Δευτέρα, 25 Αυγούστου 2014

Ebola Outbreak in West Africa 20 Aug 2014 (Guinea, Liberia, Sierra Leone, and Nigeria)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 


http://www.cdc.gov/vhf/ebola/outbreaks/guinea/index.html


Highlights

The 2014 Ebola outbreak is one of the largest Ebola outbreaks in history and the first in West Africa. It is affecting four countries in West Africa: 
Guinea, Liberia, Nigeria, and Sierra Leone, 
but does not pose a significant risk to the U.S. public. 

CDC is working with other U.S. government agencies, the World Health Organization, and other domestic and international partners in an international response to the current Ebola outbreak in West Africa. 

CDC has activated its Emergency Operations Center (EOC) to help coordinate technical assistance and control activities with partners. 

CDC has deployed several teams of public health experts to the West Africa region and plans to send additional public health experts to the affected countries to expand current response activities.
As of August 20, 2014
The Guinean Ministry of Health, 
the Ministry of Health and Sanitation of Sierra Leone, 
the Ministry of Health and Social Welfare of Liberia, and 
 the Nigerian Ministry of Health 
are working with national and international partners to investigate and respond to the outbreak.
Guinea
  • The Guinea Ministry of Health announced 607 suspect and confirmed cases of Ebola virus disease (EVD), including 443 laboratory-confirmed cases, and 406 deaths.
  • Affected districts include Conakry, Guéckédou, Macenta, Kissidougou, Dabola, Djingaraye, Télimélé, Boffa, Kouroussa, Dubreka, Fria, Siguiri, Pita, Nzerekore, and Yamou; several are no longer active areas of EVD transmission (see map).
Liberia
  • The Ministry of Health and Social Welfare of Liberia and WHO have reported 1082 suspect and confirmed EVD cases, including 269 laboratory-confirmed, and 624 deaths.
Nigeria
  • The Nigerian Ministry of Health and WHO reported 16 suspect and confirmed cases, including 12 laboratory-confirmed, and 5 deaths.
Sierra Leone
  • The Ministry of Health and Sanitation of Sierra Leone and WHO reported a cumulative total of 910 suspect and confirmed cases, including 804 laboratory-confirmed cases, and 392 deaths.
  • Cases have been reported from all 12 Sierra Leone districts.
About the virus
  • Genetic analysis of the virus indicates that it is closely related (97% identical) to variants of Ebola virus (species Zaire ebolavirus) identified earlier in the Democratic Republic of the Congo and Gabon (Baize et al. 2014).

ΜΑΝΩΛΑΔΑ: ΧΡΟΝΙΚΟ ΜΙΑΣ ΔΙΚΑΣΤΙΚΗΣ ΑΠΟΤΥΧΙΑΣ / ΕΣΠ /







































Μετά την απόφαση του Μικτού Ορκωτού Δικαστηρίου της Πάτρας για την υπόθεση της Μανωλάδας, το Ελληνικό Συμβούλιο για τους Πρόσφυγες (ΕΣΠ) το οποίο παρέστη ως πολιτική αγωγή στην υπόθεση του εργασιακού trafficking και των πυροβολισμών κατά των μεταναστών εργατών επιθυμεί να επισημάνει τα εξής ως προς τη διαδικασία και την έκβασή της:


Παρότι το θέμα απασχόλησε και συγκλόνισε την κοινή γνώμη παγκοσμίως, το αποτέλεσμα και ιδίως η διαδικασία που ακολουθήθηκε τόσο κατά την προανάκριση όσο και κατά τη διάρκεια της ακροαματικής διαδικασίας αναδεικνύει πολλές παθογένειες της ελληνικής δικαιοσύνης, οδηγώντας σχεδόν αναπόφευκτα στο τελικό αποτέλεσμα. 

Το ΕΣΠ είχε έγκαιρα επισημάνει ότι «η πλήρης διερεύνηση της υπόθεσης είναι διαρκές ζητούμενο της ποινικής προδικασίας και δη στο συγκεκριμένο περιστατικό όπου έλαβαν χώρα σοβαρές παραβιάσεις των ανθρωπίνων δικαιωμάτων».[1]

Τα προβλήματα ανέκυψαν τόσο κατά τη φάση της προδικασίας όσο και στην ακροαματική διαδικασία. 
Σε ό, τι αφορά το στάδιο της προδικασίας που ξεκίνησε στις 18/4/2013, παρά την παρέμβαση της Εισαγγελίας του Αρείου Πάγου, δεν απεφεύχθησαν προχειρότητες που είχαν επιπτώσεις στην απόφαση. 

