Study says: Communication is most important skill for public-health types

The professional development of environmental public health professionals in Canada is guided by a set of 133 discipline-specific competencies. Given the diversity of practice in environmental public health, certain competencies may be more important to job effectiveness depending on a practitioner’s context. However, the most important competencies to job effectiveness by context are unknown. Thus, the objectives of this study were to prioritize the discipline-specific competencies according to their importance to job effectiveness, and determine if importance varied by demographic variables.

A quantitative discrete-choice method termed best–worst scaling was used to determine the relative importance of competencies. Discrete choice information was electronically collected and analyzed using Hierarchical Bayesian analysis.

Our analysis indicates that communication was most important to job effectiveness relative to the other categories. Competency statements within each category differed in their importance to job effectiveness. Further, management and front-line practitioners differed in the importance placed on five of the eight categories.

This information can be used to guide new training opportunities, thereby investing in the capacity of environmental health professionals to better protect population health.

Prioritizing professional competencies in environmental public health: A best-worst scaling experiment

Aug. 2018

Environmental Health Review, vol. 61 no. 2, pg 50-63

Lauren E. Wallar,* Scott A. McEwen,* Jan M. Sargeant,* Nicola J. Mercer, Andrew Papadopoulos*

 https://doi.org/10.5864/d2018-014

http://pubs.ciphi.ca/doi/abs/10.5864/d2018-014

In memorandum: Wisconsin epidemiologist Jeffrey Davis identified Milwaukee’s Cryptosporidium outbreak

I was a new doctoral student when cryptosporidiosis sickened over 400,000 people and killed 69 in Wisconsin in the spring of 1993.

I had recently started the Food Safety Network, which was bringing daily updates to scientists and public health folks who usually had to wait 6 months for the U.S. Centers for Disease Control’s Morbidity and Mortality Weekly to arrive.

It may seem trivial now, but it was a big deal in its day.

Lotsa posers and copycats over the years, so we went to barfblog.com.

Later that year, cryptosporidiosis would sicken hundreds in Kitchener-Waterloo, where I was living with my young family.

Somehow, I was speaking about this to our home-renovator-contractor-and-therapist yesterday while he unplugged our kitchen faucet.

And then I got this.

Meg Jones of the Milwaukee Journal Sentinel writes that as doctors’ offices filled with Milwaukeeans suffering from a mysterious illness in 1993, Mayor John Norquist called a meeting with state and local officials.

Norquist asked state epidemiologist Jeffrey Davis whether he would drink a glass of Milwaukee’s water and when Davis said he would not, Norquist issued a massive boil water advisory that affected more than 1 million residents.

With decades of work in public health, Davis was the perfect person to figure out a little-known parasite cryptosporidiosis could be the culprit that sickened more than 400,000 people.

As state epidemiologist for the past four decades, Davis was Wisconsin’s doctor.

He was a medical sleuth who figured out the connection between toxic shock syndrome and tampons and helped determine the infectious agent transmitted by ticks that causes Lyme disease. 

Davis, 72, died of pneumonia in Madison Jan. 16.

“Jeff’s knowledge of the literature helped identify the (Cryptosporidium) outbreak earlier. Cryptosporidiosis at that point was a pretty rare pathogen,” said State Public Health Veterinarian James Kazmierczak.

Knowing about a similar waterborne outbreak elsewhere in the U.S., Davis asked to see data on water quality in Milwaukee and noticed a spike in turbidity at the same time that people began to get sick. At the time, city water supplies were not tested for Cryptosporidium.

“Because of Jeff’s knowledge of what happened earlier with cryptosporidiosis, that became the leading suspect,” said Kazmierczak.

Davis grew up in Whitefish Bay and earned an undergraduate degree in chemistry in 1967 at University of Wisconsin-Madison and his medical degree in 1971 at the University of Chicago. He did his internship and residency in pediatrics in Florida and from 1973 to 1975 worked for the U.S. Centers for Disease Control and the South Carolina Department of Health.

After a stint at Duke University Medical Center, he returned to Wisconsin in 1978 as state epidemiologist and chief of the division of acute and communicable diseases. In 1991, his job title changed to chief medical officer and state epidemiologist for communicable diseases.

