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Tales of an Epidemiologist’s Lunchbox: How to Prevent Foodborne Illness during Back to School Month

Posted By Kristen Felicione, Friday, August 28, 2015
Updated: Friday, August 28, 2015

As a child, one of my fondest memories of Back to School season was picking out my new lunch box. When I got to a certain age, lunch boxes became unpopular and they were replaced by cool brown paper bags. Although I begged to switch my lunch to a more trendy paper bag, my mom insisted I continue to use a fully insulated lunch bag. Now, with my background in epidemiology, I realize my mom’s commitment to providing her children with a safe school lunch every day. School-aged children are among the most vulnerable to foodborne illness. Here’s some information on proper preparation and storage of packed lunches so you and those you pack lunches for can avoid foodborne illness this school year. As epidemiologists, you can be ambassadors for food safety during Back to School and Food Safety month and share these tips with those you care about!

The facts, because we’re all epidemiologists here

  • Approximately 1 in 6 Americans becomes a victim of food poisoning each year
  • Salmonella affects an estimated 42,000 people each year, making it the most frequent cause of foodborne illness
  • 50% of Salmonella infections occur in infants and school-age children
  • Bacteria grow most rapidly in the range of temperatures between 40 °F and 140 °F, and can double in number in as little as 20 minutes
  • Norovirus is the leading cause of severe acute gastroenteritis among children less than five years of age in the U.S. who seek medical care
    • Norovirus is a contagious virus one can acquire from an infected person, contaminated food or water, or by touching a contaminated surface
    • Norovirus is often spread in food service; it is also commonly spread in day care centers
Follow these tips to keep lunch safe and bacteria-free
  • Pack lunches containing perishable food in an insulated lunchbox or soft-sided lunch bag. Perishable foods left at room temperature for more than two hours should be discarded; perishable food can be unsafe to eat by lunchtime if packed in a paper bag.
  • If the lunch/snack contains perishable food items like lunch meats, eggs, cheese, or yogurt, make sure to pack it with at least two cold sources
    • Frozen juice boxes or water can be used as freezer packs. Freeze these items overnight and use with at least one other freezer pack. By lunchtime, the liquids should be thawed and ready to drink
  • If packing a hot lunch, like soup, chili or stew, use an insulated container to keep it hot. Fill the container with boiling water, let stand for a few minutes, empty, and then put in the piping hot food. Tell children to keep the insulated container closed until lunchtime to keep the food hot (140 °F or above).
  • Pack disposable wipes for washing hands before and after eating. This is a step that is so often forgotten among kids.
  • After lunch, discard all leftover food, used food packaging, and paper bags. Do not reuse packaging because it could contaminate other food and cause foodborne illness.
  • Lunch meat can be refrigerated (40⁰F) for 3-5 days.

Please continue to support the public health of this nation while “off the clock” and follow the lunch safety tips. Remember to CLEAN, SEPARATE, COOK and CHILL your food.

Need more information?
You can find all of this information and more, by visiting the FSIS Web site at www.fsis.usda.gov. Or visit us online for assistance from our virtual representative “Ask Karen” at AskKaren.gov.

Consumers may also call our toll-free USDA Meat & Poultry Hotline at 1-888-MPHotline. That’s 1-888-674-6854.
Kristen Felicione, MPH, CPH writes this week’s article on behalf of the Food Safety and Inspection Service at the USDA.
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SHINE Fellows Welcomed in Atlanta for Orientation

Posted By Amanda Masters and Jessica Pittman, Friday, August 21, 2015
Updated: Friday, August 21, 2015

There’s a reputation of excellence among the individuals working as Project SHINE fellows in the Applied Public Health Informatics Fellowship, the Health Systems Integration Program, and the Informatics-Training in Place Program. The three SHINE fellowships attract applicants of diverse backgrounds and interests, many with doctoral and master’s degrees as well as medical and veterinary degrees. For new APHIF and HSIP fellows, the opportunity can mean relocating to a new part of the country, while I-TIPP fellows gain informatics training for capacity development within their current job roles.

Not only are Project SHINE partners CSTE, CDC, and NACCHO as well as supporters ASTHO and PHII continually amazed by the accomplishments of the exemplary fellows in all three programs, their host communities at large recognize them for their impressive contributions. In previous fellowship years, host sites have seen their fellows bridge organizational relationships, implement creative solutions, and train staff on new technologies. What fellows bring to their health departments is a unique perspective, top-notch technological literacy, and intellectual curiosity.

