Volume 7 | Issue 3
Delaware Journal of
July 2021
Public Health A publication of the Delaware Academy of Medicine / Delaware Public Health Association
Technology and Public Health
The 91st Annual Meeting www.delamed.org | www.delawarepha.org
page 66
Delaware Academy of Medicine
Board of Directors: OFFICERS S. John Swanson, M.D. President Lynn Jones, FACHE Secretary David M. Bercaw, M.D. Treasurer Omar A. Khan, M.D., M.H.S. Immediate Past President Timothy E. Gibbs, M.P.H. Executive Director, Ex-officio DIRECTORS Jeffrey M. Cole, D.D.S., M.B.A. Lee P. Dresser, M.D. Stephen C. Eppes, M.D. Eric T. Johnson, M.D. Erin M. Kavanaugh, M.D. Joseph Kelly, D.D.S. Joseph F. Kestner, Jr., M.D. Professor Rita Landgraf Brian W. Little, M.D., Ph.D. Arun V. Malhotra, M.D. Daniel J. Meara, M.D., D.M.D. Ann Painter, M.S.N., R.N. John P. Piper, M.D. Charmaine Wright, M.D., M.S.H.P. EMERITUS Robert B. Flinn, M.D. Barry S. Kayne, D.D.S.
Delaware Public Health Association
Advisory Council: Omar Khan, M.D., M.H.S. Chair Timothy E. Gibbs, M.P.H. Executive Director Louis E. Bartoshesky, M.D., M.P.H. Gerard Gallucci, M.D., M.H.S. Richard E. Killingsworth, M.P.H. Erin K. Knight, Ph.D., M.P.H.
Delaware Journal of
July 2021
Public Health Volume 7 | Issue 3
A publication of the Delaware Academy of Medicine / Delaware Public Health Association
3 | In This Issue Omar A. Khan, M.D., M.H.S. Timothy E. Gibbs, M.P.H.
4 | Guest Editors Patrick Callihan Randy Gaboriault, M.S., M.B.A.
28 | The Data Dilemma: How Delaware is Responding to the CDC’s Recommendations on Gun Violence Meghan Wallace
James P. Highberger, M.P.A. Sharon Merriman-Nai, M.C.
32 | COVID-19, Preparedness, and Technology: Meeting Access and Functional Needs at Vaccine Points of Dispensing and Beyond
10 | W hat is the Delaware SEOW?
Debra Young, M.Ed., O.T.R./L., S.C.E.M., A.T.P., C.A.P.S., F.A.O.T.A.
6 | The Value (and Nuances) of Mapping as a Public Health Tool
Sharon Merriman-Nai, M.C.
14 | Poverty, Racism, and Its Impact on Riverside Logan Herring
16 | A Qualitative Study of Implementing Universal Hepatitis C Screening Among Adults at an Urban Community-Based Health Provider in Delaware Rini Jose, M.P.H. Deborah Kahal, M.D., M.P.H. Karla Testa, M.D. Neal D. Goldstein, Ph.D., M.B.I.
24 | Bayhealth, COVID-19 and Technology – Safely Discovering our New Normal Richard Mohnk, M.S.A., M.T.(ASCP)
Melissa K. Melby, Ph.D.
36 | Evolution of the Delaware Epidemiology Response to COVID-19 Erica Smith, M.P.H., Ph.D Tabatha N. Offutt-Powell, Dr.P.H., M.P.H.
50 | Beyond COVID-19: Technology and Connectivity Help Bridge the Divide in Equitable Care Sharon Anderson, R.N., B.S.N., M.S., FACHE
58 | Delaware’s My Healthy Community Data Platform: At The Intersection of Public Health Informatics and Epidemiology Tabatha N. Offutt-Powell, Dr.P.H., M.P.H. Marcy Parykaza, M.G.A. Michael Knapp, Ph.D., M.E.M. Cassandra Codes-Johnson, M.P.A. Ian Kozak, B.A. Matthew Muspratt, J.D., M.E.M.
66 | The 91st Annual Meeting 67 | Inaugural Address S. John Swanson, M.D.
68 | A Glace at the Rear View Mirror Omar A. Khan, M.D., M.H.S.
69 | 91st Annual Meeting Pictures 70 | New Board Memebers 71 | 91st Annual Meeting Program 88 | Global Health Matters Fogarty International Center
100 | Educational Interventions to Promote COVID-19 Vaccination Among Parents Julia Pascucci
112 | Medical Respite Programs for People who Experience Homelessness Danielle Cooper
118 | From the History, Archives, and Collection: One for All and All in One? Sharon Folkenroth-Hess, M.A.
124 | Index of Advertisers
Mia A. Papas, Ph.D. Karyl T. Rattay, M.D., M.S. William J. Swiatek, M.A., A.I.C.P.
Delaware Journal of Public Health Timothy E. Gibbs, M.P.H. Publisher Omar Khan, M.D., M.H.S. Editor-in-Chief Patrick Callihan Randy Gaboriault, M.S., M.B.A. Guest Editors Liz Healy, M.P.H. Managing Editor Kate Smith, M.D., M.P.H. Copy Editor Suzanne Fields Image Director ISSN 2639-6378
COVER
The role between technology and public health has never been more critical: how we research, plan, and respond and how we interact and inform are based on our connectedness to the whole. Technology and internet access are now just as important as running water and electricity. This new social determinant of health moves at the speed of innovation, and can be tailored to a population’s needs in a matter of days.
The Delaware Journal of Public Health (DJPH), first published in 2015, is the official journal of the Delaware Academy of Medicine / Delaware Public Health Association (Academy/DPHA).
only the opinions of the authors and do not necessarily reflect the official policy of the Delaware Public Health Association or the institution with which the author(s) is (are) affiliated, unless so specified.
Submissions: Contributions of original unpublished research, social science analysis, scholarly essays, critical commentaries, departments, and letters to the editor are welcome. Questions? Write ehealy@delamed.org or call Liz Healy at 302-733-3989.
Any report, article, or paper prepared by employees of the U.S. government as part of their official duties is, under Copyright Act, a “work of United States Government” for which copyright protection under Title 17 of the U.S. Code is not available. However, the journal format is copyrighted and pages June not be photocopied, except in limited quantities, or posted online, without permission of the Academy/ DPHA. Copying done for other than personal or internal reference use-such as copying for general distribution, for advertising or promotional purposes, for creating new collective works, or for resale- without the expressed permission of the Academy/DPHA is prohibited. Requests for special permission should be sent to ehealy@delamed.org.
Advertising: Please write to ehealy@delamed.org orcall302-733-3989forotheradvertisingopportunities.Askabout special exhibit packages and sponsorships. Acceptance of advertising by the Journal does not imply endorsement of products. Copyright © 2021 by the Delaware Academy of Medicine / Delaware Public Health Association. Opinions expressed by authors of articles summarized, quoted, or published in full in this journal represent
I N T H I S I S SU E Since the early days of the internet and personal computers, we have seen explosive growth in the use of technology in the delivery of human services, planning, and more recently in managing “big data.” Even in the early days of the internet, a core group of thought leaders met in Washington, DC, on a monthly basis to discuss things like information and access redlining – that phenomenon that saw low income, remote, and rural communities with little or very primitive access to the “information superhighway” for decades. During the COVID-19 pandemic, we witnessed the profound disadvantage to individuals and to communities who were marginally connected and technology literate. Early in the pandemic, a national awareness developed around “net access” as being an additional social determinant of health. Access and literacy joined other public health utilities we take for granted – notably potable water, effective sewer systems, and a reliable power grid. If one had no internet, old or no technology, and/or minimal technology literacy, during the pandemic there were major impacts: 1) No or limited ability to work remotely, 2) No or limited ability to seek new employment, 3) No or limited ability of remote learning for children, 4) No or limited ability to maintain social connection to family and friends in a time when physical distancing was essential, and 5) No or limited ability to engage in telemedicine services. Within the human services and health care delivery realms, the importance of – and dependence on – technology has been in place for some time. This issue covers some of the many ways in which technology is deployed to address individual and public health challenges. From big data analysis to equitable care, health informatics to data mapping, we hope you enjoy this issue of the Journal. This issue also contains a special section on the 91st Annual Meeting of the Delaware Academy of Medicine / Delaware Public Health Association (see pages 66 to 87). This was a truly unique event, where we piloted a vaccine certification in order to attend, and made available both on-site and on-line options for attendee comfort and safety. For many, this was the first large professional gathering since the pandemic started 15 months ago. By design, the in-person attendance was limited, but with in-person and Zoom attendance we saw a robust and engaged membership. Governor John C. Carney, Jr. and First Lady Tracey Quillen Carney were recognized with the Lewis B. Flinn President’s award for their lifelong work in the fields of education and public health. The Executive Director’s Public Health Recognition was presented to the Delaware Rural Health Initiative and accepted by Division of Public Health Director, Dr. Karyl Rattay. Lieutenant Governor Bethany Hall-Long, a passionate public health advocate, provided opening comments to the audience, and the keynote speaker, Dr. Geoff Tabin wrapped up the evening with an inspiring lecture on overcoming obstacles, be they mountains or healthcare. As always, we welcome your comments and feedback, on the promise of technology in healthcare, and on your own ideas and views about anything we do involving Delaware health sciences, medicine & public health. Thank you as always, and enjoy the issue!
Omar A. Khan, M.D., M.H.S. Editor-in-Chief
doi: 10.32481/djph.2021.07.001
Timothy E. Gibbs, M.P.H. Executive Director 3
Patrick Callihan Patrick Callihan is the Executive Director of Tech Impact, a national technology capacity building and workforce development organization, dedicated to delivering innovative technology solutions and support to the nonprofit/non-government sector and developing and providing transformational workforce development programs that create a lasting impact on society. Randy Gaboriault, M.S., M.B.A. Randy Gaboriault is the Senior Vice President, Chief Digital and Information Officer for Delaware-based ChristianaCare. He serves as board chair for the Delaware Health Information Network, and as Board Director and Treasurer for the non-profit Tech Impact.
We are humbled to have been asked to be guest editors for this important publication, particularly because this edition focuses on the intersection of technology and public health. In the last year, the terms “unprecedented” and “extraordinary” have been used more times than we can count to describe the new paradigms that the pandemic has invoked in our work lives, in our home lives, in our education systems, and in our healthcare system. Never has there been a time we can recall that technology was pushed to the forefront so quickly. For many, our homes became our workspaces as offices shuttered. Our children now required a laptop and a corner in the house to continue their learning as schools closed their campuses. Doctors office visits were often conducted over videoconferencing platforms. And we held virtual happy hours and social distancing birthday parties to try and stay connected to one another and maintain our sanity. Thankfully, technology is widely available, and our organizations have a high adoption rate. Maintaining meetings with our teams, reviewing budgets, connecting to customers and constituents, and otherwise conducting day-to-day business shifted rather swiftly to an online medium, and we were able to keep the engines running. It seemed relatively easy, at least for those of us that had the capacity and made the investments for this time many thought might never come. What became immediately apparent to us are the vast divides in our country. The differences between the haves and the have nots. The digital divide that we were all likely somewhat aware of prior to the pandemic became front and center. The community shifted immediately to try and solve challenges that had been true but largely unsolved for decades. We could no longer ignore or accept that some households could not connect to the internet. How would children in those homes learn if the only option were on a laptop? How could those homes access healthcare if the best option were a video conference with their doctor? How could they apply for benefits if they could not get online? You will read about some of the solutions and lessons learned through the articles in this edition.
4 Delaware Journal of Public Health - July 2021
And, although technology could solve many of the challenges brought by the pandemic and be used to battle the spread of the disease itself, there were also unintended consequences. The countless hours in front of a screen, multitudes of hours in isolation, and the stress of not being in close contact with relatives and friends all took a toll on our mental health. We have listened to many stories of not being able to visit grandma, about children that cannot do something as simple as play with other kids, and about online meeting burnout. The increased anxiety and depression associated with the pandemic soared, a stark reminder that technology alone cannot solve our challenges. This issue, however, is not solely focused on the pandemic and technology’s role. It is much broader. There are inspiring stories about how technology is used to provide insights into public health issues, innovative ways organizations are using technology and data to solve problems and some stories about the individuals who dedicate their lives to improving our health. Over the last few months, we worked closely with the team at the Delaware Journal of Public Health and dug into our collective networks to find the innovators, the changemakers, and the researchers that devote their time and talent to leveraging technology for the good of public health in a variety of ways. We believe what follows in these pages will bring a greater understanding of how technology can be used for good. Technology for the good of our society, that needs to be connected, and for the good of solving problems that will enrich our lives and improve our health. We are thankful for the authors that have given freely of their time to share their work with us in this issue and we are inspired by their work to improve our lives. We hope you enjoy this edition of the Journal as much as we have enjoyed working to put this together.
doi: 10.32481/djph.2021.07.002
HIGHLIGHTS FROM
The
NATION’S HEALTH A P U B L I C AT I O N O F T H E A M E R I C A N P U B L I C H E A LT H A S S O C I AT I O N
Table of Contents June 2021; Volume 51,Issue 4 NATION Biden budget proposes big boosts for US public health infrastructure: FY 2022 outlook Kim Krisberg
HEALTHY YOU Ready for a nap? Taking the perfect quick snooze Aaron Warnick APHA NEWS
mRNA technology showing promise for range of diseases: COVID-19 vaccine spurs more research Mark Barna
Policy Action Institute builds better bridges to health: APHA event showcases successful public health policies Mark Barna
COVID-19 vaccination research turns toward young children: Clinical trials involving kids underway Aaron Warnick
National Public Health Week offers hope, resilience: Video recordings from APHA events available online Mark Barna
US pedestrian deaths rise during pandemic, national report finds Lindsay Syms
PRESIDENT’S COLUMN
SPECIAL REPORT
Continued advocacy for racial justice, police reform crucial: Police violence a pressing health issue José Ramón Fernández-Peña
System helps find preventive solutions for violent deaths: Researchers encouraged to use data Mark Barna
Vital Signs en Español: La violencia policial es un problema de salud pública José Ramón Fernández-Peña
NVDRS data supporting state work to end lethal violence: System now includes all 50 states Kim Krisberg
WEB-ONLY NEWS
Partnerships key to bringing rich data, narratives to NVDRS: Violent death system continues to expand Kim Krisberg
Newsmakers: June 2021 Aaron Warnick Resources: June 2021 Aaron Warnick
Q&A with researcher Catherine Barber: NVDRS death data can bolster public health – ‘Learn from the dead and let the data live and breathe’ Kim Krisberg
5
The Value (and Nuances) of Mapping as a Public Health Tool James P. Highberger, M.P.A. Research Associate, Center for Drug and Health Studies at the University of Delaware, Acting Principle Investigator, Delaware School Survey Sharon Merriman-Nai, M.C. Senior Consultant, Center for Drug and Health Studies at the University of Delaware
INTRODUCTION As technological barriers and cost of data entry have been reduced, the use of Geographic Information Systems (GIS) in public health will continue to increase. Scholars, public policy experts, and practitioners are all interested in place, space, and health. With Delaware’s Open Data portal, FirstMap, and My Healthy Community dashboard, it is easier now than ever to access data and geocode it to produce heat maps that tell us important geographic stories regarding population health and well-being. Heat maps are data visualizations that use variation in color or shading to demonstrate how certain phenomenon change over geographic area. They can be used to explore the rate of health conditions in a region as well as social and environmental conditions that contribute to well-being including insurance coverage, educational attainment, poverty rates, the frequency of crime and acts of violence, etc. Because they can quickly convey a story, heat maps are popular for presentations and other data sharing strategies; feedback to the State Epidemiological Outcomes Workgroup from its network members suggest that they are among the most useful data products available. However, it is critical that GIS users and audiences take a moment to explore the scope and boundaries of the geographic unit of a given map to understand specifically what is being illustrated. Geographic units are predefined geographic areas, such as ZIP codes, census tracts, or census blocks that are used to break down larger areas such as towns, cities, counties, and states. In this commentary, we consider how different geographic units can influence our understanding of important public health issues by comparing two poverty rate heat maps of New Castle County: the first based on census tracts and the second on ZIP codes. Poverty level was chosen because studies have consistently shown that economic and health status are intertwined with the stresses of poverty often being linked to adverse health effects.1 After highlighting the impact that a geographic unit can have on data visualization, we illustrate how heat maps designed by The Center for Drug and Health Studies (CDHS) at the University of Delaware have been used to track changes in substance use rates, identify resource desserts, and help policy makers and other stakeholders understand the health and prevention needs of various communities across the state.
EXPLORING THIS PHENOMENON WITH DELAWARE DATA When creating public health maps, one of the first questions that researchers and practitioners must ask is what geographic unit they are going to use to capture and define an area of study, such as a neighborhood or community. The most common geographic unit to define neighborhoods in the social sciences is census tracts,2 because of the quantity of US Census data available.3 6 Delaware Journal of Public Health - July 2021
Other convenient units of analysis are ZIP codes because participants in studies will generally know their ZIP code and can provide this information. The use of these and other predefined geographic units is convenient, and allows users to access a wide range of information about these areas; they do have some limitations. When using mapping applications to tell the story of different neighborhoods, it is critical to know that there is no precise definition of “neighborhood” in either spatial extent or social composition.4 Rather, neighborhoods are context dependent, and do not fit neatly into predefined geographic units.3 Unlike census tracts and ZIP codes, neighborhoods are not isolated units; their borders are permeable and blend with one another.5 Studies have shown that when researchers and practitioners reject predefined geographic regions and instead use borders defined by neighborhood residents there may be noticeable impacts on social indicators5 that can result in a change of the statistics.2 Understanding the impact that selected geographic units have on data visualization helps to better inform policy, programs, and practices for members of the neighborhoods and communities who are the intended beneficiaries. An example of the differences observed when we change the geographic unit of a heat map can be seen here in Delaware, especially in New Castle County where characteristics of census tracts can vary greatly within small localities. Figure 1 provides a side-by-side comparison of the percentage of residents living in poverty in New Castle County by census tracts and by ZIP codes using data from the Delaware Opioid Metric Intelligence Project (DOMIP) (2017-IJ-CX-0016), funded by the National Institute of Justice.6 Readers can see that though these two figures both identify areas in New Castle County that are below the federal poverty level, the shading between them varies a considerable amount. To further demonstrate the difference a geographic unit can have on visualization of data, Table 1 displays poverty rate and percentage of residents without health insurance between ZIP code 19711 and census tracts located within that ZIP code. Though ZIP code 19711 has an aggregated poverty rate of 16.53%, the poverty rate for census tracts located within ZIP code 19711 ranges from 0.16% - 64.52%. Using summary statistics for the rates of poverty and percent of residents without health insurance, it is noticeable how even within a relatively small geographic unit such as a ZIP code, there is still a sizable amount of variance that can take place. This demonstrates that the summary characteristic of one geographic region maybe misleading and that pockets of demographic, social, and economic characteristics may not be captured in a specific geographic unit’s summary statistic.3 Though these tables and figures demonstrate the relationship between ZIP codes and census tracts, other research has shown that this relationship is consistent when comparing smaller units, doi: 10.32481/djph.2021.07.003
Figure 1. Percent in Poverty in New Castle County; Shading Differences between Census Tracts and ZIP Codes6
such as census tracts and census blocks. A census tract may have a summary statistic that reports the tract has a middle income, but the census tract may be composed of census blocks with high income and low income.2 Table 1. Poverty Rate and Percentage of Residents Without Health Insurance, ZIP Code 197116 Poverty Rate
Percent without Health Insurance
16.53%
3.90%
145.02 City Center
64.52%
2.20%
145.01 Nottingham Green
63.69%
5.77%
144.02 Fairfield Crest
32.78%
1.18%
143 Lumbrook
12.44%
2.24%
137 Eastburn Acres
11.00%
8.10%
136.11 Chapel Hill
15.23%
2.83%
136.10 Meadowood
5.78%
4.45%
135.06 North Star
2.94%
1.84%
135.05 Town Center
0.16%
2.49%
ZIP Code 19711 Census Tracts within 19711
The above figure and table provide good insight into why users of heat maps must remember that there is often more to the story. These figures are able to showcase that the statistics, in
this case poverty levels, can change when viewed using different geographic units. But they are also important reminders that though predefined geographic units such as ZIP codes and census tracts have clear borders, in reality neighborhoods blend together. When looking at the above figures, the borders for the ZIP code geographic unit does not align with the census tract borders. Instead, both units occupy different spaces, the clear distinction between the summary statistics of one unit and another are artificially created. This is necessary when creating maps using geographic regions, in order to manage and organize the data in a presentable manner. But it also indicates why policy and program developers must work at the ground level with local communities to understand a neighborhood’s needs.
PRACTICAL APPLICATIONS: USING HEAT MAPS TO INFORM DELAWARE HEALTH AND PREVENTION INITIATIVES The Center for Drug and Health Studies (CDHS) at the University of Delaware is the home of a number of data collection and evaluation efforts, including the State Epidemiological Outcomes Workgroup (SEOW) and the Delaware School Survey (DSS). Both of these projects are funded with federal support through the Division of Substance Abuse and Mental Health, Delaware Department of Health and Social Services (DSAMH). The Center has produced a number of heat maps to support efforts for state agencies, nonprofit organizations, community groups, and researchers in the health and prevention fields. The SEOW, with the overarching mission to promote the use of data to support prevention and wellness, has presented these heat maps to stakeholders ranging from parenting groups to policy makers, and 7
have included them in publications such as the annual Delaware Epidemiological Profile. The Delaware School Survey (DSS) is an annual survey of 5th, 8th, and 11th grade public school students across the State of Delaware. The DSS provides estimates of students’ attitudes towards and rates of alcohol, tobacco, and other drug use. The data is used for assessment, planning, and funding purposes and to provide ongoing trend data for state and local stakeholders, including individual districts and schools. A series of heat maps are drafted each year using DSS data. These heat maps track substance use across the state of Delaware for 8th and 11th graders, combining two years of data to ensure a large enough sample is pulled for robust analysis. The DSS also asks students to report their ZIP code which allows CDHS to create summary statistics for ZIP codes across the state for any question asked on the survey. The most common summary statistic produced is rate of reported substance use for each ZIP code, which is plugged into the mapping application, ArcGIS, to create a heat map of substance use across the state. An example of one of these maps can be seen in Figure 2. Figure 2. Example of a Heat Map Created by the Center for Drug and Health Studies7
example, Delaware Alcohol and Tobacco Enforcement (DATE) was able to utilize the heat map depicting vaping and electronic cigarette use in Figure 2 to guide underage compliance checks. Other practitioners and prevention advocates involved with community organizations have used the Alcohol Use Map to guide their targeted efforts. Substance use heat maps have been included in grant proposals to document need and in progress reports to illustrate changes in conditions. Heat maps that track a condition over time also illustrate rate changes, which is useful for trying to determine emerging trends or the effectiveness of programs and policies. With the series of Interactive Substance Use Maps developed by CDHS, users can track changes in specific consumption rates among 11th graders from 2014 to 2019 throughout Delaware. For emerging trends such as vaping and electronic cigarette use, having data compiled in one location allows policy makers and practitioners to visualize the rapid increase in use. Along with tracking changes in substance use or other behaviors of interest, GIS can also help plan resource allocation. Human resource deserts arise when residents do not have access to valuable health and social services without traveling far distances. Often times resource deserts are located in rural communities. Using GIS, policy makers are able to geolocate certain resources and identify areas that are lacking in specific services. This can help when trying to plan where to place valuable social service centers. Using GIS and in coordination with United Way of Delaware, CDHS was able to produce An After School Program Resource Map, which pinpoints available programs across the state and provides information about each program when users click on them. This resource map serves two functions: for parents or guardians it is an easy-to-use directory for locating accessible afterschool activities for their children. For policy makers and practitioners, the same map highlights the large areas without easy access to after school programming, thus guiding future initiatives. Delaware Opioid Metric Intelligence Project (DOMIP) is an example of an initiative that uses GIS to both track the rate of a public health issue and to provide information on available resources to address the issue. The interactive map series depicts overdose death rates from 2013 through 2019 by Zip code, census tracts, State House Districts, and county. It also maps substance use treatment resources including residential treatment, detox centers, methadone clinics, and transitional sober living services, along with other supportive services.
CONCLUSION
PRACTICAL APPLICATIONS USING DELAWARE DATA Heat maps are unique tools that can help practitioners, public policy experts, and community agencies better understand and respond to behaviors and conditions in their localities. For 8 Delaware Journal of Public Health - July 2021
Whether tracking substance use rates, changes in behaviors and attitudes, or identifying resource deserts, GIS is a powerful tool that provides many benefits to a variety of audiences and users. However, it is paramount to understand both the strength and limits of GIS. To summarize, selection of geographic units can impact data visualization, how stories are told, and summary statistics of those regions. When using predefined geographic units there are clear boundaries between units such as census tracts and ZIP codes, but in reality, there are no clear boundaries between neighborhoods. Often time neighborhood boundaries and needs blend and merge with one another. When practitioners and policy experts rely solely on maps the result can be flawed findings and poor public policy decisions.2 This is especially
problematic where there are pockets of missing data (for example, due to lack of participation) or when the geographic units of analysis are too large for meaningful interpretation (such as when only county or state level data are available). As mapping tools and data become more accessible, there are many opportunities to apply them to identify emerging needs, resource deserts, and ideal program placements. They are particularly powerful in visualizing social determinants of health in association with rates of health conditions and behaviors. However, mapping also does not reflect the differences of how an individual or family may experience an adverse condition or their degrees of resilience which may be influenced by gender, race, culture, and other characteristics. GIS and other mapping tools are most effective when coupled with strong community engagement and input in order to maximize the benefit of this technology.
ACKNOWLEDGEMENT The authors would like to acknowledge and thank the Delaware Department of Health and Social Services, Division of Substance Abuse and Mental Health for funding the Delaware State Epidemiological Outcomes Workgroup (SEOW) and the Delaware School Survey (DSS), and the U.S. Department of Justice, National Institute of Justice, for funding the Delaware Opioid Metric Intelligence Project (DOMIP). We also wish to thank the team at the Center for Drug and Health Studies at the University of Delaware, including all survey administrators, for their diligence in data collection and analysis.
CORRESPONDENCE James P. Highberger, M.P.A. is a Research Associate at the Center for Drug and Health Studies at the University of Delaware. jphigh@udel.edu
REFERENCES 1. Wagstaff, A. (2002). Poverty and health sector inequalities. Bulletin of the World Health Organization, 80(2), 97–105. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2567730/ pdf/11953787.pdf Accessed April 26, 2021 PubMed 2. Sperling, J. (2012). The tyranny of Census geography: Smallarea data and neighborhood statistics. Cityscape (Washington, D.C.), 14(2), 219–223. Retrieved from http://www.jstor.org/stable/41581107 Accessed April 26, 2021 3. Coulton, C. J., Korbin, J., Chan, T., & Su, M. (2001, April). Mapping residents’ perceptions of neighborhood boundaries: A methodological note. American Journal of Community Psychology, 29(2), 371–383. Accessed April 26, 2021. https://doi.org/10.1023/A:1010303419034 PubMed 4. Knaap, E., Wolf, L. J., Rey, S. J., Kang, W., & Han, S. (2019, February 27). The dynamics of urban neighborhoods: a survey of approaches for modeling socio-spatial structure. Retrieved April 26, 2021 from https://doi.org/10.31235/osf.io/3frcz 5. Morenoff, J. D., Sampson, R., & Raudenbush, S. (2001). Neighborhood Inequality, collective efficacy, and the spatial dynamics of urban violence. Criminology, 39, 517–558. Retrieved from https://scholar.harvard.edu/files/sampson/files/2001_crim.pdf Accessed April 26, 2021 https://doi.org/10.1111/j.1745-9125.2001.tb00932.x 6. Anderson, T. L. (Principal Investigator) and O’Connell, D. (CoInvestigator). “Delaware Opioid Metric Intelligence Project,” (2017-IJ-CX-0016), funded by the National Institute of Justice, US Department of Justice. https://www.cdhs.udel.edu/projects/domip 7. University of Delaware Center for Drug and Health Studies. (n.d.). The State Epidemiological Outcomes Workgroup. Retrieved from: https://www.cdhs.udel.edu/seow/what-is-seow
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What is the Delaware SEOW? Sharon Merriman-Nai, M.C. Senior Consultant, Center for Drug and Health Studies at the University of Delaware
The State Epidemiological Outcomes Workgroup, better known as the SEOW, was established 15 years ago as part of Delaware’s first Strategic Prevention Framework (SPF) grant from the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA). SEOWs were funded to promote the use of data to inform prevention efforts at state and local levels. Because of its commitment to guiding prevention and treatment with data, the Delaware Division of Substance Abuse and Mental Health (DSAMH), Department of Health and Social Services has continued to sponsor the SEOW since its beginning. The work group is facilitated by the Center for Drug and Health Studies at the University of Delaware. The mission of the SEOW is to bring data regarding behavioral health to the forefront of prevention and treatment initiatives. Specifically, the SEOW facilitators convene a network of stakeholders – representatives of state agencies, nonprofits, community organizations, coalitions, task forces, and other entities – to identify data needs, to share data sources and resources, and to inform the development of data products to meet those needs. Based on this input, the facilitator team develops a wide range of materials including heat maps (featured in this issue), infographics, gap reports and an annual epidemiological profile, webinars, and other products to highlight behavioral health trends, risk and protective factors, and groups who may be at disproportionate risk for adversities. The team also provides customized technical assistance to help people use
data to support grant application submissions, needs assessment, program planning, evaluation, research, and public awareness and outreach. Collaboration is critical to the success of the SEOW. There are currently over 100 network members representing approximately 50 Delaware-based organizations. Many provide access to data sources and use their platforms to help “push out” data to support state and local efforts. They also provide recommendations for making data easy to understand and use so that policy makers, practitioners, advocates, and others can translate it into action to foster strong and healthy communities. The SEOW benefits from rigorous, cross-sector engagement. We are grateful to collaborate with our committed partners, including the Delaware Academy of Medicine/Delaware Public Health Association, and to share this information with readers of the Delaware Journal of Public Health. As Roberta Gealt, the former lead facilitator of the SEOW often said, “If you are not using our data, we are not doing our job.” To learn more about the SEOW or to view data resources, please visit: https://www.cdhs.udel.edu/seow/what-is-seow.
CORRESPONDENCE Sharon Merriman-Nai, M.C., Senior Consultant, Center for Drug and Health Studies at the University of Delaware, smnai@udel.edu
ChristianaCare coordinates a variety of learning opportunities for doctors, nurses, pharmacists and medical professionals working in Delaware, Maryland, New Jersey and Pennsylvania. All activities are accredited by the Accreditation Council for Continuing Medical Education and Medical Society of Delaware.
For our current offerings, visit ChristianaCare.org/CME ChristianaCare Office of Continuing Medical Education 302-623-3882 | CME@ChristianaCare.org
21CRE6 CME for Delaware Journal of Public Health.indd 10 Delaware Journal ofAdPublic Health - July 2021 1
11/5/20 10:49 AM doi: 10.32481/djph.2021.07.004
11
LGBTQ+ Affirming Spaces
*Interactive PDF: select underlined words for more information / resources.
To Learn More:
Learning About Sexual Orientation, Gender Identity & Expression (SOGIE) Defining LGBTQ
Data Note:
All Youth Risk Behavior Survey data included in this infographic were o tained through the 'D'*s pu licly availa le portal and can e accessed here.
Lesbian, Gay, or Bisexual (LGB) Victimization at School National Youth Risk Behavior Survey, 2019
32% of LGB high
12% of LGB high
bullied on school property.
threatened or injured with a weapon on school property.
school students were
Depression & Suicidal Ideation Among LGB High School Students National Youth Risk Behavior Survey, 2019
66% of LGB high school students felt sad or hopeless almost every
High School Students responded to the following uestion.
day for 2 or more weeks in a row during the past 12 months.
Which of the following best describes you? A. Heterosexual (straight) B. Gay or lesbian C. Bisexual D. Not sure
4 % LGB high school students had planned how they would attempt suicide during
Every stage of suicidal ideation presents an opportunity for prevention#intervention" "Namely, prevalence estimates of suicidal ideation, suicide plans, attempts, and attempts re uiring medical treatment were highest among sexual minority youths, those who identified as LGB, and youths who reported having had sexual contact with the same or with both sexes during 2019" (IveyStephenson, 2019).
"12% of those who reported at least one in-person LGBTQaffirming space attempted suicide in the past year compared to 20% of LGBTQ youth without in-person LGBTQaffirming spaces." (The Trevor Project, 2020*)
Citations:
school students were
the past 12 months.
47% of LGB high school students
seriously considered attempting suicide during the past 12 months.
23% of LGB high school students had attempted suicide one or more times during the past 12 months.
Suicidal Ideation Among Delaware LGB High School Students Delaware Youth Risk Behavior Survey, 2017 Among Delaware High Schoolers, approximately...
1:1 Heterosexual students reporting making a suicide plan 1:3 LGB students reported making a suicide plan
LGBTQ+ Affirming Spaces
"Transgender and nonbinary youth who reported having pronouns respected by all of the people they lived with attempted suicide at half the rate of those who did not have their pronouns respected by anyone with whom they lived." (The Trevor Project, 2021*)
Ivey-Stephenson, A. Z., Demissie, Z., Crosby, A. E., Stone, D. M., Gaylor, E., Wilkins, N., Lowry, R., & Brown, M. (2020). Suicidal Ideation and Behaviors Among High School Students - Youth Risk Behavior Survey, United States, 2019. MMWR supplements, 69(1), 47–55. https://doi.org/10.15585/mmwr.su6901a6 The Trevor Project. (2021). 2021 National Survey on LGBTQ Youth Mental Health. West Hollywood, California: The Trevor Project The Trevor Project. (2020). 2020 National Survey on LGBTQ Youth Mental Health. New York, New York: The Trevor Project.
12 Delaware Journal of Public Health - July 2021
Tips for Creating Affirming Spaces for LGBTQ+ Individuals Make Curriculum LGBTQ+ inclusive
including LGBTQ+ history include diverse families use LGBTQ+ inclusive literature celebrate LGBTQ+ events (Safe space kit, 2019)
Response to "Coming Out" offer support assure and respect confidentiality listen
Be isible
Promote Non,Discriminatory Policies and Practices for
make classrooms and work spaces safe by showing support let your actions speak for you use inclusive language respond to anti-LGBTQ+ behavior (Safe space kit, 2019)
sexual orientation gender identity gender expression
(Safe space kit, 2019)
Online Communities
(Safe space kit, 2019)
*Interactive PDF: Select underlined words for more information / resources.
Trevor Lifeline
Q Chat Space: an online community for LGBTQ+ teens TrevorSpace: affirming international community for LGBTQ young people
24/7/365 Call, text, or chat 1-866-488-7386 Text START to 678-678
Locating Affirming Spaces Local
National
Big Brothers, Big Sisters of Delaware*
Genders & Sexualities Alliance Network
"Big Brothers Big Sisters of Delaware has been serving Delaware children and youth since 1964. We have a proven record of success, providing mentoring relationships that benefit everyone involved – the child, the family, the volunteer and the community."
"GSA Network is a next-generation LGBTQ+ racial and gender justice organization that empowers and trains queer, trans and allied youth leaders to advocate, organize, and mobilize an intersectional movement for safer schools and healthier communities."
CAMP Rehoboth LGBTQ Youth*
PFLAG*
"CA ehoboth seeks to promote community wellbeing on all levels; to foster the development of community groups; to develop community space; to promote human and civil rights; to work against prejudice and discrimination; to lessen tensions among the community at large; and to help foster the economic growth of the area."
" LAG is the first and largest organization for lesbian, gay, bisexual, transgender, and queer (LGBTQ+) people, their parents and families, and allies." LAG has three chapters in Delaware with updated resources that offers virtual and local opportunities. (Delaware's chapters)*
William Way LGBTQ Community Center*
GLS0N*
"The William Way LGBTQ+ Community Center serves the LGBTQ+ community of hiladelphia and its allies 365 days a year. The center offers social groups, networking events, counseling and support services, art exhibitions and cultural experiences."
"GLSEN believes that every student has the right to a safe, supportive, and LGBTQ+-inclusive -1) education. We are a national network of educators, students, and local GLSEN Chapters working to make this right a reality."
Citations: Safe S ace it: uide to $ein an ll to $ Students. "nd edition ed.' S, Pu lis ers' " !#.
Funding for this project has been provided by the Delaware Department for Health and Social Services, Division of Substance Abuse and Mental Health through the Substance Abuse and Mental Health Services Administration (SAMHSA). Funding for the Delaware High School outh is ehavior Survey was provided through the Delaware Division of ublic Health by the !enters for Disease !ontrol and revention.
13
Poverty, Racism, and Its Impact on Riverside Logan Herring C.E.O., The WRK Group
Let’s be honest with ourselves for a moment. Poverty and racism are two sides of a centuries old coin. In fact, “…the correlation between poverty and race is undeniable; both statistics and life experiences confirm the connection. Communities of color, especially Black and Hispanic communities, experience much higher rates of income shortfalls than the population categorized as White non-Hispanic.”1 This isn’t new information, in fact, it’s far from it. But it is relevant. The Riverside Neighborhood, located in Wilmington, Delaware, is a real example of the impact of systemic racism and poverty in a local community. The Riverside Neighborhood was originally built to create an affordable neighborhood for White veterans returning from World War II. The GI bill, which gave many returning veterans the opportunity to obtain a mortgage, home, and in time, the development of generational wealth, didn’t necessarily extend to returning Black veterans. Though the bill helped White Americans prosper and accumulate wealth in the postwar years, it didn’t deliver on that promise for veterans of color. In fact, the wide disparity in the bill’s implementation ended up helping drive growing gaps in wealth, education, and civil rights between White and Black Americans.2 As a result, White veterans, their families, and their newly attained mortgages, were able to leave the Riverside Neighborhood as they pursued the “American Dream” and a life in the suburbs. Today, this mass exodus is known as “White Flight,” and the ripple effects remain present even today. As subsidized housing became available, low-to-no-income Black Americans began to move into Riverside. Without the benefit of home ownership, a major contributor to generational wealth and stability, it became harder and harder for Riverside residents to flourish and grow. Decades later, the effects of the flawed GI Bill and other contributing factors to systemic racism – such as mass incarceration – are widely felt by today’s residents. In fact, today’s Riverside is a challenging landscape that includes unsettling statistics about the neighborhood and its potential future: • 70 percent of children in Riverside live below the poverty line compared to 25 percent of children in Delaware, • 68 percent unemployment rate in public housing, • 41 percent of adults are without a high school diploma, • Median household income is $9,277 in subsidized housing ($23,456 in non-subsidized housing), • 87 percent of households are led by single women
THE DIGITAL DIVIDE One of the ripple effects of systemic racism and poverty that regularly effects the Riverside Neighborhood is the lack of access to high-speed internet. Commonly referred to as the digital divide, this separation from a tool that has become a basic necessity has long-reaching effects. Research has shown that “low-income households and people of color are less likely to have 14 Delaware Journal of Public Health - July 2021
home-internet connections. But if they do connect at home, they are more likely to rely solely on mobile wireless.”3 While a mobile wireless connection offers some assistance, “mobile-only households do not have access to the full benefits of fixed broadband connections. Fixed connections typically offer far greater speeds and higher data caps (or no caps). Furthermore, a mobile connection may not always be available to everyone in the household if the primary account holder takes the only mobile device with them when they leave the home.”3 Also, at its root, internet is an incredibly expensive commodity. Mobile access offers more diverse payment options and can eliminate the barrier of credit checks that home internet requires. A major reason for this difference between wired and mobile is that the mobile market is more competitive (for now), with incumbent providers and resellers offering lower-cost plans with no credit checks, and specifically marketing them to low-income families and people of color. … But no such plans exist for wiredbroadband options with higher capacity and faster speeds than wireless, like cable or fiber. If you want wired home internet, you have to pass a credit check — and credit checks have long fueled racial discrimination.4 Imagine having to conduct a job search, research a school project, or write a resume with only your mobile device for assistance. To bring it even more closely to home, there is no way I could have done my research or event typed up this article without the support of a laptop and high-speed internet at my fingertips.
THE WRK GROUP Now, before you start to worry that this is yet another article that leaves you with feelings of insurmountable obstacles and no clear path forward, let me relieve your fears. This is an article that lets you know that, even though there are challenges, BIG CHALLENGES, on the path to rectify what years of slavery, Jim Crow laws, segregation, and ongoing racism have embedded in our American culture, there are still ways to move forward. The WRK Group, comprised of The Warehouse, REACH Riverside, and Kingswood Community Center, is a collaboration of three organizations focused on developing and enhancing the health and well-being of the Riverside Neighborhood.
THE WAREHOUSE
http://www.teenwarehouse.org/ • Developed “For Teens, By Teens” • Innovative, one-stop center serving ages 13 to 19 • Teen-driven programming focused on recreation, education, arts, career, and health • Collaborating with over 140 youth-serving organizations • Three goals: safety, educational support, and workforce readiness doi: 10.32481/djph.2021.07.005
REACH RIVERSIDE http://www.reachriverside.org/ • Developed “With the Community, For the Community” • Member of the national Purpose Built Communities • $250 million holistic revitalization effort • Redevelopment: Up to 600 units of high quality, mixed-income housing • Education: cradle-to-college and career readiness pipeline • Community Health: health, wellness, safety services, and programming
KINGSWOOD COMMUNITY CENTER http://www.kcc.org/ • Empowering the Community of Riverside and Northeast Wilmington since 1946 • Early Learning Academy: high quality, evidence-based programming (ages one through five) • School-age services (ages six through twelve): before, after-school, and summer programming • Jimmy Jenkins Senior Center: activities to remain healthy and self-sufficient • Kingswood Academy: alternative school, located at The Warehouse (seventh through twelfth grade) • Preparing for the development of a new, state-of-theart facility that will replace and enhance the current community center With the goal of empowering the community to reach its full potential by eliminating the barriers of structural racism and revolutionizing teen engagement, The WRK Group has seen the direct impact of poverty, systemic racism, and the digital divide, and we are meeting the challenge head-on. • Riverside Relief Fund: When COVID-19 hit our communities in 2020 and schools began to transition from brick-and-mortar education to virtual classrooms, The WRK Group quickly realized that Riverside was not set up for success. That’s why they began the Riverside Relief Fund. In a short period of time, The WRK Group was able to distribute over 400 Chromebooks to Riverside families. In some scenarios, this was the first device with internet access for a household, allowing students to participate in virtual studies and providing adults with the tools they need to be successful. • Comcast Lift Zone: Kingswood Community Center partnered with Comcast to create a “Lift Zone.” About one-fourth of households in Wilmington have no internet access, according to 2018 Census Bureau estimates.5 In September 2020, Comcast announced a multiyear program to launch more than 1,000 Wi-Ficonnected Lift Zones in community centers nationwide. This effort is part of its ongoing
commitment to help connect low-income families to the Internet and provide resources to help them fully participate in educational opportunities and the digital economy. The newly established Lift Zone now provides high speed internet to the local community at no cost to the individual. • ChristianaCare Virtual Health: The WRK Group and its partner, ChristianaCare, have recently established the first primary health care provider in the community. Appointments are made via mobile phone with virtual and in-person availability. Locals are now able to obtain physicals for school or sports teams as well as having access to additional care and consultation when sick.
WHAT CAN I DO? Through these endeavors and initiatives, The WRK Group continues to look for opportunities to diminish the barriers that many people of color experience daily. They know that simply closing the digital divide will not end systemic racism or poverty, but it is one of many tools they can use to bring justice to an underserved and undervalued neighborhood. So, how can you help? Donate Today: Non-profits like The WRK Group need your support to eliminate barriers to success. Whether giving monthly or providing a one-time gift, your donation is incredibly valued. Learn More: Visit www.wrkgroup.org to learn more about the Riverside neighborhood and other ways you can get involved. Talk to Them: The best way to learn about The WRK Group is to have a good old-fashioned chat! Email today to sign up for a lunch and learn where you can learn more about this incredible neighborhood and where it is headed.
REFERENCES 1. Anti-Poverty Network of New Jersey. (2017, September). AntiPoverty Network. The Uncomfortable Truth. Retrieved from: http://www.antipovertynetwork.org/resources/Documents/ The%20Uncomfortable%20Truth%20Final%20-%20web.pdf 2. Blakemore, E. (2019, June 21). How the GI Bill’s Promise Was Denied to a Million Black WWII Veterans. History.com. https:// www.history.com/news/gi-bill-black-wwii-veterans-benefits 3. Turner, D. (2016, December). Digital Denied: The Impact of Systemic Racial Discrimination on Home-Internet Adoption. Free Press. https://www.freepress.net/sites/default/files/legacypolicy/digital_denied_free_press_report_december_2016.pdf 4. Floberg, D. (2018, December 13). The Racial Digital Divide Persists. Free Press. https://www.freepress.net/our-response/ expert-analysis/insights-opinions/racial-digital-divide-persists 5. Neiburg, J. (2021, April 17). Comcast’s ‘Lift Zones’ in Wilmington, Newark aim to help low-income families get online. The News Journal. https://www.delawareonline. com/story/news/2021/04/17/comcasts-lift-zones-help-lowincome-families-get-online-delaware-internet-access-virtuallearning/7259961002/ 15
A Qualitative Study of Implementing Universal Hepatitis C Screening Among Adults at an Urban Community-Based Health Provider in Delaware Rini Jose, M.P.H. Drexel University Dornsife School of Public Health, Department of Epidemiology and Biostatistics Deborah Kahal, M.D., M.P.H. Sydney Kimmel College of Medicine, Thomas Jefferson University Karla Testa, M.D. Sydney Kimmel College of Medicine, Thomas Jefferson University Neal D. Goldstein, Ph.D., M.B.I. Drexel University Dornsife School of Public Health, Department of Epidemiology and Biostatistics
ABSTRACT Objectives. We conducted a qualitative study of primary care providers to assess the challenges and opportunities in implementing a universal screening program for Hepatitis C Virus (HCV) at an urban communitybased health center serving a largely disadvantaged population. Methods. Qualitative semi-structured interviews of prescribing providers took place pre- and post-educational intervention, at a single federally qualified health center in Wilmington, Delaware, between September 2018 and July 2019. The intervention included a two-day didactic session and shadowing specialist providers. Data captured provider perspectives on universal screening and treatment. The interviews were transcribed verbatim, then grouped into codes, then finally, themes. Results. Emergent themes included hesitancy in managing universal screening programs in the primary care environment, positive attitudes surrounding treatment, fewer HCV cases than expected, and concern with both patient-level barriers and practice-level barriers. Pre-intervention and post-intervention themes were similar. Conclusions. Implementation programs exploring universal HCV screening in the primary care environment should include educational opportunities that are available to all individuals in the practice, sustained organizational support, and available patient literature targeted to patients with varying health literacy and in languages other than English. In short, universal HCV screening and treatment is feasible in the primary medical environment but requires ongoing support and education for providers to ensure success.
