Tennessee Department Of Health Research Articles

Alignment of Epidemiology Practice and Academic Competencies through Effective Collaboration

Online learning has recently garnered increased attention as technology use in the classroom grows. However, most of the published approaches regarding this topic in postgraduate education centers on clinical environments. Models of partnerships between applied public health agencies and academic centers to produce mutually beneficial online learning opportunities for graduate-level public health courses have not been explored in the literature. East Tennessee State University (ETSU) and the Tennessee Department of Health (TDH) partnered to build three online, asynchronous epidemiology modules for an interdisciplinary audience of graduate students. The goals of the modules were to (1) introduce students to a public health issue, (2) provide students with hands-on learning about data and information available through TDH, and (3) allow students to connect theory to practice by having them create a product for use by TDH. TDH created topic-specific modules that would be used within the infectious disease, chronic disease, and cancer epidemiology courses, and piloted during the 2015-2016 academic term. Conference calls between the two institutions occurred in the spring and the summer of 2015. Two of the three epidemiology modules were presented to ETSU staff for critique and edits at an in-person meeting during the summer. The methods of delivery for each section within a module varied from recorded webinar format to self-guided instruction. One module utilized available learning tools provided by the Centers of Disease Control and Prevention, while the other module was constructed entirely using TDH data. Both modules included various exercises and assignments to be conducted in class and as homework and concluded with the student being asked to construct a learning product as a final project. The ETSU-TDH team decided that this learning product would be provided back to TDH for possible future use. The innovative partnership between a state government agency and an academic institution has demonstrated the need for such collaborations in public health. Understanding how applied public health practice would utilize what is learned in the classroom and preparing students for real-world application may be the missing link between theory and practice.

Leveraging Public Health Emergency Informatics during the Fungal Infections Outbreak, Tennessee - 2012

Late in September 2012, the Tennessee Department of Health (TDH) deployed a web-based application for emergency management of ~1,100 patients at-risk of life-threatening fungal infections following epidural injection of methylprednisolone acetate (MPA) from a single compounding pharmacy. The custom information system and its successful use in providing situational awareness and decision support during the fungal infections outbreak will be highlighted in this presentation.

Evaluation of the feasibility of a state-based vaccine safety advice network

The vaccine safety advice network is a collaborative pilot project between Vanderbilt University Medical Center, the Tennessee Department of Health, and the Centers for Disease Control and Prevention to assess the feasibility of addressing vaccine safety questions posed by healthcare providers in near real-time. Using a two-tier response system and an electronic database for query submission, the pilot project received ten queries in three and one half months. Two of three pre-specified benchmarks for program evaluation, addressing queries within 24h of receipt and 100% provider satisfaction, were met; one benchmark, the percentage of questions addressed by Tier 1 staff, was not met. Limitations included few submitted queries primarily involving children in the pilot period, “after-only” program evaluation, and limited geographic generalizability. The study demonstrates a successful partnership between federal, state and academic institutions and a feasible method to respond to healthcare provider inquiries about vaccine safety in near real-time.

The frequency and seasonality of influenza and other respiratory viruses in Tennessee: two influenza seasons of surveillance data, 2010–2012

In 2010, the Tennessee Department of Health, in collaboration with the Centers for Disease Control and Prevention (CDC), expanded influenza surveillance in Tennessee to include other respiratory viruses. To determine the prevalence and seasonality of influenza and other respiratory viruses during the influenza seasons of 2010-2012. Nasal and nasopharangeal swabs/washings from persons with influenza-like illness were collected across Tennessee. Influenza and other respiratory viruses were identified using a molecular-based respiratory virus panel. Influenza A positives were subtyped using real-time PCR according to the CDC protocol. Data were analyzed to describe frequency and seasonality of circulating strains. Of the 933 positive specimens, 60·3% were identified as influenza viruses, 19·8% rhinovirus/enterovirus, 8·6% respiratory syncytial virus (RSV), 5·8% metapneumovirus, 3·0% adenovirus, and 2·5% parainfluenza viruses. In the 2010-2011 season, influenza B was prominent during weeks 48-3, while influenza A(H1N1) was most frequently identified during weeks 4-10. Influenza A(H3N2) was present at lower levels during weeks 48-17. However, in the 2011-2012 season, overall numbers of influenza cases were reduced and influenza A (H3N2) was the most abundant influenza strain. The expanded surveillance for other respiratory viruses noted an increase in identified specimens from the first to the second season for adenovirus, metapneumovirus, RSV, and rhinovirus/enterovirus. This study provides data of the influenza strains in circulation in Tennessee. It also establishes a baseline and time of year to expect other respiratory viruses that will aid in detecting outbreaks of non-influenza respiratory viruses in Tennessee.

