Infectious Diseases, Mental Health & Substance Abuse Maricopa County Department of Public Health, Office of Epidemiology Phoenix, Arizona

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1 Infectious Diseases, Mental Health & Substance Abuse Maricopa County Department of Public Health, Office of Epidemiology Phoenix, Arizona Assignment Description Maricopa County, Arizona, is home to approximately 4 million residents (61% of Arizona s population), making it one of the largest local public health jurisdictions in the country. For comparison, the county s population is larger than the population in 24 states. Due to its size and geographical location, the county faces unique public health challenges. The Maricopa County Department of Public Health (MCDPH) exists to address these issues and to protect and promote the health and well-being of its residents and visitors. Over the past few years, MCDPH has been preparing for public health accreditation. To become accredited, health departments must demonstrate that they meet the Public Health Accreditation Board s (PHAB) standards, which reflect the ten essential services of public health. By going through this process, MCDPH identified areas for improvement, restructured segments of the organization, and updated its systems to provide the highest quality public health services for the county. MCDPH is optimistic that it will be accredited in Once MCDPH achieves accredited status, it will be one of the largest local health departments in the country to receive the honor. The Fellow will find MCDPH s culture of high performance and quality a great environment for working with credible, recognized people in the field and expanding their skills. The Fellow will be assigned to the MCDPH Division of Disease Control, Office of Epidemiology. The Office of Epidemiology operates in two units: Epidemiology and Data Services Unit and Communicable Disease Epidemiology Unit. The Epi & Data Services Unit is responsible for managing data requests, publishing weekly and annual morbidity and mortality reports, complex data analyses (e.g., return on investment studies and geo-spatial analyses), establishing syndromic surveillance protocols, conducting community health assessments, and preparing grant proposals and manuscripts. The Communicable Disease Epidemiology Unit is responsible for monitoring emerging and zoonotic diseases, interviewing patients with notifiable diseases, conducting outbreak investigations, and providing solutions for disease control and prevention. The Fellow will work closely with members from both Units, so he/she improves skills in patient interviews, outbreak investigations, surveillance, study design, data management, statistical analysis, interpreting results, and disseminating findings. The Fellow will focus on learning the goals and operations of the health department, completing Fellowship projects, expanding his/her applied epidemiology skill-set, and attending internal and external meetings. For the initial period, the Fellow will meet with the primary mentor on a weekly basis to discuss progress on training goals and project assignments. The mentors and other staff will support the Fellow as he/she manages data, monitors data quality, performs analyses, interprets findings, and prepares reports. At the end of the first year, the Fellow will meet with the mentors to

2 report on the progress of major projects. If sufficient progress has been made, the Fellow may propose a special project that is geared toward his/her interests. The mentors are dedicated to expanding the skill-set of the Fellow so he/she is prepared for launching a career in applied public health. In addition to expanding public health-specific skills, the primary mentor will work with the Fellow to polish his/her cover letter, personal statement, and resume/cv, as well as develop skills in preparing grant proposals, protocols, reports, manuscripts, and presentations. Day-to-Day Activities Local health departments must adapt to shifting public health priorities. Thus, the Fellow should expect variety in their work activities from day-to-day. At the onset of the Fellowship, the mentor and Fellow will establish timelines for completing the surveillance evaluation and major projects. This will include a discussion regarding goals for producing deliverables (e.g., presentations and reports) and what the Fellow hopes to learn from the project. Each day, the Fellow will be responsible for managing these projects in order to meet deadlines. The beginning of the Fellowship will focus on training to orient the Fellow with data sources, statistical packages, and team operations as a whole. As the Fellow becomes familiar with MCDPH procedures and protocols, the Fellow will manage their time and projects more independently. Mentors will monitor the work and make adjustments as necessary. During special events, such as outbreaks, large-scale scheduled events, or public health emergencies, the Office of Epidemiology will shift its priorities, and the Fellow will be asked to participate in departmental activities. These activities may include patient interviews, outbreak investigation analyses, or disease control and prevention initiatives. The Office of Epidemiology is dedicated to professional development for all staff. The Office holds regular meetings to communicate recent activity within the Office and lectures to provide scientific updates in the field. Employees have created their own in- house classes to discuss best practices for using analytical methods / software and how to apply these to their current work. The Office currently has regular staff-run workshops dedicated to statistics, SAS, R, and GIS. The Fellow will be encouraged to attend meetings, lectures, and continuing education opportunities to expand his/her own skill-set and successfully complete assignments and projects.

