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Antibiotic Use/Resistance Surveillance through the National Health Care Safety Network: The Key to Data-Driven Interventions

Posted By Erica Washington, MPH, CPH, CIC, CPHQ, Friday, February 17, 2017
Updated: Wednesday, February 15, 2017

When considering the state of antibiotic resistance proliferation in today's health care landscape, the words “The Bugs are Fighting Back!” may come to mind. While this may sound like a D-list ‘80s movie, it succinctly summarizes the rapid pace of antibiotic resistance evolution, and the urgent need for stewardship in prescribing and surveillance practices. Antibiotics are ubiquitous in today's society: they are in foods, prescribed as medicine and at one point were even widely used in soaps. Each of these factors spurned the growth of resistant organisms for which antibiotics have reduced efficacy. Some consequences of antibiotic-resistant infections are longer and more complicated illnesses, increased doctor visits and increased mortality. In light of the vast problem of existing and emerging resistance, I chose to address surveillance of antibiotic prescribing practices and antibiotic threats as my project for my Informatics-Training in Place Program (I-TIPP) fellowship.

I join a myriad of stakeholders who have focused their attention on the need for antibiotic stewardship over the last several years. These efforts to combat antibiotic-resistant bacteria were propelled further by the 2015 White House Report titled National Action Plan for Combating Antibiotic-Resistant Bacteria. The report established several goals to fight “super bugs,” such as reducing the incidence of Clostridium difficile by 50 percent, reducing carbapenem-resistant Enterobacteriaceae infections by 60 percent, and maintaining the prevalence of ceftriaxone-resistant Neisseria gonorrhoeae below two percent (of all of the multi-drug resistant organisms, stating the emergence of Gonorrhoeae as a drug-resistant threat typically gets the biggest gasp from my audiences of infection preventionists and stakeholders).

The need for antibiotic stewardship is readily apparent in Louisiana, where I am pursuing my fellowship in the Louisiana Department of Health. According to Centers for Disease Control and Prevention's (CDC) Healthcare-Associated Infections 2015 Prevention Status Report, only 29.5 percent of acute care hospitals in Louisiana reported having antibiotic stewardship programs that incorporated all seven core elements deemed critical by CDC. These seven core elements include leadership commitment, accountability, drug expertise, action, tracking, reporting and education. Although this data references only acute care hospitals, antibiotic stewardship is needed across the health care spectrum. The seven core elements for antibiotic stewardship are recommended for implementation in all settings where prescribing occurs, including long-term acute care hospitals and nursing homes.

Similar to the Prevention Status Report's revelation of lack of antibiotic stewardship programs, CDC's 2014 Community Antibiotic Prescriptions Report shows data demonstrating that Louisiana's doctors' offices, emergency departments and hospital clinics administer antibiotics that are unnecessary at a rate of 1,021-1,285 prescriptions per 1,000. Overprescribing can be attributed to a number of factors. One study published in British Journal of General Practice showed that reduced antibiotic prescribing is associated with lower patient satisfaction, which may be why doctors overprescribe unnecessary medications. According to The Pew Charitable Trusts (PCT), common inappropriate uses of antibiotics in health care are for asthma, allergies, bronchitis, middle ear infections, influenza, viral pneumonia and viral upper respiratory infections. PCT has listed reducing inappropriate antibiotic use for all conditions by 50 percent by 2020 as a national goal.

Through my I-TIPP fellowship, I have identified current informatics capacities at acute care hospitals, promoted use of the National Healthcare Safety Network's (NHSN) Antibiotic Use and Resistance Module (AUR), educated facilities about the need for robust antibiotic stewardship activities and notified acute care hospitals about the eligibility of Meaningful Use Stage 3 incentives for participating in both the antibiotic use and antibiotic resistance features of the AUR. In July 2016, I conducted an introductory webinar on the AUR and in September 2016, I conducted a survey among acute care NHSN users to assess their electronic reporting capacities to participate in the AUR. Information administered in the initial webinar on AUR was reinforced at three, in-person workshops that were presented statewide in November 2016. These workshops focused on the NHSN and Emerging Infectious Disease, which are an integral part of Louisiana's health care-associated infections activities. Infection preventionists and patient safety personnel were the target audience for these workshops, however some pharmacists participated as well, in light of the demonstration of the AUR Module.