INTRODUCTION Chronic infection with Hepatitis C virus (HCV) is a widespread bloodborne infectious disease, estimated to affect approximately 2.4 million people in the United States, resulting in approximately $6.5 billion dollars in treatment costs.1–3 As a result of the opioid epidemic in the United States, increases in injection drug use behaviors have mirrored the increase in reported cases of HCV infection.4 Curative treatment is available and effective, but approximately 50 to 75% of chronically-infected individuals are unaware of their infection status and are therefore left untreated.5 If left untreated, HCV can result in cirrhosis, hepatocellular carcinoma, or death.6,7 Further, individuals with HCV can transmit this infection to others if they do not take appropriate precautions, for example, by sharing drug paraphernalia. Consequently, as a preventable disease, a primary focus has been on increasing screening and treatment rates. In 2020, the United States Preventive Services Task Force (USPSTF) recommended a one-time screen for all adults aged 18 to 79, irrespective of risk factors.8 Both the Centers of Disease Control and Prevention (CDC) and the American Association for the Study of Liver Diseases (AASLD) have released similar recommendations.9,10 These recommendations will undoubtedly help progress towards HCV elimination; however, many challenges still exist, both on the provider and patient side. 16 Delaware Journal of Public Health - July 2021
Once the diagnosis of HCV is made, a key barrier to treatment has been the need for specialty care. Prior to the availability of direct-acting antiviral medications (DAAs), HCV was treated with interferon-based therapies, which were often associated with long treatment duration and poor tolerability.11 As a result, specialist care (commonly infectious disease, hepatology, or gastroenterology) was often necessary to successfully manage and treat HCV. With the current state of curative treatment for HCV, however, there is an opportunity to deliver treatment in the primary care setting. Previous research studies have demonstrated that primary care physicians, when properly trained, can achieve high rates of sustained virologic response.12,13 In addition, delivering HCV treatment in the primary care setting may be able to overcome some patient barriers, for example inadequate access to specialty care, that prevented people with HCV from achieving cure.12,13 One study comparing on-site testing and treatment of patients with HCV to specialist care found that an on-site HCV program resulted in a significantly higher percentage of patients linked to care and cured of their HCV.14 The HCV treatment cascade measures patient progression from screening to cure: measuring the number of individuals in a given population that initially test positive for HCV, how many of those individuals are successfully linked-to-care, and of those, doi: 10.32481/djph.2021.07.006
how many eventually progress to cure.15 Many HCV elimination efforts have incorporated universal (i.e. non-risk factor based) screening for HCV among all patients aged 18 to 69 years.16 There is evidence that universal screening may be an effective approach in reducing HCV infections in the US: one study found that onetime universal screening is more cost-effective than a risk-based screening approach and is widely supported by patients.17 A recent mixed-methods study that focused on HCV screening among primary care providers in a large, integrated health system revealed ongoing education for providers, and widespread patient barriers (e.g., financial cost of treatment, competing clinical priorities) as significant barriers to implementation.18 In recognition of these findings, and to address gaps in the literature, we sought to better understand barriers to universal HCV screening and treatment among primary care providers in a federally qualified health center (FQHC) which presents unique challenges and opportunities compared to private medical practices. FQHCs are community-based health providers in the U.S. that receive federal funding to provide primary care services.12 FQHCs are typically located in underserved areas and serve historically marginalized patient populations, including uninsured patients, in culturally appropriate and accessible settings.12,13 We chose to focus on provider-level experiences and barriers to evaluate the feasibility of shifting screening and treatment to the primary care setting. The goal of this study was to evaluate the implementation of universal screening of HCV into the primary care FQHC environment, measuring the impact this program had among primary care providers in resourcelimited, underserved medical practices.
METHODS Overview of the Study and Intervention To ascertain the readiness and willingness of providers to screen, treat, and manage patients with HCV, we designed a qualitative study focused on primary healthcare providers at an urban FQHC (Figure 1) between September 2018 and July 2019. Interviews were intended to obtain contextual information on challenges and opportunities towards universal HCV screening. We interviewed physicians and other advanced practice providers (e.g., physician assistants, nurse practitioners) as these groups can have prescribing authority and manage treatment for HCV; for simplicity, we refer to both groups as “prescribers.” We chose to implement our universal screening program at Westside Family Healthcare (WFH), an urban FQHC in Wilmington, Delaware, United States. In Delaware, there is an estimated statewide HCV sero-prevalence rate of 13,600 individuals.19 Wilmington, the largest city in Delaware, is home to more than 70,000 people: more than half of this population is Black or African American, and approximately 25% of this population lives in poverty.20 We focus on the singular site, WFH, for several reasons. First, the catchment includes areas with historically higher rates of HCV, ensuring we serve a community that is disproportionately burdened. Second, the smaller size of the practice made our program feasible to implement. Third, its proximity and connection to the largest healthcare provider in the region (i.e., ChristianaCare) ensured patients would have access to the required resources should treatment and management of complicated cases of HCV not be possible at the primary care site. The educational intervention consisted of two one-day didactic sessions presented by a multidisciplinary team of infectious disease physicians, clinical pharmacists, social workers, and administrators. Topics included HCV pathophysiology, disease etiology, risk assessment and prevention, targeted risk reduction counseling, diagnosis and treatment, post-treatment monitoring, and referral guidelines. Additionally, several recently cured patients were invited to share their experiences with the group. All prescribers and staff were invited to attend day one, while prescribers attended both days. In addition to the didactic sessions, prescribers shadowed infectious disease physicians to allow for “hands-on” experience in the first few months postintervention. A patient manager was hired to help patients navigate the treatment process and support patients in scheduling appointments and obtaining curative therapies. This study was deemed IRB exempt by ChristianaCare (Newark, DE).
Data Collection and Analysis We enrolled providers to participate in semi-structured oneon-one interviews before and after the intervention. These interviews were intended to explore the barriers, opportunities, and experiences of the primary care providers in implementing universal screening at an FQHC. In order to ensure the protection of interviewed prescribers’ identities, we do not present demographic data on those interviewed. Interviews were conducted in-person in a private office at WFH in Wilmington, Delaware by one academic epidemiologist and one physician researcher, with doctoral-level degrees. Participants were first asked to describe their baseline experiences Figure 1. Study flow chart depicting the evaluation of a universal Hepatitis C with HCV screening and treatment, including self-identified strengths or weaknesses in managing patients with HCV. screening program at an urban community-based health provider. 17
Participants were probed to describe the challenges they faced in progressing toward universal screening and treatment of all patients with HCV. Participants were also asked to describe support or additional information they would need to screen and manage HCV independently. On average, each interview lasted 30 minutes and was audio recorded. Participants were asked similar questions during their pre- and post-intervention interviews (see Appendix A). The time frame from pre-intervention interview to post-intervention interview was approximately one year.
Many prescribers described the educational sessions as helpful in increasing their comfort levels but felt that their limited experience resulted in hesitancy. Although the educational intervention included shadowing of infectious disease physicians treating patients with HCV, several prescribers expressed discomfort in treating these patients independently. One provider stated that they would benefit from another educational session in the future, describing a “lag between when you learn the information and when you’re actually implementing it.”
Recordings were transcribed verbatim and managed using NVivo version 12 (QSR International, Burlington, MA). Transcripts were coded and analyzed using thematic analysis methods as follows: a priori, structured codes corresponding to the domains in the interview guides were developed. Transcripts were then read to develop a framework of emergent codes reflecting unanticipated themes from the interviews. The coding framework was then applied to the qualitative texts. Discrepancies in coding were discussed with the project team until an appropriate code was agreed upon. In subsequent readings of the text, we grouped codes into themes. Codes were initially developed separately for each interview time point but unifying themes were identified across time points. In the final phase of analysis, summative examples of each theme and representative quotes and findings were selected.
Theme 2: The availability and effectiveness of DAAs in this setting resulted in increased provider engagement, positive attitudes, and optimism in implementing universal HCV screening and treatment.
RESULTS Four prescribers completed the pre-intervention interviews and five completed the post-intervention interviews. Table 1 summarizes the major themes from the qualitative interviews that explored the prescribers’ thoughts and feelings on universal HCV screening. Themes elucidated in the pre-intervention time period were linked to the post-intervention time period.
Theme 1: Prescribers describe hesitancy and lack of comfort in screening patients for HCV, limiting measures of self-assessed preparedness. Pre-intervention Interviews All four prescribers interviewed expressed hesitancy in their abilities and readiness in independent screening and treatment of patients with HCV. Although prescribers had different comfort levels with screening and referral of patients, all prescribers expressed a lack of knowledge about the initial patient assessment needed for HCV (e.g., laboratory tests, DAA treatment options). Some prescribers stated they would feel more confident and comfortable in treating this population if these topics were included in the upcoming educational intervention. Prescribers expressed a lack of knowledge about DAAs, including contraindications, and interactions. All prescribers expressed discomfort in communicating with patients who may screen positive, given their lack of knowledge. For example, one provider said, “I need to know how to safely manage those patients.” This lack of knowledge and comfort in prescribing limited provider measures of self-assessed preparedness.
Post-intervention Interviews Although four of the interviewed prescribers felt that the additional educational sessions improved their comfort levels in assessing HCV in their patient populations, all five prescribers also felt as though their limited direct experience with screening and treating patients resulted in an ongoing lack of confidence. 18 Delaware Journal of Public Health - July 2021
Pre-intervention Interviews Three of the four prescribers interviewed described optimistic and positive attitudes when reflecting on current DAAs. All prescribers described “excitement” in learning more about HCV during the educational intervention, with the hope of being able to treat and cure HCV in their patients. For example, one prescriber felt DAAs were promising, stating: “As a practitioner, as a clinician, it’s really awesome to see that change, and really think about how HCV can be something in our lifetime that we could […] cure, and almost eradicate…”
Post-intervention Interviews Three of the five prescribers described their attitude towards HCV treatment as positive, resulting in widespread benefits from the intervention and pilot program. One prescriber said: “I think it’s definitely been a really good learning experience for me personally and the rest of the staff here and hopefully […] our patients have benefitted from that.” Prescribers described the experience as “rewarding,” because HCV is curable, stating, “you can’t say in medicine that we can actually cure many things.” The curative ability of DAAs was a large factor in engaging prescribers in universal screening and treatment. Provider reflections on curative therapy for HCV also resulted in many prescribers feeling positively about universal screening.
Theme 3: Prescribers perceived HCV to be widespread, but after implementing universal HCV screening, prescribers felt that patient volume did not reflect these beliefs. Pre-intervention Interviews When asked about their previous experiences in screening “highrisk” patients for HCV, all prescribers interviewed discussed sexually transmitted infections (STIs). Several prescribers also expressed a willingness to screen for HCV outside of STIs. As one provider stated: “…a lot of our patients are lower socioeconomic status, increased risk […] should be screened as well […] everybody should just get screened.” One provider described their screening practices as “liberal,” explaining they would screen irrespective of perceived risk status.
Three of the four prescribers discussed the need for increased screening and treatment in their patient populations, describing HCV as a highly prevalent illness. These prescribers described the true prevalence of HCV [in their patient population] as being largely unknown, which is likely why they felt that an intervention that involved increased screening and treatment was necessary. None of the prescribers expressed concern in adapting their practice to incorporate universal HCV screening. Indeed, many prescribers felt that universal HCV screening was a logical next step in screening practices.
Post-intervention Interviews Four of the five prescribers interviewed discussed a disconnect between their expectations of HCV prevalence and their subsequent experiences after instituting universal screening, describing a lack of patient volume and fewer positive cases than anticipated. Despite this, many prescribers felt that universal screening efforts were necessary and should be continued. For example, one provider stated: “I think that [increased patient volume] will come, I think it just shows that you really need time to create this groundwork…I think that treatment piece, once we actually get started and [see] more patients […] I think it [will] be great for us in the community…” Several prescribers described sexual risk and HCV risk as linked, but also described universal HCV screening as necessary to identify new cases. It is important to note that although sexual risk does play a small role in HCV transmission, shared druginjection paraphernalia is the primary mode of HCV transmission and has contributed substantially to HCV prevalence in the United States.21 Prescribers also felt that HCV was still prevalent in the community, even though several prescribers described their patient volumes as not reflecting this belief. Many prescribers also concluded that continued screening of all patients might readily identify new cases of HCV and with time, may reflect the perceived high prevalence of HCV.
Theme 4: Prescribers felt concerned with patient-level barriers and expressed frustration in implementing universal HCV screening and treatment in this setting. Pre-intervention Interviews Three of four prescribers discussed patient barriers as a major concern with implementing universal HCV screening. Prescribers listed several perceived patient barriers, including reliance on public transportation, changeable/unreliable patient contact information, unstable housing, lower health literacy, lack of finances, and insurance concerns. For example, one provider explained their frustration addressing patient barriers: “We tried to call, their phone doesn’t work anymore, they changed addresses, and so it’s more of a shell game of trying to figure out where they are...” For many of the prescribers, getting patients invested in curing their HCV felt like a barrier in and of itself: prescribers frequently described asymptomatic patients that have lived with their HCV for long periods of time as being less willing to begin treatment. Many prescribers expressed a concern that patients would not feel motivated to treat their HCV because of patients’ competing
priorities from a personal perspective (e.g., unstable housing, drug use) or from a health perspective (e.g., comorbidities). Prescribers felt that conversations with patients would be challenging because asymptomatic patients might feel that treating and curing their HCV could wait or was not a priority for them.
Post-intervention Interviews Prescribers described a challenging patient population that contended with unstable housing, little to no health insurance, and financial challenges that prevented them from seeking treatment for health issues. For example, one provider described their patient population as having, “enough issues with transportation and affordability and things like that.” Prescribers also felt that encouraging patients to invest in HCV treatment was a persistent barrier. Prescribers felt that many patients did not prioritize curing their HCV. One provider identified a “mini-theme,” among their patients: some patients with asymptomatic HCV felt their infection was benign and therefore, not necessary to be treated. All prescribers expressed the same concern. Some had an easier time negotiating these conversations, as one provider described two different patient groups they have encountered: patients who describe HCV treatment as “…not high on their priority list, whether it’s their medical issues, or whether it’s the other social issues that they’re dealing with. And then those patients who have been like, oh, yeah, like I, I definitely want to get treated.” Prescribers observed that encouraging patient engagement in treatment was the most frequent barrier to screening and treating patients for HCV. However, some prescribers felt this patient hesitancy and poor patient investment in treatment came from a lack of patient information. Several prescribers explained that increasing health literacy among patients may increase patient HCV screening and treatment. A few prescribers also described challenges in effective communication with patients who speak English as a second language. As one provider stated: “You don’t know what their background is, telling the patient something that you’re telling, you don’t know that that message is getting through.” Several prescribers noted that patient education (i.e., various media and incorporating diverse reading-levels) including nativespeaker translations in commonly spoken languages (e.g., Spanish at this FQHC) may be effective in encouraging patients to seek HCV screening and treatment.
Theme 5: Administrative and practice-level barriers persisted, limiting the provider-assessed effectiveness of universal screening for HCV in this setting. Pre-intervention Interviews Prescribers discussed staff and nurse education as an anticipated practice-level barrier in instituting universal HCV screening. One provider described the impact of educating the supportive staff as, “huge,” and that education would “help change the culture here.” In addition, many of the prescribers interviewed also discussed concerns with having enough time with patients. One provider described resistance from primary care prescribers to institute universal screening primarily due to concerns about time with patients and time for staff education. Prior to the educational intervention, prescribers were concerned about educating all staff who interact with patients. 19
Exemplary Quotes, Pre-Intervention
Exemplary Quotes, Post-Intervention
Theme 1: Prescribers describe hesitancy and lack of comfort in screening patients for HCV, limiting measures of selfassessed preparedness
• “…a weakness, I think, is just not knowing the medications…” • “…how often do I do my screenings? […] Like, how do I – how do I make sure that I’m doing the right thing by [my patients]?”
• “So, still not completely comfortable, because I haven’t had that much experience…” • “I have good theoretical knowledge.”
Theme 2: The availability and effectiveness of DAAs in this setting resulted in increased provider engagement, positive attitudes, and optimism in implementing universal HCV screening and treatment.
• “I’m really happy now, that there are a lot of treatment options…I’m really happy to be […] a part of this pilot.”
• “It’s something we can actually treat and cure…that’s been rewarding, in and of itself.”
Theme 3: Providers perceived HCV to be widespread, but after implementing universal HCV screening, providers felt that patient volume did not reflect these beliefs.
• “…everybody should just get screened.” • “…if you’re sexually active in this population, I would screen you for just about everything.”
• “I guess when it was presented, we felt like it was rampant, like [Hepatitis C] was rampant…” • “I’m not sure that we have hit the goals that we had set, where we thought we’d be as far as the percentage of patients that we’ve screened…”
Theme 4: Providers felt concerned with patientlevel barriers and expressed hesitancy in implementing universal HCV screening and treatment in this setting.
• “I think just getting to the appointment is a huge barrier.” • “[A]t some point, I think that just the burden of their healthcare becomes so great that they’re like, why am I going to go see yet another specialist and get, you know, this taken care of? […] But we’ve had a couple of those types of patients where it’s just there’s too much going on, and [Hepatitis C] is not my top priority.”
• “A lot of [patients] have the misconception that it’s a you know, more of a benign process, can just hang on to [Hepatitis C] for a while without a whole lot of serious ramifications. So that, you know, that misnomer is something that we’ve kind of been stamping out. So that’s a, that’s been at least a mini-theme, so that’s happened more than once. I think the -- those same kind of people are also aware of some of the difficulties of previous treatment regimens, duration and side effects and all that kind of stuff. So that kind of comes up in some of the initial conversations, too.” • “We’re trying to educate patients that it doesn’t matter what your risk factors are, we just screen everyone.”
Theme 5: Administrative and practice-level barriers persisted, limiting the provider-assessed effectiveness of universal screening for HCV in this setting.
• “So we’re a primary care practice, so you bring a patient in and we’re here to deal with their primary care issues, but then you have Hepatitis C or the opioid dependence, or you know the patient who is, you know, depressed. So, in that tenminute visit, how do you treat all of those things? And that’s where you get a lot of resistance from primary care because we would love to do it all and fix it all but it’s like, how can you do that in this limited time?”
• “[I]n my mind, when I’m watching kind of those folks do their thing and take these histories, my primary care brain is already saying I don’t have an hour with a patient to ask all these questions. So I’m like, how can I condense what you’re doing in an hour down to like, you know, five or ten minutes of conversation gets the salient pieces out of it? So that is something that we will, you know, we will always need, because we will never have that hour to have that conversation.”
Theme Description
1
2
3
4
5
Table 1. Major themes from qualitative interviews from provider interviews pre-intervention and post intervention, including exemplary quotes
20 Delaware Journal of Public Health - July 2021
Many prescribers felt that because staff (e.g., administrative staff, medical assistants) are sometimes the first individuals to interact with a patient in the office, they should be included in the conversation surrounding HCV screening and treatment.
Post-intervention Interviews After the educational intervention, many prescribers still felt that time was an issue. Some prescribers felt that this could be improved with increased staff with focused tasks, including additional nursing staff that are in contact with patients and are able to answer questions regarding HCV. Prescribers also voiced concerns with managing the electronic health record system, explaining that ordering testing and extracting patient data felt cumbersome. Several prescribers also described a sense of being overwhelmed with tasks which one provider described as “pilot fatigue.” As this provider explained: “In an organization like ours, where we always have a million things going on at once […] people are just used to making changes on such a regular basis.” Lack of support from staff, prescribers, and the organization at a higher-level were frequently discussed during interviews. Although overall, prescribers felt positively about HCV screening and treatment, they also expressed concern that inclusion of universal HCV screening into primary care practices could result in a sense of feeling overwhelmed or fatigued. Likely as a result of this concern, prescribers suggested that increased investment in time, personnel, or training at the organizational level may encourage sustained adoption of HCV screening and treatment by primary care prescribers.
DISCUSSION The results of this study suggest that while universal adult HCV screening in the primary care setting is feasible, and that universal adult HCV screening is an important step toward HCV eradication in the United States and elsewhere, barriers persist, especially in an FQHC environment.22 Our results echo previous findings that primary care prescribers want to increase HCV screening and treatment but feel hesitant because of their subject-specific knowledge level.23–25 Themes that emerged during the qualitative interviews suggest that although primary care prescribers feel positively about universal HCV screening and treatment, organizational and patient investment are integral in ensuring an effective program. Notably, themes identified during qualitative interviews were consistent across time points. There are several reasons for this finding: firstly, this could be a result of the time between interviews. Perhaps, additional time is necessary to observe actionable differences between pre- and post-intervention interviews. Secondly, the intervention was designed to improve the knowledge of prescribers, consisting of two one-day didactic sessions and a hands-on shadowing of practice. This intervention did not address many of the barriers that prescribers mentioned in the interview (e.g., increased nursing staff, patient buy-in). Therefore, themes were relatively consistent across time points as prescribers reiterated additional opportunities identified through their practices, which they believed would strengthen the program.
As previous research suggests, prescriber investment and support is the key to a program’s success.23,26 In our study, prescribers described “pilot fatigue,” in which resources are invested in new programs as they initialize but emphasis fades over time. This issue, as well as additional findings from our study, support the need for interventions that include training of and support for staff and physicians, despite competing priorities and limitations on time, a commonly cited barrier in implementation of programs in healthcare settings.27 Prescriber interviews included recommendations to increase organizational investment and support in programs past their initial implementation, increase staff numbers to ensure staff do not feel overwhelmed by program expectations, and encourage ongoing education for prescribers and staff. To improve our implementation of universal screening the study team conducted monthly meetings for 6 months postimplementation. This pilot program also included onboarding a patient navigator to address some of these time and task constraints, although prescribers still felt that more support was necessary. Further, this pilot program also included increased patient signage in patient areas (e.g., waiting rooms) in both English and Spanish, describing HCV infection and treatment. Despite this, prescribers still felt that patients needed additional information and educational items. The most effect strategy identified was educating the medical assistant staff, as they were the first point of engagement with the patient to offer HCV screening. Following this pilot study, WFH has since expanded universal screening to other FQHC sites in the State. Data from this study suggest that universal HCV screening and treatment may be possible in the primary care setting, however these programs need sustained organizational support and resources. Although prescribers noted several anticipated and experienced barriers in universal screening, for many, the experience of treating and curing HCV outweighed these limitations. A coordinated effort from all levels of the healthcare paradigm is necessary to ensure successful implementation of any clinical program.28 In contrast with previous efforts to introduce universal HCV screening in the primary care setting, results from the present study benefited from widespread availability of DAAs for HCV treatment. Similar studies conducted within the FQHC context found that while patients may be successfully linked to care, the number of patients who begin treatment is low.29 Insurance payers have made it increasingly difficult for patients to get prior authorization or to afford HCV treatment, resulting in low cure rates.30 As many prescribers described in their qualitative interviews, increased investment in time, personnel, and training at the organizational level may be critical in sustained and successful adoption of HCV screening and treatment programs. Our study has important strengths and limitations. In focusing on an urban FQHC, we were also able to target an underserved population and a resource-limited provider population. A limitation of this research was the relatively small number of prescribers available for our qualitative interviews: all eligible providers were interviewed. Also, our findings may only reflect experiences in an urban community-based health center serving mostly marginalized groups, and not necessarily generalize to all adult outpatient medical settings. 21
PUBLIC HEALTH IMPLICATIONS The results of this study demonstrate feasibility of expansion of universal HCV screening in primary care settings, particularly amongst a resource-limited practice situated within an underserved patient population. Our findings highlight the opportunities and challenges towards universal screening for HCV in the primary care environment and may be useful for other practices considering the implementation of a similar program. To ensure implementation of a successful program, organizations must ensure continued, sustained support and education for prescribers pre- and post-implementation.23,26,28 Conflict of Interest: The authors declare that they have no conflict of interest. Funding: Research reported in this publication was supported by an award from the Christiana Care Harrington Value Institute Community Partnership (to DK, NDG). Correspondence: Rini Jose, rj499@drexel.edu
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8. Owens, D. K., Davidson, K. W., Krist, A. H., Barry, M. J., Cabana, M., Caughey, A. B., . . . Wong, J. B., & the US Preventive Services Task Force. (2020, March 10). Screening for hepatitis C virus infection in adolescents and adults: US Preventive Services Task Force recommendation statement. JAMA, 323(10), 970–975. PubMed https://doi.org/10.1001/jama.2020.1123 9. Schillie, S., Wester, C., Osborne, M., Wesolowski, L., & Ryerson, A. B. (2020, April 10). CDC recommendations for hepatitis C screening among adults—United States, 2020. MMWR Recomm Rep, 69(2), 1–17. PubMed https://doi.org/10.15585/mmwr.rr6902a1 10. Ghany, M. G., Marks, K. M., Morgan, T. R., Wyles, D. L., Aronsohn, A. I., Bhattacharya, D., . . . Gordon, S. C. (2020). Hepatitis C guidance 2019 update: AASLD-IDSA recommendations for testing, managing, and treating hepatitis C virus infection. Hepatology (Baltimore, Md.), 71(2), 686–721. PubMed https://doi.org/10.1002/hep.31060 11. Manns, M. P., Wedemeyer, H., & Cornberg, M. (2006, September). Treating viral hepatitis C: Efficacy, side effects, and complications. Gut, 55(9), 1350–1359. PubMed https://doi.org/10.1136/gut.2005.076646 12. Arora, S., Thornton, K., Murata, G., Deming, P., Kalishman, S., Dion, D., . . . Qualls, C. (2011, June 9). Outcomes of treatment for hepatitis C virus infection by primary care providers. The New England Journal of Medicine, 364(23), 2199–2207. PubMed https://doi.org/10.1056/NEJMoa1009370 13. Kattakuzhy, S., Gross, C., Emmanuel, B., Teferi, G., Jenkins, V., Silk, R., . . . Kottilil, S., & the and the ASCEND Providers. (2017, September 5). Expansion of treatment for hepatitis C virus infection by task shifting to community-based nonspecialist providers: A nonrandomized clinical trial. Annals of Internal Medicine, 167(5), 311–318. PubMed https://doi.org/10.7326/M17-0118 14. Coyle, C., Moorman, A. C., Bartholomew, T., Klein, G., Kwakwa, H., Mehta, S. H., & Holtzman, D. (2019). The Hepatitis C Virus Care Continuum: Linkage to Hepatitis C Virus Care and Treatment Among Patients at an Urban Health Network, Philadelphia, PA. Hepatology. 15. Trooskin, S. B., Poceta, J., Towey, C. M., Yolken, A., Rose, J. S., Luqman, N. L., . . . Nunn, A. S. (2015, July). Results from a geographically focused, community-based HCV screening, linkage-to-care and patient navigation program. Journal of General Internal Medicine, 30(7), 950–957. PubMed https://doi.org/10.1007/s11606-015-3209-6 16. Saab, S., Le, L., Saggi, S., Sundaram, V., & Tong, M. J. (2018, June). Toward the elimination of hepatitis C in the United States. Hepatology (Baltimore, Md.), 67(6), 2449–2459. PubMed https://doi.org/10.1002/hep.29685 17. Coffin, P. O., Stevens, A. M., Scott, J. D., Stekler, J. D., & Golden, M. R. (2011, June 6). Patient acceptance of universal screening for hepatitis C virus infection. BMC Infectious Diseases, 11(1), 160. PubMed https://doi.org/10.1186/1471-2334-11-160 18. Higashi, R. T., Jain, M. K., Quirk, L., Rich, N. E., Waljee, A. K., Turner, B. J., . . . Singal, A. G. (2020). Patient and Provider-Level Barriers to Hepatitis C Screening and Linkage to Care: A Mixed-Methods Evaluation. Journal of viral hepatitis.
19. Rosenberg, E. S., Hall, E. W., Sullivan, P. S., Sanchez, T. H., Workowski, K. A., Ward, J. W., & Holtzman, D. (2017, June 1). Estimation of state-level prevalence of hepatitis C virus infection, US states and District of Columbia, 2010. Clin Infect Dis, 64(11), 1573–1581. PubMed https://doi.org/10.1093/cid/cix202 20. U. S. Census Bureau. Census QuickFacts. Retrieved from https://www.census.gov/quickfacts/wilmingtoncitydelaware 21. Trickey, A., Fraser, H., Lim, A. G., Peacock, A., Colledge, S., Walker, J. G., . . . Vickerman, P. (2019, June). The contribution of injection drug use to hepatitis C virus transmission globally, regionally, and at country level: A modelling study. The Lancet. Gastroenterology & Hepatology, 4(6), 435–444. PubMed https://doi.org/10.1016/S2468-1253(19)30085-8 22. Shiffman, M. L. (2016, January). Universal screening for chronic hepatitis C virus. Liver Int, 36(Suppl 1), 62–66. PubMed https://doi.org/10.1111/liv.13012 23. Grebely, J., Oser, M., Taylor, L. E., & Dore, G. J. (2013, March). Breaking down the barriers to hepatitis C virus (HCV) treatment among individuals with HCV/HIV coinfection: Action required at the system, provider, and patient levels. The Journal of Infectious Diseases, 207(Suppl 1), S19–S25. PubMed https://doi.org/10.1093/infdis/jis928 24. Litwin, A. H., Kunins, H. V., Berg, K. M., Federman, A. D., Heavner, K. K., Gourevitch, M. N., & Arnsten, J. H. (2007, July). Hepatitis C management by addiction medicine physicians: Results from a national survey. Journal of Substance Abuse Treatment, 33(1), 99–105. PubMed https://doi.org/10.1016/j.jsat.2006.12.001 25. Lambert, S. M., Page, A. N., Wittmann, J., Hayllar, J. S., Ferndale, C. W., Bain, T. M., & Macdonald, G. A. (2011). General practitioner attitudes to prescribing hepatitis C antiviral therapy in a community setting. Australian Journal of Primary Health, 17(3), 282–287. PubMed https://doi.org/10.1071/PY10069 26. Ockene, J. K., & Zapka, J. G. (2000, August). Provider education to promote implementation of clinical practice guidelines. Chest, 118(2, Suppl), 33S–39S. PubMed https://doi.org/10.1378/chest.118.2_suppl.33S 27. Rahm, A. K., Boggs, J. M., Martin, C., Price, D. W., Beck, A., Backer, T. E., & Dearing, J. W. (2015). Facilitators and barriers to implementing Screening, Brief Intervention, and Referral to Treatment (SBIRT) in primary care in integrated health care settings. Substance abuse, 36(3), 281–288. PubMed https://doi.org/10.1080/08897077.2014.951140 28. Chaudoir, S. R., Dugan, A. G., & Barr, C. H. (2013, February 17). Measuring factors affecting implementation of health innovations: A systematic review of structural, organizational, provider, patient, and innovation level measures. Implement Sci, 8(1), 22. PubMed https://doi.org/10.1186/1748-5908-8-22 29. Coyle, C., Kwakwa, H., & Viner, K. (2016, May-June). Integrating routine HCV testing in primary care: Lessons learned from five federally qualified health centers in Philadelphia, Pennsylvania, 2012–2014. Public Health Rep, 131(2, 2_Suppl), 65–73. PubMed https://doi.org/10.1177/00333549161310S211 30. Coffin, P. O., & Reynolds, A. (2014, July 3). Ending hepatitis C in the United States: The role of screening. Hepatic Medicine : Evidence and Research, 6, 79–87. PubMed https://doi.org/10.2147/HMER.S40940
APPENDIX A HCV Qualitative Interview Guide: Pre-intervention. 1. Tell me about your experience, if any, with managing hepatitis C? This can include experiences dating back to your medical training or graduate studies. 2. Describe your comfort level with taking care of patient with hepatitis C, including any strengths or weaknesses. 3. What do you think you will need to learn to be able to manage hepatitis C for your primary care patients? Can prompt them to include any specific topics including: • Screening and evaluating for HCV • Staging and screening labs/imaging • Who to treat • When to refer 4. What are you hoping to learn and/or feel more comfortable with following the HCV training that will be provided as part of this collaboration? 5. What are some ways in which your clinic can help support your ability to take care of your primary care patients with hepatitis C? 6. Is there anything we did not touch on that you would like to share surrounding hepatitis C? HCV Qualitative Interview Guide: Post-intervention. 1. Tell me about your experience, if any, with managing hepatitis C this past year [since we provided HCV education and started working together on the grant] 2. Describe your current comfort level with taking care of patient with hepatitis C, including any strengths or weaknesses. Can prompt and specifically inquire about changes in comfort level over the past year 3. Is there anything additional you feel is needed to be able to manage hepatitis C for your primary care patients? Can prompt them to include any specific topics including: • More education, (Screening and evaluating for HCV, Staging and screening labs/imaging, who to treat, A • More personnel, resources, etc. • Describe, be specific If not getting much response, can also try this question: What are some ways in which your clinic can further support your ability to screen adults for HCV and take care of those patients infected with HCV? 4. Did you attend the HCV education sessions that included formal training (2 ½ days of education) plus shadowing last year? If NO, skip to Q6 If YES, continue 5. Thinking back to the provided HCV education (includes 2 ½ days of formal training modules plus shadowing), do you have feedback or comments you would like to share on the content or delivery of that education? We will be conducting the same session at a second site in the near future. Can prompt them if needed: • Strengths • Weaknesses • Areas that needed more focus/less focus • Areas that you found to be very beneficial and/or not beneficial 6. Is there anything we did not touch on that you would like to share surrounding HCV or your experience collaborating with us to expand access to HCV care? 23
Bayhealth, COVID-19 and Technology – Safely Discovering our New Normal Richard Mohnk, M.S. Chief Information Officer, Bayhealth Medical Center
As a regional health care leader, safety and high reliability are key elements of service excellence at Bayhealth. As we all continue to discover our new normal, COVID-19 is pushing health care into this new normal as well. The first quarter of 2020 felt like a discovery of unknowns. Unknowns in how we treat COVID-19, how we manage patient care, where we place patients as we run out of beds, what will be allowed as it relates to visitors, how will we manage this crisis from our 24-hour command center, and how will we successfully work with state and federal guidance. Space, testing, supplies and understanding how to treat this new disease dominated those early days. Technology was critical. Technology supported the opening of new care spaces at the Bayhealth Kent and Sussex campuses, as well as temporary locations near our emergency departments. These new spaces were immediately equipped with all the necessary telecommunications, computers, mobile devices, and Wi-Fi capabilities. While we were fortunate to not need many of the additional care spaces created, we were prepared. The need for technology extended beyond direct patient care. Testing and supplies required dashboards and reporting mechanisms to easily send information to the Bayhealth team and state health personnel so our staff could be equipped with the necessary safety supplies to continue caring for our community. As the second and third quarters of 2020 rolled in telehealth, video conferencing, flex scheduling (working from home), safe distancing, patient monitoring, and visitation, staffing and security (ransomware/dual factor authentication/electronic prescriptions) became serious topics to address. Spring, summer and fall created significant opportunities for change. Patients
24 Delaware Journal of Public Health - July 2021
needing telehealth suddenly required video visits, staff needing to collaborate required video conferencing - all as we navigated staff working remotely, changes to how clinicians prescribed medications, new methods for visitors to comfort family members and the future of a new Graduate Medical Education program on the horizon. Video capabilities infiltrated most all aspects of health care. In person meetings were replaced with video conferences. Physician practices focused predominantly on telehealth visits. Cyber security was on everyone’s mind with the risk of ransomware infiltration into vaccination efforts all around us. Dual factor authentication became the norm and helped security access and a reduction in opioid prescriptions. Hiring of new staff members suddenly became a video interview process. The reality is, technology made all this immediately possible. Because of our focus on technology at Bayhealth, we were able to seamlessly pivot when needed to adapt to a virtual world. As time rolled into 2021 and the hope of vaccines became the rescue amid escalating COVID-19 cases, it was clear our efforts to introduce video visits with patients and monitoring with cameras for our care givers were going to be here to stay. Nursing could monitor patients safely with new camera technology and our patient advocates were making a huge difference using tablets to conduct video calls for patients and their families. These were even more examples of lasting impact leveraging technology will have on our community. As we enter the summer of 2021, the Bayhealth technology team is proud to continue supporting our health system and our community every day.
doi: 10.32481/djph.2021.07.007
The DPH Bulletin
From the Delaware Division of Public Health
June 2021
Delaware offers cash and prizes to boost COVID-19 vaccination rates Delawareans who receive the COVID-19 vaccine in Delaware by June 29, 2021 will be entered to win a $302,000 cash prize and two low-number Delaware license plates. Delawareans ages 12 to 17 vaccinated between May 25 and June 29 will be entered to win $5,000 in cash and additional prizes in twice-weekly drawings conducted by the Delaware Lottery. These incentives and more are offered through DE Wins!, a public education and incentive program launched by Governor Carney and the Division of Public Health (DPH) to increase COVID-19 vaccination rates in Delaware. Other DE Wins! prizes include: a four-day vacation, a full scholarship to a Delaware public university, Delaware State Parks annual passes, camping fees and tickets to the Firefly Music Festival. Prizes also are being offered from the following partners: Funland, The Wilmington Blue Rocks, and the Delmarva Shorebirds. The Delaware Lottery will conduct the twice-weekly drawings on Mondays and Fridays from May 31 through June 29. Between May 25 and June 29, Delawareans vaccinated at locations managed by DPH and the Delaware Emergency Management Agency, including Curative vaccination sites and DPH clinics, will also receive a $10 gift card. DPH is expanding gift card locations. “Our goal is to reach 70 percent of vaccinated adults in Delaware in the coming weeks, and to continue vaccinating as many Delawareans as possible against COVID-19,” Governor Carney said. As of June 1, Delaware providers had administered 916,758 doses of the COVID-19 vaccine. Of Delawareans 18 or older, 60.6 percent have received at least one shot. “Incentive programs are another tool to drive vaccine uptake among different audiences, particularly younger ones,” DPH Director Dr. Karyl Rattay said.
DPH and Delaware Transit offer free rides to vaccination sites The Division of Public Health (DPH) and the Delaware Transit Corporation (DTC) are providing free transportation to COVID-19 vaccination sites. If you need a ride to a DPH clinic for vaccination, call the DPH Vaccine Call Center at 1-833-643-1715. The call center will verify the caller’s vaccination appointment before arranging transportation through the Dineste Health Transportation Group or Delmarva Transportation, Inc. Clients should not call vendors directly. DPH will add two more vendors for statewide coverage. DART offers free paratransit transportation to customers traveling to COVID-19 vaccination sites, according to Corey Burris of DTC. When customers call to make a paratransit reservation, they should mention the purpose of the reservation is to get their COVID-19 vaccination. The drivers will already have the information when they arrive. “By offering free transportation to those seeking vaccine, we increase access to vaccines and reduce logistical barriers,” Dr. Rattay said. Visit de.gov/getmyvaccine to locate vaccination sites. Many locations offer walk-in hours. Anyone with questions about COVID vaccines and where to get one may call 1-833-643-1715.
Visit DEWins.org for full details on prizes and eligibility. 25
June is Pet Preparedness Month The Office of Animal Welfare’s Delaware Animal Response (DAR) program reminds household pet owners to include pets in family emergency plans.
Rabies reminders: Do not touch wild or unfamiliar animals; and vaccinate pets Rabies is an infectious and potentially fatal disease affecting the nervous system of humans and other mammals. Infection can occur through the bite or scratch of an infected animal or if saliva from infected animals gets into the eyes, nose, mouth, or an opening in the skin. Once symptoms appear, rabies in humans and animals cannot be cured. GETTY IMAGES
The disaster organization Red Rover provides these preparedness tips:
• Ask neighbors or friends to care for your pets if emergencies occur when you are not at home. • Always take pets with you during evacuations. • Find out now if you and your pets can stay with family and friends in case of evacuation. • Have a list of pet-friendly accommodations, boarding facilities, veterinary offices, and pet clinics outside your immediate area. Pet owners must also prepare their pets: • Dogs and cats should wear a collar with an identification tag. Dogs age 6 months and older that live in Delaware must be licensed. Visit www.petdata.com/for-pet-owners/dlw/licenseonline. Keep dog license tags on collars so lost pets can be returned to their owners quickly. • Have your pet microchipped and registered with up-to-date owner information. The primary contact number should be a cell phone. • Create a pet “go bag” that includes pet food, water, medications, and treats to last at least three days. Include a pet first aid kit, one leash per pet, food and water dishes, bedding, litter and pan, favorite toys, and 24-hour instant heat packs. Pack veterinary records, including proof of rabies and other vaccinations, in a waterproof bag in case veterinary care or admittance to a pet-friendly evacuation shelter is needed. In the same waterproof bag, put pet photos to help find lost pets and provide proof of ownership. • Keep a clear photo of each pet and veterinary records on your cell phone for easy access. Visit Red Rover at https://redrover.org/resource/petdisaster-preparedness-2/. Visit DAR at https://animalservices.delaware.gov/services/disaste r-preparedness.
The DPH Bulletin – June 2021 26 Delaware Journal of Public Health - July 2021
Anyone who is bitten, scratched, or contacted a stray cat or dog or wild mammal such as a raccoon, fox, bat, or groundhog should immediately contact their health care provider or call the Division of Public Health’s Rabies Program at 302-744-4995. Anyone who thinks a feral cat might have bitten their pet should call their private veterinarian for examination and treatment. In April, a stray cat bit two people in the area of Four Seasons Parkway, near Route 896 in Newark. The cat tested positive for rabies and the individuals began receiving post-exposure prophylaxis treatment: a series of four vaccinations recommended by DPH. To prevent rabies, DPH recommends: • In accordance with state law, have all dogs, cats, and ferrets 6 months of age and older vaccinated against rabies by a licensed veterinarian. • Do not let pets, especially cats, roam free. • Do not touch or otherwise handle wild or unfamiliar animals, including cats and dogs, even if they appear friendly. • Do not feed feral animals, including cats. • Keep garbage cans securely covered. GETTY IMAGES • Consider vaccinating Do not touch or handle wild or livestock and unfamiliar animals. horses by consulting with a veterinarian.
To report sick or hurt animals or those behaving aggressively, call the Office of Animal Welfare at 302-255-4646 to report dogs and cats; to report wild animals, call the Delaware Department of Natural Resources and Environmental Control’s Wildlife Section at 302-739-9912 or 302-735-3600.
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Find nutritious fruits and vegetables at local Farmer’s Markets, grocery stores Eating healthy foods reduces the risk of obesity and chronic disease such as heart disease, diabetes, and some cancers, according to the Division of Public Health (DPH). Consuming nutritious foods and beverages supports the immune system’s ability to prevent, fight, and recover from infections and illnesses. The U.S. Department of Agriculture (USDA) recommends that Americans eat fruits and vegetables daily. Dietary patterns and nutritional food goals by age group are recommended in the Dietary Guidelines for Americans, 2020-2025, published by the USDA and the U.S. Department of Health and Human Services. Americans are advised to eat 1.5 to 2.5 cups of fruit per day (1.5 to 2 cups for most women, and 2 to 2.5 cups for most men), and 2 to 4 cups of vegetables (2 to 3 cups for most women and 3 to 4 cups from most men). It does not matter if fruits and vegetables are fresh, frozen, dried, or canned. All amounts of consumed fruit and vegetables count towards daily servings and should be consumed every day, all year round. Aim to eat a rainbow of colorful fruits and vegetables for the benefits of phytonutrients, unique compounds that give plants their different colors, tastes, and aromas. Phytonutrients promote overall health. This summer, seek berries, melons, peaches, grapes, beans, carrots, corn, cucumbers, beets, eggplant, lettuce, peppers, potatoes, spinach, squash, and tomatoes. A bounty of fresh fruits and vegetables can be found at Farmer’s Markets, farm stands, grocery stores, local food banks, and food distribution centers. Use Healthy Delaware’s Healthy Lifestyles Map at www.healthydelaware.org. That website also offers listings of parks, trails, playgrounds, fitness and yoga centers, and campgrounds.
