Council of State and Territorial Epidemiologists

Atlanta, GA, United States

Council of State and Territorial Epidemiologists

Atlanta, GA, United States

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News Article | April 19, 2017
Site: www.scientificamerican.com

A bizarre medical mystery can be added to the list of growing concerns about opioid use in the U.S. Since 2012 more than a dozen illicit drug users have shown up in hospitals across eastern Massachusetts with inexplicable amnesia. In some cases the patients’ memory difficulties had persisted for more than a year. Yet this bewildering condition does not appear to be the result of a simple case of tainted goods: The drug users do not appear to have used the same batch of drugs—or even the same type of substance. To get some answers, the state’s public health officials are rolling out a new requirement that clinicians who come across any patients (not just opioid users) with these types of memory deficits—along with damage to the hippocampus—must report the cases to the state. On April 3 state public health officials received the legal green light from the Massachusetts public health commissioner to make this a required, reportable condition. This technical change, which will last for one year, authorizes public health workers to collect this information and reassures clinicians that they can—and must—share case reports. In the next couple of days workers will notify emergency room personnel as well as addiction counselors and neurology specialists about the new designation via e-mail. The new reporting requirement, state officials hope, will help epidemiologists learn how widespread the issue of potential opioid-linked amnesia may be and whether patients have specific factors in common. The change was first reported by BuzzFeed News. Massachusetts officials first documented this string of amnesia cases in the U.S. Centers for Disease Control’s Morbidity and Mortality Weekly Report (MMWR) back in January. “No clear etiology exists, but at time of initial evaluation, 13 of 14 [patients] tested positive for opioids or had opioid use recorded in their medical history,” medical workers tracking this issue wrote. Most of the patients tested positive for one or more drugs including opiates, benzodiazepine, marijuana, PCP or other substances. Although extremely rare, the amnesia–drug link is also not completely unprecedented. In the past there have been several documented cases where similar amnesia was detected among cocaine users. In 2013 there was also one case reported in France where the same kind of memory loss was associated with heroin inhalation. To better understand the recent wave of cases, Scientific American spoke with state epidemiologist Alfred DeMaria, medical director of the Massachusetts Department of Public Health’s infectious disease bureau. [An edited transcript of the interview follows.] What a puzzling situation. Can you walk us through how these patients present? Basically, it’s one of two ways: They wake up in the hospital after an acute medical condition—usually an overdose or toxicity from drugs—with an unusual degree of confusion and rockiness. The other way a patient gets medical attention, is, say, the patient’s family saw him on Friday when he seemed fine and then when they talk to him on Sunday morning he doesn’t remember seeing them on Friday or what happened the day before, and this short-term amnesia leads him to get medical attention. With both cases, the patient may have no memory of what has gone on in the previous 48 hours. So this memory loss is limited to recent events? Usually it’s relatively short term, yes, and the issue, according to their MRIs, seems to be damage to the hippocampus—an area of the brain that usually helps process information into memories. These patients don’t really have problems with long-term memory. For example, as a neurologist involved in these cases described it: They can drive to work because they have been driving to work for 20 years, so they have no trouble doing that. But if they have to go someplace new and they are given directions, just simple directions, they get in the car and can’t remember what they were just told. So the issue is also processing new memories. Your case descriptions mentioned that for a couple of these patients their memory impairment lasted a year or more. Yes. Their memory gets better and everything is relative to the amount of damage to the hippocampus, presumably. But that’s the kind of deficit they have. What do you think is the likely cause of the amnesia? Substance abuse is not a simple thing. People who are using substances very rarely use just one. So that can complicate trying to understand causality. We don’t know if people who have a history of opiate drug use were using other drugs, too. Do you have a working hypothesis about what’s going on? There is some evidence that pharmaceutical versions of fentanyl can have an effect on the hippocampus—so I think our favorite hypothesis is that, with all of the synthetic fentanyl out there, it is a contamination of that drug or some fentanyl-like chemicals that could be causing this effect. There is no standardization in an illicit synthetic fentanyl lab, so who knows what is in there or even what kind of fentanyl it is. Really, this is just a hypothesis, though. There are some reports that methamphetamine can also do similar things to the hippocampus, so we wouldn’t want to write that off either. Since your original report of these 14 cases in the MMWR in January have you heard about additional cases in Massachusetts? No, it’s really interesting. The MMWR got a lot of attention, especially in Massachusetts, but we had no extra cases reported, which surprised us. We thought with all of this attention, we would see another wave of reports. If no more cases appear, how would you explain what happened? Maybe we can’t. If we don’t see any more cases, then maybe this was just a transient contamination. That would be good from a public health and medical standpoint, but it won’t let us know what’s going on. Regarding your fentanyl theory, isn’t diagnosing fentanyl use difficult because it’s not typically tested for in the emergency room? We are hoping that in the case of amnesia reports, clinicians will have access to expanded toxicological screens and coverage for them because then more extensive tests would be medically indicated. Routinely, such expanded testing studies are not done—even on overdose deaths related to drugs like fentanyl—so we are hoping that now clinicians will call us and say, “I saw this patient last night and she or he is in the hospital now and the MRI shows this hippocampal ischemia pattern. So what do you want us to do?” Then, we are going to collect some information but also say we would like you to try to get this expanded toxicology screen and an MRI to look at the hippocampus. How are the MRIs of these patients unique? It is a bilaterally symmetric effect on the hippocampus. It’s not really vascular—it’s not a stroke where you get a clot or a bleed and then there’s no blood supply. It looks more like a toxic effect that affects the metabolism of the hippocampus. Some of these patients overdosed and had low flow [of oxygen] to the brain during their overdose, and we have gotten a lot of advice and criticism saying this is just an overdose and there’s nothing new here. But our response is if it’s just an overdose, why is the damage almost exclusively limited to the hippocampus? What could be the biological mechanism at work here? There are two things I think of in terms of this outbreak: One is an outbreak related to shellfish poisoning a number of years ago. That was with something called domoic acid that actually causes amnesia not all that dissimilar to this, but more severe. In fact, a lot of people have contacted us and asked if we had thought about domoic acid. There’s no reason to think people were exposed to it here, though. I’m suspecting what’s similar here is that it’s a toxin that hones in on the hippocampus. Back in the 1980s we saw a similar amnesia situation, only then it was a contamination of drugs out in California. Someone was manufacturing a drug that was an analogue of the opioid meperidine and made a mistake in manufacturing that produced a similar chemical, a product called MPTP, that caused Parkinson’s disease–like symptoms. I keep thinking, might the recent amnesia cases be something like these two? Is this recent phenomenon being seen outside Massachusetts? We have heard from some clinicians in Oregon who think they have seen multiple cases like this, and from what they describe it seems like they may have. Are there any plans for the Council of State and Territorial Epidemiologists to declare this a reportable condition nationwide? No. Is it likely there is something else at work here—perhaps several factors working together, including genetics, that make for a toxic stew? Absolutely. I don’t know the causes so I’m not going to hone in on one thing to the exclusion of anything else. It’s likely a combination of factors. That’s why even if there is something out there that’s toxic, maybe only some people are susceptible to its effects. Maybe many people are exposed but only a few are vulnerable.


