Complicated Invasive Pneumococcal Meningitis: Highlighting the Value of Implementing New Pneumococcal Vaccines.

Invasive Streptococcus pneumoniae disease (IPD) remains a serious cause of morbidity and loss of life in children and adults worldwide. While pneumococcal vaccines have reduced the frequency of invasive pneumococcal disease, the emergence of invasive non-vaccine serotypes has mandated the development of novel pneumococcal vaccines to further protect against these emerging serotypes. We present a case of a non-vaccine serotype invasive pneumococcal disease-causing septic shock, meningitis, and stroke in a previously healthy and appropriately vaccinated 23-month-old male.

Are we there yet? Seizing the moment to integrate medicine and public health.

Multiple promising but unsustainable attempts have been made to maintain programs integrating primary care and public health since the middle of the last century. During the 1960s, social justice movements expanded access to primary care and began to integrate primary care with public health concepts both to meet community needs for medical care and to begin to address the social determinants of health. Two decades later, the managed care movement offered opportunities for integration of primary care and public health as many employers and government payers attempted to control health costs and bring disease prevention strategies in line with payment mechanisms. Today, we again have the opportunity to align primary care with public health to improve the community's health.

Epidemic assistance by the Centers for Disease Control and Prevention: role of the Epidemic Intelligence Service, 1946-2005.

Since 1946, the Centers for Disease Control and Prevention has responded to urgent requests from US states, federal agencies, and international organizations through epidemic-assistance investigations (Epi-Aids). The authors describe the first 60 years of Epi-Aids, breadth of problems addressed, evolution of methodologies, scope of activities, and impact of investigations on population health. They reviewed Epi-Aid reports and EIS Bulletins, contacted current and former Epidemic Intelligence Service staff, and systematically searched the PubMed and Web of Science databases. They abstracted information on dates, location, staff involved, health problems, methods, and impacts of investigations according to a preplanned protocol. They assessed the methods presented as well as the quality of reports. During 1946-2005, a total of 4,484 investigations of health events were initiated by 2,815 Epidemic Intelligence Service officers. In the early years, the majority were in response to infectious agents, although environmental problems emerged. Investigations in subsequent years focused on occupational conditions, birth defects, reproductive health, tobacco use, cancer, violence, legal debate, and terrorism. These Epi-Aids heralded expansion of the agency's mission and presented new methods in statistics and epidemiology. Recommendations from Epi-Aids led to policy implementation, evaluation, or modification. Epi-Aids provide the Centers for Disease Control and Prevention with the agility to respond rapidly to public health crises.

Cumulative Incidence of Methicillin-Resistant Staphylococcus aureus Colonization in Resident Physicians Over Time.

Background Methicillin-resistant Staphylococcus aureus (MRSA) can colonize up to 14.5% of healthcare workers (HCWs). The colonization rate of HCWs or the hospital setting that contributes most to MRSA colonization is less clear. In this study, we studied new resident physicians (PGY-1), as a model for HCWs, to measure their colonization rate and hypothesized that the incidence of colonization would increase during their first year. Methodology We prospectively enrolled PGY-1 residents of multiple specialties at three academic medical centers. After obtaining informed consent, PGY-1 residents were tested for MRSA in June 2019 before starting any clinical rotations and then retested every three to four months thereafter. The coronavirus disease 2019 pandemic forced us to end the study early. If MRSA-positive, residents were treated with 2% mupirocin and retested for a cure. For comparison, upper-level residents (PGY-2-5) were also enrolled to obtain a baseline prevalence of colonization. Results We enrolled 80 PGY-1 and 81 PGY-2-5 residents in the study. The baseline prevalence of MRSA colonization was 4.94% (4/81) in PGY-2-5 residents and 2.50% (2/80) for new PGY-1 residents; however, this was not statistically significant (p = 0.68). The cumulative yearly incidence of developing MRSA colonization in PGY-1 residents was 4.51%. MRSA colonization was successfully treated in 75% of cases. Conclusions PGY-1 residents had a lower MRSA colonization rate compared to PGY-2-5 residents, although this was not statistically significant. PGY-1 residents had a small incidence of developing MRSA colonization while working in the hospital. Further research is needed to determine if this is clinically relevant to HCWs or their patients.

In snow's footsteps: Commentary on shoe-leather and applied epidemiology.

