CSTE, in collaboration with the Centers for Disease Control and Prevention (CDC), the National Association for County and City Health Officials (NACCHO) and Safe States Alliance, recently hosted the 7^th Annual National Disaster Epidemiology Workshop on May 17-18, 2016 in Atlanta, Georgia. The workshop convened epidemiologists from state, territorial, and local health departments across the country, along with partners from CDC, other federal agencies, academic institutions, and non-governmental organizations. Over 80 people attended in person and over 60 people participated via live webinar. The workshop focused on the intersection of disaster epidemiology and climate change.

Dr. George Luber, the chief of the Climate and Health Program in the Division of Environmental Hazards and Health Effects at the National Center for Environmental Health, Centers for Disease Control and Prevention, was the keynote speaker on the first day of the workshop. Dr. Luber described the key health threats and impacts from climate change, which include air pollution, changes in vector ecology, increasing allergens, water quality impacts, water and food supply impacts, and extreme weather and heat. He identified the perception of climate change as a distant, slow-moving threat as a major issue and explained that the science of event attribution, linking extreme events to climate change, could reduce this belief.

Meredith Jagger gave the keynote address on the second day of the workshop. Ms. Jagger is an all-hazards epidemiologist with the Oregon Public Health Division and previously was the program manager for the Building Resilience Against Climate Effects Program at the Florida Department of Health. She described the intersections of disaster management, epidemiology, and climate science in her work at both Florida Department of Health and Oregon Public Health Division.

In addition to the keynote presentations, the workshop featured three sessions corresponding to the phases of the disaster management cycle: planning, response, and recovery. A heat event and wildfire tabletop was conducted to discuss how to apply disaster epidemiology tools, climate change resources, and lessons learned to a realistic scenario.

The presentations are listed below and are available here.

• The Louisiana Experience: Vital Records Advances in Disaster Related Death Registration
• Public Health Implications and Usage of Electronic Death Registration Systems across the Disaster Life Cycle, One Jurisdictional Perspective
• Shelter Surveillance Guidance Document
• Planning for an Emergency: Strategies for Identifying and Engaging At-Risk Groups

• CASPER in Response to the California Drought, 2015
• Emergency Responder Health Monitoring and Surveillance and its Implementation during the 2014 Ebola Response
• Preparing for Extreme Heat in Arizona: A Heat-Health Early Warning System Approach
• Chlorine ACE investigations in California: Hotels, Scrap Yards, and Swimming Pools

• Longitudinal Community Assessment for Public Health Emergency Response to Wildfire, Mental and Physical Health Impacts, Bastrop County, Texas
• How Will I Know? Opportunities, Challenges and Considerations in Data Integration for Disaster Recovery

The CSTE Disaster Epidemiology Subcommittee provided an overview of its major activities and accomplishments during the last year. The workshop was recorded and is available on the webinar library

If you have any questions or would like more information about the CSTE Disaster Epidemiology Subcommittee, please contact Jessica Wurster.

Jessica Wurster, MPH is an associate research analyst at the CSTE national office. Tess Konen, MPH is the chair of the Disaster Epidemiology Subcommittee and is a senior epidemiologist at the Minnesota Department of Health. Michael Heumann, MPH, MA is a consultant with HeumannHealth Consulting LLC for CSTE. To learn more, visit CSTE’s Disaster Epidemiology page.

1. Filter and search through sessions on the CSTE conference app to navigate the agenda and personalize your own daily schedule. The app is updated continually to include complete agenda information. It allows you to download handouts, receive important announcements, see local Anchorage information, connect with colleagues, and more. Search your app store or Google Play for “2016 CSTE” to get the app for your tablet or smartphone before you arrive!
   
   
2. The online agenda also has a useful, searchable index of sessions. Don’t miss out on the special events (the Opening Reception, the Annual Fun Run/Group Walk, the Early Career Professional Meetup, and more).
   
