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5th Annual Disaster Epidemiology Workshop emphasized innovations in the field

Posted By Ashley Conley, Thursday, May 22, 2014
Untitled Document

On May 14-15, 2014, 55 people gathered in Atlanta from state and local health departments across the U.S., along with representatives from CDC, the Department of Homeland Security (DHS), and the American Red Cross at the Fifth Annual Disaster Epidemiology (DE) Workshop. The CSTE workshop was also broadcast live via webinar. Approximately 60 people participated virtually via webinar. The theme of the workshop was “Innovations in Disaster Epidemiology,” which reflects how widely accepted DE is becoming as a part of the public health response to large-scale emergencies. The workshop was supported through a cooperative agreement with CDC and was co-sponsored by the Safe States Alliance (SSA) and NACCHO.

Dr. Sally Phillips, RN, PhD, Principal Deputy Assistant Secretary (acting) for the Office of Health Affairs (OHA) at DHS, was the workshop’s keynote speaker. She described the evolution of DHS’s role in addressing health issues related to homeland security, including biological and chemical defense; food, agricultural, and veterinary defense; planning and exercise support; health incidence surveillance; and state and local initiatives. Another major focus of OHA is the safety and health of the more than240,000 employees in DHS, which includes staff in FEMA, US Border Patrol, and many others. OHA has overseen a strengthening of biodefense efforts of the BioWatch Program and the National Biosurveillance Integration Center. OHA is also working on guidance for radiation and nuclear disasters and for chemical defense programs. Workshop participants had many questions for Dr. Phillips about how OHA and DHS interact with public health agencies at the state and local levels.

The workshop included the following five sessions:
  • Surveillance during Disasters: Innovations in the Use of Technology and Tools
    • E-Surveillance
    • Epi-Info Applications for DE
    • Utilizing Android Tablets for Data Entry in the Field
  • Social Media and DE: Innovative Approaches to Surveillance and Situational Awareness
    • Hurricane Sandy: Changing the Landscape of Social Media Strategies
    • Operation Dragon Fire
    • Tracking Deaths during Hurricane Sandy
  • Innovating Approaches for Disaster Response to Recent Events
    • Blast Injuries from a Massive Explosion in a Residential Area in Texas, 2013
    • Acute Health Effects Associated with the Elk River Chemical Spill in West Virginia, 2014
  • Emergency Management and DE—An Innovative Partnerships from One State’s Perspective (Alabama)
  • Establishing Innovative Partnerships for Conducting DE
    • Operational Biosurveillance in the National Biosurveillance Integration Center
    • Partnering with the American Red Cross in the Disaster Cycle
The CSTE DE Subcommittee provided an overview of its major activities and accomplishments during the last year. The webinar was recorded and will be made available soon on the webinar library.
Ashley Conley, MS, CPH, CHEP is the chair of the Disaster Epidemiology Subcommittee. She is an epidemiologist at the city of Nashua Division of Public Health and Community Services in New Hampshire.
( Photo by Gil Talbot, courtesy of Saint Anselm College)
Ashley Conley, MS, CPH, CHEP
Nashua Division of Public Health and Community Services
New Hampshire

Tags:  disaster epidemiology  meeting summary 

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Applied Epi Fellowship Making a Difference!

Posted By Virginia Dick, Thursday, May 15, 2014
Updated: Wednesday, May 28, 2014
Untitled Document

For over 10 years, the Centers for Disease Control and Prevention (CDC)/Council of State and Territorial Epidemiologists (CSTE) Applied Epidemiology Fellowship (AEF) has provided recent masters and doctoral level graduates with training, mentorship, and field experience in state and local public health agencies. In 2012, CSTE began a thorough longitudinal evaluation to determine the long-term impacts of the program on the fellows, the mentors who provided guidance and expertise, and the state and local agencies that served as host agencies.

The AEF was created in 2003 to strengthen the workforce in applied epidemiology at state and local health agencies. CSTE, in collaboration with CDC, HRSA, and ASPPH, established the two-year program to give recent public health graduates rigorous preparation and advanced training for successful careers as applied epidemiologists. The Fellowship is designed around core competencies and utilizes a mentorship model to provide field-based learning and professional development opportunities. Host health agencies must demonstrate the capacity to provide an AEF fellow with technical training, research opportunities, and practical experience in the application of epidemiologic methods at the state or local level.

