A survey of statural changes with age in the adult population of the United States

A study of the patterns of height loss with age in the Anglo, black, and Mexican-American populations of the United States has been undertaken. The study was based on data gathered by the United States Public Health Service in the Second National Health and Nutrition Examination Survey and the Hispanic Health and Nutrition Examination Survey. Estimates of height loss were obtained by subtracting present stature from a calculated maximum attained height derived from sex- and race/ethnic-specific regression equations relating stature to subischial length. Anglo women have greater height losses than Anglo, black, or Mexican-American males, and black or Mexican-American females. Between 24 and 74 years of age, Anglo women average 3.8 cm. loss in stature. The black populations lose less height than Anglos or Mexican-Americans. Mexican-Americans lose less height than Anglos from 24 to 54 years and then have a greatly increased height loss so that by age 74 their total height loss is the same as Anglos. Standing height, sitting height, body mass index, and the Poverty Index were found to be negatively correlated with height loss. Age was positively correlated to height loss. The most important determinants of the magnitude of height loss with age were sex and ethnicity. ^

The prevalence of bulimia nervosa and bulimic behaviors among university students in Texas

This cross-sectional study examined by questionnaire the prevalence of bulimia nervosa and bulimic behaviors in a sample of 1175 undergraduate students enrolled in two state-supported universities in Texas. In one university, the student population was predominantly white; in the other, it was predominantly black. Fifty-nine percent of the respondents were female and 41% were male. Information regarding age, sex, ethnicity, college major, college year, marital status, housing arrangements, religion, socioeconomic status, height, weight, dieting behaviors, and family history of alcoholism, drug abuse, and depression was collected. Bulimia status was assessed using the Revised Bulimia Test (BULIT-R), which is based on the DSM-III-R criteria for bulimia nervosa. Only 1.3% of the females and 0.4% of the males were classified as having bulimia nervosa. The prevalence of bulimic behaviors was considerably higher; 6.4% of the females and 3.6% of the males were classified as having bulimic behaviors. Univariate analysis showed the following factors to be significantly associated with bulimic behaviors: female gender, single marital status, high BMI, a family history of alcoholism, drug abuse, or depression, and certain dieting behaviors. In the present study, ethnicity did not prove to be a significant factor associated with bulimia nervosa or bulimic behaviors. Multivariate analysis showed that, in comparison to normal/underweight individuals, the odds of having bulimic behaviors for severely overweight subjects were 2.23 (95% CI: 1.43, 3.50). Students who were dieting at the time of the study were 3.22 times (95% CI: 2.05, 5.06) as likely to have bulimic behaviors as were students who had never dieted. This study concludes there is a need to distinguish between bulimia nervosa and bulimic behaviors when estimating prevalence of a population. ^

Nonpurging binge eaters versus nonbinge eaters and treatment retention for adult obesity

Dropout from obesity treatment has been a major factor associated with weight control failure, with few reliable predictors of dropouts or completers. Previous studies have tended to treat obese people as a homogeneous group with standard behavior modification-based interventions. Current research indicates there may be subgroups within the obese population, binge eaters and nonbinge eaters, who have different dropout rates. Current studies also recommend focusing on the subset of this subgroup that does not engage in purging (vomiting, laxative abuse, or excessive exercise) to compensate for binge eating. This research uses a secondary dataset (N = 156) from a prospective study in which participants were randomized to a Food Dependency (FD) and a Behavioral Self-Management (BSM) group for weight reduction. Criteria for subjects in the original study included (1) scoring higher on the existing Binge Eating Scale (BES) in order to ensure enrollment of more binge eaters and (2) no compensatory purging behavior for binge eating. Subjects were then reclassified in this study as binge eaters or nonbinge eaters using the more stringent proposed 1994 DSM-IV criteria for Binge Eating Disorder (BED). Subjects were followed for dropout. Variables studied were binge status, age at obesity onset, age at study baseline, class instructor, number of previous weight loss attempts, race, marital status, body mass index (BMI kg/m$\sp2$), type of intervention, work status, educational level, and social support. Stepwise backward regression Cox survival analysis indicated binge status had a consistent, statistically significant protective effect on dropout in which binge eaters were half as likely to dropout versus nonbinge eaters (p = 0.04). Cox proportional hazards analysis indicated no statistical difference in dropout by type of intervention (FD, p = 0.13; BSM, p = 0.80) when controlling for binge status. All other variables did not reach significance, which is consistent with the literature. Implications of these findings suggest that (1) the proposed 1994 DSM-IV criteria for BED is a more useful classification that the existing DSM-III-R criteria, and (2) the identification of subgroups among obese subjects is an important step in dropout and weight loss intervention research. Future research can confirm this finding. ^

