Innovative Interstate Academic–Public Health Agency Collaborations for Case Investigations and Outbreak Surge Capacity

Abstract

Student interview teams provided essential surge capacity for the conduct of routine enteric disease surveillance and outbreak activities during the COVID-19 pandemic response, for states with that resource available. This case study describes how student interview teams based in Colorado and Washington supported enteric disease interviewing for public health agencies in Nebraska, Wyoming, Kansas, and California, and demonstrates the feasibility and value of interstate student interview team work to provide enteric and other communicable disease surge capacity. In collaboration with their respective state health agencies, the Colorado School of Public Health Enteric Disease Interview Team (EDIT) and the University of Washington Student Epidemic Action Leaders (SEAL) team amended scopes of work and procedures for hiring and onboarding, training, work management and engagement, communication, and evaluation to offer enteric disease interviewing support to the Nebraska Department of Health and Human Services, the Wyoming Department of Health, the Kansas Department of Health and Environment, and the California Department of Public Health. EDIT was assigned 467 enteric interviews in Nebraska, 193 in Wyoming, and 33 in Kansas; and the SEAL team was assigned 133 interviews from 26 clusters in California, with response rates of 68%, 79%, 58%, and 53%, respectively. The median time from case assignment to first interview for EDIT interviews was less than or equal to 1 day. The completeness of all interviews was satisfactory. Enteric disease epidemiologists from host state health departments and students reported valuing the interstate work. Establishing interstate student interview team support requires coordination but is possible and can be effective in providing essential surge capacity for states without a student interview team. It also provides intangible benefits such as strengthening relationships between states and affiliated university programs and providing professional experiences and networking opportunities for students.

Introduction

Practice-based opportunities at public health agencies have long been recognized as valuable to both students and partnering agencies.^1-5 Students build skills in a real-world setting with professional networking opportunities, and partnering agencies are offered staff support and surge capacity while developing the next generation of public health professionals. Frameworks for practice-based student opportunities include teaching and mentoring, as well as student internships, practicum placements, and work or volunteer opportunities within public health agencies.^6-8 A popular model among communicable disease groups at public health agencies is to use a student team to support surveillance and outbreak investigation activities. Typically affiliated with in-state university public health programs, student teams are efficient because students can be trained and supported as a group and can provide ongoing support or surge capacity for a public health agency, saving valuable time during an outbreak response. Student teams have successfully worked with public health agencies for many years, helping with outbreak (and pandemic) response, communicable disease surveillance, data analysis, and special projects.^9-16

During the COVID-19 pandemic, 91% of state and local communicable disease staff were fully or partially involved in the pandemic response, and thus unable to complete many core public health activities.¹⁷ Student interview teams were critical for maintaining routine surveillance and outbreak response activities during the COVID-19 pandemic, in states with that resource available.¹⁸ In an assessment of state agencies in the western United States, most states with student teams had established them before the pandemic. Other states in need of surge capacity did not have an existing student interview team or academic partnerships and struggled with hiring and training student positions.¹⁸ To address this gap, with support from the Integrated Food Safety Centers of Excellence, 2 states were able to leverage their enteric disease student interview teams to provide needed surge capacity to support routine interviewing, outbreak response, and special projects in neighboring states. This case study describes how the student interview teams worked across state lines and demonstrates the feasibility and value of interstate collaboration. Lessons learned for providing and receiving interstate student interview team support for enteric and other communicable disease surge capacity are offered for states without a local academic–public health partnership.

Methods

The Enteric Disease Interview Team (EDIT) was established by the Colorado School of Public Health and the Colorado Department of Public Health and Environment (CDPHE) in 2020 to support routine surveillance activities after more than a decade of using students to support outbreak response activities. The University of Washington Student Epidemic Action Leaders (SEAL) team was established in 2015 in collaboration with the Washington State Department of Health to provide applied epidemiologic support for Washington public health agency projects.¹¹ The Colorado School of Public Health and the University of Washington, together with their respective state health departments, are 2 of 5 Integrated Food Safety Centers of Excellence¹⁹ and are tasked with advancing enteric disease surveillance at local and state health departments in their regions and nationally.

