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Overview: Office of Public Health & Environmental Hazards (OPHEH) AMSUS SUSTAINING MEMBERS SECTION June 18, 2008 Lawrence R. Deyton, MSPH, MD Chief Public Health & Environmental Hazards Officer Major Program Responsibilities OFFICE OF PUBLIC HEALTH and ENVIRONMENTAL HAZARDS

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Overview: Office of Public Health & Environmental Hazards



June 18, 2008

Lawrence R. Deyton, MSPH, MD

Chief Public Health & Environmental Hazards Officer

major program responsibilities
Major Program Responsibilities



Environmental hazards/health

Public health

VHA emergency management

Women veterans health

VHA occupational health

‘….other duties as described’

opheh public health pillars
OPHEH Public Health Pillars
  • All OPHEH programs are built upon four pillars of population/public health:
  • Surveillance and
  • epidemiology
  • Service of underserved
  • populations
  • Risk reduction/
  • mitigation, prevention,
  • health promotion
  • Public health policy

Veterans Health AdministrationPublic Health – Patient Care Continuum

Patient Care Services

  • Patient Care Guidelines
  • Critical Pathways
  • Practice Parameters

Public Health &



  • Surveillance & Epidemiology
  • Underserved Populations
  • Risk Mitigation
  • Public Health Policy


Population focus






opheh programs
OPHEH Programs

Environmental Health SHG

Environmental Agents Service (Agent Orange, Gulf War/Iraq/Afghanistan, War Related Illness and Injury Centers, IOM, newsletters/registries)

Environmental Epidemiology Service

Radiation and Physical Exposure Service

Public Health SHG

Clinical Public Health Service (HIV/HCV/other PH)

Public Health Prevention/Tobacco Use Cessation

Center for Quality Management in Public Health (HIV, HCV and other PH case registries, databases)

National seasonal influenza program

Center for Public Health Research and Surveillance

opheh programs6
OPHEH Programs

Emergency Management SHG

VHA Comprehensive Emergency Management

Emergency Planning & Operations Service (AEMs)

VA’s National Response Plan Support (w/ DHHS, FEMA, DoD, NDMS)

Women Veterans Health SHG

Comprehensive Women’s Health

Women’s Health Education and Training

Reproductive Health

Field Coordination

Occupational Health SHG

Employee Health Clinical Support Services

Workers Comp and Occupational Health Policy

Employee Health Disease Prevention/Health Promo

opheh programs other duties as described
OPHEH PROGRAMS…other duties as described

Planning and Preparing for Pandemic Influenza

Implementation USG & VA Pandemic Flu Plans

Stockpiling: oseltamivir (with VA-wide use plan), PPE kits, N-95 respirators

Infection: Don’t Pass It On campaign

Educational materials/flu advisories, Emergency Communications Exercises

Tabletop exercises (VAMC/VISN/VACO/ & IT)

Planning for ‘Public Health’ Standards of Care

Coordination with HHS, DoD, White House-Homeland Security Council, and other Federal agencies

current issues future initiatives
Current Issues/Future Initiatives

Environmental Health SHG

IOM Reports: Agent Orange, Gulf War

Veterans Health Examination Registries (N=500,000)

Quarterly updates on OIF/OEF Veterans’ VHA utilization trends

Prospective surveillance of new veteran population

VHA Mass Casualty Decontamination Program

Toxic Embedded Fragment Center

current issues future initiatives9
Current Issues/Future Initiatives

Public Health SHG

  • Healthcare associated infection & influenza surveillance system
  • 2007-2008 Seasonal Flu Vaccine Campaign
  • Improved smoking cessation and prevention (for OIF/OEF veterans, coordination with DoD)
  • Efforts to encourage routine HIV testing and early diagnosis of HIV infection
  • Hepatitis C Resource Centers Program – end-stage liver disease/better treatments
current issues future initiatives10
Current Issues/Future Initiatives

Emergency Management SHG

Federal region VA liaisons

Enhancement of Disaster Emergency Medical Personnel System & Establishment of Retried Emergency Corps

Internal VHA patient evacuation planning

Emergency Manager Certification Program

Stakeholder evaluation of EMSHG support

“Partners in Preparedness” with States

Deployable medical units

VISN Emergency Medical Evacuation Planning

current issues future initiatives11
Current Issues/Future Initiatives

Women Veterans Health SHG

  • VHA female population doubling: most new women veterans are of childbearing age
  • Primary care provider education and training
  • Clinical inventory of women’s health care services
  • Strategic collaborations in provision of WV health care (PCS: Primary Care, MH, Oncology, Cardiol)
  • Increased focus beyond gender-specific care to cardiac health, cancer prevention, health maintenance for women
  • Preventing birth defects through RX management
current issues future initiatives12
Current Issues/Future Initiatives

