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The Meaningful Impact of Position Statements

Posted By Virginia Dick, Friday, January 9, 2015
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CSTE members work hard each spring to develop position statements, which address a broad range of public health issues and health conditions for standardized surveillance. Over the past four years, there have been between 10 and 30 position statements submitted each year. Many of these position statements have had significant impacts on the public health environment. Below are a few of the position statements that have specifically addressed public health policy areas and the progress that has been made in these areas.
10-EH-01 Asthma: a continuing public health priority and 13-CD-01 Revision to the National Chronic Disease Indicators
These indicators involve CDC, NACDD, and CSTE updating and revising the Chronic Disease Indicators. The 2010 Environmental health position statement involved the partners working together to update the Asthma Indicators that are part of the Chronic Disease Indicators. After three years of review, revisions, and additions by experts, the full list of indicators is being released January 15, 2015, including a CDC MMWR and a new website. In addition, due to the position statement process and advocacy, CDC continues to fund state partners to conduct asthma surveillance, and provide technical epidemiologic support to funded states. The work on asthma has helped lay groundwork in preparation for the Coordinated Federal Action Plan to Reduce Racial and Ethnic Asthma Disparities.
10-ID-28 Council of State and Territorial Epidemiologists - Centers for Disease Control and Prevention (CSTE-CDC) Process for Setting National Standards for Healthcare-Associated Infections Case Criteria and Data Requirements
This position statement addresses the process for setting Healthcare-Associated Infection case criteria and data requirements. A CDC-CSTE HAI standards committee has been created and has met regularly for the past two years.
11-OH-01 CDC and Cleaning Products Messages
NIOSH convened an international working group in the NORA Health Care and Social Services sector with expertise in infectious disease and occupational health to develop an analysis of cleaning products and infection control in healthcare. In 2012, the National Institute for Occupational Safety and Health (NIOSH) published a publication called “Protecting Workers Who Use Cleaning Chemicals.
12-CD-01 Proposed New and Revised Indicators for the National Oral Health Surveillance System and 12-CD-02 Developmental and Emerging Indicators for the National Oral Health Surveillance System
The National Oral Health Surveillance System (NOHSS) includes developmental and emerging indicators. A workgroup was assembled in 2012 that published a publication in 2013 called “State-based Oral Health Surveillance Systems: Conceptual Framework and Operational Definition.” There is a group that is now reviewing the indicators and working towards a 2015 position statement to revise the indicators. There are also 21 states with funded state oral health programs for the 2013-2018 period. In 2014, the Association of State and Territorial Dental Directors State Synopsis added a new section on state surveillance systems which assess the availability and use of selected NOHSS indicators. This will be released on the ASTDD site: http://www.astdd.org/publications/
13-ID-02 Healthcare-Associated Infections Data Presentation and Reporting Standards
A workgroup was formed in the fall of 2013 and it meets regularly via conference call. The workgroup produced the first draft of a toolkit which was presented at the 2014 conference with feedback currently being integrated into the toolkit. It is anticipated that the toolkit will be completed by winter 2015. Read more about this position statement and the current timeline here.

Virginia Dick, PhD is Deputy Epidemiology Program Director and Chief Program Evaluator at the CSTE national office.
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Steady She Goes: Epi Mostly Flat-Funded in “CRomnibus”

Posted By Emily J. Holubowich , Wednesday, December 31, 2014
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Emily Holubowich, Senior Vice President at CRD Associates, is CSTE’s Washington representative and leads our advocacy efforts in the nation’s capital.

On December 16, President Obama signed the bipartisan Consolidated and Further Continuing Appropriations Act, 2015 or “CRomnibus”—part continuing resolution (CR), part omnibus legislation. The massive spending bill includes a CR through February 27, 2015 for the Department of Homeland Security and 11 separate spending bills for the remaining months of the fiscal year (FY), including the Departments of Labor, Health and Human Services, Education and Related Agencies Appropriations Act (Labor-HHS).

This typically controversial Labor-HHS bill, which includes spending for the Centers for Disease Control and Prevention (CDC), holds funding essentially flat for most public health activities providing only a slight increase for CDC overall. Specifically, the legislation provides the agency $6.26 billion in FY 2015, which includes $6.024 billion in base discretionary funding, $887 million in transfers from mandatory Prevention and Public Health Fund (PPHF)—a new high—and $15 million in Public Health and Social Services Emergency Fund (PHSSEF) unobligated balances from pandemic influenza supplemental appropriations.

The agency also received an additional $1.77 billion in one-time, emergency supplemental funding to support the nation’s Ebola response. CSTE is expected to receive funding to send medical epidemiologists into surrounding, unaffected West African countries as part of the Ebola containment strategy.

