SECTI O N 1: Embargoed Funding ISSUE REPORT SECTION 1: FUNDING Outbreaks: until Tuesday, December 17 at 10:00 AM ET PROTECTING AMERICANS FROM 2013 INFECTIOUS DISEASES DECEMBER 2013 DECEMBER 2013 Acknowledgements Trust for America’s Health is a non-profit, non-par- TFAH BOARD OF DIRECTORS tisan organization dedicated to saving lives by pro- Gail Christopher, DN David Fleming, MD tecting the health of every community and working President of the Board, TFAH Director of Public Health to make disease prevention a national priority. Vice President—Health Seattle King County, Washington WK Kellogg Foundation The Robert Wood Johnson Foundation Arthur Garson, Jr., MD, MPH focuses on the pressing health and health Cynthia M. Harris, PhD, DABT Director, Center for Health Policy, care issues facing our country. As the nation’s Vice President of the Board, TFAH University Professor, largest philanthropy devoted exclusively to Director and Professor And Professor of Public Health Services health and health care, the Foundation works Institute of Public Health, Florida University of Virginia with a diverse group of organizations and A&M University individuals to identify solutions and achieve John Gates, JD comprehensive, measurable, and timely Theodore Spencer Founder, Operator and Manager change. For more than 40 years the Foundation Secretary of the Board, TFAH Nashoba Brook Bakery has brought experience, commitment, and a Senior Advocate, Climate Center Tom Mason rigorous, balanced approach to the problems Natural Resources Defense Council President that affect the health and health care of those Robert T. Harris, MD Alliance for a Healthier Minnesota it serves. When it comes to helping Americans Treasurer of the Board, TFAH lead healthier lives and get the care they need, Alonzo Plough, MA, MPH, PhD Former Chief Medical Officer and Senior the Foundation expects to make a difference in Director, Emergency Preparedness and Response Vice President for Healthcare your lifetime. For more information, visit www. Program BlueCross BlueShield of North Carolina rwjf.org. Follow the Foundation on Twitter at Los Angeles County Department of Public Health www.rwjf.org/twitter or on Facebook at www. Barbara Ferrer, PhD, MPH, ED Eduardo Sanchez, MD, MPH rwjf.org/facebook. Health Commissioner Deputy Chief Medical Officer Boston, Massachusetts American Heart Association TFAH would like to thank RWJF for their generous support of this report. REPORT AUTHORS Jeffrey Levi, PhD Laura M. Segal, MA Rebecca St. Laurent, JD Executive Director Director of Public Affairs Health Policy Research Manager Trust for America’s Health Trust for America’s Health Trust for America’s Health and Associate Professor in the Department of Dara Alpert Lieberman, MPP Health Policy Senior Government Relations Manager The George Washington University School of Trust for America’s Health Public Health and Health Services PEER REVIEWERS TFAH thanks the following individuals and organizations for their time, expertise and insights in reviewing all or portions of the Outbreaks report. The opinions expressed in the report do not necessarily represent the views of these individuals or their organizations. James S. Blumenstock Donald M. Jensen, MD Litjen (L.J) Tan, MS, PhD Chief Program Officer for Public Health Practice Professor of Medicine and Director, Center for Chief Strategy Officer Association of State and Territorial Health Liver Diseases Immunization Action Coalition Officials University of Chicago Medical Center Eric Toner, MD Christopher Chadwick, MS Dennis L. Murray, M.D., FAAP, FIDSA Senior Associate Specialist, Public Health Preparedness & Professor of Pediatrics UPMC Center for Health Security Response Georgia Regents University and Donna Hope Wegener Association of Public Health Laboratories Chair, Section on Infectious Diseases, American Executive Director Academy of Pediatrics Thomas V. Inglesby, MD National TB Controllers Association Director and CEO Scott Needle, MD, FAAP Infectious Diseases Society of America (IDSA) UPMC Center for Health Security Healthcare Network of SW Florida HIV Medicine Association (HIVMA) Pediatric Infectious Diseases Society (PIDS) 2 TFAH • healthyamericans.org SECTI O N 1: Infectious Funding INTRODUCTION SECTION 1: FUNDING Diseases Policy Report series Introduction Infectious diseases, from antibiotic-resistant superbugs to Salmonella to the seasonal flu, disrupt lives and communities and cost the country more than $120 billion each year.1 Since the 1940s, there have been Fighting infectious disease requires tremendous advancements in constant vigilance. Policies and infectious disease prevention efforts, resources must be in place to allow vaccinations, antibiotics and other scientists and public health and medical treatments that have saved countless experts to have the tools they need to: lives. The successes in infectious control ongoing outbreaks — such disease control have made it possible as HIV/AIDS, bacterial infections in for the majority of Americans to live hospitals and foodborne illnesses; detect significantly longer lives — which new or reemerging outbreaks — such also means most Americans reach the as Middle East Respiratory Syndrome ages where they develop and live with (MERS), whooping cough and drug- a range of chronic diseases — often resistant infections; and even monitor for decades. This sea change in the for potential bioterrorist threats — such health of Americans has also led to as anthrax or smallpox. a shift in attention and resources Reports from the Centers for Disease toward managing and treating chronic Control and Prevention (CDC), the disease — but it is important to Institute of Medicine (IOM) and other remember the threat that infectious expert organizations have stressed the diseases continue to pose. importance of having fundamental DECEMBER 2013 DECEMBER 2013 Millions of Americans still contract abilities in place to detect and control infectious diseases each year and, the transmission of infectious diseases worldwide, they are the leading cause of and ensure consistent, basic levels of death of people under the age of 60. 2, 3, 4 protection across the country.5, 6 CDC’s Framework for Preventing transmitted by animals or insects to Infectious Diseases: Sustaining the humans; and Essentials and Innovating for the Future l D eveloping and advancing policies stresses the importance of: such as integrating clinical infectious l S trengthening public health funda- disease preventive practices into U.S. mentals, including infectious disease healthcare; educating and working surveillance, laboratory detection with the public to understand how to and epidemiologic investigations; limit the spread of diseases; and work- ing with the global health community l I dentifying and implementing to quickly identify new diseases and high-impact strategies — such as reduce rates of existing diseases.7 vaccinations, infection control, rapid diagnosis of disease and However, efforts to prevent and control optimal treatment practices — to infectious diseases continue to be limit the spread of diseases and hampered by outdated systems and systems to reduce the diseases limited resources. The Trust for America’s Health (TFAH) and Robert Wood Johnson Foundation (RWJF) issued the Outbreaks: Protecting Americans from Infectious Diseases report to examine the country’s policies to respond to ongoing and emerging infectious disease threats. Government at all levels has the ability play, states have the primary legal juris- Protecting the country from to set policies and establish practices diction and responsibility for the health infectious disease threats is a based on the best science available to of their citizens.8 These indicators help fundamental role of government, better protect Americans from infec- illustrate the types of fundamentals that tious disease threats. are important to have in place not just and all Americans have the right to prevent the spread of disease in the to basic protections no matter To help assess policies and the capacity first place but also to detect, diagnose to protect against infectious disease out- where they live. and respond to outbreaks. breaks, this report examines a range of infectious disease concerns and a series In addition, fighting infectious diseases of 10 indicators in each state that, taken requires more than just governmental collectively, offer a composite snapshot action, it also requires cooperative of strengths and vulnerabilities as well efforts with the healthcare sector; as a range of national and global infec- pharmaceutical, medical supply and tious disease priorities. While federal, technology companies; community state and local health departments and groups, schools and employers; and healthcare providers all have roles to families and individuals. 4 TFAH • healthyamericans.org The Outbreaks report provides the III. Emerging Infectious Diseases public, policymakers and a broad and Indicator 5: Climate Change and diverse set of groups involved in public Infectious Diseases health with an objective, nonpartisan, Indicator 6: Mandatory Reporting independent analysis of the status of of Healthcare Associated Infections infectious disease policies; encourages greater transparency and accountability IV. mergency Outbreaks: Bioterrorism E of the system; and recommends ways and High-Risk New Diseases to assure the public health system Indicator 7: Laboratory meets today’s needs and works across Capabilities for Tracking Novel boundaries to accomplish its goals. Disease Outbreaks The report focuses on areas with Indicator 8: Laboratory Capacity to high-priority policy concerns for Transport Disease Samples for Testing infectious disease prevention and Indicator 9: Laboratory Capabilities control, including: during Emergency Events or Drills I. oundational Capabilities and F V. Foodborne and Waterborne Illnesses Funding for Public Health VI. IV/AIDS, Viral Hepatitis and H Indicator 1: State Public Health Budgets Tuberculosis (TB) Prevention II. Vaccine-Preventable Diseases Indicator 10: Medicaid Coverage of Indicator 2: Whooping Cough Routine Human Immunodeficiency Vaccination of Children Virus (HIV) Screening Indicator 3: Human papillomavirus (HPV) Immunization Laws Indicator 4: Flu Vaccination Rates TFAH • healthyamericans.org 5 MAJOR INFECTIOUS THREATS WA MT ND AND KEY FINDINGS MN VT ME SD WI OR ID NH WY MI NY IA MA NE PA RI IL IN OH CT NV UT NJ CO KS MO WV DE KY VA MD DC CA OK TN NC NM AR AZ SC MS AL GA TX LA Scores Color 2 3 FL AK 4 HI 5 6 7 8 SCORES BY STATE 8 7 6 5 4 3 2 (1 state) (8 states) (9 states & D.C.) (14 states) (10 states) (5 states) (3 states) New Hampshire Connecticut California Alaska Alabama Arizona Georgia Delaware Colorado Florida Idaho Arkansas Nebraska Minnesota D.C. Illinois Indiana Montana New Jersey New York Hawaii Iowa Kansas Nevada North Carolina Maryland Louisiana Kentucky Wyoming Oregon Missouri Maine Mississippi Rhode Island Pennsylvania Massachusetts North Dakota Washington Tennessee Michigan Ohio Vermont New Mexico Utah Virginia Oklahoma West Virginia South Carolina South Dakota Texas Wisconsin Infectious disease control and prevention indicator and zero points if they did not. is a concern in every state. Policies and Zero is the lowest possible score and 10 programs vary from state-to-state. This is the highest. Scores ranged from a high report includes a series of 10 indicators of eight in New Hampshire to a low of two based on high-priority areas and concerns. in Georgia, Nebraska and New Jersey. It is not a comprehensive review, but Scores are not intended to serve as a collectively, it provides a snapshot of the reflection of the performance of a specific efforts that states are taking to prevent state or local health department, since and control infectious diseases. The they reflect a much broader context, includ- indicators were selected after consulting ing resources, policy environments and the with leading public health and healthcare health status of a community, so many of officials. Each state received a score the indicators are impacted by factors be- based on these 10 indicators. States yond the direct control of health officials. received one point for achieving an 6 TFAH • healthyamericans.org l he Flu: An average of 62 million — or 20 T l nly 25 states and Washington, D.C. O MAJOR INFECTIOUS THREATS percent of — Americans get the seasonal require the HPV vaccine for teens or AND KEY FINDINGS flu each year. Between 3,000 and 49,000 fund HPV vaccination efforts or educate Americans die each year from the flu and the public about the HPV vaccine. 20 percent of Americans get the seasonal 226,000 are hospitalized, leading to eco- l E merging and Re-emerging Threats: flu each year. nomic losses of more than $10 billion in Since 2012, CDC and global health direct medical expenses and more than agencies have been tracking two $16 billion in lost earnings.9, 10 Experts serious new threats: As of October 25, also warn that flu pandemics — novel 2013, there have been 136 confirmed strains of the flu virus that humans have little-to-no immunity against — emerge cases of a new strain of the flu — H7N9, first reported in China — which 20% three to four times a century. 11 Only 41.5 has led to 45 deaths (as of November percent of adults were vaccinated against 2013), and as of November 12, 2013, the flu last year, and only 72.0 percent of 153 cases (42 percent fatal) in nine healthcare workers were vaccinated.12  countries of the new MERS coronavirus. l nly 12 states vaccinated at least half O In the United States in recent years, of their population (ages 6 months and CDC and state and local health officials Only 33 percent of female teens receive older) for the seasonal flu in 2012. have been tracking a number of re- the recommended vaccinations to help prevent Human Papillomavirus (HPV) l W hooping Cough, Measles: Childhood emerging infectious diseases, including vaccinations prevent an estimated 14 million cases of disease and save $9.9 the largest outbreak of West Nile Virus (WNV) since 2003 and the highest rates rrrrrrrrrrrrrrr billion in direct healthcare costs and $33.4 of malaria cases in the United States since 1970 (1,925 cases in 2011). rrrrrrrrrrrrrrr billion in indirect costs for each birth cohort vaccinated. More than 2 million Climate change, increased international rrrrrrrrrrrrrrr children under the age of 3 do not receive all recommended vaccinations, leaving travel and increased food imports are some factors that contribute to the rise rrrrrrrrrrrrrrr them vulnerable for preventable diseases of new diseases or the re-emergence of like measles and whooping cough, which diseases that were thought to be largely have both experienced recent resurgences under control. As of 2000, World Health in areas of the United States. Organization (WHO) had identified more than 200 new diseases that were l nly two states and Washington, D.C. meet O first spread to humans by animals the U.S. Department of Health and Human or insects, including severe acute Services (HHS) goal of vaccinating 90 respiratory syndrome (SARS), pandemic percent of young children — ages 19- to flu and HIV/AIDS.14 35-months old — against whooping cough. l nly 15 states have completed O l uman Papillomavirus and Cervical H climate change adaptation plans, Cancer: 79 million Americans carry HPV, which includes understanding which leads to 20,000 new cases of and planning for the changing cancer in women and 12,000 in men each risk for emerging and re-emerging year.13 Only 33 percent of female teens infectious diseases due to changing receive the recommended vaccinations to temperatures and weather patterns. help prevent HPV and thus cervical cancer. TFAH • healthyamericans.org 7 MAJOR INFECTIOUS THREATS AND KEY FINDINGS l H ealthcare-Associated Infections (HAIs): l E mergency Outbreaks and Bioterrorism: be needed during a major new disease out- Approximately one out of every 20 hospi- In 2001, through a deliberate act of bio- break. (July 1, 2012 to July 30, 2013). talized patients will contract an HAI. Risk terrorism, at least 22 Americans victims l 6 state public health laboratories and 4 of infection increases if a person is hav- contracted anthrax, with five people dying Washington, D.C. report having the ing invasive surgery, if they have a vein or from the infection. Since 2001, the coun- capacity in place to assure the timely bladder catheter, if they are on a ventilator try has prioritized developing strategies to transportation (pick-up and delivery) of or are on a prolonged course of antibiot- respond to major disease outbreaks and samples 24/7/365 to the appropriate ics. There were an estimated 98,987 other health emergencies, whether caused Public Health Laboratory Response Net- deaths due to HAIs in 2002, the last year by nature, accident or a bioterrorism. work (LRN) Reference Laboratory in the an official estimate was released. l nly 37 state public health laboratories O last year (July 1, 2012 to July 30, 2013). l nly 35 states and Washington, D.C. O and Washington, D.C. report having a plan l nly 27 state public health laboratories O require that healthcare facilities in their and capability to handle a significant surge reported evaluating the functionality state report healthcare-associated infec- in testing over a six to eight week period in of their Continuity of Operations Plan tions to CDC’s National Healthcare Safety response to an outbreak that increases test- (COOP) via a real event or an exercise Network (NHSN) or another system. ing over 300 percent — which is what could last year (July 1, 2012 to July 30, 2013). l S uperbugs/Antibiotic Resistance: CDC has identified 18 priority strains of infec- tions that are resistant to treatment by Contribution of Different Food Categories to Estimated antibiotics — ranging from diseases as Domestically-Acquired Illnesses and Deaths, 1998-2008* commonplace as strep throat and ear infec- tions to tuberculosis (TB) and Salmonella to Illnesses Deaths Methicillin-resistant Staphylococcus aureus (MRSA) and other healthcare-associated Produce 46% 23% infections. Each year more than two million Americans develop antibiotic-resistant infec- tions, and at least 23,000 of these individu- als die as a result. These are considered Meat and Poultry 22% 29% to be very conservative estimates, since current surveillance and data collection capabilities cannot capture the full burden. Antibiotic resistance leads to more than eight million extra days Americans spend in Dairy and Eggs 20% 15% the hospital a year and costs the country an extra $20 billion in direct medical costs and at least $35 billion in lost productivity. The number of antibiotics currently prescribed Fish and Shellfish 6.1% 6.4% for humans per year in the United States is 60 45 30 15 0 15 30 45 60 enough to treat four out of five Americans. Percent l entucky had the highest rate of K *Chart does not show 5% of illnesses and 2% of deaths attributed to other commodities. In addition, 1% of illnesses and antibiotics prescribed per person, 25% of deaths were not attributed to commodities; these were caused by pathogens not in the outbreak database, mainly Alaska had the lowest, as of 2010. Toxoplasma and Vibrio vulnificus. Source: Painter JA, Hoekstra RM, Ayers T, Tauxe RV, Braden CR, Angulo FJ, Griffin PM. Attribution of foodborne illnesses, hospitalizations, and deaths to food 8 TFAH • healthyamericans.org commodities by using outbreak data, United States, 1998–2008. Emerg Infect Dis [Internet]. 2013 Mar [date cited]. http://dx.doi.org/10.3201/eid1903.111866 l F oodborne and Waterborne Illnesses: l H epatitis B Virus (HBV) and C (HCV): MAJOR INFECTIOUS THREATS More than 48 million Americans suffer Around 5 million Americans have HBV or AND KEY FINDINGS from foodborne illnesses each year. HCV, but between 65 and 75 percent do These illnesses result in 128,000 not know they have it. HBV and HCV put Percent of people infected with Hepatitis B hospitalizations and around 3,000 people at risk for developing serious liver or C who are unaware they are infected deaths. In addition, more than 4,100 diseases and cancer. Two-thirds of Ameri- persons become ill from contaminated cans infected with HCV are Baby Boomers, drinking water and more than 13,000 and one in 10 Asian Americans has HBV. persons become ill from recreational l T B: From 1953 to 1984, tuberculosis water disease outbreaks annually in the declined from 84,304 cases, with a rate 65%-75% United States.15, 16 of 52.6 per 100,000 people in the United l he leading pathogen responsible for T States (the first year for which national foodborne illness is Norovirus, while statistics were compiled), to 22,255 Salmonella is the leading cause of cases and a rate of 9.4 per 100,000. hospitalization and death.17 However, the country experienced a TB l roduce (a combination of six plant P resurgence in the mid-1980s due to food categories) is the top cause deficient public health infrastructure, of illness, while meat and poultry drug-resistant TB, HIV/AIDS and changing (a combination of four animal food immigration patterns with more people categories) are the top causes of arriving from countries with a high TB death. 18 burden. Health officials responded with improvements in treatment, case finding, l H IV/AIDS: More than 1.1 million laboratory capacity and infrastructure Americans are living with HIV/AIDS, and cases began to decline. There were and almost one in five do not know nearly 10,000 cases of TB in the United they are infected. Since the epidemic States in 2012 with 63 percent of these began more than 636,000 Americans cases occurring in persons born outside have died from AIDS.19 There is an the United States. alarming increase in new infections among gay men — accounting for the l F unding for Public Health: 34 states cut majority of the nearly 50,000 new HIV funding for public health from Fiscal year diagnoses in 2011. 20 (FY) 2011 to 2012 to FY 2012 to 2013, l nly 33 states and Washington, D.C. O diminishing their capacity to respond to cover routine HIV screening under infectious disease outbreaks in addition to their Medicaid programs. Knowing other public health priorities. In addition, HIV-status is important to help get at a federal level, CDC’s overall budget sus- individuals into treatment and stop the tained a $577 million cut from FY 2012 to spread of the disease. FY 2013, according to the American Public Health Association (APHA).21 TFAH • healthyamericans.org 9 STATE INDICATORS (3) Requires the HPV (4) State vaccinated (1) Increased or (2) Met the HHS goal (5) State has a complete (6) State mandates vaccine for teens — or at least half of their maintained level of of vaccinating at least climate change that healthcare funds HPV vaccination population (ages 6 funding for public health 90 percent of 19- to adaptation plan that facilities in their state efforts or educates the months and older) for the services from FY 2011- 35-month-olds against include focusing on the report healthcare- public about the HPV seasonal flu of fall 2012 12 to FY 2012-13. whooping cough. impact of human health. associated infections. vaccine. to spring 2013. Alabama 3 Alaska 3 3 Arizona Arkansas 3 California 3 3 Colorado 3 3 3 Connecticut 3 3 3 3 Delaware 3 3 3 D.C. 3 3 3 Florida 3 3 Georgia 3 3 Hawaii 3 3 Idaho 3 Illinois 3 3 Indiana 3 3 Iowa 3 3 3 Kansas Kentucky Louisiana 3 3 Maine 3 3 3 3 Maryland 3 3 3 3 Massachusetts 3 3 3 Michigan 3 3 Minnesota 3 3 3 Mississippi 3 Missouri 3 3 Montana Nebraska 3 Nevada 3 3 New Hampshire 3 3 3 3 New Jersey 3 New Mexico 3 3 New York 3 3 3 North Carolina 3 3 3 North Dakota 3 3 Ohio 3 Oklahoma 3 Oregon 3 3 3 3 Pennsylvania 3 3 3 Rhode Island 3 3 3 3 South Carolina 3 3 South Dakota 3 3 Tennessee 3 3 Texas 3 3 3 Utah 3 3 3 Vermont 3 3 3 Virginia 3 3 3 Washington 3 3 3 West Virginia 3 Wisconsin 3 3 Wyoming Total 17 2 + D.C. 25 + D.C. 12 15 35 + D.C. 10 TFAH • healthyamericans.org (7) Public health lab reports having a plan (8) Public health lab reports having the (10) State covers (9) Public health lab evaluated and capability to handle a significant surge capacity in place to assure the timely routine HIV 2013 the functionality of COOP via a in testing over a six to eight week period transportation (pick-up and delivery) of screening under Total real event or exercise from July in response to an outbreak that increases samples 24/7/365 days to the appropriate their Medicaid Score 1, 2012 to June 30, 2013. testing over 300%. public health LRN Reference Laboratory. programs. Alabama 3 3 3 4 Alaska 3 3 3 5 Arizona 3 3 3 3 Arkansas 3 3 3 California 3 3 3 3 5 Colorado 3 3 3 6 Connecticut 3 3 3 7 Delaware 3 3 3 3 7 D.C. 3 3 3 6 Florida 3 3 3 5 Georgia 2 Hawaii 3 3 3 3 6 Idaho 3 3 3 4 Illinois 3 3 3 5 Indiana 3 3 4 Iowa 3 3 5 Kansas 3 3 3 3 4 Kentucky 3 3 3 3 4 Louisiana 3 3 3 5 Maine 3 5 Maryland 3 3 6 Massachusetts 3 3 5 Michigan 3 3 3 5 Minnesota 3 3 3 3 6 Mississippi 3 3 3 4 Missouri 3 3 3 3 6 Montana 3 3 3 3 Nebraska 3 2 Nevada 3 3 New Hampshire 3 3 3 3 8 New Jersey 3 2 New Mexico 3 3 3 5 New York 3 3 3 3 7 North Carolina 3 3 3 3 7 North Dakota 3 3 4 Ohio 3 3 3 4 Oklahoma 3 3 3 3 5 Oregon 3 3 3 7 Pennsylvania 3 3 3 6 Rhode Island 3 3 3 7 South Carolina 3 3 3 5 South Dakota 3 3 3 5 Tennessee 3 3 3 3 6 Texas 3 3 5 Utah 3 4 Vermont 3 3 3 6 Virginia 3 3 3 6 Washington 3 3 3 3 7 West Virginia 3 3 3 4 Wisconsin 3 3 3 5 Wyoming 3 3 3 3 37 + D.C. 46 + D.C. 27 33 + D.C. TFAH • healthyamericans.org 11 GERMS HAVE NO BOUNDARIES: FEDERAL, STATE AND LOCAL PUBLIC HEALTH RESPONSIBILITIES The nation’s public health system is core responsibilities are based in states, grants, to carry them out in states or local responsible for improving the health but diseases can be spread across state communities. Since “communicable” of Americans. Public health laws lines and around the globe. diseases pose threats to national security “authorize and obligate the government and across states, Congress authorized The federal government sets national to protect and advance the public’s the tracking of infectious disease threats health goals and priorities for the health,” including against threats from starting in 1878.24 CDC, in consultation country. The federal government can infectious diseases.22 Federal, state and with state, local and tribal health track and report on information about local health departments have different departments and the Council of State diseases, conduct biomedical and responsibilities and jurisdictions — and and Territorial Epidemiologists (CSTE), prevention research, stockpile resources must also work in partnership with establishes and routinely updates a list to supplement state and local response healthcare providers, the insurance, of “notifiable” diseases that states are capabilities and provide technical pharmaceutical and medical device required to report to CDC so they can be assistance to states and localities.23 industries, other areas of government and tracked and strategies can be developed Federal policies can steer efforts across community groups to effectively prevent to limit their spread.25 There are more the country by setting joint strategic and control diseases. Policies and than 85 notifiable infectious diseases, priorities and establishing programs programs to control infectious diseases ranging from anthrax to yellow fever.26 and then providing funds, often through are particularly complex since many of the NOTIFIABLE DISEASES IN THE UNITED STATES VIRAL HEMORRHAGIC FEVER Cryptosporidiosis Poliovirus infection, nonparalytic Toxic Shock Syndrome ANTHRAX Giardiasis Tetanus Babesiosis (other than Streptococcal) Novel influenza A virus infections ARBOVIRAL DISEASES, Botulism DENGUE VIRUS Streptococcal Brucellosis NEUROINVASIVE AND DIPHTHERIA Varicella INFECTIONS Tularemia toxic-shock syndrome GONORRHEA NON-NEUROINVASIVE YELLOW Ehrlichiosis and Anaplasmosis TRICHINELLOSIS Hantavirus FEVER Spotted Fever Rickettsiosis Hemolytic uremic TYPHOID FEVER pulmonary PSITTACOSIS syndrome, post-diarrheal Coccidioidomycosis syndrome SYPHILIS HANSEN’S chlamydia Haemophilus CYCLOSPORIASIS CHOLERA Influenza-associated trachomatis influenzae, Salmonellosis pediatric mortality DISEASE infection invasive disease HIV Infection Listeriosis Rabies Lyme disease MALARIA CHANCROID mumps Shigellosis Poliomyelitis, paralytic smallpox measles VIBRIOSIS Meningococcal disease Pertussis Tuberculosis Q fever rubella Severe Acute Respiratory Syndrome-Associated Coronavirus Disease Legionellosis Hepatitis A Hepatitis B Hepatitis C PLAGUE VANCOMYCIN-INTERMEDIATE STAPHYLOCOCCUS AUREUS & VANCOMYCIN-RESISTANT STAPHYLOCOCCUS AUREUS 12 TFAH • healthyamericans.org The federal government also has Breaking a federal quarantine authority to isolate or quarantine order is punishable by fines and patients infected with certain diseases imprisonment.30 when they pose a threat to others or States bear most of the legal the national interest. This authority responsibility for protecting the health, derives from the Commerce Clause of safety and welfare of their citizens, the Constitution. The U.S. Secretary granted by “police power” functions. of Health and Human Services is States vary in how they are structured authorized to take measures to prevent and many share different degrees of the entry and spread of communicable responsibility with local governments, diseases from foreign countries into but still maintain the ultimate power the United States and between the within their borders.31 This authority states (section 361 of the Public “underlie[s] communicable disease Health Services Act (§42 U.S. Code laws authorizing surveillance, testing, 264).27 CDC has the responsibility screening, isolation and quarantine.”32 for implementing these functions as Every state has the general public deemed necessary to protect the health authority to act to control public. Although rare, CDC may detain, communicable diseases, but state medically examine and release persons laws, programs and funding levels arriving into the United States, people vary significantly. For instance, some traveling between states or people who states have very specific or very broad may come into contact with others who quarantine laws. In most states, are traveling between states and are breaking a quarantine law is a criminal suspected of carrying communicable misdemeanor.33 Public health laws diseases of public concern. can be controversial in terms of finding Federal isolation and quarantine are an appropriate balance between currently authorized by Executive Order protecting against the risk to the of the President for cholera, diphtheria, public versus the rights of an individual infectious TB, plague, smallpox, yellow or group. In most states, for most fever, viral hemorrhagic fevers, SARS conditions, “liberty principles” and and influenza viruses that are causing “informed consent” allow individuals or having the potential to cause a to decide whether to treat an illness pandemic. 28 The President can revise they may have, but this may then lead the list by Executive Order. It is the to required isolation for a patient if the duty of U.S. Customs and Coast Guard disease can be easily spread and pose officers to aid in the enforcement of a danger to others.34 quarantine rules and regulations. 29 TFAH • healthyamericans.org 13 U.S. infectious disease control WHO revised a set of International nations to effectively detect and monitor strategies are complicated not just by Health Regulations (IHR) in 2005 in diseases and to institute disease control interstate travel, but by international the wake of the outbreak of a new practices varies significantly. Many travel and immigration. In many cases, deadly disease called SARS to help countries do not adequately fund public people carrying diseases are often improve global disease surveillance health programs, have large endemic not identified when crossing borders. and detection and encourage the public health crises, do not have strong Individuals may have an infection adoption of stronger standardized healthcare systems and do not have or illness but are not aware of it or disease control policies worldwide. 35 a tradition of setting standards for they may have not developed severe IHR sets standards for and requires adopting evidence-based disease control enough symptoms to warrant special notification to WHO of any “public health practices or for adopting principles of notice or attention. And, even in cases emergency of international concern,” objectivity, fairness and transparency.37 where a patient suspected of having or of any significant evidence of public Efforts like the WHO and CDC’s Global a dangerous infectious disease has health risks outside their territory that Disease Detection (GDD) program help been identified, carrying out quarantine may lead to or cause the international provide some additional support to and isolation laws in a timely manner spread of disease. More than 190 less wealthy nations, but there is wide and across different jurisdictions nations have signed onto the IHR. 36 variance and major gaps in public health can present a challenge. Disease programs around the world to control Even with laws in place, infectious outbreaks anywhere around the world, ongoing threats like HIV/AIDS and disease prevention and control policies therefore, are of concern to every other malaria to the ability to quickly identify can have major challenges in practice. every nation. and contain new diseases. For instance, the ability of different 14 TFAH • healthyamericans.org SECTI O N 1: Funding SECTION 1: FUNDING Funding for Public Health and Foundational Capabilities The ability to detect and control infectious diseases requires having a strong, stable public health system. Public health departments around the country have the unique role and responsibility for improving health in schools, workplaces and neighborhoods, through identifying top public health problems and developing strategies for improvement. Some keys to an effective 24/7 approach l A focused and effective response to infectious disease threats include: strategy, including targeted communications, to address the l S trong surveillance to be able to iden- concerns of at-risk populations, tify and monitor ongoing and newly such as children, the elderly and emerging infectious disease outbreaks; groups or areas that are particularly l I ntensive investigative capabilities susceptible to a particular threat; — including an expert scientific l C oordination and partnership with and medical workforce and the healthcare sector, to ensure comprehensive laboratory capabilities people in need have access to and — to quickly diagnose outbreaks; receive the best available treatment l C ontainment strategies, including at any stage of an outbreak — medicines and vaccines to stop the including surge capacity for mass spread of a disease and isolate and outbreaks when necessary; quarantine when necessary; l A n informed and involved public l S treamlined and effective that can provide material and moral communication channels so health support to professional responders, workers can swiftly and accurately and can render aid when necessary communicate with each other, other to friends, family, neighbors and front line workers and the public associates; and DECEMBER 2013 about 1) the nature of the disease l A strong research capacity to threat; 2) the risk of exposure and how rapidly be able to development new to seek treatment when needed; and vaccines or medical treatments to 3) any actions they or their families counter new threats. should take to protect themselves; Most Americans expect — and take grants which provide funding to Percentage of State and Territorial for granted — that federal, state and some states but not others. In most Health Agencies Experiencing Reduced Workforce Capacity and Programs, local health departments are able to cases, there is no officially defined December 2012 and Cumulatively carry out basic disease prevention mode of coordination for targeting (since July 2008) and food and water protection or strategically focusing the funds. Reduced 95% programs — but, unfortunately, these Services 20% l A ccording to a 2013 report by the fundamental capabilities are often Entire 71% Association of State and Territorial Programs Cut 6% hampered due to limited funds. Health Officials (ASTHO), 48 states, Mandatory 62% Public health departments at all levels three territories and Washington, Furlough 6% of government have been chronically D.C. have reported budget cuts, and Loss of Staff 91% 22% underfunded for decades. 38 Funding 91 percent of all state and territorial by Attrition comes through a combination of health agencies (SHAs) experienced Layoffs 60% 12% federal, state and local dollars. Each job losses through a combination 0% 20% 40% 60% 80% 100% level of government has different, of layoffs and attrition. SHAs have Cumulatively Dec-12 but important responsibilities for reported cuts to programs as a protecting the public’s health. result, including to public health hospitals and clinics; HIV/ AIDS According to a 2008 analysis by The and STD prevention services; New York Academy of Medicine disease specific programs; family (NYAM), there was a shortfall of health and nutrition programs; $20 billion per year in spending on maternal and child health programs; federal, state and local public health.39 tobacco prevention and control; l A t the federal level, the budget immunizations; and for programs for CDC decreased from a high of for children with special healthcare $6.62 billion in 2005 to $6.32 billion needs. Fifteen SHAs reported cuts in 2011 (adjusted for inflation). to their FY 2013 budgets.40 Between FY 2010 and FY 2012, l D uring 2012, close to one-half federal public health spending was (48 percent) of all local health reduced 8 percent. In FY 2012, departments (LHDs) reduced federal public health spending or eliminated services in at least through CDC averaged only $19.54 one program area. Immunization, per person. The amount of federal maternal and child health and funding ranged significantly from emergency preparedness services state to state, with a low of $13.72 were the three most affected per capita in Indiana and a high of program areas. Since 2008, LHDs $53.07 in Alaska. Federal funds lost almost 44,000 jobs, and 31 are distributed through a mixture percent of all LHDs expect cuts in of population-based formula grant the upcoming fiscal year.41 programs, formulas based on disease rates, and a series of competitive 16 TFAH • healthyamericans.org 17 states increased or maintained public health 33 states and Washington, D.C. cut public health INDICATOR 1: funding from FY 2011 to 2012 to FY 2012 to 2013 funding from FY 2011 to 2012 to FY 2012 to 2013 (1 point). (0 points). STATE FUNDING Alaska (14.1%) Alabama (-7.1%) Missouri (-5.3%)^ Colorado (20.7%) Arizona (-1.3%)^ Montana (-1.8%)^ Connecticut (9.9%) Arkansas (-4.0%)* Nebraska (-1.5%)^ KEY FINDING: 33 states and Georgia (6.0%) California (-5.2%) Nevada (-0.5%)^ Iowa (1.8%) Delaware (-0.7%) New Jersey (-5.2%)^ Washington, D.C. cut funding for Louisiana (2.6%) D.C. (-1.8%) New Mexico (-1.1%)^ Michigan (6.5%) Florida (-8.8%)* New York (-3.9%) public health from FY 2011 to Mississippi (22.6%) Hawaii (-8.2%) North Carolina (-17.1%) New Hampshire (8.4%) Idaho (-2.3%) Ohio (-2.3%)* 2012 to FY 2012 to 2013. North Dakota (32.8%) Illinois (-4.0%)^ Oklahoma (-4.1%) Oregon (18.1%) Indiana (-1.8%) South Dakota (-1.4%)^ Pennsylvania (1.6%) Kansas (-3.9%)^ Tennessee (-0.9%)* Rhode Island (5.3%) Kentucky (-3.1%)^ Virginia (-4.4%)^ South Carolina (0.9%) Maine (-10.6%)^ Washington (-29.5%)^ Texas (2.7%) Maryland (-1.1%)^ West Virginia (-18.6%)^ Utah (12.6%) Massachusetts (-0.6%) Wisconsin (-1.2%) Vermont (14.8%) Minnesota (-1.2%) Wyoming (-0.6%) NOTES: Bolded states did not respond to the not reply by that date were assumed to be in data check TFAH coordinated with ASTHO that accordance with the findings. was sent out October 24, 2013. States were *Budget decreased for second year in a row given until December 3, 2013 to confirm or ^Budget decreased for third year in a row correct the information. The states that did This indicator, adjusted for inflation, il- Based on this analysis, 33 states and It is important to note that several lustrates a state’s commitment and ability Washington, D.C. made cuts in their states that received points for this to provide funding for public health pro- public health budgets. Twenty states cut indicator may not have actually grams that support the infrastructure and their budget for two or more years in a increased their spending on public workforce needed to improve health in row, and 16 made cuts for three or more health programs. The ways some states each state, including the ability to prevent years in a row. The median spending report their budgets, for instance, by and control infectious disease outbreaks. in FY 2012 to FY 2013 was $27.49 per including federal funding in the totals person, down from $33.71 in FY 2008. or including public health dollars Every state allocates and reports its within healthcare spending totals, budget in different ways. States also Public health funding is discretionary make it very difficult to determine vary widely in the budget details they spending in most states and, therefore, “public health” as a separate item. provide. This makes comparisons across is at high risk for significant cuts states difficult. For this analysis, TFAH during economic downturns. States This indicator is limited to examining examined state budgets and appropria- rely on a combination of federal, state whether states’ public health budgets tions bills for the agency, department, and local funds to support public increased or decreased, it does not or division in charge of public health health activities, including infectious assess if the funding is adequate to services for FY 2011 to 2012 and FY 2012 disease prevention, immunization cover public health needs in the states to 2013, using a definition as consistent services and preparedness activities. and it should not be interpreted as as possible across the two years, based The overall infrastructure of other an indicator or surrogate for a state’s on how each state reports data. TFAH public health programs supports overall performance. defined “public health services” broadly the ability to carry out all of their For additional information on the to include all state-level health spending responsibilities, which includes methodology of the budget analysis, with the exception of Medicaid, CHIP or infectious disease prevention, please see Appendix D: Methodology for comparable health coverage programs immunization services and health Select State Indicators. for low-income residents.  