Since 2003, 12 classes of Fellows have participated in the program, and there are over 160 Fellowship alumni. Fellows have been placed in a wide variety of subject areas, including chronic disease, injury, substance abuse, environmental health, maternal and child health, infectious disease, and occupational health.
As seen in the maps below, AEF has had a significant impact across the country through location placements and post-program employment.

Fellow placements, 2003-2012


Fellowship alumni employment, 2003-2011)
The AEF has had an important impact on applied epidemiology during the past 11 years:
  • 88% of all alumni have worked in state, local, or federal public health agencies for at least a year after graduation. Fellows have provided an average of three years of service to governmental public health agencies.
  • Over 160 peer reviewed articles have been published by alumni.
  • 57% of alumni currently work in state, local, or federal public health agencies.
  • The Fellowship has a positive impact on alumni and mentor professional development and networking.
Click here for more information about AEF or the other fellowships supported by CSTE.
More information about the extensive evaluation of the AEF program will be available in the American Journal of Preventive Medicine Public Health Workforce supplement later this year.
Virginia Dick
Program Evaluation Coordinator
Council of State and Territorial Epidemiologists

Tags:  evaluation  staff spotlight  workforce development 

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CIFOR Releases the Second Edition of the CIFOR Guidelines for Foodborne Disease Outbreak Response

Posted By Dhara Patel, Thursday, May 8, 2014
Untitled Document

The Council to Improve Foodborne Outbreak Response (CIFOR) is a multidisciplinary collaboration of national associations comprised of state and local agencies representatives and federal public health agencies whose goal is to improve methods at the local, state, and federal levels to detect, investigate, control, and prevent foodborne disease outbreaks. These CIFOR member organizations represent epidemiology, environmental health, public health laboratories, and regulatory agencies involved in foodborne disease surveillance and outbreak response. CIFOR identifies barriers to rapid detection and response to foodborne disease outbreaks and develops projects that address these barriers. CSTE co-chairs the CIFOR Council. More information about CIFOR can be found at www.cifor.us.

CIFOR released the second edition of the CIFOR Guidelines for Foodborne Disease Outbreak Response on April 25, 2014. The CIFOR Guidelines describe the overall approach to foodborne disease outbreaks, including preparation, detection, investigation, control and follow-up. These guidelines also describe the roles of all key organizations in foodborne disease outbreaks. The CIFOR Guidelines are targeted at local, state and federal agencies that are responsible for preventing and managing foodborne disease.

These guidelines incorporate many significant changes that have occurred in the foodborne disease surveillance and outbreak investigation framework since the first edition of the Guidelines was published in 2009. Examples of additions and changes include information about the Food Safety Modernization Act; new information about model practices in outbreak investigation and response; updated statistics, references and examples; and enhanced alignment between the Guidelines and the Toolkit.
While the publication serves as a comprehensive source of information for individuals and organizations involved in foodborne disease investigation and control, the Guidelines are not intended to replace existing procedure manuals. Instead, they are to be used as a reference document for comparison with existing procedures, for filling in gaps and updating agency-specific procedures, for creating new procedures where they do not exist, and for targeting training of program staff.
View and download the full Second Edition of the CIFOR Guidelines. If you and/or members of your organization/health department would like to request copies, please fill out this brief survey to request copies and provide an appropriate mailing address: https://www.research.net/s/89H5ZS6.
For more information on the CIFOR Guidelines, please contact Dhara Patel, MPH, at CSTE at (770) 458-3811or dpatel@cste.org.
Dhara Patel
Associate Research Analyst
The Council of State and Territorial Epidemiologists

Tags:  CIFOR  food safety  infectious disease  staff spotlight 

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Synergy across chronic disease programs: An example from the Colorado Department of Public Health and Environment

Posted By Sara Ramey, Thursday, May 1, 2014
Untitled Document
Collaboration, integration, synergy, collective impact… whatever you call it, working with key public health partners can make efficient use of limited resources while increasing quality and reach of public health programs. Integration of chronic disease programs in public health departments has allowed for cross-cutting work on common risk factors and at-risk populations, including health care system changes, across programs that typically have worked in isolated silos.

