Non-pharmaceutical interventions in the State of Georgia: Economic implications

Background

As Covid-19 spread rapidly, many countries implemented a strict shelter-in-place to "flatten the curve" and build capacity to treat in the absence of effective preventative therapies or treatments. Policymakers and public health officials must balance the positive health effects of lockdowns with economic, social, and psychological costs. This study examined the economic impacts of state and county level restrictions during the 2020 Covid-19 pandemic for two regions of Georgia.

Methods

Taking unemployment data from the Opportunity Insights Economic Tracker with mandate information from various sites, we examined trends before and after a mandate's implementation and relaxation using joinpoint regression.

Results

We found mandates with the largest impact on unemployment claims rates were the shelters-in-place (SIPs) and closures of non-essential businesses. Specific to our study, mandates had an effect where first implemented, i.e., if the state implemented an SIP after the county, the state-wide SIP had no additional measurable effect on claims rates. School closures had a consistent impact on increasing unemployment claims rates, but to a lesser degree than SIPs or business closures. While closing businesses did have a deleterious effect, implementing social distancing for businesses and restricting gatherings did not. Notably, the Coastal region was less affected than the Metro Area. Additionally, our findings indicate that race ethnicity may be a larger predictor of adverse economic effects than education, poverty level, or geographic area.

Conclusions

Our findings coincided with other studies in some areas but showed differences in what indicators may best predict adverse effects and that coastal communities may not always be as impacted as other regions in a state. Ultimately, the most restrictive measures consistently had the largest negative economic impacts. Social distancing and mask mandates can be effective for containment while mitigating the economic impacts of strict SIPs and business closures.

Real-time forecasts of the COVID-19 epidemic in China from February 5th to February 24th, 2020

The initial cluster of severe pneumonia cases that triggered the COVID-19 epidemic was identified in Wuhan, China in December 2019. While early cases of the disease were linked to a wet market, human-to-human transmission has driven the rapid spread of the virus throughout China. The Chinese government has implemented containment strategies of city-wide lockdowns, screening at airports and train stations, and isolation of suspected patients; however, the cumulative case count keeps growing every day. The ongoing outbreak presents a challenge for modelers, as limited data are available on the early growth trajectory, and the epidemiological characteristics of the novel coronavirus are yet to be fully elucidated. We use phenomenological models that have been validated during previous outbreaks to generate and assess short-term forecasts of the cumulative number of confirmed reported cases in Hubei province, the epicenter of the epidemic, and for the overall trajectory in China, excluding the province of Hubei. We collect daily reported cumulative confirmed cases for the 2019-nCoV outbreak for each Chinese province from the National Health Commission of China. Here, we provide 5, 10, and 15 day forecasts for five consecutive days, February 5th through February 9th, with quantified uncertainty based on a generalized logistic growth model, the Richards growth model, and a sub-epidemic wave model. Our most recent forecasts reported here, based on data up until February 9, 2020, largely agree across the three models presented and suggest an average range of 7409-7496 additional confirmed cases in Hubei and 1128-1929 additional cases in other provinces within the next five days. Models also predict an average total cumulative case count between 37,415 and 38,028 in Hubei and 11,588-13,499 in other provinces by February 24, 2020. Mean estimates and uncertainty bounds for both Hubei and other provinces have remained relatively stable in the last three reporting dates (February 7th - 9th). We also observe that each of the models predicts that the epidemic has reached saturation in both Hubei and other provinces. Our findings suggest that the containment strategies implemented in China are successfully reducing transmission and that the epidemic growth has slowed in recent days.

Spatial infectious disease epidemiology: on the cusp

Infectious diseases continue to pose a significant public health burden despite the great progress achieved in their prevention and control over the last few decades. Our ability to disentangle the factors and mechanisms driving their propagation in space and time has dramatically advanced in recent years. The current era is rich in mathematical and computational tools and detailed geospatial information, including sociodemographic, geographic, and environmental data, which are essential to elucidate key drivers of infectious disease transmission from epidemiological and genetic data. Indeed, this paradigm shift was driven by dramatic advances in complex systems approaches along with substantial improvements in data availability and computational power. The burgeoning output of infectious disease spatial modeling suggests that we are close to a fully integrated approach for early epidemic detection and intervention. This special collection in BMC Medicine aims to bring together a broad range of quantitative investigations that improve our understanding of the spatiotemporal transmission dynamics of infectious diseases in order to mitigate their impact on the human population.

