Authors: Wendy Huebner , Asif Patel,  Andrea Polk-Stephenson , Howell Sasser  and Erica E. Smith

From the Chair: Ebola—The New Normal
From the Secretary: Leading by Example—The Importance of Risk Communication
Fall 2014 Update in Epidemiology Education
Polio Eradication: Progress and Challenges
One of the Greats: A Tribute to Mervyn Susser

From the Chair: Ebola: The New Normal

The news today reports that a Liberian man who developed symptoms of Ebola fever after flying to Texas has died. Various other “mini-outbreaks” in the U.S. and Europe – as well as the still-growing index event in West Africa – continue to appear on front pages and TV screens around the world. And just this morning, my employer’s Employee Assistance Program sent me an email entitled, “Ebola: What You Need to Know to Protect Yourself.”

I will leave it to my readers to fill in appropriate thoughts about the case-to- coverage ratio, and about what might happen if similar attention were directed toward any of many public health problems that are much larger but which routinely go begging for prevention and treatment dollars, let alone face time on MSNBC AND Fox News. Instead, I will offer a few thoughts on what this and other high-profile communicable disease events mean for how we work and how we think.

Numerators and denominators are largely imaginary numbers. It is perhaps a bit ironic that this year’s APHA Annual Meeting theme is “Healthography” (subtitled, “How where you live affects your health and well-being”). Place nowadays seems to have less to do with the traditional combination of agent, host and environment, than with things like proximity to airports and interstate freeways. Ease – and rapidity – of movement puts a large but poorly defined portion of the population in

the (potential) hot zone. Counting cases and calculating rates becomes a vexed topic, and forecasting is little better than guessing.

Public health becomes a police issue (again). It has been announced again lately that airport security screens in various places would begin to include remote temperature measurement, presumably by infrared sensing, as a means of identifying carriers of communicable diseases. The impulse is understandable, and it is probably too much to expect that available technology not be used when disease may be prevented and perhaps lives saved. Still, the lack of specificity, the lack of professional training and discretion on the part of those doing the screening, and the coercive nature of the whole process seems at odds with the public health ethos. Can anyone imagine doing something similar for HIV, or HPV, or anything else not getting 24/7 coverage? Ask me again when we have remote scans for pre-diabetes or prostate cancer…

Prevention gets lost, and then found again. In the heat of the moment, the public health heroes are all wearing inflatable plastic suits. “What do we do now?” drowns out “What could we have done to prevent this?” When patients are already in the beds, a multi-thousand-dollar treatment sounds a lot more reasonable than it does when public health budgets are being discussed. But all of this passes. When the news cycle moves on, a return to a focus on prevention is the — reassuring — constant. May the present outbreak burn itself out rapidly and become less a parade of plastic suits and more a topic for education.

From the Secretary
Leading by Example: The Importance of Risk Communication

On Sept. 30, 2014, the Centers for Disease Control and Prevention, the Texas Department of State Health Services and the Dallas County Health & Human Services announced the first laboratory-confirmed Ebola case diagnosed in the United States (http://www.cdc.gov/media/releases/2014/s930-ebola-confirmed-case.html). The hours that followed exemplify the 24-hour news cycle in which we currently live. In some cases, media consultants and experts provided clear and accurate commentary on the situation at hand. In others, a variety of factors contributed to misinformation and speculation. In the new age of “viral” stories, sound bytes and social media, an “outbreak” of misinformation can be almost as dangerous as the true outbreak being described.

As epidemiologists, we are often in a unique position during public health emergencies — one that can become particularly relevant in the early hours of any outbreak investigation, when publicly available information may be limited, and fear and speculation can spread quickly. We understand public health and epidemiologic principles, as well as outbreak investigation and contact tracing. We frequently negotiate the delicate balance between agency transparency and patient confidentiality. This is where grassroots communication comes into play. Even in

our own social circles, we can lead by example to promulgate more accurate information and try to quell rumors and speculation.

