Public Health, Community And Population-based Research

1. Public Health, Community And Population-based Research Children’s Health Research Summit Jan. 28, 2008, 8 am-1 pm, UTSA Downtown Campus Fernando A. Guerra, M.D., M.P.H. Director of Health - San Antonio Metropolitan Health District Brad H. Pollock, M.P.H., Ph.D. Professor and Chairman - Department of Epidemiology & Biostatistics School of Medicine - University of Texas Health Science Center http://www.sanantonio.gov/health/ http://www.uthscsa.edu/

2. Objective • Discuss opportunities to conduct population-based research in the San Antonio area • What are some of the major public health issues affecting our population? • What sorts of studies have been done? • What resources are available to promote population-based children’s research in San Antonio?

3. Local Organizations Conducting Health Research • San Antonio Metropolitan Health District • UT Health Science Center at San Antonio • UTSA • UT School of Public Health Regional Campus • Southwest Foundation for Biomedical Research • Southwest Research Institute

4. “Points to Ponder” • Public Health: A local health department has a very important role in the community, to apply surveillance, analysis and interventions; to ensure health. • Population-based Research: Public Health has experience in collection, analysis, and presentation of population-based clinical and demographic data that highlight health disparities • Academic Research: Requires careful study design and protection of individuals (IRB). It takes into consideration the impacts, both benefit and potential harm on those being studied. • Before anything else, we must assure the good health, safety, well-being and critical needs of the population.

5. A Local Public Health Department Has Many Opportunities For Population-based Research • Hurricane Katrina/Rita shelters • National Children’s Study • Clinical & Translational Science Award (CTSA) • Community Health Assessments • Maternal Health Disparities • Prenatal Care and Adverse Birth Outcomes among Documented and Undocumented Hispanics in Texas • Health Care Disparities

6. Research Under Emergency Conditions • Many researchers from across the US wanted to have access to the Hurricane Katrina/Rita shelters to conduct research on the mental and physical health and social issues of the evacuees. • Initially there was no process, later access for researchers was restricted. • Residents began to complain that they were “surveyed to death” and they “never got anything from it.” • Researchers need both: • IRB approval from their governing agency • Permission from the organization in charge of the shelter

7. Research Under Emergency Conditions cont. • Because disasters happen very quickly, plans for data collection must occur before the disaster occurs to ensure human subject protections. We need to have ready: • IRB templates • Needs assessment survey instruments with trained staff • Surveillance forms and experienced surveillance team • Ability to track patient populations and have them connected to a information system for the short and long term. • Define Special Need • Allow Environmental Health inspectors to view shelters before setting up • A local system should be pre-established to approve, coordinate and provide information to researchers.

8. Research Under Emergency Conditions cont. • Establish a group to oversee data collection by Non-Public Health Agencies • Verification of IRB approval • Regulate the number and types of surveys being conducted within the shelter • Residents receive a benefit from participating in the surveys • There must be particular attention to the needs of pregnant women, infants, children, and the elderly

9. Public Health and National Children’s Study • The Public Health department was asked to: • Aggregate five years of Bexar County births (126,453) to census blocks • Develop a 2010 population estimate (2000 population + (Births01,02,03,04,05)/5)*10+deaths01,02,03,04,05)/5)*10)*.05)*10 • Rate of change by block 2000 to 2010 (2010 Population Estimate – 2000 population)/ 2000 population • This data will be used to form segments of the expected number of births by census block over the 4-year enrollment period. • These segments will be stratified to ensure proportionate representation of geographic, demographic and socioeconomic subpopulations. * Migration=.05

10. Public Health and Clinical & Translational Science Award (CTSA) Public health resources that may apply to the CTSA • Health Profiles: Public Health has experience in collection, analysis, and presentation of population-based clinical and demographic data that highlight health disparities • Vital Stats: These databases contain demographic data, as well as clinical data. • TWICES: A state-wide, web-based system utilized at the point of care of preventive health and screening functions. • The San Antonio Immunization Registry: Contains immunization records of children, adolescents and adults in the region is also contained within this database. • Statewide databases on communicable disease, HIV/STD,

11. Lack of Education is a High Risk Health Indicator • Educational attainment is critical for reducing disparities. It assures financial security, health literacy, good health, and global competitiveness. • San Antonio’s toughest health problem, is the prevalence of poverty that continues to run its course through the community. • According to the 2000 Census, only 10% of Bexar County Hispanics have earned at least a 4-year college degree. • Health literacy is the degree to which individuals can understand the health system and make appropriate decisions

