Could funding cuts to food safety programs make you sick?

Jul 23 2014 :: Published in Food Safety, Public Policy

By Michelle Forman, senior media specialist, APHL

Could funding cuts to food safety programs make you sick? | www.aphlblog.orgWhen public health works, no one sees it.

That’s a common adage at APHL and is most frequently used when referring to the gross lack of – and ever plummeting – funding for valuable public health programs. But what does it mean? When do we see public health and when does it vanish into the background?

The public health system comprises many areas from healthy eating to smoking cessation to biomonitoring to newborn screening. To answer this question, we’re going to focus on food safety – something that impacts every person in the United States – by following the journey of peanuts as they pass through the food system and into your lunch bag.

(Note: Peanuts were chosen to make a point. They are not inherently risky. As of the original date of this post, there is no current known outbreak associated with peanuts. This journey could feature any food item.)

Our peanuts were grown on a large farm that distributes its harvests for use in many different products.

After being roasted, they are shipped to another facility to be ground into a paste. That paste is then used to make peanut butter for cookies, crackers, ice cream, dog treats and many other products.

In a perfect situation, our peanuts are grown using the safest growing practices; thoroughly roasted to kill pathogens acquired on the farm; processed in facilities that ensure utmost safety and cleanliness in accordance with all food safety guidance provided to them; sent to stores, restaurants and other food service facilities where they will be purchased and consumed by families trusting that they are receiving peanut butter crackers free of Salmonella. Public health has worked in the form of inspectors, guidelines, regulations, sample testing, quality assurance, staff training and public education to ensure that a perfect situation can and will exist most of the time. Although you never saw public health working to prevent you from getting sick, it was there.

Even when all goes right – even when there are not blatant safety oversights along the way – sneaky Salmonella can find its way in. What then?

Our peanuts have picked up Salmonella after roasting (there’s likely no more heating to kill that nasty pathogen) in the processing facility. They are then mixed with more and more peanuts, shipments from other farms, passing through machine after machine, being ground into peanut paste, infecting huge lots of peanuts along the way. Our peanuts are now causing a silent outbreak deep within the processing facility.

The lots of infected peanut paste – soon to be peanut butter – go unsuspected and are sent to the next phase of processing where they will become cookies, crackers, ice cream, dog treats, etc.

Suzy Public loves peanut butter cookies, so she picks up a package during a routine grocery store visit. Two days later, Suzy is very sick.

Vomiting takes a turn to more severe symptoms so Suzy does the right thing and heads to her doctor. In keeping with clinical care guidelines, Suzy’s doctor orders a stool sample which is then sent to a clinical lab where it tests positive for Salmonella. This is obviously important information for Suzy’s doctor who needs to determine the most effective treatment, but it is also important for the public at large, especially for those in her community.

Additional testing at the public health laboratory could link Suzy’s Salmonella to other cases in her area or across the country.

While clinical labs must submit a report alerting epidemiologists of Suzy’s Salmonella, many states don’t require clinical labs to submit isolates (a sample of the Salmonella that made Suzy sick) to the public health lab. The report allows epidemiologists to gather initial exposure information on cases, but identifying potential outbreaks among sporadic cases can be tough without additional information. An isolate allows the public health lab to subtype or get DNA fingerprints from the Salmonella (more on this below), providing greater information and more rapid outbreak detection. So why wouldn’t states require these isolates be submitted? There are likely different reasons for this; one common reason is simply that the states lack resources. Some states can afford to have a courier pick up and deliver those isolates, but not every state is able. It is hard to mandate that the clinical labs handle shipments on their own time and dime. Additionally, some states simply cannot process all of those isolates at their current funding level. Requiring all clinical labs to send those isolates would put an enormous workload on already understaffed public health laboratories.

Once the investigation has been opened, an epidemiologist or public health nurse will contact Suzy Public to begin the investigation to nab the culprit. The first question they will ask Suzy is to list everything she consumed in the week or so prior to getting sick. These interviews allow disease detectives to track patterns in sick individuals’ diets. If everyone ate peanut butter crackers, they can target their investigation.

