viernes, 29 de abril de 2016

Update: Ongoing Zika Virus Transmission — Puerto Rico, November 1, 2015–April 14, 2016 | MMWR

Update: Ongoing Zika Virus Transmission — Puerto Rico, November 1, 2015–April 14, 2016 | MMWR

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MMWR Early Release
Vol. 65, Early Release
April 29, 2016
 
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Update: Ongoing Zika Virus Transmission — Puerto Rico, November 1, 2015–April 14, 2016



Emilio Dirlikov, PhD1,2; Kyle R. Ryff, MPH1; Jomil Torres-Aponte, MS1; Dana L. Thomas, MD1,3; Janice Perez-Padilla, MPH4; Jorge Munoz-Jordan, PhD4; Elba V. Caraballo, PhD4; Myriam Garcia5,6; Marangely Olivero Segarra, MS5,6; Graciela Malave5,6; Regina M. Simeone, MPH7; Carrie K. Shapiro-Mendoza, PhD8; Lourdes Romero Reyes9; Francisco Alvarado-Ramy, MD10; Angela F. Harris, PhD11; Aidsa Rivera, MSN4; Chelsea G. Major, MPH4,12; Marrielle Mayshack1,12; Luisa I. Alvarado, MD13; Audrey Lenhart, PhD14; Miguel Valencia-Prado, MD15; Steve Waterman, MD4; Tyler M. Sharp, PhD4; Brenda Rivera-Garcia, DVM1 (View author affiliations)
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Summary

What is already known about this topic?

Zika virus transmission in Puerto Rico has been ongoing, with the first patient reporting symptom onset in November 2015. Zika virus infection is a cause of microcephaly and other severe birth defects. Zika virus infection has also been associated with Guillain-Barré syndrome.
What is added by this report?

During November 1, 2015–April 14, 2016, a total of 6,157 specimens from suspected Zika virus–infected patients from Puerto Rico were evaluated and 683 (11%) had laboratory evidence of current or recent Zika virus infection. The public health response includes increased capacity to test for Zika virus, preventing infection in pregnant women, monitoring infected pregnant women and their fetus for adverse outcomes, controlling mosquitos, and assuring the safety of blood products.
What are the implications for public health practice?

Residents of and travelers to Puerto Rico should continue to employ mosquito bite avoidance behaviors, take precautions to reduce the risk for sexual transmission, and seek medical care for any acute illness with rash or fever. Clinicians who suspect Zika virus disease in patients who reside in or have recently returned from areas with ongoing Zika virus transmission should report cases to public health officials.


Zika virus is a flavivirus transmitted primarily by Aedes species mosquitoes, and symptoms of infection can include rash, fever, arthralgia, and conjunctivitis (1).* Zika virus infection during pregnancy is a cause of microcephaly and other severe brain defects (2). Infection has also been associated with Guillain-Barré syndrome (3). In December 2015, Puerto Rico became the first U.S. jurisdiction to report local transmission of Zika virus, with the index patient reporting symptom onset on November 23, 2015 (4). This report provides an update to the epidemiology of and public health response to ongoing Zika virus transmission in Puerto Rico. During November 1, 2015–April 14, 2016, a total of 6,157 specimens from suspected Zika virus–infected patients were evaluated by the Puerto Rico Department of Health (PRDH) and CDC Dengue Branch (which is located in San Juan, Puerto Rico), and 683 (11%) had laboratory evidence of current or recent Zika virus infection by one or more tests: reverse transcription–polymerase chain reaction (RT-PCR) or immunoglobulin M (IgM) enzyme-linked immunosorbent assay (ELISA). Zika virus–infected patients resided in 50 (64%) of 78 municipalities in Puerto Rico. Median age was 34 years (range = 35 days–89 years). The most frequently reported signs and symptoms were rash (74%), myalgia (68%), headache (63%), fever (63%), and arthralgia (63%). There were 65 (10%) symptomatic pregnant women who tested positive by RT-PCR or IgM ELISA. A total of 17 (2%) patients required hospitalization, including 5 (1%) patients with suspected Guillain-Barré syndrome. One (<1%) patient died after developing severe thrombocytopenia. The public health response to the outbreak has included increased laboratory capacity to test for Zika virus infection (including blood donor screening), implementation of enhanced surveillance systems, and prevention activities focused on pregnant women. Vector control activities include indoor and outdoor residual spraying and reduction of mosquito breeding environments focused around pregnant women’s homes. Residents of and travelers to Puerto Rico should continue to employ mosquito bite avoidance behaviors, take precautions to reduce the risk for sexual transmission (5), and seek medical care for any acute illness with rash or fever.
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Epidemiologic Surveillance

In response to the introduction of Zika virus, PRDH and CDC Dengue Branch incorporated Zika virus case reporting and diagnostic testing into existing dengue and chikungunya virus surveillance systems and developed a laboratory-based Passive Arboviral Diseases Surveillance System.Health providers submit serum specimens to PRDH from patients with a clinical suspicion of Zika, chikungunya, or dengue virus infection using a case report form.§ Depending on the number of days between onset of illness and specimen collection, specimens are tested for the three arboviruses by a Trioplex RT-PCR assay, for evidence of Zika and dengue virus infection by IgM ELISA, or by both assays (4). Zika virus–infected patients were defined by positive results from either RT-PCR (confirmed) or IgM ELISA with negative dengue virus IgM ELISA (presumptive positive). Zika virus testing has been incorporated into the Sentinel Enhanced Dengue Surveillance System, which tests specimens from all febrile patients treated at either one outpatient clinic or one hospital emergency department in Ponce. Tissue and blood specimens collected during autopsy from patients who died after an acute febrile illness are tested for Zika virus infection through the Enhanced Fatal Acute Febrile Illness Surveillance System.** Following CDC interim guidance (6), symptomatic pregnant women are tested using the diagnostic algorithm, and asymptomatic pregnant women are tested for evidence of Zika and dengue virus infection by IgM ELISA. Initiated in February 2016, the Guillain-Barré syndrome Passive Surveillance System allows health providers from across the island to report clinically suspected Guillain-Barré syndrome cases by sending a case report form and serum specimen to PRDH.†† Specimens from patients with suspected Guillain-Barré syndrome are tested by both RT-PCR and IgM ELISA for all three arboviruses. Diagnostic test results are managed through an integrated data management system. Results are reported to providers, and aggregate data are available online in a weekly arboviral report.§§
During November 1, 2015–April 14, 2016, specimens from 6,157 suspected arbovirus-infected patients were evaluated and 683 (11%) were either laboratory-confirmed or presumptive positive for Zika virus infection (Table). Of these 683 Zika virus laboratory confirmed or presumptive patients, 581 (85%) were confirmed by RT-PCR, 73 (11%) were presumptive positive by IgM ELISA, and 29 (4%) were positive by both RT-PCR and IgM ELISA. Dengue, chikungunya, or unspecified flavivirus infection was identified in 110 (2%), 61 (1%), and 32 (<1%) suspected arbovirus-infected patients, respectively. No patients with evidence of coinfection with Zika, dengue, or chikungunya viruses were identified by RT-PCR. Of all identified Zika virus–infected patients, 646 (95%) were reported to the Passive Arboviral Diseases Surveillance System. Thirty-two (5%) Zika virus–infected patients were reported through the Sentinel Enhanced Dengue Surveillance System. Five (1%) suspected cases of Guillain-Barré syndrome reported to the Guillain-Barré syndrome Passive Surveillance System were presumptive positive for Zika virus infection, and two had unspecified flavivirus infection.
Weekly Zika virus disease case counts gradually increased since late November 2015, whereas incidence of dengue and chikungunya cases remained comparatively low (Figure 1). Zika virus–infected patients were reported from 50 (64%) of the 78 total municipalities (Figure 2); 146 (21%) patients were residents of the San Juan metropolitan area. Among all identified Zika virus–infected patients, 436 (64%) were female, and median age was 34 years (range = 35 days–89 years). The most frequently reported signs and symptoms were rash (74%), myalgia (68%), headache (63%), fever (63%), and arthralgia (63%). Thrombocytopenia (defined as blood platelets levels <100,000 cells/mm3) was reported in nine (1%) cases. Sixty-five (10%) symptomatic pregnant women were Zika virus–infected patients. Seventeen (2%) patients required hospitalization, including five (1%) suspected Guillain-Barré syndrome cases. In one (<1%) identified Zika virus–associated case, the patient died of complications related to severe thrombocytopenia.
To ensure the safety of the blood supply, Puerto Rico imported all blood products from the United States during March 5–April 14 (7). On April 2, blood collection resumed with donor screening using a Food and Drug Administration–approved Zika virus investigational nucleic acid detection test (Roche Molecular Systems, Inc., Pleasanton, California). Emergency blood imports ended on April 15. During April 2–14, nine (<1%) of 1,910 screened donated blood units had positive test results. These units were removed from the blood supply, and testing is pending to confirm presumptive Zika virus infection.
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Public Health Response

Through the Zika Active Pregnancy Surveillance System, Zika virus–infected pregnant women and their offspring are monitored for adverse maternal, fetal, neonatal, infant, and child health outcomes.¶¶ Surviving offspring across the island will be referred to the Children with Special Health Care Needs program for developmental surveillance and coordination of specialized services, as needed, up to age 3 years. The Birth Defects Surveillance System*** will identify newborns with congenital microcephaly, including those born to women infected with Zika virus during pregnancy, and refer all cases to Avanzando Juntos, Puerto Rico's Early Intervention Services System.
With CDC’s assistance, PRDH has also implemented comprehensive strategies to prevent Zika virus transmission. Health messaging, including posters and electronic monitors, have been implemented and health education materials are available at various locations, including health care facilities and ports of entry. Community intervention strategies have focused on pregnant women. PRDH has worked closely with Women, Infants, and Children (WIC) clinics, where 90% of Puerto Rican pregnant women received services in 2015 (Dana Miró Medina, WIC Puerto Rico, personal communication, 2016). As of April 13, a total of 13,351 pregnant women participated in Zika virus educational orientations offered by WIC clinics. PRDH and the CDC Foundation financed the purchase and delivery of Zika Prevention Kits, which include locally adapted health information, mosquito repellent, a bed net, larvicidal tablets (tablets placed in water sources where mosquitoes might breed that prevent larvae from maturating into adults), and condoms. In addition, to reduce the risk for unintended pregnancies with adverse fetal outcomes related to Zika virus infection, the response includes increasing the availability of contraceptives (8).
During February–March, an insecticide resistance study of Aedes aegypti mosquitoes was conducted to develop vector control strategies, such as truck-mounted, ultra-low volume spraying and indoor and outdoor residual spraying. Mosquitoes from across Puerto Rico were tested using the CDC bottle bioassay to determine insecticide susceptibility, particularly against pyrethroids. Results indicated a high degree of geographical variation with respect to susceptibility to insecticides, and deltamethrin was identified as the most suitable pyrethroid candidate for use in vector control programs (data not shown). Insecticide susceptibility surveillance is ongoing.
A home-based vector control program focused on pregnant women is underway. Women are contacted through WIC clinics, and are offered source reduction services (e.g., removal of water containers that can serve as mosquito breeding sites), larvicide application, and indoor and outdoor residual spraying using deltamethrin. PRDH and CDC have collaborated with the Puerto Rico Department of Housing to incorporate these services into its vector control activities.
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Discussion

