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The existence and role of state civil apparatus in the field of public services has a strategic position if without the role of state civil apparatus,the state's obligation to serve its citizens will not be carried out. The problems faced in the implementation of public services include the organizational management system that has not been maximized, the occurrence of disciplinary violations committed by state civil apparatus, poor performance, poor quality of public services provided, a lot of overlapping state civil apparatus, not maximally provided by the state, and Often there is the implementation of tasks that are not in accordance with their duties and responsibilities. At this time, the election of regional heads is a source of problems for mutations on a large scale, usually the elected regional heads make changes in the form of changing and decreasing positions to changing the workplace of an state civil apparatus. Then how is the governance of the state civil apparatus centralized and how is the merit system in managing the state civil apparatus. The research method used in this study uses qualitative methods, namely a research method by means of interviews, observation, documentation in collecting data, then on the data that has been found a data analysis will be carried out. According to the Indonesia State Civil Apparatus Act Law, the state civil apparatus recruitment system in Indonesia is inappropriate for regional head officials to transfer state civil apparatus for political reasons, based on proximity and others. If the regional head transfers his state civil apparatus without paying attention to the regulatory aspects, then a regional head has violated the law. The implementation of state civil apparatus governance in Indonesia is currently regulated by many rules, so that the legal rules for state civil apparatus governance support strongly. However, in terms of substance there are still many problems. There are so many rules that are not considered by regional head officials in transferring or promoting state civil apparatus.

Culture-independent diagnostic tests (CIDTs) are increasingly used for clinical diagnosis of gastrointestinal diseases such as salmonellosis, Shiga toxin-producing E. coli disease, and shigellosis because of their speed, convenience, and generally high-performance characteristics. These tests are also used to screen potentially infectious asymptomatic persons during outbreak investigations in sensitive settings such as childcare, food service, and healthcare. However, only limited performance data are available for CIDTs used on specimens from asymptomatic persons. The Association of Public Health Laboratories (APHL) and Council of State and Territorial Epidemiologists (CSTE) convened a workgroup to examine the available scientific data to inform interim decision-making related to exclusion and readmission criteria for potentially infectious persons in sensitive settings, the risks and benefits of different testing strategies, and to identify knowledge gaps for further research. This is the report on the Workgroup findings., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

Context: 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., Objective: 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., Design: 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., Setting: Fifty state health departments and the District of Columbia., Participants: Epidemiologists working in state health departments., Main Outcome Measures: Identification of EAoPs relevant to epidemiologists, the role of epidemiologists in these EAoPs, and readiness of epidemiologists to work in EAoPs., Results: 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., Conclusions: 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., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

The global coronavirus disease 2019 (COVID-19) pandemic has been exacerbated by social vulnerabilities and racial disparities, resulting in disproportionate morbidity and mortality that require continued attention to strategies that ensure equitable vaccine allocation. The State of New Hampshire (NH) developed a transparent framework to guide COVID-19 vaccine allocation plans, of which one key component was the allocation of 10% of vaccine supply to disproportionately impacted and highly vulnerable populations, predominantly identified through a national vulnerability index. The process, operational approaches, ethical challenges, and unanticipated consequences resulted in many valuable lessons learned. Equitable allocation of this limited and critical pandemic countermeasure required public understanding and engagement, which was achieved through a publicly available framework that was flexible, resourced using public funds, and widely communicated. Broad partnerships were also critical to addressing disparities in the delivery of vaccine. The lessons learned and described here will facilitate more nimble and equitable jurisdictional responses in future public health emergencies.

