Public Health Division Research Articles

Regional public health preparedness teams in North Carolina: An analysis of their structural capacity and impact on services provided

In December 2001, the North Carolina Division of Public Health established Public Health Regional Surveillance Teams (PHRSTs) to build local public health capacity to prevent, prepare for, respond to, and recover from public health incidents and events. Seven PHRSTs are colocated at local health departments (LHDs) around the state. The authors assessed structural capacity of the PHRSTs and analyzed the relationship between structural capacity and the frequency of support and services provided to LHDs by PHRSTs. Five categories of structural capacity were measured: human, fiscal, informational, physical, and organizational resources. In addition, variation in structural capacity among teams was also examined. The most variation was seen in human resources. Although each team was originally designed to include a physician/epidemiologist, industrial hygienist, nurse/epidemiologist, and administrative support technician, team composition varied such that only the administrative support technician is common to all teams. Variation in team composition was associated with differences in the support and services that PHRSTs provide to LHDs. Teams that reported having a medical doctor or a doctor of osteopathic medicine (chi2 = 9.95; p < 0.01) or an epidemiologist (chi2 = 5.35; p < 0.02) had larger budgets and provided more support and services, and teams that housed a pharmacist reported more partners (chi2 = 52.34; p < 0.01). Teams that received directives from more groups (such as LHDs) also provided more support and services in planning (Z = 21.71; p < 0.01), communication and liaison (Z = 12.11; p < 0.01), epidemiology and surveillance (Z = 5.09; p < 0.01), consultation and technical support (Z = 2.25; p = 0.02), H1N1 outbreak assistance (Z = 10.25; p < 0.01), and public health event response (Z = 2.19; p = 0.03). In the last 10 years, significant variation in structural capacity, particularly in human resources, has been introduced among PHRSTs. These differences explain much of the variation in support and services provided to LHDs by PHRSTs.

Lessons of Pandemic Influenza From Sub-Saharan Africa

School of Public Health and Epidemiology University of Nottingham, Nottingham, United Kingdom Correspondence: School of Public Health and Epidemiology, Room A40d Division of Epidemiology and Public Health, Clinical Sciences Building, City Hospital, Nottingham, NG5 1PB, UK ([email protected]).

Interview With Dr. Lee Riley

I nterview with L ee R iley Mike Moses, Alex Gagnon, Jennifer Cherone, John Domingo, Felicia Linn, Hannes Prescher, Pryanka Murali Dr. Lee Riley, M.D., is a UC Berkeley professor of Epidemiology and Infectious Diseases. Dr. Riley earned his B.A. in philosophy at Stanford University, and completed medical school at the University of California, San Francisco. After medical school he obtained an internship and residency at Columbia Presbyterian Medical Center in internal medicine. Riley then joined the Epidemic Intelligence Service of the Enteric Diseases Branch of the Centers for Disease Control and Prevention (CDC), where he spent three years. He also served as Laboratory Project Manager with the India Biomedical Support Project, organized by the World Health Organization, after which he joined the Cornell University Medical College as a professor of medicine in 1990. He became a tenured professor of medicine in 1994, and in 1996 came to the University of California, Berkeley to be professor of epidemiology and infectious disease. He also serves as Chair of the UC Berkeley School of Public Health Division of Infectious Diseases and Vaccinology. Berkeley Scientific Journal had the opportunity to meet with Dr. Lee Riley and talk about his work in Brazil and India. at some possible projects we could do. Cornell has been involved in Brazil for about 45 years now, so I joined the faculty as an assistant professor and they wanted me to do a project there as well, so I started on a diarrheal disease project, focusing on kids with diarrhea. It turns out most of the kids with severe diarrhea were kids from slums, and of course I sort of knew that already but didn’t pay much attention. We were interested in looking at different kinds of infectious agents that cause diarrhea. As we were doing the project, nobody seemed to really care about what happens to kids because for one, kids don’t really contribute economically to these communities, so it was kind of frustrating even though it was intellectually satisfying. So we started working on another disease, called leptospirosis. Leptospirosis is a type of bacterial infection that is transmitted by rat urine, and we were seeing all of these severe cases of leptospirosis. The clinical manifestation of leptospirosis is initial flu- like symptoms, followed by liver failure, and kidney failure. And the people die because of kidney failure, the kidneys just shut down. About 15% of them die, so it’s a pretty bad disease, and what was interesting was it predominantly affected young adult males. This is something that the government really paid attention to. BSJ: Because they are the most productive members of the economy. Riley: Exactly. Young adult males are the main income earners, and they are the ones that contribute to the economy. And it turns out that more than 95% of these cases came from the slums. This was all done in Salvador, Brazil. Salvador is the third largest city in Brazil. So the first study we did was to look at risk factors for death; why some people die from this disease and others don’t. When we reported our finding in The Lancet, the government really paid attention. It’s a major international journal, and I think the Brazilian government was embarrassed that they had this problem. Brazil is one of the richest countries in the world, economically it’s a very rich country, and yet they had this disease in their backyard, something you see in some of the poorest countries of the world. So they were embarrassed, but instead of kicking us out they became interested and asked us to set up similar surveillance in other cities, and the local government actually came into the city we were working in to try to implement some sanitation measures and other things. BSJ: So they really cared. Riley: Yes, they really cared, so we were lucky. And the B S J Dr. Lee Riley, M.D. teaches Epidemiology and Infectious Diseases at UC Berkeley. BSJ: Can you begin by telling us how you became interested in slum settlements and diseases in slums? Riley: Sure. I’ve been working abroad for many years, since the early 90’s when I was a faculty member at Cornell. When I joined the faculty at Cornell, at the school of medicine, I was then sent on to Brazil to look 28 • B erkeley S cientific J ournal • I nfectious D isease • F all 2010 • V olume 14 • I ssue 1

