Join CSTE   |   Career Center   |   Print Page   |   Contact Us   |   Report Abuse   |   Sign In
CSTE Features
Blog Home All Blogs

The rocky road to complete reportable infectious disease system integration.

Posted By Sara Ramey, Wednesday, February 26, 2014
Updated: Tuesday, February 25, 2014
Untitled Document
Since the introduction of electronic disease surveillance systems, states and localities have worked to migrate disparate and siloed legacy surveillance systems into more integrated surveillance platforms. The goals for surveillance system integration are to utilize national standards, reduce redundancy, streamline reporting, understand disease and risk factor interactions, and increase data sharing. However, the costs, benefits and obstacles of achieving complete disease surveillance system integration are poorly understood.

CDC’s Program Collaboration and Services Integration (PCSI) program recommends integration and data harmonization of disease surveillance that currently exists both in CDC-supported legacy systems (i.e., eHARS, STD*MIS) and in state-based electronic disease surveillance systems (NEDSS) (1). While the 2010 CSTE assessment of states’ NEDSS capacity identified 34 (71%) states with some degree of integration, an increase from 23 states in 2007 (2), there are few states and localities to have fully integrated all legacy reportable infectious disease surveillance systems.
In 2013, the North Carolina completed customization of modules for reporting, case management, and entry of contact investigation data of HIV and syphilis cases. Legacy systems, eHARS and STD*MIS respectively, were converted into modules within a customized commercial-off-the-shelf NEDSS product which already included modules all reportable communicable diseases including vaccine preventable disease, sexually transmitted diseases, and tuberculosis (TB).
The conversion process began in 2010 following implementation of TB and general communicable disease modules in 2006 and 2008, respectively. The integration required conversion and harmonization of hundred of case report data fields and laboratory results fields from the legacy systems. The mapping of data fields from eHARS to North Carolina’s NEDSS additionally required a corresponding extract mapping back into eHARS in order to report data to CDC. New releases of eHARS will necessitate continual validation of these extract maps until CDC is able to receive HL7 message feeds into NNDSS. The two-year process involved more than approximately 6,500 person-hours. Following integration, de-duplication of more than 20,000 case records was required prior to system roll-out to local health departments.
A completely integrated NEDSS platform will provide the opportunity to monitor disease overlap geographically within population subgroups, and to evaluate the effectiveness of the delivery of integrated public health program services. While an integrated system provides new surveillance opportunities, the process was long, complex, and expensive; and many challenges still remain. State and local health departments considering complete reportable infectious disease surveillance system integration should weigh the informatics challenges and personnel expenditures with the opportunities to enhance program integration.
Megan Davies, MD
State Epidemiologist
North Carolina Division of Public Health
 

References:

  1. CDC. Program Collaboration and Service Integration: Enhancing the Prevention and Control of HIV/AIDS, Viral Hepatitis, Sexually Transmitted Diseases, and Tuberculosis in the United States. Atlanta (GA): U.S. Department of Health and Human Services, Centers for Disease Control and Prevention; 2009.
  2. CDC. State Electronic Disease Surveillance Systems – United States, 2007 and 2010. MMWR. 2011; 60(41): 1421-1423.

Tags:  infectious disease  member spotlight  surveillance 

Share |
PermalinkComments (1)
 

Navigating Cancer Clusters

Posted By Sara Ramey, Wednesday, February 19, 2014
Updated: Wednesday, February 19, 2014
Untitled Document
In most states, public health professionals struggle with response to citizen calls reporting a suspected cancer cluster. Calls of this nature are not uncommon and often involve high levels of anxiety, mistrust of the public health agency and a sense of urgency on the part of the citizen. When environmental contaminant concerns are thrown into the mix the response becomes even more complex and media attention and lawsuits often follow.

