IC in Care Series: Public Health

By Kelly M. Pyrek

The CDC Foundation explains that public health is “the science of protecting and improving the health of families and communities through promotion of healthy lifestyles, research for disease and injury prevention and detection and control of infectious diseases.” It adds that “Public health professionals try to prevent problems from happening or recurring through implementing educational programs, recommending policies, administering services and conducting research – in contrast to clinical professionals like doctors and nurses, who focus primarily on treating individuals after they become sick or injured. Public health also works to limit health disparities. A large part of public health is promoting healthcare equity, quality and accessibility.”

The driving agency of public health in the U.S. is the Centers for Disease Control and Prevention (CDC), the disease prevention and wellness promotion agency tasked with protecting people's health and safety, providing credible information to enhance health decisions, and improving health through strong partnerships. CDC's work encompasses a wide range of health threats, including infectious and chronic diseases, injuries, birth defects, food and water safety, bioterrorism, environmental hazards, and occupational health and safety. CDC also administers funding for state and local health departments, community-based organizations and academic institutions for a wide array of public health programs and research. The CDC has approximately 14,000, full-time, part-time and contract employees located throughout the United States and in 54 countries.

With the CDC leading the public health infrastructure comprised of local and state departments of health, infection preventionists (IPs) have a wealth of resources and assistance at their disposal. That's a good thing, seeing as there is a sizable national list of notifiable/reportable diseases for which each state is required to report cases, but states may have additional diseases of interest that they are tracking so their list may include more reportable diseases. The individual reports of a reportable disease are forwarded to state and then national health departments where they are compiled, analyzed and disseminated via publications such as the CDC's Weekly Morbidity & Mortality Report, to keep all public health stakeholders informed about possible outbreaks in their area. Once a sentinel case of an infectious disease is detected, the reporting system is used to alert local healthcare providers who will watch for additional cases. The state health department receives information from the local agency and forwards it to the CDC where it becomes part of the ongoing statistics of disease outbreak. The CDC also provides support back to the local health department via the state. In cases of outbreak where the organism is unknown or the spread of disease is rapid, the CDC will provide additional expertise to identify cause and technical assistance for limiting spread of disease. The CDC will also alert its international partners about outbreaks.

Recognizing this need for collaboration, Stricof, et al. (2012) reported on the results of a 2011 survey developed by the Association for Professionals in Infection Control and Epidemiology (APIC) and the Council of State and Territorial Epidemiologists that aimed to gain a better understanding of the relationship between state and local health departments and the hospital-based infection prevention community.

The survey revealed that the majority of the 1,334 respondents (78 percent) reported that state or local laws/regulations required reporting of healthcare-associated infection (HAI) outbreaks to public health, and 37 percent of respondents had reported an HAI outbreak in the past two years. These outbreaks resulted in contacting the local department of health (DOH) (80 percent), the state DOH (58 percent), the CDC (11 percent), the Occupational Safety and Health Administration (<1 percent), and the Food and Drug Administration (3 percent). The regulatory or licensing program received outbreak reports from 18 percent. Epidemiologic assistance was most frequently provided by the state (52 percent) or local DOH (55 percent). Overall, respondents stated that public health laboratory support was available from the state (71 percent) or local DOH (23 percent).
Additionally, the survey found that 900 respondents (68 percent) were in states with mandatory public reporting of HAIs, although reporting had not yet begun for 89 (10 percent) of those respondents. Infection preventionists (IPs) in states without mandatory public reporting were more likely to have reported an increase in infection prevention resources over the previous two years than IPs in states with mandatory public HAI reporting, but the difference was not statistically significant.

Stricof, et al. (2012) note that IPs reported a substantial amount of contact with their state and local DOH. Eighty percent reported contact with their state DOH and 94 percent with their local DOH in the last year. Four percent needed prior approval to contact the DOH. Less than 1 percent had no contact with a state or local DOH in the past year. IPs were more likely to have a specific contact person at the local DOH when compared with the state DOH, but the specific person at the state was almost twice as likely to have HAI expertise (65 percent versus 39 percent, respectively).

