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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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An Update on CSTE’s 2019-2020 Presidential Priorities

Posted By Sharon Watkins, PhD, CSTE President and Pennsylvania State Epidemiologist, Wednesday, January 15, 2020
Updated: Wednesday, January 15, 2020


Happy New Year to all CSTE members and non-member applied epidemiologists in our community! We have reached the midway point of my tenure as CSTE president, and I’d like to update readers on my Presidential Priorities for the term and offer a progress report on the status of this work. Each year, the CSTE President sets forth a list of Presidential Priorities.

These are key areas impacting the field of applied epidemiology that the organization, Executive Director and Executive Board work to advance during the year. Presidential Priorities change from year to year, and I immediately began working to articulate and implement my priorities in Fall 2019. Working closely with CSTE staff, I identified two Presidential Priorities that align closely with goals in CSTE’s 2018-2020 Strategic Plan.

The identified priorities are:

• Priority B3, Under Strategic Pillar B (Develop, Expand & Diversify the Epidemiology Workforce) – Develop & Foster Leadership

• Priority A2, Under Strategic Pillar A (Establish Leading Edge Public Health Applied Epidemiology) – Co-Develop Infectious & Non-Infectious Disease Surveillance Initiatives

I am pleased to report that work is well underway in the CSTE National Office to implement both priorities. To develop and foster the next generation of epidemiology leaders, I proposed the development of a forum/platform to train mid-level leaders, some of whom are former CSTE fellows, and provide them opportunities for additional mentorship, exposure to advocacy and public policy, and partnership across states, disciplines and outside organizations. The idea is similar to APHL’s Emerging Leader Program.

In response to this priority, the CSTE Workforce Team is currently working to develop an interactive mid-level leadership training opportunity to be launched in 2020. Additional focus upon this priority will offer early career epidemiologists more exposure to the national picture in our field, and I look forward to the new trainings becoming reality.

The second Presidential Priority focuses on the co-development of Infectious Disease and non- Infectious Disease surveillance initiatives, and this is also the basis for the 2020 Presidential Priorities Award via abstract submission. Like years past, applied epidemiologists across the U.S. will have the opportunity to submit their abstract for the Presidential Priorities Award, so long as the abstract exemplifies partnership and participation between ID and non-ID entities on an outbreak or surveillance initiative. Projects demonstrating a use of data that supports cross-disciplinary partnership and a harmonized response with the best use of available tools will better compete for the award.

CSTE’s ongoing Data: Elemental to Health campaign is an example of a cross-disciplinary project that has been successful in the last year, as the effort yielded $50 million in new federal funding to modernize CDC’s data infrastructure. Ongoing national responses to the opioid crisis and the EVALI outbreak are also recent examples of ways that ID and non-ID epidemiologists are partnering on surveillance initiatives that require a harmonized approach.

We have received a number of abstracts already for the 2020 Presidential Priorities award, and I look forward reviewing these projects and determining the potential for a breakout session that will take place at the 2020 Annual Conference to discuss the award-winning project. Overall, it has been a privilege to serve as your president in 2019 and now 2020. I look forward to further implementing these priorities and to all CSTE will achieve in the future.

Dr. Sharon Watkins is CSTE’s Executive Board President for the 2019-2020 term and the Pennsylvania State Epidemiologist.

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Congress Funds $50 Million to Modernize Public Health Data Systems and Boosts CDC’s Budget

Posted By Celia Hagan, MPH, Vice President, CRD Associates, Saturday, December 21, 2019
Updated: Saturday, December 21, 2019

It has been an exciting year since the launch of the Data: Elemental to Health campaign in February! CSTE has been working non-stop to advocate for funding to improve public health data systems. After the successful inclusion of new funding in the House appropriations bill, the entire process came to a halt when Congress could not agree to a spending package by September 30 resulting in two continuing resolutions.

