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During the summer of 2021, a narrative of “two Americas” emerged: one with high demand for the COVID-19 vaccine and the second with widespread vaccine hesitancy and opposition to masks and vaccines.We analyzed “excess mortality” rates (the difference between total deaths and what would have been expected based on earlier time periods) prepared by the CDC for the United States from January 3, 2020 to September 26, 2021.Between Jan. 3, 2020 and Sept. 26, 2021, there were 895,693 excess deaths associated with COVID-19, 26% more than reported as such. The proportion of deaths estimated by the excess mortality method that were reported as COVID-19 was highest in Northeast (92%) and lowest in the West (72%) and South (76%).Of the estimated deaths, 43% occurred between Oct. 4, 2020 and Feb. 27, 2021. Before May 31, 2020, approximately 56% of deaths were in the Northeast, where 17% of the population resides. Subsequently, 48% of deaths were in the South, which makes up 38% of the population. Since May 31, 2020, the South experienced COVID-19 mortality 26% higher than the national rate, whereas the Northeast’s rate was 42% lower.If each region had the same mortality rate as the Northeast, more than 316,234 COVID-19 deaths between May 31, 2020 and Sept. 26, 2021 were “avoidable.” More than half (63%) of the avoidable deaths occurred between May 31, 2020 and February, 2021, and more than half (60%) were in the South.Regional differences in COVID-19 mortality have been strong throughout the pandemic. The South has had higher mortality rates than the rest of the U.S. since May 31, 2020, and experienced 62% of the avoidable deaths. A comprehensive COVID-19 policy, including population-based restrictions as well as vaccines, is needed to control the pandemic.

Zika virus provides an example for which public health surveillance is based primarily on health care provider notifications to health departments of potential cases. This case-based surveillance is commonly used to understand the spread of disease in a population. However, case-based surveillance is often biased—whether testing is done and which tests are used and the accuracy of the results depend on a variety of factors including test availability, patient demand, perceptions of transmission, and patient and provider awareness, leading to surveillance artifacts that can provide misleading information on the spread of a disease in a population and have significant public health practice implications. To better understand this challenge, we first summarize the process that health departments use to generate surveillance reports, then describe factors influencing testing and reporting patterns at the patient, provider, and contextual level. We then describe public health activities, including active surveillance, that influence both patient and provider behavior as well as surveillance reports, and conclude with a discussion about the interpretation of surveillance data and approaches that could improve the validity of surveillance reports.

Zika virus disease provides the latest example of a critical nexus between public health and clinical practice. Interpreting Zika virus test results is complicated by the absence of a single testing approach with superior validity across contexts and populations. Molecular tests are highly specific, variably sensitive, and have a short window period. Serologic tests identify antibodies against Zika virus and are more likely than molecular tests to cross-react with other related viruses, reducing specificity. The type of test performed and timing relative to possible Zika virus exposure depend on public health guidance, testing algorithms, test availability, and capacity. Guidance from the Centers for Disease Control and Prevention and local health departments have changed throughout the course of the US epidemic based on prevalence, geography, and clinical concerns. Women with a low pretest probability of infection should be counseled against testing. Women with a high pretest probability of Zika virus infection should still receive enhanced prenatal monitoring and newborn evaluation, regardless of the test result. An appropriate interpretation of results depends on what tests are used, patient characteristics, and reasons for testing. Clinicians should take these factors into account in shared decision making discussions with pregnant women about Zika virus testing.

Public health authorities have adopted entry screening and subsequent restrictions on travelers from Ebola-affected West African countries as a strategy to prevent importation of Ebola virus disease (EVD) cases. We analyzed international, federal, and state policies-principally based on the policy documents themselves and media reports-to evaluate policy variability. We employed means-ends fit analysis to elucidate policy objectives. We found substantial variation in the specific approaches favored by WHO, CDC, and various American states. Several US states impose compulsory quarantine on a broader range of travelers or require more extensive monitoring than recommended by CDC or WHO. Observed differences likely partially resulted from different actors having different policy goals-particularly the federal government having to balance foreign policy objectives less salient to states. Further, some state-level variation appears to be motivated by short-term political goals. We propose recommendations to improve future policies, which include the following: (1) actors should explicitly clarify their objectives, (2) legal authority should be modernized and clarified, and (3) the federal government should consider preempting state approaches that imperil its goals.