This year, five Class III fellows gained so much from the experience that they applied to extend an additional year with special funding from CDC’s National Center for Immunization and Respiratory Diseases. This summer former classes of fellows are completing their work and moving on to their post-fellowship positions and CSTE is pleased to usher in a new cohort.

This week, 8 APHIF, 8 HSIP, and 15 I-TIPP fellows will begin new positions, working on a variety of projects to build informatics and epidemiologic capacity at state and local health departments. Their projects will contribute to improving population health in their communities.. Here is a small sample from the broad scope of the projects that fellows will initiate:
  • Indiana Network for Patient Care Immunization Data Exportation, Crystal Boston-Clay, PhD(c), MS, BS
  • Integration of Local Health Department Electronic Medical Record with Public Health, Ekaette Joseph-Isang, MD
  • Improving Respiratory Syncytial Virus Surveillance through Electronic Laboratory Reporting, Heather Rubino, PhD, MS, BS
  • Enhancing Chlamydia Surveillance, Christie Mettenbrink, MSPH, BSMT
  • Influencing Influenza’s Impact in Idaho with Informatics, Ian Troesoyer, RN, BSN

Last week’s orientation educates new fellows on a cross-professional array of topics, introducing concepts that may prove useful as they begin engaging in complex projects. Orientation topics span health economics, mental models, community health needs assessments, project management, and more.

Congratulations to the 31 new fellows and 5 extension fellows for making it through the competitive application process. We are eager to hear about all of the positive outcomes you will have on your host site as well as the skills and competencies you will gain throughout your fellowship experience.

Visit shinefellows.org for more information and return in October for new updates. 2016 host-site applications will open in October and 2016 fellow applications will open in November.
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Welcome to CSTE’s New Website

Posted By CSTE, Friday, August 14, 2015
Updated: Friday, August 14, 2015
CSTE has enhanced its website this week for a more intuitive and user-friendly experience. The new site features a design that is responsive to smartphones and tablets. With this fresh, simple layout, it’s easier than ever to take advantage of CSTE as your source for applied epidemiology news and resources. Consider making CSTE.org your homepage, creating a desktop shortcut and browser toolbar link, and bookmarking the event calendar along with your favorite subcommittee pages.

Click here to visit the new www.cste.org
You can refer to this helpful guide or the search feature


Staying connected is the best way to learn about new opportunities for professional capacity building as well as events, webinars, and publications. You can search and publicize job postings in the career center and stay informed of fellowship and host-site opportunities. You can manage your subscriptions to subcommittee mailing lists, subscribe to the CSTE Features blog, and tune in to CSTE on Facebook and Twitter.

We’re confident that the new CSTE.org will be useful to you throughout the next year. We thank you for your continued engagement in CSTE activities. We will continue to leverage online media to support the productive and meaningful applied epidemiology work of CSTE members.

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10 Tips for Starting your Epidemiology Career Off on the Right Foot

