Abstract
Objectives:
To better understand the current status and challenges of the state public health department workforce, the Council of State and Territorial Epidemiologists (CSTE) assessed the number and functions of applied public health epidemiologists at state health departments in the United States.
Methods:
In 2017, CSTE emailed unique online assessment links to state epidemiologists in the 50 states and the District of Columbia (N = 51). The response rate was 100%. CSTE analyzed quantitative data (27 questions) on funding, the number of current and needed epidemiologists, recruitment, retention, perceived capacity, and training. CSTE coded qualitative data in response to an open-ended question that asked about the most important problems state epidemiologists face.
Results:
Most funding for epidemiologic activities came from the federal government (mean, 77%). State epidemiologists reported needing 1199 additional epidemiologists to achieve ideal capacity but noted challenges in recruiting qualified staff members. Respondents cited opportunities for promotion (n = 45, 88%), salary (n = 41, 80%), restrictions on merit raises (n = 36, 70%), and losses to the private or government sector (n = 33, 65%) as problems for retention. Of 4 Essential Public Health Services measured, most state epidemiologists reported substantial-to-full capacity to monitor health status (n = 43, 84%) and diagnose and investigate community health problems (n = 47, 92%); fewer respondents reported substantial-to-full capacity to conduct evaluations (n = 20, 39%) and research (n = 11, 22%).
Conclusions:
Reliance on federal funding negatively affects employee retention, core capacity, and readiness at state health departments. Creative solutions for providing stable funding, developing greater flexibility to respond to emerging threats, and enhancing capacity in evaluation and applied research are needed.
Since 2001, the Council of State and Territorial Epidemiologists (CSTE) has conducted 6 assessments of the applied public health epidemiology workforce in the United States and its territories, known as the Epidemiology Capacity Assessments (ECAs). 1 -6 Participation has been uniformly high: all 50 states and the District of Columbia have participated in all ECAs since 2004.
One purpose of the ECAs is to provide information to policy makers on the strength and capacity of the epidemiology workforce. The ECAs permit state epidemiologists to assess how data on their jurisdictions compare with national data on staffing, performance on key epidemiology competencies, the relative contribution of federal and state funds to their budgets, and salaries. In addition, ECAs provide useful data to schools and programs of public health on what skills and program area expertise are needed by students to respond to changing workforce needs and priorities (eg, systems thinking, informatics).
This article is based on a 2017 ECA. Detailed results of this study were posted on the CSTE website on June 1, 2018, 6 and elsewhere. 7 In this article, we describe the key quantitative and qualitative findings of the 2017 ECA for the 50 states and District of Columbia on funding, staffing, recruitment, retention, capacity, and challenges in a changing environment.
Methods
State epidemiologists from all 50 state health departments and the District of Columbia (N = 51) completed the ECA during summer 2017. The ECA is part of a periodic evaluation of routine public health activities among CSTE members; as such, institutional review board review was not required.
Assessment Instrument
Focus groups composed of CSTE national office staff members and CSTE members provided input to modify the assessment used in the 2013 ECA. Focus group participants reviewed the purpose, value, and content of the assessment and provided input on the training required to prepare respondents to complete it.
CSTE put the 29-question assessment into an online format by using Qualtrics software. In February 2017, 3 state health departments participated in a pilot version of the assessment. The final 2017 ECA covered the following topics: epidemiology leadership in the state health department (questions 1-4); funding sources (questions 5 and 6); current staffing and need for additional staffing (questions 7 and 8); epidemiology and surveillance capacity (questions 9-11); civil service annual salary ranges (questions 12 and 13); epidemiology training and use of the applied epidemiology competencies (questions 14-18) 8 ; existing practices, priorities, incentives, and barriers to strengthening the epidemiology workforce (questions 19-21); vacancies and retention (questions 22-26); and preparedness (question 27). These 27 questions were a mix of short answer, multiple choice, scales (eg, none, minor problem, moderate problem, major problem), and matrix tables, such as the fraction of full-time equivalent positions by program area and funding source. For the first time, 2 open-ended questions (questions 28 and 29) were included: “As the state epidemiologist, what are the most critical issues you face?” and “What other thoughts, comments, concerns, or questions would you like to share with CSTE with regard to the epidemiology workforce and training?”
