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Mass Gathering at Sturgis: Preparedness, Surveillance and Whiplash

Posted By Lon Kightlinger, Friday, April 10, 2015
Untitled Document
South Dakota’s population will double this coming August—but the risk to public health will quadruple. The Sturgis Motorcycle Rally happens every year in the Black Hills of South Dakota attracting about 500,000 rally-goers. But this year, 2015, marks the rally’s mythical 75th anniversary and over a million Harley-stomping pilgrims are expected. Although not nearly as massive as India’s Kumbh Mela gathering, the Sturgis Rally presents vast challenges to public health surveillance and response.


Sturgis (normal population 6,600) is situated where the prairie’s endless horizon meets the Black Hills, sacred to the Lakota Sioux, home to Mount Rushmore and Crazy Horse monuments, and the winding roads cyclists love. South Dakota is a rural, conservative, no-frills state that welcomes the annual boisterous mass gathering of rumbling, kick-back fun. Rally-goers come from all over the world, including far-off, exotic places like California and Pennsylvania. Catering to the million motorcyclists is an army of temporary food and drink vendors, mechanics, ad hoc camp grounds, tattooists, musicians, masseuses and more, much more. Although most rally-goers are mild-mannered gentlefolks on their home turf, while in Sturgis they let their inner Easy Rider rage for the week-long party.

The South Dakota Department of Health recognizes the risk to public health a million raucous guests might encounter: summer heat, tainted food, West Nile mosquitoes, clunker drugs, excessive Natty Ice, prairie wind storms, bothered rattlesnakes, condom scarcity, daredevil cyclist traumas, no helmet laws, 80 mph speed limits, porta-potty insufficiency, forest and prairie fire alerts, contaminated water in campgrounds that are normally cattle pastures, and old men doing things not even young cowboys should attempt.

For some this is a week of grand cycling in the Wild West, but for us in public health it is an epidemiologic OK Corral. Before and during the rally we sample, test, and enforce drinking water standards; inspect and license food venders, tattooists, and body piercing artists; implement intensive disease surveillance; activate a mobile laboratory; maintain redundant communication channels; participate in the rally emergency operations center; monitor disease cases, syndromes, hospital beds, emergency department traffic, blood supply, and morgue space; and spray for mosquitoes. The capacity of the Department of Health is stretched and local health care is overextended, as are roads and normal infrastructure.

Surveillance and response networks have been long established and work well, but the glut of accidents, cases and sudden health events engulfs and strains the disease reporters and coders in the healthcare system so that even electronic syndromic surveillance triggers are less reliable. Disaster epidemiology tools used during floods, blizzards and tornadoes need to be enhanced and envisioned for a highly mobile, raucous, wittingly uncooperative crowd who would simply not allow an outbreak of diarrheal disease to disrupt the revelry.



Lon Kightlinger, MSPH, PhD is state epidemiologist at the South Dakota Department of Health.

Learn more about the various epidemiologic domains impacted by massive events, such as the Sturgis Rally, by joining a subcommittee in Surveillance and Informatics, Occupational Health, Injury, and Infectious Disease.

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Dr. Paul Farmer to Speak at Annual Conference

Posted By Alfred DeMaria, Jr., Tuesday, April 7, 2015
Updated: Thursday, April 2, 2015

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.

We are also pleased to announce the following plenary speakers:
  • 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
The 2015 Annual Conference in Boston will span four days with 240 sessions on emerging topics. Some of this year’s topics include:
  • 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:

 
CSTE Members Lead Change

CSTE members are change makers, thought leaders, and bridge builders. Discover the opportunities that CSTE membership gives you to make waves. Become a CSTE member today and save on conference registration: http://bit.ly/1HrYoDm

Posted by Council of State and Territorial Epidemiologists on Friday, April 3, 2015

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.

 

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CSTE Informing Dialogue in Washington, D.C.

Posted By Jeff Engel and Chad McCoull, Friday, March 27, 2015
Updated: Friday, March 27, 2015
Untitled Document

CSTE meetings show progress for federal program partnerships and promise for Congressional appropriations.

