On June 9, the House Appropriations Committee advanced its Fiscal Year (FY) 2027 Labor, Health and Human Services, Education, and Related Agencies (Labor-HHS) funding bill. While the bill proposes to cut overall funding for the Centers for Disease Control and Prevention (CDC), it included some encouraging signs for public health priorities CSTE has long emphasized on Capitol Hill. 

The bill includes proposed funding increases for two programs that are foundational to the work of applied epidemiologists nationwide: Public Health Data Modernization and the Epidemiology and Laboratory Capacity (ELC) program. These increases reflect something less visible but equally important: the ongoing efforts of CSTE and its members to educate Congress about what strong public health infrastructure looks like in practice. 

The bill includes $230 million for Public Health Data Modernization, a $45 million increase over FY 2026. This program supports the modernization of public health data systems within state, Tribal, local, and territorial (STLT) jurisdictions and at the CDC. For applied epidemiologists in the field, modern data systems mean faster detection of outbreaks, clearer situational awareness, and more timely responses to emerging threats.  

Additionally, the bill includes $55 million in base funding for the ELC program, a $15 million increase over FY 2026. The ELC program, which has been flat funded at $40 million since FY 2011, supports applied epidemiologists who investigate outbreaks, conduct surveillance, analyze trends, and translate data into action.  

Together, these investments reinforce a message CSTE has emphasized for years: Public health depends on both modern data and a strong, well-supported workforce. One without the other limits the ability of health departments to protect their communities. 

CSTE has intentionally focused on educating policymakers about how applied epidemiology works in practice. Every March, the CSTE Executive Board and other state epidemiologists travel from across the country to Washington, DC to meet with their Members of Congress and congressional staff, sharing firsthand experiences from their states, territories, and jurisdictions. 

These meetings are consistently impactful. Congressional staff speak with countless organizations every year, yet because of the on-the-ground examples shared by CSTE, many offices remember CSTE’s visits and look forward to them. Offices are often eager for updates, asking what applied epidemiologists are seeing on the ground in legislators’ communities, how disease patterns are changing, and what new challenges STLT health departments are navigating. Year after year, CSTE has built a reputation as a credible, unbiased source of practical expertise. 

That trust has positioned CSTE as a resource when emerging issues arise. Whether responding to questions about Ebola, hantavirus, measles, or other public health threats, congressional offices turn to CSTE for clear, evidence-based insight rooted in real-world experience. These conversations help lawmakers better understand how federal investments translate into staffed teams, stronger investigation, and faster responses in communities across the country. 

At the same time, the broader conversation around federal public health funding continues to underscore the need for ongoing education about the role and reach of the CDC. CDC’s impact reaches far beyond Washington, as 83% of funding for epidemiologic activities in state health departments come from federal sources. In practical terms, CDC funding supports the infrastructure and workforce that protect communities every day. 

This reality reinforces why CSTE’s engagement with Congress remains so important. By elevating the voices of applied epidemiologists, CSTE helps ensure policymakers understand how federal public health programs function in practice and why sustained support for data, workforce, and scientific expertise is essential. 

Now that the House LHHS bill has moved through the committee, it will be considered by the full chamber on the floor of the House of Representatives. It is important to note that the House proposal represents just one step in the FY 2027 appropriations process. The Senate Appropriations Committee is currently working towards releasing their own Labor-HHS bill, and the two chambers will negotiate final funding levels in the months ahead. 

As that process moves forward, CSTE will continue to do what it has done year after year: bring the stories from the field to Capitol Hill and serve as a trusted resource. The proposed increases for Public Health Data Modernization and ELC program demonstrate the impact of ongoing, member-driven education, and highlight the importance of continuing this work to strengthen the nation’s public health system. 

Victoria Barahona is Senior Policy Associate at CRD Associates, LLC, which represents CSTE’s interests on Capitol Hill in Washington, DC. 

In early April, the White House released the President’s Fiscal Year (FY) 2027 Budget Request outlining the Administration’s funding and policy priorities for the coming fiscal year. The budget proposes several changes at the Centers for Disease Control and Prevention (CDC).

The proposal reflects significant shifts in CDC’s funding streams, program alignment, and organizational structure, including proposals that were offered last year and rejected by Congress. If enacted, many of these proposed changes would have direct implications for state, Tribal, local, and territorial (STLT) public health jurisdictions and the applied epidemiology workforce that relies heavily on CDC funding to carry out core public health functions.

Below is a high‑level summary of key elements included in the FY 2027 proposal. 

CDC Overview

The administration proposes $5.280 billion for CDC, a 43% decrease from FY 2026. This figure reflects reductions to CDC’s topline budget and does not account for funding for certain programs proposed to be transferred out of CDC as part of the Administration’s broader HHS reorganization. When accounting for funding proposed to be transferred from CDC to the new Administration for a Health America (AHA), the net reduction to programs historically administered by CDC is more than 30% compared to FY 2026.

• The budget includes $280 million for Public Health Data Modernization, an increase of $65 million—however the proposal also realigns funding for the Center for Forecasting and Outbreak Analytics (CFA) and the Response Ready Enterprise Data Integration (RREDI) Platform within the data modernization account.
  
• The Epidemiology and Laboratory Capacity (ELC) program would receive $40 million, level-funded compared to FY 2026. Additionally, the budget requests $927.8 million for the National Center for Emerging and Zoonotic Infectious Diseases (NCEZID), an increase of $94 million from FY 2026. 
  
• The budget includes an additional $45 million to support the continued implementation of the Biothreat Radar Detection System, an early warning capability designed to rapidly detect novel pathogens through expanded traveler based genomic surveillance, advanced molecular detection, and integration of existing CDC data via the RREDI platform.
  
• The budget proposes the elimination of the Prevention and Public Health Fund (PPHF) a critical source of funding for public health activities in STLT jurisdictions.
  
• The Public Health Emergency Preparedness (PHEP) program would receive $350 million, a $385 million decrease from FY 2026. 
  
• The Public Health Infrastructure and Capacity (PHIC) program would receive $260 million, a $100 million decrease from FY 2026. 

The budget includes two legislative proposals, which are suggestions that the Administration is making to Congress, but cannot be implemented without congressional action:

1. CDC continues to seek authority to set data reporting requirements to improve data reporting from health care providers to public health authorities.
2. CDC seeks the ability to convert CDC fellowship and training program appointments to term or permanent positions in competitive service within 12 days of program completion, without having to use the competitive examination and hiring process. 

Agency Changes

• The Administration proposes establishing the Administration for a Healthy America (AHA)—consistent with the FY 2026 proposal—as part of broader Department of Health and Human Services (HHS) reorganization efforts. 
• Under the AHA proposal, a number of programs would be consolidated and relocated from across HHS, including programs currently housed within the Office of the Assistant Secretary for Health (OASH), Health Resources and Services Administration (HRSA), Substance Abuse and Mental Health Services Administration (SAMHSA), and several CDC centers, such as:
  • National Center for Chronic Disease Prevention and Health Promotion 
  • National Center for Injury Prevention and Control
  • National Center on Birth Defects and Developmental Disabilities 

• The budget also proposes creating a new National Center for Chemicals and Toxins within CDC, bringing together related environmental and occupational health programs currently located across HHS, including:

• National Institute for Toxicological Research (FDA)
• Agency for Toxic Substances and Disease Registry (CDC)
• National Institute for occupational Safety and Health (CDC)
• National Center for Environmental Health (CDC)
• National Institute of Environmental Health Sciences (NIH)

• Additionally, the proposal includes a new $300 million grant program, consistent with the FY 2026 proposal, that would consolidate federal grant funding for hepatitis, sexually transmitted infections, and tuberculosis into a single program.

Additional Agency Changes

The budget proposes eliminating the following CDC programs:

• Tobacco and Prevention Control
• Nutrition, Physical Activity, and Obesity
• School Health
• Vision and Eye Health
• Inflammatory Bowel Diseases
• Interstitial Cystitis
• Excessive Alcohol Use
• Chronic Kidney Disease
• Chronic Disease Education and Awareness
• Prevention Research Centers
• Heart Disease and Stroke
• Diabetes
• National Diabetes Prevention Program
• Oral Health
• Arthritis
• Epilepsy
• National Lupus Patient Registry
• Racial and Ethnic Approaches to Community Health (REACH)
• Million Hearts®
• National Early Child Care Collaboratives
• Hospitals Promoting Breastfeeding
• Safe Motherhood/Infant Health
• Adverse Childhood Experiences
• Firearm Injury and Mortality Prevention Research
• Drowning
• Elderly Falls
• Other Injury Prevention Activities
• Injury Control Research Centers

As a reminder, Congress—not the Administration—has the authority to determine final funding levels and programmatic decisions through the appropriations process. Lawmakers may approve, reject, or modify the President’s proposals as they draft and negotiate FY 2027 appropriation bills. CSTE will continue to closely monitor developments and engage with policymakers to emphasize the importance of sustained, flexible investments in CDC, Public Health Data Modernization, the Epidemiology and Laboratory Capacity program, and other essential public health efforts.

That engagement is already well underway. In March alone, CSTE hosted a record‑breaking Hill Day, bringing 33 state epidemiologists and CSTE Executive Board members to Washington, DC for 56 educational meetings with congressional offices. During those conversations, members shared firsthand experiences about outbreak response, data modernization, workforce challenges, and the day‑to‑day realities of protecting public health in their jurisdictions.

Notably, many Hill staff and Members recognized or referenced their state epidemiologist by name and recalled specific examples previously shared demonstrating the lasting impact of consistent engagement and trusted relationships. These connections underscore the value of CSTE’s long‑term educational efforts and reinforce why continued advocacy is critical as Congress weighs decisions that will shape CDC funding and public health capacity for years to come.

CSTE will continue to monitor developments throughout the FY 2027 appropriations process and work with policymakers to ensure that decisions reflect the needs of the applied epidemiology workforce and the communities they serve.

Victoria Barahona is Senior Policy Associate at CRD Associates, LLC, which represents CSTE’s interests on Capitol Hill in Washington, DC.

Throughout CSTE’s 75-year history, the organization has supported health departments in five U.S. territories and three freely associated states.

"These health departments bring unique strengths to public health, including longstanding community relationships, cultural insight, and the ability to innovate in resource-limited environments with unique geographic and logistical issues," said Melissa Powell, CSTE's Director of Preparedness & Response. "Their work offers valuable insights for all jurisdictions."

To learn more, we spoke with Patrick Sotto, the Territorial Epidemiologist for the Guam Department of Public Health and Social Services and a former CSTE Applied Epidemiology Fellow (AEF). His path to this role, and his recent work preparing for the next big threat, offers a window into the challenges—and rewards—of public health in the Pacific.

Sotto's route to epidemiology was not a straight line. As an undergraduate moving between Guam and California, he considered careers in orthopedic surgery and even tailoring. What stuck was his love for the analytical side of science. "I would go through the syllabus and start working on projects before the semester even began," he recalls. When a professor suggested epidemiology, everything clicked. He reached out to the only two epidemiologists on the island, which led to a summer internship. That local foothold became his foundation.

Years later, after a crash course in public health during the COVID-19 response, Sotto saw an opportunity. The sitting Territorial Epidemiologist was planning to retire, and Guam happened to be an active host site for the CSTE fellowship program that year. Sotto applied as a fellow with the intent of being assigned there, a move of strategic dedication that worked. He served as a fellow while stepping into the acting Territorial Epidemiologist role, eventually taking over the position full-time.

Today, his week is a balancing act. "I'm always in response mode," he says. One day it is a sporadic pertussis case; the next, it is preparing for the inevitability of measles or dengue. Recently, his focus shifted to an environmental challenge: Dieldrin, a pesticide banned in the 1980s but still present in Guam's water. Because it was never regulated on the mainland, finding subject matter experts was difficult. He posted on the CSTE Connect forum asking for help.

This constant state of readiness drove his involvement in two major recent initiatives. The first was "Fire on the Horizon," a health security exercise hosted in Guam. The simulation involved a Japanese encephalitis outbreak, a disease the island had not seen in 40 years. It brought in response teams from across the South Pacific, from Fiji to the Solomon Islands, to observe and participate.

For Sotto, the exercise revealed a critical vulnerability—and an opportunity. "There was so much emphasis on the epidemiologist for guidance," he explains. But as the only epi in the department, he was being pulled into meeting after meeting to give direction, leaving him frustrated that he had no time to actually analyze the data. Sotto had also recently been nominated as Chair of the Regional EpiNet Response Group for the Pacific, and the exercise underscored just how much the response depended on Pacific Region coordination.

That realization led to action after the event ended. Sotto and his team have since developed “epi-sizes,” miniature, drill-like exercises designed specifically to train his colleagues on the unpredictable tasks that fall to epidemiologists during a crisis. The goal is to build depth on the bench, ensuring the response does not hinge on one person.

The second initiative, a conference called "Guarding the Pacific," was born from the same impulse. Focused on avian influenza, it gathered public health officials from across the US-affiliated Pacific Islands to discuss this emerging threat. Sotto was surprised to find that the most resonant topic of the event turned out to be legal preparedness, a subject he thought would make for a mundane session.

However, the session sparked intense discussion and gave Sotto the chance to discuss an incident from his first week as Territorial Epi: trying to access private property to investigate a suspicious bird die-off without a clear procedure to follow. "I knew I had the public health authority," he says, "but with no procedure in place, we needed legal backing." Others in attendance had faced similar circumstances. It was a reminder that in a region where resources are stretched, the laws on the books are just as critical as the data in the system.

Sotto’s work also reflects a broader story. Health departments in the territories bring distinct strengths—strong community and cultural traditions, as well as the ability to innovate. For 75 years, CSTE has supported these jurisdictions as essential partners in protecting the nation's health.

NPHW is a time to recognize leaders like Sotto, who carry out this work far from the mainland's view. When the next threat appears on the horizon, he will be ready.

Dr. Marci Layton, CSTE's Chief Medical Officer, has spent decades in public health. She remembers when disease surveillance meant waiting for the mail. Today, she watches fellows like Kaylia Johnson build the systems that replace that mail. Johnson, a current CSTE Applied Public Health Informatics (APHIF) Fellow and a 2025 recipient of the Hillary B. Foulkes Memorial Award, represents a new generation of applied epidemiologists—one that builds dashboards and designs systems to manage data for the long term.

Together, their perspectives offer snapshots of progress and point toward what comes next.

"When I started in public health in the 1990s, communicable disease surveillance relied on reports that came in by phone calls, faxes, and the U.S. mail," recalls Layton. "It has been so rewarding to see how far we have come since those days to leverage the increasing availability of electronic health information."

For local health departments, the path to that modernized future is often paved less with flashy technology and more with the diligent, behind-the-scenes work of standardizing systems and building sustainable processes. It's "epi in the weeds" work—and it's critically important.

Few understand that better than Kaylia Johnson. Based at the Oakland County (MI) Health Division, Johnson has spent her APHIF fellowship tackling the challenges of local health data head-on. We caught up with her to discuss her journey, her work on the innovative Medical Services Data-to-Action Hub, and what the future of data looks like at the local level.

Q: Your work on the Medical Services Data-to-Action Hub is a great example of the nitty-gritty of data modernization. Can you explain the problem you were trying to solve and how the Hub helped?

A: The problem was organization and efficiency. The director of our medical services team managed data from about 10 different teams. Every month, she'd receive their reports in all sorts of formats—Word docs, Excel spreadsheets, PDFs—and manually compile a single monthly report. It was incredibly time-consuming.

With a CSTE Data Science Team Training grant, we built the Hub to solve that. We met with each team, conducted focus groups, and figured out what data was most important. I created a system where all that disparate information could be standardized and fed into a central database. We used R to clean the data and built a dashboard. Instead of a static, 20-page report, the director could now filter by month and see real-time insights for each team.

Q: What was the biggest lesson you learned from that process?

A: That one size doesn't fit all. While the dashboard worked, we realized through follow-up conversations that not everyone needs a visualization. Some people just need to know the data is stored and accessible. So we shifted our focus to building a broader data governance structure.

We used the Hub's foundation to create a data inventory—a catalog of all the data our teams collect. We also formed a data stewardship committee. Our goal now is to create sustainable systems that manage our data assets for the entire health division. We're building what I call a "data pond" that can be accessed by anyone who needs it, especially during staff transitions.

Q: You mentioned "data stewards." Can you define that role?

A: A data steward manages how data flows in and out of their department. They are the go-to person for their team's data, handling security risks, privacy concerns, and the rules for internal and external data sharing. We're training people across the health department to fill these roles, creating a network of experts who can help us develop consistent standards and maintain our data inventory.

Q: Your work is specific to Oakland County, but how does it connect to the larger public health community through CSTE?

A: CSTE has been instrumental in connecting me with peers facing the same challenges. At CSTE conferences, I can link up with other fellows and their supervisors. We have conversations like, "We're at this point—how did you get to the next step?" It's valuable to see the frameworks other local health departments have built.

When I built our new Behavioral Risk Factor Surveillance System dashboard to share with the community, I designed it to look similar to our state's version. We want community partners to have a familiar experience whether they're looking at local or state data. It's all about building a connected ecosystem, and CSTE facilitates that collaboration.

Q: Congratulations on winning the Hillary B. Foulkes Memorial Award at the 2025 CSTE Annual Conference. What did that recognition mean to you?

A: I was completely surprised. I'm naturally one of the shyer people, so it meant the world. I am incredibly dedicated to public health—I don't see myself ever leaving this field. Receiving that award was a huge motivator and makes me want to push even harder as I finish my fellowship.
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Both NPHW and CSTE's 75th anniversary give us a chance to honor the past while building for the future. Layton sees that dual perspective embodied in fellows like Johnson.

"I am so grateful to CSTE for their work convening, training, and connecting the field, lifting up innovative solutions to ensure all health departments across the country can make progress in accessing, managing, and using data for public health action," she says.

From fax machines to dashboards to data ponds, the tools keep evolving. Thanks to leaders like Layton, who have championed change for decades, and fellows like Johnson, who are building what's next, public health's ability to act grows stronger with each generation.

Read more about CSTE's Data Modernization success stories, our 75th anniversary, and APHA's National Public Health Week campaign.

Though her time in public health was heartbreakingly brief, Hillary left a mark on everyone she knew. Today, we keep her spirit alive through an award that bears her name: the Hillary B. Foulkes Memorial Award—an honor that carries weight far beyond the typical fellowship recognition. Each year, the award recognizes one or more graduating AEF fellows who embody her spirit.

A Background of Promise

Hillary Blair Stanton Foulkes grew up in Natick, Massachusetts, and graduated from Natick High School in 2001. She went on to earn a bachelor of science degree in biology from the Massachusetts Institute of Technology (MIT) in February 2005. Following MIT, she worked at the Harvard School of Public Health, enrolled at Yale, and then headed to the Texas Department of State Health Services (DSHS) to begin her AEF fellowship. Those who worked with her quickly understood why she belonged in public health.

Why She Stood Out

To understand Hillary’s impact, consider the words of her 2007 supervisor at Texas DSHS, Brian C. Castrucci, DrPH, MA. Now the President and CEO of the de Beaumont Foundation, Castrucci still remembers her clearly.

“This kid had every bit of it,” Castrucci recalls. “She was writing stuff, and just, the skill set was far, far beyond her years.” He compares her potential to the way teams scout talent: “If we could only look at this work more like an NFL draft … you draft for the talent and the promise. She had absolutely unlimited potential.”

But Hillary wasn’t just smart. He saw in her a rare combination of humility and drive. Castrucci describes her as someone with “no sense of limit”—a person who questioned everything. In a field where institutional knowledge is vital but curiosity can wane, Hillary’s instinct to push back and dig deeper set her apart.

“She really did love governmental public health,” Castrucci says. “How few people say that? For a kid who went to Yale, to really want health department work… she stood up for that.” It wasn’t just a job; it was her chosen space to make change at scale.

The Fellowship as a Launchpad

Castrucci also reflected on AEF’s unique role. He calls it a “safe space”—a year where fellows can learn the dynamics of a health department without the pressure of a permanent role.

“It was my job to mentor her. It was my job to help her learn,” he explains. “When you just get a job, there’s no safety net.” AEF gave Hillary room to grow, to challenge ideas, and to find her footing as a leader-in-training.

A Legacy That Endures

More than 15 years later, Hillary’s influence hasn’t faded. “She stands as the bar to which I compare all my young staff,” Castrucci reflects. “This is 20 years later, and she still stands as my bar.”

Castrucci also offers a charge to future recipients of this award: “Earning the award is one step, but living up to the legacy is a different one. Take it as a burden, because every award winner, in some way, is fulfilling Hillary’s unfulfilled legacy.”

CSTE Applied Public Health Informatics Fellowship (APHIF) fellow Kaylia Johnson is a 2025 recipient of the Hillary B. Foulkes Memorial Award and works at the Oakland County (MI) Health Division. Reflecting on the honor, she put it simply: "It was an honor. And it makes me want to push myself even more as I finish out my fellowship to really see the impacts of my work and how it is able to help our communities."

Looking Ahead

As CSTE celebrates 75 years, the Hillary B. Foulkes Memorial Award reminds us that public health isn’t just about technical skills—it’s about the people who bring those skills to life with passion, humility, and an unwavering commitment to others. Hillary may have left us far too early, but the standard she set continues to guide not only new AEF fellows but CSTE as an organization.

Learn more about the Hillary B. Foulkes Memorial Award.

 So, what does a scholarly deep-dive have to do with the world’s largest sporting event? It’s all part of the wide-ranging playbook for protecting public health when millions gather. But let’s start at the beginning. 

 Laskowski’s path to the AEF and this role began in graduate school at Columbia University. While taking a course in public health surveillance, she heard about CSTE for the first time.

 “The professor was telling us about CSTE,” Laskowski said. “All the influential work that it does, specifically regarding position statements, and eventually more about the AEF opportunity. I decided to apply, and the rest is history.”

 AEF places early-career epidemiologists in state and local health departments across the country, where they receive on-the-job training under the guidance of experienced mentors.

 After being accepted into the program, Laskowski began her two-year journey at the Washington State Department of Health (DOH), focusing on Disaster Epidemiology. It’s a position she calls the "favorite role I've ever held before," citing the unique opportunity to see her work have a tangible impact on the community. 

Currently she’s faced with a colossal challenge: planning public health surveillance for the World Cup, which will bring matches and fans to Seattle’s Lumen Field. Laskowski helps lead planning on two fronts: internally at Washington State DOH and nationally with CSTE’s Public Health Response & Incident Surveillance at Mass Gatherings (PRISM) Workgroup. 

At Washington State DOH, Laskowski began internal preparedness meetings in June 2025. Efforts to engage external partners began the following month, primarily through a workgroup composed of local health jurisdictions and public health departments.

The scale of the task became clear in initial gatherings. "It is such a broad and far-reaching event," she noted. “The potential health impacts are wide-ranging, covering everything from infectious disease outbreaks and heat-related illnesses to injuries and substance use. So everyone has to be involved, from communicable disease experts to environmental health specialists.” 

This complexity also extends to the methods, which are as varied as the team. That brings us back to the literature review, which involves other CSTE AEF fellows nationwide analyzing more than 300 scholarly articles on past events, from Olympic Games to music festivals.

 "We're reading them to have this foundational analysis," she explained. The questions are practical: What health impacts have been seen at previous events? What surveillance systems worked? What public health actions were effective? This historical analysis now shapes Washington’s strategy.

A central finding has reinforced their approach: the absolute necessity of deep collaboration with healthcare partners. "[The articles] talk about really strong [partner] engagement... and that's something that we've really taken to heart," Laskowski said. To date, a majority of this collaboration has been with local health jurisdiction and public health department colleagues through the external workgroup.

 Alongside the literature review, her team conducts epidemiological capacity assessments to identify the staffing, tools, and resources they’ll need to monitor the health of millions in real-time. It’s meticulous, foundational work that turns the abstract concept of "preparedness" into an actionable plan.

 For Laskowski, the AEF fellowship has proven to be the perfect platform for this high-stakes work. "There's just so many opportunities to get involved and explore what you're interested in," she said. The role has allowed her to present at the CSTE Annual Conference, lead national workgroups, and see her efforts directly shape her state’s readiness.

 Laskowski's work may be invisible to the thousands who will fill Seattle's stadium when the World Cup arrives. But that's exactly the point: behind every mass gathering is a quiet infrastructure of people working to keep it uneventful.

Want more on 2026 World Cup and Larger Gathering prep? Learn more about CSTE’s PRISM Workgroup and join our monthly webinar series, Integrating Applied Epidemiologists into World Cup Planning.

As the Analytic Team Lead for DPH within the Epidemiology Division and the 2025 CSTE Fellowship Alumnus Award winner, we caught up with John to chat about his journey from chemistry to epidemiology and how his team is working along other GDPH partners in Applied Epidemiology, Preparedness, Laboratory, and more as a component of the overall DPH initiative to ready Georgia for an influx of thousands of international visitors and fans.

John earned his bachelor’s in chemistry and initially pursued a career in that field, but something was missing: a need to connect science to people's lives. This led him to shift his focus to public health, right around the time he was working with statistical models that predicted chemical toxicity.

“We worked on statistical machine learning models and one of the main outputs was how many fish die at this level of chemical exposure,” Olmstead recalls. “And I thought, I would really love to see the human impact of this.”

This quest led him to the CSTE Applied Epidemiology Fellowship, an experience he found invaluable for its dual perspective. Based on CDC's Epidemic Intelligence Service model, his fellowship was split between CDC and GDPH.

“The really cool thing about that project was that I was able to see it from both perspectives: the federal and the state,” he said, adding that it taught him the art of reconciling different priorities, a skill that directly informs his current role.

After completing the fellowship, Olmstead took a position at GDPH, first as a biostatistician and now as the Analytic Team Lead for a new team focused on data modernization and building analytic capacity at DPH. And with Atlanta slated to host several World Cup matches next summer, his work has big implications.

For an event like the World Cup, public health monitoring is crucial. A sudden influx of visitors can quickly lead to outbreaks of infectious diseases, spikes in emergency medical calls, or other incidents that require a rapid response. To track these threats, Olmstead’s team supports applied epidemiologists and associated partners to monitor data streams like syndromic surveillance from hospitals, emergency call logs, and wastewater data. Their challenge is maintaining this watch efficiently, especially when matches occur on weekends and evenings. “My main concern usually is how can my team free up time for our applied epidemiologists to do more with their time?” he explained. Their solution to this round-the-clock need is an automated report for leadership. “We came up with a way to create a report that you can read in 30 seconds.”

This demands a focused approach to data, where not every stream makes the cut. “One of my main concerns is that any data set that we actually include is validated and actionable for follow-up,” Olmstead notes. “If you're looking at something for a few seconds and there's a chance that it could be misinterpreted, we don't want to include that.”

For John, the reward lies not in the events, but in the daily victories of problem-solving with his team. “Day to day, I really just enjoy talking and working with my coworkers and helping solve problems,” he said. “And I like it when a month from that time they say that they have a different problem, because to me that means that that one was solved and we're moving forward. It’s motivating.”

It’s this mindset that ensures Georgia is not just preparing for a few soccer matches, but building a resilient future where data leads the way.

CSTE congratulates John once again on winning the 2025 Fellowship Alumnus Award and for his hard work and accomplishments. Learn more about the Award here.

While an America Online search of the term (this was pre-Google) piqued her interest, the concept didn’t fully take root until later. After some soul-searching about her path, she changed her major to economics with a minor in mathematics and was, by her own admission, “in love with data.”

It was in a 400-level health policy class where epidemiology resurfaced, this time striking a chord. “It just resonated with me that I could use data to make change,” she says. “With my economics brain, that's what I was trying to do anyway, but this one seemed more… human.”

Elected last summer and now serving a one-year term as CSTE President, Dr. Turner applies this fusion of analytics and humanitarian purpose to guide the organization. Her leadership focuses on two interconnected priorities: demonstrating the value of traditional and non-traditional partnerships and encouraging members to creatively commemorate the organization’s 75th anniversary.

From Vital Records to a Vision for People

Turner’s journey is a testament to the hands-on, applied work of public health. After graduate school, her data background landed her first role as a biostatistician in Idaho’s Vital Records Bureau, analyzing mortality statistics. She later directed the state’s Behavioral Risk Factor Surveillance System (BRFSS). However, she felt removed from the communities she aimed to serve. “I just want to help people,” she explains. This conviction led her to become Idaho’s Epidemiology Program Manager and eventually to her current roles as Deputy State Epidemiologist and chief of the Bureau of Environmental Health and Communicable Disease.

This trajectory from data analyst to leader instilled in her a core truth: epidemiology’s power lies not always in the data itself, but in the partnerships that translate information into action. This is the bedrock of her first presidential priority.

Priority One: The Partnership Multiplier

For Turner, partnerships are the catalysts of public health.

She offers an example of a traditional partnership: a state health department promoting HIV prevention medication (PrEP). "We can create guidance and public information," she says, "but we're not in the clinic having sensitive conversations with patients." That's where traditional partners like doctors and HIV clinics are essential. "We have to work with them to get the message directly to the community and increase the impact of prevention."

In contrast, a novel partnership might be a health department collaborating with a local TV station on a monthly public health segment, or pursuing more strategic collaborations with the academic community, something CSTE has already explored. She cites a joint data dashboard project with Johns Hopkins University as an example. “Traditionally, they're not a partner that we work with annually, but in this case, it's a non-traditional partnership that's moving work forward.”

Her philosophy is both practical and profound. “It’s important to be open to those possibilities and then to cultivate and foster them,” she says. “Because I do think that once you partner, it's really hard to break up. Once you've worked together, you're fertilizing the ground for future collaborative opportunities.”