“He loved being a sleuth and medical detective, leading investigations of all sorts, from toxic shock syndrome to Legionnaires’ outbreaks, to the Cryptosporidium water supply outbreak, which was huge,” said his wife Roseanne Clark.

“He really was passionate about trying to figure out the source to reduce the impact on as many people as possible. He cared about the health of the people of Wisconsin.”

Increasing vaccine compliance: Coercion and persuasion, shock and shame only work so much

James Colgrove, Ph.D., M.P.H., of the Department of Sociomedical Sciences, Columbia University Mailman School of Public Health, New York, writes in this commentary, in recent years, vaccine refusal and associated declines in herd immunity have contributed to numerous outbreaks of infectious diseases, consumed public health resources, and provoked increasingly polarized debates between supporters and opponents of vaccines.

vaccinationAlthough the prominence of the Internet as a forum for information and misinformation has given these conflicts a distinctly 21st-century character, they have deep historical roots. Many of the scientific, ethical, and political challenges that physicians and public health officials face today in dealing with vaccine refusal would be recognizable to their counterparts of previous eras. The heart of their task entails balancing the use of coercive and persuasive approaches.

Coercion is the older tradition in public health. During the 19th century, many states and localities passed compulsory-smallpox-vaccination laws covering both children and adults. These laws were of a piece with an expansive network of public health regulations that arose in that era concerning practices such as quarantine, sanitation, and tenement construction. Vaccination laws imposed various penalties, including exclusion from school for unvaccinated children and fines or quarantine for adults who refused vaccination. The effectiveness of the laws was soon demonstrated — jurisdictions with them consistently had fewer disease outbreaks than those without — and their constitutionality was upheld in numerous court challenges that culminated in the 1905 Supreme Court case of Jacobson v. Massachusetts.

The use of coercion has always raised concerns about state intrusions on individual liberty and the scope of parental control over child-rearing. Compulsory vaccination laws in the 19th century typically contained no explicit opt-out provisions. Today, all states offer medical exemptions, and almost all offer religious or philosophical exemptions. Nevertheless, even a law with an opt-out provision may exert a coercive effect, to the extent that the availability of the exemption may be limited and conditional and the consequence of the law is to make the choice to withhold vaccination more difficult (if only marginally so) for the parent. These laws continue to be the target of antivaccination activism.

Persuasion became an important part of the public health tool kit in the 1920s, with the rise of modern forms of mass media. Health professionals began to draw on techniques from the emerging fields of advertising and public relations to sell people on the importance of childhood immunization against diphtheria and pertussis. Such appeals began to acquire a more scientific basis in the 1950s, after the development of the polio vaccine, when sociologists, psychologists, and other social scientists began to identify the attitudes, beliefs, and social contexts that predicted vaccine-related behaviors. Their efforts brought increasing theoretical and empirical rigor to the study of why people accepted or declined vaccination for themselves and their children, and health professionals used these insights to develop approaches to increase uptake of vaccines, such as enlisting community opinion leaders as allies.1 Persuasive approaches, because they are less restrictive, are ethically preferable and more politically acceptable, but they are also time consuming and labor-intensive, and evidence indicates that by themselves they are ineffective.

Vaccine refusal revisited — The limits of public health persuasion and coercion

October 12, 2016, New Engl J Med; 375:1316-1317, DOI: 10.1056/NEJMp1608967

http://www.nejm.org/doi/full/10.1056/NEJMp1608967

Women rock, Gwyneth doesn’t: Paltrow pushes debunked breast cancer myth

Some women spend their time playing other people in front of cameras and offering lifestyle advice. Some women work in public health. Some play ice hockey, some are French professors.

girls.hockey.brisbaneFrom the annals of bad health advice, actress Gwyneth Paltrow is under fire for a post on her website GOOP by Dr. Habib Sadeghi with the inflammatory title “Could There Possibly Be a Link Between Underwire Bras and Breast Cancer??” The research discussed in the article has been widely discredited, including by the American Cancer Society.