Posted By Angela Rohan, Friday, August 7, 2015
Updated: Thursday, August 6, 2015
So, you are ready to embark on your new career as an epidemiologist. If you are anything like me, you might have explored a number of fields before finding your way to applied epidemiology. Or maybe you have always known that epidemiology is the place for you. Either way, I’ll bet that you thoroughly enjoy a good joke about confidence intervals, and perhaps you even took time out of your honeymoon in London to visit the John Snow pump (okay, I admit to that one). Here are a few lessons I have learned in my time as an applied epidemiologist that I hope will aid your success.
  1. Find a mentor
    Identify a mentor who can serve as a sounding board and provide advice on your projects and professional development activities. A peer mentor works as a great alternative if you are unable to identify a senior career mentor. If you are still in school, connect with a faculty member for opportunities to work on an analytic project under their guidance.
  2. Take advantage of learning opportunities
    You will not be able to attend every available webinar or stay completely up-to-date with each journal in your field, but by signing up for listservs and alerts you can be aware of and take advantage of these opportunities when possible. Joining CSTE subcommittees is one great way to stay connected!
  3. Consider a fellowship
    One of the most intense and rewarding learning opportunities available in public health is a 1- or 2-year fellowship program, such as the CSTE Applied Epidemiology Fellowship. I enjoyed the flexibility a fellowship provided me to identify projects that would help me to develop new skills and explore a position in epidemiology. The fellowship mentors were an amazing resource, and the host site environment exposed me to many new learning opportunities.
  4. Be open to a variety of content areas and workplace settings
    When looking for a position in applied epidemiology, don’t limit yourself to considering only one content area or workplace type. Occupational health might allow you to use and develop different skills than you would working in infectious disease epidemiology, and each will provide valuable experience for any future positions.
  5. Partner with others to expand your skills
    If you are struggling to find professional development opportunities at your current worksite, partner with colleagues to create some! Epidemiologists at many health departments have joined together to hold regular journal clubs, seminars, or poster sessions in order to learn from the work and perspectives of others.
  6. Connect with the users of your data and analyses
    We all intend for our analytic activities to help improve the health of the public. Reaching out to and understanding the needs of the program managers, health educators, and key partners who will be using your results in their work will give you the best chance of moving from data to public health action.
  7. Understand the data
    One of the biggest mistakes that we can make as epidemiologists is to jump in to an analysis before we fully understand the data source and the data set. The mode of data collection and the wording of the survey questions are just as important to be aware of as the variable type and coding in the data set. We should always interpret our results within the context of the data being used.
  8. Clearly communicate your findings
    Communicating the results and limitations of an analysis in language appropriate for a non-technical reader can be a challenge. Utilizing your understanding of the audience and data sources can help provide context to our findings and move the results to action.
  9. Remember that applied epidemiology is sometimes messy
    Few epidemiologic analyses are done with ideal and complete data, and the answer is rarely as simple as a classroom exercise where the ice cream is clearly responsible for the foodborne outbreak at a family reunion. But if you stick to the basic concepts you will find that you are able to apply them even in those messy situations.
  10. Identify creative opportunities to use and share your skills
    Take advantage of chances to use your skills in unexpected ways. Whether it is helping a local partner design a survey, providing information on key datasets to a student working on a class project, or taking on a special assignment, you will undoubtedly find value in these experiences.
Angela Rohan, PhD is an alumna of the CSTE Applied Epidemiology Fellowship (Class VI) and serves as a mentor for the program. Currently she is a Centers for Disease Control and Prevention assignee for Maternal and Child Health Epidemiology at the Wisconsin Division of Public Health.

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Climb Mt. Everest: Lead a Fun Fitness Challenge at Your Workplace

Posted By Patricia Quinlisk and Shawnice Cameron, Friday, July 31, 2015
Updated: Thursday, July 23, 2015

New research has shown that sitting for more than three hours at a time is very bad for overall health; in fact, it may be as bad for your health as smoking! 1 2 To “walk the talk” of personal wellness, a volunteer planning team at the Iowa Department of Public Health (IDPH) created a fun, friendly competition to engage employees, students, and staff. The challenge not only helped our workplace achieve its fitness goals—such as increased use of stairs, decreased time ‘just sitting,’ and improved health—but also contributed to camaraderie and morale. We did this without public funding at a minimal cost. We’ve compiled the materials into an easy-to-use, downloadable package of public domain instructions and materials, so that you can replicate or adapt the challenge at your work environment. Leading your own challenge helps your colleagues build daily routines for better long-term health.

The Climbing Mt. Everest Fun Fitness Challenge can turn any available location with steps, such as stairwells, outdoor bleachers at schools, parking ramp stairs, etc., into an opportunity for group fitness. IDPH’s first 26-week challenge concluded this month, proving to be so engaging and popular among participants that we plan to continue it.

How it works is simple and easy:

  1. Lead a pep rally, hang up announcement posters, and send an introductory e-mail
  2. Hang up the wall chart (see below) in a prominent location, such as the top of a stairwell. Table rows list participant names and columns list progressive elevations of famous mountains. The wall chart allows participants to track the flights of stairs they’ve ascended with tally marks. Counting the steps in your stairwell allows you to calculate how many tally marks are necessary to reach each mountaintop, using instructions in the downloadable packet.
  3. Ask participants to print, personalize, and hang near their desk their own achievement charts (see below):
  4. Incentivize continued participation by refreshing the daily stairway climb experience. Every day, IDPH staff posted a rotating series of trivia questions and answers, pulled from a popular board game, respectively at the bottom and top of the stairs.
  5. Recognize those who reach the summit of Mt. Everest by awarding the distinction of ‘Sherpa,’ which imparts these individuals with the role of motivator to guide all colleagues towards scaling that final summit.