The Colorado Department of Public Health and Environment’s (CDPHE) pathway to increased chronic disease integration started with organizational structure changes – centralization of epidemiology, evaluation, fiscal, and communication services. Soon thereafter, CDC selected Colorado and three other states to pilot combined chronic disease funding streams. CDPHE formed an integrated chronic disease leadership team, and the efforts of work units – newly organized along functional lines, including community-clinical linkages, health systems change, environmental approaches, and law and policy development – were increasingly evidence-based, executed at an enhanced level, and informed by science and data.
As part of the health systems change efforts, the Colorado Colorectal Cancer Control Program promoted colorectal cancer prevention and control efforts statewide by providing population-based strategies to increase screening rates and addressing the U.S. Preventive Services Task Force (USPSTF) recommended screening modalities through health systems change efforts. Through development of colorectal cancer screening policies, procedures, and protocols; client and provider-oriented reminder and recall systems; and staff training on USPSTF screening guidelines, this cancer program’s activities resulted in increased colorectal screening rates from 10 to 48 percent and from 16 to 29 percent in two Federally Qualified Health Centers (FQHCs).

Building upon its pilot integration and health systems change efforts, CDPHE is now using funding from CDC’s new collaborative chronic disease grant, “State Public Health Actions to Prevent and Control Diabetes, Heart Disease, Obesity, and Associated Risk Factors and Promote School Health” (a.k.a. “1305,” a nickname based on the RFA number) to increase the institutionalization and monitoring of aggregated/standardized quality measures at the provider and systems level. Part of CDPHE’s approach to this strategy is to combine efforts and resources across four grant programs: the Colorado Colorectal Cancer Control Program (CO CRCCP), the National Breast and Cervical Cancer Early Detection Program (NBCCEDP), the Well-Integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN) program, and “1305.” Synergy!

To leverage promotion of screening for chronic diseases and related risk factors, CDPHE staff across these previously siloed programs revised the baseline assessment methodology to align measures with National Qualify Forum (NQF) standards and statistically validated the methods for establishing baseline cancer, cardiovascular, diabetes and tobacco screening rates among patient populations. In the near future, staff will establish comprehensive baseline screening rates in selected pilot FQHCs and will then conduct clinic site visits to:

  • Review the comprehensive baseline screening rates (cancer, cardiovascular, diabetes, and tobacco)
  • Determine concordance between chart audit findings and existing electronic health record reports
  • Evaluate existing clinic policies, procedures, and protocols
  • Collaborate with clinic staff to develop action plans for quality improvement measures to increase preventive screening rates. These health system change efforts are based on The Guide to Community Preventive Services (The Community Guide) and How to Increase CRC Screening Rates in Practice: A Primary Care Clinicians’ Evidence-Based Toolbox and Guide
By working collaboratively and combining chronic disease grant funding, we will maximize our efforts in the promotion of health system change to institutionalize and monitor aggregated/standardized quality measures and increase screening rates for chronic diseases such as cancer, cardiovascular disease, and diabetes in Federally Qualified Health Centers in Colorado. CDPHE staff have been able to determine the best way to integrate chronic disease programs and which strategies to implement and how based on data, evidence, and target populations. All states benefit from hearing what colleagues in other states are doing and what initiatives are making a difference. We welcome continued related discussion and sharing of experiences, challenges, and successes.
Renee Calanan
Chronic Disease and Oral Health Epidemiologist
Colorado Department of Public Health and Environment

Tags:  chronic disease  collaboration  member spotlight 

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Influenza Data Management and Epidemiological Analysis course

Posted By Sara Ramey, Thursday, April 24, 2014
Untitled Document
A team of four CSTE members and staff traveled to Athens, Greece to facilitate and lecture at the CSTE-CDC Influenza Data Management and Epidemiological Analysis Course. Rachelle Boulton from the Utah Department of Health, Janet Hamilton from the Florida Department of Health, Dennis Perrotta, former State Epidemiologist from Texas, and Jennifer Lemmings from CSTE, joined staff from CDC and the World Health Organization European Office in a data management training course for influenza surveillance data managers/epidemiologists in the European Region. Influenza surveillance staff from Albania, Armenia, Bosnia and Herzegovina, Bulgaria, Croatia, Georgia, Kosovo, Kyrgyzstan, Macedonia, Moldova, Montenegro, Serbia, and the Ukraine participated in this 5 day course. Lectures were provided in English and translated to Russian for participants as needed.