Αμέσως μετά την επίθεση κατά των μεταναστών[2], δεν εμφανίστηκε, ως όφειλε, η ειδική υπηρεσία anti-trafficking της ΓΑΔΑ για να επιληφθεί άμεσα των προανακριτικών ενεργειών, παρά το γεγονός ότι κορυφαίος δικαστικός λειτουργός - ο Εισαγγελέας του Αρείου Πάγου - είχε ορθά παραγγείλει στην Εισαγγελία Αμαλιάδας να διερευνήσει τους πυροβολισμούς της Μανωλάδας υπό το πρίσμα του φαινομένου του εργασιακού trafficking που επί μακρόν κυριαρχούσε στην περιοχή. 

Η εμπλοκή των ειδικευμένων υπηρεσιών της Ελληνικής Αστυνομίας θα επέτρεπε,  ενδεχομένως, να αποφευχθεί η απόδοση της ιδιότητας του «θύματος εμπορίας ανθρώπων» μόνο στους τραυματίες της επίθεσης και όχι στο σύνολο των εργαζομένων της επιχείρησης που προσέγγιζαν, σύμφωνα με τη δικογραφία, τους 200, γεγονός πρωτόγνωρο στη δικαστική αντιμετώπιση του trafficking ανά τον κόσμο.


Επιπλέον, η συνέχεια της προανάκρισης – που κακώς διεξήχθη από τις τοπικές αστυνομικές αρχές – παρουσίασε επίσης σοβαρότατα λάθη. 

Πρωτίστως, ουδέποτε αναζητήθηκαν ανεξάρτητοι διερμηνείς για την εξέταση των θυμάτων. 

Αντιθέτως οι τοπικές αστυνομικές αρχές χρησιμοποίησαν ομοεθνείς των θυμάτων που κατοικούσαν στην περιοχή – συνήθως τους παλαιότερους – οι οποίοι είχαν στενή σχέση και επιχειρηματική συνεργασία με τους κατηγορούμενους. 

Μάλιστα ένας εξ αυτών προτάθηκε και ως μάρτυρας υπεράσπισης των κατηγορουμένων και είχε κληθεί να τελέσει και καθήκοντα διερμηνέα στη δίκη ενώπιον του ΜΟΔ Πατρών, γεγονός  που απεφεύχθη με πρωτοβουλία της Πολιτικής Αγωγής για να μη προκαλέσει απόλυτη ακυρότητα στη διαδικασία. 

Επιπρόσθετα, η Πολιτεία δεν έλαβε κανένα μέτρο για την ασφάλεια έστω των 35 θυμάτων που είχε θέσει υπό καθεστώς προστασίας ενόψει της δίκης, και δεν έλαβε κανένα μέτρο προκειμένου να εξασφαλίσει ότι τα θύματα θα μεταβούν στην Πάτρα ώστε να παραστούν στη δίκη[3].

Η ακροαματική διαδικασία που επακολούθησε διεξήχθη υπό το βάρος των ως άνω προβλημάτων της προδικασίας. 

Τονίζεται ότι οι δίκες θυμάτων trafficking καλύπτονται από ειδικές δικονομικές εγγυήσεις που περιγράφονται με σαφήνεια στο άρθρο 12 της Οδηγίας 2011/36/ΕΕ για την πρόληψη και καταπολέμηση της εμπορίας ανθρώπων που δεσμεύει όλα τα όργανα της ελληνικής πολιτείας.[4] 

Η παράθεση των σχετικών διατάξεων καταδηλώνει τις τεράστιες διαφορές μεταξύ της συμπεριφοράς των οργάνων της ελληνικής πολιτείας και των νομοθετικών προβλέψεων [5].

Παρά το γεγονός ότι κατά τη διάρκεια της ακροαματικής διαδικασίας καμία από τις θεσμικές εγγυήσεις δεν τηρήθηκε, θα ανέμενε κανείς από τα τακτικά κυρίως μέλη του δικαστηρίου, να λάβουν υπόψη τους την τεκμηριωμένη πρόταση της Εισαγγελέως της έδρας, η οποία αποτύπωσε νομολογιακές κατευθύνσεις δικαστηρίων κρατών-μελών της ΕΕ που εφαρμόζουν ομοιόμορφο νομικό πλαίσιο σε ανάλογες υποθέσεις, προκειμένου να διαμορφώσουν δικανική πεποίθηση  για την εργασία ως μορφή εκμετάλλευσης στο πλαίσιο της εμπορίας ανθρώπων (323α ΠΚ) σε σχέση με την παράνομη εργασία αλλοδαπών (αρ. 86 ν. 3386/2005) με την οποία συχνότατα συγχέεται. 

