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

BACKGROUND: Measles-containing vaccines (MCVs) and pneumococcal conjugate vaccines (PCVs) can prevent a large proportion of infant deaths and are recommended by international organizations for inclusion in pediatric immunization schedules. In China, MCV but not PCV is publically funded and access to vaccination may be limited among nonlocals, who are rural migrants to cities. In this study, we estimate the proportion of Shanghai children with on-time MCV and PCV administration, compare vaccination in nonlocals versus locals and assess the impact of township-level characteristics on vaccination outcomes. METHODS: Data from children in the Shanghai Immunization Program Information System were linked to township-level data from the 2010 China Census. We used generalized estimating equations with logistic regression models to assess the impact of residency and township-level predictors on on-time MCV and PCV administration. RESULTS: Nonlocals had lower vaccination levels than locals. Compared with locals, nonlocals had 0.50 times the odds of MCV dose 1 by 9 months [95% confidence interval (CI): 0.47, 0.53], 0.42 times the odds of MCV dose 2 by 24 months (95% CI: 0.39, 0.45), 0.37 times the odds of PCV by 9 months of age (95% CI: 0.33, 0.42) and 0.41 times the odds of PCV by 24 months of age (95% CI: 0.37, 0.45). Overall, children had less on-time MCV and PCV administration in nonlocal-majority than local-majority townships. CONCLUSIONS: Late vaccination negatively impacts disease control efforts in Shanghai. Nonlocals, particularly those living in nonlocal-majority townships, should especially be targeted for vaccination in order to improve disease control efforts in Shanghai.

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

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.

Public Health and Preventive Medicine Meet Integrative Health: Applications of Competency Mapping to Curriculum Education at the University of Michigan.

The University of Michigan School of Public Health Preventive Medicine Residency (UMSPH PMR) Integrative Medicine Program (IMP) was developed to incorporate integrative medicine (IM), public health, and preventive medicine principles into a comprehensive curriculum for preventive medicine residents and faculty. The objectives of this project were to (1) increase the preventive medicine workforce skill sets based in complementary and alternative medicine and IM that would address individual and population health issues; (2) address the increasing demand for evidence-based IM by training physicians to implement cost-effective primary and secondary prevention services and programs; and (3) share lessons learned, curriculum evaluations, and best practices with the larger cohort of funded IM PMR programs. The UMSPH PMR collaborated with University of Michigan IM faculty to incorporate existing IM competencies with those already established for preventive medicine and public health residency training as the first critical step for IMP curriculum integration. Essential teaching strategies incorporated didactic and practicum methods, and made use of seasoned IM faculty, along with newly minted preventive medicine integrative teaching faculty, and PMR resident learners as IM teachers. The major components of the IMP curriculum included resident participation in IMP Orientation Sessions, resident leadership in epidemiology graduate IM seminars, resident rotations in IM month-long clinical practicums, resident participation in interprofessional health system-wide IM clinical case conferences, and PMR faculty enrollment in the renowned Faculty Scholars Program in Integrative Healthcare. This paper describes the novel interdisciplinary collaborations and key curriculum components that resulted in the IMP, as well as evaluation of strengths, weaknesses, and lessons learned.

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.

Influenza vaccination of Michigan children by provider type, 2010-2011.

BACKGROUND: Influenza vaccination for all children aged 6 months to 18 years has been recommended since 2008 to prevent flu-related morbidity and mortality. However, 2010-2011 influenza vaccine coverage estimates show under-vaccination in children of all ages. We examined predictors of influenza vaccination in Michigan during the 2010-2011 influenza season. PURPOSE: To determine whether immunization provider type was associated with a child's influenza vaccination in Michigan and assess whether county-level factors were confounders of the association. METHODS: Influenza vaccinations reported to the Michigan Care Improvement Registry from the 2010-2011 influenza season were analyzed in 2012 to estimate ORs for the association between immunization provider type and influenza vaccination. RESULTS: Among 2,373,826 Michigan children aged 6 months through 17 years, 17% were vaccinated against influenza and lower vaccination rates were observed for public compared to private providers (13% vs 18%). In the unadjusted model, public providers had lower odds of vaccinating children compared to private providers (OR=0.60, 95% CI=0.60, 0.61). County-level factors, including percentage of families living below the poverty line, median household income, and percentage black race, were not shown to confound the association. In the adjusted models, public providers had lower odds of vaccinating children compared to private providers (OR=0.87, 95% CI=0.86, 0.88). CONCLUSIONS: Although a child's likelihood of influenza vaccination in Michigan varies by provider type, more effective strategies to improve influenza vaccination rates for all Michigan children are needed.

