Inter Tribal Council of Arizona, Inc.

Tribal Epidemiology Center

The History, Present, & Future

Jamie Ritchey, MPH, PhDTribal Epidemiology Center Director

Overview

• Tribal Epidemiology Centers and Inter Tribal Council of Arizona, Inc. (ITCA) Tribal Epidemiology Center (TEC):

• The History• The Present

– Census Data: Where do folks live?– American Indian Health Disparities: Top Five Causes of

death– TEC projects that address Health Disparities

• The Future– Project Plans– Internships

• Summary• Acknowledgements• Data Sources Referenced

Tribal Epidemiology Centers:

The History

The History

• 1996 Four TECs established by Congress via the Indian Health Care Improvement Act (IHCIA)

• ITCA TEC is one of the original TECs created– TECs have a common mission and purpose– Conduct very different activities

• 2010 Affordable Care Act– Permanently re-authorized the IHCIA– TECs given “public health authority” status– Health and Human Services (HHS) must give TECs access to

HHS data systems and protected health information– Centers for Disease Control and Prevention (CDC) must

provide TECs technical assistance

The History

Photo credit: Indian Health Service. National Tribal Epidemiology Center Service Areas. 2013.

TEC Area Service Map

The History

TEC Seven Core Functions

• Provide – Technical Assistance to tribes & tribal Organizations

• Develop local health priorities• Calculate incidence rates and disease prevalence of disease and illness

– Disease surveillance assistance to promote public health

• Assist tribes with data collection, analysis, and dissemination

• Monitor progress towards meeting health objectives

• Evaluate delivery systems, data systems, and health programs

• Make recommendations to– Improve health care delivery system– Identify service targets

Figure 2. ITCA TEC Over Time

ITCA TEC founded

-Hiring & Planning -Partnerships/Epi WG-Training development-Technical assistance-Surveillance data

-State data-YTS 3 Tribesa

-ATS 1 Tribeb

-Diabetes data improvement

1996 2000-2005 2006-20111996-2000

-Strategic planning-Data Sharing (DSA) Agreement with HIS-Revising training curriculum & communication documents -TMVCIPP 2nd 5yrsd

-Accreditation Readiness-CHA toolkit & pilot

-Tribal BRFSS -MCH – WICf

-NA Sisters Evaluation-Dental Program Evaluation Training

2012-2013

-7 Objectives developed-Outbreak trainingwith Preparedness & Bioterrorism-Program Evaluation-National Pediatric Ht & Wt studyc

-Cancer Workshops-Community Health profiles (CHPs)-Technical assistance

-“Public health authority” est.-TMVCIPP 1st 5yrsd

-Cancer screening & detection IHS survey-NA SISTER focus groups (HIV)-H1N1 study-RMSFe

-CHPs-Dental Clinics Needs Assessment

a YTS: Youth Tobacco Survey; b Adult Tobacco Survey; c Ht & Wt Height and Weight; d TMVCIPP Tribal Motor Vehicle Crash Injury Prevention Project; e RMSF Rocky Mountain Spotted Fever; f MCH – WIC Maternal & Child Health – Women Infant and Children Program

Inter Tribal Council of Arizona, Inc.

Tribal Epidemiology Center: The Present

The Present

• American Indian Health Disparities

– Census Data– Top Five Causes of Death– Additional Areas of Concern

• Addressing American Indian Health Disparities

The Present

• US Census 2010 Total AI/AN population a :– 5.2 million

• Distribution a :– 41% in the West– 17% in Midwest– 33% in the South– 10% in Northeast

Since Census 2000, AI/AN group grew by 28%

a AIAN alone or in combination; Source: US Census Bureau, The American Indian and Alaska Native Population: 2010

The Present

Up to 45% of AI/AN may be Misclassified a, b

Photo Credit: sweetclipart.com Diverse People Raising Hands- Free Clip Art. Accessed 3/15/13.a Puukka et al., “Measuring the Health Status Gap for American Indians/Alaska Natives: Getting Closer to the Truth” American Journal of Public Health | May 2005, Vol 95, No. 5

b Espey et al., “Methods for Improving Cancer Surveillance Data in American Indian and Alaska Native Populations”Cancer 2008;113(5 suppl):1120–30

