Between 2013-2021, sequestration’s harmful cuts shrink the amount of appropriated funding available for epidemiology, public health, and all core government functions by $1 trillion. During the last two years, we have experienced some temporary and partial sequestration relief, thanks to the Bipartisan Budget Act of 2013 negotiated by Rep. Paul Ryan and Senator Patty Murray. But sequestration returns full bore in 2016, and unless Congress acts to stop it, overall funding levels for appropriated programs, such as public health, will be 17 percent less than they were in 2010, in real terms. Under this scenario, it will be difficult if not impossible for any boats to rise.

When there’s more health funding to go around, the better the chances that our own health funding priorities—ELC grants, workforce development—do well, and vice versa (case in point: the elimination of $15 million in public health workforce funding in 2013 when sequestration first took effect). That’s why for many years CSTE has augmented our advocacy efforts to keep our own epi boat afloat by joining with our partners in the community to ensure a strong and sustained investment in health funding, writ large.

Celebrating its 45th year, the Coalition for Health Funding is the leading voice for a strong and sustained investment in the health continuum—from public health to health research and primary care services to health workforce. CSTE and 95 other national health organizations, including Association of State and Territorial Health Officials (ASTHO), National Association of County and City Health Officials (NACCHO), and Society for Healthcare Epidemiology of America (SHEA) among them, work through the Coalition to educate lawmakers about the value of health programs and the impact of funding cuts. In July 2014, CSTE contributed a story about the erosion of ELC funding for vector-borne disease surveillance to the Coalition’s report, Faces of Austerity: How Budget Cuts Hurt America’s Health. The report was shared with and has been used by lawmakers, the administration, and the media. Our story and those of other Coalition partners are available at www.cutshurt.org.

CSTE also actively participates in the Coalition’s NDD United campaign, named by The Hill newspaper as one of the “Top 10 Lobbying Victories of 2013.” NDD United is an alliance of thousands of national, state, and local organizations working across sectors to stop sequestration and protect nondefense discretionary or “NDD” programs. NDD programs are core functions the government provides for the benefit of all Americans—benefits such as public health and education, housing and social services, infrastructure and transportation, science and law enforcement, veterans services and homeland security, energy and natural resources, etc. On February 18, CSTE joined 2,100 other organizations in signing a letter coordinated by NDD United, urging Congress to stop sequestration before it returns in 2016. A copy of the letter is available here.

CSTE will continue to advocate for an end to sequestration, and for a strong and sustained investment in the nation’s disease surveillance infrastructure. For more information about these and other efforts, please contact me at eholubowich@dc-crd.com.

For the 2015 Annual Conference, CSTE is pleased to announce Dr. Paul Farmer as the Jonathan Mann Memorial Lecturer. Dr. Farmer obtained an M.D. and Ph.D. in anthropology from Harvard University, and is board certified in internal medicine and infectious diseases. He is the co-founder of an international social justice and health organization, Director of Partners in Health,  and is renowned for his years of nonprofit leadership, numerous awards, and insightful publications on global health. Read Dr. Farmer’s biography on the conference website.

• Mary T. Bassett, MD, MPH: Commissioner of the New York City Department of Health and Mental Hygiene
• Devra Lee Davis, PhD, MPH: Founding Director of the world’s first Center for Environmental Oncology and President of the Environmental Trust
• Richard Jackson, MD, MPH: Professor of Environmental Health Sciences at University of California, Los Angeles and former Director of the CDC National Center for Environmental Health
• Anne Schuchat, MD: Director of the CDC National Center for Immunization and Respiratory Diseases and Assistant Surgeon General of the United States Public Health Service
• Nancy Krieger, PhD: Professor of Social Epidemiology at Harvard University
• Pardis Sabeti, MD, DPhil: Associate Professor at the Center for Systems Biology at Harvard University

