The next analysis memo is ready by Duke Regulation scholar members of the Duke Regulation Lyme Illness Advocacy Challenge. The LDA has been working with this group for a number of years to assist analysis tough questions concerning Lyme disease coverage.
Titles and affiliations are supplied for identification functions solely. Any views, analysis, and conclusions expressed by the authors are theirs alone and don’t replicate the views, analysis, and conclusions of Duke College or any of its constituent establishments.
Memorandum Ready for the Lyme Illness Affiliation Professional Bono Challenge[1]
Concerning the Relationship Between the Facilities for Illness Management and Prevention and the Council of State and Territorial Epidemiologists[2]
Ready by:
Sam Graber-Hahn, JD ‘24
Lucas Lynn, JD ‘25
Sean Prestegord, JD ‘24
Sammy Sawyer, JD ‘25
Benjamin Spencer, JD/MA ‘24
Could 7, 2024
QUESTIONS PRESENTED
- The place does the Council of State and Territorial Epidemiologists (CSTE) get its authority to create illness surveillance case definitions?
- The place does CSTE get its authority to create Lyme disease pointers?
- Does the Facilities for Illness Management and Prevention (CDC) settle for CSTE pointers for different ailments, together with controversial ailments?
BRIEF ANSWERS
- The Council for State and Territorial Epidemiologists derives its authority to create illness surveillance standards and pointers from each federal and state legislation, in addition to from rules promulgated by the Division of Well being and Human Companies and from a longstanding partnership with the Facilities for Illness Management and Prevention.
- CDC allocates most of its funds to outdoors organizations. CSTE was created to assist CDC work with states on illness management, and the 2 organizations have an extended historical past of working collectively on infectious illness. In 1997, CDC gave discover that CSTE definitions can be used for CDC-funded Lyme analysis.
- The CDC accepts CSTE illness surveillance standards for controversial ailments along with Lyme disease, together with amebiasis and Candida auris. Since 1990, the CDC has labored with the CSTE to develop case definitions. At the moment, as a part of its Nationwide Notifiable Illness Surveillance System, the CDC updates its case definitions yearly in response to CSTE Place Statements.
BACKGROUND
Lyme disease is the commonest vector-borne illness in the USA.[3] Transmitted by blacklegged ticks and brought on by micro organism within the Borrelia household, preliminary signs of Lyme disease embrace fever, fatigue, and a rash.[4] If untreated, the an infection can unfold to the center and nervous system, doubtlessly leading to vital harm and demise.[5]
The Facilities for Illness Management and Prevention (CDC) is a authorities company answerable for detecting and responding to well being threats all through the USA.[6] To perform this objective, they keep a system for reporting ailments that many well being suppliers depend on when contemplating remedies.[7] Just lately, the CDC has claimed that they’re sure by the illness case definitions created by the Council for State and Territorial Epidemiologists.[8]
The Council for State and Territorial Epidemiologists (CSTE) is a non-government entity, fashioned on the request of then-CDC Epidemiology Director Alexander Langmuir within the Nineteen Fifties.[9] In 1951, it revealed its first checklist of nationally notifiable ailments, and has continued to assert accountability for managing and updating this checklist by way of using yearly place statements to the current day.[10]
The Council of State and Territorial Epidemiologists (CSTE) develops and adopts surveillance case definitions for these ailments. The Facilities for Illness Management and Prevention (CDC) can present enter through the improvement course of, though mechanisms are unknown. Though our analysis has not found a proper adoption course of on CDC’s half, the CDC appears to have adopted the CSTE’s surveillance case definitions for Lyme disease every time the CSTE has up to date them since their inception in 1995.[11] The CDC has all iterations of those case definitions on its web site. On many events, the CDC has said that the CSTE is answerable for surveillance case definitions as per legislative course of.[12]
Though CDC’s web site said for years that the surveillance case definition will not be for use for medical analysis or remedy, many docs proceed to make use of it to justify not diagnosing sufferers with Lyme disease, particularly when circumstances fall outdoors inflexible geographic boundaries. Many insurers proceed to make use of the Lyme disease surveillance case definition to disclaim fee for care if sufferers don’t match this restrictive definition.[13] Many clinicians and insurers have typically referred to the Lyme surveillance standards as “CDC standards.”[14]
As a result of case definition’s emphasis on rashes, testing and the geographical restrictions, amongst different points current within the CSTE surveillance case definition, many Lyme sufferers expertise vital delays in analysis and remedy, which result in worse medical outcomes.[15]
A couple of years in the past, the CDC developed its personal set of medical “pointers” for Lyme disease.[16] No document may very well be discovered of those pointers going by way of an accepted course of for growing medical follow pointers and these pointers seem much like the IDSA remedy suggestions, with out acknowledging these similarities. The CDC “pointers” don’t incorporate suggestions from different medical societies similar to ILADS, based on the Lyme Illness Affiliation President who was on a telephone name about these pointers with CDC after these had been developed.
