State Epidemiologist Research Articles

Tracking the burden, distribution, and impact of Post-COVID conditions in diverse populations for children, adolescents, and adults (Track PCC): passive and active surveillance protocols

BackgroundTrack PCC includes five geographic surveillance sites to conduct standardized population-based surveillance to estimate and track Post-COVID Conditions (PCC) by age, sex, race/ethnicity, geographic area, severity of initial infection, and risk factors among persons with evidence of SARS-CoV-2 infection (based on the Council of State and Territorial Epidemiologist [CSTE] case definitions for confirmed cases or laboratory-confirmed evidence of infection).MethodsThe study will estimate the incidence, prevalence, including temporal trends, and duration and severity of PCC symptoms, among children, adolescents, and adults. PCCs include a broad range of symptoms and conditions that continue or develop after acute SARS-CoV-2 infection or COVID-19 illness. Surveillance includes both passive and active components for diverse populations in Arizona, Indiana, and Utah as well as the Bronx Borough, NY, and part of Philadelphia County, PA. Passive surveillance will utilize electronic health records and health information exchanges within each site catchment area to longitudinally follow persons with COVID-19 to estimate PCC occurring at least 30 days after acute COVID-19 illness. Active surveillance will utilize self-report of PCCs from detailed surveys of persons ages 7 years and older with evidence of SARS-CoV-2 infection in the past 3 months. Respondents will complete follow-up surveys at 6-, 12- and 18-months post-infection.DiscussionThese data can help identify which groups are most affected by PCC, and what health differences among demographic groups exist, as well as indicate potential barriers to care. These additional levels of granularity can inform public health action and help direct needed clinical care for patients.

Legionella pneumonia as a rising public health threat in Argentina: Is it the time to worry?

Legionella pneumonia as a rising public health threat in Argentina: Is it the time to worry?

Analysis of Amino Acid Changes in the Fusion Protein of Virulent Newcastle Disease Virus from Vaccinated Poultry in Nigerian Isolates.

The roles of fusion gene in the virulence of Newcastle disease virus are well established, but the extent of its variation among the XIV, XVII, and XVIII genotypes reported in Central Africa and West Africa has until recently been understudied. In this study, virulent Newcastle disease virus (vNDV) was isolated from dead chickens among vaccinated flocks between March and April 2020. Fusion (F) gene was sequenced and analysed for characterization and information about genetic changes. Many substitutions were observed along the region and some of their functions are yet to be determined. Results showed that all study isolates have virulent cleavage site sequence 112-RRRKR-116/F117 and clustered within genotype XIVb. Sequence analysis showed K78R mutation in the A2 antigenic epitope in all isolates and more along the F-gene which varied in some instances within the isolates. Mutation in this A2 antigenic epitope has been reported to induce escape mutation to monoclonal antibodies generated using the NDV LaSota strain. The range of percentage nucleotide and amino acid homology between the study isolates and commercially available vaccine strains is 81.14%-84.39% and 0.175-0.211, respectively. This report provides evidence of vNDV among vaccinated chicken flock and molecular information about circulating vNDV strains in Kano State, Nigeria, which is useful for the development of virus matched vaccines. Newcastle disease (ND) surveillance and molecular analysis of circulating strains in this region should be encouraged and reported. Furthermore, ND outbreaks or cases among vaccinated poultry presented to veterinary clinics should be reported to the state epidemiologist. Nucleotide sequences were assigned accession numbers OK491971-OK491977.

Readying the Applied Epidemiology Workforce for Emerging Areas of Public Health Practice.

