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Channeling John Snow: Poisoning Data for HIV/HCV Prevention

Posted By Nate Wright, Tuesday, December 27, 2016
Updated: Tuesday, December 20, 2016

It is difficult to distill my experiences as a CSTE Applied Epidemiology Fellow (AEF) in the Minnesota Department of Health (MDH) into one blog post. I hit the ground running from day one of my fellowship and have been enjoying the experiences ever since. Primarily, my work focuses on suicide and drug overdose, but those topics encompass and overlap considerably with other related public health matters. For example, my projects have included evaluating Minnesota’s Violent Death Reporting System, examining American Indian drug overdose deaths in Minnesota, working with Minnesota’s American Indian community to address the drug overdose crisis, and providing epidemiological assistance to a concerned Minnesota community that saw an increase in suicides from a bridge. I have also presented at local, state, regional, and national conferences, and have produced work for various publications. These are some of the projects I expected from my AEF, but I have also been involved with projects I never would have anticipated, such as evaluating the public health impact of a new statute in Minnesota that allows for religious objections to autopsies.

One project that I am proud of, and has been rewarding to work on, has been our efforts to better understand counties in Minnesota that may be at higher risk for an outbreak of HIV or Hepatitis C Virus (HCV) associated with injection drug use. The 2014 outbreak of HIV associated with injection drug use in Indiana raised concerns about the ability to detect and respond to a similar outbreak in Minnesota. A workgroup at the MDH was convened with participation from both infectious disease and injury prevention units. The goal was to identify potentially high risk areas for an outbreak of HIV or HCV, as well as where future resources for treatment and prevention of HIV or HCV should be placed in Minnesota.

We identified currently available data sources that could provide insight into counties at greater risk of an outbreak. The results of our analyses validated current knowledge of locations throughout Minnesota with a greater number of drug poisoning hospitalizations and cases of HIV or HCV. However, the findings also highlighted areas of the state with greater numbers of poisoning hospitalizations, but fewer cases of HIV or HCV. These areas may be at greater risk of an infectious disease outbreak, and it may be beneficial to target them with prevention measures, such as disease screening, referral to care, and syringe exchange programs.

At about the same time I completed our analysis, the Centers for Disease Control and Prevention (CDC) released a similar analysis titled, “County-level Vulnerability to Rapid Dissemination of HIV/HCV Infection among Persons who Inject Drugs.” The goals of the CDC analysis were similar to ours, except the CDC analyzed data for all counties in the United States and used a more sophisticated statistical method. The CDC report only published results for the highest risk counties in the United States, of which there were no Minnesota counties. However, the methods of the CDC analysis were replicated at the MDH with Minnesota county data to compare the MDH method and the CDC method. The two methods ultimately identified a similar group of counties in Minnesota that were found to be at higher potential risk for an outbreak of disease. The methods and data used in the statistical model continue to be refined to more accurately represent the population and risk factors in Minnesota to ensure it provides the most accurate picture of risk across the state. We’ve presented the results of this project at state and national conferences, and they will continue guide our thinking at the MDH as to how to address and prevent drug poisoning hospitalizations and HIV or HCV infection from occurring. There’s also potential for these results to help inform state policymakers as they seek legislative solutions to substance abuse.

CSTE Applied Epidemiology Fellow Nate Wright presents his work before administration officials at the Substance Abuse and Mental Health Services Administration.

This project was particularly interesting because it brought together units of the MDH that often don’t have an opportunity to collaborate. Each unit brought their area of expertise to the table to work together to address this problem. For me, this project brought home the point that we as public health practitioners can accomplish more by working with each other and across our units. Bringing together colleagues with different perspectives on complex public health challenges helps push public health forward and improve the health of Minnesotans and our communities.

These project examples highlight a few of the tangible accomplishments of my AEF, but I have also grown personally and professionally as a result of these experiences. I strive to fully understand the data, including their strengths and limitations, and potential policy implications of findings. I’ve been reminded through meetings with those in my community that ultimately there are people behind the numbers—the data are representative of the true public health challenges facing people in the community that we are working to address.

The AEF has afforded me opportunities that few other recent graduates and new employees experience. My mentors have been wonderful and have provided the guidance and expertise to ensure my fellowship has been an extraordinary time as part of the Injury and Violence Prevention Section. As I reflect back on the first year of my fellowship, I begin to understand the wonderful experiences this fellowship has offered and I look forward to the work and opportunities that are still to come in my fellowship and beyond.

