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In March 2020, a tribal telehealth program—the Indian Country Extension for Community Health Outcomes (ECHO)—added emergency COVID-19 to its programming to support the pandemic response. A long-standing relationship with a network of Indian Health Service, tribal, and urban Indian clinicians supported a rapid launch of the COVID-19 telehealth program. This nationwide service offered primary care clinicians and staff serving American Indian/Alaska Native people access to virtual learning opportunities, expert clinical recommendations, technical assistance, and capacity building. From March 12, 2020, through April 30, 2021, the program provided 85 clinical sessions in 12 months, with an average participation of 120 attendees per clinic (N = 11 710). Attendees could complete a voluntary evaluation form for each session via an online link. A total of 2595 forms were completed. Attendees came from 33 states and 206 unique locations, primarily from the Pacific Northwest (n = 931, 35.9%). Most pharmacists (78.1%), providers (ie, medical doctor, doctor of osteopathy, advanced practice nurse, physician assistant, or clinical nurse midwife; 70.8%), and nurses (59.6%) gave the sessions the highest rating of “very satisfied.” The highest proportion of attendees indicating that they planned a change in practice were pharmacists (68.0%), nurses, (64.1%), and providers (61.3%). Most attendees (93.1%) said that the COVID-19 sessions gave them a sense of social support. Lessons learned were that (1) a telehealth platform can be quickly retasked for emergency response with no further delays, (2) a telehealth network can be scaled up quickly with participation from preexisting relationships, and (3) the platform is flexible and adaptable to the needs of participants. An existing telehealth program can be a key part of timely, relevant, large-scale emergency readiness and response efforts.

Toward a New Era for the Indian Health System The Indian Health System is poorly resourced and understaffed. Now is a promising time to reflect on big solutions for fostering a transformative, rath...

This review assessed sexual health and sexually transmitted infection (STI) burden among American Indian/Alaska Native (AI/AN) peoples within the context of current clinical and public health services. We conducted a review of published literature about sexual health and bacterial STIs among AI/AN populations in the United States using Medline (OVID), CINAHL (EbscoHost) and Scopus. Peer-reviewed journals published during 1 January 2005-2 December 2021 were included and supplemented by other publicly available literature. A total of 138 articles from reference lists met inclusion criteria, including 85 peer-review articles and 53 additional references. Results indicate a disproportionate burden of STIs is carried by AI/AN populations compared to non-Hispanic Whites. Risk for STIs in AI/AN people has origins in historical trauma and structural and social determinants of health. STI services are available for AI/AN populations, but many barriers to care exist. Community-based sexual health programming has been successful, but has thus far focused primarily on adolescents and young adults. A myriad of factors contributes to high rates of STIs among AI/AN populations. Longstanding disparities show a clear need to increase the availability of integrated, low-barrier STI prevention and treatment services. Implementation of multi-level (individual, physician, clinic, healthcare organisation, and/or community level), culturally relevant sexual health and STI interventions should be community-based and person-centred, acknowledge social determinants of health, and grounded in deep respect and understanding of AI/AN histories and cultures.

American Indian/Alaska Native communities are at higher risk of poor outcomes from Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). The Northwest Portland Area Indian Health Board’s program Indian Country Extensions for Community Healthcare Outcomes (ECHO) initiated telehealth sessions for health professionals. All resources were centralized at www.IndianCountryECHO.org. In its first six weeks, the program had 4,579 attendees. Participants submitted 563 questions to specialists. There were 22,683 webpage views, more than three times the pre-COVID-19 baseline. Evaluation found 94 percent of clinicians reported knowledge increase and 93 percent reported greater social support, demonstrating that a teleECHO network serving Indian country is an important part of emergency response.

Medicaid, the state-level public insurance in the United States, has widely differing criteria treatment for hepatitis C virus (HCV) such as stage of liver fibrosis, documented sobriety, and specialist consultation. In a rural health network, facilities located in two less restrictive states prescribed HCV drugs at a significantly higher rate than two more restrictive states (rate ratio 4.7, CI 2.6–8.5). Prescription rates per population were highly associated with HCV treatment policies.

Objectives Indian Health Service (IHS) screening rates for Chlamydia trachomatis are lower than national rates of chlamydia screening in the Southwest. We describe and evaluate the effect of a public health intervention consisting of electronic health record (EHR) reminders to alert health care providers to screen for chlamydia at an IHS facility. We also conducted an awareness presentation among health care providers on chlamydia screening. Methods We conducted our intervention from November 1, 2013, through October 31, 2015, at an IHS facility in the Southwest. We implemented algorithms that queried database values to assess chlamydia screening performance in 6 clinical departments. We presented data on the screening performance of clinical departments and health care providers (de-identified) in the awareness presentations. We re-queried database values 1 and 2 years after implementation of the EHR reminder intervention to evaluate before-and-after screening rates, comparing data among all patients and among female patients only. Results We found small, sustained relative increases in chlamydia screening rates during the 2012-2015 evaluation period: 20.8% pre-intervention to 24.9% and 24.2% one and two years postintervention, respectively, across all patients; 32.3% preintervention to 36.6% and 35.6% one and two years postintervention, respectively, among female patients. Increases in clinical department–specific screening rates varied and were most prominent in internal medicine (35.8% preintervention to peak 65.8% postintervention). The 1 clinic (obstetrics–gynecology) that did not receive an awareness presentation showed a consistent downward trend in screening rates, although absolute rates were consistently higher in that clinic than in other clinics. Conclusions Awareness presentations that offer feedback to health care providers on screening performance, heighten provider awareness of the importance of chlamydia screening, and promote development of novel provider-initiated screening protocols may help to increase screening rates when combined with EHR reminders.

