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Posted By John Satre,
Friday, November 20, 2015
Updated: Friday, November 20, 2015
The Public Health ELR Network: A working model that increases interstate communication and reduces connections required between laboratories and public health1
The concept of a nationwide electronic laboratory reporting (ELR) network among state public health agencies organically sprang out of a field that had already been planted with seeds requiring time to develop and grow. Over the course of the last decade, these seeds have developed and are now producing fruit across the nation. It is appropriate to briefly outline some of the relevant components that make it possible to realize a nationwide, functioning public health ELR network.
Planting the Seeds
The following developments have been necessary for a public health ELR network to blossom:
Health Level 7 (HL7) Standardization – The ELR 2.5.1 HL7 Version 2.5.1 Implementation Guide: ELR to Public Health, Release 1 (US Realm) provided a target for partners involved in public health disease surveillance to develop independent interoperable messaging.
NEDSS and ELC – the National Electronic Disease Surveillance System (NEDSS) initiative provided the overarching vision and the Epidemiology and Laboratory Capacity (ELC) cooperative agreements provided the support to adopt or develop new surveillance systems capable of handling data in a much more sophisticated manner.
LOINC, SNOMED, and HL7 – these coding systems provide a common language for data sharing partners to communicate key concepts.
HITECH – The Health Information Technology for Economic and Clinical Health (HITECH) Act provided education, valuable work products, and technical assistance to public health jurisdictions related to Meaningful Use and ELR.
Meaningful Use Public Health Objectives – These incentives provide impetus for hospitals to approach public health with the necessary resources to plan, develop, and implement electronic connections in each state.
Innovative Design
Activities in public health often take excessive amounts of time, but they also happen to be spread over short spans measured only in minutes. These activities, when summed up by day or week accumulate into a large amount of time. One of these activities is simply referring a laboratory result received by one public health jurisdiction to a different state public health jurisdiction for investigation. It is not uncommon for a public health jurisdiction to receive a reportable laboratory result when it should have been reported to a different jurisdiction. In addition, there are times when one jurisdiction – upon receipt of a laboratory report - sends a request for assistance to another state (for example, collecting treatment information from a healthcare provider in the second state). This interaction generally occurs through mail, fax, or phone communication; timeliness of the referral or response tends to linger in the midst of busy schedules. Iowa’s electronic laboratory reporting team – in collaboration with multiple disease surveillance teams in Iowa and Nebraska – has developed program-specific rules and technology to evaluate electronic lab reports upon receipt for possible referral to another jurisdiction; the process is called ELR Redirect. Every laboratory result received by ELR passes through a component where the reportable condition is identified, so it can be associated with program rules. Then the appropriate state is calculated from the combination of up to three addresses for potential referral or an automated request for assistance. These include patient state, ordering physician state, and ordering facility state. Based on the combination of condition and addresses, the laboratory report is either redirected to another state public health jurisdiction or passed on to the original recipient’s surveillance system. Sometimes it is appropriate for the lab result to be kept by the original recipient and redirected to another state. This innovative design accomplishes several things: it saves time for the original recipient and the secondary recipient, provides the lab result to the appropriate public health jurisdiction in near real-time, and allows the surveillance system to consume a standard message automatically thereby eliminating manual data entry of this record into the final destination system(s).
Taking the Next Step
Standards have been implemented over the past 10 years along with new innovative design. The next step allows for a nationwide electronic surveillance network. If a state public health agency is able to receive a laboratory report electronically and electronically pass that report on to another state public health agency, the potential exists for every state public health agency to redirect a laboratory result to every other state public health agency. Costly electronic connections that have yet to be established between laboratories and public health agencies to achieve ELR may now be rendered unnecessary. The possibility of a disease surveillance community that is 100 percent electronic is within sight.
Iowa is currently working with United Clinical Labs (UCL) which serves healthcare providers and their patients in Iowa, Illinois, and Wisconsin. Multiple projects are underway to establish an electronic connection between UCL, which is located in Dubuque, IA, and the public health agencies in Iowa, Illinois, and Wisconsin through the UCL-to-Iowa ELR connection.
1Click here for image licensing information for the video.
John Satre is an Informatics–Training in Place (I-TIPP) fellow at the Iowa Department of Public Health. For more information or to request the customizable software component, e-mail John Satre. If you would like to become an I-TIPP fellow, apply before April 1, 2016. For more information about ELR, join one of CSTE’s three Surveillance/Informatics subcommittees.
Posted By Katrina Hansen,
Friday, November 13, 2015
Updated: Friday, November 13, 2015
We, the New Hampshire Healthcare-Associated Infections (HAI) Program, have published nine annual reports on the occurrence of HAI in hospitals and ambulatory surgery centers. These reports provide a summary of HAI data routinely reported in accordance with state law and can be used to identify and monitor improvement over time. The original intent of the NH HAI law was to increase transparency for healthcare consumers and assist with making healthcare decisions. However, experience shows that these reports are primarily used by healthcare facilities. With no standardized template available, our reports have evolved over time as we created our own and adapted various practices from other states to accommodate healthcare facilities and consumers. The NH HAI Program has and continues to struggle with balancing the needs of both technical and consumer audiences while preserving the important nuance and details that are needed to understand the data.
