Public health management in invasive meningococcal diseases

At the 54(th) Scientific Congress of the German Professional Association of Public Health Service Physicians and Dentists in Marburg on 6th May 2004 the working group on meningococci (Arbeitsgemeinschaft Meningokokken, AGMK) organised the international workshop "Public Health Management of invasive Meningococcal Disease". In recent years significant changes in the epidemiology of meningococcal disease took place in Europe: in some countries and regions the number of disease caused by meningococci serogroup C has increased significantly. In the Netherlands this increase led to the introduction of an immunisation programme with conjugated meningococcal vaccines targeting children aged 1 up to 18 years. In Switzerland a peak in the number of reported meningococcal group C cases could be observed in some regions. Therefore, a regional vaccination programme has been introduced. Nevertheless, compared with Germany, the indications for vaccination against meningococci in Switzerland are more extensive. In the workshop, Professor Ulrich Vogel and Dr. Ingrid Ehrhard presented the epidemiological situation in Germany and the recommended prophylaxis regimen against meningococci.     

Glass ceiling and slippery stairs? Gender inequalities and strategies for change in the Spanish Society of Public Health and Health Services Administration

In scientific societies, as in other social fields, women's participation in decision making is lower than that of men. We describe the situation in SESPAS (Spanish Society of Public Health and Health Services Administration) where, despite representing a 40% of its members, very few women have been in positions in which decisions are taken or in those of professional recognition. The process of change implemented during recent years and some of the effects of the actions taken are presented. Making the existing inequalities known has generated debate and interest in the intervention. A gender and public health working group was set up. In the last two years more women have been promoted to more senior positions in SESPAS.     

An outbreak of meningococcal disease in Stonehouse: planning and execution of a large-scale survey

In November 1986 a large-scale survey was undertaken in the Gloucestershire town of Stonehouse during an outbreak of meningococcal disease due to group B type 15 subtype P1.16 sulphonamide-resistant strains. There were 15 cases in Stonehouse residents during the 4 years from April 1983, an annual attack rate of 56.5 per 100,000. Four secondary cases occurred despite rifampicin prophylaxis. The objectives of this community survey were to investigate patterns of meningococcal carriage, transmission and immunity and to determine the proportion of non-secretors of blood group antigens in the Stonehouse population and amongst meningococcal carriers. A total of 6237 subjects participated including 75% of the 6635 Stonehouse residents. Over 97% of the participants provided all three of the requested specimens-nasopharyngeal swabs, saliva and blood samples. The co-operation between the many organizations involved in the detailed preliminary planning was instrumental in the success of the survey; in particular the value of effective collaboration between Departments of Community Medicine and Microbiology and of the Public Health Laboratory Service network of laboratories in undertaking investigations of this size and type was clearly demonstrated.     

Can decision analysis adequately represent clinical problems?

A major weakness of medical decision analysis has been the inability of the commonly used single attribute utility models to adequately represent clinical decision making situations. To illustrate this problem, I reanalyzed a well known decision analysis that is widely interpreted as proof that two decision alternatives are equivalent in all clinically meaningful respects. The reanalysis was based on a more representative decision model made possible by the use of the analytic hierarchy process (AHP), a multiobjective decision making technique. The use of this model resulted in the identification of a clearly preferred alternative, indicating that the results of the original analysis have been widely misinterpreted. The degree to which a decision model represents clinical reality influences the correct interpretation of a decision analysis. Limited decision models can yield only limited conclusions. The use of more representative multiobjective decision models would improve the clinical usefulness of medical decision analyses.     

Evaluation of medical technologies: a generalized ROC analysis

The author describes a new methodology to solve medical decision problems involving a choice between alternatives under conditions of risk and uncertainty when imperfect empirical information from diagnostic technologies is available. The main new concept is the generalized ROC (GROC) curve, which extends considerably the scope of analysis of the traditional ROC curve as well as the threshold approach to medical decision making. Both techniques become special cases of the new general approach. The author shows how to apply the technique and derive comprehensive clinical guidelines to solve the medical decision problem involving one patient in the most general situation. The larger problem of evaluating the performances of diagnostic technologies for a population of patients with varying prior probabilities of disease is then addressed. A new measure of performance is proposed that goes beyond the well-accepted area under the ROC curve index. This measure is used to compare different technologies for a population of patients, and a new methodology is proposed to carry out such comparisons.     

