State Health Services Research Articles

Abstract TP232: Disparities in Access to Stroke Research in the State of Texas

Objective: Access to care is an important healthcare goal but access to research is also important to patients. We sought to gain an understanding of the status of stroke research among the various stroke designated hospitals in the state and to identify regions and facilities that lack access to stroke research. Methods: Texas Department of State Health Service (TDSHS) designated stroke facilities (DSF) were surveyed using a standardized questionnaire via telephone/email to confirm stroke center status, presence of a dedicated stroke coordinator, use of telestroke services, and participation in stroke research. Stroke discharge data were obtained from TDSHS and stroke volume (by ICD) were estimated for 2013 for all non-DSF. Census data were obtained from the US Census Bureau. Results: In total, 109/136 (80%) TDSHS DSF responded to the survey. Only 32/109 (29%) of the TDSHS DSF are participating in stroke research, mostly in the 4 metropolitan areas (fig 1). We identified 16 non-DSF that have 100-149 stroke discharges, and another 21 non-DSF that have ≥ 150 stroke discharges (fig 1). Over half (53%) of the DSF in the state are utilizing telestroke services. Conclusions: Most clinical stroke research conducted in Texas is in the 4 metropolitan markets. Our findings demonstrate that over 50% or ~14 million Texans reside outside of the 4 markets and therefore may lack access to stroke research. To increase access, we identified several non-DSF in the state with substantial stroke discharges (fig 1). Academic centers and non-DSF partnering through telemedicine and other relationships should be considered to expand throughout the state opportunities for participation in stroke research.

Maternal Mortality in Texas.

A commentary on maternal mortality in Texas is provided in response to a 2016 article in Obstetrics & Gynecology by MacDorman et al. While the Texas Department of State Health Services and the Texas Maternal Mortality and Morbidity Task Force agree that maternal mortality increased sharply from 2010 to 2011, the percentage change or the magnitude of the increase in the maternal mortality rate in Texas differs depending on the statistical methods used to compute and display it. Methodologic challenges in identifying maternal death are also discussed, as well as risk factors and causes of maternal death in Texas. Finally, several state efforts currently underway to address maternal mortality in Texas are described.

Using Community Based Participatory Action Research to Define Positive Youth Development Program Goal Priorities with a Latino Community

In 2010 the Texas Department of State Health Services launched a Health Adolescent Initiative with the goal of improving the overall health and well-being of adolescents in six Texas communities. E...

Administrative efficiency in the Mexican Fund for the Prevention of Catastrophic Expenditures in Health

To show that the administrative regime of specialized hospitals has some influence on the administrative processes to operate the Mexican Fund for Catastrophic Expenditures in Health (FPGC, in Spanish), for providing health care to breast cancer, cervical cancer and child leukemia. The variable for estimating administrative efficiency was the time estimated from case notification to reimbursement. For its estimation, semistructured interviews were applied to key actors involved in management of cancer care financed by FPGC. Additionally, a group of experts was organized to make recommendations for improving processes. Specialized hospitals with a decentralized scheme showed less time to solve the administrative process in comparison with the model on the hospitals dependent on State Health Services, where timing and intermediation levels were higher. Decentralized hospitals administrative scheme for specialized care is more efficient, because they tend to be more autonomous.

Disparity in maternal, newborn and child health services in high focus states in India: a district-level cross-sectional analysis

ObjectivesTo examine the level and trend in the coverage gap of a set of interventions of maternal and child health services using a summary index and to assess the disparity...

Notes from the Field: Health Care-Associated Hepatitis A Outbreak - Texas, 2015.

On August 27-28, 2015, the Texas Department of State Health Services received calls from Fort Bend County and Harris County health departments requesting postexposure prophylaxis (PEP) recommendations for contacts of two nurses (patients A and B) with confirmed hepatitis A virus (HAV) infection. Both nurses had symptom onset during August 15-19 and worked for the same pediatric home health care agency in another jurisdiction. Because of the proximity of the onset dates, a common source exposure was suspected. The state and local health departments began an investigation to identify potentially exposed patients, their families, and other agency personnel; offer PEP; and identify the source of exposure.

