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Research conducted in the context of a disaster or public health emergency is essential to improve knowledge about its short- and long-term health consequences, as well as the implementation and effectiveness of response and recovery strategies. Integrated approaches to conducting Disaster Research Response (DR2) can answer scientific questions, while also providing attendant value for operational response and recovery. Here, we propose a Concept of Operations (CONOPS) template to guide the collaborative development and implementation of DR2 among academic public health and public health agencies, informed by previous literature, semi-structured interviews with disaster researchers from academic public health across the United States, and discussion groups with public health practitioners. The proposed CONOPS outlines actionable strategies to address DR2 issues before, during, and after disasters for public health scholars and practitioners who seek to operationalize or enhance their DR2 programs. Additional financial and human resources will be necessary to promote widespread implementation of collaborative DR2 programs.

National-level evaluations may fail to identify capacity improvements for detecting and responding to outbreaks which begin and are first detected at the local level. In response to this issue, we conducted a field-based assessment of the malaria outbreak surveillance system in Mashonaland East, Zimbabwe. We visited eleven clinics in Mudzi and Goromonzi districts. Twenty-one interviews were conducted with key informants from the provincial (

ObjectivesEmergency medical dispatchers (EMDs) experience significant stress in the workplace. Yet, interventions aimed at reducing work-related stress are difficult to implement due to the logistic challenges associated with the relatively unique EMD work environment. This investigation tested the efficacy of a 7-week online mindfulness-based intervention (MBI) tailored to the EMD workforce.MethodsActive-duty EMDs from the USA and Canada (n=323) were randomly assigned to an intervention or wait list control condition. Participants completed surveys of stress and mindfulness at baseline, post intervention, and 3 months follow-up. Repeated measures mixed effects models were used to assess changes in stress and mindfulness.ResultsDifferences between the intervention group and control group in pre–post changes in stress using the Calgary Symptoms of Stress Inventory were statistically significant, with a difference of −10.0 (95% CI: −14.9, −5.2, pConclusionsDevelopment of tailored online MBIs for employees working in challenging work environments offer a promising direction for prevention and intervention. This study found that a short, weekly online MBI for EMDs resulted in reductions in reports of stress. Implications of online MBIs in other emergency responding populations and directions for future research are discussed.

BackgroundSecure and anonymous smartphone-based exposure notification tools are recently developed public health interventions that aim to reduce COVID-19 transmission and supplement traditional public health suriveillance. We assessed the impact of Washington State’s exposure notification tool, WA Notify, in mitigating the spread of COVID-19 during its first four months of implementation.MethodsDue to the constraints of privacy-preservation, aggregate metrics and disparate data sources were utilized to estimate the number of COVID-19 cases averted based on a modelling approach adapted from Wymant et al (2021) using the following parameters: number of notifications generated; the probability that a notified individual goes on to become a case; expected fraction of transmissions preventable by strict quarantine after notification; actual adherence to quarantine; and expected size of the full transmission chain if a contact had not been notified.ResultsThe model was run on a range of secondary attack rates (5.1%-13.706%) and quarantine effectiveness (53% and 64%). Assuming a 12.085% secondary attack rate and 53% quarantine effectiveness, the model shows that 5,500 cases (central 95% range of sensitivity analyses 2,800-8,200) were averted statewide during the first four months of its implementation. Based on an estimated COVID-19 case fatality of 1.4%, WA Notify saved 40-115 lives during the study period.ConclusionsThese findings demonstrate the value of exposure notification tools as a novel public health intervention to mitigate the spread of COVID-19 in the U.S. As new variants emerge and non-essential travel bans are lifted, exposure notification tools may continue to play a valuable role in limiting the spread of COVID-19.

Emergency department (ED) visits and inpatient (IP) admissions may provide an opportunity to reengage poorly engaged people living with HIV and facilitate viral suppression. In 2015, Public Health Seattle and King County partnered with the University of Washington Medicine to implement a real-time data exchange to identify virally unsuppressed people living with HIV seen at the ED/IP hospital and reengage them in HIV care. We evaluated the impact of the data exchange on care engagement and viral suppression.Public Health Seattle and King County received a text alert on weekdays 8 AM to 6 PM for ED/IP patients previously diagnosed with HIV with a most recent viral load ≥200 copies/mL. We compared viral load testing3 months and viral suppression6 months after an alert-eligible visit in the 2 years after intervention and the 7 to 30 months before intervention. To account for secular trends, we used difference-in-differences models to compare patients with alert-window visits to patients with visits outside the alert window before and after intervention.Patients with visits within the alert window in the postintervention period were 1.08 (95% confidence interval [CI], 0.97-1.20) times more likely to have a viral load test within 3 months after an ED visit/IP admission and 1.50 (95% CI, 1.27-1.76) times more likely to achieve viral suppression within 6 months than patients in the preintervention period. However, care engagement (difference-in-differences relative risk, 1.00; 95% CI, 0.84-1.18) and viral suppression (difference-in-differences relative risk, 1.01; 95% CI, 0.84-1.20) trends were similar among patients with visits outside the alert window.Real-time data exchange with ED/IP hospitals was associated with improved viral suppression, but not increased care engagement. However, our results may reflect secular trends resulting from diverse interventions, of which ours was only one. More efforts are needed to improve the effectiveness of relinkage interventions guided by real-time data exchange.

Background Nationwide, emergency response systems depend on 9-1-1 telecommunicators to prioritize, triage, and dispatch assistance to those in distress. 9-1-1 call center telecommunicators (TCs) are challenged by acute and chronic workplace stressors: tense interactions with citizen callers in crisis; overtime; shift-work; ever-changing technologies; and negative work culture, including co-worker conflict. This workforce is also subject to routine exposures to secondary traumatization while handling calls involving emergency situations and while making time urgent, high stake decisions over the phone. Our study aims to test the effectiveness of a multi-part intervention to reduce stress in 9-1-1 TCs through an online mindfulness training and a toolkit containing workplace stressor reduction resources. Methods/design The study employs a randomized controlled trial design with three data collection points. The multi-part intervention includes an individual-level online mindfulness training and a call center-level organizational stress reduction toolkit. 160 TCs will be recruited from 9-1-1 call centers, complete a baseline survey at enrollment, and are randomly assigned to an intervention or a control group. Intervention group participants will start a 7-week online mindfulness training developed in-house and tailored to 9-1-1 TCs and their call center environment; control participants will be “waitlisted” and start the training after the study period ends. Following the intervention group’s completion of the mindfulness training, all participants complete a second survey. Next, the online toolkit with call-center wide stress reduction resources is made available to managers of all participating call centers. After 3 months, a third survey will be completed by all participants. The primary outcome is 9-1-1 TCs’ self-reported symptoms of stress at three time points as measured by the C-SOSI (Calgary Symptoms of Stress Inventory). Secondary outcomes will include: perceptions of social work environment (measured by metrics of social support and network conflict); mindfulness; and perceptions of social work environment and mindfulness as mediators of stress reduction. Discussion This study will evaluate the effectiveness of an online mindfulness training and call center-wide stress reduction toolkit in reducing self-reported stress in 9-1-1 TCs. The results of this study will add to the growing body of research on worksite stress reduction programs. Trial registration ClinicalTrials.gov Registration Number: NCT02961621 Registered on November 7, 2016 (retrospectively registered).

