Turning a ship requires small but steady and deliberate efforts over time. During the past 9 years, Wisconsin's Maternal and Child Health (MCH) Program has begun to utilize the life-course perspective as its framework for guiding efforts around women's health, early childhood systems, children and youth with special health care needs, chronic disease integration, and elimination of racial and ethnic disparities in birth outcomes. In collaboration with many state and national partners, Wisconsin's MCH Program has integrated the life-course perspective into efforts that include the following: increasing professional and public awareness of the framework; creating focus groups and social marketing campaigns in communities most affected by health disparities; expanding preconception and women's health initiatives; integrating with traditionally "non-MCH" programs such as chronic disease programs; and shifting Title V resources from provision of individual services to assurance of effective early childhood systems. Wisconsin's implementation of the life-course perspective has not been without challenges, but opportunities have also been identified along the journey. Initial efforts focused on training and supporting partners in their understanding and application of the life-course framework, and a train-the-trainer model was discovered to be key to achieving these goals. We took care to engage special populations and their advocates and to work closely with local communities. We hope that the lessons we have learned in this process will provide guidance for others as they work to incorporate life course into their MCH work. The life-course perspective has helped us to inform partners, policy makers, and funders of the need for a new approach in addressing racial and ethnic disparities in health.

Severe combined immunodeficiency (SCID) is the result of genetic defects that impair normal T-cell development. SCID babies typically appear normal at birth, but acquire multiple life-threatening infections within a few months. Early diagnosis and treatment with a bone-marrow transplant markedly improves long-term outcomes. On January 1, 2008, the newborn screening (NBS) program in Wisconsin became the first in the world to routinely test all newborns for SCID. A realtime quantitative polymerase chain reaction assay measures T-cell receptor excision circles (TRECs), which are formed during the maturation of normal T-cells. A lack or very low number of TRECs is consistent with T-cell lymphopenia. The development and validation of the TREC assay and the results of the first year of screening have been published. This article describes the process used to add SCID to the NBS panel, the establishment of follow-up capacity, and the integration of SCID screening into routine NBS workflows. The development of this expanded NBS program is described so that other states might benefit from the processes used in Wisconsin.

Background: Severe combined immunodeficiency ( SCID) is characterized by the absence of functional T cells and B cells. Without early diagnosis and treatment, infants with SCID die from severe infections within the first year of life.Objective: To determined the feasibility of detecting SCID in newborns by quantitating T-cell receptor excision circles (TRECs) from dried blood spots (DBSs) on newborn screening (NBS) cards.Methods: DNA was extracted from DBSs on deidentified NBS cards, and real-time quantitative PCR (RT-qPCR) was used to determine the number of TRECs. Positive controls consisted of DBS from a 1-week-old T-B-NK+ patient with SCID and whole blood specimens selectively depleted of naive T cells.Results: The mean and median numbers of TRECs from 5766 deidentified DBSs were 827 and 708, respectively, per 3.2-mm punch (similar to 3 mu L whole blood). Ten samples failed to amplify TRECs on initial analysis; all but 1 demonstrated normal TRECs and beta-actin amplification on retesting. No TRECs were detected in either the SCID or naive T-cell-depleted samples, despite the presence of normal levels of beta-actin.Conclusions: The use of RT-qPCR to quantitate TRECs from DNA extracted from newborn DBSs is a highly sensitive and specific screening test for SCID. This assay is currently being used in Wisconsin for routine screening infants for SCID. (J Allergy Clin Immunol 2009;124:522-7.)

Objectives: Understanding the factors contributing to black/white disparities in infant mortality rates in Wisconsin is a prerequisite to decreasing these disparities and improving birth outcomes. We examined multiple determinants of infant mortality to understand the impact of specific risk factors on the infant mortality rates of blacks and whites in Wisconsin.Methods: We used the Wisconsin Interactive Statistics on Health database to examine infant mortality data for the 5-year time period, 1998-2002 (N=32,166 black infant births; 272,559 white infant births). We conducted a bivariate analysis of relative risks (RR) of infant mortality (black vs. white) using specific variables available in the database. We then examined the relationship between infant mortality rate and selected risk factors using regression analyses.Results: Unadjusted, black infants were 3.0 times more likely to die during their first year of life, compared with white infants. Adjusting for gestational age black infants were only 1.9 times more likely to die. The risk was further reduced, after adjusting for birth weight, to 1.3. However, stratifying and adjusting for 8 other multiple variables accounted for some, but not all of the disparity. Black infants who had the same risk profile as white infants still had a 2-fold excess risk of death. In addition, simultaneously controlling for 4 of the 8 risk factors (maternal age, maternal education, adequacy of prenatal care received, and region of the state) also reduced, but did not eliminate, this excess risk (RR was still 2.2 for black infants). Independent of maternal age and region of the state, adequate prenatal care and higher levels of education are significant indicators of the racial disparity between whites and blacks.Conclusions: These results suggest that, within a given racial group, increasing access to prenatal care and increasing maternal educational attainment will improve infant mortality rates but will not eliminate the black/white disparity in infant mortality. In fact, these interventions may actually widen the disparity in infant mortality rate between blacks and whites, especially if funds and programs are applied equally throughout the population, rather than targeted to high-risk individuals, who lag significantly behind the majority population. The Wisconsin white population, which has already attained an infant mortality rate of 4.5 per 1,000 live births, will continue to have greatest benefit from these programs compared to blacks who have a rate of 19.2 in 2004; thus, the disparity is not eliminated and the gap widens probably due to differential uptake of health messages secondary to health literacy issues. Further research is needed to fully understand the additional, more difficult to measure factors that contribute significantly to infant mortality, especially among black women.

