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Reducing Drug Overdose Death in New Mexico

Posted By Michael Landen, Friday, February 20, 2015
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New Mexico has led the nation in drug overdose deaths for most years over the past two decades. However, in 2011 NM dropped from this position to number two and in 2012 to number three because of a 16% decrease in drug overdose death from 2011 to 2013. This decrease has been largely due to a decrease in prescription drug overdose death that has followed a decrease in the amount of opioids prescribed in NM. Despite this improvement NM’s drug overdose death rate remains substantially higher than the U.S. rate.

In 2011 state legislation created a governor’s advisory council on drug overdose prevention and pain management, which formalized a process for bringing stakeholders together. This legislation also required that each of the seven healthcare provider entities that license providers who can prescribe controlled substances promulgate new regulations for treating chronic pain and providing mandatory continuing education on chronic pain. As a result, all licensing entities require registration and use of the prescription monitoring program. The Board of Pharmacy and the Department of Health routinely analyze prescription opioid and benzodiazepine prescribing data and provide reports to the licensing entities on outliers. The Council also recommended removing the preauthorization requirement around Medicaid suboxone prescribing, and this was removed.

Additionally, NM has built on the highly successful syringe exchange based naloxone program by adding co-prescription pilots in several communities where naloxone is provided along with chronic opioid prescriptions. NM also allows pharmacists to prescribe naloxone and has been working with pharmacies to stock naloxone so that it is available around the state. Medicaid also reimburses for naloxone and the accompanying education.

NMDOH has three substance abuse epidemiologists who are critical to the drug overdose prevention effort in NM. They collaborate with the Office of the Medical Investigator and the Board of Pharmacy to track drug overdose deaths and prescribing patterns. These data are disseminated both locally and statewide. Particularly useful are presentations of county-level overdose death and prescribing patterns that have been provided to community groups and local provider organizations. They have also led the process for tracking naloxone distribution to assure it is available in areas with the highest drug overdose death rates.

Despite being one of two states with all 10 prescription drug overdose prevention policies in place tracked by the Trust for America’s Health, NM has a long way to go to adequately address the drug overdose epidemic. The prescription drug monitoring program needs to move closer to real-time prescribing data – currently it requires data from pharmacies within seven days. Licensing entities need to better enforce their own rules on prescription monitoring program use. And naloxone needs to be far more widely available like most prescription drugs are. In the 1990s heroin was driving the NM epidemic, and more recently prescription opioids have been. This means that many of our original naloxone programs, originally directed at heroin users, now accommodate persons at high risk because of prescription opioid use. While many states have seen heroin overdose death rates increase in recent years, New Mexico hasn’t witnessed the same trend. However, one possible explanation for NM’s relatively stable heroin overdose death rate is that New Mexico already had a high prevalence of heroin drug overdose death.

The drug overdose epidemic is different in each state. Having an adequate epidemiologic infrastructure to track the epidemic in each state is critical. The CSTE Overdose Subcommittee has done critical work in developing practical approaches that can be employed in states, taking into account state-specific differences. Fellow CSTE members provide good approaches to state-specific surveillance that is the foundation for reducing inappropriate prescribing and drug overdose.

Michael Landen, MD, MPH is co-chair of the Substance Abuse Subcommittee. NM’s substance abuse epidemiology section includes Laura Tomedi, PhD, MPH, the chair of the Alcohol Subcommittee, and Jim Davis, MS a member of the Overdose Subcommittee, and Luigi Garcia-Saavedra, MPH. To find out more about substance abuse, visit the subcommittee pages and read CSTE’s 2008 State-Level Substance Abuse Epidemiology Capacity position statement. A unique, new fellowship opportunity is now available for substance abuse or mental health fellowships: Applied Epidemiology Fellowship applications will be open soon.

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Public Health Fares Better than Usual in President’s Budget

Posted By Emily J. Holubowich , Friday, February 13, 2015
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Emily Holubowich, Senior Vice President at CRD Associates is CSTE’s Washington representative and leads our advocacy efforts in the nation’s capital.

On February 2, President Obama delivered his $4-trillion fiscal year (FY) 2016 budget request to Congress. The president proposes a balanced approach for replacing sequestration (something CSTE has supported through the advocacy efforts of the Coalition for Health Funding and its anti-austerity campaign, NDD United). This sequestration relief would free up an additional $70 billion to support funding increases across the government, including the Centers for Disease Control and Prevention (CDC)—the first increase the administration has proposed in several years.

The administration seeks $7 billion for CDC in FY 2016, a 2 percent increase that includes $6.096 billion in base discretionary funding or “budget authority,” and $914 million in mandatory funds from the Affordable Care Act’s Prevention and Public Health Fund (PPHF). Together, this funding translates into increases for Emerging and Zoonotic Infectious Diseases (73 percent increase) and Public Health Workforce (29 percent increase) through which applied epidemiology fellows are funded.

