The 10 Essential Public Health Services in Action
Local health departments are responsible for creating and maintaining conditions that keep people in their communities healthy and safe. The Centers for Disease Control and Prevention (CDC) has defined and recently updated 10 essential public health services that communities should undertake to protect and promote the health of all people in their community. This training uses a case study (based on an actual infectious disease outbreak) to relate each step of the investigation to one of the 10 essential public health services. Public health professionals should be able to describe each of these essential services, and should work to ensure that all 10 services are provided in their community.
After completing this training, you will be able to:
The 10 Essential Public Health Services (EPHS) provide a framework for public health to protect and promote the health of all people in all communities. To achieve equity, the EPHS actively promote policies, systems, and overall community conditions that enable optimal health for all, and seek to remove systemic and structural barriers that have resulted in health inequities. Such barriers include poverty, racism, gender discrimination, ableism, and other forms of oppression. Everyone should have a fair and just opportunity to achieve optimal health and well being.
The framework is organized around three core public health functions:
In order to achieve those core functions, the 10 EPHS were developed that detail the activities public health should be actively engaging in in their communities.
The EPHS framework was originally developed and released in 1994 and has served as a well-recognized framework for carrying out the mission of public health for the past 25 years. The framework was recently updated in 2020 to reflect the dramatic shift in the public health landscape over the past 25 years. The update brings the framework in line with current and future public health practice.
The update was a result of a collaborative effort by the Public Health National Center for Innovations (PHNCI), the de Beaumont Foundation, and a task force of public health experts, leaders, practitioners, and experts from federal agencies. Further details about the process to update the EPHS, along with accompanying materials, can be found in Additional Resources (last page of this training).
Print or save the full updated detailed text of the CDC's 10 Essential Public Health Services.
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Before moving on, review the CDC document and consider which essential services you most often provide in your community. Think about whether or not equity and social determinants of health (SDOH) are taken into consideration. The revised 10 EPHS were released on September 9, 2020. The updated framework now centers around equity and is in line with current and future public health practice.
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Please take a moment to check your knowledge about the EPHS.
As we work through this case study, assume you are the Town of Dunnit's local board of health (LBOH) public health nurse assigned to investigate the case.
As the case unfolds, assess information as it becomes available and make decisions to investigate and control the spread of disease. You might want to take notes as you move along in the case.
As Dunnit's LBOH public health nurse, you know that the Massachusetts Department of Public Health (MDPH) relies on LBOH to assess and monitor population health and to investigate, diagnose and address health hazards and root causes.
You also know that the surveillance and control of infectious diseases in Massachusetts requires collaboration between MDPH, LBOH, health care providers, laboratories, and other public health personnel to report the occurrence of reportable diseases.
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Importance of Reporting |
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Reporting data allows MDPH to accurately monitor trends, detect unusual occurrences of diseases (such as outbreaks), and appropriately address and evaluate the effectiveness of control and prevention activities. If you haven't bookmarked MDPH's Guide to Surveillance and Reporting (Guide), do so now. You will use this Guide throughout the training. |
The Guide is an online resource developed to assist with specific surveillance, response, and reporting responsibilities for infectious diseases reportable to MDPH. Each chapter is disease-specific and contains general information about the disease, as well as control recommendations and reporting requirements.
View the tabbed activity below for examples of the types of information contained in each chapter. We'll use botulism as an example.
Timely reporting is crucial to controlling infectious disease. Be sure to click on and bookmark the lists of diseases reportable to MDPH and LBOH by healthcare providers and laboratories.
Note that:
Dunnit is a suburban community with the following demographics.
In mid-to-late August, as the summer is coming to an end, some Dunnit residents begin experiencing a variety of gastrointestinal (GI) illnesses. Their symptoms include watery diarrhea, foul smelling stool, abdominal pain and distension, and anorexia.
Some of these residents visit their healthcare provider and get treated for their symptoms. While these symptoms can be attributed to a variety of ailments, let's consider four diseases.
Read the Guide then answer these questions.