The term shoe-leather epidemiology is often synonymous with field epidemiology or intervention epidemiology. All 3 terms imply investigations initiated in response to urgent public health problems and for which the investigative team does much of its work in the field (i.e., outside the office or laboratory). Alexander D. Langmuir is credited with articulating the concept of disease surveillance as it is applied to populations rather than individuals. He also founded the Epidemic Intelligence Service (EIS) Program in 1951, a 2-year training experience in applied epidemiology that places professionals in the field, domestically and internationally, in real-life situations. Today, 70-90 EIS officers are assigned each year to Centers for Disease Control and Prevention programs and to state and local health departments to meet the broad spectrum of challenges in chronic disease, injury prevention, violence, environmental health, occupational safety and health, and maternal and child health, as well as infectious diseases. Throughout their assignments, EIS officers are encouraged to strive for analytic rigor as well as public health consequence, which requires technical competence blended with good judgment and awareness of context. Effective applied epidemiologists must have skills beyond just epidemiology to improve a population's health; the field of applied epidemiology requires multiple team members, all having different but complementary skills, to be effective.

Non-Obstetric Vulvar/Paravaginal Hematoma in an Adolescent Girl with Scleroderma: An Opportunity for Intimate Partner Violence Intervention.

Description A 15-year-old female presented to the emergency department with swelling and pain in her left labial region as well as urinary retention after intercourse. This was the patient's first time having sexual intercourse and the patient stated that her boyfriend "kneed" her in the labia. A CT scan of the pelvis revealed a large vulvar/external hematoma measuring 6 × 10 × 7 cm which extended into the vaginal vault. This case is the first of a vulvar hematoma reported in a pediatric patient with scleroderma. This case was complicated by the fact that our patient claimed her boyfriend intentionally "kneed" her in the labia, thereby calling sexual abuse into question. Discerning between childhood connective tissue disorders and abuse injuries can be difficult, especially in genital trauma. The treatment team suspected early on that this was a case of intimate partner assault based on the severity of the injury alone and continued when she presented again to the emergency department with concerns for abuse. Sexual violence should be high on the differential in children with connective tissue disorders who present with vulvar or paravaginal hematomas. In our opinion, these injuries warrant a thorough investigation by a child abuse specialist, child protective services and law enforcement.

Drosophila Roc1a encodes a RING-H2 protein with a unique function in processing the Hh signal transducer Ci by the SCF E3 ubiquitin ligase.

Substrate specificity of SCF E3 ubiquitin ligases is thought to be determined by the F box protein subunit. Another component of SCF complexes is provided by members of the Roc1/Rbx1/Hrt1 gene family, which encode RING-H2 proteins. Drosophila contains three members of this gene family. We show that Roc1a mutant cells fail to proliferate. Further, while the F box protein Slimb is required for Cubitus interruptus (Ci) and Armadillo/beta-catenin (Arm) proteolysis, Roc1a mutant cells hyperaccumulate Ci but not Arm. This suggests that Slimb and Roc1a function in the same SCF complex to target Ci but that a different RING-H2 protein acts with Slimb to target Arm. Consequently, the identity of the Roc subunit may contribute to the selection of substrates by metazoan SCF complexes.

Monitoring progress toward CDC's health protection goals: health outcome measures by life stage.

OBJECTIVES: From 2004 through 2005, as part of a major strategic planning process called the Futures Initiative, the Centers for Disease Control and Prevention (CDC) developed a set of Health Protection Goals to make the best use of agency resources to achieve health impact. These goals were framed in terms of people, places, preparedness, and global health. This article presents a goals framework and a set of health outcome measures with historical trends and forecasts to track progress toward the Healthy People goals by life stage (Infants and Toddlers, Children, Adolescents, Adults, and Older Adults and Seniors). METHODS: Measurable key health outcomes were chosen for each life stage to capture the multidimensional aspects of health, including mortality, morbidity, perceived health, and lifestyle factors. Analytic methods involved identifying nationally representative data sources, reviewing 20-year trends generally ranging from 1984 through 2005, and using time-series techniques to forecast measures by life stage until 2015. RESULTS: Improvements in measures of mortality and morbidity were noted among all life stages during the study period except Adults, who reported continued declining trends in perceived health status. Although certain behavioral indicators (e.g., prevalence of nonsmokers) revealed steady improvements among Adolescents, Adults, and Older Adults and Seniors, prevalence of the healthy weight indicator was declining steadily among Children and Adolescents and dramatically among Adults and Older Adults and Seniors. CONCLUSION: The health indicators for the Healthy People goals established a baseline assessment of population health, which will be monitored on an ongoing basis to measure progress in maximizing health and achieving one component of CDC's Health Protection Goals.

Guide for applied public health workforce research: an evidence-based approach to workforce development.

