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A Decade after CSTE’s Call to Action, a New Voluntary Model Health Code Launches

Posted By Douglas Sackett, Friday, October 24, 2014


What began with strong surveillance and epidemiologic data supporting a CSTE position statement has spurred a national, multidisciplinary model pool code development process, a multi-thousand-person public dialogue, and the creation of a new non-profit organization to ensure the model code remains up to date. Learn how you can improve health and safety at public pools while saving staff time and resources by adopting this exciting, new model health code in your state or local health department.
In 2004, CSTE issued a position statement, citing the increasing trend in reporting of waterborne outbreaks at swimming pools across the country. It called for Centers for Disease Control and Prevention (CDC) to lead a national workshop to develop a unified strategy to reduce future occurrence of waterborne outbreaks at public swimming venues. The following year, over 100 individuals from public health, academia, and the aquatics industry met to develop this strategy; the major recommendation was an open-access, national model code that would help local and state agencies incorporate science-based practices without having to reinvent the wheel each time they create or revise pool codes.

What our subsequent efforts produced became the Model Aquatic Health Code (MAHC), 1st Edition, released by CDC in August 2014. The scope of the MAHC reflects its multidisciplinary approach. We expanded the prevention guidance beyond just infectious disease prevention to make the MAHC an all-inclusive guidance document covering prevention of infectious diseases, drowning, and injuries through a data and best practices-driven approach to design and construction, operation and maintenance as well as policies and management.

The steering committee set to work in 2007 with a development working plan followed by the recruitment of technical committee volunteers. As an all-volunteer effort, we took time to discuss and incorporate the multifaceted perspectives and evidence from both public health and industry participants. We opened the MAHC to two rounds of public comment. After receiving more than 4400 comments, we incorporated 72 percent of comments—over 3,000 citizen suggestions made a substantive impact. The depth, quality, and practicability of the MAHC stem from our recognition of the importance of partnerships, data-driven change, incorporation of input from all sides of aquatics, and implementable changes.

The culmination of our efforts, the MAHC 1st Edition, is now available to assist health departments in working on their pool codes through voluntary adoption. In targeting aquatic design, operation, and management, the code reflects modern epidemiological practice. The code's foundation is built on strong surveillance and investigation data from key national surveillance systems, such as National Electronic Injury Surveillance System, the National Outbreak Reporting System, and the Waterborne Disease and Outbreak Surveillance System. The annex that accompanies the MAHC lays out the rationale for code-specific requirements with scientific data and references to explain the why behind the what. The MAHC also recommends decision making informed by incorporating routine pool inspections as surveillance data.

 

Finally, CDC is setting up sentinel surveillance to track the impact of key MAHC elements on aquatic venue operation. We will have the opportunity to analyze these data, evaluate the model code's impact, and update the code based on findings. This will occur every two years as part of a meeting convened by the new non-profit organization, the Conference for the Model Aquatic Health Code, which is tasked with collecting national input and advising CDC on necessary updates.

 

If you work with or for a state or local health department, please consider taking the next step for improving health and safety at aquatic facilities: familiarize yourself with the Model Aquatic Health Code.

 

Your community can benefit from the MAHC's guidance for the prevention of chlorine-tolerant diseases such as cryptosporidiosis, improved training requirements, enhanced design features to reduce chemical injuries, and improved drowning and injury prevention. As the MAHC is fresh out of the box, you can also get involved with our conference to help drive future improvements. What CSTE members precipitated 10 years ago, based on sound epidemiologic practice and strong surveillance data, has now come to fruition.

We need CSTE to take a fresh look at the data and the MAHC and renew its commitment to health and safety improvement. CSTE members can bring the best of epidemiology to bear by raising awareness about the MAHC, driving discussion about potential adoption, and participating in future MAHC update discussions. With this renewed commitment, CSTE can continue drive data-based improvements in public health and safety at our nation's aquatic facilities.

Douglas Sackett is Executive Director for the Conference for the Model Aquatic Health Code. To learn more, look at CDC's easy-to-read infographic, outlining the problem, process, and product.


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Tags:  acquatics  cryptosporidiosis  epidemiology  health code  MAHC  occupational health  pool  rwi  waterborne diseases 

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CSTE Welcomes New Staff

Posted By Janet Hui, Nidal Kram, & Amy Patel, Friday, October 17, 2014
Today CSTE welcomes three new associate research analysts.