Even with the slight increase for CDC, most core epidemiology programs were held flat—about the best anyone can hope for in this austere fiscal environment—while some surveillance activities saw substantial increases. For example, the CRomnibus provides the National Center for Emerging and Zoonotic Infectious Diseases a significant, 20 percent increase ($66 million), but still less than the administration’s requested 31 percent increase. This increase will “trickle down” to many of the programs epidemiologists xrely upon to do our work.

Provided below is a summary of the final funding levels for some of CSTE’s key advocacy priorities:
  • Epidemiology and Laboratory Capacity Grants. The ELC “program”—a grant mechanism used by CDC to support core infectious disease surveillance capacity at state and local health departments—is once again awarded $40 million from the Prevention and Public Health Fund (PPHF), consistent with FY 2012, FY 2013, and FY 2014. Total funding for ELC grants will be determined based on emerging needs throughout the year.

    Given that the Prevention Fund was cut by $73 million due to sequestration (the Prevention Fund and other mandatory funding streams are not provided any sequestration relief), we are very pleased and relieved to see this funding re-allocated at current levels, especially as other CSTE priorities that had previously received PPHF did not receive allocations through this mechanism in FY 2014 or FY 2015.

  • Advanced Molecular Detection. The CRomnibus provides $30 million for the “AMD” initiative, consistent with FY 2014 and the administration’s FY 2015 request. This funding will be used both to improve CDC’s capability and to initiate state projects that will improve the application of genome sequencing to public health issues of concern.

    For the first time, the CRomnibus includes some of CSTE’s recommended report language on the importance of public health surveillance:

    Responding to Emerging Threats.—The agreement continues to support the Epidemiology and Laboratory Capacity and Advanced Molecular Detection Programs to strengthen epidemiologic and laboratory capacity by providing critical resources to address 21st Century public health challenges.”

  • Food Safety. The CRomnibus provides nearly $48 million for foodborne disease surveillance, an increase of 19 percent over FY 2014 but less than the administration’s request of $52 million. This includes $8 million to apply advanced DNA technology to improve and modernize diagnostic capabilities; and enhance surveillance, detection, and prevention efforts at the state and local level.

  • Epidemiology Fellows. The “Public Health Workforce” program—through which the CSTE/CDC Applied Epidemiology Fellowship Program receives funding—is slated to receive $52.2 million, a 14 percent increase over FY 2014 but still less than the administration’s request. Once again, this program is not provided any PPHF dollars—compared to $25 million in FY 2012 and $15 million in FY 2013. That means that Public Health Workforce funding remains below the high watermark of years past.

  • Ebola Containment Strategy. CSTE is expected to receive funding to send up to 24 epidemiologists to unaffected countries in West Africa within the next 6 months.
Surprisingly, the CRomnibus does not include any funding to support the nation’s response to the antibiotic resistance (AR) epidemic, despite the administration’s request for $30 million. As you know, in 2013, CDC released a comprehensive report, Antibiotic Resistance Threats in the United States about this most serious of public health threats. Earlier this year the President’s Council of Advisors on Science and Technology (PCAST) issued a report and recommendations on combatting AR, and President Obama himself issued an Executive Order to implement some of these recommendations. The administration had hoped this new funding would support implementation of the report’s recommendations, including expansion of the AR detection and response program and full integration of enhanced surveillance capacity at the local, state, and national levels. Despite the lack of new funding, our understanding is the administration will continue to move forward in its plans to combat AR.
For more information about funding levels for your specific priorities, please click here for a copy of the legislation and the explanatory statement or “report language” (health is in Division G) that includes more specificity about the funding levels.
For a copy of CSTE’s funding request letter co-signed by the Association of Public Health Laboratories, click here.
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The Inside Scoop on Ebola Post-Arrival Active Monitoring: A State Perspective

Posted By Laurie Forlano, DO, MPH, Friday, December 19, 2014

Dulles International Airport in Loudoun County, Virginia just outside Washington, DC saw nearly 7 million international passengers in 2013. As one of the most highly trafficked international travel hubs in the country, Dulles became one of five major airports in October adopting new screening and monitoring procedures for Ebola Virus Disease. Practically overnight, the Virginia Department of Health had to originate new procedures and practices based on Centers for Disease Control and Prevention (CDC) guidance. In Virginia, as I’m sure is true for other states, it was important that we adapted CDC guidance to our own jurisdiction. This created a surge of new work for us. In Virginia, we are fortunate to have a unified health department—that is, our local health departments (with a few exceptions) are part of the state system. This well established, collaborative model continues to be a critical part of our planning and response.

