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1.  Influenza surveillance using electronic health records in the American Indian and Alaska Native population 
Increasing use of electronic health records (EHRs) provides new opportunities for public health surveillance. During the 2009 influenza A (H1N1) virus pandemic, we developed a new EHR-based influenza-like illness (ILI) surveillance system designed to be resource sparing, rapidly scalable, and flexible. 4 weeks after the first pandemic case, ILI data from Indian Health Service (IHS) facilities were being analyzed.
Materials and methods
The system defines ILI as a patient visit containing either an influenza-specific International Classification of Disease, V.9 (ICD-9) code or one or more of 24 ILI-related ICD-9 codes plus a documented temperature ≥100°F. EHR-based data are uploaded nightly. To validate results, ILI visits identified by the new system were compared to ILI visits found by medical record review, and the new system's results were compared with those of the traditional US ILI Surveillance Network.
The system monitored ILI activity at an average of 60% of the 269 IHS electronic health databases. EHR-based surveillance detected ILI visits with a sensitivity of 96.4% and a specificity of 97.8% based on chart review (N=2375) of visits at two facilities in September 2009. At the peak of the pandemic (week 41, October 17, 2009), the median time from an ILI visit to data transmission was 6 days, with a mode of 1 day.
EHR-based ILI surveillance was accurate, timely, occurred at the majority of IHS facilities nationwide, and provided useful information for decision makers. EHRs thus offer the opportunity to transform public health surveillance.
PMCID: PMC3912730  PMID: 23744788
Influenza, Human; Population Surveillance; Epidemiologic Methods; Electronic Health Records; Medical Informatics Applications; Data Collection
2.  Molluscum Contagiosum in a Pediatric American Indian Population: Incidence and Risk Factors 
PLoS ONE  2014;9(7):e103419.
Molluscum contagiosum virus (MCV) causes an innocuous yet persistent skin infection in immunocompetent individuals and is spread by contact with lesions. Studies point to atopic dermatitis (AD) as a risk factor for MCV infection; however, there are no longitudinal studies that have evaluated this hypothesis.
Outpatient visit data from fiscal years 2001–2009 for American Indian and Alaska Native (AI/AN) children were examined to describe the incidence of molluscum contagiosum (MC). We conducted a case-control study of patients <5 years old at an Indian Health Service (IHS) clinic to evaluate dermatological risk factors for infection.
The incidence rate for MC in children <5 years old was highest in the West and East regions. MC cases were more likely to have a prior or co-occurring diagnosis of eczema, eczema or dermatitis, impetigo, and scabies (p<0.05) compared to controls; 51.4% of MC cases had a prior or co-occurring diagnosis of eczema or dermatitis.
The present study is the first demonstration of an association between AD and MC using a case-control study design. It is unknown if the concurrent high incidence of eczema and MC is related, and this association deserves further investigation.
PMCID: PMC4114779  PMID: 25072249
3.  Epidemiology of Ehrlichiosis and Anaplasmosis among American Indians in the United States, 2000–2007 
Ehrlichiosis and anaplasmosis infections among American Indians (AIs) have never been specifically examined, despite high rates of other tick-borne rickettsial diseases among AIs. The epidemiology of ehrlichiosis and anaplasmosis among AIs was analyzed using the National Electronic Telecommunications System for Surveillance (NETSS), Case Report Forms (CRFs), and Indian Health Service (IHS) inpatient and outpatient visits. The 2000–2007 average annual ehrlichiosis and anaplasmosis incidence among AIs reported to NETSS was almost 4-fold lower (4.0/1,000,000) than that using IHS data (14.9). American Indian cases reported from CRFs had a higher proportion of hospitalization (44%) compared with IHS (10%). American Indian incidence of ehrlichiosis and anaplasmosis was higher and showed a different age and geographical distribution than other races. These results highlight the need to improve collaboration between the ehrlichiosis and anaplasmosis surveillance systems for AIs so as to develop interventions that target the unique epidemiology and mitigate the burden of disease among this high-risk population.
PMCID: PMC3435360  PMID: 22826495
4.  Trends in Clinical Diagnoses of Rocky Mountain Spotted Fever among American Indians, 2001–2008 
American Indians are at greater risk for Rocky Mountain spotted fever (RMSF) than the general U.S. population. The epidemiology of RMSF among American Indians was examined by using Indian Health Service inpatient and outpatient records with an RMSF International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis. For 2001–2008, 958 American Indian patients with clinical diagnoses of RMSF were reported. The average annual RMSF incidence was 94.6 per 1,000,000 persons, with a significant increasing incidence trend from 24.2 in 2001 to 139.4 in 2008 (P = 0.006). Most (89%) RMSF hospital visits occurred in the Southern Plains and Southwest regions, where the average annual incidence rates were 277.2 and 49.4, respectively. Only the Southwest region had a significant increasing incidence trend (P = 0.005), likely linked to the emergence of brown dog ticks as an RMSF vector in eastern Arizona. It is important to continue monitoring RMSF infection to inform public health interventions that target RMSF reduction in high-risk populations.
