Delaware Journal of Public Health - Health Sciences Education / COVID-19 special section by Delaware Academy of Medicine and the Delaware Public Health Association

Volume 6 | Issue 1

Delaware Journal of

April 2020

Public Health A publication of the Delaware Academy of Medicine / Delaware Public Health Association

EC IAL Sta SEC r ti TIO ng N on ON p a CO ge VI 6 D-1

HEALTH SCIENCES EDUCATION

www.delamed.org | www.delawarepha.org

Delaware Academy of Medicine

Board of Directors: OFFICERS Omar A. Khan, M.D., M.H.S. President S. John Swanson, M.D. President Elect Lynn Jones Secretary

Delaware Journal of

Public Health

A publication of the Delaware Academy of Medicine / Delaware Public Health Association

www.delamed.org | www.delawarepha.org

David M. Bercaw, M.D. Treasurer Daniel J. Meara, M.D., D.M.D. Immediate Past President Timothy E. Gibbs, M.P.H. Executive Director, Ex-officio DIRECTORS Stephen C. Eppes, M.D. Eric T. Johnson, M.D. Joseph F. Kestner, Jr., M.D. Professor Rita Landgraf Brian W. Little, M.D., Ph.D. Arun V. Malhotra, M.D. Joseph A. Napoli, M.D., D.D.S. John P. Piper, M.D. EMERITUS Robert B. Flinn, M.D. Barry S. Kayne, D.D.S.

Delaware Public Health Association

Advisory Council:

Omar Khan, M.D., M.H.S. President Timothy E. Gibbs, M.P.H. Executive Director Louis E. Bartoshesky, M.D., M.P.H. Gerard Gallucci, M.D., M.H.S. Richard E. Killingsworth, M.P.H. Erin K. Knight, Ph.D., M.P.H. Melissa K. Melby, Ph.D. Mia A. Papas, Ph.D. Karyl T. Rattay, M.D., M.S. Margot L. Savoy, M.D., M.P.H. William J. Swiatek, M.A., A.I.C.P.

3 | In this Issue

Omar A. Khan, M.D., M.H.S. Timothy E. Gibbs, M.P.H.

4 | Guest Editor

Neil Jasani, M.D. M.B.A. Omar A. Khan, M.D., M.H.S.

6 | From Wuhan to Delaware: Tracking the Spread of COVID-19 Katherine Smith, M.D., M.P.H.

12 | E xams May be Cancelled, but Humanity is Not: A Medical Student Perspective on the COVID-19 Pandemic Elizabeth Avakoff, M.P.H. Omneya Ayoub, M.S.

16 | A merica and Delaware Need Investments in Public Health Now More than Ever Timothy E. Gibbs, M.P.H.

18 | U niversity of Delaware Center for Health Profession Studies David Barlow, Ph.D.

24 | U ndergraduate and Graduate Public Health Programs Need Changes to Teach the Public Health Workforce of the Future Jennifer A. Horney, Ph.D., M.P.H. Abby Heath

Delaware Journal of Public Health Timothy E. Gibbs, M.P.H. Publisher Omar Khan, M.D., M.H.S. Editor-in-Chief Neil Jasani, M.D., M.B.A. Guest Editor Liz Healy, M.P.H. Managing Editor Kate Smith, M.D., M.P.H. Copy Editor Suzanne Fields Image Director ISSN 2639-6378

April 2020

Volume 6 | Issue 1

COVER Health Education is all about the future we must create together: the future of the Delaware region’s health and wellbeing, through talented individuals and teams that serve our neighbors and communities.

28 | The Workforce Development Program at Delaware Technical Community College

62 | DIMER at 50: Delaware’s Best Value for Medical Education

32 | Global Health Matters

64 | The Community Benefits of Graduate Medical Education

Mark T. Brainard, J.D.

Fogarty International Center

46 | Training for Tomorrow: A Century of GME at ChristianaCare Brian Levine, M.D.

52 | Advanced Practice Clinician (APC) Fellowships: A Strategic Approach to a High-Quality, Stable APC Workforce Lisa Maxwell, M.D., M.H.C.D.S. Jennifer Painter, D.N.P.

54 | Innovations in Residency Training in Community Hospitals Robert Monteleone, M.D.

56 | New Rankings Show Healthiest and Least Healthy Counties in Delaware County Health Rankings

58 | Nurse Residency Programs: Providing Organizational Value?

Amy Sutor, M.S.N., R.N., C.C.R.N.-K., N.P.D.-B.C. Jennifer Painter, D.N.P., A.P.R.N., C.N.S., N.E.A.-B.C., N.P.D.-B.C., O.C.N., A.O.C.N.S., L.S.S.B.B.

Sherman L. Townsend Omar A. Khan, M.D., M.H.S.

Brintha Vasagar, M.D., M.P.H.

66 | Flexibility and Adaptation: Key Elements for Preserving Research Continuity During the COVID-19 Pandemic Mindy George-Weinstein, Ph.D.

68 | CORONAVIRUS Lexicon 69 | CORONAVIRUS Resources 72 | Index of Advertisers

Editorial note: The articles in this issue were written prior to the COVID-19 pandemic. The work herein thus reflects programming prior to the global disruption caused by the pandemic.

The Delaware Journal of Public Health (DJPH), first published in 2015, is the official journal of the Delaware Academy of Medicine / Delaware Public Health Association (Academy/DPHA).

only the opinions of the authors and do not necessarily reflect the official policy of the Delaware Public Health Association or the institution with which the author(s) is (are) affiliated, unless so specified.

Submissions: Contributions of original unpublished research, social science analysis, scholarly essays, critical commentaries, departments, and letters to the editor are welcome. Questions? Write ehealy@delamed.org or call Liz Healy at 302-733-3989.

Any report, article, or paper prepared by employees of the U.S. government as part of their official duties is, under Copyright Act, a “work of United States Government” for which copyright protection under Title 17 of the U.S. Code is not available. However, the journal format is copyrighted and pages June not be photocopied, except in limited quantities, or posted online, without permission of the Academy/ DPHA. Copying done for other than personal or internal reference use-such as copying for general distribution, for advertising or promotional purposes, for creating new collective works, or for resale- without the expressed permission of the Academy/DPHA is prohibited. Requests for special permission should be sent to ehealy@delamed.org.

Advertising: Please write to ehealy@delamed.org or call 302-733-3989 for other advertising opportunities. Ask about special exhibit packages and sponsorships. Acceptance of advertising by the Journal does not imply endorsement of products. Copyright © 2020 by the Delaware Academy of Medicine / Delaware Public Health Association. Opinions expressed by authors of articles summarized, quoted, or published in full in this journal represent

I N T H I S I S SU E This issue of the Journal focuses on education and public health. In this instance, we refer to higher education: training the healthcare workforce to operate in the realm of individual medicine and population health. We also take a look at the 2020 County Health Rankings data, National Public Health Week, and the National Institutes of Health “All of Us” Research Program. But there is an elephant in the room. “Unprecedented.” “Extraordinary.” “Unparalleled.” The global COVID-19 pandemic is unfolding as this issue of the Delaware Journal of Public Health is in final edit mode. These are unusual times indeed, as the staff of the Academy/DPHA is all working from home, meetings are being conducted online, and numerous programs and educational activities have been postponed until the risk has passed or cancelled entirely. Fortunately, we had a plan in place for situations such as this, and our transition was relatively easy. These times are unlike any other, as the profession of public health is taking center stage. The critical components of public health including (but not limited to) surveillance, epidemiology, infectious disease control and prevention, occupational health and safety, communications strategies, and global health are in the forefront of media broadcasts, social media posts, and people everywhere are educating themselves on these key areas. More people than ever understand what the nature of our work is, and ultimately that is a good thing. Three new terms have been ingrained into our vocabulary, and will likely be forever quoted when we look back on this crisis: Social Physical Distancing and social cohesiveness Flattening the Curve Pandemic We are in the thick of this “invisible blizzard” that is disrupting the very fabric of our reality. And there will be, in time, a “morning after,” when we pick up the pieces, gather the lessons learned, and apply that new knowledge to the practice of public health. And we will be stronger for it as this common foe has forced us to care for each other over compete with each other. The Great Depression (1929 to 1933) and Great Recession (2007 to 2009) caused fundamental changes in society to occur. It is up to call of us to help shape the changes ahead for the better of everyone, in Delaware, in the United States, and globally. More than ever before – we welcome your feedback. Subsequent issues of the Journal will contain COVID-19 information, research, and retrospectives. — OK and TG

Omar A. Khan, M.D., M.H.S. President

Timothy E. Gibbs, M.P.H. Executive Director 3

e are pleased to present this themed issue of the Delaware Journal of Public Health. One of us (Dr. Neil Jasani) serves as Guest Editor and together with Dr. Khan as Editor in Chief, has curated the material herein. This journal issue focuses on Health Education in all its varied forms. Realizing that we are in the midst of one of the greatest public health crises in a century, the time to engage with this Journal, and with this topic, has never been greater. We are currently embroiled in the day-to-day hard work of pandemic preparedness, patient care, and research innovations to combat the COVID-19 pandemic. Health Education is all about the future we must create together: the future of the Delaware region’s health and wellbeing, through talented individuals and teams that serve our neighbors and communities. We are proud as ever, but especially these days, to serve alongside all the members of our teams and with all of you who are part of our extended family of health professionals. This theme issue covers several important areas. We discuss some core foundational areas in ‘undergraduate medical education’ or UME (medical student education) and Graduate Medical Education (i.e., residency). We are pleased as a state to be home to many fine residency programs, including newly formed ones at Bayhealth. We collectively host programs in nursing, in public health, research, allied health and in many other areas of the healthcare workforce. Our innovative DIMER program (now in its 50th year!) offers a tremendous value for Delawareans and, with all our partners, serves as “Delaware’s medical school”. Our team of talented leaders across the state have generously given of their time as authors to bring you the latest from these areas, and more. We are a small state, but we are the First State. As such, we are proud to be recognized as leaders in regional, national and even global education programming. Please join us in reading this material, engaging with it, and taking it further. By definition, education is a dynamic field and its core strengths include the committed learners and dedicated faculty. In this unique time of crisis, we honor all those who serve, and all those who aspire to serve through learning to be the best health care professionals they can be. This issue is dedicated to them.

Neil Jasani, M.D., M.B.A. Guest Editor

4 Delaware Journal of Public Health – April 2020

Omar A. Khan, M.D., M.H.S. Editor in Chief

From Wuhan to Delaware: Tracking the Spread of COVID-19 Katherine Smith, M.D., M.P.H., Program Director, Immunization Coalition of Delaware

INTRODUCTION

THE DISEASE

On November 17, 2019, an individual presented to a healthcare facility in Wuhan, China, with flu-like symptoms. About two weeks later, on December 1, another patient entered the health care system with symptoms of fever and a dry cough. More people presented as 2019 drew to a close with this “unusual pneumonia.” Laboratory testing identified the virus as a SARS (Severe Acute Respiratory Syndrome) -like coronavirus, and on December 31, Chinese officials alerted the World Health Organization of these new findings.

The disease called COVID-19 is full of unknowns. Reported illnesses range from very mild to severe, the most serious of which has ended in death for over 7,000 individuals.5 Common symptoms of COVID-19 may appear 2-14 days after exposure (based on the incubation period of MERS-CoV), and include fever, dry cough, and shortness of breath. Individuals with more serious illness have seen symptoms like severe shortness of breath or trouble breathing (sometimes requiring assisted ventilation), pain or pressure in the chest, confusion or difficulty to awaken, and a bluish tint to their lips or face.3 Those who have died from the disease in the US have tended to be older (50 years-of age or more), with underlying chronic conditions, although children are not immune.6,7

Since the end of 2019, over 350,000 people worldwide have contracted this new virus, over 15,000 have died, and public health officials are desperately trying to study, treat, and contain it. People everywhere are suddenly faced with terms like “social distancing” and “flattening the curve,” and the virus has recently reached the pandemic stage. How did it get so bad so quickly, what can we do to help, and is there an end in sight?

THE UNKNOWN VIRUS There is a lot about this pandemic that is not yet known, and a lot that will surely come to light in the future. The 55-yearold presenting to their health care professional on November 17, 2019, could have been the first person to contract this new coronavirus.1 They may or may not have gone to the Huanan Seafood Wholesale Market in Hubei Province, China, where several of the first cases of this novel virus were said to have visited. The virus may be a brand new zoonotic infection (a disease that jumps from animals to humans), or it may have been present for a while.2

THE VIRUS Coronaviruses are a large family of viruses that are common in people and animals (including camels, cattle, cats, and bats).3 The new virus, named SARS-CoV-2, is a betacoronavirus, like MERS (Middle East Respiratory Syndrome) and SARS (Severe Acute Respiratory Syndrome). All three viruses have their origins in bats, and can be spread from animals to humans. A zoonotic disease is usually not harmful to humans, however sometimes a virus can mutate and make the jump.4 If this happens, the human has no immunity, and the individual’s immune system must make new antibodies against it. Sometimes, it ends there, with the virus only being passed from animal to humans (as seen in MERS-CoV). This is why the Chinese government took steps to cleanse and close down the Seafood Market in December – if the disease had mutated to animal-tohuman transmission, removing the animals and humans from the same area would stop the spread of the disease. Later, it was discovered that a growing number of patients had no exposure to animal markets of any kind, indicating the virus may be spread person-to-person instead. In order to begin spreading from person to person, the virus needs to mutate again.4 Unfortunately, SARS-CoV-2 mutated in such a way that it causes damage to human lungs. 6 Delaware Journal of Public Health – April 2020

PANDEMIC TIMELINE December 2019 - January 20208 By the end of December 2019, China had seen several cases of “unknown pneumonia.” The Chinese health authorities reported these to the World Health Organization (WHO) on December 31 (see Figure 1). Since some of these individuals had visited the Huanan Seafood Wholesale Market, the market was closed on January 1, 2020 as a precaution and for further study. Within the next week, health officials had discovered that these new pneumonia cases were not due to SARS or MERS, but were instead due to a new coronavirus, initially called 2019nCoV (2019 for the year of discovery, n for novel, and CoV for COronaVirus). On January 11, the first death due to 2019-nCoV was recorded; that of a 61-year-old man exposed to the virus at the Seafood Market. He died of respiratory failure due to severe pneumonia. Two days later, Thai officials reported that a Chinese national traveling from Wuhan was infected with this new coronavirus. Three days after that, on January 16, Japan reported that they, too, had a case of coronavirus in country, also from a traveler from China. By January 20, China reported 139 cases of this new disease, and three deaths. By the end of the month, Chinese authorities had locked down transport into and out of the cities of Wuhan, Huanggang, and Ezhou Huanggang; cancelled all large-scale Lunar New Year festivities and all national and international tours; and agreed to host an international team of experts from WHO, the United States Centers for Disease Control and Prevention (CDC), and other agencies to investigate the outbreak. On January 30, the WHO determined that the outbreak constituted a Public Health Emergency of International Concern (PHEIC). In the United States, the State of Washington confirmed the first coronavirus case on US soil on January 21, and by January 30, US officials confirmed the country’s first case of person-toperson transmission.

Figure 1. Coronavirus Timeline

February 2020 – March 2020 In February, the world saw the first of many deaths due to coronavirus outside of China; confirmed cases aboard quarantined cruise ships; containment efforts in major cities across both Asia and Europe; and changing criteria for presumptive coronavirus diagnoses. The WHO officially named the illness COVID-19 (COronaVIrus Disease – 2019). The United States saw the first probable case of “community spread,” the first death due to the disease was recorded in Washington State, and Vice President Mike Pence was placed in charge of the US government response to the outbreak. In March, Italy instituted travel restrictions, and then a total, country-wide lockdown in an effort to slow the spread of the disease. States of Emergency were declared in many states, the Federal Reserve slashed interest rates in the biggest one-time cut since 2008, and restrictions to coronavirus testing were removed. Travel restrictions from Europe were instituted, and the administration declared a National Emergency to free up $50 billion to slow the spread and flatten the curve. By March 18, every state had recorded at least one confirmed coronavirus case. On March 11, 2020, the WHO declared the novel coronavirus to be a pandemic. This is the first pandemic caused by a coronavirus in recorded history.

RESPONSES FROM AROUND THE WORLD International Response “International responses have unfortunately not been wellcoordinated, and seem to either undershoot and then overshoot. In China, cases are decreasing and that is a hopeful sign. In Italy, an early lack of response probably contributed to a rapid rise. In other countries, including the US, testing was delayed as was national guidance on health system preparedness.” – Dr. Omar Khan, Delaware Health Sciences Alliance Chinese officials began by locking down Wuhan, the epicenter of the outbreak, in an effort to contain the spread throughout China. Countries like the US imposed travel restrictions to and from China, and health care providers were counseled to take detailed travel histories from anyone presenting with a fever, cough, or shortness of breath.

National Response Once it was confirmed that the virus had left mainland China, medical history questions were updated to include any travel, and any history of contact with people showing similar symptoms. The CDC created a coronavirus page on their website which is updated daily, and Johns Hopkins University created an interactive map of global Coronavirus cases. US residents were told to wash their hands, engage in non-handshake behavior (fist and elbow bumps), and clean surfaces as needed. Press conferences were held to update the public on changing conditions.

Local Response In the beginning of February, the Division of Public Health (DPH) created a webpage to direct Delawareans to resources and update them on local Covid-19 cases.9 Health care providers and the DPH began monitoring individuals who might have contracted the virus through travel to China in the previous two weeks, and Delaware’s major universities transferred to distance and online learning for the remainder of the spring semester. 8 Delaware Journal of Public Health – April 2020

The DPH opened a Coronavirus Call Center, and detailed plans for at-risk populations, employers, and insurers in the event of community spread. On March 11, the first case of COVID-19 in Delaware was confirmed in an individual with ties to the University of Delaware. In the week that followed, three more cases with ties to UD were confirmed, Governor John Carney declared a State of Emergency and closed all Delaware public schools for two weeks, and public events with more than 50 attendees were canceled or rescheduled. The Delaware community was encouraged to abide by social distancing suggestions, and those individuals who might have contracted the disease were quarantined in their homes. By March 23, restaurants and bars were limited to take out or delivery services, unemployment had been extended, and Delaware had 64 confirmed cases of the virus (43 in New Castle, six in Kent, and 15 in Sussex).9,10 Governor John Carney enacted a Stay-at-Home Order for all Delawareans, effective Tuesday, March 24, 2020 at 8:00 am.11

A NEW NORMAL Since the start of the pandemic, new terms (“social distancing,” “flattening the curve”) and scary terms (“quarantine”) have been tossed around by public health officials. Italy has quarantined its citizens in their homes, limiting the movement of all but those most needed for medical, emergency, and public health responses. Individuals have been asked not to meet in groups larger than 10, events and elective medical procedures have been canceled, and restaurants and bars are no longer allowing people to dine in. Lives have shrunk to working from home, homeschooling our children, and having social dates via the internet.

Social Distancing Social distancing measures are taken to restrict when and where people can gather to go about their daily business, while simultaneously trying to slow the spread of disease. Things like remaining six feet (two arm lengths) away from people in public, limiting the gathering of large groups of people, closing buildings and canceling events can decrease the number of people we come into contact with every day. Individuals are encouraged to get outside and walk, run, and/or bike in any of Delaware’s parks, run errands while keeping their distance from others, and reaching out to their neighbors, family, and friends via telephone and online capabilities. All signs point to this disease being spread among the community by those who are unaware they are infected; by limiting our interactions with each other, we can limit the number of infected individuals in our communities, and limit the strain on our hospitals and health care systems.

Flattening the Curve In infectious disease outbreaks, one case becomes two cases, which become four, then sixteen, thirty-two… If measures like social distancing are not enacted, this exponential growth will continue until millions of individuals are infected.12 Health systems, with finite numbers of staff and beds, would be unable to accommodate all the sick – both due to the outbreak and those with other forms of disease (heart disease, stroke, etc.), and those numbers will continue to rise until all individuals in a community are infected. When social distancing is enacted, we can flatten the curve; that is, keep the number of new cases of a disease at a level that the health care system can accommodate (see Figure 2).

CONCLUSION Social distancing, isolation, and quarantine will likely remain the new normal for some time. Older Americans, and those with chronic diseases will be more likely to suffer more than mild symptoms of COVID-19. Health care services will be stressed and overworked. More information will be forthcoming every day on the disease, its treatment, and its potential outcome. Everyone needs to do their part to slow the spread of COVID-19, flatten the curve, and work for the health of our community.

REFERENCES 3

Figure 2. Flattening the Curve

Quarantine DPH is quarantining those people who may have been exposed to SARS-CoV-2, but might not be showing symptoms of the disease. These people must remain in their homes, and refrain from leaving for work, shopping, worship, or other outside activities. They must have no visitors, and keep 3-6 feet away from anyone living in the home.13 This quarantine lasts for up to two weeks, the presumed time the virus takes to incubate in an individual and for symptoms to appear.

Isolation Individuals who have tested positive for COVID-19 are kept in isolation from those who are not sick. They are being asked to stay in a separate room and use a separate bathroom from healthy family members and housemates; have no visitors; not share dishes, towels, or bedding; not take public transportation if at all possible; and wear a mask when around other people until their symptoms are gone.13 “If you are diagnosed with COVID, then the state health department should be contacting you and giving you very specific instructions around staying isolated at home. You should try to separate yourself from other people as much as possible, including from your own family living with you. Use a separate bathroom if possible, hand hygiene, covering your cough, wiping down surfaces, and just really not going out at all unless you need medical care.” – Marci Drees, MD; Chief Infection Prevention Officer, ChristianaCare

MOVING FORWARD While the full scale of the coronavirus pandemic will likely take months to unveil, some scientists have said that the scale and lethality is similar to the timeline of the Spanish Flu pandemic of 1918.14 This is one of the first pandemics in the era of global travel, social media, and rapid testing and response. “This is a game-changer, but it has lessons for the predictable epidemics as well… We need to practice effective handwashing and appropriate prevention every day of the year, not just when a novel coronavirus comes to town. We will emerge from this as will the rest of the world, and hopefully will apply the lessons we learned for the next time- as there will almost certainly be a next time.” – Dr. Omar Khan, Delaware Health Sciences Alliance All eyes are turning to vaccine manufacturers, and about thirtyfive companies have potential vaccines in the works, four are in the animal testing phase, and one has begun phase I testing on humans.15,16 Several anti-virals are being tested in hopes of finding a cure,16,17 and experts around the world are working to contain the spread of the virus and treat those already infected.18

1. Ma, J. (2020, Mar 13). Coronavirus: China’s first confirmed Covid-19 case traced back to November 17. South China Morning Post. Retrieved from: https://www.scmp.com/news/ china/society/article/3074991/coronavirus-chinas-firstconfirmed-covid-19-case-traced-back 2. Centers for Disease Control and Prevention. (2017). Zoonotic diseases. Retrieved from: https://www.cdc.gov/onehealth/basics/zoonotic-diseases.html 3. Centers for Disease Control and Prevention. (2020, Mar 13). Situation summary: Coronavirus Disease 2019 (COVID-19). Retrieved from: https://www.cdc.gov/coronavirus/2019-ncov/ cases-updates/summary.html 4. Parrish, C. R., Holmes, E. C., Morens, D. M., Park, E. C., Burke, D. S., Calisher, C. H., . . . Daszak, P. (2008, September). Crossspecies virus transmission and the emergence of new epidemic diseases. Microbiol Mol Biol Rev, 72(3), 457–470. https://doi.org/10.1128/MMBR.00004-08 5. Johns Hopkins University. (2020, Mar). Coronavirus COVID-19 Global Cases. Retrieved from https://gisanddata. maps.arcgis.com/apps/opsdashboard/index.html#/ bda7594740fd40299423467b48e9ecf6 6. Chavez, N., Watts, A., & Mack, J. (2020, Mar). Here’s what we know about the 100 people who’ve died in the US from coronavirus. CNN Health. Retrieved from: https://www.cnn. com/2020/03/17/health/coronavirus-united-states-deaths/index. html 7. Dong, Y., Mo, X., Hu, Y., Qi, X., Jiang, F. Jiang, Z., & Tong, S. (2020). Epidemiological characteristics of 2143 pediatric patients with 2019 coronavirus disease in China. Pediatrics. Prepublication release. doi.org/10.1542/peds.2020-0702 8. Health, C. N. N. (2020). Coronavirus outbreak timeline fast facts. Retrieved from: https://www.cnn.com/2020/02/06/health/ wuhan-coronavirus-timeline-fast-facts/index.html 9. Delaware Department of Health and Social Services. (2020). Coronavirus Disease (COVID-19). Retrieved from: https://dhss. delaware.gov/dhss/dph/epi/2019novelcoronavirus.html 10. Delaware Health and Social Services. (2020). Division of Public Health Press Releases. Retrieved from: https:// news.delaware. gov/tag/coronavirus/ 11. Carney, J. (2020, Mar). Governor Carney issues stay at home order for Delawareans. Retrieved from: https://news.delaware. gov/2020/03/22/governor-carney-issues-stay-at-home-order-fordelawareans/ 12. Stevens, H. (2020, Mar). Why outbreaks like coronavirus spread exponentially, and how to “flatten the curve.” The Washington Post. https://www.washingtonpost.com/ graphics/2020/world/corona-simulator/ 9

13. Delaware Division of Public Health. (2020, Mar). Coronavirus (COVID-19) quarantine vs. isolation. Retrieved from: https://dhss.delaware.gov/dhss/dph/epi/images/ QuarantinevsIsolation-8-5-11.pdf

16. Duddu, P. (2020, Mar). Coronavirus treatment: vaccines/drugs in the pipeline for Covid-19. Clinical Trials Arena. Retrieved from: https://www.clinicaltrialsarena.com/analysis/coronavirusmers-cov-drugs/

14. Boyd, C. (2020, Mar). How coronavirus compares to history’s deadliest pandemics: Visual timeline pits COVID-19 against Black Death, smallpox and AIDS - as experts warn current crisis could rival Spanish flu ‘in its lethality and scale’. The Daily Mail. Retrieved from: https://www.dailymail.co.uk/ news/article-8120631/Visual-timeline-coronavirus-compareshistorys-deadly-pandemics.html

17. McCurry, J. (2020, Mar). Japanese flu drug ‘clearly effective’ in treating coronavirus, says China. The Guardian. Retrieved from: https://www.theguardian.com/world/2020/mar/18/japanese-fludrug-clearly-effective-in-treating-coronavirus-says-china

15. Spinney, L. (2020, Mar). When will a coronavirus vaccine be ready? The Guardian. Retrieved from: https://www.theguardian.com/ world/2020/mar/18/when-will-a-coronavirus-vaccine-be-ready

10 Delaware Journal of Public Health – April 2020

18. Zimmer, C. (2020, Mar). Hundreds of scientists scramble to find a coronavirus treatment. The New York Times. Retrieved from: https://www.nytimes.com/2020/03/17/science/coronavirustreatment.html

The time is now: Why we must follow our governor’s order to stay at home Dr. Janice Nevin on slowing the spread of COVID-19 and protecting health care workers The evidence is clear, compelling and unequivocal. Staying at home, physical distancing, avoiding large gatherings, hand washing and following healthcare guidelines if you are sick – these simple measures can make all the difference for Delawareans, for our healthcare system, and most of all for our healthcare workers. Predictive modeling shows that Delaware’s tipping point is March 21 – 26. I am grateful that Governor Carney has expanded his emergency order. We have an opportunity to change the course of the COVID -19 pandemic here in Delaware, but we must act now. It is up to all of us to do what he is asking us to do – and more. Our healthcare workers need to know that as a community we have their backs. Doing everything we can to avoid spreading the virus is the most important thing we can do. It will help to ensure that we have enough test kits for those who need to be tested. It will help to ensure that we have enough personal protective equipment and supplies to keep our caregivers safe, and enough ventilators and ICU beds available for patients who are critically ill. Examples from across the United States paint a clear picture of the need for early, aggressive action to protect our communities. In cities and states that acted quickly to halt travel and social gatherings, increase social distancing and make testing available as rapidly and comprehensively as possible, coronavirus is spreading more slowly, and health care systems are being successful, so far, in meeting the needs of their communities. In cities and states where response has been slow, the number of coronavirus cases is spiking rapidly, and health care systems are bracing for the worst. At ChristianaCare we have been taking this seriously for months. We have been preparing, planning and training. We have made decisions that are hard for us and hard for our patients. We have stopped all elective procedures and non-essential outpatient services. We have a “no visitor” policy with limited compassionate exceptions. And to meet new needs, we are rapidly and dramatically expanding our ability to provide video and telehealth care through our primary care and specialty practices, and through our CareVio digital care coordination platform. We opened two Provider Referral Center testing sites (Newark and Wilmington) for patients with a physician’s order and an appointment. Additionally, we conducted free drive-through testing in mid-March for 536 people who met screening criteria because of symptoms, travel or contact. This initiative went from concept to execution in 14 hours and also served as a demonstration of emergency preparedness to respond swiftly to mass screening needs. We are constantly updating our clinical guidelines as we learn more about this disease. We are following guidelines from the Centers for Disease Control, World Health Organization and our state department. And we are learning from the experience of our colleagues around the country who are at different points in managing this illness. We are also working closely with our health partners across the state, including the Division of Public Health and the Office of the Governor. Our business and education community partners have been extraordinary. They are helping to collect personal protective equipment, refurbish ventilators, sew masks and make hand sanitizer. They are helping us to find hotel rooms for caregivers who cannot or do not want to go home and to provide safe childcare options for essential workers. Our community-based nonprofits are coming together to make sure our most vulnerable citizens get food and care. I am deeply grateful and feel honored to be part of such an amazing community. We are in this together. Our employees are brave and inspiring. They are coming to work to care for our community. But, like you, they have anxiety – anxiety about what this means for their loved ones and for their own personal health. I care deeply about their safety and am committed to doing all that it takes to make sure they have what they need. Most of all, they need you to follow the executive order. Stay at home, wash your hands, avoid large gatherings, and if you are sick call your doctor or consult the Delaware Division of Public Health website to get guidance about care and testing. Thanks to Governor Carney’s emergency order, we have a chance to change what happens in Delaware. We must act – the time is now.