The picture above is a snapshot of NH HAI 2014 Hospital Report. NH uses a ‘red, green, and yellow light’ scheme to indicate if measures are higher, lower, or similar to national data, respectively. Example 1: The central line bloodstream infection (CLABSI) standardized infection ratio (SIR) was 0.61 or 39% fewer (green) infections than predicted based on national data. Example 2: The catheter associated urinary tract infection (CAUTI) SIR was 1.26 or 26% more infections than predicted based on national data. However, this different was not statistically significant, which means the over number of CAUTI was SIMILAR (yellow).
With the leadership of Lindsey Weiner (epidemiologist at the Division of Healthcare Quality Promotion, CDC) and Andrea Alvarez (HAI/influenza program coordinator at the Virginia Department of Health), a multidisciplinary group was formed to collaborate and establish best practices in the analysis and display of HAI data, which resulted in the HAI Data Analysis and Presentation Standardization (DAPS) toolkit. I was privileged to be a part of this workgroup, learn from other HAI colleagues, and participate in discussions to develop a tool that can be used by other programs. Throughout my involvement, common themes arose, including:
We are all healthcare consumers and have competing priorities in our day-to-day lives. We need to remember that short and simple messages are best when trying to reach a general audience.
HAI metrics [e.g., the standardized infection ratio (SIR)] and data limitations are not easy to explain to a consumer audience, let alone some technical audiences.
Symbols and colors can quickly and effectively convey a message. The challenge is picking the right symbols and colors applicable to all settings.
HAI data are continuously evolving; state and federal mandates change; and we need to be flexible to adapting needs.
While on this workgroup, I learned a lot from the discussions regarding challenges other jurisdictions encounter when publishing these important data. Coming from a rural and less populated state, we struggle with having robust enough data to present information for certain measures and facility types. I know we are not the only state working within this context and it was helpful learning from others with similar experiences. I kept this in mind when providing feedback on the toolkit and the need to provide an option to states that have comparable restrictions. Similarly, I used our own experience in NH to help contribute to the healthcare personnel vaccination component of the template. Several approaches are addressed and made available within the toolkit in order to provide flexibility to states.
Going forward, I plan to incorporate as much as possible in future reports. I estimate that we will reach a wider audience and ultimately increase HAI knowledge by ensuring that these data are more meaningful and accessible to all. Participating in the CSTE workgroup was a great opportunity to not only improve our own work in New Hampshire, but also to help shape the way healthcare-associated infections programs move forward together across jurisdictions in a complementary and consistent way.
Katrina Hansen, MPH is healthcare-associated infections program manager at the New Hampshire HAI Program. Click the link above to learn more about the HAI DAPS Toolkit and join the HAI Subcommittee for the opportunity to engage in initiatives such as this.
Posted By Heather Dubendris,
Friday, November 6, 2015
Updated: Tuesday, October 27, 2015
The past year as an AEF fellow has afforded me a plethora of opportunities. From site visits and outbreak investigations to data validation, coordinating the implementation of a surveillance system to taking calls, I quickly learned that working in a state health department keeps you on your toes, as no two days are ever the same.
I started my fellowship in the midst of the Ebola crisis. My first day at the office I was met in the lobby and quickly swept upstairs to an incident management team meeting. From there, I began working with the guidance team, developing guidance materials (even filming a contact tracing trainer video), and then later in a data management role monitoring an average of 40 travelers returning from Ebola-affected countries on any given day.
Presenting at the CSTE Annual Conference in Boston, MA –June 2015
As a healthcare-associated infections (HAI) fellow, I get to work closely with highly knowledgeable public health experts from both public and private sectors on emerging public health priorities, such as antimicrobial resistance. This year, I developed a protocol and designed a surveillance system to better understand the burden of carbapenem-resistant Enterobacteriaceae (CRE) in North Carolina. This project requires collaborating with seven major healthcare facilities in our state and the state laboratory of public health. By collecting epidemiologic information from cases and conducting resistance type testing on isolates, surveillance will provide information on the incidence of CRE in North Carolina, identify common mechanisms of carbapenem resistance and identify common healthcare exposures related to CRE. Preliminary results show that of 55 isolates tested, 35 (62%) are positive for Klebsiella pneumoniae carbapenemase (KPC). KPC is a common mechanism of resistance first identified in North Carolina in 2001. Most patients, 51 (84%), have taken antibiotics in the 90 days prior to their positive result, and hospitals have reported an average of 3.7 (95% CI 2.9-4.5) surgeries or devices (such as a central line) among these patients. Final results will be available once surveillance concludes next spring.
CDC's National Healthcare Safety Network (NHSN) data are used at the state and federal level to report HAI events. North Carolina law requires the reporting of five HAIs. The government and hospitals rely on NHSN data to assess improvements over time and make comparisons between states. Therefore, it is essential that the data are valid. I am currently conducting an external validation of two reportable HAIs: central line-associated blood stream infections (CLABSI) and LabID Clostridium difficile (C. diff) events. We selected twenty-eight hospitals throughout North Carolina for validation. I used the first few months of my fellowship to learn from other states’ validation experiences and adapt items from the CDC validation toolkit to create a North Carolina-specific validation protocol, forms, medical record abstraction tools, and database. Next, I conducted a pilot validation at a hospital in March. And after making some minor changes to the validation tools, I began traveling to the selected hospitals and working with infection prevention staff to extract data from medical records. The quality assurance provided by validation is essential, as these data are used for setting public health priorities to protect patient health. Traveling for site visits has been great way to explore the different regions of North Carolina!
