Setting Priorities for Public Health Infectious Disease Programs Jay K. Varma, MD Deputy Commissioner for Disease Control New York City Department of Health and Mental Hygiene New York City Department of Health and Mental Hygiene One health department for >8 million people  Board of Health can pass regulations with force of law  ≈ 6,000 staff  Total budget $1.6 billion  ≈ 100 outbreaks/year  huff? haunt-naut- warm-Emu? mew?mm Department at Health and Mental Hygiene Table ef Drganizatiun ?ma?a: Hiram. HE: 5?3"?ng creatuemaanttner ?15 FEET *mn'l?'l mantem mm?? Wit Than-lea HELD ?lm manna - manna-1 tat-u al? Hlil'l'l HIM. HEI. MPH Hm. community Hum "El emu-HM Ina-tut [heals-e Tull?H JLIE HE REHEHEPH Deputy Hummer mm Earn-Hana [heptly Gumrrlililmer MPH mnemtmemttaI-ra Erratum; Reapers-e Heath-I uh:? Pea-cunt:? minim-u Hun?I- Catlj'n Greene. MD Merl-hm Hun-tum Pars-urns. MD. ?Him?n Begum-[Comm mun??rm Hedh?re?meaa all an. Imprm'emenl ?til-w u?u?a emu.- ?If; HE-Hil'l Wm 31:! BEBE-E mum-tut PI'E'H-E'l'lhl'l Pun-tau 31a Eatentat m: 311 5.1mm. CF51. Manama-tar MII Salim Geerga Bantam. wt Office of Viral Hepatitis Coordination Eric Rude, Director Nirah Johnson, Outreach Director Ashly Jordan, Program Manager BUREAU OF TB CONTROL Celine Gounder, MD, ScM Ass’t Commissioner Vacant Deputy Director Michelle Macaraig, PhD, MPH Ass’t Director, Policy & Planning Mary Masterson Director Administrative Services OFFICE OF THE DEPUTY COMMISSIONER, DIVISION OF DISEASE CONTROL Jay K. Varma, MD Deputy Commissioner CDC Kevin Mahoney, MSW, Ass’t Commissioner, Division Management Debora Mack, Director, Administrative Services Beth Cohen Barusek, Program Support Specialist Joycelyn Tait, Principal Administrative Associate BUREAU OF STD CONTROL Susan Blank, MD, MPH Ass’t Commissioner CDC Dianne Turner Program Management Officer Vacant Deputy Director Sam Sebiyam Program Management Officer Christopher Zimmerman, MD Medical Director David S. Haddow Director Administration Susan Wright Director STD Clinic Operations Colin Shepard, MD Director HIV/AIDS Epidemiology & Field Services Julia Schillinger, MD, MPH Director Epidemiology & Surveillance CDC Graham Harriman, MA Interim Director Care & Treatment Amy Metroka Director Citywide Immunization Diana Nilsen, MD Director Medical Affairs Shama Ahuja, PhD, MPH Director Surveillance & Epidemiology Errol Robinson Director Clinic Operations Christine Chuck Director Field Operations Martha Alexander, MHS Director, Education, Training & Outreach BUREAU OF HIV/AIDS PREVENTION & CONTROL M. Monica Sweeney, MD, MPH Ass’t Commissioner BUREAU OF PUBLIC HEALTH LABORATORY Jennifer Rakeman, PhD Ass’t Commissioner BUREAU OF IMMUNIZATION Jane Zucker, MD, MSc Ass’t Commissioner CDC Martin R. Evans, PhD Director Technical Affairs and Environmental Sciences Lori Cohen, MPH Director of Administration Mark Misener, MD, MPH Clinical/Emergency Prep William Oleszko, PhD Associate Director Virology Anne Lifflander, MD, MPH Director Medical Affairs John Rojas, MPA Director of Housing Edward Wake Adult Immunization Vacant Associate Director Microbiology Millicent Freeman Director Outreach & Education Blayne Cutler, MD, PhD Director HIV Prevention Program BUREAU OF COMMUNICABLE DISEASE Marcelle Layton, MD Ass’t Commissioner Gee Abraham Director Administrative Services Don Weiss, MD, MPH Director Surveillance Annie Fine, MD Medical Director Data Analysis Unit Scott Harper, MD, MPH Medical Director Zoonotic, Influenza & Vectorborne Disease CDC Sharon Balter, MD Medical Director Enterics Waterborne and Hepatitis Unit Brian Toro Regional Supervisor Case Investigations & Partner Services Kim Kong Director STD/TB Pharmacy DIVISION OF DISEASE CONTROL DIVISION OF DISEASE AUGUST 2012 CONTROL AUGUST 2012 Major Activities  Surveillance  Outbreak investigations  Medical consultation  Administer