The first confirmed case of Giardiasis (a young child named Benson Peppers) is reported to the Dunnit LBOH on September 16. (Remember, residents of Dunnit began experiencing GI illnesses in mid-to-late August.)
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Is this delay between symptom initiation and reporting unusual? |
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No. Many healthcare providers treat the GI symptoms and may not routinely order stool sample analysis. If an analysis is done, the Guide states: Report laboratory-confirmed cases, defined as the detection of Giardia organisms, antigen, or DNA in stool, intestinal fluid, tissue samples, biopsy specimens, or other biological samples. The laboratory test results submitted to the LBOH in Dunnit detected Giardia organisms. |
Open the Giardiasis chapter in the Guide, and use Section 3 (Reporting Responsibilities and Case Investigation) to answer the following question.
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What is MAVEN? |
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MAVEN (Massachusetts Virtual Epidemiologic Network) is a secure web-based surveillance and case management system for infectious diseases that enables rapid, efficient communication between local and state health departments and laboratories. |
After receiving the first confirmed case, a young child, you log in to MAVEN to start your required reporting to MDPH.
You use the MAVEN packages to guide your investigation (demographics, clinical, and risk exposure/control & prevention). You also schedule an interview with the mother of Benson Peppers (the young child who was confirmed to have Giardiasis).
Watch the case interview concerning Benson Peppers.
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Additional Notes from the Interview |
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By the end of September, five more Giardiasis cases are reported to the Dunnit LBOH.
You have been the public health nurse in Dunnit for many years, and when you review your records, you see that in the previous calendar year, a total of six Giardiasis cases were reported to the LBOH in Dunnit.
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Excerpt from Section 4 of the Guide - Reported Incidence Is Higher Than Usual/Outbreak Suspected |
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If the number of reported cases of Giardiasis in your city/town is higher than usual, or if you suspect an outbreak, investigate to determine the source of infection and the mode of transmission. A common vehicle (e.g., water, food, or association with a daycare center) should be sought, and applicable preventive or control measures should be instituted (e.g., removing an implicated food item from the environment). Control of person-to-person transmission requires special emphasis on personal cleanliness and sanitary disposal of feces. Consult with the epidemiologist on-call at the MDPH Division of Epidemiology and Immunization at (617) 983-6800. MDPH epidemiologists can help determine a course of action to prevent further cases and can perform surveillance for cases across town lines, which would otherwise be difficult to identify at the local level. |
As you interview the confirmed cases, you should try to identify a common vehicle.
Questions to ask yourself include:
At the same time you're conducting your case investigations, you must also work to control further spread of the disease. This will take a coordinated effort from not only the Dunnit LBOH, but also from other town agencies, community partners, and MDPH.
Depending on the number and location of the reported cases, LBOH from other towns may have to get involved. In cases of large outbreaks, MDPH can also ask for assistance from the CDC.
As you continue investigating the cases, the number of new reported cases is rapidly increasing.
In October, 40 cases are reported. You are now spending hundreds of hours investigating the cases, and continue to work closely with MDPH and other Dunnit LBOH personnel.
Because Giardiasis is spread by the fecal-oral route, the DBOH has begun collaborating with local hospitals, daycare centers, town recreational and school departments, and healthcare providers to increase awareness of proper handwashing and other methods to prevent the spread of disease.
Open the Giardiasis chapter of the Guide, then use Section 4 (Controlling Further Spread) to answer the following questions
During the investigation, many sources of exposure are considered, including local restaurants, daycare centers, municipal drinking water, and a country club. As the investigation progresses, a common link appears to be a private country club in Dunnit. Many of the cases are members or were guests of the country club.
The country club includes an 18-hole golf course, basketball and tennis courts, a clubhouse, a restaurant, an outdoor adult swimming pool and wading pool, a pool area snack bar, and pool area restrooms with showers and a diaper changing station.
Further investigation narrows the link to the pools at the country club, which closed for the season on September 5. The snack bar and restrooms also closed for the season on that date.
Many residents are anxious to know the cause of the outbreak. Some are attempting to assign blame to the municipal water supply. However, the municipal water supply is regularly tested for Giardia and has had no positive results. Additionally, the distribution of cases is centered in one geographic area of town, while the water supply is regional (providing water to many towns, with none of them reporting cases of Giardiasis).
