Enhancing Epidemiology Capacity During the 2014-15 West Africa Ebola Outbreak: An Assessment of the Role of Applied Public Health Epidemiologists.

CONTEXT: In late 2014, the Centers for Disease Control and Prevention requested the support of the Council of State and Territorial Epidemiologists to enhance epidemiologic capacity in the West African countries impacted or threatened by an outbreak of Ebola virus disease. In response, the Council of State and Territorial Epidemiologists recruited 36 senior epidemiologists who, collectively, made 45 deployments to West Africa, averaging 42 days each. OBJECTIVE: To assess the self-reported experiences and contributions of the deployed epidemiologists, as well as the role of nonprofit public health organizations in large-scale emergency response. DESIGN: Electronic assessment of the deployed epidemiologists. PARTICIPANTS: Experienced applied public health epidemiologists who volunteered to participate in the response to the West Africa Ebola virus disease emergency. MAIN OUTCOME MEASURES: Descriptive data. RESULTS: The chief, reported functional contributions made during deployments include improving surveillance processes (reported by 73.3% of respondents), building meaningful relationships to facilitate response activities (66.7%), improving data quality (53.3%), and improving understanding of the disease/outbreak (40.0%). Among the professional benefits of deployment to West Africa to assist with Ebola virus disease outbreak response are stimulating enthusiasm for public health work (93.3%, n = 30), broadened perspective of global health (86.7%), and sharpened epidemiological skills (56.7%). CONCLUSIONS: Owing to their ability to access experienced, senior professionals, the Council of State and Territorial Epidemiologists and other nonprofit public health associations can play a meaningful role boosting surge capacity in a sustained, large-scale emergency response.

Gastroenteritis outbreak associated with unpasteurized tempeh, North Carolina, USA.

During an investigation of an outbreak of gastroenteritis caused by Salmonella enterica serovar Paratyphi B variant L(+) tartrate(+), we identified unpasteurized tempeh as a novel food vehicle and Rhizopus spp. starter culture as the source of the contamination. Safe handling of uncooked, unpasteurized tempeh should be emphasized for prevention of foodborne illnesses.

Completeness of communicable disease reporting, North Carolina, USA, 1995-1997 and 2000-2006.

Despite widespread use of communicable disease surveillance data to inform public health intervention and control measures, the reporting completeness of the notifiable disease surveillance system remains incompletely assessed. Therefore, we conducted a comprehensive study of reporting completeness with an analysis of 53 diseases reported by 8 health care systems across North Carolina, USA, during 1995-1997 and 2000-2006. All patients who were assigned an International Classification of Diseases, 9th Revision, Clinical Modification, diagnosis code for a state-required reportable communicable disease were matched to surveillance records. We used logistic regression techniques to estimate reporting completeness by disease, year, and health care system. The completeness of reporting varied among the health care systems from 2% to 30% and improved over time. Disease-specific reporting completeness proportions ranged from 0% to 82%, but were generally low even for diseases with great public health importance and opportunity for interventions.

Environmental risk factors associated with pulmonary isolation of nontuberculous mycobacteria, a population-based study in the southeastern United States.

The prevalence of pulmonary nontuberculous mycobacteria (NTM) disease is increasing in the United States. Associations were evaluated among residents of central North Carolina between pulmonary isolation of NTM and environmental risk factors including: surface water, drinking water source, urbanicity, and exposures to soils favorable to NTM growth. Reports of pulmonary NTM isolation from patients residing in three counties in central North Carolina during 2006-2010 were collected from clinical laboratories and from the State Laboratory of Public Health. This analysis was restricted to patients residing in single family homes with a valid residential street address and conducted at the census block level (n = 13,495 blocks). Negative binomial regression models with thin-plate spline smoothing function of geographic coordinates were applied to assess effects of census block-level environmental characteristics on pulmonary NTM isolation count. Patients (n = 507) resided in 473 (3.4%) blocks within the study area. Blocks with >20% hydric soils had 26.8% (95% confidence interval (CI): 1.8%, 58.0%), p = 0.03, higher adjusted mean patient counts compared to blocks with ≤20% hydric soil, while blocks with >50% acidic soil had 24.8% (-2.4%, 59.6%), p = 0.08 greater mean patient count compared to blocks with ≤50% acidic soil. Isolation rates varied by county after adjusting for covariates. The effects of using disinfected public water supplies vs. private wells, and of various measures of urbanicity were not significantly associated with NTM. Our results suggest that proximity to certain soil types (hydric and acidic) could be a risk factor for pulmonary NTM isolation in central North Carolina.

