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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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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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