Hazel D. Dean

Mycobacterium chelonae causing otitis media in an ear-nose-and throat practice

Seventeen cases of otitis media caused by Mycobacterium chelonae were detected among patients seen at a single ear-nose-and-throat (ENT) office (Office A) in Louisiana between May 5 and September 15, 1987. All the patients had a tympanotomy tube or tubes in place or had one or more tympanic-membrane perforations, with chronic otorrhea that was unresponsive to standard therapy with antimicrobial agents. Middle-ear exploration in six patients revealed abundant granulation tissue; multiple granulomas and acid-fast bacilli were demonstrated on a section of tissue from one patient with a nonhealing mastoidectomy incision. Thirteen of the 14 ear isolates obtained from patients seen in Office A had the same unusual pattern of high-level resistance to aminoglycosides. M. chelonae and other nontuberculous mycobacteria were recovered from several sources of water in Office A, as well as in another ENT office (Office B) in a neighboring city that was visited by the index patient. Only one additional case was detected in Office B during the same period. Otologic instruments in Office A were cleaned in an ultrasonic bath with tap water and a liquid detergent; the contents of the bath were changed only once weekly. Instruments in Office B were placed in boiling water between patient examinations. This outbreak establishes M. chelonae as an agent of otitis media and underscores the need for high-level disinfection or sterilization of ENT instruments between examinations to prevent the transmission of this organism to patients in the office setting.

Addressing Social Determinants of Health in the Prevention and Control of HIV/AIDS, Viral Hepatitis, Sexually Transmitted Infections, and Tuberculosis

This special issue of Public Health Reports (PHR) focuses on innovations and advances in incorporating a social-determinants-of-health (SDH) framework for addressing the interrelated epidemics of human immunodeficiency virus (HIV), viral hepatitis, sexually transmitted infections (STIs), and tuberculosis (TB) in the United States and globally. This focus is particularly timely given the evidence of increasing burden and worsening health disparities for these conditions, the evolution in our understanding of the social and structural influences on disease epidemiology, and the far-reaching implications of the global economic downturn. The global trends and adverse health impact of HIV, viral hepatitis, STIs, and TB remain among the major and urgent public health challenges of our time.1 These conditions account for substantial morbidity and mortality, with devastating fiscal and emotional costs to individuals, families, and societies. Despite decades of investment and support, the U.S. still experiences a disproportionate burden of these conditions compared with other Western industrialized nations, with substantial health disparities being observed across population subgroups and geographic regions.2 The reasons for these inequities are multifaceted and complex. It is true that individual-level determinants, including high-risk behaviors such as unsafe sexual and drug-injecting practices, are major drivers of disease transmission and acquisition risk. However, it is also clear that the patterns and distribution of these infectious diseases in the population are further influenced by a dynamic interplay among the prevalence of the infectious agent, the effectiveness of preventive and control interventions, and a range of social and structural environmental factors.3,4 Many of these conditions arise because of the circumstances in which people grow, live, work, socialize, and form relationships, and because of the systems put in place to deal with illness, all of which are, in turn, shaped by political, social, and economic forces. Understanding the multilevel and overlapping nature of these epidemics, and their social and structural determinants, is key to designing and implementing more effective prevention programs.5 Individual risk behaviors influence the probability of contact with other infected or infectious individuals. However, these behaviors do not occur in a vacuum. With respect to STIs, an individuals sexual risk behavior occurs within the context of a sexual partnership or partnerships, which are, in turn, located within a wider sexual network. For other infectious diseases, including TB, the built or physical environment can influence patterns and opportunities for interpersonal contact, social mixing, and probability of onward transmission of the infectious agent.6 These more proximal determinants of transmission risk also occur within the context of wider social and structural determinants.7,8 Structural factors include those physical, social, cultural, organizational, community, economic, legal, or policy aspects of the environment that impede or facilitate efforts to avoid disease transmission. Social factors include the economic and social conditions that influence the health of people and communities as a whole, and include conditions for early childhood development, education, employment, income and job security, food security, health services, and access to services, housing, social exclusion, and stigma. Our understanding of the connections between these determinants, and their relative importance to each other, has evolved over time. Earlier models for infectious disease transmission highlighted the primacy of the interactions among the individual, the infectious agent, and the environment, with infectious disease prevention and control programs being focused predominantly on targeting interventions toward the individual—e.g., individual-level counseling, testing, screening, and treatment interventions. Thus, HIV prevention has been dominated by individual-level behavioral interventions that seek to influence knowledge, attitudes, and behaviors, such as promotion of condom use, education about sexual health, and education of injecting drug users about the dangers of sharing equipment.4 While there has been some success with this approach, public health programs have failed to achieve sustained reductions in incidence or achieve elimination of these conditions and their associated inequities. There is also a growing appreciation that although some individually oriented interventions have shown results in reducing risk behavior, their success is substantially improved when HIV prevention addresses the broader structural factors that shape or constrain individual behavior, such as poverty and wealth, gender, age, policy, and power.9 The growing recognition of the social and structural barriers to prevention and control efforts for HIV, viral hepatitis, STIs, and TB have allowed prevention experts to employ more comprehensive approaches to their interventions. Such structural approaches include actions implemented as single policies or programs that aim to change the conditions in which people live, multiple structural actions of this type implemented simultaneously, or community processes that catalyze social and political change (e.g., social mobilization to oppose a harmful traditional practice). They also include policy or legal interventions (e.g., legal actions to combat or reform a discriminatory practice), interventions to influence the way services are delivered through promoting collaboration and integration,10 contingent funding, and economic and educational interventions.11 These approaches can be applied in combination with behavioral or medical interventions targeted at individuals, and aim to address factors affecting individual behavior, rather than targeting the behavior itself. It is within this context that this special issue of PHR has been brought together to reflect upon the influences, opportunities, and impact of SDH on the transmission of HIV, viral hepatitis, STIs, and TB. Major strategic priorities for the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) at the Centers for Disease Control and Prevention (CDC)12 are promoting health equity and reducing health disparities through adopting a social-determinants approach to our prevention activities. NCHHSTP also intends to place more emphasis on structural and contextual determinants of health, particularly health policy and legislation, economic and social interventions, and cross-sectoral collaboration.

