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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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What Do CSTE Members Need To Know about CDC’s Updated Pool Code Guidance?

Posted By Michael Beach and Jasen Kunz, Friday, September 16, 2016
Updated: Friday, September 16, 2016
In July, CDC released the 2016 Model Aquatic Health Code (MAHC, 2nd Edition). Creation of the MAHC was initiated as a result of a 2004 CSTE position statement to reduce outbreaks and injuries at public pools. This second edition of the MAHC includes important updates to the first edition released in 2014.

Part of a CDC infographic outlining the benefits of swimming, health hazards at pools, and how MAHC can help. Access the full infographic and other materials.

The MAHC offers guidance that can be voluntarily adopted by state and local jurisdictions to minimize the risk for illness and injury at public aquatic facilities (for example, at apartment complexes, hotels, and waterparks) through facility design, construction, operation, maintenance, and management.

Reflecting input from state and local public health colleagues, aquatics professionals, and other stakeholders, the MAHC is being updated every 2 years to ensure that its recommendations remain current with the latest scientific data and aquatics sector innovations. The MAHC offers science-based guidance that government agencies and the aquatic sector can use to reduce risk for outbreaks, drowning, and chemical injuries at public pools and hot tubs/spas.

3 Things CSTE Members Should Know About the Updated MAHC & Supplemental Materials
  • CSTE was instrumental in getting the MAHC started, and you’re needed now too! The 2004 CSTE position statement noted increasing outbreaks at swimming pools and called for CDC action. The following year, stakeholders gathered and recommended CDC lead a process to develop a Model Aquatic Health Code. After 7 years of working with experts in public health, industry, and academia, the first edition was released in 2014. The 2016 MAHC contains updated code language for state and local jurisdictions, along with an annex with scientific rationale for the provisions.
  • The 2016 MAHC includes structural changes, clarifying edits, and new or revised recommendations in the areas of disinfection and water quality, lifeguarding and bather supervision, risk management and safety, and ventilation and air quality. The MAHC website includes a summary of key changes that are in the updated edition, and a “track changes” version with line-by-line edits.
  • CSTE members can use our updated tool to compare their current pool code and practices to key practices the MAHC recommends.
3 Questions CSTE Members Can Ask Themselves
  • Does your health department regulate or inspect swimming pools?
    Explore the MAHC website to access the latest MAHC and supporting materials, our MAHC-based inspection form and other tools, and infographics and other health promotion materials to educate yourself and others about the MAHC.
  • Interested but not sure where to start?
    Join the MAHC Network to connect with health department peers interested in learning more about the MAHC. The Network is free and includes regular webinars with CDC staff and health departments pursuing or considering the MAHC in their community. View past webinars and learn more about the Network.
  • Do you have expertise in recreational water?
    Join the Council for the Model Aquatic Health Code (CMAHC)! Much like the Food Code, the MAHC is updated every 2 years through a national process with stakeholder input. For the 2016 MAHC, 159 change requests were submitted for CMAHC members to vote on. Of these, 92 (58%) change requests were passed by CMAHC and provided to CDC for final decision. Learn more about CMAHC or check out CMAHC Executive Director, Doug Sackett’s, past CSTE blog post.

People in the United States make more than 300 million trips to pools and other bodies of water every year, but 1 in 8 pools are closed upon routine inspection for health hazards. Use the MAHC to help reduce risk and keep swimming fun and healthy in your state.
Michael Beach, PhD and Commander Jasen Kunz, MPH, REHS co-lead CDC’s Model Aquatic Health Code program. Visit www.cdc.gov/mahc for more information.

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Assessing Accessibility of Cooling Centers to Vulnerable Populations in New York State

Posted By Seema Nayak, Friday, September 2, 2016
Updated: Wednesday, August 3, 2016

The New York State Department of Health (NYSDOH) works with local health departments and county emergency preparedness management staff to track cooling center locations where people can go to cool down during periods of extreme heat (https://www.health.ny.gov/environmental/weather/cooling/index.htm). NYSDOH staff also map cooling center locations to determine their adequacy and accessibility across New York State (excluding New York City).

