Fátima Coronado

Enumeration of the Governmental Public Health Workforce, 2014

Background Regular assessment of the size and composition of the U.S. public health workforce has been a challenge for decades. Previous enumeration efforts estimated 450,000 public health workers in governmental and voluntary agencies in 2000, and 326,602 governmental public health workers in 2012, although differences in enumeration methodology and the definitions of public health worker between the two make comparisons problematic. Purpose To estimate the size of the governmental public health workforce in 14 occupational classifications recommended for categorizing public health workers. Methods Six data sources were used to develop enumeration estimates: five for state and local public health workers and one for the federal public health workforce. Statistical adjustments were made to address missing data, overcounting, and duplicate counting of workers across surveys. Data were collected for 2010–2013; analyses were conducted in 2014. Results The multiple data sources yielded an estimate of 290,988 (range=231,464–341,053) public health workers in governmental agencies, 50%, 30%, and 20% of whom provide services in local, state, and federal public health settings, respectively. Administrative or clerical personnel (19%) represent the largest group of workers, followed by public health nurses (16%); environmental health workers (8%); public health managers (6%); and laboratory workers (5%). Conclusions Using multiple data sources for public health workforce enumeration potentially improves accuracy of estimates but also adds methodologic complexity. Improvement of data sources and development of a standardized study methodology is needed for continuous monitoring of public health workforce size and composition.

Public Health Workforce Taxonomy

Thoroughly characterizing and continuously monitoring the public health workforce is necessary for ensuring capacity to deliver public health services. A prerequisite for this is to develop a standardized methodology for classifying public health workers, permitting valid comparisons across agencies and over time, which does not exist for the public health workforce. An expert working group, all of whom are authors on this paper, was convened during 2012–2014 to develop a public health workforce taxonomy. The purpose of the taxonomy is to facilitate the systematic characterization of all public health workers while delineating a set of minimum data elements to be used in workforce surveys. The taxonomy will improve the comparability across surveys, assist with estimating duplicate counting of workers, provide a framework for describing the size and composition of the workforce, and address other challenges to workforce enumeration. The taxonomy consists of 12 axes, with each axis describing a key characteristic of public health workers. Within each axis are multiple categories, and sometimes subcategories, that further define that worker characteristic. The workforce taxonomy axes are occupation, workplace setting, employer, education, licensure, certification, job tasks, program area, public health specialization area, funding source, condition of employment, and demographics. The taxonomy is not intended to serve as a replacement for occupational classifications but rather is a tool for systematically categorizing worker characteristics. The taxonomy will continue to evolve as organizations implement it and recommend ways to improve this tool for more accurate workforce data collection.

Mortality, severe acute respiratory infection, and influenza-like illness associated with influenza A(H1N1)pdm09 in Argentina, 2009.

Introduction While there is much information about the burden of influenza A(H1N1)pdm09 in North America, little data exist on its burden in South America. Methods During April to December 2009, we actively searched for persons with severe acute respiratory infection and influenza-like illness (ILI) in three sentinel cities. A proportion of case-patients provided swabs for influenza testing. We estimated the number of case-patients that would have tested positive for influenza by multiplying the number of untested case-patients by the proportion who tested positive. We estimated rates by dividing the estimated number of case-patients by the census population after adjusting for the proportion of case-patients with missing illness onset information and ILI case-patients who visited physicians multiple times for one illness event. Results We estimated that the influenza A(H1N1)pdm09 mortality rate per 100,000 person-years (py) ranged from 1.5 among persons aged 5–44 years to 5.6 among persons aged ≥65 years. A(H1N1)pdm09 hospitalization rates per 100,000 py ranged between 26.9 among children aged <5 years to 41.8 among persons aged ≥65 years. Influenza A(H1N1)pdm09 ILI rates per 100 py ranged between 1.6 among children aged <5 to 17.1 among persons aged 45–64 years. While 9 (53%) of 17 influenza A(H1N1)pdm09 decedents with available data had obesity and 7 (17%) of 40 had diabetes, less than 4% of surviving influenza A(H1N1)pdm09 case-patients had these pre-existing conditions (p≤0.001). Conclusion Influenza A(H1N1)pdm09 caused a similar burden of disease in Argentina as in other countries. Such disease burden suggests the potential value of timely influenza vaccinations.

