Mirroring national trends, Rhode Island has observed an upswing in infectious syphilis cases in recent years among gay, bisexual, and other men who have sex with men (GBMSM). In 2005 there were just 14 cases of infectious syphilis among GBMSM in Rhode Island. This number increased to 80 cases in 2014, a 417% increase. Many of these cases are individuals who use cell phone apps and online websites to meet their partners. With the goal of reaching these individuals “where they are at,” the Rhode Island Department of Health (RIDOH) embarked on an internet-based campaign to promote syphilis prevention and testing, with some encouraging results.

The first step of the campaign was to create a webpage entitled “Sexual Health Information for Gay Men” (www.health.ri.gov/sex/for/gaymen/) on the RIDOH website. This page provides simple health recommendations for syphilis prevention and testing, as well as links to other helpful sites that provide GBMSM-specific local information, such as finding a gay-friendly doctor using www.men2menri.org.

CSTE provides international consultancies for its members to support CDC programs. You may have a colleague who went to West Africa to help support Ebola efforts through CSTE. When I joined CSTE in 2011 as a new North Carolina health department employee, I had recently returned home from some international work. I let CSTE know I would be interested in international consultancy, and what my skills were. Through the CSTE international consultancy program, I was able to assist in an influenza epidemiological surveillance review in Bamako, Mali in September 2015.

I received training for the influenza surveillance review in advance of my departure. CSTE colleagues experienced in surveillance reviews offered their expertise and documents from their previous reviews in West Africa. CDC-CSTE calls were held to offer me training for the consultancy. CDC shared background documents on Mali’s influenza work. North Carolina public health has a strong history of international consultancy and influenza work, and colleagues shared their wealth of experience. I left for Bamako in early September feeling prepared.

Mali is located in West Africa, sharing borders with 7 different countries. It is south of Algeria, west of Niger, north of Burkina Faso and Cote d’Ivoire, and east of Mauritania and Senegal. Mali is twice the size of Texas and is home to 15 million people. Bamako is the capital city, located in western Mali. Bamako’s population is two million and is the sixth fastest growing city in the world.

The CDC Influenza program and the Center for Vaccine Development Mali planned the surveillance review itinerary and most of the logistics. During my week in Bamako, I used the CDC surveillance tool to document Mali’s influenza surveillance program in laboratory, Influenza-Like Illness (ILI), and Severe Acute Respiratory Illness (SARI) surveillance sites, and nationwide epidemiological surveillance. I recorded what Mali’s influenza epidemiologists, clinicians, and laboratory scientists shared with me about their budding program. With the help of CDC colleagues in Atlanta and Accra, I reported to CDC on the overall system, SARI, ILI, laboratory, data, a SARI sentinel site visit (Gabriel Toure Hospital Pediatric Department, Bamako), and an ILI site visit (Commune I, Bamako).

My international consultancy work with CSTE and CDC on influenza surveillance was inspiring. Professionally, I was impressed by my public health colleagues in Bamako. I have done several public health projects in lower resource settings and this was by far the most impressive I have seen. With time, I believe the Mali influenza program will be an example in West Africa. I am grateful to CSTE, CDC, and the Center for Vaccine Development Mali for an outstanding epidemiology experience during my September 2015 visit.

Emily Holubowich, Senior Vice President at CRD Associates, is CSTE’s Washington representative and leads our advocacy efforts in the nation’s capital.

After a couple of fiscal “close calls” this fall—shutdown threats, last-minute budget negotiations, and a couple of stopgap spending measures to keep the government running—Congress ultimately passed and the President quickly signed the Consolidated Appropriations Act of 2015 before heading home for the holidays. This trillion-dollar spending measure provided appropriations for all “discretionary” government functions, including those administered by the Department of Health and Human Services.

In the end, public health fared well, all things considered. The Centers for Disease Control and Prevention (CDC) received nearly $7.2 billion in the “omnibus” spending bill for fiscal year (FY) 2016. That’s a $277.7 million (four percent) increase over FY 2015 levels. This funding includes nearly $6.3 billion in discretionary budget authority, as well as more than $892 million in mandatory Prevention and Public Health Fund (PPHF) dollars and $15 million from the Public Health and Social Services Emergency Fund.

The overall increase in funding should translate into good news for state and territorial epidemiologists. The National Center for Emerging and Zoonotic Infectious Diseases (NCEZID) received nearly $580 million, including $52 million from PPHF. This funding level represents a $175 million (43 percent) increase over FY 2015. Within NCEZID, the antibiotic resistance (AR) initiative would receive $160 million in new funding; less than the President’s requested $264 million for CDC. Based on the President’s budget request submitted to Congress in early 2015, we would expect much of the NCEZID funding, including AR, to support core infectious disease surveillance capacity at state and local health departments through Epidemiology and Laboratory Capacity (ELC) grants. This funding would be in addition to $40 million from the mandatory PPHF provided to ELC grants for the fifth consecutive year in the omnibus. The final spending measure requires CDC to submit to Congress a detailed spend plan for AR within 60 days of the legislation’s enactment, so more specific information about ELC funding and the bill’s impact on states and territories will be available soon.