The association between CD4+ lymphocyte count and measures of body composition in HIV-infected men

Purpose. This project was designed to describe the association between wasting and CD4 cell counts in HIV-infected men in order to better understand the role of wasting in progression of HIV infection.^ Methods. Baseline and prevalence data were collected from a cross-sectional survey of 278 HIV-infected men seen at the Houston Veterans Affairs Medical Center Special Medicine Clinic, from June 1, 1991 to January 1, 1994. A follow-up study was conducted among those at risk, to investigate the incidence of wasting and the association between wasting and low CD4 cell counts. Wasting was described by four methods. Z-scores for age-, sex-, and height-adjusted weight; sex-, and age-adjusted mid-arm muscle circumference (MAMC); and fat-free mass; and the ratio of extra-cellular mass (ECM) to body-cell mass (BCM) $>$ 1.20. FFM, ECM, and BCM were estimated from bioelectrical impedance analysis. MAMC was calculated from triceps skinfold and mid-arm circumference. The relationship between wasting and covariates was examined with logistic regression in the cross-sectional study, and with Poisson regression in the follow-up study. The association between death and wasting was examined with Cox's regression.^ Results. The prevalence of wasting ranged from 5% (weight and ECM:BCM) to almost 14% (MAMC and FFM) among the 278 men examined. The odds of wasting, associated with baseline CD4 cell count $<$200, was significant for each method but weight, and ranged from 4.6 to 12.7. Use of antiviral therapy was significantly protective of MAMC, FFM and ECM:BCM (OR $\approx$ 0.2), whereas the need for antibacterial therapy was a risk (OR 3.1, 95% CI 1.1-8.7). The average incidence of wasting ranged from 4 to 16 per 100 person-years among the approximately 145 men followed for 160 person-years. Low CD4 cell count seemed to increase the risk of wasting, but statistical significance was not reached. The effect of the small sample size on the power to detect a significant association should be considered. Wasting, by MAMC and FFM, was significantly associated with death, after adjusting for baseline serum albumin concentration and CD4 cell count.^ Conclusions. Wasting by MAMC and FFM were strongly associated with baseline CD4 cell counts in both the prevalence and incidence study and strong predictors of death. Of the two methods, MAMC is convenient, has available reference population data, may be the most appropriate for assessing the nutritional status of HIV-infected men. ^

AN ATTEMPT TO MEASURE FOOD SAFETY STATUS

The main objective of this study was to attempt to develop some indicators for measuring the food safety status of a country. A conceptual model was put forth by the investigator. The assumption was that food safety status was multifactorily influenced by medico-health levels, food-nutrition programs, and consumer protection activities. However, all these in turn depended upon socio-economic status of the country.^ Twenty-six indicators were reviewed and examined. Seventeen were first screened and three were finally selected, by the stepwise multiple regression analysis, to reflect the food safety status. Sixty-one countries/areas were included in this study.^ The three indicators were life expectancy at birth with multiple correlation coefficient (R2 = 34.62%), adult literacy rate (R2 = 29.66%), and child mortality rate for ages 1-4 (R2 = 9.99%). They showed a cumulative R2 of 57.79%. ^

