Mary Ann Pass

Prospective studies of group B streptococcal infections in infants.

The incidence of GBS colonization at birth was determined prospectively among 96% of 2,407 infants born over a 12-month period in an urban community hospital. GBS were recovered from one or more of the four sites cultured in 290 (12.5%) of these newborn infants, 91 of whom were heavily colonized (3 to 4 sites positive). Sepsis or meningitis occurred in 13 infants, an attack rate of 5.4/1,000 live births. Attack rates for early and late onset disease, respectively, were 3.7 and 1.7 per 1,000 live births. All serotypes were found to cause disease. The incidence of early sepsis was strikingly high (8%) in heavily colonized infants. Those colonized at 1 to 2 sites were at no greater risk than noncolonized infants. The maternal vaginal colonization rate at delivery was 19%, with acquisition from the mother documented as the primary source of the organism in early onset infections. Perinatal events, including maternal complications and signs of illness at or immediately after birth, suggested ascending infection with exposure in utero to be likely in six infants. Passive acquisition of GBS (intrapartum exposure) probably occurred in the three remaining early onset cases. This mechanism was also likely responsible for five nonbacteremic infections. The four infants with late onset sepsis or meningitis were not colonized at birth or when discharged from the nursery (day 3); a possible maternal source for infection was found in only one of these infants.

Puerperal and perinatal infections with group B streptococci

Twenty-one patients were seen with puerperal sepsis owing to group B streptococci (GBS), resulting in an attack rate of 2/1,000 deliveries. Most were young primiparous black women from a population with a known high incidence of GBS carriage. The association among abdominal delivery, endometritis, and puerperal sepsis was striking. Cultures of the birth canal or lochia were commonly positive for the same serotype recovered from the blood. Forty-seven patients with nonbacteremic GBS infections were seen; 27 had endometritis or amnionitis. Twenty patients had GBS urinary tract infection: Eight infections occurred prenatally, seven at delivery, and five post partum. Seven neonates developed serious GBS infections; intrauterine exposure occurred in at least four cases. Fetal exposure to GBS also occurred in three of four cases in which parturients with GBS bacteremia were delivered of their infants by cesarean section. Because of the high incidence of puerperal and perinatal GBS infections in this population, antibiotic prophylaxis regimens may be beneficial.

Twin pregnancies: Incidence of group B streptococcal colonization and disease

Twin PREGNANCIES, responsible for 1% of births, account for 4 to 10% of all perinatal deaths?. 2 Premature birth appears to be the greatest hazard. Complications of delivery, intrauterine growth retardation, and hemodynamic abnormalities represent additional risks to the twin. 2 Naeye et aP have suggested that the amniotic fluid infection syndrome may be the most common identifiable cause of perinatal death in twins, being implicated in 16 to 38% of twin deaths, depending upon the population studied. Beta hemolytic streptococci, including members of serologic group B, are among tile causes of the syndrome. 4 Group B streptococcal infection in twins has been described, 5-7 but prospective data are lacking. Our prospective studies of GBS infections in infants have been in progress for several years. Data from the first year of investigation, recently reported, ~ included one set of twins who died with fulminant GBS sepsis. Additional cases, septicemia in a mother and one of her twin infants, prompted this analysis of the outcome of twin pregnancies in this population. An increased risk of GBS !nfection in twin pregnancies was strikingly evident.

The Association of Child Condition Severity with Family Functioning and Relationship with Health Care Providers Among Children and Youth with Special Health Care Needs in Alabama

Objective: The purpose of the present study is to assess how the severity of a child’s condition affects family functioning and the relationship with health care providers among children with special health care needs in Alabama. Methods: Using the data from the National Survey of Children with Special Health Care Needs (CSHCN), three variables were used as measures of condition severity: responses to the CSHCN screener questions, whether condition affected the ability to do things for children and youth with special health care needs (CYSHCN), and the level of severity of CYSHCN’s condition. The dependent variables included family functioning and provider relationship. Results: CYSHCN who only take prescription medicine for their chronic condition (MO) had lower condition severity from those who have other needs (NMO). In NMO CYSHCN, higher condition severity was associated with increased strain on family functioning outcomes and higher unmet needs in provider relationship outcomes, adjusted for demographic and insurance variables. Families of NMO CYSHCN with a more severe condition spent more temporal and financial resources and had a higher need for professional care coordination, and were less likely to have sensitive providers. Conclusions: Severity of condition is an important factor increasing strain on family resources and relationship with the provider. Our results indicate the need for professional care coordination and family support, particularly among those families in which there is a NMO CYSHCN with a more severe condition. This finding supports the mandate that all CYSHCN should have their health care coordinated and provided in the context of a medical home.

Assuring Public Health Professionals Are Prepared for the Future: The UAB Public Health Integrated Core Curriculum

In response to calls to improve public health education and our own desire to provide a more relevant educational experience to our Master of Public Health students, the University of Alabama at Birmingham (UAB) School of Public Health designed, developed, and instituted a fully integrated public health core curriculum in the fall of 2001. This curriculum combines content from discipline-specific courses in biostatistics, environmental health, epidemiology, health administration, and the social and behavioral sciences, and delivers it in a 15 credit hour, team-taught course designed in modules covering such topics as tobacco, infectious diseases, and emergency preparedness. Weekly skills-building sessions increase student competence in data analysis and interpretation, communication, ethical decision-making, community-based interventions, and policy and program planning. Evaluations affirm that the integrated core is functioning as intended: as a means to provide critical content in the core disciplines in their applied context. As public health education continues to be debated, the UAB public health integrated core curriculum can serve as one model for providing quality instruction that is highly relevant to professional practice.

