Centers for Disease Control and Prevention's Temporary Epidemiology Field Assignee program: Supporting state and local preparedness in the wake of Ebola.

OBJECTIVES: The Centers for Disease Control and Prevention launched the Temporary Epidemiology Field Assignee (TEFA) Program to help state and local jurisdictions respond to the risk of Ebola virus importation during the 2014-2016 Ebola Outbreak in West Africa. We describe steps taken to launch the 2-year program, its outcomes and lessons learned. METHODS: State and local health departments submitted proposals for a TEFA to strengthen local capacity in four key public health preparedness areas: 1) epidemiology and surveillance, 2) health systems preparedness, 3) health communications, and 4) incident management. TEFAs and jurisdictions were selected through a competitive process. Descriptions of TEFA activities in their quarterly reports were reviewed to select illustrative examples for each preparedness area. RESULTS: Eleven TEFAs began in the fall of 2015, assigned to 7 states, 2 cities, 1 county and the District of Columbia. TEFAs strengthened epidemiologic capacity, investigating routine and major outbreaks in addition to implementing event-based and syndromic surveillance systems. They supported improvements in health communications, strengthened healthcare coalitions, and enhanced collaboration between local epidemiology and emergency preparedness units. Several TEFAs deployed to United States territories for the 2016 Zika Outbreak response. CONCLUSION: TEFAs made important contributions to their jurisdictions' preparedness. We believe the TEFA model can be a significant component of a national strategy for surging state and local capacity in future high-consequence events.

United States Notifications of Travelers from Ebola-Affected Countries.

The International Health Regulations (IHR), an international law under the auspices of the World Health Organization (WHO), mandates that countries notify other countries of "travelers under public health observation." Between November 10, 2014, and July 12, 2015, the US Centers for Disease Control and Prevention (CDC) made 2,374 notifications to the National IHR Focal Points in 114 foreign countries of travelers who were monitored by US health departments because they had been to an Ebola-affected country in West Africa. Given that countries have preidentified focal points as points of contacts for sharing of public health information, notifications could be made by CDC to a trusted public health recipient in another country within 24 hours of receipt of the traveler's information from a US health department. The majority of US health departments used this process, offered by CDC, to notify other countries of travelers intending to leave the United States while being monitored in their jurisdiction.

Establishing a Timeline to Discontinue Routine Testing of Asymptomatic Pregnant Women for Zika Virus Infection - American Samoa, 2016-2017.

The first patients with laboratory-confirmed cases of Zika virus disease in American Samoa had symptom onset in January 2016 (1). In response, the American Samoa Department of Health (ASDoH) implemented mosquito control measures (1), strategies to protect pregnant women (1), syndromic surveillance based on electronic health record (EHR) reports (1), Zika virus testing of persons with one or more signs or symptoms of Zika virus disease (fever, rash, arthralgia, or conjunctivitis) (1-3), and routine testing of all asymptomatic pregnant women in accordance with CDC guidance (2,3). All collected blood and urine specimens were shipped to the Hawaii Department of Health Laboratory for Zika virus testing and to CDC for confirmatory testing. Early in the response, collection and testing of specimens from pregnant women was prioritized over the collection from symptomatic nonpregnant patients because of limited testing and shipping capacity. The weekly numbers of suspected Zika virus disease cases declined from an average of six per week in January-February 2016 to one per week in May 2016. By August, the EHR-based syndromic surveillance (1) indicated a return to pre-outbreak levels. The last Zika virus disease case detected by real-time, reverse transcription-polymerase chain reaction (rRT-PCR) occurred in a patient who had symptom onset on June 19, 2016. In August 2016, ASDoH requested CDC support in assessing whether local transmission had been reduced or interrupted and in proposing a timeline for discontinuation of routine testing of asymptomatic pregnant women. An end date (October 15, 2016) was determined for active mosquito-borne transmission of Zika virus and a timeline was developed for discontinuation of routine screening of asymptomatic pregnant women in American Samoa (conception after December 10, 2016, with permissive testing for asymptomatic women who conceive through April 15, 2017).

Systems for rapidly detecting and treating persons with ebola virus disease--United States.

The U.S. Department of Health and Human Services (HHS), CDC, other U.S. government agencies, the World Health Organization (WHO), and international partners are taking multiple steps to respond to the current Ebola virus disease (Ebola) outbreak in West Africa to reduce its toll there and to reduce the chances of international spread. At the same time, CDC and HHS are working to ensure that persons who have a risk factor for exposure to Ebola and who develop symptoms while in the United States are rapidly identified and isolated, and safely receive treatment. HHS and CDC have actively worked with state and local public health authorities and other partners to accelerate health care preparedness to care for persons under investigation (PUI) for Ebola or with confirmed Ebola. This report describes some of these efforts and their impact.

Assessing functional needs sheltering in Pike County, Kentucky: using a community assessment for public health emergency response.

