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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

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:

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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Announcing the #CSTE2016 Plenary Speakers and Mann Memorial Lecturer

Posted By CSTE, Friday, April 15, 2016
Updated: Friday, April 15, 2016
CSTE is pleased to announce an exciting lineup of speakers at this year’s conference in Anchorage, Alaska with diverse professional backgrounds and insightful presentations to share. Each speaker will shed light on applied public health epidemiology, year’s conference theme “Exploring New Frontiers.”

Camara Phyllis Jones – Jonathan M. Mann Memorial Lecture

Camara Phyllis Jones, MD, MPH, PhD is President of the American Public Health Association, and a Senior Fellow at the Satcher Health Leadership Institute and the Cardiovascular Research Institute, Morehouse School of Medicine. Dr. Jones is a family physician and epidemiologist whose work focuses on the impacts of racism on the health and well-being of the nation. She seeks to broaden the national health debate to include not only universal access to high quality health care, but also attention to the social determinants of health (including poverty) and the social determinants of equity (including racism). (read more)

Robin Bronen

Robin Bronen works as a human rights attorney and has been researching the climate-induced relocation of Alaska Native communities since 2007. Her research has been publicized by CNN and the Guardian among others. She has worked with the White House Council on Environmental Quality to implement President Obama’s Climate Change Task Force recommendation to address climate displacement as well as the UN High Commissioner for Refugees Climate Change Office. (read more)

Valerie “Nurr’araaluk” Davidson

Valerie “Nurr’araaluk” Davidson was appointed by Governor Bill Walker as Commissioner of the Alaska Department of Health & Social Services in December 2014. Prior to leading the department, she worked for over 15 years as a national policy maker on matters affecting Alaska Native and Indian health. Ms. Davidson currently serves on the U.S. Department of Justice Advisory Committee on American Indian and Alaska Native Children Exposed to Violence and as a Trustee of the First Alaskans Institute. (read more)

Susan Huang

Susan Huang, MD MPH is a Professor of Medicine in the Division of Infectious Diseases and Health Policy Research Institute at the University of California Irvine School of Medicine, and the Medical Director of Epidemiology and Infection Prevention at UC Irvine Health. She received her MD degree from the Johns Hopkins University School of Medicine and her MPH degree from the Harvard School of Public Health in Quantitative Methods. She completed her residency at the University of California San Francisco and her ID fellowship at the combined Harvard program at Brigham & Women’s Hospital and Massachusetts General Hospital. (read more)

Michael Landen

Michael Landen is the State Epidemiologist with the New Mexico Department of Health. His principal areas of professional interest include tribal epidemiology, substance abuse epidemiology, and injury prevention. Michael Landen has worked as a family physician and clinical director for the Indian Health Service in Arizona and New Mexico, and as a volunteer physician in Belize. In 1995 he began work as an Epidemic Intelligence Service officer assigned to the Alaska Department of Health and Social Services. He has been with the New Mexico Department of Health since 1997. He served as a CSTE Executive Board member from 2007-2010.

Stephen Ostroff

Dr. Stephen Ostroff, M.D., has been FDA’s Acting Commissioner since April 2015. Previously, he was FDA’s Chief Scientist, where he was responsible for leading and coordinating FDA’s cross-cutting scientific and public health efforts. The Office of the Chief Scientist works closely with FDA’s product centers, providing strategic leadership and support for FDA’s regulatory science and innovation initiatives. Dr. Ostroff joined FDA in 2013 as Chief Medical Officer in the Center for Food Safety and Applied Nutrition and Senior Public Health Advisor to FDA’s Office of Foods and Veterinary Medicine. (read more)

Pam Pontones

Pam Pontones, State Epidemiologist, has served at the Indiana State Department of Health for 25 years. She began her career as a microbiologist in 1990 and transitioned to epidemiology in 1999, serving as the Enteric Epidemiologist, Field Epidemiology Director, and Director of Surveillance and Investigation. During this time, she led investigations of many infectious disease outbreaks and served a key role in the 2009 influenza pandemic response. (read more)
To learn more, visit Remember to register by April 29 to take advantage of the Early Bird discount.