Fiore A.E.,Centers for Disease Control and Prevention | Epperson S.,Centers for Disease Control and Prevention | Perrotta D.,Council of State and Territorial Epidemiologists | Perrotta D.,Texas A&M University | And 2 more authors.
Pediatrics | Year: 2012

BACKGROUND: Despite long-standing recommendations to vaccinate children who have underlying chronic medical conditions or who are contacts of high-risk persons, vaccination coverage among school-age children remains low. Community studies have indicated that school-age children have the highest incidence of influenza and are an important source of amplifying and sustaining community transmission that affects all age groups. METHODS: A consultation to discuss the advantages and disadvantages of a universal recommendation for annual influenza vaccination of all children age ≥6 months was held in Atlanta, Georgia, in September 2007. Consultants provided summaries of current data on vaccine effectiveness, safety, supply, successful program implementation, and economics studies and discussed challenges associated with continuing a risk- and contact-based vaccination strategy compared with a universal vaccination recommendation. RESULTS: Consultants noted that school-age children had a substantial illness burden caused by influenza, that vaccine was safe and effective for children aged 6 months through 18 years, and that evidence suggested that vaccinating school-age children would provide benefits to both the vaccinated children and their unvaccinated household and community contacts. However, implementation of an annual recommendation for all school-age children would pose major challenges to parents, medical providers and health care systems. Alternative vaccination venues were needed, and of these school-located vaccination programs might offer the most promise as an alternative vaccination site for school-age children. CONCLUSIONS: Expansion of recommendations to include all school-age children will require additional development of an infrastructure to support implementation and methods to adequately evaluate impact. Copyright © 2012 by the American Academy of Pediatrics.