Priority Two: A Creative 75th Celebration

If her first priority looks outward, Turner’s second looks inward, to the heart of the CSTE community. This year holds special significance as CSTE celebrates its 75th anniversary, a landmark that will be a central focus of its 2026 Annual Conference. She believes marking this milestone requires more than a retrospective. It demands creativity.

Scientists, she argues, are inherently creative, and art is a powerful tool for expression and cultural reflection.

The inspiration came from a beloved, if unexpected, CSTE tradition: the recitation of witty, epidemiology-inspired haikus during the annual business meeting. Held on the final day of the conference, this meeting is where the membership votes on final Position Statements—and where this creative annual ritual unfolds.

 “As I was sitting there last year,” Turner remembers, “I thought, oh my gosh, we just have so many creative minds in this room. I just was looking around at all the smart, brilliant people around me and wondered what would happen if we gave them a forum to express their creativity in the arts.”

Her vision is an open invitation for members to share their talents—be it watercolor, poetry, sculpture, community theater, or even crafting memes—to express what CSTE means to them. “It allows us to let our hair down a little bit and show a different side of scientists,” she says, adding, “Creative expression is a great way to maintain your mental wellness.”

Analysis Meets Humanity

By championing partnerships and creative expression, Dr. Turner is guiding CSTE to honor its 75-year legacy. For her, it’s more than honoring the past; it’s about building a future rooted in collaboration and celebrating the people who make progress possible.

It has been a busy September for CSTE and lawmakers in Washington, DC. Here is a quick update on what’s going on and some of CSTE’s recent educational efforts of policy makers.

This fall, CSTE prioritized engaging with legislators to provide education about what applied epidemiologists in states and jurisdictions do every day to protect the health of communities. As we near the end of the federal fiscal year, Congress has yet to come to an agreement on Fiscal Year (FY) 2026 funding and health departments across jurisdictions continued to face uncertainty in accessing appropriated FY 2025 funding. CSTE members met recently with congressional offices to ensure they understand how critical federal funding – specifically CDC funding - is to state, territorial, local, and Tribal (STLT) public health efforts—epidemiology programs are funded 90-95% from CDC. Congress must now make critical decisions on FY 2026, funding and efforts like public health data modernization and the Epidemiology and Laboratory Capacity (ELC) program need substantial investment. CSTE talked about progress in both of those areas and how the work is making a difference in STLT to responding to health threats everyday. CSTE also discussed the need to ensure the health and safety of the public health workforce and the importance of maintaining the scientific integrity of CDC.

Zooming out, Congress returned from August recess facing a tight deadline in the bigger funding picture: funding for Fiscal Year (FY) 2026 must be approved before October 1—tomorrow—to avoid a government shutdown. Reminder, the appropriations process provides federal funding for all federal government agencies and programs, including the CDC and other federal health agencies. If Congress fails to pass a spending package by midnight tonight, federal funding will lapse, and many programs could pause, creating uncertainty for public health departments across the country.

With the risk of a shutdown on the table, CSTE prioritized additional education for policymakers—particularly members of the House and Senate Appropriations Committees—to emphasize the importance of sustained federal public health funding. CSTE shared information about how federal dollars support disease surveillance, outbreak response, and workforce capacity across every jurisdiction.

CSTE met with 34 offices—including several key leadership offices—to highlight the consequences of delayed awards, reduced capacity, and funding uncertainty. We reminded Congress that about 80 percent of STLT health department’s budgets come from the CDC. CSTE also shared real-world examples from the field and strengthened relationships with congressional offices, educating staff on the critical role applied epidemiologists and other public health workers play in keeping communities safe.

So, where do things stand on FY 2026 appropriations? Both the House and Senate released their versions of the Labor, Health and Human Services (LHHS) appropriations bills earlier this year. The Senate proposed a bipartisan bill with strong overall funding for CDC, while the House bill is detrimental to CDC overall, it includes key increases for priority programs such as Public Health Data Modernization and the Epidemiology and Laboratory Capacity (ELC) program. Despite this progress through committee action, the process is not far enough along to pass final bills before the end of the fiscal year.

On September 19, the House narrowly passed a short-term continuing resolution (CR) that would keep the government running through late November and continue certain health programs, including telehealth and community health centers. Democrats proposed an alternative CR that included additional health care protections—including extending subsidies for Affordable Care Act health plans. As expected, both the House-passed CR and the Democratic alternative failed to advance in the Senate.

With tonight’s deadline, the risk of a government shutdown is very real. Adding to the uncertainty, House Republican leadership announced that members will not return to Washington until the Senate passes their CR bill, leaving little opportunity for negotiation and prompting blame-shifting among lawmakers. To complicate matters further, federal agencies have been told to prepare lists of employees who could be furloughed or laid off if the government closes. While this may be a negotiating tactic, real lives and real jobs are in the balance.

As the process moves forward, CSTE urges Congress to avoid a shutdown to allow for ongoing negotiations for final FY 2026 funding that includes robust overall funding for CDC and retains the House’s proposed increases for data modernization and ELC. The road ahead remains uncertain, but CSTE will continue communicating with lawmakers to ensure Congress understands the real-world impact a government shutdown would have on public health efforts in every community across the country.

Victoria Barahona is Senior Policy Associate at CRD Associates, LLC, which represents CSTE’s interests on Capitol Hill in Washington, DC.

We’re more than halfway through the year, and there has been no shortage of action on Capitol Hill. Here’s what you need to know.

First, let’s talk about the budget reconciliation bill, also known as the One Big Beautiful Bill (H.R. 1). But before we get into what’s in it, a quick detour on how it got through Congress.

Budget reconciliation is a legislative fast-track that lets Congress pass certain tax, spending, or debt bills with just a simple majority in the Senate—bypassing the usual 60-vote threshold require to avoid a filibuster.

After months of negotiation, Congress passed the bill and on July 4, President Trump signed the $4.5 trillion package into law, pairing major tax cuts with new investments in border security and defense. To help pay for it, the bill includes $1.2 trillion in cuts to programs like Medicaid, food assistance, and student loans—sparking heated debate.

The margins were razor-thin: Vice President JD Vance broke a tie in the Senate, and House Speaker Mike Johnson (R-LA) barely rallied enough party support for passage. No Democrats backed the bill.

Second, let’s talk about rescissions. After passing the budget reconciliation bill, Congress took a short Fourth of July break, but came back to a tight deadline: they had just 10 days to act on President Trump’s rescissions package.

So, what is a rescissions package, exactly? It’s a formal request from the administration to cancel funding that Congress had already approved. If lawmakers agree to the President’s proposal, that money is pulled back and can’t be spent by the agency to which it was allocated.

There are rules, of course. Once a President submits a rescission request, Congress has 45 continuous days of congressional session to approve, amend, or reject it. In this case, lawmakers returned from recess with the clock ticking and managed to get it done just in time.

Passage of the recissions package was by no means a guarantee. The bill narrowly passed the House in June but was amended significantly to make it through the Senate. The package targeted cuts to foreign aid and public broadcasting. Although the rescissions package didn’t impact public health funding, it raised broader concerns. Some argue that pulling back already-approved federal funds sets a troubling precedent—one that could undermine confidence in the budget process and complicate future negotiations.

Since this recissions packaged passed, the White House has made it clear they would like to send a second round of cuts to Congress for approval. Early reports suggest this bill could target education funding.

Third and finally, with reconciliation and rescissions behind them, Congress shifted its focus to the FY 2026 appropriations process. Before the August recess, the House Appropriations Committee moved forward on most of its spending bills—leaving the politically charged Labor, Health and Human Services, Education, and Related Agencies (Labor-HHS) bill, which includes funding for the Centers for Disease Control and Prevention (CDC) on hold.

The delay has left health advocates uneasy—especially after the President released his FY 2026 Budget Request back in May. While the President’s budget is nonbinding (Congress holds the power of the purse), it outlines the Administration’s funding priorities and often helps shape the policy debate on Capitol Hill. The Administration proposed $4.3 billion for the CDC—a $5 million decrease from FY 2025—and called for the elimination of several key public health initiatives, including the Global Health Program, the National Center for Chronic Disease Prevention and Health Promotion, and the Prevention and Public Health Fund, which is the nation’s first mandatory fund dedicated to public health.

The Senate, meanwhile, advanced its Labor-HHS bill with a decisive 26–3 vote at the end of July, largely ignoring the White House’s proposed cuts and restructuring proposal. The Senate bill includes $9.15 billion for the CDC—a $70 million decrease from FY 2025—and allocates $160 million for Public Health Data Modernization, a $15 million cut from FY 2025. The Epidemiology and Laboratory Capacity (ELC) program received level funding at $40 million, while the Centers for Forecasting and Analytics (CFA) and Response Ready Enterprise Data Integration (RREDI) were funded at $50 million.

All of this sets up a jam-packed fall season, with a government funding deadline looming on September 30. If Congress can’t agree on a full-year spending package by then, they’ll need a continuing resolution (CR) to keep the lights on and the government running. There are already rumors about a CR through December and even the possibility of yearlong CR, which raises additional concerns about Congress’ ability to enforce its spending allocations.

With big decisions still ahead and the clock ticking toward September 30, all eyes will be on Congress when lawmakers return this fall. In the meantime, CSTE will continue working to ensure lawmakers understand the real-world impact these proposed cuts would have on public health efforts in every jurisdiction across the country.

Victoria Barahona is Senior Policy Associate at CRD Associates, LLC, which represents CSTE’s interests on Capitol Hill in Washington, DC.

Each year, CSTE supports an organization or cause that is local to our Annual Conference host city. This year’s partnership is with the AYA Youth Collective of Grand Rapids, Michigan. Read today’s blog to hear about their great work—and afterwards, please consider donating in celebration of #CSTE2025. Our donation goal is in sight, and any funds raised beyond that will be a massive contribution to this amazing nonprofit.

AYA Youth Collective (AYA) is an organization providing circles of support for youth facing homelessness in Michigan. Housing insecurity is complex, and AYA has worked for years to address its many dimensions. As a result, they have created more connective, cohesive experiences for young people on their journey toward housing and stability. AYA stands for “As You Are,” and they are committed to providing resources and authentic relationships for every youth who walks through their door. We recently sat down with AYA’s Advancement Manager, Nokomis Clarey-Schultz, to learn more about their work.

How did the AYA Youth Collective get started?

AYA originated as two separate nonprofits, 3:11 Youth Housing and HQ. HQ was a drop-in center and 3:11 Youth Housing was a housing program. Both cared deeply about supporting youth with housing instability. After years of doing combined events together, they decided that it was natural to merge so that the drop-in center would have a direct path to the housing program. And more hands working together is never a bad thing.

Walk us through the process of how you help an individual facing housing instability.

When they come in, we first get an understanding of what's going on in their life. We figure out if they’re sleeping outside, in a shelter, or transitional housing. Are they at risk of being kicked out of their home? Questions like that. There's really no requirement for getting resources in our space. You don't have to be sleeping outside. You don't have to be sleeping in a shelter. There's really so many different levels of stability, and so we meet them where they are on that journey.

Everyone needs something different, so we start in a different place with everybody. Maybe it’s getting them something to eat or letting them take a shower or getting them a backpack for their stuff or a change of clothes. From there, we can start to say, “Hey, do you have Medicaid and food assistance? If you don't have those things, we can help.”

What are the specifics of AYA’s housing program?

Our housing program is special and unique. We've got 12 homes in Grand Rapids. We just broke ground on our 13th home, which is super exciting. We've had those other 12 for a long time, and so we're building a really cool new approach to housing with micro units. It's like a hotel; there's a kitchenette, your own bathroom and bedroom, and also a larger communal space.

In our housing program, in all of the homes, they're duplexes, so half the house is youth, the other half is a mentor. The mentor is somebody with lived experience. It can really be anybody that just cares deeply about supporting youth. We have people that are teachers or accountants or just therapists or people that care.

Switching gears, let’s talk about AYA’s drop-in services. On your website, it mentions help with vital document recovery, legal assistance, etc. How do those services play a role in helping an individual who’s facing housing instability?

I like to remind people that we're still dealing with 14 to 24 year olds. Most of them don't have access to their vital documents and most of that age in general are learning how to be a grown-up for the first time. They are learning how to make meals and to go grocery shopping. They are learning how to navigate the city. They're figuring out what it's like to have a job for the first or second or third time.

Vital documents are extremely important. Transportation is also huge for literally everything. Employment, housing, school, social life—you must have some sort of transportation. So, we work with another nonprofit in the area called Upcycle Bikes to provide our youth with free bikes, helmets, and locks. We also have the bus passes available. For some of them, the difference between having a job and keeping a job is just having transportation to get to work.

We have a ton of basic needs here that we provide for our youth when it comes to backpacks and clothes. We also have free laundry at our drop-in center. Laundry is huge for dignity. If you work in food service, which a lot of our youth do, you must have a clean uniform to keep that job.

Thank you so much for your time today. What are the best ways people can help with the issue of housing instability where they live?

Every city, every town, every state, every country—everybody has people that are experiencing housing instability. I would say a huge one is just advocating for those in your community. Being a good neighbor, learning your communities, learning the people in it, looking for other organizations in your area. Becoming a recurring donor somewhere is honestly one of the most helpful things. With AYA, if someone can give $5 to $10 a month, that makes a huge difference because we know we're going to get that continuously.

Advocacy is huge. Reading, learning, advocating for your neighbors, advocating for the people in your community that are being overlooked, and making sure that you acknowledge those folks as well. When you see people on the side of the road, say hello, wave, make them feel like humans. That's really important.

Learn more about AYA Youth Collective and make a donation today.

By Ben Warden, CSTE Staff

Allison Smith, MPH is Chief Epidemiologist for the Dutchess County (NY) Department of Mental Health. While she initially sought out CSTE LEAD to help broaden stakeholder engagement during an increase of STI rates, the program also helped her navigate an uncertain time when the structure of her health department changed.

We recently spoke with Allison about her experience and how LEAD helped her manage the shake-ups and challenges she faced. (This interview has been edited for length and clarity.)

What first made you interested in public health?
I feel like this is a common story with a lot of my epi colleagues [laughs]. When I started off college and undergrad, I wanted to be a physician. I realized about halfway through that it wasn't for me. But I was always interested in epidemiology from a medical perspective, and I was more interested in research as a position.  

My biochemistry professor covered John Snow and epi basics over the course of a week. I remember sitting there thinking, "Ooh, that's it. That's what I wanted to do." I just didn't really have a concrete name for it. No one had ever really told me about it. I went to grad school right after undergrad, and it was fortunately a great fit. 

(After grad school, Smith worked at the NYC Department of Health and Mental Hygiene before taking a position near where she grew up in Dutchess County, New York.)

How did you find out about CSTE LEAD?
I can’t remember exactly, but it was from a forwarded email or just from bouncing around the [CSTE] website. I remember looking at it and having an “aha” moment of this being the next step for someone who's been in the field for almost 10 years. I'm supervising, but I'm not technically management.  

[CSTE LEAD] is specifically tailored to someone with an epi background, which I thought was great because most of my supervisors that I've had personally have not been epis. So really putting together those leadership skills in epi I thought was the right thing to do for someone in my position.

Can you tell us a little about your project?
We had increased STI rates in our region and wanted to bring in alternative data sources and different data sets from our regional health information organizations. One example would be bringing health educators or nurses out to areas facing high STI rates to give education or prophylaxis, or whatever was needed.

But I was thrown a curveball when it was announced that our department was splitting into two separate departments. There would be a Department of Mental Health, as well as a Department of Health. It then morphed into navigating that situation as well.

What was your specific end goal?
Really, it became integrating the epi bio[statistics] team into other divisions across the department. We were normally called when people were like, "Hey, I think I'm noticing an uptick in chlamydia." Or, "Hey, we got a call about someone getting sick, they think it might be implicating this restaurant." Or, "Hey, I just need data on breast cancer rates." Anything like that. Now, I think the team is much more involved in those conversations from the get-go so they can actually provide their input and feedback because not everyone thinks like an epidemiologist.

Would you say you met that goal?
I think I was pretty successful, and I think it's growing a little more. I think the LEAD program strengthened my leadership skills, but I like to think I kind of [also] maybe pushed a little into the folks I was supervising, so they feel a little more empowered to take on those roles too.

Do you have any advice for those thinking about applying to CSTE LEAD?
Do it. Especially after seeing all my peers’ final presentations, because one of all of our takeaways was the flexibility needed. Learning to move and roll with the punches, so to speak. I think having that flexibility in mind and just knowing that you are going to be studying and gaining these skills throughout the program, that's only going to strengthen you as an epi. It is focused on epis, but I think the skills can be applied to anyone, and I think the way it is delivered is really well done.

Interested in receiving similar epi-related guidance? Learn more about CSTE LEAD!

By Ben Warden, CSTE Staff

CSTE Chief Science and Surveillance Officer Annie Fine, MD, began her career as a pediatrician in an under-resourced area of Northern California with elevated crime rates. As violence permeated the community for months, Dr. Fine kept thinking about what could be done upstream to prevent tragic outcomes.   

It was just that: a thought. Until a particularly gut-wrenching day drove her towards a career change to public health. After prescribing amoxicillin for a 10-month-old with an ear infection, the mother got up to leave. Fine noticed she was on crutches.   

“I asked what happened, and the mom said, ‘Oh, I was shot in a drive-by. And so was he.’ So the 10-month-old still had a bullet in him,” Fine said. “I thought, ‘Here I am handing out amoxicillin, but the real problems facing these people and this community are violence and the social milieu that they're living in.”   

The experience was the catalyst for Dr. Fine to leave patient care and begin her long, storied career in public health. She was accepted into CDC's Epidemic Intelligence Service (EIS) program, a two-year, post-graduate training program in applied epidemiology where participants gain experience investigating and responding to public health threats. Although tackling violence prevention was an initial inspiration for her change, Fine switched her focus to infectious diseases, which was a major need and focus of CDC at the time.

“I ended up being assigned to New York City and going into communicable disease,” Fine said. “Which was something I was quite interested in.”  Fine ended up spending 25 years at the NYC Department of Health, facing everything from 9/11, anthrax, SARS and many other crises.  “While going through all of those emergencies it became very clear that we did not have good data systems,” Fine said. “We didn't have good ways to integrate the epidemiologic sides of the data that we were collecting with the laboratory data that we needed. The systems just were not efficient at all.”   

Fine was then tasked to create a better system for use in large-scale emergencies. She looked to a software system already in use by the Massachusetts Department of Public Health and built a flexible infrastructure that was able to link epidemiology investigations and cases with lab results, all in one system.   

“That was a giant learning experience and something I'm really proud of,” Fine said. “We then used that system to respond to Ebola, to Zika, to Legionnaires' disease in the South Bronx, which was a large outbreak in 2015. And then also finally to COVID, too.”  Fine said that building the system meant New York City was better prepared than most to handle the early days of COVID. But the sheer scale of the outbreak still made it incredibly challenging and overwhelming. “None of us were prepared for the scale, the number of people that died so quickly and the lack of personal protective equipment and the lack of diagnostics,” she said.

After guiding New York City through the worst pandemic in modern times, Annie decided to make a professional change. In June 2021, she accepted a position with CSTE as its first-ever Chief Science and Surveillance Officer. She longed to bring her on-the-ground experience to the national level. “The ability to impact national level policy and help build capacity across all country was just such a great challenge and inspiring opportunity,” she said. “I was hoping to bring my frontline experience of what it actually takes to make systems work and how to use the data.”    

Reflecting on her time at CSTE, Annie lauded the growth of her team, as well as the broader membership and community of CSTE. When asked about specific accomplishments she’s most proud of, Annie mentions the Stories from the Field project, the Electronic Case Reporting Workgroup and the National Syndromic Surveillance Program Community of Practice.  

Fine recently announced her retirement, but will stay with CSTE in a part-time role. As changes and uncertainty still swirl around public health, Fine’s message to younger colleagues in the field is simple: Hang in there. “Public health needs are not going to go away,” Fine said. “It may look different, and it may be organized and funded differently. But hang in there, because science and epidemiology are still going to be needed.”    

Through decades of dedication, Annie has not only helped advance our understanding of public health but also inspired countless colleagues and future scientists. Her work has saved lives, shaped policies, and strengthened communities, leaving a lasting impact that will resonate for years to come.  CSTE—and health writ large—will miss her tremendously. 

“Going into public health was literally the best decision I ever made,” she said. “I love the work, and I love the people.”  

By Ben Warden, CSTE Staff

Growing up, Lea Hamner didn’t have to go far to learn about the importance of public health. It was a regular topic at her dinner table.  

“I actually was born into public health,” she said. Hamner’s mother worked for the U.S. Agency for International Development (USAID) in the Philippines and Peru. Lea grew up abroad, immersed in her mother’s projects and passion.  

“The talk around the dinner table was very interesting because my mom was doing her dissertation on HIV prevention practices in sex workers in Peru,” Hamner said. 

“So, I was 11 and I was doing arts and crafts at Christmas with the people she was working with. Just growing up with public health being central to my mother's life meant that I was just a lot more cognizant of social determinants of health right off the bat.”  

Despite her family connections to a public health career, Hamner initially thought she would study pre-med at college. But she soon realized patient care wasn’t what she wanted to focus on.  

Her next thought was to follow in her mother’s footsteps and travel abroad to work in global health. But after an internship with Partners in Health in Guatemala, she decided her public health focus should be on her own community in Washington state and not thousands of miles away.  

“I wanted to come back to my own community and be a part of the people who are actually living out the policies and experiencing it firsthand,” she said. After college, Hamner moved to Washington state and began her infectious disease epidemiology career working in tuberculosis (TB) at Public Health-Seattle & King County.  

“It was a phenomenal place to start my career to really understand how complex things can get and how adaptable you need to be,” Hamner said.  

In addition to TB, Hamner broadened her scope after being hired as the first county epidemiologist in Skagit County, WA. She tackled a myriad of epi issues, including infectious diseases, opioid overdoses and maternal child health. She was then named operations section chief for Skagit County’s (WA) COVID-19 response.  

[Did You Know?: Skagit County, Washington borders where the first COVID case in the U.S. was identified]  

In 2022, she moved across the country to build an epi program from scratch once more: this time spanning 23 independent town health departments as a contract epidemiologist in Cape Cod, Martha’s Vineyad, and Nantcuket. Hamner jumped at the chance but quickly surmised that she needed some leadership advice and expertise. Enter CSTE LEAD, a 12-month leadership program for mid-career epidemiologists looking for professional networking, mentorship, and skill-building.  

“I did [CSTE’s] Early Career Professionals’ mentorship program and it was invaluable to me when I was starting off my career as an epidemiologist,” Hamner said. “I was just waiting for my opportunity to apply again for another mentorship opportunity and then I found out about LEAD from the CSTE website.”   

Hamner’s goals in joining the program were to talk to other epis who have had similar experience in building a department and the common issues they faced. Through the coaching, mentorship, and courses of CSTE LEAD, Hamner learned how to navigate challenges more easily than if she was left to her own devices. 

“I would've probably gone crazy if I didn't have CSTE LEAD,” she said. “I would've been in dire straits trying to negotiate all of those different stakeholders [and] all of those different priorities without tools about how to have tough conversations.”  

Hamner urges others in her position as a new epi leader to run, not walk, to CSTE LEAD. The program helped her master challenges like stakeholder engagement, consensus building, managing up-and-down on strategic planning, and public health communications. 

“It really is an incredible opportunity to engage with epidemiologists outside of your organization,” Hamner said. 

“Anyone who really wants to invest in their career and invest in their own personal growth would benefit from applying.” 

Is CSTE LEAD right for you? Learn more about the program and how to apply to the next cohort! 

By Ben Warden, CSTE Staff

Last month, CSTE’s leadership and two CSTE Board Members traveled to Washington, D.C. to participate in an educational congressional briefing titled “Public Health Academy: The Power of Public Health Data.” This event is a popular series with congressional staff and is co-hosted by the Coalition for Health Funding, CDC Foundation, and the Centers for Disease Control and Prevention (CDC).

CSTE is a member of the Coalition for Health Funding—an 86-member organization representing patients, consumers, health providers, professionals, and researchers. Through this membership, CSTE was provided the lead opportunity to educate members of Congress and their staff on the critical role public health data plays in addressing the nation’s most pressing health challenges.

Representative Rosa DeLauro (D-CT), Ranking Member of the House Committee on Appropriations, opened the event with remarks recognizing CSTE for being at the forefront of public health data modernization and for spearheading the initial recognition of the need and call to action to address the root causes. Representative DeLauro expressed her strong support for public health funding, highlighting its importance in ensuring the nation’s preparedness for health threats.

Theresa Sokol, Louisiana State Epidemiologist and CSTE Board Member, was a notable panelist at the event. She provided first-hand experience of how data modernization in public health directly improves the public health response to acute and emerging threats at the state level, including how electronic case reporting and syndromic surveillance (two key pillars of data modernization efforts) enable more rapid detection and shorten the time to take immediate actions that ultimately save lives.

Other distinguished speakers at the event included Senator Tammy Baldwin (D-WI), Chair of the Senate Appropriations Subcommittee on Labor, Health and Human Services, and Education; Dr. Mandy Cohen, Director of the CDC; Judy Faulkner, Founder and CEO of Epic Systems; Dr. Jennifer Layden, Director of CDC’s Office of Public Health Data, Surveillance, and Technology; and Dr. Dylan George, Director of CDC’s Center for Forecasting and Outbreak Analytics. Their insights underscored the critical role of data modernization in advancing public health capabilities.

The briefing highlighted the need for sustained funding for data modernization with an emphasis on the progress that has been made to date from current investments. The importance of electronic case reporting was a central theme as timely, high-quality data forms the foundation for public health response. Another key area was focused on educating attendees about how critical CDC’s funding is to state, Tribal, local, and territorial (STLT) health departments and how cuts to CDC’s budget directly impact STLT, as approximately 80% of CDC’s funding goes to STLT agencies. The event featured an engaging trivia game, where staffers and panelists interacted and tested their knowledge on facts about public health data, fostering a collaborative, educational, and fun atmosphere.

The following day, CSTE leadership and CSTE Board Members Teresa Sokol and Dr. Sarah Lyon-Callo had the opportunity to meet with members of the House and Senate Appropriations Committees, where they discussed  why Public Health Data Modernization is so important to STLT health departments: It is a long-term commitment to building and maintaining world class public health data systems and a workforce that meets the nation’s ongoing need to safeguard health. Additionally, they provided education on how data modernization dollars are being used to help people and communities to thrive by rapidly detecting, identifying, tracking, and responding to daily public health threats of all types.  Simply put, data modernization is improving how STLT health departments can make informed decisions and know if the decisions made are making a difference to slow or prevent the spread.

The CSTE National Office has asked Congress to endorse the budget allocation in the FY 2025 Senate Labor-HHS appropriations bill of at least $195 million for Public Health Data Modernization, and at least $70 million for the Center for Forecasting and Outbreak Analytics and the Response Ready Enterprise Data Integration platform. To address the unmet needs of health departments, CSTE also asked Congress to increase ELC’s base funding line to $120 million, which supports nimble response ready epidemiologists in STLT. The CDC funding is especially important for applied epidemiology work in STLT public health jurisdictions, most of which receive more than 80% of funding for epidemiology personnel and activities through federal funding.

Of note, since CSTE’s visit to Washington, Congress passed a continuing resolution (CR) to fund the government through December 20, 2024. This temporary measure ensures that federal agencies, including those critical to public health, continue to operate while budget negotiations are ongoing for final FY 2025 numbers. The CR has not only prevented a government shutdown, but now allows more time for Congress to finalize appropriations for the FY25, including the crucial funding for Public Health Data Modernization, the Center for Forecasting and Outbreak Analytics, and the ELC program. Congress is now in a six-week recess to focus on campaigning before the November 5th election.

The congressional briefing and subsequent meetings highlighted the critical importance of public health data modernization and the need for sustained investment in public health infrastructure — and the critical role of applied epidemiologists. CSTE’s efforts highlighted the essential role of timely, high-quality data in protecting public health and responding to emerging threats.

Victoria Barahona is Senior Policy Associate at CRD Associates, LLC, which represents CSTE’s interests on Capitol Hill in Washington, DC.

For more than 20 years, CSTE has regularly conducted Epidemiology Capacity Assessments (ECAs) to track the state of our applied epi workforce in state and territorial health departments. These assessments illustrate what—or rather, who—is needed to respond to emerging health threats, and where we’re at risk of falling behind.

The latest ECA, our eighth overall, was just released and reflects data gathered from January–April 2024. Spoiler alert: The number of applied epidemiologists working today will drop drastically once COVID-19 era funding runs out.

As always, the lessons learned from the ECA are paramount to CSTE’s outreach and education efforts towards policymakers. For example, data from past ECAs have been shared as testimony in Congressional hearings to support greater funding for epidemiologists in public health.

The ECA also helps us monitor changes in the applied epidemiology workforce, including the number of epidemiologists presently working, the number of epidemiologists still needed, and the skills most sought after in state, Tribal, local, and territorial (STLT) health departments.

We encourage you to take a deep dive into the findings and recommendations of the latest ECA here. But for now, here’s a quick summary of the top takeaways:

What We Have

For the first time, we have data from all 50 states, D.C., and territories! A total of 5,706 epidemiologists work in the 50 states and D.C., a 38% increase over the 4,135 reported in 2021.  

What We'll Lose

If federal pandemic-era funding expires as planned, state health departments could lose 1,020 epidemiologists—nearly one-fifth of the current epidemiology workforce.