During the pandemic response, the EDIT and SEAL teams provided surge capacity to other states in their region in need of support for conducting routine enteric disease surveillance due to reduced staff capacity. EDIT supported the Nebraska Department of Health and Human Services (NDHHS), the Wyoming Department of Health (WDH), and the Kansas Department of Health and Environment (KDHE), interviewing persons with Salmonella, Shiga toxin-producing Escherichia coli, Shigella, Cryptosporidium, Yersinia, and Cyclospora infections for all Nebraska counties from June 2020 to November 2022; persons with Salmonella and Shiga toxin-producing E coli infections for all Wyoming counties from June 2020 to March 2022; and persons with Cyclospora infections from 18 Kansas jurisdictions from June to August in 2022 and 2023. The SEAL team began supporting the California Department of Public Health (CDPH) in October 2021 and continues to do so, interviewing cases who are part of active enteric disease clusters on behalf of CDPH or local health jurisdictions.

Next, we describe the steps required to establish an enteric disease student interview team within a state (home state) and the additional steps needed to work with public health agencies located in other states (host states).

In-State Enteric Disease Student Interview Teams

Establishing a student interview team to work with a home state health agency will differ by state but involves the following broad steps: (1) hiring and onboarding, (2) training, (3) work management and engagement, (4) communication, and (5) evaluation.

Hiring and Onboarding

Hiring and onboarding necessitates fulfilling the public health agency requirements for conducting work and, if applicable, accessing the communicable disease surveillance database. For this reason, we recommend hiring students who plan to work on the team for at least the school year. Examples of onboarding tasks include creating a state-issued email account as well as securing a telephone and/or telephone number and a state-issued work laptop. Onboarding to the state agency will always be necessary for students to securely access relevant databases and applications. We have found that securing, distributing, and managing state-issued resources (eg, telephone or phone number, laptop) can create delays and logistical challenges, especially when rotating students through ongoing efforts. Accordingly, using alternate resources (eg, a Google Voice communication service instead of a physical telephone) or issuing physical equipment through the affiliated university program can be an alternative, and potentially more efficient, strategy.

Training

EDIT and SEAL team members are graduate students in master of public health programs. In addition to their coursework, training in confidentiality, work processes, and interviewing skills is critical to ensure that they are equipped to properly handle protected health information, understand workflow and task management, and perform effective interviewing. Training for both the EDIT and SEAL teams include: (1) online completion of a Health Insurance Portability and Accountability Act (HIPAA) module and how to handle protected health information; (2) confidentiality training; (3) reviewing enteric disease investigation resources, such as a series of videos on challenging interview scenarios,²⁰ which model approaches to commonly encountered scenarios including individuals who are hesitant to share information; and (4) practicing mock interviews and observing experienced interviewers perform mock interviews. Both teams also receive applicable state-specific enteric disease training: EDIT students complete a 4-hour live remote training session and SEAL members complete a 2-credit academic course on field epidemiology. Both cover topics such as surveillance systems, foodborne illness, state and federal outbreak investigation policies and procedures, working on an outbreak team, and conducting interviews. They also receive additional training on topics such as pathogen-specific forms and resources, relevant context about specific pathogens/exposures, data entry, language line use, cultural competency, and how to escalate situations requiring immediate supervisor attention.

Work Management and Engagement

Clear processes are needed to ensure that students understand the case investigation process, from case assignment to communication with supervisors. For example, both teams ensure students have a point of contact for work-related questions: EDIT has an epidemiologist on call each day on Slack, an instant messaging program, and the SEAL team has a designated site supervisor for each project. Both teams include students in regular meetings and focus on topics especially relevant to new interviewers, such as debriefing challenging interviews and interviewer self-care, including asking for help when feeling overwhelmed and managing the stress of hearing potentially upsetting information during interviews. Both teams also involve students in additional activities that align with their individual interests and facilitate their professional development.

Communication

Active communication between students and public health agency staff is important for several reasons, including being able to respond quickly when students have questions or encounter complicated or upsetting situations, following up when interviewed individuals require immediate attention by the public health agency, and keeping everyone up to date with student team scheduling and capacity. Communication is especially important when a team is working remotely. Examples include holding regular meetings and communicating through an instant messaging program such as Slack or Microsoft Teams.

