Oregon Public Health Division Research Articles

An investigation of Salmonella Fluntern illnesses linked to leopard geckos-United States, 2018.

Reptile contact can result in zoonotic non-typhoidal salmonellosis. In April 2018, Oregon Public Health Division contacted CDC about a cluster of four Salmonella serovar Fluntern (SF) illnesses in four states (OR, CA, IA, NY); patients reported contact with geckos, a popular reptile pet. PulseNet, the national molecular subtyping network of food-borne disease surveillance, subsequently identified additional SF clinical isolates. Twelve cases in 11 states were identified; median age was 5years (range: <1-58years). Three patients were hospitalized; no deaths were reported. Of those with exposure information (n=10), all reported reptile exposure; 9 (90%) specified contact with leopard geckos. No common source of geckos was identified from reported purchase locations. Los Angeles County (LAC) health officials isolated SF from one patient's leopard gecko. Five reptile/gecko isolates were identified from the USDA National Veterinary Services Laboratories (NVSL) from 2015 to 2018. Five countries responded to an Epidemic Intelligence Information System post by PulseNet; reptile isolate sequence data were received from Czech Republic. A clinical case from England was identified through the National Center for Biotechnology Information pathogen detection pipeline; the patient did not report contact with leopard geckos. Whole genome sequencing analysis revealed substantial genetic diversity between clinical and animal isolates; however, gecko and clinical isolates from LAC were highly related (1 allele difference). This investigation linking SF illnesses to leopard geckos highlights an important public health risk from pets. A better understanding of how geckos are distributed by the pet industry in the United States could improve traceability to points of origin and mitigate Salmonella transmission at gecko breeders. Earlier NVSL reports of SF isolates from geckos suggest the risk of human SF infection from geckos is not new. This investigation demonstrates a need to educate gecko breeders, retailers and gecko owners about the continued Salmonella infection risk from pet geckos.

Enhancing TX SyS by integrating EMS and Poison Data for Opioid Overdose Surveillance

ObjectiveTo improve Texas Syndromic Surveillance by integrating data from the Texas Poison Center and Emergency Medical Services for opioid overdose surveillance.IntroductionIn recent years, the number of deaths from illicit and prescription opioids has increased significantly resulting in a national and local public health crisis. According to the Texas Center for Health Statistics, there were 1340 opioid related deaths in 2015.1 In 2005, by comparison, there were 913 opioid related deaths. Syndromic surveillance can be used to monitor overdose trends in near real-time and provide much needed information to public health officials. Texas Syndromic Surveillance (TxS2) is the statewide syndromic surveillance system hosted by the Texas Department of State Health Services (DSHS). To enhance the capabilities of TxS2 and to better understand the opioid epidemic, DSHS is integrating both Texas Poison Center (TPC) data and Emergency Medical Services (EMS) data into the system.Much of the data collected at public health organizations can be several years old by the time it is released for public use. As a result, there have been major efforts to integrate more real-time data sources for a variety of surveillance needs and during emergency response activities.MethodsGuided by the Oregon Public Health Division’s successful integration of poison data into Oregon ESSENCE, DSHS has followed a similar path.2 DSHS already receives TPC data from the Commission on State Emergency Communication (CSEC), hence copying and routing that data into TxS2 requires a Memorandum of Understanding (MOU) with CSEC, which is charged with administering the implementation of the Texas Poison Control Network.EMS records are currently received by the DSHS Office of Injury Prevention (OIP) via file upload and extracted from web services as an XML file. Regional and Local Health Operations, the division where the syndromic surveillance program is located, and OIP, are both sections within DSHS. Therefore, it is not necessary to have a formal MOU in place. Both parties would operate under the rules and regulations that are established for data under the Community Health Improvement Division.CSEC and EMS will push data extracts to a DSHS SFTP folder location for polling by Rhapsody in Amazon Web Services. The message data will be extracted and transformed into the ESSENCE database format. Data are received at least once every 24 hours.ResultsTxS2 will now include TPC and EMS data, giving system users the ability to analyze and overlay real-time data for opioid overdose surveillance in one application. The integration of these data sources in TxS2 can be used for both routine surveillance and for unexpected public health events. This effort has led to discussions on how different sections within DSHS can collaborate by using syndromic surveillance data, and has generated interest in incorporating additional data streams into TxS2 in the future.ConclusionsWhile this venture is still a work in progress, it is anticipated that adding TPC and EMS data to TxS2 will be beneficial in surveilling not just opioid overdoses but other conditions and illnesses, as well as capturing disaster related injuries.

