SECTI O N 1: Embargoed Funding ISSUE REPORT SECTION 1: FUNDING Outbreaks: until Tuesday, December 17 at 10:00 AM ET PROTECTING AMERICANS FROM 2014 INFECTIOUS DISEASES DECEMBER 2014 DECEMBER 2014 Acknowledgements Trust for America’s Health is a non-profit, TFAH BOARD OF DIRECTORS non-partisan organization dedicated to Gail Christopher, DN David Fleming, MD saving lives by protecting the health of every President of the Board, TFAH Vice President community and working to make disease Vice President for Policy and Senior Advisor PATH prevention a national priority. WK Kellogg Foundation Arthur Garson, Jr., MD, MPH For more than 40 years the Robert Wood Cynthia M. Harris, PhD, DABT Director, Health Policy Institute Johnson Foundation has worked to improve the Vice President of the Board, TFAH Texas Medical Center health and health care of all Americans. We are Director and Professor striving to build a national Culture of Health that John Gates, JD Institute of Public Health, Florida A&M will enable all Americans to live longer, healthier Founder, Operator and Manager University lives now and for generations to come. For Nashoba Brook Bakery more information, visit www.rwjf.org. Follow the Theodore Spencer Tom Mason Foundation on Twitter at www.rwjf.org/twitter or Secretary of the Board, TFAH President on Facebook at www.rwjf.org/facebook. Senior Advocate, Climate Center Alliance for a Healthier Minnesota Natural Resources Defense Council TFAH would like to thank RWJF for their Kent McGuire, PhD generous support of this report. Robert T. Harris, MD President and Chief Executive Officer Treasurer of the Board, TFAH Southern Education Foundation Medical Director CSC., Inc. Eduardo Sanchez, MD, MPH Deputy Chief Medical Officer Barbara Ferrer, PhD, MPH, ED American Heart Association Chief Strategy Officer WK Kellogg Foundation REPORT AUTHORS Jeffrey Levi, PhD. Laura M. Segal, MA Kendra May, MPH Executive Director Director of Public Affairs Consultant Trust for America’s Health Trust for America’s Health Rebecca St. Laurent, JD and Professor of Health Policy Dara Alpert Lieberman, MPP Health Policy Research Manager Milken Institute School of Public Health at the Senior Government Relations Manager Trust for America’s Health George Washington University Trust for America’s Health PEER REVIEWERS TFAH thanks the following individuals and Amanda Jezek Kathryn Talkington, MPAff organizations for their time, expertise and Vice President for Public Policy and Government Senior Director, Immunization & Infectious insights in reviewing all or portions of the Relations Disease  report. The opinions expressed in the report Infectious Diseases Society of America Association of State and Territorial Health Officials do not necessarily represent the views of these Chris N. Mangal, MPH Litjen (L.J) Tan, MS, PhD individuals or their organizations. Director of Public Health Preparedness and Chief Strategy Officer John Billington Response Immunization Action Coalition Director of Health Policy Association of Public Health Laboratories Eric Toner, MD Infectious Diseases Society of America Glen P. Mays, PhD, MPH Senior Associate James S. Blumenstock F. Douglas Scutchfield Endowed Professor in UPMC Center for Health Security Chief Program Officer for Public Health Practice Health Services and Systems Research Donna Hope Wegener Association of State and Territorial Health Officials University of Kentucky School of Public Health Executive Director Thomas V. Inglesby, MD Dennis L. Murray MD, FAAP, FIDSA National TB Controllers Association Director and CEO Professor of Pediatrics UPMC Center for Health Security Chief of the Pediatric Infectious Diseases Division Georgia Regents University (GRU); and Chair, Section on Infectious Diseases (SOID) Executive Committee American Academy of Pediatrics 2 TFAH • healthyamericans.org SECTI O N 1: Infectious Funding INTRODUCTION SECTION 1: FUNDING Introduction The Ebola outbreak has been a major wake-up call to the United Diseases States — highlighting serious gaps in the country’s ability to Policy Report manage severe disease outbreaks and contain their spread. series It is alarming that many of the most quickly devolve into a flawed and basic infection disease controls failed reactionary endeavor that leaves when tested. After more than a decade Americans unnecessarily at risk. of focus on preparing for public The best offense to fighting infectious health emergencies in the wake of the diseases is a strong and steady defense. September 11 and anthrax tragedies, The post-2001 investments have led there have been troubling errors, lapses to significant progress in many areas and scrambles to recreate practices and of health emergency preparedness, policies that were supposed to have been but they did not lead to a serious long considered and well established. modernization of the nation’s approach The country spent more than a decade to infectious disease control. working to ensure federal, state and The current system must be brought up- hospital readiness so that policies and to-date to better match modern global practices would be in place when an disease threats, technological advances outbreak occurs. Every state has received and a clear, consistent set of baseline support to establish fundamental capabilities. This should include: infection control practices. Necessary capabilities include protocols for l Core Abilities: It is important to establishing isolation beds in hospitals rethink the public health system and safely disposing of hazardous waste; around a core set of abilities — at the developing quarantine and monitoring federal, state and local levels — that policies based on sound science and are maintained, sufficiently funded different disease contingencies; and and enhance the ability to adapt to effectively communicating with the public and effectively address changing during an evolving outbreak without health threats. Key abilities include: creating unnecessary fear. Significant • ntensive investigative capabilities I advances have been made, but many — including an expert scientific serious gaps remain, particularly as and medical workforce and resources have eroded over time. comprehensive laboratory capabilities Infectious disease control requires — to quickly diagnose outbreaks; constant vigilance. This requires • ontainment strategies, including C having systems in place and conducting medicines, vaccines and other DECEMBER 2014 DECEMBER 2014 continuous training and practice countermeasures; exercises. The Ebola outbreak is a reminder that we cannot afford to let our • rilling and training for hospitals D guard down or grow complacent when it so they are prepared to respond comes to infectious disease threats. quickly, safely and correctly when an unusual infection or circumstance Unless public health preparedness presents itself; is consistent and maintained, it can • mproving reporting and I • strong research capacity able to A l Leadership and Accountability: The implementation of infection control rapidly develop new vaccines or medical current federal structure for handling practices, procedures and training in treatments to counter new threats. public health issues is not coordinated hospitals, healthcare systems and in and lacks clear, strong leadership. l Healthcare and Public Health Integra- community health centers; Stronger leadership is needed for tion: Gaps must be addressed in the a government-wide approach to • treamlined and effective S policies and procedures that protect preparedness at the federal, state and communication channels so health patients, healthcare workers and the local levels, and there must be increased workers can swiftly and accurately public’s health — and to improve the support for integration and flexibility of communicate with each other, other way the systems work together and sup- programs in exchange for demonstration front line workers, public health port each other. of capabilities and accountability. agencies and the public; and Infectious diseases cost the country more than $120 billion each year, and worldwide, they are the leading cause of death of people under the age of 60.1, 2, 3 Beyond Ebola, there are many other contain the spread of illnesses. New the right to basic protections no matter emerging diseases of concern that emergencies require resources; the where they live. While government is health officials are monitoring — government should not pull financial only one partner in the fight against MERS-CoV, pandemic flu, Marburg, resources from already underfunded, infectious diseases — along with the dengue fever and Enterovirus D68– ongoing needs. It is essential to balance healthcare sector; pharmaceutical, all of which illustrate that infectious our attention and resources to ensure medical supply and technology disease threats can arise without notice. that diseases that sicken countless companies; community groups, schools Emerging diseases are not just a threat Americans every year are adequately and employers; and families and to health, they also have an impact on addressed. Continuing threats, like individuals — government at all level has how Americans live their daily lives. seasonal flu and healthcare-acquired the ability to set policies and establish Depending on the severity and scope of infections, which are disruptive and have practices based on the best science a threat, it can impact decisions about high healthcare and lost labor/wage available to better protect Americans sending children to schools, limiting costs, must become a priority. Millions from infectious disease threats. travel, restricting public events and even of Americans could be spared and To help assess policies and the capacity quarantine activities. billions of dollars spent on healthcare to protect against infectious disease out- could be saved with better infectious While addressing emerging threats is breaks, this report examines a range of disease prevention and control. essential, one major weakness of our infectious disease concerns. The report system is the tendency to focus on The Trust for America’s Health highlights a series of 10 indicators in the newest and most alarming threats (TFAH) and the Robert Wood Johnson each state that, taken collectively, offer at the expense of the ongoing and Foundation (RWJF) issue the Outbreaks: a composite snapshot of strengths and costly illnesses that affect communities Protecting Americans from Infectious Diseases vulnerabilities across the health system. nationwide every year. Infectious report to examine the country’s policies These indicators help illustrate the types disease control requires constant to respond to ongoing and emerging of policy fundamentals that are impor- attention, but currently in the United infectious disease threats. tant to have in place not just to prevent States, inadequate and fluctuating the spread of disease in the first place Protecting the country from infectious resources leave gaps in the ability to but also to detect, diagnose and respond disease threats is a fundamental role of quickly detect, diagnose, treat and to outbreaks. In addition, the report government, and all Americans have 4 TFAH • healthyamericans.org examines key areas of concern in the nation’s ability to prevent and control infectious diseases and offers recom- mendations for addressing these gaps. The Outbreaks report provides the public, policymakers and a broad and diverse set of groups involved in public health and the healthcare system with an objective, nonpartisan, independent analysis of the status of infectious disease policies; encourages greater transparency and accountability of the system; and recommends ways to assure the public health and healthcare systems meet today’s needs and work across borders to accomplish their goals. KEY FINDINGS l P reparing for Emerging Threats: Sig- Only 14 states vaccinated at least half l S exually Transmitted Infections (STI) nificant advances have been made in of their population against the seasonal and Related Disease Treatment and preparing for public health emergencies flu (from fall 2013 to spring 2014). Prevention: The number of new HIV infec- since the September 11, 2001 and the tions grew by 22 percent among young Only 35 states and Washington, D.C. anthrax attacks, but gaps remain and gay men, and 48 percent among young met the goal for vaccinating young have been exacerbated as resources Black men (between 2008 and 2010); children against the hepatitis B virus have been cut over time. more than one-third of gonorrhea cases (Healthy People 2020 target is 90 per- are now antibiotic-resistant; and nearly 47 states and Washington, D.C. reported cent of children ages 19 to 35 months three million Baby Boomers are infected conducting an exercise or utilizing a real receiving at least 3 doses). with hepatitis C, the majority of whom do event to evaluate the time for sentinel labo- l H ealthcare-Associated Infections: While not know they have it. ratories to acknowledge receipt of an ur- healthcare-associated infections have de- gent message from the state’s laboratory. 37 states and Washington, D.C. require clined in recent years due to stronger pre- reporting of all (detectable and undetect- Only 27 states and Washington, D.C. vention policies, around one out of every 25 able) CD4 and HIV viral load data, which met a score equal to or higher than people who are hospitalized each year still are key strategies for classifying stage of the national average for the Incident contracts a healthcare-associated infection. disease, monitoring quality of care and and Information Management domain Only 16 states performed better than the preventing further transmission of HIV. of the National Health Security national standardized infection ratio for cen- Preparedness Index. l F ood Safety: Around 48 million Americans tral-line-associated bloodstream infections. suffer from a foodborne illness each year. l V accinations: More than 2 million pre- Only 10 states reduced the number of schoolers, 35 percent of seniors and a 38 states met the national performance tar- central line-associated bloodstream in- majority of adults do not receive all rec- get of testing 90 percent of reported E.coli fections between 2011 and 2012. ommended vaccinations. O157 cases within four days (in 2011). TFAH • healthyamericans.org 5 Lessons from the Ebola EXPERT COMMENTARIES Outbreak and the Future of U.S. Public Health Q&A with Robert Kadlec, MD, MTM&H, MA What does the Ebola epidemic and as a nation, we waited until the disease cooperative agreements, Biomedical response tell us about the nation’s public got here to get serious and take steps Advanced Research and Development health preparedness for infectious to protect healthcare workers and the Authority (BARDA)) and others that disease outbreaks? American people — that’s way too late. were created over a decade ago to fight Well before the Ebola outbreak occurred, infectious diseases and bioterrorism. Now we see clearly the vulnerabilities in we had warning signs about our public the public health system. But federal grant programs are just one health infrastructure. Quite frankly, we’re piece of the puzzle. We need to evaluate losing a lot of gray haired professionals What challenges does public health new approaches to fund preparedness with extraordinary experience who aren’t preparedness face in the United States? as part of the overall healthcare being replaced. Without adequately reimbursement process. There can’t be One of the challenges we have today supported and expertly trained public two approaches to support preparedness. is competing priorities and initiatives health workers, the nation will not have a and fewer dollars. And we have taken Also, state and local health departments sustainable and successful public health for granted for too long that our public must continue to do more with less. preparedness system. health and medical systems have been They have to be innovative and nimble. While the lack of new personnel is able to perform at levels that far exceed They must look at dual use of funds — troublesome, we’ve also seen a declining those of the countries around us. for instance, using grants that support commitment across the board to fund diabetes nurses who are also trained to Overall, we’re extraordinarily fortunate. public health preparedness activities. After administer flu vaccines or implement As evidenced by West Africa, we know 9/11 and the surge of funding from 2002 disease prevention programs. what happens when a frail healthcare to 2007, policymakers paid less attention system is tested. But, unfortunately, we These models can be created and partly and subsequently resources started to ebb. saw that it might not take much to poke supported at the national level, but states As a consequence of the 2008 recession holes in our own health system. have to embrace the work and be creative. and decreases of both federal and state investments, the national public health Now is the time to make the clear Lastly, the public health community preparedness capacity was lost. and unambiguous point that we must must do a better job explaining the maintain investments in domestic and costs and downsides of turning a blind The incredible efforts and successes of international public health — so when the eye to infectious disease prevention public health professionals nationwide is next emerging disease comes, we’re better and control. We know the flu costs the an additional major contributing factor. prepared with medicines and antivirals country $10 billion in medical costs We’ve become complacent within our and a first-class public health workforce. and another $16 billion in lost earnings own borders because public health has been successful in squelching the every year, and is largely preventable, yet What do leaders need to do to ensure we don’t support prevention programs. occasional disease outbreak. However, the United States has an effective 24/7 as we have seen with the ongoing Ebola Where are the nation’s strengths in approach to fighting infectious diseases? virus outbreak, deadly diseases that are fighting infectious diseases? Weakness? rare in other parts of the world will show Similar to 2002, national leaders have a window in time where they can have an There is a great spirit in the public up in America with increased frequency extraordinarily positive impact — most health workforce. They are committed because of travel and trade. notably by restoring or increasing support and dedicated, while, at the same time, As Ebola is demonstrating so dramatically and funding to the programs (Hospital underpaid and under-supported. Public now, even a few cases in America can be Preparedness Program (HPP), Public health workers in the middle of a crisis very disruptive to our way of life. And, Health Emergency Preparedness (PHEP) work overtime to help their communities, 6 TFAH • healthyamericans.org yet are rarely adequately compensated. people. This all gets back to the core of And there aren’t enough of them. A great public health — the people who do the BLUE RIBBON PANEL ON weakness of this country is not supporting tests, manage programs and save lives. BIODEFENSE our public health workers — they are Former Senator Joe Lieberman and on the front line. But the front line is How would you improve the nation’s Former Governor Tom Ridge have getting thin. We need to improve their preparedness for infectious disease organized a Blue Ribbon Panel quality of life and recruit more of them. outbreaks? on Biodefense. Panelists include Another great weakness we have is When President Dwight D. Eisenhower Donna Shalala, Tom Daschle, Jim inconsistent and inadequate funding. created the National System of Interstate Greenwood and Ken Wainstein. Emergency supplemental funds get you and Defense Highways, he did so because They are taking a comprehensive through a short period of time but do an interconnected system would improve look at the state of the nation’s very little for the next outbreak. security, commerce and prosperity in preparedness for natural and every corner of the country. deliberate biological outbreaks and The worry I have is that adequate levels This is what public health should be — chemical incidents. As part of this of response both home and abroad interconnected systems that span the clinic study, they will be holding a series cannot be enacted in time, i.e., if we don’t and community that seamlessly share of meetings and workshops on continuously support the development of information and are manned by well- a variety of topics assessing the medical countermeasures and training for trained people that can keep the public current status of public health and public health workers on the latest devices health “roads” and “vehicles” healthy. hospital preparedness. The panel and machines, when an emergency intends to issue a report in the occurs, we’ll be hopelessly behind. There Imagine that every department spring of 2015 that recommends is no “just in time” preparedness. responsible for protecting the nation’s specific actions to the new Congress health maintains an element of surge to improve our nation’s resilience. What should America’s role be in but also manages day-to-day efforts at a strengthening global health security? high level and can work off the strengths The nation has been a leader, if not of other parts of the connected system. Department of Health and Human the leader, in strengthening global Services (HHS), and other government As noted, a big part of the blueprint is health security. We must continue and agencies who embrace a common vision people, but we also need interoperable enhance this work. Our support goes and work together. information systems and a first-class medi- to building coalitions and improving cal system that is integrated with public And, we certainly cannot ignore the world public health infrastructure in poorer health. With effective, well-trained profes- we live in, whether that be preventing countries — efforts that prevent sionals, competent information sharing, new cases of Ebola in Africa, mitigating outbreaks from ever reaching America. and first-class patient management, our mosquito-borne diseases in Latin When you look at the money America public health and clinical systems can bet- America and the Caribbean or fighting spends in helping other nations, the ter safeguard the health of all Americans. antibiotic resistance in the United point should be: our greatest investments States. Our country and the world will The country also needs a set of leaders in others is really an investment in our continue to be challenged by seen and who share the same vision, work toward health, quality of life and economy. unforeseen infectious disease agents. the same objectives and are distributed We must provide support to purchase across the system. We need professionals Consequently, the vision for public health equipment and build clinics and hospitals at the White House, Centers for Disease has to be integral to everything else that is and allocate continued funding to train Control and Prevention (CDC), U.S. happening in the world. TFAH • healthyamericans.org 7 Lessons from the Ebola EXPERT COMMENTARIES Outbreak and the Future of U.S. Public Health Q&A with Tom Inglesby, MD, Chief Executive Officer and Director of the UPMC Center for Health Security How does the Ebola response show on the radar as a potentially grave disease, strengths and weaknesses of public yet, when this outbreak occurred, there health in the United States? was not a widely available diagnostic test. The response to the Ebola epidemic This has changed, but it still takes longer has underscored a number of public than we would like to get the results back, health strengths. creating situations where patients are unable to be cared for with state-of-the-art Starting at the source of the outbreak, care while results are pending. The country has a highly CDC has been and continues to be one of the most important organizations For a time during the fall Ebola response, dedicated public health in the world in terms of providing the commentary on the response became workforce at the federal, state aid (response teams, surveillance and politically charged to the detriment of the and local levels. While outbreaks epidemiology) and mitigating the overall response. The nation does best in spread. CDC’s experts in Atlanta have addressing infectious disease crises when or unmet needs often grab also been relied upon by ministries of responses are apolitical and nonpartisan. headlines, the truth of the matter Once an outbreak develops a political health around the world looking for is that, for many diseases, the insights on how to contain the outbreak. dynamic, it diverts the attention of those country has seen decreasing working on the outbreak to managing the In the United States, we have seen that politics instead of the crisis. incidences of infection. patients treated for Ebola early in their illness have had a very good chance of Another major issue is that we don’t survival. We’ve also seen our public have a medicine or vaccine for Ebola — health system adapt to strenuous and an important example of the problems unforeseen challenges — contact we have developing new medicines and tracing and quarantining operations countermeasures to cope with new and have been performed at a scale that had emerging infectious diseases. not been seen before. The good news is that the United States In the past, we have seen a wide gap has been a world leader in rapidly between clinical and public health initiating clinical trials for Ebola medical communities during emergencies countermeasures. — but that hasn’t been the case with Ebola. The public health and clinical How do you view the attention Ebola healthcare workforce are working has received? closely together on this response. This is a very unusual and serious disease. As we have seen in West Africa, The Ebola outbreak has also Ebola has the potential to substantially demonstrated weaknesses in our system. degrade a healthcare system. It even has We have a limited number of hospitals the potential to destabilize countries. that can care for highly contagious So, while at times, the specific nature of patients while providing full protection for the media coverage of Ebola has been healthcare workers. Ebola has long been 8 TFAH • healthyamericans.org Ebola mimics other diseases early on, is transmissible person-to-person through contact with bodily fluids and has had a very high fatality rate in Africa. And we have no vaccine or antiviral at hand. It has a doubling time of as little as a few weeks. extreme, the level of attention it has every year, and about 1 in 6 don’t know resources given to mosquito abatement. received has been well deserved. it. And there are at least 5.5 million The only way to stop the widespread Americans with Hepatitis B virus (HBV) importation of dengue, chikungunya, We know what happens when Ebola or Hepatitis C virus (HCV), with up to West Nile and a whole host of other gets out of control — entire countries 75 percent unaware they have it. mosquito-borne illnesses is through and regions are ground to a halt with strong abatement policies. serious ramifications from disrupted or Chagas disease: Chagas is creeping destructed trade to extreme starvation up from the south and there is some For some time, we’ve known and stigma to restricted travel. For preliminary evidence that it is has antimicrobial resistance will pose an those reasons, Ebola must be stopped gotten into the blood supply at a low incredible problem for the country at its source, otherwise it can spread level in Texas — which could threaten if we don’t get it under control. Yet, to other nations and wreak havoc on a the safety of the blood supply there. intravascular infections are increasing in broader scale with the world’s health, hospitals and becoming infections that economy, commerce and travel. What are other national strengths/ are difficult to treat with almost all of weaknesses when it comes to responding our established antibiotics. It has been Are there other infectious disease to infectious disease outbreaks? said, but it bears repeating: if this trend threats that the United States is not The country has a highly dedicated continues, even routine procedures paying enough attention to? public health workforce at the federal, in hospitals will become dangerous The domestic attention to Ebola was state and local levels. While outbreaks because our antibiotics could become understandable — it’s frightening or unmet needs often grab headlines, ineffective at preventing infections. This and new and people saw what it did to the truth of the matter is that, for sounds like we’re going back decades West Africa. However, there are also many diseases, the country has seen to a period where any surgery was quite a number of other infectious diseases decreasing incidences of infection. deadly and dangerous. that could or already are causing Unfortunately, the nation’s system How do you view the country’s current severe disruptions and lasting health also has holes and faces incredible plan for research, development and consequences within the United States. challenges every day. stockpiling of medicines and vaccines? Antibiotic-resistant infections: More We need look no further than the Ebola For instance, our vaccination rates are than 20,000 Americans die each year as outbreak to see that there is an important nowhere near where they should be, a result of antibiotic-resistant infections. role for the federal government to which puts our children unnecessarily This, sadly, isn’t new or emerging, it’s play in developing or supporting the at risk. And when kids are at-risk, here and it’s a severe problem. While development of medicines and vaccines they end up serving as the initiator of there is a higher level of awareness, the for diseases that have no public market. broader epidemics in communities — full recommendations of an Executive There is a lot of excellent science going widespread outbreaks happen when we Order issued earlier this year have not on in universities and small companies, don’t follow routine vaccine guidance. been implemented yet. but without a dedicated and committed Also, in the parts of the country where effort from the federal government to HIV/AIDS, Hepatitis, TB and STIs: The mosquito-borne illnesses are growing, fund advanced development, those ideas nation cannot lose sight of serious and we have waxing and waning attention often die in the petri dish — and they mostly preventable infectious diseases. and declining and inconsistent never make it through. Around 1 million people contract HIV TFAH • healthyamericans.org 9 We’ve been relatively fortunate in that mosquito abatement. And there are Ebola was on the threat list, which people working in all these areas. means there was some support for the However, they need support. development of vaccines and antiviral The country needs to improve compounds. We didn’t have to start diagnostic technologies so it’s easier to from zero. But if we had a program do rapid diagnostics. For instance, with dedicated to the advanced development Ebola, it’s become as important to rule of vaccines and medicines for emerging out the disease as it is to rule it in. Until infectious diseases, we may have been Ebola is ruled out for a sick patient, they further along in development. are not going to receive the state-of-the- We have a dedicated program (BARDA) art care that a typical patient would, Quite simply, after the series that focuses on advanced development because they have to be treated as if they of medicines/vaccines for pandemic are dangerously contagious. of emerging infectious disease flu and deliberate biologic threats, but threats that the county has there is nothing within BARDA that And, as noted above, the country desperately needs new approaches to faced in the last 10 years, it effectively supports the creation of managing antimicrobial resistance and a is unacceptable that we don’t countermeasures for other naturally realistic funding strategy for 2015. occurring diseases (SARS, MERS, etc.). have adequate, dedicated and The antimicrobial resistance programs consistent funding to support What should America’s role be in within BARDA are required to have the strengthening global health security? the development pipeline. primary purpose of responding to a deliberate biological threat. The recent The United States has a very important executive order will allow BARDA to role and is already doing a great deal expand its efforts. of work in strengthening global health security. The nation has helped train Quite simply, after the series of public health workers in other countries, emerging infectious disease threats provided technologies, vaccines, that the county has faced in the last 10 medicines and other supplies and worked years, it is unacceptable that we don’t to increase the capacity of nations with have adequate, dedicated and consistent weak public health infrastructures. funding to support the development pipeline for the most urgent emerging The country also has an important role infectious diseases. in persuading other nations that it is in our collective best interest to fight Is there anything different the science diseases where they occur, which means and technology communities can do to providing more support to nations that better prepare the country for infectious have weak public health systems. disease outbreaks? To protect the health and wealth of There is room for innovation across Americans, it is absolutely vital that our the spectrum — from prevention public health system share resources to treatment to infection control to and best practices with other nations. 10 TFAH • healthyamericans.org SOME MAJOR INFECTIOUS DISEASE THREATS l Ebola: As of December 2014, symptoms of respiratory illness, West Africa has experienced more about one week before they felt than 17,000 cases of this viral muscle weakness. A little less than hemorrhagic fever and more than half of the children had EV-D68 in 6,000 deaths. In October, Congress 4 their nose secretions.9 authorized reallocation from the l Superbugs and Antibiotic Resistance: Pentagon of $750 million to fight More than two million Americans fall Ebola, in addition to $88 million sick from antibiotic-resistant bacteria in a 2014 continuing resolution.5 and more than 23,000 die from those In December 2014, Congress infections each year.10 Antibiotic provided an additional $5.4 billion resistance costs the country an in emergency supplemental funds extra $20 billion in direct medical to increase efforts to contain costs and at least $35 billion in lost the epidemic globally, strengthen productivity each year. domestic preparedness and accelerate development of vaccines l Healthcare-associated Infections: and treatments. Approximately one out of every 25 people who are hospitalized l Enterovirus D68 (EV-D68): From each year contracts a healthcare- mid-August to December 4, 2014, associated infection. There were an more than 1,100 people in 47 estimated 722,000 HAIs in 2011 states and Washington, D.C. have confirmed respiratory illness caused in acute care hospitals and around 75,000 patients with HAIs died 722,000 by EV-D68.6  EV-D68 has been during their hospitalizations.11 HAIs in 2011 detected in specimens from 12 patients who died.7 l Foodborne Illness: More than 48 million Americans suffer from l Acute Flaccid Myelitis in Children: foodborne illnesses each year. Between August and November These illnesses result in 128,000 2014, 90 children from 1 to 18 hospitalizations and around 3,000 years of age in 32 states developed 75,000 patients with HAIs died deaths. In addition, more than 4,100 sudden onset of muscle weakness persons become ill from contaminated or paralysis, mostly in their arms drinking water and more than 13,000 or legs.8 CDC does not yet know persons become ill from recreational what causes the illness or if it is water disease outbreaks annually in spread from person to person. All the United States.12, 13 the children had a fever, most with TFAH • healthyamericans.org 11 SOME MAJOR INFECTIOUS DISEASE THREATS l The Flu (Influenza): An average of CoV reported to the World Health and almost one in six do not know 62 million Americans — 20 percent Organization (WHO).18 they are infected. Since the epidemic of the population — get the flu each began, more than 648,000 Americans l Chikungunya, West Nile Virus (WNV), year. Annually, more than a quarter of have died with AIDS.24 There is a Malaria, Dengue Fever and Mosquito- a million people are hospitalized and sharp rise in new infections among borne Illnesses: Chikungunya, a between 3,000 and 49,000 die from gay men — particularly among mosquito-borne illness that causes the flu, depending on the severity of young gay men — accounting for the fever and severe joint pain, emerged that year’s strain, leading to economic majority of the nearly 50,000 new HIV in the Americas for the first time in losses of more than $10 billion in diagnoses in 2010.25 late 2013. Currently, there are more direct medical expenses and more than 780,000 suspected and 15,000 l Hepatitis B and C: Around 5 million than $16 billion in lost earnings.14, 15 confirmed cases in the Americas and Americans have hepatitis B virus or l Pandemic Flu: Experts also warn that Caribbean — including at least 11 hepatitis C virus, but between 65 and flu pandemics — novel strains of the cases in the United States. 19, 20 In the 75 percent do not know they have it. flu virus that humans have little-to-no past few years, the United States has HBV and HCV put people at risk for immunity against — emerge three to experienced the largest outbreak of developing serious liver diseases and four times a century.16 Since 2012, West Nile Virus in a decade and the cancer. Two-thirds of Americans in- global health officials have been highest number of cases of malaria fected with HCV are Baby Boomers and tracking a new strain of the flu — since 1970.21 Mosquitoes that can one in 12 Asian Americans has HBV.26 H7N9, first reported in China — which transmit dengue fever have been l Tuberculosis (TB): Nearly 10,000 has led to 175 deaths globally, primarily found in 36 U.S. states and are of people within the United States were in East Asia (as of October 2014).17 particular concern along the U.S.