Figuring out what relationship between CSTE and CDC has been legislatively decided will allow stakeholders to look at what sorts of steps could be taken to enhance the surveillance case definition.
DISCUSSION
1. THE CSTE HAS THE AUTHORITY TO CREATE DISEASE SURVEILLANCE GUIDELINES IN CONJUNCTION WITH CDC.
The Council for State and Territorial Epidemiologists (CSTE) has the authority to create illness surveillance standards and develop a listing of notifiable ailments. This authority comes from a recognition of the CSTE’s experience in growing pointers by each federal and state statutes, rules promulgated by the Division of Well being and Human Companies (DHHS), and a long-standing cooperative partnership between the CSTE and the Facilities for Illness Management and Prevention (CDC).
The CSTE isn’t named in federal statutes as a result of group’s personal character. When it’s talked about, it’s cited as an authoritative supply of steerage for illness surveillance standards. The Frank R. Lautenberg Chemical Security for the 21st Century Act is probably the most notable instance, which instructs the Secretary of DHHS to work with the CSTE and state and native well being departments to create pointers for investigating potential most cancers clusters.[17] This statute marks a Congressional recognition of the CSTE’s experience in growing surveillance case definitions for notifiable ailments.
A number of states cite to CSTE surveillance case definition as a supply of authority for his or her native well being departments. Indiana,[18] Mississippi,[19] Florida,[20] and Washington[21] all instruct their native well being departments to contemplate pointers from each the CDC and CSTE when growing their very own lists of notifiable ailments. Nevada, nonetheless, solely cited to the rules of the CSTE and uncared for to say the CDC when passing a blood-lead stage management statute.[22] Equally, Nebraska solely defines a ‘confirmed case’ of a illness as one which “meets the case definitions specified and revealed by the [CSTE].”[23] Whereas each the CDC and CSTE are persuasively authoritative on the state stage, the steadiness tilts in the direction of the larger authority of the CSTE.
Nonetheless, it ought to be famous that many states don’t observe the CSTE surveillance case definition for Lyme disease. Thus, there’s not a common recognition of CSTE’s authority. For example, New York and New Hampshire estimate Lyme disease circumstances, which the CSTE definition doesn’t allow.[24] The CDC signifies it’s not permitted by CSTE to make use of estimated numbers, so circumstances in New York and New Hampshire are vastly underreported.[25] In Wisconsin, reporting necessities are relaxed considerably, requiring suppliers to report a Lyme disease case solely when there’s Erythema Migrans rash.[26] Connecticut in 2003 modified reporting standards in relation to Lyme which considerably dropped its reported case numbers[27] and Massachusetts in 2016 modified its method to surveillance reporting which eliminated that state from one of many prime within the nation—2015 had 4,224 reported circumstances right down to 7 in 2019[28]. Along with statutory deference, rules promulgated by the Division of Well being and Human Companies additional outline the authority of each the CDC and CSTE in directing the exercise of the Nationwide Notifiable Illness Surveillance System (NNDSS), the federal government equipment used to trace illness outbreaks throughout the nation. The CDC possesses the authority to “handle and function the [NNDSS].”[29] The utilization of the phrase ‘handle and function,’ nonetheless, doesn’t suggest the authority to create the illness surveillance pointers which might be utilized by the NNDSS. That authority is as an alternative explicitly given to the CSTE. As said in a DHHS evaluate performed as a part of the Paperwork Discount Act: “Every year, the Council of State and Territorial Illness Epidemiologists (CSTE), supported by CDC, performs an evaluation of circumstances reported to state, territorial and native jurisdictions to find out which ought to be designated nationally notifiable circumstances.”[30] These illness surveillance pointers are then discovered within the Nationwide Notifiable Situations Record (NNCL), which is maintained by the CSTE. Whereas the CDC manages and operates the NNDSS, it’s inside the CSTE’s purview to create the illness [surveillance] standards and pointers of the NNCL, which the NNDSS makes use of.[31] The Council of State and Territorial Epidemiologists, an affiliate of the Affiliation of State and Territorial Well being Officers, has the authority in the USA to advocate which well being circumstances ought to be notifiable. After this checklist has been agreed upon, it’s then as much as every state to find out whether or not and the way the circumstances ought to be made reportable. Though most states report all these circumstances thought-about to be nationally notifiable, a variety of circumstances are reportable in only some states (3). States might train their authority by way of rules, boards of well being, or legislative procedures. The range of those strategies is described extra totally in Chapter XII. Every of those mechanisms entails the involvement of teams with an array of medical, administrative, public well being, and coverage pursuits.