Essential to achievement of the public health mission is a knowledgeable, competent, and prepared workforce; yet, there is little application of science and technical knowledge to ensuring the effectiveness of that workforce, be it governmental or private. In this article, I review the evidence for effective workforce development and argue for an increased emphasis on an evidence-based approach to ensuring an effective workforce by encouraging the generation of the evidence base that is required. To achieve this, I propose the appointment of an independent Task Force on Public Health Workforce Practice to oversee the development of a Guide for Public Health Workforce Research and Practice (Workforce Guide), a process that will generate and bring together the workforce evidence base for use by public health practitioners.

Perspectives on public health workforce research.

The Centers for Disease Control and Prevention Office of Workforce and Career Development is committed to developing a competent, sustainable, and diverse public health workforce through evidence-based training, career and leadership development, and strategic workforce planning to improve population health outcomes. This article reviews the previous efforts in identifying priorities of public health workforce research, which are summarized as eight major research themes. We outline a strategic framework for public health workforce research that includes six functional areas (ie, definition and standards, data, methodology, evaluation, policy, and dissemination and translation). To conceptualize and prioritize development of an actionable public health research agenda, we constructed a matrix of key challenges in workforce analysis by public health workforce categories. Extensive reviews were conducted to identify valuable methods, models, and approaches to public health workforce research. We explore new tools and approaches for addressing priority areas for public health workforce and career development research and assess how tools from multiple disciplines of social sciences can guide the development of a research framework for advancing public health workforce research and policy.

Career paths to public health: programs at the Centers for Disease Control and Prevention.

The Centers for Disease Control and Prevention offers training in specific, critically needed disciplines such as epidemiology and laboratory sciences, frequently through experiential, on-the-job service and learning fellowships. The agency also provides a more general exposure to public health as a field, often for younger participants, through shorter-term internships. In addition, other programs provide opportunity for exposure to public health thinking and public health problems in an academic setting as early as elementary school. Although a primary purpose of these programs, especially the experiential fellowships and internships, is to attract young people to public health careers, a secondary goal, particularly for the younger students, is to foster an awareness and concern regarding their personal health. The Career Paths to Public Health Program focuses on students and teachers from elementary to undergraduate schools and builds on CDC's existing postgraduate training programs. The program enhances student interest in the practical uses of mathematics and science and introduces them to the exciting work of public health. These activities also provide a nexus for working with both traditional partners in academia and public health and new academic partners to foster programs of mutual interest.

The education of physicians: a CDC perspective.

The Centers for Disease Control and Prevention (CDC) strongly supports integrating population health perspectives into the education of physicians. Physicians with critical-thinking skills, a commitment to the health of a community, and a systems-based approach are critical partners for the agency in its mission to protect and promote the public's health. To cultivate such physicians, integrating population health concepts solely into undergraduate medical education would be inadequate. A multipronged approach that establishes and maintains population health concepts with physicians at all stages of their education is needed: before medical school, during medical school, during residency and fellowship, and in research and practice (particularly for faculty who train the next generation). The authors describe relevant, CDC-conducted or CDC-supported activities that support such physician education during all these stages. Based in part on recent, cutting-edge trends assimilating community health particularly into primary care residencies, the authors also offer ideas for new ways that CDC can participate in the development of physicians who are truly competent at both medicine and population health in an integrated fashion -- physicians who focus on and care for individual patients but who also take a broader population or community perspective and can act effectively in either arena. Physicians who take such a systems approach -- who view and understand medicine and public health as a continuum rather than as distinct arenas -- are sorely needed to help solve the current health system crisis and to contribute to improving health in other ways.

The contribution of E2F-regulated transcription to Drosophila PCNA gene function.

E2F proteins control cell cycle progression by predominantly acting as either activators or repressors of transcription. How the antagonizing activities of different E2Fs are integrated by cis-acting control regions into a final transcriptional output in an intact animal is not well understood. E2F function is required for normal development in many species, but it is not completely clear for which genes E2F-regulated transcription provides an essential biological function. To address these questions, we have characterized the control region of the Drosophila PCNA gene. A single E2F binding site within a 100-bp enhancer is necessary and sufficient to direct the correct spatiotemporal program of G1-S-regulated PCNA expression during development. This dynamic program requires both E2F-mediated transcriptional activation and repression, which, in Drosophila, are thought to be carried out by two distinct E2F proteins. Our data suggest that functional antagonism between these different E2F proteins can occur in vivo by competition for the same binding site. An engineered PCNA gene with mutated E2F binding sites supports a low level of expression that can partially rescue the lethality of PCNA null mutants. Thus, E2F regulation of PCNA is dispensable for viability, but is nonetheless important for normal Drosophila development.