Download the complete packet of materials or just the instructions

Included in this packet are instructions on how to start the challenge, how to create units of measurement to climb to the top of Mt. Everest, and suggestions on how to make the use of stairs more interesting and fun. Also included are templates for the materials needed for this challenge: the wall chart, the cubicle/desk/office posters, the stickers of milestone mountains for tracking personal progress, information on mountains used for elevation milestones, and minimal costs of this challenge.

This material was developed by Iowa Department of Public Health for our employee wellness with no public funding and is in the public domain. Please feel free to customize it for your own group needs. For more information, please contact Shawnice Cameron. We want to hear if your workplace finds this packet useful.



  1. "Sitting for More Than Three Hours a Day Cuts Life Expectancy.” Seidman, Andrew. Wall Street Journal (July 2012). http://www.wsj.com/articles/SB10001424052702303343404577516853567934264.
  2. "Sedentary behavior increases the risk of certain cancers.” Schmid, Daniela and Colditz, Graham. Journal of the National Cancer Institute (2014). 106 (7). http://jnci.oxfordjournals.org/content/106/7/dju206.full


Patricia Quinlisk, MD, MPH is medical director and state epidemiologist and Shawnice Cameron is administrative assistant at the Center for Acute Disease Epidemiology at the Iowa Department of Public Health. For more information about long-term health, visit the chronic disease-related subcommittees on the CSTE page for the Chronic/Maternal and Child Health/Oral Health Steering Committee.

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Reflections on Ebola Work in Guinea, April 2015

Posted By Mari Gasiorowicz , Friday, July 24, 2015
Updated: Thursday, July 23, 2015

Mari Gasiorowicz, MA is an epidemiologist in the AIDS/HIV Program at the Wisconsin Division of Public Health. CSTE continues to seek epidemiologists who wish to be deployed for Ebola response. If you are interested, look at the bottom of the page for information on how to be considered.

I had the fortune to be part of a CSTE team of seven sent to Guinea and Liberia, West Africa for the month of April 2015 to provide epidemiologic and infection control support to help end the Ebola epidemic.

More than a year into Guinea's Ebola epidemic, banners, posters and radio messages help to create a relatively high level of awareness of existence of the disease.

The degree to which precautions were practiced was variable. In the capitol, many office buildings had guards that thermo-flashed visitors to check their temperature. We also washed our hands with 0.5% chlorine bleach solution a dozen times a day. Social distancing—avoiding handshakes and maintaining a distance of several feet—was practiced more in urban than in rural areas.

During my first assignment, in an outlying district in the capital, the day started and ended with a long meeting in a room not large enough for the 25 to 30 people in attendance. We reviewed the alerts that came into the Ebola hotline (115) overnight and the coordinator assigned teams to investigate.

Alerts include all deaths, irrespective of cause, and illness that may be due to Ebola. Each team included a Guinean doctor or trainee and one or two investigators (West African, European, or North American epidemiologists). The doctor asked questions to determine whether it was possible that the death or illness was Ebola-related—duration of illness, symptoms, travel of the patient or visitors to or from other regions of the country. Conversations typically took place in a local language, with the doctor translating into French for foreigners.

The doctor explained to the family that we needed to call Red Cross because all deaths had to be tested for Ebola and secured (wrapped in personal protective equipment (PPE) material). In my experience, close family members with whom we spoke directly were agreeable. But other family members or mourners from the community often objected to the involvement of Red Cross. Washing the body and burying a loved one is very important; ceding these responsibilities to outsiders is met with a great deal of resistance, particularly in Guinea.

The doctor then called Red Cross and we waited up to four hours for the ambulance to arrive and complete their assignment. Red Cross staff explained the steps: suiting up, testing the body, securing the body, and if the family allowed, taking the body to the morgue. If Ebola was not indicated, the family would be able to collect the body and conduct the burial themselves.

I spent the second two weeks in a rural prefecture helping observe and monitor outcomes of a four-day social mobilization campaign to reach 55,000 households. After a brief training, 500 teams of three were deployed to visit households to provide information using a laminated flipchart with graphic images of Ebola symptoms and instructions in case of illness. Teams were also supposed to thermo-flash each household member and ask if anyone was ill.

