Achieving a Healthy Oklahoma: Cross-Sector Cooperation to Improve Public Health Preparedness and Pandemic Response

In response to the COVID-19 pandemic, the University of Oklahoma Hudson College of Public Health launched the Achieving a Healthy Oklahoma (AHO) initiative in 2021. The goals of AHO were to assess lessons learned in Oklahoma from COVID-19 and set the foundation for enhanced public-private community collaboration by developing recommendations to prepare for future public health crises and promote health across all major economic sectors. Over 700 stakeholders were engaged in surveys, interviews, workgroup meetings, community listening sessions, and steering committee meetings over 8 months to accomplish these goals. Stakeholders produced 60 sector- and stakeholder-specific policy recommendations to address the major issues uncovered during the initiative. The AHO team then distilled them into 5 recommendations: (1) invest in the future of Oklahoma's health workforce to include critically needed public health professions in Oklahoma's healthcare loan repayment programs; (2) establish contracts between higher education institutions in Oklahoma and state and local health departments to monitor health sector workforce needs and provide training; (3) strengthen the delivery of coordinated public health services within local communities during emergencies and daily operations by dedicating health department roles to coordinate public health projects and services; (4) improve preparedness by coordinating annual emergency management exercises across local and state health departments; and (5) emphasize the efficiency and effectiveness of cross-sector collaborative efforts between public, private, and tribal partners. The AHO initiative serves as an action guide for assessing and improving state-level public health emergency responses and strengthening public health infrastructure. Implementing the recommendations in Oklahoma and assessing and addressing similar needs across the nation are necessary to prepare the United States for future public health emergencies.

Characterization of persons with reported SARS-CoV-2 infection in the Oklahoma City tri-county area: Evidence from the first 12 months of transmission

Background

To describe characteristics, hospitalization, and death for reported cases of SARS-CoV-2 infection in the Oklahoma City tri-county area.

Methods

We extracted notified cases of SARS-CoV-2 infection for our study area and used descriptive statistics and modeling to examine case characteristics and calculate the odds of hospitalization and death in relation to a range of explanatory variables.

Results

Between March 12th, 2020 and February 28th, 2021, 124,925 cases of SARS-CoV-2 infection were reported from the study region. Being male, White or Black/African American, aged 50 years or older, presenting with apnea, cough, and shortness of breath, and having diabetes was associated with increased odds of hospitalization. The odds of dying were significantly associated with being Black/African American, presenting with cough and fever, having kidney disease and diabetes and being aged 70 years or older.

Conclusions

The first cohort analysis of SARS-CoV-2 positive individuals in the Oklahoma City tri-county area confirms comorbidities and age as important predictors of COVID-19 hospitalization or death. As a novel aspect, we show that early symptoms of breathing difficulties in particular are associated with hospitalization and death. Initial case assessment and SARS-CoV-2 guidelines should continue to focus on age, comorbidities, and early symptoms.

Exploring the Applicability of Using Natural Language Processing to Support Nationwide Venous Thromboembolism Surveillance: Model Evaluation Study

Background

Venous thromboembolism (VTE) is a preventable, common vascular disease that has been estimated to affect up to 900,000 people per year. It has been associated with risk factors such as recent surgery, cancer, and hospitalization. VTE surveillance for patient management and safety can be improved via natural language processing (NLP). NLP tools have the ability to access electronic medical records, identify patients that meet the VTE case definition, and subsequently enter the relevant information into a database for hospital review.

Objective

We aimed to evaluate the performance of a VTE identification model of IDEAL-X (Information and Data Extraction Using Adaptive Learning; Emory University)-an NLP tool-in automatically classifying cases of VTE by "reading" unstructured text from diagnostic imaging records collected from 2012 to 2014.

Methods

After accessing imaging records from pilot surveillance systems for VTE from Duke University and the University of Oklahoma Health Sciences Center (OUHSC), we used a VTE identification model of IDEAL-X to classify cases of VTE that had previously been manually classified. Experts reviewed the technicians' comments in each record to determine if a VTE event occurred. The performance measures calculated (with 95% CIs) were accuracy, sensitivity, specificity, and positive and negative predictive values. Chi-square tests of homogeneity were conducted to evaluate differences in performance measures by site, using a significance level of .05.

