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CSTE Update on Congressional COVID-19 Relief Package

Posted By Meghan Riley, Vice President, CRD Associates, Wednesday, October 14, 2020
Updated: Wednesday, October 14, 2020

CSTE update from Washington, DC.

After coming together to enact several rounds of COVID-19 relief legislation earlier this year, Congress has failed since May to negotiate a fourth round of assistance for states, businesses, and individuals impacted by the pandemic. The House of Representatives and Senate have tried to advance differing levels of relief, but congressional leadership and the Trump administration have not found enough common ground to move legislation over the finish line. As the election rapidly approaches there is a renewed effort to pass relief legislation. However, negotiators have yet to come to an agreement on the size and scope of a legislative package and Senate Majority Leader Mitch McConnell has signaled unwillingness to pass legislation in the $1.6 trillion to $2.2 trillion range that Speaker Pelosi and the Administration are negotiating. Both the House and Senate are currently in recess, but could return to Washington if a vote is on the horizon. While President Trump announced last week that he is ending negotiations until after the election, he has since relented and some talks have have continued. Both the House and Senate are currently in recess, but could return to Washington if a vote is on the horizon.

On May 15 the House passed the Health and Economic Recovery Omnibus Emergency Solutions (HEROES) Act, which would provide upwards of $3 trillion in funding, including:

  • Nearly $1 trillion in relief to state, local, and tribal governments;
  • $75 billion for testing, contact tracing and surveillance;
  • $100 billion in relief for hospitals and health care providers; 
  • $3.5 billion for vaccine and therapeutic development;
  • Direct assistance to individuals and extended unemployment benefits; 
  • Support for small businesses; and
  • $130 billion in funding for public health data infrastructure modernization.

The Senate did not take up the HEROES Act. Instead, in July, Senate leadership attempted to advance the Health, Economic Assistance, Liability protection and Schools (HEALS) Act, a package of eight bills to provide $1 trillion in relief, including:

  • $16 billion for testing, contact tracing, and surveillance;
  • $20 billion for vaccine, therapeutic, and diagnostic development;
  • $6 billion for vaccine distribution planning;
  • $25 billion in relief for hospitals and health care providers;
  • Direct assistance to individuals and a modified extension of unemployment benefits; and 
  • Support for small businesses.

The Senate failed to secure enough votes in the Senate to move the HEALS proposal. Negotiations between House Speaker Nancy Pelosi and Administration officials continued on and off throughout the summer. While Speaker Pelosi offered to scale down from the House’s position of $3 trillion, the Administration and Senate Republicans have been unwilling to meet halfway to advance a $2 trillion package. In September, the Senate again failed to pass a $500 billion COVID-19 relief bill that was similar in scope to the HEALS package.

Fiscal Year 2021 Appropriations
Congress did succeed in passing legislation to fund the federal government and avert a shutdown prior to the end of the fiscal year on September 30. The continuing resolution (CR) extends current funding for most government agencies and programs and contains very little funding associated with the COVID-19 pandemic. The House passed the CR on September 22. The Senate followed on September 30 and the President signed the legislation into law. 

Data Modernization 
Enveloped in the COVID-19 relief negotiations is how the federal government will continue to support and fund the public health Data Modernization Initiative (DMI). As of March, Congress had provided a total of $550 million to Centers for Disease Control and Prevention (CDC) for DMI. Those funds are just now beginning to flow to states in support of critical system upgrades. Compared to the need, this funding is just a drop in the bucket. CSTE continues to advocate in Congress for another injection of foundational funding as well as for sustained investment. As noted, $130 billion for this purpose was provided in the House-passed HEROES Act. 

The COVID-19 pandemic has enlightened Congress about the long overdue need to improve public health data infrastructure, but the need is greater than the pandemic alone. On September 23 Executive Director of CSTE, Janet Hamilton testified at a hearing entitled Data for Decision-Making: Responsible Management of Data During COVID-19 and Beyond before the House Committee on Science, Space, and Technology Subcommittee on Investigations and Oversight. Janet’s testimony highlighted the importance of robust, interoperable public health data systems in responding to not only the COVID-19 pandemic, but to any future public health crisis. You can view the hearing on the committee’s website. 

CSTE is working overtime to ensure not only that Congress continue to invest in DMI, but also that CDC prioritize furthering DMI. Over the past several months several Members of Congress have contacted CSTE for input on new legislation related to data, surveillance, contact tracing and other issues tied to the COVID-19 pandemic. CSTE is working closely with Congress and remains committed to ensuring that DMI at the CDC focuses on building a data superhighway that lives beyond COVID-19 and positions our public health professionals to respond swiftly and effectively to all emerging threats.  

Meghan Riley is vice president at Cavarocchi Ruscio Dennis Associates, LLC, which represents CSTE’s interests on Capitol Hill in Washington, DC.


