disorder (P < 0.001), after adjustment for age, sex, race/ethnicity, education, marital status, employment status, adverse health behaviours, chronic conditions, body mass index, assistive technology use and perceived social support. In logistic regression analyses employing tooth loss as a dichotomous outcome (0 versus ≥1) and as a nominal outcome (0 versus 1-5, 6-31, or all), adults with depression and anxiety were more likely to have tooth loss. Adults with current depression, lifetime diagnosed depression and lifetime diagnosed anxiety were significantly more likely to have had at least one tooth removed than those without each of these disorders (P < 0.001 for all), after fully adjusting for evaluated confounders (including use of oral health services). The adjusted odds of being in the 1-5 teeth removed, 6-31 teeth removed, or all teeth removed categories versus 0 teeth removed category were increased for adults with current depression versus those without (AOR = 1.35; 95% CI = 1.14-1.59; AOR = 1.83; 95% CI = 1.51-2.22; and AOR = 1.44; 95% CI = 1.11-1.86, respectively). The adjusted odds of being in the 1-5 teeth removed and 6-31 teeth removed categories versus 0 teeth removed category were also increased for adults with lifetime diagnosed depression or anxiety versus those without each of these disorders. CONCLUSIONS Use of oral health services and tooth loss was associated with depression and anxiety after controlling for multiple confounders.

Prevalence of Household Firearms and Firearm-Storage Practices in the 50 States and the District of Columbia: Findings From the Behavioral Risk Factor Surveillance System, 2002

Objectives. To examine the prevalence of household firearms and firearm-storage practices in the 50 states and the District of Columbia and estimate the number of children exposed to unsafe storage practices. Methods. We analyzed data from the 2002 cross-sectional Behavioral Risk Factor Surveillance System survey of 240735 adults from randomly selected households with telephones in the 50 states and the District of Columbia. Results. Nationally, 32.6% of adults reported that firearms were kept in or around their home. The prevalence of adults with household firearms ranged from 5.2% in the District of Columbia to 62.8% in Wyoming (median: 40.8%). The prevalence of adults with loaded household firearms ranged from 1.6% in Hawaii, Massachusetts, and New Jersey to 19.2% in Alabama (median: 7.0%), and the prevalence of adults with loaded and unlocked household firearms ranged from 0.4% in Massachusetts to 12.7% in Alabama (median: 4.2%). Among adults with children and youth <18 years old, the prevalence of loaded household firearms ranged from 1.0% to 13.4% (median: 5.3%), and the prevalence of loaded and unlocked household firearms ranged from 0.3% to 7.3% (median: 2.3%); in each instance, Massachusetts had the lowest prevalence and Alabama had the highest. Findings indicate that ∼1.69 million (95% confidence interval: 1.57–1.82 million) children and youth in the United States <18 years old are living with loaded and unlocked household firearms. Conclusions. Substantial state variations exist in the prevalence of household firearms and firearm-storage practices. It is vital that surveillance systems such as the Behavioral Risk Factor Surveillance System continue to monitor the prevalence of household firearms and firearm-storage practices so that future interventions to promote safe storage of firearms can be evaluated and more widely implemented based on their efficacy.

Gender Differences in Coronary Heart Disease and Health-Related Quality of Life: Findings from 10 States from the 2004 Behavioral Risk Factor Surveillance System