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Community Health Assessment Data Visualized

Posted By Lois Haggard, Friday, April 8, 2016
Updated: Thursday, March 31, 2016

The New Mexico Department of Health has made significant improvements to its Indicator-based Information System for Public Health (NM-IBIS,, a web-based population health assessment and data query tool. New Mexico is one of about a dozen public health organizations, known as the IBIS-PH Community of Practice (, currently using the software and contributing to its development.

The IBIS-PH website content is maintained by public health program staff (subject-matter experts) across the department. Distributing the workload not only makes it feasible to keep the content up to date, but it ensures that the content reflects the public health communication objectives for a given topic.

The latest version of IBIS-PH features significant improvements in data discovery and visualization. Data discovery includes navigation by health topic.

The new data visualization features include interactive graphics (tables that sort and user-specified graph types) as well as dynamic maps for both our indicator reports ( and custom data queries (

One of the features that is popular with community groups is the “Community Snapshot Report” ( That report allows New Mexico communities to see at a glance how they compare to the state overall and the U.S.

NM-IBIS is used by community members, epidemiologists, educators, researchers, legislators, non-profits, and many other groups to access data and information on a broad range of New Mexico’s priority health issues. Use of the system has steadily grown since the release of the latest version in March of 2015. Currently the system is seeing about 1,000 unique users each week. That is 1,000 different people finding New Mexico data and information for public health assessment and other purposes. A recent increase in use during the state’s 2016 one-month legislative session was very encouraging.

“NM-IBIS has changed the way we share health data in New Mexico,” says New Mexico State Epidemiologist Michael Landen. “Disseminating data through IBIS not only maintains the security of the data, but using IBIS, we can provide data with a public health message at the same time.”

Most NM-IBIS users live within the state’s borders, but since it’s a public website, NM-IBIS regularly sees users from other states, and places as far-flung as Australia, Sweden and Spain.

States interested in adopting the IBIS-PH software can visit the IBIS-PH Community of Practice “Adopt IBIS” ( page.

Lois M. Haggard, PhD is community epidemiologist and program manager of the Community Health Assessment Program at the New Mexico Department of Health. To learn more about surveillance, consider joining and participating in subcommittees in the CSTE Surveillance/Informatics Steering Committee.

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Council District Reports: A Project Manager’s Perspective

Posted By Anna Oberste, Friday, April 1, 2016
Updated: Thursday, March 31, 2016

Managing the development and dissemination of 11 City Council District health reports was my first SHINE fellow assignment at Denver Public Health (DPH). Reports first created in 2011 brought community health assessment findings to the individual council districts. Being well received and promoting dialogue with policy makers, the same process was repeated with 2014 community health assessment findings. These 2015 council district reports focused on three main themes: the importance of place, prevention, and health equity.

Spanning nine months (July 2015-March 2016), the report creation process involved three phases: definition and planning, data analysis and information development, and dissemination and assessment. Each phase involved meetings with content experts, data presentation and design experts, and work group approval.

First steps included charter creation to establish stakeholder roles and expectations. To track the project, weekly and monthly status reports and timeline updates were created to facilitate problem solving at various project stages. Data analysis sources included: Medicaid enrollment, electronic health records, and calculated BMI screening. Four high-priority health topics were analyzed: access to healthcare, childhood obesity, tobacco use among young adults, and adult depression prevalence. Once analytic approaches and content were approved, we created a dissemination plan.

Eleven district reports were disseminated to council district members and the public. In addition, a website was created, containing links to information and suggesting programs to assist with addressing these health concerns. Each council district member has a meeting arranged with the director of Denver Public Health to discuss health concerns in the report and to identify opportunities to take action.

