Major components and themes of local public health laws in select U.S. jurisdictions

Municipal officials' perspectives on policymaking for addressing obesity and health equity

Background

Obesity evidence-based policies (EBPs) can make a lasting, positive impact on community health; however, policy development and enactment is complex and dependent on multiple forces.

Aims and objectives

This study investigated key factors affecting municipal officials' policymaking for obesity and related health disparities.

Methods

Semi-structured interviews were conducted with 20 local officials from a selection of municipalities with high obesity or related health disparities across the United States between December 2020 and April 2021.

Findings

Policymakers follow a general decision-making process with limited distinction between health and other policy areas. Factors affecting policymaking included: being informed about other local, state, and federal policy, conducting their own research using trustworthy sources, and seeking constituent and stakeholder perspectives. Key facilitators included the need for timely, relevant local data, and seeing or hearing from those impacted. Key local policymaking barriers included constituent opposition, misinformation, controversial issues with contentious solutions, and limited understanding of the connection between issues and obesity/health. Policymakers had a range of understanding about causes of health disparities, including views of individual choices, environmental influences on behaviors, and structural factors impacting health. To address health disparities, municipal officials described: a variety of roles policymakers can take, limitations based on the scope of government, challenges with intergovernmental collaboration or across government levels, ability of policymakers and government employees to understand the problem, and the challenge of framing health disparities given the social-political context.

Discussion and conclusion

Understanding factors affecting the uptake of EBPs can inform local-level interventions that encourage EBP adoption.

Development of a standards-based city-wide health information exchange for public health in response to COVID-19

Background

Disease surveillance is a critical function of public health, provides essential information about the disease burden and the clinical and epidemiologic parameters of disease, and is an important element of effective and timely case and contact tracing. The COVID-19 pandemic demonstrates the essential role of disease surveillance in preserving public health. In theory, the standard data formats and exchange methods provided by electronic health record (EHR) meaningful use should enable rapid health care data exchange in the setting of disruptive health care events, such as a pandemic. In reality, access to data remains challenging and, even if available, often lacks conformity to regulated standards.

Objective

We sought to use regulated interoperability standards already in production to generate awareness of regional bed capacity and enhance the capture of epidemiological risk factors and clinical variables among patients tested for SARS-CoV-2. We described the technical and operational components, governance model, and timelines required to implement the public health order that mandated electronic reporting of data from EHRs among hospitals in the Chicago jurisdiction. We also evaluated the data sources, infrastructure requirements, and the completeness of data supplied to the platform and the capacity to link these sources.

Methods

Following a public health order mandating data submission by all acute care hospitals in Chicago, we developed the technical infrastructure to combine multiple data feeds from those EHR systems—a regional data hub to enhance public health surveillance. A cloud-based environment was created that received ELR, consolidated clinical data architecture, and bed capacity data feeds from sites. Data governance was planned from the project initiation to aid in consensus and principles for data use. We measured the completeness of each feed and the match rate between feeds.

Results

Data from 88,906 persons from CCDA records among 14 facilities and 408,741 persons from ELR records among 88 facilities were submitted. Most (n=448,380, 90.1%) records could be matched between CCDA and ELR feeds. Data fields absent from ELR feeds included travel histories, clinical symptoms, and comorbidities. Less than 5% of CCDA data fields were empty. Merging CCDA with ELR data improved race, ethnicity, comorbidity, and hospitalization information data availability.

Conclusions

We described the development of a citywide public health data hub for the surveillance of SARS-CoV-2 infection. We were able to assess the completeness of existing ELR feeds, augment those feeds with CCDA documents, establish secure transfer methods for data exchange, develop a cloud-based architecture to enable secure data storage and analytics, and produce dashboards for monitoring of capacity and the disease burden. We consider this public health and clinical data registry as an informative example of the power of common standards across EHRs and a potential template for future use of standards to improve public health surveillance.

The Relationship Between Hepatitis C Virus Rates and Office-Based Buprenorphine Access in Ohio

Background

The United States is experiencing an epidemic of hepatitis C virus (HCV) infections due to injection drug use, primarily of opioids and predominantly in rural areas. Buprenorphine, a medication for opioid use disorder, may indirectly prevent HCV transmission. We assessed the relationship of HCV rates and office-based buprenorphine prescribing in Ohio.

Methods

We conducted an ecological study of the county-level (n = 88) relationship between HCV case rates and office-based buprenorphine prescribing in Ohio. We fit adjusted negative binomial models between the county-level acute and total HCV incidence rates during 2013–2017 and 1) the number of patients in each county that could be served by office-based buprenorphine (prescribing capacity) and 2) the number served by office-based buprenorphine (prescribing frequency) from January–March, 2018.

Results

For each 10% increase in acute HCV rate, office-based buprenorphine prescribing capacity differed by 1% (95% CI: –1%, 3%). For each 10% increase in total HCV rate, office-based buprenorphine prescribing capacity was 12% (95% CI: 7%, 17%) higher. For each 10% increase in acute HCV rate, office-based buprenorphine prescribing frequency was 1% (95% CI: –1%, 3%) higher. For each 10% increase in total HCV rate, office-based buprenorphine prescribing frequency was 14% (95% CI: 7%, 20%) higher.

Conclusions

Rural counties in Ohio have less office-based buprenorphine and higher acute HCV rates versus urban counties, but a similar relationship between office-based buprenorphine prescribing and HCV case rates. To adequately prevent and control HCV rates, certain rural counties may need more office-based buprenorphine prescribing in areas with high HCV case rates.