Public Health Surveillance for the Great American Solar Eclipse in Oregon

ObjectiveDevelop a public health surveillance plan for the Oregon Public Health Division (OPHD) in anticipation of the expected influx of visitors for the 2017 Great American Solar Eclipse.IntroductionThe Great American Solar Eclipse of 2017 provided a rare opportunity to view a complete solar eclipse on the American mainland. Much of Oregon was in the path of totality and forecasted to have clear skies. Ahead of the event, OPHD aggregated a list of 107 known gatherings in mostly rural areas across the state, some with estimated attendance of up to 30,000 attendees. Temporary food vendors and a range of sanitation solutions (including open latrines) were planned. International travelers were expected, along with large numbers of visitors traveling by car on the day of the eclipse.The potential for multiple simultaneous mass gatherings across the state prompted OPHD to activate an incident management team (IMT) and to create a Health Intelligence Section to design a mass gathering surveillance strategy. Statewide syndromic surveillance (Oregon ESSENCE) has been used to monitor previous mass gatherings (1) and captures statewide emergency department (ED), urgent care, Oregon Poison Center, and reportable disease data.MethodsThe OPHD Health Intelligence Section identified five categories of public health effects associated with large outdoor gatherings based on literature review (2–5) and an internal risk assessment. These included health system status (total visit or call counts), communicable disease (fever, bloody diarrhea and reportable disease counts), injuries and substance abuse (including motor vehicle accidents), and outdoor exposure (heat-related illness, snake bites and asthma-related visits). An event-related category monitored trends in eclipse-related visits or eye-related injuries (looking directly at the sun). Where possible, syndromic trends were assessed in multiple data sources. These categories were used to create dashboards within Oregon ESSENCE and shared in a guidance document for local health departments and hospitals.Health Intelligence monitored syndromes of interest during a period of enhanced surveillance (9/18-9/22), and met daily with members of the OPHD IMT to share surveillance summaries, which were also sent to OPHD leadership and external partners.ResultsDuring the enhance surveillance period, the OPHD Health Intelligence Section did not identify statewide increases in healthcare utilization (total ED visits and calls to the Oregon Poison Center), but did observe increases in visits at select emergency departments in the state. Visits by out-of-state residents (as determined by patient zip code at time of registration) increased during the surveillance period. Fever-related visits increased as well but were not accompanied by reports of illnesses clusters.Increases were noted for motor vehicle accidents, eye-related injuries, and “eclipse”-related visits. Increases in eye-related injuries appeared to be an annual seasonal trend and not related to the eclipse. There were no increases of note in the other queries monitored. Development of new queries (West Nile Virus) was begun based upon mosquito pool surveillance findings. Surveillance highlights were posted publicly in a special edition of the biweekly Oregon ESSENCE Hazard Report (see Image 1).ConclusionsStatewide public health surveillance during the 2017 Great American Solar Eclipse in Oregon did not identify clusters of infectious disease or other opportunities for real-time public health intervention. Nevertheless, surveillance identified increases in motor vehicle accidents, especially among out-of-state residents, due perhaps to increased road travel for the event. Preparations for this event increased capacity of state health department staff to conduct this type of surveillance in the future. Tools created for the eclipse have been used in several IMT activations since the eclipse.

