Overview: Office of Public Health

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• Overview Office of Public Health Environmental
  Hazards
• (OPHEH)
• AMSUS SUSTAINING MEMBERS SECTION
• June 18, 2008
• Lawrence R. Deyton, MSPH, MD
• Chief Public Health Environmental Hazards
  Officer

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Major Program Responsibilities

• OFFICE OF PUBLIC HEALTH
• and ENVIRONMENTAL HAZARDS
• Environmental hazards/health
• Public health
• VHA emergency management
• Women veterans health
• VHA occupational health
• .other duties as described

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OPHEH Public Health Pillars

• All OPHEH programs are built upon four pillars of
  population/public health
• Surveillance and
• epidemiology
• Service of underserved
• populations
• Risk reduction/
• mitigation, prevention,
• health promotion
• Public health policy

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Veterans Health AdministrationPublic Health
Patient Care Continuum

• Patient Care Services
• Patient Care Guidelines
• Critical Pathways
• Practice Parameters

• Public Health
• Environmental
• Hazards
• Surveillance Epidemiology
• Underserved Populations
• Risk Mitigation
• Public Health Policy

OPHEH Population focus
PCS Individual Patient- Clinician focus
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OPHEH Programs

• Environmental Health SHG
• Environmental Agents Service (Agent Orange, Gulf
  War/Iraq/Afghanistan, War Related Illness and
  Injury Centers, IOM, newsletters/registries)
• Environmental Epidemiology Service
• Radiation and Physical Exposure Service
• Public Health SHG
• Clinical Public Health Service (HIV/HCV/other PH)
• Public Health Prevention/Tobacco Use Cessation
• Center for Quality Management in Public Health
  (HIV, HCV and other PH case registries,
  databases)
• National seasonal influenza program
• Center for Public Health Research and Surveillance

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OPHEH Programs

• Emergency Management SHG
• VHA Comprehensive Emergency Management
• Emergency Planning Operations Service (AEMs)
• VAs National Response Plan Support (w/ DHHS,
  FEMA, DoD, NDMS)
• Women Veterans Health SHG
• Comprehensive Womens Health
• Womens Health Education and Training
• Reproductive Health
• Field Coordination
• Occupational Health SHG
• Employee Health Clinical Support Services
• Workers Comp and Occupational Health Policy
• Employee Health Disease Prevention/Health Promo

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OPHEH PROGRAMSother duties as described

• Planning and Preparing for Pandemic Influenza
• Implementation USG VA Pandemic Flu Plans
• Stockpiling oseltamivir (with VA-wide use plan),
  PPE kits, N-95 respirators
• Infection Dont Pass It On campaign
• Educational materials/flu advisories, Emergency
  Communications Exercises
• Tabletop exercises (VAMC/VISN/VACO/ IT)
• Planning for Public Health Standards of Care
• Coordination with HHS, DoD, White House-Homeland
  Security Council, and other Federal agencies

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Current Issues/Future Initiatives

• Environmental Health SHG
• IOM Reports Agent Orange, Gulf War
• Veterans Health Examination Registries
  (N500,000)
• Quarterly updates on OIF/OEF Veterans VHA
  utilization trends
• Prospective surveillance of new veteran
  population
• VHA Mass Casualty Decontamination Program
• Toxic Embedded Fragment Center

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Current Issues/Future Initiatives

• Public Health SHG
• Healthcare associated infection influenza
  surveillance system
• 2007-2008 Seasonal Flu Vaccine Campaign
• Improved smoking cessation and prevention (for
  OIF/OEF veterans, coordination with DoD)
• Efforts to encourage routine HIV testing and
  early diagnosis of HIV infection
• Hepatitis C Resource Centers Program end-stage
  liver disease/better treatments

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Current Issues/Future Initiatives

• Emergency Management SHG
• Federal region VA liaisons
• Enhancement of Disaster Emergency Medical
  Personnel System Establishment of Retried
  Emergency Corps
• Internal VHA patient evacuation planning
• Emergency Manager Certification Program
• Stakeholder evaluation of EMSHG support
• Partners in Preparedness with States
• Deployable medical units
• VISN Emergency Medical Evacuation Planning

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Current Issues/Future Initiatives

• Women Veterans Health SHG
• VHA female population doubling most new women
  veterans are of childbearing age
• Primary care provider education and training
• Clinical inventory of womens health care
  services
• Strategic collaborations in provision of WV
  health care (PCS Primary Care, MH, Oncology,
  Cardiol)
• Increased focus beyond gender-specific care to
  cardiac health, cancer prevention, health
  maintenance for women
• Preventing birth defects through RX management

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Current Issues/Future Initiatives

• Occupational Health SHG
• - Employee disease prevention/health promotion
• Violence Prevention initiative (with NCOD)
• Safe Patient Transfer Ergonomics initiative
• Workers Compensation improvement for all VHA
• Occupational Health Records System