The interplay between the NNDSS and the NNCL is the linchpin of the connection between the CDC and CSTE.[32] A collaborative partnership has existed between the 2 organizations for many years, current in its trendy kind since not less than 1971, when a reporting system for water-based ailments was created.[33] The present group of accountability is said by the CSTE Govt Committee in a steerage doc.[34] On this steerage doc, it’s particularly said that “CSTE shall set up a Nationally Notifiable Situation Record… notifiable routinely to CDC.”[35] For a situation to be included on the checklist, the CDC should request that it’s federally notifiable.[36] Nonetheless, growing the case definitions stays within the arms of the CSTE. This association is confirmed by the CDC, which “collaborate[s] with the [CSTE] to find out which circumstances reported to native, state, and territorial public well being departments are nationally notifiable. The [CSTE] brings collectively illness and surveillance specialists at CDC and within the well being departments to find out what sorts of information ought to be included in nationwide notifications.”[37]
The precise procedures concerned in updating surveillance case definition pointers exhibit the authority of the CSTE. The illness surveillance standards are promulgated in place statements that bear an in depth inside evaluate course of that features a quorum vote on the annual CSTE convention, and are then despatched out to each the CDC and state and territorial governments for responses, remark, and adoption.[38] In line with the group itself, CSTE is answerable for “defining and recommending which ailments and circumstances are reportable inside states and which of those ailments and circumstances can be voluntarily reported to CDC.”[39] This longstanding association has been independently acknowledged by the USA Authorities Accountability Workplace by way of reliance on surveillance information and standardized reporting from the CSTE.[40] Nonetheless, the CDC’s reliance on the CSTE seems extra voluntary than compulsory.
In conclusion, the CSTE has the authority to develop or to not develop illness surveillance standards and pointers. The CSTE’s experience is acknowledged in each federal and state statutes. Moreover, the DHHS has explicitly bifurcated authority for nationally notifiable ailments, instructing CDC to handle and function the NNDSS, and recognizing the CSTE’s accountability for growing case pointers for the NNCL. The collaborative, seemingly voluntary partnership between the CDC and CSTE has led to a precedent that locations main accountability for case pointers on the CSTE, nonetheless the CDC retains the suitable to not undertake the CSTE pointers because it maintains last authority to disseminate public well being surveillance info.[41]
