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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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Quitting Tobacco Incentive Program: A Project Worth Saving

Posted By Matthew Francis, Friday, January 30, 2015
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Many epidemiologists know what it’s like to face a great project on the precipice of failing despite every effort to keep it alive. I hoped that neither of my two projects in Lane County, Oregon would be in this situation. As a 12-month Health System Integration Program (HSIP) fellow, you go in knowing that some of your projects are in need of improvement; that you as the fellow are the person who will provide a solution; and that the work is scoped to be resolved within 12 months. Despite my hopes and the efforts of the project team assigned to Tobacco Cessation in Pregnancy (TCIP), this is exactly where I found myself on one project. Truth be told, I couldn’t have been more thrilled to have the opportunity to keep a truly important public health project from being scrapped due to a shaky start.

The HSIP fellowship uniquely rests on the fulcrum between informatics and epidemiology. As an epidemiologist, my role is to design questionnaires, assist with analytics, support projects, and aid in the implementation of epidemiological methodologies. As an informaticist, I make sure the variables make sense and the radio buttons are in a logical order. I also name variables, create user-friendly databases, and write codebooks. Both skillsets were needed when the TCIP initiative was failing and the decision was made to move it to The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), rename it Quit Tobacco Incentive Program (QTIP), and change the way tobacco use was measured.

That transition was in the works when I arrived. After meeting with the QTIP team, it quickly became apparent that during year one of the program, due to such issues as their tobacco screening tool being unreliable and physicians and clinic staff overburdened and dropping out, there was no data infrastructure. As discussion revolved around moving the program to WIC, the same question kept surfacing, where will the data go?

When multiple physician offices were enrolling participants, the default option involved copying paper records to spreadsheets. This system, aside from transcription errors, faced an enormous challenge. The goal of the program was 80 percent enrollment of a projected 600 pregnant smoking Medicaid mothers. Since each mother would be interviewed six to seven times and their data would be entered twice—on paper and Excel—by one individual at WIC, the volume of data entry work was well above what a 0.2 full-time equivalent counselor could complete. Had the program been in its planning stage, perhaps this issue could have easily been resolved. However, with the program on the fast track and WIC gearing up for enrollment, each participant enrollment would create a more burdensome data system. The database also needed to contain a system where the WIC staff could take notes to assist in counseling support of the pregnant mother as well as adding to the existing data that was being collected. Lane County Prevention and WIC staff also felt the need to collect data on electronic cigarette usage, since there was concern that mothers might use e-cigs to aid in cutting back on traditional cigarettes.

With guidance and input from my mentor, the prevention team, local coordinated care organization, and WIC staff, we were able to develop an Access database with forms similar to the existing paper copies housed in WIC. We were also able to create a database for the WIC staff that was on time and flexible enough to be a useful tool for present and future enrollment. The new data tool allowed for WIC staff to provide a better overall experience for pregnant mothers interested in quitting. WIC staff was able to make notes, track progress, set reminders and have a system that quickly allowed them to pull participant data when needed to assist in tobacco cessation. Being an HSIP fellow allowed me to tackle the program improvement from two key perspectives. I was able to not only address the data needs of the program by creation of the data tool, I was also in the unique position to ensure that the transition from paper to database was as seamless as possible and was able to give recruitment guidance based on my previous experiences in the field.

An important takeaway from this project has been that despite funding and availability of resources, some projects hit early road blocks that can severely jeopardize their success. Having the correct informatics and epidemiological resources is a crucial component of successful programs. It takes a determined program staff to move forward during times of change and maintain the initial program vision. Integration of multiple health systems allowed for the continuation of a great public health program that had stumbled early on. Reintegration of clinics and physicians as referral tools is an important next step for the success of the program.

Matthew Francis, MS, PhD is a Health Systems Integration Program (HSIP) fellow at Lane County Health and Human Services in Eugene, Oregon. For more information on drug surveillance, read more at the Alcohol and Other Drug Surveillance Subcommittee. The HSIP fellow application is open until February 16, 2015.

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Interview with CSTE Ebola Epidemiologists

Posted By Chad McCoull, Wednesday, January 28, 2015
CSTE is sending epidemiologists to West Africa for Ebola prevention. Watch the YouTube video as Jean-Marie Maillard of North Carolina, Raoult Ratard of Louisiana, and Katrina Hedberg of Oregon discuss their training and work:

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Syphilis Outbreak Response in Southwest Oklahoma