emergency preparedness. TFAH • healthyamericans.org 17 Key Federal Infectious Disease Program Funding CDC—INFECTIOUS DISEASES FY 2006 FY 2007 FY 2008 FY 2009 FY 20101 FY 20112 FY 20123 FY 2013 Immunization and $519,858,000 $585,430,000 $684,634,000 $716,048,000 $721,180,000 $748,257,000 $778,947,000 $678,935,000 Respiratory Diseases HIV/AIDS, Viral Hepatitis, $963,133,000 $1,002,513,000 $1,002,130,000 $1,006,375,000 $1,118,712,000 $1,115,995,000 $1,109,934,000 $1,048,374,000 STI and TB Prevention^ Emerging and Zoonotic $212,165,000 $221,643,000 $217,771,000 $225,404,000 $281,174,000 $304,193,000 $304,226,000 $291,073,000 Infectious Diseases* *In 2011 CDC integrated two existing nationals centers: the National Center for Preparedness, Detection, and Control of Infectious Diseases and the National Center for Zoonotic, Vector-Borne, and Enteric Diseases to create the National Center for Emerging and Zoonotic Infectious Diseases. ^Viral Hepatitis was added in 2007 1 Includes PPHF funding for HIV/AIDS and Emerging and Zoonotic Infectious Diseases 2 Includes PPHF funding for Immunization and Respiratory Diseases, HIV/AIDS and Emerging and Zoonotic Infectious Diseases 3 Includes PPHF funding for Immunization and Respiratory Diseases, HIV/AIDS and Emerging and Zoonotic Infectious Diseases Immunization and Respiratory Diseases Source FY 2012-2013: http://www.cdc.gov/fmo/topic/Budget%20Information/appropriations_budget_form_pdf/FY2013_CDC_Full-Year_CR_Operating_Plan.pdf Source FY 2009-2011: http://www.cdc.gov/fmo/topic/Budget%20Information/appropriations_budget_form_pdf/FY2014_CJ_CDC_FINAL.pdf, pg. 52 Source FY 2008: http://www.cdc.gov/fmo/topic/Budget%20Information/appropriations_budget_form_pdf/FY2013_CDC_CJ_Final.pdf, pg. 41 Source FY 2007: http://www.cdc.gov/fmo/topic/Budget%20Information/appropriations_budget_form_pdf/FY2012_CDC_CJ_Final.pdf, pg. 51 Source FY 2006: http://www.cdc.gov/fmo/topic/Budget%20Information/appropriations_budget_form_pdf/FY2011_CDC_CJ_Final.pdf, pg. 53 HIV/AIDS, Viral Hepatitis, STI and TB Prevention Source FY 2012-2013: http://www.cdc.gov/fmo/topic/Budget%20Information/appropriations_budget_form_pdf/FY2013_CDC_Full-Year_CR_Operating_Plan.pdf Source FY 2009-2011: http://www.cdc.gov/fmo/topic/Budget%20Information/appropriations_budget_form_pdf/FY2014_CJ_CDC_FINAL.pdf, pg. 74 Source FY 2008: http://www.cdc.gov/fmo/topic/Budget%20Information/appropriations_budget_form_pdf/FY2013_CDC_CJ_Final.pdf, pg. 60 Source FY 2007: http://www.cdc.gov/fmo/topic/Budget%20Information/appropriations_budget_form_pdf/FY2012_CDC_CJ_Final.pdf, pg. 70 Source FY 2006: http://www.cdc.gov/fmo/topic/Budget%20Information/appropriations_budget_form_pdf/FY2011_CDC_CJ_Final.pdf, pg. 73 Emerging and Zoonotic Infectious Diseases Source FY 2012-2013: http://www.cdc.gov/fmo/topic/Budget%20Information/appropriations_budget_form_pdf/FY2013_CDC_Full-Year_CR_Operating_Plan.pdf Source FY 2009-2011: http://www.cdc.gov/fmo/topic/Budget%20Information/appropriations_budget_form_pdf/FY2014_CJ_CDC_FINAL.pdf, pg. 108 Source FY 2006-2008: http://www.cdc.gov/fmo/topic/Budget%20Information/appropriations_budget_form_pdf/FY2011_CDC_CJ_Final.pdf, pg. 99 CDC OFFICE OF PUBLIC HEALTH PREPAREDNESS AND RESPONSE FUNDING TOTALS AND SELECT PROGRAMS FY 2002 FY 2003 FY 2004 FY 2005 FY 2006 FY 2007 FY 2008 FY 2009 FY 2010 FY 2011 FY 2012 FY 2013 CDC Total* $1,747,023,000 $1,533,474,000 $1,507,211,000 $1,622,757,000 $1,631,173,000 $1,472,553,000 $1,479,455,000 $1,514,657,000 $1,522,339,000 $1,415,416,000 $1,329,479,000 $1,231,859,000 State and Local Preparedness $940,174,000 $1,038,858,000 $918,454,000 $919,148,000 $823,099,000 $766,660,000 $746,039,000 $746,596,000 $760,986,000 $664,294,000 $657,418,000 $623,209,000 and Response Capability** SNS $645,000,000 $298,050,000 $397,640,000 $466,700,000 $524,339,000 $496,348,000 $551,509,000 $570,307,000 $595,661,000 $591,001,000 $533,792,000 $477,577,000 * CDC Total also includes CDC Preparedness **May include Public Health Emergency Preparedness (PHEP) cooperative agreements, All Other State and Local Capacity, Centers for Public Health Preparedness, Advanced Practice Centers (FY2004-09), Cities Readiness Initiative, U.S. Postal Service Costs (FY 2004), and Smallpox Supplement (FY 2003). CDC Funding Source: FY 2002-09: http://www.cdc.gov/phpr/publications/2010/Appendix3.pdf Source: FY 2010-11: U.S. Centers for Disease Control and Prevention. “2011 Operating Plan.” http://www.hhs.gov/asfr/ob/docbudget/2011operatingplan_cdc.pdf. Source: FY 2012-13: http://www.cdc.gov/fmo/topic/Budget%20Information/appropriations_budget_form_pdf/FY2013_CDC_Full-Year_CR_Operating_Plan.pdf NATIONAL INSTITUTES OF HEALTH (NIH)—INFECTIOUS DISEASE FY 2002 FY 2003 FY 2004 FY 2005 FY 2006 FY 2007 FY 2008 FY 2009 FY 2010 FY 2011 FY 2012 FY 2013 National Institute of Allergy and $2,367,313,000 $3,706,722,000 $4,304,562,000 $4,402,841,000 $4,414,801,000 $4,417,208,000 $4,583,344,000 $4,702,572,000 $4,818,275,000 $4,775,968,000 $4,486,473,000 $4,231,498,000 Infectious Diseases * In 2003 NIAID added biodefense and emerging infectious diseases (BioD) Source FY 2002-2011: http://officeofbudget.od.nih.gov/pdfs/FY12/Approp.%20History%20by%20IC%292012.pdf Source FY 2012-2013: http://officeofbudget.od.nih.gov/pdfs/FY14/POST%20ONLINE_NIH.pdf 18 TFAH • healthyamericans.org OFFICE OF ASSISTANT SECRETARY FOR PREPARDNESS AND RESPONSE FUNDING TOTALS AND SELECT PROGRAMS FY 2002 FY 2003 FY 2004 FY 2005 FY 2006 FY 2007 FY 2008 FY 2009 FY 2010 FY 2011 FY 2012 FY 2013 ASPR Totals -- -- -- -- $632,000,000 $694,280,000 $632,703,000 $788,191,000 $891,446,000 $913,418,000 $925,612,000 $897,104,000 HPP^ $135,000,000 $514,000,000 $515,000,000 $487,000,000 $474,000,000 $474,030,000 $423,399,000 $393,585,000 $425,928,000 $383,858,000 $379,639,000 $358,231,000 BARDA** -- -- -- $5,000,000 $54,000,000 $103,921,000 $101,544,000 $275,000,000 $304,948,000 $415,000,000 $415,000,000 $415,000,000 BioShield Special -- -- $5,600,000,000* -- -- -- -- -- -- -- -- -- Reserve Fund * One-time Funding Source: FY 2007: http://www.hhs.gov/budget/09budget/budgetfy09cj.pdf, p. 288 ^HPP moved from HRSA to ASPR in 2007 Source: FY 2008-09: http://www.hhs.gov/asfr/ob/docbudget/2010phssef.pdf, p. 8 ** BARDA has been funded via transfer from Project BioShield Special Reserve Fund balances Source: FY 2010-11: http://www.hhs.gov/asfr/ob/docbudget/2011operatingplan_ Source: HPP FY 2002: http://archive.hhs.gov/budget/04budget/fy2004bib.pdf, p. 14 phssef.pdf Source: HPP FY 2003: http://archive.hhs.gov/budget/05budget/fy2005bibfinal.pdf, p. 16 Source: FY 2012: http://www.hhs.gov/budget/safety-emergency-budget- Source HPP FY 2004:http://archive.hhs.gov/budget/06budget/FY2006BudgetinBrief.pdf, p. 16 justification-fy2013.pdf Source: HPP FY 2005: http://archive.hhs.gov/budget/07budget/2007BudgetInBrief.pdf, p. 20 Source: FY 2013: ASPR Operating Plan for FY 2013 Source: BARDA FY 2005-06: http://www.hhs.gov/asrt/ob/docbudget/2010phssef.pdf, p. 45. Source: FY 2006: http://www.hhs.gov/asfr/ob/docbudget/2008budgetinbrief.pdf, p. 109 Trends for Federal Funding of Infectious and Preparedness Programs Impact of Budget Cuts and Congressional Inaction 2013 was a year marked by limited to keep operating at existing levels. l T he government shutdown congressional action, a government However, without new funding, occurred during a foodborne shutdown, the implementation of the biotechnology industry does Salmonella outbreak and at the sequestration, and a series of short- not have the guarantee that the beginning of the 2013 flu season, term continuing resolutions (CRs) federal government will be a while many CDC epidemiologists to keep the government running reliable partner. The Office of the and investigators were furloughed.44 for weeks at a time. Each of these Assistant Secretary for Preparedness Gaps in surveillance and response conditions had a profound impact on and Response (ASPR) and expert capacity at the time could not be the ability of the public health and organizations such as the UPMC made up for when the government health systems to protect Americans. Center for Health Security have reopened, potentially putting Some examples of the effects of these reported that this unpredictability additional people at risk. events on public health include: could result in industry partners l C ongressional gridlock can delay abandoning MCM research and l U nreliable appropriations and a emergency response at critical development. failure to pass a long-term funding moments. For example, amid measure could hamper the l B etween sequestration and the debate over whether to offset funds, federal medical countermeasure government shutdown, biomedical Congress approved most Hurricane (MCM) enterprise. Funding for research funded by National Sandy relief money nearly three Project BioShield, which allows Institutes of Health and other months after the storm.45 In procurement of MCM products, federal agencies was delayed or comparison, the bulk of Hurricane and the Biomedical Advanced disrupted, including clinical trials. 42 Katrina relief funds were approved Research and Development The erosion of funding could have within 10 days of the disaster.46 Authority (BARDA), ran out at the a long-term impact on the research end of FY 2013. The short-term infrastructure, as scientists have CR passed in October included trouble finding funding or studies language that would allow BARDA are interrupted.43 TFAH • healthyamericans.org 19 RECOMMENDATIONS: Public Health Foundational Capabilities and Funding The public health system — comprised of channels of communications and resil- l E xploring new funding and business mod- federal, state and local departments — iency planning. The Transforming Public els to assure sufficient levels of funding must be modernized and funded at a level Health project also stresses the impor- to support foundational capabilities. The that allows it to fight both ongoing and tance of accountability and using tools federal government and states should newly emerging infectious disease threats. like accreditation to ensure standards develop a new financing system for public and baseline consistency. health that gives priority to foundational Currently, there are key elements of the capabilities and assures that every Ameri- system that are outdated or need in- l I ncreasing funding for public health at can is served by a health department creased support to be able to function the federal, state and local levels: To that has these capabilities. This can be more effectively. be able to carry out foundational capa- achieved through new funding mecha- bilities, federal, state and local health To achieve a more effective, efficient and nisms or by giving states more flexibility departments must receive a sufficient modern approach to combatting infectious with existing funding streams. Moderniz- level of funding, and some existing fund- disease threats, TFAH recommends that ing business practices and finding efficien- ing lines may need to be realigned. The health departments at the federal, state cies may require innovative approaches use of all federal public health funds, and local levels establish foundational such as regionalization, public-private part- and the outcomes achieved from the capabilities to ensure consistent, basic nerships and resource-sharing. use of funds, must be transparent and levels of protection across the country — clearly communicated with the public. l I ncreasing integration between public and public health departments at all levels Accreditation can be an important tool health departments and healthcare pro- must receive adequate funding to achieve to measure if states and localities are viders to help achieve maximum results these capabilities, including: meeting foundational capabilities. for improving health and containing l D efining, prioritizing and fully funding costs: As health systems are reforming, l E stablishing systems where public a set of foundational capabilities for they should be encouraged to incorpo- health departments should only pay public health departments at all levels rate public health and community-based for direct services when they cannot of government: Public health depart- prevention efforts into their systems. be paid for by insurance: The Afford- ments need the tools and skills that Integrating prevention and public health able Care Act (ACA) has expanded the are necessary to provide basic public with the larger healthcare system can be number of services covered by insur- protections while adapting to and ef- implemented in a variety of ways, includ- ance, including eliminating co-payments fectively addressing changing health ing through coordination between health- for recommended vaccinations under threats. The IOM and the Transform- care providers and existing public health new group and individual plans for ing Public Health project, funded by programs and departments. And, public in-network providers and for the Med- the Robert Wood Johnson Foundation health departments must adapt to work icaid expansion population. Public (RWJF), identified key foundational capa- with new entities and financing mecha- health departments that provide direct bilities.47, 48 Two states, Washington and nisms in the reformed health system, services should make sure they have Ohio, have begun their own assessment such as by working with Accountable Care systems in place to be able to bill an of foundational capabilities.49 Some of Organizations (ACOs) or within new capital- individual’s insurance provider, so they the most important aspects for prevent- ized care structures and global health bud- do not use their public health budgets ing and controlling infectious diseases gets, to help improve health beyond the to pay for services that should be billed include: modern, integrated, interoper- doctor’s office. These relationships need to insurers. Some states already have able real-time surveillance capabilities; to be carefully negotiated, particularly in these systems in place for some ser- a trained, expert workforce; strong the areas of infectious disease control vices, including billing for vaccinations. communication and coordination among (see, for example, discussion of prepared- However, sensitive services, such as public health departments, healthcare ness and TB in the following sections) be- those for STDs, should be monitored to providers and other government officials cause of the unique responsibility health ensure that people do not avoid seeking at all levels of government; and engage- departments have to stop the spread of these crucial prevention services due to ment with the community including on- communicable diseases, while the health confidentiality concerns. going clear, honest, culturally-sensitive system can and should be treating them. 20 TFAH • healthyamericans.org Tracking Disease Threats: Biosurviellance One of the most fundamental compo- tion Program (EIP), Environmental nents of infectious disease prevention Public Health Tracking Network, and control is the ability to identify new Epidemic Information Exchange outbreaks and track ongoing outbreaks. (Epi-X), GeoSentinel, Global Disease Detection and National Outbreak Currently, the United States lacks an Reporting System (NORS). integrated, national approach to biosur- veillance — which limits the rapid de- l W ithin each state there are also often tection and tracking of diseases. There more than a dozen health surveillance are more than 300 different health sur- systems that work independently and veillance systems or networks supported voluntarily feed data to the corre- by the federal government. 50 These sponding national network at CDC. efforts, for the most part, are neither l I n addition, other federal agencies integrated nor interoperable, and serve and departments have their own an array of purposes. biosurveillance systems, including the l A t a federal level, CDC runs the ma- Environmental Protection Agency jority of national human health sur- (EPA), the Department of Homeland veillance networks. Some of these Security (DHS), the Department of include: the Arboviral Surveillance Agriculture (USDA), the Food and System (ArboNet), BioSense, Early Drug Administration (FDA), the Warning Infectious Disease Surveil- Department of Veterans Affairs (VA), lance (EWIDS), Electronic Food- the Department of Defense (DOD) Borne Disease Outbreak Reporting and the Office of the Director of System (eFORS), Emerging Infec- National Intelligence (ODNI). TFAH • healthyamericans.org 21 RECOMMENDATIONS: Modernizing Biosurveillance Biosurveillance needs to be dramatically upgraded to take advantage of new tential to provide public health officials improved to become a true real-time, in- technological advances. For instance, with data in real time and offer two-way teroperable system, able to quickly identify technologies to make point-of-care (POC) communication between healthcare pro- outbreaks and threats and implement diagnostics increasingly available would viders and health departments. This containment and treatment strategies. greatly improve care and screen patients can provide health departments with Advances in health information technology who truly need attention during mass better, faster data to track outbreaks (HIT) and electronic health records (EHRs) emergencies and Advanced Molecular and let providers know about risks to provide new opportunities to integrate Detection (AMD) technologies hold the their patients in a more timely way. The and improve systems. TFAH recommends promise of building molecular sequenc- Office of the National Coordinator for full implementation of the 2012 National ing and bioinformatics capacities, al- Health Information Technology (ONC) Biosurveillance Strategy and the 2013 Na- lowing public health to rapidly look for must work with software developers, tional Biosurveillance and Technology Road- a pathogen’s match, saving time and public health and providers to ensure map. Implementation should include: 51 money in identifying an outbreak. 52,53 information exchange is feasible and accessible while maintaining patient pri- l M odernizing and integrating systems: Some key public health benefits of AMD vacy. Governmental agencies should The current structure of 300 separate could include: set standards for data, identify what biosurveillance systems is untenable • ore rapid and accurate disease M health information is most relevant for in a modern era of HIT. The federal diagnoses; public health purposes and ensure that government should work to upgrade • nhanced recognition of antimicrobial E public health agencies have ready ac- systems to the latest technologies to resistance; cess to these data and the capacity to allow for real-time and interoperable • etter targeting of prevention and B analyze information. tracking of diseases — to more efficiently collect and analyze data, to treatment measures; l C onnecting disease tracking and better identify threats and to understand • mproved surveillance information on I community resilience: Traditionally, how threats can be interrelated. the transmissibility of infections and tracing of infectious and chronic the extent and spread of outbreaks; diseases has been siloed. There is an • t a state and local level, many health A • aster and more effective disease F increasing recognition of the importance departments still lack the basic hard- control efforts; and of understanding how underlying health ware, software and staff training to be make some individuals and groups able to receive and interpret data from • educed diagnostic costs in the future.  R more vulnerable to disease outbreaks electronic health records or to be able to For example, states would no longer and health disasters. Better tracking integrate or upgrade systems. Support need to submit lab cultures to CDC to of the health of communities through for building and maintaining baseline ca- identify outbreak pathogens. health information exchanges, ACOs pabilities should be a high priority. l L everaging Health Information Tech- and other systems can help identify less l S upporting new technological ad- nology: The increased widespread and healthy areas to help target resources vances: Even the most developed consistent use of EHRs and electronic and special response efforts during systems at CDC must continually be laboratory reporting (ELR) have the po- outbreaks and diseases. 22 TFAH • healthyamericans.org SECTI O N 2: Vaccine- SECTION 2: VACCINE-PREVENTABLE DISEASES Vaccine-Preventable Diseases Vaccines are the safest and most effective way to manage Preventable many infectious diseases in the United States. Some of Diseases the greatest public health successes of the past century — including the worldwide eradication of smallpox and the elimination of polio, measles and rubella in the United States — are the result of successful vaccination programs.54 But, despite the recommendations of Many Americans are not receiving the medical experts that vaccines are effective recommended vaccinations. For instance, and that research has shown vaccines to adult coverage remains low for most rou- be safe, on average, an estimated 45,000 tinely recommended vaccinations and adults and 1,000 children die annually many preschool children (aged 19 to 35 from vaccine-preventable diseases in the months) and teens do not receive all the United States.55 recommended vaccinations.56, 57 DECEMBER 2013 l reschooler Immunization Gap P Vaccines are among the most cost-effec- In recent years, there have been a The failure to vaccinate all tive clinical services to prevent diseases number of outbreaks of vaccine- preschoolers with all of the among children and also provide a very preventable diseases among children, high return on investment. Each birth including measles and whooping recommended immunizations cohort vaccinated with the routine im- cough. For instance, measles, a highly on time leaves 2.1 million munization schedule saves 33,000 lives, contagious, viral illness that can young children unnecessarily prevents 14 million cases of disease, lead to health complications, such vulnerable to preventable reduces direct healthcare costs by $9.9 as pneumonia and encephalitis, and billion and saves $33.4 billion in indirect eventually death, was declared to be illnesses.58 costs for a total of $42.4 billion in savings virtually eliminated in the United due to vaccinations.59 Worldwide, vacci- States as of 2000, with around 60 Childhood Vaccinations are Responsible for nations prevent an estimated 2.5 million reported cases each year. However, Significant Healthcare Cost Savings childhood deaths annually.60 individuals traveling from outside Total Savings the country continued to import the Requirements for vaccinations before at- $42.4 billion tending school mean around 95 percent disease. Unvaccinated individuals are far more likely to contract measles of school-aged children receive vaccina- than those who have been vaccinated. tions — but there is a much bigger gap Indirect Savings From January through November in preschooler vaccination rates. $33.4 billion 2013, 175 measles cases were reported The immunization rates were higher in the United States, including the for some of the recommended largest measles outbreak in more than vaccines than others. For instance, a decade with 58 cases reported in New coverage remained above the Healthy York City.62 An investigation found People 2020 target of 90 percent for that more than one-quarter of those measles, mumps and rubella (90.8 infected got measles in other countries Direct Healthcare percent); poliovirus (92.8 percent); and brought the disease to the Cost Savings rotavirus (69 percent); and varicella United States and spread it to others. $9.9 billion (90.2 percent), according to the 2012 However, most of the cases were in National Immunization Survey. persons who were unvaccinated (82 percent) or had unknown vaccination However, not all vaccination rates status (9 percent).63 Whooping cough reached the Healthy People 2020 target outbreaks which began in 2012 have of 90 percent, including hepatitis B infected more than 48,000 individuals (89.7 percent); diphtheria, tetanus and caused 18 deaths.64 This is the and whooping cough (82.5 percent); highest number of cases of whooping pneumococcal (81.9 percent); and cough since 1955.65 the childhood full series 4:3:1:3:3:1:4 (68.4 percent).61 24 TFAH • healthyamericans.org l een Immunization Gap T The Advisory Committee on receiving the MCV4 and HPV vaccines, Immunization Practices (ACIP), the which puts teens at risk for HPV and American Academy of Pediatrics bacterial meningitis infections. In (AAP) and the American Academy 2012, vaccination coverage among of Family Physicians (AAFP) teens between the ages of 13 and recommends four routine vaccinations 17 years was about 85 percent for at for adolescents (ages 11 to 18), least one dose of Tdap vaccine, 74 including Tetanus and diphtheria percent for at least one dose of MCV4 toxoids and acellular pertussis vaccine vaccine, 75 percent for 2 doses of (Tdap), HPV vaccine, Meningococcal varicella vaccine, and, among males, conjugate vaccine, quadrivalent 21 percent for at least one dose of (MCV4) and for the seasonal flu.66 HPV vaccine and 54 percent for Vaccinating children and teens against females. Only 33 percent of female diseases like hepatitis A, pneumonia teens received all three recommended and the flu not only protects the doses of the HPV vaccine series in children themselves, it is also the most 2012. One recent study also suggests efficient way to protect adults and the how HPV vaccinations for both males entire population, since it limits the and females can provide protection spread of these diseases. to the wider community, by not just protecting the individual but The recommended medical practice is by reducing the risk of spreading that teens should receive their Tdap, illnesses to others. A 2013 study in MCV4 and the first HPV vaccine dose Pediatrics found that Tdap vaccinations during a single visit. However, the in adolescents may be partially 2012 National Immunization Survey- effective in reducing whooping cough Teen (NIS-Teen) vaccination coverage hospitalizations among infants.67 data show that many teens are not TFAH • healthyamericans.org 25 l dult Immunization Gap A Millions of American adults go caregivers. Also, Americans who travel without routine and recommended to certain foreign countries may need vaccinations. The result is thousands vaccines to protect against diseases of deaths from seasonal flu, invasive that exist in those regions but are not pneumonia, the effects of hepatitis prevalent in the United States. B and other infectious diseases that According to the National Health could have been prevented if more Interview Survey, 2011:69 adults were vaccinated.68 • Only 12.5 percent of eligible Adults need vaccinations for new dis- adults (19 to 64 years old) had the eases and “booster” shots for diseases tetanus, diphtheria, and whooping that they were vaccinated against as cough vaccine (The HPV vaccine is children, because their immunity may recommended for males through wane over time. In addition, new vac- the age of 20 and is optional for cines are being developed against old men 21 to 26 years old); diseases, and adults can benefit from • Just under 16 percent of older these vaccines as they become available. patients (60 and over) ever had the Vaccinations against diseases, such shingles vaccine; as pneumonia and influenza, are • Only 29.5 percent of eligible adult especially important for people at high women (19 to 26 year olds) had the risk, including those suffering from HPV vaccine; and chronic illnesses such as heart disease, • Only 62.3 percent of seniors had pulmonary disease, diabetes, alcoholism the pneumococcal vaccine, which is or chronic liver disease (cirrhosis), far short of the CDC’s goal of a 90 and for healthcare professionals and percent vaccination rate.70 26 TFAH • healthyamericans.org Some reasons attributed to the childhood, teen and adult vaccination gaps include: l imited Data Sharing: An L cost sharing for in-network providers under-funded and underutilized for recommended vaccinations for immunization registry system for both adults enrolled in group and indi- childhood and adult vaccinations vidual plans or are part of Medicaid and failure to integrate into evolving expansion, but co-pay requirements electronic health records systems, for the base Medicaid population including the inability to share continue to vary on a state-by-state immunization data across state lines. basis. Medicare does not consis- tently provide first collar coverage l imited access for adults:  Currently, L for vaccines, and the different poli- there is no real system or structure cies for what is covered under part in place to ensure adults have access B and Part D leaves many seniors to or receive the vaccines they need with gaps in coverage. Beneficiaries unless they are part of institutions can get their flu, pneumonia and that have vaccine requirements, HBV (for at-risk individuals) vaccine such as being enrolled in colleges or covered under Medicare Part B, but universities, serving in the military an out-of-pocket payment may be re- or working in a healthcare setting. quired, depending on the shot and Significant numbers of adults do provider. The rest of the recom- not have regular well care exams, mended vaccines are covered under switch doctors or health plans often Medicare Part D, the prescription or only seek care from specialists drug benefit, so the patient must who do not traditionally screen for find a provider who accepts Part D immunization histories or offer and carries the needed vaccine. vaccines, which makes it extremely difficult to set up ways for people l isunderstanding and M to know what vaccinations they misinformation: Many adults and need and for doctors to track and parents are misinformed about the recommend vaccines to patients. safety and effectiveness of vaccines. Many states allow children to opt-out l imited care and insurance cover- L of school-required vaccinations for age: Historically, limits on health religious or philosophical reasons, insurance coverage and high costs in addition to medical exemptions. have traditionally been an obstacle. The ACA now requires no co-pay or TFAH • healthyamericans.org 27 INDICATOR 2: WHOOPING 2 states and D.C. met the HHS goal of vaccinating 90 48 states did not meet the HHS goal of vaccinating percent of 19- to 35-month-olds against whooping 90 percent of 19-to 35-month-olds against whooping COUGH VACCINATIONS cough (1 point). cough (0 points). Connecticut (91.3%) Alabama (84.8%) Nebraska (84.5%) Delaware (90.9%) Alaska (79.4%) Nevada (81.0%) KEY FINDING: Only two states D.C. (90.7%) Arizona (82.7%) New Hampshire (88.7%) Arkansas (79.8%) New Jersey (84.7%) and D.C. met the HHS goal of California (81.6%) New Mexico (87.0%) Colorado (82.8%) New York (83.8%) vaccinating 90 percent of 19- to Florida (83.3%) North Carolina (85.9%) Georgia (86.7%) North Dakota (85.1%) 35-month-olds against whooping Hawaii (87.9%) Ohio (83.3%) Idaho (76.7%) Oklahoma (79.1%) cough (four or more doses of any Illinois (85.3%) Oregon (81.2%) Indiana (76.8%) Pennsylvania (80.1%) diphtheria and tetanus toxoids Iowa (88.2%) Rhode Island (89.0%) Kansas (79.0%) South Carolina (80.9%) and pertussis vaccines including Kentucky (83.0%) South Dakota (79.2%) Louisiana (77.8%) Tennessee (82.0%) diphtheria and tetanus toxoids, Maine (87.9%) Texas (77.4%) Maryland (83.2%) Utah (80.5%) and any acellular pertussis Massachusetts (88.2%) Vermont (86.0%) Michigan (81.5%) Virginia (82.7%) vaccine (DTaP/DTP/DT)). Minnesota (84.2%) Washington (84.0%) Mississippi (83.6%) West Virginia (79.1%) Missouri (81.9%) Wisconsin (87.8%) Montana (86.6%) Wyoming (79.4%) This indicator examines how well The ability to regularly vaccinate states vaccinate children against Americans, particularly children, is pertussis (whooping cough). Only an important measure for how well two states, Connecticut and Delaware, the system can effectively reach and and Washington, D.C. met the goal encourage vaccinations among the set by HHS in the Healthy People public. The need for this capability 2020 of vaccinating 90 percent is amplified during a time of crisis, of children ages 19 to 35 months when it is often necessary to reach against pertussis. 71 Connecticut and encourage mass segments or the had the highest rate of vaccinations whole population of a community to at 91.3 percent, while Idaho had get vaccinated against a new threat on the lowest at 76.6 percent. Eleven a time-sensitive schedule. states had rates below 80 percent. Pertussis, commonly known as The national average in 2012 was whooping cough, is a highly 82.5 percent. Meeting vaccination contagious bacterial respiratory rate goals serves as a marker for the infection that can be fatal in infants. ability to protect the population from Early symptoms mirror those of infectious diseases, and a part of this a cold, but infection progresses role involves the ability to effectively into a severe cough that can affect communicate about the importance, breathing. The best way to prevent safety and efficacy of vaccinations. pertussis is through vaccination.72 28 TFAH • healthyamericans.org In 2012, the majority of states saw States with an incidence of pertussis the same or higher than the national incidence in 2012, which is 13.4/100,000 persons. 80 increases in the number of pertussis Wisconsin 104.9 Montana 44.3 Oregon 23.3 cases, as compared with 2011, and the Vermont 100.6 Alaska 43.3 New Hampshire 16.4 Washington 67.4 Minnesota 40.8 Illinois 14.5 United States has not seen this many North Dakota 54.4 New Mexico 35.7 Pennsylvania 14.5 cases since 1955.73 Through 2012, Iowa 53.5 Colorado 28.9 Idaho 14.3 over 41,880 cases and 18 deaths (most Maine 52.9 Kansas 25.5 Missouri 14.2 Utah 47.5 New York 23.6 Arizona 14.1 in infants younger than three months) were reported to CDC.74 Rates have also the majority of states have reported increased in children ages 7 to 10 and fewer cases of pertussis in 2013 to-date, in adolescents ages 13 to 14. 75 Observa- but 13 states and Washington, D.C. tional studies suggest these outbreaks in have reported an increase compared children and adolescents may be a result with the same time during 2012.81 of early waning of immunity due to re- The Section 317 Immunization Pro- formulated vaccine in 1997.76 However, gram, which supports grants to states for some experts believe that reduced vac- vaccinating underinsured children and cination rates may also be a contributing adults, received some additional fund- factor. A 2013 study by the FDA found ing through the Prevention and Public that acellular pertussis vaccines licensed Health Fund and American Recovery by the FDA are effective in preventing and Reinvestment Act. The program in- the disease among those vaccinated, cludes support for vaccine purchase and but suggests that they may not prevent infrastructure. However, recent reduc- infection from the bacteria that causes tions to the Prevention Fund and CDC whooping cough in those vaccinated funding have dropped the 317 program or its spread to other people, including funding below FY 2011 levels. Appro- those who may not be vaccinated.77 priations have also not kept up with the Several states allow parents to refuse cost increase of additional vaccine rec- vaccination for their children based ommendations according to CDC. A FY on personal or philosophical reasons, 2012 CDC report to Congress outlined and many of those states, including that the 317 program needs about $914 Wisconsin and Washington have seen million to fully achieve its mission, about the largest spikes in incidence. In $350 million above the President’s communities facing an outbreak, reports FY2013 request.82 Meanwhile, National have shown the response is far more Association of County and City Health costly than preventive action would have Officials (NACCHO) reports that 20 been, costing a local health department percent of local health departments cut over $2,000 per case, compared to a few immunization programs in 2012, while dollars per dose of vaccine.78, 79 nearly a third of states and territories reduced vaccine programs as a result of In 2013 (as of October 19, 2013), there budget cuts, according to ASTHO.83, 84 have been 18,553 reported cases of These programs help ensure all Ameri- pertussis in the United States. Overall cans have access to vaccinations. TFAH • healthyamericans.org 29 INDICATOR 3: HUMAN 25 states and D.C. require the HPV vaccine, education 25 states do NOT require the HPV vaccine, education for parents or guardians about the HPV vaccine, or for parents or guardians about the HPV vaccine, or PAPILLOMAVIRUS fund HPV vaccinations (1 point). fund HPV vaccinations (0 points). IMMUNIZATION POLICIES Colorado New Hampshire Alabama Mississippi D.C. New Mexico Alaska Montana Idaho New York Arizona Nebraska Illinois North Carolina Arkansas New Jersey Key Finding: 25 states and Indiana North Dakota California Ohio Iowa Oregon Connecticut Oklahoma Washington, D.C. require the Louisiana Rhode Island Delaware Pennsylvania Maine South Dakota Florida South Carolina HPV vaccine, education for Maryland Texas Georgia Tennessee Michigan Utah Hawaii Vermont parents or guardians about Minnesota Virginia Kansas West Virginia Missouri Washington Kentucky Wyoming the HPV vaccine, or fund HPV Nevada Wisconsin Massachusetts vaccinations. Source: National Council of State Legislatures, as of November 2013 This indicator examines which states In June 2006, the ACIP recommended have passed school vaccination that all 11 or 12 year old girls be policies to support HPV vaccinations. vaccinated against HPV; the vaccine was also recommended for older girls Approximately 79 million Americans and women through age 26 years who are currently infected with HPV, and had not yet received any or all vaccine about 14 million people are newly doses. In 2011, ACIP extended the infected each year.85, 86 Most cases of recommendation to also include 11 HPV do not produce any symptoms or 12 year old boys; the vaccine was — but the virus is responsible for also recommended for older boys and nearly every case of cervical cancer, men through age 21 years who had genital warts and the majority of not yet received any or all vaccine oropharyngeal (middle of the throat) doses.88 The AAP also recommends cancers in the United States. There the vaccination for both males and are approximately 12,000 new cases females at 11 or 12 years of age.89 of cervical cancer, 4,000 deaths from cervical cancer and 7,500 cases of Although ACIP has recommended oropharyngeal cancer each year. 87 routine vaccinations of girls at ages Cervical cancer is the second leading 11 or 12 since 2006, by 2012 only cancer killer of women. There is 33.4 percent of girls aged 13 to 17 no treatment for HPV, but there is a had received the recommended vaccination to prevent the virus. three doses of the vaccine.90 More 30 TFAH • healthyamericans.org than half of girls received at least one time has found the HPV vaccine to dose of the vaccine, but three doses be safe based on available data.94 A are recommended. Rates increased recent large scale study in Sweden and dramatically since 2007 when only 5.9 Denmark followed girls vaccinated percent of girls received three doses, in both countries from 2006 to 2010 but rates have leveled off around 33 totaling almost 700,000 doses of HPV percent since 2010. and also found the vaccine to be safe. The authors report that the “HPV School vaccination policies are typi- vaccine firmly indicates that concern cally decided by state legislatures or about vaccine related adverse events state health departments. If they is not a rational reason to forgo this are decided by health departments, potentially lifesaving vaccine.”95 A they still require state funding from number of studies have also found legislatures to support the policy. 