An Analysis of 332 Fatalities Infected with Pandemic 2009 Influenza A (H1N1) in Argentina

Background The apparent high number of deaths in Argentina during the 2009 pandemic led to concern that the influenza A H1N1pdm disease was different there. We report the characteristics and risk factors for influenza A H1N1pdm fatalities. Methods We identified laboratory-confirmed influenza A H1N1pdm fatalities occurring during June-July 2009. Physicians abstracted data on age, sex, time of onset of illness, medical history, clinical presentation at admission, laboratory, treatment, and outcomes using standardize questionnaires. We explored the characteristics of fatalities according to their age and risk group. Results Of 332 influenza A H1N1pdm fatalities, 226 (68%) were among persons aged <50 years. Acute respiratory failure was the leading cause of death. Of all cases, 249 (75%) had at least one comorbidity as defined by Advisory Committee on Immunization Practices. Obesity was reported in 32% with data and chronic pulmonary disease in 28%. Among the 40 deaths in children aged <5 years, chronic pulmonary disease (42%) and neonatal pathologies (35%) were the most common co-morbidities. Twenty (6%) fatalities were among pregnant or postpartum women of which only 47% had diagnosed co-morbidities. Only 13% of patients received antiviral treatment within 48 hours of symptom onset. None of children aged <5 years or the pregnant women received antivirals within 48 h of symptom onset. As the pandemic progressed, the time from symptom-onset to medical care and to antiviral treatment decreased significantly among case-patients who subsequently died (p<0.001). Conclusion Persons with co-morbidities, pregnant and who received antivirals late were over-represented among influenza A H1N1pdm deaths in Argentina, though timeliness of antiviral treatment improved during the pandemic.

The Public Health Workforce: Moving Forward in the 21st Century

In 1994, the Core Public Health Functions Steering Committee, which was convened by the Assistant Secretary for Health and included representatives from U.S. Public Health Service agencies and other major public health organizations, was organized to clarify the public health functions of assessment, policy development, and assurance identified by the IOM Committee on Public Health. Among its other activities, the Steering Committee was charged with developing the framework for the Essential Public Health Services to categorize all public health activities.1 It also commissioned a subcommittee on public health workforce, training, and education to provide a profile of the public health workforce and make projections regarding the workforce of the 21st century.

State health agency & local health department workforce: Identifying top development needs

Objectives To identify occupations with high-priority workforce development needs at public health departments in the United States. Methods We surveyed 46 state health agencies (SHAs) and 112 local health departments (LHDs). We asked respondents to prioritize workforce needs for 29 occupations and identify whether more positions, more qualified candidates, more competitive salaries for recruitment or retention, or new or different staff skills were needed. Results Forty-one SHAs (89%) and 36 LHDs (32%) participated. The SHAs reported having high-priority workforce needs for epidemiologists and laboratory workers; LHDs for disease intervention specialists, nurses, and administrative support, management, and leadership positions. Overall, the most frequently reported SHA workforce needs were more qualified candidates and more competitive salaries. The LHDs most frequently reported a need for more positions across occupations and more competitive salaries. Workforce priorities for respondents included strengthening epidemiology workforce capacity, adding administrative positions, and improving compensation to recruit and retain qualified employees. Conclusions Strategies for addressing workforce development concerns of health agencies include providing additional training and workforce development resources, and identifying best practices for recruitment and retention of qualified candidates.

Elective medical and veterinary student rotations in applied epidemiology at the Centers for Disease Control and Prevention, 1975-2012.

