Posted By Jeffrey Engel, MD,
Friday, December 6, 2019
Updated: Friday, December 6, 2019
In August, CSTE activated its Concept of Operations (ConOps) Plan for emergency response for the first time. The activation was in reaction to the emerging epidemic of vaping associated lung injury in the United States. That week, there were reports of outbreaks from Illinois and Wisconsin in Epi-X, CDC’s emergency communication system, and a few days later I received a call from Minnesota State Epidemiologist, Ruth Lynfield, that her state was experiencing a similar outbreak. She was concerned about the lack of a national response given the three-state experience and anecdotal reports coming in from other states, such as Utah, California, and Massachusetts.
I quickly learned that the CDC already had three Centers involved: Injury, Environmental Health, and Chronic Disease (Office of Smoking and Health) all under the Deputy Director of Non-Infectious Diseases, and that they were managing the outbreak through a multi-state Epi Aid sending CDC Epidemic Intelligence Officers (EIS) to affected states for technical assistance. These Centers had little experience with national public health emergency responses and by August 20, well into the outbreak with hundreds of cases emerging (according to media reports) there was no central epidemiological response organized to begin surveillance, and collect and analyze case data from affected states; nor methods of lab testing of human samples and vaping fluids; nor investigations through usual mechanisms of establishing standardized case definitions, medical chart abstraction forms, and patient questionnaires. Thus, on August 21, CSTE activated its ConOps (the first organization or agency to do so) to assist states and the federal government with a national epidemiological emergency response.
I’ll stop the chronologic story telling here (as most are aware of the ongoing vaping-associated lung illness outbreak) and shift focus of this article to the ConOps process and impact on the CSTE National Office. Response to public health emergencies involves, in one way or another, activation of an incident management system. The system’s intent is to better manage and align people in an organization, ensure accurate and timely communications among stakeholders, and execute a plan that leads to a response, and eventual de-escalation back to normal operations. When CSTE activated, some staff had new job titles, reporting channels, and new responsibilities (within their skillsets), and once a new work flow was established, a daily rhythm was set. All CSTE departments were involved including program, communications, finance, information technology, and human resources.
CSTE was in Incident Command mode for nearly five weeks when we held an after-action review to discuss lessons learned and de-escalation. Importantly, we learned lessons around the activation levels articulated in our original ConOps plan, differing staff and supervisory roles, and mechanisms by which the national office staff remains updated on the emergency response and in turn provides CSTE members with regular updates. As of the writing of this blog, CSTE remains in ConOps activation and the vaping associated lung injury national outbreak continues with about 200 new cases reported per week. The CSTE-led Epi Task Force leads federal and state partners in the epidemiological response through regular calls, technical assistance, and critical communications. At this time of this writing, It appears we will scale down to a Level 1 or complete deactivation in the near future, as CDC stabilizes their new surveillance system for disease notification, analysis, and response. Overall, I am pleased CSTE has been able to execute this emergency response to the EVALI outbreak and have already discussed modifications to the ConOps plan for future emergency and/or outbreak responses.
Dr. Jeffrey Engel has been CSTE’s Executive Director since 2012. Prior, Dr. Engel was the State Health Official (2009-2012) and State Epidemiologist (2002-2009) in North Carolina and served on the CSTE Executive Board as the ID Steering Committee Chair from 2008-2009.
Posted By Stephen Clay,
Friday, September 29, 2017
Updated: Tuesday, September 26, 2017
One of CSTE’s primary objectives is to increase epidemiology and surveillance capacity in state, local, tribal and territorial jurisdictions through various programmatic and workforce capacity building initiatives. The CSTE Vector-Borne Diseases Subcommittee facilitates peer to peer technical assistance consultations to support new and less established vector-borne disease surveillance coordinators and staff. These consultations may include an orientation to the surveillance system, guidance and program requirements and day-to-day systems management.
Michael Mudgett and Zoilyn Gomez, epidemiologists at the California Tribal Epidemiology Center (CTEC), recently participating in a peer to peer technical assistance consultation supported by CSTE with staff at the Louisiana Department of Health (LDH). CTEC is one of 12 Tribal Epidemiology Centers that provide epidemiological support to each Indian Health Service region and work directly with both tribes and Indian Health Programs. CTEC monitors the health status of American Indian/Alaska Natives (AIAN) in California to develop effective public health services for their respective AIAN populations.