91 no association between the HPV vac- In Australia, where they have a cine and risky sexual behavior.96 A school-based vaccination program, 2013 study in Pediatrics found that the more than 1.9 million doses of the HPV vaccination in recommended HPV vaccine were delivered to 12 ages was not associated with increased to 17 year olds, resulting in 70 per- sexual activity.97 The ACA requires cent of girls in this age group being coverage of all ACIP recommended fully vaccinated. 92 vaccinations without co-payments for According to a review by the National all group and individual plans and for Conference of State Legislatures the Medicaid expansion population. (NCSL), there has been ongoing CDC has made the HPV vaccine avail- debate about the vaccine in many able through the Vaccines for Chil- states. For instance, “some people dren (VFC) program in all 50 states. who support availability of the vaccine Since 2006, at least 41 states and do not support a school mandate, cit- Washington, D.C. have introduced ing concerns about the drug’s cost, legislation related to the vaccine. safety and parent’s right to refuse.”93 Twenty-five states and Washington, Multiple studies have found the HPV D.C. have enacted legislation or vaccine to be safe. The WHO global requirements. Some states can advisory committee on vaccine safety change school immunization policy has reviewed HPV vaccines four times, through a regulatory process. most recently in June 2013, and each TFAH • healthyamericans.org 31 HPV Genital HPV is the most common sexually (cancer of the vulva, vagina, penis, or transmitted infection (STI) and a major anus), and a type of head and neck cause of cervical, genital and oropharyn- cancer called oropharyngeal cancer geal cancer. 98 Ninety percent of HPV in- (cancer in the back of throat, including fections go away by themselves within two the base of the tongue and tonsils); years, but, for some, HPV infections will l G enital warts (warts on the genital persist and can cause a variety of serious areas); and health problems such as:99 l R ecurrent respiratory papillomatosis l C ervical cancer, cancer on a woman’s cervix; (RRP), a rare condition in which warts l O ther, less common, but serious grow in the throat. cancers, including genital cancers Support for Vaccines for the Medicaid Population Under the ACA, all individuals covered to expand coverage of recommended by new group or individual health plans vaccinations without co-pays to their or are part of Medicaid expansion base Medicaid population, the ACA allows are covered for all vaccinations the Centers for Medicare and Medicaid recommended by ACIP without any co- Services (CMS) to offer states a 1 percent payment or cost-sharing requirements. Federal Medical Assistance Percentage This eliminates an added cost burden (FMAP) increase for these services. The for individuals — and by increasing the Medicaid program typically provides numbers of people vaccinated overall, certain levels of matching payments to helps protect the wider population by states for different types of medical care. limiting the spread of disease. As of December 2013, only five states States, however, are not required to have expanded coverage to allow all of eliminate co-pays for vaccinations for the Medicaid beneficiaries to get all the their existing or base adult Medicaid medically recommended vaccinations beneficiaries. Any given state can decide without co-pays. Medicaid-eligible policies for their coverage of different children can receive vaccinations through vaccinations. To help incentivize states the VFC at no cost. 32 TFAH • healthyamericans.org RECOMMENDATIONS: Increasing Vaccination Rates and Improving Research and Development of New Vaccines Improving the nation’s vaccination rates medical societies and medical and source of information to ensure would help prevent disease, mitigate nursing schools should support that immunizations are up-to-date suffering and reduce healthcare costs. ongoing education and expanded — for both children and adults — TFAH recommends a number of actions curricula on vaccines and vaccine- and duplicative immunizations are that can be taken to increase vaccina- preventable diseases, and expand avoided. Lifespan registries would tion rates for children, teens and adults standard practice for providers also help better track patients’ around the country, including: to discuss and track vaccination medical history to ensure they have histories for all patients — including received all needed vaccinations l I ncreasing public education adults — and offer vaccinations to throughout their lives. Providers campaigns about the safety and adults during other doctor and hospital should take advantage of electronic effectiveness of vaccines: Federal, visits. The National Vaccine Advisory health records or immunization state and local health officials, in Committee (NVAC) has recommended registries to improve information partnership with medical providers including expansion of vaccination sharing across providers and to and community organizations, services offered by pharmacists generate reminders to providers and should conduct assertive and other community immunization patients when their recommended campaigns about the importance of providers, vaccination at the routine vaccinations should be given. vaccines, particularly stressing and workplace, and increased vaccination State health information exchanges demonstrating the safety and efficacy by providers who care for pregnant can make this process simpler by of immunizations. Targeted outreach women. 102 A routine adult vaccination integrating registries into electronic should be made to high-risk groups schedule should be established, health records, and streamlined and to racial and ethnic minority where healthcare providers are solutions should be found to enable populations where the misperceptions expected to purchase, educate, advise immunization information systems about vaccines are particularly and administer immunizations to (IIS) data exchange between states. high.100 The Community Preventive patients. The Community Preventive The Community Preventive Services Services Task Force, which evaluates Services Task force also found that Task Force recommends immunization the available evidence base for public when provider education is combined information systems on the basis of health programs and strategies, with other interventions, it can strong evidence of the effectiveness has found that when education is help increase vaccination rates.103 of increasing vaccination rates.104 combined with other intervention Providers should be incentivized to components, these interventions were l E nsuring first dollar coverage of stock and administer vaccines. effective in improving vaccination all recommended vaccines under rates.101 States should make it more l B olstering immunization registries Medicare: Vaccines recommended by difficult to opt-out of recommended and tracking: Measures must ACIP should be covered under both vaccinations. be taken to encourage greater Medicare Part B and Part D without participation by healthcare providers, cost sharing, to ensure complete, l I ncreasing provider education and particularly private providers, in equitable access to vaccines for all standards of care: Professional registries, which are a crucial Medicare beneficiaries. TFAH • healthyamericans.org 33 RECOMMENDATIONS: Increasing Vaccination Rates and Improving Research and Development of New Vaccines (continued) l C ontinuing support for vaccine fund- new vaccines, such as a universal flu demiology of American (SHEA) and the ing programs: While the ACA expands vaccine, and to help assure adequate Pediatric Infectious Diseases Society no-cost coverage of recommended vac- supplies of vaccines, especially in times (PIDS) support universal immuniza- cines to most Americans, the VFC and of crisis. Stabilizing the market includes tion of healthcare personnel (HCP) by Section 317 programs will continue assuring vaccines will be purchased healthcare employers (HCE) as recom- to provide a safety net for individuals once produced, such as by government mended by ACIP for HCPs. According who are uninsured, have “grandfa- guarantee purchase agreements. to a joint policy statement by the three thered” plans that do not cover these Societies, although some voluntary l E xpanding school vaccination require- vaccinations or remain outside of the HCP vaccination programs have been ments to include the HPV vaccine: traditional healthcare system, such effective when combined with strong ACIP has acknowledged the strong evi- as children who are eligible but not institutional leadership and robust dence that the HPV vaccine can greatly enrolled in Medicaid/State Children’s educational campaigns, mandatory reduce an individual’s risk for devel- Health Insurance Program (SCHIP). immunization programs are the most oping cervical cancer, but it can also The Community Preventive Services effective way to increase HCP vaccina- stop the spread of the virus that puts Task Force has identified a number of tion rates. As such, when voluntary others at risk. HPV-associated oropha- evidence-based strategies that have programs fail to achieve immunization ryngeal cancers are increasing nation- been effective in increasing vaccina- of at least 90 percent of HCP the Soci- , ally. Medical experts recommend the tion rates in younger children, includ- eties support HCE policies that require vaccine be given to preteens, both ing vaccination programs in Women, HCP documentation of immunity or boys and girls, so it does not have any Infant and Children (WIC) Program set- receipt of ACIP-recommended vaccina- direct correlation to the time when an tings, vaccination programs in schools tions as a condition of employment, individual becomes sexually active. and organized childcare centers and unpaid service, or receipt of profes- home visits. 105, 106, 107 VFC and Sec- l F acilitating the expansion of settings sional privileges. For HCP who cannot tion 317 are the two existing national where vaccinations can be given and be vaccinated due to medical contra- vaccine funding programs. can receive adequate reimbursement: indications or because of vaccine sup- Increase the use of pharmacies, ply shortages, HCEs should consider, l P roviding adequate support for the pur- schools, workplaces, faith-based orga- on a case-by-case basis, the need for chase and administration of vaccines: nizations in providing vaccines. These administrative and/or infection control The cost to fully immunize children and types of settings should be linked to measures to minimize risk of disease adults continues to rise, due to the in- the IIS so that data can be shared transmission (e.g., wearing masks dur- creasing costs to research and develop with primary providers. ing influenza season or reassignment the new highly effective vaccines. away from direct patient care). The Soci- l R equiring universal immunization of l S upporting additional research for vac- eties also support requiring comprehen- health care personnel for all ACIP cines: Sufficient funding and increased sive educational efforts to inform HCP recommended vaccinations: The In- market incentives must be in place to about the benefits of immunization and fectious Diseases Society of American support vaccine development and pro- risks of not maintaining immunization. (IDSA), the Society for Healthcare Epi- duction to encourage development of 34 TFAH • healthyamericans.org Vaccine Safety Vaccines go through rigorous review Public health officials and scientific and testing for effectiveness and safety researchers continue to stress the by the FDA before they are released to importance of parents vaccinating their the market. The safety of vaccines is children. By choosing to delay or skip also tracked post-FDA licensure through vaccinations parents put both their own several monitoring systems to keep children, and the children of others, at track of potential patterns of adverse greater risk of illness and death.113 side effects. The Vaccine Adverse Event Reporting System (VAERS) is a joint CDC and FDA program that works with manufacturers, healthcare providers, and members of the public to report possible adverse events that people experience following vaccinations.108 In addition, the Vaccine Safety Datalink (VSD) project is a collaboration between CDC’s Immunization Safety Office (ISO) and eight large managed-care organizations to monitor safety and answer scientific questions about vaccine side effects.109 There have been numerous independent studies confirming the safety of recommended childhood vaccines. In 2004, the Institute of Medicine released its eighth report from the Immunization Safety Review Committee, which concluded vaccines, specifically the MMR vaccine and thimerosal-containing vaccines, do not have any causal link to autism.110 The most recent study, released in March 2013 in the Journal of Pediatrics, also found no link between childhood vaccines and autism.111 Researchers from CDC concluded that even when giving multiple vaccinations on the same day, there is no association to a higher risk of developing autism.112 TFAH • healthyamericans.org 35 Routine Vaccine Preventable Diseases l D iphtheria: Diphtheria is a serious bac- l H epatitis B: In the United States, l M easles: As a result of widespread vac- terial disease that frequently causes an estimated 800,000 to 1.4 million cination, measles is no longer endemic heart and nerve problems. Without persons have chronic Hepatitis B virus in the United States. However, because treatment, 40 to 50 percent of infected infection. More than 90 percent of in- measles is still widespread in many persons die, with the highest death fected infants and up to 10 percent of countries, the United States is at risk of rates occurring in the very young and infected adults develop chronic infec- importation of the disease from interna- the elderly. Diphtheria has largely been tion, increasing chances for chronic liver tional travelers and from U.S. residents eradicated in the United States and disease, cirrhosis and liver cancer. Hep- who travel abroad, and if high immunity other industrialized nations through atitis B-related liver disease kills about is not maintained in adults and children, widespread vaccination. There were 5,000 people and costs $700 million there is a risk of re-establishment of en- only seven reported cases of diphtheria annually in healthcare and productivity- demic transmission. Measles is highly between 1998 and 2009 in the United related costs.117 contagious. Each year, on average, 60 States.114 However, children and adults people in the United States are reported l H uman Papillomavirus: HPV is the who travel to endemic areas are still at to have measles. But so far in 2013 the most common STI and is a major cause risk for diphtheria. number is significantly higher—from Jan- of cervical and oropharyngeal (middle uary 1 to August 24, 2013, 159 people l H aemophilus influenza type b (Hib): of the throat) cancer. Approximately 79 have been reported to have the disease. Prior to the vaccine, Hib meningitis killed million Americans currently are infected This is the second largest number of 600 children each year and caused sei- with HPV, and another 14 million people cases in the U.S. since measles was zures among many survivors as well as become newly infected each year.118 The eliminated in 2000.120 permanent deafness and mental retar- HPV vaccine includes protection against dation. Since the vaccine’s introduction the two HPV strains that cause 70 l M eningococcal disease: Meningo- in 1987, the incidence of serious Hib percent of all cervical cancers. coccal disease is a serious bacterial bacteria infection has declined by 98 illness, and is a leading cause of bacte- l I nfluenza: Many illnesses are percent in the United States. rial meningitis in children 2 through 18 erroneously called “flu.”  These include years old in the United States. About l H epatitis A: In 2011, there were 2,000 respiratory as well as gastrointestinal 1,000 people get meningococcal dis- hepatitis A infections reported in the disorders and can be caused by a ease each year in the United States United States.115 From 2007 to 2010, it variety of infectious agents.  Influenza, and 10 percent to 15 percent of these resulted in between 70 to 100 deaths. however, is a specific respiratory people die. Infants, the elderly, young Hepatitis A disease tends to occur in infection caused by influenza viruses.  college students living in dormitories outbreaks sometimes attributed to many Influenza vaccine protects against and military recruits living in barracks people having eaten the same contami- influenza, not the other disorders. are especially vulnerable. nated food or transmission from person In an average year, influenza causes to person after exposure to hepatitis A approximately 3,000 to a high of about l M umps: Prior to the mumps vaccine, on in an endemic country. CDC confirmed 49,000 deaths and may contribute to average 200,000 mumps cases were re- an outbreak of 162 people ill with Hepa- approximately 200,000 hospitalizations ported in the United States per year with titis A in the United States in 2013. 116 in the United States. 119 20 to 30 deaths. Since a second dose 36 TFAH • healthyamericans.org of mumps vaccine was added to the l R otavirus: Rotavirus is a disease of the stant rate due to the widespread use standard childhood immunization series, digestive tract. Infection causes acute of tetanus toxoid–containing vaccines annual cases are now in the hundreds gastroenteritis (vomiting and diarrhea), since the late 1940s. According to rather than the thousands, but outbreaks and humans of all ages are susceptible to CDC, from 2000 to 2008, 233 cases of still occasionally occur. rotavirus infection. According to CDC, be- tetanus were reported with 197 being fore use of a rotavirus vaccine, each year fatal (84 percent).124 l P ertussis: Also known as whooping rotavirus was responsible for more than cough, pertussis is highly contagious and l V aricella/Chickenpox: Although usually 400,000 doctor visits; more than 200,000 can result in prolonged coughing spells a self-limiting illness, varicella (chicken- emergency room visits; 55,000 to 70,000 that may last for many weeks or even pox) is a highly contagious virus that can hospitalizations; and between 20 and 60 months. Approximately 50 out of every lead to severe illness with complications deaths in the United States. Rotavirus vac- 10,000 people who develop pertussis such as secondary bacterial infections, cine now prevents an average of 40,000 die from the disease. Since the 1980s, severe dehydration, pneumonia, central to 50,000 hospitalizations a year among the number of reported pertussis cases nervous system deficits/disease and children under the age of 5 years old. has steadily increased, especially among shingles. Each year, more than 3.5 million adolescents and adults. 121 In 2012, a l R ubella: Before the rubella vaccine was cases of varicella, 9,000 hospitalizations total of 41,880 cases of pertussis were introduced, widespread outbreaks mostly and 100 deaths are prevented by varicella reported to the CDC, the highest number affected children in the 5 to 9 year age vaccination in the United States.125 since 1955. Of these, 8,890, or 21 group. Between 1962 and 1965, rubella l Z oster (Shingles):126 Zoster (shingles) percent, occurred among those aged 20 infections during pregnancy were esti- is a very painful nerve infection caused or older.122 Young infants who die from mated to have caused 30,000 still births by the same virus as chickenpox and is pertussis often may have caught the in- and 20,000 children to be born impaired often accompanied by a localized skin fection from an adult or adolescent. or disabled. Due to a successful vaccina- rash with blisters and pain may persist for tion program, rubella is no longer transmit- l P neumococcal disease: The pneumococ- weeks or months after the rash resolves ted year round in the United States and cal bacterium is spread by coughing and (postherpetic neuralgia). Anyone who has fewer than 20 cases are reported every sneezing. It is the most common cause of ever had chickenpox can develop shingles year. Rare cases of congenital rubella syn- bacterial pneumonia, inflammation of the because the virus remains in the nerve drome continue to be reported, almost all coverings of the brain and spinal cord (men- cells of the body after the chickenpox in- are acquired outside of the United States. ingitis), bloodstream infection (sepsis), ear fection clears and can emerge years later infections and sinus infections (sinusitis) in l T etanus: Commonly known as lockjaw, to cause shingles. The disease most children under two years of age. The elderly tetanus is a severe disease that causes commonly occurs in people 50 years and are especially susceptible to this infection. stiffness and spasms of the muscles, older, and those with compromised im- There are more than 50,000 cases per year with approximately 30 percent of re- mune systems. There are approximately in the United States and rates are higher ported cases ending in death. Tetanus one million zoster cases annually; one in among elderly and very young infants. The bacteria grow in soil and are an ongoing three Americans will get shingles in their fatality rate ranges from about 20 percent threat. In the United States, mortality lifetime. Shingles and post-herpetic neu- to 60 percent among the elderly.123 due to tetanus has declined at a con- ralgia increase with age. TFAH • healthyamericans.org 37 INDICATOR 4: FLU 12 states vaccinated at least half of their population 38 states and D.C. did not vaccinate at least half of (ages 6 months and older) for the seasonal flu of fall their population (ages 6 months and older) for the VACCINATIONS AND 2012 to spring 2013 (1 point). seasonal flu of fall 2012 to spring 2013 (0 points). PREPAREDNESS Delaware (51.3%) Alabama (45.7%) Nevada (39.6%) Hawaii (54.3%) Alaska (39.7%) New Hampshire (48.9%) Iowa (50.4%) Arizona (38.3%) New Jersey (45.3%) Maine (50.0%) Arkansas (47.0%) New Mexico (48.1%) Key Finding: Twelve states Maryland (53.1%) California (44.2%) New York (46.6%) Massachusetts (57.5%) Colorado (48.3%) North Dakota (48.9%) vaccinated at least half of their Minnesota (52.5%) Connecticut (46.5%) Ohio (44.8%) Nebraska (50.3%) D.C. (47.4%) Oklahoma (46.1%) population (ages 6 months and North Carolina (50.1%) Florida (34.1%) Oregon (40.1%) Rhode Island (56.7%) Georgia (41.1%) Pennsylvania (46.2%) older) for the seasonal flu of fall South Dakota (56.7%) Idaho (37.8%) South Carolina (44.8%) Tennessee (50.8%) Illinois (43.1%) Texas (43.7%) 2012 to spring 2013. Indiana (42.2%) Utah (42.9%) Kansas (40.7%) Vermont (49.6%) Kentucky (46.6%) Virginia (49.4%) Louisiana (47.1%) Washington (47.5%) Michigan (40.8%) West Virginia (48.8%) Mississippi (40.8%) Wisconsin (40.6%) Missouri (46.4%) Wyoming (39.2%) Montana (41.7%) Vaccination is the best prevention against the seasonal flu, and CDC recommends all Americans ages 6 months and older get vaccinated, yet fewer than half of Americans ages 6 months and older were vaccinated against the flu in the last two flu seasons (2011 to 2012 and 2012 to 2013).127   This indicator examines if at least half vaccination during the 2012 to 2013 (50 percent) of a state’s population flu season. The rates ranged from a (ages 6 months and older) was vacci- high of 53.4 percent in South Dakota nated against the seasonal flu in 2012. to a low of 30.8 percent in Florida. The highest vaccination rate was in Mas- Only four states vaccinated more than sachusetts at 57.5 percent and the lowest half of those 18 and older, and 34 was in Florida at 34.1 percent. Twelve states had a vaccination rate under 40 states vaccinated 50 percent of their percent for this age group. population or higher and 44 states and When seniors are excluded (ages 65 D.C. vaccinated 40 percent or higher. and older), the rate drops to only 35.7 Nationally, 45 percent of Americans ages percent of 18 to 64 year-olds receiving 6 months and older were vaccinated. vaccinations against the seasonal flu in The vaccinations rates are lower 2012. For this population, vaccination for adults (ages 18 and older): just rates ranged from a high of 48.5 per- over 40 percent (41.5) received a flu cent in Massachusetts to a low of 22.6 38 TFAH • healthyamericans.org percent in Florida, and only 18 states died from flu complications, and had vaccination rates of 40 percent or 43 percent of these children were Experts note that generally higher.128 Traditionally, there has been completely healthy otherwise.131 vaccination rates need to be a much stronger focus on encouraging above 70 percent for “herd In addition to its health effects, flu has seniors to get vaccinated, and children a serious impact in terms of healthcare immunity” effects — which and seniors often have more interac- and worker absenteeism costs. Seasonal limit the spread and protect tion with the healthcare system where flu can often result in a half day to five they may be encouraged to get vacci- those without immunity — to days of work missed, which affects both nated or have more convenient access become apparent. the individual and his or her employer. to get vaccinated, so there is a bigger Annually, the flu leads to approximately gap in the number of people ages 18 $10.4 billion in direct costs for to 64 who are not getting vaccinated. hospitalizations and outpatient visits, Children and seniors often have more and $76.7 million in indirect costs.132 severe influenza disease. More than four in ten private sector Each year, an average of 62 million workers in the United States do not have — or 20 percent of — Americans get paid sick leave from their employers, the flu. Between 3,000 and 49,000 which means they risk not getting paid Americans die each year from the flu or possibly losing their jobs if they stay and 226,000 are hospitalized from home from work because they get sick or the flu.129, 130 must care for sick family members.133, 134 Between 2004 and 2012, 830 children This puts coworkers and clients at risk between 6 months and 18 years old by coming to work sick, known as TFAH • healthyamericans.org 39 “presenteeism.” A significant percentage eggs, which allowed for larger volumes of service workers, such as waiters or ca- and a faster manufacturing time, and shiers, who come in direct contact with a FDA approved the first vaccine made range of customers or consumers, do not using recombinant DNA technology.138 have paid sick leave. NIH scientists also reported progress in vaccinology that could lead to a The historically low demand for universal flu vaccine by discovering that seasonal vaccinations has translated into viral protein nanoparticles induced an making flu vaccine development a low immune response against a wide range priority — without a steady demand, of flu strains in animal tests.139 incentives to manufacture and research new influenza vaccines goes down. In addition to the seasonal flu, historically there have been three-to- Under the ACA, all vaccines four pandemic flu outbreaks each By preventing hospitalizations, recommended by ACIP, including century. Pandemics occur when a new influenza immunizations can flu shots, are covered for in-network influenza virus emerges against which providers in group and individual health save $80 per year, per person people have little-to-no immunity and plans and for the Medicaid expansion vaccinated.135 spreads internationally with sustained population with no co-payments or human-to-human transmission. While cost sharing, but states are still able to experts predict influenza pandemics will determine coverage for their traditional occur in the future, they cannot predict Medicaid population. As of 2010, 38 when the next pandemic will occur, states required Medicaid coverage of what strain of the virus will be involved, flu shots with no-copay for beneficiaries and how severe the outbreak will be.140 under the age of 65, while 12 states and Once a novel influenza strain mutates Washington, D.C. required a co-pay.136 and becomes easily transmissible In 2013, there were several innovations among humans, it can spread in a in flu vaccines. For the first time, a sustained manner from person-to- quadrivalent vaccine was available person and cause a worldwide pandemic to protect against four strains, in in a relatively short time. While the addition to the traditional trivalent pandemic may last several years as vaccines. 137 American adults also had it circles the globe, outbreaks in any access to flu vaccines produced with single location often come in a series of the virus grown in cells rather than “waves” that will last 6 to 8 weeks each. 40 TFAH • healthyamericans.org The U.S. experienced three flu pandemics in the 20th century and one in the 21st century: l A severe pandemic in 1918 resulted children died.145 However, accord- in 30 percent of the population ing to CDC the actual number of becoming ill and 2.5 percent deaths in children could be as high (625,000 Americans) of those who as between 910 and 1,880.146 A new became ill died.141 In modern study published in 2013 estimates times, this would translate into that worldwide mortality from the approximately 90 million Americans H1N1 pandemic could be 10 times becoming ill and roughly 2.25 higher than the original WHO esti- million deaths. Based on a series of mates, with most deaths occurring in modeling study estimates, during a people under 65.147 severe pandemic, the U.S. economy Establishing a cultural norm of could lose an estimated $683 billion annual flu vaccinations can help — a 5.5 percent decline in annual ensure the country has a strong Gross Domestic Product (GDP).142 mechanism in place to be better l M ilder pandemic outbreaks in 1957 able to vaccinate all Americans and 1968 killed over 34,000 in the U.S. quickly during a new pandemic or and over 700,000 across the globe. 143 unexpected disease outbreak. l T he 2009 H1N1 Influenza (A) virus, In addition, during the H1N1 while considered relatively mild, in- pandemic, there was increased attention fected around 20 percent of Ameri- to the role that antivirals can play in cans (approximately 60 million effective treatment of the flu. A 2013 individuals), and resulted in approx- study in Pediatrics found that timely imately 274,000 hospitalizations and treatment with neuraminidase inhibitor 12,000 deaths. 144 Proportionally, (NAI) drugs may improve the survival more people were hospitalized from of children who become very ill from 2009 H1N1 than are typically hospi- the flu. The use of antivirals has talized from the seasonal flu. And decreased since the pandemic, in part about 90 percent of the Americans because there may be less recognition who died from 2009 H1N1 were that the drugs can be used to effectively under the age of 65, and at least 340 treat the seasonal flu as well.148 TFAH • healthyamericans.org 41 RECOMMENDATIONS: Increasing Flu Vaccination Rates and Improving Flu Policies TFAH identified some additional actions a severe flu pandemic, the Task Force that could be taken to fill persistent gaps recommends pre-emptive, coordinated in flu preparedness and policy, including: school dismissal based on sufficient evidence of the effectiveness in reduc- l I ncreasing public education about ing or limiting the spread of infection the importance of getting vacci- or illness within communities.150 nated: The public health community should make educating the public — l S upporting flu shots for all Americans especially high-risk groups, front-line without co-pays: The ACA requires workers and clinicians — about the that individuals with new group and seriousness of the flu, the need to individual plans for in-network or Med- be vaccinated and the safety of the icaid expansion receive the flu shot vaccine a priority each flu season. without co-payments, but currently 12 There should also be increased edu- states and Washington, D.C. do not cation about the different types of flu require their Medicaid plans to cover vaccine and which is recommended flu shots without co-payments require- for different groups. ments for beneficiaries under the age of 65. Flu shots should be covered l E xpanding support for immunization without co-pays by all providers, includ- programs: Community vaccination ing public health departments, phar- programs by health departments, often macies and others, even if they are in cooperation with healthcare provid- not classified as in-network providers. ers, pharmacies, schools and colleges, employers, retail stores, community l I mproving and modernizing organizations, faith-based organiza- surveillance and diagnostics: There tions and other partners, can make needs to be an increased investment shots more accessible for millions of to improve diagnostics, IIS and children and adults. Partnerships are other information technologies to particularly important for connecting to ensure accurate surveillance and vulnerable and hard-to-reach groups. proper management of illnesses that The Community Preventive Services are not actually influenza. There Task Force recommends on-site, re- should also be better integration of duced cost and actively promoted influ- electronic health records and public enza vaccinations, when implemented health surveillance systems to alone or as part of a multicomponent improve surveillance of flu outbreaks intervention, based on sufficient evi- and improve two-way communication dence of their effectiveness in increas- between clinicians and public health ing influenza vaccination coverage experts. Point-of-care diagnostics among workers in worksites. 149 During could more quickly identify who 42 TFAH • healthyamericans.org actually has the flu and helplines, decreasing cases of influenza among where nurses can help triage and healthcare workers and patients when provide care to patients over the implemented alone or as part of a mul- phone, and other pre-hospital systems ticomponent intervention.153 should also be expanded to reduce l R equiring minimum sick leave benefits: the number of healthy people seeking Allow workers in businesses with 15 or medical care. more employees to earn up to seven l R equiring all healthcare personnel to job-protected paid sick days each year receive the annual seasonal flu vac- to be used to recover from their own cine every year: Healthcare workers illnesses, access preventive care or are at higher-risk than the general provide care to a sick family member. population for exposure to the flu and Currently, around 38 percent of private also for spreading the flu to their pa- workers do not have any sick leave tients. 151 By getting vaccinated, they coverage (around 40 million Americans). can reduce the spread of the disease Sick leave is especially important to and set an example to the rest of the prevent the spread of communicable public about the importance of being diseases in the workplace. vaccinated. Employees who cannot be l F unding and incentivizing vaccine vaccinated due to medical contraindi- research: The government and private cations or because of vaccine supply industry should continue investments shortages should be required to wear in expanded domestic flu vaccine man- masks or be re-assigned away from di- ufacturing capacity — including with rect patient care.152 There should also government guarantees to industry be comprehensive educational efforts to assure an adequate supply during that inform healthcare workers about bad flu seasons. Investments must the benefits and risks of influenza also continue to support research for immunization to both patients and a more effective and universal flu vac- healthcare workers and other efforts cine to replace the annual vaccine. that support implementation of a com- prehensive infection control program. l M aintaining emergency flu and pan- Vaccination of healthcare workers demic supplies in the Strategic Na- should be a condition of participation tional Stockpile (SNS): In the case of in Medicare. The Community Preven- supply shortages, an extreme outbreak tive Services Task Force recommends or new pandemic, emergency medical on-site, free and actively promoted equipment, vaccines, antivirals and influenza vaccinations based on suffi- other medicines should be routinely cient evidence of their effectiveness in maintained as part of the SNS. TFAH • healthyamericans.org 43 Pandemic Flu Preparedness: Lessons from the Frontlines In 2009, TFAH issued a report Pandemic research and development and stockpiling Flu Preparedness: Lessons from the Front- of medicines and equipment. ISSUE BRIEF Pandemic Flu Preparedness: LESSONS FROM THE FRONTLINES lines identifying key lessons from the As soon as the H1N1 virus was identified, response to the 2009 H1N1 response, scientists raced to develop a vaccine to which concluded that:154 protect against the H1N1 flu strain, yet l E mergency funds are essential — but not they were operating with an outdated vac- T he recent H1N1 (swine) flu outbreak demonstrated how rapidly a new strain of flu can emerge and spread around the world. As of June 1, 2009, the H1N1 virus was reported in 62 nations, with nearly 17,500 confirmed cases sufficient — to backfill the long-standing cine research capacity and technology. and more than 100 deaths. The sudden outbreak of this novel flu virus has tested the world’s public health preparedness. H1N1 provided a real-world test that showed the strengths and vulnerabilities in the abilities of the United States public health infrastructure issues; Despite these challenges, vaccine manu- and the rest of the world to respond to a major infectious disease outbreak. This report examines early lessons learned more virulent strain, or if a different strain of facturers were able to produce limited P andemic and emergency response plans from the response and ongoing concerns influenza, like the H5N1 (bird) flu, emerges. about overall U.S. preparedness for potential pandemic flu outbreak. The first section re- Overall, the H1N1 outbreak has shown that the l quantities of vaccine by mid-fall, which investment the country has made in preparing views 10 key lessons based on the initial re- for a potential pandemic flu has significantly im- sponse to the H1N1 outbreak; and the second must be adaptable and science-driven; proved U.S. capabilities for a large scale infec- section discusses 10 underlying concerns and tious disease outbreak, but it has also revealed provides recommendations for addressing se- how quickly the nation’s core public health ca- public health officials directed to the high- rious continued vulnerabilities in the nation’s pacity would be overwhelmed if the outbreak preparedness in the event that H1N1 returns were more widespread and more severe. in the fall, either in its current form or as a JUNE 2009 l E stablishing trust with the public through est-risk populations. However, it took until PREVENTING EPIDEMICS. PROTECTING PEOPLE. clear and honest communication is im- later in the year before enough vaccine perative — and the highest-risk groups was available for the entire U.S. popula- often have the lowest levels of trust; tion. This delay in the supply further dis- couraged people from getting vaccinated. l R ecommendations for sick leave, school closings and limiting community gather- In addition to vaccine development, within ings have major ramifications that must one week of the outbreak, the SNS de- be taken into account; livered more than 11 million courses of antiviral drugs, 12.5 million facemasks, l C oordination across communities, and 25 million N-95 respirators to 62 pre- states, and countries is extremely com- determined areas in states and localities plicated, but must be a high priority; and around the country.155  These materials in- l C ompeting emergency declarations and cluded 25 percent of the states’ fixed pan- laws must be better coordinated to avoid demic influenza allocations and was the confusion and provide liability and health first large scale distribution of its kind. In protection to medical personnel who vol- the fall, an additional 535,000 courses of unteer to help during emergencies. antiviral drugs and 59.7 million N-95 res- pirators were also deployed from the SNS The 2009 H1N1 pandemic flu outbreak in response to the pandemic emergency. also showed the importance of maintaining the research and development The relatively rapid development of a vac- of up-to-date countermeasures, including cine despite limited production capabili- vaccines and antiviral medications, ties and the quick distribution of antivirals and to keep enough pharmaceuticals and other equipment were only possible and medical equipment stockpiled for due to prior investments in research and emergencies. Having the ability to development and effective planning, stock- respond quickly is essential during an piling and practice in drills and tabletop outbreak or emergency, but requires an exercises by state and local health depart- ongoing investment in pharmaceutical ments and their key community partners. 