Evaluation

Work performed by student teams should be regularly evaluated to ensure it is of high quality and aligns well with the workflow of the health agency. Approaches include data entry spot checks and metrics for completeness, timeliness, and other data quality indicators. Regular requests for qualitative feedback from health agency staff and student team members can help proactively identify issues and process improvement opportunities.

Interstate Enteric Disease Student Interview Teams

Students gain many skills from working on a team within their home state agency that will transfer to interstate work with host states. However, interstate work necessitates additional state-specific considerations that should involve stakeholders from the host and home state health agencies and student team academic institution. These considerations are described below and presented in detail in Table 1.

Table 1.

Considerations for Interstate Enteric Disease Student Interview Teams

Category	Considerations	Examples
Scope of work	Clear parameters for planning purposes	Discuss the duration of assistance Decide on the maximum number of interviews or hours per week Agree on the type of work the team will be performing (eg, routine interviewing, outbreak response, special projects) Anticipate seasonal needs such as additional support during the summer months
Hiring and onboarding	State-specific accounts, resources, and systems access may be needed State-specific confidentiality and protected health information requirements Sustainability	Determine how students will be classified at the public health agency (eg intern, volunteer, employee) Create a data user agreement, if needed Estimate a realistic timeline, accounting for institutional delays Request necessary resources (eg, phones, phone numbers, laptops, email account) Complete state-specific forms and trainings Hire students who intend to commit to the team for the school year
Training	State-specific interview forms State-specific topics Interviewing non-English-speaking individuals Cultural competency	Hold trainings and conduct mock interviews using state-specific interview forms Discuss common state-specific exposures, policies, and exemptions Train team on the use of host state language line and/or relevant forms that are translated into non-English languages Train team on state-specific issues around cultural competency
Work management and engagement	Case assignment Data access and entry Area codes Communication guidelines for students Communication guidelines for epidemiologists Guidance documents Engaging students with state epidemiology team activities	Host state enteric disease epidemiologist independently assigns cases from their state as needed Enteric disease epidemiologists from both agencies communicate about case assignments as needed; home state enteric disease epidemiologist assigns cases from home and host state Provide team direct unrestricted access to the notifiable disease database Provide team direct access to the notifiable disease database restricted to enteric disease data Provide team direct access to questionnaire/form developed and housed in a secure platform such as REDCap electronic data capture tools Team completes interview form and securely emails it to enteric disease epidemiologists who enter data into their system Use service such as Google Voice communications service or YouMail voicemail service if a phone number with an in-state area code is preferred Develop a protocol that outlines the communication process for when the team has questions or encounters a complicated situation Home state enteric disease epidemiologist communicates with host state enteric disease epidemiologist about team case capacity and scheduling Host state enteric disease epidemiologist communicates with home state enteric disease epidemiologist if any concerns about students arise Create state-specific guidance documents for student reference Invite students to regular departmental or other meetings related to their individual interests (eg, disease intervention specialist summary calls) Share potential additional training opportunities with students (eg, webinars)
Communication	Facilitating effective working relationships	Hold a virtual “meet and greet” session with icebreaker questions with student team and stakeholders from all involved agencies before work begins Provide clear guidance on effective communication processes between the student team and host state enteric disease epidemiologist, including how to escalate urgent situations and challenging interviews Plan regular virtual team meetings (eg, weekly) with student team and host state enteric epidemiology group; stakeholders from all involved agencies can attend as needed Hold virtual office hours and/or individual meetings for student team members and host state enteric disease epidemiologist Provide regular capacity updates and alternative contact information if out of office
Evaluation	Process Quantitative data Qualitative data	Host state enteric disease epidemiologist reviews surveillance forms and follow up with students regarding any questions or clarifications needed Host state enteric disease epidemiologist spot checks surveillance forms Host state enteric disease epidemiologist determines and measures data quality metrics such as proportion of interviews completed, completeness of core variables, or time to first interview attempt Host state enteric disease epidemiologist solicits feedback from health agency and students directly about the process and ideas for improvement

Establishing Scope of Work

Clear parameters for the scope of work need to be established between the states before beginning work to ensure alignment between the host state’s needs and the students’ capacity and ability.