Κριτήριο για το χαρακτηρισμό μιας παρεχόμενης υπηρεσίας ή επαγγέλματος ως μορφή εκμετάλλευσης της εργασίας δεν είναι το είδος της δραστηριότητας που ασκείται και η οποία μπορεί να είναι καθόλα νόμιμη, αλλά η σχέση του θύματος με τον εργοδότη και οι συνθήκες υπό τις οποίες εργάζεται. 

Σύμφωνα με την κείμενη νομοθεσία, trafficker είναι το πρόσωπο που, αν και έχει κάθε δυνατότητα και υποχρέωση να παράσχει κάποιο είδος προστασίας στους εργαζομένους του, δεν θέλησε ποτέ να πληρώσει τα συμφωνημένα και εκμαίευε τη συνέχιση της παροχής εργασίας με απειλές βίας και χρήση όπλων, εκμεταλλευόμενος στο έπακρον την απουσία κράτους και συντεταγμένης Πολιτείας, με σκοπό το κέρδος σε βάρος ανυπεράσπιστων ανθρώπων – δούλων του.










 



























Τα γεγονότα της Μανωλάδας και η αντίδραση της κοινωνίας δείχνουν ότι η εργασιακή εκμετάλλευση τέτοιου είδους δεν είναι πλέον ηθικά ανεκτή. 

Ωστόσο, η αδυναμία της ελληνικής δικαιοσύνης να αντιμετωπίζει ανάλογα φαινόμενα εργασιακών συνθηκών στην Ελλάδα απαιτεί την επέμβαση του νομοθέτη για τη νομιμοποίηση των θυμάτων της επίθεσης – αλλά και της εργασιακής εκμετάλλευσης - και την αντιμετώπιση των λόγων που οδήγησαν στην επίθεση αυτή. 

Η νομιμοποίηση δεν μπορεί προφανώς να αποτελέσει δικαίωση αλλά θα είναι παρήγορο το γεγονός ότι οι συγκεκριμένοι εργάτες γης ως θύματα τελικά επικίνδυνων σωματικών βλαβών (309 ΠΚ) δεν θα εκπέσουν της νομιμότητας, όπως θέλουμε να ελπίζουμε, ενόψει της νέας ΚΥΑ 30651/2014για άδεια διαμονής για ανθρωπιστικούς λόγους και της ορθής εφαρμογής της.

[2] Παρότι στο μικρό Α.Τ. Βάρδας Ηλείας εμφανίστηκε ολόκληρη η ηγεσία της Αστυνομίας (Αρχηγός, Προϊστάμενος Οικονομικής Αστυνομίας και Προϊστάμενος Ρατσιστικής Βίας) – όπως είχαν την ευκαιρία να διαπιστώσουν οι δικηγόροι του ΕΣΠ ιδίοις όμμασι

[3] βλ. Υπηρεσίες και μονάδες παροχής προστασίας και αρωγής Παράρτημα ΠΔ 233/2003

[4] Η Ελλάδα όφειλε να έχει ενσωματώσει τις εγγυήσεις που θέσπισε η Οδηγία 2011/36 ως τις 6/4/2013, κατά τραγική ειρωνεία, 11 ημέρες πριν το επίδικο συμβάν. 
Παρά την καθυστερημένη και ατελή ενσωμάτωσή της με το νόμο 4198/2013, το άρθρο 12 και οι διαδικαστικές εγγυήσεις που προβλέπει τέθηκαν με δήλωση της πολιτικής αγωγής ενώπιον του ΜΟΔ Πατρών κατά τη διάρκεια της ακροαματικής διαδικασίας.

[5] Θα υπάρξει σχετική αναλυτική αναφορά στα αρμόδια όργανα της Ευρωπαϊκής Επιτροπής σχετικά με τις παραβιάσεις της Οδηγίας που οδήγησαν σε παρατυπίες στη διαδικασία και στην έκβαση της υπόθεσης. 

Ενδεικτικά όμως αναφέρουμε:

3. Τα κράτη μέλη εξασφαλίζουν ότι τα θύματα εμπορίας ανθρώπων τυγχάνουν της δέουσας προστασίας βάσει ατομικής αξιολόγησης κινδύνου, μεταξύ άλλων έχοντας πρόσβαση σε προγράμματα προστασίας μαρτύρων ή άλλα παρόμοια μέτρα, αν χρειάζεται και σύμφωνα με τους λόγους που ορίζονται από το εθνικό δίκαιο ή τις εθνικές διαδικασίες.

