Heterogeneity and Interoperability in Local Public Health Information Systems.

Evaluating public health surveillance systems is critical to ensuring that conditions of public health importance are appropriately monitored. Our objectives were to qualitatively evaluate 6 state and local health departments that were early adopters of syndromic surveillance in order to (1) understand the characteristics and current uses, (2) identify the most and least useful syndromes to monitor, (3) gauge the utility for early warning and outbreak detection, and (4) assess how syndromic surveillance impacted their daily decision making. We adapted evaluation guidelines from the Centers for Disease Control and Prevention and gathered input from the Centers for Disease Control and Prevention subject matter experts in public health surveillance to develop a questionnaire. We interviewed staff members from a convenience sample of 6 local and state health departments with syndromic surveillance programs that had been in operation for more than 10 years. Three of the 6 interviewees provided an example of using syndromic surveillance to identify an outbreak (ie, cluster of foodborne illness in 1 jurisdiction) or detect a surge in cases for seasonal conditions (eg, influenza in 2 jurisdictions) prior to traditional, disease-specific systems. Although all interviewees noted that syndromic surveillance has not been routinely useful or efficient for early outbreak detection or case finding in their jurisdictions, all agreed that the information can be used to improve their understanding of dynamic disease control environments and conditions (eg, situational awareness) in their communities. In the jurisdictions studied, syndromic surveillance may be useful for monitoring the spread and intensity of large outbreaks of disease, especially influenza; enhancing public health awareness of mass gatherings and natural disasters; and assessing new, otherwise unmonitored conditions when real-time alternatives are unavailable. Future studies should explore opportunities to strengthen syndromic surveillance by including broader access to and enhanced analysis of text-related data from electronic health records. Health departments may accelerate the development and use of syndromic surveillance systems, including the improvement of the predictive value and strengthening the early outbreak detection capability of these systems. These efforts support getting the right information to the right people at the right time, which is the overarching goal of CDC's Surveillance Strategy.

Local health departments (LHDs) are striving to meet public health needs within their jurisdictions, amidst fiscal restraints and complex dynamic environment. Resource sharing across jurisdictions is a critical opportunity for LHDs to continue to enhance effectiveness and increase efficiency. This research examines the extent of cross-jurisdictional resource sharing among LHDs, the programmatic areas and organizational functions for which LHDs share resources, and LHD characteristics associated with resource sharing. Data from the National Association of County & City Health Officials' 2013 National Profile of LHDs were used. Descriptive statistics and multinomial logistic regression were performed for the 5 implementation-oriented outcome variables of interest, with 3 levels of implementation. More than 54% of LHDs shared resources such as funding, staff, or equipment with 1 or more other LHDs on a continuous, recurring basis. Results from the multinomial regression analysis indicate that economies of scale (population size and metropolitan status) had significant positive influences (at P ≤ .05) on resource sharing. Engagement in accreditation, community health assessment, community health improvement planning, quality improvement, and use of the Community Guide were associated with lower levels of engagement in resource sharing. Doctoral degree of the top executive and having 1 or more local boards of health carried a positive influence on resource sharing. Cross-jurisdictional resource sharing is a viable and commonly used process to overcome the challenges of new and emerging public health problems within the constraints of restricted budgets. LHDs, particularly smaller LHDs with limited resources, should consider increased resource sharing to address emerging challenges.

Social Media Posts and Search Engine Queries as the Canary in the Coal Mine for Public Health Surveillance

One of the essential functions of public health services is to “inform, educate, and empower people about health issues” (CDC 1994). Throughout the United States, the tendency is to have decentralized public health systems that leave the decision-making and a significant part of the financing to local county and municipal governments. This strong reliance on local government financing and control translates into extreme variations in per capita expenditures and access. This paper examines whether or not individuals residing in areas without a centralized public health infrastructure have more difficulty accessing health information to help them make informed decisions about healthy living and lifestyle choices. The paper compares the ease and accuracy of accessing basic public health information in counties and municipalities without a Local Health Department (LHD) as compared to counties and municipalities served by a LHD. The study examines the case of Pennsylvania, because the state has the lowest ratio of public health workers per person in the country (Gebbie 2000), and it has only 10 LHDs covering six counties and four municipalities. The study found that in areas without a LHD, residents had to make 20% more calls and received useful information in only 64% of the inquiries. This is compared with locales served by LHDs which required fewer calls in order to receive useful information, and in which useful information was attained 100% of the time. This assessment shows that the potential for callers to receive useful public health information in areas without a LHD was impacted by both the higher number of calls that were required and in the diversity of places to which callers were referred. In locales without LHDs, the caller was much more likely to be referred to a non-public health entity, and was statistically less likely to get to speak to a public health professional early on in their inquiry.