While cooling centers are located throughout the state, accessibility to these facilities is important. To be accessible to people without their own means of transportation, cooling centers should be within walking distance (defined as half a mile in this project) or be accessible via public transportation. This may not be a concern in urban areas, but in the smaller towns and rural areas, access to these facilities by public transportation may be limited.

We assessed the accessibility of cooling centers by calculating their proximity to general and vulnerable populations and proximity to public transportation stops (bus/ferry/train). Vulnerable populations were identified from a heat-vulnerability index previously developed by the NYSDOH using 2010 US Census Bureau and 2011 National Land Cover Data. The index helped us identify 984 census tracts as moderately to highly vulnerable to heat. We used population-weighted centroids to calculate distance from general and vulnerable populations. We defined accessibility via public transportation by distance of less than 0.5 miles between cooling center and nearest public transportation stop in five metropolitan areas of New York State.

We found that, although the majority of cooling centers were primarily located in urban areas, less than 10% of the New York State general population, and only about one-fourth of the population in vulnerable census tracts, were within walking distance of a cooling center (Figure 1). However, accessibility improved greatly due to public transportation, with over 80% of the cooling centers located within one half mile of a public transportation stop (Figure 2).

Over the past three years there has been an increase in the number of counties with cooling centers as well as an increase in the total number of cooling centers overall. The Health Department plans to perform periodic assessments of cooling centers to help local agencies allocate adaptation resources, especially in areas identified as vulnerable.

Figure 1. Distance between census tracts and closest cooling center. Click on the picture to zoom.


Figure 2. Vulnerable tracts, cooling centers and transportation stops in the metropolitan areas. Click on the picture to zoom.

Seema Nayak, MPH (in picture), and Syni-An Hwang MS, PhD are Research Scientists at the New York State Department of Health; Shao Lin is a professor in the Department of Environmental Health Science at SUNY Albany and Zev Ross is a spatial analyst at ZevRoss Spatial Analysis, Ithaca NY and consultant for the project.

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A Tale of Two Assessments – How Are Virginia Hospitals Meeting the Core Elements of Antibiotic Stewardship?

Posted By Mefruz Haque and Andrea Alvarez, Friday, August 26, 2016
Updated: Friday, August 26, 2016

The emergence of antibiotic-resistant organisms has elevated antibiotic use and misuse to a national topic of conversation. In early 2015, the National Action Plan to Combat Antibiotic Resistant Bacteria was released, making antibiotic stewardship a federal priority. One goal of this plan was to have antibiotic stewardship programs (ASPs) in 100% of the nation’s hospitals by 2020. The Centers for Disease Control and Prevention (CDC) has published best practice guidelines that outline seven core elements of hospital ASPs. To evaluate hospital capacity, the CDC developed a Core Elements survey instrument, components of which are included in the National Healthcare Safety Network (NHSN) Annual Hospital Survey.

Aligning with national efforts, Virginia (VA) and Maryland (MD) formed the VA/MD Antibiotic Stewardship Affinity Group, comprised of stakeholders from public health, pharmacy, infection prevention (IP), quality improvement and clinical communities. Its first task was to characterize the current state of state antibiotic stewardship efforts according to the CDC Core Elements. In October 2015, an assessment tool developed by the Affinity Group (the VA/MD Antibiotic Stewardship Baseline Assessment) was sent to pharmacy and IP contacts at 132 acute care, critical access, and children’s hospitals in both states. Eighty-five hospitals (33 in MD, 52 in VA) responded to the assessment (response rate = 64%).

A comparative analysis was conducted among Virginia hospital respondents that evaluated differences in results between the VA/MD Baseline Assessment and the 2014 NHSN Annual Hospital Survey. Responses were matched by Virginia hospital and survey question; chi-square tests were used to determine statistical significance of percentages.