One of the administration’s top funding priorities—public health or otherwise—would rely heavily on state and local epidemiology capacity. Combating Antibiotic-Resistant Bacteria or CARB is a new, $1.2-billion initiative that spans several different federal departments (Health and Human Services and Agriculture among them) and several different health agencies, including CDC.

Within the $264-million CARB request for CDC, approximately $100 million would be dedicated to Epidemiology and Laboratory Capacity (ELC) grants to support core infectious disease surveillance capacity at state and local health departments. If appropriated, this would bring total funding for ELC to $210 million—more than double the FY 2015 level of $102.5 million.

Provided below is more detail on the proposed funding levels for some of CSTE’s key advocacy priorities. Much of the new funding requested by the president focuses on building capacity to fight infectious diseases at home and abroad. However, if appropriated these funds would ultimately serve a dual purpose. We know from past experience that funding provided to support communicable disease monitoring and response ultimately bolsters the overall epidemiology infrastructure needed to fight non-communicable diseases, as well.

  • Epidemiology and Laboratory Capacity Grants. Within the total, a $210 million funding request for ELC, the program would once again be provided $40 million from the PPHF, consistent with the last four fiscal years.
  • Advanced Molecular Detection (AMD). The president’s budget once again requests $30 million for the AMD initiative, consistent with the current funding level. This funding would be used to continue to improve CDC’s capability and to initiate state projects to improve the application of genome sequencing to public health issues of concern.
  • Food Safety. The president’s budget request seeks nearly $50.1 million for foodborne disease surveillance, an increase of $2.1 million over the current level. Approximately one half of this increase would go to state and local health departments to enhance surveillance, outbreak detection and response, and food safety prevention efforts.
  • Global Health Security. The president’s budget request seeks $448 million for global health, an increase of $31.6 million above FY 2015. Of this, the president seeks to dedicate nearly $77 million—a $21.6 million increase—to expand the global health security agenda and accelerate progress in preventing the spread of global health threats. Applied epidemiologists at the state and local level will continue to be a critical component of any response strategy.
  • National Healthcare Safety Network (NHSN). The president requests more than $32 million for the NHSN, an increase of $14 million over the current level. The new funding would support NHSN reporting in more than 17,000 health care facilities to help eliminate healthcare-associated infections and guide prevention activities.
  • Epidemiology Fellows. The Public Health Workforce program—through which the CSTE/CDC Applied Epidemiology Fellowship receives funding—would see an increase of $15.2 million under the president’s request, bringing total funding to $67.4 million. Of this, the administration would use $36.2 million from the PPHF to support professional development. It’s worth noting that two years ago Congress eliminated $15 million in PPHF dollars for Public Health Workforce in the wake of sequestration of the PPHF—so this could be a heavy lift.

    With this increase, the CDC could support up to 667 fellows, or approximately 80 additional fellows, which would ultimately increase the number of fellows assigned to state and local health departments. The budget request does not specify how much funding would be dedicated to the Applied Epidemiology Fellowship Program per se, but a rising tide would certainly lift all boats. The administration in the budget request does single out “high-priority” professional development activities, including the Epidemic Intelligence Service (EIS), the Public Health Associate Program (PHAP), public health informatics, and population health training of areas of potential funding.

Even with the increase for CDC writ large, many public health programs are not immune to cuts in the president’s budget. Section 317 Immunization Program (-$50 million or -8 percent), Environmental Public Health Tracking Network (-$12 million or -32 percent), and several chronic disease programs see proposed cuts. Of particular note, the president’s budget once again proposes to eliminate funding for the Preventive Health and Health Services Block Grant (-$160 million). So far, each year Congress has rejected such cuts to the “Prevent Block.”

With the release of the president’s budget, the appropriations process begins in earnest. The budget request serves as roadmap for funding, but the “power of the purse” ultimately lies with Congress—and it will be at lawmakers’ discretion to determine what to fund and at what level. And if Congress adopts the president’s plan for stopping sequestration or comes up with their own fix, funding levels will be held at their austere levels, making many of the president’s proposed increases impossible…at least without deep cuts to other public health programs. CSTE will once again partner with the Association of Public Health Laboratories and other colleagues in the public health community to advocate for our key priorities—strong support for disease monitoring and for training the next generation of epidemiologists. We will be sure to keep you apprised of our efforts.

For more information about funding levels for your specific priorities, please click here for a copy of CDC’s explanation of the budget request. You may also be interested in CDC’s operating plan for the current fiscal year available here, which outlines where CDC is spending funding now.