- diagnosed with TB disease in 2013 Mexico border, in Puerto Rico and in l Middle East Respiratory Syndrome with 63 percent of these cases occur- Hawaii.22 Recently, multiple cases Coronavirus (MERS-CoV): As of ring in persons born outside the United of locally-acquired dengue fever have October 2014, there have been States.27 An estimated 11 million been reported in Florida.23 more than 850 laboratory-confirmed Americans — 4 percent of the popula- cases (including more than 300 l HIV/AIDS: More than 1.2 million tion — have “latent” TB infections.28 deaths) worldwide of a new MERS- Americans are living with HIV/AIDS, > 1.2 million people with HIV/AIDS 1 in 6 don’t know they’re infected 12 TFAH • healthyamericans.org SECTI O N 1: State by State SECTION 1: STATE-BY-STATE INFECTIOUS DISEASE PREVENTION & CONTROL INDICATORS State-By-State Infectious Disease Prevention and Control Indicators Indicators All Americans deserve to be protected against infectious disease threats, no matter where they live. CDC has identified strategies and policies and programs vary from state-to- fundamental capabilities that should be state. To help assess infectious disease in place to fight infectious diseases in a policies, the Outbreaks report examines Framework for Preventing Infectious Diseases: a series of 10 indicators based on high- Sustaining the Essentials and Innovating priority areas and concerns. It is not a for the Future. Core elements of the comprehensive review; but collectively, it framework include focusing on: provides a snapshot of efforts to prevent and control infectious diseases in states l Strengthening public health funda- and within the healthcare system. mentals, including infectious disease surveillance, laboratory detection and The indicators were selected after epidemiologic investigations; consulting with leading public health and healthcare officials. Each state l Identifying and implementing received a score based on these 10 high-impact strategies — such as indicators. States received one point vaccinations, infection control, rapid for achieving an indicator and zero diagnosis of disease and optimal points if they did not. Zero is the treatment practices — to limit the lowest possible score and 10 is the spread of diseases and systems to highest. The scores ranged from a high reduce the diseases transmitted by of eight in Maryland, Massachusetts, animals or insects to humans; and Tennessee, Vermont and Virginia to a l Developing and advancing policies such low of two in Arkansas. as integrating clinical infectious disease Scores are not intended to serve as a preventive practices into U.S. healthcare reflection of the performance of a specific systems; educating and working with state or local health department or the the public to understand how to limit healthcare system or hospitals within a the spread of diseases; and working with state, since they reflect a much broader the global health community to quickly context, including resources, policy identify new diseases and reduce rates of environments and the health status of a existing diseases.29 community, so many of the indicators are Infectious disease control and prevention impacted by factors beyond the direct is a concern in every state. However, control of health officials. DECEMBER 2014 STATE INDICATORS (2) State scored equal to or (3) Met the Healthy (4) Vaccinated at least (5) State currently (1) Increased or (6) State performed higher than the national average People 2020 target of 90 half of their population has completed climate maintained level of better than the on the Incident & Information percent of children ages (ages 6 months and change adaptation funding for public national SIR for Management domain of the 19-35 months receiving older) for the seasonal plans – including the health services from FY central line-associated National Health Security recommended ≥3 doses flu for fall 2013 to impact on human 2012-13 to FY 2013-14. bloodstream infections Preparedness Index (2014). of HBV vaccine. spring 2014. health. Alabama 3 3 Alaska 3 3 Arizona 3 3 Arkansas California 3 3 3 3 Colorado 3 3 3 Connecticut 3 3 3 3 Delaware 3 3 3 3 D.C. 3 3 Florida 3 3 3 Georgia 3 3 Hawaii 3 3 3 Idaho 3 3 Illinois 3 3 3 Indiana 3 3 Iowa 3 3 3 Kansas 3 Kentucky 3 Louisiana 3 Maine 3 Maryland 3 3 3 3 Massachusetts 3 3 3 3 3 Michigan 3 3 Minnesota 3 3 3 Mississippi 3 3 Missouri 3 Montana 3 3 Nebraska 3 3 3 3 Nevada 3 New Hampshire 3 3 3 3 New Jersey 3 3 3 New Mexico 3 3 New York 3 3 3 North Carolina 3 3 3 3 North Dakota 3 3 3 3 Ohio 3 Oklahoma 3 3 3 Oregon 3 3 3 Pennsylvania 3 3 3 3 3 Rhode Island 3 3 3 South Carolina 3 3 3 South Dakota 3 3 3 3 Tennessee 3 3 3 3 Texas 3 3 3 Utah 3 3 Vermont 3 3 3 3 3 3 Virginia 3 3 3 3 Washington 3 3 West Virginia 3 3 Wisconsin 3 3 3 Wyoming Total 28 27 + D.C. 35 + D.C. 14 15 16 14 TFAH • healthyamericans.org (8) From July 1, 2013 to June 30, 2014, (10) State met the national public health lab reports conducting (9) State requires reporting performance target of (7) Between 2011 and 2012, state 2014 an exercise or utilizing a real event to of all CD4 and HIV viral testing 90 percent of reduced the number of central line Total evaluate the time for sentinel clinical load data to their state HIV reported Escherichia coli associated blood stream infections. Score laboratories to acknowledge receipt of surveillance program. (E. coli) O157 cases within an urgent message from laboratory. four days. Alabama 3 3 3 5 Alaska 3 3 4 Arizona 3 3 4 Arkansas 3 3 2 California 3 3 3 7 Colorado 3 3 3 6 Connecticut 3 3 6 Delaware 3 3 3 7 D.C. 3 3 3 5 Florida 3 3 3 6 Georgia 3 3 3 5 Hawaii 3 3 3 6 Idaho 3 3 Illinois 3 3 3 6 Indiana 3 3 3 5 Iowa 3 3 3 6 Kansas 3 3 3 Kentucky 3 3 3 Louisiana 3 3 3 Maine 3 3 3 4 Maryland 3 3 3 3 8 Massachusetts 3 3 3 8 Michigan 3 3 3 5 Minnesota 3 3 3 6 Mississippi 3 3 4 Missouri 3 3 3 4 Montana 3 3 4 Nebraska 3 3 3 7 Nevada 3 3 3 4 New Hampshire 3 3 3 7 New Jersey 3 New Mexico 3 3 3 5 New York 3 3 3 6 North Carolina 3 3 6 North Dakota 3 3 3 7 Ohio 3 3 3 Oklahoma 3 3 5 Oregon 3 3 5 Pennsylvania 3 3 7 Rhode Island 3 3 3 6 South Carolina 3 3 3 6 South Dakota 3 3 6 Tennessee 3 3 3 3 8 Texas 3 3 3 6 Utah 3 3 3 5 Vermont 3 3 8 Virginia 3 3 3 3 8 Washington 3 3 4 West Virginia 3 3 3 5 Wisconsin 3 3 3 3 7 Wyoming 3 3 3 3 10 47 + D.C. 37 + D.C. 38 + D.C. TFAH • healthyamericans.org 15 MAJOR INFECTIOUS THREATS WA ND AND KEY FINDINGS MT 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 (5 states) (7 states) (13 states) (9 states & D.C.) (8 states) (7 states) (1 state) Maryland California Colorado Alabama Alaska Idaho Arkansas Massachusetts Delaware Connecticut D.C. Arizona Kansas Tennessee Nebraska Florida Georgia Maine Kentucky Vermont New Hampshire Hawaii Indiana Mississippi Louisiana Virginia North Dakota Illinois Michigan Missouri New Jersey Pennsylvania Iowa New Mexico Montana Ohio Wisconsin Minnesota Oklahoma Nevada Wyoming New York Oregon Washington North Carolina Utah Rhode Island West Virginia South Carolina South Dakota Texas INDICATOR SUMMARY Indicator Finding 1. Public Health Funding Commitment 28 states increased or maintained funding for public health from Fiscal Year (FY) 2012 to 2013 to FY 2013 to 2014. 2. Incident and Information Management 27 states met or exceeded the average score for Incident Information and Management in the National Health Security Preparedness Index™ (NHSPI™). 3. Childhood Vaccinations 35 states and Washington, D.C. met the Healthy People 2020 target of 90 percent of children ages 19-35 months receiving the recommended ≥3 doses of HBV vaccine. 4. Flu Vaccination Rates 14 states vaccinated at least half of their population (ages 6 months and older) for the seasonal flu from fall 2013 to spring 2014. 5. Climate Change and Infectious Disease 15 states currently have completed climate change adaptation plans that include the impact on human health. 6. Healthcare-Associated Infection Control 16 states performed better than the 2012 national standard infection ratio (SIR) for central line- associated bloodstream infections. 7. Healthcare-Associated Infection Control Between 2011 and 2012, the standardized infection ratio (SIR) for central line-associated bloodstream infections decreased significantly in 10 states. 8. Public Health Laboratories – Capabilities 47 state public health laboratories and Washington, D.C. reported conducting an exercise or utilizing a real During Emergencies or Drills event to evaluate the time for sentinel clinical laboratories to acknowledge receipt of an urgent message from the state’s laboratory (from July 1, 2013 to June 30, 2014). 9. HIV/AIDS Surveillance 37 states and Washington D.C. required reporting of all (detectable and undetectable) CD4 (a type of white blood cell) and HIV viral load data to their state HIV surveillance program. 10. Food Safety 38 states and Washington, D.C. met the national performance target of testing 90 percent of reported Escherichia coli (E. coli) O157 cases within four days. 16 TFAH • healthyamericans.org GERMS HAVE NO BORDERS: FEDERAL, STATE AND LOCAL PUBLIC HEALTH RESPONSIBILITIES The nation’s public health system is the core responsibilities are based in to carry out policies in states or local responsible for improving the health states, while diseases can easily spread communities. Since communicable of Americans. Public health laws “au- across state lines and around the globe. diseases pose threats to national secu- thorize and obligate the government rity and travel across states, Congress The federal government sets national to protect and advance the public’s authorized the tracking of infectious health goals and priorities for the health,” including against threats from disease threats starting in 1878.32 country. The federal government can infectious diseases. 30 Federal, state CDC, in consultation with state, local track and report on information about and local health departments have dif- and tribal health departments and the diseases, conduct biomedical and pre- ferent responsibilities and jurisdictions, Council of State and Territorial Epide- vention research, stockpile resources and must also work in partnership with miologists (CSTE), establishes and to supplement state and local response healthcare providers; the insurance, routinely updates a list of “notifiable” capabilities and provide technical assis- pharmaceutical and medical device diseases that states are required to tance to states and localities.31 Federal industries; other areas of government; report to CDC so they can be tracked policies can steer efforts across the and community groups to effectively pre- and strategies can be developed to limit country by setting joint strategic priori- vent and control diseases. Policies and their spread.33 There are more than 85 ties and establishing programs and then programs to control infectious diseases notifiable infectious diseases, ranging providing funds, often through grants, are particularly complex since many of from anthrax to yellow fever.34 NOTIFIABLE DISEASES IN THE UNITED STATES VIRAL HEMORRHAGIC FEVER Cryptosporidiosis Poliovirus infection, nonparalytic Toxic Shock Syndrome ANTHRAX Giardiasis Tetanus Babesiosis (other than Streptococcal) EBOLA Botulism DENGUE VIRUS Novel influenza A virus infections PLAGUE Streptococcal Brucellosis DIPHTHERIA Varicella INFECTIONS Tularemia toxic-shock syndrome GONORRHEA 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 Pertussis ARBOVIRAL DISEASES, Hepatitis A smallpox measles Tuberculosis Hepatitis B NEUROINVASIVE AND VIBRIOSIS Meningococcal disease Q fever Hepatitis C NON-NEUROINVASIVE rubella Severe Acute Respiratory Syndrome-Associated Coronavirus Disease Legionellosis VANCOMYCIN-INTERMEDIATE STAPHYLOCOCCUS AUREUS & VANCOMYCIN-RESISTANT STAPHYLOCOCCUS AUREUS TFAH • healthyamericans.org 17 The federal government also has au- Federal isolation and quarantine are thority to isolate or quarantine patients currently authorized by Executive Order infected with certain diseases who are of the President for cholera, diphtheria, arriving into the United States from a infectious TB, plague, smallpox, yellow foreign country, are traveling between fever, viral hemorrhagic fevers like Ebola, states, or who may come into contact severe acute respiratory syndromes with others who are traveling between and influenza viruses that are causing states when they pose a threat to others or have the potential to cause a pan- or the national interest. This authority demic.36 The President can revise the derives from the Commerce Clause of list by Executive Order. It is the duty of the Constitution. The U.S. Secretary of U.S. Customs and Coast Guard officers HHS is authorized to take measures to to aid in the enforcement of quarantine prevent the entry and spread of commu- rules and regulations.37 Breaking a fed- nicable diseases from foreign countries eral quarantine order is punishable by into the United States and between the fines and imprisonment.38 states (section 361 of the Public Health l CDC issued Interim U.S. Guidance Services Act (42 U.S. Code § 264)).35 for Monitoring and Movement of CDC has the responsibility for implement- Persons with Potential Ebola Virus ing these functions as deemed neces- Exposure, recommending individuals sary to protect the public. Although rare, arriving into the United States from a CDC may detain, medically examine and West African country with widespread release persons arriving into the United transmission, who meet certain risk States, people traveling between states factors but are asymptomatic, should or people who may come into contact with be closely monitored for 21 days and, others who are traveling between states in some cases, have controlled move- and are suspected of carrying communi- ment and be excluded from public cable diseases of public health concern. 18 TFAH • healthyamericans.org places and/or the workplace, based finding an appropriate balance between WHO revised a set of International on an individual risk assessment. 39 protecting against the risk to the public Health Regulations (IHR) in 2005 in the Individuals who are symptomatic and versus the rights of an individual or group. wake of the outbreak of a new deadly meet risk factors would be subject to In most states, for most conditions, “lib- disease called SARS to help improve rapid isolation and care.40 erty principles” and “informed consent” global disease surveillance and detec- allow individuals to decide whether to tion and encourage the adoption of l The Department of Defense (DoD) re- treat an illness they may have, but this stronger standardized disease control quires service members returning from may then lead to required isolation for policies worldwide.48 IHR sets stan- Ebola-infected areas to undergo 21 a patient if the disease can be easily dards for and requires notification to days of isolation and “enhanced moni- spread and pose a danger to others. 46 WHO of any “public health emergency toring.” However, it cannot legally force of international concern” or of any sig- civilian DoD employees into the same States are able to establish their own nificant evidence of public health risks level of quarantine. Before deployment, quarantine and isolation policies, includ- outside their territory that may lead to civilians can decided that upon their re- ing for Ebola, and there have been sig- or cause the international spread of turn they will undergo the same military nificant variations in their policies with disease. The IHRs are also intended to quarantine or they can choose to abide many states choosing to differ from CDC’s help prevent countries from taking non- by CDC guidelines that do not require recommendations. For example, some science-based policies on trade or travel quarantine. Instead, personnel must states have required mandatory quaran- restrictions. More than 190 nations take their own temperatures twice daily tines for 21 days for healthcare workers have signed onto the IHR.49 and undergo periodic face-to-face moni- returning from treating Ebola patients in toring by a health professional.41 Offi- West Africa even if they were at low risk Even with laws in place, infectious dis- cials have noted that civilians deployed for exposure and are symptom-free.47 ease prevention and control policies can to the region — unlike infantry — are have major challenges in practice. For in- likely healthcare workers with experi- stance, the ability of different nations to ence in infectious disease. 42 Therefore, disease outbreaks effectively detect and monitor diseases anywhere are of concern and institute disease control practices States bear most of the legal responsibil- varies significantly. Many countries do ity for protecting the health, safety and everywhere. not adequately fund public health pro- welfare of their citizens, granted by “police grams, have large endemic public health power” functions. States vary in how they U.S. infectious disease control strategies crises, do not have strong healthcare are structured and many share different are complicated not just by interstate systems and do not have a tradition of degrees of responsibility with local gov- travel, but by international travel and setting standards for adopting evidence- ernments, but still maintain the ultimate immigration. In many cases, people based disease control practices or for power within their borders.43 This author- carrying diseases are often not identi- adopting principles of objectivity, fairness ity “underlie[s] communicable disease fied when crossing borders because and transparency.50 Efforts like the WHO laws authorizing surveillance, testing, they may have an infection or illness but and CDC’s Global Disease Detection screening, isolation and quarantine.”44 are unaware of it, or they may not have (GDD) program help provide some ad- Every state has the general public health developed severe enough symptoms to ditional support to less wealthy nations, authority to act to control communicable warrant special notice or attention. And, but there is wide variance and major diseases, but state laws, programs and even in cases where a patient suspected gaps in public health programs around funding levels vary significantly. For in- of having a dangerous infectious disease the world to control outbreaks like Ebola, stance, some states have very specific has been identified, carrying out quaran- ongoing threats like HIV/AIDS and ma- or very broad quarantine laws. In most tine and isolation laws in a timely man- laria and the ability to quickly identify and states, breaking a quarantine law is a ner and across different jurisdictions can contain new diseases. criminal misdemeanor.45 Public health present a challenge. laws can be controversial in terms of TFAH • healthyamericans.org 19 INDICATOR 1: 28 states increased or maintained public health 22 states and Washington, D.C. cut public health funding from FY 2012 to 2013 to FY 2013 to 2014 (1 funding from FY 2012 to 2013 to FY 2013 to 2014 PUBLIC HEALTH FUNDING point). (0 points). COMMITMENT — STATE Arizona (8.8%) Nebraska (0.1%) Alabama (-8.5%)* Missouri (-5.1%)^ PUBLIC HEALTH BUDGETS California (0.2%) Nevada (5.0%) Alaska (-1.6%) New York (-7.8%)* Connecticut (10.7%) New Hampshire (0.9%) Arkansas (-5.5%)^ North Carolina (-7.4%)* Delaware (0.6%) New Jersey (1.9%) Colorado (-1.6%) Ohio (-0.4%)^ Key Finding: 28 states increased Florida (3.7%) New Mexico (0.5%) D.C. (-0.4%)* Rhode Island (-1.7%) Georgia (0.7%) North Dakota (32.8%) Idaho (-1.8%)* Utah (-12.6%) or maintained funding for public Hawaii (6.1%) Oklahoma (13.3%) Indiana (-26.2%)* Virginia (-4.7%)^ Illinois (5.0%) Oregon (18.1%) Kansas (-12.9%)^ Washington (-11.2%)^ health from Fiscal Year (FY) 2012 Iowa (17.4%) Pennsylvania (0.7%) Kentucky (-8.1%)^ West Virginia (-17.9%)^ to 2013 to FY 2013 to 2014. Maryland (2.5%) South Carolina (4.5%) Louisiana (-5.5%) Wisconsin (-2.5%)* Massachusetts (0.3%) South Dakota (6.3%) Maine (-0.7%)^ Wyoming (-1.1%)* Michigan (11.2%) Tennessee (0.6%) Minnesota (-0.4%)* Mississippi (6.2%) Texas (14.7%) Montana (12.5%) Vermont (8.1%) *Budget decreased for second year in a row ^Budget decreased for third year in a row This indicator, adjusted for inflation, comparable health coverage programs immunization services and health illustrates a state’s commitment and for low-income residents.  emergency preparedness. ability to provide funding for public Based on this analysis, 22 states and It is important to note that several states health programs that support the Washington, D.C. made cuts in their that received points for this indicator infrastructure and workforce needed to public health budgets. Seventeen states may not have actually increased their improve health in each state, including and D.C. cut their budget for two or more spending on public health programs. the ability to prevent and control years in a row, and nine made cuts for The ways some states report their infectious disease outbreaks. three or more years in a row. The median budgets, for instance, by including federal Every state allocates and reports its spending in FY 2013 to FY 2014 was $31.06 funding in the totals or including public budget in different ways. States also per capita, down from $33.71 in FY 2008. health dollars within healthcare spending vary widely in the budget details they totals, make it very difficult to determine Public health funding is discretionary provide. This makes comparisons “public health” as a separate item. spending in most states and, therefore, across states difficult. For this analysis, is at high risk for significant cuts during This indicator is limited to examining TFAH examined state budgets and economic downturns. States rely on whether states’ public health budgets appropriations bills for the agency, a combination of federal, state and increased or decreased; it does not assess department, or division in charge of local funds to support public health if the funding is adequate to cover public public health services for FY 2012 to 2013 activities, including infectious disease health needs in the states, and it should and FY 2013 to 2014, using a definition prevention, immunization services not be interpreted as an indicator or as consistent as possible across the and preparedness activities. The surrogate for a state’s overall performance. analyses of the two budget cycles, based overall infrastructure of public health on how each state reports data. TFAH For additional information on the programs supports the ability to carry defined “public health services” broadly methodology of the budget analysis, out all of their responsibilities, which to include all state-level health spending please see Appendix A: Methodology for includes infectious disease prevention, with the exception of Medicaid, CHIP or Select State Indicators. 20 TFAH • healthyamericans.org 27 states met or exceeded the average score for In- 23 states were below the average score for Incident INDICATOR 2: cident Information and Management in the National Information and Management in the National Health Health Security Preparedness Index. (1 point). Security Preparedness Index. (0 points). INCIDENT INFORMATION Alabama (8.1) New Jersey (8.8) Alaska (6.6) Mississippi (7.8) AND MANAGEMENT Arizona (8.2) New Mexico (8.5) Arkansas (8.0) Missouri (7.2) Colorado (8.6) New York (8.5) California (8.0) Montana (7.0) Delaware (8.7) North Carolina (8.6) Connecticut (7.9) Nevada (7.8) Key Finding: 27 states met or D.C. (N/A) North Dakota (8.5) Georgia (7.7) Ohio (7.4) exceeded the average score Florida (8.4) Pennsylvania (8.8) Hawaii (7.7) Oklahoma (7.6) Illinois (8.5) Rhode Island (8.5) Idaho (6.9) Oregon (7.9) for Incident Information and Indiana (8.2) South Carolina (8.9) Kansas (7.1) South Dakota (7.5) Iowa (8.4) Tennessee (9.0) Kentucky (7.9) West Virginia (7.7) Management in the National Maryland (9.5) Texas (8.1) Louisiana (7.0) Wisconsin (7.7) Health Security Preparedness Massachusetts (8.4) Utah (9.4) Maine (7.8) Wyoming (7.8) Minnesota (8.2) Vermont (8.9) Michigan (7.6) Index™ (NHSPI™). Nebraska (8.3) Virginia (9.4) New Hampshire (8.9) Washington (8.2) Source: National Health Security Preparedness Index. Washington, D.C. was not included in the NHSPI (since information was not available, D.C. was awarded a point for the indicator). The National Health Security includes 194 measures from more than Incident Management and Multi- Preparedness Index™ was developed 35 sources — and reviews six domains Agency Coordination, Emergency as a new way to measure and advance for preparedness, including Health Public Information and Warning and the nation’s readiness to protect people Security Surveillance, Community Legal and Administrative. The domain during a disaster — including major Planning and Engagement, Incident scores a state’s ability to mobilize infectious disease outbreaks caused by and Information Management, resources; establish command, control nature or acts of bioterrorism. The Healthcare Delivery, Countermeasure and coordination within the affected NHSPI measures the health security Management and Environmental and area; provide legal, administrative preparedness of the nation by looking Occupational Health. and logistical support; and exchange collectively at existing state-level data public health and medical information, The total national average for the from a wide variety of sources. Uses intelligence and plans to more than indicators was a 7.4 out of a possible of the Index include guiding quality one jurisdiction.51 10. The state scores ranged from 6.5 in improvement, informing policy and Alaska to 8.2 in Utah and Virginia. This includes many basic and central resource decisions, and encouraging capabilities that are important during shared responsibility for preparedness This indicator examines whether a outbreaks, such as Ebola or a flu across a community. state met the national average for the pandemic. Twenty-seven states met or Incident and Information Management The NHSPI was developed by the exceeded the national average score domain — which focuses on the Association of State and Territorial of 8.1 for Incident and Information ability to respond to a public health Health Officials (ASTHO) in Management. (Washington, D.C. was emergency by dispersing resources partnership with CDC and more than not included in NHSPI). Scores ranged and information. The Incident and 20 development partners — including from a low of 6.6 in Alaska to a high of Information Management domain TFAH and RWJF — and was first 9.5 in Maryland. is comprised of three sub domains: released in 2013. The 2014 version TFAH • healthyamericans.org 21 National Health Security Preparedness Index™ State-by-State Scores 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 FL AK HI n <7 n ≥ 7 and < 7.5 n ≥ 7.5 and < 8 n ≥8 22 TFAH • healthyamericans.org 35 states and Washington, D.C. met the Healthy 15 states did not met the Healthy People 2020 target INDICATOR 3: CHILDHOOD People 2020 target of 90% of children ages 19-35 of 90% of children ages 19-35 months receiving ≥3 months receiving ≥3 doses of HBV vaccine (1 point). doses of HBV vaccine (0 points). VACCINATIONS Alabama* (89.8%) Nebraska (94.5%) Arizona (88.4%) Alaska (92.7%) New Hampshire (94.6%) Arkansas (88.6%) Key finding: 35 states and California (91.1%) New Jersey (93.2%) Colorado (84.1%) Connecticut (96.0%) New York (92.9%) Florida (89.0%) Washington, D.C. met the Healthy Delaware (93.7%) North Carolina (94.3%) Hawaii (88.3%) D.C. (92.5%) North Dakota (91.8%) Maine (84.5%) People 2020 target of 90 percent Georgia (91.5%) Oklahoma (90.9%) Michigan (87.9%) of children ages 19-35 months Idaho (90.7%) Pennsylvania (92.3%) Missouri (88.4%) Illinois* (89.5%) Rhode Island (96.7%) Nevada (88.8%) receiving the recommended ≥3 Indiana (92.0%) South Carolina (95.0%) New Mexico (86.0%) doses of HBV vaccine. Iowa (96.5%) South Dakota (92.1%) Ohio (87.4%) Kansas (93.8%) Tennessee (92.2%) Oregon (88.7%) Kentucky (90.8%) Texas* (89.5%) Washington (89.0%) Louisiana (93.0%) Utah* (89.7%) West Virginia* (85.5%) Maryland (91.0%) Vermont (92.0%) Wyoming (88.9%) Massachusetts (92.9%) Virginia (90.8%) Guam (84.6%)^ Minnesota (90.3%) Wisconsin (94.4%) Mississippi (92.8%) Montana* (89.9%) Source: CDC. *States with rates at 89.5 percent and above were rounded up to meet the 90 percent threshold. ^ Report includes data when available for Guam. Vaccines are among the most from a low of 84.1 percent in Colorado to as they get older — around 90 percent scientifically effective and cost-effective a high of 96.7 percent in Rhode Island.54 of newborns who are infected with HBV clinical services to prevent diseases during childbirth will develop a chronic CDC estimates there are between among children and they provide a infection unless they receive proper 700,000 and 1.4 million individuals very high return on investment. Each preventive care measures. Following chronically infected with HBV in the birth cohort vaccinated with the routine recommended screening, treatment and United States, and 65 percent of these immunization schedule saves 33,000 prevention practices could eliminate individuals do not know they are lives, prevents 14 million cases of disease, maternal-child transmissions. For healthy infected. In 2012, a total of 44 states reduces direct healthcare costs by $9.9 young adults, about 5 percent of HBV submitted 40,599 reports of chronic billion and saves $33.4 billion in indirect infections develop into chronic HBV. It HBV to CDC, but this is thought to be costs for a total of $42.4 billion in savings can lead to cirrhosis (scaring of the liver), an underestimate.55 One in 12 Asian due to vaccinations.52 Worldwide, liver cancer and other liver problems. Americans have HBV — and Asian vaccinations prevent an estimated 2.5 Some patients will need liver transplants. Americans and Pacific Islanders account million childhood deaths annually.53 for 50 percent of chronic HBV cases.56 Since 1982, an HBV vaccine has been This indicator examines which states available. More than 90 percent of HBV is typically spread from a mother met the Healthy People 2020 goal that American children have been vaccinated to a baby during childbirth, from direct 90 percent or more children ages 19 to for HBV and the HBV vaccine has helped contact with infected blood. Currently, 35 months receive at least three doses of cut infection rates by around 80 percent. an estimated 800 to 1,000 newborns HBV vaccine. The national target was However, approximately 10 percent of are infected with HBV in the United met in 2013 with 90.8 percent coverage infants are still not vaccinated and many States each year, and they are at the — a 1.1 percent increase from 2012 — adults were not immunized because highest risk for developing chronic and 30 states had coverage of 90 percent they came of age before the vaccine was HBV and of having greatly increased or greater. Vaccination coverage ranged available in 1982. Those Americans risk of developing serious liver disease TFAH • healthyamericans.org 23 who came of age before the vaccine was and though they often do not result in widely available, along with Americans a full cure, they can significantly reduce born to mothers who have the disease liver damage particularly if treatment or are immigrants from other countries is started early. Successful therapy of where the vaccine is not widely used, patients with advanced disease can are at risk for HBV. Seven medications prevent liver cancer, reduce the need for have been approved for treating HBV liver transplants and save lives. 57, 58 Infant and Preschooler Immunization Gaps: Requirements for to vaccinate all preschoolers with all of the recommended im- vaccinations before attending school mean around 95 percent munizations on time leaves more than 2 million young children of school-aged children receive a vaccination –but there is a unnecessarily vulnerable to preventable illnesses.59 much bigger gap in preschooler vaccination rates.  The failure INFANT VACCINATION GAPS PRESCHOOLER VACCINATION GAPS Recommended Vaccination % NOT Receiving Recommended Vaccination (19-to-35 month olds) % NOT Receiving (by 13 months unless otherwise noted) Hepatitis B- first doses within 3 days of birth.* 25.8% Childhood full series 4:3:1:3:3:1:4 27.4% Measles, mumps, rubella 45.0% Rotavirus 27.4% Varicella (chickenpox) 43.2% Pneumococcal 18.0% Pneumococcal 12.6% Diphtheria, tetanus and whooping cough 16.9% Hib (meningitis, pneumonia, epiglottis) 10.7% Hepatitis B – all three doses* 9.2% Diphtheria, tetanus and whooping cough 10.6% Varicella (chickenpox) 8.8% Hepatitis B – three doses 15.4% Measles, mumps, rubella 8.1% Polio 6.3% Polio 7.3% *Note: the first vaccination dose of Hepatitis B is recommended to be administered within 3 days of birth; many children receive their first dose after the recommended schedule. By preschool age, there is a recommendation children should receive 3 scheduled doses of the vaccine. VACCINE SAFETY Vaccines go through rigorous review and a collaboration between CDC’s Immuni- by the IOM in 2012 re-confirmed their testing for effectiveness and safety by zation Safety Office (ISO) and nine large earlier conclusion.64 Reviews in 2013 the Food and Drug Administration (FDA) managed care organizations to monitor in the Journal of Pediatrics and 2014 in before they are released to the market. safety and answer scientific questions Pediatrics, also found no link between The safety of vaccines is also tracked about health concerns that might be childhood vaccines and autism and that post-FDA licensure through several related to vaccines.61, 62 serious adverse events are very rare.65, monitoring systems to keep track of po- 66 Researchers from CDC concluded that There have been numerous independent tential patterns of adverse side effects. even when giving multiple vaccinations studies confirming the safety of recom- on the same day, there is no association The Vaccine Adverse Event Reporting mended childhood vaccines. In 2004, with any risk of developing autism.67 System (VAERS) is a joint CDC and FDA the Institute of Medicine (IOM) released program that collects reports from man- its eighth report from the Immuniza- Public health officials and scientific re- ufacturers, healthcare providers, and tion Safety Review Committee, which searchers continue to stress the impor- members of the public about possible concluded vaccines, specifically the tance of parents vaccinating their children. adverse events that people experience MMR vaccine and thimerosal-containing By choosing to delay or skip vaccinations following vaccinations.60 In addition, the vaccines, do not have any causal link to parents put both their children and others Vaccine Safety Datalink (VSD) project is autism. 63 An updated review published at greater risk of illness and death.68 24 TFAH • healthyamericans.org MEASLES AND WHOOPING COUGH (PERTUSSIS) OUTBREAKS In recent years, there have been a number U.S. saw the highest number of cases l From January 1 to April 18, California of outbreaks of vaccine-preventable dis- since 1994. From January through reported 58 cases of measles, nearly eases among children, including measles October 2014, more than 600 measles all of which were imported from other and whooping cough. cases were reported in the United countries.74 States in 22 states—a total of 20 out- Measles l In May 2014, a small outbreak breaks according to the CDC.70 Unvac- Measles is a highly contagious, viral in Washington State was traced cinated individuals are far more likely to illness that can lead to health complica- to an unvaccinated four year old contract measles than those who have tions, including pneumonia, encephalitis, returning from the Federated States been vaccinated. Because measles is and eventually death. Prior to routine vac- of Micronesia. Fourteen individuals still endemic in many parts of the world, cination, measles infected approximately became infected, the majority of which individuals traveling from outside the three to four million Americans each year were in the Micronesian community, country continually import the disease, and killed 400 to 500 individuals. In addi- where many children and adults and outbreaks can occur in communi- tion, 48,000 individuals were hospitalized have no documentation of measles ties with low vaccination coverage.71 and another 1,000 developed chronic dis- vaccination.75 ability from measles encephalitis. Wide- Many cases in the United States in Many clinicians in the United States spread use of measles vaccine has led 2014 are associated with travel from have never seen a measles case to a greater than 99 percent reduction in the Philippines, which has experienced due to our high vaccination rates and measles cases in the United States com- a serious measles outbreak in 2014.72 rapid response to outbreaks. CDC pared with the pre-vaccine era.69 l Multiple counties in Ohio experienced recommends that providers take In 2000, measles was declared virtually a measles outbreak in 2014, specimens from suspected patients eliminated in the United States, with originating from unvaccinated travelers and immediately isolate individuals around 60 reported cases each year. to the Philippines. A total of 377 before reporting to their local health Yet, in just the first half of 2014, the cases were reported.73 department.76 U.S. MEASLES CASES BY YEAR 700 600 500 400 300 200 100 0 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014* *Provisional data reported to CDC’s National Center for Immunization and Respiratory Diseases TFAH • healthyamericans.org 25 The failure to vaccinate all MEASLES AND WHOOPING COUGH OUTBREAKS, CONT. preschoolers with all of the Whooping Cough 2012 — from 48,277 cases and 20 recommended immunizations Pertussis, commonly known as whoop- deaths to 24,231 cases and nine on time leaves 2.1 million deaths.81 The states with the highest ing cough, is a highly contagious young children unnecessarily bacterial respiratory infection that can incidence of pertussis in 2013 were Montana, Alaska, Utah and New Mex- vulnerable to preventable be fatal in infants. Early symptoms mirror those of a cold, but infection ico.82 An outbreak occurred in the sum- illnesses.58 mer of 2013 in Columbia, Florida in a progresses into a severe cough that can affect breathing. The best way to large, religious community averse to prevent pertussis is through vaccina- healthcare and vaccinations. Only 15 tion. Because infants need multiple percent of students were immunized Childhood Vaccinations are Responsible for Significant Healthcare Cost Savings doses beginning at 2 months through against pertussis and a total of 109 early childhood to achieve adequate individuals contracted the disease.83 Indirect Savings protection, the CDC recommends that $33.4 billion In 2014, from January 1 to August pregnant women and all individuals 16, 17,325 cases of pertussis were Direct Healthcare who will have contact with a newborn reported to CDC — a 30 percent in- Cost Savings be vaccinated. Most whooping cough crease compared with the same time $9.9 billion deaths are among babies younger than period in 2013.84 + = 3 months so creating this “cocoon” of vaccinated caregivers is considered a l As of September 2014, California has reported 8,278 cases of pertus- Total Savings key prevention strategy.77 sis — the greatest numbers in Los $42.4 billion Pertussis does not only sicken infants. Angeles and San Diego.85 In the past several years, infections l Since the 2014 to 2015 school year have increased in children ages 7 to began, 38 cases of whooping cough 10 and in adolescents ages 13 to have been reported in Montgomery 14.78 Observational studies suggest County, Maryland.86 these outbreaks in children and adoles- l In Idaho, there were 241 reported cents may be a result of early waning cases in the first seven months of of immunity due to reformulated vac- 2014 compared with 122 cases in cine in 1997.79 However, some experts the same period in 2013.87 believe that reduced vaccination rates l As of October 2014, Colorado has may also be a contributing factor. A 2013 study by the FDA found that acel- reported 116 cases.88 lular pertussis vaccines licensed by the l In Washington State, there have been FDA are effective in preventing the clini- a total of 358 cases reported state- cal manifestations of the disease, but wide as of October 4, 2014. they may not actually prevent infection. In communities facing an outbreak, People with such asymptomatic infec- reports have shown the response is tions may still be able to spread infec- far more costly than preventive action tions to other people, especially those would have been, costing a local health who have not been vaccinated.80 department over $2,000 per case, com- The number of cases reported in 2013 pared to a few dollars spent per dose was nearly half of those reported in of vaccine.89, 90 26 TFAH • healthyamericans.org 14 states vaccinated at least half of their population 34 states and Washington, D.C. did not vaccinate half INDICATOR 4: (ages 6 months and older) for the seasonal flu from of their population (ages 6 months and older) for the fall 2013 to spring 2014 (1 point). seasonal flu from fall 2013 to spring 2014 (0 points). FLU VACCINATION RATES Colorado (51.8%) Alabama (48.3%) Montana (41.9%) Connecticut (51.8%) Alaska (41.7%) Nevada (36.4%) Key Finding: 14 states Delaware (50.0%) Arizona (38.5%) New Hampshire Hawaii (54.4%) Arkansas (49.7%) (48.0%) vaccinated at least half of their Massachusetts (53.3%) California* (N/A) New Jersey (46.1%) Minnesota (51.7%) D.C. (47.3%) New Mexico (46.6%) population (ages 6 months and Nebraska (51.0%) Florida (37.5%) New York (48.4%) older) for the seasonal flu from North Carolina (51.0%) Georgia (39.3%) North Dakota (48.9%) Rhode Island (56.9%) Idaho (37.9%) Ohio (44.7%) fall 2013 to spring 2014. South Dakota (57.4%) Illinois (43.4%) Oklahoma (46.7%) Tennessee (52.7%) Indiana (41.5%) Oregon (42.2%) Vermont (50.0%) Iowa (48.6%) Pennsylvania (46.3%) Virginia (50.4%) Kansas (47.0%) South Carolina (44.3%) West Virginia (52.6%) Kentucky (46.9%) Texas (45.2%) Louisiana (44.6%) Utah (41.5%) Maine (47.8%) Washington (48.4%) Maryland (48.9%) Wisconsin (42.3%) Michigan (42.9%) Wyoming (37.6%) Mississippi* (N/A) Missouri (48.3%) *California and Mississippi excluded due to incomplete data. As of the latest data available on FluVax, in November 2013, California’s vaccination rate was 42.6 percent, and in February 2014, Mississippi’s vaccination rate was 37.8 percent. Vaccination is the best prevention 70 percent of their population as part of against the seasonal flu. CDC the Healthy People 2020 initiative.92 recommends all Americans ages 6 The highest vaccination rate was in South months and older get vaccinated, yet Dakota at 57.4 percent and the lowest fewer than half of Americans ages 6 was in Nevada at 36.4 percent. Fourteen months and older were vaccinated states vaccinated 50 percent of their against the flu in the last three flu population or higher and 43 states and seasons (2011 to 2012, 2012 to 2013 D.C. vaccinated 40 percent or higher. and 2013 to 2014).91   Nationally, 46.2 percent of Americans ages In addition to protecting Americans 6 months and older were vaccinated.93 from the seasonal flu, establishing a Rates are significantly higher for cultural norm of annual flu vaccinations children (58.9 percent) compared to can help ensure the country has a adults (42.2 percent). The numbers are strong mechanism in place to be better the lowest among adults ages 18 to 64 at able to vaccinate all Americans quickly just 36.7 percent.94 during a new pandemic or unexpected disease outbreak. Traditionally, there has been a much stronger focus on encouraging seniors This indicator examines if at least half and children to get vaccinated, since (50 percent) of a state’s population (ages they often have more severe reactions to 6 months and older) was vaccinated the flu and have more interaction with against the seasonal flu in 2013 to 2014. the healthcare system. HHS has set a goal for states to vaccinate TFAH • healthyamericans.org 27 Experts note that vaccination rates need employers did not have a flu vaccination to generally be above 70 percent for policy. Rates were low for healthcare “herd immunity” effects — which limit professionals who were assistants and the spread and protect those without aides (57.7 percent) or non-clinical immunity — to become apparent. If all personnel (68.8 percent). seniors received a newly available high- CDC estimates that during the 2012 to dose version of the flu shot, flu cases 2013 flu season, vaccination resulted among this vulnerable population could in 79,000 fewer hospitalizations than drop 25 percent.95 otherwise would have occurred. Flu Vaccination Each year, an average of 62 million — or Overall, 17.3 percent of adverse = 79,000 20 percent of — Americans get the flu. health outcomes associated with fewer Between 3,000 and 49,000 Americans influenza were prevented.102 By hospitalizations die each year from the flu and 226,000 preventing hospitalizations, influenza are hospitalized.96, 97 immunizations can save $80 per year, per person vaccinated.103 Between 2004 and 2012, 830 children between 6 months and 18 years old died The historically low demand for from flu complications; 43 percent of seasonal vaccinations has translated into these children were completely healthy making flu vaccine development a low otherwise.98 In the 2013 to 2014 flu priority — without a steady demand, season, there were 108 influenza- incentives to manufacture and research associated pediatric deaths.99 new influenza vaccines are reduced. In addition to its health effects, flu has Under the Affordable Care Act (ACA), a serious impact in terms of healthcare all vaccines routinely recommended and worker absenteeism costs. Seasonal by the Advisory Committee on flu can often result in a half day to five Immunization Practices (ACIP), days of work missed, which affects both including flu shots, are covered when the individual and his or her employer. provided by in-network providers in Annually, the flu leads to approximately group and individual health plans and $10.4 billion in direct costs for for the Medicaid expansion population hospitalizations and outpatient visits, with no co-payments or cost sharing, and $76.7 million in indirect costs.100 but states are still able to determine coverage and cost-sharing for their Nearly one-quarter (24.8 percent) of traditional Medicaid population. As healthcare workers were not vaccinated of 2010, 38 states required Medicaid against the flu during the 2013 to coverage of flu shots with no-copay for 2014 season.101 Rates were higher beneficiaries under the age of 65, while among healthcare professionals whose 12 states and Washington, D.C. required employers required (88.8 percent) a co-pay.104 Medicare Part B covers or recommended (70.1 percent) that annual flu vaccinations for beneficiaries they be vaccinated compared to only with no co-pay. 44.3 percent among those whose 28 TFAH • healthyamericans.org 15 states currently have climate change adaptation 35 states and Washington D.C. do not currently have INDICATOR 5: CLIMATE plans that are completed (1 point). complete climate change adaptation plans (0 points). CHANGE AND INFECTIOUS Alaska Alabama Missouri California Arizona** Montana DISEASE Connecticut Arkansas Nebraska Florida Colorado** Nevada Maine Delaware* New Jersey* Key Finding: 15 states currently Maryland D.C.