Objectives Hepatitis C virus (HCV) and HIV transmission in the United States may increase as a result of increasing rates of opioid use disorder (OUD) and associated injection drug use (IDU). Epidemiologic trends among American Indian/Alaska Native (AI/AN) persons are not well known. Methods We analyzed 2010-2014 Indian Health Service data on health care encounters to assess regional and temporal trends in IDU indicators among adults aged ≥18 years. IDU indicators included acute or chronic HCV infection (only among adults aged 18-35 years), arm cellulitis and abscess, OUD, and opioid-related overdose. We calculated rates per 10 000 AI/AN adults for each IDU indicator overall and stratified by sex, age group, and region and evaluated rate ratios and trends by using Poisson regression analysis. Results Rates of HCV infection among adults aged 18-35 increased 9.4% per year, and rates of OUD among all adults increased 13.3% per year from 2010 to 2014. The rate of HCV infection among young women was approximately 1.3 times that among young men. Rates of opioid-related overdose among adults aged Conclusions Rates of HCV infection and OUD increased significantly in the AI/AN population. Strengthened public health efforts could ensure that AI/AN communities can address increasing needs for culturally appropriate interventions, including comprehensive syringe services programs, medication-assisted treatment, and opioid-related overdose prevention and can meet the growing need for treatment of HCV infection.

Background The Namibian Ministry of Health and Social Services (MoHSS) piloted the first HIV Project ECHO (Extension for Community Health Outcomes) in Africa at 10 clinical sites between 2015 and 2016. Goals of Project ECHO implementation included strengthening clinical capacity, improving professional satisfaction, and reducing isolation while addressing HIV service challenges during decentralization of antiretroviral therapy. Methods MoHSS conducted a mixed-methods evaluation to assess the pilot. Methods included pre/post program assessments of healthcare worker knowledge, self-efficacy, and professional satisfaction; assessment of continuing professional development (CPD) credit acquisition; and focus group discussions and in-depth interviews. Analysis compared the differences between pre/post scores descriptively. Qualitative transcripts were analyzed to extract themes and representative quotes. Results Knowledge of clinical HIV improved 17.8% overall (95% confidence interval 12.2–23.5%) and 22.3% (95% confidence interval 13.2–31.5%) for nurses. Professional satisfaction increased 30 percentage points. Most participants experienced reduced professional isolation (66%) and improved CPD credit access (57%). Qualitative findings reinforced quantitative results. Following the pilot, the Namibia MoHSS Project ECHO expanded to over 40 clinical sites by May 2019 serving more than 140 000 people living with HIV. Conclusions Similar to other Project ECHO evaluation results in the United States of America, Namibia’s Project ECHO led to the development of ongoing virtual communities of practice. The evaluation demonstrated the ability of the Namibia HIV Project ECHO to improve healthcare worker knowledge and satisfaction and decrease professional isolation.

PURPOSE: To evaluate liver cancer incidence rates and risk factor correlations in non-Hispanic AI/AN populations for the years 1999–2009. METHODS: We linked data from 51 central cancer registries with the Indian Health Service patient registration databases to improve identification of the AI/AN population. Analyses were restricted to non-Hispanic persons living in Contract Health Service Delivery Area counties. We compared age-adjusted liver cancer incidence rates (per 100,000) for AI/AN to white populations using rate ratios. Annual percent changes (APCs) and trends were estimated using joinpoint regression analyses. We evaluated correlations between regional liver cancer incidence rates and risk factors using Pearson correlation coefficients. RESULTS: AI/AN persons had higher liver cancer incidence rates than whites overall (11.5 versus 4.8, RR = 2.4, 95% CI 2.3– 2.6). Rate ratios ranged from 1.6 (Southwest) to 3.4 (Northern Plains and Alaska). We observed an increasing trend among AI/AN persons (APC 1999–2009 = 5%). Rates of distant disease were higher in the AI/AN versus white population for all regions except Alaska. Alcohol use (r = 0.84) and obesity (r = 0.79) were correlated with liver cancer incidence by region. CONCLUSIONS: Findings highlight disparities in liver cancer incidence between AI/AN and white populations and emphasize opportunities to decrease liver cancer risk factor prevalence.

