Local Public Health Departments Research Articles

Tuberculosis Contact Investigation: Eight Years of Experience with the QuantiFERON-TB®Gold In-Tube in Lower Saxony, Germany

Since the beginning of the 21st century, beside tuberculin skin tests (TST) and chest X-rays, interferon-gamma release assays (IGRA) have become available for diagnosing latent tuberculosis infection. In 2006, the Governmental Institute of Public Health of Lower Saxony (NLGA) established the IGRA in its laboratory, using the QuantiFERON-TB®Gold In-Tube (QFT). A cohort of 19 309 contact persons who were investigated during contact tracing by local public health departments (LPHD) was analyzed. Within 3 years, 75% of LPHDs in Lower Saxony established the QFT for tuberculosis contact tracing. Between 2007 and 2014 the percentage of contact persons≥15 years of age with initial TST declined from 65.1 to 1.7%. For contact persons<15 years of age, this proportion declined from 81.7% (2007) to 10.1% (2014). The proportion of contact persons who reported a country of birth outside Germany rose from 21.3 to 28.8% between 2008 and 2013. Cases from South Eastern European countries were increasingly reported, seldom from states of the former Soviet Union. 14.1% of the investigated contact persons had a positive QFT. 449 persons with a negative result underwent a second test within 4 months; 4% of these tested positive. Within a period of 8 years, the TST was replaced by the QFT in Lower Saxony, not least because of the modified recommendations for environmental contact tracing in tuberculosis of the German Central Committee against Tuberculosis (DZK). Higher specificity of the QFT and thus fewer X-rays, omission of the second visit for interpreting the TST, and the inappropriate package size of the TST for smaller LPHDs are further arguments in favor for the QFT. But unspecific use of the QFT must be avoided; otherwise, the value of the QFT result declines. The increasing number of contact persons with migration background and the changing countries of origin are a challenge for all who are involved in tuberculosis contact tracing.

Evaluation of the acceptability of a vaccine against herpes zoster in the over 50 years old: an Italian observational study

ObjectiveThe aim of the study was to evaluate awareness of the varicella zoster virus and the acceptability of the newly available herpes zoster (HZ) vaccine in the over 50 years...

Clearing the Air: Smoke-Free Housing Policies, Smoking, and Secondhand Smoke Exposure Among Affordable Housing Residents in Minnesota, 2014-2015.

IntroductionDuring the past 30 years, local and state tobacco use control laws in the United States have helped reduce smoking prevalence and exposure to secondhand smoke, but progress among low socioeconomic populations has been slow. Implementing smoke-free housing policies in affordable housing may help address this issue. The purpose of our study was to assess how such policies affect smoking rates and exposure to secondhand smoke among residents of affordable housing.MethodsWe conducted a pretest–posttest longitudinal study of 180 residents from 8 affordable housing properties in Minnesota. Participating properties agreed to adopt a smoke-free housing policy covering indoor grounds, and 3 of these properties also prohibited smoking on all outdoor grounds. Policies were implemented with assistance from local public health departments and the Statewide Health Improvement Program. Participants completed surveys one month before policy implementation and 6 months postimplementation. Surveys assessed smoking, quit attempts, and indoor and outdoor secondhand smoke exposure.ResultsResults indicated a significant reduction in nonsmokers’ indoor exposure to secondhand smoke (F 1,144 = 22.69, P < .001) and no change in outdoor exposure to secondhand smoke from Time 1 (pretest) to Time 2 (posttest) (F 1,140 = 2.17, P = .14). However, when examining sites that only prohibited smoking indoors, we observed an increase in outdoor secondhand smoke exposure that approached significance (F 1,118 = 3.76, P = .055). Results showed no change in quit attempts over time, but 77% of residents who smoked at pretest reported reducing the amount that they smoked at posttest, and an additional 5% reported that they had quit.ConclusionsSmoke-free housing policies may be an effective strategy to reduce exposure to indoor secondhand exposure and promote decreased cigarette smoking among residents of affordable housing.