Zika virus remains a public health challenge in Puerto Rico, and cases are expected to continue to occur throughout 2016. Building upon existing dengue and chikungunya virus surveillance systems, PRDH collaborated with CDC to establish a comprehensive surveillance system to characterize the incidence and epidemiology of Zika virus disease on the island. Expanded laboratory capacity and surveillance provided timely availability of data, allowing for continuous analysis and adapted public health response. Following CDC guidelines, both symptomatic and asymptomatic pregnant women are tested for evidence of Zika virus infection. Information from the Zika Active Pregnancy Surveillance System will be used to raise awareness about the complications associated with Zika virus during pregnancy, encourage prevention through use of mosquito repellent and other methods, and inform health care providers of the additional care needed by women infected with Zika virus during pregnancy, as well as congenitally exposed fetuses and children. In addition, the prevalence of adverse fetal outcomes documented through this system can be compared with baseline rates as further evidence of associations between Zika virus infections and adverse outcomes, such as microcephaly (2).
The finding that women constitute the majority of cases might be attributable to targeted outreach and testing. The most common symptoms among Zika virus disease cases were rash, myalgia, headache, fever, and arthralgia, which are similar to the most common signs and symptoms reported elsewhere in the Americas (9). Although Zika virus–associated deaths are rare (10), the first identified death in Puerto Rico highlights the possibility of severe cases, as well as the need for continued outreach to raise health care providers’ awareness of complications that might lead to severe disease or death. To ensure continued blood safety, blood collection resumed with a donor screening program for Zika virus infection, and all units screened positive are removed.
Residents of and travelers to Puerto Rico should continue to employ mosquito bite avoidance behaviors, including using mosquito repellents, wearing long-sleeved shirts and pants, and ensuring homes are properly enclosed (e.g., screening windows and doors, closing windows, and using air conditioning) to avoid bites while indoors.††† To reduce the risk for sexual transmission, especially to pregnant women, precautions should include consistent and proper use of condoms or abstinence (5). Such measures can also help avoid unintended pregnancies and minimize risk for fetal Zika virus infection (6). Clinicians who suspect Zika virus disease in patients who reside in or have recently returned from areas with ongoing Zika virus transmission should report cases to public health officials.
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Acknowledgment

Kathryn Conlon, PhD, National Center for Environmental Health, CDC.
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Corresponding author: Emilio Dirlikov, Zika@salud.gov.pr, 787-765-2929.
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1Office of Epidemiology and Research, Puerto Rico Department of Health; 2Epidemic Intelligence Service, Division of Scientific Education and Professional Development, CDC; 3Division of State and Local Readiness, Office of Public Health Preparedness and Response, CDC; 4Division of Vector-Borne Diseases, National Center for Emerging and Zoonotic Infectious Diseases, CDC; 5Biological and Chemical Emergencies Laboratory, Office of Public Health Preparedness and Response, Puerto Rico Department of Health; 6Public Health Laboratory, Puerto Rico Department of Health; 7Division of Congenital and Developmental Disorders, National Center on Birth Defects and Developmental Disabilities, CDC; 8Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC ; 9Puerto Rico Women, Infants, and Children Program; 10Division of Global Migration and Quarantine, National Center for Emerging and Zoonotic Infectious Diseases, CDC; 11Bill & Melinda Gates Foundation, Seattle, WA; 12Office for State, Tribal, Local, and Territorial Support, CDC; 13Ponce Health Sciences University-Saint Luke’s Episcopal Hospital Consortium, Puerto Rico; 14Division of Parasitic Diseases and Malaria, Center for Global Health, CDC; 15Puerto Rico Birth Defects Surveillance and Prevention System, Puerto Rico Department of Health.
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References

  1. Petersen LR, Jamieson DJ, Powers AM, Honein MA. Zika virus. N Engl J Med 2016;374:1552–63. CrossRef PubMed
  2. Rasmussen SA, Jamieson DJ, Honein MA, Petersen LR. Zika virus and birth defects—reviewing the evidence for causality. N Engl J Med 2016. Epub April 13, 2016.http://www.nejm.org/doi/full/10.1056/NEJMsr1604338http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=27074377&dopt=Abstract PubMed
  3. Cao-Lormeau VM, Blake A, Mons S, et al. Guillain-Barré syndrome outbreak associated with Zika virus infection in French Polynesia: a case-control study. Lancet 2016;387:1531–9.CrossRef PubMed
  4. Thomas DL, Sharp TM, Torres J, et al. Local transmission of Zika virus—Puerto Rico, November 23, 2015-January 28, 2016. MMWR Morb Mortal Wkly Rep 2016;65:154–8. CrossRefPubMed
  5. Oster AM, Russell K, Stryker JE, et al. Update: interim guidance for prevention of sexual transmission of Zika virus—United States, 2016. MMWR Morb Mortal Wkly Rep 2016;65:323–5.CrossRef PubMed
  6. Petersen EE, Polen KN, Meaney-Delman D, et al. Update: interim guidance for health care providers caring for women of reproductive age with possible Zika virus exposure—United States, 2016. MMWR Morb Mortal Wkly Rep 2016;65:315–22. CrossRef PubMed
  7. Vasquez AM, Sapiano MR, Basavaraju SV, Kuehnert MJ, Rivera-Garcia B. Survey of blood collection centers and implementation of guidance for prevention of transfusion-transmitted Zika virus infection—Puerto Rico, 2016. MMWR Morb Mortal Wkly Rep 2016;65:375–8. CrossRef PubMed
  8. Tepper NK, Goldberg HI, Bernal MI, et al. Estimating contraceptive needs and increasing access to contraception in response to the Zika virus disease outbreak—Puerto Rico, 2016. MMWR Morb Mortal Wkly Rep 2016;65:311–4. CrossRef PubMed
  9. Brasil P, Calvet GA, Siqueira AM, et al. Zika virus outbreak in Rio de Janeiro, Brazil: clinical characterization, epidemiological and virological aspects. PLoS Negl Trop Dis 2016;10:e0004636.CrossRef PubMed
  10. Sarmiento-Ospina A, Vásquez-Serna H, Jimenez-Canizales CE, Villamil-Gómez WE, Rodriguez-Morales AJ. Zika virus associated deaths in Colombia. Lancet Infect Dis 2016;16:523–4.CrossRef PubMed
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** The Enhanced Fatal Acute Febrile Illness Surveillance System is co-operated by PRDH, Institute of Forensic Sciences of Puerto Rico, and CDC.
†† Patients from across the island with clinical suspicion of Guillain-Barré syndrome can be reported to PRDH (http://www.salud.gov.pr/Sobre-tu-Salud/Documents/ingl%c3%a9s.pdf).
¶¶ Zika Active Pregnancy Surveillance System is co-operated by PRDH and CDC.
*** PRDH routinely monitors birth defects throughout the island through the Birth Defect Surveillance System.

blog.aids.gov − May Is Hepatitis Awareness Month

blog.aids.gov − May Is Hepatitis Awareness Month

update from the aids dot gov blog

MAY IS HEPATITIS AWARENESS MONTH

Rich Wolitski - headshot - March 2016
Richard J. Wolitski, Ph.D., Acting Director, Office of HIV/AIDS and Infectious Disease Policy, U.S. Department of Health and Human Services
Each May, many partners across the federal government, including the Department of Health and Human Services (HHS) and its agencies, join with numerous non-federal and community allies to raise awareness of viral hepatitis during Hepatitis Awareness Month. The month-long observance includes national Hepatitis Testing Day on May 19th. These represent important opportunities to promote hepatitis testing and improve outcomes for the estimated3.4 million to 5.3 million people living with viral hepatitis in the U.S., many of whom do not know they are infected. Chronic hepatitis B virus (HBV) and hepatitis C virus (HCV) infection can lead to serious liver disease, liver cancer, and death if undiagnosed and untreated.
White House to Host National Hepatitis Testing Day Event May 19
This year the White House, in collaboration with HHS, will host a special event, Responding to Viral Hepatitis in the U.S. – A National Hepatitis Testing Day Observance, on May 19th. Representatives from the White House Offices of National Drug Control Policy (ONDCP) and National AIDS Policy (ONAP), the Office of the Assistant Secretary for Health, CDC, and the Health Resources and Services Administration (HRSA), as well as partners from state and community groups will discuss key issues facing our country in the fight against hepatitis. You’ll be able to watch a live stream of the event. We’ll share more details about the event here on the blog soon, including the link to the live webcast.
Hepatitis Awareness-Month - cropped - May 2016Join in the Observances
Hepatitis Awareness Month offers all stakeholders across the nation an important opportunity to generate greater awareness of viral hepatitis as a critical health concern among the public and health care providers. More widespread understanding about how to prevent, diagnose, and treat viral hepatitis is essential if we are to prevent new infections and poor health outcomes, including hepatitis-related liver cancer and deaths, among those living with viral hepatitis.  Here are some of the opportunities to get involved and spread the word:
Tools to Support You
CDC’s Hepatitis Awareness Month and Testing Day Resource Center has free tools to help support your awareness activities and testing events.  In addition, CDC has developed a host of resources that you can use to help increase awareness and understanding of viral hepatitis. Check out the available factsheets, provider resources, awareness videos, posters, and other materials from these national education campaigns:Know More Hepatitis
  • The Know More Hepatitis campaign encourages HCV testing among people born between 1945-1965 (“baby boomers”), since baby boomers comprise approximately 75% of persons with chronic HCV infection and most people with hepatitis C don’t know they are infected.
  • The multi-lingual Know Hepatitis B campaign was designed to increase awareness of HBV among Asian Americans and Pacific Islanders (AAPIs), a group disproportionately impacted by chronic HBV infection with 1 in 12 AAPIs living with HBV.
hepatitis - Know Hep B“Despite a number of important advances in viral hepatitis testing, care, and treatment in recent years, awareness of HBV and HCV remain unfortunately low among both affected populations and healthcare providers,” observed my colleague Corinna Dan, R.N., M.P.H., Viral Hepatitis Policy Advisor in the HHS Office of HIV/AIDS and Infectious Disease Policy. “That’s why it is vitally important for all stakeholders – federal and nonfederal alike – to make the most of opportunities like Hepatitis Awareness Month and Hepatitis Testing Day to educate as many people as possible. These efforts will help us achieve the U.S. Viral Hepatitis Action Plan’s [PDF 2.05 MB] goals of increasing the proportion of people living with HBV and HCV aware of their infection so they can take steps to protect their health and prevent transmission to others.”
Won’t you join us by taking action in May, Hepatitis Awareness Month, that will contribute to more widespread awareness of viral hepatitis and expand our combined national efforts to improve the health of people living with chronic viral hepatitis?