What We Need

State Epidemiologists said they need nearly 2,537 additional epidemiologists to reach full capacity in the three Essential Public Health Services (EPHS). This would be a 44% increase over current levels, for a total of 8,243 epidemiologists.

We are on the cusp of losing all the gains in the applied epi workforce that have occurred during COVID-19. And in 2024, 83% of funds for state and territorial epidemiology activities were provided by the federal government. These two points alone mean that flexible, diverse funding is needed for our workforce, which will allow agencies to prioritize jurisdictional needs, enhance job security, and respond proactively to the next public health emergency.

For further reading, check out Big Cities Health Coalition (BCHC)’s local Epidemiology Capacity Assessment, also released today. The ECA was tailored for big city health department use and administered to the 35 BCHC jurisdictions.

In a significant development for the upcoming fiscal year, the House Appropriations Committee (HAC) passed its FY 2025 Labor, Health, and Human Services, Education, and Related Agencies (Labor-HHS) appropriations bill. The bill was released on June 26, followed by the accompanying report (a document that outlines the Committee’s intentions) on July 9. On July 10, the HAC considered the bill during a full committee meeting. It was a long and contentious discussion, lasting nearly six hours and filled with extensive debates. The atmosphere was far from harmonious. Democrats criticized the legislation, pointing out that the majority had excluded at least $60 billion in non-defense funding (which includes public health) that both parties had agreed to in last summer’s debt ceiling agreement. The bill passed out of committee by a party-line vote of 31 to 25.

Now, let’s take a closer look at the House’s bill. The proposed funding levels fall short of addressing the needs of our public health system. Reducing critical investments in public health, as this bill does, is a shortsighted, ineffective, and irresponsible approach to tackling the broader fiscal challenges our country faces. A particularly alarming example are the deep cuts (about 22 percent) to the Centers for Disease Control and Prevention (CDC). The cuts indicate a push to refocus the CDC toward infectious diseases at the expense of other equally important public health efforts. While this version of the bill will not become law, as proposed, these cuts would devastate public health infrastructure and reduce crucial investments for public health response.

Below are some key takeaways:

Centers for Disease Control and Prevention (CDC)

• A 22% decrease overall, $2.3 billion less than the President’s FY25 budget request, and $1.8 billion below the FY24 enacted level.
• $780.7 million for emerging and zoonotic infectious diseases, an increase of about $20 million from the FY24 enacted level. One important note is that $15 million of the increase is allocated to myotic diseases, while $8.5 million is designated for prion diseases.
• Eliminates critical efforts, such as the Opioid Overdose Prevention program.
• Ends the HIV Epidemic initiative.
• Eliminates the Center for Forecasting and Analytics.
• Eliminates the Center for Injury Prevention and Control.
• Eliminates the Climate and Health program and Tobacco Prevention and Control Program.
• Reduces funding for CDC's global health program.

More detail on topline agency numbers from the House proposal as they compare to current funding levels for FY24 is detailed below:

Centers for Disease Control and Prevention

• Final FY24: $9,222,090,000
• House FY25: $7,446,058,000

Epidemiology and Laboratory Capacity (ELC)

• Final FY24: $40,000,000
• House FY25: $40,000,000

Public Health Data Modernization

• Final FY24: $175,000,000
• House FY25: $175,000,000

Center for Forecasting and Outbreak Analytics

• Final FY24: $55,000,000 (combined with the Response Ready Enterprise Data Integration platform)
• House FY25: $0

With the bad news out of the way, all hope is not lost. The House majority intends to bring their bill to the floor the week of July 29, but with a razor thin majority and the inclusion of controversial funding levels and policy riders, it is not certain they will have the votes to pass it. It is also important to remember that the Senate usually approaches its appropriations process in a bipartisan way, so funding levels are far from final.

Now is where you come in. Now is a time to make it clear to members of Congress that continued investment in public health is crucial. The Senate Appropriations Committee has not yet released its Labor-HHS bill, but the Committee is scheduled to resume consideration of FY25 proposals the week of July 22 when Congress returns from a one-week recess.

The voices of those directly impacted by public health policies are crucial in shaping a healthier future for our communities. You can make a difference by reaching out (in your personal capacity) to your legislators to let them know public health is something important and valued by their constituents.

CSTE has partnered with the American Public Health Association to provide an opportunity for you to submit a message to your members of Congress, urging them to support increased funding for critical public health agencies and programs as they develop the FY25 Labor-HHS bill. It takes just a few minutes to submit a letter (draft provided) through the platform which will automatically route your letter to your representative. Be sure to complete the form by July 31. Feel free to share the link to APHA’s take-action site with other supporters of public health.

Additionally, including local stories about how investments in public health have positively impacted your community and challenges that could arise from disinvestment are valuable. Hearing from their own constituents about their priorities will influence decisions on Capitol Hill. 

As always, CSTE will keep representing your needs in Congress including robust funding of the public health system and will keep you informed as the appropriations process continues to unfold.

In the early days of March, CSTE’s leadership and several Board Members set out for Washington, D.C. for our annual Capitol Hill Day. Being back on the Hill in person for the first time since 2019 was exciting and presented an important opportunity to advocate for a future in which CSTE members and all public health officials have the resources needed to respond swiftly and effectively to public health threats.

Amidst the usual hustle and bustle of policymakers, CSTE’s delegation brought a unique element to the table: real stories from the trenches of public health. These accounts represented the profound impact that federal public health funding has on efforts at the state level—in our legislators’ communities. The experiences shared by epidemiologists highlighted their daily endeavors to combat diseases and protect public health. The annual Hill Day also provided an opportunity for CSTE to showcase amazing jurisdictional work on data and epidemiology, Stories from the Field, which has proven to be a great resource for Congressional staffers and leaders.

Central to the discussions was the need to appropriate at least $340 million annually for Public Health Data Modernization. CSTE emphasized the importance of a robust public health data infrastructure. The ask was clear:  continued and increased investment to ensure that our systems can keep pace with rapid advancements in technology and having the trained staff to use and manage the technology to ensure it effectively supports the science and work of applied epidemiologists whose central mission is to collect data to drive public health actions and ultimately save lives. CSTE highlighted how such funding would not only streamline processes but also enhance the nation’s ability to rapidly identify health threats, conduct rapid case investigations and halt the spread of illnesses.

Another key focus was the Centers for Disease Control and Prevention (CDC) Epidemiology and Laboratory Capacity Program (ELC). CSTE leaders asked Congress to appropriate at least $120 million for ELC, to support this crucial program, which stands as a pillar of the CDC’s efforts to monitor and protect public health. They underscored the fact that the ELC program’s support for nimble response ready epidemiologists makes it a swift and effective mechanism for new and emerging threats—a necessity in the unpredictable landscape of public health.

Reflecting on Hill Day, the message to Congress was clear: funding for Public Health Data Modernization and the ELC program must be strong and sustained. The nation’s health and safety depend on these investments. CSTE’s advocacy efforts marked a significant step towards securing a future where public health funding is not merely sufficient but exceptional, equipping epidemiologists and other public health professionals with the necessary tools and resources to safeguard the nation’s health.

Victoria Barahona is a policy associate at CRD Associates, LLC, which represents CSTE’s interests on Capitol Hill in Washington, DC.>

CSTE's Data Science Team Training (DSTT) program is a team-based, on-the job training program to promote data science upskilling. Learners in the 12-month program work collaboratively on a project that addresses a current agency need related to data modernization.

To get more insight on DSTT and its approach, we spoke with two individuals currently in the program.

First up is Lori Saathoff-Huber, epidemiologist at the Illinois Department of Public Health (IDPH). She supports the communicable disease program with surveillance, outbreak and data analytics projects.

Q: How did you first become interested in Epidemiology and Public Health?

A: I felt like it was a perfect fit for me. There is the mathematics and statistics aspect of it, certainly the science with the health part of it, but I also realized that there was a lot of problem solving in it.

I feel like that's what we do in public health. We're problem solvers. We identify where and why disease is occurring and then work to stop and prevent. I also wanted a career that was contributing to society and to the public, and I felt like I could do some good in this field.

Q: Tell me a little about your career (so far).

A: I’ve been with the Illinois Department of Public Health for 20 years within the infectious disease division. I've worked as a foodborne outbreak coordinator and as a vaccine preventable disease coordinator. Now I am a general epidemiologist where I really assist wherever's needed.

Q: How did you learn about the DSTT program?

A: We received an email through CSTE about the DSTT project. We realize the importance of sharing our data further, providing more data to our public health partners, like our local health departments, but as well as with the public. Because one part of epidemiology is not just finding the outbreaks and solving them, but also providing that information to the public so they can be informed and protect themselves from disease.

We felt like the DSTT project would really give us an opportunity to focus on that and obtain some skills in new applications.

Q: Describe the “new tools and innovations” that DSTT helped with your goal of increased data sharing.

A: We first focused on our foodborne diseases and developing dashboards in an application called Tableau. We were able to put together a couple of different ones that we hope to use for, like I said, for our local health departments, but also then for the public.

DSTT was great because it gave us training that we wanted to have for some time on that application that I mentioned, Tableau. And so our team was able to go to two days of in-person training. And we also did various trainings through the DSTT project on other application and other topics. There was such a wide range of training that was available, which was great.

Q: Has there been one moment or story you could share that has shown the impact of these tools already?

A: We recently had a measles outbreak, and so we used Tableau for that to analyze our data, visualize it, and share it and tell the story of what was happening with that outbreak. So, I think it started by having this one project that we were working towards, but then the skills that we learned will continue in different ways.

Next let’s hear from Deen Gu, epidemiologist at the North Carolina Department of Health and Human Services.

Q: How did you first become interested in Epidemiology and Public Health?

A: I went to Northwestern University and studied economics. I graduated in 2009 [during the height of the recession] so the only thing I could find was something overseas in global health, and I thought, “I'll try it for a year or two."

And I loved it. Such a life-changing moment to go overseas. I spent five years in Cambodia, Vietnam doing public health. I worked on a health-strengthening systems program and an HIV program.

Q: Tell me a little about your career (so far).

A: After my overseas experience, I worked in a hospital doing adverse event surveillance. When COVID happened, it immediately reignited my interest in public health and specifically in epidemiology. I took a certificate program with UNC and then joined the state [health department] and now do syndromic surveillance.

Q: How did you learn about the DSTT program?

A: My coworker told me about it. I remember thinking, “This is a perfect opportunity for us to work on something really cool and get some great training."

Q: Describe the need your health department identified to work on for the DSTT program.

A: We did geospatial analysis, and so, at a very basic level, it's just putting rates on maps. In some ways, we all have so much data in front of us, but when it came to rates on a map and how it changes over time and by different subgroups and populations and even subspecies for like salmonella, I felt our state didn't really do that.

We were able to do advanced statistics and 3D models. When you do it visually, everybody just sort of gets interested. Even though they might not do anything with it, they're like, "Oh, cool, it's a map. I want to see it."

We did it specifically on gastrointestinal illness, so norovirus, salmonella, E. coli, those diseases.

Q: What were your main takeaways from your time in the DSTT program?

A: I was just impressed that we hopefully will fix an actual problem from this project. Let's say we do have rates of salmonella that are different. What could we do? I think we're envisioning reaching out to the local health departments and having a conversation. We want to start understanding. The public health impact is more long-term, but DSTT helped start it.

Now it’s your turn! Help increase the data science capacity of the Public Health workforce. Learn more about CSTE’s DSTT program here. Note: These interviews were edited for length and clarity.

It’s easy to draw a connection between Hannah Gorman’s favorite childhood book series, “Harriet the Spy,” and her eventual career in epidemiology. In those stories, Harriet observes her neighborhood, writes down what she sees and takes action based on the data she collects.

Sound familiar, fellow epis?

Gorman uses these same techniques daily as a CSTE Applied Epidemiology Fellow (AEF) at the Washington State Department of Health.

Her journey to public health and epidemiology is an interesting one. It started when Gorman took a “gap year” after high school and worked for a program for children in Ethiopia whose parents had either passed away or were unable to care for them, mostly due to HIV/AIDS.

It was this experience that led her to have a different view of what the word “health” means.

“[In Ethiopia] the kids themselves did not have HIV,” she said. “But they needed to go to a good school, they needed a house, they needed a place to live, they needed a parent that could care for them -- things that are very much a part of health, but we don't always think of as health. That opened my eyes.”

This “eye opening” kicked off Gorman’s mission to improve health within communities through a focus on the social determinants of health. Work that resonates strongly with today’s National Public Health Week theme, “Healthy Neighborhoods.”

Gorman studied Anthropology as an undergrad, but when choosing her next steps, she wanted something more on-the-ground and practical than purely academic.

“[Anthropology] helped give me a scholarly way to look at it, but I didn't feel like I had very concrete tools to practice it,” she said.

This realization led to her pursuing first teaching, and then a master’s in public health degree, where she was soon bitten by the epi bug.

“I was studying social and behavioral sciences, but I took one epidemiology class my first year and said, ‘I'm done. This is it. This is what I want to do.’”

While working a summer internship at the New York City Department of Health and Mental Hygiene during graduate school, Gorman connected with a former AEF fellow through her mentor. After learning about the program, she immediately applied.

“It just sounded like exactly what I wanted.”

As an official AEF fellow at the Washington State Department of Health, Gorman focused on two important areas of work: maternal and child health evaluation work and a Healthy Youth Survey designed to gather data on trends in youth health.

“That data we collect is used by our state to inform us about risk and protective factors for youth health behavior,” she said.

Gorman lists multiple highlights of her time as an AEF fellow, including presenting at the 2023 CSTE Annual Conference on her work studying multiple different ways of categorizing transgender youth. She is also helping to create guidance on how best to deal with sexual orientation and gender identity data.

“Essentially we're trying to create a best practice guide for the whole agency, to standardize how we deal with SOGI (Sexual Orientation and Gender Identity) data,” Gorman said. “So, for any data relating to sexual orientation, gender identity, or any other concepts, we're literally writing a guide for how people should handle that data.”

Gorman’s AEF journey has recently ended, but she looks forward to a full and productive career in public health. She recently began a new position as Healthy Youth Survey Epidemiologist & Coordinator. She credits AEF for the professional experience and something even more important: confidence.

“I just accepted a full-time position [as Healthy Youth Survey Epidemiologist & Coordinator at Washington State Health Department] and I feel much more assured going into that,” she said. “Because I've had this time to make mistakes and learn from them in a protected environment.”

Harriet would be proud.

Get involved! Learn more about CSTE’s Maternal and Child Health subcommittee and how to join. Interested in the CSTE AEF fellowship? Start here.

Growing up in Texas, CSTE Applied Epidemiology Fellow (AEF) Tiffany Dimaano was far from a “lone star.” Her passion for community service and helping others was evident from childhood.

She volunteered at children’s hospitals and organizations such as the Texas Children’s Hospital, Children’s Miracle Network, Make-A-Wish foundation, and the Ronald McDonald House, and even sang the national anthem at a fundraiser for a child with cancer.

As she got older, her work became more centered around the health field. While a graduate student at UTHealth Houston during the Pandemic, Dimaano helped out at a free-standing ER and took calls for patients needing COVID-19 tests.

That experience led her to study epidemiology and public health.

“[The COVID-19 pandemic] kind of gave me a bit of motivation to understand the real importance of public health, especially when it comes to outbreaks and investigations,” she said.

After graduating, she began looking for opportunities to begin her career at a state health department.

“I stumbled upon AEF and heard it was a good way to transition from being a student to a career professional,” Dimaano said. “It seemed like a great way to get hands-on experience in a health department, and it has helped me truly understand what public health and epidemiology is all about.”

Today’s National Public Health Week theme, “Civic Engagement,” is a fitting one as Dimaano’s AEF experience at the Texas Department of Health was full of it. For starters, she participated in a foodborne outbreak investigation to interview affected individuals.

"I assisted with telephone interviews with individuals who tested positive for cyclospora," she said. “They were a little bit hesitant because they didn't want to be investigated but were interested in understanding how surveillance works.”

Another side of civic engagement Dimaano became experienced with was public outreach. She shadowed her mentor, who is the director of the Environmental Surveillance Toxicology Branch, during the Pop-Up ATX event where different departments from the city government set up booths and talk to folks about what they do.

“It was very informative, just being able to have that interaction with the public. And the ability to share helpful resources for parents.”

In addition to professional takeaways, Dimaano said that another bonus of the AEF program is the relationship between cohort members. She said it was beyond helpful to have a group of peers going through similar situations, learning similar software, and completing similar tasks.

“Having a cohort of fellows really helped because we're all very supportive of one another,” she said. “We still have an active group chat going on and ask questions to one another. It's still very strong.”

She credits CSTE’s AEF program for shaping her focus in the field and giving her a wide range of experiences in a health department setting.

Her advice for those thinking of applying?

“Go for it. [AEF] can really help people to define their career path in public health and what working in a health department is all about.”

Interested in Environmental Health like Tiffany? Learn more about our Environmental Health subcommittee on the topic and how to join.

Public health is facing a serious and recurring threat: the potential loss of a vital source of funding, the Prevention and Public Health Fund (prevention fund). The prevention fund is a dedicated funding stream created by the Affordable Care Act in 2010 to improve the nation’s public health system by supporting activities such as chronic disease prevention, immunization, tobacco control, lead poisoning prevention, and infectious disease response. It was originally intended to help improve health outcomes and reduce long-term health care costs, by preventing diseases and conditions that are costly to treat and that reduce the quality of life for millions of Americans. However, the prevention fund now also makes up a significant portion of CDC’s budget as it has been used to fund core CDC activities when base funding increases were not possible.

Unfortunately, the prevention fund has been reduced by Congress several times in recent years and is vulnerable to further budget cuts and transfers as it is seen by some policymakers as an available pot of money. Trust for America’s Health has numerous resources on their website, like this chart below:

The prevention fund provides essential resources to state, territorial, local, and tribal (STLT) health departments to protect communities from infectious diseases and many other public health threats. Any cuts to the fund would jeopardize our already-underfunded public health infrastructure.

The latest proposed cut to the prevention fund comes from a provision included in H.R. 485 , the Protecting Health Care for All Patients Act, which passed the House in a 211-208 vote on February 7. The Senate has not acted on the bill. H.R. 485 uses the prevention fund as a pay-for to address unrelated changes to federal health care programs. The cuts would result in $1.19 billion in cuts over Fiscal Years 2025-2029, which is about a 13% reduction over that period. CSTE joined more than 170 organizations in sending a letter to Congress opposing these wrongheaded proposed cuts.

Importantly, one of the programs funded by the prevention fund is the foundational Epidemiology and Laboratory Capacity (ELC) funding line, which provides flexible resources to STLT health departments to enhance their capacity to prevent and control infectious diseases. This flexible ELC funding is crucial for the public health system’s ability to detect, investigate, and respond to outbreaks that may not be addressed by disease-specific funding. However, the ELC funding line could be at risk if the latest proposed cuts to the PPHF are enacted. This would have negative consequences for public health and the health and well-being of our nation. While CSTE continues to advocate for increased funding for ELC, some voices in Congress are threatening to reduce critical prevention fund resources that aid public health in their own communities.

The prevention fund affects every state—including yours! Check out the details by visiting Trust for America’s Health’s (TFAH) prevention fund page , which shows how many grants are funded in each state through the various programs supported by the prevention fund.

The prevention fund is under constant threat and needs your advocacy to ensure their continuation. That’s why we urge you to act today and call on your legislators to protect the prevention fund. Now is the time to speak up for the health and safety of our communities. Together, we can make a difference for public health.

Victoria Barahona is policy associate at CRD Associates, LLC, which represents CSTE’s interests on Capitol Hill in Washington, DC.

Throughout the years, African Americans have made invaluable contributions to public health. However, these accomplishments often go unrecognized and underreported due to a myriad of reasons, including pervasive systemic racism in the U.S.

CSTE and the public health community have a responsibility to understand the historical effect of racism in our field and highlight the people who moved health equity forward despite that.

It’s important to recognize progress has been made. In 2021, CDC officially declared racism as a public health crisis, stating: “The future health of the nation will be determined to a large extent by how effectively we work with communities to eliminate health disparities.”

In that spirit, here are five resources to help better understand the full story of African Americans and public health.

• Learn more about specific individuals: Trust for America’s Health put together a comprehensive overview of 13 African Americans that contributed greatly to public health throughout U.S. history. And more specific to our field, last year’s CSTE Black History Month blog featured the groundbreaking accomplishments of African American epidemiologists.

• Understand the connection between racism and public health: In 2021, Tulane University’s School of Public Health and Tropical Medicine published “Why Racism Is a Public Health Issue,” an article detailing the impact of racism on public health over time.

• Take a deeper dive into history: Health Affairs’ “Racism & Health in U.S. Medicine: A Conversation with Harriet A. Washington” is a 30-minute discussion covering key moments in the history of racism in medicine and research. Ms. Washington is the author of Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present.

• For the literary minded: CSTE was honored to have Dr. Camara Phyllis Jones speak at the 2022 CSTE Annual Conference, where she delivered an excellent plenary lecture about racism in public health. We suggest reading her allegory The Gardener’s Tale, which illustrates the impacts of racism on health and offers a starting point for discussions you could have in your community. Dr. Jones is a family physician, epidemiologist, and former president of the American Public Health Association.

• For the science minded: CDC’s “Racism and Health – Science and Research” web portal is a hub for research and scientific studies demonstrating how racism itself—above and beyond other social determinants of health—negatively impacts health outcomes.

For Black History Month resources beyond public health, visit https://www.blackhistorymonth.gov/ for a collection sourced from the Library of Congress, National Archives and Records Administration, and the National Gallery of Art, among others.

And remember, you can get involved with CSTE, too! Our Health Equity subcommittee meets bi-monthly and aims to address racial, ethnic, and socioeconomic health injustices. Learn more.

As the year comes to an end, let’s look at where the appropriations process stands and what we can expect when Congress returns to Washington, DC in January.

Last month, just before the November 17 deadline, the House and Senate passed a “laddered” continuing resolution (CR), successfully averting a government shutdown. The CR (H.R. 6363) extends government funding to January 19, 2024 for four of twelve appropriations bills. The remaining 8 bills, including the Labor HHS, Education and Related Agencies Appropriations bill last until February 2, 2024. Congress will have its work cut out for it next month with two deadlines that could spell a partial or full government shutdown if bipartisan negotiations break down.

Below you’ll find topline agency numbers from the CR as they compare to current funding levels for FY 2023:

 Centers for Disease Control and Prevention

• Final FY23: $9,217,590,000
• Senate FY24: $9,197,590,000
• House FY24: $7,591,566,000

 Epidemiology and Laboratory Capacity (ELC)

• Final FY23: $40,000,000
• Senate FY24: $40,000,000
• House FY24: $40,000,000

 DMI/Public Health Data Modernization

• Final FY23: $175,000,000 
• Senate FY24: $160,000,000
• House FY24: $75,000,000

 Center for Forecasting and Outbreak Analytics

• Final FY23: $50,000,000
• Senate FY24: $45,000,000
• House FY24: $0

Major cuts have been proposed by the House, as you can see above. However, the federal budget for the full fiscal year is still undecided, as different parties in Congress have different views on how to allocate the funds. Cuts to federal programs are on the table, alongside the possibility of a long-term CR, which will decimate public health funding. Make no mistake, these cuts will impact STLT epidemiologists who rely on sustained federal investments.

February will be here before we know it. CSTE reminds you that you can take action and urge your representatives and senators to fund vital public health programs at the highest levels possible. Anybody can advocate to their legislators.

Here are some steps you can take:

1. Advocate for public health in your jurisdiction. You can write an email in your personal capacity or share your stories on social media. Your voice matters! Find your representative here and reach out through their website or by phone.

    

2. Educate and share materials on DMI with your colleagues. You can send them CSTE’s DMI report, which provides a snapshot of the state of the public health data infrastructure. Or share this infographic for a short update. And, remember to review this one-pager reflecting CSTE’s estimates on the actual cost of DMI at the STLT level.

    

3. Encourage your colleagues, friends, and family to act today. Ask them to contact their legislators and tell them that public health is at risk without adequate and sustained funding. The current FY24 funding deadline is February 2, 2024. Don’t wait, act now!

Anyone can get involved. The clock is ticking for lawmakers to reach a lasting budget deal or approve another short-term funding extension by February 2. CSTE will keep pushing for adequate funding and will keep you informed as the appropriations process unfolds in the new year.

Victoria Barahona is policy associate at CRD Associates, LLC, which represents CSTE’s interests on Capitol Hill in Washington, DC.

15 Years and running...

In 2008, CSTE and CDC collaborated to create the first set of Applied Epidemiology Competencies (AECs). The goal was simple: Improve the practice of epidemiology within the Public Health system. The first step? Define the role of an epidemiologist and determine what skills are needed for each step in their career.

Of course, the world has changed drastically since 2008, so CSTE and CDC have partnered once again to update the AECs and ensure relevancy in 2023. If you’re hungry to get started, read the full report here. But if you’re short on time, here are five fast (digestible) facts about the update:

1. We Heard You! – As part of the 2023 revisions, CSTE gathered feedback on the AECs from a diverse audience. We convened a 20-member expert panel, hosted six town halls with more than 200 participants, and distributed an online survey. In all, 43 states provided feedback.
2. New and Improved Structure – The updated AECs now have an easier, more intuitive flow that builds in skill complexity as the tiers progress. This allows for a more practical and useful document that’s simple to understand. The competency format also includes a straightforward skill statement with examples, similar to the Core Competencies for Public Health Professionals
3. Diversity, Equity, and Inclusion Infused in All Domains – Principles of health equity have been infused throughout the AECs. This includes emphasizing the application of diversity, equity, inclusion, and accessibility (DEIA) principles for identifying populations, designing, analyzing, and interpreting epidemiologic surveillance data, and implementing public health actions to ensure health equity is at the forefront of epidemiology.
4. AECs Can Help You Today! – The AECs are a great resource for recruitment and retention efforts in your health department. They can be used to create job descriptions, identify professional development opportunities, craft training plans, and more—tools that are more important than ever in this modern era of public health funding.
5. More Resources are Coming! – The 2023 AEC rollout is just beginning. CSTE plans to create an accompanying toolkit that will include evaluation tools, templates for creating job descriptions, career portfolios and training plans, interview questions, and much more!

One thing that hasn’t changed since 2008 is CSTE’s commitment to a healthy, engaged, and informed applied epidemiology workforce. We are proud to present these updated AECs—which you can read in full here—and we look forward to releasing even more companion resources soon.

To read the full AEC report, please click here. For additional questions, please contact WFResources@cste.org.

• Final FY23: $9,217,590,000
• Senate FY24: $9,197,590,000

•  Final FY23: $40,000,000
• Senate FY24: $40,000,000

• Final FY23: $175,000,000 
• Senate FY24: $160,000,000

• Final FY23: $50,000,000
• Senate FY24: $45, 000, 000

Leaders on Capitol Hill are in the throes of the Fiscal Year (FY) 2024 Appropriations process, determining where to invest scarce federal resources as Democrats and Republicans in Congress simultaneously debate how to approach lifting the federal debt ceiling, which could be reached as soon as June 1. The divided Congress must not only agree on how to fund the federal government before the end of the fiscal year on September 30, but must also raise the debt ceiling to ensure the United States does not default on its credit obligations, which would be unprecedented and have far-reaching economic consequences.

A first step in the federal appropriations process is the release of the President’s budget request. While the President’s budget has no force in law, it is an important display of spending and policy priorities, indicating to Congress and the public where the administration believes federal resources should be allocated. On March 9, while members of the CSTE Executive Board were holding their annual virtual Capitol Hill advocacy day, President Biden released his FY 2024 budget request—setting the stage for the House and Senate Appropriations Committees to move forward.

The President’s budget proposed $340 million for the Data Modernization Initiative (DMI) at the Centers for Disease Control and Prevention (CDC), a substantial $125 million dollar increase over the amount appropriated in FY 2023. This represents an important prioritization of the continued efforts of the DMI at CDC. CSTE supports this proposal and has advocated strongly for this increased investment in FY 2024 to help CDC implement advanced technologies to address ongoing threats to public health and prepare our nation for the next pandemic. As technology evolves, our public health data systems will require continual updates and staff will need to be regularly trained. As such, CSTE and our partners in the Data: Elemental to Health campaign call on Congress to support the President’s budget request and provide sustained, annual appropriations to DMI.

House Republicans, including Speaker Kevin McCarthy (R-CA), have criticized the President’s budget for its increases to non-defense discretionary spending, which includes funding for critical CDC programs like DMI. This is part of a larger House Republican effort to cut non-defense discretionary spending across the board, which they pledged to do when they gained the majority. On April 26, the House passed legislation that would raise the federal debt ceiling while making deep cuts to federally funded programs and rescinding unspent COVID-19 funds. While this legislation will not pass the Senate, it illustrates the deep divide between the two parties, who must come together in some manner to address the debt ceiling and FY 2024 federal spending.

Later this month, the House Appropriations Committee will begin marking up FY 2024 funding bills. The Senate Appropriations Committee has pledged to advance legislation under regular order (moving bills through committee mark-ups) as well. CSTE will continue to call on both chambers of Congress to make essential, sustained investments in DMI and other critical public health programs, including the Epidemiology and Laboratory Capacity program and will keep members updated at key stages of the process.

Meghan Riley is vice president at CRD Associates, LLC, which represents CSTE’s interests on Capitol Hill in Washington, DC

CSTE’s AEF Program: 20 Years of Training the Next Generation of Applied Epidemiologists

Pop Quiz: What do Finding Nemo, the Safari internet browser and iTunes all have in common? All three are celebrating their 20th anniversary this year.

