Overview: Office of Public Health & Environmental Hazards (OPHEH) AMSUS SUSTAINING MEMBERS SECTION June 18, 2008 L

1. 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

2. 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’

3. 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

4. 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

5. 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

6. OPHEH Programs Emergency Management SHG VHA Comprehensive Emergency Management Emergency Planning & Operations Service (AEMs) VA’s National Response Plan Support (w/ DHHS, FEMA, DoD, NDMS) Women Veterans Health SHG Comprehensive Women’s Health Women’s 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

7. OPHEH PROGRAMS…other 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: Don’t 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

8. Current Issues/Future Initiatives Environmental Health SHG IOM Reports: Agent Orange, Gulf War Veterans Health Examination Registries (N=500,000) Quarterly updates on OIF/OEF Veterans’ VHA utilization trends Prospective surveillance of new veteran population VHA Mass Casualty Decontamination Program Toxic Embedded Fragment Center

9. 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

10. 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

11. 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 women’s 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

12. 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

13. Update on the VA Toxic Embedded Fragment Center

14. 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 > 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

15. 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 VA Toxic Embedded Fragment Center

16. 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

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

18. 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

19. Surveillance Protocol:Surgical 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

20. Surveillance Protocol:Biomonitoring 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

21. Surveillance Protocol:Biomonitoring 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

22. 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 Registry Data

23. Health promotion in VA: Social marketing for Increased HIV testing

24. 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 <75 back to work and enjoying life A tale of two patients

26. 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

27. 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

28. 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

29. “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

30. Smoking cessation Print, broadcast, interactive (phone/Web) Link to resources (e.g., 1-800-QUIT-NOW) Promotion of nicotine replacement therapy Public health social marketing examples

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

32. 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

33. 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

34. THEN AND NOW

35. 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 women’s health care delivery

36. Women Veterans Health • Implementing major new initiatives: • Comprehensive Women’s Health Program • Women’s 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

37. Women Veterans:Underserved 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%

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

39. Women Veterans Using VA

40. 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?

41. OEF/OIF Women VeteransN=94,010

42. 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 women’s health as beyond reproductive health issues • Examine women’s health as a population of women veterans – and whether military experience plays a role in health outcomes

44. 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)

45. Deliverables Veterans Health Initiatives (N=15) Newsletters Textbooks Public Health Campaigns Events, Conferences Grant programs Curricula Emergency Management Principles and Practices for Health Care Systems

46. OPHEH Priorities for FY08 VHA Emergency Preparedness: EMSHG Evaluation & VISN/Facility interactions VHA Pandemic Influenza Plans/Preps The New Veteran – projections for this population’s 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

47. Conclusion: Always stay true to President Lincoln’s pledge: “To care for him [and her] who shall have borne the battle and for his widow/er and orphan.”