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NFL Partnership Promotes Public Health to Nine Million People

Posted By Shawn Richards, Jennifer Brown, and Pam Pontones, Friday, February 6, 2015
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The Indiana State Department of Health (ISDH) and the NFL’s Indianapolis Colts have partnered to promote an influenza vaccination, hand washing and infectious disease awareness campaign. Now in its second year, this campaign, “Join Blue Prevent the Flu (JBPF),” reached over 10 million people during the 2014-2015 flu season.

The main messages of the campaign included:
  • Get Your Flu Shot
  • Clean your Hands Often—Use Soap and Water
  • Cover Your Cough and Sneeze—Use a Tissue or Your Sleeve
  • Contain Your Illness—Stay Home When You’re Sick

The innovative partnership highlighted disease prevention and health education by using the marketing power of the Indianapolis Colts football organization. The ISDH sought this partnership due to the near-perfect market to direct the ISDH health messages and the alignment of football season and flu season. A few of the highlights of the JBPF campaign included:
  • The digital game-day recaps sent by the Colts after every game via Facebook, Twitter and Instagram included 19 different customized public health messages. The messages covered influenza-related statistics and vaccination reminders, education about Enterovirus and shigellosis outbreaks occurring in Indiana, promotion of the ISDH Ebola Call Center, and hand washing. The analytics provided by the Indianapolis Colts found that 9,339,474 people were reached using the game-day recap during the regular and postseason games. For an example, go to
  • The Colts promoted National Influenza Vaccination Week on the website, the Colts Facebook Page, Twitter, and a prepared Twitter message sent by the Colts Stampede (an online Colts fan community).
  • The ISDH supported the Bleed Blue Blood Drive and Health Fair, where the ISDH provided an influenza knowledge/attitudes/beliefs survey on influenza symptoms and prevention along with an interactive hand washing activity.
  • Indianapolis Colts player Matt Hasselbeck served as the team’s influenza spokesperson. Two influenza vaccination and hand washing videos featuring Hasselbeck and the Indiana State Health Commissioner were produced and featured on the ISDH YouTube channel located at and the ISDH influenza website at
  • A hand washing and influenza vaccination commercial produced by the Indianapolis Colts was played on the Jumbotron at every Colts home game. The commercial featured the Indiana Health Commissioner “immunizing” Blue, the Indianapolis Colts mascot.
  • A full-page color ad was included in every game-day program about influenza and antibiotic resistance. An example is provided at
  • Mirror clings promoting hand washing and featuring the ISDH and JBPF logos were installed in all stadium-level bathrooms and hand sanitizer stations. View the image of the mirror cling at
The social media presence using the game-day recaps reached 9,339,474 people, and the 650,000 fans who attended Colts home games at Lucas Oil Stadium had the opportunity to see the mirror clings, commercial, and stadium stills. Additionally, the hand washing messages provided on hand sanitizer stations and bathroom mirror clings were posted at all other events at Lucas Oil Stadium, including NCAA games, the Big Ten Championships, concerts, motor sports, high school football games, and conventions; these events reached as many as 1.5 million additional people. The ISDH and Colts partnership was used to decrease the effect of communicable diseases in Indiana by promoting hand washing, disease information and education, and influenza vaccination.

Shawn Richards, BS is Outbreak Supervisor; Jennifer Brown, DVM, MPH, DACVPM is State Public Health Veterinarian; and Pam Pontones, MA is State Epidemiologist and Director of the Epidemiology Resource Center at Indiana State Department of Health. For more information, see the CSTE influenza page.

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Quitting Tobacco Incentive Program: A Project Worth Saving

Posted By Matthew Francis, Friday, January 30, 2015
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Many epidemiologists know what it’s like to face a great project on the precipice of failing despite every effort to keep it alive. I hoped that neither of my two projects in Lane County, Oregon would be in this situation. As a 12-month Health System Integration Program (HSIP) fellow, you go in knowing that some of your projects are in need of improvement; that you as the fellow are the person who will provide a solution; and that the work is scoped to be resolved within 12 months. Despite my hopes and the efforts of the project team assigned to Tobacco Cessation in Pregnancy (TCIP), this is exactly where I found myself on one project. Truth be told, I couldn’t have been more thrilled to have the opportunity to keep a truly important public health project from being scrapped due to a shaky start.

The HSIP fellowship uniquely rests on the fulcrum between informatics and epidemiology. As an epidemiologist, my role is to design questionnaires, assist with analytics, support projects, and aid in the implementation of epidemiological methodologies. As an informaticist, I make sure the variables make sense and the radio buttons are in a logical order. I also name variables, create user-friendly databases, and write codebooks. Both skillsets were needed when the TCIP initiative was failing and the decision was made to move it to The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), rename it Quit Tobacco Incentive Program (QTIP), and change the way tobacco use was measured.