Nate Wright is a CSTE Applied Epidemiology Fellow in the Minnesota Department of Health. He is a graduate of the University of Minnesota School of Public Health where he received his Masters of Public Health in Epidemiology. Mr. Wright’s post is the first in a series of blogs by CSTE Applied Epidemiology Fellows to be posted in the coming weeks.

Tags:  data  epidemiology  Fellowship  Substance Abuse  Surveillance  Workforce development 

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Assessing the Training Needs of Epidemiologists

Posted By Jessica Arrazola, Tuesday, December 20, 2016
Updated: Tuesday, December 20, 2016

The recent publication “Examining state health agency Epidemiologists and their training needs” describes the applied epidemiology workforce as highly educated, with gaps in relevant skills requiring development.1 These gaps are not in traditional epidemiology “shoe leather,” but in the cross cutting skills of collaboration, change management, and communication. Similar to other assessments of the public health workforce, workers self-report a need for more training in these non-technical skills. As we enter into the era of “Public Health 3.0”—a major upgrade in public health practice to emphasize cross-sectoral policy to address social determinates of health—it will be necessary for epidemiologists to work beyond their silos to successfully implement surveillance and informatics initiatives.

The Council on Education for Public Health (CEPH) recognizes this need for training in cross cutting skills and is changing the accreditation criteria of schools and programs of public health.2 These changes aim to shift the delivery of the Master of Public Health (MPH) curriculum from the traditional five areas of public health to foundational knowledge and competencies as well as applied learning experiences beyond the traditional practicum. The 22 MPH competencies are arranged across eight domains: evidence-based approaches to public health, public health and health care systems, planning and management to promote health, policy in public health, leadership, communication, interprofessional practice, and systems thinking.

The change in accreditation criteria will eventually have a downstream effect in preparing the public health workforce, but training in cross cutting skills for the current workforce is needed now. The Council of State and Territorial Epidemiologists (CSTE) aims to provide epidemiologists a forum for discussion, resources, and training for cross cutting skills. One example is the recently developed toolkit of resources to promote scientific writing among applied epidemiologists. Since June 2016, CSTE has identified new leadership for the Epi Methods Subcommittee, reinvigorated the Workforce Subcommittee and added a co-chair, and has initiated an Early Career Professionals Workgroup. While other subcommittees and workgroups are topical in nature, the Epi Methods and Workforce Subcommittees’ activities strive to promote a trained and qualified workforce on cross cutting skills.

CSTE will continue to support activities to foster a prepared workforce. The Epi Methods Subcommittee Chairs, Diana Cervantes of the Texas State Department of Health and Talia Brown of Boulder County Public Health, have led the group to develop a strategic plan for 2016-2017 with two major priority areas: 1) Enhancing awareness and promoting best practices in applied epidemiology methods and 2) Working to build and maintain capacity for the application of epidemiologic methods. The Workforce Subcommittee will also develop a strategic plan to be presented at the 2017 CSTE Annual Conference.

CSTE remains committed to equipping epidemiologists with the diverse skills they need—technical and otherwise—to succeed in an evolving public health landscape. You can help us by joining the Workforce and/or Epi Methods Subcommittees to support our workforce development initiatives.

Jessica Arrazola is CSTE’s Acting Director of Workforce Development. To receive more information about the Early Career Professionals Workgroup or other CSTE workforce development projects, contact Jessica at Jarrazola@cste.org.

1 Chapple-McGruder, T., Leider, J., Beck, A., Castrucci, B., Harper, E., Sellers, K., Arrazola, J., and Engel, J. (2016). Examining state health agency epidemiologists and their training needs, Annals of Epidemiology.
2 Hadler, J. (2014). 2013 Epidemiology Capacity Assessment. Accessed via http://www.cste2.org/2013eca/CSTEEpidemiologyCapacityAssessment2014-final2.pdf
3 Council on Education for Public Health. (2016). 2016 revised criteria. Accessed via http://ceph.org/criteria-revision/

Tags:  Cross Cutting  epidemiology  Fellowship  membership  staff spotlight  Workforce Development 

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CSTE and Epi’s Work Around the World

Posted By Jennifer Lemmings, Friday, December 2, 2016
Updated: Thursday, December 1, 2016

On November 4, President Obama signed an Executive Order reinforcing the Global Health Security Agenda (GHSA) as a presidential-level priority and bolstering the United States as a major catalyst for supporting the GHSA and its promise. In his Executive Order, President Obama highlights the role of protecting global security as a key tenet of the United States’ national strategy to combat biological threats. He points out that in a globalized world, in order to protect ourselves, we must protect and bolster other nations’ health infrastructures.

