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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 This will include the development of an inter-agency council to draft guidance for the agencies and support and track global health issues and how the United States can lead and participate in addressing them, among other things.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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Real-life Outbreaks: Sorrow and Statistics

Posted By Lauren Reeves, Friday, August 29, 2014

This week’s post is the second in our series of posts about Deadly Outbreaks, a book of real-life outbreak mystery stories. You can purchase a copy of Deadly Outbreaks by author Alexandra Levitt at amazon.com.

Epidemiologists who investigate outbreaks often use their findings not only to control disease but also to prevent future outbreaks once the immediate emergency is over. For example, in the aftermath of an outbreak that occurred at a Toronto hospital during the 1980s (described in Chapter 3 of Deadly Outbreaks), the investigators recommended extensive changes in how hospitals dispense drugs and how they use mortality data to monitor and improve hospital care. Although public health experts had been advocating these improvements for some time, the experience at the Toronto hospital—which involved drug overdoses and a long lag before a problem was recognized—demonstrated their importance in a dramatic and unequivocal way.

Here is what happened in the outbreak story entitled Sorrow and Statistics:

In 1981, thirty-four babies at the Hospital for Sick Children in Toronto died from apparent overdoses of the heart medication digoxin. Although a judge dismissed murder charges against a nurse who had been on duty during some (but not all) of the deaths, the police continued to claim that she was guilty, while the hospital’s doctors insisted the babies had died of natural causes.

With the hospital under a cloud of suspicion, the hospital authorities called in outside help, in the form of an Epidemic Intelligence Service (EIS) officer from CDC. On his arrival, officials from the Ontario Ministry of Health introduced the EIS officer —James Buehler—to two experienced Canadian colleagues who served as members of his investigative team.

Buehler understood from the start that there was uncertainty about what they might be able to accomplish. As recorded in Chapter 3 of Deadly Outbreaks [page 63]:

“What could the medical detectives do that the…doctors and police had not already done? The doctors had focused on the details of each baby’s illness, finding a natural reason for each death. The police, on the other hand, had focused on a particular suspect, seeking legal evidence to build a case against her. The epidemiologists viewed the evidence from a different angle. Unlike the police or the doctors, they looked at all of the deaths at once, as part of a single mission, trying to figure out what all the cases had in common—somewhat like an FBI analyst examining deaths linked to a single serial killer. However, unlike the police or FBI, they were not concerned with legal issues or with questions about human guilt and motivation, and unlike the hospital staff, they bore no personal responsibility for the babies’ welfare. They did not interview the nurses or meeting with the victims’ parents. Thus, they were emotionally removed from the tiny victims and perhaps better able to analyze the data in a dispassionate way, using graphs and statistics—“people with the tears wiped away” as the EIS saying goes. Another way to say it is that they ignored the horror behind the numbers and plunged on, wherever the data would take them.”

James Buehler and his team, working as unobtrusively as possible at the troubled hospital, used epidemiologic data to confirm that a significant rise in the infant death rate had actually occurred on the hospital’s cardiology ward. Then they proceeded to collect hypotheses and rule them out, one by one, until only one was left….

Tags:  Deadly Outbreaks  infectious disease  outbreak 

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CSTE’s Ebola Virus Disease Activities

Posted By Lauren Reeves, Thursday, August 21, 2014

http://www.cdc.gov/vhf/ebola/pdf/infographic.pdfCSTE’s role as an advocate for state and local epidemiologists comes into focus during outbreaks and public health emergencies. CSTE is currently working with our members, CDC, and our public health partners to coordinate communication and facilitate information sharing about Ebola Virus Disease (EVD). CSTE and CDC have collaborated from the beginning on regular EVD briefing calls with State Epidemiologists and senior public health officials.

During situations like this EVD response, an enormous amount of information is disseminated very quickly. The CSTE National Office is a source for streamlined, accurate, and directed information for applied epidemiologists. CSTE is helping our members involved with emergency preparedness, infectious disease, and EVD to share best practices and experiences, ask questions, and conduct an open dialogue with their colleagues.