To stand up the airport screening and post-arrival monitoring program in Virginia, a central monitoring team was developed at the state level to support the implementation of the protocols at the local level. The priority tasks related to the airport program included developing a comprehensive Virginia-specific monitoring protocol on how to handle arriving travelers, delineated by risk level. The central or “State” team in Richmond, Virginia developed protocols, forms, interview scripts, educational materials, letters, and the data management tool. In parallel, the local health department teams worked to quickly establish staffing schedules and local procedures for conducting the monitoring visits and phone calls. Local teams also worked quickly to identify local hospital partners and engage community partners who would be needed to support the planning and response, such as county government officials, local Emergency Medical Services (EMS) systems, and neighboring jurisdictions, such as Maryland and Washington, DC.

Since October 27, Virginia has handled, in one way or another, over 200 travelers who have named Virginia as their final destination. The central office team receives daily line lists via Epi-X. The line lists are divided among the respective local health departments, who then initiate daily monitoring. Local health officials communicate the 21-day protocol to the travelers, and issue an agreement letter that details the expectations of the monitoring period, and what to do if the individual becomes ill. The most important part of this program is that local staff develop relationships with these people so that communicating early signs and symptoms is efficient and easy. The data exchange between local and state health department happens weekly, in addition to any consultations during the week.

Per our local health department staff, we’ve found that travelers in general really want to be responsible, which facilitates our monitoring program and makes it a lot easier. Sometimes, we’ve even had people overseas contact us before arriving in the United States. Thankfully, the vast majority of our travelers have been in the low-risk but not zero-risk category. The number of travelers in the Virginia post-arrival monitoring program changes daily, as travelers sometimes transfer to and from other states, and there is frequent cross-border travel as many travelers live or stay in the Maryland or Washington, DC metro areas. We’ve had the opportunity to continue to work closely with Maryland and Washington, DC health departments, and it has been a powerful partnership that has helped facilitate learning for all of us along the way. Along with the monitoring program, like all other health departments across the country, we field calls for physicians who suspect Ebola among patients. Though the frequency of these calls seems to be lessening, they are complex and time-intensive consultations. We work together as a team to ensure prompt answers are given to our clinical partners in Virginia.

While obvious to most, I do believe it’s important to acknowledge that state and local health departments are charged with a host of daily tasks for other communicable diseases and reportable conditions, so there is always concern when some of our local health districts are stretched more than others. Each health district in Virginia has a dedicated epidemiologist, so Virginia is fortunate to have a strong base capacity for such a complex undertaking. With that said, some of our local health districts have been impacted more than others by the airport program. If one of the more impacted districts also simultaneously experienced a significant disease outbreak investigation, for example, our capacity to respond would indeed be stretched thin. We have thought about this and are planning to explore some creative solutions for shifting of duties, in absence of additional funding supporting the Ebola response.

Data management requires constant attention, and staff have rotating schedules to respond 24 hours a day, including weekends and holidays. The management of those numbers is what epidemiologists do best, but here in Virginia we did need to establish a dedicated monitoring team to maintain operations and send weekly reports to CDC. I think what is hardest to all of us to process is we aren’t sure for how long this will go on. As public health always does, we will rise to the task, but if I’m being completely honest, I do worry about how we will all sustain this level of intensity and volume of work.

There aren’t enough words to express how proud I am of the epidemiology teams in both our state and local offices and what they have accomplished throughout the profound changes that have happened over the last few months. Equally, it has been nothing short of a privilege to plan for this response in collaboration with our clinical partners in both domestic and international settings. Their service in the patient care realm is obviously so important, and I think the public health and epidemiology role has been complimentary to that clinical care function. Virginia’s success through the present in balancing Ebola response with other routine responsibilities stems from our teamwork, open communications, and quality staff. Engaging with the public and individual travelers, we use consistent messages and take extra care to address fears. We hope the new tools we’ve created can be applied usefully in other states. Please visit our state health department website to access resources on Ebola management. Of course, there are many additional tools available in our internal system, which we are happy to share with our peers at any time.


We’d like to thank the following additional team members: Dr. Raja’a Satouri, Deputy Director for Medical Services and Incident Commander; Katie Brewer, Assistant Director and Operations Chief; Shawn Kiernan, District Epidemiologist and technical expert; Dr. Thomas Yun, Public Health Physician - Clinical Consultation; Jessica Ong, Public Health Nurse; Lauren Earyes, Public Health Nurse; Meg Marcus, Public Health Nurse; DeAnn Ryberg, Public Health Nurse; Kris Murphy, Public Health Nurse; and Josie Gutierrez, Public Health Nurse.
Laurie Forlano, DO, MPH is the State Epidemiologist in Virginia. For more information, CSTE members can visit the CSTE page on Ebola Virus Disease.
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New Ways for Analyzing Surveillance Data

Posted By George Turabelidze, Thursday, December 11, 2014

As epidemiologists, we monitor disease incidence and use these data to detect outbreaks when the historical norm is exceeded. But the key issue is to identify what exactly the historical norm is. Often it can be difficult to call an outbreak when the numbers straddle the gray area between the historical norm and statistical variation. So, epidemiologists might need several more days to make a final determination of outbreak, and that affects timeliness and efficiency of the outbreak management.