This week CSTE leadership met in our nation’s capital to make recommendations based on the needs and perspectives of state and local epidemiologists. Executive Board members Al DeMaria of Massachusetts, Tim Jones of Tennessee, and Janet Hamilton of Florida were accompanied by CSTE Executive Director Jeff Engel, Washington Representative Emily Holubowich, and Communications Coordinator Chad McCoull.



Meeting with our colleagues in the executive and legislative branches provided a forum to share data and stories about both the challenging day-to-day realities and heartening accomplishments of applied epidemiology in America. These continued discussions help align federal priorities with those of state and local health departments in order to better alleviate burdens and bridge capacity gaps. CSTE leaders touched upon multiple recurrent topics:
  • Recommendations on national action in antibiotic resistance
  • Gaps in healthcare-associated infection data collection and dedicated staffing
  • Strategies for harmonizing and developing national reporting systems
  • Assessment results in workforce capacity and fellowship programs
  • Institutional perspectives on Ebola Virus Disease monitoring programs
  • New directions for the Emerging Infections Programs (EIP) network
In addition to these illuminating discussions, CSTE presented a joint letter, coproduced with the Association of Public Health Laboratories and addressed to legislative subcommittees that preside over public health appropriations. The letter urges continued bipartisan support for core epidemiology activities, emerging priority areas, and more:
  • Emerging and Zoonotic Infectious Diseases
  • Combating Antibiotic Resistant Bacteria (CARB)
  • Epidemiology and Laboratory Capacity (ELC) grants
  • Foodborne Disease Surveillance
  • Advanced Molecular Detection
  • Workforce and Career Development, including CDC/CSTE Applied Epidemiology Fellowships


Read the complete letters to the House of Representatives and the Senate

 
As a direct result of this week’s meetings, CSTE is forging new partnerships to better serve its national membership. CSTE looks forward to further opportunities to work with the Office of Management and Budget and the Office of the National Coordinator for Health Information Technology (ONC) as well as the Centers for Disease Control and Prevention Washington, D.C. office and CDC National Center for Health Statistics. As public health practitioners at all levels of government come together to shape the future of epidemiology, CSTE remains a unifying voice for the national public health applied epidemiology workforce.
 
Jeffrey Engel, MD is Executive Director and Chad McCoull, MPA is Communications Coordinator at CSTE. CSTE members with messages they wish to share with CSTE leaders are welcome to contact us. For more information on CSTE’s advocacy efforts, read Emily Holubowich’s CSTE Features article on President Obama’s proposed fiscal year 2016 budget.

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Measles Outbreak in Illinois

Posted By Andrew Beron, Whitney Clegg, and Justin Albertson, Friday, March 20, 2015
Updated: Friday, March 20, 2015
Untitled Document

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.



Andrew Beron, MPH, Whitney Clegg, MD, MPH, and Justin Albertson, MS, are CDC/CSTE Applied Epidemiology fellows at the Illinois Department of Public Health. Visit the CSTE website to learn more about information about the CDC/CSTE Applied Epidemiology Fellowship. For more information on measles, mumps, and rubella, learn about the CSTE Vaccine Preventable Diseases Subcommittee.

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Epi Tool to Analyze Overdose Death Data

Posted By James Davis (NM), Jennifer Sabel (WA), Dagan Wright (OR), and Svetla Slavova (KY), Friday, March 13, 2015
Updated: Friday, March 13, 2015

Did you know that drug overdoses are the leading cause of injury death in the nation? While we know that they are a leading cause of injury death, the ICD codes often only tell us the broad class of drugs involved and not the specific drugs. However, there is often more information about the specific drugs on the death certificate.

A new analytic tool developed by the CSTE Overdose Subcommittee treads new ground by directly analyzing the cause of death information on the death certificate, sometimes referred to as the literal text. Literal text entries from the death certificates are now either entered into electronic death certificates or transcribed paper certificate. These entries are used to classify the causes of death using the ICD-10. The literal text entries are input into the SuperMICAR program of the suite of software used to code the causes of death and thus these literal text entries are sometimes referred to as the SuperMICAR literal text.