Hepatitis C virus (HCV) disproportionately affects American Indians/Alaska Natives (AI/AN). The Indian Health Service (IHS), via federal and tribal health facilities provides medical services to an estimated 2.2 million AI/AN people in the United States. HCV diagnoses, defined by International Classification of Diseases 9th Revision, Clinical Modification (ICD-9-CM) codes, were analyzed from 2005 to 2015. Results showed 29,803 patients with an HCV diagnosis; 53.4% were among persons born 1945-1965 and overall HCV burden was higher among males than females. These data will help inform local, regional, and national efforts to address, plan for and carry out a national strategy to provide treatment for HCV infected patients and programs to prevent new HCV infections.

Objectives: The objectives of this study were to use Indian Health Service (IHS) data from electronic health records to analyze human immunodeficiency virus (HIV) diagnoses among American Indian/Alaska Natives (AI/ANs) and to identify current rates and trends that can support data-driven policy implementation and resource allocation for this population. Methods: We analyzed provider visit data from IHS to capture all AI/AN patients who met a definition of a new HIV diagnosis from 2005 through 2014 by using International Classification of Diseases, Ninth Revision, Clinical Modification codes. We calculated rates and trends of new HIV diagnoses by age, sex, region, and year per 100 000 AI/ANs in the IHS user population. Results: A total of 2273 AI/ANs met the definition of newly diagnosed with HIV from 2005 through 2014, an average annual rate of 15.1 per 100 000 AI/ANs. Most (356/391) IHS health facilities recorded at least 1 new HIV diagnosis. The rate of new HIV diagnoses among males (21.3 per 100 000 AI/ANs) was twice as high as that among females (9.5 per 100 000 AI/ANs; rate ratio = 2.2; 95% confidence interval, 2.1-2.4); by age, rates were highest among those aged 20-54 for males and females. By region, the Southwest region had the highest number (n = 1016) and rate (19.9 per 100 000 AI/ANs) of new HIV diagnoses. Overall annual rates of new HIV diagnoses were stable from 2010 through 2014, although diagnosis rates increased among males ( P < .001) and those aged 15-19 ( P < .001), 45-59 ( P < .001), and 50-54 ( P = .01). Conclusions: New HIV diagnoses, derived from provider visit data, among AI/ANs were stable from 2010 through 2014. AI/ANs aged 20-54, particularly men, may benefit from increased HIV prevention and screening efforts. Additional services may benefit patients in regions with higher rates of new diagnoses and in remote settings in which reported HIV numbers are low.

INTRODUCTION American Indian/Alaska Native (AI/AN) populations are disproportionately affected by chronic hepatitis C virus (HCV) infection. Federal facilities of the Indian Health Service, in conjunction with Tribally operated and Urban Indian (I/T/U) health care facilities, serve an estimated 2.2 million AI/AN patients. The facilities are mainly rural and have few specialists. To fill the gap in specialists in I/T/U clinics, the Extension for Community Healthcare Outcomes (ECHO) telehealth model was used to support clinicians to treat HCV in primary care. METHODS Participants in 3 regional HCV ECHO networks serving AI/AN patients were surveyed by e-mail and text message to determine patterns of ECHO usage, usefulness, and barriers to treating patients with HCV at their primary care clinics. RESULTS From a total of 44 respondents from 72 eligible health care facilities, a majority (61%) stated that they started treating patients with HCV subsequent to participating in the telehealth program. Participants with more telehealth experience sought increasing complexity in patient case presentations. In California, 7 of 8 clinicians who had attended more than 10 ECHO sessions expressed diminishing need for ECHO sessions to manage cases (

Background: American Indian/Alaska Natives (AI/ANs) are disproportionately affected by hepatitis C virus (HCV), with more than double the national rate of HCV-related mortality as well as the highest rates of acute HCV. The “cascade of care” for HCV consists of screening, confirmation, treatment, and sustained virologic clearance (SVR)/cure. At each stage of this process, patients can be lost to follow-up. Federal health care facilities in an administrative area of the Indian Health Service conducted a review to identify and address gaps in HCV treatment. Facilities generally treated HCV with a strong pharmacy component using a collaborative practice agreement and HCV telehealth services to external specialists. Methods: All facilities had a pharmacist HCV program point of contact. Each pharmacist conducted a chart review of HCV patients and submitted aggregate results on HCV antibody status, HCV confirmation testing, stage of liver disease, initiation of treatment, and SVR/cure. Each facility also ranked current barriers to scaling up HCV treatment services from a defined list of options. Results: Of 1789 HCV antibody positive patients, 77% (1381) had a confirmation test, of which 67% (929) were positive. Of these patients, 62% (576) had their liver fibrosis scored, and 58% (335) had initiated treatment. Of patients with an SVR/cure test, all (274/274) were negative. Discussion: These data indicate that rural clinics can be successful providing HCV diagnosis and treatment. Pharmacists can play a key role in HCV clinical services. The outcomes of each step in the treatment process at the facility level can vary widely due to local factors. The barriers to HCV care that persist are nonclinical.

