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From Idea to Model Practice – Local Fellows from National Public Health Workforce Development Initiatives Make It Happen

Posted By Amy Sullivan, Friday, July 8, 2016
Updated: Wednesday, June 29, 2016

From left to right is Amy Sullivan, Maayan Simkes, and Amy Zlot (Maayan’s other mentor). 
From left to right is Amy Sullivan, Maayan Simkes, and Amy Zlot (Maayan’s other mentor).

 

It all started with an idea – the Portland Metro area needed a measles outbreak response plan. When Maayan Simkes approached her fellowship mentor with the idea, she was in her second year of a two year applied epidemiology fellowship funded by Centers for Disease Control and Prevention (CDC) Division of Scientific Education and Professional Development and run by Council for State and Territorial Epidemiologists (CSTE). She had matched with Multnomah County Health Department Communicable Disease Services, the front-line response agency for disease outbreaks in Oregon’s most populous county. Maayan had been analyzing the County’s vulnerability to a measles outbreak. She had also worked on our Ebola monitoring program, assembling information from state and local experts on monitoring needs and preparing workflows based on her experience providing monitoring. In looking at our measles outbreak vulnerability and thinking about the process put in place for Ebola monitoring, she struck on the need for a solid measles response plan.

 

Work on what is now the Quad-County Measles Protocol and Toolkit Development project was initiated by Maayan in October of 2014. Stakeholder input was of paramount importance. After consulting with her fellowship mentors and Health Department preparedness staff, Maayan used an emergency preparedness planning framework to get partners focused on the problem at hand, and identify gaps in our combined response capability. She added to the standard framework a set of working groups to tackle each of the gaps – distributing the workload in a way that allowed the project to move forward despite everyone’s very busy schedules.

 

While the project structure was a success, the timelines for it still meant that Maayan would be moving on to her doctoral studies before it was wrapped up. It was at this point that she reached out to another CDC-assignee working in the same unit. Kelly Howard was a CDC Public Health Associate. This program is run by the CDC’s Office for State, Tribal, Local and Territorial Support to support development of the frontline workforce in locations across the country. Maayan brought Kelly into the toolkit development process, and in turn, Kelly wrapped up the project, working closely with MCHD CDS staff. Maayan and Kelly worked together with their mutual advisor on a paper describing the project, and it’s submission to the National Association of State and Territorial Health Officials (NACCHO) Model Practice program. Quad-County Measles Protocol and Toolkit Development became a 2016 NACCHO Model Practice. As such, it will be available to all local health departments as an approach for communicable disease response planning.

 

Public Health organizations and agencies across the United States recognize the urgency of developing the next generation of public health workers in the United States. Professional in this field work at every level of government, local to federal, to meet the 10 Essential Public Health Services – covering everything from investigating communicable disease outbreaks to mobilizing communities for health. This project brought together many agencies, programs, and people. Without support of the various CDC workforce development initiatives, we would have been challenged to move forward on this important planning initiative. As one of the mentors for both Maayan and Kelly, it was great to see how each worked with their primary mentors, and to see how Maayan reached out to Kelly to bring her into the project. Many different Multnomah County staff and stakeholders had a chance to work with both of these new public health leaders: all provided much positive feedback. And now NACCHO has recognized their work too.

Amy Sullivan, PhD, MPH is director of Communicable Diseases Services at Multnomah County Health Department in Portland, Oregon. Maayan Simkes is currently pursuing a doctoral degree in epidemiology at University of Washington. For more information on the Applied Epidemiology Fellowship program, visit http://www.cste.org/?page=Fellowship
Amy Sullivan

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Welcome to the #CSTE2016 Annual Conference in Anchorage

Posted By CSTE, Monday, June 13, 2016
Updated: Friday, June 3, 2016
CSTE Features

Are you ready for the #CSTE2016 Annual Conference in Anchorage? Here’s the rundown on how to get the most out of your experience:
  1. Filter and search through sessions on the CSTE conference app to navigate the agenda and personalize your own daily schedule. The app is updated continually to include complete agenda information. It allows you to download handouts, receive important announcements, see local Anchorage information, connect with colleagues, and more. Search your app store or Google Play for “2016 CSTE” to get the app for your tablet or smartphone before you arrive!

  2. The online agenda also has a useful, searchable index of sessions. Don’t miss out on the special events (the Opening Reception, the Annual Fun Run/Group Walk, the Early Career Professional Meetup, and more).

  3. Get information on what weather-appropriate clothes to wear, shuttle times, walking directions, and maps on the conference website.

  4. Take advantage of the conference as an opportunity to get Certified in Public Health (CPH) recertification credits for a $10 fee.