As an alternative to standard quality improvement approaches and to commonly used after action report/improvement plans, we developed and tested a peer assessment approach for learning from singular public health emergencies. In this approach, health departments engage peers to analyze critical incidents, with the goal of aiding organizational learning within and across public health emergency preparedness systems. We systematically reviewed the literature in this area, formed a practitioner advisory panel to help translate these methods into a protocol, applied it retrospectively to case studies, and later field-tested the protocol in two locations. These field tests and the views of the health professionals who participated in them suggest that this peer-assessment approach is feasible and leads to a more in-depth analysis than standard methods. Engaging people involved in operating emergency health systems capitalizes on their professional expertise and provides an opportunity to identify transferable best practices.

The National Health Security Strategy calls for a systematic quality improvement efforts to improving health security. In addition, since 2001, billions of dollars have been spent on public health emergency preparedness at the federal, state, and local levels. Policy makers must now ask has this investment been effective, and in what way to measure this investment. Whether the goal is to ensure accountability to policy makers or to facilitate quality improvement, valid and reliable measures of preparedness are needed. Measuring and assessing the state of the nation's preparedness, however, are challenging. This article explores the current measurement climate and potential for improvement.

The Harvard School of Public Health Center for Public Health Preparedness exercise program has two aims: ( 1) educating the public health workforce on key public health system emergency preparedness issues, and ( 2) identifying specific systems-level challenges in the public health response to large-scale events. Rigorous evaluation of 38 public health emergency preparedness (PHEP) exercises employing realistic scenarios and reliable and accurate outcome measures has demonstrated the usefulness of PHEP exercises in clarifying public health workers' roles and responsibilities, facilitating knowledge transfer among these individuals and organizations, and identifying specific public health systems-level challenges.

Objectives: The Medical Reserve Corps (MRC) is a national network of community-based units created to promote the local identification, recruitment, training, and activation of volunteers to assist local health departments in public health activities. This study aimed to develop a toolkit for MRC coordinators to assess and monitor volunteer units' performance and identify barriers limiting volunteerism.Methods: In 2008 and 2009, MRC volunteers asked to participate in influenza clinics were surveyed in 7 different locations throughout the United States. Two survey instruments were used to assess the performance of the volunteers who were able to participate, the specific barriers that prevented some volunteers from participating, and the overall attitudes of those who participated and those who did not. Validity and reliability of the instruments were assessed through the use of factor analysis and Cronbach's alpha.Results: Two survey instruments were developed: the Volunteer Self-Assessment Questionnaire and the Barriers to Volunteering Questionnaire. Data were collected from a total of 1059 subjects, 758 participated in the influenza clinics and 301 were unable to attend. Data from the 2 instruments were determined to be suitable for factor analysis. Factor solutions and inter-item correlations supported the hypothesized domain structure for both survey questionnaires. Results on volunteers' performance were consistent with observations of both local health departments' staff and external observers.Conclusions: The survey instruments developed for this study appear to be valid and reliable means to assess the performance and attitudes of MRC volunteers and barriers to their participation. This study found these instruments to have face and content validity and practicality. MRC coordinators can use these questionnaires to monitor their ability to engage volunteers in public health activities.(Disaster Med Public Health Preparedness. 2010;4:213-219)

No standard case definition exists for interstitial cystitis/painful bladder syndrome for patient screening or epidemiological studies. As part of the RAND Interstitial Cystitis Epidemiology study, we developed a case definition for interstitial cystitis/painful bladder syndrome with known sensitivity and specificity. We compared this definition with others used in interstitial cystitis/painful bladder syndrome epidemiological studies.We reviewed the literature and performed a structured, expert panel process to arrive at an interstitial cystitis/painful bladder syndrome case definition. We developed a questionnaire to assess interstitial cystitis/painful bladder syndrome symptoms using this case definition and others used in the literature. We administered the questionnaire to 599 women with interstitial cystitis/painful bladder syndrome, overactive bladder, endometriosis or vulvodynia. The sensitivity and specificity of each definition was calculated using physician assigned diagnoses as the reference standard.No single epidemiological definition had high sensitivity and high specificity. Thus, 2 definitions were developed. One had high sensitivity (81%) and low specificity (54%), and the other had the converse (48% sensitivity and 83% specificity). These values were comparable or superior to those of other epidemiological definitions used in interstitial cystitis/painful bladder syndrome prevalence studies.No single case definition of interstitial cystitis/painful bladder syndrome provides high sensitivity and high specificity to identify the condition. For prevalence studies of interstitial cystitis/painful bladder syndrome the best approach may be to use 2 definitions that would yield a prevalence range. The RAND Interstitial Cystitis Epidemiology interstitial cystitis/painful bladder syndrome case definitions, developed through structured consensus and validation, can be used for this purpose.