Effectively intersecting with people to generate outcomes that impact population health has been the key to my success in the fellowship thus far. Understanding the needs of each facility that has indicated an interest in signing up for the AUR Module, determining what their current capacities and barriers to creating competent antibiotic stewardship programs, and showing how Meaningful Use participation can help them has been integral to my project. Through I-TIPP, I have been able to refine my communication skills and problem solving methods to achieve public health goals that will better the health of Louisianans as we fight back against super bugs.



CSTE Fellow Erica Washington presents content on the NHSN Antibiotic Use/Resistance Module at the annual Louisiana National Healthcare Safety Network/Emerging Infectious Diseases Workshops in Bossier City, LA at Willis-Knighton Health Center in November 2016.

Erica Washington is an Informatics-Training in Place Program Fellow at the Louisiana Department of Health. She received her MPH from Tulane University in New Orleans, LA. Ms. Washington's post is the fifth in a series of blogs by CSTE-sponsored fellows.

Tags:  cross cutting  epidemiology  fellowship  informatics  surveillance  workforce development 

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#FoodPoisoning: Using Social Media to Detect Outbreaks

Posted By Katelynn Devinney, Tuesday, February 7, 2017
Updated: Tuesday, February 7, 2017

Foodborne illness is not only an unpleasant experience, but also a major public health concern. Many individuals who acquire foodborne illnesses do not seek medical care and do not report their illness to health departments, which can make complete and timely outbreak detection nearly impossible. With the emergence of social media as a primary form of communication, many individuals do, however, complain to their friends and followers online about their illness, symptoms and possible causes. So, how can we harness the power of social media to stop foodborne outbreaks?

As a fellow with the Project SHINE Informatics Training in Place Program in the New York City Department of Health and Mental Hygiene (DOHMH) – with support from the Alfred P. Sloan Foundation and the National Science Foundation – I have been tasked with developing a system, using data from Twitter, to identify complaints of foodborne illness across the city. The DOHMH has a long history of applying innovative methods to improve foodborne disease surveillance. We utilize the citywide non-emergency information system, “311,” where anyone can submit a food poisoning complaint related to a New York City restaurant. Additionally, in 2011, after identifying reports of illness on the restaurant review website Yelp that were not reported to 311, DOHMH began collaborating with Yelp and Columbia University to obtain a daily feed of Yelp reviews and develop a machine learning program using text mining to identify reviews pertaining to foodborne illness. This project was supported by two former CSTE Applied Epidemiology fellows, Cassandra Harrison, MPH and Kenya Murray, MPH and resulted in the full integration of Yelp into our foodborne illness complaint system. Each year, approximately 4,000 restaurant-associated complaints are received via 311 and Yelp combined, which result in the detection of about 30 outbreaks.

Nevertheless, New York City is a large metropolitan area with more than 8.5 million residents, 78 percent of whom eat food purchased from the city’s approximately 24,000 restaurants and 15,000 food retailers at least once per week. There are ample opportunities for exposure to foodborne pathogens at New York City restaurants. Even with the integration of Yelp and 311, we remain concerned that we are not receiving all reports of restaurant-associated foodborne illness incidents in the city.

Working with Columbia University, we have developed a system very similar to that used for Yelp reviews, which pulls publicly available data from Twitter’s application program interface (API), and uses text mining and machine learning to identify tweets indicating foodborne illness. We have also developed a web-based application, which displays all Yelp reviews and tweets for epidemiologists to review and manually classify, and allows us to track follow up and conduct interviews with complainants.