Hello, my name is Janet Hui, and I am the new research analyst for Surveillance and Informatics. Originally from New York, I graduated with my Bachelor’s in Geography from Dartmouth College in 2012 and my MPH in Epidemiology from Mailman School of Public Health at Columbia University in May 2014. As an undergraduate, I had randomly enrolled in an epidemiology course and unexpectedly fell in love with the subject. I am passionate about data and technology and have a Certificate in Public Health Informatics as well as experience implementing geographic information systems for disease mapping. I am grateful and excited for the opportunity to further apply my skills in this field.

At CSTE, my primary focus will be the Reportable Conditions Knowledge Management System (RCKMS) project. Accurate reporting of disease is the cornerstone of surveillance, making it critical for providers and laboratories to have convenient access to up-to-date reporting criteria. RCKMS is envisioned to be a tool for providers, labs, and jurisdictions to better communicate and access reporting rules. This upcoming year, I will be helping to launch the feasibility pilot for the potential adoption of the RCKMS by state and local health departments. CSTE members are going to be heavily involved in all levels of the pilot, and I will be supporting them through workgroup calls and meetings. Everyone has been extremely knowledgeable and enthusiastic about the project, and I’m thrilled to be working with them!

Hi there! My name is Nidal A-Z Kram and I am the associate research analyst supporting the Chronic Disease, Maternal and Child Health, and Oral Health (CD/MCH/OH) Steering Committee. I also work with the Substance Abuse Subcommittees within the Cross Cutting I Steering Committee. I completed my undergraduate studies at Lawrence University in Appleton, Wisconsin where I majored in Biology with minors in Anthropology and Ethnic Studies. I joined CSTE after receiving my Master’s in Public Health from the Rollins School of Public Health at Emory University, focusing on Global Health and Community Health and Development.

I am eager to work with my subcommittees in developing new project ideas as well as completing ongoing projects. Most importantly, I am excited to do relevant and meaningful work that supports our members in local and state health departments. One key activity is the distribution of the CD/MCH/OH Epidemiology Capacity Assessment (ECA) report, which shows trends and indicates areas for improvement. The Chronic Disease Epidemiology Evaluation webinar series will be an interactive course designed to strengthen capacity. The Substance Abuse Subcommittees are also engaged in several interesting projects, including a computer program that searches the text on death certificates for specific drugs included in the cause-of-death statement and records those drugs as new fields. For additional information on any of these projects and to learn how to get involved in these subcommittees, please contact me!

Hi, I’m Amy Patel. A ‘Tar Heel Born and Bred,’ I graduated from the University of North Carolina at Chapel Hill with my Bachelor of Science in Biology and Anthropology in 2011 and then again with my Master of Public Health in Health Behavior with a Certificate in Global Health in 2014. I thought I would save the world through medicine when I started college but I quickly learned that community-based public health was where it was at. To gain more hands-on experience before graduate school, I pursued a 13-month fellowship in rural Alabama with the nonprofit Project Horseshoe Farm. While our programs focused on people with mental and physical disabilities, the elderly, and children, this doesn’t even begin to encapsulate the breadth and richness of our work. My passion lies in taking a comprehensive, systemic approach to health with a particular focus on social, cultural, and environmental factors.

Because of this “big picture” interest in public health, I was drawn to CSTE’s interdisciplinary approach to applied public health. My primary program area at CSTE is Occupational Health, but I am also working on projects related to injury, tribal epidemiology, local epidemiology, and epidemiology methods. I’m excited to be working with CSTE members to facilitate public health work across local and national levels. I have already seen regional differences in what the pressing concerns in occupational health and safety may be and I’m drawn to learning more about how states and organizations partner with one another to share best practices and lessons learned. I’m also excited by the variety of my work. From assisting in the collection of national indicator data to developing resources to build capacity for tribal health promotion, I look forward to the engaging opportunities my projects will bring.


Tags:  staff spotlight 

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Promoting the HPV vaccine through partnerships

Posted By Nicole Bryan, Thursday, September 18, 2014

Over the past year, CSTE has worked with the National Foundation for Infectious Diseases (NFID) on a project to highlight the importance of the human papillomavirus (HPV) vaccine as a public health priority. This project has been a great way for CSTE to extend its relationships to other partners and organizations and to find different ways to impact public health. NFID and CSTE convened subject matter experts to talk about the long-term health impact of HPV and the role of immunization.

An environmental scan of existing resources was conducted in early 2014. This scan sought to enhance access to materials that would help healthcare providers improve vaccination rates. A summary of the environmental scan found many relevant and useful materials for healthcare providers. These materials range from resources for parents and teens to information for medical professionals. The summary emphasizes that key elements be included in communications materials to ensure the information provided is comprehensive and accurate. Key elements include information about the disease; the vaccine and its importance; the vaccine’s target age range, safety, and efficacy; and the benefit to men, among others. The NFID’s new HPV Resource Center includes many tools and resources for healthcare providers and public health professionals.