CONTEXT Health professionals who can bridge the gap between public health and clinical medicine are needed. The Centers for Disease Control and Prevention Epidemiology Elective Program (EEP) offers a rotation in public health for medical and veterinary students that provides an introduction to public health, preventive medicine, and the principles of applied epidemiology through real-world, hands-on experiential learning. OBJECTIVE To describe EEP, including its role in the integration of medicine and public health, and career paths for those who subsequently have enrolled in the Epidemic Intelligence Service (EIS). DESIGN A review of files of EEP students participating June 1975 to May 2012 and EIS files to determine which EEP participants subsequently enrolled in EIS and their current employment. RESULTS During January 1975 to May 2012, a total of 1548 students participated in EEP. Six hundred thirty-eight (41.2%) EEP students participated in field-based epidemic-assistance investigations. Among 187 students completing an exit survey implemented during 2007, a total of 175 (93.6%) indicated an increased understanding or competence in applied epidemiology and public health, and 98 (52.4%) indicated that they would apply to EIS. Among the 165 (10.7%) who enrolled in and completed EIS by July 2012, 106 (64.2%) are currently employed in public health and 65 (39.4%) are board-certified in preventive medicine, board eligible, or currently enrolled in the Centers for Disease Control and Prevention Preventive Medicine Residency or Fellowship. CONCLUSIONS The CDC Epidemiology Elective Program offers opportunities for medical and veterinary students to participate in real-world public health learning activities. The Epidemiology Elective Program provides increased understanding and competence in applied epidemiology, provides students with opportunities to learn about population health and health care problems and the tools to help them bridge the gap between clinical medicine and public health, and serves as a source for EIS and other public health-related training and careers.

Reconciling Supply and Demand for State and Local Public Health Staff in an Era of Retiring Baby Boomers

INTRODUCTION The purpose of this study is to reconcile public health workforce supply and demand data to understand whether the expected influx of public health graduates can meet turnover events. METHODS Four large public health workforce data sources were analyzed to establish measures of workforce demand, voluntary separations, and workforce employees likely to retire at state and local health departments. Data were collected in 2014-2016 and analyzed in 2016 and 2017. Potential workforce supply (i.e., candidates with formal public health training) was assessed by analyzing data on public health graduates. Supply and demand data were reconciled to identify potential gaps in the public health workforce. RESULTS At the state and local level, ≅197,000 staff are employed in health departments. This is down more than 50,000 from 2008. In total, ≥65,000 staff will leave their organizations during fiscal years 2016-2020, with ≤100,000 staff leaving if all planned retirements occur by 2020. During 2000-2015, more than 223,000 people received a formal public health degree at some level. More than 25,000 students will receive a public health degree at some level in each year through 2020. CONCLUSIONS Demands for public health staff could possibly be met by the influx of graduates from schools and programs of public health. However, substantial implications exist for transferal of institutional knowledge and ability to recruit and retain the best staff to sufficiently meet demand.

Health Education Workforce: Opportunities and Challenges

Public health is facing unprecedented opportunities and challenges. Health departments face shifts from less clinical service delivery to increased population-based services to address the growing burden of chronic diseases (eg, obesity prevention, tobacco and drug use prevention) and new responsibilities to collaborate with other sectors in conducting community needs assessments and data sharing (1–3). State and local health departments continue to be challenged by health policy changes, reduced budgets, and difficulty recruiting and retaining staff (2). These challenges need to be met with a public health workforce of adequate size, composition, distribution, and skills. Formally trained health educators are an important but often underutilized part of the workforce needed to meet such challenges. Although various health workers inform the public, many employers are unaware of the professional training and roles of health educators (4). Health educators (also referred to as health education specialists) address chronic and other conditions by applying their competencies to the design and execution of behavioral health and policy or systems interventions (4). This essay highlights how the skill sets of health educators can address current and future public health challenges, the need for improved health educator workforce data, and a call to action for various stakeholders to optimally deploy health educators to improve the public’s health.