Where are they Now? APHL/CDC Emerging Infectious Disease Fellow Looks Back

Apr 10 2014 :: Published in Workforce & Professional Development

By Laura Siegel, Specialist, NCPHLL

It’s fellowship season at APHL! Last month we received over 315 applications for the 2014-2015 class of EID fellows. As the review committee evaluates this year’s applicants, let’s take a look back and see what members of last year’s class are up to.
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“It boggled my mind that there are invisible little creatures that can infect you. The fact that you can’t even see them with the naked eye – and they’re crawling all over you, is fascinating,” said Kayleigh Jennings, PulseNet Specialist and Biological Scientist III, at the Florida Department of Health- Bureau of Public Health Laboratories in Tampa, Florida.

By the time Kayleigh hit middle school, she knew she was interested with science, and ever since that first microbiology lesson, her interest never faltered.

Where are they Now? Looking Back at Class of the 18 EID Fellowship: Kayleigh Jennings | www.aphlblog.org

Kayleigh attended the Ohio State University where she majored in Microbiology and minored in Public Health. In her third year at school, she worked at a research facility alongside Michelle Landes, a student who had just received her acceptance into Class 17 of the Emerging Infectious Diseases Fellowship Program. Michelle discussed the program with Kayleigh and encouraged her to apply for Class 18. Kayleigh was so excited about the opportunity she completed the application nearly a year before it was due.

Ten months later, she packed up her life into her small sedan and made the trek from Ohio to sunny Florida to start her dream job as an EID fellow.  Florida was high on Kayleigh’s list not just for its sunny weather, but because her host laboratory, the Florida Department of Health, allowed her to rotate through all the various departments within the lab. This flexibility led her to discover what she enjoyed doing most – working with Salmonella outbreak surveillance using pulsed-field gel electrophoresis (PFGE) and PulseNet – the Centers for Disease Control and Prevention’s national network connecting cases of foodborne illness to detect outbreaks.

“Analyzing Salmonella – I felt like I was doing something important,” said Kayleigh. “It’s gratifying — I’ve seen a series of DNA patterns that are exactly the same, which means they could be a cluster contributing to an outbreak.  I’ve had times where I’ve had to make a phone call to the epidemiologist, and say ‘You should take a look at this…”

One day Kayleigh was glad she didn’t have to make that call; the day she came across one of the most virulent Salmonella strains she had ever seen.

“An 18 year old boy originally from Nigeria came to a local ER soon after he presented with symptoms, and passed away a few hours later. The medical examiner routinely sends cultures to the Clinical Microbiology Department at the Department of Health for analysis, and it was determined to be an atypical septicemic Salmonella infection.  Since the Salmonella was isolated, the sample was then sent to our PFGE laboratory, and thus landed in my hands.” said Kayleigh.

After running PFGE, uploading the pattern to the appropriate databases, and sending the sample to the CDC for further verification, it was quickly determined that it was a rare strain, not typically endemic to the U.S. Thankfully, this particular strain posed little risk to the rest of the population.

While death from Salmonella is rare, foodborne illnesses are quite common and can make individuals very ill without proper treatment. With more than 48 million people in the US acquiring foodborne illnesses each year, food surveillance systems and the laboratory professionals that support them are critical.

“Foodborne illnesses are not going away anytime soon. If someone is sick, you want to know if that strain is contributing to an outbreak. If there was no PFGE or food safety… an outbreak could be spreading rampant and no one would know.”

Other highlights from Kayleigh’s fellowship include working in a BSL-3 laboratory for the first time, touring the CDC headquarters in Atlanta, GA, and training at the local county health department.

“I never would have had any of these life-changing experiences if not for this fellowship,” she said.

When asked about her future plans, she said, “Will I stay in public health? Definitely — I don’t even know what else I would do,” she joked.  “I enjoy helping, and I like the feeling that what I do matters.

Stay tuned for more posts on past EID fellows!

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Measuring Household Dust for Potentially Dangerous Chemicals

Apr 08 2014 :: Published in Environmental Health

This blog post is part of a biomonitoring series.

Can analyzing our household or workplace dust help scientists predict the levels of potentially dangerous chemicals inside our bodies?

In a world where furniture, carpets, curtains and electronics are treated with potent flame-retardant chemicals, we are exposed continuously to novel chemical substances upon which little research has been conducted. The use of flame retardants has become necessary due to changing types of materials used in our household goods.

Measuring Household Dust for Potentially Dangerous Chemicals | www.aphlblog.org

“Think of your living room and all the synthetic materials used in the furnishings and curtains,” said Myrto Petreas, PhD, MPH, from the California Department of Toxic Substances Control. “Now compare that to what was in your grandmother’s living room. Her furniture was probably made with horsehair and wool, and was inherently not prone to fire. With synthetic fabric, there is more fire danger.”

The concern about flame retardants, she said, is that very little is known about these chemicals or what levels, if any, are safe for humans.

Around the time polychlorinated biphenyls, more commonly known as PCBs, were banned in 1979 due to human carcinogenic effects, chemists began creating new flame-retardant chemicals. Fifteen years ago, Petreas and her staff encountered one of the newer ones for the first time. “We were measuring chemicals in a study of breast cancer and looking at the body fat, levels of PCBs, etc. I went to a meeting in Sweden in 1998, where a researcher presented on these new chemicals, PBDEs (polybrominated diphenyl ethers), found in high levels in human breast milk. Back at the lab, I wondered, ‘Can we see it here?’ The levels were so high, I thought it was a mistake.”

Pausing, Petreas added, “The levels are 30 times higher in California now than they were in Sweden then.”

While researchers do not know for sure that the brominated flame retardants, especially the PBDEs, are carcinogens, they are structurally similar to the banned PCBs. They also assimilate into our fat. PCBs, although banned 35 years ago, are still found commonly in people, said Petreas, “because they are in the food web now.” Banning a chemical cannot eradicate it from the population, she explained, but “PBDEs are placed on purpose in our products. We are exposed through dust more than diet. After they are banned, 20 years from now, those PBDEs will be in the food web too, in birds and cows. They stay a long time in the body.”