Growth scaling for the early dynamics of HIV/AIDS epidemics in Brazil and the influence of socio-demographic factors

The early dynamics of an infectious disease outbreak can be affected by various factors including the transmission mode of the disease and host-specific factors. While recent works have highlighted the presence of sub-exponential growth patterns during the early phase of epidemics, empirical studies examining the contribution of different factors to early epidemic growth dynamics are lacking. Here we aim to characterize and explain the early incidence growth patterns of local HIV/AIDS epidemics in Brazil as a function of socio-demographic factors. For this purpose, we accessed annual AIDS incidence series and state-level socio-demographic variables from publicly available databases. To characterize the early growth dynamics of the HIV/AIDS epidemic, we employed the generalized-growth model to estimate with quantified uncertainty the scaling of growth parameter (p) which captures growth patterns ranging from constant incidence (p=0) to sub-exponential (0 < p < 1) and exponential growth dynamics (p=1) at three spatial scales: national, regional, and state levels. We evaluated the relationship between socio-demographic variables and epidemic growth patterns across 27 Brazilian states using mixed-effect regression analyses. We found wide variation in the early dynamics of the AIDS epidemic in Brazil, displaying sub-exponential growth patterns with the p parameter estimated substantially below 1.0. The mean p was estimated to be 0.81 at the national level, with a range of 0.72-0.85 at the regional level, and a range of 0.28-0.96 at the state level. Our findings support the notion that socio-demographic factors contribute to shaping the early growth dynamics of the epidemic at the local level. Gini index and socio-demographic index were negatively associated with the parameter p, whereas urbanicity was positively associated with p_. The results could have theoretical significance in understanding differences in growth scaling across different sexually transmitted disease systems, and have public health implications to guide control.

Perceived condom norms and HIV risks among social and sexual networks of young African American men who have sex with men

The association between condom norms and unprotected sexual intercourse was examined within social and sexual networks of young African American men who have sex with men (MSM) in an HIV epicenter of the southern United States. We used a chain-link design to recruit 158 young African American men: 95 initial participants, 56 contacts of participants (alters) and 7 contacts of alters. Men in the high-risk group, compared with those in the no-risk group, perceived significantly lower approval concerning condom use in their social and sexual networks. Also, 100 participants could be connected to each other in 86 dyads of social and sexual networks. Within these dyads, men perceived that their friends and acquaintances approved for them to use condoms but that their friends and acquaintances did not use condoms themselves. Low HIV risk behavior appears associated with perceived social norms that support one's use of condoms, even when perceived norms do not support condom use by network members themselves.

Maintenance of endemicity in urban environments: a hypothesis linking risk, network structure and geography

In industrialised countries, a rapid epidemic phase of HIV transmission has largely given way to more moderated endemic transmission. The dynamics of endemic transmission may differ substantially from those generating epidemic spread. We hypothesise that three elements play an important role in maintaining endemicity in high prevalence urban environments. First, persons are likely to be subject to multiple risks from multiple sources rather than engaging in a single, hierarchically classified, risk behaviour. Second, the network structure in these environments may include a substrate of "fixed" factors (a large connected component, a characteristic degree distribution and small world phenomenon) upon which is superimposed a number of variable factors (transitivity, assortativity) that determine the level of prevalence. Third, the geographic range of persons in these milieux is constricted, making it likely that new partners will already be connected. The confluence of these three factors assures the ongoing risk bombardment needed for maintenance of endemicity. Further empirical and theoretical analysis will be required in order to validate this hypothesis.