BACKGROUND Our objective was to examine differences in health-related quality of life (HRQOL) between people with coronary heart disease (CHD) and those without this condition in a population-based sample of U.S. adults and to examine the interaction between CHD and diabetes on HRQOL. METHODS AND RESULTS We performed a cross-sectional analysis of data from 50,573 participants aged >or=18 years from 10 states of the 2004 Behavioral Risk Factor Surveillance System (BRFSS). Data were self-reported. HRQOL was assessed with the Centers for Disease Control and Prevention (CDC) HRQOL-4 measures. After adjusting for age, gender, race or ethnicity, educational status, marital status, employment status, smoking status, body mass index (BMI), and alcohol use, the percentages of women without CHD who, during the previous 30 days, reported experiencing >or=14 physically unhealthy days, >or=14 mentally unhealthy days, and >or=14 activity-limitation days were 7.5%, 10.4%, and 3.6%, respectively, compared with 16.5% (odds ratio [OR] = 2.49, 95% confidence interval [CI] 2.02, 3.07), 14.5% (OR = 1.58, 95%, CI 1.22, 2.04), and 8.4% (OR = 2.56, 95% CI 1.98, 3.30) for women with CHD. The adjusted percentages of men without CHD who reported experiencing >or=14 physically unhealthy days, >or=14 mentally unhealthy days, and >or=14 activity-limitation days were 5.6%, 6.0%, and 3.0%, respectively, compared with 10.1% (OR = 1.85, 95% CI 1.47, 2.32), 8.7% (OR = 1.32, 95% CI 1.00, 1.74), and 6.4% (OR = 1.99, 95% CI 1.49, 2.66) for men with CHD. A higher adjusted percentage of women with CHD reported experiencing >or=14 physically unhealthy days (p < 0.001) and >or=14 mentally unhealthy days (p = 0.002) but not >or=14 activity-limitation days (p = 0.090) than men with CHD. CONCLUSIONS People with CHD have significantly impaired HRQOL compared with those without CHD. HRQOL among women with CHD is worse than that among men with CHD.

Geographic and sociodemographic variation in self-reported seat belt use in the United States

BACKGROUND With new data available, we sought to update existing literature on the prevalence of self-reported seat belt use by state, region, and rural/urban status and to estimate the strength of the association between seat belt use and rural/urban status adjusted for type of seat belt law and several other factors. METHODS We examined data on self-reported use of seat belts from 50 states, the District of Columbia, and three territories using the 2008 Behavioral Risk Factor Surveillance System, a state-based random-digit-dialed telephone survey (n=406,552). Reported seat belt use was assessed by state, U.S. Census regions, and U.S. Department of Agriculture (USDA) rural/urban continuum codes. RESULTS Overall, 85% of adults in the United States reported they always used seat belts. Regionally, the West had the highest prevalence of persons who reported that they always wear seat belts (89.6%) and the Midwest had the lowest (80.4%). States with primary seat belt laws had the highest prevalence of reported seat belt use, compared with states with secondary or no laws. After adjusting for various sociodemographic characteristics, body mass index, and type of seat belt law, persons in the most densely populated metropolitan areas were significantly more likely to report always wearing seat belts than those in most sparsely populated rural areas (adjusted odds ratio=2.9). CONCLUSION Our findings reinforce the evidence that primary enforcement seat belt laws are effective for increasing seat belt use, and suggest that upgrading to primary enforcement laws will be an important strategy for reducing crash-related fatalities in rural areas.

Leisure-time aerobic physical activity, muscle-strengthening activity and mortality risks among US adults: the NHANES linked mortality study.

Background Regular physical activity elicits multiple health benefits in the prevention and management of chronic diseases. We examined the mortality risks associated with levels of leisure-time aerobic physical activity and muscle-strengthening activity based on the 2008 Physical Activity Guidelines for Americans among US adults. Methods We analysed data from the 1999 to 2004 National Health and Nutrition Examination Survey with linked mortality data obtained through 2006. Cox proportional HRs with 95% CIs were estimated to assess risks for all-causes and cardiovascular disease (CVD) mortality associated with aerobic physical activity and muscle-strengthening activity. Results Of 10 535 participants, 665 died (233 deaths from CVD) during an average of 4.8-year follow-up. Compared with participants who were physically inactive, the adjusted HR for all-cause mortality was 0.64 (95% CI 0.52 to 0.79) among those who were physically active (engaging in ≥150 min/week of the equivalent moderate-intensity physical activity) and 0.72 (95% CI 0.54 to 0.97) among those who were insufficiently active (engaging in >0 to <150 min/week of the equivalent moderate-intensity physical activity). The adjusted HR for CVD mortality was 0.57 (95% CI 0.34 to 0.97) among participants who were insufficiently active and 0.69 (95% CI 0.43 to 1.12) among those who were physically active. Among adults who were insufficiently active, the adjusted HR for all-cause mortality was 44% lower by engaging in muscle-strengthening activity ≥2 times/week. Conclusions Engaging in aerobic physical activity ranging from insufficient activity to meeting the 2008 Guidelines reduces the risk of premature mortality among US adults. Engaging in muscle-strengthening activity ≥2 times/week may provide additional benefits among insufficiently active adults.