Pravo pacijenta - potrošača na naknadu troškova prekogranične zdravstvene zaštite

Summary: The exercise of fundamental market freedoms in the European Union includes the freedom of movement of persons in order to attain the right to health care. A part of the possibility to access health services in the Member States where they are insured, the citizens of the Union can also demand such a service in another Member State and obtain reimbursement. This is the so called cross-border healthcare. Directive 2011/24/EU on the application of patients' rights in cross-border healthcare is a new legal instrument adopted to ensure the mobility of patients within the European Union and eliminate the existing differences in the application of two parallel systems - one based on Regulation 883/2004/EC on the coordination the social security system, and the other on the principles and views of the Court of the European Union, which are based on the provisions of the Treaties on the fundamental market freedoms. The first report of the Commission on the application of Directive 2011/24/EU from October 2015 shows that all the objectives proclaimed in the Directive have not yet been achieved and all the dilemmas related to different mechanisms of reimbursement for cross-border healthcare in the EU have not been eliminated. Analysis of the organization of health care systems in Bosnia and Herzegovina and the right to mobility of patients within and outside of its borders illustrates the complexity and inefficiency of this system, the discrimination related to patient’s mobility as well as a high level of noncompliance of Bosnian legislation with the acquis in this area.

Longitudinal Community Assessment for Public Health Emergency Response to Wildfire, Bastrop County, Texas.

On September 4, 2011, a wildfire ignited in Bastrop County, Texas, resulting in losses of 34,068 acres of land and 1,645 homes and 2 deaths. At the request of the Texas Department of State Health Services Health Service Region 7 and the Bastrop County Office of Emergency Management, Community Assessments for Public Health Emergency Response (CASPER) were conducted in the weeks following the wildfire and again 3.5 years later to assess both the immediate and long-term public health and preparedness impacts of the wildfire. The objective of these assessments was to learn more about the trajectory of disaster recovery, including rebuilding, evacuation, household emergency planning, and mental and physical health outcomes among both adults and children. In 2015, households exposed to the 2011 wildfires were significantly more likely to have established a family meeting place and evacuation route, to have confidence in the local government's ability to respond to disaster, and to report symptoms of depression and higher stress. Longitudinal assessments using the CASPER method can provide actionable information for improved planning, preparedness, and recovery to public health and emergency management agencies and community residents.

Association between Ambient Air Pollution and Asthma Prevalence in Different Population Groups Residing in Eastern Texas, USA.

Air pollution has been an on-going research focus due to its detrimental impact on human health. However, its specific effects on asthma prevalence in different age groups, genders and races are not well understood. Thus, the present study was designed to examine the association between selected air pollutants and asthma prevalence in different population groups during 2010 in the eastern part of Texas, USA.The pollutants considered were particulate matter (PM2.5 with an aerodynamic diameter less than 2.5 micrometers) and surface ozone. The population groups were categorized based on age, gender, and race. County-wise asthma hospital discharge data for different age, gender, and racial groups were obtained from Texas Asthma Control Program, Office of Surveillance, Evaluation and Research, Texas Department of State Health Services. The annual means of the air pollutants were obtained from the United States Environmental Protection Agency (U.S. EPA)’s air quality system data mart program. Pearson correlation analyzes were conducted to examine the relationship between the annual mean concentrations of pollutants and asthma discharge rates (ADR) for different age groups, genders, and races. The results reveal that there is no significant association or relationship between ADR and exposure of air pollutants (PM2.5, and O3). The study results showed a positive correlation between PM2.5 and ADR and a negative correlation between ADR and ozone in most of the cases. These correlations were not statistically significant, and can be better explained by considering the local weather conditions. The research findings facilitate identification of hotspots for controlling the most affected populations from further environmental exposure to air pollution, and for preventing or reducing the health impacts.

Executive Summary: Recommendations for Criminal Justice and Community Agencies in Contact with Criminal Justice-Involved Veterans

Official statistics indicate that approximately 10% of incarcerated offenders are veterans. Increased attention has been paid to a distinct constellation of issues and needs in relation to military service and/or training (e.g., mental health, post-traumatic stress disorder, reintegration, substance abuse), which may increase the likelihood of contact with the criminal justice system. Individuals facing these challenges require specific services, but barriers to their access exist, including insurance coverage and stigmatization. With the increased awareness of the “invisible wounds of war,” practitioners have called for initiatives to: 1) improve public safety, including the safety of first responders and the veterans they are responding to 2) provide treatment focused responses 3) reduce recidivism (later contact with the criminal justice system).This summary reports the results from the first annual Justice Involved Veterans Stakeholder Summit that took place from November 9th through 11th of 2015 in Huntsville, Texas. The summit was organized by the Texas Veterans Commission, the Department of State Health Services, the Bell/Lampasas County Community Supervision and Corrections Department, and the Meadows Mental Health Policy Institute in partnership with the Law Enforcement Management Institute and Correctional Management Institute of Texas at Sam Houston State University. Participants included of subject matter experts on veterans, mental health, and criminal justice issues and practitioner participants from all stages of the criminal justice system. All participants are listed at the end of this report.The Summit’s goal was to produce recommendations for strategies targeting veterans in contact with the criminal justice system specifically using the GAINS Center Sequential Intercept Model. This model focuses on partnerships between mental health and criminal justice entities and includes the five following intercepts:1) 911/Law Enforcement2) Initial Detention/Initial Court Hearings3) Jails/Specialty Courts4) Jail Reentry/Prison Reentry5) Community SupervisionThe practitioner participants were divided into five groups, one for each intercept, based on their roles in their institutions and agencies. The subject matter experts moved between groups and were called upon by groups to advise as needed.This report presents the problems, needs, barriers, and corresponding solutions collectively identified by the groups and subject matter experts. While the focus was on the State of Texas, these recommendations can be implemented by a wide variety of communities.

