State Department Of Public Health Research Articles

Disaggregating Racial and Ethnic Data: A Step Toward Diversity, Equity, and Inclusion

Data on race and ethnicity are crucial for identifying and addressing health disparities. Incomplete or inaccurate data constrain the ability of researchers, administrators, and policymakers to provide targeted assistance to groups who otherwise could be overlooked. Unfortunately, a large discrepancy exists between the many racial and ethnic categories individuals use to self-identify and available categories in typical databases. In the health care setting, categories for race and ethnicity generally follow the Office of Management and Budget (OMB) minimum standards for reporting federal data, which have not been updated since 1997.1Office of Management and BudgetRevisions to the standards for the classification of federal data on race and ethnicity.https://obamawhitehouse.archives.gov/omb/fedreg_1997standardsDate: 1997Date accessed: October 20, 2022Google Scholar The OMB minimum standards for classification of race and ethnicity (Table 1) use 5 categories for race (American Indian or Alaska Native, Asian, Black or African American, Native Hawaiian or Other Pacific Islander, and White) and 2 categories for ethnicity (Hispanic or Latino and Not Hispanic or Latino). These broad categories combine subgroups of individuals with distinct ancestries and cultures as well as socioeconomic realities. Many individuals—especially those who identify with minoritized subgroups—do not have the option to choose the specific ethnic group they prefer. Similarly, those who are of Middle Eastern or North African descent have not been provided options but historically have chosen White as their race. In this context, individuals become anonymous members of a larger group, and potential health disparities within these broader racial and ethnic categories are concealed in the aggregate data. In this article, our objectives are to show the importance of disaggregating racial and ethnic data in gastroenterology and hepatology, as well as to suggest solutions for addressing this problem at the individual, institutional, and societal levels (Table 2).Table 1OMB Racial and Ethnic Categories and Alternative Disaggregated CategoriesOMBHHSNew York StateaThese categories are required by NY S.6639-A/A.6896-A,17 which specifically addressed the Asian, Native Hawaiian, and Pacific Islander populations.American Indian or Alaska NativeAsian7 subgroups: Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, and Other Asian20 subgroups: 7 HHS subgroups, Laotian, Cambodian, Bangladeshi, Hmong, Indonesian, Malaysian, Pakistani, Sri Lankan, Taiwanese, Nepalese, Burmese, Tibetan, and ThaiBlack or African AmericanHispanic or Latino4 subgroups: Mexican/Mexican American/Chicano/a, Puerto Rican, Cuban, and Another Hispanic/Latino/Spanish originNative Hawaiian or Other Pacific Islander4 subgroups: Native Hawaiian, Guamanian or Chamorro, Samoan, and Other Pacific Islander6 subgroups: 4 HHS subgroups, Fijian, and TonganWhiteHHS, Department of Health and Human Services; OMB, Office of Management and Budget.a These categories are required by NY S.6639-A/A.6896-A,17The New York State SenateSenate Bill S6639A.https://www.nysenate.gov/legislation/bills/2021/S6639Date: 2021Date accessed: November 2, 2022Google Scholar which specifically addressed the Asian, Native Hawaiian, and Pacific Islander populations. Open table in a new tab Table 2Potential Solutions for Disaggregating Racial and Ethnic DataLevel of actionPotential solutionsImpactIndividualClinician: use disaggregated categories for intake forms or in clinical notesResearcher: collect disaggregated primary data, use existing disaggregated data sets, acknowledge limitation of aggregated data, and specify component groups+aThese are qualitative markers of impact, with + representing the least impact and +++ representing the most impact.InstitutionalDisaggregate categories in electronic health record (using a comprehensive list or based on local demographics), use evidence-based algorithms to reclassify existing data++aThese are qualitative markers of impact, with + representing the least impact and +++ representing the most impact.SocietalAdvocate for policy change on a local, state, or federal level by working with community-based or national organizations or by participating in Office of Management and Budget listening session with the public+++aThese are qualitative markers of impact, with + representing the least impact and +++ representing the most impact.a These are qualitative markers of impact, with + representing the least impact and +++ representing the most impact. Open table in a new tab HHS, Department of Health and Human Services; OMB, Office of Management and Budget. In the following section, we present 2 of the many examples in gastroenterology and hepatology that illustrate the importance of disaggregating race and ethnicity. Asian and Hispanic/Latino individuals, on aggregate, have among the lowest colorectal cancer screening uptake in the United States. In the 2015 National Health Interview Survey (NHIS), 62.4% of the overall population were up-to-date with screening, compared with 52.1% of Asian and 47.4% of Hispanic/Latino persons.2White A. Thompson T.D. White M.C. et al.Cancer screening test use—United States, 2015.MMWR Morb Mortal Wkly Rep. 2017; 66: 201-206Crossref PubMed Scopus (328) Google Scholar Because there are 49 Asian nations and 19 nations and territories in the Americas and Caribbean with predominantly Hispanic/Latino populations, it is unsurprising that screening uptake in Asian and Hispanic/Latino subgroups varies substantially. These nations and territories have distinct geopolitical histories and patterns of emigration, which have resulted in vastly different socioeconomic circumstances for immigrants who arrive in the United States. Disaggregated data collected by the NHIS indicate that screening uptake in the Hispanic/Latino population ranged from 63.2% for Puerto Rican to 36.0% for Mexican individuals.2White A. Thompson T.D. White M.C. et al.Cancer screening test use—United States, 2015.MMWR Morb Mortal Wkly Rep. 2017; 66: 201-206Crossref PubMed Scopus (328) Google Scholar Similarly, data from the 2014 New York City Community Health Survey showed that although 61.7% of Asian and Pacific Islander persons were up-to-date with colonoscopy, this ranged from 70.4 % for Chinese to 45.1% for Asian Indian individuals.3Rastogi N. Xia Y. Inadomi J.M. et al.Disparities in colorectal cancer screening in New York City: an analysis of the 2014 NYC Community Health Survey.Cancer Med. 2019; 8: 2572-2579Crossref PubMed Scopus (16) Google Scholar These granular details highlight disparities in communities that would benefit from targeted screening campaigns, and that otherwise would have been hidden in the aggregate data. Hepatitis B virus (HBV) is a major risk factor for cirrhosis and hepatocellular carcinoma, and the risk of HBV is higher for many individuals who are born outside of the United States. For this reason, the US Preventive Services Task Force recommends screening persons for HBV if they are either born in a country where the prevalence of HBV exceeds 2%, or are US-born persons who are unvaccinated and whose parents were born in countries where HBV prevalence exceeds 8%.4Krist A.H. Davidson K.W. et al.US Preventive Services Task ForceScreening for hepatitis B virus infection in adolescents and adults: US Preventive Services Task Force recommendation statement.JAMA. 2020; 324: 2415Crossref PubMed Scopus (25) Google Scholar The prevalence of HBV surpasses 8% in some Asian countries (Kyrgyzstan, Laos, Mongolia, Vietnam, and Yemen), and falls short of 2% in others (eg, India, Malaysia, and Japan). Similarly, the prevalence exceeds 2% in a handful of Latin American countries (Belize, Colombia, Ecuador, Peru, and Suriname). Without detailed disaggregated data on race, ethnicity, and country of origin for recent immigrants, it would be difficult to follow these recommendations in clinical practice and impossible to measure adherence or impact across a health care system. In this case, the likely consequence of relying on broad racial and ethnic categories would be both overscreening low-risk individuals and underscreening high-risk individuals. In addition to identifying hidden health disparities, there are other reasons to collect disaggregated racial and ethnic data. First, nuanced demographic information provides clarity in patient-centered care. Understanding the prevalence of disease in a specific group or community is intrinsically valuable, regardless of how it compares with other groups. Second, giving individuals a chance to select a racial or ethnic category that they self-identify with promotes a culture of inclusivity and counters the sense of invisibility that many communities feel. It may serve as a momentary but meaningful acknowledgment of a small community in the larger fabric of society. Third, disaggregated data help to challenge stereotypes, such as the heterogenous Asian American population being uniformly considered the model minority, having minimal health disparities, or universally benefiting from the healthy immigrant effect.5Yi S.S. Kwon S.C. Suss R. et al.The mutually reinforcing cycle of poor data quality and racialized stereotypes that shapes Asian American Health: study examines poor data quality and racialized stereotypes that shape Asian American health.Health Aff (Millwood). 