Assessment of the epidemiologic capacity in state and territorial health departments—United States, 2001

Morbidity and Mortality Weekly Report, Oct 31, 2003 by ML Boulton, RA Malouin, L Robinson, K Hodge

Epidemiology is essential for the detection, control, and prevention of major health problems. Described as the foundation of all public health functions (1), epidemiology provides information needed to perform the 10 essential public health services (2). One of the national health objectives for 2010 calls for increases in the proportion of tribal, state, and local public health agencies that provide or ensure comprehensive epidemiology services to support essential public health services (objective 23-14) (3). Although national infectious disease capacity has been assessed (4-6), no comprehensive national assessment of epidemiologic capacity has been conducted. To assess core epidemiology and infectious disease capacity of public health departments, the Council of State and Territorial Epidemiologists (CSTE) surveyed state and territorial health departments in November 2001 (7), immediately before the release of approximately $1 billion in federal funding to state health departments for terrorism and public health emergency preparedness. This report summarizes the results of that survey, which indicate that the national epidemiology infrastructure in state and local health departments is far below optimal capacity and that approximately 42% of epidemiologists working in public health have no formal epidemiologic training. Although recent terrorism preparedness initiatives have improved capacity in infectious disease epidemiology, increased resources are needed to build epidemiologic capacity necessary to address the major causes of morbidity and mortality.

In October 2001, a draft version of the Epidemiology Capacity Assessment (ECA) was piloted in 10 states. In November, the final version was sent electronically and by mail to the 50 states, the District of Columbia, and the five territories. Responses were received during November 2001--April 2002. ECA included general questions about the epidemiology workforce and specific questions pertaining to the 10 essential public health services. Of the 108 questions, 22 addressed core epidemiologic capacity, and 86 addressed infectious disease capacity. State epidemiologists were identified as key informants, and follow-up was made by telephone and e-mail to nonresponding states. A total of 41 states and three territories (78.6%) responded to the survey.

As of November 2001, responding state and territorial health departments employed 1,366 persons as epidemiologists in all program areas; 652 (47.7%) worked in infectious disease programs, and <50 worked in each of the areas of injury epidemiology, occupational epidemiology, or oral health. A total of 77 (5.6%) persons were former CDC Epidemic Intelligence Service (EIS) officers. Among persons employed as epidemiologists in state health departments, the level of training varied substantially (Table); 787 (42.4%) persons had no formal training in epidemiology. Formal training included either academic coursework or other training in epidemiology (e.g., the EIS program).

The median total state (n = 26) expenditure for all epidemiology programs was $2.7 million (interquartile range [IQR]: $1.15 million--$6.6 million), with a median per-capita expenditure of $0.70 (IQR: $0.31-$1.73). Federal sources provided 61.3% and state sources 36.6% of funding for all epidemiology programs in the reporting state and territories (n = 42).

States were asked to assess core epidemiologic capacity in eight program areas (i.e., infectious disease, chronic disease, maternal/child health, injury, bioterrorism/emergency management, environmental health, oral health, and occupational health) by using a four-point scale* based on the estimated percentage of the activity or resource described in the question that was met (Figure). In addition, states were asked to assess the four essential public health services with a substantial epidemiologic component. "Partial" or "minimal to no" capacity was reported by 24 (54.5%) respondents in monitoring health status to identify and solve community health problems; 17 (39.5%) in diagnosing and investigating health problems and health hazards in the community; 32 (72.7%) in evaluating effectiveness, accessibility, and quality of personal and population-based services; and 41 (93.2%) in conducting research for new insights and innovative solutions to health problems.

States' self-assessed capacity for conducting the 10 essential services varied substantially. Although 31 (72.1%) states reported "full/almost full" capacity to monitor all diseases under the Nationally Notifiable Disease Surveillance System, only eight (18.6%) states had "full/almost full" capacity for analysis and reporting of data from the 24 different databases (e.g., emergency rooms, poison control centers, or Medicaid) mentioned in the survey. Few states and territories reported having "full/almost full" capacity to maintain surveillance systems for health outcomes related to emergencies, including four (9.3%) for bioterrorism events, two (4.8%) for radio-logic events, and three (7.5%) for environmental or other hazardous substances; no respondents reported "full/almost full" surveillance capacity for incendiary devices or natural disasters.