3 ILO Committee on Freedom of Association: Complaint against the Government of Peru presented by the National Union of State Health Service Nurses (SINESSS), Case No. 3096, Report in which the Committee Requests to be Kept Informed of Developments, 11 November 2015

3 ILO Committee on Freedom of Association: Complaint against the Government of Peru presented by the National Union of State Health Service Nurses (SINESSS), Case No. 3096, Report in which the Committee Requests to be Kept Informed of Developments, 11 November 2015

Abstract TP237: Uneven Distribution of Stroke Patients and Stroke Centers

Background: Texas is a large state with high demographic and geographic diversity. We analyzed the distribution of high-risk patients and stroke care hospitals to determine how to optimally distribute resources to benefit the largest number of patients. Methods: Data on overall state demographics were based on 2013 estimates derived from 2010 US census data. The number of hospitals was provided by the Department of State Health Services (DSHS). Stroke patients were ascertained via cms.gov and Texas DSHS data. Stroke data were available from 233 of 254 counties. Hospital designation in Texas is based on state-based criteria, but largely follows the definitions used by the Joint Commission. Results: Texas has approximately 26.4 million people (43% white, 39% Hispanic, 12% black, and 6% other). There are almost 3.3 million Medicare beneficiaries, of whom 94,071 have had a stroke. Texas has 649 hospitals with 84,000 licensed beds. There are 135 stroke facilities in 49 counties; 205 counties have no designated stroke facilities. Stroke designated hospitals include 12 CSCs, 110 PSCs, and 13 ASRH. There are 79 Critical Access Hospitals (CAH) that provide varying degrees of stroke care but have diverse locations (see map). The majority of Stroke Centers are located in or around large urban areas. The number of stroke patients varied significantly by county, with as few as 11 and as many as 12,844 in some counties. Many counties with large Medicare populations have few or no stroke centers. Conclusions: The distribution of stroke patients and stroke facilities in Texas is often mismatched. Processes to better match stroke resources with high-risk populations might improve stroke systems of care and perhaps outcomes. Conversion of some CAHs to ASRHs might alleviate some of these disparities.

Healthcare-Associated Infections (HAI): The Perfect Storm has Arrived!

1. Rodney E. Rohde, PhD, MS, SV, SM (ASCP)CM, MBCM[⇑][1] 1. Clinical Laboratory Science Program, College of Health Professions, Texas State University, San Marcos, TX 2. Marilyn Felkner, DrPH, MT(ASCP) 1. Emerging and Acute Infectious Disease Branch (EAIDB), Infectious Disease Control Unit, Texas Department of State Health Services (DSHS), Austin, TX 3. Julie Reagan, PhD, JD, MPH 1. Georgia Southern University, Jiann-Ping Hsu College of Public Health, Statesboro, GA 4. Amber Hogan Mitchell, DrPH, MPH, CPH 1. The International Safety Center, Apopka, FL 5. Pat Tille, PhD, MT(ASCP) 1. Medical Laboratory Science, College of Pharmacy, South Dakota State University, SD 1. Address for Correspondence: Rodney E. Rohde, PhD, MS, SV, SM (ASCP)CM, MBCM, Professor & Chair, CLS Program; Associate Dean for Research, Clinical Laboratory Science Program, College of Health Professions, Texas State University, 601 University Drive, San Marcos, TX 78666, 512-245-2562, 512-245-7860, rrohde{at}txstate.edu INTRODUCTION On any given day approximately 1 of every 25 inpatients in U.S. acute care hospitals has at least one healthcare–associated infection (HAI), adding up to about 722,000 infections in 2011. Pneumonia and surgical-site infection are the most common infection types, and Clostridium difficile is the most common pathogen.1 The CDC Multistate Point-Prevalence Survey of Healthcare-Associated Infections, published in the New England Journal of Medicine, used 2011 data from 183 U.S. hospitals to estimate the burden of a wide range of infections in hospital patients. That year, about 721,800 infections occurred in 648,000 hospital patients. About 75,000 patients with HAI died during their hospitalizations. The most common healthcare-associated infections were pneumonia (22%), surgical site infections (22%), gastrointestinal infections (17%), urinary tract infections (13%), and bloodstream infections (10%). The most common germs causing HAI by rank were C. difficile (12%), Staphylococcus aureus , including Methicillin Resistant S. aureus (MRSA, 11%), Klebsiella (10%), E. coli (9%), Enterococcus (9%), and Pseudomonas (7%). Klebsiella and E. coli are members of the Enterobacteriaceae bacteria family, which has become increasingly resistant to last-resort antibiotics known as carbapenems, typically referred to as carbapenem resistant Enterobacteriaceae (CRE).1 Practically, what this means is that over 200 patients will die the day you read this article and every day until the global community is able to address this healthcare crisis. If you do the simple math you will realize this results in about 4% of hospitalized patients who developed one or more HAI due to the care received in the hospital… ABBREVIATIONS: CAUTI – Catheter-associated urinary tract infection, CDC – Centers for Disease Control and Prevention, CLABSI – Central line-associated blood stream infection, EVS – Environmental services, HAI – Healthcare-associated infections, HCW – Healthcare Worker, MRSA – Methicillin resistant Staphylococcus aureus , SSIs – Surgical site infections [1]: #corresp-1