This article by ChristianaCare President and CEO Janice E. Nevin, M.D., MPH, appeared in The News Journal on March 23, 2020. 11

Exams May be Cancelled, but Humanity is Not: A Medical Student Perspective on the COVID-19 Pandemic Elizabeth Avakoff, M.P.H. and Omneya Ayoub, M.S.; Philadelphia College of Osteopathic Medicine

“Stay at home!” Public health pleas to help “flatten the curve” amidst the COVID-19 pandemic have led to a wave of societal disruptions. Social distancing, defined as keeping yourself at least six feet away from others and avoiding gatherings of ten or more people, has become the new norm for Americans over the past three weeks. These (among other) dramatic societal changes and growing pressure on our nation’s hospital systems have had a distinct impact on medical education, particularly when it comes to clinical training. As third year medical students, our professional development has heavily relied on in-person clinical experiences, directly interacting with patients and healthcare providers. However, with the national push for a 14-day quarantine, students across the country were pulled from their clinical settings until further notice.1,2 In a vast departure from our normally structured path to residency, licensing examinations were also temporarily suspended and our professional lives were placed on hold.3 Medical education institutions across the country have faced the challenge of inventing new ways of supporting student learning in these critical years of clinical training. In many medical schools, this has led to the roll-out of new virtual clinical experiences and greater utilization of dynamic, online training modalities. Students at the University of Illinois, for example, are observing procedures through video conferencing and utilizing mock scenarios to prepare for future patient encounters.4 Likewise, on the East Coast at the Philadelphia College of Osteopathic Medicine, students log-in to live virtual journal clubs, lectures and morning reports. These “online clerkships” support students’ continued professional development and progression through educational requirements. In an informal survey of medical students across the country, there was a resounding concern for what the sweeping societal changes would mean for our residency preparations and our clinical training overall. Simultaneous with online learning, medical students have taken ownership over their residency preparedness, utilizing their additional time to work on personal statements, curriculum vitaes, and study for licensing examinations. Students also expressed concern for their mental health in these uncertain times, finding relief in connecting with family and friends and catching up on much needed self-care. Whether revisiting lost culinary skills, reading a new book, or even going for a run, many have found this time at home to be grounding and introspective. As medical students, we are constantly engrossed in our education and learning the details needed for each progressive step in our training. This new time out of the hospital has allowed us to take a step back and in light of our nation’s COVID-19 response, see the system as a whole from a new perspective. At the same time, we have not lost sight of our colleagues and mentors on the frontlines in this pandemic. In fact, students across all healthcare professions have voiced an earnest desire to do our part in the COVID-19 pandemic.5 Through the power of social media, communities across the MidAtlantic have seen an outpouring of volunteerism, donations and camaraderie amongst students across the healthcare spectrum. Through Facebook groups such as the “Philadelphia Organization of Health Professions Students - COVID Response,”6 nearly 2,000 students in nursing, medicine, dental medicine, podiatry, veterinary medicine and physician assistant programs have come together for a united goal of stepping off the sidelines. This group has allowed 12 Delaware Journal of Public Health – April 2020

students to collaborate, allocate resources, spread awareness and collect much needed personal protective equipment from the community. From blood drives, to child and pet care for healthcare workers, to meals for our region’s most vulnerable populations, this group continues to develop innovative ways of supporting our mentors, colleagues and patients from our new positions at home. Through this enthusiasm for public service, our Mid-Atlantic medical and allied health professions students have found a way to continue making a difference, while forging new inter-professional cross-collaborations. As our nation learns some hard and invaluable lessons in the spread and management of infectious diseases, emergency preparedness, and population health, we too have found this period to be transformative. The COVID-19 pandemic has shed new light on our individual roles as future physicians in the greater community at large. Students have expressed a greater appreciation for the physician’s role in population health, citing the importance of elevating public awareness, preventing the spread of infectious diseases and having resources on hand to effectively treat large numbers of critically ill patients. As future physicians, we are witnessing humanity at one of its most vulnerable times, not only for our nation, but across the world. In this transformative period, “stay at home” has thus become more than a blanket directive to self-isolate. To us, it represents a civic responsibility to protect one another from unnecessary exposures and a movement to individually and collectively do our part in this COVID-19 pandemic.

REFERENCES 1. Madhani, A. (2020, March 15). Top US infectious disease expert open to a 14-day ‘national shutdown’ to combat virus spread. Chicago Tribune. Retrieved from https://www.chicagotribune.com/ coronavirus/ct-nw-coronavirus-national-shutdown-infectiousdisease-20200315-abn7gckptbd6tch24nlewgr2je-story.html 2. Ostrov, B. F. (2020, March 17). In Face Of Coronavirus, Many Hospitals Cancel On-Site Training For Nursing And Med Students. Kaiser Health News. Retrieved from https://khn.org/news/in-faceof-coronavirus-many-hospitals-cancel-on-site-training-for-nursingand-med-students/ 3. American Medical Association. (2020, March 19). Resident & medical student COVID-19 resource guide. Retrieved March 26, 2020, from https://www.ama-assn.org/delivering-care/public-health/ resident-medical-student-covid-19-resource-guide 4. Cheung, A. (2020, March 25). Just as the need soars for health care workers to fight coronavirus, Chicago-area medical students are sidelined from seeing patients. Chicago Tribune. Retrieved from https://www.chicagotribune.com/coronavirus/ ct-coronavirus-medical-school-rotations-chicago-20200323dn2h3gzbwrd3hgo6ga3iwpmsmu-story.html 5. Lee, Y. J. (2020, March 24). The coronavirus is preventing medical students from getting hands-on training in hospitals. Frustrated future doctors are looking for new ways to help. Business Insider. Retrieved from https://www.businessinsider.com/medical-studentstaken-off-hospital-rotations-want-to-help-2020-3 6. Philadelphia Organization of Health Professions Students - COVID Response. (2020, March 20). Facebook. Retrieved from https://www. facebook.com/groups/152353182650533/

The DPH Bulletin

From the Delaware Division of Public Health

Coronavirus disease (COVID-19) arrives in Delaware

The global outbreak of coronavirus disease (COVID19), reached Delaware on March 11, the same day the World Health Organization (WHO) named it a pandemic. As of March 29, 232 laboratoryconfirmed cases in the state have been reported to the Division of Public Health (DPH) since March 11. The Delawareans diagnosed with COVID-19, by county, are: New Castle County, 141; Kent County, 25; and Sussex County, 66. Nine Delawareans have recovered from COVID-19 and six have passed away due to COVID-19 complications. Thirty-three individuals are currently hospitalized; nine are critically ill. Of the 232 cases, 114 are male and 118 are female; ages range from 1 to 90. The source of exposure for many of these positive cases is unknown, which indicates community spread of the virus is occurring in the state. “Sick persons should not leave their homes, especially if they have fever, cough, shortness of breath, vomiting, or diarrhea; and they should call their health care provider,” said DPH Director Dr. Karyl Rattay. “Those who are well should practice social distancing (6 feet or more from others), practice good hygiene, and clean and sanitize commonly touched surfaces every day. We all have to behave as if we are carrying the virus.” COVID-19 was first detected in mainland China in December 2019. In its March 29 Situation Report, WHO reported 634,835 confirmed cases worldwide and 29,891 deaths.

March 2020 DPH encourages residents who are well to practice social distancing (keeping at least six feet away from others) and avoiding large gatherings or crowds. Individuals with underlying conditions should be especially careful and contact their primary provider if they have any COVID-19 concerns. Individuals who are sick, particularly with fever, cough, and shortness of breath, should stay home and contact their primary health care provider for guidance. COVID-19 symptoms include fever, cough, and shortness of breath and may appear between two and 14 days after exposure. Reported illnesses range from people with little to no symptoms (similar to the common cold) to people being severely ill and dying. While some ill individuals are hospitalized, many recover by resting, drinking plenty of liquids, and taking pain and fever-reducing medications. The CDC recommends that all individuals, especially those who are age 65 and older and those with chronic underlying health conditions: • Stay home. • Wash your hands often with soap and water. • Avoid touching your eyes, nose, and mouth. • Avoid all cruise travel and non-essential air travel. • Avoid close contact with people, especially those who are sick, by keeping six feet away. • Clean and disinfect frequently touched surfaces. • Have enough household items and groceries on hand so you are prepared to stay at home for a period of time. • Have a plan in the event you get sick and discuss with household members, other relatives, and friends what you might need. For the latest information on Delaware’s response, visit de.gov/coronavirus. Those with general COVID-19 questions can call DPH’s Coronavirus Call Center at 1-866-408-1899, or 711 for individuals who are hearing impaired; or email DPHCall@delaware.gov. Hours of operation are 8:30 a.m. to 6:00 p.m. Monday through Friday, and 10:00 a.m. to 4:00 p.m. Saturday and Sunday.

Representative press release from April 9, 2020

DHSS Press Release Dr. Kara Odom Walker, Secretary Jill Fredel, Director of Communications Cell: 302-357-7498 Email: DPHMedia@Delaware.gov

Date: April 8, 2020 DHSS-4-2020

COVID-19 UPDATE FOR APRIL 8, 2020: DPH ANNOUNCES 188 ADDITIONAL POSITIVE CASES; 30 ADDITIONAL HOSPITALIZATIONS; THREE NEW DEATHS SMYRNA (April 8, 2020) — The Delaware Division of Public Health (DPH) is announcing three additional fatalities related to coronavirus disease 2019 (COVID-19) and is providing an update on the number of positive cases and recovered individuals. In total, 19 Delawareans have passed away due to complications from COVID-19. Nine of the deaths have been related to longterm care facilities, including eight in New Castle County (six at Little Sisters of the Poor) and one in Sussex County. The most recent individuals who died were hospitalized and had underlying health conditions including a: • 88-year-old male long-term care resident from New Castle County • 74-year-old female from Sussex County • 81-year-old male from New Castle County To protect personal health information, DPH will not disclose additional information about the individuals who passed away, nor will DPH confirm specific information about any individual case, even if other persons or entities disclose it independently. The latest Delaware COVID-19 case statistics, cumulatively since March 11, include: • 1,116 total laboratory-confirmed cases • New Castle County cases: 636 • Kent County cases: 201 • Sussex County cases: 279 • Males: 495; Females: 614; Unknown: 7 • Age range: 1 to 97 • Currently hospitalized: 177; Critically ill: 51 (This data represents individuals currently hospitalized in a Delaware hospital regardless of residence, and is not cumulative.) • Delawareans recovered: 159 • 8,323 negative cases* *Data on negative cases are preliminary, based on negative results reported to DPH by state and commercial laboratories performing analysis. DPH epidemiologists are transitioning to a new data reporting system. During the transition period, not all fields (sex) have complete information. Delaware is considering patients fully recovered seven days after the resolution of their symptoms. Three days after symptoms resolve, patients are no longer required to self-isolate at home; however, they must continue to practice strict social distancing for the remaining four days before returning to their normal daily routine. Widespread community transmission is occurring throughout the state, which means COVID-19 is actively circulating in the community. If you are sick with any of the following symptoms, stay home: fever, cough, shortness of breath, sore throat, muscle fatigue, or digestive symptoms such as vomiting, diarrhea, abdominal pain or lack of appetite. If you are sick and need essential supplies, ask someone else to go to the grocery store or the pharmacy to get what you need. 14 Delaware Journal of Public Health – April 2020

If you think you have been exposed to someone with COVID-19, or have symptoms of illness, make sure to distance yourself from others, particularly vulnerable populations. Older adults and people of any age with serious underlying medical conditions including serious heart conditions, chronic lung conditions, including moderate to severe asthma, severe obesity and those who are immunocompromised, including through cancer treatment - might be at higher risk for severe illness from COVID-19. Statewide testing at standing health facility testing sites require a physicianâ&#x20AC;&#x2122;s order or prescription to be tested (*Bayhealth patients will be pre-screened via phone without needing to see a provider first). These are not walk-in testing sites. Those without a primary care provider can call the DPH Call Center Line at 1-866-408-1899. In New Castle County, individuals can call ChristianaCare at 1-302-733-1000 and Sussex County residents who do not have a provider can call the Beebe COVID-19 Screening Line at 302-645-3200. Individuals awaiting test results, should wait to hear back from their medical provider. The DPH Call Center does not have test results. DPH began a new collaboration with the United Way of Delaware to better triage incoming calls related to COVID-19. Anyone with a question about COVID-19, whether related to medical or social service needs, should call Delaware 2-1-1; or 7-1-1 for individuals who are deaf or hard of hearing, or text your ZIP code to 898-211. Hours of operation are 8 a.m. to 9 p.m. Monday through Friday; 9 a.m. to 5 p.m. Saturday and Sunday. In addition, the Division of Public Health asks any Delaware health care, long-term care, residential, or other high-risk facility with questions or concerns to email: DPH_PAC@delaware.gov or call the DPH Call Center at 1-866-408-1899 and press ext. 2. Questions can also be submitted by email at DPHCall@delaware.gov. DPH will continue to update the public as more information becomes available. For the latest on Delawareâ&#x20AC;&#x2122;s response, go to de.gov/coronavirus. ###

America and Delaware Need Investments in Public Health Now More than Ever Timothy E. Gibbs, M.P.H.; Executive Director, Delaware Academy of Medicine/Delaware Public Health Association

Every day, in our Delaware community and in every community across the country, the public health system works in the background to help Americans stay healthy. When we turn on the tap, clean water comes out. When flu season hits, public service announcements tell us where we can get vaccines and when we should stay home from work. Public health departments, organizations and agencies have resources at the ready to help us with everything from responses to extreme weather to tobacco cessation to immunizations. The entire response to the COVID-19 pandemic is within the dual realms of public health and healthcare. In order to continue to protect the health and well-being of the people, public health needs strong investments, but progress on the federal level has stalled over the years. For nearly the last decade, federal funding for public health programs and agencies has fallen. In fiscal year (FY) 2018, discretionary health spending represented less than 2% of all federal spending, and projections indicate that this will continue to shrink over the coming years. In addition, the president’s FY 2021 budget proposal would make major cuts to key public health programs and agencies, including the Centers for Disease Control and Prevention (CDC) and the Health Resources and Services Administration (HRSA). Congress has mostly rejected these proposed cuts, and last year passed a FY 2020 Labor-HHS-Education appropriations bill, the primary spending bill that supports public health programs, which includes critical increases for public health programs and agencies including CDC and HRSA. Federal spending on public health makes a big difference on the state and local level. Funding for federal public health programs and agencies often goes toward solving community problems like preventing childhood lead poisoning, reducing infant mortality, curbing tobacco use, and lowering obesity rates. Budget cuts to federal public health programs can exacerbate reductions to public health programs at the state and local level. The future of our nation’s health depends on a strong and properly equipped public health infrastructure at the community level — in Wilmington, Newark, Dover, Georgetown and Felton – and everywhere in between. Adequately funding our public health system is essential to protecting Delawareans’ health every day, and will save millions of lives: • Delaware receives $31.34 per person in funding from the CDC (8th in the nation), and $35.97 per person from HRSA (13th in the nation). The Prevention and Public Health Fund (PPHF) has awarded over $36 million in grants to Delaware since 2010 for community and clinical prevention efforts, and improvements to public health infrastructure. 16 Delaware Journal of Public Health – April 2020

• In Delaware, 5.7 percent of people do not have health insurance coverage (compared to the national uninsured rate of 8.6 percent). • The number and location of practicing health care providers is an important measure of an individual’s ability to access health care. Delaware only has 44.3 dentists per 100,000 people, ranking the state 47th in the nation. Sussex County has one psychiatrist available for the behavioral health of the entire county. We are very fortunate to have a Congressional delegation in Delaware that is strongly supportive of public health. For the health of all Delawareans, we must continue to fight for public health funding - in Delaware and in the nation. Amid this global crisis, your voice can still be heard. During National Public Health Week (April 6 – 12, 2020), you can: Call your local representative in Dover, and your State Representatives in Washington, D.C. and thank them for a job well done. Let them know what your community needs, and get involved in supporting solutions together. Join the All of Us Research Program run by the National Institute of Health (NIH). The program is inviting one million people across the United States to help build one of the most diverse health databases in history, and eliminate health and medical research disparities. It welcomes participants from all backgrounds, and researchers will use the data to learn how biology, lifestyle, and environment affect health. Their goal is to develop better treatments and ways to prevent different diseases, but they cannot continue to do so without continued funding. We have come together in this time of social isolation by helping our neighbors, checking on our older Delawareans, and following the guidelines set forth nationally and locally to keep us healthy. Once this unprecedented occurrence of COVID-19 has passed, we can work together for so much more. Learn about more ways to get involved at www.nphw.org and www.allofus.nih.gov. Together, we can make a difference.

Wellness and Prevention Digest TODAY'S NEWS - April 7th, 2020

COVID-19 Update

These are extraordinary times. COVID-19 has demonstrated the importance of the public health sector and the need to have sustained focus on prevention and preparedness as priority issues. Trust for America’s Health (TFAH) has been actively engaged in the COVID-19 response efforts – testifying before Congress, talking to the media, highlighting necessary policy changes, and emphasizing the importance of supporting the public health system at the local, state, federal, tribal, and territorial levels (and not only during an emergency). We believe we have played an important role in raising the issues that need attention. • TFAH continues to be featured in COVID-19 news coverage. Recent outlets include: • Associated Press • ProPublica • USA Today • Reminder: TFAH has launched a web portal featuring resources and documents related

to the novel coronavirus outbreak and response. These materials cover what needs to be done to stop the spread of COVID-19 and better equip the nation’s public health system to deal with this and future health emergencies.

• To receive additional updates from TFAH on infectious disease and other topics,

subscribe to our Health Security and Preparedness Update here.

University of Delaware Center for Health Profession Studies David Barlow, Ph.D., Director, University Center for Health Professions Studies; Director, College of Arts & Sciences Medical/Dental Scholars Program; Faculty, University of Delaware

HISTORICAL FOUNDATION Origin The Office of the Provost created a taskforce in the spring of 2011 to examine the status of “premedical education at the University of Delaware” existing at that time. Membership on the Taskforce was highly diverse with representatives from Thomas Jefferson University, Christiana Care Hospital Services, the College of Arts & Sciences, the College of Health Sciences, the Office of Admissions, and premedical/health profession students. Dr. David Barlow from the College of Health Sciences was designated Chair. The taskforce was charged to review and evaluate current premedical studies practices, with the goal of making recommendations for changes perceived essential for enhancing the success of all students in gaining admission into medical schools and other health profession programs. The first major recommendation endorsed unanimously by the taskforce was to create a “Center for Premedical and Health Profession Studies.” The focus of this Center would be to help students across all colleges who wanted to pursue careers in the health professions. The Provost’s taskforce viewed the Center as the best approach for advising pre-health profession students in a comprehensive manner.

Figure 1. Pearson Hall

18 Delaware Journal of Public Health – April 2020

Locations A three-year agreement was created in the summer of 2011 to locate and host the new Center for Premedical and Health Profession Studies (CPHPS) within the facilities of the Career Services Center. Reporting to the Office of the Provost, the Center was formally announced with a University-wide opening ceremony in January of 2013. The Center’s goal was to benefit students in all colleges, and the success of the Center would depend on University-wide support. The cross-college initiative is reflective of a new emerging approach to healthcare which is inter-professional and across disciplines. Initial funding for the Center came in part from a UNIDEL grant received in 2012. The name of the Center was shortened to the Center for Health Profession Studies (CHPS) in 2017. Following an almost two-year temporary location in Hullihen Hall, the Center was formally relocated and re-dedicated at its permanent location in 105e Pearson Hall in October of 2017 (see Figure 1).

Initial Staffing Initial staffing included the assignment of a Center Director (David Barlow) and an Administrative Assistant (Laura Pawlowski). The demand for staffing increased dramatically and, starting in 2014, expanded to include a Program Manager, two

partial workload faculty Health Professions Advisors (HPA), a miscellaneous wage HPA/HPEC Assistant, a Graduate Assistant HPA, and a number of undergraduate assistants/peer mentors. The additional staffing served to address a rapid increase in the demand for advisement services, the growing popularity of numerous co-curricular programs, and the increased sponsored activities that the Center provides students.

MISSION STATEMENT AND GOALS The Center for Health Profession Studies supports and encourages students from all majors who are pursuing careers in the health professions. The Center remains focused on student outcomes – helping students achieve success in careers that they have chosen: medicine, dentistry, optometry, podiatry, physician assistant, advanced practice registered nurse, pharmacy, physical/ occupational therapy and other health profession programs. The Center provides advisement and referral services to a growing community of pre-health profession students in all colleges in their academic and extracurricular preparation to improve success of acceptance into healthcare profession programs. Over 1900 students utilized the resources and services of the Center in 2019 alone. Three main goals of the Center are to: • Help students make informed decisions about their choice of a future healthcare profession. • Promote academic excellence by providing accurate and up-to-date guidelines for completing pre-health profession curricular requirements, for thoroughly understanding all admission requirements, and for using all available resources of the Center. • Support active student engagement within the healthcare community, primarily through clinical work, voluntary service, and translational research.

SERVICES/PROGRAM ACTIVITIES OF THE CENTER In addition to group meetings, special programs, field trips, and sponsored monthly guest lecturers, students may seek individual assistance from the Center. Students can schedule an appointment via email, online, or phone to meet with one of the health professions advisors. Additionally, Center administrative staff members are available for walk-in students to meet briefly, one-on-one, to discuss their academic goals or concerns. No appointments are necessary and students are seen on a first-come, first-served basis. Walk-in hours are provided during the fall and spring semesters. A few phone appointments are set aside each week.

Standardized Test Preparation Resources KAPLAN/NextStep/UWorld/ExamKrackers and other standardized test preparation programs are frequently supported often with financial incentives/discounts to aid pre-health profession students in their preparation for MCAT/ DAT/GRE examinations.

Pre-Health Profession’s Living Learning Community Since 2014 the Center has created and sponsored a highly successful first-year Pre-Health Professions Living Learning Community for freshmen students interested in pre-health professions. Students accepted into the program have the opportunity to live in close proximity with over 65 other freshmen, mentored by two upperclassman peer mentors and one graduate assistant, all who have similar career interests and are taking similar courses. The students have access to extra support from faculty and staff of the Center to pursue career and graduate school interests. In addition, they have access to professionals knowledgeable about standardized tests (e.g., MCAT), graduate school applications, academic, and co-curricular requirements. Programs and events in the residence hall include exciting speakers from the healthcare industry, extracurricular enrichment, health-related volunteer experiences, and social events. Since the initiation of this Living Learning Community, the program has produced a remarkable 100% retention rate over the past five years.

Medical Internships Abroad Programs Students have the opportunity to participate in exciting health profession medical internship opportunities abroad sponsored by the Center during special sessions. Since 2012, over 160 students have performed medical internships traveling to seven different countries including Spain, Portugal, Italy, Greece, Hungary, China, and Turkey in partnership with the University Institute of Global Studies and a program called Atlantis. In all the programs, students shadow doctors, interact with health profession students from other cultures, and gain an understanding of international healthcare systems. In June of 2014, students participated in St. George’s University “Summer Leadership Academy” in the West Indies experiencing introductions to their medical, veterinary, and public health professional programs of study on the island of Granada in the West Indies. All of these study abroad experiences hosted and guided by UD faculty help students distinguish themselves as outstanding applicants for medical school and other health-related professional schools.

Premedical Post-Baccalaureate Certificate Program This unique program, limited to 20 post-baccalaureate students, is designed for those qualified individuals who have previously completed a bachelor’s degree in a non-science related field but who now want to fulfill the requirements for admission to medical, dental, or other health profession schools. Accepted students work closely with the Center to develop a structured individualized program of study that addresses the academic and co-curricular requirements to be considered for admission to medical, dental, or other health profession schools. Since 2015, over 90% of these post baccalaureate students completing this program achieving a certificate of academic excellence have successfully matriculated into medical/physician assistant programs of study. Designed to support “career changers”, this program is affiliated with the Philadelphia College of Osteopathic Medicine which is a part of a cohort agreement with the UD Post Baccalaureate Program. 19

COLLABORATIONS The Center has established affiliations/agreements with area hospitals and healthcare organizations to provide UD students with unique learning experiences. Some of these include the Delaware Institute for Medical Education and Research (DIMER) and the Delaware Health Science Alliance (DHSA). In addition, the Center has agreements with Christiana Care Health System and St. Francis Hospital of Wilmington. These latter affiliations support approximately 35 premedical studies students each year performing over 250 hours each of shadowing medical preceptors in a variety of different healthcare settings. In the past this also included shadowing opportunities for students in the Delaware Division of Forensic Science. Through the Medical Scholars Program, the Center has formal affiliations with the Sidney Kimmel Medical College at Thomas Jefferson University, the Philadelphia College of Osteopathic Medicine, and the Rowan University School of Osteopathic Medicine. The Center sponsors frequent field trips to these institutions as well as to other institutions such as The Pennsylvania State University Hershey College of Medicine, Cooper Medical School of Rowan University, and the Geisinger Commonwealth School of Medicine. In addition, students in the past have visited the Virtual Education Simulation Training Center at Christiana Care Health System.

studies in the arts, humanities, and social sciences. Seniors in the MSP must continue to demonstrate a high level of academic performance and achieve a minimum score on the MCAT prior to medical school matriculation. Since 2008, a total of 482 students have obtained baccalaureate degrees in the Medical Scholars Program resulting in a medical school matriculation rate of 72% in post-graduate year one (PGY1) (see Figure 2). In PGY2 the success rate rises to a remarkable 95% over this same period. DIMER eligible in-state students accounted for slightly more than 62% of these former UD MSP graduates. In the past 12 years a total of 384 medical practica/internships were performed by these same students involving at minimum 48,000 hours of shadowing healthcare professionals regionally and internationally. Note that the major percentage of these shadowing hours were supported by ChristianaCare and other local area medical facilities such as St. Francis Hospital in Wilmington.

Medical Scholars Program (MSP) Established in 1993, the Medical Scholars Program is a unique early admissions premedical 4 + 4 academic program in the Center sponsored by the College of Arts and Sciences at the University of Delaware and by the Sidney Kimmel Medical College of Thomas Jefferson University. As a dual major, eightyear academic program, in 2018/19 the UD MSP expanded to affiliate with the Philadelphia College of Osteopathic Medicine and the Rowan School of Osteopathic Medicine. It is designed for students who are certain that they want to become physicians and who desire a program that blends the scientific and cultural aspects of the medical humanities. The MSP is accomplished by providing highly qualified students with a balanced education in liberal arts, science, and professional studies. The program includes the traditional courses in the life/physical sciences as well as a specialization in areas related to medicine dealing with Bioethics, Administration and Public Policy, Translational Research, or Nutrition and Health. Small group discussions, problem-based instruction, and discipline specific practicum experiences in clinical/ institutional settings, all experienced with strong mentoring, are special aspects of this program. To become a part of this early conditional acceptance programs, students in the second semester of their freshman year attend an orientation meeting to declare an interest in the program. Students are required to attend monthly Medical Scholar Program (MSP) meetings, accumulate volunteer/shadowing hours, obtain letters of recommendation, and achieve academic excellence. During the spring semester of the sophomore year, students from this group complete an application to the program, and as qualified rising juniors, are recommended by the University of Delaware for interviews at one of the prestigious medical school cohorts. Following a successful interview, students are granted provisional acceptance to medical school. Students then declare a second major, Bachelor of Arts in Liberal Studies, completing the core science medical school requirements, combined with 20 Delaware Journal of Public Health – April 2020

Figure 2. Recent UD MSP Graduates now in Medical Schools

The MSP is operated through the Center for Health Profession Studies under the direction of David A. Barlow, PhD, since 2008.

CENTER FUTURE GOALS The Center for Health Profession Studies strives to expand services to students and alumni not only to the University, but also to our neighboring state institutions who are considering careers in the various health professions. Available to students across all majors and colleges, the Center will continue to enable a growing population of students who are interested in the highly competitive health profession careers to make conscious and thoughtful decisions about their future paths. Increased guidance and resources are provided along the “pre-health profession” pathways, from curricular planning, to securing clinical and research opportunities, to preparation for required standardized tests, to participation in health-related internships/ in-service activities, and finally to the successful completion of the application process for medical, dental, veterinary and other health profession graduate schools. For more information about the CENTER, please visit: Center for Health Profession Studies, University of Delaware 105e Pearson Hall 125 Academy Street Newark, Delaware 19716 https://sites.udel.edu/healthpro

SUMMARY LIST OF CENTER SPONSORED PROGRAMS Medical/Dental Scholars Program (College of Arts & Sciences) Premedical Post Baccalaureate Certificate Program (PMPB) Pre-Health Professions Living Learning Community Medical Internships Abroad/Domestically Medical Practica Capstone Courses: ARSC480, ARSC482, HOSP300, SOCI410

REGIONAL MEDICAL/DENTAL SCHOOL FIELD TRIPS MEDICAL SCHOOL AFFILIATIONS Sydney Kimmel Medical College (Thomas Jefferson University) Philadelphia College of Osteopathic Medicine Rowan School of Osteopathic Medicine St. George’s University (Medicine/Veterinary Medicine)

AREA HOSPITAL AFFILIATIONS Christiana Care Health Services St. Francis Hospital (Wilmington)

STANDARDIZED TEST PREPARATION PROGRAMS Writing Personal Essays Mock Interview Training Admissions Applications/Process (AMCAS, AACOMAS, OTCAS, PTCAS, CASPA)

EXAM PREPARATION AFFILIATIONS (MCAT, GRE, DAT, ETC.) Kaplan NextStep UWorld

ExamKrackers Magoosh Baron

HEALTH PROFESSIONS ADVISEMENT SERVICES Medicine Dentistry Optometry Podiatry

Physician Assistant Advanced Nurse Practitioner Pharmacy

Occupational/Physical Therapy Anesthetist Assistant Veterinary Medicine

Chiropractic PrepMed/Medical Devices

POST BACCALAUREATE CERTIFICATE PROGRAM REGISTERED STUDENT ORGANIZATION SPONSORSHIPS Pre-SOMA Pre-Dental Society Phi Delta Epsilon Making Doctors

Minority Association of Pre-Health Students Occupational Therapy Club Annual Spring “Health Professions Fair”

PROFESSIONAL AFFILIATIONS North East Association of Advisors for the Health Care Professions (NEAAHP) National Association of Advisors for the Health Professions (NAAHP) 21

22 Delaware Journal of Public Health â&#x20AC;&#x201C; April 2020

Responding to COVID-19: A Science-Based Approach Brought to you by the American Public Health Association and the National Academy of Medicine, this webinar series will explore the state of the science surrounding the current outbreak of COVID-19 in the United States and globally, with a focus on the emerging evidence on how to best mitigate its impact. Hear from trusted experts in such fields as public health, infectious disease, risk communication, and crisis standards of care. https://covid19conversations.org/

Undergraduate and Graduate Public Health Programs Need Changes to Teach the Public Health Workforce of the Future Jennifer A. Horney, Ph.D., M.P.H.; Professor and Founding Director, Epidemiology Program, University of Delaware Abby Heath; Graduate Research Assistant, Epidemiology Program, University of Delaware

The past two decades have been a time of great change for the public health system, including the workforce. Following the September 11, 2001 attacks on the World Trade Center and the use of the U.S. Postal Service to send Anthrax spores, the public health workforce grew rapidly, sustained largely through public health and emergency preparedness funding.1 By 2005, the focus on emergency preparedness began to wane, and federal funding for state and local health departments from the Centers for Disease Control and Prevention (CDC) was reduced by nearly 40% by 2012.2,3 Data collected by the National Association of County and City Health Officials (NACCHO) between 2008 and 2012 found that many local health departments had experienced budget cuts, loss of staff, and service reductions.4 By 2011, nearly a quarter of local health departments surveyed by NACCHO reported they had reduced or eliminated programs, including emergency preparedness and clinical health services.4 Adding to the rapid change of the public health landscape, during a similar period of time, the number of accredited schools and programs of public health rapidly increased in response to calls from groups like the Institute of Medicine, the CDC and the U.S. Governmental Accountability Office.5,6 These groups had recognized that the state and local public health workforce, in addition to public health emergency preparedness and response, was also essential for disease prevention, health promotion, and partnership building with other sectors to advance health and was facing a crisis that included severe worker shortages, especially among certain concentrations like epidemiology and environmental health,7,8 a lack of access to competency based training,9,10 and no pipeline from academic public health programs to employment in traditional public health agencies.11–13 In 1995, there were 27 Council on Education for Public Health (CEPH) accredited schools of public health; in 2005, there were 37.14 The number of accredited programs increased from 21 to 63 during the same time period. Currently, there are 65 schools, 126 programs, and 16 stand-alone baccalaureate programs.15 Even with this growth, according to the Association of State and Territorial Health Officers, by 2017, only 14% of the public health workforce had formal education in public health.16,17 For epidemiology specifically, functions such as disease surveillance, study design, data collection and analysis, and implementing disease control were still being carried out by public health nurses or environmental health specialists.18 24 Delaware Journal of Public Health – April 2020

One-third of epidemiology staff in small and medium jurisdictions (i.e., those serving populations less than 100,000) lacked formal academic training in epidemiology, limiting the overall epidemiological capacity of the public health system.19 Therefore, it seems the “if you build it, they will come” approach to graduate-level public health education as the pipeline for building the state and local public health workforce in the U.S. has not worked. Students completing a Master of Public Health degree are considered unprepared by health departments in areas including data management and analysis, leadership, and ability to effectively respond to requests for proposals for funding.20 There are several approaches to consider to potentially address these continued shortfalls beyond growing the number of graduate public health programs. One approach is to develop graduate programs in public health with more explicit linkages to the work of applied public health partners. For example, globally, the CDC has attempted to address the challenge of retaining applied public health staff in low-resource counties through the Field Epidemiology Training Program, which is an applied program jointly developed and delivered by local ministries of health and universities.21 In one evaluation of the programs, 85% of graduates remain in their county of training; 56% report working in Ministries of Health or non-governmental public health agencies.22 Domestically, graduate programs that explicitly integrate service-learning – a type of experiential learning that has been shown to enhance course relevance and change student attitudes towards community initiatives – with local public health partners can provide students with firsthand experience in the areas necessary to join the public health workforce upon graduation and provide needed surge capacity for public health agencies.23–26 Another approach would be to expand and change the focus of undergraduate public health programs.27 Undergraduate public health education has primarily been seen as a way to pique student’s interest in graduate public health education or as pre-professional education for students interested in medical or dental school.27,28 However, more recently, based on the findings of the Consensus Conference on Undergraduate Public Health Education, there have been calls to change public health undergraduate education to focus more on the professional skills needed for entry-level

public health careers, so that a graduate degree is not immediately required to successfully enter the workforce.29 If undergraduate programs are successful in meeting this call, graduate programs will need to make changes to further differentiate their curriculum – particularly their core curriculum in biostatistics, environmental health, epidemiology, health behavior, and health policy – from undergraduate introductory courses. In our opinion, a renewed emphasis on service-learning programs in the Master of Public Health curriculum could be one way to effectively differentiate these programs from undergraduate education in public health and demonstrate value to both students and the public health agencies that will employ them. Service-learning builds a clear bridge between in-class learning and the application of learning in the workplace, making the future public health workforce more likely to be life-long learners.30 It encourages reciprocity between universities, local agencies, and the individuals and communities they serve, fostering civic responsibility and leadership among graduate students who go onto careers in applied public health.31 While the value of service-learning and its explicit linkages with choosing an applied, public service career has been made in medicine32 and nursing,33 as well as in fields like journalism,34 urban planning,35 and geography,36 a better understanding of how service-learning in graduate public health education is linked to entering the public health workforce is needed. This will require Master of Public Health Programs to focus more attention on developing and maintaining strong community connections, sustaining programs and partnerships, and building an evidence base beyond traditional practice or short-term field placements. The growth of undergraduate public health programs that provide students the classroom skills and content needed to enter the workforce may provide graduate programs in public health with the incentive needed to do just this.