  5. Familiarize yourself with the 2016 position statements so you can give feedback according to your subject-matter expertise. The full list of 18 2016 submitted position statements is available through member login on the CSTE website.

  6. Are you presenting or moderating? Watch the presenter instructions and the moderator instructions YouTube videos!

  7. Are you looking for more information on how to prepare? Read the FAQs on the conference website.

  8. Share group photos of you and colleagues and interact with @CSTEconference on social media with hashtag #CSTE2016 to win gift cards and giveaway prizes.

  9. Check out the sponsored sessions to learn more about emerging software and services that are tailored to modern local, state, and federal epidemiologists’ needs.

  10. Let us know what you think and how we can improve the conference experience by completing the Annual Conference Evaluation – a link will be provided to attendees at the end of the conference by e-mail. By completing the evaluation, you could win a the giveaway prizes: an Apple TV, a FitBit, and five free year-long CSTE memberships.

We look forward to seeing you in Alaska!

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CSTE Welcomes New Staff

Posted By Stephen Clay, Friday, June 10, 2016
Updated: Wednesday, June 1, 2016
CSTE continues to expand its national staff to facilitate new public health projects and support existing activities. We hope you get a chance to work with our newest team members in coming months and get a chance to meet them at the upcoming Annual Conference.
 

Brooke Beaulieu

I joined CSTE in September 2015 as an associate research analyst for the Infectious Disease Steering Committee. I earned a bachelor’s degree in biology from Georgia Tech and a Master of Public Health degree with a focus in epidemiology from Georgia State University. Before joining the CSTE team, my research focused on the relationship between traumatic events and stressors/depression, particularly after natural disasters and military deployment.


I have also contributed to projects concerning vectorborne disease and healthcare-associated infections. When I’m not acting as the CSTE staff lead for HIV, STD, and National Association of State Public Health Veterinarians (NASPHV), I enjoy hiking, reading, and continuing my ongoing search for the best Thai food in Atlanta.

 

Jessica Helms

I joined CSTE as the new program assistant in February 2016. Born and raised in Atlanta, I received my bachelor’s in biology from the Georgia Institute of Technology in May 2015. I have always been interested in disease from a population level, so I began my career working for the Georgia Department of Public Health in the Health Protection Laboratory. In the lab, I focused on receipt and reporting of infectious diseases throughout Georgia, as well as the implementation of a new electronic health record.


As the program assistant at CSTE, I will be supporting all the epidemiology program areas and I look forward to working on a breadth of projects in the different steering committees. I will also be serving as an information technology liaison for CSTE program staff and ensuring the securement of confidential documents. The diverse range of projects will allow me to experience the different facets of public health prior to pursuing my MPH. I look forward to be working with all the members of CSTE in different fashions.

 

Jessica Mynatt

I joined CSTE in November 2015. As the workforce and fellowship administrator, I provide logistical and programmatic support to the CDC/CSTE Applied Epidemiology Fellowship program as well as the three Project SHINE fellowship programs: the Applied Public Health Informatics Fellowship, Health Systems Integration Program, and Informatics-Training in Place Program. I graduated with a bachelor’s degree in psychology and a minor in anthropology from the University of Tennessee in 2010 and am now an aspiring MPH candidate. Prior to joining CSTE, I served as a non-profit manager specializing in fund development, membership growth and retention, and program management.
 

Maria Patselikos

Hi, my name is Maria Patselikos and I am the evaluation coordinator for CSTE. Born and raised in New Orleans, I received my bachelor’s degree in political science from Loyola University of New Orleans followed by my master’s degree in international affairs from Florida State and a certificate in emergency preparedness. It was during my time at FSU that my interest in public health began to grow, as the combination of international affairs and emergency preparedness awakened my aspiration to improving the overall quality of life through community health education and communication. In May 2014, I graduated from the Tulane University School of Public Health with a Master of Public Health degree.


During my time at Tulane, I interned at the Center for Continuing Education, where I was exposed to evaluation work by analyzing the evaluation data of the university’s grand round program and drafting summary reports for the department chair. Upon graduation, I was hired at the Center for Continuing Education and realized I could contribute to the improvement of the quality of life by aiding in the education of medical professionals and the overall improvement in patient care. With one chapter of my career behind me, I am excited to expand my evaluation work into CSTE’s many subcommittees and projects.

 

Megan Toe

Before joining CSTE, I worked for the Mental Health Liberia Initiative at the Carter Center, managing activities in partnership with the Government of Liberia to strengthen the national mental health system through training, policy and advocacy. Prior to the Carter Center, I was an assistant director at a grassroots organization that supported community leaders in West Africa on activities related to health promotion and social supports for the benefit of vulnerable youth.


