Public Health Crusade

Texas Fights to Win Public Health Battles

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Public Health Feature — March 2014

By Crystal Zuzek

Tex Med. 2014;110(3):57-62.

In the crusade to improve immunization rates, reduce obesity's health burden, prevent HIV, and tackle a whole host of crucial public health concerns, research shows certain evidence-based strategies can make a big impact in a short time. The Centers for Disease Control and Prevention (CDC) refers to such areas of public health as "winnable battles." Six items on the list of CDC's 10 winnable battles overlap with some of Texas' public health priorities:  

  • Immunization,
  • Obesity,
  • Food safety,
  • Tobacco, 
  • Health care-associated infections, and
  • HIV.

Texas Department of State Health Services (DSHS) Commissioner David Lakey, MD, named other public health priorities that don't match the CDC's winnable battles. They include the DSHS Expanded Primary Health Care Program, birth outcomes, mental health, and substance use disorders. (See "Public Health in Action.") 

The agency focuses on a list of Texas-specific priorities developed over time by examining statistics that determine drivers of poor health and considering those areas in which the state can provide effective interventions to improve health. Dr. Lakey says the legislature also requires the department to work to improve health in those priority areas.

"Texas is a large, diverse state with unique public health challenges. We have priorities we focus on that have the ability to improve health in Texas," Dr. Lakey said.

John Carlo, MD, chair of the Texas Medical Association Council on Science and Public Health, says many of the council's priorities — tobacco use, obesity, unintentional injuries, teen pregnancy, and immunizations — also align with CDC's winnable battles. (See "CDC's Top 10 Winnable Battles.") 

"The council works specifically on policies and charges that relate to many of these targets, and our members are well-aligned and interested in tackling these public health challenges," he said.

Texas Public Health Coalition Chair Eduardo Sanchez, MD, says the state has an opportunity to make significant strides in the public health priority areas that intersect with CDC's winnable battles. 

"A statewide indoor smoking ordinance would have a very big impact in a short period of time. Nutrition and physical activity policies, programs, and practices would improve health status in a shorter time frame than … it takes the long list of chronic diseases associated with unhealthy dietary habits, sedentary lifestyle, and obesity to destroy health," he said. 

Striving to Improve Vaccination Rates

Key Stats:   

  • National Immunization Survey data for 2012 show vaccination coverage levels for Texas children aged 19 to 35 months were 64.8 percent, a decrease of 7.9 percentage points from 2011 following a change in survey methodology. 
  • Texas is below the national immunization average of 68.4 percent.

 Key Strategies:    

  • Last legislative session, DSHS received $168.5 million for 2014-15 — an $18 million increase from the previous biennium — to provide adult and childhood immunizations. 
  • To boost immunization rates, DSHS employs the following:
    • Promoting full vaccination services in a medical home for children and adolescents;
    • Promoting the use of ImmTrac, the state's immunization registry; 
    • Educating health care professionals and the general public;
    • Promoting immunization reminder and recall systems in medical offices; and
    • Increasing public and private collaborations to improve each of the above strategies.  

When it comes to vaccinating the residents of such a large, diverse state, Dr. Lakey says immunization "continues to be an issue," citing TMA as a "strong partner in working to improve immunization rates."

"We're very focused on improving immunization rates in Texas. We work with our partners to promote regular immunizations as well as the seasonal flu vaccine," Dr. Lakey said. (See "TMA's Immunization Resources.")

Curtailing Obesity

Key Stats: 

  • Behavioral Risk Factor Surveillance System data indicate the prevalence of obesity is 29.2 percent among Texas adults and 15.6 percent among high school students.
  • The prevalence of obesity among 4th, 8th, and 11th grade Texas students is 23.8 percent, 23 percent, and 21.6 percent, respectively, according to the 2009-11 School Physical Activity and Nutrition Survey. 

Key Strategies: 

  • To help reduce obesity's detrimental impact on adults and children, DSHS collaborates with partners across the state on projects like these:
    • The Community and Worksite Wellness Program works to strengthen the certification criteria related to nutrition standards in early child education settings and supports physical activity at the facilities. 
    • The Childhood Obesity Research Demonstration Project seeks to identify a successful model for referring children and their families who are at risk for obesity to community-based education and physical activity programs.  

Dr. Lakey says reducing obesity's impact on the state has multiple benefits, including preventing diabetes and lowering rates of heart disease. 