CSTE is pleased to add the Applied Epidemiology Fellowship (AEF) to that list of milestone anniversaries! Since 2003, AEF has guided recent graduates through the expanding field of applied epidemiology. In 20 years, CSTE has placed 519 fellows in 45 states and the District of Columbia, 27 local, three territorial, and one tribal jurisdiction. AEF participants receive two years of on-the-job training at a state or local health department under the guidance of two experienced mentors. During the program, all fellows work in public health emergency responses and 70% of fellowship graduates remain in the governmental public health sector.

In celebration of these two decades of shaping the next generation of epis, we spoke with two fellows, past and present, on what led them to AEF, their experience in the program, and the doors it has opened for their careers.

Note: These interviews have been edited for length and clarity.

Past Fellow – Ellyn Marder, DrPH, MPH, Tennessee

Ellyn Marder was an AEF fellow from 2012 to 2014, working at the Tennessee Department of Health. After graduating, she worked as a surveillance epidemiologist for CDC and is now a Senior Epidemiologist in Washington state. Ellyn has a BS in chemical science from Florida State University and earned an MPH in epidemiology from Emory University in Atlanta.

Q: Was there a certain “aha” moment you had that led you being interested in epidemiology?

In college, I really kind of struggled to figure out what it was I was interested in. I liked the concept of public health, I loved science, but I was a little lost at how to apply it. My advisor suggested I take population health courses. Through being exposed to all of these different concepts, it drove me to epidemiology, where I could still bring in the science and understanding of diseases and transmission mechanisms, but really use my skills best working with data.

Q: How did you become interested in applying for CSTE’s AEF Program?

I interned at CSTE when I was in my MPH program at Emory. So, I became really familiar with the CSTE staff and members as I attended work group, subcommittee calls, other meetings, and worked on projects with the staff. The more I learned from members and staff about what kind of work was happening at the state and local level, I just became really excited to have that experience myself. So very luckily, I was able to apply to AEF and be accepted.

Q: You completed your fellowship at the Tennessee Department of Health. What did you work on and what was a typical day like?

A lot of what I did was outbreak investigations, whether those were from animal contact, restaurants or widely distributed food products where those were usually multi-state outbreaks. I was doing patient interviewing, designing case control studies, collecting the data, analyzing the data, and helping inform any kind of public health measures we needed to take, what testing we should be doing at the lab. Did we need to get receipts to find out what did consumers buy at Costco or wherever else it was? What food item on this restaurant menu could have made them sick? And then doing case finding, calling everyone who maybe dined at a restaurant that day to ask them if they also got sick so that we could figure out what was causing the illness.

Q: What lessons did you learn during your time in the AEF Program?

I think the biggest lesson is I gained so much confidence in my skills and expertise as an epidemiologist. I have phenomenal mentors and support at the state health department who gave me opportunities to try things, advice for when something wasn’t working, and then praise when something did that really showed me where I could provide value throughout my career. And that really has just driven everything I do. I know where I can provide value in different meetings, in different context. I have that expertise and because of the confidence that they instilled in me, I know there’s so much that I can contribute now and I’m excited to contribute it.

Q: What advice do you have for someone thinking about applying to AEF?

Do it a hundred percent. If I could go back, I would be a fellow. I tell everyone that every day. I think the fellowship provides such a unique opportunity to be on the ground, learn from renowned experts at state health departments, contribute in such a meaningful way while learning so much about what you’re going to enjoy in public health to help shape your career. I think anyone considering it, even folks who aren’t sure about the direction they want to take, I think the AEF fellowship just provides such a great foundation and a starting place for what public health can be for your career.

Current Fellow – Hannah Lund, MPH, Pennsylvania

Hannah Lund is a current fellow at the Pennsylvania Department of Health where she specializes in infectious disease. Hannah has a BA in Biology from Southwest Minnesota State University and earned an MPH in epidemiology from the University of Nebraska Medical Center.

Q: Was there a certain “aha” moment you had that led you being interested in epidemiology?

I was a junior in college in undergrad, and I was majoring in biology, and I wasn’t really sure what it was that I wanted to do, and I happened to just pick up a book and I read about what they were doing. It was a former EIS officer who went on to work at CDC for several years, and he outlined how he got into public health, and the investigations he did while in EIS, and then working for CDC, and I was like, “Wow, that sounds like something I would really like to do.”

Q: How did you become interested in applying for CSTE’s AEF Program?

My career counselor at University of Nebraska was outstanding. She told me about a lot of different paths you can take leaving the MPH program here and mentioned CSTE’s AEF. We also had a PhD student who was a former CSTE fellow. I had the chance to hear her speak about her AEF experience, what she did and how it helped her. And after that day, I thought, “Oh, that seems like something I would really like to do.”

Q: Your fellowship is at the Pennsylvania Department of Health. Walk us through a typical day?

I’m in the Infectious Diseases team, but don’t have a specific focus. I am really spread out through everywhere. Somebody has a project, and they need help on it, my supervisors ask, “Hannah, do you want to do this?” So, I’ve helped with hepatitis, I’ve helped with some environmental projects with wastewater, influenza and vectorborne. I’ve done some COVID stuff. I’ve really just been kind of spread throughout and it’s been great, because I get to experience all these different things, and I get to see what I like and I don’t like.

Q: What are your future career goals?

I would say a dream job would be working with enteric diseases. I have really enjoyed doing interviews for any enterics outbreak. I like to stay busy and always have things going on, and that’s something that is busy year-round. Everything has its season, but there’s always something happening. And so, I think that would be my dream job.

CSTE established the Applied Epidemiology Fellowship (AEF) in 2003, closely modeled the program after the Center for Disease Control and Prevention’s (CDC) Epidemic Intelligence Service (EIS) program, which uses a mentorship model to train recent graduates in the expanding field of applied epidemiology. To learn more about AEF, please visit the newly refreshed and relaunched AEF website for more information – www.cstefellows.org.

By Ben Warden, CSTE Staff

Today’s National Public Health Week 2023 theme is Reproductive Health, a subject close to current AEF fellow Bonnie Bloxom. Below, Bonnie shares how she found her way to epidemiology, her time studying abroad and her current work in Maternal Child Health at the Oregon Health Authority. 

“You should try Public Health. Just take the intro course.”

Little did she know at the time, but those ten words from Bonnie Bloxom’s undergraduate academic advisor at Elon University ended up shaping the next course of her career.

She’d always been interested in analytics, research and data, so her advisor asked her to give public health a try. After taking the course, Bloxom was hooked.

“The very first class in the course covered social determinants of health, population levels and global health,” she said. “I thought ‘Wow, this is exactly what I wanted.’ I didn’t know public health existed until this class.”

Bonnie finished her time at Elon University with a B.S in Biology and a B.A. in Public Health Studies. At first interested in medical school, she decided to pursue her newfound passion for public health. Part of the initial course she took covered Global Health, which she found to be particularly inspiring and enjoyed learning.

Bloxom decided she’d like to learn more about a potential career in global health and her next move proved it. She went to graduate school … in Taiwan.

Bonnie received a funded Fulbright grant to attend National Taiwan University, the home of the only internationally accredited master’s program in Public Health. She earned her MPH degree in 2021.

While studying in Taiwan, Bloxom noticed a difference in how public health is practiced there as opposed to the U.S., especially since her time in the country coincided with the onset of the COVID-19 pandemic.

“One of the main differences is just from a cultural perspective”, she said. “There’s an idea of collectivism there — everyone working towards a shared common goal and sacrificing some of your own personal ones for the good of society.”

Specifically, she points to masking, a common and apolitical practice in Taiwan even before the pandemic. Since the significant impact by the 2004 SARS outbreak, masking in grocery stores and public transportation was a part of life.

“During Covid, my Taiwanese classmates asked me: ‘Why is it such a big deal for people to wear masks and to get the vaccine in the United States?’ They have a lot of trust in their government and their public health system.”

As her time in Taiwan was wrapping up, Bonnie looked for her next opportunity back home in the U.S. Through good, old fashion Googling, she learned about CSTE’s Applied Epidemiology Fellowship (AEF). Having spent the past few years immersed in ‘theory’, the chance to work in a local health department and gain on-the-job experience in applied epidemiology appealed to her.

Bonnie applied and was accepted into the two-year program working at the Oregon Health Authority. She’s been there since August 2021 and will graduate later this summer. One aspect of the experience she’s appreciated is working closely with mentors.

“My mentors here in Oregon have just been amazing and I can't speak highly enough of them. They're great.”

Bonnie also mentioned the excitement of the unpredictable day-to-day nature of being a fellow.

“Each week can look different just depending on which projects and what's going on,” Bloxom said. “For example, this past week, I was at a hospital because they had a novel outbreak of a fungus. I was working with their infection preventionist and trying to understand how to prevent this from spreading in the future.”

Outside of the unexpected crisis, Bloxom’s specific area of focus is Maternal Child Health (MCH). She works closely with the Pregnancy Risk Assessment Monitoring System (PRAMS) and publishes its pertinent data. PRAMS is also the cornerstone of a project Bonnie is working on for CSTE.

“It's using six or seven years of PRAMS data and looking at the impact of racial discrimination on prenatal, preconception and postpartum care utilization among pregnant Oregonians. And so that's been taking up a lot of my time reading, writing a literature review and writing up manuscripts.”

After her time in the AEF program ends this year, Bonnie intends to continue her education by attending nursing school. Her ideal work life would be a mix of hands-on clinical work in MCH, but also to continue honing her craft in epidemiology with data and statistics.

“My dream would be to have that sort of dual career where I'm in the clinic, but also working at a state or local health department doing public health as well,” she said. “I hope to combine both my work as a nurse and as an epidemiologist.”

Looking back on her almost two years at the Oregon Health Authority, Bloxom said one overarching theme has popped up again and again throughout her fellowship: The importance of working with the community.

“What I’ve learned is that community-based public health works, community-based epidemiology works. But how can we really engage in true partnership and true community participation with a population? That is really lacking right now.”

Bonnie said that idea hit home even more when she learned about this year’s CSTE Annual Conference theme.

“It's interesting that one of the themes of CSTE this year is working with epidemiology, not on, communities. My immediate thought was ‘We want to do this so badly in Oregon.’”

Bonnie Bloxom is a current fellow at the Oregon Health Authority where she specializes in Maternal Child Health. Hannah has an M.S. in Global Health from National Taiwan University and a B.S. in Biology from Elon University.

For more information on the CSTE AEF program, please visit www.cstefellows.org.

By Ben Warden, CSTE Staff

Welcome to National Public Health Week 2023! In recognition of today’s theme, Community, we’re kicking the week off by interviewing Jim Collins, MPH, RS, Director of the Communicable Disease Division of the Michigan Department of Health and Human Services (MDHHS). Jim is also the CSTE Surveillance and Informatics Steering Committee Vice Chair. He discussed his career as an epidemiologist and what ‘community’ means to him. Note: This interview has been edited for length and clarity.

Q: What led you to being interested in epidemiology?

A: Back in the early '80s there wasn't much in the news about epidemiology. I was attending Alma College, a small liberal arts school in Michigan, and took a microbiology class that touched on the transmission dynamics of various infectious diseases. It was interesting to me and illustrated a connection between biology and math. At the time, I just wasn't sure where I wanted to go with it. I did know one thing; I've always wanted to see if I could make a positive difference. When I started reading about epidemiology, it made a lot of sense for the work I wanted to do. After graduating from Alma College, I decided to continue my education with an MPH program at the University of Michigan School of Public Health.

Q: What was the landscape for young epis back then?

A: When I finished graduate school, the job market for epidemiologists was not nearly as open as it is right now. At the time, I knew I wanted to go into a career focusing on infectious disease, recognizing it would be challenge.  A lot of folks thought infectious disease was passé because of antibiotics and other medical advancements. As we’ve since learned, infectious disease epidemiology will always be an important and dynamic field and that’s one of the reasons that I’m glad to be part of it. 

Q: How did you come to join CSTE?

I was an epidemiologist at the local level for about eight years, but I didn’t learn about CSTE until I worked at the state level. Our State Epidemiologist at the time, Dr. Matthew Boulton, recruited me to come work for the state and encouraged my involvement with CSTE.

Throughout my career at the state health department, our administration has continued to promote engagement with CSTE. I believe they agree that it contributes to our national public health voice and allows for information sharing that serves the greater good of the department and country.  I’ve found that to be absolutely true and I'm grateful for it.

Q: Take me through a typical day?  

A: I am the Director of the Communicable Disease Division at the MDHHS, the state health department. Michigan has a population of about 10 million people. A little over 100 people in my Division work on communicable disease issues, exclusive of HIV. There is still a daily component in my job focused on the COVID-19 response, and I don't see that changing in the immediate future. We talked about how dynamic the field of infectious disease epidemiology is. While we continue to respond to COVID-19, on a different front, we're also actively working on an outbreak of blastomycosis in the Upper Peninsula that's associated with occupational exposures. I don't think there are many typical days in infectious disease epidemiology, but that's one of the many reasons I enjoy it.

Q: Today’s theme for National Public Health week is Community. How does a sense of community help you in your work?

A: In terms of CSTE, there are so many opportunities to learn from partners from across the country that are doing the same work, but in different environments.  After every call or meeting, I leave with at least some notion of how to do our jobs better. I think you must be open-minded to these teaching moments from the community of CSTE colleagues in order to move the field of infectious disease epidemiology forward. Having a community of like-minded people with similar objectives, that share the same passions, the same hopes, the same aspirations, helps tremendously. It's a community that ranges in age, experience, and perspectives. I'm probably on the upper end of the age range for the community we're in, but I think my experience can help contribute. There's so much collective knowledge out there in CSTE and that’s a major aspect to what makes it valuable and productive.

I've been doing this for about 35 years now, but I am still incredibly passionate about public health and epidemiology. I still love the work we do, and I think it's very important.

As Women’s History Month comes to a close, CSTE is featuring Alice Hamilton, the “first female epidemiologist” and a pioneer in industrial health and safety. We are pleased to celebrate the importance of women in occupational health and epidemiology.

Alice Hamilton: Industrial Health Pioneer and the First Female Epidemiologist

When we think about women fighting for worker protection and workplace reform, images from movies like “Silkwood” and “Norma Rae” may spring to mind – everyday people protesting and trying to better their work environments. Those characters (and their real-life inspirations) made critical improvements, but we can go much further back in history to see the beginnings of women’s influence on safety for all workers.

During the late Industrial Revolution, social reformers like Jane Addams were beginning to lay the groundwork for women’s, children’s, workers’ and immigrants’ rights in the U.S. At Hull-House, a “settlement house” in Chicago, Addams and other reformers lived and worked closely with poor, working-class immigrant families. They focused on addressing the social and health issues created by urbanization and industrialization, including housing shortages and unsanitary living conditions.

Working conditions for the area’s poor also created health issues. However, at that time there were no legal protections for workers in the numerous mills, plants and factories across the country. In fact, no official connection had even been made between occupations and health.

Enter Alice Hamilton, a pioneer in industrial health and safety and the “first female epidemiologist.”

Hamilton was born into a prominent family in Indiana in 1869. She graduated from medical school at the University of Michigan in 1893 and moved into Hull-House several years later, opening a well-baby clinic and treating residents of the settlement house neighborhood.

As she came to know local families, Hamilton saw firsthand the diseases and injuries resulting from dangerous conditions, industrial accidents, and exposure to poisonous substances like lead and mercury. In her autobiography, “Exploring the Dangerous Trades: The Autobiography of Alice Hamilton, M.D.,” she said her experiences at Hull-House aroused her interest in industrial diseases. “Living in a working-class quarter, coming in contact with laborers and their wives, I could not fail to hear tales of dangers that workingmen faced, of cases of carbon-monoxide gassing in the great steel mills, of painters disabled by palsy, of pneumonia and rheumatism among the men in the stockyards.”

In 1910, Hamilton made her first formal investigation into the connection between the workplace and disease. The governor of Illinois appointed a commission to study industrial illness, particularly the high mortality rates due to industrial poisoning in the lead and associated enamelware industries, rubber production, painting trades, and explosives and munitions. Hamilton directed the survey and focused on lead – the most widely used industrial poison – while others on the team reported on arsenic, brass manufacturing, zinc smelting, turpentine and carbon monoxide.

The Illinois report proved the connection between occupation and illness. In 1911, the state’s legislature passed an occupational disease law requiring employers to implement new safety procedures, provide monthly medical examinations for workers in dangerous trades, and report illnesses to the Department of Factory Inspection.

Dr. Karla Armenti, research assistant professor at the University of New Hampshire and a member of the CSTE Occupational Health Subcommittee, stresses the importance of Hamilton’s efforts in making the connection between work and health. “Alice Hamilton’s work at Hull-House was critical, because of course there was no pollution prevention then, no workplace protections,” she said. “Hamilton and Jane Addams really made the link between work and exposure and workers’ health. They were like urban industrial environmentalists.”

Hamilton’s work in Illinois led to similar studies for the U.S. Bureau of Labor. As with the earlier survey, she carefully studied hospital records to connect specific illnesses and occupations and thoroughly investigated factories to learn which processes used dangerous chemicals. Over the years, her many reports for the federal government – first regarding the lead trades, then other dangerous trades – illustrated the high mortality rates in these occupations and brought about many landmark changes in state and federal industrial safety legislation.

CSTE Executive Director Janet Hamilton (no relation to Alice) emphasizes the importance of Hamilton’s perspective as a woman. “We need women in occupational health to really see the women in the workforce, to study the jobs that are often not seen otherwise. It goes back to the roots of epidemiology – demos, the people – if you don’t know or understand the people, you don’t know the questions to ask or the things to look for.” Her grandmother immigrated to the U.S. as a child with only her brother, working as a maid for years. “Definitely no one was looking at her job or the hazards associated with it,” she said.

Alice Hamilton joined the industrial medicine faculty at Harvard Medical School in 1919, becoming the first woman on the Harvard faculty. She taught one semester each year so she could continue her investigative work and return to Hull-House every spring. While at Harvard, she wrote “Industrial Poisons in the United States” (1925), the first textbook in the field, and “Industrial Toxicology” (1934).

Dr. Armenti enjoys teaching her own students about Hamilton in Occupational and Environmental Health classes. “Hamilton looked at the intersection of the social, political and economic worlds and how that connects to public health and worker health,” she said. “Her work was one of the first times people weren’t just responding to illness afterwards but looking to prevent it in the first place.”

After mandatory retirement at age 65, Hamilton continued her focus on social issues, campaigning against McCarthyism and the U.S. war in Vietnam. Recognitions for her 100th birthday included a telegram from President Nixon praising her successes in industrial medicine. She died on September 22, 1970, at the age of 101. Three months later, Congress passed the Occupational Safety and Health Act.

Janet Hamilton believes recognizing Alice Hamilton and her work helps all women in the field. “Seeing people like yourself in elevated positions is so important and can be a great influence,” she said. “It’s so helpful in paving that path. Public health needs are great and many, and the perspectives that women bring that no one else can bring to the table are completely inspiring,” she said.

It makes me hope, that the day is not far off when we shall take the next step and investigate a new danger in industry before it is put into use, before any fatal harm has been done to workmen…and the question will be treated as one belonging to the public health from the very outset, not after its importance has been demonstrated on the bodies of the workmen.” – Alice Hamilton

CSTE celebrates February 2023 as Black History Month

In recognition of Black History Month, CSTE spoke with Heather Butts, Assistant Professor of Health Policy and Management at the Mailman School of Public Health at Columbia University in New York. Ms. Butts shared a few unsung Black epidemiologists and their contribution to modern day epidemiology.

Past is Prologue: What Untold Stories of Black Epis Tells Us About Today

Heather Butts is an Assistant Professor at Columbia University and accomplished author. After her first book, African American Medicine in Washington, D.C.: Healing the Capital During the Civil War Era, was published in 2014, she received a curious question from a reader.

“I like your book, but why should we care about this now?”

It’s a sentiment often asked of historians and academics. Professor Butts answered it not with pie-in-the sky platitudes, but with a hardwired belief in how the past can inform today.

“Part of the book was about morphine use during the Civil War and finding that connection between trauma, coping and addiction,” she said. “There’s a direct line from that to what we’re seeing with the rise of the opioid crisis during the COVID-19 pandemic.”

Connecting the dots between past and present is a large part of Professor Butts’ class, “The Untold Stories in U.S. Health Policy History,” which covers the contributions of Black Americans to the history of healthcare, including epidemiology.

“We benefit from these individuals works, and yet they go unnamed,” she said “Their stories are not told. So, we benefit from what they've done for us, but we don't benefit from knowing who they are, and if we knew who they were, we might be able to benefit even more from what they've done.”

In the spirit of Black History Month, Ms. Butts spoke to CSTE about a few unrecognized Black epidemiologists and  the impact of their contributions to modern day.

In 1965, Bernard Challenor was the first Black American appointed to be an Epidemiological Intelligence Service Officer at the CDC. He also worked at the World Health Organization, where he led efforts to vaccinate for and eradicate smallpox.

“[Dr. Challenor] was one of the premier individuals at the School of Public Health at Columbia,” Professor Butts said. “His history and what he accomplished is so underknown that his niece actually contacted me to learn more about him. The reason why I teach the course is really for people to have a better understanding of who some of these individuals are.”

Another underknown name is Rebecca Crumpler, who some claim to be the first Black American woman to earn a medical degree in the U.S. In 1883, she wrote the Book of Medical Discourses, which provided early guidance on maternal and child health.

“Her contributions over 150 years ago to the field of maternal and child health stay with us today,” Professor Butts said. “We just don't know that they’re from her. And that’s problematic.”

Another untold story Professor Butts talked about was Vivien Thomas, a laboratory supervisor who developed a surgical procedure, the Blalock-Taussig shunt, used to treat blue baby syndrome. While doing his work, he was technically classified as a janitor and paid as one.

“It’s distressing,” she said. "You have this Blaylock-Taussig-shunt, and really it should be called the Blaylock-Taussig-Thomas-shunt, or maybe it should be called the Thomas-Blaylock-Taussig-shunt. It’s concerning that we don't know these stories and that they’re just not fully formed.”

Professor Butts stressed that even though these individuals may not officially be known or trained as epis, the work they did contributed to the field. She also draws a line between her historical perspective and the epi method.

“Epidemiology to me is history in real time,” she said. “It’s we see the trends, they happen over time, and if we can take a moment to learn from them, we can see everything old is new again.”

Too many stories of Black History, especially in regards to public health, have slipped through the cracks. Recognizing them is not just about knowing the past … but to also glimpse into the future.

“I think if we can know where we came from, we can have lessons not only to where we are now, but where we are headed, where we could be going,” Professor Butts said.

“To me, that's why knowing our history, our complete history, our full history, it's so critical. It's so instrumental.”

Professor Butts received her Bachelor of Arts from Princeton University. She was a history major, concentrating in American and African American Studies. She received her Juris Doctor from St. John’s University School of Law, her Master of Public Health from Harvard University and her Master of Education from Teachers College, Columbia University.

She is also the co-founder or H.E.A.L.T.H for Youths, Inc. a nonprofit organization that focuses on college readiness and preparation. Her organization partners with 25 programs each year to help more than 1,000 students achieve their dream of going to college.

Read more about Professor Butts and her class, The Untold Stories in U.S. Health Policy History

In late December, Congress passed an omnibus spending bill funding federal agencies through the remainder of Fiscal Year (FY) 2023. CSTE was pleased to see its advocacy efforts pay off with an increase to $175 million for the Data Modernization Initiative (DMI) at the Centers for Disease Control and Prevention (CDC). Given the wide range of competing budgetary priorities across the federal government, this $75 million increased investment indicates that Congress continues to recognize the importance of modernizing our nation’s public health data systems. The omnibus bill also included $9.2 billion for CDC overall, an increase of $760 million, $350 million for Public Health Infrastructure and Capacity, an increase of $150 million, and $50 million for the new Center for Forecasting and Outbreak Analytics.

After many wins in FY 2023, there are new factors to consider as the FY 2024 appropriations process begins. First, the mid-term elections resulted in a slim Republican majority in the House, with Democrats retaining control of the Senate. House Republicans have continuously expressed a desire to cut spending. As Rep. Kevin McCarthy (R-CA) jockeyed to be elected Speaker of the House, reports indicated an informal agreement between him and more conservative members of the Republican party to limit FY 2024 spending to FY 2022 levels. The most drastic of proposed cuts are likely to impact non-defense discretionary spending, as opposed to the military budget. While such draconian cuts will be difficult to achieve with a Democratic Senate and President, we may indeed see protracted funding battles in Congress resulting in continuing resolutions and the threat of government shutdowns down the line.

On January 19, the U.S. reached its statutorily imposed debt ceiling and the Treasury began using extraordinary measures to ensure the federal government could fulfill its credit obligations. Congress must come to an agreement to raise the debt ceiling before the extraordinary measures are exhausted sometime this summer. Conservative Republicans have discussed leveraging the debt ceiling increase to negotiate spending cuts. We will continue to follow this debate and its potential repercussions on future domestic spending, including for critical public health programs.

While the new makeup of Congress and the debt ceiling debate may pose obstacles to further robust increases, CSTE will continue its ambitious advocacy efforts to secure long-term sustained funding for DMI. For FY 2024, CSTE and partners in the Data: Elemental to Health campaign are pushing for a $250 million investment in DMI, which would help further scale up efforts at the federal level, and in State, Territorial, Local, and Tribal (STLT) health agencies. The President’s annual budget request, usually released in February, is expected to be delayed this year.

CSTE is committed to bipartisan action on DMI and will continue to work with legislators on both sides of the aisle to achieve long-term support for a modernized public health infrastructure. COVID-19 and other recent threats have made universally clear the importance of public health surveillance and analytics and have demonstrated the need for robust sustained investment in DMI. While we seek increased appropriations for FY 2024, CSTE and our partners will also continue to call for a dedicated investment of at least $7.84 billion over five years to ensure STLT agencies have modern systems that keep pace with evolving technology.

For more information on CSTE’s DMI advocacy, visit https://www.cste.org/page/DM-2021.

Meghan Riley is vice president and Noah Hames is policy associate at CRD Associates, LLC, which represents CSTE’s interests on Capitol Hill in Washington, DC

“I understood at that moment that I needed to go into more of a public health policy realm to affect change for people rather than just one-on-one patient care,” she said. “I knew that my interest and skill set would be better used at ensuring people like this gentleman got the care they needed and were diagnosed early so that they could go about their lives in a healthy way.”

Angela saw epidemiology as a natural transition from the clinical sciences she was studying, due to its data-driven methodologies and the detective-like mindset it takes to succeed at the job.

“[Epidemiology] really does speak to the science side of my brain, but then also that desire to make a bigger change at a larger population level really excites me,” she said.

After many years as Utah’s State Epidemiologist, Dunn is now the Executive and Medical Director of the Salt Lake County Health Department. A longtime member of CSTE, she was elected President in June 2022 for the 2022-23 term.

Like the CSTE Presidents before her, Angela has developed and crafted a few presidential priorities to spotlight during her term. Her first priority, “Formalizing Cross Jurisdictional Partnerships,” focuses on maximizing CSTE’s ability to bring together epis to share best practices experiences to help each other out.

“Having that group of people be able to say, ‘Well, here's how I deal with it,’ is really important,” Angela said. “But beyond that, it really is just that sharing of best practices within applied epi across state lines, because when we're able to bounce ideas off each other, that's how we make sure we're all practicing the best public health we can.”

The genesis of this priority came from the isolating early days of the COVID-19 pandemic, where Angela, then still a State Epidemiologist, noticed how much her and her colleagues in other states relied on each other to both keep up morale and share resources.

“It was nice knowing that there was a group of people out there that definitely had your back and understood what you were going through.”

If the community of epis is at the heart of Angela’s first presidential priority, then the community at large is at the heart of her second priority, “Equipping Epidemiologist to Practice Epidemiology WITH Rather Than ON Communities.”

Traditionally applied epidemiologists are very disease focused, describing how a particulate disease could spread, risk factors, etc. However, Angela feels that COVID-19 highlighted that since its typically the same communities that are at the highest risk for many public health diseases, epis need to “work with” communities and not just “talk at” them.

“As epidemiologists, we don't want our data to just sit unused in a spreadsheet,” Angela said. “We want it to be used to improve the health of the community. To do that, the communities must trust what we're doing. It's about incorporating a community perspective into our applied epidemiology, so that we can bring the whole community up and not just talk about one disease.”

While Angela admits her priorities are lofty, she is certain they are achievable in part due to the expertise and resiliency of CSTE members. One story from her pre-COVID days as the Utah State Epidemiologist specifically came to her mind that connects those attributes with both of her priorities.

In 2019, many Utah residents were visiting a camp in Jackson, Wyoming, when a rabid bat exposure occurred. In a very timely matter, Angela had to work and share resources with the Wyoming State Epidemiologist (whom she knew from CSTE) to identify all the individuals at risk, as well as work with the community to disseminate facts and not induce panic. During that time, communication between the two states was easy thanks to the connections that CSTE fosters. That efficiency also translated working with the community in a constructive manner.

“That's part of the bread and butter of applied epidemiology,” she said. “Working across state lines is to be able to work quickly, and that happens better when you know the people on the other side.”

“And honestly, it's because CSTE brings us together.”

Angela Dunn, MD, MPH is Executive Director of the Salt Lake City County Health Department, and CSTE President for the 2022-2023 term. For information on CSTE’s Presidential Priorities Award, which is given at the CSTE Conference, please visit https://www.cste.org/page/presidential-priorities-award.