That transition was in the works when I arrived. After meeting with the QTIP team, it quickly became apparent that during year one of the program, due to such issues as their tobacco screening tool being unreliable and physicians and clinic staff overburdened and dropping out, there was no data infrastructure. As discussion revolved around moving the program to WIC, the same question kept surfacing, where will the data go?

When multiple physician offices were enrolling participants, the default option involved copying paper records to spreadsheets. This system, aside from transcription errors, faced an enormous challenge. The goal of the program was 80 percent enrollment of a projected 600 pregnant smoking Medicaid mothers. Since each mother would be interviewed six to seven times and their data would be entered twice—on paper and Excel—by one individual at WIC, the volume of data entry work was well above what a 0.2 full-time equivalent counselor could complete. Had the program been in its planning stage, perhaps this issue could have easily been resolved. However, with the program on the fast track and WIC gearing up for enrollment, each participant enrollment would create a more burdensome data system. The database also needed to contain a system where the WIC staff could take notes to assist in counseling support of the pregnant mother as well as adding to the existing data that was being collected. Lane County Prevention and WIC staff also felt the need to collect data on electronic cigarette usage, since there was concern that mothers might use e-cigs to aid in cutting back on traditional cigarettes.

With guidance and input from my mentor, the prevention team, local coordinated care organization, and WIC staff, we were able to develop an Access database with forms similar to the existing paper copies housed in WIC. We were also able to create a database for the WIC staff that was on time and flexible enough to be a useful tool for present and future enrollment. The new data tool allowed for WIC staff to provide a better overall experience for pregnant mothers interested in quitting. WIC staff was able to make notes, track progress, set reminders and have a system that quickly allowed them to pull participant data when needed to assist in tobacco cessation. Being an HSIP fellow allowed me to tackle the program improvement from two key perspectives. I was able to not only address the data needs of the program by creation of the data tool, I was also in the unique position to ensure that the transition from paper to database was as seamless as possible and was able to give recruitment guidance based on my previous experiences in the field.

An important takeaway from this project has been that despite funding and availability of resources, some projects hit early road blocks that can severely jeopardize their success. Having the correct informatics and epidemiological resources is a crucial component of successful programs. It takes a determined program staff to move forward during times of change and maintain the initial program vision. Integration of multiple health systems allowed for the continuation of a great public health program that had stumbled early on. Reintegration of clinics and physicians as referral tools is an important next step for the success of the program.

Matthew Francis, MS, PhD is a Health Systems Integration Program (HSIP) fellow at Lane County Health and Human Services in Eugene, Oregon. For more information on drug surveillance, read more at the Alcohol and Other Drug Surveillance Subcommittee. The HSIP fellow application is open until February 16, 2015.

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Interview with CSTE Ebola Epidemiologists

Posted By Chad McCoull, Wednesday, January 28, 2015
CSTE is sending epidemiologists to West Africa for Ebola prevention. Watch the YouTube video as Jean-Marie Maillard of North Carolina, Raoult Ratard of Louisiana, and Katrina Hedberg of Oregon discuss their training and work:

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Syphilis Outbreak Response in Southwest Oklahoma

Posted By Jan Fox and Kristy Bradley, Friday, January 23, 2015
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On July 28, 2014, a case of primary syphilis was identified at the Comanche County Health Department (CHD) in Oklahoma. Between July 28 and September 25, eight additional cases were diagnosed in that county. These numbers reflected a 300 percent increase in reported cases for Comanche County from 2013. Upon review of the cases, the Oklahoma State Department of Health (OSDH) HIV/STD Service and the Comanche CHD determined that an outbreak of syphilis was occurring and outbreak response efforts were initiated. The outbreak was found to be occurring among men who have sex with men (MSM) and included risk factors of multiple sex partners, new and/or anonymous sex partners, using drugs, and/or trading sex for money and/or drugs. It was also noted that some infected were on the ‘down-low’ (slang for men who identify as heterosexual, but who have sex with men and avoid sharing this information even if they have female sexual partners and/or are married).
Working in partnership, the HIV/STD Service and the Comanche CHD quickly implemented the following activities:
  • Conducted a ‘blitz’, in which a team of Disease Intervention Specialists was dispatched to Comanche County to quickly initiate contact tracing (partner services) for all reported cases in an effort to get in front of the outbreak. Contact tracing is the cornerstone of public health response efforts for infectious diseases and involves face-to-face interviewing of infected persons to elicit reporting of sexual partners in order to subsequently locate, test, and treat persons who have been exposed to the disease. To date, a total of 110 sexual partners were identified as a contact to at least one of the 11 cases, with 73 in need of treatment. Among these, 81 have been located and tested, 52 have received treatment, and 8 required interstate assistance for follow-up.
  • A health alert went out to local clinicians and a syphilis educational meeting was held at the Comanche CHD in order to make local clinicians aware of the syphilis problem and to ask for assistance in testing and treating their at-risk patients. The meeting was well attended with 35-40 clinicians present.
  • A media news release was utilized to disseminate facts about syphilis to the public and included prevention, testing, and treatment information. The release resulted in wide distribution of information, including a live interview with KFOR, in-person on-camera interviews for KSWO-TV 7 News in Lawton, Telemundo, and Fox25 as well as a phone interview with the Daily Oklahoman and the Cameron Collegian Weekly. Additionally, the online story was shared more than 12,000 times on social media.
  • Posters and other print material were created and distributed in the Lawton area to raise awareness of syphilis and the outbreak. A quick response (QR) code was created and added to the print material; when scanned, this code would lead the person to a website that provided information about the health alert and basic syphilis information.
To date, 17 syphilis cases have been identified that are associated with this outbreak. Disease prevention and control efforts continue in order to ensure that the outbreak is brought to an end.
Jan Fox, RN, MPH, is the Director of the HIV/STD Service at the Oklahoma State Department of Health. Kristy K. Bradley, DVM, MPH is State Epidemiologist and State Public Health Veterinarian at the Oklahoma State Department of Health. She also serves as CSTE Executive Board Chair for Infectious Disease. For more information about STIs, visit CSTE’s National Notifiable Diseases Surveillance System NNDSS Modernization Initiative page and the Infectious Disease overview page.

