Boston Public Health Commission Research Articles

Visualizing Neighborhood COVID-19 Levels, Trends, and Inequities in Wastewater: An Equity-Centered Approach and Comparison to CDC Methods.

Monitoring neighborhood-level SARS-CoV-2 wastewater concentrations can help guide public health interventions and provide early warning ahead of lagging COVID-19 clinical indicators. To date, however, U.S. Centers for Disease Control and Prevention's (CDC) National Wastewater Surveillance System (NWSS) has provided methodology solely for communicating national and state-level "wastewater viral activity levels." In October 2022, the Boston Public Health Commission (BPHC) began routinely sampling wastewater at 11 neighborhood sites to better understand COVID-19 epidemiology and inequities across neighborhoods, which vary widely in sociodemographic and socioeconomic characteristics. We developed equity-centered methods to routinely report interpretable and actionable descriptions of COVID-19 wastewater levels, trends, and neighborhood-level inequities. To produce these data visualizations, spanning October 2022 to December 2023, we followed four general steps: (1) smoothing raw values; (2) classifying current COVID-19 wastewater levels; (3) classifying current trends; and (4) reporting and visualizing results. COVID-19 wastewater levels corresponded well with lagged COVID-19 hospitalizations and deaths over time, with "Very High" wastewater levels coinciding with winter surges. When citywide COVID-19 levels were at the highest and lowest points, levels and trends tended to be consistent across sites. In contrast, when citywide levels were moderate, neighborhood levels and trends were more variable, revealing inequities across neighborhoods, emphasizing the importance of neighborhood-level results. Applying CDC/NWSS state-level methodology to neighborhood sites resulted in vastly different neighborhood-specific wastewater cut points for "High" or "Low," obscured inequities between neighborhoods, and systematically underestimated COVID-19 levels during surge periods in neighborhoods with the highest COVID-19 morbidity and mortality. Our methods offer an approach that other local jurisdictions can use for routinely monitoring, comparing, and communicating neighborhood-level wastewater levels, trends, and inequities. Applying CDC/NWSS methodology at the neighborhood-level can obscure and perpetuate COVID-19 inequities. We recommend jurisdictions adopt equity-focused approaches in neighborhood-level wastewater surveillance for valid community comparisons.

Implementation of Neighborhood-Level Wastewater-Based Epidemiology to Measure and Mitigate Inequities in SARS-CoV-2 Infection in Boston, Massachusetts.

Starting October 2022, the Boston Public Health Commission implemented a neighborhood-level wastewater-based epidemiology program to inform strategies to reduce COVID-19 inequities. We collected samples twice weekly at 11 neighborhood sites, covering approximately 18% of Boston, Massachusetts's population. Results from the program's first year revealed inequities unobservable in regional wastewater data both between the City of Boston and the greater Boston area and between Boston neighborhoods. We report program results and neighborhood-specific recommendations and resources to help residents interpret and use our findings. (Am J Public Health. Published online ahead of print August 8, 2024:e1-e5. https://doi.org/10.2105/AJPH.2024.307749).

De Novo Exposomic Geospatial Assembly of Chronic Disease Regions with Machine Learning & Network Analysis.

Determining spatial relationships between disease and the exposome is limited by available methodologies. aPEER (algorithm for Projection of Exposome and Epidemiological Relationships) uses machine learning (ML) and network analysis to find spatial relationships between diseases and the exposome in the United States. Using aPEER we examined the relationship between 12 chronic diseases and 186 pollutants. PCA, K-means clustering, and map projection produced clusters of counties derived from pollutants, and the Jaccard correlation of these clusters with counties with high rates of disease was calculated. Pollution correlation matrices were used together with network analysis to identify the strongest disease-pollution relationships. Results were compared to LISA, Moran's I, univariate, elastic net, and random forest regression. aPEER produced 68,820 maps with human interpretable, distinct pollution-derived regions. Diseases with the strongest pollution associations were hypertension (J=0.5316, p=3.89x10-208), COPD (J=0.4545, p=8.27x10-131), stroke (J=0.4517, p=1.15x10-127), stroke mortality (J=0.4445, p=4.28x10-125), and diabetes mellitus (J=0.4425, p=2.34x10-127). Methanol, acetaldehyde, and formaldehyde were identified as strongly associated with stroke, COPD, stroke mortality, hypertension, and diabetes mellitus in the southeast United States (which correlated with both the Stroke and Diabetes Belt). Pollutants were strongly predictive of chronic disease geography and outperformed conventional prediction models based on preventive services and social determinants of health (using elastic net and random forest regression). aPEER used machine learning to identify disease and air pollutant relationships with similar or superior AUCs compared to social determinants of health (SDOH) and healthcare preventive service models. These findings highlight the utility of aPEER in epidemiological and geospatial analysis as well as the emerging role of exposomics in understanding chronic disease pathology. Boston Public Health Commission, NHLBI (R03 HL157890) and the CDC.