** New Mexico have completed climate change Massachusetts Georgia North Carolina** New Hampshire Hawaii* North Dakota adaptation plans that include New York Iowa** Ohio Oregon Idaho Oklahoma the impact on human health. Pennsylvania Illinois Rhode Island* Vermont Indiana South Carolina** Virginia Kansas South Dakota Washington Kentucky Tennessee Wisconsin Louisiana Texas Michigan** Utah** Minnesota* West Virginia Mississippi Wyoming Source: Center for Climate and Energy Solutions *Plans in progress ** Adaptation Plan Recommended in the Climate Action Plan This indicator examines which states have and extreme heat events.106 Climate eradicated or thought to be under comprehensive climate adaptation plans, change will require enhanced control.108, 109 The President issued an which includes a plan by a governmental monitoring of potential disease vectors Executive Order in 2013 to prepare body that has at least two sections. These and outbreaks. Factors like potential for the effects of climate change, can include planning for changing risk changes in water quantity and quality, including how increases in excessively of emerging and reemerging infectious air quality, extreme temperatures and high temperatures, heavy downpours, diseases due to changing temperatures insect control are all important public wildfires, severe droughts, permafrost and weather patterns, and issues such as health concerns. According to a review thawing, ocean acidification and sea- vector control, air quality and food and by the Georgetown Climate Center, level rise affect communities and public water safety. states’ plans vary significantly in terms health.110 In addition, the EPA released of scope and goals.107 Its review also draft Climate Change Adaptation According to reviews by the Center for found that California and New York Implementation Plans for public Climate and Energy Solutions (C2ES), have demonstrated the most progress review and comment in early 2013. The 15 states currently have comprehensive in carrying out aspects of their plans, Implementation Plans aim to protect climate adaptation plans, and four achieving 14 percent of stated goals. public health and the environment additional states have plans in progress.105 by integrating climate adaptation While the existence of a plan does show According to the Environmental planning into EPA programs, policies, consideration of concerns by a state, Protection Agency (EPA), as the rules and operations.111 Most recently, it does not necessarily mean a state is environment changes, Americans will the Federal Emergency Management currently following or has invested in be at higher risk for a range of health Agency (FEMA) incorporated climate supporting the plan. threats. A 2003 IOM report, Microbial preparedness into its September 2014 Threats to Health: Emergence, Detection, Depending on the region’s specific draft State Mitigation Plan Review Guide. and Response, listed climate and weather, needs, adaptation plans can focus on In order for states to continue receiving changing ecosystems, and land use as a variety of issues, including sea-level federal disaster preparedness funding, factors contributing to the emergence rise and associated flooding, drought FEMA may require them to “[assess] of new diseases or the reemergence mitigation and water insecurity, future risk in light of a changing or spread of diseases that were nearly hurricanes and other severe weather climate and changes in land use and TFAH • healthyamericans.org 29 l Annual influenza epidemics occur development. This will ensure that the mitigation strategy addresses risks primarily during cold weather, while and takes into consideration possible meningococcal meningitis is associated future conditions in order to identify, with dry climates. Changing weather prioritize, and implement actions to patterns puts people in different regions increase statewide resilience.”112, 113 at increased risk for both diseases. l The rise in extreme weather events Certain zoonotic and vector-borne diseases, as well as food and waterborne and natural disasters also leads to diseases, may increase and spread as a more fertile environment for the changes in temperature and weather spread of infectious diseases and patterns allow pathogens to expand germs. For instance, cryptosporidiosis into different geographic regions. For outbreaks — which cause diarrheal instance: disease — are associated with heavy rainfall, which can overwhelm sewage l The presence and number of rodents, treatment plants or cause lakes, rivers mosquitoes, ticks and other insects and streams to become contaminated and animals that can carry infectious by runoff containing waste from diseases rise in warmer temperatures, infected animals. Experts also believe so as temperatures rise and stay that an El Niño occurrence may have warmer for longer periods of times, contributed to increases of cholera.116 the patterns of diseases ranging from Communities recovering from a West Nile virus to Lyme and other disaster may see food or waterborne tick-borne diseases to encephalitis are illnesses associated with power outages expected to shift.114 or flooding, as well as infectious disease l Large-scale climate change may have transmission in emergency shelters. an effect on the timing of migration of To help prepare for the health impact of wild birds. Wild birds are a concern extreme weather incidents and climate for public health because they can change, CDC’s Climate-Ready States and be infected by a number of microbes Cities Initiative awarded $4.5 million in that can be transmitted to humans. grants to 16 states and two cities to build In addition, birds migrating across resilience to the health impacts of climate national and intercontinental borders change in FY 2014.117 CDC will assist can become long-range carriers of any awardees in developing and using models bacteria, virus or parasite they harbor. to more accurately anticipate health Birds are the source of the rapid impacts, monitor health effects, and spread of West Nile virus after it was identify the most vulnerable areas in their first identified in 1999, and by 2012 the region. Awardees include departments virus had been reported in humans, of health in Arizona, California, Florida, mosquitoes, and birds in 48 states. In Illinois, Maine, Maryland, Massachusetts, addition to West Nile virus, migratory Michigan, Minnesota, New Hampshire, birds were reported to be one possible New York City, New York State, North source of the 2006 global outbreak of Carolina, Oregon, Rhode Island, San the H5N1 avian influenza virus.115 Francisco, Vermont and Wisconsin.118 30 TFAH • healthyamericans.org In 2012, 16 states performed better than the national 34 states and D.C. performed similar to or worse INDICATORS 6 AND 7: SIR for central line-associated bloodstream infections than the national SIR for central line-associated (1 point). bloodstream infections in 2012 (0 points). REDUCTIONS IN CENTRAL California Similar to national SIR Worse than national SIR LINE-ASSOCIATED Colorado Arkansas Alabama BLOODSTREAM Hawaii Idaho Delaware Florida Alaska Arizona INFECTIONS Michigan Illinois Connecticut Missouri Iowa D.C. North Carolina Indicator 6 Key Finding: Kansas Georgia North Dakota Maryland Indiana 16 states performed better than Ohio Massachusetts Kentucky Oklahoma Minnesota Louisiana the 2012 national standard Oregon Pennsylvania Montana Maine infection ratio (SIR) for central Nevada Mississippi South Dakota New Hampshire Nebraska line-associated bloodstream Vermont New Mexico New Jersey West Virginia Rhode Island New York infections. Note: Only three Wisconsin Tennessee South Carolina states performed worse than Texas Utah the 2008 national SIR baseline. Virginia Washington Wyoming Note: In 2012, all but three states (Alaska, Maine and Mississippi) performed better than the 2008 national baseline SIR for central line-associated bloodstream infections Between 2011 and 2012, 10 states reduced the num- 40 states and Washington, D.C. had either the same or ber of central line associated blood stream infections more central line associated blood stream infections Indicator 7 Key Finding: Between (1 point). between 2011 and 2012 (0 points). 2011 and 2012, the standardized California Alabama Missouri Colorado Arkansas Montana infection ratio for central Georgia Alaska Nebraska Maryland Arizona New Hampshire line-associated bloodstream Nevada Connecticut New Jersey infections decreased significantly New York Delaware New Mexico South Carolina D.C. North Carolina in 10 states. Tennessee Florida North Dakota Virginia Hawaii Ohio Wisconsin Idaho Oklahoma Puerto Rico^ Illinois Oregon Indiana Pennsylvania Iowa Rhode Island Kansas South Dakota Kentucky Texas Louisiana Utah Maine Vermont Massachusetts Washington Michigan West Virginia Minnesota Wyoming Mississippi Source: CDC. ^ Report includes data for Puerto Rico when available TFAH • healthyamericans.org 31 Approximately 1 out of every 25 These infections are usually serious, prevention initiatives.128, 129 In addition, hospitalized patients will contract often resulting in prolonged hospital in 2008, Medicare provided an incentive a healthcare-associated infection, stays and increased cost and risk of to reduce infections by adopting a “no which is an infection patients can get mortality.121 Nationally, the number of pay” rule for infections acquired during while receiving medical treatment in CLABSI infections was 44 percent lower a hospital stay, requiring the hospitals a healthcare facility.119 Healthcare- in 2012 than the national baseline in themselves to cover any costs incurred associated infections not only happen 2008, and the national standardized by these infections.130 According to a in hospitals but can also occur in infection ratio was 0.56.122 2012 survey, 80 percent of infection- outpatient surgery centers, nursing control professionals believe the rules A person’s risk for a HAI, which homes and other long-term care have resulted in a greater focus on includes a range of antibiotic-resistant facilities, rehabilitation centers, reducing HAIs. The ACA also requires infections, increases if they are having community clinics or physicians’ offices. in-patient hospitals to report certain invasive surgery, if they have a catheter infections to National Healthcare These indicators examine the status in a vein or their bladder, or if they are Safety Network (NHSN) in order to of one form of HAI — central line on a ventilator or are on a prolonged receive their full payment updates, associated blood stream infections course of antibiotics as part of their and the information will be available (CLABSI) according to the CDC’s care.123, 124 In 2011, there were an on CMS’ Hospital Compare website.131 National and State Healthcare- estimated 722,000 HAIs and 75,000 The NHSN is the largest healthcare- Associated Infections Progress Report.120 patients with HAIs died during their associated infection reporting system They examine: 1) whether states were hospitalizations in the United States.125 in the United States, serving more than above or below the national standard Of the infections, 157,500 were from 14,000 healthcare facilities of all types, infection ratio for the number of pneumonia; 157,500 from surgical site or through other established systems.132 CLABSI — 16 were above the national infections; 123,100 from gastrointestinal ratio, and 2) whether states saw a illness; 93,300 from urinary tract Many states are seeing decreases in HAIs. reduction in their number of CLASBIs infections; 71,900 from primary Between 2008 and 2012, there were 44 from 2011 to 2012 — 10 states saw bloodstream infections; and 118,500 percent fewer central line-associated reductions. A central line is a tube that from other types of infections. bloodstream infections and 20 percent is typically inserted in a patient’s large fewer surgical site infections related Prevention and education efforts have vein, usually in the neck, chest, arm to 10 surgical procedures in in-patient been helping to decrease the rates of or groin, to give important medical healthcare settings. 133, 134 There were an HAIs. CDC, the Centers for Medicare treatment. When not put in correctly or estimated 30,800 fewer invasive MRSA and Medicaid Services (CMS), states kept clean, central lines can become a infections in the United States from and medical providers have launched freeway for germs to enter the body and 2005 to 2011, with hospital-onset MRSA a series of provider education and cause deadly infections in the blood. decreasing by more than 50 percent.135 HAIs cost the country $28 to $33 billion in preventable healthcare expenditures each year.126 According to CDC, if 20 percent of these infections were prevented, healthcare facilities could save nearly $7 billion, and reducing infections by 70 percent could result in $23 billion in savings.127 32 TFAH • healthyamericans.org 47 state public health laboratories and Washington, D.C. 3 state public health laboratories reported they did not INDICATOR 8: reported conducting an exercise or utilizing a real event conduct an exercise or utilize a real event to evaluate to evaluate the time for sentinel clinical laboratories to the time for sentinel clinical laboratories to acknowledge PUBLIC HEALTH acknowledge receipt of an urgent message for the state’s receipt of an urgent message for the state’s laboratory LABORATORIES — laboratory from July 1, 2013 to July 30, 2014 (1 point). from July 1, 2013 to July 30, 2014 (0 points). Alabama Montana Louisiana CAPABILITIES DURING Alaska Nebraska New Jersey EMERGENCIES OR DRILLS Arizona Nevada Washington Arkansas New Hampshire California New Mexico Colorado New York Key Finding: 47 state public Connecticut North Carolina Delaware North Dakota health laboratories and D.C. Ohio Florida Oklahoma Washington, D.C. reported Georgia Oregon Hawaii Pennsylvania conducting an exercise or Idaho Rhode Island Illinois South Carolina utilizing a real event to evaluate Indiana South Dakota Iowa Tennessee the time for sentinel clinical Kansas Texas Kentucky Utah laboratories to acknowledge Maine Vermont Maryland Virginia receipt of an urgent message Massachusetts West Virginia Michigan Wisconsin for the state’s laboratory (from Minnesota Wyoming Mississippi Puerto Rico^ July 1, 2013 to June 30, 2014). Missouri Source: Association of Public Health Laboratories (APHL) 2014 Survey of State Public Health Laboratories. ^ Report includes data for Puerto Rico when available. This indicator examines whether a state’s without knowing how they will hold up receipt — of laboratory samples 24 hours public health laboratory reported that they during an actual incident or simulated a day, 7 days a week, 365 days a year to an evaluated how quickly urgent messages drill, it is hard to evaluate where there appropriate Public Health Laboratory were received as part of the larger may be gaps in the plan. Response Network during the time laboratory network during a real event or period from July 1, 2013 to July 30, 2014. FEMA stresses that individual agencies exercise, from July 1, 2013 to July 30, 2014. This can include a state-operated courier, should be able to continue to perform Forty-seven states and Washington, D.C. use of a private delivery company such during a wide range of emergencies reported meeting this objective. as FedEx, or a contract courier service. and disruptive events, including Each state should have the capacity to test Communications during exercises and localized acts of nature, accidents samples of potential infectious disease responding to real events is important and technological or attack-related threats during major new outbreaks to gauge how well emergency plans emergencies.136 Aspects of a continuity — or have arrangements to get the will work during actual events, and of operations (COOP) plan include: samples to labs where they can quickly be to evaluate strengths and areas of essential functions; orders of succession; tested. For infectious diseases or food- vulnerabilities to improve on. delegations of authority; continuity or water-borne outbreaks, timeliness is facilities; continuity communications; vital One key aspect of responding to an often of the essence to confirm needed records management; human capital; emergency is ensuring that public health treatments and to contain a problem. tests, training and exercises; devolution of departments and laboratories, and other This can include getting the samples to control and direction; and reconstitution. aspects of government, will be able to and from a particular lab or being able continue to function during a time of l In addition, according to the APHL to transport a specimen to a lab with stress, such as a mass disease outbreak survey, all 50 states and Washington, D.C. the technology required to test for a or bioterrorism event. Laboratories and reported having the capacity to assure the particular threat as part of the nation’s most agencies have continuity plans, but timely transportation — for delivery and Laboratory Response Network (LRN). TFAH • healthyamericans.org 33 LABORATORY RESPONSE NETWORK Since 2001, public health labs have cre- the Naval Medical Research Center Labs not only help detect and diagnose ated networks to be more efficient and (NMRC) — are responsible for special- problems, the information they provide effective, so that every state has a base- ized strain characterizations, bioforen- help public health officials track the line of capabilities but does not have to sics, select agent activity and handling emergence and spread of different invest the resources required to maintain highly infectious biological agents; outbreaks and are an essential part of every type of state-of-the-art equipment l Reference laboratories, which are monitoring disease threats and under- or staffing expertise. Samples can be responsible for investigation and/or standing how to control them. shipped to facilities with the needed ex- referral of specimens. They are made In 2010, CDC began funding 57 state, pertise as quickly and safely as possible. up of more than 100 state and local local and territorial health departments The Laboratory Response Network for public health, military, international, to encourage increased electronic report- Biological Threat Preparedness (LRN-B) veterinary, agriculture, food- and water- ing of lab results to help make reporting includes labs with a hierarchy of differ- testing laboratories; and faster and more complete.138 Data col- ent capabilities, so labs with increased l Sentinel laboratories, which provide lected since then shows various improve- capabilities provide support for other routine diagnostic services, rule-out ments. By the end of July 2013, 54 of the labs, consisting of:137 and referral steps in the identification 57 jurisdictions were getting some labora- l National laboratories — including process. While these laboratories tory reports through Electronic Laboratory those operated by CDC, U.S. Army may not be equipped to perform the Reporting (ELR), and 62 percent of labora- Medical Research Institute for Infec- same tests as LRN Reference labora- tory reports were being received through tious Diseases (USAMRIID), and tories, they can test samples. ELR compared to 54 percent in 2012.139 EPIDEMIOLOGY AND LABORATORY SAFETY LAPSES LABORATORY CAPACITY FOR In 2014, safety lapses in the handling of safety at the agency.142 Less than a INFECTIOUS DISEASES dangerous pathogens were identified at month later, six sealed vials of smallpox CDC’s Epidemiology and Laboratory multiple federal laboratories. In March, virus from the 1950s were found in a Capacity for Infectious Diseases at a CDC influenza laboratory, a culture cold storage room in an FDA lab on the (ELC) Cooperative Agreements of relatively harmless avian influenza National Institutes of Health (NIH) cam- provide state, local and territorial was accidentally cross-contaminated pus. Upon further inspection, 12 boxes health department grantees with with the highly pathogenic H5N1 strain and 327 vials were discovered with la- financial and technical resources and shipped to a BSL-3 lab operated bels indicating a variety of pathogens, in- to strengthen epidemiological, by the U.S. Department of Agriculture cluding dengue, influenza and Q fever.143 laboratory and health information (USDA).141 In June, staff at another CDC While no staff were sickened with an- systems to detect, prevent and lab used inadequate procedures to inac- thrax and no one became exposed to control infectious diseases. The tivate (kill) anthrax samples for use in a H5N1 or the pathogens discovered in ELC cooperative agreements BSL-2 lab, resulting in potentially live and the FDA storage room, these incidents totaled $93.5 million in FY 2014.140 infectious samples being used by numer- and their potential for harm is troubling. ous researchers not wearing appropriate They highlight a lack of oversight, failures personal protective equipment (PPE). As of safety protocol by individuals, and a result of these incidents, CDC issued also in the case of the storage room, an an internal moratorium on the movement alarming unawareness of the over 60- of biological materials from its BSL-3 year presence of dangerous pathogens or BSL-4 facilities and implemented ad- on-site — stored in a manner inconsis- ditional measures to improve laboratory tent with current safety procedures. 34 TFAH • healthyamericans.org 37 states and D.C. require reporting of all (detectable 13 states do not require reporting of all (detectable and INDICATOR 9: and undetectable) CD4 and HIV viral load data (1 point). undetectable) CD4 and HIV viral load data (0 points). HIV/AIDS SURVEILLANCE Alabama Montana Alaska** Arizona* Nebraska Arkansas California New Hampshire Colorado** Key Finding: 37 states and Delaware New Mexico Connecticut D.C. New York Idaho Washington D.C. required Florida North Carolina Kansas reporting of all (detectable and Georgia North Dakota Kentucky Hawaii Oregon Nevada undetectable) CD4 (a type of Illinois Rhode Island New Jersey Indiana South Carolina Ohio white blood cell) and HIV viral Iowa South Dakota Oklahoma load data to their state HIV Louisiana Tennessee Pennsylvania Maine Texas Vermont surveillance program. Maryland Utah Massachusetts Virginia Michigan Washington Minnesota West Virginia Mississippi Wisconsin Missouri Wyoming Source: CDC’s Prevention Status Report *Based on information provided by the state **States provided updated information after publication saying they require full reporting. More than 1.2 million Americans are requirement.147 CDC and CSTE More recently, health departments have living with HIV/AIDS, and about one recommend reporting both detectable begun using these data to assess whether in six do not know they are infected. and undetectable viral loads. Viral load people diagnosed with HIV are receiving Since the epidemic began, more than data can be used to identify cases, classify medical care and to re-engage those who 648,000 Americans have died with stage of disease and diagnosis and have dropped out of care. AIDS.144 Recently, there has been an monitor disease progression. They can These viral load data are critical to the alarming rise in new HIV infections, also be used to assess HIV testing and health of people living with HIV, because particularly among young gay men (ages prevention efforts, inform treatment and they help ensure that individuals are 13 to 24).145 There are around 50,000 unmet healthcare needs and measure linked to HIV medical care and retained new HIV diagnoses each year. Between viral load suppression. National analyses in care.149 In order to assure the best 2008 and 2010, there was a 22 percent to monitor progress against HIV is only health outcomes, people living with increase in new infections among young effective if all HIV-related CD4 and viral HIV need to be engaged in care and men who have sex with men (MSM) load test results are reported by every treatment, with the goal of achieving overall, and a 48 percent increase state and jurisdiction. viral suppression. When the HIV virus is among young Black men.146 According These tests are used to assess stage of suppressed, individuals are healthier and, to CDC, half of young people with HIV disease and response to treatment. An quite importantly from a public health do not know they are infected. HIV viral load test measures the amount standpoint, are also less likely to transmit This indicator examines whether a of virus in a person’s blood, while a CD4 HIV. Nationally, CDC estimates that only state requires reporting of all CD4 lymphocyte test measures his or her 30 percent of those living with HIV are and HIV viral load results (detectable immune function and can determine virally suppressed.150 Jurisdictions where and undetectable) to the state HIV the stage of HIV infection. Its results are high rates of viral load suppression are surveillance program — 37 states often used to monitor disease progression achieved have seen declines in infection and Washington, D.C. have this and guide timing for clinical care.148 rates, in contrast to national trends. TFAH • healthyamericans.org 35 2 out of every 3 people More than half of all people About 50% of people who who get HIV each year living with HIV have died from AIDS And Make Up 1 in 5 New HIV Infections If you’re a gay or bisexual man, do you know your HIV status? HIV SCREENING AND MEDICAID COVERAGE 20% How often should gay and bisexual According to a survey conducted by the treatment as soon tested? men get as possible and can Kaiser Family Foundation’s Commission take action to prevent spreading the 12 on Medicaid and the Uninsured, pub- EVERY infection to others. An estimated 49 lished in February 2014, 34 states and percent of new HIV infections are from OF GAY OR BISEXUAL MEN Washington, D.C. reported coverage of the 20 percent of people living with HIV LIVING WITH HIV routine HIV screening under their Medic- who are unaware of their infection.152, 153 DON’T KNOW IT aid programs, while 16 states reported MONTHS Experts believe that providing screen- coverage of testing only when it is con- THAT’S 1 IN 5 ing services for Medicaid beneficiaries Some men might benefit from more sidered “medically necessary.”151 Rou- frequent testing, (e.g., every 3 to 6 months). is particularly important since these tine HIV screening is required in states Americans include many of the lowest- participating in Medicaid expansion. income and most vulnerable in terms of 2 WAYS TO FIND A TESTING SITE NEAR YOU The U.S. Preventive Services Task Force quality of health and risk for HIV infec- (USPSTF) and CDC recommend routine tion. More than 20 percent of individu- 1 HIV screening for all adolescents and Enter 2 Call als diagnosed with HIV are covered by your ZIP code at Medicaid in 301-800-CDC-INFO adults. HIV screening is considered states, and more than hivtest.cdc.gov (1-800-232-4636) particularly important so those who may 30 percent of individuals with HIV are not know they are infected canyour status is just the first step. 12 states.154 Knowing receive covered by Medicaid in Do you know how to stay healthy? IF YOU DON’T HAVE HIV IF YOU DO HAVE HIV Stay that way by choosing less Get HIV medical care and medicines (called ART) to risky sexual behaviors like oral sex lower the amount of virus in your body and protect and reducing your number of your health. These medicines will also help prevent partners. transmitting the virus to others. Practice prevention methods like Try to find a doctor who specializes in HIV consistently using condoms and treatment, stay in medical care, take ART consider taking medicine to as directed and find support. prevent getting HIV (called PrEP). LEARN MORE WAYS TO LEARN MORE ABOUT TREATMENT PROTECT YOURSELF AT AND HOW TO STAY HEALTHY AT Start Talking. Stop HIV. HIV Treatment Works www.cdc.gov/actagainstaids www.cdc.gov/hivtreatmentworks Source: U.S. Centers for Disease Control and Prevention 36 TFAH • healthyamericans.org Did you know not everyone with HIV is getting the care they need? 38 states met the national performance target of 12 states did not meet the national performance INDICATOR 10: testing 90 percent of reported E. coli O157 cases target of testing 90 percent of reported E. coli O157 within four days. (1 point). cases within four days. (0 points). FOOD SAFETY Alabama (100%) Missouri (98.8%) Arizona (40%) Alaska (100%) Nebraska (90.0%) California (77.7%) Key Finding: 38 states met the Arkansas (93.8%) Nevada (100%) Georgia (82.4%) Colorado (93.8%) New Hampshire Idaho (88.9%) national performance target of Connecticut (100%) (100%) Mississippi (80.0%) D.C. (N/A) New Mexico (100%) Montana (71.4%) testing 90 percent of reported Delaware (100%) North Dakota (100%) New Jersey (71.4%) Escherichia coli (E. coli) O157 Florida (92.9%) Ohio (100%) New York (88.0%) Hawaii (100%) Oklahoma (96.9%) North Carolina (71.4%) cases within four days. Illinois (92.6%) Pennsylvania (97.6%) Oregon (80.7%) Indiana (94.6%) Rhode Island (100%) South Carolina (50.0%) Iowa (94.4%) Tennessee (92.5%) South Dakota (71.4%) Kansas (92.0%) Texas (92.5%) Kentucky (100%) Utah (95.5%) Louisiana (100%) Vermont (93.8%) Maine (100%) Virginia (98.2%) Maryland (92.9%) Washington (90.9%) Massachusetts (97.2%) West Virginia (100%) Michigan (90.2%) Wisconsin (90.3%) Minnesota (92.2%) Wyoming (100%) Source: CDC’s Prevention Status Report *Data were not available for Washington, D.C.; they were awarded a point for the indicator. Annually, around 48 million Americans fewer than 60 percent.157 Quickly suffer from foodborne illnesses. detecting E. coli O157 contamination According to USDA’s Economic Around one million of those who are serves as a marker for the ability of Research Service, E. coli costs stricken in a given year will suffer from states to protect their populations and the country over $271 million long-term chronic complications.155 the nation from foodborne illness. Foodborne illnesses are responsible for a year.161 E. coli is a diverse group of bacteria around 128,000 hospital visits and kill that live harmlessly in the guts of approximately 3,000 individuals each Outbreak Response that can help states humans and animals. However, some year.156 Virtually all of these illnesses prevent or reduce foodborne illness. pathotypes of E. coli can cause acute could be prevented if stronger measures One practice is increasing the speed gastro-intestinal illness. Most reported were taken to improve the U.S. food of pulsed-field gel electrophoresis outbreaks are caused by Shiga toxin- safety system. (PFGE) testing (DNA fingerprinting) of producing E. coli O157, which is reported E. coli O157 cases. According This indicator examines how quickly primarily transmitted through the fecal- to the CDC, “Speed of PFGE testing is states test reported cases of Escherichia oral route. People can be sickened by defined as the annual proportion of coli (E. coli) O157 — one of the most consuming contaminated leafy greens, E. coli O157 PFGE patterns reported common foodborne illnesses in the raw dairy products, and undercooked to CDC…within four working days United States — and report them to meat.158 In the spring of 2014, 12 of receiving the isolate in the state CDC. Thirty-eight states met CDC’s people in four states fell ill from public health PFGE lab.”160 Detecting national performance target of testing contaminated beef.159 outbreaks quickly not only prevents new 90 percent of reported E. coli O157 CDC’s Prevention Status Reports cases of illness, but can help the food cases within four days. Ten states tested highlight practices recommended by industry identify gaps and minimize between 60 percent and 89.9 percent the Council to Improve Foodborne adverse economic impact. of reported cases and two states tested TFAH • healthyamericans.org 37 S EC T I ON 2 : National SECTION 2: NATIONAL ISSUES AND RECOMMENDATIONS National Issues and Issues & Recommendations Recommendations Ebola has shown how much the rest of the world respects and turns to the United States — relying on world-class leadership, expertise and research from CDC, NIH and medical and public health experts — to help manage serious outbreaks and contain their spread. Yet, while the United States has continued Project funded by the RWJF and other to maintain an elite but limited set of leading public health groups have called infectious disease experts, the core of the for reenergizing the public health system nation’s public health system has not kept around foundational capabilities that pace, and in many areas has eroded. ensure basic abilities are maintained and sufficiently funded — while policies, The Ebola outbreak demonstrated that the programs, training and technologies can nation’s ability to contain a novel emerging adapt to meet changing threats.162, 163 infectious disease threat is fundamentally flawed — and makes the case for Prioritizing foundational capabilities fundamental change. For instance: would help ensure the country maintains a consistent baseline for protecting l Unless basic policies and procedures the public against both emerging and — like quarantine guidelines and ongoing health threats. This means drills for a potential mass outbreak — focusing on the fundamental, proven are consistently maintained and are practices of infectious disease control — flexible enough to respond to different and implementing them well. Achieving possible contingencies and threats, this goal will require restructuring public they are not battle-ready when a new health programs — exploring new infectious disease threat emerges; funding and business models that can l Much of the nation’s approach to assure consistent resources are devoted to fighting infectious disease has not been support these foundational capabilities. modernized in decades, with particularly This can be achieved through new severe lags in disease surveillance funding mechanisms or by giving states and research and development of and localities more flexibility in exchange new vaccines, diagnostics, antiviral for increased demonstration of capabilities medications and antibiotics; and and accountability. Modernizing business practices and finding efficiencies may l Limited funding and cuts to existing require exploring innovative approaches programs have undermined many such as regionalization, increased DECEMBER 2014 fundamental public health capabilities healthcare and public health integration, and these capabilities are inconsistent public-private partnerships, resource- around the country. sharing and working with Accountable It is time to rethink key aspects of the Care Organizations (ACOs), or within country’s public health defenses. The new capitated care structures and global IOM, the Transforming Public Health health budgets. Since the 1940s, tremendous advances in infectious disease prevention efforts, vaccines and antibiotics, and other medical treatments have saved countless lives. These successes, however, may have contributed to a sense of complacency around infectious disease threats. It also means updating systems — Enterovirus D68, dengue, antibiotic investing in state-of-the-art equipment, resistant superbugs, MERS-CoV and integrating legacy surveillance systems, measles; tackle ongoing outbreaks — ending the current overuse of existing such as HIV/AIDS, bacterial infections medications, especially antibiotics, in hospitals and foodborne illnesses; and partnering with other countries and even monitor for potential bioterror health agencies around the globe and threats — such as smallpox or anthrax. incentivizing research and development In this section TFAH examines a set of of medical countermeasures. top concerns in the country’s infectious Fighting infectious diseases requires disease policies and recommendations detecting, treating and containing them for improvements, including: as quickly and effectively as possible. A. ncreased Attention and Resources I Public health systems and practices to Maintain and Modernize Public must be upgraded to match the modern Health Capabilities and Have infectious disease threats we face. Consistent and Science-Based Policies Each year, millions of Americans develop Across the Country illnesses that result in billions of dollars • nnovation Priority Areas: I of healthcare costs — most of which Modernizing Biosurveillance, Medical could be prevented. Further, emerging Countermeasure Research and and reemerging diseases pose not only Development, Climate Change and a threat to health but also a global Infectious Disease Outbreaks security threat with major implications for economics and trade. According to B. ealth System Preparedness — H the National Intelligence Council, “these Enhancing Surge Capacity and diseases will endanger U.S. citizens at Infection Control home and abroad, threaten U.S. armed C. hanging Healthcare and Public C forces deployed overseas, and exacerbate Health Norms to Increase Vaccinations social and political instability in key and Combat Antibiotic Resistance countries and regions in which the U.S. has significant interests.”164 D. dditional Persistent — Under A Addressed — Infectious Disease Threats Fighting infectious diseases necessitates having the tools, resources and policies • riority Areas: Sexually Transmitted P in place to detect and contain new or Infections, TB and Food Safety reemerging threats — such as Ebola, TFAH • healthyamericans.org 39 KEY INFECTIOUS AND EMERGENCY RESPONSE COMPONENTS Requirements for an effective 24/7 approach to combat infectious disease threats include: l Strong surveillance to identify and workers can swiftly and accurately l Coordination and partnership with the monitor ongoing and emerging infectious communicate with each other, other healthcare sector, to ensure people in disease outbreaks; front-line workers and the public about need have access to and receive the best 1) the nature of the disease threat; 2) available treatment at any stage of an l Intensive investigative capabilities the risk of exposure and how to seek outbreak — including surge capacity for — including an expert scientific and treatment when needed; and 3) any mass outbreaks when necessary; medical workforce and comprehensive actions they or their families should take laboratory capabilities — to quickly l An informed and engaged public that can to protect themselves; diagnose outbreaks; provide material and moral support to lA focused and effective response professional responders, and can render l Containment strategies, including strategy, including targeted aid when necessary to friends, family, medicines and vaccines to prevent communications, to address the neighbors and associates; and and stop the spread of a disease and concerns of at-risk populations, such as isolation and quarantine when necessary; lA strong research capacity that is able to children, the elderly, pregnant women rapidly develop new vaccines or medical l Streamlined and effective and groups or areas that are particularly treatments to counter new threats. communication channels so health susceptible to a particular threat; CDC’s Epidemic Intelligence Service Since 1951, over 3,500 Epidemic EIS officers currently are assigned to Department of Public Health investigated Intelligence Service (EIS) officers have states across the country and to global a fatal outbreak of hantavirus infections responded to requests for assistance partners to help address ongoing or urgent among visitors to Yosemite National within the United States and throughout problems. EIS officers interact closely Park, discovering that a particular type of the world. EIS officers serve as CDC’s with epidemiologists in affected states tent cabin was susceptible to infestation “disease detectives,” professionals who — many of whom are former EIS officers by rodents that carried the virus; are trained to conduct epidemiologic themselves — illustrating the network and l EIS officers responded to a ten-fold in- investigations, research and public extended reach of the program. crease in the incidence of pertussis in health surveillance. The EIS program Washington State, assisting state health Some notable examples of epidemiologic is a two-year post-graduate training authorities with characterization and con- investigations conducted recently by EIS program comprised of 75 to 78 trol of the outbreak; and officers include: new officers each year. EIS attracts l EIS officers assisted the Missouri health l EIS officers and other staff responded to candidates from diverse backgrounds a multistate cluster of rare Salmonella; department with investigation of an E. coli — physicians, nurses, veterinarians and O157 outbreak possibly linked to a re- PhD-trained scientists. l The EIS officer assigned to the California gional grocery chain. 