What do an elephant, a wedding cake, and people with gonorrhea have in common?
They’re all public health risks Maine has faced in the last two years, state epidemiologist Stephen Sears told a class of Colby College students Thursday morning, part of a message about the emerging challenges faced by public health workers in Maine.
After the lecture to Colby Professor Thom Klepach’s Human Anatomy and Physiology students, Sears said he wanted to raise awareness about epidemiology, which is full of challenges for a new generation of public health workers. As hospitals shift toward disease prevention and population health, he said, epidemiology is gaining in importance in the health field.
“I just wanted to let them know it’s a big world,” he said. “Not everyone who wants to help has to become a medical doctor.”
One significant challenge state health officials faced came in 2012, when there was a spike in the number of gonorrhea cases reported in Maine.
In 2008, there were fewer than 100 cases of gonorrhea reported in the state, Sears said, but in 2012, that number had skyrocketed to 458, enough to make it a major concern for Sears and his colleagues in the infectious disease division at the Maine Center for Disease Control and Prevention.
The numbers showed that the sexually transmitted disease threatened to get out of control.
Sears, who said after the lecture he hoped to make students more aware of public health as a career option, offered a behind-the-scenes look at how the state viewed and responded to the breakout.
First, public health workers collected and analyzed the data, which showed who was getting the disease, and where.
Some areas of Maine, the CDC team found, were worse than others. Statewide, the rate of gonorrhea cases in 2012 was still lower than the nation as a whole. An average of 34 cases per 100,000 people was reported in Maine, far lower than the national average of 104 cases per 100,000 people.
But Androscoggin County was off the chart, with a rate of 179 cases per 100,000 people.
The team also found that the increase was most apparent among young women. In 2007, women accounted for 38 percent of reported cases, but that percentage grew to a majority, 53 percent of cases, by 2012. And most of the women were aged 18 to 28.
“Now we have an idea of what’s going on,” Sears said. “So now what? What do we do with this information?”
The goal was to stop people, especially young women, from having unprotected sex and from unknowingly spreading the disease to others. But getting the message into the right hands was a challenge.
Sears said the team worked with public health students at Bates College in Lewiston — it’s in Androscoggin County, the epicenter of the outbreak — to create a marketing campaign with some pizazz to it.
Posters included a “hunk series,” which featured shirtless, well-muscled men shooting dreamy looks into the camera.
“Hey girl,” one reads. “Did you know gonorrhea is curable, if treated early? Get tested, beautiful.”
Other posters included depictions of young women in cool, retro styles, also advising STD tests.
The campaign was printed on palm cards, posters and coasters, which were posted in bars, hair salons, nail salons and tanning salons.
“They’re not the typical public health partners,” Sears said, “but we wanted to get to all the places that younger women might be hanging out.”
State officials also contacted health practitioners to let them know that the disease was on the rise, and distributed condoms to encourage safe sex.
Sears said he considered the campaign a success.
In 2013, the rate of gonorrhea cases in Androscoggin County dropped significantly, from 181 cases per 100,000 to 84.5 cases. Because the county’s unusually high rate was affecting the state average as a whole, the improvement meant the state average dropped from 34 cases per 100,000 to 18.5.
The public awareness campaign that reduced gonorrhea is just one way the CDC manages public health, Sears said.
âWEDDING FROM HELL’
At times, his description of the work was like that of a detective, as in the case of what he jokingly referred to as the wedding from hell, which took place at a Penobscot County inn in 2012.
A woman who attended the wedding reported that she and several other guests had come down with horrific bouts of nausea, diarrhea and vomiting. Some also reported cramps and fever.
The report prompted an investigation team, which interviewed most of the 87 guests and found that at least 55 of them had suffered similar symptoms. The victims ranged in age from 5 months to 83 years old and included both the bride and groom, who were so ill they had to delay their honeymoon.
“This was not what you’d call a successful wedding,” Sears said.
Investigators asked for guest lists and menus so that they could begin to get a handle on what, exactly, had made people ill.
The team developed a questionnaire that tried to narrow down the possibilities.
Each guest was given a basket of Maine-grown products, such as blueberry jam, maple syrup and wine in their hotel rooms. Some ate at a rehearsal dinner; others had the Sunday brunch.
Investigators quickly grew suspicious of the wedding cake, a last-minute substitution that was necessary because someone carrying the original cake tripped and fell, destroying it. Their interest in the cake was heightened when they learned it had been displayed on a cut log, and decorated with real pine cones.
The team’s hunch about the cake was proven correct. In addition to sugar and flour, the cake contained a strain of norovirus, the most common cause of foodborne disease outbreaks in the United States, with about 20 million cases a year.
The team had ruled out more serious disease possibilities, or a chance that the virus was present in a large batch of some food that was being distributed elsewhere. Those who were affected by this strain of virus — including the bride and groom — recovered in a few days.
HIGH HEALTH STAKES
Sears also spoke about the team’s efforts to slow the spread of Lyme disease, which has grown dramatically in Maine over the past 15 years, mostly along the coastal areas and in the state’s river valleys, including the Kennebec. In 1988, he said, there were only six cases of Lyme disease in the state, while in 2012, there were more than 1,100.
The challenge is teaching people with old habits how to adapt to a new threat, he said. “We continue to have a population that doesn’t quite realize you have to take care of ticks,” he said.
Sears said some people attack the tick with hairspray or cigarette butts, but those measures are likely to do more harm than good. The best way to remove a tick, he said, is to grasp it with a pair of tweezers and pull it out of the skin.
Sometimes, an epidemiologist can be called upon in unusual situations, Sears said, such as when a group founded the Hope Elephant sanctuary in Hope, Maine.
The concern, he said, was tuberculosis, a disease which can be transmitted from people to elephants, and vice versa. The sanctuary’s first elephant, Rosie, had spent time in another sanctuary with another elephant that was diagnosed with the disease, so the CDC was called upon to determine whether it was safe for children to be around Rosie.
The stakes were high, he said, because the sanctuary was gearing up to be a popular destination for field trips.
“I have every kid in every elementary school potentially being exposed to tuberculosis,” he said.
Rosie was determined not to have the disease and Sears said he and his team developed a set of medical procedures that help to keep Rosie healthy, including a quarterly test to make sure the 2,200-pound animal hasn’t picked up tuberculosis from a human visitor.