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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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When a Natural Disaster Strikes……..

Posted By Sara Ramey, Wednesday, March 5, 2014
Updated: Wednesday, March 5, 2014
Untitled Document
Oklahomans live in “twister alley”, so those of us who live and work here are all too familiar with meteorologic terms like hook echoes, EF ratings, and tornado outbreaks. It’s expected that epidemiologists will be working diligently during an infectious disease outbreak, but public health staff, including epidemiologists also play an important role after a tornado outbreak.

During May 19 -31, 2013, central Oklahoma experienced three separate days of severe spring storms that generated EF4 and EF5 tornadoes affecting residents of six counties. The Oklahoma State Department of Health (OSDH) activated its emergency preparedness and response operations immediately following each of these events. In the immediate aftermath, public health response workers helped coordinate evacuation of a hospital that took a direct hit from a tornado and coordinated access to temporary water supplies for area hospitals and dialysis units affected by a major water station shut down. Recognizing that many persons will sustain puncture wounds from nails and other sharp debris during the clean-up and recovery phase, the OSDH mobilized static vaccination clinics and numerous “strike teams” to go into the hardest hit areas to provide over 7,400 tetanus immunizations to residents and volunteer workers in need of a booster vaccination. The CDC and Advisory Committee on Immunization Practices (ACIP) recommend that persons over 18 years of age get a tetanus-containing vaccination every 10 years with one of these being a tetanus-diptheria-acellular pertussis (Tdap) vaccination to boost their immunity to pertussis (whooping cough), which is a resurging problem in the United States. The OSDH strike teams administered Tdap vaccine to provide this dual protection.
Epidemiologists from the OSDH Injury Prevention Service conducted an intensive review of medical records of all persons treated for injuries at 32 hospitals from May 19 to June 2, 2013 to fully assess the extent of tornado-related injuries, populations impacted, and protective actions taken. The results of this epidemiologic study were recently released at the National Tornado Summit in Norman, Oklahoma. A total of 49 deaths and 755 injuries were determined to be associated with the May 2013 tornado disaster. Somewhat surprisingly, over half of the injuries (419) occurred indirectly meaning persons were injured attempting to get into or out of a shelter (35%), fleeing the area (6%), or rescuing an animal or person (5%); 35% of the indirect injuries leading to hospital visits were sustained by persons assisting with clean-up after the tornado. Based on these findings, the OSDH will work with other partners to develop clear and consistent messages on where to shelter, when fleeing the area is the safest approach, and use of appropriate protective equipment or gear when sheltering and when cleaning up to help prevent injuries. All persons living in tornado-susceptible zones should develop readiness plans with their family before tornado season is here again.
Kristy Bradley, DVM, MPH
State Epidemiologist
Oklahoma State Department of Health

Tags:  disaster epidemiology  emergency preparedness  member spotlight 

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The rocky road to complete reportable infectious disease system integration.

Posted By Sara Ramey, Wednesday, February 26, 2014
Updated: Tuesday, February 25, 2014
Untitled Document
Since the introduction of electronic disease surveillance systems, states and localities have worked to migrate disparate and siloed legacy surveillance systems into more integrated surveillance platforms. The goals for surveillance system integration are to utilize national standards, reduce redundancy, streamline reporting, understand disease and risk factor interactions, and increase data sharing. However, the costs, benefits and obstacles of achieving complete disease surveillance system integration are poorly understood.

CDC’s Program Collaboration and Services Integration (PCSI) program recommends integration and data harmonization of disease surveillance that currently exists both in CDC-supported legacy systems (i.e., eHARS, STD*MIS) and in state-based electronic disease surveillance systems (NEDSS) (1). While the 2010 CSTE assessment of states’ NEDSS capacity identified 34 (71%) states with some degree of integration, an increase from 23 states in 2007 (2), there are few states and localities to have fully integrated all legacy reportable infectious disease surveillance systems.
In 2013, the North Carolina completed customization of modules for reporting, case management, and entry of contact investigation data of HIV and syphilis cases. Legacy systems, eHARS and STD*MIS respectively, were converted into modules within a customized commercial-off-the-shelf NEDSS product which already included modules all reportable communicable diseases including vaccine preventable disease, sexually transmitted diseases, and tuberculosis (TB).
The conversion process began in 2010 following implementation of TB and general communicable disease modules in 2006 and 2008, respectively. The integration required conversion and harmonization of hundred of case report data fields and laboratory results fields from the legacy systems. The mapping of data fields from eHARS to North Carolina’s NEDSS additionally required a corresponding extract mapping back into eHARS in order to report data to CDC. New releases of eHARS will necessitate continual validation of these extract maps until CDC is able to receive HL7 message feeds into NNDSS. The two-year process involved more than approximately 6,500 person-hours. Following integration, de-duplication of more than 20,000 case records was required prior to system roll-out to local health departments.
A completely integrated NEDSS platform will provide the opportunity to monitor disease overlap geographically within population subgroups, and to evaluate the effectiveness of the delivery of integrated public health program services. While an integrated system provides new surveillance opportunities, the process was long, complex, and expensive; and many challenges still remain. State and local health departments considering complete reportable infectious disease surveillance system integration should weigh the informatics challenges and personnel expenditures with the opportunities to enhance program integration.
Megan Davies, MD
State Epidemiologist
North Carolina Division of Public Health


