Volume 4: No. 3, July 2007
LETTER TO THE EDITOR
Assessment of Chronic Disease Epidemiology Workforce in State Health Departments — United States, 2003
Suggested citation for this article: Siegel PZ,
Huston SL, Powell KE, Baptiste MS, Tilson HH, Jacobellis J, Brownson RC. Assessment of
chronic disease epidemiology workforce in state health departments — United States, 2003
[letter to the editor]. Prev Chronic Dis [serial online] 2007 Jul [date cited]. Available from:
To the Editor:
Despite the huge burden of chronic disease in the United States — four of every five deaths and $325 billion in health care costs and lost worker productivity per year (1) — the number of epidemiologists
who work on chronic disease at state health departments remains less than half the number
who work on infectious disease and less than one-third the combined
number who work on infectious disease and bioterrorism (2). The percentage of state and territorial health departments that reported having “full/almost full or substantial” capacity in epidemiology and surveillance for chronic disease did not improve between 2001 (52%) and 2004 (48%) (3). The Council of State and Territorial Epidemiologists (CSTE) recommends that every state have a
minimum of five full-time chronic disease epidemiologists (CDEs), at least one of whom should have a doctoral degree (4).
To obtain detailed information about chronic disease epidemiology capacity, including workforce, at state health departments, CSTE conducted a national assessment in March 2003. States were asked to report the number of people
who spent at least 50% of their time at the health department doing work related
to chronic disease epidemiology, as well as the training (academic degrees) and
years of chronic disease epidemiology experience for each of those people. In the survey, chronic disease epidemiology was described as
[…analyzing and interpreting…] data related to chronic diseases or
risk factors for chronic diseases. At the very least, chronic disease
epidemiologists combine data from different sources, such as vital
statistics and population estimates, to calculate rates. Commonly they
calculate rates at one or across several points in time for groups of
persons (e.g., rates by sex, rates by health district). Depending upon
their duties and skills, [Behavioral Risk Factor Surveillance System]
coordinators, cancer registry workers, people in data analyst positions,
and others may be considered chronic disease epidemiologists. If they
calculate and interpret rates, they may be counted as chronic disease
States were asked to include CDEs who worked at the health department even if they received their paycheck from another organization (e.g., an academic institution).
Responses were received from 47 states (including the District of Columbia) during April
through July 2003. One state is excluded from the analysis because of missing information about the educational background of chronic disease epidemiology staff. Among the 46 states included in the analysis, 25 (54%) had five or more full-time CDEs, as recommended by CSTE; 40 (87%) had at
least one doctoral-level CDE; and 24 (52%) had both (Table).
Our analysis indicates that, despite the large public health burden of chronic diseases, as of 2003 only about half of states
had the minimum chronic disease epidemiologic workforce recommended by CSTE. As the U.S. population continues to age, states will need even more
CDEs to maintain adequate surveillance and plan data-based interventions
control high-prevalence chronic conditions such as heart disease, stroke, cancer, diabetes, chronic respiratory diseases, and arthritis, as well as risk factors such as smoking, physical inactivity, poor nutrition, and obesity.
State agencies can use the CSTE recommendations and the results of this survey to customize their approach to developing capacity for chronic disease epidemiology. For example, the 16 states that have a doctoral-level CDE but fewer
than five total CDEs might focus their workforce development efforts on hiring junior-level epidemiologists. Every state should have an
epidemiology job series in its personnel system (4) to facilitate the hiring of chronic disease and other types of epidemiologists. Results of this capacity survey can also help CSTE and
the Centers for Disease Control and Prevention (CDC) identify states that are highest priority for technical assistance and capacity-building support.
Workforce, although critical, is not the only component of chronic disease epidemiology capacity. Other components of capacity that have been suggested include 1) access to data and consultants, 2) data analysis, 3) data interpretation, 4) information dissemination, and 5) outreach
and partnership (4). To improve chronic disease epidemiology capacity in state health departments,
CDC and CSTE should
- Develop capacity-building strategies to address specific gaps in either workforce or other components of capacity in state public health agencies.
- Develop minimum standards for routine analysis of chronic disease data.
- Identify factors that foster a productive chronic disease epidemiologic unit in state public health agencies.
- Identify elements of the 2003 survey that are most likely to be useful for ongoing surveillance of capacity for chronic disease epidemiology.