Access challenges to opioid use disorder treatment among individuals experiencing homelessness: Voices from the streets

BackgroundAchieving equitable access to medications for opioid use disorder (MOUD) such as buprenorphine is a pressing issue. Evidence suggests disparities in MOUD access based on race and socioeconomic status, further exacerbated by the COVID-19 pandemic. However, the drivers behind this access gap remain poorly understood. This study explores barriers to treatment access among individuals with opioid use disorder (OUD) experiencing homelessness. MethodsWe interviewed 28 individuals in and around the Boston Public Health Commission (BPHC) Engagement Center, an area known for its high density of active substance use and homelessness. We asked about people's experiences, perceptions, and attitudes toward OUD treatment. We conducted a thematic analysis of our interview data. ResultsFifty-four percent of participants sampled were not prescribed MOUD. None of the participants reported having an active prescription of sublingual buprenorphine or buprenorphine/naloxone. White participants were more likely to have been prescribed buprenorphine in the past compared to participants of other races even in this socioeconomically homogeneous sample. Themes that emerged in our data included challenges to accessing MOUD due to reduced services during the COVID-19 pandemic, lost or stolen medications, fewer inpatient withdrawal management beds for women, transportation challenges, fear of adverse effects of MOUD, the perception that taking MOUD replaces one addiction for another, and community disapproval of MOUD. Participants also reported stigma and discrimination based on race, gender, and socioeconomic status. ConclusionSystems and individual-level factors contribute to the MOUD treatment gap across race and socioeconomic status. The COVID-19 pandemic posed additional access challenges. This study provides important, actionable insights about the barriers faced by a particularly vulnerable population of individuals with OUD experiencing homelessness.

Facilitating exit from encampments: combining low-barrier transitional housing with stabilizing treatment for substance related problems

BackgroundTent encampments in the neighborhood surrounding Boston Medical Center (BMC) grew to include 336 individuals at points between 2019 and 21, prompting public health concerns. BMC, the City of Boston, and Commonwealth of Massachusetts partnered in 2/2022 to offer low-barrier transitional housing to encampment residents and provide co-located clinical stabilization services for community members with substance use disorders (SUDs) experiencing homelessness.MethodsTo meet the needs of some of the people who had been living in encampments, BMC established in a former hotel: 60 beds of transitional housing, not contingent upon sobriety; and a low-barrier SUD-focused clinic for both housing residents and community members, offering walk-in urgent care, SUD medications, and infection screening/prevention; and a 24/7 short-stay stabilization unit to manage over-intoxication, withdrawal, and complications of substance use (e.g., abscesses, HIV risk, psychosis). A secure medication-dispensing cabinet allows methadone administration for withdrawal management. Housing program key metrics include retention in housing, transition to permanent housing, and engagement in SUD treatment and case management. Clinical program key metrics include patient volume, and rates of initiation of medication for opioid use disorder.ResultsHousing: Between 2/1/22–1/31/2023, 100 people entered the low-barrier transitional housing (new residents admitted as people transitioned out); 50 former encampment residents and 50 unhoused people referred by Boston Public Health Commission. Twenty-five residents transferred to permanent housing, eight administratively discharged, four incarcerated, and four died (two overdoses, two other substance-related). The remaining 59 residents remain housed; none voluntarily returned to homelessness. One hundred residents (100%) engaged with case management, and 49 engaged with SUD treatment. Clinical: In the first 12 months, 1722 patients (drawn from both the housing program and community) had 7468 clinical visits. The most common SUDs were opioid (84%), cocaine (54%) and alcohol (47%) and 61% of patients had a co-occurring mental health diagnosis in the preceding 24-months. 566 (33%) patients were started on methadone and accepted at an Opioid Treatment Program (OTP).ConclusionsDuring the 1st year of operation, low-barrier transitional housing plus clinical stabilization care was a feasible and acceptable model for former encampment residents, 49% of whom engaged with SUD treatment, and 25% of whom transitioned to permanent housing.