Teen birth rates fall nearly 50 percent among Hispanic and black teens, dropping national teen birth rate to an all-time low | CDC Online Newsroom | CDC

Teen birth rates fall nearly 50 percent among Hispanic and black teens, dropping national teen birth rate to an all-time low | CDC Online Newsroom | CDC





Teen birth rates fall nearly 50 percent among Hispanic and black teens, dropping national teen birth rate to an all-time low

But important gaps remain for many communities


Press Release

Embargoed Until: Thursday, April 28, 2016, 1:00 p.m. ET
Contact: Media Relations
(404) 639-3286
Births among Hispanic and black teens have dropped by almost half since 2006, according to a new analysis published by CDC. This mirrors a substantial national decline: births to all American teenagers have dropped more than 40 percent within the past decade. Despite this progress, key challenges persist for many communities, according to the report.
While dramatic declines among Hispanic and black teens (51 percent and 44 percent, respectively) have helped reduce gaps, birth rates remain twice as high for these teens nationally compared with white teens. Published today in CDC’s Morbidity and Mortality Weekly Report, the new analysis highlights key community- and state-level patterns:
  • Dramatic racial and ethnic differences: In some states, birth rates among Hispanic and black teens were more than three times as high as those of whites.
  • Socioeconomic and education gaps: Higher unemployment and lower income and education are more common in communities with the highest teen birth rates, regardless of race.
  • Key in-state differences: In some states with low overall birth rates, pockets of high birth rates exist in some counties.
  • Regional patterns: Counties with higher teen birth rates were clustered in southern and southwestern states.
“The United States has made remarkable progress in reducing both teen pregnancy and racial and ethnic differences, but the reality is, too many American teens are still having babies,” said CDC Director Tom Frieden, M.D., M.P.H. “By better understanding the many factors that contribute to teen pregnancy we can better design, implement, evaluate, and improve prevention interventions and further reduce disparities.”
In the new report, CDC researchers analyzed national- and state-level data from the National Vital Statistics System (NVSS) to examine trends in births to American teens ages 15 to 19 years between 2006 and 2014. County-level NVSS data for 2013 and 2014 also offer a point-in-time picture of local birth rates. To better understand the relationship between key social and economic factors and teen birth rates, researchers examined data from the American Community Survey between 2010 and 2014. 
Researchers highlight the importance of teen pregnancy prevention interventions that address socioeconomic conditions like unemployment and lower education levels, for reducing disparities in teen birth rates. State and community leaders can use local data to better understand teen pregnancy in their communities and to direct programs and resources to areas with the greatest need.
“These data underscore that the solution to our nation’s teen pregnancy problem is not going to be a one-size-fits-all – teen birth rates vary greatly across state lines and even within states,” said Lisa Romero, Dr.PH., a health scientist in CDC’s Division of Reproductive Health and lead author of the analysis. “We can ensure the success of teen pregnancy prevention efforts by capitalizing on the expertise of our state and local public health colleagues. Together, we can work to implement proven prevention programs that take into account unique, local needs.”
Research has shown that teen pregnancy and childbirth cost U.S. taxpayers an estimated $9 billion each year and have negative health and social consequences. 
Preventing teen pregnancy remains one of CDC’s top priorities and the agency is working on a number of fronts. One key component of this work is encouraging community-centered efforts. For example, between 2010 and 2015, CDC and the HHS Office of Adolescent Health (OAH) collaborated to demonstrate the effectiveness of innovative, multicomponent, communitywide initiatives in reducing rates of teen pregnancy and births in communities with the highest rates, with a focus on reaching African American and Latino or Hispanic young people ages 15 to 19 years. Preliminary outcome data indicate that the community-wide initiatives were successful - each community increased the number of teens who received evidence-based teen pregnancy prevention interventions and reproductive health services, as well as the percentage of teens who received moderately or highly effective contraceptive methods, including long-acting reversible contraception. Many of those strategies are now being implemented across the U.S. through 84 new five-year teen pregnancy prevention grants supported by OAH.
May is Teen Pregnancy Prevention Month. Communities can use this new information about teen pregnancy in the U.S. to inform the dialogue aboutpregnancy and its health and social consequences for youth.

Surveillance for Certain Health Behaviors, Chronic Diseases, and Conditions, Access to Health Care, and Use of Preventive Health Services Among States and Selected Local Areas — Behavioral Risk Factor Surveillance System, United States, 2012 | MMWR

Surveillance for Certain Health Behaviors, Chronic Diseases, and Conditions, Access to Health Care, and Use of Preventive Health Services Among States and Selected Local Areas — Behavioral Risk Factor Surveillance System, United States, 2012 | MMWR

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MMWR Surveillance Summaries
Vol. 65, No. SS-4
April 29, 2016
 
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Surveillance for Certain Health Behaviors, Chronic Diseases, and Conditions, Access to Health Care, and Use of Preventive Health Services Among States and Selected Local Areas — Behavioral Risk Factor Surveillance System, United States, 2012



Pranesh P. Chowdhury, MD1; Tebitha Mawokomatanda, MSPH1; Fang Xu, PhD1; Sonya Gamble, MS1; David Flegel, MS2; Carol Pierannunzi, PhD1; William Garvin, MS1; Machell Town, PhD1 (View author affiliations)
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Abstract

Problem: Chronic diseases (e.g., heart diseases, cancer, chronic lower respiratory disease, stroke, diabetes, and arthritis) and unintentional injuries are the leading causes of morbidity and mortality in the United States. Behavioral risk factors (e.g., tobacco use, poor diet, physical inactivity, excessive alcohol consumption, failure to use seat belts, and insufficient sleep) are linked to the leading causes of death. Modifying these behavioral risk factors and using preventive health services (e.g., cancer screenings and influenza and pneumococcal vaccination of adults aged ≥65 years) can substantially reduce morbidity and mortality in the U.S. population. Continuous monitoring of these health-risk behaviors, chronic conditions, and use of preventive services are essential to the development of health promotion strategies, intervention programs, and health policies at the state, city, and county level.
Reporting Period: January–December 2012.
Description of the System: The Behavioral Risk Factor Surveillance System (BRFSS) is an ongoing, state-based, random-digit–dialed landline- and cellular-telephone survey of noninstitutionalized adults aged ≥18 years residing in the United States. BRFSS collects data on health-risk behaviors, chronic diseases and conditions, access to health care, and use of preventive health services related to the leading causes of death and disability. This report presents results for all 50 states, the District of Columbia, participating U.S. territories that include the Commonwealth of Puerto Rico (Puerto Rico) and Guam, 187 Metropolitan/Micropolitan Statistical Areas (MMSAs), and 210 counties (n = 475,687 survey respondents) for the year 2012.
Results: In 2012, the estimated prevalence of health-risk behaviors, chronic diseases or conditions, access to health care, and use of preventive health services substantially varied by state and territory, MMSA, and county. The following portion of the abstract lists a summary of results by selected BRFSS measures. Each set of proportions refers to the range of estimated prevalence for health-risk behaviors, chronic diseases or conditions, and use of preventive health care services among geographical units, as reported by survey respondents. Adults with good or better health: 64.0%–88.3% for states and territories, 62.7%–90.5% for MMSAs, and 68.1%–92.4% for counties. Adults aged 18–64 years with health care coverage: 64.2%–93.1% for states and territories, 35.4%– 93.7% for MMSAs, and 35.4%–96.7% for counties. Adults who received a routine physical checkup during the preceding 12 months: 55.7%–80.1% for states and territories, 50.6%–85.0% for MMSAs, and 52.4%–85.0% for counties. An influenza vaccination received during the preceding 12 months among adults aged ≥65 years: 26.3%–70.1% for states and territories, 20.8%–77.8% for MMSAs, and 24.1%–77.6% for counties. Ever received pneumococcal vaccination among adults aged ≥65 years: 22.2%–76.2% for states and territories, 15.3%–83.4% for MMSAs, and 25.8%–85.2% for counties. Adults who had a dental visit in the past year: 53.7%–76.2% for states and territories, and 44.8%–81.7% for MMSAs and counties. Adults aged ≥65 years who have lost all of their natural teeth from tooth decay or gum disease: 7.0%–33.7% for states and territories, 5.8%–39.6% for MMSAs, and 5.8%–37.1% for counties. Adults aged 50–75 years who received a colorectal cancer screening on the basis of the U.S. Preventive Services Task Force recommendation: 40.0%–76.4% for states and territories, 47.1%–80.7% for MMSAs, and 47.0%–81.0% for counties. Women aged 21–65 years who had a Papanicolaou test during the preceding 3 years: 68.5% to 89.6% for states and territories, 70.3% to 92.8% for MMSAs, and 65.7%–94.6% for counties. Women aged 50–74 years who had a mammogram during the preceding 2 years: 66.5%– 89.7% for states and territories, 61.1%–91.5% for MMSAs, and 61.8%–91.6% for counties. Current cigarette smoking among adults: 10.6%–28.3% for states and territories, 5.1%–30.1% for MMSAs, and 5.1%–28.3% for counties. Binge drinking among adults during the preceding month: 10.2%–25.2% for states and territories, 6.2%–28.1% for MMSAs, and 6.2%–29.5% for counties. Heavy drinking among adults during the preceding month: 3.5%–8.5% for states and territories, 2.0%–11.0% for MMSAs, and 1.9%–11.0% for counties. Adults who reported no leisure-time physical activity: 16.3%–42.4% for states and territories, 9.2%–47.3% for MMSAs, and 9.2%–39.0% for counties. Self- reported seat belt use: 62.0%–93.7% for states and territories, 54.1%–97.1% for MMSAs, and 50.1%–97.4% for counties. Adults who were obese: 20.5%–34.7% for states and territories, 14.8%–44.5% for MMSAs and counties. Adults with diagnosed diabetes: 7.0%–16.4% for states and territories, 3.4%–17.4% for MMSAs, and 3.1%–17.4% for counties. Adults who ever had any type of cancer: 3.0%–13.7% for states and territories, 3.8%–19.2% for MMSAs, and 4.5%–19.2% for counties. Adults with current asthma: 5.8%–11.1% for states and territories, 3.1%–15.0% for MMSAs, and 3.1%–15.7% for counties. Adults with some form of arthritis: 15.6%–36.4% for states and territories, 16.8%–45.8% for MMSAs, and 14.8%–35.9% for counties. Adults having had a depressive disorder: 9.0%–23.5% for states and territories, 9.2%–28.3% for MMSAs, and 8.5%–28.4% for counties. Adults aged ≥45 years who have had coronary heart disease: 7.4%–19.0% for states and territories, 6.1%–23.3% for MMSAs, and 6.1%–20.6% for counties. Adults aged ≥45 years who have had a stroke: 3.1%–7.3% for states and territories, 2.1%–9.3% for MMSAs, and 1.5%–9.3% for counties. Adults with limited activities because of physical, mental, or emotional problems: 15.0%–28.6% for states and territories, 12.0%–31.7% for MMSAs, and 11.3%–31.7% for counties. Adults using special equipment because of any health problem: 4.8%–11.6% for states and territories, 4.0%–14.7% for MMSAs, and 2.8%–13.6% for counties.
Interpretation: This report underscores the need for continuous surveillance of health-risk behaviors, chronic diseases or conditions, health care access, and use of preventive care services at state and local levels. It will help to identify high-risk populations and to evaluate public health intervention programs and policies designed to reduce morbidity and mortality from chronic disease and injury.
Public Health Action: State and local health departments and agencies can continue to use BRFSS data to identify populations at high risk for unhealthy behaviors and chronic diseases or conditions, lack of health care access, and inadequate use of preventive care services. Additionally, states can use the data to design, implement, monitor, and evaluate public health programs and policies at state and local levels.
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Introduction