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USVI Implements Suicide Prevention Program in Partnership with CSTE and CDC

Posted By Irving Julien, USVI Suicide Prevention Program Coordinator, Thursday, October 8, 2020
Updated: Tuesday, October 6, 2020

Sharifa Charles, Professional Development Specialist at MHA’s Center for Behavioral Health, leads participants during a gatekeeper training in St. Thomas, November 2019.

In Fall 2019, the U.S. Virgin Islands Department of Health (VIDOH) developed the USVI Suicide Prevention Program under the leadership of Commissioner Justa Encarnacion and in collaboration with the Centers for Disease Control and Prevention (CDC) and the Council of State and Territorial Epidemiologists (CSTE). Irving Julien was hired to serve in the role of Suicide Prevention Program Coordinator. Once fully developed, the program included two in-person gatekeeper trainings in November 2019, outreach activities throughout the winter and spring, and two virtual Suicide Prevention “Train the Trainer” sessions in June 2020.   

VIDOH was pleased to have Sharifa J. Charles, a Native Virgin Islander, and Professional Development Specialist currently with the Center for School Behavioral Health, Mental Health America of Greater Houston as the trainer for the four training sessions. Initially, the Train the Trainer sessions were planned to take place in person. However, due to the COVID-19 pandemic, the curriculum was adapted to a virtual format. This was the first time that a training of this magnitude was conducted virtually in the territory. A total of 85 individuals were trained with each training session lasting four hours. Attendees participated in pre- and post-training test assessments and received certification of completion after the training. Ninety-seven percent of participants responding to the post-test agreed or strongly agreed that the training content would help them be more effective in their jobs. 


Attendees participate in a gatekeeper training in St. Thomas, November 2019 

First responders who participated in the November sessions were trained on tactical skills to be used to train others at their respective government agencies, as well as members of the community. Educational trainings focused on recognizing the warning signs of a suicide crisis, the steps necessary to help intervene and prevent suicide, and techniques to help the healing process after a suicide. Attendees learned from mental health professionals, crisis workers, volunteers, and suicide survivors using a culturally sensitive approach when speaking about suicide, suicide assessments, intervention techniques, and prevention practices. 


The diagram in this slide illustrates the phases of community response and outcomes to disaster events, such as Hurricanes Irma and Maria in 2017 

The latest epidemiological data from CDC and VIDOH shows an increase in suicides in the territory and the nation, especially considering the COVID-19 pandemic. Vernita Bicette, Director of Behavioral Health Alcoholism and Drug Dependency Services at the Department of Health stated, “We are taking a proactive approach in the territory to this national crisis by implementing preventative measures, which include this suicide prevention training.” VIDOH and community partners are dedicated to building program sustainability.  

The territory will continue outreach efforts focused on promoting mental health and decreasing the number of suicide attempts and deaths. The most recent of these efforts is the launch of a radio commercial targeting young adults who may be experiencing suicidal thoughts.

Irving Julien was the 2019-2020 USVI Suicide Prevention Program Coordinator. The Virgin Islands Department of Health (VIDOH) is pleased to continue its suicide prevention initiatives with future educational trainings and outreach activities. For more information, please contact the VIDOH Suicide Prevention Program at 340-718-1311. 


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CSTE Mentorship Program offers Professional Growth Opportunities for both Mentors, Mentees

Posted By Jessica Arrazola, DrPH, MPH, MCHES® and Symone Richardson, CSTE , Wednesday, September 23, 2020
Updated: Wednesday, September 30, 2020

The Mentor Application for the 2020-2021 Early Career Professional Mentorship Program is now open.

The Council of State and Territorial Epidemiologists (CSTE) continues to offer opportunities for growth through its workforce development and professional training projects. For the last four years, CSTE has facilitated the Early Career Professional Mentorship Program, providing both seasoned and early career applied epidemiologists an opportunity to build relationships and foster shared learning. By connecting mentors and mentees to share experiences and advice, public health practice will improve by preparing future public health professionals with necessary skills and knowledge. The goal of the program is to allow mentees to connect with mentors that promote the exploration of State, Tribal, Local, and Territorial (STLT) career opportunities. Participants engage in activities such as professional and educational webinars, goal exercises, networking, and journal clubs.  

The Mentorship Program facilitates discussion about careers in applied epidemiology and the growth of professional skills. The program provides a forum for epidemiologists with diverse educational and experiential backgrounds to share about their personal experiences. Mentors offer insight to guide mentees in identifying their strengths and professional goals. While the world is focused on the response to COVID-19, it is important to continue to invest in our workforce. The Mentorship Program offers an opportunity for mentors and mentees to reflect and identify areas for their own personal growth.