A prospective study of the effectiveness of the New Zealand meningococcal B vaccine

The effectiveness of a new group B strain-specific meningococcal vaccine referred to as "MeNZB," developed by Chiron Vaccines (Siena, Italy) in collaboration with the Norwegian Institute of Public Health, was assessed in a prospective observational study following a nationwide vaccination program in New Zealand. The vaccination program began in July 2004, and the study uses data from January 2001 to June 2006. A generalized estimating equation model was used to estimate vaccine effectiveness that included potential confounding variables, such as disease progression over time, age, ethnicity, socioeconomic status, seasonality, and geographic region. The model provides strong statistical evidence for a vaccine effect (p < 0.0001), with estimated disease rates 3.7 times higher in the unvaccinated group than in the vaccinated group (95% confidence interval: 2.1, 6.8) and a vaccine effectiveness of 73% (95% confidence interval: 52, 85). An estimated 54 epidemic strain meningococcal cases were prevented in the 2 years since the vaccination program began (95% confidence interval assuming a fixed population size: 22, 115). In a sensitivity analysis, these estimates proved to be robust to modeling assumptions, including population estimates, estimates of the numbers vaccinated, effects of partial vaccination, and temporal autocorrelation.     

DECIDE: a decision-making model for more effective decision making by health care managers

The purpose of this article is to describe a step-by-step process for decision making, and a model is developed to aid health care managers in making more quality decisions, which ultimately determines the success of organizations. The DECIDE model is the acronym of 6 particular activities needed in the decision-making process: (1) D = define the problem, (2) E = establish the criteria, (3) C = consider all the alternatives, (4) I = identify the best alternative, (5) D = develop and implement a plan of action, and (6) E = evaluate and monitor the solution and feedback when necessary. The DECIDE model is intended as a resource for health care managers when applying the crucial components of decision making, and it enables managers to improve their decision-making skills, which leads to more effective decisions.     

An outbreak of meningococcal disease in a secondary school--implications for public health practice.

This report describes briefly the management of three cases of meningococcal disease which all occurred within one week at a secondary school on the Central Coast of New South Wales in late winter 2003. The Central Coast health area has a population of approximately 300,000. Between 10 and 15 cases of meningococcal disease are notified to the Central Coast Public Health Unit each year. The three cases all presented to Gosford Hospital, Cases 1 and 2, both in Year 9, on Thursday 14 August 2003 and Case 3 in Year 8 on Friday 15 August 2003.     

Implementation and impact of a meningococcal C conjugate vaccination program in 13- to 25-year-old individuals in Galicia,Spain

Background  

In response to increased case numbers of meningococcal group C disease, catch-up vaccination strategies have been shown to be successful. This paper describes the results of a repeat vaccination program in Galicia, Spain, and the strategy used for it.     

Making Good Decisions in Healthcare with Multi-Criteria Decision Analysis: The Use,Current Research and Future Development of MCDA

Healthcare decision making is usually characterized by a low degree of transparency. The demand for transparent decision processes can be fulfilled only when assessment, appraisal and decisions about health technologies are performed under a systematic construct of benefit assessment. The benefit of an intervention is often multidimensional and, thus, must be represented by several decision criteria. Complex decision problems require an assessment and appraisal of various criteria; therefore, a decision process that systematically identifies the best available alternative and enables an optimal and transparent decision is needed. For that reason, decision criteria must be weighted and goal achievement must be scored for all alternatives. Methods of multi-criteria decision analysis (MCDA) are available to analyse and appraise multiple clinical endpoints and structure complex decision problems in healthcare decision making. By means of MCDA, value judgments, priorities and preferences of patients, insurees and experts can be integrated systematically and transparently into the decision-making process. This article describes the MCDA framework and identifies potential areas where MCDA can be of use (e.g. approval, guidelines and reimbursement/pricing of health technologies). A literature search was performed to identify current research in healthcare. The results showed that healthcare decision making is addressing the problem of multiple decision criteria and is focusing on the future development and use of techniques to weight and score different decision criteria. This article emphasizes the use and future benefit of MCDA.     

Entwicklung eines Fragebogens zur Partizipativen Entscheidungsfindung

The German Ministry for Health and Social Security is funding ten projects to introduce shared decision making into clinical practice. The medical problems the projects are focussing on were chosen from among various diseases (e. g. depression, multiple sclerosis, cancer). The ten projects achieved consensus on a core set of instruments for the measurement of process and outcome of the shared decision making. Instruments developed in German-speaking countries are currently not available. Thus, linguistic and cultural validation had to be performed for the core set instruments. The results of the data analysis as well as patient interviews demonstrate the need for improving these instruments. Therefore, the members of the methodological working group concentrated on the integration of these results in a new instrument. In a first step the construct of "shared decision making" was defined, followed by a definition of the process elements characterising shared decision making. Thereafter, items were developed on the basis of the process elements. The new instrument will now be validated for different diseases.     