For purposes of the evaluation, CSTE defined epidemiology capacity as that which ensures the state health department’s ability to lead activities, provide subject matter expertise, and apply for, receive, and manage resources to conduct the 4 Essential Public Health Services most closely related to epidemiology: (1) monitoring health status, (2) investigating community health problems and hazards, (3) evaluating the effectiveness of public health interventions, and (4) conducting applied research. 9 States were asked to estimate their capacity in each area using the following categories: none (0%), minimal (1%-24%), partial (25%-49%), substantial (50%-74%), almost full (75%-99%), and full (100%). For the analyses, CSTE used 3 categories of capacity to conduct an Essential Public Health Service: none to minimal (0%-24%), partial (25%-49%), and substantial to full (50%-100%).
Respondents were asked to estimate the percentage of funding for activities and for personnel that came from federal, state, and other sources. CSTE did not define “activities,” although CSTE suggested that respondents review the applied epidemiology competencies for examples of epidemiology activities, which include surveillance, outbreak investigation, evaluation, and applied research, and exclude personnel.
Administration and Analysis
In April 2017, CSTE emailed each state epidemiologist with a unique link to the online assessment. CSTE hosted a webinar on how to complete the assessment and held 2 virtual ECA office hour sessions during the response period. The state epidemiologists received a copy of their 2013 ECA state reports to ensure that responses considered previous staff enumeration methods, which differed by state. The deadline for assessment completion was mid-August 2017. CSTE staff members contacted states via email to request clarifications and additional information for incomplete responses.
CSTE used Epi InfoTM version 7 10 and Microsoft Excel to calculate the number of actual and additional desired positions overall and by program area to examine frequency distributions for categorical variables and to calculate means, medians, and ranges for continuous variables. CSTE used grounded theory to code qualitative data from the open-ended question that asked about the most critical problems and grouped data thematically.
Results
Funding
Of all funding for epidemiologic activities in state public health departments, respondents estimated that the federal government provided a mean of 77% (range, 46%-99%), state health departments provided a mean of 19% (range, 4%-50%), and other sources provided a mean of 4% (range, 0%-32%) (Figure 1). The percentages of funding sources for epidemiology personnel were similar to those for epidemiologic activities: federal (mean: 77%; range, 46%-96%), state (mean: 20%; range, 4%-50%), and other (mean: 4%; range, 0%-36%). Epidemiologic activities were supported by other sources of funding in only 23 states and the District of Columbia, and other sources of funding for epidemiology personnel were reported in only 25 states.
Mean percentage and range of funding sources for epidemiologic activities and epidemiological personnel at state health departments, Epidemiology Capacity Assessment, 50 US states and Washington, DC, 2017. The middle lines in the bars represent the mean percentage. Data source: Council of State and Territorial Epidemiologists. 6
In response to the open-ended question that addressed the most critical issues facing state epidemiologists, several respondents indicated funding as an important issue at state health departments. Respondents reported that state public health programs’ reliance on federal funding had a negative effect on perceived job security, job satisfaction, staff morale, and staff retention. Furthermore, unfunded and inconsistently funded mandates affected health department readiness to respond to new threats. Respondents also reported budget problems at public health laboratories: The high level of dependency on federal funding sources limits the flexibility of the state to respond to emerging public health threats and increases vulnerability of the workforce to reductions in federal appropriations. Recent public health threats (H1N1, Ebola, Zika) have exacerbated the cycle of increased attention and funding to specific program areas followed by loss of attention and funding, but these threats have not resulted in acknowledgment of the need to maintain a basic level of readiness for all existing and emerging threats.