Although previous studies have found no differences in response to antidepressant pharmacotherapy between selective serotonin reuptake inhibitors (SSRIs), some recent trials suggest benefits associated with more rapid onset of action.The aim of this work was to compare the likelihood that patients initiating treatment with branded escitalopram, rather than with any of 3 SSRIs (ie, citalopram, fluoxetine, and paroxetine) that are available in generic or branded formulations, would continue therapy with the initial medication after 2 and 6 months.We used propensity score-weighted logistic regression to assess the effect of antidepressant choice on the likelihood of continuing treatment, based on data from a large administrative claims database with information about US patients. We modeled the propensity to initiate treatment with escitalopram based on demographic, diagnostic, insurance, and service-use characteristics in the 6 months before treatment initiation and used the results to calculate weights for analysis of treatment continuation. The primary outcome measures were receipt of 2 prescriptions of the index drug in the first 2 months and, among those continuing at 2 months, 4 prescriptions in the first 6 months. Antidepressant choice, cost, and service-use characteristics during the treatment period were included as covariates. Patients who initiated therapy between July 2002 and April 2005 were eligible for inclusion.Based on data for 43,921 patients, at 2 months, escitalopram initiators were more likely to have continued initial medication than those receiving the other SSRIs (66.1% vs 61.9%, respectively; P0.01) and less likely to have switched or augmented treatment (4.8% vs 7.6%; P0.01). At 6 months, escitalopramtreated patients were also more likely to have continued initial medication (47.1% vs 41.0%; P0.01) and less likely to have switched or augmented treatment (9.4% vs 14.4%; P0.01).Patients initiating treatment with escitalopram were more likely to continue and less likely to switch or augment treatment at 2 and 6 months of therapy compared with those who initiated with alternative SSRIs.

The conference had three broad goals: first, to review the basic structure of epidemiology and demography to provide a backdrop to more-effective dialogue; second, to present research on specific areas of inquiry that have been addressed by both disciplines; and third, to discuss explicit ways of improving communication and collaboration across the disciplines.

Objectives. The purpose of this study was to review instruments that assess the level of preparedness of state and local public health departments to respond to health threats such as bioterrorism. Methods. The authors examined 27 published population-based instruments for planning or evaluating preparedness that were mostly unavailable in the peer-reviewed literature. Using the Essential Public Health Services framework, the instruments were evaluated for ( 1) clarity of measurement parameters, ( 2) balance between structural and process measures, ( 3) evidence of effectiveness, and ( 4) specification of an accountable entity. Results. There was a great deal of overlap but little consistency in what constitutes “preparedness” or how it should be measured. Most instruments relied excessively on subjective or structural measures, lacked scientific evidence for measures assessed, and failed to clearly define what entity was accountable for accomplishing the task or function. Conclusion. Strategies for improvement include measure standardization, better interagency communication, and investment in public health practice research to develop the underlying evidence base required for developing quality measures and assessments.

Epidemiology is a core science of public health, focusing on research related to the distribution and determinants of both positive and adverse health states and events and on application of knowledge gained to improve public health. The American College of Epidemiology (ACE) is a professional organization devoted to the professional practice of epidemiology. As part of that commitment, and in response to concerns for more explicit attention to core values and duties of epidemiologists in light of emerging issues and increased scrutiny of epidemiology, the College developed, adopted, and published a set of Ethics Guidelines. The structure of the ACE ethics guidelines is in four parts: (1) a brief statement of core values and duties of epidemiologists, coupled with the virtues important to professional practice; (2) concise statements of key duties and obligations; (3) exposition of the duties and obligations with more applications; and (4) a brief summary and conclusion. The Guidelines have been published on the ACE website and in the official College journal Annals of Epidemiology. The guidelines contain (and maintain) core elements that define the discipline of epidemiology and its fundamental duties, but they are also intended to be dynamic and evolving, responsive to a changing professional and social environment.

