Increasing Health Department Epidemiological Response Capacity: The OFRD APHT Model

1. Increasing Health Department Epidemiological Response Capacity: The OFRD APHT Model LCDR D. Fermín Argüello, MD, MPH Centers for Control & Prevention

2. Presentation outline • Epidemiology Capacity in United States • Applied Public Health Team (APHT) Model & Structure • APHT & Health Department collaboration: Tennessee Example • Summary

3. 1. Epidemiology Capacity in United States

4. United States Epidemiology Capacity • National health objectives repeatedly call to increase epidemiology capacity at local, state, territorial, & tribal levels* • Only 55% of state public health agencies have comprehensive epidemiology capacity to support essential public health (PH) services† • 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 http://wonder.cdc.gov/data2010/obj.htm & http://www.healthypeople.gov/2020/default.aspx. †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.

5. 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 † http://preparedness.asph.org/perlc/index.cfm

6. 2. APHT Model & Structure

7. 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

8. 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

9. APHT Structure • 5 teams of 40-50 officers under direction of USPHS OFRD • Multidisciplinary • Epidemiologists • Preventive medicine physicians & nurses • Health educators • Environmental health scientists & industrial hygienists • Occupational health physicians • Veterinarians • Deployable in national disaster declarations • Response within 48 hours • On call every 5 months

10. APHT Structure APHT Team Commander APHT Team Deputy Commander APHT Team Deputy Commander Blue Environmental Public Health Group (EPHG) Lead Gold EPHG Lead Blue EPHG team Gold EPHG team Epidemiology, Surveillance, Preventive Services Group (ESPSG) Lead Gold ESPSG Lead Blue ESPSG team Gold ESPSG team

11. 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

12. Recent APHT-3 Training & Responses • Paducah, KY (2011) • Temporary emergency shelter assessments • Public health environmental evaluations • CASPER survey (disaster preparedness)

13. 3. APHT & Health Department Collaboration: Tennessee Example

14. 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 makers

15. Investigation • 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

16. Telephone Survey • March 16-17 • Hypotheses & survey instrument developed by CHCHD/APHT epidemiologists • 11 contractors & 5 APHT members trained & conducted 1,537 telephone interviews

17. 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

18. Email Survey, Data Entry & Analysis • March 17-18 • Data collection, entry, cleaning, & analysis

19. Health Education • March 17-18 • H1N1/seasonal influenza information for providers & community

20. 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)

21. Outcomes • 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

22. 4. Summary

23. 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

24. “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.

25. Acknowledgements OFRD CAPT Beck, Acting & Deputy Director CAPT Elenberg, Medical Readiness Training Manager APHT-3 CAPT Rapp, Team Commander RADM Rodenbeck, former team commander CAPT Kim, Team Deputy-Commander CDR Chang, Blue Epidemiology, Surveillance & Prevention Services Group Lead CDR Hausman, Gold Epidemiology, Surveillance & Prevention Services Group Lead APHT-3 Epidemiology, Surveillance & Prevention Services Group members Chattanooga-Hamilton County Health Department Dawn Ford, Emergency Response Coordinator Sarah Stuart Sloan, MPH, Epidemiologist Margaret Zylstra, BSN, Epidemiology Manager Valerie Boaz, MD, County Health Officer Telephone survey workers Tennessee Department of Health Susan R. Cooper, MSN, RN, State Health Commissioner Tim F. Jones, MD, State Epidemiologist University of Tennessee at Chattanooga Chattanooga Community College Southern Adventist University Study participants

26. Thank you.

27. 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

29. Abstract submission • Short title (limit 90 characters): Increasing health department epidemiological response capacity--The OFRD APHT model • 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 department-administered 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.

30. 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 Chattanooga-Hamilton 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.