The cause of death section from the US standard death certificate

This new program searches the electronic version of the literal text for references to specific drugs and other words of interest that are included in the cause of death statement and the “how the injury occurred” text box. The program creates additional variables in the data set to record the drug names and number of drugs.

After processing the literal text data with this program (and after a thorough manual review of the output), state and local analysts can learn more about the leading drugs involved in deaths in their jurisdictions. For example, the leading drugs involved may be oxycodone, methadone, heroin, and alprazolam. These data could be used for surveillance to monitor the number of deaths from a particular drug. Analysts could also use the search terms spreadsheet to monitor the literal text for new drug threats.

There are some limitations to the current program. Importantly, in some states these literal text data are restricted and may not be available to all analysts. The drug list is a work in progress and can be improved. Also, the program searches for mentions of a drug without considering the context. There are likely to be false positives; that is, a drug is mentioned, but did not contribute to the death. For instance, “insulin” is on the drug name list and would identify “non-insulin dependent diabetes.” Another example would be “heroin user” which does not necessarily imply that heroin was involved in the death.

Click here to download the tool
The downloadable zip file includes an Excel document, an SAS document, and a PDF document.

The tool is available here on the CSTE website. We are requesting feedback though updates will be made as times permits. Please send feedback to Nidal Kram. We hope that you will take the tool and expand on it and use it in your work reviewing other causes of death.


James Davis, MA is Substance Abuse Epidemiologist at the New Mexico Department of Health. This project was prepared by the CSTE overdose workgroup on literal text analysis, including Jennifer Sabel, Jim Davis, Dagan Wright, Svetla Slavova from CSTE; Margaret Warner, Ari Minino, from NCHS; and Len Paulozzi, and Rose Rudd from NCIPC. For more information, read about the CSTE overdose subcommittee and the CSTE Substance Abuse Subcommittee.
 

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Foodborne Illness Outbreak in a High School Banquet

Posted By Caroline Stamatakis, Friday, March 6, 2015
Updated: Thursday, March 5, 2015
Untitled Document

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.


Figure 1.Probable cases of Salmonella Thompson infection by date of illness onset from December 7, 2014 to December 11th, 2014.

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.



Caroline Stamatakis, MPH is the CDC/CSTE Applied Epidemiology Fellow in the Fulton County Department of Health and Wellness, Epidemiology Branch. For more information on foodborne illness, please visit the CSTE Food Safety page. The Second Edition of the CIFOR Guidelines for Foodborne Disease Outbreak Response and CIFOR Toolkit is now available. To request hard copies, please contact Dhara Patel at the CSTE National Office.

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Reportable Disease Program in Louisiana

Posted By Raoult Ratard, Friday, February 27, 2015
Updated: Tuesday, February 24, 2015

Reporting of notifiable diseases in Louisiana has been in transition for years. Until 1998 reporting was done by phone and mostly by cards, followed by a Microsoft Access database installed in every hospital. The next step was to develop a home-grown web-based Reportable Disease Database (RDD). To meet security requirements, a commercial web-based Infectious Diseases Reporting Information System (IDRIS) replaced RDD. As the cost of maintenance became a financial burden and Electronic Laboratory Reporting became a priority, the Louisiana Infectious Disease Epidemiology Section took a leap of faith and decided to move to a free and ELR-friendly reportable system, namely the NEDSS Base System (National Electronic Disease Surveillance System).

Past the initial enthusiasm, we were overwhelmed by the magnitude of the task we had volunteered to undertake. As there were financial restrictions, the transition had to be done in house by our troupe of young and dedicated epidemiologists. The hurdles were to learn the new vocabulary, the structure of the poorly documented database, the system management, user accounts, permissions, lab and case workflow. There were over a dozen system reference tables that required SQL (Structure Query Language) scripts to populate. Besides, there were about 30 unused tables and utilities (they may be useful but we could not find how to use them and have done well without). Then there were 37 case investigation pages to be built with a page builder to be consistent with CDC and Louisiana state case report forms.