The Present

Causes of Death Age-adjusted rate b, c

Age-adjusted rate ratio b-d

Heart Disease 125.8 0.9

Cancer 113.3 0.8

Unintentional Injury

92.6 2.1

Diabetes 54.2 3.4

Chronic Liver Disease & Cirrhosis

54.0 4.4

Table 1. American Indian Top Five Causes of Death in Arizona, 2009a,b

a Rates include all deaths in American Indian AZ/NV/UT residents not just American Indians from tribes in the Phoenix and Tucson Service Areas b Rates are per 100,000 c Age-adjusted to 2000 standard populationd Rate of American Indians / All of Arizona Rate

The Present

Causes of Death Age-adjusted rate b, c

Age-adjusted rate ratio b-d

Kidney Disease 19.6 2.5

Influenza & Pneumonia

42.7 2.9

Cervical Cancer 4.1 2.2

Septicemia 31.4 4.0

HIV 3.7 2.3

All Fire Arms 8.3 2.2

Alcohol-Induced 62.1 5.1

All Homicide 13.2 2.4

Table 2. American Indian death rates in Arizona, 2009a,b

a Rates include all deaths in American Indian AZ residents not just American Indians from tribes in the Phoenix and Tucson Service Areas b Rates are per 100,000 c Age-adjusted to 2000 standard populationd Rate of American Indians / All of Arizona Rate

The Present

Causes of Death Age-adjusted rate a-c

Age-adjusted rate ratio a-d

Heart Disease 120.3 0.6

Cancer 100.5 0.5

Accidents 42.3 1.0

Diabetes 22.4 1.5

Chronic Liver Disease & Cirrhosis

19.8 1.8

Table 3. American Indian Top Five Causes of death in Nevada, 2011a,b

a Rates include all deaths in American Indian NV residents not just American Indians from tribes in the Phoenix and Tucson Service Areas b Rates are per 100,000 c Age-adjusted to 2000 standard populationd Rate of American Indians / All of Nevada Rate

The Present

Causes of Death Age-adjusted rate b,

c

Age-adjusted rate ratio b-d

Kidney Disease 17.5 1.0

Influenza & Pneumonia

26.8 1.4

Cervical Cancer NA NA

Septicemia 7.7 0.7

HIV NA NA

All Fire Arm 17.8 1.4

Alcohol-Induced e 32.3 1.5

All Homicide 5.1 0.9

Table 4. American Indian death rates in Nevada, 2011 a,b

a Rates include all deaths in American Indian NV residents not just American Indians from tribes in the Phoenix and Tucson Service Areas b Rates are per 100,000 c Age-adjusted to 2000 standard populationd Rate of American Indians / All of Nevada Ratee 100% Attributable only

The Present

Causes of Death

Age-adjusted rate a-c

Age-adjusted rate ratio a-d

Cardiovascular Disease

210.0 1.0

Respiratory Disease

115.1 1.8

Cancer 107.3 0.8

Motor Vehicle Crashes

56.1 5.8

Poisoning 32.8 2.5

Table 5. American Indian Top Five Causes of Death in Utah, 2011a, b

a Rates include all deaths in American Indian UT residents not just American Indians from tribes in the Phoenix and Tucson Service Areas b Rates are per 100,000 c Age-adjusted to 2000 standard populationd Rate of American Indians / All of Utah Rate

• Strengths– Standard definitions

and coding for causes of death

– Methodologies are similar for age-adjusted death rates using the 2000 US Census Standard population

– Race/ethnicity often allows for multiple groups

• Limitations– Race/ethnicity

misclassification for is common AI/AN • Severe under counts

are possible

– Small numbers for AI/AN• Unstable rates

– Data is not specific to Tribal population

– 2 year data lag or more National / State data

The Present

ITCA TEC Programs and Partnerships

Addressing Health Disparities

The Present: Overview

• Cancer• Diabetes• Motor vehicle crash (injury)• Respiratory disease• HIV• Rocky Mountain spotted fever

The Present: Cancer

• Cancer surveillance among American Indians in Arizona, Nevada, and Utah (available in 2013)

• Incidence and mortality from three databases– Surveillance, Epidemiology, and End Results (SEER)– National Program of Cancer Registries (NPCR)– American College of Surgeons Commission on Cancer’s National Cancer

Data Base (NCDB)

• Addresses American Indian cancer disparities that are present at both the national and state levels (AZ, NV, UT)