Using this application, we can respond to Twitter users we believe to be tweeting about a potential food poisoning incident and ask them to complete a brief online survey. The survey asks about the restaurant name and location, date of their visit, details of the incident and contact information for follow-up. DOHMH staff attempt to interview all users who submit surveys to obtain more information about their symptoms, incubation period and a three-day food history.

The process of developing and launching the application was extensive; we encountered many roadblocks, such as accessing data through firewalls and obtaining secure public facing servers to allow survey data collection. We have only recently started tweeting and sending surveys; so far, the survey completion rate has been low (roughly two percent), but we have observed an overall positive reaction from the public to our tweets. We hope the response rate increases over time and the application is successful, so we can share our work and lessons learned with other health departments who want to incorporate social media into their surveillance and outbreak detection efforts.

Already, our project was recognized at the 2016 New York City Technology Forum as the Most Innovative Use of Social Media/Citizen Engagement. Since then, we’ve enhanced the application to allow us to automate processes and increase the sustainability of the project over time. We have also evaluated different data sources and aim to incorporate those that will increase both the timeliness and completeness of foodborne illness outbreak detection in New York City.



Pictured: New York City Social Media Foodborne Team accepting the award for
Most Innovative Use of Social Media/Citizen Engagement on November 14, 2016.

This project has been an incredible learning experience. I am very thankful to DOHMH, my mentors and Project SHINE for their continued support and guidance. None of this would have been possible without the work of Communicable Disease, Environmental Health and Information Technology staff at DOHMH, our partners at Columbia, our grant administrators at the Fund for Public Health New York and our funders. This collaboration provided me with an amazing opportunity to learn how to effectively communicate and coordinate between groups to promote innovation in informatics, which I will continue to apply throughout my public health career.
Katelynn Devinney, MPH, is an Informatics-Training in Place fellow at the New York City Department of Health and Mental Hygiene. She received her MPH from Columbia University Mailman School of Public Health. Ms. Devinney’s post is the fourth in a series of blogs by CSTE-sponsored fellows.

Tags:  cross cutting  epidemiology  fellowship  food safety  surveillance  workforce development 

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Putting People First in Public Health Informatics

Posted By Juliet Sheridan, MPH, Monday, January 23, 2017
Updated: Monday, January 23, 2017

As a self-proclaimed data nerd, I was initially excited about being accepted into the Applied Public Health Informatics Fellowship (APHIF) because I’d have the chance to improve my technical skills in a real-world setting. Supported by CDC, the Council of State and Territorial Epidemiologists (CSTE) and the National Association of County and City Health Officials (NACCHO), my APHIF work is part of the “Project SHINE” professional development collaboration. Imagine my surprise when my main fellowship project for the Family Success Alliance turned out to be more about people than the technical specs.

The Family Success Alliance (FSA) is a collective impact initiative developed to ensure that children whose families struggle to make ends meet have the educational and economic opportunities to succeed in Orange County, NC. Modeled after the Harlem Children’s Zone, FSA works in two neighborhoods called ‘Zones’ to provide a “pipeline” of evidence-based programs, services and supports from cradle to career. With over 200 participants in the first two years and yearly expansion planned, FSA needed a way to keep track of demographic, program and outcome information for each participant and their family.


The Family Success Alliance (FSA) is a collective impact initiative developed to ensure that children whose families struggle to make ends meet have the educational and economic opportunities to succeed in Orange County, NC.

Because the collaborative spans many sectors, including local government, school districts, non-profit organizations and funders, we couldn’t just set up a regular database. It was important to track not only what was happening, e.g., tracking participation in programming, but also how partners were interacting, e.g., whether the afterschool tutoring organization also referred participants to our mental health partners. We needed this tracking to occur in real-time across 13 different organizations, while also being HIPAA and FERPA compliant.