Social Determinants of HIV/AIDS and Sexually Transmitted Diseases Among Black Women: Implications for Health Equity

Recent epidemiologic reports show that black women are at risk for HIV infection and other sexually transmitted diseases (STDs). In this report, we go beyond race and consider a number of social and economic trends that have changed the way many black women experience life. We discuss poverty, loss of status and support linked to declining marriage participation, and female-headed single-parent household structure-all of which influence sexual risks. We also discuss the Centers for Disease Control and Prevention-led national efforts to advance consideration of social determinants of health (SDH) and promotion of health equity in public health activities that may have impact on black and other women.

Epidemiologic Differences Between Native-Born and Foreign-Born Black People Diagnosed with HIV Infection in 33 U.S. States, 2001-2007

Objective. Few studies have examined the extent to which foreign-born people contribute to the human immunodeficiency virus (HIV) epidemic among non-Hispanic black people in the U.S. We sought to determine differences in the epidemiology of HIV infection among native- and foreign-born black people, using data from the national HIV surveillance system of the Centers for Disease Control and Prevention. Methods. We estimated the number of HIV infections among black adults and adolescents diagnosed from 2001 to 2007 in 33 U.S. states. We compared annual HIV diagnosis rates, distributions of demographic characteristics and HIV-transmission risk factors, late diagnoses of HIV infection, and survival after an acquired immunodeficiency syndrome (AIDS) diagnosis for native- and foreign-born black people. Results. From 2001 to 2007, an estimated 100,013 black adults and adolescents were diagnosed with HIV infection in 33 U.S. states, for which country-of-birth information was available. Of these, 11.7% were foreign-born, with most from the Caribbean (54.1%) and Africa (41.5%). Annual HIV diagnoses decreased by 5.5% per year (95% confidence interval [CI] −5.9, −5.0) among native-born black people. Decreases were small among foreign-born black people (–1.3%; 95% CI −2.6, −0.1), who were more likely to be female, have HIV infection attributable to high-risk heterosexual contact, be diagnosed with AIDS within 12 months of HIV diagnosis, and survive one year and three years after an AIDS diagnosis. Conclusions. The epidemiology of HIV infection differs for foreign-born black individuals compared with their native-born counterparts in the U.S. These data can be used to develop culturally appropriate and relevant HIV-prevention interventions.

Identifying the Impact of Social Determinants of Health on Disease Rates Using Correlation Analysis of Area-Based Summary Information

Objectives. We developed a statistical tool that brings together standard, accessible, and well-understood analytic approaches and uses area-based information and other publicly available data to identify social determinants of health (SDH) that significantly affect the morbidity of a specific disease. Methods. We specified AIDS as the disease of interest and used data from the American Community Survey and the National HIV Surveillance System. Morbidity and socioeconomic variables in the two data systems were linked through geographic areas that can be identified in both systems. Correlation and partial correlation coefficients were used to measure the impact of socioeconomic factors on AIDS diagnosis rates in certain geographic areas. Results. We developed an easily explained approach that can be used by a data analyst with access to publicly available datasets and standard statistical software to identify the impact of SDH. We found that the AIDS diagnosis rate was highly correlated with the distribution of race/ethnicity, population density, and marital status in an area. The impact of poverty, education level, and unemployment depended on other SDH variables. Conclusions. Area-based measures of socioeconomic variables can be used to identify risk factors associated with a disease of interest. When correlation analysis is used to identify risk factors, potential confounding from other variables must be taken into account.