Hiring and Onboarding

States may have different laws and policies around confidentiality, data access, and physical resources that will need to be fulfilled. Although it is now more common for health agencies to work with employees residing in other states, the process can involve bureaucratic delays and should be started as early as possible. The best approach to obtaining and managing access to host state resources for students will depend on the situation. For example, students on the SEAL team working with CDPH were classified as unpaid intern employees and issued physical equipment through the affiliated university program, whereas EDIT members working with WDH were classified as volunteers and issued laptop computers through CDPHE. Data use agreements were established for some partnerships, but not all, due to the short timeline required to establish collaborations during the pandemic.

Selecting students whose skills and experience match the needs of the host state is also important. For example, among the SEAL members supporting CDPH, it was useful to have at least 1 fluent Spanish-speaking student.

Training

Host state-specific required onboarding trainings, surveillance forms, enteric disease exposures, policies for escalating situations, and exemptions may differ from those in the students’ home state. Training on host state-specific issues is needed for students to conduct effective interviews. For example, NDHHS and WDH provided detailed training about agricultural and animal exposures, and CDPH focused on the Spanish-translated enteric disease form.

Work Management and Engagement

If students are working simultaneously on interviews from multiple states, it is important to establish a clear line of communication for assigning cases to the student. In some instances, the home state enteric disease epidemiologist may assume responsibility for coordinating the daily or weekly assignment of all cases to the student, including communicating case assignment from the host states to the student. In other situations, it may be preferrable for the host state epidemiologist to assign cases. Creating clear state-specific guidance documents that students can easily refer to is also important, especially if students are working in more than 1 state. Another work management consideration is data access and entry, which can be accomplished either through direct access to the host state notifiable disease surveillance system or through an alternative approach, such as the use of health agency-approved secure online platforms and encrypted emails. For example, NDHHS used a Box cloud storage folder to manage and share data with the EDIT students. Using this folder, Nebraska state staff input relevant demographic, clinical, and public health interview data into a spreadsheet. Students were assigned interviews, and recorded interview attempts and outcomes on the spreadsheet. They documented interview data on a paper-based surveillance form that was securely scanned using an approved platform and emailed to NDHHS staff using encrypted email. Staff at NDHHS then entered the data into their surveillance system and deleted the form in accordance with protected health information policies. EDIT students working with WDH were issued government email accounts (after completing the standard required WDH HIPAA training), contained within the WDH Google Workspace. This allowed them access to the cloud-based surveillance system and ensured end-to-end encryption of all communication and information between the students and the WDH enteric disease epidemiologist.

Communication

Facilitating effective working relationships is critical and can require additional effort for interstate work if the individuals and agencies are unable to work together in person and do not yet have an established relationship. Holding a virtual “meet and greet” session with icebreaker questions with student team members and stakeholders from all involved agencies before work begins can be an effective way to set the stage for open communication between the groups. Similar to home state student teams, regular virtual team meetings, office hours, and individual meetings are important to maintain communication, share updates about ongoing investigations, answer questions, and provide further training with host states. For example, weekly team meetings that include the host state enteric disease epidemiology group and the student team have been an effective tool for CDPH and the SEAL team to collaborate remotely, coordinate assignments, and troubleshoot issues. Guidance on who to contact at the host state, and how, for questions and situational escalation is also important, including alternative contact information if the host state enteric disease epidemiologist is out of the office. Likewise, it is necessary to provide the host state with student team capacity and scheduling updates, especially if student availability will be affected by the academic schedule, including university exams or vacations.

Evaluation

Similar to home states, host state enteric disease epidemiologists should review interview forms for completeness including spot checks for select data elements, and questions or concerns should be shared with the students. Host state enteric disease epidemiologists can also determine and measure data quality metrics and ask students for feedback on the process to identify areas for improvement.

Ethics Statement

The Colorado Multiple Institutional Review Board determined this study to be public health surveillance and not human subjects research and therefore exempt from full approval and requirements for informed consent.