The microbubble or the microparticle?

decompression sickness (DCS) has long been attributed to physical forces exerted by inert gas bubbles that may form in tissues, resulting in vascular occlusion and tissue disruption. Bubble formation occurs when a decrease in ambient pressure exceeds the rate at which soluble inert gas (e.g.,

State Calculations of Cultural Survival in Environmental Risk Assessment: Consequences for Alaska Natives

In 2007, the Alaska Division of Public Health issued their first-ever fish consumption advisory to reduce exposure to methylmercury. Interestingly, they utilized a toxicity level in their calculations of risk that is four times higher than the U.S. Environmental Protection Agency's (EPA) level, arguing that the EPA's calculation is "inappropriately restrictive" for Alaskans. This article explores the institutional reasoning and scientific calculations behind the state's fish consumption advice, with special attention paid to the consequences for Alaska Natives. I argue that a discourse of "Alaskan exceptionalism" is utilized by the health department to justify their assessment of risk. Although this exceptionalist discourse is intended to accommodate the unique lifestyles of Alaskan citizens, it may actually serve to undermine the very lifeways and traditions that it presumes to preserve. This article contributes insights into the ways that states can influence the social and material reproduction of communities through the deployment of "cultural difference" during the risk-assessment process.

An Academic/Government Partnership to Provide Technical Assistance with Pandemic Influenza Planning to Local Health Departments in North Carolina

In 2006, the North Carolina Division of Public Health (NC DPH) required all 85 local health departments (LHDs) in North Carolina to develop a pandemic influenza plan. Because few LHDs had experience in developing such plans, NC DPH engaged in a unique partnership with an academic center, the North Carolina Center for Public Health Preparedness (NCCPHP), to provide technical assistance to local planners. This article describes the technical assistance program implemented by NCCPHP, the use of technical assistance by local planners, subsequent completeness of local pandemic influenza plans, and lessons learned throughout the program. We discuss selected topic areas (surveillance, vaccine/antiviral, and vulnerable populations) observed within local pandemic influenza plans to highlight the variability in planning approaches and identify potential opportunities for state and local standardization.

Evaluation of Routinely Collected Veterinary and Human Health Data for Surveillance of Human Tick-Borne Diseases in North Carolina

Tick-borne diseases are an important cause of human morbidity in North Carolina. This study evaluated the use of routinely collected veterinary hospital and human hospital emergency department (ED) data for earlier signal detection compared with routine reporting of tick-borne diseases to the North Carolina Division of Public Health in 2006 and 2007. The Early Aberration Reporting System was used to detect the earliest indication of an increase in number of dogs infested with ticks that were brought to veterinary hospitals and in number of people presenting to EDs with a tick-related chief complaint or who had an ED International Classification of Diseases diagnosis code of tick-borne disease. Results indicate that systematic monitoring of veterinary hospital and human ED data can detect increases in tick activity 4 weeks earlier than the current surveillance method, which would facilitate timely initiation of tick prevention and increased clinical awareness among veterinarians and physicians.