3 Potential Projects Surveillance Situational awareness using traditional and syndromic surveillance Activity Surveillance is an essential public health activity. MCDPH relies on data from notifiable disease reports, school absentee records, 911 and poison control center call logs, hospital records, and community surveys to maintain situational awareness in the county. Over the course of the Fellowship, the Fellow will rotate through the office and work with nurses, disease investigators, data analysts, and epidemiologists to gain experience in conducting patient interviews, managing outbreak investigations, analyzing data, writing reports, and sharing findings at local, state, and national meetings. In the process, the Fellow will become intimately familiar with the means in which MCDPH: systematically acquires data related for infectious diseases, environmental exposures, injuries, chronic diseases, death, and their risk factors; designs epidemiological studies; selects appropriate statistical methods to carry out real-world analyses; writes SAS and R programs to carry out tasks; develops reports; and uses data to make public health decisions. Surveillance Evaluation Flu Near You: Evaluation of a mobile app for conducting influenza surveillance in Maricopa County Epidemiologists are seeking novel methods for collecting real-time health data from individuals who do not seek care from a healthcare provider. â œflu Near Youâ is a free mobile app that allows community members to report their recent symptoms in an effort to improve situational awareness regarding influenza incidence. On a national level, Flu Near You data correlate well with CDC s ILI-Net data (the current gold standard for flu surveillance). MCDPH epidemiologists are collaborating with the app developers and other health department epidemiologists to assess the opportunities and challenges for using Flu Near You data at a local level. The goal of this project is to evaluate this novel source of influenza data for accuracy, utility, and feasibility. The Fellow will work closely with the Syndromic Surveillance Epidemiologist (i.e., the primary mentor) to compare these data to BioSense 2.0 syndromic surveillance data, emergency medical service dispatch data, and traditional flu surveillance data. This project will provide experience in evaluation design, SAS and R programming, statistical analysis, producing public health reports, and manuscript writing. The Fellow will discover advantages and challenges related to various surveillance data sources and gain a unique perspective into the processes of developing and validating a new surveillance system. Major Project Monitoring mental health and substance use with syndromic surveillance MCDPH uses the BioSense system for conducting syndromic surveillance, which allows epidemiologists to acquire and analyze chief complaint and diagnosis data from emergency department and inpatient hospital visits. The chief complaint field is entered as free text by healthcare providers who provide a brief description of the patient s main reasons for seeking care.

4 Over the past six months, MCDPH epidemiologists have been reviewing these chief complaint data in great depth. They noticed that many chief complaint fields mentioned mental health conditions, such as depression, anxiety, bipolar disorder, and suicidal ideation. As mental health conditions are often under-diagnosed, syndromic surveillance using chief complaint data may be a useful tool for health departments to identify its burden in the community. The purpose of this study will be to understand whether syndromic surveillance is a feasible, useful, and/or effective method for monitoring mental health conditions in Maricopa County. Since this is a new project, the Fellow will begin by conducting a literature review to understand previous work in the area, design a study based on best practices, determine terms to include in a mental health-related query, and validate the findings. After the protocol for syndromic surveillance of mental health disorders is designed and validated, the query can be combined with search terms for related conditions, such as substance use. As a result, the project will help the department better understand the burden of co-occurring affective disorders and substance use. The Fellow will work closely with the MCDPH epidemiologist who monitors county substance use and abuse. The project will also provide opportunities to collaborate with Arizona s state health department, emergency medical services, and the criminal justice department. The Fellow will gain skills to conduct literature reviews, design surveillance evaluations, develop and validate protocols, and share findings in presentations and manuscripts. Major Project Public health decision making using syndromic surveillance Surveillance efforts allow epidemiologists to quantify and characterize public health threats, but traditional surveillance methods take time. Syndromic surveillance is â œthe use of near real-time, pre-diagnostic data and statistical tools to detect and characterize unusual disease activity for further public health investigationâ. [ISDS, 2015] In an effort to enhance situational awareness, the Office of Epidemiology dedicated resources to begin developing a robust syndromic surveillance program. The MCDPH Syndromic Surveillance Strategic Planning and Development Workgroup was formed to identify existing resources, current challenges, and a unified mission for syndromic surveillance in the Office. Workgroup members began (1) developing technical guides for accessing and analyzing data, and (2) seeking collaborations with external entities. Syndromic data sources include BioSense, Poison Control Center call logs, emergency medical service dispatch logs, and the Flu Near You mobile app. As these are all newer systems for the department, a great deal of work exists to evaluate the data. The Fellow will become an integral member of the Syndromic Surveillance Workgroup. The Fellow will be trained on protocols and will become familiar with the functionality, benefits, and limitations of the various data sources. The Fellow will be responsible for developing SAS and R programs to run syndrome queries, manage data, check for quality, and analyze data. Syndrome frequencies will be compared to traditional surveillance counts, and the Fellow will provide a report regarding the