Evaluating the Impact of National Public Health Department Accreditation - United States, 2016.

In 2011, the nonprofit Public Health Accreditation Board (PHAB) launched the national, voluntary public health accreditation program for state, tribal, local, and territorial public health departments. As of May 2016, 134 health departments have achieved 5-year accreditation through PHAB and 176 more have begun the formal process of pursuing accreditation. In addition, Florida, a centralized state in which the employees of all 67 local health departments are employees of the state, achieved accreditation for the entire integrated local public health department system in the state. PHAB-accredited health departments range in size from a small Indiana health department that serves approximately 17,000 persons to the much larger California Department of Public Health, which serves approximately 38 million persons. Collectively, approximately half the U.S. population, or nearly 167 million persons, is covered by an accredited health department. Forty-two states and the District of Columbia now have at least one nationally accredited health department. In a survey conducted through a contract with a social science research organization during 2013-2016, >90% of health departments that had been accredited for 1 year reported that accreditation has stimulated quality improvement and performance improvement opportunities, increased accountability and transparency, and improved management processes.

Multidrug-resistant organisms in refugees: prevalences and impact on infection control in hospitals.

Introduction: The refugee crisis is a great challenge to the social and healthcare system in European countries, especially in Germany. An abundance of data has been published on the refugees’ health problems (infections as well as physical diseases and psychiatric problems) and their prevention (i.e., sanitary and vaccination programs). However, data on prevalences of multidrug-resistant organisms (MDRO) in refugees are scarce, although it is known that most refugees are from or travelled through countries with high prevalences of MDRO. This paper presents current data on MDRO colonization of refugees admitted to hospitals, and the impact of screening upon admission and infection control in hospitals is discussed.Methods: Anonymous data obtained by screening upon hospital admission were reported by hospitals in the Rhine-Main region of Germany to the local public health department. Screening and microbiological analyses were performed from December 2015 to March 2016 according to standardized and validated methods.Results: 9.8% of the refugees screened (32/325) exhibited colonization with methicillin-resistant Staphylococcus aureus (MRSA), and 23.3% of the refugees (67/290) were colonized with Gram-negative bacteria with extended spectrum beta-lactamases, and/or enterobacteria with resistance against 3 or 4 groups of antibacterials, so-called 3MRGN (multidrug-resistant Gram-negative bacteria with resistance against penicillins, cephalosporins and quinolones) and 4MRGN (with additional resistance against carbapenems). Carbapenem-resistant Gram-negative bacteria (CRGN) were detected in 2.1% (6/290) of the refugees.Conclusion: The data confirms the studies published between 2014 and 2016, encompassing refugees tested in Germany, the Netherlands and Israel, with prevalences of MRSA and CRGN up to 13.5% and 5.6%. The MDRO prevalences are higher than those of “risk groups” for MRSA, such as hemodialysis patients and patients depending on outpatient home-nursing care or residing in nursing homes. Therefore, screening and special infection control in hospitals is strongly suggested when refugees are admitted to hospitals, in order to ensure best medical practice and safety for all hospital patients regardless of their country of origin.

Early Identification and Prevention of the Spread of Ebola - United States.

In response to the 2014-2016 Ebola virus disease (Ebola) epidemic in West Africa, CDC prepared for the potential introduction of Ebola into the United States. The immediate goals were to rapidly identify and isolate any cases of Ebola, prevent transmission, and promote timely treatment of affected patients. CDC's technical expertise and the collaboration of multiple partners in state, local, and municipal public health departments; health care facilities; emergency medical services; and U.S. government agencies were essential to the domestic preparedness and response to the Ebola epidemic and relied on longstanding partnerships. CDC established a comprehensive response that included two new strategies: 1) active monitoring of travelers arriving from countries affected by Ebola and other persons at risk for Ebola and 2) a tiered system of hospital facility preparedness that enabled prioritization of training. CDC rapidly deployed a diagnostic assay for Ebola virus (EBOV) to public health laboratories. Guidance was developed to assist in evaluation of patients possibly infected with EBOV, for appropriate infection control, to support emergency responders, and for handling of infectious waste. CDC rapid response teams were formed to provide assistance within 24 hours to a health care facility managing a patient with Ebola. As a result of the collaborations to rapidly identify, isolate, and manage Ebola patients and the extensive preparations to prevent spread of EBOV, the United States is now better prepared to address the next global infectious disease threat.The activities summarized in this report would not have been possible without collaboration with many U.S. and international partners (http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/partners.html).