Among our other NCEZID appropriations priorities, food safety received increased funding ($52 million) and advanced molecular detection was flat funded ($30 million).

The Public Health Workforce program, through which the CDC/CSTE Applied Epidemiology Fellowship receives funding, is also provided flat funding of $52.2 million and no supplemental PPHF funding. The appropriations bills do not specify how much funding would be dedicated to the Applied Epidemiology Fellowship program per se, but with flat funding of the program we might expect flat funding for our fellows. The President had requested a $15.2-million increase in budget authority for Public Health Workforce, as well as $36.2 million in PPHF. Three years ago, Congress eliminated $15 million in PPHF dollars for Public Health Workforce in the wake of sequestration.

Some other notable items related to public health:

• The National Center for Injury Prevention and Control received $70 million to combat the opioid epidemic, a $50 million increase over FY 2015 levels.
• National Center for Environmental Health budget was increased by $2.9 million over FY 2015 and most of the cuts proposed in earlier spending legislation were restored with the exception of the $2.8-million “Built Environment and Health Initiative,” which was eliminated.
• Funding for CDC’s tobacco programs sustained a $6.5 million cut compared to FY 2015, but was mostly restored after being cut by $100 million in proposed spending bills.

With the enactment of FY 2016 spending legislation, legislators will begin work in earnest on FY 2017 spending legislation when they return to Washington in January. CSTE will once again partner with the Association of Public Health Laboratories and other colleagues in the public health community to advocate for our key priorities—strong support for disease monitoring and for training the next generation of epidemiologists. In addition, our executive leaders are travelling to Washington in early February to discuss our funding requests with key decision-makers in Congress and the administration. Until then, we anxiously await the release of the President’s final budget request of the administration, expected to be released the first week in February, to see what the White House has in store for disease surveillance.

For more information about funding levels for your specific priorities, please click here for a copy of the omnibus spending legislation, and click here for a copy of the accompanying report that provides more detailed instructions about public health funding levels and intended purposes.

Evaluation is a crucial activity for many state and local public health agencies. In addition to the evaluation requirements in many federal funding programs, more and more states are recognizing the need and value of conducting thorough process and outcome evaluations of local, state, and regional efforts. All funders, governmental and non-governmental, are placing an increasing emphasis on demonstrating the impact of the program, policy or system change.

It is only through a comprehensive evaluation that jurisdictions can gain a better understanding of the impact of programs or policy changes as well as the key components involved in implementation of those programs and policies. Many evaluators, myself included, advocate that there is a critical need for process evaluation as well as outcome evaluation. A solid process evaluation provides the foundation for understanding why a program, system change, or policy had the anticipated impact (or not) as well as what components were most critical and how replication can occur in other settings.

Unfortunately, evaluation responsibilities often fall to epidemiologists or data managers who have little direct evaluation training and experience. In ideal circumstances, epidemiologists and evaluators work hand in hand during evaluation to provide the most thorough review of the process as well as aligning related data elements and issues. However, due to staffing and funding challenges, many jurisdictions are not able to have both of these positions engaged on the same effort at the same time, or the staff are spread across many efforts. Building evaluation capacity within the current epidemiology workforce is one way to help build the overall evaluation capacity within jurisdictions.

In 2015, CSTE conducted a four-part webinar series to discuss and examine public health evaluation. The series was designed to provide a high-level overview discussion of evaluation and how evaluation broadly should be approached. While the series was developed in conjunction with the Chronic Disease Subcommittee, the presentations were done in a manner to allow generalizability across all areas of public health. All of the webinars are available in the CSTE webinar library and can be viewed at any time. Below is a brief description of each of the webinars as well as the link to the webinar itself if you would like to learn more about any of the topics.

• Lesson 1: Focusing your Evaluation Design (February 19, 2015) - Webinar Slides
  This webinar focuses on understanding how to begin the evaluation design purpose. Key questions that guided the discussion included understanding how, why and when evaluations begin, identifying the purpose and key stakeholders, and balancing utility and feasibility.

  Some “think about it” questions that were generated included: What is the first step in determining your evaluation design? What are some of the primary reasons for conducting evaluations? What is the biggest challenge you face in determining evaluation design, engaging stakeholders, and determining what tools to use?

• Lesson 2: Approaches to Evaluation / Evaluation Types (March 19, 2015) - Webinar Slides
  This webinar discussed the strengths, weaknesses, and primary focuses of four primary approaches to evaluation. The four approaches that were discussed in depth include Utilization-focused evaluation, Developmental evaluation, Theory Driven, and the Kirkpatrick model. In addition, time was spent discussing the difference between summative and formative evaluations and outcome and process evaluations. While discussing the differences, it is also important to consider the interconnectedness between the different types.