Originally it seemed that NBS was not designed to be used by external partners (in Louisiana infection preventionists or their helpers enter data into the system). For example, external partners cannot get reports on what they have entered. A workaround solution had to be designed.



The legacy data from 1988 to October 2014 had been consolidated into IDRIS. The decision was to create LaRD (Louisiana Reportable Disease), which would incorporate the legacy data plus the new data from IDRIS2. LaRD, an Access database is used to produce summary data for the surveillance reports, infection preventionists’ reports, media inquiries, performance indicators, dashboards and other documents. LaRD has the advantage of having all variables consolidated in one data warehouse, accessible to all the Infectious Disease Epidemiology Section’s epidemiologists. The policy in our section is that epidemiologists are allowed to use the statistical package they know best, ranging from their own fingers to Statistical Analysis System (SAS).

Incorporating the legacy data into NBS proved to be very time-consuming and is making slow progress. However, it allows us to search for past infections and upgrade case statuses and disease registries.

To placate those who object to change, the name IDRIS was kept and a ‘2’ added at the end. IDRIS2 has been working for the past six months without any major problems. The benefits of this transition have been a savings of $200,000 a year, a boost to the morale of the epidemiologists who can now look even smarter, and a compliance with PHIN and many other acronyms to come.


Raoult Ratard, MD MS MPH and TM (Tropical Medicine) is the state epidemiologist at the Louisiana Department of Health and Hospitals. For more information about disease reporting systems, see the Surveillance and Informatics page. To learn about the National Notifiable Disease Surveillance System Modernization Initiative (NMI), visit the NMI page.

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Reducing Drug Overdose Death in New Mexico

Posted By Michael Landen, Friday, February 20, 2015
Untitled Document

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.


Michael Landen, MD, MPH is co-chair of the Substance Abuse Subcommittee. NM’s substance abuse epidemiology section includes Laura Tomedi, PhD, MPH, the chair of the Alcohol Subcommittee, and Jim Davis, MS a member of the Overdose Subcommittee, and Luigi Garcia-Saavedra, MPH. To find out more about substance abuse, visit the subcommittee pages and read CSTE’s 2008 State-Level Substance Abuse Epidemiology Capacity position statement. A unique, new fellowship opportunity is now available for substance abuse or mental health fellowships: Applied Epidemiology Fellowship applications will be open soon.

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Public Health Fares Better than Usual in President’s Budget

Posted By Emily J. Holubowich , Friday, February 13, 2015
Untitled Document
Emily Holubowich, Senior Vice President at CRD Associates is CSTE’s Washington representative and leads our advocacy efforts in the nation’s capital.


On February 2, President Obama delivered his $4-trillion fiscal year (FY) 2016 budget request to Congress. The president proposes a balanced approach for replacing sequestration (something CSTE has supported through the advocacy efforts of the Coalition for Health Funding and its anti-austerity campaign, NDD United). This sequestration relief would free up an additional $70 billion to support funding increases across the government, including the Centers for Disease Control and Prevention (CDC)—the first increase the administration has proposed in several years.

The administration seeks $7 billion for CDC in FY 2016, a 2 percent increase that includes $6.096 billion in base discretionary funding or “budget authority,” and $914 million in mandatory funds from the Affordable Care Act’s Prevention and Public Health Fund (PPHF). Together, this funding translates into increases for Emerging and Zoonotic Infectious Diseases (73 percent increase) and Public Health Workforce (29 percent increase) through which applied epidemiology fellows are funded.

One of the administration’s top funding priorities—public health or otherwise—would rely heavily on state and local epidemiology capacity. Combating Antibiotic-Resistant Bacteria or CARB is a new, $1.2-billion initiative that spans several different federal departments (Health and Human Services and Agriculture among them) and several different health agencies, including CDC.