I received a Master of Social Work degree, community empowerment and program development track, and a certificate in nonprofit management from the University of Georgia in 2013.


I look forward to my role at CSTE as a senior research analyst focusing on behavioral health work to further my career in public mental health and workforce development via capacity building.

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Outbreak of Tattoo-Associated Nontuberculous Mycobacterial Skin Infections—Miami, Florida, 2015

Posted By Isabel Griffin, Edhelene Rico, Juan Suarez, Emily Moore, Emily Davenport, Danielle Fernandez, et al., Friday, June 3, 2016
Updated: Tuesday, May 31, 2016

As tattoos have become increasingly popular over recent years in the United States, outbreaks of tattoo-associated infections occasionally occur. On April 29, 2015, the Florida Department of Health in Miami-Dade County, Epidemiology, Disease Control, and Immunization Services (EDC-IS) was notified by a local dermatologist reporting three patients with suspect nontuberculous mycobacterial (NTM) infection after receiving new tattoos at a local tattoo studio. EDC-IS identified multiple tattoo-associated infection cases through an investigation in conjunction with the U.S. Food and Drug Administration (FDA).

On April 30, an interview with the tattoo studio owner revealed that one of the tattoo artists had purchased open bottles of greywash ink, which were reportedly used on symptomatic clients. EDC-IS contacted clients who received tattoos from December 1, 2014 to April 30, 2015, in order to identify clients who may have been exposed. FDA collected environmental samples, including the studio’s tap water and the open bottle of implicated greywash ink. In addition, FDA collected five unopened bottles of greywash ink from local tattoo studios which reported using greywash from the same implicated lot number. Case definitions were created according to interviews with initial cases. A suspect case was a person who received a tattoo and developed a rash which lasted longer than two weeks; a probable case was defined as a suspect case with histopathological or stain evidence of an infectious organism; a confirmed case was someone who met the suspect case definition with a culture identifying an infectious agent or positive immunohistochemical (IHC) stain or polymerase chain reaction (PCR).

Thirty-eight clients of 246 interviewed met the case definition: 7 confirmed, 1 probable, and 30 suspect. Twenty-seven (71%) were male, and the median age was 28 years (range: 19-54 years). Laboratory test results from clinical and environmental specimens revealed Mycobacterium abscessus in clinical samples, the tap water, and the opened bottle of greywash ink. M. chelonae was detected in five unopened bottles of greywash ink collected from the local tattoo studios. Multivariate logistic regression showed that tattoo-associated infection associated with a specific artist was not statistically significant; however, clients who reported receiving grey ink were 8.24 times as likely to have a rash than those who did not report receiving grey ink (OR: 8.24, 95% CI: 3.069—22.127) (Figure 1).

Sources of this outbreak may have included contaminated greywash, tap water tested from the tattoo studio, or a combination of both. Peaks in cases apparent from the epidemic curve, coupled with the positive NTM tap water results may indicate the presence of a biofilm in the water pipe (Figure 2). Characteristic properties of biofilms include a process of attachment, growth, and breaking off which may periodically increase levels of NTM typically found in tap water sources (1). Following M. chelonae-positive results from the unopened bottles of ink, FDA and the greywash manufacturer issued a national recall of the implicated lot number on July 22, 2015.

  1. Hall-Stoodley, Luanne, and Paul Stoodley. "Biofilm Formation and Dispersal and the Transmission of Human Pathogens." Trends in Microbiology 13.1 (2005): 7-10. Web. Sept. 2015.



Pictured from left to right: Reynald Jean, MD, Emily Moore, MPH, Edhelene Rico, MPH, Debbie Summers, Anne Barrera, MPH, Isabel Griffin, MPH, Alvaro Mejia-Echeverry, MD

Not pictured: Juan Suarez, Anthoni Llau, PhD, Christine Oliver, Samir Elmir, Guoyan Zhang, MD, MPH, Emily Davenport, Lakisha Thomas, Pedro Noya-Chaveco, MD, MPH, Marie Etienne, RN, Juan Jose Estrada, Enrique Uribarri, Yuray Martinez,Michael Ragheb, Erin Hansman, Amanda Muana, Laura Vallejo, Danielle Fernandez, MPH, Ann Schmitz, DVM, AM


Authors: Isabel Griffin, MPH, Edhelene Rico, MPH, Juan Suarez, Emily Moore, MPH, Emily Davenport, Danielle Fernandez, MPH, Anthoni Llau, PhD, Alvaro Mejia-Echeverry, MD, Guoyan Zhang, MD, Reynald Jean, MD

Acknowledgements: Christine Oliver, Samir Elmir, Michael Ragheb, Erin Hansman, Amanda Muana, Laura Vallejo, Lakisha Thomas, Anne Barrera, Pedro Noya-Chaveco, Florida Department of Health in Miami-Dade County; Florida Department of Health, Bureau of Public Health Laboratories

To take part in CSTE infectious disease-related projects, join a subcommittee that interests you in the Infectious Disease Steering Committee.

