Operationalizing Community Assessment Results to Enhance Preparedness for a Radiological Emergency.

OBJECTIVE: A radiological emergency such as the detonation of a radiological dispersal device would have catastrophic health, environmental, and economic consequences. Community assessments can provide useful information about radiological and other emergency preparedness at the household level. Tools such as logic models can be applied to link data collected in a community assessment to planned activities and targeted outcomes. This study sought to answer how public health departments can use the results of a community assessment to improve preparedness for radiological and other types of emergencies and to present a sample logic model demonstrating how questions asked in a community assessment can be used to drive intended outcomes. DESIGN: Surveys were fielded in 2019 to professionals with experience in radiological emergency preparedness, state and local health and emergency management, and journalism. Questions included the role of health departments in radiological emergency preparedness, the operationalization of results from a community assessment for preparedness, and information sharing in a radiological emergency. Descriptive statistics and a modified framework approach were used for open-ended questions. RESULTS: Nearly three-fourths of state/local officials reported that it would be at least somewhat difficult (73%; 11 of 15 state/local officials) for a local health department to operationalize the results of a community health assessment for radiological emergency preparedness. Potential barriers included competing priorities, lack of funds, and limited staff. Resources such as pretested communication materials, tailored messaging, and technical tools and training can assist health departments and emergency management agencies in using the information collected from a community assessment. CONCLUSIONS: To address implementation challenges in operationalizing the results of a community assessment, officials can use tools such as logic models to illustrate how the information gathered from a community health assessment will create an intended preparedness outcome and to advocate for funds for this type of assessment.

Developing an instrument to measure household radiological emergency preparedness using the Community Assessment for Public Health Emergency Response (CASPER) methodology: An evidence-informed approach.

INTRODUCTION: Community assessments to measure emergency preparedness can inform policies, planning, and communication to the public to improve readiness and response if an emergency was to occur. Public health and emergency management officials need an effective assessment tool to measure community preparedness for a radiological emergency. METHODS: The authors created a survey instrument to collect data on household radiological emergency preparedness that could be implemented using the Community Assessment for Public Health Emergency Response (CASPER) methodology, developed by the U.S. Centers for Disease Control and Prevention. To inform the development of the tool, the authors examined existing CASPER surveys, focusing on identifying best practices for creating a survey instrument, as well as analyzing the results of a survey of radiation preparedness experts and state/local health and emergency management officials. RESULTS: The developed survey tool includes 32 questions covering four domains: communication in an emergency, preparedness planning, physical/behavioral health, and demographics. The instrument captures information related to identified barriers in communicating in a radiological emergency as well as self-reported behaviors that could potentially be influenced through awareness and education. DISCUSSION: Using the proposed survey instrument and following the existing rapid assessment methodology provided by CASPER, public health and emergency management agencies can collect valuable information on the radiation preparedness needs of their communities, which can then be used to improve household readiness for an emergency.

Prioritizing Communication About Radiation Risk Reduction in the United States: Results from a Multi-criteria Decision Analysis.

OBJECTIVES: The lack of radiation knowledge among the general public continues to be a challenge for building communities prepared for radiological emergencies. This study applied a multi-criteria decision analysis (MCDA) to the results of an expert survey to identify priority risk reduction messages and challenges to increasing community radiological emergency preparedness. METHODS: Professionals with expertise in radiological emergency preparedness, state/local health and emergency management officials, and journalists/journalism academics were surveyed following a purposive sampling methodology. An MCDA was used to weight criteria of importance in a radiological emergency, and the weighted criteria were applied to topics such as sheltering-in-place, decontamination, and use of potassium iodide. Results were reviewed by respondent group and in aggregate. RESULTS: Sheltering-in-place and evacuation plans were identified as the most important risk reduction measures to communicate to the public. Possible communication challenges during a radiological emergency included access to accurate information; low levels of public trust; public knowledge about radiation; and communications infrastructure failures. CONCLUSIONS: Future assessments for community readiness for a radiological emergency should include questions about sheltering-in-place and evacuation plans to inform risk communication.

Evaluating Perceived Emergency Preparedness and Household Preparedness Behaviors: Results from a CASPER Survey in Fairfax, Virginia.