Escherichia colisequence type 131H30has garnered global attention as a dominant antimicrobial-resistant lineage of extraintestinal pathogenicE. coli, but its transmission dynamics remain undefined. We applied whole genome sequencing to identify putative transmission clusters among clinical isolates ofH30from children across the U.S. Of 126 isolates, 17 were involved in 8 putative transmission clusters; 4 clusters involved isolates with some evidence of healthcare-associated epidemiologic linkages. Geographic clustering analyses showed weak geographic clustering. These findings are consistent with a framework where within-hospital transmission is not a main contributor to the propagation ofH30in a pediatric setting.

Objective To conduct a field-based assessment of the malaria outbreak surveillance system in Mashonaland East, Zimbabwe. Introduction Infectious disease outbreaks, such as the Ebola outbreak in West Africa, highlight the need for surveillance systems to quickly detect outbreaks and provide data to prevent future pandemics. 1–3 The World Health Organization (WHO) developed the Joint External Evaluation (JEE) tool to conduct country-level assessments of surveillance capacity. 4 However, considering that outbreaks begin and are first detected at the local level, national-level evaluations may fail to identify capacity improvements for outbreak detection. The gaps in local surveillance system processes illuminate a need for investment in on-the-ground surveillance improvements that may be lower cost than traditional surveillance improvement initiatives, such as enhanced training or strengthening data transfer mechanisms before building new laboratory facilities. 5 To explore this premise, we developed a methodology for assessing surveillance systems with special attention to the local level and applied this methodology to the malaria outbreak surveillance system in Mashonaland East, Zimbabwe. Methods In a collaboration between the Zimbabwe Field Epidemiology Training Program and the University of Washington, an interview guide was developed based on the Centers for Disease Control and Prevention’s (CDC) Updated Guidelines for Surveillance Evaluations and WHO’s JEE tool. 4,6 The guide was tailored in country with input from key stakeholders from the Ministry of Health and Child Care and National Malaria Control Program. Interview guides included questions focused on outbreak detection, response, and control procedures, and surveillance system attributes (preparedness, data quality, timeliness, stability) and functionality (usefulness). The team utilized the tool to evaluate surveillance capacity in eleven clinics across two malaria-burdened districts of Mashonaland East, Mudzi and Goromonzi. Twenty-one interviews were conducted with key informants from the provincial (n=2), district (n=7), and clinic (n=12) levels. Main themes present in interviews were captured using standard qualitative data analysis methods. Results The majority of key informants interviewed were nurses, nurse aids, or nurse officers (57%, 12/21). This evaluation identified clinic-level surveillance system barriers that may be driving malaria outbreak detection and response challenges. Clinics reported little opportunity for cross-training of staff, with 81% (17/21) mentioning that additional staff training support was needed. Only one clinic (10%, 1/11) had malaria emergency preparedness and response guidelines present, a resource recommended by the National Malaria Control Program for all clinics encountering malaria cases. A third of interviewees (33%, 7/21) reported having a standard protocol for validating malaria case data and 29% (6/21) reported challenges with data quality and validation, such as a duplication of case counts. While the surveillance system at all levels detects malaria outbreaks, clinics experience barriers to timely and reliable reporting of cases and outbreaks to the district level. Stability of resources, including transportation and staff capacity, presented barriers, with half (48%, 10/21) of interviewees reporting that their clinics were under-staffed. Additionally, the assessment revealed that the electronic case reporting system (a WHO-developed SMS application, Frontline) that is used to report malaria cases to the district was not functioning in either district, which was unknown at the provincial and national levels. To detect malaria outbreaks, clinics and districts use graphs showing weekly malaria case counts against threshold limit values (TLVs) based on historic five-year malaria case count averages; however, because TLVs are based on 5-year historic data, they are only relevant for clinics that have been in existence for at least five years. Only 30% (3/10) of interviewees asked about outbreak detection graphs reported that TLV graphs were up-to-date. Conclusions This surveillance assessment revealed several barriers to system performance at the clinic-level, including challenges with staff cross-training, data quality of malaria case counts, timeliness of updating outbreak detection graphs, stability of transportation, prevention, treatment, and human resources, and usefulness of TLVs for outbreak detection among new clinics. Strengthening these system barriers may improve staff readiness to detect and respond to malaria outbreaks, resulting in timelier outbreak response and decreased malaria mortality. This evaluation has some limitations. We interviewed key informants from a non-random sample covering 30% of all clinics in Mudzi and Goromonzi districts; thus, barriers identified may not be representative of all clinics in these districts. Secondly, evaluators did not interview individuals who may have been involved in outbreak detection and response but were not present at the clinic when interviews were conducted. Lastly, many of the evaluation indicators were based on self-reported information from key informants. Despite these limitations, convenience sampling is common to public health practice, and we reached a saturation of key informant themes with the 21 key informants included in this evaluation. 7 By designing evaluation tools that focus on local-level knowledge and priorities, our assessment approach provides a framework for identifying and addressing gaps that may be overlooked when utilizing multi-national tools that evaluate surveillance capacity and improvement priorities at the national level. References 1. World Health Organzation. International Health Regulations - Third Edition. Vol Third. Geneva, Switzerland; 2005. doi:10.1017/CBO9781107415324.004. 2. Global Health Security Agenda. Implementing the Global Health Security Agenda: Progress and Impact from U.S. Government Investments.; 2018. https://www.ghsagenda.org/docs/default-source/default-document-library/global-health-security-agenda-2017-progress-and-impact-from-u-s-investments.pdf?sfvrsn=4. 3. McNamara LA, Schafer IJ, Nolen LD, et al. Ebola Surveillance — Guinea, Liberia, and Sierra Leone. MMWR Suppl. 2016;65(3):35-43. doi:10.15585/mmwr.su6503a6. 4. World Health Organization (WHO). Joint External Evaluation Tool: International Health Regulations (2005). Geneva; 2016. http://apps.who.int/iris/bitstream/10665/204368/1/9789241510172_eng.pdf. 5. Groseclose SL, Buckeridge DL. Public Health Surveillance Systems: Recent Advances in Their Use and Evaluation. Annu Rev Public Health. 2017;38(1):57-79. doi:10.1146/annurev-publhealth-031816-044348. 6. Centers for Disease Control and Prevention. Updated guidelines for evaluating public health surveillance systems: recommendations from the guidelines working group. MWWR. 2001;50(No. RR-13). 7. Dworkin SL. Sample size policy for qualitative studies using in-depth interviews. Arch Sex Behav. 2012;41(6):1319-1320. doi:10.1007/s10508-012-0016-6.