REFERENCES 1. Horney, J. A., Carbone, E. G., Lynch, M., Wang, Z. J., Jones, T., & Rose, D. A. (2017, September). How health department contextual factors affect Public Health Preparedness (PHP) and perceptions of the 15 PHP capabilities. American Journal of Public Health, 107(S2), S153–S160. https://doi.org/10.2105/AJPH.2017.303955 2. Gebbie, K. M., & Turnock, B. J. (2006, July-August). The public health workforce, 2006: New challenges. Health Affairs (Project Hope), 25(4), 923–933. https://doi.org/10.1377/hlthaff.25.4.923 3. Trust for America’s Health. Ready or not? Protecting the public’s health from diseases, disasters, and bioterrorism, 2012. Retrieved from: https://nasemso.org/wp-content/uploads/2012TrustFormericasHealth_ReadyorNot.pdf

4. National Association of County and City Health Officials. Local health department job losses and program cuts: Findings from the 2013 Profile Study. Retrieved from: https://www.naccho.org/uploads/downloadable-resources/Survey-Findings-Brief-8-13-13-3.pdf 5. Gebbie, K. M., Rosenstock, L., & Hernandez, L. M. (2003). Who will keep the public healthy?: educating public health professionals for the 21st century. National Research Council: Washington, D.C. 6. General Accounting Office. (n.d.). Bioterrorism: preparedness varies across state and local jurisdictions. Washington, DC: General Accounting Office; 2003. Publication GAO-03-373. Available at: https://www.gao.gov/products/GAO-03-373 7. Centers for Disease Control and Prevention (CDC). (2003, October 31). Assessment of the epidemiologic capacity in state and territorial health departments—United States, 2001. MMWR. Morbidity and Mortality Weekly Report, 52(43), 1049–1051. https://www.ncbi.nlm.nih. gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_ uids=14586299&dopt=Abstract 8. Boulton, M. L., Beck, A. J., Coronado, F., Merrill, J. A., Friedman, C. P., Stamas, G. D., . . . Leep, C. J. (2014, November). Public health workforce taxonomy. American Journal of Preventive Medicine, 47(5, Suppl 3), S314–S323. https://doi.org/10.1016/j.amepre.2014.07.015 9. Potter, M. A., Pistella, C. L., Fertman, C. I., & Dato, V. M. (2000, August). Needs assessment and a model agenda for training the public health workforce. American Journal of Public Health, 90(8), 1294–1296. https://doi.org/10.2105/AJPH.90.8.1294 10. Harrison, L. M., Davis, M. V., MacDonald, P. D., Alexander, L. K., Cline, J. S., Alexander, J. G., ... & Stevens, R. H. (2005). Development and implementation of a public health workforce training needs assessment survey in North Carolina. Public health reports, 120(1_suppl), 28-34. 11. Perlino, C. M. (2006). The public health workforce shortage: left unchecked, who will be protected? Washington: American Public Health Association. 12. Crawford, C. A., Summerfelt, W. T., Roy, K., Chen, Z. A., Meltzer, D. O., & Thacker, S. B. (2009, November). Perspectives on public health workforce research. J Public Health Manag Pract, 15(6, Suppl), S5–S15. https://doi.org/10.1097/PHH.0b013e3181bdff7d 13. Caron, R. M., Hiller, M. D., & Wyman, W. J. (2013, April). Engaging local public health system partnerships to educate the future public health workforce. Journal of Community Health, 38(2), 268–276. https://doi.org/10.1007/s10900-012-9610-8 14. Ramiah, K., Silver, G. B., & Keita Sow, M. S. (2006). 2005 Annual data report. Washington: Association of Schools of Public Health. 15. Council on Education for Public Health. (n.d.) List of accredited schools and programs. Retrieved from: https://ceph.org/about/org-info/who-we-accredit/accredited/#programs 25

16. Sellers, K., Leider, J. P., Harper, E., Castrucci, B. C., Bharthapudi, K., Liss-Levinson, R., . . . Hunter, E. L. (2015, NovemberDecember). The public health workforce interests and needs survey: The first national survey of state health agency employees. J Public Health Manag Pract, 21(Suppl 6), S13–S27. https://doi.org/10.1097/PHH.0000000000000331 17. Association of State and Territorial Health Officials. (2017). Three things to know about the governmental public health workforce: PH WINS 2017 results. Retrieved from: https://astho.org/StatePublicHealth/Three-Things-to-KnowAbout-PH-WINS-2017-Results/01-29-19/ 18. O’Keefe, K. A., Shafir, S. C., & Shoaf, K. I. (2013, December 2). Local health department epidemiologic capacity: A stratified cross-sectional assessment describing the quantity, education, training, and perceived competencies of epidemiologic staff. Frontiers in Public Health, 1, 64. https://doi.org/10.3389/fpubh.2013.00064 19. Moehrle, C. (2008). Who conducts epidemiology activities in local public health departments? Public Health Rep, 123(Suppl 1), 6–7. https://doi.org/10.1177/00333549081230S103 20. Hemans-Henry, C., Blake, J., Parton, H., Koppaka, R., & Greene, C. M. (2016, March-April). Preparing master of public health graduates to work in local health departments. J Public Health Manag Pract, 22(2), 194–199. https://doi.org/10.1097/PHH.0000000000000232 21. López, A., & Cáceres, V. M. (2008, December 16). Central America Field Epidemiology Training Program (CA FETP): A pathway to sustainable public health capacity development. Human Resources for Health, 6(1), 27. https://doi.org/10.1186/1478-4491-6-27 22. Mukanga, D., Namusisi, O., Gitta, S. N., Pariyo, G., Tshimanga, M., Weaver, A., & Trostle, M. (2010, August 9). Field epidemiology training programmes in Africa-Where are the graduates? Human Resources for Health, 8(1), 18. https://doi.org/10.1186/1478-4491-8-18 23. Ward, K., & Wolf-Wendell, L. (2000). Communitycentered service learning: Moving from doing for to doing with. The American Behavioral Scientist, 43(5), 767–780. Retrieved from https://journals.sagepub.com/doi/ abs/10.1177/00027640021955586 https://doi.org/10.1177/00027640021955586 24. Cashman, S. B., & Seifer, S. D. (2008, September). Servicelearning: An integral part of undergraduate public health. American Journal of Preventive Medicine, 35(3), 273–278. Retrieved from https://www.ajpmonline.org/article/S07493797(08)00515-1/fulltext https://doi.org/10.1016/j.amepre.2008.06.012

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25. Horney, J. A., Davis, M. K., Ricchetti-Masterson, K. L., & MacDonald, P. D. (2014, February). Fueling the public health workforce pipeline through student surge capacity response teams. Journal of Community Health, 39(1), 35–39. https://doi.org/10.1007/s10900-013-9750-5 26. Horney, J. A., Bamrara, S., Macik, M. L., & Shehane, M. (2016, January-April). EpiAssist: Service-learning in public health education. Educ Health (Abingdon), 29(1), 30–34. https://doi.org/10.4103/1357-6283.178925 27. Coronado, F., Koo, D., & Gebbie, K. (2014, November). The public health workforce: Moving forward in the 21st century. American Journal of Preventive Medicine, 47(5, Suppl 3), S275–S277. https://doi.org/10.1016/j.amepre.2014.07.045 28. Lee, J. M. (2008). Articulation of undergraduate and graduate education in public health. Public Health Rep, 123(Suppl 2), 12–17. https://doi.org/10.1177/00333549081230S203 29. Riegelman, R. K. (2008, September). Undergraduate public health education: Past, present, and future. American Journal of Preventive Medicine, 35(3), 258–263. https://doi.org/10.1016/j.amepre.2008.06.008 30. Preece, J. (2017). Community engagement through service learning. In University Community Engagement and Lifelong Learning (pp. 75-96). Palgrave Macmillan, Cham. 31. Huda, M., Teh, K. S. M., Muhamad, N. H. N., & Nasir, B. M. (2018). Transmitting leadership based civic responsibility: Insights from service learning. International Journal of Ethics and Systems. https://doi.org/10.1108/IJOES-05-2017-0079 32. Gimpel, N., Kindratt, T., Dawson, A., & Pagels, P. (2018, April). Community action research track: Community-based participatory research and service-learning experiences for medical students. Perspectives on Medical Education, 7(2), 139–143. https://doi.org/10.1007/s40037-017-0397-2 33. Yancey, N. R. (2016, April). Community-centered service learning: A transformative lens for teaching-learning in nursing. Nursing Science Quarterly, 29(2), 116–119. https://doi.org/10.1177/0894318416630102 34. Yousuf, M., & Craig, D. (2018). Service learning plus social learning: Preparing future journalists through a collaborative project. Southwestern Mass Communication Journal, 33(2), 1–13. 35. Balassiano, K. (2012). Extension projects in community planning classrooms. Journal of Extension, 50(4). 36. Cahuas, M. C., & Levkoe, C. Z. (2017). Towards a critical service learning in geography education: Exploring challenges and possibilities through testimony. Journal of Geography in Higher Education, 41(2), 246–263. https://doi.org/10.1080/03098265.2017.1293626

HIGHLIGHTS FROM

The

NATION’S HEALTH A P U B L I C AT I O N O F T H E A M E R I C A N P U B L I C H E A LT H A S S O C I AT I O N

April 2020 Highlights from the Nation’s Health Online-only news from The Nation’s Health newspaper NATION US life expectancy still lags behind, despite small increase: Overall expectancy 78.7 years in 2018 Trump budget proposal a disinvestment in US health: Cuts to CDC, HRSA Controlling COVID-19 will require flexibility, funding, says APHA’s Georges Benjamin: Congress must act to protect US health workers, general public Research: ACA drove coverage progress, but gains are eroding New surgeon general report shares most effective ways to quit tobacco Nation In Brief SPECIAL REPORT Programs foster community resilience, health equity: Kresge, RWJF supporting climate work Personal storytelling key to climate communication: Health workers effective messengers ECO Bookworms club helps adults talk to kids about climate change US tribes working to adapt in face of climate change threats: Livelihoods, economies at growing risk BRACE helping health agencies prepare for climate change effects: CDC framework supports resilience Climate change threatens mental health of vulnerable communities Water quality, availability made worse by climate change in US: Access to water linked to health equity Minority communities harmed worst and first: Q&A with climate justice expert Adrienne Hollis — Health inequities, social determinants exacerbated by climate change Sharing knowledge at nexus of climate change, social justice: Special section explores pressing issues Public health needs to play crucial role in energy justice GLOBE WHO process for declaring health emergencies scrutinized: COVID-19 response shows limitations

The Workforce Development Program at Delaware Technical Community College Mark T. Brainard, J.D.; Delaware Technical Community College

Not everyone has the financial resources to pursue a four-year degree before entering the workforce, but that doesn’t mean they can’t gain the skills they need for a high-quality career in the health-care field.

According to the results of a recent higher education study, more than half of parents surveyed believe college costs do not justify the value of a college education, and less than half agree that U.S. colleges are preparing students well for the workplace. This may be part of the reason community colleges are becoming a more popular choice for students who want to prepare themselves for a career at an affordable price. At Delaware Technical Community College, students can enroll in a degree program, or they can begin with a workforce certification program that will more quickly lead to a job in their field of interest. The College’s Workforce Development and Community Education Division is designed to offer students a fast track to the skills they need to start working in fields like health care, information technology and advanced manufacturing. With these credentials, they can start working, while at the same time pursuing additional credentials to help them advance to the next step on their career path. For example, a student could start by earning a certified nursing assistant (CNA) certificate, learning how to perform basic nursing skills under the supervision of a licensed nurse in a health-care facility. While working as a CNA, that student could then pursue credentials to become a phlebotomist or patient care technician. By “stacking” credentials in this way, students are able to chart a career path, rather than just finding a job. Students get hands-on training with equipment and high-tech simulation mannequins in a classroom lab so they can participate in simulated experiences that mimic those they would face in an actual patient-care setting. In addition, Delaware Tech is fortunate to have excellent partnerships with the state’s major health care systems and long-term care facilities, which affords students the opportunity to get hands-on experience in actual patient-care settings to help prepare them for the workforce. Many of their instructors have worked in the healthcare field, so they are able to bring their own experiences to the classroom. 28 Delaware Journal of Public Health – April 2020

Another advantage of the College’s workforce development program is that students are able to complete these programs in a matter of months, as opposed to years, which makes a significant difference for a person who doesn’t have the time, resources or desire to enroll in a degree program. And these programs aren’t just helping our students. Their skills are in high demand by local employers. The highest number of job postings listed in the last year in Delaware were for certified nursing assistants, home health aides and phlebotomists. And rates of new employment growth, while slowing over the next five years, will still be robust for the health care industry, with home health aides continuing to generate the most new jobs. Statewide, we expect to see about 460 new jobs for home health aides, and about 275 new openings for both medical assistants and for nursing assistants. Once our students enter the workforce, they often decide that after some experience on the job, they would like to pursue a degree program to help advance their careers. Those students can then return to Delaware Tech to pursue an associate or bachelor’s degree in nursing or another healthcare program, bringing with them the experience they gained in their workforce development studies, as well as on the job. In addition, those who step away from the workforce for a while could take advantage of an RN Refresher course, which gets students up-to-date on nursing practices today. They can learn about pharmacology, care planning and current trends in health care. Soon, students will have the advantage of a brand-new lab for training at the Health Care Center of Excellence on the Terry Campus in Dover. Thanks to support from the governor’s Delaware Higher Education Economic Development Fund, we will be able to renovate an existing 8,700-square-foot building on our campus to train more than 300 certified allied health technicians for in-demand jobs over the next three years. The new Health Care Center of Excellence will train students in our workforce development programs in state-of-the-art learning spaces to ensure they are well prepared for jobs with our local employers. These skills are increasingly in demand in Delaware, where the state’s 65+ population is expected to increase by roughly

60 percent (from 159,000 in 2015 to an estimated 263,532 by 2050). As Delaware’s population ages, more people will be retiring and leaving the workplace, while at the same time, increasing the demand for health care services. Our new center of excellence will help create a pipeline of skilled workers to both replace an aging workforce and to train new/existing employees. Delawareans might be surprised at the number of health care professionals in our local hospitals, clinics, doctor’s offices, and long-term care facilities who were trained at Delaware Tech. In

2002, when the state was on the brink of a statewide nursing shortage, policy makers invested health funds to expand Delaware Tech’s nursing program. As a result of that investment, there are now approximately 1,000 students in the nursing program pipeline, resulting in over 400 graduates each year statewide. We also train most of the state’s paramedics, surgical technicians, and dental hygienists, to name a few, so if you are accessing health care services in Delaware, it’s likely that you are receiving help from a Delaware Tech graduate.

nursing assistant, phlebotomist and patient care assistant. This two-year program began this academic year in three Delaware high schools, and is funded in part by Bloomberg Philanthropies, has about 45 students enrolled from Caesar Rodney, McKean and Woodbridge high schools. Students receive over 600 hours of education and training, including clinical work with local health care partners. At the completion of the program, students will have earned 12 Delaware Tech credits toward an associate degree program at the College. We are proud to be putting our students to work in Delaware’s hospitals, doctor’s offices, home health care and other patient-care facilities. Responding to the demands of our state workforce is our mission as the state’s community college system, and we couldn’t do it without our valued community partners in the health-care industry. For more information on Delaware Tech’s workforce development opportunities in health care, visit https://www.dtcc.edu/continuing-education/workforce-training

Thanks to our patient care Pathways program, high school juniors and seniors can start earning college credits and certifications for

A Message of Gratitude COVID-19 has, and continues, to challenge us all. The impacts are precedent setting, and we want to thank and stand in solidarity with our colleagues who are first responders, healthcare providers, healthcare institutions, long-term care facilities, and public health professionals. From the highest levels of State leadership, to those providing direct care and service, the Delaware response is evidence-based and evolving based on the experience, expertise and planning of front-line health care institutions and professionals, our state partners, new data, and directives from the CDC and other components of the Federal Government. Please join us in taking a moment to thank those who are working tirelessly on behalf of the well-being of all Delawareans.

@delamed1

Delamed.org

@delawarehealth1 deha.org

@dhsa1 dhsa.org

@MedicalSocietyofDelaware medsocdel.org

#thanksdelawarehealthcare 29

Academy/DPHA Leadership for National Public Health Week during the COVID-19 Pandemic The American Public Health Association’s National Public Health Week was April 6th to the 12th. As Delaware’s affiliate to the American Public Health Association we produced and shared with APHA our own NPHW COVID-19 talking points. The Academy/DPHA is pleased to report that these were adopted by APHA and became a key part of their national strategy. This was the 25th anniversary of NPHW, and it occurred during a time when public health has been in the spot for a number of weeks as a result of the COVID-19 pandemic. MONDAY: MENTAL HEALTH — advocate for and promote emotional well-being COVID-19 is causing heightened levels of stress. In particular, isolation and quarantine can be highly stressful. As can separation from loved ones, especially those detained off-shore or in other countries. And many in the public health and health care sectors, as well as those working in affected industries, are shouldering a significant mental health burden. Reach out and check on your loved ones and community members. And read and share such resources as the World Health Organization’s Mental Health Considerations During COVID-19 Outbreak and the Centers for Disease Control and Prevention’s tips on managing anxiety and stress. COVID-19 ALERT: Increased risk of drug-related overdoses. Due to State of Emergency, please go to nearest Bridge Clinic to obtain Naloxone or if in treatment, ask your behavioral health provider. If you are unable to leave your home, please contact mobile crisis at 1-800-652-2929. link TUESDAY: MATERNAL AND CHILD HEALTH — ensure the health of mothers and babies throughout the lifespan According to the Centers for Disease Control and Prevention, “We do not currently know if pregnant people have a greater chance of getting sick from COVID-19 than the general public nor whether they are more likely to have a serious illness as a result. Based on available information, pregnant people seem to have the same risk as adults who are not pregnant.” The CDC goes on to say:  Breast milk provides protection against many illnesses and is the best source of nutrition for most infants.  You, along with your family and healthcare providers, should decide whether and how to start or continue breastfeeding  In limited studies, COVID-19 has not been detected in breast milk; however we do not know for sure whether mothers with COVID-19 can spread the virus via breast milk.  If you are sick and choose to direct breastfeed – Wear a facemask and wash your hands before each feeding. (from https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/pregnancy-breastfeeding.html ) Still, pregnant women and children are considered “at-risk populations” and need some special support during the pandemic. Check out the Kaiser Family Foundation’s issue brief Novel Coronavirus “COVID-19”: Special Considerations for Pregnant Women. HealthyChildren.org has a COVID-19 page for children and families. The American Academy of Pediatrics offers links to clinical guidance and other resources, while the American College of Obstetricians and Gynecologists has posted a practice advisory. Even during these days of social distancing, there are still things we can do and resources we can use to keep our minds and spirits positive. Explore previews of these resources below. To stay informed about coronavirus in Delaware, visit de.gov/coronavirus, call 1-866-408-1899, or email DPHCall@delaware.gov. Individuals with hearing impairment can call 7-1-1. If you have concerns about symptoms, including fever and coughing or shortness of breath, contact your health care provider. link. The Delaware Department of Education (DDOE) is updating this site to provide timely education information, resources and support to Delaware educators and families. link WEDNESDAY: VIOLENCE PREVENTION — reduce personal and community violence to improve health Increased stress can lead to increased aggression, feeding a cycle of violence especially in communities already under strain. And, as APHA member Elena Ong writes in this Public Health Newswire post, “Since the first case of the new coronavirus was reported in Wuhan, China, in December, there’s been a surge in reports of microaggressions, discrimination and violent attacks against people who look Chinese or Asian.” Much of the stress people are feeling as a result of the COVID-19 pandemic is linked to fear fed by misinformation. Help counteract the “infodemic” of bad and troubling information by sharing WHO’s mythbusters and resources on APHA’s COVID19 page and Get Ready site. And as Ong reminds us, “let’s fight fear-mongering with principled and visionary leadership.” Information on COVID-19 for survivors, communities, and dv/sa programs. link. THURSDAY: ENVIRONMENTAL HEALTH — help protect and maintain a healthy planet 30 Delaware Journal of Public Health – April 2020

In perhaps one of the few silver linings of the COVID-19 pandemic, air pollution, specifically CO2 levels, diminished in Italy and China due to dramatic lifestyle changes. Yet as always, changes in people’s lifestyle patterns can have unexpected consequences on our environment. For now, remain vigilant in recycling plastics. If you are sick, dispose of soiled items by double-bagging in secured containers with lids. Continue to advocate for increased funding to improve our water infrastructure and adequate funding to support public health workers in monitoring, preparing for and responding to the health effects of climate change. THE NATIONAL ENVIRONMENTAL HEALTH ASSOCIATION (NEHA) is closely monitoring developments of COVID-19 outbreaks in the U.S. and is working to provide our members and other stakeholders with access to critical information and updates. Across the U.S. and around the globe, environmental health professionals are on the frontlines of preventive public health services delivery, and NEHA is committed to supporting the environmental health workforce to effectively and safely do their jobs. link FRIDAY: EDUCATION — advocate for quality education and schools As with any illness, reliance on science-based information and response is key. Distance learning is now more necessary than ever, heightening the need for access to technology and high-speed internet. As schools are often the key source of daily nutrition for students in low-income families, school systems are now called on to find ways to distribute meals while maintaining social distancing. Reach out to your local school system to see if volunteers are needed, whether for meal distribution, online learning support or other tasks. If you’ve found yourself suddenly at home with your school-aged children, CDC has advice on how to talk to them about COVID-19, as does the National Association of School Psychologists. Health officials are currently taking steps to prevent the introduction and spread of COVID-19 (“Coronavirus”) into communities across the United States. Coronavirus.gov offers the most up to date information about this rapidly evolving situation. Through collaboration and coordination with State and local health departments, State and local educational agencies, other education officials, and elected officials, schools can disseminate critical information about the disease and its potential transmission to students, families, staff, and community. link SATURDAY: HEALTHY HOMES — ensure access to affordable and safe housing During the COVID-19 quarantine, people are spending even more time in their homes than usual. For those living in unsafe environments, problems like mold and secondhand smoke exposure can worsen existing health conditions. Share CDC’s workplace, home and school guidance. And while designed to help people prepare their homes for an outbreak, CDC’s Protect Your Home page is still useful now, in the midst of the pandemic. The National Center for Healthy Housing’s Fact Sheets, Checklists and Guides page offers links on ways to keep your home safe, the costs of home upkeep and seasonal maintenance checklists. The general strategies CDC recommends to prevent the spread of COVID-19 in LTCF are the same strategies these facilities use every day to detect and prevent the spread of other respiratory viruses like influenza. link SUNDAY: ECONOMICS — advocate for economic empowerment as the key to a healthy life One of the most dramatic reactions to COVID-19 has been that of the stock markets and the underlying industries they represent. It already appears clear that many industries and their employees will suffer a significant financial hardship. On an individual level, the burden of being out of work and (potentially) hospitalized for an extended period of time can have disastrous impacts on financial health. Advocate for paid sick leave and a living wage. Urge your members of Congress to prioritize public health infrastructure and paid sick, family and medical leave in any future legislation to address the COVID-19 pandemic. DE Div. of Unemployment Insurance hereby waives work search requirements, registration, attendance at related reemployment appointments and workshops during the State of Emergency for claims filed due to COVID-19. DE Dept. of Labor has taken steps to reduce the spread of coronavirus (COVID-19), by suspending public access to their offices until further notice. To best assist you, contact them from 8am-4:30pm through a live chat option at DE VOCAL or visit DE Dept of Labor. Click COVID-19 Jobs for Current Job Openings. link In response to the Coronavirus (COVID-19) pandemic, small business owners in all U.S. states, Washington D.C., and territories are eligible to apply for an Economic Injury Disaster Loan advance of up to $10,000. The SBA’s Economic Injury Disaster Loan program provides small businesses with working capital loans of up to $2 million that can provide vital economic support to small businesses to help overcome the temporary loss of revenue they are experiencing. link 31

www.fic.nih.gov www.fic.nih.gov www.fic.nih.gov

GLOBAL GLOBAL HEALTH GLOBAL HEALTH M AT TERS HEALTH M AT TERS M AT TERS

Inside this issue Inside this issue Fogarty Fellow Inside this issue JAN/FEB 2020 JAN/FEB 2020 JAN/FEB 2020

Fogartynovel Fellow studies malaria Fogarty Fellow studies novel malaria detection device . . . p. 4 studies novel malaria detection device . . . p. 4

FOGARTY INTERNATIONAL CENTER • NATIONAL INSTITUTES OF HEALTH • DEPARTMENT OF HEALTH AND HUMAN SERVICES

detection device . . . p. 35 4

FOGARTY INTERNATIONAL CENTER • NATIONAL INSTITUTES OF HEALTH • DEPARTMENT OF HEALTH AND HUMAN SERVICES

NIH mobilizes research to address new coronavirus NIH mobilizes research to address new coronavirus NIH mobilizes research to address new coronavirus

FOGARTY INTERNATIONAL CENTER • NATIONAL INSTITUTES OF HEALTH • DEPARTMENT OF HEALTH AND HUMAN SERVICES

U.S. government scientists are assisting in the global response to the coronavirus outbreak, and are studying potential vaccines and treatments. U.S. government scientists are assisting in the global response to the coronavirus outbreak, are studying potential existing vaccines and treatments. NIAID isand also investigating therapeutics that might U.S. government scientists are assisting in the global response to the coronavirus help save immediately. For instance, the experimental outbreak, andlives are studying potential vaccines and treatments.

NIAID is also investigating existing therapeutics that might antiviral remdesivir successfully prevented another type of help save livesinvestigating immediately.existing For instance, the experimental NIAID is also therapeutics that might coronavirus disease in rhesus macaques being studied by antiviral remdesivir successfully prevented another type of help save lives immediately. For instance, the experimental a scientific team at NIAID’s Rocky Mountain Laboratories. coronavirus disease successfully in rhesus macaques being studied by antiviral remdesivir prevented type Several clinical studies of the drug are now another underway in of a scientific team at NIAID’s Rocky Mountain Laboratories. coronavirus disease in rhesus macaques studied . being continued oninby p. 2 Several clinical of the drugMountain are. .now underway a scientific teamstudies at NIAID’s Rocky Laboratories.

. continued oninp. 2 . . ..now continued on next page next page Several clinical studies of the drug are underway

NIH, Fogarty receive funding hikes for Fiscal Year 2020 NIH, Fogarty receive funding hikes for Fiscal Year 2020 NIH, Fogarty receive funding hikes for Fiscal Year 2020 . . . continued on p. 2

The NIH budget was approved by Congress and signed into law by President Donald Trump in late December 2019, The NIH budget was approved by Congress and signed into providing funding for Fiscal Year 2020, which began Oct. 1. law President Donald Trump late December 2019,into The by NIH budget was approved byinCongress and signed providing funding for Fiscal Year 2020, which began Oct. 1. law President Donald Trump in late 2019, NIH by received a $2.6 billion rise over theDecember previous year, with providing fundingoffor Fiscalbillion, Year 2020, which began Oct. 1. an appropriation $41.68 an increase of 6.65%. NIH received a $2.6 billion rise over the previous year, with Fogarty’s allocation was boosted by 3.4%, bringing its total an appropriation of $41.68 billion, increase of year, 6.65%. NIH received a $2.6 billion rise overan the previous with to $80.76 million. Fogarty’s allocation was boosted by 3.4%, bringing its total an appropriation of $41.68 billion, an increase of 6.65%. to $80.76 allocation million. was boosted by 3.4%, bringing its total Fogarty’s to $80.76 million.

FOCUS FOCUS FOCUS 32 Delaware Journal of Public Health – April 2020

The 2020 NIH budget includes $2.8 billion for Alzheimer’s disease studies, $3.1 billion for HIV/AIDS research, $500 The 2020 NIH budget includes $2.8 billion for Alzheimer’s million for the BRAIN initiative and $195 million for Cancer disease studies, $3.1 billion for$2.8 HIV/AIDS $500 The 2020 NIH budget includes billion research, for Alzheimer’s Moonshot initiatives. million for the BRAIN initiative and $195 million for Cancer disease studies, $3.1 billion for HIV/AIDS research, $500 Moonshot million for initiatives. the BRAIN initiativeatand $195 million for Cancer More information is available www.fic.nih.gov/About/ Moonshot initiatives. Budget. More information is available at www.fic.nih.gov/About/ Budget. More information is available at www.fic.nih.gov/About/ Budget.