• Advanced molecular detection to improve food safety
• Respiratory diseases, Chikungunya, measles, shigellosis Enterovirus D68, and Ebola
• Health impacts for 9/11 rescue and recovery workers
• Maximizing the benefits of advances in informatics
• Marijuana-associated hospitalization rates and usage surveys
• Novel approaches to collecting data with hard-to-reach populations
• Addressing the challenges of Hepatitis C surveillance
• Climate change and environmental impacts on disease
• Addressing quality of life in older adulthood

In addition to the wide array of rapid-fire, breakout, and plenary sessions, you’ll have the opportunity to participate in a variety of activities. Conference festivities include the opening reception, connections reception, and 5K walk/run. There is also a banquet at additional cost. CSTE will present awards for outstanding leaders, partners, fellows, mentors, poster presentations, and more.

This year’s conference features a new phone app to help you schedule sessions, connect to other attendees, see conference news alerts, access an interactive floorplan, and learn local information for restaurants and activities around the Hynes Convention Center.

If you register for the conference before May 1, you can receive the early-bird discount. If you aren’t already a member, joining CSTE will allow you to get the most out of the conference experience, develop your professional capacity, network, and more. The many benefits of yearlong membership are highlighted in this new video:

https://www.facebook.com/video.php?v=1040282089318703 (Please watch in HD)

CSTE President Alfred DeMaria, Jr., MD is state epidemiologist of Massachusetts. For more information about the 2015 CSTE Annual Conference, please visit http://www.csteconference.org.

Measles is a highly contagious vaccine-preventable disease that typically presents with a high fever and characteristic rash. Although it was declared eliminated from the United States in 2000, measles outbreaks still occur among unvaccinated children and adults due to importation of cases from countries where the disease remains endemic. As CDC/CSTE Applied Epidemiology fellows at the Illinois Department of Public Health, along with former CSTE fellowship alum Kelley Bemis, we had the unusual opportunity to respond to a measles outbreak connected to a suburban Chicago childcare center.

In January 2015, Illinois public health officials were notified of an adult with a febrile rash who tested positive for measles. This individual reported an unknown vaccination history and denied recent travel or exposure to ill individuals. By the middle of February, 14 additional measles cases had been identified. Twelve of these cases were infants that attended the same childcare center and were not old enough to receive the measles, mumps, and rubella (MMR) vaccine. Although no definite link to the index case was established, all cases resided in the same geographic area or attended childcare there. Of the 14 cases that were laboratory-confirmed PCR positive by the Illinois State Public Health Laboratory, nine were genotyped and found to be measles genotype B3. This genotype was also identified in a recent multistate outbreak linked to a Disney theme park in California and a large outbreak in the Philippines. The genotype has been detected in at least 14 countries and six U.S. states in recent months..

After the first case was identified, a public health investigation was initiated to prevent further spread of the virus in the affected communities. Because measles is highly infectious, it was necessary to perform extensive contact tracing and obtain thorough travel histories for each infected individual. We worked to determine locations each of the individuals visited during their infectious period. Identified exposure settings included places of employment, pediatric clinics, grocery stores, and other public settings.

Each location was notified about the potential measles exposure, and lists of potentially exposed individuals were compiled. For public locations, such as grocery stores, where it was difficult to identify exposed individuals, press releases were issued to notify the public. All identified contacts were asked about their vaccination status and educated about the signs and symptoms of measles. The incubation period of measles is seven to 21 days, so susceptible individuals were monitored via phone or email for three weeks following their last measles exposure.

Another critical component of the investigation involved determining the vaccination history of individuals that work with a susceptible population(s), which included employees at the implicated childcare center and healthcare workers at the exposed pediatric clinics and community hospital. We found that not all employees knew their MMR vaccination status. Not only did this lead to difficulties for the investigators, but determining employee vaccination history was a large task for the staff of the childcare center, community hospital, and affected pediatric clinics.

As a result of our investigation, we were able to coordinate and implement appropriate control measures to prevent further spread of the disease. This included isolating cases during their infectious period, excluding susceptible contacts from high-risk settings, coordinating community vaccination clinics, and providing post-exposure prophylaxis to contacts when applicable.

