Cost Analysis of Prevention Research Centers: Instrument Development.

The 2014-2019 Prevention Research Centers (PRC) Program Funding Opportunity Announcement stated that "all applicants will be expected to collaborate with CDC to collect data to be able to perform cost analysis." For the first time in the 30-year history of the PRC Program, a cost indicator was included in the PRC Program Evaluation and a cost analysis (CA) instrument developed. The PRC-CA instrument systematically collects data on the cost of the PRC core research project to eventually answer the CDC PRC Program Evaluation question: "To what extent do investments in PRCs support the scalability, sustainability, and effectiveness of the outcomes resulting from community-engaged efforts to improve public health?" The objective of this article is to briefly describe the development of the PRC-CA instrument. Data obtained from the PRC-CA instrument can be used to generate cost summaries to inform decision making within the PRC Program and each individual PRC.

Secondary Infections with Ebola Virus in Rural Communities, Liberia and Guinea, 2014-2015.

Persons who died of Ebola virus disease at home in rural communities in Liberia and Guinea resulted in more secondary infections than persons admitted to Ebola treatment units. Intensified monitoring of contacts of persons who died of this disease in the community is an evidence-based approach to reduce virus transmission in rural communities.

Decreased Ebola Transmission after Rapid Response to Outbreaks in Remote Areas, Liberia, 2014.

We measured the reproduction number before and after interventions were implemented to reduce Ebola transmission in 9 outbreaks in Liberia during 2014. We evaluated risk factors for secondary cases and the association between patient admission to an Ebola treatment unit (ETU) and survival. The reproduction number declined 94% from 1.7 (95% CI 1.1-2.6) to 0.1 (95% CI 0.02-0.6) after interventions began. The risk for secondary infections was 90% lower for patients admitted to an ETU (risk ratio 0.1, 95% CI 0.04-0.3) than for those who died in the community. The case-fatality rate was 68% (95% CI 60-74), and ETU admission was associated with a 50% reduction in death (hazard ratio 0.5, 95% CI 0.4-0.8). Isolation and treatment of Ebola patients had the dual benefit of interrupting community transmission and improving survival.

Economic Evaluation Enhances Public Health Decision Making.

Contemporary public health professionals must address the health needs of a diverse population with constrained budgets and shrinking funds. Economic evaluation contributes to evidence-based decision making by helping the public health community identify, measure, and compare activities with the necessary impact, scalability, and sustainability to optimize population health. Asking "how do investments in public health strategies influence or offset the need for downstream spending on medical care and/or social services?" is important when making decisions about resource allocation and scaling of interventions.

A Cost Analysis of the 1-2-3 Pap Intervention.

BACKGROUND: Cervical cancer places a substantial economic burden on our healthcare system. The three-dose human papillomavirus (HPV) vaccine series is a cost-effective intervention to prevent HPV infection and resultant cervical cancer. Despite its efficacy, completion rates are low in young women aged 18 through 26 years. 1-2-3 Pap is a video intervention tested and proven to increase HPV vaccination completion rates. PURPOSE: To provide the full scope of available evidence for 1-2-3 Pap, this study adds economic evidence to the intervention's efficacy. This study tested the economies of scale hypothesis that the cost of 1-2-3 Pap intervention per number of completed HPV vaccine series would decrease when offered to more women in the target population. METHODS: Using cost and efficacy data from the Rural Cancer Prevention Center, a cost analysis was done through a hypothetical adaptation scenario in rural Kentucky. RESULTS: Assuming the same success rate as in the efficacy study, the 1-2-3 Pap adaptation scenario would cover 1000 additional women aged 18 through 26 years (344 in efficacy study; 1346 in adaptation scenario), and almost three times as many completed series (130 in efficacy study; 412 in adaptation scenario) as in the original 1-2-3 Pap efficacy study. IMPLICATIONS: Determination of the costs of implementing 1-2-3 Pap is vital for program expansion. This study provides practitioners and decision makers with objective measures for scalability.

Characterization of the federal workforce at the Centers for Disease Control and Prevention.