But good things come to those who wait/never stop advocating for data modernization! Late Friday night, the President signed the FY20 spending bill into law solidifying $50 million in new money for CDC’s efforts to modernize public health data systems! This is a huge win for public health and the new funds will help pave the way towards a 21st century public health data superhighway. A big thanks to all of you that participated in our digital days of action to urge your elected officials to support data modernization. It goes to show that every voice counts!

Here are some highlights of CSTE’s activity over the past year for the Data: Elemental to Health campaign:

·         Janet Hamilton, CSTE’s Director of Science and Policy, testified about public health data needs before the House Labor, Health and Human Services, Education, and Related Agencies Appropriations Subcommittee;

·         Dr. Sharon Watkins, CSTE’s President and State Epidemiologist for the Pennsylvania Department of Health, testified about public health data needs in front of the House Science, Space, and Technology Committee;

·         Four authorizing bills, two in the House and two in the Senate, were introduced to support public health data modernization:

o   H.R. 2479 Section 45001 of the Leading Infrastructure for Tomorrow’s (LIFT) America Act;

o   H.R. 5321 Public Health Infrastructure Modernization Act of 2019;

o   S. 1793 Saving Lives Through Better Data Act;

o   S. 1985 Section 405 of the Lower Health Care Costs Act;

·         CSTE released a comprehensive report, Driving Public Health in the Fast Lane: The Urgent Need for a 21st Century Data Superhighway, to highlight the current challenges with public health data systems and outlining the path towards interoperability;

·         CSTE submitted written statements for two Congressional hearings on e-cigarettes.

There is more good news! Funding for CDC as a whole increased this year. FY20 includes a total of $8 billion for CDC which is $636 million above FY19 and $1.4 billion above the President’s Budget Request. A breakdown of areas of interest are listed below:

·         $230 million to address tobacco and e-cigs; an increase of $20 million

·         $622 million to Emerging and Zoonotic Infectious Diseases; an increase of $2 million

o   $170 million to the Antibiotic Resistance Initiative; an increase of $2 million

o   Flat funding for vector-borne diseases at $38.6 million

o   $14 million for Lyme disease; an increase of $2 million

o   $188.7 million for the Emerging Infectious Disease line; an increase of $31.8 million

o   Flat funding for AMD at $30 million

·         $555.4 million to Public Health Scientific Services; an increase of $59 million

o   $50 million in NEW funding for public health data modernization!

o   $9 million for all other surveillance, epidemiology, and informatics

o   Public Health Workforce is flat funded at $51 million

·         For the first time in 20 years there is $12.5 million in new funding to support firearm injury and mortality prevention research in the National Center for Injury Prevention and Control

·         $852.2 million for public health preparedness and response; a decrease of $5.7 million

o   Flat funding for the Public Health Emergency Preparedness Cooperative Agreement at $675 million

·         $85 million for the Infectious Disease Rapid Response Reserve Fund; an increase of $35 million.

At the end of the day, CSTE’s priorities fared extremely well in the year-end spending bill! Thanks to CSTE’s strong advocacy and presence on Capitol Hill, many of CSTE’s priorities saw increases in funding. Our advocacy successes this year are a good example of your membership fees at work! Without the commitment and strength of CSTE’s members, all of our wins would not be possible. Thank you for your dedication and support.

Additional information about funding levels for your specific priorities can be found in the spending bill, and in the accompanying report that provides more detailed information. 


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 Testifies at U.S. House Science, Space, and Technology Committee Flu Vaccine Hearing

Posted By Celia Hagan, MPH, Vice President, CRD Associates , Tuesday, December 17, 2019
Updated: Monday, December 16, 2019

This time of year, many people get sick. It’s cold outside, you’re cooped up indoors, and holiday stress is in full swing. Your symptoms may start with a cough and a sore throat. Could it be a cold? Then your muscles start to ache and the fatigue, headaches, and chills set in—it’s the flu.