To begin building a foundation for vector-borne disease (VBD) surveillance capacity, Michael and Zoilyn traveled to Louisiana to work with the Infectious Disease Epidemiology Section (IDEpi) within the LDH Office of Public Health in New Orleans. CTEC’s main goal was to gain a better overall understanding of VBD surveillance in order to increase surveillance capacity within tribal jurisdictions in California. Chrissie Scott-Waldron (Public Health Epidemiologist Supervisor), Julius Tonzel (Public Health Epidemiologist) and Sean Simonson (Public Health Epidemiologist) coordinated the technical consultation visit at LDH and they were all very gracious, accommodating and helpful in answering questions throughout the consultation.
Much of the consultation consisted of engaging on various aspects of VBD disease surveillance, ranging from orientations of databases and surveillance systems, demonstrations of integrated mosquito management including various traps, mosquito species identification, rearing rooms, biological control and adulticiding/larviciding equipment, touring laboratories for human and ecologic testing and other sites vital to the VBD program.
Pictured: A shot of downtown New Orleans. Photo credit: CTEC
We were quickly brought up to speed about IDEpi through introductions and key personnel presentations. Throughout our first day, we reviewed the various types of databases and surveillance systems utilized for VBD and visited the New Orleans Mosquito and Termite Control Board. At NOMTCB, we learned about the actual controlling and surveilling of the mosquito population, especially with the amount of standing water and high humidity in the area. Dr. Sarah Michaels demonstrated the various types of mosquito traps used around the city. Interestingly, we learned just how much Zika-virus potential is in the area since the mosquito Aedes aegypti is prevalent.
One of the biggest issues in the area with mosquitos breeding and standing water is that of disposed car tires. Many tires were simply dumped in areas like New Orleans East, which causes interesting problems for public health to handle. It was surprising that there were so many tires that needed to be disposed of in the area, and how the people contracted to dispose of the tires are finding it increasingly difficult to keep up with the demand.
The presentations given by the great staff at IDEpi provided a unique opportunity to see how VBD surveillance works behind the scenes with electronic lab reporting, database management, lab testing, interaction with providers and the Zika Pregnancy Registry.
Pictured (L-R): Randy Vaeth, Sean Simonson, Chrissie Scott-Waldron, Kyle Moppert, Zoilyn Gomez, Julius Tonzel and Mike Mudgett. Photo credit: Louisiana Department of Health.
One interesting conversation on Day 2 was the public perception of public health services. In recent years, the public has been debating whether they believe the risk of spraying is worth the reward of having a mosquito population controlled. We found this intriguing since the general public in California is no stranger to debating public health services and whether certain services are perceived to be more harmful than good. However, it was clear to see the vital role these entities play in controlling the mosquito populations.
Following the Mosquito Control facility tour, the group headed to the ecologic arboviral testing lab at the Louisiana Animal Disease Diagnostic Laboratory, where Dr. Alma Roy gave a tour of their facility and shared information on the comparable lab in California. She described in detail how they tested mosquitoes for endemic and important arboviral diseases via PCR, in addition to testing various animal reservoirs for these diseases.
Next, we visited the West Baton Rouge Mosquito Control District, a small yet impressive two-person operation, before rounding out the day at the Louisiana Office of Public Health State Laboratory. We toured the facility and saw how the lab conducts molecular and serologic testing to report out human results to IDEpi. It was inspiring to see the great relationships IDEpi had with all of these sites.
On our final day, we met with the CDC Epidemic Intelligence Service (EIS) Officer, Dr. Alean Frawley, where she provided insight on her role. Megan Jespersen, Surveillance Epidemiologist and Tribal Liaison, also gave us an overview of the Louisiana Early Event Detection System, which is Louisiana’s Syndromic Surveillance System, and the Louisiana Indian Health Surveillance.
Overall, the consultation was very valuable, as we received what we sought from the trip: foundational knowledge and technical guidance about VBD to support a younger public health entity. The consultation provided ample opportunity for us to bring back technical knowledge about VBD surveillance to CTEC. We hope to implement what we learned in our future work and thank CSTE and the Louisiana Department of Health for this opportunity.
Posted By Emily J. Holubowich ,
Friday, May 19, 2017
Updated: Friday, May 19, 2017
May 5 was filled with ups and downs on the public health funding front. On the upside, federal spending legislation for fiscal year (FY) 2017 was signed into law, bringing long overdue closure to public health funding—eight months into the fiscal year. All things considered, CSTE’s funding priorities fared well given that funding for the Centers for Disease Control and Prevention (CDC) was cut by $13 million. Funding for the National Center for Emerging and Zoonotic Infectious Diseases (NCEZID) increased by about $5 million, including a $3 million increase for the antibiotic resistance (AR) initiative and a $2 million increase for food safety. As always, we would expect much of NCEZID’s funding to support core infectious disease surveillance capacity at state and local health departments through Epidemiology and Laboratory Capacity (ELC) grants. This funding would be in addition to $40 million from the mandatory Prevention and Public Health Fund (PPHF) provided to ELC grants for the sixth consecutive year. Other NCEZID initiatives—vectorborne disease, advanced molecular protection, hospital acquired infections, National Healthcare Safety Network—were all flat funded.