4. Με την επιφύλαξη των δικαιωμάτων υπεράσπισης και λαμβανομένης υπόψη της ατομικής αξιολόγησης εκ μέρους των αρμόδιων αρχών της προσωπικής κατάστασης του θύματος, τα κράτη-μέλη εξασφαλίζουν ότι τα θύματα εμπορίας ανθρώπων τυγχάνουν ειδικής μεταχείρισης που αποβλέπει στην αποτροπή επακόλουθης θυματοποίησης αποφεύγοντας στο μέτρο του δυνατού, και τηρουμένων των κριτηρίων που ορίζονται στο εθνικό δίκαιο καθώς και της εξουσίας εκτίμησης, της πρακτικής και των κατευθύνσεων των δικαστηρίων, τα ακόλουθα:

α) κάθε άσκοπη επανάληψη συνεντεύξεων κατά το στάδιο της διερεύνησης, δίωξης και εκδίκασης

β) κάθε οπτική επαφή μεταξύ θυμάτων και εναγομένων συμπεριλαμβανομένης της κατάθεσης, όπως π.χ. σε συνεντεύξεις και σε κατ’ αντιπαράσταση εξέταση, χρησιμοποιώντας τα κατάλληλα μέσα, μεταξύ των οποίων και η χρήση της κατάλληλης τεχνολογίας επικοινωνιών

γ) κάθε κατάθεση σε δημόσια συνεδρίαση, και

δ) άσκοπες ερωτήσεις σχετικά με την ιδιωτική ζωή των θυμάτων.

http://www.gcr.gr/index.php/el/news/press-releases-announcements/item/414-manwlada-fiasko

Relationship of Income and Health Care Coverage to Receipt of Recommended Clinical Preventive Services by Adults — United States, 2011–2012 Weekly August 8, 2014 / 63(31);666-670


Jared B. Fox, PhD1, Frederic E. Shaw, MD, JD2 (Author affiliations at end of text)
Each year in the United States, an estimated 100,000 deaths could be prevented if persons received recommended clinical preventive care (1). 

The Affordable Care Act has reduced cost as a barrier to care by expanding access to insurance and requiring many health plans to cover certain recommended preventive services without copayments or deductibles. 

To establish a baseline for the receipt of these services and to begin monitoring the effects of the law, CDC analyzed responses from persons aged ≥18 years in the National Health Interview Survey (NHIS) for the years 2011 and 2012 combined. 

This report summarizes the findings for six services covered by the Affordable Care Act. 

Among the six services examined, three were received by less than half of the persons for whom they were recommended (testing for human immunodeficiency virus [HIV] and vaccination for influenza and zoster [shingles]). 

Having health insurance or a higher income was associated with higher rates of receiving these preventive services, affirming findings of previous studies (2 Adobe PDF file). 

Securing health insurance coverage might be an important way to increase receipt of clinical preventive services, but insurance coverage is not all that is needed to ensure that everyone is offered and uses clinical services proven to prevent disease. 

Greater awareness of Affordable Care Act provisions among public health professionals, partners, health care providers, and patients might help increase the receipt of recommended services (3).

The analysis focused on responses to questions about the receipt of six clinical preventive services recommended by the U.S. Preventive Services Task Force (USPSTF) or the Advisory Committee for Immunization Practices (ACIP). 

The six preventive services are among dozens of services for adults covered without copayments or deductibles under certain health plans according to the Affordable Care Act,* and were selected for this analysis because the recommendations closely fit NHIS survey questions. 

The six were as follows: 

HIV testing, 
smoking cessation discussion, 
influenza vaccination, 
pneumococcal vaccination, 
tetanus vaccination, and 
zoster (shingles) vaccination. 

However, the recommendations and NHIS questions are not a perfect match. 

For example, cessation intervention is recommended for all forms of tobacco use, but respondents were only asked about receiving smoking cessation interventions. 

The fit between the NHIS questions and the recommendations varied among the six preventive services (Table 1).

NHIS is administered by in-person interviews to a nationally representative sample of the noninstitutionalized, U.S. civilian population. 

For this analysis, NHIS data from the sample adult core questionnaire in 2011 and 2012 were combined to increase sample sizes and improve reliability of estimates. 

