Eden V. Wells

Reptile-Associated Salmonellosis in Preschool-Aged Children in Michigan, January 2001–June 2003

OBJECTIVES Determine the incidence of reptile-associated salmonellosis in preschool-aged children in Michigan. METHODS Cases of reptile-associated salmonellosis in children < or =5 years of age occurring in Michigan January 2001-June 2003 were identified through review of individual patient case-history forms provided by local health departments to the Michigan Department of Community Health and by identification of Michigan Department of Community Health laboratory-confirmed cultures of reptile-associated serotypes, determined by evaluation of the Public Health Laboratory Information Systems Clinical Nonhuman Salmonella data for 1990-2001. RESULTS The incidence of reptile-associated salmonellosis was 11.8% of all Salmonella cases reported in Michigan children aged < or =5 years for the period January 2001 through June 2003. CONCLUSIONS Despite the recommendations of the Centers for Disease Control and Prevention to avoid the exposure of children <5 years old to reptiles, reptile-associated salmonellosis in preschool-aged children continues to be a public health problem in Michigan.

The role of applied epidemiology methods in the disaster management cycle

Disaster epidemiology (i.e., applied epidemiology in disaster settings) presents a source of reliable and actionable information for decision-makers and stakeholders in the disaster management cycle. However, epidemiological methods have yet to be routinely integrated into disaster response and fully communicated to response leaders. We present a framework consisting of rapid needs assessments, health surveillance, tracking and registries, and epidemiological investigations, including risk factor and health outcome studies and evaluation of interventions, which can be practiced throughout the cycle. Applying each method can result in actionable information for planners and decision-makers responsible for preparedness, response, and recovery. Disaster epidemiology, once integrated into the disaster management cycle, can provide the evidence base to inform and enhance response capability within the public health infrastructure.

Michigan Clostridium difficile Hospital Discharges: Frequency, Mortality, and Charges, 2002-2008

Objective. Clostridium difficile (C. difficile) causes an intestinal bacterial infection of increasing importance in Michigan residents and health-care facilities. The specific burden and health-care costs of C. difficile infection (CDI) were previously unknown. We evaluated the frequency, mortality, and health-care charges of CDI from Michigan hospital discharge data. Methods. The Michigan Department of Community Health purchased discharge data from all Michigan acute care hospitals from the Michigan Health and Hospital Association. We extracted all hospital discharges from 2002 through 2008 containing the International Classification of Diseases, Ninth Revision code for intestinal infection due to C. difficile. Discharges were stratified by principle diagnosis and comorbidity level. Total hospitalization charges were standardized to the 2008 U.S. dollar. Results. From 2002 through 2008, 68,686 hospital discharges with CDI occurred. The annual rate increased from 463.1 to 1096.5 CDI discharges per 100,000 discharges. CDI discharge rates were substantially higher among the elderly, females, and black people. Of all CDI discharges, 5,924 (8.6%) patients died. The mean total health-care charge for the time period was

Human rabies in Tianjin, China

67,149, and the annual mean increased 35% from 2002 to 2008. Hospital charges varied significantly by race/ethnicity and age. People with Medicaid insurance accrued the highest charges. Conclusion. Across Michigan, the CDI burden is growing substantially and affecting vulnerable populations. Surveillance utilizing hospital discharge data can illuminate trends and inform intervention targets. To reduce disease and health-care charges, increased prevention and infection-control efforts should be directed toward high-risk populations, such as the elderly.

Assessing integration of clinical and public health skills in preventive medicine residencies: using competency mapping.

BACKGROUND Human rabies has recently re-emerged as a significant public health threat in Tianjin, China. METHODS Using surveillance data compiled by the Tianjin Centers for Disease Control and Prevention, we describe 60 cases of human rabies reported from 2005 to 2011 in the municipality of Tianjin, China. RESULTS All 60 cases of human rabies resulted in death. Cases were primarily male (80%), middle aged (mean 40.6 years), and exposed to rabies in a rural setting (82%). Most exposures were associated with dog bites (93%) and no animal had a history of rabies vaccination; no cases were laboratory confirmed. Fifteen percent of patients sought medical attention for their wound, and none received a complete regimen of WHO-recommended post-exposure prophylaxis (PEP). CONCLUSIONS These findings suggest the need for Chinas public health authority to improve animal rabies surveillance and control strategies through laboratory case confirmation, more rapid response to potential exposures with provision of appropriate PEP, and education to the public and to health care providers on identifying and reducing rabies risk.

Assessing Integration of Clinical and Public Health Skills in Preventive Medicine Residencies: Using Competency Mapping

OBJECTIVES We evaluated the utility of a competency mapping process for assessing the integration of clinical and public health skills in a newly developed Community Health Center (CHC) rotation at the University of Michigan School of Public Health Preventive Medicine residency. METHODS Learning objectives for the CHC rotation were derived from the Accreditation Council for Graduate Medical Education core clinical preventive medicine competencies. CHC learning objectives were mapped to clinical preventive medicine competencies specific to the specialty of public health and general preventive medicine. Objectives were also mapped to The Council on Linkages Between Academia and Public Health Practices tier 2 Core Competencies for Public Health Professionals. RESULTS CHC learning objectives mapped to all 4 (100%) of the public health and general preventive medicine clinical preventive medicine competencies. CHC population-level learning objectives mapped to 32 (94%) of 34 competencies for public health professionals. CONCLUSIONS Utilizing competency mapping to assess clinical-public health integration in a new CHC rotation proved to be feasible and useful. Clinical preventive medicine learning objectives for a CHC rotation can also address public health competencies.

