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Addressing critical global health issues, such as antimicrobial resistance, infectious disease outbreaks, and natural disasters, requires strong coordination and management across sectors. The One Health approach is the integrative effort of multiple sectors working to attain optimal health for people, animals, and the environment, and is increasingly recognized by experts as a means to address complex challenges. However, practical application of the One Health approach has been challenging. The One Health Systems Mapping and Analysis Resource Toolkit (OH-SMART) introduced in this paper was designed using a multistage prototyping process to support systematic improvement in multi-sectoral coordination and collaboration to better address complex health concerns through an operational, stepwise, and practical One Health approach. To date, OH-SMART has been used to strengthen One Health systems in 17 countries and has been deployed to revise emergency response frameworks, improve antimicrobial resistance national action plans and create multi agency infectious disease collaboration protocols. OH-SMART has proven to be user friendly, robust, and capable of fostering multi-sectoral collaboration and complex system-wide problem solving. [ABSTRACT FROM AUTHOR]

Estimation of influenza-like illness (ILI) using search trends activity was intended to supplement traditional surveillance systems, and was a motivation behind the development of Google Flu Trends (GFT). However, several studies have previously reported large errors in GFT estimates of ILI in the US. Following recent release of time-stamped surveillance data, which better reflects real-time operational scenarios, we reanalyzed GFT errors. Using three data sources—GFT: an archive of weekly ILI estimates from Google Flu Trends; ILIf: fully-observed ILI rates from ILINet; and, ILIp: ILI rates available in real-time based on partial reporting—five influenza seasons were analyzed and mean square errors (MSE) of GFT and ILIp as estimates of ILIf were computed. To correct GFT errors, a random forest regression model was built with ILI and GFT rates from the previous three weeks as predictors. An overall reduction in error of 44% was observed and the errors of the corrected GFT are lower than those of ILIp. An 80% reduction in error during 2012/13, when GFT had large errors, shows that extreme failures of GFT could have been avoided. Using autoregressive integrated moving average (ARIMA) models, one- to four-week ahead forecasts were generated with two separate data streams: ILIp alone, and with both ILIp and corrected GFT. At all forecast targets and seasons, and for all but two regions, inclusion of GFT lowered MSE. Results from two alternative error measures, mean absolute error and mean absolute proportional error, were largely consistent with results from MSE. Taken together these findings provide an error profile of GFT in the US, establish strong evidence for the adoption of search trends based 'nowcasts' in influenza forecast systems, and encourage reevaluation of the utility of this data source in diverse domains. [ABSTRACT FROM AUTHOR]

The Medical Monitoring Project (MMP) is an HIV surveillance system that provides national estimates of HIV-related behaviors and clinical outcomes. When first implemented, MMP excluded persons living with HIV not receiving HIV care. This analysis will describe new case-surveillance-based methods to identify and recruit persons living with HIV who are out of care and at elevated risk for mortality and ongoing HIV transmission. Stratified random samples of all persons living with HIV were selected from the National HIV Surveillance System in five public health jurisdictions from 2012–2014. Sampled persons were located and contacted through seven different data sources and five methods of contact to collect interviews and medical record abstractions. Data were weighted for non-response and case reporting delay. The modified sampling methodology yielded 1159 interviews (adjusted response rate, 44.5%) and matching medical record abstractions for 1087 (93.8%). Of persons with both interview and medical record data, 264 (24.3%) would not have been included using prior MMP methods. Significant predictors were identified for successful contact (e.g., retention in care, adjusted Odds Ratio [aOR] 5.02; 95% Confidence Interval [CI] 1.98–12.73), interview (e.g. moving out of jurisdiction, aOR 0.24; 95% CI: 0.12–0.46) and case reporting delay (e.g. rural residence, aOR 3.18; 95% CI: 2.09–4.85). Case-surveillance-based sampling resulted in a comparable response rate to existing MMP methods while providing information on an important new population. These methods have since been adopted by the nationally representative MMP surveillance system, offering a model for public health program, research and surveillance endeavors seeking inclusion of all persons living with HIV. [ABSTRACT FROM AUTHOR]

Background: Physician Orders for Life-Sustaining Treatment (POLST) programs have expanded rapidly, but evaluating their impact on hospital care is challenging. Objectives: To demonstrate how careful study design can reveal POLST’s impact at hospital admission and why analyses of state registry data are unlikely to capture POLST’s effects. Design: Prospective cohort study. Setting and participants: Adult in-patients with Do Not Intubate and/or Do Not Resuscitate (DNR/I) orders in the electronic medical record at the time of discharge from Johns Hopkins Hospital over 18 months. For patients with unplanned readmissions within 30 days, records were reviewed to determine if a Maryland Medical Order for Life-Sustaining Treatment (MOLST) form was presented and for the time from readmission to a DNR/I order in the EMR. Analyses were stratified by whether patients could communicate or were accompanied by a proxy at readmission. Results: Among 1,507 patients with DNR/I orders at discharge, 124 (8%) had unplanned readmissions, 112 (90%) could communicate or were accompanied by a proxy at readmission, and 12 (10%) could not communicate and were unaccompanied. For patients who were unaccompanied and could not communicate, MOLST significantly decreased the median time from readmission to DNR/I order (1.2 vs 27.1 hours, P = .001), but this association was greatly attenuated among patients who could communicate or were accompanied by a proxy (16.4 vs 25.4 hours P = .10). Conclusion: Among patients who wanted to avoid intubation and/or CPR, MOLST forms were protective when the patient was unaccompanied by a healthcare proxy at admission and could not communicate. Fewer than 10% of patients met these criteria during unplanned readmissions, and state registry data does not allow this sub-population to be identified. [ABSTRACT FROM AUTHOR]