The goals of national health promotion and disease prevention are to prevent or delay disease, decrease premature mortality, and improve health-related quality of life for all U.S. residents (1). Chronic diseases (e.g., heart disease, cancer, chronic lower-respiratory disease, stroke, diabetes, and arthritis) and unintentional injuries are the leading causes of death and disability in the United States (2). Engaging in healthy behaviors (e.g., quitting smoking, being more physically active, wearing seat belts while riding in vehicles, getting sufficient sleep, reducing alcohol consumption, and eating a nutritious diet) and using preventive services (e.g., routine medical checkup, blood pressure and cholesterol screening, cancer screening, and recommended vaccinations) can reduce morbidity and premature mortality from these chronic diseases and injuries (3). Monitoring health-risk behaviors, chronic diseases or conditions, and the use of preventive services to help identify high-risk groups with the greatest need for intervention is important for preventing morbidity and mortality and unintentional injuries.
The Behavioral Risk Factor Surveillance System (BRFSS) is a state-based landline and cellular telephone survey conducted by state health departments with assistance from CDC (4). Since 1984, BRFSS has been a unique source of data for health-risk behaviors, chronic diseases or conditions, health care access, and the use of preventive health services for states/territories. Since 2002, the large sample size in BRFSS has facilitated calculation of prevalence estimates for selected Metropolitan and Micropolitan Statistical Areas (MMSAs), metropolitan divisions, and selected counties (5). BRFSS data are frequently used to set health goals as well as to monitor progress of public health programs and policy implementation at national, state, and local levels (6). This report provides prevalence estimates for selected health-risk behaviors, health care access, use of preventive care services, and chronic diseases or conditions by states/territories, selected MMSAs, and selected counties for 2012.
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Methods

BRFSS is the largest continuously conducted telephone health survey in the world with approximately 400,000 adult interviews completed each year. BRFSS is conducted by states with assistance from CDC. BRFSS uses a multistage sampling design to select a representative sample of the noninstitutionalized civilian population aged ≥18 years residing in states and territories of the Unites States (7). All the responses were self-reported; proxy interviews are not conducted by BRFSS.
Since 2011, BRFSS includes both landline telephone- and cellular telephone-based surveys. In conducting the BRFSS landline telephone survey, interviewers collect data from a randomly selected adult in a household. Cellular telephone interviews are treated as one-person adult household, and survey interviewers collect data from adults answering the cellular telephones (4). Using a dual-frame survey including combined landline and cellular telephones improved validity, data quality, and representativeness of BRFSS data (8).
Details on methodology, random sampling procedures, design, and reliability and validity of measures used in BRFSS have been described previously (9,10). MMSA and metropolitan divisions are defined by the Office of Management and Budget. County names were collected from the respondents during the demographics section of the interviews and were used to determine the corresponding American National Standards Institute county codes. Respondents were assigned to MMSAs on the basis of their county codes. MMSAs were included in this report if there were ≥500 respondents; similarly counties that had ≥500 respondents were included for county level estimates (11).
This report provides prevalence estimates for selected health risk behaviors, use of preventive health care services, and chronic conditions among residents living in the 50 states, the District of Columbia (DC), Guam, Puerto Rico, 187 MMSAs, and 210 counties.

Questionnaire

All questions included in BRFSS go through technical review, cognitive testing, and field testing before being placed in the questionnaire. The standard BRFSS questionnaire consists of three sections: core questions, optional modules, and state-added questions. Eligible respondents answer the same core questions. Optional modules were selected by states on the basis of the specific needs and goals of the programs in each state’s health department. Although core questions are always collected on both landline telephone and cellular telephones, optional module data might have been collected by landline telephone or cellular telephone. Not all modules are used by every state, and states can opt out of collecting any module data. States could have chosen to split the modules by dividing the samples so only a portion of the respondents answer certain module questions. In 2012, there were as many as three module versions; there were no split versions of a module whose data were collected only by cellular telephone. State-added questions are developed or acquired by participating states and are added to their questionnaires; they are not edited or evaluated by CDC.
The 2012 core questions (12) were used to inquire about participants’ health status, number of healthy days in the past 30 days, health care access, exercise, inadequate sleep, chronic health conditions, oral health, demographics, disability, tobacco use, alcohol consumption, immunization, falls, seat belt use, drinking and driving, breast and cervical cancer screening, prostate cancer screening, colorectal cancer screening, and human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS). The following optional models were used by at least one state in both the landline and cellular telephone survey during 2012 data collection: adult asthma history (two states), adult human papilloma virus (HPV) (six states), adverse childhood experience (four states), cancer survivorship (six states), childhood asthma prevalence (33 states), childhood immunization (12 states), chronic obstructive pulmonary disease (11 states), diabetes (28 states), excess sun exposure (four states), consumption of fruits and vegetables (five states), general preparedness (two states), HIV/AIDS (two states), inadequate sleep (four states), mental illness and stigma (11 states), prediabetes (26 states), prostate cancer screening decision making module (three states), random child selection (36 states), reaction to race (two states), shingles (Zostavax or ZOS) (four states), social context (five states), sugar-sweetened beverages and menu labeling (11 states), tetanus-diphtheria vaccination in adults (four states), and veteran’s health (two states).

Data Collection and Processing

BRFSS data are collected according to standard BRFSS protocol across all states, DC, and participating territories (4). States can conduct interviews internally or opt to contract with a private company or university to conduct interviews but maintain standard procedures to ensure respondents’ confidentiality, document the quality of the interviewing process, and supervise and monitor the interviewers. Since 2007, BRFSS surveys have been collected monthly in all 50 states, DC, and participating U.S. territories. State-collected data are submitted to CDC for processing, checking, and weighting.

Sampling

A BRFSS sample record is one telephone number in the list of all telephone numbers selected for dialing. States obtain two types of samples of telephone numbers from CDC: one for landline telephone respondents and one for cellular telephone respondents. For the landline survey, all 50 states and DC used a disproportionate stratified sample (DSS) design; but Guam and Puerto Rico used a simple random sample design (4). In a DSS design, landline telephone numbers are divided into two groups, or strata: high-density and medium-density strata containing telephone numbers that are expected to belong mostly to households. The two strata are sampled to obtain a probability sample of all households with telephones. For the cellular telephone survey, phone samples are randomly drawn from confirmed cellular telephone sampling frames for each state (4). The target population for cellular telephone samples consist of adults aged ≥18 years, living in households or college housing who have a working cellular telephone, and receive ≥90% of their calls on cellular telephones (13). Because of the portability of the cellular telephone, some of the numbers in the cellular telephone sample will reach respondents who have moved into other states. In those cases, the contacting state completes the core BRFSS interview with respondents from other states; data from out-of-state interviews are transferred to the appropriate states at the end of each data-collection period.