44 TFAH • healthyamericans.org SECTI O N 3: Emerging and SECTION 3: EMERGING — AND REEMERGING — INFECTIOUS DISEASES Emerging — and Reemerging — Infectious Diseases Reemerging Infectious An essential role of infectious disease experts is to identify Diseases new, emerging threats — or the reemergence of threats that were thought to be under control. The sooner new diseases can be detected and identified, the faster strategies can be implemented to prevent their spread and determine the best course of treatment. Emerging diseases are not just a threat also have major implications for to health, they also have an impact on economics and trade. how Americans live their daily lives — CDC, the National Institute of Allergy depending on the severity and scope and Infectious Diseases (NIAID), WHO of a threat, issues can include things and state and local health agencies like decisions about sending children are tasked with the responsibilities of to schools, limiting travel, restricting working to prevent and contain new public events and even quarantines. threats as quickly as possible. According to the National Intelligence New diseases can emerge in a number Council, “newly emerging and of ways. For instance, they can spread reemerging infectious diseases will from animals or insects to humans, pose a rising global health threat and come from contaminated food or will complicate U.S. and global security water, or new strains of existing over the next 20 years. These diseases diseases can evolve that are resistant to will endanger U.S. citizens at home and antimicrobial treatments. In addition, abroad, threaten U.S. armed forces infectious disease experts must also deployed overseas, and exacerbate monitor for the reemergence of social and political instability in key diseases that may be new to a region countries and regions in which the U.S. or were previously mostly under has significant interests.”156 Outbreaks control in particular regions. DECEMBER 2013 Animal-Borne Diseases (Zoonoses) An estimated 75 percent of new infectious at risk for contracting illnesses and as to reduce the spread of a disease once diseases that have emerged in recent then spreading them to other humans. it reaches humans. For instance, the One decades were spread to humans from Experts attribute the rise in new zoonotic Health Initiative was launched in 2010 animals, birds or insects. 157 As of 2000, diseases to a range of factors such to foster greater collaboration among more than 200 diseases occurring in as increased worldwide travel, global physicians, veterinarians, public health humans have been found to originate importing and exporting of food, growth officials, and other scientific-health and in animals. 158 Some recent emerging in human and animal populations, and environmentally-related disciplines, includ- diseases that are zoonotic (diseases that the impact of climate change, such as ing the American Medical Association, originated in animals) or vector-borne shifts in where people live, deforestation American Veterinary Medical Association, (diseases transmitted by insects like and changes in migration patterns of American Academy of Pediatrics, American mosquitoes or ticks) include the H1N1 animals and birds. 159, 160 Nurses Association, American Association pandemic flu, West Nile virus, monkeypox, of Public Health Physicians, the American CDC, NIAID, FDA, WHO and state and local Ebola, SARS and HIV/AIDS. Society of Tropical Medicine and Hygiene, health agencies work to develop special CDC, USDA, and the U.S. National Environ- Humans who come into contact with strategies to prevent the spread of dis- mental Health Association (NEHA).161 infected animals (disease vectors) are eases from animals to humans — as well 2013 NOVEL AVIAN INFLUENZA A OUTBREAK — H7N9 2012: A NEW MIDDLE EAST RESPIRATORY SYNDROME CORONAVIRUS The first outbreak of a new avian influenza A (H7N9) virus in humans was reported in China by the WHO on April 1, MERS was first reported in humans in September 2012. 2013. 162 Through mid-October 2013, WHO has reported a In July 2013, the WHO International Health Regulations total of 136 laboratory-confirmed human cases including 45 Emergency Committee determined that MERS should be deaths. As of October 2013, three patients were still hospi- considered a serious concern, but not yet a “public health talized and 88 had been discharged. 163 After following close emergency of international concern.”172 contacts of confirmed H7N9 patients, very limited person-to- As of October 18, 2013, a total of 139 cases from eight person spread of the virus was found. Instead many of the countries have been reported to WHO and almost half have people infected with H7N9 reported contact with poultry. No been fatal. All cases have been directly or indirectly linked cases of H7N9 outside of China have been reported.164 to four countries: Saudi Arabia, Qatar, Jordan and the United Although H7N9 is not currently spreading from person-to- Arab Emirates. No cases have been reported in the United person, the pandemic potential of this virus is a concern to sci- States, although 82 persons from 29 states have been entists. Influenza viruses are constantly evolving and experts tested for MERS infection.173 are watching for the possibility that this virus could eventually Individuals with chronic conditions appear to be more spread through sustained person-to-person contact, triggering a susceptible to MERS. The largest study to date of those global pandemic of H7N9. CDC and the WHO are both closely infected included 47 patients and found that all but two monitoring the situation.165, 166 HHS also invested in develop- patients had one or more chronic medical conditions, including ment of different H7N9 seed strains for vaccine production and diabetes, hypertension, heart disease and kidney disease. provided grants to WHO to support production of H7N9 pre-pan- And, 72 percent had more than one chronic condition.174 demic vaccine candidates and subsequent clinical trials.167, 168 46 TFAH • healthyamericans.org CDC: West Nile Virus Neuroinvasive Disease Incidence by State per 100,000 population – United States, 2013 (as of December 3, 2013)175 WA MT ND MN VT ME SD WI OR ID NH WY MI NY IA MA NE PA RI IL IN OH CT NV UT NJ CO KS MO WV DE KY VA MD DC CA OK TN NC NM AR AZ SC MS AL GA TX LA 0.0 0.01-0.24 0.25-0.49 FL 0.5-0.99 >=1.00 WEST NILE VIRUS OUTBREAK UPSWING 2012 TO 2013 In 2012, the country experienced its humans, birds or mosquitoes. There symptoms that last from a few days second-largest and deadliest outbreak have been a total of 2,271 cases of to several weeks. Possible symptoms of WNV. Every state but Alaska and WNV disease in humans, including include fever, headache, body aches, Hawaii reported infections in people, 100 deaths. 171 Older adults are nausea, vomiting, swollen lymph glands birds or mosquitoes. There were a at higher risk for developing WNV and rashes on the trunk of the body. total of 5,674 human cases of the neuroinvasive disease. A small portion of infected people (one disease, with 286 deaths. Half of the WNV is a potentially serious illness in 150) will develop serious symptoms cases were classified as neuroinvasive that is spread by infected mosquitoes that can last several weeks and may (e.g. meningitis or encephalitis).169 that contract the virus from feeding result in permanent neurological The majority of cases—80 percent— on infected birds. WNV prevention effects. Possible symptoms include were reported from 13 states: strategies focus on preventing high fever, headache, neck stiffness, Texas, California, Louisiana, Illinois, mosquito bites by eliminating standing disorientation, coma, tremors, Mississippi, Michigan, South Dakota, water, using a quality insect repellent convulsions, muscle weakness, vision Oklahoma, Nebraska, Colorado, Arizona, and appropriate clothing and other loss, numbness and paralysis. There is Ohio and New York. Texas reported behavior changes. no specific treatment or human vaccine almost a third of all cases.170 for WNV, though those with severe The majority of individuals (80 There were also a significant number symptoms can receive supportive care percent) who contract WNV develop of cases in 2013; as of November, in a hospital setting. no symptoms. Up to 20 percent of 48 states and Washington, D.C. infected individuals develop minor have reported WNV infections in TFAH • healthyamericans.org 47 2003: SARS — THE FIRST SEVERE NEWLY EMERGENT DISEASE OF THE 21ST CENTURY In 2003, a new deadly disease, SARS, second quarter of 2003 and Toronto, put into work/home quarantine, had a infected more than 8,000 people, which experienced one of the more 13.4 percent drop in tourism that year leaving 774 dead. 176 It was a new form severe outbreaks outside of Southeast and an overall estimated economic loss of a coronavirus and represented the Asia with more than 27,000 individuals of nearly $1 billion.178 first severe, newly emergent disease of the 21st century. The disease emerged in China, but within six weeks spread worldwide due to international travel and infected individuals from 29 nations around the world. SARS was contained and controlled because public health officials in the most affected communities quickly mounted an intense rapid response. SARS also demonstrated the economic consequences that an emerging infec- tious disease can have. It caused wide- spread social disruption as schools, hospitals and some borders were closed and thousands of people were placed on quarantine. International travel to affected areas fell by 50 per- cent to 70 percent, hotel occupancy dropped by more than 60 percent and local businesses were sharply im- pacted. Overall, the economic losses, due to deaths, quarantines and lost tourism dollars, are estimated to have been $30 billion to $50 billion.177 The World Bank found that the East Asian region’s GDP fell by 2 percent in the 48 TFAH • healthyamericans.org MALARIA: A CONCERN FOR U.S. TRAVELERS Malaria is rampant in developing coun- In 2010, the most recent year for which tries, particularly in sub-Saharan Africa there is reliable data, there were 219 and South Asia, but malaria transmis- million malaria cases worldwide and sion has been considered eliminated 660,000 deaths.182 Although malaria in the United States for decades. has been virtually eliminated in devel- However, imported cases and sporadic oped nations with temperate climates, episodes of local transmission con- it is still prevalent in tropical and sub- tinue to occur and the malaria vector tropical countries in Africa, Asia, the mosquitoes capable of transmitting Middle East, South America, and Central the disease are present in the United America. Recent efforts to expand ma- States (Anopheles quadrimaculatus laria control in endemic countries have and An. Freeborni). In 2011, 1,925 im- substantially reduced the burden of ma- ported malaria cases were reported in laria worldwide since 2000.146 Evolving fetus before or during childbirth.183 A the United States, which is the highest strains of drug-resistant parasites and malaria infection is generally character- since 1971, and represents a 14 per- insecticide-resistant mosquitoes con- ized by fever and chills, along with head- cent increase since 2010.179 In 2011, tinue to make this emerging infectious ache, malaise, fatigue, muscular pains, five people in the U.S. died from malaria disease a global health threat. occasional nausea, vomiting, and diar- or associated complications. 180 All but rhea.184 Doctors can treat malaria effec- Malaria is caused by a single-celled par- five of the malaria cases reported in the tively with antimalarial drugs. However, asite from the genus Plasmodium and U.S. were acquired overseas with more there is increasing worry about drug- is typically transmitted to humans by than two-thirds of the cases imported resistant parasites that have rendered mosquitoes. Malaria can also be trans- from Africa. 181 The growing number of some of these medicines ineffective and mitted through blood transfusions, organ imported malaria cases in the United increasing resistance of the mosquitoes transplants, or contaminated needles or States reflects changing patterns of that carry malaria to insecticides also syringes. “Congenital” malaria refers to travel and migration to and from ma- pose a global threat. the transmission from a mother to her laria-endemic countries. Malaria Facts185 l A pproximately half of the world’s l M alaria accounts for at least $12 billion The Lantos-Hyde United States Global population is at risk of malaria. in economic losses each year in Africa, Malaria Strategy (USG) has contributed l A child dies of malaria every 60 and a reduction in annual economic to the drop in malaria rates. USG in- seconds. growth estimated at 1.3 percent. vestments in 20 countries through the l M alaria is preventable and curable. President’s Malaria Initiative (PMI) have l I n 2010, malaria caused an estimated resulted in significant improvements in 660,000 deaths. l D ue to increased malaria prevention population coverage of proven effective in- l T here were about 219 million cases efforts, Malaria mortality rates have terventions. It has helped reduce mortal- of malaria in 2010, mostly among fallen by more than 25 percent globally ity rates in children under the age of 5 by infants, young children and pregnant since 2000, and by 33 percent in the 16 to 50 percent in these countries over women; most of them live in Africa. WHO African Region. the past 5 to 7 years.186 TFAH • healthyamericans.org 49 CHAGAS DISEASE Chagas disease is caused by the para- In Chagas disease-endemic areas, regions but is not endemic. Generally, site Trypanosoma cruzi, which is trans- the main way people become infected in the United States people can mitted to animals and people by insect is through vectorborne transmission. become infected through mother to vectors found exclusively in the Ameri- Infected bugs pass T. cruzi parasites baby transmission; blood transfusion; cas. As many as eight million people in in their feces and the person can organ transplantation; and accidental Mexico, Central America and South Amer- become infected if T. cruzi parasites in laboratory exposure. But, rare ica have Chagas disease, the majority of the bug feces enter the body through vectorborne cases of Chagas disease whom do not know they are infected. If mucous membranes or breaks in the have been noted in the southern untreated, infection is lifelong and can skin. Chagas disease can also be United States. be symptom free or life threatening. found in the United States and other CDC’s Epidemic Intelligence Service Since 1951, over 3,500 Epidemic demic assistance from CDC for an urgent l W hen an organ transplant recipient tested Intelligence Service (EIS) officers have public health problem. In FY 2013, CDC positive for rabies virus, CDC responded responded to requests for assistance mobilized EIS officers 82 times to provide by mobilizing a large, multi-jurisdictional within the United States and throughout the epidemiologic expertise and support to 40 investigation to look for and stop other world. EIS officers serve as CDC’s “disease states, the District of Columbia, and the possible occurrences of infection. detectives,” professionals who are trained Navajo Nation — as well as to 18 coun- l T he EIS officer assigned to the California to conduct epidemiologic investigations, tries and three U.S. territories. Department of Public Health investigated research and public health surveillance. a fatal outbreak of Hantavirus infections EIS officers interact closely with The EIS program is a 2-year post-graduate epidemiologists in affected states— among visitors to Yosemite National training program comprised of 75 to many of whom are former EIS officers Park, revealing that a particular type of 78 new officers each year. EIS attracts themselves—illustrating the network and tent cabin was susceptible to infestation candidates from diverse backgrounds— extended reach of the program. by rodents that carried the virus. physicians, nurses, veterinarians, and l E IS officers responded to a ten-fold Here are a few notable examples of PhD-trained scientists. increase in the incidence of pertussis in epidemiologic investigations conducted Washington State, assisting state health EIS officers currently are assigned to 32 recently by EIS officers: authorities with characterization and states and the District of Columbia, as l E IS officers and other staff responded to control of the outbreak. well as at CDC headquarters. Regardless a multistate cluster of rare Salmonella of their assignment location, EIS officers l E IS officers assisted the Missouri health Braenderup infections that were linked help many states and countries through department with investigation of an E. to live poultry ordered from mail-order Epi-Aids — where state, local, federal, and coli O157 outbreak possibly linked to a hatcheries. global partners request short-term epi- regional grocery chain. 50 TFAH • healthyamericans.org CDC’s Global Disease Detection Program (GDD) The GDD is a CDC program for developing 4. oonotic disease investigation and Z and strengthening global health security control: Include veterinary expertise in to rapidly detect, accurately identify and detecting and responding to zoonotic promptly contain emerging infectious dis- diseases to help strengthen capacity. ease and bioterrorist threats that occur 5. ealth communication and informa- H internationally.187 tion technology: Improve communica- GDD helps countries with limited tion with affected populations during resources develop the essential detection outbreaks, and ensure public health and control capacities. Currently, CDC responses are culturally, technologically operates 10 GDD Centers in Bangladesh, and scientifically appropriate. China, Egypt, Georgia, Guatemala, India, 6. aboratory systems and biosafety: En- L Kazakhstan, Kenya, South Africa and sure appropriate facilities, equipment, Thailand.188 policies, security precautions and occu- Six core capacities were established by pational health programs. various GDD stakeholders to effectively GDD has been enhancing global health identify and control emerging infectious security for almost 10 years. In 2011 diseases including:189 some of the accomplishments of GDD 1. Emerging infectious disease detection Centers include:190 and response: Identify and respond to l S upported responses to 209 disease out- emerging infections through disease breaks or other public health emergencies; surveillance, prevention and control. l 1 09 epidemiologists and laboratory 2. Training in field epidemiology and scientists graduated from the Field Epi- laboratory methods: Train scientists demiology Training Programs (FETP) as- and public health practitioners in field sociated with GDD Regional Centers; epidemiology and laboratory methods. l 5 89 FETP professionals remained in pub- 3. Pandemic influenza preparedness lic health positions in-country or within the and response: Develop influenza region where they originally graduated; surveillance capacity, including l M ore than 8,500 people participated in improving and expanding global short-term public health training; surveillance networks, increasing l D etected six pathogens new to their region; virus isolation and epidemiological l D iscovered one organism new to the data collection and increasing quick world; and identification, reporting and response to outbreaks. l B uilt host nation capacity for 29 new diagnostic tests. TFAH • healthyamericans.org 51 INDICATOR 5: CLIMATE 15 states currently have climate change adaptation 35 states and Washington D.C. do not currently have plans that are completed (1 point). complete climate change adaptation plans (0 points). CHANGE AND INFECTIOUS Alaska Alabama Missouri DISEASE California Arizona** Montana Connecticut Arkansas Nebraska Florida Colorado** Nevada Maine Delaware* New Jersey* Key Finding: 15 states currently Maryland District of Columbia New Mexico Massachusetts Georgia North Carolina** have completed climate change New Hampshire Hawaii North Dakota New York Iowa** Ohio adaption plans — that include Oregon Idaho Oklahoma Pennsylvania Illinois Rhode Island* focusing on the impact on Vermont Indiana South Carolina** Virginia Kansas South Dakota human health. Washington Kentucky Tennessee Wisconsin Louisiana Texas Michigan** Utah** Minnesota* West Virginia Mississippi Wyoming Source: Center for Climate and Energy Solutions191 *Plans in progress ** Adaptation Plan Recommended in the Climate Action Plan This indicator examines which states new diseases or the reemergence or have complete climate adaptation spread of diseases that were nearly plans, which includes understanding eradicated or thought to be under and planning for changing risk control.192, 193 The President issued an for emerging and reemerging Executive Order in 2013 to prepare infectious diseases due to changing for the effects of climate change, temperatures and weather patterns. including how increase in excessively This includes the need to integrate high temperatures, heavy downpours, climate readiness into all policies and wildfires, severe droughts, permafrost programs, such as vector control, air thawing, ocean acidification and quality and food and water safety. sea-level rise affect communities and public health.194 In addition, the According to the Environmental EPA released draft Climate Change Protection Agency (EPA), as the Adaptation Implementation Plans environment changes, Americans for public review and comment in will be at higher risk for a range early 2013. The Implementation of health threats, and a 2003 IOM Plans aim to protect public health report, Microbial Threats to Health: and the environment by integrating Emergence, Detection, and Response, climate adaptation planning into listed climate and weather, changing EPA programs, policies, rules and ecosystems, and land use as factors operations.195 contributing to the emergence of 52 TFAH • healthyamericans.org Certain vector- and zoonotic-borne l nnual influenza epidemics occur A States have promoted an increase in diseases may increase and spread — primarily during cold weather, while the population of white-tailed deer, along with food- and water-borne meningococcal meningitis is associated which are a host of the ticks that diseases — as changes in temperature with dry climates, so changing weather carry Lyme disease.199, 200 and weather patterns allow pathogens patterns means people in different l I ncreasing temperatures can also to expand into different geographic regions would be exposed to increased lead to an increase the risk for regions. For instance: risk for both diseases. foodborne disease outbreaks. l T he presence and number of l T he rise in extreme weather events l I ncreases in flooding and rising rodents, mosquitoes, ticks and other and natural disasters also leads to sea-levels can lead to an increase in insects and animals that can carry a more fertile environment for the water-borne diseases. infectious diseases rise in warmer spread of infectious diseases and temperatures, so as temperatures germs. For instance, cryptosporidiosis Public health departments are rise around the country and stay outbreaks are associated with heavy uniquely positioned to help commu- warmer for longer periods of times, rainfall, which can overwhelm nities prepare for the adverse effects the patterns of diseases ranging sewage treatment plants or cause of climate change given their role in from WNV to Lyme and other tick- lakes, rivers and streams to become building healthy communities. Public borne diseases to encephalitis are contaminated by runoff that contains health workers are trained to develop expected to shift.196 waste from infected animals, and communication campaigns that both experts also believe that an El Niño inform and educate the public about l L arge-scale climatic change may occurrence may have contributed to health threats and can use these skills have an effect on the timing of increases of malaria and cholera. 198 to educate the public about climate migration of wild birds. Wild birds Communities recovering from a change prevention and prepared- are a concern for public health disaster may see food or waterborne ness. Public health departments are because they can be infected by a illnesses associated with power outages also on the frontlines when there is number of microbes that can be or flooding and infectious disease an emergency, whether it’s a natural transmitted to humans. In addition, transmission in emergency shelters. disaster or an infectious disease out- birds migrating across national and break. These types of emergency pre- intercontinental borders can become l D eforestation and the expansion paredness and response skills will be long-range carriers of any bacteria, of land used for agriculture and invaluable as extreme weather events virus or parasite organism they ranching has contributed to an become more common. harbor. Birds are the source of the upswing in infectious diseases, as it rapid spread of WNV after it was first changes the relationships between According to a review by the Center identified in 1999, and by 2012 the humans and disease vectors. for Climate and Emergency Solutions, virus had been reported in human, Changes in land use and human 15 states currently have complete mosquitoes, and birds in 48 states. settlement patterns have coincided climate adaptation plans, and four ad- In addition to WNV, migratory birds with increased malaria outbreaks in ditional states have plans in progress. are reported to be the source of the Africa, Asia and Latin America, while Depending on the region’s specific 2009 global outbreak of the H1N1 reforestation in the Northeast and needs, adaptation plans can focus on avian influenza virus. 197 upper Midwest regions of the United a variety of issues, including sea-level TFAH • healthyamericans.org 53 rise and associated flooding, drought plans has not changed since 2012. All by 2016. CDC will assist awardees in mitigation and water insecurity, hur- 15 states with adaptation plans include developing and using models to more ricanes and other severe weather, public health responses. accurately anticipate health impacts, and extreme heat events. 201 Climate monitor health effects, and identify To help prepare for the health impact change will require enhanced moni- the most vulnerable areas in their re- of extreme weather incidents and cli- toring of potential disease vectors gion. Awardees include departments of mate change, CDC’s Climate-Ready and outbreaks. Factors like potential health in Arizona, California, Florida, Il- States and Cities Initiative awarded changes in water quantity and qual- linois, Maine, Maryland, Massachusetts, $7.25 million in grants to 16 states and ity, air quality, extreme temperatures Michigan, Minnesota, New Hampshire, two cities to build resilience to the and insect control are all important New York City, New York State, North health impacts of climate change, with public health concerns. The number Carolina, Oregon, Rhode Island, San plans to award up to $19.25 million of states with complete climate change Francisco, Vermont and Wisconsin.202 RECOMMENDATIONS: Preventing and Preparing for the Adverse Impact of Climate Change on Infectious Disease Outbreaks To help prevent and prepare for the l I mproving coordination across public become a centralized, nationwide health new and increased infectious disease health and environmental agencies: tracking center, and each state should threats that climate change poses, TFAH Public health agencies at all levels receive the necessary funding to fully recommends: must work in coordination with conduct health tracking activities. A fully environmental and other agencies to funded tracking network should demon- l E nsuring every state has a undertake initiatives to reduce known strate interoperability with the larger HIT comprehensive climate change health threats from food, water and air, system to facilitate two-way communica- adaptation plan that includes and educate the public about ways to tion with clinicians and state and local a public health assessment avoid potential risks. public health officials. and response: State and local health agencies should engage l E xpanding the National Environmental l B uilding resilience to climate-related in public education campaigns Health Tracking Network: The CDC’s health effects at the state and local and establish relationships with environmental public health tracking level: Funding should be significantly vulnerable populations as part of program should be expanded and fully increased to support CDC’s Climate any plan. The Federal Emergency funded to cover every state. Currently, Ready States and Cities Initiative to Management Agency (FEMA) should the program only supports efforts in 23 build capacity at the state and local require climate change adaptation states and New York City. CDC should level to understand the impact of as part of state hazard mitigation be provided with the mandate and re- climate change and apply this to long- plans. sources to expand the network so it can range health planning. 54 TFAH • healthyamericans.org 35 states and D.C. require facilities in the state to re- 15 states do not require facilities in the state to re- INDICATOR 6: MANDATORY port HAI data through the National Healthcare Safety port HAI data through the National Healthcare Safety Network (NHSN) or other systems (1 point). Network (NHSN) or other systems (0 points). REPORTING OF Alabama New Hampshire Alaska Mississippi HEALTHCARE ASSOCIATED Arkansas New Jersey Arizona Montana California New Mexico Idaho Nebraska INFECTIONS (HAIS) Colorado New York Iowa North Dakota Connecticut North Carolina Kansas South Dakota Delaware Ohio Kentucky Wisconsin D.C. Oklahoma Louisiana Wyoming Key Finding: 35 states and Florida Oregon Michigan Georgia Pennsylvania Washington, D.C. mandate that Hawaii Rhode Island Illinois South Carolina healthcare facilities in their state Indiana Tennessee Maine Texas report healthcare-associated Maryland Utah Massachusetts Vermont infections to CDC’s National Minnesota Virginia Missouri Washington Healthcare Safety Network Nevada West Virginia NHSN or another system. Source: CDC This indicator examines how many if they are on a ventilator or are on a states legally require reporting of prolonged course of antibiotics as part healthcare-associated infections — of their care.205, 206 In 2002, 98,987 either to CDC’s NHSN, the largest deaths were estimated to be associated healthcare-associated infection with HAIs in hospitals, including reporting system in the United States, 35,967 from pneumonia, 30,665 from serving more than 12,000 healthcare bloodstream infections, 13,088 from facilities of all types, or through other urinary tract infections, 8,205 from established systems.203 surgical site infections and 11,062 from infections of other sites.207 Approximately one out of every 20 hospitalized patients will contract HAIs cost the country $28 billion to an HAI.204 Healthcare-associated $33 billion in preventable healthcare infections not only happen in hospitals expenditures each year.208 According to but can also occur in outpatient CDC, if 20 percent of these infections surgery centers, nursing home were prevented, healthcare facilities and other long-term care facilities, could save nearly $7 billion, and, by rehabilitation centers, community reducing infections by 70 percent, it clinics or physicians’ offices. could result in $23 billion in savings.209 A person’s risk for a HAI, which Prevention and education efforts have includes a range of antibiotic-resistant been helping to decrease the rates of infections, increases if they are HAIs. CDC, CMS, states and medical having invasive surgery, if they have a providers have launched a series of catheter in a vein or their bladder, or provider education and prevention TFAH • healthyamericans.org 55 initiatives.210, 211 In addition, in 2008, the U.S. Department of Health and Medicare provided incentive to reduce Human Services Action Plan in only infections by adopting a “no pay” rule three years.216 Previously, Tennessee’s to no longer cover infections acquired rate of HAIs was significantly greater during a hospital stay, requiring the than the national average, but in three hospitals themselves to cover any years they now fall below the national costs incurred by these infections. 212 reference rate of HAIs. Also, a recent According to a 2012 survey, 80 percent study found a significant decrease in of infection-control professionals MRSA infections. An estimated 30,800 believe the rules have resulted in a fewer MRSA infections occurred in greater focus on reducing HAIs. The the United States from 2005 to 2011.217 ACA also requires in-patient hospitals And, more specifically hospital to report certain infections to NHSN acquired MRSA decreased by over in order to receive their full payment 50 percent during that time. These updates, and the information will results show the efforts states and be available on the CMS’ Hospital hospitals have been making in recent Compare website. 213 years to prevent infections. Between 2008 and 2012, there were 41 While all 50 states use NHSN or have percent fewer central line-associated other systems in place, according bloodstream infections, 7 percent to an ongoing review by CDC, as of fewer catheter-associated urinary November 2013, only 35 states and tract infections and 17 percent fewer Washington, D.C. are required by law surgical site infections in in-patient to report HAIs to the NHSN or other healthcare settings. 