Fungal Infections Associated with Contaminated Methylprednisolone in Tennessee

BackgroundWe investigated an outbreak of fungal infections of the central nervous system that occurred among patients who received epidural or paraspinal glucocorticoid injections of preservative-free methylprednisolone acetate prepared by a single compounding pharmacy.MethodsCase patients were defined as patients with fungal meningitis, posterior circulation stroke, spinal osteomyelitis, or epidural abscess that developed after epidural or paraspinal glucocorticoid injections. Clinical and procedure data were abstracted. A cohort analysis was performed.ResultsThe median age of the 66 case patients was 69 years (range, 23 to 91). The median time from the last epidural glucocorticoid injection to symptom onset was 18 days (range, 0 to 56). Patients presented with meningitis alone (73%), the cauda equina syndrome or focal infection (15%), or posterior circulation stroke with or without meningitis (12%). Symptoms and signs included headache (in 73% of the patients), new or worsening back pain (in 50%), neurologic symptoms (in 48%), nausea (in 39%), and stiff neck (in 29%). The median cerebrospinal fluid white-cell count on the first lumbar puncture among patients who presented with meningitis, with or without stroke or focal infection, was 648 per cubic millimeter (range, 6 to 10,140), with 78% granulocytes (range, 0 to 97); the protein level was 114 mg per deciliter (range, 29 to 440); and the glucose concentration was 44 mg per deciliter (range, 12 to 121) (2.5 mmol per liter [range, 0.7 to 6.7]). A total of 22 patients had laboratory confirmation of Exserohilum rostratum infection (21 patients) or Aspergillus fumigatus infection (1 patient). The risk of infection increased with exposure to lot 06292012@26, older vials, higher doses, multiple procedures, and translaminar approach to epidural glucocorticoid injection. Voriconazole was used to treat 61 patients (92%); 35 patients (53%) were also treated with liposomal amphotericin B. Eight patients (12%) died, seven of whom had stroke.ConclusionsWe describe an outbreak of fungal meningitis after epidural or paraspinal glucocorticoid injection with methylprednisolone from a single compounding pharmacy. Rapid recognition of illness and prompt initiation of therapy are important to prevent complications. (Funded by the Tennessee Department of Health and the Centers for Disease Control and Prevention.)

Improving an outreach service by analyzing the relationship of health information disparities to socioeconomic indicators using geographic information systems

