Widespread Community Transmission of Hepatitis A Virus Following an Outbreak at a Local Restaurant - Virginia, September 2021-September 2022.

Hepatitis A is a vaccine-preventable liver infection caused by the hepatitis A virus (HAV); it is transmitted through ingestion of food or drink that has been contaminated by small amounts of infected stool, or through direct contact, including sexual contact, with a person who is infected (1). After years of historically low rates of hepatitis A in the United States, the incidence began increasing in 2016, with outbreaks characterized by person-to-person HAV transmission among persons who use drugs, persons experiencing homelessness, and men who have sex with men (2,3). As of September 2022, 13 states were experiencing outbreaks, including Virginia (3). In September 2021, the Roanoke City and Alleghany Health Districts (RCAHD) in southwestern Virginia investigated an outbreak of hepatitis A. The outbreak, which resulted in 51 cases, 31 hospitalizations, and three deaths, was associated with a food handler who was infected. After the outbreak, the community experienced ongoing person-to-person transmission of HAV, predominantly among persons who use injection drugs. As of September 30, 2022,* an additional 98 cases had been reported to RCAHD. The initial outbreak and community transmission have exceeded US$3 million in estimated direct costs (4,5). This report describes the initial outbreak and the ongoing community transmission of HAV. Increasing vaccination coverage among persons with risk factors for hepatitis A infection is important, including among those who use drugs. Strengthening community partnerships between public health officials and organizations that employ persons with risk factors for acquisition of HAV could help to prevent infections and outbreaks.

A local health department's journey to the summit: a case study of a decade of quality improvement.

As the interest in quality improvement (QI) efforts in public health agencies gathers momentum, organizations looking to initiate or strengthen QI processes may benefit from learning about existing programs. This article serves as a case study for other agencies to consider as they embark upon their QI journey. Specifically, this article reviews more than a decade of QI efforts in a mid-sized local health department and highlights areas of success (including an annual QI summit), barriers to implementation of QI, and areas needing improvement.

Appraising outbreak investigation skills in a public health emergency: an examination based on an actual event.

The purpose of this article is to provide a method of appraising skills in surveillance, assessment, and public health emergency investigation by using an examination based on an actual outbreak occurrence. This article presents an examination that uses a problem-based approach that works sequentially through the steps of an outbreak investigation to assess the investigation skills of individual students. Designed for graduate public heath students enrolled in a course in infectious disease epidemiology at East Carolina University, the examination can be used to appraise the outbreak investigation skills of medical students or practitioners.

A case exercise in public health preparedness: a community outbreak of influenza-like illness.

Public health emergency preparedness has been a priority of local and state health departments as well as other community partners for several years. This article provides a tool for teaching a wide audience of learners the essential steps in training for a disease outbreak. This teaching case involves an investigation of and the community's response to an outbreak of influenza-like illness. Students learn skills in surveillance and hypothesis generation with regard to the outbreak. During the exercise, the learners are divided into teams to develop a response plan. The teams include Command and Coordination, Public Communication, Hospitals and Health Care Providers, Emergency Management and Public Safety, and Public Health. While the teams are developing their response plan, the etiology of the outbreak becomes clear. Once the etiology is known, each of the teams then develops an action plan to minimize the impact of the outbreak.

Determining local colorectal cancer screening utilization patterns.

Appropriate screening for colorectal cancer saves lives, yet many Americans at average risk for this disease are not being screened. This article presents the results of an inexpensive, manageable telephone survey that can be used by health departments to determine point prevalence estimates for colorectal cancer screening in their community and to determine local barriers to screening. In Onondaga County, this survey demonstrated that only 17% of the eligible population had been screened with annual fecal occult blood test and a flexible sigmoidoscopy. The study also demonstrated that locally the most significant barrier to screening was lack of knowledge of the importance of such testing. Finally, health care professionals were shown to play a pivotal role in improving the health of their patient population by encouraging screening for colorectal cancer.

Case-based teaching in preventive medicine: rationale, development, and implementation.