The course was designed to help surveillance data managers establish, maintain, and improve influenza surveillance systems by teaching Influenza data managers and staff roles and responsibilities, minimum data requirements for influenza surveillance, quality assurance, quality control (standardized data entry, methods for checking accuracy and consistency of data), basic data analysis, data interpretation, and reporting. Some of the lectures focused on very specific details of data management methods, such as setting up tables in Microsoft Excel, while others encouraged discussion of general concepts such as deciding on which type of baseline to choose for their data.
There was a wide range of capabilities among the participants with some having advanced knowledge and experience and others a more basic understanding of influenza surveillance data management concepts and tools. Participants especially enjoyed the hands-on work using their most recent 12 months of seasonal influenza surveillance data. These data were usually counts of influenza-like illness (ILI) or Severe Acute Respiratory Illness (SARI). CSTE members and staff each provided several lectures and individual attention to participants as they worked case studies and group activities in data management and epidemiological analysis. On the last day of training, each country provided a short presentation using their influenza data and the methods learned during the training in a mock effort to convince their Minister of Health that influenza surveillance was of vital importance and should be continued.
Dennis Perrotta
CSTE Consultant

Tags:  infectious disease  influenza  meeting summary  member spotlight 

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Welcome and Opening plenary sessions in Nashville

Posted By Sara Ramey, Thursday, April 17, 2014
Monday, June 23, 8:00 am – 10:00 am
The Future is Here
Welcome and Opening plenary sessions featuring

David W. Fleming, M.D., is Director and Health Officer for Public Health - Seattle & King County, a large metropolitan health department with 1431 employees, 48 sites, and a budget of $332 million, serving a resident population of 1.9 million people. Department activities include core prevention programs, environmental health, community oriented primary care, emergency medical services, correctional health services, Public Health preparedness, and community-based public health assessment and practices.

Prior to assuming this role, Dr. Fleming directed the Bill & Melinda Gates Foundation’s Global Health Strategies Program. In this capacity, Dr. Fleming was responsible for the creation, development, and oversight of cross-cutting programs targeting diseases and conditions disproportionately affecting the world’s poorest people and countries. He oversaw the Foundation’s portfolios in vaccine-preventable diseases, nutrition, newborn and child health, leadership, emergency relief, and cross-cutting strategies to improve access to health tools in developing countries.

Dr. Fleming has also served as the Deputy Director of the Centers for Disease Control and Prevention (CDC). While at CDC, Dr. Fleming led efforts to develop the agency’s scientific and programmatic capabilities, and served as the principal source of scientific and programmatic expertise in CDC’s Office of the Director. He provided oversight of CDC’s global health portfolio through its Office of Global Health, and also oversaw the Director’s offices of Minority Health, Women’s Health, and the Associate Director for Science.

Dr. Fleming has published scientific articles on a wide range of public health issues. He has served on a number of Institute of Medicine and federal advisory committees, the Boards of the Global Alliance for Vaccines and Immunizations and the Global Alliance for Improved Nutrition, as President of the Council of State and Territorial Epidemiologists and as the State Epidemiologist of Oregon.

Dr. Fleming received his medical degree from the State University of New York Upstate Medical Center in Syracuse. He is board certified in internal medicine and preventive medicine and serves on the faculty of the departments of public health at both the University of Washington and Oregon Health Sciences University.

