* * *
Douglas Thoroughman, PhD, MS
CAPT, USPHS
CDC Career Epidemiology Field Officer
Kentucky Department for Public Health
(Standing in for Linda J. Neff, PhD)
Office of Science and Public Health Practice – CEFO Program
Office of the Director, Public Health Preparedness and Response

Today’s Talk

Describe the CEFO Program and it’s history

Discuss our evaluation efforts

Give basic results of recent evaluations

• The program was created in 2002 after terrorist events of 9/11 & anthrax incidents.
• A CEFO is a CDC epidemiologist that is assigned to a state or local health department.
• The overarching aim is to address critical gaps in epidemiologic capacity as part of public health preparedness.

• 2002 - Epidemiology Program Office
• 2004 - Coordinating Center for Health Information and
Service
• 2006 – Coordinating Office for Terrorism Preparedness and Emergency Response (COTPER), Division of State and Local Readiness
• 2007 - COTPER, Office of Science and Public Health
Practice
(
COTPER was renamed the Office of Public Health Preparedness and Response
(OPHPR) in 2009
)

• Funded through Public Health Emergency Preparedness
(PHEP) Cooperative Agreement via direct assistance (DA) mechanism
• Shift in strategy
• From: Placement in areas of perceived risk and need
• To: Placement where states choose to fund a CDC epidemiologist using a portion of Public Health Emergency Preparedness (PHEP)
Cooperative Agreement allocations.
• Initial 2-year assignment period
• Assignment may be extended annually, based on need and available funding
• Currently, 30 epidemiologists assigned at state and local health departments in 24 states

• CEFO Headquarters provides administrative and technical support to the CEFOs.
• CEFOs have a supervisor in their field location, and also have a supervisor from CEFO Program
Headquarters at CDC.
• State PHEP funds do not support HQ program

State expresses an interest in retaining a
CDC epidemiologist
CEFO is hired. CEFO program and DSLR PO work with State on developing a work plan for CEFO.
CEFO Program and
DSLR discuss state program needs and resources with State
Preparedness Director and Epidemiologist
CEFO program recruits and selects
CEFO via routine
AHRC PAR. Consults with State on potential candidates.
State request for
Direct Assistance submitted to DSLR
PO

Assignment Locations, June 2012
Sun
Pertowski
Carter
Sunenshine
Nett
O’Leary
McFadden Goode
Manning
Pickard
Tarkhashvili
Holzbauer
Buss
Rey
Dentinger &
Harper (NYC)
Morrison
States with CEFOs
Radcliffe
Kurkjian
Patel (Philadelphia)
Campagnolo (Harrisburg)
Lando (Pittsburgh)
& ???
Fleischauer &
MacFarquhar
Thoroughman
& ???
Roth &
Murphree
Török & Schmitz
As of June 2012, 29 CEFOs are assigned to state and local health departments in 23 states.

By Type of Appointment
 USPHS Commissioned Corps Officers 73%
 Civil Servants 20%
 Senior Service Fellows 7%
By Professional Discipline
 Physicians
 Veterinarians
 Public Health Scientists
 Nurses
33%
30%
23%
13%




Qualitative Review of Quarterly Reports
Survey of CEFOs
 Type and distribution of work activities,
 Satisfaction with support provided by CDC
 Satisfaction with CEFO Program operational elements
Stakeholder Survey
 Awareness of the CEFO Program
 Whether they have ever had a CEFO in their health department;
 Satisfaction with CEFO activities and contributions
 Satisfaction with support provided by CEFO Program
Headquarters
 Satisfaction with how CEFOs are funded


CEFO field assignees required to submit a report on a quarterly basis.

Standard template used to report work activities in
5 categories.
1. Building epidemiologic, surveillance and emergency response capacity
2. Partnership and collaboration activities that support public health infrastructure
3. Education, training, and workforce development
4. Communications and information technology capacities and risk communications and health information dissemination
5. Federal obligations



Reviewed 143 reports submitted by 23 CEFOs.
Period: 10/01/2008 and 09/30/2010.
Framework used to standardize coding of activities.


Web-based survey
 Assessment conducted among 30 CEFO field assignees in 23 states
 April 28, 2011 to May 11, 2011
 Launched via a link to a web-site for a total of 9 days
 IBM-SPSS® Data Collection web-based survey tool
 Response rate was 87% (n=26)

 Web-Based Survey
– Developed with IBM-SPSS® Data Collection tool
– OMB approval for one-time use of the FDA generic information collection mechanism (OMB Control No. 0910-
0360)
– Administered to all 62 PHEP Directors, all 59 State and
Territorial Epidemiologists, and 24 others were PHEP points of contact (n=145)
– Survey open from May 12 - May 25, 2011 (reminder on May 17)
– No respondent identifiers were collected
– Response rate was 44% (64/145)