CSTE has acted as an advisory council to the project and conducted interviews with the states that have the highest and lowest HPV vaccination rates. CSTE members identified and conducted calls with State Epidemiologists and immunization program staff to discuss successes and barriers with regard to Vaccines for Children (VFC) and public clinics, HPV vaccination compared with other adolescent vaccination, and communication efforts toward healthcare practitioners and the public. Common themes were found among all states after having these conversations. Key messaging content focused primarily on cancer prevention, and funding playing a large role, as either a barrier or a success. All jurisdictions interviewed also stated that they would appreciate more helpful, easy-to-share resources in new formats for healthcare providers. There were also some key differences between jurisdictions with higher HPV vaccination rates and those with lower rates. Jurisdictions with higher or lower rates had different access to the vaccine, different cultures (particularly regarding perceptions of the HPV vaccine) and varying relationships with partners, such as pediatric hospitals and school nurses.
A virtual roundtable with several stakeholder organizations was conducted to discuss the importance of HPV vaccination and to develop a call to action document. The call to action urges healthcare providers to prioritize and actively promote HPV vaccination with parents and adolescents. The document lays out why HPV is an important issue, how vaccination addresses the burden of HPV, and how healthcare providers can help reduce the burden of HPV-related cancers in the U.S.
This work continues in the form of CSTE’s Vaccine-Preventable Diseases (VPD) Subcommittee. The subcommittee combines the work of the Adult and Child Immunization Subcommittees and will continue the work begun with CSTE’s partnership with NFID. The first VPD Subcommittee call will be September 23 at 2:00 pm ET via WebEx (login information below). It will include a presentation on the challenges and new directions for the pertussis case definition from Anna Acosta and Jeff Davis, an update on this Promotion of HPV Vaccination through Partnerships project, and an open forum to discuss future subcommittee projects.
Join us for the subcommittee call and explore the HPV Resource Center’s materials!
To join the 9/23 VPD Subcommittee call:
  • Access the webinar at: https://cste.webex.com/cste/k2/j.php?MTID=t477a14ed74004ea840415d5223914708
  • Enter your full name and jurisdiction abbreviation in the name field, your email address, and session password (vpd123). You can log in to the webinar beginning at 1:45 PM ET by following the instructions on your screen.
  • To join the audio portion of the call:
    • To receive a call back, provide your phone number when you join the training session, or call the number below and enter the access code.
    • Call-in number: (877) 668-4490
    • Access code: 798 883 447
  • Check the WebEx system requirements before the webinar. Please contact WebEx for webinar troubleshooting.

Nicole Bryan
Associate Research Analyst
Council of State and Territorial Epidemiologists

Tags:  infectious disease  staff spotlight  subcommittee  vaccine preventable disease 

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Inspiration or Obsession?

Posted By Lauren Reeves, Thursday, September 11, 2014
This week's post is the third in our series of posts about Deadly Outbreaks , a book of outbreak mystery stories, written by Alexandra Levitt. The book is available for purchase at amazon.com .

Epidemiologists who investigate disease clusters and epidemics typically work in close partnership with laboratory scientists who identify pathogens that cause outbreaks. In many cases, infectious disease mysteries are quickly solved once the causative agent is known, because public health experts know how a particular pathogen is transmitted and what can be done to interrupt its transmission. But what happens when an outbreak is caused by an unknown pathogen for which there are no diagnostic tests? Here is what happened in a real-life outbreak story recounted in Deadly Outbreaks, entitled Inspiration or Obsession:

In August of the Bicentennial year of 1976, several people died of a flu-like illness after attending an American Legion convention at an elegant Philadelphia hotel. Public health authorities suspected that the Legionnaires might be the first victims of the dreaded “Swine Flu,” caused by a new strain of influenza, identified eight months previously. However, the ensuring investigation ruled out Swine Flu and a range of other respiratory, foodborne, and waterborne diseases. Instead, the epidemiologic data suggested an airborne chemical or microbe inhaled by people who walked in front of the hotel or entered the hotel lobby. Otherwise, the investigative trail yielded no useful clues. Some said it was a Communist Plot or a terrorist attack. Others thought that the cause might never be known.