Epidemiologists are key professionals within the public health workforce. As the role of public health agencies changes over time, epidemiologists will need to adapt and develop new skill sets to work in emerging areas of (public health) practice (EAoPs), which are areas of practice that are new or are growing in interest and use. This mixed-methods research study sought to explore the role and readiness of state health department epidemiologists in the United States to work in EAoPs. Three phases of data collection and analysis were conducted including secondary analysis of the Public Health Workforce Interests and Needs Survey, a survey of the designated state epidemiologist in all 50 states and the District of Columbia, and focus groups with early-, mid-, and senior-career epidemiologists working in state health departments. Fifty state health departments and the District of Columbia. Epidemiologists working in state health departments. Identification of EAoPs relevant to epidemiologists, the role of epidemiologists in these EAoPs, and readiness of epidemiologists to work in EAoPs. Participant state health department epidemiologists indicated that the studied EAoPs were important to their work and that epidemiologists have some role in them. Key facilitators identified to working in EAoPs included supportive organizational strategy and leadership, dedicated time for training and work, cross-training across programs, and the development of crosscutting skills. There is much opportunity for epidemiologists to be more engaged in current EAoPs. Not only can epidemiologists supply relevant data but they can also bring skills and expertise to help improve the overall success of population health improvement work. Workforce development strategies should be implemented to ensure a nimble epidemiology workforce that can readily adapt to the needs of future public health practice.

Celebrity diplomacy during the Covid-19 pandemic? The chief state epidemiologist as “the face of the Swedish experiment”

Celebrity diplomacy during the Covid-19 pandemic? The chief state epidemiologist as “the face of the Swedish experiment”

1170Investigation of COVID-19 outbreak in a South West State of Nigeria: Preliminary findings

1170Investigation of COVID-19 outbreak in a South West State of Nigeria: Preliminary findings

Use of Job Classifications, Career Ladders, and the Applied Epidemiology Competencies to Support Recruitment, Retention, and Practice of State Health Department Epidemiologists.

State health departments report that recruitment and retention of qualified epidemiologists is a significant challenge to ensuring epidemiology capacity to support essential public health services. To collect information on the use of epidemiology job classifications, career ladders, and professional competencies in state health departments to inform workforce development activities that improve epidemiology capacity. Electronic survey of the designated state epidemiologist. Fifty state health departments and the District of Columbia. State epidemiologists working in state health departments. Use and perceived benefit of epidemiology job classifications, career ladders, and professional competencies. All 50 states and the District of Columbia responded to the survey. Most state health departments reported having epidemiology-specific job classifications (n = 44, 90%) and career ladders (n = 36, 71%) in place. State epidemiologists strongly agreed or agreed that having an epidemiology-specific classification positively contributed to recruitment (n = 37, 84%) and retention (n = 29, 66%) of epidemiologists in their agency. State epidemiologists strongly agreed or agreed that having an epidemiology-specific career ladder positively contributed to recruitment (n = 24, 69%) and retention (n = 23, 66%) of epidemiologists in their agency. Only 10 (29%) state epidemiologists reported using the applied epidemiology competencies to develop or revise their jurisdiction's epidemiology career ladder. State health departments should implement well-maintained epidemiology-specific job classifications and career ladders that are based on current epidemiology competencies. Career ladders should be supported with opportunities for competency-based training to support career progression.

Swedish Response to COVID-19.

Editorial Among the global responses to COVID-19, Sweden's response has received both praise and criticism for the implementation of certain measures. This paper, provided by Public Health Agency Sweden's Director General Johan Carlson and State Epidemiologist Anders Tegnell, describes the main goals of Sweden's public health response: minimizing transmission, mortality, and morbidity;minimizing other negative health effects and externalities of the pandemic;and safeguarding essential services in the society. While some of the stances or strategies described may differ from China CDC's recommendations or other measures adopted in China, China CDC Weekly seeks to act as a platform for global voices to disseminate and discuss a variety of viewpoints to achieve an improved, mutual understanding of our counterparts.