Fogarty program spurs innovative mHealth solutions • Cellphone microscope early cancer detection Fogarty program spursenables innovative mHealth solutions • Scientists develop app to diagnose, treat leishmaniasis • Cellphone microscope early cancer detection Fogarty program spursenables innovative mHealth solutions • Mobile tool designed to alleviate cancer pain • Scientists develop app to diagnose, treat leishmaniasis • Cellphone microscope enables early cancer detection Read moreon onpages pages36 6 -–39 9 Read More • tool designed cancer pain • Mobile Scientists develop apptotoalleviate diagnose, treat leishmaniasis Read more on pages 6 – 9 • Mobile tool designed to alleviate cancer pain Read more on pages 6 – 9

Photo by Photo James by Photo Gathany/CDC James by James Gathany/CDC Gathany/CDC

The coronavirus outbreak that began in China in late 2019 has focused the world’s attention on how best to slow The coronavirus outbreak that began in China in late 2019 transmission, diagnose and treat those with the illness, has focused the world’s attention on how best to The coronavirus outbreak that began in China inslow late 2019 named COVID-19. transmission, diagnose and treat those with the has focused the world’s attention on how best to illness, slow named COVID-19. transmission, diagnose and treat the illness,to The WHO recently convened morethose than with 300 scientists named COVID-19. help coordinate the research agenda. “I was very encouraged The WHO recently convened more than 300 scientists to to see the energy and speed with which the global research help coordinate theconvened research more agenda. “I was very encouraged The WHO recently than 300 scientists community has taken up this challenge,” said WHO to to see the energy and speed with which the global research help coordinate the agenda. “IGhebreyesus. was very encouraged Director-General Dr.research Tedros Adhanom community has taken up this challenge,” said WHO to see the energy and speed with which the global research Scientists are already addressing the most pressing issues Director-General Dr. Tedros Adhanom Ghebreyesus. community has taken this challenge,” said WHO such as creating quickup and inexpensive diagnostics, Scientists are already addressing the most pressing issues Director-General Dr.approaches Tedros Adhanom Ghebreyesus. discovering the best for prevention, studying such as creating quick and inexpensive diagnostics, Scientists are already addressing the most pressing issues effectiveness of potential therapies and accelerating developdiscovering the best approaches for prevention, studying such as creating quick and inexpensive diagnostics, ment of existing vaccine candidates, he said. In addition, effectiveness of potential therapies and accelerating developdiscovering approaches studying researchers the are best trying to identify for theprevention, source of the virus and ment of existing vaccine candidates, he said. In addition, effectiveness of potential therapies and accelerating developprevent further transmission from animals to humans. researchers are trying to candidates, identify the he source virus and ment of existing vaccine said.ofInthe addition, prevent further fromthe animals toofhumans. researchers are transmission trying identify source theJanuary virus and At NIH, scientists havetobeen working since early prevent further transmission fromand animals to develop a coronavirus vaccine hope to to humans. have it ready At NIH, scientists have been working since early January for initial testing soon. “We are proceeding as if we will have to develop a coronavirus vaccine and hope to have it ready At NIH, scientists have been early January to deploy a vaccine,” said Dr.working Anthonysince S. Fauci, director of for initial testing soon. “We are proceeding as if we will have to a coronavirus vaccineand andInfectious hope to have it ready thedevelop National Institute of Allergy Diseases. to deploy a vaccine,” said Dr. Anthony S. Fauci, director of for initial testing “We are proceeding as if we will have “We’re looking at soon. the worst scenario if this becomes a bigger the National Institute of Allergy and Infectious Diseases. to deploy a vaccine,” said Dr. Anthony S. Fauci, director of outbreak.” “We’re looking at the worst scenario this becomes a bigger the National Institute of Allergy and if Infectious Diseases. outbreak.” “We’re looking at the worst scenario if this becomes a bigger outbreak.”

JANUARY/FEBRUARY 2020

NIH mobilizes research to address new coronavirus . . . continued from previous page China. Meanwhile, researchers in Thailand reported seeing improvement in several patients treated with HIV drugs lopinavir and ritonavir, in combination with the flu drug oseltamivir. Image courtesy of NIAID

To encourage coronavirus research, NIAID has issued a funding call to current grantees whose work would benefit from a funding supplement.

At Fogarty, a team of disease modelers led by Dr. Cécile Viboud has been working around the clock to process and analyze initial publicly available data. An online The virus that causes COVID-19. community for Chinese physicians and health care professionals provides real-time situation reports of the outbreak, including cumulative case counts, outbreak maps and real-time streaming of health authority announcements.

The data provide a snapshot of patient information in terms of age, gender and symptom onset. HHS has offered to send American experts to China to help with the response and the State Department has pledged $100 million to aid China and other countries affected by COVID-19. Considering early lessons from the outbreak, The Lancet editor Dr. Richard Horton encouraged policymakers to take note. “Research is sometimes seen as a luxury when countries are being urged to invest in primary health care,” Horton observed. “But the COVID-19 outbreak has shown the foundational importance of research for any effective public health response.” RESOURCES http://bit.ly/COVID19_info

Global sepsis burden is double previous estimates

Source: 2017 Global Burden of Disease study

Sepsis, a life-threatening organ dysfunction due to infection, occurs in nearly 50 million people each year and causes about 11 million deaths worldwide. The toll is double previous estimates, according to a recent article in The Lancet, based on data from the 2017 Global Burden of Disease study. Diarrheal disease was the most common underlying cause of sepsis, among all ages, genders and locations. Road traffic injuries and maternal disorders were the

most frequent noncommunicable diseases complicated by sepsis. Sub-Saharan Africa was the region with the highest sepsis mortality rate. Research and policy interventions targeting antimicrobial resistance, a key driver of sepsis, are “imperative,” the authors noted. RESOURCES http://bit.ly/sepsis_global 33

JANUARY/FEBRUARY JANUARY/FEBRUARY 2020 JANUARY/FEBRUARY 20202020

Scientist studiesthe the Scientist studies moringa plant’s medicinal, moringa plant’s medicinal, nutritional benefits nutritional benefits By By January January W. W. Payne Payne

By January W. Payne

enabling farmers to increase their moringa crop yield and improve the purity of the end product, a powdered A A growing growing body body of of evidence evidence suggests suggests that that moringa moringa diet supplement. (Moringa oleifera) helps fight inflammation, a known

(Moringa oleifera) helps fight inflammation, a known contributor contributor to to chronic chronic conditions conditions such such as as cancer, cancer, A growing body of evidence suggestsWaterman, that moringa diabetes diabetes and and obesity. obesity. Dr. Dr. Carrie Carrie Waterman, a a natural natural (Moringa oleifera) helpsat fight inflammation, a known products chemist the of Davis, products chemist at the University University of California, California, Davis, secured five-year Fogarty Research contributor to a such as cancer, secured achronic five-yearconditions Fogarty International International Research Scientist Development Award (IRSDA) diabetes and obesity. Dr. Carrie a natural Scientist Development AwardWaterman, (IRSDA) to to explore explore moringa’s potential. The IRSDA provides support to moringa’s potential. The IRSDA provides support to products chemist at the University of California, Davis, advanced postdoctoral U.S. research scientists for an advanced postdoctoral U.S. research scientists for secured a five-year Fogarty International Research an intensive, mentored research experience leading to an intensive, mentored research experience leading to an Scientist Development Award (IRSDA) to explore independent research career focused on global health. independent research career focused on global health. moringa’s potential. The IRSDA provides support to

advanced postdoctoral U.S. research scientists for an She She first first became became interested interested in in moringa moringa as as a a Peace Peace intensive, mentored research experience leading to an Corps Corps volunteer volunteer in in 2002. 2002. “I “I was was growing growing it, it, eating eating it it and and working with gardens,” Waterman said. independent career focused global health. workingresearch with community community gardens,”on Waterman said. "It's "It's got got high high nutritional nutritional value value and and also also has has polyphenols polyphenols and and

antioxidants.” She first became interested in moringa as a Peace antioxidants.” Corps volunteer in 2002. “I was growing it, eating it and Waterman—who holds a to processWaterman—who holds a patent patent related related to the thesaid. processworking with community gardens,” Waterman "It's ing of moringa and consults for several moringa ing of moringa and consults for several moringa got high nutritional value and also has polyphenols and companies—used her her Fogarty Fogarty grant grant to to work work with with companies—used antioxidants.” farmers in Kenya to determine the most effective

farmers in Kenya to determine the most effective cultivation cultivation and and processing processing techniques. techniques. She She compared compared Waterman—who holds ato related to the processplanting find ideal between planting strategies strategies topatent find the the ideal spacing spacing between plants produce the yield. trying ing of moringa consults for several moringa plants to to and produce the highest highest yield. By By trying different different fertilizers, showed that stems companies—used her Fogarty grant work with fertilizers, Waterman Waterman showed thattoground-up ground-up stems on plant farmersand in discarded Kenya to portions determine themoringa most effective and discarded portions on the the moringa plant worked worked as well as cow manure, which might help reduce costs as well as cow manure, which might help reduce costs cultivation and processing techniques. She compared for farmers. She discovered the purity of the product for farmers. She discovered the purity of the product planting strategies to find the ideal spacing between improved if were before drying. She if leaves leaves were crushed crushed drying. She also also plants improved to produce the highest yield. before By trying different conducted conducted an an economic economic impact impact analysis analysis to to demonstrate demonstrate fertilizers, Waterman showed that ground-upmore stems net net positive positive economic economic returns, returns, encourage encourage more farmers farmers and discarded portions on the moringa plant worked to to start start growing growing moringa, moringa, and and lure lure more more investment investment in in as wellmoringa as cow start-ups manure, and which might help reduce costs community development. moringa start-ups and community development.

for farmers. She discovered the purity of the product In Waterman and a improved if leaves were crushed beforepublished drying. She also In 2015, 2015, Waterman and colleagues colleagues published a study study that showed feeding mice moringa extract could that showed feeding mice moringa extract could conducted an economic impact analysis to demonstrate delay onset diabetes. Mice a delay the the onset of ofreturns, diabetes.encourage Mice that that ate ate a high-fat high-fat net positive economic more farmers diet supplemented with 5% moringa concentrate had diet supplemented with 5% moringa concentrate to start growing moringa, and lure more investmenthad in moringa start-ups and community development. 34 Delaware Journal of Public Health – April 2020

With Fogarty funding, Dr. Carrie Waterman helped Kenyan farmers improve With Fogarty funding, Dr. Carrie Waterman helped Kenyan farmers improve cultivation and processing of the moringa plant, known for its medicinal and cultivation and processing of the moringa plant, known for its medicinal and nutritional properties. nutritional properties.

With Fogarty funding, Dr. Carrie Waterman helped Kenyan farmers improve cultivation and processing of the moringa insulin plant, known for its medicinal and improved improved glucose glucose tolerance tolerance and and insulin signaling signaling and and nutritional properties. didn’t develop fatty liver disease. The moringa-fed

didn’t develop fatty liver disease. The moringa-fed mice 18% less than the mice also also gained gained 18% less weight weight than the control control improved glucose tolerance and insulin signaling and group. In fact, the supplement nearly eliminated group. In fact, the supplement nearly eliminated didn’t developgain fatty liver by disease. The moringa-fed excess excess weight weight gain caused caused by a a high-fat high-fat diet. diet. The The NIH NIH mice also gained 18% less weight than the control supported this research through its National supported this research through its National Center Center for for group. In fact, the nearly eliminated Complementary and Integrative and its Complementary and supplement Integrative Health Health and its Office Office of of Dietary Supplements. excess gain caused by a high-fat diet. The NIH Dietary weight Supplements.

supported this research through its National Center for With Waterman she was With the the Fogarty Fogarty grant, grant, Waterman said said she and was able able Complementary and Integrative Health its Office of to study basic moringa-related research questions, to study basic moringa-related research questions, Dietary Supplements. as as well well as as the the “whole “whole value value chain chain of of not not just just what what do do these compounds do in a petri dish, but how does this these compounds do in a petri dish, but how does this With the Fogarty grant, Waterman saidnutritional she was able help people on the ground who are facing help people on the ground who are facing nutritional to study basic moringa-relatedrecent research questions, and and health health issues?” issues?” Waterman’s Waterman’s recent work work in in Kenya Kenya as well as the “whole value chain of not just what do allowed her to interact with local communities. allowed her to interact with local communities. “I “I helped them improve their cultivation and processing these dotheir in acultivation petri dish, but how does this helpedcompounds them improve and processing of so powder they were making would have help on the ground facing nutritional of it, it, people so that that the the powder they who were are making would have more nutrients and more phytochemicals,” she said. and issues?” Waterman’s recent she work in Kenya morehealth nutrients and more phytochemicals,” said.

allowed her to interact with local communities. “I The funding has also inspired The Fogarty Fogarty hastheir also cultivation inspired bidirectional bidirectional helped themfunding improve and processing learning. Cultivation, processing and consumption learning. Cultivation, processing and consumption of it, so that the powder they were making would have strategies strategies used used in in Kenya Kenya have have been been shared shared with with more nutrients and and more phytochemicals,” she said. farmers in California vice versa. “We have also farmers in California and vice versa. “We have also built built chimney chimney solar solar dryers dryers to to process process moringa moringa in in both both The Fogarty funding has also inspired bidirectional Kenya and California,” said Waterman, who serves Kenya and California,” said Waterman, who serves as for funded the learning. Cultivation, processing consumption as an an adviser adviser for research research funded by byand the California California Department of Food and Agriculture to farmers strategies in Kenya have been shared with Departmentused of Food and Agriculture to assist assist farmers in Fresno. farmers in California and vice versa. “We have also in Fresno.

built chimney solar dryers to process moringa in both Waterman plans to for and Waterman to apply apply said for NIH NIH and U.S. U.S. Department Department Kenya andplans California,” Waterman, who serves of Agriculture funding to support additional research of Agriculture funding to support additional research as an adviser for research funded by the California into how consuming moringa can affect inflammation into how consuming moringa can affect inflammation Department of Food and Agriculture to assist farmers and and chronic chronic disease disease in in humans. humans. “It “It can can both both generate generate in Fresno. income for farmers, as well as provide food security,”

income for farmers, as well as provide food security,” she she said. said. “I “I think think moringa moringa can can be be a a smart smart tool tool in in our our toolbox of strategies to approach global health in Waterman plans toto apply for NIH and U.S. needs Department toolbox of strategies approach global health needs in an environmentally and socially conscious way.” of funding to support additional anAgriculture environmentally and socially conscious way.” research

into how consuming moringa can affect inflammation RESOURCES RESOURCES and chronic disease in humans. “It can both generate http://bit.ly/MoringaPlant http://bit.ly/MoringaPlant income for farmers, as well as provide food security,” she said. “I think moringa can be a smart tool in our3 3 toolbox of strategies to approach global health needs in

Photo Photocourtesy courtesyofofDr. Dr.Carrie CarrieWaterman Waterman

The The moringa moringa plant plant has has been been used used for for centuries centuries throughout the tropics for medicinal throughout the tropics for medicinal purposes purposes and and to to The moringa plant has been usedinfor centuries improve nutrition, especially children. A Fogartyimprove nutrition, especially in children. A Fogartythroughout the tropics for medicinal purposes and to funded funded researcher researcher is is helping helping to to provide provide the the scientific scientific evidence behind the “superfood,” as improve nutrition, especially in children. A Fogartyevidence behind the so-called so-called “superfood,” as well well as as enabling farmers to increase increase their moringa moringa crop yield yield fundedenabling researcher is helping to provide the scientific farmers to their crop and improve theso-called purity of of “superfood,” the end end product, product, awell powdered evidence behind the as a as and improve the purity the powdered diet supplement. supplement. diet

PPRROOFFIILLEE Fogarty FogartyFellow Fellowstudies studiesnovel novel malaria malariadetection detectiondevice device ByByJanuary JanuaryW.W.Payne Payne

Photo courtesy of Dr. Carrie Waterman

For Forself-described self-described“talker” “talker”Jillian JillianArmstrong, Armstrong,learning learning totolisten listenhas hasbeen beena akey keylesson lessonofofher hercurrent currentFogarty Fogarty fellowship fellowshipininCameroon. Cameroon.Living Livingand andworking workinginina aFrenchFrenchspeaking speakingcountry countrywith withnonoFrench Frenchbackground backgroundhas hasbeen been rewarding, rewarding,but butchallenging. challenging.“Although “AlthoughI am I amlearning learning French, French,I do I donot nothave havea afirm firmgrasp graspofofthe thelanguage languageyet,” yet,” she shesaid. said.“I “Ihave havetotolisten listenincredibly incrediblycarefully carefullywhen whenothers others speak speakand andchoose choosemy mywords wordswisely wiselywhen whenI respond. I respond.This This experience experiencehas hashelped helpedme metruly trulyengage engagewith withthe thepeople people and andworld worldaround aroundme.” me.” Armstrong, Armstrong,a aPh.D. Ph.D.student studentatatYale YaleUniversity, University,isisworking working onona aresearch researchproject projectevaluating evaluatingphotoacoustic photoacousticflow flow cytometry cytometry (PAFC) (PAFC) for for the the non-invasive non-invasive detection detection ofof malariamalariainfected infectedred redblood bloodcells cellsininCameroon. Cameroon.Fogarty’s Fogarty’sGlobal Global Health HealthProgram Programfor forFellows Fellowsand andScholars Scholarsprovides providesdoctoral doctoral and andpostdoctoral postdoctoralstudents studentslike likeArmstrong Armstrongwith witha ayear-long year-long mentored mentoredresearch researchexperience experienceinina alowlow-orormiddle-income middle-income country. country. Armstrong Armstrongand andher hercolleagues colleaguesbelieve believethe theproject projectisisthe the first firsttotouse usethis thistechnique techniquetotodiagnose diagnosemalaria. malaria.It’s It’sfunded funded bybyFogarty Fogartyand andNIH’s NIH’sNational NationalInstitute InstituteofofBiomedical Biomedical Imaging Imagingand andBioengineering. Bioengineering.Malaria Malariaisisa asignificant significant problem problemininCameroon Cameroonwhere whereit itaccounts accountsfor fornearly nearly20% 20% ofofallalldeaths, deaths,according accordingtotothe theU.S. U.S.President’s President’sMalaria Malaria Initiative. Initiative.Current Currentdiagnostic diagnostictests testslack lacksufficient sufficient sensitivity sensitivityand andspecificity, specificity,and andrequire requirea ablood bloodspecimen. specimen. However, However,PAFC PAFCisisa anovel, novel,non-invasive non-invasivediagnostic diagnosticmethod method that thatcan candetect detecthemozoin, hemozoin,ananiron-containing iron-containingpigment pigmentthat that accumulates accumulatesininmalaria malariaparasites. parasites. PAFC PAFChas hasbeen beendemonstrated demonstratedtotobebehighly highlysensitive sensitive ininanimal animalstudies, studies,and andit itmay mayoffer offerbenefits benefitsover overother other diagnostic diagnostictests, tests,Armstrong Armstrongsaid. said.Additionally, Additionally,the therealrealtime timenature natureofofPAFC PAFCmeans meansthat thatit itcan canalso alsobebeused usedtoto study studyhow howdrugs drugsused usedtototreat treatmalaria malariawork—especially work—especially important importantininchildren childrenunder under5,5,who whoare arevulnerable vulnerablefor for adverse adversemalaria malariaoutcomes outcomesand andmay maynot notreceive receivethe theproper proper dose doseofofmedicine medicinetotofully fullyclear clearinfections. infections. The ThePAFC PAFCproject projectisisstill stillininitsitsimplementation implementationstage stagebut but Armstrong Armstrongisisoptimistic. optimistic.“We “Webelieve believethe thefindings findingswill will demonstrate demonstratethat thatthe thePAFC PAFCdevice deviceaddresses addressesmany manyofofthe the

Jillian JillianArmstrong, Armstrong,M.S. M.S. Fogarty Fogarty Fellow: Fellow:

2019-2020 2019-2020

Fellowship Fellowship at:at:

University University of of Yaoundé, Yaoundé, Cameroon Cameroon

U.S. U.S. Institution: Institution:

Yale Yale University University

Research Research topic: topic:

malaria malaria diagnostics diagnostics

limitations limitationsofofcurrent currentdiagnostics diagnosticsand andprovides providesa acostcosteffective effectiveway waytotodetect detectmalaria malariainina anon-invasive, non-invasive,realrealtime timemanner,” manner,”Armstrong Armstrongsaid. said.“Our “OurPAFC PAFCtechnology technology has hasthe thepotential potentialtotoimprove improveaccess accesstotohighly-sensitive highly-sensitive malaria malariadetection detectionininresource-limited resource-limitedsettings.” settings.” The Theexperience experiencehas hasbeen been“extremely “extremelyinfluential” influential”inin helping helpingArmstrong Armstrongprepare preparefor forher herdissertation, dissertation,she she said. said.It Itwas washer herfirst firstexperience experienceininthe thelead leadrole roleonona a study studyand andallowed allowedher hertotosee seefirsthand firsthandallallthat thatentails. entails. “Working “Workingonona anew newproject projectmeant meantthat thatI have I havebeen been involved involvedinineverything—from everything—fromthe thefirst firstconception conceptionofofthe the project projectidea ideatotothe theproposed proposedanalysis analysisofofdata, data,and andallall ofofthe thehurdles hurdlesininbetween,” between,”she shesaid. said.“I “Ihave havelearned learned how howtotowrite write(and (andre-write) re-write)project projectproposals, proposals,calculate calculate sample-sizes sample-sizesfor forstudy studyaims, aims,and andperform performnew newdata data analysis analysisand andlaboratory laboratorytechniques.” techniques.” AsAsshe shecontinues continuesher herwork workininCameroon, Cameroon,Armstrong Armstrong says saysshe sheisisgrateful gratefulfor forlessons lessonslearned learnedfrom fromfacing facing challenges, challenges,such suchasasthe thelanguage languagebarrier, barrier,asaswell well asasdealing dealingwith withthe theunexpected—like unexpected—likehow howdust dustcan can affect affecther herwork. work.“You “Youwould wouldbebesurprised surprisedhow howmany many biomedical biomedicaldevices devicesand andinnovations innovationsdodonot nottake take environmental environmentaldirt dirtand anddust dustinto intoconsideration, consideration,which which can canquickly quicklyaffect affecta adevice,” device,”she shesaid. said. The Thedesire desiretotoovercome overcomesuch suchdifficulties difficultiesisispart partofof why whyArmstrong Armstrongisissosopassionate passionateabout aboutapplying applying engineering engineeringinnovations innovationstotoglobal globalhealth healthproblems. problems. Listening Listeningtotopartners partnersatatevery everystep stepofofthe theresearch research process processisisvital, vital,she shesaid. said.“I “Ithink thinkit’s it’simportant importanttoto involve involvelocal localresearchers researchersand andcommunities communitiesininthe the research researchyou youconduct conducttotomake makesure surethat thatit italigns alignswith with both boththe theneeds needsand andthe thepriorities prioritiesofofthe thepeople peopleyou’re you’re trying tryingtotohelp.” help.” 35

Q&A

JEAN N ACHEGA , MD, PHD, MPH

With more than 25 years of HIV/AIDS research experience, Dr. Jean Nachega was a principal investigator (PI) on the $130 million Medical Education Partnership Initiative (MEPI), which was managed by Fogarty and funded by NIH and the President’s Emergency Plan for AIDS Relief (PEPFAR). Nachega holds faculty positions at the University of Pittsburgh and Stellenbosch University in Cape Town, South Africa, and is an adjunct professor at Johns Hopkins University. He is now PI on the African Association for Health Professions Education and Research award, which supports AFREhealth, the leadership and convening organization intended to continue and strengthen the MEPI network.

What has MEPI’s impact been? MEPI was really a game changer. This was the first large program to award funds directly to African institutions. At Stellenbosch University, the MEPI team was able to strengthen our medical school curricula and increase the number of graduates in rural and remote locations where they were needed most. By establishing training programs in these underserved areas, we could recruit locally, which improved retention of trainees who would practice at home and give back to their local communities. MEPI was transformative not only for its ability to provide medical education to remote locations using innovative methods such as distance-learning tools and hands on information technology, but also because it offered opportunities to conduct local research so trainees didn’t feel they were missing out. This was a great outcome and provided a fantastic return for their communities. MEPI also provided a great opportunity to strengthen North-South partnerships, in collaboration with U.S. institutions. Even more important were the South-South relationships that formed. MEPI helped us look for new ways to share resources, establish a community of practice, and, innovatively, learn from those from diverse health profession backgrounds. Prior to MEPI, we had not had a tradition of partnership among medical schools in the South, but we now routinely work together to write grants and collaborate on many activities. That legacy lives on and is being scaled up in AFREhealth.

What are AFREhealth’s goals? AFREhealth is a pan-African initiative that is the child of MEPI. Just as when you give birth to a child you must nourish it to make sure it can grow and flourish, AFREhealth is a network of institutions that aims to work together to continue to strengthen medical education and research. Our challenge is to leverage the MEPI investments to continue to make progress. We are bringing together and embracing all health professionals—not just doctors and nurses—but also pharmacists, dentists, lab 36 Delaware Journal of Public Health – April 2020

scientists, community health workers, and others from allied health sciences. We hope to create a vibrant research environment and together tackle pressing research questions. As we are concerned about funding sustainability, we will be writing grant proposals to submit to NIH and other public and private organizations, as well as engaging with the African Union and governments throughout sub-Saharan Africa. We hope in the next 5 to 10 years that AFREhealth will have multiple stakeholders and supporters.

How are you building a knowledge base? One thing we are doing is sharing our lessons learned. Fogarty’s Center for Global Health Studies has convened the community to consider best practices from our HIV/ AIDS treatment and prevention programs. One size does not fit all, but through an implementation science approach, we are studying what interventions are the most cost-effective and have the most impact in real-life practice. We are also exploring how to use the HIV care platform to better manage chronic conditions.

What are your research priorities? Now that we are able to keep people alive longer with antiretroviral therapy (ART), we need to focus on the comorbidities and chronic diseases that occur with aging. We must conduct multi-disciplinary research to tackle the noncommunicable diseases (NCDs), which are now killing more people than AIDS. Cardiovascular disease and cancer have high mortality rates in Africa, especially among those living with HIV. We have discovered that even if the virus is suppressed with ART, there are higher than normal levels of ongoing inflammation that impact the heart, kidneys and other organs. Initially, we didn’t appreciate the enormity of this problem. We would like to better understand hypertension and stroke, both of which are prevalent in Africa. We know the genetic aspects of these diseases play a significant role and need to work in partnership with the NIH-funded Human Heredity and Health in Africa initiative to better understand these links.

F FO OC CU US S FOCUS

Developing Developing mobile mobile solutions solutions to to improve improve health health Developing mobile solutions to improve health

TT T

Photo Photo by David by Photo David Snyder bySnyder David for the Snyder for CDC the CDC forFoundation. theFoundation. CDC Foundation.

he speed of technological advances and the ubiquity hecellphones—even speed of technological advances and the ubiquity of in low-resource settings—have of cellphones—even low-resource created tremendous in opportunities tosettings—have deploy mobile he speed of technological advances and the ubiquity created tremendous opportunities to health, deploy mobile health to advance research and improve of cellphones—even in low-resource settings—have health to advance research and explosion improve health, especially in remote areas. The of available created tremendous opportunities to deploy mobile especially in combined remote areas. explosion of available health data, withThe advances in machine learnhealth to advance research and improve health, health data, combined with provide advances in machine learning or artificial intelligence, great potential. especially in remote areas. The explosion of available ing or artificial intelligence, provide great potential. health data, combined with advances in machine learnSince its inception in 2014, Fogarty’s mHealth program ing or artificial intelligence, provide great potential. Since its inception in 2014, Fogarty’s mHealththrough program has supported projects to catalyze innovation has supported projects to catalyze innovation through multidisciplinary research that addresses global health Since its inception in 2014, Fogarty’s mHealth program multidisciplinary research that60 addresses global health problems. Through more than grants, Fogarty is has supported projects to catalyze innovation through problems. Through more than 60 for grants, Fogarty is helping develop an evidence base the use of mobile multidisciplinary research that addresses global health helping develop an evidence basehealth, for theas use of as mobile technology solutions to improve well to problems. Through more than 60 grants, Fogarty is technology solutions to improve health,inaslowwelland as to strengthen mHealth research capacity helping develop an evidence base for the use of mobile strengthen mHealth research capacity in low- and middle-income countries (LMICs). technology solutions to improve health, as well as to middle-income countries (LMICs). strengthen mHealth research capacity in low- and A broad range of novel initiatives has been supported, middle-income countries (LMICs). A broad range of novel initiatives hasapps beentosupported, such as portable diagnostic devices, improve such as portable diagnostic devices, apps and to improve adherence to disease treatment protocols text A broad range of novel initiatives has been supported, adherence to disease to treatment protocols text messaging programs encourage healthyand behaviors. The such as portable diagnostic devices, apps to improve messaging to development, encourage healthy behaviors. The grants fundprograms technology as well as rigorous adherence to disease treatment protocols and text grants fund technology development, feasibility and effectiveness studies. as well as rigorous messaging programs to encourage healthy behaviors. The feasibility and effectiveness studies. grants fund technology development, as well as rigorous A number of the projects are designed to overcome feasibility and effectiveness studies. A number thethat projects designed to overcome barriers to of care existare in many underserved LMIC barriers to care that exist in many underservedtoLMIC communities, including lack of transportation A number of the projects are designed to overcome communities, including lack of of doctors transportation clinics, inadequate numbers and thetochronic barriers to care that exist in many underserved LMIC clinics, inadequate numbers of doctors and the chronic shortage of health care workers. By using cellphones communities, including lack of transportation to shortage ofrural health care workers. By using cellphones to connect patients with knowledgeable care clinics, inadequate numbers of doctors and the chronic to connect rural patients with knowledgeable care shortage of health care workers. By using cellphones Since 2014, Fogarty has provided funding to catalyze development of mobile to connect rural patients with toknowledgeable careof mobile health technologies and support research their development effectiveness. Since 2014, Fogarty has provided funding tostudy catalyze health technologies and support research to study their effectiveness. Since 2014, Fogarty has provided funding to catalyze development of mobile health technologies and support research to study their effectiveness.

providers, diagnoses can be made and treatment providers, diagnoses made and treatment recommendations cancan be be given remotely. Also, mobile recommendations be givenhealth remotely. mobile devices can providecan front-line care Also, workers with providers, diagnoses can be made and treatment devicesto can provide front-line health care guidelines workers with access current information, treatment and recommendations can be given remotely. Also, mobile access to current information, treatment guidelines and the ability to consult electronically with experts, when devices can provide front-line health care workers with the ability to consult electronically with experts, when needed. access to current information, treatment guidelines and needed. the ability to consult electronically with experts, when Other grantees have explored adapting and developing needed. Other grantees have explored adapting and developing powerful yet inexpensive, portable microscopes and powerful yetcan inexpensive, portable microscopes and probes that be connected to cellphones, bringing Other grantees have explored adapting and developing probes thatcapabilities can be connected to cellphones, diagnostic to remote populations.bringing With powerful yet inexpensive, portable microscopes and diagnostic capabilities to remote populations. With instant diagnoses, patients can begin treatment probes that can be connected to cellphones, bringing instant diagnoses, patients cantobegin treatment immediately, without the need return later for test diagnostic capabilities to remote populations. With immediately, without the need mHealth to returntechnologies later for test results. Projects are exploring instant diagnoses, patients can begin treatment results. are exploring technologies to screenProjects for a variety of issuesmHealth including breast and immediately, without the need to return later for test to screencancer, for a variety issues including cervical anemiaofand hearing loss. breast and results. Projects are exploring mHealth technologies cervical cancer, anemia and hearing loss. to screen for a variety of issues including breast and Text messaging programs are also being created and cervical cancer, anemia and hearing loss. Text messaging are also being created and studied for theirprograms effectiveness at encouraging behavior studied for their effectiveness at encouraging behavior change, such as smoking cessation, or promoting Text messaging programs are also being created and change, such as smoking treatment cessation, protocols or promoting adherence to challenging including studied for their effectiveness at encouraging behavior adherence to challenging treatment including those required for people living with protocols TB and HIV/ change, such as smoking cessation, or promoting those required for people living withmore TB and HIV/ways AIDS. Other projects are exploring effective adherence to challenging treatment protocols including AIDS. Othermanaging projects are exploringdiabetes, more effective ways of remotely gestational providing those required for people living with TB and HIV/ of remotely managing gestational providing support to breastfeeding mothers,diabetes, and monitoring AIDS. Other projects are exploring more effective ways supportdisorder to breastfeeding mothers, and monitoring bipolar and depression. of remotely managing gestational diabetes, providing bipolar disorder and depression. support to breastfeeding mothers, and monitoring Several initiatives are examining best practices in using bipolar disorder and depression. Several initiatives aredistance examining best practices in using mHealth to promote learning, so that health mHealth to promote distance so that health in care workers on the front lineslearning, can develop expertise Several initiatives are examining best practices in using care workers on the front lines can develop expertise in cancer and other specialized topics. mHealth to promote distance learning, so that health cancer and other specialized topics. care workers on the front lines can develop expertise in To help establish a community of practice among cancer and other specialized topics. To help establish a community of practice those studying potential mHealth solutionsamong in LMICs, those studying mHealth in LMICs, Fogarty’s Centerpotential for Global Healthsolutions Studies hosted a To help establish a community of practice among Fogarty’sinstitute Center for Studies hosted a the training on Global the NIHHealth campus and has made those studying potential mHealth solutions in LMICs, training institute the NIH and has made the curriculum freely on available oncampus the Center’s website. Fogarty’s Center for Global Health Studies hosted a curriculum freely available on the Center’s website. training institute on the NIH campus and has made the In addition to Fogarty, mHealth program cosponsors curriculum freely available on the Center’s website. In NIH addition to Fogarty, mHealth program cosponsors at include the National Cancer Institute, National at NIH include the National Cancer National Institute of Biomedical Imaging and Institute, Bioengineering, In addition to Fogarty, mHealth program cosponsors Institute Institute of Biomedical Imaging and NIH Bioengineering, National of Mental Health, Office of at NIH include the National Cancer Institute, National National Institute of Mental Health, NIH Office of Behavioral and Social Sciences Research, the Eunice Institute of Biomedical Imaging and Bioengineering, Behavioral and Social Sciences Research, Eunice Kennedy Shriver National Institute of Childthe Health and National Institute of Mental Health, NIH Office of KennedyDevelopment, Shriver National Institute of Child and Human National Institute on Health Deafness Behavioral and Social Sciences Research, the Eunice Human Development, National Institute on Deafness and Other Communication Disorders, National Institute Kennedy Shriver National Institute of Child Health and and Other Communication Disorders, National Institute of Neurological Disorders and Stroke, and NIH Office of Human Development, National Institute on Deafness of Neurological Disorders and Stroke, and NIH Office of Research on Women's Health. and Other Communication Disorders, National Institute Research on Women's Health. of Neurological Disorders and Stroke, and NIH Office of Research on Women's Health.