2022; 41: 296-303Crossref PubMed Scopus (9) Google Scholar These stereotypes perpetuate a false sense of well-being that deprioritizes research and funding for these communities. Clinicians should recognize that screening and management recommendations for certain conditions may differ depending on a patient’s race, ethnicity, and country of origin. More nuanced data also allow clinicians to be aware of potential cultural sensitivities of their patients. Therefore, creating a workflow that incorporates the collection of disaggregated racial and ethnic data is a clinically valuable endeavor. If a provider uses a patient intake form or questionnaire and has control over its content, then adding additional racial and ethnic categories based on local demographics would be an efficient way to capture these data. Alternatively, updating clinical note templates to add a question about a patient’s self-identified race and ethnicity in the Social History section will accomplish a similar goal. Researchers should collect and report disaggregated racial and ethnic primary data whenever possible. When using secondary data, researchers should consider using data sources such as the NHIS or American Community Survey, which provide subcategories of the American Indian or Alaska Native, Asian, Native Hawaiian or Other Pacific Islander, and Hispanic/Latino classifications. In instances in which aggregated data must be used—whether because of the method of collection or because of small sample sizes for reporting—use of aggregated data should be acknowledged as a study limitation. Groups within the aggregated data category also should be specified when possible. We strongly encourage systems-level change in the electronic health record. Collecting disaggregated data is consistent with patient-centered care and upholds the principles of diversity, equity, and inclusion. Change at the level of an institution or health care system requires engagement of and support from administrators, and the impact will far exceed individual efforts. The prospective and retrospective data disaggregation initiatives at NYU Langone Health serve as illustrative examples. A collaboration between health equity researchers and the institutional leadership led to the introduction of multiple Asian and Hispanic/Latino subgroup options in the electronic health record for new patients. Simply providing the new categories, however, did not lead to a rapid shift in how patients were classified. From this experience, we learned that increasing awareness about the update among clinical staff and patients was a crucial step in the implementation process, and training and support are necessary for a successful rollout. Additional engagement with data managers responsible for reporting to federal agencies, clinicians, and community members have been critical toward building the new data capture system. In addition to prospective efforts, we also are exploring several methods to disaggregate existing data in the electronic health record. We have used a name list algorithm successfully to identify a large number of Arab Americans who often previously were misclassified as White, Other, or Unknown. The algorithm also doubled the size of Asian Americans in the data set and permitted specific identification of ethnic groups (eg, Chinese, Asian Indian). We also are using a statistical method called Bayesian Improved Surname Geocoding (BISG) to predict the probability of an individual belonging to broad racial and ethnic groups based on surname and residential address.6Elliott M.N. Morrison P.A. Fremont A. et al.Using the Census Bureau’s surname list to improve estimates of race/ethnicity and associated disparities.Health Serv Outcomes Res Methodol. 2009; 9: 69-83Crossref Scopus (124) Google Scholar BISG is the best algorithm available for classifying individuals with missing race and ethnicity, and it has been shown to have high predictive accuracy for Asian, Black, Hispanic/Latino, and White individuals.7Yee K. Hoopes M. Giebultowicz S. et al.Implications of missingness in self-reported data for estimating racial and ethnic disparities in Medicaid quality measures.Health Serv Res. 2022; 57: 1370-1378Crossref PubMed Scopus (2) Google Scholar,8Sartin E.B. Metzger K.B. Pfeiffer M.R. et al.Facilitating research on racial and ethnic disparities and inequities in transportation: application and evaluation of the Bayesian Improved Surname Geocoding (BISG) algorithm.Traffic Inj Prev. 2021; 22: S32-S37Crossref PubMed Scopus (4) Google Scholar Patient self-reported data remain the gold standard. However, evidence-based methods such as name lists and BISG can help direct quality improvement activities including translation services and educational support toward specific communities and geographic areas. At the institutional level, it is important to recognize that racial and ethnic data categories vary by region. For instance, individuals of Dominican descent account for 23% of the Hispanic/Latino community in the New York metropolitan area but make up less than 1% of the Hispanic/Latino population in the Los Angeles and Houston metropolitan areas.9Noe-Bustamante L. Key facts about U.S. Hispanics and their diverse heritage.https://www.pewresearch.org/fact-tank/2019/09/16/key-facts-about-u-s-hispanicsDate: 2019Date accessed: November 1, 2022Google Scholar Institutions should either adopt a comprehensive list of racial and ethnic subgroups10Agency for Healthcare Research and QualityRace, ethnicity, and language data: standardization for health care quality improvement.https://www.ahrq.gov/research/findings/final-reports/iomracereport/reldataaptabe1.htmlDate: 2018Date accessed: November 2, 2022Google Scholar or build one using local population demographics, preferably with feedback from the community. Regardless of how many categories are available for selection, it also is important that they can rollup or combine into the 5 race and 2 ethnicity groups in the OMB minimum standard to maintain comparability with other data sources. With support from the Robert Wood Johnson Foundation, the research institute PolicyLink produced a comprehensive report on methods for collecting and analyzing data and government policies that enable data disaggregation.11Rubin V. Ngo D. Ross A. et al.Counting a diverse nation: disaggregating data on race and ethnicity to advance a culture of health.https://www.policylink.org/sites/default/files/Counting_a_Diverse_Nation_08_15_18.pdfDate accessed: October 18, 2022Google Scholar At the federal level, modifying the OMB minimum standards remains the shortest path to widespread change. Although the US Census Bureau’s internal research in 2015 concluded that “it is optimal to use a dedicated” Middle Eastern or North African category,12US Census Bureau2015 National content test race and ethnicity analysis report.https://www2.census.gov/programs-surveys/decennial/2020/program-management/final-analysis-reports/2015nct-race-ethnicity-analysis.pdfDate: 2017Date accessed: November 2, 2022Google Scholar and a 2017 proposal from the Federal Interagency Working Group for Research on Race and Ethnicity concurred, the OMB ultimately rejected these recommendations and the 2020 Census did not incorporate the proposed change. However, the Biden administration OMB recently signaled a willingness to reassess the minimum standards by reconvening an Interagency Working Group and beginning a series of listening sessions with the public.13Orvis K. OMB launches new public listening sessions on federal race and ethnicity standards revision.https://www.whitehouse.gov/omb/briefing-room/2022/08/30/omb-launches-new-public-listening-sessions-on-federal-race-and-ethnicity-standards-revisionDate: 2022Date accessed: November 2, 2022Google Scholar It is worth noting that the Department of Health and Human Services, which oversees the NHIS, has adopted an expanded data standard for race and ethnicity (Table 1).14US Department of Health and Human ServicesExplanation of data standards for race, ethnicity, sex, primary language, and disability.https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=3&lvlid=54#:∼:text=The%20OMB%20minimum%20categories%20for,and%20Not%20Hispanic%20or%20LatinoDate: 2021Date accessed: October 20, 2022Google Scholar The Centers for Medicare & Medicaid Services, which operates within the Department of Health and Human Services, also has announced that new enrollment forms for Medicare Advantage and Medicare prescription drug (Part D) plans are required to include disaggregated racial and ethnic categories in January 2023.15Centers for Medicare & Medicaid ServicesModel individual enrollment request form to enroll in a Medicare Advantage Plan (MA) or a Medicare prescription drug plan (Part D), and advance announcement of January 2023 software release - addition of race and ethnicity data fields on enrollment transactions.https://www.cms.gov/files/document/hpms-announcement-memo-race-and-ethnicity.pdfDate: 2022Date accessed: November 29, 2022Google Scholar The majority of federal agencies, however, continue to follow the OMB minimum standard. Although federal reform has been hindered, states have led efforts for data disaggregation. In 2000, the Massachusetts Department of Public Health developed a new data collection form that offered additional racial and ethnic groups choices, including Cape Verdean, Haitian, and Puerto Rican.11Rubin V. Ngo D. Ross A. et al.Counting a diverse nation: disaggregating data on race and ethnicity to advance a culture of health.https://www.policylink.org/sites/default/files/Counting_a_Diverse_Nation_08_15_18.pdfDate accessed: October 18, 2022Google Scholar In 2016, the Accounting for Health and Education in API Demographics Act became law in California and required the State Department of Public Health to collect more detailed data on Asian American, Native Hawaiian, and Pacific Islander groups, including Bangladeshi, Indonesian, Taiwanese, Fijian, and Tongan.16State of CaliforniaAB-1726.http://leginfo.legislature.ca.gov/faces/billNavClient.xhtml?bill_ id=201520160AB1726Date: 2016Date accessed: November 2, 2022Google Scholar In 2021, New York passed a law that required every state agency that collected racial and ethnic data to include options for at least 20 Asian and 6 Native Hawaiian and Pacific Islander groups (Table 1).17The New York State SenateSenate Bill S6639A.https://www.nysenate.gov/legislation/bills/2021/S6639Date: 2021Date accessed: November 2, 2022Google Scholar Critics of disaggregation argue the following: (1) these distinctions are a manifestation of identity politics that fragment US society, (2) disaggregation weakens the political strength of a larger umbrella group, and (3) smaller populations may be more susceptible to privacy concerns.11Rubin V. Ngo D. Ross A. et al.Counting a diverse nation: disaggregating data on race and ethnicity to advance a culture of health.https://www.policylink.org/sites/default/files/Counting_a_Diverse_Nation_08_15_18.pdfDate accessed: October 18, 2022Google Scholar,18Kader F. Doan L.N. Lee M. et al.Disaggregating race/ethnicity data categories: criticisms, dangers, and opposing viewpoints.http://www.healthaffairs.org/do/10.1377/forefront.20220323.555023/fullDate: 2022Date accessed: October 12, 2022Google Scholar In addition, smaller groups may make data analysis and interpretation more challenging. However, each legislative success described earlier required years of persistent advocacy from a coalition of community-based organizations while contending with opposing viewpoints. For groups that historically have been subjected to surveillance and monitoring, working with community organizations to explain the rationale for disaggregation and underscore a commitment to privacy is crucial. A number of strategies for suppressing data that do not meet statistical reliability, data quality, or confidentiality criteria have been developed.19Klein R.J. Proctor S.E. Boudreault M.A. et al.Healthy people 2010 criteria for data suppression.Healthy People 2010 Stat Notes. 2002; 24: 1-12Google Scholar Smaller groups that have an insufficient sample size also can be combined in an aggregate category for analysis. Collecting and reporting disaggregated racial and ethnic data is an important, practical step toward building a more diverse, equitable, and inclusive society and to improve health care quality. Going beyond the broad demographic categories of the OMB minimum standard allows us to unmask and address health disparities in our patients and bring more resources and attention to smaller communities. From modifying how we record patient or participant data to advocating for policy changes at the state and national levels, there are numerous ways to contribute to and advance health equity across our health systems.