Could funding cuts to food safety programs make you sick? | www.aphlblog.org

Delays in testing or reporting will delay these disease detectives, and that means Suzy and the others who were made ill may not remember so far back. Even if they do remember and the disease detectives can identify a common food item in their diets, that product may already be off the shelves and in more people’s homes thus exacerbating the outbreak. Additionally, departments of public health face staff shortages that mean overloaded epidemiologists and public health nurses. Their ability to conduct thorough interviews requires ample time – and time is limited when staff are carrying a workload suited for several people.

If that isolate was sent to the public health lab, additional testing is done to confirm Salmonella and to subtype the pathogen. There are over 2,500 subtypes of Salmonella, so the first step in outbreak detection is determining which type has made this individual sick. PFGE testing delves further into the identification of the pathogen by identifying its DNA fingerprint. For example, there could be multiple outbreaks associated with Salmonella Typhimurium at the same time but that doesn’t mean it is the same culprit. Isolating the DNA fingerprints is like a detective pulling fingerprints from a crime scene – when there are multiple offenses committed, fingerprints can link them to the same perpetrator. The DNA fingerprints are then entered into the PulseNet database, a system used to detect clusters nationally. This information is used by epidemiologists to further target their investigation.

But staff shortages in public health laboratories mean not all isolates can be tested, and those that are tested could be delayed. That means less information is making its way into the PulseNet database or it is being entered too late.

Delays or gaps in information make the investigation extremely difficult.

The case of the contaminated peanuts is a complicated one. We know the contaminated peanut butter used to make Suzy’s cookies caused her illness, but identifying those cookies as the source is only the beginning of the investigative process. Was it the flour, sugar, salt, eggs, peanuts, or one or more of the other ingredients that made Suzy sick? And what about the people who were sickened by peanut butter crackers? Or energy bars? Finding the common denominator – and drilling all the way down to where contamination occurred – is very difficult. These complicated investigations can last upwards of a year, but they are being closed without resolution simply because public health departments don’t have the means to keep them open. No resolution means contamination at the processing facility could continue and more people could become ill. It also means the rest of the industry cannot learn from the outbreak and implement changes to improve product safety.

Rapid detection leads to faster recalls of contaminated products. That means fewer people get sick. But our public health system does not have the means to investigate every case of foodborne illness. There are not enough resources to follow up on every cluster.

Without question, more outbreaks would be found if there were sufficient resources to detect and investigate them all. Simply put, funding cuts are ultimately causing more people to get sick.

Advocates continue to work hard to convince decision makers that increasing funding for the public health system is a very good investment in our population. Healthy people are better for every aspect of society. While the advocates are working, public health professionals continue to seek more ways to improve the system with fewer staff and fewer resources. Whole genome sequencing, for example, could provide more information to better understand outbreak clusters, and that could mean less follow up testing which could mean operating with fewer staff. However, implementation of advancements such as whole genome sequencing requires time and money that the system simply does not have.

Every day that you wake up without foodborne illness, thank the public health system. Waking up healthy did not happen without the dedicated men and women working hard to prevent the spread of dangerous bacteria.

When public health works, no one sees it… but it still needs adequate support to continue protecting our health. The disease identification system described above operates on only $40 million annually and is in immediate need of at least an additional $10 million as indicated in the 2015 budget request. To realize significant improvements, CDC funding for food safety should be doubled at a minimum.

Tell Congress that more money is needed for food safety! Follow these two simple steps:

  1. Here is a letter telling Congress that more funding is needed for public health. Complete the information and it will be sent to your elected officials.
  2. Copy the following sentence and paste it into the letter to draw attention to the specific needs for food safety: I am especially concerned with the need for funding to improve our nation’s food safety system. CDC’s food safety office is in immediate need of an additional $10 million as indicated in the 2015 budget request. Without this funding, more Americans will get sick from foodborne illness.