Background: The Indian Health Service (IHS), a federal agency, provides direct patient care to an estimated 1.9 million American Indian/Alaska Native patients across a large and decentralized network of health facilities. The IHS sought to implement HIV screening of adults and adolescents per national recommendations. The IHS facilities received technical support such as electronic clinical reminders (ECRs) and sample HIV-testing policies. Purpose: To determine what facility-wide policy and practices were associated with high HIV screening rates. Methods: Survey of clinical directors of 61 federal health facilities on use of ECRs, testing policies/standing orders, and other factors associated with HIV screening. These results were correlated with HIV screening performance results for each facility as derived from the IHS national database. Results: A total of 51 (84%) of 61 facilities were interviewed. In univariate analysis, factors that were correlated with higher rates of HIV screening were having an HIV screening standing order (unadjusted odds ratio [UOR] 8.7, 95% confidence interval [CI] 2.0-37.3), sexually transmitted disease (STD) screening standing order (UOR 5, CI 1.1-21.7), having an HIV ECR in place for a year or longer (UOR 10.2, CI 2.8-37.5), and inclusion of both providers and nurses in offering HIV screening (UOR 4.8, CI 1.4-16.7). In multivariate analysis, ECRs (adjusted odds ratio [AOR] 9.1, 95% CI 1.8-45.1) and STD standing orders (AOR 7.4, 95% CI 1.1-51.0) remained significantly associated with higher HIV screening. Conclusion: Policy and practice interventions such as ECRs and standing order/testing policies and delegation of screening are correlated with high HIV screening, are scalable across health networks, and will be used for improving other infectious disease screening indicators in such as STD and hepatitis C.

Hepatitis C virus (HCV) infection is a substantial and largely unrecognized public health problem. An estimated 3.5 million persons in the United States are currently living with HCV infection, at least half of whom are unaware of their infection (1-3). Persons born during 1945-1965 (the "baby boomer" birth cohort) have a sixfold higher prevalence (2.6%) than adults of other ages, and represent 81% of all persons chronically infected with HCV (4). Therefore, in addition to recommending testing for all persons at risk for HCV infection, CDC and the U.S. Preventive Services Task Force (USPSTF) recommend one-time HCV testing for the birth cohort (5,6). Compared with the national average, American Indian/Alaska Native (AI/AN) persons have approximately twofold the rate of acute HCV incidence and HCV associated mortality (2). In June 2012, the Indian Health Service (IHS) implemented HCV testing in the 1945-1965 birth cohort and created a nationally standardized performance measure to monitor implementation of the recommendation. As of June 2015, the proportion of the birth cohort screened for HCV increased from a baseline of 7.9% (14,402/182,503) to 32.5% (68,514/211,014) among the AI/AN population served by IHS nationwide; provider training and the use of clinical decision tools were associated with increases in HCV testing. With this fourfold increase in testing in just 3 years, IHS needs to prepare for the challenges associated with increased identification of persons living with HCV infection.

In recent years, the Department of Veterans Affairs health care system has mounted a response to hepatitis C that should be the envy of any health system. On the other hand, the Indian Health Service is struggling to meet the needs of its patients with hepatitis C.

The US Centers for Disease Control and Prevention recently issued new recommendations to screen persons born between 1945 and 1965 for hepatitis C virus. Federal facilities in the US Indian Health Service were surveyed on knowledge and support for the hepatitis C virus recommendations, as well as barriers and concerns.

Background: In August 2012, the Centers for Disease Control and Prevention released recommendations to screen persons born from 1945 to 1965 for hepatitis C virus (HCV). In September 2012, Warm Springs Health and Wellness Center (WSHWC) initiated a quality improvement (QI) project to conduct HCV screening among all patients in this birth cohort. Methods: Screening rates were tracked using a nationally standardized HCV screening measure in the Indian Health Service. At the end of the project period, WSHWC staff took a brief survey to review the impact of the HCV QI Project. Results: Screening for HCV among eligible patients at WSHWC increased from 5% (47/938) in September 2012 to 76% (593/785) in September 2014. Survey data indicated that clinicians felt increased screening for HCV had a positive impact on patient communication and care. Conclusions: Primary care clinics can successfully increase HCV screening in a relatively short time period. Age based screening recommendation may provide opportunities to increase communication with others at risk for HCV. As more patients are screened, it will be important to ensure appropriate linkage to care for HCV patients.

Purpose: The Kodiak Area Native Association (KANA) provides primary health care in Kodiak, Alaska and 6 outlying villages. KANA sought to actively improve key preventive screening rates for its patients. Methods: KANA adopted an electronic health record in 2008 and deployed national clinical reminders from the Indian Health Service for 5 key preventive screenings: tobacco use, alcohol use, depression, intimate partner violence, and a comprehensive cardiovascular exam. Clinical reminders were deployed in a 5-step process: ( a) establish clinical demand, ( b) pilot test reminder, ( c) expand reminder to all providers, ( d) measure outcomes and share results, and ( e) delegate clinical reminder follow-up (primarily to nurses). Results: Data from 2007-2011 show screening rates for all 5 measures improved considerably, to levels significantly above the national average for Indian Health Service facilities. Conclusions: Clinical reminders have been a key part of a multistep process to improve screening for depression, tobacco cessation, intimate partner violence, alcohol use, and cardiovascular disease. If deployed correctly, reminders are valuable tools in identifying patients who are overdue for preventive health screenings.

