In July 2013, the North Dakota Department of Health (NDDoH) was notified of a patient presumptively diagnosed with active tuberculosis (TB) disease. The investigation revealed the patient was from Mexico and employed at a local dairy whose primary duties required extensive direct contact with dairy cattle. Due to the potential animal-human interaction, a collaborative investigation ensued between the NDDoH, the North Dakota Department of Agriculture-Animal Health Division and Board of Animal Health (NDDA-AHD and BOAH).

In November 2013, the BOAH conducted whole herd testing on 319 cattle. 11 cattle responded to the caudal fold (CF) tuberculin test and were then tested using the comparative cervical test (CCT). One cow (Cow A) was classified as a reactor to the CCT and was subsequently euthanized. Cow A had a small visible granuloma in a lymph node on necropsy, suggesting acute infection. The herd was quarantined when the first reactor was identified. The 10 remaining CF suspect animals were euthanized and tested for tuberculosis, resulting in two additional positives. Cow A was positive for Mycobacterium bovis (M.bovis) on both polymerase chain reaction (PCR) and culture testing, Cow B was PCR-positive only, and Cow C was culture-positive only. Neither Cow B nor Cow C showed any gross lesions.

Testing was also done on the dairy farmer’s 161 beef animals resulting in no caudal fold responders. In January 2014, a second dairy herd test was completed and six additional caudal fold responders were identified. These animals were shipped to slaughter; no gross lesions were found on examination, and all laboratory tests were negative for tuberculosis. A subsequent herd test of all dairy and beef cattle in April identified seven additional responders which had no evidence of TB at post-mortem examination or upon laboratory testing. In October of 2014, all cattle were again tested and found to be negative. The herd was released from quarantine on November 4th and will undergo annual herd tests for the next five years.

Difficulties in identifying the causative agent in the initial human case led to a delay in appropriate treatment. Culture results confirming M.bovis were not available until mid-November. TB treatment drug sensitivity results showed the expected pyrazinamide resistance but also a low-level resistance to isoniazid (INH).

The case lived in a remote area, so the NDDoH contracted with a local clinic to provide directly observed therapy (DOT). In December 2013, the case had to return to Mexico for approximately two months. Follow-up care was coordinated with the border initiative Cure TB to ensure DOT would continue when the dairy worker returned to Mexico. The dairy worker has since returned to the United States where he successfully completed his treatment.

Early collaboration and communication between agencies allowed for a prompt and comprehensive investigation. This collaboration also led to a One Health approach for education efforts targeting dairy employees and employers as well as the general public.

To better understand disease transmission, the human case isolate and the two cattle isolates were sent to the National Veterinary Services Laboratories for whole genome sequencing. The human isolate had the same single nucleotide polymorphisms (SNP) profile as Cow A. The isolate recovered from Cow C, while very similar to Cow A and the human strain, was divergent by seven separate unique SNPs, which suggests another strain of M. bovis is present. Both of these TB strains indicate a Mexico origin, yet both Cow A and Cow C were born, raised, and had never been outside of North Dakota.

The cavitary disease of the human and the small grossly visible lesions in Cow A suggest that the human case was further along in active disease progression. That finding—along with the Mexican origin of the TB strains, North Dakota cattle, and further epidemiological data—support the likelihood that the dairy worker transmitted the disease to the cattle.

Not many people know that pond scum can be a threatening public health issue. I certainly didn't during the last semester of my MPH program when my supervisor encouraged me to apply for the CDC/CSTE Applied Epidemiology Fellowship. At first I was unsure about how I’d fit into the fellowship categories, but Class XI—which was set to start the summer I graduated—hosted a pilot group of Environmental Health – Waterborne Diseases fellows, primarily focused on harmful algal blooms (HABs) and other recreational water issues. This aligned perfectly with my previous experience and interests, although I knew very little about HABs myself. Compared to other more classical public health issues, HABs have only recently been identified as health hazards, and not many states have dedicated programs to track their associated illnesses. While working in my fellowship with the Indiana State Department of Health (ISDH), I have learned that new and crosscutting issues, such as HABs, require collaboration from multiple agencies with different types of expertise.

Working at ISDH, I’ve been integrated into day-to-day activities and allowed to develop projects based on the state’s needs. Creating and distributing HAB information for the general public was identified as a need, so I developed materials for the general public, healthcare providers, and veterinarians. My state mentors, Jen Brown and Shawn Richards, help me keep a pulse on the state’s needs to create relevant and timely materials.