On the downside, the Public Health Workforce program, through which the CDC/CSTE Applied Epidemiology Fellowship receives funding, was cut by $2 million. The appropriations bills do not specify how much funding would be dedicated to the Applied Epidemiology Fellowship program per se, but we should expect this cut to have an impact on future fellowships.
Photo credit: Emily J. Holubowich
While many were cheering the passage federal spending legislation and the avoidance of a government shutdown on May 5, the House of Representatives resurrected and passed by one vote the American Health Care Act (AHCA) as part of its efforts to “repeal and replace” the Affordable Care Act (ACA). If enacted, the legislation would terminate the PPHF beginning in FY 2019. The loss of the nearly $1 billion PPHF would result in a 12 percent cut to CDC’s total budget and a significant reduction or elimination of funding to many state and local public health programs—ELC, immunizations and the Preventive Health and Health Services Block Grant among them.
Upon its passage in the House, the Senate almost immediately rejected the AHCA, with leadership announcing their intentions to move forward in drafting their own ACA repeal legislation. A working group of 13 GOP Senators representing centrists and conservatives is working to craft a compromise, and another small group of Republicans and Democrats led by Senators Susan Collins (R-ME) and Bill Cassidy (R-LA) are simultaneously working to craft an ACA “repair” package that can garner support on both sides of the aisle. In sum, as the future of the ACA repeal is murky at best one thing is clear: don’t expect any swift action from the “World’s Greatest Deliberative Body.”
All eyes now turn to FY 2018, and the release of the President’s budget on May 23. The full budget will provide more information about the administration’s specific funding priorities—we’re anticipating cuts and consolidations galore! But of course, it will be up to Congress to ultimately decide how to prioritize spending. The budget resolutions that will emerge from the House and Senate Budget Committees in June will set the tone for ongoing discussions about public health funding and largely determine the fate of spending bills going forward. Deep cuts to spending in the budget resolutions will be rejected by Democrats, making it nearly impossible to move any appropriations legislation—legislation that will require bipartisan support to clear either chamber.
For more information about funding levels for your specific priorities, please click here for a copy of the omnibus spending legislation, and click here for a copy of the accompanying report that provides more detailed instructions about public health funding levels and intended purposes.
Emily Holubowichis Senior Vice President at CRD Associates and serves as CSTE’s Washington representative, leading our advocacy efforts in the nation’s capital.
Posted By Janet Hui , MPH,
Friday, April 7, 2017
Updated: Friday, March 31, 2017
This February, CSTE attended the 2017 HIMSS Annual Conference and Exhibition in Orlando, Florida. HIMSS – the Healthcare Information and Management Systems Society – is a global non-profit whose mission is to improve health through information technology. Their annual conference is one of the largest health IT conferences in the world, with over 40,000 representatives from health care and health IT attending this year. The enormous HIMSS exhibit hall featured some of the biggest names in health care and technology, such as Allscripts, Cerner, Epic IBM and many others.
This year, CSTE was invited by CDC to participate in the HIMSS Interoperability Showcase to demonstrate the Reportable Conditions Knowledge Management System (RCKMS). The Interoperability Showcase is a guided exhibit at HIMSS, where companies and organizations partner together and demonstrate how different technologies can work together to address a health problem. For our use case, CSTE partnered with the Association of Public Health Laboratories (APHL), Utah Department of Health, Epic and others to demonstrate how new technologies and standards can be used to enhance public health (PH) surveillance. Together, we demonstrated the electronic case reporting flow for a potential case of Zika virus infection.
During the Showcase, we simulated a patient visiting a clinic in Utah and receiving a positive PCR result for Zika virus, which triggered the process of PH reporting. The clinic’s EHR, represented by Epic, built and sent an initial electronic case report (elCR) to the APHL AIMS platform, which invoked the RCKMS decision support service to determine that this potential case should be reported to Utah Department of Health. AIMS routed the eICR and a Reportability Response (RR) to the Utah Department of Health and a RR to the Epic EHR system. Utah consumed the eICR and RR into their surveillance system, and Epic received and processed the RR.
Pictured: CSTE staff member Janet Hui leads a demonstration of the Reportable Conditions Knowledge Management System (RCKMS) during the 2017 HIMSS Conference in Orlando, FL.
Overall, CSTE’s participation in this year’s HIMSS Conference was very productive in educating attendees on CSTE’s role in the work of public health reporting, RCKMS and other technology currently being developed in the surveillance/reporting realm. The Conference presented a great opportunity to engage fellow public health professionals on the ongoing work of RCKMS, and I look forward to participation in future HIMSS Conferences.