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Zika Funding Before Mosquito Season – Where Are We Now?

Posted By Emily Holubowich and Zara Day, Thursday, May 26, 2016
Updated: Thursday, May 26, 2016
Washington representatives Zara Day (left) and Emily Holubowich (right)

In February, the Obama administration requested from Congress $1.9 billion in supplemental, emergency funding to combat the Zika virus through a comprehensive approach: prevention and mosquito control; development of and access to therapeutics; further study into the biological implications of Zika and its transmission; and funding to the states so that they can attack the threat. It also includes additional funding to Medicaid in Puerto Rico and other U.S. territories to support pregnant women at-risk or who have contracted Zika, children with microcephaly, and to cover other healthcare costs.


After more than 40 congressional hearings this year, the good news is that lawmakers from both sides of the aisle agree that the Zika threat justifies new funding. The bad news is, three months after the White House's initial request, there remains little agreement about how much funding to provide, for what, when to provide it, and through what mechanism. And while Congress debates the details, public health agencies can't afford to wait. The administration has been forced to redirect nearly $600 million previously allocated to fight the ongoing Ebola threat toward the Zika efforts--under the assumption this funding will eventually be made whole by Congress in the Zika package--as well as $44 million from emergency preparedness grants intended for use by the states. As the Washington Post recently reported, the reallocation of these Public Health and Emergency Preparedness (PHEP) funds is particularly concerning because that money is critical for states to address ongoing and emerging public health crises such as outbreaks and natural disasters in real time. As Cynthia Harding, interim director of the Los Angeles Department of Public Health told the Post, "this is stealing from Peter to pay Paul."


So where are we now?


On May 18, the House of Representatives passed a $622 million Zika supplemental bill, which was completely offset using “unobligated” Ebola funds and unused administrative funds at the Department of Health and Human Services. As expected, the vote was almost entirely partisan, highlighting the fundamental differences in strategies between parties on almost every piece of the supplemental funding process. The House bill provides funding only for FY2016, as lawmakers plan to use the normal appropriations process to provide additional funds for 2017. This would inevitably lead to cuts to other programs. On May 19, the Senate passed the Blunt-Murray amendment to a transportation appropriations package which would provide $1.1 billion for the public health response, and the funding by the Senate is not offset and would be available for FY2016 and FY2017. The White House will likely support the Senate compromise, but there have already been veto threats from the administration for the House bill. In short: as usual, we are functioning in dysfunction here in Washington.


Zika is pressing. In doing the necessary and immediate work of responding to Zika, however, lawmakers should not ignore the underlying public health infrastructure that has been neglected and is in dire need of repair. We need to keep training our public health workforce, reinvesting in early warning systems, and continuing our upkeep of preventive and responsive public health services on a state and local level. We need Congress to support supplemental funding for Zika now, and to continue to support the public health system that protects us against the next Zika that has yet to emerge.


CSTE has been closely involved with advocacy efforts to support robust a supplemental funding stream for Zika prevention, research, and therapeutics development which does not steal from our already eroding public health infrastructure. CSTE representatives have joined meetings on the Hill to discuss the needs of the states, and have vocally opposed any funding which pulls from PHEP, the Public Health Prevention Fund, or other public health funding streams.


Emily Holubowich, MPH and Zara Day, JD, MPH are CSTE’s Washington representatives in the nation’s capital at Cavarocchi Ruscio Dennis Associates, LLC. Find out more about CSTE’s advocacy activities on the CSTE Advocacy page. You can also read Executive Director Jeff Engel’s article in the new edition of journal JPHMP. Log in as a CSTE member through this link to access it for free or visit the journal’s public webpage.

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Share Your Expertise with Readers of CDC’s MMWR

Posted By Sonja Rasmussen, MD, MS, Friday, May 20, 2016
Updated: Thursday, May 19, 2016
Untitled Document

A month from now many of you will be in Anchorage, gathered for the CSTE Annual Conference, sharing your expertise and building collaborations.

Those are the very reasons it was important to me as the Editor-in-Chief of CDC’s Morbidity and Mortality Weekly Report (MMWR) that we be there, too.

On Monday, June 20 (2:00-3:30 p.m.), Jeff Sokolow, Technical Writer/Editor for MMWR, and I will be presenting on “Publishing in Today’s MMWR: Widely Read, Widely Respected.” MMWR is often considered “the voice of CDC,” but that doesn’t mean the reports are only from CDC authors. We want to be publishing your scientific work and we welcome your submissions.