Occupational Health SHG

- Employee disease prevention/health promotion

  • Violence Prevention initiative (with NCOD)
  • Safe Patient Transfer Ergonomics initiative
  • Workers’ Compensation improvement for all VHA
  • Occupational Health Records System
va toxic embedded fragment center
VA Toxic Embedded Fragment Center
  • Mission: To provide care and medical surveillance for veterans with retained fragments
    • Many traumatic injuries are occurring from use of improvised explosive devices (IEDs) in the Iraq War
    • Estimates suggest > 5,000 soldiers with traumatic injuries may have retained embedded fragments
    • IEDs are packed with heterogeneous material; thus both metallic and non-metallic fragments are possible
va toxic embedded fragment center15
Objective: Identify and manage (prevent) health effects related to fragment retention

Risk of the development of tumors at fragment sites

Foreign body carcinogenesis

Chemical carcinogenesis

Risk of systemic effects arising from chemicals released from fragments

VA Toxic Embedded Fragment Center
objectives of the tef center
Objectives of the TEF Center
  • Establish a registry of wounded veterans with retained fragments
  • Develop laboratory collaborations that allow determination of fragment composition
  • Develop medical and surgical management guidelines for veterans with fragments
  • Provide biomonitoring services to assist in medical management of these veterans
  • Offer in-patient referral to Baltimore Center for complex cases
developing the center
Developing the Center














Registry Data


initial steps patient care management guidelines
Initial Steps: Patient Care/Management Guidelines
  • Hosted a meeting of experts on implanted medical devices and embedded fragments
    • Identified toxicants to include in biomonitoring panels
    • Identified potential biomarkers of early effects
    • Identified additional outcomes of concern and potential means of surveillance
surveillance protocol surgical specimens removed fragments
Surveillance Protocol:Surgical Specimens/Removed Fragments
  • Chemical analysis of fragments
    • Surface chemistry
    • Total fragment composition
  • Analysis of tissue surrounding fragments
    • Histology – including histochemical staining for proliferative cells
    • In situ metal and non-metallic fragments (e.g., polymers, ceramics) analysis
surveillance protocol biomonitoring for release of chemicals from retained fragments
Surveillance Protocol:Biomonitoring for Release of Chemicals from Retained Fragments
  • Biomonitoring/toxicological screening
    • Selection of chemicals
      • Metals: As, Cd, Cr, Co, Cu, Fe, Mn, Ni, Pb, U, W
      • Plastics/polymer components: Isocyanate, Acrylics, Diethylhexylphthalates
      • Others: Identify sources of information on IED/fragment content
    • Selection of biological specimens
      • Urine, blood, other body fluids
    • Monitoring frequency
surveillance protocol biomonitoring for potential for systemic effects of embedded fragments
Surveillance Protocol:Biomonitoring for Potential for Systemic Effects of Embedded Fragments
  • Biomarkers of effect
      • Identification of potential target organs
      • Genotoxicity
      • Urinary system – kidney and bladder
      • Hematopoetic system – bone marrow
      • Immune system
  • Surveillance tools
      • X-ray
      • Ultrasound
      • MRI
      • CT scan
registry data
What information should be collected and included in the database?

Demographic information

History/circumstances of exposure

Number and location of removed of fragments

Composition of all removed fragments

Location of fragments not removed

Types of injury

Biomonitoring data

Health Outcomes

Goal – to optimize the health of veterans with embedded fragments

Registry Data
a tale of two patients
May 1985

35 year-old man with newly diagnosed HIV infection admitted to West LA VAMC with severe dehydration

Dx: P. carinii pneumonia

Course: Pt dies after 1 week

April 2005

46-year-old man with newly diagnosed HIV infection admitted to DC VAMC with severe dehydration

Dx: Systemic C. neoformans


Successful tx with liposomal AmB

HAART started

April 2008 CD4 450, VL <75 back to work and enjoying life

A tale of two patients
hiv testing in va the challenge
HIV testing in VA: The Challenge

HIV has become a manageable chronic condition

  • 8 million veterans enrolled
  • Most veterans are not tested
  • Many at-risk veterans are not tested
  • Substantial numbers of newly diagnosed veterans present with late disease – harder to treat, worse outcomes
  • Earlier diagnosis will save lives and money
barriers to early hiv diagnosis
Barriers to early HIV diagnosis
  • Legal barriers – HIV consent law
  • Cultural barriers
    • Focus on risk-based testing as opposed to routine testing
    • Perceived need for special training: “Not my table”
  • Logistic barriers
    • Decentralized system (no “one size fits all” strategy)
    • Local barriers (especially for rapid testing)
    • VA HIV consent documentation – lots of work
    • Competing priorities of clinical staff
  • Information barriers
    • Lack of information on rapid testing
    • Lack of information on importance of early diagnosis of HIV
va hiv testing goals
VA HIV Testing Goals
  • Promote HIV testing as part of routine medical care
  • Routinely provide information on HIV testing
  • Tools for incorporating HIV testing into primary care setting
  • Logistic support for rapid testing
  • There is no excuse for late diagnosis of HIV infection
social marketing for hiv testing in va
“Social Marketing” for HIV Testing in VA