PBDEs are endocrine disruptors that compete with the thyroid’s hormones, potentially affecting development and cognitive abilities. “In animals,” said Petreas, “they are carcinogens; in humans, we can now look and see but do not have the answers yet.”

The question about whether chemical levels found in dust can help predict the levels in our bodies is an interesting one to biomonitoring scientists who study chemical levels in the human body. “What you see in the dust takes many steps to reach your body,” said Petreas. Just because the chemical is in the air or dust does not mean that your body will absorb it. Also, it is possible that chemicals may be dangerous in combinations rather than alone. Genetics also likely influence susceptibility. Biomonitoring is a sufficiently new science that many questions remain unanswered.

However, it is feasible that scientists could get a good idea of exposure merely by studying the contents of a household’s vacuum cleaner.

Petreas’ lab has worked on two dust studies. One, the California Childhood Leukemia Study, with UC Berkeley, is looking for correlations between childhood leukemia and chemical exposures found in the home. The study is not complete but after looking at the dust samples, Petreas said, “we have seen differences among homes and geography. There is a socio-economic factor: there are higher levels of PBDEs in house dust among lower income households and people of color.”

They also found a high correlation in results from dust tests repeated 3-8 years apart on the same home, showing that the chemical levels were not declining much over time.

The second study, the Firehouse Dust Study that compared levels of pollutants in the blood of firefighters and in the dust of the firehouses, was a side-study of the Firefighters’ Occupational Exposures (FOX) study, conducted by Biomonitoring California with UC Irvine.

“In this pilot study, we tested the blood and urine of 99 men and 2 women,” said Petreas. “We had questionnaires about their work: do they work with forest fires or structural fires? What kind of protective gear do they have and is it used? Later, we wanted to combine the environmental measure with this earlier biological measure. We took samples of dust from the station’s vacuum cleaners. This gives an overall integrated measurement to what the firefighters have been exposed to over time in the firehouse.”

They discovered, perhaps unsurprisingly, that firefighters did have much higher levels of flame retardants in their blood than an average person. Researchers are still trying to identify the main sources of exposure.

Actually, PBDE levels in Californians are higher than in most Americans, largely because of the state’s unique flammability requirements. Petreas pointed out that because the California market is so large, many corporations are designing products to meet the state’s stringent flammability standards and then selling them across North America. As a result, PBDE levels in North Americans are much higher than in Europeans or Asians.

“[Researchers] are always a few levels behind the marketplace,” said Petreas. “We measure the PBDEs now, but already there are different chemicals being used and we don’t know what they are. We can see these chemicals in our samples, but we haven’t studied them yet.”

An important factor in launching these studies has been the creation of Biomonitoring California, a legislatively mandated program that aims to determine baseline levels of environmental contaminants in Californians, study chemical trends over time, and advise regulatory programs. Biomonitoring California is a collaborative effort between the California Department of Public Health, the Office of Environmental Health Hazard Assessment, and the Department of Toxic Substances Control.

“What else is out there that we don’t know about and haven’t looked for?” Petreas asked, echoing a concern that led to the creation of Biomonitoring California.

To reduce exposure to potentially dangerous chemicals, whether from dust or other sources, Petreas said, “Wash your hands before you eat. Just like your mother told you. Never eat at your computer. Leave your shoes outside. These things help with most public health concerns, whether avian flu or chemicals.”

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Without biomonitoring, public health practitioners face challenges in understanding whether environmental contaminants are actually being absorbed into people’s bodies. Given improvements in technology, the capabilities and expertise that exist in public health laboratories, and the increasing demand from the public for more information about chemical exposures, biomonitoring is poised to become an integral component of public health practice.

To learn more about biomonitoring, check out some of APHL’s Biomonitoring Resources:

Stay tuned for our soon-to-be-unveiled Meeting Community Needs page and of course, let us know if you have any feedback or suggestions.  

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APHL Global Health: My Touchstone

Apr 01 2014 :: Published in Global Health

by David Mills, PhD, Director, Scientific Laboratory Division, NM Department of Health

It all began with a late afternoon phone call from my boss, asking if I had any interest in volunteering my time on an APHL project to help public health laboratories in Central America recover from the devastation of Hurricane Mitch. “Sure,” I casually replied, not realizing that my answer was launching me on a journey that, over the next 14 years, would take me to 17 countries on four continents and provide me with some of the most meaningful and rewarding experiences of my professional life.

Looking back, I have to say that I have thoroughly enjoyed the ride. Much of the satisfaction and enjoyment my experiences with the APHL Global Health Program have provided are what I might have anticipated when I first got involved. Philosophically, I had always been a proponent of international assistance and a fan of engineer and inventor, R. Buckminster Fuller, who described the planet as a boat and pointed out the fallacy of the notion that people living in the starboard side of the boat could allow the port-side to sink “without getting their own feet wet, let alone being drowned.” So, international work appealed to me on that level.

APHL Global Health: My Touchstone | www.aphlblog.org

In addition, I have always enjoyed travelling and experiencing different cultures, and my work with the APHL Global Health Program has certainly provided that. And then there was the opportunity for adventures; finding time, after the official work of APHL was finished, to squeeze a day or two for personal activities before returning home, e.g. a safari in Tanzania or a visit to the Forbidden City in China. Other “excitements” were smaller, serendipitous and, perhaps because of that, even more memorable. I will always remember stepping off a small plane near Mt. Kilimanjaro at sunset, catching my first intoxicating whiff of dry grass and faint smoke and being told, “You will never forget that; it is the smell of Africa,” or eating breakfast at sunrise on the edge of a Namibian water hole and spying a troupe of baboons, with babies on their backs, moving through the brush on the far side. Nor will I forget an initially staid and formal evening dinner in a Ukrainian garden that (d)evolved into a boisterous evening of singing, toasting (vodka…) and laughing with new friends after the electricity failed and the gathering continued long into the night by candlelight.