Although flu viruses circulate in the U.S. year round, a peak of activity in the fall and winter months defines the flu season. Consider: while we know flu season will come each year, the season itself is unpredictable – when and where it will start, what virus strain will be circulating, how severe will the season be, and how well will the vaccine strains match. This unpredictability necessitates robust public health surveillance. The respiratory virus changes quickly making it challenging to develop a fully effective vaccine to prevent and mitigate illness. Tracking the virus is a multinational effort that relies on year-round public health surveillance and data collection.

It’s this complicated, yet coordinated scientific process of seasonal flu vaccine development that drew interest from the U.S. House of Representative’s Science, Space, and Technology Committee, which held a Fighting Flu, Saving Lives: Vaccine Science and Innovation hearing on November 20. Today, a universal flu vaccine—a one-and-done dose that would provide lifetime immunity—does not exist, hence the need to get annual flu vaccines each fall. The Committee was interested in understanding the full cycle from basic research to vaccine development, production, distribution and public health surveillance. The House Science, Space, and Technology Committee used this year’s flu season to highlight the scientific and innovation challenges around vaccine development and also focused on efforts to discover alternative influenza vaccine manufacturing processes from the current egg-based process.

CSTE’s President Dr. Sharon Watkins, State Epidemiologist for the Pennsylvania Department of Health, was invited to testify to share the public health perspective and express the need for better public health data. She highlighted that collecting and exchanging public health data is critical to detect and respond to flu outbreaks, gain an understanding of potential changes in the virus, and deliver life-saving vaccines. In her testimony, Dr. Watkins emphasized the need for interoperable data systems to share data, such as birth and death records and immunization registries and the need to be seamlessly connected to hospital emergency departments. Highlighting CSTE’s recent report, Driving Public Health in the Fast Lane: The Urgent Need for a 21st Century Data Superhighway, Dr. Watkins also spoke of the challenges public health faces when it has to rely on paper-based, manual data exchange methods. In the midst of the vaping epidemic that is occurring concurrently with flu season, it is important for public health professionals to distinguish between the two. As part of her written testimony, a four-page sample of a 350-page faxed medical record for an e-cigarette case showed that it is largely illegible and takes a public health professional significant amounts of time to input into the health department’s system. Dr. Watkins’ testimony helped to emphasize the need to improve public health data systems that has been an ongoing effort of CSTE’s through the Data: Elemental to Health Campaign.

Pictured: CSTE President and PA State Epidemiologist Sharon Watkins, PhD and Dr. Anthony S. Fauci, MD, Director, National Institute of Allergy and Infectious Disease, NIH, on November 20 during a hearing of the U.S. House Science, Space and Technology Committee.

Dr. Watkins testified alongside Dr. Tony Fauci the Director of the National Institute of Allergy and Infectious Disease at the National Institutes of Health, Dr. Dan Jernigan the Director of the Influenza Division in the National Center for Immunization and Respiratory Diseases (NCIRD) at the Centers for Disease Control and Prevention (CDC), and Dr. Robin Robinson, former head of the Biomedical Advanced Research and Development Authority (BARDA) and current Vice President of Scientific Affairs at RenovaCare. Dr. Fauci discussed NIH’s research efforts to discover a universal flu vaccine through its collaborations with academia, philanthropic organizations, and biotechnology and pharmaceutical companies. Dr. Jernigan emphasized that the flu vaccine is the single best way to protect yourself, and that CDC is working with other federal partners to use cutting edge science to improve the effectiveness of seasonal flu vaccines. He also discussed the importance of public health surveillance data to help inform policy recommendations and better vaccines. Dr. Robinson discussed his former role as head of BARDA, preparedness efforts to build national stockpiles of pre-pandemic flu vaccines, and BARDA’s activities to improve vaccine manufacturing.

The panel was well received by the House Science, Space, and Technology Committee, and the presiding Chair of the Committee emphasized that the flu vaccine is safe and the best way to stay healthy during flu season.

To protect yourself and your loved ones from flu, which can have severe complications requiring hospitalization and sometimes result in death, the CDC recommends getting an annual flu vaccine.

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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