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New and Improved Chronic Disease Indicators

Posted By Sara Huston, Thursday, January 15, 2015
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CSTE, along with our partners CDC and National Association of Chronic Disease Directors (NACDD), is excited to share the release of two new important tools for chronic disease surveillance: 1) the MMWR Recommendations and Reports “Indicators for Chronic Disease Surveillance — United States, 2013” and 2) the redesigned CDC Chronic Disease Indicators website. These tools are products of a multi-year collaborative effort between CDC, CSTE, and NACDD to review and update the Chronic Disease Indicators (CDIs), which were first adopted in 1999.
The MMWR publication details the history of the CDIs and the process we went through in this most recent update. Did you know that the CDI work has been a successful collaboration between CSTE, CDC, and NACDD since way back in the mid-1990s? Many CSTE members dedicated their time and provided their expertise to help with this most recent CDI revision process – serving on or even chairing the content-specific working groups, or participating in the 2013 CSTE position statement process that officially adopted the newly revised CDIs. All the working group members are acknowledged in the MMWR. Thank you for your contributions!

The MMWR publication also highlights the major areas of change to the CDIs and provides detailed technical definitions – including numerator, denominator, and data sources – for each of the 124 indicators in 18 topic groups. The detailed definitions will enable epidemiologists to create estimates that are consistent with the data that CDC publishes on the CDI website, and may be especially helpful to local health departments in creating their own sub-state-level estimates.

CDC’s redesigned CDI website, just launched this week, provides data for each of the indicators at the state, territorial, and national level as well as for 40 large metropolitan areas. In addition to updating and adding data for all the CDIs, CDC worked hard to create a more user-friendly display, navigation, and data retrieval functionality for the website. Please take a few minutes to visit the site at, bookmark it and check it out!

If you haven’t taken a look at the CDIs since their last formal update in 2002, you’ll see many changes that reflect the growth in chronic disease programs in state and territorial health departments over the past decade and keep the CDIs relevant for present-day chronic disease surveillance. For example, the CDIs include 22 new indicators of systems and environmental change, reflecting the increased focus on environmental and systems change strategies in chronic disease program efforts. The updated CDIs also include five new topic areas – disability, mental health, older adults, reproductive health, and school health – reflecting the increased scope of work of many state and territorial chronic disease programs and increased collaboration with other program areas.

Here are just a few of the new CDIs you might find interesting:

  • Nutrition, physical activity, and weight status 8: Number of farmers markets per 100,000 residents (data source: USDA National Farmers’ Market Directory)
  • Asthma 5.1: Influenza vaccination among noninstitutionalized adults aged 18–64 years with asthma (data source: Behavioral Risk Factor Surveillance System)
  • Older adults 3.1: Proportion of older adults aged ≥65 years who are up to date on a core set of clinical preventive services (data source: Behavioral Risk Factor Surveillance System)
These newly revised Chronic Disease Indicators provide state and territorial health departments and other health agencies with a framework for chronic disease surveillance in the form of rigorously-defined consensus measures that are relevant to their programs. Our challenge going forward is to keep them relevant and to not let a whole decade pass before the next update! Please stay tuned for upcoming opportunities to learn more about the new CDIs and get involved in the next update process.
Sara L. Huston, Ph.D. is on the faculty of the University of Southern Maine’s Muskie School of Public Service and serves as the Lead Chronic Disease Epidemiologist for Maine. She is former chair of CSTE’s Chronic Disease/MCH/Oral Health Committee. For more information, please visit the CSTE page on CDIs and the 2013 CSTE position statement Revision to the National Chronic Disease Indicators.