Living in Boston during COVID-19: Economic Strains

In the Summer of 2020, the Boston Area Research Initiative (BARI) at Northeastern University, the Center for Survey Research (CSR) at University of Massachusetts Boston, and the Boston Public Health Commission (BPHC) conducted a survey that captures the experiences of 1626 Bostonians during the first months of the COVID-19 pandemic. The survey provides unique insights into how experiences and challenges varied across the populations and neighborhoods of a single city—something not currently available from any other source, in Boston or otherwise. This third report in a series describes how the pandemic has affected the employment trajectories and economic resources of Boston’s residents. By examining how these impacts were distributed by race and ethnicity, socioeconomic status, and family composition, we reveal a range of inequities in how different populations have experienced financial disadvantage due to the pandemic.

Lessons Learned From Introducing Staff to Quality Improvement Through Systematic Training at the Boston Public Health Commission.

The widespread adoption of quality improvement (QI) in public health departments holds the promise of transformational change for the American public health system; however, there is a lack of published literature pertaining to organization-level experiences with introductory QI training programs for health department staff. This practice report aims to share the innovative approach, experience, and results of introducing staff to QI principles at the Boston Public Health Commission (BPHC). The BPHC is an accredited health department that introduced more than 80% of its 1100 staff members to QI between January 2015 and December 2018. The commission's QI training program benefited from (1) visible support from senior leaders, (2) well-documented QI training plans, (3) innovative QI training curricula, (4) flexible delivery methods, and (5) a responsive monitoring and evaluation system. To assess the effectiveness of QI training at the BPHC, participant questionnaires from QI training sessions (run between January 2015 and June 2018) and a separate questionnaire on organizational QI culture (administered to the supervisory staff in May 2018) were assessed using the Kirkpatrick model of training evaluation. On the basis of Kirkpatrick's 4 levels of training effectiveness, 91% of participants were satisfied with training content (level 1), 94% of participants found the facilitators effective (level 2), 84% of participants indicated they would apply QI concepts in everyday work (level 3), and 75% of supervisors reported an organization-wide improvement in QI culture (level 4). These results show that the BPHC's QI training program has been resoundingly effective, with positive outcomes across all 4 levels of the Kirkpatrick model. These results reinforce the idea of the BPHC's experience as an exemplar for introductory QI training. Interested health departments should heed the lessons learned from this and other organizational experiences as they attempt to scale up QI competencies among staff members.

A Pornography Literacy Program for Adolescents.

In 2016, in response to concern about the impact of pornography on adolescents, the Boston Public Health Commission partnered with a university researcher to develop a nine-session media literacy curriculum on pornography for adolescents. The curriculum was pilot-tested with five small classes of adolescents between 2016 and 2019 (n = 31). Many adult teachers of sex education also expressed interest in being trained to use the curriculum, so our team has now trained 300 adults to use it.

Evaluation of a Teen Dating Violence Prevention Intervention among Urban Middle-School Youth Using Youth Participatory Action Research: Lessons Learned from Start Strong Boston.

Almost half of adolescents aged 11 to 14 have dated and between 10% and 30% report experiencing Teen Dating Violence (TDV). However, there are no evidence-based TDV prevention interventions designed for afterschool, community-based settings with middle-school youth, in high-risk neighborhoods. Start Strong Boston (SSB) is a model that fills all three gaps, founded on partnerships between the Boston Public Health Commission, community afterschool sites, academic experts and evaluators, and youth. Here, we describe the SSB program and discuss how this collaboration built upon successes of this peer-engaged intervention, by developing and implementing a youth participatory action research (YPAR) evaluation study of SSB. Use of the YPAR framework tested the feasibility of employing Peer Researchers in an interdisciplinary evaluation team. We describe how through participation in evaluation research, Peer Researchers improve professional and leadership skills while informing measurement and conceptualization of a program affecting their own neighborhoods. Lessons learned are presented.