The Legal Landscape: HAI Public Reporting in the United States

1. Julie Reagan, PhD, JD, MPH 1. Georgia Southern University, Jiann-Ping Hsu College of Public Health, Statesboro, GA 2. Rodney E. Rohde, PhD, MS, SV, SM (ASCP)CM, MBCM[⇑][1] 1. Clinical Laboratory Science Program, College of Health Professions, Texas State University, San Marcos, TX 3. Amber Hogan Mitchell, DrPH, MPH, CPH 1. The International Safety Center, Apopka, FL 4. Marilyn Felkner, DrPH, MT(ASCP) 1. Emerging and Acute Infectious Disease Branch (EAIDB), Infectious Disease Control Unit, Texas Department of State Health Services (DSHS), Austin, TX 5. Pat Tille, PhD, MT(ASCP) 1. Medical Laboratory Science, College of Pharmacy, South Dakota State University, SD 1. Address for Correspondence: Rodney E. Rohde, PhD, MS, SV, SM (ASCP)CM, MBCM, Professor & Chair, CLS Program; Associate Dean for Research, Clinical Laboratory Science Program, College of Health Professions, Texas State University, 601 University Drive, San Marcos, TX 78666, 512-245-2562, 512-245-7860, rrohde{at}txstate.edu 1. Discuss the role of federal influences on state-level HAI program initiatives and reporting activities. 2. Describe the progression of state-level initiatives to reduce HAIs from 2004 to the current date. 3. Describe core provisions of state HAI reporting laws: surveillance, collection system, healthcare settings subject to the laws, types of infections reported, public reporting requirements, and advisory committee structure. 4. Identify healthcare worker infection and illness reporting mandates. INTRODUCTION Since early 2000, there has been a “growing interest in the use of law as a tool to address” healthcare-associated infections (HAIs) in the U.S.1 All 50 states and two territories have HAI programs established within their public health agencies.2 Likewise, the majority of states have HAI public reporting laws.3-4 HAI data is being reported from hospitals in all 50 states, either voluntarily or under state or federal legal reporting mandates.5 Additionally, while the current national focus is on reporting HAIs in the patient population, requirements for reporting infections and illness in the healthcare worker population also exists. The purpose of this article is to provide a review of the federal and state-level legal environment applicable to HAI prevention in the context of the overall response to HAIs. Federal Influences To fully grasp state-level HAI program initiatives and reporting activities, it is important first to understand the many federal influences. Through the U.S. Department of Health and Human Services (HHS) and the Centers for Disease Control and Prevention (CDC), the federal government plays a central role in the control and prevention of HAIs. From 2004 to 2008, states began to recognize the need for state policies aimed at HAI prevention.4 Several states made significant strides toward HAI surveillance and prevention as the awareness of the public health impact of HAIs grew. However, due to budget constraints and the associated poor economic conditions starting in 2008, most states were unable to implement or further develop their HAI programs. Significant improvements… ABBREVIATIONS: ACA – The Patient Protection and Affordable Care Act, CDC – Centers for Disease Control and Prevention, CMS – Centers for Medicare and Medicaid Services, CLABSI – central line-associated bloodstream infection, CAUTI – catheter-associated urinary tract infection, CRE – Carbepenem-resistant Enterobacteriaceae, HAIs – healthcare-associated infections, HHS – U.S. Department of Health and Human Services, IQR – Inpatient Quality Reporting Program, MRSA -- Methicillin Resistant Staphylococcus aureus , NHSN – National Healthcare Safety Network, OSHA – Occupational Safety and Health Administration, VAP – ventilator-associated pneumonia 1. Discuss the role of federal influences on state-level HAI program initiatives and reporting activities. 2. Describe the progression of state-level initiatives to reduce HAIs from 2004 to the current date. 3. Describe core provisions of state HAI reporting laws: surveillance, collection system, healthcare settings subject to the laws, types of infections reported, public reporting requirements, and advisory committee structure. 4. Identify healthcare worker infection and illness reporting mandates. [1]: #corresp-1