This week, CSTE launched a members-only webpage for up-to-date information, resources, and links about EVD. To access the page, members can log into the CSTE website with their logins and passwords. Links to help members who have forgotten their login email or password are available on the login screen. The EVD page gives CSTE members access to a discussion board forum, where members can contribute and share guidance and protocols, quarantine orders, and other documents from their jurisdictions. The forum also allows members to post questions and comments to facilitate conversation about managing the EVD crisis. CSTE has also compiled an after-hours phone list so jurisdictions and public health partners can easily access emergency contact information for state and local agencies.

CSTE and its partners are continuously working with CDC to discuss state and local jurisdictions’ needs to make sure their concerns are advocated for adequately. CSTE participates in national briefing calls as well as calls that focus on epidemiology to be more specific to the issues and concerns important to epidemiologists.
In addition, three CDC/CSTE Applied Epidemiology Fellows have been deployed to the CDC Emergency Operations Center (EOC) to augment EOC staffing during its activation. The Fellows are assisting with the data management team. Aiden Varan, a fellow placed in infectious disease in a joint assignment with San Diego County and the San Diego quarantine station, arrived at CDC to assist in early August. Hanna Oltean, a fellow working in infectious disease at the Washington State Department of Health, and Cara Bergo, a fellow placed at the Louisiana Department of Health working in maternal and child health, recently joined Aiden at the EOC. Additional fellows may be called to assist as the outbreak response continues.
CSTE and CDC have set up email accounts for specific questions related to each organization’s EVD preparedness and response activities. Contact the CSTE National Office at commandcenter@cste.org with EVD-related questions so that CSTE can focus and direct questions appropriately. State and local senior health officials who need assistance with EVD-related issues can contact CDC’s Incident Management System State Coordination Task Force EOC desk directly at eocsctfeocdesk@cdc.gov.
For more information, visit CSTE’s EVD webpage or CDC’s Ebola Hemorrhagic Fever webpage, which has the most up-to-date information from CDC.
To join and access CSTE’s members-only page, visit CSTE’s membership page.

Tags:  infectious disease  outbreak  staff spotlight 

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The McConnon Strain - A mysterious outbreak of unknown spread

Posted By Lauren Reeves, Thursday, August 14, 2014
Untitled Document

Despite advances in healthcare, infectious microbes continue to be formidable adversaries to scientists and doctors. Deadly Outbreaks—a book of real-life outbreak mystery stories—recounts the scientific adventures of a special group of intrepid individuals who investigate disease outbreaks and figure out how to stop them.

Several upcoming blog posts will describe stories from Deadly Outbreaks, written by Alexandra Levitt. (You may recognize some of these outbreak or their causes, or you may know some of the epidemiologists. Read on to find out….) For example, this week’s post concerns an outbreak of a dangerous drug-resistant disease with the potential for international spread. Like today’s Ebola outbreak in West Africa, the dangers posed by this outbreak underscore the critical importance of maintaining local public health systems that do the day-to-day work of investigating outbreaks and stopping them at their source. We rarely know in advance which small outbreak or disease cluster will turn out to be something truly dangerous and devastating.

Here is what happens in the outbreak story entitled The McConnon Strain:
Epidemiologists sometimes face difficult choices, with moral, political, and financial repercussions that must be weighed against risks to human health. In 1983, for example, two officials, Patrick McConnon (from the United States) and Roland Sutter (from Switzerland), agonized about whether to delay the long-awaited repatriation of 20,000 Cambodian refugees, fearing that some might carry a rare, multidrug-resistant form of malaria. The U.S. Government planned to fly the refugees from Thailand, where they lived in border camps, to the Philippines (where they would be processed for entry into the United States). Stopping the flight would prolong the misery of hundreds of desperate families eager to resettle and start new lives. On the other hand, introducing an untreatable form of malaria into a mosquito-infested part of the Philippines could bring illness or death to thousands or even millions of people. As recorded in Deadly Outbreaks (page 38):

People stranded in refugee camps, displaced, impoverished, and malnourished, are at special risk for infectious diseases such as malaria, measles, and cholera that flourish in crowded and unsanitary living conditions. When infected refugees are moved to new holding sites, repatriated, or resettled in new countries, they can bring these diseases with them. As a result, public health officials like McConnon have overlapping and sometimes conflicting aims: to safeguard the health and welfare not only of the refugees themselves, but also of the people in countries that host refugee camps or accept refugees as permanent residents.