Directed blood donation: a matter of public trust

Trust is the key issue in blood treatment with respect to public policy. Public trust in the blood system in Canada continues to be exceedingly low. According to the February, 1996 Gallup poll conducted by Janssen-Ortho Inc., 89% of those surveyed chose alternatives to the Red Cross (volunteer) blood. Strategies directed at improving the safety of the blood system will fall short of this goal unless public knowledge and consumer participation are considered. Consumers need to participate in decision making for themselves with the physicians, as well as in the decision making process at the level of public policy. Consumer involvement would contribute to an overall plan of rebuilding public trust. Canadian health care consumers have been significantly affected by the blood tragedy of the 1980s. Public perception of blood safety has been characterized by misunderstanding and fear. The search for alternate methods of transfusion, such as directed donation, are based on a lack of trust of the current blood system. As introducing a program of directed blood donation would not increase safety or decrease the expense of blood transfusions, such a program should not be introduced in Ontario at this time.     

Meningococcal disease in Louisiana 1978–1985

Data were analyzed from 729 meningococcal cases reported to the Epidemiology Section, Office of Preventive and Public Health Services, Louisiana Department of Health and Human Resources from 1978 through 1985. A total of 122 deaths (16.8%) occurred from these cases, with the highest case fatality rate (23.7%) noted in 1981. The eight-year average incidence rate per 100,000 population was 2.1. For individual years, the incidence rate was highest (3.6) in 1978 and lowest (0.8) in 1985. Although incidence rates per 100,000 population were greater for males during all years except 1978 and 1985 and greater for nonwhites in 1978, 1980, 1981, 1983 and 1984, the eight-year average incidence rates by sex and race were almost the same. Incidence rates were found to be highest in the less than one, and one to four-year age groups. For all eight years, over half of the cases were in the four years and under age group; the same was true for deaths, except in 1982 (46.7%). February was found to be the month with the highest frequency of reported case onset and death. The mean difference between date of disease onset and death for all fatal cases was 2.716 days (S.D.=6.48). Ten of the 64 Louisiana parishes reported no meningococcal disease cases from 1978–1985. There were 25 parishes with an eight-year average incidence rate of greater than 2.1. The overall incidence rates in Louisiana were greater than rates in the United States for the time periods reviewed.John B. Vaughn, D.V.M., M.P.H. Chairman and Professor, Department of Applied Health Sciences, Tulane University School of Public Health and Tropical Medicine, Theresa J. Forti, B.S.N., M.S. Hyg., Dr. P.H. Associate Professor, Department of Applied Health Sciences, Tulane University School of Public Health and Tropical Medicine. James E. Banta, M.D., M.P.H. Dean and Professor Tulane University School of Public Health and Tropical Medicine, Louise McFarland, M.P.H., Dr. P.H. is Chief, Epidemiology Section State of Louisiana Department of Health and Human Resources, and Karen Y. Kelso, C.R.N., B.S. is Nurse Epidemiologist State of Louisiana Department of health and Human Resources.The authors extend thanks to Mrs. Audrey P. Collins, Biostatistician, Louisiana Department of Health and Human Resources, and Barbara H. Denton, Demographer, Louisiana Tech University for their assistance in providing population data. Gratitude is also expressed to Dr. Charles T. Caraway for help with review of data.     

Using the national guidelines to manage a meningococcal group C outbreak in a Brisbane boarding school--some discretionary judgements are needed.

The management of an organisational outbreak of meningococcal disease using the national Guidelines for the early clinical and public health management of meningococcal disease in Australia (the Guidelines), could be considered a relatively straightforward task. Nevertheless, discretional judgements are often still required by the outbreak control team, as no guidelines can fully cover every eventuality. The greatest challenges generated by this outbreak did not result from the magnitude of the intervention, but from the difficulties in defining the margins of the intervention in the face of heightened community and professional concern. Also Public Health decisions and communication strategies needed to be responsive to these concerns.     