U.S. Senator Thomas R. Carper greets Delaware National Guard (DNG) personnel outside the Division of Public Health (DPH) vaccination clinic at the Blue Hen Corporate Center in Dover, Delaware. The DNG assists DPH staffs at vaccination sites. Senator Carper toured the clinic on May 24 with Delaware Health and Social Services Secretary Molly Magarik, left. For walk-in hours for a COVID-19 vaccine, visit de.gov/covidvaccine. To have vaccination questions answered, call the DPH Vaccine Call Center at 1-833-643-1715. Photo by Sean Dooley.
Those who attended the COVID-19 vaccination event held at the Rehoboth Beach Convention Center on May 21 gave it a “thumbs up.” Above are Jodi Johnson, left, and Kathryn Giles. Below are Ed Rowles, left, and Bill Minturn. Photos by Sharon Smith.
Find healthy summer recipes on Healthy Delaware’s Blog and Harvard University’s Healthy Living Blog. View recipe videos on DPH’s Women, Infant and Children Program website: https://www.dhss.delaware.gov/dhss/dph/chca/dphw ichominf01.html Households interested in growing their own fruit and vegetables can find helpful videos and tips from the University of Delaware Cooperative Extension Master Gardeners.
The DPH Bulletin – June 2021
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The Data Dilemma: How Delaware is Responding to the CDC’s Recommendations on Gun Violence Meghan Wallace Co-Founder and Managing Partner, Social Contract
ABSTRACT In 2015, in response to a rising problem of gun violence in the City of Wilmington, Delaware, and due to the urging of local public officials, the Centers for Disease Control and Prevention (CDC) conducted a groundbreaking study around the public health crisis and issued three recommendations on opportunities for prevention. The ideal solutions centered on the creation of a predictive analytic tool that would help social service providers determine who is most likely, based on a set of weighted risk factors, to engage in gun violence. As various entities started to lay the foundation for implementing the CDC’s recommendations, they faced several hurdles directly related to this new technological solution. After careful consideration and thorough vetting, which was also recommended by the CDC, led by Governor Carney’s Family Services Cabinet Council (FSCC), Delaware concluded two things: a tool of this nature presents ethical issues, and there are evidence-based strategies to identify those engaging or likely to engage in gun violence; and notwithstanding the ethical concerns surrounding the tool, Delaware lacked the technology infrastructure and staffing to develop such a tool. Ultimately, good collaboration (facilitated by Social Contract, a local consulting firm) through the FSCC fostered an alternate path forward in keeping with the spirit of the CDC’s recommendations; while the CDC’s recommendations were not precisely enacted, their contribution has led to investments and capacity building in Delaware to support individuals and families most proximal to the problem. Ultimately, convening stakeholders to fully examine an issue and ideate solutions with the most potential for impact resulted in two meaningful outcomes: (1) an innovative approach to ultimately reduce gun violence in the City of Wilmington through widespread collaboration of state services, developing meaningful relationships with those directly engaged in gun violence; and (2) the creation of a statewide data-sharing system that will help improve service delivery and outcomes for Delawareans in need.
INTRODUCTION The modern world is a testament to the power of technology, especially in health care, education, and transparent access to information. There’s no doubt technology can improve lives. But with the immense potential technology presents, it’s important to consider any unintended impact of executing an idea. In 2013, City Council asked the Centers for Disease Control and Prevention (CDC) to take a deep look at youth gun violence in Wilmington. As a result of the study, the CDC made three recommendations for how the city could prevent individuals from committing gun crimes. One of these focused on the creation of a data-sharing tool that would use predictive analysis to identify at-risk youth using key areas like Social Determinants of Health (SDOH) and collaboration between courts, hospitals, and schools. At the time, Social Contract, a Wilmington-based consulting firm that partners with community, corporate, government, and philanthropic leaders to design and implement solutions to complex social challenges, was brought in to support the newly re-enacted Family Services Cabinet Council.1 The organization has a commitment to building authentic solutions, driven by 28 Delaware Journal of Public Health - July 2021
meaningful engagement directly with the communities meant to be served. They believe that people can (and must) be part of the design phase, implementation, testing, and iteration of any solution, including technology tools. For this effort, Social Contract saw the need for any solution, whether powered by technology or by people, to impact the behavior of the people who are most at risk of committing gun violence. Over the course of the next few years, Social Contract engaged leaders, both at the state level, as well as on the ground, that helped stakeholders navigate roadblocks to implementing the CDC’s exact recommendations and ideate actionable solutions. Because the CDC recommendations presented technology as the primary solution to a deeply complex human problem, Social Contract’s integration of the human experience was critical in building solutions that could work in Wilmington and beyond. As the organization dug deeper, it became clear that to be truly effective, there would need to be a technology solution paired with meaningful service delivery to those most directly impacted by the epidemic of violence in Wilmington. doi: 10.32481/djph.2021.07.008
MAPPING A PATH FORWARD The CDC’s report, Elevated Rates of Urban Firearm Violence and Opportunities for Prevention,2 marked the first time the CDC had “provided technical assistance to study the impact of gun violence as a public health issue.”3 By “analyzing shootings with the same methods used to study diseases and infections, researchers identified risk factors in the lives of those involved in violence. They recommended the state integrate its social service, criminal justice, school and other databases to better identify who could be next — and target them with comprehensive services to prevent another injury or death.”4 Specifically, the CDC’s report recommended the following. • Increase collaboration between Delaware social service agencies in preventing violence by developing the capacity to link and share data between Delaware’s various social service agencies in an ongoing fashion; • Further refine the pilot risk assessment tool by using the full administrative dataset. The proposed tool is to be used by social service providers to inform violence prevention efforts, and provisions should be established to preclude use by law enforcement; • Establish a community advisory board to provide recommendations on proposed evidence-based, wraparound services/programs to be provided for high risk youth in conjunction with the recommended risk assessment tool; As recommended by the CDC, in 2015, the Department of Health and Social Services (DHSS) in partnership with thenWilmington City Council and City Council President Hanifa Shabazz, established what would become the Wilmington Community Advisory Council (WCAC), key stakeholders tasked with providing recommendations on proposed evidence-based, integrated services for youth who are considered at high risk of committing violence. This WCAC released its own report in January 2017 in response to the CDC recommendations titled, “Accelerating Youth Violence Prevention and Positive Development,” detailing six recommendations to prevent youth violence and promote positive youth development5: 1. Foster violence-free environments and promote positive opportunities and connections to trusted adults; 2. Intervene with youth and families at the first sign of risk; 3. Restore youth who have gone down the wrong path; 4. Protect children and youth from violence in the community; 5. Integrate services; and 6. Address policy issues that have unintended adverse consequences for youth. The WCAC acknowledged it was not an “implementing body,” but rather, it serves as a convener of stakeholders committed to promoting youth violence prevention and positive youth development. Notably, the early focus of the advisory council was to respond to youth gun violence. Since then, the mission has expanded to focus more broadly on structural issues driving violence and promoting community resilience.
In 2017, Governor John Carney’s Family Services Cabinet Council (FSCC) was re-established and tasked with addressing the CDC’s recommendations. In 2018, under the leadership of then Cabinet Secretary, Dr. Kara Odom Walker, DHSS received an invitation to partner with the University of Pennsylvania’s Actionable Intelligence for Social Policy team to further develop the necessary infrastructure for data sharing across agencies and to consult with states, counties, and municipalities across the country on best practices related to integrating government data. But roadblocks emerged specifically around the creation of a predictive analytic data tool.
THE CHALLENGES OF IMPLEMENTATION The CDC recommended that the State implement the use of a predictive analytic tool that would help social service providers to determine who is most likely, based on a set of weighted risk factors, to engage in gun violence. The focused attention of several initiatives related to the CDC’s recommendations enabled the FSCC to vet the feasibility of creating a predictive analytic tool and to understand the degree to which such a tool would be necessary to begin driving down Wilmington’s high rates of shootings and homicides. Delaware concluded there were a few key challenges in developing this kind of technology. Several state agencies raised legal concerns around data sharing, consent and privacy. State agencies are limited, by state and federal law, in their abilities to combine and share identified data indicators for the purpose of a predictive analytical tool. Ultimately, the CDC researchers were able to circumvent the restrictions typically applied to data held by state agencies, because their intent was never to identify individuals through their study. More importantly, a tool of this nature presents ethical issues, and many agree there are more strategic ways to identify those engaging or likely to engage in gun violence. The use of predictive analytics by other government entities has presented a potential for profiling individuals based on their personal risk factors, outweighing the opportunity for support of this population. Nonetheless, even if there were not ethical concerns with this type of tool, Delaware lacked the technology infrastructure and staffing to develop such a tool at the time. Ultimately, the existence of a predictive analytic tool (for identifying individuals based on a risk profile) would not resolve the question of which services should be offered to meet the needs of this population, and how those services would be introduced to the individuals identified by this tool.
A COMPREHENSIVE SOLUTION TO A COMPLEX PROBLEM With support from Social Contract, the FSCC focused on addressing the delivery of targeted services to accomplish the intent of the CDC predictive analytic tool. In response to the major roadblocks related to implementation, the state embarked on two key efforts: building and implementing the Delaware Integrated Data System (DIDS) so agencies have a streamlined approach to interagency data-sharing projects, and the implementation of evidence-based gun violence reduction programs, like Group Violence Intervention, which seek to provide those engaged in or affiliated with the groups and gangs that drive retaliatory gun violence with supportive social services, as recommended in the CDC report. 29
Over the course of 2019, the FSCC drafted and established the foundational agreements to share data across agencies through the establishment of DIDS, in compliance with state and federal requirements (overcoming the many of the legal challenges of the original recommendation). To operate DIDS, the agreements require ongoing collaboration across agencies, on a project-byproject basis, as well as related data infrastructure to be built and maintained through the Department of Technology and Information (DTI). DIDS will allow data to be shared from different agencies through a streamlined process, for research and analysis purposes; not to reach out to identified individuals, but to enable more efficient data sharing to truly understand impact. DIDS will not enable ongoing data reporting on identified individuals; it will, however, provide the procedural and process opportunity to evaluate the impact of cross-agency programs, including those targeting populations most at-risk for gun violence. While the CDC report recognized the risk factors associated with individuals engaged in gun violence, the report did not identify what the role of group or gang involvement in perpetuating largely retaliatory violence by a very small number of individuals in the City of Wilmington. Though the science behind reducing community gun violence is an emerging field, there are select evidence-based programs that are recommended by experts; Group Violence Intervention (GVI) is one such tactic, embraced by the state. Other equally critical strategies aimed at intervening in community gun violence include communitybased intervention as well as hospital-based violence intervention (which aims to reduce reinjury). Each of these strategies are in the early stages of implementation in the City of Wilmington, and as with all public health interventions, commitment to effective practices over time and sustained resourcing of efforts will quite literally save lives. It will take collective dedication to the science of violence intervention for impact to be seen, and sustained, in the years to come. The state’s primary investment to-date, Group Violence Intervention, is a multi-sector approach established through the FSCC and law enforcement partners to reduce shootings and homicides in the City of Wilmington. In 2017, Mayor Mike Purzycki appointed Wilmington Police Department Chief Robert Tracy, who has implemented this strategy in other jurisdictions and was a key advocate for the initiative’s launch in Wilmington. GVI is a partnership between law enforcement at the city, state and federal level, as well as social service providers, and incorporates community members as “moral voices.” The objective of this focused deterrence policing strategy is to clearly communicate with those individuals actively driving the violence (who might otherwise be identified by the proposed predictive tool) in the city. The message delivered by partners, directly to those involved, is that the violence will not be tolerated by law enforcement and they will support individuals with an opportunity to take alternative paths. If those engaged in violence elect to accept the offer of assistance, social service providers will work across agencies to support their needs; these services include housing supports, employment and training opportunities, assistance with financial management and planning, state and federal benefit enrollment, counseling, and services for substance abuse and mental health, among other services. The services are provided not just to those directly engaged in violence, but also 30 Delaware Journal of Public Health - July 2021
to their family and members of their support system and are delivered through intensive case management of each client. To better understand the individuals driving gun violence, the Wilmington Police Department worked in partnership with the Delaware Department of Correction to conduct an audit (supported by the National Network for Safe Communities (NNSC) at City University of New York at John Jay College of Criminal Justice) of all group-involved individuals known to law enforcement based on both police intelligence as well as traditional risk assessments administered by the DOC. This analysis underscored that, on any given day, there are less than 150 individuals actively engaged in the retaliatory gun violence in the City. This exercise also signified that, although a predictive analytic tool might convenience social service providers, absent the intelligence of law enforcement, most of those engaged in high-risk behaviors culminating in gun violence are known to the law enforcement community and can be reached and supported by ensuring effective partnership across government entities.
PROMISING RESULTS, WITH ROOM TO GROW Although the recommendations from the CDC offered a wellintentioned response to the acute crisis of community gun violence facing Delaware’s largest city, the need to create a “Criminal Violence Data Sharing and Risk Assessment” had been vetted by the FSCC and ultimately rejected due to legality and feasibility concerns. Nevertheless, the FSCC, in partnership with the Wilmington Police Department and other law enforcement partners, is steadily working to address high rates of retaliatory firearm violence; the GVI partnership aims to change the trajectory of Wilmington’s standing issues with gun violence by meeting the needs of a highrisk population known to law enforcement partners. After its first year (which included navigating the unprecedented challenges of COVID-19), 73% of the individuals GVI has touched have accepted some level of services, and 46% have fully engaged in the intensive case management component of the program, which is significantly above the national average. The need for employment and safe and affordable housing have been consistent themes in the population served. The GVI method of supportive engagement is offered to all group members and affiliates identified by law enforcement partners, and those accepting services provide written consent to social service providers to share their personally identifiable information on a need-to-know basis to meet their needs. This relieves providers of the problem of consent posed by the CDC’s proposed predictive tool, while still enabling them to offer support in a targeted way to individuals engaged in violence. GVI, among other key evidence-based intervention programs, stands to decrease gun violence in Wilmington by meeting the needs of at-risk populations and addressing the social determinants of health, ultimately providing individuals with a supported exit from violence. Social Contract, under the direction of the FSCC, is part of this ongoing work, ensuring that human needs are at the forefront of implementation efforts DIDS, an equally important undertaking, will enable evaluation of the program to ensure Delaware is contributing to a growing
body of evidence on how to reduce shootings and homicides in jurisdictions across the country. The opportunity presented by DIDS for program analysis will ensure proper evaluation of program outcomes in a way that, typically, is not prioritized in government initiatives. Data plays a critical role in understanding and addressing public health outcomes. Data will continue to play a role in the effort to drive down gun violence in Wilmington, but an initiative with an emphasis on consent to share data for the purposes of improved social services and meaningful engagement are preferable to any predictive analysis. What the CDC report and the efforts since have taught us is that technological tools, absent human relationships, appropriate support and resources, and collaboration for shared impact, are just tools. Since the CDC’s report, partners across sectors have worked diligently to build the necessary infrastructure to drive down community gun violence in Wilmington, and Social Contract is privileged to play a role in the collective efforts on behalf of the FSCC. We know that interventions are not a quick fix to a tragic epidemic that is decades, if not centuries, in the making. Interventions also won’t fix the societal and structural conditions, historical inequalities and oppressions that have led to the realities that foster community gun violence, but interventions are still a life-saving step that must be taken and committed to for as long as it takes to see results. In his book Bleeding Out: The Devastating Consequences of Urban Violence–And a Bold New Plan for Peace in the Streets, Thomas Abt put it best: “First you stop the bleeding, because unless you stop the bleeding, nothing else matters... Meaningful progress on fundamental socioeconomic conditions will take generations to achieve. People living with the reality of urban violence need relief right now.”
REFERENCES 1. Office of the Governor. (2017, Feb 28). Executive Order 5. Retrieved from: https://governor.delaware.gov/executive-orders/eo05/
2. Sumner, S., Mercy, J., Hillis, S., Maenner, M., & Socias, C. (2015, Nov 3). Elevated rates of urban firearm violence and opportunities for prevention – Wilmington, Delaware. Division of Violence Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. Retrieved from: https://dhss.delaware.gov/dhss/dms/files/ cdcgunviolencereport10315.pdf
3. Pizzi, J. (2015, Nov 3). CDC to Wilmington: Target at-risk youth for help. Delaware Online. Retrieved from: https://www.delawareonline.com/story/news/crime/2015/11/03/ cdc-wilm-target-risk-youth-more-services/75085884/
4. Kuang, J. (2020, Dec 21). 5 Years after the CDC’s big ideas on Wilmington gun violence, the state has changed course. Delaware Online. Retrieved from: https://www.delawareonline.com/story/news/2020/12/21/ delaware-officials-cite-ethical-concerns-cdc-gun-violencedatabase/6465999002/
5. Wilmington Community Advisory Council. (2017, Jan 16). Accelerating youth violence prevention and positive development: A call to action. Retrieved from: https://www.dhss.delaware.gov/dhss/ communityadvisorycouncilfinalreport.pdf
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COVID-19, Preparedness, and Technology: Meeting Access and Functional Needs at Vaccine Points of Dispensing and Beyond Debra Young, M.Ed., O.T.R./L., S.C.E.M., A.T.P., C.A.P.S., F.A.O.T.A. Disability & Preparedness Specialist, Association of State and Territorial Health Officials & Wanderly, Office of Preparedness, Division of Public Health, Delaware Department of Health and Social Services
Technology has become even more important to ensure that the needs of individuals with disabilities and others with access and functional needs (AFN) are met. This is especially apparent in the Delaware Office of Preparedness’ planning, mitigation, and response efforts throughout the Coronavirus disease 2019 (COVID-19) pandemic. The office, based within the Delaware Department of Health and Social Services (DHSS), Division of Public Health (DPH), had already integrated multiple technologies into preparedness planning, mitigation, and recovery efforts prior to the pandemic. It uses the CMIST framework (Communication, Maintaining Health, Independence, Safety/Support Services/SelfDetermination, and Transportation) which encompasses meeting the needs of individuals with disabilities and others with AFN. The framework helps identify individuals’ needs before, during, and after an incident.1 By using the U.S. Department of Health and Human Services’ (HHS) emPOWER data with GIS overlays from the HHS Office of the Assistant Secretary for Preparedness and Response, the Office of Preparedness can locate and support persons who rely on life-maintaining, electricity-dependent medical and assistive equipment, such as ventilators, and essential health care services.2 There are 7,777 electricity-dependent Medicare beneficiaries in Delaware: 3,617 in New Castle County, 1,601 in Kent County, and 2,559 in Sussex County, according to HHS. Prolonged power outages and other emergencies can be lifethreatening for these individuals, who live in their homes. In the event of prolonged outages due to natural disasters, there may be a need for these individuals to be temporarily housed in shelters. These data can assist with possible evacuations and to access alternative power sources. To better accommodate these Delawareans during such an event, the Office of Preparedness created two kits: an assistive technology (AT) kit and an AFN kit that include purchased equipment. After training DPH’s Northern and Southern Health Services personnel on how to use the AT kit, preparedness officials piloted it at multiple small-scale flu vaccine points of dispensing (V-PODs). With an eye to sustainable program development and an allhazards approach, the Office of Preparedness envisioned setting up a Functional Assessment Service Team (FAST) to conduct functional assessments and provide support to individuals with disabilities and others with AFN within community shelters and a variety of centers, including heating, cooling, recovery, respite, radiation recovery, community recovery, and/or family assistance centers. As the pandemic unfolded, DPH personnel piloted FAST at COVID-19 mass V-PODs. 32 Delaware Journal of Public Health - July 2021
Utilizing an equity lens throughout the COVID-19 response was a top priority, and technology ensured equitable vaccine access through the use of low-tech and high-tech accommodations. Low-tech accommodations are devices or equipment that do not require much training, may be less expensive, and do not have complex or mechanical features (see figure 1).3 High-tech accommodations are described as “the most complex devices or equipment, that have digital or electronic components, and may be computerized.”3 The Office of Preparedness made a variety of low to high-tech accommodations available at the DPH COVID-19 V-PODs for: • Vision, such as large print materials and magnifiers; • Hearing, such as portable voice amplifiers, a device to augment hearing aids, a dry erase white board, clear face masks, and Picture Exchange Communication symbols (PECS) and boards; • Communication, including a Federal Emergency Management Agency website that provides video remote interpretation for American Sign Language (ASL) via the use of a tablet, clear face masks, PECS and boards, and over-the-phone language translation for individuals with limited English proficiency; and • Mobility, including wheelchairs and walkers. An estimated more than 300 individuals with disabilities and others with AFNs were served at the V-PODs held between January 30, 2021 and June 9, 2021. At one of the mass COVID-19 vaccination events held at the Dover International Speedway, an attendee quickly put his hand up to his ear in an attempt to hear a Delaware National Guard (DNG) member. The DNG member alerted an onsite disability and preparedness specialist from the Association of State and Territorial Health Officials to provide support. Upon assessing the gentleman’s needs, the specialist determined that he might benefit from using a voice amplification device. The person requiring the assistive listening support wears headphones, while the other person speaks into the device’s microphone and adjusts the volume to meet the individual’s needs. Disposable earphone covers are used for hygiene. When the headphones were placed over the gentleman’s ears, the specialist asked, “Can you hear me?” The gentleman began to cry joyfully and expressed, “Yes;” he could hear and was grateful that someone cared enough to help him hear better to access the vaccine. Not all technology needs to be high-tech. There is also a place for low-tech to allow for successful vaccine access. One of the items included in the AT kit is a social story about getting the COVID-19 vaccination. A social story is a social learning tool that supports the safe and meaningful exchange of information doi: 10.32481/djph.2021.07.009
Figure 1. William Leger, a client of DHSS’ Division for the Visually Impaired (DVI), used a signature guide when he came to the Route 9 Library on April 22, 2021 for his second dose of Moderna vaccine. The person with vision loss places their writing instrument in the rectangular cutout area to sign their name in the proper place. Mr. Leger is assisted by Gina Fletcher, a DVI administrative specialist. Source: DVI photo.
between parents, professionals, and people with autism and/or intellectual disabilities of all ages.4 The story is illustrated with PECS to present the concepts in clear, simple terms. When a woman and her young adult son arrived at a V-POD, she alerted the DNG that her son had autism. The disability and preparedness specialist provided the mother with the social story and asked her to read it to her son so he would gain a clear expectation of the vaccination process. He successfully received the vaccine. To communicate information about the COVID-19 vaccine specifically to meet the needs of individuals with disabilities and others with AFN, the Office of Preparedness has posted much information at https://coronavirus.delaware.gov/vaccine/. The webpage provides communication and clarity surrounding vaccine access, such as V-POD accommodations at vaccination events hosted by the State of Delaware and DPH vendors. Visitors can also find DHSS COVID-19 vaccine initiatives to serve individuals with disabilities and multiple resource links such as a COVID-19 ASL video series and access to Braille and plain language resources.5 With its all-hazards approach, the Office of Preparedness continues to utilize technology to support individuals with disabilities and others with AFNs through this crisis and in preparation of future emergencies.
REFERENCES 1. U.S. Department of Health & Human Services Office of the Assistant Secretary for Preparedness and Response (HSS/ ASPR). (2020, Aug 27). The CMIST Framework. Public Health Emergency. Retrieved from: https://www.phe.gov/emergency/events/COVID19/atrisk/ discharge- planning/Pages/CMIST-framework.aspx 2. U.S. Department of Health & Human Services (HHS). (n.d.) HHS emPOWER Program Platform. Retrieved from: https://empowerprogram.hhs.gov 3. Georgia Tech Tools for Life. (n.d.) What is assistive technology? Retrieved from: https://gatfl.gatech.edu/assistive.php 4. Center For Dignity In Healthcare for People With Disabilities. Retrieved from: https://centerfordignity.com/covid-19/ 5. Delaware Department of Health and Social Services, Division of Public Health. (n.d.) COVID-19 vaccine information for persons with disabilities or access and functional needs. Retrieved from: https://coronavirus.delaware.gov/vaccine/covid- 19-vaccineinformation-for-persons-with-disabilities-or-access-andfunctional-needs/ 33
FOR IMMEDIATE RELEASE Contacts: Mark B. Thompson, MHSA Executive Director Medical Society of Delaware (302) 444-6958 Mark.Thompson@medsocdel.org
Mary Fenimore Office of Communications Delaware Division of Public Health
DPHMedia@delaware.gov
Voluntary Initiative Program (VIP) Celebrates 20th Anniversary Serving Delawareans in Need for Two Decades Newark, Delaware – June 11, 2021- The Medical Society of Delaware (MSD) has renewed the contract with the Division of Public Health (DPH) to continue the Voluntary Initiative Program (VIP) into the fiscal year 2022. June 11, 2021, marks the 20th consecutive year that MSD has proudly served the community in this capacity. VIP is administered by MSD and supported by the Delaware Foundation for Medical Services (DFMS), a charitable foundation of MSD. The Voluntary Initiative Program is part of the Health Care Connection (HCC), a statefunded program that helps coordinate charitable medical services by physicians and provides additional health service resources for patients. Physician participation adds value and improves medical outcomes for patients enrolled in HCC. Enrolled HCC participants receive discounted medical services based on their income. Specifically, the HCC links uninsured Delawareans who meet specific criteria with a medical home and specialty care. In addition, the program provides care coordination and health navigation services to assist patients through the continuum of care. Health Promotion Advocates (HPA) are in place to educate clients about healthy lifestyle behaviors (physical activity, nutrition and tobacco use) as well as to ensure clients enrolled in HCC obtain appropriate cancer screenings. HPAs refer Delawareans to community resources for which they may be eligible for or have a need. “The partnership between DPH and MSD has been invaluable to ensure patients are obtaining the resources they so desperately need. This program establishes a continuity of care for patients that is critical in improving health outcomes over the long term.” said Division of Public Health Director, Dr. Karyl Rattay.
34 Delaware Journal of Public Health - July 2021
OUTCOMES: Professional external evaluation of the program has shown that patients: Increase their rate for completion of preventive screenings Reduce the use of emergency department services Lower their length of hospital stays Improve their management of chronic diseases Self-report increased satisfaction with their health care Utilize no-cost or discounted ancillary services such as pharmacy assistance, laboratory services, radiology, physical therapy, etc. As of February 2021, over 70,700 low-income uninsured individuals have been identified and assisted through the VIP. In addition, over 4,000 were enrolled in a public insurance program. “The Medical Society of Delaware is proud and honored to celebrate the 20th anniversary of partnering with the State of Delaware to provide this critically important safety net program for access to care for such a vulnerable population. This initiative is vital in connecting those who don’t have access to health insurance to primary care, specialists, and prescription medicine.” said Matthew Burday, DO, President of the Medical Society of Delaware. ### About the Medical Society of Delaware The Medical Society of Delaware is the third oldest institutions of its kind in the United States and rich in history. Founded in 1776 and incorporated on February 3, 1789, the Medical Society of Delaware continues its support of physicians in their vigor and spirit to advance the profession, which was the basis for its creation. Its mission is “To guide, serve and support Delaware Physicians, promoting the practice and profession of medicine to enhance the health of our communities.” About the Delaware Foundation for Medical Services, Ltd. (DFMS) The Delaware Foundation for Medical Services, Ltd. (DFMS) is a charitable foundation of the Medical Society of Delaware. The corporation is a nonprofit organization organized and operated exclusively for charitable and educational purposes within the meaning of Section 50l(c)(3) of the Internal Revenue Code of 1954, as amended, or the corresponding provision of any subsequent Federal tax law. The corporation is to receive and administer gifts of property for charitable, benevolent civic, health, scientific and educational purposes, primarily for the purpose of enhancing the quality of medical care in the State of Delaware, in a manner which shall: Afford to persons an opportunity to make gifts with a greater beneficial result than possible through individual action; Afford to corporations an opportunity equal to that of individuals to create memorials or make gifts as the circumstances of their economic situation warrant, from time to time; Safeguard and provide for the permanent security of' such gifts.
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Evolution of the Delaware Epidemiology Response to COVID-19 Erica Smith, M.P.H., Ph.D Deputy State Epidemiologist, Epidemiology, Health Data, and Informatics Section, Division of Public Health, Delaware Department of Health and Social Services Tabatha N. Offutt-Powell, Dr.P.H., M.P.H. State Epidemiologist; Chief, Epidemiology, Health Data, and Informatics Section, Division of Public Health, Delaware Department of Health and Social Services
ACKNOWLEDGEMENTS To the many DPH staff who dedicated hours upon hours upon days and months and now over a year to assist the COVID-19 epidemiology response, words cannot express our most sincere and heartfelt gratitude for what you helped us to achieve by ensuring that public health received laboratory test results, maintaining our surveillance and information systems, investigating cases, making public health recommendations regarding isolation and quarantine, conducting contact tracing, providing data to the My Healthy Community website, and the many more aspects of Delaware’s epidemiologic response to the COVID-19 pandemic.
INTRODUCTION As of June 1, 2021, over 108,000 confirmed and probable cases of coronavirus disease 2019 (COVID-19) and 1,677 deaths have been reported in Delaware since the start of pandemic in March 2020. Over 720,000 persons have been tested in Delaware, including 1.85 million total tests reported. As the pandemic evolved, multiple data systems were used for data management and reporting internally to Division of Public Health leadership and externally to partners and the public. Daily public reporting updates were shared on Delaware’s My Healthy Community website since April 2020. This article discusses a history of COVID-19 in Delaware, the changing landscape of data management tools used during the pandemic, and the epidemiology team that has grown and adapted over the past year and a half.
JANUARY 2020 - SCREENING FOR PATIENTS UNDER INVESTIGATION On December 31, 2019, the World Health Organization announced news of patients from Wuhan, China with pneumonia-like symptoms and unknown etiology.1,2 As a result, in early January 2020, a Division of Public Health (DPH) team of five infectious disease epidemiologists, one preparedness epidemiologist, the Deputy State Epidemiologist, and State Epidemiologist began preparing for the possibility that the novel coronavirus (then called 2019-nCoV) would arrive in the United States or Delaware. The U.S. Centers for Disease Control and Prevention (CDC) and other governmental partners held weekly and daily all-state calls, press briefings, and other sessions to share information across agencies. In mid-January, CDC established a patient under investigation (PUI) case definition3 to assist health departments in identifying and testing patients. The initial PUI case definition focused solely on symptomatic people with recent travel to Wuhan, or exposure to other PUIs, but was later expanded to include travel to 36 Delaware Journal of Public Health - July 2021
anywhere in mainland China.3 In response to calls from providers seeking clinical guidance, DPH developed a Patient Screening Flowchart to help epidemiologists interpret and apply the CDC’s January 29, 2020 PUI case definition, which is depicted in Figure 1. On January 29, 2020, Delaware announced its first PUI, a hospitalized Kent County resident who later tested negative for n-CoV.4
FEBRUARY 2020 - TRAVELER MONITORING PROGRAM BEGINS On January 31, President Donald Trump announced that travel from China to the United States would be restricted.5 Three days later, the CDC, the Transportation Security Administration (TSA), and state and local health departments began a symptom monitoring program for travelers returning from China.5 Initially, DPH developed paper questionnaires, illustrated in Figure 2a, for initial interviews and periodic symptoms monitoring during the 14-day self-quarantine period, and later used an Epi-Info 7™ database, illustrated in Figure 2b, to manage the traveler monitoring program. In February and March, the traveler monitoring program expanded to include Iran, Japan, South Korea, and Europe, and then any country with a Level 2 or Level 3 travel advisory.6 DPH received traveler lists through CDC’s secure platform, Epi-X, and contacted recently returned travelers from designated countries to ask them to self-quarantine for 14 days after their return and monitor their symptoms. Between February 5 and April 7, DPH monitored 200 travelers, predominantly those returning from China (68, 34%) and Europe (36, 18%).
MARCH 2020 – COVID-19 SPREADS IN THE USA; FIRST CASES IDENTIFIED IN DELAWARE In March 2020, COVID-19 began to spread widely in the United States. On March 7, CDC reported 213 cases in 19 states.7 Shortly thereafter, on March 11, 2020, Delaware identified its first presumptive positive case of COVID-19 in a Delaware resident.8 On March 12, Governor John Carney declared a State of Emergency9 and DPH activated its State Health Operations Center (SHOC) at Level 3. All epidemiology staff relocated to the SHOC as other DPH staff were activated to help with COVID-19related activities. On March 13, all Delaware schools closed10; the closure was later extended to the entire school year.11 Upon identification of the first cases of COVID-19 in Delaware, DPH developed paper case investigation forms, illustrated in Figure 3. Case investigations were conducted by a five-member team of epidemiologists that expanded to 12 and included epidemiologists from other DPH programs such as the cancer program, chronic disease program, and HIV/STD programs. doi: 10.32481/djph.2021.07.010
Figure 1. Novel Coronavirus (2019 nCOV) Patient Screening Flowchart using January 29, 2020 Patient Under Investigation Case Definition 37
Figure 2a. Initial Paper Forms Used for Monitoring of Travelers Returning From China 38 Delaware Journal of Public Health - July 2021
Figure 2b. Epi-Info 7 ™ Database Used for Management of Traveler Monitoring Program
39
and symptoms, underlying health conditions, recent health care visits, employment information, and exposures to other persons with COVID-19. Cases were also asked about any household contacts with whom they may have exposed and any highrisk exposures (e.g., long-term care facilities, group settings, and correctional facilities). Limited information from case investigation questionnaires was entered into a line list managed by a single user in Microsoft Excel, and daily COVID-19 Epi data summaries were sent to internal DPH partners and leadership. The summaries included demographics, hospitalizations, deaths, exposures to other COVID-19 cases, and international/domestic travel. To give a richer picture of the spread, exposures, and risk of COVID-19 in Delaware, deidentified case summaries were shared daily with DPH and intergovernmental leadership. Contact tracing was performed for the first nine COVID-19 cases that were identified in mid-March. Contacts were initially contacted and monitored by a team of six DPH staff who were activated for the SHOC from other programs within the division. DPH discontinued contact tracing after the first nine cases and reassigned contact tracing staff to other duties within the COVID-epi SHOC response. By March 22, COVID-19 was rapidly spreading throughout the U.S. and 65 cases were identified in Delaware. The same day, Governor Carney announced a stay-at-home order for Delawareans and ordered all non-essential businesses to close.12 Four days later, Delaware announced the first COVID-19 -related death13 and on March 29, out-of-state visitors were asked to quarantine for 14 days upon arrival in Delaware.14 In late April, a public mask mandate was issued.15
APRIL 2020 - ADDITIONAL CASES IDENTIFIED, REDCAP CASE INVESTIGATION DATABASE DEPLOYED In April 2020, cases began to spread quickly in Delaware and around the country, with CDC reporting “widespread” COVID activity in 25 states on April 1, 2020.16 Figure 4 shows an epidemic curve by week of COVID-19 cases in Delaware from March 11, 2020 to May 15, 2020. The peak of Delaware’s first wave occurred during the week of April 19, approximately one month after stayat-home orders were issued, with 1,531 cases reported. On April 10, 2020, with approximately 1,130 existing cases, DPH replaced its paper forms and Excel line list with a case investigation and monitoring database built in Research Electronic Data Capture (REDCap).17 Figure 5a shows a screen capture of the REDCap Case Investigation Questionnaire. The COVID-19 Epidemiology (Epi) Team of 12 cross-cutting epidemiologists conducted case investigation interviews using the new platform, with questions similar to the previously used paper forms. The epidemiologists settled into a rhythm of processing incoming laboratory test results in the Delaware Electronic Reporting and Surveillance System (DERSS) in the morning and conducting case investigation interviews in the afternoon. The team created a daily batch process for new cases to be loaded into the REDCap system (Figure 5b). Each day’s reported cases were assigned to an epidemiologist for case interview by the next day. Three call attempts were made to each case before cases were marked as lost to follow-up. DPH stood up a Case Monitoring Team who, using this same REDCap database used for case 40 Delaware Journal of Public Health - July 2021
investigations, routinely called cases during their isolation periods and cleared them from isolation when symptoms resolved. In late April, just after what would later be recognized as the first peak, a large outbreak among poultry plant workers was identified on the Delaware-Maryland-Virginia peninsula.18 Among 9,400 workers at six Delaware poultry plants, DPH identified 336 cases and four deaths.18 Additional testing and mitigation resources were focused on Sussex County, the epicenter of Delaware’s poultry industry, which Governor Carney declared a COVID-19 hotspot on April 28.19 Since English was not the primary spoken language for many poultry workers, the COVID-19 Epi team recruited DPH staff who spoke Spanish and Haitian Creole to assist with case interviews; language line translation resources were also used.
MAY 2020 - CASES REMAIN ELEVATED, COVID-19 EPI TEAM EXPANDS, CONTACT TRACING BEGINS As cases continued to increase in April and remained elevated in May, additional DPH staff were activated as part of the SHOC COVID-19 Epi response and a revised team structure was implemented. A team of “case creators,” that eventually included 25 members, processed laboratory reports in DERSS every morning and classified cases as “confirmed,” “probable,” or “not a case” (i.e. negative) using CDC’s surveillance case definitions.20 The Epi Investigation Team, eventually including 37 members of staff from across DPH, used REDCap’s case investigation database to call cases and conduct initial interviews before transferring cases to the Case Monitoring Team. The Case Monitoring Team, which eventually included 24 members, called cases periodically until symptoms resolved and individuals were released from isolation. A COVID-19 Epi Data Team including an epidemiologist and two data analysts was established to assist with administration of the data systems used by the team. On May 12, Governor Carney announced a statewide contact tracing plan “to contain COVID-19, limit Delawareans’ exposure to the disease, and restart Delaware’s economy.”21 One hundred members of the Delaware National Guard (DNG) were immediately activated to perform contact tracing and began their training. On May 11, cases were asked about any close or household contacts they had who may have been exposed to COVID-19, and a second REDCap database was built exclusively for the DNG to house and manage contact tracing data. Named contacts were extracted from the case investigation REDCap system, imported into the contact tracing REDCap system, and assigned for a DNG call by the next day. A team of epidemiologists and CDC contact tracing experts was deployed to assist with establishing the DNG contact tracing effort, and a summary of contact tracing from May 11 to June 25 was published.22 As cases started declining in May, restrictions began to lift in several sectors with masking, social distancing, and capacity restrictions in place. Houses of worship were allowed to reopen,23 businesses were allowed to operate by appointment,24 and on May 22 preceding Memorial Day, Delaware beaches were reopened with restrictions as a mandatory 14-day quarantine for out-ofstate travelers and a ban on short term rentals remained in effect.25
Figure 3. Initial Paper Forms Used for COVID-19 Case Investigation 41
Figure 4. Confirmed and Probable COVID-19 Cases by Week, Delaware, March 11, 2020 to May 15, 2021.
JUNE 2020 - PHASE 1 AND 2 OF REOPENING, AND LONG-TERM CONTACT TRACING
JULY AND AUGUST 2020 FIRST COHORT OF COVID-19 EPIDEMIOLOGISTS HIRED
Beginning on June 1, 2020, Phase 1 of the Delaware COVID-19 reopening plan included an end to the stay-at-home orders and out-of-state quarantine, retail and restaurants reopening at 30% capacity, and a 250-person cap on outdoor gatherings. Phase 2, which began June 15, expanded retail and restaurant capacity to 60% and allowed childcare, personal care, and exercise facilities to reopen with restrictions.26
In May, the CDC awarded a $67 million Epidemiology Laboratory Capacity (ELC) grant to support COVID-19 activities in Delaware.27 From this funding, over a dozen limited term COVID-19 epidemiologist positions were made available. The initial cohort of COVID-19 Epidemiologists was hired in July and August. As the dedicated COVID-19 Epi team was trained and onboarded, other SHOC-activated staff on the Epi Investigation and Case Monitoring teams returned to their regular DPH duties.
Earlier in May, DPH was working on a long-term solution and hired, onboarded, and trained 150 contact tracers with the nonpartisan research institution National Opinion Research Center (NORC) at the University of Chicago. On June 26, DPH launched the new Delaware Contact Tracing System (DCTS). The case investigation and contact tracing REDCap databases were retired, and all the historical data were moved into a new master database using a Salesforce platform (Figure 6). The Epi Investigation Team was trained on the new Salesforce© platform. Contact tracers interviewed cases and contacts using questionnaire scripts during live phone calls; individuals who could not be reached were called by the COVID-19 Epi Team or visited by a newly stood up DPH Field Team, which eventually grew to around 45 members and represents DPH’s largest Field Team to date. 42 Delaware Journal of Public Health - July 2021
Initially, the case interview questionnaires in DCTS were focused on identifying exposed contacts and calling contacts to notify them of their exposure and ask them to self-quarantine. Early on, the COVID-19 Epi Team focused on calling cases and contacts that the contact tracers were unable to reach, and the DPH Field Team visited persons the Epi Team was not able to reach, at home. Case counts remained relatively low throughout the summer, with a small second peak in late June/early July (Figure 4). During the summer, questions were added to the survey to ask cases where they had been prior to their illness, and where they might have been exposed to COVID-19. The COVID-19 Epidemiology Team began to analyze the data and look for trends among cases to detect possible clusters associated with public venues, private gatherings, and employment.