OBJECTIVE: During 2009-2011, Pike County, Kentucky, experienced a series of severe weather events that resulted in property damage, insufficient potable water, and need for temporary shelters. A Community Assessment for Public Health Emergency Response (CASPER) survey was implemented for future planning. CASPER assesses household health status, preparedness level, and anticipated demand for shelters. METHODS: We used a 2-stage cluster sampling design to randomly select 210 representative households for in-person interviews. We estimated the proportion of households with children aged 2 years or younger; adults aged 65 years or older; and residents with chronic health conditions, visual impairments, physical limitations, and supplemental oxygen requirements. RESULTS: Of all households surveyed, 8% included children aged 2 years or younger, and 27% included adults aged 65 years or older. The most common chronic health conditions were heart disease (51%), diabetes (28%), lung disease (23%), and asthma (21%). Visual impairments were reported in 29% of households, physical limitations in 24%, and supplemental oxygen use in 12%. CONCLUSIONS: Pike County residents should be encouraged to maintain an adequate supply of medications and copies of their prescriptions. Emergency response plans should include transportation for persons with physical limitations; and shelter plans should include sufficient medically trained staff and adequate supplies of infant formula, pharmaceuticals, and supplemental oxygen. (Disaster Med Public Health Preparedness. 2013;7:597-602).

Brucellosis seroprevalence among workers in at-risk professions: northwestern Wyoming, 2005 to 2006.

OBJECTIVE: Brucellosis is uncommon in the United States; however, its circulation among wildlife and domestic cattle has been ongoing in Wyoming. To assess the public health threat of brucellosis circulation among animals, a seroprevalence study was undertaken among workers in professions considered to be at the highest risk for infection. METHODS: A seroprevalence study was undertaken targeting individuals in at-risk professions in the affected area of the state. RESULTS: Seroprevalence among study participants was 14.4%. Veterinarians were the main professional group that demonstrated a statistically significant association with measurable anti-Brucella antibodies. Vaccinating animals with Brucella vaccines was associated with seropositivity. CONCLUSION: The risk to the general public's health from the circulation of Brucella among wildlife and cattle can be attributed primarily to a limited subpopulation at high risk rather than a generally elevated risk.

Follow-up assessment of health consequences after a chlorine release from a train derailment--Graniteville, SC, 2005.

INTRODUCTION: After a train derailment released chlorine gas in Graniteville, South Carolina, in 2005, a multiagency team performed an epidemiologic assessment of chlorine exposure and resulting health effects. Five months later, participants were resurveyed to determine their health status and needs and to assist in planning additional interventions in the community. METHODS: Questionnaires were mailed to 279 patients interviewed in the initial assessment; follow-up telephone calls were made to nonresponders. The questionnaire included questions regarding duration of symptoms experienced after exposure and a posttraumatic stress disorder (PTSD) assessment tool. RESULTS: Ninety-four questionnaires were returned. Seventy-six persons reported chronic symptoms related to the chlorine exposure, 47 were still under a doctor's care, and 49 were still taking medication for chlorine-related problems. Agreement was poor between the first and second questionnaires regarding symptoms experienced after exposure to the chlorine (κ=0.30). Forty-four respondents screened positive for PTSD. PTSD was associated with post-exposure hospitalization for three or more nights [relative risk (RR) = 1.7; 95% confidence interval (CI)=1.1-2.6] and chronic symptoms (RR=9.1; 95% CI=1.3-61.2), but not with a moderate-to-extreme level of chlorine exposure (RR=1.2; 95% CI=0.8-1.8). CONCLUSIONS: Some victims of this chlorine exposure event continued to experience physical symptoms and continued to require medical care 5 months later. Chronic mental health symptoms were prevalent, especially among persons experiencing the most severe or persistent physical health effects. Patients should be interviewed as soon as possible after an incident because recall of acute symptoms experienced can diminish within months.

The effect of the 1995 heat wave in Chicago on all-cause and cause-specific mortality.

OBJECTIVES: We sought to reexamine the effects of the 1995 Chicago heat wave on all-cause and cause-specific mortality, including mortality displacement, using advanced time-series analysis methods. METHODS: We used Poisson regression with penalized regression splines to model excess mortality and mortality displacement over a 50-day period centered on the day in which the heat wave temperature peaked, adjusting for meteorological and other variables. We controlled for temporal trends by using daily mortality data during 1993-1997. We estimated relative risks (RRs) with reference to the first day of the 50-day period. RESULTS: We estimated that there were 692 excess deaths from June 21, 1995, to August 10, 1995; 26% of these deaths were owing to mortality displacement. RR for all-cause mortality on the day with peak mortality was 1.74 (95% confidence interval=1.67, 1.81). Risk of heat-related death was significantly higher among Blacks, and mortality displacement was substantially lower. CONCLUSIONS: The 1995 Chicago heat wave substantially effected all-cause and cause-specific mortality, but mortality displacement was limited. Mortality risks and displacement affected Blacks disproportionally. Appropriately targeted interventions may have a tangible effect on life expectancy.