Although many of us have no direct role in the current case follow-up and contact tracing in Texas, risk communication is key in any emergency situation. Staying informed is crucial, and an excellent source “related to emergency preparedness and response and emerging public health threats” is CDC’s Clinician Outreach and Communication Activity, or COCA) “COCA prepares clinicians to respond to emerging health threats and public health emergencies by communicating relevant, timely information related to disease outbreaks, disasters, terrorism events and other health alerts.” For more information and to subscribe,

visit http://www.bt.cdc.gov/coca/. Not all of us are specialists in risk communication, but CDC also provides some excellent resources on Crisis and Emergency Risk Communication (http://emergency.cdc.gov/cerc/index.asp) and Social Media Tools, Guidelines and Best Practices (http://www.cdc.gov/socialmedia/tools/guidelines/socialmediatoolkit.html).

As CDC DirectornTom Frieden, MD, MPH, stated in the CDC’s September 30 news release, “Ebola can be scary. But there’s all the difference in the world between the U.S. and parts of Africa where Ebola is spreading. The United States has a strong health care system and public health professionals who will make sure this case does not threaten our communities. While it is not impossible that there could be additional cases associated with this patient in the coming weeks, I have no doubt that we will contain this.”

Without clairvoyance we cannot predict the future of Ebola in the United States or the world, but an emphasis on good risk communication strategies can benefit all of us, whether we are talking about Ebola or any other situation.

Cheers,
Erica Smith,
Secretary, Epidemiology Section

Fall 2014 Update in Epidemiology Education

The Epidemiology Education Committee welcomes you to our corner. The Committee’s goal is to support efforts to increase and enhance epidemiology education for key target groups. These groups include the public health workforce, public health policymakers, the media, the general public, and our youth and their teachers. We will report activities and events that address one or more of these groups. Let us know if you have any such news to include in the EE Corner.

Using Smartphone Technologies in Undergraduate Epidemiology Classes

This article is written by Jeffrey Bethel, PhD, assistant professor of epidemiology at Oregon State University, College of Public Health and Human Sciences. As a member of the Epidemiology Education Committee, he is responding to the Committee’s desire to share information about using technology in the epidemiology classroom.

I was looking for a way to better engage the roughly 80 students in my undergraduate introduction to epidemiology course. Having heard of a few student engagement and response systems used by colleagues, I wanted to use one that utilized cell phones since cell phones had been a point of contention in the classroom. If you can’t get students off their phones, use the phones in class! I decided to use Top Hat (https://tophat.com/), which was touted as a way to transform students’ mobile devices into powerful classroom engagement tools. Students took their weekly quizzes on Top Hat rather than in paper form. This eliminated manual grading, saved paper, provided me with instant feedback, allowed students to view their scores in a timely manner, and stored all quizzes online for students to review at their leisure. No passing back quizzes that students may misplace. I also used Top Hat to assess student comprehension during lectures and used the instant feedback to review certain concepts in greater detail. Students also completed in-class exercises in groups and submitted their responses using Top Hat. These exercises were also available online for students to review in preparation for exams. After some difficulty getting students registered for Top Hat, the class quickly became adept at using the software that was available on smartphones, tablets, and laptops. Connectivity was rarely an issue. Student feedback was generally positive — they liked having access to quizzes and in-class exercises and really liked that it saved a large amount of paper. The consistent criticism was that they felt the added cost, while quite modest ($20), was unfair given they had already paid tuition and fees. Overall, my first experience using student engagement and response systems was positive. With a few tweaks, I believe I can more effectively use Top Hat to improve student learning in the future. Looking ahead, I am hoping to incorporate additional technology that could be used for data collection exercises in the epidemiology classroom to simulate real world experience in administering surveys. Contact: [email protected]

High School Standards For Epidemiology — Update on Tennessee’s program

In the Spring 2013 and Summer 2014 newsletters, we reported that there were three states that have adopted high school standards focused on public health and epidemiology. Here is more about what is happening in Tennessee, written by Sheila Carlton, RN, MSN, who is at the Tennessee Department of Education’s Division of Career and Technical Education, and is working at the forefront of developing these standards as the Health Science, Law, Public Safety, Correction and Security, Government and Public Administration Career Cluster Consultant.