In the current environment, when public health professionals are working harder than ever, the Mentorship Program offers the opportunity to pause and reflect on where our careers are today and the direction they are going in the future. Through the program, CSTE provides a community of practice with like-minded, interested colleagues, and lifelong learners across the country. The Mentorship Program can help you foster these relationships early into your career.

Here is what some participants from the 2019-2020 program had to say about their experience: 

“I have participated in many other mentoring programs over the years. Some have worked well, many have not. CSTE’s did work.” - Mentor 

“My new mentor has been an amazing advocate and sounding board as I work through doctoral studies and balance work, school, and the family commitments of a new parent.” - Mentee  

“I think having this program is an excellent way to educate new epidemiologists. I was able to still communicate with my mentees even throughout the pandemic to see what they were doing and how they were coping in their respective states.” - Mentor 

Applications for the 2020-2021 Early Career Professionals Program are now open. Consider serving as a mentor.

Mentors are required to have at least five years of work experience and can be work at STLT, federal, academic or nonprofit organizations. No previous mentorship experience is necessary, which presents mid-level epidemiologists a great opportunity to mentor the next generation of applied epidemiologists. Watch CSTE’s recorded Prospective Mentor Webinar to learn more about the Mentor’s role in our program. 

Early career professionals can participate as mentees. Eligible mentees should be current students or graduates within the last five years with an interest in applied epidemiology. Start your application today to participate in the 2020-2021 Mentorship Program. All applications are due by September 30, 2020. Please note that all applicants may not be accepted; space is limited based on the number of mentors that apply.

For specific questions about the Early Career Professionals Mentorship Program, please email Jessica Arrazola (jarrazola@cste.org). 


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Notes from CSTE’s Vaping-Associated Pulmonary Injury (VAPI) Outbreak Response

Posted By Ruth Lynfield, MD and Landen, MD, Friday, July 17, 2020
Updated: Friday, July 17, 2020

Notes from CSTE’s Vaping-Associated Pulmonary Injury (VAPI) Outbreak Response. 

In July 2019, Illinois and Wisconsin were the first states to call attention to a then-unidentified severe lung illness among previously healthy individuals reporting use of vapes and e-cigarettes. Shortly thereafter, Minnesota also began reporting a similar outbreak, and Utah, California, and Massachusetts quickly followed suit. On August 21, 2019, CSTE activated its Incident Command System (ICS) to support state and local epidemiologists responding to the multi-state outbreak of e-cigarette use, or vaping, associated lung injury (EVALI). In conjunction with the Centers for Disease Control and Prevention (CDC), CSTE coordinated the Vaping-Associated Pulmonary Illness (VAPI) Task Force consisting of state and local epidemiologists. 


The CSTE VAPI Epidemiology Task Force operated between August 2019 and February 2020 and was instrumental in assisting CDC to develop case definitions and data collection tools. The VAPI Task Force quickly grew to over 100 members, and CSTE established a Leadership Group comprised of members in California, Illinois, Minnesota, New Mexico, North Carolina, Utah, and Wisconsin to guide the overall Task Force. Ruth Lynfield and Mike Landen, State Epidemiologists in Minnesota and New Mexico chaired the VAPI Task Force. The Task Force and Leadership Group met weekly with CDC ICS leadership to discuss data and surveillance issues, typically centered on providing feedback on CDC materials. The VAPI Task Force input on the CDC case reporting and interview forms, as well as the EVALI outbreak case definition and DCIPHER platform for reporting cases highlighted the critical impact that CSTE members can have during a national outbreak response. 


Several smaller groups emerged, led by CSTE members on various epidemiology studies of interest: the CDC National YouGov survey, a multi-state EVALI severity analysis, and an analysis of cases in states with legalized recreational THC. CSTE collaborated with national partners at the Association of Public Health Labs (APHL) and the Food and Drug Administration (FDA) regularly as we navigated how to best support our members as laboratory data began to demonstrate that vitamin E acetate, an additive in some THC-containing vaping products, is strongly linked to the EVALI outbreak. CSTE members discussed strategies for communicating warnings to the public against the use of THC products, particularly those sold in illegal and informal markets, such as through family, friends, and in-person or online dealers. 


In January 2020, CSTE developed brief EVALI questionnaire to all 50 states, the District of Columbia, and the affected territories of Puerto Rico and the U.S. Virgin Islands to learn more about ongoing challenges and response capacity. The results of this questionnaire informed CDC efforts to stand down their response in early February, shortly followed by CSTE’s deactivation and incorporation into normal daily operations under the Substance Use and Injury programsCDC reports that as of February 18, 2020 (the last day for DCIHPER reporting), a total of 2,807 hospitalized EVALI cases or deaths have been reported. While CSTE has several major takeaways from our EVALI response, there was little opportunity to implement changes or host an in-person After Action Review (AAR) due to the rapid escalation of COVID-19 across the U.S. As CSTE navigates the current pandemic, we will not forget the lessons learned from EVALI and what it means to respond to a non-infectious disease outbreak. 