To this end, I was selected to implement a shared measurement system that all our partners could access and utilize. The United Way, one of our funders, uses a web-based case management system called Efforts to Outcomes (ETO), created by Social Solutions, Inc., which we decided to adopt for FSA. I focused first on the technical components necessary for success, such as gathering requirements, managing permissions and building reports. However, I realized that the most important pieces of this project were non-technical. How do you build trust among partners? Maintain common goals and accountability? Allow for unique organizational needs? Prioritize equity? These questions ultimately informed most of my work during my fellowship experience.



Pictured: FSA partners are pictured here during a working meeting.

Before I could begin setting up ETO, we had to create and sign a Master Data Sharing Agreement that outlined the appropriate use, storage, analysis and security for the data we would enter into our system. We found that this agreement could not move forward without numerous conversations about each partners’ experience with similar data, capacity for data management and expectations for security, confidentiality and privacy. Fundamentally, these conversations were about building trust. Do you and your partners trust each other to be good stewards of the data? Do your clients trust you to maintain their information in a secure way? The Data Sharing Agreement is just the first step in a continuing conversation about data use and practices; my role is to accompany our partners in that discussion.

Now that the Master Data Sharing Agreement is almost complete, I’ve turned my attention to getting the system set up for our community partners. In designing the forms and user interface on the website, it is crucial to keep the end goals of the collaborative in mind, so that we can measure the impact on the community. One of the guiding principles of the Alliance is equity, and that is no less true when it comes to data. This principle informs both logistical and measurement questions about our data, including who enters the data, how we train staff, if we are capturing community strengths, and whether we’re contributing to a “fixing systems” mentality instead of “fixing people”. The real questions we want to answer using this database are about families living in Orange County and whether their children are ready for kindergarten; if they have appropriate, stable housing; and if there more families living above the poverty line as a result of our work. If I focused only on the technical requirements of the database, I’d lose sight of what is truly important about the work we’re doing.



Pictured: Here, a teacher reads to children in the Kindergarten Readiness Program.

Through my APHIF experience, I’ve found that informatics is about so much more than just technical skills. Systems like ETO improve our processes and contribute to data-driven decision making, but they must also be designed with human “requirements” in mind, like trust, accountability and equity in order to be truly successful. I am so grateful to my mentors, our community partners, Family Success Alliance staff and funders for their continued support and assistance. The Orange County Health Department and the APHIF program have afforded me this unique opportunity that has changed the way I will approach public health informatics throughout my career.

Juliet Sheridan is an Applied Public Health Informatics Fellow at the Orange County Health Department in North Carolina. She received her MPH from the University of North Carolina at Chapel Hill. Ms. Sheridan’s post is the third in a series of blogs by CSTE-sponsored fellows.

Tags:  Cross cutting  Epidemiology  Fellowship  Informatics  Surveillance  Workforce Development 

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Using Electronic Health Data to Prevent Traffic Injuries & Save Lives

Posted By Kenneth Scott, PhD, MPH, Tuesday, January 10, 2017

2016 was a big year for Denver. In addition to the Denver Broncos’ Super Bowl championship, the regional transit agency introduced three new train lines, with a fourth coming soon, and Denver’s Mayor Michael Hancock launched an initiative known as “Vision Zero.” First enacted by the Swedish Parliament in 1997, Vision Zero was designed to eliminate all traffic-related deaths and serious injuries by 2020. That anyone in the 21st century could seriously imagine a city or country with no serious road traffic injuries is an indicator of how far public health and safety professionals have come in making transportation safer. Improved traffic safety has been a public health goal for decades, due in part to the early intellectual leadership of Dr. William Haddon Jr. as well as the political activism of Ralph Nader. The Center for Disease Control and Prevention (CDC) counts motor vehicle safety as one of the greatest public health achievements of the 20th century. Even so, Sweden’s notion that traffic deaths and serious injuries can be eradicated was, well… visionary.