   
3. Get information on what weather-appropriate clothes to wear, shuttle times, walking directions, and maps on the conference website.
   
   
4. Take advantage of the conference as an opportunity to get Certified in Public Health (CPH) recertification credits for a $10 fee.
   
   
5. Familiarize yourself with the 2016 position statements so you can give feedback according to your subject-matter expertise. The full list of 18 2016 submitted position statements is available through member login on the CSTE website.
   
   
6. Are you presenting or moderating? Watch the presenter instructions and the moderator instructions YouTube videos!
   
   
7. Are you looking for more information on how to prepare? Read the FAQs on the conference website.
   
   
8. Share group photos of you and colleagues and interact with @CSTEconference on social media with hashtag #CSTE2016 to win gift cards and giveaway prizes.
   
   
9. Check out the sponsored sessions to learn more about emerging software and services that are tailored to modern local, state, and federal epidemiologists’ needs.
   
   
10. Let us know what you think and how we can improve the conference experience by completing the Annual Conference Evaluation – a link will be provided to attendees at the end of the conference by e-mail. By completing the evaluation, you could win a the giveaway prizes: an Apple TV, a FitBit, and five free year-long CSTE memberships.
    
    

As tattoos have become increasingly popular over recent years in the United States, outbreaks of tattoo-associated infections occasionally occur. On April 29, 2015, the Florida Department of Health in Miami-Dade County, Epidemiology, Disease Control, and Immunization Services (EDC-IS) was notified by a local dermatologist reporting three patients with suspect nontuberculous mycobacterial (NTM) infection after receiving new tattoos at a local tattoo studio. EDC-IS identified multiple tattoo-associated infection cases through an investigation in conjunction with the U.S. Food and Drug Administration (FDA).

On April 30, an interview with the tattoo studio owner revealed that one of the tattoo artists had purchased open bottles of greywash ink, which were reportedly used on symptomatic clients. EDC-IS contacted clients who received tattoos from December 1, 2014 to April 30, 2015, in order to identify clients who may have been exposed. FDA collected environmental samples, including the studio’s tap water and the open bottle of implicated greywash ink. In addition, FDA collected five unopened bottles of greywash ink from local tattoo studios which reported using greywash from the same implicated lot number. Case definitions were created according to interviews with initial cases. A suspect case was a person who received a tattoo and developed a rash which lasted longer than two weeks; a probable case was defined as a suspect case with histopathological or stain evidence of an infectious organism; a confirmed case was someone who met the suspect case definition with a culture identifying an infectious agent or positive immunohistochemical (IHC) stain or polymerase chain reaction (PCR).

Thirty-eight clients of 246 interviewed met the case definition: 7 confirmed, 1 probable, and 30 suspect. Twenty-seven (71%) were male, and the median age was 28 years (range: 19-54 years). Laboratory test results from clinical and environmental specimens revealed Mycobacterium abscessus in clinical samples, the tap water, and the opened bottle of greywash ink. M. chelonae was detected in five unopened bottles of greywash ink collected from the local tattoo studios. Multivariate logistic regression showed that tattoo-associated infection associated with a specific artist was not statistically significant; however, clients who reported receiving grey ink were 8.24 times as likely to have a rash than those who did not report receiving grey ink (OR: 8.24, 95% CI: 3.069—22.127) (Figure 1).

Sources of this outbreak may have included contaminated greywash, tap water tested from the tattoo studio, or a combination of both. Peaks in cases apparent from the epidemic curve, coupled with the positive NTM tap water results may indicate the presence of a biofilm in the water pipe (Figure 2). Characteristic properties of biofilms include a process of attachment, growth, and breaking off which may periodically increase levels of NTM typically found in tap water sources (1). Following M. chelonae-positive results from the unopened bottles of ink, FDA and the greywash manufacturer issued a national recall of the implicated lot number on July 22, 2015.

1. Hall-Stoodley, Luanne, and Paul Stoodley. "Biofilm Formation and Dispersal and the Transmission of Human Pathogens." Trends in Microbiology 13.1 (2005): 7-10. Web. Sept. 2015.