The reporting burden for facilities in states that had implemented mandatory HAI reporting was an average of 25 hours per month with a range of 0 to 605 hours. The mean number of hours per occupied bed per month was 0.25 hours. The most hours were spent by IPs in Pennsylvania where all HAIs are reportable.

The infection prevention and control program is responsible for general communicable disease reporting in 90 percent of the facilities. Respondents reported spending an average of nine hours per month on communicable disease reporting (0 to 200 hours per month).

“Although not directly related to the interaction between infection prevention and control programs and public health, the most surprising and discouraging finding in the 2011 survey was the lack of additional resources for infection prevention and control programs for facilities in states with mandatory public reporting,” Stricoff says.  “I would have hoped that given the increased burden, the critical role of infection preventionists and hospital epidemiologists and the recognition that so many infections are preventable; resources would have been substantively increased.”

The increasing workload doesn’t seem to be letting up anytime soon, especially in light of the constant threat of the next outbreak.

“Recent events (i.e., Ebola, extremely drug resistant microorganisms, meningitis associated with compounded medications, endoscope-related infections) have clearly demonstrated the need for ongoing, bidirectional flow of information and collaboration between public health and healthcare facilities,” Stricoff emphasizes. “The public health community is highly dependent upon the infection prevention and control community to serve as their eyes and ears - to detect and report unusual events and threats, and to work together to prevent and control infections within and between healthcare settings and the community.”

To that end, the 2011 survey revealed IPs’ perspectives on this critical partnership. The survey asked respondents to identify the factors they thought were most important in establishing an effective relationship between the local and/or state health departments and hospitals. Respondents said that communication and interaction were critical to this process, emphasizing the importance of building personal relationships with the health department. Another frequently cited factor by respondents was building a collaborative environment, with IPs underscoring the importance of mutual trust and respect between hospitals and health departments. Key to the respondents was the health department’s availability and reliability, as well as knowledge and expertise.

Those expectations include the DOH’s abilities to provide the infrastructure necessary to detect and investigate outbreaks, conduct research to enhance prevention, develop and advocate sound public health policies, implement prevention strategies, and provide leadership and training to the DOH’s stakeholders.

The continued threat of infectious disease outbreaks warrants IPs doing all they can to strengthen relationships with their local and state DOHs, and Stricoff notes, “I have always believed that this relationship is critical….we have never been without infectious disease threats and unfortunately, I fear, we never will.” Stricoff says that relationship can be strengthened through “mutual respect, understanding and appreciating the depth and breadth of one another’s roles, responsibilities, and duties.”

No discussion of public health would be complete without considering the bigger context of the demands placed upon the field and the ongoing resourcing needs. As Lederberg (2000) explains, “The public health system also is continually challenged by unexpected disease outbreaks, whether an influenza epidemic or an act of bioterrorism. To be prepared and responsive to these infections and outbreaks, the public health infrastructure requires attention and resources. Periodic infectious disease outbreaks serve to remind the public of the importance of the public health system. That outbreaks and epidemics of infectious diseases have been successfully prevented or controlled leads to the common misconception that the public health system is more than sufficient. Such misconceptions, however, belie the true risks to public health, and reinforce the public’s expectations in the face of increasingly complex emerging infections and the changing health care environment. Disease investigations are now more complex in nature than they were in the past because of a variety of new pathogens and risk factors, outbreaks, and bioterrorist activities that cross state and national boundaries-often raising political and economic concerns.”

In 2000, the Forum on Emerging Infections convened a workshop to identify, clarify and solidify some of the current and potential best practices in the public health arena to combat the threat of emerging infectious diseases, focusing on four major areas of importance to public health systems that shape and are shaped by the nature of emerging infections: epidemiological investigations; disease surveillance; communication, coordination, and education and outreach; and strategic planning, resource allocation, and economic support.