Objective: For children aged 1–5 years, the authors used the Delphi method to determine (1) the most important injury hazards in each area of the home; (2) the most important injury prevention behaviors; and (3) feasible and efficacious safety devices and behaviors to reduce injury risks. Design: The authors used a modified Delphi method to prioritize home injury hazards for children 1–5 years of age. The Delphi method is an indirect, anonymous, iterative process aimed at achieving consensus among experts; in this study, the authors queried key informants electronically. Thirty four key informants, primarily from the United States, participated in at least one of the three rounds of questionnaires. Responses were submitted by email or fax. Participants identified, rated, and ranked home injury hazards and prevention methods. Results: The overall response rate for each survey ranged from 82% to 97%. Initially, 330 unique hazards and prevention behaviors/devices were identified in seven areas of the home. The 126 home injury hazards were rated based on frequency, severity, and preventability of injury; and the 204 behaviors and devices were rated by efficacy and feasibility. These experts rated firearms and pools as the most significant hazards, and smoke alarms and safe water temperature as the most important preventions. Conclusions: The modified Delphi method of consensus was useful to prioritize home injury hazards and prevention methods for children under the age of 6 years.

In 2003, the Centers for Disease Control and Prevention (CDC) awarded the Wisconsin Department of Health and Family Services, Injury Prevention Program, a grant to participate in a multistate project called the National Violent Death Reporting System (NVDRS). The purpose of the Wisconsin Violent Death Reporting System (WVDRS) is to link violent death records (death certificates, police reports, medical examiner and coroner reports, crime laboratories, and perhaps child fatality review teams) from the same event, promote more timely information retrieval, describe in detail circumstances that may have contributed to the violent death, and identify and characterize perpetrators and their relationships to victims. This article describes the development of WVDRS and its importance in understanding and preventing violent injury and death in Wisconsin.

OBJECTIVE To review Wisconsin data on youth suicide mortality, hospitalizations from nonfatal self-inflicted injuries, and self-reported risk behaviors. METHODS Suicide mortality data for youth (defined here as persons 10-24 years of age) were obtained from the Centers for Disease Control and Prevention (CDC) for 1995-2001 and from the Wisconsin Division of Public Health for 2002. Hospitalization data for Wisconsin from 1995-2002 were obtained from the Wisconsin Division of Public Health. Survey data on self-reported risk behaviors were obtained from the CDC for 2001. RESULTS While the rate of youth suicide declined by 24% in the United States during the 9-year period studied, Wisconsin's rate declined only slightly (8%). Firearms accounted for 60% of completed youth suicides in Wisconsin. Medication overdoses and cutting accounted for 88% of self-inflicted injury hospitalizations for Wisconsin youth from 1995 to 2002. Wisconsin high school students reported similar rates of risk factor behaviors as youth in New Jersey (the state with the lowest suicide rates in the nation), but were more likely to use firearms (60% versus 32%). CONCLUSION Rates of suicide mortality, attempts, and self-reported risk behaviors among youth in Wisconsin continue to be unacceptably high. Physicians can play an important role in reducing youth suicide rates by acting within their clinical practices, as leaders in community suicide-prevention activities, and as advocates for policy change.

Learning to ride a bicycle and enjoying the pleasures of cycling are synonymous with childhood; unfortunately, cycling does not come without risk of serious injury. Children under 15 years old account for the majority of cycling time in the United States, and on average, 1 child dies every day from a bicycle-related injury. Health care professionals can play an important role in making cycling a safe activity by encouraging and advocating for safe bicycling practices. Specific areas for physicians and health care professionals to emphasize involve the cyclist, environmental factors, and equipment factors. Helmet use by cyclists, avoidance of risk-taking, safe cycling road behavior, and proper cycling equipment fit and usage are all areas in which health care professionals can instruct families during office visits. The physician and the health care community can also be advocates for mandatory helmet legislation in order to achieve higher helmet usage rates and decreased cycling injuries. The health care professional's role in bicycle safety is an important component in building a foundation for safe cycling.