Neonatal tetanus surveillance in Bayelsa state of Nigeria: a five-year review

ObjectiveTo assess the performance of neonatal tetanus surveillance in Bayelsa state of Nigeria.IntroductionNeonatal tetanus (NT) though a preventable disease, remains a disturbing cause of neonatal morbidity and mortality particularly in low income countries where maternal and child care are substandard and antitetanus immunization coverage is still poor. The disease, which is mostly fatal, is particularly common in hard to reach and rural areas where deliveries take place at home or with untrained attendants without adequate sterile procedures and in unclean environment. Since eliminating NT became a global target, significant reductions in NT deaths have been reported. The most recent estimates by WHO (2015) put death of newborns due to NT at 34,019, a 96% reduction from the situation in the late 1980s.All countries are committed to “elimination” of maternal and neonatal tetanus (MNT), i.e., a reduction of NT incidence to below one case per 1000 live births per year in every district. A strong neonatal tetanus surveillance (NTS) is however required to achieve this. As of March 2018, only 14 countries were yet to eliminate MNT and this includes Nigeria.The different types of NTS recommended are conducted to varying degrees of efficiency and effectiveness in Nigeria under the major surveillance strategy – the Integrated Disease Surveillance and Response (IDSR). These include routine monthly surveillance, zero reporting, active surveillance and retrospective record review.Nigeria comprises six geopolitical zones, 36 states and a Federal Capital territory (FCT), and is made up of 774 Local Government areas (LGA) (districts) – an LGA being the lowest administrative level. This study was conducted in Bayelsa state – one of the six states in the south zone. It is made up of eight LGAs, more than half of which are riverine and consists of many hard-to-reach communities, where formal functional health facilities are few and far between. Health workers are in short supply and funding of health care delivery is poor in the state.MethodsThis was a retrospective review of all confirmed cases of neonatal tetanus that were managed at the two tertiary hospitals in the state - Niger Delta University Teaching Hospital Okolobiri (NDUTH), and Federal Medical Centre Yenagoa (FMC) - between January 2009 and December 2013. These were the only two public facilities that had the capacity to manage NT cases in the state. Relevant data including sociodemographics, pregnancy and birth history of patients, cord care and tetanus toxoid immunization of mothers were abstracted from the case files. The cases were traced to the office of the State Epidemiologist, where all cases were expected to be documented and investigated in line with the existing neonatal tetanus surveillance. Ethical approval was obtained from the Research and Ethics Committee of NDUTH for the research and permission was given to access case files.ResultsA total of 48 cases were managed in both facilities (36/75.0% in NDUTH and 12/25.0% in FMC) in the period under review but only 13 cases (27.1%) were reported to the office of the State Epidemiologist. Figure 1 shows the number of cases per year of review. The cases were resident in seven out of the eight LGAs. The mean age of cases was 8.98 (SD = 5.14) days and 29 (60.4%) were male while 19 (39.6%) were female. Available evidence showed that only 2.1% of the cases were protected at birth (mothers had TT2+); 91.7% of mothers did not have antenatal care and all the mothers were delivered by traditional birth attendants; 70.8% had their umbilical cord cut with new (?sterile) blade; and 43.8% had their cord treated with methylated spirit, others were treated with just water or some herbal preparation. Educational attainment of mothers of cases was primary (54.2%) and secondary (45.8%).ConclusionsThere were gaps in Neonatal Tetanus Surveillance in Bayelsa State as only 27.1% of cases were captured at the state level. Many mothers and their newborns were still not protected against tetanus, and delivery and cord care were done in unhygienic conditions. There is an urgent need to strengthen NT surveillance, improve vaccination against tetanus, and encourage skilled birth attendance in the state.

Assessing the quality of the Acute Flaccid Paralysis surveillance system in Edo state, Nigeria 2017

This paper accesses the quality of the Acute Flaccid Paralysis (AFP) surveillance system in Edo state using the May/June 2017 Rapid Surveillance Assessment tool for reviewing existing surveillance systems. This was a descriptive cross-sectional study involving the Disease surveillance and notification officers (DSNOs), and their assistants (ADSNOs) in all 18 Local Government Areas (LGAs). All the surveillance officers were 100% knowledgeable on the AFP case definition. About, 94% of the ADSNOs knew how the AFP stool specimens were transported. Only 75% and 50% of the DSNOs and ADSNOs respectively could mention all seven AFP differential diagnosis stated in the AFP surveillance guidelines. Active surveillance was conducted by 89% of the DSNOs in their respective LGAs within the last six months prior to this study. Only 22% of the ADSNOs were actively involved in surveillance activities. Records of documentation of AFP surveillance activities dating as far back as three years were readily available at the offices of 90% of the DSNOs and with the state epidemiologist. Edo state has shown attributes of a quality surveillance system in terms of knowledge, AFP surveillance and documentation. We however encourage a surveillance system that is more inclusive with active participation from the ADSNOs.