Not pictured: Juan Suarez, Anthoni Llau, PhD, Christine Oliver, Samir Elmir, Guoyan Zhang, MD, MPH, Emily Davenport, Lakisha Thomas, Pedro Noya-Chaveco, MD, MPH, Marie Etienne, RN, Juan Jose Estrada, Enrique Uribarri, Yuray Martinez,Michael Ragheb, Erin Hansman, Amanda Muana, Laura Vallejo, Danielle Fernandez, MPH, Ann Schmitz, DVM, AM

Authors: Isabel Griffin, MPH, Edhelene Rico, MPH, Juan Suarez, Emily Moore, MPH, Emily Davenport, Danielle Fernandez, MPH, Anthoni Llau, PhD, Alvaro Mejia-Echeverry, MD, Guoyan Zhang, MD, Reynald Jean, MD

Acknowledgements: Christine Oliver, Samir Elmir, Michael Ragheb, Erin Hansman, Amanda Muana, Laura Vallejo, Lakisha Thomas, Anne Barrera, Pedro Noya-Chaveco, Florida Department of Health in Miami-Dade County; Florida Department of Health, Bureau of Public Health Laboratories

To take part in CSTE infectious disease-related projects, join a subcommittee that interests you in the Infectious Disease Steering Committee.

A month from now many of you will be in Anchorage, gathered for the CSTE Annual Conference, sharing your expertise and building collaborations.

Those are the very reasons it was important to me as the Editor-in-Chief of CDC’s Morbidity and Mortality Weekly Report (MMWR) that we be there, too.

On Monday, June 20 (2:00-3:30 p.m.), Jeff Sokolow, Technical Writer/Editor for MMWR, and I will be presenting on “Publishing in Today’s MMWR: Widely Read, Widely Respected.” MMWR is often considered “the voice of CDC,” but that doesn’t mean the reports are only from CDC authors. We want to be publishing your scientific work and we welcome your submissions.

Tim Jones will be moderating our session. Since 2015, he has served as chair of the MMWR Editorial Board, but his history with the publication goes back many years including during his time as a part of CDC’s Epidemic Intelligence Service. He’s now the State Epidemiologist for the Tennessee Department of Health and of course is a past president of CSTE.

Jeff Sokolow will outline the structure of an MMWR Weekly Report, highlighting how the first paragraph serves as an abstract containing background, methods, main results, discussion, and a SOCO (single overriding communications objective) that states the public health action recommended. He will also discuss the MMWR editorial review process, give clear writing tips and note errors to avoid.

It will also be our pleasure to introduce you to two MMWR authors from state health departments. We will be joined by Joan M. Duwve of the Indiana State Department of Health. Joan and her department colleagues used an MMWR template to develop their report on a community outbreak of HIV infection and in three weeks’ time went from inception to publication. Her description of the process and the impact of the publication will put you in the shoes of an MMWR author.

Ali Hamade of the Alaska Section of Epidemiology will talk about publishing on what might have seemed to be a very esoteric topic - suspected palytoxin inhalation exposures – that ended up garnering widespread attention. In his words, “Publishing in MMWR with its wide reach and open access has helped serve global public health by spreading the message. We saw evidence of this from the many technical assistance requests from the public and public health agencies, to national and international media inquiries and postings on multiple hobbyist and professional blogs.”

As Ali notes, he and his co-authors chose MMWR because it reaches a broad audience including state and federal public health officials, is open access and therefore freely available to all, and is easily retrieved in internet searches.

Please come hear their stories and learn how publishing in MMWR can further your own public health impact.

Our goal is to help you share what you’ve learned. We’re coming to the conference hoping to build many collaborations. We look forward to meeting you in June.