2. THE CSTE HAS THE AUTHORITY TO CREATE LYME DISEASE GUIDELINES.
The CDC is a big federal company that spends the overwhelming majority of its price range on outdoors “grants, cooperative agreements, and contracts.”[42] CSTE is a smaller, impartial group of epidemiologists. The CSTE was created as a result of the CDC wished state enter into choices about the way to deal with illness, and the 2 organizations have labored collectively as companions for many years.[43] Since its starting in 1951, the CSTE has been answerable for “defining and recommending which ailments and circumstances are reportable inside states and which of those ailments and circumstances can be voluntarily reported to CDC.”[44] In contrast to the CDC, the CSTE has a ten-member Govt Board that features a chair representing power illness.[45] The CDC follows the CSTE definitions for influenza[46] and for COVID-19.[47]
The Public Well being Service Act[48] authorizes the CDC to conduct a Lyme analysis program.[49] The CDC requires recipients of grants beneath this program to “[i]mplement, keep, and consider an lively Lyme disease surveillance system based mostly on the 1990 (or subsequent) nationwide case definition adopted by the Council of State and Territorial Epidemiologists (CSTE)” [emphasis added].[50] This follows the CDC’s basic method to defining infectious ailments.[51]
The CDC has promulgated pointers recognizing the necessity to deal with questions on power Lyme disease.[52] The CDC’s basic protocol for power illness pointers is the Persistent Illness Indicators (CDI).[53] The CDIs are “developed by consensus amongst” the CDC, the CSTE, and the Nationwide Affiliation of Persistent Illness Administrators (NACDD).[54] “CDI is the one built-in supply for complete entry to a variety of indicators for the surveillance of power ailments, circumstances, and danger elements on the state stage.”[55] The CDI was most lately up to date in 2012-2013 when the CDC, CSTE, and NACDD “collaborated on a collection of opinions that had been knowledgeable by subject-matter knowledgeable opinion” to make suggestions on indicators and subject teams thought-about “important for surveillance, prioritization, and analysis of public well being interventions.”[56] Lyme was not included within the CSTE’s 2013 place assertion on the proposed revisions to the CDI.[57] No purpose may very well be discovered for Lyme disease not being included. The CDC states that solely that, past the collection of CIDs being chosen along with the CSTE and NACDD, that CIDs are recognized along with state well being departments to construct a consensus set of “state-based well being surveillance indicators.”[58] As a result of it was not included in the latest 2012-2013 revision, the CDI doesn’t presently deal with long-term implications of Lyme or present information on it.[59]
The Tick-Borne Illness Working Group (TBDWG) was established by the DHHS to evaluate federal analysis and applications that deal with tick-borne illness.[60] The Babesiosis and Tick-Borne Pathogens Subcommittee Report back to the TBDWG recommends that state well being authorities observe CSTE case definitions and encourages the CSTE to proceed growing case standards for newly found ailments.[61] These subcommittee studies supply extra detailed coverage options than the CSTE offers, and TBDWG’s collected studies to Congress replicate vital disagreement amongst specialists on the way to perceive and deal with Lyme.[62] These disagreements of particular person members are expressed as minority responses, and reveal the extent of disagreement inside and between completely different organizations. In gentle of this stage of knowledgeable disagreement, the CDC incorporates Lyme info from organizations past the CSTE, similar to[63] the Infectious Illnesses Society of America (IDSA).[64] In truth, the CDC has used IDSA’s suggestions as the idea for his or her pointers, regardless of not citing IDSA instantly.[65] Nonetheless, the CDC might additionally think about various remedy pointers and diagnostic standards from one other medical society particularly devoted to Lyme disease, such because the Worldwide Lyme and Related Illnesses Society (ILADS).[66]
The CSTE’s most up-to-date revisions to its Lyme Surveillance pointers,[67] which the CDC has adopted,[68] embrace a number of sorts of power arthritis as indicators and signs of Lyme, recognizing that “post-antibiotic Lyme arthritis is a well-studied, post-treatment, goal manifestation of Lyme disease.”[69] The Nationwide Institute of Allergy and Infectious Illnesses (NIAID) on the Nationwide Institute of Well being (NIH) has drawn consideration to the true struggling that the broad vary of reported signs of what it characterizes as “‘power Lyme disease syndrome” causes for sufferers and their caregivers, even when the trigger and remedy of the signs will not be understood by medical researchers.[70] Different organizations embrace extra info that addresses different long-term results of Lyme than the CSTE offers. For example, the medical society ILADS “recommends longer durations of antibiotic remedy for Lyme disease prevention, erythema migrans remedy, and retreatment of sufferers with persistent signs. A few of these variations are as a consequence of variations within the interpretation and adoption of medical trial outcomes.”[71] Neither CSTE nor the federal government acknowledges ILADS pointers.
3. THE CDC USES CSTE GUIDELINES FOR OTHER CONTROVERSIAL DISEASES.
The CDC accepts CSTE pointers for circumstances along with Lyme disease, together with a number of controversial circumstances.