Ruth Lynfield, MD, is Minnesota’s State Epidemiologist, and Michael Landen, MD, is now retired as State Epidemiologist of New Mexico. Dr. Lynfield and Dr. Landen served as CSTE’s VAPI Task Force chairs during the outbreak response. 


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CIFOR Announces Upcoming Release of Third Edition Guidelines

Posted By India Bowman, MPH, Friday, July 10, 2020
Updated: Friday, July 10, 2020

CIFOR Announces Upcoming Release of 3rd Edition Guidelines.

The Council to Improve Foodborne Outbreak Response (CIFOR) has released the third edition of its internationally recognized CIFOR Guidelines for Foodborne Outbreak Response. The landmark edition of these Guidelines was published in 2009 and helped to set the tone for foodborne outbreak investigations across the U.S. Since development, CIFOR Guidelines have been widely accepted by public health officials and practitioners, which even resulted in its translation for use by the Chinese CDC. Because of increasing globalization of our food supply, updates to these Guidelines would follow in 2014 and now in 2020 for the third edition.


The third edition CIFOR Guidelines began in 2018 with the onboarding of lead author, Dr. Craig Hedberg of the University of Minnesota. With Dr. Hedberg’s direction, the third edition took a transformative shape distinguishing itself from the previous versions in several ways. Feedback from end users across the nation indicated a need to streamline the Guidelines to better illustrate how the fields of epidemiology, laboratory science, and environmental health work together in outbreak investigations. This streamlining resulted in the inclusion of detailed graphics to illustrate new or complex processes and points and the elimination of redundancy between chapters. Additionally, the evolution of advancing technology and methodology has had a significant impact on how surveillance is conducted; thus arose a need for the incorporation of updated sub-cluster investigation methodology, complaint systems information, product traceback methodology, and laboratory practices such as whole genome sequencing (WGS) and culture-independent diagnostic tests. An important distinction was also made in this edition between environmental assessments and investigations. 


The Guidelines are now organized into two main blocks of chapters: The first focuses on the foundational aspects of an investigative approach. These chapters (1-3) highlight the evolving challenges of foodborne outbreak response and outlines the tools investigative teams need to plan for investigations. The remaining five chapters (4-8) describe operational aspects of conducting an investigation, such as performing sub-cluster and traceback investigations, and then how to use after-action reviews and performance metrics procured from many foodborne illness programs to assess and improve response activities in the future. These chapters also contain communications sections that will foster more effective and timely communications between team members and various stakeholders. 


Major changes from the previous guidelines to current guidelines include:


  • The implementation of WGS, advanced molecular detection (AMD) and culture-independent diagnostic tests. 

  • The integration of consumer complaint systems with pathogen-specific surveillance. 

  • The importance of sub-cluster investigations and epidemiologic tracebacks. 

  • The importance of environmental assessments. 

  • The importance of after action reviews (AAR). 

  • More coordinated inclusion of communications sections. 

  • Elimination of CIFOR metrics and better referencing of existing program metrics.


With these new updates and changes, foodborne outbreak investigators will have updated guidelines on how to incorporate new investigative tools into their new or existing practices. Written during the period of transition from pulsed-field gel electrophoresis to WGS, these Guidelines are not intended to be a prescriptive guidance for one technological method over another, but rather are written in a way that makes allowances for incorporation of new technologies as they become available.  


It was the intention of the project team to describe a standard in investigative practice that most jurisdictions can use, regardless of if they are beginning to build their investigative teams or looking to improve their current practices. The complementary CIFOR Toolkit is designed to assist jurisdictions in putting these Guidelines into practice. The third edition of the Toolkit will be available soon at www.cifor.us.

India Bowman, MPH, is a CSTE program analyst focused on enteric disease epidemiology and AMD.


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San Mateo County, California Creates Novel Approach to Monitoring Emergency Room Visits Related to Wildfire Smoke Events

Posted By Alesha Thompson, MPH, Friday, May 15, 2020
Updated: Thursday, May 14, 2020

In 2019, wildfires burned an estimated 259,823 acres of land in the state of California. 