Utility of International Classification of Diseases, Ninth Revision, Clinical Modification codes for communicable disease surveillance.

International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes have been proposed as a method of public health surveillance and are widely used in public health and clinical research. However, ICD-9-CM codes have been found to have variable accuracy for both health-care billing and disease classification, and they have never been comprehensively validated for use in public health surveillance. Therefore, the authors undertook a comprehensive analysis of the positive predictive values (PPVs) of ICD-9-CM codes for communicable diseases in 6 North Carolina health-care systems for the year 2003. Stratified random samples of patient charts with ICD-9-CM diagnoses for communicable diseases were reviewed and evaluated for their concordance with the Centers for Disease Control and Prevention surveillance case definitions. Semi-Bayesian hierarchical regression techniques were employed on the ensemble of disease-specific PPVs in order to reduce the overall mean squared error. The authors found that for the majority for diseases with higher incidence and straightforward laboratory-based diagnoses, the PPVs were high (>80%), with the important exception of tuberculosis, which had a PPV of 28.6% (95% uncertainty interval: 15.6, 46.5).

Evaluating North Carolina's policy for healthcare personnel living with HIV and hepatitis B who perform invasive procedures after 25 years of implementation.

Healthcare personnel who perform invasive procedures and are living with HIV or hepatitis B have been required to self-notify the NC state health department since 1992. State coordinated review of HCP utilizes a panel of experts to evaluate transmission risk and recommend infection prevention measures. We describe how this practice balances HCP privacy and patient safety and health.

Application of diagnostic criteria for non-tuberculous mycobacterial disease to a case series of mycobacterial-positive isolates.

The American Thoracic Society (ATS) and Infectious Diseases Society of America (IDSA) have provided guidelines to assist in the accurate diagnosis of lung disease caused by nontuberculous mycobacteria (NTM). These microbiologic, radiographic, and clinical criteria are considered equally important and all must be met to make the diagnosis of NTM lung disease. To assess the significance of the three criteria, each was evaluated for its contribution to the diagnosis of NTM lung disease in a case series. Laboratory reports of any specimen positive for NTM isolation were collected between January 1, 2006 and December 31, 2010 at a university medical center. Medical records were reviewed in detail using a standardized form. The total number of patients with a culture from any site positive for NTM was 297 while the number from respiratory specimens during the same period was 232 (78%). Samples from two of these patients also yielded M. tuberculosis complex and were excluded. While 128 of the remaining 230 patients (55.7%) in the cohort met the microbiologic criterion for diagnosis of NTM lung disease, 151 (65.6%) and 189 (78.3%) met the radiologic and clinical criteria respectively. Only 78 patients (33.9%) met all three criteria provided by the ATS/IDSA for diagnosis of NTM lung disease. This evaluation reaffirms that defining NTM lung disease using either one or two of the criteria provided by the 2007 ATS/IDSA guidelines may significantly overestimate the number of cases of NTM lung disease. Based on the experience of defining NTM lung disease in this case series, recommendations for modification of the ATS/IDSA guidelines are provided which include expansion of both radiologic patterns and the list of symptoms associated with NTM lung disease.

Partnering to meet training needs: a communicable-disease continuing education course for public health nurses in North Carolina.