NC Division of Public Health HAI Prevention Program with Evelyn and Tom McKnight
(HONOReform) and Dr. Joe Perz at the NC APIC Conference–September 2015
While I am primarily an HAI fellow, I sit in the Communicable Disease Branch, so I learn about a variety of infectious diseases and associated events. I serve as epi on call and conduct outbreak investigations. When on call, I provide guidance and recommendations to local health departments, providers, and the public about a variety of reportable diseases and conditions. Last February I worked with our Epidemic Intelligence Service (EIS) officer to investigate an outbreak of late-onset group B Streptococcus in a neonatal intensive-care unit, and I have also assisted with investigations of hepatitis, Legionella, and a fungal brain mass.
In my current position I get to travel to a variety of trainings and meetings, including trainings in infection control, SAS programming courses and national conferences focusing on infectious diseases. Being part of a cohort of fellows provides a network throughout the country to reach out to for support and insight when a new perspective is needed. The professional relationships developed during this fellowship and the experience gained at the health department have set me up to succeed in a future career as a public health epidemiologist. If you are a recent public health graduate and are interested in a career at a public health agency, I strongly recommend the CDC/CSTE Applied Epidemiology Fellowship to you.
Heather Dubendris, MSPH is a CDC/CSTE Applied Epidemiology fellow at the Communicable Disease Branch of the North Carolina Department of Health and Human Services. Learn more about healthcare-associated infections by joining the CSTE HAI Subcommittee. Do you want to be a fellow like Heather? The application is now open for the CDC/CSTE Applied Epidemiology Fellowship.
Posted By Luke Baertlein,
Friday, October 30, 2015
Updated: Friday, October 30, 2015
In the Montana Asthma Control Program we were faced with a problem of wanting to report on the geographic distribution of asthma burden while not having spatial data or data we could report at county-level aggregation. To get around this, we used an indirect spatial estimation method to explore and report on the spatial distribution of asthma morbidity. Indirect spatial estimation can be conducted when aggregate data are available for small areas, providing a means to approximate the spatial distribution of a metric when spatial data are unavailable. We analyzed emergency department (ED) visits for asthma and estimated the spatial variation in population-based rates using kernel density estimation (KDE) applied to ZIP-code area aggregated data.
Data for this project came from emergency department datasets for 2010 through 2013, accessed through the Montana Hospital Discharge Data System (MHDDS) and provided by the Montana Hospital Association. At the time of the analysis, our data use agreement did not allow reporting data aggregated below the region level, including at the county level. This was later changed, allowing us to compare our spatial estimates to county-aggregated estimates. MHDDS datasets are based on the Uniform Billing forms collected from participating hospitals and represent over 90 percent of hospitalizations and ED visits in the state. Asthma ED visits were defined as any visit with a primary diagnosis coded as ICD-9-CM 493. The ZIP code of residence was used to approximate location of residence.
The creation of the spatial map followed four key steps:
Create a polygon map of rates: The ZIP-code area counts of asthma ED visits and population were used to estimate and map ZIP-code area rates of asthma ED visits per 100,000 persons per year.
Convert from polygon to raster format: A cell grid was overlaid on the map of ZIP-code area rates and each cell was assigned the rate of the ZIP-code area containing it.
Apply KDE to raster data: KDE with a 50km bandwidth was applied to the cell grid, producing a rate for each point equal to the average rate within a 50km radius of the point. A bandwidth that would cross ZIP-code boundaries from most points was used so that the rates were smoothed across ZIP-code areas.
Test for regions with rates different from the statewide average: Significance testing was applied using the Getis-Ord GI* statistic, again with a 50km bandwidth, to test the difference of each point and its surrounding points from the statewide rate.
The map of the spatial estimates of asthma ED visit rates is shown in Figure 1. For comparison, the same data aggregated at the county level is shown in Figure 2.
Figure 1. Spatial estimates of the relative rate of asthma emergency department
visits, Montana, 2010-2013, Montana Hospital Discharge Data System
Figure 2. County estimates of the relative rate of asthma emergency department
visits, Montana, 2010-2013, Montana Hospital Discharge Data System
We found a trend in overlap of regions with rates higher than the state and American Indian reservations. Of the six regions with rates higher than the state, five overlapped with reservations. Only one of the six reservations did not have a rate detectably higher than average. While a racial disparity in asthma prevalence in Montana has been found in the statewide BRFSS, race is not recorded in the Montana hospital discharge data system. By examining the spatial distribution, we were able to point to a potential racial disparity in ED visit rates. However, the pattern is not as apparent in the county-aggregated map. This could be further examined by including more detailed geographic race distribution data, such as census data, in the analysis.