Categories of CEFO Activities:
1. Improve epidemiologic capacity
2. Improve public health preparedness and response
3. Provide education, training, and workforce development
4. Improve communications
5. Improve policy recommendations
6. Increase health department's access to professional networks and resources
7. Contribute to scientific knowledge base

EPIDEMIOLOGIC CAPACITY
Example activities:
• Surveillance on mental health and physical effects related to disaster
• Expanded and improved syndromic surveillance
• Developed and assessed new surveillance systems
• Conducted multiple outbreak investigations:
• salmonella, norovirus, Escherichia coli 0157:H7
• respiratory virus outbreaks in institutions
• multi-state outbreak of campylobacteriosis
• health-care associated infections
• suspected bioterrorism agent

PUBLIC HEALTH PREPAREDNESS AND RESPONSE
Example activities:
• Facilitated trainings in Community Assessment for
Public Health Emergency Response (CASPER)
• Conducted CASPER planning exercise
• Led exercise for medical countermeasure dispensing in a community
• Developed protocols, staffing, and training for
Epidemiology Strike Teams
• Every CEFO participated in state and federal H1N1 response.

EDUCATION, TRAINING, AND WORKFORCE
DEVELOPMENT
Example activities:
 Primary or secondary supervisor to EIS officers, epidemiology staff, CSTE fellows and student interns
 Trained epidemiology staff on how to use data from
ESSENCE syndromic surveillance system
 Facilitated EPIINFO training for staff epidemiologists
 Conducted incident command system, diseasespecific, and epidemiology trainings for public health practitioners, healthcare professionals and other community partners.

COMMUNICATIONS
Example activities:
 Developed outbreak investigation manuals and guides for local health departments.
 Collaborated on project to evaluate the effectiveness of message venues for sending public health alerts to healthcare providers.

POLICY RECOMMENDATIONS
Example activities:
 Assisted with the development of guidance for alternate standards of care for pandemic influenza.
 Assisted with the development of standing orders
(with policy) for dispensing prophylactic medications to large populations.

PROFESSIONAL NETWORKS AND RESOURCES
Example activities:
 Served on advisory committees and workgroups to provide epidemiology expertise, including: o o o o
Preparedness and Emergency Response Research
Center (PERRC) Advisory Committee.
State Agro-terrorism working groups.
Hospital Bioterrorism Preparedness Planning Group.
Epidemiology expert for state’s BioWatch planning group.
o
Emergency Management Agency Disaster Shelter
Planning Work Group.
 Established and fostered partnerships with community organizations, including the American Red Cross, to enhance preparedness.

Mapping CEFO Activities to PHEP Capabilities
Table 2. CEFO activities mapped to public health preparedness capabilities.
(October 2008-September 2010)
Public Health Preparedness Capability (PC)
No.
Recorded
Activities
(all)
No.
Recorded
Activities
(H1N1 only)
PC 1. Community Preparedness
PC 2. Community Recovery
PC 3. Emergency Operations Coordination
PC 4. Emergency Public Information and Warning
PC 5. Fatality Management
PC 6. Information Sharing
PC 7. Mass Care
PC 8. Medical Countermeasure Dispensing
PC 9. Medical Material Management and Distribution
PC 10. Medical Surge
PC 11. Non-pharmaceutical Interventions
PC 12. Public Health Laboratory Testing
PC 13. Public Health Surveillance and Epidemiological
Investigation
PC 14. Responder Safety and Health
PC 15. Volunteer Management
17
0
3
4
9
194
105
2
22
7
3
30
2
2
0
10
0
2
3
3
45
6
4
1
7
0
15
0
1
0
TOTAL 400 97

Most CEFOs are moderately to greatly involved in:
 Consulting on surveillance projects 93% (n=24)
 Supervising or conducting outbreak investigations 77% (n=20)
 Linking epidemiology and laboratory capacities 70% (n=18)

PUBLIC HEALTH PREPAREDNESS AND RESPONSE
Most CEFOs are moderately to greatly involved in:
 Developing state or local preparedness plans 73% (n=19)
 Conducting response trainings 57% (n=15)
 Evaluating state or local preparedness plans 53% (n=14)
 Conducting response exercises 53% (n=14)
 Evaluate state or local emergency response 50% (n=13)

EDUCATION, TRAINING, AND WORKFORCE
DEVELOPMENT
Most CEFOs are moderately to greatly involved in:
 Mentoring students, epidemiologists, EIS, or other staff 100% (n=26)
 Provide workshops and training 81% (n=21)

Most CEFOs are moderately to greatly involved in:
 Contributing to public outreach 77% (n=20)
 Contributing to briefing statements 73% (n=19)
 Contributing as subject matter expert on campaigns 69% (n=18)
 Consulting on public health recommendations 69% (n=18)

Most CEFOs are moderately to greatly involved in:
 Consultative role in revisions of public health policies 69% (n=18)
 Consultative role in state or local public health department policy development
65% (n=17)