Denver Public Health believes local health data can inspire action. Community health assessments, health impact assessments, and geographically targeted reports used to engage community partners, healthcare providers, and policy makers permit collaborative health improvement efforts.
Lessons Learned
By clearly defining roles and responsibilities, we increased the efficiency of the collaborative processes. Communication has been key and different communication modes work better for different people. Timelines need to be flexible to adjust to obstacles and competing demands by subject matter experts and analytic and design staff. Learning to adjust schedules and anticipate delays helped me manage my own, and others’ expectations, creating a more relaxed environment. Using project management tools permitted me to stay organized and identify problems earlier. The DPH team’s comments and recommendations helped provide valuable insight which positively impacted the project to completion.
Anna Oberste PharmD, MPH, BCNSP is a Health System Integration Program (HSIP) fellow at Denver Public Health. To learn more about mentoring an HSIP fellow or applying to be one, visit Participate in CSTE’s Public Health Law Subcommittee to engage in related national activities.

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The Contribution of Local Public Health to Heroin Surveillance in Orange County, Florida

Posted By Ben Klekamp, Toni Hudson, and Sarah Matthews, Friday, March 25, 2016
Updated: Tuesday, March 22, 2016

From left to right, Sarah Matthews, Ben Klekamp, and Toni Hudson


To better inform community decisions in the fight against heroin addiction, the Florida Department of Health in Orange County used multiple data sources to conducted heroin-related morbidity and mortality surveillance from 2010 to present.

Data from the Orange County Medical Examiner’s Office and Florida Department of Health was used to conduct a descriptive analysis on Orange County deaths where heroin was listed as the cause of death or heroin was in the blood stream at the time of death (Figure 1). To identify areas for potential interventions, addresses where heroin-related deaths occurred were analyzed using spatial cluster analysis (i.e., kernel density) in ArcGIS (Figure 2).


Figure 1. Epidemic Curve of Heroin-related Deaths in Orange County, Florida 2010-2014.


Figure 2. Cluster Analysis of Heroin-related Deaths in Orange County, Florida 2010-2014.

Two data sources were used in heroin-related morbidity surveillance. The Florida Agency for Health Care Administration (ACHA) is the regulatory authority for Florida’s health facilities, which includes capturing health data from these facilities. AHCA data was queried utilizing heroin specific international classification of disease (ICD) codes in Orange County hospitals. This analysis provided information on the heroin-related hospital burden including hospital specific information, insurance status, and demographic information of identified patients. Zip Codes of patients utilizing hospitals for heroin-related healthcare needs were mapped to better understand the geographic burden of heroin morbidity in Orange County (Figure 3).

Figure 3. Agency for Health Care Administration Data: Rate and Frequency of Heroin-related Morbidity by Zip Code, Orange County, Florida 2010-2014.

Due to the delay in data availability in both the Medical Examiner and AHCA datasets, the Department’s syndromic surveillance system ESSENCE-FL (Electronic Surveillance System for the Early Notification of Community-Based Epidemics) was utilized to understand current demographic and geographic trends related to heroin morbidity (Figure 4). ESSENCE-FL is the Florida Department in Health’s syndromic surveillance system and captures data on hospital emergency department visits, poison control consultations, Merlin reportable diseases, and vital statistics death records. All hospital emergency departments in Orange County send daily updates to ESSENCE-FL on chief complaints and discharge diagnoses. A query for heroin (and common misspellings) was developed and compared to the AHCA data to understand if the developed ESSENCE-FL data query was comparable to the AHCA data.

Figure 4. ESSENCE-FL Data: Rate and Frequency of Heroin-related Morbidity by Zip Code, Orange County, Florida 2010-2014.

Overlay of the three data sources used in this surveillance highlights the data trend agreement between data sources and relative timeliness of data availability of each source (Figure 5). While ESSENCE-FL data may misclassify and overestimate the true burden of heroin-related morbidity in a community compared to the AHCA data trends, the rapid availability of the data may prove useful in understanding a population health problem until more accurate datasets (e.g., medical examiner) become available for analysis.