  1. CDC. Program Collaboration and Service Integration: Enhancing the Prevention and Control of HIV/AIDS, Viral Hepatitis, Sexually Transmitted Diseases, and Tuberculosis in the United States. Atlanta (GA): U.S. Department of Health and Human Services, Centers for Disease Control and Prevention; 2009.
  2. CDC. State Electronic Disease Surveillance Systems – United States, 2007 and 2010. MMWR. 2011; 60(41): 1421-1423.

Tags:  infectious disease  member spotlight  surveillance 

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Navigating Cancer Clusters

Posted By Sara Ramey, Wednesday, February 19, 2014
Updated: Wednesday, February 19, 2014
Untitled Document
In most states, public health professionals struggle with response to citizen calls reporting a suspected cancer cluster. Calls of this nature are not uncommon and often involve high levels of anxiety, mistrust of the public health agency and a sense of urgency on the part of the citizen. When environmental contaminant concerns are thrown into the mix the response becomes even more complex and media attention and lawsuits often follow.

The recently published MMWR “Investigating Suspected Cancer Clusters and Responding to Community Concerns” (MMWR1993;62(No.RR-8) presents new guidelines developed by a joint CDC and CSTE workgroup tasked with updating the 1990 MMWR guidelines for investigating clustering of health events. Things have changed in public health since 1990: all states have a cancer registry and access to record level data on cancer patients, statistical tools have expanded including geospatial analysis, and geocoding of data has become a norm. These new tools are discussed in the guidelines.
Public expectations have changed since 1990 as well; the internet is accessible to most and search of public websites and blogs are one new way citizens communicate and gather information during a cluster inquiry. Communication with the public has always been a key component of these investigations and this aspect was highlighted in the new guidelines. Emphasizing the importance of community communication, the guidelines recommend earlier partnership with all community partners in these situations. In addition, the CDC also collaborated with the National Public Health Information Coalition (NPHIC) to develop a document “Cancer Clusters” A Toolkit for Communicators” Both of these documents are on the CSTE website for membership use. Both documents recognize that ineffective communication can rapidly spin these situations out of control and put the public health agency in an adversarial light.
We only need to look toward recent news articles to understand the national picture on cancer clusters. In December 2013, ATSDR found that mothers at Camp Lejeune Marine Base in North Carolina with first trimester exposures to PCE, vinyl chloride, or DCE were more likely to have a child with leukemia or non-Hodgkin lymphoma compared with unexposed mothers although higher exposures did not increase the likelihood that the child would have these cancers. In May 2013, an 11-year study of the incidence of brain cancer associated with the Pratt & Whitney jet engine plant in Connecticut ended with university researchers saying they found no statistically significant elevations in the rate of cancer among workers related to exposures to contaminants. In January 2014, the Minnesota Department of Health found normal cancer rates for the Como neighborhood near the General Mills plant in Minneapolis despite concerns about elevated levels of solvent vapors detected in the soil. And in Clyde Ohio, the Ohio Department of Health has been investigating contamination concerns and cancer rates in the areas surrounding a Whirlpool facility for a number of years without resolution. My home state, Florida, has had some high profile investigations in recent years as well.
Please take some time to read these documents and share the links . Having a state specific protocol and guidelines in place in your own state before an event of this nature happens may be the key to successful resolution of cancer cluster calls and inquiries.
Sharon Watkins, PhD
Florida Department of Health

Tags:  cancer  chronic disease  member spotlight  surveillance 

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Charting an Epidemic, Confronting an Epidemic

Posted By Sara Ramey, Wednesday, February 12, 2014
Updated: Wednesday, February 12, 2014
Untitled Document
The governor of Vermont got a lot of attention when he dedicated his entire State of the State address to one topic: heroin. That attention was highly warranted because opioid abuse, prescription and non-prescription alike, is a major epidemic in this country, and epidemiologists are charting this epidemic and its consequences in many ways.

