Assessment of Epidemiology Capacity in State Health Departments — United States, 2021

In 2021, during the COVID-19 response, the Council of State and Territorial Epidemiologists (CSTE) conducted its seventh periodic Epidemiology Capacity Assessment (ECA), a national assessment that evaluates trends in applied epidemiology workforce size, funding, and epidemiology capacity at state health departments.* A standardized web-based questionnaire was sent to state epidemiologists in 50 states and the District of Columbia (DC). The questionnaire assessed the number of current and optimal epidemiologist positions; sources of epidemiology activity and personnel funding; and each health department’s self-perceived capacity to lead activities, provide subject matter expertise, and obtain and manage resources for the three essential public health services (EPHS) most closely linked to epidemiology.^† CSTE enumerated 4,136 epidemiology positions across the United States, with an additional 2,196 positions needed to provide basic public health services. From 2017 to 2021, the number of epidemiologists in state health departments increased 23%, an increase primarily accounted for by the number of those supporting the COVID-19 response^§. The number of staff members decreased in program areas of infectious diseases, chronic diseases, and maternal and child health (MCH). Federal funding supports most epidemiology activities (85%) and epidemiology personnel (83%). Overall capacity to deliver the EPHS has declined, and epidemiology workforce and capacity needs remain unmet. More epidemiologists and sustainable funding are needed to consistently and effectively deliver EPHS. Additional resources (e.g., funding for competitive compensation and pathways for career advancement) are essential for recruitment and retention of epidemiologists to support public health activities across all program areas.

The ECA questionnaire instrument was updated in 2021 to include new epidemiology program areas for generalists and COVID-19 specialists and the revised EPHS (1). The COVID-19 program area sought to capture epidemiologists who were added for the COVID-19 response or reallocated for response efforts, separate from general infectious disease capacity. A set of core questions has remained essentially unchanged and permits monitoring of trends in the epidemiology workforce employed by the 50 states, DC, U.S. territories, and freely associated states, including current funding sources for epidemiology activities and personnel, capacity in the three EPHS relevant to epidemiology, and issues faced by health departments in recruitment, retention, and training of skilled epidemiologists to meet current needs and evolving priorities.

After CSTE pilot-tested the questionnaire instrument, the 2021 ECA was disseminated electronically to the lead state and territorial epidemiologist for each jurisdiction, using Qualtrics,^¶ an online survey tool. Data collection began January 11, 2021, and was completed April 1, 2021. Virtual technical assistance was provided to support the completion of the ECA. All 50 states, DC, and four territories responded to the assessment; this analysis includes responses only from U.S. states and DC. The number of full-time equivalent (FTE) epidemiologist positions (rounded to the nearest 0.1 FTE) by program area and source of funding was collected. For purposes of the ECA, CSTE defined capacity as “the state health department’s ability to lead activities, provide subject matter expertise, and apply for, receive, and manage resources to conduct key activities.” Respondents subjectively evaluated their capacity** as none (0%), minimal (1%–24%), partial (25%–49%), substantial (50%–74%), almost full (75%–99%), and full (100%). Data were analyzed using SAS (version 9.4; SAS Institute). This activity was reviewed by CDC and was conducted consistent with applicable federal law and CDC policy.^††

Respondents from 50 states and DC reported that 4,136 FTE epidemiologists were working in state health departments in 2021, a 23% increase over the 3,370 reported in 2017 (2). Overall, the number of epidemiologists per 100,000 population was 1.26 (range = 0.13–7.58), 21% higher than the 1.04 per 100,000 calculated in 2017. The size of the epidemiology workforce in each jurisdiction ranged from four to 255 FTEs.

Epidemiology activities in 2021 were supported in large part by federal funds (85%, an increase of 8% from 2017), followed by state funds (12%) and other sources (3%). As part of the federal funding for epidemiology activities, 39% was designated for COVID-19 activities with time-limited funding. The federal government funds 85% of epidemiology personnel positions, with 33% of these funds designated specifically for COVID-19 personnel. The remaining epidemiology personnel positions are funded by state government (15%) and other sources of funding (2%). Federal funding supports approximately 80% of epidemiology positions for COVID-19 response, preparedness, and substance use. In contrast, state and other sources of funding support approximately 50% of informatics, environmental health, generalist, and vital statistics positions.

Among program areas, infectious disease accounted for 1,498 (36%) of the 4,136 epidemiology positions, followed by COVID-19 response (24%) and MCH (7%) (Table 1). Program areas with the fewest epidemiologists included genomics, mental health, oral health, and occupational health. Most of the overall increase in workforce size can be attributed to new positions supporting the COVID-19 response.

The largest absolute and relative increases between 2017 and 2021 were in informatics, where 103 positions were added, representing a 107% increase (Table 2). Since 2017, infectious diseases positions decreased 19% (loss of 341 epidemiologists), chronic diseases decreased 18% (loss of 55 epidemiologists), and MCH decreased 9% (loss of 29 epidemiologists).

Participating state epidemiologists expressed the need for an additional 2,196 epidemiologists to deliver the EPHS, a 53% increase over the current number (Table 1). The largest number of positions needed were in infectious diseases (562), COVID-19 response (454), informatics (166), chronic diseases (153), MCH (135), and environmental health (135). The largest proportional increases needed were in genomics (922% increase, from five to 51), mental health (656% increase, from nine to 66), oral health (155% increase, from 20 to 52), and occupational health (143% increase, from 34 to 82). At the time of the assessment, among 852 position vacancies nationwide, 688 (81%) were being actively recruited. Filling these vacancies will address only 31% of the estimated additional 2,196 positions needed.

In 2021, 75% of jurisdictions had substantial-to-full capacity for monitoring health status (EPHS 1) and 88% capacity for diagnosing and investigating health problems and hazards (EPHS 2); both represented declines from 2017 (84% and 92%, respectively). Substantial-to-full capacity to conduct research and evaluation (EPHS 9) was 43%.^§§

When overall capacity was examined by program area, substantial-to-full capacity was highest for infectious diseases (88%), MCH (70%), chronic diseases (66%), vital statistics (54%), substance use (52%), injury (50%), and preparedness (50%) (Figure). States reported minimal-to-no capacity in genomics (90%) and mental health (78%). Since 2017, there was a decline in the proportion of states reporting substantial-to-full capacity in preparedness (17%), chronic disease (12%), and infectious disease (8%). In contrast, there was an increase in the proportion of states reporting substantial-to-full capacity in the areas of substance use (36%), informatics (17%), mental health (12%), occupational health (10%), and oral health (10%).