214 systems.218 Mandatory reporting is important to ensure that cases are Many states are seeing decreases in being accurately counted and tracked HAIs. For instance, both Kansas — in particular to effectively track and Tennessee have recently outbreaks and to develop effective released reports detailing progress interventions and control strategies. in reducing the rate of HAIs in their Without mandatory reporting, there is states. The Kansas Department of an ongoing concern that some facilities Health and Environment published may underreport infections and deaths. data suggesting that Kansas facilities had 67 percent fewer bloodstream A report issued by ASTHO and infections from central-line devices CDC emphasized the importance of and 26 percent fewer urinary tract requiring standardized and publicly infections from urinary catheter available reporting of infection rate devices as compared to national information as a cornerstone of a state- reference data. 215 Tennessee achieved wide prevention programs for HAI.219 a five-year prevention target set by 56 TFAH • healthyamericans.org 2012 to 2013 Fungal Meningitis Outbreak220 As of September 2013, CDC has reported received joint injections are not thought to 750 cases in 20 states of fungal be at risk for fungal meningitis, but could meningitis caused by contaminated develop joint infections. steroid injections. Sixty-four deaths have The outbreak raised questions about the been reported.221 Approximately 14,000 need to increase regulatory oversight of patients may have received spinal or joint compounding pharmacies and the need for injections with medication from three clarification of federal and state authority implicated lots of methylprednisolone; so and resources to conduct oversight and far, almost all have been contacted for inspections. It also tested the ability of follow-up. The FDA recalled the three lots health departments and private sector part- on September 26, 2012. ners to track contaminated medications This form of meningitis is not contagious and the clinics and patients who received and is slow to develop—symptoms can them. In November 2013, the Drug Quality manifest one to four weeks following injec- and Security Law was passed that will give tion. Fungal meningitis patients may ex- U.S. health regulators increased oversight perience a spectrum of symptoms ranging of bulk pharmaceutical compounding and from headache, fever and neck stiffness strengthens their ability to track drugs to coma, seizures and death. Those who through the distribution pipeline.222 PUBLIC HEALTH DEPARTMENT RESPONSE TO U.S. FUNGAL MENINGITIS OUTBREAK In September 2012, a clinician in Ten- descriptions of some of the specific ac- l S tate and local public health nessee found a case of fungal menin- tions taken by health departments dur- departments worked with FDA to gitis in a patient following an epidural ing the response to the outbreak: 223 recall products and helped track steroid injection. This was the first sign down and contact over 14,000 l T he Tennessee Department of Health of the multi-state outbreak of fungal exposed patients in 23 states identified the first case of fungal men- meningitis. CDC’s “disease detec- with facilities that received the ingitis and quickly contacted CDC to tives” from the EIS were part of the implicated medication and worked begin the investigation into the unex- early nationwide response to the out- with FDA on product recall efforts. plained case. break. More than 80 EIS officers were During the outbreak, public health marshaled for the response, providing l T he Virginia Department of Health departments at the local, state and critical assistance with identifying cases, laboratory was the first to identify the federal level worked together as tracking down and communicating with very rare fungal pathogen, Exserohi- well as communicated across all of those exposed to the contaminated lum. This discovery saved time and the departments and CDC to rapidly medication and developing treatment provided the nation with critical infor- identify and contact all potentially guidelines for an infection rarely seen mation to help with diagnostic and exposed patients.224 A review found in humans. In addition, public health treatment recommendations. that state and local public health departments around the country worked preparedness strategies helped l T he Michigan Department of Community quickly and efficiently to identify the respond to this emerging infection Health identified the first case of a joint outbreak and notify patients. Below are and reduce future potential harm.225 infection associated with the products. TFAH • healthyamericans.org 57 MRSA MRSA infection is caused by Staphylococ- though MRSA is still a major health threat, or CA-MRSA, has become increasingly cus aureus bacterium. Often called “staph,” a recent study showed that life-threatening responsible for serious skin and soft tis- this organism is a common cause of seri- HA-MRSA infections are declining. Invasive sue infections and for a serious form of ous skin, soft tissue and bloodstream HA-MRSA infections declined 54 percent pneumonia among previously healthy per- infections. The advent of antibiotics revolu- between 2005 and 2011, with 30,800 sons.230 CA-MRSA rates continue to rise at tionized the treatment of staph infections, fewer severe MRSA infections.228 Data an alarming rate, now accounting for more greatly reducing morbidity and mortality. from the NHSN also shows that rates of than half of community-acquired staph in- MRSA is a strain of staph that is resistant MRSA bloodstream infections occurring in fections in many communities.231 to antibiotics commonly used to treat it. hospitalized patients fell almost 50 percent Both HA- and CA-MRSA infections are MRSA can cause potentially life-threatening from 1997 to 2007. And CDC found that painful, difficult to treat, and cost the U.S. infections in bones, joints, surgical wounds, medical professionals have reduced blood- healthcare system billions of dollars annu- the bloodstream, heart valves and lungs.226 stream infections in hospital intensive care ally. While both types of MRSA still respond unit patients by 58 percent since 2001.229 In the past, most invasive MRSA infections to a few medications, there are growing occurred in hospitals or other healthcare This decrease in HA-MRSA infections is concerns that medication may be losing settings, such as nursing homes and dialy- encouraging, but MRSA remains an im- effectiveness. Some U.S. hospitals report sis centers. This is known as healthcare- portant public health problem and more seeing strains of MRSA that are less eas- associated MRSA, or HA-MRSA. Older remains to be done to further decrease ily killed by vancomycin, and 13 cases of adults and people with weakened immune risks of developing these infections. More complete resistance were reported in this systems are at most risk of HA-MRSA. 227 Al- recently, community-associated MRSA, country between 2000 and 2006.232 RECOMMENDATIONS: Reducing Healthcare-Associated Infections Recent efforts to improve infection patterns may go un-detected. Re- Roadmap to Elimination:235 Some key control practices have started showing sources must also be provided to strategies in the Action Plan include: promising results in reducing HAIs. TFAH states to validate the data reported by • educing inappropriate and unneces- R recommends that public health and facilities and to improve the science sary use of devices, like catheters healthcare officials should make limiting and research gap in HAI prevention.233 and ventilators; HAIs a top priority, which includes: l A ligning incentives to promote pre- • dhering to the best hygiene practices; A l R equiring all states and facilities vention: Initiatives like the Medicare • rescribing antibiotics only when P to report HAIs to the NHSN or other “no pay” rules and prevention-oriented really necessary; recognized system, and fully funding healthcare payment strategies outlined • mproving education, communication I the NHSN and Prevention Epicenters in a call to action in the American Jour- and best-practice protocols as the reg- at CDC: Fighting infections requires nal of Infection Control can provide ular standard-of-care throughout entire complete and accurate reporting. All incentives for healthcare providers to healthcare facilities, to practitioners states and facilities should be re- improve practices to reduce infections and to families and patients; and quired to provide information about and infection-related costs.”234 HAIs in addition to information about • mproving reporting and regulatory over- I l F ully and Swiftly Implementing the sight of HAIs and financial incentives outbreaks — without this information National Action Plan to Prevent for reducing the number of infections. prevention strategies are limited and Healthcare-Associated Infections: A the emergence of new outbreaks or 58 TFAH • healthyamericans.org Superbugs: Antibiotic Resistance Antibiotic Prescriptions per 1000 Persons of All Ages According to State, 2010241 Antimicrobial resistance presents one WA ND MT MN of the greatest threats to human health VT ME SD WI around the world. OR ID NH WY MI NY IA MA NE Each year more than 2 million Americans IL IN OH PA CT RI NV UT NJ CO develop antibiotic-resistant infections — and KS MO WV DE KY VA MD DC at least 23,000 of these people die as a re- CA OK TN NC AR sult.236 These are considered to be very con- AZ NM SC MS AL servative estimates, since current surveillance LA GA TX and data collection capabilities cannot capture 529-656 the full impact. Experts warn that antibiotic- 689-774 FL AK 780-836 resistance is expected to continue to grow and HI 843-896 become increasingly difficult to manage. 899-972 996-1237 Antibiotic resistance leads to more than eight million additional days Americans spend in the hospital a year, costs the bacterial infections. CDC’s Get Smart: Know ous and life-threatening infections.244 Many country an estimated extra $20 billion in When Antibiotics Work and other efforts are pharmaceutical companies have abandoned direct healthcare costs and at least $35 helping physicians, other prescribers and antibiotic research and development due to billion in lost productivity annually. 237, 238 patients better understand when antibiotic regulatory and economic barriers (i.e. antibi- prescriptions are appropriate and effective. 242 otics are less profitable than drugs to treat Antibiotics have been used to success- longer term conditions). In 1990, there were fully treat countless numbers of bacterial There are now forms of diseases ranging almost 20 pharmaceutical companies with infections since the 1940s. Over time, from things as common-place as strep large antibiotic research and development however, some infections — also called throat or ear infections to foodborne ill- (R&D) programs. Today, there are only three Superbugs — have adapted so that antibi- nesses like Salmonella to infections that or four large companies with strong and ac- otics can no longer effectively treat them. can be acquired while a person is hospital- tive programs and only a small number of ized or receiving healthcare, such as staph While antibacterial medications are the effec- companies have more limited programs. infections like MRSA, which are either un- tive course of treatment for many bacterial treatable with antibiotics or antibiotics are CDC, FDA, USDA and other public health infections and can be lifesaving, according less effective to fight against them. agencies have identified a number of strate- to CDC, in many cases antibiotics are actu- gies to reduce antibiotic resistance. A federal ally being used unnecessarily, often being CDC issued an Antibiotic Resistance Threats Interagency Task Force on Antimicrobial Resis- prescribed for viruses or other ailments. CDC in the U.S. 2013 report, where they priori- tance was created in 1999 and in 2001, they estimates up to half of antibiotic use in hu- tized a list of 18 “nightmare bacteria,” which released A Public Health Action Plan to Com- mans and much of antibiotic use in animals are resistant or increasingly resistant to bat Antimicrobial Resistance and updated the is unnecessary.239 According to a study in the antibiotics or have become more common plan in 2012.245 CDC, FDA and USDA also New England Journal of Medicine, the num- because of widespread use of antibiotics.243 have been tracking antibiotic resistance in ber of antibiotics prescribed per year could As resistance rates continue to increase foodborne bacteria since 1996 through the treat four out of every five Americans.240 The and more and more people are sickened National Antimicrobial Resistance Monitoring highest rates of antibiotic prescribing are in and die due to resistant infections, we are System (NARMS) and CDC tracks infectious Southeastern states, and lowest in the West. seeing fewer and fewer new antibiotics ap- diseases, HAIs and foodborne illnesses Overuse increases the likelihood that drugs proved, particularly to treat the most seri- through a range of surveillance systems.246 will be less effective when needed against TFAH • healthyamericans.org 59 CDC has identified some key strategies for important action needed to greatly slow preventing and reducing antibiotic resis- down the development and spread of an- tance, including:247 tibiotic-resistant infections is to change the way antibiotics are used. Up to half l P reventing the Spread of Resistance: of antibiotic use in humans and much of Avoiding infections in the first place antibiotic use in animals is unnecessary reduces the amount of antibiotics that and inappropriate and makes everyone have to be used and reduces the likeli- less safe. Stopping even some of the hood that resistance will develop during inappropriate and unnecessary use of therapy. There are many ways that drug- antibiotics in people and animals would resistant infections can be prevented: help greatly in slowing down the spread immunization, safe food preparation, of resistant bacteria. This commitment hand washing, and using antibiotics as to always use antibiotics appropriately directed and only when necessary. In and safely—only when they are needed addition, preventing infections also pre- to treat disease, and to choose the right vents the spread of resistant bacteria. antibiotics and to administer them in l T racking: CDC gathers data on the right way in every case—is known as antibiotic-resistant infections, causes antibiotic stewardship. of infections and whether there are l D eveloping New Drugs and Diagnostic particular reasons (risk factors) that Tests: Because antibiotic resistance oc- caused some people to get a resistant curs as part of a natural process in which infection. With that information, experts bacteria evolve, it can be slowed but not can develop specific strategies to stopped. Therefore, we will always need prevent those infections and prevent the new antibiotics to keep up with resistant resistant bacteria from spreading. bacteria as well as new diagnostic tests l I mproving Antibiotic Prescribing/ to track the development of resistance. Stewardship: Perhaps the single most Pediatric Prescribing AAP and CDC released Principles of Judi- l W eigh benefits versus harms of cious Antibiotic Prescribing for Bacterial antibiotics: Symptom reduction and Upper Respiratory Tract Infections during prevention of complications and the November 2013 Get Smart About secondary cases should be weighed Antibiotics Week. 248 The report highlights against the risk for side effects and recent AAP guidance about responsible resistance, as well as cost. prescribing of antibiotics, which include: 249 l I mplement accurate prescribing l D etermine the likelihood of a bacterial strategies: Select an appropriate infection: Antibiotics should not be used for antibiotic at the appropriate dose for viral diagnoses when a concurrent bacterial the shortest duration required. infection has been reasonably excluded. 60 TFAH • healthyamericans.org RECOMMENDATIONS: Reducing Antibiotic-Resistance TFAH recommends policies that help to appropriate prescription and use of • he FDA should also greatly en- T curb antibiotic overuse and encourage antibiotics across all relevant providers hance information collection and re- new antibiotic development become and healthcare settings. CMS, CDC, porting about antibiotic use in food high priorities, including: accrediting organizations, healthcare fa- animals so that the public better cilities and medical organizations must understands the volume and class l M aking countering antibiotic resis- also work together to reduce overpre- of antibiotics used, the targeted spe- tance and the development of new scribing and misuse of antibiotics by cies of animals, how the drugs are antibiotics a top health and national tracking and publicly reporting prescrib- administered, and for what purpose.  security priority: Given the rapid growth ing data, educating providers and pa- Better data will help public health of antibiotic-resistant diseases and tients about the harm of inappropriate officials be able to spot problematic the potential harm this could pose to prescribing, and providing clinical deci- trends and target solutions. Americans coupled with the limited re- sion support through HIT. search currently being done to develop • ncentivizing Development of New I new medicines, there needs to be • educing Overuse in Agriculture: It has R Antibacterial Drugs through BARDA renewed effort to raise the priority level been 36 years since FDA began working and Other Mechanisms: TFAH of addressing the problem. The federal on addressing overuse of medically-im- supports initiatives such as the new government should engage in a compre- portant antimicrobials on farms, but the FDA Antibacterial Drug Development hensive strategy to combat antimicrobial actions to date have been highly limited. Task Force and the recommendations resistance to help support research, im- • he FDA should ensure full implemen- T issued by The Brookings Institution, prove tracking of resistant bacteria and tation and evaluation of two voluntary in partnership with the FDA, for the identify a director within HHS to coordi- FDA Guidances for Industry, num- need to reevaluate acceptable levels nate efforts across the agency. 250 bers 209 and 213, which provide of risk and benefit in new treatments; guidelines for drug makers on the harnessing novel statistical and l F ully implementing the 2012 Public judicious use of antibiotics in food methodological approaches; Health Action Plan to Combat Anti- animals, such as eradicating use for streamlining the clinical trials microbial Resistance:251 The plan re- growth promotion and ending over-the- process; and prioritizing unmet need. leased by the Interagency Task Force on Antimicrobial Resistance, stressed counter use of medically-important • pproving Limited Population Antibacte- A that strong Administration leadership antibiotics in animal feed. rial Drug (LPAD) Pathway: FDA should is necessary to coordinate efforts • he FDA should finalize, implement, T have the authority to approve drugs for across agencies and prioritize this and evaluate the proposed regulation a limited population of patients with pressing public health problem. amending the Veterinary Feed Direc- serious or life-threatening infections tive, providing rules for veterinary over- and for drugs that fill an unmet need l I mplementing a comprehensive sight of antibiotic use in animal feed. based upon more limited data (e.g. national approach to combat resis- • Eventually, the U.S. should phase out smaller clinical trials). This mechanism tance, including: all unnecessary use of antibiotics (or, would speed access to new antibacte- • educing Overprescribing: CMS should R rial drugs to the patients who most all uses of antibiotics for reasons make an effective antibiotic steward- need them. In addition, the limited other than treating and controlling ship program a Condition of Participa- indication would help protect those new disease) in food animals, as has tion for all CMS-enrolled facilities, and antibacterial drugs from losing their ef- been done in countries such as Den- HHS should drive the development and fectiveness through overuse. mark with minimal economic impact.  adoption of quality measures related TFAH • healthyamericans.org 61 ANTIBIOTIC RESISTANT THREATS IN THE UNITED STATES, 2013 – CDC’S REPORT AND PRIORITIZATION OF THREATS252 How It Spreads (Most commonly: Drug-Resistant healthcare associated; Superbug Infections STI; Types of Infections in U.S. Annually food/water/agriculture; outside of healthcare setting) URGENT THREAT LIST Carbapenem-resistant 9,000; Often healthcare associated, via catheters, ventilators, Bloodstream infections from CREs can result in Enterobacteriaceae (CRE) 600 deaths surgical site or when patient is on a prolonged course death rates as high as 50 percent. Can also cause of antibiotics as part of their care. CDC classifies as urinary tract infections, pneumonia, inter-abdominal urgent because of a recent rapid rise in infection rates, abscesses, and other forms of infection. CREs can spread quickly and resistance to carbapenems is particularly worrisome, as one of the most powerful, “last resort” forms of antibiotics. Drug-resistant Gonorrhea 246,000 resistant to any Second most commonly reported infectious disease in Can result in discharge and inflammation at the drug (one third of cases); the U.S., sexually transmitted urethra, cervix, pharynx, or rectum, and can cause 3,280 reduced susceptibility infertility. to ceftriaxone (the currently used form of treatment) Clostridium difficile 250,000; Infection acquired while individual is taking antibiotics Can cause life-threatening diarrhea or colon 14,000 deaths for other care. Often healthcare associated inflammation SERIOUS THREAT LIST Multidrug-resistant 7,300 multi-drug; Healthcare associated – often among critically ill Pneumonia or bloodstream infections Acinetobacter 12,000 single-drug; patients 500 deaths Drug-resistant Campylobacter 310,000; Contaminated food or water or exposure through Diarrhea, fever, abdominal cramps, complications 120 deaths antibiotic use in animals like temporary paralysis Fluconazole-resistant Candida 3,400; Often healthcare associated -- bloodstream infection Number of types of yeast infections, such as (a fungus) 200 deaths related to this bacteria is fourth leading form of HAI bloodstream and skin infections Extended spectrum 26,000; Often healthcare associated -- an enzyme that Can lead to bloodstreamand other forms of infection ß-lactamase producing 1,700 deaths allows bacteria to become resistant to many forms of Enterobacteriaceae (ESBLs) antibiotics Vancomycin-resistant 20,000; Often healthcare associated – resistant to vancomycin, Bloodstream, surgical site and urinary tract Enterococcus (VRE) 1,300 deaths one of the antibiotics of ‘last resort’ infections Multidrug-resistant 6,700; Healthcare associated – responsible for 8 percent Bloodstream, urinary and surgical site infections Pseudomonas aeruginosa 440 deaths of all HAIs and pneumonia Drug-resistant Non-typhoidal 100,000 Mostly spreads through contaminated food and Diarrhea, fever, abdominal cramps, blood infections Salmonella sometimes exposure through agriculture Drug-resistant Salmonella 38,000 Food and water contaminated by feces, Americans who Causes typhoid fever, which can lead to bowel Typhi develop typhoid fever often are exposed when traveling perforation, shock and death. There is a vaccine that abroad. can prevent against this infection. Drug-resistant Shigella 27,000; Inadequate hand washing and hygiene habits, and can Diarrhea, fever, and abdominal pain, can lead to 40 deaths be sexually transmitted complications including reactive arthritis Drug-resistant Streptococcus 1.2 million; Pneumococcal infections often in young children or the Leading cause of bacterial pneumonia and meningitis pneumoniae 7,000 deaths elderly in the U.S. Can cause bloodstream, ear, and sinus infections. Rates in the U.S. have decreased with extensive use of PCV 13 vaccine. Methicillin-resistant 80,461 severe infections; Staph infections, including MRSA, are a leading cause of Can lead to a range of illnesses, from skin and Staphylococcus aureus 11,285 deaths healthcare associated infections wound infections to pneumonia and bloodstream (MRSA) infections to sepsis and death Drug-resistant tuberculosis 1,042 Most common serious infectious disease worldwide, Often attacks the lungs but can attack other parts spreads through the air via coughs, sneezes or of the body respiratory fluids CONCERNING THREAT LIST Vancomycin-resistant 13 since 2002 Healthcare associated staph infection, often via a Can lead to bloodstream infections, pneumonia, Staphylococcus aureus catheter, ventilator or surgical site heart valve infections, and bone infections (VRSA) Erythromycin-resistant Group 1,300; Bacteria spread to a part of the body that is normally Strep throat, toxic shock syndrome, “flesh-eating” A Streptococcus 160 deaths sterile, young children, the elderly and people with disease, scarlet fever, rheumatic fever, and skin underlying conditions are most vulnerable infections Clindamycin-resistant Group 7,600; Leading cause of bacterial infections in newborns, can Bloodstream infections, pneumonia, meningitis, and B Streptococcus 440 deaths cause infections in people of all ages skin infections. 62 TFAH • healthyamericans.org SECTI O N 4: Emergency SECTION 4: EMERGENCY OUTBREAKS: BIOTERRORISM AND HIGH-RISK NEW DISEASES Outbreaks Emergency Outbreaks: Bioterrorism and High-Risk New Diseases Since the September 11th and the anthrax tragedies, the United States has prioritized developing strategies to be prepared for emergency outbreaks — such as new diseases that have the potential to spread quickly and widely throughout the populations or diseases that are intentionally introduced through an act of bioterrorism. TFAH’s annual Ready or Not? and administration; surveillance; Protecting the Public’s Health from communications; legal and liability Diseases, Disasters and Bioterrorism protections; increasing and upgrading report documented considerable public health staffing trained to progress that had been made in prevent and respond to emergencies; the past decade to more effectively and limited improvements in prepare for and respond to public medical surge capacity. However, the health emergencies of all kinds reports have also tracked persistent — including major infectious areas of vulnerability, including disease outbreaks and bioterrorism. in biosurveillance, the ability to DECEMBER 2013 Since 2001, investments have led provide mass care in emergencies, to significant accomplishments maintaining a stable MCM strategy to in preparedness planning and continue research and development coordination; public health of vaccines and antiviral medications laboratories; vaccine manufacturing; and helping communities become the SNS; pharmaceutical and more resilient to cope with and medical equipment distribution recover from emergencies. Decrease in the Hospital Preparedness Instead of working to fill these gaps, in (HPP), has declined from $515 million Program Funding — 2003 vs. 2013 recent years funding has declined from in FY 2003 to $358 million in FY 2013, the levels needed to maintain existing without taking inflation into account. $515 million capabilities. Since 2001, there has been The PHEP and HPP programs address $358 million a 42 percent cut to federal funds from complementary areas of preparedness. CDC to support state and local pre- In 2012, these two major preparedness paredness, including the Public Health grant programs were aligned to improve Emergency Preparedness (PHEP) coordination and leverage resources. cooperative agreement. 253 In addi- The federal cuts combined with state tion, federal support for health system and local budget and staffing cuts mean preparedness for the nation, through that many of the capabilities that were 2003 2013 the Hospital Preparedness Program built are starting to erode. National Health Security Preparedness Index (NHSPI) On December 4, 2013, ASTHO, in part- across an entire community) and Surge Homeland Security; Federal Emergency nership with CDC and 20 development Management (the ability to quickly expand Management Agency; Fleishman-Hillard; partners, released the National Health Se- care and reach large numbers of people). International Association of Emergency curity Preparedness Index™ (NHSPI™), a Managers; McKinsey and Company; Health Surveillance (detecting new way to measure and advance the na- National Association of County and City and investigating potential health tion’s readiness to protect people during Health Officials; National Association of threats), Incident and Information a disaster — including major infectious State EMS Officials; National Emergency Management (responding to a public disease outbreaks caused by nature or Management Association; National health emergency by dispersing resources acts of bioterrorism. Governors Association; National Public and information), and Countermeasure Health Information Coalition; Office of the The NHSPI™ measures the health security Management (managing and deploying Assistant Secretary for Preparedness and preparedness of the nation by looking col- materials to prevent/treat health issues) Response; Preparedness and Emergency lectively at existing state-level data from were the domains with the highest results. Response Research Centers (PERRCs) a wide variety of sources. Uses of the Other stakeholders contributing to the from the following institutions: Emory Index include guiding quality improvement, project, included: American Public University, Harvard University, Johns informing policy and resource decisions, Health Association; American Red Cross; Hopkins University, University of California and encouraging shared responsibility for Association of Public Health Laboratories; — Los Angeles, University of Minnesota, preparedness across a community. Association of Schools and Programs University of North Carolina — Chapel Utilizing data from 128 measures from of Public Health; Association of State Hill, University of Pittsburgh, University of more than 35 sources, the NHSPI found and Territorial Health Officials; Boston Washington; RAND Corporation; Robert that that the national result was a 7.2 out Consulting Group; Center for Infectious Wood Johnson Foundation; Trust for of 10. The state scores ranged from 5.9 Disease Research and Policy; Centers for America’s Health; University of North in Nevada to 8.0 in Massachusetts. The Disease Control and Prevention; Council Carolina School of Medicine, Department lowest results were in domains for Com- of State and Territorial Epidemiologists; of Emergency Medicine; and UPMC Center munity Planning and Engagement (working Department of Defense; Department of for Health Security. 64 TFAH • healthyamericans.org PUBLIC HEALTH EMERGENCY PREPAREDNESS (PHEP) COOPERATIVE AGREEMENT PROGRAM The PHEP cooperative agreement pro- PHEP focuses on 15 key capability gram awards funds to states, territories areas, including: community and urban areas to build and sustain preparedness; community recovery; public health preparedness capabilities emergency operations coordination; that enhance their ability to respond to emergency public information and public health emergencies. PHEP awards warning; facility management; funds to 62 public health departments information sharing; mass care; nationwide, including the 50 states; four medical countermeasure dispensing; large metropolitan areas, Chicago, Los medical material management and Angeles County, New York City and Wash- distribution; medical surge; non- ington, D.C.; and eight U.S. territories pharmaceutical interventions; public and freely associated states: American health laboratory testing; public health Samoa, Guam, U.S. Virgin Islands, North- surveillance and epidemiological ern Mariana Islands, Puerto Rico, Feder- investigations; responder safety and ated States of Micronesia, Republic of health; and volunteer management. the Marshall Islands and the Republic of PHEP also supports the Cities Palau.254 The distribution of PHEP funds Readiness Initiative (CRI) to help cities is calculated using a formula that in- and large metropolitan areas prepare cludes a base amount for each awardee to dispense medicine quickly, on a plus population-based funding.255 large scale.256 TFAH • healthyamericans.org 65 Public Health Laboratories Public health laboratories are essential l N ational laboratories - including those to quickly identifying and diagnosing new operated by CDC, U.S. Army Medical Re- outbreaks and tracking ongoing outbreaks. search Institute for Infectious Diseases (USAMRIID), and the Naval Medical Re- Labs require highly expert staffing, extreme search Center (NMRC) — are responsible safety measures, specialized equipment, re- for specialized strain characterizations, bi- agents and other biological materials to use oforensics, select agent activity and han- for testing, and enough capacity to test for dling highly infectious biological agents; a large threat or multiple threats at once. They have ongoing responsibilities, such as l R eference laboratories, which are re- testing water and environmental conditions, sponsible for investigation and/or refer- as well as responding to emergency and ral of specimens. They are made up of Percentage of laboratory reports novel threats, such as an outbreak of Sal- more than 100 state and local public received by public health agencies monella or a suspicious white powder that health, military, international, veterinary, through electronic laboratory reporting — United States, 2013 could be an act of bioterrorism. agriculture, food and water testing labo- ratories; and l S entinel laboratories, which provide routine diagnostic services, rule-out and referral steps in the identification process. While these laboratories may not be equipped to perform the same tests as LRN Reference laboratories, they can test samples. Labs not only help detect and diagnose prob- lems, the information they help public health officials track the emergence and spread of different outbreaks and are an essential part of monitoring disease threats and under- Since 2001, public health labs have cre- standing how to control them. ated networks to be more efficient and ef- In 2010, CDC began funding 57 state, fective, so that every state has a baseline local and territorial health departments of capabilities but does not have to invest to encourage increased electronic the resources required to maintain every reporting of lab results to help make type of state-of-the-art equipment or staff- reporting faster and more complete.258 ing expertise. Samples can be shipped Data collected since then shows various to facilities with the needed expertise as improvements. By the end of July quickly and safety as possible. 2013, 54 of the 57 jurisdictions were The Laboratory Response Network for Bio- getting some laboratory reports through logical Threat Preparedness (LRN-B) includes Electronic Laboratory Reporting (ELR), labs with a hierarchy of different capabilities, and 62 percent of laboratory reports were so labs with increased capabilities provide being received through ELR compared to support for other labs, consisting of: 257 54 percent in 2012.259 66 TFAH • healthyamericans.org 37 state public health laboratories and D.C. report 9 state public health laboratories report NOT having INDICATOR 7: PUBLIC having a plan and capacity to handle a significant surge a plan and capacity to handle a significant surge in in testing over a six to eight week period in response testing over a six to eight week period in response to HEALTH LABORATORIES to an outbreak that increased testing over 300 percent an outbreak that increases testing over 300 percent from July 1, 2012 to July 30, 2013 (1 point). from July 1, 2012 to July 30, 2013 (0 points). — SURGE WORKFORCE Alabama Missouri Alaska Declined to respond: Arizona Montana Georgia Louisiana, Maryland, Arkansas New Hampshire Maine Nevada, Texas Key Finding: 37 state public California New Mexico Massachusetts Colorado New York Nebraska health laboratories and Connecticut North Carolina New Jersey Delaware Ohio North Dakota Washington, D.C. report having D.C. Oklahoma Utah Florida Oregon Vermont a plan and capacity to handle Hawaii Pennsylvania Idaho Rhode Island a significant surge in testing Illinois South Carolina Indiana South Dakota over a six to eight week period Iowa Tennessee Kansas Virginia in response to an outbreak that Kentucky Washington Michigan West Virginia increases testing over Minnesota Wisconsin Mississippi Wyoming 300 percent. Source: APHL 2013 Survey of State Public Health Laboratories This indicator examines whether lic health labs were also stretched The surveillance testing allows public a state’s public health laboratory beyond capacity. According to an health officials to gather enough would have enough trained staff to article published in the journal of the information to track the pandemic be able to work the hours necessary Association of Public Health Laborato- and monitor any genetic mutations or to respond to a major, widespread ries (APHL), “The peak public health changes in the virus. new disease outbreak. This type of laboratory response was unsustain- During a pandemic flu or other outbreak requires labs to be able to able; state and federal cutbacks have infectious disease outbreak, the test a large number of samples in a drained critical surge capacity from a demand on the public health lab very short period of time, not only to system already weakened by long-term workforce is great, and in some cases, identify infected individuals, but also workforce shortages.”261 exceeds supply. According to a survey to understand the scope and patterns In the initial phases of an outbreak of by APHL conducted of state public of the new disease — whether caused a novel influenza virus, public health health laboratory directors in the fall naturally or by an act of bioterrorism. labs are on the front lines conducting of 2013, 37 states and Washington, For instance, in 2001, between diagnostic testing since other labs D.C. reported having a plan and October and December, public health generally lack this capacity. Once capacity to handle a significant surge labs around the country tested more the novel virus is established in the in testing over a six to eight week than 120,000 samples for anthrax. 260 population, diagnostic testing is no period in response to an outbreak longer as important and public health that increases testing over 300 percent During the first wave of the H1N1 labs switch to surveillance testing. (during July 1, 2012 to June 30, 2013). pandemic in the spring of 2009, pub- TFAH • healthyamericans.org 67 INDICATOR 8: PUBLIC 46 states and Washington, D.C. reported having the 2 states report NOT having the capacity in place capacity in place to assure the timely transportation to assure the timely transportation (pick-up HEALTH LABORATORIES (pick-up and delivery) of samples 24/7/365 days to an and delivery) of samples 24/7/365 days to an appropriate Public Health Laboratory Response Network appropriate Public Health Laboratory Response — RAPID, SAFE Reference Laboratory (between July 1, 2012 to July 30, Network Reference Laboratory (between July 1, 2012 TRANSPORTATION OF 2013) (1 point). to July 30, 2013) (0 points). Alabama Montana Georgia Declined to respond: SAMPLES FOR TESTING Alaska Nebraska Indiana Nevada and Texas Arizona New Hampshire Arkansas New Jersey California New Mexico Key Finding: 46 states Colorado New York Connecticut North Carolina and Washington, D.C. have Delaware North Dakota D.C. Ohio the capacity to assure the Florida Oklahoma Hawaii Oregon timely transportation of Idaho Pennsylvania Illinois Rhode Island samples 24/7/365 days to Iowa South Carolina Kansas South Dakota an appropriate Public Health Kentucky Tennessee Louisiana Utah Laboratory Response Network Maine Vermont Maryland Virginia (LRN) Reference Laboratory. Massachusetts Washington Michigan West Virginia Minnesota Wisconsin Mississippi Wyoming Missouri Source: APHL 2013 Survey of State Public Health Laboratories This indicator examines whether a water-borne outbreaks, timeliness state’s public health laboratory has is often of the essence to confirm the capacity to be able to deliver and needed treatments and to contain a receive laboratory specimens on a 24- problem. This can include getting hour, seven day a week basis. This can the samples to and from a particular include a state operated courier, use lab or being able to transport a of a private delivery company such as specimen to a lab with the technology FedEx, or a contract courier service. required to test for a particular threat as part of the nation’s Laboratory Each state should have the capacity Response Network. to test samples of potential infectious disease threats needed during According to APHL’s survey of public major new outbreaks — or have health laboratory directors, from July arrangements to get the samples to 1, 2012 to July 30, 2013, 46 states and labs where they can quickly be tested. Washington, D.C. reported having For infectious diseases or food- or the capacity. 