Teaching has also always brought me a great deal of satisfaction—I was a university professor before switching to a public health career—so developing courses and providing training to laboratory professionals for APHL has been extremely enjoyable. I have had the good fortune to be able to share the lessons of my professional experiences (successes and failures) with colleagues in other countries and also to learn from theirs.

But what I never could have anticipated so many years ago and what, more than anything, has kept me coming back again and again to volunteer are the inspiration and humility that that I experience on every single project for Global Health. My day job is terrific—as director of a state public health laboratory, I go to work every day in a new multi-million dollar facility equipped with millions of dollars of analytical instrumentation (and a staff engineer to maintain it) and sophisticated engineering safety systems. Our laboratory is supported by a central team that responds immediately to IT issues, and a courier system that delivers specimens overnight. We have access to federal laboratories for specialty testing and technical support and a national organization, APHL, which provides training and professional support. And yet, with all of these resources, I find that much of my time is spent focusing what is perceived as lacking—budget, staff, competitive salaries, flexible work schedules, new instrumentation, software and so on. These challenges, difficult and ubiquitous, are the reality of management in public health. Over time, however, immersion in these details day after day can make the excitement over the greater purpose of the mission and the people we serve fade and seem very far away, and it is this that keeps me coming back to volunteer.

To periodically leave my day job and travel to a place where smart and talented professionals pursue the mission of the public health laboratory, performing testing similar to that in our own laboratories, but under very difficult conditions, is inspiring. What do I mean by difficult? Difficult is a laboratory performing serology testing when it has electricity irregularly for only 2-4 hours per day. Difficult is washing and reusing latex gloves because of their scarcity. Difficult is performing microscopy in a room with high water stains on the walls a meter off the floor and all of the refrigerators on blocks to keep them above the periodic floodwaters. Difficult is not having a single repair technician in the country to service analytical instruments. Despite these incredible challenges, the people I have worked with in country are enthused, dedicated and optimistic about the work they perform and its importance. Seeing how much they accomplish under these circumstances, I often have thought to myself, “If these people had even half of the resources and support that I have in my laboratory, they would leave me in their dust!”

Quite simply, the international projects are my touchstone. They remind me how fortunate we are, and they re-energize me and rekindle my enthusiasm for my career as a scientist in public service… and after each experience, I return to my laboratory able to do my job better than before I left. Without a doubt, I gave my boss the right answer.

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HIV Testing Where Ice Melts Fast: EID Fellow Reports from Botswana

Mar 26 2014 :: Published in Workforce & Professional Development

By R. Suzanne Beard, PhD, Emerging Infectious Disease Research Fellow

Dried blood spots (DBS), drops of blood collected to screen newborns for congenital disorders, are the wave of the future for HIV testing of all sorts; at least that is what I am trying to prove during my Emerging Infectious Disease Research Fellowship. How am I doing this, you ask? Great question! I am helping design studies to evaluate filter papers from different manufacturers for viral load testing and drug resistance genotyping in resource-limited settings.

As antiretroviral treatment expands in resource-limited areas, so does the need to complete testing quickly. The problem is that plasma – to date the gold standard in HIV testing — requires separation from whole blood, and then it needs to be frozen and kept that way until testing. This leads to the need for cold chain transport in places that may not have stable electricity or the infrastructure to maintain freezers. And all this in a place that makes summer in the south look refreshing. Trust me, if you order an ice water in Botswana in November, the ice doesn’t last very long, and the same thing goes for ice in a cooler with specimens.

HIV Testing Where Ice Melts Fast: EID Fellow Reports from Botswana | www.aphlblog.org

In the year since I started working with HIV, I have discovered that much of the research with DBS does not consider conditions in resource-limited settings, as a result, when protocols are implemented in these areas, the impact on patient care may not be as profound as it could or should be. My team is working to produce quality research that takes this into account and actually conducts the work in areas where cold chain transport isn’t an easy, inexpensive option.

I spent a month in Botswana initiating a protocol to investigate the usefulness of three DBS filter paper cards to evaluate viral loads, and in those failing treatment, the prevalence of HIV drug resistance in pediatric patients on anti-retroviral therapies (ART). As with every protocol, what you dream up sitting in your cubicle, doesn’t always account for the issues you find on the ground during implementation. It took almost two weeks before specimen collection could begin. In the meantime, we amended the protocol to speed up specimen collection and added a collaborator (Baylor Pediatric Clinic). The key to a successful trip to a new country is to be flexible and focus on the unique assets in front of you!

I also assisted in troubleshooting several assays in use at the Ministry of Health and CDC-Botswana labs. The opportunity to do technology transfer and troubleshooting is one of the things I like best about traveling to labs in other countries. Each new lab represents a completely different set of obstacles and challenges, even if those labs are right across the street from each other. On this trip, I was working to transfer a new, more cost-effective in-house HIV drug resistance genotyping test.  I had a great time working together with all of the technicians. We modified the protocols to fit what they had available to them and worked on sequencing analysis. After a couple of days, they felt more confident in their own abilities.

My final job was to visit clinics around Gaborone (the capital) and Francistown (the second largest city) to collect information on ART enrollment for an upcoming protocol with the Ministry of Health. After database issues delayed efforts to collect numbers needed to determine how many clinics should be established in the region, we decided to tackle the problem in a low tech fashion.  With the approval of the Ministry of Health, we spent several days visiting clinics. This gave me a chance to get to know the country a bit better and to interact with nurses, doctors and other community health support staff who work on the front lines of the HIV pandemic.