J. Lloyd Michener, M.D., (Course Director) is the Professor and Chairman of the Duke Department of Community and Family Medicine, Director of the Duke Center for Community Research, and Clinical Professor in the Duke School of Nursing. He directs a national program for the “Practical Playbook” which facilitates the integration of Primary Care and Public Health, supported by the Centers for Disease Control and Prevention, the Health Resources and Services Administration, and the de Beaumont Foundation. Dr. Michener is a member of the National Quality Forum Population Health Committee, the Council for the National Center for Complementary and Alternative Medicine of the National Institutes of Health, the National Academic Affiliations Advisory Council of the Department of Veterans Affairs, and the North Carolina Institute of Medicine.

Dr. Michener has served on multiple national boards, including the Board of the Association of American Medical Colleges, the National Patient Safety Foundation, and the Association of Departments of Family Medicine. He is also past President of the Association for Prevention Teaching and Research, received the APTR Duncan Clark Award in 2013, is past co-chair of the Community Engagement Steering Committee for the Clinical Translation Science Awards of the NIH and served as a member of the Institute of Medicine Committee that led to the publication of “Primary Care and Public Health: Exploring Integration to Improve Population Health”.

At Duke, Dr. Michener founded the training programs in nutrition and prevention; helps coordinate the institutional chronic disease programs, and oversees the Master’s Program in Clinical Leadership, a joint program of the Schools of Medicine, Nursing, Business, Law, and the Institute of Public Policy. As Chair of the Department, he leads the family medicine, preventive/occupational medicine, community health, informatics, and physician assistant and physical therapy programs.

For additional information on the conference please vist www.csteconference.org.


Tags:  Annual Conference 

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Dr. Thomas Farley to give Mann Lecture in Nashville

Posted By Sara Ramey, Wednesday, April 9, 2014
The Jonathan M. Mann Memorial Lecture is made possible annually by the CDC Foundation with proceeds from a generous grant provided by Richard E. Hoffman, MD, MPH, former Colorado state epidemiologist (1986-2001) and CSTE president (1994-1995). In 1999, the lecture was established to honor Dr. Jonathan Mann, who lost his life in the Swissair plane crash off Nova Scotia in 1998. Dr. Mann was an accomplished state epidemiologist who was called the “architect of the global mobilization against AIDS” for his role as the founding director of the World Health Organization’s Global Program on AIDS.

The 2014 Jonathan M. Mann Memorial Lecturer is Thomas A. Farley, M.D., M.P.H. Dr. Farley is the Joan H. Tisch Distinguished Fellow in Public Health Policy at Hunter College of the City University of New York. From May 2009 to January 2014, he was Commissioner of the New York City Department of Health and Mental Hygiene.
During his time as Health Commissioner, he advocated for innovative public health policies in New York City, including making the city’s parks and beaches smoke-free, prohibiting price discounting of cigarettes, raising the legal sales age of tobacco to 21, capping the portion size of sugary drinks sold in restaurants at 16 ounces, and restricting the burning of air-polluting dirty fuels to heat buildings. During Dr. Farley’s time at the agency, the NYC Health Department led the National Salt Reduction Initiative, which has successfully worked with major food companies to reduce sodium levels in food nationwide. Dr. Farley also used mass media to deliver powerful messages to promote health behaviors, including creating the “Pouring On the Pounds” sugary drink ads on subways and televisions, introducing the “Two Drinks Ago” campaign to reduce binge alcohol drinking, and developing a series of hard-hitting ads on the health consequences of smoking.

Before joining the New York City Department of Health and Mental Hygiene Agency, Dr. Farley was chair of the Department of Community Health Sciences at the Tulane University School of Public Health and Tropical Medicine. He received his MD and Master of Public Health degrees from Tulane University.

Trained as a pediatrician, he served in the Centers for Disease Control's Epidemic Intelligence Service and worked for the CDC and the Louisiana Office of Public Health from 1989 to 2000. During that period, Dr. Farley directed programs to control various infectious diseases. He has conducted research and published articles on a wide range of topics, including Legionnaires' disease, prevention of HIV/STDs, infant mortality, and obesity.

Dr. Farley is coauthor of Prescription for a Healthy Nation (Beacon Press) with RAND Senior Scientist Deborah Cohen.