Summary Chlamydia cases diagnosed in the women's clinic were more likely to receive expedited partner therapy (EPT) and to be re-tested as compared with urgent and emergent care settings. Fewer re-infections occurred among patients who received EPT. Disproportionate rates of chlamydia occur among American Indian (AI) populations. To describe use of EPT among chlamydia cases diagnosed at an urban Indian Health Service (IHS) facility in Arizona, health records were used to extract confirmed cases of chlamydia diagnosed between January 2009 and August 2011. Medical records of 492 patients diagnosed with chlamydia were reviewed. Among the 472 cases who received treatment, 246 (52%) received EPT. Receipt of EPT was significantly associated with being female (odds ratio (OR) 2.1, 1.03–4.4, P < 0.001) and receipt of care in the women's clinic (OR 9.9, 95% CI 6.0–16.2) or in a primary care clinic (OR 2.4, 95% CI 1.1–5.1). Compared with those receiving care in the women's clinic, the odds of receipt of EPT were significantly less in those attending the urgent/express care clinic (OR 0.1, 95% CI 0.06–0.2), and the emergency department (OR 0.1, 95% CI 0.05–0.2). Among treated patients who underwent re-testing ( N = 323, 68% total treated) re-infection was less common among those that received EPT (13% versus 27%; OR 0.5, 95% CI 0.3–0.9). In this IHS facility, EPT was protective in preventing chlamydia re-infection. Opportunities to expand the use of EPT were identified in urgent and emergent care settings.

An estimated 3.5 million persons in the United States are living with hepatitis C virus (HCV) infection, resulting in approximately 20,000 deaths each year, primarily from cirrhosis or hepatocellular carcinoma (1,2). American Indian/Alaska Native (AI/AN) populations have the highest incidence of acute HCV infection among all U.S. racial/ethnic groups and are at greater risk for HCV-related mortality compared with the general population (3). In 2013, new antiviral drugs became available that make possible 8-12 week treatment regimens with fewer adverse events and are able to achieve sustained virologic response (SVR) in >90% of treated patients (4), equivalent to a cure of HCV infection. Also of note, HCV testing recommendations were expanded in 2012 by CDC and in 2013 by the U.S. Preventive Services Task Force to include one-time testing of persons born during 1945-1965 (the "baby boomer" cohort) in addition to anyone at increased risk for HCV infection (5,6). Given the availability of new HCV drugs, expanded testing recommendations, and high incidence of HCV infection in AI/AN populations, in October 2012, Cherokee Nation Health Services (CNHS) implemented a tribal HCV testing policy.* As part of the policy, CNHS added a reminder in the electronic health record (EHR) for clinical decision support and provided HCV education to primary care clinicians. From October 2012 to July 2015, among 92,012 persons with at least one CNHS clinic encounter, the cumulative number who received HCV screening for the first time increased from 3,337 (3.6%) to 16,772 (18.2%). The largest percentage of HCV screening was among persons born during 1945-1965. Of 715 persons who tested positive for HCV antibodies, 488 (68.3%) were tested for HCV RNA; among those 488 persons, 388 (79.5%) were RNA positive and were thus confirmed to have chronic HCV infection. Treatment was initiated for 223 (57.5%) of the 388 with chronic infection; 201 (90.1%) completed treatment, of whom 180 (89.6%) achieved SVR. CNHS has successfully increased HCV testing and treatment and is now collaborating with CDC and other external partners to develop an HCV elimination program for the Cherokee Nation that might serve as a model for similar settings.

OBJECTIVES We sought to determine attitudes and needs among health care providers in the Indian Health Service toward implementing routine human immunodeficiency virus (HIV) screening among 13- to 64-year-olds as per Centers for Disease Control and Prevention (CDC) guidelines. METHODS We surveyed a random sample of Indian Health Service physicians and nurses by e-mail and telephone interview. A total of 205 eligible respondents (response rate = 70%) completed the survey. RESULTS A majority (58%) of respondents were familiar or somewhat familiar with the 2006 CDC guidelines on HIV screening for 13- to 64-year-olds. A proportion of respondents (43%) felt that community HIV prevalence was below the 0.1% threshold the CDC recommends to initiate screening. Respondents supported routine, rather than solely risk-based HIV testing (70%) and stated that HIV screening would be realistic in their health facility (51%). Respondents felt that they needed special qualification to offer an HIV test (49%) or to notify a patient of a "reactive" HIV test result (67%). CONCLUSIONS A majority of Indian Health Service physicians and nurses support the CDC HIV screening guidelines. Providers need more information and training on HIV screening guidelines, implementation strategies, and relevant state HIV regulations.