Collection of social determinant of health measures in U.S. national surveillance systems for HIV, viral hepatitis, STDs, and TB.

Challenges exist in the study of social determinants of health (SDH) because of limited comparability of population-based U.S. data on SDH. This limitation is due to differences in disparity or equity measurements, as well as general data quality and availability. We reviewed the current SDH variables collected for HIV, viral hepatitis, sexually transmitted diseases, and tuberculosis at the Centers for Disease Control and Prevention through its population-based surveillance systems and assessed specific system attributes. Results were used to provide recommendations for a core set of SDH variables to collect that are both feasible and useful. We also conducted an environmental literature scan to determine the status of knowledge of SDH as underlying causes of disease and to inform the recommended core set of SDH variables.

Summary of CDC Consultation to Address Social Determinants of Health for Prevention of Disparities in HIV/AIDS, Viral Hepatitis, Sexually Transmitted Diseases, and Tuberculosis

In December 2008, the Centers for Disease Control and Prevention (CDC) convened a meeting of national public health partners to identify priorities for addressing social determinants of human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS), viral hepatitis, sexually transmitted diseases (STDs), and tuberculosis (TB). The consultants were divided into four working groups: (7) public health policy, (2) data systems, (3) agency partnerships and prevention capacity building, and (4) prevention research and evaluation. Groups focused on identifying top priorities; describing activities, methods, and metrics to implement priorities; and identifying partnerships and resources required to implement priorities. The meeting resulted in priorities for public health policy, improving data collection methods, enhancing existing and expanding future partnerships, and improving selection criteria and evaluation of evidence-based interventions. CDC is developing a national communications plan to guide and inspire action for keeping social determinants of HIV/AIDS, viral hepatitis, STDs, and TB in the forefront of public health activities.

AIDS Cases Among Women Who Reported Sex with a Bisexual Man, 2000-2004–United States

ABSTRACT Introduction: Some HIV-infected men who have sex with men also have sex with women. Additionally, some women do not know that they are or have been in a sexual relationship with a bisexual man. Knowledge of their male partners risks for HIV infection is crucial if reductions in HIV/AIDS are to occur among women. Methods: We examined AIDS diagnosed cases reported to CDC from the 50 states and the District of Columbia, 2000 through 2004, in women aged 13 years and older. Cases were analyzed by transmission category, race/ethnicity, age at diagnosis, and geographic region, and data were adjusted for missing risk factor information and reporting delays. Results: From 2000 through 2004, an estimated 1,576 women (from a total of 35,376 women reported with HIV from heterosexual contact and diagnosed with AIDS) reported sexual contact with a bisexual man (BSXM) as their primary risk factor for HIV infection. Non-Hispanic blacks accounted for the majority (62.8%) of cases, followed by non-Hispanic whites (20.5%) and Hispanics (14.8%). The average AIDS rate attributed to sex with a BSXM differed significantly by race/ethnicity (p < 0.01), with the rate for non-Hispanic black women 13 times the rate for non-Hispanic whites and 4 times the rate for Hispanics. Sexual contact with a BSXM accounted for 6.3% of AIDS cases among non-Hispanic white women with heterosexually acquired HIV compared to 4.4% among Hispanics and 4.0% among non-Hispanic blacks. Conclusions: The proportion of AIDS cases among women attributed to sex with a BSXM was similar across races/ethnicities; however, rates were highest among non-Hispanic black women. Because some women were unaware of their male partners risk for HIV infection, the number of women with AIDS who had a bisexual partner was probably under-reported. HIV prevention programs should provide information on risks of sex with BSXM, as many women may not be fully aware of their risks for acquiring HIV infection.