THE RECOVERY OF ENTEROPATHOGENS FROM CONTAMINATED COOKED FOODS AT HOLDING TEMPERATURES

Hot foods served in foodservice establishments, institutions and homes, have always been regarded as safe, since cooking temperatures are more likely to kill the bacterial agents that may cause foodborne diseases. However, foods that are otherwise served hot have been epidemiologically incriminated for causing foodborne diseases. This situation arises due to the possible post-cooking food contamination. Post-cooking contamination of hot-held food is most threatening for it gives the contaminating agents the possibility of proliferation. On one hand, post-cooking contamination is least understood and on the other, hot-holding of food gives the consumer a false sense of freedom from foodborne diseases. In this study, the dynamics of food contamination before or after cooking and during hot-holding are discussed and a food contamination dynamics model is presented.^ The literature on foodborne cholera, cholera-like diarrhea, shigellosis and E. coli gastroenteritis together with the literature on the occurrence and growth of the causative enteropathogens; 01 V. cholerae, non-01 V. cholerae, S. sonnei, S. flexneri and E. coli were reviewed. The literature on the infective doses of these organisms were also cited.^ In the study, four cooked food types held hot at 40-60(DEGREES)C were deliberately contaminated with 01 V. cholerae, non-01 V. cholerae, S. sonnei, S. flexneri and E. coli, one at a time at each of the hot-holding temperatures. Tested food samples for the recovery of these enteropathogens were withdrawn at various time intervals of hot holding.^ The results showed bacterial recovery to decline with increasing temperature and with increasing hot-holding time within each holding temperature. All the bacterial types except V. cholerae were recovered even after holding the food at 60(DEGREES)C for one hour. V. cholerae was not recovered after hot-holding the food at 50-60(DEGREES)C at certain holding periods. After 48 hrs incubation, V. cholerae was recovered on TCBS agar plates that read negative after the initial 24 hrs of incubation. Effective hot-holding temperatures were determined for each of the food types contaminated by each of the bacterial types.^ Statistical analysis of the collected data showed temperature, bacterial type and their interaction to be significant in enteropathogen recovery. Food type and its interactions with temperature and bacterial type were found not significant. ^

THE BACON CHOW STUDY: THE RELATIONSHIP BETWEEN INFECTIOUS ILLNESS AND GROWTH OF INFANTS

Multiple dietary deficiencies and high rates of infectious illness are major health problems leading to malnutrition and limitation of growth of children in developing countries. Longitudinal studies which provide information on illness incidence and growth velocity are needed in order to untangle the complex interrelationship between nutrition, illness and growth. From 1967 to 1973, researchers led by Dr. Bacon Chow of the Johns Hopkins University School of Hygiene undertook a quasi-experimental prospective study in Suilin Township, Taiwan to determine the effects of a nutritional supplement to the diets of pregnant and lactating women on the growth, development and resistance to disease of their offspring. This dissertation presents results from the analysis of infant morbidity and postnatal growth.^ Maternal nutritional supplementation has no apparent effect on the postnatal growth or morbidity of infants. Significant sex differences exist in growth response to illness and in illness susceptibility. Male infants have more diarrhea and upper respiratory illness. Respiratory illness is positively associated with growth rate in weight in the first semester of life. Diarrhea is significantly negatively associated with growth in length in the second semester. Small-for-date infants are more susceptible to illness in general and have a different pattern of growth response than large-for-date infants.^ Principal components analysis of illness data is shown to be an effective technique for making more precise use of ambiguous morbidity data. Multiple regression with component scores is an accurate method for estimating variance in growth rate predicted by indepenent illness variables. A model is advanced in which initial postnatal growth rate determines subsequent susceptibility to nutritional stress and infection. Initial growth rate is a function of prenatal nutrition, but is not significantly affected by maternal supplementation during gestation or lactation. Critical evaluation is made of nutritional supplementation programs which do not afford disease control.^