To examine rates of ectopic pregnancy (EP) among American Indian and Alaska Native (AI/AN) women aged 15–44 years seeking care at Indian Health Service (IHS), Tribal, and urban Indian health facilities during 2002–2009. We used 2002–2009 inpatient and outpatient data from the IHS National Patient Information Reporting System to identify EP-associated visits and obtain the number of pregnancies among AI/AN women. Repeat visits for the same EP were determined by calculating the interval between visits; if more than 90 days between visits, the visit was considered related to a new EP. We identified 229,986 pregnancies among AI/AN women 15–44 years receiving care at IHS-affiliated facilities during 2002–2009. Of these, 2,406 (1.05 %) were coded as EPs, corresponding to an average annual rate of 10.5 per 1,000 pregnancies. The EP rate among AI/AN women was lowest in the 15–19 years age group (5.5 EPs per 1,000 pregnancies) and highest among 35–39 year olds (18.7 EPs per 1,000 pregnancies). EP rates varied by geographic region, ranging between 6.9 and 24.4 per 1,000 pregnancies in the Northern Plains East and the East region, respectively. The percentage of ectopic pregnancies found among AI/AN women is within the national 1–2 % range. We found relatively stable annual rates of EP among AI/AN women receiving care at IHS-affiliated facilities during 2002–2009, but considerable variation by age group and geographic region. Coupling timely diagnosis and management with public health interventions focused on tobacco use and sexually transmitted diseases may provide opportunities for reducing EP and EP-associated complications among AI/AN women.

Objectives. We used race-corrected data and comprehensive diagnostic codes to better compare HIV and tuberculosis (TB) mortality from 1999 to 2009 between American Indian/Alaska Natives (AI/ANs) and Whites. Methods. National Vital Statistics Surveillance System mortality data were adjusted for AI/AN racial misclassification through linkage with Indian Health Service registration records. We compared average annual 1990 to 2009 HIV and TB death rates (per 100 000 people) for AI/AN persons with those for Whites; Hispanics were excluded. Results. Although death rates from HIV in AI/AN persons were significantly lower than those in Whites from 1990 to 1998 (4.2 vs 7.0), they were significantly higher than those in Whites from 1999 to 2009 (3.6 vs 2.0). Death rates from TB in AI/AN persons were significantly higher than those in Whites, with a significant disparity during both 1990 to 1998 (3.3 vs 0.3) and 1999 to 2009 (1.5 vs 0.1). Conclusions. The decrease in death rates from HIV and TB was greater among Whites, and death rates remained significantly higher among AI/AN individuals. Public health interventions need to be prioritized to reduce the TB and HIV burden and mortality in AI/AN populations.

Russia has experienced a large increase in injecting drug use since the collapse of the Soviet Union. Injecting drug use is presently attributed with up to 90 perccent of newly acquired HIV. Peer educators of an outreach program conducted a survey of injecting drug users (IDUs) in Moscow. The survey was supplemented by qualitative field notes. Due to differences in settings and methods, the hospital and street survey results are presented separately. A total of 298 hospital and 126 street surveys were collected. Results showed that IDUs are young (average 20 years), and the majority were studying or working. Needles were rated as easy to get, although police pressure often deters carrying a syringe. Sharing needles was common; IDUs that used only heroin were significantly less likely to share (RR 0.38 to 0.56). IDUs that had spoken to a peer educator were also less likely to share (RR 0.55). Heroin users had lower rates of hepatitis. Self-assessed HIV risk was unclear for many IDUs. HIV prevalence was 3 percent.

Recent rounds on the infectious disease ward in Mir Wais Hospital, in Kandahar, Afghanistan, found a young farmhand recuperating from meningitis sitting with the two friends who had accompanied him to the hospital. He had survived the disease, but only barely, and the episode had left him blind. In quiet tones, the man discussed with the medical staff whether his condition was permanent. In another room, a family of six was recovering from typhoid fever. The family members were fortunate that they had sought care early, because typhoid has a fatality rate of nearly 10 percent in Kandahar. The most . . .

Medical record review was used to identify missed opportunities for chlamydia screening among 103 American Indian/Alaska Native women. Of these, 69% had received a pregnancy test and 74% had received a urine test in the previous 12 months. Chlamydia screening may increase if linked to the other routine clinical testing.

We reviewed charts of newly diagnosed STD patients in three health facilities to determine the proportion who received follow-up STD screening. In a 12-month period, the three facilities had 140 STD cases. STD screening was not indicated for 50 (36%) patients. Among the 90 remaining STD patients, 29 (32%) were screened and 61 (68%) not screened. Among non-screened patients, 36% (22/61) were tested, but outside the time parameters allowed by the audit. The remaining 64% (39/61) received no screening at all, and represented clinical missed opportunities; in this group, nearly all (95%) had chlamydia but were not screened for HIV or syphilis. Linking chlamydia patients with a screen for HIV and syphilis using a clinical reminder in the facilities' electronic health record (EHR) or other tool, would eliminate 95% of the missed opportunities in this sample.