Hepatitis C screening in a community pharmacy setting: Patient perspective

BackgroundHepatitis C virus (HCV) is an infection of the liver, which contributes to over 15,000 deaths in the United States annually. When treated, HCV has a 90% or greater cure rate, however testing for HCV remains low. ObjectivesTo assess patient perspectives on HCV screenings in the community pharmacy setting including awareness of screening, willingness to be screened, barriers to screening, and willingness to pay for HCV screening. MethodsThis study used a cross-sectional survey design. The surveys were distributed by staff at an independent community pharmacy participating in an HCV screening initiative through the state department of public health. Eligible patients were born between 1945 and 1965. Descriptive statistics were calculated for survey variables. Open-ended responses were analyzed for additional context. ResultsFifty-seven surveys were returned and analyzed. The majority of the respondents were White (94%), female (56%), and had some college education (26%). Only 7% were aware that a finger-stick point-of-care test was available and 67% were unaware of the Centers for Disease Control and Prevention (CDC) recommendation for testing. The most frequently reported barrier or hesitation to screening was the patient not thinking they were at risk (29%) followed by uncertainty about cost (14%). Over half of respondents (63%) were either somewhat interested or very interested in testing in a community pharmacy, however, the majority (71%) were not willing to pay or only willing to pay less than $20. ConclusionsSurvey respondents were largely unaware of the recommendations and availability of finger-stick HCV screenings at community pharmacies but many were willing to be tested if low-cost. Providing patient education on the importance of HCV screenings and CDC recommendations may bolster interest in screening.

AIDS-related mortality in Pará Province, Brazilian Amazon region: Spatial and temporal analysis.

In this ecological study, data from 2007 to 2018 were extracted from the Mortality Information System provided by the State Department of Public Health of Pará. For the temporal analysis, the integrated autoregressive model of moving average (ARIMA) and locally weighted polynomial regression (STLF) were used to forecast AIDS mortality from 2019 to 2022. For the spatial analysis, spatial autocorrelation and geographically weighted regression (GWR) analyses were employed. The samples consisted of 6,498 notifications for AIDS-related deaths. From 2007 to 2013, the AIDS mortality rates showed an upward trend, followed by a stabilization until 2018 and an upward forecasted trend from 2019 to 2022. High mortality rates and high-high clusters were found in economic pole municipalities. Furthermore, AIDS mortality risk was directly associated with per capita income and demographic density, except in the southwestern region of Pará, which exhibited an inverse association with population density. Although the policies against HIV may have contributed to the stabilization of AIDS mortality rates from 2013 in Pará, the upward forecasted trend until 2022 raises an alert and concern to health authorities to provide reinforcement of the policies. The geographic variability of AIDS mortality promoted by SDH provides subsidies to health authorities to implement SDH-focused strategies for AIDS mortality reduction.

Incidência de malária entre indígenas associada à presença de garimpos

ABSTRACT Objective: To analyze the incidence of malaria among indigenous people associated with the presence of artisanal miningin the state of Pará. Method: Analytical, cross-sectional study conducted with 20,774 cases of malaria in indigenous people in the state of Pará (2011 to 2020). The data came from the Malaria Epidemiological Surveillance Information System, obtained from the Pará State Department of Public Health. In the analysis, Spearman’s correlation coefficient was used, with a significance of 5% (p < 0.05). Results: Incidence rates were high, especially in the Tapajós River Indigenous Special Health District (372.2/1,000 inhabitants). There was association between the incidence of malaria and the presence of indigenous people in artisanalmining activities on the Tapajós River (p=0.0008). Conclusion: The occurrence of malaria is unequal among the Special Indigenous Health Districts, being more frequent in those with greater mining activity, configuring exposure to the disease. It is necessary to adopt intersectoral measures, especially in areas of vulnerability to illness.

1365. Public Health’s Role in ECHO via the Experiences of a State Department of Public Health

Abstract Background In April 2019, Georgia became the second state department of public health to implement and utilize an ECHO program to unite the Ryan White Part B HIV community. Project ECHO is a global telementoring program used to provide cutting-edge medical techniques and knowledge to medical providers in rural settings with fewer resources. Today, the GA-DPH ECHO program reaches over 300 individuals at the local, state, national, and international levels, providing essential insight to healthcare workers and a forum for discussion in several key fields, including infectious diseases and viral hepatitis. The objective is to reveal via participation and demographical data drawn from ECHO sessions the challenges and successes in implementing and potential expanded utility of this type of program within public health, ultimately demonstrating why public health has an important role within the ECHO community. Image 1Map of United States showing outreach of GA-DPH Project ECHO. The map does not include one user based in Africa. Methods iECHO, a partner relations management tool, was utilized in extracting demographical and participation from all GA-DPH ECHO sessions from 2019 to 2021. Data was chosen based on participation over time for each ECHO in addition to who was attending sessions while determining variations in attendance. Once compiled, data was charted into tables with iECHO software utilization to construct graphs illustrating trends over time for each ECHO to be analyzed for future expansion and evaluate the challenges. Results The data revealed a steady growth of GA-DPH ECHO specifically the pilot infectious disease ECHO in 2019 which has grown from 14 attendees at the time to 20. A large attendance spike coincided with ECHO initiations of acute stroke and cancer registry in January 2021, with March 2021 the most attended month for the three ECHOs existing at the time. Initiated in April 2021, viral hepatitis quickly produced the most didactic sessions than any other program. ECHO Figure 1 Graph of participation in 2021 for all five ECHOs with the highest attendance for three ECHOs during March 2021. Sessions are scheduled monthly or bi-monthly (representing months with 0 attendance) and are 1-hour in length Figure 2Graph of participation for Infectious Disease ECHO from 2019-2021, noted as the first GA-DPH ECHO, starting 21 months prior to other GA-DPH ECHOsTable 1Average and total attendees for each ECHO in addition to the date of initiation and a total number of sessions. Average number of attendees include individuals registered with GA-DPH ECHO as well as anonymous (unregistered) users who join via invitation. Conclusion GA-DPH Project ECHO has grown in attendees with a variety of sessions offered and plans for further growth and initiation of new ECHO topics. While there have been challenges, there have been far more successes with the development of 5-ECHOs. The hope is experiences of GA-DPH ECHO will show how this platform may be utilized in departments of public health across the globe. Disclosures All Authors: No reported disclosures.