ASSOCIATIONS AND INTERRELATIONSHIPS OF SOCIOECONOMIC STATUS, BEHAVIORAL FACTORS AND BIOLOGICAL FACTORS WITH BIRTH WEIGHT

Although the influences of socioeconomic, behavioral and biological factors on birth weight have been extensively studied, most studies have been limited to clinical populations. This study examines such relationships in a national probability sample, the National Health and Nutrition Examination Survey of 1971-1974. The study sample consisted of 2161 white children and 812 black children, aged 1 to 5 years. Analyses were performed on a subsample consisting of 753 white and 138 black children whose mothers were also selected into the survey. Detailed analyses examined interrelationships among socio-economic, behavioral and biological factors by means of multiple regression and partial correlation procedures in the white population. These analyses were not carried out among blacks because of an observed clustering bias introduced in the black subsample that hampered generalization to the US population.^ The results among the whites indicated that the biological factors of maternal height, maternal weight, maternal size (weight/height('2)), maternal age and sex of child were independently related to birth weight and were also interrelated with socioeconomic factors such as family income, education of the mother and education of the head of the household. The joint effect was significantly associated with birth weight.^ Mothers' dietary practices represented the behavioral factors. Selected nutrients from the mothers' 24-hour dietary recall were used to develop indices of dietary quality. Dietary quality was significantly interrelated with socioeconomic status, biological factors and birth weight.^ The findings of this study suggest that smaller, younger mothers of lower socioeconomic status and female children were significantly associated with lower birth weight. The findings also suggest that dietary quality is a mediating factor among socioeconomic status and biological factors in that mothers with more financial and educational resources have better dietary practices. Such mothers may also practice other health behaviors that would prevent having a low birthweight baby. This dissertation contributes primarily to the further conceptualization and empirical testing of the interrelationships among socioeconomic, behavioral and biological factors with respect to birth weight. ^

Mexico: A new heavy weight in a global world

In the last three decades, obesity has been gaining recognition as a serious public health problem in Mexico. This epidemic developed insidiously in a country that was still focused on chronic under-nutrition in the population. During that same period, macro-economic reforms projected Mexico into the global economic arena. Foreign investments, trade in goods and services, and technological transfers were promoted through participation in numerous trade agreements between Mexico and other countries. The North American Trade Agreement (NAFTA), signed in 1994, promised an integrated market between the three North American countries: Canada, the United States, and Mexico. Although these trade policies were likely to have effects on the available food supply in Mexico, this association has not been elucidated. In this case study, we examine how these trade liberalization policies may have influenced the food supply in Mexico.^ Information on the trade of food commodities between the United States and Mexico and the nature of foreign investment in Mexico was compiled using public data available through American, Mexican, and other international published reports for 1986 through 2011. After the implementation of NAFTA, an increase in trade and investments was observed between Mexico and its two North American partners, but most of the trade increase occurred between the US and Mexico. Since the liberalization of trade policies between these counties, exports of fruit and vegetables into the U.S. from Mexico have increased, while exports of cereals, fats, vegetable oils, meat, dairy products and processed foods from the U.S. into Mexico have increased. During this same time period, there has been an increase in the foreign direct investment in the food industry in Mexico, as well as changes in the types and amounts of dietary energy available on a population level. Specifically, between 1990 to 2006, the dietary energy supply per person has increased 6.1% available animal protein has increased 35.8%, and available fat has increased 18.9%.^ Thus, this case study suggests that the recent changes in food-related industries through foreign direct investment and market liberalization may be likely contributors to the obesogenic food environment in Mexico. Although this initial case study provides interesting data, whether trade liberalization policies should be considered hazardous for health as a distal determinant of the obesity epidemic needs to be further examined using a more stringent study design or further follow up of the US Mexico trade data.^