The risk environment for HIV transmission: results from the Atlanta and Flagstaff network studies

The purpose of this study was to investigate the hypothesis that human immunodeficiency virus (HIV) transmission may be facilitated or obstructed by network structure, incorporating a measure of risk that combines true risk and surrogates. Persons at presumed high risk for HIV were enrolled in long-term follow-up studies of urban and rural networks in Atlanta, Georgia, and Flagstaff, Arizona. We focused on respondents who were also contacts to evaluate information on both sides of the observed dyads and constructed a Risk Indicator, based on a four-digit binary number, that permitted assessment and visualization of the overall risk environment. We constructed graphs that provided visualization of the level of risk, the types of relationships, and the actual network. Although some of the findings conform to the hypotheses relating network structure to transmission, there were several anomalies. In Atlanta, HIV prevalence was most strongly related to men with a male sexual orientation, despite the widespread use of injectable drugs. In Flagstaff, an area of very low prevalence and no transmission, the risk environment appeared more intense, and the frequency of microstructures was as great or greater than representative areas in Atlanta. The network hypothesis is not yet sufficiently developed to account for empirical observations that demonstrate the presence of intense, interactive networks in the absence of transmission of HIV.

Role of spirituality in patients with sickle cell disease

BACKGROUND

Patients with sickle cell disease cope with their disease in various ways, such as psychological counseling, hypnosis, medication, and prayer. Spirituality is a coping mechanism in a variety of diseases. This study evaluates the role of spirituality in patients coping with the pain of sickle cell disease.

METHODS

Seventy-one patients from the Georgia Sickle Cell Clinic completed a questionnaire addressing their ability to cope with the pain of sickle cell disease and their degree of spirituality. A descriptive cross-sectional design was used. Correlation and multiple regression analyses were calculated for the relation between coping with the pain of sickle cell disease and spirituality.

RESULTS

The questionnaire provided several scales with high internal consistency for measuring spiritual well-being and its two components, existential well-being and religious well-being, that show a correlation between high levels of spirituality and life control. The study population exhibited high levels of spirituality and religiosity, but the influence of these feelings on coping with sickle cell disease was variable. Spiritual well-being was correlated with life-control but not with perceived pain severity.

CONCLUSIONS

Existential well-being was associated with general coping ability. Spiritual well-being is important for some patients who must cope with the pain of sickle cell disease.

Correlates of physicians' prevention-related practices. Findings from the Women Physicians' Health Study

BACKGROUND

Determinants of physicians' prevention-related counseling and screening practices are not well understood. Such determinants are worth knowing because we can then intervene on malleable variables and produce physicians with stronger prevention-related skills. Of the few such variables that have been examined, they have typically only been studied in univariate analyses or in small or otherwise limited populations and have been especially sparsely studied in women physicians.

OBJECTIVE

To explore the effect of potential counseling- and screening-related variables in 4501 respondents to the Women Physicians' Health Study, a questionnaire-based study of a representative sample of US women MDs.

RESULTS

Being a primary care practitioner and practicing a related health habit oneself were significantly correlated with reporting counseling and screening for all prevention-related variables examined. Current attempts to improve a related habit oneself, ethnicity, region, practice site, and amount of continuing medical education were sometimes significantly correlated with counseling and screening; most other variables studied (i.e., personal health status, a personal or family history of disease, control of work environment, and career satisfaction) were rarely significantly correlated.

CONCLUSIONS

Being a primary care practitioner and having related healthy habits oneself were the most significant correlates of US women physicians' self-reported prevention-related counseling and screening practices. These findings suggest potential new directions for physician training.

Social network methods for endemic foci of syphilis: a pilot project

BACKGROUND

Social network methods have improved our understanding of sexually transmitted disease transmission dynamics, and may be of use in routine field operations for partner notification.

GOAL

To augment traditional syphilis-control activities with social network methods in an Atlanta area with high syphilis morbidity.

STUDY DESIGN

Disease investigators conducted interviews, used network diagrams to prioritize their work, and relied on network connections for finding hard-to-reach persons.

RESULTS

A total of 396 contacts were elicited from 48 infected and 50 uninfected persons. The cumulative prevalence of syphilis was 12.6%, and 24 persons infected with HIV were identified. Network methods disclosed a large, interconnected group (276 persons) characterized by high network centrality and the substantial presence of small, interactive subgroups (microstructures).