Treatment provision for gambling disorder in Britain: call for an integrated addictions treatment and commissioning model.

Treatment provision for individuals with gambling problems in Britain is at best inadequate. Here we call for gambling treatment provision to be integrated into mainstream drug and alcohol services, and for its commissioning responsibilities to fall under local public health departments.

Qualitative Assessment of a Novel Efficacy-Focused Training Intervention for Public Health Workers in Disaster Recovery.

We trained local public health workers on disaster recovery roles and responsibilities by using a novel curriculum based on a threat and efficacy framework and a training-of-trainers approach. This study used qualitative data to assess changes in perceptions of efficacy toward Hurricane Sandy recovery and willingness to participate in future disaster recoveries. Purposive and snowball sampling were used to select trainers and trainees from participating local public health departments in jurisdictions impacted by Hurricane Sandy in October 2012. Two focus groups totaling 29 local public health workers were held in April and May of 2015. Focus group participants discussed the content and quality of the curriculum, training logistics, and their willingness to engage in future disaster recovery efforts. The training curriculum improved participants' understanding of and confidence in their disaster recovery work and related roles within their agencies (self-efficacy); increased their individual- and agency-level sense of role-importance in disaster recovery (response-efficacy); and enhanced their sense of their agencies' effective functioning in disaster recovery. Participants suggested further training customization and inclusion of other recovery agencies. Threat- and efficacy-based disaster recovery trainings show potential to increase public health workers' sense of efficacy and willingness to participate in recovery efforts. (Disaster Med Public Health Preparedness. 2016;10:615-622).

Enhancing Syndromic Surveillance at a Local Public Health Department

In an effort to enhance situational awareness, Maricopa County Department of Public Health (Arizona) dedicated resources to begin developing a robust syndromic surveillance program. This abstract shares how the CDC Framework for Program Evaluation and a logic model were used to enhance syndromic surveillance at a local public health department.

A Digital Platform for Local Foodborne Illness and Outbreak Surveillance

Foodborne illness affects 1 in 4 Americans, annually. However, only a fraction of affected individuals seek medical attention. In this presentation, we will discuss our collaboration with local public health departments to develop a foodborne disease surveillance platform to supplement ongoing surveillance efforts. The platform currently uses digital data from Twitter and Yelp. We developed a machine learning classifier to differentiate between relevant and irrelevant data. The classifier had an accuracy and precision of 85% and 82%, respectively based on an evaluation using 6084 tweets. These performance results are promising, especially given the similarities between the data classes.

Adapting to the Changing Climate: An Assessment of Local Health Department Preparations for Climate Change-Related Health Threats, 2008-2012.

BackgroundClimate change poses a major public health threat. A survey of U.S. local health department directors in 2008 found widespread recognition of the threat, but limited adaptive capacity, due to perceived lack of expertise and other resources.MethodsWe assessed changes between 2008 and 2012 in local public health departments' preparedness for the public health threats of climate change, in light of increasing national polarization on the issue, and widespread funding cutbacks for public health. A geographically representative online survey of directors of local public health departments was conducted in 2011–2012 (N = 174; response rate = 50%), and compared to the 2008 telephone survey results (N = 133; response rate = 61%).ResultsSignificant polarization had occurred: more respondents in 2012 were certain that the threat of local climate change impacts does/does not exist, and fewer were unsure. Roughly 10% said it is not a threat, compared to 1% in 2008. Adaptation capacity decreased in several areas: perceived departmental expertise in climate change risk assessment; departmental prioritization of adaptation; and the number of adaptation-related programs and services departments provided. In 2008, directors' perceptions of local impacts predicted the number of adaptation-related programs and services their departments offered, but in 2012, funding predicted programming and directors' impact perceptions did not. This suggests that budgets were constraining directors' ability to respond to local climate change-related health threats. Results also suggest that departmental expertise may mitigate funding constraints. Strategies for overcoming these obstacles to local public health departments' preparations for climate change are discussed.

