1. Welcome to “E is for Epi: Epidemiology Basics for Non-Epidemiologists” a training series from the University of North Carolina Center for Public Health Preparedness.

2. Epidemiology: A Basic Public Health Science
Session 1, Part 1
Epidemiology: A Basic Public Health Science
Although this training is part of a series, it can be viewed independently. This is Part 1 of Session 1 of the series, and is titled, “Epidemiology: A Basic Public Health Science”.

3. E is for Epi Series Overview
Designed for non-epidemiologists
Provides introduction to:
History of epidemiology
Epidemiology specialties
Key terminology, measures, and resources
Describes examples of epidemiology in public health practice
This training series is for non-epidemiologists, with the intention of preparing you to work collaboratively with epidemiologists and public health surveillance personnel in your region. This training series was designed to introduce you to the history and applications of the public health science of epidemiology. It will also introduce and explain terminology, measures, and resources commonly used by practicing epidemiologists. Finally, the series describes several examples of how epidemiology is used in public health practice.
There are 5 sessions in the E is for Epi series, each of which focuses on a different aspect of epidemiology. Four of the sessions are divided into 2 parts and one of the sessions is divided into 3 parts. While the lessons can be viewed and used individually, they are designed as part of a single training package.
For each training in the E is for Epi series, we will point out how the training aligns with the Public Health Preparedness Capabilities developed by the Centers for Disease Control and Prevention. These PHEP Capabilities were designed to provide consistent guidance with both the Department of Health and Human Services Essential Public Health Services and the Department of Homeland Security’s National Preparedness Guidelines and Target Capabilities List. This first session lays the groundwork for the basic work of public health. In future sessions, we will point out how the work of an epidemiologist is carried out to accomplish the Essential Public Health Services and how this work also supports the PHEP Capabilities.

4. Learning Objectives Session 1, Part 1
Define the 10 Essential Public Health Services
Explain the science of epidemiology in the broader context of the ten Essential Public Health Services
The learning objectives for Session 1, Part 1 are to:
Define the 10 Essential Public Health Services; and
Explain the science of epidemiology in the broader context of the 10 Essential Public Health Services

5. Overview Session 1, Part 1 “Quiz”
The 10 Public Health Essential Services
We will begin with a little “quiz”, and then we will give you the background on the 10 Essential Public Health Services and provide a description of each service.

6. Quiz
The quiz will consist of three multiple-choice questions based on short public health scenarios. Here’s the first one…

7. Scenario
As you read the front page of the local paper, you notice an alarming article about an outbreak of “disease X” in your community. You read on to learn about the scientifically established cause of “disease X,” and precautionary measures for avoiding exposure.
As you read the front page of the local paper, you notice an alarming article about an outbreak of “disease X” in your community. You read on to learn about the scientifically established cause of “disease X”, and precautionary measures for avoiding exposure.

8. Question 1
This valuable information was published as a front-page story because:
The local football team lost its game last night
The front-page columnist is on vacation
State and local health officials and their staff have worked for weeks to gather data, conduct laboratory and statistical tests, generate hypotheses, and collaborate with the media to alert and educate the public about “disease X” as effectively as possible
This valuable information was published as a front-page story because:
a. The local football team lost its game last night
b. The front-page columnist is on vacation
c. State and local health officials and their staff have worked for weeks to gather data, conduct laboratory and statistical tests, generate hypotheses, and collaborate with the media to alert and educate the public about “disease X” as effectively as possible.

9. Question 1
This valuable information was published as a front-page story because:
The local football team lost its game last night
The front-page columnist is on vacation
State and local health officials and their staff have worked for weeks to gather data, conduct laboratory and statistical tests, generate hypotheses, and collaborate with the media to alert and educate the public about “disease X” as effectively as possible
And the answer is. . .you guessed it – “C!”

