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Overview: Office of Public Health


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Title: Overview: Office of Public Health

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

Major Program Responsibilities
  • Environmental hazards/health
  • Public health
  • VHA emergency management
  • Women veterans health
  • VHA occupational health
  • .other duties as described

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

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
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,
  • National seasonal influenza program
  • Center for Public Health Research and Surveillance

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

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

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

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

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

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
  • Strategic collaborations in provision of WV
    health care (PCS Primary Care, MH, Oncology,
  • Increased focus beyond gender-specific care to
    cardiac health, cancer prevention, health
    maintenance for women
  • Preventing birth defects through RX management

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

Update on the VA Toxic Embedded Fragment Center
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
  • 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

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

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

Developing the Center
Advisory Panel
Patient Care
Medical/Surgical Management Guidelines
Fragment Analysis
Population Surveillance
Registry Data
Initial Steps Patient Care/Management Guidelines
  • Hosted a meeting of experts on implanted medical
    devices and embedded fragments
  • Identified toxicants to include in biomonitoring
  • Identified potential biomarkers of early effects
  • Identified additional outcomes of concern and
    potential means of surveillance

Surveillance ProtocolSurgical Specimens/Removed
  • 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

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

Surveillance ProtocolBiomonitoring for
Potential for Systemic Effects of Embedded
  • 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

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

Health promotion in VA Social marketing for
Increased HIV testing
A tale of two patients
  • May 1985
  • 35 year-old man with newly diagnosed HIV
    infection admitted to West LA VAMC with severe
  • 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
  • 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

Barriers to early HIV diagnosis
  • Legal barriers HIV consent law
  • Cultural barriers
  • Focus on risk-based testing as opposed to routine
  • Perceived need for special training Not my
  • Logistic barriers
  • Decentralized system (no one size fits all
  • 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

VA HIV Testing Goals
  • Promote HIV testing as part of routine medical
  • 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

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

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

Social Marketing Hepatitis C
  • Print
  • Interactive (phone/Web)
  • Links to resources
  • diagnosis
  • Treatment
  • Support groups

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
  • 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

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
  • 4. Roll out national campaign
  • Target audiences PCPs, veterans, VSOs
  • Media print, interactive, narrowcast

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

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

Women VeteransUnderserved population
  • Utilization data indicate current models of care
    delivery present barriers to women veterans using
  • 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

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

Women Veterans Using VA
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?

OEF/OIF Women VeteransN94,010
Women Veterans SUMMARY
  • Shrinking total veterans population but a
    doubling of women veterans using VHA for their
  • 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
  • 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)

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

Emergency Management Principles and Practices for
Health Care Systems
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

  • 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.
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