County Level Study (CLS)

The Office of Epidemiology (OOE) is currently collaborating with the University of Missouri-Columbia Health and Behavioral Risk Research Center (HBRRC) to conduct the 2022 Missouri County-level Study (CLS). The last CLS in Missouri was done in 2016 and was well received across the state because of its ability to provide county level data on a variety of chronic disease and MCH indicators. This project has finished data collection and the data is being prepared for analysis and public dissemination.

The Missouri Behavioral Risk Factor Surveillance System (BRFSS) has been in existence for over 35 years and is the primary surveillance system that combines demographic information as well as social and environmental factors (e.g. health care access) with information on chronic diseases (e.g. diabetes) or other related health conditions (e.g. obesity) and behaviors associated with health outcomes (e.g. smoking or physical activity). The Missouri BRFSS survey is conducted annually with partial funding from the Centers for Disease Control and Prevention (CDC). One of the major limitations of the Missouri BRFSS is that the current budget can only fund approximately 7,000 surveys per year. This sample size is insufficient to address county-level health questions. The Missouri BRFSS Program recommends enhancing data collection by adding up to 10,000 additional survey responses per year.

The CLS is modelled after the Missouri BRFSS. Earlier versions of this study were successfully conducted in 2007, 2011, and 2016 using funding sources that are no longer available. Since many public health interventions are implemented at county or sub-county levels, an estimated 50,000 surveys are required to provide detailed data to inform prevention and planning at the local level. The CLS is similar to the Missouri BRFSS in terms of following the CDC’s best practices for sampling, data collection, and weighting methodologies; however, the DHSS has greater control over the survey design and the opportunity to collect a sample size sufficient for county- and sub-county-level analyses. The intended target of the study is approximately 50,000 Missouri adults ages 18 and older, distributed across all 114 Missouri counties and the City of St. Louis. The interviews were conducted via randomly selected landline and cell telephone numbers using a standard questionnaire that was developed in collaboration with internal and external public health partners. The questions are tailored to address data collection needs surrounding COVID-19. Collecting comprehensive, granular information through state and local needs assessments enables data-driven intervention planning and allocation of resources to more effectively target populations for public health interventions.

Pregnancy Risk Assessment Monitoring System (PRAMS) – Social Determinants of Health Supplement

The Council of State and Territorial Epidemiologists (CSTE) partnered with the CDC-Division of Reproductive Health (DRH) to provide technical assistance to state, local and territorial public health agencies for the implementation of routine population-based data collection to inform public health’s understanding of the effects of Social Determinants of Health (SDoH) on the experiences and attitudes of pregnant and postpartum women. The project supports jurisdictions to collect SDoH information about participants’ experiences with housing instability, food and transportation insecurity, barriers to mental health access, and race or ethnic discrimination among women with a recent live birth before, during and immediately after pregnancy. Participating jurisdictions have implemented the SDoH questionnaire supplement as part of the Pregnancy Risk Assessment Monitoring System (PRAMS) to collect population-based data on the impact of SDoH on pregnant and postpartum women and infants. Missouri PRAMS has been implementing the SDoH supplement and collecting data since May 2022. Data collection has been completed and data will be accessible in the fall 2023.

The PRAMS project is also beginning data collection for a new phase of the core survey. The survey is updated approximately every five years. The new survey includes new questions related to emergency preparedness, respectful maternal and infant care, and maternal mortality warning signs. This additional data collected from these new questions will provide baseline measures and inform Title V initiatives.

Surveillance for Emerging Threats to Mothers and Babies Network (SET-NET)

Missouri receives funding from the CDC to participate in Surveillance for Emerging Threats to Mothers and Babies Network (SET-NET) through the Epidemiology and Laboratory Capacity for Prevention and Control of Emerging Infectious Diseases (ELC) cooperative agreement. SET-NET supports states and other jurisdictions to adapt and expand existing surveillance systems to monitor for emerging infectious diseases and health threats during or around the time of pregnancy through the child’s first year of life. SET-NET collects data on mothers, and infants and the impact of various health threats including Zika, Hepatitis C, Congenital Syphilis, and COVID-19. SET-NET also tracks birth defects, developmental problems, and other disabilities as these children age. Epidemiologists use these data to:

• Monitor and improve the health of pregnant people and infants;
• Link families to medical and social services to get recommended care;
• Strengthen laboratory and clinical testing to find emerging health threats quickly; and
• Ensure public health is ready and prepared to meet the needs of pregnant people and infants during emergencies.

This surveillance builds upon the US Zika Pregnancy and Infant Registry. The Registry collected health information on pregnant people and their infants who had laboratory evidence of Zika infection during pregnancy. A key part of this unique surveillance is the ability to find exposures during pregnancy and link them with health outcomes of pregnant people and infants. This innovative and nimble approach enables CDC and state, local and territorial health departments to monitor exposures of concern during pregnancy and collect follow-up data on affected infants over time.