10. Scenario 2
On your way into the local grocery store, you notice a flyer advertising a toll-free hotline number for enrolling uninsured children in a federally funded health insurance program.
Here is the second quiz scenario:
On your way into the local grocery store, you notice a flyer advertising a toll-free hotline number for enrolling uninsured children in a federally funded health insurance program.

11. Question 2 This insurance program is being offered because:
The federal government has a budget surplus and is looking for a way to spend it
A telephone company offered the state health department a great deal on numbers
Public health professionals have documented the numbers of uninsured children in their states, and worked with federal and state policy makers to institute outreach and “wrap around services” that assure the universal provision of health care
This insurance program is being offered because:
a. The Federal government has a budget surplus and is looking for a way to spend it
b. A telephone company offered the state health department a great deal on numbers
c. Public health professionals have documented the numbers of uninsured children in their states, and have worked with federal and state policy makers to institute outreach and “wrap around services” that assure the universal provision of health care.

12. Question 2 This insurance program is being offered because:
The federal government has a budget surplus and is looking for a way to spend it
A telephone company offered the state health department a great deal on numbers
Public health professionals have documented the numbers of uninsured children in their states, and worked with federal and state policy makers to institute outreach and “wrap around services” that assure the universal provision of health care
You guessed it. . . the correct answer is, “C.”

13. Scenario 3
You and your sweetheart share a romantic dinner at your favorite restaurant. Not only is the meal delicious – you do not get food poisoning!
And here is the third and final scenario. . .
You and your sweetheart share a romantic dinner at your favorite restaurant. Not only is the meal delicious – you do not get food poisoning!

14. Question 3 This enjoyable experience has been brought to you by:
The restaurant management
Your local health department
A joint effort of the restaurant management and your local health department
This enjoyable experience has been brought to you by:
a. The restaurant management
b. Your local health department
c. A joint effort of the restaurant management and your local health department

15. Quiz #3: Question
This enjoyable experience has been brought to you by:
The restaurant management
Your local health department
A joint effort of the restaurant management and your local health department
You guessed it again! The correct answer is, “C.”
So what, besides the same answer, do the three quiz scenarios have in common? They are real life, everyday examples of some of the 10 Essential Public Health Services that public health professionals—including epidemiologists—strive to deliver in the counties and states that they serve.
At the end of this segment, we will revisit these scenarios to see which Essential Public Health Services they represent.

16. 10 Essential Public Health Services
Now let’s jump into our introduction to the 10 Essential Public Health Services.

17. Comparison of Services
Public Health Model
Medical Model
Primary focus on population
Primary focus on the individual
Public service ethic, tempered by concerns for the individual
Personal service ethic, conditioned by awareness of social responsibilities
Emphasis on community prevention and health promotion
Emphasis on patient diagnosis, treatment, and care
Interventions for the environment, human behavior and lifestyles, and medical care
Interventions are medical care
As you know, public health is everywhere—it is a part of the infrastructure that keeps our communities safe and healthy.
But public health services may go unnoticed within a community because they are often (but not always) preventive versus reactive. For example, which community service are you more likely to notice: an environmental health specialist inspecting the safety of a local university’s food service establishments, or a fire truck speeding down the street with its lights and sirens on?
Despite having a relatively ‘low profile’ status, public health services play a key role in assuring the health and well being of communities. And the Ten Essential Services have the potential to create a comprehensive infrastructure that can provide a supportive context for any public health priority in a community. This slide shows you some key ways in which professionals come to the table with different training perspectives and approaches to health priorities in communities.
Public health and medicine both have a primary intervention focus: The public health model focuses on the population, and the medical model focuses on the individual.
A service ethic underlies each model: The public health model is based upon a public service ethic that is tempered by concerns for the individual, and the medical model is based upon a personal service ethic that is aware of social responsibilities.
In the public health model, the emphasis is on community-level prevention and health promotion. In the medical model, the emphasis is on individual patient diagnosis, treatment, and care.
Finally, public health interventions target the environment, human behavior/lifestyles, and medical care, and medicine’s primary intervention is medical care.