Strong data quality (DQ) is a precursor to strong data use. In resource limited settings, routine DQ assessment (DQA) within electronic medical record (EMR) systems can be resource-intensive using manual methods such as audit and chart review; automated queries offer an efficient alternative. This DQA focused on Haiti's national EMR - iSanté - and included longitudinal data for over 100,000 persons living with HIV (PLHIV) enrolled in HIV care and treatment services at 95 health care facilities (HCF).This mixed-methods evaluation used a qualitative Delphi process to identify DQ priorities among local stakeholders, followed by a quantitative DQA on these priority areas. The quantitative DQA examined 13 indicators of completeness, accuracy, and timeliness of retrospective data collected from 2005 to 2013. We described levels of DQ for each indicator over time, and examined the consistency of within-HCF performance and associations between DQ and HCF and EMR system characteristics.Over all iSanté data, age was incomplete in1% of cases, while height, pregnancy status, TB status, and ART eligibility were more incomplete (approximately 20-40%). Suspicious data flags were present for3% of cases of male sex, ART dispenses, CD4 values, and visit dates, but for 26% of cases of age. Discontinuation forms were available for about half of all patients without visits for 180 or more days, and60% of encounter forms were entered late. For most indicators, DQ tended to improve over time. DQ was highly variable across HCF, and within HCFs DQ was variable across indicators. In adjusted analyses, HCF and system factors with generally favorable and statistically significant associations with DQ were University hospital category, private sector governance, presence of local iSante server, greater HCF experience with the EMR, greater maturity of the EMR itself, and having more system users but fewer new users. In qualitative feedback, local stakeholders emphasized lack of stable power supply as a key challenge to data quality and use of the iSanté EMR.Variable performance on key DQ indicators across HCF suggests that excellent DQ is achievable in Haiti, but further effort is needed to systematize and routinize DQ approaches within HCFs. A dynamic, interactive "DQ dashboard" within iSanté could bring transparency and motivate improvement. While the results of the study are specific to Haiti's iSanté data system, the study's methods and thematic lessons learned holdgeneralized relevance for other large-scale EMR systems in resource-limited countries.

In 2015, the University of Washington School of Public Health, Department of Epidemiology established the Student Epidemic Action Leaders (SEAL) team to provide public health students with experience in field epidemiology in state and local public health communicable disease divisions. The University of Washington Department of Epidemiology developed the SEAL team in collaboration with the Washington State Department of Health to offer public health graduate students opportunities to contribute to the real-time needs of public health agencies during a communicable disease event and/or preparedness event. The SEAL team combines classroom and field-based training in public health practice and applied epidemiology. During the first 2 years of the SEAL team (2016-2018), 34 SEALs were placed at 4 agencies contributing more than 1300 hours of assistance on 24 public health projects.

ObjectivesHealth care providers play an essential role in public health emergency preparedness and response. We conducted a 4-year randomized controlled trial to systematically compare the effectiveness of traditional and mobile communication strategies for sending time-sensitive public health messages to providers.MethodsSubjects (N=848) included providers who might be leveraged to assist with emergency preparedness and response activities, such as physicians, pharmacists, nurse practitioners, physician’s assistants, and veterinarians. Providers were randomly assigned to a group that received time-sensitive quarterly messages via e-mail, fax, or cell phone text messaging (SMS) or to a no-message control group. Follow-up phone interviews elicited information about message receipt, topic recall, and perceived credibility and trustworthiness of message and source.ResultsOur main outcome measures were awareness and recall of message content, which was compared across delivery methods. Per-protocol analysis revealed that e-mail messages were recalled at a higher rate than were messaged delivered by fax or SMS, whereas the as-treated analysis found that e-mail and fax groups had similar recall rates and both had higher recall rates than the SMS group.ConclusionsThis is the first study to systematically evaluate the relative effectiveness of public health message delivery systems. Our findings provide guidance to improve public health agency communications with providers before, during, and after a public health emergency. (Disaster Med Public Health Preparedness. 2016;10:98–107)

Public health surveillance of communicable diseases depends on timely, complete, accurate, and useful data that are collected across a number of healthcare and public health systems. Health Information Exchanges (HIEs) which support electronic sharing of data and information between health care organizations are recognized as a source of ‘big data’ in healthcare and have the potential to provide public health with a single stream of data collated across disparate systems and sources. However, given these data are not collected specifically to meet public health objectives, it is unknown whether a public health agency’s (PHA’s) secondary use of the data is supportive of or presents additional barriers to meeting disease reporting and surveillance needs. To explore this issue, we conducted an assessment of big data that is available to a PHA—laboratory test results and clinician-generated notifiable condition report data—through its participation in a HIE.

Background: Infectious diseases can appear and spread rapidly. Timely information about disease patterns and trends allows public health agencies to quickly investigate and efficiently contain those diseases. But disease case reporting to public health has traditionally been paper-based, resulting in somewhat slow, burdensome processes. Fortunately, the expanding use of electronic health records and health information exchanges has created opportunities for more rapid, complete, and easily managed case reporting and investigation. To assess how this new service might impact the efficiency and quality of a public health agency's case investigations, we compared the timeliness of usual case investigation to that of case investigations based on case report forms that were partially pre-populated with electronic data. Intervention: Between September 2013-March 2014, chlamydia disease report forms for certain clinics in Indianapolis were electronically pre-populated with clinical, lab and patient data available through the Indiana Health Information Exchange, then provided to the patient’s doctor. Doctors could then sign the form and deliver it to public health for investigation and population-level disease tracking. Methods: We utilized a novel matched case analysis of timeliness changes in receipt and processing of communicable disease report forms. Each Chlamydia cases reported with the pre-populated form were matched to cases reported in usual ways. We assessed the time from receipt of the case at the public health agency: 1) inclusion of the case into the public health surveillance system and 2) to close to case. A hierarchical random effects model was used to compare mean difference in each outcome between the target cases and the matched cases, with random intercepts for case. Results: Twenty-one Chlamydia cases were reported to the public health agency using the pre-populated form. Sixteen of these pre-populated form cases were matched to at least one other case, with a mean of 23 matches per case. The mean Reporting Lag for the pre-populated form cases was 2.5 days, which was 2.7 days shorter than the mean Reporting Lag for the matched controls (p =