ED and poison center surveillance for the Great American Solar Eclipse in Oregon

ObjeciveIdentify surveillance priorities for emergency department (ED) and Oregon Poison Center (OPC) data ahead of the 2017 Great American Solar Eclipse gatherings in Oregon and create a suite of queries for use in the Health Intelligence Section of the Oregon Public Health Division (OPHD) Incident Management Team (IMT).IntroductionOregon’s statewide syndromic surveillance system (Oregon ESSENCE) has been operational since 2012. Non-federal emergency department data (and several of their associated urgent care centers) are the primary source for the system, although other data sources have been added, including de-identified call data from OPC in 2016 (1).OPHD epidemiologists have experience monitoring mass gatherings (2) and have a strong relationship with OPC, collaborating on a regular basis for routine and heightened public health surveillance. Nevertheless, surveillance for the Great American Solar Eclipse (August 2017) presented a challenge due to the 107 reported simultaneous statewide eclipse-watching events planned for the day of the eclipse (some with estimated attendance of greater than 30,000 people and most in rural or frontier regions of the state).Scientific literature is limited on mass gathering surveillance in the developed world (3), particularly in rural settings (4), so OPC and OPHD worked together to develop a list of health conditions of interest, including some that would warrant both an ED visit and a call to OPC (e.g., snake bites). Monitoring visits in both data sources in would allow for assessment of total burden on the healthcare system, especially in the case of snake bites where only specific bites require administration of anti-venom.MethodsAhead of the planned mass gatherings, OPHD Health Intelligence and OPC compiled a list of expected risks from the literature (4,5) and input from members of the IMT including the Public Information Officer, who monitored media for stories about health. Priority health conditions presented a clear risk to public health (e.g., limited supply of snake anti-venom warranted surveillance of snake bites) or were the subject of substantial media coverage. Query development focused on risks that had specific, well-defined health effects and that would be captured by syndromic ED and OPC data.During an enhanced surveillance period (8/18-8/24), OPHD Health Intelligence reviewed and interpreted trends in common queries with OPC and disseminated a daily statewide surveillance report.ResultsOPHD and OPC created four new queries for both ED and OPC data streams: snake bites, psychedelic mushrooms, 2nd and 3rd degree body burns and eye-related calls and visits. ED queries used chief complaint, discharge diagnosis, or triage note. OPC queries used generic code, therapy and clinical effect.From 8/18-8/22, OPHD Health Intelligence distributed daily surveillance reports to the OPHD IMT and external partners. An increased in eye-related injuries was identified on the day after the eclipse, prompting OPHD Health Intelligence to consult with OPC. ED surveillance data indicated that the increase in eye-related visits was likely a seasonal trend. OPC staff reviewed the charts of patient calls captured by the query and concluded the calls were not related to retinal issues from looking at the sun. No other trends were noted in the joint OPHD/OPC queries.ConclusionsOPHD Health Intelligence piloted four new queries for surveillance during this mass gathering event and exercised the process for disseminating trend information from OPC and ED data. The eclipse event was fairly quiet and very few trends of note were captured by surveillance. Prior to this event, OPC data had not been a part of the Health Intelligence surveillance plan. However, assessing trends in OPC data provides an opportunity to better understand trends seen in ED data (e.g., whether or not a surge in ED visits for snake bites is accompanied by a surge in OPC calls for anti-venom is meaningful). By building a process to review disparate data in tandem, OPHD and OPC strengthened regional surveillance for this event. Applicable queries will continue to be used for planned event surveillance and several additional queries are currently under development.

Recognizing Recreational Water Exposure and Habituating HAB Surveillance in ESSENCE

Recognizing Recreational Water Exposure and Habituating HAB Surveillance in ESSENCE

