1. November 30, 2010 Epidemiology Case Study Nashville Public Health Learning Collaborative

2. Learner Objectives At the end of the presentation, participants will be able to: 1. Articulate the major role of epidemiology in the broad field of public health. 2. Discuss the importance of forging relationships & collaboration among agencies to achieve public health goals & objectives. 3. Explain the importance of maintaining disease surveillance systems in public health operations.

3. Jail Syphilis Screening in Nashville, Davidson County Jail, 1999 – 2005 Incidence & prevalence rates are measures of disease frequency Critical tools in developing disease surveillance systems, especially for Health Departments Unprecedented high rates of syphilis in Nashville, Davidson County between ‘99 – ‘05

4. Evidence: the Data Syphilis rates increased by 99% (18.3 to 36.1 cases) in one year – 1995 – 1996 Nashville’s ranking based on incidence rates moved from 11 th in 1990 to 3 rd in 1997 Nashville residents accounted for 37% of cases, although city has only 10% of TN’s population

5. Risk Factors Metro Public Health Department (MPHD) was alarmed and commenced a study Study Findings Rates were higher among individuals arrested or charged with drug- and sex- related offenses Syphilis acquisition increased by 62.2% for each additional sex-related charge, and by 4.9% for each additional drug charge (dose- response)

6. Main Conclusion Association – syphilis epidemic & criminal arrest

7. The Solution: Collaboration between MPHD & Davidson County Criminal Justice Center (DCCJC) The Center was the central point where all arrestees were taken for booking, unless otherwise released MPHD officials met with officials of the DCCJC to collaborate on an intervention strategy

8. The Solution: Collaboration between MPHD & Davidson County Criminal Justice Center (DCCJC) Cont. The Solution: Collaboration between MPHD & Davidson County Criminal Justice Center (DCCJC) Cont. In November 1996, the DCCJC Screening project began screening for syphilis during intake that led to treatment Between Nov. 1999, to end of August 2005, (34.8%) 313 cases of syphilis were detected

9. Lessons Learned Having a public health “facility” on site at the jail was critical Program would be impossible without cooperation of the various collaborators – MPHD, DCCJC, TDH laboratories, staff of the Prison Health Services As rates plummeted, many believed this project was responsible for the syphilis eradication in Nashville.

11. Nashville Public Health Learning Collaborative Public Health Sciences 1: Epidemiology

12. Objectives Define epidemiology Understand health in Middle Tennessee Understand determinants of health Using data to drive decisions Identify local, state, & national data

13. Assumptions Health events do not occur randomly Certain characteristics influence disease –Predisposing effects –Protective effects Understanding this information can guide improvements in public health

14. Epidemiology Study of health of populations –“Epi”=On or upon –“Demos”=People –“Logos”=Study of

15. Epidemiology: Tools for Public Health Define a problem: descriptive, surveillance Measure its magnitude: burden Understand key determinants: risk factors Understand natural history and prognosis Develop interventions Inform policies Evaluate the effect of policies

16. News and Epidemiology News –What –Who –Where –When –Why/How Epidemiology –What: Health event –Who: Persons –Where: Places –When: Time –Why: Risk Factors

17. Distribution of Disease Frequency –Number of health events –Relationship to the population size Pattern –Time –Place –Persons

18. Determinants of Disease

19. Epidemiology & Public Health What are the community’s health problems? Where are they occurring? Who is at risk? Which problems have increased/decreased? How do these patterns relate to the distribution of public health services?

20. Nashville: Mortality Davidson County Mortality Report, 2008

21. Nashville Mortality by Group Davidson County Mortality Report, 2008

22. Nashville: Causes of Death Davidson County Mortality Report, 2008

23. Nashville Healthy People 2010 Report Chronic Kidney Disease and Diabetes Chronic Disease Patterns

24. From Patients to Populations Core Epidemiology Functions –Public Health Surveillance –Field Epidemiology –Analytic Studies –Evaluation –Linkages –Policy

25. Surveillance

26. Surveillance Role: Syphilis Providers –Health department clinics –Case workers –Others Public health –Reporting –Clinic use Community

27. Field Epidemiology: John Snow Cholera outbreak Different patterns of disease Tracked to Broad Street Pump

28. Analytic Studies In-depth understanding of diseases Formal studies –Design study Cross-sectional, Cohort, Case-Control –Conduct work –Analyze data –Interpret - implications

29. Syphilis: Understanding More

30. Evaluation How effective is the program? –Achieving the desired effects in the field How efficient is the program? –Balance of intended results with expenditure TimeResources

31. Linkages Epidemiology as a “team sport” –Epidemiologist –Laboratorians –Sanitarians –Infection control –Nurses –Support staff Linkages to other institutions/agencies

32. Policy Development Provide input to decision-making –Reports –Testimony Communicate to public

33. Approach to Epidemiology Count –N cases or events –Careful definitions –Describe time, place, persons Divide –Denominator –Rates, often including time Compare for different groups

34. Syphilis Annual Rates by Neighborhood, Nashville, 1996- 1997

35. Rate N cases Divided by Size of the population per unit of time

36. Disease Occurrence: Causation

37. Using Data to Drive Decisions WhatWhoWhereWhenWhy/How

38. Public Health Data Sources America’s Health Rankings –http://www.americashealthrankings.org http://www.americashealthrankings.org Health, United States, 2009 from the CDC –http://www.cdc.gov/nchs/hus.htm http://www.cdc.gov/nchs/hus.htm National Cancer Institute, SEER database and Health Disparities Calculator –http://seer.cancer.gov/hdcalc/index.html http://seer.cancer.gov/hdcalc/index.html Healthy People 2010 database –http://wonder.cdc.gov/data2010/ http://wonder.cdc.gov/data2010/

39. Summary Define epidemiology Understand health in Middle Tennessee Understand determinants of health Using data to drive decisions Identify local, state, & national data