In 1990, the CDC collaborated with the CSTE to create the Morbidity and Mortality Weekly Report (MMWR), which revealed case definitions for infectious ailments.[72] A case definition is a set of standardized standards used to outline a situation.[73] This permits public well being officers to determine and document circumstances constantly throughout completely different states.[74] About 20 years later, the CSTE emphasised a have to create an official checklist of nationally notifiable circumstances: each infectious and non-infectious.[75] To be able to support on this effort, the CSTE steered the adoption of a standardized case definition for every situation on the official checklist.[76]
Underneath the advice of the CSTE, state well being departments now report recognized circumstances of specified circumstances to the CDC’s Nationwide Notifiable Illnesses Surveillance System (NNDSS).[77] The CDC offers corresponding case definitions on its official web site.[78] These case definitions are accepted by the CDC and up to date yearly utilizing the CSTE’s Place Statements.[79]
Whereas these definitions are largely determined by the CSTE, every definition should adjust to American Well being Info Neighborhood requirements.[80] In July 2008, the CSTE recognized sixty-eight circumstances warranting inclusion on the official checklist of notifiable ailments, and supplied every of those circumstances, together with Lyme disease, with a case definition.[81]
The official checklist has since grown dramatically, now together with over 120 identifiable circumstances.[82] Admittedly, this checklist primarily consists of well-accepted and simply diagnosable ailments, similar to chickenpox and strep throat.[83] There are, nonetheless, various controversial circumstances—along with Lyme disease—for which the CDC accepts the CSTE case definitions.
Some ailments trigger widespread, obscure, and sophisticated signs, leading to difficulties with analysis, case definition, and classification.[84] Two such controversial examples are amebiasis (also called amoebic dysentery) and varied types of Candida auris.[85]
First, Amebiasis is a parasitic an infection of the colon from the amoeba Entamoeba histolytica.[86] The situation is controversial due partially to its rarity in the USA. Nearly a whole century has handed for the reason that final amebiasis outbreak, which occurred in Chicago on the 1933 World’s Truthful.[87] Amebiasis is commonest in tropical areas with poor sanitation circumstances or untreated water.[88] Consequently, circumstances are uncommon in the USA, and accordingly, many docs could also be unfamiliar with the situation.[89]
Moreover, much like Lyme disease, amebiasis is controversial due partially to its gentle and customary signs. In truth, most individuals who contract amebiasis present no signs.[90] Those that do present signs are inclined to solely undergo from nausea, cramping, or diarrhea.[91] These signs are gentle and could be mistakenly attributed to a variety of different circumstances. Moreover, intestinal parasites generally are controversial within the medical discipline. Particularly, gastroenterologists differ on which microbes are literally dangerous and require antibiotics, and that are higher left alone.[92]
Second, Candida auris is a kind of fungus that usually lives within the physique in locations such because the mouth and abdomen with out inflicting any issues.[93] Nonetheless, it might trigger an an infection if it enters the bloodstream or sure organs similar to the center.[94] Just like Lyme disease, Candida auris is controversial due partially to disagreement concerning the perfect analysis standards.[95] For instance, Dr. William Criminal, who supplied the unique description for the situation, created a listing of 70 signs to information analysis.[96] Extra lately, nonetheless, Dr. Jeffrey McCombs prolonged the checklist to 100,[97] whereas Dr. Amy Myers trimmed the checklist all the way in which right down to 10.[98] Moreover, the CDC itself admits that analysis is tough, as Candida auris could be simply confused with different sorts of funguses.[99]
CONCLUSION
The Council of State and Territorial Epidemiologists derives its authority to create illness standards and surveillance pointers from federal and state legislation, rules promulgated by the Division of Well being and Human Companies, and a longstanding partnership with the Facilities for Illness Management and Prevention. By the CDC’s long-standing reliance on CSTE surveillance standards for Lyme disease, amongst different circumstances and controversial ailments, the CDC has de facto delegated particular accountability to the CSTE for growing Lyme disease surveillance pointers. Nonetheless, it doesn’t seem that the CDC should undertake CSTE’s surveillance pointers, because it maintains authority to manage dissemination of public well being info. Additionally, the CDC seems to have the ability to develop its personal medical remedy and diagnostic standards.
REFERENCES:
[1] This paper and the findings by the Lyme Illness Advocacy Challenge don’t characterize the views or conclusions by Duke College or Duke College Faculty of Regulation.
[2] The authors reached out to the CSTE and the CDC. The CSTE didn’t reply. The CDC responded that “the Council of State and Territorial Epidemiologists brings collectively illness and surveillance specialists at CDC and within the well being departments to find out what sorts of information ought to be included in nationwide notifications.”
[3] Lyme Illness, Facilities for Illness Management and Prevention (Jan. 19, 2022), https://www.cdc.gov/lyme/index.html.
[4] Id.
[5] Id.
[6] Mission, Position and Pledge, Facilities for Illness Management and Prevention (Feb. 25, 2022), https://www.cdc.gov/about/group/mission.htm.