Tim Jones will be moderating our session. Since 2015, he has served as chair of the MMWR Editorial Board, but his history with the publication goes back many years including during his time as a part of CDC’s Epidemic Intelligence Service. He’s now the State Epidemiologist for the Tennessee Department of Health and of course is a past president of CSTE.


 
When outbreaks are first identified, we don’t always know what they will become. This 1976 MMWR report on a “Respiratory Infection -- Pennsylvania” was the first report on what became known as Legionnaires’ disease.

 
CDC discovered that two cases of febrile respiratory illness in children from Southern California were caused by a new H1N1 influenza virus of swine origin. These two cases – the first of the 2009 H1N1 pandemic – were reported as an MMWR Early Release.

Maybe you know the history of MMWR, the first journal to publish descriptions of cases of Legionnaires’ disease, AIDS, and 2009 H1N1 influenza. I’ll talk about how MMWR has informed and shaped public health for many decades and I’ll introduce you to our broad readership that runs the gamut from physicians to epidemiologists and educators. And we’ll talk about how MMWR reports are widely highlighted in news reports and redistributed by other journals and medical associations.

 
After being alerted by a CDC Epidemic Intelligence Service officer assigned to the Los Angeles County Department of Health, MMWR published a report in 1981 on five cases of a rare type of pneumonia in otherwise healthy young men – the first indication of the AIDS epidemic.

Jeff Sokolow will outline the structure of an MMWR Weekly Report, highlighting how the first paragraph serves as an abstract containing background, methods, main results, discussion, and a SOCO (single overriding communications objective) that states the public health action recommended. He will also discuss the MMWR editorial review process, give clear writing tips and note errors to avoid.

It will also be our pleasure to introduce you to two MMWR authors from state health departments. We will be joined by Joan M. Duwve of the Indiana State Department of Health. Joan and her department colleagues used an MMWR template to develop their report on a community outbreak of HIV infection and in three weeks’ time went from inception to publication. Her description of the process and the impact of the publication will put you in the shoes of an MMWR author.

Ali Hamade of the Alaska Section of Epidemiology will talk about publishing on what might have seemed to be a very esoteric topic - suspected palytoxin inhalation exposures – that ended up garnering widespread attention. In his words, “Publishing in MMWR with its wide reach and open access has helped serve global public health by spreading the message. We saw evidence of this from the many technical assistance requests from the public and public health agencies, to national and international media inquiries and postings on multiple hobbyist and professional blogs.”

As Ali notes, he and his co-authors chose MMWR because it reaches a broad audience including state and federal public health officials, is open access and therefore freely available to all, and is easily retrieved in internet searches.

Please come hear their stories and learn how publishing in MMWR can further your own public health impact.

Our goal is to help you share what you’ve learned. We’re coming to the conference hoping to build many collaborations. We look forward to meeting you in June.

 
Sonja Rasmussen, MD, MS is editor-in-chief of the Morbidity and Mortality Weekly Report (MMWR) and director of the Division of Public Health Information Dissemination at the CDC Center for Surveillance, Epidemiology, and Laboratory Services. Visit the publication on the web at http://www.cdc.gov/mmwr/.
 

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Announcing New Recommendations for Epidemiologists to Improve Reporting of Drug Overdose Deaths on Death Certificates

Posted By Jennifer Sabel, Friday, May 13, 2016
Updated: Thursday, May 12, 2016

Did you know that drug overdoses are the leading cause of injury death in the nation? However, about 20% of death certificates on drug overdose deaths do not include information about the specific drugs involved in the overdose. The lack of detail on the specific drugs involved varies between 1-52% of drug overdose deaths by state. Knowing the specific drugs involved is critical to developing appropriate prevention strategies.

A new recommendations document developed by the CSTE Overdose Subcommittee provides concrete steps and lessons learned to epidemiologists and public health professionals wanting to improve drug overdose reporting in their jurisdiction.

These new recommendations include resources for how to review the quality of your jurisdiction’s drug overdose data, and how and why to collaborate with your state’s vital statistics registrar and medical examiners and/or coroners to enlist their support in helping to improve the quality of the data.

The new recommendations document also includes specific examples from jurisdictions that have made efforts to improve data quality. For example, in Kentucky, staff produced a figure showing that a third of drug overdose deaths had no specific drugs listed on the death certificate. This figure was widely shared with stakeholders who then collaborated to develop a drug overdose fatality reporting framework to improve the reporting of drug overdose deaths.