In 2004, the General Communicable Disease Control Branch of the North Carolina Division of Public Health and the North Carolina Center for Public Health Preparedness partnered to create a free continuing education course in communicable-disease surveillance and outbreak investigations for public health nurses. The course was a competency-based curriculum with 14 weeks of Internet-based instruction, culminating in a two-day classroom-based skills demonstration. In spring 2006, the course became mandatory for all public health nurses who spend at least three-fourths of their time on tasks related to communicable diseases. As of December 2006, 177 nurses specializing in communicable diseases from 74 North Carolina counties had completed the course. Evaluations indicated that participants showed statistically significant improvements in self-perceived confidence to perform competencies addressed by the course. This course has become a successful model that combines academic expertise in curriculum development and teaching technologies with practical expertise in course content and audience needs. Through a combination of Internet and classroom instruction, this course has delivered competency-based training to the public health professionals who perform as frontline epidemiologists throughout North Carolina.

Knowledge and practice of foodborne disease clinical specimen testing and reporting in North Carolina, 2004.

BACKGROUND: Detection of foodborne disease outbreaks relies on health care practitioners (HCPs), infection control practitioners (ICPs), and clinical laboratorians to report notifiable diseases to state or local health departments. METHODS: To examine knowledge and practices about notifiable foodborne disease reporting among HCPs and ICPs in western North Carolina and among clinical laboratorians statewide, participants responded to a self-administered questionnaire about foodborne pathogen testing and reporting, referencing Campylobacter, shiga-toxin producing Escherichia coli, and other organisms. RESULTS: Three hundred seventy-two of 1442 health care providers participated in this survey. Of 372 study participants, fewer than 20% knew that both the clinician and the laboratorian were legally responsible for reporting the study pathogens. Most laboratorians identified the ICP (57%) as responsible for reporting. There was a lack of understanding about which infections and test results were reportable. LIMITATIONS: The response rate was very low, particularly among HCPs; participants may have been biased towards those with a particular interest in foodborne disease or surveillance. This descriptive study cannot be used to determine rates of reporting among the medical community. CONCLUSIONS: Although not legally obliged to report, ICPs were found to play a significant role in disease reporting. Dissemination of surveillance information and training through the established network of North Carolina ICPs may be ideal for improving foodborne disease surveillance in this state.

Epidemiology of nontuberculous mycobacteria isolations among central North Carolina residents, 2006-2010.

BACKGROUND: Nontuberculous mycobacteria (NTM) are environmental mycobacteria associated with a range of infections. Reports of NTM epidemiology have primarily focused on pulmonary infections and isolations, however extrapulmonary infections of the skin, soft tissues and sterile sites are less frequently described. METHODS: We comprehensively reviewed laboratory reports of NTM isolation from North Carolina residents of three counties during 2006-2010. We describe age, gender, and race of patients, and anatomic site of isolation for NTM species. RESULTS: Among 1033 patients, overall NTM isolation prevalence was 15.9/100,000 persons (13.7/100,000 excluding Mycobacterium gordonae). Prevalence was similar between genders and increased significantly with age. Extrapulmonary isolations among middle-aged black males and pulmonary isolations among elderly white females were most frequently detected. Most isolations from pulmonary sites and blood cultures were Mycobacterium avium complex; rapidly growing NTM (e.g. Mycobacterium chelonae, Mycobacterium fortuitum) were most often isolated from paranasal sinuses, wounds and skin. CONCLUSIONS: We provide the first characterization of NTM isolation prevalence in the Southeastern United States (U.S.). Variation in isolation prevalence among counties and races likely represent differences in detection, demographics and risk factors. Further characterization of NTM epidemiology is increasingly important as percentages of immunocompromised individuals and the elderly increase in the U.S.

The descriptive epidemiology of yersiniosis: a multistate study, 2005-2011.