The spread of smallpox after the 1971 Pakistani civil war illustrates what can happen when a pathogen incubated in a refugee camp infects the wider population. Smallpox was carried to the newly established nation of Bangladesh by Bengali refugees returning home from India. According to public health lore, the presence of smallpox in the camps was detected by an epidemiologist in Atlanta, sitting in his living room watching TV, who noticed a man with a suspicious rash in a newsreel about a camp near Calcutta... The epidemiologist called the director of CDC, who called the director of the WHO Smallpox Vaccination Program, who called the Indian Ministry of Health. But it was already too late. Thousands of Bengalis had already left the camp, leading to widespread outbreaks in Bangladesh and making the last Asian country to eliminate smallpox.

McConnon was well aware of this history, because he had worked in Bangladesh in 1975, the final year of the smallpox eradication effort in Asia. He tried to convince an official at the U.S. State Department that it was dangerous to send refugees to the Philippines before screening them for this unusual strain of drug-resistant malaria. But the State Department official was skeptical and demanded to see some evidence.
With few resources and little time, McConnon and Sutter conducted a small-scale epidemiologic study in the border camp. If they could figure out which activities (e.g., farming, fishing, water collection) exposed people to malaria, they might delay the departure of exposed refugees while allowing unexposed refugees to proceed to the Philippines. As part of the study, they plotted the location of each malaria case on a map of the refugee camp, hoping to see a pattern. However, the data did not support any of their hypotheses. There was no association between the malaria cases and growing crops or working near the forest, swamp, chicken coops, or garbage dump. In fact, the distribution of malaria cases seemed entirely random, except for one thing: nearly all the cases involved males between the ages of 13 and 35.
This did not make sense! The mosquitoes that carry malaria do not distinguish between women and men or between the young and the old. McConnon and Sutter remained frustrated and puzzled—until they stumbled on an explanation during a conversation in a local bar when an aid worker mentioned a border-camp activity they had not tested for…
Stephen Ostroff, MD, former deputy director of CDC’s National Center for Infectious Diseases and former director of Pennsylvania’s Bureau of Epidemiology, said that “anyone with even a passing interest in disease investigation will find Deadly Outbreaks to be a great read. So too will all practitioners of public health, from students contemplating a career in epidemiology to the most seasoned veteran.” You can purchase a copy of Deadly Outbreaks by author Alexandra Levitt at amazon.com.

Tags:  deadly outbreaks  infectious disease  malaria  outbreak 

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When Something Smells Fishy

Posted By Sara Ramey, Wednesday, March 26, 2014
Untitled Document
It started with a call from an astute provider (as it usually does), an infectious disease physician, who had noticed a few cases of skin and soft tissue infections among older women from Chinatown. The lesions were described as erythematous, tender subcutaneous nodules on the fingers and hands, and one patient was subsequently diagnosed with Mycobacterium marinum. M. marinum is a bacteria that often causes cutaneous infection after contact with both fresh and salt water, especially due to aquarium exposures or fish or shellfish associated injuries. At least a few of the initial cases in New York City (NYC) reported handling fresh whole fish, purchased live or on ice from one of our local markets. Over the next few weeks, we started to hear about more cases - from other providers as well as from the routine reports we receive from CDC’s Infectious Disease Pathology Branch as dermatology providers in NYC were submitting biopsy specimens for immunohistochemical staining.