18. Public Health Mission:
“To promote physical and mental health, and prevent disease, injury, and disability”
The 10 Essential Public Health Services provide a ‘common ground’ for professionals trained in either the public health or the medical model, as well as grassroots workers and non-public health civic leaders, so all individuals can work collaboratively towards fulfilling the public health mission:
“To promote physical and mental health, and prevent disease, injury, and disability.”

19. Origin and Purpose
Consensus statement defines a detailed model of core public health functions
“Core Functions” of Public Health
Assessment
Policy development
Assurance
1990
1991
1992
1993
1994
1988
1989
So what are the 10 Essential Public Health Services, and who developed them?
From 1988 to the early 1990s, the recognized “core functions” of public health were:
Assessment;
Policy development; and
Assurance.
In 1993, with a new presidential administration and federal and state attempts to reform the health care system in the United States, public health leaders decided to set forth a more detailed and utilitarian consensus statement that would “speak with one voice” to public health professionals, the general population, and the policy makers who would shape health care reform.
Public health leaders worked to define a more detailed model of the core public health functions. The end result was a consensus statement that included the three recognized core functions and 10 Essential Public Health Services. The statement was adopted in 1994, and over the years has proven to be a critical foundational framework for public health responsibilities.
Federal health care system reform

20. Core Public Health Functions and Essential Services
This graphic, developed by the CDC, shows the 3 Core Functions and 10 Essential Public Health Services. Every public health professional should be familiar with these Functions and Services, since they form the backbone of all public health work. The Core Functions, shown around the edge of this wheel, are assessment, policy development, and assurance. Assessment is surveillance of disease and other health outcomes. Policy development is the process of translating surveillance information into programs and policies, and assurance is taking steps to make sure that policies and programs do indeed improve health outcomes.
The 10 Essential Services of public health fit into the 3 broad Core Functions. The theme of prevention is the most powerful element in the implementation of the 10 Essential Public Health Services. Through prevention, injuries, illnesses, and even chronic diseases can be avoided.
Keep in mind that the Services do not necessarily need to be implemented in a “1 through 10” sequence, or even independently, even though they are presented here in this manner. Next, let’s walk through the relevance of epidemiology to each of the 10 Essential Public Health Services. . .
CDC, 2010

21. #1: Monitor health status to identify and solve community health problems
Identification of health risks and determination of health service needs
Utilization of technology to interpret and communicate health information to diverse audiences
Attention to the vital statistics and health status of specific groups that are at higher risk
Collaboration in integrating and managing public health information systems
Essential Service #1 is to monitor health status to identify and solve community health problems.
While this slide presents a list that is not exhaustive, it will give you a feel for the scope of activities encompassed by this Essential Service. The list includes:
Identification of health risks and determination of health service needs;
Utilization of technology and other methods to interpret and communicate health information to diverse audiences in different sectors;
Attention to the vital statistics and health status of specific groups that are at higher risk than the total population; and
Collaboration in integrating and managing public health related information systems.
All of the activities listed on this slide are relevant to work conducted by epidemiologists. You will see later in this session, and even throughout this series, how the many epidemiological specialties and tasks relate to these services.
Much of Essential Service #1 relates to “surveillance.” In session 4 of this series, you will learn specifically about the major types of surveillance, their applications and limitations, and local, state, and federal data sources.