Data Weighting

In 2011, a new weighting methodology called iterative proportional fitting (or “raking”) replaced post stratification. The latter had been used to weight the data every year before 2011. Raking allows incorporation of cellular telephone survey data and permits the introduction of additional demographic characteristics (e.g., education level, marital status, and home renter/owner) in addition to age-race/ethnicity-sex that improves the degree and extent to which the BRFSS sample properly reflects the sociodemographic make-up of both individual states and, when aggregated, the entire United States (14). After combining landline and cellular telephone data, BRFSS performs raking by adjusting one or a combination of demographic categories at a time in an iterative process until a convergence of a set value is reached. During 2012, state-level BRFSS raking included the following demographic categories: sex by age, detailed race and ethnicity groups, education levels, marital status, home renter/owner, sex by race and ethnicity, age groups by race and ethnicity, and phone-source. Those states that used regional weighting also included four additional categories: region, region by age, region by sex, and region by race and ethnicity. The state-level weights were raked to five margins including age group, sex, race and ethnicity group, sex by age group, and sex by race and ethnicity group at the MMSA or county level to produce MMSA or county weights. Information about weighting MMSA and county BRFSS data can be found on the BRFSS SMART webpage (11).

Statistical Analyses

To account for the complex sampling design of BRFSS, all the prevalence estimates were computed on the basis of a statistical analysis (SAS version 9.3, SAS Institute Inc., Cary, NC, USA) using weights and strata. The prevalence estimates in this report are direct estimates. This report provides unweighted sample size, weighted prevalence estimates with standard errors, and 95% confidence intervals for prevalence of health-risk behaviors, chronic diseases or conditions, and use of preventive health care services by states and territories, MMSAs, and counties on the basis of 2012 BRFSS data. If the unweighted sample size was represented by <50 survey participants or the relative standard error (RSE) was >30%, the results were suppressed to avoid unstable estimates. RSE was calculated by dividing the standard error by the estimated prevalence and multiplying by 100 (for percent). Responses coded as “do not know” or “refused” were excluded from the analyses.

About This Report

This report presents the results and a discussion of the following topics: 1) health status indicators (self-rated health status and health care coverage for persons aged 18–64 years), 2) preventive practices (recent routine physical checkup, influenza vaccination, and pneumococcal vaccination for persons aged ≥65 years), 3) oral health (dental visit in the past year and loss of all natural teeth among adults aged ≥65 years), 4) cancer screening (e.g., colorectal cancer screening, cervical cancer screening, and breast cancer screening), 5) health-risk behaviors (current cigarette smoking, binge drinking, heavy drinking, no leisure-time physical activity, and self-reported seat belt use), 6) chronic health conditions (obesity, diagnosed diabetes, cancer survivors, current asthma, arthritis, depression, coronary heart disease, and stroke for persons aged ≥45 years), and 7) disability (activity limitation and use of special equipment because of physical, mental, or emotional problems). The 2012 questionnaire and all related support documents are available on the BRFSS webpage (http://www.cdc.gov/brfss/annual_data/annual_2012.html).
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Results

In 2012, a total of 475,687 adults completed interviews by landline and cellular telephones. For data collected by landline telephone, 377,013 respondents completed the interview and the numbers of participants ranged from 1,728 in Guam to 18,325 in Massachusetts (median: 6,085). For data collected by cellular telephone, 98,674 respondents completed the interview, with participant numbers ranging from 303 in Guam to 3,990 in Nebraska (median: 1,580). Response rates for BRFSS were calculated using the standard set by the American Association of Public Opinion Research (AAPOR) response rate formula 4 (RR4), which is the number of respondents who completed the survey as a proportion of all eligible and likely eligible persons (15). For landline telephone data, the RR4 response rate ranged from 28.2% in California to 62.9% in Puerto Rico (median: 49.1%) and the RR4 response rate for cellular telephone data ranged from 16.4% in Washington to 55.7% in Iowa (median: 35.3%). For combined landline telephone and cellular telephone data, the weighted response rate (based on a combination of the landline telephone response rate with the cellular telephone response rate proportional to the total sample used to collect the data for a state) ranged from 27.7% in California to 60.4% in South Dakota (median: 45.2%). Detailed information on response, cooperation, and refusal rates for landline and cellular telephone data can be found in the BRFSS 2012 Summary Data Quality Report (16).

Health Status Indicators

Health Status

Respondents were asked to rate their general health as excellent, very good, good, fair, or poor. Those who reported their general health as excellent, very good, or good were categorized in one group, and the other group included those who reported their general health as fair or poor. In 2012, the estimated prevalence of self-reported good or better health among adults aged ≥18 years ranged from 64.0% in Puerto Rico to 88.3% in Minnesota (median: 82.9%) (Table 1). Among the selected 187 MMSAs, the estimated prevalence of self-reported good or better health among respondents ranged from 62.7% in Aguadilla-Isabela, Puerto Rico, to 90.5% in Fargo, North Dakota-Minnesota, Boulder, Colorado, and Hilton Head Island-Beaufort, South Carolina (median: 83.6%) (Table 2). Among the selected 210 counties, the estimated prevalence of self-reported good or better health among respondents ranged from 68.1% in San Juan Municipio, Puerto Rico to 92.4% in Douglas County, Colorado (median: 84.4%) (Table 3).

Health Care Coverage

Health care coverage was defined as respondents having reported that they had private health insurance, prepaid plans (e.g., health maintenance organizations) or government health plans (e.g., Medicare or Medicaid) among adults aged 18–64 years. In 2012, the estimated prevalence of health care coverage among persons aged 18–64 years ranged from 64.2% in Texas to 93.1% in Massachusetts (median: 79.6%) (Table 4). Among selected MMSAs, the estimated prevalence ranged from 35.4% in McAllen-Edinburg-Mission, Texas, to 93.7% in Cambridge-Newton-Framingham, Massachusetts (median: 80.7%) (Table 5). Among selected counties, the estimated prevalence ranged from 35.4% in Hidalgo County, Texas, to 96.7% in Norfolk County, Massachusetts (median: 81.4%) (Table 6).

Preventive Practices

Recent Routine Physical Checkup

A recent routine physical checkup was defined as a visit to a doctor for a general physical examination rather than for a specific injury, illness, or condition during the preceding 12 months. In 2012, the estimated prevalence of having a recent routine physical checkup among adults aged ≥18 years ranged from 55.7% in Idaho to 80.1% in Delaware (median: 67.7%) (Table 7). Among selected MMSAs, the estimated prevalence ranged from 50.6% in Norfolk, Nebraska, to 85.0% in Barnstable Town, Massachusetts (median: 68.3%) (Table 8). Among selected counties, the estimated prevalence ranged from 52.4% in Utah County, Utah, to 85.0% in Barnstable County, Massachusetts (median: 68.0%) (Table 9).

Annual Influenza Vaccination for Adults Aged ≥65 Years

Respondents were asked whether they had the annual influenza vaccination. In 2012, the estimated prevalence of influenza vaccination among adults aged ≥65 years during the preceding 12 months ranged from 26.3% in Puerto Rico to 70.1% in Iowa (median: 60.1%) (Table 10). Among selected MMSAs, the estimated prevalence of annual influenza vaccination ranged from 20.8% in Aguadilla-Isabela, Puerto Rico, to 77.8% in Greensboro-High Point, North Carolina (median: 60.5%) (Table 11); among selected counties, the estimated prevalence ranged from 24.1% in San Juan Municipio, Puerto Rico, to 77.6% in Kanawha County, West Virginia (median: 60.8%) (Table 12).

Pneumococcal Vaccination for Adults Aged ≥65 Years

In 2012, the estimated prevalence of ever having received a pneumococcal vaccination among adults aged ≥65 years ranged from 22.2% in Puerto Rico to 76.2% in Oregon (median: 68.5%) (Table 13). Among selected MMSAs, the estimated prevalence ranged from 15.3% in Aguadilla-Isabela, Puerto Rico, to 83.4% in Eugene, Oregon (median: 70.0%) (Table 14). Among selected counties, the estimated prevalence ranged from 25.8% in San Juan Municipio, Puerto Rico, to 85.2% in Denver County, Colorado (median: 70.1%) (Table 15).

Oral Health

Dental Visit in the Past Year

BRFSS assessed use of dental care services by asking when an adult last visited a dentist or a dental clinic for any reason. In 2012, the estimated prevalence of having had a dental visit in the past year among adults aged ≥18 years ranged from 53.7% in Guam to 76.2% in Massachusetts (median: 67.2%) (Table 16). Among selected MMSAs, the estimated prevalence ranged from 44.8% in McAllen-Edinburg-Mission, Texas, to 81.7% in Barnstable Town, Massachusetts (median: 67.5%) (Table 17). Among selected counties, the estimated prevalence ranged from 44.8% in Hidalgo County, Texas to 81.7% in Barnstable County, Massachusetts and Norfolk County, Massachusetts (median 68.9%) (Table 18).

Loss of All Natural Teeth for Adults Aged ≥65 Years

BRFSS assessed oral health status by asking adults the number of their permanent teeth were removed because of tooth decay or gum diseases. In 2012, the estimated prevalence of adults aged ≥65 years who had lost all of their natural teeth ranged from 7.0% in Hawaii to 33.7% in West Virginia (median: 16.2%) (Table 19). Among selected MMSAs, the estimated prevalence ranged from 5.8% in San Diego-Carlsbad, California, to 39.6% in Lafayette, Louisiana, (median: 15.8%) (Table 20). Among selected counties, the estimated prevalence ranged from 5.8% in San Diego County, California, to 37.1% in Aroostook County, Maine (median: 14.5%) (Table 21).

Cancer Screening

Colorectal Cancer Screening for Adults Aged 50–75 Years

The 2008 U.S. Preventive Services Task Force (USPSTF) recommendation for colorectal cancer screening in adults aged 50–75 years is a blood stool test (either a guaiac fecal occult blood testing [FOBT] or fecal immunochemical test [FIT]) every year, a colonoscopy every 10 years, or a flexible sigmoidoscopy every 5 years with FOBT every 3 years. In 2012, the estimated prevalence of adults aged 50–75 years who received a colorectal cancer screening on the basis of the USPSTF recommendation ranged from 40.0% in Guam to 76.4% in Massachusetts (median: 64.9%) (Table 22). Among selected MMSAs, the estimated prevalence ranged from 47.1% in El Paso, Texas, to 80.7% in Barnstable Town, Massachusetts (median: 67.0%) (Table 23). Among selected counties, the estimated prevalence ranged from 47.0% in El Paso County, Texas to 81.0% in Washington County, Rhode Island (median: 67.3%) (Table 24).