OBJECTIVES: Using data collected from a Community Assessment for Public Health Emergency Response (CASPER) conducted in Fairfax Health District, Virginia, in 2016, we sought to assess the relationship between household-level perceived preparedness and self-reported preparedness behaviors. METHODS: Weighted population estimates and 95% confidence intervals were reported, and Pearson's chi-squared test was used to investigate differences by group. RESULTS: Examining responses to how prepared respondents felt their household was to handle a large-scale emergency or disaster, an estimated 7.4% of respondents (95% CI: 4.3-12.3) reported that their household was "completely prepared," 37.3% (95% CI: 31.4-43.7) were "moderately prepared," 38.2% (95% CI: 31.6-45.2) were "somewhat prepared," and 14.4% (95% CI: 10.2-20.0) were "unprepared." A greater proportion of respondents who said that their household was "completely" or "moderately" prepared for an emergency reported engaging in several behaviors related to preparedness. However, for several preparedness behaviors, there were gaps between perceived preparedness and self-reported readiness. CONCLUSIONS: Community assessments for public health preparedness can provide valuable data about groups who may be at risk during an emergency due to a lack of planning and practice, despite feeling prepared to handle a large-scale emergency or disaster.

An assessment of household water quality among Peace Corps volunteers in Guatemala.

BACKGROUND: Gastrointestinal (GI) illness is the most commonly reported health concern among Peace Corps Volunteers (PCVs) serving in Guatemala. This project identified water types and treatment and storage practices used by PCVs and measured select water quality parameters in their household water. METHODS: A survey about water types and practices was conducted of PCVs in Guatemala. The water type most frequently consumed in the household ("primary drinking water") and other water types present in the household ("secondary water") were tested for free chlorine residual (FCR) and for the presence of Escherichia coli and total coliforms. A negative binomial regression model was used to analyze data on incidence of self-reported GI illness. RESULTS: Tambo (commercially purified water in a 5-gal bottle) was the water type most frequently (64%) reported as primary drinking water in 39 PCV households. Most (74%) PCVs reported drinking water other than primary drinking water ≥1 day per week; the incidence rate of GI illness per PCV per month was significantly lower among PCVs who reported never consuming water other than primary drinking water compared to those who did (0.4 and 1.6 GI illnesses per PCV per month, respectively) (p < 0.05). E. coli was not detected in any primary drinking water sample, but was detected in 35% of secondary water samples. Total coliforms were detected in more than two-thirds of primary drinking water and secondary water samples. Nearly all water samples had an FCR of < 0.2 mg/L. CONCLUSIONS: Consuming primary drinking water exclusively likely contributes to reducing the rate of GI illness among PCVs. However, most PCVs reported drinking multiple water types, which may include contaminated secondary water types in the household. All water intended for consumption, including secondary sources within and outside the household, should be properly treated and safely stored.

Use of electronic medical records to conduct surveillance of malaria among Peace Corps volunteers.

OBJECTIVE: The Peace Corps' disease surveillance for Peace Corps Volunteers (PCVs) was incorporated into an electronic medical records (EMR) system in 2015. We evaluated this EMR-based surveillance system, focusing particularly on malaria as it is deadly but preventable. MATERIALS AND METHODS: In 2016, we administered a survey to Peace Corps Medical Officers (PCMOs), who manage PCVs' medical care, and semistructured phone interviews to headquarters staff. We assessed the structure of the surveillance system and its utility to stakeholders, evaluated surveillance case definitions for malaria, and compared clinical information in the EMR for malaria cases captured by surveillance during the first half of 2016. RESULTS: Of 131 PCMOs, 77 (59%) completed the survey. Of 53 respondents in malaria-endemic nations, 98% believed most PCVs contact them about possible malaria. Of 134 cases with a malaria clinical diagnosis in the EMR between January and August 2016, 58 (43% sensitivity) were reported to the surveillance system by PCMOs. The remaining cases in the surveillance system were added during data cleaning, which is time-intensive. Among the 48 malaria cases identified by surveillance between January and June 2016, positive predictive value was 67%. DISCUSSION: Areas for improvement include streamlining PCMO documentation, refining case definitions, and improving data quality. With such improvements, surveillance data can be used to inform epidemiological analysis, clinical care, health education, and policy. CONCLUSION: The EMR is an important tool for malaria surveillance among PCVs and, with the refinements mentioned, could serve as a framework for other multinational organizations to monitor their staff.

Long term health outcomes among Returned Peace Corps Volunteers after malaria prophylaxis, 1995-2014.