Dick V.R.,Council of State and Territorial Epidemiologists | Masters A.E.,Council of State and Territorial Epidemiologists | McConnon P.J.,Council of State and Territorial Epidemiologists | Engel J.P.,Council of State and Territorial Epidemiologists | And 2 more authors.
American Journal of Preventive Medicine | Year: 2014

Results More than half the alumni (67%) indicated the fellowship was essential to their long-term career. In addition, 79% of the mentors indicated that participating in the fellowship had a positive impact on their career. Mentors also indicated significant impacts on host site capacity. A majority (88%) of alumni had worked for at least 1 year or more in government public health environments after the fellowship.Conclusions Evaluation findings support previous research indicating need for competency-based field-based training programs that include a strong mentoring component. These characteristics in a field-based training program can increase applied epidemiology capacity in various ways.Background The Council of State and Territorial Epidemiologists (CSTE) implemented the Applied Epidemiology Fellowship (AEF) in 2003 to train public health professionals in applied epidemiology and strengthen applied epidemiology capacity within public health institutions to address the identified challenges. The CSTE recently evaluated the outcomes of the fellowship across the last 9 years. .Purpose To review the findings from the outcome evaluation of the first nine classes of AEF alumni with particular attention to how the fellowship affected alumni careers, mentors' careers, host site agency capacity, and competencies of the applied epidemiology workforce.Methods The mixed-methods evaluation used surveys and administrative data. Administrative data were gathered over the past 9 years and the surveys were collected in late 2013 and early 2014. Descriptive statistics and qualitative thematic analysis were conducted in early 2014 to examine the data from more than 130 alumni and 150 mentors. © 2014 American Journal of Preventive Medicine.


Rosenberg L.,Council of State and Territorial Epidemiologists | Kubota K.,Association of Public Health Laboratories
Foodborne Pathogens and Disease | Year: 2013

Over 1,100 foodborne disease outbreaks cause over 23,000 illnesses in the United States annually, but the rates of outbreaks reported and successful investigation vary dramatically among states. We used data from the Centers for Disease Control and Prevention's outbreak reporting database, Association of Public Health Laboratories' PulseNet laboratory subtyping network survey and Salmonella laboratory survey, national public health surveillance data, and national surveys to examine potential causes of this variability. The mean rate of reporting of Salmonella outbreaks was higher in states requiring submission of all isolates to the state public health laboratory, compared to those that do not (5.9 vs. 4.1 per 10 million population, p=0.0062). Rates of overall outbreak reporting or successful identification of an etiology or food vehicle did not correlate at the state level with population, rates of sporadic disease reporting, health department organizational structure, or self-reported laboratory or epidemiologic capacity. Foodborne disease outbreak surveillance systems are complex, and improving them will require a multi-faceted approach to identifying and overcoming barriers. © Mary Ann Liebert, Inc.


Sugerman D.E.,Epidemic Intelligence Service | Barskey A.E.,Centers for Disease Control and Prevention | Delea M.G.,Council of State and Territorial Epidemiologists | Ortega-Sanchez I.R.,Centers for Disease Control and Prevention | And 5 more authors.
Pediatrics | Year: 2010

OBJECTIVE: In January 2008, an intentionally unvaccinated 7-year-old boy who was unknowingly infected with measles returned from Switzerland, resulting in the largest outbreak in San Diego, California, since 1991. We investigated the outbreak with the objective of understanding the effect of intentional undervaccination on measles transmission and its potential threat to measles elimination. METHODS: We mapped vaccination-refusal rates according to school and school district, analyzed measles-transmission patterns, used discussion groups and network surveys to examine beliefs of parents who decline vaccination, and evaluated containment costs. RESULTS: The importation resulted in 839 exposed persons, 11 additional cases (all in unvaccinated children), andthe hospitalization of an infant too young to be vaccinated. Two-dose vaccination coverage of 95%, absence of vaccine failure, and a vigorous outbreak response halted spread beyond the third generation, at a net public-sector cost of $10 376 per case. Although 75% of the cases were of persons who were intentionally unvaccinated, 48 children too young to be vaccinated were quarantined, at an average family cost of $775 per child. Substantial rates of intentional undervaccination occurred in public charter and private schools, as well as public schools in upper-soeioeconomic areas. Vaccine refusal clustered geographically and the overall rate seemed to be rising. In discussion groups and survey responses, the majority of parents who declined vaccination for their children were concerned with vaccine adverse events. CONCLUSIONS: Despite high community vaccination coverage, measles outbreaks can occur among clusters of intentionally undervaccinated children, at major cost to public health agencies, medical systems, and families. Rising rates of intentional undervaccination can undermine measles elimination.