Improving Syndromic Data Quality through Implementation of Error Capture Module

Objective: To streamline emergency department data processing in Oregon ESSENCE (Oregon’s statewide syndromic surveillance) by systematically and efficiently addressing data quality issues among submitting hospital systems.Introduction: Oregon Public Health Division (OPHD), in collaboration with The Johns Hopkins University Applied Physics Laboratory, implemented Oregon ESSENCE in 2011. ESSENCE is an automated, electronic syndromic surveillance system that captures emergency department data from hospitals across Oregon. While each hospital system sends HL7 2.5.1-formatted messages, each uses a uniquely configured interface to capture, extract, and send data. Consequently, ESSENCE receives messages that vary greatly in content and structure. Emergency department data are ingested using the Rhapsody Integration Engine 6.2.1 (Orion Health, Auckland, NZ), which standardizes messages before entering ESSENCE. Mechanisms in the ingestion route (error-handling filters) identify messages that do not completely match accepted standards for submission. A sub-set of these previously-identified messages with errors are corrected within the route as they emerge.Existence of errors does not preclude a message’s insertion into ESSENCE. However, the quality and quantity of errors determine the quality of the data that ESSENCE uses. Unchecked, error accumulation also can cause strain to the integration engine. Despite ad-hoc processes to address errors, backlogs accrue. With no meta-data to assess the importance and source of backlogged errors, the ESSENCE team had no guide with which to mitigate errors. The ESSENCE team needed a way to determine which errors could be fixed by updating the Rhapsody Integration Engine and which required consultation with partner health systems and their data vendors. To formally address these issues, the ESSENCE team developed an error-capture module within Rhapsody to identify and quantify all errors identified in syndromic messages and to use as a guide to prioritize fixing new errors.Methods: Members of OPHD’s informatics team and the Oregon ESSENCE team met to brainstorm solutions to error accumulation and message-processing inefficiencies. The team agreed that existing infrastructure and resources were sufficient to accomplish this project. Using Rhapsody, the team created filters that generated error messages each time an HL7 message failed to validate pre-determined message parameters (a standard HL7 2.5.1 syndromic message definition). In order to capture information about errors that were currently being fixed by the ingestion route, two filters were inserted into the processing route: one before and one after previously-existing error-fixing message-modifiers. The team created a FileMaker database to collect information about each error identified, including submitter, location of error (segment, field, component), type of error (too long for field, not in value set, doesn’t adhere to correct message structure). The team enabled error-capture for 81 days (June 16 – September 5, 2017) at which point they evaluated error data so as to guide repair of message modifying filters within the integration engine.Results: The module captured 16,273,963 error messages over 81 days. The two error capture filters (before and after existing modifiers) each generated 50% of the error messages. The module identified errors across seven HL7 message segments (DG1, EVN, OBX, PID, PR1, PV1, PV2). One submitter produced 87% of the error messages. Of those, 93% were errors in two fields in the PID segment. Based on the results, ESSENCE team members contacted this submitter and resolved this error, greatly reducing the ingestion and error assessment burden of Rhapsody and the development team. Currently the ESSENCE team is still analyzing the rest of the errors, applying fixes and contacting submitting facilities as needed. Once completed, the ESSENCE team will enable the error capture module bi-annually to continue refinement of its system strategically guide data quality work.Conclusions: Oregon ESSENCE developed a tool to evaluate errors in emergency department HL7 messages it receives for syndromic surveillance. Its quick development and reusability make it a cost-effective and sustainable data quality solution for focusing effort in regional installations of syndromic surveillance.

Are Older Adults a Burden?

Are Older Adults a Burden?