Assessment of Epidemiology Capacity in State Health Departments - United States, 2017.

In 2017, the Council of State and Territorial Epidemiologists performed its sixth periodic Epidemiology Capacity Assessment, a national assessment that evaluates trends in workforce size, funding, and epidemiology capacity among state health departments. A standardized web-based questionnaire was sent to the state epidemiologist in the 50 states, the District of Columbia (DC), and the U.S. territories and the Federated States of Micronesia inquiring about the number of current and optimal epidemiologist positions; sources of epidemiology activity and personnel funding; and each department’s self-perceived capacity to lead activities, provide subject matter expertise, and obtain and manage resources for the four Essential Public Health Services (EPHS)* most closely linked to epidemiology. From 2013 to 2017, the number of state health department epidemiologists† increased 22%, from 2,752 to 3,369, the greatest number of workers since the first full Epidemiology Capacity Assessment enumeration in 2004. The federal government provided most (77%) of the funding for epidemiologic activities and personnel. Substantial to full capacity (50%–100%) was highest for investigating health problems (92% of health departments) and monitoring health status (84%), whereas capacity for evaluating effectiveness (39%) and applied research (29%) was considerably lower. An estimated additional 1,200 epidemiologists are needed to reach full capacity to conduct the four EPHS. Additional resources might be needed to ensure that state health department epidemiologists possess the specialized skills to deliver EPHS, particularly in evaluation and applied epidemiologic research.

Status of Legislation and Factors affecting Disease Surveillance in Nigeria: A qualitative inquiry

ObjectiveAssess the legal framework establishing disease surveillance in Nigeria and identify major factors affecting the performance of the surveillance system.IntroductionThe outbreak of infectious diseases with a propensity to spread across international boundaries is on an upward rise. Such outbreaks can be devastating with significant associated morbidity and mortality. The recent Ebola Virus Disease outbreak in West Africa which spread to Nigeria is an example.(1) Nigeria like several other African countries implements the Integrated Disease Surveillance and Response (IDSR) system as its method for achieving the International Health Regulations (IHR). Yet, compliance to the IDSR is questioned. This study seeks to investigate the legal instruments in place and the factors affecting performance of the disease surveillance in the country.MethodsThe study reports the first objective of a larger study to investigate compliance to disease surveillance by private health providers.(2) An investigative search of the literature for legal instruments on disease surveillance in Nigeria was carried out. In addition, key informants were identified and interviewed at the national level and in selected states. The six states in the South-West were identified for an in-depth study. The IHR focal person and the National Health Management Information System officer were interviewed at the national level. The state epidemiologists and the state health management information system (HMIS) officers across the six states were interviewed. Each state has only one state epidemiologist and one HMIS officer as such it was a total sample. In all, 14 key informants were interviewed.ResultsSix legal instruments were identified as seen in table 1. The most recent comprehensive legal instrument on infectious disease control in Nigeria is a 2005 policy on IDSR. This is further supported by the National Health Act of 2014. However, the National Health Act is not detailed for infectious disease control. The substantive law which governs infectious diseases in Nigeria, the Quarantine Act was enacted almost a century ago during the colonial era in 1926. None of the states studied has an active law on infectious disease surveillance as noted by key informants. While all states refer to the IDSR policy, none has formally ratified the document. There are two independent overlapping data collection systems on infectious diseases: the IDSR and the National Health Management Information System (NHMIS). Data on malaria, HIV and tuberculosis are among data collected across the two systems. This was identified by key informants as a problem since the data collection forms differed across systems and almost always result in differing statistics. In addition, this duplication causes overburdening of frontline workers expected to fill the parallel data collection tools and results in inefficiency of the system. Funding of the surveillance system was identified to be inadequate with significant reliance on international partners.ConclusionsA review of the national law on disease surveillance to address emerging global health security challenges is necessary. State legislators need to enact or ratify national laws on infectious disease monitoring and control in their states. The duplication across the NHMIS and the IDSR surveillance system requires harmonization to improve efficiency. Government needs to invest more resources in disease surveillance.References. Makinde OA. As Ebola winds down, Lassa Fever reemerges yet again in West Africa. J Infect Dev Ctries [Internet]. 2016 Feb 28;10(02):199–200. Available from: http://www.jidc.org/index.php/journal/article/view/81482. Makinde OA, Odimegwu CO. Disease Surveillance by Private Health Providers in Nigeria: A Research Proposal. Online J Public Health Inform [Internet]. 2016 Mar 24;8(1). Available from: http://ojphi.org/ojs/index.php/ojphi/article/view/6554

Epidemiological Characteristics and Laboratory Findings of Zika Virus Cases in New York City, January 1, 2016-June 30, 2017.