HIV testing social marketing campaign

  • Change provider/patient mindset
  • Tools for routine HIV testing in primary care
  • Support for rapid testing
  • Counseling materials

Ongoing clinical demonstration project

  • Collaboration with VA QUERI group
  • Multiple VISNs
public health social marketing examples
Smoking cessation

Print, broadcast, interactive (phone/Web)

Link to resources (e.g., 1-800-QUIT-NOW)

Promotion of nicotine replacement therapy

Public health social marketing examples
social marketing hepatitis c

Interactive (phone/Web)

Links to resources



Support groups

Social Marketing: Hepatitis C
va hiv testing social marketing campaign
VA HIV Testing Social Marketing Campaign
  • HIV is now a chronic treatable disease
  • Late HIV diagnosis is an avoidable tragedy
  • HIV testing is the only avenue to early HIV diagnosis
  • Change provider and patient attitudes
    • Make part of routine medical care
    • Demystify testing
    • Emphasize importance of HIV testing
  • Promote health and prevent disease
    • Among all veterans in care
    • Among at-risk veterans
  • Improve linkage to care
    • HIV-positive
    • HIV-negative
campaign phases
Campaign phases

1. Perform formative work

  • Define barriers among veterans and providers
  • Test potential messages

2. Develop test messages

  • Evaluate among veterans and providers
  • Target all appropriate segments

3. Pilot test messages

  • Examine in multiple VAMCs and outpatient clinics
  • Evaluate using quantitative and qualitative methods

4. Roll out national campaign

  • Target audiences: PCPs, veterans, VSOs
  • Media: print, interactive, narrowcast
women veterans health strategic health care group
Women Veterans Health Strategic Health Care Group
  • March 2007 the Women Veterans Health Program elevated to a Strategic Health Care Group (SHG)
  • Identify and address gender disparities in provision of care to women veterans
  • Key focus has been a comprehensive evaluation of women’s health care delivery
women veterans health
Women Veterans Health
  • Implementing major new initiatives:
    • Comprehensive Women’s Health Program
    • Women’s Health Education
    • Quality and Performance Data
    • Birth Defects Prevention
  • VA Medical Centers have received $32.5 million in FY 08 Supplemental Funds
    • Funds to specifically improve women veterans’ health diagnostic capabilities
women veterans underserved population
Women Veterans:Underserved population

Utilization data indicate current models of care delivery present barriers to women veterans using VA

We have chronically under-served the population

  • Market penetration for women veterans 2003-2007 between 11.9 and 14.6%
  • Market penetration for all living male veterans has been steady from 2003-2007= 22%
women veterans using va
Women Veterans Using VA

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

the new oif oef era veteran
The New OIF/OEF Era Veteran
  • She is utilizing VA services: 42% enroll
  • She is coming to VA frequently
    • 45.6% were seen 2-10 visits
    • 38.5 % seen 11 or more times since 2003
    • 1.5 % Inpatient Stay (one or more)

VHA Challenge:

The total number of women using VA services will nearly double in the next 2-4 years.

How will VHA best provide health services as the numbers increase?

women veterans summary
Women Veterans SUMMARY
  • Shrinking total veterans population but a doubling of women veterans using VHA for their healthcare
  • Increasing recognition of women veterans’ specific health needs
  • Prepare for influx of younger women veterans
  • Primary care for women at every VA
  • Comprehensive view of women’s health as beyond reproductive health issues
  • Examine women’s health as a population of women veterans – and whether military experience plays a role in health outcomes
office of public health and environmental hazards deliverables
Office of Public Health and Environmental Hazards Deliverables

Customers are: veterans, their families, VA employees, VISNs and Facilities, VSOs, Congress, other Federal/state health


Products include:

VHA Directives, Information Letters,

Handbooks, Advisories

Training and exercises

Topical reports, plans,

clinical/public health


Presentations, journal articles

Posters, brochures, fact sheets

Radiologic & Physical Exposure

Comp Evaluations (approx 1200/yr)


Veterans Health Initiatives (N=15)



Public Health Campaigns

Events, Conferences

Grant programs


Emergency Management Principles and Practices for Health Care Systems

opheh priorities for fy08
OPHEH Priorities for FY08

VHA Emergency Preparedness:

EMSHG Evaluation & VISN/Facility interactions

VHA Pandemic Influenza Plans/Preps

The New Veteran – projections for this population’s future health needs

Women Veterans – current & future needs

VHA Occupational Health Program

Smoking and Tobacco Use Cessation

Healthcare Associated Infection & Influenza Surveillance System

HIV Testing Social Marketing Campaign and HepC/HepB


Always stay true to President Lincoln’s pledge:

“To care for him [and her] who shall have borne the battle and for his widow/er and orphan.”