Accurate Influenza Monitoring and Forecasting Using Novel Internet Data Streams: A Case Study in the Boston Metropolis.

BackgroundInfluenza outbreaks pose major challenges to public health around the world, leading to thousands of deaths a year in the United States alone. Accurate systems that track influenza activity at the city level are necessary to provide actionable information that can be used for clinical, hospital, and community outbreak preparation.ObjectiveAlthough Internet-based real-time data sources such as Google searches and tweets have been successfully used to produce influenza activity estimates ahead of traditional health care–based systems at national and state levels, influenza tracking and forecasting at finer spatial resolutions, such as the city level, remain an open question. Our study aimed to present a precise, near real-time methodology capable of producing influenza estimates ahead of those collected and published by the Boston Public Health Commission (BPHC) for the Boston metropolitan area. This approach has great potential to be extended to other cities with access to similar data sources.MethodsWe first tested the ability of Google searches, Twitter posts, electronic health records, and a crowd-sourced influenza reporting system to detect influenza activity in the Boston metropolis separately. We then adapted a multivariate dynamic regression method named ARGO (autoregression with general online information), designed for tracking influenza at the national level, and showed that it effectively uses the above data sources to monitor and forecast influenza at the city level 1 week ahead of the current date. Finally, we presented an ensemble-based approach capable of combining information from models based on multiple data sources to more robustly nowcast as well as forecast influenza activity in the Boston metropolitan area. The performances of our models were evaluated in an out-of-sample fashion over 4 influenza seasons within 2012-2016, as well as a holdout validation period from 2016 to 2017.ResultsOur ensemble-based methods incorporating information from diverse models based on multiple data sources, including ARGO, produced the most robust and accurate results. The observed Pearson correlations between our out-of-sample flu activity estimates and those historically reported by the BPHC were 0.98 in nowcasting influenza and 0.94 in forecasting influenza 1 week ahead of the current date.ConclusionsWe show that information from Internet-based data sources, when combined using an informed, robust methodology, can be effectively used as early indicators of influenza activity at fine geographic resolutions.

Cross-Disciplinary Consultancy to Enhance Predictions of Asthma Exacerbation Risk in Boston

This paper continues an initiative conducted by the International Society for Disease Surveillance with funding from the Defense Threat Reduction Agency to connect near-term analytical needs of public health practice with technical expertise from the global research community. The goal is to enhance investigation capabilities of day-to-day population health monitors. A prior paper described the formation of consultancies for requirements analysis and dialogue regarding costs and benefits of sustainable analytic tools. Each funded consultancy targets a use case of near-term concern to practitioners. The consultancy featured here focused on improving predictions of asthma exacerbation risk in demographic and geographic subdivisions of the city of Boston, Massachusetts, USA based on the combination of known risk factors for which evidence is routinely available. A cross-disciplinary group of 28 stakeholders attended the consultancy on March 30-31, 2016 at the Boston Public Health Commission.Known asthma exacerbation risk factors are upper respiratory virus transmission, particularly in school-age children, harsh or extreme weather conditions, and poor air quality. Meteorological subject matter experts described availability and usage of data sources representing these risk factors. Modelers presented multiple analytic approaches including mechanistic models, machine learning approaches, simulation techniques, and hybrids. Health department staff and local partners discussed surveillance operations, constraints, and operational system requirements. Attendees valued the direct exchange of information among public health practitioners, system designers, and modelers. Discussion finalized design of an 8-year de-identified dataset of Boston ED patient records for modeling partners who sign a standard data use agreement.

Synthetic Cannabinoid Use in a Transitional Housing Shelter: A Survey to Characterize Awareness of Risks and Reasons for Use

Synthetic Cannabinoid Use in a Transitional Housing Shelter: A Survey to Characterize Awareness of Risks and Reasons for Use

Life in the big city: building a culture of health.

Life in the big city: building a culture of health.