Respondents of the VA/MD Baseline Assessment reported meeting core elements more frequently. Comparisons of the two assessments yielded significant differences in specific survey questions. Hospitals responding to the VA/MD Assessment reported lower frequencies of having a formal written statement of leadership report, using an antibiotic time out, and sharing an annual antibiogram.

After matching results by hospital and specific survey question, similar percentages were observed in general. However, significant differences were seen for leadership support and education.

For the VA/MD Assessment, the total number of hospitals meeting all seven CDC core elements was stratified across key hospital characteristics: region, medical school affiliation, and hospital size. Results showed that the Northern health region had the highest percentage (71.4%) of hospitals that had ASPs.

This analysis identified gaps in Virginia hospital ASPs, particularly with respect to leadership support and educating clinicians about optimal prescribing. Differences in response rates and key variables suggest variability in responses between survey types, even among the same Virginia hospitals. Virginia plans to use the results from the assessments to develop targeted educational programs and resources to strengthen existing ASPs as well as support new ones.

Mefruz Haque, MPH, CPH is CDC/CSTE Applied Epidemiology fellow at Virginia Department of Health and Andrea Alvarez, MPH is healthcare-associated infections program manager at the Virginia Department of Health. For more information about the Applied Epidemiology Fellowship, visit the CSTE AEF webpage.

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Carbon Monoxide Detector Presence among Reproductive-Age Women in South Carolina: A 2011 Behavioral Risk Factor Surveillance System Analysis

Posted By Chelsea Lynes and Harley T. Davis, Friday, August 19, 2016
Updated: Wednesday, August 3, 2016

Carbon monoxide (CO) is a colorless, odorless gas that can be detected by a CO detector in the home. Acute CO poisoning in pregnancy has been associated with increased maternal (18-24%) and fetal (36-67%) mortality [1]. Accidental household exposure to CO is the most frequent cause of poisoning in pregnancy [1]. From 2012-2013, 53.7% of women in South Carolina (SC) reported their pregnancy was unintended (29.0% mistimed; 8.4% unwanted; 16.3% unsure) [2]. Due to the high fetal mortality rate associated with CO exposure and high incidence of unintended pregnancy in SC, we investigated associations between CO detector presence in the residence and demographic characteristics of reproductive aged (18-44 years old) women in SC using data from the Behavioral Risk Factor Surveillance System (BRFSS).

SC BRFSS data were obtained from 2011 (n=12,948). The study sample was restricted to reproductive aged women who were not currently pregnant and who gave a valid response to the question, “Do you have a CO detector in your home?”. The final sample was comprised of 1,160 women. We utilized survey logistic regression procedures in SAS 9.2 [3]. Significance of bivariate associations between demographic characteristics and CO detector presence were evaluated via odds ratios and 95% confidence intervals.

Results are displayed in Figure 1.

Figure 1
Figure 1: Odds ratios and 95% confidence intervals measuring association between
CO detector presence in home and covariates of interest (SC BRFSS 2011)

In conclusion, non-pregnant women of reproductive age with lower odds of having a CO detector in the home: reported lower educational attainment and income level; had never been married; rented their home; were not Non-Hispanic White. We found the same associations in the general population of SC. Family planning was not associated with the presence of CO detectors. Regardless, it may be important to focus educational efforts, i.e. CO sources and detector placement, on reproductive age women in SC due to high incidence of unintended pregnancy. We plan to add the CO detector question to future iterations of SC BRFSS to monitor the prevalence of use of this important safety device in the home.


[1] Friedman P, Guo XM, Stiller RJ, Laifer SA. Carbon monoxide exposure during pregnancy. Obstet Gynecol Surv. 2015 Nov;70(11):705-12.

[2] South Carolina Pregnancy Risk Assessment Monitoring System. 2012-2013 data.

[3] SAS 9.2. SAS Institute, Inc. Cary, NC.


Chelsea Lynes, MSPH and Harley T. Davis, MSPH, PhD are epidemiologists at the South Carolina Department of Health and Environmental Control, Public Health Statistics and Information Services, Division of Surveillance. Join the CSTE Maternal and Child Health Subcommittee to learn more about public health topics regarding pregnancy.

