2016 All State Epidemiologists Conference Call

2016 All State Epidemiologists Conference Call

October 24, 2016

Agenda

1. Welcome

• Mississippi New State Epidemiologist: Paul Byers, MD
• SRCA launch date is November 1. As a reminder SRCA is joint CSTE/ CDC effort to collect information on what condition are reportable where, in states, territories, and other jurisdictions. SRCA is completely web base and comments and question please submit to

2. PFA Contamination of Ground Water* power point

Dr. Sharon Watkins, PA State Epi; Dr. Ben Chan; NH State; Dr. Lynn Wilder CDC Agency for Toxic Substance and Disease Registry

Highlights (New Hampshire Experience)

Perfluoroalkyl Substances (PFAS)

• Also called perfluorochemicals (PFCS)
• Group of synthetics chemicals
• Used in products that resist stain, oil, grease, and water
• Surface protection: carpeting, furniture, clothing, coating for paper and cardboard
• Surfactants in free flowing products
• Firefighting foams
• Commercial and Industrial Products that Use PFAS
• Commercial Products
• Cookware (Teflon, Nonstick)
• Fast Food Containers
• Candy Wrappers
• Microwave Popcorn Bags
• Persona Care Products (Shampoo, Dental Floss)
• Paints and Varnishes
• Stain Resistant Carpet
• Stain Resistant Chemicals (Scotchgard)
• Water Resistant Apparel (Gore-Tex)
• Cleaning Products
• Electronic
• Ski Wax
• Industrial Uses
• Photo Imaging
• Metal Plating
• Semiconductor Coatings
• Aviation Hydraulic Fluids
• Medical Devices
• Firefighting Aqueous Film-Forming Foam
• Insect Baits
• Printer and Copy Machine Parts
• Chemically Driven Oil Production
• Textiles, Upholstery, Apparel and Carpets
• Paper and Packaging
• Rubber and Plastics

PFAS Exposure is Through Oral Ingestion

• Consumption of food and water is the most important source for exposure to PFAS (includes migration of PFCs into food from boxes/packaging)
• Ingestion of contaminated dust is a significant source of exposure (carpets, upholstery, etc.)
• In infants, toddlers, and children, hand-to-mouth behavior is a significant source of exposure
• Limited exposure through breathing
• Minimal exposure through skin contact

Specific PFAS with Long Half-Lives in the Human Body

• Perflourooctanoic Acid (PFOA): 4 years
• Perflourooctane sulfonic acid (PFOS): 5 years
• Perfluorohexane sulfonic acid (PFHxS): 8 Years

Public Dirking Water Contamination on Pease Tradeport, Portsmouth, NH

• Pease Tradeport is a Superfund site from its former years as a U.S. Air Force base
• The EPA and DES asked the Air Force to Test the wells on the Tradeport for PFAS in April 2014
• Water one of three drinking water wells contained PFOS levels above the EPA’s Provisional Health Advisory level (est. 2009)
• Also with elevated levels of PFOA and PFHxS

EPA Created lifetime Health Advisory Levels for PFOA and PFOS in May 2016

• Drinking water levels that are considered safe over a lifetime
• Based on studies of rats/mice
• Protective for all individuals:
• Fetuses expose in –utero
• Nursing infants
• Children and adults

Active NH Site Investigations for Drinking Water Contamination

• Pease Tradeport (PFOA, PFOS, PFHxS)
• Multiple towns in Southern NH:
• Saint-Gobain (PFOA): Merrimack, Litchfield, Bedford, Manchester, Londonderry
• Textiles Coated International (TCI): Amherst
• Two former landfills: Merrimack, Salem

Private Drink Well Sampling in Southern NH Since February 2016

Community Demands

• Widespread PFAS blood testing availability
• Recommendations from public health that healthcare providers screen exposed individuals for health effects (i.e. LFTs, TFTs, Lipids, etc)
• Health registry
• Health study
• Create and enforceable drinking water standard including PFOA, PFOS, and other PFAS Like PFHxS
• Non-detectable PFAS levels

Health Effects Being Studies

• Changes the liver enzymes levels
• Increase in total cholesterol levels
• Increase in uric acid levels (marker for CV disease)
• Changes in sex hormone levels that could affect reproductive development and puberty
• Changes in thyroid hormone levels
• Lower immune function (lower antibody response to immunization)
• Growth and development (lower birth weight in infants, obesity in adolescents/adults, cognitive and behavioral development)
• Occurrence of some types of cancers: prostate, kidney, and testicular cancer

Overall the science is Uncertain and Long-Term Health Effects are Unclear

• Studies are not consistent
• Studies are not designed to show a causal relationship
• Often confounding factors are not considered
• Associations identified often are not clinically (biologically) relevant

Pennsylvania Experience

Sharon Watkins, Ph.D

• Sites involved are multi-military facilities in Pennsylvania, were foam fighting solutions used on base.
• Exposed population is approximately 70,000 to 80,000 at the military facilities with other potential sites that can increase the number of exposed.
• Pennsylvania Health Department Concerns
• The military facilities have been explored by ASTDR, the community, and the states, as Health assessment sites and have undergone years of investigations and remediation.
• Struggle with what types of responses that are feasible with the amount of exposed? Dealing with the expectation from the community, the elected officials are the driving force to what is the priority.
• Pennsylvania reached out to federal partners for addition information and to help coordinate responses.
• Pennsylvania is watching and learning and trying to learn from their neighbors and working with Agency for Toxic Substance and Disease Registry (ASTDR) to better understand and to participate in any national studies that maybe coming from ASTDR.