Background: Cancer survivors living in rural areas experience unique challenges due to additional burdens, such as travel and limited access to specialists. Rural survivors of breast cancer have reported poorer outcomes, poorer mental health and physical functioning, and lower-than-average quality of life compared to urban survivors. Objective: To explore the feasibility and acceptability of developing a mobile health survivorship care app to facilitate care coordination; support medical, psychosocial, and practical needs; and improve survivors' long-term health outcomes. Methods: An interactive prototype app, SmartSurvivor, was developed that included recommended survivorship care plan components. The prototype's feasibility and acceptability were tested by a sample of breast cancer survivors (n=6), primary care providers (n=4), and an oncologist (n=1). Results: Overall, both survivors and providers felt that SmartSurvivor was a potentially valuable tool to support long-term survivorship care plan objectives. Portability, accessibility, and having one place for all contact, treatment, symptom tracking, and medication summaries was highly valued. Conclusions: Our pilot study indicates that SmartSurvivor is a feasible and acceptable approach to meeting survivorship care objectives and the needs of both breast cancer survivors and their health care providers. Exploration of mobile health options for supporting survivorship care plan needs is a promising area of research.

Background Escherichia coli sequence type (ST) 131-H30 is a globally important pathogen implicated in rising rates of multidrug resistance among E. coli causing extraintestinal infections. Previous studies have focused on adults, leaving the epidemiology of H30 among children undefined. Methods We used clinical data and isolates from a case-control study of extended-spectrum cephalosporin-resistant E. coli conducted at 4 US children's hospitals to estimate the burden and identify host correlates of infection with H30. H30 isolates were identified using 2-locus genotyping; host correlates were examined using log-binomial regression models stratified by extended-spectrum cephalosporin resistance status. Results A total of 339 extended-spectrum cephalosporin-resistant and 1008 extended-spectrum cephalosporin-susceptible E. coli isolates were available for analyses. The estimated period prevalence of H30 was 5.3% among all extraintestinal E. coli isolates (95% confidence interval [CI], 4.6%-7.1%); H30 made up 43.3% (81/187) of extended-spectrum β-lactamase (ESBL)-producing isolates in this study. Host correlates of infection with H30 differed by extended-spectrum cephalosporin resistance status: Among resistant isolates, age ≤5 years was positively associated with H30 infection (relative risk [RR], 1.83 [95% CI, 1.19-2.83]); among susceptible isolates, age ≤5 years was negatively associated with H30 (RR, 0.48 [95% CI, .27-.87]), while presence of an underlying medical condition was positively associated (RR, 4.49 [95% CI, 2.43-8.31]). Conclusions ST131-H30 is less common among extraintestinal E. coli collected from children compared to reported estimates among adults, possibly reflecting infrequent fluoroquinolone use in pediatrics; however, it is similarly dominant among ESBL-producing isolates. The H30 subclone appears to disproportionately affect young children relative to other extended-spectrum cephalosporin-resistant E. coli.

BackgroundE. coli ST131-H30 is a globally important pathogen implicated in rising rates of multidrug resistance among E. coli causing extraintestinal infections. Previous studies have focused on adults, leaving the epidemiology of H30 among children undefined.MethodsWe used clinical data and isolates from a case-control study of extended-spectrum cephalosporin-resistant E. coli conducted at four US children’s hospitals to estimate the burden and identify host correlates of infection with H30. H30 isolates were identified using two-locus genotyping; host correlates were examined using log-binomial regression models stratified by extended-spectrum cephalosporin resistance status.ResultsA total of 339 extended-spectrum cephalosporin-resistant and 1008 extended-spectrum cephalosporin-susceptible E. coli isolates were available for analyses. The estimated period prevalence of H30 was 5.3% among all extraintestinal E. coli isolates (95% confidence interval [CI] 4.6%-7.1%); H30 made up 43.3% (81/187) of ESBL-producing isolates in this study. Host correlates of infection with H30 differed by extended-spectrum cephalosporin resistance status: among resistant isolates, age ≤5 years was positively associated with H30 infection (relative risk [RR] 1.83, 95% CI 1.19-2.83); among susceptible isolates, age ≤5 years was negatively associated with H30 (RR 0.48, 95% CI 0.27-0.87), while presence of an underlying medical condition was positively associated (RR 4.49, 95% CI 2.43-8.31).ConclusionsST131-H30 is less common among extraintestinal E. coli collected from children compared to reported estimates among adults, possibly reflecting infrequent fluoroquinolone use in pediatrics; however, it is similarly dominant among ESBL-producing isolates. The H30 subclone appears to disproportionately affect young children relative to other extendedspectrum cephalosporin-resistant E. coli.SummaryST131-H30 was responsible for 5.3% of all extraintestinal E. coli infections and 43.3% of ESBL-producing extraintestinal E. coli infections among US children. The clinical and demographic correlates of infection with ST131-H30 differed between extended-spectrum cephalosporin-resistant and -sensitive isolates.

Purpose System use is a key criterion of success in an electronic medical record (EMR) implementation, and there is little research on long-term use of systems following implementation. The aim of the paper was to describe the development, implementation and use of iSante, Haiti's national HIV care and treatment EMR. Methods To build a picture of the history of iSante, we interviewed 11 staff involved with the development and implementation of the EMR, and reviewed organization records. Data entry and report use were ascertained by querying the central patient database. Results By the end of 2010 there were 67 sites with iSante installed, and the scope of the system had been expanded to include primary care and obstetrics and gynecology. New functionality includes data forms specific to subpopulations, the ability to transfer patient records among clinics, and integration with an electronic laboratory system. We observed fluctuations in use over time, with substantial reductions in the number of active sites during times of large-scale disruptions in Haiti. A surge in report use following the January 2010 earthquake suggests that clinics found the EMR to be a valuable source of data during the recovery phase. Conclusion There is real potential for EMRs in developing countries to improve clinical practice and make data available for efficient reporting, quality improvement and other population health uses. An approach of continuous system improvement, combined with regular assessments of use, is necessary for achieving an effective, national implementation of a standardized EMR. We have achieved successes in terms of rolling out new functionality and expanding to new sites, but more work remains to be done to improve perceptions of data quality and increase use of population data for accurate and timely reporting.