Figure 5a. REDCap Case Investigation Questionnaire
Figure 5b. REDCap Case Monitoring Questionnaire 43
Figure 6. Delaware Contact Tracing System Case Initial Interview Questionnaire
SEPTEMBER AND OCTOBER 2020 NOVEMBER AND DECEMBER 2020 SCHOOLS BEGIN TO REOPEN, LONG-TERM HOLIDAY SURGE AND THE THIRD WAVE CARE CASES INCREASE COVID-19 cases began to steadily increase as temperatures In late summer and early fall 2020, the COVID-19 Epi team began to plan how schools would safely reopen. During school year 2020-2021, schools were allowed to reopen for hybrid learning28; families chose whether students would attend school in-person or remotely if the school district allowed an in-person option. DPH and the Department of Education issued reopening guidance for schools29 and a dedicated COVID-19 Epi School Team of seven epidemiologists was established to answer calls from school nurses about cases or exposures in their schools. When cases and outbreaks in long-term care facilities began to increase in September, DPH began releasing case totals by facility among facilities experiencing significant outbreaks of COVID-19.30 A dedicated COVID-19 Epi Long-term Care Team of four epidemiologists was created to manage inquiries from longterm care facilities, using a resource email account where facilities could submit inquiries, daily line lists, and other information. 44 Delaware Journal of Public Health - July 2021
dropped in late fall and winter 2020, culminating with two peaks during the weeks of December 6, 2020 and January 3, 2021. Each peak occurred about 10 days after the Thanksgiving and Christmas holidays. On November 17, Governor Carney announced additional COVID-19 restrictions, including a 10-person limit on private gatherings and a 30% restriction on indoor restaurant capacity.31 As the surge began in November, priorities for the COVID-19 Epi Team shifted from interviewing individual cases and contacts to classifying cases daily in DERSS and detecting and responding to cases and clusters in high-risk settings. As of early December, all but two SHOC-activated staff had returned to their regular jobs within DPH, and the COVID-19 Epi Team included 20 epidemiologists and five additional support staff. There were now five teams: the existing Data Team, School Team, and Long-Term Care Team, plus two new teams, the Cluster Team and the Queues
Team. Funding for additional COVID-19 Epi staff and team leads was identified to continue to respond to the growing need for epi support, particularly for school-related calls and clusters detected following holiday gatherings. To address the surge, on December 3, additional public COVID-19 restrictions were announced. They included a stay-athome advisory and universal indoor mask order; a reduction in capacity in large retail stores to 20%; and a “pause” on hybrid K-12 school learning from December 14 to January 11, 2021.32–34 As COVID-19 vaccines were approved in December 2020, DPH activated its vaccination plan and strongly recommended eligible Delawareans to receive the vaccine as soon as possible. Health care personnel, emergency medical services personnel, and the residents and staff of long-term care facilities were the first to become eligible in Phase 1A. A critical care nurse was the first Delawarean to receive the vaccine on December 15.35 Vaccination of long-term care residents and staff began on December 17.36
JANUARY AND FEBRUARY 2021 SOLIDIFYING THE COVID-19 EPI TEAM STRUCTURE COVID-19 cases remained high through January and February 2021, and the COVID-19 Epi Team continued to detect and respond to clusters and inquiries from schools and nursing homes. During and after the K-12 school hybrid learning “pause,” while schools returned to hybrid learning and school-related calls dropped significantly, the COVID-19 Epi Team regrouped and reviewed its resources, capacity, and structure, resulting in teams streamlining activities. The School Team moved from managing school-related calls in a single-user Excel spreadsheet to a School Triage REDCap database. This new database allows school nurses to submit inquiries to the COVID-19 Epi Team using a web form. Those inquiries were then immediately assigned to an epidemiologist to follow-up. Although the volume of inquiries remained high due to the ongoing surge in cases, critical information was collected from school nurses up front, reducing the need for back-and-forth phone calls between the COVID-19 Epi Team and school nurses. A team of 12 DNG members were onboarded to re-establish a DERSS case-creation team, allowing COVID-19 Epi staff time to respond to high-priority cases and clusters in high-risk settings. On January 19, Delaware transitioned to Phase 1B of its vaccination plan,37 focusing on persons age 65 and older, frontline essential workers, and Phase 1A-eligible persons who had not yet been vaccinated. An electronic system was launched for eligible individuals to request a vaccine appointment, and it received more than 56,000 requests on its first day.38 Although not detailed here within, the state’s vaccination response efforts were a coordinated government effort that served as a primary prevention avenue for the state to drastically impact the spread of the virus. The Delaware Public Health Laboratory (DPHL) began sequencing its COVID-19 specimens, and on January 29 identified the first three cases of COVID-19 variant SARS-CoV-2 B.1.1.7, which was first identified in the United Kingdom.39 With sequencing of specimens on the rise, the Cluster Team began tracking all variant cases in Delaware. On March 5, DPH announced the first case of another COVID-19 variant, SARSCoV-2 B.1.351, first identified in South Africa.40
As distribution of vaccines expanded in long-term care facilities, nursing home cases began to fall, and DPH announced on February 12 that it would report COVID-19 cases and deaths in long-term care facilities weekly instead of daily.41 By late March, DPH released guidance for in-person visitation in nursing homes.42
MARCH, APRIL, MAY 2021 - VACCINE ROLLOUT, BREAKTHROUGH, AND VARIANT CASES In March, the COVID-19 Queues Team began tracking cases who tested positive for COVID-19 after being fully vaccinated. During case interviews, cases were asked about COVID-19 vaccination. If more than 14 days had passed since their last dose, they were classified as “breakthrough” cases. Breakthrough cases, hospitalizations, and deaths were reported to CDC until May 1, when reporting was limited to only hospitalizations and deaths among breakthrough cases.43 As of May 27, DPH identified 330 cases of COVID-19 among fully-vaccinated individuals in Delaware, out of more than 381,498 Delaware residents who are fully vaccinated (0.09%).44 On March 17, COVID-19 vaccination opened to all Delawareans over 50 and anyone 16 and older with high- and moderate-risk health conditions.45 At that time, 20% of Delaware’s population had received at least one dose of a COVID-19 vaccine, and case counts began to decline to counts only slightly higher than those before the winter surge as illustrated in Figure 4. Just a few weeks later on April 6, COVID-19 vaccination opened to all Delawareans 16 and older.46 In April 2021, COVID-19 cases once again began to rise, with a small peak the week of April 4. Variants of concern continued to be identified, with 64 cases of B.1.1.7 reported by April 9.47 The B.1.1.7 variant was the dominant variant in the United States on April 10, accounting for 59.5% of all sequenced COVID-19 specimens, according to the CDC.48 By May 14, DPHL identified 568 cases of the B.1.1.7 variant out of 2,215 specimens sequenced.49 May 14 marked the first week where fewer than 1,000 cases were identified since October 2020. DPH retired its COVID-19 vaccination “wait list” (appointment request system) on May 6, reflecting increases in vaccine supply and uptake around the state.50 As of May 14, over 830,000 doses of COVID-19 vaccines were administered, 56% of the eligible population had received at least one dose, and more than 44% were fully vaccinated.49
MAY 2021 AND BEYOND - THE FUTURE OF THE DELAWARE COVID EPI TEAM Sixteen months into the pandemic, as vaccine doses administered increase and cases counts continue to decline, the COVID-19 Epi Team is looking to the future and how best to adapt to a rapidly changing pandemic in Delaware. DPH brought a COVID-19 Epi Bureau Chief on board in late March of 2021, and a senior COVID-19 Epidemiologist in late May. The COVID-19 Epidemiologist will assume many day-to-day COVID-19 responsibilities from the State Epidemiologist and Deputy State Epidemiologist, who will return to supporting other epidemiology and program staff throughout the Division. 45
The COVID-19 Epi Team is committed to continuous quality improvement and constantly evaluates the epidemiology needs of the COVID-19 response in Delaware. With anticipated testing to occur in schools during the summer and fall, the School Team is planning to address any potential increases in cases among school students and staff, and inquiries from school nurses, once the 2021-2022 school year begins. The Cluster Team continues to track variant cases to document the changing picture of variants of concern and interest in Delaware. The Data Team continues to identify opportunities to streamline daily and weekly reports, transitioning more fully into “big data” analysis strategies as COVID-19 case counts and testing continue to decrease over time. The Long-Term Care team continues to respond to inquiries from facilities regarding both cases, clusters, and deaths. The Queues team continues to improve the DCTS and track breakthrough cases, monitoring trends as vaccination numbers increase. From humble beginnings of a small team and paper forms, the Delaware COVID-19 Epi Team has grown and adapted to a rapidly changing pandemic and is ready to take on the new challenges in what lies ahead. Corresponding author: Erica Smith, M.P.H., Ph.D. is the Deputy State Epidemiologist in the Division of Public Health, Delaware Department of Health and Social Services. erica.smith@delaware.gov
REFERENCES
7. Centers for Disease Prevention and Control. (2020, March 8). Updated guidance on evaluating and testing persons for coronavirus disease 2019 (COVID-19). CDC Health Alert Network. https://emergency.cdc.gov/han/2020/HAN00429.asp 8. Delaware Department of Health and Social Services. (2020, March 11). Public Health announces first presumptive positive case of coronavirus in Delaware resident. News. https://news.delaware.gov/2020/03/11/public-health-announces-firstpresumptive-positive-case-of-coronavirus-in-delaware-resident/ 9. Carney, G. J. (2020, March 12). Declaration of a State of Emergency for the state of Delaware due to a public health threat. Office of the Governor. https://governor.delaware.gov/health-soe/state-of-emergency 10. Carney, G. J. (2020, May 23). Governor Carney closes Delaware schools through May 15. Office of the Governor. https://news.delaware.gov/2020/03/23/governor-carney-closesdelaware-schools-through-may-15/ 11. Carney, G. J. (2020, April 24). Delaware schools closed through academic year. Office of the Governor. https://news.delaware.gov/2020/04/24/delaware-schools-closedthrough-academic-year/ 12. Carney, G. J. (2020, March 22). Governor Carney issues stay-athome order for Delawareans. Office of the Governor. https://news.delaware.gov/2020/03/22/governor-carney-issues-stayat-home-order-for-delawareans/
1. Allam Z. (2020). The first 50 days of COVID-19: A detailed chronological timeline and extensive review of literature documenting the pandemic. Surveying the Covid-19 Pandemic and its Implications, 1–7. https://doi.org/10.1016/B978-0-12-824313-8.00001
13. Delaware Department of Health and Social Services. (2020, March 26). Public Health announces first coronavirus-related death of Delaware resident. News. https://news.delaware.gov/2020/03/26/public-health-announces-firstcoronavirus-related-death-of-delaware-resident/
2. World Health Organization. (2020, December 28). Listings of WHO’s response to COVID-19. World Health Organization News. https://www.who.int/news/item/29-06-2020-covidtimeline
14. Carney, G. J. (2020, March 29). Governor Carney order outof-state travelers to immediately self-quarantine for 14 days. Office of the Governor. https://news.delaware.gov/2020/03/29/governor-carney-orders-outof-state-travelers-to-immediately-self-quarantine-for-14-days/
3. Centers for Disease Control and Prevention. (2020, January 17). Interim guidance for healthcare professionals. 2019 Coronavirus. https://web.archive.org/web/20200130185924/https://www.cdc.gov/ coronavirus/2019-nCoV/hcp/clinical-criteria.html 4. Delaware Department of Health and Social Services. (2020, January 30). News. Information on 2019 Novel Coronavirus from Division of Public Health. https://news.delaware.gov/2020/01/30/information-on-2019-novelcoronavirus-from-division-of-public-health/ 5. U.S. Department of Homeland Security. (2020, February 2). DHSS issues supplemental instructions for inbound flight with individual who have been in China. News Archive. https://www.dhs.gov/news/2020/02/02/dhs-issues-supplementalinstructions-inbound-flights-individuals-who-have-been-china 6. National Public Radio. (2020, February 29). Map: Which countries have CDC travel advisories because of coronavirus. The Coronavirus Crisis. https://www.npr.org/sections/ goatsandsoda/2020/02/29/810440382/map-which-countries-havecdc-travel-advisories-because-of-coronavirus 46 Delaware Journal of Public Health - July 2021
15. Carney, G. J. (2020, April 25). Governor Carney requires Delawareans to wear face coverings in public settings. Office of the Governor. https://news.delaware.gov/2020/04/25/governor-carney-requiresdelawareans-to-wear-face-coverings-in-public-settings/ 16. Schuchat, A., & the CDC COVID-19 Response Team. (2020, May 8). Public health response to the initiation and spread of pandemic COVID-19 in the United States, February 24–April 21, 2020. MMWR. Morbidity and Mortality Weekly Report, 69(18), 551–556. https://doi.org/10.15585/mmwr.mm6918e2 PubMed 17. Vanderbilt. (n.d.). Research Electronic Data Capture. REDCap. https://www.project-redcap.org/ 18. Dyal, J. W., Grant, M. P., Broadwater, K., Bjork, A., Waltenburg, M. A., Gibbins, J. D., . . . Honein, M. A. (2020, May 8). COVID-19 Among Workers in Meat and Poultry Processing Facilities— 19 States, April 2020. MMWR. Morbidity and Mortality Weekly Report, 69(18), 557–561. https://doi.org/10.15585/mmwr.mm6918e3 PubMed
19. Carney, G. J. (2020, April 28). Governor Carney declares COVID-19 hot spot in Sussex County, announces expansion of community testing sites. Office of the Governor. https://news.delaware.gov/2020/04/28/governor-carney-declarescovid-19-hot-spot-in-sussex-county-announces-expansion-ofcommunity-testing-sites/ 20. Centers for Disease Control and Prevention. (n.d.). Coronavirus Disease 2019 (COVID-19) 2020 interim case definition, approved August 5, 2020. National Notifiable Disease Surveillance System. https://wwwn.cdc.gov/nndss/conditions/coronavirus-disease-2019covid-19/case-definition/2020/08/05/) 21. Carney, G. J. (2020, May 12). Governor Carney announces statewide contact tracing plan for COVID-19. Office of the Governor. https://news.delaware.gov/2020/05/12/governor-carney-announcesstatewide-contact-tracing-plan-for-covid-19/ 22. Kanu, F. A., Smith, E. E., Offutt-Powell, T., Hong, R., Dinh, T. H., & Pevzner, E., & the Delaware Case Investigation and Contact Tracing Teams. (2020, November 13). Declines in SARS-CoV-2 transmission, hospitalizations, and mortality after implementation of mitigation measures— Delaware, March–June 2020. MMWR. Morbidity and Mortality Weekly Report, 69(45), 1691–1694. https://doi.org/10.15585/mmwr.mm6945e1 PubMed 23. Carney, G. J. (2020, May 18). Governor Carney issues guidance for churches, houses of worship. Office of the Governor. https://news.delaware.gov/2020/05/18/governor-carney-issuesguidance-for-churches-houses-of-worship/ 24. Carney, G. J. (2020, May 19). Governor Carney announces additional interim steps for retail, restaurant businesses to expand operations. Office of the Governor. https://news.delaware.gov/2020/05/19/governor-carney-announcesadditional-interim-steps-for-retail-restaurant-businesses-to-expandoperations/ 25. Carney, G. J. (2020, May 14). Governor Carney reopening of beaches to Delawareans. Office of the Governor. https://news.delaware.gov/2020/05/14/governor-carney-announcesreopening-of-beaches-to-delawareans/ 26. Carney, G. J. (2020, June 2). Governor Carney announces Phase 2 of Delaware’s economic reopening to begin on June 15. Office of the Governor. https://news.delaware.gov/2020/06/02/governor-carney-announcesphase-2-of-delawares-economic-reopening-to-begin-on-june-15/ 27. Delaware Department of Health and Social Services. (2020, March 21). Division of Public Health awarded $67 million grant. News. https://news.delaware.gov/2020/05/21/division-of-public-healthawarded-67-million-grant/ 28. Carney, G. J. (2020, August 4). Governor Carney announces Delaware schools may reopen in hybrid scenario. Office of the Governor. https://news.delaware.gov/2020/08/04/governor-carney-announcesdelaware-schools-may-open-in-hybrid-scenario/ 29. Delaware Department of Education. (n.d.). Guidance, resources in school year 2020 – 2021. COVID-19. https://www.doe.k12.de.us/Page/4242)
30. Delaware Department of Health and Social Services. (2020, September 25). Delaware surpasses 20,000 positive cases of COVID-19; new daily cases remain elevated. News. https://news.delaware.gov/2020/09/25/delaware-surpasses-20000-positivecase-of-covid-19-new-daily-cases-remain-elevated/ 31. Carney, G. J. (2020, November 17). Governor Carney announces additional COVID-19 restrictions. Office of the Governor. https://news.delaware.gov/2020/11/17/governor-carney-announcesadditional-covid-19-restrictions/ 32. Carney, G. J. (2020, December 3). Governor Carney announces stay-at-home advisory, universal indoor mask order. Office of the Governor. https://news.delaware.gov/2020/12/03/governor-carney-announcesstay-at-home-advisory-universal-indoor-mask-order/ 33. Carney, G. J. (2020, December 10). Governor Carney announces additional COVID-19 restrictions to confront winter surge. Office of the Governor. https://news.delaware.gov/2020/12/10/governor-carney-announcesadditional-covid-19-restrictions-to-confront-winter-surge/ 34. Carney, G. J. (2020, December 3). Message from Governor Carney on COVID-19. Office of the Governor. https://news.delaware.gov/2020/12/03/message-from-governorcarney-on-covid-19/ 35. Carney, G. J. (2020, December 15). Governor Carney, DPH, Bayhealth announce first Delawarean has received the COVID-19 vaccine. Office of the Governor. https://news.delaware.gov/2020/12/15/governor-carney-dphbayhealth-announce-first-delawarean-has-received-the-covid-19vaccine/ 36. Carney, G. J. (2020, December 17). Delaware begins COVID-19 vaccinations in long-term care facilities. Office of the Governor. https://news.delaware.gov/2020/12/17/delaware-begins-covid-19vaccinations-in-long-term-care-facilities/ 37. Carney, G. J. (2021, January 19). Governor Carney, DPH announce transition to vaccinate Phase 1B. Office of the Governor. https://news.delaware.gov/2021/01/19/governor-carney-dphannounce-transition-to-vaccinate-phase-1b/) 38. Delaware.gov. (2021, January 20). DPH system for vaccination requests starts with more than 56K signups in first day. Delaware News. https://news.delaware.gov/2021/01/20/dph-system-for-vaccinationrequests-starts-with-more-than-56k-signups-in-first-day/ 39. Delaware.gov. (2021, January 29). Delaware Division of Public Health confirms first COVID-19 cases with the UK variant. Delaware News. https://news.delaware.gov/2021/01/29/delaware-division-of-publichealth-confirms-first-covid-19-cases-with-the-uk-variant/ 40. Delaware Department of Health and Social Services. (2021, March 5). New positive cases begin to level off; DPH confirms first COVID-19 case with South African variant. News. https://news.delaware.gov/2021/03/05/new-positive-cases-beginto-level-off-dph-confirms-first-covid-19-case-with-south-africanvariant/ 47
41. Delaware Department of Health and Social Services. (2021, February 13). Weekly COVID-19 update – Feb. 12, 2021: new positive cases flatten as hospitalizations trend downward. News. https://news.delaware.gov/2021/02/13/weekly-covid-19-updatefeb-12-2021-new-positive-cases-flatten-as-hospitalizations-trenddownward/ 42. Delaware Department of Health and Social Services. (2021, March 26). DHSS updates guidance for visitation at Delaware’s long-term care facilities. News. https://news.delaware.gov/2021/03/26/dhss-updates-guidance-forvisitation-at-delawares-long-term-care-facilities/ 43. Centers for Disease Control and Prevention. (2021, June 11). COVID-19 vaccine breakthrough case investigation and reporting. COVID-19 vaccination. Health Departments. https://www.cdc.gov/vaccines/covid-19/health-departments/pastbreakthrough-data.html 44. Delaware Department of Health and Social Services. (2021, June 1). Weekly COVID-19 update – May 28, 2021: Delaware sees lowest number of cases since August. News. https://dhss.delaware.gov/dhss/pressreleases/2021/ weeklyupdate_060121.html 45. Carney, G. J. (2021, March 16). Governor Carney, DPH announces updates to COVID-19 vaccination program. Office of the Governor. https://news.delaware.gov/2021/03/16/governor-carney-announcesupdates-to-covid-19-vaccination-program-2/
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46. Carney, G. J. (2021, March 30). COVID-19 vaccination program will open to Delawareans 16+ on April 6. Office of the Governor. https://news.delaware.gov/2021/03/30/covid-19-vaccinationprogram-will-open-to-delawareans-16-on-april-6/ 47. Delaware Department of Health and Social Services. (2021, April 9). Weekly COVID-19 update – April 9, 2021: average daily cases decrease; current hospitalizations continue upward trend. News. https://news.delaware.gov/2021/04/09/weekly-covid-19-updateapril-9-2021-average-daily-cases-decrease-current-hospitalizationscontinue-upward-trend/ 48. Centers for Disease Control and Prevention. (n.d.). Variant proportions. COVID Tracker. https://covid.cdc.gov/covid-data-tracker/#variant-proportions 49. Delaware Department of Health and Social Services. (2021, May 14). Weekly COVID-19 update – May 14, 2021: daily cases, hospitalizations continue downward trend. News. https://news.delaware.gov/2021/05/14/weekly-covid-19-update-may14-2021-daily-cases-hospitalizations-continue-downward-trend/ 50. Delaware Department of Health and Social Services. (2021, May 6). Delaware COVID-19 vaccination “waiting list” ends. News. https://news.delaware.gov/2021/05/06/delaware-covid-19vaccination-waiting-list-ends/
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Beyond COVID-19: Technology and Connectivity Help Bridge the Divide in Equitable Care Sharon Anderson, R.N., B.S.N., M.S., F.A.C.H.E. Chief Virtual Health Officer, ChristianaCare
During the COVID-19 pandemic, virtual care delivery increased exponentially. As we continue to advance this model of care, it will be critical to address issues of access to technology with a specific focus on access to the broadband needed to support virtual care delivery. Without addressing these issues, the digital divide will widen and prevent equitable access to quality health care. Virtual care grew rapidly during the COVID-19 pandemic, with a 120% increase documented between March 2020 and May 2021 at ChristianaCare alone. As ChristianaCare is committed to the delivery of equitable, quality health care, focused effort was placed on ensuring access to virtual care for all. A grant from the Federal Communications Commission (FCC) under the COVID-19 CARES Act awarded in April 2020 is helping ChristianaCare increase broadband access to telehealth services for vulnerable and underserved Delawareans. ChristianaCare is utilizing the funds received to connect 7,500 marginalized patients to telehealth with smart phone devices and data plans. It is also supporting the establishment of on-site telehealth services in communities with high disease burden and challenges accessing virtual health services.
ADDRESSING SOCIAL DETERMINANTS OF HEALTH FOR EQUITABLE ACCESS As the COVID-19 pandemic swept through the State of Delaware, ChristianaCare cared for approximately two-thirds of all COVID-19 positive Delawareans who required hospitalization or ambulatory care. Early in the pandemic, Delaware experienced a statewide increase from 56 to 783 COVID-19 cases over the 14day period between March 22 and April 6, 2020.1 During the same 14-day period, ChristianaCare alone experienced an increase from 35 to 490 COVID-positive cases. Of those, 89 patients required hospitalization and intensive therapy. Early data suggested that Delawareans in traditionally underserved medical communities were also disproportionately more likely to contract COVID-19.2 For those individuals aged >18 years who received testing at ChristianaCare during this 14-day period, non-Hispanic Black patients were two times more likely to be COVID-19 positive compared with their White counterparts (16% (213/1353) vs. 7% (206/1901), respectively). The disparity in positivity rate for COVID-19 is thought to have largely been driven by variation in social determinants of health, that is the conditions in the environment where people live, learn, work and play.3 The social determinants of health impact wellness and care. The divide has never been more evident than during the pandemic when a significant portion of in-person ambulatory care transitioned to virtual for longitudinal outpatient monitoring and care to prevent a rise in acute care utilization. 50 Delaware Journal of Public Health - July 2021
PIVOTING QUICKLY TO CARE FOR OUR COMMUNITY In March 2020, to reduce the need for in-person visits for patients with suspected COVID-19, ChristianaCare accelerated the capabilities of an already existing robust digital transformation plan by several years. The plans already in place for virtual care made it possible to quickly pivot and remotely monitor and care for those with COVID-19, and to safely support patients with chronic health care needs. ChristianaCare developed a screening algorithm to identify the population who called for primary care and specialty practice visits who were suspected of having COVID-19 (figure 1). These patients were immediately referred to ChristianaCare’s COVID-19 Virtual Practice for a telemedicine visit and triage (figure 2). Through ChristianaCare’s COVID-19 Virtual Practice,4 patients were evaluated for the need for testing, tested, and subsequently enrolled in a HIPAA-secure texting COVID-19 monitoring system for daily assessment. Powered by ChristianaCare’s CareVio™ care management service, the virtual COVID-19 practice used secure texting to check in with patients daily, create a risk score, elevate people who have a change in their status to a virtual visit, and then intervene to provide them with additional technology, another virtual provider visit or provide additional services in the home or bring them in for in-person care. When possible, caregivers used telehealth to review the cases of hospitalized patients. An internal algorithm calculates the patient’s severity score and triggers care management intervention. The ChristianaCare Center for Virtual Health created a dashboard to monitor the COVID-19 population (figure 3).
MITIGATING RISKS FOR PATIENTS AND CAREGIVERS In November 2018, ChristianaCare launched a primary care virtual practice allowing employees, spouses and dependents to self-schedule telehealth video appointments and connect with their primary care team through secure, electronic messaging. The foresight of establishing this practice allowed the system to quickly pivot and continue to provide care during the pandemic. To mitigate risks of exposure to COVID-19 for both patients and caregivers, in a matter of weeks, ChristianaCare built on the success of its virtual employee practice to shift all primary and ambulatory patient care to video or phone visits. To safely screen and support those who tested positive for COVID-19, who had significant exposure, or who worked in high-risk professions, ChristianaCare was then able to establish two COVID-19-focused ambulatory care centers. doi: 10.32481/djph.2021.07.011
Figure 1. COVID-19 Telehealth Monitoring Workflows
Figure 2. Severity-based Triage Criteria for Monitoring Frequency
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Figure 3. The ChristianaCare Center for Virtual Health Dashboard to Monitor the COVID-19 Population.
Figure 4. Between March 2020 and May 2021, ChristianaCare’s COVID-19 Virtual Practice conducted nearly 200,000 virtual visits with more than 2,000 patients. 52 Delaware Journal of Public Health - July 2021
Figure 5. The four "touches" of virtual care increased more than 120% during FY 2021.
With this shift, telehealth utilization increased. Telehealth visits comprised 7% of ChristianaCare ambulatory care visits between July – September 2020. That number soared to 74% between October and December 2020. Between January and March 2021, nearly half (44%) of ambulatory care visits remained virtual.
we approach the tail end of the pandemic, more than 100,000 Delawareans have tested positive for COVID-19 requiring some level of ambulatory care.
In spring 2020, ChristianaCare also launched an Employer COVID-19 Symptom Monitoring Program to provide daily monitoring of employees for COVID-19 symptoms, testing, if needed, and care for those who test positive. Also powered by CareVio, this program increased safety and eased anxiety in the workplace for more than 10,000 employees from 37 companies in 14 states.
ChristianaCare’s experience in managing more than 1,700 patients in the Center for Virtual Health COVID-19 telehealth monitoring program led us to conclude that we could expand our virtual services to include a broader scope of offerings and an increased volume.
Between March 2020 and May 2021, ChristianaCare’s COVID-19 Virtual Practice conducted nearly more than 183,000 virtual visits in four touch areas with more than 2,000 patients (figures 4 & 5). • Synchronous Virtual Care – Video visits increased by 98% to more than 11,200 from a baseline of fewer than 4,800. • Asynchronous Communication – Bi-directional, secure text messaging increased to more than 121,600 messages, and patient portal messages increased to more than 40,000 per month. • Virtual Consults – Clinician use of the internal referral and Cerner’s eComm increased by 43% to 964 in March 2021 from an average of 504 in FY 2020. • Digital Frictionless Experience – patient portal activity, portal enrollment, eClipboard attachments and direct book appointments increased by 37%, with portal activity and portal enrollment accounting for highest volumes of touches. Predictive modeling reported in April 2020 by ChristianaCare’s Institute for Research on Equity and Community Health (iREACH) in collaboration with the University of Delaware (UD) and the Delaware Emergency Management Agency (DEMA), pointed to an estimated 80,000 individuals who would require ambulatory care before the pandemic’s end. In June of 2021 as
EXPANDING VIRTUAL SERVICES
Yet an estimated 20% of Delaware’s population lacks broadband internet access. In some communities in the cities of Wilmington and Dover, and in some more rural areas in the southwestern part of the state, more than 50% of the population is without broadband internet access. And across the State, limited broadband internet access is correlated with both, socioeconomic vulnerability as well as density of race/ethnic minority populations (Figure 6). The disproportionate number of potentially positive high-risk community members who reside in communities with poor broadband access (Figure 7) made improving our ability to provide virtual care to all ambulatory COVID-19 cases critically important. The majority of ChristianaCare patients are from New Castle County, Delaware, where there is substantial variation in socioeconomic conditions. Of 162,000 Delawareans who live within five New Castle County ZIP codes (19801, 19802, 19804, 19805 and 19720), approximately 20% live in poverty (a number higher than the national average), according to a recent iREACH investigation. About 56% of households in these ZIP codes are “rent burdened,” spending more than 30% of their household income on rent. These significant financial strains further translate to lack of broadband connectivity. Delaware’s Department of Technology and Information has made tremendous progress in the elimination of broadband deserts in Delaware. Through private sector partnerships, Delaware has 53
Figure 6. Delaware demographics, including broadband internet access
been able to greatly increase its fiber optic and cellular tower footprint.5,6 Therefore, most of the lack of access to broadband can be attributed to the high cost of devices and monthly fees for data plans. With funds from the FCC grant, ChristianaCare is providing smartphones to patients enrolled in ChristianaCare’s COVID-19 monitoring program. The devices are configured to allow 911 calls, video visits through ChristianaCare’s telehealth platform, and HIPAA-secure text-messaging with health care providers. They may also be configured with Bluetooth-enabled pulse oximetry monitors and the MEDPOD telediagnostic suite of applications — including sphygmomanometer, scale, thermometer, EKG, spirometer, pulse oximeter and glucometer — for diagnostic intervention and/or in-home consultation.
Figure 7. Confirmed cases of COVID-19 by ZIP code.
On-site community-based access points equipped with devices necessary for telehealth services and/or connectivity services allow us to engage with community partners to get care to the community when, where and how people need or are willing to receive it. Options such as technology kiosks located in Delaware libraries or Community Access Points staffed with a nurse and a patient digital ambassador connect patients to primary care providers, behavioral health specialists or pharmacists. These Community Access Points, such as the one located at the Kingswood Community Center, provide access to virtual care that overcomes barriers including transportation, lack of child care, or limited time off from work.
THE NEW VENUE OF CARE IS HOME, OR WHEREVER THE PATIENT IS People will often reach out for help for urgent care concerns — things like low back pain or sinus infections — but wellness tends to take a back burner for busy or stressed patients, particularly those from vulnerable communities. Virtual care is a promising avenue to help us transition from a culture of seeing a primary care doctor once a year with a long list of questions to a place
54 Delaware Journal of Public Health - July 2021
of convenient access through synchronous and asynchronous communication that longitudinally supports patients in getting the care they need when they need it. We now know that care doesn’t have to happen within the four walls of an exam room. It can happen “virtually” anywhere. And coupling care delivery with research allows us to utilize the data generated from our clinical work in underserved communities, continue to examine demographic and clinical characteristics, and understand how broadband telehealth impacts marginalized populations as we work to bridge the divide in access to care.
WHATEVER CAN, WILL The transition to virtual health goes beyond simply replacing in-person doctor visits with video visits. It calls on providers and health systems to reimagine and recreate the entire experience of care. Recognizing that the future of health care is virtual, and the new venue of care is home, ChristianaCare has committed to ensuring that whatever can be done virtually will be done virtually. In the world of virtual health, care no longer revolves around an appointment with a provider. Rather, it’s proactive, coordinated and continuous. It requires looking at ways to provide the right care at the right time by the right health professional; reduce emergency and urgent care visits, and lower the cost of care to a fraction of the cost of traditional care delivery models. • Through telephone, video, and secure, HIPAAcompliant, bi-directional texting, email or wearable devices, virtual health is also taking care management to the next level. Population health allows providers to study populations of patients and know who among them is at greatest risk, who is vulnerable, and who needs additional support. • Virtual health brings more and more care to the home in ways that are accessible and radically convenient for patients and their loved ones. This new, fully personalized virtual care model engages people with health care experts and allows patients to form stronger connections to their health care team about the things that matter most, without waiting for the next traditional office visit. • Virtual care allows providers to connect with people at the right time, and with the information that encourages them to be more involved in their own wellness journey, and creates a more integrated, continuous feedback loop. • Perhaps most importantly, virtual care continues when people are still well, providing self-service access and proactive reminders to preclude unnecessary hospital admissions and readmissions and achieve optimal health outcomes.
CARE THAT DOESN’T PAUSE BETWEEN VISITS As we look to the future of virtual health, the opportunities are as varied as our patients’ needs. ChristianaCare is moving forward with telehealth rounds for inpatient care and virtual specialty care and disease specific programs.
We have introduced telemonitoring for in-home care of patients with heart failure by ChristianaCare HomeHealth; an Alexa Skill Home Care Coach™ for customized prompts to patient questions; and a free mobile pregnancy app to help moms-to-be monitor their health, track their baby’s growth and prepare for baby’s arrival. We’ve even started to imagine a hospital at home, where acute care patients can stay in their home to receive care resulting in improved outcomes at a lower cost for the patient all at the same level and quality of care as an in-hospital stay. It’s important to note that we are not replacing in-person care options with virtual care. We are providing choices. We’re reaching people who want their care at home, who can’t — or won’t — come in person, or those who would clinically be better cared for in a different setting. And we are conducting research alongside our care delivery to make sure we are evaluating the impact of everything we do, building in a health equity lens to ensure we are closing the health disparity gap. Our model is an interdisciplinary team that delivers longitudinal care in a radically different way that breaks the model of how we have traditionally thought about health care. The old ways of in-person, facility-based care aren’t obsolete. But the new ways show tremendous progress for improving outcomes and both patient and provider experience. What’s so powerful about virtual care is that it doesn’t pause between visits; it’s continuous. By embracing data and technology — and by providing telehealth services to vulnerable patients and neighborhoods that lack broadband connectivity — we are building a telemedicine foundation to address disparities in access to care that extends well beyond COVID-19.
REFERENCES 1. State of Delaware. (n.d.). MyHealthyCommunity; COVID-19 Overview. Retrieved from: https://myhealthycommunity.dhss.delaware.gov/locations/state 2. The Beacon. (2020, Oct 5). DSU awarded $1.5M grant to study COVID-19 in underserved communities. The Beacon. https://www.milfordbeacon.com/story/news/2020/10/05/ dsu-awarded-1-5-m-grant-study-covid-19-underservedcommunities/3631400001/ 3. Orgera, K., Garfield, R., & Rudowitz, R. (2021, Jun 9). Implications of COVID-19 for social determinants of health. The Kaiser Family Foundation. https://www.kff.org/coronavirus-covid-19/issue-brief/ implications-of-covid-19-for-social-determinants-of-health/ 4. ChristianaCare. (n.d.). Virtual care. https://christianacare.org/virtual-primary-care/ 5. Governor John Carney. (2019, May 31). Governor Carney, DTI announce rural broadband expansion partnership. Office of the Governor. https://news.delaware.gov/2019/05/31/governorcarney-dti-announce-rural-broadband-expansion-partnership/ 6. Governor John Carney. (2020, Aug 24). Governor Carney announces $20 million for broadband infrastructure. Office of the Governor. https://news.delaware.gov/2020/08/24/governor-carneyannounces-20-million-for-broadband-infrastructure/ 55
The Impact of Diabetes in Delaware 2021
DELAWARE HEALTH AND SOCIAL SERVICES Medicaid and Medical Assistance Program
56 Delaware Journal of Public Health - July 2021
The Impact of Diabetes in Delaware, 2021
EXECUTIVE SUMMARY Diabetes is a chronic disease that affects how your body processes food and uses it for energy. Left untreated, diabetes can lead to heart disease, stroke, amputation, end-stage kidney disease, blindness, and death. While there is no cure for the disease, diabetes is largely preventable through basic prevention steps like eating healthy diet, getting regular physical activity, and losing a small amount of extra weight. For those diagnosed with diabetes, the disease is treatable. Effective disease management includes healthy lifestyle behaviors and a medication regimen to control blood glucose levels. Like other states, diabetes prevalence is increasing in Delaware. From 2003-2019, Delaware’s diabetes prevalence rose from 8% to 13%. In 2019, 13% of all Delaware adults reported that they had been diagnosed with diabetes, including 14,672 Medicaid clients and 12,369 Group Health Insurance Plan (GHIP) members. This estimate does not include undiagnosed Delawareans living with diabetes, a population that may include nearly 25,000 adults [1]. In 2017, an additional 13% of Delaware adults reported that they had been diagnosed with prediabetes, a condition that means a person is at risk of progressing to diabetes [2]. In 2019, 34% of Delaware adults were obese and an additional 35% were overweight, placing them at greater risk for diabetes. Conservatively, over one-quarter of all Delaware adults have or are at elevated risk for diabetes. THE FINANCIAL IMPACT OF DIABETES IN THE FIRST STATE Prediabetes and diabetes cost Delaware $1.1 billion each year [3]. This figure reflects $818 million in direct medical expenses and $293 million in indirect costs. On average, medical expenditures for a person with diabetes are 2.3 times higher than for a person without diabetes [3]. Prevention, early diagnosis, and effective self-management of diabetes can prevent and reduce the costly outcomes associated with the disease. Medicaid MCOs directly reimbursed providers $40.7 million for diabetes-related care in FY20, a 9% increase in diabetes-related expenditures compared to the previous fiscal year. In FY20, an additional $2.0 million was paid to directly to providers from State of Delaware and/or Federal funds via fee-for-service claims for diabetes-related care among Delaware Medicaid clients. Diabetes is the leading cost driver for episodes of care among members covered by Delaware’s GHIP. In FY20, the total allowed amount for diabetes, including net payments from the GHIP and member costs, reached $75.8 million – a cost 83% greater than the second-leading episode group, osteoarthritis. Costs related to diabetes episodes of care represented 6% of all GHIP net payments made on behalf of active employees and early retirees.
Delaware Department of Health and Social Services, Division of Medicaid & Medical Assistance and Division of Public Health, Diabetes and Heart Disease Prevention and Control Program; and Delaware Department of Human Resources, Delaware Statewide Benefits Office
June 2021
1
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Delaware’s My Healthy Community Data Platform: At The Intersection of Public Health Informatics and Epidemiology Tabatha N. Offutt-Powell, Dr.P.H., M.P.H. State Epidemiologist and Chief, Epidemiology, Health Data and Informatics, Division of Public Health, Delaware Department of Health and Social Services Marcy Parykaza, M.G.A. State Health Information Technology Coordinator, Chief, Information Management Services, Division of Public Health, Delaware Department of Health and Social Services Michael Knapp, Ph.D., M.E.M. Chief Executive Officer, Green River Data Analysis, Inc. Cassandra Codes-Johnson, M.P.A. Associate Deputy Director, Division of Public Health, Delaware Department of Health and Social Services Ian Kozak, B.A. Director, Strategic Development, Green River Data Analysis, Inc. Matthew Muspratt, J.D., M.E.M. Data and Science Writer, Green River Data Analysis, Inc.
ACKNOWLEDGEMENTS The authors acknowledge with gratitude the dedication and commitment of the Green River Data Analysis team members whose expertise in software development transformed conceptual ideas into the My Healthy Community platform. We gratefully acknowledge the contributions of the data stewards, funding agencies, and Delaware Division of Public Health staff whose contributions have led to the development and continued enhancements of My Healthy Community.
INTRODUCTION “Delawareans need to have access to usable, meaningful, timely, and high-quality data about the health of the communities in which they live,”1 so that data-driven evidence-based decisions result in community-focused solutions to affect positive change. This statement is the vision of the My Healthy Community (MHC) data portal,2 which serves as Delaware’s population health platform. The MHC platform shares data on a myriad of population health areas such as social vulnerability, community characteristics, the environment (e.g., public and private drinking water, air quality), chronic diseases, mental health and substance use, healthy lifestyles, maternal and child health, health care utilization, and infectious diseases. MHC continues to expand in both data and functionality to serve as a tool to track the outcomes of implementing data-driven population health interventions and utilizing technology to monitor and evaluate the effectiveness of interventions. Shortly after the coronavirus disease 2019 (COVID-19) pandemic took a foot hold in the United States, in April of 2020, only 11 months after MHC was publicly launched, the site also became Delaware’s coronavirus disease 2019 (COVID-19) dashboard, presenting statistics on COVID-19 cases, hospitalization, emergency department visits, testing, deaths, vaccination, contact tracing, and in-person contagious school cases. MHC’s origins lie in the intersection between public health informatics and epidemiology. Visionaries within Delaware’s public health agency paved the way to create MHC with the 58 Delaware Journal of Public Health - July 2021
support of DPH leadership and the perseverance and dedication of a small team of public health professionals. With their own unique lenses, one of public informatics and the other of epidemiology, the team’s efforts materialized into a tool that continues to evolve and respond to Delaware’s changing needs.
A PUBLIC HEALTH INFORMATICS FOUNDATION Public health informatics has long been recognized as a critical need in state and local health agencies; however, recent research estimates that informatics positions account for only 1% of state health agency workforces.3 Although historically the distinction between the role of informatics and information technologists has not been well understood, national efforts to clearly define the roles and skills of informatics professionals have provided a clearer picture of how these two branches of information science are distinct yet complementary.3,4 Informatics is categorized as a core science of public health where informaticians serve as the knowledge architects of public health information systems.4 Informaticians use their knowledge of data security, standards, and policy to translate public health program system needs into functional requirements for public health information and surveillance systems.3 As a team member, informaticians work in tandem with information technologists and public health programs.4 While information technologists design and implement database architecture such as network connections, database management, programming, security, and system performance, public health informaticians identify opportunities for data integration, ensure that data standards and security of protected health and personally identifiable information are met, and assess reporting, analysis, and visualization needs of public health programs.4 For example, when public health program staff need an application to onboard and process new laboratory test results or create new automated procedures for improving data consumption and integration in their existing infectious disease surveillance system, public health informaticians translate the public health program needs to the information technologists and assist throughout the duration of the project to its completion. doi: 10.32481/djph.2021.07.012
THE EPIDEMIOLOGIC LENS Epidemiology is the study of the distribution, determinants, and patterns of disease occurrence and health states in a population.4 The epidemiologic lens is one that is founded in science, exploring and understanding the interrelatedness of the components and factors that comprise the environment and world in the expanse of human behaviors, social constructs, and the impact of these aspects on health. Epidemiologists apply scientific methodologies to identify risk and protective factors, measure health related states, describe health conditions and their distribution, assess causality, and determine the effect of interventions on outcomes.5 Through the conduct of research, understanding of study designs and associated biases (selection, information) and confounding, and application of statistical methods, epidemiologists are intimately involved in describing the health continuum. Epidemiologists use these theoretical and applied underpinnings of the field in the analysis of data, presentation, interpretation, and dissemination of findings from both descriptive and analytic studies. Although most often thought of as focusing on infectious diseases, epidemiology spans a wide array of areas affecting health including but not limited to cancer and chronic diseases, social epidemiology, nutrition and physical activity, aging, injury, clinical, pharmacoepidemiology, and genetics.6 It’s through this approach across the breadth of health areas that the epidemiologic lens plays a critical role; setting the framework for transforming data into information that describes, generates hypotheses, and stimulates discussions to take a deeper look into the underlying contributing factors of health and health disparities.
THE INTERSECTION OF INFORMATICS AND EPIDEMIOLOGY The Delaware Department of Health and Social Services, Division of Public Health (DPH) recognized the significant need and benefits of public health informatics and envisioned improvements in coordination and efficiency through a centralized team of professionals dedicated to developing a robust, scalable information systems infrastructure. In 2006, DPH created the Bureau of Public Health Informatics and began efforts to ensure that the foundation of a public health informatics infrastructure were implemented. DPH also recognized the continued need for a cross-cutting epidemiologic presence to strengthen epidemiologic expertise and provide support with limited epidemiologic capacity. Subsequently, in 2014, DPH established the Epidemiology, Health Data, and Informatics Section (EHDIS) by marrying the Bureau of Public Health Informatics (BPHI), the Bureau of Health and Vital Statistics comprised of the Office of Vital Statistics and Health Statistics Center, and the Office of the State Epidemiologist. The Epidemiology Research Unit became the next epidemiology unit within EHDIS formed to provide epidemiologic expertise in injury surveillance, specifically substance use disorder and violent deaths (suicides and homicides). In response to the COVID-19 pandemic, the COVID Epidemiology Team also joined the section in 2020. From the creation of section with leadership in epidemiology, informatics, and health statistics, flourished the opportunity for epidemiology (including health statistics) and informatics together to achieve the section’s vision that “Decisions about public health interventions, programs, and policies are informed by and developed using timely data that have been translated into usable, meaningful information.” In other words, the intersection of public health informatics and epidemiology expertise work together to showcase the MCH data in innovative ways.
Using the epidemiologic lens, the conceptual design of the site originated from a review of public data dashboards, discussions regarding data needs shared by community partners, and the application of an informatics lens to translate the vision into a proposal and terminology that could be used by Green River Data Analysis, the vendor selected to transform the vision into the MHC platform. Funding from the Delaware Department of Natural Resources and Environmental Control (DNREC) served as the seed funding to jump start development of MHC and initial focus on the its roots in environmental public health tracking data from CDC’s National Environmental Public Health Tracking framework.. Funding from various other sources followed. Public health informatics and epidemiology began to work closely with Green River. It was evident from the outset that Green River shared DPH’s vision, values, and mission to utilize data to benefit communities. From the design of the site to the presentation of the data and metrics, this intersection of not only informatics and epidemiology, but with software engineers and designers from Green River, is and continues as, the driving force behind the development and enhancement of the MHC platform informed by the needs of the community.
MY HEALTHY COMMUNITY (MHC) PLATFORM In 2018, DPH partnered with Green River Data Analysis to transform DPH’s vision for usable, meaningful, timely, and highquality data about the health of the Delaware communities into a data platform focused on population health metrics. The result was Delaware’s MHC data portal,2 a database and platform which lives online at myhealthcommunity.dhss.delaware.gov, and has readily and publicly shared indicators of health outcomes since its launch on May 13, 2019. Achieving Health Equity is one of DPH’s strategic goals. MCH was designed as a tool that can be utilized by a wide variety of audiences to access dis-aggregated data. This allows for access to information that supports the development of data driven, health equity centered interventions, policies, and programs. MHC serves as Delaware’s population health dashboard as depicted in Figure 1 and since almost the beginning of COVID-19, has served as the state’s pandemic-data dashboard and reporting platform as depicted in Figure 2. MHC implements an innovative methodology to facilitate the presentation of Delaware’s health, demographic, and social determinant data, enabling communities, community organizations, and residents to explore health data at scales ranging from the state level down to the neighborhood or block group level. Users can type their address in the search menu and a selection of geographies including census block groups, neighborhoods, census tracts, State House Districts, State Senate Districts, zip codes, cities, counties, and the state level are available to explore. Drawing from a universe of data sources, the platform spans social determinants of health data, rigorously maintains confidentiality. It contains at least 10 broad areas of population health with 55 subcategories including data sources such as Delaware’s vital records (births and deaths), surveys such as the Behavioral Risk Factor Survey and Youth Risk Behavior Survey, hospitalization and emergency department visit data, prescription drug monitoring data, U.S. Census, and CDC’s social vulnerability index, to name a few. 59
Figure 1. Screen Capture of the My Healthy Community’s Population Health Dashboard. https://myhealthycommunity.dhss.delaware.gov/locations/state/community-characteristics.
Figure 2. Screen Capture of the My Healthy Community’s Coronavirus 2019 Vaccine Tracker. https://myhealthycommunity.dhss.delaware.gov/locations/state/vaccine-tracker 60 Delaware Journal of Public Health - July 2021
The MHC experience – its functionalities, innovations, limitations, and potential – provides a better understanding of the role that public health informatics plays in population health. To successfully respond to COVID-19, policymakers, and the public require the most comprehensive data possible: information that is timely, readily available, easily communicated, and relevant at all geographic levels. In Delaware, rapid community-level reporting and coordination among DPH commercial laboratories, hospitals, and other critical information sources help residents and elected officials adopt appropriate mitigation strategies and ensure the state’s residents are protected. The MHC data platform both pulls and pushes data daily and are presented in charts, tables, and interactive maps. MHC successfully presents COVID-19 data from diverse sources, communicating developments to the public, reporting internally, and provide data that can be used to strategize state and community level response and mitigation efforts.