Context: 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., Objective: 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., Design: Electronic survey of the designated state epidemiologist., Setting: Fifty state health departments and the District of Columbia., Participants: State epidemiologists working in state health departments., Main Outcome Measures: Use and perceived benefit of epidemiology job classifications, career ladders, and professional competencies., Results: 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., Conclusions: 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., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Context: Epidemiologists working in state health agency central offices (SHA-CO) are key professionals working to monitor population health indicators. Assessing training needs to identify gaps is critical to ensuring a competent public health workforce., Objective: The objective of this research was to identify training needs of SHA-CO epidemiologists and their awareness of emerging areas of public health practice (EAoP) using data from the 2017 Public Health Workforce Interests and Needs Survey (PH WINS)., Design: SHA-CO epidemiologists were surveyed in fall 2017 using a Web-based tool. Balanced repeated replication weights were used to account for complex sample design. Differences in responses by tenure, education level, and supervisory status were assessed using multinomial logistic regression., Setting: Forty-seven state health agencies., Participants: Permanently employed SHA-CO epidemiologists., Main Outcome Measures: Training needs were identified by classifying skill gaps as those skills that participants self-reported as high relevance to day-to-day work but self-rated as having low proficiency. Awareness of EAoP was self-reported., Results: Systems and strategic thinking and budget and financial management were the areas with the greatest training needs. For most skill domains, fewer participants reported skill gaps with increasing years of public health work experience. Participants with 16 or more years of work experience were less likely to be motivated by most training motivators listed by epidemiologists with 5 or fewer years of experience. The EAoP participants reported greatest awareness of evidence-based public health practice (67%), and the EAoP they reported hearing least about was Health in All Policies (14%)., Conclusions: Stratified analyses by tenure identified important differences in training needs and motivators that employers can use to customize workforce development strategies. SHA-CO epidemiologists reported varying amounts of awareness of EAoP. Specialized training approaches may contribute to improved employee engagement and reduce skill gaps among SHA-CO epidemiologists., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Self-reports indicate that stress increases the risk for smoking; however, intensive data from sensors can provide a more nuanced understanding of stress in the moments leading up to and following smoking events. Identifying personalized dynamical models of stress-smoking responses can improve characterizations of smoking responses following stress, but techniques used to identify these models require intensive longitudinal data. This study leveraged advances in wearable sensing technology and digital markers of stress and smoking to identify person-specific models of stress and smoking system dynamics by considering stress immediately before, during, and after smoking events. Adult smokers (n = 45) wore the AutoSense chestband (respiration-inductive plethysmograph, electrocardiogram, accelerometer) with MotionSense (accelerometers, gyroscopes) on each wrist for three days prior to a quit attempt. The odds of minute-level smoking events were regressed on minute-level stress probabilities to identify person-specific dynamic models of smoking responses to stress. Simulated pulse responses to a continuous stress episode revealed a consistent pattern of increased odds of smoking either shortly after the beginning of the simulated stress episode or with a delay, for all participants. This pattern is followed by a dramatic reduction in the probability of smoking thereafter, for about half of the participants (49%). Sensor-detected stress probabilities indicate a vulnerability for smoking that may be used as a tailoring variable for just-in-time interventions to support quit attempts., (© 2021. The Author(s).)

There is substantial evidence that both N -methyl-D-aspartate receptor (NMDAR) hypofunction and dysfunction of GABAergic neurotransmission contribute to schizophrenia, though the relationship between these pathophysiological processes remains largely unknown. Although models using cell-type-specific genetic deletion of NMDARs have been informative, they display overly pronounced phenotypes extending beyond those of schizophrenia. Here, we used the serine racemase knockout (SRKO) mice, a model of reduced NMDAR activity rather than complete receptor elimination, to examine the link between NMDAR hypofunction and decreased GABAergic inhibition. The SRKO mice, in which there is a >90% reduction in the NMDAR coagonist d-serine, exhibit many of the neurochemical and behavioral abnormalities observed in schizophrenia. We found a significant reduction in inhibitory synapses onto CA1 pyramidal neurons in the SRKO mice. This reduction increases the excitation/inhibition balance resulting in enhanced synaptically driven neuronal excitability without changes in intrinsic excitability. Consistently, significant reductions in inhibitory synapse density in CA1 were observed by immunohistochemistry. We further show, using a single-neuron genetic deletion approach, that the loss of GABAergic synapses onto pyramidal neurons observed in the SRKO mice is driven in a cell-autonomous manner following the deletion of SR in individual CA1 pyramidal cells. These results support a model whereby NMDAR hypofunction in pyramidal cells disrupts GABAergic synapses leading to disrupted feedback inhibition and impaired neuronal synchrony. NEW & NOTEWORTHY Recently, disruption of excitation/inhibition (E/I) balance has become an area of considerable interest for psychiatric research. Here, we report a reduction in inhibition in the serine racemase knockout mouse model of schizophrenia that increases E/I balance and enhances synaptically driven neuronal excitability. This reduced inhibition was driven cell-autonomously in pyramidal cells lacking serine racemase, suggesting a novel mechanism for how chronic NMDA receptor hypofunction can disrupt information processing in schizophrenia.