After meeting with the village leader for permission, we observed these thorough and engaging presentations as teams traveled household to household. Children often followed the team so they heard the presentation several times. We then visited households that had received the presentation and asked what members took away. While the donor community viewed the campaign's purposes as education and case-finding, we found that receiving soap (the six-bar incentive) and learning about Ebola were the main takeaways. All agreed that the campaign was a formidable effort but that its impact could have been greater if conducted earlier in the epidemic.

While we focused on Ebola, people continued to live their regular lives – watching soccer, going to mosque, and preparing and eating perfectly cooked mango stew. Both health professionals and rural residents displayed gratitude for our efforts.

Despite uncertainty, chaos, heat, intermittent electricity and running water, traffic and difficult working conditions, I am very grateful to have had the opportunity to participate in the massive effort to address Ebola in West Africa. Thank you to CSTE for providing the opportunity, to CDC for the financial support to CSTE and support in-country, and to my health department for encouraging my participation.



CSTE is seeking to identify additional experienced epidemiologists who would be willing to travel to affected Ebola regions in West Africa. In addition to French-speaking epidemiologists, we are seeking qualified epidemiologists who speak Portuguese and those who speak only English. You can apply through the CDC/CSTE Ebola Deployment Application Form. Deployments are 30 days in length with a 3-5 day training in Atlanta, GA immediately prior to travel. CSTE would support travel and onsite expenses (per diem, lodging, travel insurance, etc.). CSTE may also support salary in terms of salary reimbursement to your health agency, reimbursement for vacation days used, or consultant pay.

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A Mixed Bag for Public Health: Appropriators Favor Infectious Disease in Spending Legislation

Posted By Emily Holubowich, Friday, July 17, 2015
Updated: Friday, July 17, 2015

Emily Holubowich, Senior Vice President at CRD Associates, is CSTE’s Washington representative and leads our advocacy efforts in the nation’s capital.

Emily Holubowich provides an update on congressional activities at the recent CSTE Annual ConferenceThe week of June 22, both the House and Senate Appropriations Committees approved along party lines their respective spending bills for the Departments of Labor, Health and Human Services, Education and Related Agencies (Labor-HHS). Starting from nearly $4 billion lower than the current, already austere funding level, the bills force draconian cuts in many programs to support increases in others. Each chamber took a slightly different approach to making these necessary tradeoffs—the House preferring big cuts to fewer programs (e.g., the Agency for Healthcare Research and Quality and Title X Family Planning, which were eliminated) and the Senate preferring to spread the pain more evenly. But in both chambers, it’s a mixed bag for public health and epidemiology.

To review, the president sought $7 billion for the Centers for Disease Control and Prevention (CDC) in FY 2016, a 2 percent increase that included $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 translated 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.

The House Appropriations Committee grants the president’s request for CDC budget authority and PPHF, but the Senate provides CDC only $5.747 billion in budget authority (a $220 million cut compared to FY 2015) and $893 million in PPHF dollars.

The National Center for Emerging and Zoonotic Infectious Diseases (NCEZID) received a $107.6 million increase in the House and a $35.6 million increase in the Senate, both still less that the president’s significant, $294 million request. Within NCEZID, the new Combating Antibiotic-Resistant Bacteria or “CARB” initiative would receive $120 million from the House and only $30 million from the Senate, in each case much less than the president’s requested $264 million. We would expect much of the NCEZID funding, including CARB, to support core infectious disease surveillance capacity at state and local health departments through Epidemiology and Laboratory Capacity (ELC) grants, in addition to $40 million from the mandatory PPHF that the House and Senate both provide for the fifth consecutive year. Among our other NCEZID appropriations priorities, food safety, advanced molecular detection, and National Healthcare Safety Network are essentially flat funded—plus or minus nominal amounts—in the House and Senate.

The Public Health Workforce program, through which the CDC/CSTE Applied Epidemiology Fellowship receives funding, would also see flat funding of $52.2 million in both chambers and no supplemental PPHF funding. The appropriations bills do not specify how much funding would be dedicated to the Applied Epidemiology Fellowship program per se, but with flat funding of the program we might expect flat funding for our fellows. The president had requested a $15.2 million increase in budget authority, as well as $36.2 million in PPHF. Two years ago, Congress eliminated $15 million in PPHF dollars for Public Health Workforce in the wake of sequestration.