CONCLUSION

The network approach is a feasible field technique, and can identify core groups involved in the intense transmission of syphilis. The targeted, network-based approach may be useful in attempts to eliminate syphilis.

Basic demographic and professional characteristics of US women physicians

Women physicians are a rapidly growing percentage of the physician population in the United States; yet, their fundamental characteristics and largely unknown. The Women Physicians' Health Study is the first large, national study of US women physicians, comprising a random sample (n = 4,501 respondents) of women physicians aged 30 to 70. Data from the Women Physicians' Health Study showed that African-American and Latina or Hispanic physicians were underrepresented, and Asian-American and foreign-born physicians were overrepresented in proportion to their prevalence in the US female population. Women physicians were more likely to be married and less likely to have never married and less likely to have never married or to be divorced or widowed than other US women. Younger physicians were more likely to be residency trained and board-certified and to work more hours per week than older physicians. Younger physicians were also less likely to be in solo practice, government work, or inactive; they tended to be concentrated in group or hospital-based practices. We found that although US women physicians have some common characteristics that differentiate them from other US women, their practice and other characteristics vary substantially by age and specialty in ways that have not previously been reported.

The relevance of social network concepts to sexually transmitted disease control

Many of the concepts of social network analysis have been tacit assumptions of sexually transmitted disease control efforts for decades. With the advent of AIDS in the 1980s, an overt rapprochement between these two fields--previously separated by culture, context, and language--was made. Social network constructs have immediate appeal to disease control workers, who view many diseases as following the conduits of social interactions. STDs and HIV, in turn, provide network analysts and those who model disease transmission with substantial sets of empirical data that test and illuminate theory. Disease control efforts can be enhanced by incorporating network concepts overtly into current practices. Such concepts offer a path to better delineation of groups at risk, to a better understanding of the interaction of personal risk taking and the social context, and to evaluation of control mechanisms.

The quality of life in the year before death

OBJECTIVES

Most Americans wish to live a long healthy life, but fear disease and dependency in their last years. Until recently, little has been known about the prevalence of opposite extremes of health in old age, particularly in the period leading up to death.

METHODS

We used results from the 1986 National Mortality Follow-back Survey to estimate proportions of elderly decedents who were "fully functional" or "severely restricted" in the last year of life. Estimates were based on responses from proxies to questions regarding the decedent's functional status, mental awareness, and time spent in institutions.

RESULTS

Approximately 14% of all decedents aged 65 years and older were defined as fully functional in the last year of life; 10% were defined as severely restricted. Proportions varied with the decedent's age and sex, the underlying cause of death, and the presence of other preexisting conditions.

CONCLUSIONS

Results from this survey and future surveys can be used to learn more about "successful agers"--their medical histories, their life-styles, and whether their relative number is increasing or decreasing overtime.

Ischemic heart disease prevention: estimating the impact of interventions

The potential impact of ischemic heart disease intervention programs has usually been assessed using the dichotomy between those programs targeted to high risk groups and those that are population based, but this distinction does not adequately describe the spectrum of possibilities. Using data from the National Health and Nutrition Examination Survey Epidemiologic Follow-up Study (NHEFS), we assessed the effect of a spectrum of 27 potential interventions on mortality reduction and on an Intervention Index (defined as the number of persons whose risk must change to prevent one death). Using combinations of cholesterol reductions of 20% and decreases in the prevalence of smoking and hypertension of 50%, reductions in mortality varied from 1 to 27% and the Intervention Index varied from 26 to 520. A number of potential interventions were equivalent in their mortality reduction of their Intervention Indexes, despite their affecting differing proportions of the population. The Intervention Index provides some measure of the relative efficiency of programs and points to the comparability of different interventive approaches. In addition, this analysis suggests that the potential impact of intervention programs on mortality will be modest, but that a focus on certain subgroups, such as those aged 40-59 years, can achieve substantial results within those groups, even though the population effect would be minimal.

The health of young children in American cities

Societal problems, including drug use, poverty, and violence, are the basis of many severe health problems of urban children. This article addresses the health problems and care needs of young children in American cities and summarizes the nursing knowledge and skills needed for urban nursing practice.