In New York City, staff identified a large number of deaths that listed “morphine” on the death certificate. Morphine is identified in toxicology testing, but the original source can be either heroin or pharmaceutical morphine. Discussions with the chief medical examiner identified that the majority of these deaths involved heroin. Staff worked with the chief medical examiner to develop recommendations to improve reporting of deaths involving heroin or morphine.

In Washington State, staff worked with the vital statistics office to start a query process for gathering additional information for the unspecific drug overdose death certificates that were submitted to their office. Receipt of an unspecific death certificate generated questions back to the medical examiner or coroner for more detailed information on the death and the drugs involved.


The new recommendations document is available on the CSTE website: http://www.cste.org/OverdoseRecommendations.
We hope that you will use the recommendations to improve specific drug reporting on drug overdose death certificates in your jurisdiction.


Jennifer Sabel, PhD is an epidemiologist in Non-Infectious Conditions Epidemiology in the Office of the Secretary at the Washington State Department of Health. Holly Hedegaard, MD, MSPH is an injury epidemiologist at the National Center for Health Statistics at the CDC Office of Analysis of Epidemiology. David Nordstrom, PhD, MPH, MS resides in Oregon and Wisconsin and works as a consultant in injury epidemiology for government and academic settings. Svetla Slavova, PhD is associate professor at the Kentucky Injury Prevention and Research Center at the University of Kentucky. Denise Paone, EdD, is senior director of research and surveillance and Ellenie Tuazon, MPH is an epidemiologist at the Bureau of Alcohol and Drug Use Prevention, Care, and Treatment at the New York City Department of Health and Mental Hygiene. Amy Poel, MPH is an epidemiologist at the Center for Health Statistics, Washington State Department of Health.

Join the Overdose Subcommittee by logging in as a CSTE member and clicking “join” on the webpage. The Overdose Subcommittee meets on the second Thursday each month at 1-2PM Eastern. Join the subcommittee to receive the monthly phone number and passcode, and contact CSTE Senior Research Analyst Megan Toe for more information.

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Ebola Active Monitoring After-Action Review

Posted By Lucretia Jones, Friday, May 6, 2016
Updated: Thursday, April 28, 2016

Active monitoring of travelers who are at low (but not zero) risk for Ebola Virus Disease (EVD) for 21 days was a labor-intensive activity for health departments, especially those with large volumes of returning travelers. Taking on this new and daunting task was especially demanding while also sustaining ongoing public health responsibilities. New York City Department of Health and Mental Hygiene (NYC DOHMH) began receiving files from CDC with contact information for travelers who had arrived from West Africa in the fall 2014. An active monitoring call center (AMCC) was set up and staff from several different programs were reassigned from their regular jobs to serve as AMCC operators. After several months, these staff were replaced with grant hires and temp agency staff. They called travelers daily to collect temperatures and document any symptoms; these efforts are described in more detail at http://www.cdc.gov/mmwr/volumes/65/wr/mm6503a3.htm.

When a traveler was unable to be reached by AMCC for two consecutive days, the traveler was referred to the DOHMH Surveillance and Epidemiology Emergency Response Group’s Field Surveillance Unit (FSU). Activated under DOHMH’s Incident Command System, FSU consists of approximately 200 staff from six different bureaus. FSU staff are trained and experienced in patient/provider outreach, interviewing, and medical chart abstraction. Upon being assigned a traveler who was lost to follow-up, FSU staff initially attempted to contact the traveler or his or her listed emergency contact by phone. FSU staff used subscription-based people search databases to search for travelers or their emergency contacts to identify additional contact information. After calling all phone numbers and leaving messages for the traveler to call the AMCC, FSU staff would send an email to the traveler if an email address was available. If there was no response by phone or email after 2–3 hours, a FSU staff or team of two staff would conduct a site visit to the traveler’s home, hotel, or local address. If the traveler was not found, a letter from DOHMH explaining the need to speak with the traveler was left at the hotel’s front desk or under the apartment door, if possible.

From October 11, 2014 to May 31, 2015, DOHMH conducted active monitoring for 2,941 travelers, which resulted in 235 (8%) hard-to-locate referrals to FSU. Of the 235 referrals, 80 (34%) were successfully contacted by phone within a day of referral and 67 (29%) required a field visit. Of these 67 field visits, 17 (25%) were located and interviewed, letters asking the traveler to call were left with someone at the home/hotel or placed it under the door for 41 (61%), and 9 (13%) did not have a valid address. Seventy-eight (33%) of all referrals had other outcomes (e.g. traveler left NYC or contact made after 24 hours) and for 10 (4%) FSU was unable to proceed with any outreach due to lack of valid contact information.