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Consideration of Seasonality in Antimicrobial Use

Posted By Raphaelle H. Beard, Jessica Vakili, Ashley Fell, and Marion A. Kainer, Friday, August 12, 2016
Updated: Wednesday, August 3, 2016

The Tennessee Dept of Health Team
The team from left to right: in the back row are Daniel Muleta, Jarred Gray, Corinne Davis, Gwen Holman, Ashley Fell. In the front row are Rebecca Meyer, Shannon Jones, Vicky Reed, and Katherine Buechel. Absent from the team photo are Michael Cavett, Patricia Lawson, Allison Chan, and Jessica Vakili (who left TDH last fall).

In 2013, the Tennessee Department of Health (TDH) developed a 21-question REDCap survey to gather data on antimicrobial use among acute care hospitals in our Antimicrobial Stewardship Collaborative. Data collection began in January 2014 and has been ongoing since. We send report packets to participating hospitals quarterly, with summary tables and graphs comparing facilities to themselves over time and how the collaborative is doing that quarter. As of May 2016, only four hospitals in TN submit antimicrobial use (AU) data to the National Healthcare Safety Network (NHSN) AU Module. While TDH is strongly encouraging participation in the NHSN AU module, we are using this survey as an interim method to assess current prescribing habits and trends and encourage antimicrobial stewardship.

Our simple point prevalence survey captures patient census data and the number of patients with an active order for (not administration of) specific classes of antibiotics during a 24 hour period. The initial query set up usually takes about 30min. Once set up, it only takes 5-10min to run the query and no more than 10min to enter the data into the survey. Clinical pharmacists usually enter the data into REDCap and submit it to us. Ten quarters of data have been collected since survey implementation. We perform descriptive analysis quarterly, using SAS 9.4 and Excel 2010.

Each quarter, between 9 and 18 hospitals submit data. One hospital consistently submits data daily, while the majority submit quarterly. Some facilities have made big strides in antimicrobial stewardship. These efforts are reflected in their results. We have also observed a seasonal increase in AU during the winter quarters, which correlates with influenza like illness (ILI) levels in the data from the Sentinel Provider Network in TN. Third generation cephalosporins have the most pronounced seasonality.

3rd generation Cephalosporin and ILI weekly data 2014-2015

In examining trends over the first eight quarters, the highest quarters were Q3 and Q4 of 2014, when 61% and 56.5% of patients had orders for any antibiotic. In 2015, this proportion improved and remained below 50%. Quinolones continue to have the highest median proportion of antimicrobial orders, hovering at an average of 14.3%.

Any antibiotic by quarter

As an interim measure, this survey has provided useful insights into the trends of AU in Tennessee. There has been an overall decrease in AU among our participating hospitals. Our data suggest that consideration should be given to the seasonality of AU when creating benchmarks like the new Standardized Antibiotic Administration Ratio (SAAR).

Raphaelle Beard    Marion Kainer
Raphaelle Beard and Marion Kainer

Raphaelle H. Beard, MPH is epidemiologist II for Communicable and Environmental Diseases and Emergency Preparedness in the Healthcare Associated Infections Program at the Tennessee Department of Health. To take part in CSTE's ongoing efforts in antimicrobial resistance, join the Healthcare-Associated Infections Subcommittee.

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Public Health Funding on Hold and in the Crossfire

Posted By Emily J. Holubowich , Friday, August 5, 2016
Updated: Thursday, August 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.

The dog days of summer have arrived and lawmakers have left town for the campaign trail, leaving behind a weighty to-do list for the few short weeks between Labor Day and the end of the fiscal year, September 30. Before the summer recess, both the House and Senate Appropriations Committees approved spending legislation for the Department of Health and Human Services and within it, the Centers for Disease Control and Prevention (CDC). At the same time, funding for the Zika virus has hit a political roadblock.