Working with Local, State and Federal Partners to Address Health Education Needs of Hurricane Katrina evacuees in Houston

For health educators to successfully meet the challenges of responding to public health emergencies, it is important to establish and understand the role of collaborations with local, state and federal partners in identifying potential public health issues and to develop theory-based models or strategies to address these issues before, during and after an event. This paper presents a case study examining the health education and communication response to Hurricane Katrina in Houston, Texas. CDC's Health Education and Communication Teams and the Harris County Public Health and Environmental Services Division of Health Education worked with identified populations, environmental specialists, epidemiologists and other key partners to identify health education needs and develop appropriate messages and then developed and implemented a broad comprehensive health education and promotion plan. The paper discusses lessons learned and how health educators can use the model developed for this response to plan for future disasters and public health emergencies, including pandemic influenza.

Patient experience.

The Division of Public Health and Primary Health Care, at the University of Oxford, runs an award-winning website, at www.healthtalkonline.org , concerning people's experiences of health and illness.

More health for your buck: health sector functions to secure environmental health

a Department of Medical Informatics, Biometry and Epidemiology, University of Munich, Marchioninistrasse 15, 81377, Munich, Germany.b Division of Public Health, University of Liverpool, Whelan Building Quadrangle, Liverpool, L69 3GB, England.c Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, United States of America.Correspondence to: Eva A Rehfuess (e-mail: rehfuess@ibe.med.uni-muenchen.de).(

Probe of Norovirus Outbreaks Yields LTC Clues

Probe of Norovirus Outbreaks Yields LTC Clues

Sidebar: Highlights from the North Carolina Preconception Health Strategic Plan

In June 2006 the North Carolina Folic Acid Council, the North Carolina Chapter of the March of Dimes, and the UNC Center for Maternal and Infant Health created an inventory of preconception health activities in North Carolina. The resulting booklet, Looking Back Moving Forward: North Carolina’s Path to Healthier Mothers and Babies,was developed in response to a recommendation from the US Centers for Disease Control and Prevention (CDC) and included action steps for the state. The booklet was officially released on March 14, 2007 by a leadership team that included the North Carolina Chapter of the March of Dimes, the North Carolina Folic Acid Campaign, the University of North Carolina Center for Maternal and Infant Health, and the North Carolina Division of Public Health.

Eat Smart, Move More, Weigh Less: A Community-Based Weight Management Program for Adults

Describes development of a comprehensive low cost weight management program to be delivered by local public health educators or cooperative extension agents. The program was developed by a unique partnerships of the NC Cooperative Extension Serive the NC Division of Public Health and the Brody School of Medicine at East Carolina University.

Quality and Safety Education

Since 1988, Case Western Reserve University (CWRU), through its School of Medicine, Frances Payne Bolton School of Nursing, and Division of Public Health, has committed to the development and implementation of quality improvement and safety education as a formal part of its health professions curriculum. Faculty moved quality and safety education from the "background" of implicit learning to the "foreground" of established curriculum. The transformation has affected not only course content but also many academic careers in the process. This article highlights 3 of the many quality and safety education activities that have evolved at the CWRU: the graduate-level course on quality improvement, medical student education, and doctoral education. Based on these activities, 4 key elements are presented as essential for a successful and sustainable quality and safety education program: quality improvement role models and champions, strong academic-practice partnerships, a variety of educational modalities, and a supportive learning environment.