To better serve our patients, we sought to identify missed opportunities for prenatal HIV screening across Indian Health Service and potential ways to increase screening. Twenty-seven of 161 Federal or Tribal IHS health facilities were randomly selected. Each facility received a standardized set of commands to identify the charts of prenatal patients who were not screened for HIV according to the national Health Information Technology (HIT) platform. We reviewed 598 records at 27 sites of prenatal patients who were identified as not screened for HIV during their pregnancy. According to on-site chart review, nearly half (267/598, 45%) had been screened for HIV, and a slight majority (331/598, 55%) had not been screened. Among the 331 pregnant women not screened for HIV, about half had no HIV screening despite having had ≥2 prenatal care encounters and no screening exclusions (167/331, 50%). A majority of missed opportunities (118/167, 71%) had prenatal testing for other infectious diseases. Based on these results, the National HIV/AIDS program has encouraged increased bundling of HIV with infectious disease tests in prenatal laboratory panels. Improvements in documentation of HIV screening are expected with the IHS transition to electronic health records.

Background India and Pakistan have disputed ownership of the Kashmir Valley region for many years, resulting in several conflicts since the end of partition in 1947. Very little is known about the prevalence of violence and insecurity in this population. Methods We undertook a two-stage cluster household survey in two districts (30 villages) of the Indian part of Kashmir to assess experiences with violence and mental health status among the conflict-affected Kashmiri population. The article presents our findings for confrontations with violence. Data were collected for recent events (last 3 months) and those occurring since the start of the conflict. Informed consent was obtained for all interviews. Results 510 interviews were completed. Respondents reported frequent direct confrontations with violence since the start of conflict, including exposure to crossfire (85.7%), round up raids (82.7%), the witnessing of torture (66.9%), rape (13.3%), and self-experience of forced labour (33.7%), arrests/kidnapping (16.9%), torture (12.9%), and sexual violence (11.6%). Males reported more confrontations with violence than females, and had an increased likelihood of having directly experienced physical/mental maltreatment (OR 3.9, CI: 2.7–5.7), violation of their modesty (OR 3.6, CI: 1.9–6.8) and injury (OR 3.5, CI: 1.4–8.7). Males also had high odds of self-being arrested/kidnapped (OR 8.0, CI: 4.1–15.5). Conclusion The civilian population in Kashmir is exposed to high levels of violence, as demonstrated by the high frequency of deliberate events as detention, hostage, and torture. The reported violence may result in substantial health, including mental health problems. Males reported significantly more confrontations with almost all violent events; this can be explained by higher participation in outdoor activities.

Background India and Pakistan have disputed ownership of the Kashmir Valley region for many years, resulting in high levels of exposure to violence among the civilian population of Kashmir (India). A survey was done as part of routine programme evaluation to assess confrontation with violence and its consequences on mental health, health service usage, and socio-economic functioning. Methods We undertook a two-stage cluster household survey in two districts of Kashmir (India) using questionnaires adapted from other conflict areas. Analysis was stratified for gender. Results Over one-third of respondents (n = 510) were found to have symptoms of psychological distress (33.3%, CI: 28.3–38.4); women scoring significantly higher (OR 2.5; CI: 1.7–3.6). A third of respondents had contemplated suicide (33.3%, CI: 28.3–38.4). Feelings of insecurity were associated with higher levels of psychological distress for both genders (males: OR 2.4, CI: 1.3–4.4; females: OR 1.9, CI: 1.1–3.3). Among males, violation of modesty, (OR 3.3, CI: 1.6–6.8), forced displacement, (OR 3.5, CI: 1.7–7.1), and physical disability resulting from violence (OR 2.7, CI: 1.2–5.9) were associated with greater levels of psychological distress; for women, risk factors for psychological distress included dependency on others for daily living (OR 2.4, CI: 1.3–4.8), the witnessing of killing (OR 1.9, CI: 1.1–3.4), and torture (OR 2.1, CI: 1.2–3.7). Self-rated poor health (male: OR 4.4, CI: 2.4–8.1; female: OR 3.4, CI: 2.0–5.8) and being unable to work (male: OR 6.7, CI: 3.5–13.0; female: OR 2.6, CI: 1.5–4.4) were associated with mental distress. Conclusion The ongoing conflict exacts a huge toll on the communities' mental well-being. We found high levels of psychological distress that impacts on daily life and places a burden on the health system. Ongoing feelings of personal vulnerability (not feeling safe) was associated with high levels of psychological distress. Community mental health programmes should be considered as a way reduce the pressure on the health system and improve socio-economic functioning of those suffering from mental health problems.

A study was conducted to assess the acceptability and utilization of voluntary counselling and testing (VCT) and sexually transmitted infection (STI) services in Kahsey Abera Hospital, Humera.Retrospective data was taken from hospital consultation logbooks from January 2002 to February 2003, and focus group discussions were conducted in March 2003 in the community.While the services were known and utilization is increasing, important misconceptions about the medical services, disease transmission, and STI treatment persist. Although hospital care was generally considered of high quality, persons often go to pharmacies to self-treat for STIs due to concerns about confidentiality, and the stigma of HIV deters many from wanting to know their serostatus.Additional education is needed on HIV/AIDS, STIs, and the medical services provided. Education may make use of community health workers or outreach workers in a small group where participants can feel comfortable to ask sensitive questions. HIV/AIDS treatment is planned for the near future and may be significant in reducing HIV/AIDS stigma.