Staffing
In 2017, US state health departments employed 3370 epidemiologists (Table 1). The number of epidemiologists per state ranged from 5 to 208, and the number of epidemiologists per 100 000 population was 1.04.
Epidemiology positions by program area, Epidemiology Capacity Assessment, 50 US states and Washington, DC, 2017a
aData source: Council of State and Territorial Epidemiologists. 6
bCurrent/ideal x 100.
cPositions for which human resources is working actively to fill.
More than half of state health department epidemiologists (n = 1839, 55%) worked in infectious diseases (Table 1), followed by maternal and child health (n = 321, 10%) and chronic diseases (n = 304, 9%). The fewest number of state epidemiologists worked in substance abuse (n = 59), occupational health (n = 28), oral health (n = 18), genomics (n = 4), and mental health (n = 4), which together accounted for 3% of the total.
Respondents estimated that to reach full capacity in each program area, an additional 1199 epidemiologists at the master’s level or higher would be needed in all program areas, with the most epidemiologists needed for infectious diseases (n = 338), chronic diseases (n = 137), environmental health (n = 122), and maternal and child health (n = 122) (Table 1). The number of currently vacant positions in the 50 states and the District of Columbia (n = 355) was 30% of the number needed to reach full capacity.
The disparity between the number of current epidemiologists and the ideal number of epidemiologists, as well as the limited number of vacancies, reportedly restricted health departments’ ability to maintain basic epidemiologic services and respond to emerging problems. Respondents reported that both funding and administrative issues restricted health departments’ ability to create new positions to address emerging public health problems: We have a small staff overwhelmed with growing responsibilities, including prescription drug overdose, syndromic surveillance, health care–associated infections, and others. [There is a] lack of funding and state positions to expand capacity in areas with existing epidemiologic activities and to create capacity in areas without current epidemiologic activities.
Recruitment of Qualified Staff Members
Most state health departments required a bachelor’s degree (n = 30, 59%) or master’s degree (n = 17, 33%) for entry-level epidemiologists. Twenty-five states (49%) required <1 year of experience for these entry-level positions, 13 (26%) required 2 years of experience, and 5 (10%) required >2 years of experience. The median minimum salary for entry-level positions was $44 283 (range, $30 000-$70 000), the median maximum salary was $68 855 (range, $35 000-$110 000), and salaries increased by degree level (Table 2).
Estimated median minimum and maximum salaries and salary ranges of epidemiologists, by degree and career level, Epidemiology Capacity Assessment, 50 US states and Washington, DC, 2017a
aData source: Council of State and Territorial Epidemiologists. 6
The factors that state epidemiologists cited most frequently as major and moderate recruitment problems related primarily to compensation and opportunities for advancement: restrictions on offering competitive pay (n = 41, 80%), salary scale (n = 39, 76%), opportunities for promotion (n = 37, 73%), and hiring quickly enough (n = 31, 62%). Several respondents reported having to use contractors because of state hiring restrictions. Respondents also said it was difficult to find qualified candidates. Some respondents reported difficulties in recruiting epidemiology candidates with appropriate skill sets, especially nurses, physicians, persons with public health experience, and persons with expertise in emerging fields, such as informatics.
Retention, Maintaining Capacity, and Institutional Memory
The factors state epidemiologists cited most frequently as major and moderate problems for staff member retention were opportunities for promotion (n = 45, 88%), salary (n = 41, 80%), restrictions on merit raises (n = 35, 70%), and loss to the private sector or government sector (n = 33, 65%). Other problems included loss of pension programs, uncertain funding for staff positions, and undefined career paths. Respondents reported that epidemiologists with an MPH degree tended to leave the workforce to start PhD programs, and staff members with MPH and PhD degrees were inclined to leave public health for the private sector.