Adapting an evidence-based cancer survivor lifestyle program for cancer prevention and control in African American and Hispanic/Latino communities.

10545 Background: Cancer is the second leading cause of death in Wisconsin with higher mortality rates observed for Black/African American (B/AA) and Hispanic/Latino(a) (Hisp/Lat) communities. Affordable lifestyle interventions targeting healthy nutrition and physical activity patterns tailored to the needs/interests of these communities are critically needed to prevent and control cancer. In this project, we adapted the evidence-based Moving Forward lifestyle program for B/AA breast cancer survivors, which included a program workbook, in-person education/supervised exercise classes, and text messages. We sought to address cancer prevention among B/AA and Hisp/Lat community members in the general population by implementing the program within an urban public recreation system for sustainability. Methods: To help guide the adaptation process, project partners included an academic cancer center, an urban public recreation system, the state department of public health, and a community advisory board. Our approach comprised of focus groups with B/AA and Hisp/Lat residents, surveys collected at community events, and an After-Action Review of a 4-week program pilot. Results: One-hundred community members (58 B/AA and 42 Hisp/Lat) participated in the adaptation phase through eight focus groups (N = 27), 48 surveys, and 25 pilot participants. Seven key program content adaptations were targeted: 1) integrate information on basic cancer biology; 2) explain the association between cancer, nutrition and physical activity; 3) address other diseases besides cancer (heart disease, diabetes); 4) provide cooking demonstrations with culturally relevant tips to facilitate dietary changes; 5) update workbook images and content to reflect race/ethnicity of targeted populations; 6) add information on cancer screening; 7) provide information on local healthy eating and exercise resources. Key adaptations related to conducting the program within a public recreation system included: 1) dividing the program into two 8-week sessions to meet the public recreation system program calendar; 2) eliminating the text message component; 3) providing the program workbook/classes in English and Spanish; and 4) integrating different exercise approaches to meet needs/interests of different age groups, genders, and different fitness levels. Conclusions: Community-academic partnerships and ongoing community engagement led to meaningful adaptations to a cancer prevention and lifestyle program to address cancer disparities in the B/AA and Hisp/Lat communities.

Using Surveillance With Near-Real-Time Alerts During a Cluster of Overdoses From Fentanyl-Contaminated Crack Cocaine, Connecticut, June 2019.

In 2019, Connecticut launched an opioid overdose-monitoring program to provide rapid intervention and limit opioid overdose-related harms. The Connecticut Statewide Opioid Response Directive (SWORD)-a collaboration among the Connecticut State Department of Public Health, Connecticut Poison Control Center (CPCC), emergency medical services (EMS), New England High Intensity Drug Trafficking Area (HIDTA), and local harm reduction groups-required EMS providers to call in all suspected opioid overdoses to the CPCC. A centralized data collection system and the HIDTA overdose mapping tool were used to identify outbreaks and direct interventions. We describe the successful identification of a cluster of fentanyl-contaminated crack cocaine overdoses leading to a rapid public health response. On June 1, 2019, paramedics called in to the CPCC 2 people with suspected opioid overdose who reported exclusive use of crack cocaine after being resuscitated with naloxone. When CPCC specialists in poison information followed up on the patients' status with the emergency department, they learned of 2 similar cases, raising suspicion that a batch of crack cocaine was mixed with an opioid, possibly fentanyl. The overdose mapping tool pinpointed the overdose nexus to a neighborhood in Hartford, Connecticut; the CPCC supervisor alerted the Connecticut State Department of Public Health, which in turn notified local health departments, public safety officials, and harm reduction groups. Harm reduction groups distributed fentanyl test strips and naloxone to crack cocaine users and warned them of the dangers of using alone. The outbreak lasted 5 days and tallied at least 22 overdoses, including 6 deaths. SWORD's near-real-time EMS reporting combined with the overdose mapping tool enabled rapid recognition of this overdose cluster, and the public health response likely prevented additional overdoses and loss of life.

Changes in COVID-19-Associated Deaths During a Year Among Blacks and Hispanics Compared to Whites in the State of Connecticut.

Background With recent COVID-19 vaccination rates relatively high in the USA, the USA still maintains the most documented cases globally,[1] even though COVID-19 cases, hospitalization, and mortality have been declining. However, the health burden has been largely felt in communities involving racial and ethnic minorities. Thus, in order to provide a clearer picture of what is happening in Black, Indigenous, and people of color communities, we examined the racial/ethnic differences of monthly COVID-19 deaths in Connecticut.MethodsThis is an epidemiological study analyzing mortality data from March 1, 2020, to February 28, 2021, obtained from the Connecticut State Department of Public Health. The data include cause of death (COVID-19 death identified by ICD-10 code U071), race/ethnicity (non-Hispanic White (White), non-Hispanic Black (Black), and Hispanic), sex, and age. Both crude and age-adjusted rates were reported by racial/ethnic groups. To compare age-adjusted rates between racial groups, with estimated age-adjusted death counts as outcomes, between-racial group rate ratios, 95% confidence intervals, and p values significant at < 0.05 were derived from the Poisson regression model.ResultsFrom March 2020 to May 2020 (wave 1) of COVID-19 cases, the COVID-19-related mortality rates were the highest for all three race groups (Whites, Blacks, and Hispanics) with statistical group differences (p < 0.05). Blacks had the highest rates of deaths followed by Hispanics and then Whites. Further, more Whites died in a nursing home when compared to Blacks and Hispanics. From June 2010 to October 2020 (wave 2), COVID-19 mortality declined significantly for all three race groups with no statistical differences between groups. COVID-19 deaths in nursing homes declined for all three racial/ethnic groups. From November 2020 to February 2021 (wave 3), COVID-19 mortality rates were significantly higher compared to wave 2 but lower than wave 1 for all three race groups. The mortality rates for Blacks and Hispanics were higher than Whites. Hispanics had the highest rates of deaths, followed by Blacks, and then Whites (p < 0.05). Whites showed the lowest mortality rates among all three racial/ethnic groups.ConclusionsIn summary, COVID-19 health disparities among Black and Hispanic populations were evident in this study. Blacks and Hispanics had significantly higher mortality rates when compared to Whites. Blacks had the highest mortality rates during wave 1, and in wave 3, Hispanics has the highest mortality rates. Our data are important because they show monthly COVID-19 deaths data by race. Data reported this way gives a better and more accurate understanding of what is really happening in Black, Indigenous, and people of color populations.

Evaluation of a Multisite Safe Infant Sleep Education and Crib Distribution Program.

Rates of sleep-related infant deaths have plateaued in the past few decades despite ongoing infant sleep practice recommendations to reduce risk of sleep-related infant deaths by the American Academy of Pediatrics. The state department of public health trained facilitators at 28 sites across the state to facilitate a group safe sleep educational program. A prospective, matched pre- and post-test cohort design with follow-up was used to evaluate changes in self-reported knowledge, intentions, and practices. The final sample included 615 matched pre- and post-test surveys, and 66 matched follow-up surveys. The proportion of correct responses on all knowledge and intended practice items increased significantly from pre- to post-test. When asked where their babies would have slept if they had not received the portable crib, 66.1% of participants planned to use a recommended sleep location (e.g., crib or bassinet). At post-test, 62.3% planned to change something about their infant’s sleep based on what they learned. At follow-up, knowledge was maintained for all but two items and practices and for half of practice items. The results suggest that participating in the education program was associated with increased knowledge and intended adherence, but that these changes were not maintained at follow-up. These results are in line with the research literature that finds a difference in intentions and actual practices after the baby is born.

Opioid Prescribing After Implementation of Single Click Access to a State Prescription Drug Monitoring Program Database in a Health System's Electronic Health Record.

To determine the effect of one-click integration of a state's prescription drug monitoring program (PDMP) on the number of PDMP searches and opioid prescriptions, stratified by specialty. Our large health system worked with the state department of public health to integrate the PDMP with the electronic health record (EHR), which enabled providers to query the data with a single click inside the EHR environment. We evaluated Schedule II or III opioid prescriptions reported to the Massachusetts PDMP 6 months before (November 15, 2017-May 15, 2018) and 6 months after (May 16, 2018, to November 16, 2018) integration. Search counts, prescriptions, patients, morphine milligram equivalents, as well as prescriber specialty were compared. There were 3,185 unique prescribers with a record of a Schedule II and/or III opioid prescription in both study periods that met inclusion criteria. After integration, the number of PDMP searches increased from 208,684 in the pre-integration phase to 298,478 searches in the post-integration phase (+43.0%). The number of opioid prescriptions dispensed decreased by 4.8%, the number of patients receiving a prescription decreased by 5.1%, and the mean morphine milligram equivalents (MMEs) per prescriber decreased by 5.4%. There were some notable specialty-specific differences in these measures. Integration of the PDMP into the EHR markedly increased the number of searches but was associated with modest decreases in opioids prescribed and patients receiving a prescription. Single click EHR integration of the PDMP, if implemented broadly, may be a way for states to significantly increase PDMP utilization.