• Highlights 18 cancer sites divided into four categories– Cancers detected by screening– Cancers associated with lifestyle and environmental factors– Blood cancers– Other cancers

The Present: Motor vehicle crashes (MVCs)

• ITCA TEC MVC Injury Prevention Capacity Building Assistance

– Injury Prevention Working Group • Partnerships with tribes, and state and federal

agencies

– Tribal MVC Injury Prevention Project • Small grants • Technical assistance • Training to tribes

The Present: Respiratory disease

• “A Template for Developing an Influenza Pandemic Response Plan: Guidance for Tribal Governments in Arizona”– Plan an emergency response in the event of an

influenza pandemic

• Influenza A (pH1N1) among AI/AN– The 2009 pandemic disproportionately affected

AI/AN (e.g., severe influenza disease and deaths)– ITCA TEC partnered with Arizona Department of

Health Services in a multi-state investigation to determine the risk factors for pH1N1 deaths among AI/AN

The Present: Respiratory Disease

• TB Sentinel Event worked with tribal partner, IHS, and 3 state partners

• Provided health literature on TB for the community

The Present: HIV

• NA SISTER Program

– Program Goals • Adapt and implement an HIV prevention education

curriculum for AI/AN women• Enhance tribal community linkages with AI/AN women to

increase access to STD/HIV/AIDS screening, testing, and counseling services

• Increase awareness of risk reduction strategies among AI/AN women

– 3 Tribal partners piloted the curriculum

– Technical assistance provided to evaluate the program

– Showed an increase in knowledge about HIV transmission and prevention (pre- post- survey tool)

The Present: Rocky Mountain spotted fever

• Partnership with tribal, state, and federal agencies

• TEC provides educational materials for infectious diseases

FR

ON

T

BA

CK

ITCA TEC:The Future

The Future

Potential Partnership Areas:

• Kidney disease prevention, education, and technical assistance

• Septicemia and nosocomial infections prevention and technical assistance

• Alcohol and drug use prevention and technical assistance

• Fire arm and homicide prevention and technical assistance

The Future• Strategic Plan for National TECs and ITCA TEC in

progress

• Seeking additional partnerships with internal and external programs:– Substance Abuse– HIV– RMSF– Septicemia– Maternal and Child Health – Program Evaluation

• Several grant applications in review/process:– Maternal and Child Health– HIV– RMSF– Health care system structures– Improving infrastructure & capacity

The Future

Does it include you?

• Strengths – Mentored by me and

staff epidemiologists– Will have a defined

project – Will work towards and

complete at least one final product

– Will apply concepts and theories learned during MPH program

– Will learn valuable professional and epidemiology skills- if you allow yourself to learn!

• Limitations– Unpaid– Hard Work!!– Status: Intern– Will not work with

confidential Tribal data or identified partner data

– Won’t work on or be given a “Framingham Study”

ITCA TEC Public Health Internships

Summary

• Tribal Epidemiology Centers are located in each Indian Health Service area, were established by an act of Congress, and have seven core functions

• Data challenges make health disparities among American Indian difficult to quantify and analyze

• ITCA TEC works to improve data collection, and provides direct technical assistance to tribes to build capacity

• ITCA TEC has internship/project opportunities in development for second year MPH student projects

Federal Partners• Indian Health Service• Office of Minority Health• Centers for Disease Control

and Prevention

State Partners• Arizona Department of

Health Services • Nevada Department of

Health• Utah Department of Health

Tribal Partners• Arizona (CA)• Nevada • Utah

Other Partners• Inter Tribal Council of

Nevada• National Association of

County and City Health Officials

• Robert Wood Johnson Foundation

• Council of State and Territorial Epidemiologists

Acknowledgements

Data Sources

1. US Census Bureau, The American Indian and Alaska Native Population: 2010. http://www.census.gov/#

2. Arizona Department of Health Services. Health Status Profile of American Indians in Arizona, 2009. http://www.azdhs.gov/plan/report/hspam/indian09.pdf

3. Nevada State Health Division. Bureau of Health Statistics, Planning, Epidemiology, and Response. Office of Public Health Informatics and Epidemiology. http://health.nv.gov/Epidemiology.htm

4. Utah Department of Health. Center for Health Data. http://health.utah.gov/chd/contactus.htm

Contact Us At:602.258.4822

TECinfo@itcaonline.com