At the end of the summer, after three and a half weeks of field work, the CDC team assisting the Pennsylvania Department of Health returned home with the mystery unsolved. Public health officials had identified 221 cases of the illness, which came be known as Legionnaires Disease (LD); 34 people had died. Although the outbreak had stopped, with no additional cases identified after August 18, public worry—inflamed by the Swine Flu scare—continued unabated. CDC was criticized by politicians, journalists, and local health officials for its failure to find the cause of the outbreak, as well as its decision to vaccinate the U.S. population against a pandemic of Swine Flu—a catastrophe that never materialized.
Enter Joseph McDade, a dedicated young scientist who began as a bit player in the drama, helping to rule out an animal-borne disease called Q fever as the cause of LD. With that task accomplished, McDade turned back to his day job, which involved developing methods for the detection of epidemic typhus. For most of the fall, he was uninvolved in the LD investigation and oblivious to the ongoing turmoil at CDC—at least at first. His natural bent was to screen out all distractions and focus single-mindedly the scientific problem at hand. Nevertheless, from time to time—especially when he came up for air after completing a round of typhus experiments—he had little, niggling thoughts about some tiny rod-shaped bacteria he’d seen on a few of his Q fever slides. At the time, he had dismissed the rods as insignificant contaminants. But now he was not so sure.
As recorded in Deadly Outbreaks [page 104], McDade thought of the rods as a “hook” on which his thoughts were snagged:
McDade felt more and more compelled do something, anything! …He had to go back and look at those rods once again. He decided to make himself stop what he was doing (a whole other set of typhus experiments) and re-focus [on the mystery disease]. He knew there was little chance that he would find anything that his colleagues had missed, but he was more and more bothered by the problem, almost to the point of obsession. Instead of worrying himself to death, he decided, he would “clarify the issue” one more time and then forget about it.
Alone in the laboratory over the Christmas holiday—nearly five months after the first LD cases appeared—McDade retrieved the Philadelphia specimens from deep-freeze and set out to figure out what had really happened…

Tags:  Deadly Outbreaks  infectious disease 

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Small and square and vital

Posted By Renata Howland, Friday, September 5, 2014

What’s small and square and given to everyone when they’re born? A blanket is an obvious answer, but after two years with the New York City Bureau of Vital Statistics, I think of a birth certificate. Before joining the New York City Health Department as a CSTE/CDC Applied Epidemiology fellow in August 2012, I had never really spent much time thinking about birth certificates—but over the course of two years I learned a great deal about vital event registration in New York City and how it relates to epidemiologists’ work.

As part of the Fellowship requirements, my first project was evaluating the New York City birth registration system as a surveillance system. As I interviewed stakeholders, observed procedures, and analyzed data to assess the usefulness, timeliness, simplicity, quality, and representativeness of the system, these attributes—which at first seemed abstract and academic—became increasingly concrete. I witnessed firsthand the enormous effort of the Bureau’s staff to process certificates quickly, maintain complex electronic systems, clean and improve data, publish annual vital event summaries, and provide data to local maternal and child health programs, researchers, and national organizations. This evaluation spurred on other projects, including assisting in the development and evaluation of a new training program for birth registrars and studying the reliability of tobacco use questions for new moms. It was exciting to see how this research directly affected the collection, quality, and interpretation of birth data.