  “Think about it” questions to consider from this week included: examining which evaluation approach you are most comfortable with, identifying what types of evaluation are typically conducted within your agency, and whether your approach is consistent with the types of evaluation that you have typically been involved with in your agency.

• Lesson 3: Outcome/Process Evaluations (April 16, 2015) - Webinar Slides
  This webinar spent significantly more time delving into the distinction between and relationship among formative/summative and outcome/process evaluation. Items considered and discussed including the appropriate different types of questions for each type of evaluation, how different evaluation theories or approaches examine each of the types of evaluation, and most appropriate data, analysis, and reporting mechanisms for each type of evaluation. Significant time was spent in this session discussing the importance of mixed methods designs in robust evaluations.
  
  “Think about it” questions that were generated from this session included considering the most appropriate evaluation questions for each evaluation type, examining how summative evaluations can be used to inform programmatic practice, and thinking about the pitfalls of relying on only summative evaluation reports.

• Lesson 4: Data Visualization and Reporting ( June 14, 2015) - Webinar Slides
  The final webinar in this series discussed data visualization and reporting. In particular, how to determine the best reporting mechanisms for various stakeholder audiences, different methods for visualizing data, and the critical importance of different reporting tools were all discussed. This session tied together several underlying themes from the other sessions, including consideration of all stakeholders and ensuring the usability and relevance of the evaluation by all stakeholders.
  
  Some of the “think about it” questions that were generated at this session included how to handle challenging responses from stakeholders to evaluation findings, how to identify and engage with key stakeholders to discuss the data, and how stakeholders can support evaluation efforts by providing more detailed understanding of key findings.

That response effort was a community rapid needs assessment, called a Community Assessment for Preparedness and Emergency Response (CASPER). The Emergency Preparedness Team (EPT) within the Division of Environmental and Occupational Disease Control at CDPH had been asked by the Public Health Division in Napa County, one of the hardest-hit counties, for assistance assessing earthquake-related physical injuries, chronic disease exacerbation, mental health issues, and general emergency preparedness among households in Napa County. A team comprised of epidemiologists, health educators, and physicians from the county and state health departments and the CDC was formed to plan the CASPER event. Using guidance from CDC’s CASPER toolkit, the team worked together to design a 48-question questionnaire for household-based interviews, to select the geographic areas for household sampling, to recruit volunteers to canvass the selected households, and to coordinate myriad logistics for a three-day field sampling event scheduled three weeks after the earthquake. Over those three days, 15 two-person teams of volunteers approached 488 households and successfully completed an interview with a member of 201 of those households.

Although we assessed many different health impacts related to the earthquake, impacts to mental health were a major focus of the CASPER. Just over a quarter of households had a member who experienced a traumatic psychological exposure, which is known to be associated with posttraumatic stress disorder, in the immediate aftermath of the earthquake. Feelings of psychological distress, such as feeling anxious, fearful, or distracted, were experienced in 75% of households. Among all households in which a traumatic or distressing psychological experience occurred, professional help or other emotional support was sought in 41% of households. In response to the data generated by the CASPER, Napa County was able to more effectively reallocate its mental health resources in the immediate aftermath of the earthquake. In addition, the county conducted public training sessions and education campaigns to support those with mental health risks, conducted community social events on the earthquake anniversary date to promote community resilience and earthquake preparedness, and provided psychological first aid training to outreach workers.

The CASPER findings were summarized in a report drafted by the EPT and submitted to Napa County Public Health. We also communicated our findings to a wider public health audience at a number of different meetings through both poster and oral presentation platforms: a webinar sponsored by the Safe States Alliance; poster presentation at the 10th Annual Preparedness Summit (Atlanta, GA); an invited talk at the 2015 CSTE Disaster Epidemiology Subcommittee Workgroup Meeting (Atlanta, GA); and presentations at the 2015 EIS Conference (Atlanta, GA) and the 2015 CSTE Annual Conference (Boston, MA). In addition, our findings specific to mental health needs as a result of the earthquake were presented in a MMWR report.

In addition to the actionable data that were generated, the CASPER, the first large-scale project to which I contributed as a CDC/CSTE fellow, also provided a comprehensive and intensive introduction to the work and workings of local and state health departments. I was part of the collaboration and discussions that occurred among local, state, and federal health officials. I was involved in the development of survey materials, in the training of volunteers in sampling and interviewing methods, in the analysis of our collected data, in the drafting of the report, and in presenting our findings across many forums. From start to finish, the CASPER provided opportunities both for learning and for developing my epidemiologic skills in the applied public health space.

Moreover, the CASPER afforded me the opportunity to meet community members affected by the earthquake. Many wanted to share their stories of the shaking and disorienting chaos that gave way to weeks and months of rebuilding their homes and regaining their physical and emotional health. Yet when asked at the conclusion of the interview what their household was most in need of now, the residents I spoke to most often replied, “nothing.” They were simply grateful that their plight had not been more severe. And so my experience on the frontlines of public health had taught me another important lesson, which was the resiliency of those impacted by disaster.