PMCID: PMC3247124  PMID: 22232466
5.  Changing Trends in Viral Hepatitis-Associated Hospitalizations in the American Indian/Alaska Native Population, 1995–2007 
Public Health Reports  2011;126(6):816-825.
We described the changing epidemiology of viral hepatitis among the American Indian/Alaska Native (AI/AN) population that uses Indian Health Service (IHS) health care.
We used hospital discharge data from the IHS National Patient Information Reporting System to determine rates of hepatitis A-, B-, and C-associated hospitalization among AI/ANs using IHS health care from 1995–2007 and summary periods 1995–1997 and 2005–2007.
Hepatitis A-associated hospitalization rates among AI/AN people decreased from 4.9 per 100,000 population during 1995–1997 to 0.8 per 100,000 population during 2005–2007 (risk ratio [RR] = 0.2, 95% confidence interval [CI] 0.1, 0.2). While there was no significant change in the overall hepatitis B-associated hospitalization rate between time periods, the average annual rate in people aged 45–64 years increased by 109% (RR=2.1, 95% CI 1.4, 3.2). Between the two time periods, the hepatitis C-associated hospitalization rate rose from 13.0 to 55.0 per 100,000 population (RR=4.2, 95% CI 3.8, 4.7), an increase of 323%. The hepatitis C-associated hospitalization rate was highest among people aged 45–64 years, males, and those in the Alaska region.
Hepatitis A has decreased to near-eradication levels among the AI/AN population using IHS health care. Hepatitis C-associated hospitalizations increased significantly; however, there was no significant change in hepatitis B-associated hospitalizations. Emphasis should be placed on continued universal childhood and adolescent hepatitis B vaccination and improved vaccination of high-risk adults. Prevention and education efforts should focus on decreasing hepatitis C risk behaviors and identifying people with hepatitis C infection so they may be referred for treatment.
PMCID: PMC3185317  PMID: 22043097
6.  Tuberculosis in Indigenous Peoples in the U.S., 2003–2008 
Public Health Reports  2011;126(5):677-689.
We examined trends and epidemiology of tuberculosis (TB) across racial/ethnic groups to better understand TB disparities in the United States, with particular focus on American Indians/Alaska Natives (AI/ANs) and Native Hawaiians/other Pacific Islanders (NH/PIs).
We analyzed cases in the U.S. National Tuberculosis Surveillance System and calculated TB case rates among all racial/ethnic groups from 2003 to 2008. Socioeconomic and health indicators for counties in which TB cases were reported came from the Health Resources and Services Administration Area Resource File.
Among the 82,836 TB cases, 914 (1.1%) were in AI/ANs and 362 (0.4%) were in NH/PIs. In 2008, TB case rates for AI/ANs and NH/PIs were 5.9 and 14.7 per 100,000 population, respectively, rates that were more than five and 13 times greater than for non-Hispanic white people (1.1 per 100,000 population). From 2003 to 2008, AI/ANs had the largest percentage decline in TB case rates (−27.4%) for any racial/ethnic group, but NH/PIs had the smallest percentage decline (−3.5%). AI/ANs were more likely than other racial/ethnic groups to be homeless, excessively use alcohol, receive totally directly observed therapy, and come from counties with a greater proportion of people living in poverty and without health insurance. A greater proportion of NH/PIs had extrapulmonary disease and came from counties with a higher proportion of people with a high school diploma.
There is a need to develop flexible TB-control strategies that address the social determinants of health and that are tailored to the specific needs of AI/ANs and NH/PIs in the U.S.
PMCID: PMC3151185  PMID: 21886328
7.  Disparities in Infectious Disease Hospitalizations for American Indian/Alaska Native People 
Public Health Reports  2011;126(4):508-521.
We described disparities in infectious disease (ID) hospitalizations for American Indian/Alaska Native (AI/AN) people.
We analyzed hospitalizations with an ID listed as the first discharge diagnosis in 1998–2006 for AI/AN people from the Indian Health Service National Patient Information Reporting System and compared them with records for the general U.S. population from the Nationwide Inpatient Survey.