An outbreak of Zika virus (ZIKV) began in May 2015 in Brazil and rapidly spread throughout the Americas; New York City (NYC) has a diverse population with ∼1.8 million residents who were born in ZIKV-affected areas. Before July 24, 2017, the Centers for Disease Control and Prevention (CDC) ZIKV testing recommendations included nucleic acid amplification-based tests for serum and urine specimens collected ≤14 days of illness onset or last potential exposure, and ZIKV immunoglobulin M (IgM) assay when ZIKV RNA is not detected or for specimens collected within 2-12 weeks of illness onset or last potential exposure, followed by a plaque reduction neutralization test (PRNT). However, the New York public health laboratories and commercial laboratories tested specimens collected beyond these time frames. We analyzed 1080 noncongenital ZIKV cases in NYC residents who met the Council for State and Territorial Epidemiologist's ZIKV case definitions. Among cases, 98% were travel associated, 1% were sexually transmitted, and 1% had unknown exposures; 412 (38%) cases were pregnant women. Of 672 patients with ZIKV RNA detected in serum or urine specimens, 48 (7%) tested positive >14 days after either symptom onset or last potential exposure date (range 15-99 days). Of 390 patients diagnosed based on serology alone (i.e., not tested or not detectable for ZIKV RNA), 60 (15%) had a positive ZIKV IgM and PRNT >12 weeks after symptom onset or last potential exposure date (range 85-273 days). Our findings correspond with CDC's updated guidance to test symptomatic pregnant women up to 12 weeks past onset of symptoms. ZIKV IgM antibody testing may also be warranted for pregnant women regardless of symptoms if their exposure occurred during their pregnancy or periconception period. Providers should understand the scope of diagnostic testing and its limitations to appropriately counsel patients, especially pregnant women.

EPIDEMIOLOGICAL REPORT ON OUTBREAK INVESTIGATION OF AES/JE IN MUZAFFARPUR DISTRICT, BIHAR IN 2016.

08Mar 2018 EPIDEMIOLOGICAL REPORT ON OUTBREAK INVESTIGATION OF AES/JE IN MUZAFFARPUR DISTRICT, BIHAR IN 2016. Ragini Mishra and Navin Mishra. State Epidemiologist, State Surveillance Unit, State Health Society, Bihar, (2) Asst. Prof. Dept. of Dentistry, IGIMS, Patna.

Enhanced Surveillance for White-Nose Syndrome in Bats

Enhanced Surveillance for White-Nose Syndrome in Bats

Evaluation of knowledge resources for public health reporting logic: Implications for knowledge authoring and management

To control disease, laboratories and providers are required to report conditions to public health authorities. Reporting logic is defined in a variety of resources, but there is no single resource available for reporters to access the list of reportable events and computable reporting logic for any jurisdiction. In order to develop evidence-based requirements for authoring such knowledge, we evaluated reporting logic in the Council of State and Territorial Epidemiologist (CSTE) position statements to assess its readiness for automated systems and identify features that should be considered when designing an authoring interface; we evaluated codes in the Reportable Condition Mapping Tables (RCMT) relative to the nationally-defined reporting logic, and described the high level business processes and knowledge required to support laboratory-based public health reporting. We focused on logic for viral hepatitis. We found that CSTE tabular logic was unnecessarily complex (sufficient conditions superseded necessary and optional conditions) and was sometimes true for more than one reportable event: we uncovered major overlap in the logic between acute and chronic hepatitis B (52%), acute and Past and Present hepatitis C (90%). We found that the RCMT includes codes for all hepatitis criteria, but includes addition codes for tests not included in the criteria. The proportion of hepatitis variant-related codes included in RCMT that correspond to a criterion in the hepatitis-related position statements varied between hepatitis A (36%), acute hepatitis B (16%), chronic hepatitis B (64%), acute hepatitis C (96%), and past and present hepatitis C (96%). Public health epidemiologists have the need to communicate parameters other than just the name of a disease or organism that should be reported, such as the status and specimen sources. Existing knowledge resources should be integrated, harmonized and made computable. Our findings identified functionality that should be provided by future knowledge management systems to support epidemiologists as they communicate reporting rules for their jurisdiction.