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Tags:  cdi  chronic disease  chronic disease indicators 

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The Meaningful Impact of Position Statements

Posted By Virginia Dick, Friday, January 9, 2015
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CSTE members work hard each spring to develop position statements, which address a broad range of public health issues and health conditions for standardized surveillance. Over the past four years, there have been between 10 and 30 position statements submitted each year. Many of these position statements have had significant impacts on the public health environment. Below are a few of the position statements that have specifically addressed public health policy areas and the progress that has been made in these areas.
10-EH-01 Asthma: a continuing public health priority and 13-CD-01 Revision to the National Chronic Disease Indicators
These indicators involve CDC, NACDD, and CSTE updating and revising the Chronic Disease Indicators. The 2010 Environmental health position statement involved the partners working together to update the Asthma Indicators that are part of the Chronic Disease Indicators. After three years of review, revisions, and additions by experts, the full list of indicators is being released January 15, 2015, including a CDC MMWR and a new website. In addition, due to the position statement process and advocacy, CDC continues to fund state partners to conduct asthma surveillance, and provide technical epidemiologic support to funded states. The work on asthma has helped lay groundwork in preparation for the Coordinated Federal Action Plan to Reduce Racial and Ethnic Asthma Disparities.
10-ID-28 Council of State and Territorial Epidemiologists - Centers for Disease Control and Prevention (CSTE-CDC) Process for Setting National Standards for Healthcare-Associated Infections Case Criteria and Data Requirements
This position statement addresses the process for setting Healthcare-Associated Infection case criteria and data requirements. A CDC-CSTE HAI standards committee has been created and has met regularly for the past two years.
11-OH-01 CDC and Cleaning Products Messages
NIOSH convened an international working group in the NORA Health Care and Social Services sector with expertise in infectious disease and occupational health to develop an analysis of cleaning products and infection control in healthcare. In 2012, the National Institute for Occupational Safety and Health (NIOSH) published a publication called “Protecting Workers Who Use Cleaning Chemicals.
12-CD-01 Proposed New and Revised Indicators for the National Oral Health Surveillance System and 12-CD-02 Developmental and Emerging Indicators for the National Oral Health Surveillance System
The National Oral Health Surveillance System (NOHSS) includes developmental and emerging indicators. A workgroup was assembled in 2012 that published a publication in 2013 called “State-based Oral Health Surveillance Systems: Conceptual Framework and Operational Definition.” There is a group that is now reviewing the indicators and working towards a 2015 position statement to revise the indicators. There are also 21 states with funded state oral health programs for the 2013-2018 period. In 2014, the Association of State and Territorial Dental Directors State Synopsis added a new section on state surveillance systems which assess the availability and use of selected NOHSS indicators. This will be released on the ASTDD site:
13-ID-02 Healthcare-Associated Infections Data Presentation and Reporting Standards
A workgroup was formed in the fall of 2013 and it meets regularly via conference call. The workgroup produced the first draft of a toolkit which was presented at the 2014 conference with feedback currently being integrated into the toolkit. It is anticipated that the toolkit will be completed by winter 2015. Read more about this position statement and the current timeline here.

Virginia Dick, PhD is Deputy Epidemiology Program Director and Chief Program Evaluator at the CSTE national office.
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Steady She Goes: Epi Mostly Flat-Funded in “CRomnibus”

Posted By Emily J. Holubowich , Wednesday, December 31, 2014
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Emily Holubowich, Senior Vice President at CRD Associates, is CSTE’s Washington representative and leads our advocacy efforts in the nation’s capital.

On December 16, President Obama signed the bipartisan Consolidated and Further Continuing Appropriations Act, 2015 or “CRomnibus”—part continuing resolution (CR), part omnibus legislation. The massive spending bill includes a CR through February 27, 2015 for the Department of Homeland Security and 11 separate spending bills for the remaining months of the fiscal year (FY), including the Departments of Labor, Health and Human Services, Education and Related Agencies Appropriations Act (Labor-HHS).

This typically controversial Labor-HHS bill, which includes spending for the Centers for Disease Control and Prevention (CDC), holds funding essentially flat for most public health activities providing only a slight increase for CDC overall. Specifically, the legislation provides the agency $6.26 billion in FY 2015, which includes $6.024 billion in base discretionary funding, $887 million in transfers from mandatory Prevention and Public Health Fund (PPHF)—a new high—and $15 million in Public Health and Social Services Emergency Fund (PHSSEF) unobligated balances from pandemic influenza supplemental appropriations.