INTRODUCTIONThe use of geographic information systems (GIS) withUS Census data provides libraries with the power tocombine, analyze, and present information in newways. GIS is a valuable tool capable of ‘‘capturing,storing, analyzing, and displaying geographicallyreferenced information’’ [1]. GIS software combinesmaps with layers of associated data to provide avisual picture that allows greater understanding andanalysis than static figures and tables. Although thesoftware was expensive in the past, GIS has becomeincreasingly more affordable for libraries since it hasbecome available in web-based applications, includ-ing open source options [2].Libraries began incorporating US Census data withGIS when the 1990 census materials were given tothe US federal depository libraries as Topological-ly Integrated Geographic Encoding and Reference(TIGER) files [3]. TIGER files are a set of geographicbase files that contain features of the United Statesdown to the street level and census boundaries forcensus statistical areas. TIGER files are designed foruse with GIS software and include geographic codesthat can be linked with demographic and socioeco-nomic data from American Fact Finder (AFF) and theAmerican Community Survey (ACS) [4, 5]. All TIGER,AFF, and ACS files and data are free to the public.Combined with US Census data, GIS is particularlyuseful for libraries in the area of service planning. Forexample, the Public Library Geographic Databasehas compiled US Census demographics on all 16,000public libraries in order to assist decision makers inlibrary planning [6]. Other examples of the use of GISand US Census data include analyzing service mapsfor proposed branches [7], mapping service areas [8],analyzing demographics of populations surroundingthe library [9, 10], analyzing market segmentation[11], and establishing a public library consumer healthcollection [12].In 2011, the Preston Medical Library, in Knoxville,Tennessee, conducted research using GIS and USCensus data. Our goal was to analyze demographicand socioeconomic patterns in order to improvehealth literacy information outreach through our freetelephone-based Consumer and Patient Health Infor-mation Service (CAPHIS). The library’s free tele-phone-based CAPHIS has been in place for overtwo decades, and call data are maintained in an SQLdatabase. The library staff responds to calls to theCAPHIS by mailing packets of health information atthe appropriate literacy level to the caller. The Pres-ton Medical Library provides a useful alternative forthose individuals who do not have Internet access ormay need additional assistance because of limitedhealth literacy and socioeconomic disparities.Several studies have examined the relationship ofsocioeconomic factors and limited health literacy toincreased health costs, chronic disease, and morbidity[13–16]. Health information through libraries is valu-able and can affect consumer health care decisions.Consumers who use libraries for health informationreport positive health actions such as lifestyle changesand compliance with physician instructions [17, 18].However, consumers with low health literacy andcompounding socioeconomic factors are often notaware of the services provided by libraries. Outreachis conducted by libraries to address these disparitiesand provide information services to those surround-ing communities most in need.RESEARCH BACKGROUNDIn 2003, an SQL database was created that containsinformation regarding consumer calls to CAPHIS.Data on calls from 1998 to the present include thecaller’s name, address, and health information re-quest. Although the names and addresses are kept inseparate tables for privacy, the zip codes of theaddresses can be used to establish geographic localitythat can be plotted on a state map and calculated toestablish a rate and area of calls by zip code. Therequested health topics, which are in keyword forminitially, are subsequently indexed by library staffusing the National Library of Medicine’s (NLM’s)Medical Subject Headings (MeSH) in order to becross-referenced with existing information regardingprevalence of diseases in the state that is madeavailable by the Tennessee Department of Health [19].

Neighborhood disparities in stroke and myocardial infarction mortality: a GIS and spatial scan statistics approach.

BackgroundStroke and myocardial infarction (MI) are serious public health burdens in the US. These burdens vary by geographic location with the highest mortality risks reported in the southeastern US. While these disparities have been investigated at state and county levels, little is known regarding disparities in risk at lower levels of geography, such as neighborhoods. Therefore, the objective of this study was to investigate spatial patterns of stroke and MI mortality risks in the East Tennessee Appalachian Region so as to identify neighborhoods with the highest risks.MethodsStroke and MI mortality data for the period 1999-2007, obtained free of charge upon request from the Tennessee Department of Health, were aggregated to the census tract (neighborhood) level. Mortality risks were age-standardized by the direct method. To adjust for spatial autocorrelation, population heterogeneity, and variance instability, standardized risks were smoothed using Spatial Empirical Bayesian technique. Spatial clusters of high risks were identified using spatial scan statistics, with a discrete Poisson model adjusted for age and using a 5% scanning window. Significance testing was performed using 999 Monte Carlo permutations. Logistic models were used to investigate neighborhood level socioeconomic and demographic predictors of the identified spatial clusters.ResultsThere were 3,824 stroke deaths and 5,018 MI deaths. Neighborhoods with significantly high mortality risks were identified. Annual stroke mortality risks ranged from 0 to 182 per 100,000 population (median: 55.6), while annual MI mortality risks ranged from 0 to 243 per 100,000 population (median: 65.5). Stroke and MI mortality risks exceeded the state risks of 67.5 and 85.5 in 28% and 32% of the neighborhoods, respectively. Six and ten significant (p < 0.001) spatial clusters of high risk of stroke and MI mortality were identified, respectively. Neighborhoods belonging to high risk clusters of stroke and MI mortality tended to have high proportions of the population with low education attainment.ConclusionsThese methods for identifying disparities in mortality risks across neighborhoods are useful for identifying high risk communities and for guiding population health programs aimed at addressing health disparities and improving population health.