68 TFAH • healthyamericans.org 27 state public health laboratories reported evaluating 18 state public health laboratories and Washington, INDICATOR 9: PUBLIC the functionality of their COOP via a real event or D.C. reported they did NOT evaluate the functionality exercise, from July 1, 2012 to July 30, 2013 (1 point). of their COOP via a real event of exercise from July 1, HEALTH LABORATORIES 2012 to July 30, 2013 (0 points). — CAPABILITIES DURING Alabama Mississippi Arkansas Ohio Alaska Missouri Colorado Oregon EMERGENCIES OR DRILLS Arizona New Hampshire Connecticut Pennsylvania California New York D.C. Utah Delaware North Carolina Georgia West Virginia Florida Oklahoma Idaho Wisconsin Key Finding: 27 state public Hawaii South Carolina Iowa Wyoming Indiana South Dakota Maine health laboratories reported Kansas Tennessee Montana Did not respond: Kentucky Texas Nebraska Illinois, Massachusetts, evaluating their functionality of Louisiana Vermont New Mexico Nevada, New Jersey Maryland Virginia North Dakota and Rhode Island their Continuity of Operations Michigan Washington Minnesota Plan (COOP) during a real event Source: APHL 2013 Survey of State Public Health Laboratories or exercise (from July 1, 2012 to July 31, 2013). This indicator examines whether to perform during a wide range of a state’s public health laboratory emergencies and disruptive events, reported that they evaluated their including localized acts of nature, COOP during a real event or exercise, accidents and technological or attack- from July 1, 2012 to July 30, 2013. related emergencies.262 Aspects of a COOP include: essential functions; Conducting exercises and responding orders of succession; delegations to real events is important to gauge of authority; continuity facilities; how well emergency plans will work continuity communications; vital during actual events, and to evaluate records management; human strengths and areas of vulnerabilities capital; tests, training and exercises; to improve on. devolution of control and direction; One key aspect of responding to an and reconstitution. emergency is ensuring that public In the fall 2013 APHL survey of public health departments and laboratories, health laboratory directors, 26 state and other aspects of government, public health laboratories reported they will be able to continue to function were able to evaluate the functionality during a time of stress, such as a mass of their COOP during a real event or disease outbreak or bioterrorism event. exercise last year. In addition, 21 states Laboratories and most agencies have reported that they have documented continuity plans, but without seeing how that they have a COOP consistent they hold up during an actual incident with National Incident Management or simulated drill, it is hard to evaluate System (NIMS) guidelines, and 27 where there may be gaps in the plan. states reported that they have a state FEMA stresses that individual agency- or department-wide COOP that agencies should be able to continue includes the laboratory. TFAH • healthyamericans.org 69 RECOMMENDATIONS: Ensuring Fully-Functioning Labs Public health labs are critical for public to maintain the LRN-bio system to ef- health and building strong infectious ficiently and cost-effectively be able disease prevention and control capabili- to test and respond to threats, and ties. They are essential for diagnosing, maintain ongoing continuity of opera- treating and containing threats. To tions capabilities. ensure labs are fully-functional, TFAH l D eveloping and implementing recommends: plans to facilitate communication l E nsuring sufficient support for pub- between the healthcare providers lic health laboratories: To properly and systems and the public health function, public health labs need up- system and labs: As the health care to-date equipment, testing agents, a system is reforming, it is essential highly-trained workforce and safety to ensure that providers, including protections. Labs need appropriate ACOs and other emerging types of resources to maintain their daily re- models, have the ability to commu- sponsibilities as well as surge capac- nicate with state and local public ity to respond during major or new health laboratories. disease outbreaks. It is important 70 TFAH • healthyamericans.org ONGOING PREPAREDNESS GAP: Health System Preparedness And Enhancing Surge Capacity The ability of our healthcare system The HPP which is part of the Office , However, there continue to be major to quickly provide care for an influx of the Assistant Secretary of gaps, particularly in plans for mass of patients during an emergency is Preparedness and Response (ASPR) trauma events, which could overload the critical, but it is often identified as one at HHS, provides leadership and system, demand a surplus of equipment of the most difficult components of a funding through grants and cooperative and staffing and even incapacitate part preparedness response. agreements to states, territories and of the system itself. There has been eligible municipalities to improve surge increasing recognition that healthcare During a severe health emergency, the capacity and enhance community and system preparedness models must extend healthcare system would be stretched hospital preparedness for public health beyond focusing on individual hospitals, beyond normal limits. Patients would emergencies.264  HPP builds capabilities since during times of emergencies a larger quickly fill emergency rooms and doctors’ in the areas of health system community, including multiple hospitals, offices, exceed the existing number of preparedness, health system recovery, providers and other government and available hospital beds, and cause a medical surge, emergency operations community groups, need to work together surge in demand for critical medicines coordination, fatality management, to be effective. A number of independent and equipment. information sharing, responder safety assessments have encouraged moving toward a coalition-based model to better leverage resources, disseminate The challenge of how to equip hospitals and train healthcare staff information, enhance credibility and to handle the large influx of critically injured or ill patients who broaden reach.266, 267, 268 A healthcare show up for treatment after or during a public health emergency coalition (HCC) is a collective network of healthcare organizations, and public and remains the single most challenging issue for public health and private sector partners that work together medical preparedness.263 to prepare for, respond to and recover from a disaster. Since 2007, HPP has piloted In public health emergencies, such as a and health and volunteer management. a coalition-based model, and in 2012, new disease outbreak, a bioterror attack, Through the planning process launched new measures to move the full or catastrophic natural disaster, U.S. and cooperation within healthcare program toward a coalition approach. hospitals and healthcare facilities are coalitions, facilities are learning to The new measures focus on continuity of on the front lines providing triage and leverage resources, such as developing operations, medical surge and healthcare medical treatment to individuals. In the interoperable communications systems, coalition development assessment. HPP best of times, however, most emergency tracking available hospital beds, and has worked with CDC to better coordinate rooms and intensive care units (ICUs) sharing assets such as mobile medical and integrate preparedness programs to must confront bed shortages and staffing units. HPP was recently reauthorized support communities and states toward issues; in a mass casualty event — in the Pandemic and All-Hazards the goal of having a baseline set of particularly a pandemic influenza or mass Preparedness Reauthorization Act foundational capabilities in place that surge bioterror attack — the situation could (PAHPRA, P 113-5). .L. 265 and emergency plans can build upon.269 quickly become out of control. TFAH • healthyamericans.org 71 RECOMMENDATIONS: Enhancing Surge Capacity and Health System Preparedness Health system preparedness capabilities that healthcare coalitions should meet able in a way that would permit shar- have been one of the most persistent a federally-defined standard for their ing data across states if people are problems in public health preparedness ability to respond to a disaster; evacuated in large numbers. and require increased agreement and • lign HPP measures with other health A • ospitals should incorporate commu- H implementation on crisis standards of system quality initiatives, such as nity-wide disaster preparedness plan- care and improved integration of pre- CMS measures, Joint Commission ning and community resilience into paredness concerns into overarching standards and National Quality Forum their community benefit work. For ex- healthcare systems and coordination (NQF) measures; and ample, hospitals can integrate disas- across public health and healthcare pro- ter plans for individuals dependent on • ublicly report data from the recently P viders. To help improve surge capacity electricity or medication into patients’ revamped HPP measures so policy- concerns, TFAH recommends: discharge information. makers can track progress and gaps l C ontinuing to modernize the Hospital in the program. l E nsuring crisis standards of care Preparedness Program: TFAH sup- planning is underway in localities and l I ncorporating preparedness into the ports the move toward healthcare co- states: In 2013, the Institute of Medi- healthcare delivery system: alitions and updating of measures to cine issued Crisis Standards of Care: reflect a capabilities-based approach. • MS should work to expedite the C A Toolkit for Indicators and Triggers, Within the context of shrinking re- release of emergency preparedness a follow-up to its previously released sources, the Assistant Secretary for requirements for Medicare and Med- framework for crisis standards plan- Preparedness and Response should: icaid participating providers.270 CMS ning. ASPR has also developed a and ASPR should work together to align • ontinue to prioritize coordination C Communities of Interest clearinghouse those requirements and track progress. between the inpatient and outpatient website with resources for planners. health systems, including long term • ewly established federal and state N However, implementation has been care facilities, and ensure that health- healthcare marketplaces should begin limited at many local levels. Public care coalitions are reaching out to planning for disasters. Exchange mar- health must take a leadership. as well these partners; ketplace systems, using information as quality assurance role, to ensure provided by providers and insurers, health facilities and systems are en- • efine a minimum set of standards D should have the ability to operate and gaging in meaningful crisis standards that a healthcare coalition must meet maintain key enrollment and coverage of planning. If necessary, the federal to be considered effective. While HPP information in case of emergency. In government should require such plan- has avoided being overly-prescriptive addition, systems must be interoper- ning of PHEP and HPP grantees. with grantees, limited budgets demand 72 TFAH • healthyamericans.org ONGOING PREPAREDNESS GAP: Medical Countermeasures The government is the only real customer for most medical countermeasure products, such as anthrax and smallpox vaccines. As a result of the lack of a natural marketplace, the U.S. government has invested in the re- search, development and stockpiling of emer- gency MCMs for a pandemic, bioterror attack, emerging infectious disease outbreak, or chemical, radiological or nuclear events. Development of medical products for the nation’s biodefense is a key piece of any public health emergency response. By preparing for a bioterror attack with ad- equate supplies of countermeasures that can be rapidly deployed and administered, the nation can effectively neutralize that threat. A successful domestic MCM en- terprise will prepare the nation for new threats, expected or unexpected, by build- ing the science, policy and production ca- pacity in advance of an outbreak. The Public Health Emergency Medical Congress enacted Project BioShield Countermeasures Enterprise (PHEMCE), in 2004 to spur development and pro- created in 2006 by HHS, is made up of curement of MCMs and under the Pan- federal partners responsible for protecting demic and All-Hazards Preparedness the nation from the health effects associ- Act (PAHPA) of 2006 established and ated with chemical, biological, radiological authorized the BARDA to speed up the and nuclear (CBRN) threats, through the development of MCMs by supporting use of MCMs. In 2012, ASPR released advanced research, development, and a PHEMCE Strategy and PHEMCE Imple- testing; working with manufacturers mentation Plan, which together provide and regulators; and helping companies the blueprint the PHEMCE will follow in devise large-scale manufacturing strate- the near, mid- and long-term to achieve its gies. BARDA bridges the funding gap strategic goals, which include developing between early research and commercial new MCMs, establishing clear regulatory production. The Special Reserve Fund pathways, developing operational plans for of $5.6 billion was established to help use, and addressing gaps—all while pri- guarantee a market for newly developed oritizing investments in the most efficient vaccines and medicines needed for bio- ways possible — and plans for making defense that would not otherwise have a sure new MCMs are available, distributed commercial market. 271, 272 and used when needed in an incident.273 TFAH • healthyamericans.org 73 In August 2010, FDA launched a new anthrax antitoxins, awarded contracts for Medical Countermeasures Initiative (MCMi) cytokines to treat neutropenia associated to improve the agency’s efforts to minimize with exposure to ionizing radiation and red tape, maximize innovation and maintain awarded a contract to procure midazolam safety in its review and standards for to treat seizures associated with the development of MCMs. At first the exposure to chemical agents. In addition, initiative was limited to preparing for two products funded by BARDA under responding to a flu pandemic, but in 2011, Project BioShield were approved by the the project was expanded to address all FDA in fiscal year 2013: Raxibacumab, vaccines and medications related to CBRN an anthrax antitoxin, and heptavalent threats.274, 275 Additional coordination with botulinum antitoxin (HBAT). These BARDA and private industry is essential are the first novel products approved/ to understand priorities and to find ways licensed under the FDA’s “animal to improve processes to make them less rule.” Under advanced research and burdensome on companies. Through the development BARDA has initiated new initiative, FDA is developing new scientific programs to support MCM development and analytic tools to speed the approval of for candidate products for biodosimetry, lifesaving drugs and devices. biodiagnostics, antimicrobial resistance and biothreat pathogens, chemical, As of the end of fiscal year 2013, BARDA burns, blood products, sub-syndromes of investments resulted in 80 to 90 new acute radiation exposure (hematopoietic, candidate products in the pipeline under gastrointestinal, lung and skin), and advanced research and development and additional programs for anthrax and 12 products in the SNS. In 2013, under smallpox. BARDA has strategically Project BioShield, BARDA exercised an invested the dollars available under the option to procure additional doses of Special Reserve Fund, and in addition to smallpox vaccine for individuals with HIV procuring critical MCMs, has established or atopic dermatitis to include all age a robust portfolio of candidate ranges and nursing and pregnant women; products under advanced research maintaining preparedness levels for this and development with the potential to MCM, took delivery of the first treatment transition to procurement in the future, courses of a smallpox antiviral, awarded addressing remaining preparedness gaps. contracts to maintain the current level of 74 TFAH • healthyamericans.org STRATEGIC NATIONAL STOCKPILE The SNS is a national repository of The SNS maintains a variety of critical PHEMCE is currently evaluating how antibiotics, chemical antidotes and pharmaceuticals and medical supplies to replenish supplies used during other medicines and medical supplies such as antibiotics like ciprofloxacin the H1N1 pandemic, including N-95 for use during a major disease and doxycycline, chemical nerve agent respirators and surgical masks, and will outbreak, bioterror or chemical attack, antidotes like atropine and pralidoxime, develop a strategy to address the gap or other public health emergency. The antiviral drugs, pain management that includes stockpiling goals. program focuses on responding quickly drugs like morphine, vaccines for The federal government also can work with to a large-scale event in a large city or agents like smallpox and radiological partners in the public sector to strengthen metropolitan area (where more than half countermeasures like Prussian blue and the deployment of countermeasures. of the country’s population lives). The DTPA. In addition to pharmaceuticals, For instance, they worked with private first line of support is “12-hour Push the SNS contains supportive care pharmaceutical distribution companies Packages,” which contain over 50 tons supplies like endotracheal tubes and IV and pharmacies to distribute vaccines of medicines, antidotes and medical supplies, burn and blast supplies such during the H1N1 outbreak. supplies designed to provide rapid as sutures and bandages, ventilators, immediate help, even when the cause personnel protective equipment such Examples of Some SNS Contents: of an attack or event is uncertain. as N-95 respirators and surgical gloves l E nough smallpox vaccine to protect Push Packages are kept in secure and other life-saving medical materiel. every man, woman and child in warehouses across the country, ready America; During the H1N1 pandemic, the U.S. for rapid deployment to a designated government distributed both antivirals l M illions of regimens of city or site. SNS also has further and personal protective equipment countermeasures against anthrax; supplies, designed to arrive within 24 to from the SNS to state and local health l T herapeutic anthrax antitoxins to treat 26 hours, if necessary.276 departments. As of the most recent symptomatic patients; SNS Contents publicly available data in June 2010, l M illions of doses of the anthrax Quantities in the SNS change based the total quantity of antiviral drugs in vaccine (AVA); and on national planning guidance and the stockpile was 68 million treatment courses. CDC reports that the antiviral l H undreds of thousands of doses of prioritization, modeling scenarios, drugs, including pediatric formulations, countermeasures to address radiation standard inventory management have been replenished and increased. exposure. procedures and funding. TFAH • healthyamericans.org 75 RECOMMENDATIONS: Improving Research and Development of Medical Countermeasures TFAH recommends that the United l I mproving leadership and • ecognizing SNS and BARDA as the R States place a higher priority on re- accountability: The MCM enterprise sole purchaser and SNS as sole dis- search and development of MCMs, could benefit from a series of tributor of certain countermeasures. including vaccines, medicines and measures, including improved • mproving coordination among federal, I technology. Policymakers must ensure White House leadership and state and local public health partners. that the public health system is involved definition and coordination of roles • pplying lab science and animal mod- A in this process, from initial investment and responsibilities, increased els to guide SNS requirements. through distribution and dispensing. The transparency of contracting and nation’s MCM enterprise could be ad- decision-making process at HHS, long- l E nsuring the development and avail- vanced through the following activities: term funding, streamlined contracting ability of safe vaccines and medica- process, and continued progress in tions for children: The MCM enterprise l S upporting the entire medical coun- creating clear regulatory pathways at should continue to prioritize adapting termeasure enterprise, from initial FDA, as was recommend in a report the use of medical countermeasures research through dispensing: The by the Alliance for Biosecurity and MD to ensure they are safe and effective MCM enterprise must receive robust Becker Partners. 277 for children. While some progress has federal funding to ensure continuation been made to make sure there are safe of the pipeline, provide assurances to l D eveloping an ongoing plan for options available for children, a 2013 industry that the government will be maintaining and restocking the SNS: GAO report found that 40 percent of a reliable partner in development and Given limited budgets, PHEMCE must SNS products have not been approved procurement of new products, and assess how it will prioritize restocking for pediatric use.279 The federal govern- ensure products reach the intended of expiring materiel and stockpiling ment should set a goal to increase the recipients. As of FY 2014, the Proj- new products for the SNS based on development and procurement of pedi- ect BioShield Special Reserve Fund risk. The National Biodefense Sci- atric medical countermeasures so that (SRF) and supplemental funds from ence Board (NBSB) recently issued a the right countermeasure, in the right the H1N1 pandemic has expired. An statement recommending ways to im- dose and formulation, at the right time anomaly in the FY2014 continuing prove and measure the nation’s SNS can be safely delivered to all children resolution was necessary to allow by 2020, which included:278 during an emergency. BARDA to continue operations with ex- • sing science as a key strategy and U isting HHS funds, but will only maintain management tool. l F ostering public-private partnerships the program until January 2014. The for distributing and administering vac- • oving to a single appropriation M PHEMCE enterprise should receive cines and medications: Federal, state model to boost fiscal management. additional, long-term funding, most no- and local health departments should tably no-year funding in the SRF for pro- • rticulating an SNS vision for 2020. A partner with nongovernmental entities curement, annual funding for advanced • ailoring surge capacity. T to develop the most efficient distribu- development at BARDA and the Strate- • nhancing critical review processes. E tion and dispensing mechanisms for gic National Stockpile at CDC to enable medical countermeasures. In some • sing cost-benefit decisions as man- U storage and distribution of appropriate communities, private sector, health- agement components. MCMs, and regulatory science in FDA’s care, community-based or faith-based MCM initiative to promote safe path- • aking greater use of computational M organizations may have better systems ways to approval for new products. modeling and simulation. in place to reach target populations. 76 TFAH • healthyamericans.org ONGOING PREPAREDNESS GAP: Community Resilience Ensuring communities can cope with and have poor kidney function can need different To reach diverse communities, experts also recover from emergencies is a significant dose levels of medications, which can lead recommend providing information through challenge to public health preparedness, to worse health outcomes. Currently, two- channels beyond the Internet, such as which includes dealing with major infec- thirds of Americans are overweight or obese. radio and racial and ethnic publications tious disease outbreaks or disease threats and television, and in languages other than Experts recommend that improving resil- that may arise in the wake of a disaster. English. In addition, idiomatic translations ience, particularly among vulnerable popu- are important to reach specific cultural per- The most vulnerable members of a com- lations, requires: spectives effectively, and messages should munity, such as children, the elderly, l I mproving the overall health status be delivered by trusted sources, such as people with underlying health conditions of communities so they are in better religious and community leaders. and racial and ethnic minorities, face spe- condition to weather and respond to cial challenges that must be considered emergencies. Initiatives and programs In 2013, HHS and DHS launched a beta before disaster strikes. supported by the Prevention and Public version of a Community Health Resilience Health Fund’s Community Transforma- Initiative (CHRI). The CHRI is a public- The resilience of a community — including tion Grants can assist in these efforts; private collaboration intended to provide its ability to recover from disasters — is in- stakeholders with resources and guidance extricably linked to the underlying health of l P roviding clear, accurate, straightforward to promote resilience in their communi- that community and the basic, ongoing ca- guidance to the public; ties.282 CDC has also funded the develop- pabilities of that community’s public health l H ealth officials developing ongoing rela- ment of a Community Resilience Index: department or region. Without strong core tionships with members of the commu- Composite of Post-Event Wellbeing (CoPE- capabilities, a public health department nity, so they are trusted and understood WELL), to develop a predictor of the ability cannot be expected to meet additional de- when emergencies arise; and of a community to prepare for, survive and mands that arise during emergencies. Ded- l E ngaging members of the community di- rebuild from a disaster scenario.283 icating and maintaining ongoing resources rectly in emergency planning efforts. for these foundational public health capa- bilities, as measured in indicator one of this report, are tied to the ability of states and communities to be resilient in the face of unexpected and major threats. Building community resilience is one of the two overarching goals identified by HHS in the release of the draft Biennial Implemen- tation Plan for the National Health Security Strategy. It calls for fostering informed, empowered individuals and communities. Establishing ongoing strong relationships between public health officials and the com- munities they serve and efforts to improve the overall health status of the community are both strongly tied to resilience.280, 281 For instance, individuals who are obese or TFAH • healthyamericans.org 77 RECOMMENDATIONS: Improving Community Resilience Helping build healthier and stronger health and help restrain the rate of obesity, tobacco and other ongoing communities ensures they can cope growth in private and public health public health concerns helps forge rela- with and recover from major outbreaks, care costs.” 285 Community Preventive tionships between the community and health emergencies and other disasters Services Task Force recommendations public health officials, which lays an more easily. TFAH recommends that im- based on a review of effective important foundation for trust and com- proving community resilience should be prevention programs serve as the munication during times of emergency. a top priority for federal, state and local evidence base for CTGs and support Having partnerships with other ser- governments, including: the NPS.286 vices, agencies and community groups, such as housing and faith-based l S upporting prevention and public l I ncluding community resilience in organizations, also builds important health programs: Prevention programs emergency preparedness plans: It channels for reaching and providing that help improve the health of is important for health officials to assistance to at-risk individuals and communities, such as community know and understand special needs neighborhoods in times of crisis. resilience strategies, diabetes and concerns in different areas of the and obesity prevention efforts and community, particularly where there l P rioritizing plans for protecting chil- infectious control programs, can are high rates of poverty, high rates dren: Special efforts must be made decrease the vulnerability for infectious of seniors and children, high rates of to work with childcare centers and diseases by improving American’s chronic diseases, low community en- schools to coordinate and plan for underlying health and can contribute gagement, limited English proficiency emergencies. This should include to strategies to contain the spread and limited access to transportation. ensuring all childcare facilities have ap- of infections.284  The Prevention and Health officials and emergency man- propriate disaster plans in place, and Public Health Fund (PPHF), the National agement officials must have plans public health officials should work with Prevention Strategy (NPS), Community and mechanisms in place to provide parents, educators, schools and school Transformation Grants (CTGs) and assistance to these neighborhoods in systems to ensure every school has a other programs focused on improving times of crisis, and members of these plan in place, that plans are tested and the health of communities, particularly communities should be part of any to help teach children how to be pre- targeting health inequities in lower- emergency planning effort to ensure pared, such as having plans for how to income communities and empowering the needs and concerns of the public reunify with teachers or parents. those communities to actively engage are heard and addressed. Federal l E nsuring rebuilding efforts incorpo- their residents in improving the partners must provide strong techni- rate best practices for making the health of their neighborhoods, help cal assistance to allow for the cre- community even stronger: As com- all communities be better prepared to ation of models that can be adapted munities recover from a disaster, they weather and recover in the aftermath to meet the needs of specific commu- should be rebuilt to maximize commu- of disease outbreaks and other nities across the United States. nity resilience, health outcomes and health emergencies. The Prevention l I ncorporating preparedness activities social services. The IOM is beginning Fund was created by the ACA as the into the ongoing work of public health a relevant study, Post-Disaster Recov- first mandatory funding stream “to departments and other social ser- ery of a Community’s Public Health, provide for expanded and sustained vices: Supporting community health Medical and Social Services, that national investment in prevention and organizations and coalitions to address should inform such an approach. public health programs to improve 78 TFAH • healthyamericans.org Examples of Bioterror Threats CDC classifies biological agents that could Inspection Service (USPIS) formed a effective means of transmission.290 That is be used for an intentional bioattack into task force to investigate the crime. The why anthrax is considered by many to be three categories: investigation lasted seven years and was the ideal bioweapon. It is extremely stable undertaken by FBI field offices in Miami, and can be stored almost indefinitely as a l C ategory A, or “High-Priority Agents,” is New York, Newark, New Haven, Baltimore dry powder. The costs of producing anthrax considered the most dangerous and in- and Washington, D.C. At the beginning of material are relatively low and knowledge cludes: Anthrax, botulism, plague, small- the investigation, the limitations on sci- about production is widely available and pox, tularemia, and viral hemorrhagic entific analysis prevented the task force does not require high degrees of technol- fevers (e.g., Ebola, Marburg). from finding the culprit because it was ogy. According to DOD, anthrax is easy l C ategory B, or “Second-highest Priority impossible to determine precisely from to weaponize and can be loaded, in a Agents,” includes food safety threats which spores the anthrax came. freeze-dried condition, in munitions or dis- (e.g., Salmonella and E. coli), ricin toxin, seminated as an aerosol with crude spray- At least 22 victims contracted anthrax, Typhus fever, and viral encephalitis, ers.291 Currently, detection of this anthrax with five people dying from the infection. among others. is limited. In 1999, CDC classified anthrax In addition, 31 people tested positive for as a Category A bioterrorism agent, which l C ategory C, or “Third-highest Priority exposure to anthrax spores. In all, 35 post means it poses the highest level of threat Agents” include emerging pathogens offices and mailrooms were contaminated to national security. However, unlike some that could be engineered for mass along with seven buildings on Capitol Hill other Category A agents (e.g. smallpox), dissemination in the future because in Washington, D.C. The investigation in- anthrax does not spread from person to of availability; ease of production and cluded over 600,000 investigator hours, person, limiting the risk to those directly dissemination; and potential for high 10,000 witness interviews, 80 searches exposed in an attack.292 morbidity and mortality rates and major and over 6,000 pieces of evidence. In ad- health impact. Hantavirus is an example dition, there were 5,750 federal grand jury Historically, numerous nations have ex- of a Category C agent. 287 subpoenas issued and 5,730 environmen- perimented with anthrax as a biological tal samples collected from over 60 sites. weapon, including the U.S. offensive biologi- Two threats that have been of high focus in The investigation cost $100 million. 288, 289 cal weapons program that was disbanded in U.S. bioterrorism preparedness strategies 1969.293 The worst documented outbreak include: Anthrax is a potentially lethal infection of inhalation anthrax in humans occurred in caused by the bacterium Bacillus anthracis. l A nthrax: In September and October Russia in 1979, when anthrax spores were Outside of a host, this bacterium normally 2001, at least five envelopes containing accidentally released from a military biologi- resides as a spore — a hardy, dormant cell Bacillus anthracis (anthrax) were mailed cal weapons facility near the town of Sverd- that may become active (germinate) in the to Senators Patrick Leahy and Thomas lovsk, killing at least 66 people. right conditions. Anthrax generally affects Daschle and to members of the media in large grazing animals, but it can also infect Much of the planning for the Cities Readi- New York City and Boca Raton, Florida. humans who handle products of infected ness Initiative has centered on planning After the bioterrorist attacks were identi- animals. However, deliberate exposure to for the ability to respond to a major an- fied, the Federal Bureau of Investiga- aerosolized anthrax spores also is a highly thrax attack in urban areas. tion (FBI) and the United States Postal TFAH • healthyamericans.org 79 Potential Economic Costs of an Anthrax Attack l A ccording to an article in the Wash- l A ccording to a report in the New York workers’ compensation losses, which ington Post, the clean-up from the Times, under a hypothetical scenario would be three times greater than the 2001 anthrax attacks exceeded $1 developed by DHS involving an anthrax entire $30 billion workers’ compensa- billion.294 A reported $42 million was attack, if terrorists were to spray aero- tion industry.297 spent to decontaminate the Hart Sen- solized anthrax from a van in three cit- l R isk Management Solutions (RMS), a ate Office Building and other Capitol ies initially, followed by two more cities leading risk consulting firm, believes an Hill offices, and it cost in excess of shortly afterward, casualties could well attack on downtown New York City could $200 million to decontaminate the exceed 13,000, and result in a loss of result in 173,000 casualties. In this postal facilities at Brentwood in Wash- billions of dollars.296 Other estimates scenario, anthrax is weaponized and ington, D.C. and in Hamilton Township, are that anthrax could result in more dispersed in aerosol form, resulting in New Jersey.295 This does not include than 13,000 deaths in a single city. inhalation of anthrax by approximately the cost of the public health response l A ccording to a study by Towers Perrin one million people. RMS estimates and laboratory testing of specimens Consulting, one anthrax attack in New economic losses of $91 billion from around the country. York City could lead to $90 billion in workers compensation alone.298 l S mallpox: Although WHO declared that “number one bio-threat facing the country” l I ndividuals designated by public health smallpox was eradicated in 1980, this and made planning for an attack a top authorities to conduct investigation and contagious and deadly infectious dis- priority.299 The Administration launched follow-up of initial smallpox cases that ease caused by the Variola major virus, a national smallpox vaccination initiative might necessitate direct patient contact remains high on the list of possible bio- with the goal of immunizing 500,000 should receive the smallpox vaccine. terror threats. healthcare workers in 30 days and 10 l E very state and territory should establish million emergency response personnel The last naturally occurring case of and maintain one smallpox response team. within a year. Immunization rates fell well- smallpox was reported in 1977. Currently, below that target level with approximately l E ach acute-care hospital should identify there is no evidence of naturally occurring 40,000 people actually vaccinated. The health-care workers who can be vac- smallpox transmission anywhere in the plan faced obstacles, including unexpected cinated and trained to provide direct world. Although a worldwide immunization side effects, worker compensation issues, medical care and management for the program eradicated smallpox disease and liability concerns that precluded its full first smallpox patients requiring hospital decades ago, small quantities of smallpox implementation. 300, 301 admission. But, if possible, the smallpox virus officially still exist in research vaccination program should include previ- laboratories in Atlanta, Georgia, and ACIP and the Healthcare Infection Control ously vaccinated health-care personnel to in Novosibirsk, Russia. There is a fear Practices Advisory Committee (HICPAC) decrease the potential for adverse events. there may be other unknown sources have developed recommendations for of smallpox virus that could fall into the using smallpox vaccine in the pre-event l P ersons administering smallpox vaccine hands of terrorists. In January 2003, the vaccination program in the United States, in this pre-event vaccination program Bush Administration declared smallpox the including that: 302 should be vaccinated. 80 TFAH • healthyamericans.org SECTI O N 5: Food Safety SECTION 5: FOOD SAFETY Food Safety Annually, 48 million Americans suffer from foodborne illnesses. These illnesses send 128,000 people to the hospital and kill approximately 3,000.303 Virtually all of these illnesses could be prevented if the right measures are taken to improve the U.S. food safety system. Every year, approximately one million Major outbreaks can also contribute Americans who are stricken with to significant economic losses in foodborne illnesses will suffer from the agriculture and food retail long-term chronic complications.304 industries, which account for Foodborne illnesses take a high approximately 13 percent of the U.S. health and financial toll. For GDP and are the largest industries instance, Salmonella infections, which and employers in the United are responsible for an estimated States.308 Americans spend more $365 million in direct medical costs than $1 trillion on food annually. annually, have not decreased over the Through FoodNet, CDC tracks past 15 years and have increased by infections caused by the bacteria 10 percent recently.305 Campylobacter, E. coli O157, Foodborne diseases caused by major Listeria, Salmonella, Shigella, Vibrio, pathogens alone are estimated to cost and Yersinia, and the parasites up to $44 billion annually in medical Cryptosporidium and Cyclospora.309 costs and lost productivity.306, 307 DECEMBER 2013 In 2011 and 2012, Salmonella was According to another study by the the most common bacterial infection Center for Science in the Public tracked by FoodNet, followed closely Interest (CSPI), 10 foods regulated by Campylobacter, and Campylobacter by the FDA account for almost 40 infections have been on the rise in percent of all foodborne outbreaks the last five years. 310 Campylobacter since 1990. The list includes 1) infections usually occur due to leafy greens; 2) eggs; 3) tuna; 4) consumption of undercooked poultry, oysters; 5) potatoes; 6) cheese; 7) raw milk, produce and untreated water, ice cream; 8) tomatoes; 9) sprouts; as well as contact with young animals. 311 and 10) berries. 