Cervical Cancer Screening for Women Aged 21–65 Years

In 2012, the estimated prevalence of women aged 21–65 years who have not had a hysterectomy and had a Papanicolaou (Pap) test during the preceding 3 years ranged from 68.5% in Guam to 89.6% in Massachusetts (median: 84.0%) (Table 25). Among selected MMSAs, the estimated prevalence ranged from 70.3% in Aguadilla-Isabela, Puerto Rico, to 92.8% in Lewiston-Auburn, Maine (median: 85.2%) (Table 26). Among selected counties, the estimated prevalence ranged from 65.7% in Canyon County, Idaho to 94.6% in Lorain County, Ohio (median: 85.9%) (Table 27).

Breast Cancer Screening for Women Aged 50–74 years

A mammogram is a radiograph of each breast used to test for breast cancer. The state-specific estimated prevalence of having a mammogram during the preceding 2 years among women aged 50–74 years ranged from 66.5% in Wyoming to 89.7% in Massachusetts (median: 78.4%) (Table 28). Among selected MMSAs, the estimated prevalence ranged from 61.1% in Fort Wayne, Indiana to 91.5% in Barnstable Town, Massachusetts (median: 79.6%) (Table 29). Among selected counties, the estimated prevalence ranged from 61.8% in Natrona County, Wyoming to 91.6% in Suffolk County, Massachusetts (median: 79.7%) (Table 30).

Health-Risk Behaviors

Current Cigarette Smoking

Respondents were classified as current smokers if they reported having smoked at least 100 cigarettes during their lifetime and indicated that they smoked every day or some days at the time of survey participation. The estimated prevalence of current cigarette smoking among adults aged ≥18 years ranged from 10.6% in Utah to 28.3% in Kentucky (median: 19.6%) (Table 31). Among selected MMSAs, the estimated prevalence ranged from 5.1% in Provo-Orem, Utah to 30.1% in Huntington-Ashland, West Virginia-Kentucky-Ohio (median: 19.5%) (Table 32). Among selected counties, the estimated prevalence ranged from 5.1% in Utah County, Utah, to 28.3% in Lorain County, Ohio (median: 18.3%) (Table 33).

Binge Drinking

Binge drinking was defined for men aged ≥18 years as having on average five or more drinks during one occasion and for women aged ≥18 years as having on average four or more drinks on one occasion during the preceding month. In 2012, the estimated prevalence of binge drinking among adults aged ≥18 years ranged from 10.2% in West Virginia to 25.2% in Wisconsin (median: 16.9%) (Table 34). Among selected MMSAs, the estimated prevalence ranged from 6.2% in Provo-Orem, Utah to 28.1% in Fargo, North Dakota-Minnesota (median: 17.2%) (Table 35). Among selected counties, the estimated prevalence ranged from 6.2% in Utah County, Utah, to 29.5% in Lincoln County, South Dakota (median: 17.5%) (Table 36).

Heavy Drinking

For men aged ≥18 years, heavy drinking was defined as having, on average, more than two drinks per day during the preceding month; women aged ≥18 years were heavy drinkers if they had, on average, more than one drink per day during the preceding month. In 2012, the estimated prevalence of heavy drinking among adults aged ≥18 years ranged from 3.5% in West Virginia to 8.5% in Wisconsin and Montana (median: 6.1%) (Table 37). Among selected MMSAs, the estimated prevalence ranged from 2.0% in Provo-Orem, Utah to 11.0% in Hilo, Hawaii (median: 6.1%) (Table 38). Among selected counties, the estimated prevalence ranged from 1.9% in Utah County, Utah to 11.0% in Hawaii County, Hawaii (median: 6.1%) (Table 39).

No Leisure-Time Physical Activity

No leisure-time physical activity was defined from the respondent’s indication of no participation in any physical activities or exercise (e.g., running, calisthenics, golf, gardening, or walking for exercise) other than their regular job during the preceding month. In 2012, the estimated prevalence of no leisure-time physical activity among adults aged ≥18 years ranged from 16.3% in Oregon to 42.4% in Puerto Rico (median: 23.1%) (Table 40). Among selected MMSAs, the estimated prevalence ranged from 9.2% in Boulder, Colorado, to 47.3% in Aguadilla-Isabela, Puerto Rico (median: 22.2%) (Table 41). Among selected counties, the estimated prevalence ranged from 9.2% in Boulder County, Colorado, to 39.0% in Robeson County, North Carolina (median: 21.5%) (Table 42).

Seat Belt Use

Respondents were asked how often (always, nearly always, sometimes, seldom, and never) they use a seat belt when they drive or ride in a car. In 2012, the estimate of always wearing a seat belt among adults aged ≥18 years ranged from 62.0% in South Dakota to 93.7% in California (median: 84.7%) (Table 43). Among selected MMSAs, the estimated prevalence ranged from 54.1% in Berlin, New Hampshire-Vermont, to 97.1% in San Jose-Sunnyvale-Santa Clara, California (median: 85.7%) (Table 44). Among selected counties, the estimated prevalence ranged from 50.1% in Coos County, New Hampshire, to 97.4% in Clackamas County, Oregon (median: 86.0%) (Table 45).

Chronic Health Conditions

Obesity

Self-reported weight and height were used to calculate body mass index (BMI) (weight [kg]/height [m2]). Respondents were obese if their BMI was ≥30.0. In 2012, the estimated prevalence of adults aged ≥18 years with obesity ranged from 20.5% in Colorado to 34.7% in Louisiana (median: 28.1%) (Table 46). Among selected MMSAs, the estimated prevalence ranged from 14.8% in Boulder, Colorado, to 44.5% in McAllen-Edinburg-Mission, Texas (median: 28.3%) (Table 47). Among selected counties, the estimated prevalence ranged from 14.8% in Boulder County, Colorado, to 44.5% in Hidalgo County, Texas (median: 26.7%) (Table 48).

Diabetes

Respondents were identified as having diabetes if they reported ever being told by a doctor that they have diabetes. For this report, gestational diabetes, prediabetes, or borderline diabetes were not included in the estimates. In 2012, the estimated prevalence of diagnosed diabetes among adults aged ≥18 years ranged from 7.0% in Alaska to 16.4% in Puerto Rico (median: 9.7%) (Table 49). Among selected MMSAs, the estimated prevalence ranged from 3.4% in Boulder, Colorado, to 17.4% in Lumberton, North Carolina (median: 9.6%) (Table 50). Among selected counties, the estimated prevalence ranged from 3.1% in Douglas County, Colorado, to 17.4% in Robeson County, North Carolina (median: 9.3%) (Table 51).

Cancer Survivors

Respondents were identified as being a cancer survivor if they had ever been told by a doctor, nurse, or other health professional that they had any type of cancer, including skin cancer. In 2012, the estimated prevalence of cancer survivors among adults aged ≥18 years ranged from 3.0% in Guam to 13.7% in Florida (median: 11.0%) (Table 52). Among selected MMSAs, the estimated prevalence ranged from 3.8% in Aguadilla-Isabela, Puerto Rico, to 19.2% in Ocean City, New Jersey (median: 10.8%) (Table 53). Among selected counties, the estimated prevalence ranged from 4.5% in Hudson County, New Jersey, to 19.2% in Cape May County, New Jersey (median: 10.8%) (Table 54).

Currently Have Asthma

Respondents were identified as currently having asthma if they reported having ever been told by a doctor, nurse, or other health care professional that they had asthma and still had it during the time of the survey. In 2012, the estimated prevalence of current asthma among adults aged ≥18 years ranged from 5.8% in Guam to 11.1% in Kentucky and Maine (median: 8.9%) (Table 55). Among selected MMSAs, the estimated prevalence ranged from 3.1% in McAllen-Edinburg-Mission, Texas, to 15.0% in Vineland-Bridgeton, New Jersey (median: 8.9%) (Table 56). Among selected counties, the estimated prevalence ranged from 3.1% in Hidalgo County, Texas, to 15.7% in Hampden County, Massachusetts (median: 9.2%) (Table 57).

Arthritis

Respondents were identified as having arthritis if they had ever been told by a health professional that they had some form of arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia. In 2012, the estimated prevalence of arthritis among adults aged ≥18 years ranged from 15.6% in Guam to 36.4% in West Virginia (median: 25.5%) (Table 58). Among selected MMSAs, the estimated prevalence ranged from 16.8% in Heber, Utah, to 45.8% in Kingsport-Bristol-Bristol, Tennessee-Virginia (median: 25.3%) (Table 59). Among selected counties, the estimated prevalence ranged from 14.8% in Travis County, Texas, to 35.9% in Aroostook County, Maine and Mobile County, Alabama (median: 24.5%) (Table 60).

Depression

Depression was defined as having ever been told by a health professional that the participants had a depressive disorder, which includes depression, major depression, dysthymia, or minor depression. In 2012, the estimated prevalence of depression among adults aged ≥18 years ranged from 9.0% in Guam to 23.5% in Kentucky (median: 17.6%) (Table 61). Among selected MMSAs, the estimated prevalence ranged from 9.2% in Anaheim-Santa Ana-Irvine, metropolitan division, California, to 28.3% in Lewiston-Auburn, Maine (median: 18.2%) (Table 62). Among selected counties, the estimated prevalence ranged from 8.5% in Union County, New Jersey, to 28.4% in Androscoggin County, Maine (median: 17.8%) (Table 63).

Coronary Heart Disease

Respondents were identified as having coronary heart disease if they reported that they had ever been told by a doctor, nurse, or other health care professional that they had a heart attack (also known as myocardial infarction, or MI) or angina (i.e., coronary heart disease). In 2012, the estimated prevalence of coronary heart disease among adults aged ≥45 years ranged from 7.4% in Hawaii to 19.0% in West Virginia (median: 11.4%) (Table 64). Among selected MMSAs, the estimated prevalence ranged from 6.1% in Boulder, Colorado, to 23.3% in Charleston, West Virginia (median: 11.0%) (Table 65). Among selected counties, the estimated prevalence ranged from 6.1% in Boulder County, Colorado, to 20.6% in Kanawha County, West Virginia (median: 10.0%) (Table 66).