The United States, joining the World Health Organization (WHO), Food and Agriculture Organization of the United Nations (FAO), World Organisation for Animal Health (OIE), Global Partnership Against the Spread of Weapons and Materials of Mass Destruction, the International Criminal Police Organization (INTERPOL), and other relevant organizations and stakeholders, will coordinate amongst governmental and non-governmental entities in order to advance the “global health agenda.” This will include the development of an inter-agency council to draft guidance for the agencies and support and track global health issues and how the United States can lead and participate in addressing them, among other things.

CSTE is pleased to support the President’s efforts, acknowledging that walls cannot stop the spread of disease, and therefore national health security can only be achieved through the protection of global health security. CSTE’s international role has accelerated rapidly within the last two years as we work to better support epidemiology surge capacity needs. Funding from the Centers for Disease Control and Prevention (CDC) and the CDC Foundation enabled CSTE to support international public health emergencies in Ebola, and now in Zika.

In January 2015, four French speaking senior epidemiologists traveled to four high risk Ebola Virus unaffected countries in Western Africa. As part of a comprehensive strategy to contain the regional Ebola epidemic, CDC and other international partners during this period were working in 18 unaffected high risk countries, with the aim of increasing capacity to detect and control any introduced Ebola Virus cases. The goal was to enhance the epidemiologic capacity in these countries and to provide:

  • Capacity building, technical assistance and guidance to the Ministries of Health/Health Departments surrounding Guinea, Sierra Leone and Liberia; and
  • Assessment of existing capacities and recommendations for improvement of policies and procedures
Funding for this work continued, and since August 2015 CSTE has supported an additional 40 deployments including those from the New York City Department of Health and Mental Hygiene, with an average deployment in Western Africa of 43 days.
As needs in the Zika response efforts have increased, CSTE is also supporting epidemiology work in Puerto Rico. Currently six deployments are completed or underway.

CSTE urges the new administration to continue support for these important efforts, and will continue to advocate for funding for epidemiologists to protect our nation’s health.

Tags:  Disaster Epidemiology  epidemiology  Global Health  Health security  infectious disease  Outbreak  surveillance 

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Welcome CSTE's New Face of Finance

Posted By CSTE, Friday, November 18, 2016
Updated: Thursday, November 17, 2016

Earlier this month, the Council of State and Territorial Epidemiologists (CSTE) welcomed John Lisco to the organization as its new Senior Director of Finance. John has a wealth of experience in public health and management, overseeing several programs and projects at the Centers for Disease Control and Prevention (CDC), serving on the Emory University faculty, and working in the private sector. We asked John to share more about what drives him, his goals for this new position and CSTE, and what keeps him busy in his spare time.


How have your prior work experiences prepared you for CSTE?
Over the course of my career, I have had the opportunity to work in a variety of public health and health care settings in both the public and private sectors. These experiences have allowed me to develop leadership, management, and financial skills, which I bring to my position as Senior Director of Finance at CSTE.

I began my CDC career in 1995 in the Division of Cancer Prevention and Control as a program consultant with the National Breast and Cervical Cancer Early Detection Program and National Skin Cancer Prevention Education Program. While there, I led a workgroup to develop projections for a national colorectal cancer screening program, which led to federal funding for colorectal cancer screening several years later. Subsequently, I held leadership positions that focused on workforce development, helping to prepare the current and future public health workforce to meet the emerging and on-going challenges in the 21st century. These positions included serving as Chief of the Public Health Prevention Service, Coordinator of the CDC/Agency for Toxic Substances and Disease Registry (ATSDR) Leadership and Management Institute, and Deputy Director of the Division of Scientific Education and Professional Development, where I was responsible for the effective planning, implementation, and monitoring of an annual budget that ranged from $32 - $62M. In my last position at CDC, I served as the Deputy Director of the Program Integration Unit in the Center for Surveillance, Epidemiology, and Laboratory Services helping to further solidify and nurture CDC’s relationships with several critical partners, including CSTE, the Association of Public Health Laboratories, and the Association of Schools & Programs of Public Health.