Measuring and monitoring progress toward health equity: local challenges for public health.

To address health disparities, local health departments need high-resolution data on subpopulations and geographic regions, but the quality and availability of these data are often suboptimal. The Boston Public Health Commission and the Los Angeles County Department of Public Health faced challenges in acquiring and using community-level data essential for the design and implementation of programs that can improve the health of those who have social or economic disadvantages. To overcome these challenges, both agencies used practical and innovative strategies for data management and analysis, including augmentation of existing population surveys, the use of combined data sets, and the generation of small-area estimates. These and other strategies show how community-level health data can be analyzed, expanded, and integrated into existing public health surveillance and program infrastructure to inform jurisdictional planning and tailoring of interventions aimed at achieving optimal health for all members of a community.

Public–private partnership from theory to practice: Walgreens and the Boston Public Health Commission supporting each other before and after the Boston bombings

This paper presents an overview of the public health and medical services continuity of operations, response and recovery efforts in the aftermath of the Boston bombings. Countless public and private organisations and agencies came together to support the community and the survivors. The efforts of these organisations define what it means to be Boston Strong.

Bringing Life Course Home: A Pilot to Reduce Pregnancy Risk Through Housing Access and Family Support

Proponents of life course comment that while the theory is persuasive, translating theory to practice is daunting. This paper speaks to the challenges and possibilities of intervention based on life course theory. It describes Healthy Start in Housing (HSiH), a partnership between the Boston Public Health Commission (BPHC) and the Boston Housing Authority (BHA) to reduce stress due to housing insecurity among low-income, pregnant women. HSiH seeks improved birth outcomes and long term health of mothers and infants. BHA goals are improved quality of life for participants, greater public housing stability and enhanced impact of housing on community well-being. HSiH is a 1 year pilot offering 75 housing units to pregnant women at risk of adverse birth outcomes and homelessness. BHA provides housing and expedites processing of HSiH applications; BPHC staff oversee enrollment, guide women through the application process, and provide enhanced, long-term case management. Of 130 women referred to HSiH to date, 53 were ineligible, 59 have submitted applications, 13 are preparing applications and 5 dropped out. Nineteen women have been housed. Among eligible women, 58 % had medical conditions, 56 % mental health conditions, and 14 % prior adverse outcomes; 30 % had multiple risks. Standardized assessments reflected high levels of depressive symptoms; 41 % had symptoms consistent with post-traumatic stress disorder. Life course theory provides both the framework and the rationale for HSiH. HSiH experience confirms the salience of daily social experience to women's health and the importance of addressing stressors and stress in women's lives.

Collaboration Between Local Health Authorities, Hospitals, Residents, and Community-Based Organizations in Boston

As public health practitioners in Boston, we read with interest both the original article from Sprague Martinez et al.1 about youth perceptions of neighborhood sanitation in our city as well as the follow-up exchange between the authors and Jarris et al.,2 who noted rightly that these neighborhood-level observations should be shared with local, state, and federal health agencies to improve public health and quality of life. In fact, Jarris et al. posited, new Internal Revenue Service regulations and accreditation standards will soon require local health agencies and hospitals to complete community health assessments in collaboration with local residents. In their response to Jarris et al., Sprague Martinez et al.,3 with some skepticism, asked whether true collaboration involving neighborhood residents, community-based organizations, local health authorities, and hospitals could be operationalized given various constraints on time, resources, and political will. “Cabbages & Condoms” is a restaurant with an important message to share that recently opened in Oxfordshire, UK, and is based upon a concept that originated in Thailand. The name of the eatery refers to the idea that people might ... We are pleased to report that this collaboration is well under way in Boston. Together with community health coalitions and community-based organizations, the Boston Alliance for Community Health is undertaking a community health planning process in partnership with the Boston Public Health Commission (our local health agency) and hospitals. This process, which is expected to take two years, will be used to mobilize residents around their neighborhood’s prioritized health issues, support local organizations to improve their service delivery systems, create strategies for collective action, and advocate increasing the amount and more effective use of scarce resources. We invite and encourage Sprague Martinez and all others with a stake in health planning and policy in Boston to join us in this process.

