Public Health Collaboration Research Articles

Effectiveness of primary care–public health collaborations in the delivery of influenza vaccine: a cluster-randomized pragmatic trial

ObjectiveTo assess effectiveness and feasibility of public–private collaboration in delivering influenza immunization to children. MethodsFour pediatric and four family medicine (FM) practices in Colorado with a common public health department (PHD) were randomized at the beginning of baseline year (10/2009) to Intervention (joint community clinics and PHD nurses aiding in delivery at practices); or control involving usual care without PHD. Generalized estimating equations compared changes in rates over baseline between intervention and control practices at end of 2nd intervention year (Y2=5/2011). Barriers to collaboration were examined using qualitative methods. ResultsOverall, rates increased from baseline to Y2 by 9.2% in intervention and 3.2% in control (p<.0001), with significant increases in both pediatric and FM practices. The largest increases were seen among school-aged and adolescent children (p<.0001 for both), with differences for 6-month-old to 5-year-old children and for children with high-risk conditions not reaching significance. Barriers to collaboration included uncertainty regarding the delivery of vaccine supplies, concerns about using up all purchased vaccine by practices, and concerns about documentation of vaccination if collaboration occurred. ConclusionsIn spite of barriers, public–private collaboration resulted in significantly higher influenza immunization rates, particularly for older, healthy children who visit providers less frequently.

Shifting sands – from descriptions to solutions

BackgroundPublic health practitioners and policymakers value research evidence as one of many resources to use in evidence-informed decision making (EIDM) for public health. However, both researchers and decision-makers have described persistent barriers and facilitators involved in using research evidence for public health practice and policy. This is likely to affect the extent to which research evidence is influential or useful in decisions. Numerous taxonomies, typologies and frameworks are available to guide action in EIDM, but their application in practice is relatively unknown. MethodsThe Public Health Evidence group based in Australia, which incorporates The Cochrane Collaboration's Public Health Review Group, have adapted a number of conceptualizations of research use and types of evidence into a practical typology that defines and illustrates three main types of evidence used in evidence-informed public health: data (Type 1), intervention effectiveness (Type 2) and implementation evidence (Type 3). The authors have actively used this typology within our primary research, evidence synthesis, workforce development and stakeholder engagement strategies, which has enabled practical application of these concepts. To test the relevance of the typology in practice, relevant findings from our applied research and evaluation (including two exploratory studies of evidence use in decision-making and evaluations of the use and impact of systematic reviews among end-users) were triangulated. ResultsThe typology has been useful in stakeholder interactions when defining evidence, and identifying processes for EIDM. There was a preference for defining evidence as descriptive evidence (data) rather than impact evidence and implementation evidence. Practitioners were confident and competent at generating and using data and community views descriptively for priority setting (describing the problem). However, finding and using impact and implementation evidence appropriate for strategy development (effective solutions) was often described as a more daunting task. As a result, there was low awareness of, and competence with, Types 2 and 3 evidence. Organizational processes for using these types of evidence were almost non-existent. DiscussionApplying this typology with stakeholders has allowed us to observe that it; (1) has been useful in conceptualizing useful evidence for public health, which has guided our work (2) has been useful in stakeholder interactions to introduce evidence, its definition and what it means to be ‘evidence-informed’ and (3) has identified ‘faults’ in the EIDM approach. The typology includes examples of common questions in public health, and suggestions of the types of evidence that may be useful to answer those questions. Findings that test the use of the typology have been synthesized. These have demonstrated inconsistencies in defining and applying evidence, and low awareness about what types of evidence are crucial to ensure that interventions are effective and minimize harm. Based upon these findings, the authors would argue that current investment in type 1 evidence (e.g. data repositories) shifts to make way for KT strategies, which facilitate the uptake of type 2 and 3 evidence (interventions and implementation guidance). ConclusionsBuilding a shared understanding of the types of evidence and their importance in public health decision-making is crucial if we wish to build a system that supports EIDM and results in effective interventions being delivered. There are a number of ‘faults’ in the system which the authors have illuminated through understanding the individual and organizational realities of evidence use. These faults could be addressed through KT strategies with the public health workforce, and development of organizational cultures and the broader system.