The importance of prevention teaching is increasingly recognized in medical education, but its implementation in medical school curricula is hampered by its cross-specialty nature, lack of curricular time, and perception as a topic of less importance than the traditional basic and clinical sciences. The Case-Based Series in Population-Oriented Prevention (C-POP) was developed to address national objectives for prevention education in a format that recognizes the students' abilities and preferences for case-based learning. This series uses small-group discussion cases that can be adapted to a variety of settings and instructor capabilities. These cases guide the learners from a specific clinical problem to the broader clinical and population-based prevention issues for the topic. The cases were developed with the use of local health department scenarios and data and have been taught and refined in a number of settings. As part of the curriculum development project, evaluation tools that examined prevention skills and orientation were developed and tested. With its emphasis on small-group learning, clinical relevance, and adaptability to a variety of learner and instructor needs, the C-POP project effectively integrates prevention concepts into medical education.

Evaluation of a preventive medicine curriculum: incorporating a case-based approach.

BACKGROUND: Evaluating the acquisition of skills in prevention is an increasing priority in prevention education. Assessment instruments were developed to measure student skills before and after an education intervention at State University of New York (SUNY)-Upstate Medical University. METHODS: The evaluation method used three testing instruments that measure preventive medicine skills. We selected three surrogate topics, each their own instrument: sexually transmitted disease, lead toxicity, and ischemic heart disease. All three instruments measure four key preventive medicine skills areas: (1) using and interpreting data sources; (2) measuring disease frequency, including incidence and prevalence; (3) making inferences and identifying bias in data presentations; and (4) identifying appropriate study design and screening tests. Second-year medical students were assessed before and after our preventive medicine course in spring 2002, using our evaluative instruments. RESULTS: Before and after instruction analysis, overall, and by skills area tested revealed a significant increase in student preventive medicine skills (p< or =0.001) in all four categories. On conclusion of the case-based curriculum, students were also asked to rate the cases. The majority (60%) of the students thought the cases were of value to their medical education, and 58% believed that they added to their skills in population prevention. CONCLUSIONS: These instruments can measure change in preventive medicine skills before and after a course in preventive medicine.

Measuring orientation to population-based prevention.

BACKGROUND: Assessing orientation to population-based preventive alternatives is useful in the evaluation of preventive medicine curricula. METHODS: An instrument was developed using hypothetical situations describing a health issue that could be encountered by a primary care physician. Options to be selected were in three categories: (1) treatment, (2) clinical prevention, or (3) population-based prevention. Respondents allocated 900 points among alternatives for nine situations (100 points per situation). Pilot testing of the instrument was implemented, comparing the responses of public health physicians with two groups (Syracuse and Baltimore) of family medicine physicians. RESULTS: For the overall instrument, the scores on the population scale and population-treatment differential showed statistically significant differences between the public health physicians and both groups of family medicine physicians (p<0.01). For medical students taught the Case-Based Series in Population-Oriented Prevention (C-POP), there was an overall increase in the population scale (p<0.0001) and the population-treatment differential (p<0.0004). CONCLUSIONS: The development of a scenario-based tool to assess changes in population-based prevention orientation shows preliminary promise for future evaluation efforts involving preventive medicine curricula.

Community health assessment.

This case-community health assessment-is one of a series of teaching cases in the Case-Based Series in Population-Oriented Prevention (C-POP). It has been developed for use in medical school and residency prevention curricula. The complete set of cases is presented in this supplement to the American Journal of Preventive Medicine. Community health assessment is key to understanding the health problems and priorities of a population. This case outlines a process by which the participants can complete a health assessment of a community using indicator-based methods. Students construct a set of health indicators from a variety of domains, evaluate problems, and report on the health priorities for a community. The students relate identified health issues to underlying behavioral risk factors.

Outbreak of tuberculosis in a homeless men's shelter.