Figure 5. Heroin-related Morbidity and Mortality, Orange County Florida 2010-2016

The Department presented the surveillance findings to the public and community leaders as part of the Orange County Mayor’s Heroin Taskforce on February 29, 2016. The full presentation and an Orange County Heroin factsheet, in addition to other Orange County authored publications, can be viewed on the Epidemiology Program Publications webpage. The Epidemiology Program will continue to support and track the health related outcomes of community efforts to combat the heroin epidemic through ongoing surveillance.

Questions and comments on the Florida Department of Health in Orange County Epidemiology Program heroin-related morbidity and mortality surveillance can be directed to Ben Klekamp at or Toni Hudson at

Ben Klekamp, MSPH, CPH, is an epidemiologist and Project SHINE I-TIPP fellow, Toni Hudson, MSPH, CIC, is an epidemiologist, and Sarah Matthews, MPH, is the epidemiology program manager for the Florida Department of Health in Orange County. To learn more about substance abuse surveillance, visit the Substance Abuse Subcommittee. Informatics-Training in Place Program (I-TIPP) fellowships enable current health department staff to develop capacity in their roles—learn more and apply by April 1, 2016 at


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Hawaii Raises Legal Smoking Age to 21

Posted By Lola Irvin, Friday, March 18, 2016
Updated: Thursday, March 17, 2016

On January 1, 2016, Hawaii became the first state in the nation to raise the smoking age of tobacco sales and purchases from 18 to 21. The law prohibits the sale, purchase, possession, and consumption of cigarettes, other tobacco products and electronic smoking devices to anyone under the age of 21.

Although 125 cities and counties have similar laws, Hawaii is the first to raise the age limit statewide. Hawaii Governor David Ige proclaimed, “Raising the minimum age as part of our comprehensive tobacco control efforts will help reduce tobacco use among our youth and increase the likelihood that our keiki [children] will grow up tobacco-free.”

Nationally, 95% of adults who smoke began smoking before reaching the age of 21. Similarly, in Hawaii, 86% of current adult smokers started before age 21. About 10% of Hawaii high school youth, and 7% of young adults aged 18 to 20 years currently smoke cigarettes. However, tobacco use is not limited to cigarettes alone. In Hawaii, e-cigarette use has increased six-fold among middle school students from approximately 2% in 2011 to 12% in 2015, and more than quadrupled among high school students during the same time period from about 5% to 22%; 20% of 18-20 year olds used e-cigarettes in 2014.

The timely March 2015 report by the Institute of Medicine (IOM) concluded that raising the tobacco sale age would yield substantial public health benefits. The increase to age 21 would significantly delay the age when young people first experiment or begin using tobacco, reduce the risk that they will transition to regular tobacco use, and increase their chances of quitting if they become regular users.

The Centers for Disease Control and Prevention (CDC) concurred, since numerous studies show that nicotine exposure during adolescence can negatively impact brain development, cause serious addiction, and lead to persistent tobacco use.

In Hawaii, there was widespread support for this landmark legislation from the public health sector, as well as from educators, youth advocates, legislators, public safety representatives, law enforcement, and many community groups that are concerned about the health of Hawaii’s youth.

Raising the smoking age to 21 had the full support of the armed forces in Hawaii. All military branches in the state have directed retail outlets that are located on military properties to stop selling tobacco products, including smokeless tobacco and electronic smoking devices, to anyone under age 21. All military personnel and dependents, as well as other family members, guests and base residents, have been notified to comply with the new law on military bases throughout the state.

Click here to see the print advertisements to announce the
Hawaii Age 21 and the E-cigs in Clean Air laws

The passage of the age-to-21 law was a critical step to promote progress in the fight against tobacco and for Hawaii’s next generation to live tobacco-free.