A descriptive analysis of the consumers at farm stands outside WIC clinics

Because fruit and vegetable intake remains low in low-income populations, the attention of public health researchers has focused on different strategies to reach this population. One possible method of reaching low income populations is through government food assistance programs like the WIC's Farmers Market Nutrition Program (FMNP). This program provides vouchers to WIC recipients that are redeemable only at farmers' markets. In the summer of 2010, two farm stands near WIC clinics in Austin were surveyed in order to establish socio-demographic characteristics of the clientele of the markets. The overall purpose of this pilot study was to describe the clientele of the markets and to examine associations between food insecurity, acculturation, socio-demographic factors, and farmers' market participants' fruit and vegetable intake. The sample was a convenience sample of farmers' market customers. One hundred study participants completed self-administered surveys. Independent t-tests were used to explore the differences in means of fruit and vegetable intake according to acculturation and food insecurity levels. The overall mean (SD) of daily fruit and vegetable intake was 4.20±2.69 for customers of both markets. Significant differences were reported between the two markets in overall fruit and vegetable intake and specifically in the following: 100% juice (P=.023), fruit consumption (P=.028), green salad (P=.003), and salsa (P=.044). The differences showed that customers at the market in a more busy location were on average reporting eating more fruits and vegetables than customers at another market that was located in a more secluded location. When examined by level of food security, individuals who were more food secure consumed more fruit (P=.016). When examined by level of acculturation, the overall fruit and vegetable intake was not significantly different between levels of acculturation. The overall findings in this report suggest that the population at these markets consists of individuals who are food insecure and on government assistance programs. While there were no significant differences between fruit and vegetable intake, acculturation and food insecurity, this report suggests the need for culturally tailored interventions that serve the Hispanic population and would assist this population to become more food secure.^

Pediatric motivational interviewing to address obesity and overweight

Not only are obesity and overweight associated with a myriad of medical and psychological concerns in childhood, but these health problems can persist even into adulthood. With the obvious need for better approaches in tackling childhood obesity and overweight and the strong evidence of motivational interviewing's effectiveness in the adult population, it is likely that an updated review will provide a more complete picture of the application of motivational interviewing in the pediatric population. The objective of this review is whether or not motivational interviewing will be instrumental in promoting factors that help in reducing the number of children who are or become overweight or obese. A literature search was completed that identified ten studies that incorporated MI as an intervention. Studies focused on either behavior health changes like increased physical activity, improved nutrition, or reducing parameters of weight like BMI or body composition. Three out of the 10 articles were still in progress and no results were provided. Five studies were able to achieve statistical significance in health benefits to control childhood overweight and obesity. Results revealed the overall feasibility of applying MI in the pediatric overweight and obese population, but the scarce number of studies limits conclusions about its efficacy. Therefore, additional scientific evidence is necessary to fully understand MI's role in affecting behavior changes in this population.^

Policy analysis of iron micronutrient programs at USAID: The FANTA program in East Africa and the micronutrient initiative in Bihar region of India, using comparative cost effective and cost benefit analysis

It is the aim of this paper to examine iron supplementation programs which receive funding from United States Agency for International Development (USAID) but approach combating iron deficiency anemia in two vastly different ways. A brief literature review and background information on iron deficiencies and the differences between supplementation programs and micronutrient fortification were reviewed. Two non-governmental organizations (NGO's) were examined for this paper: the Food and Nutrition Technical Assistance II (FANTA) and the MicroNutrient Initiative. The FANTA program included an educational component to their supplementation program while the MicroNutrient Initiative solely used supplementation of micronutrients to their population. Methods used were cost-benefit analysis and cost-effectiveness analysis to determine the overall effectiveness of each program in reducing iron deficiency anemia in each population, if the added costs of the incentives in the FANTA program changed the cost-effectiveness of the program compared to the MicroNutrient Initiative program and to determine which program imparted the greatest benefit to each population by reducing the disease burden in Disability Adjusted Life Years (DALY). Results showed that the unit cost of the FANTA program per person was higher than the MicroNutrient Initiative program due to the educational component. The FANTA program reduced iron deficiency anemia less overall but cost less for each percentage point of anemia decreased in their respective populations. The MicroNutrient Initiative program had a better benefit cost ratio for the populations it served. The MicroNutrient Initiative's large scale program imparted many advantages by reducing unit cost per person and decreasing iron deficiency anemia. The FANTA program was more effective at decreasing iron deficiency anemia with less money: $5,660 per 1% decrease in iron deficiency anemia versus $18,450 per 1% decrease in iron deficiency anemia for the MicroNutrient Initiative program. ^ In conclusion, economic analysis cannot measure all of the benefits associated with programs that contain an educational component or large scale supplementation. More information needs to be gathered by NGOs and reported to USAID, such as detailed prevalence rates of iron deficiency anemia among the populations served. Further research is needed to determine the effects an educational supplementation program has on compliance rates of participants and motivation to participate in supplementation programs whose aim is to decrease iron deficiency anemia in a targeted population.^

