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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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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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We’ve just begun!

Posted By Jennifer Lemmings, Thursday, June 26, 2014
Untitled Document
We at the CSTE National Office spend a lot of time planning for the Annual Conference – determining the topics and the session presentations, finding plenary speakers, getting the right mix of formal sessions and informal discussion and developing networking opportunities. And then, all of a sudden, the conference is here!
We’re at the last day of the conference already, and we’ve had another excellent meeting. Attendees from all over the country gathered to discuss topics ranging from occupational health to surveillance methods to oral health to vectorborne disease. We discussed and approved occupational health and infectious disease position statements that will be posted on our website soon. In addition, Steering Committees and several subcommittees held meetings to discuss their activities in the past year and plans for the upcoming year.
The work doesn’t end with the conference. In fact, CSTE program activities are year round. This summer, CSTE has several collaborative projects and ways for you to stay or get involved.
NNDSS Modernization Initiative (NMI)
CSTE is partnering with APHL to provide technical support for CDC’s NMI on the completion of six message mapping guides (MMGs): generic guide v.2, STD, hepatitis, congenital syphilis, pertussis, and mumps. Through this collaboration, CSTE and APHL will provide technical assistance to invited state and local jurisdictions and assist them in adopting the MMGs and using them to send test case notification messages to the CDC Platform. Stay tuned for webinars, online technical guides, and other training materials to support this implementation. More information on CDC’s NNDSS Modernization Initiative can be found on the CDC website.
New Vectorborne Diseases Subcommittee
This week marked the first meeting of the new vectorborne diseases (VBD) subcommittee. This subcommittee was formed to increase knowledge and improve practices related to VBD epidemiology in local, state, tribal, and territorial settings. The subcommittee will also serve as an overseeing body for reviewing and developing national position statements on VBD-related topics. Activities will include regular conference calls, training webinars, developing white papers, and convening a pre-conference workshop at the 2015 CSTE Annual Conference. If you are interested in joining this new subcommittee, please contact Dhara Patel at the National Office.
Epidemiology Methods Subcommittee
The Epidemiology Methods Subcommittee is another new subcommittee, which aims to increase knowledge and practice of epidemiological methods in state, local, tribal, and territorial settings. The subcommittee meets monthly via conference call to address relevant and emerging topics in epidemiologic methods. The CSTE webinar library is a great place to view past training webinars from this subcommittee and other CSTE program areas—I highly encourage you to check out recent sessions.
Public Health and Primary Care Integration Subcommittee
The Public Health and Primary Care Integration Subcommittee aims to promote partnerships between health providers and public health. This subcommittee addresses community epidemiologic surveillance to support community health needs assessments, the public health interface and use of electronic health records, and sharing lessons learned from successful public health and primary care professional partnerships. Subcommittee activities include regular calls and webinars (available at the webinar library). Contact Jessica Pittman if you are interested in participating in this subcommittee.
CSTE committee conference calls are a great way to find out what’s happening in a subcommittee and participate in discussions. Don’t miss out! Upcoming calls and information can be found on the CSTE calendar.
Not sure what fits best with your interests, or have an idea to share? Call any member of our program staff. We can discuss how you can contribute and be involved. There are plenty of examples of members trying out a committee and finding something they’re passionate about, like Andrea Alvarez or Renee Calanan.
We’re looking forward to working with you!
Jennifer Lemmings
Epidemiology Program Director

Tags:  cross cutting  staff spotlight  surveillance 

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Recreational Marijuana and the role of the Colorado Department of Public Health and Environment

Posted By Sara Ramey, Thursday, April 3, 2014
Untitled Document
It started with a public vote on November 6, 2012 – the citizens of Colorado decided by a vote of 55% to 45% to legalize marijuana. This set the wheels in motion to develop a regulatory system for the production, sale, and use of marijuana. An implementation task force was established in December of 2012 to hash out the major issues. This task force grappled with issues surrounding legalization including taxation, cultivation, laboratory testing processes, and public health. By March of 2013, this task force produced recommendations that Colorado legislators turned into law by June of 2013. In just 18 months, the first set of comprehensive laws regulating marijuana in a way similar to alcohol was produced.

