On June 2, 2015, the Council of State and Territorial Epidemiologists (CSTE) was one of 150 organizations invited to the White House Forum on Antibiotic Resistance. Representing CSTE was Dr. Marion Kainer, Tennessee Department of Health epidemiologist, and chair of the CSTE Healthcare Associated Infections Subcommittee.

Combatting antibiotic resistant bacteria (CARB) became a presidential priority when the National Strategy for CARB (URL ref. 1) was released in September 2014, and in 2015 President Barack Obama requested $1.2 billion of new funding to address the strategy in his FY 2016 federal budget. In this proposed budget, the Centers for Disease Control and Prevention (CDC) portion is $264 million, a line item that CSTE heavily advocated for during our Capitol Hill visit on March 25, 2015. The National Action Plan for CARB (URL ref. 2) was released in March 2015, a few days after the CSTE Capitol Hill visit.

The new CDC funding would go primarily to the Division of Healthcare Quality Promotion (DHQP) in the National Center for Emerging and Zoonotic Infectious Diseases (NCEZID). Importantly for CSTE members, a portion of the new funding would establish antibiotic resistance and antibiotic use monitoring capacities in state and local health departments. Channeled through the Epidemiology and Laboratory Capacity grant, this capacity building would include a coordinating epidemiologist position and strengthened surveillance with healthcare providers using both the National Health Safety Network and the National Notifiable Diseases Surveillance System. The CSTE national office will benefit as well with expansion of the Applied Epidemiology Fellowship program to include workforce development in antibiotic resistance surveillance and antibiotic use monitoring.

To launch the CARB initiatives and encourage Congress to support the proposed funding, the Executive Office of the President hosted a White House forum. As part of the event, more than 150 food companies, retailers, and human and animal health stakeholders highlighted commitments to implement changes over the next five years to slow the emergence of resistant bacteria and prevent the spread of resistant infections.

The forum started in the Eisenhower Executive Office (EEO) where it was announced that President Obama just signed a presidential memorandum directing federal departments to buy meats and poultry that have been raised using responsible antibiotic-use policies. The forum was opened by Dr. John Holdren, the Director of the Office of Science and Technology Policy, and included addresses by Health and Human Services Secretary Sylvia Burwell, Secretary for Agriculture Tom Vilsack, and CDC Director Tom Frieden. A-five member panel described commitments from their respective organizations; panelists included representatives from human health (acute care and long-term care), the animal health industry, Walmart, and Tyson foods. Walmart stated that in an effort to provide safe, affordable and sustainable food, they are asking meat producers, eggs suppliers and others to use antibiotics only for disease prevention or treatment and not for growth promotion. All five panelists stated that there was a very good business case for antibiotic stewardship. Dr. Jonathan Perlin (from the American Hospital Association and HCA) described the 5 “D”s of antimicrobial stewardship: right Diagnosis, Drug, Dose, Duration and appropriate De-escalation. A video of the opening panel can be found on the White House website.

• Optimal use of data
• The need for meaningful and valid measures
• The importance of transparency
• The ongoing need for better surveillance
• Financial incentives
• Better tools (especially diagnostics that communicated results not only to the provider at the point of care, but also to the electronic health records)
• A need for a “culture change” in healthcare and education and training, including meaningful involvement of patients, families and consumers

Multiple attendees were able to ask questions of the panelists and share perspectives. The human face of antimicrobial resistance was highlighted by the attendance and comments of family members of patients who suffered and/or died from the consequences of antimicrobial resistance.

The CARB initiative is broad in scope, engaging the animal and human health enterprise, the public and private sector, and interventions from prevention to new drug development. CSTE is committed to be the voice for prevention and improved surveillance of antibiotic resistance and use as it affects human health; always at the cutting edge of program and workforce development in applied epidemiology for public health practice.

In January 2015, the Illinois Department of Public Health (IDPH) received a measles case report, the initial case identified in what soon became the second-largest US measles outbreak, with 15 confirmed cases and many exposed contacts in suburban Cook County in 2015. IDPH had recently acquired Research Electronic Data Capture (REDCap) from Vanderbilt University, a free and secure web application for building and managing online surveys and databases. REDCap is accessible through computers, tablets, and smartphones.

REDCap was being evaluated and tested for symptom monitoring in Ebola contacts, when the measles outbreak began. The robust and customizable functionality in REDCap allowed IDPH to rapidly mobilize the tool to support the local health department’s measles contact investigation. IDPH’s Applied Public Health Informatics Fellow, Jennifer Vahora, quickly modified the Ebola module she had built the month before in order to create a measles-specific questionnaire.

IDPH worked with the Medical Research Analytics and Informatics Alliance, a non-profit entity that supports the development and maintenance of the Public Health Node (PHN). The Public Health Node, as an agent of IDPH, connects directly to the Illinois Health Information Exchange and supports the technical receipt, aggregation and transformation of data sent to IDPH for the purpose of collecting Meaningful Use data from hospitals and providers, as well as the eXtensively Drug Resistant Organism (XDRO) registry.

Within 72 hours, the measles module was ready to be demonstrated and deployed by local health departments. The survey instrument was demonstrated to the Cook County and Chicago Departments of Public Health. Whitney Clegg and AJ Beron, two IDPH CDC/CSTE Applied Epidemiology Fellows, were trained to use REDCap and lead REDCap response activities at Cook County.