On November 7, the Dunnit LBOH issues an advisory, in consultation with MDPH. It explains:
The advisory does not mention the link to the pools at the country club because the investigation is still ongoing. While it does appear that the initial cases were linked to those pools, many new cases were reported after the pools were closed (well beyond the exposure period). It is clear that something else is causing the continued spread of the disease.
In November, another 50 new cases are reported.
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Is this an unexpected increase? No. Due to all of the case investigation and follow up work by the DBOH, residents are aware of the outbreak and many are getting laboratory testing if they have GI symptoms. The Dunnit LBOH is continuing their collaboration with local hospitals, daycares, and healthcare providers to increase awareness and testing. Proper handwashing to prevent fecal-oral spread is a focus of health education efforts. |
Finally, only one new case is reported during the first week of December. It seems that public education and other efforts to control the spread of Giardiasis are working.
The Dunnit LBOH must still work to determine what caused and sustained the outbreak.
Based on their findings, the LBOH in Dunnit will make determinations about how to proceed with policy or enforcement actions. The country club pool and food establishments are regulated by the LBOH in Dunnit and require annual permits and routine inspections.
In collaboration with MDPH and CDC, the Dunnit LBOH has now found out this information about the 97 laboratory confirmed cases:
The CDC wants to gather more information to better understand the country club link. With the country club's cooperation, the EIS officer develops a questionnaire and sends it to all country club members.
The questionnaire asks about:
Of the 498 members that received the questionnaire, 175 completed it. Results indicate that most of the cases were children (median age 6 years for primary and 5 years for secondary).
Of the 149 cases identified by the survey (not laboratory analysis):
A primary case is defined as a case whose illness onset was between June 2 and October 5, and who had no contact with an ill individual during their shedding period. A secondary case is defined as a case whose illness onset was on or after October 5, or who had an illness onset within 60 days of contact with another case.
The country club pools were closed on September 5, so, given the incubation period of Giardia (up to 30 days), it was estimated that a case could be linked to a pool exposure and become symptomatic no later than October 5.
Statistical analysis determined an increased risk for those who swam in the wading pool, but no significant risk for those who used the swimming pool.
The research article about the actual case can be found in the Additional Resources (last page of this training).
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Think about actions the LBOH in Dunnit should take, especially for the swimming and wading pools (both of which will require a permit from the LBOH next summer). In the actual case, there had been an unreported fecal accident in the swimming pool in mid-July that was discovered during the case investigations. The Certified Pool Operator (CPO) was overruled by the club manager and forced to re-open the swimming pool without following the MDPH policy to response to fecal incidents. The DBOH took a number of actions. They scheduled a hearing with the country club and required them to:
The Dunnit LBOH was satisfied with the country club's response, and the pools were opened the next summer with no further cases of disease. The LBOH did realize they needed to improve risk communication (as they did not have a plan/protocol in place at the time of the outbreak), and sent staff to appropriate training so the LBOH could adopt a written communication plan.
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Let's revisit the 10 essential public health services to see how each one was an integral component of this outbreak investigation.
Think about all of the different partners and agencies that were involved in this outbreak. It involved government agencies at all levels, medical providers, laboratories, and private organizations.
View the tabbed activity to relate specific actions by the LBOH to the core functions and EPHS.
Now complete a knowledge check.
Congratulations! You have completed the training.
Print or save this Job Aid (PDF) that summarizes the key points.
You are now able:
If you feel you need additional exposure to this material, you may repeat the training or return to any of the pages at any time.
If you would like further information about this topic, please consult the following websites and articles.
(Katz, D E et al. "Prolonged outbreak of giardiasis with two modes of transmission." Epidemiology and infection vol. 134,5 (2006): 935-41. doi:10.1017/S0950268805005832)
Thank you for taking this training! We hope you will take another one soon.
If you planned to receive a certificate of completion, you should have completed the pre-test before starting this training. You won't be able to access the post-test if you haven't completed the pre-test.