In each household identified, one adult (aged ≥18 years) from each family was randomly selected to complete the questionnaire. NHIS 2011 and 2012 adult core samples included 33,014 and 34,525 respondents, respectively, and the overall response rates were 66.3% and 61.2%. 

Participants were asked whether they had health insurance at the time of the interview. 

They were considered uninsured if they reported currently not having private health insurance, Medicare, Medicaid, Children's Health Insurance Program, a state-sponsored or other government-sponsored health plan, or a military plan. 

Respondents also were defined as uninsured if they had only a private plan that paid for one type of service (e.g., injury or dental care) or had only Indian Health Service coverage.§ 

Multiple imputations were performed on family income to account for missing responses to income questions. 

NHIS data were adjusted for nonresponse and weighted to provide national estimates of insurance status and receipt of preventive care; 95% confidence intervals were calculated, taking into account the survey's multistage probability sample design. 

Generalized linear modeling and the t-test were used to calculate prevalence ratios and statistical significances of differences in preventive services receipt between 

1) persons who were insured and those who were uninsured, 
2) those with current family incomes >200% of the federal poverty level (FPL) ($46,100 for a family of four in 2012**) and those with incomes ≤200% of the FPL, and 
3) those with any private health insurance and those with only public coverage. 

For the six services examined, prevalence of receipt of service was as follows: 
zoster vaccination, 17.9%; 
influenza vaccination, 39.4%; 
HIV testing, 41.7%; 
smoking cessation discussion, 52.0%; 
pneumococcal vaccination, 61.4%; and 
tetanus vaccination, 62.0% (Table 2). 

A higher percentage of adults with health insurance received five of six recommended clinical preventive services (all but HIV testing) compared with those who were uninsured (Table 2). 

Among those five services, the service receipt prevalence ratio for those with insurance compared with those without insurance ranged from 1.2 for tetanus vaccination to 3.4 for pneumococcal vaccination (Table 2). 

However, service receipt for persons with health insurance was <50% for three of six recommended clinical preventive services. 

Persons with family incomes >200% of the FPL received five of six recommended clinical preventive services at a statistically significant higher prevalence compared with those with incomes below that threshold (Table 3).

Among those five services, the service receipt prevalence ratio for those with family incomes >200% of the FPL compared with those with incomes ≤200% of the FPL ranged from 1.1 for pneumococcal vaccination to 1.9 for zoster vaccination (Table 3).

Persons with private health insurance received three of six recommended clinical preventive services at a higher prevalence, and three of six at a lower prevalence, compared with those with only public insurance (Table 4). 

Discussion

 

The findings in this report indicate that during 2011–2012, large portions of the adult population were not receiving recommended preventive care, those with insurance were more likely to receive recommended preventive services than those without coverage, and those with higher income were more likely to receive recommended care. 

This supports previously published studies, including one that found prevalence ratios in the range of 1–3 for those with insurance receiving recommended preventive services compared with those without coverage (2 Adobe PDF file). 

However, even among persons with insurance and higher income, in this analysis, receipt of recommended preventive services was suboptimal.

This report could serve as a baseline for tracking the effects of the Affordable Care Act on the receipt of six preventive services. 

Although the law began to require certain plans to cover clinical preventive services in September 2010, the data from 2011–2012 provide a feasible baseline for measuring the law's effects because 

1) a high number of persons remained uninsured during 2011–2012, 
2) there was little awareness of the preventive care provisions of the new law, and 
3) many plans in existence before enactment of the Affordable Care Act were not subject to the preventive services provisions (4–6).

The findings in this report are subject to at least four limitations. 

First, this was a cross-sectional study, and associations between receipt of a service and other factors do not imply a causal relationship. 

Second, insurance coverage and income level are just two of many factors that might be associated with service receipt rates. 

This analysis does not include possible confounders such as education, health status, or other factors. 

Third, receipt of preventive services was self-reported and might be subject to recall bias. 

Finally, inferences from these results are limited by differences in time between when the questions were asked and when the services were received. 

For example, NHIS identifies whether the respondent is insured at the time of interview; however, depending on the service, NHIS asks whether the respondent received preventive care in the last 12 months, last 10 years, or ever during their lifetime. 

Currently uninsured respondents might have received preventive care during a time when they had insurance, or vice versa. 

In addition, NHIS is limited to noninstitutionalized civilians, excluding certain populations (e.g., the institutionalized and the military) that might be especially likely to receive recommended preventive services. 

All new private health plans, alternative benefit plans for the newly Medicaid eligible, and Medicare now provide coverage without copayments or deductibles for recommended clinical preventive services. 