Altogether, these experiences gave me a new perspective on my work as an applied epidemiologist, someone truly engaged with the people, processes, and consequences surrounding data. Of course, I also learned that the work was messier, more complicated, and slower moving than anything I had done in school, but ultimately I also found it to be much more rewarding.
Four months ago, I transitioned to a job in the Bureau of Maternal, Infant, and Reproductive Health. I’m now a research analyst for new grant funded project on severe maternal morbidities, using none other than birth certificate data linked with inpatient hospital discharge records. So far it’s been an amazing opportunity to apply what I learned as a Fellow to a project about which I feel passionate, and I’m grateful to my mentors in New York City who helped to make this possible.
Renata Howland, MPH is the Severe Maternal Morbidity Data Analyst at the New York City Department of Health and Mental Hygiene. She was in Class X of the CDC/CSTE Applied Epidemiology Fellowship program, graduating in 2014. Ms. Howland was awarded the Hillary B. Foulkes Memorial Award in recognition of her outstanding work as a Fellow.
The other Applied Epidemiology Fellowship
Class X graduates are:
The Applied Public Health Informatics Fellowship
graduates are:
Robert Arciuolo, MPH—Infectious Diseases
Darlene Bhavnani, PhD—Infectious Diseases, Quarantine
Sarah Blackwell, MPH—Maternal and Child Health
Megan Christenson, MS, MPH—Environmental Health
MyDzung Chu, MSPH—Occupational Health
Kathleen Creppage, MPH, CPH—Substance Abuse
Kathryn DeYoung, MS—Infectious Diseases
Sarah File, MPH—Infectious Diseases, HAI
Mark Gallivan, MPH—Infectious Diseases
Rachel Gicquelais, MPH—Infectious Diseases
Michelle Housey, MPH—Chronic Diseases
Rebecca Jackson, MPH—Environmental and Occupational Health
Nicholas Kalas, MPH—Infectious Diseases
Jillian Knorr, MPH—Infectious Diseases
Tess Konen, MPH—Chronic Diseases
Jennifer Kret, MPH—Chronic Diseases
Kristine Lynch, PhD—Infectious Diseases, Food Safety
Michelle March, MPH—Infectious Diseases, HAI
Michelle Marchese, PhD, MPH—Environmental Health
Ellyn Marder, MPH—Infectious Diseases, Food Safety
Jason Mehr, MPH—Infectious Diseases, HAI
Catharine Prussing, MHS—Infectious Diseases, HAI
Olivia Sappenfield, MPH—Maternal and Child Health
Nathaniel Schafrick, MPH, MS—Environmental Health
Kacie Seil, MPH—Injury
Victoria Tsai, MPH—Infectious Diseases
Joshua Van Otterloo, MSPH—Infectious Diseases
Andrew Wiese, MPH—Infectious Disease, HAI
Bonnie Young, PhD, MPH—Infectious Diseases, Quarantine
Crystal Boston-Clay, MS
Bethany Bradshaw, MPH
Kailah Davis, PhD
Harold Gil, MSPH
Hannah Mandel, MS
Brittani Harmon, DrPH, MHA
Sandhya Swarnavel, BDS, MS
Lauren Snyder, MPH
Melinda Thomas, MPH

Tags:  fellowship  vital records  workforce development 

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Real-life Outbreaks: Sorrow and Statistics

Posted By Lauren Reeves, Friday, August 29, 2014

This week’s post is the second in our series of posts about Deadly Outbreaks, a book of real-life outbreak mystery stories. You can purchase a copy of Deadly Outbreaks by author Alexandra Levitt at amazon.com.

Epidemiologists who investigate outbreaks often use their findings not only to control disease but also to prevent future outbreaks once the immediate emergency is over. For example, in the aftermath of an outbreak that occurred at a Toronto hospital during the 1980s (described in Chapter 3 of Deadly Outbreaks), the investigators recommended extensive changes in how hospitals dispense drugs and how they use mortality data to monitor and improve hospital care. Although public health experts had been advocating these improvements for some time, the experience at the Toronto hospital—which involved drug overdoses and a long lag before a problem was recognized—demonstrated their importance in a dramatic and unequivocal way.

Here is what happened in the outbreak story entitled Sorrow and Statistics:

In 1981, thirty-four babies at the Hospital for Sick Children in Toronto died from apparent overdoses of the heart medication digoxin. Although a judge dismissed murder charges against a nurse who had been on duty during some (but not all) of the deaths, the police continued to claim that she was guilty, while the hospital’s doctors insisted the babies had died of natural causes.

With the hospital under a cloud of suspicion, the hospital authorities called in outside help, in the form of an Epidemic Intelligence Service (EIS) officer from CDC. On his arrival, officials from the Ontario Ministry of Health introduced the EIS officer —James Buehler—to two experienced Canadian colleagues who served as members of his investigative team.

Buehler understood from the start that there was uncertainty about what they might be able to accomplish. As recorded in Chapter 3 of Deadly Outbreaks [page 63]:

“What could the medical detectives do that the…doctors and police had not already done? The doctors had focused on the details of each baby’s illness, finding a natural reason for each death. The police, on the other hand, had focused on a particular suspect, seeking legal evidence to build a case against her. The epidemiologists viewed the evidence from a different angle. Unlike the police or the doctors, they looked at all of the deaths at once, as part of a single mission, trying to figure out what all the cases had in common—somewhat like an FBI analyst examining deaths linked to a single serial killer. However, unlike the police or FBI, they were not concerned with legal issues or with questions about human guilt and motivation, and unlike the hospital staff, they bore no personal responsibility for the babies’ welfare. They did not interview the nurses or meeting with the victims’ parents. Thus, they were emotionally removed from the tiny victims and perhaps better able to analyze the data in a dispassionate way, using graphs and statistics—“people with the tears wiped away” as the EIS saying goes. Another way to say it is that they ignored the horror behind the numbers and plunged on, wherever the data would take them.”

James Buehler and his team, working as unobtrusively as possible at the troubled hospital, used epidemiologic data to confirm that a significant rise in the infant death rate had actually occurred on the hospital’s cardiology ward. Then they proceeded to collect hypotheses and rule them out, one by one, until only one was left….

