Are we there yet? Seizing the moment to integrate medicine and public health.

Multiple promising but unsustainable attempts have been made to maintain programs integrating primary care and public health since the middle of the last century. During the 1960s, social justice movements expanded access to primary care and began to integrate primary care with public health concepts both to meet community needs for medical care and to begin to address the social determinants of health. Two decades later, the managed care movement offered opportunities for integration of primary care and public health as many employers and government payers attempted to control health costs and bring disease prevention strategies in line with payment mechanisms. Today, we again have the opportunity to align primary care with public health to improve the community's health.

Epidemic assistance by the Centers for Disease Control and Prevention: role of the Epidemic Intelligence Service, 1946-2005.

Since 1946, the Centers for Disease Control and Prevention has responded to urgent requests from US states, federal agencies, and international organizations through epidemic-assistance investigations (Epi-Aids). The authors describe the first 60 years of Epi-Aids, breadth of problems addressed, evolution of methodologies, scope of activities, and impact of investigations on population health. They reviewed Epi-Aid reports and EIS Bulletins, contacted current and former Epidemic Intelligence Service staff, and systematically searched the PubMed and Web of Science databases. They abstracted information on dates, location, staff involved, health problems, methods, and impacts of investigations according to a preplanned protocol. They assessed the methods presented as well as the quality of reports. During 1946-2005, a total of 4,484 investigations of health events were initiated by 2,815 Epidemic Intelligence Service officers. In the early years, the majority were in response to infectious agents, although environmental problems emerged. Investigations in subsequent years focused on occupational conditions, birth defects, reproductive health, tobacco use, cancer, violence, legal debate, and terrorism. These Epi-Aids heralded expansion of the agency's mission and presented new methods in statistics and epidemiology. Recommendations from Epi-Aids led to policy implementation, evaluation, or modification. Epi-Aids provide the Centers for Disease Control and Prevention with the agility to respond rapidly to public health crises.

In snow's footsteps: Commentary on shoe-leather and applied epidemiology.

The term shoe-leather epidemiology is often synonymous with field epidemiology or intervention epidemiology. All 3 terms imply investigations initiated in response to urgent public health problems and for which the investigative team does much of its work in the field (i.e., outside the office or laboratory). Alexander D. Langmuir is credited with articulating the concept of disease surveillance as it is applied to populations rather than individuals. He also founded the Epidemic Intelligence Service (EIS) Program in 1951, a 2-year training experience in applied epidemiology that places professionals in the field, domestically and internationally, in real-life situations. Today, 70-90 EIS officers are assigned each year to Centers for Disease Control and Prevention programs and to state and local health departments to meet the broad spectrum of challenges in chronic disease, injury prevention, violence, environmental health, occupational safety and health, and maternal and child health, as well as infectious diseases. Throughout their assignments, EIS officers are encouraged to strive for analytic rigor as well as public health consequence, which requires technical competence blended with good judgment and awareness of context. Effective applied epidemiologists must have skills beyond just epidemiology to improve a population's health; the field of applied epidemiology requires multiple team members, all having different but complementary skills, to be effective.

Monitoring progress toward CDC's health protection goals: health outcome measures by life stage.

OBJECTIVES: From 2004 through 2005, as part of a major strategic planning process called the Futures Initiative, the Centers for Disease Control and Prevention (CDC) developed a set of Health Protection Goals to make the best use of agency resources to achieve health impact. These goals were framed in terms of people, places, preparedness, and global health. This article presents a goals framework and a set of health outcome measures with historical trends and forecasts to track progress toward the Healthy People goals by life stage (Infants and Toddlers, Children, Adolescents, Adults, and Older Adults and Seniors). METHODS: Measurable key health outcomes were chosen for each life stage to capture the multidimensional aspects of health, including mortality, morbidity, perceived health, and lifestyle factors. Analytic methods involved identifying nationally representative data sources, reviewing 20-year trends generally ranging from 1984 through 2005, and using time-series techniques to forecast measures by life stage until 2015. RESULTS: Improvements in measures of mortality and morbidity were noted among all life stages during the study period except Adults, who reported continued declining trends in perceived health status. Although certain behavioral indicators (e.g., prevalence of nonsmokers) revealed steady improvements among Adolescents, Adults, and Older Adults and Seniors, prevalence of the healthy weight indicator was declining steadily among Children and Adolescents and dramatically among Adults and Older Adults and Seniors. CONCLUSION: The health indicators for the Healthy People goals established a baseline assessment of population health, which will be monitored on an ongoing basis to measure progress in maximizing health and achieving one component of CDC's Health Protection Goals.