DATA INTEGRATION An integral component of effective public health informatics is data integration. Data integration can sometimes be viewed with different frameworks, (1) one in which disparate datasets are joined into one dataset using linking or matching variables (e.g, name, date of birth, unique identifier, etc.) or (2) one in which disparate datasets are combined through visualizations and analytics to display a unified view. MHC has successfully achieved the second framework of presenting data from disparate datasets into a unified form on the platform. Additionally, MHC has taken steps toward achieving the first framework of data integration in which disparate datasets are joined to provide a deeper understanding of health across the continuum. Intra- and interagency siloes of information hinder the ability to monitor, report, and mitigate disease. By understanding health and illness in the context of both population demographics and social determinants of health, adequate efforts can be made to identify and protect those most vulnerable to poor health outcomes. Such analyses rely on expansive, combined data sets encompassing the demographic and social determinants of health information, health outcomes, and more. Those data are stored by – and must be integrated from – disparate sources with different timeframes, different resolutions (individual-level records, county-level data, etc.), and different formats (Application Programming Interface (API) calls to other systems, spreadsheet uploads, online collection forms, etc.). A combined data store facilitates the generation of hypotheses about potential associations that would be otherwise difficult, and across all kinds of health topics. For example, with air quality and hospitalization data in a combined data store, the results can be charted over time and across a geography to depict similarities in trends between ozone levels and asthma. Given that the infrastructure and architecture for managing HIPAA protected data was already a part of the MHC platform, DPH was more readily able to transition COVID-19 data reporting to the MHC platform’s existing menu of health topics. Through a mixture of automated and manual upload processes, it consumes a host of data flows, including: vaccination doses delivered to Delaware, pulled from the federal government’s Tiberius system; doses administered, pulled from DelVAX (Delaware’s immunization registry); positive cases and possible contacts, pulled from the
Delaware Contact Tracing System; and other negative and positive test results compiled from other sources. MHC also gathers daily and weekly data feeds on current hospitalizations, new hospital admissions, school in-person contagious data, and school census data. All of these data are processed and presented for government reporting and public consumption at varying levels of spatial and temporal resolution as illustrated in Figure 3. Note: MHC contains data on numerous other health topics, and this figure illustrates only the COVID-19 related data feeds. SFTP= Secure File Transfer; Source of the SFTP data is a data file that is generated from DERSS and uploaded to the secure MHC site. DelVAX- Delaware’s statewide immunization registry; DCTS= Delaware Contact Tracing System; DERSS= Delaware Electronic Reporting and Surveillance System; DOE= Department of Education; DHIN= Delaware Health Information Network; SDOH= social determinants of health.
UNDERSTANDING HEALTH IN TERMS OF SOCIAL AND DEMOGRAPHIC CONTEXT The application and utility of public health informatics and epidemiology is perhaps most evident when considering health in terms of social and demographic contexts and spatial and temporal trends. Both present considerable challenges. Structuring an effective social determinants of health construct is challenging because information must be organized both by health topic and geographic entity. Hierarchical classification, which works well for many types of information categorized on the web, is antithetical to an integrated public health approach striving to emphasize and promote understanding of the connections between environmental conditions, social determinants, demographics, and diseases – not each in isolation. Figure 3 illustrates MHC’s solution to this data-navigation issue through a search by community and topics. A related challenge for MHC and any platform intended for a broad audience concerns breadth of functionality and ease-ofuse. Whereas a researcher might benefit from data download capabilities and appreciate the presentation of statistical model findings, community organizations and citizens might focus more on findings that touch their neighborhood, and which aspects are notably better or worse than in other similar neighborhoods. This finding is consistent with MHC user research. Yet another concern is that an inadvertent emphasis on a few variables or datasets can lead to difficulty communicating the difference between causation and correlation. For example, visual presentation of a correlation between two variables is highly likely to be misunderstood by the public as causation. These are important considerations for presenting data on MHC and supports the key role of epidemiology and informatics involvement when partnering with information technologists.
UNDERSTANDING HEALTH IN TERMS OF SPATIAL AND TEMPORAL TRENDS MHC uses extensive geographic information systems and methods to portray disease cases through charts and tables. Users can evaluate temporal changes within a geography of interest, zooming in and out on a map. The use of animated maps of disease rates reveal trends, patterns, geographic clusters of disease, or random occurrences over space or time as displayed in Figure 4. 61
Figure 3. Data Flow for the My Healthy Community’s Coronavirus Dashboard Showing the Data Sources Required for Public and Internal Display
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MHC’s maps incorporate statistical techniques and algorithms to smooth rates over less populated areas. Furthermore, MHC’s animated maps of disease patterns define population groups independent of geopolitical boundaries, side-stepping the traditional but misleading use of county, town, and zip code boundaries on choropleth maps. Those are misleading because of the Modifiable Areal Unit Problem (MAUP), a bias whereby the geographic unit used to aggregate a measure actually determines the pattern seen.7 Likewise, the presentation of time must respect privacy and avoid granular details, as trendlines show whether a particular indicator is improving, getting worse, or changing randomly. As with geography, too much granularity risks revealing “who” and “when.”
PROTECTING PRIVACY Implementing technology and legal processes to ensure privacy and compliance with the Health Insurance Portability and Accountability Act (HIPAA) are fundamental to the success of any public health informatics system. The MHC software is likely one of a few in the nation capable of presenting pandemic information and other health indicators at spatial resolutions as low as the census block group level, a small geography comprising as few as 600 people. The HIPAA-protection algorithm designed to detect and suppress data in these situations is one of MHC’s most important innovations.
To ensure confidentiality, and consistent with HIPAA privacy rule 45 CFR § 164.514(b), the MHC team arranged outside expert review to determine that there is minimal risk that information on the platform could be used alone or in combination with other reasonably available information to identify any individual.8 As an example measure, MHC guards against displaying frequencies with fewer than 11 individuals.8 When counts fail to meet this threshold, the system aggregates data in three ways: automated aggregation over a longer period of time; automated aggregation over a larger geographic unit; and in some cases, aggregation of the attribute itself (e.g., displaying an overall cancer category instead of reporting on separate cancer types). A related challenge is the incompatibility of different types of geographic level data. A smaller unit, like a neighborhood, may intersect more than one larger unit, like a census block group, causing difficultto-analyze disclosure risks. Use of animated maps showcase MHC’s anonymization processes while accurately depicting the movement of disease over time across the landscape.
MHC EXPANSION Delaware’s MHC platform is a resilient, stable foundation for transparent and timely public information and public reporting across all neighborhoods. This complete data publication and dissemination system helps support state agencies, the business and education sectors, and communities make informed datadriven decisions.
Figure 4. Screen Capture of Animated Map of COVID-19 Case Rates Over Time (2020-2021) 63
The next phase of MHC expands the provision baseline data for population-based and community-level interventions into opportunities to collect community specific intervention level data that measure the effectiveness of interventions, presents relevant data for monitoring the outcomes and impact of the interventions over time, and shares the stories of the data-driven solutions being used to affect positive change. Data on the MHC platform can be used to assist in the delivery of coordinated, neighborhood-specific, highly targeted mitigation strategies (figure 5). As attention eventually returns to managing other public health issues in Delaware, the data systems, analytic and information visualization tools, and mitigation support developed during the pandemic can be leveraged for use in health areas, including mental health, obesity, suicide, the impact of climate change on the health of vulnerable populations, and substance use disorder. Looking at the continued evolution of MHC to incorporate the COVID-19 dashboard, this serves as a powerful example of the significant role public health informatics can play in periods of crisis. In just over one year, the MHC platform has proven to be a dependable source through which DPH shares time-sensitive, actionable COVID-19 data. This is due in great part to the application of informatics working together with epidemiologists, communications, and technology driven functionalities developed and integrated into MHC prior to the pandemic. These functionalities include: geographic scalability of reports; presentation of social determinants of health to help encourage strategies toward healthy outcomes; geographically specific and timely visualizations to communicate effectively with community organizations (while maintaining individual privacy); and intuitive controls and user research to inform interfaces for health care providers, public health professionals, and community organizations. Later in 2021, DPH plans to apply the platform’s advances to other population health topics of importance to
Delawareans and which support public health interventions. A redesign of the demographic and social determinants of health section is under development that applies software design patterns built during the pandemic as illustrated in Figure 6. Since charts and animated maps have limitations, platform users must navigate a tremendous amount of information to discover and act upon findings. By supplementing the MHC site with narrative story, the presented data will be more useful for making data-driven decisions and providing a feeling of ownership over public data. Narratives as straight text or multimedia make data and findings more meaningful by contextualizing data points and analyses. DPH developed an initial data story around the impact of opioid use disorder in Delaware9 and community profiles so users understand why local events occur and how they compare to other neighborhoods. DPH views MCH as a useful tool for partnership with communities in expansion of health equity centered approaches through incorporation of additional indicators tied to social determinants factors that can influence improved health and wellbeing outcomes. MHC’s success is due to the application of public health informatics informed by epidemiology and working closely with subject matter experts. DPH’s experience with the platform throughout the COVID-19 pandemic demonstrated the vital role of informatics and epidemiology in public health and the new fields that are necessary to make effective use of emerging technology. DPH is committed to an integrated data system with effective public reporting and mitigation support as this viable tool continues to expand and grow in its utility and functionality. Correspondence: Tabatha Offutt-Powell, Dr.P.H., M.P.H. is the State Epidemiologist and Section Chief of the Epidemiology, Health Data and Informatics Section of the Division of Public Health, Delaware Department of Health and Social Services. tabatha.offutt-powell@delaware.gov
Figure 5. User interface facilitating navigation by both geographies and topics supported
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REFERENCES 1. Offutt-Powell, T. N., Parykaza, M., Caputo, C., & Perkins, R. (2017, October). Health data for Delaware: The path towards creating Delaware’s Environmental Public Health Tracking Network. Delaware Journal of Public Health, 3(5), 32–41. https://doi.org/10.32481/djph.2017.10.007
5. Gordis, L. (2009). Epidemiology. Philadelphia: Elsevier/Saunders.
2. Delaware Department of Health and Social Services. Division of Public Health. (n.d.). My Healthy Community. https://myhealthycommunity.dhss.delaware.gov/
7. Buzzelli, M. (2020). Modifiable areal unit problem. International Encyclopedia of Human Geography, 169–173. https://doi.org/10.1016/B978-0-08-102295-5.10406-8
3. McFarlane, T. D., Dixon, B. E., Grannis, S. J., & Gibson, P. J. (2019, March/April). Public health informatics in local and state health agencies: An update from the public health workforce interests and needs survey. J Public Health Manag Pract, 25(Suppl 2, Public Health Workforce Interests and Needs Survey 2017), S67–S77. PubMed https://doi.org/10.1097/PHH.0000000000000918
8. Office of Management and Budget, Federal Committee on Statistical Methodology. (2005). Statistical policy working paper 22 (Second version, 2005): Report on statistical disclosure limitation methodology. https://www.hhs.gov/sites/default/files/spwp22.pdf
4. Public Health Informatics Institute. (2020). Reframing public health informatics: a communications toolkit. https://phii.org/informatics-communication-toolkit/introduction
6. Gulis, G., & Fujino, Y. (2015). Epidemiology, population health, and health impact assessment. Journal of Epidemiology, 25(3), 179–180. https://doi.org/10.2188/jea.JE20140212 PubMed
9. Delaware Department of Health and Social Services. (2019). Delaware’s opioid crisis. My Healthy Community. https://myhealthycommunity.dhss.delaware.gov/stories/opioid-crisis
Figure 6. Proposed New Layout of Community Characteristics Section within My Healthy Community Site
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The 91st Annual Meeting & Awards Ceremony 2021
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Inaugural Address S. John Swanson, M.D. President (2021-2023), Delaware Academy of Medicine/Delaware Public Health Association
I am honored and humbled to be president of the Delaware Academy of Medicine/Delaware Public Health Association for the next two years, and extend my thanks to the board, membership, and staff, as well as the immediate past president, Omar A. Khan, M.D., M.H.S. Local readers of this publication may know me as the chief of the Kidney Transplant Program at ChristianaCare. Many colleagues and friends also know me as “Andrew’s dad.” Andrew is our 32-year-old son with severe autism who works in the pharmacy, in a job that uniquely fits the skills of a person with autism and not in a job fitted to a person with autism. His preparation for employment began 30 years ago in Maryland and continued until age 21 here in the Delaware school system as he prepared for adult life. Like many other adults with Intellectual and Developmental Disability (IDD), beyond age 21 Andrew’s future is less certain. Many adults with IDD live with, and are supported by, obviously older parents. We remain Andy’s guardians and make important decisions on his behalf. A question my spouse and I ask everyday - What happens when we are gone? This is a question shared by so many others in Delaware, and beyond. I hope we can all agree that the social determinants of health (such as satisfying employment, secure housing, personal safety, financial security, and a robust social life) make for a full and rich life. Add accessible and appropriate health care, and the picture is complete. As difficult as any of these issues are for us “normo-typical” people, they often seem insurmountable for the person with IDD and for their caregivers. Influenced by my personal experience, and by the experiences of the hundreds of persons with IDD and their families that we have met in Andrew’s journey, I see a looming public health crisis. This has prompted me to propose a platform over the two years of my presidency to explore the public health issues of persons with IDD, and provide a venue for discussion, debate, and possibly, just possibly, some solutions to improve the lives of these wonderful people and their families. I ask you to join me. Thank you.
Dr. Swanson was the surgical director for the Kidney Transplant Program at ChristianaCare and Chief of Transplantation Surgery until his retirement in June 2021. He is a board-certified urologist who completed a residency in 1989 and kidney/pancreas fellowship training in 1991. From that time until his retirement in 2005, he had been the UNOS certified surgical director of the Walter Reed Army Medical Center Kidney/Pancreas Transplant Program. In 1994, he also became chief of the Organ Transplant Service, which he held until his retirement.
Outgoing President Dr. Omar Khan passes the gavel to incoming President Dr. John Swanson
doi: 10.32481/djph.2021.07.013
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A Glance at the Rearview Mirror The Delaware Academy of Medicine/Delaware Public Health Association capped off a most unusual year in customary fashion – it was the same, yet incredibly different.
To look in the rearview mirror a moment: the Academy/DPHA, along with you, rose to the challenge of COVID-19 in perhaps the best way possible. Drawing on our team and collective reserves to never retreat from the threat posed by the virus, but in fact to be better. To be more innovative, more scientific, more empathetic. To insist on compassion and evidence, together. This paid off, with many Delawareans rapidly becoming vaccinated with at least one shot (a cohort which is now over 60%). We have done lots of work since the early days of the pandemic – and we have more to do yet. Our Annual Meeting is more than just a dinner, awards and celebrations. It is equal parts education and collegiality. We have a tradition of bringing a world-class speaker to Delaware; and much as our other scientific conferences in Delaware do, we provide our speakers an engaged, interested audience and the best of the Delaware way of hospitality. And was this year’s keynote speaker ever one to engage his audience! Dr. Geoffrey Tabin, a friend, an ophthalmologist, an adventurer. In his introduction, I spoke of first meeting Geoff at the University of Vermont, of learning about his work with the Himalayan Cataract Project, and of marveling that this amazing individual – a medical celebrity, a curer of blindness – had still resisted the cult of celebrity. Geoff ’s presentation was a tour de force of culture, history, cataract-related blindness, resilience, partnership with his mentor and friend Dr. Sanduk Ruit, and of personal journeys. His book, Blind Corners, touches on many parts of this; Oliver Relin’s book about this work, titled Second Suns, updates and adds to it. No few words could adequately sum up Dr. Tabin’s and Dr. Ruit’s work and impact. For that, I ask you to view his TED talks, read the books above, and check out www.cureblindness.org. The Academy/DPHA Board and staff agreed that, for this unique 2021 meeting, we would follow the best evidence in favor of the safest experience for our attendees. By necessity, this meant double the work for our staff: planning months ahead for an online AND an onsite event. My everlasting gratitude to this amazing team of professionals (Liz Lenz, Kate Smith, and Tim Gibbs primary among them). We were fortunate to partner with a venue that had strict and rigorous meeting rules, in accordance with CDC guidance. We also followed closely all State of Delaware regulations on restrictions, and waited with cautious optimism in hope that the COVID situation in June 2021 would be better, and we would greet each other with ‘mask-optional’ rather than ‘mask-mandatory.’ We also instituted an evidence-based measure which the rest of the U.S. and the media have talked about, but few have implemented: the vaccine passport. Admittedly, we had a great group to work with; in the world of direct healthcare, virtually everyone who is eligible has been vaccinated. We also aim to include all our colleagues, thus we provided an online option 68 Delaware Journal of Public Health - July 2021
for attendees and committed to delivering the same quality of education in that format. Several of you remarked that our system of conference registration/vaccine attestation, paired with on-site high safety and limits on numbers, with our robust online option, blazed the trail for future medical conferences. Our guests included the Governor and First Lady of Delaware, and the Lieutenant Governor; healthcare leadership from Delaware, community physicians, Delaware Institute for Medical Education and Research (DIMER) and Delaware Branch Campus students, and health sciences professionals from across the Delaware Valley. It was, literally, a breath of fresh air to interact safely and try out the new normal. To realize that some of our new ways – a bit more physical distancing, enhanced hand hygiene, masking when appropriate – would probably help us indefinitely, whether from novel coronavirus outbreaks or seasonal influenza. Along with the passing of the torch (or, oversized gavel in our case), each meeting sees a different kind of generational advance: that of our teachers and learners. This is why the Academy/ DPHA, in partnership with the Delaware Health Sciences Alliance (www.dhsa.org), emphasizes student engagement. By providing registration for them to our events, we want to model the community of practice that is Delaware healthcare. We remain pleased and proud of these relationships (including with DIMER, the State’s medical education program). We are thrilled to send Delaware students to Thomas Jefferson University and the Philadelphia College of Osteopathic Medicine for their basic medical training, and to welcome them back to Delaware for their clinical work – as students, residents, and practicing physicians. As you peruse the photos and the smiling faces of your friends and colleagues, I ask you to reflect and remember: our country paid too heavy a price these last couple of years. We have thankfully begun to emerge into the light, and for that we have many to thank: all those who were at this unique conference, in one format or another. For that, and a lot more that has happened and yet to come, we say Thank You, and as always, Drive On! Omar Khan M.D., M.H.S. Immediate Past-President Chair, Advisory Council, DPHA Editor in Chief, Delaware Journal of Public Health
L-R: The faces and phases of Delaware medical education. Kelsey Mellow, MS-3 (PCOM); Dr. Omar Khan; Sherman Townsend, Board Chair of DIMER.
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Lieutenant Governor Bethany Hall-Long and Governor John Carney
91stAnnual Meeting & Awards Ceremony
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Executive Director Timothy Gibbs, MPH (L) and Outgoing President Dr. Omar Khan (R) with President’s Awardees Governor John Carney and First Lady Tracey Quillen Carney
Outgoing President Dr. Omar Khan introduces Lieutenant Governor Bethany Hall-Long
Incoming President Dr. S. John Swanson, and DIMER Chair Mr. Sherman Townsend
Division of Public Health Director Dr. Karyl Rattay accepts the Public Health Recognition Award on behalf of the Delaware Rural Health Initiative 69
The Academy Welcomes its New Board Members Daniel J. Meara, M.D., D.M.D. Immediate Past President (2018-2021), Delaware Academy of Medicine/Delaware Public Health Association S. John Swanson, M.D. President (2021-2023), Delaware Academy of Medicine/Delaware Public Health Association
Every two years (in this case, three years due to the pandemic), new members are added to the Board of Directors, as other officers and Directors cycle off. This year, it was the duty of the immediate past president, Daniel J. Meara, M.D., D.M.D., to oversee this process as Chair of Nominations. The process, as described in the Academy/DPHA by-laws, is that the immediate past president convenes a nominating committee of including two members of the Academy/DPHA who are members of the Board, and two members of the Academy/DPHA who are not members of the board.
Immediate Past President Daniel Meara discusses the process for adding new Board Members, while Secretary Lynn Jones looks on
This year, the nominations committee included the following individuals: •
Sarina Pasricha, M.D.
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Anand Panwalker, M.D.
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Lynn Jones, FACHE
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Professor Rita Landgraf
Secretary Lynn Jones presides over the voting in of new Board Members
Through a series of brainstorming activities and discussions, a list of over twenty potential board members was developed, and from that list, six individuals were approached to become board members. That list of recommendations was submitted to and approved by the Academy/DPHA Board of Directors at our May 2021 meeting, and approved by the membership at the June 2021 Annual Meeting. Those new board members include: Jeff Cole, D.D.S. – General dentistry practice. Immediate Past President of the American Dental Association. Program Director, General Practice Dentistry Residency, Department of Oral and Maxillofacial Surgery and Hospital Dentistry, ChristianaCare
Joe Kelly, D.D.S. – General Dentistry Practice. immediate Past President of the Delaware State Dental Society. Private Practitioner.
Lee Dresser, M.D. – Adult Neurologist and a specialist in Sleep Medicine. Affiliated with St. Francis Hospital, Chair of the Delaware Stroke Initiative.
Ann Painter, M.S.N., R.N. – Senior Vice President, ChristianaCare Home Health and Community Services.
Erin Kavanaugh, M.D. – Family Physician, Past President of the Delaware Academy of Family Physicians. Clinical Assistant Professor of Family and Community Medicine, Sidney Kimmel Medical College. Program Director, Family Medicine Residency Program, Co-Program Director, Emergency Medicine/Family Medicine Residency Program, ChristianaCare. 70 Delaware Journal of Public Health - July 2021
Charmaine Wright, M.D., M.S.H.P. – Medical Director of the Center for Special Health Care Needs at ChristianaCare, Medical Director of the Mary Campbell Center, and is on the Easterseals of Delaware and Maryland’s Eastern Shore Board of Directors
doi: 10.32481/djph.2021.07.015
91stAnnual Meeting & Awards Ceremony
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Why Go to a Hospital That Drives Innovation Forward?
FOR THE LOVE OF HEALTH ®
Health care is always changing. It’s important to find a health partner highly-skilled in the most innovative techniques and technology for your care. Every healthy decision we make guides our well-being and shapes our future. Why do we do it? The answer is simple — FOR THE LOVE OF HEALTH.
Learn more at ChristianaCare.org
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a health partner echnology for r well-being and
OVE OF HEALTH.
Recognizing the accomplishments and contributions of Governor John C. Carney, Jr and First Lady Tracey Quillen Carney and The Delaware Rural Health Initiative
Public Health Management Corporation, proud home to
the Pennsylvania Public Health Association and the Delaware Public Health Institute, and member of the Mid-Atlantic Partnership.
Public Health Management Corporation: Public Health Management Corporation (PHMC) is a nonprofit public health institute that creates and sustains healthier communities. PHMC uses best practices and evidence-based guidelines to improve community health through direct service, partnership, innovation, policy, research, technical assistance and a prepared workforce. PHMC has served the region since 1972. For more information on PHMC, visit www.phmc.org. Pennsylvania Public Health Association (PPHA), a subsidiary of PHMC and a state affiliate of the American Public Health Association, is an all membership organization working to promote the health of Pennsylvania residents. PPHA does this through the advancement of sound public health polices and practice. Delaware Public Health Institute: DPHI is a nonprofit organization dedicated to advancing public health practice and improving population health in Delaware by providing outreach, health promotion, education, research, planning, technical assistance, and direct services. DPHI is a collaboration between two regional leaders in public health and human services: University of Delaware’s College of Health Sciences (CHS) and Public Health Management Corporation (PHMC) and operates through its designation from the National Network of Public Health Institutes.
Centre Square East, 1500 Market Street, Philadelphia, PA 19102 P 215.985.2500 PHMC.ORG @PHMCtweets @publichealthmanagementcorp @publichealthmanagementcorporation
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Our Mission Statement “Our mission is to enhance the well-being of the community through education and the promotion of public health.” The 1930 Founding Resolution “Medicine, more than any other profession, undergoes constant change. The rapid progress of science necessitates continuous revision of the management of all phases of disease. Weekly and monthly periodicals record these advances but no single physician, particularly the younger practitioner, can subscribe to this ever increasing volume of literature. It is, then, only with greatest difficulty that practising physicians and dentists in this community in which there is no medical library, are able to keep abreast of the times and maintain that high professional standard so essential to the public good. Convinced, therefore, that there should be accessible to the medical and dental professions of Delaware, appropriate facilities for scientific reading and research, as well as for scientific and social entertainment, certain physicians having met together and constituted themselves a committee, have founded the Delaware Academy of Medicine, duly incorporated under the laws of the State of Delaware as a non-profit making corporation.” February 19, 1930
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Delaware Academy of Medicine BOARD OF DIRECTORS 2018-2021 Officers Omar A. Khan, M.D., M.H.S. President S. John Swanson, M.D. President-Elect Lynn C. Jones, FACHE Secretary David M. Bercaw, M.D. Treasurer Daniel J. Meara, M.D., D.M.D. Immediate Past President Timothy E. Gibbs, M.P.H. Executive Director, Ex-officio Directors Stephen C. Eppes, M.D. Eric T. Johnson, M.D. Joseph F. Kestner, Jr., M.D. Professor Rita Landgraf Brian W. Little, M.D., Ph.D. Arun V. Malhotra, M.D. John P. Piper, M.D.
Emeritus Members Robert B. Flinn, M.D. Barry S. Kayne, D.D.S.
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DHSA is a proud partner and supporter of the Delaware Academy of Medicine Delaware Public Health Association
We Work For Health salutes this year’s honorees: Governor John C. Carney, Jr. and First Lady Tracey Quillen Carney and the Delaware Rural Health Initiative We are proud to partner with the Academy/DPHA throughout the year.
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Participate in the NEW Delaware Healthy Heart Ambassador Blood Pressure Self-Monitoring Program Help your patients improve their hypertension with a new CDC evidence-based program, a Delaware Division of Public Health and Quality Insights initiative, that helps people with hypertension learn how to monitor and take control of their high blood pressure using simple yet effective techniques.
As a participating practice, your patients will receive: • •
• •
A BP monitor (if needed) and training on how to measure and track BP at home Virtual one-on-one support from specially Program Referrals: trained facilitators & virtual learning You can refer patients sessions to this program via a direct Cooking demos & nutrition referral by calling 302-208-9097, education patient portal/text messaging, or a referral letter. For more details, Support to help your patients please email Robina Montague at make real changes for rmontague@qualityinsights.org. heart health
. This publication was supported by the Cooperative Agreement Number NU58DP006516 from the Centers for Disease Control and Prevention. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention. Publication number DEDPH-HD-052821A
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Evening Program 6:00 P.M. Cocktails and Hors D’Oeuvres 6:45 P.M. Welcome from Delaware Lt. Governor Bethany Hall-Long 7:00 P.M. Dinner 7:30 P.M. Welcome and Open of Business Meeting Timothy E. Gibbs, M.P.H. Omar A. Khan, M.D., M.H.S. S. John Swanson, M.D. Lynn C. Jones, FACHE Presentations Lewis B. Flinn President’s Award Governor John C. Carney, Jr. and First Lady Tracey Quillen Carney Public Health Recognition Award Delaware Rural Health Initiative 8:15 P.M. Keynote Presentation Geoff C. Tabin, MD
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About the Lewis B. Flinn President’s Award... This award is made in the name of Lewis B. Flinn, M.D., a founder, and the first president of the Delaware Academy of Medicine. It is awarded to an individual or organization that has achieved distinction by substantive contributions to the well-being of our community through education, leadership, philanthropy, or service. Previous recipients include: 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019
Victor F. Battaglia, Sr., Esq. Robert W. Frelick, M.D. Leslie W. Whitney, M.D. Robert B. Flinn, M.D. Edwin L. Granite, D.M.D. Katherine L. Esterly, M.D. LTG(DE) William H. Duncan, M.D. Joseph A. Kuhn, M.D. J. Kent Riegel, Esq. Hon. Susan C. Del Pesco, Esq. Nicholas J. Petrelli, M.D., F.A.C.S. Sherman L. Townsend
About the Executive Director’s Public Health Recognition Award... Started by the Delaware Academy of Medicine in 2010, the Executive Director’s Public Health Recognition Award is given to a Delaware nonprofit organization who has shown outstanding leadership and dedication to the improvement of our community’s public health. Previous awardees include: 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019
The Heart Truth Delaware Delaware Breast Cancer Coalition Immunization Coalition of Delaware St. Michael’s School and Nursery Vietnam Veterans of America, Chapter 83, Gold Star Program Gift of Life Donor Program Hon. Jack Markell - Governor of Delaware, 2009-2017 American Lung Association of the Mid-Atlantic Jewish Family Services of Delaware William J. Holloway M.D. Community Clinic at ChristianaCare
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Lewis B. Flinn President’s Award Governor John C. Carney, Jr. and First Lady Tracey Quillen Carney
Born in Wilmington, Governor Carney has had a career-spanning track record of working on behalf of the well-being of our community. Initiatives his administration championed include: increasing the age to purchase tobacco and vape products from 18 to 21; creating a reinsurance program to lower health care costs on the ACA market place; enacting a ban on single-use plastic bags; signing legislation that codifies consumer protections of the Affordable Care Act in Delaware law; directing DNREC to initiate efforts to eliminate the use of hydrofluorocarbons (HFCs); supporting U.S. Climate Alliance’s “Clean Car Promise;” establishing health care benchmarks; enacting “Aiden’s Law” to ensure a coordinated plan of care for infants born addicted or exposed to drugs; launching the START initiative to engage more Delawareans suffering from substance use disorder in treatment; signing legislation allowing both the sale of naloxone, access to substance abuse treatment and strengthened oversight of opioid prescriptions; implementing new opioid prescription regulations; creating the Behavioral Health Consortium and Addiction Action Committee; and launching HelpIsHereDE.com (Delaware’s onestop website for information and services related to addiction prevention). Governor Carney also prioritizes building strong communities, improving schools, and public safety, along with strengthening Delaware’s economy – which ultimately benefits us all. Governor Carney has led Delaware’s COVID-19 response, one of the most difficult challenges of the past 100 years.
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First Lady, Tracey Quillen Carney, was born at the Dover Air Force Base and grew up in New Castle, and is a graduate of Wilmington Friends School and the University of Pennsylvania. Her focus as First Lady is to support efforts that, in a foundational way, help give children a chance to succeed. With funding and operational support from Casey Family Programs, she coordinates those efforts under the umbrella of the First Chance Delaware initiative. First Chance Delaware has three pillars – ending childhood hunger in Delaware; promoting early language skills; and advancing effective recognition of, and response to, childhood trauma. Tracey seeks to use the convening and outreach powers of the First Lady’s office to bring organizations together to work collaboratively toward those goals.
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Executive Director’s Public Health Recognition In 1999/2000, and in recognition of the unique and predominantly rural nature of Sussex County, the State of Delaware Department of Social Services - Division of Public Health (DPH) applied for Federal Office of Rural Health Policy grant funding to develop a Rural Health Plan (RHP). The Plan was designed to present an organized and strategic approach to improving the health of Sussex County residents. As a result, the Delaware Rural Health Initiative (DRHI) was formed. It includes representatives from the DPH and the three southern hospital systems: Bayhealth, Beebe Healthcare and TidalHealth Nanticoke. The DRHI was created as a collaborative vehicle for addressing shared regional health concerns in a more coordinated manner. The goals of the Delaware Rural Health Initiative are to: • Establish a mission to carry a single voice for issues affecting rural Delawareans, • Expand membership and the value derived from membership, • Increase visibility of the new entity throughout the state, and • Strengthen credibility through promoting and completing a collaboratively designed agenda of local initiatives and advocacy.
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EXECUTIVE DIRECTOR'S PUBLIC HEALTH RECOGNITION Presented to
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Delaware’s Affiliate to the American Public Health Association The Delaware Academy of Medicine was granted affiliate status by the American Public Health Association in November of 2013 to be the new Delaware Public Health Association. But the story does not begin there.... In 2007, at the suggestion of President Joseph F. Kestner, Jr., M.D., a delegation from the Board of the Delaware Academy of Medicine traveled to New York City to visit the New York Academy of Medicine with the goal of learning how they fulfilled their mission and remained a relevant, vital Academy of Medicine. The NYAM had maintained its traditional role as a center of medical knowledge and education, had kept a world-renowned history and archives collection, and had become a significant influencer in public health within New York City in a time when many other similar institutions had ceased to exist. Two years later, Dr. Jeremiah Barondess, President Emeritus of the New York Academy of Medicine, was the keynote speaker for our annual meeting with his talk “On Being Useful - New Roles for Old Institutions.” The die was cast, and the mission statement of the Delaware Academy of Medicine, its by-laws, and its overall strategic direction was changed. During subsequent years, under the direction of the board and executive director, we built new programs, removed ourselves from some traditional roles, and kept an ever watchful eye on our financial health. The parameters for membership in the Academy were broadened to encompass those with broader expertise than ever before, including nursing, research, and public health professions. We applied to the American Public Health Association (APHA) for affiliate status, which led to the formation of the founding advisory council, led by Omar A. Khan, M.D., M.H.S., and the Delaware Academy of Medicine was granted affiliate status in November, 2013. From that moment on, we became the Delaware Academy of Medicine / Delaware Public Health Association. Our mission - “To promote the health of Delaware residents through the advancement of sound public health policies and practice.” Our vision - “Work together for a healthy Delaware,” and be one of the five healthiest states in the country in one generation. Additional information is available at www.delamed.org 14
84 Delaware Journal of Public Health - July 2021
The Powe
The Power of Partnerships and People We would like to take this opportunity to publicly thank the individuals and organizations who partner with the Delaware Academy of Medicine and the Delaware Public Health Association: American College of Surgeons, Delaware Chapter American Planning Association, Delaware Chapter American Public Health Association Bayhealth Medical Center Christiana Care Health System Delaware Academy of Family Physicians Delaware Academy of Physician Assistants Delaware Health Care Commission Delaware Health Sciences Alliance Delaware Nurses Association Delaware State Dental Society Delaware Stroke Initiative Medical Society of Delaware Nemours - Alfred I. duPont Hospital for Children State of Delaware - DHSS, Division of Public Health State of Delaware - Division of Libraries University of Delaware - College of Health Sciences University of Delaware - Osher Lifelong Learning Institute Investment Advisory Committee: Mr. Scott Gates Mr. Richard Laird Mr. Marty Mand Mr. Rodney Scott
Public Health Advisory Council: Louis E. Bartoshesky, M.D., M.P.H. Gerard Gallucci, M.D., M.S.H. Richard E. Killingsworth, M.P.H. Erin K. Knight, Ph.D., M.P.H. Melissa K. Melby, Ph.D. Mia A. Papas, Ph.D. Karyl T. Rattay, M.D., M.S. William J. Swiatek, M.A., A.I.C.P.
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Keynote Speaker Geoffrey C. Tabin, MD
Co-founder and Chairman of the Himalayan Cataract Project Professor of Ophthalmology and Global Medicine at Stanford University Dr. Geoff Tabin: Mountaineer, relentless adventurer, pioneering ophthalmologist and visionary. Dr. Tabin is the fourth person in the world to reach the tallest peak on each of the seven continents. His passion for mountain climbing directed him to his professional career in eye care. After summiting Mt. Everest, on one of his expeditions, he came across a Dutch team performing cataract surgery on a woman who had been needlessly blind for three years. It was then he understood his life calling.
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Tabin graduated from Yale University and then earned an MA in Philosophy at Oxford University on a Marshall Scholarship. From there, he took his interest in moral philosophy and health care delivery to Harvard Medical School where he earned his MD in 1985. After completing an ophthalmology residency at Brown University and a fellowship in corneal surgery in Melbourne, Australia, Dr. Tabin returned to Nepal to work with eye surgeon Dr. Sanduk Ruit. Tabin and Nepalese eye surgeon Dr. Sanduk Ruit established the Himalayan Cataract Project in 1995 – with a vow to work to eliminate all preventable and treatable blindness from the Himalayan region in their lifetime, a goal, in Tabin’s words, “more audacious than setting out to make the first ascent of the East Face of Mount Everest.” Today, he is Chairman of the Himalayan Cataract Project Board of Directors and a Professor of Ophthalmology and Global Medicine at Stanford University The Himalayan Cataract Project has since expanded beyond the Himalayas to encompass Sub-Saharan Africa as well. Dr. Tabin spends a considerable part of the year working abroad throughout the Himalayas and Sub-Saharan Africa. He is co-author of the book “Blind Corners”; he and Dr. Ruit were subjects of the acclaimed book “Second Sunds: Two Trailblazing Doctors and Their Quest to Cure Blindness, One Pair of Eyes at a time.”
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www.fic.nih.gov www.fic.nih.gov www.fic.nih.gov
GLOBAL GLOBAL HEALTH GLOBAL HEALTH M HEALTH M AT AT TERS TERS M AT TERS
Inside this issue Inside this issue Dr. John Reeder reflects Inside this issue MAR/APR 2021 MAR/APR 2021
Dr. John Reeder reflects on his career path and Dr. John Reeder reflects on his career path and goals for TDR . . . . . p. 5 on his for career goals TDR path . . . .and . p. 5
FOGARTY INTERNATIONAL CENTER • NATIONAL INSTITUTES OF HEALTH OFTDR HEALTH goals for . . . . .AND p.92 5 HUMAN SERVICES MAR/APR 2021• DEPARTMENT FOGARTY INTERNATIONAL CENTER • NATIONAL INSTITUTES OF HEALTH • DEPARTMENT OF HEALTH AND HUMAN SERVICES
CUGH meeting explores COVID-19 and health equity CUGH meeting explores COVID-19 and health equity CUGH meeting explores COVID-19 and health equity FOGARTY INTERNATIONAL CENTER • NATIONAL INSTITUTES OF HEALTH • DEPARTMENT OF HEALTH AND HUMAN SERVICES
FOCUS FOCUS FOCUS 88 Delaware Journal of Public Health - July 2021
COVID-19 was the main topic of the CUGH annual meeting, including during this interview with NIH’s Dr. Anthony Fauci, conducted by Stanford University’s Dr. COVID-19 was the main topic of the CUGH annual meeting, including during this Michele Barry. interview with NIH’s Dr. Anthony Fauci, conducted by Stanford University’s Dr. COVID-19 was the main topic of the CUGH annual meeting, including during this Michele Barry. like to eclipse,” offered interview with NIH’s Dr. Anthony Dr. Fauci,Joshua conductedGordon, by Stanforddirector University’sof Dr. Michele the National Institute Mental Health (NIMH). Students like toBarry. eclipse,” offeredofDr. Joshua Gordon, director of
should also look for opportunities to conduct research the National Institute of Mental Health (NIMH). Students like to eclipse,” offered Dr. Joshua Gordon, director of overseas, said Fogarty Director Dr. Roger I. Glass. “Those should also look for opportunities to conduct research the National Institute of Mental Health (NIMH). Students field experiences are really life-changing.” overseas, said Fogarty Director Dr. Roger I. Glass. “Those should also look for opportunities to conduct research field experiences are really life-changing.” overseas, said Fogarty Director Dr. Roger I. Glass. “Those The COVID-19 response has benefited from leveraging field experiences are really life-changing.” global networksresponse that werehas built throughfrom previous NIH The COVID-19 benefited leveraging investments, thethat discussants noted. For previous instance,NIH NICHD global networks were built through The COVID-19 response has benefited from leveraging is using scientists with machine learning expertiseNICHD to see investments, the discussants noted. For instance, global networks that were built through previous NIH if artificial intelligence predict which children test is using scientists withcan machine learning expertisewho to see investments, the discussants noted. For instance, NICHD positive for the virus will need treatment “because they if artificial intelligence can predict which children who test is using scientists with machine learning expertise to see can turnfor onthe a dime” deteriorate, said Bianchi. positive virus and will quickly need treatment “because they if artificial intelligence can predict which children who test COVID-19 has also caused NIH to look inward to speed can turn on a dime” and quickly deteriorate, said Bianchi. positive for the virus will need treatment “because they progress and critical NIH funding more quickly, observed COVID-19 hasaward also caused to look inward to speed can turn on a dime” and quickly deteriorate, said Bianchi. Dr. Bruceand Tromberg, who leads the National Institute of progress award critical funding more quickly, observed COVID-19 has also caused NIH to look inward to speed Biomedical Imaging and “It’sInstitute all aboutof Dr. Bruce Tromberg, whoBioengineering. leads the National progress and award critical funding more quickly, observed introducing Imaging innovation the process as “It’s well,all soabout this Biomedical andinBioengineering. Dr. Bruce Tromberg, who leads the National Institute of example hasinnovation shown us that weprocess can go as faster. introducing in the well,We so can this be Biomedical Imaging and Bioengineering. “It’s all about impactful and we can do better.” example has shown us that we can go faster. We can be introducing innovation in the process as well, so this impactful and we can do better.” example has shown us that we can go faster. We can be NIH-funded advances made in low-resource settings often impactful and we can do better.” hold valuable lessons for theinUnited States. Bianchi NIH-funded advances made low-resource settings said oftena globalvaluable networklessons her institute to improve maternal hold for thesupports United States. Bianchi said a NIH-funded advances made in low-resource settings often and child health demonstrates the benefits of personal global network her institute supports to improve maternal hold valuable lessons for the United States. Bianchi said a . . . continued on p. 2 and child health demonstrates the benefits of personal global network her institute supports to improve maternal .. . .. .continued on next continued on p.page 2 and child health demonstrates the benefits of personal . . . continued on p. 2
MEPI Junior Faculty program strengthens Africa’s research capacity MEPI Junior Faculty program strengthens Africa’s investigators research capacity • Offers protected research time to nurture independent Develops skills inresearch writing research proposals and scientific publications • Offers protected time to nurture independent investigators MEPI Junior Faculty program strengthens Africa’s research capacity • Propels career advancement, influence in health policymaking Develops skills in writing research proposals and scientific publications • Offers protected research time to nurture independent investigators • Propels career advancement, influence in health policymaking Read more on onpages pages93–96 6–9 • Develops skills in writing research proposalsRead and More scientific publications Readpolicymaking more on pages 6 – 9 • Propels career advancement, influence in health Read more on pages 6 – 9
PhotoPhoto courtesy courtesy Photo of CUGH courtesy of CUGH of CUGH
The global coronavirus pandemic dominated discussions at the Consortium of Universities for Global Health (CUGH) The global coronavirus pandemic dominated discussions first virtual annual meeting. “COVID-19 has exploited at the Consortium of Universities for Global Health (CUGH) The global coronavirus pandemic dominated discussions and exacerbated many of our“COVID-19 world’s social economic first virtual annual meeting. hasand exploited at the Consortium of Universities for Global Health (CUGH) inequalities,” saidmany WHOofDirector-General Dr. Tedros and exacerbated our world’s social and economic first virtual annual meeting. “COVID-19 has exploited Adhanom Ghebreyesus opening remarks. inequalities,” said WHO in Director-General Dr.Nearly Tedros1,900 and exacerbated many of our world’s social and economic attendees Ghebreyesus from more than 100 nations participated in Adhanom in opening remarks. Nearly 1,900 inequalities,” said WHO Director-General Dr. Tedros the three-day preceded by 30 topical attendees fromconference more thanthat 100was nations participated in Adhanom Ghebreyesus in opening remarks. Nearly 1,900 satellite sessions. the three-day conference that was preceded by 30 topical attendees from more than 100 nations participated in satellite sessions. the three-day conference that was preceded by 30 topical Investments should be made to increase the scientific satellite sessions. capacity of lower-income regions and countries so they Investments should be made to increase the scientific can test and produce vaccines against COVID-19, capacity of lower-income regions and countries so said they Dr. Investments should be made to increase the scientific Anthony Fauci, director of the NIH’s National Institute can test and produce vaccines against COVID-19, said of Dr. capacity of lower-income regions and countries so they Allergy and Infectious Diseases. “ThisNational is not something Anthony Fauci, director of the NIH’s Institute of can test and produce vaccines against COVID-19, said Dr. that’s going to go awayDiseases. in one year. It will have to go away Allergy and Infectious “This is not something Anthony Fauci, director of the NIH’s National Institute of for thegoing entiretoplanet before we year. can feel comfortable we that’s go away in one It will have to gothat away Allergy and Infectious Diseases. “This is not something are out of danger.” for the entire planet before we can feel comfortable that we that’s going to go away in one year. It will have to go away are out of danger.” for the entire planet before we can feel comfortable that we Scientists and policymakers need to be a beacon of truth are out of danger.” and a source evidence-based knowledge on COVID-19, Scientists andofpolicymakers need to be a beacon of truth he said. “You of have to go by yourknowledge conscienceon and maintain and a source evidence-based COVID-19, Scientists and policymakers need to be a beacon of truth your integrity—once lose it, you’re done.” he said. “You have toyou go by your conscience and maintain and a source of evidence-based knowledge on COVID-19, your integrity—once you lose it, you’re done.” he said. “You have to go by your conscience and maintain Fauci encouraged students with the slightest inclination your integrity—once you lose it, you’re done.” to pursue careers in global health. certainlyinclination is a very Fauci encouraged students with the“Itslightest gratifying choice of a life.” to pursue careers in global health. “It certainly is a very Fauci encouraged students with the slightest inclination gratifying choice of a life.” to pursue careers in global health. “It certainly is a very More advice was given to early-career scientists during gratifying choice of a life.” a panel discussion of NIH leaders. Trainees should More advice was given to early-career scientists during consider identifyingofpotential mentors by studying a panel discussion NIH leaders. Trainees should publicly More advice was given to early-career scientists during available identifying informationpotential in the NIH Reporter databasepublicly to consider mentors by studying a panel discussion of NIH leaders. Trainees should see what’sinformation going on inin a the specific researchto available NIH country Reporterordatabase consider identifying potential mentors by studying publicly topic, suggested Diana Bianchi, who leads the Eunice see what’s going Dr. on in a specific country or research available information in the NIH Reporter database to Kennedy Shriver National Institute of Child Health and topic, suggested Dr. Diana Bianchi, who leads the Eunice see what’s going on in a specific country or research Human Development (NICHD). “Seek in the area Kennedy Shriver National Institute of mentors Child Health and topic, suggested Dr. Diana Bianchi, who leads the Eunice that youDevelopment are interested in, in the kindmentors of scientist you’d Human (NICHD). “Seek in the area Kennedy Shriver National Institute of Child Health and like to become, maybe even that you are interested in, inthe thekind kindofofscientist scientistyou’d you’d Human Development (NICHD). “Seek mentors in the area like to become, maybe even the kind of scientist you’d that you are interested in, in the kind of scientist you’d like to become, maybe even the kind of scientist you’d
MARCH/APRIL 2021 MARCH/APRIL 2021
CUGH meeting explores COVID-19 and health equity CUGH meeting .. ... .continued from previous continued from p.1 pageexplores COVID-19 and health equity . . . continued from p.1 contact. “The workers who are a part of that network have contact. “The workers whowomen are a part of that have frequent contact with the during theirnetwork pregnancies frequent with the women during their and aftercontact they deliver. They are collecting data pregnancies but also and after they deliver. and Theysupport—that’s are collecting data but also providing information something providing information that’s sorely lacking inand the support—that’s U.S.” Similarly, something an NIMH project that’s sorely in thebench,” U.S.” Similarly, NIMH project known as thelacking “friendship designed an to task-shift known as the “friendship bench,” designed to task-shift mental health care from professionals to specially trained mental health care from professionals specially trained community members, was developed intoZimbabwe and is community members, was developed in Zimbabwe and is now being adapted for use in New York City. “They’re finding now really being improves adapted for use in City. “They’re finding this access to New care York and reduces stigma,” this really improves access to care and reduces stigma,” said Gordon. said Gordon. As research becomes more complex, the need for data As research becomesin more complex, the need which for data analysis capabilities LMICs has increased, is why analysis capabilities in LMICs has which is why NIH is starting a major initiative inincreased, Africa, said Tromberg. NIH isidea starting a major initiative in Africa, network said Tromberg. “The here is to support a continental to “The idea herebuild is to support continental to and develop tools, on manyayears of NIH network investments develop tools, build many years of NIH investments and take us another stepon forward.” take us another step forward.” A cadre of emerging global health leaders also shared A cadre of emerging global health leaders alsoparticipants shared their efforts to advance science. Six previous their efforts Global to advance science. Sixand previous participants of Fogarty’s Health Fellows Scholars program of Fogarty’sresearch Global Health Fellows and Scholars presented on diverse topics such as air program pollution presented dengue researchdiagnostics on diverse and topics such as air pollution exposure, HIV-associated cognitive exposure, dengue diagnostics and HIV-associated impairment. For Dr. Adaeze Wosu, the opportunitycognitive to impairment. For Dr. Adaeze Wosu, to conduct research in Uganda taughtthe heropportunity about leadership, conduct research in Uganda taught her about leadership, collaboration, patience and perseverance. “I challenged my collaboration, patience and perseverance. “I challenged own perspectives and assumptions and gained a deepermy own perspectives assumptions understanding of and research ethics.” and gained a deeper understanding of research ethics.” Strategies to address global health inequities were Strategiesintoa address global health session, inequities were explored pre-meeting satellite co-hosted by explored in a pre-meeting satellite session, co-hosted by Fogarty. A fundamental shift in approach and underlying Fogarty. A fundamental in approach assumptions is required,shift according to Dr. and Lisa underlying Adams of the assumptions to Dr.“We Lisareally Adams of the Geisel School is ofrequired, Medicine according at Dartmouth. need Geisel School of Medicine at Dartmouth. “We really need
to make sure that we strive to understand the context, to make sure that we strive understand thework context, the historical legacies of the to places where we —and the legacies of the we work —and thishistorical is true whether they areplaces acrosswhere an ocean or across this is true whether they are across oceanreciprocal or across town.” Research partnerships shouldanenable town.” Research partnerships should enable reciprocal learning and there should be recognition of the burden learningtrainees and there should recognition of added. the burden hosting places on be LMIC hosts, she “We hosting trainees places on LMIC hosts, added. “We need to put our relationships under theshe microscope and needthem to put our relationships under the microscope and give critical review and honest appraisal. We need give them critical review and honest appraisal. We need to understand the historical and colonial legacies of the to understand the historical and to colonial legacies the places where we work to be able bring equity toof the places where we engage work toin.” be able to bring equity to the partnerships partnerships we engage in.” Global cancer research and control was the subject of a Global cancerhosted research and control was the subject of a side meeting by NIH’s National Cancer Institute side meeting by NIH’s Nationaladvances, Cancer Institute (NCI). Despitehosted numerous NCI-funded they are (NCI). Despite numerous they are not accessible to all, said NCI-funded NCI Directoradvances, Dr. Ned Sharpless. not accessible to all, said NCI Director Dr. Ned Sharpless. “We should acknowledge this progress that we’ve seen over “We last should thisbeen progress that we’ve seento over the five acknowledge decades has not equitably delivered all the lasteverywhere.” five decades has not been equitably delivered to all people people everywhere.” Climate change was explored during a session organized Climate change was explored a session organized by the NIH’s National Instituteduring of Environmental Health by the NIH’s National Institute of Environmental Health Sciences. There’s a huge gap between the evidence-base Sciences. a huge gap between thetoevidence-base for action There’s and actual practice, according NIEHS’s Dr. for action and “If actual to NIEHS’s Dr. John Balbus. therepractice, was everaccording a time, place and subject John Balbus. wastoever a time, place and as subject where we need“Iftothere be able apply our knowledge swiftly where we need to possibly be able to apply as realm swiftly and surely as we can, it’s our now,knowledge here, in the and surelychange as we possibly can, it’s now, here, in the realm of climate in health.” of climate change in health.” Finally, the science of stigma reduction was discussed by Finally, the science of reduction discussed by a panel coordinated bystigma Fogarty’s Centerwas for Global Health a panel coordinated by Fogarty’s Center for Global Health Studies. The conversation examined various aspects of Studies. Thebest conversation examined various aspects of stigma and practices to reduce it. The session grew stigma and best practices to reduce it. The sessionagenda grew from a trans-NIH effort to develop a cross-cutting from transcends a trans-NIHdisease, effort topopulation develop a cross-cutting agenda that and geographic silos. that transcends disease, population and geographic silos.