The ID hospitalization rate for AI/AN people declined during the study period. The 2004–2006 mean annual age-adjusted ID hospitalization rate for AI/AN people (1,708 per 100,000 populiation) was slightly higher than that for the U.S. population (1,610 per 100,000 population). The rate for AI/AN people was highest in the Southwest (2,314 per 100,000 population), Alaska (2,063 per 100,000 population), and Northern Plains West (1,957 per 100,000 population) regions, and among infants (9,315 per 100,000 population). ID hospitalizations accounted for approximately 22% of all AI/AN hospitalizations. Lower-respiratory--tract infections accounted for the largest proportion of ID hospitalizations among AI/AN people (35%) followed by skin and soft tissue infections (19%), and infections of the kidney, urinary tract, and bladder (11%).
Although the ID hospitalization rate for AI/AN people has declined, it remains higher than that for the U.S. general population, and is highest in the Southwest, Northern Plains West, and Alaska regions. Lower-respiratory-tract infections; skin and soft tissue infections; and kidney, urinary tract, and bladder infections contributed most to these health disparities. Future prevention strategies should focus on high-risk regions and age groups, along with illnesses contributing to health disparities.
PMCID: PMC3115210  PMID: 21800745
9.  The Incidence of Molluscum contagiosum among American Indians and Alaska Natives 
PLoS ONE  2009;4(4):e5255.
The epidemiology of Molluscum contagiosum (MC) in the United States is largely unknown, despite the fact that the virus is directly communicable and large outbreaks occur. This study provides population-based estimates to describe the epidemiology of MC in the United States among American Indian and Alaska Native (AI/AN) persons. This population was selected because of the comprehensiveness and quality of available data describing utilization of out-patient services.
Principal Findings
Outpatient visits listing MC as a diagnosis in the Indian Health Service National Patient Information Reporting System during 2001–2005 were analyzed to assess patient characteristics, visit frequency and concurrent skin conditions. Outpatient visit rates and incidence rates were calculated based on known population denominators (retrospective cohort). Overall outpatient visit rates were also calculated for the general US population using national data. The average annual rate of MC-associated outpatient visits was 20.15/10,000 AI/AN persons for 2001–2005 (13,711 total visits), which was similar to the rate for the general US population (22.0/10,000 [95% CI: 16.9–27.1]). The incidence of MC-associated visits was 15.34/10,000. AI/AN children 1–4 years old had the highest incidence (77.12), more than twice that for children 5–14 years old (30.79); the incidence for infants (<1 year) was higher than that for adults. AI/AN persons living in the West region had the highest incidence, followed by those in the East and Alaska regions (26.96, 22.88 and 21.38, respectively). There were age-specific associations between MC and concurrent skin conditions (e.g., atopic dermatitis, eczema).
This study highlights the need for periodic population-based measurements to assess trends in incidence and healthcare utilization for MC in the United States. High rates of MC were found among AI/AN persons, especially among children <15 years old. The AI/AN population would benefit from greater availability of effective strategies for prevention and treatment of MCV infection.
PMCID: PMC2667635  PMID: 19381289
10.  Infectious Disease Hospitalizations Among Older American Indian and Alaska Native Adults 
Public Health Reports  2006;121(6):674-683.
American Indians and Alaska Natives (AI/AN) adults ≥65 years of age (older adults) have the second highest age group-specific infectious disease (ID) hospitalization rate. To assess morbidity and disparities of IDs for older AI/AN adults, this study examined the epidemiology of overall and specific infectious disease hospitalizations among older AI/AN adults.
ID hospitalization data for older AI/AN adults were analyzed by using Indian Health Service hospital discharge data for 1990 through 2002 and comparing it with published findings for the general U.S. population of older adults.
ID hospitalizations accounted for 23% of all hospitalizations among older AI/AN adults. The average annual ID hospitalization rate increased 5% for 1990–1992 to 2000–2002; however, the rate increased more than 20% in the Alaska and the Southwest regions. The rate for older AI/AN adults living in the Southwest region was greater than that for the older U.S. adult population. For 2000–2002, lower respiratory tract infections accounted for almost half of all ID hospitalizations followed by kidney, urinary tract, and bladder infections, and cellulitis.
The ID hospitalization rate increased among older AI/AN adults living in the Southwest and Alaska regions, and the rate for the older AI/AN adults living in the Southwest region was higher than that for the U.S. general population. Prevention measures should focus on ways to reduce ID hospitalizations among older AI/AN adults, particularly those living in the Southwest and Alaska regions.
PMCID: PMC1781909  PMID: 17278402

Results 1-10 (10)