Why a decade of road traffic safety?

Each year, 1.24 million people die as a result of road traffic collisions around the world, and millions more are left to suffer the resultant disabilities of their nonfatal typically musculoskeletal injuries. The most productive members of society are the ones affected the most, and the subsequent economic impact cannot be ignored. Reducing the morbidity and mortality associated with road traffic injuries will reduce suffering and increase available resources that can be used more effectively. Road traffic injuries are preventable, and the impact of those that do occur can be mitigated. Adequate national and global funding, strategy, and measurable targets are fundamental to a sustainable response to road safety. Over the last decade, the United Nations and World Health Organization have been part of the gaining momentum toward addressing this issue, through resolutions and coordinating global efforts. This is what brought about the "Decade of Action for Road Traffic Safety," and as orthopaedic surgeons, our involvement is key for the collaborative public health response toward this effort.

Infection Prevention Outreach for Outpatient Healthcare Settings: A Local Chapter's Experience with Public Health Collaboration

Healthcare-associated outbreaks in outpatient settings continue to occur nationally despite public health infection prevention (IP) initiatives. Gaps in formal IP training, regulatory oversight, administrative support and infrastructure contribute to disease transmission during outpatient care. Federal and state patient safety efforts in outpatient settings have included increased legislation, patient activism and advocacy, and collaborative partnership formation. APIC Chapter involvement can support public health partners with educational program development and provision to their local healthcare provider community.

Medusa's Ugly Head Again: From SARS to MERS-CoV

In this issue, Arabi and colleagues report a case series of severely ill patients infected with the Middle East respiratory syndrome coronavirus. The editorialists comment on the report and emphasi...

An Analysis of Sodium, Total Fat and Saturated Fat Contents of Packaged Food Products Advertised in Bronx-Based Supermarket Circulars

Americans' consumption of sodium, fat, and saturated fat exceed federally recommended limits for these nutrients and has been identified as a preventable leading cause of hypertension and cardiovascular disease. More than 40% of the Bronx population comprises African-Americans, who have increased risk and earlier onset of hypertension and are also genetically predisposed to salt-sensitive hypertension. This study analyzed nutrition information for packaged foods advertised in Bronx-based supermarket circulars. Federally recommended limits for sodium, saturated fat and total fat contents were used to identify foods that were high in these nutrients. The proportion of these products with respect to the total number of packaged foods was calculated. More than a third (35%) and almost a quarter (24%) of the 898 advertised packaged foods were high in saturated fat and sodium respectively. Such foods predominantly included processed meat and fish products, fast foods, meals, entrees and side dishes. Dairy and egg products were the greatest contributors of high saturated fat. Pork and beef products, fast foods, meals, entrees and side dishes had the highest median values for sodium, total fat and saturated fat content. The high proportion of packaged foods that are high in sodium and/or saturated fat promoted through supermarket circulars highlights the need for nutrition education among consumers as well as collaborative public health measures by the food industry, community and government agencies to reduce the amounts of sodium and saturated fat in these products and limit the promotion of foods that are high in these nutrients.

Intersectoral collaboration in Public Health: too complex to investigate or not?

Intersectoral collaboration in Public Health: too complex to investigate or not?

The Haiti Research-Based Model of International Public Health Collaboration

For 3 decades, GHESKIO (the Groupe Haitien d'Etude du Sarcome de Kaposi et des Infections Opportunistes), the Haitian Ministry of Health, and Weill Cornell have pursued a tripartite mission of service, training, and translational research. The initial focus was on AIDS and tuberculosis. The mission has expanded to include the local community and now provides maternal-child health, family planning, cancer prevention and treatment, immunizations (including human papillomavirus, cholera), and primary education through vocational and microcredit programs. Outcome measures include a reduction in HIV prevalence from 6.2% to the current 2.2%, extensive tuberculosis and cholera prevention and treatment programs, and national training programs for biomedical and community health workers.

