Public Health-Seattle & King County Research Articles

Lessons Learned From Applying a Monitoring and Evaluation Framework to Economic, Social, and Other Health Impacts of the COVID-19 Pandemic.

Individual and community-level COVID-19 mitigation policies can have effects beyond direct COVID-19 health outcomes, including social, behavioral, and economic outcomes. These social, behavioral, and economic outcomes can extend beyond the pandemic period and have disparate effects on populations. Public Health-Seattle & King County (PHSKC) built on the Centers for Disease Control and Prevention's community mitigation strategy framework to create a local project tracking near-real-time data to understand factors affected by mitigation approaches, inform decision-making, and monitor and evaluate community-level disparities during the pandemic. This case study describes the framework and lessons learned from PHSKC's collation, use, and dissemination of local data from 20 data sources to guide community and public health decision-making. Social, behavioral, economic, and health indicators were regularly updated and disseminated through interactive dashboards and products that examined data in the context of applicable policies. Data disaggregated by demographic characteristics and geography highlighted inequities, but not all datasets contained the same details; local surveys or qualitative data were used to fill gaps. Project outcomes included informing city and county emergency response planning related to implementation of financial and food assistance programs. Key lessons learned included the need to (1) build on existing processes and use automated processes and (2) partner with other sectors to use nontraditional public health data for active dissemination and data disaggregation and for real-time data contextualized by policy changes. This project provided programs and communities with timely, reliable data to understand where to invest recovery funding. A similar framework could position other health departments to examine social and economic effects during future public health emergencies.

Addressing hygiene needs of housing insecure populations: A qualitative analysis of Seattle and King County's mobile hygiene station intervention

ObjectiveTo evaluate the Seattle Public Utility mobile hygiene station program, a program deployed using public funds in response to the large-scale closures of public hygiene facilities due to COVID-19. Study designWe conduct a qualitative analysis using semi-structured interviews. MethodsWe interviewed four Seattle Public Utility (SPU) and Public Health Seattle & King County (PHSKC) employees involved in the design, deployment, and management of the hygiene station intervention. Data were also collected from communications and reports released through SPU/PHSKC web sources. ResultsOur analysis revealed factors affecting the implementation of the hygiene program included the rental of hygiene trailers, community partnership to mediate between housed and housing insecure populations, funding source and cost-effectiveness, geographic location of the units, and maintenance of the units to continue population hygiene support. ConclusionThe SPU/PHSKC hygiene station was designed to support the housing insecure and homeless by compensating for the large-scale closures of public restrooms and showers. Several logistical and financing challenges need to be addressed to ensure the continuity of the program.

A Multifaceted Evaluation of a COVID-19 Contact Tracing Program in King County, Washington.

Context:Despite the massive scale of COVID-19 case investigation and contact tracing (CI/CT) programs operating worldwide, the evidence supporting the intervention's public health impact is limited.Objective:To evaluate the Public Health—Seattle & King County (PHSKC) CI/CT program, including its reach, timeliness, effect on isolation and quarantine (I&Q) adherence, and potential to mitigate pandemic-related hardships.Design:This program evaluation used descriptive statistics to analyze surveillance records, case and contact interviews, referral records, and survey data provided by a sample of cases who had recently ended isolation.Setting:The PHSKC is one of the largest governmental local health departments in the United States. It serves more than 2.2 million people who reside in Seattle and 38 other municipalities.Participants:King County residents who were diagnosed with COVID-19 between July 2020 and June 2021.Intervention:The PHSKC integrated COVID-19 CI/CT with prevention education and service provision.Results:The PHSKC CI/CT team interviewed 42 900 cases (82% of cases eligible for CI/CT), a mean of 6.1 days after symptom onset and 3.4 days after SARS-CoV-2 testing. Cases disclosed the names and addresses of 10 817 unique worksites (mean = 0.8/interview) and 11 432 other recently visited locations (mean = 0.5/interview) and provided contact information for 62 987 household members (mean = 2.7/interview) and 14 398 nonhousehold contacts (mean = 0.3/interview). The CI/CT team helped arrange COVID-19 testing for 5650 contacts, facilitated grocery delivery for 7253 households, and referred 9127 households for financial assistance. End of I&Q Survey participants (n = 304, 54% of sampled) reported self-notifying an average of 4 nonhousehold contacts and 69% agreed that the information and referrals provided by the CI/CT team helped them stay in isolation.Conclusions:In the 12-month evaluation period, CI/CT reached 42 611 households and identified thousands of exposure venues. The timing of CI/CT relative to infectiousness and difficulty eliciting nonhousehold contacts may have attenuated the intervention's effect. Through promotion of I&Q guidance and services, CI/CT can help mitigate pandemic-related hardships.

