Increasing Health Department
Epidemiological Response Capacity:
LCDR D. Fermín Argüello, MD, MPH
Centers for Control & Prevention
Presentation outline
1. Epidemiology Capacity in United States
2. Applied Public Health Team (APHT) Model & Structure
3. APHT & Health Department collaboration: Tennessee
4. Summary
1. Epidemiology Capacity in United States
United States Epidemiology Capacity
• National health objectives repeatedly call to increase
epidemiology capacity at local, state, territorial, & tribal
• Only 55% of state public health agencies have comprehensive
epidemiology capacity to support essential public health (PH)
• Despite sizable increases in federal funding after 2001,
shortfalls epidemiology personnel persist†
– ~2,193 epidemiologists in 2009‡  60% increase from 2001§
– 3,683 estimated need  ~68% shortfall‡
– 17% health department epidemiologists plan to retire or leave
their jobs in next 5 years§
* Health People 2010 & 2020 available at &
† Boulton et al. J Pub Health Manage & Pract 2009;15(4):328—36.
‡ CDC. MMWR 2009; 58(49);1373—7.
§ CDC. MMWR 2003; 52(43);1049—51.
Enhancing Epidemiology Capacity
• Programs providing epidemiology workforce surge capacity
enhance health departments ability to conduct key functions*
• Sources of epidemiology surge capacity
– Council of State & Territorial Epidemiologists
• Applied Epidemiology Fellowship
– Centers for Disease Control & Prevention
• Epidemic Intelligence Service
– Preparedness & Emergency Response Learning Centers†
• Coalition of schools of public health with agreements to
assist regional health departments during responses
– United States Public Health Service (USPHS), Office of Force
Readiness & Deployment (OFRD)
• Applied Public Health Teams
* McDonald et al. Public Health Reports 2010;125(S5):70
2. APHT Model & Structure
APHT Model
Scalable & deployable team of federal responders specially
trained to assist health departments in rapid assessment &
response to important public health problems
“Public Health Department in a Box”
-RADM Sven Rodenbeck
* RADM Rodenbeck
APHT Tool Box
• Epidemiology, Surveillance, & Preventive Services
Epidemiologic data collection & analysis
Community health status profile assessments
Program effectiveness & service delivery evaluation
Illness/injury surveillance & outbreak investigation
Health information dissemination
• Environmental Health
Food & water safety
Temporary shelter planning & assessment
Industrial hazard assessment & intervention
Environmental/occupational health & safety
Veterinarian public health
APHT Structure
• 5 teams of 40-50 officers under direction of USPHS OFRD
• Multidisciplinary
Preventive medicine physicians & nurses
Health educators
Environmental health scientists & industrial hygienists
Occupational health physicians
• Deployable in national disaster declarations
• Response within 48 hours
• On call every 5 months
APHT Structure
APHT Team Deputy
APHT Team Deputy
Blue Environmental
Public Health
Group (EPHG) Lead
Gold EPHG Lead
Blue EPHG team
Gold EPHG team
Preventive Services
Group (ESPSG) Lead
Gold ESPSG Lead
Gold ESPSG team
Recent APHT-3 Training & Responses
• Hurricane Ike—Austin, TX (2008)
Shelter surveillance of illnesses & injuries
Infection control evaluations
Industrial hygiene assessments
Food establishment inspections
Community Assessment for Public Health Emergency Response
(CASPER) surveys (post-disaster needs)
• Maryville & Chattanooga, TN (2010)
– Environmental & industrial evaluations
– Water safety assessments
– Seasonal & H1N1 influenza vaccination coverage survey
– Influenza information distribution to providers & community
Recent APHT-3 Training & Responses
• Paducah, KY (2011)