Keeping Food Safe

Key Stats: 

  • DSHS estimates foodborne disease causes approximately 6 million illnesses, 26,000 hospitalizations, and 400 deaths each year in Texas.
  • The Texas Public Interest Research Group reports that since October 2012, foodborne illnesses have cost Texas $2 million in lost wages, medical expenses, and deaths. 

Key Strategies: 

  • To ensure a safe food supply, DSHS enforcement activities include:
    • Follow-up inspections at establishments that have problems, 
    • Warning letters, 
    • Management meetings with the firms, and 
    • Technical assistance. 
  • DSHS is funding 13 new epidemiology positions in 13 local health departments to focus on foodborne illness surveillance and investigation, including outbreaks. 
  • DSHS has increased the number of food inspectors in the state from 42 in 2009 to 63 last year. 

"The department is focused on addressing food safety and is ramping up the number of epidemiologists in the state who can identify the source of foodborne illness outbreaks quicker. We've also increased the number of inspectors and have rapid response teams that can quickly identify and respond to events," Dr. Lakey said. 

Stamping Out Tobacco Use

Key Stats: 

  • DSHS data show more than 24,000 Texans die from smoking or exposure to secondhand smoke each year.
  • Tobacco costs the state's economy $13.04 billion in health care costs and lost productivity, the American Lung Association reports. 

Key Strategies: 

  • DSHS funding for 2014-15 includes $29.7 million for the Tobacco Prevention and Control Program. 
  • An additional $11.7 million will increase tobacco prevention and cessation funding for Quitline counseling services and help prevent smokeless tobacco use among children in rural counties.  

The DSHS tobacco program provides technical assistance to community organizations, schools, worksites, health professionals, and law enforcement agencies on tobacco prevention. It also serves as a clearinghouse of information on tobacco prevention issues and conducts a media campaign to educate Texans about the dangers of tobacco use. For more information, visit the DSHS website.  

Preventing Infection

Key Stats: 

  • DSHS estimates 200,000 health care-associated infections (HAIs) occur annually, causing about 9,000 deaths.
  • The Institute of Medicine reports nationally an estimated 2 million people acquire HAIs annually, and as many as 98,000 patients die needlessly due to preventable medical harm.
  • A total of 320 Texas health care facilities reported HAI data to Texas in 2012 with 996 central line-associated bloodstream infections and 1,075 surgical site infections (SSIs) identified. 

Key Strategies: 

  • DSHS worked with The University of Texas Health Science Center at San Antonio and the Texas Hospital Association Foundation to form networks of hospitals that developed best practices to help reduce central line-associated bloodstream infections and SSIs.
  • Texas law requires general hospitals and ambulatory surgery centers to report to DSHS certain HAIs to promote infection prevention activities within health care facilities and improve patient safety. 
  • The first annual statewide summary HAI report is available online and includes data from January 2012 to December 2012 regarding the following infections:
    • Central line-associated bloodstream infections data for any adult, pediatric, or neonatal intensive care units in general hospitals;
    • SSIs and related data for spinal surgery with instrumentation, cardiac procedures, and ventricular shunt operations in children's general hospitals; and
    • SSIs and related data for procedures like colon surgery, hip and knee arthroplasties, and abdominal hysterectomies in adult care general hospitals and ambulatory surgery centers.    

"Texas has worked hard to require health facilities to report HAIs. The department collaborates with hospitals to implement best practices to prevent HAIs," Dr. Lakey said.

Fighting HIV

Key Stats: 

  • DSHS estimates that 72,932 Texans are living with HIV, and DSHS data indicate that the number of new HIV diagnoses in Texas has remained relatively stable over the past decade, with about 4,400 new diagnoses and 1,300 deaths reported per year. 
  • Some 17,000 people in Texas are living with HIV but are currently unaware of their status. 
  • In Texas, about one-third of new HIV diagnoses are late diagnoses in which the patient develops AIDS within a year of initial HIV diagnosis. 

Key Strategies: 

  • Federal 2014 CDC funding alone for HIV, hepatitis, sexually transmitted diseases, and tuberculosis totals $1.07 billion. 
  • AIDS Arms has a portfolio of programs aimed at thwarting the spread of HIV in identified high-risk populations:
    • Reentry programs work closely with individuals recently released from the Texas criminal justice system to link them to medical care immediately. 
    • Another program addresses Texans with multiple diagnoses of mental illness, substance use, and HIV. 
    • An intensive linkage-to-care model helps individuals who are homeless or at risk of being homeless. 
    • Viviendo Valiente uses a culturally-based access-to-care framework to reach those of Mexican descent who are HIV positive.
    • Retention in care programs work to keep individuals in medical treatment through coaching, peer mentorship, and group activities. 