Population aging patterns: the expansion of mortality

We used the hypothesis of mortality compression as a framework to examine patterns of mortality from 1962 to 1984. Data from national vital statistics records were used for analysis of the changing age at death for percentiles of the population. Data from the Social Security Administration and the U.S. Census Bureau were used to calculate the force of mortality. The mean age at death for all percentiles, including the oldest groups, has risen during the interval. Examination of the coefficient of variation for the mean age at death suggests that there is a relative increase in the variability of age at death among the oldest old. The available data do not fit a hypothetical sequence of normal density distributions with an increasing mean and declining standard deviation. The force of mortality in those over 85 years appears to be decreasing in a pattern similar to that for those under 85 years. Current mortality patterns suggest an "expansion," rather than compression, of mortality at the oldest ages. Further refinement of these observations, with improved data on mortality among the oldest old, will be helpful in delineating mortality patterns.

Case-control study of in situ and invasive carcinoma of the vagina

A case-control study of 41 patients with carcinoma in situ (CIS) or invasive cancer of the vagina and 97 community controls was undertaken to identify potential risk factors. Although vaginal and cervical cancers often occur as multiple primaries, only a few common risk factors prevailed. Similar to cervical cancer, low education and family income were risk factors for vaginal CIS and invasive cancer. In addition, history of genital warts was strongly related (RR = 2.9), although other sexual factors were not. Previous genital abnormalities related to subsequent cancer risk, with significant associations seen for vaginal discharge or irritation (RR = 6.1), a previous abnormal Pap smear (RR = 3.8), or an early hysterectomy (RR = 6.7). In addition, there was some evidence that vaginal trauma might be involved, with nonsignificant and independent associations relating to regular douching with preparations other than water or vinegar (RR = 2.7) and frequent washing of the genital area (RR = 2.7). Further studies are needed to determine whether our findings persist among a larger series of cases.

Full dose subcutaneous heparin therapy

Anticoagulation is used extensively for the treatment and prevention of thromboembolic disease. Full dose anticoagulation with heparin is usually administered intravenously via continuous 24-hour infusion to avoid complications with intermittent intravenous administration. Continuous intravenous therapy is costly and cumbersome for nurses and patients. Subcutaneous administration of heparin in full dosage offers an attractive therapeutic alternative. This study examines the safety, efficacy, and cost considerations of this form of therapy. Fifteen patients admitted to the hospital for myocardial infarction were evaluated. After the patients were transferred from the cardiac intensive care unit, intravenous heparin was discontinued, while therapeutic anticoagulation was maintained via the subcutaneous route. Complications were limited to local hematoma formation. A cost comparison revealed substantial savings with subcutaneous administration.

Epidemiologic aspects of control of penicillinase-producing Neisseria gonorrhoeae

Although first identified in 1976, penicillinase-producing Neisseria gonorrhoeae (PPNG) began to have significant epidemiologic impact in the United States only after 1980. The epidemic curve has been marked by a series of successive sigmoidal increases, the result of staggered epidemic activity in Los Angeles, California, New York, New York, and Miami. The most recent increase and current plateau has led to a provisional total of 16,608 cases for 1986, with the proportion of PPNG isolates as high as 30% in some communities. The intensity of PPNG transmission appears to parallel that of gonorrhea in general, with high attack rates in central city areas (i.e., among core groups) and with a dimmishing gradient outward from the center. The endemicity of PPNG is related in a general way to the size of the inoculum. A county experiencing seven cases in a month at the time of introduction, for example, has less than a 50% probability of reverting to zero cases during the next 12 months. It would appear that the inoculation of PPNG organisms into a community leads to a "take" when high-level transmitters of gonorrhea are affected. Though current projections suggest as many as 35,000-40,000 cases of PPNG infections by 1991, control programs that focus resources on core-group transmitters of gonorrhea may alter that course.