Funding increases in some areas such as CARB necessitated cuts to other public health programs. For example:

  • NCZEID’s “emerging infectious disease” program was cut by $11 million in the House;
  • The National Center for Chronic Disease Prevention and Promotion was cut by $100 million in the House and $146 million in the Senate;
  • CDC’s safe water program was zeroed out in the Senate and the environmental and health outcome tracking network was cut significantly in both chambers;
  • The childhood lead poisoning prevention program’s budget authority was zeroed out in both chambers (though both House and Senate do continue PPHF funding).

Given the political and fiscal environment, forward progress on Labor-HHS and other spending bills is expected to halt. The House leadership seems to have postponed floor action on appropriations bills after pro-Confederate flag amendment on the Interior and Environment spending bill caused a melee on the House floor last week. In the Senate, Democrats have vowed to filibuster all spending bills that come to the floor on the grounds that they lock in austere spending levels under sequestration. A continuing resolution to keep the government running on autopilot seems imminent come September 30. The question is whether or not it will be only for a limited period of time while Congress finalizes spending legislation before the end of the calendar year; or whether it will be for the full year if Congress determines there’s no path to a compromise on final appropriations language. And of course, the big question in Washington is will there or won’t there be a government shutdown come October 1. It’s too soon to tell, but the fact that budget experts are suggesting it—and lawmakers are already pointing fingers across the aisle to place blame—leads one to believe that a shutdown is more than a distinct possibility.

For more information about funding levels for your specific priorities, please click here for a copy of CDC’s detailed budget table.

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New Report Assesses State Activities in Non-Infectious Environmental Health Exposure Monitoring and Investigation

Posted By Jessica Wurster, Friday, July 10, 2015
Updated: Wednesday, July 8, 2015

CSTE is pleased to announce the release of the Assessment of State Activities in Non-Infectious Environmental Health Exposure Monitoring and Investigation report. The scope of state environmental health applied epidemiology activities in non-infectious conditions had never before been systematically assessed. Therefore, the Council of State and Territorial Epidemiologists (CSTE) in collaboration with the National Center for Environmental Health at the Centers for Disease Control and Prevention (CDC) undertook a national assessment to determine current processes for and experiences with the monitoring and investigation of environmental exposures and associated acute non-infectious health effects.

The purpose of this assessment is to better understand how these processes have been standardized in terms of response algorithms, case definitions, and investigation forms and protocols; how agencies store, share, and use this information; and how the activities are linked with related programs, such as occupational and injury epidemiology. The results demonstrate environmental health-related activities that are being successfully implemented in many health departments and can be used to build environmental health investigation and response capacity nationwide.

In total, 80.5 percent of the 56 requested agencies completed the assessment during the time span of December 2013 to March 2014. The report presents assessment data of 11 environment-related health conditions and nine types of environmental exposure events. Additionally, the assessment addresses whether syndromic surveillance has been used as a tool for environmental monitoring and response, the effect of the location of radiation control agency on radiation event reporting and activities, and resources and barriers to monitoring and response. To read the results of the report, click here.

The recommendations of the report are to:
  1. Focus on greater public dissemination of investigation results of case reports and exposure events.
  2. Develop a repository of procedures and tools used by the 35 jurisdictions that were willing to share these items, and make the repository available to all state and local health departments.
  3. Provide guidance on strategies for the monitoring of and response to non-reportable health conditions.
  4. Conduct within-agency training on current reporting requirements and practices.
  5. Promote the use of syndromic surveillance as a source for environment-related health conditions.
  6. Expand the current levels of national funding originating from the Environmental Public Health Tracking and the National Institute for Occupational Safety and Health at CDC.

The authors are:

Henry Anderson, MD, Wisconsin Department of Health Services
Kristina W. Kintziger, PhD, Florida Department of Health
Erin Simms, MPH, (Former) Council of State and Territorial Epidemiologists
Martha Stanbury, MSPH, Michigan Department of Community Health
Sharon M. Watkins, PhD, Florida Department of Health
Jessica Wurster, MPH, Council of State and Territorial Epidemiologists

If you have any questions or would like more information about CSTE Environmental Health programs, please contact Jessica Wurster.

Jessica Wurster, MPH is an associate research analyst at the CSTE national office. To learn more, visit CSTE’s Environmental Health page.