5 usefulness of the syndromic data. This evaluation will be critical for helping MCDPH epidemiologists decide how to use the data in reports and to make public health decisions. Through this project, the Fellow will gain skills in evaluating novel surveillance systems, programming in SAS and R, preparing evaluation reports, writing protocols, and sharing findings at professional venues. Once the Fellow becomes familiar with the data and syndromic surveillance protocols, he/she will have a great opportunity to propose and explore public health questions that peak his/her interest (if time permits). Additional Project Evaluation of climate change and extreme heat on the county s home-bound population Maricopa County residents experience the nation s most extreme heat. Public health officials are concerned that homebound individuals face barriers while trying to prevent heat-associated illness and death. The Office of Epidemiology was recently awarded a grant by the Public Health Institute, Center for Climate Change and Health to identify the needs of homebound individuals during extreme heat events, determine whether the county s existing services are sufficient, and determine how to improve accessibility for this vulnerable population. One aim of the project is to identify community organizations that provide essential services and facilitate their visibility and interaction with community members. Findings from this project will have a direct impact on how homebound individuals receive services. The Fellow will be welcomed to community meetings and have a unique opportunity to interact with community stakeholders and residents. The Fellow will support this project by managing data, performing data quality checks, and conducting statistical analyses. The Fellow will learn important lessons regarding survey design and gain skills in quantitative analysis (using SAS), data interpretation, and presenting scientific data to various audiences. The Fellow will have an opportunity to contribute to a manuscript. Preparedness Role Maricopa County is home to 4 million people and several large venues, which hold major events. Recent events include: Super Bowl, BCS National Championship, Fiesta Bowl, and the Waste Management Open. The Fellow will have an opportunity to use syndromic surveillance systems to monitor all hazards during public health emergencies or scheduled large-scale events. The Office of Preparedness and Response (OPR) and the Office of Epidemiology are housed in MCDPH s Disease Control Division. The Offices are located in the same office suite, which helps facilitate the exchange of knowledge, staff, and resources. The Fellow will have opportunity to participate in emergency preparedness and response initiatives, such as the annual Preparedness Expo, tabletop simulations, Point of Dispensing (POD) evaluations, and Incident Command Center

6 (ICC) activation. The primary mentor will arrange for the Fellow to be trained in FEMA s Incident Command System (ICS) and National Incident Management System (NIMS). Additional Activities Advantages of working at MCDPH include: diverse project topics; multi-disciplinary teams (rather than silos); collaborations with local universities and organizations; and opportunities to interact directly with community members. The Fellow may be asked to support a variety of internal or external public health initiatives. Recently, Office of Epidemiology employees have contributed to the following initiatives: Take a Hike, Do it Right! campaign for preventing heat-related illness during hikes The Great Arizona Mosquito Hunt partnership with 4-H to set mosquito traps and raise mosquitoborne disease awareness among youth - Safe Sleep Awareness Campaign to help prevent infant deaths by informing parents about unsafe sleep environments The mentors are dedicated to providing their expertise and guidance to motivate and prepare the Fellow to become a competent, well-rounded public health professional. Together, the mentors and Fellow will discuss a plan for applying skills obtained in school to realworld scenarios. The Fellow will rotate through different divisions within the department, so he/she may gain insight related to: applying the fundamentals of epidemiology and biostatics; infectious and chronic disease control; laboratory science; environmental health; community health; program management and evaluation; and health policy and management. If relevant skills are not obtained during day-to-day activities, projects, or rotations, the Fellow may request to sharpen specific skills, and the mentors will strive to provide the appropriate experiences. Mentors Primary Secondary Jessica White, DrPH, MS, CPH Syndromic Surveillance Epidemiologist Vjollca Berisha, MD, MPH Senior Epidemiologist