Results

The VTE model of IDEAL-X "read" 1591 records from Duke University and 1487 records from the OUHSC, for a total of 3078 records. The combined performance measures were 93.7% accuracy (95% CI 93.7%-93.8%), 96.3% sensitivity (95% CI 96.2%-96.4%), 92% specificity (95% CI 91.9%-92%), an 89.1% positive predictive value (95% CI 89%-89.2%), and a 97.3% negative predictive value (95% CI 97.3%-97.4%). The sensitivity was higher at Duke University (97.9%, 95% CI 97.8%-98%) than at the OUHSC (93.3%, 95% CI 93.1%-93.4%; P<.001), but the specificity was higher at the OUHSC (95.9%, 95% CI 95.8%-96%) than at Duke University (86.5%, 95% CI 86.4%-86.7%; P<.001).

Conclusions

The VTE model of IDEAL-X accurately classified cases of VTE from the pilot surveillance systems of two separate health systems in Durham, North Carolina, and Oklahoma City, Oklahoma. NLP is a promising tool for the design and implementation of an automated, cost-effective national surveillance system for VTE. Conducting public health surveillance at a national scale is important for measuring disease burden and the impact of prevention measures. We recommend additional studies to identify how integrating IDEAL-X in a medical record system could further automate the surveillance process.

Professors and Practitioners: Assessing the Impact of COVID-19 in the State of Oklahoma with and Without Residents of Long-Term Care Facilities

OBJECTIVES

Our analysis, which began as a request from the Oklahoma Governor for useable analysis for state decision making, seeks to predict statewide COVID-19 spread through a variety of lenses, including with and without long-term care facilities (LTCFs), accounting for rural/urban differences, and considering the impact of state government regulations of the citizenry on disease spread.

METHODS

We utilize a deterministic susceptible exposed infectious resistant (SEIR) model designed to fit observed fatalities, hospitalizations, and ICU beds for the state of Oklahoma with a particular focus on the role of the rural/urban nature of the state and the impact that COVID-19 cases in LTCFs played in the outbreak.

RESULTS

The model provides a reasonable fit for the observed data on new cases, deaths, and hospitalizations. Moreover, removing LTCF cases from the analysis sharpens the analysis of the population in general, showing a more gradual increase in cases at the start of the pandemic and a steeper increase when the second surge occurred.

CONCLUSIONS

We anticipate that this procedure could be helpful to policymakers in other states or municipalities now and in the future.

Zika virus infection in the Veterans Health Administration (VHA), 2015-2016

BACKGROUND

Zika virus (ZIKV) is an important flavivirus infection. Although ZIKV infection is rarely fatal, risk for severe disease in adults is not well described. Our objective was to describe the spectrum of illness in U.S. Veterans with ZIKV infection.

METHODOLOGY

Case series study including patients with laboratory-confirmed or presumed positive ZIKV infection in all Veterans Health Administration (VHA) medical centers. Adjusted odds ratios of clinical variables associated with hospitalization and neurologic complications was performed.

PRINCIPAL FINDINGS

Of 1,538 patients tested between 12/2015-10/2016 and observed through 3/2017, 736 (48%) were RT-PCR or confirmed IgM positive; 655 (89%) were male, and 683 (93%) from VA Caribbean Healthcare System (VACHCS). Ninety-four (13%) were hospitalized, 91 (12%) in the VACHCS. Nineteen (3%) died after ZIKV infection. Hospitalization was associated with increased Charlson co-morbidity index (adjusted odds ratio [OR] 1.2; 95% confidence interval [CI], 1.1-1.3), underlying connective tissue disease (OR, 29.5; CI, 3.6-244.7), congestive heart failure (OR, 6; CI, 2-18.5), dementia (OR, 3.6; CI, 1.1-11.2), neurologic symptom presentation (OR, 3.9; CI, 1.7-9.2), leukocytosis (OR, 11.8; CI, 4.5-31), thrombocytopenia (OR, 7.8; CI, 3.3-18.6), acute kidney injury (OR, 28.9; CI, 5.8-145.1), or using glucocorticoids within 30 days of testing (OR, 13.3; CI 1.3-133). Patients presenting with rash were less likely to be hospitalized (OR, 0.29; CI, 0.13-0.66). Risk for neurologic complications increased with hospitalization (OR, 5.9; CI 2.9-12.2), cerebrovascular disease (OR 4.9; CI 1.7-14.4), and dementia (OR 2.8; CI 1.2-6.6).

CONCLUSION

Older Veterans with multiple comorbidities or presenting with neurologic symptoms were at increased risk for hospitalization and neurological complications after ZIKV infection.