If we are to have a chance at achieving an AIDS free generation, we must collaborate to build capacity in labs and clinics through training and access to inexpensive specimen collection and testing. This capacity isn’t just useful in far-off, exotic places; everything we do is applicable here at home. During emergencies when power is down for long periods of time — think Katrina or Super Storm Sandy — DBS technology can keep key public health initiatives on track.

I look forward to returning to Botswana to continue working with my colleagues to transfer technology and expand use of DBS.

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TB Vanquished by Lab System in the “Malibu of the Midwest”

Mar 24 2014 :: Published in Infectious Diseases

By William Murtaugh, specialist, HIV/TB programs, Infectious Disease, APHL

“Defeat TB: Now and in the Future.”  This was the first theme of World Tuberculosis Day declared by the International Union Against Tuberculosis and Lung Disease (IUATLD) 32 years ago today in 1982, and 100 years after Dr. Robert Koch announced his discovery of the bacteria that cause tuberculosis disease (TB).

Well, the future is March 24, 2014, and TB has not yet been defeated.  But year after year,  and theme after inspiring theme,  the global public health community still proclaims a call to arms, aiming to inspire the world to take up the cause of TB elimination.

TB Vanquished by Lab System in the “Malibu of the Midwest” | www.aphlblog.org

In the United States, the burden of TB is very low relative to many parts of the world. Why then should we be concerned with Mycobacterium tuberculosis, the obligate bacillus demanding our attention today?

It is common to cite TB statistics to emphasize the disease’s impact and the progress toward its elimination. Indeed any TB expert can pull some staggering historical numbers out of his or her pocket.  But reconciling unembellished phrases like “billions infected,” “millions of new cases,” “over a million deaths,” with the experience of those of us average Americans who’s TB “exposure” is limited to news bulletins on World TB Day, is challenging. For us, World TB Day serves as a gentle nudge that the disease is still a threat, and the fight for its elimination continues. Yet while I would be remiss if I did not mention that the United States has seen 21 years of consecutive decline in annual TB cases, I must contend that TB awareness is particularly important here in the United States because of the country’s low TB burden.

Lest we take our progress for granted, repeating the mistakes of the 1980’s and 90’s, it’s important to remember the consequences when the health system falters.  But for the one day, hour or minute that we consider World TB Day, let’s recognize that our progress to date has been achieved through the quiet efforts of a public health system that functions not one day, but all year long.

A TB outbreak in April 2013 exemplifies this point. Along the shores of Lake Michigan sits Sheboygan, WI, a city whose description could be mistaken for a Garrison Keillor monologue “where all the children are above average” and so too are its TB case rates. This Midwestern community learned the hard way that the damaging effects of TB can still be very real.

Prior to 2013, Sheboygan County typically saw fewer than three TB cases per year.  Known as the “Malibu of the Midwest” for its lake surfing competition (the largest in the world in fact), Sheboygan was a place more familiar with the phrase “Hang Ten” than “MDR-TB.”  Then in mid-April, the Sheboygan County Health Department was notified of a suspected TB case that would lead to an outbreak that would engage its resources and generate national media coverage for the remainder of the year.

Before it was over, the outbreak would cross the county and spread through multiple generations of a single family, school children and healthcare workers. It would lead to a case of MDR-TB, 11 additional cases of active pulmonary TB disease and 38 latent (non-symptomatic, non-contagious) TB infections. Over $6 million in state and federal funds ($4.7 million state, $1.4 million federal) would be expended to cover costs associated with outbreak investigation, testing, treatment and prevention measures.

Because TB is uncommon in the US, doctors may not consider it as a potential diagnosis. The first (i.e., index) case in the Sheboygan outbreak sought medical care for symptoms at least eight months before receiving a diagnosis of TB. What should have been a straightforward case – in which a suspected TB patient is diagnosed, treated and transmission prevented – led to eight months of transmissions.

Once TB was finally proposed as a diagnosis, the Wisconsin State Laboratory of Hygiene (WSLH) responded quickly, performing initial screening in two days and confirming diagnosis in less than two weeks. This diagnosis kick-started the TB control system into high gear. The patient was isolated and treated, and contact investigations were initiated to find related cases.

Next the WSLH assessed the standard drug regimen to determine if it would prove effective with this patient. With assistance from the Centers for Disease Control and Prevention (CDC), the lab identified  multi-drug resistant TB (MDR-TB) a category of infection that involves resistance to multiple drug therapies, is more difficult and expensive to treat, and holds a higher risk of death — as the cause of the patient’s illness. Now the concern was, “Had other patients been exposed to MDR-TB in the past eight months?”

More specimens began arriving at the local laboratory near Sheybogan, which quickly exceeded its capacity. With the threat of an MDR-TB outbreak, a solution was needed quickly. Enter the integrated public health laboratory system!  State and local laboratories coordinated with the community hospital in Sheboygan and decided jointly that all specimens from TB suspects would go to the WSLH.

As diagnosis after diagnosis of active pulmonary TB was confirmed, the state TB Control Program wanted to know if all these cases were part of the same outbreak.  While this may seem an obvious “YES!”, not all TB is created equal. Numerous strains of TB are continually in circulation. Without identification of the specific strain, public health officials could not understand the chain of transmission, and without this information, they could not control the outbreak.

Through a CDC initiative designed to strengthen national response to TB outbreaks, state public health laboratory in Michigan performed complex testing to uniquely identify each strain of M. tuberculosis (called genotyping). They determined that the MDR-TB patient was infected with two different strains of TB, one of which was not MDR-TB.  The state laboratories confirmed that other TB strains also belonged to the outbreak. None of these strains, however, were MDR-TB and therefore were more easily treated.

Not bad for a low burden TB setting.

Sheboygan’s story reminds us that TB outbreaks can happen anywhere. Yet if an outbreak does occur in our community we can look with confidence to the response capability of the nation’s public health laboratory system. The impressive response to the outbreak in Sheboygan testifies to the expertise and commitment of  these laboratory professionals. It also epitomizes CDC’s World TB Day theme:  “Find TB. Treat TB. Working together to eliminate TB.”

