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Learning to Expect the Unexpected: My First Year as an AEF Fellow

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.

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Exploring Geographic Rate Variation Using Indirect Spatial Estimation in Montana

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:

  1. 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.
  2. 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.
  3. 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.
  4. 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.

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Massachusetts Title V—Caring for Mothers and Families in the Commonwealth

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.

The Maternal and Child Health Bureau (MCHB) website is accessible at http://mchb.hrsa.gov/ and the Title V website is accessible at https://mchdata.hrsa.gov/tvisreports/.

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.


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Expanding Intranasal Naloxone Availability among Emergency Medical Personnel in Oklahoma

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.

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Health Systems Integration in Minnesota: How Informatics Plays a Key Role

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.

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Maps as a Tool for Combating Antimicrobial Resistance

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.”

Source: http://www.cdc.gov/drugresistance/pdf/ar-threats-2013-508.pdf

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.

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CSTE Welcomes Largest Class of CDC/CSTE Applied Epidemiology Fellows

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.

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The Spring of Spice: Alabama Department of Public Health (ADPH) Conducts Outbreak Investigation in April and May

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.

The Spice team includes the following Central Office staff and the FSS from each area:
EPI Kelly Stevens, MS Epidemiology Division Director
EPI Cassie Brailer, BA Public Health Associate
EPI Shirley Offutt, RN, BSN Surveillance Nurse Manager
EPI Sherri Davidson, MPH Epidemiologist Supervisor
DCP Mary G. McIntyre, MD, MPH State EPI
CEFO Melissa Morrison, MPH Commander, US Public Health Service
EMS MisChele White, BSBA, MPA EMS Data Program Administrator
PHA1 Kathy Linzey, RN, BSN Surveillance Nurse Coordinator
PHA2 Theresa Tucker, RN, BSN Surveillance Nurse Coordinator
PHA2 Toni Richie, RN, BSN Surveillance Nurse Coordinator
PHA3 Jenny Parker-Long, RN, BSN Surveillance Nurse Coordinator
PHA4 Stephanie Millsap, MPH Epidemiologist Jefferson CHD
PHA4 Bridgette Kennedy, MPH Epidemiologist Jefferson CHD
PHA5 Michelle Marlow, RN, BSN Surveillance Nurse Coordinator
PHA6 Kelly Haywood, RN, BSN Surveillance Nurse Coordinator
PHA7 Tina Norwood, RN, BSN Surveillance Nurse Coordinator
PHA8 Patti Stadlberger, RN, BSN Surveillance Nurse Coordinator
PHA9 Kelly Singleton, RN, BSN Surveillance Nurse Coordinator
PHA10 Catherine Person, RN, BSN Surveillance Nurse Coordinator
PHA11 Becky Dixon, RN, BSN Surveillance Nurse Mobile CHD
PHA11 Cheryl Lahrs, RN, BSN Surveillance Nurse Mobile CHD

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Upcoming Webinars on Resources to Improve Foodborne Disease Outbreak Response

Posted By Jeanette Stehr-Green, Friday, September 11, 2015
Updated: Friday, September 11, 2015

The Council to Improve Foodborne Outbreak Response (CIFOR) released the second edition of the CIFOR Guidelines for Foodborne Disease Outbreak Response in April of 2014. The Guidelines describe the overall approach to foodborne disease outbreak response (including preparation, surveillance and outbreak detection, cluster and outbreak investigation, and control) and provide recommended practices in each of these areas to help agencies and jurisdictions improve local foodborne disease outbreak response.

The Guidelines capture the approaches (and genius) of some of the great foodborne disease investigation and control programs in this country, portraying their successful practices in black and white for all to see (and learn from). The Guidelines are chockfull of recommended activities that can help every program in the country (big and small) be one of the greats!

But the Guidelines were not made for light (or bedtime) reading (nor for finding the practices that will help improve your program on the fly). They are lengthy (244 pages plus appendices!) and read more like a textbook. They include hundreds of recommended practices some of which are well accepted with demonstrated effectiveness in most settings and some of which that are more cutting-edge show promise. Because the recommended practices require vastly different resources and result in different levels of impact, implementation of any particular practice cannot be recommended wholesale to all programs. Rather individual practices must be carefully considered by each agency/jurisdiction in the context of a host of factors before limited resources are used on their implementation.

So what’s a foodborne disease program to do? That is where the CIFOR Guidelines Toolkit comes in. The Toolkit was designed to help agencies and jurisdictions easily explore and implement the CIFOR Guidelines in a way most appropriate to the agency’s/jurisdiction’s mission, goals, and resources.