According to state epidemiologists, the frequent loss of staff members affected the available number of skilled supervisory-level epidemiologists, a problem that they expected to worsen as experienced epidemiologists retire. The problem of turnover was reportedly compounded by changes in public health priorities and emerging public health threats that necessitate ongoing training activities and diversion of experienced staff members to train and supervise new employees: Emerging diseases or public health threats would not be as disruptive if the staff were more seasoned and more comfortable with the day-to-day activities before the crisis hits. Hiring entry-level [epidemiologists] requires a good deal of training and mentoring that taxes existing staff. It is vital that new epidemiologists overlap as much as possible with our experienced [epidemiologists] in the next 2 to 3 years to retain institutional memory and be public health savvy.
Capacity and Training
Most respondents reported having substantial-to-full capacity to monitor health status to identify and solve community health problems (n = 43, 84%) and to diagnose and investigate community health problems and health hazards (n = 47, 92%). In contrast, fewer state epidemiologists reported substantial-to-full capacity for evaluating effectiveness, accessibility, and quality of personal and population-based health services (n = 20, 39%) and for conducting research for new insights and innovative solutions to health problems (n = 11, 22%). Capacity to fulfill the Essential Public Health Services varied widely by program area (Figure 2).
State health department capacity to fulfill the 10 Essential Public Health Services, by program area, Epidemiology Capacity Assessment, 50 US states and Washington, DC, 2017. Capacity is defined as the ability to lead activities, provide subject matter expertise, and apply for, receive, and manage resources to conduct the key activities for each Essential Public Health Service. State health departments that reported no programs in an area were considered to have no capacity in that area. Data source: Council of State and Territorial Epidemiologists. 6
State epidemiologists reported the greatest perceived need for improved capacity to fulfill the Essential Public Health Services, by program area, in mental health (n = 30/32, 94%), substance abuse (n = 44/48, 92%), informatics (n = 43/47, 91%), and injury (n = 46/51, 90%). The highest priorities for program improvement were substance abuse (n = 30/48, 63%) and informatics (n = 25/47, 53%).
With respect to training, most state epidemiologists (n = 38/51, 75%) identified data analytics (ie, informatics and applying and translating public health data) as a training priority. The 51 respondents reported other training priorities, including systems thinking (n = 12, 24%), persuasive communication (n = 12, 24%), leadership development (n = 12, 24%), and continuing education (n = 11, 22%). The most commonly cited training partners for state health departments were the Centers for Disease Control and Prevention and schools and programs of public health, each of which was mentioned by 47 (92%) state epidemiologists (Figure 3).
Health department training partners, Epidemiology Capacity Assessment, 50 US states and Washington, DC, 2017. Data source: Council of State and Territorial Epidemiologists. 6
Respondents also commented on the changing needs of health departments, the lack of capacity for addressing these new challenges, and training needs: One of my main concerns is having a workforce prepared to function in the new world of public health epidemiology. We are facing big changes right now in how we receive information, the volume of data/information, emerging programs related to [hospital-acquired infections] with large expectations [and] rapid changes in lab testing…that affect the information we receive and the need to adapt all our investigation protocols accordingly. It is challenging to keep the workforce well prepared in the face of so much change at such a rapid pace. [Epidemiologists] need to be able to assess not only the “how” of data analysis, but also be able to evaluate the work that is being performed by the various programs they support to address questions of health impact and use the published evidence-base to help direct and steer the work being performed. This often is in the realm of “program evaluation” and utilizes a slightly different skill set, but epidemiologists need to be cross-trained in these skills as their work overlaps with that of evaluation.