Lola H. Irvin, M.Ed. is administrator for the Chronic Disease Prevention and Health Promotion Division at the Hawaii Department of Health. Join subcommittees in the Chronic Disease / Maternal and Child Health / Oral Health Steering Committee to participate in chronic disease activities at CSTE and visit the Alcohol and Other Drug Indicators Subcommittee to learn more about related surveillance.

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Washington’s Roadmap to Advance Informatics

Posted By Kim Peifer, Travis Kushner, and Bryant Karras, Friday, March 11, 2016
Updated: Thursday, March 10, 2016

“Data” is a word that we hear or use in every aspect of our lives. In public health, we want a lot of it—it represents the puzzle pieces that we try to work into a picture. The Washington State Department of Health (WA DOH) collects data from a wide array of sources—labs, health clinics, schools, hospitals, and national surveys are a few examples.

Let’s consider the clinician at a health clinic as an example. To fulfill their responsibilities in reporting to WA DOH, a single clinician might share data (paper, fax or electronic interface) through 10 different systems (or more!). We are overwhelming our data source(s) with the burden of number of reports and method of reporting.

Figure 1. The number of connections to other practices that the “average primary care physician” coordinates with (1). Figure by Jeff Horsager (University of Washington Capstone Project, Health Informatics and Health Information Management)
Below is a list of systems at WA DOH that each require different data-sharing interfaces (paper, fax, or electronic webpage or automated system). One clinician or health system may need to connect/report to all of these systems, and each must be done separately. The data collected spans the life of the patient. At WA DOH these systems are in four different divisions of the agency.
  • Birth Record
  • Newborn Screening
  • Birth Defects Surveillance
  • Immunization
  • Early Hearing Detection Diagnosis and Intervention
  • Syndromic Surveillance
  • Reportable conditions
    • Communicable (e.g. pertussis)
    • Cancer
    • Blood Lead
  • Death Reporting (EDRS)
  • Trauma Registry
  • Prescription Drug monitoring Program
  • Meaningful Use Registration of Intent
  • Clinician License Renewal

This isn’t just a problem for the party that must establish multiple connections with WA DOH based on the needs of different programs. The maintenance of these systems occupies a huge amount of resources at WA DOH. Currently, the IT team at WA DOH supports 220 systems, 305 applications, and 48 services.

We recognize that this isn’t a sustainable arrangement for our partners or for us, and see a role for public health informatics in generating solutions. The Public Health Informatics Institute (PHII) defines public health informatics as “…the discipline that supports the effective use of information and information technology to improve public health practice and population health outcomes.” We aim to leverage this field to improve scenarios like the one outlined above, and to this end we have generated an Informatics Roadmap.

The Informatics Roadmap is a three-year operational plan to advance public health informatics in the agency, with the broader intention of advancing public health informatics in Washington State.

Development of the Informatics Roadmap began in 2014 with agency-wide qualitative interviews by the WA DOH Informatics Team. We then partnered with PHII as the first real-world user of their tool “Building an Informatics-Savvy Health Department.” The tool was developed by PHII in collaboration with the Minnesota Health Department and the Oregon Public Health Division. The assessment uses the capability maturity model (a registered trademark of Carnegie Mellon University) to assess three core domains:

Figure 2. Components contributing to Informatics capacity (2)

We used the tool to determine the current informatics capability within the agency as well as local health jurisdictions in the state. Nine program areas, representing the six DOH agency divisions and three local health jurisdictions (Whatcom County, Seattle & King County, and Spokane), completed the assessment in teams. In total, the Informatics Roadmap engaged 100 participants.

With the results of the assessment as a foundation, the WA DOH informatics team proposed goals and objectives to advance our capabilities. These were vetted at an in-person meeting with representatives from each group, as well as field leaders/subject experts (Oregon Public Health, Minnesota Health Department, and PHII).