CONTEXT: Studies characterizing the public health workforce are needed for providing the evidence on which to base planning and policy decision making both for workforce staffing and for addressing uncertainties regarding organizing, financing, and delivering effective public health strategies. The Centers for Disease Control and Prevention (CDC) is leading the enumeration of the US public health workforce with an initial focus on CDC as the leading federal public health agency. OBJECTIVE: To characterize CDC's workforce, assess retirement eligibility and potential staff losses, and contribute these data as the federal component of national enumeration efforts. METHODS: Two sources containing data related to CDC employees were analyzed. CDC's workforce was characterized by using data elements recommended for public health workforce enumeration and categorized the occupations of CDC staff into 15 standard occupational classifications by using position titles. Retirement eligibility and potential staffing losses were analyzed by using 1-, 3-, and 5-year increments and compared these data across occupational classifications to determine the future impact of potential loss of workforce. RESULTS: As of the first quarter of calendar year 2012, a total 11 223 persons were working at CDC; 10 316 were civil servants, and 907 were Commissioned Corps officers. Women accounted for 61%. Public health managers, laboratory workers, and administrative-clerical staff comprised the top 3 most common occupational classifications among CDC staff. Sixteen percent of the workforce was eligible to retire by December 2012, and more than 30% will be eligible to retire by December 2017. CONCLUSIONS: This study represents the first characterization of CDC's workforce and provides an evidence base upon which to develop policies for ensuring an ongoing ability to fulfill the CDC mission of maintaining and strengthening the public's health. Establishing a system for continually monitoring the public health workforce will support future efforts in understanding workforce shortages, capacity, and effectiveness; projecting trends; and initiating policies.

Non-pharmaceutical interventions during an outbreak of 2009 pandemic influenza A (H1N1) virus infection at a large public university, April-May 2009.

Nonpharmaceutical interventions (NPIs), such as home isolation, social distancing, and infection control measures, are recommended by public health agencies as strategies to mitigate transmission during influenza pandemics. However, NPI implementation has rarely been studied in large populations. During an outbreak of 2009 Pandemic Influenza A (H1N1) virus infection at a large public university in April 2009, an online survey was conducted among students, faculty, and staff to assess knowledge of and adherence to university-recommended NPI. Although 3924 (65%) of 6049 student respondents and 1057 (74%) of 1401 faculty respondents reported increased use of self-protective NPI, such as hand washing, only 27 (6.4%) of 423 students and 5 (8.6%) of 58 faculty with acute respiratory infection (ARI) reported staying home while ill. Nearly one-half (46%) of student respondents, including 44.7% of those with ARI, attended social events. Results indicate a need for efforts to increase compliance with home isolation and social distancing measures.

Notes from the field: outbreak of 2009 pandemic influenza A (H1N1) virus at a large public university in Delaware, April-May 2009.

BACKGROUND: In late April 2009, the first documented 2009 pandemic influenza A (pH1N1) virus infection outbreak in a university setting occurred in Delaware, with large numbers of students presenting with respiratory illness. At the time of this investigation, little was known about the severity of illness, effectiveness of the vaccine, or transmission factors of pH1N1 virus infection. We characterized illness, determined the impact of this outbreak, and examined factors associated with transmission. METHODS: Health clinic records were reviewed. An online survey was administered to all students, staff, and faculty to assess influenza-like illness (ILI), defined as documented or subjective fever with cough or sore throat. RESULTS: From 26 April-2 May 2009, the health clinic experienced a sharp increase in visits for respiratory illness, with 1080 such visits among a total of 1430 student visits, and then a return to baseline visit levels within 2 weeks. More than 500 courses of oseltamivir were distributed, and 24 cases of influenza A (pH1N1) virus infection were confirmed. Of 29,000 university students and faculty/staff, 7450 (30%) responded to the survey. ILI was reported by 604 (10%) of the students and 73 (5%) of the faculty/staff. Travel to Mexico (relative risk [RR], 2.9; 95% confidence interval [CI], 1.8-4.7) and participation in "Greek Week" activities (RR, 2.2; 95% CI, 1.8-2.8) were associated with ILI. Recipients of the 2008-2009 seasonal influenza vaccine had the same risk of ILI as nonrecipients (RR, 1.0). Four (3%) of the students with ILI were hospitalized; there were no deaths. CONCLUSIONS: pH1N1 spread rapidly through the University of Delaware community with a surge in illness over a 2-week period. Although initial cases appear to be associated with travel to Mexico, a rapid increase in cases was likely facilitated by increased student interactions during Greek Week. No protective effect from receiving seasonal influenza vaccine was identified. Although severe illness was rare, the outbreak caused a substantial burden and challenge to the university health care system. Preparedness efforts in universities and similar settings should include enhancing health care surge capacity.

Severe acute respiratory syndrome in children.