[7] Nationwide Notifiable Illnesses Surveillance System (NNDSS), Facilities for Illness Management and Prevention (Sept. 29, 2021), https://www.cdc.gov/nndss/about/index.html.
[8] This was relayed based mostly on info obtained from Pat Smith, President of the Lyme Illness Affiliation, on a telephone name with the CDC.
[9] CSTE Historical past, Council of State and Territorial Epidemiologists (2022), https://www.cste.org/web page/About_CSTE.
[10] Id.
[11] This may be seen in evaluating all CSTE’s positional statements defining Lyme disease to the CDC’s definition of Lyme disease.
[12] CSTE Historical past, Council of State and Territorial Epidemiologists (2022), https://www.cste.org/web page/About_CSTE.
[13] Coaching, Training, Entry to Care, and Reimbursement Subcommittee Report back to the Tick-Borne Illness Working Group, U.S. Division of Well being and Human Companies, https://www.hhs.gov/ash/advisory-committees/tickbornedisease/studies/training-education-access-to-care-and-reimbursement-subcomm-2020/index.html.
[14] See, e.g., Info High quality Request for Correction, Disclaimers Wanted for Lyme Illness Case Definition, U.S. Division of Well being and Human Companies, Could 20, 2021 (stating “sufferers and docs look to the Facilities for Illness Management and prevention (CDC) for info on and steerage about Lyme disease, together with diagnostic standards”).
[15] Annemarie G. Hirsch, et al., Danger Components and Outcomes of Remedy Delays in Lyme Illness: A Inhabitants-Based mostly Retrospective Cohort Examine, Nationwide Library of Medication (Nov. 26, 2020).
[16] Steering for Clinicians, Caring for Sufferers After a Tick Chew, Middle for Illness Management (Dec. 21, 2021), https://www.cdc.gov/lyme/assets/FS-Steering-for-Clinicians-Sufferers-after-TickBite-508.pdf.
[17] Frank R. Lautenberg Chemical Security for the 21st Century Act, 42 USCS § 280g-17(c) (2016).
[18] Ind. Code Ann. § 16-41-2-1(c) (2022).
[19] 128 Miss. Gov’t Reg. 95 (March 2008).
[20] Fla. Stat. § 381.0031(4) (2022).
[21] 11 Wash. Reg. 28 (June 2, 2021).
[22] Nev. Rev. Stat. § 442.700(2) (2021).
[23] 173 Neb. Admin. Code Title § 1-002 (2022).
[24] New York Division of Well being, Communicable Illness In New York State Instances Reported In 2020, https://www.well being.ny.gov/statistics/ailments/communicable/2020/docs/circumstances.pdf; Amy Coveno, Regardless of Prevalence of Lyme disease, NH Offers Solely Estimates of Instances, WMUR 9 ABC (Apr. 30, 2018), https://www.wmur.com/article/despite-prevalence-of-lyme-disease-nh-provides-only-estimate-of-cases/20107070#.
[25] See id.; This was confirmed by way of Pat Smith, the President of the Lyme Illness Affiliation.
[26] https://www.well being.ny.gov/statistics/ailments/communicable/2020/docs/circumstances.pdf
[27] Lyme Illness Affiliation, Lyme Illness Reporting Standards Modifications, LDA Apps, https://lymediseaseassociation.org/LDA_Apps/content material/Maps/criteriachanges.htm (citing Connecticut Epidemiologist E-newsletter, Vol. 23, No. 1).
[28] Id. (citing the CDC for a change in Massachusetts reporting method).
[29] Facilities for Illness Management and Prevention: Assertion of Group, Capabilities, and Delegations of Authority, 59 Fed. Reg. 24451 (Could 11, 1994).
[30] Company Types Present process Paperwork Discount Act Evaluation, 78 Fed. Reg. 69092 (Nov. 18, 2013).
[31] Steven M. Teutsch, Concerns in Planning a Surveillance System, in Ideas and Apply of Public Well being Surveillance 18, 28-29 (2010).
[32] U.S. Gov’t Accountability Off., GAO-10-645, Biosurveillance (2010).
[33] U.S. Gov’t Accountability Off., GAO-05-376 App. XIV, Environmental Info (2005).