The Changing Role of the Healthcare Environment

1. Amber Hogan Mitchell, DrPH, MPH, CPH 1. The International Safety Center, Apopka, FL 2. Rodney E. Rohde, PhD, MS, SV, SM (ASCP)CM, MBCM[⇑][1] 1. Clinical Laboratory Science Program, College of Health Professions, Texas State University, San Marcos, TX 3. Pat Tille, PhD, MT(ASCP) 1. Medical Laboratory Science, College of Pharmacy, South Dakota State University, SD 4. Julie Reagan, PhD, JD, MPH 1. Georgia Southern University, Jiann-Ping Hsu College of Public Health, Statesboro, GA 5. Marilyn Felkner, DrPH, MT(ASCP) 1. Emerging and Acute Infectious Disease Branch (EAIDB), Infectious Disease Control Unit, Texas Department of State Health Services (DSHS), Austin, TX 1. Address for Correspondence: Rodney E. Rohde, PhD, MS, SV, SM (ASCP)CM, MBCM, Professor & Chair, CLS Program; Associate Dean for Research, Clinical Laboratory Science Program, College of Health Professions, Texas State University, 601 University Drive, San Marcos, TX 78666, 512-245-2562, 512-245-7860, rrohde{at}txstate.edu 1. Describe the role of the healthcare environment in its contribution to acquisition and transfer of microorganisms. 2. Discuss the role the environment has related to the risk of infection and illness in both patient and healthcare worker populations. 3. Summarize recently published scientific evidence related to transmission of microbes from environmental surfaces including textiles. 4. Explore laundering practices and procedures of healthcare textiles and uniforms. 5. Discuss new technologies and programs that can address reducing risk associated with contaminated environmental surfaces. INTRODUCTION The role of the healthcare environment and its contribution to acquisition and transfer of microorganisms that cause infection and illness in both patients and healthcare workers is not by any means straightforward. Considerations include potential contamination of hard surfaces like desks, sinks, beds, light switches, carts, walls, and floors, as well as porous surfaces like wheelchairs, bedding, linen, curtains, and upholstery. Historically the focus on managing the role of environmental variables was considered less critical because we knew less about the impact those surfaces had in infection prevention. Several factors are now monitored within healthcare settings that are considered environmental controls. One of the primary areas includes environmental surfaces. These have been categorized by the Spaulding Classification as “noncritical items” or those that do not come into contact with a patient's vascular system or body cavities, but rather simply by a brief or momentary touch from a patient or healthcare worker.1 Critical or semi-critical items, in contrast to environmental or touch surfaces, are medical devices that are either implanted into a patient like joints, stints or other devices used during medical or surgical procedures like scalpels, endoscopes or probes that are in contact with a patient for minutes, hours, weeks, or years. These items pose a higher risk than noncritical items because they come into direct contact with a patient's blood or body fluids. This year, the U.S. witnessed how improper cleaning and disinfection or sterilization or medical devices like endoscopes can result in serious patient illness and infection,… ABBREVIATIONS: ACHA – American College of Healthcare Architects, AHE - Association for the Healthcare Environment, CRE - carbapenem-resistant Enterobacteriaceae, CDC – Centers for Disease Control and Prevention, CDI – Clostridium difficile Infection, CFU – Colony Forming Units, EVS – Environmental Services, FDA - Food and Drug Administration, HCW – Healthcare Worker, HICPAC – Healthcare Infection Control Practices Advisory Committee, MDRO – Multiple Drug Resistant Organisms, MRSA – Methicillin Resistant Staphylococcus aureus , OR – Operating Room, OSHA - Occupational Safety and Health Administration, PPE – Personal Protective Equipment, VRE - Vancomycin-resistant Enterococci 1. Describe the role of the healthcare environment in its contribution to acquisition and transfer of microorganisms. 2. Discuss the role the environment has related to the risk of infection and illness in both patient and healthcare worker populations. 3. Summarize recently published scientific evidence related to transmission of microbes from environmental surfaces including textiles. 4. Explore laundering practices and procedures of healthcare textiles and uniforms. 5. Discuss new technologies and programs that can address reducing risk associated with contaminated environmental surfaces. [1]: #corresp-1