Results for Interstate Enteric Disease Interviewing

Host State Interview Data Quality

NDHHS assigned EDIT 467 individuals to interview in Nebraska, WDH assigned 193 individuals in Wyoming, and KDHE assigned 33 individuals to interview in Kansas. Between October 2021 and January 2024, the SEAL team interviewed persons from 26 clusters of Salmonella, Listeria, and Shiga toxin-producing E coli infections from 9 jurisdictions across California (15% of the state’s 61 total local health jurisdictions), and cluster-associated cases from several other states that occurred after a California wedding. The proportion of successful interviews was high for all interstate collaborations, given the challenges of public health interviewing during the COVID-19 pandemic²¹ (Tables 2 and 3). For EDIT, 68% of assigned individuals in Nebraska, 79% in Wyoming, and 58% in Kansas were interviewed. The median number of days from case assignment to first interview attempt for all states was ≤1 day (Table 2). The SEAL team was able to interview 53% of assigned individuals overall. Among the interviews attempted in Spanish, the SEAL team interviewed 65% of assigned individuals. Interview forms completed by both EDIT and SEAL members were individually reviewed by host state enteric disease epidemiologists for completeness. Epidemiologists from all host states reported a (subjectively defined) satisfactory level of completeness, including clear information for individuals who worked in high-risk settings and/or would need additional follow-up.

Table 2.

Interstate Interviewing Metrics for EDIT, by Jurisdictional Pair

Metric	Colorado–Nebraska	Colorado–Wyoming	Colorado–Kansas
Cases assigned, n	467	193	33
Interviews attempted, n	432	193	33
Interviews completed, n (%)	317 (68)	153 (79)	19 (58)
Days from case assignment to first call, median	0	1	0

Table 3.

Interstate Interviewing Metrics for the SEAL Team

Metric	Washington–California
Clusters assigned, n	26
Total interviews attempted, n	133
Total interviews completed, n (%)	71 (53)
Interviews attempted in Spanish, n	20
Interviews completed among those attempted in Spanish, n (%)	13 (65)

Perspectives of Host State Agencies and Students

Enteric disease epidemiologists from host state health departments and students were asked for their perspectives on student interview teams working in host states. Both the epidemiologists and students valued the interstate work. An epidemiologist in Nebraska commented:

With the assistance of EDIT, enteric disease surveillance was still being monitored and managed for the state of Nebraska during the COVID pandemic. Nebraska state and local health departments are forever grateful for the support EDIT provided.

A Kansas epidemiologist mentioned:

We sought assistance from EDIT for completing cyclosporiasis investigations, which require completing a 12-page questionnaire. Kansas has many local health departments that are not open 5 days a week, with only a few staff members each, most of whom have never attempted a cyclosporiasis investigation before. Using EDIT reduced the burden on the health departments while ensuring more timely investigations with more uniform data collection.

Likewise, a WDH enteric disease epidemiologist emphasized that the surge capacity provided by EDIT was critical to maintaining outbreak detection capabilities. For example, interview information recorded by EDIT was used by WDH and the Wyoming Department of Agriculture while investigating the selling of uninspected meat and animal products due to pandemic-related delays in processing by licensed Wyoming meat and animal processing facilities. The California site SEAL team supervisor expressed a similar sentiment:

[W]e weren’t quite sure how it would work to have out-of-state students interview our patients. But these past 2 years have been wonderful as the students have helped us expand our capacity to interview enteric pathogen cases in multiple languages and solve more outbreaks. In addition, we’ve tried to make it a mutually beneficial experience by providing students with additional field experience so they can learn about the similarities and differences between how different states approach outbreak investigations, as well as coordinating informational interviews with other public health colleagues to help them with career goals. We love our SEALs and Integrated Food Safety Centers of Excellences!

Students also valued the experience of working across states. According to a current SEAL member:

[W]orking with CDPH has been incredibly eye opening for me as a student. Oftentimes, graduate public health programs focus heavily on curated examples and situations, without preparing students for the messy, unpredictable, and amazing real world of public health.

Two graduated EDIT members who now work as epidemiologists in local health jurisdictions similarly found the experience to be useful. One reported:

[T]he opportunity I had to work on Wyoming enteric disease cases […] has helped me have a better understanding of navigating communicable disease work in rural communities. Additionally, it has taught me unique and effective ways to approach a population that might have less trust for government agencies that have historically ignored these populations.

The other commented:

It was interesting to work with a different population and I loved being able to connect with epidemiologists from another state. This interagency work provided me with valuable experience that I can rely on when working with external partners in my role today.