I've also been able to work with different state agencies to learn about HABs for different purposes. For instance, I donned fashionable waders to help the Indiana Department of Environmental Management (IDEM) take samples of lake water for routine HAB sampling. We then took the samples to the IDEM lab where I shadowed the laboratory workers as they determined certain risk level indicators, such as cell count and toxins present in the samples. Back at ISDH, I reported the results to the geographic information systems team to produce an interactive map, showing the state’s test results with color warning symbols coordinated with risk level. With real-time data, public health outreach materials, and HAB reporting forms on ISDH’s webpage, we developed the site into a one-stop shop for HAB information. By having a hands-on role in the process—from collecting samples to posting results online—I was able to learn about HABs beyond what a literature review could provide.

Our class has four Waterborne Diseases fellows placed in Indiana, Ohio, Minnesota, and Wisconsin. Being a part of the pilot Waterborne group, we rely heavily on each other, state mentors, and partners at the CDC Waterborne Disease Prevention Branch to provide guidance and work through issues as they arise. We have also had the unique opportunity to collaborate with other state and federal stakeholders to mold the program while meeting the standard CSTE fellowship competencies. In addition, Class XII expanded the Waterborne cohort by adding three new waterborne fellows in Illinois, Michigan, and New York. Together, our work helps expand and promote surveillance in order to capture more HAB data in future years. Who knew that pond scum could be responsible for such an interesting and productive learning experience?

A growing body of evidence shows that these early experiences are common and can have long-lasting effects on mental and physical wellbeing. Findings from the original 1995-1997 ACE Study showed a strong, graded relationship between ACEs and several poor health outcomes in adulthood. As the number of ACEs a person experiences increase, what also increases are the risks of alcohol and drug abuse, obesity, suicidality, depression, intimate partner violence, heart disease, and a range of other poor health outcomes in adulthood. Data specific to ACEs among North Carolinians first became available in 2012 when questions about ACEs were included on the North Carolina Behavioral Risk Factor Surveillance System survey. My task was to analyze this data and create North Carolina’s first state report on the topic.

The finding that ACEs impact health outcomes in adulthood, long after the events have occurred, supports ACE prevention as an effective long-term strategy for population health and highlights the importance of a life-course perspective in such prevention efforts. The finding that ACEs impact a wide range of outcomes from social, emotional, and behavioral problems to chronic diseases presents an opportunity to foster collaboration among diverse stakeholders and suggests such collaboration will be important to successful ACE prevention. Increasing awareness of ACEs as a public health issue will be important in North Carolina for mobilization.

We are engaging stakeholders from across the state to support local prevention efforts. I presented the findings from the state report at the North Carolina Public Health Association Conference alongside colleagues from the Innovative Approaches Initiative in Buncombe County. This initiative is developing a toolkit and website to educate local primary care providers on ACEs, connect them to local resources, and provide referral options for affected children and families. I have also collaborated with Harry Herrick, a survey analyst at the North Carolina State Center for Health Statistics, to respond to requests for data regarding ACEs among special populations, such as current smokers and persons with disabilities. I am also currently working on a multi-state study of ACEs among persons who identify as gay, lesbian, and bisexual. Ideally, data from each of these studies will help inform programs and policies aimed at ACE prevention and the enhancement of current efforts. This project has proved invaluable to my experience as a fellow, and I am extremely grateful for the opportunities, support, and guidance my mentors and colleagues have provided throughout the process.

Hello, my name is Janet Hui, and I am the new research analyst for Surveillance and Informatics. Originally from New York, I graduated with my Bachelor’s in Geography from Dartmouth College in 2012 and my MPH in Epidemiology from Mailman School of Public Health at Columbia University in May 2014. As an undergraduate, I had randomly enrolled in an epidemiology course and unexpectedly fell in love with the subject. I am passionate about data and technology and have a Certificate in Public Health Informatics as well as experience implementing geographic information systems for disease mapping. I am grateful and excited for the opportunity to further apply my skills in this field.

At CSTE, my primary focus will be the Reportable Conditions Knowledge Management System (RCKMS) project. Accurate reporting of disease is the cornerstone of surveillance, making it critical for providers and laboratories to have convenient access to up-to-date reporting criteria. RCKMS is envisioned to be a tool for providers, labs, and jurisdictions to better communicate and access reporting rules. This upcoming year, I will be helping to launch the feasibility pilot for the potential adoption of the RCKMS by state and local health departments. CSTE members are going to be heavily involved in all levels of the pilot, and I will be supporting them through workgroup calls and meetings. Everyone has been extremely knowledgeable and enthusiastic about the project, and I’m thrilled to be working with them!