Discussion
The number of applied epidemiologists working at state health departments in the United States increased by 22%, from 2752 in 2013 to 3370 in 2017, and the number of epidemiologists per 100 000 population increased from 0.87 to 1.04 during the same period. 6,11 Furthermore, epidemiology capacity to fulfill the Essential Public Health Services improved from 2013 to 2017, although the number of epidemiologists required to achieve ideal capacity remained high. 7 Current staff members are faced with maintaining their workloads while addressing public health emergencies and improving their capacity in evaluation and applied research. These constraints appear to influence job satisfaction and retention, as observed elsewhere. 12
Many challenges stem from state health departments’ reliance on federal funding to support epidemiology activities and personnel in the absence of stable funding for routine epidemiologic activities from states. Federal funding is time limited (ie, must be used within a certain time frame) and is often restricted to specific topic areas or tasks. This lack of flexibility perpetuates staffing challenges and affects the ability of state health departments to conduct routine activities, such as surveillance and outbreak investigation, and to strengthen capacity in evaluation and research. The levels of state funding were generally low, and other sources contributed even less to epidemiologic activities and personnel. This problem of funding is often exacerbated by delays in providing funding to meet changing needs and priorities (eg, the opioid epidemic).
A potential solution to these challenges is the use of “flexible epidemiologists,” who are trained across program areas to respond to emerging threats and unanticipated events. 13 Federal funding for flexible epidemiologists is one way to strengthen epidemiology capacity in state health departments. Unless consistently funded, however, such positions could lead to poor staff morale and uncertain job security, 12 which may further contribute to the challenges of recruitment and retention. It is also unclear whether flexible epidemiologists can cover the broad range of program areas (eg, mental health and substance abuse), which may require different skill sets than for responding to emerging threats. Balancing the restrictions of funding and the challenge of maintaining staff member capacity can leave state health departments struggling to address emerging issues while continuing to support routine operations.
A second challenge for epidemiologic capacity is a mismatch between the current skill sets and subject matter expertise of health department epidemiologists and the skill sets and expertise required to meet current epidemiology challenges. New and continued programs and partnerships are needed to provide training to the current workforce and to ensure that public health graduates have the skills needed to conduct applied epidemiology work. Academic institutions are a natural partner to ensure that curriculums align with employers’ needs. A new trend of “academic health departments” has emerged across the country, in which academic institutions, including large public universities, partner with state or local health departments to focus on improving communities by boosting public health education, research, and services. 14 Expanding this trend would provide an opportunity for state agencies to communicate their needs to academic institutions and train the future applied epidemiology workforce.
In addition, harnessing the potential of the existing workforce will require on-the-job training. Traditionally, on-the-job training is provided through internal mentorship in an agency. However, when agency resources are constrained, staff members may seek out other training resources, such as professional associations, the private sector, academia, and online user groups. Although training may be accessible, it may not be feasible for staff members to complete training unless leadership can allocate dedicated time and reassign normal duties.
Limitations
This study was limited by the accuracy of enumerating epidemiologists. Although the ECA defined epidemiologist, the definition does not necessarily align with job titles and it has a subjective component, which may have affected enumeration. In addition, epidemiologists were enumerated by program area, and the enumeration might not have included generalist epidemiologists. Furthermore, the definition did not include epidemiologists who worked outside the state health department. Moreover, calculations of the total number of epidemiologists per 100 000 population did not include epidemiologists employed by city or county health departments.
Conclusion
Although overall staffing and capacity in monitoring and diagnosing health problems have improved, state health departments face continued challenges in obtaining consistent funding to maintain current activities, enhance their capacity to conduct evaluation and applied research, and develop and maintain a stable workforce to handle existing and emerging problems. Identifying additional sources of funds, creating flexible epidemiology positions, and partnering with schools and programs of public health to improve skill sets and develop a new generation of applied epidemiologists will be important in meeting rapidly changing public health priorities.
Footnotes
Acknowledgments
The Council of State and Territorial Epidemiologists (CSTE) completed the Epidemiology Capacity Assessment in cooperation with members at state and territorial health departments. This article is based on a previously published report by CSTE, the 2017 Epidemiology Capacity Assessment Report, which is available at 
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Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors declared the following funding with respect to the research, authorship, and/or publication of this article: This publication was supported in part by the Centers for Disease Control and Prevention (CDC) cooperative agreement number 5U38OT000143. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the views of CDC.