[34] Jeffrey Engel, Council of State and Territorial Epidemiologists, CSTE Place Assertion 08-EC-02, Standards for Inclusion of Situations on CSTE Nationally Notifiable Situations Record and for Categorization as Instantly or Routinely Notifiable 2 (2008).
[35] Id.
[36] Id. at 3.
[37] What’s Case Surveillance?, Facilities for Illness Management and Prevention (Sept. 29, 2021), https://www.cdc.gov/nndss/about/.
[38] Introduction to Place Assertion Course of, Council of State and Territorial Epidemiologists (2022), https://www.cste.org/web page/PSLanding#intro-process.
[39] CSTE Historical past, Council of State and Territorial Epidemiologists (2022), https://www.cste.org/web page/About_CSTE.
[40] U.S. Gov’t Accountability Off., GAO-01-973, Meals Security (2001).
[41] Facilities for Illness Management and Prevention: Assertion of Group, Capabilities, and Delegations of Authority, 59 Fed. Reg. 24451 (Could 11, 1994).
[42] Justification of Estimates for Appropriation Committees, Facilities for Illness Management and Prevention 27 (2021), https://www.cdc.gov/price range/paperwork/fy2023/FY-2023-CDC-congressional-justification.pdf.
[43] CSTE Historical past, Council of State and Territorial Epidemiologists (2022), https://www.cste.org/web page/About_CSTE.
[44] Id.
[45] About CSTE, Council for State and Territorial Epidemiologists (2022), https://www.cste.org/web page/about-cste.
[46] Nationwide Institute of Allergy and Infectious Illnesses; Discover of Closed Assembly. 76 Fed. Reg. 67742 (Nov. 2, 2011).
[47] Coronavirus Illness 2019 (COVID-19) 2021 Case Definition, Facilities for Illness Management and Prevention (2021), https://ndc.providers.cdc.gov/case-definitions/coronavirus-disease-2019-2021/.
[48] 42 U.S.C. 241 and 247b(okay)(2).
[49] Cooperative Agreements to Conduct Analysis and Training Packages on Lyme Illness in the USA, 62 Fed. Reg. 26516 (Could 14, 1997).
[50] Id. at 26517.
[51] David P. Fidler et. al., Rising and Reemerging Infectious Illnesses: Challenges for Worldwide, Nationwide, and State Regulation, 31 Int’l Regulation. 773, 781 (1997).
[52] 62 Fed. Reg. at 26517.
[53] Persistent Illness Indicators, Facilities for Illness Management and Prevention (2021), https://www.cdc.gov/cdi/overview.html.
[54] Id.
[55] Id.
[56] Id.
[57] Sara Huston, et. al, Council of State and Territorial Epidemiologists, CSTE Place Assertion 13-CD-01, Revision to the Nationwide Persistent Illness Indicators (2013).
[58] See, Persistent Illness Indicators, Facilities for Illness Management and Prevention (2021), https://www.cdc.gov/cdi/overview.htm.
[59] Id.
[60] Tick-Borne Illness Working Group Report back to Congress, U.S. Division of Well being and Human Companies (2020), https://www.hhs.gov/websites/default/recordsdata/tbdwg-2020-report_to-ongress-final.pdf.
[61] Id.
[62] Id.
[63] Pitrak, D., Nguyen, C.T., Cifu, A.S.. Analysis of Lyme Illness. JAMA. (2022) 327(7):676–677. doi:10.1001/jama.2022.0081.
[64] 2020 Tips for the Prevention, Analysis and Remedy of Lyme Illness, Infectious Illnesses Society of America (2020), https://www.idsociety.org/practice-guideline/lyme-disease/.
[65] This was relayed based mostly on info obtained from Pat Smith, President of the Lyme Illness Affiliation, on a telephone name with the CDC.
[66] Proof Assessments and Tips Suggestions in Lyme Illness, Worldwide Lyme and Related Illnesses Society (2023), https://www.ilads.org/patient-care/ilads-treatment-guidelines/.
[67] Catherine M. Brown, Council of State and Territorial Epidemiologists, CSTE Place Assertion 21-ID-05, Modification of Lyme Illness Case Definitions (2021).
[68] Lyme Illness (Borrelia burgdorferi) 2022 Case Definition, Facilities for Illness Management and Prevention (2021) https://ndc.providers.cdc.gov/case-definitions/lyme-disease-2022/.