The impact of hepatitis B vaccine in China and in the China GAVI Project

The China GAVI Project (CGP) was initiated in 2002 to provide hepatitis B (HB) vaccine to infants born in the less developed areas of China including the Western provinces and poverty counties of Middle provinces, to prevent the consequences of hepatitis B virus infection. By 2009, the project areas had raised coverage of 3 doses of HB vaccine and timely birth doses to almost 90% among infants, comparable to those in wealthier Eastern provinces, and reduced HBV prevalence to <1% among children in these areas. We estimated the impact in disease prevented by HB vaccine in China between 1992, when the vaccine was routinely recommended, and 2009, and in CGP areas for the years 2003–2009, when the CGP was active. A published model was used to estimate the burden of chronic and acute HBV infection and death prevented due to HB vaccination in China and the CGP areas using data from national serosurveys in China in 1992 and 2006, and HB vaccine coverage from surveys in 2004, 2006 and 2010. We used sigmoid modeling to estimate vaccine coverage nationally, regionally, and CGP areas. We also estimated the incremental impact of the CGP on HB vaccine coverage in those underserved areas. Our findings suggest that between 1992 and 2009, HB vaccination in China has prevented 24million chronic HBV infections and 4.3million future deaths due to cirrhosis, hepatocellular carcinoma and acute hepatitis. During the CGP between 2003 and 2009, an estimated 3.8million chronic HBV infections and 680,000 deaths were prevented in CGP areas. We found that the CGP funding increased HB vaccine coverage in project areas by 4–15% for HB3 and 4–27% for timely birth dose beyond the coverage expected without the CGP. The CGP represents a highly successful public health collaboration between the national government and international partners.

Did legislation to regulate school meals in England widen dietary inequalities in children aged 4–7 years? A repeat cross-sectional study

BackgroundThere is an urgent need for policies to address obesity and its health consequences. Children's diets lay the foundations for healthy nutrition across the life course. School meals can contribute substantially to total diet. From 2008, primary schools in England were required to comply with legislation specifying the frequency with which certain foods can and cannot be served and maximum and minimum levels of nutrients (food and nutrient based standards) in school meals. The effect of this legislation on dietary inequalities is unknown. We aimed to assess the effect of the legislation on children's mean nutrient intake at lunch and in their total diet. MethodsWe undertook cross-sectional surveys in 2003–04 (before) and 2008–09 (after legislation) in 12 primary schools in northeast England. Schools represented the socioeconomic spectrum. All children aged 4–7 years were eligible. Ethics approval and informed, written parental consent was obtained. We used a validated, prospective 4-day food diary to record children's dietary intake (n=368 in 2003–04; n=624 in 2008–09). The index of multiple deprivation 2007 was used to categorise socioeconomic status into quintiles. A linear mixed-effect model explored the effect of year, lunch type, socioeconomic status, and interactions between these factors on nutrient intake. FindingsSchool lunch uptake decreased significantly in the most deprived quintile after compared with before legislation (74% to 60%, χ2 test p=0·019). After legislation, children's mean intake from a school lunch had a lower percentage of energy from fat (difference in mean change −8·4%, 95% CI −9·9 to −6·8) and saturated fat (−4·5%, −5·4 to −3·6) and higher non-starch polysaccharides (NSPs; 1·6 g, 1·3 to 1·9) and iron (0·5 mg, 0·3 to 0·7) than those consuming a home-packed lunch. After legislation, children in the least deprived quintile had higher mean nutrient intakes from their lunch than children in the most deprived quintile (differences in mean change: NSP 0·8 g, 95% CI 0·4–1·2; iron 0·4 mg, 0·2–0·6; zinc 0·3 mg, 0·1–0·5). After legislation, children's mean micronutrient intakes in their total diet increased in the least deprived quintile and fell in the most deprived quintile (differences in mean change: NSP 1·2 g, 95% CI 0·3–2·1; iron 0·9 mg, 0·3–1·5; zinc 0·64 mg 0·3–1·0). For children consuming a school lunch, mean total dietary intake of vitamin C increased across all quintiles but increased more for children in the most deprived quintile; for children consuming a home-packed lunch, mean vitamin C intake fell in the most deprived quintile and increased in the least deprived quintile (p=0·035). A key limitation was the use of repeated cross-sectional surveys and lack of control group, which limits the extent to which changes in nutrient intakes can be fully attributed to the implementation of the school food legislation. InterpretationThis legislation has led to children who consume school lunches having a healthier mean nutrient profile than those who consume home-packed lunches. Nutrient intakes have improved overall for the most deprived children. However, inequalities in micronutrient intakes persist at lunchtime and in total diet regardless of lunch type. Additional interventions are needed: for the most deprived families, uptake of school lunch needs to be encouraged; for all children, guidance is needed on how to make the healthiest choices from the foods offered. FundingThis work was undertaken as part of the research programme of the Public Health Research Consortium, which is funded by the Department of Health Policy Research Programme. The views expressed in this publication are those of the authors. MW and AJA are partly funded as members of Fuse, the Centre for Translational Research in Public Health, a UK Clinical Research Collaboration (UKCRC) Public Health Research Centre of Excellence. We thank the British Heart Foundation, Cancer Research UK, Economic and Social Research Council, MRC, and the NIHR, under the auspices of the UKCRC for funding. AJA is funded by a NIHR Professorship.