By expanding access to insurance and requiring many plans to cover recommended clinical preventive services, the Affordable Care Act is expected to reduce barriers to receipt of recommended preventive care. 

The number of uninsured persons aged <65 years is expected to drop from 55 million in 2013 to 30 million in 2017 (7)

Lack of insurance, however, is not the only barrier to receiving services; a number of other factors likely will continue to inhibit receipt of preventive care. 

First, many persons are currently insured under "grandfathered" health plans not required to provide coverage without copayments or deductibles for all recommended preventive services (8). 

Second, other barriers, such as transportation costs and lack of a regular physician, might inhibit receipt of recommended preventive care. 

Finally, even after the Affordable Care Act is implemented fully, millions of persons are expected to remain uninsured (7). 

To date, about half of the 50 states have not yet implemented the law's expansion of Medicaid, leaving an estimated 40% of their adult residents who have been uninsured in the last 2 years without access to affordable care (9). 

Studies have indicated that 60%–74% of children who are eligible for Medicaid are uninsured, in part as a result of failure to renew enrollment in Medicaid (10). 

Efforts to increase enrollment and coverage retention could help these populations maintain continuous coverage, thereby increasing receipt of preventive services and reducing avoidable complications from illness, long-term health care costs, and premature deaths (10).

Office of Health System Collaboration, Office of the Associate Director for Policy, CDC; 2Center for Surveillance, Epidemiology, and Laboratory Services, CDC 
 
(Corresponding author: 
Jared Fox, jaredfox@cdc.gov, 404-639-7620)

References

  1. National Commission on Prevention Priorities. Preventive care: a national profile on use, disparities, and health benefits. Washington, DC: Partnership for Prevention, National Commission on Prevention Priorities; 2007. Available at http://www.prevent.org/data/files/initiatives/ncpppreventivecarereport.pdf Adobe PDF fileExternal Web Site Icon.
  2. CDC. Use of selected clinical preventive services among adults—United States, 2007–2010. MMWR 2012;61(Suppl) Adobe PDF file.
  3. Frieden TR. Six components necessary for effective public health program implementation. Am J Public Health 2014;104:17–22.
  4. Kaiser Family Foundation; Health Research and Educational Trust. Employer health benefits: 2011 annual survey. Menlo Park, CA: Kaiser Family Foundation; Chicago, IL: Health Research and Educational Trust; 2011. Available at http://kaiserfamilyfoundation.files.wordpress.com/2013/04/8225.pdf Adobe PDF fileExternal Web Site Icon.
  5. Kaiser Family Foundation; Health Research and Educational Trust. Employer health benefits: 2012 annual survey. Menlo Park, CA: Kaiser Family Foundation; Chicago, IL: Health Research and Educational Trust; 2012. Available at http://kff.org/report-section/ehbs-2012-section-13External Web Site Icon.
  6. Reed ME, Graetz I, Fung V, Newhouse JP, Hsu J. In consumer-directed health plans, a majority of patients were unaware of free or low-cost preventive care. Health Aff (Millwood) 2012;31:2641–8.
  7. Congressional Budget Office. Insurance coverage provisions of the Affordable Care Act—CBO's February 2014 baseline. Washington, DC: Congressional Budget Office; 2014. Available at http://www.cbo.gov/sites/default/files/cbofiles/attachments/43900-2014-02-ACAtables.pdf Adobe PDF fileExternal Web Site Icon.
  8. Kaiser Family Foundation; Health Research and Educational Trust. Employer health benefits: 2013 annual survey. Menlo Park, CA: Kaiser Family Foundation; Chicago, IL: Health Research and Educational Trust; 2013. Available at http://kaiserfamilyfoundation.files.wordpress.com/2013/08/8465-employer-health-benefits-20131.pdf Adobe PDF fileExternal Web Site Icon.
  9. Rasmussen PW, Collins SR, Doty MM, Garber T. In states' hands: how the decision to expand Medicaid will affect the most financially vulnerable Americans. Issue Brief (Commonw Fund) 2013;23:1–8. 
  10. Sommers BD. Why millions of children eligible for Medicaid and SCHIP are uninsured: poor retention versus poor take-up. Health Aff (Millwood) 2007;26:w560–7.
* For adults, the Affordable Care Act recognizes 
as organizations whose clinical preventive service recommendations receive coverage without copayments and deductibles for certain health plans.

Additional information available at 

§ Consistent with other population surveys conducted by U.S. federal agencies, CDC does not regard Indian Health Service coverage as health insurance for the purpose of identifying uninsured populations.

