Laboratory Criteria for Exclusion and Readmission of Potentially Infectious Persons in Sensitive Settings in the Age of Culture-Independent Diagnostic Tests: Report of a Multidisciplinary Workgroup.

Culture-independent diagnostic tests (CIDTs) are increasingly used for clinical diagnosis of gastrointestinal diseases such as salmonellosis, Shiga toxin-producing E. coli disease, and shigellosis because of their speed, convenience, and generally high-performance characteristics. These tests are also used to screen potentially infectious asymptomatic persons during outbreak investigations in sensitive settings such as childcare, food service, and healthcare. However, only limited performance data are available for CIDTs used on specimens from asymptomatic persons. The Association of Public Health Laboratories (APHL) and Council of State and Territorial Epidemiologists (CSTE) convened a workgroup to examine the available scientific data to inform interim decision-making related to exclusion and readmission criteria for potentially infectious persons in sensitive settings, the risks and benefits of different testing strategies, and to identify knowledge gaps for further research. This is the report on the Workgroup findings.

Ensuring Equitable COVID-19 Vaccine Allocation in New Hampshire: The First Eight Months toward a New Era.

The global coronavirus disease 2019 (COVID-19) pandemic has been exacerbated by social vulnerabilities and racial disparities, resulting in disproportionate morbidity and mortality that require continued attention to strategies that ensure equitable vaccine allocation. The State of New Hampshire (NH) developed a transparent framework to guide COVID-19 vaccine allocation plans, of which one key component was the allocation of 10% of vaccine supply to disproportionately impacted and highly vulnerable populations, predominantly identified through a national vulnerability index. The process, operational approaches, ethical challenges, and unanticipated consequences resulted in many valuable lessons learned. Equitable allocation of this limited and critical pandemic countermeasure required public understanding and engagement, which was achieved through a publicly available framework that was flexible, resourced using public funds, and widely communicated. Broad partnerships were also critical to addressing disparities in the delivery of vaccine. The lessons learned and described here will facilitate more nimble and equitable jurisdictional responses in future public health emergencies.

Readying the Applied Epidemiology Workforce for Emerging Areas of Public Health Practice.

CONTEXT: Epidemiologists are key professionals within the public health workforce. As the role of public health agencies changes over time, epidemiologists will need to adapt and develop new skill sets to work in emerging areas of (public health) practice (EAoPs), which are areas of practice that are new or are growing in interest and use. OBJECTIVE: This mixed-methods research study sought to explore the role and readiness of state health department epidemiologists in the United States to work in EAoPs. DESIGN: Three phases of data collection and analysis were conducted including secondary analysis of the Public Health Workforce Interests and Needs Survey, a survey of the designated state epidemiologist in all 50 states and the District of Columbia, and focus groups with early-, mid-, and senior-career epidemiologists working in state health departments. SETTING: Fifty state health departments and the District of Columbia. PARTICIPANTS: Epidemiologists working in state health departments. MAIN OUTCOME MEASURES: Identification of EAoPs relevant to epidemiologists, the role of epidemiologists in these EAoPs, and readiness of epidemiologists to work in EAoPs. RESULTS: Participant state health department epidemiologists indicated that the studied EAoPs were important to their work and that epidemiologists have some role in them. Key facilitators identified to working in EAoPs included supportive organizational strategy and leadership, dedicated time for training and work, cross-training across programs, and the development of crosscutting skills. CONCLUSIONS: There is much opportunity for epidemiologists to be more engaged in current EAoPs. Not only can epidemiologists supply relevant data but they can also bring skills and expertise to help improve the overall success of population health improvement work. Workforce development strategies should be implemented to ensure a nimble epidemiology workforce that can readily adapt to the needs of future public health practice.

Training Needs and Awareness of Emerging Areas of Public Health Practice Among Epidemiologists Working in State Health Agency Central Offices in the United States, 2017.