– Temporary emergency shelter assessments
– Public health environmental evaluations
– CASPER survey (disaster preparedness)
3. APHT & Health Department Collaboration:
Tennessee Example
APHT Annual Training 2010—Tennessee
• March 14 (Sunday): APHT-3 arrives in Knoxville to train with
Tennessee Department of Health
– 10 person APHT-3 Epidemiology & Surveillance Group deployed
to collaborate with Chattanooga-Hamilton Country Health
Department (CHCHD)
• March 15: APHT-3 Epidemiology & Surveillance Group meet
with CHCHD leaders to decide on focus/scope of investigation
• March 16-18: CHCHD epidemiologist & APHT-3 Epidemiology
& Surveillance Group conducts investigation & develops
health information for county
• March 19 (Friday): Presented findings to county health policy
• Problem
– After 2009 H1N1 education & vaccine campaign in Hamilton
County, CHCHD discovered substantially low rates of CHDHD
administered vaccinations in:
 19-24 year olds (6.7%)
 African Americans (1.6%)
 Residents in 13 zip codes (0.15-3.3%)
• Objectives
– Confirm vaccination acceptance rates in key communities
– Identify barriers to H1N1 vaccine acceptance
– Develop strategies & materials to “market” future vaccine
coverage in the county
• Method
– Cohort telephone survey of low vaccine uptake zip codes
– In person & email-based surveys of students in 3 local colleges
Telephone Survey
March 16-17
• Hypotheses & survey instrument developed by CHCHD/APHT
• 11 contractors & 5 APHT members trained & conducted 1,537
telephone interviews
On-site Survey at Colleges
March 17-18
• 4 APHT members conducted 658 in-person interviews
• 2 APHT members programmed email surveys that were sent to
12,000 students & faculty
Email Survey, Data Entry & Analysis
March 17-18
• Data collection, entry, cleaning, & analysis
Health Education
March 17-18
• H1N1/seasonal influenza information for providers & community
Key findings: Telephone Survey of Selected Zip Codes
• 22% H1N1, 47% seasonal influenza vaccine uptake overall
– 16% H1N1, 29% seasonal vaccine uptake among 19-24 year olds
– 21% H1N1, 46% seasonal vaccine uptake among African Americans
• No difference H1N1 or seasonal influenza vaccination on race
• H1N1 influenza vaccination increased with increasing age
• Reason for H1N1 & seasonal influenza vaccination: “Protect
myself & family”
• Reason for influenza vaccine refusal: H1N1  “Fear of adverse
effects”; Seasonal  “Vaccine not needed”
• Most common location for influenza vaccination: Doctors’
office (42% for H1N1, 49% for seasonal)
• Findings used to help develop 2010 seasonal/H1N1 influenza
vaccine campaign strategy
• Target 19-24 year-olds at appropriate venues
• Vaccine coverage for African-Americans similar to that for
general population
• Intensify efforts to link with “doctors’ offices”
• Develop education materials that align with reasons for
vaccine acceptance & refusal
4. Summary
• Incorporated real-time & impactful investigation into force
readiness training
• Negotiated, conducted, & presented findings of a sizeable
study, & developed appropriate health education materials
in 4 days
• Findings used to guide seasonal/H1N1 influenza vaccination
& education campaign in following year
• Demonstrates utility of specially trained federal responders
augmenting local health department epidemiology capacity
• Through this example, we demonstrate an example of local,
state, & federal collaborations that impact community
“As the scope of the public health enterprise increases, new
partnerships must be forged to increase collaboration in
communities and at the national and state levels”
Baker & Koplan
Baker & Koplan. Health Affairs 2002;21(6):15—27.