Most CEFOs are moderately to greatly involved in:
100% (n=26)  Collaborate with federal partners
 Collaborate with state partners
 Consult with subject matter experts (SMEs)
 Collaborate with local health departments
96% (n=25)
92% (n=24)
81% (n=21)

Most CEFOs are moderately to greatly involved in:
 Facilitate special projects 92% (n=24)
 Other consultations as subject matter expert (SME) 88% (n=23)
 Provide conference presentations 81% (n=21)

INTERACTIONS WITH CDC HEADQUARTERS

The survey respondents rated their level of satisfaction with each of the following statements about their interactions with CDC headquarters:
 My expectations for CEFO Headquarters interactions are met.
 I receive the amount of support that I would like to receive from the CEFO Program Headquarters staff.
 The CEFO Program Headquarters staff are accessible when I try to contact them.
 The CEFO Program Headquarters are responsive when I make requests.
96 % (n=25) of the respondents agreed or strongly agreed with each statement.

By CEFO Assignee Status

Stakeholder Assessment of the
Value of CEFO Assignments (n=64)
Reasons the Health Department Chose or Might Choose to
Employ a CEFO (n=64)
0% 20% 40% 60% 80%
Assist with PHEP cooperative agreement requirements
66%
Improve surveillance 52%
100%
83% Improve epidemiologic capacity
Assist with preparedness and response activities
Other 11%
66%

Satisfaction with CEFO Activities among
Stakeholders Currently or Previously Assigned a
CEFO (n=43)

Highest satisfaction rating: Over 90% of respondents reported that CEFOs met or exceeded expectations for six activities:
 Consulting with subject matter experts (SMEs) (98%)
 Collaborating with federal partners (95%)
 Consulting on surveillance activities (93%)
 Surveys related to public health investigations (91%)
 Collaborating with state partners (91%)
 Participating in workgroups or other councils (91%)

Satisfaction with CEFO Activities among
Stakeholders Currently or Previously Assigned a
CEFO (n=43)
CEFO Activity
Serving as adjunct faculty in institutes of higher learning
Conducting policy analysis
Providing national training
Minimally
Meets
Expectations
Meets or
Exceeds
Expectations
12%
21%
14%
33%
51%
47%
N/A
56%
28%
40%


Lowest satisfaction rating :
At least 60% of respondents believed that CEFO contributions met or exceeded expectations for all but three activities
These 3 activities were also most frequently rated as not applicable to the work of CEFOs.

Challenges in Requesting a CEFO
Among Respondents Interested But Not Currently
Assigned a CEFO (n=26)

Stakeholders’ Views about the Strengths of the
CEFO Program for their Health Department (n = 43)
A selection of open-ended responses to:
7.1 In your opinion, what are the strengths of the CEFO Program for your health department?
 “CEFO filled a critical technical and leadership gap that we had been unable to fill for - literally - years.“
 “We get access to a talent pool we could not otherwise afford or attract to our organization”
 “Access to well-trained medical epis, with outbreak leadership skills, usually well connected to the centers, excellent at recruiting and supervising EISOs, and able to push projects to closure”
 “Provides epidemiologic support, connects emergency preparedness with epidemiology, provides scientific expertise, and staff mentoring”
 “Additional highly-trained staff in the face of state hiring freezes”

Assessment of Stakeholder Satisfaction with
Current CEFO Funding Mechanism
100%
80%
60%
40%
20%
0%
72%
17%
11%
54%
39%
7%
42%
25%
33%
39%
61%
50%
25%
25%
36%
64%
Equitable
Currently Assigned CEFO
Sustainable Optimal
Not Currently Assigned CEFO

Evaluation Results: Summary
Strengths
Weaknesses
Opportunities for
Improvement
• Epidemiologic expertise of CEFO field assignees
• CEFO’s functioning in wide range of capacity-building activities
• CEFOs improve epidemiologic capability and preparedness
• Uncertain funding
• Insufficient funds in PHEP is a barrier to establishing and maintaining CEFOs
• Lack of flexibility for CEFO to conduct broad epi activities
• Better articulation of CEFO
Headquarters’ role
• Sustainable funding model
• Possible to use combined funding sources?

 CEFO Program is considered useful and effective by stakeholders and
CEFO’s
 Epidemiologic capacity and public health preparedness are being affected positively by placement of CEFO’s in state and local HD’s
 Next Steps: o Continue to consider and fill state requests for CEFO’s o Exploring core competencies of CEFO field assignees to facilitate career development and to sustain superior workforce.
o Exploring alternate funding mechanisms using Direct Assistance authority in other program cooperative agreements to share cost of CEFO. (e.g. immunization, tobacco)
42

For more information please contact Centers for Disease Control and Prevention
1600 Clifton Road NE, Atlanta, GA 30333
Telephone, 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348
E-mail: cdcinfo@cdc.gov Web: www.cdc.gov
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.