In the first decade of Vision Zero, the number of road deaths in Sweden was cut in half. Other governments have since followed Sweden’s model, adopting Vision Zero policies of their own. In the United States, cities like Boston, Chicago and San Francisco have taken the lead with efforts to implement. Vision Zero in Denver, as in Sweden, has come both from community activism as well as political leadership. Mayor Hancock made a formal commitment to Vision Zero in February 2016 after receiving support from a network of community organizations in the Denver area. A group of city agencies is currently working to develop a Vision Zero Action Plan for Denver, with ongoing guidance from interested community groups.

Tracking progress in achieving Vision Zero requires data, which is where public health informatics comes in. Public health informatics is ultimately about transforming health-related data into useful information for public health action. I am currently a fellow working at Denver Public Health through the Applied Public Health Informatics Fellowship (APHIF) program. APHIF is supported by CDC, the Council of State and Territorial Epidemiologists (CSTE), and the National Association of County and City Health Officials (NACCHO) as part of the “SHINE” professional development collaboration. Fellows in my program are typically recent graduates of academic programs in public health or computer & information science (I defended my dissertation in epidemiology this past August). We receive one year of on-the-job training at a state or local health agency, where we learn how to communicate and work with the diverse teams of professionals involved in public health informatics.

In an effort to build injury epidemiology capacity within our department, I have been responding to information requests we receive related to injury prevention—my PhD focus. Denver Environmental Health—one of the agencies working on the Vision Zero Action Plan—requested that the Denver Public Health’s Public Health Informatics Group (PHIG) where I am embedded conduct a “hot spot” analysis of transportation injuries in the city. After evaluating different information systems, my fellowship mentors and I concluded that electronic health record data collected by Denver’s paramedics would be best suited to identify hazardous locations. Geographic location data assigned by the 911 call system are the most precise measures of injuries’ incident locations in any available health records. Also, the paramedic data capture injuries that police reports—which are publicly available and have previously been analyzed—might miss.

Through a partnership with the Denver Health Paramedics Division, we evaluated five years of transportation injury data and identified specific locations in Denver that might benefit from additional attention (e.g., intersection redesign, traffic enforcement, etc.). Denver Environmental Health and the other members of the Vision Zero work group will use our report to help develop recommendations to improve transportation safety in Denver. I look forward to seeing how the report is used.

What I have enjoyed the most about this fellowship has been working in an applied setting with committed public health practitioners and learning from professionals trained in other disciplines, including computer science, software development and database management. This cross cutting, interprofessional education is helping me and other fellows in my cohort build skills to translate across disciplines and, hopefully, secure long-term career placement in governmental public health. It has been rewarding to apply my formal education in epidemiology to public health issues and information systems specific to Denver—the city where I was born and raised. As a child, I was treated by Denver’s paramedics for injuries I sustained after running through a glass door. A surgeon at Denver Health helped me return to play after I experienced a shoulder injury playing high school football. And as a bike commuter, I have crossed through intersections that our analyses highlight for improvements. In other words, working with these particular information systems carries a personal significance for me. And from a professional standpoint, the APHIF program has given me valuable experience working in local public health which, as we say, is where the rubber meets the road.


Dr. Ken Scott is an Applied Public Health Informatics Fellow at Denver Public Health. He received his PhD from the University of Colorado and his MPH from the University of Washington. Dr. Scott’s post is the second in a series of blogs by CSTE-sponsored fellows.

Tags:  cross cutting  epidemiology  fellowship  informatics  surveillance  workforce development 

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Working Together for a Healthier Public Health Workforce

Posted By Dr. Patricia M. Simone, Tuesday, January 3, 2017
Updated: Tuesday, January 3, 2017

With 2016 now behind us, it is not an understatement to say it was a record year. Together, we faced persistent challenges such as eradicating the Ebola virus disease in West Africa, and addressing complex challenges such as opioid abuse and addiction, and lead contamination in our own backyard. We also faced newly emerging health threats, such as the emergence of the Zika virus across the continental and territorial United States and its devastating effect on infants—the first vector-borne disease to cause birth defects.

