Us Versus Disease

New State Epidemiologist Takes Office

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Public Health Feature – March 2012

Tex Med. 2012;108(3):49-54.

By Crystal Conde
Associate Editor

Thomas Erlinger, MD, MPH, state epidemiologist at the Texas Department of State Health Services (DSHS), says his training as a physician affects his approach to improving public health.

"When disease becomes personal, as it does for a physician, that experience changes how you view it," Dr. Erlinger said.

A graduate of The University of Texas Health Science Center at San Antonio School of Medicine, Dr. Erlinger completed his residency in internal medicine at the University of Chicago. After residency, Dr. Erlinger completed a three-year general internal medicine fellowship at the Johns Hopkins University School of Medicine in Baltimore and earned a master's degree in public health at the Johns Hopkins Bloomberg School of Public Health. At Johns Hopkins, he conducted research in various areas of chronic disease epidemiology and clinical research, including cardiovascular disease, nutrition, and obesity.

Dr. Erlinger remained on the Johns Hopkins faculty for five years before returning to Texas in 2005 to become director of clinical research development for The University of Texas Medical Branch (UTMB) Austin campus.

From 2007 to 2010, Dr. Erlinger was director of hospital epidemiology and infection control and the director of measurements, evaluation, and clinical research for the Seton Family of Hospitals.

In August 2010, Dr. Erlinger joined DSHS.

Additionally, he attends Texas Public Health Coalition meetings to update members on disease trends in the state. The Texas Medical Association is a charter member of the coalition, created in 2006 to unite groups interested in advancing core public health principles at the state and community levels.

Texas Medicine: What attracted you to the position of state epidemiologist?

Dr. Erlinger: My father and brother were career military, and my sister worked for the state as an attorney. I hadn't yet followed in my family's footsteps in public service, so the position of state epidemiologist appealed to me. Plus, I wanted to get out in the community and learn new things; I knew I'd get that challenge as state epidemiologist.

Texas Medicine: What do you hope to accomplish in your role at DSHS?

Dr. Erlinger: Infection control and outbreak investigation are important parts of epidemiology. It's also the understanding of the disease process in a population and the monitoring of health care quality.

One broad goal I have is to determine how we can continue to advance in core areas. We need to evaluate how new technologies and analytic tools emerging in public health affect work flow and patient outcomes. They can help us monitor and evaluate the effectiveness of disease interventions, but they also require us to coordinate with a broad spectrum of stakeholders, communities, and agencies. These collaborations are mutually beneficial. We all can bring data and information to the table and determine together how to serve the needs of the community better.

Texas Medicine: How does the state epidemiologist collaborate with local epidemiologists?

Dr. Erlinger: Texas' local health departments have a highly skilled workforce and do a great job of advancing public health. The state's collaboration with epidemiologists can occur at all levels, and sometimes it's very informal. We're partners on the same team – us versus disease.

One of our roles is to support local epidemiologists. Our regional offices meet epidemiological needs in areas that lack a local health department.

During disease outbreaks or investigations, for example, the local health departments may work with the regional public health offices and then involve DSHS and even the Centers for Disease Control and Prevention (CDC) if necessary. DSHS can assist local health departments and can help facilitate communication across agencies and with CDC.

DSHS is using funding from the CDC's National Public Health Improvement Initiative to help implement quality improvement principles into the practice of public health. Last year, DSHS received a $500,000 Strengthening Public Health Infrastructure for Improved Health Outcomes grant under the national initiative. The Houston Department of Health and Human Services, the Dallas County Department of Health and Human Services, and the San Antonio Metropolitan Health District received about $800,000 in total grant money.

The grant funding provides a forum for DSHS to work with local health departments to advance the delivery and impact of public health services by improving how we track the performance of programs.

We're also joining forces to identify and foster adoption of public health best practices and to ensure seamless and coordinated services for Texas residents across communities.

Texas Medicine: In what ways do you think health information exchange (HIE) and health information technology (HIT) have the potential to facilitate higher quality, safer care?