COVID-19 Surveillance and Investigations in Workplaces - Seattle & King County, Washington, June 15-November 15, 2020.

Workplace activities involving close contact with coworkers and customers can lead to transmission of SARS-CoV-2, the virus that causes COVID-19 (1,2). Information on the approach to and effectiveness of COVID-19 workplace investigations is limited. In May 2020, Public Health - Seattle & King County (PHSKC), King County, Washington established a COVID-19 workplace surveillance and response system to enhance COVID-19 contact tracing and identify outbreaks in workplaces. During June 15-November 15, 2020, a total of 2,881 workplaces in King County reported at least one case of COVID-19. Among 1,305 (45.3%) investigated workplaces,* 524 (40.3%) met the definition of a workplace outbreak.† Among 306 (58.4%) workplaces with complete data,§ an average of 4.4 employee COVID-19 cases¶ (median=three; range=1-65) were identified per outbreak, with an average attack rate among employees of 17.5%. PHSKC and the Washington State Department of Health optimized resources by establishing a classification scheme to prioritize workplace investigations as high, medium, or low priority based on workplace features observed to be associated with increased COVID-19 spread and workforce features associated with severe disease outcomes. High-priority investigations were significantly more likely than medium- and low-priority investigations to have two or more cases among employees (p<0.001), two or more cases not previously linked to the workplace (p<0.001), or two or more exposed workplace contacts not previously identified during case interviews (p = 0.002). Prioritization of workplace investigations allowed for the allocation of limited resources to effectively conduct workplace investigations to limit the potential workplace spread of COVID-19. Workplace investigations can also serve as an opportunity to provide guidance on preventing workplace exposures to SARS-CoV-2, facilitate access to vaccines, and strengthen collaborations between public health and businesses.

A Time-Based Objective Measure of Exposure to the Food Environment.

Exposure to food environments has mainly been limited to counting food outlets near participants’ homes. This study considers food environment exposures in time and space using global positioning systems (GPS) records and fast food restaurants (FFRs) as the environment of interest. Data came from 412 participants (median participant age of 45) in the Seattle Obesity Study II who completed a survey, wore GPS receivers, and filled out travel logs for seven days. FFR locations were obtained from Public Health Seattle King County and geocoded. Exposure was conceptualized as contact between stressors (FFRs) and receptors (participants’ mobility records from GPS data) using four proximities: 21 m, 100 m, 500 m, and ½ mile. Measures included count of proximal FFRs, time duration in proximity to ≥1 FFR, and time duration in proximity to FFRs weighted by FFR counts. Self-reported exposures (FFR visits) were excluded from these measures. Logistic regressions tested associations between one or more reported FFR visits and the three exposure measures at the four proximities. Time spent in proximity to an FFR was associated with significantly higher odds of FFR visits at all proximities. Weighted duration also showed positive associations with FFR visits at 21-m and 100-m proximities. FFR counts were not associated with FFR visits. Duration of exposure helps measure the relationship between the food environment, mobility patterns, and health behaviors. The stronger associations between exposure and outcome found at closer proximities (<100 m) need further research.

A Web Application to Facilitate Syphilis Reactor Grid Evaluations.

Many health departments use a "reactor grid" to determine which laboratory-reported syphilis serologic test results require investigation. We developed a Web-based tool, the Syphilis Reactor Grid Evaluator (SRGE), to facilitate health department reactor grid evaluations and test the tool using data from Seattle & King County, Washington. We developed SRGE using the R Shiny Web application framework. When populated with a data set including titer results and final disposition codes, SRGE displays the percent of verified early syphilis cases by serologic titer result and patient age in each cell of the grid. The results can be optionally stratified by sex, test type, and previous rapid plasma reagin titer. The impact of closing laboratory results without investigation in cells selected by the user is dynamically computed. The SRGE calculates the percent of all laboratory reports closed ("efficiency gained"), the proportion of all early syphilis cases closed without investigation ("case finding loss"), and the ratio of percent of cases identified for investigation to percent of all laboratory reports investigated ("efficiency ratio"). After defining algorithms, users can compare them side-by-side, combine subgroup-specific algorithms, and export results. We used SRGE to compare the current Public Health-Seattle & King County (PHSKC) reactor grid to 5 alternate algorithms. Of 13,504 rapid plasma reagin results reported to PHSKC from January 1, 2006, to December 31, 2015, 1565 were linked to verified early syphilis cases. Updating PHSKC's current reactor grid could result in an efficiency gain of 4.8% to 25.2% (653-3403 laboratory reports) and case finding loss of 1% to 8.4% (10-99 fewer cases investigated). The Syphilis Reactor Grid Evaluator can be used to rapidly evaluate alternative approaches to optimizing the reactor grid. Changing the reactor grid in King County to close more laboratory results without investigation could improve efficiency with minimal impact on syphilis case finding.