It is an accepted part of a doctor's job to awaken at night to an emergency call. But in many parts of Colombia, such a visit is often reason for a doctor to shudder with fear. The people knocking on your door may wield guns as they summon you to tend to their ill or wounded compatriots. If you refuse, you might be killed. Yet if you go with them, another armed faction may kill you as a collaborator. If the government discovers you cooperated with any of them, you may be interrogated or detained. This is Colombia's “low-intensity conflict,” . . .

Afghanistan’s health system is severely limited in terms of preventive and curative services, referral systems, and human resources. Most of the country’s citizens reside in rural areas, a majority of which are served by “basic health units” (small and simple facilities that provide primary care), and these rural residents face additional challenges regarding timely access to quality health care. The analysis described in this article, which focuses on data derived from 2 rural health units during a 1-year period, revealed that infectious diseases, mainly acute respiratory infections, were a primary concern and that there is a clear need for increasing access to health services. In addition, our results showed that women are underrepresented as patients and appear to be at higher risk than men of tuberculosis.

On February 28, the Vietnam French Hospital of Hanoi, a private hospital of about 60 beds, contacted the Hanoi office of the World Health Organization (WHO). A patient had presented with an unusual influenza-like virus. Hospital officials suspected an avian influenzavirus and asked whether someone from the WHO could take a look. Dr. Carlo Urbani, a specialist in infectious diseases, answered that call (Figure). In a matter of weeks, he and five other health care professionals would be dead from a previously unknown pathogen. We now know that Hanoi was experiencing an outbreak of severe acute respiratory syndrome (SARS). . . .

Editor—Sri Lanka's 20 years of war has killed over 60 000 people and displaced hundreds of thousands more. The LTTE (the Liberation Tigers of Tamil Eelam) has been fighting for its own state, resulting in areas of permanent conflict in the north and east of the country. Civilians are caught in crossfire; landmines and unexploded ordnance pose a constant threat; hospitals have been destroyed. Medecins Sans Frontieres runs a substitution medical programme in the northern rebel controlled area, known as the Wanni, supplying specialists, including a surgeon, a paediatrician, an obstetrician, and an anaesthetist. Most medical professionals have fled: 21 of the 27 vacancies for government doctors in the region remain vacant, and only 34 of the 108 midwife positions are filled (rates of maternal and neonatal death are higher than the national average). Government training of medical workers has not taken place in the region since the war began. Population displacement has led to a rise in infectious diseases and malnutrition. As a result, malaria has increased 20-fold since the conflict began owing to disrupted vector control activities and limited access to treatment facilities, being among the leading causes of death in some areas. For seven years many essential supplies to the Wanni, including basic items such as sutures, surgical gloves, and oxygen, were subject to government embargo, and drugs and medical materials are often critically low. No postoperative analgesics are available, and often only life saving essential surgery can be performed. In sharp contrast to many other conflicts, humanitarian law is for the most part respected: soldiers fight soldiers. Both sides cooperate on certain health issues such as emergency patient transfers across the front line and temporary ceasefires to allow polio immunisation campaigns to take place for children. Sri Lanka's conflict seems nationally and internationally to be have been accepted as a chronic, ethnic conflict, but there are signs of improvement. In January the government embargo was lifted, and previously limited medical supplies are beginning to become available, albeit sporadically. Medical transfers should now be easier. Peace talks are planned. More could be done to protect the health of civilians. Official training leading to government certification should be given in the rebel controlled area to meet the acute demand for medical staff, and the LTTE should assume greater responsibility for health care in regions under its control. In Sri Lanka as elsewhere, the terrible damage caused by the war to people's health and life expectancy should not be accepted as an inevitable consequence of the fighting.

A long-term, large-scale ethnic armed conflict continues in Sri Lanka, where militant separatists control a northern section of the island. The conflict has resulted in a large population of internally displaced persons and a shortage of medical staff. Drug and equipment shortages compound the difficulty in access to medical care. This article reports the experiences from 1 November 2000 to 30 April 2001 recorded by review of medical records and by interviews, in the peripheral unit, in a separatist controlled area of the Mallavi maternity ward. There were 704 births. Most of the mothers had been displaced by the war (69.5 per cent) and had experienced food shortage (67.5 per cent). Referred patients (18.1 per cent) had a high rate of caesarean section (44.3 per cent) and had travelled a mean of 57.6 km to reach Mallavi. There had been substantial antenatal care (94.0 per cent), tetanus toxoid vaccination (95.1 per cent) and malaria prophylaxis (86.4 per cent). Risk factors for low birth weight included a maternal body mass index less than 19 (RR 1.55, CI 1.11-2.16, P = .011), primiparity (RR 1.44, CI 1.05-1.97, P = .024) and self-reported malarial infection during pregnancy (RR 1.42, CI 1.03-1.97, P = .036). Rates of low birth weight, stillbirths, neonatal deaths and maternal mortality in the Mallavi units were higher than the Sri Lankan national averages. Improvements in quality of care and access to health care are unlikely while the war continues.