 

 

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Safe Drinking Water Act has Been Protecting You for 40 Years

Jun 25 2014 :: Published in Environmental Health

By Michael Heintz, MS, JD, senior specialist, environmental laboratoriesAPHL

Safe Drinking Water Act has Been Protecting You for 40 Years | www.aphlblog.org

Raise a glass—of tap water, that is. December 16, 2014 marks the 40 years since the enactment of the Safe Drinking Water Act (SDWA). Although many states had drinking water standards before SDWA, there was no national standard for public drinking water protections.

The 1970s saw a significant wave of environmental statutes enacted by the US government. President Gerald Ford signed SDWA into law on December 16, 1974. In addition to SDWA, that decade also saw the enactment of the Clean Air Act (1970) and the Clean Water Act (1972), as well as the formation of the US Environmental Protection Agency (1970) and the first Earth Day (1970).

But this isn’t a history or civics lesson (well, maybe a little). The question then is: What does the Safe Drinking Water Act do? Glad you asked!

The Safe Drinking Water Act sets standards for the safety of drinking water including disinfection, filtration, and setting maximum contaminant levels. Public water supplies must meet these minimum, health-based standards when supplying drinking water to 25 or more people. In addition to setting standards for the distributed water, SDWA reaches secondary parts of the drinking water system. For instance, SDWA sets the amount of lead that can be in plumbing products that come in contact with drinking water, and regulates potable water on airline flights. For drinking water that comes from groundwater sources, SDWA requires protections for wellhead zones—those areas where groundwater is extracted for municipal drinking water. And yes, SDWA protects areas that use surface water as drinking water sources (like rivers, lakes, and reservoirs). There are even whistleblower safeguards for people who report violations of the standards. In total, SDWA is responsible for substantial improvements to public health through virus and chemical removal, source protection, and monitoring and other efforts.

It is also important to note, though, that SDWA does not regulate bottled water or private wells (those serving fewer than 25 people). While there are recommendations for private wells, non-public sources of drinking water are largely unregulated.

In order to ensure public systems are meeting the SDWA requirements, the law requires certified laboratory testing for drinking water—overseen by a Principal State Laboratory (usually the state public health or environmental laboratory; to learn more, see APHL’s position statement). Those results must be made available to the public in the form of Consumer Confidence Reports (CCRs). While increasingly available electronically, these CCRs are typically sent to water customers annually and explain the contaminant levels in individual water systems.

I encourage you to learn more about SDWA and some of the details of the law. SDWA ensures that the water at your kitchen faucet is safe for you, your family and your neighbors. So while I normally wouldn’t toast with water, I’ll make an exception this time and raise my glass to say happy anniversary to the Safe Drinking Water Act!

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What We’re Reading

Jun 12 2014 :: Published in What We're Reading

Is it just me or is there an abundance of important infectious disease articles floating around this week?  Here are just a few that we have found particularly interesting.

  • How one unvaccinated child sparked Minnesota measles outbreak — This is a scary look back at a 2011 measles outbreak in Minnesota where 21 people (19 kids and two adults) became ill. A new report determined that one unvaccinated two-year-old contracted measles while traveling with her family in Kenya and brought the disease back home. It only takes one.
  • Rotavirus Vaccine Still Reaping Dividends With Fewer Hospitalizations, ER Visits, And Healthcare Costs — A new study shows that since the introduction of the rotavirus vaccine in the 1990s, nearly $1 billion in health care costs have been saved. Fewer sick people means fewer hospital stays, fewer trips to the emergency room and fewer doctor visits. Talk about return on investment!
  • US Virgin Islands Confirms 1st Chikungunya Case — Chikungunya is a painful mosquito-borne virus that has been plaguing people in the Caribbean for some time. CDC is anticipating its arrival in the mainland US this summer. We are watching it creep closer and closer with imported cases arriving in Florida, cases in Puerto Rico and now a case in the US Virgin Islands. Public health labs are prepared.
  • 11 amazing images from high-powered microscopes –  Despite the seriousness of these diseases, they sure do pose beautifully for photos!  The image of the immune system cell swallowing anthrax looks like something from a Dr. Seuss book.