Dr. Erlinger: Just digitizing information isn't enough; we need to understand the value. We need to determine what information to exchange and how to use the information effectively and safely while focusing on the privacy and security of the data.

HIE at the clinical level, for instance, could decrease duplication of testing and could improve patient safety. It might be useful for communities that want to measure their efforts and get a comprehensive view of the health issues and the health care system in their area.             

Texas Medicine: What are the biggest health challenges Texas faces?

Dr. Erlinger: Health challenges vary by region in Texas, and we have significant initiatives in place to reduce the number of preterm births, improve our understanding of the impact mental illness has on patients' health, and reduce the incidence of preventable hospitalizations.

Preventable hospitalizations account for billions of dollars in health care charges each year. Hospitalizations for bacterial pneumonia, dehydration, congestive heart failure, urinary tract infections, asthma, and other diseases are considered potentially preventable.

We can't prevent these hospitalizations until we address their causes at the community level. We need to examine factors that lead to better control of chronic diseases. One community may have a high volume of residents with chronic obstructive pulmonary disease, for example. Public health officials and health professionals in that community can work together to design an initiative that will help prevent hospitalizations for the disease.

In addition, Texas is constantly struggling to combat obesity in children and adults and to reduce smoking and tobacco use among residents. These are areas public health continually focuses on that have no quick fix. The bottom line is that Texas is a large state with many health challenges. Having a positive impact requires teamwork, and that's what we are all working toward.

Local Epidemiologists Fight Disease

Epidemiologists in Texas work with local and state partners to improve the public's health. Whether overseeing disease outbreak investigations at a county health department or tracking antibiotic-resistant bacteria in hospitals, epidemiologists are vital and rely on physicians to help them make a positive impact. The profiles that follow examine the role of epidemiologists and their approaches to disease surveillance and public health response.

Outbreak Investigator
Wendy Chung, MD, MSPH, has been chief epidemiologist of Dallas County Health and Human Services since 2007. She's a 2011 graduate of the TMA Leadership College. She says public health epidemiology gives her a bird's eye view of local disease trends.

"I get satisfaction from connecting with physicians to determine the source of an outbreak. For me, public health epidemiology offers a unique opportunity to participate in the implementation of control measures and the development of preventive measures, as well," she said.

The 2009 H1N1 influenza outbreak was one of her more memorable disease outbreak investigations. It involved close collaboration with area physicians, DSHS, and CDC. Dr. Chung describes the response as "a template for future infectious disease disasters."

"Lessons from H1N1 provided models for timely communication between physicians and public health. It also highlighted the importance of strong dialogue between practicing physicians and health departments," she said.

She says frontline physicians are the "eyes and ears of public health," and the county health department made efforts to keep physicians up to speed about rapidly evolving developments in H1N1 epidemiology, reporting requirements, and clinical care recommendations.

"We distilled large volumes of guidance from the Centers for Disease Control and Prevention into practical tools physicians could easily implement in their practices. During the outbreak, our public health physicians valued the constant feedback of the medical community, which enabled quick recognition and response to needs."

From a public health epidemiologist's standpoint, Dr. Chung says, some of the future local challenges include the need to develop an integrated electronic database system, laboratory information management systems, electronic health records, and registries to improve the efficiency of public health surveillance and case management.

Another focus for the department is investing in the surveillance of "actionable data," according to Dr. Chung.

"We want to measure what matters. In an era of resource reduction, we need to maintain directed efforts toward epidemiological surveillance of data with practical applications and direct impact on public health practice," she said.

Patient Advocate 
Edward J. Septimus, MD, of Houston, is medical director of the Infection Prevention and Epidemiology Clinical Services Group with HCA Holdings Inc., the world's largest private health care system. He has served in his current role for three years and is president of the Texas Infectious Diseases Society. Before joining HCA, he held a similar role with Memorial Hermann in Houston for 25 years. He also teaches twice a week in the Department of Internal Medicine at Texas A&M Health Science Center.