CONTEXT: Epidemiologists working in state health agency central offices (SHA-CO) are key professionals working to monitor population health indicators. Assessing training needs to identify gaps is critical to ensuring a competent public health workforce. OBJECTIVE: The objective of this research was to identify training needs of SHA-CO epidemiologists and their awareness of emerging areas of public health practice (EAoP) using data from the 2017 Public Health Workforce Interests and Needs Survey (PH WINS). DESIGN: SHA-CO epidemiologists were surveyed in fall 2017 using a Web-based tool. Balanced repeated replication weights were used to account for complex sample design. Differences in responses by tenure, education level, and supervisory status were assessed using multinomial logistic regression. SETTING: Forty-seven state health agencies. PARTICIPANTS: Permanently employed SHA-CO epidemiologists. MAIN OUTCOME MEASURES: Training needs were identified by classifying skill gaps as those skills that participants self-reported as high relevance to day-to-day work but self-rated as having low proficiency. Awareness of EAoP was self-reported. RESULTS: Systems and strategic thinking and budget and financial management were the areas with the greatest training needs. For most skill domains, fewer participants reported skill gaps with increasing years of public health work experience. Participants with 16 or more years of work experience were less likely to be motivated by most training motivators listed by epidemiologists with 5 or fewer years of experience. The EAoP participants reported greatest awareness of evidence-based public health practice (67%), and the EAoP they reported hearing least about was Health in All Policies (14%). CONCLUSIONS: Stratified analyses by tenure identified important differences in training needs and motivators that employers can use to customize workforce development strategies. SHA-CO epidemiologists reported varying amounts of awareness of EAoP. Specialized training approaches may contribute to improved employee engagement and reduce skill gaps among SHA-CO epidemiologists.

Use of Job Classifications, Career Ladders, and the Applied Epidemiology Competencies to Support Recruitment, Retention, and Practice of State Health Department Epidemiologists.

CONTEXT: State health departments report that recruitment and retention of qualified epidemiologists is a significant challenge to ensuring epidemiology capacity to support essential public health services. OBJECTIVE: To collect information on the use of epidemiology job classifications, career ladders, and professional competencies in state health departments to inform workforce development activities that improve epidemiology capacity. DESIGN: Electronic survey of the designated state epidemiologist. SETTING: Fifty state health departments and the District of Columbia. PARTICIPANTS: State epidemiologists working in state health departments. MAIN OUTCOME MEASURES: Use and perceived benefit of epidemiology job classifications, career ladders, and professional competencies. RESULTS: All 50 states and the District of Columbia responded to the survey. Most state health departments reported having epidemiology-specific job classifications (n = 44, 90%) and career ladders (n = 36, 71%) in place. State epidemiologists strongly agreed or agreed that having an epidemiology-specific classification positively contributed to recruitment (n = 37, 84%) and retention (n = 29, 66%) of epidemiologists in their agency. State epidemiologists strongly agreed or agreed that having an epidemiology-specific career ladder positively contributed to recruitment (n = 24, 69%) and retention (n = 23, 66%) of epidemiologists in their agency. Only 10 (29%) state epidemiologists reported using the applied epidemiology competencies to develop or revise their jurisdiction's epidemiology career ladder. CONCLUSIONS: State health departments should implement well-maintained epidemiology-specific job classifications and career ladders that are based on current epidemiology competencies. Career ladders should be supported with opportunities for competency-based training to support career progression.

A review of the applied epidemiology workforce in the United States: past, present, and future.

Applied epidemiologists are key professionals within the public health workforce, fulfilling core public health science functions. The public health system in the United States has been rapidly transforming over the last decade and epidemiologists will need to develop new skill sets to be successful in the future of public health. A review of the literature was undertaken to gain a comprehensive understanding of the past and present of the applied epidemiology workforce to inform future workforce initiatives aimed at improving applied epidemiology practice. The literature search identified 48 articles related to applied epidemiologists working in the United States at the federal, state, and local levels. These articles described efforts to build, enumerate, and assess the competency of the applied epidemiology workforce in addition to putting forward opinions about it. Overall, the articles demonstrated significant prior work enumerating the applied epidemiology workforce, some prior work identifying epidemiology training needs, and few prior studies assessing competency. The functions, skill sets, and training needs of epidemiologists have changed over time and the literature provides a number of recommendations for future training. Continued assessment of the workforce literature is recommended to monitor training needs and competency for use in implementing effective workforce development activities.