22. #2: Diagnose and investigate health problems and health hazards in the community
Epidemiological identification of outbreaks, patterns of infectious and chronic diseases and injuries
Public health laboratory capability using modern technology to conduct rapid screening and high volume testing
Infectious disease epidemiology programs
Technical capacity for investigation of disease outbreaks and assessing patterns of chronic disease and injury
Essential Service #2 is to diagnose and investigate health problems and health hazards in the community. This is directly tied to activities conducted by practicing epidemiologists. Service implementation includes:
Epidemiological identification of outbreaks, patterns of infectious and chronic diseases and injuries;
Public health laboratory capability using modern technology to conduct rapid screening and high volume testing;
Active infectious disease epidemiology programs; and
Technical capacity for investigation of disease outbreaks and assessing patterns of chronic disease and injury.
Epidemiologists monitor patient diagnoses and other disease reports to assess levels of disease in the population, investigate problems, and recommend prevention measures. Laboratory confirmation of epidemiologic specimens is one key method used to identify disease patterns and outbreaks.
At the local level, public health laboratories provide diagnostic and research services to the communities they serve. Public health laboratory professionals work to accomplish such tasks as newborn screening, identification of outbreak pathogens, and identification of novel viruses and bacteria. You will learn more about the role of public health laboratories in epidemiological practice in Session 2 of this series.

23. #3: Inform, educate, and empower people about health issues
Health information, health education, and health promotion activities
Health communication plans and activities such as media advocacy and social marketing
Accessible health information and educational resources
Health education and promotion program partnerships
The third Essential Service is to inform, educate, and empower people about health issues.
This includes:
Health information, health education, and health promotion activities designed to reduce health risk and promote better health;
Health communication plans and activities such as media advocacy and social marketing;
Accessible health information and educational resources; and
Health education and promotion program partnerships with schools, faith communities, work sites, personal care providers, and others to implement and reinforce health promotion programs and messages.
Public health epidemiologists use information in a variety of ways to communicate both internally with public health colleagues, and externally with physicians, the media, and the public. For example, in 2009, there was a significant amount of media and public attention focused on the novel influenza H1N1 variant. During these types of situations, epidemiologists work with a team of colleagues, including a designated Public Information Officer, to develop and disseminate press releases and specialized educational materials so prevention and health care access information can effectively reach target populations.

24. #4: Mobilize community partnerships and action to identify and solve health problems
Partnerships among community groups and associations to undertake preventive, screening, rehabilitation, and support programs
Coalitions to draw upon the full range of potential human and material resources in the cause of community health
The fourth Essential Service is to mobilize community partnerships and action to identify and solve health problems
This includes:
Convening and facilitating partnerships among groups and associations (including those not typically considered to be health-related to undertake defined health improvement projects, including preventive, screening, rehabilitation, and support programs); and
Building coalitions to draw upon the full range of potential human and material resources to improve community health.
As will be discussed in more detail later in today’s session, epidemiologists have a significant role in the collaborative element of community partnerships. Public health preparedness and response draws upon many sectors of the community and many public health specialties.
For example, both before and after Hurricane Irene hit the east coast in August of 2011, medical and public health professionals, including epidemiologists, worked diligently to mobilize community and national resources to protect and restore basic sanitation, provide emergency shelter, treat and prevent disease and injury, and address factors contributing to stress and mental health.

25. #5: Develop policies and plans that support individual and community health efforts
Systematic community-level and state-level planning
Development and tracking of measurable health objectives
Establishing strategies and actions to guide community health improvement
Development of legislation, codes, regulations, ordinances, and other policies to enable performance of the Essential Public Health Services
The fifth Essential Public Health Service is to develop policies and plans that support individual and community health efforts.
This pertains to:
Systematic community-level and state-level planning for health improvement in all jurisdictions;
Development and tracking of measurable health objectives;
Establishing strategies and actions to guide community health improvement at the state and local levels; and
Development of legislation, codes, rules, regulations, ordinances and other policies to enable performance of the Essential Public Health Services.
Particularly in the context of pandemic and other preparedness and response initiatives, epidemiologists and other public health professionals in most states are working to enhance community and state level plans to better coordinate between jurisdictions and agencies, so that daily public health services are carried out competently and systems are already being used in the event of a public health emergency.
One example of legislation that guides the practice of public health at the state level are the communicable disease reporting laws that regulate public health surveillance in each state. You will learn more about this in Session 4 of this series.

