JESSICA
Hi, this is Jessica Hill. Welcome to the latest episode of “Inform Me, Informatics.” Last year, I had the opportunity to speak with Dr. Alan Hinman, who is the director for programs at the Center for Vaccine Equity called CVE, here at The Task Force for Global Health. Alan has announced his retirement from the Task Force and his teaching at the Rollins School of Public Health at Emory University. We here at the podcast wanted to share in the celebration of his many years of public health service and so we’re very happy to bring you this conversation. Alan started with describing his time as an Epidemic Intelligence Service officer or an EIS officer. This role is often described as a disease detective.
ALAN
And so I came to Atlanta to the EIS conference in April of 1965, found that I was going to be assigned to the state health department in Berkeley, California, as a general epidemiologist. And so after five weeks of training in Atlanta, my bride and I drove out to California and the day we arrived, I walked into the health department in Berkeley in the morning. And in the afternoon, I drove out in a state car to investigate an outbreak of gastroenteritis in the Central Valley in a town, city called Madera where one out of every six people in the city had what we call the don’t-knows. You don’t know which end to put on the pot. And it turns out that this outbreak was a result of the fact, first of all, that Madera as most places in California got their water from deep wells, which was viewed as virgin water and not even chlorinated. It wasn’t treated in any way.
They also had a sewage treatment plant that discharged partially treated sewage to irrigate fields around the treatment plant. And it turns out that one of the fields that was flooded with partially treated sewage had a gopher, who dug a tunnel from the field that was flooded down into the pit where the well had been dug out for the well pipes to be put in. And someone had removed the cap from the tube on the well that was used to determine what the water level was. And the sewage flowed down into the pit and then rose up until it got above the level of the tube and then was siphoned down into the well and then went out. And we did a house-to-house survey and found out that people who live closest to this well, which was one of 14 wells in the city, had the highest incidence of gastroenteritis. Okay, so I spent 10 days investigating that. And then in rapid succession, I investigated California’s first case of human plague in 15 years and two cases of botulism from home-canned tuna, and an outbreak of meningococcal disease at an institution, an outbreak of tuberculosis in the mountains of Northern California. And I spent five weeks in Honduras investigating a polio epidemic and helping organize an immunization campaign.
Oh, my God, with that kind of an experience, how could you leave public health? I had intended to do my two years duty and then go back and be a hospital infectious disease doc, but this was just so incredible. It was so fascinating and potentially having a much greater impact than I could in dealing with people one on one. So I never again considered going back to clinical medicine. But we wanted to go overseas, so I transferred from general epidemiology to the Malaria Eradication Program at CDC.
JESSICA
A couple of things jumped out at me. Going back to what happened with the first outbreak that you were working with in Berkeley, California, how would it be that an epidemiologist would come to learn that a gopher had dug a hole near a well? Like, how do you find that out in 10 days?
ALAN
You have some other people working with you. It’s very clear that I could never have figured this out myself. I mean, we knew which well was contaminated, but how it got contaminated was determined by an environmentalist, what used to be called a sanitarian. And they are extremely important members of the health department team. And I guess it’s a good example of the fact that essentially nothing in public health gets done by one individual. It’s all a group effort. And to go further on that, an environmentalist was really critical in this case of plague that I investigated because plague is endemic in some ground squirrels in California. And the little boy who developed plague lived in an area which was not known to have plague. His father had captured a ground squirrel and brought it home to be a pet. And, unfortunately, after a few days, the ground squirrel died.
And the father took the carcass and threw it in a landfill not far away, and the little boy became sick three weeks or four weeks after that, beyond the usual incubation period of plague. The question was, “Clearly it seems this must be related. This ground squirrel most likely died of plague. And how did the little boy get it?” An environmentalist then scoured the area and found ground squirrel die-off, that is corpses of ground squirrels spreading out essentially from the landfill area to very close to the house where the little boy lived, and retrieved the carcass, which then in the laboratory was found to test positive for plague bacilli. So that sanitarian or environmentalist was critical to determining the mechanism by which this little boy got plague.
JESSICA
The next chapters in Alan’s career led him to many different places. He went to El Salvador, where he worked on malaria eradication programs, to Harvard University, where he earned a Master of Public Health degree, and to state health departments in New York and Tennessee. In the 1970s, he came back to Atlanta and the Centers for Disease Control and Prevention as the director of the Immunizations division. A decade later, he became the director of the National Center for Prevention Services. Alan retired from government service in 1996, but he continued working on public health projects in the U.S. and abroad. One of his earliest projects here at the Task Force was called All Kids Count. That project would later grow into the Public Health Informatics Institute. You will hear Alan use the acronym RWJ in this next section. He’s talking about the Robert Wood Johnson Foundation, a key funder for the original All Kids Count project.
ALAN
A problem that we’ve had in immunizations essentially forever is keeping track of what kids have gotten what doses of what vaccines. And 45 years ago, when I was in New York State, this was a problem, trying to figure out that kids get all the doses they needed. And there was an attempt to try to follow up using, typically, postcards after a child was born, to remind the mother that the child needed immunization. This was before computers. There was a long-standing desire to have some mechanism of being able to track immunizations. And in the late ’80s and early ’90s, as computers became a part of our life, the notion of having an electronic system to be able to keep track of immunizations became very popular. And a number of places established immunization registries. They typically were facility-based, like a doctor’s office or a hospital. They were not population-based. And it was clear that a population-based registry could be most useful because kids get care from a variety of different facilities. About 25% of children in the United States get immunizations from more than one provider over the course of their immunization schedule. So trying to centralize things was an important notion. And so in November 1992, funding was arranged for one-year planning grants to 23 different health department or similar kinds of things around the country. And this was a time when nobody really knew what an immunization registry was, just that it’s a good idea. But exactly what does that mean? It wasn’t clear.