Increases in Neisseria gonorrhoeae With Reduced Susceptibility to Azithromycin Among Men Who Have Sex With Men in Seattle, King County, Washington, 2012-2016.

Antimicrobial-resistant Neisseria gonorrhoeae is a major public health threat. The Centers for Disease Control and Prevention (CDC) recommends ceftriaxone 250 mg plus azithromycin (AZM) 1 g for gonorrhea treatment. Resistance to AZM could affect gonorrhea control efforts. Using gonococcal isolates collected at the Public Health-Seattle & King County (PHSKC) Sexually Transmitted Disease (STD) Clinic from 2012 to 2016, focusing on 2014-2016, we compared cases with the CDC AZM alert value minimum inhibitory concentration (MIC) (≥2 µg/mL) to those with AZM MIC ≤1 µg/mL, antimicrobial susceptibility profiles and clinical outcomes. In 2012 and 2013, none of the 263 patients from whom we isolated N. gonorrhoeae from the urethra were infected with organisms with an AZM MIC ≥2 µg/mL. Between 2014 and 2016, 4.4% of 926 gonorrhea cases demonstrated reduced susceptibility to AZM; 93% of these cases occurred among men who have sex with men (MSM). Among MSM, 5.0% of 2014-2016 cases demonstrated reduced susceptibility to AZM. No AZM alert value isolates had concomitant cephalosporin resistance. There were 2 potential treatment failures: 1 pharyngeal infection treated with AZM 2 g alone, and 1 pharyngeal infection that persisted after study drug. Among MSM with gonorrhea in Seattle, 5% have gonorrhea with reduced susceptibility to AZM. The World Health Organization recommends changing treatment guidelines when >5% of isolates are resistant to a recommended drug. The emergence of resistant AZM gonorrhea should prompt reconsideration of current treatment recommendations, and highlights the need for new therapies for gonorrhea.

Notes from the Field: Outbreak of Multidrug-Resistant Salmonella Infections Linked to Pork--Washington, 2015.

During June-July 2015, Public Health-Seattle & King County (PHSKC) and Washington State Department of Health (WADOH) investigated 22 clusters of Salmonella serotype I 4,[5], 12:i:- infections. Serotype I 4,[5], 12:i:- is the fifth most frequently reported Salmonella serotype in the United States, but is uncommon in Washington. On July 29, 2015, WADOH and PHSKC requested assistance from CDC to identify the infection source, determine risk factors, and make recommendations for prevention.

The University of Washington's Community-Oriented Public Health Practice Program and Public Health–Seattle &amp; King County Partnership

The Community-Oriented Public Health Practice (COPHP) program, a 2-year in-residence MPH degree program in the University of Washington School of Public Health, has partnered with Public Health-Seattle & King County (PHSKC) since 2002 to create a mutually beneficial set of programs to improve teaching and address community-based public health problems in a practice setting. The COPHP program uses a problem-based learning approach that puts students in small groups to work on public health problems. Both University of Washington-based and PHSKC-based faculty facilitate the classroom work. In the first year for students, COPHP, in concert with PHSKC, places students in practicum assignments at PHSKC; in the second year, students undertake a master's project (capstone) in a community or public health agency. The capstone project entails taking on a problem in a community-based agency to improve either the health of a population or the capacity of the agency to improve population health. Both the practicum and the capstone projects emphasize applying classroom learning in actual public health practice work for community-based organizations. This partnership brings PHSKC and COPHP together in every aspect of teaching. In essence, PHSKC acts as the "academic health department" for COPHP. There are detailed agreements and contracts that guide all aspects of the partnership. Both the practicum and capstone projects require written contracts. The arrangements for getting non-University of Washington faculty paid for teaching and advising also include formal contracts.