Guide for applied public health workforce research: an evidence-based approach to workforce development.

Essential to achievement of the public health mission is a knowledgeable, competent, and prepared workforce; yet, there is little application of science and technical knowledge to ensuring the effectiveness of that workforce, be it governmental or private. In this article, I review the evidence for effective workforce development and argue for an increased emphasis on an evidence-based approach to ensuring an effective workforce by encouraging the generation of the evidence base that is required. To achieve this, I propose the appointment of an independent Task Force on Public Health Workforce Practice to oversee the development of a Guide for Public Health Workforce Research and Practice (Workforce Guide), a process that will generate and bring together the workforce evidence base for use by public health practitioners.

Perspectives on public health workforce research.

The Centers for Disease Control and Prevention Office of Workforce and Career Development is committed to developing a competent, sustainable, and diverse public health workforce through evidence-based training, career and leadership development, and strategic workforce planning to improve population health outcomes. This article reviews the previous efforts in identifying priorities of public health workforce research, which are summarized as eight major research themes. We outline a strategic framework for public health workforce research that includes six functional areas (ie, definition and standards, data, methodology, evaluation, policy, and dissemination and translation). To conceptualize and prioritize development of an actionable public health research agenda, we constructed a matrix of key challenges in workforce analysis by public health workforce categories. Extensive reviews were conducted to identify valuable methods, models, and approaches to public health workforce research. We explore new tools and approaches for addressing priority areas for public health workforce and career development research and assess how tools from multiple disciplines of social sciences can guide the development of a research framework for advancing public health workforce research and policy.

Career paths to public health: programs at the Centers for Disease Control and Prevention.

The Centers for Disease Control and Prevention offers training in specific, critically needed disciplines such as epidemiology and laboratory sciences, frequently through experiential, on-the-job service and learning fellowships. The agency also provides a more general exposure to public health as a field, often for younger participants, through shorter-term internships. In addition, other programs provide opportunity for exposure to public health thinking and public health problems in an academic setting as early as elementary school. Although a primary purpose of these programs, especially the experiential fellowships and internships, is to attract young people to public health careers, a secondary goal, particularly for the younger students, is to foster an awareness and concern regarding their personal health. The Career Paths to Public Health Program focuses on students and teachers from elementary to undergraduate schools and builds on CDC's existing postgraduate training programs. The program enhances student interest in the practical uses of mathematics and science and introduces them to the exciting work of public health. These activities also provide a nexus for working with both traditional partners in academia and public health and new academic partners to foster programs of mutual interest.

The education of physicians: a CDC perspective.

The Centers for Disease Control and Prevention (CDC) strongly supports integrating population health perspectives into the education of physicians. Physicians with critical-thinking skills, a commitment to the health of a community, and a systems-based approach are critical partners for the agency in its mission to protect and promote the public's health. To cultivate such physicians, integrating population health concepts solely into undergraduate medical education would be inadequate. A multipronged approach that establishes and maintains population health concepts with physicians at all stages of their education is needed: before medical school, during medical school, during residency and fellowship, and in research and practice (particularly for faculty who train the next generation). The authors describe relevant, CDC-conducted or CDC-supported activities that support such physician education during all these stages. Based in part on recent, cutting-edge trends assimilating community health particularly into primary care residencies, the authors also offer ideas for new ways that CDC can participate in the development of physicians who are truly competent at both medicine and population health in an integrated fashion -- physicians who focus on and care for individual patients but who also take a broader population or community perspective and can act effectively in either arena. Physicians who take such a systems approach -- who view and understand medicine and public health as a continuum rather than as distinct arenas -- are sorely needed to help solve the current health system crisis and to contribute to improving health in other ways.

Planning an integrated disease surveillance and response system: a matrix of skills and activities.