On November 11, 2014, the Journal of Applied Mathematics published our new methodology that provides a more accurate and timelier solution to reportable conditions data analysis. Using mathematical models and Monte Carlo simulations, the article details how our methodology helps to find aberrations in the surveillance data. During the past year, real-life pilot testing has shown that the system performed well, identifying outbreaks such as E. coli and Shigella infections, pertussis, and Q fever.



Steven Rigdon, PhD; Ehsan Jahanpour, MS; George Turabelidze, MD, PhD
To create this methodology, we combed through databases and analyzed ten years’ worth of reportable conditions data in Missouri. With the help of the St. Louis University Biostatistics Department, we decided to apply trigonometric analysis to the data using software called R, a free program for statistical computing that is gaining widespread use in public health. R produces data analysis output and the Shiny software, an add-on package to R, provides graphic displays allowing for interactivity. With this versatile platform, our collective efforts have produced what we call DESTEM (Disease Electronic Surveillance with Trigonometric Models).
DESTEM offers epidemiologists a new analytic approach that not only produces a report, but allows data analysis from different “angles.” Users can customize their analysis according to specific disease, geographic region, calendar year, statistical parameters, etc. Users can set automatic communicable disease reports, which are comprehensible to non-technical audiences as they simplify results from the complex formulas underlying the tool. Most health department surveillance reports are merely descriptive; frustratingly, they do not qualify how abnormal the “abnormal” data is. By contrast, DESTEM shows red flags for data aberrations that go beyond what can be reasonably expected based on 10 years of historical data. Analysis is applied to aggregate data, and no personal identifiable information is housed on the servers.
Epidemiologists may be interested in using DESTEM as an analytical add-on to their existing surveillance systems. In Missouri, DESTEM is envisioned as an automated analytical complement to the current communicable disease surveillance system. We are working on making system accessible to the local health departments as well. It is anticipated that the full implementation of electronic lab reporting will greatly increase surveillance data coming to the health departments, thereby increasing need for analytical tools even further.

All CSTE members can use their accounts to access the demo of DESTEM software.
Click here to try the DISTEM demo

George Turabelidze, MD, PhD is a State Epidemiologist at the Missouri Department of Health and Senior Services. For more information about DESTEM, please visit the open-access article “Trigonometric Regression for Analysis of Public Health Surveillance Data.” You can also read more about CSTE’s work in surveillance and informatics.
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Information is Power: Inform Your Strategic Decisions with New Capacity Reports

Posted By Meredith Lichtenstein, Becky Lampkins, and Erin Simms, Monday, December 8, 2014
CSTE is pleased to announce the release of the 2013 Epidemiology Capacity Assessment (ECA) core report! The 2013 ECA report represents the most complete and comprehensive national data on epidemiology workforce needs. Data from the most recent assessment have already been shared as Congressional hearing testimony in support of greater targeted funding for capacity development. Your health department will benefit from the report’s insightful recommendations to address capacity gaps.
This report is a culmination of efforts that began in July 2012 with an ECA workgroup that reviewed and revised the core ECA tool, followed by your hard work in the completion of the multiple sections of the ECA. The national office performed data analysis with direction from our lead ECA consultant, Dr. Jim Hadler. We hope that the 2013 ECA results will help illuminate the status of state epidemiology efforts and assist our member states with targeting improvements in epidemiology capacity within their health departments.
Please click here to view the core ECA report from the 2013 National Assessment of Epidemiology Capacity: Findings and Recommendations.
Some features of the report include:
  • Trends in the number of epidemiologists nationwide and by state population size groupings;
  • Trends in epidemiology capacity within each of the 10 assessed program areas;
  • Salary ranges for various levels of epidemiologists;
  • Gaps in program- and Essential Public Health Service-specific capacity that still exist;
  • And recommendations for CSTE and health departments moving forward.
Members voiced opinions, we listened! We know how much time is required to complete the ECA and while this core report is very detailed and comprehensive, it may not be the most efficient tool for leveraging policy or hiring decisions with your executive leadership. To better serve member needs, the CSTE national office is developing individual state core profiles that will compare your specific state to the nation as a whole, as well as to groupings of similar states for certain key ECA questions. These reports will be distributed in the coming weeks.