As with all methods, this one is not without limitations. There is a general bias in this method against detecting small areas with high rates surrounded by areas with low rates. These tend to be estimated to have a lower than actual rate due the lower rates of their surrounding points. For example, geographically small cities with high rates located in regions with low rates outside the city would likely be underestimated. There is also potential bias from the use of ZIP-code area aggregation. The spatial approximation assumes that the rate is constant within each ZIP-code area. Also, the spatial estimates are influenced by choice of bandwidth which is somewhat arbitrary. For this map a 50km bandwidth was chosen to ensure adequate smoothing over ZIP-code boundaries at a state-wide level. However, a smaller bandwidth may have been more appropriate for areas with smaller ZIP code areas, such as major cities. Finally, this method does not take the precision of the ZIP-code area rate estimates into account. Given these limitations, inferences about the true spatial distribution of asthma ED visit rates based on this method should be made with caution.
While the limitations of an indirect spatial estimation using the method outlined above may limit its use for scientific inference, it may be useful for public health planning and communication when other options are not available, especially when used in conjunction with political-area estimates, such as county asthma ED rate estimates in this case. A map of a spatial distribution rather than of a distribution by political boundaries, such as by counties in a state, can be a tool to communicate the geographic distribution of a disease that promotes consideration of environmental factors (in a broad sense, including the social and economic environment as well as the physical) while de-emphasizing the role of local political areas (e.g. counties).
Luke Baertlein, MPH is an epidemiologist for the Asthma Control Program at the Montana Department of Public Health and Human Services. For more information about environmental health issues related to asthma, visit CSTE’s Environmental Health / Occupational Health / Injury Steering Committee page.
Posted By Sarah L. Stone,
Friday, October 23, 2015
Updated: Friday, October 23, 2015
What do you think of when someone says “Massachusetts?” Maybe you think of the Boston Marathon, our famous chowda’ or Paul Revere’s midnight ride. Or, if you’re a maternal and child health (MCH) epidemiologist, maybe you think of our leadership in healthcare. With four medical schools and ten neonatal intensive care units—nine of which are within birthing hospitals with advanced obstetrical care units— Massachusetts is able to provide excellent clinical care to our most vulnerable infants and their mothers. Massachusetts is now recognized as having one of the lowest infant mortality rates in the country at less than 42 deaths per 10,000 live births. Yet our MCH excellence also extends beyond the hospitals, directly to the communities. The framework that supports Massachusetts as a MCH leader comes from the Title V program. Title V is a federal–state partnership that focuses on improving the health of all mothers and children. Title V is administered by the Health Resources and Services Administration (HRSA)/ Maternal and Child Health Bureau (MCHB) and has its roots in the Children’s Bureau of 1912 and Title V of the 1935 Social Security Act. Title V supports core public health functions of assessment, policy development and assurance through surveillance, education, community partnerships and outreach, policy development, linking services to those in need, and increasing MCH capacity.
The start of my CDC/CSTE Applied Epidemiology fellowship at the Massachusetts Department of Public Health coincided with the national five-year Title V block grant (TVBG) application cycle for 2016-2020 and our state’s five-year needs assessment, which is a year-long process. The statewide needs assessment entailed reviewing all current MCH programs and evaluating data from national and state surveys to create a picture of the state’s MCH needs. Beyond National Performance Measures, on which every state reports, states draft seven to ten priorities to address MCH needs for the next five years. These priorities focus on women of reproductive age, mothers and their children from birth through young adulthood, as well as children and youth with special health care needs and their families.
With so many possibilities, how were we to decide our priorities? As epidemiologists do, we started with quantitative data. We analyzed data as diverse as Vital Records, the National Survey of Children’s Health, the National Survey of Children and Youth with Special Health Care Needs, the Pregnancy Risk Assessment Monitoring System and the Massachusetts Youth Health Survey, to name just a few. But quantitative data alone were not enough. It was crucial to listen directly to the voices of the Commonwealth. Through 67 internal and external key informant interviews, we identified the most important issues for the MCH population for the next five years. We then held 14 focus groups with residents across Massachusetts, in English, Spanish and Vietnamese. These focus groups, which included pregnant and parenting teens, low-income mothers, non-English speaking families, lesbian, gay, bisexual, transgender or questioning (LGBTQ) adolescents, parents of children and youth with special health care needs, military families, fathers, and families facing housing insecurity, allowed us to hear first-hand of residents’ needs as well as their suggestions for strategies. We also considered current Title V MCH programs—were they making a difference? One Title V program, the Early Intervention Partnership Program (EIPP), a high-risk maternal and newborn screening, assessment and service system, told us of a recent event. One of the EIPP nurses was scheduled to meet with a pregnant mom for an initial visit and comprehensive assessment. The assessment began and when the nurse asked about her physical health and asked about any problematic symptoms, the mom discussed that she had started bleeding that morning. The mom was just going to wait until the next visit with her doctor to share this information. The EIPP nurse called 911 and both went to the ER. The baby was born prematurely but safely, and both mom and baby are now thriving. Without EIPP and their home visiting services, it is unlikely that this story would have had a happy ending.