Additional information available at 

** Additional information available at 


What is already known on this topic?

Rates of receipt of some clinical preventive services by adults are low, but higher for persons with insurance coverage or higher incomes. 

The Affordable Care Act's expansions of health insurance access and coverage requirements for clinical preventive services were developed to increase access to health services to improve the health of the population.

What is added by this report?

Analysis of combined adult responses to the National Health Interview Survey in 2011 and 2012 indicated that persons with health insurance were more likely to have received five of six recommended preventive services than persons without insurance.

However, regardless of insurance status, receipt was below 50% for three services and ranged from 17.9% for zoster vaccination to 62.0% for tetanus vaccination. 

What are the implications for public health practice?

Increased insurance coverage might lead to a substantial increase in receipt of preventive care and improvements in population health. 

However, low rates of service receipt even among those with insurance suggest that additional efforts beyond insurance coverage expansion might be needed to increase offering and use of services.








 
TABLE 1. Comparison of recommendations from the United States Preventive Services Task Force (USPSTF) and the Advisory Committee on Immunization Practices (ACIP) with questions regarding six recommended clinical preventive services in the National Health Interview Survey (NHIS) — United States, 2011–2012
Clinical preventive service (age group)
Recommendation
Question to NHIS participants
Key distinctions for this analysis of use of recommended services
HIV test (age 18–65 years)
HIV infection screening is recommended for persons aged 15–65 years. Screening is recommended for other age groups at increased risk. Recommended screening interval for the general population is not specified.*
To adults aged ≥18 years: "Except for tests you may have had as part of blood donations, have you ever been tested for HIV?"
NHIS asks this question to those aged ≥18 years. Those aged 15–17 years are not included in the analysis.
Smoking cessation discussion (age ≥18 years)
Tobacco cessation interventions are recommended for those who use tobacco products. A recommended screening interval for the general population is not specified.*
To adults aged ≥18 years who currently smoke cigarettes every day or some days: "During the past 12 months, has a doctor or other health professional talked to you about your smoking?"
Adults who use tobacco only in forms other than cigarettes are not included in the analysis.
Influenza vaccination (age ≥18 years)
Annual vaccination against influenza is recommended for all persons aged ≥6 months.§
To adults aged ≥18 years: "During the past 12 months, have you had a flu shot?" and "During the past 12 months, have you had a flu vaccine sprayed in your nose by a doctor or other health professional?" A"yes" response to either question is coded as vaccination received.
This analysis focuses on adults aged ≥18 years.
Pneumococcal vaccination (age ≥65 years)
Pneumococcal vaccination is recommended for all persons aged ≥65 years and for persons with certain other risk factors aged <65 years.§
"Have you ever had a pneumonia shot?"
This analysis focuses on those aged ≥65 years.
Tetanus vaccination (age ≥19 years)
Vaccination with Td booster (or 1-time dose of Tdap) for all adults aged ≥19 years.§
To adults aged ≥18 years: "Have you received a tetanus shot in the past 10 years?"
This analysis focuses on those aged ≥19 years for consistency with the recommendation for adults.
Zoster (shingles) vaccination (age ≥60 years)
Zoster vaccination is recommended for adults aged ≥60 years.§
To adults aged ≥50 years: "Have you ever had the zoster or shingles vaccine, also called Zostavax?"
This analysis focuses on those aged ≥60 years for consistency with the recommendation for adults.
Abbreviations: HIV = human immunodeficiency virus; Td = tetanus and diphtheria; Tdap = tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis.
* Source: USPSTF.
At any age.
§ Source: ACIP.