background The new reality of biologic terrorism and warfare has ignited a debate about whether to reintroduce smallpox vaccination. methods We developed scenarios of smallpox attacks and built a stochastic model of outcomes under various control policies. We conducted a systematic literature review and estimated model parameters on the basis of European and North American outbreaks since World War II. We assessed the trade-offs between vaccine-related harms and benefits. results Nations or terrorists possessing a smallpox weapon could feasibly mount attacks that vary with respect to tactical complexity and target size, and patterns of spread can be expected to vary according to whether index patients are hospitalized early. For acceptable results, vaccination of contacts must be accompanied by effective isolation. Vaccination of contacts plus isolation is expected to result in 7 deaths (from vaccine or smallpox) in a scenario involving the release of variola virus from a laboratory, 19 deaths in a human-vector scenario, 300 deaths in a building-attack scenario, 2735 deaths in a scenario involving a low-impact airport attack, and 54,728 deaths in a scenario involving a high-impact airport attack. Immediate vaccination of the public in an attacked region would provide little additional benefit. Prior vaccination of health care workers, who would be disproportionately affected, would save lives in large local or national attacks but would cause 25 deaths nationally. Prior vaccination of health care workers and the public would save lives in a national attack but would cause 482 deaths nationally. The expected net benefits of vaccination depend on the assessed probability of an attack. Prior vaccination of health care workers would be expected to save lives if the probability of a building attack exceeded 0.22 or if the probability of a high-impact airport attack exceeded 0.002. The probability would have to be much higher to make vaccination of the public life-saving. conclusions The analysis favors prior vaccination of health care workers unless the likelihood of any attack is very low, but it favors vaccination of the public only if the likelihood of a national attack or of multiple attacks is high.

Health departments use after-action reports to collect data on their experience in responding to actual public health emergencies. To address deficiencies in the use of such reports revealed in the 2009 H1N1 influenza pandemic and to develop an effective approach to learning from actual public health emergencies, we sought to understand how the concept and operations of a "critical incident registry," commonly used in other industries, could be adapted for public health emergency preparedness. We conducted a workshop with public health researchers and practitioners, reviewed the literature on learning from rare events, and sought to identify the optimal characteristics of a critical incident registry (CIR) for public health emergency preparedness. Several key critical characteristics are needed for a CIR to be feasible and useful. A registry should: (1) include incidents in the response in which public health agencies played a substantial role, are "meaningful," test one or more emergency preparedness capabilities, and are sufficiently limited in scope to isolate specific response issues; (2) be supported by a framework and standard protocols for including reports based on rigorous analysis of individual incidents and methods for cross-case analysis; and (3) include explicit incentives for reporting, to overcome intrinsic disincentives. With proper incentives in place, a critical incident registry can be a useful tool for improving public health emergency preparedness. Standard protocols for reporting critical events and probing analysis are needed to enable identification of patterns of successes and failures.

The health of a community is a shared responsibility of many entities. Within this context, specific entities should identify, and be held accountable for, the actions they can take to contribute toward the community's health. Governmental public health agencies, especially at the state and local levels, can take the lead in getting public and private community organizations to advance the health of the community, and should play a leadership role by developing partnerships with managed care organizations and community-based organizations.

BACKGROUND: The 2009 H1N1 vaccination campaign was the largest in US history. State health departments received vaccines from the federal government and sent them to local health departments (LHDs) who were responsible for getting vaccines to the public. Many LHD’s used school-based clinics to ensure children were the first to receive limited vaccine supplies, but the success of school-based distribution strategies varied in different locations. The goal of this project was to identify and learn from high-performing school-based vaccination clinics in order to share successes and improve performance in future school-based vaccination campaigns. METHODS: We used a combination of process mapping and comparative analysis to identify and derive lessons from positive outlier cases observed during 2009 H1N1 school-based vaccination clinic implementation. We created process maps to identify the activities of LHDs conducting school-based vaccinations and used them as the basis for in-depth interviews of LHD staff. We asked interviewees to describe their activities during the 2009 H1N1 pandemic (pH1N1) school-based vaccination campaign with a focus on successful processes. RESULTS: We identified positive deviants, that is, those that performed better than expected, and categorized qualitative data from in-depth interviews with 13 successful LHDs according to the process maps. Key mechanisms for school-based vaccination success included having a relationship with local school authorities, communicating effectively with parents, and ensuring clinic logistics allowed for an easy flow of students through the vaccination process. CONCLUSIONS: Utilizing rigorous methodology, we defined and learned lessons from successful LHDs when conducting school-based vaccination clinics, which can be applied to future school-based vaccination campaigns.