Tags:  Deadly Outbreaks  infectious disease  outbreak 

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CSTE’s Ebola Virus Disease Activities

Posted By Lauren Reeves, Thursday, August 21, 2014

http://www.cdc.gov/vhf/ebola/pdf/infographic.pdfCSTE’s role as an advocate for state and local epidemiologists comes into focus during outbreaks and public health emergencies. CSTE is currently working with our members, CDC, and our public health partners to coordinate communication and facilitate information sharing about Ebola Virus Disease (EVD). CSTE and CDC have collaborated from the beginning on regular EVD briefing calls with State Epidemiologists and senior public health officials.

During situations like this EVD response, an enormous amount of information is disseminated very quickly. The CSTE National Office is a source for streamlined, accurate, and directed information for applied epidemiologists. CSTE is helping our members involved with emergency preparedness, infectious disease, and EVD to share best practices and experiences, ask questions, and conduct an open dialogue with their colleagues.

This week, CSTE launched a members-only webpage for up-to-date information, resources, and links about EVD. To access the page, members can log into the CSTE website with their logins and passwords. Links to help members who have forgotten their login email or password are available on the login screen. The EVD page gives CSTE members access to a discussion board forum, where members can contribute and share guidance and protocols, quarantine orders, and other documents from their jurisdictions. The forum also allows members to post questions and comments to facilitate conversation about managing the EVD crisis. CSTE has also compiled an after-hours phone list so jurisdictions and public health partners can easily access emergency contact information for state and local agencies.

CSTE and its partners are continuously working with CDC to discuss state and local jurisdictions’ needs to make sure their concerns are advocated for adequately. CSTE participates in national briefing calls as well as calls that focus on epidemiology to be more specific to the issues and concerns important to epidemiologists.
In addition, three CDC/CSTE Applied Epidemiology Fellows have been deployed to the CDC Emergency Operations Center (EOC) to augment EOC staffing during its activation. The Fellows are assisting with the data management team. Aiden Varan, a fellow placed in infectious disease in a joint assignment with San Diego County and the San Diego quarantine station, arrived at CDC to assist in early August. Hanna Oltean, a fellow working in infectious disease at the Washington State Department of Health, and Cara Bergo, a fellow placed at the Louisiana Department of Health working in maternal and child health, recently joined Aiden at the EOC. Additional fellows may be called to assist as the outbreak response continues.
CSTE and CDC have set up email accounts for specific questions related to each organization’s EVD preparedness and response activities. Contact the CSTE National Office at commandcenter@cste.org with EVD-related questions so that CSTE can focus and direct questions appropriately. State and local senior health officials who need assistance with EVD-related issues can contact CDC’s Incident Management System State Coordination Task Force EOC desk directly at eocsctfeocdesk@cdc.gov.
For more information, visit CSTE’s EVD webpage or CDC’s Ebola Hemorrhagic Fever webpage, which has the most up-to-date information from CDC.
To join and access CSTE’s members-only page, visit CSTE’s membership page.

Tags:  infectious disease  outbreak  staff spotlight 

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The McConnon Strain - A mysterious outbreak of unknown spread

Posted By Lauren Reeves, Thursday, August 14, 2014
Untitled Document

Despite advances in healthcare, infectious microbes continue to be formidable adversaries to scientists and doctors. Deadly Outbreaks—a book of real-life outbreak mystery stories—recounts the scientific adventures of a special group of intrepid individuals who investigate disease outbreaks and figure out how to stop them.

Several upcoming blog posts will describe stories from Deadly Outbreaks, written by Alexandra Levitt. (You may recognize some of these outbreak or their causes, or you may know some of the epidemiologists. Read on to find out….) For example, this week’s post concerns an outbreak of a dangerous drug-resistant disease with the potential for international spread. Like today’s Ebola outbreak in West Africa, the dangers posed by this outbreak underscore the critical importance of maintaining local public health systems that do the day-to-day work of investigating outbreaks and stopping them at their source. We rarely know in advance which small outbreak or disease cluster will turn out to be something truly dangerous and devastating.