26. #6: Enforce laws and regulations that protect health and ensure safety
Enforcement activities in areas of public health concern
Protection of drinking water and enforcement of clean air standards
Re-inspection of workplaces following safety violations
Enforcement of laws governing the sale of alcohol and tobacco to minors
Seat belt and child safety seat usage
Childhood immunizations
The implementation of Essential Service #6 reflects many duties of practicing epidemiologists. This service is the enforcement of laws and regulations that protect health and ensure safety.
This Service includes:
Enforcement activities in areas of public health concern, including, but not limited to the protection of drinking water; enforcement of clean air standards; regulation of care provided in health care facilities and programs; re-inspection of workplaces following safety violations; review of new drug, biological, and medical device applications; enforcement of laws governing the sale of alcohol and tobacco to minors; seat belt and child safety seat usage; and childhood immunizations.

27. #7: Link people to needed personal health services and assure the provision of health care when otherwise unavailable
Identifying populations with barriers to personal health services
Identifying personal health service needs of populations with limited access
Assuring the linkage of people to appropriate personal health services through
Coordination of provider services
Development of interventions that address barriers to care (e.g. language)
The seventh Essential Service is to link people to needed personal health services, and assure the provision of health care when otherwise unavailable.
This means:
Identifying populations with barriers to personal health services;
Identifying personal health service needs of populations with limited access to a coordinated system of clinical care; and
Assuring the linkage of people to appropriate personal health services through coordination of provider services and development of interventions that address barriers to care such as culturally and linguistically appropriate staff and materials, and transportation services.
While you might not think an epidemiologist’s primary role is that of linking people to health services, there are, in fact, instances when this occurs.
For example, in post-hurricane response, public health professionals, including epidemiologists, conduct door-to-door rapid needs assessments in affected populations. While one purpose of the needs assessments is to conduct interviews and collect data to be analyzed, epidemiologists also assure the provision of health care services by overseeing follow up and referrals to link disaster victims to appropriate agencies and resources.
And when any survey is implemented, it must be linguistically appropriate. For example, some counties might require a Spanish version of the rapid needs assessment survey instrument.

28. #8: Assure a competent public and personal health care workforce
Education and training
Credentialing technical and professional health personnel
Adoption of continuous quality improvement and life-long learning programs
Partnerships with professional workplace development programs
Continuing education in management, cultural competence, and leadership development programs
The eighth Essential Service is to assure a competent public and personal health care workforce.
In order to do this, there must be:
Education and training for personnel to meet the needs for public and personal health service;
Efficient processes for credentialing technical and professional health personnel;
Adoption of continuous quality improvement and life-long learning programs;
Partnerships with professional workplace development programs to assure relevant learning experiences for all participants; and
Continuing education in management, cultural competence, and leadership development programs.
Pandemic or emergency preparedness and response programs in some states may oversee training to prepare the public health workforce for preparedness and response in addition to the traditional public health functions that prevent, detect, and respond to morbidity and mortality in communities.
Some specific ways in which public health staff in local health departments train are via “tabletop exercises” – or group case study exercises in which there is role playing and problem solving – and actual “field exercises” that test the response coordination, capacity and times, as well as the overall technological and staffing infrastructure.

29. Evaluation and critical review of health programs
#9: Evaluate effectiveness, accessibility, and quality of personal and population-based health services
Evaluation and critical review of health programs
based on analyses of health status and service utilization data
to determine program effectiveness
to provide information for allocating resources and reshaping programs
Essential Service #9 is to evaluate effectiveness, accessibility, and quality of personal and population-based health services.
This involves the evaluation and critical review of health programs, based on analyses of health status and service utilization data. These analyses are conducted to determine program effectiveness and to provide information necessary for allocating resources and reshaping programs for improved efficiency, effectiveness, and quality.
One type of data that is helpful in ongoing evaluation of health programs is surveillance. Surveillance is a key activity conducted by epidemiologists—that is why we will devote an entire session to the topic later in this series.
Let’s again use the example of influenza. In the context of Essential Service #9, epidemiologists might monitor influenza vaccination rates to determine whether or not high risk populations are being reached, or they may monitor the geographic distribution of vaccinations to see if there is enough vaccine to reach the number of people living in a particular community.