Bladder pain syndrome/interstitial cystitis is a poorly understood condition that can cause serious disability. We provide the first population based symptom prevalence estimate to our knowledge among United States adult females.We developed and validated 2 case definitions to identify bladder pain syndrome/interstitial cystitis symptoms. Beginning in August 2007 we telephoned United States households, seeking adult women with bladder symptoms or a bladder pain syndrome/interstitial cystitis diagnosis. Second stage screening identified those subjects who met case definition criteria. Each completed a 60-minute interview on the severity and impact of bladder symptoms, health care seeking and demographics. Data collection ended in April 2009. Using population and nonresponse weights we calculated prevalence estimates based on definitions spanning a range of sensitivity and specificity. We used United States Census counts to estimate the number of affected women in 2006. The random sample included 146,231 households, of which 131,691 included an adult female. Of these households 32,474 reported an adult female with bladder symptoms or diagnosis, of which 12,752 completed the questionnaire.Based on the high sensitivity definition 6.53% (95% CI 6.28, 6.79) of women met symptom criteria. Based on the high specificity definition 2.70% (95% CI 2.53, 2.86) of women met the criteria. These percentages translated into 3.3 to 7.9 million United States women 18 years old or older with bladder pain syndrome/interstitial cystitis symptoms. Symptom severity and impact were comparable to those of adult women with established diagnoses. However, only 9.7% of the women reported being assigned a bladder pain syndrome/interstitial cystitis diagnosis.Bladder pain syndrome/interstitial cystitis symptoms are widespread among United States women and associated with considerable disability. These results suggest bladder pain syndrome/interstitial cystitis may be underdiagnosed.

Background: U.S. Black women have higher breast cancer mortality rates than White women despite lower incidence. The aim of this study is to investigate how much of the mortality disparity can be attributed to racial differences in natural history, uptake of mammography screening, and use of adjuvant therapy. Methods: Two simulation models use common national race, and age-specific data for incidence, screening and treatment dissemination, stage distributions, survival, and competing mortality from 1975 to 2010. Treatment effectiveness and mammography sensitivity are assumed to be the same for both races. We sequentially substituted Black parameters into the White model to identify parameters that drive the higher mortality for Black women in the current time period. Results: Both models accurately reproduced observed breast cancer incidence, stage and tumor size distributions, and breast cancer mortality for White women. The higher mortality for Black women could be attributed to differences in natural history parameters (26–44%), use of adjuvant therapy (11–19%), and uptake of mammography screening (7–8%), leaving 38% to 46% unexplained. Conclusion: Black women appear to have benefited less from cancer control advances than White women, with a greater race-related gap in the use of adjuvant therapy than screening. However, a greater portion of the disparity in mortality appears to be due to differences in natural history and undetermined factors. Impact: Breast cancer mortality may be reduced substantially by ensuring that Black women receive equal adjuvant treatment and screening as White women. More research on racial variation in breast cancer biology and treatment utilization is needed. Cancer Epidemiol Biomarkers Prev; 20(1); 112–22. ©2011 AACR.