Here is what happens in the outbreak story entitled The McConnon Strain:
Epidemiologists sometimes face difficult choices, with moral, political, and financial repercussions that must be weighed against risks to human health. In 1983, for example, two officials, Patrick McConnon (from the United States) and Roland Sutter (from Switzerland), agonized about whether to delay the long-awaited repatriation of 20,000 Cambodian refugees, fearing that some might carry a rare, multidrug-resistant form of malaria. The U.S. Government planned to fly the refugees from Thailand, where they lived in border camps, to the Philippines (where they would be processed for entry into the United States). Stopping the flight would prolong the misery of hundreds of desperate families eager to resettle and start new lives. On the other hand, introducing an untreatable form of malaria into a mosquito-infested part of the Philippines could bring illness or death to thousands or even millions of people. As recorded in Deadly Outbreaks (page 38):

People stranded in refugee camps, displaced, impoverished, and malnourished, are at special risk for infectious diseases such as malaria, measles, and cholera that flourish in crowded and unsanitary living conditions. When infected refugees are moved to new holding sites, repatriated, or resettled in new countries, they can bring these diseases with them. As a result, public health officials like McConnon have overlapping and sometimes conflicting aims: to safeguard the health and welfare not only of the refugees themselves, but also of the people in countries that host refugee camps or accept refugees as permanent residents.

The spread of smallpox after the 1971 Pakistani civil war illustrates what can happen when a pathogen incubated in a refugee camp infects the wider population. Smallpox was carried to the newly established nation of Bangladesh by Bengali refugees returning home from India. According to public health lore, the presence of smallpox in the camps was detected by an epidemiologist in Atlanta, sitting in his living room watching TV, who noticed a man with a suspicious rash in a newsreel about a camp near Calcutta... The epidemiologist called the director of CDC, who called the director of the WHO Smallpox Vaccination Program, who called the Indian Ministry of Health. But it was already too late. Thousands of Bengalis had already left the camp, leading to widespread outbreaks in Bangladesh and making the last Asian country to eliminate smallpox.

McConnon was well aware of this history, because he had worked in Bangladesh in 1975, the final year of the smallpox eradication effort in Asia. He tried to convince an official at the U.S. State Department that it was dangerous to send refugees to the Philippines before screening them for this unusual strain of drug-resistant malaria. But the State Department official was skeptical and demanded to see some evidence.
With few resources and little time, McConnon and Sutter conducted a small-scale epidemiologic study in the border camp. If they could figure out which activities (e.g., farming, fishing, water collection) exposed people to malaria, they might delay the departure of exposed refugees while allowing unexposed refugees to proceed to the Philippines. As part of the study, they plotted the location of each malaria case on a map of the refugee camp, hoping to see a pattern. However, the data did not support any of their hypotheses. There was no association between the malaria cases and growing crops or working near the forest, swamp, chicken coops, or garbage dump. In fact, the distribution of malaria cases seemed entirely random, except for one thing: nearly all the cases involved males between the ages of 13 and 35.
This did not make sense! The mosquitoes that carry malaria do not distinguish between women and men or between the young and the old. McConnon and Sutter remained frustrated and puzzled—until they stumbled on an explanation during a conversation in a local bar when an aid worker mentioned a border-camp activity they had not tested for…
Stephen Ostroff, MD, former deputy director of CDC’s National Center for Infectious Diseases and former director of Pennsylvania’s Bureau of Epidemiology, said that “anyone with even a passing interest in disease investigation will find Deadly Outbreaks to be a great read. So too will all practitioners of public health, from students contemplating a career in epidemiology to the most seasoned veteran.” You can purchase a copy of Deadly Outbreaks by author Alexandra Levitt at amazon.com.

Tags:  deadly outbreaks  infectious disease  malaria  outbreak 

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Integrating our work with primary care