Tags:  Annual Conference 

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Recreational Marijuana and the role of the Colorado Department of Public Health and Environment

Posted By Sara Ramey, Thursday, April 3, 2014
Untitled Document
It started with a public vote on November 6, 2012 – the citizens of Colorado decided by a vote of 55% to 45% to legalize marijuana. This set the wheels in motion to develop a regulatory system for the production, sale, and use of marijuana. An implementation task force was established in December of 2012 to hash out the major issues. This task force grappled with issues surrounding legalization including taxation, cultivation, laboratory testing processes, and public health. By March of 2013, this task force produced recommendations that Colorado legislators turned into law by June of 2013. In just 18 months, the first set of comprehensive laws regulating marijuana in a way similar to alcohol was produced.

From a public health standpoint, Colorado is fortunate that marijuana legislation took advantage of the last 50 years of public health research on reducing tobacco use. The legislation included specific requirements to limit youth access and prevent the normalization of marijuana use. This legislation also established a specific role for the Colorado Department of Public Health and Environment (CDPHE). CDPHE was charged with monitoring changes in drug use patterns and health effects. In addition, CDPHE was charged with setting up a panel of healthcare professionals with expertise in “cannabinoid physiology” to conduct literature reviews to make science-based recommendations for policies protecting consumers and the public. In addition to the duties outlined above, CDPHE played a role in establishing laboratory testing procedures, food safety recommendations for the manufacture of marijuana-infused edible products, waste disposal requirements and prevention messaging.
In the fall of 2013, before the official legalization of marijuana, there was an “outbreak” of synthetic marijuana users presenting at emergency rooms in the Denver area with severe adverse reactions. In less than a month, there were 263 reported emergency room visits which was far greater than the normal volume. The description of this outbreak has been published elsewhere. But, more important for CDPHE were the lessons learned that could be applied to potential events associated with legal marijuana. This “outbreak” quickly brought home the point that our surveillance infrastructure was not prepared for an event related to a toxic exposure disseminated over a large geographic area. Specific lessons learned included the insensitivity of poison center call data to indicate a problem for an illicit substance, the lack of an established network of emergency room case reporters, and our inexperience in utilizing atypical disease surveillance intelligence sources such as law enforcement.

Legal marijuana activity at CDPHE began in earnest in January of 2014 as implementation funding became available. Between January and March of 2014, the CDPHE internal marijuana steering committee grew from four to 22 members, as the public health considerations of legal marijuana became clear. It has become clear that legal marijuana affects nearly every division in our organization from injury prevention, to foodborne disease investigation, to regulation of health facilities. It also has become clear that there are numerous issues that need to be addressed in new ways due to the legalization of marijuana including surveillance for acute health effects from contaminated marijuana products, safety of edible marijuana products, accidental poisonings of young children from edible products, youth prevention, use among pregnant and breastfeeding women, marijuana disposal issues, marijuana lab testing issues, substance abuse prevention, injury and impaired driving prevention, and occupational health and safety issues among growers – just to name a few.

We have just begun to develop our surveillance program. In order to monitor the prevalence of marijuana use, we have added questions to the major population-based surveys in Colorado including the Behavioral Risk Factor Surveillance System (BRFSS), the Pregnancy Risk Assessment Monitoring System (PRAMS), and the Child Health Survey (CHS). We have also started analyzing hospital discharge and emergency department data to evaluate baseline levels of marijuana-related trauma and morbidity. Procedures for foodborne illness investigations are being modified to include the consumption of marijuana. Finally, we have been working to shore up the weaknesses in our surveillance infrastructure by developing a more extensive network of case reporters from emergency rooms, law enforcement, medical toxicologists, and the poison center.

