Tuba City Regional Health Care

American Indian (AI) communities in the Southwest have a high burden of invasive pneumococcal disease (IPD) and COVID-19. Through laboratory-based surveillance, the impact of the pandemic on IPD incidence and serotype distribution was evaluated in two AI communities. IPD rates were lower during the pandemic (21.8 vs. 39.0/100 000 pre-pandemic). Rates increased in 2021 compared to 2020 but not to pre-pandemic levels. Cases with SARS-CoV-2 co-infection had a higher case fatality rate (45.2% vs. 17.6% without co-infection). No significant change in serotype distribution was observed. Continued surveillance in these communities is critical to understand the changing IPD burden as the pandemic evolves.

We assessed the impact of pneumococcal conjugate vaccines on pneumococcal otitis media (OM) among children living in Navajo and White Mountain Apache Tribal lands. During the PCV7 era (2000-2009), the proportion of vaccine-type OM declined. However, vaccine-type OM (predominantly 3, 19A, and 19F) persisted in the PCV13 era (2010-2019).

Youths who are negatively affected by social determinants of health suffer adverse effects like increased risks of chronic health conditions and mental health issues. Part 2 of this series describes the adverse effects social determinants of health can have on vulnerable children around the world. Available for purchase at https://shop.aap.org/pediatric-collections-social-determinants-of-health-part-2-effect-of-inequity-paperback/

Prescription opioids play a significant role in the ongoing opioid crisis. Guidelines and physician education have had mixed success in curbing opioid prescriptions, highlighting the need for other tools that can change prescriber behavior, including nudges based in behavioral economics. To determine whether and to what extent changes in the default settings in the electronic medical record (EMR) are associated with opioid prescriptions for patients discharged from emergency departments (EDs). This quality improvement study randomly altered, during a series of five 4-week blocks, the prepopulated dispense quantities of discharge prescriptions for commonly prescribed opioids at 2 large, urban EDs. These changes were made without announcement, and prescribers were not informed of the study itself. Participants included all health care professionals (physicians, nurse practitioners, and physician assistants) working clinically in either of the 2 EDs. Data were collected from November 28, 2016, through July 9, 2017, and analyzed from July 16, 2017, through May 14, 2018. Default quantities for opioids were changed from status quo quantities of 12 and 20 tablets to null, 5, 10, and 15 tablets according to a block randomization scheme. Regardless of the default quantity, each health care professional decided for whom to prescribe opioids and could modify the quantity prescribed without restriction. The primary outcome was the number of tablets of opioid-containing medications prescribed under each default setting. A total of 104 health care professionals wrote 4320 prescriptions for opioids during the study period. Using linear regression, an increase of 0.19 tablets prescribed (95% CI, 0.15-0.22) was found for each tablet increase in default quantity. When evaluating each of the 15 pairwise comparisons of default quantities (eg, 5 vs 15 tablets), a lower default was associated with a lower number of pills prescribed in more than half (8 of the 15) of the pairwise comparisons; there was a higher quantity in 1 and no difference in 6 comparisons. These findings suggest that default settings in the EMR may influence the quantity of opioids prescribed by health care professionals. This low-cost, easily implementable, EMR-based intervention could have far-reaching implications for opioid prescribing and could be used as a tool to help combat the opioid epidemic. ClinicalTrials.gov identifier: NCT04155229.

Native Americans experience cancer-related health disparities. Yet, little is known about the current cancer experience in one of the largest Native American tribe, Navajo. A qualitative study of among Navajo cancer survivors, in which focus groups and individual interviews included questions related to perceptions of cancer causes, prevention, and treatment, allowed us to evaluate several aspects of the cancer experience from the Navajo perspective. An experienced, bilingual facilitator led the discussions using a standardized guide. Discussions were audio-recorded, documented by field notes, translated, as needed, and transcribed. NVivo software was used to summarize major themes according to the PEN-3 and health belief models. Navajo cancer survivors (N = 32) were both males (n = 13) and females (n = 19) that had been previously diagnosed with a variety of cancers: colorectal, breast, ovarian, cervical, esophageal, gall bladder, stomach, prostate, kidney, and hematologic. Many survivors had accurate knowledge of risk factors for cancer. Barriers to screening and clinical care included language, expense, geography, fear, lack of information, skepticism related to Western medicine, and treatment side effects. While some survivors experienced familial support, others were isolated from the family and community due to the perspective of cancer as a contagion. However, resilience, hope, trust in select community organizations, a desire to restore balance, and to support younger generations were positive attributes expressed regarding the treatment and recovery process. These evaluations need to be replicated across a larger cross-section of the Native cancer survivor community.

Severe combined immunodeficiency disease occurs at a high incidence among Athabascan-speaking Navajo and Apache children (SCIDA). We linked the SCIDA gene to chromosome 10p and recently identified a common nonsense mutation in Artemis/SCIDA. In this study we compared polymorphic markers linked to SCIDA and the point mutation which creates an NspI site on exon 8 for prenatal diagnosis and carrier detection. We tested five amniocentesis samples, two cord blood and two blood samples from eight at-risk families using polymorphic DNA markers tightly linked to SCIDA. We amplified the region of exon 8 of Artemis/SCIDA and evaluated the products for the NspI site in each sample plus samples from 30 unrelated healthy Navajos. We correctly predicted that three were affected and six were unaffected. Two of the unaffected appear to be carriers based on our haplotype analysis. Retrospective analysis for the gene mutation confirmed the DNA analysis. Finally, 10% of the normal Navajo controls were carriers. We demonstrate the feasibility of prenatal diagnosis and carrier detection for SCIDA in the families at risk as well as the availability of a rapid screening test for the SCIDA founder mutation that can be used in all Navajo and Apache newborns and at-risk fetuses.