Risk of tornado-related death and injury in Oklahoma, May 3, 1999.

On May 3, 1999, powerful tornadoes, including a category F5 tornado, swept through Oklahoma. The authors examined all tornado-related deaths, hospital admissions, and emergency department visits to identify important risk factors. Data on deaths and injuries directly related to the tornadoes and information obtained from a survey of residents in the damage path of the F5 tornado were used in a case-control analysis. The direct force of the tornadoes caused 40 deaths, 133 hospital admissions, and 265 emergency department outpatient visits. The risk of death from the F5 tornado was greater for persons who were in mobile homes (odds ratio (OR) = 35.3, 95% confidence interval (CI): 7.8, 175.6) or outdoors (OR = 141.2, 95% CI: 15.9, 6,379.8) when the tornado struck than for those in permanently anchored houses. Risk of severe injury was also greater for persons in mobile homes (OR = 11.8, 95% CI: 3.4, 51.7) or outdoors (OR = 34.3, 95% CI: 4.4, 1,526.2). However, the risk of death (OR = 0.0, 95% CI: 0.0, 9.9), severe injury (OR = 0.0, 95% CI: 0.0, 2.0), or minor injury (OR = 0.8, 95% CI: 0.1, 3.1) was not greater among persons in motor vehicles than among those in houses. The risk of death (OR = 0.6, 95% CI: 0.1, 1.7), severe injury (OR = 0.2, 95% CI: 0.1, 0.6), or minor injury (OR = 0.3, 95% CI: 0.2, 0.7) was lower among those fleeing their homes in motor vehicles than among those remaining. Recommendations involving the relative safety of motor vehicles during a tornado should be evaluated using experience from recent tornado events.

Lead poisoning among young children in Russia: concurrent evaluation of childhood lead exposure in Ekaterinburg, Krasnouralsk, and Volgograd.

The Gore-Chernomyrdin Commission encouraged a binational collaboration to evaluate pediatric lead poisoning in Russia. The study evaluated children in three Russian cities: Krasnouralsk, a small city with minimal traffic centered around a copper smelter; and Ekaterinburg and Volgograd, both of which are large cities with multiple factories and heavy vehicular traffic. This project was the first international use of portable blood lead analysis instruments. In each city, at least 90% of children attending selected neighborhood kindergartens participated. We selected kindergartens on the basis of their proximity to industrial areas and major traffic corridors. We obtained capillary blood samples and analyzed for lead content and hemoglobin (Hgb) levels in the field, and collected environmental samples (i.e., indoor dust, tap water, play area soil, and interior and exterior paint) and analyzed for each participating school and in the homes of about 10% of the children who had elevated blood lead levels (BLLs; greater than or equal to 10 microg/dL). We calculated all age-, sex-, and city-specific geometric means using generalized estimating equations to account for covariance within kindergartens, and used multivariate logistic regression models to identify variables predictive of elevated BLLs. Overall, 23% of study children had elevated BLLs and 2% were anemic, defined as Hgb < 11 g/dL. Krasnouralsk had the highest geometric mean BLL (10.7 microg/dL), the highest percentage of children (60%) with elevated BLLs, and the highest percentage of anemic children (4%). All soil samples in Krasnouralsk had detectable lead levels. Volgograd was the only city that had paint samples with elevated lead levels. We found apparent city-specific differences in the percentages of children with elevated BLLs. Lead-contaminated soil and dust, which can result from lead-based automotive fuel and from lead-related industrial emissions, appear to be the most important routes of lead exposure of those evaluated in this study. Elevated lead levels found in paint samples from Volgograd may indicate old undercoats of lead-based paint that could represent a regionally rather than nationally important source of exposure.

Needs assessment of the displaced population following the August 1999 earthquake in Turkey

In Augusto 1999 a major earthquake struck north-western Turkey. An assessmento followed to identify the immediate needs of the displaced population. A random cluster sample of displaced families living in temporary shelter outside of organised relief camps was designed. Representatives of 230 households form the four communities worse affected by the earthquake were interviewed. Most families lived in makeshift shelters (84 per cent), used bottled water (90 per cent), obtained food form relief organisations (53 per cent) and obtanined information by word of mouth (81 per cent). Many respondents reported having family members who were over the age of 65 (32 per cent) or under age three (20 per cent), who were pregnand (6 per cent), or who had been ill since the earthquake (64 per cent). The greatest immediate need reported by most families was shelter requirements (37 per cent), followed by food (23 per cent) and hygiene requirements (19 per cent). Ten days after the earthquake, basic environmental health needs of food, shelter and hygiene still predominated in this displaced population. Significant portions may have special needs due to age or illness. (AU)