Challenges in NYC to locating these travelers differed depending on if the traveler was a NYC resident returning from a trip abroad versus a foreign resident visiting the city. Challenges included the traveler not being reachable in the daytime because they were at work or not at the hotel because they were out sightseeing or visiting relatives. Incorrect or incomplete addresses lacking apartment numbers, no access to apartment buildings, common last names, language barriers, and safety in the field also hindered our ability to locate travelers.

Distributing pre-paid cell phones to travelers when they arrived facilitated efforts to contact them for daily active monitoring. In the first four weeks of active monitoring before CDC phones were given to travelers upon arrival in NYC, FSU had to identify additional contact information on travelers for 41 of 136 (30%) of referrals; after phones were distributed, only 14 of 99 (14%) required identifying additional contact information (2 P=0.004). Before phones were distributed, 49 of 136 (36%) referrals required a field visit; after phones were distributed, only 18 of 99 (18%) referrals required a field visit (2 P=0.003).

The number of referrals for locating hard-to-reach travelers decreased from 136 in November 2014 to 30 in December 2014 and remained less than 17 a month for the remaining months. This decrease was due to several reasons including AMCC’s success in contacting travelers by phone within 48 hours and the addition of free cellphones to travelers. However, valuable time and resources were still expended on calling travelers daily for 21 days and sending field staff to locate and make contact with travelers who did not respond to the cellphone attempts. Having a unit of staff trained and experienced in tracking down additional contact information, finding hard-to-reach people in the field, and interviewing reluctant clients was critical to the success of Ebola virus active monitoring in New York City.

 


Lucretia Jones, DrPH, MPH is director of the General Surveillance Unit at the Bureau of Communicable Disease at the New York City Department of Health and Mental Hygiene (NYC DOHMH). For more information about preparedness, join the Public Health Emergency Preparedness Subcommittee.

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“Cloudy with a chance of…” Classification of Emergency Department Visits related to Extreme Weather

Posted By Teresa J. Hamby, Hui Gu, and Stella Tsai, Friday, April 29, 2016
Updated: Thursday, April 28, 2016
 

In New Jersey, real-time emergency department (ED) data are received from 78 of 80 EDs by Health Monitoring Systems Inc.’s (HMS) EpiCenter system, which collects, manages, and analyzes ED registration data for syndromic surveillance.

Hurricane ‘Superstorm’ Sandy struck October 29, 2012, causing harm to New Jersey residents and extensive damage to businesses, transportation, and infrastructure. Monitoring health outcomes for increased illness and injury due to a severe weather event is important in measuring the severity of conditions and the efficacy of state response, as well as in emergency response preparations for future severe weather events. After Hurricane Sandy, the need to be prepared for future severe weather events prompted the New Jersey Department of Health (NJDOH) to develop a suite of 19 syndromic surveillance classifications for extreme weather-related conditions in EpiCenter. Examples include carbon monoxide poisonings resulting from generator misuse and disrupted medical care where patients needed emergency visits for medicine refills after losing their medicines in the flood or running out with no pharmacy available, and the need for oxygen or dialysis due to power outages at homes and procedure locations.

The development of these classifications followed a two-stage validation of keyword lists using diagnostic codes. First, staff identified possible inclusion keywords using records with ICD codes that met case definition. Then, exclusion text was determined by evaluation of cases with keywords of interest but without ICDs meeting case definition. Sensitivity and positive predictive values were computed for both the initial keyword list and the final keyword list to ensure the keywords were a good fit for the process.

NJDOH has since used these classifiers in more recent events to monitor for weather-related visits to storm-affected area ED’s. In June, 2015, a squall line of damaging thunderstorms, known as a “bow echo,” caused downed wires and power outages in two southern New Jersey counties. In the aftermath, there was a spike in the rate of visits for disrupted medical care, in particular for oxygen needs. In January, 2016, Winter Storm Jonas dropped more than a foot of snow over New Jersey. During and after that storm, carbon monoxide poisoning visits spiked, likely due to the misuse of generators, as did visits for medication refills.

While not every classification would be relevant in every extreme weather event, having the elements available provides tools for state and local users to monitor storm impacts locally and at the state level.

Teresa Hamby, MSPH is a data analyst, Hui Gu, MS is a health data specialist, and Stella Tsai, PhD, CIH is a research scientist at the New Jersey Department of Health. For more information about disaster epidemiology, join the Disaster Epidemiology Subcommittee.

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Participatory Program Evaluation Planning in Support of the Vermont Comprehensive Cancer Control Initiative

Posted By Leanne Shulman, Friday, April 22, 2016
Updated: Friday, April 22, 2016

In the fall of 2014 the Comprehensive Cancer Control (CCC) program in Vermont was in particular need of evaluation expertise. In the next year (2015) the program oversaw the creation of a new five-year cancer plan, the 2020 Vermont Cancer Plan, and the end of the existing external evaluation contract. Financial resources for evaluation were very limited, with no funding available until 2016 to contract out the development of a new evaluation plan, evaluation questions and revised logic model to accompany the new cancer plan.