Stricof R.,Council of State and Territorial Epidemiologists | Stricof R.,New York State Department of Health
Clinical Governance | Year: 2012

Purpose: This paper aims to describe experience to date with mandatory public reporting of healthcare-associated infection rates from a perspective inside one of the first and most advanced of the state programs, to help frame the research agenda of an interdisciplinary university faculty collaborative. Design/ methodology/ approach: The paper is a narrative review of personal experience. Findings: Key factors enabling program achievements include starting with a sufficient pilot phase, including strong provisions for audit and validation, a balance of viewpoints among advisors to the program, adoption of internationally respected data systems, and ability to sponsor improvement projects in reporting hospitals. Identified pitfalls and needs for more progress also must be addressed. Practical implications: Public health departments are in uncharted territory with this new area of activity, faced with fundamental knowledge gaps that potentially hamper chances of success. Perspectives explored in this part of the Universities Council Symposium help frame a research agenda and guide evolution of less advanced programs. Originality/value: This review helps frame the research agenda of an interdisciplinary university faculty collaborative and guides evolution of less advanced programs. © 2012 Emerald Group Publishing Limited.


Haley V.B.,New York State Department of Health | DiRienzo A.G.,Albany State University | Lutterloh E.C.,New York State Department of Health | Lutterloh E.C.,Albany State University | Stricof R.L.,Council of State and Territorial Epidemiologists
Infection Control and Hospital Epidemiology | Year: 2014

objective. To assess the effect of multiple sources of bias on state- and hospital-specific National Healthcare Safety Network (NHSN) laboratory-identified Clostridium difficile infection (CDI) rates. design. Sensitivity analysis. setting. A total of 124 New York hospitals in 2010. methods. New York NHSN CDI events from audited hospitals were matched to New York hospital discharge billing records to obtain additional information on patient age, length of stay, and previous hospital discharges. "Corrected" hospital-onset (HO) CDI rates were calculated after (1) correcting inaccurate case reporting found during audits, (2) incorporating knowledge of laboratory results from outside hospitals, (3) excluding days when patients were not at risk from the denominator of the rates, and (4) adjusting for patient age. Data sets were simulated with each of these sources of bias reintroduced individually and combined. The simulated rates were compared with the corrected rates. Performance (ie, better, worse, or average compared with the state average) was categorized, and misclassification compared with the corrected data set was measured. results. Counting days patients were not at risk in the denominator reduced the stateHOrate by 45% and resulted in 8%misclassification. Age adjustment and reporting errors also shifted rates (7% and 6% misclassification, respectively). conclusions. Changing the NHSN protocol to require reporting of age-stratified patient-days and adjusting for patient-days at risk would improve comparability of rates across hospitals. Further research is needed to validate the risk-adjustment model before these data should be used as hospital performance measures. © 2013 by The Society for Healthcare Epidemiology of America. All rights reserved.


Boulton M.L.,University of Michigan | Hadler J.,Council of State and Territorial Epidemiologists | Beck A.J.,University of Michigan | Ferland L.,Council of State and Territorial Epidemiologists | Lichtveld M.,Tulane University
Public Health Reports | Year: 2011