Survival with the acquired immunodeficiency syndrome. Experience with 5833 cases in New York City

In a cohort of 5833 subjects in whom the acquired immunodeficiency syndrome (AIDS) was diagnosed in New York City before 1986, the cumulative probability of survival (mean +/- SE) was 48.8 +/- 0.7 percent at one year and 15.2 +/- 1.8 percent at five years. The group with the most favorable survival rate--white homosexual men 30 to 34 years old who presented with Kaposi's sarcoma only--had a one-year cumulative probability of survival of 80.5 percent; that group was used as the reference group in assessing the effect of five variables: sex, race or ethnic background, age, probable route of acquiring AIDS (risk group), and manifestations of AIDS at diagnosis. The range in the mortality rate was greater than threefold, depending on these variables. Black women who acquired the disease through intravenous drug abuse, for example, had a particularly poor prognosis. The manifestations of disease at diagnosis had the most influence on survival, accounting on average for 56.3 percent of the excess risk. This variable was followed in importance by age (12.2 percent), race or ethnicity (10.6 percent), risk group (8.4 percent), and sex (8.0 percent), with 4.5 percent of the risk attributable to interactions between variables. When we compared subcohorts based on the year of diagnosis (1981 through 1985), we found a significant improvement in the one-year cumulative probability of survival among subjects with Pneumocystis carinii pneumonia, but not among subjects without P. carinii pneumonia.

The role of hospice in reducing the impact of bereavement

Survivors of patients in a randomized controlled trial of a hospital-based hospice were followed for 18 months after the patient's death. There were no significant differences in the anxiety or depression between hospice survivors (N = 56) and controls (N = 40). Neither were there significant differences in bed days, physician visits or scores on a 6-item health scale, even when the survivor's initial health status was held constant. No clear pattern of differences emerged in social participation, contacts with friends or relatives, smoking or drinking behaviors. We conclude that hospice care did not provide any protective effect for the bereavement period.

Acute hospitalization in a home for the aged

All acute hospitalizations from a 229-bed home for the aged for a four-year period were analyzed. Of 373 residents eligible for the study, 239 individuals were hospitalized a total of 503 times. Five patients were admitted seven times. Median length of stay was 9.4 days. Of 235 primary diagnoses, only nine occurred at least 1% of the time. Sixty-six different complications, representing 131 occurrences, were noted during hospitalization. Hospital mortality was 11.7%. Of first admissions 9.2% died and 19% of survivors required a higher level of care. One year later 40% had died and 17% were at a higher level of care. Logistic regression identified four variables significantly associated with death within six months of first hospitalization: age, hospital complication, surgical procedure, and diagnosis of acute myocardial infarction. Compared with nonhospitalized residents, hospitalized residents were more likely to be male, but no age effect was noted. Survival differences did not emerge until the third year of the study.

Hospice effectiveness in controlling pain

Terminal cancer patients were randomly assigned to receive comprehensive hospice care or traditional medical care. Patients were followed up for two years or until death. Pain was measured by the McGill Pain Scale. Frequency and intensity of cancer-related symptoms were also noted. Over the course of the study, 34% of hospice patients and 21% of control patients never reported pain. No significant differences between the two groups could be detected in either the proportion of patients with pain at any time or the intensity of pain. Neither were there differences in the intensity or frequency of cancer-related symptoms. The presence of pain was associated with the presence of other symptoms; a significant correlation was found between the levels of depression and anxiety and pain scores.

Hospice role in alleviating the emotional stress of terminal patients and their families

Terminally ill cancer patients in a Veterans Administration hospital were randomly assigned to receive hospice care. Follow-up evaluation through the time of death revealed no significant differences in anxiety or depression between hospice or control patients, but hospice patients exhibited significantly greater improvement in two of three measures of satisfaction (interpersonal care and involvement in care decisions). Hospice patients' significant others (SOs) showed some decrease in anxiety and greater satisfaction with involvement in care than did control SOs. The differences were attributable in part to hospice staff better meeting SOs' perceived needs.