Within the $264-million CARB request for CDC, approximately $100 million would be dedicated to Epidemiology and Laboratory Capacity (ELC) grants to support core infectious disease surveillance capacity at state and local health departments. If appropriated, this would bring total funding for ELC to $210 million—more than double the FY 2015 level of $102.5 million.

Provided below is more detail on the proposed funding levels for some of CSTE’s key advocacy priorities. Much of the new funding requested by the president focuses on building capacity to fight infectious diseases at home and abroad. However, if appropriated these funds would ultimately serve a dual purpose. We know from past experience that funding provided to support communicable disease monitoring and response ultimately bolsters the overall epidemiology infrastructure needed to fight non-communicable diseases, as well.

  • Epidemiology and Laboratory Capacity Grants. Within the total, a $210 million funding request for ELC, the program would once again be provided $40 million from the PPHF, consistent with the last four fiscal years.
  • Advanced Molecular Detection (AMD). The president’s budget once again requests $30 million for the AMD initiative, consistent with the current funding level. This funding would be used to continue to improve CDC’s capability and to initiate state projects to improve the application of genome sequencing to public health issues of concern.
  • Food Safety. The president’s budget request seeks nearly $50.1 million for foodborne disease surveillance, an increase of $2.1 million over the current level. Approximately one half of this increase would go to state and local health departments to enhance surveillance, outbreak detection and response, and food safety prevention efforts.
  • Global Health Security. The president’s budget request seeks $448 million for global health, an increase of $31.6 million above FY 2015. Of this, the president seeks to dedicate nearly $77 million—a $21.6 million increase—to expand the global health security agenda and accelerate progress in preventing the spread of global health threats. Applied epidemiologists at the state and local level will continue to be a critical component of any response strategy.
  • National Healthcare Safety Network (NHSN). The president requests more than $32 million for the NHSN, an increase of $14 million over the current level. The new funding would support NHSN reporting in more than 17,000 health care facilities to help eliminate healthcare-associated infections and guide prevention activities.
  • Epidemiology Fellows. The Public Health Workforce program—through which the CSTE/CDC Applied Epidemiology Fellowship receives funding—would see an increase of $15.2 million under the president’s request, bringing total funding to $67.4 million. Of this, the administration would use $36.2 million from the PPHF to support professional development. It’s worth noting that two years ago Congress eliminated $15 million in PPHF dollars for Public Health Workforce in the wake of sequestration of the PPHF—so this could be a heavy lift.


    With this increase, the CDC could support up to 667 fellows, or approximately 80 additional fellows, which would ultimately increase the number of fellows assigned to state and local health departments. The budget request does not specify how much funding would be dedicated to the Applied Epidemiology Fellowship Program per se, but a rising tide would certainly lift all boats. The administration in the budget request does single out “high-priority” professional development activities, including the Epidemic Intelligence Service (EIS), the Public Health Associate Program (PHAP), public health informatics, and population health training of areas of potential funding.

Even with the increase for CDC writ large, many public health programs are not immune to cuts in the president’s budget. Section 317 Immunization Program (-$50 million or -8 percent), Environmental Public Health Tracking Network (-$12 million or -32 percent), and several chronic disease programs see proposed cuts. Of particular note, the president’s budget once again proposes to eliminate funding for the Preventive Health and Health Services Block Grant (-$160 million). So far, each year Congress has rejected such cuts to the “Prevent Block.”

With the release of the president’s budget, the appropriations process begins in earnest. The budget request serves as roadmap for funding, but the “power of the purse” ultimately lies with Congress—and it will be at lawmakers’ discretion to determine what to fund and at what level. And if Congress adopts the president’s plan for stopping sequestration or comes up with their own fix, funding levels will be held at their austere levels, making many of the president’s proposed increases impossible…at least without deep cuts to other public health programs. CSTE will once again partner with the Association of Public Health Laboratories and other colleagues in the public health community to advocate for our key priorities—strong support for disease monitoring and for training the next generation of epidemiologists. We will be sure to keep you apprised of our efforts.