From a public health standpoint, Colorado is fortunate that marijuana legislation took advantage of the last 50 years of public health research on reducing tobacco use. The legislation included specific requirements to limit youth access and prevent the normalization of marijuana use. This legislation also established a specific role for the Colorado Department of Public Health and Environment (CDPHE). CDPHE was charged with monitoring changes in drug use patterns and health effects. In addition, CDPHE was charged with setting up a panel of healthcare professionals with expertise in “cannabinoid physiology” to conduct literature reviews to make science-based recommendations for policies protecting consumers and the public. In addition to the duties outlined above, CDPHE played a role in establishing laboratory testing procedures, food safety recommendations for the manufacture of marijuana-infused edible products, waste disposal requirements and prevention messaging.
In the fall of 2013, before the official legalization of marijuana, there was an “outbreak” of synthetic marijuana users presenting at emergency rooms in the Denver area with severe adverse reactions. In less than a month, there were 263 reported emergency room visits which was far greater than the normal volume. The description of this outbreak has been published elsewhere. But, more important for CDPHE were the lessons learned that could be applied to potential events associated with legal marijuana. This “outbreak” quickly brought home the point that our surveillance infrastructure was not prepared for an event related to a toxic exposure disseminated over a large geographic area. Specific lessons learned included the insensitivity of poison center call data to indicate a problem for an illicit substance, the lack of an established network of emergency room case reporters, and our inexperience in utilizing atypical disease surveillance intelligence sources such as law enforcement.

Legal marijuana activity at CDPHE began in earnest in January of 2014 as implementation funding became available. Between January and March of 2014, the CDPHE internal marijuana steering committee grew from four to 22 members, as the public health considerations of legal marijuana became clear. It has become clear that legal marijuana affects nearly every division in our organization from injury prevention, to foodborne disease investigation, to regulation of health facilities. It also has become clear that there are numerous issues that need to be addressed in new ways due to the legalization of marijuana including surveillance for acute health effects from contaminated marijuana products, safety of edible marijuana products, accidental poisonings of young children from edible products, youth prevention, use among pregnant and breastfeeding women, marijuana disposal issues, marijuana lab testing issues, substance abuse prevention, injury and impaired driving prevention, and occupational health and safety issues among growers – just to name a few.

We have just begun to develop our surveillance program. In order to monitor the prevalence of marijuana use, we have added questions to the major population-based surveys in Colorado including the Behavioral Risk Factor Surveillance System (BRFSS), the Pregnancy Risk Assessment Monitoring System (PRAMS), and the Child Health Survey (CHS). We have also started analyzing hospital discharge and emergency department data to evaluate baseline levels of marijuana-related trauma and morbidity. Procedures for foodborne illness investigations are being modified to include the consumption of marijuana. Finally, we have been working to shore up the weaknesses in our surveillance infrastructure by developing a more extensive network of case reporters from emergency rooms, law enforcement, medical toxicologists, and the poison center.

We are still learning about the potential public health implications of legal marijuana and look forward to reporting the actual outcome data as it becomes available. In the meantime, those who would like a head start if legal marijuana comes to their state can follow our progress and public outreach at www.colorado.gov/marijuana.
Mike Van Dyke, Ph.D., CIH
Chief, Environmental Epidemiology, Occupational Health, and Toxicology Section
Colorado Department of Public Health and Environment

Tags:  marijuana  member spotlight  surveillance 

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Electronic Laboratory Reporting: Opportunities for Innovation and the Public Health Workforce

Posted By Sara Ramey, Wednesday, March 19, 2014
Updated: Tuesday, March 18, 2014
Untitled Document
The Health Information Technology for Economic and Clinical Health Act (HITECH) and the associated Meaningful Use (MU) requirements represent an unprecedented opportunity for public health to benefit from greater electronic connectivity, public health reporting and population health monitoring. Health information technology innovation and improvements motivated by the MU program offer tremendous potential to improve the timeliness, quality, quantity, and efficiency of public health surveillance. This in-turn enables public health decisions makers to take action to protect their communities more rapidly and effectively. Electronic laboratory reporting and other public health MU objectives provide a bridge for public health agencies to engage healthcare professionals and health information technologists in order to link public health agencies and systems more effectively with the clinical care system. To achieve full benefits of ELR, electronic health record transformations and the MU program public health should expect there will be work flow and workforce challenges and changes.