30. #10: Research for new insights and innovative solutions to health problems
Link with institutions of higher learning and research
Mount timely epidemiological and economic analyses
Conduct needed health services research
Survey design; conducting interviews and facilitating focus groups
Conducting clinical trials
Accessing and using public records
The tenth Essential Service is to conduct research for new insights and innovative solutions to health problems.
This includes:
Having a linkage with institutions of higher learning and research;
Ensuring an internal capacity to mount timely epidemiological (such as outbreak investigations) and economic analyses (for example, cost-benefit studies); and
Having an internal capacity to conduct needed health services research (for example, survey design; conducting interviews and facilitating focus groups; conducting clinical trials; and accessing and using public records).
There are many relevant places for the practice of epidemiology within the activities associated with Essential Service #10.
For example, in the event of an outbreak, epidemiologists working at local or state health departments need to know how to conduct an investigation. Keeping up on any new research related to the disease being investigated may assist epidemiologists in understanding what is causing people to get sick. In addition the epidemiologist must be able to design surveys and conduct interviews—all things that are done in an outbreak investigation.

31. Corresponding Services
Quiz Scenario
Essential Service
Informing the public of an outbreak investigation in the community
#2: Diagnose and investigate health problems and hazards in the community
Promoting enrollment in a federally subsidized health insurance program
#7: Link people to needed personal health services and assure the provision of health care when otherwise unavailable
Maintenance of a sanitary restaurant environmental for public well-being
#6: Enforce laws and regulations that protect health and ensure safety
So now that we have discussed each Essential Public Health Service, let’s revisit those three scenarios from the quiz at the beginning of the session:
The first scenario, about the newspaper article informing the public of an outbreak investigation in the community, illustrates Essential Service #2: “Diagnose and investigate health problems and health hazards in the community.”
The second scenario, with the flyer promoting enrollment in a federally subsidized health insurance program, illustrates Essential Service #7: “Link people to needed personal health services and assure the provision of health care when otherwise unavailable.”
And the third scenario when you do not get food poisoning in a restaurant, which is the maintenance of a sanitary restaurant environment for public well-being, illustrates Essential Service #6: “Enforce laws and regulations that protect health and ensure safety.”
Part 2 of this session will discuss the practice of epidemiology.

32. Summary
Core Functions of public health are assessment, policy development, and assurance
The 10 Essential Public Health Services create a “common ground” and a comprehensive infrastructure that provides a supportive context for any public health priority in a community
Epidemiology is a quantitative tool that can be used to implement Essential Public Health services
Let’s summarize what we’ve covered in this training:
The 3 Core Functions of public health are assessment, policy development, and assurance.
The 10 Essential Public Health Services that fall within these core functions create a “common ground” and a comprehensive infrastructure for public health and other agencies, and provide a supportive context for any public health priority in a community.
Epidemiology, as the basic science of public health, is a quantitative tool that can be used to implement many aspects of the Essential Public Health services.

33. References and Resources
Gordis L. Epidemiology. 2nd ed. Philadelphia, Pa: WB Saunders Company; 2000.
Hearne SA, Segal LM, Earls MJ, Unruh PJ. Ready or Not? Protecting the Public’s Health in the Age of Bioterrorism. Washington, DC: Trust for America’s Health; December Issue Report. Available at: Accessed March 1, 2012.
Office for State, Tribal, Local and Territorial Support, Centers for Disease Control and Prevention 10 Essential Public Health Services [National Public Health Performance Standards Program Web site]. December 9, Available at: Accessed March 1, 2012.
Kipp A. Overview of Epidemiology in Public Health [online training]. North Carolina Center for Public Health Preparedness, University of North Carolina at Chapel Hill School of Public Health; NCCPHP Training Web Site.