The COVID-19 Global Pandemic

INTRODUCTIONThe recent outbreak of a novel coronavirus illness (COVID-19) has grown into a global pandemic. As a response, there have been several treatment recommendations published by international, federal, state, and local governing bodies.METHODSWe performed a comprehensive review of COVID-19 policies and aggregated multi-disciplinary expertise at our quaternary care academic facility to formulate objective criteria for scheduling surgery, providing neurosurgical coverage, and engaging in neurosurgical research during the COVID-19 outbreak. Recommendations from the CDC, WHO, California State Department of Public Health (CDPH), San Francisco Department of Public Health (SFDPH), and the UCSF School of Medicine were collected and reviewed by the expert panel. Treatment algorithms regarding the following issues were drafted: (1) neurosurgical case scheduling, (2) neurosurgical clinic scheduling, (3) contingency plans for neurosurgical staffing and ICU utilization, and (4) staffing neurosurgical research directives.RESULTSHere, we present a neurosurgical treatment algorithm for varying levels of COVID-19 community infection. This algorithm (with an accompanying checklist) is centered around a three-tiered system of viral ‘surge’ quantification, which we use to triage case scheduling, and a paired coverage model for inpatient services.CONCLUSIONCOVID-19 represents a challenge to ongoing practice, however with clear algorithms, checklists, and contingency planning, it is possible to provide focused neurosurgical care during this pandemic.

Association Between Cardiac Surgeons’ Number of Years in Practice and Surgical Outcomes in New York Cardiac Centers

More than half of US cardiothoracic surgeons are older than 55 years, and the association between surgeon number of years in practice and surgical outcomes remains unclear. To assess the association between cardiac surgeons' time in practice and operative outcomes for coronary artery bypass grafting (CABG) and valve surgery. Cross-sectional analysis performed of surgeon-level outcomes data from the 2014-2016 New York State Cardiac Data Reporting System across the 38 New York cardiac surgery centers. Years in practice were characterized as early career (<10 years) and late career (≥10 years). Participants were 120 cardiothoracic surgeons who performed CABG and 112 cardiothoracic surgeons who performed valve procedures between 2014 and 2016. Data were analyzed in April 2020. Surgeons who trained outside of the United States or had unclear training history were excluded. Risk-adjusted operative mortality rate (RAMR). Mortality was defined as all-cause death within 30 days of surgery or within the index hospitalization, whichever was longer. Risk adjustment was performed by a multivariable risk model developed by the New York State Department of Public Health. Restricted cubic spline curve identified the association between risk-adjusted mortality rate and surgeon number of years in practice. Linear regression models adjusted for surgeons' annual case volumes. A total of 112 CABG surgeons and 120 valve surgeons performed 39 436 CABG and 18 596 valve procedures between 2014 and 2016. The median number of surgeon years in practice was 20.0 (interquartile range [IQR], 12.0-28.5) years. The median surgeon annual case volume was 160.0 (IQR, 92.5-245.0) for CABG procedures and 104.0 (IQR, 43.0-210.0) for valve procedures. The median RAMR was 1.3% (IQR, 0.2%-2.2%) for CABG procedures and 3.1% (IQR, 1.7%-5.1%) for valve procedures. Surgeons with less than 10 years of practice had higher RAMR for valve procedures compared with surgeons with more than 10 years of practice (4.0 [IQR, 1.5-7.7] vs 2.9 [IQR, 1.7-4.7]; P = .20), but the finding was not statistically signficant. The RAMR for surgeons with less than 10 years of practice was similar compared with surgeons with more than 10 years of practice for CABG procedures (1.3 [IQR, 0.3-2.1] vs 1.3 [IQR, 0.0-2.2]; P = .73). A lower number of years in practice was significantly associated with higher RAMR for valve procedures (RAMR estimates for linear term: -1.144; 95% CI, -1.955 to -0.332; P = .006; quadratic term: 0.059; 95% CI, 0.015 to 1.102; P = .008; and cubic term: -0.001; 95% CI, -0.002 to 0.000; P = .01). This association was not observed for CABG. In this cross-sectional study, compared with late-career cardiac surgeons, early-career cardiac surgeons were associated with worse risk-adjusted outcomes for valve operations but not for CABG. This finding suggests certain competence deficiency for valve surgery early after finishing training in cardiac surgery.

Covid-19 e o cenário atual da Cidade de Castanhal –PA, Brasil

A COVID-19, doença descoberta em 31 de dezembro de 2019, possui os sintomas semelhantes aos de uma gripe comum, e impacta a vida da população mundial de forma gradativa. Um estudo realizado pela Universidade Federal de Pelotas (UFPEL), apontou 11 cidades situadas na região norte com percentual elevado de contaminações pela COVID-19. O município de Castanhal, localizado no nordeste do Estado do Pará, Amazônia, Brasil, destaca-se entre as cidades brasileiras com uma das maiores taxas de contaminação, estando alocada em terceiro lugar no ranking nacional do índice de prevalência. Desse modo, este artigo tem como objetivo verificar os índices da COVID-19 em Castanhal-Pará, Brasil. Metodologicamente, realizou-se o levantamento de dados no site da Secretaria Estadual de Saúde Pública do Pará (SESPA), além da pesquisa bibliográfica, com abordagem quanti-qualitativa que consiste no envolvimento de métodos mistos. Nos resultados, constatou-se o aumento da taxa de casos confirmados assim como de óbitos e recuperados. De apenas 01 caso confirmado no dia 27 de março de 2020, o município passou para 1.215 confirmações da COVID-19 até o dia 12 de Junho de 2020. Além disso, verificou-se a função estratégica da cidade de Castanhal para o funcionamento de parte significativa de municípios do nordeste paraense. Conclui-se que várias medidas estaduais e municipais foram tomadas, na tentativa de enfrentar a COVID-19, porém são necessários cuidados contínuos, tanto da população, quanto do poder público no combate ao novo coronavírus.

P158 Implementation of an I + PSE Technical Assistance Opportunity to Reduce Childhood Obesity: A Qualitative Evaluation of Facilitators, Barriers, and Outcomes

<h3>Background</h3> Childhood obesity is disproportionately higher among low-income women and children, racial and ethnic minorities, and rural populations. To effectively promote sustainable change, healthy eating and active living (HEAL) initiatives are beginning to apply an individual + policy, systems, and environmental (I + PSE) framework for change. <h3>Objective</h3> Development of strategic plans to include I + PSE into 4 states' nutrition programming. <h3>Study Design, Setting, Participants</h3> Four, State Department of Public Health, Title V, maternal and child nutrition leaders participated in a 12-month technical assistance (TA) opportunity to develop strategic plans to include I + PSE into each state's nutrition programming. TA was delivered through a combination of online modules, community of practice group meetings, and individual coaching sessions. <h3>Measurable Outcome/Analysis</h3> Semi-structured, in-depth interviews were conducted post TA delivery with the 4 state nutrition leaders. Interviews were audio-recorded and transcribed verbatim. Two independent coders used qualitative content analysis to analyze the data characterizing themes and sub-themes. <h3>Results</h3> Facilitators to implementing I + PSE in state program planning included having education delivered through online modules, a community of practice to discuss ideas and issues that arose, individual coaching to address local barriers to implementation and supervisor support. Barriers identified were time and funding limitations, working in isolation, and lack of self-efficacy and infrastructure. Co-learning helped TA participants to overcome stagnancy and promote development of creative solutions. Participants recognized relationship-building as integral to systems development. <h3>Conclusions</h3> The TA identified factors that drive improved nutrition programming utilizing I + PSE in the planning process. Inclusion of both upstream and downstream influences is key to achieving optimal impact to improve HEAL in individuals and communities.

Letter: The Coronavirus Disease 2019 Global Pandemic: A Neurosurgical Treatment Algorithm.