PhotoPhoto courtesy courtesy of theofInternational the International AIDSAIDS Society Society
Award established to honor Dr. James G. Hakim Award established to honor Dr.professor James G. Hakim The late scientist Dr. James G. and an important leader in advancing medical
Dr. James G. Hakim Dr. James G. Hakim
2 2
The latewill scientist Dr. James through G. Hakim be memorialized Hakim will award be memorialized through an annual to be established an annual award to be established in his name, supported by the in his name, supported by the African Forum for Research and African Forum for Research and Education in Health (AFREhealth), Education in Health (AFREhealth), the Consortium of Universities for the Consortium of Universities for Global Health (CUGH) and Fogarty. Global Health (CUGH) and Fogarty. Hakim, who died in January 2021, Hakim, who died in January 2021, was an acclaimed researcher and was an acclaimed researcher and
professorand andeducation an important leaderChair in advancing medical research in Africa. of medicine at the research and education in Chair of medicine at the University of Zimbabwe, heAfrica. was also a founding member University of Zimbabwe, he was also a founding member of AFREhealth, a CUGH member and partner, and a of AFREhealth, a CUGH member and partner, and a longstanding Fogarty grantee. longstanding Fogarty grantee. Each year, the James G. Hakim award will provide an Each year, the trainee James G. Hakim awardhealth will provide an African health or early-career professional African healthtotrainee or early-career with funding cover registration andhealth travel professional to the annual with funding to cover travel tofor thetheir annual CUGH meeting, whereregistration they will beand recognized CUGH meeting,The where they will be recognized for in their achievements. inaugural award will be given 2022. achievements. The inaugural award will be given in 2022.
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Experts Experts urge urge global global adoption adoption of of One One Health Health approach approach By Susan Scutti By Susan Scutti
Photo Photo by Boniface by Boniface Mwangi/Africa Mwangi/Africa Knows Knows
The theme of interdependence dominated discussions at The theme of interdependence dominated discussions at a recent workshop on One Health, which aims to improve a recent workshop on One Health, which aims to improve the well-being of people, animals and the environment by the well-being people, animals and the environment by integrating theof efforts of multiple disciplines. “COVID-19 integrating the efforts of multiple disciplines. “COVID-19 reminds us that no country acting alone can respond reminds no country alone can respond effectivelyustothat human, animalacting or environmental health effectively to human, animal or environmental health threats in a globalized world,” said Dr. Eric Goosby in threats in a globalized world,” said Dr. Eric Goosby in his keynote address at the event hosted by the National his keynote address at the event hosted by the National Academies of Science, Engineering Academies of Science, Engineering and Medicine. and Medicine.
research opportunities, collaboration mechanisms, comresearch opportunities, collaboration mechanisms, community engagement strategies, educational opportunities munity engagement strategies, educational opportunities and policies to operationalize One Health principles. A panel and policies to operationalize One Health principles. A panel of experts that examined challenges to integrating policy of experts that examined challenges to integrating policy within health systems included Dr. John Balbus, of the within health systems Dr. John Balbus, of the NIH’s National Instituteincluded of Environmental Health Sciences, NIH’s National Institute of Environmental Health Sciences, and Dr. Christopher Braden, of the CDC. and Dr. Christopher Braden, of the CDC. Public health interventions Public interventions dealinghealth with wildlife or land dealing with wildlife or land management or ecosystem management or ecosystem manipulation—as opposed to manipulation—as opposed to vaccine or drug interventions— vaccine or drug interventions— are often met with skepticism, are met“We withhave skepticism, saidoften Balbus. to buildsaid Balbus. “We have to buildin metrics and evaluation in metrics and evaluation to demonstrate that these to demonstrate that these methods are successful.” methods are successful.” Another stumbling block: One Another stumbling One Health programs inblock: the U.S. Health programs in the U.S. government have not been government haveand notcurrently been “mainstreamed” “mainstreamed” and currently function as policy islands. One function islands. One Health isas notpolicy just zoonotic Health is not just zoonotic crossover and pandemics, it also crossover andless-studied pandemics,ocean, it also includes the includes the less-studied ocean, fungal and microbial worlds, fungal microbial worlds, Balbusand noted. Balbus noted.
The current paradigm of pandemic The current paradigm of pandemic management is “typically management is “typically reactive” with nations and reactive” with nationsworking and health organizations in health organizations working silos—an approach that leadsin silos—an approach that leads to “breathtaking” economic and to “breathtaking” economic and human losses, observed Goosby, human losses, observed Goosby, who is professor of medicine who isUniversity professor of at the of medicine California, at the University of California, San Francisco. Meanwhile, 60% San Francisco. Meanwhile, 60% of human diseases arise from of human diseases arise from pathogens in animals, and, in the pathogens animals, in the U.S. alone, in animals areand, consuming U.S. alone, animals are consuming two times the medically important two times the medically important A global One Health approach to disease surveillance and panantibiotics as people. Within the demic response shouldapproach include low-resource settings where A global One Health to disease surveillance and people panantibiotics as people. Within the coming decades, scientists project and animals often live in close proximity, scientists in apeople recent demic response should include low-resource settingssaid where coming decades, scientists project that spillover animal-to-human workshop. and animals often live in close proximity, scientists said in a recent that animal-to-human workshop. viral spillover events plus antimicrobial viral events plus antimicrobial Examining national coordination from another resistance could result in huge death tolls. If nations Examining national coordination from resistance could result in huge death tolls. If nations angle, Braden emphasized the need foranother technological collaborated to implement a One Health approach, the angle, Braden emphasized the need for technological collaborated to implement a One Health approach, the modernization to help scientists collaborate across silos. globe could better prevent, prepare for and respond to modernization to that helpagencies scientistsand collaborate across globe could betteroutbreaks prevent, prepare for and respond to Layering data so researchers cansilos. see inevitable future of infectious disease, said Layering data so that agencies and researchers canthe see inevitable future outbreaks of infectious disease, said “what's being collected in the animal health sector, Goosby, who also serves on Fogarty’s advisory board. “what's being collected in the animal health sector, the Goosby, who also serves on Fogarty’s advisory board. human health sector and the environmental sector— human health and We thework environmental that's where wesector struggle. with rathersector— antiquated Lower-resource regions often have little surveillance that's where we struggle. We work antiquated Lower-resource regions often have little surveillance systems and ideas about how datawith and rather surveillance can capacity, which makes it especially difficult for them to systems and ideas about how data and surveillance capacity, which makes it especially difficult for them to work,” he said. Use of modern system architectures, can new identify and respond to outbreaks, Goosby explained. He work,” he said. Use of modern system architectures, new identify and outbreaks, surveillance Goosby explained. data sources and sophisticated integration tools could envisions anrespond effective,tosustainable systemHe data sources and sophisticated integration tools could envisions an effective, sustainable surveillance system address these issues and also improve data interactions in that would function as a rolodex of talent that is regionally address these issues and also improve data interactions in that wouldAfunction as amobilize rolodex of regionally the cloud. identified. team could in talent hours that afterisan alarm is the cloud. identified. A team could mobilize in hours after an alarm is raised “to assess and report back and initiate an infusion raised “to assess andcreating report back and initiate an infusion Finally, participants explored better ways to prepare a One of resources.” While “a blanket of surveillance Finally, participants explored need bettertoways tobackwards” prepare a One of resources.” While creating “a blanket of surveillance Health workforce. Academies “work that covers everything” is unrealistic, Goosby said better Health workforce. Academies need to “work backwards” that covers everything” is unrealistic, Goosby said better to provide a needs-based and critical competency-based use of sophisticated technologies that utilize cellphone, to provide aaccording needs-based and critical competency-based use of sophisticated technologies that utilizedata cellphone, education, to Dr. Lonnie King, dean emeritus of purchasing pattern and human movement could education, according to Dr. Lonnie King, deanGraduates emeritus of purchasing pattern and human movement data could veterinary medicine at Ohio State University. help anticipate threats. The WHO may be best suited for veterinary medicine at Ohio State University. Graduates help anticipate threats. The WHO may be best suited for need to have multidisciplinary knowledge and the ability identifying unmet needs, yet filling those needs must be a need to effective have multidisciplinary knowledge and the ability identifying unmet needs, yet filling needs must bethe a to form partnerships, King said. “Relationshipshared responsibility, he said. “For those so many countries, to form effective partnerships, King said. “Relationshipshared responsibility, he said. “For so many countries, the building is the number one skill for this decade.” option of acting alone and expecting that to achieve what's building is the number one skill for this decade.” option alone and expecting that to achieve what's neededofisacting not realistic.” needed is not realistic.” RESOURCES RESOURCES The workshop also featured experts from various http://bit.ly/global-one-health The workshop also featured experts from various http://bit.ly/global-one-health academies and international institutions who explored 3 academies and international institutions who explored 90 Delaware Journal of Public Health - July 2021
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PROFILE PROFILE Fogarty Fellow investigates Fogarty Fellow investigates HIV self-testing in Ugandan HIV self-testing in Ugandan fishing communities fishing communities By Susan Scutti By Susan Scutti
Self-test kits can improve rates of HIV testing but Self-test kits caninimprove of HIV but distributing them remote rates regions cantesting be challenging. distributing them inleaders remotewere regions can be When social network trained to challenging. disseminate social network leaders were trained to disseminate theWhen test kits within a Ugandan fishing community, more the95% test were kits within a Ugandan fishing community, than properly used and returned, a studymore by than 95% were andfound. returned, a study by Fogarty Fellow Dr.properly Joseph used Matovu Fogarty Fellow Dr. Joseph Matovu found. Matovu, a behavioral research scientist with a doctorate Matovu, a behavioral research with research a doctorate in public health, concentrates onscientist HIV testing in public health, concentrates on HIV testing because only when patients know their status research can they because only when patients know their status can they begin treatment and care. HIV prevalence is thought to be begin treatment and care. HIV prevalence is thought to be as high as 37% in Ugandan fishing communities, explained as high as 37% in Ugandan fishing communities, explained Matovu. Since workers typically fish at night and sleep Matovu. Since workers typically fish at night and sleep during the day, they miss out on health care services, he during the day, they miss out on health care services, he said. “So, we’ve been looking for something innovative that said. “So, we’ve been looking for something innovative that would reach them when they are awake, self-testing they would reach them when they are awake, self-testing they cancan do do in in thethe convenience ofoftheir convenience theirown ownhomes.” homes.” ForFor hishis Fogarty project, Matovu Fogarty project, Matovuand andhis histeam teamidentified identified 21 21 overlapping social networks overlapping social networkswithin withinthe thetargeted targeted community. They included groups community. They included groupssuch suchas asboat boatpushers, pushers, motorcycle taxi operators, card motorcycle taxi operators, cardplayers playersand andsex sexworkers. workers. After each group chose aa “peer After each group chose “peerleader,” leader,”Matovu’s Matovu’steam team vetted and trained these leaders vetted and trained these leaderstotouse usethe thekits kitsand and counsel others, making referrals counsel others, making referralsfor fortreatment treatmentwhen when necessary. Next, the peer leadersdistributed distributedself-testing self-testing necessary. Next, the peer leaders their networks. “We gaveout out298 298self-testing self-testingkits kits kitskits to to their networks. “We gave and of these only two peoplerefused refusedthe thekits, kits,so sowe wehad had and of these only two people 99% acceptability,” said Matovu,who whoadded addedthat thatresults results 99% acceptability,” said Matovu, also showed “just under 98% confirmation of use.” also showed “just under 98% confirmation of use.” About test-kit receiptpopulation populationtested testedpositive positive About 7%7% of of thethe test-kit receipt for HIV, which is a much lower prevalence than estimated, for HIV, which is a much lower prevalence than estimated, said Matovu, who believes histeam teamhad hadunknowingly unknowingly said Matovu, who believes his missed some higher risk networks. Ten of the 12 individmissed some higher risk networks. Ten of the 12 individuals who tested positive for the first time had their results uals who tested positive for the first time had their results confirmed by laboratory analyses and 9 went on to receive confirmed by laboratory analyses and 9 went on to receive care. The study was co-funded by the Africa Research care. The study was co-funded by the Africa Research Excellence Fund. Excellence Fund. The fellowship taught Matovu new skills, including how to Thedesign fellowship taught Matovu skills, including to interventions and hownew to write and apply forhow grants. design interventions and how to write and apply for grants. It also helped him strengthen and expand his network of It also helped him strengthen and expand his network of
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Joseph K.B. Matovu, M.H.S., Ph.D. JosephFellow: K.B. Matovu, M.H.S., Ph.D. Fogarty 2018-2019 Fogarty Fellow: US Institution: US Institution: Foreign Institution: Foreign Institution: Research area: Research area:
2018-2019 Yale University Yale University Makerere University School of Public Health Makerere University School of Public Health HIV self-testing in Ugandan fishing communities HIV self-testing in Ugandan fishing communities
collaborators. With his travel stipend, he made stops collaborators. With the his travel stipend, he made stops at Yale University, Rand Corporation and South at Yale University, the Rand Corporation and South Carolina University’s School of Medicine in September Carolina University’s School of Medicine in September 2019, delivering presentations on his research at each. 2019, delivering presentations on his research at each. “The fellowship connected me with people I’d never have “The fellowship connected me with people I’d never have met otherwise,” said Matovu. met otherwise,” said Matovu. His project also helped to strengthen existing research His project also helped to strengthen existing research capacity in Uganda. Uganda.“I’d “I’dworked workedwith withthis thisteam team capacity in inin the past and this time they not only helped to collect the past and this time they not only helped to collect data but also in the analysis of data and writing and data but also in the analysis of data and writing and publishing papers,”explained explainedMatovu. Matovu.“Usually “Usually you work publishing papers,” you work with people collecting collectingdata dataand andwhen whenthey theyfinish, finish, they with people they disappear. Now they theyknow knowhow howdata dataanalysis analysisisis done and disappear. Now done and how to write write and and publish publishaapaper.” paper.”InInhis hisnext next study, study, hehe plans to include include master’s master’sdegree degreestudents. students. two Since completing completing his hisstudy, study,Matovu Matovuhas haspublished published two forfor papers with with two two more moreunderway. underway.He Healso alsoapplied applied and won aa grant grant from fromthe theEuropean Europeanand andDeveloping Developing Countries Clinical Trials Partnership to the Countries Clinical Trials Partnership toexpand expand the research to other Ugandan fishing communities. “We research to other Ugandan fishing communities. “We have about soso this have about 4,000 4,000 fishing fishingcommunities communitiesininUganda, Uganda, this pilot study was a drop in the ocean,” he said. “I believe pilot study was a drop in the ocean,” he said. “I believe the findings findings will since the will also alsotranslate translatetotoother othercountries countries since fishing communities share similar characteristics and fishing communities share similar characteristics and are organized in the same way—fishing done at night, far are organized in the same way—fishing done at night, far from medical centers.” from medical centers.” A Fogarty fellowship is a “lifetime experience,” said A Fogarty fellowship is a “lifetime experience,” said Matovu, who expects to continue working with his Matovu, who expects to continue working with his newfound mentors and collaborators for many years. newfound mentors and collaborators for many years. “The opportunities that come mean you actually achieve “The that come meancould you actually in one year than you normally in 10.” achieve more opportunities more in one year than you normally could in 10.” R ES O U R CES RESOURCES http://bit.ly/joseph-matovu http://bit.ly/joseph-matovu
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Q&A
JOHN REEDER, PHD
Microbiologist Dr. John Reeder is director of TDR, the Special Programme for Research and Training in Tropical Diseases, based at the WHO. He also heads the WHO Department of Research for Health. Reeder previously held leadership posts at the Centre for Population Health and the Burnet Institute. Earlier in his career, Reeder directed the Papua New Guinea Institute of Medical Research. Reeder—who has advised organizations including Fogarty, the Wellcome Trust and the Bill & Melinda Gates Foundation—has published more than 180 scientific papers.
What did your early career look like?
I left school at 16 and, as luck would have it, I managed to get a job as a technician in the public health laboratory of a local hospital, so I spent my first dozen or so years working for the U.K.’s National Health Service. It’s been an incredibly good foundation in technique—being clean on the bench—because people’s lives depend on it in a hospital laboratory. While working in the laboratory I undertook a series of part-time higher education courses and at the age of 22, I became the youngest person in the country to become a fellow of the Institute of Medical Laboratory Sciences. By the age of 26, I was running a teaching hospital laboratory while working part-time on my Ph.D. I completed my doctorate while still in my late 20s. The town where I grew up outside Manchester, England was not an area that typically sent people to university, so my experience coming up gave me an appreciation for the importance of giving people a break. There’s a lot of potential out there and not everybody has an easy road to get an education, to become qualified and move forward.
What are TDR’s goals?
Like Fogarty, we aim to ensure that good science makes a difference and we focus on increasing capacity. Over the past few years, TDR has emphasized training for implementation science—others are driving for creative innovation within countries but there’s a massive gap in delivery science. We work closely with product development partnerships as well. TDR also aims to democratize research, all while making sure it’s done to an appropriate standard so we can rely on the evidence. We’ve got a real interesting program called the Social Innovation and Health Initiative where we work with grassroots projects—for instance, people who train teachers to test school children for malaria. And the idea is not to drive the projects but instead put the tool of research in their hands and help them
strengthen their case for a fantastic idea that otherwise might not get scaled up due to a lack of research expertise. The absolute truth is we miss so much innovation if we don’t listen to the voices of the people on the ground.
What about neglected tropical diseases?
I’ve started talking about neglected populations rather than neglected tropical diseases (NTDs). The key to these diseases is a lack of interest because the populations they affect do not have the political power to drive advancements. If you look at drugs in development, this is the bottom end where no one is really working even though the population sizes are immense. Not all NTDs have high mortality rates, but all have enormous socioeconomic and well-being impact. Some issues are common to many, if not all, these diseases. While we need to be specialists about certain aspects of disease—for example, we will always need people who know every single thing about the biochemistry of a specific parasite—we also need to keep in mind that the issues of implementation science are often similar. Whether it is river blindness or malaria, some thing, some therapy, must be delivered to the neglected population.
Do you miss your days at the bench?
The way I see it is if you’re a virtuoso musician, it’s great fun and you can play your violin or whatever but if you get the chance to pick up the baton and conduct a whole orchestra, you can do so much more. I feel my current role at TDR is picking up the baton. I hope to someday look back and see that less people have a disease or a problem because of work we’ve done together. It isn’t the individual performance that you might get at the bench but at a bigger scale you can look at your career and think, I did my best work then. RESOURCES http://bit.ly/john-reeder-tdr
92 Delaware Journal of Public Health - July 2021
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FOCUS FOCUS
MEPI Junior Faculty MEPI Juniorstrengthens Faculty program program strengthens Africa’s research capacity Africa’s research capacity
MEPI Jr faculty fellows reported the program helped them become independent investigators, improve their ability to write successful grant applications and journal articles, and advance in their careers. MEPI Jr faculty fellows reported the program helped them become independent investigators, improve their ability to write successful grant applications and The program enabled fellows to take part in journal articles, andalso advance in their careers.
Photo by Richard Lord for Fogarty Photo by Richard Lord for Fogarty
A A
lthough sub-Saharan Africa (SSA) bears an enormous portion of the global burden of disease, lthough sub-Saharan (SSA) bears an enorit lacks the adequateAfrica research capacity to investimous portion of the global burden of disease, gate locally relevant solutions needed to improve health. it lacks adequate research to investiBrain drainthe is also a problem, withcapacity many well-trained gate locally relevant solutions needed totoimprove professionals continuing to leave SSA work inhealth. betterresourced helpmany address this shortfall, Brain drain ishealth also asystems. problem,Towith well-trained the NIH began a program in 2015 to to develop professionals continuing to leave SSA work research in betterexpertise and improve faculty retention at this institutions resourced health systems. To help address shortfall, eight countries acrossinthe region. More than $36.4 thein NIH began a program 2015 to develop research millionand was improve invested faculty over fiveretention years, with funding from expertise at institutions the President’s for More AIDS than Relief$36.4 (PEPFAR), in eight countries Emergency across the Plan region. the NIH and years, nine other partners. million wasCommon investedFund over five withNIH funding from Fogarty managed the program, which provided training, the President’s Emergency Plan for AIDS Relief (PEPFAR), andFund research to 362 faculty thementorship NIH Common and support nine other NIHjunior partners. fellows. The Medical Education Partnership Initiative Fogarty managed the program, which provided training, Junior Faculty Research Training (MEPI-Jr) program mentorship and research support to 362 junior faculty builds on its predecessor, MEPI, which earlier provided fellows. The Medical Education Partnership Initiative $130 million over five years to enhance the quality and Junior Faculty Research Training (MEPI-Jr) program quantity of medical school graduates in SSA. builds on its predecessor, MEPI, which earlier provided $130 million over five years to enhance the quality and As the MEPI-Jr program comes to a close, its participants quantity of medical school graduates in SSA. are reporting impressive accomplishments. Many said the fellowship helped them begin to envision a scientific career As the to a close, its participants and MEPI-Jr provided program their firstcomes opportunity for protected time areto reporting impressive accomplishments. carry out research projects. Their studyMany topicssaid werethe fellowship helped them begin to envision a scientific intended to focus on urgent local research prioritiescareer and andran provided theirfrom firstinfectious opportunity for protected timeand the gamut diseases such as HIV to carry research Theirtostudy topics were TB, toout maternal andprojects. child health, noncommunicable intended to focus on urgent local research priorities and diseases including diabetes, hypertension and depression. ran the gamut from infectious diseases such as HIV and TB,Many to maternal and they childwere health, fellows said abletotononcommunicable complete master’s or doctoral degrees with MEPI-Jr support. A number diseases including diabetes, hypertension and depression. revealed the program helped them earn promotions in their academic expand their networks and Many fellows said institutions, they were able to complete master’s gain confidence applying for grants andA submitting or doctoral degreesinwith MEPI-Jr support. number research for helped publication. workshopsin revealed thepapers program them Writing earn promotions hosted by theinstitutions, program resulted in their a total of 886 published their academic expand networks and scientific papers. With an for additional 191 papers currently gain confidence in applying grants and submitting in-process, thefor total is more than 1,000workshops manuscripts. research papers publication. Writing Over the life of the program, participants 552 hosted by the program resulted in a total ofsubmitted 886 published applications for grants and fellowships, with a success scientific papers. With an additional 191 papers currently rate of 34% or 187 awards. in-process, the total is more than 1,000 manuscripts. Over the life of the program, participants submitted 552 applications for grants and fellowships, with a success rate of 34% or 187 awards.
regional and international conferences, where they made more than scientific presentations. The program also450 enabled fellows to take partThe in initiativeand alsointernational spawned 71 independent regional conferences,classes, where they courses andthan workshops focusingpresentations. on epidemiology, made more 450 scientific The mentorship training, project management, biostainitiative also spawned 71 independent classes, tistics analysis and scientific writing. Early reports courses and workshops focusing on epidemiology, from three participating institutions indicate that mentorship training, project management, biostaMEPI-Jr fellows have themselves mentored 866 tistics analysis and scientific writing. Early reports students and postgraduates. Post-program success from three participating institutions indicate that stories include fellows whose research results have MEPI-Jr fellows have themselves mentored 866 earned them a place at the table with health ministry students and postgraduates. Post-program success policymakers. stories include fellows whose research results have earned them a place at the table with health ministry Generally, MEPI-Jr fellows reported acquiring policymakers. important new skills, particularly in the areas of
research design, project implementation and data Generally, MEPI-Jr fellows reported acquiring analysis. All expressed greater confidence in their important new skills, particularly in areas of ability to communicate both in writingthe and in dayresearch design, project implementation and data to-day interactions with other scientists. They also analysis. All expressed greater confidence in their said the local and international mentors framed their ability to communicate both in writing and in dayexpectations, provided them with new opportunities to-day interactions with other scientists. also and taught them invaluable lessons about They mentoring said the local and international mentors framed their others. expectations, provided them with new opportunities MEPI Jr funding included the NIH and taught them partners invaluable lessonsPEPFAR; about mentoring Common Fund; Eunice Kennedy Shriver National others. Institute of Child Health and Human Development; Fogarty; Nationalpartners Heart, Lung, and Blood Institute; MEPI Jr funding included PEPFAR; the NIH National Institute of Dental and Craniofacial Research; Common Fund; Eunice Kennedy Shriver National National of Institute of Mental National Institute Institute Child Health andHealth; Human Development; of Neurological Disorders and Stroke; National Fogarty; National Heart, Lung, and Blood Institute; Institute Institute of Nursing National Institute on National of Research; Dental and Craniofacial Research; Minority Health and Health Disparities; NIH Office of National Institute of Mental Health; National Institute AIDS Research and NIH Office of Research on Women’s of Neurological Disorders and Stroke; National Health. Institute of Nursing Research; National Institute on Minority Health and Health Disparities; NIH Office of AIDS Research and NIH OfficeScutti of Research on Women’s Articles in this section by Susan Health. Resources: http://bit.ly/mepi-jr-faculty
Articles in this section by Susan Scutti Resources: http://bit.ly/mepi-jr-faculty
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FOCUS ON MEPI JUNIOR FACULTY PROGRAM
Voices of MEPI Junior Faculty fellows DR. EDWIN WALONG
Photo courtesy of Kevin Omondi
DR. BONGANI NKAMBULE
Photo courtesy of UKZN
Hematologist and associate professor University of Kwazulu-Natal, South Africa A common complication among people living with HIV (PLWH) are blood clots and associated diseases, so my MEPI-Jr project focused on PLWH and platelets, which can cause clots. One result is a published meta-analysis showing how baseline platelet hyperactivity continues even when PLWH go on treatment and so over time they become susceptible to cardiovascular disease. The fellowship’s personal development workshops were the most important part of the program. These helped me envision a career direction and make progress as both a researcher and a teacher. I have moved up from senior
lecturer to associate professor. MEPI-Jr also taught me grant writing, project budgeting, supervision methods and communication skills. Students come from very different educational backgrounds and now I can look at an individual and understand their unique needs and assist them in their individual journey. This fellowship helped me acquire leadership skills, where I learned how to “read” and work with different personalities. Some mentors were not in my field and this helped me to find, articulate and explain the impact of my work beyond just publishing papers. My collaboration with an HIV clinician really opened my eyes; beyond my test tubes, I now see a patient, a family and a story and I can appreciate the societal impacts of my work. Opportunity is what often makes a career, yet opportunity is exactly what a lot of excellent individuals lack. This fellowship allowed participants to gravitate toward other scientists who were equally eager to excel.
DR. PATIENCE A. MUWANGUZI
Emergency and trauma nurse, head of nursing Makerere University, Uganda In Uganda there is a high prevalence of HIV—every family is affected—so we offer HIV testing to everyone who comes into the ER. The women usually accept but men typically say “no.” For my MEPI-Jr project, I thought, what if we brought the HIV test to men at work? In one district we found that most who came to be tested were at the lower levels of the hierarchy, maybe janitors or security guards, while the managers did not participate. One recommendation was that we bring a variety of tests, such as blood pressure, blood glucose, cancer screening and also HIV self-test kits. This worked well. Some people had never had a blood pressure test, while others discovered they might have diabetes. Overall, this was a very good strategy so that men would not be stigmatized when taking an HIV test. We did find HIV positive cases and linked them to care and treatment, which is the most important outcome. This fellowship was the best two years of my life! I learned and practiced both advanced statistics and writing skills; I have submitted eight manuscripts and applied for 10 grants of which four have been successful. My research project opened doors to international networks and also at Uganda’s health ministry, where I am now invited to contribute because I have data from research and evidence that can influence policy.
7 94 Delaware Journal of Public Health - July 2021
Photo courtesy of Racheal Nabunya
Pathologist and lecturer University of Nairobi, Kenya Autopsy is a platform for gaining insight and learning additional pathology— for example, a patient’s cardiovascular response to a disease or the liver’s response. We can save lives when we communicate our findings to colleagues in frontline clinical care. My fellowship project aims to identify what happens to the kidneys of children who’ve died due to pneumonia, a major cause of child death in Kenya. The MEPI-Jr program exposed me to biostatistics, epidemiological techniques and public health-based studies, which helped me identify what is of clinical, epidemiological and general scientific importance in each autopsy report I write. The main skill I acquired is communication. The fellowship also expanded my research skills. I can now construct case-controlled studies and broad cross-sectional projects that can define populations. I learned how to acquire data and then properly clean and analyze it. This experience helped me transition my practice from a single case-based approach to using data to identify patterns of disease. By training others to conduct time-consuming autopsies, I can scale up and spend more time on statistical research. This fellowship also broadened my network and improved my ability to interpret clinical trials and apply what I’ve learned. We may have challenges in Kenya but we also have opportunities. I intend to apply autopsy and broad mortality-based surveillance to identify areas that need improvement.
F O C U S O N M E P I J U N I O R FA C U LT Y P R O G R A M
Voices of MEPI Junior Faculty fellows DR. TARIRO MAWOZA-CHIKUNI
Ethnopharmacologist and pharmacology chair University of Zimbabwe In Zimbabwe, many women take folk medicines during pregnancy and delivery to help open the birth canal. This inspired my MEPI-Jr project, where I looked at prevalence of traditional medicine use. I found that just under 70% of women used folk medicine during pregnancy, mainly in hopes of facilitating labor and making delivery easier, while more than 17% of women used them for postpartum care. My previous work was mainly lab-based so asking people about a sensitive issue taught me a lot about how to conduct questionnairebased research and then translate the results. Despite the widespread use of traditional medicines, there is insufficient scientific data to justify their use in pregnancy and concerns some might be harmful to the mother and fetus. To shed light on this, I conducted in vitro animal experiments with some of the most commonly used folk remedies. Through this fellowship, I also learned more about scientific writing, starting with a skeleton and going step-by-step, perfecting the methodology, refining the conclusion and finally submitting it for publication. The program provided mentors, local and international, who taught me how best to mentor my own students. I also met researchers in other fields and now we are coordinating our work and writing grants together. Next, I am planning to examine the active substances of traditional medicines to better understand their effects.
DR. GEORGE GWAKO
Photo courtesy of University of Nairobi
OB/GYN and lecturer University of Nairobi, Kenya For obstetricians, nothing is more disheartening than losing a mother during childbirth or seeing a mother or couple lose a baby. In my MEPI-Jr project, I examined why stillbirth is still so prevalent in Kenya and determined the risk factors. My study showed the prevalence of stillbirth in Kenya is 35 in every 1,000 deliveries, compared with 20 to 100 across Africa and 1 to 3 in the U.S. One of the main drivers of stillbirth in Kenya is preeclampsia, my study showed. Other factors are antepartum hemorrhage, diabetes mellitus and prematurity, and there are associations with anemia and HIV. Through
the fellowship program, I took courses in data collection and data analysis so I applied what I learned directly to my project. In general, I learned practical skills, including grant and manuscript writing, grant management, and new leadership and mentoring methods. Importantly, the fellowship provided me with time as well as funds to conduct my research. I had both local and international mentors, which opened my eyes to the unique health challenges in each setting. Having done research with topnotch scientists, I now participate in WHO projects as a co-investigator. Together with other fellows, I formed a consortium of African researchers, the Stillbirth Advocacy and Research in Africa Hub (SARAH), which aims to understand prevalence, risk factors and possible prevention interventions that can work in our unique contexts.
DR. MARGARET ILOMUANYA
Pharmacist, biomedical engineer and lecturer University of Lagos, Nigeria Working as a pharmacist in a hospital that delivers HIV care opened my eyes to HIV drug adherence problems due to medication design— children couldn’t swallow the large tablets or drink the bitter medications, and discordant couples and women in polygamous relationships needed to protect themselves from spreading or contracting the virus. These clinical issues inspired me to obtain a Ph.D. in pharmaceutics and led to my MEPI-Jr project, where I developed a palm oil-based gel for HIV prophylaxis. The product is applied using an applicator in the vagina, where the presence of semen and body heat triggers release of an antiretroviral drug. This offers protection for six hours, preventing a woman from becoming infected by HIV or transmitting the virus to her partner. The fellowship provided me access to the NIH’s AIDS reagent program, so I could obtain materials to test my product against HIV cell lines. MEPI-Jr also taught me scientific writing skills, leading to the publication of two project-related papers and two successful grant applications. The fellowship also helped me transition from a university lecturer to a senior lecturer. In 2019, the U.K.’s Royal Academy of Engineering named me one of the top 100 biomedical researchers in Africa. In 2020, I spent six months in New York as the first African fellow at the Population Council. Ultimately, I want to develop a pharmaceutical product used worldwide. Research should be translatable, something used at the bedside to make a difference.
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DR. TSITSI MONERA-PENDUKA
Photo by Sarudzai Muyambo
Photo by Christine Mukiza
biopsies. People were excited by the findings and we have published two papers and received funding for a Pharmacist and senior lecturer FOCUS ON MEPI JUNIOR FACULTY PROGRAM larger follow-up study. This will help us acquire more University of Zimbabwe evidence to inform policy. MEPI-Jr taught me how to Surveys have shown that design a scientific investigation and analyze herbal medicine use among biopsies. People were excited by the findings and we the findings. DR. TSITSI MONERA-PENDUKA fellowship was quite an enriching experience—I people living with HIV (PLWH) haveThis published two papers and received funding for a Pharmacist and senior lecturer larger follow-upmy study. This will helpexpanded us acquiremy more improved research skills, network and University of Zimbabwe ranges from 54% to 96%. evidence to informon policy. taught me how to Surveys shown collaborated a fewMEPI-Jr successful grant applications. I’ve When I have checked thethat patient design a scientific investigation and analyze the findings. herbal medicine use among grown as a faculty member and now help vet research assessment tools used in Thissubmissions fellowship wasbyquite an enriching experience—I people living withI HIV (PLWH) students and faculty here at Makerere. our HIV clinic, found there improved my research skills, expanded my network and ranges from 54% to 96%. I also work as a consultant, facilitating academic is only one question about collaborated on a few successful grant applications. I’ve When I checked the patient workshops and as an external examiner. In addition, I herbal medicine. For my grown as a faculty member and now help vet research assessment tools used in sit on editorial boards work as at anMakerere. associate editor MEPI-Jr project, I developed submissions by students andand faculty here our HIV clinic, I found there and reviewer. This fellowship has been a great journey a new tool to help clinicians I also work as a consultant, facilitating academic is only one question about and I’ve advanced immensely in my career. this and pharmacists workshops and as an external examiner. In addition,Through I herbal medicine. Fortalk my about program, haveand built a critical mass ofeditor people who sit on editorial we boards work as an associate herbal medicine use with PLWH. My project, fellowship offered MEPI-Jr I developed and are reviewer. This fellowship has been a great journey transferring their skills to colleagues. As we improve a new toolby to help clinicians qualitative research classes delivered experts so I and I’ve advanced immensely in my career. Through this and pharmacists talk about training, eventually we will see better health outcomes in learned how to frame research questions, what methods program, we have built a critical mass of people who herbal medicine use with PLWH. My fellowship offered our communities. to use and how to apply statistics. The mentoring sessions are transferring their skills to colleagues. As we improve qualitative research classes delivered by experts so I included weekly meetings where we informally talked with training, eventually we will see better health outcomes in learned how to frame research questions, what methods DR. HENRY MARK LUGOBE experienced researchers at the university. I liked how they our communities. to use and how to apply statistics. The mentoring sessions OB/GYN and lecturer delivered feedback; it was always in a kind and gentle way included weekly meetings where we informally talked with of Science & Technology, Uganda but with authority. The meetings were inter-professional, DR.Mbarara HENRY University MARK LUGOBE experienced researchers at the university. I liked how they My MEPI-Jr so delivered I learnedfeedback; from colleagues in other departments and OB/GYN and lecturer it was always in a kind and gentle way at but the with same time I had opportunity to express myself Mbarara University of Science & Technology,project Ugandalooked at authority. Thethe meetings were inter-professional, the maternal and My MEPI-Jr as so anI expert mycolleagues own domain. That was invaluable learnedin from in other departments and to project looked at the helped same time had the opportunityMy to express myself fetal outcomes meatand meI build confidence. association with the maternal and as an expert in my own domain. That was invaluable to for Hypertensive the MEPI program gave me clout so I was invited to work fetal outcomes methe andhealth helped ministry me build on confidence. My association Disorders of with HIV management andwith to help for Hypertensive the MEPI program gave me clout so I was invited to work Pregnancy (HDP). write COVID-19 guidelines. Here in Zimbabwe, we recently Disorders of with the health ministry on HIV management and to help Our study found started regulating formulated herbal supplements and Pregnancy (HDP). write COVID-19 guidelines. Here in Zimbabwe, we recently 12% of HDP I am on the national regulatory committee for reviewing Our study found started regulating formulated herbal supplements and mothers had these products. We should not be quick to dismiss 12% of HDP I am on the national regulatory committee for reviewing these traditional medicine since so modern therapeutics mothersexperienced had these products. We should notmany be quick to dismiss disorders come from herbs. experienced these in traditional medicine since so many modern therapeutics disorders in babies had their previous pregnancies—most of their come from herbs. theirlow previous pregnancies—most their babies birth weight and over a of quarter were had stillbirths. DR. MUBUUKE GONZAGA low birth weight and over a quarter were stillbirths. DR. MUBUUKE GONZAGA HDP mothers often had postpartum hemorrhage and Breast imaging specialist and lecturer HDPtheir mothers often hadheightened postpartumrisk hemorrhage Breast imaging specialist and lecturer babies had of brainand disorders. Makerere University, Uganda their babies had heightened risk of brain disorders. Makerere University, Uganda Our most unusual finding was that a high number of Two of my relatives passed Our most unusual finding was that a high number of Two of my relatives passed patients presented with HDP in the wet season. If HDP away as a result of breast patients presented with HDP in the wet season. If HDP away as a result of breast seasonality it needs to be understood, especially cancer, so I became interested has has seasonality it needs to be understood, especially cancer, so I became interested in light of global warming. The other thing I noted is in radiology and specialized in light of global warming. The other thing I noted is in radiology and specialized the difficulty in follow-up. Many patients had in breast breastimaging. imaging. don’t the difficulty in follow-up. Many patients had to travel to travel in WeWe don’t a distance we need might fromfrom quitequite a distance so we so might to need come to upcome with up with have aanational nationalbreast breast cancer have cancer an innovative solution to offertothem care. In care. In screening in in Uganda an innovative solution offercontinued them continued screeningprogram program Uganda addition to supporting my research, the fellowship also so upup dying. addition to supporting my research, the fellowship also so many manywomen womenend end dying. provided classes on research methods, including one Mammography is the gold provided classes on research methods, including one Mammography is the gold with experts from the U.K. and U.S. where I learned standard but it is very expensive, with experts from the U.K. and U.S. where I learned standard but it is very expensive, cohort study skills and how to write and publish my while ultrasound is more widely cohort study skills and how to write and publish my while ultrasound is more widely manuscripts in peer-reviewed journals. The grant available and relatively cheap. manuscripts in peer-reviewed journals. The grant available and relatively cheap. writing sessions taught me how to respond to funding My fellowship project examined whether there’s enough sessions taught applications. me how to respond Myevidence fellowship project examined whether there’s enough callswriting and how to put together I’ve also to funding to use ultrasound as an initial evaluation tool and calls and how to put together applications. evidence to use ultrasound as an initial evaluation tool and worked with mentors here on quality improvement I’ve also discovered the sensitivity of ultrasound in a small cohort worked mentors here We on quality improvement discovered of which ultrasound in slightly a smallbelow cohort processes forwith mothers with HDP. developed a of women the wassensitivity around 58%, was only sheetfor so mothers health care workers and a processes with HDP.can We provide developed of mammography. This was encouraging of that women was around 58%, which was only because slightly below treatment document proper careso forhealth these women. Every mother it means we might at least use it to identify patients treatment sheet care workers can provide and that of mammography. This was encouraging because deserves a live baby at the her term. with highly suspicious masses of immediate document proper careend forofthese women. Every mother it means we might at least usein it need to identify patients 9 deserves a live baby at the end of her term. with highly suspicious masses in need of immediate 96 Delaware Journal of Public Health - July 2021
OPINION
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By Dr. Roger I. Glass, Director, Fogarty International Center
NIH and Fogarty stand against structural racism I applaud NIH Director Dr. Francis S. Collins on the strong stance he is taking to eliminate structural racism at NIH and throughout the biomedical research community. We at Fogarty join him in condemning racism and bigotry in all its forms and remain committed to our mission to work toward achieving equity for all the world’s people. While the NIH has long supported programs to improve the diversity of the scientific workforce, those efforts have not been sufficient to achieve racial equity across the biomedical research enterprise. We’re committed to identifying and dismantling any policies and practices that may harm our workforce and our science. To begin this critical work, NIH has launched a new program called UNITE.