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Update on the VA Toxic Embedded Fragment Center
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VA Toxic Embedded Fragment Center

• Mission To provide care and medical
  surveillance for veterans with retained fragments
  
• Many traumatic injuries are occurring from use of
  improvised explosive devices (IEDs) in the Iraq
  War
• Estimates suggest gt 5,000 soldiers with traumatic
  injuries may have retained embedded fragments
• IEDs are packed with heterogeneous material thus
  both metallic and non-metallic fragments are
  possible

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VA Toxic Embedded Fragment Center

• Objective Identify and manage (prevent) health
  effects related to fragment retention
• Risk of the development of tumors at fragment
  sites
• Foreign body carcinogenesis
• Chemical carcinogenesis
• Risk of systemic effects arising from chemicals
  released from fragments

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Objectives of the TEF Center

• Establish a registry of wounded veterans with
  retained fragments
• Develop laboratory collaborations that allow
  determination of fragment composition
• Develop medical and surgical management
  guidelines for veterans with fragments
• Provide biomonitoring services to assist in
  medical management of these veterans
• Offer in-patient referral to Baltimore Center for
  complex cases

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Developing the Center
Advisory Panel
Consultation
Patient Care
Biomonitoring
Medical/Surgical Management Guidelines
Fragment Analysis
Population Surveillance
Registry Data
Literature
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Initial Steps Patient Care/Management Guidelines

• Hosted a meeting of experts on implanted medical
  devices and embedded fragments
• Identified toxicants to include in biomonitoring
  panels
• Identified potential biomarkers of early effects
• Identified additional outcomes of concern and
  potential means of surveillance

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Surveillance ProtocolSurgical Specimens/Removed
Fragments

• Chemical analysis of fragments
• Surface chemistry
• Total fragment composition
• Analysis of tissue surrounding fragments
• Histology including histochemical staining for
  proliferative cells
• In situ metal and non-metallic fragments (e.g.,
  polymers, ceramics) analysis

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Surveillance ProtocolBiomonitoring for Release
of Chemicals from Retained Fragments

• Biomonitoring/toxicological screening
• Selection of chemicals
• Metals As, Cd, Cr, Co, Cu, Fe, Mn, Ni, Pb, U, W
• Plastics/polymer components Isocyanate,
  Acrylics, Diethylhexylphthalates
• Others Identify sources of information on
  IED/fragment content
• Selection of biological specimens
• Urine, blood, other body fluids
• Monitoring frequency

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Surveillance ProtocolBiomonitoring for
Potential for Systemic Effects of Embedded
Fragments

• Biomarkers of effect
• Identification of potential target organs
• Genotoxicity
• Urinary system kidney and bladder
• Hematopoetic system bone marrow
• Immune system
• Surveillance tools
• X-ray
• Ultrasound
• MRI
• CT scan

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Registry Data

• What information should be collected and included
  in the database?
• Demographic information
• History/circumstances of exposure
• Number and location of removed of fragments
• Composition of all removed fragments
• Location of fragments not removed
• Types of injury
• Biomonitoring data
• Health Outcomes
• Goal to optimize the health of veterans with
  embedded fragments

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Health promotion in VA Social marketing for
Increased HIV testing
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A tale of two patients

• May 1985
• 35 year-old man with newly diagnosed HIV
  infection admitted to West LA VAMC with severe
  dehydration
• Dx P. carinii pneumonia
• Course Pt dies after 1 week

• April 2005
• 46-year-old man with newly diagnosed HIV
  infection admitted to DC VAMC with severe
  dehydration
• Dx Systemic C. neoformans
• Course
• Successful tx with liposomal AmB
• HAART started
• April 2008 CD4 450, VL lt75 back to work and
  enjoying life

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HIV testing in VA The Challenge

• HIV has become a manageable chronic condition
• 8 million veterans enrolled
• Most veterans are not tested
• Many at-risk veterans are not tested
• Substantial numbers of newly diagnosed veterans
  present with late disease harder to treat,
  worse outcomes
• Earlier diagnosis will save lives and money

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Barriers to early HIV diagnosis

• Legal barriers HIV consent law
• Cultural barriers
• Focus on risk-based testing as opposed to routine
  testing
• Perceived need for special training Not my
  table
• Logistic barriers
• Decentralized system (no one size fits all
  strategy)
• Local barriers (especially for rapid testing)
• VA HIV consent documentation lots of work
• Competing priorities of clinical staff
• Information barriers
• Lack of information on rapid testing
• Lack of information on importance of early
  diagnosis of HIV

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VA HIV Testing Goals

• Promote HIV testing as part of routine medical
  care
• Routinely provide information on HIV testing
• Tools for incorporating HIV testing into primary
  care setting
• Logistic support for rapid testing
• There is no excuse for late diagnosis of HIV
  infection

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Social Marketing for HIV Testing in VA