The agency also received an additional $1.77 billion in one-time, emergency supplemental funding to support the nation’s Ebola response. CSTE is expected to receive funding to send medical epidemiologists into surrounding, unaffected West African countries as part of the Ebola containment strategy.

Even with the slight increase for CDC, most core epidemiology programs were held flat—about the best anyone can hope for in this austere fiscal environment—while some surveillance activities saw substantial increases. For example, the CRomnibus provides the National Center for Emerging and Zoonotic Infectious Diseases a significant, 20 percent increase ($66 million), but still less than the administration’s requested 31 percent increase. This increase will “trickle down” to many of the programs epidemiologists xrely upon to do our work.

Provided below is a summary of the final funding levels for some of CSTE’s key advocacy priorities:
  • Epidemiology and Laboratory Capacity Grants. The ELC “program”—a grant mechanism used by CDC to support core infectious disease surveillance capacity at state and local health departments—is once again awarded $40 million from the Prevention and Public Health Fund (PPHF), consistent with FY 2012, FY 2013, and FY 2014. Total funding for ELC grants will be determined based on emerging needs throughout the year.

    Given that the Prevention Fund was cut by $73 million due to sequestration (the Prevention Fund and other mandatory funding streams are not provided any sequestration relief), we are very pleased and relieved to see this funding re-allocated at current levels, especially as other CSTE priorities that had previously received PPHF did not receive allocations through this mechanism in FY 2014 or FY 2015.

  • Advanced Molecular Detection. The CRomnibus provides $30 million for the “AMD” initiative, consistent with FY 2014 and the administration’s FY 2015 request. This funding will be used both to improve CDC’s capability and to initiate state projects that will improve the application of genome sequencing to public health issues of concern.

    For the first time, the CRomnibus includes some of CSTE’s recommended report language on the importance of public health surveillance:

    Responding to Emerging Threats.—The agreement continues to support the Epidemiology and Laboratory Capacity and Advanced Molecular Detection Programs to strengthen epidemiologic and laboratory capacity by providing critical resources to address 21st Century public health challenges.”

  • Food Safety. The CRomnibus provides nearly $48 million for foodborne disease surveillance, an increase of 19 percent over FY 2014 but less than the administration’s request of $52 million. This includes $8 million to apply advanced DNA technology to improve and modernize diagnostic capabilities; and enhance surveillance, detection, and prevention efforts at the state and local level.

  • Epidemiology Fellows. The “Public Health Workforce” program—through which the CSTE/CDC Applied Epidemiology Fellowship Program receives funding—is slated to receive $52.2 million, a 14 percent increase over FY 2014 but still less than the administration’s request. Once again, this program is not provided any PPHF dollars—compared to $25 million in FY 2012 and $15 million in FY 2013. That means that Public Health Workforce funding remains below the high watermark of years past.

  • Ebola Containment Strategy. CSTE is expected to receive funding to send up to 24 epidemiologists to unaffected countries in West Africa within the next 6 months.
Surprisingly, the CRomnibus does not include any funding to support the nation’s response to the antibiotic resistance (AR) epidemic, despite the administration’s request for $30 million. As you know, in 2013, CDC released a comprehensive report, Antibiotic Resistance Threats in the United States about this most serious of public health threats. Earlier this year the President’s Council of Advisors on Science and Technology (PCAST) issued a report and recommendations on combatting AR, and President Obama himself issued an Executive Order to implement some of these recommendations. The administration had hoped this new funding would support implementation of the report’s recommendations, including expansion of the AR detection and response program and full integration of enhanced surveillance capacity at the local, state, and national levels. Despite the lack of new funding, our understanding is the administration will continue to move forward in its plans to combat AR.
For more information about funding levels for your specific priorities, please click here for a copy of the legislation and the explanatory statement or “report language” (health is in Division G) that includes more specificity about the funding levels.
For a copy of CSTE’s funding request letter co-signed by the Association of Public Health Laboratories, click here.
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The Inside Scoop on Ebola Post-Arrival Active Monitoring: A State Perspective

Posted By Laurie Forlano, DO, MPH, Friday, December 19, 2014

Dulles International Airport in Loudoun County, Virginia just outside Washington, DC saw nearly 7 million international passengers in 2013. As one of the most highly trafficked international travel hubs in the country, Dulles became one of five major airports in October adopting new screening and monitoring procedures for Ebola Virus Disease. Practically overnight, the Virginia Department of Health had to originate new procedures and practices based on Centers for Disease Control and Prevention (CDC) guidance. In Virginia, as I’m sure is true for other states, it was important that we adapted CDC guidance to our own jurisdiction. This created a surge of new work for us. In Virginia, we are fortunate to have a unified health department—that is, our local health departments (with a few exceptions) are part of the state system. This well established, collaborative model continues to be a critical part of our planning and response.