40 TFAH • healthyamericans.org Global Health Security Agenda The Global Health Security Agenda (GHSA) biosafety and biosecurity, immunization, was launched in February 2014 to bring national laboratory systems, real-time together nations to work on prioritizing the surveillance, disease reporting, workforce prevention, detection and response to in- development, emergency operations cen- fectious disease outbreaks before they be- ters, public health law, multi-sector rapid come epidemics. In September, President response, medical countermeasures and Obama and top U.S. officials met with inter- personnel deployment. national organizations and senior leaders The United States has committed to as- from 44 nations to work toward concrete sist at least 30 countries over five years to commitments to implement the GHSA, in- Photo: ChameleonsEye / Shutterstock.com achieve the objectives of the GHSA and has cluding assisting West Africa in developing prioritized U.S. actions toward strengthening health security capacity within three years. national laboratory systems, combating anti- Working together, countries developed biotic resistant bacteria, addressing zoonotic 11 Action Packages that outline tangible, diseases, promoting real time surveillance, measurable steps required to prevent improving biosafety and biosecurity on a outbreaks, detect threats in real time, and global basis, workforce development and rapidly respond. These include addressing preventing bioterrorism.165 166 antibiotic resistance, zoonotic diseases, CDC’s Global Disease Detection Program The GDD is a CDC program intended to develop and strengthen global health security in order to rapidly detect, accurately identify, and promptly contain emerging infectious disease and intentional bioterrorist threats that occur.167 GDD helps countries with limited resources develop essential detection and infection control capacities. Currently, CDC has GDD coverage in all WHO regions with GDD Centers in Bangladesh, China, Egypt, Georgia, Guatemala, India, Kazakhstan, Kenya, South Africa and Thailand.168 Six core capacities were established by various GDD stakeholders to effectively identify and control emerging infectious diseases including:169 1. Emerging infectious disease detection and epidemiological data collection, 6. aboratory systems and biosafety: L and response: Identify and respond to increasing quick identification, reporting Ensure appropriate facilities, equipment, emerging infections through disease and response to outbreaks. policies, security precautions and surveillance, prevention and control. occupational health programs. 4. oonotic disease investigation and Z 2. Training in field epidemiology and labo- control: Include veterinary expertise in During the 2014 West Africa Ebola outbreak, ratory methods: Train scientists and detecting and responding to zoonotic GDD centers have been deploying staff to public health practitioners in field epi- diseases. the region to support response operations, demiology and laboratory methods. contact tracing and laboratory diagnostics. 5. ealth communication and information H Staff from these centers have also assisted 3. andemic influenza preparedness P technology: Improve communication with their host countries outside of the region in and response: Develop influenza affected populations during outbreaks, preparing for possible Ebola importation and surveillance capacity, including improving and ensure public health responses infection control. and expanding global surveillance are culturally, technologically and networks, increasing virus isolation scientifically appropriate. TFAH • healthyamericans.org 41 World Health Organization WHO directs and coordinates health within assistance with safe medical procedures the United Nations system — providing and burial practices.171 In August 2014, leadership on global health matters, WHO released a roadmap to scale up helping to define evidence-based policy and recruit additional international options, setting norms and standards and attention and resources to help fight providing technical support and monitoring Ebola in West Africa to help contain and of health trends and concerns.170 There limit wider spread of the disease.172 A are more than 190 member states of WHO, number of philanthropies have contributed including the United States. It is funded additional support to help with the Ebola through support from member nations as response. For instance, in September, well as private philanthropic support. Bill Gates announced that the Bill and Melinda Gates Foundation would donate WHO has been helping lead the global $50 million to fight Ebola in West Africa, response to the Ebola outbreak and while Facebook founder Mark Zuckerberg supports surveillance, community announced in October that he is donating engagement case management, laboratory $25 million to the CDC Foundation’s services, contact tracing, infection efforts.173 control, logistical support and training and Public Health Emergency Preparedness Cooperative Agreement Program The PHEP cooperative agreement program PHEP focuses on 15 key capability areas, in- awards funds to states, territories and cluding community preparedness; community urban areas to build and sustain public recovery; emergency operations coordination; health preparedness capabilities that emergency public information and warning; enhance their ability to respond to public facility management; information sharing; health emergencies. PHEP awards mass care; medical countermeasure dis- funds to 62 public health departments pensing; medical materiel management and nationwide, including the 50 states; four distribution; medical surge; non-pharmaceu- large metropolitan areas — Chicago, tical interventions; public health laboratory Los Angeles County, New York City and testing; public health surveillance and epide- Washington, D.C.; and eight U.S. territories miological investigations; responder safety and freely associated states — American and health; and volunteer management. Samoa, Guam, U.S. Virgin Islands, PHEP also supports the Cities Readiness Northern Mariana Islands, Puerto Rico, Initiative (CRI) to help cities and large metro- Federated States of Micronesia, Republic politan areas prepare to dispense medicine of the Marshall Islands and the Republic quickly and on a large scale.176 of Palau.174 The distribution of PHEP funds The cooperative agreements require the de- is calculated using a formula that includes velopment of all-hazards preparedness and a base amount for each awardee plus response plans, which should include the population-based funding, with possible development of policies to mount an effec- additional funds based on significant tive response, including isolation and quar- unmet needs or high degree of risk.175 antine guidelines for different scenarios. 42 TFAH • healthyamericans.org STRATEGIC NATIONAL STOCKPILE (SNS) — SUPPLY AND EXPIRATION CONCERNS The SNS is a national repository of an- the deployment of countermeasures. For in- l Enhancing critical review processes; tibiotics, chemical antidotes and other stance, CDC worked with private pharmaceuti- l Using cost-benefit decisions as manage- medicines and medical supplies for use cal distribution companies and pharmacies to ment components; during a major disease outbreak, bioterror distribute vaccines during the H1N1 outbreak. l Making greater use of computational or chemical attack, or other public health There are concerns that many of medica- modeling and simulation. emergency. The program focuses on re- tions and vaccinations in the SNS pro- l Recognizing SNS and BARDA as the sole sponding quickly to a large-scale event in a cured after September 11 and the anthrax purchaser and SNS as sole distributor of large city or metropolitan area (where more tragedies have exceeded their shelf life certain countermeasures; than half of the country’s population lives). (beyond shelf life extensions) — and that The first line of support can come from l Improving coordination among federal, equipment and supplies, such as respira- either “12-hour Push Packages,” which con- state and local public health partners; and tors, used during the H1N1 pandemic tain over 50 tons of medicines, antidotes l Applying lab science and animal models have not been replenished. CDC uses and medical supplies designed to provide to guide SNS requirements. cost management to estimate the annual rapid immediate help, even when the cause costs over the life of a product to help plan of an attack or incident is uncertain, or may procurement and replacement/restocking come from Managed Inventory when the The federal Shelf Life Extension Program costs over a five-year budget cycle. cause of the incident is known. Push Pack- (SLEP), administered by the Department of ages are kept in secure warehouses across During the H1N1 pandemic, the U.S. gov- Defense and FDA, extends the expiration the country, ready for rapid deployment to a ernment distributed both antivirals and per- dates on qualifying drugs and other materiel designated city or site. SNS also has fur- sonal protective equipment from the SNS in federal stockpiles.179 The shelf life of ther supplies, designed to arrive within 24 to state and local health departments. As drugs and other medical products may be to 36 hours, if necessary.177 of the most recent publicly available data in longer than their stated expiration date, and June 2010, the total quantity of antiviral flu SLEP aims to reduce replacement costs of Quantities in the SNS change based on drugs in the stockpile was 68 million treat- stockpiled drugs by extending their useful life. national planning guidance and prioritiza- ment courses. CDC reports that the antivi- tion, modeling scenarios, standard inven- The program was established in 1986 ral drugs, including pediatric formulations, tory management procedures and funding. through an interagency agreement be- have been replenished and increased. The The SNS maintains a variety of critical phar- Public Health Emergency Medical Counter- tween DoD and FDA to extend the shelf maceuticals and medical supplies such as measures Enterprise (PHEMCE) is currently life of U.S. Air Force drug stockpiles.180 antibiotics like ciprofloxacin and doxycy- evaluating how to replenish supplies used Now, more federal agencies have entered cline, chemical nerve agent antidotes like during the H1N1 pandemic, including N-95 into a memorandum of agreement with the atropine and pralidoxime, antiviral drugs, respirators and surgical masks, and will DoD to participate in SLEP, including other pain management drugs like morphine, develop a strategy to address the gap that branches of the military, the SNS, the De- vaccines for agents like smallpox, and ra- includes stockpiling goals. partment of Veterans Affairs (VA), the U.S. diological countermeasures like Prussian Postal Service, the Federal Bureau of In- In 2013, the National Preparedness and vestigation, the Bureau of Federal Prisons blue and diethylenetriamine pentaacetate Response Science Board (NPRSB) issued and several other federal agencies.181   (DTPA), a treatment to radiation exposure. a statement recommending ways to im- In addition to pharmaceuticals, the SNS SLEP is currently available only for federally- prove and measure the nation’s SNS by contains supportive care supplies like maintained stockpiles. An interagency 2020, which included: 178 endotracheal tubes and IV supplies, burn workgroup that included FDA, DoD, CDC and l Using science as a key strategy and and blast supplies such as sutures and the VA determined that including state an- bandages, ventilators, personal protective management tool; tiviral stockpiles in SLEP is not possible to equipment such as N-95 respirators, gloves l Moving to a single appropriation model implement at the present time.182 and other life-saving medical materiel. to boost fiscal management; l Articulating an SNS vision for 2020; The federal government also can work with partners in the public sector to strengthen l Tailoring surge capacity; TFAH • healthyamericans.org 43 FDA and Biomedical Infectious Disease Research, Development and Safety FDA plays a significant role during in- works to clarify regulatory requirements, fectious disease outbreaks, including provides input on manufacturing and pre- providing advice on medical product devel- clinical and clinical trial designs and expe- opment, authorizing the emergency use of dites the regulatory review of data as it is new diagnostic tools, and quickly enabling received. Under its Emergency Use Autho- access to investigational therapies. FDA rization (EUA) authority, FDA can allow the can expedite the development and avail- use of an unapproved medical product — ability of medical products — treatments, or an unapproved use of an approved medi- vaccines, diagnostic tests and PPE — with cal product — for a larger population during the potential to help bring an epidemic emergencies, when there is no adequate, under control as quickly as possible. It approved and available alternative.183 Department of State and Global Health The Department of State (DoS) is the lead HIV pandemic through the President’s Emer- foreign affairs agency for the United States gency Plan for AIDS Relief (PEPFAR), and the and it provides considerable foreign assis- bureaus of International Organization Affairs tance investments to fight HIV/AIDS, TB and (IO), and Oceans and International Environ- malaria globally. Within DoS, the office of mental and Scientific Affairs (OES).185 Global Health Diplomacy supports Ambas- During foreign infectious disease out- sadors and health teams on the ground breaks, DoS issues warnings for citizens to strengthen the diplomatic engagement to avoid non-essential travel to infected needed to build sustainable country-owned regions.186 DoS also provides a free health systems that effectively improve the service — the Smart Traveler Enrollment health status of their populations.184 It sup- Program — to allow U.S. citizens and na- ports the work of other federal agencies’ tionals traveling abroad to enroll their trip programs like U. S. Agency for International with the nearest U.S. Embassy or Consul- Development (USAID), CDC, the Peace Corps ate in order to receive safety information and DoD. Key departmental counterparts and help the Embassy and loved ones get include the Office of the Global AIDS Coordi- in touch during an emergency.187 nator, which leads the U.S. response to the 44 TFAH • healthyamericans.org Department of Homeland Security and Disease Threats The Department of Homeland Security U.S. Customs and Border Protection (DHS) has the broad mission to ensure (CBP) works to limit entry of infectious a safe, secure and resilient nation. DHS disease at our borders. CBP personnel is home to several entities that support observe, in the course of their routine the fight against infectious disease. duties, all travelers entering the United The National Bio and Agro-Defense States for general overt signs of illnesses Facility (NBAF) works closely with USDA’s (visual observation, questioning and Agriculture Research Service (USDA-ARS) notification to CDC as appropriate) at all and Animal Plant Health Inspection Service, U.S. ports of entry. Currently, DHS has Veterinary Services (USDA-APHIS-VS) on instituted additional screening and protec- medical countermeasure development. tive measures for travelers from Ebola-af- fected countries: All persons traveling to The Institute for Infectious Animal Diseases the United States from West African coun- Photo: ChameleonsEye / Shutterstock.com (IIAD) — founded in 2004 as a Science and tries where there is widespread transmis- Technology Center of Excellence — focuses sion of Ebola must enter the U.S. through on research, education and outreach to New York’s Kennedy, Newark’s Liberty, prevent, detect, mitigate and recover from Washington’s Dulles, Chicago’s O’Hare, or exotic animal, emerging and/or zoonotic Atlanta’s Hartsfield-Jackson airports and diseases, which may be introduced inten- undergo enhanced Ebola screening.189 tionally or through natural processes.188 Department of Defense and Fighting Infectious Threats DoD, while primarily responsible for the discovery of Ebola-Reston. It was United States Strategic Command Center for the health and protection of its service found lethal to monkeys, but harmless to Combating Weapons of Mass Destruction members, contributes to global disease humans. Researchers from USAMRIID has invested over $300 million to develop surveillance, training, research and have been in West Africa since 2006 MCMs for hemorrhagic fever viruses. DTRA response to emerging infectious working on diagnostic tests for Lassa contracts — along with support from NIH disease threats. 190 For instance, fever. In response to the Ebola outbreak, and BARDA — helped fund the development within DoD, the United States Army they have helped set up diagnostic labs in of the drug ZMapp, a monoclonal antibody Medical Research Institute of Infectious Liberia and Sierra Leone. 192 therapeutic cocktail discovered in January Diseases (USAMRIID) researches and of 2014, in collaboration with USAMRIID, In addition, the Defense Threat Reduction develops medical countermeasures Mapp Biopharmaceutical Inc., Defyrus LLC, Agency (DTRA) — DoD’s official Combat (MCMs) — vaccines, drugs, diagnostics and the Public Health Agency of Canada.194 Support Agency for countering weapons and information — to protect service ZMapp was given to seven Ebola patients, of mass destruction across the entire members from biological threats. five of whom survived. It is expected to Chemical, Biological, Radiological, Nuclear USAMRIID has Biosafety Level 3 and Level enter clinical trials in early 2015.195 In late and high-yield Explosives (CBRNE) spectrum 4 laboratories, expertise in the generation October 2014, DTRA posted a Broad Agency — has been active in the Ebola response.193 of biological aerosols for testing Announcement (BAA) to solicit Ebola-related Its programs include basic and applied candidate vaccines and therapeutics, science and technology proposals.196 research and development as well as and fully accredited animal research operational support. Since 2003, DTRA and facilities.191 USAMRIID was involved in TFAH • healthyamericans.org 45 A. Increased Attention and Resources to Maintain and Modernize Public Health Capabilities and Have Consistent and Science-Based Policies Across the Country Funding to support the nation’s public health system is insufficient to adequately protect Americans, according to a range of analyses.197 Stable, sufficient, dedicated funding respond to public health emergencies of l Currently, there is a shortfall in baseline is essential to assure that states and all kinds — including major infectious support for public health at the federal, communities around the country disease outbreaks and bioterrorism. state and local levels. Analyses by the have the basic capabilities needed to Since 2001, investments have led IOM, CDC, Government Accountability prevent and contain disease outbreaks. to significant accomplishments in Office (GAO), and other experts have Infectious disease control requires preparedness planning and coordination; found that public health departments constant vigilance — and inadequate public health laboratories; vaccine at all levels of government have been and fluctuating resources leave gaps in manufacturing; the SNS; pharmaceutical chronically underfunded for decades.198 the ability to quickly detect, diagnose, and medical equipment distribution A review by The New York Academy treat and contain the spread of illnesses. and administration; surveillance; of Medicine (NYAM) estimates that communications; legal and liability an additional $20 billion per year The country has a history of responding protections; increasing and upgrading would be required for public health after a new high-profile threat has public health staffing trained to prevent departments to meet their mandated emerged — including the requests and respond to emergencies; and limited responsibilities.199 for emergency supplemental funds improvements in medical surge capacity. to support the Ebola response — and l Federal funding for public health has While many improvements have been expecting emergency supplemental funds remained at a relatively flat level for achieved, resources have been insufficient to be able backfill basic infrastructure years.  CDC’s budget was cut by almost to support all of the goals. And, over the needs that have long deteriorated. The 12 percent between FY 2006200 and FY past decade, preparedness funding has country fails to regularly designate 2014201 (adjusting for inflation). Federal been repeatedly cut. resources to ensure that these systems are spending on public health through CDC kept in place to fight new threats, nor are The reports have also tracked averages $21.67 per person. we ever able to make significant headway persistent areas of vulnerability, • HEP Cooperative Agreement P into combatting persistent high-impact including in biosurveillance, the ability Funding has dropped from a high threats, like the flu and food safety. to provide mass care in emergencies, of nearly $1 billion in 2006 to a low maintaining a stable MCM strategy to of $640 million in 2014. Thirteen years ago, the nation had a big continue research and development wake-up call — the September 11th and • he SNS does not have enough T of vaccines, antiviral medications and anthrax tragedies, which pointed out funds to replenish expiring items antibiotics, and helping communities major weaknesses in the country’s ability against a variety of threats. become more resilient to cope with and to respond to health emergencies. These • he HPP has experienced almost T recover from emergencies. events helped inspire a series of smart yearly cuts, from a high of $515 million and strategic investments to bolster basic And, over time, the country has let in fiscal year 2004 to just $255 million capabilities in our system. TFAH’s annual its guard down and investments have in FY 2014, a cut of more than 50 Ready or Not? Protecting the Public’s Health experienced a series of cuts, and percent. The HPP provides grants from Diseases, Disasters and Bioterrorism the result is that many protections and leadership to develop coalitions report documented considerable progress Americans expect and take for granted of healthcare facilities to improve that had been made in the past decade have eroded — leaving the nation medical surge capacity and enhance to more effectively prepare for and unnecessarily vulnerable. community and hospital preparedness. 46 TFAH • healthyamericans.org l Health departments in 48 states, two response and preparedness, state and Emergency requests acknowledge U.S. territories and Washington, D.C. local preparedness, training and other ongoing gaps and vulnerabilities in have reported budget cuts, and state and needs; $733 million for the Public Health the system. However, while emergency local health departments have lost 19 and Social Services Emergency Fund funds are important, they cannot percent of their workforce — or 51,000 (PHSSEF), including BARDA and Assistant backfill all problems, such as supporting jobs — since 2008.202 Secretary for Preparedness and Response ongoing expert, trained staff or (ASPR); $238 million for NIH for vaccine capacities, or address problems quickly In November 2014, the Administration and treatment trials; $25 million for enough to keep pace with a new threat requested emergency funding of FDA; $2.5 billion for DoS, including the as it unfolds. It is essential to provide $6.18 billion to support the Ebola response in Africa; $112 million for the sufficient and sustained funding on outbreak. In December 2014, Congress DoD research and procurement; and a a continued basis to make sure that provided $5.4 billion of that request. $1.54 billion contingency fund to enable capabilities are in place, established and The emergency funds included: $1.77 rapid response as the crisis develops.203 well-tested when threats arise. billion for CDC, including international Key Federal Infectious Disease Program Funding CDC—INFECTIOUS DISEASES FY 2006 FY 2007 FY 2008 FY 2009 FY 20101 FY 20111 FY 20121 FY 20131 FY 20142 FY 2015 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 $744,700,000 $798,405,000 Respiratory Diseases HIV/AIDS,Viral Hepatitis, STI $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 $1,072,834,000 $1,117,609,000 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 $339,300,000 $404,990,000 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 FY10-FY14 numbers reflect total budget authority and include PPHF funding for Immunization and Respiratory Diseases, HIV/AIDS and Emerging and Zoonotic Infectious Diseases 2 FY2014 numbers are enacted levels. Beginning in FY14, CDC moves funds from each budget line to the Working Capital Fund for business services, resulting in different operating budgets from enacted levels. Source: http://www.cdc.gov/fmo/topic/wcf/index.html Immunization and Respiratory Diseases Source FY 2015: http://rules.house.gov/sites/republicans.rules.house.gov/files/113-1/PDF/113-HR83sa-ES-G.pdf Source FY 2014: http://docs.house.gov/billsthisweek/20140113/113-HR3547-JSOM-G-I.pdf 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 2015: http://rules.house.gov/sites/republicans.rules.house.gov/files/113-1/PDF/113-HR83sa-ES-G.pdf Source FY 2014: http://docs.house.gov/billsthisweek/20140113/113-HR3547-JSOM-G-I.pdf 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 2015: http://rules.house.gov/sites/republicans.rules.house.gov/files/113-1/PDF/113-HR83sa-ES-G.pdf Source FY 2014: http://docs.house.gov/billsthisweek/20140113/113-HR3547-JSOM-G-I.pdf 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 TFAH • healthyamericans.org 47 Key Federal Infectious Disease Program Funding 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 FY 2014^ FY 2015^^ 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 $1,231,858,000 $1,323,450,000 $1,352,551,000 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 $655,750,000 $661,042,000 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 $535,000,000 $534,343,000 * CDC Total also includes CDC Preparedness and BioSense ** 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). ^ FY2014 numbers are enacted levels. Beginning in FY14, CDC moves funds from each budget line to the Working Capital Fund for business services, resulting in different operating budgets from enacted levels. Source: http://www.cdc.gov/fmo/topic/wcf/index.html ^^ Totals do not include Ebola funding Source FY 2015: http://rules.house.gov/sites/republicans.rules.house.gov/files/113-1/PDF/113-HR83sa-ES-G.pdf Source: FY 2014: http://docs.house.gov/billsthisweek/20140113/113-HR3547-JSOM-G-I.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 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 2002-09: http://www.cdc.gov/phpr/publications/2010/Appendix3.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 FY 2014 FY 2015^^ 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 $4,230,080,000 $4,392,670,000 $4,358,541,000 Infectious Diseases * In 2003 NIAID added biodefense and emerging infectious diseases (BioD) ^^ Totals do not include Ebola funding Source FY 2015: http://rules.house.gov/sites/republicans.rules.house.gov/files/113-1/PDF/113-HR83sa-ES-G.pdf Source FY 2013-2014: http://officeofbudget.od.nih.gov/pdfs/FY15/FY2015_Supplementary_Tables.pdf Source FY 2012: http://officeofbudget.od.nih.gov/pdfs/FY14/POST%20ONLINE_NIH.pdf Source FY 2002-2011: http://officeofbudget.od.nih.gov/pdfs/FY12/Approp.%20History%20by%20IC%292012.pdf 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 FY 2014 FY 2015^^ 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 $1,054,375,000 $1,045,580,000 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 $254,555,000 $254,555,000 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 $415,000,000 $415,000,000 BioShield Special -- -- $5,600,000,000* -- -- -- -- -- -- -- -- -- $255,000,000 $255,000,000 Reserve Fund * One-time Funding Source FY 2010-11: http://www.hhs.gov/asfr/ob/docbudget/2011operatingplan_phssef.pdf ^ HPP moved from HRSA to ASPR in 2007 Source FY 2008-09: http://www.hhs.gov/asfr/ob/docbudget/2010phssef.pdf, p. 8 ** BARDA was funded via transfer from Project BioShield Special Reserve Fund balances for FY2005-FY2013 Source FY 2007: http://www.hhs.gov/budget/09budget/budgetfy09cj.pdf, p. 288 ^^ Totals do not include Ebola funding Source FY 2006: http://www.hhs.gov/asfr/ob/docbudget/2008budgetinbrief.pdf, p. 109 Source FY 2015: http://rules.house.gov/sites/republicans.rules.house.gov/files/113-1/PDF/113-HR83sa- Source BARDA FY 2005-06: http://www.hhs.gov/asrt/ob/docbudget/2010phssef.pdf, p. 45. ES-G.pdf Source HPP FY 2005: http://archive.hhs.gov/budget/07budget/2007BudgetInBrief.pdf, p. 20 Source FY 2014: http://www.hhs.gov/budget/fy2015/fy2015-public-health-social-services-emergency- Source HPP FY 2004:http://archive.hhs.gov/budget/06budget/FY2006BudgetinBrief.pdf, p. 16 budget-justification.pdf Source HPP FY 2003: http://archive.hhs.gov/budget/05budget/fy2005bibfinal.pdf, p. 16 Source FY 2013: http://www.hhs.gov/budget/fy2015/fy2015-public-health-social-services-emergency- budget-justification.pdf Source HPP FY 2002: http://archive.hhs.gov/budget/04budget/fy2004bib.pdf, p. 14 Source FY 2012: http://www.hhs.gov/budget/safety-emergency-budget-justification-fy2013.pdf 48 TFAH • healthyamericans.org RECOMMENDATIONS: Public Health — Leadership, Foundational Capabilities and Funding The public health system — comprised of l A ppointing a permanent Special while adapting to and effectively federal, state and local departments — Assistant to the President for Health addressing changing health threats. must be modernized and funded at a level Security: There should be a White The IOM and RWJF’s Transforming that allows it to fight both ongoing and House public health leadership position Public Health project have identified newly emerging infectious disease threats. to manage infectious and other public key foundational capabilities.204, 205 health threats — and be responsible Two states, Washington and Ohio, Currently, there are key elements of for coordinating a government-wide have begun their own assessment of the system that are outdated or need approach to preparedness, response foundational capabilities.206 increased support to be able to function and recovery efforts. While the more effectively. l I ncreasing funding for public health appointment of an emergency Ebola at the federal, state and local To achieve a more effective, efficient response coordinator has been levels: Federal, state and local health and modern approach to combatting important, it has demonstrated that departments must receive a sufficient infectious disease threats, TFAH recom- there is a gap in the permanent level of funding, and some existing mends that health departments at the structure of the White House to funding lines may need to be realigned federal, state and local levels establish respond effectively to emerging and to be able to ensure all states are foundational capabilities to ensure ongoing public health threats. able to meet and maintain a core set consistent, basic levels of protection l I ncreasing support for global infec- of foundational capabilities so they across the country — and public health tious disease prevention and control can adequately respond to emerging departments at all levels must receive programs: Infectious disease control and ongoing threats. The use of all adequate funding to achieve these capa- strategies rely on the ability to detect federal public health funds and the bilities, including: and contain diseases as quickly as pos- outcomes achieved from the use of l I nfectious disease policy — including sible — which means working with other funds must be transparent and clearly for pandemic and emerging threats — countries and across borders to contain communicated with the public. should be driven by the best available threats globally. Additional support and l I ncreasing funding for public health science and be consistent across priority must be placed on strengthen- at the federal, state and local the country, especially in the midst ing global public health infrastructure levels: Federal, state and local health of a dynamic outbreak: Public health and the Global Health Security Agenda departments must receive a sufficient should be based on the best avail- — including the need to improve surveil- level of funding, and some existing able evidence to weigh the potential lance, communications and other basic funding lines may need to be realigned benefits and harms of policies such as capabilities; and global disease pro- to be able to ensure all states are social distancing and quarantine. grams at CDC, the DoS, DoD, NIH and able to meet and maintain a core set other U.S. based programs; and partner- l C onducting a timely and comprehen- of foundational capabilities so they ing with WHO and other countries. sive After-Action Review and Improve- can adequately respond to emerging ment Plan for the initial phase of the l D efining, prioritizing and fully funding and ongoing threats. The use of all Ebola response: It is essential to a set of foundational capabilities federal public health funds and the capture the experiences and lessons for public health departments at outcomes achieved from the use of learned from the Ebola outbreak and all levels of government: Public funds must be transparent and clearly parlay them into ways to improve and health departments need the tools communicated with the public. upgrade the nation’s ability to respond and skills that are necessary to to infectious disease threats. provide basic public protections TFAH • healthyamericans.org 49 RECOMMENDATIONS: Public Health — Leadership, Foundational Capabilities and Funding l E nsuring the country maintains l E stablishing systems where public business practices and finding sufficient personal protective health departments should only efficiencies may require innovative equipment to be able to provide pay for direct services when they approaches such as regionalization, adequate protection for healthcare cannot be paid for by insurance: public-private partnerships and workers, patients and others during The ACA expanded the number resource sharing. an outbreak: Limits in the availability of services covered by insurance, l I ncreasing integration between and training on the appropriate use of including eliminating co-payments for public health departments and PPE have been a cause for concern recommended vaccinations under healthcare providers to help achieve for healthcare workers and others new group and individual plans for maximum results for improving during the Ebola outbreak. Issues in-network providers and for the health and containing costs: As of sufficiently available PPE become Medicaid expansion population. health systems are reforming, they exponentially amplified during a Public health departments that provide should be encouraged to incorporate widespread outbreak, such as a direct services should make sure they public health and community-based pandemic flu. A 2012 review by ASTHO have systems in place to be able to prevention efforts into their systems. found that most acute care hospitals bill an individual’s insurance provider, Integrating prevention and public in the United States do not have robust so they do not use their public health health with the larger healthcare supplies of respiratory PPE to use in budgets to pay for services that system can be implemented in a the event of an influenza pandemic, and should be billed to insurers. Some variety of ways, including through slightly more than half (56 percent) of states already have these systems coordination between healthcare the hospitals did not own an emergency in place for some services, including providers and existing public health cache of these supplies.207 billing for vaccinations. However, programs and departments. And sensitive services, such as those for l I mproving and coordinating risk public health departments must adapt STIs, should be monitored to ensure communications: The Ebola outbreak to work with new entities and financing that people do not avoid seeking has also raised concerns about risk mechanisms in the reformed health these crucial prevention services due communications and media relations system, such as by working with to confidentiality concerns. capabilities — there was a significantly ACOs or within new capitalized care disproportionate sense of concern l E xploring new funding and business structures and global health budgets, in relation to the very low risk that models to assure sufficient levels to help improve health beyond the Americans have faced. Conflicting of funding to support foundational doctor’s office. These relationships messages from different sources and capabilities: The federal government need to be carefully negotiated, unnecessary actions taken based and states should develop a new particularly in the areas of infectious on perception rather than science financing system for public health disease control (see, for example, compounded the confusion and that gives priority to foundational discussion of preparedness and TB contributed to rising levels of fear. capabilities and assures that in the following sections) because Improved communications strategies every American is served by a of the unique responsibility health could help better educate and inform health department that has these departments have to stop the spread the public and communities about their capabilities. This can be achieved of communicable diseases, while the relative risk and what measures, if any, through new funding mechanisms or health system can and should be are being taken or are needed to help by giving states more flexibility with treating them. protect themselves and their families. existing funding streams. Modernizing 50 TFAH • healthyamericans.org INNOVATION PRIORITY: Biosurveillance — for Detecting, Diagnosing and Tracking Disease Threats One of the most fundamental components lance systems, including the EPA, DHS, of infectious disease prevention and con- USDA, FDA, VA, DoD and the Office of the trol is the ability to identify new outbreaks Director of National Intelligence (ODNI). and track ongoing outbreaks. Recognizing this fragmented and inef- Currently, the United States lacks an inte- ficient approach to biosurveillance, CDC grated, national approach to biosurveillance released a Surveillance Strategy in early — which limits the rapid detection and 2014 to facilitate work to consolidate tracking of diseases. As of 2011, there systems, eliminate unnecessary redun- were more than 300 different health sur- dancies in reporting, and reduce reporting veillance systems or networks supported burden. The strategy included four cross- by the federal government. 