Applied epidemiologists are key professionals within the public health workforce, fulfilling core public health science functions. The public health system in the United States has been rapidly transforming over the last decade and epidemiologists will need to develop new skill sets to be successful in the future of public health. A review of the literature was undertaken to gain a comprehensive understanding of the past and present of the applied epidemiology workforce to inform future workforce initiatives aimed at improving applied epidemiology practice. The literature search identified 48 articles related to applied epidemiologists working in the United States at the federal, state, and local levels. These articles described efforts to build, enumerate, and assess the competency of the applied epidemiology workforce in addition to putting forward opinions about it. Overall, the articles demonstrated significant prior work enumerating the applied epidemiology workforce, some prior work identifying epidemiology training needs, and few prior studies assessing competency. The functions, skill sets, and training needs of epidemiologists have changed over time and the literature provides a number of recommendations for future training. Continued assessment of the workforce literature is recommended to monitor training needs and competency for use in implementing effective workforce development activities., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: In May 2012, the New Hampshire (NH) Division of Public Health Services (DPHS) was notified of 4 persons with newly diagnosed hepatitis C virus (HCV) infection at hospital X. Initial investigation suggested a common link to the hospital cardiac catheterization laboratory (CCL) because the infected persons included 3 CCL patients and a CCL technician. NH DPHS initiated an investigation to determine the source and control the outbreak., Methods: NH DPHS conducted site visits, case patient and employee interviews, medical record and medication use review, and employee and patient HCV testing using enzyme immunoassay for anti-HCV, reverse-transcription polymerase chain reaction for HCV RNA, nonstructural 5B (NS5B) and hypervariable region 1 (HVR1) sequencing, and quasispecies analysis., Results: HCV HVR1 analysis of the first 4 cases confirmed a common source of infection. HCV testing identified 32 of 1074 CCL patients infected with the outbreak strain, including 3 patients coinfected with >1 HCV strain. The epidemiologic investigation revealed evidence of drug diversion by the HCV-infected technician, evidenced by gaps in controlled medication control, higher fentanyl use during procedures for confirmed cases, and building card key access records documenting the presence of the technician during days when transmission occurred. The employee's status as a traveling technician led to a multistate investigation, which identified additional cases at prior employment sites., Conclusions: This is the largest laboratory-confirmed drug diversion-associated HCV outbreak published to date. Recommendations to reduce drug diversion risk and to conduct outbreak investigations are provided.

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., Competing Interests: All authors have completed and submitted the ICMJE form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.

Background: Per- and polyfluoroalkyl substances (PFAS) are synthetic chemicals used in manufacturing that resist environmental degradation, can leach into drinking water, and bioaccumulate in tissues. Some studies have shown associations with negative health outcomes. In May 2014, a New Hampshire public drinking water supply was found to be contaminated with PFAS from a former U.S. Air Force base., Objectives: We established a serum testing program to assess PFAS exposure in the affected community., Methods: Serum samples and demographic and exposure information were collected from consenting eligible participants. Samples were tested for PFAS at three analytical laboratories. Geometric means and 95% confidence intervals were calculated and analyzed by age and exposure variables., Results: A total of 1578 individuals provided samples for PFAS testing; >94% were found to have perfluorooctane sulfonic acid (PFOS), perfluorooctanoic acid (PFOA), and perfluorohexane sulfonic acid (PFHxS) detectable in serum. Geometric mean serum concentrations of PFOS, PFOA, and PFHxS were 8.6 μg/L (95% CI:8.3-8.9), 3.1 μg/L (95% CI: 3.0-3.2), and 4.1 μg/L (95% CI: 3.9-4.3), respectively, which were statistically higher than the general U.S., Population: Significant associations were observed between PFAS serum concentrations and age, time spent in the affected community, childcare attendance, and water consumption., Conclusions: PFOS, PFOA, and PFHxS were found in significantly higher levels in the affected population, consistent with PFAS drinking water contamination. Given increased recognition of PFAS contamination in the U.S, a coordinated national response is needed to improve access to biomonitoring and understand health impacts., (Copyright © 2018 Elsevier GmbH. All rights reserved.)