The effect of socioeconomic inequalities in receipt of, and time to, treatment on socioeconomic inequalities in lung cancer survival: an observational, data-linkage study

BackgroundSocioeconomic inequalities in lung cancer survival have been suggested to be at least partly caused by inequalities in receipt of treatment. In England, there are target waiting times for referral (14 days to first hospital appointment) and treatment (31 days from diagnosis) for suspected cancer. In a systematic review and meta-analysis, we found evidence of socioeconomic inequalities in receipt of lung cancer treatment in the UK, USA, and elsewhere. Northern and Yorkshire Cancer Registry and Information Centre (NYCRIS), Hospital Episode Statistics (HES), and lung cancer audit (LUCADA) data were linked via NHS number to investigate the effect of socioeconomic inequalities in receipt of and time to treatment on lung cancer survival. MethodsNYCRIS data for 22 967 patients diagnosed in 2006–09 with a primary diagnosis of lung cancer (ICD 10 C33 and C34) were analysed, including information about referral date and type and date of treatment. Socioeconomic position (SEP) was measured with the income domain of the index of multiple deprivation. Stage and performance status (a measure of patient wellbeing) were recorded in LUCADA for 5233 (23%) of the cohort. Comorbidity score was obtained from HES for 17 621 (77%). Survival time was from date of diagnosis to death or end of follow-up on Dec 31, 2011. Cox regression models were used to calculate hazard of death and logistic regression to examine likelihood of being alive 2 years after diagnosis, by SEP, in the full cohort and the subset with stage recorded. Findings3513 (15%) of 22 967 patients were alive 2 years after diagnosis. This proportion increased to 1562 (70%) of 2236 who had surgery. Patients referred (odds ratio [OR] 0·76, 95% CI 0·69–0·84; p<0·0001) and treated (0·37, 0·34–0·41; p<0·0001) within guideline targets had a lower likelihood of surviving to 2 years compared with those referred and treated later. Socioeconomic inequalities in survival were found in a multivariable analysis controlling for stage and performance status, with those in the lowest socioeconomic group significantly less likely to be alive after 2 years compared with those in the highest group (OR 0·78, 95% CI 0·69–0·88; p<0·0001). Timely referral did not change this result. However, when receipt of treatment was included, the association was no longer significant (OR 0·87, 95% CI 0·75–1·00; p=0·06). Timeliness of treatment did not alter the conclusion. InterpretationSocioeconomic inequalities in survival from lung cancer were statistically explained by socioeconomic inequalities in receipt of treatment, but not by inequalities in timeliness of referral and treatment. We were unable to examine smoking status and there might be residual confounding from this and other factors. Missing stage and performance status data are an important limitation. However, patterns of survival in the subset of patients with stage data were similar to those in the full cohort. Research into unexplained variance in treatment rates is needed to develop interventions that address socioeconomic inequalities in receipt of treatment and survival. This factor might have a greater effect on improvement of survival than the present clinical focus on time-interval targets. FundingLFF (ESRC studentship ES/I020926/1) is a PhD student funded by ESRC as a member of Fuse, the Centre for Translational Research in Public Health (www.fuse.ac.uk). JA, MW, and GR are funded in part as a staff member (JA), director (MW), and senior investigator (GR) of Fuse. Fuse is a UK Clinical Research Collaboration (UKCRC) Public Health Research Centre of Excellence. Funding for Fuse from the British Heart Foundation, Cancer Research UK, Economic and Social Research Council, MRC, NIHR, under the auspices of the UKCRC, is acknowledged. The views expressed do not necessarily represent those of the funders or UKCRC. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Innovators and Early Adopters of Population Health in Healthcare: Real and Present Opportunities for Healthcare–Public Health Collaboration