A 2014 study in which 1,044 women ages 55 to 74 were interviewed about their bra wearing, Fred Hutchinson Cancer Research Center (also known as Fred Hutch) found absolutely no link between bras and breast cancer. Specifically, Lu Chen, a researcher in the Public Health Sciences Division at Fred Hutch, said in an article on the center’s website (one that’s cited in a footnote of the GOOP article), “Our study found no evidence that wearing a bra increases a woman’s risk for breast cancer. The risk was similar no matter how many hours per day women wore a bra, whether they wore a bra with underwire, or at what age they began wearing a bra.”

disease.detectiveDiane Mapes, who was diagnosed with breast cancer in 2011 and underwent chemotherapy, radiation and a double mastectomy (what she calls “the full monty”), is a public health writer for FredHutch.org and also blogs about her breast cancer experience at DoubleWhammied.com. She told Salon, “If you get your advice from Gwyneth Paltrow, you’re probably not serving yourself particularly well. If people want public health advice, there’s a lot of other sites where they can go to get it.”

Girls rock. Women rock. People rock. Gwyneth doesn’t.

Public health opportunity? Skype chat and fast diagnosis

The same forces that have made instant messaging and video calls part of daily life for many Americans are now shaking up basic medical care.

telemedicine-e1351178723955Health systems and insurers are rushing to offer video consultations for routine ailments, convinced they will save money and relieve pressure on overextended primary care systems in cities and rural areas alike. And more people, fluent in Skype and FaceTime and eager for cheaper, more convenient medical care, are trying them out.

The university I used to work at couldn’t figure this out, but others have moved on, and so have I.

While telemedicine consultations have been around for decades, they have mostly connected specialists with patients in remote areas, who almost always had to visit a clinic or hospital for the videoconference. The difference now is that patients can be wherever they want and use their own smartphones or tablets for the visits, which are trending toward more basic care.

Even as virtual visits multiply, researchers say it is not clear whether they really save money or provide better outcomes.

Virtual urgent care visits are undoubtedly less expensive than trips to the emergency room, said Dr. Ateev Mehrotra, a professor of health policy at Harvard Medical School, who has studied telemedicine.

Oregon public health employee faked 56 infection case reports

A former employee in the public health division of the Oregon Health Authority committed misconduct in 56 case reports about Clostridium difficile infections in Klamath County, Oregon, as well as in a manuscript submitted to JAMA Internal Medicine and a published report in the Morbidity and Mortality Weekly Report in March, 2012.

faking.itRyan Asherin, previously a Surveillance Officer and Principal Investigator at the OHA,

falsified and/or fabricated fifty-six (56) case report forms (CRFs) while acquiring data on the incidence of Clostridium difficile infections in Klamath County, Oregon. Specifically, the Respondent (1) fabricated responses to multiple questions on the CRFs for patient demographic data, patient health information, and Clostridium difficile infection data, including the diagnoses of toxic megacolon and ileus and the performance of a colectomy, with no evidence in patient medical records to support the responses; and (2) falsified the CRFs by omitting data on the CRFs that clearly were included in patient medical records.

In addition, Asherin was found guilty of “falsifying and/or fabricating data” that appeared in the research record of the U.S. Centers for Disease Control and Prevention, a manuscript sent to JAMA Internal Medicine in January 2013, and a paper about C. diff that appeared in the CDC’s MMWR journal. The paper — about a potentially deadly infection that’s a common feature of healthcare settings — has been cited 75 times, according to Thomson Scientific’s Web of Knowledge.

Some of these messy data also made their way into 2012 presentations to the CDC and the 11th Biennial Congress of the Anaerobe Society, according to the ORI report.

The OHA told us Asherin no longer works there.

Problems public health investigators face: It’s a tough job (but we love ya for it)

In Ontario, Canada (that’s in Canada), enteric case investigators perform a number of functions when conducting telephone interviews including providing health education, collecting data for regulatory purposes ultimately to prevent further illness, enforcement, illness source attribution and outbreak detection. Information collected must be of high quality as it may be used to inform decisions about public health actions that could have significant consequences such as excluding a person from work, recalling a food item that is deemed to be a health hazard, and/or litigations. The purpose of this study was to describe, from the perspectives of expert investigators, barriers experienced and the techniques used to overcome these barriers during investigation of enteric disease cases (that’s Sider, right, exactly as shown).

doug.siderMethods

Twenty eight expert enteric investigators participated in one of four focus groups via teleconference. Expert investigators were identified based on their ability to 1) consistently obtain high quality data from cases 2) achieve a high rate of completion of case investigation questionnaires, 3) identify the most likely source of the disease-causing agent, and 4) identify any possible links between cases. Qualitative data analysis was used to identify themes pertaining to successful techniques used and barriers experienced in interviewing enteric cases.