Prior to joining CDC, I served as a senior associate faculty member in the Department of Behavioral Science and Health Education at the Rollins School of Public Health, Emory University. Before the Emory appointment, I worked as an area manager for the national employee health promotion program at AT&T™.

In addition to holding a master of public health degree in health policy and management from the Rollins School of Public Health, I also have advanced degrees in musicology and music therapy. During my tenure as a music therapist, I held several staff and leadership positions, working in a number of hospital-based settings, including adult and adolescent psychiatry, alcohol and drug rehabilitation, chronic pain, and physical rehabilitation.

What most excited you about the Senior Director of Finance position?
Over the last 10 years I have had the opportunity to work with leadership and staff at CSTE on the funding for several cooperative agreements related to workforce development, including the Applied Epi Fellowship, Applied Public Health Informatics Fellowship, Health Systems Integration Program, and the Informatics Training in Place Program. When I was approached about the Senior Director of Finance position, I was excited about the possibility of working with CSTE’s Executive Director Jeff Engel and many of the staff with whom I had developed strong professional relationships and for an organization whose mission and work I understood and respected. In addition, I was at a point in my life and career where I was ready for a new challenge and considering what kind of work to do next. This opportunity came along at just the right time.

What do you see as the key challenges and opportunities for CSTE?
Not only is my position new, but there is a new organizational structure at CSTE, which includes three other new Senior Director positions that also report to the Executive Director. Although we have all worked together in different roles in the past, moving forward the new organizational structure provides both a challenge and an opportunity for the five of us to develop a robust, cohesive primary leadership team for CSTE overall, while providing strong leadership for our own functional teams.

As CSTE has grown under Jeff’s leadership, we have outgrown many of the financial management systems we use to monitor, track, and analyze how we use our resources. We need to replace them with systems that will meet our current and future needs, and allow us to respond to internal and external requests for information and reports in real-time.

Likewise, as the number of projects has grown, we need to ensure that we have the appropriate staff on board to lead the writing of proposals and statements of work, develop budgets, and track all grants and contracts.

What are your top three priorities in your first year?
First, I want to work with key staff to conduct a thorough business requirements assessment to identify CSTE’s financial management needs and ensure that new, interoperable systems are in place that fulfill those needs. Second, I hope to hire one to two new staff to coordinate all grants and contracts for CSTE. Finally, I want to get up to speed on all aspects of CSTE’s financial activities and needs, and provide leadership that ensures that the finance team supports the organization’s mission, vision, and strategic plan.

Where do you hope to see CSTE in five years?
It may be a bit early for me to talk about where I see CSTE in five years, since I am so new to the organization. That said, I expect that we will have the systems, people, and resources in place to ensure that the day-to-day fiscal operations of CSTE run smoothly and that we are able to support the continued growth of the organization.

Just for fun, what can you share with us about your personal life?
I am a firm believer in work-life balance and the importance of having interests outside of the workplace. As you may have noticed by my education and work background, I have had a circuitous route to public health, that has included a life-long interest in music. I studied piano and harpsichord in college, and growing up in the 1960’s and 1970’s learned to play the guitar, as well. For the past two years, I have been playing keyboards in a garage band called Cover to Cover, which has performed at several venues in the Atlanta area. Likewise, exercise has been a great outlet for me. I go to the gym every morning before work and try to get outdoors on the weekends for runs and walks with my daughter.

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The Never Ending Fight for Public Health Funding

Posted By Emily J. Holubowich , Friday, November 4, 2016
Updated: Friday, November 4, 2016
Emily Holubowich, Senior Vice President at CRD Associates, is CSTE’s Washington representative and leads our advocacy efforts in the nation’s capital.

On September 28, Congress provided $1.1 billion in emergency supplemental funding to support epidemiologists and other public health professionals in the fight against the Zika virus—280+ days late and $800 million short of the President’s funding request. Despite the bill’s shortcomings, the funding is a welcome relief for those on the frontlines of the Zika response.