Additional previously published recommendations for increasing capacity should be given serious consideration as well. These include the following:
- Identify funding to support CDEs in states with the greatest need.
- Foster, support, and encourage collaboration among state health agencies and academic organizations in teaching, research, and special joint state and academic projects.
- Develop a national educational effort targeted at state health officials, agency or bureau directors, and program administrators to enhance understanding and awareness of the role of epidemiologists and chronic disease programs in states (5).
Our study is subject to at least three limitations. First, it may overestimate the chronic disease epidemiology workforce because all epidemiologists who work at least 50% of their time at the health department doing work related to chronic disease epidemiology were considered to be full-time
employees. Therefore, the true number of chronic disease epidemiologists in some
health departments may actually be lower than what is reported here. Second, five states were excluded from the analysis because of nonresponse or missing data. Third, some states, especially those with large populations or an excessive burden of chronic disease, may require more than the minimum workforce recommended by CSTE.
Although techniques for assessing and characterizing capacity for chronic disease epidemiology should be refined, some steps to increase workforce have been undertaken. Since 1991 the
chronic disease State-based Epidemiology for Public Health Program Support (STEPPS) activity at CDC has provided staff or salary support to 30 states for chronic disease epidemiology positions. Of the 23 states
that no longer receive support from STEPPS, at least 16 (70%) have made the successful transition to one or more chronic disease epidemiology positions that are supported independently by the state. More recent capacity-building activities include the CSTE/CDC Applied Epidemiology Fellowship Program (6), which places trainees under the supervision of experienced
state health departments, and a mentoring program, which pairs CDEs in states that have limited capacity with more experienced epidemiologists for a period of
6 to 12 months. Both of these activities met with early success but had limited implementation because of limited funding.
Our study did not examine factors that may be associated with the epidemiology capacity in state health departments. We intend to conduct such analysis in the future, which will consider factors such as workforce, competencies, access to key data sets and software, and academic linkages.
Paul Z. Siegel, MD, MPH
Division of Adult and Community Health
National Center for Chronic Disease Prevention and Health Promotion
Centers for Disease Control and Prevention
Sara L. Huston, PhD
North Carolina Division of Public Health
Kenneth E. Powell, MD
Mark S. Baptiste, PhD
New York State Department of Health
Hugh H. Tilson, MD, DrPH
Public Health Leadership Program
University of North Carolina, School of Public Health
Chapel Hill, NC
Jillian Jacobellis, PhD
Prevention Services Division
Colorado Department of Public Health and Environment
Ross C. Brownson, PhD
Prevention Research Center
Saint Louis University School of Public Health
St. Louis, Mo
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We received no financial support to perform this work. We are aware of no financial conflicts of interest or professional affiliations that may potentially be regarded as having biased the manuscript.
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- National Academy of Science, Institute of Medicine. The future of the public’s
health in the 21st century. Washington (DC): National Academies Press; 2003.
- 2004 National assessment of epidemiologic capacity: findings and recommendations. Atlanta (GA): Council of State and Territorial Epidemiologists; 2004. Available
- Centers for Disease Control and Prevention.
Assessment of epidemiologic capacity in state and territorial health departments — United States, 2004.
MMWR Morb Mortal Wkly Rep 2005;54(18):457-9.
- National assessment of epidemiologic capacity in chronic disease: findings and
recommendations. Atlanta (GA): Council of State and Territorial Epidemiologists; 2004. Available
- Frey CA, Remington PL, Lengerich E.
Evaluation of the Centers for Disease Control and Prevention’s chronic disease State-based Epidemiology for Public Health Program Support (STEPPS) program. J Public Health Manag Pract 2003;9(4):266-74.
- CSTE/CDC applied epidemiology fellowship program overview. Atlanta (GA):
Council of State and Territorial Epidemiologists;[cited 2006 Dec 1]. Available
from: http://www.cste.org/Workforcedev/main1.htm *
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Number of States with Minimum Recommended Chronic Disease Epidemiologist (CDE)a Workforce, United States, 2003
State had at least one doctoral-level CDEb
State had at least 5 CDEs
|| 46 (100)
aAny CDE (filled position, at least 50% of the person’s time is spent doing work related to chronic disease epidemiology), regardless of education or experience.
bCDE (filled position, at least 50% of the person’s time is spent doing work related to chronic disease epidemiology) with any doctoral degree (e.g., PhD, MD), regardless of experience.
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