Background The role of Mycoplasma pneumoniae (Mp) in the initiation and persistence of asthma remains elusive. Mp community-acquired respiratory distress syndrome toxin (CARDS Tx) is a unique virulence factor that induces an intense lymphocytic response and exacerbates asthma in animal models. We sought to determine the incidence of Mp infection and the presence of CARDS Tx in subjects with refractory asthma (RA). Methods We conducted a prospective observational study in 64 subjects with RA. Respiratory secretions (sputum, nasal lavage, and throat swab) and blood were analyzed for the presence of CARDS Tx and P1 adhesin (P1) DNA by polymerase chain reaction (PCR), and CARDS Tx by antigen capture. Serum IgM and IgG antibodies to CARDS Tx were determined by enzyme-linked immunosorbent assay (ELISA). Results Thirty-three of 64 subjects (52%) tested positive for Mp: 29 of 33 by CARDS Tx vs 10 of 33 by P1 assays. Ten subjects followed longitudinally for up to 633 days tested persistently positive for Mp. There were no significant differences in Mp-specific IgG responses between Mp-positive and Mp-negative groups. Eight of 10 subjects who tested persistently positive failed to mount a substantial IgG response to CARDS Tx, and up to 8 weeks of clarithromycin failed to eradicate Mp in five subjects. Conclusions Subjects with RA may be chronically infected with Mp. PCR for CARDS Tx appears to be the most sensitive method of identifying Mp infection. Despite the persistence of Mp in subjects with RA, some subjects failed to mount an IgG response, and macrolide therapy was insufficient to eradicate Mp.

The objective of this study was to determine the prevalence and concordance of Mycoplasma genitalium (MG) among Mexican American and African American women and their male sexual partners. Secondary objectives were to determine symptoms of MG infection and persistence of MG after antibiotic therapy. Heterosexual couples were tested for MG and interviewed separately regarding symptoms and behavioural/epidemiologic variables at baseline, six and 12 months. The overall prevalence of MG among women and men was 9.5% and 10.6%, respectively. Subjects were five times more likely to be infected with MG if their sexual partner was MG positive. Among men and women, MG prevalence and mean bacterial loads were similar after receiving single-dose azithromycin, doxycycline or no antibiotics. MG was associated with current urethral discharge in men. No clinical symptoms were specifically diagnostic of MG infection in women.

Given that the integration of human papillomavirus type 16 (HPV16) into the host genome occurs preferentially with the disruption of the E2 gene, a ratio of E2 to E7 gene copies is often used as a marker for integration. It is largely undetermined, however, whether ratio estimates are affected by HPV intratypic variations. We assembled four plasmid constructs, each containing a DNA fragment from an HPV16 European, Asian-American, African-1, or African-2 variant. These constructs and nine cervical swab samples were assayed by real-time PCR with two primer-probe sets for each gene: a specific set, fully complementary to the HPV16 prototype, and a degenerate set, incorporating degenerate bases at positions where nucleotides differed among the variants. The ratio of E2 to E7 gene copies for the European variant construct was close to 1, no matter which sets of primers and probes were used. While the ratios for the African-1 and Asian-American variant constructs remained close to 1 with the degenerate sets of primers and probes, the ratios were 0.36 and 2.57, respectively, with the specific sets of primers and probes. In addition, a nucleotide alteration at the position immediately following the 3′ end of the E2 forward primer binding site was found to be responsible for an underestimation of E2 gene copies for the African-2 variant construct. Similar patterns were found in nine cervical samples. In conclusion, mismatches between the primers and probes and their targets due to HPV16 intratypic variations would introduce errors in testing for integration; this situation can be sufficiently ameliorated by incorporating degenerate bases into the primers and probes.

Detection of Mycoplasma genitalium -mediated, chlamydia-negative nongonococcal urethritis and other M. genitalium -linked infectious etiologies has been very challenging. Although M. genitalium is considered a leading cause of genitourinary symptoms in men and women, extreme difficulties in its cultivation due to its highly fastidious nature and the lack of routine and effective diagnostic tests have slowed the generation of clinical data which directly implicate the presence of M. genitalium in disease pathogenesis. In this study, we compared enzyme-linked immunosorbent assays (ELISAs) and immunoblot and PCR assays in M. genitalium culture-positive women over 1 to 3 years of clinical visits to determine the usefulness of independent diagnostic strategies. Furthermore, the value of combinatorial diagnostic assessments is described, which provides insights into the dynamics of M. genitalium -host interactions. Overall, we show that neither ELISA nor PCR, alone or in combination, provides the sensitivity required to confidently predict the existence of viable M. genitalium organisms in cervical and vaginal samples. Additionally, culture-positive women exhibited a range of antibody responsiveness to M. genitalium based upon ELISA and immunoblot assessments, indicating immune diversity among this high-risk population.

Objectives. To prospectively examine the effect of a 6F urethral catheter on the urinary flow rate in healthy women without lower urinary tract symptoms undergoing pressure-flow studies. Methods. Women between the ages of 30 and 70 years, without lower urinary tract complaints and without a history of surgery for incontinence, were recruited. All women completed the Urogenital Distress Inventory-6 questionnaire, and only women with mild or no symptoms were enrolled. After a free flow rate was determined, cystometry and pressure-flow studies were performed once and then repeated using a 6F urethral catheter. The peak flow rates during the first and second studies were compared with one another and with the nonintubated values. Results. Of the 59 women that applied, 20 volunteers (mean age 41.7 years) met the entry criteria and were evaluated. The mean nonintubated flow rate was 22.65 mL/s. With a 6F urethral catheter in place, our cohort had a mean peak flow rate of 16.25 mL/s on the first study and 15.25 mL/s on the second. A significant difference was demonstrated between the free and intubated peak flow rates for both the first ( P = 0.0006) and the second ( P = 0.0001) study. No significant difference was detected between the two intubated peak flow rates ( P = 0.262). Conclusions. Our data suggest that the presence of a 6F urethral catheter significantly reduces the maximal flow rate compared with free flow studies. Whether these findings represent a truly obstructive effect of the catheter, detrusor fatigue, or other possible effect of the catheter remains to be elucidated.