To the Editor: The recent outbreak of a novel coronavirus illness (coronavirus disease 2019; COVID-19) has grown into a global pandemic. As a response, there have been several treatment recommendations published by international, federal, state, and local governing bodies. Here, we aim to help neurosurgeons synthesize these recommendations into an institutional policy that fits the unique demands of neurosurgical practice. We performed a comprehensive review of COVD-19 policies and aggregated multi-disciplinary expertise at our institution to formulate recommendations for scheduling surgery, providing neurosurgical coverage, and engaging in neurosurgical research during the COVID-19 outbreak. Here, we present a neurosurgical algorithm for varying levels of COVID-19 community infection. This algorithm (with an accompanying checklist) is centered around a 3-tiered system of viral “surge” quantification, which we use to triage case scheduling, and a paired coverage model (PCM), which we use to provide inpatient services. COVID-19 represents a challenge to ongoing practice; however, with clear algorithms, checklists, and contingency planning, it is possible to provide focused neurosurgical care during this pandemic. INTRODUCTION In late 2019, a new coronavirus disease emerged, and has been referred to as coronavirus disease 2019, abbreviated “COVID-19.”1-3 This virus initially caused a local infection of the city of Wuhan, China,1,4,5 and then quickly spread to over 30 countries and was declared a global pandemic by the World Health Organization (WHO) on March 11, 2020.6-12 As of March 13, 2020, there were 1629 cases and 41 total deaths in the United States, according to the statistics compiled by the Centers for Disease Control (CDC).13 These cases have been concentrated in California, Washington, and New York; however, almost all states have reported cases of COVID-19. As our health-care system faces this outbreak, the most pressing issues facing neurosurgeons involve (1) the decision to cancel elective cases and outpatient clinics, (2) organizing staff (including advanced practitioners and resident physicians) to minimize exposure risk, and (3) handling neurosurgical emergencies in situations where intensive care unit (ICU) bed availability is compromised by an increasing number of COVID-19 patients. Throughout this crisis, it is important to respect the nuances of COVID-19 policies set forth by local hospital systems and health-care institutions. However, such institutions often seek the advice of the neurosurgeon to synthesize national and international policy to formulate local treatment algorithms. This report is designed to aid neurosurgeons in this endeavor, and to serve as a reasonable starting point in making such local policy. The situation regarding COVID-19 is rapidly evolving, and changes daily. Although timely policies should be implemented to facilitate objective decision-making, it is inevitable that such directives will need to adapt to this fluid environment. The challenge of COVID-19 for the neurosurgeon is to minimize the risk of transmission of the virus, while continuing to provide care for neurosurgical patients in need of urgent and emergent treatments. Here, we provide our institutional experience to serve as an example for neurosurgeons facing these issues related to the ongoing COVID-19 outbreak. METHODS Literature Review and Chinese Neurosurgical Experience We first performed a literature review by submitting the terms “COVID-19” to PubMed. This yielded an initial set of 947 results, that were manually reviewed for relevance to neurosurgery, surgical case scheduling, and resident and advance practitioner staffing. Only articles in the English language were considered for this literature review. Once all relevant articles were identified, we extracted epidemiological information regarding the scheduling of surgical cases14 and the need for ICU care.15-17 We then used these data to form a multi-disciplinary panel from our institution in the departments of surgery, anesthesia and peri-operative care, critical care, hospital administration, and neurosurgery (“evidence review panel” (ERP)). In addition to this literature review, we sought the advice and expertise from neurosurgeons who had direct experience in China caring for neurosurgical patients during the COVID-19 outbreak. These neurosurgeons provided first-hand knowledge of how neurosurgical cases were scheduled during the peak of the COVID-19 outbreak in China. We included these recommendations as discussion points in our ERP. Because no patient data were used for this report, Institutional Review Board approval and patient consent was not sought or obtained. The Standards for Quality Improvement Reporting Excellence checklist was used when preparing the treatment algorithm. Interdisciplinary Panel Recommendations from the CDC, WHO, California State Department of Public Health, San Francisco Department of Public Health, and the University of California San Francisco (UCSF) School of Medicine were collected and reviewed by the ERP, and algorithms regarding the following issues were drafted: (1) neurosurgical case scheduling, (2) neurosurgical clinic scheduling, (3) contingency planning for neurosurgical staffing and ICU utilization, and (4) staffing neurosurgical research directives. These algorithms were formalized and distributed to the department, and communicated via email to all faculty, residents, and staff. Daily emails were used to document changes in the algorithms, enabling alterations based on rapidly evolving data and outbreak statistics. Final Algorithm and Checklist Our goal was the enactment of an algorithm and contingency plan in order to allow for dynamic resource allocation to meet the needs of the outbreak, while also caring for neurosurgical patients. All essential clinical staff (faculty, residents, and advanced practitioners) were notified of their role based on rising levels of infection risk. Teams were formed based on models of emergent surgical “outbreak” coverage.11 To facilitate communication across disciplines in crisis settings, we also devised a surgical checklist to be applied to neurosurgical cases. The checklist helped to focus attention on the barriers to booking urgent surgery during the pandemic. The final checklist and treatment algorithms were provided to faculty, residents, and advanced practitioners. RESULTS Scheduling Neurosurgical Cases Based on our literature review, no publications specifically addressing a neurosurgical response to COVID-19 have been published since the outbreak in late 2019. Although articles have addressed the effect on outpatient clinics,18 the virus’ effect on the central nervous system,19 and the preparation of the operating room (OR) for emergent surgeries for COVID-19 patients,14 there have also been no studies on algorithms for scheduling neurosurgical cases during the pandemic. The American College of Surgeons (ACS) does recommend that surgeons postpone or cancel elective cases during the COVID-19 pandemic.20 Although these recommendations are helpful, they do not address how to triage cases that require urgent neurosurgical scheduling (within ∼2 wk). To adequately handle these cases, our ERP first created a system to quantify the “surge level” of the disease (Figure 1). Using this system, the current surge level is given a color code that correlates with the rising viral transmission threat to our community. The green, yellow, and red levels represent the lowest, moderate, and highest levels of surge, respectively. The black level corresponds to the need for significant resources outside of our institution. As Figure 1 indicates, in the green level, all elective cases proceed as scheduled. In the yellow level, the OR schedule is capped for 3 wk to 75% of capacity, yielding a 25% reduction in all elective and procedural cases. During this time, all outpatient procedures should be designated to an off-site hospital where COVID-19 patients are not expected to be admitted. In addition, there is a hard cap on the number of cases requiring post-operative admission. In the red level, these numbers are more strict. Namely, there is a 50% reduction in all elective case scheduling, and a 12 patient limit on postoperative admissions for all surgical cases (including non-neurosurgical cases). Finally in the black level, in which significant state or federal resources are needed to fight the outbreak, all urgent scheduled surgical cases will be canceled.FIGURE 1.: Volume limiting approach to elective scheduling. The surge level criteria are shown in the left column, the emergent case and the elective case recommendations are shown in the middle two columns, and the transfer center recommendations are shown in the right column. OR: operating room; ED: emergency department; appy: appendectomy; chole: cholecystectomy; hip fx: hip fracture; ERCP: endoscopic retrograde cholangiopancreatography; IR: interventional radiology; cath: cardiac catheterization; PACU: post-anesthesia recovery unit. Community cases refer to active cases in the local region.This system responds to a dynamic level of transmission surge, and is flexible in the kinds of cases allowed to proceed. In particular, by setting limits on the number of cases as opposed to the types of cases, it allows the surgeon to triage his or her own schedule. This “volume limiting approach” encourages maximal adaptability, in which the supply of hospital capability meets the demand of scheduling needs. In addition, the surgeon should reduce outpatient clinic volume by 25% in the yellow level and by 50% in the red level. In the black level, outpatient clinic should be canceled. Finally, throughout all levels, neurosurgeons are encouraged to convert meetings (with staff, colleagues, and patients) to video conferencing. The neurosurgeon is provided with full information technology support to set up video conferencing and tele-health. At the surgeons’ discretion, patient follow-ups and clinic appointments, when possible, should be converted to tele-medicine. In addition, consistent with policy from the San Francisco Department of Public Health and the California Department of Public Health, staff and patients over the age of 65 are encouraged to avoid coming to the hospital and clinic. In these situations, the surgeon should make every effort to engage in telemedicine and remote meetings. Emergent Cases and Hospital Staffing At all