Janet Hui is CSTE’s Associate Research Analyst on the RCKMS initiative. For more information about the ongoing RCKMS work or other projects in the Surveillance/Informatics area, contact Janet at email@example.com.
Posted By Jeremy Arieh and Emily Holubowich,
Thursday, March 23, 2017
Updated: Thursday, March 23, 2017
Each year, members of CSTE’s executive leadership team visit Washington, DC to meet with key Congressional offices on behalf of the applied epidemiology profession. Advocacy is one of CSTE’s integral functions, and the activity is a key component of the overall CSTE mission. On March 8-9, President Joe McLaughlin of Alaska, President-Elect Janet Hamilton of Florida, Secretary-Treasurer Sarah Y. Park of Hawaii, Senior Board Advisor Tim Jones of Tennessee and Executive Director Jeff Engel attended meetings with members of the U.S. House and Senate, and the Centers for Disease Control and Prevention’s (CDC) Washington office as part of the 2017 “Hill Day.”
Pictured (L-R): Janet Hamilton, Jeff Engel, Tim Jones, Sarah Park, Emily Holubowich and Joe McLaughlin attend CSTE Hill Day at the U.S. Capitol.
Led by CSTE’s Washington representative Emily Holubowich, advocacy efforts during this year’s Hill visits hinged upon the preservation of CDC’s Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) funding, which in fiscal year 2016 awarded over $240 million to help states detect, prevent and respond to the growing threats posed by infectious diseases, including foodborne and vaccine-preventable diseases. In particular, CSTE’s meetings focused on proposed cuts to the Prevention and Public Health Fund (PPHF) as part of legislation to repeal and replace the Affordable Care Act (ACA). The loss of the PPHF would deal a $900 million blow to the CDC’s budget, and a $50 million blow to epidemiology capacity at the state and local level. This funding comprises around 12 percent of the CDC’s overall budget, and it is a vital aspect of our nation’s public health infrastructure. Cuts of this magnitude could severely hamper core CDC programs, such as immunization, workforce capacity, vector-borne disease management and more.
With the House’s introduction of the American Health Care Act (ACHA) to repeal the ACA earlier in the week, this year’s Hill visit was very well-timed, as CSTE leaders spoke to the proposed PPHF cut during meetings with Senate and House staff. Our packed March 8th agenda began with an ASTHO briefing at the Capitol Visitors Center. The briefing featured panel discussions on hot topic issues, such as Zika prevention and opioid addiction. CSTE Senior Board Advisor and Tennessee State Epidemiologist Tim Jones joined a panel of state health department experts from Georgia, Florida and Minnesota to convey his experiences during Tennessee’s Zika response.
Pictured: Tim Jones highlights Tennessee’s Zika response during an ASTHO panel, entitled Zika Response: State & Territorial Public Health Acting to Protect America’s Health.
From there, CSTE attended meetings with Senate and House staffers, including the offices of Sen. Lisa Murkowski of Alaska, Sens. Marco Rubio and Bill Nelson of Florida, Sen. Brian Schatz of Hawaii, Sen. Richard Burr of North Carolina, Sens. Lamar Alexander and Bob Corker of Tennessee and Sen. Chris Coons of Delaware. Meetings were held with staff of the Senate Health, Education, Labor & Pensions (HELP) Committee and Senate and House Appropriations Subcommittees on Labor, Health and Human Services, Education & Related Agencies. Our Hill visits concluded with a meeting with staff at the CDC Washington offices on March 9th.
Pictured: CSTE leadership met with staff in the offices of Sens. Richard Burr, Lisa Murkowski, Marco Rubio, Brian Schatz and several others.
As part of our ongoing advocacy efforts, CSTE once again partnered with the Association of Public Health Laboratories (APHL) in co-signing request letters to Senate and House appropriators urging support of CDC’s core epidemiology and laboratory programs in the FY 2018 federal budget. The letters emphasize the need for vital funding of Emerging and Zoonotic Infectious Disease prevention and Public Health Workforce and Career Development.
Our presence on Capitol Hill was more important than ever. Last week, President Trump provided a preview of his FY 2018 budget and proposed an 18 percent cut to HHS. The high-level budget summary does not specify the level of cuts to CDC, but one must assume that the full budget released in May will include deep cuts given the cuts proposed for the Department itself. CSTE will continue to educate lawmakers about the value of disease surveillance activities at the state and local levels, and work with our partners in the public health community to protect CDC from further cuts.
Click HERE to view a table of ELC and HAI funding for each state in FY 2016.
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 theLouisiana 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.
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.
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.
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.
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.