So we ramped up our outbreak response – developing our case definitions for suspect, probable and confirmed cases; sending a health alert to medical providers and laboratories requesting that they call us if they were seeing similar cases; setting up a more formal triage system to screen the initial provider calls; conducting more active casefinding by calling primary care providers, dermatologists, pathologists and hand surgeons, especially those who practice in one of the three Chinatown areas of the city; developing a structured questionnaire and database to better characterize the clinical illness and potential risk exposures; alerting public health partners via an EpiX alert to see if anyone else was seeing similar cases; getting any available isolates to our laboratory for molecular typing; working with our environmental colleagues at the city and state to begin traceback investigations and environmental testing; and alerting our federal partners, including the CDC, FDA and USDA.
Though we are still in the midst of this investigation, some clues are falling into place. We are now up to about 60 cases, with most being female, between the ages of 50-80, of Chinese ethnicity who reported purchasing fresh whole fish from a tank or on ice. About 2/3 recalled having a cut or injury prior to symptom onset. But a number of different markets are involved, and we are just beginning the traceback investigation. However, unlike other foodborne outbreak investigations, there is no federal or state regulatory agency to work with who oversees the interstate sale of live fish for food consumption. So we needed to step into this regulatory void, and use our public health authority to conduct the environmental investigations at both the markets and the distributors.
I have been overseeing communicable disease outbreak investigations in NYC for over 20 years now. It still amazes me that though the approach to each one is very similar, there is always something new to learn -- whether a new infectious disease etiology or a novel mode of transmission or just learning about a new setting or practice that I was unfamiliar with (in this case, the apparently well-established interstate trade of live fish for food). Our tools for outbreak detection and response have improved so dramatically since I first started here as an EIS officer in 1992 ---- with electronic laboratory reporting, syndromic surveillance, more robust IT systems for managing our surveillance and outbreak data, enhanced analytic methods to detect aberrations in our data, improved laboratory molecular diagnostics and electronic networks to communicate more rapidly with our provider and laboratory partners.
But more times than not, it’s the basics we depend on – the astute provider calling us and setting in motion the initial outbreak response steps that I first learned during my EIS training to determine if something unusual is occurring and whether there is a common exposure. With a city of over 8 million people and 50,000 providers, we still mostly rely on that one call from a provider seeing just a few cases that she or he considers unusual enough to alert us that something larger may be going on citywide. And it’s why that in addition to continuing our investments in improving our electronic surveillance infrastructure, it’s just as critical that we continue to foster relationships with our healthcare provider partners and always remind them of how powerful a single phone call can be in allowing us to detect the next big outbreak.
Marcelle Layton, MD
Assistant Commissioner Bureau of Communicable Disease
New York City Department of Health

Tags:  infectious disease  member spotlight  outbreak 

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Raw Milk Strikes Again

Posted By Sara Ramey, Wednesday, February 5, 2014
Updated: Wednesday, February 5, 2014

Tennessee recently experienced an outbreak of E. coli O157 associated with raw (unpasteurized) milk, in which 9 children became ill, 5 of whom were hospitalized, and 3 of whom developed hemolytic uremic syndrome (HUS). While the sale of unpasteurized milk is unlawful in Tennessee, it seems virtually impossible to entirely stop people intent on obtaining it. In this case, the affected families participated in a "cow share" program, in which they purchased a "share" of a cow (along with 20 or so others) from a farm which then distributes the raw milk from its herd to the "owners". This scheme skirts the issue of milk sales, as the consumers are purportedly drinking milk from their own animals

There is an almost endless list of concerning aspects to this outbreak. As is typically the case in these types of situations, the people who suffered the most harm were children, who are not the ones who made the decision about what they consumed. The implicated farm is not regulated by our Department of Agriculture, as it is not a commercial milk producer, and in the absence of a disease outbreak the Department of Health has no oversight of the facility. As soon as the outbreak was over, the farm reverted to the same situation, with no required testing or other regulatory oversight (though they did ask our department to declare them safe to reopen!).Overwhelming epidemiologic evidence and matching E. coli strains from the cows and farm environment were insufficient to convince many of this farm's consumers that the milk was the source of the outbreak (after all, we did not find it in batches of milk produced many days after the implicated lots were distributed).

Important lessons can be learned in any outbreak investigation. In this case, "social media" was a useful tool, as the farm's customers were active in a Facebook group, through which case finding and education could be done. While many consumers remained distrustful and resentful of government intervention, at least one distraught family of a very ill child subsequently agreed to videotape their story for public education about the risks of raw milk. In public health I think we are all too familiar with the seeming lack of response to presentations of data and scientific evidence, compared to the dramatic effect that a single compelling personal testimonial can have on people. When even one victim of such an event has the courage to share their story, we should do everything we can to help maximize the effect of that message to prevent future similar events.
It's extremely frustrating and sad to see outbreaks like this continue to occur, all over the country, despite widespread efforts to halt them. We will continue to fight to plug the regulatory gaps and try to stay a step ahead of creative attempts to circumvent our intention of protecting the public's health. In the meantime, vigorous investigation and intervention in outbreaks can continue to build our case, and hopefully help educate our communities (including those responsible for the health of vulnerable children).
Tim Jones, MD
State Epidemiologist
Tennessee Department of Health

Tags:  food safety  infectious disease  member spotlight  outbreak 

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