levels of outbreak, the algorithm in Figure 1 allows for emergent surgery. To care for these patients, neurosurgery services require 24 h in-house coverage, which is provided at our institution by resident physicians. It is thus important to develop a system to minimize patient and provider viral exposure, while also simultaneously ensuring uninterrupted inpatient coverage for neurosurgical emergencies. The system that we have designed to meet these goals is shown in Figure 2. This system is based on the “paired coverage model.” In this system, each hospital will be covered by 2, nonoverlapping teams. Each team will only rotate at 1 hospital (no cross-covering) and will only have contact with members within their team. Teams at the same site will not have any overlapping clinical time with each other. Teams will rotate in 3 d cycles: ie, each team will cover for 3 d, and then have 3 d off while the second team covers. The transition between teams will occur virtually, avoiding unnecessary team-to-team contact. This system ensures adequate coverage, minimizes hand-off issues, and, most importantly, minimizes transmission risk across teams.11 Because the likelihood of infection is present among inpatient providers, there will be a designated “alternate pool” of providers that will substitute for those who show COVID-19 symptoms.FIGURE 2.: Paired Coverage Model. The following model of team-based paired coverage will go into effect during red levels of COVID-19 (see Figure 1). In this model, each individual hospital (columns) will have 3 groups of providers: 2 teams that switch coverage on a 3-d cycle, and an alternate group that substitutes for any team member who shows signs of illness. In this way, if a team becomes contaminated, the other team will take over, and the alternates will fill the gap. Contact between teams and alternates is prohibited. VA: Veterans Affairs Peds: pediatric; PGY: post-graduate year (resident level).The PCM is triggered by a red level of surge (Figure 1). All residents are aware of their role in the PCM ahead of time. In addition, site-specific needs are addressed within the team. For example, teams at the main hospital in our institution are larger than teams at other satellite hospitals, given the large volume at the main hospital compared to the satellite hospitals. Thus, the PCM is adaptable such that the number of team members can vary, along with the experience level of the team. However, the core function of the PCM (limiting healthcare worker transmission of the virus) remains. In addition to the PCM, it is also important that neurosurgeons provide their anesthesia colleagues, nursing staff, and the OR with objective data about which cases should be expected to proceed during a COVID-19 outbreak. Indeed, although it may be straight forward for neurosurgeons to predict what cases should be classified as an emergency, it will reduce ambiguity if the entire team is also aware of such cases. To that end, we developed a checklist that can be applied to neurosurgical case during the COVID-19 pandemic (Figure 3). Previous work has shown that checklists help organize surgical staff during times of crisis, such as guiding action during “red alerts” from neuromonitoring during spinal surgery.21 Here, we adapt the checklist strategy to organize surgical staff around the common goal of booking cases during the outbreak (Figure 3). Distribution of the checklist to all surgical staff will facilitate effective communication and the ease with which appropriate neurosurgical cases can be scheduled.FIGURE 3.: Checklist for booking neurosurgical cases during COVID-19 outbreak.Research Directives and Staffing Finally, our institution has addressed how COVID-19 affects research directives. We have required that all staff not essential to clinical care stay at home. This applies to lab workers, research track faculty, postdoctoral fellows, and graduate students. Animal facilities will be run by institutional staff outside the Department of Neurosurgery. As of March 18th, the UCSF Office of Research will institute a shutdown of all noncritical research activities. Understanding that the needs of long-term viability of many research programs will require management of essential animal lines, equipment, liquid nitrogen stocks, and certain long-term experiments, they are permitting 1 to 2 designated key personnel who will be responsible for this essential maintenance. Larger laboratories are allowed to name up to 3 to 4 key personnel. It is advised to select key personnel whose commute does not depend on public transportation. In mouse facilities, breeding is to be reduced to a minimum. There will be no increases in cage counts permitted. For other facilities housing aquatic, avian, or United States Department of Agriculture-covered animals, basic animal care and husbandry operations are to continue. Studies related to COVID-19 itself are exempt from the requirements since they have the potential to mitigate the spread of the pandemic. Staff with dual clinical and research roles (such as faculty, resident physicians, as well as clinic coordinators) are required to come in only if they are symptom free. During this time, if they have research time scheduled, research activities may be permitted. We have recommended that researchers working from home engage in writing projects, literature review, data analyses, or online learning (eg, computer coding and advanced statistics). Labs are charged with providing members with the ability to work remotely, including enabling virtual private network access. All new patient enrollments in on-going research studies are suspended. DISCUSSION COVID-19 is a global pandemic, and causes a severe infection that can lead to respiratory failure and death.22 The death rate for COVID-19 is much higher than the typical influenza seasonal viral illness, and disproportionally affects the elderly and patients with major cardiopulmonary co-morbidities.13 The high rate of transmission and virulence of COVID-19 is not only associated with a high mortality rate, but also risks putting such a strain on the health-care system that other patients will not be able to receive urgent treatments.16 In particular, respiratory failure from COVID-19 leads to a high rate of intubation requiring ventilator beds, creating a shortage of ICU capacity, making the treatment of all critical diseases extremely difficult, or even impossible.16 From a neurosurgical perspective, COVID-19 requires that the neurosurgeon balance the surgical needs of patients suffering from “urgent” diseases (eg, malignant brain tumors, spinal instability, and severe traumatic brain injury), with the need to allocate hospital resources for a possible outbreak. This report is designed to help the neurosurgeon with these difficult decisions. After a thorough review of the literature, there are no current studies that address the strains on neurosurgical practice from COVID-19. Furthermore, although several studies address the general strategies to cope with the strain that COVID-19 may place on the hospital system,6,15,17 specific recommendations for surgical practice are sparse. And, while the ACS lays out general principles,20 a detailed COVID-19 surgical treatment algorithm has not been previously published. Thus, our tiered volume limiting approach to restricting OR access based on the current surge level of the virus is novel. This volume limiting approach allows for dynamic resource allocation. By contrast, an alternative model would be to rank every type of surgical case ahead of time, and then triage cases based on these rankings. However, the volume limiting approach is more fluid, and allows surgeons to triage on a case-by-case basis, permitting more flexible operative plans based on the surge level, OR availability, and need for emergent cases. Thus, although neurosurgeons may feel pressure to cancel cases due to fear of intra- and perioperative COVID-19 transmission, these algorithms and checklists identify objective criteria for doing so. In addition, the PCM provides a flexible model of how to cover critically ill patients during COVID-19. Again, the basis of the model is identifying levels of COVID-19 surge using objective criteria of the presence of the viral outbreak level in the local community. Once triggered, the PCM allows for neurosurgical coverage while also minimizing the possibility of interteam transmission. Having a plan to provide coverage and handle emergency procedures ensures the functioning of the neurosurgery service despite increasing levels of community and hospital COVID-19 infections. Although our algorithms and checklists provide objective criteria to help neurosurgeons develop local protocols for COVID-19 outbreaks, there are a number of limitations in this study. First, most of the criteria are specific to one institution. Although the principles apply to other systems, the algorithms and checklists will need to be adapted accordingly. Second, our PCM requires a pool of resident physicians of different levels in order to implement. This may be translatable to other academic centers; however, neurosurgeons in smaller centers may have difficulty implementing PCM coverage. Finally, our surge level system requires knowledge about the number of cases in the community, which may not be obtainable in all practices. CONCLUSION We have established a set of algorithms and checklists for scheduling of neurosurgery cases (Figure 4), as well as neurosurgical coverage during the COVID-19 pandemic (Figure 5). These algorithms may be used as an example when implementing protocols in local neurosurgical practices; however, such protocols should adhere to local institutional polices and directives.FIGURE 4.: COVID-19 for the neurosurgeon: summary and take-away points.FIGURE 5.: Illustration of SARS-CoV-2, the pathogen of the COVID-19 global pandemic. © UCSF Department of Neurosurgery, 2020. All rights reserved. Used with permission.Disclosures The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article. Dr Chan has research support for nonrelated study from Orthofix, Inc. Dr Chou is a consultant for Globus and Medtronic. Dr Praveen Mummaneni is a consultant for DePuy Spine, Globus, and Stryker, has direct stock ownership in Spinicity/ISD, receives clinical/research support from NREF, receives royalties from DePuy Spine, Thieme Publishers, and Springer Publishers, and has grants from AOSpine and ISSG.