Discussion

Collaboration between student interview teams and public health agencies benefits both groups. However, there are states that do not have access to students or student teams for a variety of reasons, such as not having a local school of public health (or lacking a student team “champion” at a local school of public health), not having enough “need” in nonpandemic or nonsurge times, a lack of funding, and institutional barriers. Furthermore, coordination in states with decentralized public health systems can make the use of student teams challenging. In a recent enteric disease capacity assessment, less than half of responding states reported having a student team to assist with routine surveillance/outbreak detection (36%) and outbreak investigation/response (40%).²²

We found that interstate student teams can work effectively, opening the opportunity for all states to potentially use student teams continuously or as flexible surge capacity support with routine interviewing, outbreak response, and other projects. Furthermore, while our experience is specific to enteric diseases, much of what we describe could apply to other communicable diseases, thus broadening the potential public health impact.

Though it requires coordination, based on these examples, interstate collaborations have produced tangible benefits as well as intangible value, such as strengthening relationships between the host states, home states, and affiliated university programs; and providing professional networking opportunities for students. Furthermore, many of the skills student team members learn from training and working in their home state are transferable to working in other states, and most of the work preparing students to work in host states occurs in the home state.

To ensure the success of interstate student teams, we recommend beginning the process early and anticipating institutional delays when developing a timeline. We suggest establishing clear parameters with the host state before work begins, determining onboarding and work management processes for working with individuals from host states, and providing easily accessible written protocols, guidance, and references. Hiring students who can commit to working on the team for at least the school year encourages team sustainability. Investing effort to build relationships between the home and host state health agencies and affiliated university program, and encouraging open communication were key to our successes.

The complexities and challenges that arise are likely to vary state-by-state depending on factors such as onboarding processes and system configurations. Though the recommendations we have provided can serve as a guide, it will be helpful for all involved to anticipate that unique challenges will arise and that effective solutions will require creative thinking from the entire group.

The interstate partnerships described in this case study occurred during the COVID-19 pandemic. While some process examples may not apply during nonpandemic times, we believe that many may be relevant and that the general lessons learned are broadly applicable. Comprehensive assessment of EDIT and SEAL team data quality for host state interviews was limited by working during the pandemic. For example, we were unable to compare the proportion of host state interviews completed by the student interview teams to state enteric disease interviewers because the state enteric disease interviewers were mainly performing SARS-CoV-2 interviews. Likewise, due to the unique data management processes established during the pandemic, we were unable to quantify the completion rate of core variables. However, each interview form was reviewed for completeness by the host state enteric disease epidemiology team. A more sustainable and rigorous evaluation of host state interview completeness and quality would be feasible during nonpandemic times.

Conclusion

Public health agencies and academic institutions have long collaborated within states. This case study demonstrates the feasibility and value of student interview teams to provide flexible surge capacity for enteric and other communicable disease programs located outside of their state. Lessons learned for providing and receiving interstate student interview team support are offered and may be especially salient for states without a local academic–public health partnership.

Footnotes

Acknowledgments

Many people made significant contributions to the interstate enteric disease student team collaborations, and thus to this case study, including Sadie Oppegard, Tiffany Greenlee, Courtney Tillman, Amanda Tran, and the EDIT interviewers for Nebraska, Wyoming, and Kansas: Keanu Kikau, Taylor Cook, Shaylee Warner, Natasha Thaweesee, Brian Whaley, Angela Golding, Danielle Lagana, and especially Maddie Hostetler and Jeremy Lozano. We would also like to thank Soyeon Lippman and Jeff Higa, whose efforts were invaluable in developing the CDPH collaboration, as well as the SEAL students: Anna Howard, Stephanie Buchbinder, Sandra Mata-Diaz, Alyssa Suarez, Olivia McCollum, Orlando Cervantes, Makena Leavitt, and Julio Ramos-Vazquez.

The Colorado Integrated Food Safety Center of Excellence is supported by the Epidemiology and Laboratory Capacity for Infectious Diseases Cooperative Agreement through the Centers for Disease Control and Prevention (grant no. 5 NU50CK000552-03-00). The investigations performed by the California Department of Public Health were supported by the Centers for Disease Control and Prevention Epidemiology and Laboratory Capacity for Infectious Diseases Cooperative Agreement (grant no. 5 NU50CK000539-05-00).

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