Epidemiology and burden of influenza in the U.S. Department of Veterans Affairs

We describe influenza activity in the US Veterans Affairs (VA) population for the 2010-2011 through 2015-2016 seasons and compare with national CDC FluView data. VA confirmed influenza cases ranged from 1005 to 11 506 per season; triage calls from 6090 to 10 346; outpatient visits from 3849 to 13 406; antiviral prescriptions from 3650 to 32 826; hospitalizations from 546 to 4673; and deaths in hospitalized patients from 17 to 139. Peak activity was generally the same as observed nationally by the CDC. For the seasons analyzed, correlation between VA and CDC %ILI visits (r = .863), influenza hospitalizations (r = .953), positive tests (r = .948), and percent of tests positive (r = .938) was strong. Understanding influenza burden is important for evaluating prevention priorities and resource allocation within VA.

Factors for Hospitalizations and Neurologic Complications in Zika Virus Infection in the Department of Veterans Affairs (VA)

Background

Zika virus (ZIKV) is an important flavivirus, but severity of infection is poorly described in adults. We investigated factors associated with hospitalization and neurologic complications as measures of severity.

Methods

ZIKV cases from December 1, 2015 to October 31, 2016 were identified from clinical samples tested in VA, state and commercial laboratories, and patients were followed until 3/31/2017. ZIKV positive patients (RT-PCR or screening IgM positive confirmed by a plaque-reduction neutralization test [PRNT] IgM positive for ZIKV alone or including dengue virus) were reviewed for demographic and clinical factors. Logistic regression analysis was performed to evaluate factors associated with 1) hospitalization and 2) neurologic complications in VA ZIKV positive patients.

Results

736 of 1,538 (48%) patients tested were ZIKV positive; 655 (89%) were male and 683 (93%) were diagnosed at the VA Caribbean Healthcare System (VACHCS). In total, 94 (13%) were hospitalized with 91 (12%) at VACHCS. 19 (3%) patients, all at VACHCS, died from any cause after ZIKV diagnosis. Hospitalization was more likely with increased age, co-morbidities, neurologic symptoms, thrombocytopenia, or preadmission glucocorticoid use, and less likely if rash was present (Table 1). Hospitalization, prior cerebrovascular disease and dementia were associated with neurologic complications.

Conclusion

Older Veterans with multiple comorbidities or presenting with neurologic symptoms were more likely to be hospitalized after ZIKV infection, and those with a prior history of cerebrovascular disease and dementia were at increased risk for neurological complications.

Disclosures

All authors: No reported disclosures.

Identifying heat-related deaths by using medical examiner and vital statistics data: Surveillance analysis and descriptive epidemiology - Oklahoma, 1990-2011

OBJECTIVES

Approximately 660 deaths occur annually in the United States associated with excess natural heat. A record heat wave in Oklahoma during 2011 generated increased interest concerning heat-related mortality among public health preparedness partners. We aimed to improve surveillance for heat-related mortality and better characterize heat-related deaths in Oklahoma during 1990-2011, and to enhance public health messaging during future heat emergencies.

METHODS

Heat-related deaths were identified by querying vital statistics (VS) and medical examiner (ME) data during 1990-2011. Case inclusion criteria were developed by using heat-related International Classification of Diseases codes, cause-of-death nomenclature, and ME investigation narrative. We calculated sensitivity and predictive value positive (PVP) for heat-related mortality surveillance by using VS and ME data and performed a descriptive analysis.

RESULTS

During the study period, 364 confirmed and probable heat-related deaths were identified when utilizing both data sets. ME reports had 87% sensitivity and 74% PVP; VS reports had 80% sensitivity and 52% PVP. Compared to Oklahoma's general population, decedents were disproportionately male (67% vs. 49%), aged ≥65 years (46% vs. 14%), and unmarried (78% vs. 47%). Higher rates of heat-related mortality were observed among Blacks. Of 95 decedents with available information, 91 (96%) did not use air conditioning.

CONCLUSIONS

Linking ME and VS data sources together and using narrative description for case classification allows for improved case ascertainment and surveillance data quality. Males, Blacks, persons aged ≥65 years, unmarried persons, and those without air conditioning carry a disproportionate burden of the heat-related deaths in Oklahoma.

Thrombosis: a major contributor to global disease burden

BACKGROUND

Thrombosis is the common pathology underlying ischemic heart disease, ischemic stroke, and venous thromboembolism (VTE). The Global Burden of Disease Study 2010 (GBD 2010) documented that ischemic heart disease and stroke collectively caused 1 in 4 deaths worldwide. GBD 2010 did not report data for VTE as a cause of death and disability.

OBJECTIVE

To review the literature on the global burden of disease caused by VTE.