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Photo by Christine Mukiza
UNITE has five components with the following specific aims: U – Understanding stakeholder experiences through listening and learning
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N – New research on health disparities, minority health and health equity I – Improving the NIH culture and structure for equity, inclusion and excellence T – Transparency, communication and accountability with our internal and external stakeholders E – Extramural research ecosystem: changing policy, culture and structure to promote workforce diversity
h
The UNITE initiative was established to identify and address structural racism within the NIH-supported and the greater scientific community. With representation from across NIH, UNITE aims to establish an equitable and civil culture within the biomedical research enterprise and reduce barriers to racial equity in the biomedical research workforce. To reach this goal, UNITE is facilitating research to identify opportunities, make recommendations, and develop and implement strategies to increase inclusivity and diversity in science. These efforts will bolster the NIH’s effort to continue to strive for diversity within the scientific workforce and racial equity on the NIH campus and within
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the extramural community. The COVID-19 pandemic has heightened awareness of the deeply ingrained inequities, racist violence and bigotry that continue to exist in our society. This was brought home to me recently with the tragic shooting of Asian-Americans in Atlanta, the city where I live. It is painful to me that many of my longtime research colleagues of Asian descent are experiencing unpleasant acts of bigotry and discrimination. I am distressed that some of them and their families now feel unsafe and unwelcome in the country they have called home for decades, where they have worked tirelessly to make scientific contributions that improve health for all people. The Atlanta violence spurred the White House to issue a statement condemning acts of discrimination, bullying, harassment and hate crimes directed toward Asian American and Pacific Islander (AAPI) communities. NIH Director Dr. Francis S. Collins pointed out recently that the COVID-19 vaccines we have today were made possible by the rapid public disclosure by Chinese researchers of the novel coronavirus’s genetic sequence. Science continues to be a global effort, he added, and we are all in this together. This is an opportunity for all of us to reflect on what more we can do to address these continuing problems, to determine how we can contribute to meaningful solutions— individually and through our collective efforts—so that one day all people will live in a just and equitable world. We must channel our outrage, grief and frustration into positive change. For us in the global health community, we are also considering how we can work together with our grantees and collaborators to decolonize and democratize global health research. Both remain complex and challenging barriers to health equity. Identifying and dismantling racist components of a system that has been hundreds of years in the making is no easy task and this is just the beginning. I call on all in the Fogarty community to join us in our quest for peace, equality and social justice, here at home, as well as around the globe. RESOURCES http://bit.ly/nih-fogarty-unite 97
PEOPLE Becerra confirmed as HHS Secretary Xavier Becerra, the former Attorney General of California and long-time champion of expanding access to health care, has been confirmed as Secretary of Health and Human Services. A lawyer and former member of Congress, Becerra helped drive passage of the Affordable Care Act. He is the first Latino to lead HHS.
Pace to helm HHS Office of Global Affairs Loyce Pace, a former member of President-elect Joe Biden’s COVID-19 advisory board, has been tapped to head the HHS Office of Global Affairs. Until recently, Pace led the Global Health Council, where she advocated strongly for increased investments in global health. Previously, she directed regional programs for the American Cancer Society.
U.S. global malaria coordinator selected Dr. Raj Panjabi has been appointed to lead the U.S. President’s Malaria Initiative. Born in Liberia, Panjabi settled in the U.S. after fleeing civil war at age 9. Before joining PMI, Panjabi served as CEO of Last Mile Health, a nonprofit he founded to deliver care to remote places.
Elvander to represent US in Beijing Erika Elvander has been selected to serve as the U.S. health attaché to China. Until recently, she was director of the Asia and Pacific portfolio in the HHS Office of Global Affairs. In that role, she worked to foster global relationships and coordinate international engagement across HHS and the U.S. government.
Fogarty McAndrew honored for advocacy efforts Mary Fogarty McAndrew, daughter of Fogarty’s namesake, the late Congressman John E. Fogarty, is being honored by Research! America with the 2020 Gordon and Llura Gund Leadership Award in recognition of her advocacy for health research. Fogarty McAndrew is chair of the Fogarty Foundation for Persons with Intellectual and Developmental Disabilities in Providence, R.I.
Research!America recognizes scientists The advocacy group Research!America is honoring two scientists with its Clear Voice Award in recognition of their effective public communication regarding COVID-19. Awardee Dr. Anne Schuchat has served as the CDC’s Principal Deputy Director since 2015. In that role, she has provided leadership in several emergency responses including the COVID-19 pandemic. Honoree Dr. Michelle Williams is dean of Harvard University’s T.H. Chan School of Public Health and holds a joint faculty appointment at Harvard’s Chan and Kennedy schools. She is an internationally renowned epidemiologist and public health scientist, an award-winning educator and a widely recognized academic leader. Williams currently serves on Fogarty’s advisory board. 98 Delaware Journal of Public Health – July 2021
Global HEALTH Briefs Equitable partnerships hub launched
A new online toolkit provides information about the principles of equitable partnerships from institutions around the world. The hub aims to help funders, scientists and administrators develop or embed equitable policies and practices into their research partnerships. It was developed by the U.K. Collaborative on Development Research and ESSENCE. Website: http://bit.ly/equitable_research
Africa needs investment in research
Despite considerable advances made by African scientists over the past decade, African governments still invest little in health research, according to a study funded by the Wellcome Trust. The project’s findings underscore the importance of centering research capacity strengthening and investment in Africa on national ownership of health research systems. Full report: http://bit.ly/Invest_Research_Africa
CEPI launches plan to end pandemics
The world should invest $3.5 billion to reduce the risk of future pandemics, according to CEPI, a global partnership focused on developing vaccines to stop future disease outbreaks. CEPI’s plan calls for investment in preparation against known threats, transformation in pandemic response and enhanced global coordination. Full report: https://endpandemics.cepi.net/
Global COVID data repository unveiled
A COVID-19 dataset containing detailed information on more than five million anonymized cases from over 100 countries has been made publicly available. The platform is a collaboration of leading international institutions intended to build a trusted, detailed and accurate resource of real-time infectious disease data. Website: https://global.health
WHO: violence against women pervasive
Violence against women remains devastatingly pervasive and starts alarmingly young, according to new data from the WHO and partners. During their lifetime, 1 in 3 women—around 736 million— are subjected to physical or sexual violence by an intimate partner or sexual violence from a nonpartner. Full report: http://bit.ly/WHO_violence
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MARCH/APRIL 2021
Funding Opportunity Announcement
Deadline
Details
Global Trauma and Injury Research Training D43 International Research Training Grants
Apr 16, 2021
http://bit.ly/injurytrauma
International Bioethics Training R25 Clinical Trial Not Allowed D43 Clinical Trial Optional
Jun 4, 2021
http://bit.ly/BioethicsTraining
Hubs of Interdisciplinary Research and Training in Global Environmental and Occupational Health (GEOHealth) U01 Research Project Cooperative Agreements U2R International Research Training Cooperative Agreements
July 8, 2021
http://bit.ly/geohealthhubs
Global Infectious Disease (GID) Research Training D43 Clinical Trials Optional
Aug 3, 2021
http://bit.ly/IDtraining
Fogarty HIV Research Training for LMIC Institutions D43 Clinical Trial Optional D71 Clinical Trial Not Allowed G11 Clinical Trial Not Allowed
Aug 20, 2021
http://bit.ly/NIHGlobalHIV
For more information, visit www.fic.nih.gov/funding
WHO examines global burden of hearing loss
March/April 2021
Nearly 2.5 billion people worldwide—one in four—will be living with some degree of hearing loss by 2050, warns the WHO’s first World Report on Hearing. At least 700 million of these people will require access to ear and hearing care and other rehabilitation services unless action is taken.
Volume 20, No. 2 ISSN: 1938-5935 Fogarty International Center National Institutes of Health Department of Health and Human Services Managing editor: Ann Puderbaugh Ann.Puderbaugh@nih.gov Web manager: Anna Pruett Ellis Anna.Ellis@nih.gov Writer/editor: Susan Scutti Susan.Scutti@nih.gov Designer: Carla Conway
All text produced in Global Health Matters is in the public domain and may be reprinted. Please credit Fogarty International Center. Images must be cleared for use with the individual source, as indicated.
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Courtesy of the WHO
Global Health Matters
“Our ability to hear is precious. Untreated hearing loss can have a devastating impact on people’s ability to communicate, to study and to earn a living. It can also impact on people’s mental health and their ability to sustain relationships,“ said Dr. Tedros Adhanom Ghebreyesus, WHO Director-General. Lack of accurate information and stigmatizing attitudes to ear diseases and hearing loss often limit people from accessing care for these conditions, according to the study. Even among health care providers, there’s often a shortage of knowledge about prevention, early identification and management of hearing loss and ear diseases, hampering their ability to provide the care required. The report is being widely disseminated to promote implementation of its recommendations by WHO member states. WHO has said it will provide technical support and, where required, develop evidencebased guidance to facilitate country responses. R ESOURCE Full report: www.who.int/publications/i/item/world-report-on-hearing 99
SPOTLIGHT This issue, we are spotlighting two recent interns of the Delaware Academy of Medicine/Delaware Public Health Association. During their internship, students research a ‘gap’ of their choice present in public health, and create a program to close that gap. They choose a public health theory to inform their program, and create a logic model to describe it. The Student Internship Program is open to any high school, undergrad, or graduate student, in Delaware and beyond. If you or someone you know would like to apply, please check out our webpage, https://delamed.org/programs/student-internship/.
Educational Interventions to Promote COVID-19 Vaccination Among Parents Julia Pascucci University of Delaware; Intern, Delaware Academy of Medicine/Delaware Public Health Association
INTRODUCTION The topic of COVID19 Vaccine Education for Caregivers (CVEC) was chosen for this internship project in an attempt to contribute to ending the global pandemic. The COVID19 pandemic has pushed the American public to take public health measures seriously in order to protect themselves and others. Pandemicinduced fears have also generated a significant amount of anxiety throughout many people in the country in regards to confusion and uncertainty regarding the COVID19 pandemic information as well as vaccine information. American adults caring for children are experiencing higher levels of stress, compared to adults without children, as they have to manage additional challenges regarding at-home care in the absence of traditional schooling and extracurricular activities.1 In addition to making vaccination decisions for themselves, these caregivers are also responsible for making healthcare decisions for their children, which is why it is extremely important that they have the information necessary to make informed decisions to receive COVID19 vaccination. CVEC was designed to educate and answer questions caregivers may have in order for them to feel educated and comfortable in receiving COVID19 vaccination. Working with the Delaware Academy of Medicine and the Delaware Public Health Association, CVEC resources were published online through the Immunization Coalition of Delaware, which works to ensure nobody in Delaware suffers from vaccine preventable illnesses.
BACKGROUND COVID-19 is a global pandemic that is quickly spreading around the world, infecting over 33 million Americans by May 2021 and has killing over 591,000 people in the United States.2 Social distancing measures were shown early on to be one of the most effective ways in limiting the spread of SARS-CoV-2, which led to the enforcement of practices such as wearing a mask, limiting gatherings, and keeping six feet apart.3 Global disease epidemiologists state that 70 to 80 percent of the population will need to get the COVID-19 vaccination in order to control the COVID-19 global pandemic.4 100 Delaware Journal of Public Health - July 2021
OPERATION WARP SPEED & EMERGENCY USE AUTHORIZATION Operation Warp Speed (OWS) was implemented in the United States with the goal of developing, making, and distributing millions of safe and effective vaccine doses for COVID-19 in response to the global pandemic. This has led to the development of multiple effective vaccines beginning to be distributed to the public in early 2021. COVID-19 vaccine development has been in progress since January 2020, with phase one studies being started in March and phase three trials starting in May. By the end of 2020, OWS had announced six vaccines in their portfolio in partnership with the following companies: Moderna, Pfizer/ BioNTech, AstraZeneca, Janssen, Novavax and Sanofi/GSK.5 The first BNT162b2 mRNA COVID-19 vaccine released by Pfizer had an efficacy of 95%, and a second mRNA-1273 SARS-CoV-2 vaccine was released by Moderna with an efficacy of 94.1%.6,7 Vaccine development in public health emergencies are atypical, and funded by organizations like OWS so that money and funding is not a limit to companies developing multiple potential vaccines. The US Food and Drug Administration (FDA) released both Moderna’s and Pfizer’s/BioNTech’s mRNA COVID-19 vaccines under an Emergency Use Authorization (EUA) in December 2020. Johnson and Johnson’s single dose vaccine proving a 66.9% efficacy gained EUA approval in March 2021.8 EUAs are issued in order to facilitate vaccine availability before companies obtain official licensure because this process is known to take a long time. Efforts to quickly find an effective vaccine have not sacrificed the safety of the vaccine or the integrity and standards of the FDA approval process.9
MISINFORMATION AND FAKE NEWS INFLUENCE VACCINE HESITANCY Despite the rigorous vaccine approval process, a distrust in the American government, the spread of misinformation and ‘fake news’ has led many Americans to be skeptical of the COVID-19 vaccines, which has major implications for public health.10 Social media attacks are one tool used in opposition to vaccination efforts, with a plethora of misinformation spread on popular sites such as Twitter or Facebook, which many Americans rely on for doi: 10.32481/djph.2021.07.016
their news. Research supports that misinformation and conspiracy theory campaigns are motivated by the spread of distrust in the government rather than any goal relating to health or safety. These attacks are a serious threat to national security and are known to happen during moments of high political tension and at the start of national vaccination campaigns; creating a perfect storm for the COVID-19 pandemic during the 2020 US presidential election and the release of a new coronavirus vaccine.10 Social media platforms have made it easier for anti-vaccination misinformation to spread, even some misinformation shared by leaders and celebrities such as former US President Donald J. Trump.11 Social media platforms are also designed to connect like-minded people, meaning that those sharing fake news will be directed to more sites to support their suspicions.12 Fake news on social media sites such as Twitter is 70% more likely to be retweeted than accurate and truthful news.13 The emergence and rapid spread of this new wave of vaccine and pandemic misinformation has prompted the World Health Organization (WHO) to publish a mythbusters site to combat popular conspiracies surrounding COVID-19 and the vaccine, such as 5G network virus transmission and hydroxychloroquine treatment.14
POLITICIZATION OF THE COVID-19 PANDEMIC IN THE UNITED STATES In this new wave of vaccine hesitancy surrounding the COVID-19 vaccine, association of health behaviors to end the global pandemic with personal identity and political affiliation has changed the way the American public perceives the pandemic.15 One of the most important messages for the American public to understand is that vaccination is not a liberal nor conservative ideology. Many people embraced public health initiatives such as mask wearing and social distancing, however people who oppose those public health measures are likely to oppose a vaccine as they may view these initiatives as a threat to their freedom and ultimately their democracy.16 Anti-science ideologies such as anti-mask or anti-vax ideologies use similar arguments tied to long-standing concerns surrounding public health initiatives such as compulsory vaccinations.17 The impact these associations will have on the United States’ ability to recover from the pandemic are largely unknown, but it is important for people not to see political or personal identity as a barrier to getting vaccinated.
COVID-19 VACCINE HESITANCY COVID-19 vaccine hesitancy has varied throughout the course of the pandemic, and the proportion of the US adult population willing to get vaccinated has fluctuated in 2020 from 72% in May down to 51% in September, back up to 60% in November; 18% of Americans who indicated they were not comfortable with getting the vaccine said they would be open to vaccination once other people started getting it and more information becomes available.18 In order to combat vaccine hesitancy, vaccination efforts ‘may need to go beyond just communications campaigns correcting misinformation about a COVID-19 vaccine to also focus on re-establishing public trust in government agencies’19. A survey asked participants, “When a vaccine for the coronavirus becomes available, will you get vaccinated?” with response
options of yes, no, or not sure. Of the participants that answered ‘not sure’ or ‘no,’ almost half of the responses related to antivaccination beliefs as well as lack of trust in the vaccine, vaccine developmental process, the government, and the CDC. Common concerns about the vaccine to those who answered ‘not sure’ were specific to the development of the coronavirus vaccine, uncertainty regarding side effects and efficacy, and concern over the ‘newness’ of the vaccine; others needed additional information regarding the vaccine.20
VACCINE HESITANCY ADDRESSED THROUGH EDUCATIONAL INTERVENTIONS Vaccine hesitancy was common surrounding the Human Papillomavirus (HPV) vaccine for young girls and boys, leading to the development of HPV educational intervention sessions.21 This research also supported that access to accurate information is necessary for making informed health decisions regarding vaccinations, and showed how providing accurate information is a common component of behavioral interventions.22 These techniques, in conjunction with more recent studies evaluating the American perception of COVID-19 vaccines, can be applied to a vaccination education intervention for the COVID-19 vaccine.
COVID-19 VACCINATION EDUCATION FOR CAREGIVERS (CVEC) TO COMBAT VACCINE HESITANCY Adequate knowledge and disproving misinformation about the COVID-19 vaccine will drive informed health decisions for parents who make vaccine decisions for their minor children. American’s attitudes towards receiving the vaccine are divided, with some waiting in line to get the vaccine while others actively protest against its development. This is why ‘any successful marketing strategy will be multifaceted,’ using a combination of key strategies found through consumer research and behavioral economics to promote vaccination.16 COVID-19 Vaccination Education for Caregivers (CVEC) will educate caregivers of middle- and high-school-aged children on the benefits of vaccination, as well as address questions and concerns from participants. In addition to actual knowledge about COVID-19 and the vaccine, it is important parents feel high levels of selfrated knowledge in order to feel confident in discussing the vaccine with their peers, as well as their own children. Given the influx of misinformation and uncertainty surrounding emerging COVID-19 vaccines, educational interventions designed to accurately inform parents about the COVID-19 vaccine are an important step in getting a majority of the population vaccinated in order to control the COVID-19 pandemic. Vaccines have been able to make many dangerous childhood diseases rare, as now it is common for infants to receive dozens of vaccines in the first years of their life.22 Research on vaccine hesitancy and interventions aimed to combat vaccine hesitancy have commonly focused on parents, ‘who are the key propagators of vaccine hesitancy and consumers of anti-vaccine influences, while the children are the key victims.’23 It is critical for adults and specifically parents - to have accurate information regarding the COVID-19 vaccine. 101
THEORY OF PLANNED BEHAVIOR In the late 1980s and early 1990s, the theory of planned behavior (TPB) was created as a revision to the theory of reasoned action (TRA). The aim of both theories is to predict and understand an individual’s intention to engage in a behavior at a specific time or place. An issue soon recognized in the TRA was that it operated under the assumption of total volitional control, and could not be applied to behaviors in which at least in part determined by factors outside an individual’s volitional control.24 An elaboration was made to turn the TRA to the TPB, in order to address human behaviors and actions that would require knowledge, skills, resources, or triumph over environmental obstacles.25 In the TPB a construct was introduced to address the non-volitional part of human behavior. This construct is ‘perceived behavioral control’ and is defined as the perceived difficulty of engaging in a behavior. The TPB was designed to predict an individual’s intention to engage in a behavior at a specific time or place.25 The key components to the TPB are behavioral intentions, which are influenced by the attitude about the likelihood that the behavior will have the expected outcome, and the subjective evaluation of the risks and benefits associated with that outcome.26 The TPB imposes the use of constructs collectively representing an individual’s ability to make a decision, which fall into three types of beliefs: behavioral, normative, and control. The TPB has “been used successfully to predict and explain a wide range of health behaviors and intentions including smoking, drinking, health services utilization, breastfeeding, and substance use.”26 In order to use the TPB, it is necessary to identify the constructs and beliefs the theory is based upon; including behavioral beliefs, normative beliefs, and control beliefs.
TPB CONSTRUCTS Hales, et al. defined and measured the TPB constructs to evaluate health behaviors regarding postpartum physical activity.27 The definitions used in that study were used to define the same constructs in this study. The seven constructs of the TPB include: • Behavioral beliefs • Normative beliefs • Control beliefs • Subjective norms • Perceived behavior • Attitude • Intention Behavioral beliefs are perceived advantages and disadvantages of performing a behavior. Normative beliefs are the sense of approval or disapproval from family, friends, and physicians. Control beliefs are the resources allowing and the impediments stopping a person from engaging in a behavior. Attitude is an overall or general feeling regarding a behavior. A subjective norm is the perceived social pressure to perform a behavior. Perceived behavioral control is the perceived difficulty of engaging in a behavior. Intention is the plan or goal for performing the behavior in a given time period. These constructs will be measured through a series of targeted survey questions presented at the beginning and end of the 102 Delaware Journal of Public Health - July 2021
intervention to predict a participant’s intention to get the COVID-19 vaccination. Similar to the HPV vaccination intervention, participants will answer survey statements designed to measure identified constructs stated above using a Likert scale in their responses on a 5 point scale (-2 to 2), anchored at each end by a descriptor (“strongly disagree” and “strongly agree”).27
THEORY OF PLANNED BEHAVIOR IN COVID-19 VACCINATION EDUCATION For for the purpose of this intervention design, the behavior being studied is the decision to get the COVID-19 vaccine. Education on the COVID-19 vaccine and benefits of vaccination will be disseminated within this program to increase participant knowledge of the advantages of receiving a COVID-19 vaccine. In the past, TPB constructs have been measured through a series of aimed survey questions (figure 1).27 CVEC will include questions that will measure these identified constructs and will be delivered before and after the educational intervention session to participants. Measuring the constructs through the same series of survey questions before and after the intervention is delivered will determine if participants have changed their beliefs due to the intervention. The constructs will be measured by having participants answer statements relating to each construct (see Table 1).
CAREGIVER VACCINE EDUCATION FOR COVID-19 The Kellogg Logic Model is an effective planning tool used in designing a well-planned program or action, and was used to implement this intervention (see Appendix A). CVEC was designed with the purpose of creating a short program aimed to educate parents with up to date information about the coronavirus vaccine. There are multiple reasons for implementing this intervention, but in a successful national recovery from a global pandemic it is important for parents to be knowledgeable about the coronavirus vaccine. This will characterize their behaviors regarding the vaccine, and help them make informed health decisions for themselves and their children.28 CVEC seeks to decrease COVID-19 vaccine hesitancy among parents of middle- and high-school-aged children in the State of Delaware. Inputs are the constructs of the CVEC Logic Model representing the resources to be invested in order to conduct this intervention. One resource necessary is staff members, with one of them being a licensed medical professional in order to deliver the medical information to parents. Staff responsibilities will also include working with local middle and high schools to recruit parent participants, as well as designing virtual advertisements for sign ups. CVEC sessions will require a staff member to be a presenter, as well as another staff member to facilitate the Zoom to address any live chat questions from participants. This non-presenting staff member will also filter any questions regarding COVID-19 vaccines as well as information in the presentation to the medical professional presenter to be answered at the end of the session. Another resource necessary for this intervention is for all staff members to have access to a laptop and appropriate technology to run the Zoom program during sessions. Outputs are the constructs of the CVEC Logic Model representing what the intervention plans to do (activities), and who it intends
Figure 1. TPB Constructs
Construct
Statement Designed to Measure Construct
Behavioral Belief
If I were to receive the COVID-19 vaccine, I would be taking an important step in ending the COVID-19 pandemic.
Normative Belief
My family and friends would approve of me getting the COVID-19 vaccine.
Control Belief
I am aware of vaccination resources in my area.
Subjective Norms
My family and friends would want me to get the COVID-19 vaccine.
Perceived Behavioral Control
When I am eligible to receive the COVID-19 vaccine, it would be easy for me to get one.
Attitude
The development of the COVID-19 vaccine has benefited the United States.
Intention
I intend to get the COVID-19 vaccine as soon as I am eligible.
Table 1. TPB Constructs in CVEC Survey
103
to reach (participation). CVEC was designed for parents with middle- and high-school-aged children in the State of Delaware. To find and identify participants the program will recruit parents from local middle and high schools throughout the State.
CVEC PROGRAM DESIGN The intervention will be delivered online via Zoom platform for a 40 minute period, with 5 minutes during the end used for participants to fill out their post-survey. Participants will be directed to submit questions into a chat box. The nonpresenting staff member can address any participant questions or comments during the session, and there will be ten minutes at the end of the CVEC session for the medical presenter to answer questions asked by participants. The pre-intervention and postintervention surveys will be delivered through SurveyMonkey. Links to the SurveyMonkey for the pre-surveys will be sent upon registering for a CVEC session. Links to the SurveyMonkey for the post-surveys will be sent out via the Zoom chat during the presentation. Participants will be using their email in submitting their survey for the purpose of linking their pre- and postsurveys. Upon completion of the pre- and post-survey, and after participating in the educational session, participants will be eligible to receive a gift card. Participants will not be able to see other participants and will only be able to hear and see the meeting hosts. Because participants cannot interact with one another, the number and location of those participating in each session will not impact individual participant experience. The program will recruit parents from at least two to three middle and/or high schools locally in the State of Delaware. CVEC will have 200 parents participate throughout the eight sessions offered, having an average attendance at every session of 25 participants. At the end of the educational session, participants will be entered into a drawing for a virtual $10 Walgreens gift card. All of the live educational sessions will be recorded, and at the end of all the sessions offered one presentation will be edited (including the live Q&A section) and be emailed out to local middle and high schools that partnered with this program. Short term outcomes from these educational sessions will include participants’ increased self-rated and objective knowledge about the COVID-19 vaccine, increased knowledge on how the COVID-19 vaccine was developed, and more complete knowledge of general information regarding COVID-19. Short term outcomes also include a shift in attitude and opinion to have parents be more accepting of the COVID-19 vaccination. Midterm outcomes include the action of parents deciding to get vaccinated once the option is available to them, and parents deciding to vaccinate their children from COVID-19 once a vaccine for children becomes available. Ultimately, long-term outcomes and impact of this intervention will be a decrease of general vaccine hesitancy among parents in Delaware.
DISCUSSION Social Determinants of Health Addressed in CVEC
Social determinants of health (SDOH) have a large impact on the wellbeing and the quality of life, and are important in establishing health equity. There are many examples of SDOH that relate to caregivers in Delaware regarding COVID19 vaccination including education, discrimination, misinformed beliefs, and access to vaccination sites. 104 Delaware Journal of Public Health - July 2021
One of the main goals of the CVEC program is to address COVID-19 vaccine hesitancy and educate caregivers about COVID-19 vaccination in relation to themselves and their children (Appendix A). Education has proven to be a successful tool in addressing vaccine hesitancy, as seen in HPV vaccination intervention research studies conducted after the release of the cancer-preventing HPV vaccine in 2006. Past studies have proven that allowing parents to be knowledgeable about diseases and vaccine information will characterize their behaviors regarding vaccination, helping them make informed health decisions for themselves and the children they are responsible to make health decisions for. Another aspect of the SDOH addressed in the CVEC program was to ensure participants that no vaccination discrimination is taking place against those of any ethnic background or financial class. COVID19 vaccination is available free of charge to all vaccine-eligible Delaweareans, regardless of whether a patient is insured or not. All participants were also informed that safety trials were conducted among participants of multiple backgrounds and ethnicities with no increased risk found. Participants were also informed their ethnic background would have no impact on which vaccine was available to them, as vaccine distribution and availability varies based largely on testing site capabilities and characteristics. Vaccine hesitancy relating to the COVID19 pandemic has largely been fueled by the spread of misinformation, conspiracies and ‘fake news’ spread on television as well as on popular social media sites such as Twitter. These conspiracies are often believed by those who have lower levels of education, as lower levels of education are shown to have a positive correlation to those who are less likely to be skeptical of a simple solution to a complex problem.29 Common misconceptions and popular conspiracy theories were disproved during the CVEC program and survey questions designed were aimed to examine the effectiveness of debunking of COVID-19 vaccine conspiracies through educational interventions. Furthermore, the research and biostatistics gathered from this study can be used to inform further research, specifically research regarding educational interventions regarding vaccine hesitancy. The CVEC program addressed these SDOH discussed above and gave access to resources to assist those who wanted more information about the COVID-19 pandemic or vaccine. Resources were available for any participant with additional questions regarding COVID-19 vaccination or the pandemic as they were directed to contact the Delaware Public Health Call Center. Additionally, at the end of the program a Frequently Asked Questions section was utilized to answer recurring questions and correct any common misconceptions held among participants.
Initial Survey to Inform CVEC Design In February, an email announcement was sent out to parents of students attending selected middle- and high-schools to submit any questions they have regarding COVID-19 and COVID-19 vaccines. The purpose of this survey was to allow parents to express what topics they feel are most important to address in learning about the COVID-19 vaccine, as well as drafting answers to a Frequently Asked Questions section to be delivered at the end of the educational session. At the end of the survey, participants
entered their email address to be entered to win a $25 Walgreens gift card. Participants had the option to identify whether they would like to be contacted about being part of a focus group for upcoming CVEC sessions and/or indicate if they would like to receive emails about upcoming CVEC program dates and times available to them.
Implementation of CVEC
COVID-19 VACCINATION EDUCATION FOR CAREGIVERS
Modifications to Program Design
At the end of February, a series of email announcements were sent out that informed parents of optional educational sessions on the COVID-19 vaccine beginning in March 2021. A focus group would meet on February 25th at 5pm to completely go through a sample CVEC session and use the feedback to develop the final presentation. Participants of the focus group would receive $20 Walgreens gift cards at the end of the meeting through the emails they used to complete their pre- and post-surveys. The first announcement was sent out with a resource allowing parents to sign up for available online CVEC session time slots offered through Zoom. The educational sessions were offered during the two week time period of March 21 - March 28, 2021. Sign up slots were available for 6:30 pm on Monday and Wednesday nights, as well as 1:00 pm and 6:30 pm slots on Sundays.
At the beginning of the study, the research team reached out to 14 middle schools and 20 high schools in Delaware as prospective partners in the CVEC program (Appendix B). Out of the 34 combined prospective schools, responses were received from two schools. Administrative obstacles stood in the way of distributing presurveys to prospective parents. Due to administrative rules, parent information could not be collected through survey responses for privacy reasons. Due to the lack of interest in participation as well as obstacles encountered in distributing the pre-survey, the surveys were not implemented. The CVEC program was also re-designed to be non-exclusive to schools, so any caregiver could sign up for a session. Flyers were distributed to caregivers at prospective schools, but no caregiver participants signed up (figure 2). Due to these issues, the CVEC program was adapted to become an administered recording. CVEC education was made available to caregivers at any prospective schools with whom resources were shared. This video was uploaded to the website.30 Despite the limitations and obstacles encountered, the research team was still able to implement some of the initial program goals. The CVEC program was designed to address vaccine hesitancy among caregivers in order for them to make informed health decisions regarding COVID19 vaccination. Without the implementation of survey measures, it is impossible to interpret trends between pre- and post- survey results. This recorded program was shared with the original 34 middle and high schools. Printed brochures meant to be distributed to partner schools were replaced by sharing a link to the website of the CVEC page with the attached recording of the program. These modifications were made in hopes to make the CVEC program more accessible to caregivers who might benefit from participation, as well as helping to overcome obstacles with privacy issues and survey distribution.
CONCLUSION During my internship at The Delaware Academy of Medicine/ Delaware Public Health Association (Academy/DPHA), I had the pleasure of creating my own independent research project. I chose to do research involving COVID-19 vaccination in the hopes of making a difference in my local community during the global pandemic. Reviewing past research studies regarding HPV vaccination education, I felt inspired by seeing how educational interventions given to caregivers have shown to decrease vaccine hesitancy. Furthermore, it has been proven that caregivers have an increase in objective knowledge about vaccination post intervention completion, they feel more comfortable spreading that information with those in their community. The COVID-19 Vaccination Education for Caregivers program I created falls in line with the Academy/DPHA mission to enhance the wellbeing of the community through education and the promotion of public health.
Figure 2. CVEC Flyer
During my internship at the Academy/DPHA and the creation of CVEC, I was able to gain valuable skills in time management and professionalism as well as having the experience to learn more about research and the process of research design. 105
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13. Vosoughi, S., Roy, D., & Aral, S. (2018, March 9). The spread of true and false news online. Science, 359(6380), 1146–1151. https://doi. org/10.1126/science.aap9559 PubMed 14. World Health Organization. (2020). COVID-19 mythbusters. Retrieved from: https://www.who.int/emergencies/diseases/novelcoronavirus-2019/advice-for-public/myth-busters 15. Pedersen, M. J., & Favero, N. (2020, May 22). Social distancing during the COVID‐19 pandemic: Who are the present and future noncompliers? Public Administration Review, 80(5), 805–814. https://doi.org/10.1111/puar.13240 PubMed 16. Wood, S. & Schulman, K. (2021). Beyond politics — promoting COVID-19 vaccination in the United States. NEJM.org. Retrieved from: https://doi.org/10.1056/NEJMms2033790 17. Brig, K. (2020). Anti-vax to anti-mask: Processing anti-science claims during a pandemic [Web blog post]. Retrieved from: https:// biomedicalodyssey.blogs.hopkinsmedicine.org/2020/09/antivax-to-anti-mask-processing-anti-science-claims-during-apandemic/ 18. Funk, C., & Tyson, A. (2020). Intent to get a COVID-19 vaccine rises to 60% as confidence in research and development process increases. Retrieved from https://www.pewresearch.org/ science/2020/12/03/intent-to-get-a-covid-19-vaccine-rises-to-60as-confidence-in-research-and-development-process-increases/ 19. Guidry, J. P. D., Laestadius, L. I., Vraga, E. K., Miller, C. A., Perrin, P. B., Burton, C. W., . . . Carlyle, K. E. (2021, February). Willingness to get the COVID-19 vaccine with and without emergency use authorization. American Journal of Infection Control, 49(2), 137–142. https://doi.org/10.1016/j.ajic.2020.11.018 PubMed 20. Fisher, K. A., Bloomstone, S. J., Walder, J., Crawford, S., Fouayzi, H., & Mazor, K. M. (2020, December 15). Attitudes toward a potential SARS-CoV-2 vaccine: A survey of U.S. adults. Annals of Internal Medicine, 173(12), 964–973. https://doi.org/10.7326/M20-3569 PubMed 21. Reiter, P. L., Stubbs, B., Panozzo, C. A., Whitesell, D., & Brewer, N. T. (2011, November). HPV and HPV vaccine education intervention: Effects on parents, healthcare staff, and school staff. Cancer Epidemiol Biomarkers Prev, 20(11), 2354–2361. https://doi. org/10.1158/1055-9965.EPI-11-0562 PubMed 22. Stanford Children’s Health. (2021). Why childhood immunizations are important. Retrieved from https://www.stanfordchildrens.org/en/topic/default?id=whychildhood-immunizations-are-important-1-4510 23. Damnjanović, K., Graeber, J., Ilić, S., Lam, W. Y., Lep, Ž., Morales, S., . . . Vingerhoets, L. (2018, June 13). Parental decision-making on childhood vaccination. Frontiers in Psychology, 9, 735. https://doi.org/10.3389/fpsyg.2018.00735 PubMed 24. Sheppard, B., Hartwick, J., & Warshaw, P. (1988). The theory of reasoned action: A meta-analysis of past research with recommendations for modifications and future research. The Journal of Consumer Research, 15(3), 325–343. Retrieved from: http://www.jstor.org/stable/2489467 https://doi.org/10.1086/209170 25. Ajzen, I. (1991). The theory of planned behavior. Organizational Behavior and Human Decision Processes, 50, 179–211. https://doi. org/10.1016/0749-5978(91)90020-T 26. LaMorte, W. W. (2019, September 9). Behavioral change models: The theory of planned behavior. Retrieved from https://sphweb. bumc.bu.edu/otlt/mph-modules/sb/behavioralchangetheories/ BehavioralChangeTheories3.html
27. H Hales, ales, D., Evenson, K. R., Wen, F., & Wilcox, S. (2010, July-August). Postpartum physical activity: Measuring theory of planned behavior constructs. American Journal of Health Behavior, 34(4), 387–401. https://doi.org/10.5993/AJHB.34.4.1 PubMed 28. A Abraham, braham, C., & Michie, S. (2008, May). A taxonomy of behavior change techniques used in interventions. Health Psychol, 27(3), 379–387. PubMed https://doi.org/10.1037/0278-6133.27.3.379
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APPENDIX A: CVEC LOGIC MODEL Implementation Activities/Objectives
Goal WEngagement
Education
Short Term Deliverables
Mid Term Outputs
Long Term Outcomes
1
Identify middle and high schools locally in the state of DE to offer optional CVEC sessions held virtually
2-3 Partnered schools identified and letter of potential participation sent by 2/22
Partner schools participating in CVEC sessions send out initial survey via email to allow parents to ask any COVID-19 vaccine related questions & identify future FG participants
2
Survey to identify reasons for COVID-19 vaccine hesitancy among parents of middle and high school aged children
Optional survey for parents to submit any questions regarding COVID-19 & the vaccine sent out to all partnered schools on 2/25
Focus group participate in CVEC curriculum shaped by initial survey questions by 3/11
3
FG to identify which topics caregivers feel most uncertain about regarding COVID-19 pandemic & COVID-19 vaccine questions for themselves and their children
Final CVEC curriculum & FAQ section created based on focus group by 3/18
4
Survey of behavioral measures
Email registration & presurvey for available CVEC sessions sent by 3/14
Pre-survey measures in comparison to postsurvey measures to identify behavioral change
Use demographic answers to guide the development of future research
1
CVEC sessions will be conducted to address COVID-19 vaccine hesitancy and educate caregivers about COVID-19 vaccination in relation to themselves and their children
Eight CVEC sessions are offered via Zoom at 6:30pm EST (Mon/ Wed/Sunday) and 1pm EST(Sunday) [3/21-3/28]
Increased. objective knowledge about COVID19 vaccine & pandemic knowledge among parents
COVID19 vaccine hesitancy is decreased among parent participants and feel confident in the knowledge gained of the COVID19 vaccine and feel confident in discussing it with peers
One page brochures created with content of presentation & FAQs in English, Spanish & Haitian Creole
100 printed brochures delivered to each partner school
2
Parents feel confident/ motivated for themselves to receive COVID-19 vaccine
Online PDFs of brochures are created and put on website available in English, Spanish & Haitian Creole
Additional schools identified as needed
Additional translation of brochures made available as online PDFs posted to website
107
Apendix A continued Implementation Activities/Objectives
Goal
Short Term Deliverables
Mid Term Outputs
Long Term Outcomes
Enduring Education
1
Recorded presentation sent out to partner schools
Webinar is live on CVEC website & partnered school’s website
Webinar remains on websites and FB page for enduring material
Future CVEC sessions held are recorded and put on website
Dissemination
1
Social media channel created on Facebook
Webinar and PDF brochures are live on CVEC FB page
Use FB to publish posts containing information from CVEC presentations & to accept questions from caregivers
Use caregiver questions to guide future CVEC sessions and educational materials
2
Page devoted to CVEC project on immunizedelaware.org
Webinar and PDF brochures are linked to website post
APPENDIX B: LIST OF PROSPECTIVE DELAWARE SCHOOLS Middle Schools (14)
High Schools (20)
• Newark Charter School*
• Newark Charter School*
• Shue-Medill Middle School
• Newark High School
• Gauger-Cobbs Middle School
• Christiana High School
• The Brennen School
• Glasgow High School
• George V Kirk Middle School (Ogletown Middle School)
• Paul M. Hodgson Vocational High School
• Skyline Middle School
• Thomas McKean High School
• A.I. duPont Middle School
• Saint Mark’s High School
• DuPont (HB) Middle School
• The John Dickinson School
• Stanton Middle School
• A.I. du Pont High School
• George Read Middle School • McCullough Middle School
• Sussex Academy of Arts and Sciences
• Springer Junior High School
• Conrad Schools of Science
• Alfred G Waters Middle School
• Caesar Rodney High School
• The Bayard School
• Mount Pleasant High School • Concord High School • Middletown High School • Appoquinimink High School • Brandywine High School • Dover High School • Smyrna High School • Delmar High School
108 Delaware Journal of Public Health - July 2021
Molly Magarik, Secretary Jill Fredel, Director of Communications 302-255-9047, Cell 302-357-7498 Email: jill.fredel@delaware.gov
Date: June 25, 2021 DHSS-6-2021
WEEKLY COVID-19 UPDATE - JUNE 25, 2021: DELAWARE NEARS PRESIDENT BIDEN’S VACCINATION GOAL DOVER (June 25, 2021) — The Delaware Division of Public Health (DPH) is providing an update on the most recent statistics related to coronavirus disease 2019 (COVID-19) in Delaware, as of 6 p.m. Thursday, June 24, 2021. A total of 109,636 positive cases of COVID-19 among Delaware residents have been reported to DPH since March 11, 2020. The seven-day average of new positive cases decreased to 20.6 as of Thursday, June 24. As of Tuesday, June 22, the seven-day average for the percentage of total tests that were positive was 1.1%, a minor increase from 1% as of Tuesday, June 15. There is a two-day lag for presenting data related to percent of tests that are positive to account for the time delay between the date of the test and the date that DPH receives the test result. In addition, 23 individuals are currently hospitalized due to COVID-19 in Delaware, a decrease of three from last week. Six of the hospitalized persons are critically ill, up two from last week. A total of 1,693 Delawareans have passed away due to complications from COVID-19. Thirteen deaths were reported in the last week. Twelve were from a review of vital statistics, and one was a newly reported death. The total number of individuals who have died from COVID-19 range in age from younger than 5 to 104 years old. Of those who have died, 847 were female and 846 were male. A total of 845 individuals were from New Castle County, 349 were from Kent County, and 499 were from Sussex County. COVID-19 Vaccinations According to data from the Centers for Disease Control and Prevention (CDC), 69.3% of Delawareans ages 18+ have received at least one dose of the vaccine. This puts Delaware closer to meeting President Biden’s initial goal of 70% by July 4. As of 12:01 a.m. June 25, a total of 990,742 administered doses of the COVID-19 vaccine have been reported to the state’s immunization information system, DelVAX. Among Delawareans 12+, 501,422 have received at least one dose of the COVID-19 vaccine, and 432,948 Delawareans are fully vaccinated. Delaware’s latest COVID-19 vaccination statistics can be found under the Vaccine Tracker dashboard at de.gov/healthycommunity. Vaccines are the best protection we have against COVID-19. For the latest information on the COVID-19 vaccine and the vaccination rollout in Delaware, visit de.gov/covidvaccine. DE Wins! Update More prize winners have claimed their prizes since last week. Not all prize winners have agreed to have their names publicly shared, but DPH is pleased to share the following who did: Sophie Douglas, Bear - Blue Rocks Prize Package In addition, two more $5,000 dollar prize winners, and the winner of the New Castle County vacation package have claimed their prizes. Next week is the final week of the DE Wins! vaccine incentive program weekly drawings. Twelve total winners will be drawn. Prizes offered include tickets to the Grand, State Fair VIP tickets, Wawa catering, tuition to Delaware State University, a scholarship to Wilmington University for both graduate and undergraduates, more state park passes, and $5,000 to four winners. To be entered for a chance to win, get vaccinated as soon as possible before June 29. Visit de.gov/getmyvaccine for a location near you. The grand prize drawings will take place on June 30. Any Delawarean vaccinated at any time in Delaware is eligible. The prizes include $302,000 and two low-digit license plates. For information on the vaccine incentive program visit DEWins.org. DPH COVID Vaccine Mobile Units DPH in partnership with the Delaware National Guard (DNG) has launched mobile units to offer COVID-19 vaccines in underserved communities. Medically trained DNG staff are offering the Pfizer vaccine (for ages 12+) and the J&J vaccine (for persons 18+). These mobile units are visiting communities with low vaccination rates in an effort to eliminate potential barriers to access. The 109
mobile units, which utilize trailers to transport the vaccine and provide vaccinations, are scheduled to visit communities in New Castle, Kent and Sussex counties next week. Monday, June 28 Newark Farmers Market, Newark, 11:00 a.m. - 1:00 p.m. Murray Manor, Wilmington, 2:00 p.m. - 4:00 p.m. Tuesday, June 29 Manchester Square, Dover, 10:00 a.m. - 12:00 p.m. Diamond Court I & II, Harrington, 1:30 p.m. - 3:30 p.m. Wednesday, June 30 Joseph R. Biden, Jr. Aquatic Center, Wilmington, 10:30 a.m. - 1:00 p.m. Adams Street Basketball Courts, Wilmington, 2:30 p.m. - 5:30 p.m. Thursday July 1 Blades Elementary School, Seaford, 10:00 a.m. - 12:00 p.m. Woodbridge Elementary School, Greenwood, 1:30 p.m. - 3:30 p.m. *dates may be rescheduled if there is inclement weather For a full list of community-based events statewide including those organized by vaccinating partners and community groups at de.gov/getmyvaccine. COVID-19 Vaccinations As of 12:01 a.m. June 25, a total of 990,742 administered doses of the COVID-19 vaccine have been reported to the state’s immunization information system, DelVAX. Among Delawareans 12+, 501,422 have received at least one dose of the COVID-19 vaccine, and 432,948 Delawareans are fully vaccinated. Delaware’s latest COVID-19 vaccination statistics can be found under the Vaccine Tracker dashboard at de.gov/healthycommunity. Vaccines are the best protection we have against COVID-19. For the latest information on the COVID-19 vaccine and the vaccination rollout in Delaware, visit de.gov/covidvaccine. Update on COVID-19 Variant Cases in Delaware As of Friday, June 25, the Division of Public Health has identified the following COVID-19 variants in Delaware through routine surveillance of test specimens. These variants are based on the Centers for Disease Control and Prevention (CDC) list of Variants of Concern and Variants of Interest. Variants of Concern Variant
Origin
# of Cases
Alpha/B.1.1.7
United Kingdom
Beta/B.1.351
South Africa
1
Epsilon/B.1.427
California, US
10
Epsilon/B.1.429
California, US
11
Gamma/P.1
Brazil
50
Delta/B.1.617.2
India
13
933
Variants of Interest Variant
Origin
# of Cases
Eta/B.1.525
UK/Nigeria (formerly New York, US)
Iota/B.1.526
New York, US
277
B.1.526.1
New York, US
36
2
In aggregate, the cases include 1,094 adults ranging in age from 18-98, as well as 239 individuals under the age of 18. A total of 1002 individuals were from New Castle County, 176 were from Kent County and 155 were from Sussex County. The Delaware Public Health Laboratory has sequenced 3,189 specimens for COVID-19 variant strains to date, including 62 within the past week. Virus mutation is common. Public health approach and treatments are currently not any different, but as these variants may be more contagious, it is even more important that individuals who are not fully vaccinated remain vigilant and continue taking the necessary steps to avoid spreading the virus - wear a mask, wash your hands, avoid gatherings. The science is clear that the vaccines are extremely safe and effective - and Delawareans who are fully vaccinated have significant protection from COVID-19 infection and serious illness. We would encourage all Delawareans to get vaccinated de.gov/getmyvaccine 110 Delaware Journal of Public Health - July 2021
For more information regarding CDC variant classifications, visit https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/ variant-surveillance/variant-info.html. Breakthrough Cases Vaccination significantly reduces the chance to developing COVID-19 or becoming seriously ill from it. To date, 432,983 Delawareans have been fully vaccinated. Of those, there have been 397 breakthrough cases of COVID-19, less than one-tenth of 1 percent. A breakthrough case is defined as testing positive for COVID-19 after an individual has been fully vaccinated for two weeks or more - although it does not mean that the infection actually occurred after vaccination. Nineteen of the reported breakthrough cases involved hospitalizations, five individuals passed away, although it does not mean COVID was the cause of death. Breakthrough cases are extremely rare, and the science is clear, the best way to prevent serious illness from COVID-19 is to get vaccinated. In-Person Contagious School Cases Dashboard The In-Person Contagious School Cases Dashboard on the My Healthy Community website is no longer being updated due to summer vacation. As of June 30, that section will be removed. Long-term Care Statistics As of 6:00 p.m. Thursday, June 24, there have been a total of 2,744 positive COVID-19 cases involving long-term care residents, and 759 residents of Delaware long-term care facilities have died from complications related to COVID-19. Symptoms and Testing It’s especially important for unvaccinated persons, to be aware of, and self-monitor for, the symptoms of COVID-19. Even fully vaccinated persons should get tested if they develop symptoms. If you are sick with any of the following symptoms, stay home: fever, cough, shortness of breath, sore throat, muscle aches, fatigue, chills, shaking with chills, loss of smell or taste, nausea or vomiting, diarrhea, or headache or congestion or runny nose without a known cause such as allergies. Other symptoms such as abdominal pain or lack of appetite have been identified as potential symptoms related to COVID-19 and may prompt further screening, action or investigation by a primary care provider. Information about testing events, including community testing sites, permanent fixed testing sites, and free-standing sites operated by the health care systems and hospitals, are listed on the testing section of the Delaware coronavirus website at de.gov/gettested DPH reminds Delawareans that if you believe you have been exposed to someone with COVID-19, or have symptoms of illness, make sure to distance yourself from others, particularly vulnerable populations. Older adults and people of any age with serious underlying medical conditions - including serious heart conditions, chronic lung conditions, including moderate to severe asthma, severe obesity and those who are immunocompromised, including through cancer treatment - may have a higher risk for severe illness from COVID-19. Individuals with general questions about COVID-19 should call Delaware 2-1-1, individuals who are deaf or hard of hearing can text their ZIP code to 898-211, or email delaware211@uwde.org. Hours of operation are: Monday - Friday: 8:00 a.m. to 9:00 p.m. Saturday: 9:00 a.m. to 5:00 p.m. Medically related questions regarding testing, symptoms, and health-related guidance can be submitted by email at DPHCall@delaware.gov. Delawareans 18 or older are encouraged to download COVID Alert DE, Delaware’s free exposure notification app to help protect your neighbors while ensuring your privacy. Download on the App Store or Google Play Questions related to business re-openings or operations as businesses re-open should go to COVID19FAQ@delaware.gov. Questions regarding unemployment claims should be emailed to: UIClaims@delaware.gov. DPH will continue to update the public as more information becomes available. For the latest on Delaware’s response, go to de.gov/coronavirus. Delaware Health and Social Services is committed to improving the quality of the lives of Delaware’s citizens by promoting health and well-being, fostering self-sufficiency, and protecting vulnerable populations. ###
111
SPOTLIGHT
Medical Respite Programs for People who Experience Homelessness Danielle Cooper Intern, Delaware Academy of Medicine/Delaware Public Health Association; Graduate Student, University of Arizona
INTRODUCTION A gap analysis was completed during my internship with the Delaware Academy of Medicine/Delaware Public Health Association (Academy/DPHA). During the gap analysis it was discovered there were no medical respite programs in Delaware for people who experience homelessness. This gap was chosen because there are outcomes via program intervention that show a decrease in hospital admissions, inpatient days, decrease in hospital costs, outpatient visits and increase social services for homeless individuals. A medical respite program for people who experience homelessness aligns with the Academy/DPHA mission because one focus of the organization is community health planning and policy development.1 Utilizing a homeless medical respite program will allow people who experience homelessness in Delaware to have a safe place to recover from a hospital stay.