On October 26, the Department of Health and Human Services (HHS) provided its spend plan to Congress as required by the law, detailing how the Centers for Disease Control and Prevention (CDC) and other agencies will allocate resources for a range of Zika-related activities. As expected, CDC will rely heavily on state and local health departments to prevent, detect, and respond to the epidemic. Specifically, CDC will award at least $70 million of its $394 million in Zika supplemental funding to support epidemiology, laboratory surveillance, and vector control and surveillance. CDC has already provided Epidemiology and Laboratory Capacity (ELC) supplemental guidance to states (proposals are due November 20) and funds will be awarded before the end of the calendar year. In addition, CDC will restore $44 million that was redirected from the Public Health Emergency Preparedness (PHEP) grants to support Zika-related activities in the absence of new funding—funding that is already making its way back to state and local health departments.

With our attention now on the swift allocation of funding and ongoing response, it’s easy to forget how difficult it was to get here. The Council of State and Territorial Epidemiologists (CSTE) was actively engaged in efforts to secure Zika emergency funding during the last 8 months, first endorsing the administration’s request for $1.9 billion in emergency funding in February. Our vector-borne disease surveillance capacity assessment published in Mortality and Morbidity Weekly Report on the impact of budget cuts was a key pillar of our advocacy and education efforts, and was featured in a congressional hearing. CSTE actively participated in the “Zika Coalition” led by the March of Dimes, co-signing multiple letters to Congress and participating in meetings with key lawmakers. CSTE’s President-Elect Janet Hamilton of the Florida Department of Health took a break from her activities on the frontlines of the state’s Zika response to travel to Capitol Hill and share her experiences with a standing-room-only crowd of advocates, congressional staff, and lawmakers as part of the Coalition for Health Funding’s annual “Public Health 101” congressional briefing series, sponsored by the Congressional Public Health Caucus.

The challenge to the public health community now becomes keeping lawmakers’ short attention spans on the long-term Zika response and the needs of the public health infrastructure, more broadly. Some lawmakers think they have already “solved” the Zika problem with the appropriation of the $1.1 billion in emergency funding. Not only is this funding insufficient to support the immediate response, it will not address Zika’s long-term threat nor will it address the underlying weaknesses of the public health system after years of underinvestment that have been exposed by the virus.

Unfortunately, Zika is here to stay and will only get worse. As CDC Director Dr. Tom Frieden noted recently, “Zika and other diseases spread by [the Aedes aegypti mosquito] are really not controllable with current technologies. We will see this become endemic in the hemisphere." Meanwhile, the public health infrastructure will continue to buckle under the weight of mounting public health threats—both known and unknown. CSTE will continue to serve on the Zika Coalition’s steering committee to drive advocacy efforts around future funding needs for Zika response. CSTE will also continue to advocate for increased investment in ELC grants and the public health workforce. Only strong, stable, and sustained investment in the underlying public health infrastructure will ensure CSTE members and other public health officials are equipped and ready to combat all public health threats.

CSTE’s Executive Director Dr. Jeff Engel, President-Elect Janet Hamilton, and Washington Representative Emily Holubowich on Capitol Hill for a congressional briefing on the Zika response (Sept. 23, 2016).

Tags:  epidemiology  infectious disease  outbreak  surveillance 

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Posted By Emily M. Putzer, MA; Rowena Samala, MPH; Delmar Little, MPH; Fern Johnson-Clarke, PhD, Friday, October 21, 2016
Updated: Thursday, October 20, 2016

Life expectancy is an important population level health outcome for several reasons: It incorporates a wide range of health “problems,” it is a concept largely understood by community residents, and it is available at the “neighborhood” level, increasing relevancy.

The District of Columbia Department of Health participated in a pilot study supported by the Centers for Disease Control and the Council of State and Territorial Epidemiologists that provided technical assistance in determining small area estimates for life expectancy. This research supported and worked in tandem with the community health improvement process that was developing DC Healthy People 2020, the District’s health priority framework that contains over 150 population level health outcome objectives and targets for the year 2020 and 85 recommended strategies.

Because of these benefits of life expectancy as a key indicator, it is really the cornerstone of how we can communicate with diverse groups of District residents and stakeholders around health status, health outcomes, and contributing factors. In shifting the public health paradigm to a more holistic concept of health, incorporating social determinants as key factors influencing health outcomes is crucial to creating impactful policies and programs that improve population health.

A key goal of DC Healthy People 2020 and the DC Department of Health is to advance health equity through a focus on social determinants of health. DC Healthy People 2020 (DC HP2020) works in tandem with our newly-created Office of Health Equity (OHE) and stakeholders to bring about changes in policies (via Health in All Policies), programs, and system-level improvements by providing key health outcome data and recommending evidence-based strategies that will most effectively improve population health outcomes, reduce health disparities, and advance health equity. We know that the most impactful interventions to improve population health include tackling socioeconomic factors and changing the context through policies in order to enable a person’s default behavior to be a healthy behavior. DC HP2020 strategies focus on these two areas as well as improving data infrastructure to better measure key health outcomes for all.