Stroke

Respondents were identified as having had a stroke if they had ever been told by a doctor, nurse, or other health care professional that they had a stroke. In 2012, the estimated prevalence of stroke among adults aged ≥45 years ranged from 3.1% in Colorado to 7.3% in Mississippi (median: 4.7%) (Table 67). Among selected MMSAs, the estimated prevalence ranged from 2.1% in Silver Spring-Frederick-Rockville, Maryland, to 9.3% in Mobile, Alabama (median: 4.4%) (Table 68). Among selected counties, the estimated prevalence ranged from 1.5% in Montgomery County, Maryland, to 9.3% in Mobile County, Alabama (median: 4.4%) (Table 69).

Disability

Activity Limitation

Respondents were asked if they were limited in any way from performing any activities because of physical, mental, or emotional problems. In 2012, the estimated prevalence of activity limitation among adults aged ≥18 years ranged from 15.0% in Guam to 28.6% in West Virginia (median: 20.0%) (Table 70). Among selected MMSAs, the estimated prevalence ranged from 12.0% in Heber, Utah, to 31.7% in Eugene, Oregon (median: 20.3%) (Table 71). Among selected counties, the estimated prevalence ranged from 11.3% in Wake County, North Carolina, to 31.7% in Lane County, Oregon (median: 19.5%) (Table 72).

Use of Special Equipment

Respondents were asked if they currently had any health problem that required them to use special equipment (e.g., a cane, a wheelchair, a special bed, or a special telephone), which included occasional use or use in certain circumstances. In 2012, the estimated prevalence of using special equipment because of any health problem among adults aged ≥18 years ranged from 4.8% in Guam to 11.6% in Kentucky (median: 8.0%) (Table 73). Among selected MMSAs, the estimated prevalence ranged from 4.0% in Boulder, Colorado, to 14.7% in Kingsport-Bristol-Bristol, Tennessee-Virginia (median: 7.8%) (Table 74). Among selected counties, the estimated prevalence ranged from 2.8% in Douglas County, Colorado, to 13.6% in Thurston County, Washington (median: 7.5%) (Table 75).
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Discussion

The findings in this report indicate substantial geographic variations in the estimated prevalence of health status indicators, preventive practices, oral health, cancer screening, health-risk behaviors, chronic health conditions, and disability status among adults in the United States at the state and territory, MMSA, and county level. These variations in crude (unadjusted) estimates might reflect differences in demographic characteristics (e.g., age, race, and sex distribution), socioeconomic conditions (e.g., education attainment, income, and employment status), cultural contexts, health care access and cost, state laws and local ordinances, or combinations of these factors. The results provided in this report were estimated on the basis of survey results (i.e., direct estimates) and might differ from those derived by other methods.

Health Status Indicators

Although measured by a single question, self-reported health status encompasses physical health, mental health, and functional capacity of a person (17). It has been validated as an independent predictor of mortality (18) and is a useful proxy indicator for perceived prevalence of acute and chronic health conditions (19). For this report, self-assessed health status was reported for good or better health. Large variations in self-rated health at the state and local levels suggest differences in the underlying etiology and severity of specific diseases and illnesses, health care access, and residents’ health related behaviors among states and territories, MMSAs, and counties. Health services research has identified that having no health insurance is a risk indicator for lower overall health status, exacerbation of chronic disease indicators (e.g., uncontrolled and undiagnosed hypertension, and hypercholesterolemia), and less access to and use of preventive health care services (e.g., blood pressure monitoring, cholesterol screening, and age appropriate cancer screenings) (20,21). In 2012, the median prevalence of health care coverage among adults aged ≤65 years at the state and local levels was approximately 81%.

Preventive Practices

A routine physical checkup can help persons stay healthy and prevent or delay disease and disability. A visit to a doctor for a routine checkup can help to identify a disease (e.g., diabetes, heart disease, and cancer) and other health problems in the early stages of development when they are most successfully treated (22); these visits also can provide opportunities for disease prevention and patient education. In 2012, the median prevalence of having received a routine physical checkup among adults, at the state or local level, was approximately 66%. In addition to geographic variation, access to health care, socioeconomic factors (e.g., education and income), and marital status are associated with routine medical checkups (23).
Influenza and pneumonia together are the seventh leading cause of death among adults aged ≥65 years (2). The vaccinations against influenza and pneumonia are safe, effective, and cost efficient ways to reduce the morbidity and mortality from these diseases in older adults (24). In 2012, the median prevalence of having received an influenza vaccination during the preceding 12 months or ever having a pneumococcal vaccination among adults aged ≥65 was approximately 61% and 71%, respectively. Estimates of influenza vaccination prevalence measured in this report are calculated from interview data collected during the calendar year and measures the proportion of persons reporting influenza vaccination during the 12 months preceding the survey. Therefore, annual estimates represent a weighted average of incomplete estimates for up to three influenza seasons. The variation in influenza and pneumococcal vaccination coverage levels observed among states and local areas suggests that coverage levels for both vaccines can be improved. Strategies such as clinician reminders, team change, and patient outreach along with patient financial incentives, audit, and feedback (for influenza vaccination only) and clinician education, case management (for pneumococcal vaccination only) can be employed at the state and local levels to increase the rates of influenza and pneumococcal vaccinations among older adults (25).

Oral Health

The Surgeon General’s report on oral health in America described the mouth as a mirror of health (26). A thorough oral examination can detect signs of numerous general health problems (e.g., nutritional deficiencies), systemic diseases (e.g., microbial infections and immune disorders), injuries, and some cancers. Routine dental visits can help prevent and control the most common oral diseases including dental caries (tooth decay) and periodontal disease (26). The loss of one’s natural teeth can reduce quality of life in many ways (e.g., bringing pain and distress, lowering self-esteem, and making it more difficult to eat, relax, or socialize) (27). Periodontal disease and dental caries are the leading causes of tooth loss (28); tooth loss is associated with poor nutrition, coronary artery disease, diabetes, smoking, and rheumatoid arthritis (29). In 2012, at the state and local levels, the median prevalence of having had a dental visit in the past year was 69%; 14% of adults aged ≥65 had lost all their natural teeth. These findings suggest an unmet need for oral health care and needs for oral disease prevention and health promotion programs at state and local levels.

Cancer Screening

Cancer is the second-leading cause of death in the United States following heart disease (2) and it is the leading cause of death among both men and women aged 40–79 years (30). Colorectal cancer is the third most-commonly diagnosed of new cancer cases and the third leading cause of cancer-related death in both men and women (30). Colorectal cancer usually begins from polyps present in the rectum or colon. The FOBT/FIT, colonoscopy, and a flexible-sigmoidoscopy, are the recommended screening tests for early detection of precancerous polyps and prevention of colorectal cancer (31). In 2012, the median prevalence of colorectal cancer screening based on the 2008 USPSTF recommendation was 67% at the state and local levels—a finding that suggests the need for population-based strategies to improve colorectal cancer screening efforts at the state and local levels.
The primary cause of cervical cancer is HPV. Early-stages of cervical cancer often can be detected easily with two tests: 1) a Pap test and 2) an HPV test (32). A Pap test that detects precancerous or abnormal cells in the cervix and a HPV test looks for the HPV that caused the precancerous or abnormal cervical cells (32). The numbers of cases and deaths from cervical cancer have declined substantially during the past decades because of early detection of cervical cancer by the Pap test and early treatment (33). USPSTF recommends that women aged 21–29 years should receive the Pap test to screen for cervical cancer every 3 years (34). Women aged 30–65 years can continue receiving the Pap test every 3 years or the Pap test in combination with the HPV test every 5 years (34). Among women aged 21–65 years, the median prevalence of having received a Pap test varied in 2012 from 66% to 93% at the state and local levels. The variation in Pap test screening rates among women in this age group at state and local levels might be related to health care access and other barriers to screening.
Breast cancer is the most commonly diagnosed cancer and second leading cause of cancer mortality in women (30). Mammograms can detect breast cancer at an early stage, when it is most treatable. This combination of early detection and advances in treatment has helped to reduce the rate of death from breast cancer in the United States (35). USPSTF recommends biennial screening mammography for women aged 50–74 years (36). In 2012, the median prevalence of having had a mammogram in the preceding 2 years for women aged 50–74 varied from 78% to 80% for the state, MMSAs, and counties.

Health-risk Behaviors

Health-risk behaviors are unhealthy behaviors that persons can change. Tobacco use, diet and activity patterns, and alcohol use are the major contributors to deaths in the United States (37). Cigarette smoking is the single-most preventable cause of morbidity and mortality in the United States (38). The prevalence of disease and death from tobacco use is overwhelmingly caused by cigarettes and other combusted tobacco products. Cigarette smoking has been causally linked to diseases of nearly all organs of the body and can harm the fetus during pregnancy (38). Moreover, secondhand tobacco smoke has been causally linked to lung cancer as well as respiratory and cardiovascular diseases, and it can damage the health of infants and children (38). The prevalence of current cigarette smoking among U.S. adults aged ≥18 years declined during 2005–2010 (39); however, current cigarette smoking remains widespread. The median prevalence of current cigarette smoking (19.6%) indicates the need for sustained, adequately funded, comprehensive tobacco control programs at the state and local levels (40).
Excessive alcohol consumption, including binge and heavy drinking, is one of the leading preventable causes of death in the United States (41). Binge and heavy drinking can lead to risky sexual activity, unintentional injuries (e.g., motor-vehicle crashes), falls, violence, and suicide (42); excessive alcohol consumption can lead to development of high blood pressure, liver disease, some cancers, dementia, and alcohol dependence (42). This report highlighted the variation in the prevalence of binge and heavy drinking among states/territories, MMSAs, and counties that might be attributable to cultural factors as well as the state/local laws governing the price, availability, and marketing of alcoholic beverages. Evidence-based population-level strategies recommended by the Community Preventive Services Task Force can be implemented to reduce and prevent excessive alcohol consumption (43).
Being physically active is an important step persons can take to improve their health; physical activity improves cardiorespiratory and muscular fitness and bone health. It helps to control weight, reduces risk for early death, cardiovascular diseases (e.g., heart disease, stroke, and high blood pressure), diabetes, and cancer (e.g., colon and breast), and prevents falls (44). The 2012 BRFSS survey measured the prevalence of participation in any physical activities or exercises (e.g., running, calisthenics, golf, gardening, or walking during the preceding month). This report indicates the need for continued effort to increase the physical activity in the population at the state and local levels.
Accidents or unintentional injuries are the fifth-leading cause of death in the United States (2). Unintentional motor-vehicle traffic injury is the second-leading cause of injury deaths among all U.S. residents (45). Seat belt use can reduce the risk for fatal injury to front-seat car occupants by 45% and the risk for moderate-to-critical injury by 50% (46). Laws and law enforcement levels related to seat belt use vary by state (47). The findings in this report indicate a great variation in seat belt use across states (62%–92%), MMSAs (54%–97%), and counties (50%–97%), despite the fact that all states have seat belt laws. Populations with lower use of seat belts are at risk for injury and death from motor vehicle crashes.

