Lessons learned after three years of legalized, recreational marijuana: The Colorado experience.

In November 2012 Colorado voters approved legalized recreational marijuana. On January 1, 2014 Colorado became the first state to allow legal sales of non-medical marijuana for adults over the age of 21. Since that time, the state has been monitoring potential impacts on population health. In this paper we present lessons learned in the first three years following legal sales of recreational marijuana. These lessons pertain to health behaviors and health outcomes, as well as to health policy issues. Our intent is to share these lessons with other states as they face the prospect of recreational marijuana legalization.

Comparison of 3 school-based influenza surveillance indicators: lessons learned from 2009 pandemic influenza A (H1N1)--Denver Metropolitan Region, Colorado.

CONTEXT: Early in the 2009 pandemic influenza A (H1N1) experience, children aged 5 to 17 years were determined to be disproportionately affected compared with recent influenza seasons. OBJECTIVE: To characterize the pandemic among school-aged children, to enable timely influenza outbreak identification, and to determine which school-based influenza surveillance indicator correlated most closely with a laboratory-based standard influenza indicator (standard) and, therefore, might be most useful for future school-based influenza surveillance. DESIGN: : During the 2009-2010 school year, we monitored students using 3 different surveillance indicators: (1) all-cause absenteeism, (2) influenza-like illness (ILI)-related absenteeism, (3) and ILI-related school health office visits. Thresholds were set for each indicator to identify individual school outbreaks. Each surveillance indicator was compared with the standard, confirmed influenza cases among hospitalized patients. SETTING: Tri-County (Denver metropolitan area), Colorado. PARTICIPANTS: Prekindergarten through 12th-grade students in public schools. MAIN OUTCOME MEASURES: Correlation coefficients comparing each influenza surveillance indicator with the standard and graphs comparing weekly rates for each influenza surveillance indicator or weekly outbreak counts with the standard. RESULTS: Correlation between the surveillance indicators and the standard varied greatly. All-cause absenteeism correlated most poorly with the standard (Pearson's r = 0.33) and ILI-related health office visits correlated moderately well (r = 0.63). Influenza-like illness-related absenteeism correlated best (r = 0.92) and could be improved (r = 0.97) by shifting ILI-absenteeism data later by 1 week. Graphs of weekly rates or weekly outbreak counts also illustrated that ILI-related absenteeism correlated best with the standard. CONCLUSIONS: For influenza surveillance among school-aged children, when feasible, we recommend using ILI-related absenteeism, which correlated best and its rate peaked more than 1 week sooner than the standard. The other 2 surveillance indicators might be useful in certain situations, such as when resources are limited.

Derby district redevelopment in Colorado: case study on the health impact assessment process.

Health Impact Assessment (HIA) is a tool that is increasingly utilized in the U.S. to shape policies that may impact the public's health. Domestic examples of HIAs and the process by which they were conducted, however, are rarely documented in the peer-reviewed literature. Through an existing relationship with the planning department in Commerce City, Colorado, Tri-County Health Department (TCHD) was able to identify a proposed redevelopment plan as a candidate for an HIA. The HIA focused on potential effects of the proposed redevelopment of Commerce City's historic Derby District on residents' physical activity and nutrition-related behaviors. This article describes the HIA process used by TCHD. Several sources of data were used, including participatory community input on walkability and safety, local health behavior data, and maps of health-influencing environmental characteristics. Using a variety of information sources including community input and local health behavior data can be useful in conducting HIAs and impacting policies. Local health departments should consider cultivating ongoing collaborative partnerships with municipal planning departments and community groups to conduct HIAs and to implement recommendations.

Needlestick injury surveillance during mass vaccination clinics: lessons learned and why more is needed--Tri-County (Denver Metropolitan) region, Colorado, 2009.

Tri-County Health Department studied needlestick injury (NSI) risks in pandemic influenza A (H1N1) mass vaccination clinics through incident reports and an Internet-based vaccinator survey. The mass vaccination clinic NSI rate was 4.9 times the mean rate observed during Tri-County Health Department's 2003 to 2009 routine vaccination clinics. There was also a trend of increased risk for NSI with vaccination inexperience. These findings can be used to improve future mass vaccination clinic safety.

Outbreak of shiga toxin-producing Escherichia coli serotype O26: H11 infection at a child care center in Colorado.