The changing epidemiology of meningococcal meningitis after introduction of bivalent A/C polysaccharide vaccine into school-based vaccination programs in Egypt

BACKGROUND: The strategy recommended by the World Health Organization (WHO) to curtail outbreaks of meningococcus in Africa is enhanced surveillance with administration of oily chloramphenicol as well as vaccination when incidence thresholds are exceeded. The role of capsular polysaccharide meningococcal vaccine in outbreak prevention has been the subject of considerable debate. The Egyptian Ministry of Health and Population initiated a school-based vaccination program with bivalent A/C capsular polysaccharide vaccine in 1992. This investigation reviews data on meningococcal meningitis in Egypt comparing years before and after introduction of the vaccine. METHODS: This is a retrospective review of several sources to examine the rates and serogroups of meningococcal meningitis before and after the introduction of the meningococcal A/C vaccine in Egypt. FINDINGS: Between 1967 and 1991, outbreaks of meningococcal disease were documented with a periodicity of 8 years in Egypt. However, there has not been an outbreak since 1991 and over the same period, there has also been a progressive decline in the baseline incidence of meningococcus. Also, a shift from a serogroup A to serogroup B predominance in meningococcal disease was noted during the study period. These data suggest that there has been an alteration in the epidemiology of meningococcal disease in Egypt that coincided with the implementation of the school-based vaccination program. INTERPRETATION: Routine use of the bivalent A/C meningococcal vaccine may be an alternative for the control and prevention of meningococcal disease in high-risk areas including the "meningitis belt".     

Shortchanged? An assessment of chronic disease programming in major US city health departments

A self-administered survey was distributed to members of The Big Cities Health Coalition, a group of Health Officers/Commissioners from 17 of the largest US metropolitan health departments. The survey asked participants about their chronic disease priorities, data sources, budgets, and funding sources as well as examples of successful chronic disease interventions. Members of the Coalition discussed the survey results in a scheduled conference call. Chronic diseases account for 70% of all deaths nationwide on average, yet the health departments surveyed allocated an average of 1.85% of their budgets to chronic disease. Average chronic disease spending per inhabitant was $2.33, with a median of $1.56. Among the group’s top chronic disease priorities were asthma, diabetes, tobacco, cancer, and cardiovascular disease (CVD). Nearly half of the group’s chronic disease spending was on tobacco. Chronic disease funding sources varied across localities, but direct federal funding was minimal. In 14 cities serving a combined 37 million people (13% of the US population), direct federal chronic disease funding totaled $8.7 million, an average of $0.24 per capita. The group described successful chronic disease interventions, particularly related to tobacco and asthma. The Big Cities Health Coalition members: John M. Auerbach, MBA (Boston Public Health Commission); Peter Beilenson, MD, MPH (Baltimore City Health Department); Matthew Carroll, AB, JD (Cleveland Department of Public Health); Mary DesVignes-Kendrick, MD, MPH (Houston Department of Health and Human Services); John F. Domzalski, JD, MPH (Philadelphia Department of Public Health); Franklin Judson, MD (Denver Public Health Department); Mitchell H. Katz, MD (San Francisco Department of Public Health); Alonzo Plough, PhD, MA, MPH (Seattle/King County Public Health); Eleni Sfakianaki, MD, MSPH (Miami-Dade County Health Department); Adewale Troutman, MD, MPH (Fulton County Department of Health and Wellness); Jonathan B. Weisbuch, MD, MPH (Maricopa County Department of Public Health); Judith West, MPH (Detroit Department of Health); John L., Wilhelm, MD, MPH (Chicago Department of Public Health); Steve Wilson, MD, MPH (Dallas County Department of Health and Human Services).     

Occupational transmission of Neisseria meningitidis --- California, 2009

Neisseria meningitidis is a leading cause of bacterial meningitis and sepsis . The case-fatality rate for meningococcal disease is 10%--14%; survivors can experience brain damage, hearing loss, limb loss, and learning disabilities . On December 11, 2009, the California Department of Public Health (CDPH) initiated an investigation of two secondary cases of meningococcal disease in a police officer and a respiratory therapist following occupational contact with an unconscious adult. This report describes the events surrounding occupational transmission of N. meningitidis and recommends measures to control and prevent secondary transmission of N. meningitidis. Breaches in infection control, notification delays, and lack of worker exposure assessment and postexposure chemoprophylaxis (PEP) likely contributed to secondary cases. Employers should provide adequate infection-control training to staff members, PEP to exposed workers, and report notifiable diseases promptly.     

Improving subjective decision making in health care administration

Managing a health care institution typically requires the consideration of many nonquantifiable factors, such as community relations, quality of service, and employee morale. As a result, subjective judgments are an inevitable, and often major, part of decision making in health care financial management. A large body of scientific research has shown that people's subjective, or intuitive, judgments tend to be biased and inaccurate. This article reviews the major types of errors typically found in four phases of decision making: defining the problem, estimating the effects of different alternatives, choosing an alternative, and evaluating the outcomes as the basis for subsequent action. In addition to alerting health care administrators to these potential judgment errors, several methods to improve subjective decision making are explained.