The Tennessee Department of Education’s Division of Career and Technical Education is excited to provide health science students and teachers the opportunity to expand the knowledge of public health across our state’s high schools. Our research found Americans’ overall health is on the decline in all areas, from very rural to dense metropolitan communities. To ensure that we were preparing our

students to meet the needs in this field, the Public Health program of study, or POS, was developed.

Within this POS, students will examine why and how the increase in chronic conditions impact and influence not only individuals, but also the health of their communities and the public. Course content includes: knowledge and skills to help communities prepare for and respond to disaster; public health problems and strategies for alleviating them; tools to evaluate the rise in mental health diseases and disorders; and the examination of how the health of the United States is related to larger global health issues. Upon completion of this POS, students will be prepared for advanced study at the postsecondary level in the areas of epidemiology, health policy and similar public health-related fields.

Currently, four schools will be offering the public health POS in the first year it is available. Three schools are located in small rural communities and one in a metropolitan area. “We are seeing unhealthily individuals in our community,” says one health science teacher, “If our students can become disease detectives in the Epidemiology course, possibly they can change their own community’s health.” The department is currently developing a resource toolkit to support teachers of these new courses. To share resources that will be valuable for these teachers, or learn more about the courses, please

visit http://www.state.tn.us/education/cte/HealthScience.shtml or email Sheila Carlton, Tennessee Career Cluster Consultant for Health Science Education,
at [email protected].

Looking for epidemiology teaching materials for the Undergraduate and Graduate level? Here are a few URLs that link to epidemiology education resources suitable for post-secondary students. For a more extensive list of links to this and other target student groups, go to http://www.epiedmovement.org and click on “Links for Teaching Material.”

• Deadly Outbreaks — How medical detectives save lives threatened by killer pandemics, exotic viruses and drug-resistant parasites — A book by Alexandra M Levitt in conjunction with the Council of State and Territorial Epidemiologists. This book project is “intended to provide the next generation of young people attracted to the fields of math and science with an exciting and worthwhile career option…”
• North Carolina Center for Public Health Preparedness — University of North Carolina
• Tephinet — A professional alliance of field epidemiology training programs, or FETP, in 32 countries, Centers for Disease Control and Prevention
• Epidemiology Case Studies, Epidemiology Intelligence Sevice (EIS) — Centers for Disease Control and Prevention
• Understanding the Fundamentals of Epidemiology — an Evolving Text, Victor J. Schoenbach, Department of Epidemiology, UNC Gillings School of Global Public Health, University of North Carolina at Chapel Hill (versión en

español: Comprendiendo los Fundamentos de la Epidemiología — un

Texto en Desarrollo)
• Epiville — Developed by the Mailman School of Public Health, Columbia

University

Polio Eradication: Progress and Challenges

As a consultant to the Centers for Disease Control and Prevention Center for Global Health, Global Immunization Division, I was privileged to be a part of a worldwide initiative to eradicate polio. I wanted to share some of what I learned so we can better understand polio epidemiology, prevention and the efforts to stop transmission of this cruel and preventable disease.

Polio is a viral infection that is usually recognized by the acute onset of flaccid paralysis caused by poliovirus types 1, 2 and 3.1 Less than 1 percent of cases result in flaccid paralysis, and the vast majority of cases go undetected.1 Poliovirus can be isolated from stool, cerebrospinal fluid, or CSF, and oropharyngeal samples, and from environmental (sewage) sampling. Transmission is generally through the fecal-oral route.1

Polio transmission has never been interrupted in Afghanistan, Nigeria and Pakistan. In 2013 and 2014, outbreaks occurred in the Horn of Africa, Cameroon, Equatorial Guinea, Syria and Iraq — all previously polio-free countries.2