Streamling Syndromic Surveillance Submission on a Dime: Oregon’s Experience

ObjectiveTo design a low budget process to enroll, track and approvesyndromic submitters for ongoing submission of data to the OregonPublic Health DivisionIntroductionIn 2012, the Oregon Public Health Division (OPHD) tookadvantage of the opportunity created by Meaningful Use, a Centersfor Medicare &amp; Medicaid Services (CMS) Incentive Program, toimplement statewide syndromic surveillance. The Oregon syndromicsurveillance project, or Oregon ESSENCE, began accepting MU-compliant HL7 2.5.1 data in late 2013. Early onboarding effortswere labor-intensive and led to the creation of a testing queue. Asinterest in submitting syndromic data increased, Oregon ESSENCEstreamlined the onboarding process by creating guidance for HL7message construction, message testing and submitter business processdetails (collectively referred to as “onboarding documents”). OregonESSENCE also built a project management database to track MUtesting statuses and data quality variations. With this system, OregonESSENCE collected, tested and approved all 32 eligible healthsystems (56 hospitals) for production-level submission by mid-2015.One health system (with four hospitals) continued to send non-MUcompliant syndromic data for the duration of the project period.MethodsInitially, Oregon ESSENCE began onboarding syndromicsubmitters on a first-come-first-served basis. The lack of a clearprocess for onboarding, a single FTE devoted the endeavor andsubstantial interest in submitting, led to a testing queue. To streamlinethe onboarding process and accommodate the testing timelines of allsubmitters, Oregon ESSENCE created tools to allow for self-pacedtesting followed by short duration, intensive testing with the project.Oregon ESSENCE-branded onboarding documents incorporatedavailable resources such as the CDC’s Public Health InformationNetwork Messaging Guide for Syndromic Surveillance: EmergencyDepartment and Urgent Care Data, Release 1.1 (August 2012) and theNIST 2014 Edition ONC Health IT Certification HL7v2 SyndromicSurveillance Reporting Validation Tool. Submitters began self-pacedtesting by testing their own messages using the NIST tool and sendingsuccessful reports back to Oregon ESSENCE. They then filled outan Oregon ESSENCE Business Process Survey which asked formeta-data and project contact information. Oregon ESSENCE built aproject managment database in FileMaker v14 (FileMaker Inc., SantaClara, CA USA), used to support the statewide communicable diseasedatabase, to store information from the Business Process Survey.After completing self-paced testing, submitters selected a singleweek for intensive testing with Oregon ESSENCE. Each healthsystem’s project staff (registration staff, technical project lead, HL7translator and data exchange lead) met daily with Oregon ESSENCEto test messages. Oregon ESSENCE used Rhapsody IntegrationEngine v6.2.1 (Orion Health, Auckland, NZ), already in use at OPHDfor electronic lab reporting, to parse test data into a test database andthen generated a report for each testing session using SAS v9.4 (SASInstitute Inc., Cary, NC, USA). The report indicated whether or notthe submitter had achieved production-level syndromic messaging bythe end of this week of intensive testing. The project managementdatabase stored notes from each testing session along with MU testingdates.ResultsOregon ESSENCE developed their onboarding documentsbetween November, 2012 and March, 2013 and achieved 100%syndromic submission from eligible health systems in June, 2015.The average duration of onboarding (from initiation of the testingprocess to achieving production submission) of a single healthsystem decreased from 23 months in 2012 to 4 months in 2014 (seeDuration of Onboarding Syndromic Submitters: Oregon 2012-2015).As interest in the project grew (number of submitters contactingOPHD), the amount of time spent onboarding decreased.Oregon ESSENCE uses their project management database forongoing syndromic data quality improvement and to communicateMU dates to submitters (by generating health system-specific emailsdirectly from the database). FileMaker, Rhapsody and SAS are allcurrently used by OPHD and did not require any additional expensefor their use in this testing process. Oregon ESSENCE plans to usethis onboarding process to collect urgent care data for Stage 3 MU.ConclusionsThe onboarding process created by Oregon ESSENCE streamlinedsyndromic data submission without the purchase of additionalprograms or the hiring of additional project staff. Submitting facilitiesbenefited from this process by testing syndromic messages withoutwaiting in a testing queue. The project management database createdfor the testing process will continue to benefit submitters by storingMU testing dates and information for ongoing quality assuranceevaluations. The success of this project took advantage of existinginformatics capabilities at OPHD and speaks to the importance ofthose skills in public health practice. Oregon ESSENCE will usethese methods again in 2017 to collect urgent care data for syndromicsurveillance.Duration of Onboarding Syndromic Submitters: Oregon 2012-2015