Assessment of Epidemiology Capacity in State Health Departments - United States, 2017.

In 2017, the Council of State and Territorial Epidemiologists performed its sixth periodic Epidemiology Capacity Assessment, a national assessment that evaluates trends in workforce size, funding, and epidemiology capacity among state health departments. A standardized web-based questionnaire was sent to the state epidemiologist in the 50 states, the District of Columbia (DC), and the U.S. territories and the Federated States of Micronesia inquiring about the number of current and optimal epidemiologist positions; sources of epidemiology activity and personnel funding; and each department's self-perceived capacity to lead activities, provide subject matter expertise, and obtain and manage resources for the four Essential Public Health Services (EPHS)* most closely linked to epidemiology. From 2013 to 2017, the number of state health department epidemiologists† increased 22%, from 2,752 to 3,369, the greatest number of workers since the first full Epidemiology Capacity Assessment enumeration in 2004. The federal government provided most (77%) of the funding for epidemiologic activities and personnel. Substantial to full capacity (50%-100%) was highest for investigating health problems (92% of health departments) and monitoring health status (84%), whereas capacity for evaluating effectiveness (39%) and applied research (29%) was considerably lower. An estimated additional 1,200 epidemiologists are needed to reach full capacity to conduct the four EPHS. Additional resources might be needed to ensure that state health department epidemiologists possess the specialized skills to deliver EPHS, particularly in evaluation and applied epidemiologic research.

Large Outbreak of Hepatitis C Virus Associated With Drug Diversion by a Healthcare Technician.

Background: In May 2012, the New Hampshire (NH) Division of Public Health Services (DPHS) was notified of 4 persons with newly diagnosed hepatitis C virus (HCV) infection at hospital X. Initial investigation suggested a common link to the hospital cardiac catheterization laboratory (CCL) because the infected persons included 3 CCL patients and a CCL technician. NH DPHS initiated an investigation to determine the source and control the outbreak. Methods: NH DPHS conducted site visits, case patient and employee interviews, medical record and medication use review, and employee and patient HCV testing using enzyme immunoassay for anti-HCV, reverse-transcription polymerase chain reaction for HCV RNA, nonstructural 5B (NS5B) and hypervariable region 1 (HVR1) sequencing, and quasispecies analysis. Results: HCV HVR1 analysis of the first 4 cases confirmed a common source of infection. HCV testing identified 32 of 1074 CCL patients infected with the outbreak strain, including 3 patients coinfected with >1 HCV strain. The epidemiologic investigation revealed evidence of drug diversion by the HCV-infected technician, evidenced by gaps in controlled medication control, higher fentanyl use during procedures for confirmed cases, and building card key access records documenting the presence of the technician during days when transmission occurred. The employee's status as a traveling technician led to a multistate investigation, which identified additional cases at prior employment sites. Conclusions: This is the largest laboratory-confirmed drug diversion-associated HCV outbreak published to date. Recommendations to reduce drug diversion risk and to conduct outbreak investigations are provided.

Per- and polyfluoroalkyl substance (PFAS) exposure assessment in a community exposed to contaminated drinking water, New Hampshire, 2015.