A recent article in the Online Journal of Public Health Informatics, “Estimating Increased Electronic Laboratory Reporting Volumes for Meaningful Use: Implications for the Public Health Workforce,” describes some of the workforce challenges and opportunities faced by public health. The authors cite specific challenges around receipt of an increase in volume of laboratory reports received as a result of implementing ELR. While public health can expect to receive an increase in volume of reports received, public health will also be able to have a more complete picture of the actual disease burden in the community leading to improved outbreak detection, investigation prioritization and thus opportunities to improve disease prevention and protect the public’s health.
The benefits of ELR are widely recognized. ELR has become a critical part of the reportable disease data submission process. Many communicable and environmental diseases that are currently under surveillance across the country are identified and confirmed by laboratory observations. In some states, ELR now accounts for the first identification of as much as 60-70% of reportable diseases. Electronic laboratory reporting provides substantial increases in efficiencies, completeness, and timeliness of reporting. Timely and complete electronic laboratory reports are an important source of information for the core public health functions of disease surveillance and responding to public health events. Reduced disease identification times as a result of ELR enables states to implement disease control measures more quickly (as in identifying outbreaks of foodborne disease, excluding ill children from daycares preventing others from getting ill; or ensuring all potentially exposed contacts of invasive meningococcal disease are identified and get their prophylactic treatment necessary to prevent life-threatening disease onset). In addition, some surveillance initiatives, such as monitoring new and reemerging antimicrobial resistance (e.g., Carbapenem-Resistant Enterobacteriaceae, considered one of CDC’s top five health threats in 2014), are conducted entirely based on laboratory observation findings and are only made possible through ELR as manual data collection processes are too resource intensive.
ELR and MU are important opportunities to support the overarching goals of improving population health management to serve more than just those that seek care but make “meaningful use” of health data to improve health for all. While states will expect an overall increase in the number of reports received due to the implementation of ELR, ELR also provides opportunities to improve the efficiency and effectiveness of public health systems through innovative data collection and processing. With ELR, the public health workforce can expect to spend less time entering data into surveillance systems allowing more time to conduct actual disease surveillance and investigation work. ELR presents ideal opportunities to leverage automated technological capacity to increase reportable disease case reporting specificity and timeliness and reduce data entry burden. The public health workflow change will require initial investments of time and human resources to transform information systems. One specific example of workflow change and innovation made possible by ELR is from my home state, FL. We were able to modify existing manual work flows. After the receipt of an ELR, the results are received automatically by the general communicable disease surveillance application, processed and interpreted electronically, created or assigned to an existing case and finally reported while at the same time the disease investigators are conducting any necessary follow-up or case investigations. This pilot was implemented for a subset of diseases where receipt of ELR volume was high (hepatitis B and C) and has resulted in increased ability to fully document chronic hepatitis B and C cases while retaining our ability to detect and investigate acute infections. Analysis of the workflow change identified an overall manual data entry and processing savings of 6.3 FTEs annually.
ELR has made the act of understanding the disease burden in the community more efficient while requiring less time for hospitals and labs to provide information to public health departments. By testing innovations and disseminating lessons learned, there are unique opportunities to improve public health surveillance (and ultimately health outcomes), and improve access to timely, quality information. In summary, ELR will positively impact the health status of the community by allowing health departments to more effectively and efficiently deploy their resources to conduct investigations around the spread of disease in their jurisdictions.
Janet J Hamilton, MPH
Surveillance and Surveillance Systems Manager
Florida Department of Health

Tags:  electronic laboratory reporting  member spotlight  surveillance 

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The rocky road to complete reportable infectious disease system integration.

Posted By Sara Ramey, Wednesday, February 26, 2014
Updated: Tuesday, February 25, 2014
Untitled Document
Since the introduction of electronic disease surveillance systems, states and localities have worked to migrate disparate and siloed legacy surveillance systems into more integrated surveillance platforms. The goals for surveillance system integration are to utilize national standards, reduce redundancy, streamline reporting, understand disease and risk factor interactions, and increase data sharing. However, the costs, benefits and obstacles of achieving complete disease surveillance system integration are poorly understood.