LITERATURE REVIEW The exact number of people who experience homelessness in Delaware changes daily but on average there are over 900 individuals.2 Medical issues are increased if a person is experiencing homelessness, and treatment of any of those conditions is hard when there is a lack of stability or a safe environment.3 With nowhere to properly heal, the only options are to keep homeless individuals hospitalized or discharge them, potentially to not recover from their illness or injury. This leads to increased costs for hospital admissions, increased admission days and increased hospital admissions.3
Medical Respite Programs Medical respite programs for people who experience homelessness are operational in several different settings such as apartments/motel rooms, standalone facilities, shelters, and assisted living centers across the United States.4 These facilities can have doctors, nurse practitioners, social workers, or case workers, depending on the setup.4 Using available information in the database, the median bed number in these facilities is 17, and average length of stay for each client is 28 days.4 This program addresses the problems like increased cost for hospital admission, increased admission days, and increased hospital admission that people who experience homelessness can face when seeking medical care.
What does a Medical Respite Program Provide? Medical respite programs have saved $1.81 for every dollar invested into the program.5 The programs reviewed have some similarities and some differences. All programs reviewed provide a dry place to sleep and a meal. The Serenity Court Homeless Medical Respite program in Philadelphia offers medication management, help accessing primary care, assistance with follow-up visits, and case management for social services such as 112 Delaware Journal of Public Health - July 2021
health insurance and applications for assistance and residential services.6 WellSpace Health, located in California, offers suicide assessments, care coordination, wound care, bathing assistance, education, medication support, housing support, income assistance, behavioral health referrals, transportation, primary care and/or specialty provider while in their facility.7 The National Health Care for the Homeless Council (NHCHC) produced a documentary at a respite facility located in Boston, Massachusetts. During this documentary, clients were interviewed who had varying degrees of medical conditions when discharged from the hospital (Achilles’ tendon tear, spinal cord injury, infected legs, etc.).8 Several clients stated the respite program saved their life, they could rest in peace and recover, did not have to die on the streets, and was a safe place to heal.8 A medical director in the documentary who worked for Boston Medical Center said if the medical respite program did not exist, these homeless individuals would not receive the care needed, medical conditions would return, clients would come to the hospital more ill and more often.8 Three meals a day are provided at the Barbara McInnis House in Boston, along with client support groups, arts and crafts, TV, washers and dryers, behavioral health, bingo, benefits assistance, music, computers, job support, dental and other case management services.9
Hospitalization Costs Decreased People who experience homelessness accrue higher costs when hospitalized compared to those who do not experience homelessness. WellSpace Health, located in California, estimates that in 2018, 169 of their program clients potentially saved a combined average total of $643,687.00 by avoiding one night in the hospital each.7 A 2000 cohort study in Illinois showed an average cost of $706 per hospital day was avoided by using medical respite care.10 The difference between the study and program could be from an estimated 18-year difference, as well as the different geographical locations. Even in countries that have universal health care such as Canada, hospitalized individuals who experience homelessness cost $2,559 more than those who do not.11 A 2017 study showed “medical system charges for these participants decreased by 48.6% from the year prior to the year following medical respite.”12
Decrease in Admissions and Inpatient Days This decrease in costs could be due to medical respite programs. According to a 2017 study, there was almost a 37% decrease in admission rates and 70% decrease in inpatient days for 29 people experiencing homelessness who were treated in a medical respite setting.12 A cohort study from 2000 showed a 49% decrease in hospital admissions and 58% decrease in inpatient days.10
Outpatients Visits Increased Outpatient visits increased 192% in one study.12 These increased outpatient visits could be due to not having to worry about a meal, laundry, a place to sleep, access to social services, transportation doi: 10.32481/djph.2021.07.017
and/or a place to recover, which have all been part of many medical respite programs across the country. Social determinants of health such as housing and income also increased for the 29 homeless individuals studied who were provided respite care following hospitalization.12
the NHCHC national website that have implemented a medical respite program.17 Although programs differ, most assist in closing the gap for people who experience homelessness when discharged from the hospital but are not ready to be released back to the street or shelter.3
Delaware
Philadelphia, PA Compared to Wilmington, DE
In Delaware, not having a medical respite homeless program is a problem for people experiencing homelessness, the local health care system, and insurance companies. Last year an outreach team completed 2,528 screenings for people who experience homelessness for a different project and found more people who experience homelessness in Delaware than previously thought.13 A study completed in 2012 tracked 108 homeless people who, in a year, had 215 hospitalizations and in three months had 302 emergency room visits in Delaware.14 The total cost of these visits and hospitalizations was over $5.5 million.14 The decrease in inpatient days, decrease in admissions, decrease in hospital costs, and increase outpatient visits benefits everyone. This has become a more viable option now that the State of Delaware has purchased a hotel and turned the hotel into a homeless shelter.15
Current Delaware Homeless Program
Delaware Health and Social Services (DHSS) department has one program listed on their website for homeless individuals, called the Projects for Assistance in Transition from Homelessness Program.16 This program focuses on those with mental illnesses and does not address hospital related discharges or respite care.16 Currently there is no program in the State of Delaware to support people who experience homelessness transition from the hospital if they are not sick enough to stay but too sick to be released.17 Thirty-five states and Washington D.C. are listed on 2019 Data
The closest medical respite program to Delaware is in Philadelphia, Pennsylvania. Geographically, the City of Wilmington and City of Philadelphia are about 40 minutes apart while driving in a car. Table 1 below shows comparable data from the United States Census between the two cities. The cities have estimated similar age demographics, housing, education, income, and poverty levels as of 2019.18
Serenity Court Homeless Medical Respite
The Serenity Court Homeless Medical Respite program is in Philadelphia and was established in 2014.6 During the last fiscal year, Laurie Corbin, Managing Director of Community at the Philadelphia Health Management Corporation provided information that the program served 202 homeless individuals. Serenity Court Homeless Medical Respite program has 20 beds, a similar bed count to what could be done in Delaware.
DELAWARE MEDICAL RESPITE PROGRAM FOR INDIVIDUALS WHO EXPERIENCE HOMELESSNESS The Delaware Medical Respite Program for Individuals Who Experience Homelessness (DMRPIWEH) will help provide structure to achieve the goal of a successful medical respite program. The program has several goals (see Appendix A). The first goal is staff and structure and was chosen as this is the Philadelphia, PA
Wilmington, DE
6.70%
6.60%
Person under 18 years
21.90%
22.70%
Person 65 years and over
13.40%
12.90%
Female
52.70%
52.60%
White
40.70%
35.60%
Black or African American
42.10%
58.30%
$163,000
$168,000
Median Monthly owner costs
$1,332
$1,368
Median Gross rent
$1,042
$1,001
2.55
2.33
84.70%
87.70%
Median income
$45,927
$45,032
Per Capita income
$27,924
$30,238
24.30%
26.00%
Age & Gender Person under 5 years
Race
Housing Medium value of owned house
Persons per household Education High school grad or above over 25 yrs. age Income
Poverty
Table 1. Comparison of the Cities of Philadelphia, PA and Wilmington, DE18 113
Figure 1. Socio-Economic Model
backbone of the medical respite program. A facility, staff, policies and procedures are needed for the program to follow local ordinances, ensure clients receive treatment, and provide a safe facility for recovery. The second goal focuses on community outreach. Many of the objectives will impact social determinants of health for individuals who experience homelessness. Mental health providers, support groups, a resource database, and assistance with obtaining access to government programs are part of the second goal. Mental health providers are needed as people who experience homelessness likely do not have access to mental health services; this will not be forced and available only if the client wants services. Support groups will be acquired not only for support for the topics discussed but will also provide social interaction that otherwise might not be something people who experience homelessness has accessible. A resource database is important both during a client’s stay and when discharged, as this will allow people who experience homelessness to be set up for better success with additional resources available. Assistance with accessing government programs will allow those who are eligible to join the Supplemental Nutrition Assistance Program (SNAP) and obtain insurance to obtain access to needed services. The third goal of DMRPIWEH is partnering with a national medical respite network. NHCHC will allow the program to have access to recommendations for programs and become searchable in the database. This is the only national database for homeless medical respite programs. Using the database will allow programs to contact other medical respite programs for best practices. 114 Delaware Journal of Public Health - July 2021
The first three goals allow for an opportunity of successful recovery for clients transitioning from the hospital. The final goal is establishing clients. People are why the program exists and building a relationship with local hospitals is the first start in obtaining client referrals. The result of these goals and objectives is to allow a proper place for people who experience homelessness to recover from hospital discharges and gain access to additional social services.
THEORY There are several theories and models that help shape health changes, for example, theory of reasoned action/behavior health, ecological, social cognitive theory, and health belief model.19 The DMRPIWEH program uses the social-ecological model (SEM, figure 1) to show how multiple factors attribute to a person’s health.20 The first level of the SEM is individual. This level includes knowledge, biological, and attitudes.20 Relationship is the next level in the SEM. This level is the relationship each person forms with others such as friends and family. At the community level, places such schools, churches and neighborhoods can help mold health behaviors. The final SEM level is societal, focusing on norms and health and social policies. The SEM was chosen because it is the best theory to assist in program development for a medical respite program for people who experience homelessness in Delaware. The individual level would include the individual’s knowledge that the program exists and an understanding of what is expected of them. People who
experience homelessness may have beliefs or an attitude that prevents them from wanting to participate (i.e. a person with addiction may not want - or be able to - refrain from behaviors such as drugs that are not allowed inside medical respite facilities). The program must be presented to show what knowledge could be gained and additional social services available to individuals in the program.
application, which will assist in decreasing food related expenses. The California based medical respite program, WellSpace Health, discharged 41% of their homeless individuals to permanent or transitional housing in 2020.7 The decrease in hospital stay time and admissions will assist with lesser medical costs. In addition, case managers will provide job announcement opportunities to clients and housing resources upon discharge.
The relationship level of the SEM could be a barrier to people who experience homelessness. The medical home respite program will provide support from peers while recovering from a hospital stay. The Barbara McInnis House in Boston has successful support groups in place within their program.9 Support groups like these will be offered using various topics such as housing, addiction, and mental health.
Neighborhood and built environments have an impact on overall health, safety, and air quality.22 People who experience homelessness endure the elements of weather, violence that may be in the streets, and pollution. The medical respite program will provide a safe, clean, and warm environment to recover from a hospital stay and resources for housing once discharged.
The community level can be used to address who will be eligible for the program and its services.21 Non-profits in Delaware like ChristianaCare would have eligibility requirements, provided by DMRPIWEH, for their clients to qualify. The medical respite program would work with organizations including homeless shelters, the Centers for Medicaid and Medicare, and Delaware Health and Social Services to qualify individuals for other programs after they were ready to leave the respite program. The community level brings partners into the respite medical program to provide services. This includes local residency programs to provide preventative measures including vaccines, colon cancer screenings and pap-smears. Portable mammograms will come monthly to the medical respite program to provide mammograms. Case managers will work with local health departments to assist with Supplemental Nutrition Assistance Program benefits and health insurance. Local food bank referrals and housing organizations will work with the medical respite staff to ensure services. Once discharged, the providers and case managers will ensure people who experience homelessness have a primary care provider. The societal level of the SEM would acquire needed funding to cover program expenses. Delaware has obtained a hotel for people who experience homelessness and therefore a big expense, where to house the program, already is completed. Policies need to be in place to ensure the program is following all local and state laws regarding health and food safety, client transportation, and sustainability.
DISCUSSION Medical respite homes for people who experience homelessness relates to several topics that impact overall health. The topics include social determinants of health, health inequity, health promotion, and population health.
Social Determinants of Health
There are several SDOH that have an impact on lives. One is health care access and quality.22 People who experience homelessness may not have insurance or transportation to receive health care services. DMRPIWEH social service assistance will help eligible individuals apply for health insurance. Services will also be provided at the facility, therefore eliminating transportation barriers. Economic instability is a known problem for those who experience homelessness. The social determinant of economic instability does not allow for stable housing. The longer a person experiences homelessness, health outcomes decrease.23 The medical respite program will be able to aid with SNAP
Social and community support is an additional social determinant of health that makes an impact in people’s lives.22 People experiencing homelessness do not always stay in the same spot and although a part of society, they are distanced. Having support groups at DMRPIWEH will allow clients to have social support and a sense of community. These impacts on the SDOH will have an impact on the population health of the homeless community in Delaware.24
Population Health
People who experience homelessness are a type of population.24 This group shares similar health outcomes for an increase in inpatient days, increased costs, and increased hospital admissions.12 The medical respite programs that have been studied have proven to decrease all three of those areas. This leads to better population health for people who experience homelessness.
Health Inequity
There are several health inequities that people who experience homelessness face. Severity of disease is a health inequity that DMRPIWEH may impact.25 In Delaware, if an individual is discharged from the hospital but should not be released to the street because they are not fully recovered, there is no alternative. Readmissions then occur because the individual’s initial reason for admission may not go away. Having the medical respite program allows for full recovery - and therefore a decrease in readmissions and worsening symptoms. Not having access to health care also impacts severity of disease. There will be health care services offered at the facility. Resources given during discharge from DMRPIWEH will increase outpatient visits as clients will have assistance completing insurance applications and provider references. The biggest inequity, life expectancy, is shorter for people who experience homelessness.23 DMRPIWEH will impact this disparity by allowing clients to heal in a clean environment and provide social services, both of which lead to more health care access. Preventative measures are typically less available for this population. Having preventive measures available at DMRPIWEH may lead to less severity of disease, which may lead to a longer life expectancy.25
Health Promotion
The focus of health promotion is to encourage individuals to take control of their own health.26 The DMRPIWEH will allow people who are experiencing homelessness to have the option to make their own health choices. With an unstable environment, health decisions are less of a choice as there are fewer options available. The program will be voluntary; individuals will be able to choose to better their health. People will also have a choice to accept 115
the additional resources once in the program (support groups, preventative health, outpatient options when discharged) and apply for social service programs. This will allow individuals a say in their future health.
CONCLUSION The first task of my internship was attending the Mid-Atlantic Partnership Regional Conference.27 Since I just moved back to Delaware, this helped me learn about current gaps in the region. After I watched every breakout session, I completed a gap analysis where I spent numerous hours researching gaps and programs in Delaware. The biggest limitation I encountered was getting programs from across the country to respond with information that was usable. The national program had few data sources for access. I tried to reach the national program several times with no response. I successfully received information from a program in Philadelphia and California.
REFERENCES 1. Delaware Academy of Medicine/Delaware Public Health Association. (n.d.). Community health planning & policy development. Retrieved from: https://delamed.org/initiatives/public-health/sections/ community-health-planning-policy-development/ 2. United States Interagency Council on Homelessness. (n.d.). Delaware homelessness statistics. Retrieved from: https://www.usich.gov/homelessness-statistics/de 3. N ational Health Care for the Homeless Council. (2016, Oct). Standards for Medical Respite Programs. Retrieved from: https://nimrc.org/wp-content/uploads/2021/04/Standards-forMedical-Respite-Programs.pdf 4. N ational Institute for Medical Respite Care. (2021, January). State of Medical Respite/Recuperative Care Programs. Retrieved from: https://nimrc.org/wp-content/uploads/2021/02/State-ofMedical-Respite_Recup-Care-01.2021.pdf 5. S hetler, D., & Shepard, D. S. (2018). Medical respite for people experiencing homelessness: Financial impacts with alternative levels of medicaid coverage. Journal of Health Care for the Poor and Underserved, 29(2), 801–813. https://doi.org/10.1353/hpu.2018.0059 PubMed 6. N ational Health Care for the Homeless Council. (n.d.). Serenity Court homeless medical respite. Retrieved from: https://nhchc.org/business-directory/245012/serenity-courthomeless-medical-respite-2/ 7. J enkins, G. (2021, Feb 14). Interim Care Program. WellSpace Health. Presentation. 8. N ational Health Care for the Homeless Council. (2014, Mar 10). Medical respite care for people experiencing homelessness - a short documentary [Video file]. Retrieved from: https://www.youtube.com/watch?v=fUrD0-tAOSc 9. B oston Health Care for the Homeless Program. (2018 August 31). Barbara McInnis House patient FAQ. Retrieved from: https://www.bhchp.org/sites/default/files/Patient%20 FAQs_8.31.2018.pdf 116 Delaware Journal of Public Health - July 2021
10. B uchanan, D., Doblin, B., Sai, T., & Garcia, P. (2006, July). The effects of respite care for homeless patients: A cohort study. American Journal of Public Health, 96(7), 1278–1281. https://doi.org/10.2105/AJPH.2005.067850 PubMed 11. H wang, S. W., Weaver, J., Aubry, T., & Hoch, J. S. (2011, April). Hospital costs and length of stay among homeless patients admitted to medical, surgical, and psychiatric services. Medical Care, 49(4), 350–354. https://doi.org/10.1097/MLR.0b013e318206c50d PubMed 12. B iederman, D. J., Gamble, J., Wilson, S., Douglas, C., & Feigal, J. (2019, May). Health care utilization following a homeless medical respite pilot program. Public Health Nurs, 36(3), 296–302. https://doi.org/10.1111/phn.12589 PubMed 13. L andgraf, R., Holloway, S., Beaman, R., & Fitzgerald, R. (2020, July 7). Delaware COVID-19 homeless community outreach partnership 2020. Delaware Journal of Public Health, 6(2), 96–100. https://doi.org/10.32481/djph.2020.07.023 14. D elaware State Housing Authority. (2013). Delaware’s plan to prevent and end homelessness. Retrieved from: http://www.destatehousing.com/FormsAndInformation/ Publications/plan_end_homeless.pdf 15. C herry, A. (2020, Dec 21). Public gets opportunity to ask questions about New Castle County’s hotel-turned-homeless shelter. WDEL. Retrieved from: https://www.wdel.com/ news/video-public-gets-opportunity-to-ask-questions-aboutnew-castle-countys-hotel-turned-homeless-shelter/article_ a57f0dec-43ce-11eb-b9b8-2fbeef6ebaa8.html 16. D elaware Health and Social Services. (n.d.). Services for the homeless. Retrieved from: https://dhss.delaware.gov/dhss/dsamh/homeless.html 17. N ational Health Care for the Homeless Council. (2020). Medical respite care directory. Retrieved from: https://nhchc.org/clinical-practice/medical-respite-care/ medical-respite-directory/ nited States Census Bureau. (n.d.). QuickFacts Philadelphia 18. U City, Pennsylvania; Wilmington City, Delaware. Retrieved from: https://www.census.gov/quickfacts/fact/table/ philadelphiacitypennsylvania,wilmingtoncitydelaware/ PST045219 19. R ural Health Information Hub. (n.d.). Ecological models - rural health promotion and disease prevention toolkit. Retrieved from: https://www.ruralhealthinfo.org/toolkits/ health-promotion/2/theories-and-models/ecological 20. C enters for Disease Control and Prevention. (2021, Jan 28). the social-ecological model: a framework for prevention. Retrieved from: https://www.cdc.gov/violenceprevention/about/socialecologicalmodel.html 21. N ational Health Care for the Homeless Council. (2016a, April). Using the Social Ecological Model to examine how homelessness is defined and managed in rural East Tennessee. Retrieved from: https://nhchc.org/wpcontent/uploads/2019/08/rural-homelessness-report_nhchcpublication.pdf 22. U .S. Department of Health and Human Services. (n.d.). Social determinants of health. Retrieved from: https://health.gov/ healthypeople/objectives-and-data/social-determinants-health
23. Stafford, A., & Wood, L. (2017, December 8). Tackling health disparities for people who are homeless? Start with social determinants. International Journal of Environmental Research and Public Health, 14(12), 1535. https://doi.org/10.3390/ijerph14121535 PubMed 24. Silverstein, M., Hsu, H. E., & Bell, A. (2019, December 24). Addressing social determinants to improve population health. JAMA, 322(24), 2379–2380. https://doi.org/10.1001/jama.2019.18055 PubMed
25. Centers for Disease Control and Prevention. (2020, Mar 11). Health equity. Retrieved from: https://www.cdc.gov/ chronicdisease/healthequity/index.htm 26. World Health Organization. (n.d.). Health promotion. Retrieved from: https://www.who.int/westernpacific/healthtopics/health-promotion 27. Mid-Atlantic Public Health Partnership. (2021). Empowering communities to address the social determinants of health. Retrieved from: https://midlantic.org/
APPENDIX A Delaware Medical Respite Program for Individuals who Experience Homelessness Logic Model Goal
Staff and Structure
Community Outreach
Implementation Activities/Objectives
Short Term Deliverables
Mid Term Outputs
Long Term Outcomes
1
Determine appropriate facility to house program
Reach out to State of DE to discuss use of Hope Center (May 2021)
Obtain additional permits for Hope Center OR determine back up facility (June 2021)
Move-in to chosen facility (July 2021)
2
Obtain staff (i.e., mental health providers, nurse, social workers, etc.)
Post job announcement with State of Delaware (May 2021)
Interview potential candidates (June 2021)
All staff positions filled (July 2021)
3
Create policies and procedures for DMRPIWEH
Download suggestions from National Institute for Medical Respite Care (May 2021)
Edit policies and procedures based on Delaware law and program objectives (June 2021)
Policies and procedures modified as needed to reflect new rules/ regulations (ongoing)
1
Establish a list of mental health providers in the State who will accept clients after discharge from DMRPIWEH
Reach out to the State of Delaware and current mental health programs for a list of providers (May 2021)
Clients are referred to providers after discharge (Sept 2021)
Referral list is updated as needed (ongoing)
2
Social work staff create support groups for clients
25% of clients are invited to join support groups within the program (Aug 2021)
60% of clients are involved in ongoing support groups (Oct 2021)
100% of clients are involved in ongoing support groups (Jan 2022)
3
Obtain database for resources
Identify database program (May 2021)
Social Worker/Case Managers obtain resources in community (Aug 2021)
100% of clients have needed resources/ referrals when discharged (Sept 2021)
4
Assist individuals in obtaining access to government programs
Social Worker(s)/Case Manager(s) trained to complete SNAP benefit applications for eligible clients (Aug 2021)
Eligible clients are enrolled in Medicaid and Medicare (Sept 2021)
Eligible clients are enrolled in housing assistance (Oct 2021)
Partner with National Network
1
Access other medical respite programs & DMRPIWEH placed in national registry
Contact National Institute for Medical Respite Care to discuss program (May 2021)
Complete forms for National Institute for Medical Respite Care database (June 2021)
Contact other medical respite programs for best practices (July 2021)
Establish Clients
1
Receive referrals from hospitals
Choose hospitals for DMRPIWEH program (May 2021)
Meet with hospital leadership (June 2021)
Clients referred to program (Aug 2021)
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From the History, Archives, and Collection Sharon Folkenroth-Hess, M.A. Collections Manager, Delaware Academy of Medicine / Delaware Public Health Association
“Healthcare, more than any other profession, undergoes constant change. The rapid progress of science necessitates a continuous revision of the methods and techniques to maintain or restore human health. Practitioners of medicine must stay informed of new developments to offer the best possible care to patients.‚ - Preamble to the Resolution to Form the Delaware Academy of Medicine, 1930. The technology to facilitate medical education, like healthcare itself, encounters constant change. Since the beginning, the Delaware Academy of Medicine has quickly adopted new tools to keep pace with healthcare and deliver vital new information to professionals and the public. The Delaware Academy of Medicine Historical Archives preserves a collection from a once-revolutionary technology that is now declared obsolete: Tel-Med. Events like the 1962 Health Fair had 65,000 visitors, and other well-attended health education projects such as the Health Forums demonstrated a need to share medical and dental with the public.1 Governor Pierre S. du Pont made the
first call to Tel-Med in a small press conference on March 31, 1980. The Delaware Academy of Medicine established the State’s Tel-Med consumer health program franchise to give the public free and anonymous access to healthrelated information entirely by telephone. The Tel-Med program was even more popular than the Academy initially planned, receiving nearly 30,000 calls in the first six weeks of operation. By the end of the first year, Tel-Med received over 143,000 calls with an average of 12,000 calls per month (statistically 1 out of every 4 Delawareans), making it one of the most heavily used Tel-Med programs in the country.2 When Tel-Med first opened the phone lines, the caller had access to a library of 204 pre-recorded audio tapes on a wide variety of medical and dental topics. Dr. Joyce Brothers and other personalities lent their voices to the appropriate subjects. By 1996 there were 898 topics from which to choose (see figure 1). To select a topic, the caller referred to a number-coded directory printed in the blue pages of the telephone book. A tape librarian would answer the call, enter the topic code into the Teletronix Information System to connect the caller to the requested tape. The Teletronix System integrated telephone and tape playback equipment into a single console allowing a librarian to operate up to fifteen phone lines. According to Teletronix, the system
Figure 1: Tel-Med Topic Directory Flyer 118 Delaware Journal of Public Health - July 2021
doi: 10.32481/djph.2021.07.018
provided a 75:1 ratio of volume, meaning that it would take 75 people to disseminate the same amount of information that one tape librarian can handle.3 This high-tech program was not cheap. A private local foundation gave a grant to the Academy to cover the initial costs for equipment and installation. The Medical-Dental Bureau of New Castle County provided space for the TelMed equipment and made available operators staff it around the clock, seven days a week. There was no charge for this service except during heavy calling volume when additional operators were needed. The Academy appealed to both medical and non-medical organizations in the area for assistance with ongoing operating costs. The Medical Society of Delaware, the New Castle County Medical Society, and ten other organizations responded by “sponsoring” 71 more tapes in addition to the 133 unsponsored tapes. In 1983, a second phone number was added to the program to handle Kent and Sussex counties (figure 2). One of the most appealing features of Tel-Med was its anonymity. Callers had access to information that would answer sensitive questions they might otherwise be too embarrassed to ask. In the first three quarters of 1992 the top five tape requests were: 1) “Am I Really Pregnant?” (requested 2,134 times); 2) “AIDS” (2,054 times); 3) “Signs of a Problem Pregnancy” (1,384 times); 4) “Homosexuality” (1,245 times); and 5) “Facts and Fears about AIDS” (1,181 times) (figure 3). The information in each pre-recorded three to five-minutelong tape was written by physicians or other specialists on that topic. Tel-Med provided each subscribing organization with transcripts for review.
Figure 2: Governor Pierre S. duPont ready to make the first phone call, Tel-Med Kick-off for Kent General, June 21, 1983.
Within ten years, the Teletronix system was outdated. In 1991, the Tel-Med program was computerized entirely to handle the nearly 6,000 monthly calls. The Tel-Med Information System (TMIS) was a state-of-the-art system that stored pre-recorded information and delivered messages to a touch-tone caller. By the late 1990s, users could also go to the World Wide Web to retrieve health information from delamed.org or email consumer@delamed.org. Despite the increasing popularity of the internet in the mid-2000s and the availability of reliable health information websites like WebMD.com, the Tel-Med system continued to be one of the Academy’s most widely-used consumer programs. Ultimately, the internet took over, rendering the Tel-Med system obsolete, and the Academy discontinued the service.
REFERENCES 1. Flinn, Dr. R. (1978, Oct 17). Request for Grant to Crystal Foundation [Letter to Dr. Burt Pratt]. 2. Dill, W. G., & Gill, G. P. (1981, September). Tel-Med in Delaware: A progress report. [Delaware Academy of Medicine Historical Archives.]. Delaware Medical Journal, 53(9), 465–466. PubMed 3. Teletronix Information Systems. (1978, January 24). Answer to Information Request [Letter to Eugene Syrovatka]
Figure 3: Tel-Med call summary from internal Academy report, 1992.
119
The DPH Bulletin
From the Delaware Division of Public Health Delaware meets President Biden’s COVID-19 vaccination goal before July 4 Governor John Carney announced that Delaware met President Biden’s initial COVID-19 vaccination goal on July 1.
July 2021 Willingness of Delaware parents and guardians to have children vaccinated for COVID-19
“Delawareans have pulled together, done their part and gotten vaccinated to protect their families, friends and communities…we reached President Biden’s target of 70 percent of adults receiving at least one shot of the COVID-19 vaccine by July 4,” Governor Carney said. “That’s a big deal. It’s why we’re beating this virus and moving past this pandemic after a long 16 months.” Division of Public Health (DPH) Director Dr. Karyl Rattay agreed, saying: “A huge thank you to everyone who has gotten vaccinated so far and helped us beat this virus back. Even as we celebrate this significant moment in time, we are continuing our efforts to get more Delawareans vaccinated. We especially want to encourage 18- to 34-year-olds who are most likely to be out and socializing with others to get the vaccine as soon as possible. It’s free, it’s safe, and it’s effective at preventing COVID, so don’t wait.” The state will reach another milestone on July 13, when Governor Carney intends to lift the State of Emergency Order that he signed on March 12, 2020. As of July 1, a total of 1,012,381 vaccine doses were administered and 109,770 positive cases and 1,694 deaths Photo by Sharon Smith. related to COVID19 were reported in Delaware according to DPH’s data portal, My Healthy Community. To find vaccination sites, visit de.gov/getmyvaccine or call 1-833-643-1715. At left, Delaware National Guard (DNG) member Lixin Wang vaccinates Melissa D. at Whatcoat Village Apartments in Dover. The DNG and the Division of Public Health set up a mobile vaccination unit there on June 15.
120 Delaware Journal of Public Health - July 2021
Delaware Rural Health Initiative lauded for its coordinated work on the opioid, mental health, and COVID-19 crises The Delaware Academy of Medicine/Delaware Public Health Association announced that the Delaware Rural Health Initiative (DRHI) received the Executive Director’s Public Health Recognition Award. The award is given to a Delaware nonprofit organization that has shown outstanding leadership and dedication to community improvement. "[It is] very heartening to see people coming together and to create a consensus agenda of issues to work on: the opioid crisis, the mental health crisis, and the response to the COVID crisis this past year,” said Division of Public Health (DPH) Director Dr. Karyl Rattay. “It really shows you how incredibly important partnerships are in addressing health issues.” DRHI addresses shared regional health concerns in a coordinated manner. Learn about DRHI’s work at https://dhss.delaware.gov/dhss/dph/chca/ruralhlthinit.html.
Avoid ticks to prevent Lyme disease Heat-related illnesses are dangerous
Heat-related illness occurs when a person’s body temperature rises faster than it can cool itself down. It can damage the brain and other vital organs. Heat stroke and heat exhaustion are the two most dangerous heat-related illnesses, according to the Centers for Disease Control and Prevention (CDC). The warning signs of heat stroke are: a body temperature above 103° Fahrenheit; red, hot, and dry skin with no sweating; a rapid, strong pulse; a throbbing headache; dizziness; nausea; confusion; and unconsciousness. Call 9-1-1 immediately to prevent death or permanent disability. Move victims to shade and spray them with water from a garden hose or immerse them in cool water. The warning signs of heat exhaustion are: heavy sweating; paleness; muscle cramps; tiredness; weakness; dizziness; headache; nausea or vomiting; fainting; cool and moist skin; a fast and weak pulse; and fast and shallow breathing. Have victims drink cool, non-alcoholic beverages; take cool showers, baths, or sponge baths; and rest in an air-conditioned place. Get medical attention if symptoms worsen or last longer than one hour. Untreated heat exhaustion can lead to heat stroke. Those at high risk of heat-related illness are infants and children 4 years old and younger, the elderly, outdoor workers, athletes, and people who are lowincome, obese, and have cardiovascular and mental health conditions. Other risks are having a fever or sunburn, being dehydrated, and drinking alcohol. During hot weather, drink cool water and non-alcoholic, non-caffeinated beverages every hour. Do not wait until you are thirsty. Stay in airconditioned places and wear light, loose-fitting clothing. For more information, visit the CDC at https://www.cdc.gov/disasters/extremeheat/heattips.html.
The DPH Bulletin – July 2021
Lyme disease, caused by bites from the blacklegged or deer tick, is the state’s most common tick-borne disease. The ticks can transmit the bacteria that causes Lyme disease, Borrelia burgdorferi, to humans and animals. Lyme disease symptoms include an expanding red, “bull’s-eye” rash, fever and chills, fatigue, severe headaches, muscle and joint aches, heart palpitations, dizziness, and Bell’s palsy (when facial muscles temporarily droop on one side). There may also be severe joint pain and swelling, particularly affecting the knees; and neck stiffness due to meningitis. Untreated infections can lead to serious, debilitating, and chronic joint, heart, and neurological problems. Those bitten by a tick who develop symptoms should immediately contact a physician. Oral antibiotics A “bull’s-eye” rash often accompanies Lyme cure most cases. disease. CDC photo.
The Division of Public Health (DPH) recommends taking these precautions (think “BLAST”): ● Bathe
or shower within two hours of coming inside.
● Look
for ticks and remove them from yourself, your children, and pets.
Apply tick repellent (containing less than 50 percent DEET for adults and less than 30 percent DEET for children) to the skin. Do not use repellents with DEET on infants younger than two months old. Repellents with permethrin should be used on shoes and clothing only.
●
● Safeguard
Adult female Blacklegged or deer tick. The species transmits the Lyme disease bacterium. CDC photo.
your yard by keeping grass mowed and creating a three-foot or wider mulch or gravel barrier between lawns and woods. Use plantings that do not attract deer, the main food source for adult ticks.
Treat dogs with a tick preventive product after consulting with a veterinarian. ●
For more information, visit DPH at dhss.delaware.gov/dhss/dph/epi/lyme.html and the Centers for Disease Control and Prevention at https://www.cdc.gov/ticks/index.html.
Page 2 of 2 121
Delaware Journal of
Public Health
Submission Guidelines
updated April, 2020
About the Journal Established in 2015, The Delaware Journal of Public Health is a bi-monthly, peer-reviewed electronic publication, created by the Delaware Academy of Medicine/Delaware Public Health Association. The publication acts as a repository of news for the medical, dental, and public health communities, and is comprised of upcoming event announcements, past conference synopses, local resources, peer-reviewed content ranging from manuscripts and research papers to opinion editorials and personal interest pieces, relating to the public health sector. Each issue is largely devoted to an overarching theme or current issue in public health. The content in the Journal is informed by the interest of our readers and contributors. If you have an event coming up, would like to contribute an Op-Ed, would like to share a job posting, or have a topic in public health you would like to see covered in an upcoming issue, please let us know. If you are interested in submitting an article to the Delaware Journal of Public Health, or have any additional inquiries regarding the publication, please contact DJPH Deputy Editor Elizabeth Healy at ehealy@delamed.org, or the Executive Director of The Delaware Academy of Medicine and Delaware Public Health Association, Timothy Gibbs, at tgibbs@delamed.org
Information for Authors Submission Requirements The DJPH accepts a wide variety of submission formats including brief essays, opinion editorials pieces, research articles and findings, analytic essays, news pieces, historical pieces, images, advertisements pertaining to relevant, upcoming public health events, and presentation reviews. If there is an additional type of submission not previously mentioned that you would like to submit, please contact a staff member.
Cover Letters must address the following four article requirements: 1. A description of what the paper adds to current knowledge, in particular with respect to material previously published in DJPH, and if systematic reviews exist on the topic. 2. The public health importance of the paper. 3. One sentence summarizing the main message(s) of the paper, which may be used to disseminate the paper on social media.
The initial submission should be clean and complete, without edits or markups, and contain both the title and author(s) fulls name(s). Submissions should be 1.5 or 4. For individual or group randomized trials, provide the double spaced with a font size of 12. Initial submissions date of trial registration and the NCT number from must also contain a cover letter with concise text www.Clinicaltrials.gov or other approved registry. (maximum 150 words). Once completed, articles In the cover letter only, not in the paper. Do NOT should be submitted via email to Elizabeth Healy at include the trial registration or NCT number in the ehealy@delamed.org as an attachment. Graphics, images, abstract or the body of the manuscript during the info-graphics, tables, and charts, are welcome and initial submission. encouraged to be included in articles. Please ensure that all pieces are in their final format, and all edits and track All manuscripts must be submitted via email to Elizabeth Healy at ehealy@delamed.org. changes have been implemented prior to submission. 122 Delaware Journal of Public Health - July 2021
To view additional information for online submission requirements, please refer to the website for the Delaware Journal of Public Health: https://djph.org/sample-page/submit-an-article/. Submission Length While there is no prescribed word length, full articles will generally be in the 2500-4000-word range, and editorials or brief reports will be in the 1500-2500-word range. If you have any questions regarding the length of a submission, or APA guidelines, please contact a staff member. Copyright Opinions expressed by contributors and authors do not necessarily reflect the opinions of the DJPH or affiliated institutions of authors. Copying for uses other than personal reference or interest without the consent of the DJPH is prohibited. All material submitted alongside written work, including graphics, charts, tables, diagrams, etc., must be referenced properly in accordance with APA formatting. Conflicts of Interest Any conflicts of interest, including political, financial, personal, or academic conflicts, must be declared prior to the submission of the article, or in conjunction with a submission. Conflicts of interest are any competing interests that may leave readers feeling misled or deceived, and/or alter their perception of subject matter. Declared conflicts of interest may be published alongside articles in the final electronic publication.
Additional Documents and Information for Authors Please Note: All authors and contributors are asked to submit a brief personal biography (3 sentences maximum) and a headshot along submissions. These will be published alongside final submissions in the final electronic publication. For pieces with multiple authors, these additional documents are requested for all contributors. Abstracts Authors must submit a structured or unstructured abstract along with their article. The word limit is 200 words, including headings. A title page should be submitted with this abstract as well. Structured abstracts should employ 4-5 headings: Objectives (begins with “To…”) Methods Results Conclusions A fifth heading, Policy Implications, may be used if relevant to the article. Trial Registration information is required for clinical trials and must be included in the final version abstract All abstracts should provide the dates(s) and location(s) of the study is applicable. Note: There is no Background heading.
Nondiscriminatory Language Use of nondiscriminatory language is required in all DJPH submissions. The DJPH reserves the right to reject any submission found to be using sexist, racist, or heterosexist language, as well as unethical or defamatory statements.
123
Index of Advertisers The Nation's Health. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 American Public Health Association ChristianaCare's Center for Special Health Care Needs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 ChristianaCare Making the Decision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Public Health Communications Collaborative LGBTQ+ Affirming Spaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Delaware Division of Public Health The DPH Bulletin - June 2021 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Delaware Division of Public Health MSD Press Release. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 Medical Society of Delaware Now What? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 Public Health Communications Collaborative The Impact of Diabetes in Delaware, 2021. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 Delaware Division of Public Health DHSS Press Release. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109 Delaware Division of Public Health The DPH Bulletin - July 2021. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120 Delaware Division of Public Health Submission Guidelines. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122 Delaware Journal of Public Health
124 Delaware Journal of Public Health - July 2021
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Delaware Academy of Medicine / DPHA 4765 Ogletown-Stanton Road Suite L10 Newark, DE 19713
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The Delaware Academy of Medicine is a private, nonprofit organization founded in 1930. Our mission is to enhance the well being of our community through medical education and the promotion ofpublic health. Our educational initiatives span the spectrum from consumer health education tocontinuing medical education conferences and symposia. The Delaware Public Health Association was officially reborn at the 141st Annual Meeting of the American Public Health Association (AHPA) held in Boston, MA in November, 2013. At this meeting, affiliation of the DPHA was transferred to the Delaware Academy of Medicine officially on November 5, 2013 by action of the APHA Governing Council. The Delaware Academy of Medicine, who’s mission statement is “to promote the well-being of our community through education and the promotion of public health,” is honored to take on this responsibility in the First State.
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