The population health approach - which has long been a cornerstone ideology for those in public health - is increasingly embraced by various actors in the healthcare sector, including but not limited to those in primary healthcare. There is much to be gained from public health's involvement in these early efforts, which could enable the pursuit of approaches that integrate both individual- and population-level interventions. These collaborative efforts could serve as the initial building blocks for transformative change, provided that others follow suit. Lessons from the study of the diffusion of innovation teach us that new ideas can spread or wither in unpredictable ways. However, the odds of success would be improved if we could (1) make population health concepts less complex and more actionable, (2) socialize early adopter activities and make them more observable to others so that they could help model the way, (3) invest in evaluation so that the benefits of the approach could be more clearly demonstrated and (4) address social and cultural barriers to adoption through opinion leaders within respective professional communities.

Introducing a model of cardiovascular prevention in Nairobi's slums by integrating a public health and private-sector approach: the SCALE-UP study

IntroductionCardiovascular disease (CVD) is a leading cause of death in sub-Saharan Africa (SSA), with annual deaths expected to increase to 2 million by 2030. Currently, most national health systems in SSA are not adequately prepared for this epidemic. This is especially so in slum settlements where access to formal healthcare and resources is limited.ObjectiveTo develop and introduce a model of cardiovascular prevention in the slums of Nairobi by integrating public health and private sector approaches.Study designTwo non-profit organizations that conduct public health research, Amsterdam Institute for Global Health and Development (AIGHD) and African Population and Health Research Center (APHRC), collaborated with private-sector Boston Consulting Group (BCG) to develop a service delivery package for CVD prevention in slum settings. A theoretic model was designed based on the integration of public and private sector approaches with the focus on costs and feasibility.ResultsThe final model includes components that aim to improve community awareness, a home-based screening service, patient and provider incentives to seek and deliver treatment specifically for hypertension, and adherence support. The expected outcomes projected by this model could prove potentially cost effective and affordable (1 USD/person/year). The model is currently being implemented in a Nairobi slum and is closely followed by key stakeholders in Kenya including the Ministry of Health, the World Health Organization (WHO), and leading non-governmental organizations (NGOs).ConclusionThrough the collaboration of public health and private sectors, a theoretically cost-effective model was developed for the prevention of CVD and is currently being implemented in the slums of Nairobi. If results are in line with the theoretical projections and first impressions on the ground, scale-up of the service delivery package could be planned in other poor urban areas in Kenya by relevant policymakers and NGOs.

Implications of Network Structure on Public Health Collaboratives

Interorganizational collaboration is an essential function of public health agencies. These partnerships form social networks that involve diverse types of partners and varying levels of interaction. Such collaborations are widely accepted and encouraged, yet very little comparative research exists on how public health partnerships develop and evolve, specifically in terms of how subsequent network structures are linked to outcomes. A systems science approach, that is, one that considers the interdependencies and nested features of networks, provides the appropriate methods to examine the complex nature of these networks. Applying Mays and Scutchfields's categorization of "structural signatures" (breadth, density, and centralization), this research examines how network structure influences the outcomes of public health collaboratives. Secondary data from the Program to Analyze, Record, and Track Networks to Enhance Relationships (www.partnertool.net) data set are analyzed. This data set consists of dyadic (N = 12,355), organizational (N = 2,486), and whole network (N = 99) data from public health collaborations around the United States. Network data are used to calculate structural signatures and weighted least squares regression is used to examine how network structures can predict selected intermediary outcomes (resource contributions, overall value and trust rankings, and outcomes) in public health collaboratives. Our findings suggest that network structure may have an influence on collaborative-related outcomes. The structural signature that had the most significant relationship to outcomes was density, with higher density indicating more positive outcomes. Also significant was the finding that more breadth creates new challenges such as difficulty in reaching consensus and creating ties with other members. However, assumptions that these structural components lead to improved outcomes for public health collaboratives may be slightly premature. Implications of these findings for research and practice are discussed.