12. TAKS Grade 9 Total % Economically Math, % Met Students % Hispanic Disadvantaged Standard 83% Somerset ISD 3,481 79% 26% 95% Harlandale ISD 14,390 91% 34% 96% S San Antonio ISD 9,667 90% 35% 97% Edgewood ISD 12,075 92% 37% 88% San Antonio ISD 56,422 92% 39% 55% East Central ISD 8,143 56% 39% 83% Southside ISD 4,853 81% 42% 88% Southwest ISD 9,950 81% 47% 45% Judson ISD 19,250 54% 49% 44% Northeast ISD 59,817 38% 64% 61% Northside ISD 78,711 49% 70% 30% Alamo Heights ISD 4,531 18% 83% Math is a “Gatekeeper" Course for StudentsTAKS Grade 9 Math % Who Met Standard by District 2005-2006 Education Statistics

13. % Economically Disadvantaged Children by School District 2005 SAT Mean Total Score by School District 2005 Generally, SAT scores are lower for the largely Hispanic inner city schools

14. Bexar County Age Distribution (Hispanic, NH White & African American) NH White African American Hispanic Female Male Female Male Female Male Age Source: 2000 Census

15. Projected Population of Bexar County by Race and Ethnicity, 1950-2040 Population Year Source: U.S. Census and Texas State Data Center

16. Bexar County/ San Antonio Community Health Assessments • Health Profiles highlight existing and emerging health issues facing our community. • Information is provided on maternity statistics, child abuse numbers, immunization rates, obesity, asthma, communicable diseases, deaths, etc. http://www.sanantonio.gov/health/profiles

17. Bexar County Scorecard – Maternal Health HP 2010 Status YR 2006 Maternal Indicators Total Births 26,194 Mother's Age <18 1,350 5% 5% Low Birth Weight < 5% 2,543 10% Late Prenatal Care < 10% 7,365 28% Births to Single Mothers 10,977 42% Premature <37 Weeks 3,622 13.8% 7.6% Medicaid Births 13152 50% Births to mothers BMI 30 & above before pregnancy 6,316 24% Births occurring < 24 mos previous birth 4,392 17% Infant Deaths* 177 6.76 4.5 * Preliminary data subject to change.

18. 1 2 3 4 5 6 Total Age of Mother 12 1 1 - - - - - 13 9 9 - - - - - 14 39 37 2 - - - - 15 196 180 16 - - - - 16 393 352 36 5 - - - 17 710 582 113 15 - - - 18 1,015 740 231 40 4 - - 19 1,343 877 362 87 15 2 - 20 1,504 843 454 169 35 3 - 21 1,486 689 484 230 66 12 5 Total 4,310 1,698 546 120 17 5 6,696 Bexar County 2006 Births to Mothers <22 Yrs. by Birth Order and Age ( 77% Medicaid) * Birth order of infant not given in birth record

19. Bexar County Maternal Health Disparities • Unplanned childbearing, financial issues, substance abuse, depression or domestic violence may contribute to having a low birth weight baby • To counter low birth weight, prematurity, and infant mortality among women of color, the health care system must talk to women about preconceptual health and the importance of identifying and treating medical conditions, such as hypertension and diabetes, prior to pregnancy • Based on pilot tests conducted in San Antonio in 2007, among 40 survey participants, 72% of mothers claimed they did not plan on getting pregnant.

20. Prenatal Care and Adverse Birth Outcomes • Undocumented Hispanic immigrants had the lowest utilization of prenatal care, more pronounced in counties closer to Mexico, and the lowest rates of adverse birth outcomes. • Inadequate PNC is associated with adverse birth outcomes in all ethnicities, although the effects are stronger for documented Hispanics. • These findings support public funding of routine PNC to undocumented Hispanic immigrants. • Birth certificate data from 2005 for Bexar, El Paso, Dallas, and Harris counties, were used for this analysis. *Andrea Ries Thurman MD et al. Prenatal Care Adequacy and Adverse Birth Outcomes among Documented and Undocumented Hispanics in Texas unpublished 2008

21. Health Care Disparities • Studies reveal uninsured patients do not receive primary/preventive treatment for life-threatening/chronic conditions (hypertension, diabetes, heart disease). • Bexar County Uninsured ~ 372,000 (24.3%). • How many others move on and off insurance? Or are underinsured (no preventive care, catastrophic care only)? • Even if everyone were covered, inner cities and rural areas lack personnel/facilities to provide care for all residents. • Early death is often preceded by high medical bills and loss of wages