BACKGROUND: Per- and polyfluoroalkyl substances (PFAS) are synthetic chemicals used in manufacturing that resist environmental degradation, can leach into drinking water, and bioaccumulate in tissues. Some studies have shown associations with negative health outcomes. In May 2014, a New Hampshire public drinking water supply was found to be contaminated with PFAS from a former U.S. Air Force base. OBJECTIVES: We established a serum testing program to assess PFAS exposure in the affected community. METHODS: Serum samples and demographic and exposure information were collected from consenting eligible participants. Samples were tested for PFAS at three analytical laboratories. Geometric means and 95% confidence intervals were calculated and analyzed by age and exposure variables. RESULTS: A total of 1578 individuals provided samples for PFAS testing; >94% were found to have perfluorooctane sulfonic acid (PFOS), perfluorooctanoic acid (PFOA), and perfluorohexane sulfonic acid (PFHxS) detectable in serum. Geometric mean serum concentrations of PFOS, PFOA, and PFHxS were 8.6 µg/L (95% CI:8.3-8.9), 3.1 µg/L (95% CI: 3.0-3.2), and 4.1 µg/L (95% CI: 3.9-4.3), respectively, which were statistically higher than the general U.S. POPULATION: Significant associations were observed between PFAS serum concentrations and age, time spent in the affected community, childcare attendance, and water consumption. CONCLUSIONS: PFOS, PFOA, and PFHxS were found in significantly higher levels in the affected population, consistent with PFAS drinking water contamination. Given increased recognition of PFAS contamination in the U.S, a coordinated national response is needed to improve access to biomonitoring and understand health impacts.

Use of Emergency Department Data to Monitor and Respond to an Increase in Opioid Overdoses in New Hampshire, 2011-2015.

OBJECTIVES: Opioid-related overdoses and deaths in New Hampshire have increased substantially in recent years, similar to increases observed across the United States. We queried emergency department (ED) data in New Hampshire to monitor opioid-related ED encounters as part of the public health response to this health problem. METHODS: We obtained data on opioid-related ED encounters for the period January 1, 2011, through December 31, 2015, from New Hampshire's syndromic surveillance ED data system by querying for (1) chief complaint text related to the words "fentanyl," "heroin," "opiate," and "opioid" and (2) opioid-related International Classification of Diseases ( ICD) codes. We then analyzed the data to calculate frequencies of opioid-related ED encounters by age, sex, residence, chief complaint text values, and ICD codes. RESULTS: Opioid-related ED encounters increased by 70% during the study period, from 3300 in 2011 to 5603 in 2015; the largest increases occurred in adults aged 18-29 and in males. Of 20 994 total opioid-related ED visits, we identified 18 554 (88%) using ICD code alone, 690 (3%) using chief complaint text alone, and 1750 (8%) using both chief complaint text and ICD code. For those encounters identified by ICD code only, the corresponding chief complaint text included varied and nonspecific words, with the most common being "pain" (n = 3335, 18%), "overdose" (n = 1555, 8%), "suicidal" (n = 816, 4%), "drug" (n = 803, 4%), and "detox" (n = 750, 4%). Heroin-specific encounters increased by 827%, from 4% of opioid-related encounters in 2011 to 24% of encounters in 2015. CONCLUSIONS: Opioid-related ED encounters in New Hampshire increased substantially from 2011 to 2015. Data from New Hampshire's ED syndromic surveillance system provided timely situational awareness to public health partners to support the overall response to the opioid epidemic.

Candida Interface Infections After Descemet Stripping Automated Endothelial Keratoplasty.

PURPOSE: To describe 2 Candida interface keratitis infections occurring in the setting of positive donor rim cultures from precut corneal tissue used for Descemet stripping automated endothelial keratoplasty (DSAEK) and the ensuing public health investigation. METHODS: Following 2 clinical Candida interface keratitis infections, patients from 2012 to 2014 in the same surgical center were evaluated for bacterial and fungal rim cultures and subsequent infection. All cases of fungal infections occurring post-DSAEK were analyzed. Data included patient demographics, surgical technique, donor rim cultures, donor mate outcomes, clinical courses, and outcomes. A review of the relevant literature was also undertaken. RESULTS: From 2012 to 2014, among 99 DSAEK procedures performed, 7 (7.1%) donor rim cultures were positive for fungi. Use of this tissue with positive donor rim cultures resulted in 2 (28.6%) episodes of confirmed fungal interface keratitis, both Candida species, and presumptive treatment in an additional 2 patients. An investigation did not identify any breach in sterile technique or procedures by the surgeon or surgery center. Our literature review identified 15 reports of postoperative fungal infection associated with DSAEK, of which 11 involved Candida spp. CONCLUSIONS: While postoperative infection remains rare, our 2 additional cases along with those previously reported suggest that DSAEK may be susceptible to infection with Candida spp. Furthermore, this report of correlated rim cultures and clinical infection suggests a need for reevaluation of the utility of obtaining routine corneoscleral donor rim fungal culture.