208 Most of the cutting initiatives aimed at large surveil- systems are not integrated or interoperable lance systems: the Notifiable Diseases and serve an array of different purposes. Surveillance System (NNDSS), BioSense, electronic lab reporting and the National The existing systems do not capitalize on Vital Statistics System (NVSS). Perfor- the potential advances that have been mance objectives include the following: made in information technology to be able to track disease threats and trends, which l By 2016, 90 percent of data reported compromises the ability to quickly detect, through NNDSS will be by standardized diagnose and contain outbreaks. forms of messages, thereby enhancing timeliness, availability and usability by l At a federal level, CDC runs the majority CDC programs and state, territorial, local of national human health surveillance and tribal (STLT) agencies. networks. Some of these include the Arboviral Surveillance System (ArboNet), l By mid-2015, BioSense will provide en- BioSense, Early Warning Infectious Dis- hanced public health situational aware- ease Surveillance (EWIDS), Electronic ness utilizing electronic health records Food-Borne Disease Outbreak Reporting (EHR) data and active CDC and STLT System (eFORS), Emerging Infection Pro- analyses to better support public health gram (EIP), Environmental Public Health decisions and programs at the local, Tracking Network, Epidemic Information state and national level. Exchange (Epi-X), GeoSentinel, Global l By 2016, 80 percent of laboratory reports Disease Detection and the National Out- to public health agencies (CDC and states) break Reporting System (NORS). will be received as electronic lab reports. l Within each state there are also often l By 2016, 80 percent of death reports more than a dozen health surveillance (i.e., cause of death) occurring in at systems that work independently and least 25 states will be transmitted elec- voluntarily feed data to the correspond- tronically to public health agencies within ing national network at CDC. one day of registration and to CDC/Na- l In addition, other federal agencies and tional Center for Health Statistics within departments have their own biosurveil- 10 days of the event.209 TFAH • healthyamericans.org 51 RECOMMENDATIONS: Modernizing Biosurveillance Biosurveillance needs to be dramatically • DC grants that support disease sur- C faster data to track outbreaks and let improved to become a true real-time, in- veillance should bolster the agency’s providers know about risks to their pa- teroperable system, able to quickly iden- surveillance strategy by prioritizing tients in a more timely way. The Office tify outbreaks and threats and implement interoperability of data systems, up- of the National Coordinator (ONC) must containment and treatment strategies. grading state and local surveillance work with software developers, public Advances in health information technol- workforce and technical capacity, re- health professionals and providers to ogy (HIT) and EHRs provide new opportu- ducing redundancy, and incorporating ensure information exchange is fea- nities to integrate and improve systems. new technologies and data sources. sible and accessible while maintaining TFAH recommends expeditiously moving patient privacy. Government agencies l S upporting new technological ad- forward on the recommendations of the should set standards for data, identify vances: Even the most developed 2014 CDC Surveillance Strategy, 210 the what health information is most rel- systems at CDC must continually be 2012 National Biosurveillance Strategy evant for public health purposes, and upgraded to take advantage of new and the 2013 National Biosurveillance ensure that public health agencies have technological advances. For instance, Science and Technology Roadmap 211 ready access to these data and the technologies to make point-of-care and addressing key concerns, including: capacity to analyze information. Safety (POC) diagnostics increasingly available net providers, including health depart- l M odernizing and integrating systems: would greatly improve care and screen ments, should be eligible for the CMS The federal government should work to patients who truly need attention dur- EHR incentive program. upgrade systems to the latest technol- ing mass emergencies and continued ogies to allow for real-time and interop- support for Advanced Molecular Detec- l C onnecting disease tracking and com- erable tracking of diseases — to more tion (AMD) technologies to build mo- munity resilience: Traditionally, tracing efficiently collect and analyze data, to lecular sequencing and bioinformatics infectious and chronic diseases has better identify threats and to under- capacities, allowing public health to been siloed. There is an increasing stand how threats can be interrelated. rapidly look for a pathogen’s match to recognition of the importance of under- more efficiently identify an outbreak.212 standing of how underlying health condi- • t a state and local level, many A tions make some individuals and groups health departments still lack the l L everaging Health Information Tech- more vulnerable to disease outbreaks basic hardware, software, and staff nology: The increased widespread and and health disasters. Better tracking training to be able to receive and consistent use of EHRs and electronic of the health of communities and social interpret data from EHRs or other laboratory reporting have the potential determinants of health through health sources and to be able to integrate or to provide public health officials with information exchanges, ACOs and other upgrade systems. Support for build- data in real time and offer two-way com- systems can help identify less healthy ing and maintaining baseline capabili- munication between healthcare provid- areas to target resources and direct spe- ties should be a high priority. ers and health departments. This can cial response efforts during outbreaks. allow health departments with better, 52 TFAH • healthyamericans.org INNOVATION PRIORITY: Medical Countermeasures Research and Development The government is often the only real cus- tomer for most medical countermeasure products, such as anthrax and smallpox vaccines. As a result, the U.S. government has invested in the research, development and stockpiling of emergency MCMs for a pandemic, bioterror attack, emerging infec- tious disease outbreak, or chemical, radio- logical, or nuclear event. Development of medical products for the na- tion’s biodefense is a key piece of any public health emergency response. By preparing for a bioterror attack with adequate supplies of countermeasures that can be rapidly de- was expanded to address all vaccines and private companies have been instrumental ployed and administered, the nation can ef- medications related to CBRN threats. 215, in making advances toward developing vac- fectively neutralize that threat. A successful 216 Through the initiative, FDA is developing cines and treatments being piloted for Ebola. domestic MCM enterprise will prepare the na- new scientific and analytic tools to speed the tion for new threats, expected or unexpected, As of the end of fiscal year 2013, BARDA approval of lifesaving drugs and devices. by building the science, policy and production investments resulted in 80 to 90 new capacity in advance of an outbreak. The Public Health Emergency Medical Coun- candidate products in the pipeline under termeasures Enterprise, created in 2006 by advanced research and development, and Congress enacted Project BioShield in 2004 HHS, is made up of federal partners, includ- 12 products in the SNS.218 to spur development and procurement of ing the Office of the Assistant Secretary for MCMs. The Pandemic and All-Hazards Pre- Under advanced research and develop- Preparedness and Response, CDC, FDA, paredness Act (PAHPA) of 2006 established ment, BARDA has initiated new programs NIH, DoD, VA, DHS and USDA, responsible and authorized BARDA to speed up the to support MCM development for candidate for protecting the nation from the health ef- development of MCMs by supporting ad- products for biodosimetry, biodiagnostics, fects associated with chemical, biological, vanced research, development and testing; antimicrobial resistance and biothreat radiological and nuclear (CBRN) threats, working with manufacturers and regulators; pathogens, chemical, burns, blood products, through the use of MCMs. In 2012, ASPR and helping companies devise large-scale sub-syndromes of acute radiation exposure released a PHEMCE Strategy and PHEMCE manufacturing strategies. BARDA bridges (hematopoietic, gastrointestinal, lung and Implementation Plan, which together provide the funding gap between early research and skin) and additional programs for anthrax the blueprint the PHEMCE will follow in the commercial production. The Special Reserve and smallpox. BARDA has strategically in- near, mid- and long-term to achieve its stra- Fund (SRF) of $5.6 billion was established vested the dollars available under the Special tegic goals, which include developing new to help guarantee a market for newly devel- Reserve Fund and, in addition to procuring MCMs, establishing clear regulatory path- oped vaccines and medicines needed for critical MCMs, has established a robust port- ways, developing operational plans for use, biodefense that would not otherwise have a folio of candidate products under advanced and addressing gaps and plans for making commercial market. 213, 214 research and development with the potential sure new MCMs are available, distributed to transition to procurement in the future, In August 2010, FDA launched a new and used when needed in an incident — all addressing remaining preparedness gaps. Medical Countermeasures Initiative (MCMi) while prioritizing investments in the most effi- In addition, the September 2014 Executive to improve the agency’s efforts to minimize cient ways possible.217 An updated PHEMCE Order on Combating Antibiotic Resistant Bac- red tape, maximize innovation and maintain Strategy and Implementation plan is due by teria expanded BARDA’s authority to develop safety it its review and standards for the the end of 2014. new and next generation countermeasures development of MCMs. At first, the initiative BARDA, along with partners at NIH, FDA, that target antibiotic-resistant bacteria that was limited to preparing for responding to DoD, international health agencies and present a serious threat to public health. a flu pandemic, but in 2011, the project TFAH • healthyamericans.org 53 RECOMMENDATIONS: Improving Research and Development of Medical Countermeasures TFAH recommends that the United and to replace used or expiring States place a higher priority on research products, based on which products and development of MCMs, including are deemed absolutely essential. vaccines, medicines and technology. Poli- Given limited budgets, the PHEMCE cymakers must ensure that the public must assess how it will prioritize pur- health system is involved in this process, chases based on risk. from initial investment through distribu- l I nvesting in multiuse products tion and dispensing. The nation’s MCM and technologies and targeted enterprise could be advanced through biodefense products. the following activities: l E nsuring the development and l S upporting the entire medical coun- availability of safe vaccines and termeasure enterprise, from initial medications for children in the SNS: research through dispensing: The Progress continues to be made to PHEMCE must receive robust federal make sure there are safe options funding to ensure continuation of available for children. The federal the pipeline, provide assurances to government should set a goal to industry that the government will be increase the development and pro- a reliable partner in development and curement of pediatric MCMs so that procurement of new products, and the right countermeasure in the right ensure products reach the intended dose and formulation at the right recipients. These funding priorities time can be safely delivered to all should include no-year funding in the children during an emergency. SRF for procurement; annual funding for advanced development at BARDA; l F ostering public-private partnerships the Strategic National Stockpile at CDC for distributing and administering to enable replenishment, maintenance, vaccines and medications: Federal, storage and distribution of appropriate state and local health departments MCMs; and regulatory science in FDA’s should partner with nongovernmental MCMi to promote safe pathways to ap- entities to develop the most efficient proval for new products. distribution and dispensing mecha- nisms for MCMs in an emergency. In l D eveloping an ongoing plan for some communities, private sector, maintaining and restocking the SNS healthcare, community-based or faith- and for the development of clinical based organizations may have better guidance for the best use of MCMs: systems in place to reach target A mandatory funding stream should populations. be created to keep the SNS stocked 54 TFAH • healthyamericans.org INNOVATION PRIORITY: Climate Change and Disease Outbreaks Health departments have an important role to play in helping communities prepare for the adverse effects of climate change, given their role in building healthy commu- nities. Public health workers are trained to develop communication campaigns that both inform and educate the public about health threats and can use these skills to educate the public about climate change-related disease prevention and preparedness. Public health departments are also on the frontlines when there is an emergency, whether it’s a natural disaster or an infectious disease outbreak. These types of emergency preparedness and re- sponse skills will be invaluable as extreme weather events become more common. Source: King County, www.kingcounty.gov/exec/climatechange RECOMMENDATIONS: Preventing and Preparing for the Adverse Impact of Climate Change on Infectious Disease Outbreaks To help prevent and prepare for the reduce known health threats from food, resources to expand the network so it new and increased infectious disease water and air, and educate the public can become a centralized, nationwide threats that climate change poses, TFAH about ways to avoid potential risks. health tracking center, and each state recommends: should receive the necessary funding to l D eveloping sustainable state and fully conduct health-tracking activities. l E nsuring every state has a compre- local mosquito control programs: A re- A fully funded tracking network should hensive climate change adaptation view by ASTHO found that many states demonstrate interoperability with the plan that includes a public health and local communities are challenged larger HIT system to facilitate two-way assessment and response: State and to develop and maintain vector control communication with clinicians and state local health agencies should engage in programs, especially in tight budgetary and local public health officials. public education campaigns and estab- times and when emergency situations lish relationships with vulnerable popu- have quieted, but that these programs l B uilding resilience to climate-related lations as part of any plan. States are a vital public health strategy to help health effects at the federal, state should update state hazard mitigation control vector-borne diseases.219 and local level: Climate change plans to include climate change adap- preparedness should be a required l E xpanding the National Environmental tation, as proposed by FEMA. element of PHEP and HPP plans Health Tracking Network: The CDC’s and grants. Funding should be sig- l I mproving prioritization and coordina- environmental public health tracking nificantly increased to support CDC’s tion across public health and envi- program should be expanded and fully Climate Ready States and Cities Initia- ronmental agencies: Public health funded to cover every state. Currently, tive to build capacity at the federal, agencies at all levels must work in co- the program only supports efforts in 23 state and local level to understand the ordination with environmental and other states and New York City. CDC should impact of climate change and apply agencies to undertake initiatives to be provided with the mandate and this to long-range health planning. TFAH • healthyamericans.org 55 INNOVATION PRIORITY: Building Community Resilience Ensuring communities can cope with and fostering informed, empowered individuals such as radio, racial and ethnic recover from emergencies is a significant and communities. publications and television, and in challenge to public health preparedness. languages other than English. In addition, Resilience is strongly tied to ongoing idiomatic translations are important The most vulnerable members of strong relationships between public health to reach specific cultural perspectives a community, such as children, the officials and the communities they serve effectively, and messages should be elderly, people with underlying health and efforts to improve the overall health delivered by trusted sources, such as conditions and limited-English proficiency, status of the community.221, 222 For in- religious and community leaders. face special challenges that must be stance, individuals who are obese or have considered before disaster strikes. poor kidney function can need additional In 2013, HHS and DHS launched a help and medications during an emer- Community Health Resilience Initiative The resilience of a community — including gency. Currently, two-thirds of Americans (CHRI). The CHRI is a public-private its ability to recover from disasters — is are overweight or obese. collaboration intended to provide inextricably linked to the underlying health stakeholders with resources and of that community and the basic, ongoing Experts recommend that improving guidance to promote resilience in their capabilities of that community’s public resilience, particularly among vulnerable communities.223 CDC has also funded health department or region. Without populations, requires: the development of a Community strong core capabilities, a public health l Improving the overall health status of Resilience Index: Composite of Post- department cannot be expected to meet communities so they are in better condi- Event Wellbeing (CoPE-WELL), to develop additional demands that arise during tion to weather and respond to emergen- a predictor of the ability of a community emergencies. Dedicating and maintaining cies. Initiatives and programs supported to prepare for, survive and rebuild from a ongoing resources for these foundational by the Prevention and Public Health Fund disaster scenario.224 public health capabilities, as measured (PPHF) can assist in these efforts; in indicator one of this report, are tied In 2014, the HHS Climate Adaptation Plan l Providing clear, accurate, straightforward to the ability of states and communities outlined different health risks and respon- guidance to the public in multiple to be resilient in the face of unexpected sibilities and initiatives within the depart- languages; and major threats. RAND identifies ment for helping to protect Americans l Developing ongoing relationships be- the levers of community resilience as from these threats. wellness, access to services, education, tween health officials and members of the community, so they are trusted and One key element of the plan includes the engagement, self-sufficiency, partnership, understood when emergencies arise; and Sustainable and Climate Resilient Health quality and efficiency.220 Care Facilities Initiative, which includes an l Engaging members of the community Building community resilience is one of information tool kit for use by a wide range directly in emergency planning efforts. the two overarching goals identified by of healthcare facilities to assess their HHS in the release of the draft Biennial To reach diverse communities, experts specific vulnerabilities and identify potential Implementation Plan for the National also recommend providing information measures to address those vulnerabilities. Health Security Strategy. It calls for through channels beyond the Internet, 56 TFAH • healthyamericans.org RECOMMENDATIONS: Improving Community Resilience Helping build healthier and stronger are many vulnerable populations. patients’ discharge information. Hospi- communities ensures they can cope Health officials and emergency tals can also add questions and data with and recover from major outbreaks, management officials must have plans on community resilience into commu- health emergencies and other disasters and mechanisms in place to provide nity health needs assessments. Under more easily. TFAH recommends that im- assistance to these neighborhoods in proposed changes to hospitals’ Form proving community resilience should be times of crisis, and members of these 990 reporting, the Internal Revenue a top priority for federal, state and local communities should be part of any Service (IRS) will allow a hospital’s ef- governments, and they should: emergency planning effort to ensure forts on community resilience to count the needs and concerns of the public as a community benefit activity.225 l S upport prevention and public health are heard and addressed. Federal programs: Prevention programs that l P rioritize plans for protecting children: partners must provide strong technical help improve the health of communi- Special efforts must be made to work assistance to allow for the creation of ties, such as diabetes and obesity with childcare centers and schools to models that can be adapted to meet prevention efforts and infection control coordinate and plan for emergencies. All the needs of specific communities. programs, can decrease the vulnerabil- childcare facilities should have appropri- ity for infectious diseases by improving l I ntegrate preparedness activities into ate disaster plans in place, and public American’s underlying health and can the ongoing work of public health de- health officials should work with parents, contribute to strategies to contain the partments and other social services educators, schools and school systems spread of infections.  The PPHF, the and community organizations: Build- to ensure every school has a plan in National Prevention Strategy (NPS) and ing partnerships and preparedness en- place and that the plans are tested. other programs focused on improving gagement between health departments Children should be taught how to be pre- the health of communities — particu- and other services, agencies and com- pared, for example by creating plans to larly targeting health inequities in lower- munity groups, such as housing and reunify with teachers or parents. income communities and empowering faith-based organizations, creates im- l E nsure rebuilding efforts incorporate those communities to actively engage portant channels for reaching and pro- best practices for making the their residents in improving the health viding assistance to at-risk individuals community even stronger: As of their neighborhoods — help prepare and neighborhoods in times of crisis. communities recover from a disaster, all communities for disease outbreaks l I ncorporate community resilience into they should be rebuilt to maximize and other health emergencies. hospital activities: Hospitals should community resilience, health l I nclude community resilience in incorporate community-wide disaster outcomes and social services. emergency preparedness plans: It preparedness planning and community The IOM is beginning a relevant is important for health officials to resilience into their community benefit study, Post-Disaster Recovery of a know and understand special needs work. For example, hospitals can inte- Community’s Public Health, Medical and concerns in different areas of the grate disaster plans for individuals de- and Social Services, that should community, particularly where there pendent on electricity or medication into inform such an approach.226 TFAH • healthyamericans.org 57 EXAMPLES OF KEY Ebola EMERGING AND Ebola is one of several rare, but deadly viral December 2014, there have been more than EMERGENCY THREATS hemorrhagic fevers, first discovered in 1976 17,000 cases and over 6,000 deaths from in what is now the Democratic Republic of Ebola in several West African nations, and the Congo. Symptoms include fever, severe there have been two fatalities on U.S. soil.227 headache, muscle pain, vomiting, diarrhea In the last few months, the U.S. has signifi- and unexplained bleeding or bruising. The cantly increased its capacity to handle poten- virus can be transmitted through contact tial Ebola infections nationwide — increasing with bodily fluids of a symptomatic patient. the number of treatment facilities from three There is no cure or vaccine for Ebola and to 35 and the number of testing labs from survival depends on supportive care and 13 to 42, in addition to completing phase 1 the patient’s immune response. As of early clinical trials of the first Ebola vaccine.228 Strait of Gibraltar HEALTH ADVISORY: EBOLA Recently in West Africa? If you get sick, call a doctor. Tell the doctor Watch for fever, where you headaches, and traveled. body aches in the next 3 weeks. Image of a calendar with 3 weeks highlighted. Image of a person experiencing fever, headaches, and body aches. For more information: visit www.cdc.gov/travel or call 800-CDC-INFO. CS250513 Enterovirus D68 Enterovirus D68 is one of over 100 non- While cases of EV-D68 occur yearly in the polio enteroviruses that causes flu-like summer and fall, 2014 has seen a significant symptoms and severe respiratory illness spike in the number of infections—starting in in some patients. Infants, children and the Midwest. From mid-August to December teenagers are most likely to contract the 4, 2014, 1,121 people in 47 states and D.C. disease because of their limited immunity have confirmed respiratory illness caused and those with asthma are at greatest risk by EV-D68.230  EV-D68 has been detected in of severe illness. There is no cure or vac- specimens from 12 patients who died and cine for EV-D68.229 had samples submitted for testing. 58 TFAH • healthyamericans.org Middle East Respiratory Syndrome Coronavirus MERS-CoV was first reported in humans in September 2012. In July 2013, the WHO International Health Regulations Emergency Committee HEALTH ADVISORY: Middle East Respiratory Syndrome (MERS) determined that MERS-CoV should be considered a serious concern, Going to the Arabian Peninsula? but not yet a “public health emergency of international concern.”231 A new disease called MERS has been identified in some countries. As of June 11, 2014, 699 laboratory-confirmed cases (including 209 The risk to most travelers is low, but you should Symptoms include take these steps to prevent the spread of germs: deaths) of MERS-CoV have been reported to WHO. 232 Individuals fever, cough, and •Wash your hands often. shortness of breath. with chronic conditions appear to be more susceptible to MERS-CoV. •Avoid touching your face. 14 If you get sick within •Avoid close contact with sick people. The largest study to date of those infected included 47 patients and days 14 days of being in the Arabian Peninsula, call a doctor and tell the doctor found that all but two had one or more chronic medical conditions, in- where you traveled. For more information: visit www.cdc.gov/travel cluding diabetes, hypertension, heart disease or kidney disease, and or call 800-CDC-INFO. CS248339 72 percent had more than one chronic condition.233 Pandemic Flu In addition to the seasonal flu, historically 2.25 million deaths. Based on a series of there have been three-to-four pandemic modeling study estimates, during a severe flu outbreaks each century. Pandemics pandemic, the U.S. economy could lose an occur when a new influenza virus emerges estimated $683 billion — a 5.5 percent against which people have little-to-no decline in annual Gross Domestic Product immunity and the virus spreads interna- (GDP).236 tionally with sustained human-to-human l Milder pandemic outbreaks in 1957 and transmission. While experts predict 1968 killed over 34,000 in the U.S. and influenza pandemics will occur in the fu- over 700,000 across the globe.237 ture, they cannot predict when the next l The 2009 H1N1 Influenza (A) virus, pandemic will occur, what strain of the while considered relatively mild, infected virus will be involved, or how severe the around 20 percent of Americans (ap- outbreak will be.234 Once a novel influenza proximately 60 million individuals), and strain mutates and becomes easily trans- resulted in approximately 274,000 missible among humans, it can cause a hospitalizations and 12,000 deaths.238 worldwide pandemic in a relatively short Proportionally, more people were hospital- time. While the pandemic may last several ized from 2009 H1N1 than are typically years as it circles the globe, outbreaks in hospitalized from the seasonal flu. And any single location often come in a series about 90 percent of the Americans who of “waves” that last 6 to 8 weeks each. died from 2009 H1N1 were under the The United States experienced three flu age of 65 and at least 340 children pandemics in the 20th century and one in died.239 However, according to CDC, the the 21st century: actual number of deaths in children could lA severe pandemic in 1918 resulted in 30 be as high as between 910 and 1,880.240 percent of the population becoming ill and A study published in 2013 estimates that 2.5 percent (625,000 Americans) of those worldwide mortality from the 2009 H1N1 who became ill died. 235 In modern times, pandemic could be 10 times higher than this would translate into approximately 90 the original WHO estimates, with most million Americans becoming ill and roughly deaths occurring in people under 65.241 TFAH • healthyamericans.org 59 2013 NOVEL AVIAN INFLUENZA A OUTBREAK — H7N9 The first outbreak of a new avian influenza A (H7N9) virus in hu- ing for the possibility that this virus could eventually spread mans was reported in China by the WHO on April 1, 2013.242 The through sustained person-to-person contact, triggering a global first case outside of China was in Malaysia and was reported on pandemic of H7N9. CDC and WHO are closely monitoring the February 12, 2014.243 situation.244, 245 HHS invested in development of different H7N9 seed strains for vaccine production and has provided grants to Although H7N9 is not currently spreading from person-to-person, WHO to support production of H7N9 pre-pandemic vaccine can- the pandemic potential of this virus is of concern to scientists. didates and subsequent clinical trials.246, 247 Influenza viruses are constantly evolving and experts are watch- PANDEMIC FLU PREPAREDNESS: LESSONS FROM THE FRONTLINES In 2009, TFAH issued a report Pandemic limited quantities of vaccine by mid-fall, Flu Preparedness: Lessons from the which public health officials directed to Frontlines identifying key lessons the highest-risk populations. However, it ISSUE BRIEF Pandemic Flu Preparedness: from the response to the 2009 H1N1 LESSONS FROM THE FRONTLINES took until later in the year before enough response, which concluded that: 248 vaccine was available for the entire U.S. l Emergency funds are essential — but population. This delay in the supply dis- not sufficient — to backfill the long-stand- couraged people from getting vaccinated. ing public health infrastructure issues; 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 In addition to vaccine development, within and more than 100 deaths. The sudden outbreak of this novel flu virus has l Pandemic and emergency response plans tested the world’s public health preparedness. H1N1 provided a real-world test one week of the outbreak, the SNS de- that showed the strengths and vulnerabilities in the abilities of the United States and the rest of the world to respond to a major infectious disease outbreak. must be adaptable and science-driven; This report examines early lessons learned from the response and ongoing concerns more virulent strain, or if a different strain of influenza, like the H5N1 (bird) flu, emerges. livered more than 11 million courses of about overall U.S. preparedness for potential Overall, the H1N1 outbreak has shown that the antiviral drugs, 12.5 million facemasks, pandemic flu outbreak. The first section re- investment the country has made in preparing l Establishing trust with the public through 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 section discusses 10 underlying concerns and proved U.S. capabilities for a large scale infec- tious disease outbreak, but it has also revealed provides recommendations for addressing se- and 25 million N-95 respirators to 62 pre- how quickly the nation’s core public health ca- rious continued vulnerabilities in the nation’s clear and honest communication is im- 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 perative — and the highest-risk groups JUNE 2009 determined areas in states and localities PREVENTING EPIDEMICS. often have the lowest levels of trust; PROTECTING PEOPLE. around the country.249  These materials in- cluded 25 percent of the states’ fixed pan- l Recommendations for sick leave, of up-to-date countermeasures, including demic influenza allocations and was the school closings and limiting community vaccines and antiviral medications, and to first large-scale distribution of its kind. In gatherings have major ramifications keep enough pharmaceuticals and medi- the fall, an additional 535,000 courses of that must be taken into account; cal equipment stockpiled for emergencies. antiviral drugs and 59.7 million N-95 respi- l Coordination across communities, states Quick response capacity is essential rators were also deployed from the SNS in and countries is extremely complicated, during an outbreak or emergency, but it response to the pandemic emergency. but must be a high priority; and requires an ongoing investment in phar- maceutical research and development and The relatively rapid development of a vac- l Competing emergency declarations and stockpiling of medicines and equipment. cine despite limited production capabili- laws must be better coordinated to avoid ties and the quick distribution of antivirals confusion and provide liability and health As soon as the H1N1 virus was identi- and other equipment were only possible protection to medical personnel who vol- fied, scientists raced to develop a vaccine due to prior investments in research and unteer to help during emergencies. to protect against the H1N1 flu strain, development and effective planning, stock- yet they were operating with outdated The 2009 H1N1 pandemic flu outbreak piling and practice in drills and tabletop vaccine research capacity and technol- also demonstrated the importance of exercises by state and local health depart- ogy. Despite these challenges, vaccine maintaining the research and development ments and their key community partners. manufacturers were able to produce 60 TFAH • healthyamericans.org Chikungunya: A Concern for U.S. Travelers Chikungunya is a mosquito-borne virus her blood, generally during the first week of that, while rarely fatal, causes fever and infection when viremia is high. That mos- joint pain that can be excruciating.250 quito then carries the disease with it to its There are no vaccines or treatments next host.256 Because chikungunya is not for chikungunya, but symptoms usually a notifiable disease and symptoms in most subside in about a week. In some people, people subside quickly, the actual number joint pain can persist for months.251 of infections is likely much higher than The best way to protect oneself from reported.257 Fortunately, once infected, contracting the virus is by avoiding patients are likely immune to further infec- mosquito bites. 252 tions.258 Prevention strategies include eliminating standing water, using insect While other parts of the world have experi- repellent and appropriate clothing and be- enced chikungunya outbreaks in the past, havior changes to reduce mosquito bites. it wasn’t until late 2013 that chikungunya first appeared in the Americas in the Caribbean islands.253 As of October 31, 2014, nearly 780,000 suspected and over RECENTLY IN THE AMERICAN TROPICS? 