Agency for Toxic Substance and Disease Registry (ASTDR)

Dr. Lynn Wider, CDC

• ASTDR is currently working with a dozen of health departments.
• The biggest issues are that everyone in the community wanting to be tested and explaining the results when there is no comparisons or scientific data available on long-term effects.
• ASTDR is providing support to states by providing technical assistance. There are people in every US. Environmental Protection Agency (EPA) Region available upon request to go out to states and can assist states at a public meeting.
• Currently working with the Department of Defense (DOD) and trying get them more engaged in the health side activities such as the biomonitoring activities.
• Developing a biomonitoring framework that will give the states the umbrella that explains why everybody who wants to get tested and getting the test is not as good as ASTDR coming in doing statistics base recruitment approach.
• Working towards a national strategy that includes a Tool Kit Protocol
• Statistic base recruitment
• Toxicological profile
• Fact sheets
• Site work interpreting data
• Biomonitoring
• A Toxprofile will be completed early 2017
• ATSDR is currently working with the following agencies:
• US Environmental Protection Agency( EPA)
• United States Department of Defense (DOD)
• US Food And Drug Administration (FDA)
• National Institute of Environmental Health Sciences (NIEHS)

3. Who can call an Epi Aid?* Email Handout

Michael Iademarco, Director CDC Center for Surveillance, Epidemiology and Laboratory Services

Requesting and Epi-Aid

Epidemiologic assistance from CDC

What is an Epi-Aid?

An epi-Aid is an investigation of an urgent public health problem, such as infectious or non-communicable disease outbreaks, unexplained illnesses, or natural or manmade disasters. When a public health authority requests assistance from the U.S. Centers for Disease Control and Prevention, and Epi-Aid allows rapid, short-term (1-3 weeks), generally onsite, technical assistance by Epidemic Intelligence Service (EIS) officers and other CDC subject matter experts. The focus of an Epi-Aid investigation is to assist partners in making rapid, practical decision for action to prevent and control the public health problem.

Who participates?

An Epi-Aid team includes at least one EIS officer and other CDC subject matter experts. This team joins local staff in the community where assistance is requested. The requesting public health authority provides overall leadership for the investigation, while the Epi-Aid team provides technical assistance.

Who can request an Epi-Aids?

Various officials with authority for public health can request an Epi-Aid.

• State public health authorities
• Local public health authorities, in coordination with the state authorities
• Elected Tribal leaders of Federally Recognized Tribes
• Federal agency officials
• American military base commanding generals
• CDC’s Vessel Sanitation Program officials

Can a local jurisdiction request an Epi-Aid?

Yes. CDC responds to direct request from local jurisdictions. When a local jurisdiction requests an Epi-Aid, CDC is committed to ensuring the state is aware of the request and is appropriately engaged in the Epi-Aid. The EIS program frequently helps with coordination among the state and local jurisdiction and CDC programs.

How can public health authority request and Epi-Aid?

• The requesting authority contacts the subject matter expert at CDC or the EIS program.
• The CDC subject matter expert contacts the EIS program (or vice versa) to discuss the Epi-Aid request. Once CDC decides it can support the Epi-Aid, the CDC subject matter expert notifies the requesting authority.
• If CDC can support the Epi-Aid, upon notification, the requesting authority emails and invitation to the CDC subject matter expert contact or to the EIS program chief at .
• The EIS program approves the Epi-Aid

How do Epi-Aids benefit public health?

An Epi-Aid Benefits public health in several ways. Epi-Aid can

• Increase the technical capacity and workforce available for rapid response;
• Streamline access to CDC subject matter experts and laboratory resources;
• Build epidemiologic capacity through collaboration;
• Enhance public health relationship
• Contribute to practical understanding about the problem being addressed

What is the role of the requesting public health authority?

The public health authority provides overall leadership of the Epi-Aid investigation while benefitting from a collaborative relationship with the Epi-Aid team. The public health authority generally retains custody and control over all data collected as part of the investigation. After the Epi-Aid is completed, the public health authority often requests CDC’s continued collaboration and assistance in data analysis, report writing, presentation preparation, and additional programmatic technical assistance.

How can I get more information?

For more information about Epi-Aids, call the EIS office at -1 (404) 498-6110, send an e-mail to , or visit the EIS website.

Centers for Surveillance, Epidemiology and Laboratory Services

Division of Scientific Education and Professional Development

4. Washington DC update:

Emily Holubowich

• Three weeks away before Congress is back in session.
• Work is being finalized to the spending bill. We are current operating under continue resolution at current levels with a little bit of a cut until December 9.
• Staffers are going to try to move an Omnibus spending bill in the remaining 15 working days of the 114 Congress before they adjourn.
• However, we are watching very closely for a potential yearlong continuing resolution should they fail in that effort.
• The continuing resolution that passed before the recess included:
• 1.1 billion in funding for the Zika response but it is 800 million dollars less in what was administration requested and eight months late.
• Of the 1.1 billion of the funding 933 million dollars is going to HHS and 394 million dollars going to CDC.
• CDC is working to develop a spending plan to move the funding quickly.
• CDC will provide 50 million dollars to establish regional centers of excellence for studying diseases that are spread by mosquitos and other vectors.
• 25 million in funding for states and cities CDC is going to open an award application period for up 120 million dollars to support local disease tracking and diagnostic capacity.

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