• HIV testing social marketing campaign
• Change provider/patient mindset
• Tools for routine HIV testing in primary care
• Support for rapid testing
• Counseling materials
• Ongoing clinical demonstration project
• Collaboration with VA QUERI group
• Multiple VISNs

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Public health social marketing examples

• Smoking cessation
• Print, broadcast, interactive (phone/Web)
• Link to resources (e.g., 1-800-QUIT-NOW)
• Promotion of nicotine replacement therapy

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Social Marketing Hepatitis C

• Print
• Interactive (phone/Web)
• Links to resources
• diagnosis
• Treatment
• Support groups

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VA HIV Testing Social Marketing Campaign

• HIV is now a chronic treatable disease
• Late HIV diagnosis is an avoidable tragedy
• HIV testing is the only avenue to early HIV
  diagnosis
• Change provider and patient attitudes
• Make part of routine medical care
• Demystify testing
• Emphasize importance of HIV testing
• Promote health and prevent disease
• Among all veterans in care
• Among at-risk veterans
• Improve linkage to care
• HIV-positive
• HIV-negative

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Campaign phases

• 1. Perform formative work
• Define barriers among veterans and providers
• Test potential messages
• 2. Develop test messages
• Evaluate among veterans and providers
• Target all appropriate segments
• 3. Pilot test messages
• Examine in multiple VAMCs and outpatient clinics
• Evaluate using quantitative and qualitative
  methods
• 4. Roll out national campaign
• Target audiences PCPs, veterans, VSOs
• Media print, interactive, narrowcast

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THEN AND NOW
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Women Veterans Health Strategic Health Care Group

• March 2007 the Women Veterans Health Program
  elevated to a Strategic Health Care Group (SHG)
• Identify and address gender disparities in
  provision of care to women veterans
• Key focus has been a comprehensive evaluation of
  womens health care delivery

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Women Veterans Health

• Implementing major new initiatives
• Comprehensive Womens Health Program
• Womens Health Education
• Quality and Performance Data
• Birth Defects Prevention
• VA Medical Centers have received 32.5 million in
  FY 08 Supplemental Funds
• Funds to specifically improve women veterans
  health diagnostic capabilities

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Women VeteransUnderserved population

• Utilization data indicate current models of care
  delivery present barriers to women veterans using
  VA
• We have chronically under-served the population
• Market penetration for women veterans 2003-2007
  between 11.9 and 14.6
• Market penetration for all living male veterans
  has been steady from 2003-2007 22

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Women Veterans Using VA

• VA Healthcare Utilization Among 94,010 Female
  OIF/OEF Veterans Through 1st Qtr. FY 2008-
  Environmental Epidemiology Service

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Women Veterans Using VA
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The New OIF/OEF Era Veteran

• She is utilizing VA services 42 enroll
• She is coming to VA frequently
• 45.6 were seen 2-10 visits
• 38.5 seen 11 or more times since 2003
• 1.5 Inpatient Stay (one or more)
• VHA Challenge
• The total number of women using VA services
  will nearly double in the next 2-4 years.
• How will VHA best provide health services as the
  numbers increase?

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OEF/OIF Women VeteransN94,010
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Women Veterans SUMMARY

• Shrinking total veterans population but a
  doubling of women veterans using VHA for their
  healthcare
• Increasing recognition of women veterans
  specific health needs
• Prepare for influx of younger women veterans
• Primary care for women at every VA
• Comprehensive view of womens health as beyond
  reproductive health issues
• Examine womens health as a population of women
  veterans and whether military experience plays
  a role in health outcomes

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Office of Public Health and Environmental Hazards
Deliverables

• Customers are veterans, their families, VA
  employees, VISNs and Facilities, VSOs, Congress,
  other Federal/state health
• departments
• Products include
• VHA Directives, Information Letters,
• Handbooks, Advisories
• Training and exercises
• Topical reports, plans,
• clinical/public health
• recommendations
• Presentations, journal articles
• Posters, brochures, fact sheets
• Radiologic Physical Exposure
• Comp Evaluations (approx 1200/yr)

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Deliverables

• Veterans Health Initiatives (N15)
• Newsletters
• Textbooks
• Public Health Campaigns
• Events, Conferences
• Grant programs
• Curricula

Emergency Management Principles and Practices for
Health Care Systems
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OPHEH Priorities for FY08

• VHA Emergency Preparedness
• EMSHG Evaluation VISN/Facility interactions
• VHA Pandemic Influenza Plans/Preps
• The New Veteran projections for this
  populations future health needs
• Women Veterans current future needs
• VHA Occupational Health Program
• Smoking and Tobacco Use Cessation
• Healthcare Associated Infection Influenza
  Surveillance System
• HIV Testing Social Marketing Campaign and
  HepC/HepB

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Conclusion

• Always stay true to President Lincolns pledge
• To care for him and her who shall have borne
  the battle and for his widow/er and orphan.