Indian Health Service Support for Tribal Epidemiology Centers

This editorial provides background information on the Tribal Epidemiology Centers (TECs) program. The program was authorized by Congress in 1992 to provide public health support to multiple Tribes and Urban Indian communities in each of the Indian Health Service (IHS) administrative areas. IHS is divided into 12 physical areas (hereinafter, Areas) of the United States: Alaska, Albuquerque, Bemidji, Billings, California, Great Plains, Nashville, Navajo, Oklahoma, Phoenix, Portland, and Tucson. Each area has a unique group of Tribes that they work with on a day-to-day basis. TEC grantees were selected for their capacity and position within Tribal and Urban Indian communities to conduct disease surveillance and public health research; prevent and control disease, injury, or disability; and assess the effectiveness of American Indian and Alaska Native (AI/AN) health delivery and public health programs.

TECs have been funded to complement IHS capacities by offering, tracking, and reporting technical assistance and outreach activities to constituent Tribes and Urban Indian Organizations and supporting the requirements of the Government Performance and Results Act, ¹ which entails reporting on the activities that are included in annual IHS budget requests. Since the inception of the TEC program, awardees have developed and implemented innovative strategies to monitor the health status of their Tribes and Urban Indian communities, including the establishment of Tribal health registries and the use of sophisticated record-linkage methods to improve the accuracy of the reporting of AI/AN race in public health datasets. Overall, TECs work in partnership with IHS to provide a more complete national picture of AI/AN health status than IHS could produce independently. Some TECs are already assisting Tribal and Urban Indian communities in such priority areas as COVID-19 response and recovery, sexually transmitted disease control, and cancer prevention.

IHS established its initial funding support for TECs in 1996 with awards to sites in 4 IHS administrative areas: Alaska, Great Lakes, Phoenix, and Portland. In 2000, additional awards were made to new TEC grantees with purview over the IHS Nashville administrative area and all Urban Indian Health Program sites. IHS TEC program coverage increased again in 2005 to include the Great Plains, Rocky Mountain, and Oklahoma City administrative areas. The 2006 funding cycle expanded the program by adding the Albuquerque, Tucson, and Navajo administrative areas. The program became truly national in scope when the California administrative area TEC was first funded in 2008. IHS launched its current 5-year TEC funding cycle with cooperative agreement awards made in September 2021. These cooperative agreements allow IHS to have substantial programmatic involvement with TECs through active partnership.

Beginning with an overall initial annual budget of $750 000 in 1996, IHS cooperative agreement awards to TECs grew to more than $28 million in 2021 and included funding from IHS, the Centers for Disease Control and Prevention, the National Institutes of Health, and the US Department of Health and Human Services (HHS). This amount includes a portion of the $24 million authorized for TECs by the Coronavirus Aid, Relief, and Economic Security (CARES) Act ² to support the prevention of, response to, and recovery from the COVID-19 public health emergency.

In 2010, Congress enacted the Patient Protection and Affordable Care Act (ACA), ³ which permanently reauthorized the Indian Health Care Improvement Act (IHCIA) and the authority to establish TECs. Originally passed in 1976 and subsequently amended, IHCIA declares, “It is the policy of this Nation, in fulfillment of its special responsibilities and legal obligations to the American Indian people, to assure the highest possible health status for Indians and Urban Indians and to provide all resources necessary to effect that policy.” ³ IHCIA extended the legal and programmatic structure for providing health and public health services to AI/AN populations.

TECs share the mission of improving AI/AN health by identifying health risks, strengthening public health capacity, and developing solutions for disease prevention and control. This mission is accomplished by offering culturally informed approaches that work toward eliminating health disparities and achieving health equity for AI/AN populations. The IHCIA authorizes TECs to perform 7 core functions:

1. Collecting and monitoring data on the health status objectives of IHS, Indian Tribes, Tribal organizations, and urban Indian organizations;

2. Evaluating delivery and data systems that impact Indian health;

3. Assisting Tribes, Tribal organizations, and urban Indian organizations to determine health status objectives and services needed to meet those objectives;

4. Making recommendations of services to assist Indian communities;

5. Making recommendations to improve Indian health care delivery systems;

6. Providing technical assistance to Tribes, Tribal organizations, and urban Indian organizations to develop local health priorities and disease incidence and prevalence rates; and

7. Providing disease surveillance and promoting public health.

While each TEC is unique and varies widely in structure, staffing, and programs, every TEC works “in consultation with and on the request of Indian Tribes, Tribal organizations, and urban Indian organizations.” ³

TECs provide critical support for activities that inform Tribal self-governance and effective management of Tribal and Urban Indian health programs. Data analyzed and reported by TECs enable Tribes and Urban Indian communities to effectively plan and make decisions that best meet the needs of their communities. In addition, TECs can promptly provide feedback to local, regional, and national data systems, which will lead to improvements in Indian health data overall.