Development and implementation of a local government survey to measure community supports for healthy eating and active living

The ability to make healthy choices is influenced by where one lives, works, shops, and plays. Locally enacted policies and standards can influence these surroundings but little is known about the prevalence of such policies and standards that support healthier behaviors. In this paper, we describe the development of a survey questionnaire designed to capture local level policy supports for healthy eating and active living and findings and lessons learned from a 2012 pilot in two states, Minnesota and California, including respondent burden, survey sampling and administration methods, and survey item feasibility issues. A 38-item, web-based, self-administered survey and sampling frame were developed to assess the prevalence of 22 types of healthy eating and active living policies in a representative sample of local governments in the two states. The majority of respondents indicated the survey required minimal effort to complete with half taking < 20 min to complete the survey. A non-response follow-up plan including emails and phone calls was required to achieve a 68% response rate (versus a 37% response rate for email only reminders). Local governments with larger residential populations reported having healthy eating and active living policies and standards more often than smaller governments. Policies that support active living were more common than those that support healthy eating and varied within the two states. The methods we developed are a feasible data collection tool for estimating the prevalence of municipal healthy eating and active living policies and standards at the state and national level.

Outcomes, Approaches, and Challenges to Developing and Passing a Countywide Mandatory Vaccination Policy: St. Louis County's Experience with Hepatitis A Vaccine for Food Service Personnel

In the early 1990s, St. Louis County had multiple foodservice worker-related hepatitis A outbreaks uncontrolled by standard outbreak interventions. Restaurant interest groups and the general public applied political pressure to local public health officials for more stringent interventions, including a mandatory vaccination policy. Local health departments can enact mandatory vaccination policies, but this has rarely been done. The study objectives were to describe the approach used to pass a mandatory vaccination policy at the local jurisdiction level and illustrate the outcome from this ordinance 15 years later. A case study design was used. In-depth, semi-structured interviews using guided questions were conducted in spring, 2015, with six key informants who had direct knowledge of the mandatory vaccination policy process. Meeting minutes and/or reports were also analyzed. A Poisson distribution analysis was used to calculate the rate of outbreaks before and after mandatory vaccination policy implementation. The policy appears to have reduced the number of hepatitis A outbreaks, lowering the morbidity and economic burden in St. Louis County. The lessons learned by local public health officials in passing a mandatory hepatitis A vaccination policy are important and relevant in today's environment. The experience and lessons learned may assist other local health departments when faced with the potential need for mandatory policies for any vaccine preventable disease.

Navigating the legal framework for state foodborne illness surveillance and outbreak response: observations and challenges

Public health and food safety officials have long recognized the important role that state agencies play in protecting consumers from foodborne disease. With the increasing occurrence of multi-jurisdictional outbreaks, efforts have been underway to modernize and make more uniform the patchwork of state laws, protocols, and policies that exist across the U.S. for food-borne illness surveillance and outbreak response activities. To aid in this endeavor, and to better understand the role of law in a state's ability to carry out these functions effectively, we are creating a database of key legal authorities and provisions relating to foodborne illness surveillance and outbreak response across the 50 states and District of Columbia. There appears to be wide variation in the legal infrastructure for these activities, ranging from how certain terms are defined, to what and when foodborne illnesses must be reported, to which level of government has responsibility over investigation and response of foodborne outbreaks. As outbreaks become more widespread and involve multiple jurisdictions, it is important that public health and food safety stakeholders understand the legal authorities under which they operate, how such authorities may impede or promote efficient and effective surveillance and outbreak response, and use that knowledge to determine if state laws should be updated or strengthened.

Coded statutory data sets for evaluation of public health law

BACKGROUND AND OBJECTIVES

The evaluation of public health law requires reliable accounts of underlying statutes and regulations. States often enact public health-related statutes with nonuniform provisions, and variation in the structure of state legal codes can foster inaccuracy in evaluating the impact of specific categories of law. The optimal format for empirical analysis is a machine-readable 50-state coded data set. This study provides a comprehensive assessment of these resources and related materials with a focus on statutory data sets.

RESEARCH DESIGN

An exhaustive literature search was followed by a "pearling" or "snowball" approach to assure the most complete inventory of this very diverse and diffuse information. We also interviewed three leading investigators to identify barriers to wider use and availability of coded legal data sets.

RESULTS

We identified relatively few accessible coded statutory data sets, and others that are not available for use outside the group or individual that compiled them. The Robert Wood Johnson Foundation-funded Public Health Law Research Program has made funding available for the development and dissemination of additional data sets, as well as extensive guidance regarding their use in the evaluation of public health law. Investigators reported serious obstacles to these activities in the past.

CONCLUSIONS

Compilation of coded statutory data sets requires a focused investment of resources that has only recently become available. Funders should require grantees to make their work accessible to other investigators so as to assure development of public health law research and evaluation.

Legal considerations in a nuclear detonation

This article summarizes public health legal issues that need to be considered in preparing for and responding to nuclear detonation. Laws at the federal, state, territorial, local, tribal, and community levels can have a significant impact on the response to an emergency involving a nuclear detonation and the allocation of scarce resources for affected populations. An understanding of the breadth of these laws, the application of federal, state, and local law, and how each may change in an emergency, is critical to an effective response. Laws can vary from 1 geographic area to the next and may vary in an emergency, affording waivers or other extraordinary actions under federal, state, or local emergency powers. Public health legal requirements that are commonly of concern and should be examined for flexibility, reciprocity, and emergency exceptions include liability protections for providers; licensing and credentialing of providers; consent and privacy protections for patients; occupational safety and employment protections for providers; procedures for obtaining and distributing medical countermeasures and supplies; property use, condemnation, and protection; restrictions on movement of individuals in an emergency area; law enforcement; and reimbursement for care.