Outbreak of late-onset group B Streptococcus in a neonatal intensive care unit

In September 2007, the Tennessee Department of Health was notified of a cluster of late-onset group B streptococcal (GBS) infections in a neonatal intensive care unit (NICU). Outbreaks of late-onset GBS are rare. A case was defined as culture-confirmed invasive GBS infection in a neonate aged > or =7 days, identified in hospital A during August 23 to September 6, 2007. We reviewed medical records; examined NICU microbiology reports; and performed serotyping, pulsed-field gel electrophoresis (PFGE), and multilocus sequence typing (MLST) on invasive isolates. Maternal GBS screening, prophylaxis, and infection control policies were reviewed and staff practices observed. Five cases of late-onset GBS were identified. None of the mothers of the infants received optimal GBS prophylaxis. Patient isolates were of 2 serotypes, 3 PFGE patterns, and 2 MLST patterns. Three isolates were indistinguishable on subtyping. These 3 cases were clustered in time. No common health care providers were identified. Infection control deviations in the NICU were observed. We identified a multiclonal cluster of 5 late-onset GBS cases. Multiple factors likely contributed to the outbreak, including nosocomial transmission of GBS. Further efforts to prevent late-onset GBS disease are necessary.

Something Old Is New Again

This article is the result of inquiries and ethnographic encounters over a 15-year period, with the governmental agency known as the Tennessee Office of Minority Health (TOMH), a division of the Tennessee Department of Health. This article concerns the innovative and participatory response of TOMH to support African American health in Tennessee. For the purposes of this article, an innovative and participatory response to alleviate any form of human suffering is defined as mutual aid. How TOMH uses mutual aid will be considered. The intent of this article is to show that mutual aid has historic roots in African American communities and the Black Church. Yet today, government agencies like TOMH use mutual aid to create outputs-altering processes that support health and redress health needs for African American communities.

Logistic Investigation of the Effects of Race and Insurance Coverage on Potentially Avoidable Hospitalization in Tennessee

Rationale: To examine: (1) the rates of potentially avoidable hospitalization (AH) of patients insured under Tennessee's Medicaid managed care program (TennCare) and compare them to those who have other types of insurance (e.g., Medicare or commercial insurance) and with those who are uninsured, and (2) the role of race in influcing the variations in hospitalization rate among the different insurance types. Objectives: The purpose of this paper is to test the hypothesis that significant variation exists in the probability of having an AH across different health insurance types and to evaluate indirectly the relative effectiveness of providing primary care across insurance types. Methodology: Logistic regression estimation of a multi-year, patient level UB-92 hospital discharge dataset for 2002-04 Anticipated Outcomes: The most direct outcome of the study will be baseline population-based relative prevalence rates of potentially avoidable hospitalization among different racial and insurance groups. These rates will reveal how severely the prevalence rate of avoidable hospitalizations of one population group (e.g., African Americans) differs from that of another group (e.g., white Americans) in Tennessee. Another important outcome will be a predictive model that can be used to estimate and predict the likelihood of being admitted to a hospital for an avoidable hospitalization and how that likelihood may be influenced by an individual's race, ethnicity, and insurance coverage. These probability estimates will be produced for each of the underlying medical conditions, called ambulatory-care sensitive or ACS conditions that can give rise to avoidable hospitalizations and for different racial/ethnic and insurance subgroups. Also available will be similar rates for individual hospitals and for different geographic areas across Tennessee based on, for example, the Health Planning Areas established by Tennessee Department of Health. When completed, the results will assist practitioners and hospital administrative staff in targeting groups at risk for unnecssary hospitalizations in an effort to improve quality of care and reduce costs.

Report of the Tennessee Task Force on Screening Newborn Infants for Critical Congenital Heart Disease