Evaluation of Electronic Ambulatory Care Data for Use in the Influenza-like Illness Surveillance Network (ILINet)

Washington State Department of Health and Public Health Seattle King County sought to evaluate the utility of electronic ambulatory data for monitoring influenza-like illness (ILI). A definition of ILI that was previously validated using emergency department data was applied to ambulatory care records. During August 2007 through August 2012, the proportion of ILI visits strongly correlated with the number and percentage of positive influenza tests reported by the network laboratory. The results will aid in formulating guidance for ambulatory care providers who wish to utilize electronic medical record systems for weekly ILINet reporting.

Ru2hot?: A public health education campaign for men who have sex with men to increase awareness of symptoms of acute HIV infection

ObjectivesTeach HIV-negative men who have sex with men (MSM) symptoms of acute HIV infection (AHI) and direct them to nucleic acid amplification testing (NAAT) though Public Health—Seattle & King County...

HIV intertest interval among MSM in King County, Washington

ObjectivesThe authors examined temporal trends and correlates of HIV testing frequency among men who have sex with men (MSM) in King County, Washington.MethodsThe authors evaluated data from MSM testing for...

Feasibility of Partnering with Emergency Medical Services to Identify People at Risk for Uncontrolled High Blood Pressure

Uncontrolled high blood pressure (HBP) is a significant health problem and often goes undetected. In the prehospital care-delivery system of 9-1-1 emergency medical services (EMS) calls, emergency medical technicians (EMTs) routinely collect medical information, including blood pressure values, that may indicate the presence of chronic disease. This information is usually archived without any further follow-up. We conducted several planning activities during the fall of 2006 to determine if a partnership between researchers at the Health Marketing Research Center at the University of Washington, Public Health Seattle King County EMS division, and several large fire departments could be developed to help identify community residents with uncontrolled HBP and determine the most effective way to communicate HBP information to them. We partnered with 4 King County, Washington, fire departments that provide 9-1-1 EMS to develop an intervention for people with uncontrolled HBP who were attended by EMTs in response to a 9-1-1 call for assistance. On the basis of discussions with EMS personnel at all levels, we developed a system by which we could identify at-risk community residents by using medical incident report forms that EMS personnel completed; we consulted with EMS personnel to determine the most effective means of reaching these people. In addition we developed a survey to assess community residents' beliefs about blood pressure control, the role of EMTs as health care providers, and the convenience of fire stations as places to have blood pressure checked. Using contact information that EMS personnel obtained, we surveyed 282 community residents from a total of 794 people whom EMTs had identified as at risk for uncontrolled HBP to help us understand our target audience. In consultation with EMS personnel, we determined that direct mail was the most effective way to reach people with uncontrolled HBP identified from EMS records to advise them of their risk. On the basis of the number with a known response to each question, 67% (n = 180/269) of the respondents reported that a doctor or other health professional had told them they had HBP, 95% (246/259) believed that regular screening for HBP was important, 65% (166/254) said that EMTs were highly credible health care providers, and 82% (136/165) said that they would feel comfortable receiving blood pressure screening at a local fire station. Partnering with local EMS may be an effective way to identify and reach community residents with uncontrolled HBP with information on their medical condition and to encourage them to have follow-up screening.

P1-S6.31 HIV intertest interval among MSM in King County, Washington

BackgroundHIV testing remains one of the most effective HIV prevention interventions because most persons newly diagnosed with HIV alter their behaviours to reduce the risk of transmission to others. We...

An Evaluation of HIV Partner Counseling and Referral Services Using New Disposition Codes

New Centers for Disease Control recommendations suggest that all persons with newly diagnosed HIV receive partner counseling and referral services (PCRS). We evaluated the King County, WA, PCRS program using a new set of disposition codes that disaggregate the components of PCRS (notification, testing, and test results), distinguish verified and unverified outcomes, and differentiate outcomes that occur before and after cases receive PCRS. Between 2005 and 2007, 427 (65%) of 659 persons with newly diagnosed HIV received PCRS. The number of cases staff needed to interview to identify 1 new case of HIV varied from 12.2 to 47.4 depending on whether number needed to interview was defined to include both verified and unverified outcomes and whether it excluded partners diagnosed with HIV before cases' receipt of PCRS. Age <25, testing HIV negative within the last year, receipt of PCRS within 58 days of HIV diagnoses, and participation in a program to link persons with HIV to medical care were significantly associated notifying more partners. PCRS evaluations may overestimate success because of limitations inherent in Centers for Disease Control PCRS disposition codes. Efforts to promote frequent HIV testing, assure timely provision of PCRS, and integrate PCRS with programs that link patients to care may improve PCRS outcomes.