Lyme disease (LD) is a common tick-borne disease in New Hampshire (NH). While LD is a reportable condition and cases are counted for public health surveillance, many more people receive care for tick bites or diagnoses of LD than are reflected in surveillance data. NH's emergency department (ED) data system was queried for tick bite and LD-related encounters. Chief complaint text was queried for words related to LD or tick bites. International Classification of Diseases 9th Revision (ICD-9) codes were queried for the LD diagnosis code (088.81). Emergency department patient data were matched to reportable disease data to determine the proportion of ED patients reported to the health department as a suspected LD case. Data were analysed to calculate frequencies for key demographic and reporting characteristics. From 2010 to 2014, 13,615 tick bite or LD-related ED encounters were identified in NH, with most due to tick bites (76%). Of 3,256 patients with a LD-related ED encounter, 738 (23%) were reported to the health department as a suspected LD case. The geographic distribution of ED patients was similar to reported LD cases; however, the regions of the state that experienced higher rates of ED encounters were different than the regions that observed higher rates of reported LD cases. Seasonal distribution of ED encounters peaked earlier than reported LD cases with a second peak in the fall. While age and sex distribution was similar among ED patients and reported LD cases, the rates for children 5 years and younger and adults 65 years and older were greater for ED encounters. Patients frequently visit the ED to seek care for tick bites and suspected LD. Results of ED data analyses can be used to target education, in particular for ED providers and the public through timely distribution of evidence-based educational materials and training programmes., (© 2017 Blackwell Verlag GmbH.)

Objectives: Opioid-related overdoses and deaths in New Hampshire have increased substantially in recent years, similar to increases observed across the United States. We queried emergency department (ED) data in New Hampshire to monitor opioid-related ED encounters as part of the public health response to this health problem., Methods: We obtained data on opioid-related ED encounters for the period January 1, 2011, through December 31, 2015, from New Hampshire's syndromic surveillance ED data system by querying for (1) chief complaint text related to the words "fentanyl," "heroin," "opiate," and "opioid" and (2) opioid-related International Classification of Diseases ( ICD) codes. We then analyzed the data to calculate frequencies of opioid-related ED encounters by age, sex, residence, chief complaint text values, and ICD codes., Results: Opioid-related ED encounters increased by 70% during the study period, from 3300 in 2011 to 5603 in 2015; the largest increases occurred in adults aged 18-29 and in males. Of 20 994 total opioid-related ED visits, we identified 18 554 (88%) using ICD code alone, 690 (3%) using chief complaint text alone, and 1750 (8%) using both chief complaint text and ICD code. For those encounters identified by ICD code only, the corresponding chief complaint text included varied and nonspecific words, with the most common being "pain" (n = 3335, 18%), "overdose" (n = 1555, 8%), "suicidal" (n = 816, 4%), "drug" (n = 803, 4%), and "detox" (n = 750, 4%). Heroin-specific encounters increased by 827%, from 4% of opioid-related encounters in 2011 to 24% of encounters in 2015., Conclusions: Opioid-related ED encounters in New Hampshire increased substantially from 2011 to 2015. Data from New Hampshire's ED syndromic surveillance system provided timely situational awareness to public health partners to support the overall response to the opioid epidemic.

Purpose: To describe 2 Candida interface keratitis infections occurring in the setting of positive donor rim cultures from precut corneal tissue used for Descemet stripping automated endothelial keratoplasty (DSAEK) and the ensuing public health investigation., Methods: Following 2 clinical Candida interface keratitis infections, patients from 2012 to 2014 in the same surgical center were evaluated for bacterial and fungal rim cultures and subsequent infection. All cases of fungal infections occurring post-DSAEK were analyzed. Data included patient demographics, surgical technique, donor rim cultures, donor mate outcomes, clinical courses, and outcomes. A review of the relevant literature was also undertaken., Results: From 2012 to 2014, among 99 DSAEK procedures performed, 7 (7.1%) donor rim cultures were positive for fungi. Use of this tissue with positive donor rim cultures resulted in 2 (28.6%) episodes of confirmed fungal interface keratitis, both Candida species, and presumptive treatment in an additional 2 patients. An investigation did not identify any breach in sterile technique or procedures by the surgeon or surgery center. Our literature review identified 15 reports of postoperative fungal infection associated with DSAEK, of which 11 involved Candida spp., Conclusions: While postoperative infection remains rare, our 2 additional cases along with those previously reported suggest that DSAEK may be susceptible to infection with Candida spp. Furthermore, this report of correlated rim cultures and clinical infection suggests a need for reevaluation of the utility of obtaining routine corneoscleral donor rim fungal culture.