Public health surveillance data is critical as it provides actionable information to guide public health response. Thirty interviews were conducted across North Carolina from May to September, 2009 with local public health department staff to describe the use of routine syndromic surveillance data during a local outbreak and compared this to usage during a large, statewide outbreak, during which the state disseminated syndromic data. The study examined the use of the syndromic surveillance system (NC DETECT) and the reportable communicable disease system (NC EDSS) during the 2009 novel influenza A (H1N1) pandemic and during another respondent-selected infectious disease outbreak. A larger percent of local health department (LHD) staff reported using information from NC DETECT (52%) during the 2009 H1N1 pandemic than during another infectious disease outbreak (20%) (P value = 0.01). North Carolina local public health staff used information from syndromic surveillance data more when the state health department disseminated summary syndromic surveillance reports than when this summary information was not provided. State aggregation and dissemination of timely and disease-relevant syndromic surveillance data may facilitate greater usage of such information at the local health department level.   Key words: Public health surveillance, public health practice, outbreaks, influenza A virus (H1N1) subtype.

ObjectiveThis panel will focus on the experiences from the Department of Defense (DoD) and Virginia Department of Health (VDH) data sharing project using the National Syndromic Surveillance Program (NSSP) ESSENCE and will discuss lessons learned, challenges, and recommendations within the following areas: 1) data sharing authority, 2) coordination and implementation of data sharing with a focus on personnel, training, and managing access and 3) communication between local, state, and federal agencies.IntroductionThe DoD and VDH both maintain local ESSENCE installations to monitor the health status of their military and civilian populations, respectively, and submit syndromic surveillance data to the NSSP ESSENCE to foster data sharing and collaborative initiatives among public health entities. Military Treatment Facilities (MTFs), housed on DoD installations, provide healthcare to all service members and their beneficiaries stationed in the area. Service members and their beneficiaries represent a substantial portion of the local community and interact with the civilian population throughout daily activities. Sharing syndromic surveillance data between DoD and public health jurisdictions can provide public health situational awareness among both civilian and military populations to support disease surveillance. DoD and VDH engaged in a pilot project to develop processes and procedures for data sharing, data access, and communication with the aim they can serve as best practices for other jurisdictions seeking to share syndromic surveillance data with DoD.DescriptionThe pilot project began in June 2018 with the Centers for Disease Control and Prevention (CDC) NSSP team providing technical support. NSSP ESSENCE users from the VDH state and local health departments across nine Virginia city/counties participated in the project. VDH shared syndromic surveillance data from 34 healthcare facilities (17 urgent cares, 3 emergency care centers, and 14 hospitals) with DoD, which shared syndromic surveillance data from 18 MTFs (16 clinics and 2 hospitals) in Virginia. To standardize the analysis of syndromic surveillance data and use of NSSP ESSENCE across project participants, myESSENCE tabs were created and shared by between VDH and DoD. The goal was to facilitate and enhance communication between local public health departments and their DoD counterparts through the sharing of syndromic surveillance data.How the Moderator Intends to Engage the Audience in Discussions on the TopicThe moderator will solicit feedback from the audience regarding their data sharing experiences with other entities or agencies, data sharing practices, and ideas for use cases when sharing syndromic surveillance data with DoD.

In 2017, Public Health 3.0 was introduced, providing recommendations that expand traditional public department functions and programs. Operationalizing the framework requires that local health departments invest in the requisite professional skills to respond to their community’s needs. The purpose of this paper is to determine the professional skills that are most important for local health departments to respond to large public health issues and challenges that are having a major impact on their communities. The study used a cross-sectional assessment of the education and training needs of local public health departments in Nebraska following the principles of practice-based systems research. The assessment was designed to assess the training and education needs of local health department staff members. The questions measured the perceived importance of and respondent’s capacity across 57 core competencies for public health professionals modified from the Council on Linkages Between Academia and Public Health Practice. A total of 104 staff members from seven local health departments were requested to complete the assessment and 100% of the individuals responded to and completed the assessment. Twenty-eight skills were identified as the most important skills needed for local health departments. The skills were themed and categorized into four domains. (1) Data, Evaluation, and Quality Improvement, (2) Community Engagement and Facilitation, (3) Systems Thinking and Leadership, and (4) Policy and Advocacy. The results from this analysis provide direction to strengthen and transform the public health system into one that is connected, responsive, and nimble. Additionally, it also highlighted a glaring omission that Equity, Diversity, and Inclusion should be included as the fifth domain.