Challenges to Recruitment and Retention of the State Health Department Epidemiology Workforce

With nearly one quarter of the combined governmental public health workforce eligible for retirement within the next few years, recruitment and retention of workers is a growing concern. Epidemiology has been identified as a potential workforce shortage area in state health departments. Understanding strategies for recruiting and retaining epidemiologists may help health departments stabilize their epidemiology workforce. The Council of State and Territorial Epidemiologists conducted a survey, the Epidemiology Capacity Assessment (ECA), of state health departments to identify recruitment and retention factors. The ECA was distributed to 50 states, the District of Columbia (DC), and four U.S. territories in 2009. The 50 states and DC are included in this analysis. The State Epidemiologist completed the organizational-level assessment; health department epidemiologists completed an individual-level assessment. Data were analyzed in 2010. All states responded to the ECA, as did 1544 epidemiologists. Seventeen percent of epidemiologists reported intent to retire or change careers in the next 5 years. Ninety percent of states and DC identified state and local government websites, schools of public health, and professional organizations as the most useful recruitment tools. Top recruitment barriers included salary scale, hiring freezes, and ability to offer competitive pay; lack of promotion opportunities and merit raise restrictions were main retention barriers. Although the proportion of state health department epidemiologists intending to retire or change careers during the next 5 years is lower than the estimate for the total state public health workforce, important recruitment and retention barriers for the employees exist.

ABORTION AND SUBSTANCE USE: CAUSE OR CONFOUNDING?

Willy Pedersen claims that his study 1 demonstrates that legal abortion may ‘be associated with increased risk of nicotine dependence, alcohol problems and use of cannabis and other illegal drugs’. In an interview with a Norwegian newspaper prior to publication of the study, he gave the even bolder statement that the association is causal: ‘Even after we remove known risk factors, having had an abortion remains a strong, independent risk factor for substance use.’2, my translation]. I think he is wrong. Pedersen recruited 768 teenagers in 1992 and surveyed them again with questionnaires at ages 15, 20 and 27 years. At age 27, some of the women had the study outcomes smoking, alcohol problems, cannabis use last year or other illegal drug use last year. Pedersen then tries to explain each of these outcomes in logistic regression models that include legal abortion between ages 20 and 27 as the explanatory variable, controlling for some potential confounders measured at ages 15 or 20, which is 0–7 years before the abortion. This conduct of the study introduces two major flaws. First, there is no consideration of the temporal sequence of exposure and outcome in the period between ages 20 and 27. For instance, if a woman starts smoking (or drinking or using illegal drugs) at age 23 and continues this habit until age 27 while terminating a pregnancy at age 25 her abortion will, in Pedersen's analysis, be counted as a predictor of the smoking, which is clearly inaccurate. Secondly, Pedersen makes no attempt to control for confounding factors that occur between ages 20 and 27; in fact, abortion is the only potential risk factor considered in this period. Consider a woman who, at age 23, drops out of university, loses her boyfriend, finds herself lonely and without a stable income and develops an anxiety disorder. A casual encounter leads to a pregnancy which she terminates immediately. In this period, she gradually develops a drinking problem. At age 27, her responses to Pedersen's questionnaire show only that she has had a legal abortion and that she still has a drinking problem. The analysis will disregard the obvious confounders, such as mental disease and socio-economic problems. The association that Pedersen finds between abortion in the period 20–27 years and smoking, alcohol problems and illegal drug use at age 27 is, in all likelihood, caused by confounding factors, i.e. factors that are both known causes of substance use and associated with abortion. Among these may be certain personality traits, mental diseases, adverse life events and socio-economic status. Thus, I believe Pedersen's claim to have shown that legal abortion causes smoking, alcohol problems and illegal drug use is invalid. Dr Aavitsland is Department Director and State Epidemiologist at the Norwegian Institute of Public Health and Consultant Physician at the Oslo Contraceptive Clinic. He is a member of the Norwegian Medical Association and Human-Etisk Forbund (The Norwegian Humanist Association). He has no affiliations to any business, religious or other group.