BACKGROUND: The threat of a global influenza pandemic and the adoption of the World Health Organization (WHO) International Health Regulations (2005) highlight the value of well-coordinated, functional disease surveillance systems. The resulting demand for timely information challenges public health leaders to design, develop and implement efficient, flexible and comprehensive systems that integrate staff, resources, and information systems to conduct infectious disease surveillance and response. To understand what resources an integrated disease surveillance and response system would require, we analyzed surveillance requirements for 19 priority infectious diseases targeted for an integrated disease surveillance and response strategy in the WHO African region. METHODS: We conducted a systematic task analysis to identify and standardize surveillance objectives, surveillance case definitions, action thresholds, and recommendations for 19 priority infectious diseases. We grouped the findings according to surveillance and response functions and related them to community, health facility, district, national and international levels. RESULTS: The outcome of our analysis is a matrix of generic skills and activities essential for an integrated system. We documented how planners used the matrix to assist in finding gaps in current systems, prioritizing plans of action, clarifying indicators for monitoring progress, and developing instructional goals for applied epidemiology and in-service training programs. CONCLUSION: The matrix for Integrated Disease Surveillance and Response (IDSR) in the African region made clear the linkage between public health surveillance functions and participation across all levels of national health systems. The matrix framework is adaptable to requirements for new programs and strategies. This framework makes explicit the essential tasks and activities that are required for strengthening or expanding existing surveillance systems that will be able to adapt to current and emerging public health threats.

Measuring health program effectiveness in the field: an assessment tool.

To assist field workers in program evaluation and to explicitly discuss program strengths and weaknesses, a practical method to estimate the effectiveness of public health interventions within the existing program capacity was developed. The method and materials were tested in seven countries (Afghanistan, Zimbabwe, Tanzania, Uganda, Guatemala, the Philippines, and Ghana). In this method, four core components are assessed using a questionnaire: (1) the efficacy of the intervention; (2) the level of existing human resources (i.e., quality of recruitment, training, and continuing education); (3) the infrastructure (i.e., supplies, salary, transportation, and supervision); and (4) the level of community support (i.e., access and demand). Using the assessment tool provided, program staff can determine if all necessary elements are in place for a successful program that can deliver the specific intervention. Based on the results of the assessment program, weaknesses can be identified, explicitly discussed, and addressed. The usefulness of this tool in humanitarian relief may be twofold: (1) to assess the design and implementation of effective programs; and (2) to highlight the inevitable need for capacity building as the disaster situation evolves.

Health burden and funding at the Centers for Disease Control and Prevention.

BACKGROUND: The relationship between domestic funding for selected conditions to the Centers for Disease Control and Prevention (CDC) and the burden of disease and disability in the United States was assessed systematically. METHODS: Using mortality, years of potential life lost (YPLLs), disability-adjusted life years (DALYs), hospital days, hospital discharges, and direct medical costs of conditions, 34 high-burden conditions addressed by CDC programs were identified, and information was collected about the funds spent on each by CDC during fiscal year (FY) 2003. The 34 conditions were grouped into 15 categorical areas, and the relationship between budget and burden was analyzed using correlation and regression methods for each of the categorical areas and for each measure of burden. RESULTS: Of CDC's total FY 2003 budget of $6.9 billion, 62% ($4.3 billion) of funding was allocated to one of the 34 conditions studied. A positive relationship between budget and burden was identified for all measures of burden, although the correlations varied for the different conditions. CONCLUSIONS: Although examination of the relationship of CDC's budget to burden measures provides insight into the agency's portfolio of investments, this exercise also highlights a number of limitations with this approach and the currently available burden measures. Assessment of key public health functions such as emergency preparedness and the collection of vital statistics require development of metrics different from the burden measures used in this analysis. Investment in the development of such metrics warrants consideration.

Measuring the public's health.

Allocation of public health resources should be based, where feasible, on objective assessments of health status, burden of disease, injury, and disability, their preventability, and related costs. In this article, we first analyze traditional measures of the public's health that address the burden of disease and disability and associated costs. Second, we discuss activities that are essential to protecting the public's health but whose impact is difficult to measure. Third, we propose general characteristics of useful measures of the public's health. We contend that expanding the repertoire of measures of the public's health is a critical step in targeting attention and resources to improve health, stemming mounting health care costs, and slowing declining quality of life that threatens the nation's future.

The evidence base for public health informing policy at the Centers for Disease Control and Prevention.

BACKGROUND: As part of a major re-examination of its organization, in 2004, the Centers for Disease Control and Prevention (CDC) assessed the evidence base for the effectiveness of population-based public health intervention programs. METHODS: For the leading causes of disease, injury, and disability, evidence was systematically reviewed for modifiable risk factors and their attributable fractions, and for public health interventions and their preventable fractions. RESULTS: For 31 conditions, 194 modifiable risk factors were identified, and attributable fractions were found for 65 (33.5%). For 137 (70.6%) of the risk factors, 702 population-based interventions were found. Preventable fractions were found for 31 (4.4%) of the interventions. CONCLUSIONS: Despite considerable information about both modifiable risk factors and interventions designed to reduce the risks of the major causes of disease, injury, and disability, the evidence base that describes the effectiveness of these interventions is limited. The CDC is committed to support research that will set priorities for program development and identify effective public health interventions.