15,000 laboratory-confirmed chikungunya MOSQUITOES spread diseases such as cases had been reported in the western CHIKUNGUNYA hemisphere.254 A total of 1,627 chikungu- and DENGUE nya cases have been reported to ArboNET from U.S. states — most of which were Watch for fever 2 WEEKS with joint pains in travelers returning from elsewhere in or rash in the the Americas. However, 11 cases were next 2 weeks. contracted in Florida this year — the first transmission of the disease on U.S. soil.255 Chikungunya can jump to new If you get sick, see a doctor. Tell the doctor where you traveled. geographic locations if an infected person U.S. Department of returns home and is bitten by a local mos- For more information: call 800-CDC-INFO (232-4636) or Health and Human Services Centers for Disease visit www.cdc.gov/travel. Control and Prevention quito while the virus is present in his or CS246591 Dengue Fever Dengue fever is a mosquito-borne illness to prevent dengue and no drugs for treat- that causes flu-like symptoms and severe ment. Although dengue rarely occurs in joint, muscle and bone pain. Dengue has the continental United States, it is en- emerged as a worldwide problem only demic in Puerto Rico and in many popular since the 1950s. WHO estimates that tourist destinations in Latin America, 50 to 100 million infections occur yearly, Southeast Asia and the Pacific islands. including 500,000 cases of dengue hem- Small dengue outbreaks occurred in Ha- orrhagic fever and 22,000 deaths, mostly waii in 2001, Texas in 2005 and most among children. There are no vaccines recently in Florida in 2013.259, 260 TFAH • healthyamericans.org 61 Chagas Disease Chagas disease is caused by the parasite they are infected. If untreated, infection is most healthcare providers and public health Trypanosoma cruzi and can lead to severe lifelong and can be either symptom free or professionals are not familiar with Chagas cardiac and gastrointestinal disease. It is life threatening. In the United States, there disease, which leads to under-diagnosis and transmitted to animals and people by insect have been limited cases of infection through under-reporting. Chagasic cardiomyopathy vectors found exclusively in the Americas. insects but people have also become in- affects approximately 30,000 to 45,000 As many as 8 million people in Mexico, Cen- fected through mother-to-baby transmission, people in the United States but can be pre- tral America and South America—and over organ transplantation, and accidental labora- vented through early treatment, so expanded 300,000 in the United States—have Chagas tory exposure. Despite the large number awareness and knowledge about Chagas disease, the majority of whom do not know of infected persons in the United States, disease is essential.261 West Nile Virus In 2012, the United States experienced Oklahoma, Nebraska, Colorado, Arizona, were classified as non-neuroinvasive its second-largest and deadliest outbreak Ohio and New York. Texas reported almost disease.264 Older adults are at higher risk of West Nile virus. Every state but Alaska a third of all cases.263 for developing WNV neuroinvasive disease. and Hawaii reported infections in people, As of December 2, 2014, 47 states and WNV is a potentially serious illness that birds or mosquitoes. There were a total Washington, D.C. have reported WNV is spread by infected mosquitoes that of 5,674 human cases of the disease, infections in humans, birds or mosquitoes. contract the virus from feeding on infected with 286 deaths. Half of the cases were Overall, 2,002 cases of West Nile virus birds. WNV prevention strategies focus on classified as neuroinvasive (e.g., meningitis disease have been reported to CDC. Of preventing mosquito bites by eliminating or encephalitis).262 The majority of cases these, 1,196 (60 pecent) were classified as standing water, using quality insect — 80 percent — were reported from 13 neuroinvasive disease (such as meningitis repellent and appropriate clothing and states: Texas, California, Louisiana, Illinois, or encephalitis) and 806 (40 pecent) other behavior changes. Mississippi, Michigan, South Dakota, The majority of individuals (80 percent) who contract WNV develop no symptoms. Up to West Nile Virus Nueroinvasive Disease Incidence 20 percent of infected individuals develop Reported to CDC by Year, 1999–2013 minor symptoms that last from a few days to several weeks. Possible symptoms include fever, headache, body aches, nausea, vomiting, swollen lymph glands and rashes on the trunk of the body. A small portion of infected people (one in 150) will develop serious symptoms that can last several weeks and may result in permanent neurological effects. Possible symptoms include high fever, headache, neck stiffness, disorientation, coma, tremors, convulsions, muscle weakness, vision loss, numbness and paralysis. There is no specific treatment or human vaccine for WNV, although those with severe symptoms can Source: ArboNET, Arboviral Diseases Branch, Centers for Disease Control and Prevention receive supportive care in a hospital setting. 62 TFAH • healthyamericans.org Malaria: A Concern for U.S. Travelers Malaria — which is preventable and cur- substantially reduced the burden of ma- able — is rampant in developing coun- laria worldwide since 2000.146 Evolving tries, particularly in sub-Saharan Africa strains of drug-resistant parasites and and South Asia, but malaria transmission insecticide-resistant mosquitoes continue has been considered eliminated in the to make this emerging infectious disease United States for decades. However, im- a global health threat. ported cases and sporadic episodes of Malaria is typically transmitted to humans 1,925 Malaria Cases local transmission continue to occur and the most since 1971 by mosquitoes, but it can also be trans- the malaria vector mosquitoes capable of mitted through blood transfusions, organ transmitting the disease are present in transplants, contaminated needles or the United States (Anopheles quadrimacu- syringes or from mother to baby before or latus and An. Freeborni). In 2011, 1,925 during childbirth.269 A malaria infection is imported malaria cases were reported in generally characterized by fever and chills, the United States, which is the highest along with headache, malaise, fatigue, since 1971, and represents a 14 percent muscular pains, occasional nausea, vomit- increase since 2010.265 In 2011, five ing and diarrhea.270 Doctors can treat ma- people in the U.S. died from malaria or as- laria effectively with antimalarial drugs. sociated complications.266 All but five of the malaria cases reported in the United Due to increased malaria prevention ef- States were acquired overseas with more forts, malaria mortality rates have fallen than two-thirds of the cases imported from by more than 25 percent globally since Africa. 267 The growing number of imported 2000, and by 33 percent in the WHO Af- malaria cases in the U.S. reflects chang- rican Region.271 The Lantos-Hyde United ing patterns of travel and migration to and States Global Malaria Strategy (USG) has from malaria-endemic countries. contributed to the drop in malaria rates. U. S. investments in 20 countries through In 2010, there were 219 million malaria the President’s Malaria Initiative (PMI) cases worldwide and 660,000 deaths.268 have resulted in significant improvements Although malaria has been virtually elimi- in population coverage of proven effec- nated in developed nations with temper- tive interventions. It has helped reduce ate climates, it is still prevalent in tropical mortality rates in children under the age of and subtropical countries in Africa, Asia, 5 by 16 to 50 percent in these countries the Middle East, South America and Cen- over the past 5 to 7 years.272 tral America. Recent efforts to expand malaria control in endemic countries have TFAH • healthyamericans.org 63 Valley Fever Valley fever (coccidioidomycosis) is severe infection include Blacks, Filipinos, 2000 and 2011 reported that the aver- an infection caused by the fungus pregnant women and people with diabetes age hospital stay was 6 days, cost per Coccidioides, which is endemic to the soils or weakened immune systems.275 day was $6,800, and cost per patient of the U.S. southwest, mainly Arizona and was over $55,000. Adjusting for inflation, Despite its over 100-year existence, much California. People can breathe in dust the average total charges for valley fever is unknown about valley fever and many containing spores that are able to dive in the United States from 2000 to 2011 medical personnel are unfamiliar with it. deep into the lungs with one breath. For was over $2.2 billion. Sixty-two percent Its symptoms — fever, cough, headache, most people, the spores settle in the of those charges were paid by government rash and muscle and joint pain — mirror lungs, but never cause symptoms.273 payers — over $1.38 billion.280 those of other common diseases, so it In others, the spores grow roots in the is most often misdiagnosed.276 A 2013 Awareness of valley fever is increasing. In lungs and cause more severe problems MMWR article states that more than September 2013, prompted by the “Just — requiring treatment with anti-fungal 20,000 cases of valley fever are reported One Breath” series developed by the Re- drugs. Some patients develop flu-like each year, but the true number of infec- porting on Health Collaborative, valley fever symptoms that last from weeks to months tions could be significantly higher due to experts — including leaders from CDC and and 5 percent to 10 percent will develop mild symptoms and misdiagnosis — up- NIH — convened in Bakersfield, California long-term lung problems. Around 1 wards of 150,000. 277 Approximately 100 for Valley Fever Research Day. The two- percent of patients develop disseminated people a year die of valley fever — more day symposium focused on the disease valley fever, where the disease wreaks than from pertussis, hantavirus and sal- and its impact on the community and the havoc elsewhere in the body — causing monella poisoning combined.278 Though it critical need for national attention and sci- meningitis, infections of the skin, bones sickens more people per month than West entific research.281 In October 2014, the and joints or even death.274 Nile virus does in a year, it has historically FDA announced the fast-tracking of a new Anyone can catch valley fever, but those garnered little attention from the media or anti-fungal drug called Nikkomycin Z (NikZ) at highest risk for contracting the disease government officials.279 created specifically to treat valley fever. are those who work outside in soil- Clinical trials will begin next year since the The economic impact of valley fever is disrupting activities (e.g., construction FDA has designated the drug a “qualifying significant. A recent study on valley or agriculture) and people over age 60. infectious disease product.”282 fever-associated hospitalizations between Those at greatest risk of developing a Carbapenem-resistant Enterobacteriaceae (CRE) Enterobacteriaceae are a family of bacteria wound infections and meningitis. are difficult to treat because they are that include Klebsiella species and E. Enterobacteriaceae are one of the most resistant to commonly used antibiotics. coli, which are found in normal human common causes of bacterial infections in Infections with these germs can be deadly intestines. These bacteria can cause both healthcare and community settings. — one report cites they can contribute to major infections when spread outside the Carbapenem are a type of antibiotic death in up to 50 percent of patients who gut, including pneumonia, bloodstream frequently used to treat severe infections. become infected.283 infections, urinary tract infections, Carbapenem-resistant Enterobacteriaceae 64 TFAH • healthyamericans.org BIOTERROR THREATS CDC classifies biological agents and was undertaken by FBI field offices Cities Readiness Initiative has centered that could be used for an intentional in Miami, New York, Newark, New on planning for the ability to respond to bioattack into three categories: Haven, Baltimore and Washington, D.C. a major anthrax attack in urban areas. At the beginning of the investigation, l Category A, or “High-Priority Agents,” l Smallpox: Although WHO declared the limitations on scientific analysis is considered the most dangerous that smallpox was eradicated in 1980, prevented the task force from finding and includes: Anthrax, botulism, this contagious and deadly infectious the culprit because it was impossible plague, smallpox, tularemia and disease caused by the Variola major to determine precisely which spores viral hemorrhagic fevers (e.g., Ebola, virus, remains high on the list of the anthrax came from. Marburg). possible bioterror threats. At least 22 victims contracted anthrax, l Category B, or “Second-highest The last naturally occurring case and five people died from inhalation Priority Agents,” includes food safety of smallpox was reported in 1977. anthrax. An additional 31 people tested threats (e.g., Salmonella and E. coli), Currently, there is no evidence positive for exposure to anthrax spores. ricin toxin, Typhus fever and viral of naturally occurring smallpox In all, 35 post offices and mailrooms were encephalitis, among others. transmission anywhere in the world. contaminated along with seven buildings Although a worldwide immunization l Category C, or “Third-highest Priority on Capitol Hill in Washington, D.C. program eradicated smallpox disease Agents” include emerging pathogens Anthrax is a potentially lethal infection, decades ago, small quantities of that could be engineered for mass particularly when it manifests as smallpox virus officially still exist dissemination in the future because inhalation anthrax. Outside of a host, in research laboratories in Atlanta, of availability; ease of production and this bacterium normally resides as a Georgia, and in Novosibirsk, Russia. dissemination; and potential for high spore — a hardy, dormant cell that may There is a fear there may be other morbidity and mortality rates and become active (germinate) in the right unknown sources of smallpox virus that major health impact. Hantavirus is an conditions. Anthrax generally affects could fall into the hands of terrorists. In example of a Category C agent.284 large grazing animals, but it can also January 2003, the Bush Administration Two threats that have been of high infect humans who handle products of declared smallpox the “number one focus in U.S. bioterrorism preparedness infected animals. However, deliberate bio-threat facing the country” and made strategies include: exposure to aerosolized anthrax spores planning for an attack a top priority.287 also is a highly effective means of The Administration launched a national l Anthrax: In September and October transmission.285 Historically, numerous smallpox vaccination initiative with 2001, at least five envelopes nations have experimented with anthrax the goal of immunizing 500,000 containing Bacillus anthracis (anthrax) as a biological weapon, including the healthcare workers in 30 days and 10 were mailed to Senators Patrick U.S. offensive biological weapons million emergency response personnel Leahy and Thomas Daschle and to program that was disbanded in 1969.286 within a year. Immunization rates members of the media in New York The worst documented outbreak of fell well below that target level with City and Boca Raton, Florida. After inhalation anthrax in humans occurred approximately 40,000 people actually the bioterrorist attacks were identified, in Russia in 1979, when anthrax spores vaccinated. The plan faced obstacles, the FBI and the United States Postal were accidentally released from a including unexpected side effects, Inspection Service (USPIS) formed a military biological weapons facility near worker compensation issues and task force to investigate the crime. the town of Sverdlovsk, killing at least liability concerns that precluded its full The investigation lasted seven years 66 people. Much of the planning for the implementation.288, 289 TFAH • healthyamericans.org 65 B. Health System Preparedness and Enhancing Surge Capacity and Infection Control In public health emergencies, such as a new or major disease outbreak, a bioterror attack or catastrophic natural disaster, U.S. hospitals and healthcare facilities are on the front lines providing triage and medical treatment to individuals. The ability of our healthcare system to quickly provide safe care for an influx of patients during an emergency is critical, but it is often identified as one of the most difficult components of a preparedness response. Not only must healthcare facilities be facilities must have standard procedures in able to quickly ramp up staffing to meet place to not only safely diagnose and treat increasing demand, but — as highlighted patients, but also ensure that other patients by the Ebola outbreak — they must be and the healthcare workers themselves are able to do so with clear and effective safety protected from exposure. This requires a protocols in place, including adequate solid foundation built on basic infection personal protective equipment, and staff control principles and not only sufficient that are highly trained to protect not only personal protective equipment, but also patients, but themselves. Two nurses who thorough training in the proper use, treated an Ebola patient in Dallas con- removal and disposal of protective gear. tracted the virus. While both survived, l Surge Capacity: During a severe health their experience highlights gaps in local emergency — such as a pandemic flu implementation of guidance and commu- outbreak or mass bioterror attack — the nication from CDC and in basic infection healthcare system would be stretched control safety procedures and training. beyond normal limits. Patients would l Basic Infection Control and Safety: It is quickly fill emergency rooms and doctors’ critical that all medical care be provided offices, exceed the existing number of under conditions that minimize or elim- available hospital beds, and cause a surge inate risks of healthcare-associated in- in demand for critical medicines and fections and adverse events. Outbreaks equipment. The challenge of how to and large-scale patient notifications con- equip hospitals and train healthcare staff tinue to be associated with breakdowns to handle the large influx of critically in standard precautions and lack of injured or ill patients who show up for adherence to recommended prevention treatment after or during a public health practices. A strong foundation in infec- emergency remains the single most tion control and prevention is needed challenging issue for public health and across the healthcare continuum. This medical preparedness.290 Emergency will require clear standards, training rooms and intensive care units (ICUs) and dedicated resources. have limited numbers of beds, staff and equipment to be able to respond to a l Emerging Threats: When faced with a major influx of patients. deadly contagion like Ebola, healthcare 66 TFAH • healthyamericans.org The HPP, administered by ASPR, HPP has been working toward a model As Ebola has grown as a domestic concern, provides leadership and funding that recognizes that healthcare system a government-wide response has been through grants and cooperative preparedness must extend beyond fo- developed in partnership with the health agreements to states, territories and cusing on individual hospitals, toward a system to create a tiered system for being eligible municipalities to improve surge coalition-based model to better leverage able to diagnose and treat Ebola patients capacity and enhance community resources, disseminate information, en- quickly, effectively and safely.296 Initially in and hospital preparedness for public hance credibility and broaden reach.292, August 2014, only three U.S. healthcare health emergencies.291  HPP was 293, 294 A healthcare coalition is a collec- facilities had the capacity to treat Ebola created to build capabilities in the tive network of healthcare organizations patients. As of December 2014, a tiered areas of health system preparedness, and public and private sector partners system has been developed for diagnosing health system recovery, medical surge, that work together to prepare for, re- and treating patients by 1) increasing emergency operations coordination, spond to and recover from a disaster. the availability of Ebola training and fatality management, information Since 2007, HPP has piloted a coalition- PPE available for healthcare providers sharing, responder safety and health based model, and in 2012, launched nationwide; 2) working with state and and volunteer management. Through new measures to move the full program local public health officials to increase the the planning process and cooperation toward a coalition approach. The new number of “Ebola Assessment Hospitals” within healthcare coalitions, facilities measures focus on continuity of opera- — as healthcare facilities that can serve as are learning to leverage resources, tions, medical surge and healthcare coali- points of immediate referral for individuals such as developing interoperable tion development assessment. To help who have a travel history and symptoms communications systems, tracking understand and address gaps during compatible with Ebola to be safely available hospital beds, and sharing the initial domestic phases of the Ebola screened, isolated and then transported assets such as mobile medical units. response, a 2014 IOM and National to facilities with additional capabilities; 3) HPP was reauthorized in the Pandemic Research Council ad hoc committee of expanding the number of Ebola Treatment and All-Hazards Preparedness experts convened to identify a set of po- Centers from three to 35 hospitals around Reauthorization Act (PAHPRA, P.L. tential research priorities to inform pub- the country; and 4) maintaining the three 113-5), but funding for the program lic health and medical practice, including national bio-containment facilities — at has been cut from a high point of $515 gaining an understanding of the environ- Emory University Hospital, Nebraska million in 2004 and is now funded at mental characteristics of the Ebola virus Medical Center and the National Institutes about $255 million annually to support and standards for use for personal pro- of Health — for patients who are medically the entire healthcare system. tective equipment and behavior.295 evacuated from overseas. TFAH • healthyamericans.org 67 RECOMMENDATIONS: Enhancing Health System Preparedness for Infectious Diseases and Surge Capacity Health system preparedness capabilities as CMS measures, Joint Commission care system should be able to screen have been one of the most persistent standards and National Quality Forum for emerging threats, isolate patients problems in public health preparedness (NQF) measures; and when necessary, protect healthcare and require increased agreement and • Publicly report data from the recently workers and prepare patients for implementation on crisis standards of revamped HPP measures so policy- transport if unable to treat; care and improved integration of pre- makers can track progress and gaps • ealth systems and HIT vendors H paredness concerns into overarching in the program. should incorporate health alerts from healthcare systems and coordination CDC into electronic medical records l Improving hospital preparedness — as across public health and healthcare pro- so that the triage process includes rel- viders. To help improve health system a partnership across hospitals, HPP evant screening questions and decision preparedness concerns, while ensuring and public health –- for emerging and support; and safety protocols are in place, TFAH rec- ongoing infectious disease threats: • linical laboratories should have ongo- C ommends: • very hospital should have baseline E ing staff training to ensure familiarity capabilities for screening and basic l Continuing to rebuild and modernize and adherence with protocols for isolation capabilities to ensure health- the Hospital Preparedness Program, handling, packaging and preparing care workers and patients are safe including focusing on: dangerous pathogens and waste for from a potential threat — including • ebuilding the program by restoring R transport. training in infection control and use of funding to enable adequate develop- protective gear and safe removal and l Incorporating preparedness into the ment of healthcare coalitions and train- disposal of protective gear and waste. healthcare delivery system: ing and exercising of hospital staff; To maximize efficient and effective • tate and local emergency medical S • ontinuing to prioritize coordination C use of expertise and resources, hos- services (EMS), 9-1-1 public safety between the inpatient and outpatient pitals should be part of a “tiered” answering points (PSAP) and other health systems, including long-term system — where patients are safely medical first responders should be in- care facilities and clinical laboratories, transported to a set of hospitals with cluded as partners and participants in and ensure that healthcare coalitions increased capabilities and facilities to the U.S. healthcare delivery system to are reaching out to these partners; treat different potential scenarios for ensure a coordinated response with • efining a minimum set of standards D a range of types of emerging threats well-trained and equipped personnel and population size that a healthcare — such as the network of Ebola-ready during a medical surge. coalition must meet to be considered hospitals or a tiered system for being • MS should finalize and expedite the C effective. While HPP has avoided able to screen, triage and treat a release of emergency preparedness being overly-prescriptive with grant- mass influx of patients during a se- requirements for Medicare and Medic- ees, limited budgets demand that vere pandemic flu outbreak; aid participating providers.297 CMS and healthcare coalitions should meet a • ospitals and public health agencies H ASPR should work together to align federally-defined standard for their should invest in training, drills and pre- those requirements, provide technical ability to respond to a disaster; paring frontline healthcare workers for assistance to eligible entities, ensure • ligning HPP measures with other A unfamiliar infections and disasters; coordination with healthcare coalitions health system quality initiatives, such • very hospital and outpatient health- E and track progress. 68 TFAH • healthyamericans.org • ewly established federal and state N • xpand telemedicine and telephone E created by the IOM and ASPR’s Commu- healthcare marketplaces should begin triage to increase surge capacity and nities of Interest website. If necessary, planning for disasters. Exchange mar- concentrate resources where needed. the federal government should require ketplace systems, using information pro- crisis standards planning of PHEP and l Establishing and implementing vided by providers and insurers, should HPP grantees. Meanwhile, given recent effective crisis standards of care and have the ability to operate and maintain shortages of saline solution and other resource allocation planning: key enrollment and coverage information everyday medical products, the roles and in case of emergency. In addition, sys- • ublic health must take a leadership and P potential actions of federal agencies, tems must be interoperable in a way that quality assurance role to ensure health including ASPR, CMS and FDA, should be would permit sharing data across states facilities and systems are engaging in clarified before the next outbreak, disas- if people are evacuated in large numbers. meaningful crisis and contingency stan- ter drug or medical supply shortage. dards of planning and using resources TFAH • healthyamericans.org 69 RECOMMENDATIONS: Reducing Healthcare-Associated Infections Across the Healthcare Spectrum HAIs continue to be an ongoing, serious in a call to action in the American • educing inappropriate and R preventable problem, where millions of Journal of Infection Control can provide unnecessary use of devices, like Americans are infected each year while incentives for healthcare providers to catheters and ventilators; receiving routine medical care. HAIs improve practices to reduce infections • xpanding HAI prevention efforts E are still a problem in hospitals, and at and infection-related costs.” 298 beyond the hospital setting, to include the same time there is an increasing ambulatory surgery centers, dialysis l Supporting State HAI and Infection amount of medical care being delivered clinics, and nursing homes; Control Programs: Key areas where through outpatient venues and long- states can play a critical role in support- • Adhering to the best hygiene practices; term care facilities. HAI prevention, ing infection control and HAI prevention: • rescribing antibiotics only when ab- P surveillance and outbreak reporting re- quirements are lacking in many of these • oordinate and assess infection con- C solutely necessary; additional settings. Compared to acute trol capacity at healthcare facilities in • mproving education, communication I care facilities, these facilities often op- each jurisdiction; and best-practice protocols as the erate with limited oversight from state • ngoing tracking of local facilities per- O regular standard-of-care throughout licensing boards, accrediting organiza- formance through National Healthcare entire healthcare facilities; and tions or federal authorities. Ongoing Safety Network to identify facilities in • mproving reporting and regulatory over- I outbreaks stemming from breakdowns need of assistance and to monitor na- sight of HAIs and financial incentives in basic infection control such as reuse tional progress in infection control; for reducing the number of infections. of syringes and the spread of infections • Support the identification of single in- l All healthcare facilities should make with drug-resistant bacteria point to fections and clusters of infections, and unmet prevention needs. following infection control best prac- rapidly implement control measures; tices a top priority. Recent efforts to improve infection • mplement and facilitate new infection I • fforts to define and enforce basic E control practices have started show- control licensure requirements for standards of infection control in ing promising results in reducing HAIs. healthcare workers and collaborate inpatient and outpatient settings TFAH recommends that public health with state hospital associations and (e.g., www.cdc.gov/hai/settings/ and healthcare officials should make medical societies to survey infection outpatient/outpatient-care-guidelines. limiting HAIs a top priority in hospitals control training needs and provide html) and effective oversight activities and across the U.S. healthcare system, CDC supported trainings. (e.g., audits and inspections), though which includes: l Fully and Swiftly Implementing the increasing, require strengthening at l Aligning incentives to promote pre- National Action Plan to Prevent both the state and federal levels. vention: Initiatives like the Medicare Healthcare-Associated Infections: A l All hospitals should have an infection “no pay” rules and prevention-oriented Roadmap to Elimination:299 Some key prevention specialist on staff. healthcare payment strategies outlined strategies in the Action Plan include: 70 TFAH • healthyamericans.org EXPERT COMMENTARY The Basics of Hospital Infection By Eric Toner, MD, Senior Associate, UPMC Center for Health Security Control and How It Applies to Diseases Like Ebola It is clear that the unlucky Dallas hospital that treated that first U.S.-diagnosed Ebola patient was not well prepared for such a disease. It is also reasonable to assume that most U.S. hospitals were also not optimally prepared then to take care of a patient with Ebola or another highly contagious and lethal disease. Why is that? Quite simply, it is not enough to have Centers for Disease Control and plans, guidance and equipment, the Prevention hospital personnel at the bedside have CDC is not a regulatory agency. It does to implement the plans flawlessly. This not inspect healthcare facilities nor does takes extraordinary training and lots it enforce any laws or regulations related of practice — both of which are quite to infection control within hospitals. It expensive and disruptive to normal does, however, provide the comprehensive operations. So, who is in charge of National Healthcare Safety Network ensuring that hospitals are prepared surveillance system to monitor healthcare- for any potential infectious disease related infections and process of care outbreak? The answer to that question, measures, and issues relevant guidelines as described below, is complicated. that are generally quite influential but Most U.S. hospitals are licensed by the which hospitals are not required to states, not by the federal government follow. CDC also generates education and are therefore mostly subject to state and training materials, alerts and best laws and regulations. In reality, there practices. Each hospital, and to some is no single set of infection prevention extent each clinician within each hospital, and control requirements for healthcare makes his or her own decision about facilities and no single agency with which aspects of the guidelines and other regulatory authority. Rather, infection materials he or she will follow and how control in hospitals is governed by a they will be implemented. mélange of local, state and federal laws State and Federal Public Health and regulations and standards set by Departments and Agencies funding and accrediting organizations. Typically, states have laws that require There are numerous sets of useful healthcare facilities to maintain hygienic guidelines promulgated by government conditions and address general infection agencies and professional societies control. The state health departments such as the Association of Professional have the authority to inspect hospitals in Infection control and Epidemiology and enforce state laws and regulations. (APIC) and Society for Healthcare Local and state health departments Epidemiology of America (SHEA). TFAH • healthyamericans.org 71 Accrediting organizations, such as The Joint Commission’s Infection Prevention and Control Standards, require that a participating hospital have at least one individual who is responsible for an infection control program although there is no training or expertise requirement for that individual. all have lists of infectious diseases that therefore be paid by CMS, hospitals hospitals to undertake infectious disease must be reported to them by healthcare must agree to abide by Conditions of surveillance, investigate outbreaks, and practitioners and facilities. These Participation (COP),302 which include report certain diseases to local, state reportable diseases typically include provisions related to infection control and federal public health authorities as infections such as sexually transmitted (§482.24) and requirements to report required by law. The Joint Commission infections, salmonella and measles. In healthcare-associated infections to conducts onsite surveys (inspections) of addition, CSTE annually publishes a the CDC National Healthcare Safety participating hospitals on a periodic basis list of infectious diseases of particular Network.303 CMS, typically acting (every few years) and looks for evidence concern that should be reported within through state health departments, of compliance with its standards.304 The each state and to CDC. Included in conducts unannounced surveys Joint Commission has been granted this list are diseases that have caused (inspections) of hospitals that are not “deeming authority” by CMS, meaning outbreaks of global concern such as surveyed by the Joint Commission that these surveys also serve to document anthrax, SARS, MERS and Ebola.300 (see below). CMS, again through the compliance with CMS’s COP. state health departments, will also Occupational Safety and Health Conclusion conduct unannounced surveys as part Administration Unfortunately, the hospital-acquired of an investigation of a complaint. In Healthcare facilities are required by federal a nutshell, CMS requires that hospitals Ebola infections in Dallas demonstrate law (29 CFR 1910.1030) to adhere to have “an active program for the that normal day-to-day infection minimal standards of precautions against prevention, control, and investigation of control practices are far from perfect. bloodborne pathogens as determined by infections and communicable diseases” Although Ebola makes infection control the federal Occupational Safety and Health along with a quality assurance process to deficiencies very obvious, the same sorts Administration (OSHA).301 This includes address infection related issues. of lapses are the root cause of HAIs that use of universal precautions (wearing occur every day. CDC, CMS and the Joint gloves and washing hands), handling Accrediting Organizations Commission have made reducing HAIs of needles and other sharp objects, Accrediting organizations, such as The a top priority in recent years and there training employees, and having a written Joint Commission’s Infection Prevention is evidence that these efforts have had bloodborne exposure plan. Beyond this, and Control Standards, require that a some success. But a perpetual high-level hospitals are required to have an infection participating hospital have at least one commitment to rigorous infection control control program if they participate in individual who is responsible for an in every hospital is needed. Hospital Medicare or Medicaid or if they are infection control program although executives and boards must become accredited by The Joint Commission, there is no training or expertise more proactive when alerted about a a non-governmental organization that requirement for that individual. The contagious and lethal threat and not wait accredits most U.S. hospitals. individual must also have access to an until there is misadventure that becomes infection control expert. Further, the “breaking news.” CDC and federal Centers for Medicare and hospital must provide the program with leaders, for their part, must realize that Medicaid Services some amount of funding, equipment extraordinary measures are needed to CMS funds the healthcare of more and laboratory resources. The Joint truly prepare the U.S. healthcare system than100 million people in the United Commission’s standards require for an Ebola-like disease. States. In order to participate and 72 TFAH • healthyamericans.org C. Changing Healthcare and Public Health Norms to Increase Vaccinations and Combat Antibiotic Resistance Two of the most revolutionary advances in fighting infectious diseases have been biomedical — vaccines to prevent diseases and antibiotics to treat them. The current system, however, perpetuates Both require major public and healthcare the underuse of vaccines and overuse of educations efforts — to help educate antibiotics — diminishing their potential about the effectiveness and safety of and effectiveness as tools against disease. available vaccinations and to discourage overuse of antibiotics. And both require Increasing the use of vaccines and changes in healthcare delivery practices discouraging the misuse of antibiotics — to make vaccines more easily accessible requires rethinking how they are as part of routine healthcare and beyond provided as part of routine healthcare the traditional healthcare system, and to and how their use is supported as part disincentivize unnecessary prescribing. of the larger public health system. 