Environmental Health ECA report. In addition to the core report, CSTE is announcing the release of the 2013 Environmental Health ECA report, produced by the CSTE Environmental Health Subcommittee and the CSTE national office. The report addresses: (1) environmental health epidemiology capacity and activities, (2) data access and support, (3) data collection and dissemination, (4) organizational structure and capacity and (5) collaborations with internal and external partners and participation in national workgroups/meetings.
Please click here to view the 2013 Environmental Health Epidemiologic Capacity Assessment of State and Territorial Health Departments.
Thank you again for your participation in the 2013 ECA efforts and please stay tuned for the core state profiles and the release of the CSTE Epidemiology Capacity Assessment Report: Chronic Disease, Maternal and Child Health, and Oral Health module-specific ECA report. For results from previous ECA, please visit the CSTE website.
Meredith Lichtenstein, MPH is the senior associate research analyst and Becky Lampkins, MPH is the associate research analysts in surveillance and informatics at the CSTE national office. Erin Simms, MPH is the CSTE associate research analyst in environmental health. For more information on the ECA, visit the ECA webpage and the environmental health page.

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We Herd You Had TB

Posted By Dee Pritschet, Beth Carlson, DVM, Susan Keller, DVM, Tracy Miller, PhD, Monday, December 1, 2014
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In July 2013, the North Dakota Department of Health (NDDoH) was notified of a patient presumptively diagnosed with active tuberculosis (TB) disease. The investigation revealed the patient was from Mexico and employed at a local dairy whose primary duties required extensive direct contact with dairy cattle. Due to the potential animal-human interaction, a collaborative investigation ensued between the NDDoH, the North Dakota Department of Agriculture-Animal Health Division and Board of Animal Health (NDDA-AHD and BOAH).

In November 2013, the BOAH conducted whole herd testing on 319 cattle. 11 cattle responded to the caudal fold (CF) tuberculin test and were then tested using the comparative cervical test (CCT). One cow (Cow A) was classified as a reactor to the CCT and was subsequently euthanized. Cow A had a small visible granuloma in a lymph node on necropsy, suggesting acute infection. The herd was quarantined when the first reactor was identified. The 10 remaining CF suspect animals were euthanized and tested for tuberculosis, resulting in two additional positives. Cow A was positive for Mycobacterium bovis (M.bovis) on both polymerase chain reaction (PCR) and culture testing, Cow B was PCR-positive only, and Cow C was culture-positive only. Neither Cow B nor Cow C showed any gross lesions.

Testing was also done on the dairy farmer’s 161 beef animals resulting in no caudal fold responders. In January 2014, a second dairy herd test was completed and six additional caudal fold responders were identified. These animals were shipped to slaughter; no gross lesions were found on examination, and all laboratory tests were negative for tuberculosis. A subsequent herd test of all dairy and beef cattle in April identified seven additional responders which had no evidence of TB at post-mortem examination or upon laboratory testing. In October of 2014, all cattle were again tested and found to be negative. The herd was released from quarantine on November 4th and will undergo annual herd tests for the next five years.

Difficulties in identifying the causative agent in the initial human case led to a delay in appropriate treatment. Culture results confirming M.bovis were not available until mid-November. TB treatment drug sensitivity results showed the expected pyrazinamide resistance but also a low-level resistance to isoniazid (INH).

The case lived in a remote area, so the NDDoH contracted with a local clinic to provide directly observed therapy (DOT). In December 2013, the case had to return to Mexico for approximately two months. Follow-up care was coordinated with the border initiative Cure TB to ensure DOT would continue when the dairy worker returned to Mexico. The dairy worker has since returned to the United States where he successfully completed his treatment.

Early collaboration and communication between agencies allowed for a prompt and comprehensive investigation. This collaboration also led to a One Health approach for education efforts targeting dairy employees and employers as well as the general public.

To better understand disease transmission, the human case isolate and the two cattle isolates were sent to the National Veterinary Services Laboratories for whole genome sequencing. The human isolate had the same single nucleotide polymorphisms (SNP) profile as Cow A. The isolate recovered from Cow C, while very similar to Cow A and the human strain, was divergent by seven separate unique SNPs, which suggests another strain of M. bovis is present. Both of these TB strains indicate a Mexico origin, yet both Cow A and Cow C were born, raised, and had never been outside of North Dakota.

The cavitary disease of the human and the small grossly visible lesions in Cow A suggest that the human case was further along in active disease progression. That finding—along with the Mexican origin of the TB strains, North Dakota cattle, and further epidemiological data—support the likelihood that the dairy worker transmitted the disease to the cattle.