To review, the president sought $7.014 billion for CDC in FY 2017, a 2 percent decrease from current levels that included $5.967 billion in base discretionary funding or “budget authority,” and roughly $1 billion in mandatory funds from the Affordable Care Act’s Prevention and Public Health Fund (PPHF). The House Appropriations Committee provides CDC $7.783 billion in budget authority and PPHF, and the Senate provides CDC $7.060 billion in budget authority and PPHF.

The National Center for Emerging and Zoonotic Infectious Diseases (NCEZID) received a $97.6 million increase in the House and a $1 million decrease in the Senate. The wide discrepancy in funding levels between the chambers is based on their different approaches to funding the Zika response; the House preferring to provide at least some funding through the regular appropriations process, and the Senate preferring to provide supplemental funding (more on that below!). Within NCEZID, both the House and Senate continue funding for the Combating Antibiotic-Resistant Bacteria or “CARB” initiative at $160 million and $163 million, respectively. As with the recent award of $64 million to build CARB capacity in the states, we would expect much of the CARB funding, and NCEZID funding overall, to support disease surveillance capacity at state and local health departments through Epidemiology and Laboratory Capacity (ELC) grants, in addition to $40 million from the mandatory PPHF that the House and Senate both propose for the sixth consecutive year.

A summary table of funding levels for CDC and all program lines proposed by the administration, the House Appropriations Committee, and the Senate Appropriations Committee is available here:  https://www.cste2.org/docs/2017_House_and_Senate_Mark_Detail_Table.pdf.


Meanwhile, the debate about the Zika virus response is hot. There was hope cooler heads would prevail during the lawmakers’ summer break, but it’s only getting hotter as we get closer to the election and more domestic cases emerge. To review, the President requested $1.9 billion in supplemental, emergency funding in February. The House and Senate both passed legislation to fund the response—$1.1 billion with no strings attached in the Senate, and about half of that funding in the House with offsets and conditions unappealing to Democrats. Lawmakers convened a conference to negotiate a final package and were making progress; that is until House Democrats staged a sit-in to force a vote on gun violence legislation (which has yet to happen). In what some have called a retaliatory move, the House Republicans walked away from the Zika negotiations and passed a partisan $1.1 billion package in the late evening of the Democrats’ protest. The Senate has since tried twice to move the House package but has failed as Democrats object to politically toxic provisions that would negatively impact women’s access to family planning and roll back environmental regulations of pesticides. Senate Majority Leader Mitch McConnell is expected to call up the House bill for another vote the week of Labor Day when lawmakers return. Though some members of Congress—including Senate Minority Leader Harry Reid and Florida Senators Bill Nelson and Marco Rubio—are urging colleagues to return from recess to act now.

While Congress dawdled, the administration was forced to redirect toward the Zika efforts nearly $600 million previously allocated to fight Ebola—under the assumption that this funding will eventually be made whole by Congress—as well as $44 million from public health emergency preparedness grants intended for use by the states (indeed, the House in its appropriations bill does provide $45 million to make “PHEP” whole in FY 2017). Unfortunately, the administration now reports half of that funding has already been used. Secretary of Health and Human Services Sylvia Burwell yesterday sent this letter to Congress, summarizing the response and expenditures to date, and providing examples of activities that “demonstrate the urgent need” for additional funding soon.


So what now? Political and fiscal dynamics make it unlikely that either chamber’s public health spending bill will see floor time. With just four working weeks remaining before the September 30 fiscal year’s end—and the recess for the November elections—the best-case scenario is a short-term continuing resolution to keep the government running. Worst-case scenario: a six-month continuing resolution that kicks the can until March. And in the end, all Congress may be able to accomplish is a year-long continuing resolution at current levels if passing final spending legislation proves too hard in the lame-duck scramble. It wouldn’t be the first time; Congress has passed year-long continuing resolutions in the last two presidential election cycles.


As for Zika, it’s anyone’s guess how they will proceed or when the stalemate will break. If confirmed cases continue to multiply and/or extend beyond Miami, lawmakers may feel a renewed sense of urgency to put politics aside and act. In the meantime, expect to see lots of finger pointing on the airwaves and the Op Ed pages (e.g., this, by House Speaker Paul Ryan in USA Today).