The impact of climate change on health is receiving increasing attention at the national level, especially when extreme weather events such as hurricanes and wildfires are affecting communities across the country. The Council of State and Territorial Epidemiologists (CSTE) provides a forum through its Climate, Health, and Equity Subcommittee for epidemiologists who work in the climate and health field at state, tribal, local, and territorial levels. The subcommittee was formed in 2004 to create the State Environmental Health Indicators Collaborative (SEHIC) and has continued to allow members to collaborate and share best practices.
The subcommittee is supported by funds from the CDC Climate and Health Program. In 2018, CSTE was awarded funds for pilot projects to address wildfire events and respiratory health outcomes. San Mateo County Health was one of two sites selected to receive this funding. San Mateo County, which is located in the San Francisco Bay Area, has a very high fire hazard severity zone designation in eight of its cities. Additionally, the San Mateo Medical Center had the highest daily average percentage of emergency room visits for all respiratory health syndromes among the emergency departments participating in the county's BioSense system, during the deadly Camp Fire in Butte County that occurred in 2018.
Karen Pfister is the supervising epidemiologist in the San Mateo County Health’s Office of Epidemiology and Evaluation. In addition to Karen, epidemiologists Edwina Williams, Aracely Tamayo, and Tiffany Tsukuda, and epi intern Morgan Rousch, worked on a project to assess asthma burden in the county’s vulnerable populations. They also used epidemiologic methods to build surveillance capacity for asthma-related emergency room visits following wildfire-smoke events. The team named their project the 2019 Climatic Exposures and Respiratory Health Outcomes Pilot (CERHOP).
The CERHOP team developed a modified vulnerability/risk index and surveillance plan for sensitive populations in the county and developed working relationships with key partners. When creating the modified vulnerability index, they combined data from local, state, and federal surveillance levels into the index. When finished, users will be able to select indicators and decision support layers to visualize the impact of wildfire events. They also used modified ESSENCE syndromic surveillance methods for acute and intermediate respiratory health effects during wildfire events. The team is currently finalizing a public dashboard to share this risk index and syndromic surveillance data. Lastly, they initiated the development of an asthma and respiratory disease registry of San Mateo County Health patients.
San Mateo County plans to finalize the project and share it with the public health community this year. CSTE was also awarded funds to work with the National Syndromic Surveillance Program Community of Practice (NSSP CoP) to develop a wildfire syndromic surveillance guidance document for state and local health jurisdictions to use when planning for and responding to wildfire events.
Projects such as the San Mateo County Climatic Exposures and Respiratory Health Outcomes Pilot allow for continued sharing of lessons learned and best strategies for preparing for wildfire events.


Alesha Thompson, MPH, is a CSTE program analyst focused on Environmental Health, Climate, and Disaster Epidemiology activities.


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Nearly $3 Trillion Provided in Emergency Funding to Respond to COVID-19

Posted By Celia Hagan, MPH, Vice President, CRD Associates, Friday, May 8, 2020
Updated: Friday, May 8, 2020

 There has been a flurry of activity on Capitol Hill over the past month as the U.S. Congress responds to the COVID-19 pandemic by providing emergency supplemental funding. In just over seven weeks, Congress has provided nearly $3 trillion to assist state and local public health efforts, stabilize the economy, provide assistance to small businesses and industries, and increase testing capacity. Notably, $500 million was provided to the Data Modernization Initiative to transition public health data systems to automated, interoperable, electronic systems. Below is a high-level summary of the public health provisions passed in the supplemental bills.

March 5, 2020

Phase 1: The Coronavirus Preparedness and Response Supplemental Appropriations Act, 2020 (H.R. 6074)

Designed to prevent, prepare for, and respond to COVID-19

  • Total funding: $8.3 billion
  • Funding for CDC: $1.9 billion

o   $950 million for state and local response efforts

o   $300 million to replenish the Infectious Disease Rapid Reponses Reserve Fund

  • Other significant provisions:

o   Funds BARDA and NIH to conduct research and develop vaccines, therapeutics, and diagnostics

o   Funds NIH to conduct research on therapies, vaccines, diagnostics, and other health technologies

o   Funds FDA to develop and review vaccines, therapeutics, medical devices and counter measures, and address supply chain issues.

o   Funds the Small Business Administration to provide disaster loans

March 18, 2020

Phase 2: Families First Coronavirus Response Act (H.R. 6201)

Designed to provide immediate relief to individuals out of work due to the pandemic

  • Total funding: $3.5 billion
  •  Other significant provisions:

o   Requires employers to provide emergency sick leave

o   Provides funding to cover COVID-19 testing costs

o   Extends unemployment benefits

March 27, 2020

Phase 3: Coronavirus Aid, Relief, and Economic Security (CARES) Act (H.R. 748)

Designed to provide financial assistance to individuals, small businesses, distressed industries, hospitals, and health care providers

  • Total funding: $2 trillion
  • Funding for CDC: $4.3 billion

o   $1.5 billion for grants and cooperative agreements for state and local responses

o   $500 million for global disease detection

o   $500 million for the Data Modernization Initiative

o   $300 million to replenish the Infectious Disease Rapid Response Reserve Fund

  • Other significant provisions:

o   Establishes the Paycheck Protection Program

o   Establishes the Economic Injury Disaster Loans for small, medium, and large businesses

o   Provides relief for hospitals and health care providers to reimburse COVID-19 related expenses and lost revenue