Objectives. To assess the number of epidemiologists and epidemiology capacity nationally, the Council of State and Territorial Epidemiologists surveyed state health departments in 2004, 2006, and 2009. This article summarizes findings of the 2009 assessment and analyzes five-year (2004-2009) trends in the epidemiology workforce. Methods. Online surveys collected information from all 50 states and the District of Columbia about the number of epidemiologists employed, their training and education, program and technologic capacity, organizational structure, and funding sources. State epidemiologists were the key informants; 1,544 epidemiologists provided individual-level information. Results. The number of epidemiologists in state health departments decreased approximately 12% from 2004 to 2009. Two-thirds or more states reported less than substantial (<50% of optimum) surveillance and epidemiology capacity in five of nine program areas. Capacity has diminished since 2006 for three of four epidemiology-related Essential Services of Public Health (ESPHs). Fewer than half of all states reported using surveillance technologies such as Web-based provider reporting systems. State health departments need 68% more epidemiologists to reach optimal capacity in all program areas; smaller states (<5 million population) have higher epidemiologist-to-population ratios than more populous states. Conclusions. Epidemiology capacity in state health departments is suboptimal and has decreased, as assessed by states' ability to carry out the ESPHs, by their ability to use newer surveillance technologies, and by the number of epidemiologists employed. Federal emergency preparedness funding, which supported more than 20% of state-based epidemiologists in 2006, has decreased. The 2009 Epidemiology Capacity Assessment demonstrates the negative impact of this decrease on states' epidemiology capacity. ©2011 Association of Schools of Public Health.


Beck A.J.,University of Michigan | Boulton M.L.,University of Michigan | Lemmings J.,Council of State and Territorial Epidemiologists | Clayton J.L.,University of Michigan
American Journal of Preventive Medicine | Year: 2012

With nearly one quarter of the combined governmental public health workforce eligible for retirement within the next few years, recruitment and retention of workers is a growing concern. Epidemiology has been identified as a potential workforce shortage area in state health departments. Understanding strategies for recruiting and retaining epidemiologists may help health departments stabilize their epidemiology workforce. The Council of State and Territorial Epidemiologists conducted a survey, the Epidemiology Capacity Assessment (ECA), of state health departments to identify recruitment and retention factors. The ECA was distributed to 50 states, the District of Columbia (DC), and four U.S. territories in 2009. The 50 states and DC are included in this analysis. The State Epidemiologist completed the organizational-level assessment; health department epidemiologists completed an individual-level assessment. Data were analyzed in 2010. All states responded to the ECA, as did 1544 epidemiologists. Seventeen percent of epidemiologists reported intent to retire or change careers in the next 5 years. Ninety percent of states and DC identified state and local government websites, schools of public health, and professional organizations as the most useful recruitment tools. Top recruitment barriers included salary scale, hiring freezes, and ability to offer competitive pay; lack of promotion opportunities and merit raise restrictions were main retention barriers. Although the proportion of state health department epidemiologists intending to retire or change careers during the next 5 years is lower than the estimate for the total state public health workforce, important recruitment and retention barriers for the employees exist.


Pittman J.,Council of State and Territorial Epidemiologists
Journal of Public Health Management and Practice | Year: 2016

CONTEXT:: Communication in the form of written and oral reports and presentations is a core competency for epidemiologists at governmental public health agencies. Many applied epidemiologists do not publish peer-reviewed articles, limiting the scientific literature of best practices in evidence-based public health. OBJECTIVES:: To describe the writing and publishing experiences of applied epidemiologists and identify barriers and facilitators to publishing. DESIGN:: Telephone focus groups and an 18-question multiple-choice and short-answer Web-based assessment were fielded in 2014. SETTING AND PARTICIPANTS:: Six focus groups composed of 26 applied epidemiologists and an online assessment answered by 396 applied epidemiologists. Sample selection was stratified by years of experience. MAIN OUTCOME MEASURES:: Past publishing experience, current job duties as related to publishing, barriers and facilitators to writing and publishing, and desired training in writing and publishing were assessed through focus groups and the online assessment. RESULTS:: Focus groups identified 4 themes: job expectations, barriers to publishing, organizational culture, and the understanding of public health practice among reviewers as issues related to writing and publishing. Most respondents (80%) expressed a desire to publish; however, only 59% had published in a peer-reviewed journal. An academic appointment (among doctoral educated respondents) was identified as a facilitator to publishing as was access to peer-reviewed literature. Time (68%) was identified as the greatest barrier to writing and publishing. Other major barriers included lack of encouragement or support (33%) within the public health agency and agency clearance processes (32%). Assistance with journal selection (62%), technical writing skills (60%), and manuscript formatting (57%) were listed as the most needed trainings. CONCLUSION:: Public health agencies can be facilitators for epidemiologists to contribute to the scientific literature through increasing access to the peer-reviewed literature, creating a supportive environment for writing and publishing, and investing in desired and needed training. The results have implications for modifying workplace policies surrounding writing and publishing. Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.

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