BACKGROUND: Shiga toxin-producing Escherichia coli (STEC) O26:H11 is an emerging cause of disease with serious potential consequences in children. The epidemiology and clinical spectrum of O26:H11 are incompletely understood. We investigated an outbreak of O26:H11 infection among children younger than 48 months of age and employees at a child care center. METHODS: Every employee at the center (n = 20) and every child <48 months (n = 55) were tested for STEC and administered a questionnaire. Thirty environmental health inspections and site visits were conducted. A cohorting strategy for disease control was implemented. RESULTS: Eighteen confirmed and 27 suspect cases were detected. There were no hospitalizations. The illness rate was 60% for children and employees. The risk of being a case in children <36 months was twice the risk among children of 36 to 47 months (risk ratio: 2.10; 95% confidence interval: 1.00, 4.42). The median duration of shedding among symptomatic confirmed cases was 30.5 days (range: 14-52 days). Four (22%) confirmed cases were asymptomatic and 3 (17%) shed intermittently. Nearly half (49%) of the household contacts of confirmed cases developed a diarrheal illness. The outbreak was propagated by person-to-person transmission; cohorting was an effective disease control strategy. CONCLUSIONS: This was the largest reported outbreak of O26:H11 infection in the United States and the largest reported non-O157 STEC outbreak in a US child care center. Non-O157 STEC infection is a differential diagnosis for outbreaks of diarrhea in child care settings. Aggressive disease control measures were effective but should be evaluated for outbreaks in other settings.

Primary care physicians perceptions and practices regarding fall prevention in adult's 65 years and over.

BACKGROUND: Falls are the leading cause of injury deaths and the most common cause of disability, premature nursing home admissions, medical costs, and hospitalizations among people 65 years and over. Interventions targeting multiple fall risk factors can reduce fall rates by 30-40%. Yet, national studies show that screening conducted by physicians for older adult falls is short of acceptable standards. Tri-County Health Department (TCHD) in Colorado conducted a study to examine fall prevention practices among primary care physicians in our jurisdiction. METHODS: TCHD randomly sampled primary care physicians (n=100) obtained from a statewide healthcare provider database and surveyed them about fall prevention screening practices and perceived barriers to screening. Data were examined using single and multiple logistic regression analysis. RESULTS: The response rate was 67.6%. Only 8% of responding physicians based their fall prevention practices on clinical guidelines from any recognized organizations. Frequently reported barriers included a lack of time during visits, more pressing issues, and a lack of educational materials. Physicians who did not accept Medicare (OR 0.163 [CI 0.03-0.84]) remained significantly less likely to refer patients for home safety assessments than those who did, on multivariate analysis. CONCLUSIONS: This study reveals certain physicians require targeted interventions to improve fall prevention practices and use of clinical guidelines. Recommendations include providing physicians with trainings, screening guides, educational materials, environmental/home safety checklists, and referral resources.

Use of hospital discharge data to evaluate notifiable disease reporting to Colorado's Electronic Disease Reporting System.

OBJECTIVE: Notifiable disease surveillance systems are critical for communicable disease control, and accurate and timely reporting of hospitalized patients who represent the most severe cases is important. A local health department in metropolitan Denver used inpatient hospital discharge (IHD) data to evaluate the sensitivity, timeliness, and data quality of reporting eight notifiable diseases to the Colorado Electronic Disease Reporting System (CEDRS). METHODS: Using IHD data, we detected hospitalized patients admitted from 2003 through 2005 with a discharge diagnosis associated with one of eight notifiable diseases. Initially, we compared all cases identified through IHD diagnoses fields with cases reported to CEDRS. Second, we chose four diseases and conducted medical record review to confirm the IHD diagnoses before comparison with CEDRS cases. RESULTS: Relying on IHD diagnoses only, shigellosis, salmonellosis, and Neisseria meningitidis invasive disease had high sensitivity (> or = 90%) and timeliness (> or = 75%); legionellosis, pertussis, and West Nile virus infection were intermediate; and hepatitis A and Haemophilus influenzae (H. influenzae) invasive disease had low sensitivity (> or = 25%) and timeliness (< or = 33%). Medical record review improved the sensitivity to > or = 90% and timeliness to > or = 80% for H. influenza invasive disease, legionellosis, and pertussis; however, hepatitis A retained suboptimal sensitivity (67%) and timeliness (25%). CONCLUSIONS: Hospital discharge data are useful for evaluating notifiable disease surveillance systems. Limitations encountered by using discharge diagnoses alone can be overcome by conducting medical record review. Public health agencies should conduct periodic surveillance system evaluations among hospitalized patients and reinforce notifiable disease reporting among the people responsible for this activity.

Cluster of presumed organic dust toxic syndrome cases among urban landscape workers-Colorado, 2007.

BACKGROUND: Organic dust toxic syndrome (ODTS) is an influenza-like illness typically affecting agricultural workers exposed to organic dusts. In July 2007, Tri-County Health Department investigated a cluster of acute respiratory illnesses among urban landscape workers with known mulch exposure. METHODS: An epidemiologic study of landscape workers was conducted. Employees were interviewed regarding illness and occupational exposures. Medical records were reviewed. Mulch samples were tested for fungi and endotoxins. RESULTS: Five (12%) of 43 employees experienced respiratory illness compatible with ODTS. Illness was associated with prolonged mulch exposure (>or=6 vs. <6 hr/day; relative risk = 24.7; 95% confidence interval = 3.3-184.9). Mulch samples contained high levels of Aspergillus spores and endotoxin. CONCLUSIONS: Contaminated mulch was implicated as the source of presumed ODTS among landscape workers, highlighting that ODTS is not limited to rural agricultural settings. Education of employers, safety officers, and clinicians is necessary to improve recognition and prevention of ODTS within urban occupational groups.