For more information about funding levels for your specific priorities, please click here for a copy of CDC’s explanation of the budget request. You may also be interested in CDC’s operating plan for the current fiscal year available here, which outlines where CDC is spending funding now.

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NFL Partnership Promotes Public Health to Nine Million People

Posted By Shawn Richards, Jennifer Brown, and Pam Pontones, Friday, February 6, 2015
Untitled Document
The Indiana State Department of Health (ISDH) and the NFL’s Indianapolis Colts have partnered to promote an influenza vaccination, hand washing and infectious disease awareness campaign. Now in its second year, this campaign, “Join Blue Prevent the Flu (JBPF),” reached over 10 million people during the 2014-2015 flu season.


The main messages of the campaign included:
  • Get Your Flu Shot
  • Clean your Hands Often—Use Soap and Water
  • Cover Your Cough and Sneeze—Use a Tissue or Your Sleeve
  • Contain Your Illness—Stay Home When You’re Sick


The innovative partnership highlighted disease prevention and health education by using the marketing power of the Indianapolis Colts football organization. The ISDH sought this partnership due to the near-perfect market to direct the ISDH health messages and the alignment of football season and flu season. A few of the highlights of the JBPF campaign included:
  • The digital game-day recaps sent by the Colts after every game via Facebook, Twitter and Instagram included 19 different customized public health messages. The messages covered influenza-related statistics and vaccination reminders, education about Enterovirus and shigellosis outbreaks occurring in Indiana, promotion of the ISDH Ebola Call Center, and hand washing. The analytics provided by the Indianapolis Colts found that 9,339,474 people were reached using the game-day recap during the regular and postseason games. For an example, go to http://bit.ly/1yYAFt4.
  • The Colts promoted National Influenza Vaccination Week on the colts.com website, the Colts Facebook Page, Twitter, and a prepared Twitter message sent by the Colts Stampede (an online Colts fan community).
  • The ISDH supported the Bleed Blue Blood Drive and Health Fair, where the ISDH provided an influenza knowledge/attitudes/beliefs survey on influenza symptoms and prevention along with an interactive hand washing activity.
  • Indianapolis Colts player Matt Hasselbeck served as the team’s influenza spokesperson. Two influenza vaccination and hand washing videos featuring Hasselbeck and the Indiana State Health Commissioner were produced and featured on the ISDH YouTube channel located at http://bit.ly/1E0dePX and the ISDH influenza website at http://bit.ly/1A2bjH1.
  • A hand washing and influenza vaccination commercial produced by the Indianapolis Colts was played on the Jumbotron at every Colts home game. The commercial featured the Indiana Health Commissioner “immunizing” Blue, the Indianapolis Colts mascot.
  • A full-page color ad was included in every game-day program about influenza and antibiotic resistance. An example is provided at http://bit.ly/1H5L8Iw.
  • Mirror clings promoting hand washing and featuring the ISDH and JBPF logos were installed in all stadium-level bathrooms and hand sanitizer stations. View the image of the mirror cling at http://bit.ly/1tlBtXR.
The social media presence using the game-day recaps reached 9,339,474 people, and the 650,000 fans who attended Colts home games at Lucas Oil Stadium had the opportunity to see the mirror clings, commercial, and stadium stills. Additionally, the hand washing messages provided on hand sanitizer stations and bathroom mirror clings were posted at all other events at Lucas Oil Stadium, including NCAA games, the Big Ten Championships, concerts, motor sports, high school football games, and conventions; these events reached as many as 1.5 million additional people. The ISDH and Colts partnership was used to decrease the effect of communicable diseases in Indiana by promoting hand washing, disease information and education, and influenza vaccination.

Shawn Richards, BS is Outbreak Supervisor; Jennifer Brown, DVM, MPH, DACVPM is State Public Health Veterinarian; and Pam Pontones, MA is State Epidemiologist and Director of the Epidemiology Resource Center at Indiana State Department of Health. For more information, see the CSTE influenza page.

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