Active monitoring of travelers who are at low (but not zero) risk for Ebola Virus Disease (EVD) for 21 days was a labor-intensive activity for health departments, especially those with large volumes of returning travelers. Taking on this new and daunting task was especially demanding while also sustaining ongoing public health responsibilities. New York City Department of Health and Mental Hygiene (NYC DOHMH) began receiving files from CDC with contact information for travelers who had arrived from West Africa in the fall 2014. An active monitoring call center (AMCC) was set up and staff from several different programs were reassigned from their regular jobs to serve as AMCC operators. After several months, these staff were replaced with grant hires and temp agency staff. They called travelers daily to collect temperatures and document any symptoms; these efforts are described in more detail at http://www.cdc.gov/mmwr/volumes/65/wr/mm6503a3.htm.

When a traveler was unable to be reached by AMCC for two consecutive days, the traveler was referred to the DOHMH Surveillance and Epidemiology Emergency Response Group’s Field Surveillance Unit (FSU). Activated under DOHMH’s Incident Command System, FSU consists of approximately 200 staff from six different bureaus. FSU staff are trained and experienced in patient/provider outreach, interviewing, and medical chart abstraction. Upon being assigned a traveler who was lost to follow-up, FSU staff initially attempted to contact the traveler or his or her listed emergency contact by phone. FSU staff used subscription-based people search databases to search for travelers or their emergency contacts to identify additional contact information. After calling all phone numbers and leaving messages for the traveler to call the AMCC, FSU staff would send an email to the traveler if an email address was available. If there was no response by phone or email after 2–3 hours, a FSU staff or team of two staff would conduct a site visit to the traveler’s home, hotel, or local address. If the traveler was not found, a letter from DOHMH explaining the need to speak with the traveler was left at the hotel’s front desk or under the apartment door, if possible.

From October 11, 2014 to May 31, 2015, DOHMH conducted active monitoring for 2,941 travelers, which resulted in 235 (8%) hard-to-locate referrals to FSU. Of the 235 referrals, 80 (34%) were successfully contacted by phone within a day of referral and 67 (29%) required a field visit. Of these 67 field visits, 17 (25%) were located and interviewed, letters asking the traveler to call were left with someone at the home/hotel or placed it under the door for 41 (61%), and 9 (13%) did not have a valid address. Seventy-eight (33%) of all referrals had other outcomes (e.g. traveler left NYC or contact made after 24 hours) and for 10 (4%) FSU was unable to proceed with any outreach due to lack of valid contact information.

Challenges in NYC to locating these travelers differed depending on if the traveler was a NYC resident returning from a trip abroad versus a foreign resident visiting the city. Challenges included the traveler not being reachable in the daytime because they were at work or not at the hotel because they were out sightseeing or visiting relatives. Incorrect or incomplete addresses lacking apartment numbers, no access to apartment buildings, common last names, language barriers, and safety in the field also hindered our ability to locate travelers.

Distributing pre-paid cell phones to travelers when they arrived facilitated efforts to contact them for daily active monitoring. In the first four weeks of active monitoring before CDC phones were given to travelers upon arrival in NYC, FSU had to identify additional contact information on travelers for 41 of 136 (30%) of referrals; after phones were distributed, only 14 of 99 (14%) required identifying additional contact information (2 P=0.004). Before phones were distributed, 49 of 136 (36%) referrals required a field visit; after phones were distributed, only 18 of 99 (18%) referrals required a field visit (2 P=0.003).

The number of referrals for locating hard-to-reach travelers decreased from 136 in November 2014 to 30 in December 2014 and remained less than 17 a month for the remaining months. This decrease was due to several reasons including AMCC’s success in contacting travelers by phone within 48 hours and the addition of free cellphones to travelers. However, valuable time and resources were still expended on calling travelers daily for 21 days and sending field staff to locate and make contact with travelers who did not respond to the cellphone attempts. Having a unit of staff trained and experienced in tracking down additional contact information, finding hard-to-reach people in the field, and interviewing reluctant clients was critical to the success of Ebola virus active monitoring in New York City.