Posted By Jan Fox and Kristy Bradley, Friday, January 23, 2015
Untitled Document
On July 28, 2014, a case of primary syphilis was identified at the Comanche County Health Department (CHD) in Oklahoma. Between July 28 and September 25, eight additional cases were diagnosed in that county. These numbers reflected a 300 percent increase in reported cases for Comanche County from 2013. Upon review of the cases, the Oklahoma State Department of Health (OSDH) HIV/STD Service and the Comanche CHD determined that an outbreak of syphilis was occurring and outbreak response efforts were initiated. The outbreak was found to be occurring among men who have sex with men (MSM) and included risk factors of multiple sex partners, new and/or anonymous sex partners, using drugs, and/or trading sex for money and/or drugs. It was also noted that some infected were on the ‘down-low’ (slang for men who identify as heterosexual, but who have sex with men and avoid sharing this information even if they have female sexual partners and/or are married).
Working in partnership, the HIV/STD Service and the Comanche CHD quickly implemented the following activities:
  • Conducted a ‘blitz’, in which a team of Disease Intervention Specialists was dispatched to Comanche County to quickly initiate contact tracing (partner services) for all reported cases in an effort to get in front of the outbreak. Contact tracing is the cornerstone of public health response efforts for infectious diseases and involves face-to-face interviewing of infected persons to elicit reporting of sexual partners in order to subsequently locate, test, and treat persons who have been exposed to the disease. To date, a total of 110 sexual partners were identified as a contact to at least one of the 11 cases, with 73 in need of treatment. Among these, 81 have been located and tested, 52 have received treatment, and 8 required interstate assistance for follow-up.
  • A health alert went out to local clinicians and a syphilis educational meeting was held at the Comanche CHD in order to make local clinicians aware of the syphilis problem and to ask for assistance in testing and treating their at-risk patients. The meeting was well attended with 35-40 clinicians present.
  • A media news release was utilized to disseminate facts about syphilis to the public and included prevention, testing, and treatment information. The release resulted in wide distribution of information, including a live interview with KFOR, in-person on-camera interviews for KSWO-TV 7 News in Lawton, Telemundo, and Fox25 as well as a phone interview with the Daily Oklahoman and the Cameron Collegian Weekly. Additionally, the online story was shared more than 12,000 times on social media.
  • Posters and other print material were created and distributed in the Lawton area to raise awareness of syphilis and the outbreak. A quick response (QR) code was created and added to the print material; when scanned, this code would lead the person to a website that provided information about the health alert and basic syphilis information.
To date, 17 syphilis cases have been identified that are associated with this outbreak. Disease prevention and control efforts continue in order to ensure that the outbreak is brought to an end.
Jan Fox, RN, MPH, is the Director of the HIV/STD Service at the Oklahoma State Department of Health. Kristy K. Bradley, DVM, MPH is State Epidemiologist and State Public Health Veterinarian at the Oklahoma State Department of Health. She also serves as CSTE Executive Board Chair for Infectious Disease. For more information about STIs, visit CSTE’s National Notifiable Diseases Surveillance System NNDSS Modernization Initiative page and the Infectious Disease overview page.

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New and Improved Chronic Disease Indicators

Posted By Sara Huston, Thursday, January 15, 2015
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CSTE, along with our partners CDC and National Association of Chronic Disease Directors (NACDD), is excited to share the release of two new important tools for chronic disease surveillance: 1) the MMWR Recommendations and Reports “Indicators for Chronic Disease Surveillance — United States, 2013” and 2) the redesigned CDC Chronic Disease Indicators website. These tools are products of a multi-year collaborative effort between CDC, CSTE, and NACDD to review and update the Chronic Disease Indicators (CDIs), which were first adopted in 1999.
The MMWR publication details the history of the CDIs and the process we went through in this most recent update. Did you know that the CDI work has been a successful collaboration between CSTE, CDC, and NACDD since way back in the mid-1990s? Many CSTE members dedicated their time and provided their expertise to help with this most recent CDI revision process – serving on or even chairing the content-specific working groups, or participating in the 2013 CSTE position statement process that officially adopted the newly revised CDIs. All the working group members are acknowledged in the MMWR. Thank you for your contributions!

The MMWR publication also highlights the major areas of change to the CDIs and provides detailed technical definitions – including numerator, denominator, and data sources – for each of the 124 indicators in 18 topic groups. The detailed definitions will enable epidemiologists to create estimates that are consistent with the data that CDC publishes on the CDI website, and may be especially helpful to local health departments in creating their own sub-state-level estimates.

CDC’s redesigned CDI website, just launched this week, provides data for each of the indicators at the state, territorial, and national level as well as for 40 large metropolitan areas. In addition to updating and adding data for all the CDIs, CDC worked hard to create a more user-friendly display, navigation, and data retrieval functionality for the website. Please take a few minutes to visit the site at www.cdc.gov/cdi, bookmark it and check it out!

If you haven’t taken a look at the CDIs since their last formal update in 2002, you’ll see many changes that reflect the growth in chronic disease programs in state and territorial health departments over the past decade and keep the CDIs relevant for present-day chronic disease surveillance. For example, the CDIs include 22 new indicators of systems and environmental change, reflecting the increased focus on environmental and systems change strategies in chronic disease program efforts. The updated CDIs also include five new topic areas – disability, mental health, older adults, reproductive health, and school health – reflecting the increased scope of work of many state and territorial chronic disease programs and increased collaboration with other program areas.

Here are just a few of the new CDIs you might find interesting:

  • Nutrition, physical activity, and weight status 8: Number of farmers markets per 100,000 residents (data source: USDA National Farmers’ Market Directory)
  • Asthma 5.1: Influenza vaccination among noninstitutionalized adults aged 18–64 years with asthma (data source: Behavioral Risk Factor Surveillance System)
  • Older adults 3.1: Proportion of older adults aged ≥65 years who are up to date on a core set of clinical preventive services (data source: Behavioral Risk Factor Surveillance System)
These newly revised Chronic Disease Indicators provide state and territorial health departments and other health agencies with a framework for chronic disease surveillance in the form of rigorously-defined consensus measures that are relevant to their programs. Our challenge going forward is to keep them relevant and to not let a whole decade pass before the next update! Please stay tuned for upcoming opportunities to learn more about the new CDIs and get involved in the next update process.
Sara L. Huston, Ph.D. is on the faculty of the University of Southern Maine’s Muskie School of Public Service and serves as the Lead Chronic Disease Epidemiologist for Maine. She is former chair of CSTE’s Chronic Disease/MCH/Oral Health Committee. For more information, please visit the CSTE page on CDIs and the 2013 CSTE position statement Revision to the National Chronic Disease Indicators.

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Tags:  cdi  chronic disease  chronic disease indicators 

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