April 24, 2020

Phase 3.5: Paycheck Protection Program and Health Care Enhancement Act (H.R. 266)

  • Total funding: $484 billion

o   $321.3 billion in additional lending authority for the Paycheck Protection Program, with some funds set aside to support loans issued by smaller lenders

o   $10 billion for additional economic impact disaster loans to small businesses

o   $75 billion for hospitals and health care providers

o   $25 billion for virus testing

§  Funding for CDC: $1 billion for surveillance, epidemiology, contract tracing and other activities to support testing

§  An additional $11 billion in the Public Health and Social Services Emergency Fund will be directed towards states, localities, territories, and American Indian tribes to support COVID-19 responses based on their relative number of cases

  • Other significant provisions:

o   Replenishes the Paycheck Protection Program

o   Provides additional relief for hospitals and health care providers to reimburse COVID-19 related expenses and lost revenue

o   Funds COVID-19 testing activities to detect active infection and to determine previous exposure

Looking ahead, Congress has expressed interest in a Phase 4 supplemental package, but the timing of this is still uncertain. While the House wants to move quickly, the Senate has pushed back on moving too quickly in face of the growing deficit – some Republicans have expressed an interest in allowing more time to pass while we review what resources are needed before investing more. Democratic leadership and the White House have mentioned policy proposals that could include state and local government funding to infrastructure initiatives or payroll tax relief. CSTE will continue to keep you updated as the supplementals evolve and different aspects of the relief efforts are implemented broadly.

Celia Hagan, MPH is vice president at Cavarocchi Ruscio Dennis Associates, LLC, which represents CSTE’s interests on Capitol Hill in Washington, DC.


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CSTE announces Janet Hamilton, MPH as new Executive Director

Posted By CSTE Staff, Saturday, March 28, 2020
Updated: Friday, March 27, 2020


The Council of State and Territorial Epidemiologists (CSTE) is pleased to announce the selection of Janet Hamilton, MPH, as new Executive Director, effective March 29, 2020. As Executive Director, Hamilton will work directly with the Executive Board and senior management team to lead and shape CSTE’s mission of advancing the field of applied public health epidemiology in the U.S.  


She will also oversee CSTE’s strategic objectives, public health partnerships, and operations. Hamilton will replace current Executive Director Dr. Jeffrey Engel, who announced his retirement in November 2019.   


“With the ongoing COVID-19 pandemic response, CSTE is fortunate to welcome a new Executive Director who really understands applied epidemiology from the state and national perspective and has hands-on state public health department experience from her previous role in the Florida Department of Health,” said Dr. Sharon Watkins, current CSTE president and Pennsylvania State Epidemiologist. “Janet’s scientific and policy expertise has truly boosted CSTE’s national profile, and I am pleased we’ll have this continuity of leadership at such a crucial juncture.” 


Prior to her selection as Executive Director, Janet served as CSTE’s Senior Director of Science and Policy, leading organizational efforts to strategically combine applied epidemiology science with policy efforts to advance public health and applied epidemiologic public health practice. Hamilton is an epidemiologist with over 15 years of public health work experience at the national, state, and local levels. In 2019, Janet spearheaded the efforts of a coalition of partners to modernize public health surveillance through the Data: Elemental to Health campaign, which secured an initial appropriation of $50 million to the Centers for Disease Control and Prevention (CDC) to support this foundational need. She has also helped lead CSTE’s response to EVALI and now COVID-19. Prior to CSTE, Janet worked in the Florida Department of Health, where she oversaw surveillance programs, both the epidemiologic scientific content and the surveillance systems that support them. Hamilton also served as CSTE’s Executive Board President during the 2017-18 term, and as Surveillance and Informatics Steering Committee Chair from 2011 to 2015. 


“It is such an honor to be chosen to serve as CSTE’s next Executive Director,” added Hamilton upon the announcement. “I am grateful for the leadership and guidance of our retiring executive, Dr. Jeffrey Engel. Public health is facing the most intense challenge of our lifetime responding to the COVID-19 pandemic, and we must do everything we can to support our members who are facing even greater challenges on the ground. Public health is meeting this moment with calm, courage and resilience. I look forward to collaborating with our Board, our federal, state, and local partners, and all of our members to foster growth and the advancement of CSTE and our field.” 


Hamilton replaces outgoing Executive Director Jeffrey Engel, MD, who will retire after eight years of guiding CSTE through a successful period of growth as Executive Director. Engel will remain at CSTE as Senior Advisor for the COVID-19 response, assisting as a subject matter expert in infectious disease epidemiology.  