315 Vibrio infections are rare (0.41 cases Norovirus is the leading cause of illness reported per 100,000 population), but from contaminated food in the United have increased by almost 50 percent States. During 2009-2010, norovirus since they were measured from 2006 was responsible for the largest number to 2008.312 They are often attributable of outbreaks and outbreak-associated to eating raw oysters, and specifically illnesses, similar to trends identified during warmer months when water during the preceding decade.316, 317 contains more Vibrio organisms.313 In Foodborne norovirus outbreaks result a recent study, CDC reported on the most commonly from handling of ready- types of food commodities that cause to-eat foods by infected individuals, the most illnesses and deaths and found but can also occur due to use of that produce causes the most illness (46 fecally-contaminated water during percent), but meat and poultry cause production.318 the most deaths (29 percent).314 82 TFAH • healthyamericans.org 2013 Major Foodborne Illness Outbreak: Cyclosporiasis Cyclospora cayetanensis is a parasite that causes an intestinal infection called cyclo- sporiasis. In 2013, CDC, FDA and state and local health departments investigated multi-state outbreaks of cyclosporiasis that included dozens of individual restaurant- or grocery store-associated clusters linked to fresh cilantro and a bagged salad mix, both imported from Mexico. A total of 631 cyclosporiasis cases from 25 states and New York City were identified as part of these outbreaks, from Arkansas, Califor- nia, Connecticut, Florida, Georgia, Illinois, Iowa, Kansas, Louisiana, Massachusetts, Michigan, Minnesota, Missouri, Nebraska, New Hampshire, New Jersey, New York, Ohio, Pennsylvania, South Dakota, Tennes- see, Texas, Virginia, Wisconsin and Wyo- ming.319 Most of the illnesses occurred from June through July. Almost 10 percent of cases reported being hospitalized, but no deaths were reported. TFAH • healthyamericans.org 83 RECOMMENDATIONS: Fixing Food Safety To improve food safety in the United to restructure food safety functions States, TFAH recommends: across the federal government into a single, unified food safety agency l F ully funding and implementing the to carry out a prevention-focused, Food Safety Modernization Act: Al- integrated food safety strategy. This though the Food Safety Modernization same type of coordinated, cross-gov- Act passed in 2011, the White House ernmental approach to food safety is has yet to finalize several key rules to also needed at the state level. implement the law, including preven- tive controls for human food, produce l I mproving surveillance of foodborne safety and a foreign supplier verifica- illnesses: Currently, foodborne ill- tion program. 320 Several of these rules nesses are radically underreported in are well past the statutory deadline the United States and the quality of for implementation. Congress and reporting varies dramatically by state. the Administration should also pro- New standards and requirements vide enough funding to FDA, CDC and should be put in place to incentiv- relevant state agencies to be able to ize states to improve reporting and implement and enforce the law. penalize states for underreporting. Surveillance for foodborne illness l I mproving inspection capacity: There outbreaks should be fully integrated are insufficient resources to support with other HIT systems, which will enough inspectors for foods regulated help improve tracking and identifica- by FDA, and there is not enough au- tion of the scope of problems as well thority for FDA to have oversight over as sources of outbreaks. FDA and state and third party inspections. CDC should also have a plan for re- l M oving toward a unified government quiring clinics to send cultures from food safety agency: The government rapid response tests showing prob- currently does not have a coordi- lems to public health labs to allow for nated, cross-governmental approach subtype pathogen testing. to food safety. Right now, food l P reventing the tainting of food by safety activities are siloed across a environmental contaminants: Mea- range of agencies, and many priori- sures should be implemented to ties and practices are outdated. As prevent the tainting of food by envi- a first step, food safety functions ronmental contaminants, such as un- should continue to be unified within treated sewage or manure that enter the FDA, and a plan with a set time- waters and pollute crops downstream. line should be developed for how 84 TFAH • healthyamericans.org SECTI O N 6: HIV/AIDS, SECTION 6: HIV/AIDS, VIRAL HEPATITIS and TUBERCULOSIS PREVENTION HIV/AIDS, Viral Hepatitis and Tuberculosis Prevention Viral Hepatitis and Even though they are largely preventable, HIV/AIDS, viral hepatitis and TB remain serious public health threats Tuberculosis in the United States.321 Misperceptions plague each of Prevention the diseases, which have taken away from the urgency and resources devoted to their prevention and control. Millions of Americans are living with nearly half (46 percent) of HIV/AIDS, hepatitis B and hepatitis Americans living with HIV and C, but do not know they are infected. 44 percent of new infections, but This not only puts them at risk by not only constitute 14 percent of the receiving needed treatment, it puts total population.325 In 2010, Black them at risk for spreading the disease. MSM accounted for almost as many new HIV infections as white l IV/AIDS: Over the years, H MSM, despite their differences successful treatment regimens for in population size. Young gay HIV/AIDS has led to complacency Black men (ages 13 to 24) were and feeling that the disease is at the highest risk, accounting for largely under control, when the the greatest number of new HIV reality is that more than 1.1 million infections (4,800 in 2010).326 Americans are living with the disease, and of those, roughly one in five do • ehavioral risks alone do not ac- B not know they are infected. 322 The count for the disproportionately high complacency has also contributed to new HIV infections among Black gay an alarming rise in new infections men. A review of 53 studies found among young gay men. In 2011, that key risk factors were comparable there were almost 50,000 diagnoses or lower compared to white MSM. of new HIV infections. 323 Sixty-two Other factors, such as the legacy of percent of new infections were in higher infection rates among Blacks men who have sex with men (MSM), in the earlier years of the epidemic, even though they represent only less frequent use of available treat- DECEMBER 2013 around 2 percent of the total U.S. ment and higher rates of individuals population. 324 who do not know they are infected (e.g. have not been screened for • The risk is even more acute for HIV), exacerbate the trends.327 gay men of color. Blacks represent l epatitis B and C: Around five H racial and ethnic minorities, million Americans have HBV or persons experiencing homelessness, HCV, but between 65 percent and incarceration, substance and 75 percent do not know they have alcohol abuse and people who them. 328 As they age, they are at risk have weakened immune systems for developing serious liver diseases or from HIV/AIDS, diabetes and cancer unless they receive treatment. other conditions. These diseases Two-thirds of those with HCV are can also co-exist, contribute to the Baby Boomers and one in 12 Asian susceptibility of other diseases and Americans has HBV. worsen symptoms of diseases. For instance, of Americans living with l uberculosis: During the 1970’s, TB T HIV, 25 percent are also co-infected cases had greatly declined (from more with hepatitis C and 10 percent are than 84,000 cases to just over 22,000). co-infected with hepatitis B, and This led to a sense of complacency HIV is one of the biggest risk factors that allowed the deterioration of TB for progression of TB, while TB control programs.”329 However, the accelerates HIV progression.330, 331 country experienced a resurgence of the disease in the mid-1980s and There is strong evidence that if the best early-1990s with emergence of drug- practices for prevention were widely resistant TB, HIV/AIDS and changing implemented, there could be sharp immigration patterns with more reductions in each of these diseases. people arriving from countries with However, the misperceptions that a high TB burden. Improvements in these problems are not as severe as treatment, case finding, laboratory they are — and a reluctance to invest capacity, and infrastructure allowed in prevention strategies — leaves the US to regain control from the millions of Americans at continued resurgence, and cases again declined. and unnecessary risk. For instance, prevention through safe sex and l verlapping Risks and Conditions: O condom use, syringe exchange According to CDC, HIV/AIDS, viral programs and routine screening can hepatitis, STIs and TB have some help identify those in need of treatment overlapping at-risk populations, and help prevent the additional spread including racial and ethnic of the diseases and ensure those who minorities. Populations at-risk need treatment receive appropriate for HIV, viral hepatitis and STIs care and services.332, 333 In addition, include MSM and injection drug providing treatment to those who have users — and most STIs have similar HIV is one of the most effective ways prevention strategies. Persons at to limit the continued spread of the high-risk for TB include people disease to others. born outside the United States, 86 TFAH • healthyamericans.org 33 states and D.C. cover routine HIV screening under 16 states do not cover routine HIV screening under INDICATOR 10: their Medicaid programs (1 point). their Medicaid programs (0 points). One state declined to respond. SCREENING FOR HIV/AIDS Alaska New Hampshire Alabama Michigan California New Mexico Arizona Mississippi Colorado New York Arkansas Nebraska Key Finding: 33 states and Connecticut North Carolina Florida South Carolina Delaware North Dakota Georgia South Dakota Washington, D.C. cover routine D.C. Ohio Indiana Utah Hawaii Oklahoma Iowa Virginia HIV screening under their Idaho Oregon Maine Illinois Pennsylvania Maryland Declined to respond: Medicaid programs. Kansas Rhode Island New Jersey Kentucky Tennessee Louisiana Texas Massachusetts Vermont Minnesota Washington Missouri West Virginia Montana Wisconsin Nevada Wyoming Source: Kaiser Commission on Medicaid This indicator examines whether Screening is considered particularly a state’s Medicaid program covers important so individuals who may not routine HIV screening, which is know they are infected can receive recommended by CDC for all patients treatment as soon as possible and between the ages of 13 and 64. take action to prevent spreading the infection to others. While CDC According to a survey conducted by the estimates that 18 percent of those Kaiser Family Foundation’s Commission who were HIV positive as of 2009 on Medicaid and the Uninsured, were unaware of their infection, the as of January 1, 2013, 33 states and proportions were substantially higher Washington, D.C. reported coverage among younger Americans. Lack of of routine HIV screening under their awareness among people ages 13 to Medicaid programs, while 16 states 24 (59.5 percent) and 25 to 34 (28.1 reported coverage of testing only when percent) was particularly high.336 An it is considered “medically necessary.”334 estimated 49 percent of new HIV (One state — New Jersey did not infections are from the 20 percent respond to the survey). States in the of people living with HIV who are South were least likely to cover routine unaware of their infection.337 screening (50 percent, or 8 in 16), while over half of states in the Midwest did In 2006, CDC released screening (58 percent, or 7 of 11). Western states guidelines recommending routine were most likely to provide coverage (85 HIV screening in all healthcare percent, or 12 of 13), followed by the settings for 13 to 64 year olds, unless Northeast (78 percent, or 6 of 9). a patient opts out. This is in contrast TFAH • healthyamericans.org 87 since these Americans include many Rates of Diagnoses of HIV Infection among Adults and Adolescents, 2011—United States and 6 Dependent Areas of the lowest-income and most N = 50,007 Total Rate = 19.1 vulnerable in terms of quality of health and risk for HIV infection. According to a 2007 study, 20 percent of individuals diagnosed with HIV were already on Medicaid.340 HIV testing is the first step in the HIV care continuum. In order to assure best health outcomes, people living with HIV need to be engaged in care and treatment, with the goal of achieving viral suppression. When the HIV virus is suppressed, individuals are healthier and, quite importantly Note. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data have been from a public health standpoint, statistically adjusted to account for reporting delays, but not for incomplete reporting. are also less likely to transmit HIV. Nationally, CDC estimates that only to “medically necessary” or targeted 25 percent of those living with HIV testing for those considered at are virally suppressed.341 Jurisdictions higher risk. In addition, screening where high rates of viral load of pregnant women helps decrease suppression are achieved have seen the vertical transmission of infection. declines in infection rates, in contrast In 2013, the U.S. Preventive Services to national trends. Task Force (USPSTF) gave routine screening of all Americans ages 15 In addition to expanding coverage to 64 an “A” rating, which means of screenings for most insured under the ACA, new group and Americans, the ACA made it illegal individual plans, Medicare and for insurers to deny coverage due to Medicaid Expansion programs are patients with pre-existing conditions required to provide the service — so insurers can no longer deny without co-payment or cost-sharing. 338 coverage or drop coverage for This requirement, however, is not children and adults living with HIV/ extended to the base Medicaid AIDS, and it also eliminated lifetime programs in states, so decisions about caps on insurance coverage, which covering routine HIV screenings is has been a long-standing issue for left up to the states. 339 HIV/AIDS coverage and treatment. In addition, the ACA helped expand Experts believe that providing coverage for a significant number screening services for Medicaid of Americans living with HIV/AIDS beneficiaries is particularly important 88 TFAH • healthyamericans.org by allowing states to expand their Medicaid programs to cover all HIV incidence among 13–29 year old men who have sex with men adults earning up to 133 percent (MSM) overall and by race/ethnicity — United States, 2006–2009 of the federal poverty level in 2014. As of October 2013, 25 states and Washington, D.C. are participating in Medicaid Expansion.342 The Health Resources and Services Administration (HRSA) which administers the Ryan White Program, a federal program that pays for healthcare and related services for uninsured and underinsured people living with HIV/AIDS, notes that many Ryan White patients will gain access to or see their current health insurance plans improve under the ACA, and is working on transition plans to ensure patients receive all Source: Prejean J, Song R, Hernandez A, Ziebell R, Green T, et al. (2011) Estimated HIV Incidence available services and benefits.343 in the United States, 2006–2009. PLoS ONE 6(8): e17502. doi:10.1371/journal.pone.0017502 . http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0017502 Estimated Risk for HIV Infection for High-Risk Groups 2,735 (Infections per 100,000 people in each group, 2006) 1,881 1,710 716 344 47 23 12 2 White Black Black Hispanic Black White Hispanic Black Black MSM MSM Heterosexual MSM Heterosexual Heterosexual Heterosexual Male IDUs Female IDUs Women Men Women Women Estimated Group Size: 3,846,000 592,000 15,740,000 798,000 14,116,000 94,559,000 18,231,000 107,000 54,000 Source: National HIV/AIDS Strategy for the United States. July 2010. Holtgrave, D., Johns Hopkins Bloomberg School of Public Health based on analysis of HIV incidence in the 50 states from MMWR, October 3, 2008, with the inclusion of HIV incidence for Puerto Rico, where all Puerto Rico cases were classified as Hispanic and taken from CDC’s MMWR , June 5, 2009. Population sizes for 2006 are rounded estimates derived from analysis of the following sources: Statistical Abstract US, 2009; CDC estimate of 4% of men are MSM (MSM denotes men who have sex with men); The National Survey on Drug Use and Health Report, October 29, 2009; Brady et al., Journal of Urban Health 2008; and Thierry et al., Emerging Infectious Diseases, 2004. TFAH • healthyamericans.org 89 HIV/AIDS Worldwide, an estimated 35.3 million peo- cine exists to protect against HIV/AIDS, so ple are living with HIV/AIDS, and over half of efforts to curb the spread of the virus focus them are women.344 And though the spread on prevention, treatment and education. of the virus has slowed in some countries, Some significant federal initiatives to com- it has escalated or remained steady in bat HIV/AIDS include: others.  Since 1981, more than 25 million people have died due to AIDS (the most l N IH conducts ongoing research to ad- advanced stage of HIV).  More than 2.3 vance treatments for HIV/AIDS and to try million people were newly infected with HIV to develop a vaccine, microbicides, behav- and 1.6 million died in 2012 alone. 345 ioral and social science prevention inter- ventions and strategies to limit the spread By damaging or destroying the cells of the of the disease through better treatment.349 body’s immune system, HIV interferes with the ability to effectively fight off viruses, l T he Division of HIV/AIDS Prevention bacteria, fungi and neglected parasites that (DHAP) at CDC supports a range of preven- cause disease.346 This makes individuals tion, control and surveillance programs.350 with HIV more susceptible to certain types l I n 1990, the Ryan White AIDS Resources of cancers and to opportunistic infections Emergency Care Act (now the Ryan that the body would normally resist, such White HIV/AIDS Treatment Extension as pneumonia, TB and meningitis. Act of 2009) was enacted as the larg- An individual can become infected with HIV est federally funded program for people in several ways, including unprotected sex; in the United States living with HIV/ transfusion of infected blood; transmission AIDS. The program has provided at least through needle sharing or accidental nee- some level of care for around 500,000 dle sticks; re-use of syringes in a medical Americans each year as a “payer of last setting, especially where the medical infra- resort” to fund treatment and support structure is lacking; or transmission from services when no other resources are mother to child during pregnancy, delivery, available, including for drug therapy.351 or through breast feeding.347 In rare cases, l I n 2003, the President’s Emergency Plan the virus may be transmitted through organ for AIDS Relief (PEPFAR) was launched, or tissue transplants or unsterilized dental committing $15 billion over five years to or surgical equipment. combat global HIV/AIDS. In 2008, PEP- CDC, NIH, WHO, scientists, doctors and FAR funding was increased to $39 billion public health experts all over the world have for five years, including $4 billion in fund- been working to find ways to prevent and ing to fight TB and $5 billion to malaria. In treat HIV/AIDS. There have been significant 2013, the one-millionth baby born HIV-free advancements in treatment and care, so due to PEPFAR’s efforts to curb mother- people with access to treatment and proper to-child transmissions was announced on medications are often able to live longer the tenth anniversary of the program.352 and with a better quality of life than ever In 2012 alone, the program supported an- before.348 Despite research efforts, no vac- tiretroviral treatment for nearly 5.1 million 90 TFAH • healthyamericans.org people and HIV screening and counseling “to be overseen by the Director of the for more than 49 million people in 15 tar- Office of National AIDS Policy. The Initia- get countries in Sub-Saharan Africa, Asia tive will mobilize and coordinate Federal and the Caribbean. 353, 354 efforts in response to recent advances regarding how to prevent and treat HIV in- l I n 2010, a National HIV/AIDS Strategy fection. The Initiative will support further was issued, focusing on domestic policies integration of HIV prevention and care to reduce new HIV infections, increase efforts; promote expansion of successful access to care and improve health out- HIV testing and service delivery models; comes for people living with HIV, reduce encourage innovative approaches to ad- HIV-related disparities and health inequi- dressing barriers to accessing testing ties and achieve a more coordinated re- and treatment; and ensure that Federal sponse to the HIV epidemic.355 resources are appropriately focused on l I n 2013, President Obama issued an implementing evidence-based interven- executive order creating an HIV Care Con- tions that improve outcomes along the tinuum Initiative within the United States HIV care continuum.”356 HHS GUIDELINES FOR THE USE OF ANTIRETROVIRAL AGENTS IN HIV-1-INFECTED ADULTS AND ADOLESCENTS HHS released an updated version of its the recommendations include new sec- l C D4 count 350 to 500 cells/mm3 Guidelines for the Use of Antiretroviral tions on aging with HIV and drug costs, l C D4 count >500 cells/mm3 Agents in HIV-1-Infected Adults and Ado- information on ART as prevention, and lescents in 2012.357 The major change recommendations for use in HIV/HCV And, Regardless of CD4 count, initiation is a recommendation for treatment of co-infected individuals. of ART is strongly recommended for indi- all people with HIV due to increasing viduals with the following conditions:359 ART is recommended for all HIV-infected evidence showing the harmful impact l P regnancy individuals. The strength of this recom- of HIV replication as well as evidence l H istory of an AIDS-defining illness mendation varies on the basis of pre- showing the effectiveness of anti-retro- treatment CD4 cell count:358 l H IV-associated nephropathy (HIVAN) viral therapy (ART) preventing secondary transmission of HIV. Other updates to l C D4 count < 350 cells/mm3 l H IV/HBV co-infection In 2013, Treatment Action Group (TAG) “to develop a community-based agenda and the Foundation for AIDS Research to improve implementation of effective (amfAR) released a Filling the Gaps in the service-delivery approaches and identify U.S. HIV Treatment Cascade: Developing research priorities for improved manage- a Community-Driven Research Agenda, ment of HIV treatment and prevention, which includes recommendations and with a particular focus on filling the gaps priorities for follow-up to end the AIDS epi- in the United States HIV continuum of demic, particularly focusing on the need care (or treatment cascade).”360 TFAH • healthyamericans.org 91 RECOMMENDATIONS: HIV/AIDS Prevention and Control TFAH recommends that all state Medicaid men that affect HIV risk taking and adher- for the conditions, which also helps more programs should cover routine screening of ence to treatment if HIV infected. These efficiently use available resources. HIV, regardless of risk (consistent with CDC have been described as syndemics—co- l R emoving the ban of use of federal funds and USPSTF guidelines). Knowing HIV status occurring challenges that gay men (and for needle exchange programs as part is important to help connect individuals with others face), including high rates of men- of the next appropriations cycle — and treatment and to help limit the spread of the tal health problems, substance abuse, support syringe public safety campaigns disease. TFAH also recommends routine stigma and other negative experiences. and syringe exchange programs: There screening for other STIs as recommended by l S upporting “treatment as prevention” has been a recurring “rider” on the Labor, the U.S. Preventive Services Task Force. strategies: Recent studies have shown Health and Human Services, Education In addition in 2012, TFAH and amfAR, The that HIV-positive individuals with full viral and Related Agencies appropriations bill Foundation for AIDS Research, undertook a suppression are far less likely to transmit since 1988. Omitting the ban in the next formal process to reconsider recent scien- HIV infection, while modeling studies have appropriations cycle would effectively tific and political developments to chart a demonstrated the potential for “treat- repeal the ban. There should also be new path forward for HIV prevention in the ment as prevention” or “test and treat” increased state, local and private sup- United States.361 The committee included initiatives in combination with other ap- port for syringe exchange programs and more than 50 leading national experts and proaches to dramatically slow the HIV campaigns to inform the public about was supported by the M•A•C AIDS Founda- epidemic.363 These strategies can only the effectiveness of syringe exchange tion. Given the particularly high risk and be successful if individuals know their HIV programs for limiting the spread of HIV/ growing rates of infection among MSM, status and receive full treatment. AIDS, HBV and HCV, including for pro- the group was challenged to redefine HIV tecting first-responders and healthcare In addition, TFAH recommends: prevention priorities among gay men by workers. Needle exchange programs l E xploring the use of “pre-exposure pro- have been shown to be one of the most identifying interventions that were evidence- phylaxis” (PrEP) for high-risk individuals: effective, scientifically based methods for based, could be implemented in the near There is growing evidence that regular reducing these diseases and have been term and that took full advantage of recent use of anti-retroviral drugs by those who endorsed by leading scientific organiza- legislative and scientific advances. Some are not infected with HIV can prevent tions, including the IOM; WHO; AAP; the key recommendations included: transmission from an infected partner. American Medical Association (AMA); the l I mplementing traditional risk reduction Assuring adherence to a PrEP regimen American Nurses Association (ANA); and efforts: This includes 1) reducing HIV risk and continued following of other risk re- the APHA.366, 367 Alternative approaches to behaviors, particularly through condom duction guidelines requires careful imple- needle exchange, such as disinfection and use, and 2) learning HIV status since re- mentation of this approach.364 decontamination and outlawing the sale search shows that those who are aware of l R eassessing sexual risk reduction guide- of needles, have been shown to be much their infections engage in less risky behav- lines in light of treatment as prevention less effective.368 Many needle exchange ior.362 However, these interventions are and pre-exposure prophylaxis: CDC should programs often also work to target the un- essential, but are also “inherently limited.” release revised guidelines to assist individ- derlying problems of drug use by providing l F ocusing on the overall wellness of gay uals in assessing their risk in the context and/or referring individuals to substance men: Programs must focus on improv- of these new treatment and chemoprophy- abuse treatment or other health and social ing the health and well-being of gay men laxis approaches to match the most recent services. Hundreds of scientific studies generally, and specific interventions must evidence-based epidemiological data.365 have been conducted that have found help HIV-positive gay men learn their needle exchange programs can help to re- l C oordinating prevention strategies and status, connect to appropriate healthcare duce HIV transmission and do not promote treatment when appropriate for HIV/ services, stay in care and maintain treat- illegal drug use. There is also evidence AIDS, hepatitis and TB: Since the at-risk ment adherence and prevent transmis- that needle exchange programs do not in- populations often overlap for the condi- sion to others. Young gay men must be crease unsafe disposal of unused syringes tions, it is important to coordinate strate- a priority. Particular focus is needed on among participants in those programs.369 gies, surveillance and treatment programs behavioral health issues faced by gay 92 TFAH • healthyamericans.org Viral Hepatitis Hepatitis — particularly hepatitis B and In 2013, the USPSTF recommended rou- Hepatitis is an inflammation of the liver. C — are silent epidemics in America. tine one-time HCV screening of individuals Symptoms of acute viral hepatitis can Nearly two percent of the U.S. population born between 1945 and 1965 for the first include fever, fatigue, loss of appetite, may have some form of the disease — time, which means the test is now avail- nausea, vomiting, abdominal pain, joint and approximately five million of these able to these individuals who are enrolled pain and jaundice. Individuals with acute individuals will develop a chronic from of in new group or individual health insur- or chronic hepatitis do not always show the disease, but many of them will not ance, Medicare or Medicaid Expansion symptoms. even know they have a hepatitis infection programs with no cost-sharing. 371 l H epatitis A:374 There were an esti- for years or decades, often until it has In the next decade, unless more mated 2,700 cases of hepatitis A in caused significant, irreversible damage to individuals are identified at an earlier the United States in 2011.375 Hepatitis their livers.370 stage, the IOM estimates that 150,000 A is a highly contagious liver infection Baby Boomers (born between 1945 and Americans could die from liver cancer typically contracted from contaminated 1965) account for more than two-thirds or end-stage liver disease associated food or water or though contact with a of the 2.7 to 3.9 million Americans with with HBV and HCV, and an independent contaminated individual who has not HCV, but most of them do not know they Milliman report found total medical properly washed their hands after using have the disease, which they may have costs for HCV patients could more than the bathroom or changing diapers. been infected with through infected blood double over the next 20 years — from Symptoms can range from very mild to contact when they were younger but may $30 billion to $80 billion per year. 372, 373 very severe. A hepatitis A vaccination have not yet reached an age where it has Medicare would likely bear most of these was introduced in 1995 and is recom- progressed to recognizable symptoms. costs, since individuals often live with the mended for all children, individuals infection for years before they age into traveling to certain countries, and other Testing for HBV and HCV can help identify liver diseases and other symptoms. at-risk individuals. those who are infected but are not aware of it. HEPATITIS A OUTBREAK—2013 150,000 Americans could die As of September 20, 2013, 162 least three different products were re- from liver cancer or end-stage people have been confirmed ill from called because of potential Hepatitis A liver disease associated with HBV hepatitis A after eating ‘Townsend contamination in June 2013.377 and HCV in the next 10 years. Farms Organic Antioxidant Blend’ in 10 Hepatitis A is an acute liver disease states: Arizona, California, Colorado, lasting from a few weeks to several Hawaii, New Hampshire, New Jersey, months, but does not lead to chronic New Mexico, Nevada, Utah, and Wis- infection. Hepatitis A is transmitted consin.376 Seventy-one individuals have through ingestion of fecal matter, from been hospitalized, and no deaths have person-to-person contact, including been reported. The investigation is sexual contact, or ingestion of contami- ongoing and CDC continues to track nated food or drinks. Hepatitis A can be cases in all states and test specimens prevented through vaccination, and due in order to determine if any other to the vaccine, rates of the disease are cases are related to this outbreak. In the lowest they have been in 40 years. an effort to prevent more illness, at TFAH • healthyamericans.org 93 l H epatitis B:378, 379 CDC estimates there Since 1982, an HBV vaccine has been Blacks than other ethnic groups. In are between 800,000 and 1.4 million available. More than 90 percent of Ameri- 2011, Blacks died from HCV 91.6 per- individuals chronically infected with HBV can children have been vaccinated for HBV cent more often than whites.382 in the United States and 65 percent of — and the HBV vaccine has helped cut in- It is typically spread through blood-to-blood these individuals do not know they are fection rates by around 80 percent, but ap- contact, such as the reuse of contami- infected. In 2007, there were at least proximately 10 percent of infants are still nated drug injection equipment (needles, 43,000 new infections, but CDC consid- not vaccinated and many adults were not cookers, etc.) or through exposure in a ers this to be an underestimate. Asian- vaccinated because they came of age be- healthcare setting resulting from poor Americans and Pacific Islanders account fore it was available in 1982. Those Amer- infection control practices, or occasionally for 50 percent of chronic HBV cases. icans who came of age before the vaccine through sexual contact. Individuals who was widely available, along with Americans It is typically spread through sexual activity, received blood transfusions or procedures born to mothers who have the disease or from a mother to a baby during childbirth, or before 1992, when blood started to be are immigrants from other countries where direct contact with infected blood, such as screened, may be at risk. the vaccine is not widely used are at risk during household sharing of razors or con- for HBV. Seven medications have been ap- Medical complications can include cirrho- tact with cuts or wounds, through needle proved for treating HBV. They often do not sis (scarring of the liver), liver cancer and sharing, or exposure in a healthcare setting result in a full cure, but can significantly other liver problems. Some patients need resulting from poor infection control prac- reduce liver damage particularly if treat- liver transplants. HCV is the most com- tices. Currently an estimated 800 to 1,000 ment is started early. However, successful mon cause of adult liver transplants in the newborns are infected with HBV in the therapy of patients with advanced disease United States and worldwide. There is no United States each year, and they are at the can prevent liver cancer, reduce the need vaccine for HCV. The treatment involves a highest risk for developing chronic HBV and for liver transplants and save lives. combination of antiviral medications. Ap- of having greatly increased risk of serious proximately 60 to 80 percent of patients re- liver disease as they get older — around l H epatitis C:380, 381 Between 2.7 and spond to treatments initially (depending on 90 percent of newborns who are infected 3.9 million Americans are infected with genotype). Blacks only have a 28 percent with HBV during childbirth will develop a HCV, but 75 percent of these individuals success rate. New treatments have been chronic infection unless they receive proper do not know they are infected. There recently introduced and more are expected preventive care measures. If recommended were an estimated 17,000 new infec- in the next few years that are significantly screening, treatment and prevention prac- tions in 2007, but CDC considers this to less complicated and showing promising tices were followed, it could eliminate be an underestimate. Seventy percent results, with success rates consistently maternal-child transmissions. For healthy to 80 percent of people who contract over 80 percent with shorter, more easily young adults, about 5 percent of HBV infec- an HCV infection develop chronic HCV. tolerated treatment regimens, and these tions develop into chronic HBV. It can lead In addition to the disproportionate risk new treatment options also hold increased to cirrhosis (scaring of the liver), liver cancer faced by Baby Boomers, Blacks account promise for closing the treatment response and other liver problems. Some patients for 22 percent of HCV cases. Death gap between Blacks and other groups.383 end up needing liver transplants. rates have also been higher among 2.7 to 3.9 million Americans are infected with HCV 75% don’t know they are infected 94 TFAH • healthyamericans.org RECOMMENDATIONS: Preventing and Controlling Viral Hepatitis Health reform combined with new sci- l M aking HBV and HCV screening rou- education campaigns and improved entific advances provide the chance to tine: HBV and HCV screening for at-risk surveillance must be put in place to dramatically improve hepatitis prevention, groups, including Baby Boomers, as help prevent new infections. help identify people who do not know they recommended by the USPSTF and HBV l R educing disparities: The National are infected for earlier treatment and treat vaccination should be the standard of Medical Association studied the dis- people in the most effective ways possi- care in the reformed health system. proportionate impact of HCV among ble. TFAH recommends a comprehensive Doctors and other healthcare providers Blacks and supported a number of strategy be carried out to better prevent, should be educated about the at-risk strategies to reduce the disparities control and treat hepatitis, including: populations, including the USPSTF rec- including a Black-specific campaign ommendation to screen all Baby Boom- l P romoting universal HBV vaccination: to created awareness about the risks ers for HCV and the need to screen HBV vaccinations have helped reduce associated with HCV infections among all pregnant women, Asian-Americans rates of infection by around 80 per- Blacks and providing adequate educa- and other at-risk populations for HBV cent, but around 10 percent of infants tion and training to providers of all — and appropriate health measures still do not get vaccinated, and adults races and ethnicities about racial dis- should be taken to prevent perinatal who came of age before the vaccine parities in HCV epidemiology, clinical transmission from infected mothers to was available in 1992 or were born course and treatment outcomes and their newborns.  All newborns should abroad where the vaccine is not widely barriers to care and treatment.385 receive their initial birth-dose of HBV used should also be vaccinated. vaccine within twelve hours of birth. l E liminating healthcare-associated HBV l P romoting hepatitis A vaccination Despite the screening guidelines and and HCV infections: Infection control for at-risk populations: Americans insurance coverage for screening at- practices must be strengthened to traveling abroad to certain countries risk groups, many of these individuals reduce healthcare associated hepatitis where hepatitis A is more prevalent, are still not actually being screened. A infections. gay men, drug users and other at-risk 2013 study of 1,578 patients born be- l I nvesting in biomedical, behavioral and populations should be routinely vac- tween 1945 and 1965 found that only health services research and develop- cinated against hepatitis A. 2 percent (31) of these Baby Boomers ment: The investment in hepatitis-re- were screened for HCV.384 l I mproving surveillance: The scope of lated biomedical and behavioral research the infections have long been under- l E nsuring everyone who is diagnosed must be significantly increased including reported, which has hampered the receives appropriate care: Every support for understanding the differential ability to reduce the spread of the person diagnosed with HBV or HCV response to treatment among certain diseases, target treatment and gener- should have access to and receive a populations, improving screening and ate support for needed research. A standardized level of care and receive diagnostic tools, and for new and better comprehensive surveillance system support services. vaccines. Research support should be should be developed with the build more proportionate to the public health l B olstering prevention campaigns out of electronic health records. threat associated with hepatitis. and public awareness: Strong public TFAH • healthyamericans.org 95 TB Case Rates,* United States, 2012386 Tuberculosis (TB) In the early 1980s, TB was thought to born persons. The declining number of TB be well on its way toward elimination in cases masks the increasing complexity of the United States. In the mid-1980s, the cases being reported. There are high D.C. the country experienced a resurgence numbers of cases with co-morbid condi- of the disease. Lax support for TB tions (HIV/AIDS and other immune-compro- control programs, immigration from mising conditions), increases in multi-drug countries where TB is more common, or extensively-drug resistant cases requir- the emergence of drug-resistant TB ing longer, more toxic and more expensive and cases among people with HIV/AIDS treatment regimens and cases with signifi- < 3.2 (2012 national average) contributed to the resurgence. 