Crucially, a well-trained army of highly skilled public health professionals has met each of these challenges. Without their tireless efforts, consequences for the American public and others around the world could have been much worse. We’ve seen these disease detectives in the news. They are dedicated public health heroes, like the professionals in Miami-Dade County, Florida who went door-to-door with clipboards to track the spread of Zika infections, while others even now are at work sequencing a vaccine for the virus. Public health professionals stepped forward, suited up, and deployed to 50 medical centers in Liberia to provide emergency treatment and vaccinations to 1,750 individuals with a high risk of contracting Ebola. Disease detectives assisted Indiana in addressing the needs of a community facing the complex, coupled issues of opiate addiction and an HIV outbreak. They also climbed rooftops to swab cooling towers in New York to search for the source of a Legionellosis outbreak. Yet this same public health workforce now is endangered—not by the ravages of a foreign climate or an exotic virus – but by preventable reductions to public health budgets by federal and state governments.

U.S. Centers for Disease Control and Prevention (CDC) hosts a premier public health workforce development program. CDC has built a wide variety of workforce development opportunities over 65 years that range from placements with academic and professional institutions, to inter-agency applied fellowships, to placements in communities such as those coordinated by the Council of State and Territorial Epidemiologists (CSTE). CDC supports fellowships and programs, along with partners, to train the next generation of epidemiologists, laboratorians, decision scientists (public health economists), informaticians, and preventive medicine specialists, to name just a few.

Developing well-rounded public health professionals from many interests and backgrounds demands well-tested programs that encourage learning through experience with respected public health experts, coupled with excellent training. In addition to these opportunities, CDC offers free online learning and is the only agency in the Department of Health and Human Services currently accredited to award seven types of continuing education certifications for health professionals. Most graduates of CDC fellowships choose careers in governmental public health.

But our successes—and the health security of Americans—are at risk. CDC over the past several years has become increasingly unable to keep up with the demand for public health professionals who are prepared to meet the constantly evolving public health challenges America and our neighbors throughout the world face. Our resources are stretched thin, and we now must make difficult decisions about which public health fellowships cannot be sustained fully. CDC and public health departments cannot predict what new challenges we will face tomorrow or in the coming years. We know from experience how important it is for America to have highly trained, dedicated professionals ready to meet the next challenge. Yet the threat of proposed budget reductions persists, while federal and local costs to support these programs continue to rise. And demand for CDC’s programs continues to exceed the available opportunities. For example, CSTE’s applied epidemiology fellows program in 2016 received more than 600 applications, but the CDC budget only allowed funding for 22. If more reductions occur, even fewer applicants will be accepted for training.

Public health professionals, like the brave men and women in our military, face the enemy on the front lines. For public health professionals, that means being on the ground wherever America’s health security is threatened—at home or overseas. And like our defense security, our nation’s public health security requires sustained investments in these people who dedicate their careers to service in public health. In the end, a healthy public health workforce is the only way to ensure a healthy nation.


Dr. Patricia M. Simone is the Director of CDC’s Division of Scientific Education and Professional Development in the Center for Surveillance, Epidemiology and Laboratory Services. She has held numerous leadership positions in CDC and has served on the frontlines of public health herself, retiring as a captain from the U.S. Public Health Service Commissions Corps in 2013.

Tags:  Epidemiology  Fellowship  Surveillance  Workforce Development 

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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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Using Childhood Adversity Data to Improve Adult Health

Posted By Anna Austin, Thursday, October 30, 2014
As a CDC/CSTE Applied Epidemiology fellow in the Injury and Violence Prevention branch at the North Carolina Division of Public Health, one project that has particularly developed my skills as an epidemiologist and public health professional relates to adverse childhood experiences (ACEs). ACEs are traumatic or stressful events experienced before age 18 and include eight categories of childhood abuse and household dysfunction, such as physical, sexual, and emotional abuse; adult substance abuse; and household domestic violence.