A practice-based culminating experience: Writing a HRSA grant application with Texas Organ Sharing Alliance for public education efforts to increase solid organ donation

In November 2010, nearly 110,000 people in the United States were waiting for organs for transplantation. Despite the fact that the organ donor registration rate has doubled in the last year, Texas has the lowest registration rate in the nation. Due to the need for improved registration rates in Texas, this practice-based culminating experience was to write an application for federal funding for the central Texas organ procurement organization, Texas Organ Sharing Alliance. The culminating experience has two levels of significance for public health – (1) to engage in an activity to promote organ donation registration, and (2) to provide professional experience in grant writing. ^ The process began with a literature review. The review was to identify successful intervention activities in motivating organ donation registration that could be used in intervention design for the grant application. Conclusions derived from the literature review included (1) the need to specifically encourage family discussions, (2) religious and community leaders can be leveraged to facilitate organ donation conversations in families, (3) communication content must be culturally sensitive and (4) ethnic disparities in transplantation must be acknowledged and discussed.^ Post the literature review; the experience followed a five step process of developing the grant application. The steps included securing permission to proceed, assembling a project team, creation of a project plan and timeline, writing each element of the grant application including the design of proposed intervention activities, and completion of the federal grant application. ^ After the grant application was written, an evaluation of the grant writing process was conducted. Opportunities for improvement were identified. The first opportunity was the need for better timeline management to allow for review of the application by an independent party, iterative development of the budget proposal, and development of collaborative partnerships. Another improvement opportunity was the management of conflict regarding the design of the intervention that stemmed from marketing versus evidence-based approaches. The most important improvement opportunity was the need to develop a more exhaustive evaluation plan.^ Eight supplementary files are attached to appendices: Feasibility Discussion in Appendix 1, Grant Guidance and Workshop Notes in Appendix 2, Presentation to Texas Organ Sharing Alliance in Appendix 3, Team Recruitment Presentation in Appendix 5, Grant Project Narrative in Appendix 7, Federal Application Form in Appendix 8, and Budget Workbook with Budget Narrative in Appendix 9.^

Using intervention mapping to develop a community garden program at the women's home

This culminating experience was a practice based intervention conducted by an organization, utilizing an intervention mapping approach for the program planning. It took place summer 2010 through spring 2011 and included incorporating a community garden into the Gusto wellness program at The Women's Home. This organization offers long-term residential care, and therapeutic services. Literature relating to community gardens and nutrition behavior change was reviewed. Short-term objectives included: 1) Conducting a needs assessment using focus groups, 2) Designing gardening program components based on intervention mapping guidelines, 3) Constructing a garden bed at Midtown Community Garden for use of The Women's Home, 4) Planning and implementing gardening education, and 5) Assessing feasibility of the garden program. The target population included 24 residents living at the residential dormitory of The Women's Home at the time of this project. The major variables are intervention mapping constructs including: 1) Needs assessment, 2) Preparing matrices of change objectives, 3) Selecting theory-informed intervention methods and practical strategies, 4) Producing program components and materials, 5) Planning program adoption, implementation, and sustainability, and 6) Planning for evaluation. The specific focus was lack of access to fresh fruits and vegetables (FV) for this population. Focus group responses revealed interest in community garden participation. Matrices of change were developed for lack of FV access based on performance objectives for behavioral and environmental factors and related determinants and theory. Methods and strategies were developed to implement a community garden and encourage participation. Program components included initiating a garden club, networking activities, creating gardening curriculum, and participating at Midtown Community Garden. Adoption and implementation performance objectives were outlined, and many were carried out. Evaluation questions were designed and outcomes of the garden project were discussed. ^ Outcomes of the project included exposure of garden topics and activities for The Women's Home residents, focus group responses revealing an interest in gardening among this population, gardening program components designed based on intervention mapping steps, and a constructed garden bed that was used for planting vegetables and flowers through fall 2010. Limited resources and budget along with a lack of a residential coordinator at The Women's Home were the main limiting factors for this project. Future garden projects can be developed using the intervention mapping process.^