We combined our qualitative information with quantitative data and used an iterative process to propose ten Massachusetts priorities (Table 1 and TVIS screenshot) that reflected our state’s needs, while also aligning with HRSA/ MCHB’s National Performance Measures. We then developed a state action plan, aligning specific objectives, strategies and evidence-based measures to each priority, detailing what we plan to achieve, and how we will do it. Finally, a full year after we began, we submitted our TVBG needs assessment and state action plan. But we aren’t done yet. States are held accountable for achieving progress on these priorities through annual reports. The action plan provides a roadmap to accountability and progress. In every annual report, we ask ourselves: Are we successfully addressing our chosen priorities? Do we see our strategies making a difference in outcomes? Do we need to revise our objectives or strategies? It is this iterative process of data evaluation and listening to residents that is key to our ability to serve the MCH population.
We have come a long way in improving the health and lives of mothers and children since the Children’s Bureau was established—a time that saw one in five children die before reaching their fifth birthday, and a maternal death rate of one mother’s death per every 150 live births. The Title V program is an integral part of that improvement, continuing to help mothers and their families achieve the best health outcomes possible.
Sarah Lederberg Stone, PhD, MPH is a CDC/CSTE Applied Epidemiology fellow at the Massachusetts Department of Health. If you would like to contribute to the public health field like Sarah, the Applied Epidemiology Fellowship application has just opened. If you are a CSTE member and would like to learn more about MCH, join the MCH Subcommittee.
Posted By Rachel Jantz,
Friday, October 16, 2015
Updated: Friday, October 16, 2015
Unintentional poisoning has become the leading cause of injury death in Oklahoma. Of the more than 4,600 unintentional poisoning deaths from 2007-2013, 78% involved prescription drugs and 87% of those deaths involved opioid analgesics. In Oklahoma, a particular challenge to preventing opioid-related mortality is opioid use in rural areas that have long transport times from the scene to an emergency room. Some emergency medical service agencies report transport times of 45 minutes or longer; in the case of an opioid overdose, this is critical time in ensuring patient survivability. In such a scenario, the use of naloxone, an opioid antagonist that reverses the effects of opioids, can be lifesaving.
Legislation passed during the 2013 session in Oklahoma that authorized trained family members, friends, and first responders to obtain and administer naloxone. Although HB 1782 became law, few emergency medical service agencies adopted the protocol to carry naloxone (paramedics, however, were previously authorized to administer the drug). In Oklahoma, these non-paramedic-level agencies cover the majority of the rural areas of the state, and the lack of naloxone coverage represented a crucial gap in the prevention of opioid-related mortality.
To expand naloxone usage, the Oklahoma State Department of Health (OSDH) developed a training program to educate emergency medical personnel across Oklahoma about intranasal naloxone administration and to equip agencies with naloxone kits. As a CDC/CSTE Applied Epidemiology Fellow in the Injury Prevention Service at the OSDH, I had the opportunity to become involved in this important learning experience: using epidemiologic skills to evaluate a public health program and policy effectiveness involving other partner agencies to address the epidemic of prescription drug overdose.
From January to July 2015, the OSDH provided eight trainings across the state for emergency medical personnel and encouraged trainees to train others at their agency and nearby agencies. An interagency collaboration with the Oklahoma Department of Mental Health and Substance Abuse Services provided naloxone kits and training materials. As of August 31, 2015, a total of 754 emergency medical personnel representing 160 agencies have been trained on intranasal naloxone administration. The OSDH has distributed 328 doses of naloxone and 405 atomizers. Excitingly, the OSDH has received reports of 22 appropriate administrations of naloxone.
In order to evaluate the success of the program, databases were created and maintained to assess the following outcome measures:
Number of emergency medical personnel trained in intranasal naloxone administration;
Results of pre- and post-training surveys;
Number of emergency medical service agencies that adopt an intranasal naloxone protocol;
Number of emergency medical service agencies that sign an MOA and receive naloxone kits and/or atomizers;
Number of naloxone kits and atomizers distributed (starter and replacement);
Number of intranasal naloxone doses administered by emergency medical service agencies; and
Number of appropriate administrations or “overdose reversals.”
As a result of the trainings, the number of agencies adopting the protocol to carry and administer naloxone in Oklahoma has increased by 50%, but further efforts are needed to ensure 100% coverage of naloxone in the state. Next steps include identifying, training, and providing naloxone kits and/or atomizers to emergency medical service agencies that have not been trained on intranasal naloxone administration.
Educating emergency medical personnel about the opioid epidemic and equipping them with a tool to reverse an overdose may reduce opioid-related mortality in Oklahoma. These trainings may also increase the ownership emergency medical personnel feel for the health of their own community. Based on pre- and post-training surveys administered during naloxone trainings, support for the administration of naloxone by emergency medical personnel increased from 71% to 87%, and willingness to administer naloxone to an overdose victim increased from 77% to 91%. As noted by a first responder at a training, “I really wasn't aware of the problem and what we can do for patient care. This is another tool we can use to save lives.”
Rachel Jantz, MPH is a CDC/CSTE Applied Epidemiology Fellow for the Injury Prevention Service at the Oklahoma State Department of Health. For related CSTE discussion and projects, consider joining the Substance Abuse Subcommittee and the Injury Surveillance and Control Subcommittee. The Applied Epidemiology Fellowship application opens October 20, 2015. Apply online by January 13, 2016.