The recently published MMWR “Investigating Suspected Cancer Clusters and Responding to Community Concerns” (MMWR1993;62(No.RR-8) presents new guidelines developed by a joint CDC and CSTE workgroup tasked with updating the 1990 MMWR guidelines for investigating clustering of health events. Things have changed in public health since 1990: all states have a cancer registry and access to record level data on cancer patients, statistical tools have expanded including geospatial analysis, and geocoding of data has become a norm. These new tools are discussed in the guidelines.
Public expectations have changed since 1990 as well; the internet is accessible to most and search of public websites and blogs are one new way citizens communicate and gather information during a cluster inquiry. Communication with the public has always been a key component of these investigations and this aspect was highlighted in the new guidelines. Emphasizing the importance of community communication, the guidelines recommend earlier partnership with all community partners in these situations. In addition, the CDC also collaborated with the National Public Health Information Coalition (NPHIC) to develop a document “Cancer Clusters” A Toolkit for Communicators” Both of these documents are on the CSTE website for membership use. Both documents recognize that ineffective communication can rapidly spin these situations out of control and put the public health agency in an adversarial light.
We only need to look toward recent news articles to understand the national picture on cancer clusters. In December 2013, ATSDR found that mothers at Camp Lejeune Marine Base in North Carolina with first trimester exposures to PCE, vinyl chloride, or DCE were more likely to have a child with leukemia or non-Hodgkin lymphoma compared with unexposed mothers although higher exposures did not increase the likelihood that the child would have these cancers. In May 2013, an 11-year study of the incidence of brain cancer associated with the Pratt & Whitney jet engine plant in Connecticut ended with university researchers saying they found no statistically significant elevations in the rate of cancer among workers related to exposures to contaminants. In January 2014, the Minnesota Department of Health found normal cancer rates for the Como neighborhood near the General Mills plant in Minneapolis despite concerns about elevated levels of solvent vapors detected in the soil. And in Clyde Ohio, the Ohio Department of Health has been investigating contamination concerns and cancer rates in the areas surrounding a Whirlpool facility for a number of years without resolution. My home state, Florida, has had some high profile investigations in recent years as well.
Please take some time to read these documents and share the links . Having a state specific protocol and guidelines in place in your own state before an event of this nature happens may be the key to successful resolution of cancer cluster calls and inquiries.
Sharon Watkins, PhD
Florida Department of Health

Tags:  cancer  chronic disease  member spotlight  surveillance 

Share |
PermalinkComments (0)
 

Charting an Epidemic, Confronting an Epidemic

Posted By Sara Ramey, Wednesday, February 12, 2014
Updated: Wednesday, February 12, 2014
Untitled Document
The governor of Vermont got a lot of attention when he dedicated his entire State of the State address to one topic: heroin. That attention was highly warranted because opioid abuse, prescription and non-prescription alike, is a major epidemic in this country, and epidemiologists are charting this epidemic and its consequences in many ways.

Prescription monitoring programs seek patterns consistent with “doctor shopping”, forgery and other diversion. Substance abuse programs track drug seizures and treatment admissions to follow patterns of abuse. Epidemiology programs track newly diagnosed cases of hepatitis C. Overdoses and overdose deaths are tracked in emergency departments and through vital records. All of these important surveillance systems track the underlying problem (addiction and substance abuse) and the consequences (overdose, infection, interaction with the criminal justice system). But, beyond counting, the epidemiologist must also be an advocate for using the data for action.
In Massachusetts, between 1990 and 2010, drug overdose deaths tripled, exceeding motor vehicle related death rate in 2000, and doubling it by 2010. These observations led to resources for the technical and programmatic enhancement of the prescription monitoring program and, in 2007, the initiation of a naloxone (Narcan®) program to train first responders, public safety officials and family members to administer the opiate receptor antagonist naloxone by nasal spray to potential overdoses. The program has resulted in the reversal of over 2,000 overdoses, so far, and an instance where drug users followed a police car to alert them so that they could reverse an overdoses. The philosophy is that one has to survive to kick the habit. Driven by the data, federal and state funding has also gone to community prevention programs and multi-community Opioid Abuse Prevention Collaboratives.
The Massachusetts Department of Public Health has observed increasing numbers of reported cases of hepatitis C virus infection in people between the ages of 15 and 25; the rate almost doubling between 2002 and 2012, while newly diagnosed cases went down in other age groups. These 15-25 year-olds almost certainly acquired their infection well within the previous 10 years. While much attention has been appropriately directed toward the hepatitis C epidemic in the “baby boomer” generation, hepatitis C in adolescents and young adults represents a new epidemic wave of hepatitis C. All indications are that these infections were acquired through injection drug use. Interviews are difficult to obtain, but the most common story is prescription opioid use leading to injection of prescription opioids and heroin. Heroin is cheaper than prescription drugs and all too available. Because of the difficulty in getting enough data from interviews to explore the networks of transmission of hepatitis C among adolescents and young adults, we are exploring sequencing of hepatitis C viruses that come to our public health laboratory to try to use the virus RNA sequences to construct networks. There hasn’t been much HIV co-infection yet, but that may be just a matter of time before that virus is introduced into these networks.
While the hepatitis C data are overwhelming, both in their implications for the future and the sheer number of new reports (in Massachusetts, now one to two thousand positive laboratory reports for hepatitis C in the age group each year), an approach to this massive epidemic is not easily identified. Of course, there should be every and all attempts to prevent and treat addiction. But what can be done in the meantime? As epidemiologists and public health professionals, we cannot just watch this tsunami of hepatitis C cases without actively encouraging the use of data to inform interventions, be they harm reduction approaches directed at safer injection or using observational data and network analysis to identify means of getting prevention and treatment messages to those at risk and infected.
Alfred DeMaria, MD
State Epidemiologist
Massachusetts Department of Health