Background Communication technologies that enable bi-directional/two-way communications and cell phone texting (SMS) between public health agencies and their stakeholders may improve public health surveillance, ensure targeted distribution of alerts to hard-to-reach populations, reduce mortality and morbidity in an emergency, and enable a crucial feedback loop between public health agencies and the communities they serve. Building on prior work regarding health care provider preferences for receiving one-way public health communications by email, fax or SMS, we conducted a formative, exploratory study to understand how a bi-directional system and the incorporation of SMS in that system might be used as a strategy to send and receive messages between public health agencies and community-based organizations which serve vulnerable populations, health care providers, and public health workers. Our research question: Under what conditions and/or situations might public health agencies utilize bi-directional and/or SMS messaging for disseminating time-sensitive public health information (alerts, advisories, updates, etc.) to their stakeholders? Methods A mixed methods (qualitative and quantitative) study was conducted between April and July 2014. Data collection included a survey distributed to health care providers and semi-structured interviews with providers, community- and government-based organization leaders and directors, and public health agency internal workforce staff. Survey respondents and interviewees were asked about their exposure to public health messages, how these messages are received and how the information in these messages are handled, and in what situations (for example, a local vs. a national event, a pandemic or emergency vs. a health update) a bi-directional and/or SMS messaging system might improve communications between public health agencies and their stakeholder group. Interview and survey data were qualitatively analyzed. Thematic codes were quantitized into dichotomous variables of 0 or 1 on a per respondent basis to enumerate the presence or absence of each thematic code, enable quantitative analysis, and inform interpretation of findings. Results Five major themes emerged from synthesizing survey and interview results: 1) Regardless of situational context (emergency vs. non-urgent) and message recipient (stakeholder group), e-mail is a favored modality for receiving public health messages; 2) The decision to use bi-directional, SMS or multiple communication strategies is complex and public health agencies’ need to manage messaging concerns/barriers and benefits for all parties; 3) Both public health agencies and their stakeholders share similar values/uses and concerns regarding two-way public health messaging and SMS; 4) Public health is highly trusted, thus thoughtful, effective messaging will ensure continuation of this goodwill; and 5) Information reciprocity between public health agencies and stakeholders who share their information is essential. Conclusions Multiple communication strategies might be utilized but the choice of a specific strategy needs to balance message content (emergency vs. routine communications), delivery (one- vs. two-way), channel (SMS, email, etc.), and public health agency burden with stakeholder preferences and technical capabilities, all while mitigating the risk of message overload and disregard of important communications by recipients. Electronic supplementary material The online version of this article (doi:10.1186/s12889-015-1980-2) contains supplementary material, which is available to authorized users.

Background Health care providers are an important target audience for public health emergency preparedness, response and recovery communications. Short Message Service or text messaging to cell phones may be a promising supplemental or alternative technique for reaching health care providers with time-sensitive public health information. However, studies to date have yet to investigate the message content and formatting requirements of providers with respect to public health alerts and advisories or sought to understand how to meet these needs using Short Message Service technology. Methods Data collection was completed using a two-part online survey. In the first part, health care providers identified their use of different technologies for receiving information and provided input on the message components most important in a public health message. In the second part, health care providers participated in an exercise in which they shortened three public health emergency messages, ranging from 2024–2828 characters per message, to meet the 160-character limitation for text delivery. Results were analyzed to determine associations between provider types, age ranges, gender, access to various media (text, email, fax, social media, etc.), and smart phone ownership. Results The following components were most frequently selected as essential for a public health message: Topic, Recommendation, Geographic Location, Signs & Symptoms, Population Affected, and Link to Additional Information. There was no statistically significant association between message component selection and provider type, age ranges, or gender. In the message conversion exercise, we found a statistically significant association between providers who reported receiving information by SMS and/or smart phone ownership and including a link to additional information in the converted message, ranging from 61% to over 72% on a per message analysis. Conclusions A substantive recommendation derived from this study is that public health agencies include a link to additional website information when sending messages in SMS format. SMS could be a useful public health tool for communicating with health care providers but further investigation of how to effectively use SMS and other mobile technologies is needed to inform public health decisions regarding adoption of messaging systems utilizing these newer technologies.

Background : On January 12, 2010, a devastating 7.0 magnitude earthquake struck the West Department of Haiti, killing more than 200,000 people and injuring or displacing many more. This disaster threatened continuity of HIV care and treatment services. Objectives : This case study examined the effect of the devastating 2010 earthquake in Haiti on attrition from the HIV antiretroviral therapy (ART) program. Design : The study triangulated retrospective data from existing sources, including: 1) individual-level longitudinal patient data from an electronic medical record for ART patients at two large public sector departmental hospitals differently affected by the earthquake; and 2) aggregate data on the volume of HIV-related services delivered at the two hospitals before and after the earthquake. Methods : The study compared ART attrition and service delivery in Jacmel, a site in the ‘very strong’ zone of earthquake impact, and in Jeremie, a site in the ‘light’ zone of earthquake impact. The analysis used time-to-event analysis methods for the individual-level patient data, and descriptive statistical methods for the aggregate service delivery data. Results : Adjusted ART attrition risk was lower at the hospital in Jacmel after vs. before the earthquake (HR=0.51; p =0.03), and was lower in Jacmel vs. Jeremie both before (HR=0.55; p =0.01) and after the earthquake (HR=0.35; p =0.001). The number of new ART patient enrollments, new HIV patient registrations, and HIV clinical visits dropped notably in Jacmel immediately after the earthquake, but then rapidly rebounded. On average, there was no change in new ART enrollments per month after vs. before the earthquake at either site. Conclusion : These findings underscore the resilience of Haitian ART providers and patients, and contribute evidence that it is possible to maintain continuity of ART services even in the context of a complex humanitarian crisis. Keywords : HIV/AIDS; antiretroviral therapy; attrition; Haiti; earthquake (Published: 5 August 2014) Citation : Glob Health Action 2014, 7 : 24572 - http://dx.doi.org/10.3402/gha.v7.24572

Objective. The Rapid Emergency Alert Communication in Health (REACH) Trial was a randomized control trial to systematically compare and evaluate the effectiveness of traditional and mobile communication modalities for public health agencies to disseminate time-sensitive information to health-care providers (HCPs). We conducted a sub-study to identify the communication channels by which HCPs preferred receiving public health alerts and advisories. Methods. Enrolled HCPs were blindly randomized into four message delivery groups to receive time-sensitive public health messages by e-mail, fax, or short message service (SMS) or to a no-message control group. Follow-up interviews were conducted 5–10 days after the message. In the final interview, additional questions were asked regarding HCP preferences for receiving public health alerts and advisories. We examined the relationship between key covariates and preferred method of receiving public health alert and advisory messages. Results. Gender, age, provider type, and study site showed statistically significant associations with delivery method preference. Older providers were more likely than younger providers to prefer e-mail or fax, while younger providers were more likely than older providers to prefer receiving messages via SMS. Conclusions. There is currently no evidence-based research to guide or improve communication between public health agencies and HCPs. Understanding the preferences of providers for receiving alerts and advisories may improve the effectiveness of vital public health communications systems and, in turn, may enhance disease surveillance, aid in early detection, and improve case finding and situational awareness for public health emergencies.