Prescription monitoring programs seek patterns consistent with “doctor shopping”, forgery and other diversion. Substance abuse programs track drug seizures and treatment admissions to follow patterns of abuse. Epidemiology programs track newly diagnosed cases of hepatitis C. Overdoses and overdose deaths are tracked in emergency departments and through vital records. All of these important surveillance systems track the underlying problem (addiction and substance abuse) and the consequences (overdose, infection, interaction with the criminal justice system). But, beyond counting, the epidemiologist must also be an advocate for using the data for action.
In Massachusetts, between 1990 and 2010, drug overdose deaths tripled, exceeding motor vehicle related death rate in 2000, and doubling it by 2010. These observations led to resources for the technical and programmatic enhancement of the prescription monitoring program and, in 2007, the initiation of a naloxone (Narcan®) program to train first responders, public safety officials and family members to administer the opiate receptor antagonist naloxone by nasal spray to potential overdoses. The program has resulted in the reversal of over 2,000 overdoses, so far, and an instance where drug users followed a police car to alert them so that they could reverse an overdoses. The philosophy is that one has to survive to kick the habit. Driven by the data, federal and state funding has also gone to community prevention programs and multi-community Opioid Abuse Prevention Collaboratives.
The Massachusetts Department of Public Health has observed increasing numbers of reported cases of hepatitis C virus infection in people between the ages of 15 and 25; the rate almost doubling between 2002 and 2012, while newly diagnosed cases went down in other age groups. These 15-25 year-olds almost certainly acquired their infection well within the previous 10 years. While much attention has been appropriately directed toward the hepatitis C epidemic in the “baby boomer” generation, hepatitis C in adolescents and young adults represents a new epidemic wave of hepatitis C. All indications are that these infections were acquired through injection drug use. Interviews are difficult to obtain, but the most common story is prescription opioid use leading to injection of prescription opioids and heroin. Heroin is cheaper than prescription drugs and all too available. Because of the difficulty in getting enough data from interviews to explore the networks of transmission of hepatitis C among adolescents and young adults, we are exploring sequencing of hepatitis C viruses that come to our public health laboratory to try to use the virus RNA sequences to construct networks. There hasn’t been much HIV co-infection yet, but that may be just a matter of time before that virus is introduced into these networks.
While the hepatitis C data are overwhelming, both in their implications for the future and the sheer number of new reports (in Massachusetts, now one to two thousand positive laboratory reports for hepatitis C in the age group each year), an approach to this massive epidemic is not easily identified. Of course, there should be every and all attempts to prevent and treat addiction. But what can be done in the meantime? As epidemiologists and public health professionals, we cannot just watch this tsunami of hepatitis C cases without actively encouraging the use of data to inform interventions, be they harm reduction approaches directed at safer injection or using observational data and network analysis to identify means of getting prevention and treatment messages to those at risk and infected.
Alfred DeMaria, MD
State Epidemiologist
Massachusetts Department of Health

Tags:  infectious disease  member spotlight  substance abuse  surveillance 

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Raw Milk Strikes Again

Posted By Sara Ramey, Wednesday, February 5, 2014
Updated: Wednesday, February 5, 2014

Tennessee recently experienced an outbreak of E. coli O157 associated with raw (unpasteurized) milk, in which 9 children became ill, 5 of whom were hospitalized, and 3 of whom developed hemolytic uremic syndrome (HUS). While the sale of unpasteurized milk is unlawful in Tennessee, it seems virtually impossible to entirely stop people intent on obtaining it. In this case, the affected families participated in a "cow share" program, in which they purchased a "share" of a cow (along with 20 or so others) from a farm which then distributes the raw milk from its herd to the "owners". This scheme skirts the issue of milk sales, as the consumers are purportedly drinking milk from their own animals

There is an almost endless list of concerning aspects to this outbreak. As is typically the case in these types of situations, the people who suffered the most harm were children, who are not the ones who made the decision about what they consumed. The implicated farm is not regulated by our Department of Agriculture, as it is not a commercial milk producer, and in the absence of a disease outbreak the Department of Health has no oversight of the facility. As soon as the outbreak was over, the farm reverted to the same situation, with no required testing or other regulatory oversight (though they did ask our department to declare them safe to reopen!).Overwhelming epidemiologic evidence and matching E. coli strains from the cows and farm environment were insufficient to convince many of this farm's consumers that the milk was the source of the outbreak (after all, we did not find it in batches of milk produced many days after the implicated lots were distributed).

Important lessons can be learned in any outbreak investigation. In this case, "social media" was a useful tool, as the farm's customers were active in a Facebook group, through which case finding and education could be done. While many consumers remained distrustful and resentful of government intervention, at least one distraught family of a very ill child subsequently agreed to videotape their story for public education about the risks of raw milk. In public health I think we are all too familiar with the seeming lack of response to presentations of data and scientific evidence, compared to the dramatic effect that a single compelling personal testimonial can have on people. When even one victim of such an event has the courage to share their story, we should do everything we can to help maximize the effect of that message to prevent future similar events.
It's extremely frustrating and sad to see outbreaks like this continue to occur, all over the country, despite widespread efforts to halt them. We will continue to fight to plug the regulatory gaps and try to stay a step ahead of creative attempts to circumvent our intention of protecting the public's health. In the meantime, vigorous investigation and intervention in outbreaks can continue to build our case, and hopefully help educate our communities (including those responsible for the health of vulnerable children).
Tim Jones, MD
State Epidemiologist
Tennessee Department of Health

Tags:  food safety  infectious disease  member spotlight  outbreak 

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