Transmission of Zika Virus Through Sexual Contact with Travelers to Areas of Ongoing Transmission — Continental United States, 2016

Zika virus is a flavivirus closely related to dengue, West Nile, and yellow fever viruses. Although spread is primarily by Aedes species mosquitoes, two instances of sexual transmission of Zika virus have been reported, and replicative virus has been isolated from semen of one man with hematospermia. On February 5, 2016, CDC published recommendations for preventing sexual transmission of Zika virus. Updated prevention guidelines were published on February 23. During February 6-22, 2016, CDC received reports of 14 instances of suspected sexual transmission of Zika virus. Among these, two laboratory-confirmed cases and four probable cases of Zika virus disease have been identified among women whose only known risk factor was sexual contact with a symptomatic male partner with recent travel to an area with ongoing Zika virus transmission. Two instances have been excluded based on additional information, and six others are still under investigation. State, territorial, and local public health departments, clinicians, and the public should be aware of current recommendations for preventing sexual transmission of Zika virus, particularly to pregnant women. Men who reside in or have traveled to an area of ongoing Zika virus transmission and have a pregnant partner should abstain from sexual activity or consistently and correctly use condoms during sex with their pregnant partner for the duration of the pregnancy.

Forecasting the Revenues of Local Public Health Departments in the Shadows of the “Great Recession”

The ability of local health departments (LHD) to provide core public health services depends on a reliable stream of revenue from federal, state, and local governments. This study investigates the impact of the "Great Recession" on major sources of LHD revenues and develops a fiscal forecasting model to predict revenues to LHDs in one state over the period 2012 to 2014. Economic forecasting offers a new financial planning tool for LHD administrators and local government policy makers. This study represents a novel research application for these econometric methods. Detailed data on revenues by source for each LHD in Wisconsin were taken from annual surveys conducted by the Wisconsin Department of Health Services over an 8-year period (2002-2009). A forecasting strategy appropriate for each revenue source was developed resulting in "base case" estimates. An analysis of the sensitivity of these revenue forecasts to a set of alternative fiscal policies by the federal, state, and local governments was carried out. The model forecasts total LHD revenues in 2012 of $170.5 million (in 2010 dollars). By 2014, inflation-adjusted revenues will decline by $8 million, a reduction of 4.7%. Because of population growth, per capita real revenues of LHDs are forecast to decline by 6.6% between 2012 and 2014. There is a great deal of uncertainty about the future of federal funding in support of local public health. A doubling of the reductions in federal grants scheduled under current law would result in an additional $4.4 million decline in LHD revenues in 2014. The impact of the Great Recession continues to haunt LHDs. Multiyear revenue forecasting offers a new financial tool to help LHDs better plan for an environment of declining resources. New revenue sources are needed if sharp drops in public health service delivery are to be avoided.