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Youth Violence in Cleveland, Ohio, by Neighborhood and Political Ward, 2013

Posted By Vinothini Sundaram, Friday, July 29, 2016
Updated: Thursday, July 14, 2016

 Vinothini Sundaram's poster at the Annual Conference


Communities across the country are being heavily impacted by rising levels of violence, particularly among youth and young adults. In recent years, local health departments have been playing a larger role in addressing violence using the public health model. Recently, in Cleveland, Ohio, the Cleveland Department of Public Health took a closer look at youth violence data at a more granular level, by neighborhood and political ward. Epidemiologist Vinothini Sundaram, MPH presented the results in a poster presentation for the 2016 Council of State and Territorial Epidemiologists Annual Conference in Anchorage, Alaska. The poster was selected as a Poster Award Finalist in the Environmental Health / Occupational Health / Injury Steering Committee.

The neighborhood of Goodrich-Kirtland had the highest rates of the following youth violence indicators: delinquency offenses (555.96), violent offenses (280.1), assaults (118.83), domestic violence (106.1), and sexual assaults (16.98). The St. Clair-Superior neighborhood had the highest rate of weapon law violations (12.07). The Goodrich-Kirtland and St. Clair-Superior neighborhoods are adjacent to each other. Political Ward 7 had the highest rates of the delinquency offenses (158.23), violent offenses (79.4), assaults (31.53), domestic violence assaults (21.4), and sexual assaults (6.19). Political Ward 1 had the highest rate of weapon law violations (4.67). Part of the Goodrich-Kirtland neighborhood is within the political Ward 7. However, the St. Clair-Superior neighborhood and political Ward 1 are located on opposite sides of the city.

Along with examining the violence data, it was important to start examining the state of youth in those neighborhoods most impacted by violence. Two factors of particular interest were poverty and lead poisoning. In the Kirtland-Goodrich Park neighborhood 16.63% of the neighborhood population is age 0-17 (n=644). 519 children between ages 0-17 were living below the poverty line, making the child poverty rate in this neighborhood 80.59. The child poverty rate for the state of Ohio is only 22.9.

In the St. Clair-Superior neighborhood, 25.59% of the neighborhood population is age 0-17 (n=1690). 860 children between ages 0-17 were living below the poverty line, making the child poverty rate in this neighborhood 51.44, higher than the rate for the state.
There is a great deal of research illustrating the link between lead exposure in early childhood and delinquent behavior in adolescence. Lead levels as low as 5 μg/dL have been shown to harm a child’s ability to reason and be successful in school. In November of 2014, the state of Ohio adopted 5 μg/dL as the new threshold for elevated blood lead levels in children. In 2014, there were 303 children under the age of 6 that were tested for lead in Kirtland-Goodrich Park; 12.5% of the tests were greater than or equal to 5 μg/dL. St. Clair-Superior had 256 children under the age of 6 that were tested for lead; 23.4% of the tests were greater than or equal to 5 μg/dL.

The City of Cleveland is a participating agency of the National Forum on Youth Violence and received funding to create a comprehensive plan to address youth violence in Cleveland. The Cleveland Collaborative on Youth Violence Prevention (CCYVP), also known as the Cleveland Plan, has four main goals; one of these goals is to use a public health model to support a data-driven, community-based violence intervention strategy. The findings from this research will be used to support a public health model, and provide guidance on where to prioritize efforts in the city. These findings will also be shared with Healthy Cleveland, an initiative of Mayor Frank Jackson, to address the health and well-being of Cleveland citizens. Through the Healthy Cleveland Initiative, the findings will be further disseminated to the general public and community stakeholders.

Vinothini Sundaram, MPH is epidemiologist in the Office of Communicable Disease Surveillance & Epidemiology at the Cleveland Department of Public Health. For more information on related issues, please join subcommittees under the Environmental Health / Occupational Health / Injury Steering Committee.

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