Terrorism preparedness in state health departments—United States, 2001-2003

Morbidity and Mortality Weekly Report, Oct 31, 2003 by G Shipp, P Dickson, C Lohff, N Franklin

The anthrax attacks in fall 2001 highlighted the role of infectious disease (ID) epidemiologists in terrorism preparedness and response. Beginning in 2002, state health departments (SHDs) received approximately $1 billion in new federal funding to prepare for and respond to terrorism, infectious disease outbreaks, and other public health threats and emergencies (1). This funding is being used in part to improve epidemiologic and surveillance capabilities. To determine how states have used a portion of their new funding to increase ID epidemiology capacity, the Iowa Department of Public Health's Center for Acute Disease Epidemiology and the Iowa State University Department of Microbiology conducted two surveys of U.S. state epidemiologists during September 2000-August 2001 and October 2002-June 2003. This report summarizes the results of these surveys, which determined that although the number of SHD epidemiology workers assigned to ID and terrorism preparedness increased by 132%, concern remained regarding the ability of SHDs to hire qualified personnel. These findings underscore the need to develop additional and more diverse training venues for current and future ID epidemiologists.

All 50 SHDs responded to both surveys. A total of 47 SHDs reported adding or expecting to add ID epidemiologists, who were assigned various responsibilities (e.g., terrorism preparedness, ID and terrorist agent surveillance, outbreak and possible terrorist threat investigation, public health worker and health-care provider training, and grant writing) (Table 1). Overall, during 2001-2003, the number of epidemiology workers employed in ID and terrorism preparedness increased by 132%, from 366 to 848 (Table 2).

Despite these hiring increases, the surveys identified multiple challenges, including problems 1) allocating time for planning (66% of responding SHDs), 2) establishing disease surveillance systems (55%), and 3) hiring qualified ID epidemiologists (57%). Other challenges to preparedness included the complexity of food-security issues, state hiring freezes and budget deficits, political and public policy considerations, and difficulty allocating the necessary time and resources for the pre-event smallpox vaccination program.

Reported by: G Shipp, MPA, J Dickson, PhD, Iowa State Univ, Ames; P Quinlisk, MD, C Lohff, MD, Iowa Dept of Public Health, Des Moines, Iowa. N Franklin, 2002 Knight Public Health Journalism Fellowship Program, CDC Foundation, CDC.

Editorial Note: Long before the terrorist attacks of September 11, 2001, and the subsequent anthrax attacks, public health officials recognized that the U.S. public health infrastructure was not equipped to respond adequately to events of biologic terrorism and other national public health emergencies (2). In 2003, the number of qualified persons employed in microbial threat preparedness remains dangerously low (3). Since 2001, Congress has appropriated increased amounts of funding to improve the overall capacity of state public health departments for terrorism preparedness (1). This funding was key to increasing the number of ID epidemiologists and the surveillance and response capabilities of SHDs. However, barriers to preparedness remain, and continued public, political, and financial support are essential to removing these barriers.

The findings in this report are subject to at least two limitations. First, the surveys were conducted during a period when the responsibilities of ID epidemiologists were in rapid transition, making consistent categorizing by utilization difficult. Second, although all SHD workers described in the surveys performed duties related to epidemiology, because of broad differences in academic background and experience, the nature of their roles and abilities were highly variable.

The findings in this report reflect concerns expressed by respondents to the national Epidemiology Capacity Assessment (ECA) regarding inadequate epidemiology staff and resources to conduct the 10 essential public health services (4). In the ECA survey, as of November 2001, approximately 42% of epidemiology workers were reported to have had no formal training in epidemiology, underscoring the need for increased curricula and training programs to improve the capabilities of current and future state and locally based ID epidemiologists.

TABLE 1. Number and percentage of state health departments hiring
epidemiology workers, by planned activities--United States, 2001-2003

Activity                                       No.      (%)

Develop surveillance activities for possible
  terrorist agents and infectious diseases     47/47   (100)
Investigate outbreaks and possible
  terrorist threats                            46/47    (98)
Train public health workers                    44/47    (94)
Develop and test epidemiologic plans for
  terrorism preparedness                       43/46    (93)
Train health-care providers                    43/47    (91)
Write grants for funding                       29/47    (62)
Perform other duties [dagger]                  23/47    (49)

* Number who responded "yes" versus all respondents who answered the
question.

([dagger]) Including community education and collaborating with other
agencies.


TABLE 2. Number * and percentage increase of state health department
epidemiology workers employed in infectious disease (ID) and terrorism
preparedness--United States, 2001-2003

                              New    Expected    Expected          %
                 No. in   hires in   new hires     total    increase
State              2001       2002        2003       2003   2001-2003

Alabama               3          0           2          5          67
Alaska                3          0           1          4          33
Arizona               7          6           1         14         100
Arkansas              4          2           0          6          50
California            8          4           4         16         100
Colorado             16          0          14         30          88
Connecticut           1         11           6         18       1,700
Delaware              6          2           1          9          50
Florida              20          5          11         36          80
Georgia              30         12           2         44          47
Hawaii                3          2           0          5          66
Idaho                 2          2           0          4         100
Illinois             45          5           4         54          20
Indiana               7          0          11         18         157
Iowa                  4          0           6         10         150
Kansas                4          5           2         11         175
Kentucky              5          6          10         21         320
Louisiana            18         14           9         41         128
Maine                 7          2           3         12          71
Maryland              1         16           4         21       2,000
Massachusetts        30          0           0         30           0
Michigan              3          7           5         15         400
Minnesota             4          0           7         11         175
Mississippi           9          3           2         14          55
Missouri              7         35           6         48         586
Montana               1          1           0          2         100
Nebraska              2          3           1          6         200
Nevada                4          0           2          6          50
New Hampshire         2          1           4          7         250
New Jersey           11          6           8         25         127
New Mexico            3         12           5         20         566
New York             14          9           4         27          93
North Carolina        2          1          10         13         400
North Dakota          2          0           0          2           0
Ohio                  2          4           0          6         200
Oklahoma              4          0           4          8         100
Oregon               10          5           0         15          50
Pennsylvania          1         17           0         18       1,700
Rhode Island          1          0           0          1           0
South Carolina        4         12           5         21         425
South Dakota          1          1           4          6         500
Tennessee             3         11           3         17         466
Texas                 7         19           4         30         429
Utah                 10          8           6         24         140
Vermont               7          1           2         10          43
Virginia              7         23          15         45         543
Washington            6          4           3         13         117
West Virginia         6          5           1         12         100
Wisconsin             6          2           0          8          33
Wyoming               3          5           1          9         200
Totals              366        289         193        848         132

* The numbers of ID epidemiologists employed by certain states (e.g.,
Vermont) are disproportionately high for the states populations because
no local or regional health departments exist. Other states have
acquired new ID epidemiologists primarily at the regional or local
level, and those hirings are not indicated.