Infant Bed-Sharing Practices and Associated Risk Factors among Births and Infant Deaths in Alaska

The Alaska Division of Public Health has stated that infants may safely share a bed for sleeping if this occurs with a nonsmoking, unimpaired caregiver on a standard, adult, non-water mattress. Because this policy is contrary to recent national recommendations that discourage any bed sharing, we examined 13 years of Alaskan infant deaths that occurred while bed sharing to assess the contribution of known risk factors. We examined vital records, medical records, autopsy reports, and first responder reports for 93% of Alaskan infant deaths that occurred between 1992 and 2004. We examined deaths while bed sharing for risk factors including sleeping with a non-caregiver, prone position, maternal tobacco use, impairment of a bed-sharing partner, and an unsafe sleep surface. We used Pregnancy Risk Assessment Monitoring System data to describe bed-sharing practices among all live births in Alaska during 1996-2003. Thirteen percent (n=126) of deaths occurred while bed sharing; 99% of these had at least one associated risk factor, including maternal tobacco use (75%) and sleeping with an impaired person (43%). Frequent bed sharing was reported for 38% of Alaskan infants. Among these, 60% of mothers reported no risk factors; the remaining 40% reported substance use, smoking, high levels of alcohol use, or most often placing their infant prone for sleeping. Almost all bed-sharing deaths occurred in association with other risk factors despite the finding that most women reporting frequent bed sharing had no risk factors; this suggests that bed sharing alone does not increase the risk of infant death.

Spotlighting William Alexander Darity, Sr., PhD

Spotlighting William Alexander Darity, Sr., PhD Claudia Baquet, MD, MPH (bio) Dr. William Alexander Darity, Sr. is Professor Emeritus and Dean Emeritus of Public Health at the University of Massachusetts–Amherst School of Public Health. A native of North Carolina, Dr. Darity has been a leader and pioneer in the fields of international health, operations research, and minority health and has advanced the fields of public health and advocacy as well as tobacco control. Dr. Darity was born January 15, 1924 in Flat Rock, North Carolina, a small town in the Blue Ridge Mountains. Dr. Darity completed his formal studies in North Carolina, receiving a Bachelor of Science degree from Shaw University and a Master of Science in Public Health (MSPH) degree from North Carolina Central University. He became the first African American to receive a Doctor of Philosophy (PhD) degree from the University of North Carolina at Chapel Hill in 1964. Dr. Darity accepted an Associate Professor appointment at the University of Massachusetts– Amherst in 1963. At that time, the small Department of Public Health, which offered a Bachelor of Science degree and a Master of Science degree with a concentration in Environmental Health, had three full-time faculty members. He was appointed head of the department in 1968 and then Dean in the School of Health Sciences in September 1973. In addition to the Division of Public Health (an accredited School of Public Health) and a Division of Nursing (an accredited School of Nursing), this newly created School of Health Sciences included a Department of Communications Disorders, which offered majors and graduate study in audiology and speech and language disorders. At his urging upon his retirement, the Division of Public Health became a School of Public Health with its own dean, and the Division of Nursing became a School of Nursing with its own dean. Under Dr. Darity’s aegis, the Division of Public Health was expanded widely to offer a Master of Science degree with concentrations in Biostatistics, Epidemiology, Community Health Education, Environmental Health and Health Administration. In addition, a PhD program, which offered concentrations in the above areas, was also developed under his leadership. In addition, a Master of Public Health (MPH) degree was developed to meet the needs of working professionals who sought further their education to better prepare them for professional practice. A Master of Science in Public Health Nutrition, offered jointly by the Division of Public Health and the Department of Food and Science Nutrition, was also developed during Dr. Darity’s tenure. This pioneer’s last major responsibility at the University of Massachusetts was Principal Investigator of a $3.4 million, five-year research study on Smoking and Cancer [End Page 3] in Black populations, funded by the National Cancer Institute. This landmark study examined middle-income and low-income Blacks and factors influencing smoking adoption and associated health risks. Dr. Darity’s leadership at the University of Massachusetts Division of Public Health as an accredited school continued for 16 years until 1989. Dr Darity was named a Distinguished Alumnus by the University of North Carolina in Chapel Hill in October 1996 and received the Alumni Achievement Award from Shaw University in 1997. (He had previously received an Honorary Doctor of Science Degree from Shaw University in 1990.) Immediately prior to his appointment at the University of Massachusetts, Dr. Darity served as Director of Program Development for the North Carolina Fund, Inc. (a statewide, privately funded, non-profit, anti-poverty organization). His extensive international experience included 10 years with the World Health Organization (WHO), a specialized agency of the United Nations. His tenure with WHO included teaching at the American University of Beirut School of Public Health in Lebanon and the University of Alexandria Higher Institute of Public Health in Egypt. Dr. Darity also served as a Health Consultant with the United Nations Relief and Works Agency for Palestinian Arab Refugees and as a WHO Regional Advisor for 17 countries in the Eastern Mediterranean Region, which included 11 Arab countries, as well as Israel, Cyprus, Iran, Ethiopia, Somalia, and Pakistan and West Pakistan (now Bangladesh). Dr. Darity also played a major role as a consultant with WHO in establishing the first Master...