Framing the study using segregation variables vs. “race” or poverty allows us to talk about places and how they enable healthy residents or unhealthy residents. It moves the conversation from, “how can we design public health interventions to target Black (or low-income) populations?” to “how can we change the social/structural makeup of this neighborhood to improve health?” You may have answers to these questions that overlap, but the former question may miss potential solutions such as: responsible community development, housing improvements, school integration policies, increased school funding, minimum wage policies, etc.

While income inequality is generally accepted as a structural challenge in our society, many people look the other way when confronted with the systemic/structural racism that exists. The more research that can allow people to think critically about how our society has been structured to disadvantage certain communities while advantaging others (and how those disadvantages harm health and the advantages support health), the closer we get to restructuring our society and dismantling the harmful systems, to truly allow everyone to reach his/her full potential of health.

Ultimately, we must go past simply documenting disparity. We have been doing that for many years and there has been little progress. We must discover underlying factors, tease out specific social and other neighborhood conditions that point to poor (or excellent) health outcomes, and design and implement programs and policies to effectively target those conditions. Future analyses will include more variables to describe social determinants and neighborhood conditions in order to get a more complete picture of key factors that can help explain differences in health outcomes and point to potential solutions for improving population health.

Authors: Emily M. Putzer, MA; Rowena Samala, MPH; Delmar Little, MPH; Fern Johnson-Clarke, PhD District of Columbia Department of Health
Disclaimer: The above contents are solely the viewpoints of the authors and do not necessarily represent the official views of CDC or CSTE.

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Project SHINE Fellowship Orientation

Posted By Jessica Arrazola, Friday, October 14, 2016
Updated: Friday, October 14, 2016
CSTE, with CDC and the National Association of County and City Health Officials (NACCHO), recently welcomed Project SHINE fellows in Atlanta for orientation. Fellows from the Applied Public Health Informatics Fellowship (APHIF), Health Systems Integration Program (HSIP), the Informatics-Training in Place Program (I-TIPP) convened in Atlanta for a 5 day training and orientation. The 43 fellows working at state and local health departments include 12 APHIFs, 10 HSIPs, and 21 I-TIPPs. Among these fellows, three APHIFs and three HSIPs are completing a second year extension focused on population health.

The fellows learned with and from each other as they have diverse academic and professional experiences. APHIFs and HSIPs are new to their health departments while I-TIPPs are current health department employees. All fellows focus on population health improvement though projects rooted in community engagement, epidemiology, or informatics. The networks and connections the fellows build during orientation are essential to maintaining their relationships throughout the fellowship and their public health careers.

The orientation provided an opportunity for fellows to learn from experts about population health, surveillance, and informatics. Eric Kasowski MD, DVM, MPH, Chief of the Population Health Workforce Branch at CDC opened the week with a motivational keynote highlighting the Public Health 3.0 framework, CDC’s 6|18 initiative, and the Community Chief Health Strategist. Fellows participated in a variety of sessions through the week including: standards and interoperability, legalities of data use and collection, the politics of health inequity, and project management. The week ended with an inspirational closing keynote from Judy Monroe, MD, FAAFP, President of the CDC Foundation.

Congratulations to all of the new Project SHINE Fellows. We look forward to working with you during your fellowship!
Learn more about Project SHINE, APHIF, HSIP, and I-TIPP online or contact Jessica Arrazola at the CSTE National Office.

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Capturing Work-Related Injuries from Emergency Department Data

Posted By Audrey Reichard, Suzanne Marsh, Rebecca Olsavsky, Friday, October 7, 2016
Updated: Thursday, October 6, 2016

Work-related injuries frequently occur, despite the fact that many are preventable. It is critical that we accurately describe and monitor these injuries in order to improve prevention efforts.

Because there is no comprehensive data source that captures all work-related injuries, the occupational injury community relies on multiple sources to describe the problem. The occupational supplement to the National Electronic Injury Surveillance System (NEISS-Work) is a surveillance system that provides one piece of the picture by capturing nonfatal occupational injuries treated in emergency departments (ED). The National Institute for Occupational Safety and Health (NIOSH) works with the U.S. Consumer Product Safety Commission to capture NEISS-Work data from a national sample of approximately 67 hospital EDs. These data include persons working for pay or compensation, working on a farm, or volunteering for an organized group.