The Public Health Information Technology Maturity Index: An Approach to Evaluating the Adoption and Use of Public Health Information Technology

Background: Public health information technology (PHIT) has the potential to improve the effective and efficient use of information in achieving public health objectives. Information technology maturity models have been extensively used in other domains to guide information technology assessment and planning, but an information technology maturity model tailored for public health departments has heretofore been unavailable. Purpose: The purpose of this study was to develop a Public Health Information Technology Maturity Index. Methods: An extensive literature review and content analysis was conducted of information system adoption, use, and maturity in general and in the public health systems and services research context in particular. Primary data were collected through staff interviews (61), staff observations (16), patient focus groups (3), and staff surveys (3) over the course of a multi-year technology implementation, including preand postimplementation of an electronic health record system at a large suburban public health department. Data were analyzed using qualitative and quantitative methods to extract potential categories for inclusion in the index. A Delphi exercise whose panelists included experts from state and local public health departments and national multi-stakeholder groups was conducted. Results: A Public Health Information Technology Maturity Index, questionnaire, and scoring guide were created. The Maturity Index consisted of four primary categories: Scale and Scope of PHIT Use; PHIT Quality; PHIT Human Capital, Policy and Resources; and, PHIT Community Infrastructure, along with fourteen subdimensions. Implications: The PHIT Maturity Index represents a practical approach to aid public health system stakeholders, notably health departments, in the evaluation of their information technology deployment decisions. As benchmark data become available, it will enable comparative assessment and possible linking of information technology maturity and multi-agency interoperability to population health outcomes.

Do Americans Understand That Global Warming Is Harmful to Human Health? Evidence From a National Survey

BackgroundGlobal warming has significant negative consequences for human health, with some groups at greater risk than others. The extent to which the public is aware of these risks is unclear; the limited extant research has yielded discrepant findings. ObjectivesThis paper describes Americans' awareness of the health effects of global warming, levels of support for government funding and action on the issue, and trust in information sources. We also investigate the discrepancy in previous research findings between assessments based on open- versus closed-ended questions. MethodsA nationally representative survey of US adults (N = 1275) was conducted online in October 2014. Measures included general attitudes and beliefs about global warming, affective assessment of health effects, vulnerable populations and specific health conditions (open- and closed-ended), perceived risk, trust in sources, and support for government response. FindingsMost respondents (61%) reported that, before taking the survey, they had given little or no thought to how global warming might affect people's health. In response to a closed-ended question, many respondents (64%) indicated global warming is harmful to health, yet in response to an open-ended question, few (27%) accurately named one or more specific type of harm. In response to a closed-ended question, 33% indicated some groups are more affected than others, yet on an open-ended question only 25% were able to identify any disproportionately affected populations. Perhaps not surprising given these findings, respondents demonstrated only limited support for a government response: less than 50% of respondents said government should be doing more to protect against health harms from global warming, and about 33% supported increased funding to public health agencies for this purpose. Respondents said their primary care physician is their most trusted source of information on this topic, followed by the Centers for Disease Control and Prevention, the World Health Organization, and their local public health department. ConclusionsMost Americans report a general sense that global warming can be harmful to health, but relatively few understand the types of harm it causes or who is most likely to be affected. Perhaps as a result, there is only moderate support for an expanded public health response. Primary care physicians and public health officials appear well positioned to educate the public about the health relevance of climate change

J H Woolf

J H Woolf (“Paddy”) went to Bermuda in 1955 during national service with the Royal Army Medical Corps. He liked Bermuda from day one, and on completing his national service...

Jurisdiction Size and Director Compensation in Connecticut Local Health Departments

Objective: To examine if the compensation of local public health directors responds to organizational size in the same manner found for other types of for-profit, not-for-profit, and public managers. Design: Panel data ordinary least squares with fixed effects for the local health department and time period. Control variables include median household income, the unemployment rate, and the part-time versus fulltime and independent versus district status of the local public health department. Setting: Sample of Connecticut local health departments over the period from 2001 to 2011. Main Outcome Measures: Annual wage of the local public health director and population in the jurisdiction of the local public health department. Results: The size elasticity of local public health director equals 0.2. Full-time directors are paid more than part-time directors and directors managing district health departments are compensated more than those directing independent health departments. Directors are paid more if they manage health departments in jurisdictions with higher levels of income. Conclusions: The findings for the size elasticity of compensation for local public health directors compares very closely to the size elasticity estimates found for other types of for-profit, not-for-profit, and public managers, perhaps suggesting that local public health directors are similarly motivated.