Political Pitfalls in Policymaking: The Texas HPV Vaccine Policy Saga

Political Pitfalls in Policymaking: The Texas HPV Vaccine Policy Saga Dan Bustillos In late 2005, while completing a post–doctoral fellowship at Baylor College of Medicine studying cancer disparities, I was asked to participate in a large–scale state health policy task-force on cervical cancer, a disease whose burden is [End Page 6] felt disproportionately by certain minorities and socioeconomic groups. Back then we were poised to have the unprecedented opportunity to dramatically reduce the incidence of cervical cancer due to the imminent approval and release of vaccines to immunize young girls from certain strains of the Human Papilloma Virus (HPV)–the sexually–transmitted pathogen responsible for most cases of cervical cancer. As a member of the Cervical Cancer Strategic Planning Initiative’s (CCSPI) Policy Work Group, I attended policymaking conferences convened in Austin, which were funded and organized by various agencies and organizations like the Texas Department of State Health Services and the Texas Cancer Council. But even more prominent and insistent in our policy taskforce meetings than the perpetually understaffed state agencies was the charismatic and influential presence of Women in Government (WIG), a large non–profit advocacy organization that includes many of the nation’s female legislators (including several close to then Texas governor Rick Perry). In fact, it had been at WIG’s behest, at its Cervical Cancer Summit in 2005, that Texas was singled out as the proving grounds for a push to enact liberal HPV vaccination policies into state law. And so it was that a large group of disparate stakeholders, health care professionals, grassroots activists, academics, cancer survivors, health economists and health policy wonks were all convened in Austin to prepare comprehensive policy recommendations on what Texas could and should be done once Merck’s Gardasil–projected to be the first FDA–approved HPV vaccine–became available in a few months. Beginning at the end of 2005, the taskforce worked to deliver thoughtful policy recommendations we would deliver to Rick Perry’s office. These sessions were well–financed, well–support staffed and filled with people from all over Texas with plenty of expertise, but since the actual vaccines were still in development at Merck and GlaxoS-mithKline (GSK), and little was publicly known about their relative safety and efficacy, we required access to unpublished data from the ongoing vaccine trials in order to base our recommendations on the best science available. This, it turned out, was not as difficult as it may sound. Although in private drug development the data generated by trials is usually a closely guarded trade secret until disclosure is required for patenting or for FDA approval, Merck didn’t wait for us to ask. Several Merck representatives were among the attendees at every CCSPI meeting. At first, I assumed that due to the pharmaceutical company’s obviously important role as the sole possessor of necessary information for our deliberation, Merck was asked to attend from the start. It wasn’t until later that I found out that Merck was in fact the prime mover behind this policymaking process, and their influence had begun well before the WIG summit in 2005. And although Merck’s obvious conflict of interest (the company stood to make many millions if not billions from any aggressive state vaccination policies) caused us to restrict Merck’s involvement to being a source of vaccine information when we asked for it, the pharmaceutical giant remained a constant presence throughout our policymaking. The Policymaking Process Although the morbidity and mortality associated with cervical cancer is not trifling, the policy work group decided early on not to recommend for mandatory vaccination of age–appropriate girls in Texas (the only group for which the new vaccine was expected to receive initial FDA approval). This decision was based on a variety of factors including the lack of long–term safety and efficacy data for the vaccine at the time, and the widespread belief among the policy taskforce members that a vaccine mandate bill would have little chance of passing the conservative legislature of Texas, a state that had seen very vocal criticism of the vaccine ever since it had been announced. Instead, we opted for a policy recommendation that showed...