Endemic tuberculosis, the homeless, and public transportation: A merging of geographical information systems surveillance and the Houston Tuberculosis Initiative Surveillance project

To reach the goals established by the Institute of Medicine (IOM) and the Centers for Disease Control's (CDC) STOP TB USA, measures must be taken to curtail a future peak in Tuberculosis (TB) incidence and speed the currently stagnant rate of TB elimination. Both efforts will require, at minimum, the consideration and understanding of the third dimension of TB transmission: the location-based spread of an airborne pathogen among persons known and unknown to each other. This consideration will require an elucidation of the areas within the U.S. that have endemic TB. The Houston Tuberculosis Initiative (HTI) was a population-based active surveillance of confirmed Houston/Harris County TB cases from 1995–2004. Strengths in this dataset include the molecular characterization of laboratory confirmed cases, the collection of geographic locations (including home addresses) frequented by cases, and the HTI time period that parallels a decline in TB incidence in the United States (U.S.). The HTI dataset was used in this secondary data analysis to implement a GIS analysis of TB cases, the locations frequented by cases, and their association with risk factors associated with TB transmission. ^ This study reports, for the first time, the incidence of TB among the homeless in Houston, Texas. The homeless are an at-risk population for TB disease, yet they are also a population whose TB incidence has been unknown and unreported due to their non-enumeration. The first section of this dissertation identifies local areas in Houston with endemic TB disease. Many Houston TB cases who reported living in these endemic areas also share the TB risk factor of current or recent homelessness. Merging the 2004–2005 Houston enumeration of the homeless with historical HTI surveillance data of TB cases in Houston enabled this first-time report of TB risk among the homeless in Houston. The homeless were more likely to be US-born, belong to a genotypic cluster, and belong to a cluster of a larger size. The calculated average incidence among homeless persons was 411/100,000, compared to 9.5/100,000 among housed. These alarming rates are not driven by a co-infection but by social determinants. The unsheltered persons were hospitalized more days and required more follow-up time by staff than those who reported a steady housing situation. The homeless are a specific example of the increased targeting of prevention dollars that could occur if TB rates were reported for specific areas with known health disparities rather than as a generalized rate normalized over a diverse population. ^ It has been estimated that 27% of Houstonians use public transportation. The city layout allows bus routes to run like veins connecting even the most diverse of populations within the metropolitan area. Secondary data analysis of frequent bus use (defined as riding a route weekly) among TB cases was assessed for its relationship with known TB risk factors. The spatial distribution of genotypic clusters associated with bus use was assessed, along with the reported routes and epidemiologic-links among cases belonging to the identified clusters. ^ TB cases who reported frequent bus use were more likely to have demographic and social risk factors associated with poverty, immune suppression and health disparities. An equal proportion of bus riders and non-bus riders were cultured for Mycobacterium tuberculosis, yet 75% of bus riders were genotypically clustered, indicating recent transmission, compared to 56% of non-bus riders (OR=2.4, 95%CI(2.0, 2.8), p<0.001). Bus riders had a mean cluster size of 50.14 vs. 28.9 (p<0.001). Second order spatial analysis of clustered fingerprint 2 (n=122), a Beijing family cluster, revealed geographic clustering among cases based on their report of bus use. Univariate and multivariate analysis of routes reported by cases belonging to these clusters found that 10 of the 14 clusters were associated with use. Individual Metro routes, including one route servicing the local hospitals, were found to be risk factors for belonging to a cluster shown to be endemic in Houston. The routes themselves geographically connect the census tracts previously identified as having endemic TB. 78% (15/23) of Houston Metro routes investigated had one or more print groups reporting frequent use for every HTI study year. We present data on three specific but clonally related print groups and show that bus-use is clustered in time by route and is the only known link between cases in one of the three prints: print 22. (Abstract shortened by UMI.)^