Homocyst(e)ine and cardiovascular disease: a systematic review of the evidence with special emphasis on case-control studies and nested case-control studies.

BACKGROUND: Elevated concentrations of homocyst(e)ine are thought to increase the risk of vascular diseases including coronary heart disease and cerebrovascular disease. METHODS: We searched MEDLINE (1966-1999), EMBASE (1974-1999), SciSearch (1974- 1999), and Dissertation Abstracts (1999) for articles and theses about homocyst(e)ine concentration and coronary heart disease and cerebrovascular disease. RESULTS: We included 57 publications (3 cohort studies, 12 nested case-control studies, 42 case-control studies) that reported results on 5518 people with coronary heart disease (11,068 control subjects) and 1817 people with cerebrovascular disease (4787 control subjects) in our analysis. For coronary heart disease, the summary odds ratios (OR) for a 5-micromol/l increase in homocyst(e)ine concentration were 1.06 (95% CI : 0.99-1.13) for 2 publications of cohort studies, 1.23 (95% CI : 1.07-1.41) for 10 publications of nested case-control studies, and 1.70 (95% CI : 1.50-1.93) for 26 publications of case-control studies. For cerebrovascular disease, the summary OR for a 5-micromol/l increase in homocyst(e)ine concentration were 1.10 (95% CI : 0.94-1.28) for 2 publications of cohort studies, 1.58 (95% CI : 1.35-1.85) for 5 publications of nested case-control studies, and 2.16 (95% CI : 1.65-2.82) for 17 publications of case-control studies. CONCLUSIONS: Prospective studies offer weaker support than case-control studies for an association between homocyst(e)ine concentration and cardiovascular disease. Although other lines of evidence support a role for homocyst(e)ine in the pathogenesis of cardiovascular disease, more information from prospective epidemiological studies or clinical trials is needed to clarify this role.

Evaluation of field training in the epidemic intelligence service: publications and job choices.

BACKGROUND: Since 1951, the Centers for Disease Control and Prevention's Epidemic Intelligence Service (EIS) has provided training in applied epidemiology to physicians, nurses, veterinarians, dentists, and doctoral-level health scientists. About one third of these EIS officers have been trained in the setting of state and local health departments (the field). METHODS: To evaluate two specific outcomes of field EIS training, the authors reviewed the published work and career choices of field EIS officers after completing the program. The EIS classes of 1991-1996 were selected for study. A field officer was defined as an EIS Officer who completed at least the second year of a 2-year EIS assignment in a state or local health department position. RESULTS: During this period, 430 EIS officers completed the program; 117 (27.2%) were field officers. Of these, 84 (71.8%) published one or more scientific paper as first author for a total of 202 first authored manuscripts in over 50 different journals, an average of 1.7 (range, 0-8) per officer. Most (71%) were on infectious disease topics; 16% were on environmental health or injury control topics, and 11% were on chronic diseases. Field officers were more likely than headquarters-based officers to choose positions in state or local health departments for their first job after graduating (32/117 [27.4%] versus 22/313 [7.0%]; relative risk = 3.9, 95% confidence interval = 2.4-6.4). CONCLUSIONS: EIS training in the field has contributed to the scientific literature and to the strengthening of public health infrastructure at the state and local level.

Strengthening capacity in developing countries for evidence-based public health: the data for decision-making project.

Public health officials and the communities they serve need to: identify priority health problems; formulate effective health policies; respond to public health emergencies; select, implement, and evaluate cost-effective interventions to prevent and control disease and injury; and allocate human and financial resources. Despite agreement that rational, data-based decisions will lead to improved health outcomes, many public health decisions appear to be made intuitively or politically. During 1991-1996, the US Centers for Disease Control and Prevention implemented the US Agency for International Development funded Data for Decision-Making (DDM) Project. DDM goals were to: (a) strengthen the capacity of decision makers to identify data needs for solving problems and to interpret and use data appropriately for public health decisions; (b) enhance the capacity of technical advisors to provide valid, essential, and timely data to decision makers clearly and effectively; and (c) strengthen health information systems (HISs) to facilitate the collection, analysis, reporting, presentation, and use of data at local, district, regional, and national levels. Assessments were conducted to identify important health problems, problem-driven implementation plans with data-based solutions as objectives were developed, interdisciplinary, in-service training programs for mid-level policy makers, program managers, and technical advisors in applied epidemiology, management and leadership, communications, economic evaluation, and HISs were designed and implemented, national staff were trained in the refinement of HISs to improve access to essential data from multiple sources, and the effectiveness of the strategy was evaluated. This strategy was tested in Bolivia, Cameroon, Mexico, and the Philippines, where decentralization of health services led to a need to strengthen the capacity of policy makers and health officers at sub-national levels to use information more effectively. Results showed that the DDM strategy improved evidence-based public health. Subsequently, DDM concepts and practices have been institutionalized in participating countries and at CDC.