To learn more about public health laboratories and TB, check out APHL’s TB page. Additional information and resources for World TB Day and related events can be found at CDC’s dedicated website.

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Days End; Unending Night?

Mar 18 2014 :: Published in Public Policy

By Peter Kyriacopoulos, senior director of public policy

The federal fiscal year 2014 appropriations process concluded on January 17, 2014, with enactment of the Consolidated Appropriations Act. That bill funded federal government operations for the eight month remainder of fiscal year 2014, which began October 1, 2013 with the shutdown of the federal government and runs through September 30, 2014.

Overall, the 2014 appropriations levels provide some relief for many programs on which the nation’s public health laboratory system depends. Instead of the full $36 billion cut in nondefense discretionary spending – the budget account that funds the Department of Health and Human Services and its agencies like the Centers for Disease Control and Prevention (CDC), the Health Resources and Services Administration (HRSA) and the Food and Drug Administration (FDA) – required by current law, only $14 billion will be cut in 2014.

Days End; Unending Night? | www.aphlblog.org

This $22 billion in “additional” funding has led to $30 million in funding for the CDC Advanced Molecular Detection initiative, an additional $31 million for state and local preparedness, and $9 million more for CDC food safety activities. Most other areas of CDC, HRSA and FDA of interest to the public health laboratory community get level funding, the exception being CDC’s Public Health Workforce which is cut over $11 million – a cut that imperils the APHL fellowship program in the coming year. Funding for the Environmental Protection Agency (EPA) Clean Water and Drinking Water revolving funds are also increased $73 million and $46 million respectively.

While the 2014 funding levels offer some respite, it is transitory as the agreement for spending levels in fiscal year 2015 includes a much smaller reduction is spending cuts of only $9 billion. This also means the amount cut will be $27 billion – or $1 billion more than the amount cut in 2013. Complicating the picture further, $7 billion of the $9 billion in relief is directed to other specific funding needs so that the actual relief from cuts for the rest of nondefense discretionary is closer to only $2 billion. Federal funding in 2015 will be substantially below what was provided in 2013 with the possibility that it will have the effect of a $34 billion cut, and each of the fiscal years 2016 through 2023 will have no relief from the $36 billion that will be cut annually.

One hopes that the impact of these current and projected cuts provide ample evidence on why sequestration and automatic cuts in spending were never intended to become actual policy and are so punitive that they lead to a more inspired and thoughtful resolution of financing federal government operations. If not, the dark forecast will indeed appear as unending night.

  •  SEQUESTRATION!
  • American Taxpayer Relief Act (ATRA)
  • Sequester 2013 Operating Plans
  • CDC funding cut $340 million; PHEP hit hardest at -$34 million
  • HRSA: -$365 million
  • FDA: -$209 million
  • Global Health: -$411 million
  • EPA: -$385 million
  • After Sequester?
  • Fiscal Year 2014
  • House-passed budget – 3/2013 (Congressman Paul Ryan)
    • Continues reduced sequestration funding for nondefense discretionary (NDD);
    • Cancels the reductions in defense and transfers those cuts onto NDD; and
    • Imposes  additional cuts of $700 billion on NDD over the next ten years.
    • Senate-passed budget – 3/2013 (Senator Patty Murray)
      • Eliminates sequestration,
      • Imposes cuts of $145 billion on NDD over next ten years.
      • President’s budget request – 4/2013
        • Eliminates sequestration
        • Imposes cuts of $98 billion on NDD over next ten years, staring 2017
        • CDC takes largest cut of any HHS agency, -$270 million
        • SHUTDOWN!

(Partial)

  • We Have a Deal?!
  • What is That Number?
  • Murray/Ryan Agreement
  • 2014 Appropriations

 

  • WHAT’S NEXT?!
  • What’s Next?
  • Total spending for 2015 is set –
    • $1.013  trillion
    • NDD sequestration for 2015 is set –
      • $27 billion (+$1 billion over 2013; ~+$6 billion)
      • President’s budget for 2015 March 4
        • So what?
        • How Does This End?
        • 2015 funding cuts worse than 2013 – no delays
        • 2016 full $36 billion NDD sequestration
        • Impact of mid-term election results?

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Returning Biomonitoring Test Results in an Easy-to-Understand Format

Mar 11 2014 :: Published in Environmental Health

This blog post is part of a biomonitoring series.

Returning Biomonitoring Test Results in an Easy-to-Understand Format | www.aphblog.org

California passed novel legislation in 2006 that united three state departments in a new program called Biomonitoring California. These three departments—the California Department of Public Health, the Department of Toxic Substances Control and the Office of Environmental Health Hazard Assessment—are tasked with learning more about the chemicals found commonly in Californians, studying chemical trends over time and helping assess the effectiveness of current environmental chemical regulations.

“To address this legislation, we work very closely with our partners,” said Sandy McNeel, DVM, from California’s Department of Public Health. “We have different areas of expertise, so it is a very useful collaboration.”

The legislation defines “community” broadly with respect to biomonitoring studies. “Communities are not only geographically based, but also could be a group of pregnant women or a group who, because of their occupation, may have unusual exposure to certain chemicals,” said McNeel. Since inception, the program has initiated community-based studies of various types and collaborated with other researchers within state government and academia.

As these pioneering biomonitoring studies proceed, the state’s researchers are wrangling with an interesting facet of the law: they are required to return individual test results to all study participants who request them—in an easy-to-understand format.

While it may sound simple, it is very challenging to translate medical and laboratory research into straightforward English; or Spanish, as the case may be.

Still, the greater challenge is that no one, not even the scientists, really knows what some of the biomonitoring results mean in relation to human health. Whether a chemical causes health problems depends on how toxic the chemical is, how much a person takes in, and how long a person is in contact with the chemical.