Chronic Conditions

Chronic diseases represented seven of the top 10 leading causes of death in the United States in 2013. Heart disease, malignant neoplasms (cancers), cerebrovascular diseases, and diabetes mellitus are the leading, second-, fourth-, and fifth-leading causes of death, respectively (2). BRFSS helps monitor these chronic diseases, along with chronic conditions like obesity, asthma, arthritis, and depression, to help states and local areas plan, implement, and track health interventions.

Obesity

Obesity continues to be a critical public health problem (48); it increases the risk for various chronic conditions like type 2 diabetes, hypertension, dyslipidemia, coronary heart disease, and certain types of cancer (49).The National Health and Nutrition Examination Survey (NHANES) data indicated that the obesity prevalence among U.S. adults had not changed significantly from 2003–2004 to 2011–2012; however, approximately one third of adults are obese (50). The high median prevalence of obesity at the state and local levels (range: 26.7%–28.1%) underscores the need for close monitoring of the obesity trend at the state and local levels and for implementing interventions that address obesity.

Diabetes

Diabetes is associated with extensive and serious complications that might involve many organs including loss of vision, lower-extremity amputation, heart attack, stroke, high blood pressure, kidney disease, skin infection (e.g., bacterial and fungal infection), periodontitis, erectile dysfunction, depression, and complications of pregnancy (51). In 2012, the median prevalence of diagnosed diabetes ranged from 9.3% to 9.7% at state and local levels. The disease and its complications often can be prevented, delayed, or controlled by closely monitoring and controlling blood glucose through healthy eating, increasing physical activity, taking prescribed medications, and receiving proper diabetes-related preventive care services that frequently focus on areas like foot health and diabetic patient education (52).

Cancer Survivors

A cancer survivor is any person living with a history of cancer (53). The population of cancer survivors in this country has been steadily increasing since 1970; the prevalence is projected to approach 18 million by 2022 (54). The increases in the number of cancer survivors are largely because of aging and growth of the population as well as advances in cancer detection and treatments (55). At the state and local levels, the median prevalence of cancer survivorship (11%) among BRFSS participants indicates a growing need to monitor cancer survivors to address their special health issues and needs (55) at state and local levels, including quitting tobacco use, being active and maintaining a healthy weight, and discussing follow-up care with a health care provider.

Current Asthma

Asthma is a common chronic disorder of the airways involved with breathing and respiration, characterized by periods of reversible airflow obstruction known as asthma exacerbations or attacks (56). Many persons with asthma have only occasional, mild symptoms, but others have severe asthma that can interfere with daily activity or even be life-threatening. The report on national surveillance of asthma indicated that current asthma prevalence increased from 2001 to 2010 and that there were no significant changes in rates for hospital outpatient department visits, emergency department visits, and hospitalizations for asthma (57). In 2012, the overall median prevalence of current asthma was 9%; BRFSS data indicated variability in estimated current asthma prevalence at the state, MMSA, and county level indicates the need for continued asthma surveillance in the United States.

Arthritis

Arthritis is the most common cause of disability among U.S. adults (58). Data from the 2010–2012 National Health Interview Survey indicated that 22.7% of adults reported having doctor-diagnosed arthritis and 43.2% of those with arthritis reported arthritis-attributable activity limitations. Moreover, approximately half of the adults with heart disease and diabetes and about one third of the adults who were obese had arthritis (59). In the 2012 BRFSS, the median prevalence of reported doctor-diagnosed arthritis was 25% at state and local levels, which indicates a substantial personal and societal prevalence of arthritis in the United States.

Depression

Depression is the leading cause of disability in the Global Burden of Disease during 2010 as measured by Years Lived with Disability and Disability Adjusted Life Years (60). Depressive disorders are more common among persons with chronic conditions (e.g., obesity, cardiovascular disease, diabetes, asthma, arthritis, and cancer) and among those with unhealthy behaviors (e.g., smoking, physical inactivity, and binge drinking) (61,62). It is also associated with decreased productivity in the workplace and an increased risk for absenteeism from work (63). In 2012, the median prevalence of depression was 18% at the state and local levels; the variations of prevalence among states, MMSAs, and counties indicate the need for targeted prevention and intervention efforts and the allocation of mental health treatment resources at the state and local levels.

Heart Disease and Stroke

Heart disease and stroke are the leading causes of death in the United States. During 2011–2012, heart disease accounted for 170.5 deaths and stroke accounted for 36.9 deaths per 100,000 population (2). Stroke is the leading cause of serious long-term disability in the United States and costs $34 billion annually (64). In 2012, the prevalence of self-reported coronary heart disease and stroke among adults aged ≥45 years ranged from 6%–21% and 2%–9%, respectively, at the state and local levels. This report indicates wide variation in prevalence of coronary heart disease and stroke. It is essential for states and local areas to take initiatives to improve access and quality of health care systems and to continue to build environments that support healthy behaviors through community and clinical prevention strategies (65).

Disability

Disability or health impairment caused by limitation of activities because of physical, mental, or emotional problems can affect health, functioning, and quality of life (66). During 2010 in the United States, approximately 56.7 million persons were living with some kind of disability and 12.6% of them had severe disability (67). Disability is associated with low socioeconomic status; persons with disabilities are more likely to be poor, experience barriers to education, employment, and health care (68). Persons with disabilities often require the use of special equipment and access to assistive technology to improve functioning, independence, and participation in community life (e.g., work, school, and social functions) (69).
In the 2012 BRFSS, the median prevalence of disability or health impairment was 20% at the state and local levels and the prevalence of special equipment usage (e.g., a cane, a wheelchair, a special bed, or special telephone) because of any health problem ranged from 5% to 14% at state, MMSA, and county levels. Because of the aging of the population, the number of adults reporting a disability is likely to increase, along with the need for appropriate medical and public health services; therefore, it is essential to continue surveillance of disability rates and the need for special equipment in the United States, to address quality of life issues for persons living with disabilities.
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Limitations

The findings in this report are subject to at least four limitations. First, BRFSS results might not be generalizable to the entire U.S. population because the BRFSS survey design excludes persons living in institutions, nursing homes, long-term–care facilities, military installations, and correctional institutions. In addition, because participants answer the survey on a cellular or landline telephone, persons without access to either type of telephone are excluded. Second, BRFSS data are self-reported, so the information is subject to recall (e.g., diagnosis of diabetes and duration of physical activity) and social desirability bias (e.g., underreporting of actual weight). Third, although BRFSS surveys are conducted in several languages other than English (i.e., Spanish, Mandarin, and Portuguese), the survey does not apply to persons who speak other languages exclusively. Finally, because of the small sample size producing unreliable estimates, the prevalence of certain variables (e.g., influenza and pneumococcal vaccination among adults aged ≥65 years) could not be obtained among residents living within certain MMSAs or counties.
Overall, BRFSS is a cost-effective, timely, and flexible survey that makes data available to state health departments and local communities so they can assess and monitor the health risk behaviors, chronic conditions, use of preventive health care services, health impairments, and disabilities of their residents. The response over time within BRFSS and the prevalence rates from the BRFSS survey might differ from other national and state surveys because of differences in wording of questions, the number of questions focusing on a measure or topic, survey modes (telephone versus in person), length of questionnaire, format of the questionnaire, and sampling frame.
Researchers have found BRFSS data to be reliable and to have an overall high level of validity when compared with data from other surveys (9,10); prevalence estimates from BRFSS were consistent with other national survey databases (70). Despite concerns about declines in telephone survey response rates, BRFSS response rates compare favorably to those of telephone surveys (16). The raking weighting methods used by the BRFSS survey reduces the nonresponse and noncoverage bias and helps to match more accurately the sample distribution of BRFSS to known demographic characteristics of state populations.
BRFSS data have been used in a variety of ways to improve health. Federal, state, and local health officials continue to use BRFSS as a tool for monitoring and responding to public health emergencies (71), such as the seasonal influenza vaccine shortage (2004–2005) and the effects of hurricanes Katrina, Rita, and Wilma in 2005 as well as to monitor prevalence rates of influenza-like illness and the use of H1N1 vaccination that are a part of pandemic planning (since 2009). The asthma call-back survey, funded by the National Asthma Control Program and conducted with BRFSS respondents (who reported an asthma diagnosis), helps in asthma surveillance in the United States (72). Since 2002, the Safety and Health Assessment and Research for Prevention program at the Washington State Department of Labor and Industries has been adding industry and occupation questions to the Washington BRFSS to identify worker populations with a high prevalence of chronic diseases or conditions and injury to target disease prevention efforts in work places (73).
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Conclusion

In the United States, major risk factors contributing to the prevalence of chronic disease and injury include tobacco use, poor diet (e.g., low in fruits and vegetables and high in sodium and saturated fat), physical inactivity, low seat belt use, excessive alcohol consumption, and high blood pressure. All of these risk factors can be effectively addressed at both the individual and population levels. CDC works to prevent chronic diseases and injuries through four domains: epidemiology and surveillance, environmental approaches, health care system interventions, and community-clinical links (74).
State and local health departments and agencies can use data from BRFSS to monitor risk factors, chronic conditions, and use of preventive health care practices related to chronic disease and injury. Specifically, BRFSS data can be used to evaluate public health policies and programs, to identify the needs for additional support or resources for programs, to identify emerging health problems, to educate leaders and decision makers about health-related issues, and to monitor progress toward achieving health objectives at state and local levels.
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Corresponding author: Machell Town, PhD, Division of Population Health, National Center for Chronic Disease Prevention and Health Promotion, CDC. Telephone: 770-488-4681; E-mail:mpt2@cdc.gov.
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1Division of Population Health, National Center for Chronic Disease Prevention and Health Promotion, CDC; 2Northrop Grumman Corporation, Atlanta, Georgia
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