BACKGROUND:Adolescents giving birth represents an important public health issue with social, economic, and health-related consequences.OBJECTIVE:Compare birth rates and trends in birth rates among adolescents age 15-19 years in Wisconsin and the United States by race/ethnicity.METHODS:Teen birth rates from 1998-2002, and trends in birth rates from 1995-2002 for Wisconsin and the United States were compared by race/ethnicity using data from the Wisconsin Interactive Statistics on Health and data from the Centers for Disease Control and Prevention.RESULTS:The general statewide birth rates and birth rates for Wisconsin white teens were lower than national rates, while birth rates for black, Hispanic, and American Indian teens were well above national rates from 1998-2002. Disparities between births to minority adolescents and white adolescents were higher in Wisconsin than in the United States. Although teen birth rates in general have declined nationally and in Wisconsin, rates among Hispanics in Wisconsin have increased during the 1995-2002 period.DISCUSSION:Racial disparities in teen birth rates in Wisconsin far exceed national disparities. These disparities result from far-ranging, long-term social and environmental differences in underlying determinants of health that relate to ethnic and cultural beliefs, variation in access to health care that provides family planning and reproductive health services, decreased availability of school-based clinics, lack of role models, education, and variations in income and social status. Wisconsin should focus its teen pregnancy prevention activities on the groups at highest risk.

BACKGROUND:The rate of childhood overweight is increasing among our nation's youth. This epidemic has led to an increase of comorbidities such as high blood pressure and diabetes being treated in the pediatric population. This paper analyzes self-reported heights and weights to determine trends in the prevalence of overweight among US students in grades 9-12. METHODS:Data from the Youth Risk Behavior Surveillance System from 1999 to 2003 were used to determine the prevalence of overweight--which is defined as a BMI < 85th percentile for age and gender--in 41 participating states. (Data from the "at risk of overweight" group [defined as BMI > or = 85 percentile and < 95 percentile] and the "overweight" group [defined as BMI > or = 95 percentile] were combined and labeled as "overweight" [BMI > or = 85 percentile] to make communication of results more clear.) RESULTS:The prevalence of overweight adolescents in Wisconsin increased slightly during the past 4 years, from 22.6% in 1999 to 24.1% in 2003, with adolescent males 50% more likely than females to be overweight. In 2003, Wisconsin's rate of overweight was the 14th lowest among 41 states reporting to the Centers for Disease Control and Prevention. (Colorado is lowest at 15.7% and Mississippi is highest at 31.4%.) When examining races separately, Wisconsin's ranking decreases slightly, but remains in the top half of all states reporting. CONCLUSIONS:The prevalence of childhood overweight in Wisconsin appears to be rising, following the national trend. The prevalence of overweight among high school students is lowest in the Rocky Mountain states. Understanding reasons for these differences may shed light on strategies to decrease overweight in Wisconsin.

Background: The Accreditation Council for Graduate Medical Education now requires pediatric residency programs to include advocacy training, but few guidelines for development exist. Purpose: To determine faculty and resident attitudes regarding advocacy training, and to develop consensus on the best method to teach and learn advocacy. Methods: Pediatric residents (n = 28) and faculty (n = 51) participated in a survey about experience and training in advocacy, identified issues important to address in an advocacy curriculum, and rated a variety of learning methods. Results: Nearly 90% of residents felt advocacy training was needed, and 82% felt advocacy activities would continue following residency. Faculty and residents agreed that participation in short-term or longitudinal projects was the best way to teach and learn advocacy skills. Respondents identified and ranked 45 issues to address through advocacy efforts and training, and these results were used to develop and implement an advocacy curriculum. Conclusions: Residents and faculty were interested in incorporating an advocacy curriculum, and survey results were used to guide curriculum development.

During 1999-2001, a multidisciplinary group met to develop a plan for the future of genetic services in Wisconsin. The result was The Genetic Services Plan for Wisconsin (available at www.slh.wisc.edu/genetics/stateplan_toc.html), a problem-oriented needs-identification guide to address current and future challenges likely to affect the provision of genetic services in Wisconsin. The Plan is directed to all individuals who have a stake in the future of medical genetic services in Wisconsin. These include, but are not limited to, primary and other health care professionals, genetics professionals, governmental representatives, policy makers, legislators, educators, third-party payers, and current and potential consumers. This article provides an overview of The Genetic Services Plan for Wisconsin (Plan) and highlights the recommendations made for the continuing integration of new genetic knowledge across the continuum of medical care delivery in Wisconsin.