At the North Dakota Department of Health, Dee Pritschet is the HIV/AIDS Surveillance Coordinator and TB Controller and Tracy K. Miller, PhD, MPH is the state epidemiologist. At North Dakota Department of Agriculture, Susan Keller, DVM is State Veterinarian and Beth Carlson, DVM is Deputy State Veterinarian. To learn more, see the CSTE Infectious Disease Steering Committee page.

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The Politics of Disease: Ebola Shows Worst and Now Best of Washington

Posted By Zara Day and Emily Holubowich of Cavarocchi Ruscio Dennis Associates, LLC, Thursday, November 20, 2014
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Emily Holubowich, MPP is the “Washington representative” of the Council of State and Territorial Epidemiologists, leading our advocacy efforts in the nation’s capital. Zara Day, JD, MPH has closely monitored for CSTE the evolving Ebola debate during her fall internship with CRD Associates. She will begin studying for the bar examination full-time this winter.

America’s epidemiologists have worked tirelessly for months both domestically and abroad to track and fight the spread of Ebola Virus Disease. Meanwhile here at home, the response by politicians and pundits has been counterproductive at best and harmful at worst. With the mid-term elections now out of the way, the Ebola debate in Washington has thankfully turned a corner toward tempered, responsible, and most importantly, bipartisan discussion.

The tipping point in responsible governing was the Senate Appropriations Committee hearing on Wednesday, November 12—after the election results were long in. Appropriators invited federal agency officials and practitioners to discuss the administration’s emergency supplemental spending request of $6.2 billion to support ongoing efforts to contain and eliminate the Ebola outbreak in West Africa. During the hearing, Secretary of Health and Human Services Sylvia Burwell and Department of Homeland Security Secretary Jeh Johnson emphasized the important need for the United States to continue leading the global health response to the outbreak. Officials across government sectors seem to be largely in agreement: the best way to protect the United States is to face the virus at its epicenter in West Africa.

CSTE submitted an official statement for the record to inform the committee’s deliberations. In it, we shared data from our most recent workforce assessment and highlighted the need to invest in workforce capacity and public health infrastructure, more broadly.

Lawmakers on both sides of the aisle were full of praise for the “conciliatory” and “bipartisan” tone of the deliberations. Unlike previous, pre-election Ebola hearings filled with rhetoric and finger pointing, lawmakers were deeply engaged and committed to understanding the government’s role in the West African and stateside Ebola efforts. Of course, the hearing wasn’t completely free of contention: Quarantine and travel bans, the vaccine development pipeline, accessibility and availability of personal protective equipment, and the role of the newly appointed (and noticeably absent from the hearing) Ebola czar, Ron Klain were hot-button issues.

On the recurring issue of quarantine and visa policies specifically, witnesses presented a united front: the United States should not set a harmful, international precedent by blocking from our borders individuals travelling from affected nations. Secretary Jeh Johnson noted that enormous steps have already been taken to protect the United States from travel by potentially infected individuals. There are presently no direct flights from Guinea, Sierra Leone, or Liberia to the United States, and all individuals flying from these countries are now required to travel to one of five major airports with screening facilities.

On a related note, you may recall CSTE issued a press release supporting the federal government’s quarantine policy amid public confusion and some states’ knee-jerk policy reactions that were not rooted in scientific evidence.

Now that the political dust has settled, lawmakers are engaged and committed in bolstering efforts to end the current Ebola crisis. Although current efforts seem to be having positive impacts, a recent outbreak in Mali will be enormous cause for concern if it can’t be contained. Nevertheless, it is worth noting that at least one senator mentioned the following statistic for context at last week’s hearing: There has only been one death (now two, with the recent passing of Dr. Martin Salia) in the United States due to Ebola while thousands die from the flu.

CSTE will continue to monitor the Ebola debate in Washington and promote the important role of applied epidemiologists in protecting our nation from both communicable and non-communicable health threats.

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Assessing the Threat of Pond Scum

Posted By Shawna Feinman, Friday, November 14, 2014
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Not many people know that pond scum can be a threatening public health issue. I certainly didn't during the last semester of my MPH program when my supervisor encouraged me to apply for the CDC/CSTE Applied Epidemiology Fellowship. At first I was unsure about how I’d fit into the fellowship categories, but Class XI—which was set to start the summer I graduated—hosted a pilot group of Environmental Health – Waterborne Diseases fellows, primarily focused on harmful algal blooms (HABs) and other recreational water issues. This aligned perfectly with my previous experience and interests, although I knew very little about HABs myself. Compared to other more classical public health issues, HABs have only recently been identified as health hazards, and not many states have dedicated programs to track their associated illnesses. While working in my fellowship with the Indiana State Department of Health (ISDH), I have learned that new and crosscutting issues, such as HABs, require collaboration from multiple agencies with different types of expertise.