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APHL 2014 Annual Meeting Day 4

Jun 05 2014 :: Published in Annual Meeting

Thanks to the speaks, vendors, members, partners, staff and all other attendees for making the 2014 APHL Annual Meeting a success!  See you all next year in Indianapolis!

Top Tweets

For more tweets, see our Day 4 Storify

 

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APHL 2014 Annual Meeting Day 3 Roundup

Jun 03 2014 :: Published in Annual Meeting

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For more tweets see our Day 3 Storify

 

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Attendees visit with vendors in the exhibit hall | www.aphlblog.org

2014 APHL Awards Ceremony and Breakfast | www.aphlblog.org

Jeff Moran, Director, Arkansas Public Health Laboratory, Discussing future analytical considerations of legalizing marijuana

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APHL 2014 Annual Meeting Day 2 Roundup

Jun 02 2014 :: Published in Annual Meeting

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For more tweets, see our Day 2 Storify

 

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Bill Wolfgang, Wadsworth Center, speaking on NY's experience with whole genome sequencing | www.aphlblog.org

Annual meeting attendees networking during a break | www.aphlblog.org

APHL's director of institutional research, Deborah Kim, shares the Data Visualization Dashboard with a meeting attendee | www/aphlblog.org

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Next Generation Public Health: Can Laboratories Enhance the Value Stream?

Jun 02 2014 :: Published in Annual Meeting

By Glen P. Mays, MPH, PhD, Director, National Coordinating Center for Public Health Services & Systems Research; The University of Kentucky, Lexington

Next Generation Public Health:  Can Laboratories Enhance the Value Stream? | www.aphlblog.org

Dr. Glen Mays will present the Dr. Katherine Kelley Distinguished Lecture on Tuesday, June 3, at the APHL Annual Meeting and Eighth Government Environmental Laboratory Conference in Little Rock, Arkansas. Attendees, please mark your program for this presentation scheduled for 2:00 pm in the Grand Ballroom. Dr. May’s PowerPoint presentation will be available on the APHL conference website as of Wednesday, June 3.

The Affordable Care Act and related state health reform initiatives are triggering diverse and far-reaching changes within the nation’s public health system.  Public health agencies are renegotiating their responsibilities and relationships with other health system stakeholders and to more clearly define their unique contributions to the “value stream” that produces population health.  My upcoming talk at the APHL Annual Meeting will explore strategies for demonstrating and enhancing the value that public health laboratories bring to the task of improving population health.  Here’s a preview of some of the trends and strategies I’ll discuss in my talk.

Next-generation public health places much greater emphasis on the catalytic functions of information acquisition, analysis and dissemination to mobilize and guide the actions of multiple stakeholders in the health system to achieve population health improvement.  Much of the information needed to support successful population health strategies is generated, analyzed and disseminated through the work of public health laboratories.  Counterfactual examples like the recently documented problems with newborn screening highlight the population health risks that can arise when information flows are suboptimal.  The converse is also true – generating the right information at the right time and getting it into the hands of the right decision-makers can fuel population health improvement.  Consequently, public health laboratories must think strategically about the roles that they can play in using their information flows to build, steer and sustain collaborative efforts in population health improvement, including:

  • Increasing the breadth, volume and quality of information generated through laboratory testing, particularly as the demand for testing increases as a result of expansions in health insurance coverage and new technologies for detecting and preventing disease.
  • Helping policymakers and other stakeholders understand the cost/benefit trade-offs associated with new testing technologies and opportunities.
  • Accelerating the timeliness with which information is produced and disseminated through laboratory operations.
  • Developing and testing innovations that improve the transmission and exchange of laboratory information – from specimen collection and transport through the dissemination and communication of test results. These actions include public health laboratory roles in meaningful use of electronic health records and in population-wide health information exchange.
  • Harnessing and harvesting opportunities for scientific research using the information flows that are generated and/or facilitated by public health laboratories, including the creation of specimen bio-banks, disease registries and test result archives.
  • Improving the resilience of the information flows generated by public health laboratories, including ensuring the continuity of testing and information dissemination capabilities during large-scale emergencies and hazardous events.
  • Using real-time laboratory information to better target and tailor public health interventions to the population groups that can benefit most, in keeping with the movement toward “personalized prevention and public health.”