Posted By Bree Allen,
Friday, October 9, 2015
Updated: Friday, October 9, 2015
The Minnesota Department of Health (MDH) has a reputation of being a national leader in outbreak detection and control (despite its portrayal in the 2011 blockbuster film Contagion). As examples, MDH led the 2011 investigation into a national anthrax scare and in 2007, uncovered the mystery of the pig-brain disease that was infecting employees at a Minnesota pork processing plant. I can’t fail to mention the well-known “Team D” or “Team Diarrhea,” a collaboration between graduate students at the University of Minnesota and MDH to investigate suspected food safety issues. Despite these accomplishments, like most health departments, MDH is working to improve interoperability and integration of its information systems with internal and external partners. This interoperability will help create a strong, flexible health IT ecosystem that can support scientific advancement and lead to a continuously improving health system.
I am very fortunate to be working with MDH‘s Office of Health Information Technology (OHIT) during my tenure as a Health Systems Integration Program (HSIP) fellow. OHIT does innovative work in the fields of informatics and e-health, specifically ensuring collaboration and coordination across state government to maximize federal and state investments in health information technology and infrastructure development. As I started the fellowship in June, I quickly learned how OHIT’s informatics work is interconnected with epidemiology, especially surveillance, and how the HSIP Fellowship supports both. My work this year will be done in the informatics realm, supporting the use of data, information, and knowledge to improve population health.
As a state health department we have numerous important information systems that collect, store, and use data for public health functions, including maternal and child health, disease surveillance, and vital statistics. There has been a national push to move toward modernizing public health information systems and to make these systems standards-based and interoperable.
OHIT began inventorying these datasets and the information systems in 2009, with an assessment (which is now a tool for state health departments to assess system needs and opportunities by the Public Health Informatics Institute (PHII)). Given the growing needs for better electronic exchange with data partners and expectations of bidirectional exchanges with the clinical sector, there is a compelling business need for the department to conduct agency-wide assessments of key information systems to better understand exchange capabilities and utilization of standards and to create plans to achieve improved exchange capabilities.
As an HSIP Fellow I am working with OHIT to update the 2009 MDH informatics assessment. We are identifying the needs of current information systems to better support public health practice, to allow for electronic exchange of information, and to aid in planning efforts to modernize public health information systems to become more standards-based and interoperable. The updated assessment outcomes will inform MDH prioritization and coordination of electronic data exchange with external customers including public health reporting for meaningful use. It will also help build a communications dashboard of program readiness and plans for electronic data exchange that can be shared with external customers (e.g., health care providers, hospitals, local health departments) for planning and resource allocation. Ultimately, this informatics assessment will support the creation of an agency-wide strategy to further integrate MDH information systems and to make MDH’s systems more interoperable with both internal and external exchange partners.
Bree Allen is a Health Systems Integration Program (HSIP) fellow at the Minnesota Department of Health. Are you interested in hosting a fellow? HSIP and APHIF host-site applications are now open for a limited time. Learn how to apply for your health department’s own HSIP fellow on www.shinefellows.org.
Posted By Shannon Harney,
Friday, October 2, 2015
Updated: Friday, October 2, 2015
Antimicrobial resistance is a growing concern at the top of many agendas, including for CDC and the White House. Among the multidrug-resistant organisms of greatest concern, are carbapenem-resistant Enterobacteriaceae (CRE), which CDC classified at an “urgent threat level requiring urgent and aggressive action.”
To gain a better understanding of CRE in Tennessee, we described the geographic distribution of cases reported to the state-reportable disease surveillance system in 2014. Cases with carbapenem-resistant Enterobacter spp., Escherichia coli, or Klebsiella spp. were included. A total of 143 cases were identified for 2014, with one person testing positive for two different carbapenem-resistant genera of bacteria.
For reference, below is a map depicting the major cities in Tennessee by population size.
Figure 1. Major Cities in Tennessee
Marked geographic differences were observed in the distribution of cases by genera, with possible clustering of Klebsiella spp. cases in the northeast and Enterobacter spp. cases in the Memphis and western Tennessee areas.
Figure 2. Cases of CRE by County of Residence, By Genera
Cases were further mapped with respect to the county population size to calculate rates, which indicated the greatest burden of CRE was in two counties in western Tennessee, outside of the Memphis metropolitan area.
Figure 3. Annual Incidence Rate by County of Residence, All Genera
The cases also were depicted according to the healthcare facility laboratory responsible for identifying the CRE, which highlighted facilities in western and northeastern Tennessee, as well as in the Chattanooga area.
Figure 4. Cases of CRE by Healthcare Facility Laboratory, All Genera
Based on this information, one of the healthcare facilities with a large case number was selected for further investigation. The facility provided a line list of cases for the 2014 period, specifying if each case was an inpatient (including emergency department patients) or outpatient, and if the cases were nursing home residents. Interfacility transmission is believed to be a key contributor to the spread of multidrug-resistant organisms in healthcare facilities, and therefore investigating the source of each case may be helpful for intervention. Nursing home residents comprised 43% of the inpatient/emergency department patients, and 55% of outpatients tested, suggesting patients from nursing homes may be important to interfacility transmission.
