Document Type

Capstone Experience

Graduation Date


Degree Name

Master of Public Health



First Committee Member

Dr. Abraham Mengist, PhD

Second Committee Member

Dr. Ishrat Kamal-Ahmed, M.SC., PhD

Third Committee Member

Dr. Sharon Medcalf, PhD


Objectives: Clostridioides difficile (C. diff) is a common but challenging infection both financially and medically. Due to these difficulties, Clostridioides difficile infection (CDI) caused by C. diff is a mandatory reportable disease in Nebraska and as such has been a priority disease targeted by various disease control practices across many hospitals. All CDI laboratory results are reported electronically through the Nebraska Electronic Disease Surveillance System (NEDSS). However, capturing and conceptualizing the true burden of CDIs in Nebraska has not been adequately accomplished since monitoring of CDIs began. The objective of this study is to examine the trends of C. diff infections and related deaths in Nebraska from 2018-2020. In addition, this study seeks to create a system to track CDIs in Nebraska through Geographic Information System (GIS) mapping for better conceptualizing of CDI burden in the state.

Methods: To examine the burden of C. diff on Nebraska, descriptive epidemiology using lab results reported in NEDSS from 2018-2020 and deaths reported with CDI association during the same timespan were performed using the SAS analysis tool. Social vulnerability index (SVI) provided by the Center for Disease Control and Prevention (CDC) was used to compare varying counties and CDI counts. An interactive map using GIS was created to document and visualize CDI prevalence of 2020 cases across the state of Nebraska.

Results: 8,334 CDI cases were recorded during the three-year span with case counts decreasing 36.5% from 2018-2020. The three-year prevalence rate for Nebraska was 459.07 per 100,000. Yearly incidence rates decreased yearly from 181.56 to 130.42 per 100,000 over the three-year span. 127 CDI-associated deaths were identified between 2018-2020 with increasing and decreasing numbers and rates yearly. Demographic information including gender, age, specimen/test type, race, ethnicity, and infection type of all 8,334 cases were recorded and reported. In addition to demographics, over 600 medical facilities and nursing homes were identified and stored into the state’s system for future identification of CDI case locating. ANOVA and logistic regression analysis indicated that residents of high-risk SVI counties were less likely to have a CDI than both moderate and low-risk SVI county residents. Lastly, an interactive GIS map was created depicting 2020 case demographics and rates as well as case numbers and rates by local health department (LHD) jurisdiction.

Conclusion: The overall burden of CDIs has been decreasing in Nebraska since 2018, however death counts and rates have remained similar. While complications associated with CDIs due to possible comorbidities may be harder to predict and prevent, this study has shown the positive effect of antimicrobial stewardship on CDI prevalence statewide. Case demographics that have been recorded as well as SVI analysis by this study have created a baseline understanding of at-risk populations in Nebraska and when combined with the GIS map can be used to locate CDI outbreaks and decrease response time. Furthermore, the creation of the CDI GIS map has created an efficient means of disease tracking and monitoring, and specifically for all common and reportable healthcare-associated infections (HAIs) in Nebraska as it can be used as a foundational template. Overall, this study was able to successfully describe the epidemiological situation of Clostridioides difficile in Nebraska.