We are still learning about the potential public health implications of legal marijuana and look forward to reporting the actual outcome data as it becomes available. In the meantime, those who would like a head start if legal marijuana comes to their state can follow our progress and public outreach at www.colorado.gov/marijuana.
Mike Van Dyke, Ph.D., CIH
Chief, Environmental Epidemiology, Occupational Health, and Toxicology Section
Colorado Department of Public Health and Environment

Tags:  marijuana  member spotlight  surveillance 

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When Something Smells Fishy

Posted By Sara Ramey, Wednesday, March 26, 2014
Untitled Document
It started with a call from an astute provider (as it usually does), an infectious disease physician, who had noticed a few cases of skin and soft tissue infections among older women from Chinatown. The lesions were described as erythematous, tender subcutaneous nodules on the fingers and hands, and one patient was subsequently diagnosed with Mycobacterium marinum. M. marinum is a bacteria that often causes cutaneous infection after contact with both fresh and salt water, especially due to aquarium exposures or fish or shellfish associated injuries. At least a few of the initial cases in New York City (NYC) reported handling fresh whole fish, purchased live or on ice from one of our local markets. Over the next few weeks, we started to hear about more cases - from other providers as well as from the routine reports we receive from CDC’s Infectious Disease Pathology Branch as dermatology providers in NYC were submitting biopsy specimens for immunohistochemical staining.

So we ramped up our outbreak response – developing our case definitions for suspect, probable and confirmed cases; sending a health alert to medical providers and laboratories requesting that they call us if they were seeing similar cases; setting up a more formal triage system to screen the initial provider calls; conducting more active casefinding by calling primary care providers, dermatologists, pathologists and hand surgeons, especially those who practice in one of the three Chinatown areas of the city; developing a structured questionnaire and database to better characterize the clinical illness and potential risk exposures; alerting public health partners via an EpiX alert to see if anyone else was seeing similar cases; getting any available isolates to our laboratory for molecular typing; working with our environmental colleagues at the city and state to begin traceback investigations and environmental testing; and alerting our federal partners, including the CDC, FDA and USDA.
Though we are still in the midst of this investigation, some clues are falling into place. We are now up to about 60 cases, with most being female, between the ages of 50-80, of Chinese ethnicity who reported purchasing fresh whole fish from a tank or on ice. About 2/3 recalled having a cut or injury prior to symptom onset. But a number of different markets are involved, and we are just beginning the traceback investigation. However, unlike other foodborne outbreak investigations, there is no federal or state regulatory agency to work with who oversees the interstate sale of live fish for food consumption. So we needed to step into this regulatory void, and use our public health authority to conduct the environmental investigations at both the markets and the distributors.
I have been overseeing communicable disease outbreak investigations in NYC for over 20 years now. It still amazes me that though the approach to each one is very similar, there is always something new to learn -- whether a new infectious disease etiology or a novel mode of transmission or just learning about a new setting or practice that I was unfamiliar with (in this case, the apparently well-established interstate trade of live fish for food). Our tools for outbreak detection and response have improved so dramatically since I first started here as an EIS officer in 1992 ---- with electronic laboratory reporting, syndromic surveillance, more robust IT systems for managing our surveillance and outbreak data, enhanced analytic methods to detect aberrations in our data, improved laboratory molecular diagnostics and electronic networks to communicate more rapidly with our provider and laboratory partners.
But more times than not, it’s the basics we depend on – the astute provider calling us and setting in motion the initial outbreak response steps that I first learned during my EIS training to determine if something unusual is occurring and whether there is a common exposure. With a city of over 8 million people and 50,000 providers, we still mostly rely on that one call from a provider seeing just a few cases that she or he considers unusual enough to alert us that something larger may be going on citywide. And it’s why that in addition to continuing our investments in improving our electronic surveillance infrastructure, it’s just as critical that we continue to foster relationships with our healthcare provider partners and always remind them of how powerful a single phone call can be in allowing us to detect the next big outbreak.
Marcelle Layton, MD
Assistant Commissioner Bureau of Communicable Disease
New York City Department of Health

Tags:  infectious disease  member spotlight  outbreak 

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Electronic Laboratory Reporting: Opportunities for Innovation and the Public Health Workforce

Posted By Sara Ramey, Wednesday, March 19, 2014
Updated: Tuesday, March 18, 2014
Untitled Document
The Health Information Technology for Economic and Clinical Health Act (HITECH) and the associated Meaningful Use (MU) requirements represent an unprecedented opportunity for public health to benefit from greater electronic connectivity, public health reporting and population health monitoring. Health information technology innovation and improvements motivated by the MU program offer tremendous potential to improve the timeliness, quality, quantity, and efficiency of public health surveillance. This in-turn enables public health decisions makers to take action to protect their communities more rapidly and effectively. Electronic laboratory reporting and other public health MU objectives provide a bridge for public health agencies to engage healthcare professionals and health information technologists in order to link public health agencies and systems more effectively with the clinical care system. To achieve full benefits of ELR, electronic health record transformations and the MU program public health should expect there will be work flow and workforce challenges and changes.