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 Practice's 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.

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

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 Practice's 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.

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 $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.

Botulism toxemia following laparoscopic appendectomy.

We describe a case of botulism infection in a patient who had undergone laparoscopic appendectomy, an occurrence not previously described in the literature. This case exemplifies the need for coordination between clinical and public health personnel to ensure the immediate recognition and treatment of suspected botulism cases.

Hospitalized patients with 2009 H1N1 influenza in the United States, April-June 2009.

BACKGROUND: During the spring of 2009, a pandemic influenza A (H1N1) virus emerged and spread globally. We describe the clinical characteristics of patients who were hospitalized with 2009 H1N1 influenza in the United States from April 2009 to mid-June 2009. METHODS: Using medical charts, we collected data on 272 patients who were hospitalized for at least 24 hours for influenza-like illness and who tested positive for the 2009 H1N1 virus with the use of a real-time reverse-transcriptase-polymerase-chain-reaction assay. RESULTS: Of the 272 patients we studied, 25% were admitted to an intensive care unit and 7% died. Forty-five percent of the patients were children under the age of 18 years, and 5% were 65 years of age or older. Seventy-three percent of the patients had at least one underlying medical condition; these conditions included asthma; diabetes; heart, lung, and neurologic diseases; and pregnancy. Of the 249 patients who underwent chest radiography on admission, 100 (40%) had findings consistent with pneumonia. Of the 268 patients for whom data were available regarding the use of antiviral drugs, such therapy was initiated in 200 patients (75%) at a median of 3 days after the onset of illness. Data suggest that the use of antiviral drugs was beneficial in hospitalized patients, especially when such therapy was initiated early. CONCLUSIONS: During the evaluation period, 2009 H1N1 influenza caused severe illness requiring hospitalization, including pneumonia and death. Nearly three quarters of the patients had one or more underlying medical conditions. Few severe illnesses were reported among persons 65 years of age or older. Patients seemed to benefit from antiviral therapy.

Infectious causation of chronic disease: examining the relationship between Giardia lamblia infection and irritable bowel syndrome.

AIM: To evaluate whether a higher prevalence of Giardia lamblia infection is associated with an increase in irritable bowel syndrome (IBS) prescriptions at the county level in Michigan. METHODS: The Michigan Disease Surveillance System (MDSS) was used to ascertain both the numbers of Giardia lamblia infections as well as the total number of foodborne illnesses per population by county in Michigan during 2005. This was compared with Blue Cross Blue Shield (BCBS) of Michigan numbers of drug prescriptions for IBS per one thousand members per county in 2005. These data were also analyzed for associations with per capita income by county and the number of refugees entering each county in 2005. RESULTS: There were a total of 786 confirmed cases of Giardia lamblia reported to MDSS in 2005. During the same time period, the number of prescriptions for IBS varied from 0.5 per 1000 members up to 6.0 per 1000 members per month. There was no trend towards higher numbers of IBS prescriptions in the counties with more Giardia lamblia infections. Per capita income was not associated with either IBS prescriptions or Giardiasis. There was a significant linear association between the number of refugees entering each county, and the number of Giardia lamblia cases per 100,000 population. CONCLUSION: In this ecological study, there was no association found between BCBS prescriptions for IBS and Giardia lamblia infections in Michigan counties. Our findings may have been influenced by the disparate number of refugees admitted per county.

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 System's 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.