Biomonitoring is a relatively new branch of laboratory science and new chemicals enter the marketplace every day. There are tens of thousands of chemicals in use today, many of which have not been studied throughly. Discovering possible health effects of chemicals can take years of research. Even with evidence that a chemical causes a particular health effect, it is difficult to know what level in people’s bodies would be harmful. Someone may have a high level of a chemical in her body and never have any effect from it. Another may have a similar level of the chemical and become ill, perhaps due to her genetic predisposition, an underlying health problem, other exposures, or additional unknown factors.

To help make all of this information clear to study participants, Biomonitoring California assembled a team that includes data analysts, chemists, epidemiologists, toxicologists, and health educators to identify what information would be useful to participants and how it should be worded or displayed for best effect.

After working through many versions of the results return format, the team field-tested it for feedback. The team simulated a set of biomonitoring test results and asked groups of volunteers from two ongoing studies to help refine it.

In one of those studies, the Firefighter Occupational Exposures (FOX) project, firefighters had been tested for a large number of chemicals, including some potentially dangerous flame retardants. The simulated results used in the testing process came with clarifying text, tables, graphs and a one-page fact sheet on each chemical or class of chemicals.

“We developed the materials to report results keeping in mind that the vast majority of study participants do not have a chemistry background or an understanding of what chemical exposure might mean,” said McNeel. “We spent quite a bit of time developing the text, thinking about the most understandable yet scientifically accurate way to describe the results.”

An individual can compare his or her results to others from the same study, as well as to data from the National Health and Nutrition Examination Survey (NHANES) when available.  This way a study participant can see where he or she stands in relation to a representative sample of the United States’ general population.

After the simulated results were shared with the firefighters, a couple of the biomonitoring staff met with them to identify any points of confusion. The feedback led the team to add an explanation of why this community, in particular, was being studied and why the human health implications of most chemical exposures are still largely unknown.

Going forward, as results are returned to study participants, Biomonitoring California staff will follow up to see if people have a good understanding of the test results.  “We tested, revised, tested, revised and still we consider these works-in-progress. We will continue to fine-tune the results return documents as we get more feedback from participants,” said McNeel.

McNeel added that, despite the results return team’s best efforts, some firefighters did express a degree of frustration about why they were being tested for chemicals if no one knows what the results mean. “Firefighters are an altruistic group of individuals,” she said. “We explained there just hasn’t been the research done to determine whether there are health effects associated with some of these chemicals and at what level health effects might start to occur. Some of our work is to help establish chemical levels in various groups so that we can compare and contrast them, and that this work will benefit future firefighters.”

Researchers with Biomonitoring California have found this design process rewarding. “All of us in the program really feel that it’s important for people to have a better understanding of chemicals in our environment,” said McNeel, “This is an area that deserves greater attention.”

To see an example of a results document, visit www.biomonitoring.ca.gov/sites/default/files/downloads/03162012FOXMockResultsPacket.pdf.

Without biomonitoring, public health practitioners face challenges in understanding whether environmental contaminants are actually being absorbed into people’s bodies. Given improvements in technology, the capabilities and expertise that exist in public health laboratories, and the increasing demand from the public for more information about chemical exposures, biomonitoring is poised to become an integral component of public health practice.

To learn more about biomonitoring, check out some of APHL’s Biomonitoring Resources:

Stay tuned for our soon-to-be-unveiled Meeting Community Needs page and of course, let us know if you have any feedback or suggestions.  

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Biomonitoring Project in Native American Community Helps Protect and Inform

Mar 05 2014 :: Published in Environmental Health

This blog post is part of a biomonitoring series.

Dr. Carin Huset began her career measuring chemicals in water, not people. “My doctoral thesis was on PFCs in wastewater, rivers and landfills,” she said. “It was all environmental, not public health, and much more abstract.”

Huset now spends her time testing people for chemical exposure. This work, known as biomonitoring, is on the leading edge of public health laboratory science. Huset and other laboratorians at the Minnesota Department of Health (MDH) public health laboratory are able to measure the amount of natural and manufactured chemicals inside of a person by analyzing blood or urine.

Currently, Huset and partners in the local health community are working with a group of Native American volunteers from the Fond du Lac Band of Lake Superior Chippewa to measure the chemical levels in their bodies. People living in this community may have greater contact with environmental chemicals as consumers of traditional foods such as fish and waterfowl.

Biomonitoring Project in Native American Community Helps Protect and Inform | www.aphlblog.org

This biomonitoring project is part of the wider federal Great Lakes Restoration Initiative (GLRI), which is focused on cleaning up toxins, resisting invasive species, protecting watersheds from polluted run-off and restoring wetlands. The GLRI is funding the MDH’s work with members of the Chippewa tribe to determine the impact of pollution on the local population.

Since biomonitoring is a relatively new area of laboratory science, Huset and her partners began designing a study that had no real counterpart, and therefore had to overcome a series of mundane, but critical, difficulties. Minnesota staff needed to work out tricky legal agreements with partner labs, add a new testing capability, identify and interview the study’s participants, and train clinic and other external staff.

“We needed to design a study that met the concerns of the community, as well as the requirements of the GLRI,” said Huset. The GLRI wants data on exposure to eight PCBs, Mirex, HCB, DDT and DDE, lead and mercury; the Minnesota laboratory added more than a dozen additional analytes to the test panel. Although mainly testing for chemicals resulting from potential environmental exposure, the lab chose to include a few extra, such as cholesterol and Hemoglobin A1C, which will allow study participants to follow up with their doctors to make personal health decisions. The lab is also studying the level of Omega-3 fatty acids in the participants, high levels of which are considered a positive effect of eating fish.

To conduct all of these tests, the clinic staff is “drawing 44 milliliters of blood, or about 7 tubes,” said Huset. Because each person’s blood must be divided for the varied laboratory tests and then delivered to more than one location, it was essential to design an easy-to-use sample kit; particularly since the blood is not drawn in-house, but at a clinic on the reservation. To reduce sample contamination and confusion, the kit has twenty different sample cups and vials with different colored caps.