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CSTE Supports Antibiotic Resistance Stewardship

Posted By Marion Kainer and Jeffrey Engel, Thursday, July 2, 2015
Updated: Tuesday, June 30, 2015
Untitled Document

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

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

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

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

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

The attendees were then split into the animal health sector that remained in the EEO and the human health sector group that relocated to the Cash Hall of the Treasury Building. We walked past the West Wing, cut through the North Side of the White House (through areas labeled “no tours beyond here”). The rest of the day was spent in four sessions (each with three panelists) moderated by CDC staff: hospitals (Dr. Arjun Srinivasan), outpatient use (Dr. Lauri Hicks), long term care (Dr. Nimalie Stone) and diagnostics (Dr. Jean Patel). Panelists included Kaiser Permanente and CVS. Both described their use of health information technology to support appropriate antimicrobial use, making it easy for providers to make the right choice; each performed audits and provided provider-specific feedback. They leveraged basic interoperability and infrastructure that was encouraged through meaningful use. Strengthening IT infrastructure, including interoperability, audit, and feedback as well as decision support, was a common theme. Other themes from the day included:
  • Optimal use of data
  • The need for meaningful and valid measures
  • The importance of transparency
  • The ongoing need for better surveillance
  • Financial incentives
  • Better tools (especially diagnostics that communicated results not only to the provider at the point of care, but also to the electronic health records)
  • A need for a “culture change” in healthcare and education and training, including meaningful involvement of patients, families and consumers

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

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

Marion Kainer, MD, MPH, FRACP, FSHEA is director of the Healthcare Associated Infections and Antimicrobial Resistance Program at the Tennessee Department of Health. Jeffrey Engel, MD is executive director of the Council of State and Territorial Epidemiologists. For more information about antibiotic resistance, please visit CSTE’s Infectious Disease Steering Committee page.

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The Road to a Resource for Applied Chronic Disease Epidemiologists

Posted By Annie Tran, Friday, June 26, 2015
Updated: Friday, June 26, 2015
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In June 2015, CSTE released a new resource to help orient chronic disease epidemiologists them to the changing demands of state public health.As was found in the Chronic Disease module of the 2013 Epidemiology Capacity Assessment (ECA), only 16 percent of chronic disease epidemiologists (CDEs) at state health departments had “some epidemiology coursework.” This number is a decrease from the 2009 ECA showing only 25 percent of practicing CDEs had previous epidemiology coursework. 2009 data also show nearly half of state health departments have substantial capacity 1 . With only a small fraction of existing CDEs trained in epidemiology and most health departments lacking chronic disease capacity, CSTE saw the need for additional training and resources to support chronic disease epidemiologists in state health departments.

In 2012, Dr. Sara Huston, then chair of the Chronic Disease/Maternal and Child Health/Oral Health Steering Committee, convened a group of impassioned CDEs to discuss the idea of a resource to guide CDEs through the first days of leading a CD program. This idea evolved over months of dialog, and what began as a collection of ti ps, tools, and leading practices became a more comprehensive manual to orient leading CDEs at state and local health departments, based loosely on the State Epidemiologist Orientation Manual. At the helm of this project was Dr. Renee Calanan, Chronic Disease Epidemiology Capacity Subcommittee chair and current chair of the Chronic Disease/Maternal and Child Health/Oral Health Steering Committee.

Under her direction, a small but dedicated workgroup drafted nine chapters (and several appendices) to form the Chronic Disease Epidemiologist Orientation Manual: A Resource for Applied Epidemiologist. This labor of love was published in June 2015 and contains chapters on understanding the role of a lead CDE, technical challenges faced by CDEs (data governance, data sources and indicators, data interpretation and dissemination, etc.), and organizational challenges that affect CDEs (integration, collaboration, system dynamics). In writing this manual, the authors intend for it to be a quick-start menu of resources for lead chronic disease epidemiologists working in state, territorial, tribal, or local health departments. It is not meant to be a comprehensive epidemiology manual.

We hope that this manual will encourage discussion and collaboration to address challenges and spur innovation in the delivery of data-driven chronic disease epidemiology services throughout the United States. As chronic disease becomes more prevalent, CDEs know all too well that the demands of being a lead CDE can be huge, but so can the reward. And this manual can help you get that.

Annie Tran, MPH is a former senior research analyst for CSTE. For more information on the Chronic Disease Epidemiology Capacity Subcommittee, please visit the CSTE Chronic Disease/Maternal and Child Health/Oral Health Steering Committee webpage. If you have questions or comments, please contact Nidal Kram, CSTE’s staff lead on chronic disease work.
1Substantial capacity defined as less than 50% capacity to execute epidemiologic functions. A self-assessed measure.

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