Despite the acknowledged promise of developing a public health systems research (PHSR) agenda for emergency preparedness, there has been no systematic review of the literature in this area. The purpose of this study was to conduct a systematic literature review in order to identify and characterize the PHSR literature produced in the U.S. in the past 11 years in the field of public health emergency preparedness.Articles were searched in MEDLINE and EMBASE, as well as in the gray literature. Two independent reviewers classified the articles according to study design and IOM public health emergency preparedness (PHEP) research goal areas.From January 1, 1997, through December 31, 2008, there were 547 articles that met the inclusion criteria that were published. It was possible to classify 314 (57%) articles into at least one of the four IOM PHEP research goal areas. Of these, 61 (11%) addressed Research Area 1 (usefulness of training); 39 (7%) addressed Research Area 2 (communications in preparedness and response); 193 (35%) addressed Research Area 3 (sustainable preparedness and response systems); and 39 (7%) addressed Research Area 4 (criteria and metrics to measure effectiveness and efficiency). Twenty-one studies (4%) could be classified into more than one category. The majority of the articles (81%), including commentaries/reviews and case studies, were based on qualitative analysis. Commentaries/review articles were the most common study types (62%).Since 2001, the PHSR literature on PHEP issues has grown at about 33% per year. However, most studies lack a rigorous design, raising questions about the validity of the results.

The objective of this work was to describe and assess the potential impact of the Agency for Healthcare Research and Quality’s, AHRQ’s, children’s health activities. Using AHRQ databases and publications lists and generic search engines, we developed a comprehensive list of AHRQ’s funded children’s health activities (1990–2005) and related publications (1996–2002). We conducted bibliometric analyses and used Stryer’s (2000) approach to categorize their potential impact. We found that AHRQ’s child health portfolio has changed over time with an increase in activities related to patient safety and health information technology, reflecting trends at AHRQ as a whole. Further, AHRQ has contributed a substantial body of new knowledge as a result of its funding for children’s health activities. The bibliometric analysis suggests that AHRQ’s children’s health activities have successfully disseminated research findings and new knowledge through the published literature. Most of the publications present research findings that can be building blocks early in the translation continuum rather than findings that directly inform policy or change clinical practice. Through its funding of children’s health activities, AHRQ has contributed new knowledge that has been disseminated effectively in the published literature. However, while AHRQ has successfully engaged the child health services research community, efforts to broaden into policy, practice and patient arenas have been less successful.

Comparative case studies found that regionalization originated from a crisis or perceived need for a coordinated response, a need to build local public health capacity, or an effort to use federal preparedness funds more efficiently. Regions vary in terms of their congruence with regional structures for partner agencies, such as emergency management agencies, as well as hospital and health services markets and organizational structure. Some focus on building formal organizational relationships to coordinate and sometimes standardize preparedness and response activities or build regional capacity, while others focus on building informal professional networks. Whatever the approach, strong leadership and trust are required for effective planning, emergency response, and sustainability. This article suggests that regionalization improves emergency preparedness by allowing for more efficient use of resources and better coordination and demonstrated progress in terms of planning and coordination; regional capacity-building, training, and exercises; and development of professional networks.

Objective. Survey instruments for evaluating public health preparedness have focused on measuring the structure and capacity of local, state, and federal agencies, rather than linkages among structure, process, and outcomes. To focus evaluation on the latter, we evaluated the linkages among individuals, organizations, and systems using the construct of “connectivity” and developed a measurement instrument. Methods. Results from focus groups of emergency preparedness first responders generated 62 items used in the development sample of 187 respondents. Item reduction and factors analyses were conducted to confirm the scale's components. Results. The 62 items were reduced to 28. Five scales explained 70% of the total variance (number of items, percent variance explained, Cronbach's alpha) including connectivity with the system (8, 45%, 0.94), coworkers (7, 7%, 0.91), organization (7, 12%, 0.93), and perceptions (6, 6%, 0.90). Discriminant validity was found to be consistent with the factor structure. Conclusion. We developed a Connectivity Measurement Tool for the public health workforce consisting of a 34-item questionnaire found to be a reliable measure of connectivity with preliminary evidence of construct validity.

Two examples-the "swine flu affair" in 1976 and the emergence of HIV in the blood supply in the early 1980s-illustrate the difficulties of decision-making in public health. Both cases illustrate trade-offs between product risks and public health benefits, especially with regard to uncertainty in estimates of product risks, public health risks, and the benefits of prevention. The cases also illustrate the tendency of public health policy makers to go all the way or do nothing at all, rather than consider intermediate options that can be adapted as new information emerges. This review suggests three lessons for public health policy makers: (1) be open and honest about scientific uncertainty; (2) communicate with the public, even when the facts are not clear; and (3) consider intermediate, adaptable policy options, such as obtaining more information, thus reducing uncertainty, and building in decision points to reconsider initial policies. Underlying all of these lessons is the need to commission studies to resolve important uncertainties and increase the information base for public communication, and to review regulations and other policy options in the light of the new data that emerge.

