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Emerging Infections Program Efforts to Address Health Equity - Volume 21, Number 9—September 2015 - Emerging Infectious Disease journal - CDC


Emerging Infections Program Efforts to Address Health Equity - Volume 21, Number 9—September 2015 - Emerging Infectious Disease journal - CDC

Volume 21, Number 9—September 2015
Emerging Infections Program

Emerging Infections Program

Emerging Infections Program Efforts to Address Health Equity

James L. HadlerComments to Author , Duc J. Vugia, Nancy M. Bennett, and Matthew R. Moore
Author affiliations: Connecticut Emerging Infections Program, Yale School of Public Health, New Haven, Connecticut, USA (J.L. Hadler)California Emerging Infections Program, California Department of Public Health, Richmond, California, USA (D.J. Vugia)New York Emerging Infections Program, University of Rochester Medical Center, Rochester, New York, USA (N.M. Bennett)Centers for Disease Control and Prevention, Atlanta, Georgia, USA (M.R. Moore)


The Emerging Infections Program (EIP), a collaboration between (currently) 10 state health departments, their academic center partners, and the Centers for Disease Control and Prevention, was established in 1995. The EIP performs active, population-based surveillance for important infectious diseases, addresses new problems as they arise, emphasizes projects that lead to prevention, and develops and evaluates public health practices. The EIP has increasingly addressed the health equity challenges posed by Healthy People 2020. These challenges include objectives to increase the proportion of Healthy People–specified conditions for which national data are available by race/ethnicity and socioeconomic status as a step toward first recognizing and subsequently eliminating health inequities. EIP has made substantial progress in moving from an initial focus on monitoring social determinants exclusively through collecting and analyzing data by race/ethnicity to identifying and piloting ways to conduct population-based surveillance by using area-based socioeconomic status measures.
Describing health disparities and achieving health equity have been priorities of the national public health agenda for the past 20 years. One of the 2 goals of Healthy People (HP) 2010, the public health agenda for 2000–2010, was to “eliminate health disparities among different segments of the population, including differences that occur by gender, race or ethnicity, education or income, disability, geographic location, or sexual orientation” (1). In addition, HP 2010 included a related public health infrastructure objective (23.4), to track HP 2010 objectives by each population group. HP 2020, the agenda for 2010–2020, specifically added mention of social determinants of health. It reframed the goal and the related infrastructure objective, the former as “Achieve health equity, eliminate disparities, and improve the health of all groups,” and the latter, now Public Health Infrastructure Objective (7.1), as “Increase the proportion of population-based Healthy People 2020 objectives for which national data are available for all population groups” with a specific subobjective (7.3) “by socioeconomic status” (2).The World Health Organization, in a similar vein, recently recognized that addressing the social determinants of health was a key priority to eventually achieving health equity (3).
The Emerging Infections Program (EIP), established by the Centers for Disease Control and Prevention (CDC) in 1995, is a network that now includes 10 state health departments and their collaborators in local health departments, academic institutions, other federal agencies, and public health and clinical laboratories, with a catchment area of ≈44 million persons (47). In addition to performing active, population-based surveillance for important infectious diseases, EIP activities are intended to be flexible and address new problems as they arise, answer critical public health questions, emphasize projects that lead to prevention, and develop and evaluate public health practices. In this context, the EIP has increasingly taken on the challenges posed by HP 2010 and HP 2020, moving from a focus on monitoring social determinants exclusively through collecting and analyzing data by race/ethnicity to identifying and piloting ways to conduct population-based surveillance by using socioeconomic status (SES) measures with an ultimate focus on working toward health equity.
Most data collected by EIP sites comes from laboratory-based surveillance for bacterial, parasitic, and viral diseases, which does not include individual-level SES information. Missing data, especially ethnicity, is a consistent challenge. However, because residency in an EIP catchment area is a requirement for inclusion in surveillance, and to enable deduplication of multiple reports, addresses of residence for individual case-patients are collected at the time of diagnosis, making it possible to link cases to specific census tracts. With linkage to census tract, a wealth of data on census tract–level SES status indicators (e.g., poverty, education level, crowding) becomes available. Seminal work done by Nancy Krieger and colleagues in the Public Health Disparities Geocoding Project found that these census tract–level SES measures, especially low SES status (usually the lowest quartile or quintile of each measure), often predict disease incidence and mortality rates (8,9) and do so within and across groups defined by race/ethnicity. These authors recommended routine use of area-based SES measures in disease surveillance to describe and monitor, over time, disparities by SES, particularly poverty as measured by the percentage of persons in a census tract who lived below the federal poverty level.
In this article, we describe the evolution of EIP involvement in monitoring health disparities and in working toward health equity. These efforts began with a focus on race/ethnicity and, more recently, have included the piloting use of area-based SES measures under the guidance of a Health Equity Working Group.

Dr. Hadler has worked with the EIP since its inception in 1995, first as the Connecticut State Epidemiologist and, more recently, at the Yale School of Public Health where he is clinical professor of epidemiology. He is co-chair of the Council of State and Territorial Epidemiologists Health Disparities Subcommittee. His research interests include infectious disease surveillance and prevention and health inequities.


We acknowledge the contributions of the members of the EIP Steering Committee and the Health Equity Workgroup for their interest in expanding EIP surveillance to include measures of socioeconomic status and to develop standardized protocols to facilitate it.
The work on this manuscript was supported directly by the Centers for Disease Control and Prevention (CDC) (M.R.M.) or by Cooperative Agreement 5U50-CK000195 from the CDC (J.L.H., D.J.V., N.M.B.). The authors have no conflicts of interest to disclose.


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Suggested citation for this article: Hadler JL, Vugia DJ, Bennett NM, Moore MR. Emerging Infections Program efforts to address health equity. Emerg Infect Dis. 2015 Sept [date cited]. http://dx.doi.org/10.3201/eid2109.150275
DOI: 10.3201/eid2109.150275

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