BACKGROUND: A primary reason for non-adherence to malaria chemoprophylaxis is fear of latent side effects. We examined latent effects of malaria chemoprophylaxis among Returned Peace Corps Volunteers (RPCVs). METHODS: During July 18-September 16, 2016, RPCVs who served during 1995-2014 with an e-mail address in Peace Corps' RPCV database were invited to take an internet-based survey on malaria prophylaxis and medical diagnoses. "Good adherence" meant taking prophylaxis "as prescribed" or "most of the time." Prevalence of diseases diagnosed after Peace Corps service was compared between users and nonusers of each antimalarial using log-binomial regression. RESULTS: Of 8931 participants (11% response rate), 5055 (57%) took chemoprophylaxis. Initial chemoprophylaxis was mefloquine 59%, chloroquine 13%, doxycycline 16%, atovaquone-proguanil 4%, and "other" 8%. Sixty percent reported good adherence. Mefloquine users had the best adherence (67% good adherence). Prevalences of most diseases were similar between exposed and unexposed groups. Certain psychiatric diagnoses were slightly more likely among mefloquine users (PR 1.14, 95% CI [1.04-1.25], P = 0.0048). When excluding those with prior psychiatric illness, there were no differences in psychiatric diagnosis rates. CONCLUSION: Malaria chemoprophylaxis use by Peace Corps Volunteers is safe. Avoiding mefloquine use in those with prior psychiatric illness can reduce psychiatric side effects.

Road traffic injuries in Peace Corps Volunteers, 1996-2014.

INTRODUCTION: Road traffic injuries are a leading cause of mortality and morbidity worldwide. Travellers are at risk given unfamiliarity with local road conditions and traffic rules. Peace Corps Volunteers are a unique population of long-term travellers who live and work in-country, often in remote settings, over a period of 27 months and use a range of transportation modes. METHODS: Data from Peace Corps' Epidemiologic Surveillance System (ESS) and Death In-Service (DIS) database were analysed in 2015 for non-fatal and fatal road traffic injuries among in-service Volunteers from 1996 to 2014. Volunteer-months were used to calculate incidence rates, and rates were compared among countries and regions. RESULTS: A total of 5047 non-fatal and 15 fatal road crash injuries were reported during 1 616 252 Volunteer-months for an overall rate of 3.12 non-fatal injuries and 0.01 fatalities per 1000 Volunteer-months. The total combined rate of nonfatal road traffic injuries among Volunteers generally declined from 4.01 per 1000 Volunteer-months in 1996 to 2.84 in 2014. Pedestrian and bicycle injuries emerged as the most frequent mechanisms of injury during this timeframe. Differences in rates of observed road traffic-related fatalities among Volunteers compared with expected age-matched cohort rates in the US were not statistically significant. CONCLUSIONS: Peace Corps transportation policies and training, and changes to road environments worldwide, may have led to a decrease in the rate of road traffic injuries among Peace Corps Volunteers. Pedestrians and bicyclists remain at risk of road traffic injuries.

Healthy Volunteer 2020: Comparing Peace Corps Volunteers' health metrics with Healthy People 2020 national objectives.

Healthy People 2020 (HP2020) provides a set of quantifiable objectives for improving the health and well-being of Americans. This study examines Peace Corps Volunteers' health metrics in comparison with the Leading Health Indicators (LHIs) in order to set baseline measures for Volunteers' health care and align our measurements with Healthy People 2020 standards. Health data from multiple internal Peace Corps datasets were compared with relevant LHIs and analyzed using descriptive statistics. Seventeen (65%) of the 26 LHIs were relevant to Peace Corps Volunteers. Of these, Volunteers' health measures met or were more favorable than the goals of 13 (76%) of the LHIs. There were no data available for 4 (24%) of the LHIs. The entire Volunteer population has full access to primary care, oral health, and reproductive health services. No suicides or homicides were reported among Volunteers during the analyzed time period. Utilizing the LHIs, we have identified high-priority public health issues relevant for the Peace Corps Volunteer population. We discuss the need for quality data to measure and monitor Volunteers' health progress and outcomes over time, and also to standardize our measurements with Healthy People 2020 benchmarks. This framework may foster greater collaboration to engage in health promotion and disease prevention activities driven by evidence-based information, which may, in turn, encourage healthy behavior among Volunteers.

Dengue in Peace Corps Volunteers, 2000-14.