On the Frontlines: Rural Iowa Latino/a Ministries during COVID-19

On the Frontlines: Rural Iowa Latino/a Ministries during COVID-19 Kristy Nabhan-Warren34 This past summer, I had the opportunity to be a part of a conversation about how COVID-19 has impacted Eastern Iowa Catholics among local church leaders. These individuals, who are part of the Diocese of Davenport, have decades of experience ministering to an increasingly diverse community of white, Latino/a, Vietnamese, and Burmese parishioners. Before COVID-19 hit the state in the spring, they met in person each month over coffee and pastries; these days they gather over Zoom and have coffee virtually. Yet the joys and challenges of serving multicultural and multilingual populations remains the focus of their conversations. While Iowa is a predominantly white and rural state, the sizeable and growing number of Latinos/as and their ongoing economic and social precarity are of particular concern for these men and women who are committed to a more just church and society. Three interlocking themes emerged from the Zoom meeting: Work is dangerous; There is so much fear; and Latino/a Catholics want community. Work is Dangerous According to Father Guillermo Treviño, the parochial vicar of St. Joseph parish in West Liberty and St. Patrick parish in Iowa City, Spanish-speaking parishioners have been “living in fear” because of immigration laws, potential ICE raids, and now COVID-19. Most Latinos/as in his parishes work in meatpacking at the turkey processing plant in town, West Liberty Foods, or at nearby Columbus Junction’s Tyson hog processing plant. As we have seen in the news, Latino/a workers have contracted COVID-19 at packing plants across Iowa at an alarming rate, as the slaughterhouses have been slow to respond at [End Page 18] best, negligent at worst, in addressing their workers’ safety.35 What we have not heard about as much, says Father Guillermo, is that Latinos/as and other refugees infected with COVID-19 end up spreading it to their family members, as they tend to live in multi-generational homes.36 What Father Guillermo has learned in working closely with his Spanish-speaking parishioners in West Liberty and Iowa City is that some Latinos/as who work at the meatpacking plants and who have COVID-19 have hid their symptoms and continued to work at the plants because they need the paycheck and are afraid of getting fired. According to Father Guillermo, around 500 workers at West Liberty’s turkey plant have been sickened by COVID-19. Some have died. The other Zoom participants nod in agreement when he mentions that the state has not been fully honest in its reporting of the numbers of COVID-19 cases. “The numbers are higher than they have been reported,” Father Guillermo says with a shake of his head. He continues to shake his head, looking down, as he talks about presiding over three COVID-19 funerals for Spanish-speaking parishioners in the past several months, all of whom were infected by the virus at the turkey processing plant. Father Guillermo is correct in his assessment that COVID-19 cases have been underreported in the state of Iowa. A recent report found that Iowa’s State Department of Public Health had recorded 221 cases of COVID-19 in the Tyson plant, whereas the company has counted 522 cases.37 As we have seen on a national scale in the meatpacking industry, Iowa slaughterhouses have been veritable petri dishes for the virus to develop and spread. Workers perform their jobs side by side, mere inches apart and nowhere near the recommended six feet.38 [End Page 19] Father Guillermo says that almost all of his parishioners who have contracted COVID-19 contracted it from the packing plant, or live with someone who works at a packing plant. He emphasizes that for Latinos/as in particular, the family is the central unit and extended families tend to live together, making is impossible for them to maintain social distancing.39 Father Guillermo’s ministerial relationship with his parishioners was complicated during COVID-19 when the vice president of West Liberty Foods asked him to serve as a translator and go-between for the company and his Spanish...

Crianças belas, sadias e robustas: o futuro da raça brasileira nas políticas de proteção à infância em Santa Catarina nos idos de 1940

O presente artigo analisa a relação entre o discurso médico-higienista, a eugenia e a consolidação de um pensamento racial no atendimento à pequena infância nos anos 1940, em Santa Catarina. Práticas médico-higiênicas são organizadas e difundidas pelo Departamento de Saúde Pública do estado por meio de campanhas em prol da formação de uma raça forte e sadia. Entre elas, o Concurso Infantil de Robustez e Beleza, que premiava as mães das crianças saudáveis e eugenicamente belas. O Concurso Infantil de Robustez e Beleza foi promovido e intensamente divulgado pela imprensa da época, em particular o jornal A Gazeta, que atuava em consonância com o projeto de educação higiênica e eugênica do governo Nereu Ramos. A pesquisa apontou para a evidência de um projeto nacional que visava à regeneração das crianças, especialmente as negras e pobres. Tomamos como fontes para o levantamento de dados os jornais A Gazeta e Republica e relatórios da Legião Brasileira de Assistência, que tratam do concurso, do Centro de Puericultura, Proteção à Infância e à Maternidade, Assistência Profilática, Cozinha Dietética e Serviço de Higiene da capital.

Advancing Rural Maternal and Child Health (MCH) Nutrition Initiatives for Childhood Obesity: Application of PSE Approaches (P13-019-19)

ObjectivesObesity is disproportionately represented among low-income women and children, racial ethnic minorities including American Indian/Alaskan Native (AI/AN) populations and in rural settings. Reducing health disparities is a Healthy People 2020 goal, yet few strategies have proven successful long-term or at the population level. Healthy eating and active living (HEAL) initiatives realize greater impact when including Policy, System and Environmental (PSE) actions. These are widely informed through the Spectrum of Prevention framework. However, this framework does not include contributions from the individual level (I) – often where many nutrition interventions begin. Therefore, the objectives of this project are to: 1) Test a PSE conceptual framework with four, State Department of Public Health (DPH), MCH nutrition teams that are part of a larger technical assistance effort (TA) for capacity building; and 2) Inform the science and practice of applying a PSE framework for action through development of best practices protocols in these settings. MethodsState DPH nutrition teams are provided PSE training via completion of an online series of 5 modules. Additionally, they will receive MCH-specific TA tailored for each state team including the PSE framework that is being tested. Each team will develop a strategic plan to be evaluated for: 1) resource allocation for implementation; 2) commitment of essential partners; 3) alignment with state childhood obesity strategic plan; 4) potential changes in infrastructure/systems to promote sustainability, 5) potential to reduce state healthcare costs; and 6) feasibility of replication in other states. Informing PSE science and practice will be assessed by inclusion of the PSE conceptual framework and the methods chosen for implementation. ResultsN/A. ConclusionsHEAL initiatives have proven more successful than individual approaches in improving community health indicators. Rural and AI/AN communities have unique challenges to preventing childhood obesity. Utilizing an approach that includes both individual and PSE strategies may be a more effective way to address these specific communities’ health challenges. Funding SourcesHealth Resources Services Administration, Maternal and Child Health Bureau.

Characterization of rabies post-exposure prophylaxis in a region of the eastern Amazon, state of Pará, Brazil, between 2000 and 2014.

Animal bites are a serious public health issue, and prevention strategies have been consistently documented worldwide. The aim of this study was to characterize human anti-rabies treatment in 11 counties of the Salgado microregion, Pará state, Brazil, which borders the Bragantina microregion, where exposures of human rabies were reported in 2004 and 2005. A descriptive retrospective study was conducted using anti-rabies treatment notifications registered in the Information System for Notifiable Diseases (SINAN) database of the State Department of Public Health of Pará (SESPA) from January 2000 to December 2014. In this period, 13,403 exposures were reported, with a growing annual trend (Y=68.571x+344.96). The years 2012 and 2013 presented the highest exposure incidence. Salinópolis was the county with the highest average annual incidence per 10,000 persons (62.83), followed by São João de Pirabas (43.28) and São Caetano de Odivelas (41.27). Most patients were males (59.6%) and were 1-19years old (48.7%). The main species involved in aggressions were dogs (74.1%), followed by bats (13.1%) and cats (7.4%). Biting was the most common kind of exposure, mostly on the lower limbs (39.6%). This study shows that aggression by bats was the second most common cause of demand for the service in the region for the past 14years. The low quality of records may increase the difficulty of rabies surveillance in Pará.

[Leptospirosis space-time distribution and risk factors in Belém, Pará, Brazil].

The occurrence of leptospirosis has defied epidemiology even when using different analysis technologies at local geographical levels. This cross-sectional and descriptive study sought to identify spatial correlations between social and environmental risk factors and leptospirosis in Belém in the State of Pará from 2007 to 2013. Epidemiological data were obtained from the Information System for Notifiable Diseases of the Pará State Department of Public Health and the environmental, demographic and cartographical data from the Brazilian Institute of Geography and Statistics. Men aged 20 to 39 of unknown profession and mixed ethnicity were the most affected. Laboratory diagnosis (82%) and hospital care (67.22%) confirmed satisfactory access to the Unified Health System. Numerical Kriging indicated the highest concentrations of the disease in the Guamá and Jurunas neighborhoods in lower lying areas near canals. The Buffer technique showed higher concentrations of the disease in areas with no domestic solid garbage collection service (26%), sewage (22%), piped water (38%), with unpaved roads (20%) and street flooding (65%). The Moran technique revealed a direct spatial correlation between these variables (p = 0.01543). The general trend showed the decrease of the disease.