This case-tuberculosis in a homeless men's shelter-is one of a series of teaching cases in the Case-Based Series in Population-Oriented Prevention (C-POP). It has been developed for use in medical school and residency prevention curricula. The complete set of cases is presented in this supplement to the American Journal of Preventive Medicine. Tuberculosis presents a significant public health challenge. In this teaching case, medical students are given information about four cases of active tuberculosis that occurred over a short period of time in residents of a homeless men's shelter. The students then walk through the steps that a local health department takes to identify and screen those individuals at risk for transmission of tuberculosis during an outbreak. During this process, they learn skills in epidemiology (such as defining "epidemic" and distinguishing uses for incidence and prevalence) as well as in population-based prevention of tuberculosis. Finally students discuss health policy as it relates to the control and prevention of tuberculosis.

Racial and ethnic disparity in low birth weight in Syracuse, New York.

This case-racial and ethnic disparity in low birth weight-is one of a series of teaching cases in the Case-Based Series in Population-Oriented Prevention (C-POP). It has been developed for use in medical school and residency prevention curricula. The complete set of cases is presented in this supplement to the American Journal of Preventive Medicine. Low birth weight is a leading cause of infant mortality. Unfortunately, despite declining rates of infant mortality, racial and ethnic disparities in both low birth weight and infant mortality rates persist. In this teaching case, a clinical vignette is used to draw attention to this public health priority in Syracuse, New York. Students learn essential epidemiology skills such as identifying limitations of sources of data and calculating relative risks, using the example of low birth weight. In performing these skills, students also identify etiologies for such disparity. Finally, students discuss interventions that, when implemented, may decrease infant mortality rates.

A critical look at prevention: colorectal cancer screening.

This case-colorectal cancer screening-is one of a series of teaching cases in the Case-Based Series in Population-Oriented Prevention (C-POP). It has been developed for use in medical school and residency prevention curricula. The complete set of cases is presented in this supplement to the American Journal of Preventive Medicine. This preventive medicine teaching case discusses the concepts of diagnostic test evaluation, prevention, and screening using the example of colorectal cancer screening. Features of the case include a health policy exercise concerning community screening programs and an exercise in clinical prevention decision making.

Bicycle helmet effectiveness in preventing injury and death.

This case--bicycle helmet effectiveness--is one of a series of teaching cases in the Case-Based Series in Population-Oriented Prevention (C-POP). It has been developed for use in medical school and residency prevention curricula. The complete set of cases is presented in this supplement to the American Journal of Preventive Medicine. This case examines the cost-effectiveness of three interventions to increase utilization of bicycle helmets to avert head injuries in individuals aged 18 years and under in Onondaga Count NY. Students are initially presented with data on head injuries, hospitalization, and death related to bicycle use. They then appraise a published study on the effectiveness of bicycle helmets in averting head injury. Finally, students work in groups to determine the cost-effectiveness of each intervention by calculating implementation costs and the specific number of head injuries averted associated with intervention. The three interventions are legislative, school, and community-based campaigns to increase helmet use. Students are provided with budget estimates and assumptions needed to complete the exercise. Cost-effectiveness analysis, cost-benefit analysis, and related concepts are discussed, including provider versus societal perspectives and importance of sensitivity analysis.

Future applications of case-based teaching in population-based prevention.

The Case-Based Series in Population-Oriented Prevention (C-POP) introduced in this supplement to the American Journal of Preventive Medicine provides a set of tools to integrate clinical- and community-based prevention into interactive teaching cases. These cases, which address recommended core competencies in prevention education, have been taught to both medical students and preventive medicine residents. Initial experience with the cases indicates that this method is a promising tool to enhance prevention education in medical schools and primary care residencies. Because prevention education is essential in other fields, such as public health and nursing, extension of this approach to other professional schools is possible. Such extension is feasible because the cases are designed to be adaptable for different levels of education, flexible to be tailored to local situations, and expandable to accommodate changes in the field. In addition, the cases can be made accessible to all educators through a national library and in interactive web-based format. This article describes how the C-POP series can be used to strengthen prevention education for a wide audience of physician and nonphysician learners.