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Channeling John Snow: Poisoning Data for HIV/HCV Prevention

Posted By Nate Wright, Tuesday, December 27, 2016
Updated: Tuesday, December 20, 2016

It is difficult to distill my experiences as a CSTE Applied Epidemiology Fellow (AEF) in the Minnesota Department of Health (MDH) into one blog post. I hit the ground running from day one of my fellowship and have been enjoying the experiences ever since. Primarily, my work focuses on suicide and drug overdose, but those topics encompass and overlap considerably with other related public health matters. For example, my projects have included evaluating Minnesota’s Violent Death Reporting System, examining American Indian drug overdose deaths in Minnesota, working with Minnesota’s American Indian community to address the drug overdose crisis, and providing epidemiological assistance to a concerned Minnesota community that saw an increase in suicides from a bridge. I have also presented at local, state, regional, and national conferences, and have produced work for various publications. These are some of the projects I expected from my AEF, but I have also been involved with projects I never would have anticipated, such as evaluating the public health impact of a new statute in Minnesota that allows for religious objections to autopsies.

One project that I am proud of, and has been rewarding to work on, has been our efforts to better understand counties in Minnesota that may be at higher risk for an outbreak of HIV or Hepatitis C Virus (HCV) associated with injection drug use. The 2014 outbreak of HIV associated with injection drug use in Indiana raised concerns about the ability to detect and respond to a similar outbreak in Minnesota. A workgroup at the MDH was convened with participation from both infectious disease and injury prevention units. The goal was to identify potentially high risk areas for an outbreak of HIV or HCV, as well as where future resources for treatment and prevention of HIV or HCV should be placed in Minnesota.

We identified currently available data sources that could provide insight into counties at greater risk of an outbreak. The results of our analyses validated current knowledge of locations throughout Minnesota with a greater number of drug poisoning hospitalizations and cases of HIV or HCV. However, the findings also highlighted areas of the state with greater numbers of poisoning hospitalizations, but fewer cases of HIV or HCV. These areas may be at greater risk of an infectious disease outbreak, and it may be beneficial to target them with prevention measures, such as disease screening, referral to care, and syringe exchange programs.

At about the same time I completed our analysis, the Centers for Disease Control and Prevention (CDC) released a similar analysis titled, “County-level Vulnerability to Rapid Dissemination of HIV/HCV Infection among Persons who Inject Drugs.” The goals of the CDC analysis were similar to ours, except the CDC analyzed data for all counties in the United States and used a more sophisticated statistical method. The CDC report only published results for the highest risk counties in the United States, of which there were no Minnesota counties. However, the methods of the CDC analysis were replicated at the MDH with Minnesota county data to compare the MDH method and the CDC method. The two methods ultimately identified a similar group of counties in Minnesota that were found to be at higher potential risk for an outbreak of disease. The methods and data used in the statistical model continue to be refined to more accurately represent the population and risk factors in Minnesota to ensure it provides the most accurate picture of risk across the state. We’ve presented the results of this project at state and national conferences, and they will continue guide our thinking at the MDH as to how to address and prevent drug poisoning hospitalizations and HIV or HCV infection from occurring. There’s also potential for these results to help inform state policymakers as they seek legislative solutions to substance abuse.



CSTE Applied Epidemiology Fellow Nate Wright presents his work before administration officials at the Substance Abuse and Mental Health Services Administration.

This project was particularly interesting because it brought together units of the MDH that often don’t have an opportunity to collaborate. Each unit brought their area of expertise to the table to work together to address this problem. For me, this project brought home the point that we as public health practitioners can accomplish more by working with each other and across our units. Bringing together colleagues with different perspectives on complex public health challenges helps push public health forward and improve the health of Minnesotans and our communities.

These project examples highlight a few of the tangible accomplishments of my AEF, but I have also grown personally and professionally as a result of these experiences. I strive to fully understand the data, including their strengths and limitations, and potential policy implications of findings. I’ve been reminded through meetings with those in my community that ultimately there are people behind the numbers—the data are representative of the true public health challenges facing people in the community that we are working to address.