In 2012, IHS formally established data-sharing activities with TECs to further their work as public health authorities and their support to Tribes. The formal opportunity for data sharing was announced via a Tribal Leader Letter issued by IHS, which included guidance for data requests. ⁴ The resulting data-sharing agreements with TECs provide broad access to IHS health encounter data and support extensive public health and epidemiologic analyses.

In addition to these well-established data partnerships, IHS supports other data-sharing arrangements with TECs tailored to address public health problems affecting AI/AN people. In public health administrative records and datasets, AI/AN people are often misclassified as another race (ie, racial misclassification). Racial misclassification often reduces the accuracy of health status metrics reported for AI/AN because of undercounting of AI/AN cases within health tracking systems. This underreporting may cause incidence and death rates to appear lower than they actually are for AI/AN people. While racial misclassification can affect any racial group, strong evidence indicates that its impact is exaggerated for AI/AN populations. ⁵ Without accurate health data, Tribes cannot make the most informed decisions on how to best serve their people to improve health. In 2019, IHS launched efforts allowing TEC partners access to patient registry information for patients who received health services at IHS direct health care sites as well as participating Tribally operated health care sites and Urban Indian Health Programs, otherwise known as IHS, Tribal, and Urban (I/T/U). This analysis allows for fact-based comparisons linking people receiving I/T/U services to outside public health data sources, such as state cancer registries and death records, to check for and correct racial misclassification. Demonstrating this work, the Northwest Portland Area Indian Health Board’s Northwest Tribal Epidemiology Center conducted 11 linkages with public health data sources to identify and correct racial misclassification during 2020-2021 and reported misclassification prevalence as high as 62.5% in some data sources (personal communication, Victoria Warren-Mears, PhD, RDN, Northwest Portland Area Indian Health Board, November 26, 2021).

IHS launched additional data-sharing activities with TECs to meet urgent public health needs, including response to the COVID-19 public health crisis. As examples, IHS developed a new data-sharing protocol in 2020 with the Oklahoma City Area TEC (OKTEC) facilitating partnership with the TEC to conduct COVID-19 contact tracing efforts, and by facilitating TECs’ access to broad COVID-19–related health data housed within the HHS Protect (Protect) data environment. ⁶

The new data-sharing partnership with OKTEC to inform rapid COVID-19 contact tracing efforts was established to support IHS clinical sites in the Oklahoma City Area. OKTEC can complete investigations within 72 hours and faster than other supporting agencies, facilitating rapid case and contact notifications to improve outbreak control. In addition, from January to August 2021, OKTEC’s team of 5 full-time contact tracers investigated more than 65% of all cases in designated IHS facilities across Oklahoma, reducing the workload of IHS health care workers and providing Tribal communities with more complete information on COVID-19 cases (personal communication, Tracy Prather, MHA, OKTEC, November 30, 2021). This program has also paved the way for further collaboration efforts and partnerships between OKTEC and the Oklahoma State Department of Health, county health departments, and IHS. According to the IHS chief medical officer of the Oklahoma City Area, “the collaboration has been very successful and should be a guide to helping foster more collaborative efforts [with the TEC] here in the OKC [Oklahoma City] area” (personal communication, RDML Greggory Woitte, MD, MS, assistant surgeon general, US Public Health Service, November 22, 2021).

In addition, in April 2020, HHS launched the Protect data platform to make COVID-19–related health data collected by various health care and government entities, including IHS, visible to users to inform pandemic response at federal, state, Tribal, and local levels. Protect is a secure data ecosystem powered by 8 commercial technologies for sharing, parsing, housing, and accessing COVID-19 data and is driven by 4 principles: transparency, sharing, privacy, and security. ⁶

Protect includes ≥200 sources of data categorized into the following: patient demographic characteristics, diagnostic test results, hospitalization status, hospital capacity and inventory, counts of cases and deaths, vaccinations, and medical supply chain. IHS collaborates with HHS to facilitate TEC access to Protect by advocating for and sponsoring all TEC user requests.

In addition to many other data elements, the Protect data environment includes the most complete national picture of COVID-19 vaccination data. IHS-derived information includes vaccination data for all sites (I/T/U) participating in vaccination activities and receiving COVID-19 vaccines through IHS. IHS began sharing these data with TECs in 2021, including record-level vaccination data for I/T/U patients.

A March 2022 report, “Tribal Epidemiology Centers: HHS Actions Needed to Enhance Data Access,” ⁷ described challenges reported by some TECs when seeking access to IHS data. IHS will continue its efforts toward meaningful policy development to both improve and clearly document procedures for reviewing and responding to TEC data requests, garner and respond to additional inputs including through Tribal consultation, and, informed by these efforts and outputs in tandem, establish clear guidance for TECs on accessing IHS data.

IHS is committed to continuing its support of TEC awardees as part of its overall work to strengthen public health capacity and to fund Tribes, Tribal organizations, urban Indian organizations, and inter Tribal consortia in identifying and providing information on relevant health status indicators and priorities. This commitment underpins the agency’s planning for and support of health and public health interventions to reduce morbidity and mortality in the AI/AN population, in pursuit of its mission to raise the physical, mental, social, and spiritual health of AI/AN people to the highest level.