A majority of the cases in this outbreak were among a vulnerable population. Infants are not recommended to be vaccinated with their first dose of MMR until they are 12 to 15 months of age, leaving them susceptible to measles. Young children are also at a higher risk of developing measles-related complications, such as pneumonia or encephalitis. For these reasons, vaccination of children and adults with the MMR vaccine following the recommended schedule is pivotal for protecting vulnerable individuals. Additionally, this outbreak highlights the need for those who have regular contact with vulnerable populations, such as healthcare workers and staff of childcare centers, to be properly vaccinated with documentation readily available to their employers. With the guidance and support from our mentors and colleagues, the work we accomplished in this outbreak has given us a unique and invaluable experience in the field of applied epidemiology.

A central epidemiologic methods core competency for CDC/CSTE Applied Epidemiology fellows is to write a field investigation report of an infectious disease outbreak. During my fifth month as a fellow assigned at the Fulton County Department of Health and Wellness in Atlanta, Georgia, an exciting opportunity to fulfill this competency arose.

On December 10th 2014, Fulton County Department of Health and Wellness (FCDHW) was notified of a cluster of persons with acute gastroenteritis. It was reported that illness was occurring in students, parents, staff and other guests who had attended an end-of-the-year high school sports team banquet on December 8th and that up to 150 attendees may have been ill. The epidemiology branch at FCDHW conducted a field investigation to determine the scope of the outbreak, find the source of illness, and recommend prevention and control measures. In order to gain experience in outbreak investigation, I was asked to initiate the investigation under the supervision of a senior epidemiologist and medical director. We first developed a case definition, carried out additional case finding, and created a questionnaire, which was distributed to all attendees. To identify potential sources of illness, we performed a case control study. Additionally, we collected stool samples from 12 persons who became ill. These were assessed by the Georgia Public Health Laboratory (GPHL). Staff from the Environmental Health Services Unit of FCDHW interviewed the individual who prepared the main meat entrees (pork and chicken) regarding the handling, cooking, and serving procedures used.

Responses to the survey were provided by 71 of the 200 attendees, and 69 observations were included in the analysis: 56 probable cases and 13 controls were identified. Onset of symptoms ranged from December 8th to December 10th (Fig.1) and illness lasted for an average of 5.09 days. The most common symptoms reported were headache (96.3%), diarrhea (93.0%), abdominal cramping (91.2%), body aches (91.1%), and chills (91.1%). Consumption of the smoked chicken was found to be strongly associated with illness (OR= 155.77, 95% CI= 8.19, 2,962.97, p-value: <.005).. Models using exact logistic regression indicate that only the smoked chicken was significantly associated with illness. GPHL bacteriology results identified 10 positive specimens for Salmonella Thompson. Pulsed-field gel electrophoresis (PFGE) indicated that nine of the 10 specimens had the same pattern. Findings from Environmental Health Service interviews revealed that the person preparing the chicken had limited knowledge regarding the required temperatures and procedures necessary to properly store or cook chicken for such a large number of people.

The epidemiologic, clinical, and environmental data collected indicate a point source outbreak due to contaminated smoked chicken as the probable transmission vehicle. The presence of two PFGE patterns in an outbreak such as this is not commonly reported in epidemiology literature – but it does occur. The use of PFGE can assist in identifying associated outbreaks. This facilitates quicker identification of contamination at the point of production rather than preparation. No other outbreaks of the main serotype with matching PFGE patterns were identified during the period of time around this event. This suggests that either bacterial contamination or amplification occurred during the preparation and storage of the chicken, rather than problems with bacterial contamination at the point of production and sale.

These findings indicate that proper food preparation and serving processes, such as temperature regulation, are highly important in the prevention of foodborne outbreaks. Furthermore, private entities that do not have permits for food service and catering events are not held to the same hygiene and food safety standards as professional caterers. These individuals should be educated on food safety regarding preparation and service before preparation of food for large numbers of people. This outbreak demonstrates the importance of prevention measures in food preparation to mitigate the hazards of preparing and serving food at large events.