The Toolkit promotes a simple stepwise process guided by a series of worksheets. It brings together the right people – an interdisciplinary workgroup within a jurisdiction with knowledge and practical experience in epidemiology, environmental health, food regulation, laboratory science, and communication. It provides “keys to success” to help the workgroup identify areas which are in greatest need of improvement (called “focus areas”). It slices and dices the CIFOR Guidelines recommendations within these focus areas so that the workgroup can easily drill down to the recommendations that are most appropriate for that agency or jurisdiction. And it helps the workgroup make plans to implement those activities in a prioritized fashion.

Two upcoming webinars, one for managers and directors of local and state environmental and public health departments (the decision makers) and one for staff responsible for the investigation and control of foodborne diseases and outbreaks (the worker bees), will describe the CIFOR Guidelines, Toolkit, and other available resources to improve foodborne disease outbreak response.


CIFOR Guidelines and Toolkit Implementation Webinar Series:

CIFOR Guidelines and Toolkit Implementation Webinar for Decision Makers
Thursday, September 24, 2015 at 3:00pm Eastern
Registration required: https://csteevents.webex.com/csteevents/onstage/g.php?d=668675683&t=a

CIFOR Guidelines and Toolkit Implementation Webinar for Public Health Professionals
Wednesday, October 7, 2015 at 2:00pm Eastern
Registration required: https://csteevents.webex.com/csteevents/onstage/g.php?d=663372545&t=a

Both webinars will be recorded and archived on the CIFOR website for future viewing.

Jeanette Stehr-Green, MD is a consulting medical epidemiologist for CSTE and the lead developer of the CIFOR Guidelines Toolkit. For more information on CIFOR, please visit the CIFOR website. For more information on CSTE’s food safety activities, please visit CSTE’s Food Safety Subcommittee page.

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Palm Tree Worker Suffocated by Palm Fronds – Another Death in California

Posted By Robert Harrison, Thursday, September 3, 2015
Updated: Thursday, September 3, 2015
Untitled Document

On August 13, 2015, another worker was suffocated by palm fronds in California (see news report). This is at least the fourth similar fatality since the California Fatality Assessment and Control Evaluation (FACE) program (CA/FACE) program issued a report and video on this hazard in February 2014. The drought in the Western U.S. may have intensified the problem as lack of water has led to palm trees heavy with fronds, creating the potential to crush workers who are trimming the trees from underneath the palm fronds.

When a tree trimmer cuts or pulls on dead fronds, adjacent fronds or an entire ring of fronds may collapse and encase the worker. The weight of the fronds causes pressure on the worker’s chest and can lead to suffocation. In the cases identified through CA/FACE, the workers climbed up the tree and trimmed the fronds from the bottom up, placing themselves directly beneath the fronds. Neither the workers nor the supervisors were certified tree workers. They did not follow proper safety procedures or use the correct equipment. The workers were pinned by thick layers of dead fronds and suffocated to death.

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To prevent additional deaths:
  • Only workers certified by organizations such as the Tree Care Industry Association (TCIA) or the International Society of Arboriculture (ISA) should perform or supervise palm tree trimming.
  • Proper work procedures and correct equipment should be used. Fronds should be removed by workers using an aerial device and wearing fall protection. Alternatively, workers should use climbing procedures that place them above the fronds.
  • Homeowners should hire tree trimming companies that have a current tree service contractor’s license (California State Contractors Licensing Board D49). Under certain circumstances, homeowners may be liable for worker injuries or deaths that occur on their property if they hire unlicensed tree trimmers.

Watch the seven-minute video “Preventing Palm Tree Trimmer Fatalities,” available in English and Spanish, produced by California Department of Public Health. More information can be found at California FACE Program Action Page – Preventing Palm Tree Trimmer Fatalities.
We would appreciate your help in getting the word out about this hazard to those working in landscaping or tree-trimming businesses.
Robert Harrison, MD is a Professor of Medicine at UC San Francisco and Chief of the Occupational Health Surveillance and Evaluation Program at the California Department of Public Health. Today’s article has been reprinted with permission from the National Institute for Occupational Safety and Health (NIOSH) Science Blog. The California FACE program is funded by NIOSH and is one of nine funded FACE states. Investigations conducted through the FACE program allow the identification of factors that contribute to these fatal injuries. This information is used to develop comprehensive recommendations for preventing similar deaths.
For further reading, please see Robert Harrison and Laura Styles’ July 2014 blog article on the same topic.

Tags:  occupational health 

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