Mass Gathering Surveillance: New ESSENCE Report and Collaboration Win Gold in OR

ObjectiveTo streamline production of a daily epidemiology report includingsyndromic surveillance, notifiable disease, and outbreak data duringa mass gatheringIntroductionThe 2016 U.S. Olympic Track and Field Team Trials were heldJuly 1-10 in Eugene, OR. This mass gathering included over 1,000athletes, 1,500 volunteers, and 175,000 spectators. The Oregon PublicHealth Division (PHD) and Lane County Public Health (LCPH)participated in pre-event planning and collaborated to produce adaily epidemiology report for the Incident Management Team (IMT)during the event. The state and county public health agencies hadcollaborated on surveillance for prior mass gatherings, including the2012 Trials. However, 2016 was the first opportunity to use completestate and county syndromic surveillance data.MethodsPHD staff developed an ESSENCE report, highlighting sevenpriority health outcomes: total emergency department visits; injury,gastrointestinal, respiratory, and fever syndromes; and asthma-like and heat-related illness queries. The report included side-by-side comparisons of county and state time series graphs, a tablesummarizing reportable diseases, and space to narratively describeoutbreaks. PHD staff did a virtual demonstration and in-persontutorial for LCPH staff on how to run the report. ESSENCE accesspermissions had to be modified so that county users could see andproduce state time-series graphs but not data details for non-LaneCounty visits. Emphasis was placed on interpretation of likelyscenarios, i.e., one or two days with a warning that was not indicativeof an incident of public health importance.ResultsDuring the event, LCPH staff were able to run the reportsuccessfully, i.e., there were no technical glitches. For the first fewdays, LCPH staff consulted with PHD staff about epidemiologicalinterpretation. State data were of specific interest since data detailswere suppressed. Additionally, increases were seen in the injurysyndrome in the days preceding the July 4 holiday. Stratification bykey demographic factors and looking at subsyndrome breakdownson warning and alert days provided the needed information withoutrequiring the use of the detail details.ConclusionsAfter the event, there were three main recommendations forimproving the process.LCPH suggested that the side-by-side visualization of countyand state time series graphs was useful to see trends but the relativescale of the number of visits was unclear due to size and placement(see figure 1). Solutions for future reports include additionalexplanatory text, limiting the report to only county data, and alternativevisualizations that highlight the differences in visit magnitude.As part of the IMT process, the LCPH lead felt that her efforts tophysically go to the Emergency Operations Center to run the reporthelped facilitate communication with partners. However, it is notclear if this effort directly translated into IMT use of the report, whichwas posted to the online event management system and not includedin the daily situation status reports. While LCPH leadership and staffreported anecdotally that they found the report to be very useful,no formal evaluation of use was done with either public health orIMT staff. In advance of the next event, state and county staff shouldprepare evaluation metrics.The report feature in ESSENCE is a bit cumbersome to set up, butit allows for easy production of appealing and customizable reports.This template can be modified for future mass gatherings, includingathletic competitions and county fairs. PHD staff will continueto collaborate with LCPH to repurpose and improve the report foruse in Lane and other counties. Fostering local user comfort withinterpreting ESSENCE data and generating summaries for local useis a priority of the OR ESSENCE team.

Low Completion and Disparities in Advance Care Planning Activities Among Older Medicare Beneficiaries