BACKGROUND: Dengue is an arboviral disease estimated to cause 50-100 million infections each year in >100 tropical and subtropical countries. Urbanization, human population growth and expanded global travel have resulted in an increase in the incidence of dengue worldwide. International travellers to areas with endemic dengue are at risk of contracting dengue and US Peace Corps Volunteers are one specific group of long-term travellers who are exposed to environments where dengue can be contracted. METHODS: Cases of dengue among Peace Corps Volunteers, defined as clinically apparent infections with laboratory-confirmation by a positive NS1 antigen test, demonstration of IgM antibodies or by a 4-fold increase in IgG antibodies, between 1 January 2000 and 31 December 2014, reported to the Peace Corps' Epidemiologic Surveillance System were analyzed. RESULTS: Overall there were 1448 cases of dengue reported among Volunteers, with an incidence rate of 1.12 cases per 1000 Volunteer-months (95% CI 1.06-1.17). The highest rate of dengue among Volunteers was reported in the Caribbean region, with a rate of 5.51 cases per 1000 Volunteer-months (95% CI 4.97-6.10), followed by the East Asia/South Asia region (3.34, 95% CI 2.96-3.75) and Central America (2.55, 95% CI 2.32-2.79). The rate of dengue peaked in 2007, 2010 and 2013. Each peak year was followed by a trough year. CONCLUSIONS: Globally, there appears to be a 3-year cyclical pattern of dengue incidence among Volunteers, with differences by region. Dengue continues to be a priority health issue for travellers to endemic areas, and enhanced surveillance of dengue among international travellers may result in improved patient education and prevention efforts.

Revisiting tuberculosis risk in Peace Corps Volunteers, 2006-13.

BACKGROUND: Risk of tuberculosis (TB) is generally considered to be low for long-term travellers, though risk varies with travel destination, duration and purpose. Peace Corps Volunteers (PCVs) serve for 27 months as community-level development workers in various countries around the world and may be exposed to TB in the course of their service. This study examines recent trends in TB in PCVs and compares rates with a previous analysis published by Jung and Banks. METHODS: Tuberculosis case data submitted to the Peace Corps' Epidemiologic Surveillance System by Peace Corps Medical Officers and gathered from Federal Employees Compensation Act claims for latent TB infection (LTBI) and active TB between 2006 and 2013 were aggregated and analysed for trends and significance. RESULTS: Overall, there were 689 cases of LTBI and 13 cases of active TB, for a rate of 0.95 cases of LTBI [95% confidence interval (CI) 0.88-1.02] and 0.02 cases of active TB (95% CI 0.01-0.03) per 1000 Volunteer-months. Both are significantly lower than rates presented in the initial study (P < 0.001). Per-country incidence rates for LTBI ranged from 0.00 to 4.52 cases per 1000 Volunteer-months. Per-country active TB rates ranged from 0.00 to 0.78 cases per 1000 Volunteer-months. Among the 13 cases of active TB, there was one successfully treated case of extensively drug-resistant TB. CONCLUSIONS: Overall rates of both active and latent TB in PCVs were significantly lower compared with the previous study period. PCVs continue to have statistically significantly higher rates of active TB compared with the general US population but lower rates compared with other long-term travellers.

Reasons for Child Passenger Nonrestraint in Motor Vehicles.

OBJECTIVE: Although child passenger restraint use in motor vehicles has increased, there is an important minority of children who remain unrestrained. The goal of this study was to identify the frequency of and under what circumstances parents keep their children unrestrained. METHODS: A cross-sectional, online survey was distributed to parents and caregivers of children 10 years old and younger. Survey participants were asked about child restraint practices, including frequency of and reasons for nonuse of restraints. Parents were specifically asked how acceptable it would be to keep their child unrestrained in certain situations. RESULTS: One thousand two hundred eighty-five parents and guardians responded to the survey and 1,002 completed it; 23.8% (95% confidence interval [CI], 21.3-26.6%) of respondents said they had driven with their child not fully restrained on at least one occasion. Approximately 1 in 5 parents strongly or somewhat agreed that it would be acceptable to keep their child unrestrained in certain situations, including a short drive, in a rush, an inadequate number of restraints, riding in a taxi, if somebody was holding the child, and as a reward for a child. Parents were more likely to agree that it was acceptable to keep their child unrestrained under nearly all circumstances listed if they were male, ages 18-29, with a graduate school education, in the $100,000+ income bracket, or Latino. CONCLUSIONS: There are certain situations for which parents find it acceptable to leave their children unrestrained. This has implications for targeted child passenger safety efforts designed to maximize consistent restraint use.

Expert consensus document: Mind the gaps­advancing research into short-term and long-term neuropsychological outcomes of youth sports-related concussions.