Prevention is about saving "statistical lives"-lives that society knows about only through the efforts of public health statisticians like Jack Smith. As Mr. Smith's lifework suggests, statistics in public health are critical for calling attention to problems, identifying risk factors, and suggesting solutions, and ultimately for taking credit for our successes. His work illustrates two important lessons about public health statistics today.First, it's important to get the facts straight. Mr. Smith's experience shows that a careful, thoughtful analysis is not only more convincing in the end, but also brings to light important subtleties not seen in the initial analysis. Second, it takes considerable time and attention to get the facts straight. Jack Smith's work illustrates the importance of partnerships with other federal agencies, state statistical organizations, and private-sector entities.

Background School closure was employed as a non-pharmaceutical intervention against pandemic 2009 H1N1, particularly during the first wave. More than 700 schools in the United States were closed. However, closure decisions reflected significant variation in rationales, decision triggers, and authority for closure. This variability presents the opportunity for improved efficiency and decision-making. Methods We identified media reports relating to school closure as a response to 2009 H1N1 by monitoring high-profile sources and searching Lexis-Nexis and Google news alerts, and reviewed reports for key themes. News stories were supplemented by observing conference calls and meetings with health department and school officials, and by discussions with decision-makers and community members. Results There was significant variation in the stated goal of closure decision, including limiting community spread of the virus, protecting particularly vulnerable students, and responding to staff shortages or student absenteeism. Because the goal of closure is relevant to its timing, nature, and duration, unclear rationales for closure can challenge its effectiveness. There was also significant variation in the decision-making authority to close schools in different jurisdictions, which, in some instances, was reflected in open disagreement between school and public health officials. Finally, decision-makers did not appear to expect the level of scientific uncertainty encountered early in the pandemic, and they often expressed significant frustration over changing CDC guidance. Conclusions The use of school closure as a public health response to epidemic disease can be improved by ensuring that officials clarify the goals of closure and tailor closure decisions to those goals. Additionally, authority to close schools should be clarified in advance, and decision-makers should expect to encounter uncertainty disease emergencies unfold and plan accordingly.

In 1990, the Secretary of Health and Human Services unveiled Healthy People 2000: National Health Promotion and Disease Prevention Objectives (46), which is a milestone in public health. Healthy People 2000 identifies three national health goals: increase the span of healthy life, reduce health disparities among Americans, and achieve access to preventive services for all Americans. The report also details 300 specific objectives for health promo­ tion and disease prevention programs with quantitative targets to be achieved by the year 2000. Meeting these objectives requires agreement by public health statisticians on measures of individual and community health status to guide public health policy development and priorities, especially for state and .local areas, and improvement in the methods, for tracking these measures. Healthy People 2000 challenges public health practitioners to develop surveillance systems that are both meaningful in a public health sense and statistically sound. To clarify this challenge and outline some possible re­ sponses, I begin with some background on the public health assessment activities on which the year 2000 health objectives build and considerations that should guide public health assessment efforts. The next section presents general statistical issues in formulating measurable and meaningful objec­ tives. Other sections are devoted to two specific issues: the development of a small set of health status indicators that is both meaningful and feasible to monitor and special issues associated with setting objectives and determining appropriate targets for state and local areas.

BACKGROUND. The national objectives in Healthy People 2000, drafted by health professionals aware of currently available public health interventions, represent a wealth of information about near-term future mortality and morbidity. METHODS. Life table methods were used to calculate the impact of projected changes in mortality and activity limitation rates on life expectancy and expected disability years. RESULTS. Meeting the mortality objectives would increase life expectancy at birth by 1.5 to 2.1 years, raising life expectancy to 76.6 to 77.2 years. In addition, meeting the target for disability from chronic conditions would increase the number of years of life without activity limitations from 66.8 years to 69.3-69.7 years. If the targets for coronary heart disease and unintentional injury were changed to reflect recent trends, a greater improvement in life expectancy at birth would be achieved: from 1.8 to 2.7 years to 76.9 to 77.8 years. CONCLUSION. Meeting the targets would have an important demographic impact. Including changes in the coronary heart disease and injuries targets, life expectancy in the year 2000 would be above the middle of the ranges used in current Census Bureau projections.