Figure 5. Cases of CRE by Admission Status and Nursing Home Status, Hospital A
To identify which nursing homes could be targeted for enhanced interfacility communication and infection control practices, cases were counted and ordered by nursing home of residence (de-identified).
Figure 6. Cases of CRE by Nursing Home, Hospital A
These two figures highlight the importance of understanding the connectedness of facilities when caring for patients, and of facilities in a region working together to prevent transmission. Furthermore, the collaboration between healthcare providers and public health can enhance our understanding of emerging infections and guide intervention efforts.
Our next steps will include sharing these data with the broader healthcare audience for improved situational awareness among clinicians and public health professionals. These data, along with the pending analysis of the 2015 data, will be used as the foundation to address CRE at a regional level.
Shannon Harney, MPH is a CDC/CSTE Applied Epidemiology fellow in Communicable and Environmental Diseases and Emergency Preparedness for the Healthcare Associated Infections Program at the Tennessee Department of Health. For more information on antibiotic resistance activities, read Marion Kainer and Jeffrey Engel’s article “CSTE Supports Antibiotic Resistance Stewardship.” The Applied Epidemiology Fellowship application opens October 20, 2015. Apply online by January 13, 2016. Prospective host sites may submit an application until October 16, 2015 to host a fellow.
Posted By Valerie Goodson and Amanda Masters,
Friday, September 25, 2015
Updated: Friday, September 25, 2015
CSTE is pleased to announce the onboarding of Class XIII, featuring a record-breaking class of 35 fellows. Beginning in 2003, the CDC/CSTE Applied Epidemiology Fellowship has focused on providing a high-quality training experience. Growing steadily from 10 fellows in Class I to approximately 30 fellows each year since 2009, CSTE’s goal of placing fellows in local and state health departments under the guidance of two experienced mentors has helped to develop the careers of over 300 epidemiologists. The 35 fellows placed in 30 different jurisdictions is exciting news for the organization’s staff, partners and funders.
On August 31, 2015, CSTE welcomed the 35 epidemiologists to Atlanta, GA for a week-long training geared toward preparing them for the next two years and a future career in epidemiology. The training featured sessions delivered by the Centers for Disease Control and Prevention (CDC) on surveillance, effective communication strategies, Epi Info software, cultural competency, and questionnaire design. Fellows had an opportunity to network with local program alumni and visited with their subject-area-specific colleagues during a half-day visit. Special sessions taught by the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Association of Maternal and Child Health Programs (AMCHP) gave fellows the opportunity to learn more about how challenges in one area link to others.
The subject areas fellows are placed in include: Behavioral Health (4), Environmental Health (3), Environmental Health – Waterborne Diseases (3), Infectious Diseases (8), Infectious Diseases – Food Safety (1), Infectious Diseases – Healthcare Associated Infections (9), Infectious Diseases – Quarantine (1), Injury – Drug Overdose (2), and Maternal and Child Health (4). While at their various health departments, fellows will have opportunities to participate in a surveillance system evaluation, a major project, and an outbreak, preparedness and response, and general surveillance activities.
A few projects expected during the next two years are:
Evaluation of Carbapenem-resistant Klebsiella Pneumoniae surveillance in Los Angeles County, 2010-2012, Chelsea Foo, MPH
Regional Antibiograms for the state of Alaska, Anna Frick, MPH
Assessing the impact of rural/urban designation on alcohol outlet density in New Mexico, Naomi Greene, MPH
Adverse childhood experiences and health outcomes across the life course in Maine, Emily Morian-Lozano, MPH, MSW
Identifying and prioritizing population health metrics for the Colorado state Innovation Model , Allison Rosenthal, MPH
Prescription opioid medications taken while pregnant and the outcome of neonatal abstinence syndrome among offspring, a retrospective cohort analysis in Tennessee, 2013-2014, Elizabeth Thomas, MPH
Healthcare system use before and after a drug-related poisoning using Minnesota’s all-payer claims database, Nate Wright, MPH
Kansas prescription drug overdose surveillance system plan, Fan Xiong, MPH
Impacts of harmful algal blooms on the health of Ohio’s most vulnerable populations, Amanda Zabala, MPH
With a mission to meet the nation's ongoing need for applied epidemiology workforce capacity in state and local health departments through a national fellowship-training program, CSTE looks forward to working with and watching this new group of fellows grow into confident epidemiologists.
Valerie Goodson is Workforce and Fellowship Coordinator and Amanda Masters is Director of Workforce Development at CSTE. The 2015-2016 CDC/CSTE Applied Epidemiology Fellowship host-site application is now open and the candidate application will launch October 20, 2015. For more information about the fellowship program, please visit http://www.cste.org/?page=Fellowship.
Posted By Arrol Sheehan, Mary McIntyre, Melissa Morrison, Cassie Brailer, and Kelly Stevens,
Friday, September 18, 2015
Updated: Friday, September 18, 2015
Upon learning that there was a rapid rise in emergency room visits, hospitalizations and poison center calls related to use of synthetic cannabinoids, the ADPH Epidemiology Division (EPI) of the Bureau of Communicable Diseases responded quickly to protect the health of the public.