The AEF has afforded me opportunities that few other recent graduates and new employees experience. My mentors have been wonderful and have provided the guidance and expertise to ensure my fellowship has been an extraordinary time as part of the Injury and Violence Prevention Section. As I reflect back on the first year of my fellowship, I begin to understand the wonderful experiences this fellowship has offered and I look forward to the work and opportunities that are still to come in my fellowship and beyond.


 
Nate Wright is a CSTE Applied Epidemiology Fellow in the Minnesota Department of Health. He is a graduate of the University of Minnesota School of Public Health where he received his Masters of Public Health in Epidemiology. Mr. Wright’s post is the first in a series of blogs by CSTE Applied Epidemiology Fellows to be posted in the coming weeks.
 

Tags:  data  epidemiology  Fellowship  Substance Abuse  Surveillance  Workforce development 

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Using Childhood Adversity Data to Improve Adult Health

Posted By Anna Austin, Thursday, October 30, 2014
As a CDC/CSTE Applied Epidemiology fellow in the Injury and Violence Prevention branch at the North Carolina Division of Public Health, one project that has particularly developed my skills as an epidemiologist and public health professional relates to adverse childhood experiences (ACEs). ACEs are traumatic or stressful events experienced before age 18 and include eight categories of childhood abuse and household dysfunction, such as physical, sexual, and emotional abuse; adult substance abuse; and household domestic violence.

A growing body of evidence shows that these early experiences are common and can have long-lasting effects on mental and physical wellbeing. Findings from the original 1995-1997 ACE Study showed a strong, graded relationship between ACEs and several poor health outcomes in adulthood. As the number of ACEs a person experiences increase, what also increases are the risks of alcohol and drug abuse, obesity, suicidality, depression, intimate partner violence, heart disease, and a range of other poor health outcomes in adulthood. Data specific to ACEs among North Carolinians first became available in 2012 when questions about ACEs were included on the North Carolina Behavioral Risk Factor Surveillance System survey. My task was to analyze this data and create North Carolina’s first state report on the topic.

The findings from the state report mirror the findings of the original ACE study. ACEs were found to be common among North Carolinians: 58% reported at least one ACE and 22% reported three or more ACEs. Over a quarter of North Carolinians reported having grown up with an adult who was abusing alcohol or drugs, and one in 10 reported sexual abuse by an adult. In addition, ACEs were found to cluster among North Carolinians—if a person reported having experienced one ACE, it was highly likely that he/she had also experienced additional ACEs. Lastly, the results showed that the risk of smoking, binge drinking, and obesity as well as HIV-risk behaviors, poor physical and mental health, chronic obstructive pulmonary disease, cardiovascular disease, arthritis, depression, and disability in adulthood increased as the number of ACEs reported increased.

The finding that ACEs impact health outcomes in adulthood, long after the events have occurred, supports ACE prevention as an effective long-term strategy for population health and highlights the importance of a life-course perspective in such prevention efforts. The finding that ACEs impact a wide range of outcomes from social, emotional, and behavioral problems to chronic diseases presents an opportunity to foster collaboration among diverse stakeholders and suggests such collaboration will be important to successful ACE prevention. Increasing awareness of ACEs as a public health issue will be important in North Carolina for mobilization.

We are engaging stakeholders from across the state to support local prevention efforts. I presented the findings from the state report at the North Carolina Public Health Association Conference alongside colleagues from the Innovative Approaches Initiative in Buncombe County. This initiative is developing a toolkit and website to educate local primary care providers on ACEs, connect them to local resources, and provide referral options for affected children and families. I have also collaborated with Harry Herrick, a survey analyst at the North Carolina State Center for Health Statistics, to respond to requests for data regarding ACEs among special populations, such as current smokers and persons with disabilities. I am also currently working on a multi-state study of ACEs among persons who identify as gay, lesbian, and bisexual. Ideally, data from each of these studies will help inform programs and policies aimed at ACE prevention and the enhancement of current efforts. This project has proved invaluable to my experience as a fellow, and I am extremely grateful for the opportunities, support, and guidance my mentors and colleagues have provided throughout the process.