[69] Wong, Ok.H., Shapiro, E.D. & Soffer, G.Ok., A Evaluation of Put up-treatment Lyme Illness Syndrome and Persistent Lyme Illness for the Working towards Immunologist, Clinic Rev Allerg Immunol 62, 264–271 at 266 (2022), https://doi.org/10.1007/s12016-021-08906-w.
[70] Present Efforts in Lyme Illness Analysis, Nationwide Institute of Allergy and Infectious Illnesses (2019), https://www.niaid.nih.gov/websites/default/recordsdata/NIAIDLymeRepot.pdf.
[71] Pitrak, D., Nguyen, C.T., Cifu, A.S. Prevention and Remedy of Lyme Illness, JAM (2022) 327(8):772–773, doi:10.1001/jama.2021.25302.
[72] Morbidity and Mortality Weekly Report, Vol. 39, No. RR-13 (October 19, 1990), https://www.cdc.gov/mmwr/PDF/rr/rr3913.pdf.
[73] Surveillance Case Definitions for Present and Historic Situations, Facilities for Illness Management and Prevention (Apr. 16, 2021), https://ndc.providers.cdc.gov/.
[74] Id.
[75] Steven MacDonald, Council of State and Territorial Epidemiologists, CSTE Place Assertion 07-EC-02, CSTE Official Record of Nationally Notifiable Situations (2007).
[76] Id.
[77] Surveillance Case Definitions for Present and Historic Situations, Facilities for Illness Management and Prevention (Apr. 16, 2021), https://ndc.providers.cdc.gov/.
[78] Id.
[79] Id.
[80] Christine Hahn, et. al, Council of State and Territorial Epidemiologists, CSTE Place Assertion 09-ID-11, Nationwide Surveillance for Extreme Acute Respiratory Syndrome (SARS-CoV) (2009).
[81] Id.
[82] What’s Case Surveillance?, Facilities for Illness Management and Prevention (Sept. 29, 2021), https://www.cdc.gov/nndss/about/.
[83] Surveillance Case Definitions for Present and Historic Situations, Facilities for Illness Management and Prevention (Apr. 16, 2021), https://ndc.providers.cdc.gov/.
[84] Edelberg, David, “Ten Controversial Medical Situations: An Introduction,” WholeHealth Chicago, https://wholehealthchicago.com/weblog/2018/04/30/ten-controversial-medical-conditions-an-introduction.
[85] Id.
[86] Amebiasis (amebic dysentery), New York State Division of Well being (Oct. 2021), https://www.well being.ny.gov/ailments/communicable/amebiasis/fact_sheet.htm.
[87] Bertha Spector, Amebiasis in Chicago – December, 1933, to June, 1936, American Journal of Public Well being 24, no. 7, 756-758 (July 1, 1934).
[88] Amebiasis (amebic dysentery), New York State Division of Well being (Oct. 2021), https://www.well being.ny.gov/ailments/communicable/amebiasis/fact_sheet.htm.
[89] American Journal of Public Well being, Amebic Dysentery in Chicago, AJPH 24, 7, 756-758.
[90] Amebiasis (amebic dysentery), New York State Division of Well being (Oct. 2021), https://www.well being.ny.gov/ailments/communicable/amebiasis/fact_sheet.htm.
[91] Id.
[92] Dhrati Patangia, et al., Affect of Antibiotics on the Human Microbiome and Penalties for Host Well being, MicrobiologyOpen, Vol. 11, No. 1 (Jan. 13, 2022).
[93] Common Info About Candida aurus, Facilities for Illness Management and Prevention (Nov. 13, 2019), https://www.cdc.gov/fungal/candida-auris/candida-auris-qanda.html.
[94] Id.
[95] Adekunle Sanyaolu, et al., Candida auris: An Overview of the Rising Drug Resistant Fungal An infection, Infect Chemother, Vol. 54, No. 2 (Jun. 17, 2022).
[96] Criminal, William G., M.D., The Yeast Connection Handbook (1st ed. 1995).
[97] McCombs, Jeffrey S., LifeForce: A Dynamic Plan for Well being, Vitality and Weight Loss (1st ed. 2010).
[98] Myers, Amy, M.D., The Autoimmune Answer: Stop and Reverse the Full Spectrum of Inflammatory Signs and Illnesses (2nd ed. 2017).
[99] Identification of Candida auris, Facilities for Illness Management and Prevention (Could 29, 2020), https://www.cdc.gov/fungal/candida-auris/identification.html.