Following the in-person meeting, we refined, vetted, and consulted specific program areas/teams to shape the high-level document into an operational plan (including action items and timelines to achieve each objective). Ultimately, we established these goals to advance the capability of public health informatics in Washington:

Figure 3. Components contributing to Informatics roadmap
Currently, we are working on a method to track the actions that we have outlined in the Informatics Roadmap, and we plan to meet on a quarterly basis with our state health officer to assess progress in the active items of the current quarter. The effort to synergize agency efforts and actively advance public health informatics in Washington will be challenging, but we look forward to reporting back on our progress!
Figure 4. The Informatics Roadmap team: Kim Peifer, Bryant Karras, and Travis Kushner
  1. Primary Care Phisicians' Links to Other Physicians Through Medicare Patients: The Scope of Care Coordination. Hoangmai H. Pham, MD, MPH, et al., et al. 4, 2009, Annals of Internal Medicine, Vol. 150, pp. 236-242.
  2. Public Health Informatics Institute. Informatics Savvy Health Department Resources. Public Health Informatics Institute. [Online]
Kim Peifer, MPH is Applied Public Health Informatics (APHIF) fellow, Travis Kushner, MPA is Public Health Data Exchange program coordinator, and Bryant Karras, MD is chief informatics officer in the Washington State Department of Health. For more information about surveillance and informatics, join the CSTE Surveillance/Informatics Steering Committee. To learn how to become a fellow in the APHIF program, visit the Project SHINE webpage.

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Advocating for CSTE Member Needs in Washington, D.C.

Posted By Joe McLaughlin, MD, MPH, Friday, March 4, 2016
Updated: Thursday, March 3, 2016

Advocating for the needs of the applied epidemiology workforce nationally is a fundamental component of CSTE’s mission. For this reason, Executive Board representatives visit our nation’s capital each year to meet with federal decision makers and partner organizations. This year, participants included: Vice President Al DeMaria of Massachusetts, President-Elect Megan Davies of North Carolina, Secretary-Treasurer Sarah Park of Hawaii, Surveillance/Informatics Member-at-Large Kathryn Turner of Idaho, and President Joe McLaughlin of Alaska. Accompanied by Executive Director Jeff Engel and guided by Washington Representative Emily Holubowich, CSTE convened and attended nine meetings.

During our visit, CSTE representatives met with CDC’s Washington, D.C. office, the Office of the National Coordinator for Health Information Technology, the Veterans Health Administration, the Office of Management and Budget, the office of Congressman Mike Simpson of Idaho, the Pew Charitable Trusts, and the de Beaumont Foundation.

Our meetings this year coincided with both the release of President Obama’s budget proposal for Fiscal Year 2017 and a House Foreign Affairs Subcommittee hearing on the Zika virus outbreak. The president’s proposed FY 2017 budget, which will inform the official budget to be passed by Congress, sees a $194 million-dollar decrease in CDC funding from FY 2016. At a CDC Coalition meeting at APHA, CDC Director Tom Frieden underscored how the many thousands of lives saved through public health programs often go unacknowledged without the continued advocacy of national partners. Dr. Frieden addressed the implications of the administration’s proposal, including increased funding for antibiotic resistance, prescription drug overdose, and gun violence prevention research. Dr. Frieden also emphasized the following FY 2017 funding priorities: antimicrobial resistance, Good Health and Wellness in Indian Country, and prescription drug overdose prevention.

At the Zika virus House hearing, Dr. Frieden emphasized the urgent need for $828 million to strengthen national systems for Zika virus prevention and response. If awarded, a portion of this funding would support vectorborne infrastructure at state, territorial, and local health departments. CSTE has endorsed the president’s request for $1.9 billion in emergency funding for the Zika virus response. Click here to read the requests for the House of Representatives and the Senate.

State Epidemiologist of Alaska Joe McLaughlin, MD, MPH is the president of CSTE. To learn more about CSTE’s advocacy activities, visit the CSTE website and

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