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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.

1 2 3 4 5 6
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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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.
Are you a member with an important message to tell the CSTE community? Tell us about it!
Do you use social media? Stay tuned to CSTE on Facebook and Twitter for daily updates!

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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.
Are you a member with an important message to tell the CSTE community? Tell us about it!
Do you use social media? Stay tuned to CSTE on Facebook and Twitter for daily updates!

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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.

Are you a member with an important message to tell the CSTE community? Tell us about it!
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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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