BACKGROUND: Severe acute respiratory syndrome (SARS) is a febrile, respiratory tract illness caused by infection with the newly identified SARS-associated coronavirus. A notable feature of the 2003 global SARS outbreak was the relative paucity of cases reported among children. We reviewed the epidemiologic and clinical features of SARS in children and discuss implications of these findings for diagnosis, treatment and prevention of SARS. METHODS: We performed a literature search to identify reports of pediatric (younger than 18 years of age) patients meeting the World Health Organization case definitions for SARS and abstracted relevant clinical and epidemiologic information. RESULTS: We identified 6 case series reporting 135 pediatric SARS patients (80 laboratory-confirmed, 27 probable and 28 suspect) from Canada, Hong Kong, Taiwan and Singapore. Among laboratory-confirmed and probable SARS cases, the most common symptoms included fever (98%), cough (60%) and nausea or vomiting (41%); 97% had radiographic abnormalities. The clinical presentation of SARS in patients older than 12 years of age was similar to that in adults. However, patients 12 years of age or younger had milder disease and were less likely than older children to be admitted to an intensive care unit, receive supplemental oxygen or be treated with methylprednisolone. No deaths were reported among children or adolescents with SARS, and at 6 months after illness only mild residual changes were reported in exercise tolerance and pulmonary function. There is only 1 published report of transmission of SARS virus from a pediatric patient. CONCLUSIONS: Children and adolescents are susceptible to SARS-associated coronavirus infection, although the clinical course and outcome are more favorable in children younger than 12 years of age compared with adolescents and adults. Transmission of SARS from pediatric patients appears to be uncommon but is possible.

Churning in Medicaid managed care and its effect on accountability.

There is concern that churning in Medicaid excludes children from the accountability system for managed care because they may not meet the one-year continuous enrollment requirement. This study explores the effect of churning in measuring childhood immunization coverage rates under the current accountability system. Data were collected from administrative databases at the Centers for Medicaid and Medicare Services and 12 states with high Medicaid managed care penetration. On average in the 12 states only 39% of the children enrolled in one specific managed care plan met the continuous enrollment requirement. However, Centers for Medicaid and Medicare Services data showed that 78% of children were enrolled in Medicaid (but not the same plan) continuously for 12 months. Both plan-specific rates and overall Medicaid rates varied greatly across the states. Policies that result in churning mean that many vulnerable children fall outside of the accountability structure intended to assure that they receive necessary services.

Vaccine coverage levels after implementation of a middle school vaccination requirement, Florida, 1997-2000.

OBJECTIVE: Little information is available about the effectiveness of school entry vaccination requirements at the middle school level. This study examined coverage levels among students entering seventh grade in Florida following implementation of a school entry vaccination requirement in 1997. METHODS: The authors analyzed county-specific vaccination coverage levels (three doses of hepatitis B vaccine, a second dose of measles, mumps, and rubella [MMR] vaccine, and a booster dose of tetanus and diphtheria toxoids [Td]) among students entering public and private schools in Florida from 1997 through 2000. In 1998, a survey of all county health departments was conducted, and the resulting data were linked to county-specific vaccination rates. RESULTS: During the 1997-1998 school year, the first year the requirement went into effect, at school entry 121,219 seventh-grade students (61.8%) were fully vaccinated, 72,275 seventh grade students (36.9%) lacked one or more doses of vaccine but were considered in process, 1,817 were non-compliant (0.9%), and 763 had medical or religious exemptions (0.4%). In the 2000-2001 school year, the proportions of students reported fully vaccinated at school entry had increased to 66%. Most of this change was related to an increase in hepatitis B coverage. There was a significant inverse relationship between the proportion of students fully vaccinated and the size of the county's seventh grade population. CONCLUSIONS: The seventh grade vaccination entry requirement was associated with sustained high levels of vaccination coverage. Passing a school entry vaccination requirement appears may be sufficient to increase coverage, but other strategies may be required to achieve full immunization of middle school students.

Adoption of reminder and recall messages for immunizations by pediatricians and public health clinics.

OBJECTIVE: Strong scientific evidence and national recommendations support the use of reminder and recall messages to improve immunization coverage rates, yet reports have suggested that only a minority of pediatric practices use such messages. Our aims were to 1) determine the proportions of pediatric practices and public clinics that currently use practice-based reminder or recall messages and routinely undergo immunization assessment efforts, 2) evaluate barriers and supports to implementing these practices, and 3) identify predictors of either current use or plans for future adoption of these practices. METHODS: This study combined qualitative and quantitative methods in sequential phases. In the qualitative phase, we conducted semistructured, open-ended interviews with a convenience sample of 18 clinician-administrators representing adopters and nonadopters of these messages in both private practices and public health clinics. In the subsequent quantitative phase, we mailed a structured, closed-ended survey to national samples of randomly selected pediatricians (n = 600) and public clinics (n = 600). RESULTS: Response rates were 75% for pediatricians and 77% for public clinics. Among pediatricians, 38% were conducting regular assessments of immunization coverage but only 16% were currently using routine reminder or recall messages. Among public clinics, 85% were conducting regular assessments and 51% were using reminder or recall messages. Among pediatricians' practices, the most commonly reported barriers to the adoption of reminder or recall messages were lack of time and funding and the inability to identify children at specified ages. For pediatricians' practices, the strongest predictors of current use of reminder or recall messages were having a champion who led efforts to improve immunization delivery (odds ratio: 1.85; 95% confidence interval: 1.08-3.18) and current use of regular immunization assessments (odds ratio: 2.30; 95% confidence interval: 1.33-3.84). Likewise, for public health clinics, having a champion to lead immunization improvement efforts and believing that their current system needed improvement was associated with current use of reminder or recall messages. CONCLUSIONS: Reminder and recall messages remain underused by both pediatricians and public health clinics. Promising strategies to promote adoption of these approaches in both the private and the public sectors include identifying and training champions to promote immunization delivery improvement efforts and helping practices develop methods to identify children at specific ages.