22. Disparities in Premature Deaths from Heart Disease • Reducing premature death from heart disease and eliminating disparities will require preventing, detecting, treating, and controlling risk factors for heart disease in young and middle-aged adults. • Nationally In 2001, approximately 17% of all deaths from heart disease occurred among persons aged <65 years; these deaths occurred disproportionately among racial/ethnic minorities. • The determinants of these disparities are not clear, variations might reflect differences in risk factors for heart disease, access to medical and emergency care. • Blacks have a higher prevalence of high blood pressure than whites • Hispanics are less likely than whites to have their blood pressure checked, to be aware of having high blood pressure or to be treated and controlled for high blood pressure. • In the United States, greater proportions of blacks and Hispanics than whites lack health-care coverage and cite cost as a barrier to obtaining health care. MMWR February 20, 2004 / 53(06);121-125

23. 2005 Bexar County Deaths by CauseAge Specific Rate 45-64 per 100k Rate Hispanic NH White Rate Diabetes mellitus 82 52.4 35 25.4 Chronic liver disease and cirrhosis 56 35.8 21 15.3 Acute myocardial infarction 52 33.2 30 21.8 Cerebrovascular diseases 47 30.0 16 11.6 Malignant neoplasms of liver 41 26.2 13 9.4 Alcoholic liver disease 33 21.1 10 7.3 Chronic ischemic heart disease 32 20.5 22 16.0 Malignant neoplasms of colon, rectum and anus 30 19.2 19 13.8 Renal failure 19 12.1 9 6.5 Septicemia 18 11.5 8 5.8 Motor vehicle accidents 15 9.6 12 8.7 Malignant neoplasm of stomach 15 9.6 4 2.9 Malignant neoplasms of kidney and renal pelvis 14 8.9 11 8.0 Hypertensive heart disease 13 8.3 7 5.1 Human immunodeficiency virus (HIV) disease 12 7.7 5 3.6 Viral hepatitis 11 7.0 8 5.8 2005 Bexar County Population Estimate 156,428 137,597

24. Summary-Health Disparities • Educational attainment is critical for reducing disparities. It assures financial security, health literacy, good health, and global competitiveness. • To reduce health disparities - consider the determinants of health, i.e. genetic factors, behavioral factors, environmental factors, values, and access to health care.* • Public health approach: define the problem, collect and analyze the data, determine the causes of the problem, take necessary action. For more information, contact John Berlanga jberlanga@sanantonio.gov * Partnerships to Achieve Health Equity, 11/1/2007, Alexandria, Va. - David Satcher, M.D., Ph.D.

25. Children’s Health Research at The University of Texas Health Science Center at San Antonio (UTHSCSA) • Examples • Infrastructure to support population-based/community research

26. South Texas Minority-Based Community Clinical Oncology Program (CCOP)* • Christus Santa Rosa Children’s Hospital • Methodist Children’s Hospital • Wilford Hall Medical Center, Lackland AFB • Driscoll Children’s Hospital (Corpus Christi) *Continuously funded by the National Cancer Institute since 1990 • Participate on Children’s Oncology Group research protocols • Serve as a platform for conducting regional childhood cancer research investigations

27. Obesity and Childhood Leukemia • Using the South Texas MB-CCOP consortium, we identified a cohort of 307 newly diagnosed children with acute lymphoblastic leukemia • We assessed obesity and the change in body mass index over the course of treatment

28. Demographic Correlates of Body Size Changes in Children Undergoing Treatment for Acute Lymphoblastic Leukemia Jacques Baillargeon, Ph.D., Anne-Marie Langevin, M.D., Margaret Lewis, M.S., Jaime Estrada, M.D., James J. Grady, Ph.D., Judith Mullins, M.D., Aaron Pitney, M.D., Brad H. Pollock, M.P.H., Ph.D. Pediatr Blood Cancer, 49:793-6, 2007

29. Therapy-related Changes in Body Size in Hispanic Children with Acute Lymphoblastic Leukemia Jacques Baillargeon, Ph.D., Anne-Marie Langevin, M.D., Margaret Lewis, M.S., James J. Grady, M.P.H., Dr.P.H., Paul J. Thomas, M.D., Judith Mullins, M.D., Jaime Estrada, M.D., Aaron Pitney, M.D. Nancy Sacks, M.S., R.D., Brad H. Pollock, M.P.H., Ph.D. Cancer, 103:1725-9, 2005

