Thomas R. Frieden

Tuberculosis in New York City--turning the tide.

BACKGROUND From 1978 through 1992, the number of patients with tuberculosis in New York City nearly tripled, and the proportion of such patients who had drug-resistant isolates of Mycobacterium tuberculosis more than doubled. METHODS We reviewed, confirmed, and analyzed data obtained during the surveillance of patients with tuberculosis. RESULTS From 1992 through 1994, there was a 21 percent decrease in reported cases of tuberculosis in New York City. An evaluation of the surveillance system revealed very few unreported cases. The number of cases decreased by more than 20 percent among blacks and Hispanics, persons with documented human immunodeficiency virus infection, homeless persons, and patients with multidrug-resistant tuberculosis; in all these groups, tuberculosis is likely to result from recent transmission. In contrast, the number of cases of tuberculosis increased among elderly and foreign-born persons, in whom the disease is likely to result from the reactivation of an infection acquired many years earlier. Enrollment in a program of directly observed therapy, in which health workers watch patients take their medications, increased from fewer than 100 patients to nearly 1300, with more than 32,000 patient-months of observation from 1992 through 1994. CONCLUSIONS Epidemiologic patterns strongly suggest that the decrease in cases resulted from an interruption in the ongoing spread of M. tuberculosis infection, primarily because of better rates of completion of treatment and expanded use of directly observed therapy. Another contributing factor may have been efforts to reduce the spread of tuberculosis in institutional settings, such as hospitals, shelters, and jails. Expansion of measures to prevent and control tuberculosis and support of international control efforts are needed to ensure continued progress.

Medication-Assisted Therapies — Tackling the Opioid-Overdose Epidemic

Deeming prescription-opioid overdoses an epidemic, the Department of Health and Human Services is working to reduce opioid abuse while ensuring appropriate access to opioids. One key element of the solution is greater use of medication-assisted therapies for addiction.

Purchasing behavior and calorie information at fast-food chains in New York City, 2007.

We surveyed 7318 customers from 275 randomly selected restaurants of 11 fast food chains. Participants purchased a mean of 827 calories, with 34% purchasing 1000 calories or more. Unlike other chains, Subway posted calorie information at point of purchase and its patrons more often reported seeing calorie information than patrons of other chains (32% vs 4%; P<.001); Subway patrons who saw calorie information purchased 52 fewer calories than did other Subway patrons (P<.01). Fast-food chains should display calorie information prominently at point of purchase, where it can be seen and used to inform purchases.

The Future of Public Health

Though there has sometimes been distrust between the health care and public health fields, they are inevitably and increasingly interdependent. And improvements in some types of public health interventions can increase the impact of clinical care on population health.

Adult Tobacco Use Levels After Intensive Tobacco Control Measures: New York City, 2002–2003

OBJECTIVES We sought to determine the impact of comprehensive tobacco control measures in New York City. METHODS In 2002, New York City implemented a tobacco control strategy of (1) increased cigarette excise taxes; (2) legal action that made virtually all work-places, including bars and restaurants, smoke free; (3) increased cessation services, including a large-scale free nicotine-patch program; (4) education; and (5) evaluation. The health department also began annual surveys on a broad array of health measures, including smoking. RESULTS From 2002 to 2003, smoking prevalence among New York City adults decreased by 11% (from 21.6% to 19.2%, approximately 140000 fewer smokers). Smoking declined among all age groups, race/ethnicities, and education levels; in both genders; among both US-born and foreign-born persons; and in all 5 boroughs. Increased taxation appeared to account for the largest proportion of the decrease; however, between 2002 and 2003 the proportion of cigarettes purchased outside New York City doubled, reducing the effective price increase by a third. CONCLUSIONS Concerted local action can sharply reduce smoking prevalence. However, further progress will require national action, particularly to increase cigarette taxes, reduce cigarette tax evasion, expand education and cessation services, and limit tobacco marketing.

Ebola 2014 — New Challenges, New Global Response and Responsibility

Stopping the Ebola outbreak at its source will take many months. But three core interventions have stopped every previous outbreak and can stop this one: exhaustive case and contact finding, effective response to patients and the community, and preventive interventions.

Deaths preventable in the U.S. by improvements in use of clinical preventive services.

