Patricia Sweeney

Public Goods, Private Data: HIV and the History, Ethics, and Uses of Identifiable Public Health Information

b d Public health departments collect a vast array of identifiable information in the course of mandatory reporting efforts and other surveillance activities. These undertakings span a range of conditions from infectious threats and chronic diseases including cancer, to immunization status and birth defects. Advocates for expanded surveillance extended the practice to occupational diseases and, most ambitiously, to profiles of childhood health status. Syndromic surveillance is also increasingly undertaken in the new post-September 11 security environ - ment. In the one Supreme Court case addressing public health surveillance, a unanimous tribunal upheld the right of the state to conduct surveillance. 1

Improving Competencies for Public Health Emergency Legal Preparedness

This paper is one of the four interrelated action agenda papers resulting from the National Summit on Public Health Legal Preparedness (Summit) con-vened in June 2007 by the Centers for Disease Con-trol and Prevention, and multi-disciplinary partners. Each of the action agenda papers deals with one of the four core elements of legal preparedness: laws and legal authorities; competency in using those laws; and coordination of law-based public health actions; and information. This action agenda offers options for consideration by those responsible for or interested in ensuring that public health professionals, their legal counsels, and relevant partners understand the legal framework in which they operate and are competent in applying legal authorities to public health emergency preparedness. Competencies are critical to an individual’s ability to make effective legal response to all-hazards public emergencies. The accompanying assessment paper outlines the state of existing competencies in public health legal preparedness by discussing the develop-ment of public health emergency competencies and public health law competencies and identifies gaps in competencies that detract from attainment of the goal of full legal preparedness for public health emer-gencies.

School closure as an influenza mitigation strategy: how variations in legal authority and plan criteria can alter the impact

BackgroundStates’ pandemic influenza plans and school closure statutes are intended to guide state and local officials, but most faced a great deal of uncertainty during the 2009 influenza H1N1 epidemic. Questions remained about whether, when, and for how long to close schools and about which agencies and officials had legal authority over school closures.MethodsThis study began with analysis of states’ school-closure statutes and pandemic influenza plans to identify the variations among them. An agent-based model of one state was used to represent as constants a population’s demographics, commuting patterns, work and school attendance, and community mixing patterns while repeated simulations explored the effects of variations in school closure authority, duration, closure thresholds, and reopening criteria.ResultsThe results show no basis on which to justify statewide rather than school-specific or community-specific authority for school closures. Nor do these simulations offer evidence to require school closures promptly at the earliest stage of an epidemic. More important are criteria based on monitoring of local case incidence and on authority to sustain closure periods sufficiently to achieve epidemic mitigation.ConclusionsThis agent-based simulation suggests several ways to improve statutes and influenza plans. First, school closure should remain available to state and local authorities as an influenza mitigation strategy. Second, influenza plans need not necessarily specify the threshold for school closures but should clearly define provisions for early and ongoing local monitoring. Finally, school closure authority may be exercised at the statewide or local level, so long as decisions are informed by monitoring incidence in local communities and schools.

Date of First Positive HIV Test: Reliability of Information Collected for HIV/AIDS Surveillance in the United States

Objectives. This study examined the reliability of the first positive HIV test date reported in the U.S. HIV/AIDS Reporting System (HARS). This date is essential to determine case counts for resource allocation for HIV treatment and prevention efforts. Methods. The dates of first positive HIV tests reported by individuals with HIV in an interview survey conducted in 16 states (n=16,394, interviewed 1995–2002) were compared with the dates of HIV diagnosis reported to HARS. The percentage of agreement for the year of diagnosis and the weighed kappa (k) with 95% confidence intervals (CIs) was calculated. Results. Self-reported year of diagnosis agreed with the year of diagnosis in HARS for 56% of date pairs (k=0.69; 95% CI 0.68, 0.70); 30% reported an earlier diagnosis year. Agreement differed by sex, age, race, exposure, and reason or place of testing (p<.01). Lower agreement was found when the self-reported diagnostic test was anonymous (k=0.57; 95% CI 0.52, 0.62) compared with confidential tests (k=0.66; 95% CI 0.64, 0.68). Lower agreement was also found for cases first reported with AIDS (k=0.58; 95% CI 0.55, 0.62) compared with cases first reported with HIV not AIDS (k=0.71; 95% CI 0.70, 0.73) as well as for participants interviewed three years or more after their HARS diagnosis date (k=0.55; 95% CI 0.52, 0.57) compared with those interviewed within one year (k=0.62; 95% CI 0.61, 0.63). More than 20% of participants in almost all groups, however, reported earlier diagnosis years than those recorded in HARS. Conclusion. As many as 30% of HIV diagnoses may have occurred earlier than recorded in HARS. Additional studies need to determine mechanisms to adequately capture diagnosis dates in HARS.

Performance indicators for response to selected infectious disease outbreaks: a review of the published record

The purpose of this study was to determine whether published reports of infectious disease outbreaks could serve as a source of evidence for public health practice, particularly in responding to bioterrorism. Such performance indicators are measures of practice and process that lead to optimal health outcomes. We collected data from 116 individual articles that described 59 outbreaks of eight different pathogens with potential for bioterrorist use. Analysis of these reports determined whether they addressed 12 process indicators and four outcome indicators--each generally recognized as a component of effective outbreak response. The results showed that outbreak reports typically included information about these process and outcome indicators, thus validating their practical importance. However, few reports had been written with specificity to document the chronology of outbreak response, or the dissemination of information to protect healthcare workers, or the communication with law enforcement and emergency operations that are important in response to bioterrorism. We conclude that the published record of infectious disease outbreaks can, in the future, be used as a source for practice-based evidence if agreed-upon measures for effective performance become standard components of outbreak reports.