Missouri is currently only funded to collect and report information related to COVID-19 and pregnancy. For COVID-19 surveillance, Missouri identified pregnancies of interest and collected necessary information through linking COVID-19 testing data with other data sources including: birth certificates, fetal death certificates, death certificates, COVID-19 vaccination data, and the Patient Abstract System (PAS). Key COVID-19 surveillance questions include: demographics and risk factors of pregnant people with COVID-19, timing of illness onset, presence of symptoms, severity of illness, reinfections, genetic variants (e.g. Delta), complications with pregnancy, birth/neonatal outcomes (such as infant death, low birth weight, and preterm births), infant COVID-19 testing status, severity of post-natal infection, infection and reinfection in infants, infant growth patterns, and other concerns. In order to be considered a record of interest for mother-baby surveillance of COVID-19, the mother must be a Missouri resident and have had at least one lab-confirmed positive SARS-CoV-2 RNA test result at any point during pregnancy up to and including the day of delivery. The positive test result must have occurred between January 20, 2020 and December 31, 2021. The program is currently working to develop a means of collecting longitudinal data on the baby to allow for analysis of events that occur after mother and baby are discharged from the hospital after delivery.

Levels of Care Assessment Tool (LOCATe) Process Improvements

The CDC developed the Levels of Care Assessment Tool (LOCATe) to help states and other jurisdictions create a standardized assessment of levels of maternal and neonatal care. Assessing these levels using a consistent methodology allows jurisdictions to ensure pregnant women and their babies are receiving risk-appropriate care. Missouri initially implemented this tool as a paper-based survey. In subsequent years, the program has evolved to be fully electronic with automatic notifications of a hospital’s status.

In FY23, the LOCATe team added a map of facility locations and levels to the website for Risk Appropriate Care at https://health.mo.gov/riskappropriatecare. The map shows both maternal and neonatal levels of care.

Additionally, the data collected through LOCATe is being used to update two measures on the publically available Missouri Information for Community Assessment (MICA) database at https://healthapps.dhss.mo.gov/MoPhims/MICAHome. The Birth MICA includes the ability to query data on very low birth weight births delivered in a level 3 facility and high-risk deliveries in a level 2 or 3 facility. These queries previously relied on self-reported levels from the hospitals, so the meaning of a specific level was not standardized as it is in LOCATe.

Data Dissemination Activities

In additional to the LOCATe dashboard previously mentioned, a number of publically available dashboards have been developed to support MCH programs. The MCH program dashboards that are currently available include:

• Missouri Pregnancy Risk Assessment Monitoring System (PRAMS): Available at https://health.mo.gov/data/prams/prams-dashboard.php. This dashboard includes data from the PRAMS survey and allows a variety of customization for data queries. Data is available on topics such as prenatal care, contraception, intimate partner violence, breastfeeding, and pregnancy intendedness. Users can select custom data ranges, and data may be cross-tabulated by age, education, geography, income, race/ethnicity, and WIC enrollment.
• Pregnancy-Associated Mortality Review (PAMR): Available at https://health.mo.gov/data/pamr/dashboard.php. This dashboard displays maternal mortality data from the state’s Maternal Mortality Review Committee. Counts are available at the county level, and causes of death, timing, and demographic statistics are available at the state level.
• Early Hearing Detection and Intervention (EHDI): Available at https://health.mo.gov/living/families/genetics/newbornhearing/dashboard-ehdi.php. This dashboard includes information from the newborn hearing program. It includes information about pass/fail rates, timing of diagnostic testing, and number of children receiving intervention services.
• Newborn Blood Spot Screening: Available at https://health.mo.gov/living/families/genetics/newbornscreening/blood-spot-screening.php. This dashboard reports annual data on counts of positive tests for each disorder included in the panel. It also includes information on the number of tests performed.

The Title V team is in the early stages of developing a general Maternal-Child Health dashboard for Missouri. This dashboard will be funded through state general revenue and will be used to provide a broad picture of MCH in the state rather than focusing on one specific program.

The MCH Epidemiology team also produces fact sheets on various MCH topics, available at https://health.mo.gov/living/families/mch-block-grant/. Some examples of fact sheets available include adolescent suicide, infant death and injury, breastfeeding, and pregnancy and delivery care.

Data Modernization and Integration

In early 2022, the Department of Health and Senior Services (DHSS) organized a new team, the Bureau of Data Modernization and Interoperability (BDMI), to focus on modernizing and integrating data systems. The national Centers for Disease Control and Prevention (CDC) has initiated a multi-year, billion-plus dollar effort to modernize core data and surveillance infrastructure across the federal and state public health landscape. This initiative is focused on putting the right people, processes, and policies in place to help solve problems before they happen and reduce the harm from any problems that do occur. (https://www.cdc.gov/surveillance/data-modernization/index.html) The goal of the Bureau of Data Modernization and Interoperability (BDMI) is to modernize and ensure interoperability of public health data systems with other relevant systems to reduce inefficiencies, provide more timely and accurate public health responses, and better serve Missouri residents and visitors.

This includes:

• Working with data submitters at laboratories, hospitals, clinics, local public health agencies, long term care facilities to transmit data electronically;
• Engaging with other DHSS programs, local public health agencies, and other stakeholders to identify necessary system improvements to increase staff efficiency and improve the timeliness of public health actions;
• Routine reporting of data to stakeholders at all levels; and
• Automating processes when possible.

There are a number of projects in BDMI that will impact MCH programs. First, the communicable disease system is undergoing a major upgrade. MCH populations are particularly affected by issues such as the increased incidence of sexually transmitted infections like chlamydia and syphilis. There has also been an increase in the number of cases of congenital syphilis in infants. The new system will facilitate easier case management, contact tracing, and linkages to other data systems. There are also upgrades planned for the database that hosts newborn hearing test data, as well as hospital data. BDMI also works with school nurses who assess and report the number of school-age children who have received their recommended immunizations. Additionally, BDMI works with healthcare providers to establish automated electronic reporting of immunizations to properly assess the vaccination coverage among children and adolescents.