Implementing these types of strategies will require improvements in public health laboratory capacity, which in turn requires an ability to demonstrate the health and economic value of expanded investments in public health laboratory capacity.  This task –articulating the societal return-on-investment (ROI) gained through enhanced laboratory capacity – is a central challenge for laboratory professionals and the public health community writ large.  Analytic techniques such as value stream mapping, information network analysis and value-of-information (VOI) analysis offer extremely powerful ways of valuing the information flows that are generated, processed and disseminated through public health laboratories.  These techniques can be used to show how the work of public health laboratories fuels the many processes involved in producing population health: from surveillance to investigation, prevention, protection, mitigation and resiliency.

Health reform’s push for improved population health requires more, better and faster information.  Public health laboratories are key to realizing this vision, but progress will require demonstrating and enhancing their value added.  I look forward to exploring these strategies in greater detail at the APHL annual meeting.

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APHL 2014 Annual Meeting Day 1 Roundup

Jun 01 2014 :: Published in Annual Meeting

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2014 APHL Annual Meeting Registration | www.aphlblog.org

Michael F. Iademarco, Director of CSELS, CDC at the 2014 APHL Annual Meeting | www.aphlblog.org

Dr. Glenn Paulson, Science Advisor, EPA; Keynote Speaker | www.aphlblog.org

2014 APHL Annual Meeting Opening Session | www.aphlblog.org

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APHL Introduces Local Students to Lab Careers During STEM Event

By Laura Siegel, Specialist, National Center for Public Health Laboratory Leadership, APHL

“Wanna see something fun and twisted? This is my DNA,” says a nine-year-old boy with brown hair and glasses as he greets his mom, proudly holding up his self-made DNA necklace.

APHL Introduces Local Students to Lab Careers During STEM Event | www.aphlblog.org

He was just one of approximately 30 local students who attended an event called Science League: The Heroes of Public Health on Saturday, May 31, 2014, at the University of Arkansas School for Medical Sciences (UAMS). The event invited local students in grades 6-10 to participate in hands-on science activities and learn about careers in public health.

“If we make a difference in the career aspirations of just one student, then the event will be a success,” said Pandora Ray, Director of the National Center for Public Health Laboratory Leadership at APHL.

Students were able to extract their own DNA, make a homemade lava lamp, and create their very own oobleck, a gooey substance that has properties of both a liquid and a solid.

APHL Introduces Local Students to Lab Careers During STEM Event | www.aphlblog.org“I always thought I wanted to be a doctor when I grow up, but this event opened my eyes to other options,” said Ana De Lira, currently in ninth grade at eStem Public Charter High School.

While the students were conducting experiments, their parents toured the Arkansas Public Health Laboratory, located just a few blocks from UAMS. On the tour parents watched a live demonstration of a dry-ice bubble, examined agar plates, saw equipment used for HIV and Hepatitis testing and learned about newborn screening.

“I had no idea the lab does so much testing that effects the general public. I can’t believe they do so much,” said Tracy Hobbs, who attended the parent portion of the day.

This event was sponsored by APHL, The UAMS College of Public Health and the Arkansas Department of Health, with special thanks to Bio-Rad and Fisher for donating supplies. APHL plans to host a similar event prior to the 2015 Annual Meeting in Indianapolis.

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Vectors of Change in Public Health Labs: Four Scientists Share their Views

May 31 2014 :: Published in Annual Meeting

The Affordable Care Act, molecular diagnostics, diminishing resources, global climate change: these are a few of the disparate developments shaping the future of public health laboratories in the United States. We asked four laboratory directors – all speakers at the 2014 APHL Annual Meeting – to share their views on the top vectors of change in the public health laboratory community.