NIH Support of Centers for AIDS Research and Department of Health Collaborative Public Health Research

The contributions reported in this supplemental issue highlight the relevance of NIH-funded CEWG research to health department–supported HIV prevention and care activities in the 9 US cities with the highest numbers of AIDS cases. The project findings have the potential to enhance ongoing HIV treatment and care services and to advance the wider scientific agenda. The HIV testing to care continuum, while providing a framework to help track progress on national goals, also can reflect the heterogeneities of local epidemics. The collaborative research that is highlighted in this issue not only reflects a locally driven research agenda but also demonstrates research methods, data collection tools, and collaborative processes that could be encouraged across jurisdictions. Projects such as these, capitalizing on the integrated efforts of NIH, CDC, DOH, and academic institutions, have the potential to contribute to improvements in the HIV care continuum in these communities, bringing us closer to realizing the HIV prevention and treatment goals of the NHAS.

Viewpoints about collaboration between primary care and public health in Canada

BackgroundAlthough there is a global movement toward health system integration and collaboration, little is known about values, beliefs, and attitudes towards collaboration between stakeholders in public health (i.e. promotion, protection, and prevention with vulnerable groups and/or at the population level) and primary care (i.e., family practices, nurse-led clinics). The purpose of this study was to explore viewpoints of key stakeholders regarding primary care (PC) and public health (PH) collaboration in Canada.MethodsWe used Q-methodology to identify common viewpoints held by participants who attended a national meeting in Canada in 2010 to discuss PC and PH collaboration. The study was conducted in two phases. In Phase 1 a Q-sample, a Q-sort table, and a short demographic questionnaire were developed which were used in Phase 2 for data collection. The Q-sorts then were analysed to identify the salient factors and consensus statements.ResultsIn total, 25 multidisciplinary individuals including researchers, policy-makers, directors, managers, and practitioners (e.g., nurses, family physicians, dietitians) participated. Using a by-person factor analysis, three factors (salient viewpoints) emerged. Factors were named based on their distinguishing statements as follows: a) System Driven Collaborators, b) Cautious Collaborators, and c) Competent Isolationists. System Driven Collaborators strongly believed that a clear mandate from the top is needed to enable PH, PC and the rest of the health system to effectively work together and that people in different branches in the Ministry/ Ministries have to strongly believe in collaboration, actively support it, and develop directed policies to foster organizations work together. Cautious Collaborators strongly supported the idea of having better consciousness-raising about what collaborations might be possible and beneficial, and also reflecting on the collaborations already in place. The Competent Isolationists strongly believed that it is necessary for PC and PH sectors to spend time to ensure that both parties clearly understand the differences between their roles. They believe that physicians, nurses, and social workers will not see the value in collaboration because they lack inter-professional educational programs.ConclusionsDifferent viewpoints are held by stakeholders around PC and PH collaboration which have the potential to influence the success of collaborations. Understanding and managing these differences is important to assist change management processes required to build and maintain strong PC and PH collaborations.

Modeling the Structure of Partnership Between Researchers and Front-Line Service Providers: Strengthening Collaborative Public Health Research.

Partnerships between HIV researchers and service providers are essential for reducing the gap between research and practice. Community-Based Participatory Research principles guided this cross-sectional study, combining 40 in-depth interviews with surveys of 141 providers in 24 social service agencies in New York City. We generated the Provider-Researcher Partnership Model to account for provider- and agency-level factors' influence on intentions to form partnerships with researchers. Providers preferred "balanced partnerships" in which researchers and providers allocated research tasks and procedures to reflect diverse knowledge/skill sets. An organizational culture that values research can help enhance providers' intentions to partner. Providers' intentions and priorities found in this study may encourage researchers to engage in and policy makers to fund collaborative research.