Posted By Katrina Hedberg, Thursday, August 7, 2014
Untitled Document
The landscape for both public health and the healthcare delivery system is changing for several reasons: the Affordable Care Act (ACA); efforts toward public health department accreditation; and requirements for community health assessments conducted by public health departments, hospitals, and accountable care organizations (ACOs). In Oregon, we use a coordinated care organization (CCO) model that envelopes a patient in medical, mental health, and dental care to provide care for the whole person.
For CCOs to be successful in achieving the triple aim of improved quality of care, improved population health, and lower costs, CCOs will need to focus on upstream prevention as well as improved care. CCOs are responsible for achieving metrics related to this triple aim, which should include receipt of clinical preventive services.
Public health epidemiologists can play an important role in helping to identify important metrics for CCOs and ACOs and to encourage these organizations to think about improving the health of the entire community in which their enrolled population lives. In addition, these organizations must work together with public health departments on community health assessments, as we have a role in determining the health status of our communities.
In Oregon, the Public Health Division is part of a larger agency, the Oregon Health Authority. The Office of Health Analytics, a separate division within the Oregon Health Authority, is responsible for analyzing healthcare service delivery data for Oregon’s CCOs. The Public Health Division is implementing an analytics tool that allows users to analyze public health data (e.g. birth, death, and reportable diseases) by not only the traditional state or county delineations but also by CCO service area. Looking at our data through different lenses and denominators helps us work with the CCOs to integrate healthcare and public health. Oregon also has a State Innovation Model grant from the Centers for Medicare and Medicaid Services, funds from which are being used to conduct a BRFSS-like survey of the Medicaid population to look at upstream health indicators.
Last year, CSTE Executive Director Jeff Engel and I attended a conference about the integration of public health and primary care for public health practitioners and clinicians. It was a good meeting, but epidemiologists were missing from the table. Coming away, we knew that epidemiologists have an important piece to inform the discussion, including data availability, metrics, and evaluation. Public health and healthcare systems have different definitions of ‘population health’—Epidemiologists generally think of their population as ‘everyone in a defined geographic location at a particular time,’ whereas healthcare systems hear this phrase to mean 'everyone enrolled or who received a service.' These realms are similar but slightly different, and these two definitions of the same word illustrate the difference. The epidemiologists' definition of population encompasses that of the healthcare system. We have to make sure we are using the same language and terms in order to work together to make our environment conducive to health as well.
From this meeting and these ideas, the Public Health and Primary Care Integration Subcommittee was born. It is clear CSTE can contribute to this new area for epidemiology and for public health. The subcommittee will have conversations that talk about, for example, the ways public health and healthcare use different terminology, what epidemiologists around the country are doing in this area, and how epidemiology can continue to have a seat at the table as health care transformation is implemented.
Katrina Hedberg - State Epidemiologist Oregon

Tags:  affordable care act  healthcare  member spotlight 

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Telling the Stories Behind the Data

Posted By Robert Harrison and Laura Styles, Thursday, July 31, 2014
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As epidemiologists, we view and interpret a lot of data. It's our responsibility to take action on the surveillance we conduct. Public health professionals understand that each case, each dot on a map, each block on an epi curve represents an ill patient, a person who has died, or a worker who has been injured. To us, charts and tables and summary reports tell an important story, but for others, we have to make it more personal to make an impact.
The Fatality Assessment and Control Evaluation (FACE) program is a case-based investigation program for the prevention of work-related injuries and illnesses. When workplace fatalities for landscape services increased in California and nationally from 2010 to 2012, we wanted to look closer. Data from the Census of Fatal Occupational Injuries (CFOI) confirmed that tree trimmers' fatality rate is twice the national average for worker fatalities. There is also a high incidence of workplace injury in this industry, although not all workers report these injuries or receive medical treatment.
At the California Department of Public Health, Occupational Health Branch, we have created videos about worker safety and health issues in addition to fact sheets, fatality alerts and investigation reports. These videos are a new strategy in the California FACE program’s prevention effort – written findings and prevention recommendations are brought to life with video re-creations, photos from the investigation, interviews with co-workers and family members, and clear explanations of how these tragedies can be prevented.
One such video, "Preventing Palm Tree Trimmer Fatalities," tells the story of Roberto, a 35-year-old tree trimmer, who died of suffocation when the palm fronds he was cutting fell on him. The video also explains proper equipment and climbing techniques that prevent this type of hazard. We see these workers every day around our neighborhoods, and they perform one of the most dangerous jobs in the U.S. They often don't have adequate training, and several deaths due to falls, suffocation, and other causes have occurred in California and elsewhere.
Click here to view the video, Preventing Palm Tree Trimmer Fatalities.
The California FACE video uses digital storytelling techniques to create a different kind of narrative to communicate public health data and messages. The key messages for the video are conveyed through real people and a real story; the video shows the devastating impact of not using proper palm trimming equipment or climbing techniques on the job. We listened to those affected by this issue so we could tell their story respectfully. This approach makes occupational health personal and local for viewers and the public, in order to encourage safety and prevent deaths.
A lot of planning went in to creating the video itself. We created a storyboard as a roadmap for the video with planned narration, video, and photos. Production partners included the Los Angeles County Fire Department, and tree climbing and safety professionals. We sought to balance the emotional and the factual, the problem and the solution, and to create a compelling video that could be used in trainings and would tell Roberto’s story.
We have found this and our other workplace safety videos on YouTube to be an effective medium to reach our target audiences and make our surveillance data come alive for maximum public health impact. We hope you can use our experience to weave together data and narrative to tell an important story for your program.
 
Laura Styles is the California FACE Program Manager, and Robert Harrison is the Chief of the Occupational Health Surveillance and Evaluation Program at the California Department of Public Health, Occupational Health Branch.
 

Tags:  collaboration  data  member spotlight  occupational health 

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