Kerry Buchs, MHA, MT(ASCP), Laboratory Operations Director, Philadelphia Public Health Laboratory

Vectors of Change in Public Health Labs: Four Scientists Share their Views  | www.aphlblog.org“Within the next four years, 50% of my technical staff in the laboratory will be retiring. This presents a huge challenge for us to replace these tenured staff members. Fewer students are interested in going into health and science careers so the competition is extremely tough for new graduates in our area.  Fortunately we have several medical technologist training programs in the city.  One of our strategies for filling vacancies is to capture these students during their clinical internship for a rotation within the public health laboratory.  This exposes them to the work we do in public health and how rewarding it can be.”

Daniel Rice, MS, Director, New York State Food Laboratory; Incoming APHL President

“Diminishing resources in terms of staff and funding will continue to have a major impact on the future public health laboratories. Local and state public health laboratories have lost substantial numbers of positions and funding over the last eight years or so. This has had a remarkably negative impact on testing capability and capacity. The concept of regionalization of services is much discussed and appears to be gaining momentum. While this may bring efficiencies from larger volume testing by fewer labs, it also threatens to reduce the labs’ repertoire of testing capabilities. This could have unintended consequences. For example, testing could be delayed when a once routine capability no longer exists, and a sample needs to be shipped to another lab.

Protracted hiring freezes are causing an ever-widening gap between new scientists and seasoned staff. The median age in public health laboratories continues to rise and the number of mid-career scientists is decreasing. This situation is leading to a future, one that is not too far off, when the next wave of retirements will result in a catastrophic loss of institutional knowledge within laboratory programs. There will not be a sufficient number of appropriately trained scientists in the pipeline to fill the void of competent managers and leaders.

Technology is a fundamental driving force shaping public health laboratories. Technological advancements are occurring at such a fast pace that assessing and implementing these new technologies is a real challenge to public health laboratories. It is apparent that technology is shifting public health scientists from historical roles of bench chemist or microbiologist to more instrument- and informatics-based expertise. This is likely to change the physical layout/design of future public health laboratories and the training plan/path for future scientists significantly.

Jill Taylor, PhD, Interim Director, Wadsworth Center

“There are many drivers that will shape our future, not least among them being advanced technologies and big data. However, the thought we need to keep in the front of our minds when we are deciding how to juggle priorities while managing the next public health emergency is that, to serve and protect the public, we need to rely on the best science. Ultimately we will not have served our clients well if our decisions are based on outdated methods. While this will present many fiscal and operational challenges, it is imperative that we find creative solutions to address this need to keep abreast of our fields.

Ultimately, it is all about the people. One of the things that I have always loved about working in public health is seeing the passion, energy and commitment of the scientists and support staff who work in our labs. Nobody wants another emergency but I am sure you can relate to the observation that an emergency is a marvelous time to see everyone pulling together and making the system work. While we are now faced by a myriad of challenges, fiscal, operational and technological, I am confident that our people will continue to embrace change, move forward and find the creative solutions we need.”

John Ridderhof, DrPH, Laboratory Science Officer, CDC/OPHSS/CSELS

“One under-recognized challenge is the need for public health laboratories (PHLs) to implement informatics solutions that will provide them with the capabilities to report directly into the electronic health record (EHR) and receive HL7-based test orders (ETORs).  For now, this may be OK, as many of the referring clinical laboratories are also struggling to be interoperable with EHRs and providers. This ETOR capability is the future, and we should start identifying the required solutions now, knowing this will take support from all sectors to assure PHLs continue to be effective and relevant.

There are many challenges in the way of new technology and bioinformatics capability for PHLs.  In the end, it will still come down to the PHL workforce, since the biggest hurdle is not the instrumentation, but rather the education, training and competencies to use new technologies effectively. Upgrading the workforce will require a concerted effort to both recruit new talent and assure current staff are provided continuing education, mentoring and training to adopt new skills.”

 

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