OBJECTIVES: Yersiniosis, a foodborne infection of zoonotic origin caused by the bacteria Yersinia enterocolitica and Yersinia pseudotuberculosis, is a reportable disease in 38 states. Both sporadic and foodborne outbreaks of yersiniosis have been reported in the U.S., with annual occurrence of an estimated 98,000 episodes of illness, 533 hospitalizations, and 29 deaths. We analyzed surveillance data from nine non-FoodNet-participating U.S. states during the period 2005-2011 to describe the epidemiology of this disease. METHODS: As part of a passive surveillance system, laboratory-confirmed cases of yersiniosis were reported to state health departments in Arizona, Illinois, Michigan, Missouri, Nebraska, North Carolina, South Carolina, Washington, and Wisconsin. We calculated overall, age-, and race-specific annual incidence rates per 100,000 population using 2010 Census data as the denominator. We used Poisson regression to examine seasonal variation and annual incidence trends by race, age group, and overall. RESULTS: The average annual incidence of yersiniosis was 0.16 cases per 100,000 population during 2005-2011. We observed a statistically significant decreasing annual trend of yersiniosis incidence among African Americans <5 years of age (p<0.01), whereas white people aged 19-64 years (p=0.08) and Hispanic people (p=0.05) had an overall increasing annual incidence of yersiniosis. We observed higher incidence during October-December (p<0.01) and January-March (p=0.03) quarters among African Americans, whereas white people had a higher incidence during April-June (p=0.05). CONCLUSION: This multistate analysis revealed differences in the epidemiology of yersiniosis by race/ethnicity that may be useful for future research and prevention efforts. While this study was consistent with the FoodNet report in recognizing the high and declining incidence among African American children and winter seasonality among African Americans, our study also identified April-June seasonality among the white population.

Evaluation of routinely collected veterinary and human health data for surveillance of human tick-borne diseases in North Carolina.

Tick-borne diseases are an important cause of human morbidity in North Carolina. This study evaluated the use of routinely collected veterinary hospital and human hospital emergency department (ED) data for earlier signal detection compared with routine reporting of tick-borne diseases to the North Carolina Division of Public Health in 2006 and 2007. The Early Aberration Reporting System was used to detect the earliest indication of an increase in number of dogs infested with ticks that were brought to veterinary hospitals and in number of people presenting to EDs with a tick-related chief complaint or who had an ED International Classification of Diseases diagnosis code of tick-borne disease. Results indicate that systematic monitoring of veterinary hospital and human ED data can detect increases in tick activity 4 weeks earlier than the current surveillance method, which would facilitate timely initiation of tick prevention and increased clinical awareness among veterinarians and physicians.

Transmission of hepatitis C virus during myocardial perfusion imaging in an outpatient clinic.

Reports of health care--associated viral hepatitis transmission have been increasing in the United States. Transmission due to poor infection control practices during myocardial perfusion imaging (MPI) has not previously been reported. The aim of this study was to identify the source of incident hepatitis C virus (HCV) infection in a patient without identified risk factors who had undergone MPI 6 weeks before diagnosis. Practices at the cardiology clinic and nuclear pharmacy were evaluated, and HCV testing was performed in patients with shared potential exposures. Clinical and epidemiologic information was obtained for patients with HCV infection, and molecular testing was performed to assess viral relatedness. Evidence of HCV transmission among patients who had undergone MPI at the cardiology clinic on 2 separate dates was found, involving 2 potential source patients and a total of 5 newly infected patients. Molecular testing identified a high degree of genetic homology among viruses from patients with common procedure dates. The nuclear medicine technologist routinely drew up flush from multidose vials of saline solution using the same needle and syringe that had been used to administer radiopharmaceutical doses. Multipatient use of vials was not observed, but a review of purchasing invoices and interviews with staff members suggested that this had occurred. No evidence of transmission via contamination of radiopharmaceuticals at the nuclear pharmacy was found. In conclusion, transmission of HCV occurred because of unsafe injection practices during MPI. Cardiologists should carefully review their infection control practices and the practices of other staff members involved with these procedures.

First case of bioterrorism-related inhalational anthrax, Florida, 2001: North Carolina investigation.

The index case of inhalational anthrax in October 2001 was in a man who lived and worked in Florida. However, during the 3 days before illness onset, the patient had traveled through North Carolina, raising the possibility that exposure to Bacillus anthracis spores could have occurred there. The rapid response in North Carolina included surveillance among hospital intensive-care units, microbiology laboratories, medical examiners, and veterinarians, and site investigations at locations visited by the index patient to identify the naturally occurring or bioterrorism-related source of his exposure.