Lab Matters Summer 2018 - Page 11

feature Working “Intentionally” to Reduce Health Disparities don’t think about whose specimens we should get and who we should test. More recently we’ve begun thinking about how to ensure our tests are equally available to everyone who needs them, so we’ve started to think about access to testing, what tests we provide and how we provide them, to shed light on health inequities.” F undamentally, the end goal of efforts like the Utah study is health equity, an outcome Healthy People 2020 defines as “the attainment of the highest level of health for all people.” Health equity, in turn, depends on creating social and physical environments that actually promote health for all. Mighty Fine, MPH, CHES, director of the American Public Health Association’s Center for Public Health Practice and Professional Development, said health equity encompasses everything from “who can buy homes where” to “who has access to what healthcare options.” In the public health laboratory, as in public health writ large, there is a growing effort to ‘more consciously’ address health disparities.” Jennifer Rakeman, PhD, New York City Public Health Laboratory. “Those are not arbitrary,” he said. While health equity “is not a brand new issue,” said Fine, “what’s changing is that we’re unpacking it more and looking at the social determinants of health, which is a newer concept. In public health, we want people to change adverse behaviors and live a healthy lifestyle, but sometimes people are trapped by systems that conspire against that change. So we have to work to identify, break down and dismantle those systems to make change more likely.” Organization to declare a Public Health Emergency of International Concern in early 2016, after tens of thousands of cases were confirmed in Latin America and many more suspected. Among the social determinants of health tracked by Healthy People 2020—a federal initiative that sets ten-year, national health objectives—are the proportion of people living in poverty, number of days of poor air quality and homicide rate. Fine said, “I think it’s great that public health laboratories are engaging even more in this space, because we know it’s going to take a collective effort.” He called for “thinking more strategically, thinking about how the public health workforce might more intentionally work with public health labs, and how the labs can work more intentionally with the larger public health system.” In New York City, an ambitious effort to improve Zika testing two years ago shows what can be gained by such thinking. Zika virus—a mostly mosquito-borne illness that can cause devastating birth defects when women are infected during pregnancy—prompted the World Health PublicHealthLabs @APHL Zika virus Although New York City never experi- enced local Zika virus transmission, the city documented 993 travel-associated cases that year, primarily linked to the Dominican Republic, Jamaica and Puerto Rico. At the time, all local Zika virus testing was performed at the New York City Public Health Laboratory, so authorities knew who was getting tested. Health department epidemiologists noticed early on, said Rakeman, that “the patients who were being tested were not the patients we felt had ties to Zika- affected areas, such as people born in those areas and thus more likely to travel there.” For example, a preponderance of tested patients had zip codes linked to the Upper East Side, Chelsea and other affluent neighborhoods, with far fewer from Bronx and Brooklyn neighborhoods with substantial populations hailing from Latin America. Rakeman said, historically, “Many laboratories and many laboratorians thought we just get the specimens and APHL.org Having trained at both a “well-resourced” tertiary care hospital and a “very under- resourced” county hospital, Rakeman knows that it is much harder to order tests in under-staffed facilities: “In a ten-minute visit, spending nine minutes trying to get a test ordered may not serve the patient well.” Public health laboratory staff found that this same dynamic was playing out in the case of Zika. Thus, in March 2016, the New York City Department of Health launched an “all-out effort to ensure that people who needed Zika testing got Zika testing.” One of the centerpieces of this effort was a dedicated call center to provide information to providers and clinical labs to assure appropriate patients were being tested and to streamline the test ordering process itself. Call center operators used a newly developed electronic test ordering system, eOrder, launched specifically to facilitate Zika testing. The public health laboratory, in turn, received higher quality specimen submissions, with complete and correct test ordering data. Additionally, the city health commissioner held press conferences and met with local elected officials to publicize Zika test recommendations and the new call center. The result, said Rakeman, was “striking”: “We went from a complete mismatch [before the outreach], and after outreach it completely flipped—the demographic of at-risk patients matched the patients getting tested.” By year’s end, the city public health laboratory will roll out an expanded version of eOrder that will accommodate all public health laboratory test ordering and results rep