The Perfect Storm: Emerging Trends and Pathogens in Healthcare

1. Pat Tille, PhD, MT(ASCP) 1. Medical Laboratory Science, College of Pharmacy, South Dakota State University, SD 2. Rodney E. Rohde, PhD, MS, SV, SM (ASCP)CM, MBCM[⇑][1] 1. Clinical Laboratory Science Program, College of Health Professions, Texas State University, San Marcos, TX 3. Julie Reagan, PhD, JD, MPH 1. Georgia Southern University, Jiann-Ping Hsu College of Public Health, Statesboro, GA 4. Marilyn Felkner, DrPH, MT(ASCP) 1. Emerging and Acute Infectious Disease Branch (EAIDB), Infectious Disease Control Unit, Texas Department of State Health Services (DSHS), Austin, TX 5. Amber Hogan Mitchell, DrPH, MPH, CPH 1. The International Safety Center, Apopka, FL 1. Address for Correspondence: Rodney E. Rohde, PhD, MS, SV, SM (ASCP)CM, MBCM, Professor & Chair, CLS Program; Associate Dean for Research, Clinical Laboratory Science Program, College of Health Professions, Texas State University, 601 University Drive, San Marcos, TX 78666, 512-245-2562, 512-245-7860, rrohde{at}txstate.edu 1. Explain how vulnerable populations, current healthcare delivery, and emerging pathogens have contributed to an increase in healthcare-associated infections. 2. Compare and contrast pathogens that occur in persons with HIV/AIDS, persons with cancer, and persons undergoing transplants. 3. Identify ways that community-based healthcare delivery may increase risk of HAIs. 4. Discuss the role of antibiotic overuse and international travel in the development of emerging pathogens. 5. Plan activities that are effective in preventing HAIs. INTRODUCTION In 1999, the article To Err is Human brought healthcare-associated infections (HAI) to the nation's attention. However, the risk posed by healthcare facilities to those who went there for healing had not developed overnight. Decades of changing demography, microbial evolution, and –ironically-- healthcare advancements had resulted in this perfect storm. Since the change in paradigm in healthcare that nosocomial or healthcare-associated infections are a natural consequence of treatment to a practice of surveillance and prevention, hospital acquired infections are no longer considered consequences of inpatient treatment. Prevention of healthcare-associated infections includes protecting patients, healthcare workers, visitors, volunteers and health science students. This paper aims to describe the contributory roles of affected populations with their attendant, diverse healthcare sites and healthcare workers, and emerging pathogens. Affected Populations Prior to the identification of the Acquired Immune Deficiency (AIDS) virus, persons with chronic immune deficiencies were anomalies—“bubble children” who were occasionally brought to the public's attention through the media. With the advent of HIV/AIDS, healthcare facilities faced the daunting task of caring for many individuals with immune deficiency on a long-term basis. Just as many infectious diseases seemed to have been conquered through vaccine or antibiotics, healthcare was called upon to manage a new infectious disease with no treatment and also to protect those individuals from other potential infections including pathogens that did not cause disease in persons with healthy immune systems. HIV/AIDS required healthcare facilities not only to protect their patients but their workers from a high fatality disease that was… ABBREVIATIONS: AIDS – Acquired Immune Deficiency Syndrome, CA-MRSA – Community-Associated Methicillin Resistant Staphylococcus aureus , CDC – Centers for Disease Control and Prevention, CRE - carbapenem-resistant Enterobacteriaceae, CMV – Cytomegalovirus, FDA - Food and Drug Administration, HA-MRSA – Healthcare-Associated Methicillin Resistant Staphylococcus aureus , HAI – Healthcare-Associated Infections, HCW – Healthcare Worker, HIV – Human Immunodeficiency Virus, KPC-Kp – Klebsiella pneumoniae Carbapenemase Producing, MERS – Middle Eastern Respiratory Syndrome, MDRO – Multiple Drug Resistant Organisms, MRSA – Methicillin Resistant Staphylococcus aureus , NICU – Neonatal Intensive Care Unit, NHSN – National Health Safety Network, PPE – Personal Protective Equipment, RSV – Respiratory Syncitial Virus, VRE - Vancomycin-resistant Enterococci 1. Explain how vulnerable populations, current healthcare delivery, and emerging pathogens have contributed to an increase in healthcare-associated infections. 2. Compare and contrast pathogens that occur in persons with HIV/AIDS, persons with cancer, and persons undergoing transplants. 3. Identify ways that community-based healthcare delivery may increase risk of HAIs. 4. Discuss the role of antibiotic overuse and international travel in the development of emerging pathogens. 5. Plan activities that are effective in preventing HAIs. [1]: #corresp-1

Context matters: Successes and challenges of intrapartum care scale-up in four districts of Afghanistan

ABSTRACTReducing preventable maternal mortality and achieving Sustainable Development Goal targets for 2030 will require increased investment in improving access to quality health services in fragile and conflict-affected states. This study explores the conditions that affect availability and utilisation of intrapartum care services in four districts of Afghanistan where mortality studies were conducted in 2002 and 2011. Information on changes in each district was collected through interviews with community members; service providers; and district, provincial and national officials. This information was then triangulated with programme and policy documentation to identify factors that affect the coverage of safe delivery and emergency obstetric care services. Comparison of barriers to maternal health service coverage across the four districts highlights the complexities of national health policy planning and resource allocation in Afghanistan, and provides examples of the types of challenges that must be addressed to extend the reach of life-saving maternal health interventions to women in fragile and conflict-affected states. Findings suggest that improvements in service coverage must be measured at a sub-national level, and context-specific service delivery models may be needed to effectively scale up intrapartum care services in extremely remote or insecure settings.

Farm to Work: Development of a Modified Community-Supported Agriculture Model at Worksites, 2007-2012.