Sports-related concussions and repetitive subconcussive exposure are increasingly recognized as potential dangers to paediatric populations, but much remains unknown about the short-term and long-term consequences of these events, including potential cognitive impairment and risk of later-life dementia. This Expert Consensus Document is the result of a 1-day meeting convened by Safe Kids Worldwide, the Alzheimer's Drug Discovery Foundation, and the Andrews Institute for Orthopaedics and Sports Medicine. The goal is to highlight knowledge gaps and areas of critically needed research in the areas of concussion science, dementia, genetics, diagnostic and prognostic biomarkers, neuroimaging, sports injury surveillance, and information sharing. For each of these areas, we propose clear and achievable paths to improve the understanding, treatment and prevention of youth sports-related concussions.

Preventing Child Pedestrian Injury: A Guide for Practitioners.

Each year, an estimated 270,000 pedestrians die from road traffic-related injuries, (worldwide) and children are among the most vulnerable. Child pedestrian injuries occur primarily in residential areas, often on the same street or in close proximity to the child's home, and 90% of injured child pedestrians are unaccompanied by an adult at the time of the injury. The cause of these injuries is a complex combination of factors related not only to characteristics of the child but also the built environment, the road configuration, features of the motor vehicle that might reduce injury, and driver behavior. Accordingly, effective interventions must incorporate education, technology, and improved infrastructure. The medical practitioner can not only provide the necessary education but can also be a powerful voice for changes in pedestrian infrastructure that make walking safer. This article explores the current state of childhood pedestrian injuries using examples from the United States and Australia. Pedestrian interventions and the role that primary care and lifestyle practitioners play in promoting safe pedestrian behaviors among their patients and their families are discussed.

Utilizing E-coded data for nonfatal injury surveillance in the pediatric emergency department setting: a literature review and recommendations.

OBJECTIVES: Injury surveillance in the pediatric emergency department (PED) has the potential to be an important part of program planning and clinical management. However, a lack of data has been identified as one of the critical limitations in the field of pediatric emergency services research. The aims of this article were to investigate how injury surveillance has been attempted in the PED and to develop an understanding of why E-coding has not met its full potential as an injury surveillance tool in this setting. METHODS: We conducted a literature review for E-coding in the PED as well as for injury surveillance more generally in the PED. PubMed, PubMed Central, Google Scholar, CINAHL, EMBASE, and Academic Search Elite were used. Inclusion criteria were applied for each search. RESULTS: Two reports on E-coding in the PED met the criteria and were reviewed. Five articles on PED injury surveillance were reviewed. The most common mechanism of surveillance was a review of emergency department logs (n = 4). The second most common mechanism of surveillance was a physician-administered questionnaire (n = 2). CONCLUSIONS: Two of the 5 injury surveillance articles collected injury data from questionnaires completed by physicians, which is not a long-term, sustainable approach to injury surveillance. An ideal injury surveillance system for the PED should be designed with at least 3 main elements: minimal economic and resource burden, substantial practical uses, and measures to ensure data quality.

Monitoring trends in dextromethorphan abuse using the National Poison Data System: 2000-2010.

CONTEXT: Dextromethorphan (DXM) abuse persists among US youth and should be closely monitored because of the risks of severe medical complications, addiction, and psychiatric sequelae. Prior investigations have demonstrated DXM to be an emerging drug of abuse with increasing national prevalence through 2004. OBJECTIVE: To extend existing substance abuse survey results by describing demographic, geographic, product, and outcome trends in medically significant DXM abuse cases (those reported to US poison centers). METHODS: National Poison Data System (NPDS) data are collected and compiled in real time by all 57 US poison centers. Demographic, geographic, product, and outcome data for all intentional DXM abuse cases reported to the NPDS between 2000 and 2010 were analyzed. RESULTS: A total of 44,206 DXM abuse cases met inclusion criteria, 34,755 of which were single-substance exposures. The mean annual prevalence of DXM cases reported to poison control centers was 13.4 cases per million population for all ages and 113.0 cases per million for 15-19 year olds. The prevalence of DXM cases for all ages increased steadily (p = 0.002, Cochran-Armitage trend test) until 2006 to a peak of 17.6 calls/million and has subsequently plateaued at 15.7 cases per million in 2010. This trend is also seen in the most commonly abused brand of DXM products, Coricidin(®). A preponderance of male adolescents was noted throughout the study period. The odds of a severe outcome are increased for a multi-substance exposure (OR: 2.53; 95% CI: 2.14-2.99, logistic regression); odds were not significantly increased for any of the most commonly abused product brands. CONCLUSION: The increasing trend of DXM abuse cases noted in the first half of the decade by previous studies seems to have peaked at 17.6 calls per million population in 2006. It is likely that a combination of legislative, educational, and economic initiatives are responsible for the observed plateau.