CAPT Beck, Acting & Deputy Director
CAPT Elenberg, Medical Readiness Training
• APHT-3
• Chattanooga-Hamilton County Health
Dawn Ford, Emergency Response Coordinator
Sarah Stuart Sloan, MPH, Epidemiologist
Margaret Zylstra, BSN, Epidemiology
Valerie Boaz, MD, County Health Officer
Telephone survey workers
CAPT Rapp, Team Commander
RADM Rodenbeck, former team commander
CAPT Kim, Team Deputy-Commander
CDR Chang, Blue Epidemiology, Surveillance • Tennessee Department of Health
& Prevention Services Group Lead
Susan R. Cooper, MSN, RN, State Health
CDR Hausman, Gold Epidemiology,
Surveillance & Prevention Services Group
Tim F. Jones, MD, State Epidemiologist
• University of Tennessee at Chattanooga
APHT-3 Epidemiology, Surveillance &
• Chattanooga Community College
Prevention Services Group members
• Southern Adventist University
• Study participants
Thank you.
CAPT Nancy Bill
CAPT David Kim
CDR Jodee Dennison
CDR Leslie Hausman
CDR Soju Chang
CDR Angela Shen
LCDR Eleanor Morin
LCDR Lee Ann Johnson
LCDR Fermin Arguello
LT Terrance Jones
Sarah Sloan
Dawn Ford
Abstract submission
Short title (limit 90 characters): Increasing health department epidemiological response capacity--The
Knowledge/competency gap (with evidence): A six-year study by the Council of State & Territorial
Epidemiologists found substantial shortfalls in epidemiologist staffing (Boulton et al. J Public Health
Management Practice 2009:15(4):328). Not surprisingly, programs that provide epidemiology workforce
surge capacity to health department have been shown to enhance the ability of health departments to
conduct epidemiologic investigations, respond to public health emergencies, & perform community
health assessments, among other essential public health services (McDonald et al. Public Health Reports
2010;125(S5):70). The U.S. Public Health Service Applied Public Health Team (APHT) was created in 2006
to provide expert consultation & workforce surge capacity in epidemiologic investigation & surveillance,
preventive medical services delivery, & environmental public health for health departments requesting
assistance (OFRD. APHT Concept of Operations, 2008). In March 2010, the Chattanooga-Hamilton
County Health Department (CHCHD) requested federal assistance in estimating total H1N1 vaccination
coverage & assessing factors influencing vaccination in zip codes with low health departmentadministered H1N1 vaccine acceptance rates. Over the one week investigation period, the CHCHD-APHT
team designed a survey, administered telephone interviews of a cohort of over 900 residents, completed
data analysis, & presented findings & recommendations to health department policy makers. This
collaboration is an example of the utility of specially trained federal responders augmenting a local
health department to conduct important investigations that might otherwise not be performed. Though
this example, we demonstrate a model through which local-federal collaborations make an impact on
public health.
Abstract submission
Long title: A model for increasing local & state health department capacity to rapidly assess important
public health problems--The Office of Force Readiness & Deployment (OFRD) Applied Public Health
Team (APHT) model.
Topic description (limit 350 words): In the setting of health department epidemiologist staffing
shortfalls affecting essential public health services across the United States, USPHS OFRD created the
scalable & deployable Applied Public Health Team (APHT) to assist Health Departments in rapid
assessment & response to important public health problems. This symposium will describe workforce
shortage in epidemiology in health departments across the United States, strategies in addressing this
shortfall, & the USPHS OFRD APHT model for addressing this important public health issue. To describe
the utility of specially trained federal responders assisting in conducting important investigations that
might not otherwise be performed, the symposium will focus on describing the joint ChattanoogaHamilton County Health Department (CHCHD)-APHT collaboration to conduct a rapid estimation of the
total 2009 H1N1 vaccination coverage & assess the factors influencing vaccination in zip codes with low
health department-administered H1N1 vaccine acceptance rates.
Learning objectives (at least 3):
1.) At the end of this session attendees will be able to describe public health epidemiology workforce
shortages in the United States.
2.) At the end of this session attendees will be able to describe the role of APHT in enhancing local public
health epidemiology capacity.
3.) At the end of this session attendees will be able to describe the benefits of APHT augmentation of
CHCHD in the investigation on H1N1 & seasonal influenza vaccination coverage & factors influencing
acceptance of vaccination.