APPROACH AND RESULTS

We performed a systematic review of the literature on the global disease burden because of VTE in low-, middle-, and high-income countries. Studies from Western Europe, North America, Australia, and Southern Latin America (Argentina) yielded consistent results with annual incidences ranging from 0.75 to 2.69 per 1000 individuals in the population. The incidence increased to between 2 and 7 per 1000 among those aged ≥70 years. Although the incidence is lower in individuals of Chinese and Korean ethnicity, their disease burden is not low because of population aging. VTE associated with hospitalization was the leading cause of disability-adjusted life-years lost in low- and middle-income countries, and second in high-income countries, responsible for more disability-adjusted life-years lost than nosocomial pneumonia, catheter-related blood stream infections, and adverse drug events.

CONCLUSIONS

VTE causes a major burden of disease across low-, middle-, and high-income countries. More detailed data on the global burden of VTE should be obtained to inform policy and resource allocation in health systems and to evaluate whether improved use of preventive measures will reduce the burden.

Thrombosis: a major contributor to the global disease burden

Thrombosis is a common pathology underlying ischemic heart disease, ischemic stroke, and venous thromboembolism (VTE). The Global Burden of Diseases, Injuries, and Risk Factors (GBD) Study 2010 documented that ischemic heart disease and stroke collectively caused one in four deaths worldwide. GBD 2010 did not report data for VTE as a cause of death and disability. We performed a systematic review of the literature on the global disease burden caused by VTE in low-income, middle-income and high-income countries. Studies from western Europe, North America, Australia and southern Latin America (Argentina) yielded consistent results, with annual incidence rates ranging from 0.75 to 2.69 per 1000 individuals in the population. The incidence increased to between 2 and 7 per 1000 among those aged ≥ 70 years. Although the incidence is lower in individuals of Chinese and Korean ethnicity, their disease burden is not low, because of population aging. VTE associated with hospitalization was the leading cause of disability-adjusted life-years (DALYs) lost in low-income and middle-income countries, and the second most common cause in high-income countries, being responsible for more DALYs lost than nosocomial pneumonia, catheter-related bloodstream infections, and adverse drug events. VTE causes a major burden of disease across low-income, middle-income and high-income countries. More detailed data on the global burden of VTE should be obtained to inform policy and resource allocation in health systems, and to evaluate whether improved utilization of preventive measures will reduce the burden.

Breast cancer by stage of disease at diagnosis, central Oklahoma

We describe factors associated with an initial diagnosis of stage IV breast cancer to identify segments of Oklahoma's population that need earlier screening. We obtained data from the Central Oklahoma chapter of Susan G. Komen for the Cure and from the Oklahoma Central Cancer Registry. All analyses were cross-sectional and ecologic. The distributions of breast cancer stage at diagnosis for ten central Oklahoma counties were analyzed with respect to age group, race/ethnicity, insurance status, family income, and the percent of women who reported [not] receiving a mammogram in the previous twelve months. The percentage of African American women diagnosed with stage IV disease (7.8%) was nearly double that in white (4.2%) and other races (4.1%; p < 0.01). After controlling for confounding variables, the proportion of women diagnosed with breast cancer at stage IV was still higher among African American than among white females (p < 0.01) and females aged 65+ years (p = 0.02). The availability of breast cancer screening services should be increased among African American women in central Oklahoma.

TB and HIV in St Petersburg, Russia: a looming catastrophe?

BACKGROUND

After decades of improved tuberculosis (TB) control in Russia, notification rates started to rise in 1992. Russia also faces a fast growing human immunodeficiency virus (HIV) epidemic.

OBJECTIVE

To document the extent and characteristics of HIV co-infection in TB patients in St Petersburg, Russia.

DESIGN

A prospective cross-sectional study of HIV coinfected culture-positive TB cases. Between 15 June 2002 and 31 March 2003, TB cases at the St Petersburg City TB hospitals and dispensaries were screened for HIV infection. At the HIV Prevention and Treatment Center, HIV-infected individuals were offered TB screening.

RESULTS

Forty-nine HIV-infected culture-positive TB cases were identified, mainly at TB hospitals and dispensaries. Most were new pulmonary TB cases. The majority were young (69% < or = 30 years of age), male (84%), unemployed (94%) individuals with a history of injection drug use (IDU) (92%), and, in 35% of cases a history of incarceration. Active case finding was high among contacts of cases (9%), but was not successful in HIV-infected IDUs.

CONCLUSION

Although the HIV seroprevalence rate is rising among TB patients, HIV does not yet appear to be driving the St Petersburg TB epidemic. Aggressive collaborative TB-HIV control efforts may still avert adverse effects of HIV on the TB epidemic.