1. Improving Vaccination Rates — for Children and Adults Vaccines are the safest and most effective way to manage many infectious diseases in the United States. Some of 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.305 However, despite the recommendations of medical experts that vaccines are effective and that research has shown vaccines to be safe, on average, an estimated 45,000 adults and 1,000 children die annually from vaccine-preventable diseases in the United States.306 Millions of Americans are not receiving the recommended vaccinations. For instance, more than 2 million preschoolers do not receive 2013-2014 data are not complete. Source: National Notifiable Disease Surveillance System (NNDSS) and direct report to the CDC TFAH • healthyamericans.org 73 recommended vaccinations; there have universities, serving in the military been outbreaks of measles, mumps or working in a healthcare setting. and whooping cough around the Significant numbers of adults do not country; vaccination gaps put teens have regular well care exams, switch and young adults at risk for HPV and doctors or health plans often or only bacterial meningitis; and more than 35 seek care from specialists who do not percent of seniors have not received traditionally screen for immunization the recommended pneumococcal histories or offer vaccines, which makes vaccination.307, 308, 309 it extremely difficult to establish ways for people to know what vaccinations Gaps are even larger for the number they need and for doctors to track and of adults not receiving recommended recommend vaccines to patients. vaccinations. While many efforts focus on vaccines for children, it is The Community Preventive Services also important to address the fact that Task Force, which evaluates the available currently, there is no real system or evidence base for public health programs structure in place to ensure adults have and strategies, has found that when access to or receive the vaccines they education and registry systems are in need unless they are part of institutions place and used, combined with other that have vaccine requirements, intervention components, they are such as being enrolled in colleges or effective in improving vaccination rates.310 VACCINE COVERAGE Historically, limits on health insurance for its coverage of different vaccina- through the Vaccines for Children (VFC) coverage and high costs have been tions. To help incentivize states to program at no cost. an obstacle. The ACA now requires expand coverage of recommended vac- In addition, Medicare does not consis- no co-pay or cost sharing for routinely cinations without co-pays to their base tently provide first dollar coverage for recommended adult vaccines that are Medicaid population, the ACA allows vaccines and the different policies for administered by in-network providers for CMS to offer states a 1 percent Federal what is covered under Part B and Part adults enrolled in group and individual Medical Assistance Percentage (FMAP) D leaves many seniors with gaps in cov- plans or are part of Medicaid expan- increase for these services. The Med- erage. Beneficiaries can get their flu, sion. This eliminates an added cost icaid program typically provides certain pneumonia and HBV (for at-risk individu- burden for individuals and by increasing levels of matching payments to states als) vaccine covered under Medicare Part the numbers of people vaccinated over- for different types of medical care. B, but an out-of-pocket payment may be all, helps protect the wider population As of December 2013, only five states required, depending on the shot and pro- by limiting the spread of disease. have expanded coverage to allow all of vider. The rest of the recommended vac- States, however, are not required to the Medicaid beneficiaries to get all the cines are covered under Medicare Part eliminate co-pays for vaccinations for medically recommended vaccinations D, the prescription drug benefit, so the their existing or base Medicaid benefi- without co-pays. Medicaid-eligible patient must find a provider who accepts ciaries. Any given state can set policies children can receive vaccinations Part D and carries the needed vaccine. 74 TFAH • healthyamericans.org RECOMMENDATIONS: Increasing Vaccination Rates Improving the nation’s vaccination rates would help prevent disease, mitigate suffering, and reduce healthcare costs. TFAH recommends a number of actions that can be taken to increase vaccination rates for children, teens and adults around the country, including: l Minimize vaccine exemptions: should provide reminder recalls to exchanges can make this process States should enact and enable patients and providers through text simpler by integrating registries into universal childhood vaccinations messages or other communications. EHRs and enabling Immunization except where immunization is A routine adult vaccination schedule Information Systems (IIS) data exchange medically contraindicated. Non- should be established, where between states. Measures must be medical vaccine exemptions, healthcare providers are expected to taken to encourage greater participation including personal belief exemptions, purchase, educate, advise about and by healthcare providers, particularly enable higher rates of exemptions in administer immunizations to patients. private providers, in registries. Lifespan those states that allow them. registries would also help better track l Expand alternate delivery sites: The patients’ medical history to ensure they l Increasing public education National Vaccine Advisory Committee have received all needed vaccinations campaigns about the safety and (NVAC) has recommended including throughout their lives — to help improve effectiveness of vaccines: Federal, expansion of vaccination services and track vaccination rates for both state and local health officials, in offered by pharmacists and other children and adults. partnership with medical providers community immunization providers, and community organizations, vaccination at the workplace, and in- l Supporting expanded research should conduct assertive creased vaccination by providers who and use of alternatives to syringe campaigns about the importance of care for pregnant women.312 administration of vaccination. vaccines, particularly stressing and Experiences with alternative delivery l Increasing provider education: demonstrating the safety and efficacy methods, such as using the nasal Professional medical societies and of immunizations. Targeted outreach mist intranasal administration of live- medical and nursing schools should should be made to high-risk groups attenuated influenza vaccine (LAIV), support ongoing education and and to racial and ethnic minority have been well-received by the public expanded curricula on vaccines and populations where the misperceptions and have contributed to increased vaccine-preventable diseases, and about vaccines are particularly high.311 uptake in pediatric and adult expand standard practice for providers to vaccinations.313, 314 l Routinizing adult vaccination discuss and track vaccination histories recommendations and referrals: for all patients — including adults — l Ensuring first dollar coverage of Private providers and health systems and offer vaccinations to adults during all recommended vaccines under should have standing orders for other doctor and hospital visits. Medicare and Medicaid: Vaccines vaccinations so every provider of recommended by ACIP should be l Bolstering immunization registries care for adults can assess the need, covered under both Medicare Part and tracking: States should take recommend, and either provide B and Part D without cost sharing, steps to integrate immunization directly or refer to another provider for to ensure complete, equitable registries and EHRs to help track when vaccination. Vaccine locator systems access to vaccines for all Medicare patients receive vaccines, improve should be expanded to build an beneficiaries. States that have not information sharing across providers, effective vaccine referral system so already done so should expand their remind providers to routinely provide providers can ensure the vaccine is Medicaid programs to ensure more recommended vaccinations, remind administered, just as for mammograms low-income Americans have access to patients of vaccinations and address or other preventive services. EHRs life-saving vaccines. gaps. State health information TFAH • healthyamericans.org 75 Source: U.S. Centers for Disease Control and Prevention RECOMMENDATIONS: Increasing Vaccination Rates l Continuing support for vaccine funding immunization of healthcare personnel programs: While the ACA extends (HCP) by healthcare employers (HCE) no-cost coverage of recommended as recommended by ACIP According . vaccines to most Americans, the to a joint policy statement by the three VFC and Section 317 programs will Societies, mandatory immunization continue to provide a safety net for programs are the most effective individuals who are uninsured, have way to increase HCP vaccination “grandfathered” plans that do not rates. As such, the Societies cover these vaccinations or remain support HCE policies that require outside of the traditional healthcare HCP documentation of immunity system, such as children who are or receipt of ACIP-recommended eligible but not enrolled in Medicaid/ vaccinations as a condition of State Children’s Health Insurance employment, unpaid service, or receipt Program (CHIP). Section 317 grants of professional privileges. For HCP have also been key to building the who cannot be vaccinated due to immunization infrastructure, including medical contraindications or because registries, surveillance, outreach and of vaccine supply shortages, HCEs service delivery. should consider, on a case-by-case basis, the need for administrative l Requiring universal immunization and/or infection control measures to of healthcare personnel for all minimize risk of disease transmission. ACIP recommended vaccinations: The Societies also support requiring The Infectious Diseases Society comprehensive educational efforts of American (IDSA), the Society for to inform HCP about the benefits Healthcare Epidemiology of American of immunization and risks of not and the Pediatric Infectious Diseases maintaining immunization. Society (PIDS) support universal 76 TFAH • healthyamericans.org Vaccine Preventable Diseases l Diphtheria: Diphtheria is a serious of infected adults develop chronic protects against influenza, not the other bacterial disease that frequently causes infection, increasing chances for chronic disorders. In an average year, influenza heart and nerve problems. Without liver disease, cirrhosis and liver cancer. causes approximately 3,000 to a high treatment, 40 to 50 percent of infected Hepatitis B-related liver disease kills of about 49,000 deaths and may persons die, with the highest death about 5,000 people and costs $700 contribute to approximately 200,000 rates occurring in the very young and million annually in healthcare and hospitalizations in the United States.320 the elderly. Diphtheria has largely been productivity-related costs.318 l Measles: As a result of widespread eradicated in the United States and l Human Papillomavirus (HPV): HPV is vaccination, measles is no longer other industrialized nations through the most common sexually transmitted endemic in the United States. However, widespread vaccination. There were infection and is a major cause of because measles is still widespread only seven reported cases of diphtheria cervical and oropharyngeal (middle of in many countries, the United States between 1998 and 2009 in the United the throat) cancer. Approximately 79 is at risk of importation of the disease States.315 However, children and adults million Americans currently are infected from international travelers and from who travel to endemic areas are still at with HPV, and another 14 million people U.S. residents who travel abroad, and risk for diphtheria. become newly infected each year.319 The if high immunity is not maintained in l Haemophilus influenza type b (Hib): HPV vaccine includes protection against adults and children, there is a risk of re- Prior to the vaccine, Hib meningitis killed the two HPV strains that cause 70 establishment of endemic transmission. 600 children each year, and caused sei- percent of all cervical cancers. Measles is highly contagious. Each year, zures among many survivors as well as on average, 60 people in the United l Influenza: Many illnesses are permanent deafness and mental retarda- States are reported to have measles. Yet erroneously called “flu.”  These include tion. Since the vaccine’s introduction in just the first half of 2014, the United respiratory as well as gastrointestinal in 1987, the incidence of serious Hib States saw the highest number of cases disorders and can be caused by a variety bacteria infection has declined by 98 since 1994. From January through of infectious agents.  Influenza, however, percent in the United States. October 2014, more than 600 measles is a specific respiratory infection caused cases were reported in 22 states.321 l Hepatitis A: In 2011, there were 2,000 by influenza viruses.  Influenza vaccine hepatitis A infections reported in the United States.316 From 2007 to 2010, it resulted in between 70 to 100 deaths. Hepatitis A disease tends to occur in outbreaks sometimes attributed to many people having eaten the same contami- nated food, or transmission from person to person after exposure to Hepatitis A in an endemic country. CDC confirmed an outbreak of 162 people ill with Hepatitis A in the United States in 2013.317 l Hepatitis B: In the United States, an estimated 800,000 to 1.4 million people have chronic Hepatitis B virus infection. More than 90 percent of infected infants and up to 10 percent Source: U.S. Centers for Disease Control and Prevention TFAH • healthyamericans.org 77 l Meningococcal disease: Meningococcal l Pneumococcal disease: The pneumococ- l Tetanus: Commonly known as lockjaw, disease is a serious bacterial illness, cal bacterium is spread by coughing and tetanus is a severe disease that causes and is a leading cause of bacterial men- sneezing. It is the most common cause involuntary contractions of the muscles. ingitis in children 2 through 18 years of bacterial pneumonia, inflammation Tetanus bacteria grow in soil and infec- old in the United States. About 1,000 of the coverings of the brain and spinal tion is usually caused by a dirty puncture people get meningococcal disease each cord (meningitis), bloodstream infection wounds. In the United States, mortality year in the United States and 10 percent (sepsis), ear infections, and sinus infec- due to tetanus has declined at a con- to 15 percent of these people die. In- tions (sinusitis) in children under two stant rate due to the widespread use of fants, the elderly, college students living years of age. The elderly are especially tetanus toxoid–containing vaccines since in dormitories and military recruits living susceptible to this infection. There are the late 1940s. According to CDC, dur- in barracks are especially vulnerable. more than 50,000 cases per year in the ing the period 2001 to 2008, a total of United States and rates are higher among 233 cases and 26 deaths from tetanus l Mumps: Prior to the mumps vaccine, on elderly and very young infants. The fatal- were reported in the United States.325 average 200,000 mumps cases were ity rate ranges from about 20 percent to reported in the United States per year l Varicella (Chickenpox): Although 60 percent among the elderly.324 with 20 to 30 deaths. Since a second usually a self-limiting illness, varicella is dose of mumps vaccine was added to l Rotavirus: Rotavirus is a disease of the a highly contagious virus that can lead the standard childhood immunization digestive tract. Infection causes acute to severe illness with complications series, annual cases are now in the gastroenteritis (vomiting and diarrhea) such as secondary bacterial infections, hundreds rather than the thousands, but and humans of all ages are susceptible severe dehydration, pneumonia, central outbreaks still occasionally occur. to rotavirus infection. According to CDC, nervous system deficits/disease before use of a rotavirus vaccine, each year and shingles. Each year, more than l Pertussis: Also known as whooping rotavirus was responsible for more than 3.5 million cases of varicella, 9,000 cough, pertussis is highly contagious 400,000 doctor visits; more than 200,000 hospitalizations and 100 deaths are and can result in prolonged coughing emergency room visits; 55,000 to 70,000 prevented by varicella vaccination in the spells that may last for many weeks or hospitalizations; and between 20 and 60 United States.326 even months. Approximately 50 out of deaths in the United States. Rotavirus vac- every 10,000 people who develop per- l Zoster (Shingles): Zoster is a very cine now prevents an average of 40,000 tussis die from the disease. Since the painful nerve infection caused by the to 50,000 hospitalizations a year among 1980s, the number of reported pertus- same virus as chickenpox and is often children under the age of 5 years old. sis cases has steadily increased, espe- accompanied by a localized skin rash cially among adolescents and adults. 322 l Rubella: Before the rubella vaccine was with blisters and pain may persist for In 2012, a total of 41,880 cases of introduced, widespread outbreaks mostly weeks or months after the rash re- pertussis were reported to the CDC, the affected children in the 5 to 9 year age solves.327 Anyone who has ever had highest number since 1955. In 2014, group. Between 1962 and 1965, rubella chickenpox can develop shingles be- from January 1 to August 16, 17,325 infections during pregnancy were estimated cause the virus remains in the nerve cases of pertussis were reported to to have caused 30,000 still births and cells of the body after the chickenpox CDC — a 30 percent increase compared 20,000 children to be born impaired or infection clears and can emerge years with the same time period in 2013.323 disabled. Due to a successful vaccination later. The disease most commonly Young infants who die from pertussis program, rubella is no longer transmitted occurs in people 50 years and older, often may have caught the infection from year round in the United States and fewer and those with compromised immune an adult or adolescent. than 20 cases are reported every year. systems. There are approximately one Rare cases of congenital rubella syndrome million zoster cases annually; one in continue to be reported — almost all are three Americans will get shingles in acquired outside of the United States. their lifetime. 78 TFAH • healthyamericans.org 2. Curbing Antibiotic-resistant Superbugs Antimicrobial resistance presents one of the greatest threats to human health around the world. While antibiotics have been used to treat countless bacterial infections since the 1940s, over time, some bacteria have adapted so that antibiotics can no longer effectively treat them. In these cases, once easily cured infections like strep and staph can in some cases turn lethal. While antibiotic treatment is often patient safety in the United States as they appropriate and can even be are resistant or increasingly resistant to lifesaving for many types of infections, antibiotics or have become more common antibiotics are commonly being used because of widespread use of antibiotics.331 unnecessarily — often being prescribed for viruses or other ailments. Studies have demonstrated that treatment indication, choice of agent, or duration of therapy can be incorrect in up to How Antibiotic Resistance Happens 50 percent of the instances in which antibiotics are prescribed. 1. 2. 3. 4. Lots of germs. Antibiotics kill The drug-resistant Some bacteria give l One A few are drug resistant. bacteria causing the illness, bacteria are now allowed to their drug-resistance to study reported that 30 percent as well as good bacteria grow and take over. other bacteria, causing protecting the body from more problems. of antibiotics received by hospitalized infection. adult patients, outside of critical care, were unnecessary; antibiotics often were used for longer than recommended durations or for treatment of colonizing or contaminating microorganisms. Examples of How Antibiotic Resistance Spreads l Overuse increases the likelihood that drugs will be less effective when Animals get George gets antibiotics and antibiotics and needed against bacterial infections. develop resistant develops resistant bacteria in their guts. bacteria in his gut. A 2014 study in Infection Control and Hospital Epidemiology suggests that there Drug-resistant George stays at may be pervasive use of redundant bacteria can home and in the remain on meat general community. antimicrobial therapy within U.S. from animals. When not handled Spreads resistant bacteria. George gets care at a hospitals.328 CDC estimates up to or cooked properly, the bacteria can hospital, nursing home or other inpatient care facility. spread to humans. half of antibiotic use in humans and much of antibiotic use in animals is Fertilizer or water Resistant germs spread containing animal feces directly to other patients or unnecessary.329 According to a study in and drug-resistant bacteria indirectly on unclean hands is used on food crops. of healthcare providers. the New England Journal of Medicine, the Healthcare Facility rates of antibiotics prescribed per year Resistant bacteria translate to treating four out of every Drug-resistant bacteria spread to other in the animal feces can patients from Patients five Americans.330 remain on crops and be go home. surfaces within the healthcare facility. Vegetable Farm eaten. These bacteria can remain in the CDC issued an Antibiotic Resistance human gut. Threats in the U.S. 2013 report in which it Simply using antibiotics creates resistance. These drugs should only be used to treat infections. prioritized a list of 18 organisms that are CS239559 an urgent, serious or concerning threat to TFAH • healthyamericans.org 79 These are considered to be very Bacteria, co-chaired by the Secretaries Each year more than 2 million conservative estimates, since current of Defense, Agriculture, and HHS.336 Americans develop antibiotic- surveillance and data collection The President’s Council of Advisors on capabilities cannot capture the full impact. Science and Technology (PCAST) also resistant infections — and at Experts warn that antibiotic-resistance is released a report in 2014, outlining least 23,000 of these people expected to continue to grow and become recommendations around new antibiotics die as a result.332 increasingly difficult to manage. and diagnostics, surveillance and stewardship.337 Antibiotic resistance leads to more than eight million additional days Americans By 2020, federal and private partners spend in the hospital a year, costs the will aim to meet numerous goals, among country an estimated extra $20 billion in them to develop new antibiotics, to find direct healthcare costs and at least $35 alternatives to antibiotics for promoting billion in lost productivity annually.333, 334 growth in animals and to study the relationship between antibiotic use in As resistance rates continue to increase animals and antibiotic resistance.338 Economic Impact of Antbiotic Resistance in and more and more people are sickened Lost Productivity and Extra Healthcare Costs and die due to resistant infections, fewer In October 2014, the IDSA convened and fewer antibiotics are in the pipeline the inaugural meeting of the U.S. for approval, particularly to treat the Stakeholder Forum on Antimicrobial most serious and life-threatening Resistance (S-FAR), which is comprised of Lost Productivity $35 billion infections.335 Many pharmaceutical over 90 organizations, including TFAH. companies have abandoned antibiotic In years past, CDC, FDA, USDA and other research and development because they public health agencies have identified a are less profitable than drugs to treat number of strategies to reduce antibiotic chronic conditions. resistance. A federal Interagency Task Extra Healthcare Costs Force on Antimicrobial Resistance was In 2014, the White House released $20 billion created in 1999 and in 2001, they released The National Strategy for Combating A Public Health Action Plan to Combat Antibiotic Resistant Bacteria and a related Antimicrobial Resistance and updated executive order. The Strategy included the plan in 2012.339 CDC, FDA and five goals: slowing the development USDA also have been tracking antibiotic of resistant bacteria; strengthening resistance in foodborne bacteria since surveillance; advancing development of 1996 through the National Antimicrobial diagnostic tests; accelerating research Resistance Monitoring System (NARMS) of new antibiotics and vaccines; and and CDC tracks infectious diseases, HAIs improving international collaboration. and foodborne illnesses through a range The executive order established a Task of surveillance systems.340 Force for Combating Antibiotic-Resistant 80 TFAH • healthyamericans.org RECOMMENDATIONS: Reducing Antibiotic Resistance TFAH recommends policies that help together to reduce overprescribing and addition, the limited indication would curb antibiotic overuse and encourage misuse of antibiotics by tracking and help protect those new antibacterial new antibiotic development become publicly reporting prescribing data, ed- drugs from losing their effectiveness high priorities, including: ucating providers and patients about through overuse. the harm of inappropriate prescribing, Fully and rapidly implementing the 2014 l Improving surveillance: The country and providing clinical decision support Executive Order and National Strategy needs better data to monitor resis- through HIT. for Combating Antibiotic-Resistant tance patterns to inform local action Bacteria:341, 342 The Administration l Reducing overuse in agriculture: to interrupt transmission, determine should move forward with a detailed The FDA should fully implement and which interventions are working and action plan to implement the White strengthen guidance to industry re- where they can be expanded. Na- House strategies, including a multiyear garding the nontherapeutic use of tional programs to identify emerging budget plan. Next steps should include: antibiotics in food animals, such as patterns of both resistance and antibi- by eradicating inappropriate use for otic use will quantify the magnitude of l Reducing Overprescribing: CMS disease prevention, requiring real antibiotic use in the U.S. and inform should make an effective, facility- veterinary oversight on the farm and a new interventions. appropriate antibiotic stewardship system to monitor how antibiotics are program a Condition of Participation l Reducing Transmission: Improve- being used on the farm, and tracking for all CMS-enrolled facilities. Facili- ments are needed at all levels of the the impact of these policies on antibi- ties should also participate in CDC’s healthcare system from healthcare otic usage and resistance. National Healthcare Safety Network facilities to local and state health Antimicrobial Use and Resistance l Incentivizing development of new an- departments and national agencies (AUR) Module, which allows them to tibacterial drugs through BARDA and to reduce the burden of antibiotic report and analyze antimicrobial usage other mechanisms. resistant infections, including im- at their facility as part of antimicro- provements in infection control in- l FDA should be able to approve drugs bial stewardship efforts and submit frastructure as well as research into for a limited population of patients data through NHSN. Antibiotics usage novel ways to prevent transmission with serious or life-threatening infec- should be added as a National Qual- (e.g., microbiome manipulation). Co- tions and for drugs that fill an unmet ity Forum quality measure; data to ordination of efforts through regional need based upon more limited data populate such measures should be prevention programs will facilitate (e.g. smaller clinical trials). This included as a Meaningful Use require- identification of resistance problems mechanism would speed access ment for EHRs. CMS, CDC, accrediting early and enable action across the to new antibacterial drugs to the organizations, healthcare facilities spectrum of healthcare to eliminate patients who most need them. In and medical organizations must work transmission and reduce infections. TFAH • healthyamericans.org 81 ANTIBIOTIC RESISTANT THREATS IN THE UNITED STATES, 2013 – CDC’S REPORT AND PRIORITIZATION OF THREATS343 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 contaminated device Bloodstream infections from CREs can result in Enterobacteriaceae (CRE) 600 deaths or when patient is on a prolonged course of antibiotics death rates as high as 50 percent. Can also cause as part of their care. CDC classifies as urgent because urinary tract infections, pneumonia, inter-abdominal CREs can spread quickly and resistance to carbapenems abscesses, and other forms of infection. is particularly worrisome, as one of the most powerful, “last resort” 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. May facilitate transmission and acquisition to ceftriaxone (the currently of HIV. used form of treatment) Clostridium difficile 250,000 infections per Infection often develops while individual is taking Can cause life-threatening diarrhea or colon year requiring or during antibiotics for other care. inflammation. hospitalization; 14,000 deaths SERIOUS THREAT LIST Multidrug-resistant 7,300 multi-drug; Healthcare-associated – often among critically ill Pneumonia or bloodstream infections. Acinetobacter 500 deaths patients. 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 – related to prior use of Urinary tract infections, bloodstream infections; (a fungus) 200 deaths fluconazole bloodstream infection related to this fungus is fourth leading form of HAI Extended spectrum 26,000; Often healthcare-associated — either spread between Can lead to bloodstream and other forms of infection. ß-lactamase producing 1,700 deaths patients on equipment or related to prior antibiotic use Enterobacteriaceae (ESBLs) Vancomycin-resistant 20,000; Often healthcare-associated – resistant to vancomycin, Bloodstream, surgical site and urinary tract infections. Enterococcus (VRE) 1,300 deaths one of the antibiotics of ‘last resort’. Multidrug-resistant 6,700; Healthcare-associated – either spread between patients Bloodstream, urinary and surgical site infections and Pseudomonas aeruginosa 440 deaths on equipment or related to prior antibiotic use pneumonia. Responsible for 8 percent of all HAIs. 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, 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. Often spread wound infections to pneumonia and bloodstream (MRSA) between patients in healthcare settings, although about infections to sepsis and death. one third acquired outside of healthcare settings 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 related to excessive Can lead to bloodstream infections, pneumonia, Staphylococcus aureus (VRSA) prior use of antibiotics, often in patients with chronic wounds heart valve infections, and bone infections. 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. 82 TFAH • healthyamericans.org D. Additional Persistent — Under Addressed — Infectious Threats Attention to emerging threats often overshadows persistent infectious disease threats. Despite the fact that they endanger the health of Americans and cost billions in healthcare and economic losses, there is a sense of complacency around diseases like HIV/AIDS, viral hepatitis, a resurgence of TB and foodborne illnesses. Even though they are largely preventable, they remain persistent problems. A renewed sense of urgency and the updating of strategies could significantly reduce the threats these diseases pose. 1. Ongoing Crises in Sexually Transmitted Infections and TB There are nearly 20 million new l Drug-Resistant Gonorrhea: More sexually transmitted infections in the than 330,000 Americans are infected United States each year. Half of these with gonorrhea each year.346 One- are among individuals ages 15 to 24. third of cases are drug-resistant and Overall, around 110 million Americans there is only one drug regime that is have some form of STI. They can have still recommended for treating the serious health consequences, including infection. Despite revised guidance risk for reproductive health problems, and adherence to treatment helping such as infertility and some forms of to reduce the number of cases of the cancer. STIs cost around $16 billion in disease last year, CDC continues to direct healthcare spending annually.344 warn that the potential for gonorrhea STIs can include HIV/AIDS, viral to become untreatable in the near hepatitis, chlamydia, gonorrhea, syphilis, future remains real.347, 348 human papillomavirus, herpes simplex CDC recommends that sexually active virus and trichomoniasis. men and women under 25 years old and Regular screening is important Misperceptions and effective treatments older individuals with risk factors, such as for both prevention — to help have contributed to diminished interest having multiple sex partners, be screened avoid the spread to others — and and resources devoted to prevent and at least annually for chlamydia and control these diseases, but they remain gonorrhea, and that all pregnant women ensuring timely and effective serious health threats — and many also should be screened for syphilis, chlamydia, treatment of these diseases. represent growing or renewed concerns. and, in women at risk, gonorrhea to For instance: ensure they do not spread infections to their babies. HPV vaccinations are also l HIV/AIDS and syphilis: Rates recommended for all teenage and young have been rising sharply among men and women. CDC also recommends young gay men in the past several annual screening of sexually active men years — reflecting problems of who have sex with men for syphilis, utilizing effective control measures, urethral and rectal gonorrhea and misinformation and complacency.345 TFAH • healthyamericans.org 83 chlamydia, and pharyngeal gonorrhea, These diseases can also co-exist, as appropriate. More frequent STD contribute to the susceptibility of other screening at three and six month intervals diseases and worsen symptoms of diseases. is indicated for high risk MSM. For instance, of Americans living with HIV, 25 percent are also co-infected with It is also important to consider public HCV and 10 percent are co-infected with health strategies for HIV/AIDS, viral HBV, and HIV is one of the biggest risk hepatitis, STIs and TB collectively, since factors for progression of TB, while TB they have some overlapping at-risk accelerates HIV progression.349, 350 populations, including racial and ethnic minorities. Populations at risk for HIV, Prevention through safe sex and condom viral hepatitis and STIs include MSM use, syringe exchange programs and and injection drug users — and most routine screening can help identify those STIs have similar prevention strategies. in need of treatment and help prevent Persons at high risk for TB include people the additional spread of the diseases and born outside the United States, racial and ensure those who need treatment receive ethnic minorities, persons experiencing appropriate care and services.351, 352 In homelessness, incarceration, substance addition, providing treatment to those and alcohol abuse and people who have who have HIV is one of the most effective weakened immune systems from HIV/ ways to limit the continued spread of the AIDS, diabetes and other conditions. disease to others. Source: U.S. Centers for Disease Control and Prevention 84 TFAH • healthyamericans.org HIV/AIDS Successful treatment regimens have led An individual can become infected with to complacency and a belief that HIV/AIDS HIV in several ways, including unprotected is under control. But, more than 1.2 sex; transfusion of infected blood; million Americans are living with HIV/AIDS, transmission through needle sharing and and about one in six do not know or accidental needle sticks; re-use of they are infected. 353 And there is a sharp syringes in a medical setting, especially rise in new infections among gay men — where the medical infrastructure is accounting for the majority of the nearly lacking; or transmission from mother to 50,000 new HIV diagnoses in 2012.354 child during pregnancy, delivery, or through The risk is even more acute for gay men of breast feeding.360 In rare cases, the virus color, with Blacks representing nearly half may be transmitted through organ or of Americans living with AIDS, and Black tissue transplants or unsterilized dental or men, particularly young gay Black men surgical equipment. (ages 13 to 24), are at the highest risk for new HIV infections. Infections among Some significant federal initiatives to young gay men increased by 22 percent combat HIV/AIDS include: from 2008 to 2018 and by 48 percent l NIH conducts ongoing research to among young gay Black men.355 advance treatments for HIV/AIDS and to l Behavioral risks alone do not account for try to develop a vaccine, microbicides, the disproportionately high new HIV infec- new treatments, behavioral and social tions among Black gay men. A review of science prevention interventions and 53 studies found that key risk factors were strategies to limit the spread of the comparable or lower compared to White disease through better treatment.361 MSM. Other factors, such as the legacy of l The Division of HIV/AIDS Prevention higher infection rates among Blacks in the (DHAP) at CDC supports a range of earlier years of the epidemic, less frequent prevention, control and surveillance use of available treatment and higher programs.362 rates of individuals who do not know they are infected (e.g., have not been screened l In 1990, the Ryan White AIDS for HIV), exacerbate the trends. 356 Resources Emergency Care Act (now the Ryan White HIV/AIDS Treatment Worldwide, an estimated 35 million people Extension Act of 2009) was enacted as are living with HIV/AIDS, nearly half of the largest federally funded program whom are women.357 And though the for people in the United States living spread of the virus has slowed in some with HIV/AIDS. The program has countries, it has escalated or remained provided at least some level of care steady in others.  