A recent article in the Online Journal of Public Health Informatics, “Estimating Increased Electronic Laboratory Reporting Volumes for Meaningful Use: Implications for the Public Health Workforce,” describes some of the workforce challenges and opportunities faced by public health. The authors cite specific challenges around receipt of an increase in volume of laboratory reports received as a result of implementing ELR. While public health can expect to receive an increase in volume of reports received, public health will also be able to have a more complete picture of the actual disease burden in the community leading to improved outbreak detection, investigation prioritization and thus opportunities to improve disease prevention and protect the public’s health.
The benefits of ELR are widely recognized. ELR has become a critical part of the reportable disease data submission process. Many communicable and environmental diseases that are currently under surveillance across the country are identified and confirmed by laboratory observations. In some states, ELR now accounts for the first identification of as much as 60-70% of reportable diseases. Electronic laboratory reporting provides substantial increases in efficiencies, completeness, and timeliness of reporting. Timely and complete electronic laboratory reports are an important source of information for the core public health functions of disease surveillance and responding to public health events. Reduced disease identification times as a result of ELR enables states to implement disease control measures more quickly (as in identifying outbreaks of foodborne disease, excluding ill children from daycares preventing others from getting ill; or ensuring all potentially exposed contacts of invasive meningococcal disease are identified and get their prophylactic treatment necessary to prevent life-threatening disease onset). In addition, some surveillance initiatives, such as monitoring new and reemerging antimicrobial resistance (e.g., Carbapenem-Resistant Enterobacteriaceae, considered one of CDC’s top five health threats in 2014), are conducted entirely based on laboratory observation findings and are only made possible through ELR as manual data collection processes are too resource intensive.
ELR and MU are important opportunities to support the overarching goals of improving population health management to serve more than just those that seek care but make “meaningful use” of health data to improve health for all. While states will expect an overall increase in the number of reports received due to the implementation of ELR, ELR also provides opportunities to improve the efficiency and effectiveness of public health systems through innovative data collection and processing. With ELR, the public health workforce can expect to spend less time entering data into surveillance systems allowing more time to conduct actual disease surveillance and investigation work. ELR presents ideal opportunities to leverage automated technological capacity to increase reportable disease case reporting specificity and timeliness and reduce data entry burden. The public health workflow change will require initial investments of time and human resources to transform information systems. One specific example of workflow change and innovation made possible by ELR is from my home state, FL. We were able to modify existing manual work flows. After the receipt of an ELR, the results are received automatically by the general communicable disease surveillance application, processed and interpreted electronically, created or assigned to an existing case and finally reported while at the same time the disease investigators are conducting any necessary follow-up or case investigations. This pilot was implemented for a subset of diseases where receipt of ELR volume was high (hepatitis B and C) and has resulted in increased ability to fully document chronic hepatitis B and C cases while retaining our ability to detect and investigate acute infections. Analysis of the workflow change identified an overall manual data entry and processing savings of 6.3 FTEs annually.
ELR has made the act of understanding the disease burden in the community more efficient while requiring less time for hospitals and labs to provide information to public health departments. By testing innovations and disseminating lessons learned, there are unique opportunities to improve public health surveillance (and ultimately health outcomes), and improve access to timely, quality information. In summary, ELR will positively impact the health status of the community by allowing health departments to more effectively and efficiently deploy their resources to conduct investigations around the spread of disease in their jurisdictions.
Janet J Hamilton, MPH
Surveillance and Surveillance Systems Manager
Florida Department of Health

Tags:  electronic laboratory reporting  member spotlight  surveillance 

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