Health care-associated outbreak of Salmonella Tennessee in a neonatal intensive care unit.

BACKGROUND: In December 2006, we investigated an outbreak of Salmonella serotype Tennessee in a neonatal intensive care unit (NICU) that coincided with a nationwide Salmonella Tennessee outbreak associated with contaminated peanut butter. METHODS: Salmonellosis was defined as isolation of Salmonella Tennessee from any clinical specimen or more than 1 episode of bloody stool within a 24-hour period. We conducted a cohort study among 13 NICU infants, reviewed medical records, cultured stool from infants and staff, collected environmental samples, and examined infection control practices. RESULTS: Ten of the 13 infants had salmonellosis (77%). No medical or dietary risk factors were identified. The proportion of days in which the NICU census exceeded its 11-bed design capacity was higher in December compared with the previous 11 months (41.9% vs 0.3%; P < .001). Hand sinks did not meet operational standards. Salmonella Tennessee was isolated from 9 of the 13 infants, 2 of 40 staff members, and 6 of 42 environmental samples; all isolates matched the pulsed-field gel electrophoresis pattern of the nationwide Salmonella Tennessee outbreak. CONCLUSIONS: Although the source of Salmonella Tennessee was not identified, the high census and limited access to sinks likely facilitated transmission to the NICU infants. Infection control interventions, including halting new NICU admissions, interrupted further transmission.

Internet- versus telephone-based local outbreak investigations.

We compared 5 locally conducted, Internet-based outbreak investigations with 5 telephone-based investigations. Internet-based surveys required less completion time, and response rates were similar for both investigation methods. Participant satisfaction with Internet-based surveys was high.

Active influenza surveillance at the local level: a model for local health agencies.

Laboratory-supported, community-based local surveillance systems for influenza can act as early warning systems in identifying the initial entry points of different influenza strains into the community. Unfortunately, local health departments often have limited resources to implement this type of surveillance. We developed and evaluated an active, local influenza surveillance system in 3 metropolitan Denver, Colo, counties that enabled timely case ascertainment and strain identification at little cost. When compared with Colorado's surveillance system, our system detected cases 7 to 8 weeks earlier than the state's electronic disease reporting system.

Assessment of missing immunizations and immunization-related barriers among WIC populations at the local level.

OBJECTIVE: Low childhood immunization rates have been a challenge in Colorado, an issue that was exacerbated by a diphtheria-tetanus-acellular pertussis (DTaP) vaccine shortage that began in 2001. To combat this shortage, the locally based Tri-County Health Department conducted a study to assess immunization-related barriers among children in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), a population at risk for undervaccination. METHODS: This study assessed characteristics and perceptions of WIC mothers in conjunction with their children's immunization status in four clinics. RESULTS: Results indicated poor immunization rates, which improved with assessment and referral. The uninsured were at higher risk for undervaccination. DTaP was the most commonly missing vaccine, and discrepancies existed between the children's perceived and actual immunization status, particularly regarding DTaP. Targeted interventions were initiated as a result of this study. CONCLUSION: Local health departments should target immunization-related interventions by assessing their own WIC populations to identify unique vaccine-related deficiencies, misperceptions, and high-risk subpopulations.

Rapid needs assessment among Hurricane Katrina evacuees in metro-Denver.

During September 2005, 3,600 Gulf Coast evacuees arrived in metropolitan Denver, in the aftermath of Hurricane Katrina. To better meet the medical and non-medical needs of this displaced population, a rapid needs assessment was conducted among 106 evacuee households. The assessment identified a large need for prescription medications, with 60.2% of households requiring prescription medications and 38.8% of these households lacking these medications at the time of the survey. The assessment also identified self-reported symptoms consistent with altitude sickness and the region-specific need for education on the effects of Denver's mile-high altitude. Finally, the assessment identified differential needs based on race; non-Hispanic Black households were more likely than non-Hispanic White households to require employment, housing, and dental services. These findings illustrate the importance of conducting rapid needs assessments in displaced populations, to identify unique regional, cultural, and other unanticipated needs, as well as to recognize the needs of specific sub-populations.

Cluster of invasive salmonellosis cases in a federal prison in Colorado.

We report a cluster of 3 cases of invasive salmonellosis without gastroenteritis among prisoners, in the absence of a gastroenteritis outbreak. Raw foods illicitly taken from the prison kitchen and improperly stored and prepared were possible sources of infection. We describe the investigation of this cluster and discuss the unique implications of invasive, nongastroenteritis salmonellosis in the prison setting, both for clinicians and for public health agencies that seek to control infections in prisons.