ObjectiveTo demonstrate the utility of the National Syndromic Surveillance Program’s (NSSP) version of the Electronic Surveillance System for Early Notification of Community-based Epidemics (ESSENCE) for case detection during a 2017 outbreak of hepatitis A virus (HAV) infection among persons experiencing homelessness in Maricopa County, Arizona.IntroductionOn 3/29/2017, the Maricopa County Department of Public Health (MCDPH) received three reports of confirmed HAV infection from an onsite clinic at Campus A that assists individuals experiencing homelessness, a population at risk for HAV transmission. To identify the scope of the problem, the department initiated rapid HAV infection case detection using NSSP ESSENCE.MethodsMCDPH created a myESSENCE dashboard that searched for chief complaint keywords and discharge diagnosis codes from 15 Maricopa County emergency department and inpatient hospital records using three separate queries: (1) HAV infection; (2) hepatitis virus infection; and (3) HAV infection symptoms combined with terms for homelessness. The dashboard was reviewed retrospectively for the 90 days prior to the initial report of the cluster (12/28/2016 – 3/29/2017). Based on this review, MCDPH epidemiologists decided to use the first query (HAV infection-specific) only, because reviewing the line list for all three queries was resource-intensive and resulted in duplicate cases. The query was monitored every weekday morning from 3/30/2017 to the close of the outbreak on 7/22/2017.ResultsFrom 3/30/2017 – 7/22/2017, MCDPH identified 37 potential HAV infection cases in ESSENCE. Eleven cases were classified as outbreak cases, while the other 26 patients lacked recent HAV infection symptoms, laboratory confirmation, or association with Campus A. All 11 outbreak cases’ records included the ICD-CM-10 code B15.9 (Hepatitis A without hepatic coma), and 3 records included the code Z59 (Problems related to housing and economic circumstances). The HAV infection-specific query in ESSENCE identified 11 (73%) of the 15 total outbreak cases; however, all cases were reported in MEDSIS prior to a being flagged in ESSENCE. On average, cases were reported to MEDSIS 9 days earlier than identified in ESSENCE (range, 0 - 21 days). Of note, ESSENCE helped identify the outbreak index case, previously lost to follow-up, as an individual experiencing homelessness. This information helped MCDPH perform additional follow-up, which revealed that the individual had arrived from San Diego, CA, a city with an ongoing outbreak of HAV infection in their homeless and drug-using population. This epidemiologic link was identified on 3/30/2017, over a month before the Centers for Disease Control and Prevention confirmed a match by genome sequencing between the index case and the neighboring outbreak on 5/5/2017.ConclusionsUse of ESSENCE identified most of the HAV infection cases from this outbreak among individuals experiencing homelessness but no sooner than traditional surveillance methods. However, use of ESSENCE allowed for identification of the outbreak index case, leading to epidemiological linkage to outbreak origin approximately one month prior to molecular laboratory confirmation.

Regional Public Health Training Centers: An Essential Partner in Workforce Development.

The 2021 "PH WINS for All" pilot sought to address a rural research gap by including small local health departments in the Public Health Workforce Interests and Needs Survey (PH WINS) for the first time. To do so, the de Beaumont Foundation partnered with the Public Health Training Centers in Health and Human Services Regions V and X. This article describes the collaborative efforts that made the PH WINS for All pilot successful, presents respondent demographics by agency size, and discusses the importance of gathering such data to address the unique needs of the workforce in small local health departments.

To investigate the public health domains, key informatics concepts, and information and communications technologies (ICTs) applied in articles that are tagged with the MeSH term "public health informatics" and primarily focus on applying ICTs to public health. The MeSH term "public health informatics" was searched on MEDLINE-PubMed. The results of the search were then screened in two steps in order to only include articles about applying ICTs to public health problems. First, articles were screened based on their titles and abstracts. Second, a full-text review was conducted to ensure the relevance of the included articles. All articles were charted based on public health domain, information technology, article type, and informatics concept. 515 articles were included. Communicable disease monitoring (N=235), public health policy and research (N=201), and public health awareness (N=85) constituted the majority of the articles. Inconsistent results were found regarding the validity of syndromic surveillance and the effectiveness of PHI integration within the healthcare systems. PHI articles with an ICT focus cover a wide range of themes. Collectively, the included articles emphasized the need for further research in interoperability, data quality, appropriate data sources, accessible health information, and communication. The limitations of the study include:1) only one database was searched; 2) by using MeSH tags as a selection criterion, PHI articles without the "public health informatics" MeSH term were excluded. Due to the multi-disciplinary nature of PHI, MeSH identifiers were not assigned consistently. Current MeSH-tagged articles indicate that a comprehensive approach is required to integrate PHI into the healthcare system.