CDC’s Program Collaboration and Services Integration (PCSI) program recommends integration and data harmonization of disease surveillance that currently exists both in CDC-supported legacy systems (i.e., eHARS, STD*MIS) and in state-based electronic disease surveillance systems (NEDSS) (1). While the 2010 CSTE assessment of states’ NEDSS capacity identified 34 (71%) states with some degree of integration, an increase from 23 states in 2007 (2), there are few states and localities to have fully integrated all legacy reportable infectious disease surveillance systems.
In 2013, the North Carolina completed customization of modules for reporting, case management, and entry of contact investigation data of HIV and syphilis cases. Legacy systems, eHARS and STD*MIS respectively, were converted into modules within a customized commercial-off-the-shelf NEDSS product which already included modules all reportable communicable diseases including vaccine preventable disease, sexually transmitted diseases, and tuberculosis (TB).
The conversion process began in 2010 following implementation of TB and general communicable disease modules in 2006 and 2008, respectively. The integration required conversion and harmonization of hundred of case report data fields and laboratory results fields from the legacy systems. The mapping of data fields from eHARS to North Carolina’s NEDSS additionally required a corresponding extract mapping back into eHARS in order to report data to CDC. New releases of eHARS will necessitate continual validation of these extract maps until CDC is able to receive HL7 message feeds into NNDSS. The two-year process involved more than approximately 6,500 person-hours. Following integration, de-duplication of more than 20,000 case records was required prior to system roll-out to local health departments.
A completely integrated NEDSS platform will provide the opportunity to monitor disease overlap geographically within population subgroups, and to evaluate the effectiveness of the delivery of integrated public health program services. While an integrated system provides new surveillance opportunities, the process was long, complex, and expensive; and many challenges still remain. State and local health departments considering complete reportable infectious disease surveillance system integration should weigh the informatics challenges and personnel expenditures with the opportunities to enhance program integration.
Megan Davies, MD
State Epidemiologist
North Carolina Division of Public Health


  1. CDC. Program Collaboration and Service Integration: Enhancing the Prevention and Control of HIV/AIDS, Viral Hepatitis, Sexually Transmitted Diseases, and Tuberculosis in the United States. Atlanta (GA): U.S. Department of Health and Human Services, Centers for Disease Control and Prevention; 2009.
  2. CDC. State Electronic Disease Surveillance Systems – United States, 2007 and 2010. MMWR. 2011; 60(41): 1421-1423.

Tags:  infectious disease  member spotlight  surveillance 

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Navigating Cancer Clusters

Posted By Sara Ramey, Wednesday, February 19, 2014
Updated: Wednesday, February 19, 2014
Untitled Document
In most states, public health professionals struggle with response to citizen calls reporting a suspected cancer cluster. Calls of this nature are not uncommon and often involve high levels of anxiety, mistrust of the public health agency and a sense of urgency on the part of the citizen. When environmental contaminant concerns are thrown into the mix the response becomes even more complex and media attention and lawsuits often follow.

The recently published MMWR “Investigating Suspected Cancer Clusters and Responding to Community Concerns” (MMWR1993;62(No.RR-8) presents new guidelines developed by a joint CDC and CSTE workgroup tasked with updating the 1990 MMWR guidelines for investigating clustering of health events. Things have changed in public health since 1990: all states have a cancer registry and access to record level data on cancer patients, statistical tools have expanded including geospatial analysis, and geocoding of data has become a norm. These new tools are discussed in the guidelines.
Public expectations have changed since 1990 as well; the internet is accessible to most and search of public websites and blogs are one new way citizens communicate and gather information during a cluster inquiry. Communication with the public has always been a key component of these investigations and this aspect was highlighted in the new guidelines. Emphasizing the importance of community communication, the guidelines recommend earlier partnership with all community partners in these situations. In addition, the CDC also collaborated with the National Public Health Information Coalition (NPHIC) to develop a document “Cancer Clusters” A Toolkit for Communicators” Both of these documents are on the CSTE website for membership use. Both documents recognize that ineffective communication can rapidly spin these situations out of control and put the public health agency in an adversarial light.
We only need to look toward recent news articles to understand the national picture on cancer clusters. In December 2013, ATSDR found that mothers at Camp Lejeune Marine Base in North Carolina with first trimester exposures to PCE, vinyl chloride, or DCE were more likely to have a child with leukemia or non-Hodgkin lymphoma compared with unexposed mothers although higher exposures did not increase the likelihood that the child would have these cancers. In May 2013, an 11-year study of the incidence of brain cancer associated with the Pratt & Whitney jet engine plant in Connecticut ended with university researchers saying they found no statistically significant elevations in the rate of cancer among workers related to exposures to contaminants. In January 2014, the Minnesota Department of Health found normal cancer rates for the Como neighborhood near the General Mills plant in Minneapolis despite concerns about elevated levels of solvent vapors detected in the soil. And in Clyde Ohio, the Ohio Department of Health has been investigating contamination concerns and cancer rates in the areas surrounding a Whirlpool facility for a number of years without resolution. My home state, Florida, has had some high profile investigations in recent years as well.
Please take some time to read these documents and share the links . Having a state specific protocol and guidelines in place in your own state before an event of this nature happens may be the key to successful resolution of cancer cluster calls and inquiries.
Sharon Watkins, PhD
Florida Department of Health