At the workshop, participants described the components of the current system at the national, state, and local levels. In the ensuing discussions, participants debated many of the challenges that must be overcome and identified possible opportunities for addressing the obstacles. These discussions addressed the integration of public health systems, investment in human capital, and improved collaboration between the private and public sectors.

Although this workshop was held 16 years ago, the fundamental tenets coming out of the event remain relevant. As Lederberg (2000) emphasizes, “An adequate public health system is made up of various components. Although the list presented below is not comprehensive, it nevertheless provides a good representation of the components that should be considered. The changing demographics and environmental conditions that the United States and countries around the world are experiencing have important influences on public health and include global travel; immigration and migration; movement of products, including food and other potential vectors of disease; population growth; urbanization and crowding; changing socioeconomic conditions, particularly the worsening poverty observed in so many areas of this country and other parts of the world; and significant ecological changes such as deforestation, reforestation, irrigation, and changing patterns of agricultural and pesticide use. These changes are dynamic and contribute to the complexities of emerging infectious disease outbreaks.”

Because of such events, Lederberg (2000) says the need for the development and implementation of a fundamental capability for infectious disease surveillance at the community, state, and national levels cannot be overemphasized. Uniformity needs to be established in the currently fragmented public health systems, particularly in the public health laboratories that exist throughout the country. He adds, “If the United States is to have a robust public health system, ongoing training and the creation of meaningful career ladders and opportunities for professional development within the practice of public health need to be established and considered priorities.”

In 2011, the CDC issued its Framework for Preventing Infectious Diseases: Sustaining the Essentials and Innovating for the Future, which outlined three critical elements: strong public health fundamentals, including infectious disease surveillance, laboratory detection, and epidemiologic investigation; high-impact interventions; and sound health policies.
In terms of strengthening public health fundamentals, the CDC Framework document suggested these actions: Modernize infectious disease surveillance to drive public health action; expand the role of public health and clinical laboratories in disease control and prevention, and advance workforce development and training to sustain and strengthen public health practice. As for implementing interventions, the CDC Framework identified these actions: Identify and validate high-impact tools for disease reduction, including new vaccines; strategies and tools for infection control and treatment; and interventions to reduce disease transmitted by animals or insects. And finally, for developing policies, the CDC Framework suggested: Ensure the availability of sound scientific data to support the development of evidence-based and cost-effective policies; and advance policies to improve prevention, detection, and control of infectious diseases to help integrate clinical infectious disease preventive practices into U.S. healthcare; increase community and individual engagement in disease prevention efforts; strengthen global capacity to detect and respond to outbreaks with the potential to cross borders; address microbial drug resistance; and promote “One Health” approaches to prevent emergence and spread of zoonotic diseases; and use proven tools and interventions to reduce high-burden infectious diseases, including vaccine-preventable diseases; healthcare-associated infections; HIV/AIDS; foodborne infections; and chronic viral hepatitis

No matter the threat, maintaining readiness is imperative, according to public health experts. “When you have addressed one public health threat, you have addressed just one public health threat.  We need to continue to build upon each experience and continue to work together - prevention and preparedness are active processes without a singular endpoint.”

References:
CDC Foundation. What is Public Health? Accessible at: http://www.cdcfoundation.org/content/what-public-health
Centers for Disease Control and Prevention (CDC). Framework for Preventing Infectious Diseases: Sustaining the Essentials and Innovating for the Future. 2011. Accessible at: http://www.cdc.gov/oid/docs/id-framework.pdf
Lederberg J. Public Health Systems and Emerging Infections: Assessing the Capabilities of the Public and Private Sectors: Workshop Summary. Institute of Medicine (US) Forum on Emerging Infections. National Academies Press. 2000. Accessible at: http://www.ncbi.nlm.nih.gov/books/NBK100244/
Stricof RL, Hanchett M, Beaumont J, Kaiser K and Graham D. The relationship of public health to the infection preventionists in United States hospitals, 2011: A partnership for change. Am J Infect Control. 40 (2012) 392-5.