HIV prevention, testing, and treatment for infected individuals are priorities for Texas. 

"Advances in medical care enable people with HIV to stay healthy and live longer. With access to effective treatment, the death rate among people with HIV infection has decreased dramatically," Dr. Lakey said.

Dr. Carlo says that while 72,932 HIV-infected Texans out of 26 million residents may not sound like a lot, each case of HIV and AIDS is costly. 

"For example, a month's supply of anti-HIV medication can cost upwards of $20,000. As most people living with HIV are uninsured in Texas, the cost is substantially covered through public assistance funding that everyone ultimately pays for," said Dr. Carlo, chief executive officer of AIDS Arms.

He adds that he believes ending AIDS is a winnable battle.

"But I make an important distinction of ending AIDS versus preventing HIV. AIDS is 100-percent preventable through effective anti-HIV medications, so there is almost no reason why someone living in Texas today should receive an AIDS diagnosis. It is only because someone is not tested until late in the disease course or the infected person does not stay engaged in care that AIDS happens," Dr. Carlo said.

Crystal Zuzek can be reached by telephone at (800) 880-1300, ext. 1385, or (512) 370-1385; by fax at (512) 370-1629; or by email


CDC's Top 10 Winnable Battles

The Centers for Disease Control and Prevention has identified the following 10 winnable battles in public health, with a focus on prevention: 

  1. Food safety,
  2. Global immunization,
  3. Health care-associated infections,
  4. HIV in the United States,
  5. Lymphatic filariasis in the Americas,
  6. Motor vehicle injuries,
  7. Nutrition, physical activity, and obesity,
  8. Mother-to-child transmission of HIV and syphilis globally,
  9. Teen pregnancy, and
  10. Tobacco.
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TMA's Immunization Resources

TMA's Be Wise — ImmunizeSM program works with physicians, medical students, and TMA Alliance members to improve vaccination rates in Texas through education and hands-on immunization clinics. Be Wise — Immunize is made possible via a grant from the TMA Foundation, thanks to top donors H-E-B and the TMF Health Quality Institute, as well as gifts from physicians and their families. To access immunization resources for physicians and information for patients, click here.

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Public Health in Action

Texas is a large state with a number of public health priorities, including the Texas Department of State Health Services (DSHS) Expanded Primary Health Care Program, birth outcomes, mental health, and substance use disorders.

The Texas Legislature appropriated $100 million to enhance women's health services in the DSHS Expanded Primary Health Care Program for 2014-15. The program contracts with community health clinics and nonprofit organizations to provide services for uninsured, poor Texans who don't qualify for other state health programs. DSHS estimates $60 million of the $100 million will fund family planning services. 

Additional funds in the Expanded Primary Health Care Program will allow DSHS to serve approximately 170,000 adult women annually by offering well-woman checks, cancer screenings, and family planning. 

DSHS Commissioner David Lakey, MD, says one of the department's major priorities is reducing prematurity and decreasing the number of babies who die during their first year of life. 

The department's Healthy Texas Babies initiative helps Texas communities decrease infant mortality using evidence-based interventions. 

"It involves community members, health care professionals, and insurance companies working together with the understanding that a reduction in preterm births leading to lower infant mortality will improve the health of Texas babies and mothers. This has the potential to save millions of dollars in health care costs," Dr. Lakey said.

Final DSHS data for 2011 and preliminary data for 2012 demonstrate the beginning of a downward trend in premature births in Texas. The rate fell from 13.3 percent in 2008 to 12.4 percent in 2012. Texas infant deaths per 1,000 live births are also down from 6.1 in 2008 to 5.5 in 2012.

The 2013 legislature provided DSHS an additional $332 million in mental health and substance abuse funding that Dr. Lakey says will help the department "improve services by reducing waiting lists for community mental health services and expanding treatment options."

Mental health funding includes $4 million to improve mental health services for veterans; $5 million to enhance prevention and early identification of mental illness in school-age children; $25 million for additional crisis services to be provided by local mental health authorities; and $25 million to promote public-private partnerships to improve mental health care delivery and services in the state.

Data from the state health department show 2.6 percent of Texas adults aged 18 and older and 5 percent of children aged 9 to 17 suffer from serious mental illness. Substance use disorders affect 1.4 percent of Texas adults aged 26 and older, 5.8 percent of Texans aged 18 to 25, and 4.4 percent of adolescents aged 12 to 17. For more information about the DSHS Mental Health and Substance Abuse Division, visit the DSHS website

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