Public Health and Law Collaboration: The Philadelphia Lead Court Study

We determined whether Philadelphia Lead Court is effective in enforcing lead hazard remediation in the homes of children with elevated blood lead levels. We created a deidentified data set for properties with an initial failed home inspection (IFHI) for lead hazards from January 1, 1998, through December 31, 2008, and compared compliance rates within the first year and time to compliance for lead hazard remediation between 1998 and 2002 (precourt period) and between 2003 and 2008 (court period). We evaluated predictors of time to compliance. Within 1 year of the IFHI, 6.6% of the precourt and 76.8% of the court cases achieved compliance (P < .001) for the 3764 homes with data. Four years after the IFHI, 18% had attained compliance in the precourt period compared with 83.1% for the court period (P < .001). A proportional hazard analysis found that compliance was 8 times more likely in the court than the precourt period (P < .001). Lead court was more effective than precourt enforcement strategies. Most properties were remediated within 1 year of the IFHI, and time to compliance was significantly reduced. This model court could be replicated in other cities with similar enforcement problems.

White Paper Report of the 2012 RAD-AID Conference on International Radiology for Developing Countries: Planning the Implementation of Global Radiology

The RAD-AID Conference on International Radiology for Developing Countries is a yearly forum addressing global shortages of radiology that contribute to health care disparity. In this paper, the authors present key issues and consensus positions related to the planning, analyzing, implementing, and monitoring of radiology in limited-resource areas on the basis of presentations at the 2012 RAD-AID conference, to advocate for (1) economic development to build health care capacity, (2) multidisciplinary educational strategies, (3) innovative epidemiologic and infrastructural solutions tailored to community needs, (4) advanced technical solutions leveraging the widespread use of wireless telecommunications and phone-based portable devices, and (5) improved dialog across radiology and public health institutions for coordinating global health strategies.

The epidemiology and surveillance response to pandemic influenza A (H1N1) among local health departments in the San Francisco Bay Area.

BackgroundPublic health surveillance and epidemiologic investigations are critical public health functions for identifying threats to the health of a community. Very little is known about how these functions are conducted at the local level. The purpose of the Epidemiology Networks in Action (EpiNet) Study was to describe the epidemiology and surveillance response to the 2009 pandemic influenza A (H1N1) by city and county health departments in the San Francisco Bay Area in California. The study also documented lessons learned from the response in order to strengthen future public health preparedness and response planning efforts in the region.MethodsIn order to characterize the epidemiology and surveillance response, we conducted key informant interviews with public health professionals from twelve local health departments in the San Francisco Bay Area. In order to contextualize aspects of organizational response and performance, we recruited two types of key informants: public health professionals who were involved with the epidemiology and surveillance response for each jurisdiction, as well as the health officer or his/her designee responsible for H1N1 response activities. Information about the organization, data sources for situation awareness, decision-making, and issues related to surge capacity, continuity of operations, and sustainability were collected during the key informant interviews. Content and interpretive analyses were conducted using ATLAS.ti software.ResultsThe study found that disease investigations were important in the first months of the pandemic, often requiring additional staff support and sometimes forcing other public health activities to be put on hold. We also found that while the Incident Command System (ICS) was used by all participating agencies to manage the response, the manner in which it was implemented and utilized varied. Each local health department (LHD) in the study collected epidemiologic data from a variety of sources, but only case reports (including hospitalized and fatal cases) and laboratory testing data were used by all organizations. While almost every LHD attempted to collect school absenteeism data, many respondents reported problems in collecting and analyzing these data. Laboratory capacity to test influenza specimens often aided an LHD’s ability to conduct disease investigations and implement control measures, but the ability to test specimens varied across the region and even well-equipped laboratories exceeded their capacity. As a whole, the health jurisdictions in the region communicated regularly about key decision-making (continued on next page) (continued from previous page) related to the response, and prior regional collaboration on pandemic influenza planning helped to prepare the region for the novel H1N1 influenza pandemic. The study did find, however, that many respondents (including the majority of epidemiologists interviewed) desired an increase in regional communication about epidemiology and surveillance issues.ConclusionThe study collected information about the epidemiology and surveillance response among LHDs in the San Francisco Bay Area that has implications for public health preparedness and emergency response training, public health best practices, regional public health collaboration, and a perceived need for information sharing.