To stand up the airport screening and post-arrival monitoring program in Virginia, a central monitoring team was developed at the state level to support the implementation of the protocols at the local level. The priority tasks related to the airport program included developing a comprehensive Virginia-specific monitoring protocol on how to handle arriving travelers, delineated by risk level. The central or “State” team in Richmond, Virginia developed protocols, forms, interview scripts, educational materials, letters, and the data management tool. In parallel, the local health department teams worked to quickly establish staffing schedules and local procedures for conducting the monitoring visits and phone calls. Local teams also worked quickly to identify local hospital partners and engage community partners who would be needed to support the planning and response, such as county government officials, local Emergency Medical Services (EMS) systems, and neighboring jurisdictions, such as Maryland and Washington, DC.

Since October 27, Virginia has handled, in one way or another, over 200 travelers who have named Virginia as their final destination. The central office team receives daily line lists via Epi-X. The line lists are divided among the respective local health departments, who then initiate daily monitoring. Local health officials communicate the 21-day protocol to the travelers, and issue an agreement letter that details the expectations of the monitoring period, and what to do if the individual becomes ill. The most important part of this program is that local staff develop relationships with these people so that communicating early signs and symptoms is efficient and easy. The data exchange between local and state health department happens weekly, in addition to any consultations during the week.

Per our local health department staff, we’ve found that travelers in general really want to be responsible, which facilitates our monitoring program and makes it a lot easier. Sometimes, we’ve even had people overseas contact us before arriving in the United States. Thankfully, the vast majority of our travelers have been in the low-risk but not zero-risk category. The number of travelers in the Virginia post-arrival monitoring program changes daily, as travelers sometimes transfer to and from other states, and there is frequent cross-border travel as many travelers live or stay in the Maryland or Washington, DC metro areas. We’ve had the opportunity to continue to work closely with Maryland and Washington, DC health departments, and it has been a powerful partnership that has helped facilitate learning for all of us along the way. Along with the monitoring program, like all other health departments across the country, we field calls for physicians who suspect Ebola among patients. Though the frequency of these calls seems to be lessening, they are complex and time-intensive consultations. We work together as a team to ensure prompt answers are given to our clinical partners in Virginia.

While obvious to most, I do believe it’s important to acknowledge that state and local health departments are charged with a host of daily tasks for other communicable diseases and reportable conditions, so there is always concern when some of our local health districts are stretched more than others. Each health district in Virginia has a dedicated epidemiologist, so Virginia is fortunate to have a strong base capacity for such a complex undertaking. With that said, some of our local health districts have been impacted more than others by the airport program. If one of the more impacted districts also simultaneously experienced a significant disease outbreak investigation, for example, our capacity to respond would indeed be stretched thin. We have thought about this and are planning to explore some creative solutions for shifting of duties, in absence of additional funding supporting the Ebola response.

Data management requires constant attention, and staff have rotating schedules to respond 24 hours a day, including weekends and holidays. The management of those numbers is what epidemiologists do best, but here in Virginia we did need to establish a dedicated monitoring team to maintain operations and send weekly reports to CDC. I think what is hardest to all of us to process is we aren’t sure for how long this will go on. As public health always does, we will rise to the task, but if I’m being completely honest, I do worry about how we will all sustain this level of intensity and volume of work.

There aren’t enough words to express how proud I am of the epidemiology teams in both our state and local offices and what they have accomplished throughout the profound changes that have happened over the last few months. Equally, it has been nothing short of a privilege to plan for this response in collaboration with our clinical partners in both domestic and international settings. Their service in the patient care realm is obviously so important, and I think the public health and epidemiology role has been complimentary to that clinical care function. Virginia’s success through the present in balancing Ebola response with other routine responsibilities stems from our teamwork, open communications, and quality staff. Engaging with the public and individual travelers, we use consistent messages and take extra care to address fears. We hope the new tools we’ve created can be applied usefully in other states. Please visit our state health department website to access resources on Ebola management. Of course, there are many additional tools available in our internal system, which we are happy to share with our peers at any time.

We’d like to thank the following additional team members: Dr. Raja’a Satouri, Deputy Director for Medical Services and Incident Commander; Katie Brewer, Assistant Director and Operations Chief; Shawn Kiernan, District Epidemiologist and technical expert; Dr. Thomas Yun, Public Health Physician - Clinical Consultation; Jessica Ong, Public Health Nurse; Lauren Earyes, Public Health Nurse; Meg Marcus, Public Health Nurse; DeAnn Ryberg, Public Health Nurse; Kris Murphy, Public Health Nurse; and Josie Gutierrez, Public Health Nurse.
Laurie Forlano, DO, MPH is the State Epidemiologist in Virginia. For more information, CSTE members can visit the CSTE page on Ebola Virus Disease.
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