Poliovirus can invade the brain and spinal cord of infected individuals and can result in permanent paralysis and, rarely, death. There is no cure, but safe and effective vaccines are available. Therefore, the strategy to eradicate polio is based on preventing infection by immunizing every child through routine immunization, supplemental immunization activities and/or “mop-up” vaccination campaigns in geographically-restricted areas following the identification of a case. Another cornerstone of the eradication effort is timely and sensitive clinical surveillance so that every case can be detected.2

There has been great progress since 1988 when the Global Polio Eradication Initiative was launched, and the number of annual polio cases has decreased by >99 percent. The World Health Organization, Rotary International, CDC, and the United Nations International Children’s Emergency Fund are spearheading GPEI partners.3 The Bill & Melinda Gates Foundation is also a critical partner in polio eradication activities. CDC activated its Emergency Operations Center in response to the 2012 World Health Assembly declaration that the completion of polio eradication was a programmatic emergency for public health.

In the United States, the CDC recommends the following:
The poliovirus vaccine used in the U.S. is inactivated poliovirus vaccine, or IPV. IPV is injected into the leg or arm and often given when other vaccines are administered.

It is routinely administered to children who get four doses at 2 months, 4 months, 6- 18 months, and a booster dose at 4-6 years.4

The polio program has made extraordinary progress, “The number of worldwide polio cases has fallen from an estimated 350,000 in 1988 to 407 in 2013 — a decline of more than 99 percent in reported cases.”5 Additionally, four regions of the world are certified polio free — the Americas, Europe, Southeast Asia and the Western Pacific. Within the remaining regions, only three polio-endemic countries (countries that have never interrupted the transmission of wild poliovirus) remain — Afghanistan, Nigeria and Pakistan.

However, there are challenges to the program in a number of countries. Difficulties persist in finding chronically missed children, obtaining parental consent to vaccinate children, and accessing children in areas of insecurity.

GPEI partners and other organizations continue to deploy staff, vaccine and other resources to countries around the world. As travel and trade have been globalized, we must be vigilant at home and abroad.

Further information on the Polio Eradication Initiative can be found at http://www.polioeradication.org/Home.aspx.

References:
1. Heyman, David L, Ed, Control of Communicable Diseases Manual, 19th ed.

APHA Press, 2008 p 484.
2. http://www.cdc.gov/polio/
3. http://www.polioeradication.org/AboutUs.aspx
4. http://www.cdc.gov/vaccines/vpd-vac/polio/dis-faqs.htm 5. http://www.cdc.gov/polio/progress/index.htm

One of the Greats: A Tribute to Mervyn Susser

One of the important chapters of epidemiology ended with the passing of Dr. Mervyn Susser on August 14, 2014. Dr. Susser’s work influenced a whole generation of epidemiologists and will no doubt inspire many generations in the future.

Dr. Susser’s contributions to public health began in the 1950s in South Africa, where he was a supporter of Nelson Mandela during the anti-Apartheid movement. Dr. Susser had many publications with his wife, Dr. Zena Stein; both were vocal opponents of Apartheid, and in 1955 they co-published “Medical Care in a South African Township,” which focused on community-oriented primary care in South Africa and was published in the Lancet.

Because of political pressure and his outspoken opposition to Apartheid, Dr. Susser moved from South Africa to England and then to the United States, where he joined Columbia University as the chair of the division of epidemiology in 1966. Dr. Susser’s most influential work, “Causal Thinking in the Health Sciences: Concepts and Strategies of Epidemiology,” was published in 1973 and focused on the emerging discipline-wide paradigm shift from infectious disease to chronic disease epidemiology. Later contributions of Dr. Susser and Dr. Stein during the 1980s focused on the then newly emerging disease HIV/AIDS and included the identification of women, not just men who have sex with men, as at-risk for HIV/AIDS. Dr. Susser was also the editor of the American Journal of Public Health between 1992 and 1998. Recognizing his numerous contributions to epidemiology, the APHA Epidemiology Section bestowed him with the John Snow Award. He will be long remembered for his many contributions to the fields of epidemiology and public health.

To read the entire New York Times obituary, please visit: http://www.nytimes.com/2014/08/27/us/mervyn-susser-92-dies-studied-illness- and-society.html?_r=0

 

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