A member of the Tennessee state legislature recently proposed a bill that would mandate all newborn infants to undergo pulse oximetry screening for the purpose of identifying those with critical structural heart disease before discharge home. The Tennessee Task Force on Screening Newborn Infants for Critical Congenital Heart Defects was convened on September 29, 2005. This group reviewed the current medical literature on this topic, as well as data obtained from the Tennessee Department of Health, and debated the merits and potential detriments of a statewide screening program. The estimated incidence of critical congenital heart disease is 170 in 100,000 live births, and of those, 60 in 100,000 infants have ductal-dependent left-sided obstructive lesions with the potential of presentation by shock or death if the diagnosis is missed. Of the latter group, the diagnosis is missed in approximately 9 in 100,000 by fetal ultrasound assessment and discharge examination and might be identified by a screening program. Identification of the missed diagnosis in these infants before discharge could spare many of them death or neurologic sequelae. Four major studies using pulse oximetry screening were analyzed, and when data were restricted to critical left-sided obstructive lesions, sensitivity values of 0% to 50% and false-positive rates of between 0.01% and 12% were found in asymptomatic populations. Because of this variability and other considerations, a meaningful cost/benefit analysis could not be performed. It was the consensus of the task force to provide a recommendation to the legislature that mandatory screening not be implemented at this time. In addition, we determined that a very large, prospective, perhaps multistate study is needed to define the sensitivity and false-positive rates of lower-limb pulse oximetry screening in the asymptomatic newborn population and that there needs to be continued partnering between the medical community, parents, and local, state, and national governments in decisions regarding mandated medical care.

An outbreak of hepatitis in a toxic waste recycling plant: Patrick H Jenkins, Caroline A Riely, University of Tennessee, Memphis, Memphis, TN; Ruth C Chen, Tennessee Department of Health, Nashville, TN; Tanci C Payne, Karen C Johnson, James E Bailey, University of Tennessee, Memphis, Memphis, TN

An outbreak of hepatitis in a toxic waste recycling plant: Patrick H Jenkins, Caroline A Riely, University of Tennessee, Memphis, Memphis, TN; Ruth C Chen, Tennessee Department of Health, Nashville, TN; Tanci C Payne, Karen C Johnson, James E Bailey, University of Tennessee, Memphis, Memphis, TN

Hypertrophic Pyloric Stenosis in Infants Following Pertussis Prophylaxis With Erythromycin—Knoxville, Tennessee, 1999

In February 1999, pertussis was diagnosed in six neonates born at hospital A in Knoxville, Tennessee. Because a health-care worker at hospital A was most likely the source of exposure, the local health department recommended on February 25, 1999, that erythromycin be prescribed as postexposure prophylaxis for the approximately 200 infants born at hospital A during February 1-24, 1999. In March 1999, local pediatric surgeons noticed an increased number of cases of infantile hypertrophic pyloric stenosis (IHPS) in the area, with seven cases occurring during a 2-week period. All seven IHPS cases were in infants born in hospital A during February who were given erythromycin orally for prophylaxis following possible exposure to pertussis, although none had pertussis diagnosed. The Tennessee Department of Health and CDC investigated the cluster of IHPS cases and its possible association with use of erythromycin. This report summarizes the results of the investigation, which suggest a causal role of erythromycin in this cluster of IHPS cases.

Inadvertent Esophageal Intubation in the Field: Reliance on a Fool's “Gold Standard”

Academic Emergency MedicineVolume 4, Issue 2 p. 89-91 Free Access Inadvertent Esophageal Intubation in the Field: Reliance on a Fool's “Gold Standard” Steven J. White MD, Corresponding Author Steven J. White MD Vanderbilt University Medical Center, Nashville, TN, Department of Emergency Medicine, and Dr. White is at the Tennessee Department of Health, Division of Emergency Medical Services.Department of Emergency Medicine, Vanderbilt University Medical Center, 703 Oxford House, Nashville, TN 37232–4700. Fax: 615–936–1316; e-mail: steven.white@mcmail.vanderbilt.eduSearch for more papers by this authorCorey M. Slovis MD, Corresponding Author Corey M. Slovis MD Vanderbilt University Medical Center, Nashville, TN, Department of Emergency Medicine, and Dr. White is at the Tennessee Department of Health, Division of Emergency Medical Services.Department of Emergency Medicine, Vanderbilt University Medical Center, 703 Oxford House, Nashville, TN 37232–4700. Fax: 615–936–1316; e-mail: steven.white@mcmail.vanderbilt.eduSearch for more papers by this author Steven J. White MD, Corresponding Author Steven J. White MD Vanderbilt University Medical Center, Nashville, TN, Department of Emergency Medicine, and Dr. White is at the Tennessee Department of Health, Division of Emergency Medical Services.Department of Emergency Medicine, Vanderbilt University Medical Center, 703 Oxford House, Nashville, TN 37232–4700. Fax: 615–936–1316; e-mail: steven.white@mcmail.vanderbilt.eduSearch for more papers by this authorCorey M. Slovis MD, Corresponding Author Corey M. Slovis MD Vanderbilt University Medical Center, Nashville, TN, Department of Emergency Medicine, and Dr. White is at the Tennessee Department of Health, Division of Emergency Medical Services.Department of Emergency Medicine, Vanderbilt University Medical Center, 703 Oxford House, Nashville, TN 37232–4700. Fax: 615–936–1316; e-mail: steven.white@mcmail.vanderbilt.eduSearch for more papers by this author First published: 29 September 2008 https://doi.org/10.1111/j.1553-2712.1997.tb03711.xCitations: 32AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Citing Literature Volume4, Issue2February 1997Pages 89-91 ReferencesRelatedInformation