Articles in this section by Susan Scutti. Articles in http://bit.ly/MobileHealthSolutions this section by Susan Scutti. Resources Resources http://bit.ly/MobileHealthSolutions Articles in this section by Susan Scutti. Resources http://bit.ly/MobileHealthSolutions

FOCUS ON MOBILE HEALTH

Innovative microscope enables early cancer diagnoses

“We’re streamlining the process to enable onsite, real-time, single-visit diagnoses,” says Kang, a biomedical engineering professor at the University of Arizona. “Now the patient doesn’t have to come back to the rural clinic or hospital. We can catch them when they are there.”

it as a thin section slide that a pathologist takes a look at under the microscope,” explains Kang. With his smartphone device, he is bringing the microscope to the tissue rather than the tissue to the microscope, saving the usual four-to-six weeks’ processing time. Kang’s device joins a smartphone with an optical attachment in a custom-built, optomechanical holder. It can generate two-dimensional pictures of suspected KS lesions by using light plus a prism-like component—diffraction grating— and the image sensor in a smartphone. Photo courtesy of Makerere University

martphone microscopes are showing great potential for enabling instant and affordable diagnoses of certain cancers in low-resource settings. Fogarty grantee Dr. Dongkyun Kang has developed a new method of deploying confocal microscopy technology that provides instant images on a low-cost mobile device. In a pilot study in Uganda, the device was used to examine participants’ skin lesions and samples to look for Kaposi’s sarcoma (KS). Promising results led Kang to refine the prototype to improve image quality. He also has a second Fogarty grant to develop the confocal technology to produce and study an inexpensive smartphone endoscope to screen for cervical cancer.

His pilot study of the technology conducted at Makerere University in Kampala revealed issues with poor image quality, Kang confides. Based on these results, he refined the prototype, which now uses near-infrared (NIR) light and a new optics design. The NIR version, which can be used for biopsies as well as on living patients, “reduces the speckle noise significantly and will have better imaging performance,” according to Kang, who is planning to test the new iteration of the device soon.

Although confocal microscope technology has been around His newest invention, for diagfor several decades, it’s been nosing cervical cancer, filters cost prohibitive for use in lowlight through a confocal module A smartphone confocal microscope, developed by a Fogarty and middle-income countries and sends this light through a grantee, shows promise in providing quick, inexpensive diagnoses (LMICs). The materials for fiber bundle within an endoscopic of Kaposi’s sarcoma lesions. Kang’s devices cost only catheter to the cervix. The returnabout $4,200, as compared to nearly $100,000 for a ing light waves are then bent and focused to generate an commercial confocal microscope, he says. In addition, image on the smartphone camera. his latest prototype weighs only about 2 pounds, so it is portable and easy to hold with a single hand. The endgame of his research is to develop an app powered by artificial intelligence to analyze images and Improving access to and speed of diagnoses for cancer either guide or provide a diagnosis. His work in Uganda could have an enormous health impact. KS is the most has already established an mHealth knowledge base and common HIV-associated cancer among patients who a network of collaborating researchers in the country, live in sub-Saharan Africa. Survival rates are poor: In which Kang believes will pave the way for future projects some African countries, only 30% of patients live even and innovations across Africa. three years following diagnosis. The cervical cancer picture is equally bleak, with more than 80% of the Not only will the smartphone confocal microscope make world’s diagnoses occurring in LMICs. In East Africa, the a difference in LMICs, it will also benefit Americans, mortality rate is 27.6 per 100,000. says Kang, who has begun work with an Arizona clinic that provides health care to people who lack medical “The standard way of diagnosing any cancer is to take insurance. “The whole goal is to make an impact in the a little bit of tissue out of a patient and then process U.S. as well.”

38 Delaware Journal of Public Health – April 2020

FOCUS ON MOBILE HEALTH FOCUS ON MOBILE HEALTH

Scientists Scientists develop develop app app to to diagnose, diagnose, treat treat leishmaniasis leishmaniasis Cutaneous Cutaneousleishmaniasis—caused leishmaniasis—caused by bybites bitesfrom frominfected infectedsandflies— sandflies— produces skin produces skinlesions lesionsthat thatleave leave behind both scars and behind both scars andstigma stigma that that last lastaalifetime. lifetime.Up Upto to1.2 1.2million million new new cases casesare arediagnosed diagnosedeach eachyear year across across the the90 90countries countrieswhere wherethe thedisease disease exists, exists,including includingColombia. Colombia.

Aronoff-Spencer’steam teamadapted adapted an an Aronoff-Spencer’s existinginformatics informaticsstructure structure to to existing serveas asan anend-to-end end-to-endsolution solution for for serve diagnosis and management of the diagnosis and management of the neglectedtropical tropicaldisease, disease,and and then then neglected ran a pilot study comparing mHealthran a pilot study comparing mHealthassistedcare caretotostandard standardcare. care. assisted When considering how to design an When considering how to design an mHealth solution for use in the city mHealth solution for use in the city of Tumaco, he realized stakeholder of Tumaco, he realized stakeholder input would be critical to ensuring input would be critical to ensuring the tool would be accepted. “We have the tool would be accepted. “We have so much implicit expectation of how so much implicit expectation of how these technologies work here in the these technologies work here in the U.S. and it’s not necessarily how they U.S. and it’s not necessarily how they work there,” says Aronoff-Spencer. work there,” says Aronoff-Spencer. “We had to consider everything from “We had to consider everything from the safety of using cellphones in a the safety of using cellphones in a FARC-controlled, war-torn area, to FARC-controlled, war-torn area, to how people there use cellphones how thereassumptions use cellphones andpeople what their are.” A and theirinassumptions A firmwhat believer participatoryare.” design, firm believer in participatory design, his app developers included the his app leader, developers included the village a variety of community village leader, a variety of community volunteers and the region’s profesvolunteers and the region’sinprofessional medical providers, addition sional medical providers, in addition to the U.S. team. to the U.S. team. 8

An mHealth mHealth app app developed developed and tested with An with Fogarty Fogarty support support helps helpsaahealth healthworker workerevaluate evaluatepatients patientswith with suspected leishmaniasis leishmaniasis lesions. suspected

The result? result? A mobile health app The app built built for lower-cost lower-cost Android phones that for that can be be used used by advanced medical can medical practitioners, while also being practitioners, accessible to community health accessible health workers and and patients patients who workers who have have lower lower levels of of education. education. The The app levels app allows allows for patient patient data data and and image image input, for input, and provides provides a a validated validated decisionand decisionrule to to help help community community health rule health workers assess the possibility workers assess the possibility of of aa leishmaniasis diagnosis. Based leishmaniasis diagnosis. Based on on decisions made made by by health health workers, decisions workers, the app app then then refers refers some some patients the patients for laboratory testing for laboratory testing and, and, if if aa positive diagnosis is the result, positive diagnosis is the result, the the app monitors a patient throughout app monitors a patient throughout treatment. The team recruited 75 treatment. The team recruited 75 patients for a comparison study patients for a comparison study to see if the mHealth intervention to see if the mHealth intervention was more effective than standard was more effective than standard care. Despite poor access to mobile care. Despite poor access to mobile networks, the app remained networks, the app remained completely functional throughout the completely functional throughout the study period. Results revealed that study period. Results revealed that the app provided clear benefits over the app provided clear benefits over standard care, in both treatment standard care, in both treatment adherence and followup. adherence and followup. Aronoff-Spencer is planning further Aronoff-Spencer is planning further enhancements. “It’s our intention to enhancements. “It’s our intention use machine learning and artificialto use machinetolearning intelligence combineand theartificial pictures intelligence to combine the prevalence pictures of lesions with history and of history in lesions the areawith to come up and withprevalence predictive in the area to come up with predictive models to automatically diagnose models to automatically diagnose

leishmaniasis,” leishmaniasis,”he hesays. says.Beyond Beyondthat, that, the the app app might mightone oneday daycontribute contribute to to Colombia’s Colombia’snational nationalregistry registryfor for the the neglected neglecteddisease, disease,though thoughclear clear evidence evidence is is needed neededto toprove provethe theapp app is is highly highly accurate, accurate,appropriately appropriatelyused used and and interoperable interoperablewith withColombia’s Colombia’s public public health healthsystems. systems. Among Among the theproject projectteam’s team’sachieveachievements ments was wasthe theprovision provisionofoftraining training to seven community health workers to seven community health workers in in villages villageswith withthe thehighest highestincidence incidence of cutaneous leishmaniasis. of cutaneous leishmaniasis.So Sofar, far, they’ve published one scientific they’ve published one scientificpaper paper on on how how to tobuild buildmHealth mHealthtools toolsfor for neglected tropical diseases and are neglected tropical diseases and are preparing others to detail the app’s preparing others to detail the app’s performance and clinical outcomes. performance and clinical outcomes. It’s especially critical to provide It’s especially critical to provide active disease surveillance and active disease surveillance and management in low-resource settings management in low-resource settings since pathogens are not static, since pathogens are not static, Aronoff-Spencer says. Diseases can Aronoff-Spencer says. Diseases can move—from markets where animals move—from markets where animals and humans interact causing new and humans interact causing new respiratory viruses, from the jungle respiratory viruses, from the jungle where Ebola sprung forth, and from where Ebola and from the area southsprung of the forth, U.S. border the area south of the U.S. border where dengue and zika viruses where dengue and“We zikaneed viruses circulate, he says. to enable circulate, he says. “We need to enable people in the communities where people in the communities where diseases are to be the first responders diseases to bethe thetorch first of responders and even are to carry and even to carry the torch research that helps us all.” of research that helps us all.” 39

Photo courtesy of Centro Internacional de Entrenamiento e Investigaciones Medicas. Photo courtesy of Centro Internacional de Entrenamiento e Investigaciones Medicas.

“Leishmaniasis “Leishmaniasishappens happenswhere where the themedical medicalsystem systemisn’t,” isn’t,”says says Dr. Dr. EliahAronoff-Spencer, Aronoff-Spencer,aaFogarty Fogarty Eliah mHealthgrantee granteeat atthe theUniversity University mHealth California,San SanDiego. Diego.He’s He’sbeen been ofofCalifornia, workingininrural ruralColombia Colombiato tobridge bridge working theaccess accessgap gapbetween betweenremote remote the communitiesand andthe thepublic publichealth health communities system,using usingaamobile mobiletool toolthat that system, empowerscommunity communityhealth healthworkers workers empowers identifynew newcases casesof ofthe thedisease disease totoidentify andmonitor monitortreatment. treatment. and

Mobile tool designed to alleviate late-stage cancer pain Witnessing her late-stage cancer patients’ horrific pain in rural Tanzania—and being helpless to control it—prompted oncologist Dr. Susan Miesfeldt to consider developing an mHealth solution to alleviate suffering where there is no access to care. It’s an enormous and growing problem. Sub-Saharan Africa currently experiences at least 500,000 cancer deaths each year. Estimates project a doubling of cancer mortality in the region within the next decade. In remote or underserved areas, Miesfeldt says cancer patients have few options for pain relief, beyond seeking assistance from a traditional healer.

Miesfeldt’s two year grant allowed her to design the new app in partnership with Tanzanian local researchers and specialists. Fogarty funding is also supporting field studies, including usability testing by multiple user groups and a comparison of outcomes among 45 late-stage cancer patients versus a control group receiving the usual care.

Why not deploy mobile technology to fill these gaps? Miesfeldt and her team used Fogarty funding to produce and test an app, called the m-Palliative Care Link, that works as a three-way communication system.

40 Delaware Journal of Public Health – April 2020

“I cannot stress enough the importance of assembling a multidisciplinary team and drawing on the unique expertise of each member so that the tool is both usable and adaptable as technology advances,” says Miesfeldt, who adds her partners “provided tremendous insight” throughout the development process.

Image courtesy of Dimagi, Inc.

There are significant barriers. Often, patients are not diagnosed so they remain unknown to health providers, while many lack the means to travel to and pay for care in a clinic or hospital. Add to that, the only available medicine is oral morphine, which is subject to restricted distribution, plus there’s a general lack of awareness of palliative care, says Miesfeldt, an investigator at the Maine Medical Center.

“It connects the oncology professionals with patients in their communities and also links in the local health worker. If the palliative care professionals can’t get to the patient, the local health worker can support the assessment of pain and its management for that patient,” says Miesfeldt. Among its virtues, the app allows for the collection of data and the delivery of information by way of a smartphone, tablet or PC, while possessing an intuitive

Concerns accompanied the creation of her innovative mHealth device. Miesfeldt worried that developing a smartphone app—instead of a cellphone text message system— might be too advanced for Tanzania. Her tech-savvy team anticipated an increase in uptake of smartphones as the project rolls out, which, indeed, is occurring: Smartphone use has been climbing by almost 20% a year.

interface that is easy to follow by lowliteracy users.

A Fogarty-funded mobile app aims to reduce suffering among cancer patients, especially those living in remote areas without access to care.

It’s also crucial to build community trust to increase understanding of patient and health care workers’ needs in LMICs, says Misefeldt, who has cultivated relationships in Tanzania since her first visit 10 years ago. Not only has the project resulted in a tool that might alleviate suffering, it has also provided training and mentoring to local investigators, including Dr. Mamsau Ngoma, a local oncologist, who played a key role in the analysis and reporting of project data. The importance of building research capacity in lower-income nations is not lost on Miesfeldt. “Currently, a majority of cancer deaths globally take place in countries like Tanzania,” she says, adding that this translates to a need for more research. Still, she emphasized that her team designed their innovative app to be generalizable and scalable to any country, no matter the income level, says Miesfeldt. She herself lives in Maine and can see using the mobile tool to reach remote patients in her state, as well as in other rural areas of the U.S.

OPINION OPINION

By Dr. Roger I. Glass, Director, Fogarty International Center By Dr. Roger I. Glass, Director, Fogarty International Center By Dr. Roger I. Glass, Director, Fogarty International Center

Building trust in vaccines is essential for global health Building trust in vaccines is essential for global Building trust in vaccines is essential for global health health

number of European countries have even lost their official One of the terrible ironies in number of European countries have even lost their official One of the terrible ironies in measles elimination status. Here in the U.S., there were global health is that in many number of Europeanstatus. countries have even lostthere their were official One of health the terrible ironies in measles elimination Here in the U.S., global is that in many 1,282 cases of measles in 2019, the highest number in parts of the world, parents are measles elimination status. Herethe in the U.S.,number there were globalof health is thatparents in many 1,282 cases of measles in 2019, highest in parts the world, are decades. Nearly 130 of these cases led to hospitalization desperate to secure lifesaving 1,282 cases of measles in 2019, theled highest number in parts of the are decades. Nearly 130 of these cases to hospitalization desperate toworld, secureparents lifesaving and almost half had complications, including pneumonia vaccines for their children, while decades. Nearly 130 complications, of these cases led to hospitalization desperatefor to their secure lifesaving and almost half had including pneumonia vaccines children, while and encephalitis. These are not trivial matters. here in the U.S. a significant almost half had complications, including vaccines forU.S. theira children, while and encephalitis. These are not trivial matters.pneumonia here in the significant number of wealthy parents and encephalitis. These are not trivial matters. here in the U.S. a significant number of wealthy parents While the global community has given this a neutral spurn them. number of wealthy parents While the global community has given this a neutral spurn them. and unexciting name—vaccine hesitancy—the WHO While the globalname—vaccine community has given this a neutral spurn them. and unexciting hesitancy—the WHO rightly claims this to be among the world’s top 10 health This was on my mind recently, and unexciting name—vaccine rightly claims this to be among hesitancy—the the world’s top WHO 10 health This was on my mind recently, problems! It is incredibly frustrating, since vaccination as I traveled to India to pay rightly claims to be among the world’s 10 health This was on my mindto recently, problems! It isthis incredibly frustrating, since top vaccination as I traveled to India pay has long been one of our most powerful, cost-effective tribute to my late colleague, problems! It is one incredibly frustrating, since vaccination as I traveled India to pay has long been of our most powerful, cost-effective tribute to myto late colleague, ways of preventing disease. Each year, as many as 3 Dr. Maharaj (Raj) K. Bhan, who lost his courageous has long been one of our most powerful, tribute my late colleague, ways of preventing disease. Each year, ascost-effective many as 3 Dr. Maharaj (Raj) K. Bhan, who to lost his courageous million lives are saved by vaccination. battle with cancer in January. As I gathered my ways of lives preventing disease. Each year, as many as 3 Dr. Maharaj (Raj) K. whoAs lost his courageous million are saved by vaccination. battle with cancer inBhan, January. I gathered my thoughts for his eulogy, I felt million lives are saved by vaccination. battle with in January. thoughts forcancer his eulogy, I felt As I gathered my In our ongoing battle against cancer, we admiration for my close friend thoughts forfor his eulogy, I felt In our ongoing battle against cancer, we admiration my close friend now have a vaccine that has been proven and collaborator of three decades, In our ongoing battlethat against cancer, we admiration for myofclose now have a vaccine has been proven and collaborator threefriend decades, effective in preventing cervical cancer— remembering all he had accomplished. now haveina preventing vaccine that has been proven and collaborator of three decades, effective cervical cancer— remembering all he had accomplished. one of the most difficult forms of cancer Most significantly, we developed an effective inmost preventing cervical remembering all hewe had accomplished. one of the difficult forms cancer— of cancer Most significantly, developed an to detect at its earliest stages. About Indian rotavirus vaccine—from an onedetect of theatmost difficultstages. forms About of cancer Most significantly, we developedan an to its earliest Indian rotavirus vaccine—from 570,000 cases were diagnosed globally in Indian strain, produced by an Indian to detect cases at its earliest stages. About rotavirus vaccine—from an 570,000 were diagnosed globally in Indian strain, produced by an Indian 2018 and 311,000 deaths occurred. Even company and embraced by the Indian 570,000 weredeaths diagnosed globally in Indian strain, produced by an 2018 andcases 311,000 occurred. Even company and embraced theIndian Indian so, many parents’ irrational fears have government. This inexpensive vaccine 2018 and parents’ 311,000irrational deaths occurred. Even company andThis embraced by thevaccine Indian so, many fears have government. inexpensive kept them from having their children has probably saved more than 50,000 so, many irrational have government. inexpensive kept themparents’ from having their fears children has probably This saved more thanvaccine 50,000 inoculated against the virus that causes lives in its first two years of use. In kept them from having their that children has probably saved more of than 50,000 inoculated against the virus causes lives in its first two years use. In this cancer—with only about half of 2019, we celebrated delivery of its inoculated againstonly the virus lives inwe itscelebrated first two years of use. this cancer—with aboutthat half causes of 2019, delivery of itsIn American teens having received both 125-millionth dose. What greater this cancer—with only about halfboth of 2019, we celebrated delivery of its American teens having received 125-millionth dose. What greater recommended doses of the HPV vaccine. achievement could there be for a American teensdoses having received 125-millionthcould dose.there Whatbe greater recommended of the HPV both vaccine. achievement for a pediatrician but to save the lives of the recommended doses of the HPV vaccine. achievement but could therethe be for a of the pediatrician to save lives For those of us who are old enough to world’s most vulnerable children? pediatrician to save the lives of the For those of us who are old enough to world’s mostbut vulnerable children? remember successful elimination of the Dr. Raj Bhan was my longtime collaborator and For those of us who are old enough world’s most vulnerable children? remember successful elimination of to the Dr. Raj Bhan was my longtime collaborator and And yet, as fears of coronavirus sweep close friend. His legacy endures in the lifesaving dreaded polio in the U.S. and eradication remember successful elimination of the close His endures in the lifesaving dreaded polio in the U.S. and eradication And yet, as fears of coronavirus sweep rotavirus Dr. Rajfriend. Bhan waslegacy mydeveloped. longtime collaborator and vaccine he of smallpox worldwide—both through the the globe, false rumors emerge that vaccine he developed. close friend. His legacy endures in the lifesaving dreaded polio in the U.S. and through eradication Andglobe, yet, asfalse fears of coronavirus sweep rotavirus of smallpox worldwide—both the the rumors emerge that miracle of vaccines—it is astonishing that somehow the outbreak was caused by rotavirus vaccine he developed. of smallpox worldwide—both through that the the globe, the false rumors was emerge that by miracle of vaccines—it is astonishing somehow outbreak caused these achievements are disregarded and vaccines are a vaccine attempt gone wrong. Meanwhile, researchers miracle vaccines—it is vaccines astonishing somehow the outbreak caused by these achievements are of disregarded and are that a vaccine attempt gone was wrong. Meanwhile, researchers now being shunned by some. We rely on herd immunity worldwide are working tirelessly to develop a vaccine thesebeing achievements disregarded vaccines are a vaccine attempt gone tirelessly wrong. Meanwhile, now shunned are by some. We relyand on herd immunity worldwide are working to develop researchers a vaccine for vaccine-preventable diseases to be contained. As that could halt the epidemic’s spread. nowvaccine-preventable being shunned by some. We to rely herd immunity worldwide tirelessly to develop a vaccine for diseases beon contained. As that could are haltworking the epidemic’s spread. we’ve seen with measles, diseases can quickly reemerge for vaccine-preventable be contained. As that could halt the epidemic’s spread. we’ve seen with measles,diseases diseasestocan quickly reemerge when vaccine levels drop. Hysteria surrounds this new health threat but little we’ve seen with measles, when vaccine levels drop.diseases can quickly reemerge Hysteria surrounds this new health threat but little attention is paid to influenza, which this season when vaccine levels drop. Hysteria surrounds this new health but little attention is paid to influenza, which threat this season As I continue to grieve the loss of my friend, I take has already taken 14,000 lives, nearly 100 of them attention is paid influenza, which this season As I continue to grieve the loss of my friend, I take has already takento14,000 lives, nearly 100 of them comfort in the knowledge his great achievement—the children. Many continue to avoid flu shots, despite the As I continue grieve thehis loss of my friend, I take has already taken 14,000tolives, nearly 100 of them the comfort in theto knowledge great achievement—the children. Many continue avoid flu shots, despite new rotavirus vaccine Rotavac—will save countless lives considerable body of evidence that shows the vaccine comfort in the vaccine knowledge his great achievement—the children. Many continue to avoid shots, despite the new rotavirus Rotavac—will save countless lives considerable body of evidence thatflu shows the vaccine in the years to come. This new addition to the global can offer significant protection. new rotavirus Rotavac—will savetocountless considerable body ofprotection. evidence that shows the vaccine in the years tovaccine come. This new addition the globallives can offer significant arsenal of vaccines is an important tool to improve in the years to come. new addition global can offer significant protection. arsenal of vaccines is This an important tool to the improve childhood survival among the world’s most vulnerable This lack of faith in scientific evidence is also the reason arsenal of survival vaccines among is an important tool to improve childhood the world’s most vulnerable This lack of faith in scientific evidence is also the reason and stands as Dr. Bhan’s enduring legacy. why measles is once again an urgent public health childhood among enduring the world’s most vulnerable This measles lack of faith in scientific is alsohealth the reason and standssurvival as Dr. Bhan’s legacy. why is once again anevidence urgent public threat. Infections have increased 30% globally and a and stands as Dr. Bhan’s enduring legacy. why measles is once again an urgent health threat. Infections have increased 30%public globally and a RESOURCES threat. Infections have increased 30% globally and a RESOURCES 10 http://bit.ly/VaccineTrust RESOURCES 10 http://bit.ly/VaccineTrust

http://bit.ly/VaccineTrust

PEOPLE NCI names new global health director Former Fogarty grantee Dr. Satish Gopal has taken up his new role as director of the Center for Global Health at the NIH’s National Cancer Institute. Gopal spent the last seven years in Malawi, where he was the country’s only certified medical oncologist and oversaw a largely NIH-supported cancer research portfolio.

Hib conjugate vaccine developer dies Dr. John Bennet Robbins, a former lab chief at the NIH, died in November. Robbins co-developed the process to conjugate polysaccharide’s coating of bacteria to render them immunogenic, perhaps one of the most influential discoveries in recent vaccinology, which led to new vaccines for meningitis, typhoid and other diseases.

Hahn appointed as FDA commissioner Dr. Stephen Hahn has been sworn in as FDA Commissioner. Hahn, a physician-scientist with training in oncology, was previously chief medical executive at the University of Texas MD Anderson Cancer Center. Dr. Ned Sharpless, who served as FDA Acting Commissioner, has returned to NIH as NCI Director.

Global Alliance for Chronic Diseases hires CEO The Global Alliance for Chronic Diseases has selected Dr. Morven Roberts as its new CEO. Roberts previously managed the UK Medical Research Council’s investments in topics including diabetes, cardiovascular diseases, clinical trials and global infections. She earned a Ph.D. in parasitology and her early research career included stints in Kenya and India.

Gates Foundation selects new CEO Dr. Mark Suzman is the new CEO of the Bill and Melinda Gates Foundation. Originally from South Africa, Suzman joined the foundation in 2007 and has helped build its global presence in Africa, China, Europe and India. He holds a doctorate in international relations from Oxford University.

AAAS picks new CEO, executive publisher The American Association for the Advancement of Science recently selected biochemist Dr. Sudip Parikh as its new CEO and executive publisher of the Science family of journals. Previously, Parikh was a senior vice president at the Drug Information Association and served on the staff of the U.S. Senate Appropriations Committee.

Indian rotavirus vaccine developer dies Pediatrician and rotavirus vaccine developer Dr. Maharaj (Raj) K. Bhan died in January. Bhan and Fogarty Director Dr. Roger Glass spent 30 years collaborating to develop a rotavirus vaccine for India. Rotavac was licensed in 2014 and is being distributed by the Indian government, UNICEF and GAVI. 42 Delaware Journal of Public Health – April 2020

Global HEALTH Briefs Analysis of research in higher ed released WHO has published a study of data from higher education institutions in 178 countries that offer disciplines related to health research training. The information allows users to examine available capacity, as well as gaps in teaching and training opportunities, and to monitor progress over time. Full report: http://bit.ly/WHED_data

Ethics issues studied for research in crises Better evidence about what works during global health emergencies is needed but gathering it poses a number of ethical challenges. A new report published by the Nuffield Council on Bioethics examines topics such as study design, collaborations and sample gathering. Several Fogarty staff contributed to the effort. Full report: http://bit.ly/bioethics_crises

CDC publishes global health security tips

A new report shares lessons learned from CDC and partners’ work to help countries build core public health capacities to quickly identify and address health threats at their source. Articles highlight the value of effective partnerships, and the link between local and global health. Full report: http://bit.ly/CDC_security

G-FINDER report finds uneven progress

The twelfth annual G-FINDER report has been released, providing data on investments made on neglected disease research and development in 2018. In all, 262 organizations completed the survey, which covered 36 neglected diseases, all relevant product types and basic research. Full report: www.policycuresresearch.org/analysis

GHTC develops new fact sheets

The Global Health Technologies Coalition has unveiled a new fact sheet series that examines the role of research and development in driving progress across diseases and topics, including HIV/ AIDS, malaria, TB and neglected tropical diseases. Fact sheets: http://bit.ly/GHTC_Facts

Many researchers fail to report results

A study of data in ClinicalTrials.gov published in The Lancet showed fewer than half of all trials are in full compliance with FDA regulations to report results within one year. By examining 4,209 registered trials, the authors found nearly 64% had reported some results but only 40% were fully compliant. Journal article: http://bit.ly/Lancet_CT

JANUARY/FEBRUARY 2020

Funding Opportunity Announcement

Details

Deadline

International Research Scientist Development Award K01 Independent Clinical Trial Required K01 Independent Clinical Trial Not Allowed

http://bit.ly/IRSDAK01

Mar 6, 2020

Japan Society for the Promotion of Science (JSPS) Fellowships for U.S. Postdoctoral Scientists in Japan

http://bit.ly/JSPSforUS

Mar 31, 2020

International Bioethics Training R25 Clinical Trial Not Allowed D43 Clinical Trial Optional

http://bit.ly/BioethicsTraining

Jun 4, 2020

Fogarty HIV Research Training for LMIC Institutions D43 Clinical Trial Optional D71 Clinical Trial Not Allowed G11 Clinical Trial Not Allowed

http://bit.ly/NIHGlobalHIV

Aug 20, 2020

Mobile Health: Technology and Outcomes in LMICs R21/R33 - Clinical Trial Optional - non-AIDS applications

http://bit.ly/NIHmhealth

Sep 24, 2020

For more information, visit www.fic.nih.gov/funding

Global Health Matters January/February 2020

China overtaking U.S. as global research leader ational Scien

Board | S ience & Engi eering Ind a r

020-1

Average annual growth rate of domestic R&D expenditures: 2000–17

Volume 19, No. 1 ISSN: 1938-5935

18 16

Fogarty International Center National Institutes of Health Department of Health and Human Services

Web manager: Anna Pruett Ellis Anna.Ellis@nih.gov Writer/editor: January W. Payne January.Payne@nih.gov Writer/editor: Susan Scutti Susan.Scutti@nih.gov Designer: Carla Conway

All text produced in Global Health Matters is in the public domain and may be reprinted. Please credit Fogarty International Center. Images must be cleared for use with the individual source, as indicated.

SUBSCRIBE: www.fic.nih.gov/subscribe

12 Percent

Managing editor: Ann Puderbaugh Ann.Puderbaugh@nih.gov

10 8 6 4 2 0

Japan

France

United Kingdom

United States

Germany

India (2000–15)

South Korea

China

U scientific ur pea U io and engineering investment has dropped relative to the rest of the world, U.S. N e(s while spending has risen rapidly in a number of Asian countries, according to a new ce e g report So rc ( from the National Science Board (NSB). China alone accounts for nearly a third Nat onal a ter s o R&D Resou es; OECD, Main c ence and ech ology ndica o s 201 / NES Ins u e r S tis ic Re ear h nd ofNCSES in atglobal research and development (R&D) growth since 2000, the NSB E the i increase lD l t says, Indi a and 02 is R “on a path to soon become the world’s largest R&D performer.”

In assessing math and science test scores of elementary and secondary school students, the study found U.S. education is “mediocre and stagnant relative to other countries.” The U.S. has long relied on foreign-born talent for science and engineering (S&E) expertise, with more than a third of doctoral degrees going to international students. The report notes “a startling shift” in foreign student enrollment in U.S. colleges and universities, which has slowed since 2016. Globally, R&D funding has tripled in the last 20 years, “which is good for humanity because science is not a zero-sum game,” said NSB Chair Diane Souvaine. “However, it also means that where once the U.S. was the uncontested leader in S&E, we now are playing a less dominant role in many areas.”