Planning an integrated disease surveillance and response system: a matrix of skills and activities.

BACKGROUND: The threat of a global influenza pandemic and the adoption of the World Health Organization (WHO) International Health Regulations (2005) highlight the value of well-coordinated, functional disease surveillance systems. The resulting demand for timely information challenges public health leaders to design, develop and implement efficient, flexible and comprehensive systems that integrate staff, resources, and information systems to conduct infectious disease surveillance and response. To understand what resources an integrated disease surveillance and response system would require, we analyzed surveillance requirements for 19 priority infectious diseases targeted for an integrated disease surveillance and response strategy in the WHO African region. METHODS: We conducted a systematic task analysis to identify and standardize surveillance objectives, surveillance case definitions, action thresholds, and recommendations for 19 priority infectious diseases. We grouped the findings according to surveillance and response functions and related them to community, health facility, district, national and international levels. RESULTS: The outcome of our analysis is a matrix of generic skills and activities essential for an integrated system. We documented how planners used the matrix to assist in finding gaps in current systems, prioritizing plans of action, clarifying indicators for monitoring progress, and developing instructional goals for applied epidemiology and in-service training programs. CONCLUSION: The matrix for Integrated Disease Surveillance and Response (IDSR) in the African region made clear the linkage between public health surveillance functions and participation across all levels of national health systems. The matrix framework is adaptable to requirements for new programs and strategies. This framework makes explicit the essential tasks and activities that are required for strengthening or expanding existing surveillance systems that will be able to adapt to current and emerging public health threats.

Measuring health program effectiveness in the field: an assessment tool.

To assist field workers in program evaluation and to explicitly discuss program strengths and weaknesses, a practical method to estimate the effectiveness of public health interventions within the existing program capacity was developed. The method and materials were tested in seven countries (Afghanistan, Zimbabwe, Tanzania, Uganda, Guatemala, the Philippines, and Ghana). In this method, four core components are assessed using a questionnaire: (1) the efficacy of the intervention; (2) the level of existing human resources (i.e., quality of recruitment, training, and continuing education); (3) the infrastructure (i.e., supplies, salary, transportation, and supervision); and (4) the level of community support (i.e., access and demand). Using the assessment tool provided, program staff can determine if all necessary elements are in place for a successful program that can deliver the specific intervention. Based on the results of the assessment program, weaknesses can be identified, explicitly discussed, and addressed. The usefulness of this tool in humanitarian relief may be twofold: (1) to assess the design and implementation of effective programs; and (2) to highlight the inevitable need for capacity building as the disaster situation evolves.

Health burden and funding at the Centers for Disease Control and Prevention.

BACKGROUND: The relationship between domestic funding for selected conditions to the Centers for Disease Control and Prevention (CDC) and the burden of disease and disability in the United States was assessed systematically. METHODS: Using mortality, years of potential life lost (YPLLs), disability-adjusted life years (DALYs), hospital days, hospital discharges, and direct medical costs of conditions, 34 high-burden conditions addressed by CDC programs were identified, and information was collected about the funds spent on each by CDC during fiscal year (FY) 2003. The 34 conditions were grouped into 15 categorical areas, and the relationship between budget and burden was analyzed using correlation and regression methods for each of the categorical areas and for each measure of burden. RESULTS: Of CDC's total FY 2003 budget of $6.9 billion, 62% ($4.3 billion) of funding was allocated to one of the 34 conditions studied. A positive relationship between budget and burden was identified for all measures of burden, although the correlations varied for the different conditions. CONCLUSIONS: Although examination of the relationship of CDC's budget to burden measures provides insight into the agency's portfolio of investments, this exercise also highlights a number of limitations with this approach and the currently available burden measures. Assessment of key public health functions such as emergency preparedness and the collection of vital statistics require development of metrics different from the burden measures used in this analysis. Investment in the development of such metrics warrants consideration.

Measuring the public's health.

Allocation of public health resources should be based, where feasible, on objective assessments of health status, burden of disease, injury, and disability, their preventability, and related costs. In this article, we first analyze traditional measures of the public's health that address the burden of disease and disability and associated costs. Second, we discuss activities that are essential to protecting the public's health but whose impact is difficult to measure. Third, we propose general characteristics of useful measures of the public's health. We contend that expanding the repertoire of measures of the public's health is a critical step in targeting attention and resources to improve health, stemming mounting health care costs, and slowing declining quality of life that threatens the nation's future.