A lab employee travels up to the clinic each Friday to collect the week’s frozen blood and urine samples, in part due to the clinic’s limited storage space, but more importantly, said Huset, because “the samples are precious and we worry about the potential for a power outage over the weekend, which would ruin them.”

Once the samples reach the MDH public health laboratory, some of them are then batched and sent to the Michigan Department of Community Health Laboratory or to private labs. Huset explained, “When the GLRI funding came through, one of the required tests was for PCBs, which affect other parts of the Great Lakes region, but are not a significant concern in Lake Superior or Minnesota.” Minnesota lab staff do not see a strong need for their facility to have this particular testing expertise, especially since PCB testing is relatively complex; also important, the GLRI funding did not come with an allowance to add new capacity. Fortunately, the Michigan laboratory has a robust PCB testing program.

“The contract work between the two states was more challenging than we expected. Both labs were willing participants, but we didn’t allow for the problems among the lawyers and the wording of the contracts,” said Huset. Once the technicalities were resolved, the partnership has worked smoothly.

Due to similar legal complications with a different laboratory partner, the Minnesota lab elected to allocate some of its own funds to develop testing capacity for 1-hydroxypyrene. “This was a test we wanted to develop anyway,” said Huset, “and it’s far less complicated than the PCB testing.” 1-Hydroxypyrene has been included in the study due to potential contamination in a Lake Superior watershed adjacent to a SuperFund site.

A great advantage to the researchers is that the Fond du Lac Band of Lake Superior Chippewa are “a very engaged and interested group,” said Huset. Participants have answered extensive questions about their personal history and habits.

A community’s engagement in a biomonitoring project is vital to its success. Prior to this GLRI project, the MDH ran four successful biomonitoring pilot studies, measuring arsenic levels in the urine of children who had played in contaminated soil, mercury in newborn screening collection cards, chemicals in pregnant women, and PFC levels in the blood of people affected by a contaminated community drinking water supply.

In the drinking water study, the participants’ commitment spurred the project on. “The community knew about their water contamination and were concerned. They pushed their legislators to push the funding through for the study,” said Huset.

In this case, PFC contamination had been discovered in 2004 in both private and municipal wells in a community. By the end of that year, the community’s exposure had been reduced through a combination of methods, including treating the municipal well, installing in-home filters, encouraging the consumption of bottled water, or transferring homes from private wells to the public water supply. In 2008, MDH conducted its initial biomonitoring study on people who had been exposed to the contaminated water and discovered that the levels of PFCs in their blood were higher than national levels. But then, in a follow up study in 2010, MDH discovered that the community’s average blood PFC levels had declined since 2008. The biomonitoring project demonstrated that the public health efforts undertaken in 2004 to reduce exposure had worked.

“This was a targeted public health action,” said Huset, “and it was effective.”

Part of the complexity of this process, in the pilot projects and again with the GLRI, is determining which chemicals to look for, what levels in people are safe, and when authorities should take action.

Noting the difference between measuring the chemicals levels in people and her earlier environmental work, Huset said, “People everywhere are very interested in what we do here, and they have a lot of questions.” Researchers do too, still trying to determine which pathways of exposure—such as diet, occupation or hobbies—predict contaminant concentrations in people. As studies like the GLRI project progress, it will be easier to identify public health actions that will protect people at increased risk of chemical exposure.

At the end of this study (sometime in 2014) researchers will have valuable new information about chemical exposure and human health. For more information about the Fond du Lac Band of Lake Superior Chippewa biomonitoring study, see www.health.state.mn.us/divs/eh/risk/studies/tribalstudy.html.

Without biomonitoring, public health practitioners face challenges in understanding whether environmental contaminants are actually being absorbed into people’s bodies. Given improvements in technology, the capabilities and expertise that exist in public health laboratories, and the increasing demand from the public for more information about chemical exposures, biomonitoring is poised to become an integral component of public health practice.

To learn more about biomonitoring, check out some of APHL’s Biomonitoring Resources:

Stay tuned for our soon-to-be-unveiled Meeting Community Needs page and of course, let us know if you have any feedback or suggestions.  

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West Virginia’s Spill and the Importance of Laboratories

Mar 04 2014 :: Published in Environmental Health

By Megan Weil Latshaw, Director, Environmental Health Programs

Living in the United States usually means we can expect clean water every time we turn on our tap.[1] But for over a week, hundreds of thousands of West Virginians were unable to use their water for drinking, bathing, showering or even brushing their teeth.[2]

The recent Elk River story led to many questions about chemicals policy in the US. For example, the New York Times called into question WV’s regulatory framework and National Public Radio discussed the lack of oversight of chemical storage facilities. It also drew attention to our lack of knowledge about these chemicals:

  • Deborah Blum, a Pulitzer-Prize winning writer, highlighted how little we know about chemicals in commerce.
  • The Director of the US Centers for Disease Control & Prevention (CDC) pointed out how little they knew about the original chemical of concern, 4-methylcyclohexanemethanol or MCHM.

West Virginia’s Spill and  the Importance of Laboratories | www.aphlblog.orgBut despite all the news around the spill, few articles mentioned the role of laboratories. The West Virginia Public Health Laboratory was one of the labs that stepped up to handle the surge in water samples. Environmental chemists worked around the clock and chemists from other parts of the laboratory were pulled in to help. They adapted a CDC method that allowed them to report results three times faster than the other responding laboratories. The end is not quite yet in sight: the lab continues testing tap water samples due to concerns about the lingering odor associated with the chemical.

Here at APHL we’re proud of the public health laboratories who have built capability & capacity to detect chemical contaminants, not only in water, but also in people. These public laboratories, whose sole mission is to protect the public’s health, are prepared to operate 24/7 in order to do so.