Rapid HIV Screening in an Urban Jail: How Testing at Exit With Linkage to Community Care Can Address Perceived Barriers.

Despite recommendations from the CDC, only 36 % of jails offer routine HIV screening to inmates. Our purpose was to explore the feasibility of rapid HIV testing at release from an urban jail, and to identify potential barriers to this process. This project was incorporated into an established partnership between the jail, local academic medical center, and local public health department. We offered rapid HIV testing at the time of release to 507 jail inmates over a 7 week period of 2013. Three hundred and two (60 %) inmates elected testing. All participating inmates received individual test counseling, HIV prevention education, and linkage to care in the community prior to release. All tested inmates received results before release; one inmate screened positive for HIV and was linked to care. Previous HIV testing was the most frequently cited reason given (60 %) among the 205 inmates who declined at the time of the study. Utilizing the partnership between the jail, public health, and an academic medical center, we found that rapid HIV testing at exit was feasible and acceptable in this urban jail setting and could provide immediate linkage to care for those in need.

The political economy of a public health case management program's transition into medical homes

Throughout the United States, public health leaders are experimenting with how best to integrate services for individuals with complex needs. To that end, North Carolina implemented a policy incorporating both local public health departments and other providers into medical homes for low income pregnant women and young children at risk of developmental delays. To understand how this transition occurred within local communities, a pre-post comparative case study was conducted. A total of 42 people in four local health departments across the state were interviewed immediately before the 2011 policy change and six months later: 32 professionals (24 twice) and 10 pregnant women receiving case management at the time of the policy implementation. We used constant comparative analysis of interview and supplemental data to identify three key consequences of the policy implementation. One, having medical homes increased the centrality of other providers relative to local health departments. Two, a shift from focusing on personal relationships toward medical efficiency diverged in some respects from both case managers' and mothers' goals. Three, health department staff re-interpreted state policies to fit their public health values. Using a political economy perspective, these changes are interpreted as reflecting shifts in public health's broader ideological environment. To a large extent, the state successfully induced more connection between health department-based case managers and external providers. However, limited provider engagement may constrain the implementation of the envisioned medical homes. The increased focus on medical risk may also undermine health departments' role in supporting health over time by attenuating staff relationships with mothers. This study helps clarify how state public health policy innovations unfold at local levels, and why front line practice may in some respects diverge from policy intent.

Identify-Isolate-Inform: A Modified Tool for Initial Detection and Management of Middle East Respiratory Syndrome Patients in the Emergency Department.

Middle East respiratory syndrome (MERS) is a novel infectious disease caused by a coronavirus (MERS-CoV) first reported in Saudi Arabia in September 2012. MERS later spread to other countries in the Arabian Peninsula, followed by an outbreak in South Korea in 2015. At least 26 countries have reported MERS cases, and these numbers may increase over time. Due to international travel opportunities, all countries are at risk of imported cases of MERS, even if outbreaks do not spread globally. Therefore, it is essential for emergency department (ED) personnel to be able to rapidly assess MERS risk and take immediate actions if indicated. The Identify-Isolate-Inform (3I) tool, originally conceived for initial detection and management of Ebola virus disease patients in the ED and later adjusted for measles, can be adapted for real-time use for any emerging infectious disease. This paper reports a modification of the 3I tool for use in initial detection and management of patients under investigation for MERS. Following an assessment of epidemiologic risk factors, including travel to countries with current MERS transmission and contact with patients with confirmed MERS within 14 days, patients are risk stratified by type of exposure coupled with symptoms of fever and respiratory illness. If criteria are met, patients must be immediately placed into airborne infection isolation (or a private room until this type of isolation is available) and the emergency practitioner must alert the hospital infection prevention and control team and the local public health department. The 3I tool will facilitate rapid categorization and triggering of appropriate time-sensitive actions for patients presenting to the ED at risk for MERS.