Since the epidemic for around 500,000 Americans each began, more than 36 million people have year as a “payer of last resort” to died due to AIDS (the most advanced fund treatment and support services stage of HIV).358  More than 2.1 million when no other resources are available, people were newly infected with HIV and including for drug therapy.363 1.5 million died in 2013 alone.359 TFAH • healthyamericans.org 85 U.S. Youth 2014 Youth make up 6% of the more than 1 million people in the U.S. living with HIV. Schools have direct contact with 50 million youth and play an essential role in helping youth make healthy choices. School programs are vital to achieving an HIV-free generation. l In 2003, the President’s Emergency Plan for AIDS Relief was launched, committing $15 billion over 5 years to combat global HIV Rates Among Youth HIV/AIDS. In 2008, PEPFAR funding was increased to $39 billion over 5 years, including $4 billion in funding to fight TB 12,000 and $5 billion to fight malaria. In 2013, the one-millionth baby new HIV cases among youth aged 13-24 years in 2010 1allin 4 of new born HIV-free due to PEPFAR’s efforts to curb mother-to-child transmissions was announced on the tenth anniversary of the program.364 In 2012 alone, the program supported antiretroviral HIV infections treatment for nearly 5.1 million people and HIV screening and counseling for more than 49 million people in 15 target countries 57% African American in sub-Saharan Africa, Asia and the Caribbean.365, 366 20% Latino l In 2010, a National HIV/AIDS Strategy was issued, focusing on 20% White domestic policies to reduce new infections, disparities and health 3% Other inequities, increase access to care, improve health outcomes and Among male youth, achieve a more coordinated response to the HIV epidemic.367 83% approximately male 17% female 87% of new HIV infections were from l In 2012, HHS released an updated Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents, which included a new recommendation of treatment of all male-to-male sexual contact people with HIV as important not just for treatment but also for Vital Signs: HIV Among Youth in the US, 2012 preventing secondary transmission of HIV.368 l In 2013, President Obama issued an executive order creating an HIV Care Continuum Initiative within the United States “to be overseen by the Director of the Office of National AIDS Policy. Risky Health Behaviors The Initiative will mobilize and coordinate Federal efforts in response to recent advances regarding how to prevent and treat Of high school students in 2013: HIV infection. The Initiative is supporting further integration of HIV 47% 15% have ever had sex have had sex with 4+ people prevention and care efforts; promoting expansion of successful HIV testing and service delivery models; encouraging innovative approaches to addressing barriers to accessing testing and (during their lifetime) treatment; and ensuring that Federal resources are appropriately focused on implementing evidence-based interventions that improve outcomes along the HIV care continuum.”369 34% 41% l In 2014, the U.S. Public Health Service released the first and of these... comprehensive guidance on the use of pre-exposure prophylaxis are currently sexually active did not use a condom (PrEP) — to promote regular use of anti-retroviral drugs by (have had sex during previous the last time they those who are not infected with HIV can prevent transmission 3 months) had sex from an infected partner. PrEP is considered to be a powerful National Youth Risk Behavior Survey, 2013 prevention tool and has been shown to reduce the risk of HIV infection in people who are high risk by more than 90 percent, Source: U.S. Centers for Disease Control and Prevention when taken consistently.370 HIV Education & Testing Of high school students in 2013: 85% had ever been 86 TFAH • healthyamericans.org taught in school about AIDS or HIV infection RECOMMENDATIONS: HIV/AIDS Prevention and Control For decades, the country has approached l Supporting “treatment as prevention” l Removing all restrictions on needle the HIV/AIDS epidemic focused on individ- strategies: Recent studies have shown exchange programs – and support ual behavioral risk, but the research shows that HIV-positive individuals with full syringe public safety campaigns and that is only one part of the equation. viral suppression are far less likely to syringe exchange programs to help transmit HIV infection, while modeling prevent HIV and viral hepatitis: In ad- More effective strategies include focus- studies have demonstrated the dition, there should also be increased ing on improving the overall wellbeing potential for “treatment as prevention” state, local and private support for and health of members of the lesbian, or “test and treat” initiatives in syringe exchange programs and cam- gay, bisexual and transgender (LGBT) combination with other approaches to paigns to inform the public about the community — developing supportive dramatically slow the HIV epidemic.373 effectiveness of syringe exchange and respectful policies that help reduce These strategies can only be successful programs for limiting the spread of stigma, discrimination and bullying.371 if individuals know their HIV status and HIV/AIDS, HBV and HCV, including Some key recommendations from receive full treatment. for protecting first-responders and TFAH to better prevent and control healthcare workers. Needle exchange l Routine screening for all sexually HIV/AIDS include: programs have been shown to be one transmitted infections, as of the most effective, scientifically l Implementing traditional risk reduc- recommended by the U.S. Preventive based methods for reducing these tion efforts: This includes 1) reducing Services Task Force. diseases and have been endorsed HIV risk behaviors, particularly through l All state Medicaid programs should by leading scientific organizations, condom use, and 2) learning HIV sta- cover routine screening of HIV, re- including the IOM, WHO, AAP the , tus since research shows that those gardless of risk (consistent with CDC American Medical Association (AMA), who are aware of their infections en- and USPSTF guidelines). the American Nurses Association gage in less risky behavior.372 These (ANA), and the American Public Health interventions are essential, but are l Promote the use of and insurance cov- Association (APHA).375, 376 Alternative also “inherently limited.” erage of PrEP for high-risk individuals. approaches to needle exchange, such l Focusing on the overall wellness of l Reassessing sexual risk reduction as disinfection and decontamination gay men: Programs must focus on im- guidelines in light of treatment as pre- and outlawing the sale of needles, proving the health and wellbeing of gay vention and pre-exposure prophylaxis: have been shown to be much less men generally, and specific interven- CDC should release revised guidelines effective.377 Many needle exchange tions must help HIV-positive gay men to assist individuals in assessing programs often also work to target learn their status, connect to appropri- their risk in the context of these new the underlying problems of drug use ate healthcare services, stay in care treatment and chemoprophylaxis ap- by providing and/or referring individu- and maintain treatment adherence and proaches to match the most recent evi- als to substance abuse treatment or prevent transmission to others. Young dence-based epidemiological data.374 other health and social services. Hun- gay men must be a priority. Particular dreds of scientific studies have been l Coordinating prevention strategies focus is needed on behavioral health conducted that have found needle and treatment when appropriate for issues faced by gay men that affect HIV exchange programs can help to reduce HIV/AIDS, hepatitis and TB: Since risk taking and adherence to treatment HIV transmission and do not promote the at-risk populations often overlap if HIV infected. These have been de- illegal drug use. There is also evi- for the conditions, it is important to scribed as syndemics — co-occurring dence that needle exchange programs coordinate strategies, surveillance and challenges that gay men (and others do not increase unsafe disposal of treatment programs for the conditions, face), including high rates of mental unused syringes among participants in which also helps more efficiently use health problems, substance abuse, those programs.378 available resources. stigma and other negative experiences. TFAH • healthyamericans.org 87 Hepatitis B and C Around five million Americans have HBV 2 percent (31) of these Baby Boomers or HCV, but between 65 percent and 75 were screened for HCV.383 percent do not know they have them.379 l Breakthroughs in treatments for HCV As they age, they are at risk for develop- have dramatically increased cure rates ing serious liver diseases or cancer un- — and is particularly more effective less they receive treatment. Two-thirds in treatment of Blacks with HCV, but it of those with HCV are Baby Boomers has a relatively high cost — $1,000 a and one in 12 Asian Americans has HBV. day.384 In 2014, FDA approved a new An independent Milliman report found drug called Harvoni®, which is expected total medical costs for HCV patients to be more effective that previously could more than double over the next 20 available options but is also forecasted years — from $30 billion to $80 billion to have a high cost.385, 386 A new drug per year.380, 381 called Sovaldi® had a 95 percent cure l In 2013, USPSTF recommended routine rate for HCV in clinical trials. These new one-time HCV screening of individuals treatment options offer the potential to born between 1945 and 1965 for the end the epidemic. first time, which means the test is now lA recent national rise in heroin use — re- available to these individuals who are lated to the increase in prescription drug enrolled in new group or individual health abuse and individuals using heroin as an insurance, Medicare or Medicaid Expan- alternative — and exposure while receiv- sion programs with no cost-sharing.382 ing healthcare treatment have contributed A 2013 study of 1,578 patients born to the growth of new HCV infections.387 between 1945 and 1965 found that only Source: U.S. Centers for Disease Control and Prevention Reported Number of Acute Hepatitis C Cases United States, 2000–2012 3,500 3,000 2,500 Number of cases 2,000 1,500 1,000 500 0 10 06 12 02 00 08 04 20 20 20 20 20 20 20 Year Source: National Notifiable Diseases Surveillance System (NNDSS) 88 TFAH • healthyamericans.org RECOMMENDATIONS: Preventing and Controlling Viral Hepatitis Health reform combined with new scientific advances provide the chance to dramatically improve hepatitis prevention, help identify people who do not know they are infected for earlier treatment and treat people in the most effective ways possible. TFAH recom- mends a comprehensive strategy be carried out to better prevent, control and treat hepatitis, including: l Ensuring everyone who is diagnosed and should receive their full course of strategies to reduce the disparities receives appropriate care: Every three vaccinations on schedule. including a Black-specific campaign person diagnosed with HBV or HCV to created awareness about the risks l Promoting hepatitis A vaccination should have access to and receive a associated with HCV infections and for at-risk populations: Americans standardized level of care and receive providing adequate education and traveling abroad to certain countries support services. CMS and Medicaid training to providers of all races and where hepatitis A is more prevalent, programs should take the lead in ensur- ethnicities about racial disparities in gay men, drug users and other at-risk ing patients receive the most effective HCV epidemiology, clinical course and populations should be routinely vac- treatments available and removing treatment outcomes and barriers to cinated against hepatitis A. discriminatory coverage rules for HCV care and treatment.388 Similarly, Asian treatment, such as denying treatment l Making hepatitis B and C screen- American and Pacific Islanders (AAPIs) based on behaviors or inappropriately ing routine and active: HBV and make up 50 percent of the U.S. popu- limited the types of providers who can HCV screenings should be regularly lation with chronic HBV, but most are prescribe HCV treatments. Payers, drug conducted for at-risk groups, including unaware of their status, resulting companies, and government agencies Baby Boomers, as recommended by in HBV-related death rates 7 times should address barriers to treatment. the USPSTF. HBV vaccination should greater among AAPIs than among Mechanisms should be explored for be the standard of care in the re- Whites.389 HHS and its community covering the costs of new treatments, formed health system. Doctors and partners should expand access to cul- such as the expansion of the Ryan other healthcare providers should be turally appropriate education, screen- White AIDS Drug Assistance Program educated about the at-risk populations ing, testing, and referral to treatment. (ADAP) to cover HVC for individuals who and appropriate health measures l Investing in biomedical, behavioral are not also living with HIV/AIDS. should be taken to prevent perinatal and health services research and transmission from infected mothers to l Promoting universal HBV vaccination: development: The investment in their newborns.  Individuals with HBV HBV vaccinations have helped reduce hepatitis-related biomedical and be- and HCV need to be identified early to rates of infection by around 80 percent, havioral research must be significantly move them into care and healthier be- but around 10 percent of infants still increased including support for un- haviors even before treatment begins, do not get vaccinated and adults who derstanding the differential impact of and Medicare should more fully em- came of age before the vaccine was treatment among certain populations, brace a wider range of providers. available in 1982 or were born abroad improving screening and diagnostic where the vaccine is not widely used l Reducing disparities: The National tools, and for new and better vaccines. should also be vaccinated. All new- Medical Association studied the dis- Research support should be more pro- borns should receive their first HBV proportionate impact of HCV among portionate to the public health threat vaccination within 12 hours of birth Blacks and supported a number of associated with hepatitis. TFAH • healthyamericans.org 89 Tuberculosis Globally, an estimated 8.9 During the 1970s, rates of TB cases had infections) are not contagious. One in million people develop active greatly declined (from more than 84,000 10 people infected with TB bacteria de- tuberculosis each year, and 1.5 cases to just over 22,000). This led to velops active TB. These rates are higher, a sense of complacency that allowed the however, for individuals with compromised million die from TB.393 deterioration of TB control programs.390 immune systems or that have other under- However, the country experienced a resur- lying health conditions, such as diabetes. gence of the disease in the mid-1980s and ACIP and the Health Resources and Ser- early-1990s with the emergence of drug- vices Administration (HRSA) recommend resistant TB, the emergence of HIV/AIDS routine TB testing for children at high risk and changing immigration patterns with for TB, but there currently is not a recom- more people arriving from countries with a mendation for routine screening for at-risk high TB burden.391 After significant and ded- adults by ACIP, HRSA or USPSTF.394 icated funding was provided at the federal, state and local levels to support improve- People who are at-risk for TB include those ments in treatment, case finding, labora- who do not receive regular or high-quality tory capacity, and infrastructure, the United healthcare, including people who are States was able to regain control from the homeless, foreign-born, incarcerated or resurgence, and cases again declined. co-infected with other conditions. People with weakened or compromised immune Increased resources and a concerted public systems, individuals with HIV or other health campaign helped lead to declines Over 5% in TB from 1993 to 2013, but TB remains immune-compromised conditions (diabetes, arthritis), those receiving chemotherapy, of the people who develop a threat. There were 9,582 TB cases pregnant women and young children, includ- active TB each year will reported in the United States in 2013 ing infants (under 12 months old), are at a die from it. (3 cases per 100,000 people), with 65 much greater risk for developing active TB percent of cases occurring in foreign-born disease. TB’s most common co-infection patients.392 Rates were highest among is HIV. People with HIV are four times more Asian Americans (18.7 cases per 100,000 likely to contract TB.395 Policy makers and people). Foreign-born persons and public health officials were slow to mobilize racial/ethnic minorities are disproportion- a response to the HIV-TB co-epidemic that ately affected. The declining number of TB began in sub-Saharan Africa in the 1990s. cases masks the increasing complexity of the cases being reported. There are high Prior to the ACA, states had the option of numbers of cases with co-morbid conditions adding diagnosed TB patients to Medic- (HIV/AIDS and other immune-compromising aid.396 The covered TB-related services conditions), increases in multidrug-resistant include prescribed drugs, physician’s or extremely drug-resistant cases requiring services, lab and x-ray services, clinic and longer, more toxic and more expensive treat- Federally Qualified Health Center services, ment regimens and cases with significant case management services and other ser- socio-economic challenges. vices such as those designed to encourage completion of outpatient regimens, includ- The infection is common — about one- ing directly observed therapy (DOT) — the third of the human population is infected recommended standard of care where with TB, with one new infection occurring healthcare professionals watch to make each second, but most cases of this TB sure a patient is taking all of their treat- infection (often referred to as “latent” 90 TFAH • healthyamericans.org ment medication. Nine states have elected but are in plans with high deductibles, it can for diagnosing TB — along with signifi- to provide this Medicaid waiver/expansion. lead to delays or avoidance of care, inability cant increases in costs of medications, There is receipt of matching federal dollars to afford medications and delays in diagnos- budget cuts and hiring freezes — have for treating these TB patients. However, tic testing. In addition, the ACA benefits are impacted the capacity of state and local even with the ACA in effect, many individu- generally not available to undocumented TB programs. Weakened programs have als are still uninsured or fall outside of the immigrants, who represent a high-risk group compromised the ability of many states to system of receiving routine medical care or for TB but may not seek or receive care be- conduct investigations to track down con- attention, so there is a continued role for cause of this gap. Patients with active TB tacts TB patients may have had, to test public health agencies to provide access to who do not receive appropriate care are at for and treat TB infections and to provide care and treatment, in addition to conduct- risk to spread the disease to others. directly observed therapy treatment. ing surveillance, contact tracing, outreach Most strains of TB can be treated with The non-adherence rates and medication and education. Since treating TB is compli- drug therapy, but it is imperative that peo- shortages combine to exacerbate even cated and long, most states rely on public ple finish the medicine and take the drugs more resistance development and future health experts to provide care rather than exactly as prescribed. It usually involves outbreaks. within the mainstream healthcare system. a regimen of drugs taken for six months to However, even in states that elect to add There has been a growth in not only drug- two years depending on the type of infec- TB patients to Medicaid, the majority of TB resistant TB, but extremely drug resistant tion. The treatment is long and intense in care is provided by health departments. (XDR) TB. Patients with XDR TB are left duration and is often difficult for patients The health departments then pay the costs with treatment options that are much less to tolerate, which can contribute to non- of care, including drugs and intensive case effective and considerably more expen- adherence. If patients stop taking the management (often including staff- and sive. Between 1993 and 2011, 63 cases drugs too soon or do not take the drugs time-intensive DOT). Many states are not of XDR TB have been reported in the correctly, they can become ill again and able to recover these costs, since many United States.397 Treatment for multidrug- the infection may become drug resistant. states lack the capacity to set up billing resistant TB (MDR-TB) costs an average systems or lack the legal authority to bill In recent years, severe shortages of medi- of $131,000, compared with $17,000 to insurers. For TB patients who are covered cations and antigen used in skin tests treat drug-susceptible TB.398 TB and Diabetes The rising co-epidemic of TB and diabetes population has latent TB. For most peo- — a unique partnering of an infectious dis- ple, the disease remains dormant. How- Doctors and public health ease and a chronic disease — is gaining ever, as the number of cases of diabetes workers may have to shift attention worldwide. Research shows that increase and immune systems weaken, diabetics are two to three times more likely these latent infections could progress into their thinking, given that to contract TB, due to a weakening of the active TB in alarming numbers — poten- infectious diseases and non- immune system. Diabetics are also more tially reversing much of the progress made communicable diseases are likely to die of TB, are infectious longer and in combatting TB.401 often siloed.403 relapse is more common. In addition, the Experts say that bi-directional screening of drugs that treat each disease interfere with people living with TB for diabetes and peo- one another, complicating disease control.399 ple living with diabetes for TB is essential, Worldwide, there were 390 million diabet- and India was the first country to create a ics in 2013 and cases are projected to ap- national policy of addressing the diseases proach 600 million by 2035. 400 In 2013, simultaneously after discovering high rates 1.5 million people died from TB. Further, of diabetes among TB populations.402 it is estimated that one-third of the world’s TFAH • healthyamericans.org 91 RECOMMENDATIONS: Toward Eliminating TB in America The resurgence of the disease is par- l Ensuring quality control in TB treat- ment should explore incentives for ticularly troubling since TB is treatable, ment: Treating TB is an intensive and private companies to produce these curable and preventable. TB, once largely long process. It requires patients to drugs. This includes basic science re- controlled in the United States, dispropor- take a full course of their medicine pre- search to understand the host-organ- tionally affects Americans living in poverty cisely as prescribed through DOT, and ism response as well as for research and those with HIV/AIDS who are at often requires providing wrap-around to shorten treatment, produce less higher risk for the disease. Now there are services for lower-income patients, toxic medications and combinations of antibiotic-resistant forms of the disease.  particularly since they often need to be drugs for new regimens. TFAH consulted with a set of TB control isolated for periods of time to stop the l Encouraging all states to participate experts to identify key recommendations spread of the disease and are not able in the TB Medicaid waiver/expan- for curbing a future resurgence of TB in to sustain employment. Private health- sion: All states have the option of the United States, which include: care providers and insurers should being able to add all TB patients to enter into contracts and arrangements l Fully funding TB control programs: their Medicaid program and receive with TB public health programs to refer The resurgence of TB in the mid-1980s federal matching support. As of patients to experts in TB care, since shows the need for continued vigilance. 2013, there were nine states reported improper care can exacerbate the de- TB control efforts require strong sur- to be participating.404 velopment of additional drug-resistant veillance for individuals and clusters cases or forms of the disease or lead l Supporting routine screening and di- of the disease, infection control pro- to the patient becoming ill again. Pub- agnostics for target high-risk groups: grams in communities with outbreaks lic health departments should be able CDC should work with the USPSTF to and ensuring infected patients receive to bill a patient’s insurance company assess the value of routine screening full and complete treatment, which is for direct service treatment costs. of TB for target at-risk groups.  If sup- important not only for their care but ported by the USPSTF, screening would for helping to limit the transmission l Addressing the TB drug costs and be a mandated benefit offered to of the disease. States should ensure shortages and biologics shortages: Americans with new group and individ- routine screenings in correctional facili- The shortage of treatment medication ual plans and those covered by Medic- ties and also consider TB screening and biologics used to diagnose TB in- aid expansion with no-copayments.405 for international college students. At fection and the growing cost of TB treat- the federal level, consideration should ment drugs is harming not only the care l Requiring no-cost-sharing treatment be given to expanding the screening, for individuals but also control efforts for TB patients by public and private and requirement for treatment, of inter- in states. Ensuring sufficient quanti- payers: Given the public health threat nationals seeking work visas or other ties, adequate supplies of TB biologics of TB patients spreading the disease to longer-term stays within the United (Tubersol and Aplisol) and payment for others, it is essential that all diagnosed States. Additionally, plans, procedures drugs are essential for effective TB patients receive high-quality care. and sufficient fiscal resources should control and monitoring of outbreaks and l Providing adequate federal, state and be in place to ensure the timely and co- diagnosing new infections. local support for TB prevention and ordinated management by the Immigra- l Supporting research and development control: Some states have reduced or tion and Customs Enforcement (ICE), of new treatments for TB: Drug treat- eliminated state contributions to the CDC and state and local health officials ments for TB have not advanced signif- TB control program, relying exclusively in order to ensure proper care when icantly in decades. Resources should on the federal monies provided by TB-infected individuals transition from be devoted to increased research for CDC. TB control is largely local and being a federal responsibility when they improved and alternate ways to treat federal funding alone is not sufficient seek and are granted asylum. the disease, and the federal govern- to control — and prevent — TB. 92 TFAH • healthyamericans.org 2. Fixing Food Safety Nearly all foodborne illnesses could be direct medical costs annually and the num- According to a study by the Center for Sci- avoided with a stronger U.S. food safety ber of infections has not decreased in the ence in the Public Interest (CSPI), 10 foods system. There are around 48 million past 15 years. 411 From March 2013 through regulated by the FDA account for almost 40 cases of illness each year, with 1 mil- July 2014, there were 634 cases across percent of all foodborne outbreaks since lion resulting in long-term complications, 29 states of multidrug-resistant Salmonella 1990. The list includes 1) leafy greens; 28,000 leading to hospital visits and Heidelberg infections linked to Foster Farms 2) eggs; 3) tuna; 4) oysters; 5) potatoes; 3,000 resulting in death. 406, 407 chicken. Thirty-eight percent of patients re- 6) cheese; 7) ice cream; 8) tomatoes; 9) quired hospitalization.412 sprouts; and 10) berries.417 The estimates of the economic costs of foodborne illnesses range from $15.6 to According to CDC, produce causes the most In 2014, FDA re-released proposed $77 billion annually in medical costs and illness (46 percent), but meat and poultry rules implementing portions of lost productivity.408, 409 Major outbreaks cause the most deaths (29 percent).413 the Food Safety Modernization Act can also contribute to significant economic Norovirus is the leading cause of illness (FSMA), including Produce Safety, losses in the agriculture and food retail from contaminated food in the United Preventive Controls for Human and industries, which account for approximately States.414, 415 Foodborne norovirus out- Animal Foods, and the Foreign Supplier 13 percent of the U.S. GDP and are the larg- breaks result most commonly from handling Verification Program.418 The changes est industries and employers in the United of ready-to-eat foods by infected individuals, added flexibility and broadened some States.410 Salmonella infections alone are but can also occur due to use of fecally con- exemptions for small producers. responsible for an estimated $365 million in taminated water during production. 416 Source: U.S. Centers for Disease Control and Prevention TFAH • healthyamericans.org 93 RECOMMENDATIONS: Fixing Food Safety To improve food safety in the United Modernization Act implementation States, TFAH recommends: efforts and priorities.419 In the lon- ger term, the Administration should l Fully funding and implementing the develop a plan with a set timeline Food Safety Modernization Act: FDA for how to restructure food safety should ensure public health is the functions across the federal govern- top priority as it finalizes and imple- ment into a single, unified food safety ments FSMA prevention rules. FDA agency to carry out a prevention- should also track implementation of focused, integrated strategy. This these rules to ensure that proposed same type of coordinated, cross-gov- exemptions do not increase risk from ernmental approach to food safety is foodborne illness. Sufficient funding also needed within each state. should be devoted at the federal and state levels to be able to implement l Improving surveillance of foodborne and enforce the law. illnesses: Currently, foodborne ill- nesses are radically underreported in l Improving enforcement and inspec- the United States and the quality of tion capacity: FDA should work with reporting varies dramatically by state. states to ensure they are ready to New standards and requirements enforce FSMA regulations, develop an should be put in place to incentiv- operational strategy and ensure com- ize states to improve reporting and pliance across states. penalize states for underreporting. l Moving toward a unified government Surveillance for foodborne illness out- food safety agency: The government breaks should be fully integrated with currently does not have a coordi- other HIT systems, which will help nated, cross-governmental approach improve tracking and identification to food safety. Right now, food safety of the scope of problems as well as activities are siloed across a range sources of outbreaks. FDA and CDC of agencies, and many priorities and should also have a plan for requiring practices are outdated. In 2014, FDA clinics to send cultures from rapid released a Food and Feed Program response tests showing problems to Action Plan as a framework to help public health labs to allow for subtype realign operations. Each year the Of- pathogen testing.420 fice of Regulatory Affairs (ORA), the l Preventing the tainting of food by Center for Food Safety and Applied environmental contaminants: Mea- Nutrition (CFSAN), the Center for sures should be implemented to Veterinary Medicine (CVM) and the prevent the tainting of food by envi- Office of International Programs (OIP) ronmental contaminants, such as ar- will identify deliverables to be ac- senic, lead and untreated sewage or complished that year.  The FY 2015 manure that enter waters and pollute objectives and deliverables align with crops downstream. and promote the FDA food Safety 94 TFAH • healthyamericans.org State Public APPENDIX A State Public Health Budget Methodology TFAH conducted an analysis of state only general revenue funds were used in Health Budget spending on public health for the last budget cycle, fiscal year 2013-2014. For order to separate out federal funds; these exceptions are also noted. Methodology those states that only report their budgets in biennium cycles, the 2013-2015 period Because each state allocates and reports its budget in a unique way, Appendix A (or the 2014-2016 and 2013-2014 for comparisons across states are difficult. Virginia and Wyoming respectively) This methodology may include programs was used, and the percent change was that, in some cases, the state may calculated from the last biennium, 2011- consider a public health function, but 2013 (or 2012-2014 and 2012-2013 for the methodology used was selected to Virginia and Wyoming respectively). maximize the ability to be consistent This analysis was conducted from across states. As a result, there may be September to October of 2014 using programs or items states may wish to be publicly available budget documents considered “public health” that may not through state government web sites. be included in order to maintain the Based on what was made publicly comparative value of the data. available, budget documents used Finally, to improve the comparability included either executive budget of the budget data between FY 2012- document that listed actual expenditures, 2013 and FY 2013-2014 (or between estimated expenditures, or final biennium), TFAH adjusted the FY 2013- appropriations; appropriations bills 2014 numbers for inflation (using a enacted by the state’s legislature; or 0.9778 conversion factor based on the documents from legislative analysis offices. U.S. Dept. of Labor Bureau of Labor “Public health” is defined to broadly Statistics; Consumer Price Index Inflation include all health spending with the Calculator at http://www.bls.gov/cpi/).   exception of Medicaid, CHIP, or After compiling the results from this comparable health coverage programs online review of state budget documents, for low-income residents. Federal TFAH coordinated with the Association funds, mental health funds, addiction of State and Territorial Health Officials or substance abuse-related funds, WIC (ASTHO) to confirm the findings with funds, services related to developmental each state health official.  ASTHO disabilities or severely disabled persons, sent out emails on November 4, 2014 and state-sponsored pharmaceutical and state health officials were asked to programs also were not included in order confirm or correct the data with TFAH to make the state-by-state comparison staff by December 1, 2014.  ASTHO more accurate since many states receive followed up via email with those state federal money for these particular health officials who did not respond by DECEMBER 2014 programs. In a few cases, state budget the December 1, 2014 deadline.  Twenty documents did not allow these programs, states (AL, CA, CO, DC, FL, ID, IL, KS, or other similar human services, to be LA, ME, MD, MA, MI, NM, NY, OK, disaggregated; these exceptions are PA, SD, UT and WV) did not respond noted. For most states, all state funding, by December 12, 2014 when the report regardless of general revenue or other went to print. These states were assumed state funds (e.g. dedicated revenue, fee to be in accordance with the findings. revenue, etc.), was used. In some cases, 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 months + Summary (2013) Series (2013) (4+DTaP) (2013) (2013-2014) Appendix B Alabama 78.5% (+/- 7.6) 84.0% (+/- 7.3) 39.6% (+/- 9.0) 48.3% (+/- 2.3) Alaska 67.1% (+/- 6.6) 75.5% (+/- 6.1) 27.1% (+/- 8.2) 41.7% (+/- 2.2) Arizona 66.6% (+/- 7.7) 76.6% (+/- 6.6) 37.4% (+/-9.2) 38.5% (+/- 1.8) Arkansas 60.6% (+/- 8.8) 74.3% (+/- 8.3) 24.4% (+/- 8.0) 49.7% (+/- 2.4) California 72.6% (+/- 7.6) 83.1% (+/- 6.4) 45.8% (+/- 10.2) N/A Colorado 70.3% (+/- 6.9) 81.2% (+/- 6.0) 39.1% (+/- 8.7) 51.8% (+/- 1.4) Connecticut 79.1% (+/- 6.8) 88.0% (+/- 5.9) 40.1% (+/- 9.1) 51.8% (+/- 2.4) Delaware 74.8% (+/- 6.4) 87.9% (+/- 5.0) 51.7% (+/- 8.9) 50.0% (+/- 2.4) D.C. 78.9% (+/- 7.1) 86.2% (+/- 5.8) 30.2% (+/- 12.3) 47.3% (+/- 2.9) Florida 70.7% (+/- 8.7) 80.3% (+/- 7.7) 34.3% (+/- 9.8) 37.5% (+/- 1.5) Georgia 72.9% (+/- 9.5) 83.5% (+/- 7.9) 33.2% (+/- 9.5) 39.3% (+/- 1.9) Hawaii 69.1% (+/- 7.6) 83.7% (+/- 6.1) 34.4% (+/- 9.5) 54.4% (+/- 2.6) Idaho 75.2% (+/- 6.5) 84.2% (+/- 5.3) 31.3% (+/- 9.6) 37.9% (+/- 2.0) Illinois 69.3% (+/- 5.2) 82.7% (+/- 4.5) 33.8% (+/- 7.2) 43.4% (+/- 2.0) Indiana 68.9% (+/- 6.7) 82.1% (+/- 5.3) 34.6% (+/- 7.7) 41.5% (+/- 1.6) Iowa 81.9% (+/- 6.3) 89.6% (+/- 4.4) 41.9% (+/- 8.8) 48.6% (+/- 1.7) Kansas 74.0% (+/- 6.8) 81.6% (+/- 6.1) 21.0% (+/- 8.2) 47.0% (+/- 1.5) Kentucky 77.9% (+/- 7.1) 84.1% (+/- 6.4) 26.8% (+/- 8.5) 46.9% (+/- 1.8) Louisiana 72.1% (+/- 7.3) 78.5% (+/- 6.4) 42.1% (+/- 9.8) 44.6% (+/- 2.0) Maine 71.4% (+/- 7.3) 87.9% (+/- 5.7) 45.8% (+/- 8.8) 47.8% (+/- 1.6) Maryland 77.1% (+/- 8.0) 87.4% (+/- 6.5) 33.4% (+/- 10.7) 48.9% (+/- 2.8) Massachusetts 80.2% (+/- 6.5) 93.3% (+/- 4.0) 39.3% (+/- 8.4) 53.3% (+/- 1.9) Michigan 71.1% (+/- 7.3) 79.6% (+/- 6.6) 34.5% (+/- 9.4) 42.9% (+/- 1.5) Minnesota 77.3% (+/- 7.5) 90.5% (+/- 5.0) 37.6% (+/- 9.0) 51.7% (+/- 1.3) Mississippi 76.0% (+/- 7.6) 87.4% (+/- 5.4) 25.2% (+/- 8.6) N/A Missouri 70.1% (+/- 7.7) 82.1% (+/- 6.6) 28.8% (+/- 9.0) 48.3% (+/- 2.1) Montana 66.7% (+/- 8.1) 79.0% (+/- 6.4) 28.3% (+/- 8.1) 41.9% (+/- 1.8) Nebraska 81.3% (+/- 5.5) 88.3% (+/- 4.7) 41.5% (+/- 9.1) 51.0% (+/- 1.5) Nevada 65.6% (+/- 6.1) 81.1% (+/- 5.0) 27.4% (+/- 8.3) 36.4% (+/- 2.4) New Hampshire 78.2% (+/- 6.5) 91.3% (+/- 3.9) 43.2% (+/- 8.6) 48.0% (+/- 1.9) New Jersey 73.9% (+/- 6.7) 86.4% (+/- 5.3) 31.4% (+/- 9.2) 46.1% (+/- 1.7) New Mexico 67.7% (+/- 7.2) 79.8% (+/- 6.4) 44.3% (+/- 9.2) 46.6% (+/- 1.9) New York 74.3% (+/- 4.9) 86.6% (+/- 3.8) 45.4% (+/- 6.6) 48.4% (+/- 1.8) North Carolina 75.6% (+/- 7.0) 87.5% (+/- 5.3) 32.8% (+/- 9.1) 51.0% (+/- 2.0) North Dakota 73.4% (+/- 6.2) 78.6% (+/- 5.9) 41.1% (+/- 9.1) 48.9% (+/- 2.3) Ohio 63.4% (+/- 7.6) 75.8% (+/- 7.0) 35.0% (+/- 8.8) 44.7% (+/- 1.6) Oklahoma 63.9% (+/- 6.3) 79.2% (+/- 5.4) 35.4% (+/- 8.3) 46.7% (+/- 2.0) Oregon 70.7% (+/- 6.3) 83.8% (+/- 5.2) 39.5% (+/- 8.8) 42.2% (+/- 2.5) Pennsylvania 77.4% (+/- 5.1) 88.7% (+/- 3.9) 45.9% (+/- 8.1) 46.3% (+/- 1.6) Rhode Island 84.5% (+/- 6.3) 91.6% (+/- 4.9) 56.5% (+/- 9.3) 56.9% (+/- 3.4) South Carolina 67.1% (+/- 8.3) 77.3% (+/- 7.5) 40.7% (+/- 10.4) 44.3% (+/- 1.6) South Dakota 75.9% (+/- 7.4) 86.5% (+/- 5.8) 42.3% (+/- 9.6) 57.4% (+/- 2.5) Tennessee 71.4% (+/- 6.7) 81.1% (+/- 6.0) 35.9% (+/- 9.1) 52.7% (+/- 3.2) Texas 74.1% (+/- 5.0) 81.5% (+/- 4.5) 38.9% (+/- 7.4) 45.2% (+/- 1.8) Utah 78.6% (+/- 5.9) 90.3% (+/- 4.1) 20.5% (+/- 7.8) 41.5% (+/- 1.5) Vermont 69.2% (+/- 6.5) 85.8% (+/- 5.1) 42.7% (+/- 9.1) 50.0% (+/- 2.1) DECEMBER 2014 Virginia 71.2% (+/- 9.8) 78.8% (+/- 9.3) 27.6%(+/- 10.6) 50.4% (+/- 1.8) Washington 71.0% (+/- 7.8) 79.8% (+/- 7.0) 45.3% (+/- 9.8) 48.4% (+/- 1.7) West Virginia 69.4% (+/- 7.5) 83.4% (+/- 6.2) 38.4% (+/- 9.0) 52.6% (+/- 1.9) Wisconsin 75.7% (+/- 6.8) 84.0% (+/- 6.1) 36.8% (+/- 9.0) 42.3% (+/- 2.0) Wyoming 70.1% (+/- 7.7) 80.9% (+/- 6.6) 42.1% (+/- 9.3) 37.6% (+/- 2.0) Standardized Infection Ratio* Antibiotic Hepatitis A Hepatitis B Hepatitis C Flu Vaccination West Nile HIV Rate TB Rates for Centeral Prescriptions Rates per Rates per Rates per Rate 18+ (2013- Virus Cases per 100,000 per 100,000 Line-associated per 1,000 100,000 100,000 100,000 2014) (2013) (2011) (2013) Bloodstream (2010) (2012) (2012) (2012) Infections (2011) Alabama 44.6% (+/- 2.7) 9 0.694 1,079.6 17.6 0.4 1.6 0.5 2.2 Alaska 38.7% (+/- 2.5) 0 0.716 510.7 3.7 0.1 0.1 N/A 9.7 Arizona 35.4% (+/- 2.0) 62 0.575 732.5 10.9 1.4 0.2 N/A 2.8 Arkansas 43.9% (+/- 2.9) 18 0.481 1,020.8 8.3 0.3 2.5 0.2 2.4 California N/A 379 0.565 554.6 15.8 0.5 0.4 0.2 5.7 Colorado 48.9% (+/- 1.6) 322 0.587 611.0 8.0 0.5 0.5 0.8 1.4 Connecticut 46.7% (+/- 2.9) 4 0.627 821.9 12.0 0.6 0.4 0.9 1.7 Delaware 45.5% (+/- 2.9) 3 0.534 921.1 14.0 1.0 1.2 N/A 2.1 D.C. 43.4% (+/- 3.3) 1 0.693 976.4 155.6 N/A N/A N/A 5.9 Florida 34.4% (+/- 1.6) 7 0.540 706.1 28.4 0.5 1.3 0.6 3.3 Georgia 35.5% (+/- 2.2) 10 0.816 853.0 25.7 0.5 1.1 0.8 3.4 Hawaii 50.2% (+/- 2.9) 0 0.258 543.7 5.7 0.4 0.4 N/A 8.2 Idaho 35.3% (+/- 2.2) 40 0.428 677.9 2.4 0.7 0.3 0.7 0.7 Illinois 40.3% (+/- 2.5) 117 0.593 836.1 16.6 0.5 0.7 0.2 2.5 Indiana 38.6% (+/- 1.8) 23 0.580 956.5 7.9 0.2 1.4 1.7 1.4 Iowa 46.9% (+/- 1.8) 44 0.555 851.9 4.3 0.2 0.4 0.1 1.5 Kansas 43.7% (+/- 1.6) 91 0.434 961.0 5.2 0.5 0.3 0.6 1.2 Kentucky 44.9% (+/- 2.0) 3 0.718 1,196.9 7.9 0.6 4.1 4.1 1.3 Louisiana 40.5% (+/- 2.4) 54 0.727 1,122.8 30.2 0.2 1.0 0.2 3.0 Maine 44.6% (+/- 1.8) 0 0.989 654.5 4.5 0.7 0.7 0.6 1.1 Maryland 44.1% (+/- 3.3) 16 0.670 758.1 30.6 0.5 0.9 0.7 3.0 Massachusetts 48.5% (+/- 2.2) 8 0.562 797.7 19.2 0.6 1.1 0.6 3.0 Michigan 39.5% (+/- 1.6) 36 0.362 907.0 8.1 1.0 0.8 0.8 1.4 Minnesota 48.5% (+/- 1.2) 79 0.403 679.6 6.0 0.5 0.3 0.6 2.8 Mississippi N/A 45 0.606 1,137.0 20.7 0.4 2.6 N/A 2.2 Missouri 46.6% (+/- 2.5) 29 0.468 932.1 9.4 0.3 0.8 0.1 1.7 Montana 39.6% (+/- 2.0) 38 0.408 636.9 2.2 0.6 0.2 0.9 0.6 Nebraska 47.3% (+/- 1.6) 226 0.610 935.9 4.3 0.9 0.5 0.2 1.1 Nevada 32.3% (+/- 2.9) 11 0.577 637.4 14.6 0.4 1.0 0.4 3.3 New Hampshire 43.9% (+/- 2.2) 1 0.640 619.2 4.2 0.5 0.3 N/A 1.1 New Jersey 40.2% (+/- 2.0) 12 0.728 875.7 17.8 0.7 0.8 0.8 3.6 New Mexico 40.3% (+/- 2.2) 38 0.523 689.7 7.1 0.5 0.1 1.0 2.4 New York 44.1% (+/- 2.2) 32 0.837 840.9 25.5 0.6 0.6 0.5 4.4 North Carolina 48.0% (+/- 2.4) 3 0.571 818.7 17.3 0.3 0.7 0.6 2.2 North Dakota 45.3% (+/- 2.5) 125 0.373 950.5 2.2 0.3 0.0 0.0 1.7 Ohio 41.8% (+/- 1.8) 24 0.472 874.1 10.6 0.3 1.5 0.1 1.3 Oklahoma 44.1% (+/- 2.4) 89 0.514 854.3 8.8 0.3 2.1 2.1 1.8 Oregon 39.3% (+/- 2.9) 16 0.384 556.9 6.7 0.2 0.6 0.9 1.9 Pennsylvania 42.7% (+/- 1.8) 11 0.485 787.2 12.1 0.5 0.5 0.5 1.7 Rhode Island 52.5% (+/- 4.1) 1 0.710 879.7 12.1 0.3 N/A N/A 2.6 South Carolina 40.7% (+/- 1.8) 7 0.706 880.5 18.4 0.1 0.8 0.0 2.3 South Dakota 54.0% (+/- 2.9) 149 0.443 834.5 3.2 0.0 0.2 N/A 1.1 Tennessee 50.6% (+/- 3.9) 24 0.699 1,159.4 14.5 0.4 3.7 2.0 2.2 Texas 39.3% (+/- 2.2) 183 0.559 867.4 19.7 0.5 0.7 0.2 4.6 Utah 38.0% (+/- 1.4) 7 0.673 791.0 3.3 0.1 0.5 0.6 1.1 Vermont 47.9% (+/- 2.4) 2 0.246 626.5 1.9 0.3 0.3 1.0 0.8 Virginia 47.2% (+/- 2.0) 6 0.700 768.6 13.6 0.6 1.0 0.9 2.2 Washington 45.9% (+/- 1.8) 1 0.477 571.2 8.0 0.4 0.5 0.8 3.0 West Virginia 52.3% (+/- 2.2) 1 0.460 1,177.7 5.7 0.4 7.6 3.0 0.7 Wisconsin 38.2% (+/- 2.4) 21 0.574 715.8 4.8 0.4 0.4 0.5 0.9 Wyoming 36.3% (+/- 2.2) 41 0.289 744.3 2.8 0.2 0.0 N/A N/A *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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