R E SOURCES Full report: http://bit.ly/NSB_2020 43

and the National Institutes of Health All of Us Research Program ABOUT All of Us Too often, health care is one size fits all. Treatments meant for the “average” patient may not work well for individual people. Health care providers may find it difficult to coordinate care among specialists or to access all of a patient’s health information. Researchers may spend lots of time and resources creating new databases for every study. All of Us is working to improve health care through research. Unlike research studies that focus on one disease or group of people, All of Us is building a diverse database that can inform thousands of studies on a variety of health conditions. This creates more opportunities to: • • • •

Know the risk factors for certain diseases Figure out which treatments work best for people of different backgrounds Connect people with the right clinical studies for their needs Learn how technologies can help us take steps to be healthier

PRECISION MEDICINE The National Institutes of Health formed the Precision Medicine Initiative Working Group of the Advisory Committee to the Director in March 2015. The group concluded its work in September 2015 with a detailed report. The report provided a framework for setting up the All of Us Research Program. Precision medicine: • • • • •

Is based on you as an individual Takes into account your environment (where you live), lifestyle (what you do), and your family health history and genetic makeup Gives health care providers the information they need to make customized recommendations for people of different backgrounds, ages, and regions Helps you get better information about how to be healthier Reduces health care costs by matching the right person with the right treatment the first time All of Us is part of a new era in which researchers, health care providers, technology experts, community partners, and the public work together to develop individualized health care. Learn more about who is involved. A DELAWARE PERSPECTIVE The All of Us research program is transformative as it will generate insightful data encompassing the diversity that comprises our population. I am particularly proud of Tim Gibbs and his colleagues at the Delaware Academy of Medicine / Delaware Public Health Association for their important contribution to this program, particularly because it influences how we develop CRISPR-directed gene editing for human therapy. This breakthrough technology relies heavily on the underlying DNA sequence of an individual genome for effective action so having genomic databases that truly reflect that diversity will help us design tools not for a privileged few, but for...All of Us. The research objective of this wonderful program aligns perfectly with the ChristianaCare mission of a patient first approach to therapeutic gene editing for cancer and infectious diseases. Eric B. Kmiec Director, Gene Editing Institute Helen F. Graham Cancer Center & Research Institute ChristianaCare

44 Delaware Journal of Public Health – April 2020

TAKE ACTION – OUR GOAL The goal of the Delaware Academy of Medicine / Delaware Public Health Association is to see Delaware’s residents, in all of our diversity, well represented in the All of Us Research Program. During this COVID-19 pandemic the importance of programs like All of Us is highlighted more than ever. Timothy E. Gibbs, MPH Executive Director Delaware Academy of Medicine Delaware Public Health Association Click here to join! https://participant.joinallofus.org/#/register A STATEMENT FROM THE NIH - ALL OF US COVID-19 RESPONSE The All of Us Research Program is dedicated to better health, both in the future and today. We have all watched the increase in coronavirus disease 2019 (COVID-19) cases in the U.S. We believe it is important to act in the best interest for our participants, their families, and the All of Us team to protect their health. To this end, we’re pausing all in-person All of Us appointments and events. We anticipate that this pause will last for at least one month. We will continually assess and make decisions about whether this pause will extend. It is vital at this moment that individuals, whether they feel sick or healthy, distance themselves from others to help slow the exposure and spread of this virus. In addition, postponing these appointments will help reduce the number of non-essential visits to clinics and other health care providers. We must make sure our health care providers are free to see sick patients first. We’ll continue tracking this situation and will share more updates as needed. This pause impacts only in-person activities, which include: • •

Clinic appointments to provide physical measurements and donation of biosamples (blood, urine, and/or saliva) Community events, including All of Us Journey tour stops

If you have a clinic appointment scheduled, your local enrollment partner will contact you to reschedule. People can still sign up and take part in the program online at JoinAllofUs.org. Existing participants can also sign in to their accounts and answer survey questions. In times like this, health research feels especially important. Together, we can help make a difference in speeding up research and improving the health of our communities. Please take care of yourselves and your neighbors. For updates on COVID-19 and tips on staying safe, please visit coronavirus.gov. With thanks, Josh Denny, M.D., M.S. Chief Executive Officer All of Us Research Program

Training for Tomorrow: A Century of GME at ChristianaCare Brian Levine, M.D.

Medical education is an intense developmental process for students, residents and fellows – and it’s this training that supports the health and wellness of the nation. Through more than 100 years of providing post-graduate medical education, ChristianaCare has trained thousands of physicians who now serve the Delaware Valley and beyond. The experience they gain through ChristianaCare’s nationally recognized network of urban and suburban, academic and community hospitals prepares them to meet America’s health care needs now and in the future. In accordance with its mission and commitment of the Board of Directors, ChristianaCare is dedicated to providing excellent graduate medical education (GME) for physicians and dentists in training. Instruction is designed to offer opportunities for research and scholarly activity in an environment conducive to becoming well-trained physicians and dentists who will provide high-quality, state-of-the-art patient care.

AMBITIOUS BEGINNINGS Medical education has changed quite a bit since the first three physicians were offered an internship at Wilmington’s Homeopathic Hospital in 1910 (renamed the Memorial Hospital in 1940). The focus of GME at ChristianaCare has historically focused on primary care specialties, however there are currently over 30 training programs with almost 300 physicians in training (see Table 1) in a variety of specialties. Each program has rigorous oversight, with many governed by the Accreditation Council for Graduate Medical Education (ACGME). The ACGME is a private organization that sets standards in the United States for GME residency and fellowship programs and the institutions that sponsor them. The ACGME renders accreditation decisions based on compliance with these standards. As the only level 1 trauma center and major tertiary care teaching institution between Baltimore and Philadelphia, physicians in training at ChristianaCare care for a diverse, high volume and high acuity patient population. Without its own medical school, Delaware and ChristianaCare has benefited from a strong relationship with two Philadelphia medical schools (Sidney Kimmel Medical College (SKMC) at Thomas Jefferson University and the Philadelphia College of Osteopathic Medicine (PCOM)). More than 700 medical students rotate through ChristianaCare hospitals and facilities annually. The ultimate goal is to train Delaware residents who will eventually practice and care for the patients of our state.

patient care across the spectrum of illness. The residents currently staff inpatient services at both Wilmington and Christiana hospitals; this includes providing emergency coverage to rescue and resuscitate patients throughout the hospital setting as well as providing 24-hour coverage of four floor services and two ICU services at Christiana Hospital. Each year, nearly 3000 rapid responses and 500 code blues are handled by the IM residents between the two hospitals. The IM residency provides high quality care to our patients and immediate access to a physician during an emergency. In the outpatient setting, IM residents provide a large portion of the primary care services for the Wilmington Adult Medicine Office embedded in Wilmington Hospital. The clinic serves nearly 9,000 patients, many of whom come from underserved populations in the city of Wilmington, and averages more than 14,000 primary care encounters per year. The IM residents and faculty are also very involved in scholarly activity, including both original research and quality improvement projects. In academic year 2018-2019, this resulted in seven publications, seven published abstracts, 20 national presentations, and 48 regional/state presentations at scientific meetings across all IM programs. Each year, the Internal Medicine residency graduates 12 board-eligible internists. Over the past five years, approximately 50% of graduates have gone on to fellowship training and approximately 50% to careers in general medicine. In recent years, approximately 40% of residents have been recruited to work within the ChristianaCare system. Recent initiatives have focused on enhancing primary care training, with the goal of addressing the primary care shortage both within the state of Delaware as well as nationwide; this has resulted in an increased interest in primary care careers among graduating and current residents, with 25% of the class of 2020 pursuing full or part-time careers in this field.

FAMILY MEDICINE

INTERNAL MEDICINE

Over the past 50 years of the Family Medicine (FM) residency program, there have been only five program directors-- an enviable record for any program. The original family medicine outpatient offices were housed on Jefferson Street, but the program rapidly outgrew the space. Offices were established on the third floor of the old nursing school at the Delaware Division (now Wilmington Hospital) and were used until 1992, when the department moved to more spacious quarters on Foulk Road, where they remain today. In addition to these offices, FM residents also see patients in the primary care offices in Wilmington Hospital and in a 6-resident track located at the 4th Street location of Westside Family Health Care. An inpatient Family Medicine unit was established in 1974 at Wilmington Hospital, and this continues with the residents largely based out of the 4th floor.

The Internal Medicine (IM) residency was established in the mid1940s1 and has grown since that time to include a complement of 36 IM categorical residents and 31 combined residents (MedicinePediatrics and Emergency Medicine-IM). IM residents provide

In 2010, the FM Program was accepted as one of the 14 programs to participate in P4 – “Preparing the Personal Physician for Practice.” An innovative, longitudinal, ambulatory focused curriculum was unveiled and is still in practice today.

Let’s take a journey through the history and current state of the larger training programs at ChristianaCare that have graduated more than 3000 residents and fellows since 1902.

46 Delaware Journal of Public Health – April 2020

Program Name

Program Type

Program Length (years)

Total # of Residents/ Fellows 2019-2020

Cardiovascular Disease Fellowship

Fellowship

Interventional Cardiology

Fellowship

Advanced Heart Failure

Fellowship

Diagnostic Radiology

Residency

Integrated Radiology

Residency

Emergency Medicine

Residency

Emergency Medicine - Family Medicine

Residency

Emergency Medicine - Internal Medicine

Residency

Family Medicine

Residency

General Practice Dentistry

Residency

General Surgery

Residency

Breast Surgical Oncology Fellowship

Fellowship

Surgical Critical Care Fellowship

Fellowship

Internal Medicine

Residency

Medical Physics

Residency

Medicine-Pediatrics

Residency

Obstetrics/Gynecology

Residency

Minimally Invasive Gynecologic Surgery

Fellowship

Oral Maxillofacial Surgery Residency

Residency

Pharmacy

Residency

Pharmacy Ambulatory Care

Residency

Pharmacy Critical Care

Residency

Podiatric Medicine

Residency

Psychiatry

Residency

Sports Medicine

Fellowship

Transitional Year

Residency

Vascular Interventional Radiology

Fellowship

Otolaryngology

Fellowship

Hospice and Palliative Care

Fellowship

Clinical Informatics

Fellowship

Vascular Interventional Radiology Independent

Residency

1-2

Total

281

Table 1. Residency and Fellowships that spend most of their clinical time at ChristianaCare in 2020 (does not include all joint sponsored programs)

The FM residency provides vital care to the underserved in the community. They are considered a safety net practice with a large patient population of Medicaid/Medicare, uninsured, underinsured, and those with poor health literacy. A broad range of services encompass the FM residency, including comprehensive chronic disease management, prenatal care, gender affirming care, addiction medicine in primary care, and routine outpatient procedures. Many of these services are provided during evening and weekend hours. The residents rotate through school-based health centers, the HIV/Holloway clinic, juvenile detention centers and on the addiction medicine service. Continuity of care is stressed throughout the program on both the inpatient and outpatient sides, and the academic setting provides a unique opportunity to care for patients at all levels of acuity.

The program has maintained a strong focus on osteopathic education. In 2000, the allopathic and osteopathic Family Medicine residencies at Riverside Hospital merged, and the education of both allopathic and osteopathic residents continues today. In 2017, the program received ACGME Osteopathic Recognition. The program is accredited for a total of eight residents per year and continues to graduate high-quality family physicians Delaware, and the surrounding region. One primary focus of the FM residency is retention of these much-needed graduates in the community. ChristianaCare is committed to expanding primary care and realigning models to value primary care. 47

GENERAL SURGERY The General Surgery residency program began accepting residents in 1938.1 Currently, the program graduates six surgeons per year. A high volume of surgical procedures and the diverse pathology ensures exposure to the entire spectrum of surgical practice. Surgical residents are integral to the care of our patients in this community. While receiving exceptional training and developing their skills, the surgical residents provide a key service to the institution and our patients. Christiana and Wilmington Hospitals have surgical residents and staff around the clock. There is also a surgical outpatient clinic at Wilmington Hospital that cares for the underserved of our community. Surgical residents work long, but fulfilling hours, doing the work of several FullTime-Equivalents (FTE) if they were to be compared with more traditional employees. Most years, more than half of the graduating residents enter competitive subspecialty fellowships throughout the country. Many graduates of the general surgery residency ultimately establish practice in the area, giving back to the community and expanding access to care.

OBSTETRICS AND GYNECOLOGY The residency in Obstetrics and Gynecology has been active since the late 1950s. In 1986, the entire inpatient Obstetric and Gynecologic program moved fifteen miles south from the city of Wilmington to the newly built Christiana Hospital in Newark (see Figure 1). As a center with a very large clinical volume and

Figure 1. Christiana Hospital, Opening Day, 1985

48 Delaware Journal of Public Health â&#x20AC;&#x201C; April 2020

active maternal-fetal research, the program has developed into one of the strongest in the Northeast, with an exceptional volume and diversity of cases. The program graduates seven residents per year. There is a strong emphasis on serving all women in our community. The OB/GYN residents care for women in federally funded clinics on a regular basis. Furthermore, their continuity clinics are located in Wilmington, in order to provide care to an underserved community. Residents are constantly learning and tend to be guideline-driven, leading to a consistent standard of care that is not always found in communities without a residency program. That consistent adherence to standards, in turn, improves the quality of care for the entire community.

EMERGENCY MEDICINE Through the 1970s, the emergency departments (EDs) in Delaware were staffed by attending physicians from many different specialties because emergency medicine was not recognized as a unique specialty. Both the severity of cases and the need for 24-hour coverage, 7 days a week made it difficult to get physician coverage. Dr. Ben Corballis, a local surgeon, took up the challenge and offered the hospital a plan. The physician organization he developed eventually became Doctors for Emergency Services (DFES), which continues to serve ChristianaCare today and is one of the longest running private emergency groups in the country. Dr. Corballis advocated for the development of a residency program in emergency medicine,

even though it was not yet a nationally recognized specialty, but the Wilmington Medical Center Education Committee rejected his requests. However, in 1979, emergency medicine became the 23rd specialty recognized by the American Board of Medical Specialties,2 and the Wilmington Medical Center Education Committee approved Dr. Corballis’ request. It took considerable political effort by Dr. Corballis and others to receive approval for a community (not university) based program. Provisional approval was received in November 1981, and the program began with six residents per year. In 2020, the Emergency Medicine residency enjoys a strong national reputation, with 12 categorical residents per year. The Department of Emergency Medicine also has expanded its residency spots and with the combined Emergency MedicineInternal Medicine residency (founded in 1991) with an additional three residents per year, and the Emergency Medicine-Family Medicine program (founded in 2007) with 2 residents per year. The emergency department is an essential part of the safety net of health care. Care is provided to anyone 24 hours a day, 7 days a week, regardless of insurance, ability to pay, or immigration status. We have 62 supervised residents working around the clock in more than 500 shifts per month to provide essential and emergency care to the population of Delaware and the surrounding areas. More than 50% of our graduates stay in our region to practice emergency medicine. There is no doubt that emergency care in our state would suffer if the training program did not exist. Through resident education, we can provide our patients with cutting-edge emergency care. These residents then transition into supervising roles at area hospitals to continue to provide care. The residents care deeply about the medical issues and health care delivery challenges that we face in our everyday world.

COMBINED PROGRAMS ChristianaCare is unique nationally in that it has three combined programs – an important achievement that embodies the spirit of flexibility and creativity needed for the future of healthcare. These programs are instrumental in blurring traditional lines between departments and in thinking holistically as a system of care beyond departmentalized silos. Combined residents are ambassadors from one department to the other, softening the edges of traditional territorial lines and promoting greater understanding between disciplines. As this happens, patients benefit from that broader perspective, better communication and coordination and a wider range of possible medical and social system interventions. These programs produce a different kind of physician that many consider more versatile and agile for a changing health care landscape.

EMERGENCY MEDICINE/INTERNAL MEDICINE COMBINED PROGRAM In 1990, it was recognized that it would not be possible to increase the size of the Internal Medicine residency program; however, the recent development of combined residency programs had been increasing in popularity. The development of a combined Emergency Medicine-Internal Medicine program that would be

five years in length and would allow residents to sit for the boards of both specialties was proposed and initiated. As the popularity of Emergency Medicine increased, so has the interest in EM-IM; the program now routinely recruits three high-quality residents per year. Residents uniquely trained in both EM and IM bridge the gap of both specialties to provide high-quality care across the healthcare continuum. Residents gain experience in general emergency care, hospital medicine, primary care, observation medicine, intensive care and/or subspecialty care. Having the experience described above allows EM/IM trained physicians to make the whole health care team stronger. Physicians in the emergency department, in the office, and on the inpatient units all benefit from the comprehensive experience of these providers. This has allowed many of the graduates to take on important leadership and administrative roles within ChristianaCare and the community.

EMERGENCY MEDICINE/FAMILY MEDICINE ChristianaCare offers a trail-blazing opportunity for residents who want to pursue dual training and dual board eligibility in Emergency Medicine (EM) and Family Medicine (FM). The five-year EM-FM residency program was the first allopathic program of its kind in the country. The curriculum builds a solid foundation of knowledge and experiences to create physicians who are innovative, passionate leaders in both fields, possessing a unique understanding of health care systems and delivery. Our graduates are capable of providing top-notch care in any clinical setting upon graduation, from rural to international to academics, and beyond. ChristianaCare EM-FM residents experience a broad array of clinical disciplines not only through training in both departments, but also through clinical rotations in OB-GYN, pediatrics, surgical subspecialties, emergency medical services, anesthesia, orthopedics/sports medicine, radiology, women’s health, trauma/ surgical critical care, and medical, cardiac and pediatric intensive care units.

INTERNAL MEDICINE-PEDIATRICS (MED-PEDS) This four-year program was initiated at the Medical Center of Delaware in 1989 and in conjunction with A.I. duPont Hospital for Children. The “Med-Peds” program is currently sponsored by the Sidney Kimmel Medical College at Thomas Jefferson Medical University, with all clinical rotations at ChristianaCare, Nemours/duPont Hospital for Children, and in the Delaware community. The program graduates four residents per year, each eligible to become board-certified in both Internal Medicine and Pediatrics. Dr. Allen Friedland was named the program director in 1999, and he remains the longest-running program director at ChristianaCare. The Med-Peds Residency Program attracts candidates from across the country who value the challenging academic curriculum within multiple clinical settings. The diverse patient population offers residents exceptional opportunities to diagnose and treat a broad spectrum of primary-care diseases, as well as tertiary-care medical conditions not routinely encountered in smaller hospital settings. 49

Since the beginning, the Med-Peds Residency Program has trained physicians for careers in primary care, hospitalist work and in the subspecialties in both academic and non-academic settings. Residents develop competence and excellence in both specialties alongside our large Med-Peds faculty of the community and hospital-based Med-Peds Section that consists of over 54 attending physicians. Our residents treat patients with both acute care and chronic care needs, as well as with preventive medicine and health promotion across the entire age spectrum. Many have attained a leadership role, and this program has developed one of the strongest national reputations for combined programs. There is an overall >33% local retention rate of graduates since its inception – with more than 50% retention in the past five years. The program is a strong provider of physicians for the local community and attracts Med-Peds physicians from across the country to serve as primary care physicians, hospitalists and specialists at ChristianaCare, Nemours, Westside HealthCare and private practices.

RADIOLOGY The Wilmington Medical Center established a Radiology residency in the 1950s1; however, the Diagnostic Radiology Residency Program at ChristianaCare was initially accredited in 1977 and has trained generations of radiologists who now practice locally and regionally, as well as nationally. In the past five years, 70% of our graduates have remained in the DE/PA/MD/NJ/NY region. Without our program, that local and regional presence would not be as robust. As value-based and patient-centered, our radiologists practice in multiple specialties. Having Christianatrained radiologists who have known and worked with others on the caregiver team for many years positively impacts the care of our patients. The focus of the diagnostic radiology residency program at ChristianaCare has always included training competent radiologists for community practice. The large volume and complexity of cases has ensured this; ChristianaCare’s Department of Radiology currently performs and interprets approximately 500,000 imaging studies annually. Our radiology residents are frontline caregivers 24/7. In addition, they participate in educating other departments through multidisciplinary conferences and projects. Radiologists (faculty and residents) are integral team members. Currently, the program graduates four diagnostic radiology residents each year.

PSYCHIATRY Recognizing the urgent need for psychiatrists in our community, in 2018, ChristianaCare started a psychiatry residency program. The program utilizes ChristianaCare’s ample resources and resident training infrastructure to treat a variety of mental illnesses and substance abuse disorders while simultaneously educating Delaware’s psychiatrists of the future. The psychiatry residents rotate through many different services throughout the institution during their training. Psychiatry residents provide inpatient psychiatric services at Wilmington Hospital’s newly opened inpatient unit, consult services at both Wilmington Hospital and ChristianaCare’s Newark Campus, and will also provide care in outpatient clinics at both locations. Additionally, our residents work collaboratively 50 Delaware Journal of Public Health – April 2020

in the community providing services at Nemours / A.I DuPont Hospital for Children, Recovery Innovations Crisis Response Center, and Delaware Psychiatric Center. The broad array of rotations allows our residents to gain experience and develop proficiency in psychopharmacology, psychotherapy, neuromodulation (i.e. Electroconvulsive therapy (ECT) / Transcranial Magnetic Stimulation (TMS)), emergency psychiatric assessment, and substance abuse treatment. The psychiatry residency program accepts four residents per year and will graduate its first class in 2022. The goal is to provide more psychiatrists to the patients in our region, filling a critical need.

OTHER PROGRAMS Over the years, ChristianaCare has continued to foster other residencies, fellowships, and allied health programs (see Table 1). All these programs are integral to the care of the patients in our community and enhance the system. Pharmacy, podiatry and dentistry (including oral maxillofacial surgery) have had long running programs with excellent reputations for providing vital services to those in need. These residents often rotate through many departments during their training. In addition, allied health professional programs including medical physics and psychology graduate several trainees annually. Fellowships in cardiovascular disease, hospice and palliative care, minimally invasive gynecologic surgery, sports medicine, otolaryngology, surgical breast oncology, surgical critical care, and vascular interventional radiology receive the benefit of high-quality training due to the volume and acuity of our patient population. Several medical centers in Philadelphia send their residents and/or fellows to train at ChristianaCare as well: we have rotators in trauma surgery from Inspira Health System, urogynecology from Drexel University, ophthalmology from Temple, and a joint program with SKMC in neonatology, to name a few.

THE FUTURE The Graduate Medical Education (GME) enterprise of ChristianaCare has a long history and remains strong. Our individual programs perform at a high level and remain competitive regionally and nationally. Looking forward, the future of graduate medical education in Delaware is on solid footing with ChristianaCare’s ongoing commitment to educating physicians in Delaware. However, major challenges loom. First and foremost is financing. As general health care financing and money for education becomes more complex and limited, ChristianaCare must adapt to ensure that its residency programs are financially viable. The present patchwork system of partial government funding (Medicare) and a cap placed on federal funding for residency programs will hopefully be modified in the future. As ChristianaCare moves forward, it will also have to make decisions on the importance of adding residents in both primary care and subspecialty areas, ensuring that both educational excellence and enough funding are present in each program. There has already been a movement toward enhancing or even developing new programs that can provide graduates in the most needed specialties for our community. The psychiatry residency is a prime example of this.

ChristianaCare has the responsibility to provide for the education of undergraduate medical students and to conduct programs of graduate medical education with the aim of increasing the number of physicians practicing in Delaware. The GME and residency program leadership will need to attract college students to our two affiliated medical schools, SKMC and PCOM. The Delaware Institute of Medical Education and Research (DIMER) was developed many years ago to fund and provide valued medical school applicant spots at the two medical schools. The goal is to educate medical students about our opportunities, so they utilize our branch campus (rotating their entire third year of medical school at ChristianaCare) and eventually train and stay here. Keeping residencies strong will enable many of the 700+ rotating medical students to experience the exceptional education here and choose ChristianaCare and Delaware for their training. In addition to our affiliated medical schools, ChristianaCare also hosts hundreds of medical students per year from many area schools for various rotations. Many of these students rotating at ChristianaCare match into one of our residency/fellowship programs and many of our graduating residents/fellows choose to stay and practice in Delaware. In addition to caring for our patients, the residents are afforded the opportunity for developmental growth while training at ChristianaCare. Programs such as a “pocket-MBA” and leadership training, along with the professional opportunities within our many committees, rounds out the experience for our residents. These varied experiences allow our graduates to be clinician leaders within our community and throughout the United States.

GME efforts are more aligned with ChristianaCare’s system-wide goals and initiatives than ever before, and our work has only just begun. We will continue to develop a robust culture of safety and quality in our clinical learning environment. Our commitment to continuous quality improvement of our learning environment will not only ensure that ChristianaCare is a national leader in GME but will ensure that we deliver on our commitment to serve our neighbors as expert, caring partners in their health. GME at ChristianaCare has a long and storied history. The training programs are the backbone of the health care in our community. The residents at ChristianaCare continue to drive innovation and change and, most important, will be the clinicians caring for all of us soon.

ACKNOWLEDGEMENTS I would like to thank each of the program directors and Catherine Zuk who helped with the construction of this manuscript. In addition, a great thanks goes to Daniel Hess, M.D. and Valerie Hunt for their excellent editing suggestions.

REFERENCES 1. Little, B. W. (2002, July). 100 years of graduate medical education in Wilmington, Delaware. Delaware Medical Journal, 74(7), 309–319. PubMed 2. American Board of Medical Specialties. (2019). ABMS Guide to Medical Specialties. Retrieved from: https://www.abms.org/ media/194925/abms-guide-to-medical-specialties-2019.pdf

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Advanced Practice Clinician (APC) Fellowships: A Strategic Approach to a High-Quality, Stable APC Workforce Lisa Maxwell, M.D., M.H.C.D.S., ChristianaCare Jennifer Painter, D.N.P., ChristianaCare

BACKGROUND Advanced Practice Clinicians (APCs), which include nurse practitioners and physician assistants, are valuable members of health care teams across all clinical care settings and particularly in primary care. Maintaining an engaged workforce of highly collaborative physicians and APCs is important to the success of health care systems. An engaged workforce is dependent on many factors, one of which is successful onboarding into new clinical environments. Onboarding newly graduated clinicians entering the workforce for the first time poses additional challenges. Successful transitions into practice can be directly correlated with the clinical training one receives as a learner before becoming certified as a clinician. The total time of clinical training required to become a certified APC can vary between 500 and 2000 hours. The required clinical training is vastly greater for physicians. For example, the required clinical training time for primary care physicians is 15,000 – 16,000 hours, and considerably higher for specialties outside of primary care.1 The stark difference in clinical training hours between APCs and physicians is largely due to post-graduate medical education (residency and fellowship training) required for certification and licensure of physicians. Residencies and fellowships are not required for APCs following graduation from school. APCs rely on clinical rotations while in school to adequately prepare them for practice. There is wide variability in the quality and rigor of clinical rotations. As a result, some APCs do not feel adequately prepared for clinical work and have expressed interest in more structured and rigorous experiences resembling residencies and fellowships.2 As the need for APCs continues to rise, health systems need to design structured programming that facilitates the transition of newly trained nurse practitioners and physician assistants into practice. In 2010, the Institute of Medicine (IOM) called for the development and implementation of advanced practice registered nurse residency programs, inclusive of NP residency programs.3 Several post-graduate NP programs have been established and have demonstrated success.4–8

DEVELOPMENT OF APC FELLOWSHIPS AT CHRISTIANACARE ChristianaCare is an independent academic medical center in Delaware with over 1600 members of the Medical-Dental Staff, which includes over 400 APCs. As ChristianaCare increased its APC workforce, pockets of the organization, such as primary care, began experiencing some APC turnover and job dissatisfaction. In primary care, exit interviews implied 52 Delaware Journal of Public Health – April 2020

that some nurse practitioners left these positions because they felt overwhelmed and underprepared for the pace, breadth, and complexity of the clinical environment they encountered. In other areas of the health system, they were experiencing APC vacancies that were understood to be vacant because of difficulty finding APCs with adequate experience or comfort in a particular specialty, for example, inability to recruit physician assistants in the Neonatal Intensive Care Unit (NICU). In Fiscal Year (FY) 2017, leadership in ChristianaCare’s Institute for Learning, Leadership and Development (iLEAD) embarked on a journey to explore the feasibility of starting APC fellowships to better support the transition of APCs into clinical practice and ultimately serve as a model for a high-quality, highly confident, and sustainable workforce pipeline. The authors have previously described the organizational development and foundational curricular elements of ChristianaCare’s first NP residency program.9

RECRUITMENT AND RETENTION The business case supporting the development of fellowship programs at ChristianaCare involved three financial assumptions: 1. The fellows will work clinically 50% of the time with supervision by a preceptor. The remaining 50% will be protected for education and learning through a combination of lectures, didactics, mentoring and specialty rotations. Like the model of physician residencies, the APC fellows receive a reduced salary compared to a full time APC. Because the APCs are fully licensed and credentialed before starting the fellowship, they can bill for services provided. The revenue for billed services will effectively cover the cost of their salary, justifying a considerable portion of the expenses of the program. 2. Hiring fellows into permanent positions upon completion of the program will avoid the recruitment costs normally incurred when APC positions are open. Successful recruiting from a pipeline training program would also result in avoidance of the typical costs associated with onboarding and ramp-up of a new provider because the new hires will already be well-versed in the culture, processes, policies and Electronic Medical Record (EMR) of ChristianaCare. 3. Training that supports transition to practice will result in a more prepared and confident APC workforce that will result in decreased turnover. The potential of cost-avoidance associated with decreased recruitment costs and decreased turnover were the strongest

drivers in the decision to pilot APC fellowships. To date, ChristianaCare has trained three cohorts of primary care APC fellows for a total of 15 trainees. Of the 15 trainees to complete the program, 14 were successfully recruited and hired into the system, resulting in a retention rate of 93%. While all 14 remain employed, more time is needed to make any conclusions regarding improvement in turnover rate. Currently, there is a fourth cohort of six primary care fellows as well as the first cohort of two NICU fellows.

LESSONS LEARNED Over the last three years, ChristianaCare has learned many lessons that can benefit other health systems considering APC fellowship development. Some of the most important lessons learned can be grouped into the following themes:

PARTNERING WITH CLINICAL PRACTICES/ DEPARTMENTS The central element of the curriculum is continuity of clinical practice. Fellows in primary care are assigned to a single practice over the course of their training. It is critical that the practice chosen for continuity care be extremely engaged and supportive of the model because having learners can complicate the usual operational flow of a practice. Some of the important points of negotiation include agreement of clinical ramp-up time for the fellows, scheduling standards and procedures, ensuring adequate physical space, preparing for additional clinical support staff, and messaging to the staff and patients about the existence of a teaching program in the practice.

FACULTY AND CURRICULUM Graduates of the program indicate that it was critical to have an APC fellowship coordinator who regularly met with the fellows for case reviews, didactic learning, evaluation, mentoring, and bi-directional feedback. The coordinator also plays a large role in connecting with human resources and recruiting efforts upon graduation. In addition to the coordinator, fellows benefit from a local practice preceptor committed to the clinical oversight and teaching in the practices. Without direct clinical oversight and teaching, the full value of the fellowship would never be realized. Lastly, the length of training is dependent on the specialty area and needs to be iterated with time. ChristianaCare has varied the length of its primary care residency from one year, to six months and it now currently stands as a nine-month program.

STRUCTURED HUMAN RESOURCE (HR) PROCESS Although the goal is to retain the APC trainees, fellows of the program are not obligated to continue as permanent employees and, likewise, the system is not obligated to permanently hire fellows. Therefore, the fellows must enter a recruitment process with HR to evaluate the employment fit between the fellow and the open positions within the system. ChristianaCare learned quickly that a thoughtful, transparent recruitment process was necessary. The process needs to include forecasting of open positions (often many months ahead of time), proper timing

of interviewing and offering, arrangements to spend clinical time in practices with potential openings, and the consideration around optimal start dates and schedules that allow for seamless transition into permanent positions.