BackgroundThe Farm to Work program is a modified community-supported agriculture model at worksites in Texas.Community ContextThe objective of the Farm to Work program is to increase fruit and vegetable intake among employees and their households by decreasing cost, improving convenience, and increasing access while also creating a new market for local farmers at worksites. The objectives of this article were to describe the development, implementation, and outcome of a 5-year participation trend analysis and to describe the community relationships that were formed to enable the successful implementation of the program.MethodsThe Farm to Work program began in November 2007 as a collaborative effort between the nonprofit Sustainable Food Center, the Texas Department of State Health Services, the Web development company WebChronic Consulting LLC, and Naegelin Farm. The program provides a weekly or biweekly opportunity for employees to order a basket of produce online to be delivered to the worksite by a local farmer. A 5-year participation trend analysis, including seasonal variation and sales trends, was conducted using sales data from November 2007 through December 2012.OutcomeThe total number of baskets delivered from November 2007 through December 2012 was 38,343; of these, 37,466 were sold and 877 were complimentary. The total value of sold and complimentary baskets was $851,035 and $21,925, respectively. Participation in the program increased over time and was highest in 2012.InterpretationThe Farm to Work program increased access to locally grown fruits and vegetables for employees and created a new market for farmers. Increased program participation indicates that Farm to Work can increase employees’ fruit and vegetable consumption and thus help prevent chronic diseases in this population

Abstract B20: Geospatial analysis of hepatocellular carcinoma and its risk factors in Texas (1995-2010)

Abstract Introduction: Between 1995 and 2010 there have been 1.4 million incident cancer cases in Texas. While Hepatocellular Carcinoma (HCC) accounted for a small proportion (ranked 21st in incidence), it ranked 9th by cause of death attributed to the tumor. Mortality rate was 68%, with average overall survival time 16.6 months. Unlike most cancers, HCC has resisted attempts to reduce its impact; incidence rates continue to increase especially among those < 65 years of age. We investigated the ecological relationships between HCC and 16 known/potential risk factors (PRFs) in all 254 Texas (TX) counties in order to specifically target health promotion and HCC prevention efforts. Methods: County-level data on PRFs was obtained from the TX Department of State Health Services--Reportable Diseases, County Health Rankings, TX Cancer Registry, and the Centers for Disease Control and Prevention. HCC cases were defined using the International Classification of Diseases (ICDO-3 topography C22.0 and morphologies 8170–8175). Incidence rates were calculated using the Surveillance, Epidemiology and End Results (SEER) Stat Statistical software version 8.1.5. Correlation analysis between HCC rates and each PRF was conducted using ordinary least squares linear regression (p<0.05). Choynowski's double-sided Poisson probability map was used to identify counties with rates significantly different than expected on all PRFs and HCC. Comparisons were performed by overlapping areas showing high probabilities in variable pairs, and indicating whether they were concordant (both high, both low), or discordant (one high, one low). Using GeoDa, Univariate Moran's I was calculated to evaluate spatial autocorrelation of HCC and all PRFs. Bivariate Moran's I was used to determine which PRFs clustered geographically with HCC. Contiguity-based spatial weights were calculated using the Rook's and Queen's method of first and second order. Spatial Lag regression analysis was performed to test spatial relationships of HCC and multiple PRFs. Due to the inverse relationship between population proportions of Non-Hispanic whites (NHW) and Hispanics, these variables were run in separate linear models. Results: Correlation analysis showed 12 PRFs significantly associated to HCC. All 12 PRFs were spatially auto correlated (p<0.05), and 8 (Diabetes, Chlamydia, NHW, Hispanics, physical inactivity, High School graduation rates, age over 65, violent crime rate) retained significant geographic clustering with HCC under all contiguity methods. Excessive alcohol consumption (EAC) remained significant only in Rook contiguity, likely due to low n (63) of counties with data. Spatial regression analysis showed strong spatial correlations between HCC and ethnicity (NHW, Hispanics) (p<0.001), HIV (p<0.001) and EAC (p<0.01). P values did not vary across all contiguity methods for all 3 PRFs. Conclusion: Several PRFs clustered spatially and varied geographically with HCC rates, particularly in areas with low NHW/high Hispanic populations and counties along the South TX/Mexico border. HIV's significant spatial correlation with HCC is important, as co-infection with known HCC risk factor Hepatitis C virus (HCV) accelerates liver fibrosis development vs. HCV infection alone. This study highlights the need for interventions targeted to multiple HCC PRFs including EAC and HIV, particularly in South TX. Citation Format: Laura Manuel, Edgar Munoz, Dorothy Long Parma, Amelie Ramirez. Geospatial analysis of hepatocellular carcinoma and its risk factors in Texas (1995-2010). [abstract]. In: Proceedings of the Seventh AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 9-12, 2014; San Antonio, TX. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2015;24(10 Suppl):Abstract nr B20.