The impact of stretching on sports injury risk: a systematic review of the literature.

PURPOSE: We conducted a systematic review to assess the evidence for the effectiveness of stretching as a tool to prevent injuries in sports and to make recommendations for research and prevention. METHODS: Without language limitations, we searched electronic data bases, including MEDLINE (1966-2002), Current Contents (1997-2002), Biomedical Collection (1993-1999), the Cochrane Library, and SPORTDiscus, and then identified citations from papers retrieved and contacted experts in the field. Meta-analysis was limited to randomized trials or cohort studies for interventions that included stretching. Studies were excluded that lacked controls, in which stretching could not be assessed independently, or where studies did not include subjects in sporting or fitness activities. All articles were screened initially by one author. Six of 361 identified articles compared stretching with other methods to prevent injury. Data were abstracted by one author and then reviewed independently by three others. Data quality was assessed independently by three authors using a previously standardized instrument, and reviewers met to reconcile substantive differences in interpretation. We calculated weighted pooled odds ratios based on an intention-to-treat analysis as well as subgroup analyses by quality score and study design. RESULTS: Stretching was not significantly associated with a reduction in total injuries (OR = 0.93, CI 0.78-1.11) and similar findings were seen in the subgroup analyses. CONCLUSION: There is not sufficient evidence to endorse or discontinue routine stretching before or after exercise to prevent injury among competitive or recreational athletes. Further research, especially well-conducted randomized controlled trials, is urgently needed to determine the proper role of stretching in sports.

The prevention of shin splints in sports: a systematic review of literature.

PURPOSE: To review the published and unpublished evidence regarding risk factors associated with shin splints, assess the effectiveness of prevention strategies, and offer evidence-based recommendations to coaches, athletes, and researchers. METHODS: We searched electronic data bases without language restriction, identified citations from reference sections of research papers retrieved, contacted experts in the field, and searched the Cochrane Collaboration. Of the 199 citations identified, we emphasized results of the four reports that compared methods to prevent shin splints. We assessed the methodologic quality of these reports by using a standardized instrument. RESULTS: The use of shock-absorbent insoles, foam heel pads, heel cord stretching, alternative footwear, as well as graduated running programs among military recruits have undergone assessment in controlled trials. There is no strong support for any of these interventions, and each of the four controlled trials is limited methodologically. Median quality scores in these four studies ranged from 29 to 47, and serious flaws in study design, control of bias, and statistical methods were identified. CONCLUSION: Our review yielded little objective evidence to support widespread use of any existing interventions to prevent shin splints. The most encouraging evidence for effective prevention of shin splints involves the use of shock-absorbing insoles. However, serious flaws in study design and implementation constrain the work in this field thus far. A rigorously implemented research program is critically needed to address this common sports medicine problem.

U.S. military officer participation in the Centers for Disease Control and Prevention's Epidemic Intelligence Service (1951-2001).

The Epidemic Intelligence Service (EIS) was created in 1951 to provide epidemiologists to investigate natural and intentional disease epidemics. From an initial class of 23 U.S. citizens, the program has evolved into a globally recognized, hands-on learning experience, accepting approximately 65 to 75 new officers each year. The first U.S. military epidemic intelligence service officer (EISO) was accepted into the program in 1994. Since that time, 12 such officers have completed, or have begun, EIS training. They have comprised 2.1% of all EISOs from 1994 to 2001 and 0.47% of all EISOs. This total has included nine Air Force veterinarians, one Army veterinarian, one Army physician, and one Navy physician. Each military EISO had the opportunity to lead investigations of significant public health events (e.g., Ebola, monkeypox, malaria, Nipah virus, West Nile fever, and anthrax outbreaks). All graduates from the military returned to active duty assignments in operational medical units, research institutes, or the intelligence community.