The impact of supplementary immunization activities on the epidemiology of measles in Tianjin, China.

PURPOSE To evaluate the utility of a competency mapping process for assessing the integration of clinical and public health skills in a newly developed Community Health Center (CHC) rotation at the University of Michigan School of Public Health Preventive Medicine residency. METHODS Learning objectives for the CHC rotation were derived from the Accreditation Council for Graduate Medical Education core clinical preventive medicine competencies. CHC learning objectives were mapped to clinical preventive medicine competencies specific to the specialty of public health and general preventive medicine. Objectives were also mapped to The Council on Linkages Between Academia and Public Health Practices Tier-2 Core Competencies for Public Health Professionals. RESULTS CHC learning objectives mapped to all four (100%) of the public health and general preventive medicine clinical preventive medicine competencies. CHC population-level learning objectives mapped to 32 (94%) of 34 competencies for public health professionals. CONCLUSIONS Utilizing competency mapping to assess clinical-public health integration in a new CHC rotation proved to be feasible and useful. Clinical preventive medicine learning objectives for a CHC rotation can also address public health competencies.

The Effect of Reactive School Closure on Community Influenza-Like Illness Counts in the State of Michigan During the 2009 H1N1 Pandemic

OBJECTIVES China has repeatedly used supplemental immunization activities (SIAs) to work towards measles elimination, but it is unknown if the SIAs are reaching non-locals - migrants from rural to urban areas. This study characterized temporal trends in measles incidence by local and non-local residency and evaluated the impact of SIAs on measles incidence in Tianjin, China. METHODS Daily measles case-counts were tabulated separately by residency. These two datasets were combined so that each day had two observations. Poisson regression was conducted using generalized estimating equations with an exchangeable working correlation structure to estimate rate ratios (RRs). RESULTS There were 12465 measles cases in Tianjin over the 10-year period. The rate of measles was higher in non-locals than locals before the 2008 SIA (RR 3.60, 95% confidence interval (CI) 3.27-3.96), but this attenuated to a RR of 1.22 between the 2008 and 2010 SIAs (95% CI 1.02-1.45). Following the 2010 SIA, non-locals had a lower rate of measles (RR 0.78, 95% CI 0.69-0.87). CONCLUSIONS The disparity in measles incidence between locals and non-locals was reduced following two SIAs. Sustained public health interventions will be needed to maintain low measles incidence among non-locals given the ongoing migration of people throughout China.

Knowledge, Attitudes, and Practices of Nonpharmaceutical Interventions following School Dismissals during the 2009 Influenza A H1N1 Pandemic in Michigan, United States

BACKGROUND In sum, 559 Michigan schools were closed as a nonpharmaceutical intervention during the influenza A 2009 (H1N1) pandemic. METHODS By linking the proportion of schools closed within a district to state influenza-like illness (ILI) surveillance data, we measured its effect on community levels of ILI. This analysis was centered by the peak week of ILI for each school district, and a negative binomial model compared three levels of school closure: 0%, 1%-50%, and 51%-100% of schools closed from three weeks leading up to ILI peak to four weeks following ILI peak rate. RESULTS We observed that school closures were reactive, and there was no statistically significant difference between ILI rates over the study period. There was an elevated rate ratio for ILI at 51%-100% closure, and a reduction in the rate ratio at the 1%-50% compared to the 0% closure level. CONCLUSIONS These findings suggest that district level reactive school closures were ineffective.

On-time Measles and Pneumococcal Vaccination of Shanghai Children: The Impact of Individual-level and Neighborhood-level Factors

Background Many schools throughout the United States reported an increase in dismissals due to the 2009 influenza A H1N1 pandemic (pH1N1). During the fall months of 2009, more than 567 school dismissals were reported from the state of Michigan. In December 2009, the Michigan Department of Community Health, in collaboration with the United States Centers for Disease Control and Prevention, conducted a survey to describe the knowledge, attitudes, and practices (KAPs) of households with school-aged children and classroom teachers regarding the recommended use of nonpharmaceutical interventions (NPIs) to slow the spread of influenza. Methods A random sample of eight elementary schools (kindergarten through 5th grade) was selected from each of the eight public health preparedness regions in the state. Within each selected school, a single classroom was randomly identified from each grade (K-5), and household caregivers of the classroom students and their respective teachers were asked to participate in the survey. Results In total, 26% (2,188/8,280) of household caregivers and 45% (163/360) of teachers from 48 schools (of the 64 sampled) responded to the survey. Of the 48 participating schools, 27% (13) experienced a school dismissal during the 2009 fall term. Eighty-seven percent (1,806/2,082) of caregivers and 80% (122/152) of teachers thought that the 2009 influenza A H1N1 pandemic was severe, and >90% of both groups indicated that they told their children/students to use NPIs, such as washing hands more often and covering coughs with tissues, to prevent infection with influenza. Conclusions Knowledge and instruction on the use of NPIs appeared to be high among household caregivers and teachers responding to the survey. Nevertheless, public health officials should continue to explain the public health rationale for NPIs to reduce pandemic influenza. Ensuring this information is communicated to household caregivers and teachers through trusted sources is essential.