Workplace Safety Concerns among Co-workers of Responder Returning from Ebola-Affected Country.

We surveyed public health co-workers regarding attitudes toward a physician who returned to New Hampshire after volunteering in the West African Ebola outbreak. An unexpectedly large (18.0%) proportion of staff expressed discomfort with the Ebola responder returning to work. Employers should take proactive steps to address employee fears and concerns.

Use of Digital Pens for Rapid Epidemiologic Data Collection During a Foodborne Outbreak Investigation.

OBJECTIVE: Public health investigations require rapid assessment, response, and initiation of control measures. In 2012, the New Hampshire Department of Health and Human Services used digital pens to rapidly acquire epidemiologic data during a gastrointestinal illness outbreak. METHODS: Menus were obtained and a standard questionnaire was administered to exposed persons using digital pens. Questionnaire data were downloaded into an electronic file for analysis. RESULTS: Sixty-nine (74%) of 93 exposed persons completed a questionnaire. Of 6389 data entries made on digital paper, 218 (3%) required correction; of these, 201 (92%) involved a free-form variable and 17 (8%) involved a check-box variable. Digital pens saved an estimated 5 to 6 hours of data-entry time. CONCLUSIONS: This outbreak provided an opportunity to assess the value of digital pens for decreasing data-entry burden and allowing more timely data analysis in an emergent setting. Depending on the size of the outbreak and complexity of the survey, there is likely a threshold when use of digital pens would provide a clear benefit to outbreak response. As new technology becomes available for use in emergency preparedness settings, public health agencies must continuously review and update response plans and evaluate investigation tools to ensure timely disease control and response activities.

Human outbreak of Salmonella Typhimurium associated with exposure to locally made chicken jerky pet treats, New Hampshire, 2013.

Pet treats and pet food can be contaminated with Salmonella and other pathogens, though they are infrequently implicated as the source of human outbreaks. In 2013, the New Hampshire Department of Health and Human Services investigated a cluster of Salmonella Typhimurium infections associated with contaminated locally made pet treats. Case-patients were interviewed with standardized questionnaires to assess food, animal, and social histories. Laboratory and environmental investigations were conducted, including testing of clinical specimens, implicated product, and environmental swabs. Between June and October 2013, a total of 43 ill persons were identified. Sixteen patients (37%) were hospitalized. Among 43 case-patients interviewed, the proportion exposed to dogs (95%) and pet treats (69%) in the 7 days prior to illness was statistically higher than among participants in a U.S. population-based telephone survey (61%, p<0.0001 and 16%, p<0.0001, respectively). On further interview, 38 (88%) reported exposure to Brand X Chicken Jerky, the maker of Brand X chicken jerky, or the facility in which it was made. Product testing isolated the outbreak strain from four of four Brand X Chicken Jerky samples, including an unopened package purchased at retail, opened packages collected from patient households, and unpackaged jerky obtained from the jerky maker. A site visit revealed inadequate processing of the chicken jerky, bare-hand contact with the finished product prior to packaging, and use of vacuum-sealed packaging, which may have enabled facultative anaerobic bacteria to proliferate. Seven (78%) of nine environmental swabs taken during the site visit also yielded the outbreak strain. Brand X Chicken Jerky was voluntarily recalled on September 9, 2013. Consumers should be made aware of the potential for locally made products to be exempt from regulation and for animals and animal food to carry pathogens that cause human illness, and be educated to perform hand hygiene after handling pet food or treats.

Notes from the field: update on Lyme carditis, groups at high risk, and frequency of associated sudden cardiac death--United States.