As emerging and re-emerging infectious arboviruses like dengue, chikungunya, and Zika threaten new populations worldwide, officials scramble to assess local severity and transmissibility, with little to no epidemiological history to draw upon. Indirect estimates of risk from vector habitat suitability maps are prone to great uncertainty, while direct estimates from epidemiological data are only possible after cases accumulate and, given environmental constraints on arbovirus transmission, cannot be widely generalized beyond the focal region. Combining these complementary methods, we use disease importation and transmission data to improve the accuracy and precision of a priori ecological risk estimates. We demonstrate this approach by estimating the spatiotemporal risks of Zika virus transmission throughout Texas, a high-risk region in the southern United States. Our estimates are, on average, 80% lower than published ecological estimates—with only six of 254 Texas counties deemed capable of sustaining a Zika epidemic—and they are consistent with the number of autochthonous cases detected in 2017. Importantly our method provides a framework for model comparison, as our mechanistic understanding of arbovirus transmission continues to improve. Real-time updating of prior risk estimates as importations and outbreaks arise can thereby provide critical, early insight into local transmission risks as emerging arboviruses expand their global reach. [ABSTRACT FROM AUTHOR]

The maximum entropy model, a commonly used species distribution model (SDM) normally combines observations of the species occurrence with environmental information to predict the geographic distributions of animal or plant species. However, it only produces point estimates for the probability of species existence. To understand the uncertainty of the point estimates, we analytically derived the variance of the outputs of the maximum entropy model from the variance of the input. We applied the analytic method to obtain the standard deviation of dengue importation probability and Aedes aegypti suitability. Dengue occurrence data and Aedes aegypti mosquito abundance data, combined with demographic and environmental data, were applied to obtain point estimates and the corresponding variance. To address the issue of not having the true distributions for comparison, we compared and contrasted the performance of the analytical expression with the bootstrap method and Poisson point process model which proved of equivalence of maximum entropy model with the assumption of independent point locations. Both Dengue importation probability and Aedes aegypti mosquito suitability examples show that the methods generate comparatively the same results and the analytic method we introduced is dramatically faster than the bootstrap method and directly apply to maximum entropy model. [ABSTRACT FROM AUTHOR]

Background: Health literacy (HL) skills are essential to enable self-management and shared decision-making in patients with type 2 diabetes mellitus (T2DM). Limited HL in these patients is associated with poorer outcomes. It is not clear what the burden of limited HL in patients with T2DM across countries and what factors influence it. Methods: A systematic review was conducted according to the PRISMA guidelines. The study protocol was registered with PROSPERO (CRD42017056150). We searched MEDLINE, EMBASE, PsycINFO, CINAHL and ERIC for articles published up to January 2017. Articles that measured HL levels in adult patients with T2DM; that used validated HL tools; and that were reported in English were included. Two reviewers assessed studies for eligibility and quality, and extracted the data. Prevalence of limited HL is calculated from the number of patients with less than adequate HL over the total number of patients with T2DM in the study. Meta-analysis and meta-regression analysis were conducted using the Open Meta-analyst software. Results: Twenty-nine studies involving 13,457 patients with T2DM from seven countries were included. In total, seven different HL measurement tools were used. The prevalence of limited HL ranged from 7.3% to 82%, lowest in Switzerland and the highest in Taiwan. Meta-regression analysis of all included studies showed the country of study (p<0.001), HL tool used (p = 0.002), and the country’s region (p<0.001) contributed to the variation findings. Thirteen studies in the USA measured functional HL. The pooled prevalence of inadequate functional HL among patients with T2DM in the USA was 28.9% (95% CI: 20.4–37.3), with high heterogeneity (I2 = 97.9%, p <0.001). Studies were done in the community as opposed to a hospital or primary care (p = 0.005) and populations with education level lower than high school education (p = 0.009) reported a higher prevalence of limited HL. Conclusion: The prevalence of limited HL in patients with T2DM varied widely between countries, HL tools used and the country’s region. Pooled prevalence showed nearly one in three patients with T2DM in the USA had limited functional HL. Interactions with healthcare providers and educational attainment were associated with reported of prevalence in the USA. [ABSTRACT FROM AUTHOR]