Federal Funding Update

CSTE was pleased to report earlier this year that Fiscal Year (FY) 2022 funding for the Data Modernization Initiative (DMI) at the Centers for Disease Control and Prevention (CDC) reached $100 million, a doubling in funding compared to FY 2021. This investment was made after two continuing resolutions and bill passage one day before a deadline that would have led to a government shutdown. With the many competing budgetary priorities across the federal government, we were thrilled to see a substantial increase for DMI. However, further robust and sustained investment is necessary to transform our public health data infrastructure. With our advocacy for FY 2023 funding, we are continuing our efforts to see that through.

For FY 2023, CSTE and partners in the Data: Elemental to Health campaign are calling for $250 million for DMI to help transform our public health data systems. At the start of the FY 2023 federal appropriations process, the president’s annual budget proposed $200 million for DMI, another potential doubling in funding. CSTE’s advocacy then led to proposed funding increases for DMI within the FY 2023 Labor, Health and Human Services, Education and Related Agencies (LHHS-Ed) appropriations bills released in both chambers of Congress. The House Appropriations Committee bill allocates $250 million, a $150 million increase over FY 2022, while the draft Senate Appropriations Committee bill provides $200 million, in line with the president’s budget.

While these numbers are promising, neither the House nor the Senate have passed a LHHS-Ed bill, and the likelihood of passage prior to the end of FY 2022 appears slim. The House Appropriations Committee approved its LHHS-Ed appropriations bill on June 30, but the full House did not pass the legislation before adjourning for August recess. In the Senate, Appropriations Committee Chairman Patrick Leahy (D-VT) released a chairman’s mark of the bill, but the committee is unlikely to pass any individual appropriations bills this fall.

With FY 2022 funding set to expire on September 30, 2022, and the November mid-term elections approaching, congressional leaders have yet to come to an agreement on overall spending levels. If Congress cannot reach an agreement on FY 2023 spending next month, at least one continuing resolution to extend current funding is imminent. Continuing resolutions can lead to stagnant funding, which can damage the ability of key programs like DMI to continue their work. While we do not anticipate an LHHS-Ed appropriations bill will be enacted on its own, CSTE will continue to advocate for Congress to come to a bipartisan agreement on overall funding that provides increased annual resources for DMI as a first step towards sustainable long-term investment.

The COVID-19 pandemic made it clear to legislators on both sides of the aisle that public health surveillance and analytics are essential in preventing and mitigating disease risk, and sustained federal investment is necessary for these processes to be most effective. In addition to seeking funding through the annual appropriations process, CSTE continues to call for a dedicated investment of at least $7.84 billion dollars over five years, which Data: Elemental to Health estimates is the minimal investment needed to truly transform our public health data systems. The resources we fight for will ensure state, local, tribal, and territorial public health agencies have the means to implement a more effective and sustainable data infrastructure.

Meghan Riley is vice president and Noah Hames is policy associate at Cavarocchi Ruscio Dennis Associates, LLC, which represents CSTE’s interests on Capitol Hill in Washington, DC

April is known as a month of “firsts” – the first flowers of the year bloom, the first days of warmer weather and the first baseball game of the year is played. April 2022 also saw a first for CSTE as it hosted its first Preventative Medicine Fellow, Dr. Hariharan (Hari) Athreya. 

Concurrently with his CSTE Fellowship, Dr. Athreya is finishing up a Fellowship in Preventative Medicine at Emory University. He’s passionate about providing global and community health and addressing health inequities. During his time at CSTE, he graciously sat down for an interview.

Q: Was there a certain “a-ha” moment where you became passionate about Public Health as a career?

A: If I had to pick one, it would be my experience with AmeriCorps during college. I saw that if I cared about social determinants of health and where people were living and how they were living like I was doing … then I would need a public health degree. But to be able to do that I think coupling that with a medical degree would offer the most ability to leverage my skillset and my interest in science. That experience showed me the importance of community health and trying to understand where people are living before just trying to fix them when they come to clinics, and I think that really showed me the importance of public health.

Q: Describe wanting to branch out beyond a traditional medical education to include public health?

A: Early in my medical education I was having a hard time grasping how little it allowed us to be out in the community and understand what was going on with our patients. And I think that medical education can sometimes be siloed in that we don't really understand the context of what we're giving or the context of the people that we're trying to help. And I remember in our medical school I think we only had one half-hour session on what public health meant and didn't feel like that was enough.

I started a program, GoodEats, that raised awareness of how social determinants of health affect clinical outcomes. It was born out of an attempt to help teach fellow medical students and myself about social determinants of health and how that was not just only affecting the patients in our community that came to see us, but how that was impacting our own ability to function as students and learners and be able to be present for our patients.

Q: What’s an average day like for you? 

A: My day to day varies a lot. With CSTE, there's a lot of information to absorb and that's been great. I attend a couple different group meetings daily and then sometimes ad hoc events come up, for instance today there is a White House briefing on the new data modernization initiative.

So, the day is usually sprinkled with three or four meetings and then trying to work on projects that I've been assigned to, that's both continuing projects with CSTE and sometimes projects that have been ongoing. Right now, I'm working on a project around screening for opioid use disorder in primary care clinics, working on a paper on air quality standards and how that affects preventative medicine physicians, doing different data analysis projects for the Georgia Department of Public Health.

Q: What programs or areas of CSTE’s work have interested you the most during your Fellowship?

A: I just sat in on a meeting with the health equity division of CSTE and I think that’s the most interesting [area] to me right now. And then informatics, i.e., the work that Annie Fine (CSTE’s Chief Science and Surveillance Officer) is doing around data modernization and why it's important. There is a balance necessary in trying to improve data systems that will be key for the future. It seems that working on the very local level right now, data is such a challenge to deal with. The questions around how to handle it moving forward is very interesting.

Q: Managing burnout has become a major issue for all health care workers. What have you learned, especially during the pandemic, that has helped you?

A: I think everybody who worked in direct patient care got burned out at some point during COVID, and it's how you pick yourself up from that. For me it was a lot of just trusting or being able to talk to the people around you, and share your experiences, and share your frustrations, and then together kind of resolve to find a better way to do it next time.

I think the answer to that question is one, making sure that you have people you can talk to and be open and vulnerable with when you do feel burned out or low, and then moving on to try to build a better public health infrastructure to avoid feeling burned out in the first place.

Dr. Hari Athreya is preventative medicine fellow at Emory University School of Medicine. He served as CSTE’s first preventative medicine resident in Spring 2022.

As part of National Public Health Week 2022, CSTE is highlighting the work of our members in applied epidemiology. Today is Part 2 of a spotlight of CSTE President Dr. Ruth Lynfield.

CSTE President Dr. Ruth Lynfield coped with the early stages of the COVID-19 pandemic like many of us did.

She went outside.

“Every weekend I could, I’d go to a different state park and hike,” Dr. Lynfield said. “I loved being with my family, my dog and to just be out in nature.”

As the weeks turned into years, Dr. Lynfield, the State Epidemiologist for Minnesota, understands even more how she and her public health colleagues must take care of themselves.

“Because if you don’t, you’re not going to be able to work at your best,” she said. “And you’re not going to be able to take care of your staff, your colleagues and your family.”

With that outlook, it’s easy to see how building a sustainable and resilient public workforce is one of Dr. Lynfield’s presidential priorities. Her efforts on this front include helping to produce and execute a training series allowing individuals to navigate their experiences of burnout, learn skills to support resilience, and cultivate and sustain new self-care habits. The series is for both State Epidemiologists and Deputy State Epidemiologists with a goal to expand to other CSTE members. 

Another one of Dr. Lynfield’s presidential priorities is also today’s National Public Health Week theme: Health Disparities. i.e., a particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage. Lynfield says inequities exposed during the COVID-19 pandemic has spurred her passion towards this subject even more.

“There’s been a lot of work during this pandemic to dig into the risk factors for contracting COVID and having severe COVID,” she said. “Health disparities have come through as a really important issue. Especially understanding the role that structural racism has played and how that may impact a person’s decision if they want to get vaccinated or receive healthcare. There’s a lot of work that needs to be done.”

Much of that work, according to Dr. Lynfield, involves going directly out to the community to talk with individuals in different areas and trying to understand what the barriers are.

“Certainly, if someone is suspicious about a new vaccine, hearing about it from someone in their own community is more likely to result in having more confidence in it,” she said. “That’s what we need to do. It's difficult work and multi-layered. But we need to see where the gaps are and understand them.”

Another aspect of reaching out into the community, according to Dr. Lynfield, is accepting it is a two-way street. In other words, paying attention to what individuals have to say and being open to their ideas on how to best keep their community as healthy as possible.

“We need to listen; we can’t just say ‘oh we know how to fix this’ – we need to also ask people: how do you think we should fix this,” Lynfield said “It’s going to take time. But we must do it. There are astonishing inequities, so we must start including it in everything we do and understanding where the successes are and being able to apply those successes in other areas.”

Despite a full plate of priorities and the day to day works as a State Epidemiologist, Dr. Lynfield finds it vital to still keep her commitment to mitigating stress and burnout through the activity she enjoys the most.

“When I’m out hiking in nature, it gives me perspective,” she said. “It helps me balance things.”

Ruth Lynfield, MD, is State Epidemiologist from Minnesota and CSTE President for the 2021-22 term. More information on Dr. Lynfield's current work on LEIFE and other presidential priorities can be found at https://www.cste.org/page/presidential-priorities-award.

As part of National Public Health Week 2022, CSTE is highlighting the work of our members in applied epidemiology. Today’s focus is on CSTE member Kelly Walblay, MPH.

Until college, Kelly Walblay had no idea what epidemiology was. That changed quickly.

As an undergraduate, Walblay knew she wanted to work in health care, just not exactly in which discipline. After a guidance counselor introduced her to public health, she took a chance and signed up for an internship in Buenos Aires, Argentina. Along with her fellow interns, she spent time with an underserved population within the city as a health consultant, focusing on infant care, sexual health and immunizations.

“We just set up a table in this community and people came and asked questions,” Walblay said. “Seeing this community care about their health and genuinely wanting to know answers to their questions was really cool for me. At that moment, I thought: ‘Oh we can really address some of these gaps that we’re seeing in public health knowledge.’”

From her internship to her master’s degree thesis, and onto her professional career, reaching out into the community has echoed throughout Kelly’s work as an applied epidemiologist. A fitting connection as today’s National Public Health Week theme is Community Collaboration and Resilience.

“[Argentina] was the moment where I thought ‘I really want to do something like this.’”

Ms. Walblay pursued a master's degree in public health specializing in epidemiology at the University of Michigan. She worked with a professor who did cohort studies on mosquito-born diseases in Nicaragua. Once again, Kelly grabbed her passport and went abroad to help a community in need.

“When I got to Nicaragua, it was right at the time Zika was appearing,” she added. “My job was to add Zika to the existing study and to build up a surveillance system to track cases in the pediatric population.”

The experience led to her thesis, highlighting this experience of tracking pediatric Zika and looking at factors associated with Zika virus infection, such as demographic and socioeconomic.

After earning her master’s, Ms. Walblay was accepted into CSTE’s Applied Epidemiology Fellowship (AEF) and was stationed at the Illinois Department of Health (IDPH). When her fellowship ended in 2019, she began a job at the Chicago Department of Health. A few months later, the COVID-19 pandemic began.

She had a front row view of the early weeks of the pandemic, as the first person-to-person COVID-19 transmission in the United States happened in the Chicago area. It was there that Kelly’s team, along with colleagues from IDPH, Cook County and CDC met to figure out how to identify high-risk contacts that were exposed and protect the health of their community.

“The pandemic is really when it [my role] ‘got real’ – Even though we had all these great minds and everyone was bringing something to the table, we were still figuring it out,” she said.

Subsequently during the pandemic, Walblay worked in the health care settings unit and tracked the COVID-19 cases occurring among staff and residents in skilled nursing facilities.

“My job was to track outbreaks that happened and work closely with a team of infection preventionists to try to reach out and help with infection control,” she said.

Kelly and her colleagues established strong relationships at these skilled nursing facilities through follow-up calls, site visits and biweekly roundtable video calls. The facilities were typically dealing with everything from staffing issues to a lack of PPE and internal testing. She said the key was letting them know they were there to help.

“We’re not regulatory and we’re not coming in to cite or fine them. We are genuinely there to ask how we can help support [their facility] as a health department and ask what they need,” Walblay said. “During that time, rules and guidance for things like visitation and testing were changing constantly.” We stayed very connected with our facilities.”

During this time, Ms. Walblay said it was also important to maintain a work life balance and a sense of self care. She points to small things such as turning off email notifications and organizing a virtual board game night with colleagues as ways to boost resiliency.

“You have to remind yourself and your team that you’re doing the best you can and that we are people living through this pandemic and not just public health professionals.”

In Kelly Walblay’s short yet eventful career as an epidemiologist, from Argentina to Nicaragua to Chicago, she has seen the importance of community collaboration and resilience firsthand. Her advice to aspiring epis to tackle community collaboration is, above all else, be a clear communicator.

“As an epi, it’s very important to get the message across of what you’re trying to say with your data. So, I think constantly practicing putting it in layman’s terms is a skill you need to master.”

And her advice for resilience?

“It’s vital to maintain a sense of self-care”

Kelly Walblay, MPH is a Senior Epidemiologist at the Chicago Department of Public Health working in infectious disease areas. Kelly is also an alumnus of CSTE’s Applied Epidemiology Fellowship (AEF).

As part of National Public Health Week 2022, CSTE is highlighting the work of our members in different areas of applied epidemiology. Today’s focus is on recent CSTE Fellow Hannah Collins.

As a public health epidemiologist in Seattle, Hannah Collins had a unique, front row view of the early stages of the COVID-19 pandemic. However, Ms. Collins dealt with the stress of those uncertain months in Spring 2020 like many Americans did.

She adopted a “pandemic puppy” – a labradoodle named Coco.

As this National Public Health Week continues with today’s theme of “Public Health Workforce: Essential to our Future,” Ms. Collins’ story encapsulates the next generation of young epidemiologists at the forefront of their field.

Hannah’s journey to applied epidemiology began after college. She worked on a program evaluation to understand the impact of a community-based parenting program and how it could be implemented in Head Start Preschools.

“I became really invested in how to make data more accessible to communities,” she said.

Ms. Collins then earned her master’s degree in at the University of California – Berkeley’s School of Public Health in Maternal, Child, and Adolescent Health. While working during a summer internship at the Ohio Department of Health, she learned about the CSTE Applied Epidemiology Fellowship (AEF) program, submitted an application and was accepted.

She is now completing CSTE’s AEF and working as an Epidemiologist II at Public Health – Seattle & King County in Washington State. In both her fellowship and current job, Ms. Collins has worked in three different areas: Overdose and Substance Use Surveillance, Injury and Violence Prevention and Climate Change Impacts.

Recently, she’s been evaluating an algorithm to help identify opioid overdoses in emergency medical services data to improve overdose surveillance, detect clusters, and form outreach programs.  One of those outreach programs included some tech-savvy techniques.

“Over the past year, I’ve worked on a pilot program that texts people who have survived an overdose to see if we can connect them to a range of services or if there is any support we can provide for them,” she said.

Ms. Collins’ day-to-day activities vary depending on the most pressing issue. She updates data on King County’s public health dashboards, collaborates with partners at Emergency Medical Services and the Medical Examiner’s Office, as well as Washington State’s syndromic surveillance program (Rapid Health Information Network). Her time is also spent writing and thinking about how best to communicate the most recent data to the public.

Her work in Injury and Violence Prevention has recently included a CDC-funded evaluation of the social economic and overall health impacts of COVID 19 and associated mitigation strategies.

“We’ve been monitoring things like unemployment, family violence, behavioral health data, traffic patterns and several other topics,” she said.

In addition to the general population dealing with the stresses of a major pandemic, Ms. Collins acknowledges that she and her fellow public health workers who were thrust into an ‘all hands-on deck at all times’ situation has taken its toll. However, the staff camaraderie and setting some much needed personal boundaries has helped.

“People continue to get burned out and there’s no quick, easy fix,” she said.

Despite the challenges of the last two years, Hannah is proud of her work and her team’s accomplishments. Particularly their capacity to modify and shift when a strategy or plan wasn’t working.

“I’m most proud of our ability to adapt and be innovative,” she said. “For example, if we’ve tried something that’s not getting a lot of response, we adapted and made very quick changes in real time.”

Ms. Collins referred to CSTE’s AEF program as an important bridge between her education and career and credits her mentors for helping to shape her views on applied epidemiology.

“The two epidemiologists who were my mentors for this program helped me realize the possibilities of epidemiological data at the local level to make change,” she said. “They were very influential.”

What does the future hold for Hannah Collins? She’s excited to continue working as an epidemiologist in King County and advance the use of data to improve the health of those in her area. And given that she was born and raised in Seattle & King County, having a personal connection to her work.

“I’m grateful to work in the community I grew up in,” she said. “I’m excited to have the chance to make an impact here.”

Hannah’s story represents countless young professionals working in public health today: Strong community ties, and an emphasis on updating the decades old data and technology structures in their jurisdictions. This next generation of applied epidemiologists will certainly face more obstacles and personal hardships. Supplying them with the empathy and support they need is crucial to keeping all of us healthy.

And for Hannah, when times get tough, she can always take a long stress-relieving walk with Coco.

Hannah Collins, MPH is an Epidemiologist II at Public Health – Seattle & King County. Hannah recently completed CSTE’s Applied Epidemiology Fellowship (AEF) and will graduate in Class XVIII. 

 As part of National Public Health Week 2022, CSTE is highlighting the work of our members in applied epidemiology. Today is Part 1 of a spotlight focused upon CSTE President Dr. Ruth Lynfield.

As a medical student, Dr. Ruth Lynfield spent a summer in Brazil and had an epiphany: She wanted to be an epidemiologist. 

Specifically, Dr. Lynfield was gathering data and assessing risk factors on cases of leishmaniasis, a parasitic disease that is found in parts of the tropics and subtropics.

“That really put the idea of “being an epi” in my head,” she said. “I really liked the idea of using epidemiology as a lens to understand infectious disease.”

That fascination with infectious disease has propelled Dr. Lynfield through a distinguished, decades long career in public health. The past 15 of which have been spent as the State Epidemiologist of Minnesota, and more recently as the 2021-2022 CSTE President.

While the past two years have been an almost non-stop marathon of COVID response work, before that Dr. Lynfield enjoyed the fact that no day was ever the same. For example, an outbreak of progressive inflammatory neuropathy in pork processing plant workers was related to inhalation of aerosolized swine brain.

“Interesting things happen for which you can use epidemiology and try to piece together the puzzle,” she said.

In 2020, as the COVID-19 pandemic raged, another tragedy occurred, this one closer to home for Dr. Lynfield: The murder of George Floyd in Minneapolis at the hands of police officer Derek Chauvin. The tragic loss of life and subsequent fallout helped shape the basis of one of Dr. Lynfield’s main CSTE presidential priorities: Law Enforcement Involved Fatal Encounters (LEIFE).

As today’s National Public Health Week theme is Racism as a Public Health Crisis, Dr. Lynfield reflected on her thoughts after that awful incident.

“My sense was that this was the tip of the iceberg because of the occurrence of cases of [LEIFE] in many states,” she said. “In Minnesota, we went back and looked and found that we had about 30 cases a year of [LEIFE] and that people of color, particularly African Americans and American Indians, were much more likely to be injured or have a fatal encounter with law enforcement than white non-Hispanic Minnesotans.”

According to Dr. Lynfield, one thing that the public health community can do to help reduce LEIFE is to see these tragic encounters as a public health crisis which requires taking a public health approach. As an example, there are fatality reviews for newborn deaths and a plethora of other conditions, so developing a standardized case definition for LEIFE is crucial.

Dr. Lynfield has been working with a couple of exceptional CSTE Applied Epidemiology Fellows, and the Chairs and members of the health equity and the injury subcommittees on this standardized case definition for several months and says it will allow jurisdictions to follow trends over time.

“It’s important for the public to know what is happening and I think it’s important for us to be able to describe and understand these events in order to come up with recommendations about how to change the conditions that would lead to these [LEIFE] events.”

Dr. Lynfield’s LEIFE work aims to stem the long-standing inequities and systemic racism inherent to law enforcement encounters which have too often resulted in tragic outcomes for minorities and communities of color.

She strongly believes the methods of applied epidemiology, gathering data and assessing risk, are a cornerstone of public health that can be used anywhere from the fazendas of Brazil to the streets of Minneapolis.

“If you’re able to measure it, then you’re able to deal with it better.”

Ruth Lynfield, MD, is State Epidemiologist from Minnesota and CSTE President for the 2021-22 term. More information on Dr. Lynfield's current work on LEIFE and other presidential priorities can be found at https://www.cste.org/page/presidential-priorities-award.

Part 2 of our spotlight on Dr. Lynfield will be posted later this NPHW 2022.

*Update: On February 8, the House of Representatives passed a continuing resolution to fund the federal government at current levels until March 11. The Senate passed the bill on February 17 and President Biden signed it, averting a government shutdown. House and Senate appropriators have negotiated a framework to fund the government for the remainder of Fiscal Year 2022 and are currently working to craft formal legislation.

Federal Funding Update

CSTE reported in June 2021 that President Biden released his Fiscal Year (FY) 2022 budget, calling for historic increases in funding for the Centers for Disease Control and Prevention (CDC), including resources to carry out public health efforts at the state and local levels. While the president’s budget was groundbreaking, it is not binding. Congress sets federal spending, and though FY 2022 began on October 1, 2021, the FY 2022 congressional appropriations process is still underway. Republicans and Democrats are working to bridge their differences and come to an agreement before temporary funding expires February 18, 2022.

Along with our partners in the Data: Elemental to Health campaign, CSTE has led advocacy efforts to secure robust, long-term, sustainable funding for CDC’s public health Data Modernization Initiative (DMI) to upgrade our nation’s antiquated public health data infrastructure. We were pleased to share last spring that, thanks to our efforts, President Biden’s budget proposed a $100 million increase—or tripling—in funding for DMI at $150 million. And last July, the House Appropriations Committee recommended the same level of funding, which was included in a larger package of appropriations legislation that passed the full House of Representatives.

Across the Capitol, the Senate has taken no formal action on appropriations legislation to fund public health. However, the Chairman of the Senate Appropriations Committee introduced draft legislation last fall that would also fund DMI at $150 million. While these numbers match, they are not yet set in stone as overall funding levels still face pressures that could ultimately drive CDC and other health agency funding down. However, the consistent bipartisan commitment across Congress and the Administration to provide increased funding for DMI demonstrates that policymakers understand and agree with the dire need to invest in the modernization of our deficient public health data systems. The COVID-19 pandemic illustrated just how severe the need is and CSTE and our partners continue to advocate for robust, sustained funding that keeps pace with technology and will facilitate the immediate response to any emerging public health threat.

The fiscal year ended on September 30, 2021 with no funding agreement in place. Since then, Congress has passed two consecutive continuing resolutions (CR) extending federal funding at current levels while negotiations continue. At the same time, Congress will soon begin preparing for the FY 2023 appropriations process. We will be meeting with key congressional offices to request further increased funding for DMI in FY 2023 and will share more detail in the coming weeks.

Federal funding is critical for public health. CRs of any duration damage our public health infrastructure and impede our ability to respond. CSTE has prepared talking points that can be used as you speak to colleagues and policymakers about the need for increased investment in public health.

A Call for Long-Term Investment in Public Health Data Modernization

Incremental investments through the annual appropriations process and supplemental COVID-19 relief funding have been critical and have begun to improve public health data systems, particularly at the federal level. However, we cannot realize the potential of data modernization without also providing significant resources dedicated to modernizing foundational state and local public health data systems.

Data: Elemental to Health has estimated that a modern and secure public health information system will require a federal investment of at least $7.84 billion over five years. The COVID-19 pandemic has highlighted the egregious gaps in our system, and it also taught us that modernization cannot wait. The next public health crisis will always be looming. If we do not take the necessary steps to equip our public health system for the next emergency, we will face the same devastating inadequacies we have experienced in responding to COVID-19.

Meghan Riley is vice president at Cavarocchi Ruscio Dennis Associates, LLC, which represents CSTE’s interests on Capitol Hill in Washington, DC

President Biden released his Fiscal Year (FY) 2022 budget proposal on May 28, calling for historic increases in funding for the Centers for Disease Control and Prevention (CDC), including resources to carry out public health efforts at the state and local levels. Recognizing the importance of CDC’s role in protecting the health of the nation, the budget requests just over $9.5 billion for CDC, an increase of more than $1.6 billion. Funding of this level would represent the largest increase in the CDC’s budget in nearly two decades.

As COVID-19 vaccines proliferate, case counts drop, and businesses reopen across the country, we have turned an important corner in the pandemic response. However, as epidemiologists, CSTE members know that the public health response will continue as we learn the duration of effectiveness of the vaccines and continue to track cases of COVID-19, including rare breakthrough cases in vaccinated individuals. More importantly, we know that the COVID-19 pandemic will not be the last public health crisis to gravely threaten our society. We will continue to investigate outbreaks not only of infectious viruses, but also threats like influenza, measles, and HPV and public health threats caused by natural disasters. To carry out our work, we need significant federal investment in modern data systems and in the public health workforce that executes it. The President’s budget makes public health a priority, and Congress should implement these increases, but this cannot be a one-time investment – CDC and public health need sustained increases like this to truly support our infrastructure.

COVID-19 exposed the deadly gaps in our public health data infrastructure. With our partners at the Data: Elemental to Health campaign, CSTE has advocated for years for federal funding to upgrade our nation’s antiquated public health surveillance systems. Thanks to our advocacy, Congress has appropriated nearly $1 billion in funding, mostly through COVID-19 relief legislation, to the public health Data Modernization Initiative (DMI) at CDC. This injection of funding is critical to the COVID-19 response and beyond, but to truly transform our nation’s public health data systems we need robust, sustained funding that allows us to keep pace with evolving technology. The President’s budget proposal will put us on that path. It recommends $150 million for DMI in Fiscal Year 2022 – a $100 million increase over the current fiscal year. These resources will help public health meet rapidly evolving technology needs and make critical investments in data modernization at the state and local levels.

As we know too well, new technology and data systems will not be effective without a highly skilled public health workforce to operate them. Following a historic investment of $7 billion in the public health workforce through the American Rescue Plan, the President’s FY 2022 budget proposes another important increase of $50 million for Public Health Workforce and Career Development. This funding, with the goal of building up the workforce of epidemiologists, lab scientists, data analysts and other key public health roles, is sorely needed.

The President’s FY 2022 budget sets forth the Biden administration’s priorities, but Congress ultimately determines how much funding each federal agency and program will receive. In the coming months, the Appropriations Committees in the House of Representatives and Senate will draft and debate legislation to fund the federal government before the fiscal year ends on September 30. The full House and Senate will eventually vote on a final funding package. Throughout this process, CSTE will communicate with key representatives and staff on Capitol Hill to continue to illustrate the need for robust annual funding for DMI and critical support for the public health workforce.

Meghan Riley is vice president at Cavarocchi Ruscio Dennis Associates, LLC, which represents CSTE’s interests on Capitol Hill in Washington, DC

After months of failed negotiations, in December Congress finally passed a federal funding bill that included much-needed COVID-19 relief for struggling communities across the nation. The Consolidated Appropriations Act for Fiscal Year 2021 (Omnibus) was signed by the President on December 27, 2020. The Omnibus allocated critical funding for COVID-19 vaccines and therapeutics, vaccine distribution and administration, and contact tracing and testing, with specific funds designated for high-risk and underserved populations, including communities of color.

The Omnibus allocated $50 million to the Data Modernization Initiative at the Centers for Disease Control and Prevention (CDC), a key CSTE priority. Importantly, this legislation also included language to authorize activities to improve the public health data systems at the CDC. This provision will ensure that critical investments in our nation’s public health infrastructure go toward the most necessary updates. It remains essential that funds be appropriated annually to CDC to meet the $100 million authorization level this program needs to ensure its ongoing implementation and success. CSTE was at the forefront of advocating for this critical provision and will continue to urge Congress to prioritize funding for our public health data infrastructure to improve our response to COVID-19 and help state and local health departments prepare for the inevitable next public health crisis.

Meanwhile, President Joe Biden was sworn into office on January 20, 2021. Prior to the Inauguration, Biden released his American Rescue Plan, a proposal for yet another critical round of pandemic relief funding. The American Rescue Plan contains many essential investments to boost our nation’s pandemic response, such as $20 billion for a national vaccination plan; $50 billion for diagnostic tests and screening; and critically, a strong commitment to expand the public health workforce. As the presidential transition ramped up, CSTE held numerous conversations with transition officials, and later, White House staff. During these conversations, CSTE emphasized the need for additional funding for the DMI and shared specific activities that could be undertaken immediately to help to address data modernizations needs. One of these key recommendations was to include CSTE members and leadership in the COVID-19 taskforce meetings. As a result of our outreach and ongoing communications with key officials, the American Rescue Plan contains a request for $700 million to address data modernization needs at the state, local, and federal levels. CSTE strongly supports this investment and has begun conversations with leaders on Capitol Hill to bring it to fruition.

Now the Biden Administration must work with Congress to appropriate these essential funds—and CSTE is working to ensure they go to DMI. The slim margin in the Senate will make it difficult for the new Democratic majority to push the funding proposal forward. While Congress attempts to find a bipartisan agreement, Democratic leaders in the Senate and House are also considering moving the proposal through a process called budget reconciliation, which only requires a simple majority in the Senate for passage, but may not allow for inclusion of every priority.