CONCLUSION ChristianaCare has identified this fellowship program as a strategic approach to a high-quality, stable APC workforce. Partnering with clinical practices, creating a dynamic curriculum with multiple check points of feedback, and structuring the process and relationship with HR are vital keys to success. ChristianaCare has dedicated time and resources to demonstrate the value that the APC workforce can bring to the organization and has implemented a program to ensure smooth, successful transition not only to their practice environment but to the overall changing environment and landscape of healthcare.

REFERENCES 1. Martin, S. (2019). Not All Clinicians Are Trained Equally. Retrieved from https://www.aafp.org/news/blogs/ inthetrenches/entry/20190903itt-differences.html 2. Hart, A. M., & Bowen, A. (2016). New nurse practitioners’ perceptions of preparedness for and transition into practice. The Journal for Nurse Practitioners, 12(8), 545–552. https://doi.org/10.1016/j.nurpra.2016.04.018 3. Institute of Medicine. (2010). The future of nursing: Leading change, advancing health. Retrieved from http://www. nationalacademies.org/hmd/Reports/2010/The-Future-ofNursing-Leading-Change-Advancing-Health.aspx 4. Brown, K., Poppe, A., Kaminetzky, C., Wipf, J., & Woods, N. F. (2015, May-June). Recommendations for nurse practitioner residency programs. Nurse Educator, 40(3), 148–151. https://doi.org/10.1097/NNE.0000000000000117 5. Bush, C. T., & Lowery, B. (2016). Postgraduate nurse practitioner education: Impact on job satisfaction. The Journal for Nurse Practitioners, 12(4), 226–234. https://doi.org/10.1016/j.nurpra.2015.11.018 6. Cosme, S. (2015, September). Residency and fellowship programs for RNs and Advanced Practice RNs. The Journal of Nursing Administration, 45(9), 416–417. https://doi.org/10.1097/NNA.0000000000000224 7. Dains, J. E., & Summers, B. L. (2015, March). Filling the gap: A postgraduate fellowship in oncology nursing. The Journal of Nursing Administration, 45(3), 165–171. https://doi.org/10.1097/NNA.0000000000000177 8. Ryan, M., & Ebbert, D. (2013). Nurse practitioner satisfaction: Identifying perceived beliefs and barriers. The Journal for Nurse Practitioners, 9(7), 428–434. https://doi.org/10.1016/j.nurpra.2013.05.014 9. Painter, J., Sebach, A. M., & Maxwell, L. (2019). Nurse practitioner transition to practice: Development of a residency program. The Journal for Nurse Practitioners, 15(9), 688–691. https://doi.org/10.1016/j.nurpra.2019.05.003 53

Innovations in Residency Training in Community Hospitals Robert Monteleone, M.D., Family Medicine Residency Program Director, St. Francis Hospital; Medical Director, Delaware Care Collaboration

When someone thinks about residency training, the first image that comes to mind for most people is a large tertiary care center with patients rolling in every minute and beautiful doctors and nurses running around taking care of them, sometimes with a TV romance thrown in. The reality of family medicine residency training is that the majority of family physicians in our country are trained at community hospitals with a university affiliation. The affiliation with the university mainly means that the community hospital assists with traAining medical students from the university with little or no resources supplied by the university to the community hospital. So, change the initial image of residency training to a small urban or rural hospital or to a federally qualified health center with affiliations to a community hospital. The beautiful people are still there but the patient demographic mix changes to what we actually see in our communities. I believe that the best family medicine training occurs out in the community where most of the patients live and work. The greatest opportunities to impact health care costs lie in the same communities. I was having a conversation last week with Dan Bair, the Trinity MidAtlantic Clinically Integrated Network and Accountable Care Organization executive director. He was evaluating a Medicaid program in Pennsylvania where 226 patients resulted in 46% of the spending for a panel of 7511 patients. Impacting the health and utilization patterns of those 226 patients is where the opportunity exists to have the greatest impact on both health care cost and quality. Health systems, insurance companies, the state and federal government, employers and patients can all benefit from creating models to better care for these high risk and high cost patients. I can think of no better place to develop innovative programs than in a community based family medicine residency. While university hospitals may take the lead in research, community hospitals have opportunities to take the lead in developing quality improvement in population health. Seven years ago, a quality improvement program was developed at St. Francis Hospital with the residency program, care management, and a lead social worker titled, “From Home to Hospital and Back,” focused on improving transitions in care. This program predates when Medicare started to pay for transitional care management services. This example in innovation in population health laid the groundwork for success in Medicare programs such as the Bundled Payments for Care Improvement (BPCI) and the Delaware Care Collaboration (DCC) Medicare Shared Savings Plan. Our residents are trained in performing transitions of care visits in the office and in population health management for our highest risk patients. Many processes take years to develop and improve before they are successful, and I believe that part of the success of the Delaware Care Collaboration dates back to the formation of a care management team focused on keeping patients out of the hospital by providing them with appropriate resources. 54 Delaware Journal of Public Health – April 2020

Last year the DCC achieved a savings rate of 10% which resulted in a total reduction in Medicare spend of nearly 10 million dollars for less than 10,000 patients. This resulted in Medicare writing a check to the DCC for 4.9 million dollars. We are now beginning the process of approaching other insurance companies in Delaware to look at quality payment programs with an interest in looking at models with some accountable risk taken by the health system. The latest innovations we have added in population health include adding a community health worker to the team and focusing on behavioral health integration. Health systems with limited resources have to be creative to enhance behavioral health services. Some systems have made investments to employ behavioral health specialists such as psychologists and licensed clinical social workers (LCSWs) in the outpatient setting. We have a full time bilingual LCSW employed in the residency practice as well as a behaviorist, but two people cannot possibly manage the behavioral health needs of our patients. The process of behavioral health integration in our residency program has been more collaborative with community mental health practices. The practice has implemented universal screening for depression and a team of social work interns led by our behaviorist perform brief interventions and coordinate care both with our primary care physicians and with the behavioral health specialists at Mid-Atlantic Behavioral Health, with whom we have partnered to improve the access of care for our patients with high health disparities. The population of uncontrolled diabetics is currently being targeted for brief behavioral interventions as many social and behavioral factors are why their diabetes is not controlled. Let’s now shift gears to the emergency room setting where unfortunately many patients go as their only source of care. If you look at the definition of a primary care physician, an emergency room physician is not on the list. The story is often the same—another hospital admission that could be prevented and another discharged patient goes home but never follows up with any of the resources printed out on the computer discharge document containing pages of information ranging from diet to medications. To influence change in this process, our residency training program has led the way in population health innovation by developing an emergency room follow-up program. Patients who present to the emergency room who do not have a primary care provider and are interested in having one are scheduled for an appointment in the residency practice before the patient leaves the ER. The patient is scheduled for an appointment with a resident by a care coordinator in the ER who has access to the outpatient schedule. We have blocked 16 appointments per week for ER follow-up patients who have not been seen in our office previously. Recently a second outpatient community practice site was included in this program. Facilitating outpatient care can have huge implications as we all know that having a primary care provider can dramatically improve the quality of

care and decrease cost. Targeting the ER patients who do not have a primary care provider has great potential to decrease the total cost of care for a high risk population. This program was not implemented without problems, mainly because the program did not initially add appropriate resources in the office to manage this extra volume. This population has a high no show rate which complicates office flow in a practice that already has a high no show rate. Data from the past year demonstrate a no show rate of 45% for ER follow-ups which exceeds the baseline no show rate of 20% in our urban residency practice. Office flow communication for managing these patients was probably one of the largest stressors in the outpatient setting for our residents as the appointment times were adjusted to account for the high no show rate which doesnâ&#x20AC;&#x2122;t work on a single day if everyone shows up. It took about a year before the processes were streamlined to make this program successful without negatively impacting resident wellness. The experience residents have in training shapes their practices for the remainder of their career. Community hospitals are in a position to lead the way in training our residents for the quality based payment programs that are developing in our health system. Residents have the opportunity to be at the forefront of creating and developing innovative models of care. Medicine in the past several decades has valued innovation and development of surgical and pharmaceutical programs. The future successes in our health systems need these innovations, but more importantly, we need to work to improve the health of our populations. We need to invest in our care managers and in our social workers and

in physicians who work with them. Outstanding case managers and social workers work in our community hospitals and in our federally qualified health centers as these places attract smart and energetic people who want to make a difference. Residency training working closely with diverse health care teams is instrumental in developing our future physician leaders. Innovations in graduate medical education that are supported by quality payment and risk-based models have the potential to improve our health systems and diversify the financial support for residency training in primary care. There are more changes happening in medicine now than ever before and we are in a position to influence these changes especially if we involve our residents and students.

RESOURCES Bindman, A. B., Blum, J. D, & Kronick, R. (2013). Medicareâ&#x20AC;&#x2122;s transitional care payment-A step toward the medical home. The New England Journal of Medicine, 368(8), 692-694 Bridge Model: Illinois Transitional Care Consortium (2013). Program Summary. Retrieved from: http://www.transitionalcare. org/the-bridge-model/program-summary/ Gould, D. A & Levine, C. (2013). Transitions in care 2.0 an action agenda. United Hospital Fund, 1-6 Wright, K.M., Ryan, E.R., Gatta, J.L., Anderson, L., Clements, D.S. (2016). Finding the perfect match: factors that influence family medicine residency selection. Fam Med, 48(4), 279-285

NEW RANKINGS SHOW HEALTHIEST AND LEAST HEALTHY COUNTIES IN DELAWARE Rates of Children Living in Poverty Remain an Obstacle to Better Health New Castle County ranks the most healthy in Delaware and Kent County is the least healthy county in the state, according to the annual County Health Rankings, released by the Robert Wood Johnson Foundation (RWJF) and the University of Wisconsin Population Health Institute (UWPHI). The Rankings are available at www.countyhealthrankings.org. An easy-to-use snapshot that compares counties within states, for the past decade, the Rankings show that where you live influences how well and how long you live. This year’s Delaware State Report shows fundamental differences across and within counties in the opportunity for families and children to thrive. In this year’s Rankings, we explore children living in poverty, an important indicator of community health today and in the future. The constant financial stress of living in poverty leaves a lasting mark on children as they grow up, affecting future health and earnings. The report reveals that in Delaware, 18 percent of children live in poverty. Stark differences exist among racial and ethnic groups with Asian children at 7 percent and Hispanic children at 30 percent. Children are particularly vulnerable to the adverse effects of a lack of family income that does not allow for enough money to cover basic needs and save for setbacks. Households nationwide continue to struggle with making ends meet on limited income. In Delaware, more than 47,000 households are severely housing-cost burdened, spending half or more of their income on housing. Of the 35,000 children living in poverty in Delaware, nearly 66 percent also live in a severely cost burdened household—leaving little else for the basics needed to be healthy, such as food, transportation, and childcare. “The data highlighted in the County Health Rankings should be a call to action for all of us to work purposefully to close social determinant gaps that negatively impact the health of entire communities in our state, including some of our most vulnerable residents – children,” said Dr. Karyl Rattay, Director of the Delaware Division of Public Health (DPH). “DPH is committed to continuing our work with state partners to disseminate neighborhood-level data through its My Healthy Community data portal, sharing evidencebased tools, such as the Health Equity Guide for Public Health Practitioners and Partners, and working with communities to implement community based strategies to address child poverty and other issues through the Healthy Communities Delaware initiative. Data from the County Health Rankings provides valuable insight into the places and residents who are in greatest need of supports in our state and I challenge all of us to use this data to keep advancing our efforts.” “High-quality data helps inform the decisions we collectively make for a healthier Delaware,” said Dr. Omar Khan, president of the Delaware Academy of Medicine/Delaware Public Health Association. “There are 35,000 children living in poverty in our state, and that is 35,000 too many. Our team is committed to helping alleviate poverty as one of the key social determinants of health. The County Health Rankings provide valuable insights and actionable intelligence, which will surely help us develop better solutions to vexing issues and move us toward better health for all Delaware’s counties.” According to the 2020 Rankings, in Delaware, starting with the most healthy county to the least healthy county, are New Castle, followed by Sussex and Kent. In addition to the county-level data, the Rankings also features What Works for Health, a database of more than 400 evidence-informed strategies to support local change makers as they take steps toward expanding opportunities. Each strategy is rated for its evidence of effectiveness and likely impact on health disparities. The Take Action Center also provides valuable guidance for communities who want to move with data to action.

56 Delaware Journal of Public Health – April 2020

The DPH Bulletin

From the Delaware Division of Public Health

January 2020 DPH, DHMIC award grants to reduce infant and maternal mortality In December, DPH and the Delaware Healthy Mother and Infant Consortium (DHMIC) awarded $327,925 in mini-grants to six community organizations for a one-year period.

The Office of Health Crisis Response (OHCR) was recently established within the Division of Public Health’s Emergency Medical Services and Preparedness Section to address Opioid Use Disorder and other emerging health crises. Staff surround OHCR Director Kate Brookins, CCDP, CAADC, third from right. Photo by Donna Sharp.

DPH‘s Office of Health Crisis Response created to address Opioid Use Disorder

The newly created Office of Health Crisis Response (OHCR) is saving lives and preventing Opioid Use Disorder (OUD) for the Delaware Department of Health and Social Services’ (DHSS) Division of Public Health (DPH). Based within the Emergency Medical Services and Preparedness Section, OHCR manages a threeyear, $5.8 million Overdose Data to Action grant awarded by the Centers for Disease Control and Prevention in 2019. According to OHCR Director Kate Brookins, CCDP, CAADC, work is closely aligned with the DHSS Division of Substance Abuse and Mental Health (DSAMH). DSAMH focuses on outpatient and residential drug and alcohol treatment. OHCR concentrates on the education, information, and prevention of OUD. The young office created Community Response Teams in each county to respond to crisis sentinel events, such as a bad batch of illicit drugs in an area, or a pill mill shutdown. It also created the OpiRescue Delaware app and will refresh the Help is Here website (www.helpisherede.com). Contact OHCR at 302-223-1313, Kate.Brookins@delaware.gov, or by mail at Office of Health Crisis Response, Division of Public Health, 100 Sunnyside Road, Prickett Building, Smyrna, DE 19977.

The grants are the state’s first to reduce infant and maternal mortality and aim to narrow the wide variance in birth outcomes between black women and white women by building state and local capacity and testing small-scale innovative strategies. Grant recipients will provide targeted services to women of childbearing age (15 to 44 years), children, and their families if they live in zones identified by DPH’s Healthy Women Healthy Babies program as being at high risk for poor birth outcomes. Awardees are: Delaware Adolescent Program Inc.; Reach Riverside Development Corporation; Rose Hill Community Center; Delaware Coalition Against Domestic Violence; Delaware Multicultural and Civic Organization; and Hispanic American Association of Delaware Mamas felices hijos felices (Happy Mothers, Happy Children). For more information, visit DEThrives.com.

On December 10 in Dover, six Delaware community organizations received the state’s first mini-grants to reduce infant and maternal mortality, and to narrow the wide variance in birth outcomes between black women and white women. The Delaware Department of Health and Social Services, Division of Public Health (DPH) and the Delaware Healthy Mother and Infant Consortium (DHMIC) awarded the grants, totaling $327,925 for a one-year period, to build state and local capacity and to test small-scale innovative strategies. Pictured with the grant awardees are (front row) Susan Noyes, DHMIC Co-Chair, at far left; Lieutenant Governor Bethany Hall-Long, second from left; State Representative Melissa Minor-Brown, second from right; and DPH Director Dr. Karyl Rattay, at far right. Photo by Donna Sharp.

Nurse Residency Programs: Providing Organizational Value Amy Sutor, M.S.N., R.N., C.C.R.N.-K., N.P.D.-B.C. Jennifer Painter, D.N.P., A.P.R.N., C.N.S., N.E.A.-B.C., N.P.D.-B.C., O.C.N., A.O.C.N.S., L.S.S.B.B. ChristianaCare, Newark Delaware

ABSTRACT A review and discussion of creating nurse residency programs employing the recommendations from accrediting bodies to demonstrate organizational value. Utilizing an accredited framework to create nurse residency programs demonstrates organizational impact and value by ensuring evidence-based structures and plans are incorporated to accomplish patient safety and other organizational goals, meet healthy workplace goals, decrease turnover and improve nursing job satisfaction. Analysis includes a description of the Institute of Medicine report, nurse recruitment and retention, and associated costs; and the American Nurses Credentialing Center (ANCC) Practice Transition Program guides to developing the residency program. An example curricula and exploration of improvement indicators supports the conclusion that a successful transition to practice for nurses prepares them with both confidence and competence to deliver quality patient care.

INTRODUCTION The World Health Organization (WHO) celebrates 2020 as the ‘Year of the Nurse and the Midwife’, marking the 200th anniversary of Florence Nightingale, and recognizing the vital role nurses play in healthcare delivery and population health.1 This focus is directed towards creating systems of accessible and quality healthcare service by elevating the role of the nurse and by advocating for standardized nursing education, healthy work environments, and strategies to promote nursing retention. The 2011 Institute of Medicine (IOM) report on the future of nurses proposed five major changes to meet increased demands created by healthcare reform and complexity of health care: Increase the number of nurses in a position to help redesign systems of care; institute nurse residency programs; achieve 80% BSN rate by 2020; double the number of doctorate prepared nurses; and remove barriers to nurses’ scope of practice to allow top of licensure practice.2 These recommendations aim to make significant positive changes to the landscape of healthcare. Additionally, the U.S. Bureau of Labor Statistics reports that job growth for nurses will increase by 12 percent through 2028 due to our aging population and the health conditions associated with increased age.3 With that, provision of nursing care in acute care settings continues to increase in complexity due to greater volume of higher acuity patients, shorter lengths of stay, and increased use of complex informatics solutions.4 Pairing environments of insufficient staffing levels with the greater stress of an increasingly complex workload may lead to burnout and greater rates of nursing turnover. New to practice nurses are leaving the nursing profession at a nearly 17 percent rate within their first year and up to 30 percent rate within their first 3 years.5–7 It is reasonable to assume that as new to practice Registered Nurses (RN) become overwhelmed in a negative work environment that is already overstressed, self-doubt and ineffective resiliency skills may lead them to 58 Delaware Journal of Public Health – April 2020

conclude they have entered the wrong profession altogether.8 Several consequences of high turnover lead to increases in organizational costs, poor health outcomes, and negative impacts on remaining staff.6,9 As context, a study by Nursing Solutions Inc. reports that the average cost to replace one bedside nurse is approximately $52,100.10 This highlights the fact that this cost is real in both dollars and in physical and emotional toll on the nurse and the organization. One way to combat this struggle is to implement nurse residency programs for newly licensed nurses. Nurse residencies are established in nearly half of all national hospitals, however; requirements and regulations for standardized programs have only recently emerged. While a lack of standardization leads to autonomy and license for creative interpretation, it also creates significant variation which questions the validity and generalizability of their reported outcomes.11 There are currently two accrediting organizations, ANCC (accredits RN residencies, RN fellowships, and Advanced Practice Registered Nurse (APRN) fellowships) and the Commission on Collegiate Nursing Education (CCNE) (accredits postbaccalaureate nurse residencies). Both programs recommend that a nurse residency program run for a minimum of 6 months and develop individualized curriculum to progressively build knowledge and skill (core competencies) based on management and delivery of high-quality patient care and development in their professional role as nurses.12,13 Accredited programs offer learners both formal and informal opportunities to learn by combining education sessions with learning that occurs at the bedside through practice guided by a clinical trainer. These nurse residencies evaluate their achievement of outcomes to determine program effectiveness. The outcomes of accredited nurse residencies have been studied with mixed reports of statistically significant impact, which makes it difficult to prescribe an evidence-based blueprint suited to all organizations.

Research demonstrates that onboarding of new to practice nurses through a structured and accredited residency program leads to an increase in competency, reduction of error, reduced self-reported stress, increased job satisfaction, and improved retention.4,9,14,15 All of this could also then ultimately lead to cost reductions and improved outcomes for patients and organizations. The ANCC Practice Transition Program guides the development of a nurse residency program utilizing a conceptual model influenced by Patricia Benner’s concept of skill acquisition advancing from novice, beginner, competent, proficient, to expert within nursing practice (see Figure 1). This transition from novice to expert is influenced by programs with a strong focus on five crucial design components:12,16 • Program Leadership: Strong leadership presence to guide all stakeholders within the program and support for material, financial, and human resources to safeguard the success of the program • Quality Outcomes: Program goals which are aligned with the organizational mission, vision, and values to drive benefit to the organization, customers, and nurse residents • Organizational Enculturation: Orientation to organizational values and behaviors and incorporation of professional and clinical scope and standards of practice • Development and Design: Incorporates processes to define program structure, process, and competency objectives designed to meet program goals • Practice-Based Learning: Builds learning experiences guided by clinical trainers or mentors to evaluate gaps in knowledge, skill, or attitude in practice following defined program competencies; Incorporates strategies of self-reflection, incremental goal measures, peer support, and opportunity for remediation

CONCEPTUAL MODEL AND DESCRIPTION

Figure 1. ANCC’s Practice Transition Conceptual Framework: Based on Patricia Benner’s Novice to Expert Framework (Benner, 1984).

A large community-based Academic Medical Center (AMC) in the mid-Atlantic region composed of two major hospitals and a freestanding emergency department has implemented ANCC’s recommendations into the ten unique tracts of its nurse residency program. This health system has a combined total of approximately 1,100 inpatient beds. Highly effective, accredited nurse residency programs are designed to use multimodal training and evaluation methodologies to drive competency progression, supported through an infrastructure of strong preceptorship, mentoring, peer support, and effective communication, to ultimately improve patient outcomes.6–10,12,13 ANCC and CCNE transition to practice programs propose curriculum designs incorporate training and evaluation on the following competencies: professional, specialty, consensus-based, and clinical scope and standards of practice (e.g. ANA Nursing Scope and Standards of Practice), stress management, role transition, time management, communication skills, critical thinking and clinical reasoning, ethical decision making, and their role within the interprofessional team.12,13 Learning experiences that build professional relationships, incorporate strong support from preceptors, mentors, and nursing leadership, provide respect, and build confidence, are all linked to positive perceptions of job satisfaction and are integral components of a healthy work environment which has been identified as a predictor of improved nursing retention.2,4–10 This AMC has utilized these fundamental recommendations with an emphasis on wellbeing and resiliency strategies, interprofessional education, and mentoring throughout competency development and practice-based learning as well as mechanisms to measure success of the program. A sample of the curriculum plan constructed for the accredited critical care nurse residency track (see Table 1) emphasizes the core nursing competencies, teaching and experience modalities, and methods for evaluation. Utilizing an accredited framework to create nurse residency programs demonstrates organizational impact and value by ensuring evidence-based structures and plans are incorporated to accomplish patient safety and other organizational goals. Additionally, a healthy work environment is essential to retain employees. Nurse residency programs emphasize enculturation to practice area and organizational culture and prioritizes relationship building. This type of program drives job satisfaction despite the challenges of constant workforce turnover and stressors thereof. Finally, engaged nurses who have successfully transitioned into their new role are prepared with both confidence and competence to deliver quality patient care. 59

Nurse Competency

Curriculum Design

Evaluation Method

Communication Skills

• • • • •

Cohort Model Peer Support: Discussion Groups Preceptor Led Training/Practice Based Learning Interprofessional Education/Simulation Lecture: Managing Challenging Personalities/Incivility Lecture/Activity: Active Listening and Health Literacy

• Organizational Competency Tools • Self-Assessment

Critical Thinking/ Clinical Reasoning

• • • • •

Cohort Model Peer Support: Discussion Groups Preceptor Led Training/Practice Based Learning Lecture: Critical Thinking Strategies Final Project Case Study Vendor Based/Online Competency Program

• Organizational Competency Tools • Self-Assessment • Vendor Based Assessments

Ethical Decision Making

• • • •

Cohort Model Peer Support: Discussion Groups Preceptor Led Training/Practice Based Learning Lecture: American Nurses Association (ANA) Code of Ethics Lecture: Provided by Ethicist within Organization

• Organizational Competency Tools • Self-Assessment

Evidence Based Practice

• • • • •

Cohort Model Peer Support: Discussion Groups Preceptor Led Training/Practice Based Learning Johns Hopkins Evidenced-Based Practice (EBP) guidelines Final Project Case Study Organizational EBP References/Guidelines

• Organizational Competency Tools • Self-Assessment • Workshop: Active Participation

Informatics

• • • •

Cohort Model Peer Support: Discussion Groups Preceptor Led Training/Practice Based Learning Lecture: Impact of Informatics in Healthcare Organizational Nurse Onboarding Classes

• Organizational Competency Tools • Self-Assessment • Simulation

Interprofessional Collaboration and Teamwork

• • • • •

Cohort Model Peer Support: Discussion Groups Preceptor Led Training/Practice Based Learning Interprofessional Education/Simulation Lecture: Communication Tools for Interprofessional Team Members Self-Assessment Survey: Casey-Fink

• Organizational Competency Tools • Self-Assessment

Patient Centered Care

• Cohort Model Peer Support: Discussion Groups • Preceptor Led Training/Practice Based Learning • Lecture: Nursing Professional Practice Model, Care Delivery Model, Mission, Values/Behaviors • Lecture/Activity: Active Listening and Health Literacy

• Organizational Competency Tools • Self-Assessment

Professional Development

• Cohort Model Peer Support: Discussion Groups • Preceptor Led Training/Practice Based Learning • Lecture: Professional Practice Model, Mentoring, Magnet, Clinical Ladder, Shared Governance Structure • Lecture: Human Resources Supports and Benefits • Self-Assessment Survey: Casey-Fink

• Organizational Competency Tools • Self-Assessment

Quality Improvement

• • • •

Cohort Model Peer Support: Discussion Groups Preceptor Led Training/Practice Based Learning Lecture: Organizational Resources Interprofessional Residency Quality and Safety Council

• Organizational Competency Tools • Self-Assessment

Extended Length, Multi-Unit Orientation Cohort Model Peer Support: Discussion Groups Preceptor Led Training/Practice Based Learning Adult Learning Style Preferences Organizational Nurse Onboarding Classes Competency Assessments and Measurement Strategies Self-Assessment Survey: Casey-Fink

• Organizational Competency Tools • Self-Assessment

Role Transition and Responsibilities

• • • • • • •

Safety Design

Stress Management

Time Management

• • • •

Cohort Model Peer Support: Discussion Groups Preceptor Led Training/Practice Based Learning Culture of Responsibility Lecture: Safe Handling of Sharps and Personal Protective Equipment/Simulation • Self-Assessment Survey: Casey-Fink

• Organizational Competency Tools • Self-Assessment • Self-Reporting System for Near or Real Errors

• • • • •

Cohort Model Peer Support: Discussion Groups Preceptor Led Training/Practice Based Learning Department of Provider Wellbeing Employee Assistance Program Opportunity to Achieve Staff Inspiration & Strength (O.A.S.I.S.) Program • Lecture: Preceptor Relationships • Lecture: Formal and Informal Mentoring Support • Self-Assessment Survey: Casey-Fink

• Organizational Competency Tools • Self-Assessment • Casey-Fink

• Cohort Model Peer Support: Discussion Groups • Competency Assessments and Measurement Strategies • Preceptor Led Training/Practice Based Learning

• Organizational Competency Tools • Self-Assessment

Table 1. Critical Care Nurse Residency Structured Competency Plan

60 Delaware Journal of Public Health – April 2020

REFERENCES 1. World Health Organization. (2019) Year of the nurse and the midwife 2020. Retrieved from: www.who.int/hrh/ news/2019/2020year-of-nurses/en 2. Institute of Medicine. (2011). The Future of Nursing: Leading change, Advancing health. Washington, DC: The National Academies Press. 3. Bureau of Labor Statistics, U.S. Department of Labor. (n.d.). Occupational Outlook Handbook, registered nurses. Retrieved from: https://www.bls.gov/ooh/healthcare/registered-nurses.htm 4. Goode, C. J., Glassman, K. S., Ponte, P. R., Krugman, M., & Peterman, T. (2018, May - June). Requiring a nurse residency for newly licensed registered nurses. Nursing Outlook, 66(3), 329–332. PubMed https://doi.org/10.1016/j.outlook.2018.04.004 5. Blegen, M. A., Spector, N., Lynn, M. R., Barnsteiner, J., & Ulrich, B. T. (2017, October). Newly licensed RN retention: Hospital and nurse characteristics. The Journal of Nursing Administration, 47(10), 508–514. https://doi.org/10.1097/NNA.0000000000000523 6. Park, S. H., Gass, S., & Boyle, D. K. (2016, May). Comparison of reasons for nurse turnover in Magnet and non-Magnet hospitals. The Journal of Nursing Administration, 46(5), 284–290. PubMed 7. Ulrich, B., Krozek, C., Early, S., Ashlock, C. H., Africa, L. M., & Carman, M. L. (2010, November-December). Improving retention, confidence, and competence of new graduate nurses: Results from a 10-year longitudinal database. Nurs Econ, 28(6), 363–376. PubMed 8. Chesak, S. S., Morin, K. H., Cutshall, S., Carlson, M., Joswiak, M. E., Ridgeway, J. L., . . . Sood, A. (2019, November/December). Stress management and resiliency training in a nurse residency program. Journal for Nurses in Professional Development, 35(6), 337–343. PubMed https://doi.org/10.1097/NND.0000000000000589

9. Lin, P. S., Viscardi, M. K., & McHugh, M. D. (2014, October). Factors influencing job satisfaction of new graduate nurses participating in nurse residency programs: A systematic review. Journal of Continuing Education in Nursing, 45(10), 439–450. PubMed https://doi.org/10.3928/00220124-20140925-15 10. 2019 NSI national health care retention & RN staffing report. (2019) NSI nursing solutions, Inc. Retrieved from: https://www.nsinursingsolutions.com/Documents/Library/NSI_ National_Health_Care_Retention_Report.pdf 11. Pokorny, M. (2018). Setting the standard: accrediting transition to practice programs. Nurse Leader Insider. https://www.hcpro.com/NRS-331579-868/Setting-the-StandardAccrediting-Transition-to-Practice-Programs.html 12. American Nurses Credentialing Center. (2016). Practice transition accreditation program manual. Silver Spring, MD: American Nurses Credentialing Center 13. Commission on Collegiate Nursing Education (CCNE). (2008). Standards for accreditation of post baccalaureate nurse residency programs. Retrieved from: http://www.aacn.nche.edu/ccne-accreditation/resstandards08.pdf 14. Altman, S. H., Butler, A. S., & Shern, L. (Eds.). (2016). The future of Nursing IOM update: Committee for Assessing Progress on Implementing the Recommendations of the Institute of Medicine Report The Future of Nursing: Leading Change, Advancing Health; Institute of Medicine; National Academies of Sciences, Engineering, and Medicine; Washington (DC). National Academies Press (US); Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK350161/ 15. Goode, C. J., Lynn, M. R., Krsek, C., & Bednash, G. D. (2009, MayJune). Nurse residency programs: An essential requirement for nursing. Nurs Econ, 27(3), 142–147. PubMed 16. Benner, P. E. (1984). From Novice to Expert: Excellence and power in clinical nursing practice. Menlo Park, CA: Addison‐Wesley Publishing Company, 307 p.

HEALTH CARE PROVIDERS

Research has shown that a lung cancer screening can save lives. A low-dose CT scan has been proven to reduce mortality risk in smokers and former smokers by 20 percent. The screening: • Is the result of findings of the National Lung Screening Trial • Has been endorsed by the American Cancer Society, American Lung Association, and U.S. Preventive Services Task Force Your patients should be screened if they: • Are 55 to 80 years of age. • Have smoked the equivalent of a pack a day for 30 or more years, or two packs a day for 15 or more years. • Currently smoke or quit smoking within the last 15 years. Talk to your patients who smoke or have smoked about the lung cancer screening. Or they can call (302) 754-5574 to have a screening nurse navigator schedule a screening for them.