TABLE 2. Percentage of adults in the recommended populations who received six clinical preventive services, by health insurance status — National Health Interview Survey, United States, 2011–2012
Clinical preventive service (age group)
Insured receiving service
Uninsured receiving service
Prevalence
ratio,
insured/
uninsured*
(95% CI)
Total receiving service
No.
%
(95% CI)
No.
%
(95% CI)
%
(95% CI)
HIV test (ever) (age 18–65 years)
40,823
41.5
(40.7–42.2)
11,641
43.1
(41.9–44.3)
1.0
(0.9–1.0)
41.7
(41.1–42.4)
Smoking cessation discussion (within 12 mos) (age ≥18 years)
8,935
59.1
(58.0–60.3)
3,497
32.7
(31.1–34.4)
1.8§
(1.7–1.9)
52.0
(51.0–53.0)
Influenza vaccination (within 12 mos) (age ≥18 years)
54,217
44.2
(43.6–44.7)
11,888
14.7
(13.9–15.4)
3.0§
(2.9–3.2)
39.4
(38.9–40.0)
Pneumococcal vaccination (ever) (age ≥65 years)
13,585
61.7
(60.6–62.7)
113
18.1
(9.1–27.0)
3.4§
(2.1–5.6)
61.4
(60.3–62.4)
Tetanus vaccination (within 10 years) (age ≥19 years)
51,872
63.7
(63.0–64.3)
11,431
53.7
(52.6–54.8)
1.2§
(1.2–1.2)
62.0
(61.5–62.6)
Zoster vaccination (ever) (age ≥60 years)
18,297
18.4
(17.6–19.2)
868
6.3
(4.2–8.4)
2.9§
(2.1–4.1)
17.9
(17.1–18.7)
Abbreviations: CI = confidence interval; HIV = human immunodeficiency virus.
* Generalized linear modeling was used to identify statistical significance of differences between insured and uninsured persons receiving service.
p<0.015.
§ p<0.001.

TABLE 3. Percentage of adults in the recommended populations who received six clinical preventive services, by family income level — National Health Interview Survey, United States, 2011–2012
Clinical preventive service (age group)
Income >200% FPL receiving service
Income ≤200% FPL receiving service
Prevalence
ratio,
higher income/
lower income*
(95% CI)
No.
%
(95% CI)
No.
%
(95% CI)
HIV test (ever) (age 18–65 years)
31,948
40.2
(39.4–40.9)
25,815
44.6
(43.5–45.7)
0.9
(0.9–0.9)
Smoking cessation discussion (within 12 mos) (age ≥18 years)
6,068
53.5
(52.2–54.8)
6,404
50.4
(48.9–51.9)
1.1§
(1.0–1.1)
Influenza vaccination (within 12 mos) (age ≥18 years)
40,110
42.8
(42.2–43.4)
26,201
33.4
(32.6–34.3)
1.3
(1.3–1.3)
Pneumococcal vaccination (ever) (age ≥65 years)
8,268
64.4
(63.1–65.6)
5,449
56.2
(54.5–57.9)
1.1
(1.1–1.2)
Tetanus vaccination (within 10 years) (age ≥19 years)
38,893
65.0
(64.4–65.7)
24,840
56.6
(55.7–57.5)
1.1
(1.1–1.2)
Zoster vaccination (ever) (age ≥60 years)
12,025
21.4
(20.4–22.4)
7,177
11.3
(10.3–12.3)
1.9
(1.7–2.1)
Abbreviations: CI = confidence interval; HIV = human immunodeficiency virus; FPL = federal poverty level.
* Generalized linear modeling was used to identify statistical significance of differences betweeen persons at higher income level and lower income level receiving service.
p<0.001.
§ p<0.005.

TABLE 4. Percentage of adults in the recommended populations who received six clinical preventive services, by source of health insurance coverage — National Health Interview Survey, United States, 2011–2012
Clinical preventive service (age group)
Private insurance receiving service
Only public insurance receiving service
Prevalence
ratio,
private/
public*
(95% CI)
No.
%
(95% CI)
No.
%
(95% CI)
HIV test (ever) (age 18–65 years)
31,605
38.6
(37.8–39.3)
9,218
53.0
(51.6–54.3)
0.7
(0.7–0.8)
Smoking cessation discussion (within 12 mos) (age ≥18 years)
5,399
55.3
(53.9–56.8)
3,535
65.8
(64.0–67.5)
0.8§
(0.8–0.9)
Influenza vaccination (within 12 mos) (age ≥18 years)
38,470
42.4
(41.8–43.1)
15,738
48.9
(47.9–49.9)
0.9§
(0.8–0.9)
Pneumococcal vaccination (ever) (age ≥65 years)
6,807
66.1
(64.8–67.4)
6,769
56.9
(55.3–58.4)
1.2§
(1.1–1.2)
Tetanus vaccination (within 10 years) (age ≥19 years)
36,917
65.7
(65.1–66.4)
14,946
57.9
(56.9–58.9)
1.1§
(1.1–1.2)
Zoster vaccination (ever) (age ≥60 years)
10,305
20.4
(19.4–21.4)
7,984
15.7
(14.6–16.7)
1.3§
(1.2–1.4)
Abbreviations: CI = confidence interval; HIV = human immunodeficiency virus.
* Generalized linear modeling was used to identify statistical significance of differences between persons with private insurance and only public insurance.
p<0.05.
§ p<0.001.