One of the critical policy questions raised by the AIDS epidemic is the proper size of the United States federal government's commitment to AIDS-related research. The extent of the federal government's investment in AIDS-related research in relation to research investments in cancer, coronary heart disease, and unintentional injuries is examined. Appropriation levels for fiscal year 1986 are divided by indexes of projected disease burden for 1991 to create a research investment ratio for each health impairment. Indexes of disease burden include numbers of total deaths, early deaths, expected life years lost, and discounted life years lost and direct economic costs. Despite the uncertainty about the future of the AIDS epidemic, there is no indication that AIDS is being overfunded relative to cancer and heart disease. Injuries appear to receive relatively low funding priority. Confident conclusions about research priority depend upon resolution of qualitative considerations and better understanding of the dynamics of the AIDS epidemic.

"This report contains recommendations reflecting the views of the ASA Technical Panel on the Census Undercount concerning [U.S.] Census Bureau procedures and plans in the fall of 1982." The report consists of technical statistical advice on measurement and estimation problems. A response by Barbara A. Bailar, reflecting the views of the U.S. Census Bureau, is also included (pp. 257-60).

Population projections are key elements of many planning and policy studies but are inherently inaccurate. This study of past population projection errors provides a means for constructing confidence intervals for future projections. We first define a statistic to measure projection errors independently of the size of the population and the length of the projection period. A sample of U.S. Census Bureau and United Nations projections indicates that the distributions of components of the error statistic are relatively stable. We then use this information to construct confidence intervals for the total population of the United States through the year 2000. We find that for projections of total population size, simple projection techniques are more accurate than more complex techniques.

With the history of the U.S. federal budget for fiscal year 1986 as a vehicle, the usual processes in the executive branch and the Congress that establish health research priorities and the unusual developments that have shaped priorities for AIDS are described. In the 3 years between the initial formulation of the AIDS budget and its execution, there were numerous revisions and evidence of poor communication between scientists and policy makers. On the basis of this analysis, two recommendations are made: the director of the National Institutes of Health and the heads of other U.S. Public Health Service agencies should have discretionary funds to use for AIDS activities; and better channels of communication between the Congress, the Public Health Service, and outside biomedical researchers should be established for consultation on priorities for AIDS research.

The National Institutes of Health (NIH) has earned a reputation for excellence in the support and conduct of research to improve the health of the American people. It has maintained its leadership position in the international scientific community in the face of great changes in its political and social environment. Paradoxically, pressures for changes in the mission and organizational structure of the NIH continue to arise. In the past five years there have been proposals to establish at least 11 new institutes at NIH and to transfer four existing agencies into it. Last October Congress passed but President Reagan vetoed . . .

The growth of university-industry research relationships in biotechnology has raised questions concerning their effects, both positive and negative, on universities. A survey of over 1200 faculty members at 40 major universities in the United States reveals that biotechnology researchers with industrial support publish at higher rates, patent more frequently, participate in more administrative and professional activities and earn more than colleagues without such support. At the same time, faculty with industry funds are much more likely than other biotechnology faculty to report that their research has resulted in trade secrets and that commercial considerations have influenced their choice of research projects. Although the data do not establish a causal connection between industrial support and these faculty behaviors, our findings strongly suggest that university-industry research relationships have both benefits and risks for academic institutions. The challenge for universities is to find ways to manage these relationships that will preserve the benefits while minimizing the risks.An analysis is provided of a survey of over 1,200 faculty members at 40 major U.S. universities concerning their research activities and funding by industrial sources. The survey findings suggest that university-industry biotechnology research relationships have both benefits and risks for the university. Faculty members receiving industry support tend to be more productive. They publish, patent, and earn more. They participate in more administrative and professional activities, while teaching as much as other faculty members. However, their research also leads to more unpublished trade secrets, and commercial considerations may influence their choice of projects. The authors recommend public as well as commercial funding of research, protection of the right to publish research results, and university-industry agreements that do not unduly restrict faculty behavior.