Objective To systematically compare mobile (SMS) and traditional (email, FAX) communication strategies to identify which modality is most effective for communication of health alerts and advisories between public health agencies and health care providers in order to improve emergency preparedness and response. Introduction The effectiveness of emergency preparedness and response systems depends, in part, on the effectiveness of communication between agencies and individuals involved in emergency response, including health care providers who play a significant role in planning, event detection, response and communication with the public. Although much attention has been paid to the importance of communicating clinical data from health care providers to public health agencies for purposes of early event detection and situational awareness (e.g., BioSense) and to the need for alerting health care providers of public health events (e.g., Health Alert Networks), no studies to date have systematically identified the most effective methods of communication between public health agencies and community health care providers for purposes of public health emergency preparedness and response. The REACH (Rapid Emergency Alert Communication in Health) study is a 4-year randomized controlled trial to evaluate and compare the effectiveness of mobile (SMS) and traditional (email, FAX) communication strategies for sending public health messages to health care providers—physicians, pharmacists, nurse practitioners, physician’s assistants and veterinarians. Methods Providers were recruited from three sites (King County, WA; Spokane County, WA; and across the state of Montana; N=845) and randomized to receive time-sensitive public health messages via email, Fax, short message service (SMS) or to a control group that did not receive messages. For one year, alerts based on real events of public health interest were sent quarterly with follow-up telephone interviews conducted 5–10 days after the delivery date. Interviews consisted of approximately six questions that elicited information about message receipt, recall of its content and perceived credibility and trustworthiness of the message and source. In addition, provider access to online alert information and delivery success or failure was collected. Results Frequency of receipt, timeliness, content awareness, perceived credibility and perceived trustworthiness were measured and compared across communication delivery systems. On average 84.0% of participants were contacted in each follow-up survey following all alerts and across all three sites. Primary data analysis was designed to measure differences between the three communication groups using intent-to-treat methods. A set of secondary analyses examined the outcomes excluding providers who could not have received messages (due to incorrect contact information, known technical failures, or because providers could not receive messages by the assigned delivery message—for example, a provider without a Fax number randomized to the Fax group). We will discuss preliminary results of intent-to-treat analyses regarding rate of recall of study alert message content between traditional and mobile communications and perceived trustworthiness and credibility of message and message source by providers. In addition, we will report on frequency of accessing online alert information between traditional and mobile delivery groups. Conclusions There is currently no evidence-based research to guide or improve the practice of public health communication between public health agencies and health care providers before, during and after a public health emergency. Improving this communication via the use of effective media can enhance disease surveillance, which will aid in early detection and enhance case finding and situational awareness for public health emergencies. By systematically evaluating the relative effectiveness of mobile and traditional message delivery systems for emergency preparedness and response communications, the REACH study contributes to building the evidence base for novel and effective approaches to emergency communications.

Introduction: Public health professionals engage in frequent exchange of health information while pursuing the objectives of protecting and improving population health. Yet, there has been little study of the information work of public health workers with regard to information exchange. Our objective was to gain a better understanding of information work at a local health jurisdiction before and during the early stages of participation in a regional Health Information Exchange. Methods: We investigated the information work of public health workers engaged in disease surveillance activities at a medium-sized local health jurisdiction by conducting semi-structured interviews and thematically analyzing interview transcripts. Results: Analysis of the information work of public health workers revealed barriers in the following areas: information system usability; data timeliness, accuracy and completeness; and social interaction with clients. We illustrate these barriers by focusing on the work of epidemiologists. Conclusion: Characterizing information work and barriers to information exchange for public health workers should be part of early system design efforts. A comprehensive understanding of the information practice of public health workers will inform the design of systems that better support public health work.

Notifiable condition reporting and alerting are two important public health functions. Today, a variety of methods are used to accomplish these transfers of information. The increasing use of electronic health record systems by healthcare providers makes new types of electronic communication possible. We used the XForms standard and nationally recognized technical profiles to demonstrate the communication of both notifiable condition reports and patient-tailored public health alerts. This demonstration of bi-directional communication took place in a prototypical health information exchange environment. We successfully transferred information between provider electronic health record systems and public health systems for notifiable condition reporting. Patient-specific alerts were successfully sent from public health to provider systems. In this paper we discuss the benefits of XForms, including the use of XML, advanced form controls, form initialization and reduction in scripting. We also review implementation challenges, the maturity of the technology and its suitability for use in public health.

Background Health care providers (HCPs) play an important role in public health emergency preparedness and response (PHEPR) so need to be aware of public health threats and emergencies. To inform HCPs, public health issues PHEPR messages that provide guidelines and updates, and facilitate surveillance so HCPs will recognize and control communicable diseases, prevent excess deaths and mitigate suffering. Public health agencies need to know that the PHEPR messages sent to HCPs reach their target audience and are effective and informative. Public health agencies need to know that the PHEPR messages sent to HCPs reach their target audience and are effective and informative. We conducted a literature review to investigate the systems and tools used by public health to generate PHEPR communications to HCPs, and to identify specific characteristics of message delivery mechanisms and formats that may be associated with effective PHEPR communications. Methods A systematic review of peer- and non-peer-reviewed literature focused on the following questions: 1) What public health systems exist for communicating PHEPR messages from public health agencies to HCPs? 2) Have these systems been evaluated and, if yes, what criteria were used to evaluate these systems? 3) What have these evaluations discovered about characterizations of the most effective ways for public health agencies to communicate PHEPR messages to HCPs? Results We identified 25 systems or tools for communicating PHEPR messages from public health agencies to HCPs. Few articles assessed PHEPR communication systems or messaging methods or outcomes. Only one study compared the effectiveness of the delivery format, device or message itself. We also discovered that the potential is high for HCPs to experience "message overload" given redundancy of PHEPR messaging in multiple formats and/or through different delivery systems. Conclusions We found that detailed descriptions of PHEPR messaging from public health to HCPs are scarce in the literature and, even when available are rarely evaluated in any systematic fashion. To meet present-day and future information needs for emergency preparedness, more attention needs to be given to evaluating the effectiveness of these systems in a scientifically rigorous manner.