On December 13, 2013, MMWR published a report describing three cases of sudden cardiac death associated with Lyme carditis. State public health departments and CDC conducted a follow-up investigation to determine 1) whether carditis was disproportionately common among certain demographic groups of patients diagnosed with Lyme disease, 2) the frequency of death among patients diagnosed with Lyme disease and Lyme carditis, and 3) whether any additional deaths potentially attributable to Lyme carditis could be identified. Lyme disease cases are reported to CDC through the Nationally Notifiable Disease Surveillance System; reporting of clinical features, including Lyme carditis, is optional. For surveillance purposes, Lyme carditis is defined as acute second-degree or third-degree atrioventricular conduction block accompanying a diagnosis of Lyme disease. During 2001-2010, a total of 256,373 Lyme disease case reports were submitted to CDC, of which 174,385 (68%) included clinical information. Among these, 1,876 (1.1%) were identified as cases of Lyme carditis. Median age of patients with Lyme carditis was 43 years (range = 1-99 years); 1,209 (65%) of the patients were male, which is disproportionately larger than the male proportion among patients with other clinical manifestations (p<0.001). Of cases with this information available, 69% were diagnosed during the months of June-August, and 42% patients had an accompanying erythema migrans, a characteristic rash. Relative to patients aged 55-59 years, carditis was more common among men aged 20-39 years, women aged 25-29 years, and persons aged ≥75 years.

Evaluation of a multitarget real-time PCR assay for detection of Bordetella species during a pertussis outbreak in New Hampshire in 2011.

A multitarget real-time PCR assay with three targets, including insertion sequence 481 (IS481), IS1001, and an IS1001-like element, as well as pertussis toxin subunit S1 (ptxS1), for the detection of Bordetella species was evaluated during a pertussis outbreak. The sensitivity and specificity were 77 and 88% (PCR) and 66 and 100% (culture), respectively. All patients with an IS481 C(T) of <30 also tested positive by ptxS1 assay and were clinical pertussis cases. No patients with IS481 C(T) values of ≥40 tested positive by culture. Therefore, we recommend that culture be performed only for specimens with IS481 C(T) values of 30 ≤ CT <40.

Decrease in varicella incidence after implementation of the 2-dose recommendation for varicella vaccine in New Hampshire.

Varicella is a common infectious disease, for which 2-dose vaccination was recommended in 2006. Varicella case and vaccination data in New Hampshire were analyzed to assess impact of this recommendation on disease incidence and clinical characteristics. Varicella incidence decreased after the 2-dose recommendation, with greatest reductions in ages 5-19 years. Continued vaccination efforts should further reduce disease.

Detection of 2009 pandemic influenza A(H1N1) virus Infection in different age groups by using rapid influenza diagnostic tests.

BACKGROUND: The performance of rapid influenza diagnostic tests (RIDTs) in detecting influenza A(H1N1) 2009 has varied widely. Evaluations of RIDTs among infected individuals across all age groups have not been described in depth. OBJECTIVES: Determine RIDT clinical sensitivity in comparison with influenza detection using real-time RT-PCR among patients infected with influenza A(H1N1) 2009 across all age groups. STUDY DESIGN: This study analyzed respiratory specimens received by the New Hampshire Public Health Laboratories (NHPHL) from September 1, 2009, through December 31, 2009. RIDT performance was evaluated among different age groups of patients determined to be infected with influenza A (H1N1) 2009, and the association between age and RIDT sensitivity was determined. RESULTS: Of 1373 specimens examined, 269 tested positive for influenza A(H1N1) 2009 by real-time RT-PCR (rRT-PCR) and had RIDT results available. Overall clinical sensitivity and specificity of RIDTs were 53·9 and 98·5%, respectively. By age group, clinical sensitivity was 85·7% in patients <2 years old, 60·3% in patients between 2- and 39 years old, and 33·3% in patients aged 40 and older. Logistic regression analysis indicated that increasing age was negatively associated with RIDT performance. CONCLUSION: Rapid influenza diagnostic test sensitivity decreased significantly with increasing age. Findings from this study may impact a clinician's interpretation of RIDT test results and ultimately have implications in clinical decision-making.