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CSTE 2020 Annual Awards: Recognizing Excellence and Outstanding Achievement in Applied Epidemiology

Posted By Sarah Zimmerman and Simental “Sy” Francisco, BS, Wednesday, February 26, 2020
Updated: Tuesday, February 25, 2020
Simental Francisco accepts the 2019 RWJF Award from Sarah Park, Hawaii State Epidemiologist and CSTE Board Vice President.

Each year, CSTE presents several awards recognizing excellence in applied epidemiology among our members and partners, owing to the strength and diversity in our work and membership. While some CSTE awards are decided via an annual Call for Nominations, others are eligible for self-nomination. Please see the CSTE Awards page for more details.

Note: The deadline for nominations for the 2020 Pumphandle Award, Distinguished Leader and Distinguished Partner Awards, and other awards is March 1, 2020.

Last year, CSTE presented the Robert Wood Johnson Foundation (RWJF) Award for Outstanding Epidemiology Practice in Addressing Racial and Ethnic Disparities Award to Simental "Sy" Francisco from Navajo Nation Epidemiology Center. His abstract, “Initial Data Finding from Results of the Navajo Nation Health Survey: A Foundation for Development of a Navajo Behavioral Risk Factor Surveillance Systems,” addresses racial and ethnic disparities to improve public health practice through effective use of data and epidemiology in the Navajo Nation. Health disparity research on American Indian and Alaska Native (AI/AN) populations spread across 560 federally recognized tribes is underrepresented in state Behavioral Risk Factor Surveillance (BRFSS) reporting due to the complex issues surrounding the responsibility for public health services in AI/AN populations. Francisco leads the BRFSS at the Navajo Epidemiology Center (NEC) by demonstrating Hozhó [i] of Diné [ii] People through Naałnįįh Naalkaah [iii].  

Tribal Epidemiology Centers regional locator map.


The NEC is one of 12 Tribal Epidemiology Centers (TECs) that work in partnership with local or area tribes to improve the health and well-being of tribal members by offering culturally competent approaches to eliminate health disparities faced by AI/AN populations by monitoring health status, maintaining disease surveillance, conducting health research, conducting disease outbreak investigation, reporting health data, providing technical assistance, and identifying priority health concerns.   

A core function of TECs is the collection of data related to, and monitor progress made toward meeting, each of the health status objectives for Indian Tribes, Tribal Organizations, and Urban Indian Organizations (I/T/U) in their respective Indian Health Service (IHS) service areas. The Navajo BRFSS provides behavioral risk factor data on adults residing in the Navajo Nation. Initial data findings from the results of the Navajo Nation Health Survey fulfill an original premise to provide tribal-specific data from and build a foundation for a tribal nation-specific BRFSS to identify risk factors of Navajo adults; collect data specific to Navajo Nation by in-person interviews; and key data finding results to select target audiences. 

Implementing a tribal BRFSS has public health implications. The implementation of the Navajo BRFSS includes successes learned from piloting and testing; conception of a sampling design, study methodology, and procedural survey protocol as a surveillance system representative to AI/AN populations; recognizing the prevalence of health risk behaviors among Navajo adults; comparisons with other populations to identify health disparity; definition of health measures, e.g., Healthy People 2010/2020, identifying measurable baseline data; a tribal BRFSS process representative and exclusive to AI/AN population-based health; and strengthening support continual tracking, measurement, and evaluation of health status progress with the Navajo BRFSS as a primary data source to support secondary data sources.    

This work highlights the importance of culturally appropriate survey methods in developing a tribal BRFSS, which provided information for tribal leaders to support tribal epidemiology and surveillance done by Simental Francisco and his team.    

Simental Francisco's abstract for Initial Data Finding from Results of the Navajo Nation Health Survey: A Foundation for Development of a Navajo Behavioral Risk Factor Surveillance Systems can be found here. If you would like to learn more about Tribal Epidemiology Centers and the work they do, you can read more at tribalepicenters.org.  

[i] Hózhó is the wellness philosophy of the Diné (Navajo) People, comprised of principles that guide one's thoughts, actions, behaviors, and speech. 

[ii] Diné is an autonym used by the Navajo for themselves in their own language. 

[iii] Naałnįįh Naalkaah translated literally, means “disease surveillance” in Navajo. 

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The Role of Substance Use in Birth Defects Surveillance

Posted By Luigi Garcia-Saavedra, MPH, Whitney Coffey, MA, Elizabeth McCarthy, MA, Wednesday, January 29, 2020
Updated: Tuesday, January 28, 2020

Birth defects (also known as congenital anomalies or congenital disorders) are structural or functional anomalies that occur in utero and are both common and costly. They may be inherited or environmentally induced. Identification of birth defects may occur prenatally, at birth, or much later in life (e.g. renal agenesis).