Working at ISDH, I’ve been integrated into day-to-day activities and allowed to develop projects based on the state’s needs. Creating and distributing HAB information for the general public was identified as a need, so I developed materials for the general public, healthcare providers, and veterinarians. My state mentors, Jen Brown and Shawn Richards, help me keep a pulse on the state’s needs to create relevant and timely materials.

I've also been able to work with different state agencies to learn about HABs for different purposes. For instance, I donned fashionable waders to help the Indiana Department of Environmental Management (IDEM) take samples of lake water for routine HAB sampling. We then took the samples to the IDEM lab where I shadowed the laboratory workers as they determined certain risk level indicators, such as cell count and toxins present in the samples. Back at ISDH, I reported the results to the geographic information systems team to produce an interactive map, showing the state’s test results with color warning symbols coordinated with risk level. With real-time data, public health outreach materials, and HAB reporting forms on ISDH’s webpage, we developed the site into a one-stop shop for HAB information. By having a hands-on role in the process—from collecting samples to posting results online—I was able to learn about HABs beyond what a literature review could provide.

Our class has four Waterborne Diseases fellows placed in Indiana, Ohio, Minnesota, and Wisconsin. Being a part of the pilot Waterborne group, we rely heavily on each other, state mentors, and partners at the CDC Waterborne Disease Prevention Branch to provide guidance and work through issues as they arise. We have also had the unique opportunity to collaborate with other state and federal stakeholders to mold the program while meeting the standard CSTE fellowship competencies. In addition, Class XII expanded the Waterborne cohort by adding three new waterborne fellows in Illinois, Michigan, and New York. Together, our work helps expand and promote surveillance in order to capture more HAB data in future years. Who knew that pond scum could be responsible for such an interesting and productive learning experience?

Shawna J. Feinman, MPH is the CDC/CSTE Applied Epidemiology fellow at the Surveillance and Investigation Division of the Indiana State Department of Health. The fellowship is currently accepting candidate applications. For more information, visit CDC/CSTE Applied Epidemiology Fellowship. Visit CSTE’s Environmental Health page to learn about related program activities.

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New Horizons for the Vaccine-Preventable Diseases Subcommittee

Posted By Susan Lett, Friday, November 7, 2014
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While we’ve made great strides in vaccine-preventable diseases (VPD) in past years, new waves of measles, pertussis (whooping cough), and human papillomavirus (HPV) are prominently resurfacing. Imported measles is gaining prevalence this year with 594 cases and 18 outbreaks across the country in the first nine months of 2014. In 2013 the United States reported 25,000 cases of pertussis and nine deaths of infants. CDC reports suggest that by the end of 2014, the country will have experienced a 30 percent increase in cases as compared to last year.

This resurgence is due to both waning immunity to the currently licensed vaccine and the public’s outright lack of immunization. CDC’s latest public report on pertussis shows that in 2012 only 14 percent of adults had gotten sufficient immunization. Since most incidents and all mortalities due to pertussis are among infants, there’s a new emphasis on vaccinating pregnant women. It’s crucial for healthcare providers to recognize childbirth as an opportunity, not only to offer immunization to pregnant women but to their families as well. We’ve seen the Massachusetts chapter of the American Congress of Obstetricians and Gynecologists (ACOG) do commendable work in this way. The goal of present efforts is that all children under seven receive Diphtheria, Tetanus, and Pertussis (DTaP) vaccines and all adult family members receive Tetanus, Diphtheria, and Pertussis (Tdap) boosters.

I’ve chaired the CSTE Vaccine-Preventable Disease Subcommittee since its inception this fall. We’ve had two initial meetings and now begin a stage of fact finding. Members are focusing on increasing human papillomavirus (HPV) vaccination levels. Through CSTE’s collaborations with the National Foundation of Infectious Diseases (NFID), we’ve created the document Call to Action: HPV Vaccination as a Public Health Priority, which has been helpful in framing conversations with providers. Earlier this week, our CSTE/NFID webinar exploring high and low HPV vaccination rates presented the outcomes of interviews with subject matter experts. We hope to produce more webinars soon.
The VPD subcommittee over the coming year aims to shape both itself and the national VPD dialogue. Subcommittee activities have already seen great synergy as we integrate members from related organizations, such as the Association of Immunization Managers (AIM). We look forward to many potential CSTE/AIM activities at the intersection of this expertise: spreading awareness among health departments about registry functionality and electronic health record interfaces; making sure state registries are lifespan registries; ensuring linkages to surveillance databases to help identify under-immunized people during outbreaks; and using registries as total quality assurance tools within states to prevent VPDs. More and more, health departments need to be able to enhance their immunization registries to support immunization programs, both programmatically and for disease surveillance.
We’re at an opportune moment during the rollout for the Affordable Care Act. Healthcare delivery systems in each state will increasingly give adults and children access to immunizations, so we have new impetus to encourage widespread vaccination. It’s exciting that electronic health systems and registries are poised to support this broad, population-based approach to primary prevention so that everyone, regardless of age and income, can have better access to vaccines.
Susan Lett, MD, MPH is Medical Director of the Immunization Program at the Division of Epidemiology and Immunization of the Massachusetts Department of Public Health. To find out more about the new VPD subcommittee and see how members get involved, visit Vaccine-Preventable Diseases.