We surveyed public health co-workers regarding attitudes toward a physician who returned to New Hampshire after volunteering in the West African Ebola outbreak. An unexpectedly large (18.0%) proportion of staff expressed discomfort with the Ebola responder returning to work. Employers should take proactive steps to address employee fears and concerns.

Breaking up sitting time with light- or moderate-intensity physical activity may help to alleviate some negative health effects of sedentary behavior, but few studies have examined ways to effectively intervene. This feasibility study examined the acceptability of a new technology (NEAT!) developed to interrupt prolonged bouts (≥20 min) of sedentary time among adults with type 2 diabetes. Eight of nine participants completed a 1-month intervention and agreed that NEAT! made them more conscious of sitting time. Most participants (87.5 %) expressed a desire to use NEAT! in the future. Sedentary time decreased by 8.1 ± 4.5 %, and light physical activity increased by 7.9 ± 5.5 % over the 1-month period. The results suggest that NEAT! is an acceptable technology to intervene on sedentary time among adults with type 2 diabetes. Future studies are needed to examine the use of the technology among larger samples and determine its effects on glucose and insulin levels.

Objective: Public health investigations require rapid assessment, response, and initiation of control measures. In 2012, the New Hampshire Department of Health and Human Services used digital pens to rapidly acquire epidemiologic data during a gastrointestinal illness outbreak., Methods: Menus were obtained and a standard questionnaire was administered to exposed persons using digital pens. Questionnaire data were downloaded into an electronic file for analysis., Results: Sixty-nine (74%) of 93 exposed persons completed a questionnaire. Of 6389 data entries made on digital paper, 218 (3%) required correction; of these, 201 (92%) involved a free-form variable and 17 (8%) involved a check-box variable. Digital pens saved an estimated 5 to 6 hours of data-entry time., Conclusions: This outbreak provided an opportunity to assess the value of digital pens for decreasing data-entry burden and allowing more timely data analysis in an emergent setting. Depending on the size of the outbreak and complexity of the survey, there is likely a threshold when use of digital pens would provide a clear benefit to outbreak response. As new technology becomes available for use in emergency preparedness settings, public health agencies must continuously review and update response plans and evaluate investigation tools to ensure timely disease control and response activities.

Pet treats and pet food can be contaminated with Salmonella and other pathogens, though they are infrequently implicated as the source of human outbreaks. In 2013, the New Hampshire Department of Health and Human Services investigated a cluster of Salmonella Typhimurium infections associated with contaminated locally made pet treats. Case-patients were interviewed with standardized questionnaires to assess food, animal, and social histories. Laboratory and environmental investigations were conducted, including testing of clinical specimens, implicated product, and environmental swabs. Between June and October 2013, a total of 43 ill persons were identified. Sixteen patients (37%) were hospitalized. Among 43 case-patients interviewed, the proportion exposed to dogs (95%) and pet treats (69%) in the 7 days prior to illness was statistically higher than among participants in a U.S. population-based telephone survey (61%, p<0.0001 and 16%, p<0.0001, respectively). On further interview, 38 (88%) reported exposure to Brand X Chicken Jerky, the maker of Brand X chicken jerky, or the facility in which it was made. Product testing isolated the outbreak strain from four of four Brand X Chicken Jerky samples, including an unopened package purchased at retail, opened packages collected from patient households, and unpackaged jerky obtained from the jerky maker. A site visit revealed inadequate processing of the chicken jerky, bare-hand contact with the finished product prior to packaging, and use of vacuum-sealed packaging, which may have enabled facultative anaerobic bacteria to proliferate. Seven (78%) of nine environmental swabs taken during the site visit also yielded the outbreak strain. Brand X Chicken Jerky was voluntarily recalled on September 9, 2013. Consumers should be made aware of the potential for locally made products to be exempt from regulation and for animals and animal food to carry pathogens that cause human illness, and be educated to perform hand hygiene after handling pet food or treats.