Community health assessments (CHAs) are a core function of local health departments (LHDs). Recently, completing a CHA has become a prerequisite for LHDs seeking accreditation by the Public Health Accreditation Board (PHAB). Similarly, under the Affordable Care Act, nonprofit hospitals are required to conduct periodic community health needs assessments (CHNAs). Opportunities thus exist for LHDs and hospitals to jointly complete CHAs/CHNAs. This study examined existing LHD-hospital collaborations around CHAs/CHNAs, focusing specifically on the relationship between LHDs' level of engagement with PHAB accreditation activities and their collaboration with hospitals around CHAs/CHNAs. Data came from the 2013 NACCHO (National Association of County & City Health Officials) Profile Study and the Area Health Resource File. Complete data were available for 1332 LHDs that participated in the 2013 NACCHO Profile Study. Logistic regression explored the relationship between LHDs' completion of accreditation prerequisites, in particular completion of a CHA, community health improvement plan, and strategic plan, and their involvement in collaborations with tax-exempt hospitals around CHAs/CHNAs. LHDs that collaborated with tax-exempt hospitals on CHAs/CHNAs were larger, more likely to be locally governed, and more likely to have a local board of health. Bivariate analysis showed that CHA/CHNA-related collaboration with hospitals was significantly correlated (P < .01) with an LHD's completion of accreditation prerequisites. In multivariate regression analysis, completion of all 3 PHAB accreditation prerequisites significantly increased the odds of LHDs collaborating with hospitals when controlling for other LHD and community-level characteristics. PHAB accreditation prerequisites together with IRS requirements for hospitals foster potential for collaboration around CHAs/CHNAs. Joint completion of CHAs/CHNAs not only allows partners to complete the assessment more efficiently but has also been shown to produce higher-quality assessments, thus building a strong foundation for continued collaboration to improve community health.

Creating a framework towards integrated health syndromic surveillance and response in Africa

ObjectiveThe United States Public Health Service released clinical practice guidelines for daily oral preexposure prophylaxis (PrEP) in May 2014. Local health departments (LHDs) are expected to play a critical role in PrEP implementation. We surveyed LHDs to assess awareness of and interest in supporting PrEP implementation, what roles they were taking, or believed they should take, in supporting PrEP, and what resources would be required to do so.MethodsLHDs were surveyed in 2015 to assess their engagement in PrEP implementation (n = 500). The study employed a cross-sectional survey design with a randomly selected stratified sample.ResultsAmong responding LHDs (n = 284), 109 (29%, weighted proportion) reported engagement in PrEP implementation. LHDs serving large jurisdictions (population 500,000+) and located in the West were more likely to be engaged in PrEP implementation. Making referrals for PrEP (74%) and conducting education and outreach to community members (51%) were the activities most frequently reported by LHDs engaged in PrEP implementation; 45% anticipated expanding their level of engagement. Among LHDs not engaged in PrEP implementation, 13% expected to become engaged over the next four years, 46% were undecided, and 41% reported it was unlikely. Information about PrEP for health care providers and information about PrEP for health department staff were the most frequently reported resource needs for LHDs engaged and not engaged in PrEP implementation, respectively.ConclusionsPrEP implementation by LHDs was limited in 2015, three years after Food and Drug Administration approval and one year after the U.S. Public Health Service issued clinical practice guidelines. PrEP is a recently available intervention that is requiring LHDs to adjust existing HIV prevention efforts and service delivery models. Additional resources and implementation research is needed to effectively support PrEP scale-up by LHDs. Efforts must also be undertaken to increase PrEP awareness, knowledge, and implementation capacity among LHDs.

Since the onset of the COVID-19 pandemic in New York State (NYS), local health departments (LHDs) have worked to mitigate the highly infectious disease. As lead public health experts in their communities, LHDs are responsible for providing communicable disease control, emergency response, and establishing immunization programs, including leading large-scale vaccine distribution efforts. The aim of this qualitative study was to understand the processes used by LHDs in NYS to administer COVID-19 vaccines, as well as identify successes and challenges, and highlight lessons learned to improve future mass vaccination campaigns. Data were collected in two phases: (1) extant data collection of public communications; and (2) discussion groups with public health leaders across the state. Notable themes from both phases include: partnerships, programmatic elements, communication, role of LHD, State-LHD coordination, and human and physical resources. Analysis of both public and internal communications from LHDs across NYS revealed several core challenges LHDs faced during COVID-19 vaccine rollout and identified innovative solutions that LHDs used to facilitate vaccine access, administration, and uptake in their communities. Findings from this multi-phase qualitative analysis support the need to bolster the capacity and training of the local public health workforce to ensure preparedness for future public health emergencies.