Letters Chicago; Ann Thomas, MD, MPH, Oregon Public Health Division, Portland; Teri Moser Woo, PhD, Pacific Lutheran University, Tacoma, Washington; Rachel M. Zetts, The Pew Charitable Trusts, Washington, DC. Conflict of Interest Disclosures: Dr Hersh has received funding from the CDC, the Agency for Healthcare Research and Quality, Pfizer/Joint Commission, and Merck. No other conflicts are reported. Funding/Support: This project was made possible through a partnership with the CDC Foundation. Support for this project was provided by Pew Charitable Trusts. Role of the Funder/Sponsor: The CDC participated in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. The Pew Charitable Trusts participated in the interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. The Pew Charitable Trusts sponsored in-person and telephone author meetings and supported some author travel to in-person meetings. Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the CDC. Additional Contributions: Tia Carter, MS, Allan Coukell, BSc Pharm, and Elizabeth Jungman, JD, MPH, of The Pew Charitable Trusts assisted in convening author meetings. They did not receive any compensation for their role in the study. 1. The White House. National action plan for combating antibiotic resistant bacteria. https://www.whitehouse.gov/sites/default/files/docs/national_action _plan_for_combating_antibotic-resistant_bacteria.pdf. Accessed August 3, 2015. 2. Fleming-Dutra KE, Hersh AL, Shapiro DJ, et al. Prevalence of inappropriate antibiotic prescriptions among US ambulatory care visits, 2010-2011. JAMA. 3. Joint Task Force on Practice Parameters; American Academy of Allergy, Asthma and Immunology; American College of Allergy, Asthma and Immunology; Joint Council of Allergy, Asthma and Immunology. Drug allergy: an updated practice parameter. Ann Allergy Asthma Immunol. 2010;105(4):259-273. 4. Piccirillo JF, Mager DE, Frisse ME, Brophy RH, Goggin A. Impact of first-line vs second-line antibiotics for the treatment of acute uncomplicated sinusitis. JAMA. 5. Capra AM, Lieu TA, Black SB, Shinefield HR, Martin KE, Klein JO. Costs of otitis media in a managed care population. Pediatr Infect Dis J. 2000;19(4): Table 1. Characteristics of Participants Participants, No. (%) a Variable Sociodemographic characteristics Age, y Sex Female Male Race/ethnicity White Black/African American Hispanic/Latino English-speaking Spanish-speaking Other Education High school diploma or less Greater than high school Annual income, b $ Health-related characteristics Self-rated health Excellent or very good Good Fair or poor Dementia c None Possible or probable dementia Low Completion and Disparities in Advance Care Planning Activities Among Older Medicare Beneficiaries Advance care planning (ACP) is an iterative process that in- cludes discussions about preferences for end-of-life (EOL) care, completion of advance directives (AD), and designation of a surrogate decision maker in a durable power of attorney for health care (DPOA). 1,2 Engagement in ACP has increased over time. 3 However, the rising tide of ACP may not have lifted all boats equally. Minorities, those with lower levels of educa- tional attainment, and the poor may not have benefited from rising rates of ACP to the same extent that white, highly edu- cated, affluent individuals have. Rates of ACP by older Lati- nos in particular are unknown. Further, we do not know if ACP uptake is greater among those in worse health and with poorer prognoses. Methods | We used data from the National Health and Aging Trends Study (NHATS), a longitudinal cohort study using a nationally representative sample of community-dwelling Medi- care beneficiaries ages 65 years and older (2011 round 1 re- sponse rate, 71%; 2012 round 2 response rate, 86%). 4 This cross- sectional analysis used a random one-third sample of 2015 d Number of chronic medical conditions None Number of ADLs requiring help e 1 or 2 (continued) participants who responded to a supplemental module on ACP fielded in 2012. This study was considered exempt by the institutional review board of the University of California, San Francisco. Outcome variables included 3 self-reported elements of ACP: (1) discussing with any individual the medical treat- ment desired if seriously ill in the future (EOL discussion), (2) having legal arrangements for a proxy to make decisions about medical care (DPOA), or (3) having written instructions about JAMA Internal Medicine December 2016 Volume 176, Number 12 (Reprinted) jamainternalmedicine.com Copyright 2016 American Medical Association. All rights reserved. Downloaded From: http://jamanetwork.com/pdfaccess.ashx?url=/data/journals/intemed/935892/ by a UCSF LIBRARY User on 06/15/2017

Drug Overdose Deaths: Let's Get Specific.

Oregon Public Health Division, Injury and Violence Prevention Program, Portland, ORAddress correspondence to: Svetla Slavova, PhD, University of Kentucky College of Public Health, Kentucky Injury Prevention and Research Center, 333 Waller Ave., Ste. 242, Lexington, KY 40504; tel. 859-323-7873; fax 859-257-3909; e-mail .©2015 Association of Schools and Programs of Public Health

Norovirus Outbreak Associated With a Natural Lake Used for Recreation—Oregon, 2014

Norovirus Outbreak Associated With a Natural Lake Used for Recreation—Oregon, 2014