In 2002, the Northwest Center for Public Health Practice (NWCPHP) at the University of Washington initiated the Epidemiology Competencies Project, with the goal of developing competency-based epidemiology training for non-epidemiologist public health practitioners in the northwestern United States. An advisory committee consisting of epidemiology faculty and experienced public health practitioners developed the epidemiology competencies. NWCPHP used the competencies to guide the development of in-person trainings, a series of online epidemiology modules, and a Web-based repository of epidemiology teaching materials. The epidemiology competencies provided a framework for collaborative work between NWCPHP and local and regional public health partners to develop trainings that best met the needs of a particular public health organization. Evaluation surveys indicated a high level of satisfaction with the online epidemiology modules developed from the epidemiology competencies. However, measuring the effectiveness of competency-based epidemiology training for expanding epidemiology knowledge and skills of the public health workforce remains a challenge.

Objective Our goal was to evaluate the performance of screening with (1) Papanicolaou and human papillomavirus (HPV) DNA testing and (2) Papanicolaou testing with reflex HPV testing of atypical squamous cells of undetermined significance for detecting cervical intraepithelial neoplasia grade 3 or more in clinics that serve low-income women in the United States. Study Design There were 4799 women who were recruited primarily from Planned Parenthood clinics and who were screened with liquid-based Papanicolaou testing and HPV DNA testing and referred for biopsy based on a positive test result for oncogenic HPV DNA or a Papanicolaou test that showed atypical squamous cells of undetermined significance or more. Results Among 931 women who were 30-50 years of age, the sensitivity of reflex HPV testing was 53.8% (range, 38.2%-72.3%). The sensitivity of HPV DNA and Papanicolaou testing was 91% (range, 74.6%-100%). The specificity of reflex HPV testing was 95.1% (range, 93.8%-96.3%). Generally, the specificity of HPV DNA and Papanicolaou testing was low. Conclusion Among US women who are ≥30 years old, HPV DNA and Papanicolaou testing is a reasonable cervical cancer screening strategy.

Infection with oncogenic human papillomavirus (HPV) types is a necessary cause of cervical cancer, the second most frequently occurring cancer in women worldwide. Rates of acquisition of HPV are high, particularly among sexually active young adults. Reported estimates of incident HPV infection among initially negative women have reached as high as 60% over a 5-year follow-up period. In this article, we review the epidemiology of HPV infection. In addition to estimates of disease frequency, we highlight risk factors for HPV infection, including the number of lifetime sex partners, which is the most salient risk factor. We discuss significant issues surrounding the natural history of HPV infection, including viral persistence versus clearance, immune response, development of lesions and development of cancer. Finally, we discuss strategies for preventing HPV infection.

Mycoplasma genitalium is a leading cause of chlamydia-negative, nongonoccocal urethritis and has been directly implicated in numerous other genitourinary as well as extragenitourinary tract pathologies. Detection of M. genitalium has relied almost entirely on PCR amplification of clinical specimens and evidence of seroconversion since these mycoplasmas are highly fastidious and culture isolation by microbiological techniques is very rare. We have established a combinatorial strategy using confocal immunoanalysis (CIA) and real-time PCR to qualitatively and quantitatively assess patterns of M. genitalium infection in women attending a sexually transmitted disease-related health clinic in San Antonio, Tex. CIA allows spatial examination of mycoplasmas on surfaces and inside human target cells, plus the ability to evaluate cell-to-cell patterns and variances within samples. Real-time PCR permits determination of genome copy numbers of mycoplasmas and human cells by multiplex amplification using mycoplasma gyrA and human RNase P gene sequences, which indicates overall levels of mycoplasma infection and degree of parasitism. These assays are strongly correlated and, in combination, permit detection and elucidation of heretofore-unrecognized patterns of M. genitalium infections in clinical and experimental samples.

METHODS This retrospective cohort study examined ART attrition among adult patients enrolled on ART from 2005-2011 in two large public-sector Departmental hospitals, using the iSante electronic data system. The study characterized ART attrition levels according to definitions of attrition based upon ART dispensing data and clinic encounter data. The study explored the patient demographic, clinical, temporal, and service utilization factors associated with ART attrition. The study used time-to-event analysis methods.

Background Health care providers play a significant role in large scale health emergency planning, detection, response, recovery and communication with the public. The effectiveness of health care providers in emergency preparedness and response roles depends, in part, on public health agencies communicating information in a way that maximizes the likelihood that the message is delivered, received, deemed credible and, when appropriate, acted on. However, during an emergency, health care providers can become inundated with alerts and advisories through numerous national, state, local and professional communication channels. We conducted an alert fatigue study as a sub-study of a larger randomized controlled trial which aimed to identify the most effective methods of communicating public health messages between public health agencies and providers. We report an analysis of the effects of public health message volume/frequency on recall of specific message content and effect of rate of message communications on health care provider alert fatigue. Methods Health care providers enrolled in the larger study (n=528) were randomized to receive public health messages via email, fax, short message service (SMS or cell phone text messaging) or to a control group that did not receive messages. For 12 months, study messages based on real events of public health significance were sent quarterly with follow-up telephone interviews regarding message receipt and topic recall conducted 5–10 days after the message delivery date. During a pandemic when numerous messages are sent, alert fatigue may impact ability to recall whether a specific message has been received due to the “noise” created by the higher number of messages. To determine the impact of “noise” when study messages were sent, we compared health care provider recall of the study message topic to the number of local public health messages sent to health care providers. Results We calculated the mean number of messages that each provider received from local public health during the time period around each study message and provider recall of study message content. We found that recall rates were inversely proportional to the mean number of messages received per week: Every increase of one local public health message per week resulted in a statistically significant 41.2% decrease (p < 0.01), 95% CI [0.39, .87] in the odds of recalling the content of the study message. Conclusions To our knowledge, this is the first study to document the effects of alert fatigue on health care providers’ recall of information. Our results suggest that information delivered too frequently and/or repetitively through numerous communication channels may have a negative effect on the ability of health care providers to effectively recall emergency information. Keeping health care providers and other first-line responders informed during an emergency is critical. Better coordination between organizations disseminating alerts, advisories and other messages may improve the ability of health care providers to recall public health emergency messages, potentially impacting effective response to public health emergency messages.