And after this one-year planning grant, it looked promising. So in November of 1993, four-year grants were awarded to a total of 24 different locations around the country to try to figure out what an immunization registry was and how it might work. I call this, “Let-1000-flowers-bloom phase” because nobody really knew what one was like. So these were four-year grants. The idea being to find out what a registry was and whether it could provide any utility. And at the end of the four-year period, some of them had gone belly up. Some of them were struggling mildly, and a few of them were actually doing reasonably well, but not fully contributing, not really having as much impact as one would like. But it was clear that essentially, this was a proof of concept, that there can be such a thing as an immunization registry. And along the way, there was effort, particularly through the National Vaccine Program Office, the National Vaccine Advisory Committee, working with CDC, to try to develop definitions and standards of what a registry might be like. On the target date of January 1, 2000, none of the 16 was fully functional, but most of them were close, and showing very clear support and improvement for immunization functions. So then the question became, how to try to get immunization registries to talk with other information systems? What’s logical to try to integrate?
And after a series of meetings and consultations, we came up with four functions that we thought were important and useful to try to integrate. The first, of course, being immunizations. The second vital registration with birth registration. The third is newborn dried blood spot screening. And the fourth is newborn hearing screening. Now, these four functions share a number of characteristics. They’re all universal, they apply to every child born. Secondly, they’re done at or very close to the time of birth. Third, except for vital registration, they represent a mix of private and public involvement. Most of the services are delivered in the private sector, but the public sector has a very important responsibility. And fourth, they are, again, with the possible exception of vital registration, they are things that if they’re not done on time, there can be bad consequences. So that seemed like a fairly logical group of things. And so RWJ agreed to provide additional funds for a three-year period to work on integrating child health systems. But in this instance, they did not provide funding for grants to states or to health departments. They provided funding for us to host meetings to develop a community practice among the participants. And we began working with states to try to integrate systems.
JESSICA
The early efforts of All Kids Count tell the story of how state and community-based immunization registries developed and how they grew into the immunization information systems they are today. Up next, I ask Alan the question I ask all of our podcast guests, how do you define informatics?
ALAN
I guess informatics to me is the process of making computers and computer software useful for those who are trying to do programmatic work. And we used to talk about informatics as being the translator, the interpreter between the computer folks and the program folks. As informatics has become a more established discipline, in many ways, in many places, it has veered more towards the computer side. And I think we used to say that PHII was there to sort of be the interpreter or translator between the informaticians and the program folks. But it’s whatever you want it to be. It’s not necessarily doing any writing of code or programming. It’s not necessarily carrying out programs. It’s trying to make information available and useful for achieving your program goals.
JESSICA
Most recently, Alan served as the Director of Programs for the Center for Vaccine Equity, or CVE. Most of his work focuses on international projects. Oh, in this next section, he’s going to mention a different Task Force program called ITI. That means the International Trachoma Initiative.
JESSICA
I know that you’ve also done a lot of work in polio eradication globally. So can you talk through what role does an information system play in such an effort? Why do we need it?
ALAN
Public health depends on information, and it depends on high-quality information. Very often what we have is not complete, nor is it of very good quality. Informatics offers the possibility of being able to improve the completeness and quality of information. But polio eradication, for example, depends on having very effective surveillance, finding cases that might possibly be polio. And the way we do that is by contacting healthcare facilities and asking if they have seen any child with limb weakness, with limb paralysis in the preceding week or two weeks, whatever frequency we’re using, and then finding that child, obtaining stool specimens from the child, finding out what the vaccination history is of the child and of the family, and seeing if there are any other instances of limb paralysis around that area. And this information then needs to get up to higher levels. One of the things that the polio eradication effort has accomplished has been to establish an extraordinary laboratory network with the accompanying information system to be able that a child, anywhere in the world, who falls ill with flaccid paralysis can have a stool specimen taken and delivered to a laboratory capable of testing it for polio anywhere in the world. And there are several hundred laboratories that are involved in this.
And a lot of that is still handwritten and transmitted. We have in every health post around the world where immunizations are given, somebody writes down the fact that an immunization has been administered. And at the end of the day, or the end of the week, someone tots up those numbers and writes them down and sends it up to a higher level where somebody maybe looks at it, but also transcribes from that form to a larger summary form, same information and sends it up to the next level, which results in a number of errors of transcription and also in delays in getting the information from the periphery to the most central level. One of the really exciting things that’s happening now, and people at the Task Force are in the forefront of doing this, is using handheld devices to be able to transmit information simultaneously from the field to the global level at every level in between, so that you can have real-time information about what’s happening. And the mapping that ITI is doing of trachoma in the world is really extraordinary. The kind of information that they’re taking from a hut essentially and transmitting up to the global level is really astonishing.
JESSICA
Everything you talked about, to me, had resonance in informatics and what we’re trying to accomplish with information. So why are you making that distinction? Why is that so important?
ALAN
Because informatics is a mechanism for making information useful.
JESSICA
Many thanks to Dr. Alan Hinman for spending time with us at the podcast and for sharing so many interesting stories about informatics in action. Congratulations on your retirement and we feel so lucky that you’ll continue to work on key projects with CVE. We wish you all the best in your next chapter. ”Inform Me, Informatics” is a project of the Public Health Informatics Institute and the Informatics Academy. You can find out more on phii.org or you can follow us on Twitter @PHInformatics. Many thanks to our production team, especially Piper Hale, the most awesome producer I could ever ask for. I’m Jessica Hill and you’ve been informed.
BUTTON
JESSICA
Let’s just maybe make it easy.