In an effort to better understand the accuracy and process of identifying work-related cases from ED records, NIOSH conducted on-site assessments at 20 hospitals in the NEISS-Work sample. NIOSH staff worked closely with the NEISS-Work coders at each hospital to understand the challenges of identifying work-related cases and capturing the related data.

NIOSH found several factors that facilitated the identification of work-related cases. The presence and use of a specific work-related indicator (e.g., a checkbox for “injury at work”) in the ED record clearly aided the process. A work relationship can also be indicated in the notes from the treating healthcare professionals or in the expected payer field (i.e., workers’ compensation). Consequently, having all parts of the ED record readily available to the NEISS-Work coders improved the chance of identifying cases. Also, coders who regularly interacted with ED staff, whether through formal training or informal conversations, noted that this improved the quality of the work-related information in the ED record.

NEISS-Work case identification criteria often requires a review of all sections of a complete, up-to-date ED record. Coders with access to only select parts of the records were limited in their ability to identify work-related cases. Coders also encountered barriers related to incomplete and missing records when attempting to abstract records soon after the ED visit. Additionally, data needed to identify work-related injuries were sometimes unavailable when the ED record did not contain employment information or when employment information was not updated.

Confusion around the NEISS-Work case criteria at the time of the hospital assessments resulted in some coders relying on a single identifier (e.g., expected payer of workers’ compensation) that did not capture all cases and including cases that were not work-related. It also contributed to coder difficulties identifying unique types of workers, such as students and trainees.

Based on these findings, NIOSH staff revised the guidelines for identifying a work-related injury for NEISS-Work, provided additional training to the NEISS-Work coders, and improved coding documentation used by the NEISS-Work coders in an effort to refine case identification. We anticipate that this will improve the validity of the work-related injury estimates and enable NEISS-Work data to provide more accurate estimates of nonfatal work-related injuries.

Additional details on NEISS-Work as well as a tool that can be used to analyze single years of NEISS-Work data are available at the Work-Related Injury Statistics Query System. For more information on the assessment of NEISS-Work described above, see the poster presented at the 2016 Council of State and Territorial Epidemiologists Annual Conference. Click here to view pdf.

If you have worked with ED data in occupational injury research, we are interested in hearing your experiences. Specifically, what challenges have you faced in accurately identifying work-related cases? How did you address those challenges?

Audrey Reichard (akr5@cdc.gov), MPH, OTR, is an Epidemiologist in the NIOSH Division of Safety Research. Suzanne Marsh, MPA, is a Health Statistician in the NIOSH Division of Safety Research.
Rebecca Olsavsky, MS, is a Health Communications Specialist Fellow in the NIOSH Center for Motor Vehicle Safety.


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Changing Epidemiology of Primary Amebic Meningoencephalitis in the United States: What Have We Learned in the Last Five Years?

Posted By Jennifer Cope, Friday, September 30, 2016
Updated: Friday, September 30, 2016

Naegleria fowleri (commonly referred to as the "brain-eating ameba"), is a free-living microscopic ameba. It can cause a rare and devastating infection of the brain called primary amebic meningoencephalitis (PAM) with a mortality rate >97%. The ameba is commonly found in warm freshwater (e.g. lakes, rivers, and hot springs). Naegleria fowleri infects people when water containing the ameba enters the body through the nose. Once the ameba enters the nose, it travels to the brain where it causes PAM. Infection typically occurs when people go swimming or diving in warm freshwater places, like lakes and rivers. In some instances, Naegleria infections may also occur when contaminated water from other sources (such as inadequately chlorinated swimming pool water or heated and contaminated tap water) enters the nose.

The Free-Living and Intestinal Ameba Laboratory (FLIA) at the Centers for Disease Control and Prevention (CDC) is one of the few places in the United States that can confirm a diagnosis of PAM. Although PAM is not a nationally notifiable condition, CDC collects data on a standardized case report form for all cases confirmed at CDC. Historically, case reports tended to come from southern-tier states in persons exposed to recreational freshwater; in recent years, new geographic areas and modes of transmission have been documented. CDC’s surveillance has documented substantial changes in the epidemiology of PAM in the United States over the past five years (Figure 1).