Outbreak of Escherichia coli O157:H7 Infection Georgia and Tennessee, June 1995

On June 26, 1995, the Division of Public Health, Georgia Department of Human Resources (GDPH), was notified of three cases of Escherichia coli O157:H7 infection among residents of a community in north Georgia who had onsets of illness within a 24-hour period (onset during June 19-20); in comparison, during 1993-1994, only two cases of this infection had been reported in the same community. Because of the proximity of this community to the Tennessee border, on June 28 GDPH notified the Tennessee Department of Health (TDH) about these cases. TDH subsequently identified two confirmed cases with onsets of illness during June 23-24. Both of these cases were among persons residing in eastern Tennessee approximately 100 miles from the community in Georgia, and one occurred in an 11-year-old boy who was hospitalized with hemolytic uremic syndrome (HUS). This report summarizes the investigation of this outbreak, which implicated eating hamburgers purchased at a fast-food restaurant chain (i.e., chain A) as the source of infection.

Use of readily available data for identifying local health care needs and resources.

Health departments everywhere are struggling to balance shrinking resources against increasing requests for services. According to the Institute of Medicine report, The Future of Public Health, one of the barriers to solving public health problems is "... disjointed decision-making without necessary data and knowledge ..." (p. 107). Leadership of the Middle Tennessee Region of the Tennessee Department of Health have addressed this issue by developing a practical, usable data base from which to consider the needs and resources of the region.

The reduction of black infant mortality: an eighteen month evaluation of three Tennessee Black Health Care Task Forces' demonstration projects.

The problem of low birth weight has emerged as the single most important cause of infant death or subsequent handicaps in infancy and childhood. Although low birth weight babies (below 5.5 pounds) represent a small percentage of all babies born, well over half of all infant deaths occur among this group. The problem is even more serious for tiny infants. The relationship between infant mortality/morbidity and low birth weight has been known for many years and despite dramatic overall changes and medical advances, the incidence of low birth weight among high-risk populations continues to be a perennial problem. Efforts have been made nationally to develop programs that identify the conditions which increase the risk of having a low birth weight infant; programs that seek to reduce the risk of low birth weight; and research on new approaches to prevent premature labor as well as promoting the normal growth and development of a fetus. Since 1987, the Black Health Care Task Force, established by the Tennessee Department of Health and Environment has funded three infant mortality reduction pilot projects (Alton Park/Dodson Avenue Health Care in Hamilton County, Memphis Health Center and, Memphis-Shelby County Health Department) that operated in the two Tennessee counties where the Black infant mortality rates were extremely high. The projects goals were (1) to improve birth weight and survival rates of black infants born to indigent and Medicaid women; (2) to reduce maternal morbidity among indigent and Medicaid women; (3) to enhance the participation of indigent and Medicaid maternity clients in the appropriate and timely prenatal intrapartum and postpartum services; (4) to reduce the incidence of unplanned pregnancies among adolescents; and (5) to increase the utilization of family planning services by indigent and Medicaid women. Data will be reported and analyzed to assess whether or not the projects had a positive effect on birth outcome and a subsequent reduction in infant mortality. The data for this analysis is based on enrollment data provided by the projects, and linked birth and infant death certificates for project and nonproject comparisons, as retrieved from the Department of Health and Environment's Vital Records.