As described in CSTE’s 2004 white paper “Essential Functions of Chronic Disease Epidemiology in State Health Departments,” evaluation is a Tier 2 Essential Function of chronic disease epidemiology. Chronic disease epidemiologists play a supportive or coordinating role in delivering Tier 2 functions. As the Vermont CCC program does not have dedicated evaluation staff, it is my responsibility to coordinate evaluation of the CCC program in Vermont.

Ideally, I would develop the evaluation plan alongside the 2020 Vermont Cancer Plan rather than contracting out the evaluation the year after the plan was written. However, given my limited (aka non-existent) experience in developing evaluation plans and limited access to internal evaluators within the Vermont Department of Health, I was not in a position to develop a high-quality evaluation plan.

In an effort to gain access to evaluation expertise I applied to the National Association of Chronic Disease Directors (NACDD) Epidemiology Mentorship program with a proposed project of creating an evaluation plan for the CCC program. The mentorship program paired me with Dr. Ericka Welsh of the Kansas Department of Health and Environment, Bureau of Health Promotion, a senior epidemiologist with expertise in evaluation.

With Dr. Welsh’s assistance I coordinated the development of a five-year evaluation plan to accompany the new five-year state cancer plan. We used the Comprehensive Cancer Control Branch Program Evaluation Toolkit (2010) as a framework. A participatory evaluation approach was employed, which began with an invitation to join the Vermont comprehensive cancer control coalition – Vermonters Taking Action Against Cancer (VTAAC) Evaluation Committee. The invitation was sent to the general coalition membership, as well as to specific partners with evaluation experience.

The ensuing Evaluation Committee consists of three staff from the Vermont Department of Health, the VTAAC coordinator, a cancer center communications manager, a quality improvement liaison for a major private insurer, and the coordinator for the Vermont Cancer Survivor Network.


The 2015 VTAAC Evaluation Committee: Sarah Keblin, Ali Johnson, David Cranmer, Sharon Mallory and Leanne Shulman. Not pictured – Sherry Rhynard and Micah Demers. Photo by Ali Johnson

The Evaluation Committee met five times over the course of nine months in 2015 to provide input on each step of the evaluation plan. Under my leadership, the Evaluation Committee revised the CCC initiative logic model, determined the program’s evaluation questions and created the evaluation planning matrix.


Leadership in this case entailed preparing draft documents, which were critiqued during the meeting, and then creating revised versions, which were further edited via email. This process was repeated for each of the pieces of the evaluation plan. I made a significant effort to do as much preparatory work as possible before committee meetings in order to limit the demands placed on the stakeholders. It took a full nine months to complete the evaluation plan. Although there was a great deal of investment in building relationships, creating drafts and rewriting, the ultimate product is stronger as a result of the input of a variety of voices.

The evaluation plan includes both process and outcome evaluation and is designed to measure and improve the effectiveness of the CCC program and VTAAC, to inform future program and coalition development, and to demonstrate accountability to funders.

The participatory approach, with guidance from a senior-level mentor, resulted in an evaluation plan that has buy-in from key VTAAC partners while maintaining the framework required by the funder (CDC). Activities in the plan will be implemented by staff within the Vermont Department of Health, primarily the CCC epidemiologist (me) with assistance from an external contractor who will conduct individual evaluation activities, such as focus groups. The work done by the Evaluation Committee was presented to and approved by the VTAAC Steering Committee in November 2015. The Evaluation Committee has a continued role in overseeing the implementation of the plan throughout the next five years.

If you are interested in hearing more about the participatory evaluation planning process we undertook, please come to my presentation at the CSTE Annual Conference – 11am at the Cross Cutting I – “No Seward’s Folly: Quality Improvement, Collaboration, and Evaluation” session on Wednesday, June 22, 2016.

The 2016-2020 Vermont Comprehensive Cancer Control Initiative Evaluation Plan can be found here: http://healthvermont.gov/pubs/cancerpubs/documents/evaluation_plan_comprehensive_cancer_control_program.pdf.

Leanne Shulman is the epidemiologist and evaluator for the Comprehensive Cancer Control Program in Vermont. She is also the epidemiologist for the Vermont Office of the Chief Medical Examiner. She was a mentee in the 2015 National Association of Chronic Disease Directors (NACDD) Epidemiology Mentorship program. For more information on CSTE activities, join the Cancer Subcommittee.

Photo by Ali Johnson

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