Results

Numerous barriers and strategies were identified under the following categories: case investigation preparation and case communication, establishing rapport, source identification, education to prevent disease transmission, exclusion, and linking cases. Unique challenges experienced by interviewers were how to collect accurate exposure data and educate cases in the face of misconceptions about enteric illness, as well as how to address tensions created by their enforcement role. Various strategies were used by interviewers to build rapport and to enhance the quality of data collected.

Conclusions

To our knowledge, this is the first study to examine the perspectives of expert enteric disease case investigators on successful interview techniques and barriers experienced during enteric case investigation. A number of recommendations could improve the process of enteric case investigation in the Ontario context which include formal training and development of resource materials pertaining to interviewing, standardized interviewing tools, strategies to address cultural and language barriers, and the implementation of the single interviewer approach.

A focus group study of enteric disease case investigation: successful techniques utilized and barriers experienced from the perspective of expert disease investigators

BMC Public Health, Disease epidemiology- infectious, Volume 14, doi:10.1186/1471-2458-14-1302

Stanley Ing, Christina Lee, Dean Middleton, Rachel D Savage, Stephen Moore and Doug Sider

http://www.biomedcentral.com/1471-2458/14/1302

‘Dark logic’ theorizing the harmful consequences of public health interventions

Amy’s been evaluating some potential graduate students, churning up some of her own graduate school missives, and is starting to realize what all writers must face: was that really insightful or just bullshit using fancy words?

dick.fingers.farleyI’ve been wondering the same thing about this paper one of our Canadian friends came across, that attempts to look at the possible harms of public health interventions, what the UK authors call ‘dark logic models.’

Seems to me the model has potential use in evaluating the cult-like clean-cook-chill-separate mantra in the absence of choosing wisely – sourcing food from safe sources.

I also don’t like the use of dick fingers in writing or talking.

Although it might be assumed that most public health programmes involving social or behavioural rather than clinical interventions are unlikely to be iatrogenic, it is well established that they can sometimes cause serious harms. However, the assessment of adverse effects remains a neglected topic in evaluations of public health interventions.

In this paper, we first argue for the importance of evaluations of public health interventions not only aiming to examine potential harms but also the mechanisms that might underlie these harms so that they might be avoided in the future. Second, we examine empirically whether protocols for the evaluation of public health interventions do examine harmful outcomes and underlying mechanisms and, if so, how. Third, we suggest a new process by which evaluators might develop ‘dark logic models’ to guide the evaluation of potential harms and underlying mechanisms, which includes: theorisation of agency-structure interactions; building comparative understanding across similar interventions via reciprocal and refutational translation; and consultation with local actors to identify how mechanisms might be derailed, leading to harmful consequences.

dick.fingers.stewartWe refer to the evaluation of a youth work intervention which unexpectedly appeared to increase the rate of teenage pregnancy it was aiming to reduce, and apply our proposed process retrospectively to see how this might have strengthened the evaluation.

We conclude that the theorisation of dark logic models is critical to prevent replication of harms. It is not intended to replace but rather to inform empirical evaluation.

Journal of Epidemiology & Community Health

Chris Bonell, Farah Jamal, G J Melendez-Torres, and Steven Summins

http://jech.bmj.com/content/early/2014/11/17/jech-2014-204671

Coaching vs. enforcement: Wash. restaurant inspector says ‘I’m an advocate for public health’

Jerry Caird, the Thurston County environmental health specialist, is one of 6 inspectors who oversee more than 1,000 food establishments in Thurston County. That includes full-service restaurants, grocery store delis, fast food outlets and espresso stands.

olympia.wash“I’ve never worked in a restaurant in my entire life,” he said. “But I feel like I have.”