Oregon Public Health Division

Oregon Public Health Division

Evidence Supporting the Use of Text Messaging for Partner Services

To the Editor: STD/HIV partner services need to adapt to changes in how people are communicating. More than 70% of US adults now use text messaging or short message service (SMS).1 Earlier this year, Kachur et al. provided examples of how disease intervention specialists (DISs) have used SMS for case management and partner services in New York.2 Here, we summarize our experiences at Multnomah County Health Department (Portland, OR) using SMS for partner services and report quantitative data on its utility. In Fall 2010, local DISs began a project to use SMS immediately after a phone call to cases and before mailing letters and making field visits. The project objectives were to (1) develop local procedures for using SMS for partner services, building on national guidelines3; and (2) implement these procedures for HIV, syphilis, and gonorrhea cases to reduce the need for mailings and field visits. We developed detailed local procedures from the national guidelines. They included explicit instructions that no protected health information be sent via SMS and provided messages to use for each of 3 attempts. For example, the first message is “I am with Multnomah County and I have information regarding an urgent health matter. Please call me at (phone number).” The goal of SMS is for clients to call back, so our procedures indicated that if a case responds with another text, DISs should call the case or send another text asking case to call. The procedures were approved by the local health officer and Health Insurance Portability and Accountability Act (HIPAA) officer. We purchased 2 mobile phones that allow for backing up messages, copying, and pasting messages from a master menu, remotely deleting messages, and password-protecting the phone. Our 5 local DISs are able to share the phones. When a DIS sends SMS, s/he simply needs to keep the phone near them and be available for an hour to answer incoming SMS or calls. Results to date have been promising. During January–September 2011, we sent an SMS to 149 clients immediately after a phone call; 56% of cases responded with a call after receiving the SMS. This response rate was more than 50% for HIV, early syphilis, and gonorrhea. DISs have indicated that cases respond to SMS within 10 to 15 minutes. In contrast, DISs usually wait 3 to 4 days for a response to a letter. Only one case responded that they did not want to be contacted by SMS. We found SMS to be a very useful way for DISs to reach cases, reducing the need for mailing letters and making field visits. Local DISs were initially resistant to use SMS because of discomfort with the phone technology, but this was addressed through one-on-one technical training. Once DISs used SMS several times and successfully reached cases, they became very enthusiastic about the approach. DISs are also using SMS to reach partners, and anecdotally, that is going well, but we do not yet have quantitative data to report. We recommend other STD prevention programs to use SMS for partner services. Juan Mendez, MA STD/HIV/Hep C Program Multnomah County Health Department Portland, Oregon Julie Maher, PhD Program Design and Evaluation Services Multnomah County Health Department and Oregon Public Health Division Portland, Oregon

Probe of Norovirus Outbreaks Yields LTC Clues

Probe of Norovirus Outbreaks Yields LTC Clues

Pyrethrin and Pyrethroid Illnesses in the Pacific Northwest: A Five-Year Review

Pyrethrin and pyrethroid insecticides are commonly applied in homes and businesses and on some agricultural crops. This research used a two-state regional approach to analyze reports of acute pesticide poisonings due to pyrethrin and pyrethroid insecticides. The Washington State Department of Health and the Oregon Public Health Division collected pesticide poisoning surveillance data from 2001 through 2005. Cases were included if they involved exposure to at least one pyrethrin or pyrethroid insecticide. Descriptive statistics were calculated; differences between categories were assessed using Chi-square analysis. A total of 407 cases fit our definition. Overall, the rate of poisoning in Oregon was significantly higher than in Washington (incidence rate ratio 1.70, 95% confidence interval 1.40, 2.07), and rates for both states generally increased during the time period. For both states, most exposures resulted in low severity illnesses (92%), and most were classified as possible cases (73%). Only about one-fourth of cases were related to a person's work. The most common category of clinical signs and symptoms of illness was respiratory (52% of cases), followed by neurological (40% of cases). Exposure route was predominantly inhalation; there was no association between route and case severity. There was a significant association between illness severity and losing time from work or regular activities (p<0.0001). Although the majority of pyrethrin and pyrethroid poisoning cases were low in severity, adverse reactions have occurred, as transpired in Oregon in 2005. Regional analysis has the potential to improve the surveillance system and provide unique opportunities for targeting preventive interventions.

Der Wunsch nach einem Tod in Würde. Eine Annäherung an den ärztlich assistierten Suizid

"Sentenced to life". In German newspaper and journal articles as well as on television a controversial debate has emerged about the right-to-die. In history and many Western countries people have always been discussing assisted suicide. Under Oregon's Death with Dignity Act, terminally ill adult Oregonians are allowed to obtain and use prescriptions from their physicians for self-administered, lethal medications. The Oregon Public Health Division is required by the Act to collect information on compliance and to issue an annual report. This has been made public. According to these data, there was no slippery slope. In addition, no philosophical arguments can be put forward for the absolute prohibition against suicide of the terminally ill. This should give impetus to efforts to find solutions for the patients in all Western countries.