International Attention for Zoonotic Infections

International Attention for Zoonotic Infections

Remembering Jonathan M. Mann in a world ajar.

To the Editor: September 2003 marks the anniversary of the deaths of Jonathan M. Mann and his wife Mary Lou Clements aboard Swiss Air flight 111, which crashed off the shore of Peggy’s Cove, Nova Scotia, 5 years ago. Although Jonathan and I were both members of the Council of State and Territorial Epidemiologists in the early 1980s, when Jonathan served as state epidemiologist for New Mexico, our paths did not cross until years later in 1990. Jonathan had reluctantly resigned as director, Global AIDS Activities, World Health Organization, to become full professor at Harvard School of Public Health. I had taken a year’s leave of absence from my position in Maine to enroll in Harvard’s Master of Public Health program. In a talk at the Centers for Disease Control and Prevention, Jonathan once outlined many of his hopes and fears for AIDS activities worldwide. Moved by his pleas for global commitment to the epidemic, I sought out Jonathan at the opening reception for new Harvard students. I shared his dreams for public health activism. We believed in inspiring others to careers in applied public health, so we initiated a brown bag lunch series for students and faculty to share experiences about work in public health (1). The common thread throughout these discussions was universal human rights and respect for human dignity. Jonathan went on to establish the Francis Xavier Bagnoud Center for Health and Human Rights at the Harvard School of Public Health and used his position to promote health as the broad-based core of human values. His lectures on universal human rights centered on the idea that health transcends geographic, political, economic, and cultural barriers. Jonathan drew on his past experiences with the HIV epidemic to argue that the developing world would never achieve economic or political stability unless the health of its people improved. He maintained that, if not addressed, the health problems of the developing world would pose a global threat. “Public health,” he wrote, “too often studies health without intruding upon larger, societal, inescapably laden issues…. If the public health mission is to assure the conditions in which people can achieve the highest attainable state of physical, mental and social well-being, and if these essential conditions predominantly are societal, then public health must work for societal transformation” (2). Jonathan argued that discrimination and other violations of human rights were primary pathologic forces working against the improvement of public health and that if we ignored the plight of those whose rights were violated, we would be less than human ourselves. Jonathan very much admired Eleanor Roosevelt, chair, Declaration of Human Rights Drafting Committee, who on the 10th anniversary of the declaration asked, “Where, after all, do universal human rights begin? In small places, close to home—so close and so small that they cannot be seen on any map of the world. Such are the places where every man, woman and child seeks equal justice, equal opportunity and, equal dignity. Without concerted citizen action to uphold them close to home, we shall look in vain for progress in the larger world” (3). On Jonathan’s desk at Harvard, amidst family photographs, was a framed joker taken from an ordinary deck of cards. When I asked about its significance, he responded that, despite life's challenges, it remains important to smile. So smile we must at the memory of Jonathan and his many accomplishments. Each year, the Council of State and Territorial Epidemiologists remembers by holding a distinguished lecture named in honor of Jonathan M. Mann. The public health practitioner must respond to the needs of people and yet be sensitive to world politics. In solving difficult issues, the practitioner must understand the interconnection of social values and scientific truths and work collaboratively with the medical community. Moved to the forefront by recent acts of terrorism, public health has achieved recognition as first responder and as integral part of planning for and responding to catastrophic health crises. We cannot promote safety and security if we fail to recognize, and advocate for, people around the globe who do not have access to basic health care, adequate living and working conditions, or education to enlighten their response to life’s challenges. The anniversary of Dr. Mann’s untimely death serves as reminder to the medical and public health communities of the ongoing need to promote universal human rights and to focus energies and resources on a global approach to public health.