Instead, Caird has a bachelor of science in environmental health and extensive training on looking for food-related situations that can make people sick, such as room temperature potato salad, lettuce that’s contaminated with raw meat juice and workers who aren’t handling food safely.

He was an inspector for the state of Nevada for nine years, before taking a job with Thurston County 11 years ago.

“I think of myself as an advocate for public health,” he said.

Thurston County’s full-service and fast-food restaurants, along with its grocery store delis are inspected at least twice a year.

Cassie Andreotti, the manager at the Vic’s Pizzeria on Olympia’s west side, said she usually gets a little nervous when Caird shows up. But she said she appreciates the work he does.

“I think it’s incredibly important,” said Andreotti said during a recent inspection. “Without these guys, who knows what people would be serving.”

Businesses that only have a small amount of food preparation such as espresso stands, bakeries, meat markets and the non-deli sections of grocery stores are inspected once a year.

A typical inspection can take one to two hours, depending on the size of the kitchen.

“They’re all unannounced,” Caird said.

Most violations that are noted during an inspection are corrected immediately, said Sammy Berg, a senior environmental health specialist who supervises the county’s health inspectors.

“It’s not just to find people doing things wrong,” Caird said. “But to show them a better way that will help protect public health.”

Mom and pop businesses tend to struggle the most with food inspections, Berg said. One of the big reasons why is because a lot of fast food companies have their own corporate inspectors that are in charge of quality control, he added.

When problems are found, Caird said he tries to work with restaurant owners and managers to make sure there’s a pattern of improved scores.

“A lot of owners tend to focus on what the customer sees — the bathrooms, the dining rooms,” Caird said. “But they really should focus on the kitchen.”

Thurston County’s Environmental Health Division also tracks complaints that are emailed or telephoned in by consumers. The department had 226 complaints about restaurants in 2014.

Most of those were about possible food-borne illness that callers believed were picked up at local restaurants.

“The last thing you ate isn’t necessarily the thing that made you sick,” Berg said, adding that signs of a food borne illness can take 24 to 72 hours to appear.

If the department receives several phone calls that correlate to the same restaurant, they check it out.

Make Hep A vaccinations mandatory for everyone, especially those who serve food

Guelph, the town and the university, is like every other cow-town, eager to blow itself (it’s in Canada).

hepatitis.AThe Guelph Mercury says in an op-ed the Wellington-Dufferin-Guelph Public Health board received a review this week of the agency’s response to a public health scare arising from a local restaurant staffer being diagnosed with hepatitis A.

The board heard that the organization was quickly informed by the worker’s physician of the diagnosis and made prompt, effective and smart moves upon receipt of that information.

Among other correct and timely moves the board heard the agency made in this case was using a variety of media formats to spread the word of this situation and to communicate times and locations where concerned residents could obtain vaccinations at rapidly convened clinics.

(They contacted barfblog.com to get an estimation of reach; how the hell do I know, we just put stuff out there.)

The organization also adjusted quickly and resourcefully to meet higher than anticipated public demand for vaccines, the board heard.

By the account of the board, it was a case well-handled by health unit staff — and commendations were offered to that team following the briefing.

An earlier story declared the response to the Hepatitis A outbreak was public health’s finest hour.

When a family doctor alerted Wellington-Dufferin-Guelph Public Health that he had a patient with hepatitis A, the health protection and prevention agency leapt into action.

Dr. Nicola Mercer, the local medical officer of health, painted a picture of a responsive staff and an amicable public to the board of health Wednesday as she described the series of events that led to some 1,400 vaccinations being administered after a food handler at the popular Marj’s Kitchen in Alma was diagnosed with the hepatitis A virus.

Mercer said she received the call from the physician on Jan. 21.

“Normally you wouldn’t hear about a hepatitis A case,” Mercer said. “But in this case, the patient was a food handler who had worked the entire time of being infectious.”

After examining the lab work, staff determined the individual was infectious between Jan. 2 and Jan. 20 and that potentially 4,000 people had been exposed.

A number of things happened in tandem. Staff interviewed all staff at Marj’s Kitchen and administered vaccinations since these were the people most at risk of infection.

Lost in the platitudes is a simple message: make Hepatitis A vaccinations mandatory for everybody, especially food service workers.