When President Biden took office, he also quickly released a National Strategy for the COVID-19 Response and Pandemic Preparedness. This plan represents both a comprehensive attack on COVID-19 and an approach to better equip the U.S. to respond to future threats. As part of this national strategy, President Biden issued an Executive Order Ensuring a Data-Driven Response to COVID-19 and Future High-Consequence Public Health Threats. This executive order acknowledges that a strengthened public health infrastructure will make it possible for the U.S. to better prevent, detect, and respond to future diseases and other public health crises. Under this executive order relevant federal agencies will coordinate to advance and upgrade our public health data infrastructure.

As our members work on the ground to respond to the COVID-19 pandemic, CSTE will continue to press Congress and the Administration to follow through with the funding and policy priorities that will best position our public health workforce to succeed against COVID-19 and the threats of the future.

Meghan Riley is vice president at Cavarocchi Ruscio Dennis Associates, LLC, which represents CSTE’s interests on Capitol Hill in Washington, DC.

Mariko Toyoji, MPH, epidemiologist at Public Health – Seattle & King County is the 2020 CSTE/RWJF award winner.

Gabrielle Bailey being fitted for her personal protective equipment (PPE) (photo credit: Gabrielle Bailey).

In 2018, the Council of State and Territorial Epidemiologists (CSTE) began supporting hurricane crisis relief projects in the U.S Virgin Islands through a cooperative agreement with Centers for Disease Control and Prevention (CDC). CSTE provided expedited procurement of technical expertise in applied epidemiology by hiring contractors to provide surge capacity to the U.S. Virgin Islands Department of Health in the aftermath of the 2017 Hurricanes Irma and Maria to address emerging and ongoing surveillance and epidemiology needs. Gabrielle Bailey – a USVI native – is one of the contractors hired through this funding mechanism. Gabrielle supports the USVI HIV/STD Surveillance team by establishing guidance for data collection, management, and reporting of STD/HIV cases throughout the territory.

 

Prior to moving back home for this position, Gabrielle served as a Clinical Research Associate for Emory’s Department of Pediatrics, working on data input, collection, and organization for various ongoing pediatric hepatology clinical trials. Gabrielle is passionate about utilizing current technology and software to further advance data culture and science for the purpose of informed health policy decisions. CSTE reached out to Gabrielle for a firsthand account of her work in the USVI, and its ongoing surveillance and epidemiological needs.

Aerial view of the U.S. Virgin Islands (photo credit: Gabrielle Bailey).

 

Work Life in the USVI

Community and culture are just a few words that come to mind when I think of my unique experience of working as a Data Entry Technician in the U.S. Virgin Islands. I start most mornings with a freshly brewed bush tea paired with a warm saltfish pate from the local food van across from the office. My lifestyle is utterly different from when I think back on my time in the States, but I would argue significantly for the better. My desire for a greater sense of community is essentially what brought me back home to the USVI.

It doesn’t take long to observe that the Virgin Islands' social and community context plays a significant role in the ways individuals conceptualize their own health, access to health care, and varying health needs. With a total population of around 107,000, our community's small size lends to closer connections with fellow colleagues and stakeholders. In my one year at the Department of Health, I’ve had the privilege to expand my role outside of the confines of data analytics by extending it to meet additional needs for the overall mission of the Communicable Disease Division. There is no room for a cognitive disconnect between the numerical data and the everyday people here, not when you can directly see how the work conducted impacts individuals of the community.

On numerous occasions, I have gone to the local jail and university to assist HIV testing and education. I have held intriguing conversations with individuals at outreach events that aim to break down the substantial barrier of HIV stigma and the dangerous misconceptions surrounding HIV/STDs that are quite common in Caribbean culture. In beaming 85-degree heat, I have walked the steep hills of Savan and throughout the entirety of Frenchtown for hours to help conduct survey-based interviews (CASPER Study) to analyze the public health needs of VI residents before and after Hurricanes Irma and Maria. I will never forget sitting down in the house of a woman who broke down in tears as she recalled the horrors of two category 5 hurricanes, and the great pride she experienced as the community banded together to support each other afterward. She opened her home for months after the hurricane to help provide food, coffee, shelter, and emotional support to anyone in need. These kinds of interactions speak volumes to the type of resiliency and kindness that exists here in the Virgin Islands. I myself have accepted the type of anxiety that comes with living in an area vulnerable to devastating hurricanes.

The travel required for this job is undoubtedly one of my favorite aspects of my role in the USVI. It is common to find me commuting between the islands for work. I never get used to the extraordinary ocean and landscape views I witness while traveling by sea plane to St. Croix or taking the ferry across to St. John. There is something truly special about starting your workday hundreds of feet above the blue Caribbean Sea while gazing at white coral sand shorelines. Several of these trips have focused on promoting reporting activities for HIV/STD surveillance in the territory. Through these opportunities, I have been given a chance to work directly with health care providers to improve accurate case reporting activities, sit in on trainings that advance HIV/AIDS knowledge, and conduct active HIV/STD surveillance.

I want to be clear that work in the Virgin Islands isn’t at all beaches and rainbows. There is a lot of hard work still to be done in the territory, as government agencies work to catch up to several of the technological advancements, well-established policy infrastructure, and clear protocol transparency already adapted in several states. As a millennial, I often see how old-fashioned tactics overcomplicate certain tasks. I would also be remiss if I failed to acknowledge that COVID-19 has transformed life in the Virgin Islands. The DOH has been working tirelessly to address the demanding needs that result from this worldwide pandemic. When COVID hit our shores, I was proud of how several colleagues signed up to be on the front lines and assist with the efforts. Although there is no end in sight to the pandemic, one thing stands for sure: The Virgin Islands will band together to ensure that we get through this difficult season with compassion and kindness. I am confident that this territory can overcome all types of hurdles, whether environmental, political, or public health related.

CSTE update from Washington, DC.

Sharifa Charles, Professional Development Specialist at MHA’s Center for Behavioral Health, leads participants during a gatekeeper training in St. Thomas, November 2019.

In Fall 2019, the U.S. Virgin Islands Department of Health (VIDOH) developed the USVI Suicide Prevention Program under the leadership of Commissioner Justa Encarnacion and in collaboration with the Centers for Disease Control and Prevention (CDC) and the Council of State and Territorial Epidemiologists (CSTE). Irving Julien was hired to serve in the role of Suicide Prevention Program Coordinator. Once fully developed, the program included two in-person gatekeeper trainings in November 2019, outreach activities throughout the winter and spring, and two virtual Suicide Prevention “Train the Trainer” sessions in June 2020.   

VIDOH was pleased to have Sharifa J. Charles, a Native Virgin Islander, and Professional Development Specialist currently with the Center for School Behavioral Health, Mental Health America of Greater Houston as the trainer for the four training sessions. Initially, the Train the Trainer sessions were planned to take place in person. However, due to the COVID-19 pandemic, the curriculum was adapted to a virtual format. This was the first time that a training of this magnitude was conducted virtually in the territory. A total of 85 individuals were trained with each training session lasting four hours. Attendees participated in pre- and post-training test assessments and received certification of completion after the training. Ninety-seven percent of participants responding to the post-test agreed or strongly agreed that the training content would help them be more effective in their jobs. 

 

Attendees participate in a gatekeeper training in St. Thomas, November 2019 

First responders who participated in the November sessions were trained on tactical skills to be used to train others at their respective government agencies, as well as members of the community. Educational trainings focused on recognizing the warning signs of a suicide crisis, the steps necessary to help intervene and prevent suicide, and techniques to help the healing process after a suicide. Attendees learned from mental health professionals, crisis workers, volunteers, and suicide survivors using a culturally sensitive approach when speaking about suicide, suicide assessments, intervention techniques, and prevention practices. 

 

The diagram in this slide illustrates the phases of community response and outcomes to disaster events, such as Hurricanes Irma and Maria in 2017 

The latest epidemiological data from CDC and VIDOH shows an increase in suicides in the territory and the nation, especially considering the COVID-19 pandemic. Vernita Bicette, Director of Behavioral Health Alcoholism and Drug Dependency Services at the Department of Health stated, “We are taking a proactive approach in the territory to this national crisis by implementing preventative measures, which include this suicide prevention training.” VIDOH and community partners are dedicated to building program sustainability.  

The territory will continue outreach efforts focused on promoting mental health and decreasing the number of suicide attempts and deaths. The most recent of these efforts is the launch of a radio commercial targeting young adults who may be experiencing suicidal thoughts.

The Mentor Application for the 2020-2021 Early Career Professional Mentorship Program is now open.

The Council of State and Territorial Epidemiologists (CSTE) continues to offer opportunities for growth through its workforce development and professional training projects. For the last four years, CSTE has facilitated the Early Career Professional Mentorship Program, providing both seasoned and early career applied epidemiologists an opportunity to build relationships and foster shared learning. By connecting mentors and mentees to share experiences and advice, public health practice will improve by preparing future public health professionals with necessary skills and knowledge. The goal of the program is to allow mentees to connect with mentors that promote the exploration of State, Tribal, Local, and Territorial (STLT) career opportunities. Participants engage in activities such as professional and educational webinars, goal exercises, networking, and journal clubs.  

The Mentorship Program facilitates discussion about careers in applied epidemiology and the growth of professional skills. The program provides a forum for epidemiologists with diverse educational and experiential backgrounds to share about their personal experiences. Mentors offer insight to guide mentees in identifying their strengths and professional goals. While the world is focused on the response to COVID-19, it is important to continue to invest in our workforce. The Mentorship Program offers an opportunity for mentors and mentees to reflect and identify areas for their own personal growth.

In the current environment, when public health professionals are working harder than ever, the Mentorship Program offers the opportunity to pause and reflect on where our careers are today and the direction they are going in the future. Through the program, CSTE provides a community of practice with like-minded, interested colleagues, and lifelong learners across the country. The Mentorship Program can help you foster these relationships early into your career.

Here is what some participants from the 2019-2020 program had to say about their experience: 

“I have participated in many other mentoring programs over the years. Some have worked well, many have not. CSTE’s did work.” - Mentor 

“My new mentor has been an amazing advocate and sounding board as I work through doctoral studies and balance work, school, and the family commitments of a new parent.” - Mentee  

“I think having this program is an excellent way to educate new epidemiologists. I was able to still communicate with my mentees even throughout the pandemic to see what they were doing and how they were coping in their respective states.” - Mentor 

Applications for the 2020-2021 Early Career Professionals Program are now open. Consider serving as a mentor.

Mentors are required to have at least five years of work experience and can be work at STLT, federal, academic or nonprofit organizations. No previous mentorship experience is necessary, which presents mid-level epidemiologists a great opportunity to mentor the next generation of applied epidemiologists. Watch CSTE’s recorded Prospective Mentor Webinar to learn more about the Mentor’s role in our program. 

Early career professionals can participate as mentees. Eligible mentees should be current students or graduates within the last five years with an interest in applied epidemiology. Start your application today to participate in the 2020-2021 Mentorship Program. All applications are due by September 30, 2020. Please note that all applicants may not be accepted; space is limited based on the number of mentors that apply.

Notes from CSTE’s Vaping-Associated Pulmonary Injury (VAPI) Outbreak Response. 

CIFOR Announces Upcoming Release of 3rd Edition Guidelines.

In 2019, wildfires burned an estimated 259,823 acres of land in the state of California. 

Celia Hagan, MPH is vice president at Cavarocchi Ruscio Dennis Associates, LLC, which represents CSTE’s interests on Capitol Hill in Washington, DC.

The NEC is one of 12 Tribal Epidemiology Centers (TECs) that work in partnership with local or area tribes to improve the health and well-being of tribal members by offering culturally competent approaches to eliminate health disparities faced by AI/AN populations by monitoring health status, maintaining disease surveillance, conducting health research, conducting disease outbreak investigation, reporting health data, providing technical assistance, and identifying priority health concerns.   

A core function of TECs is the collection of data related to, and monitor progress made toward meeting, each of the health status objectives for Indian Tribes, Tribal Organizations, and Urban Indian Organizations (I/T/U) in their respective Indian Health Service (IHS) service areas. The Navajo BRFSS provides behavioral risk factor data on adults residing in the Navajo Nation. Initial data findings from the results of the Navajo Nation Health Survey fulfill an original premise to provide tribal-specific data from and build a foundation for a tribal nation-specific BRFSS to identify risk factors of Navajo adults; collect data specific to Navajo Nation by in-person interviews; and key data finding results to select target audiences. 

Implementing a tribal BRFSS has public health implications. The implementation of the Navajo BRFSS includes successes learned from piloting and testing; conception of a sampling design, study methodology, and procedural survey protocol as a surveillance system representative to AI/AN populations; recognizing the prevalence of health risk behaviors among Navajo adults; comparisons with other populations to identify health disparity; definition of health measures, e.g., Healthy People 2010/2020, identifying measurable baseline data; a tribal BRFSS process representative and exclusive to AI/AN population-based health; and strengthening support continual tracking, measurement, and evaluation of health status progress with the Navajo BRFSS as a primary data source to support secondary data sources.    

This work highlights the importance of culturally appropriate survey methods in developing a tribal BRFSS, which provided information for tribal leaders to support tribal epidemiology and surveillance done by Simental Francisco and his team.    

Happy New Year to all CSTE members and non-member applied epidemiologists in our community! We have reached the midway point of my tenure as CSTE president, and I’d like to update readers on my Presidential Priorities for the term and offer a progress report on the status of this work. Each year, the CSTE President sets forth a list of Presidential Priorities.

These are key areas impacting the field of applied epidemiology that the organization, Executive Director and Executive Board work to advance during the year. Presidential Priorities change from year to year, and I immediately began working to articulate and implement my priorities in Fall 2019. Working closely with CSTE staff, I identified two Presidential Priorities that align closely with goals in CSTE’s 2018-2020 Strategic Plan.

The identified priorities are:

• Priority B3, Under Strategic Pillar B (Develop, Expand & Diversify the Epidemiology Workforce) – Develop & Foster Leadership

• Priority A2, Under Strategic Pillar A (Establish Leading Edge Public Health Applied Epidemiology) – Co-Develop Infectious & Non-Infectious Disease Surveillance Initiatives

I am pleased to report that work is well underway in the CSTE National Office to implement both priorities. To develop and foster the next generation of epidemiology leaders, I proposed the development of a forum/platform to train mid-level leaders, some of whom are former CSTE fellows, and provide them opportunities for additional mentorship, exposure to advocacy and public policy, and partnership across states, disciplines and outside organizations. The idea is similar to APHL’s Emerging Leader Program.

The second Presidential Priority focuses on the co-development of Infectious Disease and non- Infectious Disease surveillance initiatives, and this is also the basis for the 2020 Presidential Priorities Award via abstract submission. Like years past, applied epidemiologists across the U.S. will have the opportunity to submit their abstract for the Presidential Priorities Award, so long as the abstract exemplifies partnership and participation between ID and non-ID entities on an outbreak or surveillance initiative. Projects demonstrating a use of data that supports cross-disciplinary partnership and a harmonized response with the best use of available tools will better compete for the award.

CSTE’s ongoing Data: Elemental to Health campaign is an example of a cross-disciplinary project that has been successful in the last year, as the effort yielded $50 million in new federal funding to modernize CDC’s data infrastructure. Ongoing national responses to the opioid crisis and the EVALI outbreak are also recent examples of ways that ID and non-ID epidemiologists are partnering on surveillance initiatives that require a harmonized approach.

We have received a number of abstracts already for the 2020 Presidential Priorities award, and I look forward reviewing these projects and determining the potential for a breakout session that will take place at the 2020 Annual Conference to discuss the award-winning project. Overall, it has been a privilege to serve as your president in 2019 and now 2020. I look forward to further implementing these priorities and to all CSTE will achieve in the future.

But good things come to those who wait/never stop advocating for data modernization! Late Friday night, the President signed the FY20 spending bill into law solidifying $50 million in new money for CDC’s efforts to modernize public health data systems! This is a huge win for public health and the new funds will help pave the way towards a 21^st century public health data superhighway. A big thanks to all of you that participated in our digital days of action to urge your elected officials to support data modernization. It goes to show that every voice counts!

Here are some highlights of CSTE’s activity over the past year for the Data: Elemental to Health campaign:

·         Janet Hamilton, CSTE’s Director of Science and Policy, testified about public health data needs before the House Labor, Health and Human Services, Education, and Related Agencies Appropriations Subcommittee;

·         Dr. Sharon Watkins, CSTE’s President and State Epidemiologist for the Pennsylvania Department of Health, testified about public health data needs in front of the House Science, Space, and Technology Committee;

·         Four authorizing bills, two in the House and two in the Senate, were introduced to support public health data modernization:

o   H.R. 2479 Section 45001 of the Leading Infrastructure for Tomorrow’s (LIFT) America Act;

o   H.R. 5321 Public Health Infrastructure Modernization Act of 2019;

o   S. 1793 Saving Lives Through Better Data Act;

o   S. 1985 Section 405 of the Lower Health Care Costs Act;

·         CSTE released a comprehensive report, Driving Public Health in the Fast Lane: The Urgent Need for a 21st Century Data Superhighway, to highlight the current challenges with public health data systems and outlining the path towards interoperability;

·         CSTE submitted written statements for two Congressional hearings on e-cigarettes.

There is more good news! Funding for CDC as a whole increased this year. FY20 includes a total of $8 billion for CDC which is $636 million above FY19 and $1.4 billion above the President’s Budget Request. A breakdown of areas of interest are listed below:

·         $230 million to address tobacco and e-cigs; an increase of $20 million

·         $622 million to Emerging and Zoonotic Infectious Diseases; an increase of $2 million

o   $170 million to the Antibiotic Resistance Initiative; an increase of $2 million

o   Flat funding for vector-borne diseases at $38.6 million

o   $14 million for Lyme disease; an increase of $2 million

o   $188.7 million for the Emerging Infectious Disease line; an increase of $31.8 million

o   Flat funding for AMD at $30 million

·         $555.4 million to Public Health Scientific Services; an increase of $59 million

o   $50 million in NEW funding for public health data modernization!

o   $9 million for all other surveillance, epidemiology, and informatics

o   Public Health Workforce is flat funded at $51 million

·         For the first time in 20 years there is $12.5 million in new funding to support firearm injury and mortality prevention research in the National Center for Injury Prevention and Control

·         $852.2 million for public health preparedness and response; a decrease of $5.7 million

o   Flat funding for the Public Health Emergency Preparedness Cooperative Agreement at $675 million

·         $85 million for the Infectious Disease Rapid Response Reserve Fund; an increase of $35 million.

At the end of the day, CSTE’s priorities fared extremely well in the year-end spending bill! Thanks to CSTE’s strong advocacy and presence on Capitol Hill, many of CSTE’s priorities saw increases in funding. Our advocacy successes this year are a good example of your membership fees at work! Without the commitment and strength of CSTE’s members, all of our wins would not be possible. Thank you for your dedication and support.

Additional information about funding levels for your specific priorities can be found in the spending bill, and in the accompanying report that provides more detailed information. 

This time of year, many people get sick. It’s cold outside, you’re cooped up indoors, and holiday stress is in full swing. Your symptoms may start with a cough and a sore throat. Could it be a cold? Then your muscles start to ache and the fatigue, headaches, and chills set in—it’s the flu.

Although flu viruses circulate in the U.S. year round, a peak of activity in the fall and winter months defines the flu season. Consider: while we know flu season will come each year, the season itself is unpredictable – when and where it will start, what virus strain will be circulating, how severe will the season be, and how well will the vaccine strains match. This unpredictability necessitates robust public health surveillance. The respiratory virus changes quickly making it challenging to develop a fully effective vaccine to prevent and mitigate illness. Tracking the virus is a multinational effort that relies on year-round public health surveillance and data collection.

It’s this complicated, yet coordinated scientific process of seasonal flu vaccine development that drew interest from the U.S. House of Representative’s Science, Space, and Technology Committee, which held a Fighting Flu, Saving Lives: Vaccine Science and Innovation hearing on November 20. Today, a universal flu vaccine—a one-and-done dose that would provide lifetime immunity—does not exist, hence the need to get annual flu vaccines each fall. The Committee was interested in understanding the full cycle from basic research to vaccine development, production, distribution and public health surveillance. The House Science, Space, and Technology Committee used this year’s flu season to highlight the scientific and innovation challenges around vaccine development and also focused on efforts to discover alternative influenza vaccine manufacturing processes from the current egg-based process.

CSTE’s President Dr. Sharon Watkins, State Epidemiologist for the Pennsylvania Department of Health, was invited to testify to share the public health perspective and express the need for better public health data. She highlighted that collecting and exchanging public health data is critical to detect and respond to flu outbreaks, gain an understanding of potential changes in the virus, and deliver life-saving vaccines. In her testimony, Dr. Watkins emphasized the need for interoperable data systems to share data, such as birth and death records and immunization registries and the need to be seamlessly connected to hospital emergency departments. Highlighting CSTE’s recent report, Driving Public Health in the Fast Lane: The Urgent Need for a 21st Century Data Superhighway, Dr. Watkins also spoke of the challenges public health faces when it has to rely on paper-based, manual data exchange methods. In the midst of the vaping epidemic that is occurring concurrently with flu season, it is important for public health professionals to distinguish between the two. As part of her written testimony, a four-page sample of a 350-page faxed medical record for an e-cigarette case showed that it is largely illegible and takes a public health professional significant amounts of time to input into the health department’s system. Dr. Watkins’ testimony helped to emphasize the need to improve public health data systems that has been an ongoing effort of CSTE’s through the Data: Elemental to Health Campaign.

Dr. Watkins testified alongside Dr. Tony Fauci the Director of the National Institute of Allergy and Infectious Disease at the National Institutes of Health, Dr. Dan Jernigan the Director of the Influenza Division in the National Center for Immunization and Respiratory Diseases (NCIRD) at the Centers for Disease Control and Prevention (CDC), and Dr. Robin Robinson, former head of the Biomedical Advanced Research and Development Authority (BARDA) and current Vice President of Scientific Affairs at RenovaCare. Dr. Fauci discussed NIH’s research efforts to discover a universal flu vaccine through its collaborations with academia, philanthropic organizations, and biotechnology and pharmaceutical companies. Dr. Jernigan emphasized that the flu vaccine is the single best way to protect yourself, and that CDC is working with other federal partners to use cutting edge science to improve the effectiveness of seasonal flu vaccines. He also discussed the importance of public health surveillance data to help inform policy recommendations and better vaccines. Dr. Robinson discussed his former role as head of BARDA, preparedness efforts to build national stockpiles of pre-pandemic flu vaccines, and BARDA’s activities to improve vaccine manufacturing.

The panel was well received by the House Science, Space, and Technology Committee, and the presiding Chair of the Committee emphasized that the flu vaccine is safe and the best way to stay healthy during flu season.

To protect yourself and your loved ones from flu, which can have severe complications requiring hospitalization and sometimes result in death, the CDC recommends getting an annual flu vaccine.

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.

• Legislation passed in the House that, if enacted, would appropriate $100 million in fiscal year (FY) 2020 for CDC to modernize the public health surveillance enterprise and workforce at the federal and STLT levels.
• Legislation introduced in the House – the LIFT America Act – that would authorize $100 million per year for public health data modernization activities over each of the next five years.
• Two bills introduced in the Senate – The Saving Lives through Better Data Act and the Lower Health Care Costs Act – both of which are bipartisan, that would also authorize data modernization initiatives.
  

Unfortunately, the nation’s public health data systems are antiquated, rely on obsolete surveillance methods, and are in dire need of security upgrades. Lack of interoperability, reporting consistency, and data standards leads to errors in quality, timeliness, and communication. Sluggish, manual processes—paper records, spreadsheets, faxes and phone calls—still in widespread use, have consequences, most notably, delayed detection and response to public health threats of all types: chronic, emerging, and urgent.

To protect our nation’s health security we need more, better, faster, and secure data. For the first time ever, the Council of State and Territorial Epidemiologists (CSTE), Association of Public Health Laboratories, National Association for Public Health Statistics and Information Systems (NAPHSIS), and Healthcare Information & Management Systems Society (HIMSS) have joined together to spearhead a  campaign to secure $1 billion over the next decade—$100 million in fiscal year 2020—to modernize the public health surveillance enterprise at the Centers for Disease Control and Prevention (CDC) and through it, the state, local, tribal, and territorial health departments. This funding would also support efforts to modernize the public health workforce by training, recruiting (e.g., student loan repayment and fellowships), and retaining skilled data scientists. Data systems require adept staff to use them, maintain them, interpret the data, and develop and deploy actionable public health interventions to save lives. 

Pictured: CSTE Executive Board members and staff visiting Capitol Hill in March to promote the new advocacy initiative, Data: Elemental to Health

Our “Data: Elemental to Health” campaign is gaining traction in Washington, DC and beyond since its launch in February:

·         More than 80 institutions representing health care providers, patients and consumers, public health professionals, and IT developers have endorsed our funding request to Congress. You can read a copy of our letter to appropriators HERE.

·         CSTE’s leadership travelled to Capitol Hill in March to discuss our proposal with officials in Congress, the Department of Health and Human Services (HHS), and the Office of Management and Budget;

·         Senator Richard Blumenthal (D-CT)—recognizing the need to modernize the data infrastructure—sent a letter to appropriators endorsing our funding request;

·         CSTE’s Director of Science and Policy Janet Hamilton was invited to testify before the House appropriations subcommittee with jurisdiction over public health funding about the dire need to build a public health data superhighway of the 21^st Century. You can watch her testimony HERE and access her written statement for the record HERE.

We will soon know if our campaign has made an impact when the House appropriations subcommittee unveils its public health funding bill on/around April 30 and the full committee considers it on May 8.

You can help us between now and then by sharing this blog, our campaign flyer and letter, Janet’s testimony, and this Association of State and Territorial Health Officials (ASTHO) video about the campaign with your colleagues at the department of health, your governor, and to the extent you are comfortable, with your federal elected officials. This funding, if appropriated, will represent the most significant, strategic, transformative investment in data systems at the federal, state, and local levels ever, and we want as many people as possible to know about it.

Emily J. Holubowich, MPP is the Senior Vice President, Cavarocchi Ruscio Dennis Associates, LLC. Emily joined CRD Associates in 2009 and has nearly 20 years of experience in health and fiscal policy, government relations, strategic communications, and coalition management. She has represented CSTE’s interests on Capitol Hill since 2013.

CSTE was invited by the Centers for Disease Control and Prevention (CDC) to participate in the HIMSS Interoperability Showcase to demonstrate how the Reportable Conditions Knowledge Management System (RCKMS) supports electronic case reporting between healthcare providers and public health. The Interoperability Showcase is a major exhibit at HIMSS and is comprised of several guided, real-time demonstrations presented by diverse companies that work through partnerships using innovative techniques to address current health problems. CSTE joined the Association of Public Health Laboratories (APHL), CDC, several state health departments including Tennessee, Michigan, Utah, and Washington, Epic, Netsmart, FormFast, CareEvolution, National Consortium of Telehealth Resources Centers, and American Well to present our use case: The Opioid Crisis: The Person and The Population.  For this use case, we worked together to demonstrate how emerging technologies and standards are applied to enhance public health reporting and surveillance for the opioid overdose epidemic. 

Pictured: Partners demonstrating The Opioid Crisis: The Person and The Population use case at the 2019 HIMSS Global Conference’s Interoperability Showcase. From left to right, Laura Conn (CDC), Jim Fitzpatrick (Epic), Sai Valluripalli (APHL) and Charisse LaVell (CSTE).

In our showcase, we simulated a patient, who is a resident of Washington, that presented to a Tennessee emergency department with an apparent opioid overdose. The opioid overdose diagnosis entered into the electronic health record (EHR) triggered the subsequent process of reporting to public health. The emergency department’s EHR system, represented by Epic, generated and sent the electronic initial case report (eICR) to the APHL AIMS secure cloud-based platform. This process invoked the RCKMS decision support service to determine whether this potential case is reportable to public health. Based on the reporting logic for both Washington Department of Health and Tennessee Department of Health, RCKMS determined that this case of opioid overdose is reportable to Washington and Tennessee. RCKMS outputted the determination with other pertinent routing information to the APHL AIMS platform for inclusion in a reportability response (RR). AIMS then routed the RR back to the Epic EHR system. Concurrently, the eICR and RR were routed to both the Washington Department of Health and the Tennessee Department of Health. Washington’s health information exchange (HIE) and Tennessee’s surveillance system consumed the eICR and the RR, while Epic received and processed the RR.

Pictured: CSTE staff member Charisse LaVell leads the crowd through a demonstration of the Reportable Conditions Knowledge Management System (RCKMS) at the 2019 HIMSS Global Conference in Orlando, FL.

As the opioid overdose epidemic has gained more visibility as a public health crisis, CSTE’s participation in this year’s HIMSS conference was invaluable in broadening attendees’ awareness of the importance of public health reporting for opioid overdoses and how RCKMS supports surveillance and electronic case reporting. Throughout the conference, I was able to share the work of RCKMS with clinical and public health professionals. Having the opportunity to represent CSTE by presenting at my first HIMSS conference was an unforgettable experience. 

Charisse LaVell is a Program Analyst supporting the RCKMS project.  For more information about RCKMS, contact Charisse at clavell@cste.org.

• The authoring interface allows public health agencies to input, edit, and manage their jurisdiction-specific reporting criteria.
• The knowledge repository stores these criteria for use in adjudicating eCR data sent by health care electronic health record systems containing clinical encounter information.
• The decision support system uses the criteria in the knowledge repository to determine whether data sent in the eCR constitutes a reportable condition and which jurisdiction(s) the data should be sent. The decision support system also notifies the reporting organization about the reportability of the clinical encounter.