Health effects associated with exposure to radioactively contaminated gold rings

This study was designed to assess the health risks associated with exposure to radioactively contaminated gold rings. A group of 135 exposed individuals, who were identified through a statewide jewelry screening program, were studied to determine the frequency of carcinoma and other skin problems on the ring finger. Severity of skin problems increased with increasing length of wear. Forty-one of the exposures were associated with mild to severe skin problems. Nine of the individuals studied were diagnosed as having histologically confirmed squamous cell carcinomas at the site of exposure. The incidence of skin cancer on the ring finger was eleven times that expected for men and forty-five times that expected for women. These data indicate that physicians who have patients with skin lesions of the ring finger should be aware of the possibility of exposure to a radioactive gold ring.

The clinical diagnosis of urethral discharge

When a standard method for grading urethral discharge that is based on quantity (profuse, moderate, or scant) and quality (purulent, cloudy, or clear) is used, the optimal performance of the clinical diagnosis of gonorrhea is 73%. This performance (true positives over true plus false positives) is dependent not only on the sensitivity, specificity, and prevalence of gonorrhea but also on the components of that prevalence, i.e., the specific mix of patients who attend a clinical service. Optimal performance, as determined through use of a relative operating characteristics curve, will vary from setting to setting depending upon certain patient variables, such as race and sexual preference. Clinics with full diagnostic service would not employ clinical diagnosis as a screening tool directly, but rather as an epidemiologic device for helping to characterize patient populations at risk. Areas with less developed clinic facilities might apply these observations for clinical decision making in the absence of laboratory support.

Reporting of gonorrhea by private physicians: a behavioral study

Physicians in the Denver Metropolitan Area were randomly assigned to study groups and exposed to an intervention designed to test current hypotheses concerning the reasons for underreporting of gonorrhea (lack of saliency in the request, patient interference, violation of the physician-patient relationship, insufficient rewards and excessive administrative cost to the reporter). A periodic telephone contact, initiated by the Health Department and requiring only contact between clerical personnel, more than doubled the number of reported cases. The effect was most striking for those who had not previously reported, and for doctors who practiced alone. An estimate of 42 per cent was obtained for the proportion of cases reported, substantially higher than that produced by retrospective surveys based on recall. The impact of undernotification on total morbidity will vary with the preexisting mix of public and private reporting. The telephone reporting system appears to be an inexpensive and effective program tool for determining that impact locally.

Chlamydial infection of mothers and their infants

In 340 women, cultured prospectively during their pregnancies, the rate of infection with Chlamydia trachomatis was 8.8%. The women with positive cultures tended to be younger and more often single and black than their counterparts with negative cultures. There were no statistically significant clinical differences between the two groups. Eighteen children born to Chlamydia culture-positive women and 16 born to negative women were followed for nine months to examine the potential effects of maternal infection on infant growth, development, and illness. Eleven of 18 study patients had culture or tear antibody evidence of Chlamydia infection, as opposed to one of the control subjects (P = 0.00093). Eight of these 11 had clinical conjunctivitis, and two of the eight developed pneumonia. Growth retardation and developmental abnormalities were not detected in either group. It is concluded that maternal carriage of C. trachomatis is associated with a high incidence of clinical illness in the offspring.

Gonorrhea in street prostitutes: epidemiologic and legal implications

Sociodemographic characteristics of a group of street prostitutes in Colorado Springs, Colorado, were determined through retrospective chart review and compared with those of a group of nonprostitute women seen at a venereal disease clinic. Initially, the risk that prostitutes would contract gonorrhea was substantially higher than the risk for other women (31% vs. 21%) but the risks for both groups decreased over the two-year period during which control measures were applied. These measures included use of legal orders, based on the constitutional requirement of "least restrictive alternative." Prostitutes in this setting may well constitute a "core group" of transmitters.

Prepubertal infections with Neisseria gonorrhoeae: clinical and epidemiologic significance

The family constellations and epidemiologic circumstances of three prepubertal girls with vulvovaginitis due to Neisseria gonorrhoeae are reported. In each instance, an infected asymptomatic man, himself a contact to a woman with pelvic inflammatory disease, could be implicated as the potential source of infection. In one instance, asymptomatic infection in a child was uncovered through epidemiologic investigation. Prepubertal gonococcal vaginitis is important not only as a potential indicator of child abuse, but also as a possible link to important transmitters of gonococcal infection. The need for meticulous epidemiologic investigation of these cases is stressed.