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Brief Report: Terrorism and Emergency Preparedness in State and Territorial Public Health Departments --- United States, 2004

After the events of September 11, 2001, federal funding for state public health preparedness programs increased from $67 million in fiscal year (FY) 2001 to approximately $1 billion in FY 2002. These funds were intended to support preparedness for and response to terrorism, infectious disease outbreaks, and other public health threats and emergencies (1). The Council of State and Territorial Epidemiologists (CSTE) assessed the impact of funding on epidemiologic capacity, including terrorism preparedness and response, in state health departments in November 2001 and again in May 2004, after distribution of an additional $1 billion in FY 2003. This report describes the results of those assessments, which indicated that increased funding for terrorism preparedness and emergency response has rapidly increased the number of epidemiologists and increased capacity for preparedness at the state level. However, despite the increase in epidemiologists, state public health officials estimate that 192 additional epidemiologists, an increase of 45.3%, are needed nationwide to fully staff terrorism preparedness programs.

To assess preparedness, CSTE distributed a link to an online survey via e-mail to state and territorial health departments in 50 states, eight territories, and the District of Columbia (DC). The survey was made available online during May--September 2004. The overall response rate was 91.5%. The definition of epidemiologist was unchanged from the 2001 survey, although further clarification was provided regarding who should be counted as an epidemiologist in a state or territorial health department in the 2004 assessment*. If epidemiologists divided their time between two program areas, increments of 0.5 full-time equivalent were allocated to each program area.

Survey results indicated an improvement from 2001 in states' overall terrorism epidemiologic and surveillance capacity. All 54 (100%) respondents rated their ability to provide epidemiologic and surveillance capacity in terrorism and emergency preparedness by using a six-point scale, which was converted to the four-point scale used in the 2001 assessment to enable comparison. A total of 21 (38%) states and territories reported having full/almost full capacity, 22 (41%) reported substantial, eight (15%) reported partial, and three (6%) reported minimal or no capacity. From 2001 to 2004, survey results indicated a 126% increase (19 versus 43) in the number of states reporting substantial to full/almost full capacity.

The overall proportion of epidemiologists assigned to terrorism preparedness programs increased from 9% (123 of 1,366) in 2001 to 16.4% (424 of 2,580) in 2004, which was the largest increase by any epidemiology program area (3,4). Adjusting the data to reflect only DC and the 38 states that provided information for both surveys, the number of epidemiologists working in terrorism preparedness increased 103%, from 115 epidemiologists in 2001 to 234 in 2004.

Of the 424 epidemiologists working in terrorism preparedness programs, 39% (167) had a master's degree, 29% (124) had doctoral degrees, 26% (108) had bachelor's degrees, and 6% (25) had associate degrees or high school diplomas. Information on formal training in epidemiology was obtained for 67% (283 of 424) of the epidemiologists working in terrorism preparedness: 64% (180) had a degree in epidemiology, 16% (46) had completed other formal training or had academic coursework in epidemiology, and 20% (58) had no formal training or academic course work in epidemiology. Terrorism preparedness programs had one of the highest concentrations of personnel with degrees in epidemiology, compared with programs in occupational health, 64% (29 of 45); environmental health, 61% (117 of 193); chronic diseases, 58% (182 of 313); maternal and child health, 53% (121 of 227); oral health, 48% (10 of 21); injury, 44% (26 of 59); and infectious disease, 43% (314 of 732).

As of September 2004, federally appropriated terrorism preparedness funds paid the salaries of 460 epidemiologists working in several program areas: 53% (243) worked in terrorism and emergency preparedness, 33% (153) in infectious diseases, 5% (24) in environmental health, and 9% (39) in chronic disease, injury, maternal and child health, occupational health, and other relevant program areas. Among the 390 epidemiologists working in terrorism and emergency preparedness, 62% were paid with federal terrorism preparedness funds (Table), whereas 38% were paid with state or other funds. Although an overall increase in the number of infectious disease epidemiologists did not occur from 2001 to 2004, nearly 20% were paid with federal terrorism preparedness funds.

The increase in state public health capacity reflects the substantial investment in efforts to support state terrorism preparedness programs and the corresponding public health infrastructure. Despite progress in this effort, state public health officials estimate that 192 additional epidemiologists, an increase of 45.3%, are needed nationwide in terrorism preparedness programs and that essential services provided by these epidemiologists need continued improvement to reach full capacity (4). The findings in this report suggest that the efforts of states to meet federal terrorism preparedness program requirements have redirected state resources from other program areas. CSTE recommends that dual use of terrorism and emergency preparedness epidemiology resources should be substantially expanded to realign functional roles and build overall capacity of state health departments to prepare for and respond to terrorism, infectious disease outbreaks, and other public health threats and emergencies.

Reported by: ML Boulton, MD, Univ of Michigan School of Public Health. J Abellera, MPH, J Lemmings, MPH, L Robinson, MPH, Council of State and Territorial Epidemiologists.


  1. US Department of Health and Human Services. Bioterrorism preparedness grants (fact sheet 2002.06.06). Available at
  2. Last JM, Spasoff RA, Harris SS, Thuriaux MC, eds. A dictionary of epidemiology. 4th ed. New York, NY: Oxford University Press; 2001.
  3. CDC. Assessment of the epidemiologic capacity in state and territorial health departments---United States, 2001. MMWR 2003;52:1049--51.
  4. Council of State and Territorial Epidemiologists. 2004 national assessment of epidemiologic capacity: findings and recommendations. Available at


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