Editor’s Note: In spring 2018, CSTE awarded its third student scholarship to Melanie Firestone, MPH. This year, the award was renamed the Jeffrey P. Davis Student Scholarship. Melanie has written a blog post on her experience as the first recipient of the Jeff Davis Scholarship, which was named in honor of the late CSTE past president and longtime Wisconsin State Epidemiologist.

I was thrilled to be chosen as the 2018 recipient of the CSTE Student Scholarship. I was especially honored to learn I was the first recipient of the scholarship in honor of Jeffrey P. Davis. In the spring, I learned the impact of Dr. Davis’s work through Dr. Mike Osterholm’s emerging infections course at the University of Minnesota. While attending the 2018 Conference, I learned that Dr. Davis and I shared a common love for something in addition to public health – haiku. In his honor, I chose to start with the haiku above, since he was known for beginning his presentations with haiku.

Participating in the CSTE Annual Conference has long been a goal of mine, and I was particularly interested in attending this year because of the theme “Using data to weather the storms.” Public health is about problem solving, but it takes reliable surveillance data and collaboration to do so. CSTE allowed me to connect with people from state and local health departments along with federal agencies and academia to see firsthand how different agencies across the U.S. are using data to combat public health challenges. This year’s meeting was the largest gathering of epidemiologists to date and we learned that there is now approximately one epidemiologist per 100,000 population (2017 Epidemiology Capacity Assessment).

At CSTE, I was drawn to the sessions about foodborne disease and outbreak investigations since this is my particular area of interest. Through the pre-conference workshop and sessions, I gained a deeper understanding of the challenges faced by state and local epidemiologists in regards to foodborne disease surveillance. I particularly benefited from sessions that wrestled with challenges of how to effectively integrate the increased use of culture independent diagnostic tests (CIDTs) and whole genome sequencing (WGS). CIDTs can rapidly identify the general pathogen causing illness, but because they do not produce an isolate they do not yield subtyping information that can be used to identify clusters of illnesses. WGS, by contrast, provides more fine-tuned subtyping information, but takes significantly longer than the previous “gold standard” of pulsed field gel electrophoresis (PFGE). As surveillance activities evolve, there is an increased need to adapt approaches for investigating foodborne illnesses in order to rapidly stop and prevent them from occurring. As a result, many of these sessions provided an opportunity for state and local health departments to discuss how they are adapting to these changes and to learn from each other about how to handle challenges. At CSTE, innovations are tested against the reality of our public health systems.

A highlight of the conference was being able to attend the Jonathan Mann lecture and hear this year’s speaker, Dr. Eric Klinenberg. I first discovered his work as an undergraduate student where I was required to read his book, Heat Wave: A Social Autopsy of Disaster in Chicago in my freshman sociology class. I have since read some of his other works, which provide good examples of using data to understand complex problems and the importance of an interdisciplinary perspective. Dr. Klinenberg’s talk on climate change emphasized the point made by Sandra Mullin in the plenary that there is a need to move beyond statistics in order to motivate change through stories because stories are less likely to be forgotten.

Having the opportunity to network with attendees and Epidemic Intelligence Service (EIS) officers was a truly invaluable experience. I identified a dissertation topic that will be valuable to state and local health departments faced with the need to adapt to new surveillance methods. This experience also reaffirmed my interest in working in the government setting to promote effective public health change. Thank you to everyone who contributed to the student scholarship fund for making my attendance possible. This scholarship will truly serve as a meaningful opportunity to create a generation of future public health epidemiologists.

Pictured: Participants of CSTE’s 9th Annual National Disaster Epidemiology Workshop in Atlanta, GA, May 2018 (Photo credit: Hayleigh McCall, CSTE)

When thinking of epidemiologists working in public health preparedness and response, thoughts traditionally jump to many infectious disease-related activities: contact tracing in West Africa during the Ebola crisis, GIS-mapping as Zika was being locally-transmitted in the U.S., and deployments for Epi-Aids as a measles outbreak is detected. Yet, there is an entire sector of public health epidemiologists that prepare for and respond to environmental and man-made disasters – the disaster epidemiologists.

Disaster epidemiology, as defined by CDC, is “the use of epidemiology to assess the short- and long-term adverse health effects of disasters and to predict consequences of future disasters.” Its goal is to prevent further morbidity and mortality by addressing immediate and long-term needs by using gathered information to adjust priorities, allocate resources, and plan for future needs and/or disasters. In simpler terms, disaster epidemiology provides reliable and actionable health and needs information to public health response incident commanders, planners, and decision-makers.

Zika virus was initially identified in Uganda in 1947. It made surprise appearances in the Pacific Island of Yap (Micronesia) in 2007, and then in other island groups in the Pacific in 2013. Reports of cases in Brazil began accumulating in March 2015. This was Zika’s first appearance in the Western Hemisphere. By May 2015, Brazil was reporting locally acquired cases. The Zika outbreak in the Western Hemisphere presented some surprising challenges as the case counts rose rapidly and the number of affected countries also increased at an alarming rate. An association with microcephaly among infants exposed in utero represented one of the initial surprises. The second was the suggestion, since confirmed, that this arthropod-borne virus could also be transmitted sexually. This second surprise, not seen before, was a potential game changer. Prevention and control was no longer limited to traditional adult and larval mosquito spraying, eliminating mosquito breeding habitats, and the use of repellants by residents. By February 2016, the World Health Organization (WHO) declared Zika virus disease to be a Public Health Emergency of International Concern.

Many U.S. territories reported local Zika transmission, then in July 2016, locally acquired cases of Zika were identified in Florida. Zika virus prevention and control was a national public health priority. The Council of State and Territorial Epidemiologists (CSTE) supported Zika preparedness and response activities for local, state, and federal public health partners. Activities included: placing three Zika fellows in health departments, supporting six deployments to Puerto Rico for Zika response, and coordinating response efforts between CSTE members and the Centers for Disease Control and Prevention (CDC). Supplemental funding from CDC through CSTE supported development of a toolkit of Zika-related tools that can be used to accelerate state and local public health preparedness planning and operational readiness.

The Zika Virus Preparedness Resources Toolkit, which is now publicly available on CSTE’s website, has sections devoted to the following topics: General Information, Epidemiology, Data Management, Laboratory Guidance, Maternal and Child Health, Vector Research and Management, Policy Statements, and an Appendix with definitions and explanations of acronyms used in the toolkit. Each section contains reference and educational materials along with forms and letters that can be adapted and used by other jurisdictions. CDC’s supplemental funding also supported five national “Zika: Notes from the Field” webinars, which focused on Case Surveillance, Mosquito Surveillance, Diagnostics, Strategies for Expanding Surveillance, and Control and Prevention Strategies. The recordings of these webinars are also available in CSTE’s Webinar Library.

This toolkit is intended to be a content resource for applied epidemiologists and their colleagues to save time and effort looking for sources or materials that they can use in developing their own prevention and control policies and strategies. The primary vector species, Aedes aegypti and Aedes albopictus, are already distributed across much of the United States. Viral spread is of greater concern. As we move forward, we hope applied epidemiologists and other public health professionals will find this toolkit useful in strengthening their jurisdiction’s vector-borne disease surveillance and control programs to not only prevent Zika virus disease, but also other mosquito-borne diseases as well.

Are you ready for the #CSTE2018 Annual Conference in West Palm Beach? Here’s the rundown on how to get the most out of your experience:

1. Download the 2018 CSTE Conference mobile app prior to your arrival in West Palm Beach. Do this by searching the App Store or Google Play for “CSTE Conferences” or visiting http://m.core-apps.com/cste2018 on your mobile browser. Download the app for your tablet or smartphone, then filter and search through sessions on the agenda to create your custom daily Conference schedule. The app is updated regularly and allows you to download handouts, receive important announcements, see local info, connect with colleagues, and more!

2. The online agenda also has a useful, searchable index of sessions. Don’t miss out on the special events (Opening Reception, Early Career Professionals events, and more).

3. Get information on what weather-appropriate clothes to wear, shuttle information, walking directions, and maps on the Conference website. The weather in West Palm Beach will be hot, so be sure to bring a water bottle, sunscreen, insect repellent, and other items you’ll want to beat the heat.

4. CSTE is offering a variety of continuing education (CE) credits this year for physicians, nurses, health educators, veterinarians and those Certified in Public Health (CPH). For CME, CNE, CHES, and RACE there are a maximum of 12.5 hours eligible for only the conference workshops and plenary sessions. Only Certified in Public Health/CPH credits are available for all conference sessions. For questions, visit the Conference website or email Jessica Arrazola at jarrazola@cste.org.

5. Familiarize yourself with the 2018 position statements, so you can give feedback according to your subject matter expertise. The full list of 2018 submitted position statements is available through member login on the CSTE website.

6. Are you presenting or moderating? Watch the presenter instructions and the moderator instructions YouTube videos!

7. Due to unforeseen circumstances, CSTE will no longer host the annual 5K Group Walk and Run scheduled for the morning of Tuesday, June 12, 2018. As an alternative activity, CSTE will host a sunrise yoga group session on Tuesday, June 12 at 6:30 am by the pool at the Hilton West Palm Beach. Please bring a towel and a water bottle – space for the yoga class is limited and will be available on a first-come, first-served basis.

8. Are you looking for more information on how to prepare? Read the FAQs on the conference website.

9. Share group photos of you and colleagues and interact with @CSTEconference on Twitter and @CSTE.org on Facebook with hashtag #CSTE2018 to win gift cards and other giveaway prizes.

10. Check out the sponsored sessions to learn more about emerging software and services that are tailored to modern local, state, and federal epidemiologists’ needs.

11. Let us know what you think and how we can improve the CSTE Conference experience by completing the Annual Conference Evaluation – a link will be sent to attendees via email post-Conference. By completing the evaluation, you’ll be entered to win a $150 Amazon gift card or a free one-year CSTE membership.

We look forward to seeing you in West Palm Beach!

Michael Anderson

Danielle Boyd
Danielle Boyd is CSTE’s program analyst for the injury portfolio, where she oversees numerous injury workgroups and partnerships. She has helped the workgroups examine injury surveillance indicators and helped design technical assistance projects to aid states in refining their injury programs. Danielle served as a CDC Public Health Advisor from 2015-2017. She was detailed to the Toledo-Lucas County Health Department where she worked on projects related to infectious disease case management, outbreak reporting, disease surveillance, health education, and opiate-related overdose. Notably, she played an integral role on the team that designed the department’s prescription drug misuse and harm reduction program.

Danielle earned her Master’s of Public Health from Saint Louis University, and her undergraduate degree from DePauw University. In her free time, she enjoys reading and traveling.

Michelle Brown

Robert Carroll

Matt Cone

Mimi Huynh

Maria Israel

Shaily Krishan

Kiara Maddox

Hayleigh McCall

Jackie McClain

Elandis Miller

Jordan Peart

Shelia Scott

Sunbal Virk

Song Xue

Michael Young

This blog was shared with CSTE for publication by CDC's National Center for Environmental Health.

 About 1 in 9 Americans get their drinking water from a private well. We cannot ignore the importance of keeping drinking water safe to prevent needless morbidity and mortality.

The Association of State and Territorial Health Officials (ASTHO) 2016 Profile Survey found that 52 percent of state health agencies offer private water supply safety services, such as well testing and education on well maintenance. So what can you do to strengthen your jurisdiction’s ability to prevent illness from unsafe drinking water? CDC and their partners have produced a new online learning series for health departments to improve their private safe drinking water programs.

The Safe Water Program Improvement e-Learning Series (SWPI) is designed for health department staff to strengthen services to people who use wells, cisterns, springs, and other private drinking water systems not covered by the Safe Drinking Water Act. Participants have access to nine no-cost SWPI courses in the series.

Using the 10 Essential Environmental Public Health Services and the Environmental Public Health Performance Standards, SWPI provides examples of using each essential service to identify and fill gaps in drinking water programs.

Continuing education units are available from the National Environmental Health Association upon completing the courses and final evaluation.

Through SWPI course content, case studies, scenarios, and sample plans, find the resources your health department can use to improve safe drinking water in your jurisdiction. Enroll in SWPI today or share this blog with someone from your health department or partner agency who could use this training to improve water programs in your jurisdiction.

The recreational use of drugs and other substances is an emerging and important public health threat. In Minnesota, there was a 16% increase in fatal drug overdoses between 2015 and 2016. Similarly, non-fatal emergency department (ED) visits for opioid overdoses have been increasing steadily over the past 10 years. Since 2010, there have been at least four clusters of synthetic drug use in various communities in Minnesota. The burden that drug overdoses impose on health care systems is difficult to quantify. Many ED visits attributed to recreational drug use do not have a diagnosis of drug overdose, but have diagnoses of symptoms and signs related to substance abuse (e.g., altered mental status, acute respiratory failure, etc.). As such, these visits are not readily identified from typical data sources.

During the epidemiologic investigation of one of the aforementioned clusters, epidemiologists from the Minnesota Department of Health (MDH) discovered that identifying cases through chart review was impossible, as a wide variety of ICD codes were used. This cluster highlighted the need for a surveillance system to identify patients who present to the ED and/or are hospitalized for drug use or substance abuse.

In collaboration with key partners, MDH designed the Minnesota Drug Overdose and Substance Abuse Pilot Surveillance System (MNDOSA). This innovative surveillance system aims to: (1) determine the burden of overdose and substance abuse in Minnesota hospitals, (2) identify clusters of drug overdoses in near real time to provide situational awareness to stakeholders, (3) identify substances causing atypical clinical presentations, clusters, and severe illness and/or death, and (4) describe at-risk populations in order to focus and guide prevention efforts. MNDOSA is unique and novel as it collects real-time data rather than relying on data sources that have long delays in reporting, allowing for a near real-time response and notification of stakeholders.

This surveillance system combines reporting of drug overdose cases at three pilot hospitals, enhanced toxicology testing of clinical specimens, medical record reviews for a subset of patients, and the utilization of public health codes in medical records to monitor trends in drug and substance abuse and overdose in Minnesota. Active reporting includes real-time reporting to MDH of ED and in-patient admissions at the participating hospitals where the principal diagnosis is attributed to the recreational use of one or more of the following: Schedule I drugs, opioids (including prescription opioids, fentanyl or fentanyl analogs), synthetic, non-prescription drugs, prescription drugs, drug combinations, natural substances for recreational purposes, and other substances, including inhalants. ED visits and/or hospitalizations attributed to alcohol use alone are excluded from surveillance. Comprehensive data is abstracted from medical records for a subset of patients.

Clinical specimens for a small number of patients are submitted to the MDH Public Health Laboratory for enhanced toxicological testing. This testing is necessary because clinical specimens are often not obtained from non-fatal drug overdose patients in the ED. Additionally, hospital laboratory panels do not detect many of the new, synthetic drugs. The MDH Laboratory has the capacity to detect a vast array of prescription, illicit, and designer drugs. Laboratory results are used for surveillance purposes only, and the results will enhance understanding of the drugs/substances circulating in Minnesota.

In addition to active reporting, this surveillance incorporates an informatics-based, passive approach. Public health codes will be assigned to patients’ medical record for ED visits and hospitalizations attributed to the recreational use of the aforementioned drugs/substances, allowing MDH to monitor trends and patterns in drug/substance use and overdose in Minnesota.

Surveillance started in November of 2017 with plans to continue until December 2020, at which time the feasibility of continued surveillance will be assessed. MNDOSA is supported in part by funding from CSTE. The lessons learned thus far include:

• Capacity to report patients varies by ED – this pilot explores multiple methods of both active and passive reporting to assess feasibility and determine the best method of reporting
• Ability to utilize the electronic medical records to flag clinical specimens for submission to the MDH laboratory or assign public health codes to the chart also varies by site
• Some ED staff have concerns about reporting identifiable data on patients likely engaged in criminal activity (i.e. illicit drug use), which we addressed by agreeing to eliminate identifying information from the data as soon as possible

Each year, CSTE’s Applied Epidemiology Fellowship (AEF) offers recent epidemiology graduates the opportunity to experience applied epidemiology in a real-world setting. This is a powerful way for a young epidemiologist to get real-life experience and gain valuable exposure to many facets of the job. Following the completion of my MPH in epidemiology at the University of Pittsburgh, my passion to learn more and investigate mosquito-borne infectious diseases led me to apply and accept a two-year Applied Epidemiology Fellowship. I was placed at the Centers for Disease Control and Prevention-Dengue Branch (CDC-DB) and the Puerto Rico Department of Health (PRDH) in San Juan, Puerto Rico.

A month into my fellowship, CDC-DB received a call from the territory of American Samoa requesting assistance with a dengue outbreak. The outbreak started in November of 2016 when a fisherman introduced a dengue virus strain that had not been seen in American Samoa since the 1970s. In September 2017, I deployed with an EpiAid team from Puerto Rico to work with our counterparts in American Samoa. Being part of the American Samoa team, and participating in this outbreak investigation has been a highlight of my fellowship experience so far and has opened my eyes to the reality of applied epidemiology.

Pictured: American Samoa Department of Health staff drawing blood and interviewing a person during household-cluster investigations. (Photo credit: Caitlin Cotter)

Pictured: The entomology team doing outdoor aspiration collecting mosquitoes. (Photo Credit: Tyler Sharp)

An additional aim of this EpiAid response was to review medical records to evaluate clinical management of hospitalized dengue patients. This information will be used to see how dengue illness might be affected by co-morbidities, timing of when care was sought, previous infection with Zika (American Samoa had a Zika outbreak in 2016), and other variables that could possibly influence severity of disease. My work involved going to the central health clinic to collect the information, and attending doctor rounds to hear their first-hand experience with dengue patients’ stories, and alert us to current patients in the ward.

My deployment took me from the familiarity of crunching numbers behind a desk to front and center fieldwork. It cemented that I love fieldwork with all that comes with it – insect repellent, unexplained delays, outdated maps, miscommunication, and the unexpected. This opportunity also showed me more of American Samoa than most people who come here as tourists get to see.

Pictured: Stephanie surveying potential mosquito breeding sites. (Photo Credit: Tyler Sharp)

Pictured: The EpiAid team on a hike in American Samoa (Credit: Tyler Sharp)

This past spring, CDC and the Council of State and Territorial Epidemiologists (CSTE) joined forces to co-host an intensive writing training series for the Morbidity and Mortality Weekly Report (MMWR). Led by MMWR Executive Editor Charlotte Kent, PhD, MPH and CSTE Senior Program Analyst Jessica Arrazola, DrPh, MPH, CHES, the workshop was designed to increase the number of quality submissions from state, territorial, local, and tribal (STLT) health agencies and to train junior authors, strengthening their capacity to write reports appropriate for publication in MMWR.

CSTE was a natural partner for this initiative, as CSTE outlined the need for scientific writing training specific to MMWR in a special report. It was this report that also prompted the development of a toolkit of scientific writing resources for public health practitioners.

Dr. Kent and our MMWR team conducted three webinars, which were open to the public. The webinars provided an overview of MMWR and focused on cross-cutting skills and strategies for writing for scientific publications. The recorded webinars were well-attended, attracting 200 participants per webinar session. The success of this effort confirmed that there’s broad interest in writing for MMWR as well as the need for scientific writing guidance among STLT staff.

In addition to the webinars, MMWR and CSTE identified 21 junior STLT authors, selected through a competitive application process, to attend a two day in-person training. These novice authors were paired with an experienced author for mentorship and assistance in the development of an MMWR submission. In addition to Dr. Kent and myself, workshop mentors included: Paul Etkind, DrPH, MPH; John S. Moran, MD, MPH; Paul Z. Siegel, MD, MPH; and Rich Vogt, MD. The in-person training allowed for peer-to-peer feedback about their draft manuscripts and covered important topics such as engaging the media, social media outreach, and legal and ethical implications of publishing public health data.

I had the privilege of serving as mentor to Maureen Leeds, MPH, an epidemiologist for the Minnesota Department of Health. Today, MMWR is pleased to publish the first of the novice STLT authors’ manuscripts titled, “Timeliness of Receipt of Early Childhood Vaccinations Among Children of Immigrants — Minnesota, 2016,” which was written by Maureen.

"It was an honor to be accepted into this first training group, and I'm grateful for the support provided by CSTE and my CDC mentor. It's exciting to be published for the first time, especially in MMWR," shared Maureen.

Congratulations, Maureen! We look forward to publishing the work of all of our MMWR and CSTE trainees.

Photo caption: Maureen Leeds, MPH, (second from the left) and other workshop participants discuss opportunities for publishing in MMWR.

Photo caption: Dr. Charlotte Kent, MMWR Executive Editor, leads discussion of a case study about publishing in MMWR.

Pictured: CSTE Vice President Joe McLaughlin, 2017 Student Scholarship winner Carrie Clippinger and Executive Director Jeff Engel.

Editor’s note: In spring 2017, CSTE awarded the second student scholarship to Carrie Clippinger, MPH of Pennsylvania. Carrie is a recent Penn State College of Medicine graduate looking to begin her career in epidemiology with a focus on substance use, mental health and suicide prevention. Carrie has written a blog on her experience as the 2017 CSTE Student Scholar.

I am honored to have been chosen as the 2017 recipient of the CSTE Student Scholarship. Attendance at the 2017 Annual Conference was especially exciting, as it was the largest gathering of applied epidemiologists in U.S. history. It was my first time visiting the host city Boise, Idaho, and I enjoyed exploring the friendly mountain desert city, known for its scenic trails and Basque culture.

Participating in such a large event has given me valuable perspective into the work of public health professionals. As a recent graduate, it was refreshing to see real world and cutting-edge application of epidemiological principles. Although insightful work was presented in every track, I was most drawn to discussions of mental health and substance use, which align with my professional work. The topic of the hour was opioids, and it was fascinating to learn how government epidemiologists across the nation – with vastly different authority and resources at their disposal – are tracking this epidemic with the tools available. Despite huge differences in how each agency tackled this problem, most presenters agreed that strong community cooperation was an integral component of their opioid epi work.

I was also particularly interested in discussions of suicide surveillance, a topic which I am heavily involved in rural Pennsylvania. Again, I was struck by the diverse range in epidemiologists’ ability to monitor suicides, the variance in relationships with community partners and coroners or medical examiners, and the creativity with which public health professionals across the nation are collecting and analyzing data on suicides and suicidality. There was a particular emphasis on the sensitive nature of the research, the need for flexibility to address localized concerns, and ethical considerations.

Idaho’s public health efforts were well-represented during a standout plenary on the state’s work with its refugee populations – the largest per capita of any state in the nation. I also enjoyed attending breakout sessions on public health law – a timely and impactful topic that inspired reflection on epidemiology’s role in protecting public health. Engaging presentations on climate change, tickborne disease, water supply infrastructure, and maternal and child health were also eye opening. On the whole, successful projects at the conference included novel research methods such as geomapping, the use of real-time data gathered through new technologies, and the use of syndromic data – demonstrating that epidemiology is not a static discipline. Across the board, projects showcased the power of epidemiology to adapt and innovate.

Networking with CSTE fellows and attendees was truly invaluable. Seeing and learning from the practical, meaningful work of epidemiologists from a wide diversity of career paths was a unique opportunity that holds great importance for me as a recent graduate. Thank you to everyone who contributed to the scholarship for making my attendance at the CSTE Annual Conference possible. The Student Scholarship will undoubtedly continue to be an influential experience for future recipients.

To donate to the CSTE Student Scholarship, visit http://bit.ly/1YUbvp8.

Pictured: Class 15 AEF Fellows at Orientation in Atlanta (Photo credit: Robin Gaucher)

Pictured: John Anderton, CDC Acting Associate Director for Communications Science, presents on Health Communications (photo credit: Matt Cone).

Fellows’ subject areas of placement this year include behavioral health, chronic disease, environmental health, infectious diseases, healthcare-associated infections, maternal and child health, infectious disease-quarantine, substance use, and a new area of infectious diseases with a Zika focus. At their host sites, fellows will work on surveillance systems and tools, conduct case investigations, build their communication skills, and participate in training, research and field activities designed to build their epidemiologic capacity.

Some expected projects of the fellows include:

• Evaluation of the current surveillance system for coccidioidomycosis (Valley Fever) in Washington State, Mackenzie Fuller, MPH
• Evaluating the identification and reporting of migrant workers among New York City’s TB population, Carley Perez, MPH
• Critical evaluation of CJD (Creutzfeldt-Jakob Disease) surveillance program in Pennsylvania, Christina Butler, DVM, MPH
• STD surveillance data for descriptive and analytical epidemiology, Kiara Diggins-Parker, MPH
• Enhanced surveillance for Zika virus vectors, Stephanie McCracken, MPH
• Evaluate the potential usefulness and validity of data from the National Survey on Drug Use and Health (NSDUH), Abby Hagemeyer, PhD, MPH
• National Healthcare Safety Network catheter-associated urinary tract infection data validation, Lee Hundley, MPH
• Evaluation of school- and home-based asthma programs, Grace Christensen, MPH

Since 2003, the CSTE AEF program’s mission has been to provide training and real-world experience to epidemiologists early in their careers. Since its beginning, 295 fellows have completed the program, and CSTE has placed fellows in 41 states and 19 local jurisdictions.

Congratulations to the new fellows!

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

Day 1

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.

Day 2

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.

The second day had no shortage of VBD-related sites to see. The day began with a trip to Baton Rouge to meet State Medical Entomologist Kyle Moppert. We toured the East Baton Rouge Mosquito Abatement and Rodent Control District with Randy Vaeth, Assistant Director.

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.

Day 3

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.

Derry Stover (NE) presents on working in occupational safety and health.

Fall not only brings the changing of leaves and cozy sweaters, but the annual Western States Occupational Network, or WestON, meeting. Every September, participants from 19 Western states come together in Denver, CO, for a day and a half meeting to advance and build capacity for occupational safety and health in the region. This year marks the 10th anniversary of the annual WestON meeting. Each year, WestON attracts over 60 participants from the NIOSH-funded Education and Research Centers (ERCs), Agricultural Centers and Training Project Grants; Federal, State and Tribal agencies; public health scientists; trainees and policymakers. Participants present and exchange ideas while identifying collaborative activities to address occupational safety and health issues in the West.

Background

Recognizing the need to build occupational health surveillance at the state level in the West, the Council of State and Territorial Epidemiologists (CSTE), NIOSH Western States Office (now part of the NIOSH Western States Division), and Mountain and Plains Education and Research Center (MAPERC) established WestON in 2008. WestON includes participants from 19 Western states (AK, AZ, CA, CO, HI, ID, KS, MT, NE, NV, NM, ND, OK, OR, SD, TX, UT, WA, WY) who are working or strongly interested in occupational safety and health.

Western states share some collective identity based on common priority areas in workplace safety and health, such as mining, construction, and agriculture. The goal of WestON is to build and strengthen capacity among these 19 Western states to conduct state-based epidemiology, surveillance, and prevention of work-related injuries and illnesses. The framework of the WestON meeting is based on the concept that “regional” identification of common issues can help support the development of occupational epidemiology capacity in states that historically have had limited funding in this core area of public health.

Over the past 10 years, WestON agendas and topics have shifted from basic surveillance concepts to setting strategic priorities for interventions in the Western region and engaging a more diverse group of partners. Initial meetings provided participants with an opportunity to refine their surveillance skills and establish contacts in their field. More recent meetings have included participants from the NIOSH Centers of Excellence, Tribal Epidemiology Centers and journalists. The WestON meeting is one of the few venues where state, Federal and academic partners gather in a relatively small setting to share findings, promote collaboration and strategize about future activities.

WestON 2017

The 10th annual WestON meeting will take place September 13-14, 2017, in downtown Denver, with over 70 participants from the Western region. This year’s keynote speaker is Michael Grabell, a reporter from ProPublica, who will highlight workers’ compensation issues. Presentations will cover a wide array of topics, including novel uses of occupational health data, using Informatics in occupational safety and health and occupational issues related to marijuana. As with all WestON meetings, ample time will be devoted to networking and exchanging ideas for future projects. Next year’s meeting will be held in Denver on September 13-14, 2018.

How can you get involved?

Join the WestON Listserv to learn about occupational safety and health research, news, and announcements. If you would like to join, please email Song Xue at sxue@cste.org. For more information about the annual WestON meetings, please contact Yvonne Boudreau at yboudreau@cdc.gov.

In the wee hours of Friday, July 28, Senator John McCain (R-AZ) unexpectedly cast the deciding “no” vote on the “Health Care Freedom Act,” a bare bones version of Affordable Care Act (ACA) “repeal and replace” legislation. Senator McCain joined Senators Susan Collins (R-ME) and Lisa Murkowski (R-AK) in defeating this final amendment to the House-passed American Health Care Act, bringing debate on the bill to a close. Even though the Health Care Freedom Act was a shell of all previously introduced – and failed – repeal and replace legislation, the bill nevertheless included a provision to terminate the Prevention and Public Health Fund beginning in fiscal 2019.

What happens next is anyone’s guess. The administration is pressuring Congress to bring the bill back up for another vote or else, threatening to end cost sharing subsidy payments to insurers that will create a “death spiral” in the marketplace. Leading Senate Republicans, including the powerful Finance Committee Chairman Orrin Hatch (R-UT) and Senator John Thune (R-SD), who serves in the number three position in Senate Republican leadership, are pushing back. They insist that Republicans will move on from ACA repeal and replace to focus on tax reform. At the same time, bipartisan groups of lawmakers are coming together to find ways to “repair” the ACA.