30. Transient Hyperglycemia in Hispanic Children with Acute Lymphoblastic Leukemia Jacques Baillargeon, Ph.D. Anne-Marie Langevin, M.D., Judith Mullins, M.D., Guillermo DeAngulo, M.D., Paul J. Thomas, M.D., Jaime Estrada, M.D., Aaron Pitney, M.D., Brad H. Pollock, M.P.H., Ph.D. Pediatr Blood Cancer, 44:1-4, 2005

31. Adolescents with Cancer: An Underserved Population • Adolescents with cancer have poorer survival than younger children and older adults

32. 2.38% 1.72% 1.60% AYA Gap - 0.27% Relative Change in 5-Year Survival(1975–1997, NCI SEER Program) 2.4% 1.8% Underserved Average Annual%Increase All Age Average = 1.5% / yr 1.2% 0.6% 0% 0 5 10 15 20 30 35 40 45 50 55 60 65 70 75 25 -0.3% Age at Diagnosis (Years)

33. Adolescents with Cancer: An Underserved Population • Adolescents with cancer have poorer survival than younger children and older adults • Possible reasons: • Less access to state-of-the art (protocol) therapy • Different tumor biology • Lower adherence to prescribed treatment

34. Re-Mission Video Game Intervention • Primary Objective: Determine the effects of playing a interactive video game, Re-Mission, on treatment adherence • Secondary Objectives: Determine the effects on health-related quality of life, self-care behaviors, knowledge, stress, and locus of control

35. Brain Brain Lymph Node Lymph Node Colon Colon Blood Stream Blood Stream • Re-Mission • 7 Cancers • ALL • AML • Osteosarcoma • Brain tumor • Hodgkin’s • Non-Hodgkin’s • Ewing’s Sarcoma • 19 Patients • Diverse: • Gender • Ethnicity • Age • Location • Disease stage • 20 Levels • Adaptive difficulty • Diverse missions: • Chemotherapy • Radiation • Metastasis ctrl. • Infection ctrl. • Stress mgmt. • Pain mgmt. • Bonus: immunotherapy • 1 Intrepid Nanobot Description of the Intervention • Action game • English, Spanish, or French game modes are available

36. 2.5 Re-Mission 4.0 2.0 Plasma 6MMP (log10) Control 3.5 3.0 1.5 Baseline Follow-up 2.5 2.0 6MP – Adjusted for Game-PlayObjective measure of adherence to oral chemotherapy (in Rx subset) 6MMP adjusted for game-play 6TG adjusted for game-play p = .008 p = .015 Re-Mission Control Plasma 6MMP (log10) Baseline Follow-up

37. 40 0.4 30 0.3 Total MEMS Cap Events 20 0.2 10 0.1 0 0.0 Control Re-Mission MEMS – Medication Event Monitoring SystemObjective behavioral measure of adherence to oral antibiotics (in Rx subset) MEMS access events MEMS – Adherence Failure p = .008 p = .013 Fraction of participants with MEMS # < 10% Rx Control Re-Mission

38. Pilot Study of the Genetic Epidemiology of Childhood Cancer: Objectives • Assess feasibility of collecting/banking pediatric blood samples along with demographic, health, and exposure data from childhood cancer cases and their biological parents. • Determine the proportion of eligible subjects who choose to participate, respondent burden, completeness of questionnaires. • Obtain preliminary estimates of the genotypes associated with childhood cancers • Formulate analytic etiological hypotheses and develop a statewide protocol

39. Inter-Institutional Collaborations

40. Education Collaborations • UTHSCSA-UTSA • PhD in Biostatistics • Computational Biology Initiative • UTHSCSA-Regional Campus UT SPH • Proposed DrPH in Environmental and Occupational Health and Community Health Practice • UTSA-Regional Campus UT SPH • PhD in Applied Demography

41. Resources • UTHSCSA Dept. of Epidemiology and Biostatistics: • Biostatistics core resources • Biomedical informatics core resources • Institute for Health Promotion Research • National Children’s Study (NCS) • UTHSCSA Clinical Translational Science Award proposal • UTHSCSA-UTSA Computational Biology Initiative • SBC Genomics Computing Center at the SFBR • San Antonio Immunization Registry System (SAMHD) • Proposed UTSA Center for Geographic Information Systems (GIS)

42. The Future

43. San Antonio Public Health Institute? Workgroup was formed 18 months ago to identify barriers to seamless research and educational collaboration: UT School of Public Health San Antonio Regional Campus UTHSCSA UTSA SAMHD Possible future physical home