Multistate Outbreak ofEscherichia coliO157:H7 Infection Associated with Consumption of Packaged Spinach, August–September 2006: The Wisconsin Investigation

Escherichia coli O157:H7 infection often causes hemorrhagic colitis and hemolytic uremic syndrome. In 2006, the Wisconsin Division of Public Health and the Wisconsin State Laboratory of Hygiene, in cooperation with other local, state, and federal partners, investigated an outbreak of E. coli O157:H7 infection. In September 2006, the Wisconsin Division of Public Health and the Wisconsin State Laboratory of Hygiene were able to link geographically dispersed E. coli O157:H7 isolates recovered from the stool samples of ill persons, all of which had the same pulsed-field gel electrophoresis pattern (i.e., outbreak pattern). Investigators conducted a case-control study with control subjects (n = 86) matched to case patients (n = 49) by age, sex, and residential location. All case patients' onsets of illness occurred during the period from 20 August through 14 September 2006. Illness was associated with spinach consumption (matched odds ratio, 82.1; 95% confidence interval, 14.7 to >1000). Of the 49 case patients, 26 (53%) recalled eating brand A spinach. On multibrand analysis, only brand A was associated with illness (undefined matched odds ratio; 95% confidence interval, 6.8-infinity). Wisconsin's agriculture laboratory isolated E. coli O157:H7 with the outbreak pattern from spinach in 2 brand A packages, both produced on 15 August 2006. The rapid multijurisdictional epidemiologic and laboratory response, including timely pulsed-field gel electrophoresis pattern analysis and PulseNet posting, facilitated prompt voluntary recall of brand A spinach.

Piloting a State Health Department Accreditation Model

Accreditation of state and local public health agencies is a major national priority. North Carolina, a national leader in the accreditation of local public health agencies, undertook a pilot project to evaluate a process for accreditation of the state health agency, the North Carolina divisions of public and environmental health. This pilot project evaluated the instrument and process of a state public health agency accreditation effort and provided information on agency performance. The pilot project used a modified national public health performance standards state instrument to assess state health agency capacity and performance. A site visit followed a self-assessment process conducted internally within the state health department. The pilot project revealed that public health performance standards are a useful framework for state-level standards, but that measurement should focus on stem questions to ensure measurement at an appropriate, not overly detailed, level and reduce the level of work needed to complete the self-assessment process. The project also identified major strengths within the North Carolina Division of Public Health and laid the foundation for ongoing performance improvement under the leadership of the state health director and senior staff. As a result of this experience, accreditation of state health agencies is feasible and provides immediate benefit to state health agency leadership with respect to performance and quality improvement.

Ethical Decision Making in a Crisis

Public health emergencies, such as hurricanes and the constant threat of an influenza pandemic, present public health responders with many ethical issues and little time to think them through. We interviewed 13 responders in the Epidemiology Section of the North Carolina Division of Public Health to learn how they have identified and addressed ethical issues in public health emergencies affecting the state and to identify potential means of improving those processes for North Carolina and other states. The Epidemiology Section staff demonstrated an awareness of several ethical issues in public health emergencies and an ability to identify and address issues through group interactions. However, few study participants in the section had received any training in public health ethics. Perhaps for this reason, the range of ethical issues they identified excluded several mentioned in the Public Health Code of Ethics. Moreover, their ethical decision making could be enhanced by a more detailed understanding of the ethical issues they named. We recommend seven practical steps that the Epidemiology Section can take to improve their ability to identify and address ethical issues in a public health emergency. The recommendations are likely relevant to many state, city, and county public health departments throughout the United States.

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.