Parental knowledge, attitudes, and practices associated with not receiving hepatitis A vaccine in a demonstration project in Butte County, California.

OBJECTIVE: To determine hepatitis A vaccination coverage and factors associated with not receiving hepatitis A vaccine among children. METHODS: A random cluster sample survey was conducted of parents of children who attended kindergarten in Butte County, California, in 2000. Because of a history of recurrent epidemics, an aggressive hepatitis A vaccination program was ongoing during the time this study was conducted. Receipt of 1 or 2 doses of hepatitis A vaccine was studied. RESULTS: Of 896 surveys sent, 648 (72%) were completed. The vaccination coverage for at least 1 dose of hepatitis A vaccine was 398 (62%) and for 2 doses was 272 (42%). Factors associated with not receiving the vaccine included lack of provider recommendation (vs having recommendation; odds ratio [OR]: 7.8; 95% confidence interval [CI]: 4.9-12.2), not having heard of the vaccine (OR: 2.4; 95% CI: 1.2-4.9), and parent's not perceiving child is likely to get hepatitis A (vs perceiving child might get disease; OR: 2.1; CI: 1.6-2.9). CONCLUSIONS: Vaccination coverage among kindergartners did not reach high levels (ie, >90%), despite aggressive vaccination efforts in this community. Lack of provider recommendation and lack of parental awareness of hepatitis A vaccine were the 2 most significant factors associated with failure to receive vaccine. These findings will facilitate the development of vaccination strategies for communities in which hepatitis A vaccination is recommended.

Effectiveness of postexposure vaccination for the prevention of smallpox: results of a delphi analysis.

We estimated the effectiveness of postexposure smallpox vaccination in preventing or modifying disease in naive and previously vaccinated adults, using the formal Delphi technique. For persons not previously vaccinated, the median effectiveness in preventing disease with vaccination at 0-6 h, 6-24 h, and 1-3 days after exposure was estimated as 93%, 90%, and 80%, respectively, and effectiveness in modifying disease among those who develop illness was estimated as 80%, 80%, and 75%, respectively. Effectiveness was greater for those vaccinated previously. High postexposure vaccination effectiveness for preventing or modifying smallpox is consistent with the limited data available, is biologically plausible, and is similar to that seen for other viral vaccine-preventable diseases. These estimates support the Advisory Committee on Immunization Practices recommendations and provide a key parameter for mathematical models on which policy decisions may be based.

A survey of pediatricians on the reintroduction of a rotavirus vaccine.

OBJECTIVE: Rhesus-based rotavirus tetravalent vaccine (RRV-TV; RotaShield) was withdrawn voluntarily from the market in October 1999, and recommendations for use were suspended. Rotavirus infection continues to be a significant health problem affecting children worldwide. The objective of this study was to investigate whether pediatricians would either reconsider using RRV-TV or consider other, newer, and presumably safer rotavirus vaccines if they were recommended routinely and to determine factors that influence their opinion. METHODS: A questionnaire was sent to a random sample of 250 members of the Wisconsin Chapter of the American Academy of Pediatrics (AAP) and to 437 randomly selected members of the Georgia Chapter of the AAP. Nonresponders received reminder questionnaires. RESULTS: Of the 687 pediatricians surveyed, 384 (56%) responded. Responses from 319 eligible immunization providers were included in the final analysis. Although only 15% of respondents reported that they would give RRV-TV if it were available today, 94% reported that they would use a new rotavirus vaccine if proved to be safer than RRV-TV and if recommended by the AAP and Advisory Committee on Immunization Practices for routine use among infants. Barriers to reintroducing a rotavirus vaccine were fear of adverse reactions among 95% of pediatricians, followed by potential high vaccine cost (63%) and amount of time required to educate parents (57%). CONCLUSIONS: Pediatricians reported that they would use a rotavirus vaccine if it was safer than RRV-TV and routinely recommended by the AAP and the Advisory Committee on Immunization Practices.