A growing body of evidence shows that these early experiences are common and can have long-lasting effects on mental and physical wellbeing. Findings from the original 1995-1997 ACE Study showed a strong, graded relationship between ACEs and several poor health outcomes in adulthood. As the number of ACEs a person experiences increase, what also increases are the risks of alcohol and drug abuse, obesity, suicidality, depression, intimate partner violence, heart disease, and a range of other poor health outcomes in adulthood. Data specific to ACEs among North Carolinians first became available in 2012 when questions about ACEs were included on the North Carolina Behavioral Risk Factor Surveillance System survey. My task was to analyze this data and create North Carolina’s first state report on the topic.

The findings from the state report mirror the findings of the original ACE study. ACEs were found to be common among North Carolinians: 58% reported at least one ACE and 22% reported three or more ACEs. Over a quarter of North Carolinians reported having grown up with an adult who was abusing alcohol or drugs, and one in 10 reported sexual abuse by an adult. In addition, ACEs were found to cluster among North Carolinians—if a person reported having experienced one ACE, it was highly likely that he/she had also experienced additional ACEs. Lastly, the results showed that the risk of smoking, binge drinking, and obesity as well as HIV-risk behaviors, poor physical and mental health, chronic obstructive pulmonary disease, cardiovascular disease, arthritis, depression, and disability in adulthood increased as the number of ACEs reported increased.

The finding that ACEs impact health outcomes in adulthood, long after the events have occurred, supports ACE prevention as an effective long-term strategy for population health and highlights the importance of a life-course perspective in such prevention efforts. The finding that ACEs impact a wide range of outcomes from social, emotional, and behavioral problems to chronic diseases presents an opportunity to foster collaboration among diverse stakeholders and suggests such collaboration will be important to successful ACE prevention. Increasing awareness of ACEs as a public health issue will be important in North Carolina for mobilization.

We are engaging stakeholders from across the state to support local prevention efforts. I presented the findings from the state report at the North Carolina Public Health Association Conference alongside colleagues from the Innovative Approaches Initiative in Buncombe County. This initiative is developing a toolkit and website to educate local primary care providers on ACEs, connect them to local resources, and provide referral options for affected children and families. I have also collaborated with Harry Herrick, a survey analyst at the North Carolina State Center for Health Statistics, to respond to requests for data regarding ACEs among special populations, such as current smokers and persons with disabilities. I am also currently working on a multi-state study of ACEs among persons who identify as gay, lesbian, and bisexual. Ideally, data from each of these studies will help inform programs and policies aimed at ACE prevention and the enhancement of current efforts. This project has proved invaluable to my experience as a fellow, and I am extremely grateful for the opportunities, support, and guidance my mentors and colleagues have provided throughout the process.

Anna Austin, MPH is the CDC/CSTE Applied Epidemiology Fellow at the North Carolina Division of Public Health. In addition to this project, Anna has linked prescription drug overdose data from multiple sources, served on the leadership team developing the 2015 North Carolina Suicide Prevention Plan, and written surveillance reports on motor vehicle crash-related injuries.
Would you like to host or be a CDC/CSTE Applied Epidemiology fellow? Find out how. To learn more about ACEs, take a look at the CDC Injury Prevention and Control page.

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Tags:  adverse childhood experiences  data  fellowship  member spotlight  substance abuse 

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Small and square and vital

Posted By Renata Howland, Friday, September 5, 2014

What’s small and square and given to everyone when they’re born? A blanket is an obvious answer, but after two years with the New York City Bureau of Vital Statistics, I think of a birth certificate. Before joining the New York City Health Department as a CSTE/CDC Applied Epidemiology fellow in August 2012, I had never really spent much time thinking about birth certificates—but over the course of two years I learned a great deal about vital event registration in New York City and how it relates to epidemiologists’ work.