In the U.S., some estimates indicate one in every 33 babies born each year has a birth defect. Some birth defects can have a minimal impact on quality of life, whereas others are more severe and contribute to long-term disability. Not only are individuals with birth defects impacted, but so too are their families, health care systems, and societies.


Where the cause of the birth defect is known, prevention strategies have been developed to reduce risk. Avoiding use of harmful substances is one such strategy and continuous opportunities to connect a pregnant woman to services and prevention education exist. CDC defines Fetal Alcohol Spectrum Disorders (FASDs) as ‘a group of conditions that can occur in a person whose mother drank alcohol during pregnancy. These effects can include physical problems and problems with behavior and learning. Often, a person with an FASD has a mix of these problems.’ Though etiology of this condition is well known, data from the 2015-2017 Behavioral Risk Factor Surveillance System (BRFSS) showed that 11.5% of pregnant women reported current drinking.  


Alcohol is only one of the substances newborns may be exposed to in utero with negative impacts. Neonates exposed to opioids, benzodiazepines, and barbiturates (OBB) in utero who experience withdrawal signs and symptoms have Neonatal Abstinence Syndrome (NAS).  


Recently, the CSTE NAS Standardized Case Definition (NAS-SSCD) was developed through a cooperative partnership. The CSTE NAS Workgroup includes representatives from state and local public health jurisdictions, CDC, and other partners. Ratified by the Council in June 2019, this tool aims to serve as a primary resource for comparative assessment of jurisdictional and longitudinal trends in NAS by establishing uniform classification guidance. NAS-SSCD includes a tiered case definition to be applied in both provider-reported clinical documentation and administrative data. This resource will allow for better understanding of the incidence and burden of NAS, as well as monitoring for long-term effects. Additionally, standardized surveillance will facilitate the assessment of the needs of the mother-infant dyad before, during, and after pregnancy. 


In Missouri (MO) and New Mexico (NM), NAS-SSCD has been used to align reporting of NAS cases. Stakeholder education surrounding the motivation and aims of NAS-SSCD continues. Further, the 2018 MO birth defect surveillance pilot (which included NAS) indicated the many benefits of active surveillance of birth defects and perinatal conditions of interest. As a result, MO’s birth defect surveillance system will incorporate NAS as a condition of interest for future analyses due to the condition originating from in utero exposure, similar to FASDs. 


Surveillance on birth defects, in utero exposures, and behaviors associated with birth outcomes is a useful tool to inform prevention programs. However, surveillance is most effective when coupled with the provision of services to affected families. A proposed CSTE policy brief associated with NAS-SSCD, which outlines avenues for resource planning and allocation for these services, is in development. 


Presently, the NM Birth Defects Prevention and Surveillance Program (NMBDPSP) and Children’s Medical Services (CMS) have been partnering to connect services to families diagnosed with any birth defect and, more recently, with NAS. NMBDPSP surveillance and data sharing between agencies creates a systematic approach to assure that each family is given information about resources available to them and that they have access to the medical and social services they may need. This collaboration increased the percentage of birth defect-impacted families receiving services from around 50% (in 2017 when the collaboration began) to approximately 70% by 2018.


Another important birth defect-related activity, in addition to surveillance and provision of services, is education of the general public and care providers. Creation and dissemination of messaging containing not only basic health care information, but also prevention advice, research updates, and resource guides are vital. These products can enable self-efficacy in communities affected by adverse birth outcomes. The NMBDPSP is developing these types of educational materials for families with information on specific conditions (with a focus on substances such as tobacco, pain medications, and alcohol). New birth defect surveillance analyses findings in MO will be added to existing public-facing dissemination resources.


During National Birth Defects Prevention Month, it is important to remember that an area encompassing many diverse birth outcomes requires a diverse group of people working together to improve the quality of life of all of those affected. 


CSTE’s Neonatal Abstinence Syndrome (NAS) Workgroup was formed in 2017 to better understand how states define and operationalize NAS and to develop a standardize surveillance case definition. The workgroup developed and conducted an NAS Definition Environmental Scan to understand the current ways in which NAS is defined and used the data to develop the NAS Standardized Surveillance Case Definition Position Statement, which was passed at the 2019 CSTE Annual Conference.


About the authors - Luigi Garcia-Saavedra, MPH, is a Birth Defects Epidemiologists Supervisor for the New Mexico Department of Health and CSTE NAS Workgroup Co-lead; Whitney Coffey, MA, is a Research Analyst for the Missouri Department of Health and Senior Services and CSTE Workgroup Co-lead; Elizabeth McCarthy, MA, is a Research Manager for the Missouri Department of Health and Senior Services.

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