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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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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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A Decade after CSTE’s Call to Action, a New Voluntary Model Health Code Launches

Posted By Douglas Sackett, Friday, October 24, 2014


What began with strong surveillance and epidemiologic data supporting a CSTE position statement has spurred a national, multidisciplinary model pool code development process, a multi-thousand-person public dialogue, and the creation of a new non-profit organization to ensure the model code remains up to date. Learn how you can improve health and safety at public pools while saving staff time and resources by adopting this exciting, new model health code in your state or local health department.
In 2004, CSTE issued a position statement, citing the increasing trend in reporting of waterborne outbreaks at swimming pools across the country. It called for Centers for Disease Control and Prevention (CDC) to lead a national workshop to develop a unified strategy to reduce future occurrence of waterborne outbreaks at public swimming venues. The following year, over 100 individuals from public health, academia, and the aquatics industry met to develop this strategy; the major recommendation was an open-access, national model code that would help local and state agencies incorporate science-based practices without having to reinvent the wheel each time they create or revise pool codes.

What our subsequent efforts produced became the Model Aquatic Health Code (MAHC), 1st Edition, released by CDC in August 2014. The scope of the MAHC reflects its multidisciplinary approach. We expanded the prevention guidance beyond just infectious disease prevention to make the MAHC an all-inclusive guidance document covering prevention of infectious diseases, drowning, and injuries through a data and best practices-driven approach to design and construction, operation and maintenance as well as policies and management.

The steering committee set to work in 2007 with a development working plan followed by the recruitment of technical committee volunteers. As an all-volunteer effort, we took time to discuss and incorporate the multifaceted perspectives and evidence from both public health and industry participants. We opened the MAHC to two rounds of public comment. After receiving more than 4400 comments, we incorporated 72 percent of comments—over 3,000 citizen suggestions made a substantive impact. The depth, quality, and practicability of the MAHC stem from our recognition of the importance of partnerships, data-driven change, incorporation of input from all sides of aquatics, and implementable changes.

The culmination of our efforts, the MAHC 1st Edition, is now available to assist health departments in working on their pool codes through voluntary adoption. In targeting aquatic design, operation, and management, the code reflects modern epidemiological practice. The code's foundation is built on strong surveillance and investigation data from key national surveillance systems, such as National Electronic Injury Surveillance System, the National Outbreak Reporting System, and the Waterborne Disease and Outbreak Surveillance System. The annex that accompanies the MAHC lays out the rationale for code-specific requirements with scientific data and references to explain the why behind the what. The MAHC also recommends decision making informed by incorporating routine pool inspections as surveillance data.

 

Finally, CDC is setting up sentinel surveillance to track the impact of key MAHC elements on aquatic venue operation. We will have the opportunity to analyze these data, evaluate the model code's impact, and update the code based on findings. This will occur every two years as part of a meeting convened by the new non-profit organization, the Conference for the Model Aquatic Health Code, which is tasked with collecting national input and advising CDC on necessary updates.

 

If you work with or for a state or local health department, please consider taking the next step for improving health and safety at aquatic facilities: familiarize yourself with the Model Aquatic Health Code.

 

Your community can benefit from the MAHC's guidance for the prevention of chlorine-tolerant diseases such as cryptosporidiosis, improved training requirements, enhanced design features to reduce chemical injuries, and improved drowning and injury prevention. As the MAHC is fresh out of the box, you can also get involved with our conference to help drive future improvements. What CSTE members precipitated 10 years ago, based on sound epidemiologic practice and strong surveillance data, has now come to fruition.

We need CSTE to take a fresh look at the data and the MAHC and renew its commitment to health and safety improvement. CSTE members can bring the best of epidemiology to bear by raising awareness about the MAHC, driving discussion about potential adoption, and participating in future MAHC update discussions. With this renewed commitment, CSTE can continue drive data-based improvements in public health and safety at our nation's aquatic facilities.

Douglas Sackett is Executive Director for the Conference for the Model Aquatic Health Code. To learn more, look at CDC's easy-to-read infographic, outlining the problem, process, and product.


Are you a member with an important message to tell the CSTE community? Tell us about it!
Do you use social media? Stay tuned to CSTE on Facebook and Twitter for daily updates!

Tags:  acquatics  cryptosporidiosis  epidemiology  health code  MAHC  occupational health  pool  rwi  waterborne diseases 

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Epidemiology methods – Our common link

Posted By Matt Thomas, Thursday, July 24, 2014
Untitled Document
As an epidemiologist for the tobacco program and formerly with the healthcare associated infections program at the Vermont Department of Health, I’ve been exposed to several different types of public health practice within applied epidemiology. Every program area has one thing in common—each relies on the same epidemiology and surveillance concepts and methods. These methods provide a foundation that ties all of our work together.

I’m finding in my career that epidemiologist are often in situations in which they may not have enough time or resources to fully utilize their training in epidemiology methods. This might be due to the pressures to quickly provide the public and partners with data or the need to have epidemiologist play a role in a variety of other functions (e.g., disease control, program evaluation, performance measurement, or informatics). The epidemiologist may have a supporting role in all of these activities, but that role shouldn’t be at the expense of the practice of epidemiology methods. While providing data to the public and partners is an essential function of an applied epidemiologist, that data is produced as a result of epidemiology and statistical methods. Placing a priority on that final product without prioritizing methods can lead to less reliable data. The Epidemiology Methods Subcommittee was formed to address these issues.
The Epidemiology Methods Subcommittee gives us the opportunity to highlight why epidemiological methods are integral to public health. The subcommittee focuses on both providing methodological content and building capacity to better allow epidemiologists to practice their skills.
So far, this new subcommittee has begun a series of webinars, each of which focuses on a different topic pertinent to applied epidemiologists. These webinars allow us to listen to our colleagues talk about epidemiology methods in-depth so we can use them in our day-to-day work. For example, one webinar looked at analyzing public health data using census tract-level poverty. Another discussed data analysis in small jurisdictions. Continuing to learn new methods and improve our skills allows us to enhance public health.
Going forward the subcommittee will take on projects related to improving how health departments function as a system in addition to professional development about epidemiology methods. In many settings, improving the organizational setting may be a necessary step that allows epidemiologists to practice the novel methods they learn from the webinars.
I have often heard from leaders in epidemiology that we need to advocate for our role in the public health landscape, especially in an ever-tightening funding climate. The Epidemiology Methods Subcommittee can be a forum for us to improve our skills, promote the value of these skills to our partners, and advocate for the ability to use these methods to their fullest.
I’d like to see this cross-disciplinary group of epidemiologists continue to come together to learn about new topics and ways to promote and advocate for their value. We’re still in our formative stage as a subcommittee, and we could use your participation to shape it into what you want it to be. What do you want help with? What issues are you dealing with in your health department? What have you found success in that you can share?
Matt Thomas, PhD is an epidemiologist at the Vermont Department of Health and the chair of the Epidemiology Methods Subcommittee.

Tags:  epidemiology  member spotlight  professional development 

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