Tags:  infectious disease  member spotlight  substance abuse  surveillance 

Share |
PermalinkComments (0)
 

Raw Milk Strikes Again

Posted By Sara Ramey, Wednesday, February 5, 2014
Updated: Wednesday, February 5, 2014

Tennessee recently experienced an outbreak of E. coli O157 associated with raw (unpasteurized) milk, in which 9 children became ill, 5 of whom were hospitalized, and 3 of whom developed hemolytic uremic syndrome (HUS). While the sale of unpasteurized milk is unlawful in Tennessee, it seems virtually impossible to entirely stop people intent on obtaining it. In this case, the affected families participated in a "cow share" program, in which they purchased a "share" of a cow (along with 20 or so others) from a farm which then distributes the raw milk from its herd to the "owners". This scheme skirts the issue of milk sales, as the consumers are purportedly drinking milk from their own animals

There is an almost endless list of concerning aspects to this outbreak. As is typically the case in these types of situations, the people who suffered the most harm were children, who are not the ones who made the decision about what they consumed. The implicated farm is not regulated by our Department of Agriculture, as it is not a commercial milk producer, and in the absence of a disease outbreak the Department of Health has no oversight of the facility. As soon as the outbreak was over, the farm reverted to the same situation, with no required testing or other regulatory oversight (though they did ask our department to declare them safe to reopen!).Overwhelming epidemiologic evidence and matching E. coli strains from the cows and farm environment were insufficient to convince many of this farm's consumers that the milk was the source of the outbreak (after all, we did not find it in batches of milk produced many days after the implicated lots were distributed).

Important lessons can be learned in any outbreak investigation. In this case, "social media" was a useful tool, as the farm's customers were active in a Facebook group, through which case finding and education could be done. While many consumers remained distrustful and resentful of government intervention, at least one distraught family of a very ill child subsequently agreed to videotape their story for public education about the risks of raw milk. In public health I think we are all too familiar with the seeming lack of response to presentations of data and scientific evidence, compared to the dramatic effect that a single compelling personal testimonial can have on people. When even one victim of such an event has the courage to share their story, we should do everything we can to help maximize the effect of that message to prevent future similar events.
It's extremely frustrating and sad to see outbreaks like this continue to occur, all over the country, despite widespread efforts to halt them. We will continue to fight to plug the regulatory gaps and try to stay a step ahead of creative attempts to circumvent our intention of protecting the public's health. In the meantime, vigorous investigation and intervention in outbreaks can continue to build our case, and hopefully help educate our communities (including those responsible for the health of vulnerable children).
 
Tim Jones, MD
State Epidemiologist
Tennessee Department of Health

Tags:  food safety  infectious disease  member spotlight  outbreak 

Share |
PermalinkComments (0)
 
Page 17 of 17
 |<   <<   <  12  |  13  |  14  |  15  |  16  |  17
Association Management Software Powered by YourMembership  ::  Legal