Assessing the Extent of Medical Home Coverage Among Medicaid-Enrolled Children

Objectives: In light of the transition of the Alabama Medicaid program to a primary care case management model, we assessed the level to which children had access to a medical home before and after implementation of that model. Given the growing emphasis within the MCH community on assuring children medical homes, we explored whether Medicaid claims data could be used to assess medical home coverage. Methods: We operationally defined “medical home” as use of a single primary care physician combined with receipt of at least one well child visit from that physician during the year. Using Alabama Medicaid claims data we assessed whether childrens receipt of health care services met this defintion, the extent to which Medicaid-enrolled children had primary care providers and received well child visits, and changes in the source of well child visits before and after implementation of a primary care case management model in 26 of Alabamas 67 counties. Results: In general, Medicaid-enrolled children in Alabama did not meet our definition of medical home either before or after implementation of a primary care case management model. Only 11.8% of children saw a single provider and had a well child visit from that provider during the baseline year. A majority of children (49.9%) however had both a primary care provider and received a well child visit. Sixteen percent of children saw a primary care physician but received no identifiable well visit, while 11% had well child care but did not see a primary care physician. Of particular concern, 23% neither saw a primary care physician nor had a well child visit during the baseline year. These figures changed only slightly in the 26 counties examined before and after implementation of the primary care case management model. Conclusions: State Maternal and Child Health programs are required to report as a performance measure “the percent of children with special health care needs in the state who have a medical/health home” as part of their Block Grant application. Using Medicaid data, this simple measurement strategy can provide an indication of the extent to which at least one population of children receive care through a medical home.

Schools as a Setting for Health Promotion and Disease Prevention

Three areas of school-based health promotion and disease prevention will be described in this chapter, including school-based intervention research, comprehensive school health programs, and school-based health clinics. School-based intervention research is the process of developing and evaluating interventions that are delivered in the schools and designed to modify a specific set of health behaviors. Comprehensive school health programs involve the implementation of eight objectives for school health education. These objectives impact health education curricula, as well as school health policy, staff wellness, and staff training for health education. School-based health clinics involve the delivery of health services and prevention activities directly to children through clinics in the schools.

Impact of advanced maternal age on neonatal survival of twin small‐for‐gestational‐age subtypes

Aim:  We examined the impact of advanced maternal age (>40 years old) on the survival of twin small‐for‐gestational‐age (SGA) infants, that is, infants who were smaller in size than was expected for the babys sex, genetic heritage, and gestational age.

Assessing Needs and Resources for the Home Visiting System in Alabama: A Mixed Methods Approach

AbstractThe purpose of this article is to describe the initial assessment for the development of a home visiting (HV) system in a state with no existing system. We outline a mixed methods process where the quantitative component was used to identify the communities that possess “at-risk” profiles, and the qualitative component explored the resources and gaps in existing HV services. We employed a mixed methods approach, using six categories of indicators from quantitative secondary data sources to identify “at-risk” profiles for Alabama’s 67 counties. A weighted score for each indicator was calculated and counties were ranked. Surveys and focus groups were conducted to further define resources and gaps of existing HV programs. The composite indicator scores identified 13 counties as having the highest level of risk. Five of these 13 communities had no HV home visitation services. Areas of focus for future HV system development include trust, communication, availability, cost, and timeliness. In this assessment related to the Alabama HV system, we used quantitative data to apply criteria to the indicators being measured and qualitative data to supplement the quantitative findings. We examined resources, gaps, program quality, and capacity of the existing HV programs in order to assist in the future development of the HV system and early childhood system. The methods presented in this paper have potential applications beyond HV programs and systems, including broader examinations of complex systems for service provision to the maternal and child health populations.

464 PREHATAL CARRIAGE OF GBS: IMPORTANCE OF THE GUT AS A RESERVOIR

Studies on the natural history of group B streptococcal (GBS) infection, initiated in 1977, have revealed an attack rate of neonatal sepsis of 4/1000 live births. Intrauterine and intrapartum acquired infections were demonstrated; sources of late onset infection remain less certain. We now report a longitudinal study of prenatal carriage involving 2541 women enrolled over a 3 year period, from whom anal and vaginal cultures were taken. Carrier rates, according to culture site, were: anal only, 17%; vaginal only, 4%; anal and vaginal, 15%, with an overall rate of 36%. Overall rates calculated yearly for 1977, 1978 and 1979, were 37%, 36%, 33%, respectively. The serotype distribution (3 yr total) was: Type III (31%); II (24%); Ia (23%); Ib (10%) and lc (6%). Among 310 instances of simultaneous anal-vaginal carriage, serotype concordance was 85%. Further analysis of data by positive site for 913 carriers revealed the importance of the gut as a reservoir for GBS. 89% had positive GBS anal cultures (± pos vaginal) compared to 52% with positive GBS vaginal cultures (± pos anal). The gut is the likely source for birth canal colonization, and may also be an important source of GBS in infants who develop late onset disease.