BACKGROUND Healthcare reform plans refer to improved quality, but there is little quantification of potential health benefits of quality care. PURPOSE This paper aims to estimate the health benefits by greater use of clinical preventive services. METHODS Two mathematical models were developed to estimate the number of deaths potentially prevented per year by increasing use of nine clinical preventive services. One model estimated preventable deaths from all causes, and the other estimated preventable deaths from specific categories of causes. Models were based on estimates of the prevalence of risk factors for which interventions are recommended, the effect of those risk factors on mortality, the effect of the interventions on mortality in those at risk, and current and achievable rates of utilization of the interventions. RESULTS Both models predicted substantial numbers of deaths prevented by greater use of the preventive services, with the greatest increases from services that prevent cardiovascular disease. For example, the all-cause model predicted that every 10% increase in hypertension treatment would lead to an additional 14,000 deaths prevented and every 10% increase in treatment of elevated low-density lipoprotein cholesterol or aspirin prophylaxis would lead to 8000 deaths prevented in those aged <80 years, per year. Overall, the models suggest that optimal use of all of these interventions could prevent 50,000-100,000 deaths per year in those aged <80 years and 25,000-40,000 deaths per year in those aged <65 years. CONCLUSIONS Substantial improvements in population health are achievable through greater use of a small number of preventive services. Healthcare systems should maximize use of these services.

Childhood Obesity in New York City Elementary School Students

OBJECTIVES We estimated overweight and obesity in New York City elementary school children. METHODS A multistage cluster sample of New York City public elementary school children was selected. Nurses measured childrens height and weight and used a standard protocol to determine body mass index (BMI). Demographic information was obtained from official school rosters. Overweight and obese were defined as BMI-for-age at or above the 85th and 95th percentiles, respectively. RESULTS Of 3069 sampled students, 2681 (87%) were measured. The prevalence of overweight was 43% (95% confidence interval [CI] = 39%, 47%), more than half of whom were obese. Overall prevalence of obesity was 24% (95% CI = 21%, 27%), with at least 20% obesity in each grade, including kindergarten. Hispanic children had significantly higher levels (31%; 95% CI = 29%, 34%) than Black (23%; 95% CI = 18%, 28%) or White children (16%; 95% CI = 12%, 20%). Asian children had the lowest level of obesity among all racial/ethnic groups (14.4%, 95% CI = 10.9, 18.7). CONCLUSIONS Obesity among public elementary school children in New York City is an important public health issue. Particularly high levels among Hispanic and Black children mirror national trends and are insufficiently understood.

Risk Factors for Delayed Initiation of Medical Care After Diagnosis of Human Immunodeficiency Virus

BACKGROUND The full benefit of timely diagnosis of human immunodeficiency virus (HIV) infection is realized only if there is timely initiation of medical care. We used routine surveillance data to measure time to initiation of care in New York City residents diagnosed as having HIV by positive Western blot test in 2003. METHODS The time between the first positive Western blot test and the first reported viral load and/or CD4 cell count or percentage was used to indicate the interval from initial diagnosis of HIV (non-AIDS) to first HIV-related medical care visit. Using Cox proportional hazards regression, we identified variables associated with delayed initiation of care and calculated their hazard ratios (HRs). RESULTS Of 1928 patients, 1228 (63.7%) initiated care within 3 months of diagnosis, 369 (19.1%) initiated care later than 3 months, and 331 (17.2%) never initiated care. Predictors of delayed care were as follows: diagnosis at a community testing site (HR, 1.9; 95% confidence interval [CI], 1.5-2.3), the city correctional system (HR, 1.6; 95% CI, 1.2-2.0), or Department of Health sexually transmitted diseases or tuberculosis clinics (HR, 1.3; 95% CI, 1.1-1.6) vs a site with colocated primary medical care; nonwhite race/ethnicity (HR, 1.8; 95% CI, 1.5-2.0); injection drug use (HR, 1.3; 95% CI, 1.1-1.5); and location of birth outside the United States (HR, 1.1; 95% CI, 1.0-1.2). CONCLUSIONS A total of 1597 persons (82.8%) diagnosed as having HIV in 2003 ever initiated care, most within 3 months of diagnosis. Initiation of care was most timely when diagnosis occurred at a testing site that offered colocated medical care. Improving referrals by nonmedical sites is critical. However, because most diagnoses occur in medical sites, improving linkage in these sites will have the greatest effect on timely initiation of care.

Reducing Childhood Obesity Through Policy Change: Acting Now To Prevent Obesity

Childhood obesity is epidemic in the United States, and is expected to increase the rates of many chronic diseases. Increasing physical activity and improving nutrition are keys to obesity prevention and control. But changing individual behavior is difficult. A comprehensive, coordinated strategy is needed. Policy interventions that make healthy dietary and activity choices easier are likely to achieve the greatest benefits. There is emerging evidence on how to address childhood obesity, but we must take action now to begin to reverse the epidemic.