Hi there! My name is Nidal A-Z Kram and I am the associate research analyst supporting the Chronic Disease, Maternal and Child Health, and Oral Health (CD/MCH/OH) Steering Committee. I also work with the Substance Abuse Subcommittees within the Cross Cutting I Steering Committee. I completed my undergraduate studies at Lawrence University in Appleton, Wisconsin where I majored in Biology with minors in Anthropology and Ethnic Studies. I joined CSTE after receiving my Master’s in Public Health from the Rollins School of Public Health at Emory University, focusing on Global Health and Community Health and Development.

I am eager to work with my subcommittees in developing new project ideas as well as completing ongoing projects. Most importantly, I am excited to do relevant and meaningful work that supports our members in local and state health departments. One key activity is the distribution of the CD/MCH/OH Epidemiology Capacity Assessment (ECA) report, which shows trends and indicates areas for improvement. The Chronic Disease Epidemiology Evaluation webinar series will be an interactive course designed to strengthen capacity. The Substance Abuse Subcommittees are also engaged in several interesting projects, including a computer program that searches the text on death certificates for specific drugs included in the cause-of-death statement and records those drugs as new fields. For additional information on any of these projects and to learn how to get involved in these subcommittees, please contact me!

Hi, I’m Amy Patel. A ‘Tar Heel Born and Bred,’ I graduated from the University of North Carolina at Chapel Hill with my Bachelor of Science in Biology and Anthropology in 2011 and then again with my Master of Public Health in Health Behavior with a Certificate in Global Health in 2014. I thought I would save the world through medicine when I started college but I quickly learned that community-based public health was where it was at. To gain more hands-on experience before graduate school, I pursued a 13-month fellowship in rural Alabama with the nonprofit Project Horseshoe Farm. While our programs focused on people with mental and physical disabilities, the elderly, and children, this doesn’t even begin to encapsulate the breadth and richness of our work. My passion lies in taking a comprehensive, systemic approach to health with a particular focus on social, cultural, and environmental factors.

Because of this “big picture” interest in public health, I was drawn to CSTE’s interdisciplinary approach to applied public health. My primary program area at CSTE is Occupational Health, but I am also working on projects related to injury, tribal epidemiology, local epidemiology, and epidemiology methods. I’m excited to be working with CSTE members to facilitate public health work across local and national levels. I have already seen regional differences in what the pressing concerns in occupational health and safety may be and I’m drawn to learning more about how states and organizations partner with one another to share best practices and lessons learned. I’m also excited by the variety of my work. From assisting in the collection of national indicator data to developing resources to build capacity for tribal health promotion, I look forward to the engaging opportunities my projects will bring.

Epidemiologists who investigate disease clusters and epidemics typically work in close partnership with laboratory scientists who identify pathogens that cause outbreaks. In many cases, infectious disease mysteries are quickly solved once the causative agent is known, because public health experts know how a particular pathogen is transmitted and what can be done to interrupt its transmission. But what happens when an outbreak is caused by an unknown pathogen for which there are no diagnostic tests? Here is what happened in a real-life outbreak story recounted in Deadly Outbreaks, entitled Inspiration or Obsession:

In August of the Bicentennial year of 1976, several people died of a flu-like illness after attending an American Legion convention at an elegant Philadelphia hotel. Public health authorities suspected that the Legionnaires might be the first victims of the dreaded “Swine Flu,” caused by a new strain of influenza, identified eight months previously. However, the ensuring investigation ruled out Swine Flu and a range of other respiratory, foodborne, and waterborne diseases. Instead, the epidemiologic data suggested an airborne chemical or microbe inhaled by people who walked in front of the hotel or entered the hotel lobby. Otherwise, the investigative trail yielded no useful clues. Some said it was a Communist Plot or a terrorist attack. Others thought that the cause might never be known.

McDade felt more and more compelled do something, anything! …He had to go back and look at those rods once again. He decided to make himself stop what he was doing (a whole other set of typhus experiments) and re-focus [on the mystery disease]. He knew there was little chance that he would find anything that his colleagues had missed, but he was more and more bothered by the problem, almost to the point of obsession. Instead of worrying himself to death, he decided, he would “clarify the issue” one more time and then forget about it.