As part of the Fellowship requirements, my first project was evaluating the New York City birth registration system as a surveillance system. As I interviewed stakeholders, observed procedures, and analyzed data to assess the usefulness, timeliness, simplicity, quality, and representativeness of the system, these attributes—which at first seemed abstract and academic—became increasingly concrete. I witnessed firsthand the enormous effort of the Bureau’s staff to process certificates quickly, maintain complex electronic systems, clean and improve data, publish annual vital event summaries, and provide data to local maternal and child health programs, researchers, and national organizations. This evaluation spurred on other projects, including assisting in the development and evaluation of a new training program for birth registrars and studying the reliability of tobacco use questions for new moms. It was exciting to see how this research directly affected the collection, quality, and interpretation of birth data.

Altogether, these experiences gave me a new perspective on my work as an applied epidemiologist, someone truly engaged with the people, processes, and consequences surrounding data. Of course, I also learned that the work was messier, more complicated, and slower moving than anything I had done in school, but ultimately I also found it to be much more rewarding.
Four months ago, I transitioned to a job in the Bureau of Maternal, Infant, and Reproductive Health. I’m now a research analyst for new grant funded project on severe maternal morbidities, using none other than birth certificate data linked with inpatient hospital discharge records. So far it’s been an amazing opportunity to apply what I learned as a Fellow to a project about which I feel passionate, and I’m grateful to my mentors in New York City who helped to make this possible.
Renata Howland, MPH is the Severe Maternal Morbidity Data Analyst at the New York City Department of Health and Mental Hygiene. She was in Class X of the CDC/CSTE Applied Epidemiology Fellowship program, graduating in 2014. Ms. Howland was awarded the Hillary B. Foulkes Memorial Award in recognition of her outstanding work as a Fellow.
The other Applied Epidemiology Fellowship
Class X graduates are:
The Applied Public Health Informatics Fellowship
graduates are:
Robert Arciuolo, MPH—Infectious Diseases
Darlene Bhavnani, PhD—Infectious Diseases, Quarantine
Sarah Blackwell, MPH—Maternal and Child Health
Megan Christenson, MS, MPH—Environmental Health
MyDzung Chu, MSPH—Occupational Health
Kathleen Creppage, MPH, CPH—Substance Abuse
Kathryn DeYoung, MS—Infectious Diseases
Sarah File, MPH—Infectious Diseases, HAI
Mark Gallivan, MPH—Infectious Diseases
Rachel Gicquelais, MPH—Infectious Diseases
Michelle Housey, MPH—Chronic Diseases
Rebecca Jackson, MPH—Environmental and Occupational Health
Nicholas Kalas, MPH—Infectious Diseases
Jillian Knorr, MPH—Infectious Diseases
Tess Konen, MPH—Chronic Diseases
Jennifer Kret, MPH—Chronic Diseases
Kristine Lynch, PhD—Infectious Diseases, Food Safety
Michelle March, MPH—Infectious Diseases, HAI
Michelle Marchese, PhD, MPH—Environmental Health
Ellyn Marder, MPH—Infectious Diseases, Food Safety
Jason Mehr, MPH—Infectious Diseases, HAI
Catharine Prussing, MHS—Infectious Diseases, HAI
Olivia Sappenfield, MPH—Maternal and Child Health
Nathaniel Schafrick, MPH, MS—Environmental Health
Kacie Seil, MPH—Injury
Victoria Tsai, MPH—Infectious Diseases
Joshua Van Otterloo, MSPH—Infectious Diseases
Andrew Wiese, MPH—Infectious Disease, HAI
Bonnie Young, PhD, MPH—Infectious Diseases, Quarantine
Crystal Boston-Clay, MS
Bethany Bradshaw, MPH
Kailah Davis, PhD
Harold Gil, MSPH
Hannah Mandel, MS
Brittani Harmon, DrPH, MHA
Sandhya Swarnavel, BDS, MS
Lauren Snyder, MPH
Melinda Thomas, MPH

Tags:  fellowship  vital records  workforce development 

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