Hand, Foot, and Mouth Disease Caused by Coxsackievirus A6

Hand, Foot, and Mouth Disease Caused by Coxsackievirus A6

Podcast Interview Transcript

Podcast Interview Transcript Susan Sommer, Laurie Stillman, Polly Hoppin, and Leandris Liburd In each volume of the Journal, the editors select one article for our Beyond the Manuscript post-study interview with the authors. Beyond the Manuscript provides the authors the opportunity to tell listeners what they would want to know about the project beyond what went into the final manuscript. The associate editors who handled the articles conduct our Beyond the Manuscript interviews. Beyond the Manuscript podcasts are available for download at the Journal’s website at http://pchp.press.jhu.edu. This issue’s Beyond the Manuscript podcast was conducted by REACH special issue Guest Editor Leandris Liburd and features Susan Sommer, Laurie Stillman, and Polly Hoppin, the lead author and community partners for “Children’s Hospital Boston Community Asthma Initiative: Partnerships and Outcomes Advance Policy Change” The following is an edited transcript of the Beyond the Manuscript podcast. Leandris Liburd Susan, can you provide a brief summary of your asthma project, including its purpose and any results you’ve found for everybody who is listening to give them an orientation to the project? Susan Sommer The Children’s Hospital Boston Community Asthma Initiative was founded as the result of an extensive community needs assessment back in 2003 and 2004. At that time, the community identified asthma as one of their four major pediatric concerns; in addition, from Children’s perspective, asthma was the number one cause of hospitalizations, and 70% of those children came from the five low-income neighborhoods very close to the Hospital. We also noted that there were very high rates for Latino and Black children, and in fact, three to five times the rate for White children. So there was a very marked health disparity that needed to be addressed and many social determinants of health that were underlying these statistics. We identified four ZIP Codes within inner city Boston, largely African American and Latino communities, who were the populations hardest hit by these asthma rates. And at that point consulted, (and then we’ll get into this more) with many of our already existing partners and people working on asthma issues throughout the city and region as to how to go about addressing these disparities. As a result, we developed a case management model with a strong home visiting component. Home visits were conducted by both nurses and community health workers, and delivered tailored asthma education as well as home environmental assessments, and a moderate level of remediation. Thanks to our partners, we had built in a strong evaluation component including cost analysis, and had very positive results, with a 79% reduction in hospitalizations, and a 64% reduction in emergency department visits after 1 year as well as a return on investment of 1.46. [End Page 337] Susan Sommer We realized from the beginning that there were larger, systemic, policy issues that needed to be addressed. Certainly, many of them housing issues—a lot of substandard housing with many environmental triggers. We are active in coalitions working on that, but also looking for sustainable payment models for these kinds of asthma programs that clearly were very effective, but were really limited by grant funding. That’s where we turn to our partners and coalitions to work on that policy issue. Leandris Liburd These are quite impressive findings. You had a team of partners, and I know they included community as well as academic partners, that represented different disciplines and backgrounds. How was this an asset for the project? Susan Sommer We did, in fact, have a strong group of partners even before our particular project started, including the Boston Public Health Commission that was doing a lot of work around home environmental triggers, and in particular pests and mold in the houses. Inspectional Services, Boston Medical Center, and then a local advocacy group, Boston Urban Asthma Coalition was its name at the time. And then in addition, the Asthma Regional Council which is represented by Laurie Stillman today, and UMass Lowell represented by Polly Hoppin, who were instrumental in helping us set the policy agenda Laurie Stillman The Asthma Regional Council of New England is a coalition of governmental, academic, and...

Meeting People Where They Are: Engaging Public Housing Residents for Integrated Pest Management

In a unique partnership, the Boston Public Health Commission, the Boston Housing Authority (BHA), Boston University School of Public Health, the Committee for Boston Public Housing, and the West Broadway Task Force (WBTF) led an Integrated Pest Management (IPM) intervention in Boston's public housing developments. Key to the success of the program was recruiting residents to participate. Residents who were trained as Community Health Advocates (CHAs) at the West Broadway Development in South Boston, Massachusetts, recruited over 300 homes to participate in the IPM intervention (out of 484 living units). This article describes the recruitment strategy and success from the perspective of CHAs at the West Broadway development.