Laboratory Services in Support of Public Health: A Status Report

When Healthy People (HP) 2000 was promulgated by the U.S. Department of Health and Human Services (HHS) in 1991, it contained no focus area on public health infrastructure.1 As a result, it did not include objectives measuring critical components of public health, such as laboratory services. During the 1990s, there was a collective effort to formally define public health practice in the U.S., culminating in the 10 Essential Public Health Services (hereafter, Essential Services).2 It became clear that to address the Essential Services, a robust public health infrastructure was required. In 1992, the Association of State and Territorial Public Health Laboratory Directors (now the Association of Public Health Laboratories [APHL]) published Laboratory Initiatives for the Year 2000 (LIFT 2000),3 which demonstrated that all Essential Services required laboratory infrastructure. As a result of these efforts, HP 2010 included a section (focus area 23) on public health infrastructure.4 Within focus area 23 was an objective (HP 23-13) to “increase the proportion of tribal, state, and local health agencies that provide or assure comprehensive laboratory services to support essential public health services.” At the outset, this objective was identified as a developmental—rather than measurable—objective, as there was no data source available to measure progress. Among the organizations identified as potentially being able to develop a tool for measuring comprehensive laboratory services were APHL and the Centers for Disease Control and Prevention (CDC). In 2002, a committee of APHL, including representation from CDC's Division of Laboratory Systems (DLS), began to devise a survey that could be used to transform HP 23-13 from a developmental objective to a measurable objective. In 2002, APHL and CDC co-published a report5 defining the 11 Core Functions and Capabilities of State Public Health Laboratories (hereafter, Core Functions). The APHL committee, in continued collaboration with CDC DLS, proposed that measuring the extent to which state health agencies were fulfilling those Core Functions would be a reasonable metric for the provision or assurance of comprehensive laboratory services. The committee also determined it would be more appropriate to measure each of the Core Functions independently. This resulted in a request to HHS, which oversees the HP process, to add 11 sub-objectives under HP 23-13. At that time, it was also clear that no comparable description of the Core Functions had ever been established for the large, diverse population of local public health laboratories (PHLs) in the United States. As a result, a modified HP 23-13 was written, removing the term “local” and adding 11 sub-objectives corresponding to the 11 Core Functions. In 2004, when HHS had approved the modifications, APHL conducted the first Comprehensive Laboratory Services Survey (CLSS), the results of which have been published.6 A major finding was that many states did not meet several sub-objective goals, including those for food safety, emergency response, and environmental health and protection. Given there had been no prior survey tool to measure comprehensive laboratory services, the 2004 version of the CLSS served well as a pilot. The planned collection and comparison of data on a biennial basis would allow for the measurement of progress toward HP 23-13 throughout the decade. Results for all HP objectives are available through the CDC Data 2010 website and are updated as new data are made available.7 Following a review of CLSS 2004's results, and in preparation for conducting CLSS 2006, the committee completed a thorough analysis of the survey instrument and feedback from the respondents. The analysis revealed that some survey questions were unclear and needed revisions, some terms used in the survey were not consistently understood, and the process for scoring the responses required changes. In addition, CLSS 2004 did not distinguish between providing or assuring specific laboratory services. The result of this analysis was a significantly improved CLSS 2006. The challenge of trying to reconcile the two surveys proved so formidable that ultimately the data collected for CLSS 2004 were used in a stand-alone format and the data obtained from CLSS 2006 were established as new baseline data. A third survey conducted in 2008, essentially equivalent to CLSS 2006, allowed for a comparison between the findings of those two years. This article compares the progress (or lack thereof) made within the 11 sub-objectives from 2006 to 2008.