The Wisconsin Division of Public Health (DPH) and its partners have developed the necessary public health infrastructure and core expertise to prepare for, and respond to, public health threats and emergencies. The infrastructure includes 12 public health preparedness consortia that have been established across the state. An important part of the response plan is to assure that the responder workforce is adequate to meet the need at the local, regional, and statewide levels. The responder workforce includes health professional volunteers who, if called on, will take on a variety of assigned roles relevant to a defined incident. In order to facilitate an organized system for volunteers to indicate their skills and availability, DPH has developed a secure and confidential database--the Wisconsin Emergency Assistance Volunteer Registry (WEAVR)--to collect and organize contact information on health professional volunteers and to make contact with volunteers when needed. Physicians, as well as other health professional volunteers, are critical to protect the health and safety of the community, especially if the need to dispense prophylactic medications or to vaccinate the entire population of Wisconsin arises. At the time of an event, volunteers will receive "just-in-time" training after reporting to their assigned location. In other states, physicians have found this emergency training to be of value to their overall practice of medicine. Information about how to sign on to WEAVR is provided.

Wisconsin's death rate due to falls among adults 65 years and older is more than twice the national average. The hospitalization rate due to falls-related injuries in Wisconsin increased slightly from 1995 to 2002, with an injury rate of 2159 per 100,000 in 1995, and 2263 per 100,000 in 2002. Emergency department (ED) utilization and hospitalization rates for falls-related injury are higher for women than for men in Wisconsin. In 2002, the total statewide charges for hospitalizations and ED visits for falls-related injuries were more than $96 million. Two thirds of those admitted to the hospital for a falls-related injury were discharged to a nursing home or rehabilitation facility. Multifactorial intervention strategies have been shown to decrease the rate of falls in randomized, controlled trials. The purpose of this paper is to describe trends in falls-related injury fatalities, hospitalizations, and ED visits in Wisconsin. Also included are cost data related to falls, identification of risk factors, and descriptions of the possible role of physicians and other health care professionals in interdisciplinary, multifocal programs to prevent falls-related injuries in high-risk older adults.

BACKGROUND:The infant mortality rate (IMR), low birth weight (LBW) rate, and first trimester entry into prenatal care (PNC) are indicators that reflect the health of a population.OBJECTIVE:To examine these indicators in Wisconsin from 1979 through 2001 and compare them to those of the United States, looking at trends and relative rank compared with other states.METHODS:Three-year averages for IMR, LBW, and PNC were analyzed for the periods 1979-1981, 1984-1986, 1989-1991, 1994-1996, and 1999-2001 from data sources published by the Centers for Disease Control and Prevention. Wisconsin's rank relative to other states was compared for the overall, black, and white populations.RESULTS:Wisconsin's overall IMR was consistently at, or slightly better than, the national IMR. From 1979-1981 to 1999-2001, the US black IMR decreased by 37.4%, while the Wisconsin black IMR declined 12.4%; thus, Wisconsin's rank among the states fell from third best to 32 among 34 states with a sufficient number of black births. LBW rates for Wisconsin's black population were consistently at least twice that of the white population. In 1979-1981, early entry into PNC for all Wisconsin women (82.9%) was significantly higher than that of the US population (74.1%). Wisconsin's early PNC entry rates improved slightly; as other states also improved, Wisconsin's ranking dropped. Wisconsin's relative ranks for IMR, LBW, and PNC declined for all 3 indicators from 1979-1991 to 1999-2001.DISCUSSION:Birth outcome disparities in Wisconsin pose challenges for physicians, public health, and private agencies; all must collaborate and act to improve health, housing, employment, education, and the social capital and support that makes up the fabric of our society.

Approximately half of all pregnancies in the United States are unintended. The purpose of the Family Planning Waiver, a Wisconsin Medicaid program implemented in 2003, is to expand access to contraceptive care and other reproductive health services. The waiver provides women with birth control services and supplies, emergency contraception, routine reproductive health exams, and diagnosis and treatment of sexually transmitted diseases. With greater availability of contraception, the expected outcome is a reduction of unintended pregnancies and subsequent therapeutic abortion, which results in a decreased financial burden to the state, as well as an opportunity for women to experience motherhood when they are emotionally prepared to do so.

Wisconsin Statute 253.12 was enacted in May 2000 to create the Wisconsin Birth Defects Registry (WBDR), replacing the Birth and Developmental Outcome Monitoring Program, a previous birth defects and developmental disabilities reporting system initiated in 1989. In the summer of 2004, the new registry began collecting demographic, diagnostic, and identifying information for children from birth to 2 years of age who are born with reportable birth defects and/or are receiving health care services for them in Wisconsin. This article describes the development of the registry and outlines expectations for reporting of birth defects.