Anna Austin, MPH is the CDC/CSTE Applied Epidemiology Fellow at the North Carolina Division of Public Health. In addition to this project, Anna has linked prescription drug overdose data from multiple sources, served on the leadership team developing the 2015 North Carolina Suicide Prevention Plan, and written surveillance reports on motor vehicle crash-related injuries.
Would you like to host or be a CDC/CSTE Applied Epidemiology fellow? Find out how. To learn more about ACEs, take a look at the CDC Injury Prevention and Control page.

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Tags:  adverse childhood experiences  data  fellowship  member spotlight  substance abuse 

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Charting an Epidemic, Confronting an Epidemic

Posted By Sara Ramey, Wednesday, February 12, 2014
Updated: Wednesday, February 12, 2014
Untitled Document
The governor of Vermont got a lot of attention when he dedicated his entire State of the State address to one topic: heroin. That attention was highly warranted because opioid abuse, prescription and non-prescription alike, is a major epidemic in this country, and epidemiologists are charting this epidemic and its consequences in many ways.

Prescription monitoring programs seek patterns consistent with “doctor shopping”, forgery and other diversion. Substance abuse programs track drug seizures and treatment admissions to follow patterns of abuse. Epidemiology programs track newly diagnosed cases of hepatitis C. Overdoses and overdose deaths are tracked in emergency departments and through vital records. All of these important surveillance systems track the underlying problem (addiction and substance abuse) and the consequences (overdose, infection, interaction with the criminal justice system). But, beyond counting, the epidemiologist must also be an advocate for using the data for action.
In Massachusetts, between 1990 and 2010, drug overdose deaths tripled, exceeding motor vehicle related death rate in 2000, and doubling it by 2010. These observations led to resources for the technical and programmatic enhancement of the prescription monitoring program and, in 2007, the initiation of a naloxone (Narcan®) program to train first responders, public safety officials and family members to administer the opiate receptor antagonist naloxone by nasal spray to potential overdoses. The program has resulted in the reversal of over 2,000 overdoses, so far, and an instance where drug users followed a police car to alert them so that they could reverse an overdoses. The philosophy is that one has to survive to kick the habit. Driven by the data, federal and state funding has also gone to community prevention programs and multi-community Opioid Abuse Prevention Collaboratives.
The Massachusetts Department of Public Health has observed increasing numbers of reported cases of hepatitis C virus infection in people between the ages of 15 and 25; the rate almost doubling between 2002 and 2012, while newly diagnosed cases went down in other age groups. These 15-25 year-olds almost certainly acquired their infection well within the previous 10 years. While much attention has been appropriately directed toward the hepatitis C epidemic in the “baby boomer” generation, hepatitis C in adolescents and young adults represents a new epidemic wave of hepatitis C. All indications are that these infections were acquired through injection drug use. Interviews are difficult to obtain, but the most common story is prescription opioid use leading to injection of prescription opioids and heroin. Heroin is cheaper than prescription drugs and all too available. Because of the difficulty in getting enough data from interviews to explore the networks of transmission of hepatitis C among adolescents and young adults, we are exploring sequencing of hepatitis C viruses that come to our public health laboratory to try to use the virus RNA sequences to construct networks. There hasn’t been much HIV co-infection yet, but that may be just a matter of time before that virus is introduced into these networks.
While the hepatitis C data are overwhelming, both in their implications for the future and the sheer number of new reports (in Massachusetts, now one to two thousand positive laboratory reports for hepatitis C in the age group each year), an approach to this massive epidemic is not easily identified. Of course, there should be every and all attempts to prevent and treat addiction. But what can be done in the meantime? As epidemiologists and public health professionals, we cannot just watch this tsunami of hepatitis C cases without actively encouraging the use of data to inform interventions, be they harm reduction approaches directed at safer injection or using observational data and network analysis to identify means of getting prevention and treatment messages to those at risk and infected.
Alfred DeMaria, MD
State Epidemiologist
Massachusetts Department of Health

Tags:  infectious disease  member spotlight  substance abuse  surveillance 

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