389 cant socio-economic challenges. >3.2 *Cases per 100,000. TB is one of the leading causes of death and disability around the world. An esti- Reported TB Cases United States, 1982–2012*387 mated 8.8 million people globally develop 30,000 active tuberculosis each year.391 Approxi- 25,000 mately 1.4 million people die from TB each year, with 95 percent of those deaths oc- No. of Cases 20,000 curring in developing countries. Around 15,000 1.1 million of the TB cases are among patients living with HIV/AIDS. The infec- 10,000 tion is common — about one-third of the 5,000 human population is infected with TB, with one new infection occurring each second, 0 but most cases of TB infection are not con- tagious. One in 10 people infected with Year TB bacteria develops TB cases. *Updated as of June 10, 2013. Most strains of TB disease can be treated with drug therapy — usually treated with Reported TB Cases by Race/Ethnicity,* Increased resources and a concerted pub- a regimen of drugs taken for six months United States, 2012388 lic health campaign helped lead to declines to two years depending on the type of in- American Indian or in TB from 1993 to 2012, but TB remains Alaska Native (1%) fection — but it is imperative that people a threat. There were 9,945 TB cases finish the medicine, and take the drugs ex- Black or reported in the United States in 2012 African actly as prescribed. If they stop taking the Hispanic or (3.2 cases per 100,000 people), with 63 American (22%) Latino (29%) drugs too soon or do not take the drugs percent of cases occurring in foreign-born correctly, they can become ill again and patients.390 Rates were highest among the infection may become drug resistant. Asian White Asian Americans (18.9 cases per 100,000 (31%) (16%) people). Foreign-born persons and racial/ ACIP and HRSA recommend routine TB ethnic minorities are disproportionately testing for children at high risk for TB, but Native Hawaiian or Other Pacific Islander (1%) affected — new or reactivated infections there currently is not a recommendation *All races are non-Hispanic. Persons reporting two or among foreign-born persons in the U.S. for routine screening for at-risk adults by more races accounted for less than 1% of all cases. were 12 times greater than among U.S.- ACIP HRSA or USPSTF.392 , 96 TFAH • healthyamericans.org People who are at-risk for TB include those some jurisdictions, patients with TB cannot patient care and could contribute to TB who are uninsured, and people who are be forced to undergo treatment, but they can transmission in the United States. Results homeless, foreign-born, incarcerated or be isolated or detained if they refuse treat- of the survey found that of the responding co-infected with other conditions. Prior to ment.395 Some states have laws requiring health departments:396 the ACA, states had the option of adding DOT, where healthcare professionals ensure • 9 percent reported difficulties with pro- 7 diagnosed TB patients to Medicaid. 393 The that the patient completes therapy by provid- curing INH within the last month; covered TB related services include: pre- ing patient support, monitoring side effects • 5 percent reported that they no longer 1 scribed drugs, physician’s services, lab and and response to medication, sometimes pro- had INH; x-ray services, clinic and Federally Qualified viding incentives and enablers (food, trans- Health Center services, case manage- portation tokens, and housing). • 1 percent reported that they would no 4 ment services, and other services such longer have a supply within one month Recent shortages of medications and of the survey; as- services that were designed to encour- antigen used in skin tests for diagnosing age completion of outpatient regimens, • 9 percent were changing INH suppliers; 6 TB, budget cuts, and hiring freezes have including directly observed therapy (DOT) • 2 percent were prioritizing patients for 7 impacted the capacity of state and local TB where healthcare professionals watch to treatment of latent TB infection; programs. For example, weakened programs make sure a patient is taking all of their may have difficulty conducting large, com- • 8 percent were delaying latent TB in- 6 treatment medication. DOT is the standard plex investigations to locate contacts to TB fection treatment; and of care for TB. It is recommended by the cases, test for and treat TB infection, and in • 8 percent were changing to alternative 8 AAP for all children with TB disease and some cases, provide treatment through DOT. latent TB infection treatment regimens. for latent tuberculosis infection when fea- sible. Nine states have elected to provide l S hortage of Medications In April 2013, there was a nationwide this Medicaid waiver/expansion. There In November 2012, the United States shortage of Tubersol and Aplisol, the only is receipt of matching federal dollars for began to experience a severe decrease in FDA approved solutions for use in tubercu- treating these TB patients. However, even the supply of isoniazid (INH), one of the four lin skin testing (TST).397 While it was antici- with the ACA in effect, there will be many core drugs used to treat TB disease and pated that the shortages would last a few individuals who are still uninsured or fall the primary drug used to treat TB infection. months, many states continued to report outside of the system of receiving routine The results of a nationwide survey showed difficulties obtaining both Tubersol and Apli- medical care or attention, so there is a that the INH shortage was interfering with sol through November 2013. continued role for public health agencies to provide access to care and treatment, in addition to conducting surveillance, contact States reporting difficulty obtaining isoniazid (INH) during 2012–2013* and state investigations, and outreach and educa- tuberculosis case counts in 2011 — National Tuberculosis Controllers Association tion. In addition, the lengthy regimens and survey, United States398 specialized care required to cure TB require a repository of expertise that is usually found in public health departments. Legal issues can arise around TB treatment, such as the potential need to isolate patients DC to prevent the spread of the disease. CDC >100 50–100 issued Tuberculosis Control Laws and Poli- <50 cies: A Handbook for Public Health and Legal Difficulty obtaining INH Did not respond to survey Practitioners to help identify both the state’s * As of January 2013. and individual’s rights.394 For instance, in TFAH • healthyamericans.org 97 l R ising costs l C uts to budget and staff most potent TB drugs. These drugs are • new regimen of medication (rifapen- A • ity and state TB programs are facing C used to treat all persons with TB disease. tine and INH) lasting only three months funding shortfalls from the local, state and XDR-TB is a rare type of MDR-TB that is rather than the nine month treatment federal levels. New York City’s TB program, resistant to isoniazid and rifampin, plus any course is now available, which means for example, will have its federal funding fluoroquinolone and at least one of three an increase in costs. The new regimen slashed by $2 million in 2013, on top of a injectable second-line drugs (i.e., amikacin, has a higher completion rate among $300,000 rescission from 2012.401 kanamycin, or capreomycin). patients. Health departments, CDC, and • recent survey of TB control programs A Because XDR-TB is resistant to the most drug companies are seeking the best conducted by the National TB Controllers potent TB drugs, patients are left with treat- way to assure access to the regimen. Association (NTCA) revealed that, as a ment options that are much less effective. • igh costs also make it extremely diffi- H result of reduced funding, 60 percent of XDR-TB is of special concern for people with cult for TB programs to pay for the treat- the TB programs have eliminated staff HIV infection or other conditions that can ment of drug-resistant TB. TB programs and 25 percent have restricted some of weaken the immune system. These people in the U.S. identified cost as a leading the activities considered the core of TB are more likely to develop TB disease once challenge to obtaining medications for public health efforts (provision of DOT for they are infected, and also have a higher multidrug-resistant TB (MDR-TB) and high-risk TB infection cases and pulmo- risk of death once they develop TB. extensively drug-resistant TB (XDR-TB). nary TB patients, contact investigations While cases of MDR-TB and XDR-TB are The average total cost of treating an and capacity for outbreak response). relatively infrequent in the United States, individual with XDR-TB in the U.S. was In addition, there are now drug-resistant they are considered a serious public health $430,000.399 And, in 2011 the price of forms of TB. TB can be resistant to a threat. Between 1993 and 2011, 63 cases capreomycin, a drug used for at least six single drug or multiple-drugs. MDR-TB is of XDR-TB have been reported.402 While months in the treatment of multidrug- caused by an organism that is resistant drug-resistant TB is generally treatable, it resistant TB, doubled.400 to at least isoniazid and rifampin, the two requires extensive chemotherapy (up to two years of treatment) with second-line anti-TB drugs that are more costly than Recent TB U.S. Outbreaks first-line drugs, and which produce adverse drug reactions that are more severe, though manageable.403 According to a recent CDC study, treatment for MDR-TB costs an aver- age of $131,000, compared with $17,000 to treat drug-susceptible TB.404 A 2012 study of TB patients found drug- resistant TB was more common than previously thought — of 1,278 patients in Estonia, Latvia, Peru, Philippines, Russia, South Africa, South Korea and Thailand, nearly 44 percent of patients were resistant to at least one second-line drug and 6.7 per- cent had XDR-TB. Prior treatment with sec- ond-line drugs was the strongest risk factor for subsequent resistance—increasing the risk of XDR-TB by more than four times.405 98 TFAH • healthyamericans.org TB and Recent U.S. Outbreaks TB is an airborne disease caused by infec- It is usually treated with a regimen of in December, 2012, and two subsequent tion with Mycobacterium tuberculosis. TB drugs taken for six months to two years cases were diagnosed in June. Over 400 typically affects the lungs; however it also depending on the type of infection. It is im- families were contacted by the health de- may affect any other organ of the body, such perative that people who have TB disease partment for screening.409 as the brain, the kidneys, or the spine.406 finish the medicine, and take the drugs ex- l os Angeles, California: Health work- L There is a difference between TB infection actly as prescribed. If they stop taking the ers identified almost 5,000 people who and active TB disease, which makes people drugs too soon or do not take the drugs were probably exposed to a TB out- sick and can be spread to others. correctly, they can become ill again and the break on downtown Los Angeles’ skid infection may become more drug resistant. Symptoms of active disease include cough, row area. Eleven have died from 2007 loss of weight and appetite, fever, chills, Although rates of TB have been decreas- through 2013, and 60 of the 78 cases and night sweats as well as symptoms ing in recent years in the United States, were among homeless people who live from the specific organ or system that is there have been a number of TB out- on and around skid row.410 affected; for example, coughing up blood breaks in 2012 and 2013. l acksonville, Florida: In April 2012, CDC J or sputum in pulmonary TB or bone pain if l heboygan, Wisconsin: On April 11, 2013 S issued a report to Florida health officials the bacteria have invaded the bones. TB a case of MDR-TB was diagnosed. The warning that Jacksonville was in the germs spread when a person infected with patient’s family included children who at- midst of the largest TB outbreak it had active TB disease in the lungs or throat tended the local high school and middle investigated in the U.S. in the last 20 coughs or sneezes. As a result of this air- school. The Sheboygan County Depart- years.411 Nine days earlier, Governor Rick borne transmission, TB can affect anyone, ment of Health and Human Services Scott had signed a bill to close A.G. Hol- anywhere. However, people with active screened approximately 130 individuals ley State Hospital—the state’s only TB TB disease are most likely to spread it to and found nine cases of active TB. 407 hospital.412 The Duval County Health De- people they spend time with every day, es- partment, Florida Department of Health pecially when they are interacting in a con- l reenwood County, South Carolina: In G and CDC conducted an investigation from fined space with poor, or no, ventilation. March 2013, a physician in Greenwood February to March 2012, which identified County, South Carolina, reported a TB People with weakened or compromised 99 cases and 13 deaths since 2004 case to the Department of Health and En- immune systems — individuals with HIV that were attributable to one TB strain. vironmental Control. Because the patient disease, individuals with other immune- Of these 99 cases, 78 had a history of worked at an elementary school, the public compromised conditions (diabetes, homelessness, incarceration, or sub- health investigation resulted in the screen- arthritis), those receiving chemotherapy, stance abuse.413 Researchers identified ing of 1,364 individuals, 94 of whom pregnant women, young children, including one homeless shelter, a jail and an out- tested positive for TB. Of these, 13 pro- infants (under 12 months old)-- are at a patient mental health facility as the main gressed to active TB and were placed on a much greater risk for developing active TB points of TB transmission. Since the standard TB treatment regimen. No cases disease. When these people breathe in TB CDC investigation, state health officials of drug resistant TB were reported.408 bacteria, the bacteria settle in the lungs have screened over 3,000 individuals and start growing because the individual’s l airfax County, Virginia: In June 2013, of- F who could have been exposed and have immune system cannot fight the bacteria. ficials at the Fairfax County Health Depart- found 311 people who tested positive for In these people, TB disease may develop ment found three cases of TB at a Virginia TB infection and one with active TB.414 within days or weeks after the infection. high school. The first case was diagnosed TFAH • healthyamericans.org 99 RECOMMENDATIONS: Toward Eliminating TB in America The resurgence of the disease is par- being a federal responsibility when ity. Ensuring adequate supplies of TB ticularly troubling since TB is treatable, they seek and are granted asylum. biologics (Tubersol and Aplisol) are curable and preventable. TB, once essential for effectively monitoring TB l E nsuring quality control in TB treat- largely controlled in the United States, outbreaks and diagnosing new infec- ment: Treating TB is an intensive and disproportionally affects Americans liv- tion. TB drugs and biologics should long process. It requires patients to ing in poverty and those with HIV/AIDS be added as essential resources to take a full course of their medicine pre- who are at higher risk for the disease. the Strategic National Stockpile. cisely as prescribed through DOT, and Now there are antibiotic-resistant forms often requires providing wrap-around l E ncouraging all states to participate of the disease.  TFAH consulted with a services for lower-income patients, in the TB Medicaid waiver/expan- set of TB control experts to identify key particularly since they often need to be sion: All states have the option of recommendations for curbing a future isolated for periods of time to stop the being able to add all TB patients to resurgence of TB in the United States, spread of the disease and are not able their Medicaid program and receive which include: to sustain employment. Private health- federal matching support. As of l F ully funding TB control programs: care providers and insurers should 2013, there were nine states reported The resurgence of TB in the mid- enter into contracts and arrangements to be participating.415 1980s shows the need for continued with TB public health programs to refer l S upporting routine screening of tar- vigilance. TB control efforts require patients to experts in TB care, since get high-risk groups: CDC should strong surveillance for individuals and improper care can exacerbate the de- work with the USPSTF to assess the clusters of the disease, infection con- velopment of additional drug-resistant value of routine screening of TB for trol programs in communities with out- cases or forms of the disease or lead target at-risk groups.  If supported breaks and ensuring infected patients to the patient becoming ill again. Pub- by the USPSTF, screening would be receive full and complete treatment, lic health departments should be able a mandated benefit offered to Ameri- which is important not only for their to bill a patient’s insurance company cans with new group and individual care but for helping to limit the trans- for direct service treatment costs. plans and those covered by Medicaid mission of the disease. States should l A ddressing the TB drug costs and expansion with no-copayments.416 ensure routine screenings in correc- shortages and biologics shortages: tional facilities and also require TB l P roviding adequate federal, state and The shortage of INH and biologics screening for international college stu- local support for TB prevention and used to diagnose TB infection and dents. Additionally, plans, procedures control: Some states have reduced the growing cost of TB treatment and sufficient fiscal resources should or eliminated state contributions to drugs is harming not only the care for be in place to ensure the timely and the TB control program, relying exclu- individuals but also control efforts in coordinated management by the Im- sively on the federal monies provided states. Ensuring sufficient quantities migration and Customs Enforcement, by CDC. TB control is largely local and and payment for drugs is essential CDC, and state local health officials federal funding alone is not sufficient to effective TB control. Finding new in order ensure proper care when TB- to control, and prevent, TB. treatments for TB should be a prior- infected individuals transition from 100 TFAH • healthyamericans.org SECTI O N 7: Conclusion SECTION 7: CONCLUSION CONCLUSION: Q&A with Tom Inglesby, MD, Chief Executive Officer  and Director of the UPMC Center for Health Security. What are the infectious disease to appear this past year is H7N9, threats that, in your opinion, pose which has emerged in China. We the greatest risk? have been fortunate that, up to this There are a range of infectious disease point, it hasn’t developed a capacity threats that pose extraordinary risks. to spread widely. Like MERS, H7N9 In no particular order, these would does not spread widely, but has had include: a high case fatality rate. l iddle East Respiratory Syndrome M l n accident involving a lethal A (MERS) is a virus that has killed engineered virus that was altered nearly 40 percent of those known to to enhance lethality and/or the be infected and is in 12 countries. ability to spread rapidly. Recently, we However, we still don’t have a good have seen some scientists working handle on how it spreads, and there is on trying to confer transmissibility no treatment for it or vaccine against into lethal viruses, such as the it. With the extensive travel between H5N1 influenza strain. If there the Middle East and the United were an inadvertent lab accident or States, it is not unlikely we will see a escape involving such a strain, this case in the U.S. at some point. could have the potential to start an extraordinary and lethal epidemic. l novel influenza virus. The great A concern would be the outbreak l I n terms of major global killers, of a new influenza virus that tuberculosis (TB) is the most widely maintains the ability to spread prevalent infectious disease in the widely - like seasonal flu — but world and there are increasing comes with a far higher mortality numbers of drug resistant strains. rate. The world hasn’t seen this The level of drug resistance is combination in a new flu strain in growing and coping with this needs a long time. Our most recent new to be a real priority. HIV, too, is a flu pandemic of 2009, H1N1, posed national threat and a global scourge many challenges, but the overall that continues to take a terrible DECEMBER 2013 case fatality remained relatively low. toll with antiviral resistance also a The most important new flu strain serious problem. l T he rise of antibiotic resistance. purposes, eliminated from United Antibiotic resistance is finally getting States, but is now back in the south- recognized as the potentially grave ern part of the country. We need to problem that it is. However, many reinvigorate our strategy for mosquito people are still unclear how widely control and the infectious diseases and dangerous the consequences of that come with mosquitoes. antibiotic resistance could become. For example, if pathogens continue Where is the nation the weakest to develop multi-drug resistance to in preparing/responding to these the most important antibiotics we threats?  What are the country’s use in hospitals, there could be a greatest strengths? time where elective surgery (which From a public health standpoint, requires effective antibiotics) might an infectious disease outbreak must not be possible because the types be responded to at the individual of antibiotics that would allow for clinical level (the treatment of those these minor surgeries would be who need medical care) and at the ineffective. We need to step up our population level to contain or manage national and international efforts an outbreak and prevent more people against antibiotic resistance. from getting seriously ill. l eliberate biological threats are D On the public health side of that always on my list because of the ledger, there are many components of feasibility and great consequences of public health response that we need even a small biological weapons event. to strengthen. For example, for some In the event of a biological attack, time, our vaccination programs were we could have high levels of illness among the strongest in the world. But, and fatality, communication troubles in recent years, we are struggling with (in terms of getting information to falling vaccination rates. Public health the public) and a whole series of is a central part of solving this problem. response challenges which could be Further, for a number of the infectious very difficult for the public health and disease outbreak threats, we don’t have medical system to manage. a vaccine or therapy, nor do we have a l L astly, the rise of mosquito borne diagnostic test that can tell whether the illness in the United States and the infectious disease is present in a person. larger trend that is driving it: change We have great losses in the public in climate, which is allowing mos- health workforce — more than 40,000 quitoes back into places where they people in the last five years. Further, haven’t been for some time. Most while the digital revolution is animating notably and recently, we have seen a clinical care, it has not proceeded in the spike of West Nile Virus and sporadic, same way in the public health world. but increasing, cases of Dengue Fever. We don’t have the connections between Dengue had been, for all intents and public health and medicine, which are 102 TFAH • healthyamericans.org needed to identify and respond quickly help remove a barrier to preventive to an emerging threat. care, it will also make public health funds available for other public health In terms of strengths, we do continue priorities, as they will no longer to have one of the best healthcare and have to use scarce resources to cover public health systems in the world — vaccination programs. we can build on these strengths to make good progress. We have a surge When it comes to responding to an of new young people wanting to come outbreak, health reform will reduce the into the field. People are motivated barriers for potentially infected people and eager to get engaged in the fight getting medical care. When people against infectious diseases. develop a communicable infectious dis- ease that can lead to an outbreak, one There is some increased awareness in the of the most important things they can country about infectious diseases and do is get care. If someone has a highly the dangers they pose. We went through contagious disease, it is important for a stage where some people declared them to be isolated at home or in the infectious diseases over and dead, but hospital, so the sooner a proper diagno- people are realizing that’s just wrong. sis is made, the sooner someone can be Globally, American scientists and isolated and receive good care. health officials are working more Lastly, reform will also change closely with other governments around how healthcare institutions are the world to try and get a handle on compensated for their work. For new outbreaks, provide assistance example, hospitals are not going to be where it might be needed, and, treat paid if a patient contracts a hospital and contain potential outbreak before acquired infection. By rewarding good it reaches the United States. Having patient outcomes instead of paying these working relationships will be vital for services, there is an incentive when new outbreaks emerge around for institutions to reduce hospital the world in the time ahead. acquired infections and antibiotic resistance in their hospitals. How can health reform improve public health response to infectious How do science and technology need disease outbreaks? to operate differently to meet the One of the major goals of health current and future threats? reform has been to get more people To prepare for and respond to covered by some form of insurance. infectious disease outbreaks, we need When that occurs and people medicines, vaccines and diagnostics. increasingly access preventive services, Unfortunately, vaccines and medicines we can broaden vaccine coverage in pose a challenge because there is no places where it is needed. And, as consumer market for them, meaning more people having insurance should there is no market incentive for TFAH • healthyamericans.org 103 companies to make a MERS vaccine, What can Americans do to better for example. A drug that treats protect themselves and what can hypertension has a clear and defined they ask officials to do to better market. In the case of some of the most protect communities? concerning infectious disease threats, There are a few commonsense things government is the only customer. all families and individuals can do, start- ing with: getting vaccinated. People Therefore, to make a vaccine or should follow the vaccination recom- a therapeutic for many of these mendations of the CDC and other infectious disease threats, government public health organizations. Vaccination needs to get involved, stay involved programs are born out of substantial re- and provide consistent funding and search, resources and judgment — they support. The country needs better are intended to save lives. It is public collaboration between government and health’s responsibility to educate Ameri- the private sector on this. The Food cans about the benefits and risks (which and Drug Administration, Centers are minimal) of vaccines. for Disease Control and Prevention and BARDA have been making In addition, we all need to get bet- headway on these issues in recent ter educated on antibiotic use and years. The challenge will be sustaining the trends around antibiotic use. For engagement with the private sector and example, patients often put pressure operating in ways that overcome many on doctors for antibiotics even when of the roadblocks that have existed in antibiotics aren’t needed and won’t this public-private partnership. help. Unnecessary antibiotic usage is one of the main drivers of antibiotic re- On new diagnostic technology, when sistance. The more people understand it comes to figuring out ways to utilize about antibiotics and the dangers of advanced molecular techniques to antibiotic resistance the better. discover infectious disease outbreaks, we have to be careful not to lose the Americans can also go further and let great value we have in laboratory their elected officials know that they culture — which has been the gold support preserving antibiotics for standard. If you talk to people illnesses that actually require them and involved in public health, laboratory not for animal use to promote growth. practice and outbreak response, one People should also tell legislators they of their great worries is that we will want a strong public health and medical move away from culture to rapid system that will help keep people safe molecular techniques and lose all the from infectious diseases. These are information that we have gotten from the kinds of programs that tend to get laboratory culture. So as we develop eaten away as times get tough. These new diagnostic approaches, we have to programs need to be continually take that into account. supported if they are to be effective. 104 TFAH • healthyamericans.org State Public APPENDIX A State Public Health Budget Methodology TFAH conducted an analysis of state revenue, etc.), was used. In some cases, Health Budget spending on public health for the last budget cycle, fiscal year 2012-2013. For only general revenue funds were used in order to separate out federal funds; these Methodology those states that only report their budgets in biennium cycles, the 2013-2015 period exceptions are also noted. Appendix A Because each state allocates and reports (or the 2012-2014 and 2012-2013 its budget in a unique way, comparisons for Virginia and Wyoming respectively) across states are difficult. This methodol- was used, and the percent change was ogy may include programs that, in some calculated from the last biennium, 2011- cases, the state may consider a public 2013 (or 2010-2012 and 2011-2012 for health function, but the methodology used Virginia and Wyoming respectively). was selected to maximize the ability to This analysis was conducted from be consistent across states. As a result, August to October of 2013 using publicly there may be programs or items states available budget documents through state may wish to be considered “public health” government web sites. Based on what was that may not be included in order to main- made publicly available, budget documents tain the comparative value of the data. used included either executive budget Finally, to improve the comparability of the document that listed actual expenditures, budget data between FY 2011-2012 and estimated expenditures, or final FY 2012-2013 (or between biennium), appropriations; appropriations bills enacted TFAH adjusted the FY 2012-2013 numbers by the state’s legislature; or documents for inflation (using a 0.9817 conversion from legislative analysis offices. factor based on the U.S. Dept. of Labor “Public health” is defined to broadly Bureau of Labor Statistics; Consumer include all health spending with the Price Index Inflation Calculator at http:// exception of Medicaid, CHIP or comparable , www.bls.gov/cpi/).   health coverage programs for low-income After compiling the results from this online residents. Federal funds, mental health review of state budget documents, TFAH funds, addiction or substance abuse- coordinated with the Association of State related funds, WIC funds, services related and Territorial Health Officials (ASTHO) to to developmental disabilities or severely confirm the findings with each state health disabled persons, and state-sponsored official.  ASTHO sent out emails on October pharmaceutical programs also were not 24, 2013 and state health officials were included in order to make the state-by-state asked to confirm or correct the data with comparison more accurate since many TFAH staff by November 8, 2013.  ASTHO states receive federal money for these DECEMBER 2013 followed up via email with those state particular programs. In a few cases, state health officials who did not respond by the budget documents did not allow these November 8, 2013 deadline.  In the end, programs, or other similar human services, six states did not respond by December 3, to be disaggregated; these exceptions are 2013 when the report went to print.  These noted. For most states, all state funding, states were assumed to be in accordance regardless of general revenue or other with the findings.  state funds (e.g. dedicated revenue, fee State Facts APPENDIX B STATE FACTS AND FIGURES SUMMARY and Figures Childhood Vaccination Rate 4:3:1:3:3:1:4 Whooping Cough Vaccination Rate HPV teen girls 3 doses Flu Vaccination Rate 6 Summary (2012) months + (2012-2013) Series (2012) (4+DTaP) (2012) Appendix B Alabama 71.0% (+/- 6.9) 84.8% (+/- 5.9) 31.1% (+/- 9.9) 45.7% (+/- 2.3) Alaska 59.1% (+/- 7.8) 79.4% (+/- 5.8) 31.4% (+/- 8.8) 39.7% (+/- 2.5) Arizona 69.1% (+/- 8.3) 82.7% (+/- 5.8) 36.9% (+/- 9.3) 38.3% (+/- 2.3) Arkansas 66.3% (+/- 7.5) 79.8% (+/- 6.4) 18.3% (+/- 7.2) 47.0% (+/- 2.3) California 65.3% (+/- 7.4) 81.6% (+/- 6.6) 35.8% (+/- 8.4) 44.2% (+/- 1.8) Colorado 65.6% (+/- 7.8) 82.8% (+/- 6.7) 38.0% (+/- 11.2) 48.3% (+/- 1.5) Connecticut 74.5% (+/- 6.3) 91.3% (+/- 3.8) 43.6% (+/- 10.5) 46.5% (+/- 2.0) Delaware 69.4% (+/- 7.1) 90.9% (+/- 4.3) 50.4% (+/- 10.2) 51.3% (+/- 2.4) D.C. 68.0% (+/- 7.7) 90.7% (+/- 4.0) 38.5% (+/- 9.7) 47.4% (+/- 3.1) Florida 70.3% (+/- 7.8) 83.3% (+/- 6.5) 25.3% (+/- 8.8) 34.1% (+/- 2.0) Georgia 75.0% (+/- 7.0) 86.7% (+/- 5.2) 29.0% (+/- 9.0) 41.1% (+/- 2.0) Hawaii 71.8% (+/- 6.8) 87.9% (+/- 4.6) 43.4% (+/- 9.7) 54.3% (+/- 2.6) Idaho 61.4% (+/- 8.0) 76.6% (+/- 6.7) 27.8% (+/- 8.2) 37.8% (+/- 2.1) Illinois 71.2% (+/- 5.2) 85.3% (+/- 3.6) 21.1% (+/- 6.3) 43.1% (+/- 2.7) Indiana 63.7% (+/- 7.7) 76.8% (+/- 6.5) 35.2% (+/- 9.1) 42.2% (+/- 1.5) Iowa 71.3% (+/- 6.4) 88.2% (+/- 4.4) 35.6% (+/- 9.3) 50.4% (+/- 1.9) Kansas 71.7% (+/- 6.9) 79.0% (+/- 6.0) 25.1% (+/- 9.3) 40.7% (+/- 1.3) Kentucky 75.1% (+/- 7.1) 83.0% (+/- 5.4) 34.9% (+/- 9.9) 46.6% (+/- 1.9) Louisiana 67.7% (+/- 8.3) 77.8% (+/- 6.6) 40.5% (+/- 9.0) 47.1% (+/- 2.3) Maine 69.5% (+/- 6.6) 87.9% (+/- 5.1) 41.8% (+/- 9.6) 50.0% (+/- 1.8) Maryland 71.5% (+/- 6.6) 83.2% (+/- 6.2) 30.9% (+/- 9.4) 53.1% (+/- 2.1) Massachusetts 70.8% (+/- 7.1) 88.2% (+/- 4.5) 43.0% (+/- 9.1) 57.5% (+/- 1.6) Michigan 71.8% (+/- 7.4) 81.5% (+/- 6.7) 32.2% (+/- 9.3) 40.8% (+/- 1.5) Minnesota 68.5% (+/- 7.7) 84.2% (+/- 5.6) 33.1% (+/- 9.9) 52.5% (+/- 1.6) Mississippi 76.0% (+/- 6.8) 83.6% (+/- 6.4) 12.1% (+/- 5.9) 40.8% (+/- 2.1) Missouri 62.5% (+/- 7.7) 81.9% (+/- 7.0) 34.5% (+/- 9.7) 46.4% (+/- 2.2) Montana 60.8% (+/- 7.4) 86.6% (+/- 4.4) 41.6% (+/- 10.1) 41.7% (+/- 1.8) Nebraska 72.5% (+/- 7.0) 84.5% (+/- 5.2) 37.3% (+/- 10.0) 50.3% (+/- 1.7) Nevada 63.4% (+/- 8.0) 81.0% (+/- 5.5) 37.2% (+/- 10.2) 39.6% (+/- 3.7) New Hampshire 75.8% (+/- 6.1) 88.7% (+/- 4.7) 34.5% (+/- 9.7) 48.9% (+/- 2.2) New Jersey 71.2% (+/- 6.4) 84.7% (+/- 5.1) 31.6% (+/- 8.5) 45.3% (+/- 1.6) New Mexico 68.0% (+/- 8.2) 87.0% (+/- 4.9) 30.3% (+/- 8.7) 48.1% (+/- 2.1) New York 61.5% (+/- 5.2) 83.8% (+/- 3.5) 39.7% (+/- 7.2) 46.6% (+/- 1.8) North Carolina 70.7% (+/- 8.0) 85.9% (+/- 5.4) 35.5% (+/- 9.5) 50.1% (+/- 1.9) North Dakota 74.3% (+/- 7.1) 85.1% (+/- 6.2) 40.9% (+/- 9.6) 48.9% (+/- 1.9) Ohio 67.6% (+/- 8.4) 83.3% (+/- 6.0) 31.9% (+/- 10.5) 44.8% (+/- 1.7) Oklahoma 60.7% (+/- 7.6) 79.1% (+/- 6.0) 38.4% (+/- 9.4) 46.1% (+/- 2.2) Oregon 68.4% (+/- 6.8) 81.2% (+/- 5.8) 38.6% (+/- 9.3) 40.1% (+/- 1.9) Pennsylvania 70.4% (+/- 5.2) 80.1% (+/- 5.3) 44.6% (+/- 8.2) 46.2% (+/- 1.9) Rhode Island 70.2% (+/- 6.5) 89.0% (+/- 4.9) 57.7% (+/- 10.0) 56.7% (+/- 2.8) South Carolina 69.7% (+/- 7.1) 80.9% (+/- 6.0) 26.6% (+/- 9.5) 44.8% (+/- 1.9) South Dakota 64.8% (+/- 7.2) 79.2% (+/- 5.5) 31.8% (+/- 9.3) 56.7% (+/- 3.4) Tennessee 74.6% (+/- 6.7) 82.0% (+/- 6.0) 28.6% (+/- 9.4) 50.8% (+/- 2.4) Texas 67.5% (+/- 4.1) 77.4% (+/- 3.6) 30.3% (+/- 5.3) 43.7% (+/- 2.0) Utah 71.2% (+/- 7.7) 80.5% (+/- 6.6) 24.1% (+/- 8.4) 42.9% (+/- 2.1) Vermont 66.5% (+/- 7.0) 86.0% (+/- 5.0) 46.2% (+/- 9.6) 49.6% (+/- 2.0) DECEMBER 2013 Virginia 72.8% (+/- 6.8) 82.7% (+/- 6.6) 27.9% (+/- 9.2) 49.4% (+/- 2.1) Washington 61.7% (+/- 8.4) 84.0% (+/- 5.5) 43.5% (+/- 9.8) 47.5% (+/- 1.8) West Virginia 61.9% (+/- 7.0) 79.1% (+/- 6.8) 36.1% (+/- 10.2) 48.8% (+/- 1.9) Wisconsin 73.3% (+/- 6.9) 87.8% (+/- 5.3) 37.5% (+/- 10.5) 40.6% (+/- 2.5) Wyoming 60.9% (+/- 7.9) 79.4% (+/- 6.0) 30.3% (+/- 8.7) 39.2% (+/- 2.4) Standardized Infection Ratio* Antibiotic Hepatitis A Hepatitis B Hepatitis C Flu Vaccination West Nile HIV Rate TB Rate for Centeral Prescriptions Rate per Rate per Rate per Rate 18+ (2012- Virus Cases per 100,000 per 100,000 Line-associated per 1,000 100,000 100,000 100,000 2013) (2012) (2011) (2012) Bloodstream (2010) (2011) (2011) (2011) Infections (2011) Alabama 43.8% (+/- 2.5) 62 0.694 1,079.6 17.6 0.2 2.5 0.5 2.8 Alaska 37.4% (+/- 2.9) 0 0.716 510.7 3.7 0.6 0.4 N/A 9.0 Arizona 34.9% (+/- 2.7) 133 0.575 732.5 10.9 1.2 0.2 N/A 3.2 Arkansas 42.3% (+/- 2.5) 64 0.481 1,020.8 8.3 0.1 1.9 0.0 2.4 California 40.2% (+/- 2.0) 479 0.565 554.6 15.8 0.5 0.4 0.1 5.8 Colorado 45.2% (+/- 1.6) 131 0.587 611.0 8.0 0.4 0.4 0.5 1.2 Connecticut 41.2% (+/- 2.4) 21 0.627 821.9 12.0 0.5 0.5 1.3 2.1 Delaware 46.8% (+/- 2.5) 9 0.534 921.1 14.0 0.2 N/A N/A 3.1 D.C. 42.4% (+/- 3.5) 10 0.693 976.4 155.6 N/A N/A N/A 5.9 Florida 30.8% (+/- 2.2) 73 0.540 706.1 28.4 0.5 1.1 0.3 3.5 Georgia 37.4% (+/- 2.2) 99 0.816 853.0 25.7 0.3 1.4 0.5 3.6 Hawaii 50.0% (+/- 2.7) 0 0.258 543.7 5.7 0.6 0.4 N/A 8.4 Idaho 35.5% (+/- 2.4) 17 0.428 677.9 2.4 0.4 0.1 0.8 0.9 Illinois 40.2% (+/- 3.3) 290 0.593 836.1 16.6 0.6 0.7 0.0 2.7 Indiana 38.8% (+/- 1.6) 77 0.580 956.5 7.9 0.4 1.1 1.3 1.6 Iowa 49.7% (+/- 2.2) 31 0.555 851.9 4.3 0.3 0.5 0.0 1.5 Kansas 39.0% (+/- 1.2) 56 0.434 961.0 5.2 0.1 0.5 0.3 1.5 Kentucky 43.0% (+/- 2.0) 23 0.718 1,196.9 7.9 0.2 3.5 3.2 1.8 Louisiana 44.1% (+/- 2.7) 335 0.727 1,122.8 30.2 0.1 1.4 0.2 3.2 Maine 46.9% (+/- 2.0) 1 0.989 654.5 4.5 0.5 0.6 0.9 1.3 Maryland 48.9% (+/- 2.2) 47 0.670 758.1 30.6 0.4 1.1 0.6 3.8 Massachusetts 52.8% (+/- 1.8) 33 0.562 797.7 19.2 0.6 1.0 0.3 3.2 Michigan 37.9% (+/- 1.6) 202 0.362 907.0 8.1 0.7 0.9 0.3 1.5 Minnesota 50.3% (+/- 1.6) 70 0.403 679.6 6.0 0.5 0.4 0.3 3.0 Mississippi 39.2% (+/- 2.4) 247 0.606 1,137.0 20.7 0.2 1.9 N/A 2.7 Missouri 44.8% (+/- 2.5) 20 0.468 932.1 9.4 0.2 1.0 0.1 1.5 Montana 40.6% (+/- 2.0) 6 0.408 636.9 2.2 0.3 0.0 0.9 0.5 Nebraska 47.2% (+/- 1.8) 193 0.610 935.9 4.3 0.3 0.7 0.1 1.2 Nevada 36.0% (+/- 4.7) 9 0.577 637.4 14.6 0.2 1.1 0.4 3.0 New Hampshire 46.1% (+/- 2.5) 1 0.640 619.2 4.2 0.0 0.2 N/A 0.7 New Jersey 39.1% (+/- 1.8) 48 0.728 875.7 17.8 0.9 0.8 0.6 3.4 New Mexico 42.1% (+/- 2.4) 47 0.523 689.7 7.1 0.3 0.5 0.7 1.9 New York 42.7% (+/- 2.2) 107 0.837 840.9 25.5 0.6 0.7 0.3 4.4 North Carolina 47.8% (+/- 2.2) 7 0.571 818.7 17.3 0.3 1.1 0.6 2.2 North Dakota 45.3% (+/- 2.0) 89 0.373 950.5 2.2 0.0 0.0 0.0 3.7 Ohio 42.0% (+/- 1.8) 121 0.472 874.1 10.6 0.3 0.8 0.1 1.3 Oklahoma 44.9% (+/- 2.4) 191 0.514 854.3 8.8 0.3 2.6 1.4 2.3 Oregon 38.0% (+/- 2.2) 11 0.384 556.9 6.7 0.3 0.8 0.5 1.6 Pennsylvania 41.2% (+/- 2.0) 60 0.485 787.2 12.1 0.5 0.7 0.3 1.8 Rhode Island 50.2% (+/- 3.3) 4 0.710 879.7 12.1 0.8 N/A N/A 2.2 South Carolina 42.7% (+/- 2.2) 29 0.706 880.5 18.4 0.2 0.8 0.0 2.6 South Dakota 53.4% (+/- 3.9) 203 0.443 834.5 3.2 0.2 0.2 N/A 2.3 Tennessee 49.2% (+/- 2.7) 33 0.699 1,159.4 14.5 0.4 3.0 1.3 2.5 Texas 39.2% (+/- 2.4) 1,868 0.559 867.4 19.7 0.5 0.8 0.1 4.7 Utah 39.9% (+/- 2.4) 5 0.673 791.0 3.3 0.3 0.4 0.4 1.3 Vermont 46.7% (+/- 2.2) 3 0.246 626.5 1.9 1.0 0.0 1.0 0.6 Virginia 46.0% (+/- 2.2) 30 0.700 768.6 13.6 0.4 1.0 0.3 2.9 Washington 44.4% (+/- 1.8) 4 0.477 571.2 8.0 0.5 0.5 0.6 2.7 West Virginia 47.2% (+/- 2.2) 10 0.460 1,177.7 5.7 0.4 6.1 2.5 0.4 Wisconsin 36.5% (+/- 2.9) 57 0.574 715.8 4.8 0.1 0.3 0.3 1.2 Wyoming 37.2% (+/- 2.5) 7 0.289 744.3 2.8 0.4 0.0 0.4 0.5 *The standardized infection ratio (SIR) is a summary measure and adjusts for the fact that each healthcare facility treats different types of patients. 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