HCA has 163 acute care facilities and more than 100 ambulatory sites, and employs nearly 200,000 people in the United States.

Dr. Septimus oversees updating HCA facilities on clinical services activities and best practices to promote infectious disease treatment and prevention. That involves a lot of travel and meetings.

"I'll visit a couple of hospitals in a particular HCA division and meet with the local leadership. I may provide continuing medical education programs at the division or hospital level, depending on the facilities' needs. I'm able to get my colleagues engaged in HCA's clinical programs."

Because he can't be in several locations at once, his group uses webinars and other tools to communicate with HCA facilities throughout the United States.

A big part of his job is developing appropriate procedures and policies to reduce or eliminate preventable infections and diseases from occurring in hospitals and other acute care settings.

"Hospitals across the nation are reporting more antibiotic-resistant bacteria during a time when we have fewer new antibiotics entering the marketplace," he said. "Appropriate use of antibiotics across the continuum of care is an effective way to prevent the occurrence of resistant bacteria."

Dr. Septimus' group also tries to emphasize the importance of vaccination to prevent disease.

In 2009, for example, HCA began requiring health care workers who treat patients in its facilities to be vaccinated against influenza or to wear a mask if they choose not to receive the flu shot. Dr. Septimus says such policies are a positive first step in reducing the spread of preventable disease in health care facilities.

Above all else, Dr. Septimus says his position at HCA makes him a patient advocate.

"My role is to educate my colleagues on best practices they can implement to obtain better outcomes for patients. We look at compliance with best practice and opportunities to improve compliance. It can be as simple as adding resources or making them more convenient for our caregivers, but we have to talk to frontline health care workers to figure out where the opportunities are," he said.

Infectious Disease Specialist
Charles J. Lerner, MD, epidemiologist for Methodist Healthcare System in San Antonio and past chair of the TMA Committee on Infectious Diseases, says hospital epidemiologists face unique challenges, including the promotion of hand washing and hand hygiene practices among health care workers before and after patient contact.

"In any hospital, when you ask managers to report hand hygiene, they indicate compliance with hand hygiene policies is in the 90th percentile, up to 100 percent. In reality, when we secretly send employees on the floor to observe, known as secret shoppers, compliance is anywhere from 30 percent to 50 percent," he said. Dr. Lerner uses this data to educate health care workers on hand hygiene procedures and to improve adherence to policies.

The role of a hospital epidemiologist is to focus on infection surveillance and control within the institution. This differs from epidemiology at state and local health departments, which focus on the population as a whole.

Dr. Lerner played a role in the investigation of the 2010 Listeria outbreak that affected South Texas. It turned out raw celery was the culprit.

In October 2010, DSHS ordered Sangar Fresh Cut Produce in San Antonio to stop processing food and recall all products shipped from the plant since January 2010. Laboratory tests of chopped celery from the plant indicated the presence of Listeria monocytogenes, a bacterium that can cause severe illness. The testing was part of a DSHS investigation into 10 listeriosis cases, including five deaths, reported to the department in eight months.

Dr. Lerner collaborated closely with Methodist's infection control department and with DSHS, CDC, and the San Antonio Metropolitan Health District.

"Methodist Healthcare System had 60 percent of the Listeria cases. I did formal investigations with food culturing and kitchen culturing. I met with CDC, DSHS, and the Metro Health District to determine how to go about conducting investigations to ensure they were scientifically rigorous," Dr. Lerner said.

While the Listeria outbreak presented him with an opportunity to investigate a food-borne illness outbreak, Dr. Lerner says he mostly monitors incidences of hospital-acquired infections and colonization in an effort to minimize their spread within the hospital.

"I also work to ensure vaccination against influenza and other communicable diseases for hospital workers, and I promote hand washing and the use of protective equipment to prevent the spread of disease," he said.

Crystal Conde can be reached by telephone at (800) 880-1300, ext. 1385, or (512) 370-1385; by fax at (512) 370-1629; or by email.

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