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Using Childhood Adversity Data to Improve Adult Health

Posted By Anna Austin, Thursday, October 30, 2014
As a CDC/CSTE Applied Epidemiology fellow in the Injury and Violence Prevention branch at the North Carolina Division of Public Health, one project that has particularly developed my skills as an epidemiologist and public health professional relates to adverse childhood experiences (ACEs). ACEs are traumatic or stressful events experienced before age 18 and include eight categories of childhood abuse and household dysfunction, such as physical, sexual, and emotional abuse; adult substance abuse; and household domestic violence.

A growing body of evidence shows that these early experiences are common and can have long-lasting effects on mental and physical wellbeing. Findings from the original 1995-1997 ACE Study showed a strong, graded relationship between ACEs and several poor health outcomes in adulthood. As the number of ACEs a person experiences increase, what also increases are the risks of alcohol and drug abuse, obesity, suicidality, depression, intimate partner violence, heart disease, and a range of other poor health outcomes in adulthood. Data specific to ACEs among North Carolinians first became available in 2012 when questions about ACEs were included on the North Carolina Behavioral Risk Factor Surveillance System survey. My task was to analyze this data and create North Carolina’s first state report on the topic.

The findings from the state report mirror the findings of the original ACE study. ACEs were found to be common among North Carolinians: 58% reported at least one ACE and 22% reported three or more ACEs. Over a quarter of North Carolinians reported having grown up with an adult who was abusing alcohol or drugs, and one in 10 reported sexual abuse by an adult. In addition, ACEs were found to cluster among North Carolinians—if a person reported having experienced one ACE, it was highly likely that he/she had also experienced additional ACEs. Lastly, the results showed that the risk of smoking, binge drinking, and obesity as well as HIV-risk behaviors, poor physical and mental health, chronic obstructive pulmonary disease, cardiovascular disease, arthritis, depression, and disability in adulthood increased as the number of ACEs reported increased.

The finding that ACEs impact health outcomes in adulthood, long after the events have occurred, supports ACE prevention as an effective long-term strategy for population health and highlights the importance of a life-course perspective in such prevention efforts. The finding that ACEs impact a wide range of outcomes from social, emotional, and behavioral problems to chronic diseases presents an opportunity to foster collaboration among diverse stakeholders and suggests such collaboration will be important to successful ACE prevention. Increasing awareness of ACEs as a public health issue will be important in North Carolina for mobilization.

We are engaging stakeholders from across the state to support local prevention efforts. I presented the findings from the state report at the North Carolina Public Health Association Conference alongside colleagues from the Innovative Approaches Initiative in Buncombe County. This initiative is developing a toolkit and website to educate local primary care providers on ACEs, connect them to local resources, and provide referral options for affected children and families. I have also collaborated with Harry Herrick, a survey analyst at the North Carolina State Center for Health Statistics, to respond to requests for data regarding ACEs among special populations, such as current smokers and persons with disabilities. I am also currently working on a multi-state study of ACEs among persons who identify as gay, lesbian, and bisexual. Ideally, data from each of these studies will help inform programs and policies aimed at ACE prevention and the enhancement of current efforts. This project has proved invaluable to my experience as a fellow, and I am extremely grateful for the opportunities, support, and guidance my mentors and colleagues have provided throughout the process.

Anna Austin, MPH is the CDC/CSTE Applied Epidemiology Fellow at the North Carolina Division of Public Health. In addition to this project, Anna has linked prescription drug overdose data from multiple sources, served on the leadership team developing the 2015 North Carolina Suicide Prevention Plan, and written surveillance reports on motor vehicle crash-related injuries.
Would you like to host or be a CDC/CSTE Applied Epidemiology fellow? Find out how. To learn more about ACEs, take a look at the CDC Injury Prevention and Control page.

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!

Tags:  adverse childhood experiences  data  fellowship  member spotlight  substance abuse 

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