preventive interventions, including: Vaccines Condoms Public education Major Activities  Diagnose disease Directly: STDs, TB, public health lab, HIV Indirectly: HIV  Treat disease Directly: STD, TB Indirectly: HIV Major Activities  Applied public health research  Reference lab services, including bioterrorism response  Policy and regulation  Emergency preparedness The Age of Austerity  Hitting infectious disease programs hard  ~50% of Department budget protected by law (none of it infectious diseases)  New emphasis on chronic diseases  New infectious disease threats and opportunities but no funding, e.g., Hepatitis C, resistant gonorrhea  Threat of programs being eliminated before diseases are, e.g., TB New York City Funds, Staffing for Infectious Disease Control Fiscal Yr 2008 2009 2010 2011 City Funds (in millions) FTE $85.5 $65.5 $62.2 $42.4 508 416 406 377  During this time, Federal grants declined from $260  $246 million Push to move staff to grants Most FTEs (~ 700) now grant funded Criteria to Assess Value of Infectious Disease Programs  Legal requirement  Likelihood that someone else will do it  Incremental value – health return on investment  Revenue generating  Are the Feds paying for it? What?s Left on the Table 9 Public health laboratory 9 Clinical services Public Health Laboratory  Unlike epidemiology programs, predominantly funded by local dollars  An easy target for accountants Work in isolation and in facilities that no one wants to visit Low volume Lots of private laboratories Value difficult to quantify No natural constituency Why You Can’t Eliminate the Public Health Laboratory  An unbiased reference laboratory Many labs don’t perform classical microbiology and need us to definitively identify pathogens  Low volume, high consequence testing, e.g., botulism, rabies Why You Can’t Eliminate the Public Health Laboratory  Low clinical, high epidemiology value testing, e.g., genotyping  Outsourcing is not cheaper over the long term Clinical labs pull you in with bargain prices, then suddenly increase price  Once gone, you can’t bring it back without enormous investment Whither Clinical Services?  50% of TB cases, >80% of STD cases already treated in private sector A population health focus means we should shift focus toward assurance  Mandated by state law to insure free, confidential treatment for TB and STDs Major cost is infrastructure, so substantial savings even with outsourcing Whither Clinical Services? to collect 3rd party reimbursement for some services  Authorized State law does not allow us to bill for diagnosis, treatment of STDs, but does allow us to bill for other services provided in STD clinics, e.g., HIV testing  For TB, global experience that private sector does not reliably adhere to standards when diagnosing, treating  Clinical services creates a constituency Staffing – The Biggest Challenge  New hiring frozen by City, with intermittent, erratic thaws Even grant funded positions not always approved, threatening grant performance  Recruitment hampered by restrictions on salaries, prolonged hiring delays  Turnover increasing with reductions in support staff, loss of perks, low morale What Can We Do?  Re-align ourselves according to services only public health departments can provide E.g., surveillance, assurance, policy  Reassess value of services that public health has been paying for E.g., partner services for some patients with bacterial STDs, individual and group level HIV behavioral risk reduction What Can We Do?  Let the rich take care of the poor Creative ways to use funding from wealthy programs to support poorer programs  Focus on cheap, effective approaches Regulation and other policies Leverage health information technology, e.g., immunization information systems  Regionalization and shared lab services  Small morale builders