The summer of 2016 has continued the trend of identifying new types and geographic areas of water exposures associated with PAM cases. For the first time, a patient was diagnosed with PAM after falling out of a whitewater raft on a closed-loop, recirculated artificial whitewater river in North Carolina. An environmental investigation of the whitewater facility identified Naegleria fowleri in all of the samples collected from the artificial whitewater river. Additionally, the first case of PAM associated with water exposure in the state of Maryland was reported in August. This summer also saw the 4th U.S. survivor of PAM. The Florida teenager’s survival was achieved through prompt diagnosis, early anti-amebic treatment, and close monitoring of intracranial pressure.

The epidemiology of PAM in the United States is evolving. Beginning in 2010, the first PAM case was reported from Minnesota, 600 miles farther north than a case had ever previously been reported. While CDC continues to see cases with recreational freshwater exposures, we have now documented cases associated with the use of piped water, bringing to light the threat posed by Naegleria colonizing building plumbing and water distribution systems. Standardized surveillance and reporting of amebic encephalitis, including PAM, is crucial to understanding the changing epidemiology. When state and local health departments are notified of a possible PAM case, they are encouraged to contact CDC 24/7 (via the Emergency Operations Center at 770-488-7100), where a CDC subject matter expert can provide treatment recommendations for clinicians, specimen submission instructions for testing of specimens at CDC, and guidance for conducting an epidemiologic investigation of water exposures.


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Job Sharing the Position of State Epidemiologist

Posted By Sandi Larson and Melissa Peek-Bullock, Saturday, September 24, 2016
Updated: Friday, September 23, 2016

Introducing the new State Epidemiologists from the Nevada Division of Public and Behavioral Health – Sandi Larson, MPH (pictured left) and Melissa Peek-Bullock (pictured right).  Together, we are job sharing the position to better serve the state.  It means we both work part-time and divide the work 51-49 based on our expertise.  While job sharing isn’t new for the agency, it hasn’t been widely adopted.

 Sandi  Melissa

The agency decided to offer the job share for several reasons.  First, to provide statewide representation.  Our state capital and the bulk of our staff and administrative offices is in the north, and we need to be available to provide a subject matter expert for legislature, media and to consult closely with the administration.  The bulk of morbidity is in the south along with our largest local health authority.  The former State Epidemiologist had to travel a lot across the state to serve the needs of both the north and south; the job share reduces the amount of travel associated with the position as we now have local representation.  Second, as State Epidemiologists, we want to be an integral part of the two growing schools of public health both in the north and south.  Third, agency leadership recognized that younger staff are interested in upper management, but also want a healthy work-life balance.  Job sharing this position allows us to pursue our public health careers and have quality family time.  Fourth, agency leadership hopes the job sharing arrangement will increase retention, provide additional coverage during periods of leave, and reduce staff burn out.  Turnover is detrimental to any program including management.  Long-term investment in the position fosters stability for our state.


The Nevada State Epidemiologist positions focus on providing technical assistance.  Sandi’s previous experience is in the areas of STD, HIV, hepatitis, TB, mental health and substance abuse as a Health Program Manager at the state.  Melissa was formerly an Epidemiologist at a local health department where her portfolio included general communicable diseases, such as enteric diseases, vector-borne diseases, viral hepatitis, influenza, and perinatal hepatitis B.  Together we have complementary skills and expertise to improve the epidemiology capacity at the agency.  


For job sharing to work effectively, those sharing the position must have strong communication skills and be able to work together seamlessly.  We do not want to second guess each other or duplicate work.  Work will be distributed as evenly as possible and effective communication is critical.  We do not want to confuse staff as to who they need to work with on a particular issue.  Technology, including video conferencing and desk sharing, helps us stay connected with each other and to our co-workers.    For external partners, we are setting up a shared email account, so to them, they do not need to distinguish between us.  External partners who email or call will be directed to whomever is most appropriate.  


While we are both new to the position, we are excited to serve Nevada using our epidemiology skills through job sharing while continuing to have a strong work-life balance. 


Sandi Larson, MPH and Melissa Peek-Bullock are the State Epidemiologists at the Nevada Division of Public and Behavioral Health.  Join the CSTE Workforce Subcommittee to learn more about other workforce development strategies.  If you have questions or would like to learn more about CSTE’s Workforce Development portfolio, please contact Jessica Arrazola.

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