We’re also proud of the progress being made by federal agencies to build laboratory networks across the country, able to handle just such emergencies (such as EPA’s Water Laboratory Alliance and the Laboratory Response Network for Chemical Threats funded by CDC). There still remains a lot of work to be done though:

  • Barriers to activating these networks remain. We need additional funding to increase their visibility, broad usefulness & efficiency.
  • Neither of these networks provides funding to detect radiological agents.
  • Electronic exchange of data between laboratories, crucial during emergencies for prompt decision making, remains highly inefficient.
  • Due to funding cuts, laboratories struggle to maintain well-trained personnel and aging equipment.

 


[1] As NPR recently pointed out though, we only monitor public water supplies for ‘known’ contaminants. What about all those ‘unknowns’ like pharmaceuticals or personal care products that get washed down the drain or flushed? APHL called on EPA to work with states on additional drinking water contaminant monitoring systems.

[2] The Wall Street Journal published a timeline of the spill and response.

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Integrating Biomonitoring with CDC’s National Environmental Public Health Tracking Program

Feb 26 2014 :: Published in Environmental Health

This blog post is part of a biomonitoring series.

In 2011, CDC’s National Environmental Public Health Tracking Program formed a Biomonitoring Task Force, composed of grantees from the agency’s Tracking Network. Members of the new task force were asked to find out what biomonitoring data exists in states and, where possible, to add it to the national tracking network’s data portal.

“There is an important and growing partnership between CDC-funded state tracking programs and laboratories interested in biomonitoring,” said Jean Johnson, PhD, supervisor, environmental epidemiology unit, and director, environmental public health tracking and biomonitoring program, at the Minnesota Department of Health. “CDC tracking programs bring the environmental epidemiology piece that is a critical resource for state laboratories interested in population-based biomonitoring.”

Integrating Biomonitoring with CDC’s National Environmental Public Health Tracking Program | www.aphlblog.org

Identifying Environmental Health Surveillance as a Priority

The Tracking Network was established in response to a 2000 Pew Environmental Health Commission Report, which revealed a fragmented surveillance system. Information gaps and data silos prevented scientists from connecting data on environmental exposures with chronic disease data.

“The consensus was that, if we created surveillance for environmental health, we would do a much better job connecting environmental hazards and exposures to Americans’ health,” said Johnson.

In 2002, CDC funded the new surveillance program that is typically referred to as the Tracking Network. Sixteen states were brought on board to systemically collect, analyze and disseminate environmental public health data. Since that time the network has grown to 23 states plus New York City and several academic partners. The participating states pull the data together by identifying and exploring existing data sources. Epidemiologists analyze the data for trends and spatial patterns. The academic partners then take a research angle, examining the data for connections.

There are approximately 15 content areas tracked in each state, including air quality, drinking water, chronic disease from cancer registries, heart disease, and carbon monoxide poisoning. In most states, children’s blood lead levels are the only biomonitoring data that have been tracked systematically, although federal support for blood lead surveillance in the states was recently cut.

All of this data is available to the public on web portals. “That’s an important part of tracking too because it’s not just states that use the data,” said Johnson. “Universities, advocate organizations, community and local public health folks: if it’s public data, it’s accessible to everyone who wants to use it.”

The participating states all agree to track certain things so that the network is supplied with nationally consistent data and measures. Teams from the states first identify what a consistent measure is, and then provide the data to CDC and post it to the public portals. Yet states are also free to add supplemental information that may be particularly relevant to their region.

“This program has really helped build significant environmental epidemiology capacity in state health departments,” said Johnson.

Taking Environmental Health Surveillance a Step Further by Adding Biomonitoring Data

In 2011, network participants decided to investigate whether any of the biomonitoring work conducted in the states was consistent enough to allow for national tracking of the data. The Biomonitoring Task Force was established, and it developed and sent a survey to the 23 states in the tracking program. The survey asked the states to review the past 10 years of available biomonitoring data to identify what analytes were tested, how, on what populations and with what kind of funding. Essentially the network was searching for consistencies that would make a particular chemical (in populations) trackable on a national platform.

In the survey, biomonitoring testing was split into five categories:

1) Mandatory report data: some states require hospitals or clinics to report poisonings or chemical exposures

2) Population-based survey: surveillance to measure spatial or temporal differences in population exposure or to evaluate the efficacy of public health actions to reduce exposure (for example, any state programs similar to NHANES)

3) Targeted public health investigation: in response to community health concerns about contamination or a disease cluster (drinking water contamination)

4) Rapid response: in response to an emergency situation, such as a chemical emergency in a school or community

5) Support of academic research project: providing laboratory support to academic institutions

Overall the results (see slide image below) reveal that there is very limited consistency among state biomonitoring programs, which would make it difficult to enter the data into a national tracking program. Very few of the studies use probability-based population sampling methods, meaning that researchers cannot generalize the results outside of the tested group.

Johnson pointed out that each state likely has more biomonitoring data than was identified in the survey since a lot of work never gets reported or published in peer-reviewed journals.

The survey results made it clear that the state tracking grantees want to build their biomonitoring programs. However, there is a significant lack of sustained resources to support state biomonitoring work.

The next activity on the task force’s agenda is to write a white paper to describe the current limitations posed by the existing data, and recommend strategies to help create consistent data across the country.

In the years to come, as states develop their biomonitoring programs, it will be important to work with the tracking network so that this valuable data is accessible and useful to anyone who needs it.

Without biomonitoring, public health practitioners face challenges in understanding whether environmental contaminants are actually being absorbed into people’s bodies. Given improvements in technology, the capabilities and expertise that exist in public health laboratories, and the increasing demand from the public for more information about chemical exposures, biomonitoring is poised to become an integral component of public health practice.

To learn more about biomonitoring, check out some of APHL’s Biomonitoring Resources:

Stay tuned for our soon-to-be-unveiled Meeting Community Needs page and of course, let us know if you have any feedback or suggestions.  

No comments yet

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