Objective: To systematically review the literature on women’s experiences traveling for abortion and assess how this concept has been explored and operationalized, with a focus on travel distance, cost, delays, and other barriers to receiving services. Background: Increasing limitations on abortion providers and access to care have increased the necessity of travel for abortion services around the world. No systematic examination of women’s experiences traveling for abortion has been conducted; this mixed-methods review provides a summary of the qualitative and quantitative literature on this topic. Methods: A systematic search was conducted using PubMed, Embase, Web of Science, Popline, and Google Scholar in July 2016 and updated in March 2017 (PROSPERO registration # CRD42016046007). We included original research studies that described women’s experiences traveling for abortion. Two reviewers independently performed article screening, data extraction and determination of final inclusion for analysis. Critical appraisal was conducted using CASP, STROBE, and MMAT checklists. Results: We included 59 publications: 46 quantitative studies, 12 qualitative studies, and 1 mixed-methods study. Most studies were published in the last five years, relied on data from the US, and discussed travel as a secondary outcome of interest. In quantitative studies, travel was primarily conceptualized and measured as road or straight-line distance to abortion provider, though some studies also incorporated measures of burdens related to travel, such as financial cost, childcare needs, and unwanted disclosure of their abortion status to others. Qualitative studies explored regional disparities in access to abortion care, with a focus on the burdens related to travel, the impact of travel on abortion method choice, and women’s reasons for travel. Studies generally were of high quality, though many studies lacked information on participant recruitment or consideration of potential biases. Conclusions: Standardized measurements of travel, including burdens associated with travel and more nuanced considerations of travel costs, should be implemented in order to facilitate comparison across studies. More research is needed to explore and accurately capture different dimensions of the burden of travel for abortion services on women’s lives. [ABSTRACT FROM AUTHOR]

Background: Racial/ethnic disparities in rates of influenza vaccinations in the US remain an issue even among those with access, no out-of-pocket costs, and after adjusting for confounders. We used an approach called the Oaxaca-Blinder (OB) decomposition method to ascertain the contribution of covariates individually and in aggregate to the racial disparity in influenza vaccination. Methods: We included members > = 18 years of age as of 05/01/2014 with continuous enrollment through 04/30/2015. Influenza vaccination was defined by diagnosis, procedure, or medication codes, or documentation in the immunization table. Characteristics were reported by race. Logistic regression models estimated the odds of vaccination associated with: (1) race; and (2) covariates stratified by race. The Oaxaca-Blinder (OB) method calculated the contribution of covariates to the difference or disparity in vaccination between Blacks and Whites. Results: We found that among adults, 44% were vaccinated; 55% were Black; and 45% were White. Black members have 42% lower odds of vaccination than White members. The contribution of the differences in the average value of the study covariates between Black and White members (the OB covariate effect) accounted for 29% of the racial disparity. The contributions to the total White-Black disparity in vaccination included: age (16%), neighborhood median income (11%), and registration on the online patient portal (13%). The contribution of the differences in how the covariates impact vaccination (OB coefficient effect) accounted for 71% of the disparity in vaccination between Blacks and Whites. Conclusion: In conclusion, equalizing average covariate values in Blacks and Whites could reduce the racial disparity in influenza vaccination by 29%. For health system vaccine campaigns, improving registration on the patient portal may be a target component of an effective system-level strategy to reduce racial disparities in vaccination. Additional information on patient-centered factors could further improve the value of the OB approach. [ABSTRACT FROM AUTHOR]

Introduction: Flavored e-cigarettes are enticing to new users and established cigarette smokers using e-cigarettes to quit smoking due to the wide variety of flavor options. However, specific flavor combinations that are popular among e-cigarette users are understudied. Recently, the Deeming rule extended the US Food and Drug Administration’s authority over all tobacco products, including e-cigarettes. Methods: The Population Assessment of Tobacco and Health Study Wave 2 data were analyzed to assess the prevalence of self-reported flavor categories that are used individually and in combination with other flavor categories among past 30-day youth and adult e-cigarette users in the US. Results: Most youth and adult participants reported using a flavored e-cigarette. Reporting an individual flavor category was more common than reporting a combination of flavor categories. Fruit flavor was the most common flavor category reported among youth, and ‘menthol/mint’ was most common among adults. Fruit and candy/other sweets were the most common flavor categories reported together among both youth and adult past 30-day e-cigarette users. Conclusions: The use of flavored e-cigarettes is very popular among youth and adults. Most consumers reported using a single flavor category, although some consumers did use a combination of flavor categories. Preference for menthol/mint among adults may represent a carryover from associations with tobacco cigarettes. Typically, sweeter flavors, such as fruit, were among the most popular flavor categories reported, both individually and in combination with other flavors, while more bitter flavors (i.e.: clove/spice) were less common. Implications: This study identified predominant flavor categories among past 30-day youth and adult e-cigarette users. Findings indicate that the wide variety of flavors available and the freedom to “mix-and-match” flavors may maintain use of e-cigarettes among youth and adults, and future research should focus on the composition of the ENDS liquid/vapor to disentangle the contributions of sweeteners and flavorants. [ABSTRACT FROM AUTHOR]