Regardless of where the ACA debate goes from here, it is clear Republicans are intent on repealing the Prevention Fund given that provision was included in every iteration of ACA repeal and replace legislation. These bills were not the first attempt to repeal the Prevention Fund, and they certainly won’t be the last. The public health community must continue its efforts to educate lawmakers about the value of public health, and the perils of repealing the Prevention Fund.

August is an ideal time to connect with lawmakers while they’re back home in district/state to educate them on the value of public health broadly and applied epidemiology particularly. We recommend downloading this guide prepared by the Association of State and Territorial Health Officials (ASTHO), which explains why it’s important for public health professionals to interact with policymakers and how to do so.

There was a flurry of activity on Capitol Hill last week – and this week – with big implications for public health funding. The House Appropriations Committee approved along party lines its fiscal 2018 spending bill for the Departments of Labor, Health and Human Services, Education and Related Agencies (Labor-HHS). Starting from $5 billion lower than the current, already austere funding level, the bill forces more cuts in many health programs to support increases in others. As in years past, the bill is a mixed bag for applied epidemiology.

To be sure, the bill is a marked improvement from the president’s fiscal 2018 budget request for the Centers for Disease Control and Prevention (CDC), which proposed an 18 percent cut to the agency’s total budget, deeper cuts to many of the agency’s programs, and the outright elimination of others. The House’s proposal largely rejects many of the President’s priorities, and provides the agency roughly $7 billion – nearly 2.5 percent below current levels.

Within CDC’s budget, the Public Health Workforce activities, through which the CDC/CSTE Applied Epidemiology Fellowship receives funding, are cut by roughly $5 million, with total proposed funding of $45 million. The appropriations bills do not specify how much funding would be dedicated to the Applied Epidemiology Fellowship program per se, but with a cut in funding for the program we might expect a cut in available funding for our fellows. The president had requested a $7 million cut in the program.

The National Center for Emerging and Zoonotic Infectious Diseases (NCEZID) receives $599.5 million, $33.4 million less than current funding, but $122.5 million more than the president’s request. Within NCEZID, the emerging infectious diseases programs absorbs most of the proposed cut. Most other programs receive flat funding – antibiotic resistance ($163 million), advanced molecular detection ($30 million), food safety ($54 million), vector-borne diseases ($26.4 million) – which means we might expect Epidemiology and Laboratory Capacity (ELC) grants to be flat funded since much of ELC funding is driven by NCEZID’s overall budget.

Interestingly, the House’s spending bill would appropriate funding from the Affordable Care Act’s (ACA) Prevention and Public Health Fund, including flat funding of $40 million for ELC and $12 million for hospital acquired infections at the same time the House voted to repeal the Prevention Fund beginning in fiscal 2019 as part of its ACA repeal effort, the American Health Care Act (AHCA). As we’ve noted before, elimination of the Prevention Fund would deal a devastating blow to CDC and public health more broadly, resulting in a 12 percent cut to CDC’s overall budget, a 20 percent cut to ELC, a 33 percent cut to immunizations, and complete elimination of all funding for core public health capacity supported by the Preventive Health and Health Services Block Grant.

On Tuesday, the Senate narrowly agreed to begin debate on ACA repeal or rather, the various repeal options released to date, and potentially others yet to be released. Of the bills made publicly available, all include repeal of the Prevention Fund.

First up was a vote on the Better Care Reconciliation Act (BCRA) – the repeal and replace legislation that would repeal the Prevention Fund beginning fiscal 2019. The BCRA was rejected by a vote of 43-57. On Wednesday, Senators rejected 45-55 the Obamacare Repeal Reconciliation Act (ORRA), the “repeal” only bill that was vetoed by President Barak Obama in early 2016. If enacted, ORRA would've repealed the Prevention Fund immediately more or less, and rescinded unobligated funds.

As a last ditch effort to pass some sort of ACA repeal, Senate Majority Leader Mitch McConnell is reportedly considering a “skinny repeal” bill that may be more likely to gain 50 votes needed for passage, since it would simply eliminate the penalty for the ACA's individual mandate – possibly along with its employer mandate and some taxes on the health care industry. There are also credible reports this “skinny repeal” will include a provision to repeal the Prevention and Public Health Fund to ensure the bill complies with reconciliation instructions. If introduced, this legislation would likely be the last and final bill to be considered, possibly around 5:00 am Friday morning (check out this helpful article and up-to-date flowchart on the procedural timetable here).

With Congress set to leave Washington for the August recess, there won’t be any further activity on fiscal 2018 spending legislation until after Labor Day when they return to the Capitol. At that time, we should have a better sense of where the Prevention Fund stands and when the Senate will consider its own public health spending bill. In any event, a continuing resolution to keep the government running on autopilot after September 30 will be needed.

In the meantime, August is an ideal time to connect with lawmakers while they’re back home in district/state to educate them on the value of public health broadly and applied epidemiology particularly. We recommend downloading this guide prepared by the Association of State and Territorial Health Officials (ASTHO), which explains why it’s important for public health professionals to interact with policymakers and how to do so. With all the threats facing public health, your voices are needed now more than ever.

Health systems integration is defined as the collaborations between public health and clinical health sectors. The Institute of Medicine’s call to integrate public health and clinical health sectors to improve and promote better population health and public health’s emphasis on prevention emphasizes the need to develop leaders intersecting public health and clinical health sectors. Health systems integration professionals are needed to complement discipline-specific expertise and work across program or disease-specific public health practice.

Recognizing a need for health systems integration professionals, the Centers of Disease Control and Prevention (CDC), Council of State and Territorial Epidemiologists (CSTE), and the National Association of County and City Health Officials (NACCHO) collaboratively offered a one-year training program, the Health Systems Integration Program (HSIP). HSIP was the only national program to train health systems integration professionals at state and local health departments. HSIP placed experienced public health or clinical health practitioners with a masters or doctoral degree into state and local health departments. Fellows provided a service to the host agencies, and received training through the fellowship program, such as leadership, project management and public health informatics. Determined together with the host sites, fellows worked on data-driven projects that address community-level health concerns and improve population health. These projects were rooted in the HSIP core competencies. These competencies included five domains: analysis, assessment and evaluation; policy development and program planning; communication and cultural competency; public health sciences; and health systems.

Since 2013, 24 fellows have participated in the training and provided a service to seven local and nine state health departments. HSIP Class II (2015-2016) had eight fellows matched to four state and four local health departments. Five Class II fellows’ experiences (Marion Tseng, Ekaette Joseph-Isang, Bree Allen, Koneng Lor and Crystal Boston-Clay) were utilized to examine the skills required for health systems integration professionals. For this report, fellows selected one project from fellowship assignments, and summarized the project outcomes and impacts from their activity reports. Fellows’ selected project summaries were analyzed to identify common skills required for successful health systems integration.

These five fellows selected projects covering areas ranging from disease surveillance, population health assessment to policy. Fellows identified public health informatics skills as the most critical in accomplishing health systems integration projects. Public health informatics is defined as, “the systematic application of information, computer science and technology to public health practice.” Having skills to practice public health informatics is fundamental to ensuring the robust use of data to guide public health actions. The fellows found that public health informatics skills were important to many of the health systems integration competencies. For example, public health informatics skills helped fellows describe how evidence-based approaches and linking public health and health care perspectives can be used to improve the population’s health care needs and delivery.

Pictured: CSTE’s Class II Health System Integration Program fellows in 2016.

At Chicago Department of Public Health, Marion led a project to establish an electronic provider reporting interface for chlamydia and gonorrhea cases. Public health informatics skills helped Marion to understand requirements for this electronic provider reporting interface, and ensure the interface meets data needs of all stakeholders. Ekaette established an Informatics Workgroup at the Kentucky Department for Public Health. She presented and led group brainstorming sessions to help participants understand how public health informatics could enhance data use to guide public health practice. In Minnesota, Bree connected local public health departments and health care providers to encourage the use of electronic health records data for community population health assessments. She applied public health informatics skills, such as communication and systems thinking, to engage stakeholders to gather lessons learned and developed an informatics framework and toolkit. In Marion County, Indiana, Crystal improved community partnerships and enhanced timeliness of electronic laboratory reports to Indiana Health Information Exchange. She exercised public health informatics skills rooted in the project management methodology to conduct business process analysis and communicate with stakeholders regarding project milestones. Koneng completed a pilot stakeholder survey and made recommendations for improving an existing information mapping system at Washington State Department of Health. She engaged stakeholders by frequently communicating project progress, and connected with subject matter experts to inform the recommendations.

Public health informatics skills are critical for health systems integration professionals to leverage actionable data-driven information to engage and collaborate with partners. The HSIP fellows built and strengthened multi-disciplinary and cross-sector partnerships, and facilitated data exchange among these partners. Public health needs health systems integration professionals to collaborate with non-traditional multisector stakeholders to implement data-driven solutions that improve population health. Health systems integration professionals can be trained through on-the-ground experiential learning, such as the HSIP fellowship

This blog post was supported in part by appointments to HSIP administered by CSTE and funded by CDC Cooperative Agreement 3U38-OT000143-01S3. The authors would like to thank all HSIP Class II host sites, mentors and fellows: April Moreno, Anna Oberste and Michael Ray for their contribution to this blog post.

Pictured: Gabriela in the field in Puerto Rico conducting surveys with a group of entomologists (photo credit: Gabriela Escutia)

Just a few months into my fellowship, Zika virus disease (ZIKV) emerged in the Americas, and a year later, the U.S. declared a public health emergency in Puerto Rico. By September 2016, there were over 20,000 symptomatic ZIKV cases reported in Puerto Rico. In October 2016, I was deployed to Puerto Rico to assist in the emergency response to Zika. Working on the frontlines of the Zika outbreak in Puerto Rico has been one of the richest experiences of my career in applied epidemiology.

During my deployment, I assisted in a household cluster investigations project to identify factors associated with the underreporting of ZIKV in Puerto Rico. I supported the collection of demographics, household characteristics, recent illness and health care-seeking behaviors by conducting interviews of households within 100 meters of households where patients with confirmed ZIKV disease lived in five municipalities in Puerto Rico. My work varied from conducting surveys to transporting specimens and field materials to cluster locations. The interviews were conducted in the Spanish language.

Pictured: A bottle of mosquitos used during outreach activities (photo credit: Gabriela Escutia)

As epidemiologists, we are responsible for studying the distribution of disease in populations for the design of appropriate interventions; however, this can become complex during a public health emergency, as sometimes urgent problems that demand immediate solutions arise. Early in my field work, I realized that my experience would be incomplete without observing the social aspects of the situation. With almost 50% of the population living below poverty in Puerto Rico, there is no doubt that health on the island is determined by access to social and economic opportunities. As a young epidemiologist in training eager to learn, I quickly drafted an observation items list to use every time I went into the field. I learned that the way you knock on the door in a middle-class neighborhood was not the same way you would in a low-income neighborhood.

My Zika deployment also took me from the familiarity of the office to an environment where I gained a new perspective on the role of an epidemiologist. As epidemiologists, we get the best answers by going into the field and talking to people. In the field, I gained a greater understanding of Puerto Rican culture through observation. For instance, applying mosquito repellent might not be a cultural practice, as some elderly people I met in Puerto Rico believe that repellent disrupts the natural ecosystem and might harm the lizards around their homes that eat the mosquitos.

At the Puerto Rico Department of Health Emergency Operations Center (EOC), health officials played an important role in closely monitoring the outbreak and providing a platform for deployed and local health professionals to collect and analyze information for response activities. I joined the behavioral science team as a data manager. Our team was responsible for conducting a two-phase interview among pregnant women to assess the distribution of Zika prevention kits and CDC educational materials. This included the distribution of topical insect repellent, condoms to avoid potential sexual transmission of Zika, and mosquito dunks to reduce mosquito populations in standing water, which were delivered through Women, Infants, and Children (WIC) clinics. During a public health emergency, timely access to relevant data is essential. Time is limited and population needs must be addressed.

Pictured: Gabriela’s last day at the Emergency Operations Center with a behavioral science team (photo credit: Gabriela Escutia)

Gabriela Escutia is a CSTE Class XIII AEF Fellow in the San Diego Health & Human Services Agency Quarantine Unit

This publication was supported by Cooperative Agreement Number 5U38OT000143 from CDC. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of CDC.

After much anticipation, Senate Republican Leader Mitch McConnell unveiled the Better Care Reconciliation Act (BCRA) late last week – the upper chamber’s version of Affordable Care Act (ACA) repeal legislation – following the House’s passage of the American Health Care Act (AHCA) almost two months prior.

Just when you thought it couldn’t get worse, it did.

To review, Section 101 of the House’s AHCA would repeal the ACA’s Prevention and Public Health Fund (PPHF) beginning in fiscal year (FY) 2019, the loss of which would result in a 12 percent reduction in the Centers for Disease Control and Prevention (CDC) budget. More specifically, the loss of the Prevention Fund would leave Epidemiology and Capacity (ELC) grants with one-fifth less funding, immunizations with one-third less funding, and would completely eliminate all funding for core public health capacity supported by the Preventive Health and Health Services Block Grant. Former CDC Director Dr. Tom Frieden spoke on CNN this week about the impact of the Prevention Fund loss HERE.

Facing such cuts in more than a year from now is bad enough, but the Senate’s BCRA would repeal the Prevention Fund beginning in FY 2018 – just three short months from now.

Why does timing matter?

The FY 2018 appropriations process is behind schedule, and it is certain that lawmakers will not complete their work before the end of the fiscal year on September 30. That means Congress will have to pass – and the president will need to sign – a continuing resolution to keep the government running for a specified period of time while lawmakers work out their differences. By definition, a continuing resolution continues programs at the previous year’s funding levels. If the funding doesn’t exist – because it is repealed, for example – the funding can’t be continued. In the case of the Prevention Fund, this would mean that several core CDC programs – ELC, immunizations, chronic disease, Prevent Block among them – would be operating at significantly reduced capacity for a specified period of time. If Congress ultimately can’t complete its budgetary work and then passes a year-long continuing resolution, lawmakers will not have the opportunity to backfill the CDC losses created by the Prevention Fund cut through spending legislation repeal for another year.

In sum, enactment of the BCRA would pull the rug out from under CDC and core governmental functions that are essential to our nation’s health security.

Despite all of this, the future of the BCRA is tenuous at best. This week, leader McConnell delayed a vote on the bill before lawmakers leave for the July 4th recess after failing to secure the requisite 50 Republican votes to pass it – several conservative and moderate Senators have come out in opposition and/or expressed skepticism about the legislation as written. Several notable polls this week, including an NPR/PBS poll and a USA Today poll, show dwindling support for repeal/replace legislation in its current form. However, it is certainly possible that Senators will take up a revised version of the bill when they return after Independence Day; in fact, some are saying a vote could be scheduled for July 11th.

Background Information

For background information, including a detailed analysis on the impact the loss of this fund will have on state public health departments, please view the Trust for America’s Health factsheets and analysis.

I first became aware of Flu Near You (FNY) from a colleague while I worked at my previous job at the Tazewell County Health Department (TCHD) in central Illinois. I was the epidemiologist for the County, which housed roughly 135,000 residents. At TCHD, I was less of an epidemiologist than a general ‘data & technology’ guy. There just wasn’t enough local data to do proper epidemiological analyses. Our data was too sporadic, too sparse and too noisy. We regularly were frustrated by this problem, but accepted it as a fact of life for being in a county that didn’t have a million people.

FNY works by transforming a regular citizen into a citizen scientist. Every Monday, these citizen scientists collect the previous week’s health data about themselves and their families. They then transmit the data through the web or through the FNY smartphone app. This data is then aggregated and analyzed to determine influenza-like illness trends for states and the nation by the team at HealthMap at Boston Children's Hospital, which runs FNY. These analyses have been shown to be very consistent with CDC estimates of influenza-like activity¹ .

Local and State Health Departments can easily and quickly gain access to these data. HealthMap has committed itself to sharing the de-identified data widely in the hopes that the data can lead to positive public health action. After being given access to the data, I wanted to see how many users were necessary to gain a good signal that still correlated to CDC’s ILINet data. At over 10,000 weekly participants, the data correlates very, very well (R ~ 0.96). I conducted the same analysis with 1,000 weekly participants and was surprised to see that the correlation continued to be very strong (R ~ 0.88). At 500 participants, it was still strong (R ~ 0.80). It wasn’t until approximately 200 weekly participants or fewer that the signal started dropping off and becoming unreliable.

The major conclusion from this analysis was that a local health department only needed to find 200 individuals willing to participate for this tool to be worthwhile within its jurisdiction. For most areas, this will require some active recruiting efforts, but I believe it is achievable. Once an area has reached the 200 mark, I believe public health officials can interpret FNY data with enough confidence for it to trigger public health action – say a news alert stating that influence has spiked within the county and encouraging the public to get vaccinated.

Flu Near You is tool that transforms regular people into citizen scientists

FNY, ILINet, and CDC Virological data, transformed by scaling each value as a proportion of the peak value, correlate very tightly with each other.

Correlation between bootstrapped samples of FNY estimated percent ILI and observed percent ILI, as reported by the CDC (grey), and laboratory confirmed influenza cases (red) at the national resolution with 95% Confidence Intervals for the 2014-2015 flu season.

Flu Near You is a participatory disease surveillance system for volunteer reports of ILI symptoms that was created in 2011 by APHA, HealthMap of Boston Children’s Hospital, and the Skoll Global Threats Fund (SGTF). In 2016, CSTE and SGTF partnered to further explore the utility of Flu Near You data as a novel data source for influenza surveillance in the state and local health department setting. For more information, please contact mschroeder@cste.org.

Eric Bakota, MS is a staff analyst in the Office of Surveillance and Public Health Preparedness at the Houston Health Department. Eric is currently a CSTE Informatics-Training in Place Fellow.

As summer approaches, many Americans will be searching for solace from the heat in recreational water. Each year, the week before Memorial Day is designated as Healthy and Safe Swimming Week (May 22-28). This year’s observance marks its 13^th anniversary of promoting healthy and safe swimming practices for both swimmers and pool operators.

Whether it be in lakes, rivers, water parks, splash pads or neighborhood swimming pools – epidemiologists know that it is no coincidence there is an uptick of waterborne disease outbreaks during the hot summer months. The last major outbreak I investigated before I left the Alabama Department of Public Health (ADPH) in late 2016 to join the CSTE team happened to be a Cryptosporidum outbreak at a local water park. We were happy to have had cooperation from the water park owners and staff who voluntarily closed their facility for treatment. Unfortunately, we were not able to recover organisms from the water. That summer, other states also experienced waterborne disease outbreaks and our collective stories were published in a recently released MMWR.

Pictured: CSTE staff member Thuy Kim, MPH contributed to a CDC MMWR focused on a Crypto outbreak in Alabama, Arizona and Ohio in 2016.

In the spirit of this week, a few CSTE members have also written and created an educational music video on water safety. The video was written by Taishayla Mckitt and stars Miranda Daniels and Allison Roebling – all from ADPH.  Please enjoy, like, comment, share and take some notes!

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.

Keiji Fukuda , MD, MPH– Jonathan M. Mann Memorial Lecture

Caleb Banta-Green, PhD, MPH, MSW

CAPT. Martin (Marty) Cetron, MD

Dr. Cetron is director of the Division of Global Migration and Quarantine (DGMQ) at the National Center for Emerging and Zoonotic Infectious Diseases (NCEZID). He previously served as director of DGMQ when it was within the National Center for Preparedness, Detection, and Control of Infectious Diseases. DGMQ’s mission is to prevent the introduction and spread of infectious diseases into the U.S. and to prevent morbidity and mortality among immigrants, refugees, migrant workers and international travelers. Dr. Cetron’s primary research interest is international health and global migration with a focus on emerging infections, tropical diseases and vaccine-preventable diseases in mobile populations.

Since coming to CDC in 1992, Dr. Cetron he has led a number of domestic and international outbreak investigations, conducted epidemiologic research and been involved in domestic and international emergency responses to provide medical screening and disease prevention programs to refugees prior to U.S. resettlement. He played a leadership role in CDC responses to intentional and naturally acquired emerging infectious disease outbreaks, including the anthrax bioterrorism incident, the global SARS epidemic, the U.S. monkeypox outbreak and the H1N1 pandemic. Dr. Cetron is also part of CDC’s Pandemic Influenza Planning and Preparedness Team. He holds faculty appointments in the Division of Infectious Diseases at the Emory University School of Medicine and the Department of Epidemiology at Rollins School of Public Health.

Dr. Cetron received his bachelor of arts degree from Dartmouth College in 1981 and his MD from Tufts University in 1985. He trained in internal medicine at the University of Virginia and infectious diseases at the University of Washington before becoming a commissioned officer in the U.S. Public Health Service in 1992.

Jacqueline MacDonald Gibson, PhD, MS

Dr. Gibson is currently an associate professor in the Department of Environmental Sciences and Engineering at the University of North Carolina, Chapel Hill. She had a 13-year career working for public policy research institutions before returning to school to earn a dual Ph.D. and entering academia.

As a senior engineer at the nonprofit RAND Corp., she served as liaison to the White House Office of Science and Technology Policy and conducted technical reviews of risk assessment methods adopted by government agencies. As associate director of the Water Science and Technology Board of the National Research Council, which advises Congress and the federal government on science policy matters, Dr. Gibson led a range of studies of issues at the interface between water science and public policy.

Studies included assessment of options for improving potable water service to small U.S. communities, evaluation of regulatory requirements for the remediation of contaminated groundwater, and assessment of research priorities for new environmental remediation technologies. She has also given briefings on these and other topics to a variety of federal officials, members of Congress and their staffs, and institutional advisory boards.

Christine Hahn, MD

Christine Hahn, MD, known for her common-sense approach to often challenging situations, has wanted to help as many people as possible since she finished her training as an Epidemic Intelligence Service Officer with the Centers for Disease Control and Prevention in 1995. She realized then she enjoys helping people live healthier lives now, as well as in the future. That led her to accept the position as Idaho’s state epidemiologist in 1996, and she continues to be the go-to authority for an array of healthcare professionals in the state, as well as the state’s public health districts. Her favorite part of the job is being able to help busy medical providers get the tools they need so they and their patients are successful. Her work overseeing the Idaho Refugee Health Screening Program has helped to provide better coordination and standardization of screening processes between clinics throughout the state in the last two years. She also has been instrumental in aligning Idaho’s immunization requirements with the CDC’s Advisory Committee on Immunization Practices, meaning that more children are starting school with the recommended panel of vaccines. As the state’s tuberculosis controller, she has advised and supported physicians treating and managing the disease.

Hahn attended Medical School at Michigan State University and completed a residency in Internal Medicine at the Mayo Clinic’s Graduate School of Medicine. She then completed a Fellowship in Infectious Diseases at Duke University Medical Center. After a two-year training program as an Epidemic Intelligence Service Officer with the CDC, she became the Idaho state epidemiologist. Hahn served on the CDC’s Advisory Committee for the Elimination of Tuberculosis until June 2012. She was recently named the Medical Director for the Division of Public Health with oversight of the Bureau of Communicable Disease Prevention and the Idaho Bureau of Laboratories. She served as president of the Council of State and Territorial Epidemiologists from 2004-2005, and remains active in that organization. She is the organization’s liaison to the CDC Advisory Committee on Immunization Practices, which sets national vaccination policy. Locally, Hahn serves on the infection prevention committees of Saint Alphonsus and St. Luke’s regional medical centers in Boise and is on the board of Idaho’s Immunization Policy Commission.

Debra Houry, MD, MPH

Dr. Houry is the Director of the National Center for Injury Prevention and Control (NCIPC) at CDC. In this role, Dr. Houry leads innovative research and science-based programs to prevent injuries and violence and to reduce their consequences. She joined the CDC in October 2014. She has previously served as Vice-Chair and Associate Professor in the Department of Emergency Medicine at Emory University School of Medicine and as Associate Professor in the Departments of Behavioral Science and Health Education and in Environmental Health at the Rollins School of Public Health. Dr. Houry also served as an Attending Physician at Emory University Hospital and Grady Memorial Hospital and as the Director of Emory Center for Injury Control. Her prior research has focused on injury and violence prevention in addition to the interface between emergency medicine and public health, and the utility of preventative health interventions and screening for high-risk health behaviors. She has received several national awards for her work in the field of injury and violence prevention.

Dr. Houry received the first Linda Saltzman Memorial Intimate Partner Violence Researcher Award from the Institute on Violence, Abuse, and Trauma and the Academy of Women in Academic Emergency Medicine’s Researcher Award. She is past president of the Society for Academic Emergency Medicine, Society for Advancement of Violence and Injury Research and Emory University Senate. Dr. Houry has served on numerous other boards and committees within the field of injury and violence prevention. She has authored more than 90 peer-reviewed publications and book chapters on injury prevention and violence. Dr. Houry received her MD and MPH degrees from Tulane University and completed her residency training in emergency medicine at Denver Health Medical Center.

Lyle R. Petersen, MD, MPH

Dr. Petersen is the director of the Division of Vector-Borne Diseases in the National Center for Emerging and Zoonotic Infectious Diseases (NCEZID). The division, located in Fort Collins, Colorado, supports CDC’s mission to protect the American public from exotic and domestic bacterial and viral pathogens transmitted by mosquitoes, ticks, fleas and other vectors.

Dr. Petersen earned his medical degree from the University of California, San Francisco. His career at CDC began in the Epidemic Intelligence Service (EIS) in 1985. During that time, he completed CDC’s Preventive Medicine Residency Program, received a Master of Public Health degree from Emory University, and served in several posts, including the Chief of the HIV Seroepidemiology Branch. In 1996, Dr. Petersen accepted an assignment in Germany, where he helped guide that country’s efforts in creating a new national infectious disease epidemiology program at the Robert Koch Institute in Berlin. In 2000, he returned to the United States to serve as the Deputy Director of Science of the Division of Vector-Borne Diseases, and he became the division’s Director in 2004.

Continuing Education through CDC

This year, CSTE has partnered with CDC to provide continuing education to Annual Conference attendees. We anticipate offering CE for doctors, nurses, health educators, veterinarians, certified in public health and general practitioners. Approval is pending with more details to come.

To learn more, visit www.csteconference.org.

Mosquitoes are responsible for transmitting diseases to millions of people worldwide, with substantial morbidity and mortality. Epidemiologists know mosquitoes spread diseases such as West Nile virus, dengue, chikungunya and Zika. Preventing and reducing the spread of many of these diseases depends on controlling mosquito vectors or interrupting human-vector contact. Several factors, including the type and timing of mosquito control activities, are critical to reducing mosquito populations.
A new online training is now available for the public health workforce that focuses on vector control and pest management, and incorporates the 10 Essential Environmental Public Health Services and the Environmental Public Health Performance Standards developed by CDC’s National Center for Environmental Health (NCEH).

The online learning series Vector Control for Environmental Health Professionals (VCEHP) provides the knowledge and resources necessary to prevent and control vector-borne illnesses spread by insects, rodents, ticks and more. VCEHP provides resources on using an integrated pest management (IPM) approach.

• Credible: It includes the latest science and evidence from vector control experts.
• Practical: It addresses concrete principles, practices and resources for vector control.
• Free and Flexible: Professionals can take the courses they want, when they want.
• Available for Continuing Education Units: The National Environmental Health Association offers optional CEUs.

Pictured: VCEHP includes a subset of courses particularly helpful for understanding and addressing Zika virus and other mosquito-borne diseases. Photo credit: CDC/ Prof. Frank Hadley Collins, Dir., Cntr. for Global Health and Infectious Diseases, Univ. of Notre Dame

• Vector-borne diseases, IPM basics, pesticide toxicology.
• Performance assessment and improvement for vector control programs.
• Biology and control of bedbugs, ticks, rodents, and mosquitoes.
• Vector control and pest management in specific locations like schools, restaurants, and hotels.
• Risk communication.

VCEHP was developed by CDC, the National Network of Public Health Institutes, Liljana Baddour, MPH, is Senior Manager for Workforce and Education Initiatives at the National Network of Public Health Institutes (NNPHI), one of CDC’s core partners for VCEHP. Martin A. Kalis, MA, is a Public Health Advisor with CDC’s Environmental Health Services Branch and is the CDC lead for VCEHP.

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.

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.

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

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

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

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

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

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

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

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.

Jeremy Arieh

Derwin Henderson

Thuy Kim

Meri Phillips

Meri attended Georgia Southern University where she obtained her Master of Public Health with a concentration in Environmental Health Sciences. She began her career in public health as a Florida Epidemic Intelligence Service fellow where she gained hands-on experience in applied epidemiology. Here in Georgia, she has worked at both the state (Georgia Emerging Infections Program) and local levels (Gwinnett, Newton, and Rockdale County Health Departments) as an Epidemiologist. Most recently, she was the lead for Zika response activities in GNR Counties by facilitating testing through the Georgia Public Health Laboratory (GPHL), interviewing positive travel-associated Zika cases and couriering specimens to GPHL. Her experience in infectious disease epidemiology with an emphasis on vector-borne diseases and public health preparedness will be invaluable to her new role at CSTE.

Nikka Sorrells

Prior to CSTE, Nikka worked at the Tennessee Department of Health as a Public Health Educator in the Health Promotion Department. During that time, she worked with community county health councils, subcommittees and workgroups on various county-wide health initiatives, projects and grants, which were primarily focused on Chronic Diseases, Maternal Child Health and Minority Health. In addition, Nikka worked with the Primary Prevention Initiative teams at the local health departments to facilitate trainings for staff and develop SMART objectives. Nikka has valuable experience in project management, meeting facilitation and budget management, and will be an asset to the CSTE team.

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.

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.

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.

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.