Tags:  cancer  chronic disease  member spotlight  surveillance 

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Charting an Epidemic, Confronting an Epidemic

Posted By Sara Ramey, Wednesday, February 12, 2014
Updated: Wednesday, February 12, 2014
Untitled Document
The governor of Vermont got a lot of attention when he dedicated his entire State of the State address to one topic: heroin. That attention was highly warranted because opioid abuse, prescription and non-prescription alike, is a major epidemic in this country, and epidemiologists are charting this epidemic and its consequences in many ways.

Prescription monitoring programs seek patterns consistent with “doctor shopping”, forgery and other diversion. Substance abuse programs track drug seizures and treatment admissions to follow patterns of abuse. Epidemiology programs track newly diagnosed cases of hepatitis C. Overdoses and overdose deaths are tracked in emergency departments and through vital records. All of these important surveillance systems track the underlying problem (addiction and substance abuse) and the consequences (overdose, infection, interaction with the criminal justice system). But, beyond counting, the epidemiologist must also be an advocate for using the data for action.
In Massachusetts, between 1990 and 2010, drug overdose deaths tripled, exceeding motor vehicle related death rate in 2000, and doubling it by 2010. These observations led to resources for the technical and programmatic enhancement of the prescription monitoring program and, in 2007, the initiation of a naloxone (Narcan®) program to train first responders, public safety officials and family members to administer the opiate receptor antagonist naloxone by nasal spray to potential overdoses. The program has resulted in the reversal of over 2,000 overdoses, so far, and an instance where drug users followed a police car to alert them so that they could reverse an overdoses. The philosophy is that one has to survive to kick the habit. Driven by the data, federal and state funding has also gone to community prevention programs and multi-community Opioid Abuse Prevention Collaboratives.
The Massachusetts Department of Public Health has observed increasing numbers of reported cases of hepatitis C virus infection in people between the ages of 15 and 25; the rate almost doubling between 2002 and 2012, while newly diagnosed cases went down in other age groups. These 15-25 year-olds almost certainly acquired their infection well within the previous 10 years. While much attention has been appropriately directed toward the hepatitis C epidemic in the “baby boomer” generation, hepatitis C in adolescents and young adults represents a new epidemic wave of hepatitis C. All indications are that these infections were acquired through injection drug use. Interviews are difficult to obtain, but the most common story is prescription opioid use leading to injection of prescription opioids and heroin. Heroin is cheaper than prescription drugs and all too available. Because of the difficulty in getting enough data from interviews to explore the networks of transmission of hepatitis C among adolescents and young adults, we are exploring sequencing of hepatitis C viruses that come to our public health laboratory to try to use the virus RNA sequences to construct networks. There hasn’t been much HIV co-infection yet, but that may be just a matter of time before that virus is introduced into these networks.
While the hepatitis C data are overwhelming, both in their implications for the future and the sheer number of new reports (in Massachusetts, now one to two thousand positive laboratory reports for hepatitis C in the age group each year), an approach to this massive epidemic is not easily identified. Of course, there should be every and all attempts to prevent and treat addiction. But what can be done in the meantime? As epidemiologists and public health professionals, we cannot just watch this tsunami of hepatitis C cases without actively encouraging the use of data to inform interventions, be they harm reduction approaches directed at safer injection or using observational data and network analysis to identify means of getting prevention and treatment messages to those at risk and infected.
Alfred DeMaria, MD
State Epidemiologist
Massachusetts Department of Health

Tags:  infectious disease  member spotlight  substance abuse  surveillance 

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