302-754-5574 | HealthyDelaware.org/LungScreenings

DELAWARE HEALTH AND SOCIAL SERVICES Division of Public Health Bureau of Chronic Diseases

DIMER at 50: Delaware’s Best Value for Medical Education Sherman L. Townsend, Chair Delaware Institute of Medical Education and Research Board Omar Khan, M.D., President & CEO, Delaware Health Sciences Alliance; Faculty, Thomas Jefferson University; Faculty, Philadelphia College of Osteopathic Medicine; Faculty, University of Delaware; Attending Physician, Family Medicine, ChristianaCare

BACKGROUND The Delaware Institute for Medical Education and Research (DIMER) was founded in 1969, with its first class entering medical school in 1970 (50 years ago). At the time, as now, it was an alternative to an in-state medical school, addressing the concern of access to high-quality medical education for Delaware residents in the absence of such a school. DIMER initially formalized a relationship with Thomas Jefferson University for twenty admission slots for Delawareans at Jefferson Medical College (now Sidney Kimmel Medical College (SKMC)). In 2000, DIMER expanded its education relationships to also include the Philadelphia College of Osteopathic Medicine (PCOM), further increasing access to medical education for Delawareans. Upon creation, PCOM held five admission slots for qualified Delaware applicants. In 2019, that number was increased to ten. In the last 2 years, DIMER and the Delaware Health Sciences Alliance (DHSA) have worked closely together to gather data; enhance outreach to students; conduct evaluations; and bring the entire Delaware healthcare together to focus on medical education and provider workforce. The DHSA was founded by 4 core members: ChristianaCare, Nemours, Thomas Jefferson University and University of Delaware. Recently, membership has expanded to include Bayhealth, PCOM, and the Delaware Academy of Medicine/Delaware Public Health Association.

THE DIMER ADVANTAGE There are five US states without an in-state allopathic medical school: Alaska, Delaware, Idaho, Montana, and Wyoming. One of those, Idaho, has an osteopathic school of medicine. Excepting Delaware, the other four are part of the WWAMI Consortium by which the University of Washington serves as their medical school.1 The DIMER program predates WWAMI by two years, as the latter was started in 1971. There are important differences between the two programs, notably, that WWAMI provides for the states of medical student origin to also house them for the basic sciences part of their medical education (e.g., a student from Wyoming would complete a Foundations phase at the University of Wyoming before proceeding to the University of Washington for their clinical training, and then return back to their home states in many cases for clinical experiences). As a state with no in-state medical school, this potentially presents a barrier to medical education for Delaware residents. However, through its relationships with SKMC and PCOM, Delaware has secured a minimum number of slots for qualified Delaware applicants. On annual average, SKMC and PCOM each receive an estimated 10,000 applications for approximately 280 slots per respective institution. As DIMER applicants, Delaware applications are pulled from the overall 10,000 applications received and evaluated against other Delaware applicants. This significantly improves the odds of being in the applicant pool, and being offered one of 30 or more medical school slots reserved for Delaware 62 Delaware Journal of Public Health – April 2020

students. DIMER provides one of the best medical education admission advantages in the country for qualified applicants from the First State.

DELAWARE BRANCH CAMPUS AND RESIDENCY While DIMER’s charge is to ensure access to quality medical education for Delaware residents, DIMER’s mission and values extend beyond access. DIMER and its partners are committed to providing a network of support for its students and engage students throughout the academic year in a variety of ways. Ensuring Delaware students understand the opportunities that are available to them through DIMER’s partnerships will help to increase the qualified Delaware applicant pool and ensure Delaware is well-represented from all three counties. The DIMERDHSA partnership has resulted in providing personal letters to each student at the beginning of each academic year; co-hosting receptions with PCOM and SKMC for DIMER students to network with both DIMER and institutional leadership; and conducting participatory panels in every county with prospective students and families to discuss the many benefits of DIMER. Outreach events provide an opportunity for students to hear from a panel of experts including DIMER leadership, current DIMER medical students, DIMER alumni, DHSA leadership, and practicing physicians as well as representatives from all our medical education partners and admissions offices. We are optimistic that through continued partnership, outreach and engagement, more Delawareans will seek high quality medical education opportunities from our exceptional partner institutions. DIMER is not only focused on providing medical education opportunities for Delawareans but also in the retention of Delaware physicians to serve our communities. DIMER medical students at SKMC and PCOM have an opportunity to conduct their thirdand fourth-year rotations at the Delaware Branch Campus. The Delaware Branch Campus provides medical students clinical training at ChristianaCare, Nemours / A.I. Dupont Hospital for Children, and the Wilmington VA Medical Center, and DIMERDHSA has co-hosted graduation receptions for graduating Branch Campus students. In addition, PCOM clinical rotations have grown to now also include Bayhealth’s Kent and Sussex Campuses. It is clear that many physicians stay to practice where they trained for residency; DIMER’s relationships thus extend beyond its education partners and into Delaware’s health systems. Delaware residency match opportunities are not limited to Delaware Branch Campus partners, as St. Francis also has a Family Medicine residency program, and Bayhealth is in the process of launching its own Family Medicine residency. This range of options will provide increased opportunity for Delawareans to complete their medical training and serve their community in their home state.

DIMER RESULTS Since 1969, DIMER has matriculated 1,145 Delaware students (888 students to SKMC and 257 students to PCOM). Of these, 702 are male and 443 are females. By county, 680 originated from New Castle County, while Kent and Sussex Counties were represented by a combined total of 465 students. DIMER graduates from SKMC and PCOM went into primary care (n=334) and specialty care (n=645). As of 2019, 229 DIMER students have returned to practice in Delaware. Twenty percent have stayed in Delaware, while 33.9% have ever practiced in Delaware (i.e. 13.9% ultimately practiced elsewhere). The full 2020 DIMER Anniversary Report2 details data on the significant impact that DIMER and partners are making in the First State.

NEXT STEPS DIMER has been a successful model of Delaware’s medical education program, focusing on access for Delaware students. We increasingly recognize the importance of financial and debt burden, and several measures are underway this legislative session to provide greater incentives to return to the state for practice. Through partnership with DHSA, DIMER will continue to play an active role in the arc of education through workforce: • Educating entering college students about their career choices, • Assisting pre-medical students in applying to partner schools, • Maintaining close touch with learners through medical school and residency, and

• Linking graduates to employment opportunities throughout the state upon completion of their graduate medical education.

CONCLUSION The DIMER program at 50 is revitalized and strong through its partnerships. It continues to represent high value for Delawareans’ medical education. We refer readers to the full DIMER 2020 Anniversary Report2 which provides more in-depth information on demographics and data on DIMER graduates, as well as personal stories from state and institution leadership and DIMER alumni. DIMER’s partnering with the DHSA has resulted in a robust array of services intended to facilitate Delawareans’ pathway to medical school and improved chances of returning to Delaware to practice needed specialties in their home communities. There remain important areas of needed investment, such as more robust student financial support. We are confident that with the support of the State and our many partners, we can improve healthcare access for our communities with the best-trained medical workforce anywhere. In this way we hope to address any foreseeable barriers to a high-quality education for qualified Delawareans, and to supporting a healthier Delaware.

REFERENCES 1. University of Washington Medicine. (n.d.). WWAMI. Retrieved from: https://www.uwmedicine.org/school-of-medicine/mdprogram/wwami 2. Delaware Institute for Medical Education and Research. (2019). DIMER Anniversary Report. Retrieved from: https://dhss.delaware.gov/dhcc/files/dimer50annrpt_2020.pdf

The Community Benefits of Graduate Medical Education Brintha Vasagar, M.D., M.P.H., Bayhealth Medical Center

ABSTRACT Graduate Medical Education (GME) can have far-reaching benefits to improve the health of a community. Most directly, GME increases the pipeline of physicians who consider careers in areas close to where they train. Indirectly, improvements in patient care outcomes, decreases in physician burnout, and implementation of innovative programming are also seen. In this article, we highlight some of the key benefits of developing GME in the context of the current healthcare landscape of Delaware.

INTRODUCTION Graduate Medical Education (GME) can improve the health of a community by adding a pipeline of physicians, improving quality of care, and piloting unique initiatives to meet the specific needs of the community. As the physician shortage grows in the United States, access to high quality medical care becomes one of our greatest public health needs. In Delaware, Kent and Sussex counties are already designated Health Professional Shortage Areas (HPSAs) with less than one primary care physician for every 2000 people.1 The increasing imbalance between the number of new physicians moving to Delaware and those leaving or retiring, compound the issue.2 The availability of physicians who are accepting new patients varies greatly by region, and the number of patients seeking a new physician is only increasing as more physicians shift to a concierge or VIP model of care due to lower reimbursement in traditional models.2 With the recent announcement of the closure of the Dover Air Force Base medical facilities to families and retired service members, even more physicians will be needed.3 Patients feel this deeply, with long wait times for appointments and the inability to find a primary care physician accepting new patients. As our population grows and ages, new strategies are needed to meet the primary care needs of our community. GME can be part of a strategic plan to grow the physician workforce. A 2013 study found that 56% of family medicine residents practice within 100 miles of their residency program, with 39% practicing within 25 miles.4 This finding is consistent with trends seen in Delaware, where a majority of primary care physicians have a strong tie to the region (Delaware, Maryland, New Jersey, New York, or Pennsylvania). In fact, 61% of primary care physicians went to high school in the region, 53% attended medical school in the region, and 78% completed residency in the region.1 The only residency programs that currently exist in Delaware are in New Castle County, so it is no surprise that this is reflected in the geographic distribution of residency graduates. As seen in Figure 1, only 14.5% of primary care physicians in Sussex County completed a residency in Delaware, compared to 16.3% of those in Kent County, and 43.3% in New Castle County.1 The addition of Bayhealth’s primary care residency programs to Kent and Sussex counties will bring 74 new primary care physicians in the residents alone, with additional core faculty. Their exposure to central and southern Delaware increases the likelihood that they develop a tie to Delaware and continue to practice in these areas after graduating. With the greatest need for primary care workforce 64 Delaware Journal of Public Health – April 2020

development located in Kent and Sussex counties, it follows that new GME programming in these counties would help to meet this critical need. Teaching itself has been positively linked to combatting burnout and more physicians are seeking opportunities to be involved in GME. The development of GME in Kent and Sussex programs creates these opportunities for existing physicians to increase joy in practice, and can be helpful in attracting new physicians to the area. It is important to note, however, that GME in itself is not a definitive solution to the physician workforce dilemma. While nationwide the in-state retention rates of residents are 47.5%, Delaware currently ranks amongst the lowest at only 28.6% retention.5 Additional strategies, such as loan repayment and primary care reimbursement, need to be implemented to make the practice of medicine in Delaware more attractive to new physicians. GME has benefits for the community beyond growing the workforce. Teaching hospitals tend to have an overall higher quality of care than non-teaching hospitals in metrics such as length of stay and cost.6 This is particularly pertinent in Delaware, which was ranked the 35th healthiest state by America’s Health Rankings in 2019.7 The presence of learners drives the use of the latest medical evidence in clinical decision-making, leading to better outcomes. For attending physicians, modeling excellence in practice and participating in critical review of cases leads to fewer adverse outcomes.6 Teaching physicians have found that the presence of learners gives an added incentive to keep up with the latest guidelines and the resources, such as continuing medical education offerings, which allow them to do so. The addition of residents also improves interdisciplinary communication and teamwork, which can improve care and also decrease burnout.8 There is opportunity for synergy between efforts to meet GME requirements and efforts to improve outcomes for the healthcare system. Research, for example, is a requirement for residents and faculty, which can help emphasize the importance of quality improvement within the healthcare system. By joining hospital teams focused on commonly seen clinical challenges, such as reducing hospital acquired infections, reducing readmission rates, or improving metrics of chronic diseases, residents can help create solutions which directly improve the health of their patients. Wellness is another GME requirement that is also an area of focus for most healthcare systems. At Bayhealth, we plan to share ideas and resources between GME programs and the physician wellness program. By coordinating efforts from physicians who are just beginning their careers and those who have been practicing for decades, we hope to improve wellness in some creative ways.

GME programs also have the freedom to try new approaches which directly address the needs of the particular community served.6 For example, over the past 3 years, Delaware saw a 61% increase in drug related deaths, an increase in frequent mental health distress, and an increase in obesity.7 Bayhealth’s new family medicine residency outpatient practice will address these needs directly by providing Medication Assisted Therapy for addiction, embedding a behavioral health provider in the practice to facilitate team-based care with residents, and focusing on diet and exercise as key drivers of health. Finally, GME adds the opportunity to develop social consciousness in resident physicians by giving them opportunities to treat populations who are underserved.6 Bayhealth’s family medicine residency program takes a community-focused approach by partnering with FQHCs, homeless shelters, free clinics, and a nursing home for veterans. These sorts of efforts at building social capital early have been shown to create better health for the community and lower healthcare costs.6 They also expose residents to a variety of practice needs and opportunities within the state. GME programs create physicians who understand the resources and needs of the community where they have trained. By growing GME in Kent and Sussex counties, we can create a pipeline of physicians to mitigate our growing physician shortage, improve quality of care, and implement new programming to address the needs of our community.

REFERENCES 1. Delaware Department of Health and Social Services, Division of Public Health. (2018). Primary Care Physicians in Delaware 2018.

2. Delaware Primary Care Collaborative. (2019). Primary Care Collaborative Report 2019. 3. Kime, P. (2020, Feb 19). These military clinics will stop taking 200,000 non-active duty patients. Here’s the list. Military Times. Retrieved from https://www.militarytimes.com/ 4. Fagan, E. B., Finnegan, S. C., Bazemore, A. W., Gibbons, C. B., & Petterson, S. M. (2013, November 15). Migration after family medicine residency: 56% of graduates practice within 100 miles of training. American Family Physician, 88(10), 704. https://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=24364487&dopt=Abstract 5. Association of American Medical Colleges. (2019). Delaware Physician Workforce Profile. Retrieved from https://www.aamc.org/ system/files/2019-12/state-physician-Delaware-2019%5B1%5D.pdf 6. Pugno, P. A., Gillanders, W. R., & Kozakowski, S. M. (2010, June). The direct, indirect, and intangible benefits of graduate medical education programs to their sponsoring institutions and communities. Journal of Graduate Medical Education, 2(2), 154–159. https://doi.org/10.4300/JGME-D-09-00008.1 7. America’s Health Rankings. (2019). Delaware Annual Report. Retrieved from https://www.americashealthrankings.org/explore/ annual/measure/Overall/state/DE 8. Fletcher, S., Mullett, J., & Beerman, S. (2014, September). Value of a regional family practice residency training program site: Perceptions of residents, nurses, and physicians. Canadian Family Physician Medecin de Famille Canadien, 60(9), e447–e454. https://www.ncbi. nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_ uids=25217693&dopt=Abstract

Figure 1. State of Medical Residency of Primary Care Physicians by County, Delaware, 20181

Flexibility and Adaptation: Key Elements for Preserving Research Continuity During the COVID-19 Pandemic Mindy George-Weinstein, Ph.D.; Chief Research and Science Officer, Division of Research, Philadelphia College of Osteopathic Medicine

Limiting the spread of the coronavirus by social-distancing has eclipsed nearly all normal daily activities and routines. Healthcare services for those with COVID-19 and protection of vulnerable populations have escalated exponentially. State and local governments are mandating closure of non-essential businesses while classifying operations of pharmaceutical and biotechnology companies as essential. Education of students at all levels is, for the most part, virtual across the U.S. Epidemiologic studies, development of a vaccine and other prevention and treatment strategies, examination of correlates of disease resistance and analyses of the coronavirus itself are critical for combating the COVID-19 pandemic. Research in these areas is being conducted at an aggressive pace in federal and private sector institutions.1 The questions become, what research activities unrelated to the corona virus and COVID-19 are essential and at what level should ongoing programs be maintained when safety is the first priority? Restrictions aimed at preventing disease spread have been imposed in all research facilities. Clinical trial centers and universities have developed and shared recommendations for research in the face of COVID-19 with guidance from the Center for Disease Control and Prevention (CDC) and the National Institutes of Health (NIH).2,3 Continuation of clinical trials is essential for monitoring subject safety and assessing outcomes. The NIH recommends flexibility in the timing and location of testing, limiting study visits to those needed for the safety of participants and clinical care, and conducting virtual study visits.4 Institutional Review Boards are encouraged to be responsive to the need for out-of-cycle reviews of amendments to study protocols. Continuity of basic and translational research programs must be given thoughtful and individualized consideration. Policies vary in their level of restriction of activities and access to laboratories and core facilities, ranging from a complete shutdown of projects and buildings to limited occupancy for essential operations. Definitions of essential operations also vary, but generally include tasks and services required to maintain continuity of research programs that in many cases have developed over the course of years and even decades. A minimal level of activity includes safe storage of tissue samples, cell lines, biologics and other reagents, and daily husbandry of preclinical research models. Time sensitive analyses may be considered essential for completing ongoing experiments. In some institutions, principal investigators (PIs) and research support staff have been assigned essential tasks on a rotating basis in order to reduce population density to a bare minimum. Work-study students are considered employees, and although they are important contributors to our research programs, they are likely to have restricted access to facilities, in some cases with continued financial support. 66 Delaware Journal of Public Health â&#x20AC;&#x201C; April 2020

All research personnel are encouraged or required to work remotely to the extent possible. Literature searches, data reduction and interpretation, and preparation of manuscripts, grant applications and progress reports can be performed offsite with access to the internet, library holdings, institutional servers and software site licenses. Working remotely with fewer distractions than normally experienced in a research intensive or academic environment can be productive. However, many faculty are currently consumed with creating and providing educational content online for at least one semester. Postdoctoral fellows, graduate students and experienced research support staff can shoulder a great deal of the responsibility for data management and preparing drafts of papers while PIs respond to the shift in their teaching methods. The scale-back of experimentation poses additional challenges for the continuation of research focused degree programs. A cohort of graduate students anticipates completion of their degree by late spring and have already been accepted into PhD programs, postdoctoral fellowships and medical and dental schools. Advisors and thesis committee members are strongly encouraged to reevaluate preexisting milestones and be flexible in their requirements for data accumulation. Remote access to PubMed and statistical, graphing and image analysis programs will facilitate completion of the written thesis. The oral defense can occur via videoconferencing. Additional recommendations for students and other trainees engaged in research pertain to the curriculum vitae (CV). This is an active time for applying to advanced degree programs, postdoctoral fellowships, graduate medical education residencies and employment. Documentation of research accomplishments within the CV enhances applicantsâ&#x20AC;&#x2122; competitiveness for these positions. Publications are an important measure of research productivity. Submission of manuscripts will likely be delayed as a result of reduced access to research facilities. While reviewers of manuscripts always should be judicial in their expectations for additional experimentation, this is especially important now when it is unclear when research operations will return to normal and what resources will be available to support reactivation of projects. Presentations to the scientific community are another important metric of scholarship. Trainees and faculty have experienced tremendous disappointment resulting from cancellation of regional, national and international conferences. Titles of abstracts, accompanied by a statement that they were invited to give a platform or poster presentation at the conference, followed by a notation that the conference was cancelled, can be included in the CV. Some conferences are allowing online presentations. This option must be carefully considered given the potential for unwanted methodology and data capture.

The scientific community has been part of an extraordinary effort to communicate, cooperate and adapt to significant reductions in or temporary cessations of their research programs imposed by the spread of the coronavirus. Highly focused and productive researchers are now more flexible in their expectations for the pace of experimentation and progress of their mentees. Clearly, research programs will suffer setbacks from interruptions in work flow and lost resources. Loss may be minimized by inclusion of active researchers in the process of developing and updating policies to maintain the highest possible level of safety. Purpose, vigor, ingenuity and financial support will drive a dramatic resurgence in research that will accompany the control of the COVID-19 pandemic.

REFERENCES 1. Centers for Disease Control and Prevention. (2020). COVID-19 (2019 Novel Coronavirus) research guide. Retrieved from: https://www.cdc.gov/library/researchguides/2019NovelCoronavirus.html 2. Centers for Disease Control and Prevention. (2020). Interim Guidance for Administrators of US Institutions of Higher Education. Retrieved from: https://www.cdc.gov/coronavirus/2019-ncov/community/guidance-ihe-response.html 3. National Institutes of Health. (2020). Coronavirus Disease 2019 (COVID-19): Information for NIH Applicants and Recipients of NIH Funding. Retrieved from: https://grants.nih. gov/grants/natural_disasters/corona-virus.htm 4. National Institutes of Health. (2020). Guidance for NIH-funded Clinical Trials and Human Subjects Studies Affected by COVID-19. Retrieved from: https://grants.nih.gov/grants/ guide/notice-files/NOT-OD-20-087.html

CORONAVIRUS – LEXICON Community Spread

When a disease is sustained and easily spread throughout a community.

Contact Tracing

The process of identification of anyone who may have come into contact with an Infected person.

Coronavirus

Any of a family (Coronaviridae) of single-stranded RNA viruses that have a lipid envelope studded with club-shaped projections, infect birds and many mammals including humans, and include the causative agents of MERS, SARS, and COVID-19

COVID-19

A new disease that can cause respiratory illness (like the flu) with symptoms such as a cough, fever (39 C / 101.8 F), and in more severe cases, difficulty breathing.

Flattening the Curve

Slowing the rate of infection of a disease.

Isolation

Separating infected and/or contagious people from those who are uninfected

Middle East Respiratory Syndrome (MERS)

Is viral respiratory illness that is new to humans. It was first reported in Saudi Arabia in 2012 and has since spread to several other countries, including the United States. Most people infected with MERS-CoV developed severe respiratory illness, including fever, cough, and shortness of breath.

Outbreak

A sudden or violent start of something unwelcome, such as disease, war, etc.

Pandemic

A disease prevalent over a whole country or the world

Person to Person Transmission

Transmission of a disease that occurs when an infected person touches or exchanges body fluids with someone else

Pneumonia

Lung inflammation caused by bacterial or viral infection, in which the air sacs fill with pus and may become solid. Inflammation may affect both lungs (double pneumonia), one lung (single pneumonia), or only certain lobes (lobar pneumonia).

Public Health Emergency of International Concern

An extraordinary event which is determined, as provided in these Regulations: (i) to constitute a public health risk to other States through the international spread of disease; and (ii) to potentially require a coordinated international response. This definition implies a situation that: is serious, unusual or unexpected; carries implications for public health beyond the affected State’s national border; and may require immediate international action.

Quarantine

A state, period, or place of isolation in which people or animals that have arrived from elsewhere or been exposed to infectious or contagious disease are placed.

Severe Acute Respiratory Syndrome (SARS)

A contagious and sometimes fatal respiratory illness caused by a coronavirus. SARS appeared in 2002 in China. It spread worldwide within a few months, though it was quickly contained. SARS is a virus transmitted through droplets that enter the air when someone with the disease coughs, sneezes, or talks. No known transmission has occurred since 2004.

SARS-CoV-2

The disease causing agent of the COVID-19 disease.

Social Distancing

Social distancing is a term applied to certain actions that are taken by Public Health officials to stop or slow down the spread of a highly contagious disease.

State of Emergency

A situation in which a government is empowered to perform actions or impose policies that it would normally not be permitted to undertake.

Zoonotic Infection

An infectious disease caused by bacteria, viruses, or parasites that spread from non-human animals (usually vertebrates) to humans.

68 Delaware Journal of Public Health – April 2020

CORONAVIRUS â&#x20AC;&#x201C; RESOURCES CENTERS FOR DISEASE CONTROL AND PREVENTION (CDC) RESOURCES WEBSITE: https://www.cdc.gov/coronavirus/2019-ncov/index.html

RESOURCES FOR: Businesses & Employers:

https://www.cdc.gov/coronavirus/2019-ncov/community/organizations/businesses-employers.html

Clinics and Health Care Facilities:

https://www.cdc.gov/coronavirus/2019-ncov/healthcare-facilities/index.html

Community & Faith-based Leaders:

https://www.cdc.gov/coronavirus/2019-ncov/community/organizations/index.html

Health Care Professionals:

https://www.cdc.gov/coronavirus/2019-ncov/hcp/index.html

Schools & Childcare:

https://www.cdc.gov/coronavirus/2019-ncov/community/schools-childcare/index.html

Travelers:

https://www.cdc.gov/coronavirus/2019-ncov/travelers/index.html

DELAWARE DEPARTMENT OF HEALTH AND SOCIAL SERVICES Website:

http://de.gov/coronavirus

Information Line: 1-866-408-1899 Information Line (TTY): 1-800-232-5460 Press Releases:

https://news.delaware.gov/tag/coronavirus/

Johns Hopkins Interactive Map https://coronavirus.jhu.edu/map.html

World Health Organization

https://www.who.int/emergencies/diseases/novel-coronavirus-2019

Delaware Journal of

Public Health

Submission Guidelines

updated April, 2020

About the Journal Established in 2015, The Delaware Journal of Public Health is a bi-monthly, peer-reviewed electronic publication, created by the Delaware Academy of Medicine/Delaware Public Health Association. The publication acts as a repository of news for the medical, dental, and public health communities, and is comprised of upcoming event announcements, past conference synopses, local resources, peer-reviewed content ranging from manuscripts and research papers to opinion editorials and personal interest pieces, relating to the public health sector. Each issue is largely devoted to an overarching theme or current issue in public health. The content in the Journal is informed by the interest of our readers and contributors. If you have an event coming up, would like to contribute an Op-Ed, would like to share a job posting, or have a topic in public health you would like to see covered in an upcoming issue, please let us know. If you are interested in submitting an article to the Delaware Journal of Public Health, or have any additional inquiries regarding the publication, please contact DJPH Deputy Editor Elizabeth Healy at ehealy@delamed.org, or the Executive Director of The Delaware Academy of Medicine and Delaware Public Health Association, Timothy Gibbs, at tgibbs@delamed.org

Information for Authors Submission Requirements The DJPH accepts a wide variety of submission formats including brief essays, opinion editorials pieces, research articles and findings, analytic essays, news pieces, historical pieces, images, advertisements pertaining to relevant, upcoming public health events, and presentation reviews. If there is an additional type of submission not previously mentioned that you would like to submit, please contact a staff member. The initial submission should be clean and complete, without edits or markups, and contain both the title and author(s) fulls name(s). Submissions should be 1.5 or double spaced with a font size of 12. Initial submissions must also contain a cover letter with concise text (maximum 150 words). Once completed, articles should be submitted via email to Elizabeth Healy at ehealy@ delamed.org as an attachment. Graphics, images, info-graphics, tables, and charts, are welcome and encouraged to be included in articles. Please ensure that all pieces are in their final format, and all edits and track changes have been implemented prior to submission. 70 Delaware Journal of Public Health â&#x20AC;&#x201C; April 2020

Cover Letters must address the following four article requirements: 1. A description of what the paper adds to current knowledge, in particular with respect to material previously published in DJPH, and if systematic reviews exist on the topic. 2. The public health importance of the paper. 3. One sentence summarizing the main message(s) of the paper, which may be used to disseminate the paper on social media. 4. For individual or group randomized trials, provide the date of trial registration and the NCT number from Clinicaltrials.gov or other approved registry. In the cover letter only, not in the paper. Do NOT include the trial registration or NCT number in the abstract or the body of the manuscript during the initial submission. All manuscripts must be submitted via email to Elizabeth Healy at ehealy@delamed.org.

To view additional information for online submission requirements, please refer to the website for the Delaware Journal of Public Health: https://delamed.org/ initiatives/delaware-journal-of-public-health/. Submission Length While there is no prescribed word length, full articles will generally be in the 2500-4000-word range, and editorials or brief reports will be in the 1500-2500-word range. If you have any questions regarding the length of a submission, or APA guidelines, please contact a staff member. Copyright Opinions expressed by contributors and authors do not necessarily reflect the opinions of the DJPH or affiliated institutions of authors. Copying for uses other than personal reference or interest without the consent of the DJPH is prohibited. All material submitted alongside written work, including graphics, charts, tables, diagrams, etc., must be referenced properly in accordance with APA formatting. Conflicts of Interest Any conflicts of interest, including political, financial, personal, or academic conflicts, must be declared prior to the submission of the article, or in conjunction with a submission. Conflicts of interest are any competing interests that may leave readers feeling misled or deceived, and/or alter their perception of subject matter. Declared conflicts of interest may be published alongside articles in the final electronic publication.

Additional Documents and Information for Authors Please Note: All authors and contributors are asked to submit a brief personal biography (3 sentences maximum) and a headshot along submissions. These will be published alongside final submissions in the final electronic publication. For pieces with multiple authors, these additional documents are requested for all contributors. Abstracts Authors must submit a structured or unstructured abstract along with their article. The word limit is 200 words, including headings. A title page should be submitted with this abstract as well. Structured abstracts should employ 4-5 headings: Objectives (begins with “To…”) Methods Results Conclusions A fifth heading, Policy Implications, may be used if relevant to the article. Trial Registration information is required for clinical trials and must be included in the final version abstract All abstracts should provide the dates(s) and location(s) of the study is applicable. Note: There is no Background heading.

Nondiscriminatory Language Use of nondiscriminatory language is required in all DJPH submissions. The DJPH reserves the right to reject any submission found to be using sexist, racist, or heterosexist language, as well as unethical or defamatory statements.

Index of Advertisers Office of the Governor, Press Release . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Office of the Governor, John Carney, Press Release The Time is Now. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 ChristianaCare The DPH Bulletin March 2020 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Division of Public Health, Department of Health and Social Services DHSS Press Release . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Division of Public Health, Department of Health and Social Services Wellness and Prevention Digest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Trust for America’s Health Responding to COVID-19: A Science-Based Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 American Public Health Association Support COVID-19 Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Office of the Governor, John Carney, Press Release The Nation’s Health - April 2020 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 American Public Health Association A Message of Gratitude . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Delaware Journal of Public Health Academy/DPHA Leadership for National Public Health Week . . . . . . . . . . . . . . . . . . . . . . . . . . 30 National Public Health Week Top Global Health Research Stories of 2020. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Fogarty International Center All of Us Research Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 All of Us Delaware Goes Purple . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 Delaware Health and Social Services The DPH Bulletin January 2020 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 Division of Public Health, Department of Health and Social Services Lung Cancer Screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 Division of Public Health, Department of Health and Social Services DJPH Submission Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 Delaware Journal of Public Health

72 Delaware Journal of Public Health – April 2020

Delaware Academy of Medicine / DPHA 4765 Ogletown-Stanton Road Suite L10 Newark, DE 19713

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The Delaware Academy of Medicine is a private, nonprofit organization founded in 1930. Our mission is to enhance the well being of our community through medical education and the promotion ofpublic health. Our educational initiatives span the spectrum from consumer health education tocontinuing medical education conferences and symposia. The Delaware Public Health Association was officially reborn at the 141st Annual Meeting of the American Public Health Association (AHPA) held in Boston, MA in November, 2013. At this meeting, affiliation of the DPHA was transferred to the Delaware Academy of Medicine officially on November 5, 2013 by action of the APHA Governing Council. The Delaware Academy of Medicine, who’s mission statement is “to promote the well-being of our community through education and the promotion of public health,” is honored to take on this responsibility in the First State.

ISSN 2639-6378

Delaware Journal of Public Health - Health Sciences Education / COVID-19 special section

Articles inside

Flexibility and Adaptation: Key Elements for Preserving Research Continuity During COVID-19

CORONAVIRUS - Lexicon

Index of Advertisers

Global Health Matters: NIH mobilizes research to address new coronavirus

Training for Tomorrow: A Century of GME at ChristianaCare

Innovations in Residency Training in Community Hospitals

Nurse Residency Programs: Providing Organizational Value

The Community Benefits of Graduate Medical Education

DIMER at 50. Delaware Best Value for Medical Education

New Rankings Show Healthiest and Least Healthy Counties in Delaware

Advanced Practice Clinician Fellowships: A Strategic Approach to a High-Quality, Stable Workforce

The Workforce Development Program at Delaware Technical Community College

Undergraduate and Graduate Public Health. Programs Need Changes to Teach the Public Health Workforce

America and Delaware need Investment in Public Health Now More Than Ever

University of Delaware - University of Delaware Center for Health Profession Studies

Exams May be Cancelled, but Humanity is Not: A Medical Student Perspective on the COVID-19 Pandemic

From Wuhan to Delaware: Tracking the Spread of COVID-19

Guest Editors - Neil Jasani, MD, MBA and Omar Khan, MD, MHS

In this Issue