Hospital policies, state laws, and healthcare worker influenza vaccination rates.

This study used hierarchical linear modeling to determine the relative contribution of hospital policies and state laws to healthcare worker (HCW) influenza vaccination rates. Hospital mandates with consequences for noncompliance and race were associated with 3%-12% increases in HCW vaccination; state laws were not significantly related to vaccination rates.

Association of State Laws and Healthcare Workers’ Influenza Vaccination Rates

State laws are being used to increase healthcare worker (HCW) influenza vaccine uptake. Approximately 40% of states have enacted such laws but their effectiveness has been infrequently studied. Data sources for this study were the 2000-2011 U.S. National Health Interview Survey Adult Sample File and a summary of U.S. state HCW influenza vaccination laws. Hierarchical linear modeling was used for two time periods: 1) 2000-2005 (before enactment of many state laws) and 2) 2006-2011 (a time of increased enactment of state HCW influenza vaccination legislation). During 2000-2005, two states had HCW influenza vaccination laws and HCW influenza vaccination rates averaged 22.5%. In 2006-2011, 19 states had such laws and vaccination rates averaged 50.9% (p < 0.001). The likelihood of HCW vaccination increased with the scope and breadth, measured by a law score. Although laws varied widely in scope and applicability, states with HCW influenza vaccination laws reported higher HCW vaccination rates.

Transition from Response to Recovery: A Knowledge Commons to Support Decision Making Following the 12 January 2010 Haiti Earthquake

The transition between disaster response operations and sustainable recovery represents a critical stage in rebuilding communities following disaster. We document this transition process following the 12 January 2010 earthquake in Haiti through direct field observation, review of documents and official situation reports, as well as interviews with key managers from organizations engaged in disaster operations in Haiti. Without an effective transition to recovery, disaster-stricken communities risk escalating failures in performance of key technical functions that underlie the provision of basic services in health, housing, education, commercial activity, and environmental restoration essential to building a resilient society. The interactions among social, environmental and technical systems are rarely tracked systematically, but are central to the longer-term economic, social, and technical development of a disaster-resilient community. We propose developing a “knowledge commons” infrastructure—multilingual, interdisciplinary, and interjurisdictional—to sustain a system-wide learning process as a primary goal for the reconstruction of Haiti.

Social network analysis: a novel approach to legal research on emergency public health systems.

T he public health system (PHS) involves many agencies and organizations working together. Systems function to connect, coordinate, and provide feedback among separate agents to fulfill specific purposes. On the basis of previous consensus reporting3 and research,4 the PHS is made up of governmental public health agencies, hospitals, communitybased health care providers, law enforcement, faith institutions, emergency medical services, and others. A critical purpose of the PHS is to prevent, protect against, quickly respond to, and recover from emergencies with public health consequences. Statutes, regulations, plans, and protocols define emergency PHSs— for example, by outlining scopes of authority for governmental agencies, mandating mutual responsibilities (such as, communication and reporting) among agencies and community organizations, and establishing when emergency conditions warrant the departure from routine practices. In the effort to understand how laws and policies define the PHS for emergency purposes, traditional legal researchers can borrow from the methods of social network analysts. Previous studies have applied network analysis to communication patterns of workers within local health departments and interrelationships within public health agencies, cooccurrence of words and citation patterns in the US Code, and citation patterns in French legal codes. The network analysis tool might equally well provide a way to analyze the qualities of emergency PHS networks. In preliminary studies, we have combined legal analysis of statutes and policies with network analysis to explore the relationships among agents in state PHSs for emergency purposes. Eleven states were selected for national geographic diversity, variation of population density, and risk profile variation: Alaska, California,

State courts and public health: building partnerships to enhance preparedness.

Laws and regulations can facilitate or impede emergency preparedness and response activities. State legislators, judges, and lawyers play critically important roles in creating and interpreting laws that affect the ability of public health practitioners and their partners to effectively respond to emergencies. In an age when political unrest, global travel, and emerging biological threats can combine to create social and economic havoc worldwide, it is critical that those responsible for upholding the rule of law during emergencies understand the law and its implications. In 2003, the University of Pittsburgh Center for Public Health Preparedness (UP-CPHP) created a Preparedness Law and Policy Program to advance legal preparedness for public health emergencies across Pennsylvania and the nation. To achieve this goal, UP-CPHP has partnered with local, state, and national organizations. In the course of these activities, Pennsylvania judges, the Administrative Office of Pennsylvania Courts, UP-CPHP, and the Centers for Disease Control and Preventions Public Health Law Program have developed a strong and enduring collaborative relationship that has put the Pennsylvania judiciary in a better position today to plan for and respond to a public health crisis than it has been at any other point in its history. The tools and resources developed through this collaboration can readily be adapted to assist other jurisdictions nationwide in their efforts to ensure that their judicial systems are similarly prepared.