A Health Alert Network (HAN) notification was issued and health care providers statewide were asked to consider exposure to synthetic cannabinoids, also known as Spice, as a diagnosis for patients presenting with the following symptoms: rapid heart rate, nausea and vomiting, agitation, confusion, lethargy, hallucinations, paranoia, kidney and respiratory problems.
ADPH also actively engaged the media to inform the public. Dr. Mary G. McIntyre, State Epidemiologist, emphatically cautioned the public, "Responses to these chemicals can be unpredictable and deadly. People have experienced coma, kidney failure, and heart attacks just to mention some of the effects experienced by users. Please do not take the risk. Do not use these products."
EPI field surveillance staff contacted hospitals on a weekly basis to monitor the numbers of emergency room visits and hospitalizations; reports were provided by 82 of the 99 Alabama hospitals. During the surveillance period of April 15 to May 28, 1,046 emergency room visits and 259 hospitalizations were reported; however, those are likely underestimates. Five deaths were reported, with ages of the deceased ranging from the 20s through the 40s.
Additionally, a review of Alabama Emergency Medical Services Information System (EMSIS) data identified 693 emergency calls for spice-related exposure in April and May, compared to only 105 for January through March. The demographics of the 693 patients are as follows: 572 (83%) were male, 497 (72%) were black or African American, 179 (26%) were white, 9 (1.3%) were American Indian or Alaska Native and 12 (2%) were Hispanic. The patient ages ranged from 9 to 67 years with a mean of 31 and median of 27.
In July, the staff gathered for a videoconference to review the outbreak and share lessons learned. Future plans include collaboration between EPI and the Office of Emergency Medical Services to incorporate EMSIS data into surveillance activities so that similar events will be identified sooner. ADPH plans to reach out to providers through the Medical Association of the State of Alabama (MASA) to further raise awareness of signs and symptoms and to educate providers on recommendations for management.
This article was adapted from the article of the same name written by Arrol Sheehan, MA, and published in Alabama’s Health, August 2015, Volume 48, Number 3, a Publication of the Alabama Department of Public Health. This article was written by Arrol Sheehan, M.A., Public Information Manager; Mary G. McIntyre, M.D., M.P.H., State Epidemiologist and ASHO for Disease Control & Prevention; Melissa Morrison, M.P.H., Commander, US Public Health Service; Cassie Brailer, B.S., Public Health Associate; and Kelly Stevens, M.S., Director, Epidemiology Division. Join the CSTE Marijuana Subcommittee for discussion, publications, and resources surrounding related risk issues.
Acknowledgements
The Spice team includes the following Central Office staff and the FSS from each area:
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While on this workgroup, I learned a lot from the discussions regarding challenges other jurisdictions encounter when publishing these important data. Coming from a rural and less populated state, we struggle with having robust enough data to present information for certain measures and facility types. I know we are not the only state working within this context and it was helpful learning from others with similar experiences. I kept this in mind when providing feedback on the toolkit and the need to provide an option to states that have comparable restrictions. Similarly, I used our own experience in NH to help contribute to the healthcare personnel vaccination component of the template. Several approaches are addressed and made available within the toolkit in order to provide flexibility to states.
What do you think of when someone says “Massachusetts?” Maybe you think of the Boston Marathon, our famous chowda’ or Paul Revere’s midnight ride. Or, if you’re a maternal and child health (MCH) epidemiologist, maybe you think of our leadership in healthcare. With four medical schools and ten neonatal intensive care units—nine of which are within birthing hospitals with advanced obstetrical care units— Massachusetts is able to provide excellent clinical care to our most vulnerable infants and their mothers. Massachusetts is now recognized as having one of the lowest infant mortality rates in the country at less than 42 deaths per 10,000 live births. Yet our MCH excellence also extends beyond the hospitals, directly to the communities. The framework that supports Massachusetts as a MCH leader comes from the Title V program. Title V is a federal–state partnership that focuses on improving the health of all mothers and children. Title V is administered by the Health Resources and Services Administration (HRSA)/ Maternal and Child Health Bureau (MCHB) and has its roots in the Children’s Bureau of 1912 and Title V of the 1935 Social Security Act. Title V supports core public health functions of assessment, policy development and assurance through surveillance, education, community partnerships and outreach, policy development, linking services to those in need, and increasing MCH capacity.
To expand naloxone usage, the Oklahoma State Department of Health (OSDH) developed a training program to educate emergency medical personnel across Oklahoma about intranasal naloxone administration and to equip agencies with naloxone kits. As a CDC/CSTE Applied Epidemiology Fellow in the Injury Prevention Service at the OSDH, I had the opportunity to become involved in this important learning experience: using epidemiologic skills to evaluate a public health program and policy effectiveness involving other partner agencies to address the epidemic of prescription drug overdose.
This article was adapted from the article of the same name written by Arrol Sheehan, MA, and published in Alabama’s Health, August 2015, Volume 48, Number 3, a Publication of the Alabama Department of Public Health. This article was written by Arrol Sheehan, M.A., Public Information Manager; Mary G. McIntyre, M.D., M.P.H., State Epidemiologist and ASHO for Disease Control & Prevention; Melissa Morrison, M.P.H., Commander, US Public Health Service; Cassie Brailer, B.S., Public Health Associate; and Kelly Stevens, M.S., Director, Epidemiology Division. Join the