As a result of this outbreak investigation, the following public health actions have been implemented: our team reported findings from the case control study to school administrators, distributed a USDA brochure “Cooking for Groups: A Volunteer's Guide to Food Safety” and a flyer from the health department. Additional health communications regarding food safety at large events are in the development stage.

The Applied Epidemiology Fellowship has facilitated my participation in many opportunities such as this outbreak, in which I have been able to develop epidemiology skills through hands-on experience. During this outbreak investigation I learned the importance of active case finding in order to determine the extent of an outbreak. Timely data collection from a large group of people was a challenge that we faced and addressed through administration of the online survey through the State Electronic Notifiable Disease Surveillance System. Public health communications with the school administration and parents were a large part of this outbreak, demonstrating the challenges that can accompany disseminating health information to the public. Through this experience I was able to gain an applied perspective on outbreak investigations and an even greater appreciation for field epidemiology.

New Mexico has led the nation in drug overdose deaths for most years over the past two decades. However, in 2011 NM dropped from this position to number two and in 2012 to number three because of a 16% decrease in drug overdose death from 2011 to 2013. This decrease has been largely due to a decrease in prescription drug overdose death that has followed a decrease in the amount of opioids prescribed in NM. Despite this improvement NM’s drug overdose death rate remains substantially higher than the U.S. rate.

In 2011 state legislation created a governor’s advisory council on drug overdose prevention and pain management, which formalized a process for bringing stakeholders together. This legislation also required that each of the seven healthcare provider entities that license providers who can prescribe controlled substances promulgate new regulations for treating chronic pain and providing mandatory continuing education on chronic pain. As a result, all licensing entities require registration and use of the prescription monitoring program. The Board of Pharmacy and the Department of Health routinely analyze prescription opioid and benzodiazepine prescribing data and provide reports to the licensing entities on outliers. The Council also recommended removing the preauthorization requirement around Medicaid suboxone prescribing, and this was removed.

Additionally, NM has built on the highly successful syringe exchange based naloxone program by adding co-prescription pilots in several communities where naloxone is provided along with chronic opioid prescriptions. NM also allows pharmacists to prescribe naloxone and has been working with pharmacies to stock naloxone so that it is available around the state. Medicaid also reimburses for naloxone and the accompanying education.

NMDOH has three substance abuse epidemiologists who are critical to the drug overdose prevention effort in NM. They collaborate with the Office of the Medical Investigator and the Board of Pharmacy to track drug overdose deaths and prescribing patterns. These data are disseminated both locally and statewide. Particularly useful are presentations of county-level overdose death and prescribing patterns that have been provided to community groups and local provider organizations. They have also led the process for tracking naloxone distribution to assure it is available in areas with the highest drug overdose death rates.

Despite being one of two states with all 10 prescription drug overdose prevention policies in place tracked by the Trust for America’s Health, NM has a long way to go to adequately address the drug overdose epidemic. The prescription drug monitoring program needs to move closer to real-time prescribing data – currently it requires data from pharmacies within seven days. Licensing entities need to better enforce their own rules on prescription monitoring program use. And naloxone needs to be far more widely available like most prescription drugs are. In the 1990s heroin was driving the NM epidemic, and more recently prescription opioids have been. This means that many of our original naloxone programs, originally directed at heroin users, now accommodate persons at high risk because of prescription opioid use. While many states have seen heroin overdose death rates increase in recent years, New Mexico hasn’t witnessed the same trend. However, one possible explanation for NM’s relatively stable heroin overdose death rate is that New Mexico already had a high prevalence of heroin drug overdose death.

The drug overdose epidemic is different in each state. Having an adequate epidemiologic infrastructure to track the epidemic in each state is critical. The CSTE Overdose Subcommittee has done critical work in developing practical approaches that can be employed in states, taking into account state-specific differences. Fellow CSTE members provide good approaches to state-specific surveillance that is the foundation for reducing inappropriate prescribing and drug overdose.