Within three days of the demonstration, Cook County deployed the REDCap survey instrument and offered REDCap to 33 (52%) of 63 low-risk contacts. After initial phone communication with contacts to explain the electronic monitoring option, REDCap was offered to contacts as an alternative to daily phone calls to report body temperature and the presence of symptoms. Seventeen contacts (52%) completed at least one survey. In a post-evaluation discussion, Cook County staff indicated that REDCap reduced staff time and effort necessary for monitoring low-risk contacts, made follow-up easier, and the layout enabled a quick review for detecting contacts who failed to report their symptoms daily. To enhance the tool for future use, Chicago and Cook County requested Spanish and Polish language translation, a vaccination history data collection tool, and the ability to manage multiple contacts within one household.

IDPH presented its experience with REDCap on a CSTE webinar on state innovations in active monitoring with the Georgia Department of Public Health. To date, IDPH has received inquiries from four state and local health departments and one international institute. IDPH is currently working to develop a protocol for the use of REDCap in outbreaks, modify the existing REDCap project to meet LHD needs, and expand use of REDCap for foodborne illness outbreaks, rabies animal testing, and sharing of lab testing information. While IDPH’s use of REDCap is evolving, it has the potential utility for additional public health surveillance activities and future collaborations with other public health jurisdictions.

In early January 2015, a University of Oregon undergraduate student who lived off campus developed fever, hemorrhagic conjunctivitis, and a non-blanching rash, but no symptoms of meningitis. Blood cultures yielded Neisseria meningitidis, serogroup B. Lane County Public Health staff identified close contacts and arranged for antimicrobial prophylaxis.

Without prompt antibiotic treatment, meningococcal disease is essentially 100 percent fatal. Those who survive may have negative long-term health effects (e.g. hearing loss, loss of limbs, etc). Household members of cases have an attack rate 500 to 1,000 times higher than the general population.¹ Even with antibiotics, the fatality rate among cases reported in Oregon during 2005 to 2014 was 8.5 percent.

Meningococci come in 13 flavors, called “serogroups.” Of these, serogroups B, C, and Y each cause about one third of cases in the United States.² Quadrivalent polysaccharide and conjugate vaccines are available US to prevent disease caused by serogroups A, C, Y and W135. Since October 2014, the FDA has licensed two new vaccines that protect against serogroup B: Bexsero® (a two-dose series) and Trumenba™ (three doses).

Seventeen days after the first U of O case, another student developed signs of meningococcemia, the diagnosis of which was confirmed by blood culture yielding N. meningitidis, serogroup B. Again, Lane County Public Health worked with U of O to identify close contacts and arranged prophylaxis. No epidemiologic link between the two ill students could be identified. The day after the second student fell ill, a third U of O undergrad developed malaise and possible fever; a few days later this student was admitted to hospital where serogroup B meningococcemia was confirmed. An epidemiological link was identified with one of the earlier ill students, and again close contacts were given antimicrobial prophylaxis.

Two-and-a-half weeks later, a fourth student developed severe meningococcemia and died. CDC recommends that broader community vaccination be considered when ≥3 cases of infection by a single meningococcal serogroup have occurred within a three-month period, without direct epidemiological links between the cases, and yielding an attack rate of >10 cases per 100,000 in the community at risk.⁴ The lack of direct links between cases implies that the infection has escaped the ring of antimicrobial prophylaxis and signals risk to the broader group: the cat has gotten out of the bag.

Vaccines were offered to students at the Student Health Service and then through local pharmacies. The U of O arranged for vaccinators and undertook a mass vaccination campaign using Trumenba™ at the campus basketball arena March 2-6. Through the Student Health Service, Lane County Public Health, pharmacies, and the mass vaccination effort on campus, approximately 8,800 students were immunized. Despite school being in session, news of the event ubiquitous on campus, mass vaccination clinics, and incentives of free t-shirts, store gift cards, and, yes, even pizza, more than 13,000 students remained unvaccinated.

Two more cases of serogroup B meningococcemia have since been confirmed. Vaccination efforts continue, and as of 28 March, 9,193 students had been immunized — 42 percent of the 22,000 target group, which is the entire undergraduate population at the University.

Collaborative Effort

• Only 58% of respondents published work in the peer-reviewed literature as a job function.
• State health department epidemiologists were nearly twice as likely to report that publishing their work was a requirement of a funding source as local health department epidemiologists.
• Publishing among those with academic appointments (19% of the sample) was statistically more likely than among applied epidemiologists who did not have an academic appointment.
• Just over half of the respondents reported having access to peer-reviewed literature (55%), oftentimes through academic appointments.
• Organizational structure, resources, and competing demands provide a better understanding of perceived barriers to scientific writing with time to write being the most common barrier expressed by 68% of applied epidemiologists, though 28% report they receive some protected time for this task.
• Facilitating factors that influence scientific writing in health departments included: supportive organizational culture; technical support including writers, editors and communication specialists; access to peer-reviewed literature; university partnerships and the option for electronic publishing.
• Templates for general publications were requested by about half of participants.
• Access to a mentoring network of experienced writers from state and local health departments was also similarly desired, and access to editors (46%) and access to technical writers (44%) were also suggested as helpful.
• A journal club to encourage publishing and peer review was requested by two out of every five respondents.

A roundtable discussion will be held at the 2015 CSTE Annual Conference on Monday, June 14, 2015 at 1pm. The roundtable will provide an opportunity to talk about what types of resources can be developed and prioritized to support applied epidemiologists’ scientific writing.

The Applied Epidemiology Scientific Writing Trends, Needs, and Recommendations, 2014 report was created as a result of the hard work of the Scientific Writing Workgroup: Michelle Housey, Sarah Marikos, Sarah Patrick, Jessica Pittman, Maayan Simckes, Mandy Stahre, Laura Tolmedi, and Jessica Wurster.