Use of Data Systems to Address Social Determinants of Health: A Need to Do More

This supplement to Public Health Reports (PHR) focuses on data systems and their use in addressing social determinants of health (SDH). This particular topic requires attention now given the evidence of increasing burden and worsening inequities in some health outcomes, in spite of decades of work to change individual behaviors, as well as the need to be efficient in our use of existing data. A holistic approach to disease prevention is urgently needed to reduce the inequities that have been perpetuated in our society for so long. Despite concerted, targeted, and coordinated efforts to reduce inequities in health outcomes, gross inequities still exist,1–4 and some evidence indicates that the gap between the best health outcomes and the worst health outcomes is growing.1,3–5 Well-meaning efforts have substantially focused on individual-related behavior changes, with less focus on wider social and structural determinants of health, which can be defined as follows:6,7 Structural factors include those physical, social, cultural, organizational, community, economic, legal, or policy aspects of the environment that impede or facilitate efforts to avoid disease transmission. Social factors include the economic and social conditions that influence the health of people and communities as a whole, and include the conditions for early childhood development, education, employment, income and job security, food security, health services, and access to services, housing, social exclusion, and stigma.8 In addition to addressing individual factors, there is an urgent need to address social and structural factors and to better understand their relationship to each other as we develop effective programs and policies to reduce inequities. A holistic approach to disease prevention involves not only addressing individual, social, structural, and environmental determinants, but also working with a wide array of sectors, such as health, education, justice, environment, and labor. Additionally, it means working with diverse kinds of data, including disease surveillance, legal, land use, marketing, workforce, education, and financial. Making the best use of a wide variety of data at the individual, neighborhood, community, and county levels, for example, can provide a more complete description of the underlying factors that may influence health outcomes than using disease surveillance data alone. As a matter of fact, using disease surveillance data alone, which often are limited to variables such as disease of interest, age, sex or gender, and race/ethnicity, can be stigmatizing and only tells part of the story. Public health professionals have an obligation to fairly and accurately describe disease occurrence in populations. As a result, we should be compelled to use data from available sources to provide a complete picture of the environment in which the disease occurs and any underlying factors contributing to its occurrence. Addressing underlying factors of health has been advocated by many health practitioners for decades.1,9–12 The Institute of Medicine Committee on Public Health Strategies to Improve Health released a report in 2010 that recommended gathering, analyzing, and communicating health information that includes not only disease-outcome data, but also data on underlying factors contributing to poor health.13 In many cases, national disease surveillance systems do not include information on underlying determinants of disease, necessitating linking to existing sources of social, structural, legal, environmental, and financial data to provide a more comprehensive description of the affected population.14 This special issue of PHRaims to reflect on the types of data we routinely gather, analyze, report, and communicate, and it calls us to take a holistic approach to data use both in the sources (e.g., United Nations, Centers for Disease Control and Prevention [CDC], Census Bureau, Department of Transportation, and Department of Justice) and kinds (e.g., disease outcome, policy, financial, land use, service usage, achievement, and segregation) of data used in public health. It calls us to be good public health stewards by challenging us to move beyond our routine analyses based mostly on individual-level data and include data from other sectors and levels in the work we do. This supplement provides examples of innovative uses and analyses of data for local, state, and national governments and organizations to consider. Promoting health equity through a holistic approach is a major strategic priority of CDCs National Center for HIV/AIDS, Viral Hepatitis, STD, and TB -Prevention (NCHHSTP).15 NCHHSTPs recent white paper entitled “Establishing a Holistic Framework to Reduce Inequities in HIV, Viral Hepatitis, STDs, and Tuberculosis in the United States” calls for a systematic approach to monitoring disease by simultaneously reporting on disease outcomes and underlying factors of poor health.16 NCHHSTP is also placing more emphasis on addressing structural determinants of health, including health policy, economic and social interventions, and cross-sectoral collaborations. The articles in this supplement clearly expand the knowledge base on social determinants and data use and are examples of the holistic approach to public health suggested in the CDC white paper.

From Theory to Action: Applying Social Determinants of Health to Public Health Practice

Recent approaches to population health have encouraged public health practitioners and policy makers to consider the broader determinants of health as part of a more comprehensive approach to improving health, addressing health inequalities, and accelerating health impact.1–3 Implementing action on social determinants involves understanding the dynamic interaction among the behavioral, clinical, policy, systems, occupational, and environmental determinants of health; identifying synergisms and antagonisms; and employing costeffective strategies to achieve sufficient and sustainable population coverage and scale. In an era of health system transformation, greater attention is now being paid to access, utilization, and quality of health care and its influence on population health. Similarly, research highlighting the importance of poverty, residential segregation, stigma and discrimination, incarceration, and educational attainment on health outcomes provides a deeper understanding of the complex social and structural determinants of health and pinpoints additional opportunities for enhancing prevention and control efforts.4–8 Our expanded understanding of the wider determinants of health and disease suggests that significant advances in health could be achieved if policy makers, program developers, and implementers address these broader influences on health outcomes while maintaining excellence in traditional disease control approaches. This supplement is both timely and critical to continuing the momentum in incorporating the social determinants of health (SDH) into prevention programming. This supplement seeks to advance scientific knowledge and illustrate how public health professionals can address SDH across a range of public health activities that promote health equity among the populations most disproportionately impacted by infectious and chronic diseases. By focusing on the ways in which SDH approaches are being integrated into public health research, surveillance, communication, policy, program, capacity building, and partnership activities, we hope to highlight best practices in addressing SDH across a broad range of public health activities.